Fighting malaria in Shangla District, Pakistan: insight into epidemiology, risk factors, and strategic control measures (2020–2024)

(2025) 24:353 Ullah et al. Malaria Journal https://doi.org/10.1186/s12936-025-05515-2 Malaria Journal Open Access RESEARCH Fighting malaria in Shangla District, Pakistan: insight into epidemiology, risk factors, and strategic control measures (2020–2024) Ihsan Ullah1,7*, Ruqia Mehmood Baig4, Aayesha Riaz3, Muhammad Mukhtar2, Muhammad Ajmal Khan1, Afia Zaib1, Nazar Muhammad1, Salahuddin Khan1, Amir Ali6, Ajaz Ahmad5 and Rosa Maria Del Angel Nunez7* Abstract Background Malaria remains a significant public health challenge in District Shangla, Pakistan, exacerbated by ecological diversity, seasonal transmission, and limited health infrastructure. This 5-year epidemiological study aimed to assess malaria trends, species distribution, risk factors, and intervention outcomes from 2020 to 2024. Methods A retrospective analysis was performed on 130,401 laboratory-confirmed malaria cases identified from 572,696 febrile individuals screened between 2020 and 2024. Data were collected through district health surveillance systems and field-based reports. Epidemiological indicators, including Annual Parasite Incidence (API), Test Positivity Rate (TPR), and Annual Blood Examination Rate (ABER), were analyzed alongside demographic, diagnostic, seasonal, and behavioral data. The impacts of interventions were assessed by comparing trends before and after the interventions. Results Malaria incidence increased sharply from 2020 to 2023, with API rising from 2 to 61 per 1000 populations, TPR from 3 to 32%, and ABER from 5 to 19%. In 2024, these indicators declined (API: 46/1000; TPR: 27%; ABER: 18%) following targeted interventions. Plasmodium vivax comprised 95% of cases, followed by Plasmodium falciparum (4.6%) and mixed infections (0.4%). Only 18% of cases were microscopy-confirmed; the remainder relied on rapid diagnostic tests (RDTs). Adults ≥ 15 years accounted for 67% of cases, with a male predominance (54%). Seasonal peaks varied: P. vivax peaked in July–August, while P. falciparum peaked in October–November. Risk factors included poor treatment adherence (only 14% completed primaquine regimens), absence of G6PD screening, misinformation, reliance on informal providers, and population mobility. Discussion The rise in malaria burden reflects climate-sensitive transmission, diagnostic gaps, and inadequate treatment adherence. The decline in 2024 corresponds to coordinated responses, including deploying 78 diagnostic and treatment centers, expanded IRS, LLIN distribution, and health education campaigns. However, persistent gaps in vector surveillance, diagnostic accuracy, primaquine adherence, and health worker training hinder progress. Conclusion Malaria control in Shangla requires an integrated, climate-adaptive elimination strategy. Priorities include enhanced vector control, improved diagnostic access, universal G6PD testing, community-based health education, *Correspondence: Ihsan Ullah Rosa Maria Del Angel Nunez Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. Ullah et al. Malaria Journal (2025) 24:353 Page 2 of 11 and use of short-course antimalarial regimens with full primaquine adherence to sustain control and advance toward elimination. Keywords Plasmodium vivax, Plasmodium falciparum, Malaria epidemiology, Shangla, Primaquine adherence, Seasonal transmission, Vector control, G6PD deficiency, Climate change, Pakistan Background Malaria remains a significant global public health challenge, particularly in tropical and subtropical regions, with an estimated 249 million cases and 608,000 deaths reported globally in 2022, the majority of which occurred in sub-Saharan Africa [1]. Underage children (below 5 years) and pregnant women continue to bear the highest burden of the disease. Despite progress in prevention and treatment, emerging drug-resistant Plasmodium falciparum strains and insecticide-resistant mosquito vectors threaten malaria control efforts [2]. Climate change further exacerbates the risk by expanding the geographic range of Anopheles mosquitoes [3]. In Pakistan, malaria is among the top 5 diseases by burden, in rural and peri-urban regions where climatic and socioeconomic conditions favor transmission. It is reported that 3.5 million suspected cases and over 400,000 confirmed cases occurred in [4]. The current study area (district) has one of the highest incidences of malaria reported. Malaria in Pakistan is unevenly distributed, with the highest incidence reported in Baluchistan, Khyber Pakhtunkhwa (KP), Sindh, and the Federally Administered Tribal Areas (FATA). Baluchistan reported the highest malaria burden, with an API of approximately 70.3 per 1000 population, reflecting widespread transmission and limited access to preventive services [5]. Sindh province, which accounted for nearly 49.4% of the national malaria cases, had a high API, though lower than Baluchistan, due to persistent transmission in riverine and flood-prone districts [6]. In Khyber Pakhtunkhwa (KP), including the merged tribal areas (formerly FATA), the API ranged between 11.0 and 12.9 per 1000, placing it among the moderately high transmission zones [1]. These values underscore the urgent need for region-specific interventions under Pakistan’s National Malaria Strategic Plan 2021–2035 [7]. The districts bordering Afghanistan and Iran account for 37% of cases and annual parasite incidence (API) exceeding 4.5 per 1000 population [8]. Plasmodium vivax dominates (79.1% of cases), though Plasmodium falciparum prevalence has risen to 16.3%, particularly in regions where P. vivax was historically endemic [9]. Recent estimates indicate a national pooled prevalence of 23.3%, with extreme variability across districts—ranging from 1.7% in Larkana to 99.8% in Karachi. Malaria transmission in Pakistan follows seasonal patterns, peaking in the post-monsoon period (July–November) due to increased mosquito breeding sites. The primary vector, Anop (...truncated)