DEMOCRATIC PEOPLE S REPUBLIC OF KOREA

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1 COUNTRY BRIEFING Eliminating malaria in the DEMOCRATIC PEOPLE S REPUBLIC OF KOREA DPRK, which was malaria-free from the early 1970s to 1997, is working to reduce its remaining malaria burden by 50 percent by Overview 1, 2 At a Glance 15,633 Reported cases of malaria (P. vivax only) Deaths from malaria % of population at risk (total population: 24.5 million) 0.64 Annual parasite incidence (cases/1,000 total population/year) % Slide positivity rate Source: World Health Organization, World Malaria Report 2012 : Data not available Malaria Transmission Limits Plasmodium vivax The Democratic People s Republic of Korea (DPRK) has experienced an 84 percent reduction in malaria cases since 2000, from more than 140,000 to fewer than 16,000, and is categorized in the pre-elimination phase by the World Health Organization (WHO).1 The DPRK first eliminated malaria in the early 1970s.2 The country was malaria-free until cases reemerged in 1998 and quickly spread along the border with the Republic of Korea.3 All malaria cases are now concentrated in the central and southern regions; 70 percent of cases are in the three provinces bordering the demilitarized zone (DMZ) between the DPRK and the Republic of Korea.4 Plasmodium vivax is the only malaria parasite found in the DPRK, and the primary vector is Anopheles sinensis, which breeds in fresh, sun-exposed water such as that found in rice fields.5, 6 Other important vectors are An. lesteri, An. anthropophagus, and An. yatushiroensis, which breed in the low hills, rice fields, and wetlands in the southern part of the country.6, 7 Malaria in the DPRK is unstable, with a high potential for outbreaks during the June-to-September transmission season.8 The highest burden of disease is among men and women between 17 and 59 years of age.4 Over 80 percent of all malaria cases occur in workers in the agricultural and industrial sectors. Overall, there are an estimated 14.9 million Water P. vivax free Unstable transmission (API <0.1) Stable transmission ( 0.1 API) 0 AUGUST Kilometres P. vivax malaria risk is classified into no risk, unstable risk of <0.1 case per 1,000 population (API) and stable risk of 0.1 case per 1,000 population (API). Risk was defined using health management information system data and the transmission limits were further refined using temperature and aridity data. Data from the international travel and health guidelines (ITHG) were used to identify zero risk in certain cities, islands and other administrative areas. 1

2 people at risk for contracting malaria, most residing in rural areas. 1, 8 No malaria deaths have been reported in the DPRK in more than 30 years, and mass chemoprophylactic efforts using primaquine were successful in reducing the malaria burden to its current low levels. 4, 7, 9 The DPRK has recently updated its national malaria strategy and is planning to lower the remaining burden by improving case reporting, vector control, community awareness, and program management. 4 The DPRK is a country partner of the Asia Pacific Malaria Elimination Network (APMEN), a network composed of 14 Asia Pacific countries and other partner institutions working 10, 11 to eliminate malaria in the region. Progress Toward Elimination P. vivax has been endemic and unstable on the Korean Peninsula for centuries. Japan invaded Korea in 1910 and there was no concerted effort to control malaria during the 35 years of its colonial control. 19 The end of World War II in 1945 divided the Korean Peninsula into North and South, separated by a demilitarized zone (DMZ). 20 Although malaria case data specific to the DPRK was not available during the Korean War ( ), it has been reported that thousands of national and foreign troops were afflicted by P. vivax as a result of wartime conditions. After the war, the number of malaria cases in DPRK reportedly diminished, yet endemic foci remained along the southern border. Radical elimination efforts by both countries led to a dramatic decrease in P. vivax prevalence in the 1960s and 1970s, and by 1979 the World Health Organization declared the Korean Peninsula malaria 3, 19, 21 free. However, in 1993 a soldier stationed in the DMZ was diagnosed with the first case of indigenous malaria on the Korean Peninsula in 14 years. 22 Soon after, malaria spread in the DMZ and in the Republic of Korea, but the first official indigenous case in the DPRK was not reported until In the four years that followed, the number of reported cases had increased almost 100-fold, from over 1,000 cases in 1998 to over 140,000 cases in This rapid increase in cases was due in part to heavy rainfall and subsequent flooding that led to an increase in stagnant water in rice fields, creating ideal breeding conditions for An. sinensis. 23 Deforestation in the 1990s, coupled with changes in rice-field irrigation systems, also contributed to the resurgence. Further compounding the matter, the government response to the ballooning epidemic was delayed due to significant economic disruptions and intense flooding. Reported Malaria Cases 150,000 Number of cases 120,000 90,000 6, ,000 2,100 cases Source: World Health Organization, World Malaria Report 2012 GOALS: 1. By 2012, reduce overall malaria morbidity by 50 percent of the 2007 level 4 2. By 2012, reduce malaria morbidity in the higher transmission zones by 70 percent of the 2007 level 4 AUGUST

3 But beginning in 2002, with support from the WHO, malaria control efforts for at-risk populations focused on mass chemoprophylaxis with primaquine. 9 Over the next five years, this treatment proved successful in decreasing the national caseload from 16,578 confirmed cases in 2002 to 4,795 in , 4 Chemoprophylaxis was discontinued in 2008, and during that year the number of cases increased by 70 percent to 16, But beginning in 2009, the DPRK revamped its elimination efforts with support from a Global Fund Round 8 grant. The US$11.5 million grant enabled the DPRK to: 1) enhance case management through maximizing confirmed diagnosis and treatment; 2) implement an integrated vector control approach through delivery of indoor residual spraying (IRS) and long-lasting insecticide-treated nets; 3) encourage community involvement and awareness through malaria education campaigns; and 4) improve national and local program management through capacitybuilding and training. 4 Eligibility for External Funding The Global Fund to Fight AIDS, Tuberculosis and Malaria 4, Economic Indicators GNI per capita (US$) $975 Country income classification Total health expenditure per capita (US$) $40 Total expenditure on health as % of GDP 6 Private health expenditure as % total health expenditure Low income 14.4 Yes U.S. Government s President s Malaria Initiative No World Bank International Development Association No Challenges to Eliminating Malaria Cross-border collaboration No formal cross-border collaboration exists between the DPRK and Republic of Korea. This is problematic since most of the DPRK s cases are concentrated in the southern provinces bordering the DMZ. Political tension between the North and South is prohibitive to any formal agreement concerning a peninsula-wide approach to controlling malaria Logistical and operational weaknesses Since the reemergence of P. vivax in the DPRK in 1998, there has been a shortage of antimalarial drugs, diagnostic supplies, and vector control equipment; therefore many cases are not yet properly diagnosed or managed. 4, 8 Additionally, there is no formal surveillance system, so the actual number of cases is difficult to measure. Economic constraints Economic and trade sanctions prevent the DPRK from obtaining finances or supplies for malaria control activities to which other low-income countries have access. Although they have received Round 8 funding from the Global Fund, the DPRK does not qualify for many other international aid programs, and only receives sporadic donor support. 4, 7 Persistent food shortages have compounded challenges in implementing effective malaria control by necessitating the diverting of aid toward malnutrition and other infectious diseases. 23 Conclusion The DPRK, with the support of APMEN, the Global Fund, and WHO, has put forth a strong effort in developing and implementing a comprehensive malaria control program to combat unstable and relapsing P. vivax with limited resources. 27 Increased cross-border collaboration between the DPRK and the Republic of Korea and continued malaria control efforts are critical to once again eliminate malaria from the Korean Peninsula. AUGUST

4 Sources 1. WHO. World Malaria Report Geneva: World Health Organization; Dr. Partha Pratim Mandal. Personal communication: Technical Officer - Project Manager World Health Organization - DPR Korea. Pyongyang, DPR Korea; WHO. Synopsis of the world malaria situation,1979. Wkly Epid Rec. 1981; 56: Round 8 grant: Aiming for the pre-elimination of malaria in the Democratic People s Republic of Korea through an expanded and comprehensive approach to malaria control programming. The Global Fund to Fight AIDS, Tuberculosis and Malaria; HI Ree HH, YH Paik. Study on natural infection of P. vivax in Anopheles sinensis in Korea. Korean J Parasitol. 1967; 5: Sinka ME, Bangs MJ, Manguin S, Chareonviriyaphap T, Patil AP, Temperley WH, et al. The dominant Anopheles vectors of human malaria in the Asia-Pacific region: occurrence data, distribution maps and bionomic precis. Parasit Vectors. 2011; 4: Thimasarn K. Updates on Malaria Elimination in DPR Korea. Asia Pacific Malaria Elimination Network Inaugural Meeting; February, 2009; Brisbane, Australia. 8. Round 3 grant: Sustainable Malaria Control in DPR Korea. The Global Fund to Fight AIDS, Tuberculosis and Malaria; Phu N. Malaria mass prophylaxis with primaquine in DPR Korea. New Delhi: World Health Organization: Regional Office for South East Asia; APMEN. Asia Pacific Malaria Elimination Network. [Available from: Hsiang MS, Abeyasinghe R, Whittaker M, Feachem RG. Malaria elimination in Asia-Pacific: an under-told story. Lancet. 2010; 375(9726): World Bank. International Development Association Eligibility [Available from: ABOUTUS/IDA/0,,contentMDK: ~menuPK: ~pagePK: ~piPK:437394~theSitePK:73154,00.html] 13. President s Malaria Initiative. U.S. Government s President s Malaria Initiative (PMI) [Available from: countries/index.html] 14. The Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund Eligibility List [Available from: org/en/application/applying/ecfp/eligibility/] 15. United Nations data. United Nations Statistics Division 2011; [Available at: Central Intelligence Agency. The World Factbook: North Korea [Available from: United Nations Children s Fund. GNI per capita: DPR Korea. State of the World s Children: Special Edition on Human Rights World Health Organization. Per capita total expenditure on health (PPP int. $); Yeo I-S. The Return of Malaria in Modern Korea. XIV International Economic History Congress. Helsinki, Finland; World War II and Korea. In: Savada AS, W, eds., editor. South Korea: A Country Study. Washington, DC: GPO for the Library of Congress; Ree H. Unstable vivax malaria in Korea. Korean J Parasitol. 2000; 38: Chai IH LG, Yoon SN, Oh WI, Kim SJ, Chai JY. Occurence of tertian malaria in a male patient who has never been abroad. Korean J Parasitol. 1994; 32: Hagard S, Noland M. Famine in North Korea: markets, aid and reform. New York: Columbia University Press; Korean leaders in historic talks. BBC news. [Available at: witn/2007/10/071003_korea_summit.shtml]; Anger at North Korea over sinking. BBC News. [ Lee M. Clinton: Koreas security situation precarious. Associated Press. Beijing. [ Park JW, Kim KH, Jung YJ, Bae I, Yeom JS. Status of vivax malaria in North Korea (in Korean). Korean Unific Health Care. 2007; 6: Transmission Limits Map Sources Guerra, CA, Howes, RE, Patil, AP, Gething, PW, Van Boeckel, TP, Temperley, WH, Kabaria, CW, Tatem, AJ, Manh, BH, Elyazar, IRF, Baird, JK, Snow, RW and Hay, SI. (2010). The international limits and population at risk of Plasmodium vivax transmission in Public Library of Science Neglected Tropical Diseases, 4(8): e774. Rakesh M. Rastogi (2010), World Health Organization/Regional Office for South-East Asia, New Delhi, Republic of India (Data years ) AUGUST

5 About This Briefing This country briefing was produced through a collaboration of the Global Health Group, in partnership with the Ministry of Public Health in the Democratic People s Republic of Korea. Malaria transmission risk maps were provided by the Malaria Atlas Project (MAP). Funding was provided through a grant to the Global Health Group from the Exxon Mobil Corporation. The Malaria Elimination Initiative at the Global Health Group of the University of California, San Francisco ( edu/global-health-group) convenes the Malaria Elimination Group ( and supports countries actively pursuing elimination at the endemic margins of the disease. Funding for the Malaria Elimination Initiative is provided by the Bill & Melinda Gates Foundation and Exxon Mobil Corporation. The Malaria Atlas Project (MAP) provided the malaria transmission maps. MAP is committed to disseminating information on malaria risk, in partnership with malaria endemic countries, to guide malaria control and elimination globally. Find MAP online at: APMEN asia pacific malaria elimination network Additional support was provided by the Asia Pacific Malaria Elimination Network (APMEN). Find APMEN online at: GLOBAL HEALTH GROUP PROJECT TEAM Editor: Allison Phillips Managing Editor: Chris Cotter Researcher and Content Developers: Janelle Downing and Saehee Lee Graphic Designer: Kerstin Svendsen AUGUST