Medizinisch klinische Diagnostik bei Schimmelpilzexposition in Innenräumen – Update 2023 (AWMF-Register-Nr. 161/001)

Zusammenfassung

Die von der Gesellschaft für Hygiene, Umweltmedizin und Präventivmedizin (GHUP) federführend aktualisierte Leitlinie „Medizinisch klinische Diagnostik bei Schimmelpilzexposition in Innenräumen – Update 2023“ ist Gegenstand des vorliegenden Beitrags. Schimmelwachstum im Innenraum ist als ein potenzielles Gesundheitsrisiko zu betrachten, auch ohne dass ein quantitativer und/oder kausaler Zusammenhang zwischen dem Vorkommen einzelner Arten und Gesundheitsbeschwerden gesichert werden kann. Es liegt keine Evidenz für einen kausalen Zusammenhang zwischen Feuchte-/Schimmelschäden und Krankheiten des Menschen vor. Wesentliche Gründe dafür sind das ubiquitäre Vorkommen von Schimmelpilzen und und bislang unzureichende diagnostische Methoden. Es liegt lediglich ausreichende Evidenz für folgende Assoziationen von Feuchte-/Schimmelschäden und folgenden Erkrankungen vor: allergische Atemwegserkrankungen, allergische Rhinitis, allergische Rhinokonjunktivitis, Allergische bronchopulmonale Aspergillose (ABPA), andere Allergische bronchopulmonale Mykosen (ABPM), Aspergillom, Aspergillus-Bronchitis, Asthma (Manifestation, Progression, Exazerbation), Begünstigung von Atemwegsinfekten, Bronchitis (akut, chronisch), Community-acquired Aspergillus-Pneumonie, Exogen-allergische Alveolitis (EAA), invasive Aspergillosen, Mykosen, Organic Dust Toxic Syndrome (ODTS) [Arbeitsplatzexposition], pulmonale Aspergillose (subakut, chronisch) und Rhinosinusitis (akut, chronisch invasiv oder granulomatös, allergisch). Dabei ist das sensibilisierende Potenzial von Schimmelpilzen im Vergleich zu anderen Umweltallergenen deutlich geringer einzuschätzen. Aktuelle Studien zeigen europaweit eine vergleichsweise geringe Sensibilisierungsprävalenz von 3–22,5 % gemessen an der Gesamtbevölkerung. Eingeschränkte oder vermutete Evidenz für eine Assoziation liegt vor hinsichtlich des atopischen Ekzems (atopische Dermatitis, Neurodermitis, Manifestation), Befindlichkeitsstörungen, chronisch obstruktive Lungenerkrankung (COPD), Geruchswirkungen, Mucous Membrane Irritation (MMI) und Sarkoidose. Inadäquate oder unzureichende Evidenz für eine Assoziation liegt vor für akute idiopathische pulmonale Hämorrhagie bei Kindern, Arthritis, Autoimmunerkrankungen, chronisches Müdigkeitssyndrom (CFS), Endokrinopathien, gastrointestinale Effekte, Krebs, luftgetragen übertragene Mykotoxikose, Multiple chemische Sensitivität (MCS), Multiple Sklerose, neuropsychologische Effekte, neurotoxische Effekte, plötzlicher Kindstod, renale Effekte, Reproduktionsstörungen, Rheuma, Schilddrüsenerkrankungen, Sick-Building-Syndrom (SBS), Teratogenität und Urtikaria. Das Infektionsrisiko durch die in Innenräumen regelmäßig vorkommenden Schimmelpilzarten ist für gesunde Personen gering, die meisten Arten sind in die Risikogruppe 1 und wenige in 2 (Aspergillus fumigatus, Aspergillus flavus) der Biostoffverordnung eingestuft. Nur Schimmelpilze, die potenziell in der Lage sind, Toxine zu bilden, kommen als Auslöser einer Intoxikation in Betracht. Ob im Einzelfall eine Toxinbildung im Innenraum stattfindet, entscheiden die Umgebungs- und Wachstumsbedingungen und hier vor allem das Substrat. Von Geruchswirkungen und/oder Befindlichkeitsstörungen kann bei Feuchte-/Schimmelschäden im Innenraum grundsätzlich jeder betroffen sein. Hierbei handelt es sich nicht um eine akute Gesundheitsgefährdung. Prädisponierende Faktoren für Geruchswirkungen können genetische und hormonelle Einflüsse, Prägung, Kontext und Adaptationseffekte sein. Prädisponierende Faktoren für Befindlichkeitsstörungen können Umweltbesorgnisse, -ängste, -konditionierungen und -attributionen sowie eine Vielzahl von Erkrankungen sein. Besonders zu schützende Risikogruppen bezüglich eines Infektionsrisikos sind Personen unter Immunsuppression nach der Einteilung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut (RKI), Personen mit schwer verlaufender Influenza, Personen mit schwer verlaufender COVID-19 und Personen mit Mukoviszidose (zystischer Fibrose), bezüglich eines allergischen Risikos Personen mit Mukoviszidose (zystischer Fibrose) und Personen mit Asthma bronchiale. Die rationale Diagnostik beinhaltet die Anamnese, eine körperliche Untersuchung, eine konventionelle Allergiediagnostik einschließlich gegebenenfalls Provokationstests. Zum Vorgehen bei Schimmelpilzinfektionen wird auf die entsprechenden Leitlinien verwiesen. Hinsichtlich der Mykotoxine existieren zurzeit keine brauchbaren und validierten Testverfahren, die in der klinischen Diagnostik eingesetzt werden könnten. Präventivmedizinisch ist wichtig, dass Schimmelpilzbefall in relevantem Ausmaß aus Vorsorgegründen nicht toleriert werden darf. Zur Beurteilung des Schadensausmaßes und zum Vorgehen wird auf den „Schimmelpilzleitfaden“ des Umweltbundesamtes verwiesen.

Abstract

This article is an abridged version of the updated AWMF mould guideline “Medical clinical diagnostics in case of indoor mould exposure – Update 2023”, presented in July 2023 by the German Society of Hygiene, Environmental Medicine and Preventive Medicine (Gesellschaft für Hygiene, Umweltmedizin und Präventivmedizin, GHUP), in collaboration with German and Austrian scientific medical societies, and experts. Indoor mould growth is a potential health risk, even if a quantitative and/or causal relationship between the occurrence of individual mould species and health problems has yet to be established. There is no evidence for a causal relationship between moisture/mould damage and human diseases, mainly because of the ubiquitous presence of fungi and hitherto inadequate diagnostic methods. Sufficient evidence for an association between moisture/mould damage and the following health effects has been established for: allergic respiratory diseases, allergic rhinitis, allergic rhino-conjunctivitis, allergic bronchopulmonary aspergillosis (ABPA), other allergic bronchopulmonary mycosis (ABPM), aspergilloma, Aspergillus bronchitis, asthma (manifestation, progression, exacerbation), bronchitis (acute, chronic), community-acquired Aspergillus pneumonia, hypersensitivity pneumonitis (HP; extrinsic allergic alveolitis (EEA)), invasive Aspergillosis, mycoses, organic dust toxic syndrome (ODTS) [workplace exposure], promotion of respiratory infections, pulmonary aspergillosis (subacute, chronic), and rhinosinusitis (acute, chronically invasive, or granulomatous, allergic). In this context the sensitizing potential of moulds is obviously low compared to other environmental allergens. Recent studies show a comparatively low sensitization prevalence of 3–22,5 % in the general population across Europe. Limited or suspected evidence for an association exist with respect to atopic eczema (atopic dermatitis, neurodermatitis; manifestation), chronic obstructive pulmonary disease (COPD), mood disorders, mucous membrane irritation (MMI), odor effects, and sarcoidosis. (iv) Inadequate or insufficient evidence for an association exist for acute idiopathic pulmonary hemorrhage in infants, airborne transmitted mycotoxicosis, arthritis, autoimmune diseases, cancer, chronic fatigue syndrome (CFS), endocrinopathies, gastrointestinal effects, multiple chemical sensitivity (MCS), multiple sclerosis, neuropsychological effects, neurotoxic effects, renal effects, reproductive disorders, rheumatism, sick building syndrome (SBS), sudden infant death syndrome, teratogenicity, thyroid diseases, and urticaria.

The risk of infection posed by moulds regularly occurring indoors is low for healthy persons; most species are in risk group 1 and a few in risk group 2 (Aspergillus fumigatus, A. flavus) of the German Biological Agents Act (Biostoffverordnung). Only moulds that are potentially able to form toxins can be triggers of toxic reactions. Whether or not toxin formation occurs in individual cases is determined by environmental and growth conditions, water activity, temperature and above all the growth substrates.

In case of indoor moisture/mould damage, everyone can be affected by odor effects and/or mood disorders.

However, this is not an acute health hazard. Predisposing factors for odor effects can include genetic and hormonal influences, imprinting, context and adaptation effects. Predisposing factors for mood disorders may include environmental concerns, anxiety, condition, and attribution, as well as various diseases. Risk groups to be protected particularly regarding infection risk are immunocompromised persons according to the classification of the German Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionsprävention, KRINKO) at the Robert Koch-Institute (RKI), persons suffering from severe influenza, persons suffering from severe COVID-19, and persons with cystic fibrosis (mucoviscidosis); with regard to allergic risk, persons with cystic fibrosis (mucoviscidosis) and patients with bronchial asthma must be protected. The rational diagnostics include the medical history, physical examination, and conventional allergy diagnostics including provocation tests if necessary; sometimes cellular test systems are indicated. In the case of mould infections, the reader is referred to the specific guidelines. Regarding mycotoxins, there are currently no useful and validated test procedures for clinical diagnostics. From a preventive medical point of view, it is important that indoor mould infestation in relevant magnitudes cannot be tolerated for precautionary reasons.

For evaluation of mould damage in the indoor environment and appropriate remedial procedures, the reader is referred to the mould guideline issued by the German Federal Environment Agency (Umweltbundesamt, UBA).

Schlüsselwörter

Feuchte - Schimmel - Schimmelpilze - Erkrankungen - Allergien - Infektionen - Toxische Reaktionen - Geruchswirkungen - Befindlichkeitsstörungen - Risikopersonen - Exposition - Innenraum - Diagnostik - Therapie - Sanierung - Prävention

Keywords

dampness - mould - fungi - illnesses - allergies - infections - toxic reactions - odor effects - mood disorders - people at risk - exposure - indoor air - diagnostics - therapy - remediation - prevention

^a Mitautor*in

^b Stimmberechtigt*e Mandatsträger*in einer Wissenschaftlichen Medizinischen Fachgesellschaft, einer Gesellschaft, eines Ärzteverbandes

Publication History

Article published online:
09 February 2024

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• 706 Pallarés N, Carballo D. et al. High-Throughput Determination of Major Mycotoxins with Human Health Concerns in Urine by LC-Q TOF MS and Its Application to an Exposure Study. Toxins (Basel) 2022; 14: 42
• 707 Tittlemier SA, Cramer B. et al. Developments in mycotoxin analysis: an update for 2020-2021. World Mycotoxin J 2022; 15: 3-25
• 708 Föllmann W, Ali N. et al. Biomonitoring of mycotoxins in urine: pilot study in mill workers. J Toxicol Environ Health A 2016; 79: 1015-1025
• 709 Franco LT, Ismail A. et al. Occurrence of toxigenic fungi and mycotoxins in workplaces and human biomonitoring of mycotoxins in exposed workers: a systematic review. Toxin Reviews 2021; 40: 576-591
• 710 Habschied K, Kanižai Šarić G. et al. Mycotoxins-Biomonitoring and Human Exposure. Toxins (Basel) 2021; 13: 113
• 711 van den Brand AD, Bajard L. et al. Providing Biological Plausibility for Exposure – Health Relationships for the Mycotoxins Deoxynivalenol (DON) and Fumonisin B1 (FB1) in Humans Using the AOP Framework. Toxins 2022; 14: 279
• 712 Neuhann HF, Wiesmüller GA Hornberg C, Schlipköter HW. III-2.4 Aufgaben und Strukturen umweltmedizinischer Beratungsstellen in Deutschland. In: Wichmann H-E, Schlipköter H-W, Fülgraff G. Hrsg. Handbuch der Umweltmedizin, 25. Erg. Lfg. 9/02. Landsberg/Lech: ecomed Verlagsgesellschaft; 2002: 1-23
• 713 Kommission „Methoden und Qualitätssicherung in der Umweltmedizin“. Einsatz immunologischer Untersuchungsverfahren in der Umweltmedizin. Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz 2002; 45: 740-744
• 714 Kommission „Methoden und Qualitätssicherung in der Umweltmedizin“. Diagnostische Relevanz des Lymphozytentransformationstests in der Umweltmedizin. Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz 2002; 45: 745-749
• 715 Kommission „Methoden und Qualitätssicherung in der Umweltmedizin“. Bedeutung von Zytokinbestimmungen in der umweltmedizinischen Praxis. Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz 2004; 47: 73-79
• 716 Kommission „Methoden und Qualitätssicherung in der Umweltmedizin“. Bedeutung der Bestimmung von Lymphozyten-Subpopulationen in der Umweltmedizin. Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz 2006; 49: 468-484
• 717 Kommission „Methoden und Qualitätssicherung in der Umweltmedizin“. Oxidativer Stress und Möglichkeiten seiner Messung aus umweltmedizinischer Sicht. Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz 2008; 51: 1464-1482
• 718 Kommission „Methoden und Qualitätssicherung in der Umweltmedizin“. Leitlinien Diagnostische Validität. Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz 2008; 51: 1353-1356
• 719 Oepen I. Unkonventionelle diagnostische und therapeutische Methoden in der Umweltmedizin. Gesundheitswesen 1998; 60: 420-430
• 720 Agnihotri NT, Greenberger PA. Unproved and controversial methods and theories in allergy/immunology. Allergy Asthma Proc 2019; 40: 490-493
• 721 Burkhard B. Unkonventionelle Konzepte in der Umweltmedizin. Versicherungsmedizin 1996; 48: 179-184
• 722 Greiner A, Drexler H. Unnötige Diagnostik in der Umweltmedizin. Eine retrospektive Kohortenstudie. Dtsch Ärztebl Int 2016; 113: 773-780
• 723 Hudnell HK, Shoemaker RC. Visual Contrast Sensitivity: Response. Environ Health Perspect 2002; 110: A121-A123
• 724 Pateras E, Karioti M. Contrast Sensitivity Studies and Test – A Review. Int J Ophthalmol Clin Res 2020; 7: 116
• 725 Swinker M, Burke WA. Correspondence – Visual Contrast Sensitivity as a Diagnostic Tool. Environ Health Perspect 2002; 110: A120-A121
• 726 Bundesärztekammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF). NVL-Programm. S3-Leitlinie Nationale VersorgungsLeitlinie Asthma, Registernummer nvl-002. Stand: 07.09.2020, Gültig bis: 06.09.2025. https://register.awmf.org/de/leitlinien/detail/nvl-002 (Stand: 06.03.2023)
• 727 Klimek L, Bachert C. et al. ARIA-Leitlinie 2019: Behandlung der allergischen Rhinitis im deutschen Gesundheitssystem. Allergo J 2019; 28: 20-46
• 728 Pfaar O, Ankermann T. et al. Guideline on allergen immunotherapy in IgE-mediated allergic diseases: S2K Guideline of the German Society of Allergology and Clinical Immunology (DGAKI), Society of Pediatric Allergology and Environmental Medicine (GPA), Medical Association of German Allergologists (AeDA), Austrian Society of Allergology and Immunology (ÖGAI), Swiss Society for Allergology and Immunology (SSAI), German Dermatological Society (DDG), German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), German Society of Pediatrics and Adolescent Medicine (DGKJ), Society of Pediatric Pulmonology (GPP), German Respiratory Society (DGP), German Professional Association of Otolaryngologists (BVHNO), German Association of Paediatric and Adolescent Care Specialists (BVKJ), Federal Association of Pneumologists, Sleep and Respiratory Physicians (BdP), Professional Association of German Dermatologists (BVDD). Allergol Select 2022; 6: 167-232
• 729 Alvaro-Lozano M, Akdis CA. et al. EAACI Allergen Immunotherapy User's Guide. Pediatr Allergy Immunol 2020; 31 (Suppl. 25) 1-101
• 730 Dreborg S, Agrell B. et al. A double-blind, multicenter immunotherapy trial in children, using a purified and standardized Cladosporium herbarum preparation. I. Clinical results. Allergy 1986; 41: 131-140
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• 734 Bozek A, Pyrkosz K. Immunotherapy of mold allergy: A review. Hum Vaccin Immunother 2017; 13: 2397-2401
• 735 Twaroch TE, Curin M. et al. Mold allergens in respiratory allergy: from structure to therapy. Allergy Asthma Immunol Res 2015; 7: 205-20
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• 737 Lange L, Kopp M. Komplementäre Diagnose- und Therapieverfahren in der Kinderallergologie. In: Kinderallergologie in Klinik und Praxis. Berlin, Heidelberg: Springer; 2014.
• 738 Wasik AA, Tuuminen T. Salt Therapy as a Complementary Method for the Treatment of Respiratory Tract Diseases, With a Focus on Mold-Related Illness. Altern Ther Health Med 2021; 27 (Suppl. 01) 223-239
• 739 Sauni R, Uitti J. et al. Remediating buildings damaged by dampness and mould for preventing or reducing respiratory tract symptoms, infections and asthma. Cochrane Database Syst Rev 2011; 7: CD007897
• 740 Burr ML, Matthews IP. et al. Effects on patients with asthma of eradicating visible indoor mould: a randomised controlled trial. Thorax 2007; 62: 767-772
• 741 Heinrich J. Influence of indoor factors in dwellings on the development of childhood asthma. Int J Hyg Environ Health 2011; 214: 1-25
• 742 Kalayci O, Miligkos M. et al. The role of environmental allergen control in the management of asthma. World Allergy Organ J 2022; 15: 100634
• 743 Krieger J, Jacobs DE. et al. Housing interventions and control of asthma-related indoor biologic agents: a review of the evidence. J Public Health Manag Pract 2010; 16 (05) S11-S20
• 744 Schmidt S. Sinnvolle Wohnraumsanierungsempfehlungen bei Hausstaubmilben-, Tier- und Schimmelpilzallergien (Teil 1). Stellungnahme der Dokumentations- und Informationsstelle für Allergiefragen im Kindes- und Jugendalter (DISA). Allergo J 1998; 7: 156-163 https://www.g-n-n.de/solva_udocs/Wohnraumsanierung_1.pdf (Stand: 06.03.2023)
• 745 Schmidt S. Sinnvolle Wohnraumsanierungsempfehlungen bei Hausstaubmilben-, Tier- und Schimmelpilzallergien (Teil 2 +3). Stellungnahme der Dokumentations- und Informationsstelle für Allergiefragen im Kindes- und Jugendalter (DISA). Allergo J 1998; 7: 217-202 https://www.g-n-n.de/solva_udocs/Wohnraumsanierung_2.pdf (Stand: 06.03.2023)
• 746 Albertsmeyer M, zur Nieden A. et al. Häusliches Hygieneverhalten von Mukoviszidosepatienten: Status – standardisierte Schulung – Hygienescore – Evaluation. Umweltmed – Hygiene – Arbeitsmed 2013; 18: 65-80
• 747 Bernstein JA, Levin L. et al. A pilot study to investigate the effects of combined dehumidification and HEPA filtration on dew point and airborne mold spore counts in day care centers. Indoor Air 2005; 15: 402-407
• 748 Wood RA. Air filtration devices in the control of indoor allergens. Curr Allergy Asthma Rep 2002; 2: 397-400
• 749 McDonald E, Cook D. et al. Effect of air filtration systems on asthma: a systematic review of randomized trials. Chest 2002; 122: 1535-1542
• 750 Sublett JL, Seltzer J. et al. Air filters and air cleaners: rostrum by the American Academy of Allergy, Asthma & Immunology Indoor Allergen Committee. J Allergy Clin Immunol 2010; 125: 32-38
• 751 Deutsche Gesellschaft für Kinder- und Jugendmedizin e.V. (DGKJ), Deutsche Gesellschaft für Pädiatrische Infektiologie e.V. (DGPI), Deutsche Gesellschaft für Epidemiologie e.V. (DGEpi). S3-Leitlinie Maßnahmen zur Prävention und Kontrolle der SARS-CoV-2-Übertragung in Schulen – Lebende Leitlinie (Living Guideline). Registernummer 027 – 076. 2022. https://register.awmf.org/de/leitlinien/detail/027-076 (Stand: 06.03.2023)
• 752 Hubbard HF, Coleman BK. et al. Effects of an ozone-generating air purifier on indoor secondary particles in three residential dwellings. Indoor Air 2005; 15: 432-444
• 753 Waring MS, Siegel JA. The effect of an ion generator on indoor air quality in a residential room. Indoor Air 2011; 21: 267-276
• 754 Brasche S, Bischof W. Vorkommen, Ursachen und gesundheitliche Aspekte von Feuchteschäden in Wohnungen – Auswertung zu Schimmelpilzschäden in nach Wärmeschutzverordnung von 1995 erbauten Gebäuden. Universitätsklinikum Jena, Institut für Arbeits-, Sozial- und Umweltmedizin, Arbeitsgruppe Raumklimatologie; 2007
• 755 Landesfachverband Schreinerhandwerk Baden-Württemberg. Schimmelpilze hinter Möbeln – Eine Praxishilfe zur Vermeidung. https://docplayer.org/36911011-Schimmelpilze-hinter-moebeln-eine-praxishilfe-zur-vermeidung.html (Stand: 06.03.2023)
• 756 Oswald R, Liebert G, Spilker R. Schimmelpilzbefall bei hochwärmegedämmten Neu- und Altbauten. Erhebung von Schadensfällen – Ursachen und Konsequenzen. Bauforschung für die Praxis, Band 84. Stuttgart: Fraunhofer IRB Verlag; 2008
• 757 Umweltbundesamt. Kinder-Umwelt-Survey (KUS) 2003/06. Sensibilisierungen gegenüber Innenraumschimmelpilzen. Berlin: Umweltbundesamt; 2011. https://www.umweltbundesamt.de/sites/default/files/medien/461/publikationen/4176.pdf (Stand: 06.03.2023)
• 758 Netzwerk Schimmelpilzberatung Baden-Württemberg. Feuchte-/Schimmelpilzschäden vermeiden und beheben. 2022
• 759 Weber A, Fuchs N. et al. Exploring the associations between parent-reported biological indoor environment and airway-related symptoms and allergic diseases in children. Int J Hyg Environ Health 2017; 220: 1333-1339
• 760 Rolke M, Engelhart S. et al. Exogen-allergische Alveolitis von einem Dampfbügeleisen. Allergologie 2003; 26: 327-328
• 761 Diette GB, McCormack MC. et al. Environmental issues in managing asthma. Respir Care 2008; 53: 602-615
• 762 Fischer PJ. Elternratgeber – Atemwegsallergien durch Schimmelpilze. Überarbeitet 04/2021. Pädiatr Allergologie 2021; 2: 53-55 https://www.gpau.de/fileadmin/user_upload/GPA/dateien_indiziert/Elternratgeber/ER_Atemwegsallergien_Schimmelpilze.pdf (Stand: 06.03.2023)
• 763 Grinn-Gofroń A, Bosiacka B. et al. A comparative study of hourly and daily relationships between selected meteorological parameters and airborne fungal spore composition. Aerobiologia (Bologna) 2018; 34: 45-54
• 764 Werchan B, Werchan M. et al. Die Wochenpollenvorhersage der Stiftung Deutscher Polleninformationsdienst (PID) – ein Hilfsmittel für Pollenallergiker und deren behandelnde Ärzte in Deutschland. Allergologie 2021; 44: 920-926
• 765 Apangu GP, Adams-Groom B. et al. Sentinel-2 satellite and HYSPLIT model suggest that local cereal harvesting substantially contribute to peak Alternaria spore concentrations. Agric Forest Meteorol 2022; 326: 109156
• 766 Olsen Y, Gosewinkel UB. et al. Regional variation in airborne Alternaria spore concentrations in Denmark through 2012–2015 seasons: the influence of meteorology and grain harvesting. Aerobiologia 2019; 35: 533-551
• 767 Umweltbundesamt. Häufige Fragen bei Schimmelbefall. https://www.umweltbundesamt.de/themen/gesundheit/umwelteinfluesse-auf-den-menschen/schimmel/haeufige-fragen-bei-schimmelbefall (Stand: 06.03.2023)
• 768 Verbraucherzentrale, Hrsg. Feuchtigkeit und Schimmelbildung – Erkennen, beseitigen, vorbeugen. Verfasser: Donadio S, Gabrio T, Kussauer K, Lerch P, Wiesmüller GA. 2. Auflage 2023. Kapitel: Woran erkenne ich eine qualifizierte Firma für die Schimmelsanierung. ISBN: 9783863360603 149-150
• 769 Deitschun F, Warscheid T. Richtlinie zum sachgerechten Umgang mit Schimmelpilzschäden in Gebäuden – Eine Empfehlung des BVS – Erkennen, Bewerten und Instandsetzen. Der Sachverständige 2010; 37: 345-357 sowie Der Sachverständige 2012; 39: 98–113
• 770 Deitschun F, Warscheid T. Richtlinie zum sachgerechten Umgang mit Schimmelpilzschäden in Gebäuden – Eine Empfehlung des BVS – Erkennen, Bewerten und Instandsetzen 2014. https://www.bvs-ev.de/fileupload/files/617731b9d5740_Schimmelpilzrichtlinie.pdf (Stand: 06.03.2023)
• 771 WTA-Merkblatt 6-15 Ausgabe: 08.2013/D. Technische Trocknung durchfeuchteter Bauteile Teil 1: Grundlagen 2013. https://www.beuth.de/de/technische-regel/wta-merkblatt-6-15/200010841 (Stand: 06.03.2023)
• 772 WTA-Merkblatt 6-16 Ausgabe: 01.2019/D. Technische Trocknung durchfeuchteter Bauteile Teil 2: Planung, Ausführung und Kontrolle 2019. https://www.beuth.de/de/technische-regel/wta-merkblatt-6-16/305869554 (Stand: 06.03.2023)
• 773 WTA-Merkblatt 4-12-21/D:2021-05. Ziele und Kontrolle von Schimmelpilzschadensanierungen in Innenräumen 2021. https://www.beuth.de/de/technische-regel/wta-merkblatt-4-12/342998074 (Stand: 06.03.2023)
• 774 Lampert T, Müters S. et al. Messung des sozioökonomischen Status in der KiGGS-Studie. Erste Folgebefragung (KiGGS Welle 1). Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz 2014; 57: 762-770
• 775 Gabrio T, Valtanen K, Herr C. Schimmel im Innenraum – gesundheitliche Symptome und Zusammenhänge mit Armutsgefährdung. Umweltmed – Hygiene – Arbeitsmed 2021; 26: 245-265
• 776 Bundeszentrale für politische Bildung. Ausgewählte Armutsgefährdungsquoten. 2020 https://www.bpb.de/nachschlagen/zahlen-und-fakten/soziale-situation-in-deutschland/61785/armutsgefaehrdung (Stand: 06.03.2023)
• 777 Bundeszentrale für politische Bildung. Soziale Lagen in Deutschland. 2021 https://www.bpb.de/kurz-knapp/zahlen-und-fakten/datenreport-2021/sozialstruktur-und-soziale-lagen/330013/soziale-lagen-in-deutschland (Stand: 06.03.2023)
• 778 statista. Bruttoinlandsprodukt (BIP) je Einwohner nach Bundesländern im Jahr 2021. https://de.statista.com/statistik/daten/studie/73061/umfrage/bundeslaender-im-vergleich-bruttoinlandsprodukt/ (Stand: 06.03.2023)
• 779 Statistisches Bundesamt (destatis). Verbraucherpreisindizes für Deutschland – Jahresbericht 2021. https://www.destatis.de/DE/Themen/Wirtschaft/Preise/Verbraucherpreisindex/Publikationen/_publikationen-verbraucherpreisindex.html;jsessionid=16CA58D32352426707F2514FD8C613A5.live732?nn=214056#_f639b3ked (Stand: 06.03.2023)
• 780 Statistisches Bundesamt (destatis). Wohnen. Belastungen durch Wohnumfeld und Unterkunft, 2021. https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Wohnen/Tabellen/belastung-wohnsituation-silc.html (Stand: 06.03.2023)
• 781 Brasche S, Heinz E. et al. Vorkommen, Ursachen und gesundheitliche Aspekte von Feuchteschäden in Wohnungen – Ergebnisse einer repräsentativen Wohnungsstudie in Deutschland. Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz 2003; 46: 683-693
• 782 Landesgesundheitsamt Baden-Württemberg. Monitoring Gesundheit und Umwelt – Untersuchung Schimmelpilze, Wohnen und Gesundheit 2014/15. Tabellenband. Stuttgart: Landesgesundheitsamt Baden-Württemberg; 2017
• 783 Thißen M, Niemann H. Wohnen und Umwelt – Ergebnisse aus dem bundesweiten Gesundheitsmonitoringsystem des Robert Koch-Instituts. UMID 2016; 2: 18-29 https://www.umweltbundesamt.de/sites/default/files/medien/360/publikationen/umid_02_2016_wohnen_rki.pdf (Stand: 06.03.2023)
• 784 Gesundheitsamt Bremen, Abteilung Gesundheit und Umwelt, Hrsg. Feuchtigkeit und Schimmel in Wohnungen – Praxisbericht 2012. Bremen: Freie Hansestadt Bremen; 2012. http://www.bremer-netzwerk-schimmelberatung.de/materialien-broschueren.html (Stand: 06.03.2023)
• 785 Robert Koch-Institut. KiGGS: Studie zur Gesundheit von Kindern und Jugendlichen in Deutschland, 2011. http://www.rki.de/DE/Content/Gesundheitsmonitoring/Studien/Kiggs/kiggs_node.html (Stand: 06.03.2023)
• 786 Dewitz A, Valtanen K. 3.4 Inequalities in dampness in the home. In: WHO Regional Office for Europe, Hrsg. Environmental health inequalities in Europe. Second assessment report. Copenhagen: WHO Regional Office for Europe; 2019. https://www.who.int/europe/publications/i/item/9789289054157 (Stand: 06.03.2023)
• 787 Marschewski W. Hrsg. Umweltgerechtigkeit, Public Health und soziale Stadt. Kulmbach: mg Fachverlag; 2001
• 788 Netzwerk Schimmelpilzberatung Deutschland. Statement des Netzwerkes Schimmelpilzberatung Deutschland. Schimmel im Innenraum – Gesundheitliche Risiken in Zusammenhang mit Armutsgefährdung. Umweltmed – Hygiene – Arbeitsmed 2022; 27: 249-252
• 789 Statistisches Bundesamt (destatis). Wohnen. Wohnkosten: Knapp 13 % der Bevölkerung fühlen sich belastet, 2023. https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Wohnen/eu-silc-armut.html (Stand: 06.03.2023)
• 790 Statistisches Bundesamt (destatis). Presse. Armutsgefährdung in Bremen, Hessen und Nordrhein-Westfalen von 2009 bis 2019 am stärksten gestiegen, 2020. https://www.destatis.de/DE/Presse/Pressemitteilungen/2020/08/PD20_308_634.html (Stand: 06.03.2023)
• 791 Statistisches Bundesamt (destatis). Bauen und Wohnen. Mikrozensus – Zusatzerhebung 2010. Bestand und Struktur der Wohneinheiten Wohnsituation der Haushalte, 2012. https://sozialberatungkiel.files.wordpress.com/2012/11/stabu-wohnsituation-haushalte-2010-mz-zusatz-fs5-h1.pdf (Stand: 06.03.2023)
• 792 Statistisches Bundesamt (destatis). Presse. 2 Millionen Menschen in Deutschland konnten 2019 aus Geldmangel ihre Wohnung nicht angemessen heizen, 2021. https://www.destatis.de/DE/Presse/Pressemitteilungen/2021/02/PD21_066_639.html (Stand: 06.03.2023)
• 793 Cornely OA, Böhme A. et al. Primary prophylaxis of invasive fungal Infections in patients with hematologic malignancies. Recommendations of the Infectious Diseases Working Party of the German Society for Haematology and Oncology. Haematologica 2009; 94: 113-122
• 794 Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Böhme A. et al. Treatment of invasive fungal infections in cancer patients – Recommendations of the Infectious Diseases Working Party (Agiho) of the German Society of Hematology and Oncology (DGHO). Ann Hematol 2009; 88: 97-110
• 795 Rocchi S, Reboux G. et al. Evaluation of invasive aspergillosis risk of immunocompromised patients alternatively hospitalized in hematology intensive care unit and at home. Indoor Air 2014; 24: 652-661
• 796 Rao D, Phipatanakul W. Impact of environmental controls on childhood asthma. Curr Allergy Asthma Rep 2011; 11: 414-420
• 797 Verbraucherzentrale, Hrsg. Feuchtigkeit und Schimmelbildung – Erkennen, beseitigen, vorbeugen. Verfasser: Donadio S, Gabrio T, Kussauer K, Lerch P, Wiesmüller GA. 2. Auflage. 2023. ISBN: 9783863360603
• 798 VDI 4300 Blatt 8: Messen von Innenraumluftverunreinigungen – Probenahme von Hausstaub (VDI 4300 Blatt 8:2001-06). Berlin: Beuth Verlag GmbH; 2001. [zurückgezogen]