During natural infections of P. vivax malaria a variety of immune responses to the infection affect infectivity of the parasites to mosquitoes. Sexual stage antigens present in the blood stage parasites induce antibodies which may either enhance or suppress the infectivity of the sexual parasites to mosquitoes. Subsequent infections of P. vivax do not, unless occurring within less than 4 months, boost this response indicating a very short immune memory for the relevant antigens. Blood infection also results in the release of cytokines and other non-antibody factors which together can mediate death of the blood stage sexual parasites. These factors are associated with paroxysm in non-immune individuals. In individuals from an endemic area with age-acquired anti-disease immunity clinical symptoms are mild and the parasite killing factors are not induced.