Limited evidence associates inadequate classroom ventilation rates (VRs) with increased illness absence (IA). We investigated relationships between VRs and IA in California elementary schools over two school years in 162 3rd-5th-grade classrooms in 28 schools in three school districts: South Coast (SC), Bay Area (BA), and Central Valley (CV). We estimated relationships between daily IA and VR (estimated from two year daily real-time carbon dioxide in each classroom) in zero-inflated negative binomial models. We also compared IA benefits and energy costs of increased VRs. All school districts had median VRs below the 7.1 l/s-person California standard. For each additional 1 l/s-person of VR, IA was reduced significantly (p<0.05) in models for combined districts (À1.6%) and for SC (À1.2%), and nonsignificantly for districts providing less data: BA (À1.5%) and CV (À1.0%). Assuming associations were causal and generalizable, increasing classroom VRs from the California average (4 l/s-person) to the State standard would decrease IA by 3.4%, increase attendance-linked funding to schools by $33 million annually, and increase costs by only $4 million. Further increasing VRs would provide additional benefits. These findings, while requiring confirmation, suggest that increasing classroom VRs above the State standard would substantially decrease illness absence and produce economic benefits. Practical ImplicationsThese findings suggest a potentially large opportunity to improve the attendance and health of elementary school students in California through provision of increased classroom ventilation. The majority of classrooms in this study provided less ventilation than specified in current State guidelines. If the relationships observed here (and in several prior studies) and the costs and benefits estimated here are confirmed, it would be advantageous to students, their families, and school districts, and highly cost-effective, to ensure that ventilation rates in elementary school classrooms not only meet but substantially exceed current ventilation guidelines. Because specific exposures and response mechanisms involved have not been determined, it is possible that more energy-efficient alternatives to increased ventilation, such as filtration and reduced indoor emissions, might provide similar benefits. Nomenclature

BackgroundDampness and mold have been shown in qualitative reviews to be associated with a variety of adverse respiratory health effects, including respiratory tract infections. Several published meta-analyses have provided quantitative summaries for some of these associations, but not for respiratory infections. Demonstrating a causal relationship between dampness-related agents, which are preventable exposures, and respiratory tract infections would suggest important new public health strategies. We report the results of quantitative meta-analyses of published studies that examined the association of dampness or mold in homes with respiratory infections and bronchitis.MethodsFor primary studies meeting eligibility criteria, we transformed reported odds ratios (ORs) and confidence intervals (CIs) to the log scale. Both fixed and random effects models were applied to the log ORs and their variances. Most studies contained multiple estimated ORs. Models accounted for the correlation between multiple results within the studies analyzed. One set of analyses was performed with all eligible studies, and another set restricted to studies that controlled for age, gender, smoking, and socioeconomic status. Subgroups of studies were assessed to explore heterogeneity. Funnel plots were used to assess publication bias.ResultsThe resulting summary estimates of ORs from random effects models based on all studies ranged from 1.38 to 1.50, with 95% CIs excluding the null in all cases. Use of different analysis models and restricting analyses based on control of multiple confounding variables changed findings only slightly. ORs (95% CIs) from random effects models using studies adjusting for major confounding variables were, for bronchitis, 1.45 (1.32-1.59); for respiratory infections, 1.44 (1.31-1.59); for respiratory infections excluding nonspecific upper respiratory infections, 1.50 (1.32-1.70), and for respiratory infections in children or infants, 1.48 (1.33-1.65). Little effect of publication bias was evident. Estimated attributable risk proportions ranged from 8% to 20%.ConclusionsResidential dampness and mold are associated with substantial and statistically significant increases in both respiratory infections and bronchitis. If these associations were confirmed as causal, effective control of dampness and mold in buildings would prevent a substantial proportion of respiratory infections.

Limited evidence has associated lower ventilation rates (VRs) in schools with reduced student learning or achievement. We analyzed longitudinal data collected over two school years from 150 classrooms in 28 schools within three California school districts. We estimated daily classroom VRs from real-time indoor carbon dioxide measured by web-connected sensors. School districts provided individual-level scores on standard tests in Math and English, and classroom-level demographic data. Analyses assessing learning effects used two VR metrics: average VRs for 30 days prior to tests, and proportion of prior daily VRs above specified thresholds during the year. We estimated relationships between scores and VR metrics in multivariate models with generalized estimating equations. All school districts had median school-year VRs below the California VR standard. Most models showed some positive associations of VRs with test scores; however, estimates varied in magnitude and few 95% confidence intervals excluded the null. Combined-district models estimated statistically significant increases of 0.6 points (P = 0.01) on English tests for each 10% increase in prior 30-day VRs. Estimated increases in Math were of similar magnitude but not statistically significant. Findings suggest potential small positive associations between classroom VRs and learning.

a b s t r a c tBackground: Limited evidence has associated lower ventilation rates (VRs) in offices with higher illnessrelated absence rates. Methods: We studied spaces in office buildings, selected without knowledge of their VRs, in three California climate zones. In each study space, real-time logging sensors measured carbon dioxide and thermal parameters for one year. Web-based surveys every three months collected data on occupants' health outcomes. Using multivariate models, relationships were assessed between CO 2 concentrations, or VRs estimated from CO 2 , and adverse occupant outcomes including respiratory infections and illness absences. For all outcomes, positive associations were hypothesized with higher CO 2 levels (and negative associations with higher VRs). Results: Low survey response limited sample size and study power. In the 16 study spaces, CO 2 concentrations were uniformly low over the year, and most estimated VRs ranged from twice to nine times the California office minimum VR standard (7 L/s or 15 cfm per person). Primary CO 2 and VR metrics had no statistically significant relationships with occupant outcomes. Conclusions: Within the observed range of uniformly low CO 2 and high VRs (mostly 16e42 L/s per person), little variation in contaminant concentrations would be expected, which would explain lack of relationships with occupant outcomes. These high VRs resulted partly from frequently used energysaving "economizer" cycles in moderate California climates, but VRs at other times also substantially exceeded required VRs. These findings suggest, consistent with theory, that within a higher VR range, increased VRs do not reduce respiratory illness. Further studies are needed to better characterize such relationships.