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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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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

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


History of malaria in korea

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


Vivax malaria epidemiology health

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.


Malaria a re emerging health threat to the republic of korea

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.


  • Vivax malaria epidemiology transmission

    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


    Annual trend of malaria cases diagnosed in the republic of korea

    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


    Malaria a re emerging health threat to the republic of korea

    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


    Malaria a re emerging health threat to the republic of korea

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

    Number Malaria Cases

    Month


    Latent non latent and unknown forms of vivax malaria diagnosed in korea and outside of korea

    Latent, Non-latent, and Unknown Forms of Vivax Malaria Diagnosed in Korea and Outside of Korea

    Number Malaria Cases

    Month


    Month of diagnosis for latent and non latent vivax malaria forms

    Month of Diagnosis for Latent and Non-latent Vivax Malaria Forms

    Number Malaria Cases

    Month


    Distribution of malaria usfk 2002 2006

    Distribution of Malaria, USFK, 2002 - 2006


    Malaria a re emerging health threat to the republic of korea

    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.


    Taxonomy and distribution of malaria vectors

    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


    Determine species distribution

    Determine Species Distribution

    1 Km

    1 Km


    Malaria a re emerging health threat to the republic of korea

    KSK-2


    Malaria a re emerging health threat to the republic of korea

    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


    Malaria a re emerging health threat to the republic of korea

    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


    Malaria a re emerging health threat to the republic of korea

    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


    Malaria a re emerging health threat to the republic of korea

    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


    Risk reduction

    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.


    Malaria control

    Malaria Control

    • Develop, evaluate, and implement efficient and effective vector and disease reduction strategies

    Pre-ULV fogging

    Post-ULV fogging

    Warrior Base


    Education

    EDUCATION

    • Public awareness.

      • Television

      • Newspaper

      • Health related pamphlets

      • Inform the public of their responsibilities

    • Human surveillance.

      • Reporting requires a standardized program


    Personal protective measures

    PERSONAL PROTECTIVE MEASURES

    PPM is safe and it works!


    Personal protection

    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.


    Questions

    QUESTIONS


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