MALARIA CONTROL IN DPR KOREA EVALUATION OF A MALARIA CONTROL PROJECT IN DPR KOREA, 2001-2003 PT Chol1, N Suwannapong2 and N Howteerakul2 1National Program Officer, WHO, DPR Korea; 2Faculty of Public Health, Mahidol University, Bangkok, Thailand Abstract. This cross-sectional study aimed to evaluate a malaria control project implemented from 2001 to 2003. The evaluation indicators included assessing malaria prevalence, people’s know- ledge, awareness, and preventive behavior regarding malaria. First, a review of clinical records in the study areas was used to measure malaria prevalence. Second, a cross-sectional study was done, and 1,007 people aged ≥15 years who lived in Saenal Ri (rural area) Sichon County, South Hwanghae Province and Hwangju Up (urban area), North Hwanghae Province, were randomly sampled and interviewed. The prevalence of malaria, from review of clinical records, declined from 20.5 cases per 1,000 population in 2001 to 4.9 cases per 1,000 population in 2003. Of the 245 malaria cases, 1.6% had three, and 13.9% had two, experiences of malaria infection. Survey data showed that the prevalence of malaria was 2.7 cases per 1,000 population. About 75.6% (31/41) were in the age group 30-49 years. Overall outcome evaluation showed that the targets had been achieved: preva- lence (2.7 vs 9 per 1,000 population), people’s good knowledge of malaria (97.5 vs 90.0%), aware- ness (93.8 vs 85.0%), and preventive behavior (84.7 vs 80.0%). However, some aspects of the individual target indicators still needed improvement, ie people’s knowledge of malaria symptoms and mosquito-source elimination behavior. The malaria control project appeared to be effective in reducing malaria prevalence and improving people’s knowledge, awareness and preventive behav- ior about malaria in the studied areas. INTRODUCTION mortality, and the parasite has acquired resis- tance to standard anti-malarial drugs (WHO, Malaria is a life-threatening parasitic disease 2001). The main burden of P. vivax malaria (56%) transmitted by Anopheles mosquitoes. Four occurs in Southeast Asia. Globally, there is a kinds of malaria parasites can infect humans, pattern of co-endemicity with P. falciparum in the Plasmodium falciparum, P. vivax, P. ovale, and tropics, and an increasing proportion of P. vivax P. malariae (WHO, 2000). The World Health Or- occurs in the higher latitudes, with P. vivax alone ganization (WHO) reported that about 100 coun- occurring in northern and central China, the tries or territories in the world were considered Korean peninsula, and areas such as the malaria-endemic areas. The incidence of malaria Caucasus (WHO/SEARO, 2002). worldwide is estimated at 300–500 million clini- In DPR Korea, malaria was eradicated in the cal cases each year, with about 90% of these 1970s, but re-emerged as a serious problem in occurring in Africa, south of the Sahara, and 1997. In 1998, 2,100 P. vivax malaria were de- mostly caused by P. falciparum. Approximately tected in some areas of Kangwon Province, 2.48 million malaria cases are reported annually South Hwanghae Province and Kaesong City, in from South-Asia. Of these, 1.06 million (42.7%) the south of the country. The shortage of anti- are P. falciparum cases. P. falciparum is associ- malarial drugs and imperfect preparedness for ated with malaria outbreaks and malaria-related treating and managing malaria cases resulted in Correspondence: Nawarat Suwannapong, Department rapid transmission of malaria, increasing from of Public Health Administration, Faculty of Public around 100,000 cases in 1999 to 300,000 cases Health, Mahidol University, 420/1 Rajvithi Road, in 2001. Most of the cases have been clinically Bangkok, 10400, Thailand. diagnosed, those diagnosed by laboratory test Tel: +66 (0) 2354-8529; Fax: +66 (0) 2354-8558 were 36.8%. The relapse rate among malaria E-mail: [email protected] cases in 2000 was about 7.9 % (MOPH Korea, Vol 36 No. 3 May 2005 565 SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH 2001a; Phu, 2002). and further sub-divided into smaller administra- Since 1999, the Ministry of Public Health, tive units, ie Ri (rural) and Dong (urban) areas. DPR Korea has developed a national malaria Saenal Ri is a rural area with 1,010 households control project in co-operation with the WHO, and a population of 4,714; the majority are farm- to reduce the burden of malaria (Kondrachine, ers. Hwangju Up is a small city with 1,012 house- 2000). In 2000, national malaria treatment guide- holds and a population of 3,759. The capital of lines were developed and distributed to health Hwangju County is located in the central zone facilities. In 2001, support from the WHO made of the country, about 100 km from Pyongyang. it possible to carry out most proposed activities This study was part of the malaria control in the year 2000 action plan. This included dis- project evaluation in North and South Hwanghae tribution of 40,000 treated bed-nets for families, Province, DPR Korea. First, the clinical records insecticide, and microscopes for health labora- of Ri clinics and the resident registration system tories in counties with anti-epidemic stations and in the study areas from 2001 to 2003 were hospitals. About 70 participants were trained in reviewed to identify the prevalence of malarial malaria microscopy. The anti-malarial drugs, episodes. Second, a cross-sectional study was chloroquine and primaquine, were provided for done; a total of 1,007 eligible population, 460 200,000 cases. Health education materials re- people from Hwangju Up, North Hwanghae garding malaria prevention and control were dis- Province and 547 people in Saenal Ri, South tributed to people in malaria-epidemic areas to Hwanghae Province, were recruited by system- improve the people’s knowledge, awareness and atic random sampling (Fig 1). We estimated the practice related to malaria prevention. Key per- sample size using the single proportion formula, sons responsible for the malaria control project with 95% confidence interval. Sample size cal- in provinces, cities and counties were trained in culation was based on 1% of DPR Korea ma- vector control, and baseline surveillance for laria prevalence (WHO, 2001). Precision was set monitoring and evaluation of the malaria control at 0.062%. The respondents were interviewed project (WHO, 1999; MOPH Korea, 2001b). with structured questionnaires during February While the variety of malaria found in the DPR 2004. Inclusion criteria were people aged ≥15 Korea has a relatively low fatality rate, patients years who had lived in the study areas for at least suffer from high fever and chills. Agricultural 12 months prior to conducting the survey. Se- workers are most at risk. WHO officials in vere patients or persons in the household who Pyongyang estimated that sickness from malaria could not communicate verbally were excluded. accounted for one million lost working days in 2001 (Gluck, 2002). The Seanal Ri (rural) and Hwangju Up (urban) are areas of paddy fields or flat terrain and low hills located in the south and central zones of the country, and are some of Saenal Ri, Sinchon County and the worst affected areas, involved with the na- Hwangju Up City tional malaria control project since 1999. This Systematic study aimed to evaluate the effectiveness of the household current malaria control project’s implementation sampling between 2001 and 2003. The outcome evalua- Households tion indicators included assessing malaria preva- lence, people’s knowledge, awareness, and pre- ventive behavior related to malaria. 2 persons per household Subjects MATERIALS AND METHODS DPR Korea is geographically divided into 9 provinces, 3 major municipalities, 212 counties, Fig 1–Flow diagram of sampling method. 566 Vol 36 No. 3 May 2005 MALARIA CONTROL IN DPR KOREA The study protocol was reviewed and ap- urban area, especially in the year 2003 (8.3 vs proved by the Ethics Committee for Human Re- 0.8 cases per 1,000 population) (Fig 2). Of the search, Faculty of Public Health, Mahidol Uni- 245 malaria cases, 1.6% had three, and 13.9% versity. Written consent was gained from all par- had two, experiences of malaria infection. The ticipating respondents before data collection. recurrent episodes were reported only from the Instruments rural area (Table 2). The survey instrument was a four-part ques- Cross-sectional survey tionnaire. The first part comprised closed-ended General characteristics of respondents. Of the questions about the respondent’s general char- 1,007 respondents, 54.3% resided in the rural acteristics and malaria history. The second part area, and 56.2% were females. Ages ranged comprised 29 items for knowledge of malaria. from 15 to 89 years, with a mean age of Dichotomous measurement was used by an- 42.7(±15.1) years; 33.0% were in the age group swering ‘Yes’ or ‘No’. The Cronbach’s alpha 30-39 years and 23.9% in the age group 40-49 coefficient was 0.82. The third part was aware- years. Eighty-seven percent had a secondary ness of malaria, divided into awareness of sus- level of education; 40.1% were farmers. An iden- ceptibility, severity, and the benefits of malaria tical proportion of respondents (26.6%) were prevention. Altogether, 7 items with a 3-point workers and house-wives/students/others. Likert scale were rated as 3=agree, 2=uncertain, Malaria prevalence from the survey. Survey data and 1=disagree. Reverse scores were given for showed that the prevalence of malaria was 2.7 negative items. The Cronbach’s alpha coefficient cases per 1,000 population. About 76% (31/41) was 0.80. The fourth part dealt with preventive of these were in the age group 30-49 years and behavior, composed of 7 items regarding per- 12.2% (5/41) in the age group 50-59 years.