Does dampness and mold in schools affect health? Results of a meta‐analysis

This paper provides meta‐analyses of the published findings relating the respiratory health of occupants of schools with visible dampness, water damage, visible mold, and/or mold odor. Random effects models were used to develop central estimates and confidence limits for the associations of respiratory health effects with school dampness and mold. Eleven studies, all with cross‐sectional designs, were included in the meta‐analyses; however, analyses for some health outcomes were based on as few as four studies. Analyses were performed using data from adults and children combined, using only data from children, and using data from adults and children after excluding two studies. The central estimates of odds ratios from the meta‐analyses were consistently above unity. The evidence of adverse health effects was strongest for cough and wheeze, which had confidence limits excluding unity in some or all analyses. The odds ratios of 1.32 for cough and 1.68 for wheeze suggest moderate increases in health risk. Studies not included in the meta‐analyses provide additional evidence that dampness and mold in schools are associated with adverse health outcomes. These meta‐analyses and the published literature not included in the meta‐analyses suggest that dampness and mold in schools are associated with adverse respiratory health effects.     

Evaluating the effect of building construction periods on household dampness/mold and childhood diseases corresponding to different energy efficiency design requirements

Despite concerns about building dampness and children’ health, few studies have examined the effects of building energy efficiency standards. This study explored the connections between self-reported household dampness and children’ adverse health outcomes across buildings corresponding to construction periods (pre-2001, 2001-2010, post-2010). Significant differences of dampness-related indicators were found between buildings; the prevalence was remarkable in pre-2001 buildings. The prevalence of lifetime-ever doctor-diagnosed diseases for children was significantly associated with building dampness (adjust odd ratios > 1), but was not affected by construction periods. The hygrothermal performance for a typical residence was simulated, varying in U-values of envelopes and air change rates. The simulated performance improvement increased indoor temperatures in 2001-2010 and post-2010 buildings. The frequency with higher indoor relative humidity was higher in pre-2001 buildings, leading to the highest values for maximum mold index (M_max) on wall surface, especially in winter. Compared to buildings in 2001-2010, increased insulation and lower air change rate led to a relatively higher relative humidity in post-2010 buildings, adversely increasing the M_max values. The findings addressed the positive and negative role of building standard development, which help suggesting appropriate environmental and design solutions to trade-off energy savings and dampness/mold risk in residences.     

Dampness and mold in homes across China: Associations with rhinitis,ocular, throat and dermal symptoms,headache and fatigue among adults

We studied dampness and mold in China in relation to rhinitis, ocular, throat and dermal symptoms, headache and fatigue. A questionnaire study was performed in six cities including 36 541 randomized parents of young children. Seven self‐reported signs of dampness were evaluated. Multilevel logistic regression models were used to calculate odds ratios (ORs). Totally, 3.1% had weekly rhinitis, 2.8% eye, 4.1% throat and 4.8% skin symptoms, 3.0% headache and 13.9% fatigue. Overall, 6.3% of the homes had mold, 11.1% damp stains, 35.3% damp bed clothing, 12.8% water damage, 45.4% window pane condensation, 11.1% mold odor, and 37.5% humid air. All dampness signs were associated with symptoms (ORs from 1.2 to 4.6; P < 0.001), including rhinitis (ORs from 1.4 to 3.2; P < 0.001), and ORs increased by number of dampness signs. The strongest associations were for mold odor (ORs from 2.3 to 4.6) and humid air (ORs from 2.8 to 4.8). Associations were stronger among men and stronger in Beijing as compared to south China. In conclusion, dampness and mold are common in Chinese homes and associated with rhinitis and ocular, throat and dermal symptoms, headache and fatigue. Men can be more sensitive to dampness and health effects of dampness can be stronger in northern China.     

Characterization and pro-inflammatory potential of indoor mold particles

A number of epidemiological studies find an association between indoor air dampness and respiratory health effects. This is often suggested to be linked to enhanced mold growth. However, the role of mold is obviously difficult to disentangle from other dampness-related exposure including microbes as well as non-biological particles and chemical pollutants. The association may partly be due to visible mycelial growth and a characteristic musty smell of mold. Thus, the potential role of mold exposure should be further explored by evaluating information from experimental studies elucidating possible mechanistic links. Such studies show that exposure to spores and hyphal fragments may act as allergens and pro-inflammatory mediators and that they may damage airways by the production of toxins, enzymes, and volatile organic compounds. In the present review, we hypothesize that continuous exposure to mold particles may result in chronic low-grade pro-inflammatory responses contributing to respiratory diseases. We summarize some of the main methods for detection and characterization of fungal aerosols and highlight in vitro research elucidating how molds may induce toxicity and pro-inflammatory reactions in human cell models relevant for airway exposure. Data suggest that the fraction of fungal hyphal fragments in indoor air is much higher than that of airborne spores, and the hyphal fragments often have a higher pro-inflammatory potential. Thus, hyphal fragments of prevalent mold species with strong pro-inflammatory potential may be particularly relevant candidates for respiratory diseases associated with damp/mold-contaminated indoor air. Future studies linking of indoor air dampness with health effects should assess the toxicity and pro-inflammatory potential of indoor air particulate matter and combined this information with a better characterization of biological components including hyphal fragments from both pathogenic and non-pathogenic mold species. Such studies may increase our understanding of the potential role of mold exposure.     

Public health and economic impact of dampness and mold

The public health risk and economic impact of dampness and mold exposures was assessed using current asthma as a health endpoint. Individual risk of current asthma from exposure to dampness and mold in homes from W.J. Fisk, Q. Lei-Gomez & M.J. Mendell [(2007) Indoor Air, [corrected] 17, 284-296], and [corrected] asthma risks calculated from additional studies that reported the prevalence of dampness and mold in homes were used to estimate the proportion of US current asthma cases that are attributable to dampness and mold exposure at 21% (95% confidence internal 12-29%). An examination of the literature covering dampness and mold in schools, offices, and institutional buildings, which is summarized in the Appendix, suggests that risks from exposure in these buildings are similar to risks from exposures in homes. Of the 21.8 million people reported to have asthma in the USA, approximately 4.6 (2.7-6.3) million cases are estimated to be attributable to dampness and mold exposure in the home. Estimates of the national cost of asthma from two prior studies were updated to 2004 and used to estimate the economic impact of dampness and mold exposures. By applying the attributable fraction to the updated national annual cost of asthma, the national annual cost of asthma that is attributable to dampness and mold exposure in the home is estimated to be $3.5 billion ($2.1-4.8 billion). Analysis indicates that exposure to dampness and mold in buildings poses significant public health and economic risks in the USA. These findings are compatible with public policies and programs that help control moisture and mold in buildings. PRACTICAL IMPLICATIONS: There is a need to control moisture in both new and existing construction because of the significant health consequences that can result from dampness and mold. This paper demonstrates that dampness and mold in buildings is a significant public health problem with substantial economic impact.     

Allergy and respiratory health effects of dampness and dampness‐related agents in schools and homes: a cross‐sectional study in Danish pupils

Little is known about the health effects of school‐related indoor dampness and microbial exposures. In this study, we investigated dampness and dampness‐related agents in both homes and schools and their association with allergy and respiratory health effects in 330 Danish pupils. Classroom dampness was identified based on technical inspection and bedroom dampness on parents' self‐report. Classroom and bedroom dust was analyzed for seven microbial components. Skin prick testing determined atopic sensitization. Lung function was expressed as z‐scores for forced expiratory volume in one‐second (zFEV₁), forced vital capacity (zFVC) and the ratio zFEV₁/zFVC using GLI‐2012 prediction equations. The parents reported children's allergies, airway symptoms, and doctor‐diagnosed asthma. High classroom dampness, but not bedroom dampness, was negatively associated with zFEV₁ (β‐coef. ?0.71; 95% CI ?1.17 to ?0.23) and zFVC (β‐coef. ?0.52; 95% CI ?0.98 to ?0.06) and positively with wheezing (OR 8.09; 95% CI 1.49 to 43.97). No consistent findings were found between any individual microbial components or combination of microbial components and health outcomes. Among other indoor risk factors, environmental tobacco smoke (ETS) decreased zFEV₁ (β‐coef. ?0.22; 95% CI ?0.42 to ?0.02) and zFEV₁/zFVCratio (β‐coef. ?0.26; 95% CI ?0.44 to ?0.07) and increased upper airway symptoms (OR 1.66; 95% CI 1.03–2.66). In conclusion, dampness in classrooms may have adverse respiratory health effects in pupils, but microbial agents responsible for this effect remain unknown.     

Day care center characteristics and children's respiratory health

Day care centers provide an important exposure arena with potential harmful health effects for children. This study has linked health effect data from a survey among 942 3-5-year-old Oslo children with information on day care center characteristics collected during inspection of the 175 day care centers these children attended. The aim of the study was to estimate associations between dampness problems and other building characteristics and several respiratory health outcomes. Dampness problems (sign of molds, water leakage, damage to floor/wall) were observed in 51% of the day care centers. In multiple logistic regression analyses none of the studied symptoms and diseases (nightly cough, blocked or runny nose without common cold, wheeze, heavy breathing or chest tightness, the common cold, tonsillitis/pharyngitis, otitis media, bronchitis, pneumonia, asthma, and allergic rhinitis) were systematically associated with dampness problems or type of ventilation in day care centers. None of the studied indicators of day care center exposures were found to have a clear effect on day care children's respiratory health. Even so this study does not rule out negative health effects of day care center exposures. The study demonstrates that population-based studies of these relations are demanding with regard to assessment of exposure and health outcomes. PRACTICAL IMPLICATIONS: Simple and easy-to-register indicators of exposures like dampness problems and type of ventilation assessed in 175 day care centers were not related to respiratory health among 3-5-year-old Norwegian children attending the day care centers. The study does not rule out negative health effects of day care center exposures, but demonstrates methodological challenges needed to be addressed in studies of health effects of the day care environment.     

Building-related respiratory symptoms can be predicted with semi-quantitative indices of exposure to dampness and mold

Using a semi-quantitative mold exposure index, the National Institute for Occupational Safety and Health (NIOSH) investigated 13 college buildings to examine whether building-related respiratory symptoms among employees are associated with environmental exposure to mold and dampness in buildings. We collected data on upper and lower respiratory symptoms and their building-relatedness, and time spent in specific rooms with a self-administered questionnaires. Trained NIOSH industrial hygienists classified rooms for water stains, visible mold, mold odor, and moisture using semi-quantitative scales and then estimated individual exposure indices weighted by the time spent in specific rooms. The semi-quantitative exposure indices significantly predicted building-related respiratory symptoms, including wheeze [odds ratio (OR) = 2.3; 95% confidence interval (CI) = 1.1-4.5], chest tightness (OR = 2.2; 95% CI = 1.1-4.6), shortness of breath (OR = 2.7; 95% CI = 1.2-6.1), nasal (OR = 2.5; 95% CI = 1.3-4.7) and sinus (OR = 2.2; 95% CI = 1.2-4.1) symptoms, with exposure-response relationships. We found that conditions suggestive of indoor mold exposure at work were associated with building-related respiratory symptoms. Our findings suggest that observational semi-quantitative indices of exposure to dampness and mold can support action to prevent building-related respiratory diseases. PRACTICAL IMPLICATIONS: Current air sampling methods have major limitations in assessing exposure to mold and other biological agents that may prevent the demonstration of associations of bioaerosol exposure with health. Our study demonstrates that semi-quantitative dampness/mold exposure indices, based solely on visual and olfactory observation and weighted by time spent in specific rooms, can predict existence of excessive building-related respiratory symptoms and diseases. Relative extent of water stains, visible mold, mold odor, or moisture can be used to prioritize remediation to reduce potential risk of building-related respiratory diseases. From a public health perspective, these observational findings justify action to correct water leaks and repair water damage in order to prevent building-related respiratory diseases. This approach can also be a basis for developing practical building-diagnostic tools for water-incursion.     

Associations between questionnaire reports of home dampness and childhood respiratory symptoms.

The relationship between home dampness and respiratory health was studied in two populations of children of 6-12 years old, living in the south east of the Netherlands. In one study, lung function was measured at the schools, and in both studies, information on respiratory symptoms was collected from a self-administered questionnaire completed by the parents of the children. Information on home dampness was collected by questionnaire. Information on other potential indoor determinants of respiratory health, like (sources of) nitrogen dioxide and smoking in the home was collected by questionnaire as well. Respiratory symptoms were found to be associated with home dampness. There was a weak, negative association between MMEF and reporting of mould in the home. Several potential biases were evaluated. It was not considered likely that the results could be explained by information, selection or confounding bias. However, further work is needed to conclusively exclude these biases, and to develop objective measures of home dampness for use in epidemiologic studies.     

Observation‐based metrics for residential dampness and mold with dose–response relationships to health: A review

An important proportion of respiratory illness is considered attributable to residential dampness or mold (D/M). Developing health‐protective D/M guidelines has been challenging, in part because unhealthy levels of indoor D/M cannot be defined using available microbiological measurements. This review paper explores reported multilevel, observation‐based (eg visual or olfactory) D/M metrics for potential in defining unhealthy levels of residential D/M. For many of the 33 multilevel residential D/M metrics identified, health risks generally increased as observed D/M increased. Although some metrics seemed too complex for practical use, simple metrics had among the strongest associations with health outcomes. Available findings suggest the feasibility of setting observation‐based D/M thresholds to trigger remedial action, using further improved D/M metrics without microbiological measurements (at least until the actual dampness‐related agents that cause illness are better quantified). Additional data would allow setting health‐protective D/M thresholds more precisely. Also, metrics could better reflect hidden D/M by more strongly emphasizing mold odor, which has demonstrated strong associations with health effects.     

Air filter materials, outdoor ozone and building-related symptoms in the BASE study

Used ventilation air filters have been shown to reduce indoor environmental quality and worker performance and increase symptoms, with effects stronger after reaction of filters with ozone. We analyzed data from the US EPA Building Assessment Survey and Evaluation (BASE) study to determine if ozone and specific filter media have interactive effects on building-related symptoms (BRS). We analyzed a subset of 34 buildings from the BASE study of 100 US office buildings to determine the separate and joint associations of filter medium [polyester/synthetic (PS) or fiberglass (FG)] and outdoor ozone concentration (above/below the median, 67.6 microg/m(3)) with BRS. Using logistic regression models and general estimating equations, we estimated odds ratios (ORs) and 95% confidence intervals for the association of filter medium, ozone, and filter medium x ozone with BRS. Relative to FG + low ozone, PS alone or high ozone alone, were each significantly (P < 0.05) associated only with fatigue/difficulty concentrating (ORs = 1.93 and 1.54, respectively). However, joint exposure to both PS + high ozone, relative to FG + low ozone, had significant associations with lower and upper respiratory, cough, eye, fatigue, and headache BRS (ORs ranged from 2.26 to 5.90). Joint ORs for PS + high ozone for lower and upper respiratory and headache BRS were much greater than multiplicative, with interaction P-values <0.10. Attributable risk proportion (ARP) estimates indicate that removing both risk factors might, given certain assumptions, reduce BRS by 26-62%. These findings suggest possible adverse health consequences from chemical interactions between outdoor ozone and PS filters in buildings. Results need confirmation before recommending changes in building operation. However, if additional research confirms causal relationships, ARP estimates indicate that appropriate filter selection may substantially reduce BRS in buildings, especially in high-ozone areas. PRACTICAL IMPLICATIONS: The results indicate that a better understanding of how filters interact with their environment is needed. While the mechanism is unknown and these findings need to be replicated, they indicate that the joint risk of BRS from polyester/synthetic filters and outdoor ozone above 67.6 microg/m(3) is much greater than the risk from each alone. These findings suggest potential reductions in BRS from appropriate selection of ventilation filter media or implementing strategies to reduce ozone entrained in building ventilation systems. If the relationships were found to be causal, filter replacement and ozone abatement should be undertaken.     

Measured moisture in buildings and adverse health effects: A review

It has not yet been possible to quantify dose‐related health risks attributable to indoor dampness or mold (D/M), to support setting specific health‐related limits for D/M. An overlooked target for assessing D/M is moisture in building materials, the critical factor allowing microbial growth. A search for studies of quantified building moisture and occupant health effects identified 3 eligible studies. Two studies assessed associations between measured wall moisture content and respiratory health in the UK. Both reported dose‐related increases in asthma exacerbation with higher measured moisture, with 1 study reporting an adjusted odds ratio of 7.0 for night‐time asthma symptoms with higher bedroom moisture. The third study assessed relationships between infrared camera‐determined wall moisture and atopic dermatitis in South Korea, reporting an adjusted odds ratio of 14.5 for water‐damaged homes and moderate or severe atopic dermatitis. Measuring building moisture has, despite extremely limited available findings, potential promise for detecting unhealthy D/M in homes and merits more research attention. Further research to validate these findings should include measured “water activity,” which directly assesses moisture availability for microbial growth. Ultimately, evidence‐based, health‐related thresholds for building moisture, across specific materials and measurement devices, could better guide assessment and remediation of D/M in buildings.     

Home dampness,childhood asthma,hay fever,and airway symptoms in Shanghai,China: associations,dose‐response relationships,and lifestyle's influences

Numerous studies of associations between dampness and respiratory diseases have been conducted, but their implications remain inconclusive. In this study of 13,335 parent‐reported questionnaires (response rate: 85.3%), we analyzed associations between home dampness and asthma and related symptoms in 4‐ to 6‐year‐old children in a cross‐sectional study of Shanghai. Indicators of home dampness were strongly and significantly associated with dry cough, wheeze, and rhinitis symptoms. In the current residence, children with visible mold spots (VMS) exposure had 32% higher risk of asthma (adjusted OR, 95% CI: 1.32, 1.07–1.64); damp clothing and/or bedding (frequently) was strongly associated with dry cough (1.78, 1.37–2.30); condensation on windows was strongly associated with hay fever (1.60, 1.27–2.01). In the early‐life residence, VMS or damp stains (frequently) were strongly associated with dry cough (2.20, 1.55–3.11) and rhinitis ever (1.57, 1.11–2.21). Associations between dampness and diseases among children with or without family history of atopy were similar. The total number of dampness indicators had strong dose‐response relationships with investigated health outcomes. Actions, including opening windows of the child's room at night and cleaning the child's room frequently, could potentially mitigate 25% of home VMS, thereby preventing more than 1.5% of attributable risk of the studied symptoms.     

Building dampness and mold in European homes in relation to climate,building characteristics and socio‐economic status: The European Community Respiratory Health Survey ECRHS II

We studied dampness and mold in homes in relation to climate, building characteristics and socio‐economic status (SES) across Europe, for 7127 homes in 22 centers. A subsample of 3118 homes was inspected. Multilevel analysis was applied, including age, gender, center, SES, climate, and building factors. Self‐reported water damage (10%), damp spots (21%), and mold (16%) in past year were similar as observed data (19% dampness and 14% mold). Ambient temperature was associated with self‐reported water damage (OR=1.63 per 10°C; 95% CI 1.02‐2.63), damp spots (OR=2.95; 95% CI 1.98‐4.39), and mold (OR=2.28; 95% CI 1.04‐4.67). Precipitation was associated with water damage (OR=1.12 per 100 mm; 95% CI 1.02‐1.23) and damp spots (OR=1.11; 95% CI 1.02‐1.20). Ambient relative air humidity was not associated with indoor dampness and mold. Older buildings had more dampness and mold (P<.001). Manual workers reported less water damage (OR=0.69; 95% CI 0.53‐0.89) but more mold (OR=1.27; 95% CI 1.03‐1.55) as compared to managerial/professional workers. There were correlations between reported and observed data at center level (Spearman rho 0.61 for dampness and 0.73 for mold). In conclusion, high ambient temperature and precipitation and high building age can be risk factors for dampness and mold in homes in Europe.     

Association of ventilation rates and CO2 concentrations with health and other responses in commercial and institutional buildings

This paper reviews current literature on the associations of ventilation rates and carbon dioxide concentrations in non-residential and non-industrial buildings (primarily offices) with health and other human outcomes. Twenty studies, with close to 30,000 subjects, investigated the association of ventilation rates with human responses, and 21 studies, with over 30,000 subjects, investigated the association of carbon dioxide concentration with these responses. Almost all studies found that ventilation rates below 10 Ls-1 per person in all building types were associated with statistically significant worsening in one or more health or perceived air quality outcomes. Some studies determined that increases in ventilation rates above 10 Ls-1 per person, up to approximately 20 Ls-1 per person, were associated with further significant decreases in the prevalence of sick building syndrome (SBS) symptoms or with further significant improvements in perceived air quality. The carbon dioxide studies support these findings. About half of the carbon dioxide studies suggest that the risk of sick building syndrome symptoms continued to decrease significantly with decreasing carbon dioxide concentrations below 800 ppm. The ventilation studies reported relative risks of 1.5-2 for respiratory illnesses and 1.1-6 for sick building syndrome symptoms for low compared to high low ventilation rates.     

Dampness in buildings and health. Nordic interdisciplinary review of the scientific evidence on associations between exposure to "dampness" in buildings and health effects (NORDDAMP)

Several epidemiological investigations concerning indoor environments have indicated that "dampness" in buildings is associated to health effects such as respiratory symptoms, asthma and allergy. The aim of the present interdisciplinary review is to evaluate this association as shown in the epidemiological literature. A literature search identified 590 peer-reviewed articles of which 61 have been the foundation for this review. The review shows that "dampness" in buildings appears to increase the risk for health effects in the airways, such as cough, wheeze and asthma. Relative risks are in the range of OR 1.4-2.2. There also seems to be an association between "dampness" and other symptoms such as tiredness, headache and airways infections. It is concluded that the evidence for a causal association between "dampness" and health effects is strong. However, the mechanisms are unknown. Several definitions of dampness have been used in the studies, but all seems to be associated with health problems. Sensitisation to mites may be one but obviously not the only mechanism. Even if the mechanisms are unknown, there is sufficient evidence to take preventive measures against dampness in buildings.     

Respiratory Symptoms and Housing Characteristics

A health and housing questionnaire was administered to children, ages 9-11, living in 24 communities in the United States and Canada. Logistic regression analysis examined the relationship between respiratory health symptoms (bronchitic, asthmatic and lower respiratory) and housing factors. The health risks (expressed as relative odds) were controlled for gender, parental asthma, parental chronic obstructive pulmonary disease and parental education, as well as between-city differences. Lower respiratory symptoms had significantly higher odds ratios reported in older homes (1.12), homes with smokers (1.24), air conditioners (1.14), air cleaners (1.37), and humidifiers (1.47). Home dampness (1.48) and the individual mold and water variables were all significantly associated with increased symptoms. Similar results were reported for bronchitic and asthmatic symptoms. While air conditioners and air cleaners were confounded with symptoms, humidifiers remained significant after controlling for childhood atopy.     

Residential culturable fungi, (1‐3, 1‐6)‐β‐d‐glucan,and ergosterol concentrations in dust are not associated with asthma,rhinitis, or eczema diagnoses in children

Qualitative reporting of home indoor moisture problems predicts respiratory diseases. However, causal agents underlying such qualitative markers remain unknown. In the homes of 198 multiple allergic case children and 202 controls in Sweden, we cultivated culturable fungi by directly plating dust, and quantified (1‐3, 1‐6)‐β‐d ‐glucan and ergosterol in dust samples from the child's bedroom. We examined the relationship between these fungal agents and degree of parent or inspector‐reported home indoor dampness, and microbiological laboratory's mold index. We also compared the concentrations of these agents between multiple allergic cases and healthy controls, as well as IgE‐sensitization among cases. The concentrations of culturable fungal agents were comparable between houses with parent and inspector‐reported mold issues and those without. There were no differences in concentrations of the individual or the total summed culturable fungi, (1‐3, 1‐6)‐β‐d ‐glucan, and ergosterol between the controls and the multiple allergic case children, or individual diagnosis of asthma, rhinitis, or eczema. Culturable fungi, (1‐3, 1‐6)‐β‐d ‐glucan, and ergosterol in dust were not associated with qualitative markers of indoor dampness or mold or indoor humidity. Furthermore, these agents in dust samples were not associated with any health outcomes in the children.     

Students' school-level symptoms mediate the relationship between a school's observed moisture problems and students’ subjective perceptions of indoor air quality

Moisture damage can influence the subjective assessment of indoor air quality (subjective IAQ) in various ways. We studied whether the frequency of symptoms reported across students at school level mediates the relationship between observed mold and dampness in a school building and students’ subjective IAQ. To answer this research question, we tested a multilevel path model. The analyzed data were created by merging two nationwide data sets: (a) survey data from students, including information on subjective IAQ (N = 24,786 students); (b) data from schools, including information on mold and dampness in a school building (N = 222). After the background variables were adjusted, schools’ observed mold and dampness were directly and significantly related to poor subjective IAQ (standardized beta (β)= 0.22, P = .002). In addition, in schools with mold and dampness, students reported significantly more symptoms (β = 0.22, P = .023) than in schools without; the higher the prevalence of symptoms at school level, the worse the students’ subjective IAQ (β = 0.60, P < .001). This indirect path was significant (P = .023). In total, schools’ observed mold and dampness and student-reported symptoms explained 52% of the between-school variance in subjective IAQ.