Fighting malaria in Shangla District, Pakistan: insight into epidemiology, risk factors, and strategic control...

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.

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.

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.

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.

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, and use of short-course antimalarial regimens with full primaquine adherence to sustain control and advance toward elimination.