Integrated vector and parasite management for malaria control in high-endemic areas: pummel and pin strategy to prevent malaria setbacks

(2025) 24:349 Ranjbar and Opigo Malaria Journal https://doi.org/10.1186/s12936-025-05538-9 Malaria Journal Open Access PERSPECTIVE Integrated vector and parasite management for malaria control in high‑endemic areas: pummel and pin strategy to prevent malaria setbacks Mansour Ranjbar1* and Jimmy Opigo2 Abstract Rebounding to a higher malaria endemicity level or remaining at the same level despite implementation of malaria control interventions has been reported in high-endemic areas of many sub-Saharan Africa (SSA) countries. Based on current trends, the 2030 targets of the World Health Organization, which aim for at least a 90% reduction in malaria mortality and morbidity, are out of reach. Moreover, the experiences of many countries in SSA show that the implementation of various packages of malaria control interventions in areas of low to moderate transmission can achieve a significant reduction in the disease burden but ultimately fail to interrupt malaria transmission. Multiple factors may contribute to the stagnation or even reversal of the declining trend of malaria endemicity intensity in endemic countries across SSA. Notably, high levels of receptivity and vulnerability can hinder the sustainability of achieved reductions in malaria transmission. To address these challenges, based on evidence from the literature focusing on Uganda, this article presents a novel approach- the Integrated Vector and Parasite Management (IVPM)- for endemicity reduction and maintaining hard-earned gains following reduction of malaria endemicity intensity in high-endemic areas. In line with IVPM, the article also proposes the “Pummel and Pin” strategy, outlining an implementation framework for IVPM. The IVPM Pummel-and-Pin model emphasizes the need to reduce both the parasite reservoir and vectorial capacity, highlighting the often-neglected Pin strategy as essential to sustaining achieved reductions in endemicity without any lag. It may offer a practical solution to prevent setbacks and accelerate progress towards achieving the national malaria targets on burden reduction in Uganda and other SSA countries. However, assessing its feasibility and cost-effectiveness across different endemicity levels remains a priority for operational research, particularly since IVPM is resource-driven and malaria control programmes worldwide have faced growing financial deficits. Operational research aimed at reducing malaria endemicity in high-transmission areas of sub-Saharan African countries needs to cover two key questions: how to reduce transmission intensity and how to sustain those reductions. Keywords IVPM, IVM, aEIR, High endemic, Rebound malaria, Malaria outbreak, Receptivity, Vulnerability, Malaria transmission *Correspondence: Mansour Ranjbar 1 World Health Organization Uganda, Kampala, Uganda 2 Ministry of Health Uganda, Kampala, Uganda Background In 2023, Uganda was the third-largest contributor to global malaria burden, accounting for approximately 5% of malaria cases and 3% of malaria deaths worldwide[1]. Since 2009, Uganda has made considerable progress in the fight against malaria. Malaria prevalence declined © 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/. Ranjbar and Opigo Malaria Journal (2025) 24:349 by 80%, from 42% in 2009 to 9% in 2019 [2]; however, analysis of data from the Uganda Health Information Management System (HMIS) reveals that major outbreaks occurred in 2015/2016, 2019, and 2022 [3]. This demonstrates that the path to elimination is not linear, and rebounds to previous or even higher levels of endemicity are common in the country. Moreover, in Uganda, some districts, mainly in the southeast or highland regions, have been classified as low or very low malaria endemic areas for over a decade; however, malaria transmission has never been fully interrupted. The phenomena of rebound to higher malaria endemicity levels or remaining at the same level despite malaria control efforts has also been reported in other African countries [2]. Since 2015, the rate of progress in decreasing prevalence of both cases and deaths has stopped in several countries with moderate or high malaria transmission in African region of the World Health Organization (WHO) [4, 5]. Globally, a 40% reduction in malaria case incidence by 2020 compared to 2015 was targeted; however, only a 3% reduction was achieved, falling 37% short of the goal [5]. This is not limited to high malaria endemic areas; the experiences of many countries in in sub-Saharan Africa (SSA) show that implementation of various packages of malaria control interventions in areas of low to moderate transmission can achieve a significant reduction in the disease burden but ultimately fail to interrupt malaria transmission [6]. Some studies claimed that using current tools, malaria elimination in SSA will not be achievable by 2050 [7, 8]. Based on current trends, the 2030 WHO global targets for malaria mortality and morbidity and the interim milestones are out of reach [5]. Many reasons may contribute to stepping back or no progress towards malaria elimination in Uganda and other endemic countries in SSA, such as growing human population, climate change, humanitarian emergencies, the emergence of biological threats, changes in vector biology, and inadequate coverage of the interventions, mainly because of insufficient financial resources [5]. However, an important question is how the effectiveness of the current package of interventions can be enhanced to accelerate reduction of malaria endemicity in highendemic areas to support progress towards a Malaria Free Uganda. This article aims to review the available evidence in the literature on the drivers of malaria transmission, with a focus on the concepts of receptivity and vulnerability, as well as the impact of different packages of interventions across various endemicity settings. Based on the review, the article introduces a practical new model for achieving sustainable reduction of malaria (...truncated)