Shared risk factors for malaria and schistosomiasis co-infection: a systematic review and meta-analysis

BackgroundMalaria and schistosomiasis are co-endemic across sub-Saharan Africa, resulting in frequent co-infection, yet the shared risk factors driving co-infection remain poorly synthesized. MethodsWe conducted a systematic review and meta-analysis to identify shared risk factors for malaria-Schistosoma co-infection and to narratively synthesize the statistical methodologies applied in the literature. We searched PubMed/MEDLINE, Embase, Web of Science, Global Index Medicus, and Global Health from inception to February 19, 2025 (PROSPERO CRD420250648824). We pooled effect sizes for risk factors across sociodemographic, environmental, and behavioral dimensions. Fixed-effects meta-analysis with inverse variance weighting was used to calculate pooled Odds Ratios (OR) and 95% confidence intervals (CIs). Study quality was assessed using a modified version of the Quality Assessment tool for Observational Cohort and Cross-Sectional Studies by the National Institutes of Health. ResultsWe screened 1,345 records and included 30 studies conducted across 12 African countries. A meta-analysis of 27 studies showed that schistosomiasis infection was associated with 1.27 times higher odds of malaria (OR 1.27; 95% CI: 1.17-1.39). Narrative synthesis identified age as an important predictor, with risk consistently peaking in older children and adolescents (typically 8-17 years). Sex influences were setting-dependent: males had significantly higher odds of co-infection in community-based studies (OR 2.08; 95% CI: 1.64-2.63), whereas no significant association was found in school-based studies (OR 0.87; 95% CI: 0.64-1.19). Direct water contact was strongly associated with co-infection (OR 2.53; 95% CI: 1.60-4.00). Heterogeneity was high (I2 > 80%). Only one study was categorized as high risk of bias. ConclusionThe association between malaria and schistosomiasis appears driven by overlapping environmental and behavioral exposures, specifically water contact in older children. Author summaryMalaria and schistosomiasis are parasitic diseases that frequently infect the same individuals, particularly in sub-Saharan Africa. While it is known that co-infection exacerbates clinical outcomes like anemia, the specific behaviors and environmental conditions that put individuals at risk of co-infection are not well understood. We performed a systematic review of 30 studies to identify risk factors for co-infection. We found that individuals infected with schistosomiasis were 27% more likely to harbor malaria. Our analysis suggests this relationship is largely driven by shared risk factors rather than biological interaction. Risk appears to peak in older children and adolescents (ages 8-17 years). Gender roles influence risk differently depending on the setting: males were at higher risk in community settings, likely due to occupational activities like fishing or farming, but this risk disappeared in school settings where boys and girls have similar daily routines. Direct water contact was a risk factor for co-infection, but it was inconsistently measured across studies. Our findings support the case for investigation of interventions to support integrated disease control for schistosomiasis and malaria.