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RUEHSH/AMCONSUL SHENYANG 3660
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RHMFISS/COMUSKOREA CC SEOUL KOR
RHMFISS/COMUSKOREA J5 SEOUL KOR

UNCLAS SEOUL 000881 
 
SIPDIS 
 
SIPDIS 
SENSITIVE 
 
STATE FOR EAP, EAP/K, INR/I AND OES/IHA 
STATE PASS USAID FOR GLOBAL HEALTH 
HHS FOR GLOBAL AFFAIRS: BHAT 
HHS PASS NIH/FIC AND NIAID 
CDC FOR NCID - NATL CTR FOR INFECTIOUS DISEASES 
USDA FOR FAS/DLP - WETZEL 
COMM CENTER PLEASE PASS TO COMUSKOREA SCJS 
GENEVA FOR USMISSION WHO 
 
E.O. 12958: N/A 
TAGS: TBIO EAID PINR ECON SOCI KN
SUBJECT: NORTH KOREA STRUGGLES WITH SHORTAGE OF MEDICINE AND 
EQUIPMENT FOR CONFRONTING INFECTIOUS DISEASES 
 
REFS: A) 07 SEOUL 1080 
      B) SEOUL 499 
 
------- 
SUMMARY 
------- 
 
¶1.  (SBU) Famine, natural disaster, mismanagement, a lack of safe 
drinking water, and shortages of essential drugs and vaccines have 
left the population of the Democratic Peoples' Republic (DPRK) 
vulnerable to infectious diseases, despite the existence of an 
adequately-trained corps of medical personnel in the regime's 
four-tiered state medical system.  The most troublesome infectious 
diseases currently include tuberculosis, malaria, hepatitis B, 
diarrheal diseases, and intestinal parasites.  The looming food 
shortages in North Korea will likely further aggravate the disease 
burden of the population.  If relations between the United States 
and the DPRK improve, and if North Korean authorities become more 
open to outside humanitarian aid, the infectious disease problem in 
the DPRK could provide the United States with numerous opportunities 
(beyond existing projects) to reach out to the North's public by 
providing drugs, vaccines, diagnostic equipment, and other 
much-needed health-related aid.  End summary. 
 
------------------------- ------------------------ 
SCIENCE FELLOW EXAMINES INFECTIOUS DISEASE IN DPRK 
------------------------- ------------------------ 
 
¶2.  (SBU) Dr. Karl A. Western, MD, DTPH, Senior International 
Scientific Advisor at the National Institute of Allergy and 
Infectious Diseases (NIAID -- part of NIH), spent four weeks in 
November 2007 in Embassy Seoul as an Embassy Science Fellow (ESF -- 
see ref A), examining infectious disease management in the 
Democratic People's Republic of Korea (DPRK).  He gathered 
information from Republic of Korea (ROK) government sources, 
ROK-based non-governmental organizations (NGOs) active in the DPRK, 
and international NGOs and organizations.  The goal was to provide 
U.S. policymakers with a detailed snapshot of the DPRK public health 
sector, as well as to outline possible avenues for enhanced U.S. 
health-related cooperation with the DPRK, should our relationship 
improve as the denuclearization process proceeds. 
 
¶3.  (U) The project focused on four essential issues: A) the 
infectious disease situation in DPRK; B) the capability of the DPRK 
health system to diagnose and manage current endemic infectious 
disease as well as potential infectious disease threats; C) existing 
efforts by NGOs and other donors to increase the DPRK capacity to 
deal with infectious diseases; and D) unmet needs creating 
opportunities that U.S. assistance could potentially address.  The 
following is Dr. Western's report. 
 
------------ 
Methodology 
------------ 
 
¶4.  (U) Prior to beginning the Embassy fellowship, Dr. Western and 
Dr. Boris Pavlin, MD, MPH, a Johns Hopkins University Preventive 
Medicine Resident at NIAID, conducted an extensive review of public 
information available on the Internet on infectious diseases in 
DPRK.  They also conducted interviews with U.S. Government (USG) 
agencies and organizations active in the DPRK.  In Seoul, Dr. 
Western met with officials from the Ministry of Health and Welfare 
(MOHW), the Ministry of Unification (MOU), international 
organizations active in DPRK, and ten of the 20 ROK-based NGOs with 
health programs in DPRK. 
 
 
 
¶5. (SBU) Official data from the DPRK Government on infectious 
diseases are incomplete, unverifiable, and may be biased by 
political considerations.  North Korea reports few infectious 
diseases to the World Health Organization (WHO) and other 
international organizations.  Multiple sources indicated that 
effective infectious disease surveillance and reporting do not exist 
in North Korea.  Furthermore, the lack of microbiological and 
serological diagnostic laboratories results in an inability to 
confirm suspected diseases, and therefore in substantial 
underreporting.  DPRK sensitivity also prevents external 
organizations from verifying reported figures or independently 
evaluating infectious disease conditions.  The DPRK also does not 
report on a number of important infectious diseases.  In those 
circumstances, if the disease is endemic in border areas of 
neighboring countries such as ROK, China, and Russia, it is 
reasonable to assume that the DPRK is infected with the pathogen or 
at risk of becoming so. 
 
-------------------------------------------- 
STATUS OF INFECTIOUS DISEASES IN NORTH KOREA 
-------------------------------------------- 
 
¶6.  (U) The DPRK Government established 14 health priorities in its 
2004-2008 Five Year Plan.  Tuberculosis, malaria, and HIV/AIDS 
ranked first.  Other infectious diseases (hepatitis B, intestinal 
infectious diseases and parasitoses) were ranked second. 
 
Tuberculosis 
------------ 
 
¶7.  (U) There was a dramatic increase of reported tuberculosis 
during the past decade as a result of the overall deterioration in 
the population's nutritional status, deterioration of the public 
health infrastructure, scarcity of medicines, and increased 
attention given to the problem.  The DPRK has had a long-term 
commitment to tuberculosis treatment and control through its 
vertical National Tuberculosis Program (NTP).  There are currently 
approximately 67 district tuberculosis care facilities 
(second-level) and 13 hospitals dedicated exclusively to the 
isolation and care of tuberculosis patients. 
 
¶8.  (U) With technical assistance from the World Health Organization 
(WHO), the DPRK initiated Directly Observed Therapy Program, 
Short-Course (DOTS) in 1998 with a three-phased expansion to cover 
the country by 2004.  As a result, DOTS coverage has approached 100% 
and DOTS case detection has increased from two percent before 1998 
to 108% (sic) in 2004.  In 2004, there were 52,591 cases diagnosed 
and treated under DOTS with successful treatment rates ranging from 
88% to 94%, compared with a 76% success rate from non-DOTS 
treatment.  According to official DPRK statistics, in 2005, incident 
(new and relapsed) cases of tuberculosis totaled 42,722 
(178/100,000), with 3,015 deaths (13/100,000), and with a prevalence 
rate of 179/100,000 population.  (For comparative purposes, the 2005 
official incidence rate per 100,000 population was 96.4 in South 
Korea, and 4.5 in the United States.)  Multiple drug-resistant (MDR) 
tuberculosis accounted for 2.8% of new cases in North Korea's 
official statistics, and 15% of previously treated cases in 2004. 
The DPRK tuberculosis program is currently supported by the World 
Bank Global Development Finance Program, the Global Fund to Combat 
AIDS, Tuberculosis and Malaria (GFATM), and donations from multiple 
NGOs. 
 
¶9.  (SBU) Tuberculosis is the most important infectious disease 
among DPRK defectors arriving in South Korea, and the incidence 
 
among defectors is suggestive of a much higher infection rate, and 
of a much higher incidence of drug resistance, than are reflected in 
the North's official statistics.  In a 2004 study of arriving 
defectors, 42 cases of tuberculosis (88% pulmonary) were diagnosed, 
giving an extrapolated incidence of 900 cases per 100,000 
population.  Nine tuberculosis isolates were tested for drug 
resistance: four were isoniazid (INH)-resistant, three were MDR, and 
only two were susceptible to all primary tuberculosis drugs. 
 
¶10.  (U) Major ongoing challenges in the area of tuberculosis 
treatment include sustaining and expanding DOTS throughout the 
country; improving tuberculosis diagnosis (Gram stain, X-ray, sputum 
culture, drug-sensitivity testing); ensuring the availability of 
primary tuberculosis drugs and secondary drugs for MDR cases; and 
shifting tuberculosis care from isolation facilities to ambulatory 
treatment. 
 
Malaria 
------- 
 
¶11.  (U) Although the fact was never certified by WHO, the DPRK was 
considered free of indigenous malaria from the 1970's to 1998, when 
Plasmodium vivax reemerged in human populations on both the north 
and south sides of the Demilitarized Zone (DMZ).  To date, 
indigenous malaria in North Korea has been exclusively P. vivax with 
no confirmed resistance to chloroquine.  Mefloquine, however, 
appears to be the most commonly administered drug, often without the 
addition of an appropriate drug (e.g. primaquine) to eliminate the 
hepatic stage of the parasite to prevent relapses.  Endemic malaria 
continues to be largely confined to the DMZ, but potential mosquito 
vectors occur throughout the country below 2,000 meters.  The press 
reported malaria outbreaks in Pyongan Namdo Province in 2006 
following monsoon-related heavy rainfall. 
 
¶12.  (U) In response to the malaria epidemic, DPRK and WHO 
established a Malaria Control Program in 1999.  The number of 
officially-reported cases surged to 295,570 in 2001, but by 2006 the 
number reported dropped to 9,300.  According to the latest detailed 
reports (2003), only 26% of cases were confirmed by peripheral blood 
smear.  Malaria reports among children (962 cases) and pregnant 
women (92 cases) were relatively low.  No hospital malaria deaths 
were reported.  During that same year, WHO reported that 0.7% of 
deaths in children less than 5 years old were attributed to malaria 
infection.  Dr. Western could find no information about mosquito 
vector ecology and epidemiology and was told that the DPRK considers 
this a sensitive issue.  (In contrast, the ROK has conducted 
epidemiology and vector biology studies of vivax malaria south of 
the DMZ.  This information is available in peer-reviewed 
publications and in reports of the Korea Center for Disease Control 
and Prevention (KCDC).) 
 
¶13.  (U) The DPRK malaria control program relies upon the 
distribution of donated permethrin-impregnated bed nets, treatment 
of clinical cases, and prophylaxis of high-risk populations such as 
the military and civilian populations along the DMZ. In 2003, 90,360 
new bed nets were sold or distributed, and 394,000 bed nets were 
treated or retreated with insecticide.  No data were available on 
total malaria drug donations. 
 
¶14.  (U) Ongoing challenges include increasing the percentage of 
confirmed malaria cases through peripheral blood smear examination, 
more appropriate treatment of malaria cases to prevent relapse, 
maintaining the availability and use of appropriate anti-malarial 
drugs, sustaining the bed net program, and a better understanding of 
malaria epidemiology in North Korea to develop scientifically-based 
 
prevention and control strategies. 
 
HIV/AIDS 
-------- 
 
¶15.  (U) North Korea denies the existence of HIV infection and 
clinical AIDS cases.  The United Nation AIDS Agency (UNAIDS) 
estimated (2004) that there were fewer than 100 cases in the 
country.  DPRK HIV/AIDS surveillance consists almost entirely of 
screening blood donors, foreign visitors and returning North 
Koreans.  In 1988, the DPRK issued a Public Health Directive on 
HIV/AIDS, usually an indication that there is an actual or real 
threat.  In October 2003, the Ministry of Public Health organized 
the first national HIV/AIDS workshop. 
 
¶16.  (U) To date, only one DPRK defector has tested HIV positive and 
his infection may have been acquired in a transit country. 
 
¶17.  (U) While the level of HIV infection is currently extremely 
low, DPRK is at risk from the disease due to unsafe medical 
injection practices, decreased blood screening due to economic 
constraints, and increased population movements both within the 
country and to third countries, such as China, where HIV prevalence 
is increasing. 
 
Hepatitis B 
----------- 
 
¶18.  (U) Hepatitis B Virus (HBV) is usually transmitted by dirty 
needles, during sexual intercourse, or from mother to newborn.  The 
majority of patients infected with HBV eventually clear the 
infection, but a minority becomes chronically infected.  In addition 
to morbidity from the acute infection, HBV is a major cause of liver 
failure and liver cancer in chronically-infected HBV surface antigen 
positive (HBsAg+) individuals.  Infection with Hepatitis B Virus 
(HBV) is one of the DPRK's biggest public health problems, but no 
country-wide data are available on its overall prevalence.  Outside 
the WHO Expanded Program on Immunization (EPI), which targets 
infants under one year of age, HBV vaccine is not widely available 
in the DPRK. According to the Eugene Bell Foundation (EBF), only 
about 10% of newborns born to HBV-antigen-positive mothers become 
infected.  HBV diagnostic testing is not routine, but patients who 
present with jaundice are isolated in hepatitis care facilities in 
district (second-level) clinics until they die or recover. 
Antiviral treatment for HBsAg+ patients is not available. 
 
¶19.  (U) The best HBV data available come from a baseline serosurvey 
conducted by the Ministry of Public Health and the EBF in 2004 in 
Wonsan, a northeast coastal city, in advance of a school-based pilot 
immunization program.  Wonsan authorities told EBF that there are 
approximately 800-1,000 new cases each year in a population of about 
310,000, a prevalence of 6-7% in adult populations, and 7-8% HBV 
antigen+ in pregnant women.  The serosurvey of school children aged 
7-10 years old found an HIV antigen+ prevalence of 33%.  This cohort 
of school children was born before HBV was incorporated into the EPI 
immunization program.  Independently, the U.S. Centers for Disease 
Control and Prevention (CDC) assesses DPRK as "highly endemic" for 
HBV with HBsAg+ prevalence above 8%. 
 
¶20.  (SBU) A study of DPRK defectors by South Korea's Ministry of 
Health showed an anti-HBsAg antibody rate of 83.9%, an indication of 
nearly universal exposure to the virus at some time in life, and a 
HBsAg+ rate of 15.4%. 
 
¶21.  (U) HBV is a vaccine preventable disease.  Ongoing challenges 
 
are to institute a universal immunization program for newborns and 
school entrants to complement the existing EPI effort, and to 
deinstitutionalize the care of patients with jaundice attributed to 
HBV. 
 
Diarrheal Diseases 
------------------ 
 
¶22. (U) Diarrhea is caused by person-to-person spread, non-potable 
drinking water, failure to wash hands, contaminated food, unsanitary 
latrines and sewage, and poor hygienic practices.  Poor nutrition is 
a contributing factor to intestinal diarrhea.  Many intestinal 
bacteria and viruses and a few one-cell parasites (e.g. amoeba, 
giardia, cryptosporidia) cause acute and chronic diarrhea.  Current 
microbiological techniques can identify the cause of infectious 
diarrhea in about 80% of cases.  North Korea lacks diagnostic 
laboratories, so the infectious agents causing diarrhea in 
individual patients or causing epidemics in communities are unknown. 
 
 
¶23.  (U) Diarrhea continues to be the most common cause of childhood 
illness and hospitalization in DPRK.  An October 2002 nutritional 
assessment revealed that 20% of young children had had diarrhea 
within the two weeks preceding the survey.  This rate was similar to 
the findings of an earlier nutritional survey in 1998.  According to 
the survey, most DPRK mothers (78.4%) were aware of diarrheal 
symptoms and indications for referral to a health center.  The 
majority (90.9%) of DPRK children with diarrhea received 
WHO/UNICEF-recommended home treatments (e.g. oral rehydration 
solution or rehydration fluids), but few (17.9%) increased their 
fluid intake and continued eating. 
 
¶24.  (U) The DPRK Ministry of Public Health (MOPH) has initiated 
disease surveillance in two pilot counties (Icheon-gun, Gangwon 
Province and Pyongsan, Hwanghae Bukdo Province), and reported 
increases in the numbers of diarrhea cases from mid-August to 
mid-September 2007 of 45% and 36% respectively.  The epidemic 
investigation should now be completed and the MOPH may eventually 
share the results with WHO and other partners.  WHO is currently 
awaiting approval of the proposed National Disease Surveillance 
Report Project. 
 
Acute Respiratory Infections 
---------------------------- 
 
¶25.  (U) Acute respiratory infections, along with diarrheal 
diseases, are the most common causes of infant morbidity and 
mortality in developing countries.  In a 2000 nutritional survey, 
the DPRK Government reported that 12.2% of children under five years 
of age had had an acute respiratory infection in the two weeks prior 
to the survey.  A reported 82.7% of those children were seen by a 
health care provider. 
 
¶26.  (U) Seasonal influenza undoubtedly occurs in DPRK but no 
information is reported.  DPRK suffered an outbreak of H7N1 (not 
H5N1) avian influenza in chickens in March 2005. No human cases were 
reported.  No suspected cases of Severe Acute Respiratory Syndrome 
(SARS) have been reported. 
 
Intestinal Parasites 
-------------------- 
 
¶27.  (U) Most intestinal parasitic infections are caused by Soil 
Transmitted Helminths (STH) such as ascaris (roundworm), tricuris 
(whipworm), and hookworm. The DPRK has had a strategic plan to 
 
reduce STH infections through twice-yearly community deworming.  As 
a result, roundworm and hookworm prevalence decreased to 5.0% and 
0.1% by the 1980's.  Since then, natural disasters, economic slumps, 
limited water supplies, and improper handling and use of "night 
soil" have led to wide-spread environmental contamination and 
increased STH rates. In 2003, the situation reached a low point when 
only 38 of 2,679 primarily schools dewormed only 14,180 children out 
of an eligible population of 3,110,620 (0.5%).  DPRK conducted a 
national STH Survey in 2004.  The overall prevalence of infection 
with one or more soil helminth was 42.6%.  Roundworm infection was 
most common (41.1%) and had the highest rates of moderate/severe 
infection (4.6%) followed by whipworm (27.0%/1.0%) and hookworm 
(0.3%/0.0%). According to the 2007 UN Children's International Child 
Emergency Fund (UNICEF) Action Plan, almost 97% of DPRK children 
aged two-five years of age will receive deworming tablets this year. 
 
 
¶28.  (U) Intestinal parasite surveys of DPRK defectors found one or 
more intestinal parasites in 28.9% of them, with the highest rate 
occurring among teenagers (44.8%).  This second figure is remarkably 
similar to the 42.6% intestinal parasite rate found in the survey of 
school children in North Korea. 
 
Recent Infectious Disease Outbreaks 
----------------------------------- 
 
¶29. (U) The Good Friends Center for Peace, Human Rights, and 
Refugees and other NGOs have reported endemic leprosy, high 
prevalence of head lice and skin infections (tinea and boils), 
epidemics of measles, scarlet fever, cholera, typhoid fever, 
paratyphoid fever, hemorrhagic fever, severe hepatitis with liver 
failure, and tuberculous meningitis among children in military 
households.  (There have also been outbreaks of foot and mouth 
disease among animals, with a potentially severe economic impact, 
but the disease does not affect humans directly.) 
 
¶30.  (U) The DPRK Government has not recognized or reported any of 
the above conditions except for measles.  Prompt recognition and 
accurate diagnosis of infectious disease epidemics in DPRK are 
severely hampered by the secrecy and sensitivity of the Government, 
and by the virtual absence of microbiologic diagnostic laboratories. 
 Compounding these obstacles is the North's unwillingness to share 
specimens for diagnosis outside the country.  The diagnosis of 
leprosy, head lice, tinea, and boils can be made by a trained 
clinician, but most of the other diseases reported by Good Friends 
require laboratory confirmation to be certain of appropriate 
treatment. 
 
¶31.  (U) The practical effect of these unsubstantiated reports is 
that donor organizations and NGOs have offered drugs and supplies to 
DPRK that may be inappropriate or harmful.  Scarlet fever is not 
affected by measles vaccination and penicillin does not affect the 
clinical course or spread of measles. 
 
Vaccine Preventable Childhood Diseases 
-------------------------------------- 
 
¶32. (U) The DPRK participates in the WHO Expanded Program on 
Immunization (EPI), which is designed to provide infants with 
primary vaccination coverage during the first year of life.  MOPH 
and WHO partners include UNICEF, the Global Alliance for Vaccines 
and Immunization (GAVI), and NGOs (including the South Korean Red 
Cross).  Vaccines are distributed from the national level to the 
provinces for administration at the county level.  Each province is 
assigned an immunization day each month when immunization is 
 
provided at the local level.  Prior to the immunization day, section 
doctors remind households with infants requiring vaccines to attend 
the clinic.  Individual vaccinations are recorded in Child Health 
Care Cards which remain at the local clinic unless the family moves 
elsewhere.  Newborns are vaccinated against tuberculosis (BCG 
vaccine) by the attending midwife or physician whether at home or in 
an institution. 
 
¶33.  (U) Official DPRK records indicate relatively high infant 
immunization rates: 1) BCG: 94% (2004); 2) Measles: 95% (2004); 3) 
Diphtheria-Pertussis-Tetanus-times 3 (DPT3): 79% (2005); 4) 
Hepatitis B Vaccine-times 3 (HBV3): 92% (2005); and Poliomyelitis 
times 3 (Polio3): 97% (2005).  HBV vaccines were introduced in 1997. 
 Historical review indicates that coverage with the other EPI 
vaccines has substantially improved over ten years ago.  GAVI has 
independently verified the reliability of these figures (including 
the relatively low DPT3 coverage) through an audit of Child Health 
Care Cards at the local level. 
 
¶34.  (U) A review of DPRK reporting of vaccine preventable childhood 
diseases indicated that the EPI Program is very effective overall. 
 
-  BCG/Tuberculosis.  BCG vaccine confers significant protection 
against primary tuberculosis infection in infants and children, but 
has little or no effect on infection and disease in adults. There is 
anecdotal reporting by NGOs that pediatric tuberculosis is 
increasing, but there are no well-done studies on this subject. 
 
-  Measles.  On April 20, 2007, a WHO Press Release reported the 
first measles outbreak in DPRK since 1992.  The epidemic occurred in 
30 of the 204 counties in DPRK and caused the deaths of two adults 
and two infants.  The DPRK Government reported that 9% of cases 
occurred in children under the age of five years and 40% in 11-19 
year-olds.  In response to the epidemic, the DPRK distributed 16 
million doses of donated measles vaccine.  Measles immunization 
before one year of age does not protect approximately 30% of infants 
and re-immunization at 18-27 months is necessary to achieve 
protection of school children at the 95%-plus level. Re-immunization 
at school entry or in young adulthood is necessary to convey 
life-long protection.  Information on the percentage of cases from 
one-four years of age is lacking, but the measles epidemic pattern 
is consistent with failure to administer a booster dose of measles 
vaccine and to re-immunize upon school entry, rather than a failure 
of the EPI Program. 
 
-  Diphtheria. The last reported diphtheria cases in DPRK were 
reported in 1981.  Re-immunization with adult diphtheria-tetanus 
(dT) vaccine is necessary to maintain life-long protection. 
 
-  Pertussis (Whooping Cough).  Pertussis has persisted in the DPRK. 
 In 2006, DPRK reported 409 cases with no deaths.  Pertussis 
immunity following DPT3 lasts several years.  Booster doses are 
required at school entry to maintain immunity through adolescence. 
The age breakdown of reported cases would be needed to assess the 
effectiveness of the EPI Program. 
 
-  Tetanus.  North Korea has reported no cases of tetanus since 
1998, when six neonatal cases were reported.  Immunity to tetanus 
immunization lapses after 10-15 years.  Booster immunizations are 
required to maintain immunity during childbearing years and 
adulthood.  Neonatal tetanus occurs when unvaccinated mothers give 
birth to infants under unsanitary conditions and the newborn is 
infected with tetanus spores.  No figures were found on the 
percentage of pregnant women immunized against tetanus. 
 
-  Hepatitis B.  Immunity against HBV lasts three to five years, 
depending on the vaccine product administered.  Re-immunization is 
required at school entry and during adulthood to ensure continued 
protection. 
 
-  Poliomyelitis.  The DPRK participates in the WHO Poliomyelitis 
Eradication Program and has not reported a case of paralytic 
poliomyelitis since before 1980. As part of the WHO Program, the 
DPRK has reported and investigated 63 cases of acute flaccid 
paralysis (AFP), none of which was caused by wild poliomyelitis 
infection.  It is not known how many (if any) of the AFP cases were 
due to adverse effects of the live poliomyelitis vaccine. 
Immunization with oral trivalent poliomyelitis vaccine (OPV) three 
times during infancy requires one booster dosage to convey life-long 
protection. 
 
-  Other Vaccine Preventable Diseases.  DPRK does not routinely 
immunize against Haemophilus influenzae type B (Hib - also called 
bacterial meningitis), rubella (German measles), mumps, or varicella 
(chicken pox).  These diseases are not routinely reported by DPRK. 
 
Sexually-transmitted Diseases 
----------------------------- 
 
¶35.  (U) North Korea does not report sexually-transmitted diseases 
(STDs).  Serologic testing for syphilis is available in Pyongyang, 
and there have been rumors of syphilis outbreaks during the past ten 
years.  No seroprevalence studies have been done.  The ROK 
Government and NGOs working in the DPRK have noted that, while there 
is no organized or sanctioned commercial sex in DPRK, food shortages 
and famine have resulted in women practicing cottage-industry 
commercial sex work to save themselves and their families. 
 
¶36.  (U) Among female defectors, there have been a total of 137 
cases of STDs since the testing program was begun in 2004.  The 
annual number of STDs remained between 28 and 35 from 2004-2006, but 
jumped to 45 in the six months through June 2007.  This may be a 
true increase, or be due to an increased number of female defectors, 
to an expansion of STD testing, or to other factors.  Since most 
STDs (syphilis being an exception) have incubation periods in days 
and many defectors were sexually abused or practiced commercial sex 
in transit countries, it is difficult to determine where they 
acquired the STD. 
 
Hemorrhagic Fever with Renal Syndrome 
------------------------------------- 
 
¶37.  (U) Hemorrhagic Fever with Renal Syndrome (Hantavirus/Korean 
Hemorrhagic Fever - HFRS) is caused by members of the bunyavirus 
family first recognized in Korea during the Korean War among UN 
military personnel.  DPRK reported 316 cases of HFRS from 1961-1997 
when reporting stopped.  Since mice are the reservoir for the virus 
and spread the infection through urine and feces, increases in mouse 
populations and/or lapses in rodent control and increased 
human-rodent contact may result in human cases.  Note:  There are 
numerous anecdotal reports of North Koreans capturing and eating 
rodents to survive, especially in prison camps.  The looming food 
shortages will likely make this phenomenon more widespread, 
increasing the risk of hantavirus infection.  End note.) 
 
Japanese Encephalitis 
--------------------- 
 
¶38.  (U) Japanese Encephalitis (JE), the most common cause of viral 
encephalitis in Asia, is endemic on the Korean Peninsula.  JE is 
 
 
transmitted by Culex mosquitoes; wild birds are the natural host, 
and domestic pigs are reservoirs for the virus.  South Korea has 
largely controlled JE through immunization programs and the 
reduction of human-pig interaction.  North Korea does not routinely 
immunize against JE.  The International Vaccine Institute (IVI) in 
Seoul launched a pilot program in February and March this year, 
immunizing two cohorts of 3,000 children each in Nampo and Sariwon 
(municipalities west and south, respectively of Pyongyang) against 
JE and Hib (bacterial meningitis).  IVI will follow up to assess 
safety and efficacy in the DPRK setting. 
 
Rickettsial Diseases 
-------------------- 
 
¶39.  (U) Scrub typhus (Orientia tsutsugamushi) and murine typhus 
(Rickettsia typhi) are endemic to the region, but no data are 
available because these are not notifiable diseases and due to a 
lack of laboratory diagnostic capability. 
 
Other Parasitic Diseases 
------------------------ 
 
¶40.  (U) The June 2007 issue of the Korean Journal of Parasitic 
Diseases reported on an ELISA test serological survey of 137 DPRK 
citizens resident along the China border and 133 female defectors 
resident in ROK, testing for Clonorchis sinensis (lung fluke), 
Taenia solium (pork tape worm, the causative agent of 
cysticercosis), and Sparganum, a second cestode parasite.  Among the 
270 specimens tested, 11.5%, 9.3%, and 4.1% tested positive for 
immunoglobulin G (IgG) to the antigens of these specific parasites. 
Overall, 38.2% of men and 15.8% of women were positive to one or 
more of these pathogens.  The results suggest that these parasites 
may be highly prevalent in some areas of DPRK.  Paragonimiasis (lung 
fluke) was once common on the Korean Peninsula and entered into the 
differential diagnosis of tuberculosis.  The Korean Institute of 
Tuberculosis reports that this disease is very rare in ROK and has 
not been found in DPRK defectors. 
 
------------------------------- 
DISEASE MANAGEMENT CAPABILITIES 
------------------------------- 
 
¶41.  (U) North Korea, in contrast to most developing countries, 
possesses an organized four-level healthcare system.  It is staffed 
at the first, or local, level with "quasi-physicians" who receive 
three years of medical training and who are responsible for the 
medical care of 200 families.  Primary care, health education, and 
prevention programs are carried out at the local level.  Although 
the first-level primary facilities suffer severely from lack of 
electricity, heating, basic equipment, and drugs or vaccines, 
indications are that they are usually staffed by dedicated, 
hard-working, and resourceful health staff who try to make the best 
of the circumstances. 
 
¶42.  (U) Second-level (district) clinics provide basic medical care 
and tuberculosis and hepatitis resident care.  Third-level 
(provincial) hospitals provide both ambulatory and inpatient care. 
Fourth-level national and specialty hospitals are located primarily 
in Pyongyang and provide health services to members of the elite. 
Comparatively speaking, Pyongyang-based health facilities are better 
staffed and equipped than those at the provincial, district, and 
local level, but shortages of electricity, fuel, safe water 
supplies, refrigeration, functional diagnostic equipment, 
microbiological laboratories, vaccines, and medications exist 
throughout the system.  Essential drugs (including antibiotics) are 
 
usually not available within the health system and must be obtained 
by the patient in the open or "black" market.  The sources and 
quality of these drugs are open to question. 
 
Obstacles to the Provision of Care 
---------------------------------- 
 
¶43.  (U) The absence of electrical power at the first-level 
healthcare facilities, and intermittent or fluctuating power at 
secondary, tertiary and national facilities, have a profound impact 
on the ability to run both basic equipment (e.g. refrigerators, 
microscopes, X-ray machines) and more sophisticated medical devices. 
 The recent announcement of a USD 4 million USAID Energy Assistance 
Program, to provide generators at rural and peripheral health 
clinics through U.S.-based NGOs, will help address this obstacle. 
The money will be disbursed in two tranches of USD 2 million each. 
 
¶44.  (U) The scarcity and low quality of fuel in the DPRK may be a 
limiting factor in efforts to combat the shortage of electricity by 
providing generators.  During the frequent interruptions to 
electrical power, generators may be used intermittently or only when 
there is the need to run a diagnostic test.  This practice will not 
only adversely affect the storage of vaccines and medicines that 
require refrigeration, but may damage the equipment. 
 
¶45.  (U) Urban areas of North Korea had urban water supplies and 
sewage systems, but these facilities have deteriorated to the point 
where sewage contamination of water supplies is frequent, and many 
hospitals are without reliable running water regardless of 
potability.  Frequent hand-washing is the critical feature of 
effective infection control in the hospital and clinic setting. 
Rural areas usually do not have potable water or sewage disposal. 
 
¶46.  (U) With the exception of the EPI and blood banking in the 
Pyongyang area, DPRK does not have access to disposable needles, 
infusions, surgical equipment, or disposable gloves. As a result of 
the lack of electricity and water, needles, syringes, and equipment 
are either chemically disinfected or reused with multiple patients. 
 
¶47.  (U) A "cold chain" is essential for the successful execution of 
immunization programs as well as for proper storage of many 
infectious disease diagnostic kits and most injectable antibiotics. 
Multiple sources indicate that there is no functional "cold chain" 
or reliable refrigeration in DPRK.  In a broader sense, the lack of 
refrigeration will have an impact on food safety and food-borne 
 
infectious diseases. 
 
Obstacles to Reliable Diagnoses 
------------------------------- 
 
¶48.  (U) First-level clinicians usually do not have thermometers, 
stethoscopes, blood pressure cuffs, or microscopes.  Without 
thermometers and microscopes, it is not possible to confirm febrile 
conditions for referral, let alone diagnose specific pathogens. 
Tertiary level and central hospitals also lack X-ray machines 
(relying instead on dangerous fluoroscopy) and supplies such as 
X-ray plates.  Maintenance and repair of existing or donated 
equipment is a serious problem. 
 
¶49.  (U) In all his research and interviews, Dr. Western was unable 
to identify a single functioning general or specialized microbiology 
diagnostic laboratory anywhere in DPRK.  Most infectious diseases 
cannot be diagnosed without serological and/or microbiological 
confirmation.  Recent examples in North Korea are the fact that 75% 
of malaria cases are not confirmed by peripheral blood smear, and 
 
recent epidemics of scarlet fever and measles could not be confirmed 
because of a lack of diagnostics.  At present, limited numbers of 
tuberculosis specimens from the DPRK are being cultured and tested 
for drug susceptibility in South Korea, but the DPRK does not seem 
to be connected to various WHO Collaborating Centers and other 
diagnostic and reference networks. 
 
A Strength -- Human Capital 
--------------------------- 
 
¶50.  (SBU) The DPRK's greatest strength in infectious disease 
management and public health is its health infrastructure, which 
reaches to the community and family level.  The IVI reports that 
members of the DPRK Academy of Medicine with whom they collaborate 
are extraordinarily well-read and up-to-date on the medical 
literature, but have had no opportunity to apply or practice the 
latest advances and developments in infectious diseases diagnosis, 
prevention, or control.  There are three teaching hospitals in 
Pyongyang, but once again the training is largely theoretical. 
North Korea has an adequate supply of fully trained 
"quasi-physicians" to meet its citizens' needs, but does not pay 
them or provide them with drugs or vaccines to practice their 
profession.  As usual in a system relying on "quasi-physicians," the 
nursing profession is under-represented (MD/RN ratio of 1:1) and 
under-utilized.  The consensus among NGOs active in the DPRK is that 
medical and nursing staffs are knowledgeable at all levels about 
medical care.  However, several NGOs, including EBF, indicated that 
the understanding of sanitation and antisepsis was frequently 
lacking or inadequate. 
 
Treatment and Immunization Programs 
------------------------------------ 
 
¶51.  (U) There is a major effort through WHO and NGOs to maintain a 
DOTS program to treat tuberculosis in DPRK.  A second treatment 
program is the recently rejuvenated Soil Transmitted Helminth (STH) 
school-based deworming program.  Other treatment programs such as 
penicillin therapy for strep throat are frustrated by the lack of 
microbiologic culture and antibiotics (i.e. penicillin).  The STH 
Program may provide a framework or template to establish a school 
immunization program to provide booster vaccination in follow-up to 
the EPI Program. 
 
¶52.  (U) The DPRK is completely dependent on external procurement 
and donations for the vaccines used in the EPI.  The DPRK is not 
capable of producing any vaccines at the present time or in the 
foreseeable future.  On the other hand, as a socialist country with 
a healthcare system penetrating to the local (200 family) level, the 
DPRK is in a position to educate and mobilize families to 
participate in public health activities.  The monthly Immunization 
Day in the EPI Program is a successful example of this approach. 
EPI must be supported and sustained, but it is focused only on 
infants under one year of age.  EPI's goals are in danger of being 
undermined by inadequate attention to pre-natal care (nutrition, HBV 
serology testing, tetanus toxoid), newborn programs (HBV 
vaccination), and vaccine boosters upon starting school. 
 
----------------------- ---------------------- 
EXISTING EFFORTS TO AID HEALTHCARE IN THE DPRK 
----------------------- ---------------------- 
 
¶53.  (U) U.N. agencies, particularly WHO and UNICEF, have 
long-standing assistance programs in North Korea.  The DPRK is 
dependent upon these and other international organizations for the 
most of their essential drugs and vaccines.  While the DPRK 
 
Government health priorities are disease-specific, the top WHO 
technical assistance program priorities include: 1) disease 
prevention and control; 2) vaccines and immunization; 3) 
evidence-based health policies and health care (clinical guidelines, 
rational drug use); 4) strengthening basic health services at the 
community level; 5) medical education and updating of health 
personnel technical skills; 6) blood safety; 7) strengthening 
technical and research capacity in public health and epidemiology; 
8) health system development; 9) tobacco control; and 10) increasing 
MOPH capability to partner. 
 
¶54.  (U) There are several U.S.-based NGOs that are active in the 
DPRK, most notably the EBF (which also has a base in Seoul), 
Samaritan's Purse, Mercy Corps, and Global Resource Services.  EBF, 
in particular, has been very active in combating tuberculosis in the 
North. 
 
¶55. (U) According to the ROK-based NGO Anum International, there are 
55 South Korean NGOs providing assistance to the DPRK.  Twenty of 
these NGOs are operating in the health sector.  During his ESF 
period in Seoul, Dr. Western met with ten of these organizations: 1) 
Anum International; 2) Eugene Bell Foundation (EBF); 3) Foundation 
for Inter-Korean Medical Cooperation (FIKMC); 4) "Good Friends" 
Center for Peace, Human Rights, and Refugees; 5)"Good Neighbors" 
International; 6) "Join Together" Society (JTS); 7)Korean Health 
Industry Development Initiative; 8) the Korean Institute of 
Tuberculosis (KIT); 9) the Korean Medical Association (KMA); and 10) 
the Korean Red Cross. 
 
¶56.  (U) With the exception of KMA and KIT, the organizations that 
Dr. Western consulted are humanitarian assistance organizations in 
which health is one of several program areas.  Except for "Good 
Neighbor" and "Join Together", the NGOs' international humanitarian 
experience was limited to North Korea.  Many of the NGOs had medical 
and/or public health advisors, but only KMA had medical leadership 
with clinical expertise in clinical and laboratory diagnosis or the 
medical management of infectious diseases. 
 
¶57.  (U) Typically the ROK-based NGOs respond to requests from the 
DPRK Government.  At least in the initial years of their 
relationship, there is little or no opportunity to negotiate and 
modify the request, determine the field site or point of delivery 
(usually Pyongyang), or verify the delivery and use of the 
donations.  (See ref B for an analysis of the difficulties faced by 
South Korean NGOs trying to work in North Korea.) 
 
¶58.  (U) The MOU indicated that it has no formal coordinating body 
for the many ROK-based NGOs active in the DPRK, but Anum 
International indicated that it is currently the lead agency in an 
informal health network that meets quarterly (and as needed) to 
exchange information and coordinate efforts.  Similar informal 
networks exist among NGOs assisting with agriculture and emergency 
response.  Because of their broad mission, many NGOs participate in 
more than one network. The MOU also has an NGO consultative body 
that meets quarterly. 
 
¶59.  (U) Some bilateral donors, such as the Italian government, are 
involved in efforts to strengthen healthcare and improve healthcare 
facilities in the DPRK. 
 
------------------------------------ 
POTENTIAL AREAS FOR U.S. INVOLVEMENT 
------------------------------------ 
 
¶60.  (SBU) There are several potential areas where the U.S. 
 
Government could consider providing health-related humanitarian or 
technical assistance, if the future evolution of the U.S.-DPRK 
relationship leads to deeper U.S. engagement there. 
 
-    Electrical Power.  First steps have been taken by the recent 
award by USAID of the first tranche (USD 2.0 million) of a USD 4 
million program to provide generators to first-level health clinics. 
 The award was given to four U.S.-based NGOs.  If successful, this 
program could be expanded.  Provision of electrical power is crucial 
to the proper storage of drugs and vaccines, light microscopy, and 
the operation of X-ray machines, medical equipment, and surgical 
suites.  Gasoline- or diesel-powered generators may be difficult to 
sustain.  Consideration should be given to low-technology solar 
generators to provide core services. 
 
- Potable Water.  The availability of potable drinking water is 
critical to the prevention of diarrhea and other water-borne 
diseases.  Consideration should be given to the provision of 
chlorination tablets and educational programs to use them.  A second 
approach would be a program to construct tube wells along with 
provision for maintenance. 
 
- Microbiological Diagnosis.  Short of establishing a central 
microbiological and reference laboratory in Pyongyang, the U.S. 
could consider providing infectious disease diagnostic kits to 
provincial and district healthcare facilities for the diagnosis of 
bacterial and viral diseases of public health importance (e.g. 
tuberculosis, influenza, hepatitis, typhoid fever, and measles). 
 
- National Immunization Program.  The DPRK national immunization 
program is one of the few functional public health programs at the 
present time.  A major drawback of the program is that it focuses on 
the immunization of infants before the age of one year.  The 
epidemics of vaccine preventable diseases that DPRK is experiencing 
are due to infections in older children who have not received 
booster immunizations.  The U.S. could consider sponsorship of a 
school-entry immunization program providing booster doses of 
pediatric vaccines. 
 
- Tuberculosis.  The Eugene Bell Foundation, a U.S.- and South 
Korea-based NGO, is the major player in providing technical 
assistance and support to tuberculosis diagnosis and treatment in 
the DPRK.  Eugene Bell is also one of the four U.S.-based NGOs 
participating in the USAID electric generator project.  The U.S. 
National Institutes of Health (NIH) have received an invitation from 
the Eugene Bell Foundation to develop a tuberculosis research 
component to ongoing and planned activities. 
 
- Hepatitis.  There are licensed vaccines against hepatitis A virus 
(HAV) and hepatitis B virus (HBV).  HBV vaccine could be 
incorporated into NIP for infants and school-entry programs. 
 
- Intestinal Parasites.  DPRK has a functional school deworming 
program.  Roundworm and hookworm are among the infections recognized 
in the new U.S. Neglected Tropical Diseases Initiative.  The U.S. 
could consider including the DPRK in the Initiative. 
 
- Training. DPRK physicians, nurses, and biomedical scientists have 
been isolated from advances in medicine and public health for sixty 
years.  While medical and nursing students are trained to provide 
good care, they are not provided with the scientific basis of 
medical practice.  They also suffer severely from lack of access to 
diagnostic tools, drugs, and prevention products.  The USG could 
explore offering refresher training for medical and academic leaders 
on-site or through distance learning.  USG agencies such as the 
 
Centers for Disease Prevention and Control (CDC) and the National 
Institutes of Health (NIH) could be approached to lead this effort. 
 
------- 
COMMENT 
------- 
 
¶61.  (SBU)  Health conditions in the DPRK will deteriorate further 
as the looming food shortages strain immune systems.  U.S. 
humanitarian aid will need to be focused on nutrition in the short 
term.  For the longer term, should the evolution of the U.S.-DPRK 
relationship lead to deeper U.S. engagement with North Korea, the 
U.S. will find numerous options in the health sector for reaching 
out to the North Korean public in ways that could have a lasting 
impact.  End comment. 
 
VERSHBOW