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

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.