Background 

The Democratic People’s Republic of Korea (DPRK) has made impressive progress in the past three decades-reducing by one fourth the mortality rate of children under 5 years old from 120/1000 in 1960 to only 30/1000 in the year 1996. The total population of DPRK is 22.8 million, of which 11.6% are under the age of five. The country’s population growth rate is 1.5 per cent per year; one of the rather low rates in among the developing countries. More than 60 percent of the population live in the urban areas. 

The DPRK has a well-established curative and preventive health care system with complete coverage of the population. There are some 220 county hospitals, 6,249 ri-hospitals and ri-clinics, as well as at least one referral hospital in each province. For every 10,000 inhabitants there are 30 doctors, 18 nurses and 15 midwives (table 1). Health care is free of charge. 

Between 1994 and 1997, the DPRK suffered a series of natural disasters which severely affected the nation. While the organization of the existing health system is impressive there are, however, numerous problems related to the shortage and distribution of resources. The infrastructure is showing signs of deterioration and the maintenance of health and other facilities is becoming increasingly less effective as the economic situation worsens thus compromising the health care and delivery system. 

Preventive as well as curative services, with an integrated lifecycle approach and comprehensive care, need to be restored. 

Child Survival: Reviving the EPI 

The DPRK’s previous success in achieving immunization coverage of over 99 per cent for all antigens are now threatened by the closure of their factories producing vaccines and the country’s inability, financially, to procure vaccines from the international market. The cold chain is virtually non existence compounded by unreliable or nonfunctioning electric supply. Consequently, children are not being regularly vaccinated. The expanded program on immunization (EPI) has therefore become an urgent priority to protect children against preventable diseases. 

A recently conducted Multiple Indicator Cluster Survey indicate that a large majority of children aged 12-23 months did not receive the necessary vaccination during their first year of life. 

Data from the vaccination cards of 294 children (94.3%) of between 12 and 23 months showed that BCG coverage was 63.9%, and the DPT3 coverage was only 37.4%. Measles coverage had also fallen to 34.4%. The OPV3 coverage, however, stood at 76.5%; this is attributed largely to the NIDs observed with WHO and UNICEF assistance in 1997 and 1998. 

MICS also looked at the immunization status of a total of 563 pregnant women and mothers of children less than 2 years. Only 59.7% of women had their cards at home. The information analyzed from the cards revealed that whereas a total of 91.1% women were given one dose of tetanus toxoid (TT), only 4.6% had received two doses of TT. 

Also, DPRK has a very complex vaccination schedule with several contacts and doses of vaccine (table 2) 

Regularizing the immunization program to achieve sustainable coverage above 80 per cent for children under one year of age in the country, has emerged as the highest priority under the DPRK-UNICEF Program of Cooperation. Towards this objective, UNICEF in collaboration with WHO, will assist the government in following areas: 

• A review of national immunization policy to bring it in harmony with the global WHO standard;
• Establishment of a cold chain system;
• Procurement of vaccines and revival of local production capacity;
• Strengthening of logistics and staff capacity through training; and
• Strengthening of monitoring and disease surveillance system.

1 Cold Chain 

The cold chain in the country is largely ineffective due to equipment shortage and unreliable electricity supply. Ensuring adequate storage at the central level and strengthening cold chain in the provincial and county level is to be emphasized. 

1. Two cold room (30 cbm 2-8*C & -20 cmb 20*C) are to be placed in the Central Anti-epidemic Station, Pyongyang for storage of all the incoming vaccines from where there will be distributed to the Provinces.

 

Total cost: $60,000 

  

2. Two cold trucks (8cbm) are to be provided to the Central Anti-epidemic Station at Pyongyang to assist in distribution of vaccines to the provinces. 

 

Total cost: $100,000. 

 

3. Twelve freezers, 12 refrigerators, and 12 generators (5KVA) are to be placed at each provincial or Anti Epidemic Stations to store and redistribute the vaccine to the county Anti-epidemic Stations. Provinces with large populations will add other freezers and refrigerators that have been provided by UNICEF/WHO earlier (table 3). 

2. Vaccines 

There are approximately 430,000 children born each year. Presently, all the vaccines, along with the syringes and safety boxes, will need to be imported to fully immunize all new born. Additional supplies of vaccines will also be required to vaccinate children who have missed vaccination earlier due to an interruption in the routine immunization programme. The total vaccine requirement, including the wastage factors, is given below. 

1. 7.7 million doses of DPT (20 dose vials) with auto-destruct syringes and safety boxes to vaccinate all the children up to the age of three as a catch up campaign and regular vaccination for the children born in 1999. DPT vaccination has stopped since 1996

 

Total cost: $1,200,000 (inclusive of freight) 

 

2. 1.3 million doses of Measles (10 dose vials) with auto dystruct syringes and safety boxes to vaccinate the 1998 and the 1999 cohort

 

Total cost: $299,000 (inclusive of freight) 

 

3. 1.2 million doses of BCG (20 dose vials) with disposable BCG syringes to vaccinate the 1998 and the new children to be born in 1999. 

 

Total cost: $150,000 (inclusive of freight) 

 

4. 1.7 million doses of OPV (20 dose vials) with dropper to immunize the 1999 cohort. This is not incorporating the National Immunization Days (NID) program to be held in October and November 1999. OPV for the NIDs will be procured by WHO

 

Total cost: $144,000 (inclusive of freight) 

 

5. 1.2 million doses of TT (10 dose vials) with disposable syringes and needles to immunize all the pregnant women in 1999 with two dose of TT during antenatal visits.

3 Logistics 

To strengthen the immunization programme of the country, it is necessary to ensure that the nation has the capability to deliver vaccines to the provinces and to evaluate and monitor the implementation of the programme in the fields. 

1. Twelve double cab pick-up trucks are to be placed at each provincial or city Anti Epidemic Stations to coordinate and facilitate the immunization programme of the province.

 

Total cost: $300,000 (including freight) 

 

2. Hundred motorcycles, 1,000 bicycles and 8 pick-up trucks are also to be procured by WHO to be used in the counties to coordinate and facilitate the immunization programme. 

 

3. Reusable syringes and sterilization equipment are also being procured by WHO. 

(note: 500 vaccine thermometers, 100 sterilizable syringe kits and 1,200 safety boxes (at an estimated cost of $12,000) have already been ordered under the 1998 funding to arrive in early 1999 to assist the immunization program.)  

4 Monitoring and Evaluation 

The immunization program will be monitored and evaluated through process indicators, such as immunization rates and impact indicators, such as reduction of infant and child mortality, and reduction in incidence of targeted immunizable diseases. Revision of the current EPI strategy, schedule and guidelines will also be emphasized. 

1. In collaboration with WHO, strengthening the national’s capacity of collecting primary information and of data analysis at provincial and central levels is to be enhanced.

 

2. Data processing equipment and printing materials and supplies to print forms and cards are to be provided. 

5. Human resources and capacity building

1. In collaboration with WHO, a cold chain expert is to be identified to assist in installing the cold rooms and to conduct training on maintenance and repair of the cold chain equipment provided. 

 

Total cost: $12,000 

 

2. Twenty-five EPI staff from the provincial and central Anti Epidemic Stations is to participate in this cold chain training to take place in the month of March 1999. The Provincial Staff will, in turn, conduct provincial cold chain training to train EPI staffs from the county. Three hundred and fifty staff will be trained in total.

 

Total cost: $ 10,000 

 

3. EPI training courses for doctors and nurses of provincial and county hospitals, ri-hospitals and ri-clinics countrywide and medical personnel in nurseries, kindergartens and institutions are to be conducted. In total four hundred Ministry of Public Health staff are to be trained to improve their capacity for program implementation. The training is to emphasize on the modified immunization schedule and distribution system along with updated immunization technology and safety. The first training is to start in April 1999. 

 

Total cost: $20,000 

 

4. Support is to be provided in printing of the new schedules and production of IEC materials and advocacy of the immunization program.

It needs to be pointed out that a similar proposal has been incorporated in the emergency appeal for 1999. UNICEF and WHO have made a joint appeal amounting to $4,993,600 for 1999 ($2,516,600 for UNICEF and $2,477,000 for WHO supported interventions). 

The funds provided for EPI and other health interventions under General Resources (GR) for 1999 is only $150,000. Out of this amount, $132,000 has been reserved for the new post of the Project Officer, Health. The remaining $18,000 is for the EPI, Safe Motherhood, and Child Health program activities. 

Regularizing the immunization program of the country and achieving high immunization coverage by the end of 1999 is of the highest priority for the government, WHO and UNICEF. The proposed EPI activities are extremely essential in order to revive the EPI in the DPRK. 

Since the funds requested through the emergency appeal are not guaranteed and usually become available in small contributions over an extended period, this request is put forward to secure guaranteed and timely funding to immediately implement the above mentioned activities and achieve Universal Child Immunization by the end of 1999. 

The natural disasters and the economic difficulties faced by the country has also brought in malnutrition, micronutrient deficiencies, lack of energy for heating during winter, and has adversely effected the water and sanitation system. This has increased the risk of acute respiratory infections (ARI) and diarrheal diseases (DD) amongst children. Ministry of Public Health stated that 4,452 children under five died of diarrhea and 5,088 died of ARI in 1997. 

UNICEF, in 1999, aims to reduce the morbidity and mortality due to ARI and DD through support of extensive use of oral rehydration therapy and standard case management for ARI. Assistance to rehabilitate the water supply and sanitation system to full status will also be a major UNICEF program in 1999. 

TABLE 3 Cold chain equipment provided in 1997/98 

  
 

Item	Provided by UNICEF	Provided By  WHO	Total  Number provided	Total cost (including freight) US$
Freezer	137	28	165	95,000
Refrigerator	174	19	193	177,500
Cold box	1,000	224	1,224	253,400
Vaccine carrier	3,480	10,000	13,480	310,000
Voltage stabilizer		50	50	18,400
Ice packs	10,000	5,400	15,400	14,100

$868,400  

TABLE 2 Existing Immunization Schedule in DPRK 

  
 

Age of child	Vaccine
Birth	BCG, OPV 0
6 weeks	OPV 1, DPT 1
10 weeks	OPV 2, DPT 2
14 weeks	OPV 3
6-12 months after 2nd dose	DPT 3
12 months	Measles 1
2 years	OPV 4
3 years	OPV 5
7 years	OPV 6, DPT 4, Measles 2
Birth ? 10 years	HBV (2 doses, 1 month apart)
17 years	Measles 3
8 months ? 6 years	Mump (1 dose)
18 ? 45 years	TT (every 7 years)

  

Standard WHO recommended schedule for childhood Immunization. 

  
 

Age of Child	Vaccine
Birth	BCG, OPV 0, HBV 1
6 weeks	OPV 1, DPT 1, HBV 2
10 weeks	OPV 2, DPT 2
14 weeks	OPV 3, DPT 3, HBV 3
9 months	Measles

  

TABLE 1 Population and medical establishment 

 
 

Province/  City	Population	No. of County	No. of District &  County Hospital	No. of  Dong or Ri Hospital	No. of Dong or Ri Clinic	No. of Medical workers
Pyongyang City	2,954,400	23	62	43	655	24,400
Kaesong City	360,400	4	13	51	53	2,332
Nampo City	787,200	6	24	24	112	4,061
South Pyongan	3,089,300	22	94	135	565	14,614
North Pyongan	2,627,100	24	97	107	666	12,242
Jagang	1,242,000	18	67	60	425	7,694
South Hwanghae	2,167,100	20	55	126	466	9,035
North Hwanghae	1,629,400	16	49	91	357	7,661
Kangwon	1,406,300	17	42	77	509	7,742
South Hamgyong	2,943,300	27	108	94	701	14,409
North Hamgyong	2,220,200	23	110	71	518	12,469
Ryanggang	687,200	12	56	29	314	4,529
TOTAL	22,114,000	213	777	908	5,341	121,188