**4. The malaria vector**

4 Malaria Parasites

Human Malaria is a parasitic disease caused by apicomplexan protozoan (single celled) coccidian. These parasites are haematozoans or haemosporinas of the family plasmodiidae. A contributing factor to the malaria problem in sub-Saharan Africa is the diversity of the parasite that infects humans. Four species infect man of which *Plasmodium falciparium* is the most virulent. The other species are *P. vivax, P. malariae* and *P. ovale. P. falciparium* and *P.* 

In sub-Saharan Africa, *P. falciparium* poses the greatest threat because of its high level of mortality and the complications arising. *P*. *vivax* is worldwide in tropical and some temperate regions. *P*. *vivax* accounts for more than half of all malaria cases outside sub-Saharan Africa. *P. vivax* is unique in that a sporozoite injected into the blood stream may stay in hepatocytes as hyponozoites. *P*. *ovale* is mainly in found in tropical West Africa and *P*. *malariae* is found worldwide but with patchy distribution [3]. These malaria parasites can develop within, invade red blood cells (erythrocytes) and consume up to 75% - 80% of their

For both *P. vivax* and *P. ovale*, clinical relapses may occur weeks to months after the first infection, even if the patient has left the malarious area. These new episodes arise from "dormant" liver forms (absent in *P. falciparum* and *P.malariae*), and special treatment –

*P*. *falciparium* causes severe complications as cerebral malaria, severe anaemia, acute renal failure, hypoglycemia and pulmonary infection. The two features that actually separate *P*. *falciparium* from the other human malaria are the ability to attack erythrocytes of all ages, causing high parasitaemia and enhanced growth and the capability to adhere to vascular

*P*. *falciparium* is a threat because of high level of mortality and spreading drug resistance. Cerebral malaria caused by *P*. *falciparium* is when infected blood cells obstruct blood vessels

Malaria in pregnancy is widespread. Pregnant women are especially vulnerable because of iron deficiency, a special problem in malaria endemic areas .It endangers the health of women and prospects for the new born. Malaria causes anaemia and low birth weight babies. This is due to the loss of previously existing immunity. *P*. *falciparium* infects the Red Blood cells (RBC) that adheres to and accumulates in the placenta in pregnant women. Pregnancy exacerbates malaria through a nonspecific hormone-dependent depression of the Immune system. The protective antiplasmodial activity is suppressed at pregnancy, which has clinical consequences with important public health implications on pregnant women [2]. Malaria accounts for 6.5%

Malaria infection leads to increased morbidity and mortality and the delivery of premature infants with low birth weights due to intrauterine growth retardation (IUGR) that may have been as a result of placental parasitisation [2]. Malaria infection in pregnancy is significant in

in the brain; other vital organs can also be damaged often leading to death of patient.

targeted at these liver stages – is mandatory for a complete cure [3].

of abortions, 15% of premature deliveries and 0.7% death in utero [3].

The following factors have made malaria a pending problem in sub-Saharan Africa.

**2. The malaria parasite** 

*vivax* are the most common [3].

haemoglobin as nutrient source [1].

**3. Complications of malaria** 

endothelium through sequestration [2].

Malaria is transmitted by the *Anopheles* mosquito which carries infective sporozoites stage in its salivary glands which it injects into the human blood stream during a blood meal. Several *Anopheles* mosquitoes have been incriminated as the major malaria vectors. About 20 different *Anopheles* species are locally important around the world. The vector population in sub-Saharan Africa is uniquely effective, with the six species of the *Anopheles gambiae* complex being the most efficient vectors of human malaria in the region, and often considered the most important in the world [4]. *An. funestus* is also capable of producing very high inoculation rates in a wide range of geographic, seasonal, and ecological conditions. These vectors have proven effective in transmitting the malaria parasite to humans across the region, in rural and urban areas alike. *An. pharoensis* is also widely distributed in Africa, geographically and ecologically, and can maintain active transmission of malaria even in the absence of the main malaria vector.

All of the important vector species bite at night. They breed in still waters or shallow collections of freshwater like puddles, rice fields, and hoof prints. Transmission is more intense in places where the mosquito is relatively long-lived (so that the parasite has time to complete its development inside the mosquito) and where it prefers to bite humans rather than other animals. For example, the long lifespan and strong human-biting habit of the African vector species is the underlying reason why more than 85% of the world's malaria deaths are in sub-Saharan Africa [3]. Mosquito's habits therefore determine the geographic spread of the disease.

Malaria transmission is variable from one area to the other and this will impact on its epidemiology and control. In a study by Oyewole *et al* [7] in a coastal area of southern Nigeria in sub-Saharan Africa, several species of *Anopheles* mosquitoes occurred in sympatry. These species all combined to the transmission of malaria in the area. They were all competent vectors. For a mosquito to transmit malaria to man or other hosts the following points are crucial:

i. Vector capacity and competence:

Vectoral capacity has been used interchangeably to describe the ability of mosquitoes to serve as a disease vector. It is defined qualitatively and is influenced by such variables as vector density, longetivity and vector competence. Vectoral capacity takes into account environmental, behavioral, cellular and biochemical factors that influence the association

Malaria**,** a Pending Problem in Sub**-**Saharan Africa 7

There can also be differences in host attractiveness for those mosquito species that feed on humans, and it is not uncommon for some people to be more attractive to mosquitoes than others. Studies have shown that humans appear to exude different amounts of the volatile compounds that mosquitoes loves. Scientists are currently studying the reasons for the difference in attractiveness in order to assist development of repellent compounds for

Some mosquito species may never attack man. Different mosquito species have evolved to blood feed on various types of vertebrate hosts. Some mosquitoes prefer mammalian blood, while others would rather feed solely on birds. There are even mosquitoes specialized to feed on amphibians or reptiles. Opportunistic feeding mosquitoes will feed on any animal,

Some *Anopheles* mosquitoes feed indoors and hence endophagic, while others feed outdoors hence exophagic. After blood feeding, some *Anopheles* mosquito may prefer to rest indoors hence are endophilic, while others prefer to rest outdoors hence exophilic. Some mosquito species search for hosts during daylight hours while others are active at dawn and dusk [10, 11] The main factor governing the ability of *Anopheles* specie to act as malaria vector is the frequency with which it feeds on humans. The vectors associated with stable malaria are those which are strongly antropophagic, often feeding on humans to the exclusion of other hosts. Anopheline vectors of malaria consists of various behavior associated with their

This is another important factor, especially among adults in areas of moderate or intense transmission conditions. Immunity is developed over years of exposure, and while it never gives complete protection, it does reduce the risk that malaria infection will cause severe disease. For this reason, most malaria deaths in sub-Saharan Africa occur in young children, whereas in areas with less transmission and low immunity, all age groups are at risk [3].

Transmission also depends on climatic conditions that may affect the abundance and survival of mosquitoes, such as rainfall patterns, temperature and humidity. In many places, transmission is seasonal, with the peak during and just after the rainy season. Malaria epidemics can occur when climate and other conditions suddenly favour transmission in areas where people have little or no immunity to malaria. They can also occur when people with low immunity move into areas with intense malaria transmission, for instance to find

Treatment and control of malaria have become more difficult because of drug and vector resistances. Growing resistance to antimalarial medicines has spread very rapidly, undermining malaria control efforts. Chloroquine was introduced in the 1950s. When resistance to the drug developed in the 1970s, (Fansidar) sulphadoxine-pyrimethamine (SP) was introduced. Resistance to these drugs is now so high as to render them "virtually useless [12]. These ineffective drugs continue to be used despite the spectacular levels of resistance, leading to

preventing blood feeding and attractants for mosquito traps [10,11].

depending on host availability during the host-seeking period [10].

biting activities and hence transmission dynamics [6].

**5. Human immunity** 

**6. Climatic conditions** 

work, or as refugees [3].

**7. Drug and vector resistances** 

between a vector, the pathogen transmitted by the vector and the vertebrate host to which the pathogen is transmitted [7].

Vector competence is a component of vectoral capacity and is governed by intrinsic and generic factors that influence the ability of a vector to transmit a pathogen. Susceptibility to sporozoite stage of *Plasmodium species* is an important component of vectoral competence.

Vectors competence, however differ from one species to another and from place to place. There are vector species complexes that vary in their behaviors, vectorial capacities and competence and these present a real problem to malaria control. The main factor governing the ability of *Anopheles* specie to act as malaria vector is the frequency with which it feeds on humans. The vectors associated with stable malaria are those which are strongly antropophagic, often feeding on humans to the exclusion of other hosts. Anopheline vectors of malaria consists of various behavior associated with their biting activities and hence transmission dynamics [6].

There is a considerable lack of information regarding vector habits, such as where *Anopheles* rest during the day, information that is critical for control efforts. Awolola *et al.* [8] reported that there is little information on sporozoite rates of *Anopheles* mosquitoes. This observation was the basis of several studies he carried out in Nigeria from 2003 – 2005. The paucity of data on species complexes and their bionomics hampers future vector control as an important component of malaria control.

Correct analysis of the distribution of specific malaria vectors is one of the prerequisites for meaningful epidemiological studies and for planning and monitoring of successful malaria control or eradication programmes. Control measures can only be effective if the abundance, behaviour and proportion of the vectors are known. The existence of species complexes containing morphologically cryptic sibling or isomorphic forms presents a major challenge to malaria control programmes as these require vector identification using molecular techniques. Meanwhile, the distribution of the molecular M (Mopti) and S (Savannah) forms of *An. gambiae s.s* is still being determined for much of the West African regions [6, 8]. The malaria problem in sub-Saharan Africa represents a peculiar case because the vectoral system is the most complex anywhere.

Beier [9] had suggested that malaria transmission dynamics is variable throughout Africa with huge variability in transmission patterns even within villages few kilometers apart. This vectoral system diversity impacts on malaria epidemiology and control. The *An. gambiae* complex is not the only vector in the field [6, 8]. Targeting only this species by whatever method is nonsense. The diversity of the epidemiological situation within sub-Saharan ecotypes presents differing malaria situation. Comprehensive knowledge of behaviour and heterogeneities that exist within, and among these vectors, will always be of benefit. Any strategy aiming at control will have to account for this heterogeneity.

ii. Host preference:

In some areas of sub-Saharan Africa people receive 200 to 300 infective bites per year [4]. This is another component of vectoral capacity and competence. The attractiveness of a blood meal host and the subsequent feeding success of a mosquito depend on characteristics such as host size, proximity to mosquito habitats, host abundance during mosquito hostseeking periods, and host defense mechanisms [7, 8].

between a vector, the pathogen transmitted by the vector and the vertebrate host to which

Vector competence is a component of vectoral capacity and is governed by intrinsic and generic factors that influence the ability of a vector to transmit a pathogen. Susceptibility to sporozoite stage of *Plasmodium species* is an important component of vectoral competence. Vectors competence, however differ from one species to another and from place to place. There are vector species complexes that vary in their behaviors, vectorial capacities and competence and these present a real problem to malaria control. The main factor governing the ability of *Anopheles* specie to act as malaria vector is the frequency with which it feeds on humans. The vectors associated with stable malaria are those which are strongly antropophagic, often feeding on humans to the exclusion of other hosts. Anopheline vectors of malaria consists of various behavior associated with their biting activities and hence

There is a considerable lack of information regarding vector habits, such as where *Anopheles* rest during the day, information that is critical for control efforts. Awolola *et al.* [8] reported that there is little information on sporozoite rates of *Anopheles* mosquitoes. This observation was the basis of several studies he carried out in Nigeria from 2003 – 2005. The paucity of data on species complexes and their bionomics hampers future vector control as an

Correct analysis of the distribution of specific malaria vectors is one of the prerequisites for meaningful epidemiological studies and for planning and monitoring of successful malaria control or eradication programmes. Control measures can only be effective if the abundance, behaviour and proportion of the vectors are known. The existence of species complexes containing morphologically cryptic sibling or isomorphic forms presents a major challenge to malaria control programmes as these require vector identification using molecular techniques. Meanwhile, the distribution of the molecular M (Mopti) and S (Savannah) forms of *An. gambiae s.s* is still being determined for much of the West African regions [6, 8]. The malaria problem in sub-Saharan Africa represents a peculiar case because the vectoral

Beier [9] had suggested that malaria transmission dynamics is variable throughout Africa with huge variability in transmission patterns even within villages few kilometers apart. This vectoral system diversity impacts on malaria epidemiology and control. The *An. gambiae* complex is not the only vector in the field [6, 8]. Targeting only this species by whatever method is nonsense. The diversity of the epidemiological situation within sub-Saharan ecotypes presents differing malaria situation. Comprehensive knowledge of behaviour and heterogeneities that exist within, and among these vectors, will always be of

In some areas of sub-Saharan Africa people receive 200 to 300 infective bites per year [4]. This is another component of vectoral capacity and competence. The attractiveness of a blood meal host and the subsequent feeding success of a mosquito depend on characteristics such as host size, proximity to mosquito habitats, host abundance during mosquito host-

benefit. Any strategy aiming at control will have to account for this heterogeneity.

the pathogen is transmitted [7].

transmission dynamics [6].

important component of malaria control.

system is the most complex anywhere.

seeking periods, and host defense mechanisms [7, 8].

ii. Host preference:

There can also be differences in host attractiveness for those mosquito species that feed on humans, and it is not uncommon for some people to be more attractive to mosquitoes than others. Studies have shown that humans appear to exude different amounts of the volatile compounds that mosquitoes loves. Scientists are currently studying the reasons for the difference in attractiveness in order to assist development of repellent compounds for preventing blood feeding and attractants for mosquito traps [10,11].

Some mosquito species may never attack man. Different mosquito species have evolved to blood feed on various types of vertebrate hosts. Some mosquitoes prefer mammalian blood, while others would rather feed solely on birds. There are even mosquitoes specialized to feed on amphibians or reptiles. Opportunistic feeding mosquitoes will feed on any animal, depending on host availability during the host-seeking period [10].

Some *Anopheles* mosquitoes feed indoors and hence endophagic, while others feed outdoors hence exophagic. After blood feeding, some *Anopheles* mosquito may prefer to rest indoors hence are endophilic, while others prefer to rest outdoors hence exophilic. Some mosquito species search for hosts during daylight hours while others are active at dawn and dusk [10, 11]

The main factor governing the ability of *Anopheles* specie to act as malaria vector is the frequency with which it feeds on humans. The vectors associated with stable malaria are those which are strongly antropophagic, often feeding on humans to the exclusion of other hosts. Anopheline vectors of malaria consists of various behavior associated with their biting activities and hence transmission dynamics [6].

#### **5. Human immunity**

This is another important factor, especially among adults in areas of moderate or intense transmission conditions. Immunity is developed over years of exposure, and while it never gives complete protection, it does reduce the risk that malaria infection will cause severe disease. For this reason, most malaria deaths in sub-Saharan Africa occur in young children, whereas in areas with less transmission and low immunity, all age groups are at risk [3].

### **6. Climatic conditions**

Transmission also depends on climatic conditions that may affect the abundance and survival of mosquitoes, such as rainfall patterns, temperature and humidity. In many places, transmission is seasonal, with the peak during and just after the rainy season. Malaria epidemics can occur when climate and other conditions suddenly favour transmission in areas where people have little or no immunity to malaria. They can also occur when people with low immunity move into areas with intense malaria transmission, for instance to find work, or as refugees [3].

#### **7. Drug and vector resistances**

Treatment and control of malaria have become more difficult because of drug and vector resistances. Growing resistance to antimalarial medicines has spread very rapidly, undermining malaria control efforts. Chloroquine was introduced in the 1950s. When resistance to the drug developed in the 1970s, (Fansidar) sulphadoxine-pyrimethamine (SP) was introduced. Resistance to these drugs is now so high as to render them "virtually useless [12]. These ineffective drugs continue to be used despite the spectacular levels of resistance, leading to

Malaria**,** a Pending Problem in Sub**-**Saharan Africa 9

The health costs of malaria include both personal and public expenditures on prevention

Malaria disproportionately affects poor people who cannot afford treatment or have limited access to health care, trapping families and communities in a downward spiral of poverty. Malaria is the commonest cause of work and school absenteeism in the tropics. It is the commonest cause of outpatient attendance in sub-Saharan Africa. Economic costs due to

Socio economic consequences of diseases are better appreciated when expressed as loss of manpower. Poverty promotes malaria and malaria yields poverty. Socio economic cost can be measured in terms of absenteeism, drugs purchase, doctor's fee, transport, and opportunity cost of time spent waiting for treatment. In Africa alone, the estimated annual direct and indirect costs of malaria were US\$800 million in 1987 and exceeded US\$1800 million by 1995. Malaria undermines the health and welfare of families, endangers the survival and education of children, debilitates the active population and impoverishes individuals and countries. It is one of the most serious obstacles to mankind's effort to

Knowledge, attitudes and practices are essential for control programmes. Without the rational concept of the cause of a disease, it is impossible to design control programmes.

Women bear more brute of the disease than men in sub-Saharan Africa. They often tolerate symptoms of malaria until they are critically ill because of the perception that sick women are mean or lazy. Women are reproached when there are malaria epidemics for having failed as custodians of health. Women are increasingly been informed to help them recognize the symptoms of malaria in themselves and family members e.g., fever chills, headache. When children are sick from malaria, women usually bear the psychological effects. Severe convulsions, fever and other symptoms affecting children leave a

Malaria in sub-Saharan Africa is a problem of dimensions unlike malaria seen anywhere else in the world today [13]. The magnitude of malaria is affected by a variety of factors, none of which addressed alone is likely to effect a resolution. It is further compounded by the

Malaria could be brought under control in sub-Saharan Africa as it has been in Europe and America. Instead, it is being allowed to run out of control just like the AIDS epidemic because of the indifference of Western governments to the lives of the poorest people on the

Poor people who represent most of the continent's malaria disease burden cannot afford to pay much more than what they currently pay for the old treatments, so costs must be subsidized by national governments with the help of international donors. What is missing

and treatment. In some heavy-burden countries, the disease accounts for:

develop agriculture, settlement, development projects and irrigation

There still exist wrong misconceptions of malaria in sub Saharan Africa.

psychological effect of fear and restlessness on the mothers [14].

generally poor social and economic conditions in sub-Saharan Africa.

**9. Conclusion** 

planet [15].

• up to 40% of public health expenditures; • 30% to 50% of inpatient hospital admissions; • up to 60% of outpatient health clinic visits.

malaria are enormous if quantified [13].

increased treatment failure. There have also been reports of increasing multiple-drug resistance to drugs other than chloroquine, such as amodiaquine, mefloquine, rendering treatment of malaria even more problematic. Currently, the best available treatment, particularly for *P. falciparium* malaria, is artemisinin-based combination therapy (ACT) [3]. Artemisinin is part of a combination therapy that reduces or prevents the problem of drug resistance.

Artemisinin and its derivatives like Artesunate, artemether, arteether and dihydroartemisin are the more common drugs now in sub- Saharan Africa. This is not surprising as there is currently no evidence for clinically relevant Artemisinin resistance. Nevertheless, Chloroquine and SP continue to be used because they cost around 10 US cents per treatment, whilst artemisinin combination treatment (ACT) costs US\$1.50 per treatment. This is estimated to be an annual cost of between US\$100 million and US\$200 million a year [4].

When treated with an artemisinin-based monotherapy, patients may discontinue treatment early following the rapid clearance of malaria symptoms. This results in partial treatment and patients still have persistent parasites in their blood. Without a second drug given as part of a combination (as is done with an ACT), these resistant parasites survive and can be passed on to a mosquito and then another person. Monotherapies are therefore the primary force behind the spread of artemisinin resistance [3]. The limitations of these group of drugs are the short duration of antimalarial activity and high recrudescence rate. However, there is low toxicity and they are highly potent and rapidly metabolized [10].

If resistance to artemisinin develops and spreads to other large geographical areas, as has happened before with chloroquine and (SP), the public health consequences could be dire, as no alternative antimalarial medicines will be available in the near future [3]. At least 300 to 500 million malaria episodes are treated annually in sub-Saharan Africa. Moreover, many communities engage in preventive and treatment practices outside what is provided by "official" programs.

Malaria vectors have shown resistance to numerous insecticides, including DDT, various organo-phosphates, and some carbamates. Mosquito control is being strengthened in many areas, but there are significant challenges, including:


The development of new, alternative insecticides is an expensive and long-term endeavour. Detection of insecticide resistance should be an essential component of all national malaria control efforts to ensure that the most effective vector control methods are being used [3].

#### **8. Socio economy aspects**

Malaria was a serious obstacle to the colonization of Africa. It caused a lot of suffering and tragedy. Its effect was devastating. It interfered with human progress and development. The disease is still a serious impediment to economic and social development in sub- Saharan Africa.

The socio- economic aspects of a disease is a significant factor in the epidemiology and control of the disease. Malaria causes significant economic losses, and can decrease gross domestic product (GDP) by as much as 1.3% in countries with high levels of transmission. Over the long term, these aggregated annual losses have resulted in substantial differences in GDP between countries with and without malaria, particularly in Africa.

increased treatment failure. There have also been reports of increasing multiple-drug resistance to drugs other than chloroquine, such as amodiaquine, mefloquine, rendering treatment of malaria even more problematic. Currently, the best available treatment, particularly for *P. falciparium* malaria, is artemisinin-based combination therapy (ACT) [3]. Artemisinin is part of a

Artemisinin and its derivatives like Artesunate, artemether, arteether and dihydroartemisin are the more common drugs now in sub- Saharan Africa. This is not surprising as there is currently no evidence for clinically relevant Artemisinin resistance. Nevertheless, Chloroquine and SP continue to be used because they cost around 10 US cents per treatment, whilst artemisinin combination treatment (ACT) costs US\$1.50 per treatment. This is estimated to be

When treated with an artemisinin-based monotherapy, patients may discontinue treatment early following the rapid clearance of malaria symptoms. This results in partial treatment and patients still have persistent parasites in their blood. Without a second drug given as part of a combination (as is done with an ACT), these resistant parasites survive and can be passed on to a mosquito and then another person. Monotherapies are therefore the primary force behind the spread of artemisinin resistance [3]. The limitations of these group of drugs are the short duration of antimalarial activity and high recrudescence rate. However, there is

If resistance to artemisinin develops and spreads to other large geographical areas, as has happened before with chloroquine and (SP), the public health consequences could be dire, as no alternative antimalarial medicines will be available in the near future [3]. At least 300 to 500 million malaria episodes are treated annually in sub-Saharan Africa. Moreover, many communities engage in preventive and treatment practices outside what is provided by

Malaria vectors have shown resistance to numerous insecticides, including DDT, various organo-phosphates, and some carbamates. Mosquito control is being strengthened in many

• an increasing mosquito resistance to insecticides, including DDT and pyrethroids,

The development of new, alternative insecticides is an expensive and long-term endeavour. Detection of insecticide resistance should be an essential component of all national malaria control efforts to ensure that the most effective vector control methods are being used [3].

Malaria was a serious obstacle to the colonization of Africa. It caused a lot of suffering and tragedy. Its effect was devastating. It interfered with human progress and development. The disease is still a serious impediment to economic and social development in sub- Saharan Africa. The socio- economic aspects of a disease is a significant factor in the epidemiology and control of the disease. Malaria causes significant economic losses, and can decrease gross domestic product (GDP) by as much as 1.3% in countries with high levels of transmission. Over the long term, these aggregated annual losses have resulted in substantial differences

in GDP between countries with and without malaria, particularly in Africa.

combination therapy that reduces or prevents the problem of drug resistance.

an annual cost of between US\$100 million and US\$200 million a year [4].

low toxicity and they are highly potent and rapidly metabolized [10].

areas, but there are significant challenges, including:

• a lack of alternative, cost-effective and safe insecticides.

particularly in Africa; and

**8. Socio economy aspects** 

"official" programs.

The health costs of malaria include both personal and public expenditures on prevention and treatment. In some heavy-burden countries, the disease accounts for:


Malaria disproportionately affects poor people who cannot afford treatment or have limited access to health care, trapping families and communities in a downward spiral of poverty.

Malaria is the commonest cause of work and school absenteeism in the tropics. It is the commonest cause of outpatient attendance in sub-Saharan Africa. Economic costs due to malaria are enormous if quantified [13].

Socio economic consequences of diseases are better appreciated when expressed as loss of manpower. Poverty promotes malaria and malaria yields poverty. Socio economic cost can be measured in terms of absenteeism, drugs purchase, doctor's fee, transport, and opportunity cost of time spent waiting for treatment. In Africa alone, the estimated annual direct and indirect costs of malaria were US\$800 million in 1987 and exceeded US\$1800 million by 1995. Malaria undermines the health and welfare of families, endangers the survival and education of children, debilitates the active population and impoverishes individuals and countries. It is one of the most serious obstacles to mankind's effort to develop agriculture, settlement, development projects and irrigation

Knowledge, attitudes and practices are essential for control programmes. Without the rational concept of the cause of a disease, it is impossible to design control programmes. There still exist wrong misconceptions of malaria in sub Saharan Africa.

Women bear more brute of the disease than men in sub-Saharan Africa. They often tolerate symptoms of malaria until they are critically ill because of the perception that sick women are mean or lazy. Women are reproached when there are malaria epidemics for having failed as custodians of health. Women are increasingly been informed to help them recognize the symptoms of malaria in themselves and family members e.g., fever chills, headache. When children are sick from malaria, women usually bear the psychological effects. Severe convulsions, fever and other symptoms affecting children leave a psychological effect of fear and restlessness on the mothers [14].
