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

School-related risk factors for tungiasis among children aged 8 to 14 years in nine counties of Kenya: a cross-sectional survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article School-related risk factors for tungiasis among children aged 8 to 14 years in nine counties of Kenya: a cross-sectional survey Lynne Elson, Christopher Kamau, Sammy Koech, Christopher Muthama, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5070518/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract 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. Tungiasis NTDs schools sanitation WASH Figures Figure 1 Background Tungiasis is a skin disease mostly affecting children under 15 years, the elderly and disabled people in the most resource poor populations in Latin America and Sub-Saharan Africa[1]. It has been neglected by governments, donors, and the scientific community to this day, and was only recently added to the World Health Organization’s list of neglected tropical disease[2] and neglected diseases of the skin [3].Due to this neglect, the global burden of tungiasis is unknown. Surveys have been conducted in endemic countries, but all specifically targeted villages known to be affected, where the prevalence ranged from 7 in a village in Kenya to 63% in the Karamoja region of northeastern Uganda [4, 5]. The current study is nested within the only country-level, randomized survey conducted to-date to estimate the national prevalence of tungiasis, which found the prevalence among school children aged 8 to 14 years in nine counties in Kenya in 2021 was 1.35% [6]. The prevalence across the Kenya was heterogeneous with county-level prevalence ranging from 0.08 to 3.2% and the school-level prevalence ranged from 0.9 to 22%. Tungiasis is caused by the sand flea, Tunga penetrans. The female of this species burrows into the skin of both humans and animals, where it remains embedded for the duration of its five-week adult life, unless removed by its host [7]. The dead flea carcass is expelled from the skin by natural skin-regeneration processes [7]. The flea is less than 1mm in length when it seeks out its host, once in the skin it copulates with the free-living male flea and grows 2000 times in size as eggs develop in the abdomen. Hundreds of eggs are released into the environment, where larvae will hatch and develop in the upper layer of soil and dust if conditions are suitable. After one week the larvae pupate, cloaking themselves in sand grains, and after one more week the adult emerges [8]. The rapid growth of the embedded female in the skin causes considerable pain and the flea induces an inflammatory response resulting in intense itching, often exacerbated by secondary bacterial infection [9, 10]. A few studies have demonstrated tungiasis reduces a patient’s quality of life through reduced mobility, disturbed sleep, concentration at school or work, stigma and discrimination [11, 12]. It was also shown that tungiasis was associated with higher absenteeism and lower school performance [11]. Identifying the major sources of infection and associated risk factors is important to guide the development of prevention interventions and policies. Previously people’s own homes have been identified as the most likely source of infection due to two major factors; firstly the most common risk factor identified in multiple studies in Brazil and Sub-Saharan African countries is sleeping in a house with an earthen floor [13, 14] and secondly the flea larvae are mostly found in the soil floors of sleeping rooms [15]. Other risk factors identified include people’s socioeconomic status and behaviors including not wearing closed shoes [16], not washing feet frequently with soap [17] and the ownership of dogs [13] or pigs [18]. As part of the national prevalence survey in Kenya, school pupils were interviewed to assess their risk factors and found tungiasis was associated with male sex, low socio-economic status, not washing their feet twice a day and never using soap to wash their feet [6]. Although endemic communities and local health officials often suggest schools are the source of infection (anecdotal reports), no study has been conducted to assess the school environment. This is surprising since the most affected population are school-aged children (six to 15 years) and it might be expected that schools, which have a high density of children for a large proportion of each day, may contribute to the risk of infection. Consequently, the objective of the current study was to determine whether any aspects of the school environment may be associated with tungiasis infection among pupils aged 8-to-14 years, and also to explore headteachers’ and teachers’ knowledge and attitudes relating to risk factors for, and the impact of tungiasis on their pupils. Methods Study design and population This study used a mixed methods approach to compare school-related risk factors for infected and uninfected pupils selected from nine counties across Kenya. The study was nested in a cross-sectional survey in the nine counties which was designed to determine the national prevalence of tungiasis in Kenya as described previously [6, 19]. The nine counties were purposively selected to be as representative of the whole country as possible, including the five major ecological zones of the country: very arid (Turkana), arid (Samburu and Taita Taveta), semi-arid (Makueni, Kajiado and Kilifi), semi-humid (Nakuru) and humid (Kericho, Muranga). The selections within ecological zones were also conducted to ensure representation of a geographic cross-section of the country and to include multiple cultural groups including nomadic pastoralists (the Masai, Samburu, Turkana) and farmers (the Mijikenda, Taita, Kikuyu, Kamba, Kalenjin). Sample size and selection The number of pupils and schools to enrol was based on the sample size of pupils needed for the national prevalence estimate a total of 11,010 pupils spread across the nine counties which was repeated in a second phase, as described previously [6]. Within each of the nine counties 22 primary schools were stratified randomly selected from pre-existing school lists for each sub-county, selecting at least two schools from each sub-county. The schools were surveyed in two phases, 11 schools between April and June 2021 and 11 different schools between September 2021 and April 2023. Within each selected school, 114 pupils aged 8 to 14 years, were quasi-randomly selected, by asking the pupils to assemble in three age groups; 8 and 9 years; 10 and 11 years; 12 to 14 years, and by gender within each age group. For each of these age/gender groups, every n th pupil (n = total number in the group/ 19) was selected until 19 were selected, giving a total of 114 pupils overall. All selected pupils gave verbal assent and were examined for tungiasis [6]. Examinations were conducted by non-clinical field officers who were trained by the principal investigator to identify embedded fleas: a round white lesion with a dark spot at the center (live); a black, irregular-shaped lesion (dead); or a lesion from where a flea had clearly been removed (manipulated). Procedures Observations were conducted of the school infrastructure including the composition and structural condition of buildings, washing and sanitation facilities, and the presence of animals on the compound. In the second phase of the survey, observations were also made of individual classrooms: measuring the length and width of the classroom, obtaining enrolment and absentee numbers for the day of the visit, the materials used for construction, the condition of the classroom floor and building and the amount of loose soil on a concrete floor. In every school, the headteacher or their representative, and during the second phase of the survey up to eight teachers per school were interviewed, using a semi-structured questionnaire regarding themselves, the school and pupil welfare. Headteachers and teachers who said they currently or previously had tungiasis cases in the school were asked questions about their knowledge and attitudes of tungiasis and infected pupils. Where questions were open, limited space was provided for responses. The tool was piloted, and necessary adjustments were made before implementation. The questionnaire was pre-translated and administered in Kiswahili. The field interviewers were trained by the lead investigator. All interview responses were entered into electronic tablets using the REDCap web application [20] and uploaded to the Kenya medical Research Institute (KEMRI)-Wellcome Trust servers. Explanatory variables School and classroom factors The selection of explanatory variables for the regression models was based on the biology of the parasite. For instance, buildings in poor structural condition, unsealed earthen floors, concrete floors that are broken/ cracked and/ or covered with loose soil or dust and general poor cleanliness might be expected to support the development of off-host stages of T. penetrans . All of the variables were subjective measures: structural condition of buildings was categorized as poor, average or good. The general cleanliness of the compound and classrooms was a binary response, “were the compound and classrooms clean, yes or no?”. The measure for classroom floor condition was categorized as good, slightly cracked or very broken up and the amount of loose dust or soil on a hard floor was categorized as none, a little or a lot. The cleanliness of the classroom was categorized as tidy and clean, slightly tidy and clean or very untidy and dirty. The presence of animals was observed as animals have previously been shown to be a risk factor for infection [13, 18], either through being infected themselves and dropping sand flea eggs into the environment or through their feces providing organic matter for the larvae to feed on. Verbal descriptions of the subjective measures were used to train the field teams. Inter-observer variability was not assessed. Previously it has been shown that adult female fleas can jump from one heavily infected host to another in proximity [21], so we included the total pupil enrolment in a school and the density of pupils in a classroom. We also collected the number of pupils absent on the day of the visit since this could reflect a situation in the school which caused children to be absent, that could have been associated with a child who was present being infected. Past studies have identified factors relating to hygiene and sanitation to be associated with disease, therefore access to water, washing stations, presence of hygiene promotion signs, access to toilets and the condition of toilets were included in the observations. (Head) teacher-related factors The attitudes of headteachers and teachers towards pupil welfare were explored as they could potentially impact the vulnerability of pupils for infection. In this context, questions were asked about the supervision of pupil hygiene behaviors and shoe-wearing, the actions taken if pupils do not match the school standards, and whether regular hygiene promotion, deworming or jigger programs were conducted. Since county of residence, pupil age and sex have previously been shown to be important factors associated with tungiasis in this study [6], these were also included in the models. Data Analysis School and classroom-related risk factors The outcome of interest for the risk factors was a pupil’s infection status defined as a tungiasis case if they had at least one embedded flea (live, dead or manipulated) on their hands or feet, and uninfected otherwise. Mixed effects logistic regression models were used to identify factors related to the school and classrooms that may be associated with pupils’ tungiasis infection status (pupil infected or not). Fixed effects included the county, pupil age and sex, school and classroom characteristics described in the observations paragraph above. The subjective measures with three categories were collapsed into two. The school unique identifier was used as a random effect to adjust for the clustered study design. The county unique identifier was also used as a random effect, to adjust for any inter-observer variability between the county teams, particularly for the subjective measures of classroom cleanliness, building condition and amount of soil on concrete floors. All variables with a p-value less than 0.2 in univariable models were included in a multivariable model. Backward elimination, sequentially excluding variables was used to obtain the final model. Akaike information criteria (AIC) was used to compare the models. Models with lower AIC values were preferred. Additional consideration on variable selection was expert knowledge on potential relationships with the outcome. Given the large number of variables explored which could have increased type I-error we also used Wald tests to guide variable selection in the models. Results are presented as odds ratios or adjusted odds ratios with 95% confidence intervals and p-values. Missing responses were analyzed under the “missing at random” assumption [22] since none included in the multivariable models were missing more than 5% of the observations (Additional files S1 and S3), and the final models included no less than 97% of the observations. Headteacher and teacher interviews Pearson Chi-square was used to test whether headteachers’ awareness of the tungiasis status of pupils (said yes to question “are there any tungiasis cases in your school”) was different to the actual status established during foot examinations. The same was conducted for teachers’ awareness of tungiasis cases in the grade that they taught most of the time. The sensitivity and specificity, positive predictive value and negative predictive value of teachers and headteachers awareness was also calculated. Wilcoxon rank-sum tests were used to test whether their awareness was related to the prevalence of tungiasis in their school. The remaining responses were summarized using the percentage of respondents who gave each response type. Responses to open questions were analyzed manually assigning codes to themes and summarizing as percent of respondents who gave each response. All analyses were conducted using Stata BE version 18 (Stata Corp LLC, College Station, Texas, USA). All tests were performed at 5% significance level. No qualitative analysis software were used. Results Study population A total of 196 schools were enrolled in the study, and 21,466 pupils were examined, of whom 242 (1.1%) were found to be infected. The infected pupils were from 76 schools (“affected schools” in Fig 1). In all 196 schools, observations were made of the school infrastructure and enrollment records and headteachers or their representatives were interviewed. In the second phase of the survey, 97 schools were enrolled, 35 of whom had tungiasis cases, detailed observations were made of 322 classrooms, and 117 teachers were interviewed (Fig 1). Within the 76 affected schools, the school prevalence of tungiasis varied from a low of 0.8% to a high of 22.3% among pupils aged 8 to 14 years. The distribution of pupils by all explanatory variables is presented in the Additional file S1. Figure 1. Flow chart of participants and activities. A school was considered “affected” if at least one case was identified during examinations of 114 randomly selected pupils aged 8 to 14 years. n: number. “Tungiasis responses” refers to the number of headteachers or teachers who responded to questions regarding tungiasis in the interview. School-related risk factors During univariable analysis, many of the observed factors were associated with tungiasis (Table 1) and were included in the multivariable analysis. In the final model, pupil age and sex were associated with tungiasis status and only a few school factors. Several of the factors were retained in the final model despite having a p-value slightly higher than 0.05, based on the 95% confidence interval, AIC and Wald test results which indicated they play a role in the model. Pupils had twice the odds of infection in a day school rather than a mixed day and boarding school (aOR 2.57, 95% CI 0.99-6.66, p=0.052) ; the 40% of schools who had more than 400 pupils enrolled (aOR 2.17, 95% CI 1.14-4.14, p=0.018); the 40% of schools where clean water was not always available (aOR 2.15, 95% CI 1.15-4.01, p=0.016). Although only 3.6% of pupils were in schools where the buildings were not clean, they had a nearly four times higher odds of infection (aOR 3.93, 95% CI 0.92-16.69, p=0.064) . Half (50.8%) of all pupils were in schools where the buildings were in poor structural condition and they had a higher odds of infection (aOR 1.83, 95% CI 0.96--3.50, p=0.066). The intra-class coefficient for county was 0.04 (95% CI 0.01-0.24) and for the schools it was 0.41 (95% CI 0.31-0.53). Table 1. Mixed effects logistic regression of school-related factors for tungiasis infection in pupils, county and school as random effect (n=21,465, 242 cases). Univariable Full multivariable (n=19277) Final multivariable (n=21021) Variables Categories N (%) 1 % pupils infected OR 2 (95% CI 3 ) P 4 aOR 5 (95% CI) P aOR (95% CI) P Pupil age (years) 21466 (100) 1.1 0.81 (0.76-0.87) <0.001 0.82 (0.76-0.88) <0.001 0.82 (0.76-0.88) <0.001 Pupil sex Female 10889 (50.7) 0.8 1 1 1 Male 10576 (49.3) 1.5 1.98 (1.51-2.61) <0.001 1.96 (1.47-2.60) <0.001 1.91 (1.45-2.53) <0.001 School type Private 1854 (8.6) 0.2 1 1 Public 19612 (91.4) 1.2 5.96 (1.23-28.75) 0.026 2.86 (0.56-14.67) 0.207 School location Urban 3554 (16.6) 0.7 1 Rural 17912 (83.4) 1.2 1.26 (0.55-2.90) 0.586 School structure Mixed 6 4067 (18.9) 0.9 1 1 1 Day only 17399 (81.1) 1.2 2.69 (1.03-7.07) 0.044 1.48 (0.52-4.26) 0.463 2.57 (0.99-6.66) 0.052 Total enrolment ≤400 12907 (60.1) 0.9 1 1 1 >400 8559 (39.9) 1.5 1.59 (0.84-3.02) 0.154 1.78 (0.90-3.53) 0.095 2.17 (1.14-4.14) 0.018 Boy: girl ratio 21356 (99.5) 1.1 2.91 (0.78-10.90) 0.113 1.97 (0.46-8.51) 0.362 Condition of toilets Good 6751 (31.5) 0.8 1 1 Not good 14271 (66.5) 1.3 2.37 (1.13-4.96) 0.022 0.97 (0.43-2.20) 0.942 Clean water available Always 12656 (59.0) 0.8 1 1 1 Not always 8589 (40.0) 1.5 2.58 (1.37-4.79) 0.003 1.81 (0.95-3.47) 0.073 2.15 (1.15-4.01) 0.016 Handwashing stations on compound No 3257 (15.2) 1.0 1 Yes 18209 (84.8) 1.2 1.02 (0.42-2.48) 0.958 Hygiene promotion signs on compound Yes 13200 (61.5) 0.9 1 1 No 8266 (38.5) 1.4 1.84 (0.96-3.53) 0.066 0.88 (0.45-1.71) 0.700 Classrooms clean Yes 20697 (96.4) 1.1 1 1 No 769 (3.6) 2.7 4.46 (1.00-19.84) 0.050 3.55 (0.81-15.53) 0.093 3.93 (0.92-16.69) 0.064 Condition of building Good 10342 (48.2) 0.8 1 1 1 Not good 10902 (50.8) 1.5 2.31 (1.19-4.49) 0.013 1.50 (0.73-3.09) 0.275 1.83 (0.96-3.50) 0.066 Headteacher age 21393 (99.7) 1.1 1.02 (0.99-1.07) 0.333 Conduct Income generating activity Yes 4009 (18.7) 0.6 1 1 No 17457 (81.3) 1.3 2.01 (0.83-4.91) 0.124 1.43 (0.59-3.43) 0.426 Check pupils washed No 606 (2.8) 0.3 1 Yes 20752 (96.7) 1.2 3.04 (0.36-25.76) 0.308 Action if not washed Wash at school 7259 (33.8) 0.9 1 1 Other 13564 (63.2) 1.3 2.23 (1.05-4.73) 0.036 1.23 (0.55-2.76) 0.606 Check pupils wear shoes No 4789 (22.3) 0.8 1 Yes 16677 (77.7) 1.2 1.12 (0.50-2.49) 0.789 Action if no shoes Other 18349 (85.5) 1.1 1 1 Send home 2448 (11.4) 1.8 2.20 (0.89-5.45) 0.087 1.92 (0.77-4.75) 0.159 Notice pupil ill health No 774 (3.6) 0.5 1 Yes 20692 (96.4) 1.2 2.09 (0.32-13.61) 0.442 Deworming event No 3315 (15.4) 0.9 1 Yes 18151 (84.6) 1.2 1.01 (0.43-2.37) 0.976 Jigger treatment in school No 7451 (84.9) 2.0 1 Yes 1328 (15.1) 2.5 1.32 (0.48-3.64) 0.594 Hygiene program in school No 1868 (8.7) 1.5 1 Yes 19520 (90.0) 1.1 0.78 (0.27-2.26) 0.652 Jigger prevention program in school No 19296 (89.9) 1.0 1 Yes 2057 (9.6) 2.4 1.59 (0.57-4.48) 0.371 1 number of observations in univariable model and percent of all observations, 2 odds ratio 3 confidence interval, 4 p value, 5 adjusted odds ratio, 6 mixed day and boarding school Classroom-related factors. Specific classroom factors were collected in 97 schools for 322 classrooms of which 40 (12.4%) classrooms had at least one case. A total of 5,106 pupils studied in the 322 classrooms, of whom 56 (1.1%) were infected. Although the construction materials of the classrooms were recorded, these were not included in the models since 99.4% of classrooms had an iron sheet roof, 95.6% had walls of bricks, cement blocks or stones and 99% had concrete floors. The distribution of pupils by all classroom variables is presented in Additional file S3. In the univariable analysis, tungiasis was positively associated with all the variables assessed except the number of pupils enrolled in a classroom and the pupil density (number of pupils per m 2 ) in a classroom (Table 2). The condition of the concrete floor, the amount of soil on the floor and cleanliness of the classroom were all correlated to each other according to Pearson’s chi2 (p<0.001, Additional file S3). However, the Variance Inflation Factors of 1.04, 1.37 and 1.39 respectively suggest there was no collinearity. After Backward elimination only the amount of soil on the concrete floor was retained in the final model. Fifteen percent of pupils studied in a classroom with a lot of loose soil on the floor and they had a three times higher odds of being infected than those in a classroom with none or only a little soil on the floor (aOR 3.23, 95% CI 1.40---7.46, p=0.006) (Table 2). Tungiasis was also positively associated with the number of pupils absent on the day of the survey (aOR 1.12, 95% CI 1.03-1.23, p=0.013), that is, the more pupils who were absent the higher the odds a child who was present had tungiasis. As before, pupil sex was also associated with infection. The intra-class coefficient for county was 0.00 (95% CI 0.00-1.0) and for the schools it was 0.33 (95% CI 0.17-0.55). Table 2. Mixed effects logistic regression for classroom factors associated with pupil infection, county and school as random effects (n=5106 pupils, 56 infected). Univariable Full multivariable (n=4872) Final multivariable (n=5101) Variables Categories N (%) 1 % infected OR 2 (95% CI 3 ) P 4 aOR 5 (95% CI) P aOR (95% CI) P Pupil age 5106 (100) 1.1 0.84 (0.72-0.99) 0.032 0.90 (0.76-1.07) 0.226 Pupil sex Female 2582 (50.6) 0.7 1 1 1 Male 2523 (49.5) 1.5 2.25 (1.27-4.01) 0.006 2.04 (1.10-3.78) 0.024 2.23 (1.25-3.97) 0.006 Number of pupils enrolled 5071 (99.3) 1.1 1.01 (0.99-1.03) 0.328 Number of pupils absent 5106 (100) 1.1 1.11 (1.01-1.22) 0.031 1.08 (0.98-1.98) 0.131 1.12 (1.03-1.23) 0.012 Pupil density 6 5054 (99.0) 1.1 0.47 (0.13-1.66) 0.242 Condition of concrete floors Good 2212 (43.4) 0.8 1 1 Cracked 2661 (52.2) 1.1 2.20 (0.79-6.06) 0.129 1.24 (0.49-3.17) 0.651 Amount of loose soil 7 None or a little 4322 (84.7) 0.7 1 1 1 A lot 780 (15.3) 3.2 3.08 (0.76-10.82) 0.011 1.78 (0.64-4.86) 0.275 3.23 (1.40-7.46) 0.006 Classroom cleanliness Not tidy & clean 585 (11.5) 0.8 1 1 Tidy & clean 4521 (88.6) 3.6 2.22 (0.92-5.38) 0.077 1.51 (0.53-4.29) 0.437 1 number of observations in univariable model and percent of total observations, 2 odds ratio 3 confidence interval, 4 p value, 5 adjusted odds ratio, 6 number of pupils/ m 2 of classroom, 7 amount of loose soil, dust or sand on top of concrete floors Headteachers and teachers’ knowledge and attitudes Of the 197 headteachers interviewed, 26.4% (52) were female, while 51% (60) of the 117 teachers were female. Both teachers and headteachers had worked in the school for a median of three years (IQR 2-6). Head (Teacher) awareness of tungiasis situation in schools To assess the level of awareness of the tungiasis status of pupils in their school, headteachers were asked if they thought there were cases in the school, and we compared their response to the results of our foot examinations. At the time of the interview respondent headteachers were not aware of the results of the pupil examinations conducted by the research team. Of the 76 headteachers in schools with at least one case, only 45% (34) were correct in reporting there were cases in their school (Pearson Chi 2 p <0.001, Table 3). Teachers were asked if they knew of cases in their grade. Of the 19 teachers in grades with at least one case, 74% (14) were correct in reporting they had cases in their grade (Table 3). Awareness of teachers had a 74% sensitivity and 96% specificity, while that of head teachers had only 45% sensitivity but 92% specificity (Table3). The 55% of headteachers who incorrectly reported that the school had no cases, were in schools with a lower prevalence (median 0.95%, IQR 0.9-2.7) than those who were correct (median 2.25%, IQR 0.9-4.4, p=0.065). However, this difference was not statistically significant in the Wilcoxon rank sum test. For teachers the difference was significant (median 2.7%, IQR 1.8-5.4 vs. 0.9%, IQR 0.9-1.8, p<0.001). Table 3. (Head)teacher awareness of the tungiasis situation in their school. Chi2 tests and sensitivity/ specificity tests of their awareness as an indicator of the tungiasis status of pupils in their school or grade. Teachers Headteachers Foot exam diagnosis Yes, have cases in my grade No cases in my grade Total Yes, have cases in my school No cases in my school Total At least one case 14 (73.7%) 5 (26.3%) 19 34 (44.7%) 42 (55.3%) 76 No cases 4 (4.1%) 94 (95.9%) 98 9 (7.5%) 111 (92.5%) 120 Total 18 (15.4%) 99 (84.6%) 117 43 (21.9%) 153 (78.1%) 196 Pearson Chi 2 p value <0.001 <0.001 95% CI 95% CI Sensitivity 73.70% 48.8%-90.9% 44.70% 33.3%-56.6% Specificity 95.90% 89.9%-98.9% 92.40% 86.1%-96.5% Positive predictive value 77.80% 52.4%-93.6% 79.10% 64.0%-90.0% Negative predictive value 94.90% 88.6%-98.3% 72.40% 64.5%-79.3% One limitation often proposed for using school-based surveys to assess prevalence and risk factors, is that the most severe cases will be missed as they are unable to attend school on account of their poor mobility. To date there is no evidence to support this, so we asked teachers if they knew if there were pupils missing from their class due to tungiasis, and four teachers from four schools (11.4% of affected schools) said there were. The schools with pupils absent on account of tungiasis had higher prevalence among the pupils who did attend, than schools who did not have any pupils absent on account of tungiasis (median 4.6, IQR 2.3-7.1 vs. 1.8, IQR 0.9-3.1, Wilcoxon rank sum p=0.002). Knowledge of and impact of tungiasis Those headteachers and teachers who said they currently or previously had tungiasis cases in their school were asked more questions about the disease and its impact on pupils. A total of 80 headteachers and 30 teachers responded (Fig 1). The headteachers and teachers were asked why they thought infected pupils had tungiasis and the majority attributed it to family poverty (70%) and poor hygiene (87%). A few also suggested it was due to lack of adult care (15.5%), lazy parents (18.2%), and to living in an area with red soil (14.5%), and 80% consider the disease to be seasonal, being worse during “hot, dry, and dusty” times of the year. Respondents were asked their opinion as to how they thought pupils with tungiasis are affected by the disease. The most common impacts mentioned were poor concentration in class, low academic performance, poor attendance, mobility, stigma, “poor health/ sickly”, low self-esteem, and being “uncomfortable or restless”. Other impacts mentioned by a few respondents were being “tired”, sleeping in class, “mentally disturbed”, “poor memory”, and “socially isolated”. When headteachers and teachers were specifically asked about the psychological impact on pupils compared to uninfected pupils, only two felt they were no different to uninfected pupils. Around one third mentioned that they were sad (29.1%), quiet (25.5%), withdrawn (36.4%) and seemed ashamed or embarrassed (38.2%). More than half (60%) said pupils with tungiasis are excluded by other pupils and 42.7% said pupils with tungiasis were ridiculed by others. When asked about the parents of the infected pupils, 58% felt the parents of infected pupils engage less, and 60% felt parents were less likely to come to school when asked, compared to parents of uninfected pupils. Health programs in school In Kenya, public health officers run school health programs and regularly visit schools to do so and to identify health issues in the schools. All schools run a health club and have a teacher responsible for coordinating this and monitoring pupil health. Often non-governmental organizations partner with the department of health and schools to assist with these programs. During the interviews headteachers were asked what health interventions had been conducted, including for tungiasis, and when. Despite 21.9% (43) of headteachers thinking they had pupils in their school with tungiasis and being aware of the impact it had on their academic achievement, only 6.1% (12) of all headteachers reported there had been an intervention activity run by the local health department or a non-governmental organization to treat the pupils, and for 75% (9) of those, that was more than a year before the interview. For the 12 schools who had had an intervention, in only six had pupils been treated, either with potassium permanganate, coconut oil or neem oil, and for three schools fumigation of pupils’ homes had been conducted. Only 9.6% (19) of all headteachers reported having an active program to teach pupils about tungiasis and prevention, while 91.3% (179) of headteachers reported having a hygiene program and 60.7% (119) had other health interventions (COVID-19, polio, measles, trachoma, nutrition, menstrual hygiene, human papilloma virus and cervical cancer) in their school. Discussion We provide evidence of an association of infection in pupils aged 8-to-14 years with studying in schools with neglected infrastructure and poor cleanliness, having broken concrete floors and large amounts of loose soil or sand on the classroom floor. These factors are all linked to the developmental biology of the sand flea. The larvae need a certain amount of soil or sand to burrow in to prevent dehydration and avoid predation. The pupae require particles of soil/sand to coat themselves for protection [8]. Sand flea eggs expelled from the feet of an infected pupil wearing open or no shoes during class time, could drop on the sand and the off-host life cycle could be completed in the classroom. Consequently, keeping classroom floors in good condition and dust/soil-free may help to reduce parasite development and pupil infection. Apart from one other study conducted previously in Kilifi County in 2014 [17], no other study has investigated factors in schools that may be associated with tungiasis. Many risk factor studies have been conducted with school pupils in schools, but these have focused on the pupil and their home. In our own work, we previously concluded that the home environment is largely responsible for infection risk, but we also found indications that the school environment is a contributing factor [17]. Tungiasis has previously, and in the current study population, been associated with not washing feet at least once a day with soap [4, 6, 17, 23]. Children in resource poor families may well not have access to water and/or soap at home, or parents lack the ability to enforce washing every day before and/or after school. We have found that in addition, if a school did not have constant access to water, the pupils had a higher risk of infection. Promoting foot hygiene and providing facilities for foot washing in school for those who do not have access at home could help reduce infection among pupils. The majority of headteachers and teachers in affected schools knew that tungiasis was associated with poverty and poor hygiene and its impact on children, but there was rarely systematic action to help individual children to wash in school, nor implement a school-wide intervention program. While most schools had a general hygiene program, these programs focused on handwashing to prevent diarrheal diseases and soil transmitted helminths, and of course at the time of this study, COVID-19. The findings of this study indicate headteachers are not very aware of the tungiasis situation in their school and are only likely to be if the school prevalence is over 1%. Consequently, if health officials or organizations rely on asking headteachers about the tungiasis situation, they are unlikely to get an accurate report. A higher proportion of teachers than headmasters correctly reported there were cases in the school or grade. This is not surprising since teachers have more contact with pupils each day, but there seems to be a lack of communication with school management to potentially address the problem. Most headteachers and teachers felt tungiasis is seasonal and associated with the hot, dry or dusty times of year. Only one past survey in Brazil [24], has systematically investigated the seasonality and found the prevalence to be highest in the dry season. More studies are clearly needed to confirm this to provide health departments with the best time of the year to target for prevention interventions, before transmission begins to rise. Most headteachers and teachers were not aware of the major impacts tungiasis has on children, except that they are stigmatized by other pupils, being excluded and ridiculed. Only a third or less of respondents in affected schools identified lack of concentration in class, absenteeism, poor academic performance, and the child’s psychological state. We have reported previously how the infected pupils in these schools, themselves reported having difficulty concentrating in class and sleeping at night, being ashamed, sad and angry, and observations of their school records found infected pupils missed more days of school and had lower exam results [11]. Many of these impacts have also been documented by previous studies [12, 25]. Something that has rarely been explored before in relation to children with tungiasis is the role parents may play in the child’s risk of infection. Two thirds of headteachers and teachers felt that parents of children with tungiasis were less engaged with the school than parents of uninfected pupils and were less likely to attend a meeting when specifically asked to come. This could reflect parental neglect of the child or shame regarding their child’s infection. Some teachers thought the child’s infection was caused by “lack of adult care”, or from having “lazy parents” and some were aware that there were problems at home for infected children and named poverty, alcohol use, divorce and illiteracy. The causes of neglect are likely to be many, but previously tungiasis has been shown to be associated with caregiver depression [26], which itself has been associated with child neglect [27] and poor hygiene of children [28]. Further research is needed to determine if there is an association between tungiasis and parental neglect, and to explore the possible reasons for child neglect in these communities and how that might be changed. LIMITATIONs This study had one major limitation which was that it was not designed as a case: control study for school-related risk factors but rather was nested in a fully randomized prevalence survey which resulted in a low number of tungiasis cases encountered during the surveys, particularly when the detailed classroom observations and teacher interviews were conducted. Another limitation was the use of semi-structured interview tools which did not allow (head)teachers to give much depth in their responses. However, this would have required more time for the interviews and more complex training for the field teams which had to be conducted online due to the COVID-19 epidemic restrictions. A third limitation was the use of subjective measures for several of the variables, such as building condition, cleanliness and the amount of soil on concrete floors. The field teams were trained using verbal descriptions only and inter-observer reliability was not tested, so some inter-observer variability and bias is possible. To reduce the impact of this source of bias the countyunique identifier was used as a second random effect in the logistic regression models. However, the intra-cluster coefficients for county in both models indicate there was no cluster effect related to the counties . Lastly, the purposive selection of counties could bias the conclusions to be only relevant for the specific climates included. However, the selection included all major climate types from very arid to humid, as well as a cross-section of geography and cultures of Kenya. Since these climates are typical of most endemic countries the findings are likely generalizable to other countries in both Sub-Saharan Africa and Latin America. In addition, the analyses included the county as a random effect so that all findings are relevant to all climate types included. Conclusion “While the cross-sectional study design did not enable us to identify causation, we have identified several modifiable school-related factors that were associated with a higher odds of tungiasis for pupils aged 8-to-14 years. Changing these factors could reduce the likelihood of schoolchildren becoming infected. These findings underscore the importance of a One Health, multisectoral approach to tungiasis control. The Department of Health in endemic areas should collaborate with school Boards of Management and headteachers to raise awareness of tungiasis, implement routine pupil monitoring, and ensure school environments are well-maintained, clean, and consistently supplied with water. Pupils should also be encouraged to wash their feet at school if they are not able to do so at home.” Abbreviations a OR Adjusted odds ratio CHMT County Health Management Team CI Confidence Interval KEMRI Kenya Medical Research Institute NTDs Neglected Tropical Diseases OR Odds ratio PTA Parent Teachers Association SES Socio-economic status SD Standard deviation WASH Water, sanitation and hygiene Declarations Ethics approval and consent to participate The study was conducted in accordance with the Helsinki Declaration. It was initially approved by the KEMRI Scientific and Ethics Review Committee (approval number KEMRI/SERU/CGMR-C/170/3895) as well as the Oxford Tropical Research Ethics Committee (reference number 38-19) in August 2019. During the community engagement phase, a presentation was made to the national Director for Neglected Tropical Diseases at the Ministry of Health, the county and sub-County Health Management Teams and the Department of Education in all counties to obtain their approval. In each school a meeting was held with the school Parent Teachers’ Association (PTA) or management board to obtain their permission to conduct the survey in their school. The head teacher and PTA chairperson signed the consent form on behalf of the parents and school for the pupils to be examined and observations to be made of the school. Each child gave verbal assent. Community health workers were hired and trained in each school to assist and be the link with the community emphasizing that participation was completely voluntary, and subjects had the opportunity to withdraw from the study at any point in the study. Each of the headteachers and teachers who were interviewed first gave informed consent. All data were collected on PIN protected electronic tablets, stored on password protected RedCap databases on the KEMRI-Wellcome Trust servers. Data were analyzed after export to Excel spreadsheets without inclusion of personal identifiers. All pupils with tungiasis were referred for treatment to the community health workers or the local health facility using benzyl benzoate provided by the study. For those with secondary bacterial infection and other illnesses requiring treatment, a referral was made to the nearest health facility. Consent for publication All the authors have reviewed and approved the publication of this paper. Availability of data and materials The datasets and other materials supporting the conclusions of this article are available on KWTRP Research Data Repository at Harvard Dataverse through the following link: https://doi.org/10.7910/DVN/XM4K5I. Supplementary material S1 Distribution of pupil population by school variables S2 Distribution of pupil population by classroom variables S3 Correlation of classroom variables with each other Competing interests All authors declare no conflict of interest. Funding Information Research funding for this work was provided by the Wellcome Trust through the project “Epidemiology of Tungiasis” (grant number 213724/Z/18/) granted to Lynne Elson as a Career Re-Entry Fellowship. This work was written with the permission of Director KEMRI-CGMRC. The views expressed herein do not necessarily reflect the official opinion of the donors. The funders had neither a role in the design of the study, nor in collection, analysis, interpretation of data nor in writing the manuscript. Author Contributions Conceptualization, LE, UF, MM, IA, PB; Methodology, LE, UF, PB, BO, MM, IA; Formal Analysis, LE, BO; Investigation, LE, CK, SK, CM, GG, EC, MO, ES, JK, EM, MW, JL; Resources, LE, PB; Data Curation, LE ; Writing – Original Draft Preparation, LE.; Writing – Review & Editing, CK, SK, CM, GG, EC, MO, ES, JK, EM, MW, JL , UF, BO, PB, MM, IA; Visualization, LE.; Supervision, PB; Project Administration, LE, MM, PB; Funding Acquisition, LE, MM, PB. Acknowledgements We are grateful to the County Tungiasis Team Leaders: Wambani Zablon 3 , Collins Kipkorir 4 , Philip Nzyoka 5 , Moses Obiero 6 , Marawan Elijah 7 , Jacob Kapombe 8 , Kuyan Malano 9 , Caleb Kasuku 10 , Rael Kukule 11 from Departments of Health in 3 Muranga, 4 Kericho, 5 Makueni, 6 Nakuru, 7 Samburu, 8 Kilifi, 9 Kajiado, 10 Taita Taveta, 11 Turkana, We are also grateful to the communities who participated, the school Parent Teacher Associations and Head Teachers who allowed us to work in their schools, the county Directors of Health and Education who gave their approval for the study and assisted in many ways to ensure its success. We acknowledge the efforts and dedication of Henry Kivuva (RIP) to set up the survey in Makueni County. References Feldmeier H, Heukelbach J, Ugbomoiko US, Sentongo E, Mbabazi P, von Samson-Himmelstjerna G, et al. Tungiasis--a neglected disease with many challenges for global public health. PLoS Negl Trop Dis. 2014;8(10):e3133. doi: 10.1371/journal.pntd.0003133. World_Health_Organization. Ending the neglect to attain the Sustainable Development Goals: a road map for neglected tropical diseases 2021–2030. Geneva: World Health Organization 2020. Available from: https://www.who.int/publications/i/item/9789240010352. World_Health_Organization. Ending the neglect to attain the Sustainable Development Goals: a strategic framework for integrated control and management of skin-related neglected tropical diseases. Geneva2022. Available from: https://www.who.int/publications/i/item/9789240051423. Wiese S, Elson L, Reichert F, Mambo B, Feldmeier H. Prevalence, intensity and risk factors of tungiasis in Kilifi County, Kenya: I. Results from a community-based study. PLoS Negl Trop Dis. 2017;11(10):e0005925. doi: 10.1371/journal.pntd.0005925. Mutebi F, McNeilly H, Thielecke M, Reichert F, Wiese S, Mukone G, et al. Prevalence and Infection Intensity of Human and Animal Tungiasis in Napak District, Karamoja, Northeastern Uganda. Trop Med Infect Dis. 2023;8(2). doi: 10.3390/tropicalmed8020111. Elson L, Kamau C, Koech S, Muthama C, Gachomba G, Sinoti E, et al. National prevalence and risk factors for tungiasis in Kenya. Infect Dis Poverty. 2023;12(1):85. doi: 0.1186/s40249-023-01131-x. Eisele M, Heukelbach J, Van Marck E, Mehlhorn H, Meckes O, Franck S, et al. Investigations on the biology, epidemiology, pathology and control of Tunga penetrans in Brazil: I. Natural history of tungiasis in man. Parasitol Res. 2003;90(2):87-99. doi: 10.1007/s00436-002-0817-y. Nagy N, Abari E, D'Haese J, Calheiros C, Heukelbach J, Mencke N, et al. Investigations on the life cycle and morphology of Tunga penetrans in Brazil. Parasitol Res. 2007;101 Suppl 2:S233-42. doi: 10.1007/s00436-007-0683-8. Feldmeier H, Eisele M, Van Marck E, Mehlhorn H, Ribeiro R, Heukelbach J. Investigations on the biology, epidemiology, pathology and control of Tunga penetrans in Brazil: IV. Clinical and histopathology. Parasitol Res. 2004;94:275–82. Feldmeier H, Heukelbach J, Eisele M, Sousa AQ, Barbosa LM, Carvalho CB. Bacterial superinfection in human tungiasis. Trop Med Int Health. 2002;7(7):559-64. doi: 10.1046/j.1365-3156.2002.00904.x. Elson L, Kamau C, Koech S, Muthama C, Gachomba G, Sinoti E, et al. Children with tungiasis in Kenya have poor school performance and quality of life. medRxiv preprint. 2023. doi: 10.1101/2023.11.17.23298667v1. Wiese S, Elson L, Feldmeier H. Tungiasis-related life quality impairment in children living in rural Kenya. PLoS Negl Trop Dis. 2018;12(1):e0005939. doi: 10.1371/journal.pntd.0005939. Muehlen M, Feldmeier H, Wilcke T, Winter B, Heukelbach J. Identifying risk factors for tungiasis and heavy infestation in a resource-poor community in northeast Brazil. Trans R Soc Trop Med Hyg. 2006;100(4):371-80. doi: 10.1016/j.trstmh.2005.06.033. Elson L, Matharu AK, Riithi N, Ouma P, Mutebi F, Feldmeier H, et al. Characterization of tungiasis infection and morbidity using thermography in Kenya revealed higher disease burden during COVID-19 school closures. Infectious Diseases of Poverty. 2023;12(1):24. doi: 10.1186/s40249-023-01080-5. Matharu AK, Ouma P, Njoroge MM, Amugune BL, Hyuga A, Mutebi F, et al. Identification of tungiasis infection hotspots with a low-cost, high-throughput method for extracting Tunga penetrans (Siphonaptera) off-host stages from soil samples-An observational study. PLoS Negl Trop Dis. 2024;18(2):e0011601. doi: 10.1371/journal.pntd.0011601. Nyangacha RM, Odongo D, Oyieke F, Bii C, Muniu E, Chasia S, et al. Spatial distribution, prevalence and potential risk factors of Tungiasis in Vihiga County, Kenya. PLoS Negl Trop Dis. 2019;13(3):e0007244. doi: 10.1371/journal.pntd.0007244. Elson L, Wiese S, Feldmeier H, Fillinger U. Prevalence, intensity and risk factors of tungiasis in Kilifi County, Kenya II: Results from a school-based observational study. PLoS Negl Trop Dis. 2019;13(5):e0007326. doi: 10.1371/journal.pntd.0007326. Ugbomoiko US, Ariza L, Ofoezie IE, Heukelbach J. Risk factors for tungiasis in Nigeria: identification of targets for effective intervention. PLoS Negl Trop Dis. 2007;1(3):e87. doi: 10.1371/journal.pntd.0000087. Elson L, Kamau C, Koech S, Muthama C, Gachomba G, Sinoti E, et al. Tungiasis among children in Kenya is associated with poor nutrition status, absenteeism, poor school performance and high impact on quality of life. PLoS Negl Trop Dis. 2024;18(5):e0011800. doi: 10.1371/journal.pntd.0011800. Harris P, Taylor R, Thielke R, Payne J, Gonzalez N, Conde J. Research electronic data capture (REDCap) – A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-81. doi: 10.1016/j.jbi.2008.08.010. Elson L, Thielecke M, Fillinger U, Feldmeier H. Infection with tungiasis through interhost movement of adult female sand fleas, Tunga penetrans. Trans R Soc Trop Med Hyg. 2022;116(2):85-6. doi: 10.1093/trstmh/trab117. Dziura JD, Post, L. A., Zhao, Q., Fu, Z., & Peduzzi, P. . Strategies for dealing with missing data in clinical trials: from design to analysis. The Yale journal of biology and medicine. 2013;86(3):343. Nsanzimana J, Karanja S, Kayongo M, Nyirimanzi N, Umuhoza H, Murangwa A, et al. Factors associated with tungiasis among primary school children: a cross-sectional study in a rural district in Rwanda. BMC Public Health. 2019;19(1):1192. doi: 10.1186/s12889-019-7481-y. Heukelbach J, Wilcke T, Harms G, Feldmeier H. Seasonal variation of tungiasis in an endemic community. Am J Trop Med Hyg. 2005;72(2):145-9. McNeilly H, Thielecke M, Mutebi F, Banalyaki M, Reichert F, Wiese S, et al. Tungiasis Stigma and Control Practices in a Hyperendemic Region in Northeastern Uganda. Trop Med Infect Dis. 2023;8(4). doi: 10.3390/tropicalmed8040206. Otieno B, Elson L, Matharu AK, Riithi N, Chongwo E, Katana K, et al. Neurocognitive and mental health outcomes in children with tungiasis: a cross-sectional study in rural Kenya and Uganda. Infectious Diseases of Poverty. 2023;12(1):100. doi: 10.1186/s40249-023-01154-4. Cummings EM, Davies PT. Maternal depression and child development. Journal of child psychology and psychiatry. 1994;35(1):73-112. Runyan D, Wattam C, Ikeda R, Hassan F, Ramiro L. Child abuse and neglect by parents and other caregivers. In: Krug EG, Dahlberg JA, Mercy AB, Lozano Z, LozanoR, editors. World report on violence and health Geneve, Switzerland: World Health Organization; 2002. p. 57–86. Additional Declarations No competing interests reported. Supplementary Files ElsonTungiasisSupplementarymaterial.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 06 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviewers invited by journal 05 Feb, 2026 Submission checks completed at journal 21 Oct, 2025 First submitted to journal 20 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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participants and activities. A school was considered “affected” if at least one case was identified during examinations of 114 randomly selected pupils aged 8 to 14 years. n: number. “Tungiasis responses” refers to the number of headteachers or teachers who responded to questions regarding tungiasis in the interview.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5070518/v1/0918ef4d72ec292d32f17b01.jpg"},{"id":95531572,"identity":"cc10d132-799b-4bc8-b2db-30081d56c2ef","added_by":"auto","created_at":"2025-11-10 10:23:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1493479,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5070518/v1/c9c4e25e-5888-4c81-9024-22bcc955eab2.pdf"},{"id":95499160,"identity":"c9291acd-9af5-4370-aa93-e88288d0d1f9","added_by":"auto","created_at":"2025-11-10 05:14:50","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":49090,"visible":true,"origin":"","legend":"","description":"","filename":"ElsonTungiasisSupplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-5070518/v1/0e766cca1a1625cf6dd07d18.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"School-related risk factors for tungiasis among children aged 8 to 14 years in nine counties of Kenya: a cross-sectional survey","fulltext":[{"header":"Background","content":"\u003cp\u003eTungiasis is a skin disease mostly affecting children under 15 years, the elderly and disabled people in the most resource poor populations in Latin America and Sub-Saharan Africa[1]. It has been neglected by governments, donors, and the scientific community to this day, and was only recently added to the World Health Organization\u0026rsquo;s list of neglected tropical disease[2] and neglected diseases of the skin [3].Due to this neglect, the global burden of tungiasis is unknown. Surveys have been conducted in endemic countries, but all specifically targeted villages known to be affected, where the prevalence ranged from 7 in a village in Kenya to 63% in the Karamoja region of northeastern Uganda [4, 5]. The current study is nested within the only country-level, randomized survey conducted to-date to estimate the national prevalence of tungiasis, which found the prevalence among school children aged 8 to 14 years in nine counties in Kenya in 2021 was 1.35% \u0026nbsp;[6]. The prevalence across the Kenya was heterogeneous with county-level prevalence ranging from 0.08 to 3.2% and the school-level prevalence ranged from 0.9 to 22%.\u003c/p\u003e\n\u003cp\u003eTungiasis is caused by the sand flea, \u003cem\u003eTunga penetrans.\u0026nbsp;\u003c/em\u003eThe female of this species burrows into the skin of both humans and animals, where it remains embedded for the duration of its five-week adult life, unless removed by its host [7]. The dead flea carcass is expelled from the skin by natural skin-regeneration processes [7]. The flea is less than 1mm in length when it seeks out its host, once in the skin it copulates with the free-living male flea and grows 2000 times in size as eggs develop in the abdomen. Hundreds of eggs are released into the environment, where larvae will hatch and develop in the upper layer of soil and dust if conditions are suitable. After one week the larvae pupate, cloaking themselves in sand grains, and after one more week the adult emerges [8]. The rapid growth of the embedded female in the skin causes considerable pain and the flea induces an inflammatory response resulting in intense itching, often exacerbated by secondary bacterial infection [9, 10]. A few studies have demonstrated tungiasis reduces a patient\u0026rsquo;s quality of life through reduced mobility, disturbed sleep, concentration at school or work, stigma and discrimination [11, 12]. It was also shown that tungiasis was associated with higher absenteeism and lower school performance [11].\u003c/p\u003e\n\u003cp\u003eIdentifying the major sources of infection and associated risk factors is important to guide the development of prevention interventions and policies. Previously people\u0026rsquo;s own homes have been identified as the most likely source of infection due to two major factors; firstly the most common risk factor identified in multiple studies in Brazil and Sub-Saharan African countries is sleeping in a house with an earthen floor [13, 14] and secondly the flea larvae are mostly found in the soil floors of sleeping rooms [15]. Other risk factors identified include people\u0026rsquo;s socioeconomic status and behaviors including not wearing closed shoes [16], not washing feet frequently with soap [17] and the ownership of dogs [13] or pigs [18]. As part of the \u0026nbsp;national prevalence survey in Kenya, school pupils were interviewed to assess their risk factors and found tungiasis was associated with male sex, low socio-economic status, not washing their feet twice a day and never using soap to wash their feet [6].\u003c/p\u003e\n\u003cp\u003eAlthough endemic communities and local health officials often suggest schools are the source of infection (anecdotal reports), no study has been conducted to assess the school environment. This is surprising since the most affected population are school-aged children (six to 15 years) and it might be expected that schools, which have a high density of children for a large proportion of each day, may contribute to the risk of infection. \u0026nbsp;Consequently, the objective of the current study was to determine whether any aspects of the school environment may be associated with tungiasis infection among pupils aged 8-to-14 years, and also to explore headteachers\u0026rsquo; and teachers\u0026rsquo; knowledge and attitudes relating to risk factors for, and the impact of tungiasis on their pupils.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch3\u003eStudy design and population\u003c/h3\u003e\n\u003cp\u003eThis study used a mixed methods approach to compare school-related risk factors for infected and uninfected pupils selected from nine counties across Kenya. The study was nested in a cross-sectional survey in the nine counties which was designed to determine the national prevalence of tungiasis in Kenya as described previously [6, 19]. The nine counties were purposively selected to be as representative of the whole country as possible,\u0026nbsp;including the five major ecological zones of the country: very arid (Turkana), arid (Samburu and Taita Taveta), semi-arid (Makueni, Kajiado and Kilifi), semi-humid (Nakuru) and humid (Kericho, Muranga). The selections within ecological zones were also conducted to ensure representation of a geographic cross-section of the country and to include multiple cultural groups including nomadic pastoralists (the Masai, Samburu, Turkana) and farmers (the Mijikenda, Taita, Kikuyu, Kamba, Kalenjin).\u003c/p\u003e\n\u003ch3\u003eSample size and selection\u003c/h3\u003e\n\u003cp\u003eThe number of pupils and schools to enrol was based on the sample size of pupils needed for the national prevalence estimate a total of 11,010 pupils spread across the nine counties which was repeated in a second phase, as described previously [6]. Within each of the nine counties 22 primary schools were stratified randomly selected from pre-existing school lists for each sub-county, selecting at least two schools from each sub-county. The schools were surveyed in two phases, 11 schools between April and June 2021 and 11 different schools between September 2021 and April 2023. Within each selected school,\u0026nbsp;114 pupils aged 8 to 14 years, were quasi-randomly selected, by asking the pupils to assemble in three age groups; 8 and 9 years; 10 and 11 years; 12 to 14 years, and by gender within each age group. For each of these age/gender groups, every n\u003csup\u003eth\u0026nbsp;\u003c/sup\u003epupil (n = total number in the group/ 19) was selected until 19 were selected, giving a total of 114 pupils overall. All selected pupils gave verbal assent and were examined for tungiasis\u0026nbsp;[6]. Examinations were conducted by non-clinical field officers who were trained by the principal investigator to identify embedded fleas: a round white lesion with a dark spot at the center (live); a black, irregular-shaped lesion (dead); or a lesion from where a flea had clearly been removed (manipulated).\u003c/p\u003e\n\u003ch3\u003eProcedures\u003c/h3\u003e\n\u003cp\u003eObservations were conducted of the school infrastructure including the composition and structural condition of buildings, washing and sanitation facilities, and the presence of animals on the compound. In the second phase of the survey, observations were also made of individual classrooms: measuring the length and width of the classroom, obtaining enrolment and absentee numbers for the day of the visit, the materials used for construction, the condition of the classroom floor and building and the amount of loose soil on a concrete floor.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn every school, the headteacher or their representative, and during the second phase of the survey up to eight teachers per school were interviewed, using a semi-structured questionnaire regarding themselves, the school and pupil welfare. Headteachers and teachers who said they currently or previously had tungiasis cases in the school were asked questions about their knowledge and attitudes of tungiasis and infected pupils. Where questions were open, limited space was provided for responses. The tool was piloted, and necessary adjustments were made before implementation. The questionnaire was pre-translated and administered in Kiswahili. The field interviewers were trained by the lead investigator.\u0026nbsp;All interview responses were entered into electronic tablets using the REDCap web application [20] and uploaded to the Kenya medical Research Institute (KEMRI)-Wellcome Trust servers.\u003c/p\u003e\n\u003ch3\u003eExplanatory variables\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eSchool and classroom factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe selection of explanatory variables for the regression models was based on the biology of the parasite. For instance, buildings in poor structural condition, unsealed earthen floors, concrete floors that are broken/ cracked and/ or covered with loose soil or dust and general poor cleanliness might be expected to support the development of off-host stages of \u003cem\u003eT. penetrans\u003c/em\u003e.\u0026nbsp;\u0026nbsp;All of the variables were subjective measures: structural condition of buildings was categorized as poor, average or good. The general cleanliness of the compound and classrooms was a binary response, “were the compound and classrooms clean, yes or no?”. The measure for classroom floor condition was categorized as good, slightly cracked or very broken up and the amount of loose dust or soil on a hard floor was categorized as none, a little or a lot. The cleanliness of the classroom was categorized as tidy and clean, slightly tidy and clean or very untidy and dirty. The presence of animals was observed as animals have previously been shown to be a risk factor for infection [13, 18], either through being infected themselves and dropping sand flea eggs into the environment or through their feces providing organic matter for the larvae to feed on. Verbal descriptions of the subjective measures were used to train the field teams. Inter-observer variability was not assessed.\u003c/p\u003e\n\u003cp\u003ePreviously it has been shown that adult female fleas can jump from one heavily infected host to another in proximity [21], so we included the total pupil enrolment in a school and the density of pupils in a classroom. We also collected the number of pupils absent on the day of the visit since this could reflect a situation in the school which caused children to be absent, that could have been associated with a child who was present being infected. Past studies have identified factors relating to hygiene and sanitation to be associated with disease, therefore access to water, washing stations, presence of hygiene promotion signs, access to toilets and the condition of toilets were included in the observations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(Head) teacher-related factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe attitudes of headteachers and teachers towards pupil welfare were explored as they could potentially impact the vulnerability of pupils for infection. In this context, questions were asked about the supervision of pupil hygiene behaviors and shoe-wearing, the actions taken if pupils do not match the school standards, and whether regular hygiene promotion, deworming or jigger programs were conducted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSince county of residence, pupil age and sex have previously been shown to be important factors associated with tungiasis in this study [6], these were also included in the models.\u003c/p\u003e\n\u003ch3\u003eData Analysis\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eSchool and classroom-related risk factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe outcome of interest for the risk factors was a pupil’s infection status defined as a tungiasis case if they had at least one embedded flea (live, dead or manipulated) on their hands or feet, and uninfected otherwise. Mixed effects logistic regression models were used to identify factors related to the school and classrooms that may be associated with pupils’ tungiasis infection status (pupil infected or not). Fixed effects included the county, pupil age and sex, school and classroom characteristics described in the observations paragraph above. The subjective measures with three categories were collapsed into two. The school unique identifier was used as a random effect to adjust for the clustered study design. The county unique identifier was also used as a random effect, to adjust for any inter-observer variability between the county teams, particularly for the subjective measures of classroom cleanliness, building condition and amount of soil on concrete floors. All variables with a p-value less than 0.2 in univariable models were included in a multivariable model. Backward elimination, sequentially excluding variables was used to obtain the final model. Akaike information criteria (AIC) was used to compare the models. Models with lower AIC values were preferred. Additional consideration on variable selection was expert knowledge on potential relationships with the outcome. Given the large number of variables explored which could have increased type I-error we also used Wald tests to guide variable selection in the models. Results are presented as odds ratios or adjusted odds ratios with 95% confidence intervals and p-values.\u003c/p\u003e\n\u003cp\u003eMissing responses were analyzed under the “missing at random” assumption [22] since none included in the multivariable models were missing more than 5% of the observations (Additional files S1 and S3), and the final models included no less than 97% of the observations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHeadteacher and teacher interviews\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePearson Chi-square was used to test whether headteachers’ awareness of the tungiasis status of pupils (said yes to question “are there any tungiasis cases in your school”) was different to the actual status established during foot examinations. The same was conducted for teachers’ awareness of tungiasis cases in the grade that they taught most of the time. The sensitivity and specificity, positive predictive value and negative predictive value of teachers and headteachers awareness was also calculated.\u0026nbsp;Wilcoxon rank-sum tests were used to test whether their awareness was related to the prevalence of tungiasis in their school. The remaining responses were summarized using the percentage of respondents who gave each response type. Responses to open questions were analyzed manually assigning codes to themes and summarizing as percent of respondents who gave each response. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll analyses were conducted using Stata BE version 18 (Stata Corp LLC, College Station, Texas, USA). All tests were performed at 5% significance level. No qualitative analysis software were used.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eA total of 196 schools were enrolled in the study, and 21,466 pupils were examined, of whom 242 (1.1%) were found to be infected. The infected pupils were from 76 schools (\u0026ldquo;affected schools\u0026rdquo; in Fig 1). In all 196 schools, observations were made of the school infrastructure and enrollment records and headteachers or their representatives were interviewed. In the second phase of the survey, 97 schools were enrolled, 35 of whom had tungiasis cases, detailed observations were made of 322 classrooms, and 117 teachers were interviewed (Fig 1). Within the 76 affected schools, the school prevalence of tungiasis varied from a low of 0.8% to a high of 22.3% among pupils aged 8 to 14 years. The distribution of pupils by all explanatory variables is presented in the Additional file S1.\u003c/p\u003e\n\u003cp\u003eFigure 1. Flow chart of participants and activities. A school was considered \u0026ldquo;affected\u0026rdquo; if at least one case was identified during examinations of 114 randomly selected pupils aged 8 to 14 years. n: number. \u0026ldquo;Tungiasis responses\u0026rdquo; refers to the number of headteachers or teachers who responded to questions regarding tungiasis in the interview.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;School-related risk factors\u003c/p\u003e\n\u003cp\u003eDuring univariable analysis, many of the observed factors were associated with tungiasis (Table 1) and were included in the multivariable analysis. In the final model, pupil age and sex were associated with tungiasis status and only a few school factors. Several of the factors were retained in the final model despite having a p-value slightly higher than 0.05, based on the 95% confidence interval, AIC and Wald test results which indicated they play a role in the model. Pupils had twice the odds of infection in a day school rather than a mixed day and boarding school (aOR 2.57, 95% CI 0.99-6.66, p=0.052) ; the 40% of schools who had more than 400 pupils enrolled (aOR 2.17, 95% CI 1.14-4.14, p=0.018); the 40% of schools where clean water was not always available (aOR 2.15, 95% CI 1.15-4.01, p=0.016). \u0026nbsp;Although only 3.6% of pupils were in schools where the buildings were not clean, they had a nearly four times higher odds of infection (aOR 3.93, 95% CI 0.92-16.69, p=0.064) . Half (50.8%) of all pupils were in schools where the buildings were in \u0026nbsp;poor structural condition and they had a higher odds of infection (aOR 1.83, 95% CI 0.96--3.50, p=0.066). \u0026nbsp;The intra-class coefficient for county was 0.04 (95% CI 0.01-0.24) and for the schools it was 0.41 (95% CI 0.31-0.53).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Table 1. Mixed effects logistic regression of school-related factors for tungiasis infection in pupils, county and school as random effect (n=21,465, 242 cases).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"1001\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 183px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFull multivariable (n=19277)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinal multivariable (n=21021)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategories\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003csup\u003e1\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e% pupils infected\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003csup\u003e2\u003c/sup\u003e (95% CI\u003csup\u003e3\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003csup\u003e4\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eaOR\u003csup\u003e5\u003c/sup\u003e (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eaOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003ePupil age (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e21466 (100)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e0.81 (0.76-0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e0.82 (0.76-0.88)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0.82 (0.76-0.88)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003ePupil sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e10889 (50.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e10576 (49.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1.98 (1.51-2.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1.96 (1.47-2.60)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.91 (1.45-2.53)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003eSchool type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1854 (8.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003ePublic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e19612 (91.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e5.96 (1.23-28.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e2.86 (0.56-14.67)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.207\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003eSchool location\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e3554 (16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e17912 (83.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1.26 (0.55-2.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.586\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003eSchool structure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eMixed \u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e4067 (18.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eDay only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e17399 (81.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e2.69 (1.03-7.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.044\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1.48 (0.52-4.26)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.463\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2.57 (0.99-6.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003eTotal enrolment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026le;400\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e12907 (60.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026gt;400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e8559 (39.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1.59 (0.84-3.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1.78 (0.90-3.53)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.095\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2.17 (1.14-4.14)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.018\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003eBoy: girl ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e21356 (99.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e2.91 (0.78-10.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1.97 (0.46-8.51)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.362\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003eCondition of toilets\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e6751 (31.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eNot good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e14271 (66.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e2.37 (1.13-4.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e0.97 (0.43-2.20)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.942\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 130px;\"\u003e\n \u003cp\u003eClean water available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eAlways\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e12656 (59.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eNot always\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e8589 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e2.58 (1.37-4.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1.81 (0.95-3.47)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.073\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2.15 (1.15-4.01)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.016\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 130px;\"\u003e\n \u003cp\u003eHandwashing stations on compound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e3257 (15.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e18209 (84.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1.02 (0.42-2.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.958\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 130px;\"\u003e\n \u003cp\u003eHygiene promotion signs on compound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e13200 (61.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e8266 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1.84 (0.96-3.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e0.88 (0.45-1.71)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.700\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003eClassrooms clean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e20697 (96.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e769 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e4.46 (1.00-19.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.050\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e3.55 (0.81-15.53)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.093\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3.93 (0.92-16.69)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.064\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 130px;\"\u003e\n \u003cp\u003eCondition of building\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e10342 (48.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eNot good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e10902 (50.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e2.31 (1.19-4.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1.50 (0.73-3.09)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.275\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.83 (0.96-3.50)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.066\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003eHeadteacher age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e21393 (99.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1.02 (0.99-1.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.333\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 130px;\"\u003e\n \u003cp\u003eConduct Income generating activity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e4009 (18.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e17457 (81.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e2.01 (0.83-4.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1.43 (0.59-3.43)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.426\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 130px;\"\u003e\n \u003cp\u003eCheck pupils washed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e606 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e20752 (96.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e3.04 (0.36-25.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eAction if not washed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eWash at school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e7259 (33.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e13564 (63.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e2.23 (1.05-4.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.036\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1.23 (0.55-2.76)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.606\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 130px;\"\u003e\n \u003cp\u003eCheck pupils wear shoes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e4789 (22.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e16677 (77.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1.12 (0.50-2.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.789\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eAction if no shoes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e18349 (85.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eSend home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e2448 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e2.20 (0.89-5.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.087\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e1.92 (0.77-4.75)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.159\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eNotice pupil ill health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e774 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e20692 (96.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e2.09 (0.32-13.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.442\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eDeworming event\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e3315 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e18151 (84.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1.01 (0.43-2.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.976\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eJigger treatment in school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e7451 (84.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1328 (15.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1.32 (0.48-3.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.594\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eHygiene program in school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1868 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;Yes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e19520 (90.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e0.78 (0.27-2.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.652\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eJigger prevention program in school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e19296 (89.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e2057 (9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e1.59 (0.57-4.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.371\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003enumber of observations in univariable model and percent of all observations, \u003csup\u003e2\u003c/sup\u003eodds ratio \u003csup\u003e3\u003c/sup\u003econfidence interval, \u003csup\u003e4\u003c/sup\u003e p value, \u003csup\u003e5\u003c/sup\u003eadjusted odds ratio, \u003csup\u003e6\u003c/sup\u003e mixed day and boarding school\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eClassroom-related factors.\u003c/p\u003e\n\u003cp\u003eSpecific classroom factors were collected in 97 schools for 322 classrooms of which 40 (12.4%) classrooms had at least one case. A total of 5,106 pupils studied in the 322 classrooms, of whom 56 (1.1%) were infected. Although the construction materials of the classrooms were recorded, these were not included in the models since 99.4% of classrooms had an iron sheet roof, 95.6% had walls of bricks, cement blocks or stones and 99% had concrete floors. The distribution of pupils by all classroom variables is presented in Additional file S3.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the univariable analysis, tungiasis was positively associated with all the variables assessed except the number of pupils enrolled in a classroom and the pupil density (number of pupils per m\u003csup\u003e2\u003c/sup\u003e) in a classroom (Table 2). The condition of the concrete floor, the amount of soil on the floor \u0026nbsp;and cleanliness of the classroom were all correlated to each other according to Pearson\u0026rsquo;s chi2 (p\u0026lt;0.001, Additional file S3). However, the Variance Inflation Factors of 1.04, 1.37 and 1.39 respectively suggest there was no collinearity. After Backward elimination only the amount of soil on the concrete floor was retained in the final model. Fifteen percent of pupils studied in a classroom with a lot of loose soil on the floor and they had a three times higher odds of being infected than those in a classroom with none or only a little soil on the floor (aOR 3.23, 95% CI 1.40---7.46, p=0.006) (Table 2). Tungiasis was also positively associated with the number of pupils absent on the day of the survey (aOR 1.12, 95% CI 1.03-1.23, p=0.013), that is, the more pupils who were absent the higher the odds a child who was present had tungiasis. As before, pupil sex was also associated with infection. \u0026nbsp;The intra-class coefficient for county was 0.00 (95% CI 0.00-1.0) and for the schools it was 0.33 (95% CI 0.17-0.55).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Table 2. Mixed effects logistic regression for classroom factors associated with pupil infection, county and school as random effects (n=5106 pupils, 56 infected).\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"959\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 191px;\"\u003e\n \u003cp\u003eUnivariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 180px;\"\u003e\n \u003cp\u003eFull multivariable (n=4872)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 184px;\"\u003e\n \u003cp\u003eFinal multivariable (n=5101)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eCategories\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eN (%)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e% infected\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003eOR\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e(95% CI\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003eP\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003eaOR\u003csup\u003e5\u003c/sup\u003e (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003eaOR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003ePupil age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e5106 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e0.84 (0.72-0.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.90 (0.76-1.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.226\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003ePupil sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e2582 (50.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e2523 (49.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e2.25 (1.27-4.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2.04 (1.10-3.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2.23 (1.25-3.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003eNumber of pupils enrolled\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e5071 (99.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e1.01 (0.99-1.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.328\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003eNumber of pupils absent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e5106 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e1.11 (1.01-1.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1.08 (0.98-1.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1.12 (1.03-1.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003ePupil density\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e5054 (99.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e0.47 (0.13-1.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.242\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eCondition of concrete floors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;Good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e2212 (43.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;Cracked\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e2661 (52.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e2.20 (0.79-6.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1.24 (0.49-3.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.651\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 112px;\"\u003e\n \u003cp\u003eAmount of loose soil\u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;None or a little\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e4322 (84.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp; A lot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e780 (15.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e3.08 (0.76-10.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1.78 (0.64-4.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.275\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e3.23 (1.40-7.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 112px;\"\u003e\n \u003cp\u003eClassroom cleanliness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;Not tidy \u0026amp; clean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e585 (11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;Tidy \u0026amp; clean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e4521 (88.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e2.22 (0.92-5.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.077\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1.51 (0.53-4.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.437\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003enumber of observations in univariable model and percent of total observations, \u003csup\u003e2\u003c/sup\u003eodds ratio \u003csup\u003e3\u003c/sup\u003econfidence interval, \u003csup\u003e4\u003c/sup\u003e p value, \u003csup\u003e5\u003c/sup\u003eadjusted odds ratio, \u003csup\u003e6\u003c/sup\u003e number of pupils/ m\u003csup\u003e2\u003c/sup\u003e of classroom, \u003csup\u003e7\u0026nbsp;\u003c/sup\u003eamount of loose soil, dust or sand on top of concrete floors\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Headteachers and teachers\u0026rsquo; knowledge and attitudes\u003c/p\u003e\n\u003cp\u003eOf the 197 headteachers interviewed, 26.4% (52) were female, while 51% (60) of the 117 teachers were female. Both teachers and headteachers had worked in the school for a median of three years (IQR 2-6).\u003c/p\u003e\n\u003ch4\u003eHead (Teacher) awareness of tungiasis situation in schools\u003c/h4\u003e\n\u003cp\u003eTo assess the level of awareness of the tungiasis status of pupils in their school, headteachers were asked if they thought there were cases in the school, and we compared their response to the results of our foot examinations. At the time of the interview respondent headteachers were not aware of the results of the pupil examinations conducted by the research team. Of the 76 headteachers in schools with at least one case, only 45% (34) were correct in reporting there were cases in their school (Pearson Chi\u003csup\u003e2\u003c/sup\u003e p \u0026lt;0.001, Table 3). Teachers were asked if they knew of cases in their grade. Of the 19 teachers in grades with at least one case, 74% (14) were correct in reporting they had cases in their grade (Table 3). Awareness of teachers had a 74% sensitivity and 96% specificity, while that of head teachers had only 45% sensitivity but 92% specificity (Table3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe 55% of headteachers who incorrectly reported that the school had no cases, were in schools with a lower prevalence (median 0.95%, IQR 0.9-2.7) than those who were correct (median 2.25%, IQR 0.9-4.4, p=0.065). However, this difference was not statistically significant in the Wilcoxon rank sum test. For teachers the difference was significant (median 2.7%, IQR 1.8-5.4 vs. 0.9%, IQR 0.9-1.8, p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Table 3. (Head)teacher awareness of the tungiasis situation in their school. Chi2 tests and sensitivity/ specificity tests of their awareness as an indicator of the tungiasis status of pupils in their school or grade.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"626\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 235px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTeachers\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 268px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHeadteachers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003eFoot exam diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes, have cases in my grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003eNo cases in my grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003eYes, have cases in my school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eNo cases in my school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eAt least one case\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e14 (73.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e5 (26.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e34 (44.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e42 (55.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eNo cases\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4 (4.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e94 (95.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e9 (7.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e111 (92.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e18 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e99 (84.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e43 (21.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e153 (78.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e196\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003ePearson Chi\u003csup\u003e2\u003c/sup\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eSensitivity \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e73.70%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e48.8%-90.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e44.70%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e33.3%-56.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eSpecificity \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e95.90%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e89.9%-98.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e92.40%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e86.1%-96.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003ePositive predictive value \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e77.80%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e52.4%-93.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e79.10%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e64.0%-90.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eNegative predictive value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e94.90%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e88.6%-98.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e72.40%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e64.5%-79.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;One limitation often proposed for using school-based surveys to assess prevalence and risk factors, is that the most severe cases will be missed as they are unable to attend school on account of their poor mobility. To date there is no evidence to support this, so we asked teachers if they knew if there were pupils missing from their class due to tungiasis, and four teachers from four schools (11.4% of affected schools) said there were. The schools with pupils absent on account of tungiasis had higher prevalence among the pupils who did attend, than schools who did not have any pupils absent on account of tungiasis (median 4.6, IQR 2.3-7.1 vs. 1.8, IQR 0.9-3.1, Wilcoxon rank sum p=0.002).\u003c/p\u003e\n\u003ch4\u003eKnowledge of and impact of tungiasis\u003c/h4\u003e\n\u003cp\u003eThose headteachers and teachers who said they currently or previously had tungiasis cases in their school were asked more questions about the disease and its impact on pupils. A total of 80 headteachers and 30 teachers responded (Fig 1). The headteachers and teachers were asked why they thought infected pupils had tungiasis and the majority attributed it to family poverty (70%) and poor hygiene (87%). A few also suggested it was due to lack of adult care (15.5%), lazy parents (18.2%), and to living in an area with red soil (14.5%), and 80% consider the disease to be seasonal, being worse during \u0026ldquo;hot, dry, and dusty\u0026rdquo; times of the year.\u003c/p\u003e\n\u003cp\u003eRespondents were asked their opinion as to how they thought pupils with tungiasis are affected by the disease. The most common impacts mentioned were poor concentration in class, low academic performance, poor attendance, mobility, stigma, \u0026ldquo;poor health/ sickly\u0026rdquo;, low self-esteem, and being \u0026ldquo;uncomfortable or restless\u0026rdquo;. Other impacts mentioned by a few respondents were being \u0026ldquo;tired\u0026rdquo;, sleeping in class, \u0026ldquo;mentally disturbed\u0026rdquo;, \u0026ldquo;poor memory\u0026rdquo;, and \u0026ldquo;socially isolated\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003eWhen headteachers and teachers were specifically asked about the psychological impact on pupils compared to uninfected pupils, only two felt they were no different to uninfected pupils. Around one third mentioned that they were sad (29.1%), quiet (25.5%), withdrawn (36.4%) and seemed ashamed or embarrassed (38.2%). More than half (60%) said pupils with tungiasis are excluded by other pupils and 42.7% said pupils with tungiasis were ridiculed by others. When asked about the parents of the infected pupils, 58% felt the parents of infected pupils engage less, and 60% felt parents were less likely to come to school when asked, compared to parents of uninfected pupils.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealth programs in school\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn Kenya, public health officers run school health programs and regularly visit schools to do so and to identify health issues in the schools. All schools run a health club and have a teacher responsible for coordinating this and monitoring pupil health. Often non-governmental organizations partner with the department of health and schools to assist with these programs. During the interviews headteachers were asked what health interventions had been conducted, including for tungiasis, and when. Despite 21.9% (43) of headteachers thinking they had pupils in their school with tungiasis and being aware of the impact it had on their academic achievement, only 6.1% (12) of all headteachers reported there had been an intervention activity run by the local health department or a non-governmental organization to treat the pupils, and for 75% (9) of those, that was more than a year before the interview. For the 12 schools who had had an intervention, in only six had pupils been treated, either with potassium permanganate, coconut oil or neem oil, and for three schools fumigation of pupils\u0026rsquo; homes had been conducted. Only 9.6% (19) of all headteachers reported having an active program to teach pupils about tungiasis and prevention, while 91.3% (179) of headteachers reported having a hygiene program and 60.7% (119) had other health interventions (COVID-19, polio, measles, trachoma, nutrition, menstrual hygiene, human papilloma virus and cervical cancer) in their school.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe provide evidence of an association of infection in pupils aged 8-to-14 years with studying in schools with neglected infrastructure and poor cleanliness, having broken concrete floors and large amounts of loose soil or sand on the classroom floor. These factors are all linked to the developmental biology of the sand flea. The larvae need a certain amount of soil or sand to burrow in to prevent dehydration and avoid predation. The pupae require particles of soil/sand to coat themselves for protection [8]. Sand flea eggs expelled from the feet of an infected pupil wearing open or no shoes during class time, could drop on the sand and the off-host life cycle could be completed in the classroom. Consequently, keeping classroom floors in good condition and dust/soil-free may help to reduce parasite development and pupil infection. Apart from one other study conducted previously in Kilifi County in 2014 [17], no other study has investigated factors in schools that may be associated with tungiasis. Many risk factor studies have been conducted with school pupils in schools, but these have focused on the pupil and their home. In our own work, we previously concluded that the home environment is largely responsible for infection risk, but we also found indications that the school environment is a contributing factor [17].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTungiasis has previously, and in the current study population, been associated with not washing feet at least once a day with soap [4, 6, 17, 23]. Children in resource poor families may well not have access to water and/or soap at home, or parents lack the ability to enforce washing every day before and/or after school. We have found that in addition, if a school did not have constant access to water, the pupils had a higher risk of infection. Promoting foot hygiene and providing facilities for foot washing in school for those who do not have access at home could help reduce infection among pupils.\u003c/p\u003e\n\u003cp\u003eThe majority of headteachers and teachers in affected schools knew that tungiasis was associated with poverty and poor hygiene and its impact on children, but there was rarely systematic action to help individual children to wash in school, nor implement a school-wide intervention program. While most schools had a general hygiene program, these programs focused on handwashing to prevent diarrheal diseases and soil transmitted helminths, and of course at the time of this study, COVID-19.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe findings of this study indicate headteachers are not very aware of the tungiasis situation in their school and are only likely to be if the school prevalence is over 1%. Consequently, if health officials or organizations rely on asking headteachers about the tungiasis situation, they are unlikely to get an accurate report. A higher proportion of teachers than headmasters correctly reported there were cases in the school or grade. This is not surprising since teachers have more contact with pupils each day, but there seems to be a lack of communication with school management to potentially address the problem.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost headteachers and teachers felt tungiasis is seasonal and associated with the hot, dry or dusty times of year. Only one past survey in Brazil [24], has systematically investigated the seasonality and found the prevalence to be highest in the dry season. More studies are clearly needed to confirm this to provide health departments with the best time of the year to target for prevention interventions, before transmission begins to rise.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost headteachers and teachers were not aware of the major impacts tungiasis has on children, except that they are stigmatized by other pupils, being excluded and ridiculed. Only a third or less of respondents in affected schools identified lack of concentration in class, absenteeism, poor academic performance, and the child’s psychological state. We have reported previously how the infected pupils in these schools, themselves reported having difficulty concentrating in class and sleeping at night, being ashamed, sad and angry, and observations of their school records found infected pupils missed more days of school and had lower exam results [11]. Many of these impacts have also been documented by previous studies [12, 25].\u003c/p\u003e\n\u003cp\u003eSomething that has rarely been explored before in relation to children with tungiasis is the role parents may play in the child’s risk of infection. Two thirds of headteachers and teachers felt that parents of children with tungiasis were less engaged with the school than parents of uninfected pupils and were less likely to attend a meeting when specifically asked to come. This could reflect parental neglect of the child or shame regarding their child’s infection. Some teachers thought the child’s infection was caused by “lack of adult care”, or from having “lazy parents” and some were aware that there were problems at home for infected children and named poverty, alcohol use, divorce and illiteracy. The causes of neglect are likely to be many, but previously tungiasis has been shown to be associated with caregiver depression [26], which itself has been associated with child neglect [27] and poor hygiene of children [28]. Further research is needed to determine if there is an association between tungiasis and parental neglect, and to explore the possible reasons for child neglect in these communities and how that might be changed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLIMITATIONs\u003c/p\u003e\n\u003cp\u003eThis study had one major limitation which was that it was not designed as a case: control study for school-related risk factors but rather was nested in a fully randomized prevalence survey which resulted in a low number of tungiasis cases encountered during the surveys, particularly when the detailed classroom observations and teacher interviews were conducted. \u0026nbsp;Another limitation was the use of semi-structured interview tools which did not allow (head)teachers to give much depth in their responses. However, this would have required more time for the interviews and more complex training for the field teams which had to be conducted online due to the COVID-19 epidemic restrictions. \u0026nbsp;A third limitation was the use of subjective measures for several of the variables, such as building condition, cleanliness and the amount of soil on concrete floors. The field teams were trained using verbal descriptions only and inter-observer reliability was not tested, so some inter-observer variability and bias is possible. To reduce the impact of this source of bias the countyunique identifier was used as a second random effect in the logistic regression models. However, the intra-cluster coefficients for county in both models indicate there was no cluster effect related to the counties\u003cstrong\u003e.\u003c/strong\u003e\u0026nbsp; Lastly, the purposive selection of counties could bias the conclusions to be only relevant for the specific climates included. However, the selection included all major climate types from very arid to humid, as well as a cross-section of geography and cultures of Kenya. Since these climates are typical of most endemic countries the findings are likely generalizable to other countries in both Sub-Saharan Africa and Latin America. In addition, the analyses included the county as a random effect so that all findings are relevant to all climate types included.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e“While the cross-sectional study design did not enable us to identify causation, we have identified several modifiable school-related factors that were associated with a higher odds of tungiasis for pupils aged 8-to-14 years. Changing these factors could reduce the likelihood of schoolchildren becoming infected. These findings underscore the importance of a One Health, multisectoral approach to tungiasis control. The Department of Health in endemic areas should collaborate with school Boards of Management and headteachers to raise awareness of tungiasis, implement routine pupil monitoring, and ensure school environments are well-maintained, clean, and consistently supplied with water. Pupils should also be encouraged to wash their feet at school if they are not able to do so at home.”\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ea\u003cem\u003eOR\u003c/em\u003e Adjusted odds ratio\u003c/p\u003e\n\u003cp\u003eCHMT County Health Management Team\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCI\u003c/em\u003e Confidence Interval\u003c/p\u003e\n\u003cp\u003eKEMRI Kenya Medical Research Institute\u003c/p\u003e\n\u003cp\u003eNTDs Neglected Tropical Diseases\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOR\u003c/em\u003e Odds ratio\u003c/p\u003e\n\u003cp\u003ePTA Parent Teachers Association\u003c/p\u003e\n\u003cp\u003eSES Socio-economic status\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSD\u003c/em\u003e Standard deviation\u003c/p\u003e\n\u003cp\u003eWASH Water, sanitation and hygiene\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in accordance with the Helsinki Declaration. It was initially approved by the KEMRI Scientific and Ethics Review Committee (approval number KEMRI/SERU/CGMR-C/170/3895) as well as the Oxford Tropical Research Ethics Committee (reference number 38-19) in August 2019. During the community engagement phase, a presentation was made to the national Director for Neglected Tropical Diseases at the Ministry of Health, the county and sub-County Health Management Teams and the Department of Education in all counties to obtain their approval. In each school a meeting was held with the school Parent Teachers’ Association (PTA) or management board to obtain their permission to conduct the survey in their school. The head teacher and PTA chairperson signed the consent form on behalf of the parents and school for the pupils to be examined and observations to be made of the school. Each child gave verbal assent. Community health workers were hired and trained in each school to assist and be the link with the community emphasizing that participation was completely voluntary, and subjects had the opportunity to withdraw from the study at any point in the study. Each of the headteachers and teachers who were interviewed first gave informed consent.\u003c/p\u003e\n\u003cp\u003eAll data were collected on PIN protected electronic tablets, stored on password protected RedCap databases on the KEMRI-Wellcome Trust servers. Data were analyzed after export to Excel spreadsheets without inclusion of personal identifiers.\u003c/p\u003e\n\u003cp\u003eAll pupils with tungiasis were referred for treatment to the community health workers or the local health facility using benzyl benzoate provided by the study. For those with secondary bacterial infection and other illnesses requiring treatment, a referral was made to the nearest health facility.\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eAll the authors have reviewed and approved the publication of this paper.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eThe datasets and other materials supporting the conclusions of this article are available on KWTRP Research Data Repository at Harvard Dataverse through the following link: \u0026nbsp; https://doi.org/10.7910/DVN/XM4K5I.\u003c/p\u003e\n\u003ch3\u003eSupplementary material\u003c/h3\u003e\n\u003cp\u003eS1 Distribution of pupil population by school variables\u003c/p\u003e\n\u003cp\u003eS2 Distribution of pupil population by classroom variables\u003c/p\u003e\n\u003cp\u003eS3 Correlation of classroom variables with each other\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eAll authors declare no conflict of interest.\u003c/p\u003e\n\u003ch3\u003eFunding Information\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eResearch funding for this work was provided by the Wellcome Trust through the project “Epidemiology of Tungiasis” (grant number 213724/Z/18/) granted to Lynne Elson as a Career Re-Entry Fellowship.\u0026nbsp;This work\u0026nbsp;was written\u0026nbsp;with the permission of Director KEMRI-CGMRC.\u0026nbsp;The views expressed herein do not necessarily reflect the official opinion of the donors. The funders had neither a role in the design of the study, nor in collection, analysis, interpretation of data nor in writing the manuscript.\u003c/p\u003e\n\u003ch3\u003eAuthor Contributions\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eConceptualization,\u0026nbsp;LE, UF, MM, IA, PB; Methodology,\u0026nbsp;LE, UF,\u0026nbsp;PB, BO, MM, IA; Formal Analysis, LE,\u0026nbsp;BO; Investigation,\u0026nbsp;LE, CK, SK, CM, GG, EC, MO, ES, JK, EM, MW, JL; Resources,\u0026nbsp;LE, PB; Data Curation, LE\u0026nbsp;; Writing – Original Draft Preparation, LE.; Writing – Review \u0026amp; Editing,\u0026nbsp;CK, SK, CM, GG, EC, MO, ES, JK, EM, MW, JL\u0026nbsp;, UF,\u0026nbsp;BO, PB, MM, IA; Visualization, LE.; Supervision,\u0026nbsp;PB; Project Administration,\u0026nbsp;LE, MM, PB; Funding Acquisition,\u0026nbsp;LE, MM, PB.\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eWe are grateful to the County Tungiasis Team Leaders:\u0026nbsp;Wambani Zablon\u003csup\u003e3\u003c/sup\u003e, Collins Kipkorir\u003csup\u003e4\u003c/sup\u003e, Philip Nzyoka\u003csup\u003e5\u003c/sup\u003e, Moses Obiero\u003csup\u003e6\u003c/sup\u003e, Marawan Elijah\u003csup\u003e7\u003c/sup\u003e, Jacob Kapombe\u003csup\u003e8\u003c/sup\u003e, Kuyan Malano\u003csup\u003e9\u003c/sup\u003e, Caleb Kasuku\u003csup\u003e10\u003c/sup\u003e, Rael Kukule\u003csup\u003e11\u003c/sup\u003e from Departments of Health in \u003csup\u003e3\u003c/sup\u003eMuranga, \u003csup\u003e4\u003c/sup\u003eKericho, \u003csup\u003e5\u003c/sup\u003eMakueni, \u003csup\u003e6\u003c/sup\u003eNakuru, \u003csup\u003e7\u003c/sup\u003eSamburu, \u003csup\u003e8\u003c/sup\u003eKilifi, \u003csup\u003e9\u003c/sup\u003eKajiado, \u003csup\u003e10\u003c/sup\u003eTaita Taveta, \u003csup\u003e11\u003c/sup\u003eTurkana,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe are also grateful to the communities who participated, the school Parent Teacher Associations and Head Teachers who allowed us to work in their schools, the county Directors of Health and Education who gave their approval for the study and assisted in many ways to ensure its success. We acknowledge the efforts and dedication of Henry Kivuva (RIP) to set up the survey in Makueni County. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eFeldmeier H, Heukelbach J, Ugbomoiko US, Sentongo E, Mbabazi P, von Samson-Himmelstjerna G, et al. Tungiasis--a neglected disease with many challenges for global public health. PLoS Negl Trop Dis. 2014;8(10):e3133. doi: 10.1371/journal.pntd.0003133.\u003c/li\u003e\n \u003cli\u003eWorld_Health_Organization. Ending the neglect to attain the Sustainable Development Goals: a road map for neglected tropical diseases 2021\u0026ndash;2030. Geneva: World Health Organization 2020. Available from: https://www.who.int/publications/i/item/9789240010352.\u003c/li\u003e\n \u003cli\u003eWorld_Health_Organization. Ending the neglect to attain the Sustainable Development Goals: a strategic framework for integrated control and management of skin-related neglected tropical diseases. Geneva2022. Available from: https://www.who.int/publications/i/item/9789240051423.\u003c/li\u003e\n \u003cli\u003eWiese S, Elson L, Reichert F, Mambo B, Feldmeier H. Prevalence, intensity and risk factors of tungiasis in Kilifi County, Kenya: I. Results from a community-based study. PLoS Negl Trop Dis. 2017;11(10):e0005925. doi: 10.1371/journal.pntd.0005925.\u003c/li\u003e\n \u003cli\u003eMutebi F, McNeilly H, Thielecke M, Reichert F, Wiese S, Mukone G, et al. Prevalence and Infection Intensity of Human and Animal Tungiasis in Napak District, Karamoja, Northeastern Uganda. Trop Med Infect Dis. 2023;8(2). doi: 10.3390/tropicalmed8020111.\u003c/li\u003e\n \u003cli\u003eElson L, Kamau C, Koech S, Muthama C, Gachomba G, Sinoti E, et al. National prevalence and risk factors for tungiasis in Kenya. Infect Dis Poverty. 2023;12(1):85. doi: 0.1186/s40249-023-01131-x.\u003c/li\u003e\n \u003cli\u003eEisele M, Heukelbach J, Van Marck E, Mehlhorn H, Meckes O, Franck S, et al. Investigations on the biology, epidemiology, pathology and control of Tunga penetrans in Brazil: I. Natural history of tungiasis in man. Parasitol Res. 2003;90(2):87-99. doi: 10.1007/s00436-002-0817-y.\u003c/li\u003e\n \u003cli\u003eNagy N, Abari E, D\u0026apos;Haese J, Calheiros C, Heukelbach J, Mencke N, et al. Investigations on the life cycle and morphology of Tunga penetrans in Brazil. Parasitol Res. 2007;101 Suppl 2:S233-42. doi: 10.1007/s00436-007-0683-8.\u003c/li\u003e\n \u003cli\u003eFeldmeier H, Eisele M, Van Marck E, Mehlhorn H, Ribeiro R, Heukelbach J. Investigations on the biology, epidemiology, pathology and control of Tunga penetrans in Brazil: IV. Clinical and histopathology. Parasitol Res. 2004;94:275\u0026ndash;82.\u003c/li\u003e\n \u003cli\u003eFeldmeier H, Heukelbach J, Eisele M, Sousa AQ, Barbosa LM, Carvalho CB. Bacterial superinfection in human tungiasis. Trop Med Int Health. 2002;7(7):559-64. doi: 10.1046/j.1365-3156.2002.00904.x.\u003c/li\u003e\n \u003cli\u003eElson L, Kamau C, Koech S, Muthama C, Gachomba G, Sinoti E, et al. Children with tungiasis in Kenya have poor school performance and quality of life. medRxiv preprint. 2023. doi: 10.1101/2023.11.17.23298667v1.\u003c/li\u003e\n \u003cli\u003eWiese S, Elson L, Feldmeier H. Tungiasis-related life quality impairment in children living in rural Kenya. PLoS Negl Trop Dis. 2018;12(1):e0005939. doi: 10.1371/journal.pntd.0005939.\u003c/li\u003e\n \u003cli\u003eMuehlen M, Feldmeier H, Wilcke T, Winter B, Heukelbach J. Identifying risk factors for tungiasis and heavy infestation in a resource-poor community in northeast Brazil. Trans R Soc Trop Med Hyg. 2006;100(4):371-80. doi: 10.1016/j.trstmh.2005.06.033.\u003c/li\u003e\n \u003cli\u003eElson L, Matharu AK, Riithi N, Ouma P, Mutebi F, Feldmeier H, et al. Characterization of tungiasis infection and morbidity using thermography in Kenya revealed higher disease burden during COVID-19 school closures. Infectious Diseases of Poverty. 2023;12(1):24. doi: 10.1186/s40249-023-01080-5.\u003c/li\u003e\n \u003cli\u003eMatharu AK, Ouma P, Njoroge MM, Amugune BL, Hyuga A, Mutebi F, et al. Identification of tungiasis infection hotspots with a low-cost, high-throughput method for extracting Tunga penetrans (Siphonaptera) off-host stages from soil samples-An observational study. PLoS Negl Trop Dis. 2024;18(2):e0011601. doi: 10.1371/journal.pntd.0011601.\u003c/li\u003e\n \u003cli\u003eNyangacha RM, Odongo D, Oyieke F, Bii C, Muniu E, Chasia S, et al. Spatial distribution, prevalence and potential risk factors of Tungiasis in Vihiga County, Kenya. PLoS Negl Trop Dis. 2019;13(3):e0007244. doi: 10.1371/journal.pntd.0007244.\u003c/li\u003e\n \u003cli\u003eElson L, Wiese S, Feldmeier H, Fillinger U. Prevalence, intensity and risk factors of tungiasis in Kilifi County, Kenya II: Results from a school-based observational study. PLoS Negl Trop Dis. 2019;13(5):e0007326. doi: 10.1371/journal.pntd.0007326.\u003c/li\u003e\n \u003cli\u003eUgbomoiko US, Ariza L, Ofoezie IE, Heukelbach J. Risk factors for tungiasis in Nigeria: identification of targets for effective intervention. PLoS Negl Trop Dis. 2007;1(3):e87. doi: 10.1371/journal.pntd.0000087.\u003c/li\u003e\n \u003cli\u003eElson L, Kamau C, Koech S, Muthama C, Gachomba G, Sinoti E, et al. Tungiasis among children in Kenya is associated with poor nutrition status, absenteeism, poor school performance and high impact on quality of life. PLoS Negl Trop Dis. 2024;18(5):e0011800. doi: 10.1371/journal.pntd.0011800.\u003c/li\u003e\n \u003cli\u003eHarris P, Taylor R, Thielke R, Payne J, Gonzalez N, Conde J. Research electronic data capture (REDCap) \u0026ndash; A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-81. doi: 10.1016/j.jbi.2008.08.010.\u003c/li\u003e\n \u003cli\u003eElson L, Thielecke M, Fillinger U, Feldmeier H. Infection with tungiasis through interhost movement of adult female sand fleas, Tunga penetrans. Trans R Soc Trop Med Hyg. 2022;116(2):85-6. doi: 10.1093/trstmh/trab117.\u003c/li\u003e\n \u003cli\u003eDziura JD, Post, L. A., Zhao, Q., Fu, Z., \u0026amp; Peduzzi, P. . Strategies for dealing with missing data in clinical trials: from design to analysis. The Yale journal of biology and medicine. 2013;86(3):343.\u003c/li\u003e\n \u003cli\u003eNsanzimana J, Karanja S, Kayongo M, Nyirimanzi N, Umuhoza H, Murangwa A, et al. Factors associated with tungiasis among primary school children: a cross-sectional study in a rural district in Rwanda. BMC Public Health. 2019;19(1):1192. doi: 10.1186/s12889-019-7481-y.\u003c/li\u003e\n \u003cli\u003eHeukelbach J, Wilcke T, Harms G, Feldmeier H. Seasonal variation of tungiasis in an endemic community. Am J Trop Med Hyg. 2005;72(2):145-9.\u003c/li\u003e\n \u003cli\u003eMcNeilly H, Thielecke M, Mutebi F, Banalyaki M, Reichert F, Wiese S, et al. Tungiasis Stigma and Control Practices in a Hyperendemic Region in Northeastern Uganda. Trop Med Infect Dis. 2023;8(4). doi: 10.3390/tropicalmed8040206.\u003c/li\u003e\n \u003cli\u003eOtieno B, Elson L, Matharu AK, Riithi N, Chongwo E, Katana K, et al. Neurocognitive and mental health outcomes in children with tungiasis: a cross-sectional study in rural Kenya and Uganda. Infectious Diseases of Poverty. 2023;12(1):100. doi: 10.1186/s40249-023-01154-4.\u003c/li\u003e\n \u003cli\u003eCummings EM, Davies PT. Maternal depression and child development. Journal of child psychology and psychiatry. 1994;35(1):73-112.\u003c/li\u003e\n \u003cli\u003eRunyan D, Wattam C, Ikeda R, Hassan F, Ramiro L. Child abuse and neglect by parents and other caregivers. In: Krug EG, Dahlberg JA, Mercy AB, Lozano Z, LozanoR, editors. World report on violence and health Geneve, Switzerland: World Health Organization; 2002. p. 57\u0026ndash;86.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Tungiasis, NTDs, schools, sanitation, WASH","lastPublishedDoi":"10.21203/rs.3.rs-5070518/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5070518/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003cbr\u003e\nTungiasis 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\nThis 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nKey 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003cbr\u003e\nTo 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.\u003c/p\u003e","manuscriptTitle":"School-related risk factors for tungiasis among children aged 8 to 14 years in nine counties of Kenya: a cross-sectional survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-10 05:14:46","doi":"10.21203/rs.3.rs-5070518/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-06T09:46:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2026-02-05T05:50:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-05T05:48:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-21T06:34:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-10-20T06:19:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"95e6436a-8a63-4d83-add4-d228735309a3","owner":[],"postedDate":"November 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-05T05:53:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-10 05:14:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5070518","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5070518","identity":"rs-5070518","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}