Abstract

Background: Intestinal parasitic infections remain a public health concern in tropical regions, particularly among school-aged children who are exposed to risk factors such as animal husbandry and inadequate sanitation conditions.

Objective: This study aimed to determine the prevalence of intestinal parasitosis in schoolchildren and subsequently to evaluate the relationship between ivermectin use, handwashing practices, and animal husbandry and the prevalence of intestinal parasitosis in schoolchildren in a tropical region of Peru.

Methods: A cross-sectional analytical study was conducted from June 2022 to December 2022 among 107 schoolchildren in Tingo María, Peru. Data were collected through a structured questionnaire administered to parents/guardians and direct coproparasitological analysis of fecal samples. Statistical analysis included descriptive statistics, Chi-square tests, and Poisson regression.

Results: A high prevalence of intestinal parasitosis was observed (76.6%). Among the evaluated factors, prior ivermectin use was significantly associated with a lower frequency of parasitic infection (p=0.037; PR=0.63; 95% CI: 0.42-0.93). Animal husbandry also showed a significant association, whereas handwashing was not identified as a determining factor.

Conclusion: The finding that prior ivermectin use may be associated with a reduced prevalence of intestinal parasitosis opens new avenues for further research into its potential role in endemic regions. This result warrants further research to evaluate its effectiveness as part of community-level parasitic control strategies.

Keywords: Intestinal parasitosis, ivermectin, COVID, mass drug administration, Peru.

INTRODUCTION

Intestinal parasitic infections remain a significant public health issue, particularly in developing countries and regions. It is estimated that more than 30% of the global population is affected by intestinal parasitic infections, compromising over 40 million preschool-aged children in Latin America alone [1]. In general, the incidence and severity of these infections are higher during school age, which is associated with an increased risk of morbidity [2].

In Peru, the Pan American Health Organization (PAHO) reports that intestinal parasitosis shows a high prevalence and ranks among the top ten causes of morbidity and mortality. A 2022 study reported an overall parasitic infection prevalence of 63.6% and a helminth infection prevalence of 9.8% [3]. Furthermore, 68% of the country's regions (17 out of 25) reported high prevalence rates, with Amazonas, La Libertad, Cajamarca, Huancavelica, and Huánuco being the most affected [1].

Intestinal parasitic infections, particularly when associated with nutritional anemia, protein-energy malnutrition, and growth delays, can have detrimental effects on child health and impair cognitive development [4]. In many endemic settings, these infections persist as chronic and latent conditions at both the individual and collective levels, maintaining a state of stable endemicity [5].

In endemic regions where the burden of intestinal parasitic diseases is high, the widespread use of medications such as ivermectin—driven by fear of COVID-19—may have indirectly contributed to a reduction in the prevalence of these infections [6]. In the field of pharmacology, it is not uncommon for certain drugs initially approved for a specific indication to exhibit secondary effects that prove beneficial for other health conditions. This phenomenon has led to the extended use of medications for purposes not contemplated initially, a practice known as "off-label" use [7].

Preventing parasitic diseases requires comprehensive interventions that improve living conditions, including nutrition, access to adequate housing, health education, and environmental sanitation [8]. However, a substantial proportion of the population still lacks these necessities, underscoring the urgent need to implement health education strategies to prevent these infections [9].

In this context, it is relevant to explore how standard practices during recent public health events—such as the widespread use of ivermectin during the COVID-19 pandemic—may have indirectly influenced the prevalence of intestinal parasitic infections. Given the high burden of intestinal parasitosis in tropical regions and limited access to healthcare services, the present study aimed to determine the prevalence of intestinal parasitosis among schoolchildren. Subsequently, it aimed to determine the relationships among ivermectin use, handwashing practices, and animal husbandry and the prevalence of intestinal parasitosis in school children.

METHODS

A cross-sectional study was conducted from June 2022 to December 2022 among 4th and 5th-grade students at the César Vallejo Educational Institution in Tingo María, Peru. The research protocol was approved by the Ethics and Research Committee of the Faculty of Human Medicine of the National University Hermilio Valdizán on February 17, 2022, in Huánuco. Participants were excluded if they had received antiparasitic Treatment within the past 3 months, had chronic gastrointestinal conditions, or provided incomplete questionnaire or fecal sample data. Students and their parents/guardians who declined to participate were also excluded. Before data collection, written informed consent was obtained from parents or legal guardians, and verbal assent from participating students. These criteria were implemented to maintain internal validity while preserving the representative nature of this school-based study in an endemic area.

Instead of selecting a sample, this study adopted a census-based approach to include the entire eligible population of 4th- and 5th-grade primary students enrolled at the César Vallejo Educational Institution during the 2022 academic year (N=150). Therefore, no formal sample size calculation or statistical software was employed, as the objective was to maximize participant inclusion from the complete target population during the study period. After applying the exclusion criteria and obtaining all necessary informed consents, 107 students were ultimately included, yielding a participation rate of 71.3% of the target population.

Data collection was synchronized with the school term to maximize participant availability and minimize disruptions to educational activities. The study tool consisted of a data collection form with two sections: a structured questionnaire for the parent/guardian interview and a record of direct coproparasitological analysis results from the fecal samples.

Within the structured questionnaire, 'Knowledge of hand washing technique' was assessed through three specific items: situations for handwashing, adherence to hand washing steps, and types of supplies used. Participants who answered correctly to two or more of these three items were categorized as having 'adequate' knowledge. In comparison, those who responded correctly to one or zero items were considered to have 'inadequate' knowledge.

Separately, 'Hand washing technique' (referring to the quality of the practice) was assessed using a 10- item questionnaire administered to parents/guardians, evaluating various aspects of proper handwashing execution. Participants who correctly answered five or fewer of these 10 items were categorized as having 'inadequate' hand washing technique. In contrast, those with more than five correct answers were considered to have 'adequate' handwashing technique.

Additionally, sterile containers were provided for the collection of fecal samples. All stool samples collected were transported in a cold chain (43.2°F to 47.2°F) and processed within 2 to 4 hours. Parasitological examination was performed using direct saline smears and the spontaneous sedimentation concentration technique (Ritchie). All samples were analyzed by an expert microbiologist at the Tingo María hospital laboratory to identify cysts, eggs, or larvae.

Data were entered into Microsoft Excel and subsequently analyzed using SPSS version 26. Bivariate and multivariable Poisson regression analyses with robust standard errors were performed to estimate Prevalence Ratios (PRs) and their 95% confidence intervals to assess the association between various factors and intestinal parasitosis. This approach, using Poisson regression with a log link, was specifically chosen for our cross-sectional study with a binary outcome and high observed prevalence to estimate prevalence ratios [10, 11] directly. P-values less than or equal to 0.05 were taken as statistically significant.

RESULTS

During the study period, 107 students from the 4th and 5th grades of primary education at the César Vallejo Educational Institution in Castillo Grande, Tingo María, participated in the study in 2022. Regarding sociodemographic characteristics, 43.93% were male and 56.07% female. The average age was 10 ± 1 years. A total of 55.14% were enrolled in the 4th grade and 44.86% in the 5th grade.

Table 1 presents the clinical characteristics obtained from the questionnaires and laboratory reports. The prevalence of intestinal parasitosis was 76.60%, with Ascaris lumbricoides being the most frequently identified parasite (34.10%), followed by Giardia lamblia (24.40%). A high prevalence of domestic animal rearing was also observed, with poultry as the most common farm animal (37.40%) and dogs as the most frequent companion animal (59.80%).

The results of the bivariate analysis are presented in Table 2. Several factors were significantly associated with the prevalence of intestinal parasitosis. Ivermectin consumption was associated with a lower prevalence of parasitosis (p=0.037; PR=0.797, 95% CI: 0.636- 0.998), indicating a 20.3% lower prevalence among children who had taken the medication. Similarly, adequate handwashing technique was associated with a 23% lower prevalence of intestinal parasitic infection (p=0.015; PR=0.770, 95% CI: 0.635-0.933).

In contrast, animal husbandry showed a significant positive association with intestinal parasitosis (p=0.008; PR=1.346, 95% CI: 1.052-1.722), corresponding to a 34.6% higher prevalence among children living in households that raised farm animals. Likewise, household overcrowding was associated with a 24.8% higher prevalence of parasitic infection (p=0.040; PR=1.248, 95% CI: 1.026-1.518).

No significant associations were found for grade of study, sex, age, presence of companion animals, timing of ivermectin consumption, reason for taking ivermectin, or ivermectin dosage.

CI: Confidence interval, PR: Prevalence ratio, *Significant at p<0.05

CI: Confidence interval, PR: Prevalence ratio, *Significant at p<0.05

In the multivariate Poisson regression analysis, adequate handwashing technique remained significantly associated with a lower prevalence of intestinal parasitosis (PR=0.794, 95% CI: 0.652-0.966; p=0.021), while household overcrowding remained significantly associated with a higher prevalence (PR=1.223, 95% CI: 1.001-1.486; p=0.042) (Table 3).

DISCUSSION

The main objective of this study was to determine the relationships among ivermectin use, handwashing practices, and animal husbandry and the prevalence of intestinal parasitosis among 4th- and 5th-grade primary school students.

Consistent with our findings, several studies have reported a high prevalence of intestinal parasitic infections in children and school-aged populations, indicating that, despite accumulated knowledge, significant challenges remain in reducing these infections and addressing their multiple contributing factors [12-15]. Intestinal parasitoses remain a persistent public health challenge in tropical regions, where climatic conditions, poverty, and poor sanitation create an ideal environment for the transmission of these pathogens. In areas such as the Brazilian Amazon, high prevalence rates of helminthic and protozoan infections have been documented, particularly in communities with limited access to healthcare and sanitation services [16].

In the bivariate analysis, ivermectin consumption was significantly associated with a lower prevalence of intestinal parasitosis; however, this association was not maintained in the multivariate Poisson regression model. Although ivermectin has proven efficacy against several intestinal parasites, its incidental use during the COVID-19 pandemic likely produced heterogeneous exposure in the studied population, which may explain the absence of an independent association. Studies in Latin America have shown that ivermectin is highly effective against strongyloidiasis and other intestinal helminths when used in proper dosing schemes [17]. During the pandemic, ivermectin was widely used without standardized regimens and for non-parasitic indications, which might have limited its antiparasitic impact [18]. In contrast, in onchocerciasis-endemic countries, where mass drug administration with ivermectin is essential, the COVID-19 pandemic negatively impacted deworming efforts [19]. Furthermore, recent studies suggest that periodic ivermectin treatment can interrupt the transmission cycle of certain parasites by reducing reinfection rates, particularly in settings with limited access to clean water and sanitation [20]. In this context, incorporating ivermectin into school-based public health programs may represent a cost-effective strategy to reduce the burden of intestinal parasitoses in children, especially in tropical regions with continuous exposure to parasitic agents [21].

The multivariate analysis confirmed that adequate handwashing technique remained significantly associated with a lower prevalence of intestinal parasitosis. A study in Indonesia found that handwashing alone was insufficient to prevent parasitic infections, highlighting the importance of factors such as overcrowding, water quality, and excreta disposal [22]. In contrast, multiple studies emphasize the role of hand hygiene in reducing the risk of parasitic infections. For instance, Aveiga reported that poor hygiene habits were significant risk factors in children under 7 years of age [23]. Poor hygiene has also been linked to acute diarrheal diseases caused by parasites [24]. In Nigeria, caregiver handwashing habits were associated with intestinal parasitic infections in children [25].

Household overcrowding also remained independently associated with intestinal parasitosis. Overcrowded conditions facilitate parasite transmission by increasing person-to-person contact and limiting sanitation facilities. This finding is consistent with reports by Chris Ster et al. [26] and Rivero [27], who found that overcrowding significantly increases intestinal parasite prevalence in children. Therefore, improving housing conditions and ensuring access to sanitation services should be central components of public health interventions targeting parasitic infections in vulnerable populations.

In contrast, although animal husbandry showed a positive association in the bivariate analysis, this relationship did not reach statistical significance in the adjusted model. Nonetheless, the observed trend suggests that children exposed to domestic or farm animals may have an increased risk of zoonotic parasite transmission, as reported by Serrano et al. [28]. Acosta also noted that domestic animal husbandry was directly related to a high prevalence of parasitosis among children (63.5%) [29]. Continuous surveillance and deworming of domestic animals could help reduce this potential transmission route.

Overall, the findings of this study indicate that preventive practices—particularly adequate handwashing and reduction of household overcrowding—are key protective factors against intestinal parasitoses in school-aged children. These results emphasize the need for integrated school and community health programs that combine hygiene education, infrastructure improvements, and periodic parasitic control campaigns. Moreover, the findings highlight those interventions against intestinal parasitosis should go beyond pharmacological measures to address environmental and behavioral determinants. The persistent significance of hand washing and overcrowding indicates that modifiable household and hygiene factors play a crucial role in parasite transmission. Recent studies emphasize that inadequate sanitation, limited water access, and household crowding significantly increase the risk of infection among schoolchildren, underscoring the need for integrated WASH (Water, Sanitation, and Hygiene) and school-based health programs aligned with the Sustainable Development Goals [30].

While the potential link between COVID-19-era ivermectin use and enteroparasite prevalence is a compelling, yet relatively unexplored, hypothesis, it is crucial to emphasize the preliminary nature of this evidence. The cross-sectional design of our study precludes any definitive conclusions about causality. It is plausible that unmeasured confounding factors influenced both ivermectin consumption and parasitosis risk. Therefore, our findings should be interpreted as speculative and hypothesis-generating. They underscore the need for future longitudinal studies or controlled trials to establish a causal relationship and definitively elucidate the underlying mechanisms.

LIMITATIONS

This study has several limitations that should be acknowledged. First, information on ivermectin use, hygiene practices, and animal husbandry was self- reported by parents or guardians, which may have introduced recall and social desirability bias during interviews. Although a structured questionnaire administered by trained personnel was used to minimize these effects, the lack of objective verification of the reported behaviors limits the accuracy of these variables. Second, the study faced difficulties in identifying all parasitic species, which prevented a more detailed analysis of risk factors associated with specific pathogens. Third, the sample was drawn from a single school in Huánuco, with a participation rate of 71.3%, limiting the generalizability of the findings. The 28.7% of absent children or those who declined to participate may differ systematically from those included, potentially introducing selection bias into prevalence estimates. Fourth, although the sample was representative of the school census, its size may have limited the multivariable analysis's statistical power, increasing the likelihood of Type II errors and leading to inconclusive results for variables such as ivermectin consumption. Finally, data collection took place in 2022, during the fourth and fifth waves of the COVID-19 pandemic in Peru—a period marked by widespread public attention to ivermectin use. Although this temporal proximity may have improved recall accuracy for this specific exposure, it also limits the temporal generalizability of the findings beyond the pandemic context.

CONCLUSION

The findings of this study reveal a high prevalence of intestinal parasitosis among schoolchildren in a tropical region of Peru, primarily associated with inadequate handwashing practices and household overcrowding. The findings suggest that insufficient handwashing practices and household overcrowding are associated with a higher frequency of infection, highlighting the importance of hygiene behaviors and living conditions in parasite transmission. Although ivermectin consumption appeared protective in the bivariate analysis, this association was not maintained after adjustment, suggesting that unmeasured confounders may have confounded its apparent effect.

Given the cross-sectional nature of the research, these associations should be interpreted with caution. Nonetheless, the results emphasize the need to strengthen school- and community-based health programs focused on hygiene promotion, sanitation, and reducing overcrowding. Future longitudinal or interventional studies are recommended to confirm these relationships and provide more substantial evidence to guide preventive strategies in endemic areas.

ETHICS APPROVAL

The Ethics and Research Committee of the Faculty of Human Medicine of the National University Hermilio Valdizán approved the research protocol. All procedures performed in studies involving human participants were following the ethical standards of the institutional and/ or national research committee and the Helsinki Declaration.

CONSENT FOR PUBLICATION

Before data collection, written informed consent was obtained from parents or legal guardians, and verbal assent was obtained from participating students.

AVAILABILITY OF DATA

The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ACKNOWLEDGEMENTS

Declared none.

AUTHORS' CONTRIBUTION

Mijay Hyde Tolentino-Inocente: Conceptualization, Methodology, Formal Analysis, Research, Writing - Original Draft, Visualization.

GENERATIVE AI AND AI-ASSISTED TECHNOLOGIES IN THE WRITING PROCESS

During the preparation of this work, the authors made limited use of ChatGPT (GPT-4, OpenAI) to improve translation, obtain linguistic suggestions, and make minor corrections to some parts of the manuscript. After using this tool/service, all authors reviewed and edited the content as necessary and assume full responsibility for the content of the published article.

REFERENCES

1. Vidal-Anzardo M, Yagui Moscoso M, Beltrán Fabian M, Vidal- Anzardo M, Yagui Moscoso M, Beltrán Fabian M. [Intestinal parasitosis: Helminths. Prevalence and trend analysis from 2010 to 2017 in Peru]. An Fac Med 2020; 81: 26-32. DOI: https://doi.org/10.15381/anales.v81i1.17784

2. Murillo-Zavala AM, Rivero ZC, Bracho-Mora A. [Intestinal parasitosis and risk factors for enteroparasitosis in schoolchildren in the urban area of the Jipijapa canton, Ecuador]. Kasmera 2020; 48(1): e48130858. DOI: https://doi.org/10.5281/zenodo.3754787

3. Arando Serrano JJ, Valderrama Pomé AA. [Prevalence of intestinal parasites in the child population of Tamburco (Peru) associated with hygiene practices and animal husbandry]. Rev Med Vet 2021; 43: 61-72. DOI: https://doi.org/10.19052/mv.vol1.iss43.6

4. Boy L, Franco D, Alcaraz R, Benítez J, Guerrero D, Galeno E, et al. [Intestinal parasitoses in school-age children of an educational institution in Fernando de la Mora, Paraguay]. Rev Científica Cienc Salud 2020; 2: 54-62. DOI: https://doi.org/10.53732/rccsalud/02.01.2020.54-62

5. Raval A, Jadav M, Gohil R, Vora M. Incidence and pathological analysis of parasitic infections in underserved communities. J Pharm Bioallied Sci 2024; 16: S3176-8. DOI: https://doi.org/10.4103/jpbs.jpbs_705_24

6. Khandelwal A, Singh GP, Jamil S. Ivermectin as a multifaceted drug in COVID-19: Current insights. Med J Armed Forces India 2021; 77: S254-6. DOI: https://doi.org/10.1016/j.mjafi.2021.06.002

7. Langedijk J, Mantel-Teeuwisse AK, Slijkerman DS, Schutjens M-HDB. Drug repositioning and repurposing: terminology and definitions in literature. Drug Discov Today 2015; 20: 1027-34. DOI: https://doi.org/10.1016/j.drudis.2015.05.001

8. Loukas A, Maizels RM, Hotez PJ. The yin and yang of human soil- transmitted helminth infections. Int J Parasitol 2021; 51: 1243-53. DOI: https://doi.org/10.1016/j.ijpara.2021.11.001

9. World Health Organization. Soil-transmitted helminth infections. Available at: https://www.who.int/news-room/fact-sheets/detail/soil-transmitted-helminth-infections (Accessed on: April 18, 2025).

10. Barros AJ, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003; 3: 21. DOI: https://doi.org/10.1186/1471-2288-3-21

11. Ar T, Ao W, Ga B, Gr C. Prevalence odds ratio versus prevalence ratio: Choice comes with consequences. Stat Med 2016; 35(30): 5730-35. DOI: https://doi.org/10.1002/sim.7059

12. Garba B, Asowe HA, Dirie NI, Umar Y, Salah AO, Hussien AA, et al. Prevalence and intensity of intestinal and soil-transmitted helminths infection among children in internally displaced camps in Mogadishu, Somalia. Sci Rep 2025; 15: 12697. DOI: https://doi.org/10.1038/s41598-025-93364-z

13. Lotz CN, Schneeberger PHH, Concu M, Ali SM, Mrimi EC, Keiser J. Implementation of real-time PCR assays for diagnosing intestinal protozoa infections. Parasitol Res 2025; 124: 40. DOI: https://doi.org/10.1007/s00436-025-08483-3

14. Sombié OO, Zeba AN, Somé JW, Kazienga A, Bationo JF, Davis C, et al. Association between vitamin A status, inflammations, and infections in children 36-59 months of age in rural Burkina Faso: A cross-sectional study. J Health Popul Nutr 2025; 44: 107. DOI: https://doi.org/10.1186/s41043-025-00840-3

15. Addis T, Yohannes T. Intestinal Parasitic Infection: Prevalence and associated risk factors at Delgi Primary Hospital, Northwest Ethiopia. ScientificWorldJ 2025; 2025: 8787678. DOI: https://doi.org/10.1155/tswj/8787678

16. Martins AJ de A, Rocha AC da S, Assis-Silva ZM de, Maia GO, Alves-Ribeiro BS, Duarte RB, et al. Risk of environmental contamination by gastrointestinal parasites in public areas of the Central Plateau Microregion of Brazil: A public health concern. Pathog Basel Switz 2025; 14: 211. DOI: https://doi.org/10.3390/pathogens14030211

17. Ordóñez LE, Angulo ES. [Efficacy of ivermectin in the treatment of children parasitized by Strongyloides stercoralis]. Biomédica 2004; 24: 33-41. DOI: https://doi.org/10.7705/biomedica.v24i1.1246

18. Hernandez AV, Liu A, Roman YM, Burela PA, Pasupuleti V, Thota P, et al. Efficacy and safety of ivermectin for Treatment of non- hospitalized COVID-19 patients: A systematic review and meta- analysis of 12 randomized controlled trials with 7,035 participants. Int J Antimicrob Agents 2024; 64: 107248. DOI: https://doi.org/10.1016/j.ijantimicag.2024.107248

19. Shintouo CM, Shey RA, Yengo BN, Yaah NE, Teh RN, Ngwese RA, et al. Effects of the suspension of mass drug administration during the COVID-19 pandemic on onchocerciasis prevalence in the Bandjoun and Massangam health districts, West Region of Cameroon. Acta Trop 2023; 246: 106999. DOI: https://doi.org/10.1016/j.actatropica.2023.106999

20. Le B, Clarke NE, Legrand N, Nery SV. Effectiveness of ivermectin mass drug administration in the control of soil-transmitted helminth infections in endemic populations: A systematic review and meta- analysis. Infect Dis Poverty 2024; 13: 16. DOI: https://doi.org/10.1186/s40249-024-01185-5

21. Mayfield HJ, Sartorius B, Sheridan S, Howlett M, Martin BM, Thomsen R, et al. Ongoing transmission of lymphatic filariasis in Samoa 4.5 years after one round of triple-drug mass drug administration. PLoS Negl Trop Dis 2024; 18: e0012236. DOI: https://doi.org/10.1371/journal.pntd.0012236

22. Pasaribu AP, Alam A, Sembiring K, Pasaribu S, Setiabudi D. Prevalence and risk factors of soil-transmitted helminthiasis among school children living in an agricultural area of North Sumatera, Indonesia. BMC Public Health 2019; 19: 1066. DOI: https://doi.org/10.1186/s12889-019-7397-6

23. Hidalgo MVA, Herrera MCB, Yandún SLC, Erazo APA. [Risk factors for intestinal parasitosis in children under 7 years of age]. Gac Médica Estud 2023; 4: e149.

24. Zambrano A de los ÁM, Diaz CIE. [Acute diarrhea due to intestinal parasitosis in children 5 to 10 years of age of the Shuar ethnic group in an Amazonian indigenous community in Ecuador]. AVFT - Arch Venez Farmacol Ter 2017; 36: 192-6.

25. Njoku MO, Iloh KK, Okike CO, Njoku GC, Iloh ON, Ojinnaka NC. Intestinal helminthiasis: Risk factors and relationship with nutritional status and anaemia among institutionalised children in three states of South-East Nigeria. West Afr J Med 2023; 40: 1262-73.

26. Chis Ster I, Niaz HF, Chico ME, Oviedo Y, Vaca M, Cooper PJ. The epidemiology of soil-transmitted helminth infections in children up to 8 years of age: Findings from an Ecuadorian birth cohort. PLoS Negl Trop Dis 2021; 15: e0009972. DOI: https://doi.org/10.1371/journal.pntd.0009972

27. Rivero MR, De Angelo C, Feliziani C, Liang S, Tiranti K, Salas MM, et al. Enterobiasis and its risk factors in urban, rural and indigenous children of subtropical Argentina. Parasitology 2022; 149: 396-406. DOI: https://doi.org/10.1017/S0031182021001955

28. Serrano Ramos DH, Valderrama Pomé AA. [Nutritional status, housing characteristics, and backyard animal husbandry as factors associated with enteroparasitosis in children]. Rev Investig Vet Perú 2020; 31: e17297. DOI: http://dx.doi.org/10.15381/rivep.v31i3.17297

29. Acosta LSV. [Risk factors for parasitosis in children under five years of age in a human settlement—Peru, 2020]. Rev Venez Salud Pública 2021; 9: 65-76.

30. Wolf J, Hubbard S, Brauer M, Ambelu A, Arnold BF, Bain R, et al. Effectiveness of interventions to improve drinking water, sanitation, and handwashing with soap on risk of diarrhoeal disease in children in low-income and middle-income settings: A systematic review and meta-analysis. Lancet 2022; 400: 48-59. DOI: https://doi.org/10.1016/S0140-6736(22)00937-0