School-related risk factors for tungiasis among children aged 8 to 14 years in nine counties of Kenya: a cross-sectional survey

Background Tungiasis is a neglected tropical skin disease primarily affecting children under 15, the elderly, and people with disabilities in resource-poor communities across Latin America and Sub-Saharan Africa. In Kenya, the national prevalence among schoolchildren was 1.35% in 2021, with individual school rates ranging from 0.9% to 22%. Although transmission predominantly occurs within homes, this study aimed to identify school-related factors that may increase children's risk of infection. Methods This two-phase, cross-sectional school-based survey examined 21,466 pupils aged 8-to-14 years across 196 schools in nine counties of Kenya. School infrastructure was assessed, and headteachers were interviewed. In phase two, 5,102 pupils from 97 schools were studied in greater detail, including observations of 322 classrooms and interviews with 117 teachers using semi-structured questionnaires. Mixed-effects binary logistic regression was used to identify school-related risk factors for infection. Results Key risk factors included studying in classrooms with concrete floors covered in loose soil (aOR 3.23, 95% CI 1.40–7.46, p=0.006), inconsistent access to clean water (aOR 2.15, 95% CI 1.15–4.01, p=0.016) and attending schools with over 400 pupils (aOR 2.17, 95% CI 1.14–4.14, p=0.018). Additional factors associated with increased odds of infection were poor structural condition of school buildings (aOR 1.83, 95% CI 0.96–3.50, p=0.066) and lack of cleanliness (aOR 3.93, 95% CI 0.92–16.69, p=0.064). Only 45% of headteachers in affected schools were aware of infected pupils, and just 3 of 76 affected schools had received any tungiasis-related intervention in the past year. Conclusion To reduce school-based transmission, the Departments of Education and Health in endemic areas should enhance teacher awareness, promote routine pupil monitoring, and support improvements in school infrastructure—ensuring buildings are well-maintained, clean, and supplied with water consistently.