Epidemiology of intestinal parasitic infections among school-aged children in low- and middle-income countries of Africa and Asia: a systematic review and meta-analysis

Abstract

Background and Aims

Intestinal parasitic infections (IPIs) remain a significant public health challenge, particularly among school-aged children in low- and middle-income countries (LMICs). This systematic review and meta-analysis aimed to estimate the pooled prevalence of IPIs and identify associated risk factors in Africa and Asia.

Method

A systematic search of Medline/PubMed, Embase, Scopus, ScienceDirect, Epistemonikos, and additional searches such as Google and Google Scholar was conducted between January 2019 and April 2024. The review followed the PRISMA guidelines. Data extraction was performed using Microsoft Excel, and meta-analyses were conducted using STATA. Methodological quality was assessed using the Newcastle–Ottawa Scale. A random-effects model was used to estimate the pooled prevalence, while heterogeneity was assessed using the I² statistic. Publication bias was evaluated through funnel plots and Egger’s regression test. The study protocol was registered in PROSPERO (CRD42024536604).

Results

47 studies comprising 20,334 school-aged children were included. The pooled prevalence of at least one intestinal parasitic infection was 39% (95% CI: 33%–45%). Regional analysis showed a higher prevalence in Africa (41%) compared to Asia (35%). Protozoan infections (29%) exceeded those of helminths (19%) and mixed infections (2%). The most common parasites were Blastocystis hominis (16%), Endolimax nana (16%), Entamoeba histolytica (15%), Entamoeba coli (12%), and Ascaris lumbricoides (11%). Infections were primarily single (37%), followed by double (10%), triple (3%), and quadruple (1%). Significant risk factors included school type, socioeconomic status, larger family size, presence of domestic animals, and finger-sucking habits.

Conclusion

Intestinal parasitic infections remain a significant public health challenge among school-aged children in Africa and Asia. The findings underscore the need for sustained, school-based health programs that integrate regular deworming, hygiene education, and targeted sanitation improvements. Strengthening surveillance and addressing behavioral and environmental risk factors are essential to reducing infection burden and promoting child health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13643-025-03063-z.

Introduction

Intestinal parasite infection (IPI) refers to an infection that is caused by one or more species of protozoa, Cestodes, trematodes, and nematodes [1, 2]. It has been stated that intestinal parasite infections are the leading cause of illness and disease globally, and they are endemic everywhere [3]. In developing nations, intestinal parasite infections are one of the major problems with public health [4]. In these nations, the prevalence of infection ranges from 30 to 60%, while it is less than 2% in developed nations [5]. More than 3.5 billion people are affected, and 450 million are ill as a result of these infections, the majority being children [6, 7]. These infections cause over 33% of deaths worldwide [8].

Ascaris lumbricoides, Entamoeba histolytica, and Giardia lamblia are common public health problems in developing countries globally. Over 1.5 billion persons are infected with Ascaris lumbricoides globally, leading to an annual morbidity rate of 335 million and 60,000 related deaths [9]. Anaerobic enteric protozoan parasite Entamoeba histolytica is thought to infect over 50 million people globally [10]. Moreover, Giardia lamblia, which infects about 200 million individuals worldwide, is the most prevalent intestinal parasite protozoan globally [11].

Intestinal parasite infections are more frequent among school-age children, and they tend to occur with high intensity in this age group [3]. Globally, 267 million preschool-age children and 568 million school-age children live in areas where these parasites are intensively transmitted [12]. This is due to their poor hygienic practices and weak immune status [13].

In addition to increased morbidity and mortality, intestinal parasitic infections in children are associated with a wide range of adverse outcomes including intestinal obstruction from heavy Ascaris burdens [14], chronic abdominal pain and diarrhea, impaired nutrient absorption (malabsorption) [15], deficiencies of micronutrients beyond iron (notably vitamin A and others) [16], stunting and delayed physical development [17], reduced cognitive/psychomotor development, increased risk of protein-energy malnutrition and iron deficiency anemia [18, 19], poorer school performance (including selective attention) [20], increased school absenteeism and loss of educational attainment [20], greater susceptibility to other infections due to immune disruption and broader socioeconomic impacts from reduced learning and productivity [21].

The high prevalence rate of intestinal parasites is mostly linked to low socioeconomic position, inadequate medical treatment, lack of access to safe drinking water, overcrowding, poor hygienic living conditions, poor sanitation, severe malnutrition, warm and humid climate, low educational background and lack of personal hygiene in many regions of the world [8, 22–28]. School-age children are the most affected ones due to their habits of playing or handling infested soils, eating with soiled hands, unhygienic toilet practices, drinking and eating contaminated water and food [29].

To address these intestinal parasite infections, baseline data on the burden, distribution, and trend of IPI can offer crucial information for the deployment of preventative policies that work [30]. In this regard, the number of published articles on the prevalence of IPI and associated factors has remarkably increased in recent years. Several studies have been conducted on IPI in school children in different parts of the world. To determine the overall pooled prevalence and the impact of related factors for IPI, it is therefore necessary to summarize and critically analyze the existing research. While the term low- and middle-income (LMICs) includes nations across all continents, this review focuses on countries in Africa and Asia, where the burden of intestinal parasitic infections is highest and where relevant studies were available for synthesis. To date, a comprehensive understanding of the burden of intestinal parasitic infections (IPIs) among school-aged children in these settings is lacking. This study aimed to address this gap by conducting the first systematic review and meta-analysis to synthesize existing data on IPI prevalence among schoolchildren in low- and middle-income countries. By compiling and analyzing available data on prevalence and associated factors, we sought to generate reliable and current prevalence estimates to inform the development and implementation of targeted prevention and control measures.

Methods

Protocol and registration

This systematic review and meta-analysis were registered on PROSPERO with registration number CRD42024536604. Available at: https://www.crd.york.ac.uk/prospero/#myprospero

Search strategies

The systematic review was developed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [31], and the review procedure was reported using the PRISMA-P 2020 checklist [32] (supplementary file 1). Published and peer-reviewed studies were searched in electronic databases such as Medline/PubMed, Embase, Scopus, Science Direct, Epistemonikos, and additional searches from Google and Google Scholar between April 13 to 16 April, 2024. All papers published between January 2019 and 12th of April, 2024, were searched from databases (supplementary file 2). The review was restricted to this timeframe because (i) a sufficient number of studies were available to allow a comprehensive synthesis of recent evidence; (ii) the period represents the post-COVID-19 era, during which significant changes occurred in public health priorities, hygiene practices, and school-based health interventions that may have influenced the epidemiology of intestinal parasitic infections; and (iii) focusing on recent studies enhances the relevance and comparability of findings by reflecting current diagnostic methods, intervention coverage, and socioeconomic contexts. MeSH terms and entry terms were used with the following keywords: “prevalence”, “intestinal parasite”, “intestinal parasite infection”, “school children”, “school age children”, “associated risk factor”, “risk factor”, “determinant factor”, “associated factor”, and “predictor”. The search terms were used separately and in combination using Truncation and Boolean operators like “OR” and “AND”.

Eligibility criteria

Inclusion criteria

Studies were considered eligible if they met the following criteria:

• Published in English.

• Conducted in low- and middle-income countries (LMICs) in Africa or Asia.

• Focused on school-aged children.

• Published between 2019 and April 12, 2024.

• Reported the prevalence (magnitude) of intestinal parasitic infections (IPIs) and/or their associated risk factors.

• Addressed both protozoan and helminthic infections.

• Utilized observational study designs, including cross-sectional, case–control, or cohort studies.

• Published in peer-reviewed journals to ensure scientific quality and reliability.

Exclusion criteria

Studies that did not report the overall prevalence of intestinal parasite infection, and impossible to estimate based on the results and confusing or unclear analysis results, studies other than observational studies, studies with no full-text article, and those of corresponding authors who did not respond to email two times, systematic reviews, conference abstracts, and case reports were excluded.

Definition of intestinal protozoan infection and outcome measures

In the context of this study, Intestinal parasites were defined as the detection of one or more of pathogenic protozoan parasites, non-pathogenic protozoan parasites, and helminths. Some of the intestinal parasites are the following: E. histolytica/dispar, Giardia spp., Cryptosporidium spp., E. coli, Hookworm, Ascaris lumbricoides, Schistosoma mansonii, Strongyloides stercolaris, Trichuris trichiura, Hymenolepis nana, Taenia species, Enterobius vermicularis, and other non-pathogenic protozoan parasites.

The main outcome of this systematic review and meta-analysis was the estimated pooled prevalence of intestinal parasite infections among school children in LMIC of Africa and Asia. The prevalence of intestinal parasite infections was defined as the proportion of positive samples to the total number of samples. For factors associated with intestinal parasite infection, data from the primary studies were collected in the form of two-by-two tables, and the odds ratio (OR) was calculated to determine the relationship between each of the explanatory variables and intestinal parasite infection.

Study selection

Two reviewers (GY and LD) performed study selection independently. EndNote reference manager software version 20.5(Thomson Reuters, Philadelphia, PA, USA) [33] was used to organize, remove duplicates, and remove irrelevant titles and abstracts. Studies were assessed based on the inclusion criteria, and irrelevant studies and duplicates were removed. Any discrepancies that arose between reviewers during study selection and data extraction were resolved through discussion and consensus. When consensus could not be reached, a third reviewer was consulted to make the final decision.

Data extraction and management

The data were extracted using the Joanna Briggs Institute (JBI) data extraction checklist. Two review authors (GY and LD) extracted the data independently using a Microsoft Excel 2021 spreadsheet. The differences between the two review authors were solved through discussion. Any discrepancies were resolved through a review by the other review authors (TK, EAA, FG, AHT, and HB). From each study, information such as the name of the first author, the year of publication, year of data collection, the study design, the study country, study continent, study setting, Residence, Data collection tool, the total sample size, the number of intestinal parasite infection cases among school children, the prevalence of intestinal parasite infection among school children and its standard error, the parasite identified with their prevalence and standard error, determinant factors for intestinal parasite infection with their standard errors, and for each study's measures of association (OR) were extracted.

Data processing and analysis

The extracted data were exported from Microsoft Excel 2021 to STATA version 17 for further analysis (supplementary file 4). Prevalence estimates from individual studies were pooled using a random-effects model to account for between-study heterogeneity. To stabilize variances, the Freeman-Tukey double arcsine transformation was applied, and pooled estimates were subsequently back-transformed to the original proportion scale. Prevalence and odds ratios with 95% confidence intervals were calculated using DerSimonian-Laird weights [34, 35]. Heterogeneity was assessed using the I² statistic, which expresses the proportion of overall variation across studies attributable to heterogeneity as opposed to chance. Heterogeneity was classified as low (I² = 0–25%), moderate (I² = 26–50%), and high (I² > 50%) [36]. Significant heterogeneity between the studies was revealed by the test statistic (I2 = 99.01%, P < 0.001). While subgroup analysis was planned for factors such as diagnostic methods, study settings (urban vs. rural), and study year, these variables were either uniform across studies (e.g., nearly all used microscopy) or insufficiently reported (e.g., study setting) to permit meaningful stratification. Consequently, subgroup analyses were limited to geographical classifications (continent and subcontinent) to identify the reason for the heterogeneity. Furthermore, sensitivity analysis was performed to identify the impact of individual studies (extreme outliers) on the pooled estimate. Publication bias (the small study effect) was detected using the visual funnel plot test and Egger’s statistical test at P < 0.05 [37]. Further Trim and Fill analysis was performed to see the imputed studies. For each intestinal parasite species, pooled prevalence was calculated as the proportion of infected children out of the total number of examined school-aged children included across the studies, rather than only among those with confirmed parasitic infections. To estimate the relationship between intestinal parasite infection and associated factors, the odds ratio with a 95% confidence level was used, and a significance level of 0.05 was considered for the P-value.

Risk of bias assessment

A full-text review of studies was performed before the inclusion of studies in the final meta-analysis using the “Newcastle–Ottawa Scale (NOS)” quality appraisal tool adapted for both cross-sectional and case–control study designs [38, 39], with a total score of 10 for cross-sectional and 9 for case–control studies. Cross sectional studies with score point 9–10 was considered very good, studies with score point 7–8 was considered good studies, studies with score point 5–6 points was considered satisfactory studies, studies with score point 0 to 4 was considered unsatisfactory studies and there is no standard score classification for case control study and we gave them a score from 0 to 9. The components of quality assessment for cross cross-sectional study include representativeness of the sample, sample size and non-respondents, ascertainment of the exposure (risk factor), comparability of subjects, confounding factors, statistical test, and assessment of outcome. The components of quality assessment for case case–control study include case definition, representativeness of the cases, selection of controls, definition of controls, comparability of cases and controls, ascertainment of exposure, ascertainment for cases and controls, and non-response rate. GY and LD (supplementary file 3) reviewed the independent quality assessment of the studies. Any discrepancies that arose between reviewers during study selection and data extraction were resolved through discussion and consensus.

Results

A total of 28,854 articles were retrieved using electronic database searches: Medline/PubMed, Embase, Scopus, Science Direct, Epistemonikos, and manual searches of Google and Google Scholar. 17,553 duplicate articles were removed, and 10,993 articles were removed by title and abstract. 261 articles were excluded due to their study population, systematic reviews, no full text, not clearly described study setting, no clearly stated study design, publication year, study location, and study year. Finally, 47 articles were included in this systematic review and meta-analysis (Fig. 1).

Fig. 1.

PRISMA 2020 flow diagram of included studies to estimate the pooled prevalence of intestinal parasite infection and its associated factors among school-age children in LMIC of Africa and Asia from 2019 up to 2024

Characteristics of the studies

A total of 45 cross-sectional, 1 Cohort, and 1 case control studies with 20,334 sample sizes were included in this systematic review and meta-analysis. Thirty-five studies were from Africa, and twelve studies were from Asia. From Africa, Ethiopia, and from Asia, Nepal has the highest frequency, with twenty-two and three studies, respectively. Based on the school type, fourteen studies were conducted in primary school, five from both primary and secondary school, one from kindergarten, and one from both kindergarten and primary school. The sample size ranged from 36 in Yobe State, Nigeria [40] to 2000 in Uyo, Akwa Ibom State, Nigeria [41]. The entire set of included studies was conducted in both sexes. Before any analysis, the articles were all re-evaluated by impartial assessors, and the studies passed the quality fit test (Table 1). According to the Newcastle–Ottawa Scale (NOS) assessment, most studies scored moderately to high on selection and comparability domains. However, a considerable number of studies were cross-sectional in design, and some had small sample sizes. Detailed NOS scores for each study are presented in Supplementary File 3.

Table 1.

The characteristics of included articles for the systematic review and meta-analysis of the prevalence of intestinal parasite infection and associated risk factors among school-aged children in LMIC of Africa and Asia, 2024

Author (s) and Publication Year	Study location and Country	Study design	Sample size	Response rate	Cases	Prevalence	Weight (%)
Awoke Aschale et.al, 2021 [42]	Dessie, Ethiopia	CS	407	96.20	66	16.0	2.16
Saleh Mohammed et.al, 2022 [40]	Yobe state, Nigeria	CS	36	100	19	52.65	1.79
Gedamu Gebreamlak et.al, 2021 [43]	Debre Berhan, Ethiopia	CS	645	100	341	52.90	2.15
Ayalew Sisay et.al, 2019 [44]	Lake zewai, Ethiopia	CS	384	100	86	22.40	2.15
Shristi Raut et.al, 2021 [45]	Bhairahawa, Nepal	CS	408	100	190	46.50	2.14
Oyono Martin et.al, 2022 [46]	Akonolinga, Cameroon	CS	416	100	252	60.58	2.14
Yasmin. Hussein et.al, 2021 [47]	Al Qurain District, Egypt	CS	320	100	112	35	2.13
Bello Musawa et.al, 2020 [48]	Katsina state, Nigeria	CS	266	100	78	29.30	2.13
Ahmed Alsaifi et.al, 2021 [49]	Sana’a city Yemen	CS	173	100	107	61.85	2.09
Yin Ai-Wen et.al, 2022 [50]	Kingdom of Eswatini, South Africa	CS	316	100	128	40.50	2.13
Shaimaa Alsamir et.al, 2020 [51]	Basrah city, south of Iraq	CS	153	100	25	32.50	2.08
Adnan Alhindi et.al 2021 [52]	Gaza City, Palestine	CC	508	100	90	17.10	2.16
Ayalew Jejaw et.al, 2021 [53]	Mizan-Aman town, Ethiopia	CS	460	100	353	76.70	2.15
Asegid Geleta et.al, 2018 [54]	Arsi Negelle Town, Ethiopia	CS	295	100	117	39.60	2.12
Haytham Mahmoud et.al, 2022 [55]	Dakahlia governorate, Egypt	CS	726	98.9	239	32.90	2.16
Raden Bagus et.al, 2021 [56]	Sumenep District, Indonesia	CS	68	100	39	57.35	1.96
Talal Alharazi et.al, 2020 [57]	Taiz city, Yemen	CS	385	100	107	27.80	2.14
Jitendra Shrestha et.al, 2019 [58]	Kathmandu, Nepal	CS	508	100	101	19.90	2.16
Agumas Ayalew et.al, 2019 [59]	Bahir Dar, Ethiopia	CS	418	100	188	45	2.14
Minoo Shaddel et.al, 2024 [60]	Tehran, Iran	CS	250	100	45	18	2.14
Awrajaw Dessie et.al, 2019 [61]	Northern Ethiopia, Ethiopia	CS	422	100	126	29.90	2.15
Rizal Subahar et.al, 2020 [62]	Jakarta, Indonesia	CS	219	100	41	18.70	2.13
Christine Karimi et.al, 2023 [63]	Njiru Nairob, Kenya	CS	446	100	165	37	2.14
Ahmed Hussein et.al, 2020 [64]	Guangua woreda Ethiopia	CS	551	91	309	56.10	2.15
Eshetie Shiferaw et.al, 2022 [65]	Alefa district, Ethiopia	CS	403	100	144	35.70	2.14
Baye Sitotaw et.al, 2020 [66]	Bure town, Ethiopia	CS	430	100	172	40	2.14
Tadesse, Mulumebet et.al, 2019 [67]	Adele town, East Arsi, Ethiopia	CS	417	98.80	113	27.10	2.15
Misganaw [69] [68]	Jigjiga Town, Ethiopia	CS	422	100	259	61.40	2.14
Biniyam Sahiledengle et.al, 2020 [69]	Shashamane town, Ethiopia	CS	294	88	58	19.70	2.14
Doaa Yones et.al, 2019 [70]	Egypt	CS	630	92	355	56.30	2.15
Sintayehu, Shituneh, 2022 [71]	Gilgel Beles Town, Ethiopia	CS	379	94	142	37.50	2.14
Maqdi. Bayoumi et.al, 2020 [72]	Khartoum, Sudan	CS	1856	96.70	150	8.10	2.18
Ranjit Kumar et.al, 2021 [73]	Janakpurdham, Nepal	CS	155	100	17	10.96	2.14
Usip, L.P.E. et.al, 2023 [41]	Uyo Akwa Ibom state, Nigeria	CS	2000	100	952	47.60	2.17
Naomi Chege et.al, 2020 [74]	Nakuru town, Kenya	CS	248	100	43	17.30	2.14
Tegenaw Tiruneh et.al, 2021 [75]	Dessie, Ethiopia	CS	236	100	157	66.50	2.12
Wadhah Hassan et.al, 2022 [76]	Sana’a City, Yemen	CS	173	100	107	61.85	2.09
Mohammed Suliman et.al, 2019 [77]	White Nile State, Sudan	CS	253	100	144	56.90	2.11
Dires Tegen et.al, 2021 [78]	Dera district, Ethiopia	CS	382	100	238	62.30	2.14
Kibrework Tadesse, 2019 [79]	Aboker, Harari, Ethiopia	CS	384	100	121	31.77	2.14
Boonchai Wongstitwilairoong et.al, 2023 [80]	Kanchanaburi Province, Thailand	CS	661	100	445	67.32	2.16
Melaku Wale et.al, 2022 [81]	Jaragedo Town, Ethiopia	CS	396	98	259	65.40	2.14
Maru Wassie et.al, 2020 [82]	Finoteselam town, Ethiopia	CS	422	100	245	58	2.14
Naomi Mumbi et.al, 2021 [83]	Nakuru town, Kenya	CS	248	98	40	16.13	2.14
Destaw Damtie et.al, 2021 [84]	Merawi Town, Ethiopia	CS	403	100	173	42.90	2.14
Yordanos Gizachew et.al, 2020 [85]	Rama Town, Ethiopia	CS	312	90.7	76	24.40	2.14
Habtye Bisetegn et.al, 2023 [86]	Dessie town, Ethiopia	CS	450	99	130	28.90	2.15

CC Case–control, CS Cross-sectional. Weights (%) represent each study’s statistical contribution to the pooled prevalence estimate under a random-effects model. Due to substantial heterogeneity, individual study weights are similar, reflecting the influence of both within-study variance and between-study variance.

Quality assessment of included studies

The methodological quality of the included studies was assessed using the Newcastle–Ottawa Scale adapted for cross-sectional studies. Studies were classified as very good (9–10 points), good (7–8 points), satisfactory (5–6 points), or unsatisfactory (0–4 points). Among the 47 included studies, 32 (68%) were rated as very good, and 15 (32%) were rated as good. No studies were classified as satisfactory or unsatisfactory, indicating that the overall quality of evidence included in this review was high. A detailed quality assessment table is provided in Supplementary File 3.

Meta-analysis

The pooled prevalence of intestinal parasite infection among school-aged children in LMIC of Africa and Asia

The overall pooled prevalence of intestinal parasitic infections among school-aged children in low- and middle-income countries (LMICs) of Africa and Asia was estimated at 39% (95% CI: 33%–45%). The lowest prevalence was reported in Janakpurdham, Nepal (11%, 95% CI: 7%–17%) [73], while the highest was found in Mizan-Aman town, Ethiopia (77%, 95% CI: 73%–80%) [53]. A substantial level of heterogeneity was observed across studies (I² = 99.01%, p < 0.001), likely due to differences in geographic settings, diagnostic methods, population characteristics, and study periods. These variations highlight the importance of considering contextual factors when interpreting pooled estimates in meta-analyses of parasitic infections (Fig. 2).

Fig. 2.

Forest plot of the pooled prevalence of intestinal parasite infection among school-aged children in LMIC of Africa and Asia, 2024

Galbraith plot and heterogeneity assessment

A Galbraith plot was generated to assess the heterogeneity among the 47 included studies in the meta-analysis. In this plot, each study is represented as a point, with the standardized effect size plotted against the inverse of its standard error. The majority of the studies fall outside the standard deviation lines, indicating substantial heterogeneity across the studies. The wide scattering of points and their deviation from the central regression line further confirm the inconsistency among study findings. This visual evidence supports the statistical findings of significant heterogeneity consistent with the I² statistic. This dispersion indicates that the pooled estimate should be interpreted cautiously and justifies the use of a random-effects model and further subgroup or meta-regression analyses to explore potential sources of variability (Fig. 3).

Fig. 3.

Galbraith (radial) plot of the included 47 studies illustrating the magnitude of between-study heterogeneity

Subgroup analysis

To explore potential sources of heterogeneity, subgroup analyses were performed based on continent, sub-continent, and diagnostic method. At the continental level, the pooled prevalence of intestinal parasitic infections (IPIs) was 41% (95% CI: 34%–48%) in Africa and 35% (95% CI: 23%–47%) in Asia (Fig. 3). Subgroup analysis by sub-continent revealed notable variation: 40% (95% CI: 31%–48%) in East Africa, 47% (95% CI: 35%–59%) in West Africa, 24% (95% CI: 10%–38%) in South Asia, 41% (95% CI: 26%–57%) in Northeast Africa, 42% (95% CI: 21%–63%) in West Asia, 41% (95% CI: 35%–46%) in South Africa, and 48% (95% CI: 12%–83%) in Southeast Asia (Table 2). Additionally, subgroup analysis by diagnostic method was conducted by classifying studies into three categories. The first group, “simple microscopy only,” included techniques such as wet mount and direct smear using saline or iodine preparations, and showed a pooled prevalence of 33% (95% CI: 23%–43%). The second group, “microscopy with concentration techniques,” such as formol-ether concentration, sedimentation, or flotation methods, yielded a higher prevalence of 43% (95% CI: 37%–49%). The third group, “enhanced diagnostic methods,” which included more sensitive and specialized techniques such as Kato-Katz, PCR, and Modified Ziehl–Neelsen staining, showed a pooled prevalence of 26% (95% CI: 10%–43%) (Fig. 4). Despite these stratified analyses, substantial heterogeneity remained across all subgroups as indicated by high I² values. Further subgrouping based on study setting (e.g., urban vs. rural) was not feasible due to limited reporting of included studies.

Table 2.

Summary of pooled prevalence of intestinal parasite infection among school-aged children in LMIC of Africa and Asia, stratified by subcontinent, 2024

Author (s) and Publication Year	Pooled prevalence	LCI	UCI
East Africa
Awoke Aschale et.al, 2021 [42]	16%	13%	20%
Gedamu Gebreamlak et.al, 2021 [43]	53%	49%	57%
Ayalew Sisay et.al, 2019 [44]	22%	19%	27%
Ayalew Jejaw et.al, 2021 [53]	77%	73%	80%
Asegid Geleta et.al, 2019 [54]	40%	34%	45%
Agumas Ayalew et.al, 2019 [59]	45%	40%	50%
Awrajaw Dessie et.al, 2019 [61]	30%	26%	34%
Christine Karimi et.al, 2023 [63]	37%	33%	42%
Ahmed Hussein et.al, 2020 [64]	56%	52%	60%
Eshetie Shiferaw et.al, 2022 [65]	36%	31%	41%
Baye Sitotaw et.al, 2020 [66]	40%	35%	45%
Tadesse, Mulumebet et.al, 2019 [67]	27%	23%	32%
Misganaw [69] [68]	61%	57%	66%
Biniyam Sahiledengle et.al, 2020 [69]	20%	16%	25%
Sintayehu, Shituneh, 2022 [71]	37%	33%	42%
Maqdi. Bayoumi et.al, 2020 [72]	8%	7%	9%
Naomi Chege et.al, 2020 [74]	17%	13%	23%
Tegenaw Tiruneh et.al, 2021 [75]	67%	60%	72%
Mohammed Suliman et.al, 2019 [77]	57%	51%	63%
Dires Tegen et.al, 2021 [78]	62%	57%	67%
Kibrework Tadesse, 2019 [79]	32%	27%	36%
Melaku Wale et.al, 2022 [81]	65%	61%	70%
Maru Wassie et.al, 2020 [82]	58%	53%	63%
Naomi Mumbi et.al, 2021 [83]	16%	12%	21%
Destaw Damtie et.al, 2021 [84]	43%	38%	48%
Yordanos Gizachew et.al, 2020 [85]	24%	20%	29%
Habtye Bisetegn et.al, 2023 [86]	29%	25%	33%
Sub-total (Iᴧ2 = 96.30% P = 0.00)
Random Pooled Estimate	40%	31%	48%
Western Africa
Saleh Mohammed et.al, 2022 [40]	53%	37%	68%
Oyono Martin et.al, 2022 [46]	61%	56%	65%
Bello Musawa et.al, 2020 [48]	29%	24%	35%
Usip, L.P.E. et.al, 2023 [41]	48%	45%	50%
Sub-total (Iᴧ2 = 96.83% P = 0.00)
Random pooled Estimate	47%	35%	59%
South Asia
Shristi Raut et.al, 2021 [45]	47%	42%	51%
Jitendra Shrestha et.al, 2019 [58]	20%	17%	24%
Minoo Shaddel et.al, 2024 [60]	18%	14%	23%
Ranjit Kumar et.al, 2021 [73]	11%	7%	17%
Sub-total (Iᴧ2 = 90.53% P = 0.00)
Random pooled Estimate	24%	10%	38%
Northeast Africa
Yasmin. Hussein et.al, 2021 [47]	35%	30%	40%
Haytham Mahmoud et.al, 2022 [55]	33%	30%	36%
Doaa Yones et.al, 2019 [70]	56%	52%	60%
Sub-total (Iᴧ2 = % P =.)
Random pooled Estimate	41%	26%	57%
Western Asia
Ahmed Alsaifi et.al, 2021 [49]	62%	54%	69%
Adnan Alhindi et.al 2021 [52]	18%	15%	21%
Talal Alharazi et.al, 2020 [57]	28%	24%	32%
Wadhah Hassan et.al, 2022 [76]	62%	54%	69%
Sub-total (Iᴧ2 = 96.53% P = 0.00)
Random pooled Estimate	42%	21%	63%
South Africa
Yin Ai-Wen et.al, 2022 [50]	41%	35%	46%
West Asia
Shaimaa Alsamir et.al, 2020 [51]	16%	11%	23%
Southeast Asia
Raden Bagus et.al, 2021 [56]	57%	46%	68%
Rizal Subahar et.al, 2020 [62]	19%	14%	24%
Boonchai Wongstitwilairoong et.al, 2023 [80]	67%	64%	71%
Sub-total (Iᴧ2 = % P =.)
Random pooled Estimate	48%	12%	83%
Heterogeneity between groups p = 0.00
Overall (Iᴧ2 = 99.01% P = 0.00)
Random pooled Estimate	39%	33%	45%

LCI represents “lower confidence interval” and UCI represents “upper confidence interval”

Fig. 4.

Forest plot of pooled prevalence of intestinal parasite infection among school-aged children in LMIC of Africa and Asia, stratified by diagnostic method, 2024

Sensitivity analysis

A sensitivity analysis was performed on all forty-seven included studies to assess the influence of individual studies on the overall pooled prevalence. The findings indicated that no single study significantly altered the pooled estimate in the meta-analytic model (Fig. 5) (Table 3).

Fig. 5.

Sensitivity analysis for prevalence of intestinal parasite infection among school-aged children in LMIC of Africa and Asia, 2024

Table 3.

Summary of Sensitivity analysis for prevalence of intestinal parasite infection among school-aged children in LMIC of Africa and Asia, 2024

Author (s) and Publication Year	Pooled prevalence	LCI	UCI
Awoke Aschale et.al, 2021 [42]	40.31	34.25	46.37
Saleh Mohammed et.al, 2022 [40]	39.51	33.49	45.54
Gedamu Gebreamlak et.al, 2021 [43]	39.51	33.48	45.54
Ayalew Sisay et.al, 2019 [44]	40.17	34.09	46.25
Shristi Raut et.al, 2021 [45]	39.65	33.59	45.69
Oyono Martin et.al, 2022 [46]	39.34	33.36	45.33
Yasmin. Hussein et.al, 2021 [47]	39.89	33.83	45.96
Bello Musawa et.al, 2020 [48]	40.02	33.96	46.08
Ahmed Alsaifi et.al, 2021 [49]	39.31	33.31	45.32
Yin Ai-Wen et.al, 2022 [50]	39.78	33.72	45.84
Shaimaa Alsamir et.al, 2020 [51]	39.95	33.91	45.99
Adnan Alhindi et.al 2021 [52]	40.29	34.21	46.36
Ayalew Jejaw et.al, 2021 [53]	38.99	33.24	44.74
Asegid Geleta et.al, 2019 [54]	39.79	33.74	45.86
Haytham Mahmoud et.al, 2022 [55]	39.94	33.82	46.07
Raden Bagus et.al, 2021 [56]	39.41	33.39	45.43
Talal Alharazi et.al, 2020 [57]	40.05	33.97	46.13
Jitendra Shrestha et.al, 2019 [58]	40.23	34.14	46.31
Agumas Ayalew et.al, 2019 [59]	39.68	33.62	45.74
Minoo Shaddel et.al, 2024 [60]	40.27	34.21	46.32
Awrajaw Dessie et.al, 2019 [61]	40.01	33.92	46.09
Rizal Subahar et.al, 2020 [62]	40.25	34.20	46.30
Christine Karimi et.al, 2023 [63]	39.85	33.77	45.93
Ahmed Hussein et.al, 2020 [64]	39.44	33.43	45.45
Eshetie Shiferaw et.al, 2022 [65]	39.88	33.80	45.96
Baye Sitotaw et.al, 2020 [66]	39.79	33.72	45.86
Tadesse, Mulumebet et.al, 2019 [67]	40.07	33.98	46.15
Misganaw [69] [68]	39.32	33.34	45.30
Biniyam Sahiledengle et.al, 2020 [69]	40.23	34.17	46.29
Doaa Yones et.al, 2019 [70]	39.43	33.43	45.44
Sintayehu, Shituneh, 2022 [71]	39.84	33.77	45.91
Maqdi. Bayoumi et.al, 2020 [72]	40.48	35.36	45.60
Ranjit Kumar et.al, 2021 [73]	40.42	34.39	46.44
Usip, L.P.E. et.al, 2023 [41]	39.62	33.49	45.75
Naomi Chege et.al, 2020 [74]	40.28	34.23	46.33
Tegenaw Tiruneh et.al, 2021 [75]	39.21	33.24	45.19
Wadhah Hassan et.al, 2022 [76]	39.31	33.31	45.32
Mohammed Suliman et.al, 2019 [77]	39.42	33.41	45.44
Dires Tegen et.al, 2021 [78]	39.30	33.33	45.28
Kibrework Tadesse, 2019 [79]	39.97	33.89	46.05
Boonchai Wongstitwilairoong et.al, 2023 [80]	39.19	33.33	45.06
Melaku Wale et.al, 2022 [81]	39.24	33.29	45.19
Maru Wassie et.al, 2020 [82]	39.39	33.39	45.39
Naomi Mumbi et.al, 2021 [83]	40.31	34.26	46.35
Destaw Damtie et.al, 2021 [84]	39.73	33.66	45.79
Yordanos Gizachew et.al, 2020 [85]	40.13	34.06	46.19
Habtye Bisetegn et.al, 2023 [86]	40.03	33.94	46.12

LCI represents “lower confidence interval” and UCI represents “upper confidence interval”

Small study effect test (Assessment of publication bias)

All forty-seven studies were evaluated for potential publication bias using both visual and statistical methods. The funnel plot (Fig. 6) displayed an asymmetric pattern, suggesting the presence of small study effects. Furthermore, Egger’s regression test confirmed evidence of publication bias, with a statistically significant result (p-value = 0.000) (Table 4). This finding implies that smaller studies with higher or more extreme prevalence estimates may be disproportionately represented in the analysis. As a result, the pooled prevalence could be overestimated. To address this, further statistical adjustments such as the “trim and fill” method are recommended to explore and potentially correct for this bias in the meta-analysis.

Fig. 6.

Funnel plot of the forty-seven studies included in the meta-analysis of the prevalence of intestinal parasite infection among school children in LMIC of Africa and Asia, 2024

Table 4.

Egger’s test of the forty-seven studies included in the meta-analysis of the prevalence of intestinal parasite infection among school children in LMIC of Africa and Asia, 2024

Egger’s test for small-study effect:
Number of studies = 47 Root MSE = 8.643
Std Eff	Coefficient	Std.err	t	P >|t|	[95% conf. interval]
Slope	0.0937335	0.0621342	1.51	0.138	−0.0314111	0.2188782
Bias	12.50501	3.055415	4.09	0.000	6.35109	18.65893
Test of HO: no small-study effects p = 0.000

Trim and fill analysis

Publication bias was observed during the Egger’s test and funnel plot. In response, a trim-and-fill analysis was performed to assess and adjust for this potential bias [87]. However, the results of the trim-and-fill method showed that no additional studies needed to be imputed, and the adjusted pooled prevalence of intestinal parasitic infection among school-aged children in LMICs of Africa and Asia remained unchanged at 39%, consistent with the original meta-analysis (Table 5).

Table 5.

Trim and fill analysis of forty-seven studies included in the meta-analysis of prevalence of intestinal parasite infection among school-aged children in LMIC of Africa and Asia, 2024

Nonparametric trim and fill analysis of the publication bias linear estimator, imputing on the left Iteration Number of studies = 47 Model: Random effect Observed = 47 Method: DerSimonian-Laird Imputed = 0 Pooling Model: Random effect Method: DerSimonian-Laird
Studies	Effect size	[95% conf. interval]
Observed	0.397	0.337	0.457
Observed + imputed	0.397	0.337	.457

This apparent discrepancy can be interpreted in several ways. While the Egger’s test is highly sensitive to asymmetry and can flag small study effects, it may also detect other sources of heterogeneity or chance variation, especially when the number of studies is large. On the other hand, the trim-and-fill method is more conservative and may fail to adjust if the asymmetry is not strong enough or not due to publication bias. Therefore, although statistical indicators suggest a small study effect, the stability of the pooled estimate after trim-and-fill analysis suggests that any bias may not meaningfully influence the overall findings or validity of the meta-analysis. In summary, while small study effects may be present, their impact on the pooled prevalence estimate appears minimal, and the primary conclusions of the study remain robust.

Pooled prevalence of various intestinal parasites among school-aged children in LMICs of Africa and Asia

A variety of intestinal parasites were identified across the included studies, including Entamoeba histolytica, Giardia lamblia, Blastocystis hominis, Cryptosporidium parvum, Endolimax nana, Entamoeba coli, Cyclospora cayetanensis, Pentatrichomonas hominis, Ascaris lumbricoides, Ancylostoma duodenale, Enterobius vermicularis, hookworm, Strongyloides stercoralis, Trichuris trichiura, Hymenolepis nana, Taenia species, and Schistosoma mansoni. Among these, the highest pooled prevalence was reported for Blastocystis hominis and Endolimax nana, both at 16% (95% CI: 9%–24% and 4%–28%, respectively). The lowest prevalence estimates were observed for Pentatrichomonas hominis and Strongyloides stercoralis, each at 1% (95% CI: 0%–1% and 1%–2%, respectively). A detailed summary of the pooled prevalence for each intestinal parasite is presented in Table 6 and Supplementary File 5.

Table 6.

Pooled prevalence of individual intestinal parasites among school-aged children in LMICs of Africa and Asia, 2024

Intestinal Parasite	Pooled prevalence	95% CI	Forest plot supplementary file number
Entamoeba histolytica	15%	13%−18%	Supplementary File 5A
Giardia lamblia	9%	8%−11%	Supplementary File 5B
Blastocystis hominis	16%	9%−24%	Supplementary File 5C
Cryptosporidium parvum	3%	2%−4%	Supplementary File 5D
Endolimax nana	16%	4%−28%	Supplementary File 5E
Entamoeba coli	12%	9%−16%	Supplementary File 5F
Cyclospora cayetanensis	3%	2%−5%	Supplementary File 5G
Penta trichomonas hominis	1%	0%−1%	Supplementary File 5H
Ascaris lumbricoides	11%	9%−12%	Supplementary File 5I
Ancylostoma duodenale	4%	1%−8%	Supplementary File 5 J
Enterobius vermicularis	3%	2%−3%	Supplementary File 5 K
Hookworm	5%	4%−7%	Supplementary File 5L
Strongyloides stercolaris	1%	1%−2%	Supplementary File 5 M
Trichuris trichiura	3%	2%−4%	Supplementary File 5N
Hymenolepis nana	5%	4%−7%	Supplementary File 5O
Taenia spp	2%	1%−2%	Supplementary File 5P
Schistosoma mansoni	5%	3%−6%	Supplementary File 5Q

Pooled prevalence of protozoan and helminthic intestinal parasites among school-aged children in LMICs of Africa and Asia

The pooled prevalence of intestinal parasitic infections varied by parasite type. Protozoan parasites had a higher pooled prevalence of 29% (95% CI: 22%–36%) compared to helminths, which had a pooled prevalence of 19% (95% CI: 14%–24%). Mixed infections involving both protozoan and helminthic parasites showed a lower pooled prevalence of 2% (95% CI: 1%–3%). These findings are summarized in Table 7 and detailed further in Supplementary File 6.

Table 7.

Pooled prevalence of protozoan and helminth parasites among school children in LMIC of Africa and Asia, 2024

Intestinal Parasite	Pooled prevalence	95% CI	Forest plot supplementary file number
Protozoan parasite	29%	22%−36%	Supplementary file 6A
Helminthes	19%	14%−24%	Supplementary file 6B
Both	2%	1%−3%	Supplementary file 6C

Pooled prevalence of single and multiple intestinal parasitic infections among school-aged children in LMICs of Africa and Asia

Intestinal parasitic infections were further categorized based on the number of concurrent infections into single, double, triple, and quadruple infections. The pooled prevalence varied accordingly, with the highest observed in single infections at 37% (95% CI: 31%–43%). In contrast, quadruple infections had the lowest pooled prevalence at 1% (95% CI: 0.00%–1%). These findings are presented in Table 8 and detailed in Supplementary File 7.

Table 8.

Pooled prevalence of single and multiple intestinal parasitic infections among school-aged children in LMICs of Africa and Asia, 2024

Intestinal parasite infection	Pooled prevalence	95% CI	Forest plot supplementary file number
Single infection	37%	31%−43%	Supplementary file 7A
Double infection	10%	8%−12%	Supplementary file 7B
Triple infection	3%	2%−4%	Supplementary file 7C
Quadruple infection	1%	0%−1%	Supplementary file 7D

Factors associated with intestinal parasite infection among school-aged children in LMICs of Africa and Asia.

Several socio-demographic, behavioral, and environmental factors were identified as associated with intestinal parasite infection (IPI) among school-aged children. These included sex, grade level, school type, residence, parental education and occupation, family size, social status, nail hygiene, hand washing practices, swimming and water contact habits, availability of soap, presence of domestic animals, waste disposal, soil contact, dietary habits, shoe wearing, water source, and knowledge about IPI and prevention.

The pooled effect estimates are presented in Table 9, highlighting that male children, younger grades, rural residence, children of less-educated parents, larger families, poor hygiene practices, certain environmental exposures, and risky behavioral habits were associated with higher odds of IPI. Some factors, such as school type, domestic animals, and the habit of finger sucking.

Table 9.

Identified associated factors of IPI among school-aged children in LMIC of Africa and Asia, 2024

Variable (Reference)		Number of studies	Effect size (POR with 95% CI)	Heterogeneity
				I2	P-value
Sex (Female)		29	1.113 (1.029–1.203)	0.0%	0.997
Grade (5–8)		10	1.246 (1.021–1.521)	24.8%	0. 215
School type (Private)		4	1.036 (0.520–2.064) *	76.2%	0.006
Residence (Urban)		8	1.211 (1.028–1.426)	0.0%	0.855
Mother’s education (secondary and above)	Illiterate	11	1.389 (1.159–1.664)	0.0%	0.502
	Primary school	11	1.154 (0.950–1.402)	0.0%	0.953
Father’s education (secondary and above)	Illiterate	9	1.126 (0.912–1.39)	0.0%	0.891
	Primary school	9	0.950 (0.776–1.164)	0.0%	0.965
Parents’ occupation (employed)	Farmer	6	1.240 (0.905–1.698)	0.0%	0.691
	Business	6	1.114 (0.781–1.587)	0.0%	0.994
	Other	6	1.127 (0.804–1.580)	0.0%	0.877
Social status (moderate and high)		3	1.473 (0.783–2.770) *	70.2%	0.035
Family size (< 5)		14	1.253 (1.060–1.480) *	42.3%	0.048
Nail cleanness (Yes)		9	1.334 (1.141–1.559)	0.0%	0.630
Trimmed Nail (Yes)		10	1.312 (1.078–1.597)	12.4%	0.329
Hand washing after defecation (Always)		13	1.272 (1.087–1.489)	0.0%	0.973
Hand washing before a meal (Always)		12	1.485 (1.215–1.816)	32.4%	0.131
Swimming habit (No)		3	1.506 (0.966–2.348)	63.9%	0.063
Playing with water (No)		2	1.716 (1.448–2.034)	0.0%	0.361
Soap availability for washing hands (Yes)		2	0.856 (0.631–1.160)	0.0%	0.737
Domestic animals (No)		6	1.264 (0.818–1.955) *	74.0%	0.002
Waste disposal (Burry or burning, or proper collection)		6	1.060 (0.876–1.282)	0.0%	0.930
Habit of playing with soil (No)		5	1.296 (0.868–1.935)	50.1%	0.091
Habit of eating while playing (No)		2	2.148 (1.351–3.414)	0.0%	0.361
Habit of sucking finger (No)		4	1.545 (0.892–2.675) *	67.4%	0.027
Habit of playing barefoot (No)		3	1.235 (0.919–1.659)	0.0%	0.508
Eating raw vegetables (NO)		9	1.214 (1.006 −1.465)	0.0%	0.570
Eating raw meat (NO)		10	1.129 (0.966–1.320)	0.0%	0.545
Geophagia (No)		2	1.173 (0.722–1.907)	0.0%	0.814
Shoe-wearing habit (Regularly)		14	1.464 (1.164–1.842)	54.2%	0.08
lake water for bathing (NO)		2	1.007 (0.576–1.759)	0.0%	0.498
Defecation area (latrine)		16	1.236 (1.050–1.455)	20.9%	0.216
Washing vegetables before consumption (Yes)		3	0.965 (0.625–1.490)	0.0%	0.684
Washing fruits before consumption (Yes)		4	1.553 (1.042–2.313)	23.9%	0.268
Drinking Water (Treated)		4	1.284 (0.939–1.756)	0.0%	0.756
Specific water source (Tap water)	Well/Spring water	6	1.226 (0.857–1.753)	17.3%	0.301
	Borehole/Groundwater	4	0.967 (0.716–1.305)	0.0%	0.704
	Stream/river/dam/rain water/lake	5	1.473 (0.899–2.413)	36.6%	0.177
Hand washing (with soap and water)		2	1.405 (0.876–2.253)	0.0%	0.558
Hand washing habit (Regularly)		3	1.081 (0.775–1.508)	0.0%	0.846
Water source (Protected)		4	1.143 (0.868–1.506)	0.0%	0.929
Knowledge about intestinal parasite infection (Yes)		2	0.927 (0.668–1.286)	0.0%	0.692
Parents' knowledge about the prevention of intestinal parasites (Yes)		3	1.180 (0.923–1.509)	0.0%	0.692
Source of food (Home)		2	0.695 (0.427–1.133)	0.0%	1

, also showed notable associations. Detailed effect sizes, confidence intervals, and heterogeneity measures are provided in the table. Variables reported in.

only one study such as effect of fishing habit, water treatment before consumption, children’s knowledge about WASH, water access, irrigation practice, consumption of street food, deworming drug in the past 6-month, past parasite infection, environment cleanness, ground water for bathing, eating by finger/fork were not pooled (Table 9) (Supplementary file 8).

Discussion

This review focuses on LMICs in Africa and Asia, where the burden of intestinal parasitic infections is highest due to high exposure risk from inadequate sanitation, limited health access, and socioeconomic vulnerability. The findings of this study revealed the pooled prevalence of IPI among school-aged children in LMIC. The current study gathered relevant information from 47 studies. A total of 20,334 schoolchildren were examined for intestinal parasite infection. The included studies' prevalence rates of IPI in the LMIC of Africa and Asia in School-aged children varied widely.

The overall pooled prevalence of IPI among school-aged children was 39% (95% CI: 33, 45). This finding was in line with a systematic review conducted in Ethiopia (33.35%) [88] and Iran(38%) [89]. On the other hand, a systematic review studies that showed higher prevalence than our findings were done in Guinea (52%) [90], Colombia (55%) [91], Ethiopia (53.64%) [92] and Brazil (46%) as well as a recent meta-analysis from Egypt, which reported a pooled prevalence of at least one IPI at 46.5% [93]. The pooled prevalence of this study was less than the findings of a systematic review conducted in Nepal (20.4%) [94] and Africa (25.8%) [95]. This difference could be due to poor hygiene, given that the disease is transmitted via food, water, and fingers that are contaminated with feces, environmental conditions, and socioeconomic status that vary between and within the countries, and different detection methods, personal and cultural habits.

Our study demonstrated a higher pooled prevalence of intestinal parasitic infections (IPIs) among school-aged children in Africa (41%) compared to Asia (35%), highlighting notable regional disparities. This difference may be attributed to several contextual factors, including sanitation coverage, access to clean water, education, and implementation of deworming programs. Prior research supports this regional contrast; a global meta-analysis by Pullan et al. [97] estimated a higher prevalence of soil-transmitted helminths in sub-Saharan Africa compared to South and Southeast Asia due to differences in socioeconomic conditions and hygiene infrastructure [96]. Similarly, a systematic review by Belay et al. (2022) reported that the prevalence of intestinal protozoan infections among African children reached up to 42%, consistent with our findings, while studies from South and Southeast Asia generally report lower Figs. [97]. The higher burden in Africa may reflect challenges such as limited access to sanitation and health services, especially in rural communities. In contrast, some Asian countries have made substantial progress in school-based deworming, hygiene promotion, and clean water supply, which may have contributed to the comparatively lower prevalence. Nevertheless, heterogeneity remains high within each continent, as shown by the wide confidence intervals and high I² values, suggesting significant variability even within sub-regions. These findings underscore the need for targeted public health interventions, particularly in African settings, and context-specific strategies to control and eliminate IPIs among school-aged children.

Furthermore, subgroup analyses of diagnostic methods reflect patterns seen in other reviews. In one analysis, studies using combined Kato-Katz techniques reported significantly higher prevalence estimates than those using only wet mount or formol-ether methods, indicative of higher sensitivity [98]. Similarly, analyses of strongyloidiasis in Africa demonstrated that combining techniques such as FECT and PCR yielded markedly different prevalence rates than microscopy alone [99]. Our own results, where prevalence was highest with microscopy plus concentration (43%) and lowest with enhanced methods (26%), support the consistent finding that diagnostic method influences reported prevalence.

While our subgroup analyses by continent, sub-continent, and diagnostic method helped reveal geographic and methodological variation, a substantial level of heterogeneity (I² ≈ 99%) persisted across all strata. This finding mirrors previous meta-analyses of intestinal parasitic infections. For instance, studies in Ethiopia found I² values exceeding 98% even after stratifying by diagnostic technique and region [100]. This suggests that unmeasured factors such as variations in study setting (e.g., rural vs. urban), sample size, socioeconomic conditions, or sanitation infrastructure likely contribute to the residual heterogeneity. Due to the limitation of such information in the included studies, our ability to disentangle other sources of heterogeneity was limited, which is a common challenge in meta-analyses relying on published aggregate data.

This study identified Blastocystis hominis (16%), Endolimax nana (16%), Entamoeba histolytica (15%), Entamoeba coli (12%), and Ascaris lumbricoides (11%) are among the most prevalent parasites among school-aged children. These prioritized parasites were also identified in a study conducted in Slovakia [101], Ethiopia [95], Brazil [102], Thailand [103, 104], Iran [105], and Colombia [106]. Differences in the degree of contamination of drinking water sources, consumption of raw or unwashed vegetables, hand hygiene practices, shoe-wearing habits, socioeconomic status, and personal behaviors such as finger-sucking may account for variations in prevalence across studies. Notably, Blastocystis hominis was the most frequently detected parasite. This could be attributed to its widespread distribution in both developed and developing regions, its capacity for asymptomatic carriage, and its transmission through multiple routes, including contaminated water and food. Blastocystis is known for its high environmental resilience, especially in areas with inadequate sanitation infrastructure, and it is frequently detected even in healthy individuals, making it one of the most common intestinal protozoa globally [107]. Furthermore, school-aged children are particularly vulnerable to Blastocystis infection due to their close contact in school settings, limited hygiene awareness, and increased exposure to contaminated food and water sources. In some cases, Blastocystis may even co-exist with other intestinal pathogens, suggesting a potential role in polymicrobial infections, although its pathogenicity remains under debate [108]. Given its high prevalence Blastocystis hominis should not be overlooked in public health monitoring, and further investigation is warranted to understand its clinical significance, transmission dynamics, and potential for intervention.

The pooled prevalence of protozoan parasites (29%), helminths (19%), and mixed infections (2%) revealed that protozoan infections were the most prevalent among school-aged children in LMICs of Africa and Asia. The prevalence of protozoan parasites was higher compared to other pathogens. This finding was supported by studies conducted in Nepal [109, 110], Thailand [111], Yemen [112], Kenya [113], and Ethiopia [114]. However, this finding contradicts the findings of a study conducted in Ethiopia [115] and Nepal [116]. One potential explanation for the higher prevalence of protozoans is their resistance to routine deworming programs, which typically target helminths rather than protozoan parasites. Albendazole and mebendazole, commonly used in mass drug administration (MDA) campaigns, are ineffective against protozoans such as Giardia lamblia and Entamoeba histolytica [117]. Additionally, protozoan cysts, particularly those of Giardia and Cryptosporidium, are resistant to conventional chlorination used in drinking water treatment [118]. This resilience allows protozoa to survive in treated water and continue transmission through fecal–oral routes. Unlike helminths, which have longer life cycles and may require weeks to months before shedding eggs post-infection or deworming, protozoan trophozoites and cysts are shed in feces almost immediately, allowing rapid transmission in communities with poor sanitation [119]. Furthermore, the relatively lower prevalence of helminths may be attributed to effective and sustained biannual deworming programs, vitamin A supplementation, and school-based MDA initiatives across several LMICs. These programs commonly use single-dose albendazole, which has demonstrated efficacy in reducing soil-transmitted helminth (STH) burdens in endemic areas [120].

Moreover, single (37%), double (10%), triple (3%), and quadruple infection (1%) were different kinds of infection that have been observed among school-age children in the world. This order was supported by a study conducted in Turkey [121], Ghana [122], and Ethiopia [123]. However, it contradicts a study conducted in Colombia [124] where the prevalence of double and triple infection is higher than compared of single infection. These infections of intestinal parasites can be influenced by a complex interplay of factors related to transmission dynamics, host-parasite interactions, environmental conditions, and diagnostic practices. The initial transmission of a single parasite to a host is often easier than multiple parasites simultaneously infecting the same host. Diagnostic techniques may be more sensitive in detecting single infections as compared to multiple infections. As a result, single infections may appear more prevalent.

School-aged children attending public school were 1.036 times more likely to have IPI as compared to private school-aged children. This finding is supported by a study conducted in Nepal [125]. The higher positive rate among public school children as compared to private school-aged children might be due to low socio-economic status, overcrowding, poor infrastructure, poor hygienic habits, lack of sanitation prevailing in the school, and a high number of students in the class.

The intestinal parasite infection among school children with poor social status has a 1.473 times higher chance of developing the case than those have moderate and high economic statuses. This finding is supported by a study conducted in Kenya [126]. The economic development resulted in further improvements in the sanitation conditions, such as infrastructures, education, incomes, water and food quality, vector control, and sewage and waste disposal, which favor lower odds of intestinal parasites in school children from families who have moderate and high economic statuses.

The present study showed that family size was strongly associated with intestinal parasitic infection. The likelihood of being infected by intestinal parasites was increased by 1.253-fold among students belonging to a family size of above 5, as compared with students belonging to a small family size. The present finding is in agreement with other studies conducted in Iran [127], Saudi Arabia [128], and Ethiopia [129]. An increase in family size may lead to issues with undernourishment, poor personal hygiene, inadequate sanitation, and overcrowding, which may facilitate the spread of parasites and make family members more vulnerable to parasite diseases.

Schoolchildren who live in a house with a domestic animal have a 1.264 times higher chance of developing intestinal parasite infection. This finding is supported by a study conducted in Nepal [130], Iran [131], India [132], Burkina Faso [133], Ghana [122], and Ethiopia [134], which also determined the association of domestic animals with intestinal parasite infection. This could be since increased physical proximity to domestic animals like pets leads to the transfer of parasites. Pets can shed parasite eggs or cysts in their feces which can contaminate surfaces in the home, if these surfaces aren't properly cleaned and sanitized children’s can inadvertently ingest the parasites by touching contaminated objects or surfaces and then touching their mouths. In addition, domestic animal licking or grooming themselves that can transfer parasites to their fur. When humans interact closely with pets, they can come into contact with these parasites, increasing the risk of infection.

School-aged children who had the habit of sucking their fingers had about 1.545 times higher chances of being infected with IPIs compared with the school children who did not have the habit. The finding of this study is supported by studies conducted in Ethiopia [135, 136], Western Nigeria [137], Nepal [23], and China [138]. Children who suck could explain this; their fingers may inadvertently touch surfaces or objects contaminated with parasite eggs or cysts, such as playground equipment. By putting their fingers in their mouths, they can then ingest these parasites, increasing the likelihood of infection.

The methodological quality of the included studies, as assessed using the Newcastle–Ottawa Scale (NOS), varied across studies. While most studies met criteria for selection and comparability, notably, a substantial proportion of the included studies employed cross-sectional designs, which constrain the ability to establish causal relationships. Additionally, some studies had relatively small sample sizes, potentially limiting statistical power and the generalizability of findings. These methodological constraints should be considered when interpreting the pooled estimates and underscore the need for more rigorously designed studies to strengthen the evidence base.

Conclusions and recommendations

This systematic review and meta-analysis demonstrated a notably high pooled prevalence (39%) of intestinal parasitic infections (IPIs) among school-aged children in low- and middle-income countries (LMICs) of Africa and Asia, with marked variation across regions and diagnostic approaches. Subgroup analyses by continent, sub-continent, and diagnostic method helped reveal geographic and methodological variation; however, a substantial level of heterogeneity (I² ≈ 99%) persisted across all strata. Protozoan parasites were more frequently identified (29%) than helminths (19%), with Blastocystis hominis (16%), Endolimax nana (16%), Entamoeba histolytica (15%), Entamoeba coli (12%), and Ascaris lumbricoides (11%). Single infections (37%) were significantly more prevalent than co-infections (double (10%), triple (3%), and quadruple (1%)) infections. Identified risk factors, including low socioeconomic status, larger family size, contact with domestic animals, and poor personal hygiene behaviors, highlight the multifactorial nature of transmission.

To mitigate the high burden of IPIs in the regions studied, we recommend the implementation of school-based intervention programs that include biannual mass deworming, health education curricula on hygiene and sanitation, routine screening, and targeted WASH (Water, Sanitation, and Hygiene) improvements. Furthermore, investigations into the potential role of domestic animals in disease transmission warrant immediate attention. Additionally, strengthening diagnostic capacity and community-based surveillance systems, especially in underserved settings, will be essential for early detection and sustained control. By informing evidence-based interventions and guiding resource allocation, this study can make a significant contribution to reducing the burden of IPIs and improving the overall health and well-being of school-aged children in LMICs of Africa and Asia. Future research should consistently report key contextual variables such as diagnostic protocols, water quality, and sanitation infrastructure to better understand and explain the underlying heterogeneity and to inform more tailored public health responses.

Strengths and limitations of the study

This systematic review and meta-analysis offer important evidence on the pooled prevalence and associated risk factors of intestinal parasitic infections among school-aged children in low- and middle-income countries (LMICs), particularly across Africa and Asia. Its comprehensive approach, including subgroup analyses by region and diagnostic methods, enhances understanding of both geographic and methodological variability.

However, several limitations should be considered. First, restricting the inclusion criteria to English-language publications may have led to language bias, potentially omitting relevant studies published in other languages. Second, the analysis was based solely on observational studies, which are inherently susceptible to residual confounding and may limit the ability to infer causality. Third, some included studies had small sample sizes, which could affect the robustness and generalizability of the pooled estimates. In addition, variability in diagnostic methods, inconsistent reporting of environmental and sociodemographic factors, and the lack of standardized outcome definitions across studies may have contributed to the high heterogeneity observed. While we used the DerSimonian-Laird random-effects model to pool prevalence estimates and Egger’s test to assess publication bias, it is important to acknowledge that these methods may underestimate between-study heterogeneity and have limited reliability when the number of studies is small or heterogeneity is substantial. These limitations should be considered when interpreting our pooled estimates. Future research should aim to address these gaps by expanding geographic coverage, including non-English language sources, and promoting standardized reporting of risk factors and diagnostic protocols.

Abbreviations

CI

Confidence interval

IPI

Intestinal parasite infection

LCI

Lower confidence interval

LMIC

Low- and middle-income countries

POR

Pooled odds ratio

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

spp.

Species

UCI

Upper confidence interval

Author’s contributions

G.Y. was involved in the conceptual development, data abstraction, selection, review of articles, and report writing. L.D., T.K., H.B, K.C.A., E.A.A., Z.G., and F.G. were involved in the data extraction, data analysis, and writing of the manuscript. G.Y., A.H., D.A., and L.D. were involved in guiding the work and manuscript writing. All the authors read and approved the final manuscript.

Funding

This study did not receive any funding.

Data availability

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no conflicts of interest.