This paper provides a review and synthesis of current knowledge about the associations of ventilation system types in office buildings with sick building syndrome symptoms and discusses potential explanations for the associations. Relative to natural ventilation, air conditioning, with or without humidification, was consistently associated with a statistically significant increase in the prevalence of one or more SBS symptoms. Prevalences were typically higher by approximately 30% to 200% in the air conditioned buildings. In two of three assessments from a single study, symptom prevalences were also significantly higher in air conditioned buildings than in buildings with simple mechanical ventilation and no humidification. In approximately half of assessments, SBS symptom prevalences were significantly higher in buildings with simple mechanical ventilation than in buildings with natural ventilation. Insufficient information was available for conclusions about the potential increased risk of SBS symptoms with humidification. The statistically significant associations of mechanical ventilation and air conditioning with SBS symptoms are much more frequent than expected from chance and also not likely to be a consequence of confounding by several potential personal, job, or building related confounders. The reasons for the increases in symptom prevalences with mechanical ventilation and particularly with air conditioning remain unclear. Multiple …