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Soldiers from the Republic of Korea and the United States conduct armistice military operations at Twin Bridges Training Area (TBTA) located near the demilitarized zone (DMZ) and are exposed to zoonotic disease pathogens that small mammals and their potentially disease-carrying ectoparasites transmit. TBTA is a 36 km2 rural training site with small villages and various forms of agriculture along its boundary. At TBTA, rodents, insectivores, and their ectoparasites are commonly found in association with unmanaged habitats of various densities of tall grasses, herbaceous plants, shrubs, briars, and crawling vegetation. Rodents and insectivores were collected during the winter (November-December 2005 and December 2006) and early spring (March 2007), and serologically tested for the presence of scrub typhus, murine typhus, and leptospirosis antibodies. Of the six species of small mammals collected, Apodemus agrarius, the common striped field mouse and known reservoir of scrub typhus, was the most frequently collected (96.1%), followed by Crocidura lasiura (2.5%), Micromys minutus (0.5%), Myodes regulus (0.5%), Mus musculus (0.3%), and Rattus rattus (0.1%). A. agrarius (56.1%), M. musculus (66.7%), M. minutus (25%), and R. rattus (100%) were positive for scrub typhus antibodies. Only A. agrarius (14.7%) and C. lasiura (4.5%) were positive for murine typhus antibodies, whereas only A. agrarius (1.5%) was seropositive for leptospirosis. Seroprevalence rates of scrub typhus and murine typhus based on weight and sex of A. agrarius are presented.

Malaria was eradicated and the Republic of Korea (ROK) declared "malaria free" in 1979. However, in 1993, a temperate strain of vivax malaria, expressing both latent and nonlatent disease populations, re-emerged near the demilitarized zone (DMZ), rapidly spread to civilian sectors near the DMZ, and increased exponentially in ROK military, veteran, and civilian populations through 1998. Malaria among all ROK populations decreased 5-fold from a high of 4142 cases in 2000 to a low of 826 cases in 2004, before increasing again to 2180 cases by 2007. Each malaria case in the ROK is reported in the metropolitan area/province where the diagnosis is made, which may be at some distance from the area where infection occurred. Therefore, it is difficult to ascertain transmission sites since approximately 60% of vivax malaria in Korea is latent with symptoms occurring1 month to 24 months after infection. A review of case diagnosis for civilian, veteran, and military populations shows that nearly all malaria south of Gyeonggi and Gangwon Provinces is the result of veterans exposed in malaria high-risk areas along the DMZ and returning to their hometowns where they later develop malaria. Thus, malaria currently remains localized near the DMZ with limited transmission in provinces south of Seoul and has not spread throughout Korea as previously hypothesized. This report describes the reemergence of vivax malaria cases in civilian and military ROK populations and U.S. military personnel and assesses variables related to its transmission and geographic distribution.

Malaria is a significant health threat to U.S. combat forces that are deployed to malaria-endemic regions. From 1979, when the Republic of Korea (ROK) was declared malaria free, malaria did not present a health threat to U.S. forces deployed to Korea until the early 1990s. In 1993, a temperate strain of vivax malaria expressing both latent (long prepatent incubation periods of usually 6-18 months after infection) and nonlatent (short prepatent incubation periods30 days after infection) disease reemerged near the demilitarized zone (DMZ) and once again presented a primary health threat to U.S. military populations in the ROK. Following its reemergence, malaria rates increased dramatically through 1998 and accounted for44% of all malaria cases among U.S. Army soldiers from 1997 to 2002. More than 60% of all Korean-acquired malaria among U.S. soldiers was identified as latent malaria. Nearly 80% of all latent malaria attributed to exposure in Korea was diagnosed in the U.S. or other countries where soldiers were deployed. These data illustrate the requirement for a comprehensive malaria education program, especially for those soldiers residing or training in malaria high-risk areas, to inform soldiers and providers of the risk of developing malaria after leaving Korea.

A seroepidemiological study of selected rodent-borne diseases (hantavirus [Seoul [SEO] virus], scrub typhus [Orientia tsutsugamushi], murine typhus [Rickettsia typhi], and leptospirosis [Leptospira interrogans]), as part of the U.S. military rodent surveillance and control program, was conducted from 2001 through 2005 at Yongsan Garrison, Seoul, Republic of Korea. Rodents were collected to determine the prevalence of rodent-borne diseases at a U.S. military installation in an urban environment. A total of 1,750 rodents representing three species was collected by using baited live traps (Tomahawk), glue boards, and poison baits (dead rodents observed but not assayed). The Norway rat, Rattus norvegicus (99.8%), accounted for nearly all of the rodents captured/observed. Only three roof rats, Rattus rattus (0.2%), and one house mouse, Mus musculus (0.1%), were collected. R. norvegicus rats were the only rodents that were serologically positive for SEO virus (9.6%), scrub typhus (2.8%), murine typhus (3.8%), and leptospirosis (4.6%). One of six rodents that were positive for SEO virus by immunofluorescent antibody test was positive for SEO virus antigen by reverse transcriptase-polymerase chain reaction. Infection rates for SEO virus, scrub typhus, murine typhus, and leptospirosis varied annually. Rodents were captured from 228 (20.7%) of 1,104 total buildings in Yongsan Garrison. The Yongsan commissary had the highest annual infestation rate (22 rodents per year), followed by Commisky's Club (18 rodents per year). Annual infestation rates were high for food service facilities, which often store perishable food products outdoors for short periods of time, attracting rodent populations; refuse from these facilities provides harborage and food for rodents. The effect of rodent populations outside the boundary of Yongsan Garrison was not determined.

Plasmodium vivax malaria reemerged in the Republic of Korea in 1993 after it had been declared malaria free in 1979. Malaria rapidly increased and peaked in 2000 with 4,142 cases with lower but variable numbers of cases reported through 2011. We examined the association of regional climate trends over the Korean Peninsula relative to malaria cases in U.S. military and Republic of Korea soldiers, veterans, and civilians from 1950 to 2011. Temperatures and anomaly trends in air temperature associated with satellite remotely sensed outgoing long-wave radiation were used to observe temporal changes. These changes, particularly increasing air temperatures, in combination with moderate rains throughout the malaria season, and distribution of malaria vectors, likely supported the 1993 reemergence and peaks in malaria incidence that occurred through 2011 by accelerating the rate of parasite development in mosquitoes and increased numbers as a result of an expansion of larval habitat, thereby increasing the vectorial capacity of Anopheles vectors. High malaria rates associated with a favorable climate were similarly observed during the Korean War. These findings support the need for increased investigations into malaria predictive models using climate-related variables.

As part of an operational effort to control the transmission of malaria after its reemergence in the Republic of Korea, a number of U.S. military and Korean civilian health workers assessed the situation at a large training site where two cases had been transmitted. The vector mosquitoes (Anopheles sinensis) probably had a limited flight range (< 1 km) in this situation based on low numbers in permanent light traps and biting collections at the billeting area compared with collections from light traps and larval surveys where the mosquito was abundant. The threat of malaria was proven by the presence of infected local Korean residents (13 of 105 sampled). However, only a small proportion of U.S. soldiers (39 of 78 surveyed) at the training site used personal protective measures. Further efforts should include improved techniques for informing and motivating soldiers to use personal protective measures and cooperation with Korean authorities to perform vector control in civilian areas bordering the training area.

New formulations of camouflage face paint (CFP), one with 30% N,N-diethyl-3-methylbenzamide (DEET) and the other without DEET, were evaluated for soldier-user acceptability during a military field-training exercise in the Republic of Korea. Soldiers testing the CFP formulations were members of one of four U.S. Army infantry companies (A, B, C, or D). The formulations were evaluated while soldiers participated in simulated combat exercises for 5 days during hot, humid summer weather in Korea. Results showed that soldiers found both of the new formulations easier to apply (91.3% of respondents who used CFP without DEET and 87.9% of respondents who used CFP with DEET) and remove (82.6% without DEET and 81.2% with DEET) than the previous standard military-issue CFP. Soldier acceptability was higher for the new CFP formulation with 30% DEET (70.5%) than for the formulation without 30% DEET (52.9%). Soldiers recommended it more frequently (70.5%) than the formulation without 30% DEET (50.0%). The new CFP formulation with 30% DEET was rated more often (79.5%) as either good or excellent than the new formulation without 30% DEET (67.4%). Soldiers reported that the CFP formulation with 30% DEET more successfully camouflaged the face (92.7%) than the formulation without 30% DEET (80.0%).