Abstract

Background: Malaria remains a major public health challenge in Pakistan, where persistent transmission, heterogeneous risk patterns, and evolving treatment practices continue to impede control and elimination efforts. Methods: A community-based cross-sectional study was conducted among 9211 symptomatic individuals in District Dera Ismail Khan, northwestern Pakistan, from January 2024 to December 2025. Malaria was diagnosed using rapid immunochromatographic assays for Plasmodium vivax (P. vivax) and Plasmodium falciparum (P. falciparum), and associated risk factors were assessed using multivariable logistic regression. Results: Overall malaria prevalence was 36.27% (3341/9211). P. vivax predominated, accounting for 93.8% (3133/3341) of infections, while P. falciparum represented 5.8% (195/3341) and mixed infections 0.4% (13/3341). Infection risk was significantly associated based on multivariate analysis with male sex, younger age, pregnancy (AOR = 4.69), and absence of mosquito net use (AOR = 6.17), whereas indoor residual spraying (AOR = 0.08) showed a strong protective effect. Malaria transmission showed two peaks: October–December (AOR = 3.78–4.97) and February–March (AOR = 2.25–2.31) and declined significantly based on unadjusted analysis from 39.5% in 2024 to 32.8% in 2025 (OR = 0.74; p < 0.001). Blood groups B+ (AOR = 0.77), B− (AOR = 0.78), and AB− (AOR = 0.86) were significantly associated with reduced odds of malaria infection. A notable shift toward artemisinin-based combination therapy was observed, with artemether–lumefantrine largely replacing chloroquine for malaria treatment. Conclusions: The persistence of P. vivax-dominated transmission alongside ongoing P. falciparum circulation highlights the need for targeted vector control, enhanced surveillance, and evidence-based treatment strategies to accelerate malaria elimination in Pakistan.

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