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Malaria, A Re-emerging Health Threat to the Republic of Korea

Malaria, A Re-emerging Health Threat to the Republic of Korea. COL (Ret) Terry A. Klein, PhD Regional Emerging Infectious Disease Consultant Force Health Protection, 18th Medical Command Republic of Korea 12 February 2007. Collaborators. Dr. Heung-Chul Kim, 5 th MED DET

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Malaria, A Re-emerging Health Threat to the Republic of Korea

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  1. Malaria, A Re-emerging Health Threat to the Republic of Korea COL (Ret) Terry A. Klein, PhD Regional Emerging Infectious Disease Consultant Force Health Protection, 18th Medical Command Republic of Korea 12 February 2007

  2. Collaborators • Dr. Heung-Chul Kim, 5th MED DET • Dr. Won-Ja Lee, Korea NIH • Dr. Desmond Foley, WRBU • LTC William Sames, 18th MEDCOM • Dr. Leopoldo Rueda, WRBU • Dr. Richard Wilkerson, WRBU • Commanders/personnel, MED DETs

  3. History of Malaria in Korea • 1950-53: vivax malaria presented a health threat to US Forces during the Korean War. • 1973: Korea declared itself to be malaria free • 1993: Plasmodium vivax malaria re-emerged and increased exponentially through 1998. • 1998-00: overall, malaria stabilized, increasing slightly. • 2001-04: malaria rates rapidly decreased annually. • 2005: malaria rates increased, continue to increase in 2006. • Chemoprophylaxis: • 1997-98: US Forces, increased reliance (>14,000), then decreased usage to  1,300 personnel in 2000 and <500 from 2001-Present. • 1998-2005: increased reliance by ROK Military (40,000 to >165,000) • Evidence that ROK soldiers placed on chemoprophylaxis have higher rates of delayed malaria. • 2006: ROK Army increases chemoprophylaxis to 200,000

  4. Vivax Malaria – EpidemiologyHealth • Vivax malaria is a significant health threat. • Vivax malaria is non-lethal. • High Risk Areas - defined only by troop movement and clinical reporting, not area of transmission. • Once diagnosed and treatment initiated, soldiers lose about 72--96 hours of duty time. Total recuperation may extend 1 week+. • Malaria is a significant threat to the blood supply for Korea. • No vaccine available.

  5. Vivax Malaria – Epidemiology Chemoprophylaxis Increased Pressure to put US and ROK soldiers on chemoprophylaxis. • Departing US personnel presents a significant US public health threat at their new station in the US. • 2004, at least 6 US Soldiers deployed to Iraq from Korea developed malaria (attributed to exposure in Korea). • Vivax malaria among retiring ROK soldiers pose a threat to the spread of malaria throughout Korea. • Hasty reliance on chemoprophylaxis minimizes the doctrinal importance of PPM, vector surveillance and control. • Potential resistance of P. vivax to chloroquine and/or primaquine.

  6. Vivax Malaria - Epidemiology Transmission • Environment • Low/moderate endemicity • Epidemic outbreaks • Climate (cold winters, typhoons) favorable for short periods • Host • Delayed or immediate disease manifestation. • Low immunity • Vector(s) • Zoophilic (?) • Low-survival rates • Low infection rates/ high vector density • Distributions unknown • Vector status not well understood

  7. Annual Trend of Malaria Cases Diagnosed in the Republic of Korea (90,000) (37,000) (60,000) (120,000) Chemoprophylaxis initiated (145,000) (165,000) (200,000) (16,000) YEAR As of 31 December 06

  8. Annual Trend of Malaria Cases Among US Soldiers and Attributed to exposure in the Republic of Korea, 1993 – 2006 Chemoprophylaxis Initiated Chemoprophylaxis stopped, except for JSA and Cp Greaves YEAR

  9. Number of Cases of Plasmodium Spp. In US Servicemen Attributed to Exposure in Korea and Other Countries Number Malaria Cases Month

  10. Latent, Non-latent, and Unknown Forms of Vivax Malaria Diagnosed in Korea and Outside of Korea Number Malaria Cases Month

  11. Month of Diagnosis for Latent and Non-latent Vivax Malaria Forms Number Malaria Cases Month

  12. Distribution of Malaria, USFK, 2002 - 2006

  13. Adult Mosquito Surveillance Mosquito Magnet New Jersey Light Trap CDC Light Trap 1Anopheles sinensis group includes An. lesteri, An. pullus and two undescribed species. 2Culex tritaeniorhynchus are rarely collected in June near the demilitarized zone. 3 All traps baited with octenol, an artificial attractant, collected more An. sinensis, Cx. tritaeniorhynchus, and Ae. vexans, but fewer Cx. pipiens.

  14. Taxonomy and Distribution of Malaria Vectors • 5 members of the An. sinensis Group An. sinensis An. lesteri An. pullus An. belenrae An. kleini • Identify vector species • Identify vector species distributions • Identify vector species habitats

  15. Determine Species Distribution 1 Km 1 Km

  16. KSK-2

  17. Geographical Distribution of Four Members of the An. sinensis Group An. sinensis s.s. An. kleini An. pullus An. belenrae Darker blue indicates areas of greater agreement amongst 10 replicate Ecological Niche models

  18. Number/Proportion of Species from of Adult Anopheles Mosquitoes Collected by NJ Light Trap, ROK, Jun-Oct 2005 Rodriguez Range Cp Bonifas Warrior Base Cp Long Cp Humphreys Cp Eagle Gunsan AB Cp Carroll Gwangju AB

  19. Proportion of Anopheles spp. Larvae, Republic of Korea, Mar-Oct 2005 Tongilchon N=1098 Majeong-ri, N=1163 Cheongpyeong N=244 Gimpo N=183 Taebaek N=28 Ilsan N=157 Jaecheon N=86 Gimcheon N=45

  20. Proportion of Anopheles spp. Larvae, Republic of Korea, Mar-Oct 2005 Anmyeon-do N=251 Cheongsong N=76 Jeonju N=108 Busan N=152 Gwangju N=99 Geoje Is N=7 Sacheon N=41 Boseung N=71 Gimcheon N=45 Jeju Is N=43

  21. RISK REDUCTION • Develop and implement efficient and effective vector and disease reduction strategies. • Larval control • Eliminate water source. • Drain rice paddies periodically. • Pesticides. • Adult control • Pesticides. • Repellents. • Evaluate vector and disease control strategies.

  22. Malaria Control • Develop, evaluate, and implement efficient and effective vector and disease reduction strategies Pre-ULV fogging Post-ULV fogging Warrior Base

  23. EDUCATION • Public awareness. • Television • Newspaper • Health related pamphlets • Inform the public of their responsibilities • Human surveillance. • Reporting requires a standardized program

  24. PERSONAL PROTECTIVE MEASURES PPM is safe and it works!

  25. Personal Protection 1One patient reported DEET use, but didn't know if formulation was civilian or military. 2One patient reported using bed nets only when in tents; otherwise they were not used when sleeping on the ground. 3Not all respondents answered all questions. 4Policy changed to sleeves rolled up while in installations, but down when in the field.

  26. QUESTIONS

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