As North Korea faces a rising number of COVID-19 cases, simply having vaccines may be insufficient to roll out a countrywide immunization process that experts say needs to be accompanied by adequate cold storage units and trained medical and technical staff that the nation lacks.
Pyongyang announced on Tuesday that "more than 32,810 fevered cases" were detected in the country from June 12 to 13, through its state media Korea Central News Agency (KCNA). The total, "since late April," surged past 4.5 million as of June 14, added the KCNA.
Outbreak first reported in May
North Korea first reported the outbreak of the virus on May 12. Until Pyongyang acknowledged the outbreak, it claimed zero cases since the global pandemic in early 2020.
The regime is battling the spread with "vigorous" anti-epidemic work by conducting tests to "confirm coronavirus infected cases" in Pyongyang, border areas and high-risk regions. It is also implementing quarantine measures such as installing "more than 11,300 temporary quarantine wards," said the KCNA on a separate report on Tuesday.
Gavi, a global vaccine distribution network, told VOA's Korean Service that North Korea "has accepted an offer of vaccines from China and has started to administer doses."
Gavi, attributing comments to a spokesperson, did not say when the immunization began and what kind of WHO-approved Chinese vaccines such as Sinopharm, Sinovac or CanSino were sent.
North Korea, however, did not indicate it has begun a countrywide vaccination program that experts say is the only viable way to try to prevent severe illnesses and deaths.
Arthur Reingold, division head of epidemiology at University of California who served as a member of the WHO's Strategic Advisory Group of Experts on Immunization (SAGE) from 2005 to 2012, said, "Vaccination with an effective SARS-Cov-2 vaccine is really the only approach that can limit morbidity, hospitalization, (and) death at this point."
SARS-CoV-2 is the severe acute respiratory syndrome coronavirus 2 that causes coronavirus disease 2019, which came to be called COVID-19.
Gavi 'ready to support'
Pyongyang has not accepted vaccine offers from the U.S., South Korea or international vaccine sharing programs such as Gavi. The Gavi spokesperson said it "has always been ready to support Pyongyang should it request our assistance, but so far," did not receive "formal request for COVID-19 vaccine support."
Heeje Lee is a researcher with the Korea Health Policy Project at Harvard Medical School who has traveled to North Korea multiple times since 2016 to teach at Pyongyang University of Science and Technology, North Korea. He told VOA’s Korean Service that the regime might have opted out of conducting a massive vaccination program due to medical challenges.
"Considering and weighing benefits and risks, they might have selected the zero-COVID strategy instead of nationwide vaccination," Lee said. "They are very good at mobilization. It might have been easier for them to control behavior of the population such as lockdown and border closure than handling medical accidents from the vaccination."
Experts said North Korea needs to overcome several medical and technical hurdles if it wants to begin a COVID-19 immunization program as it would need to import cold storage units and medical and technical experts. This is especially true if Pyongyang wants to use the mRNA vaccines, which need careful handling.
David Salisbury, associate fellow of Global Health Program at Chatham House, a policy institute in London, and director of immunization at the U.K.'s Department of Health until 2013, said, "Given the very demanding cold chain requirements for mRNA vaccines, this is likely to be very difficult for North Korea."
The most effective vaccines, such as Pfizer and Moderna, use mRNA technology that instructs cells in the body to produce protein, which triggers immunity against the virus.
Pfizer vaccines are shipped at temperatures between minus 90-60 degrees Celsius and can be stored in the freezer between minus 25-15 degrees Celsius for up to two weeks.
Moderna vaccines are shipped at temperatures between minus 50-15 degrees Celsius and can be stored in the freezer at the same temperature.
After thawing, both vaccines can be kept in the refrigerator between 2-8 degrees Celsius for up to one month.
"Those [mRNA] vaccines need to be shipped and stored in very cold freezers and then thawed and delivered, by needle injection within several hours, perhaps a day," said John Moore, a professor of microbiology and immunology at Weill Cornell Medical College in New York City.
"There are real logistical challenges to providing and using these freezers," he said. "The mRNA (vaccines) may just be more than what the North Koreans can actually handle."
Chinese vaccines and Novavax must also be kept in refrigerator temperature of approximately 4 degrees Celsius, said Moore.
Nagi Shafik, former project manager for WHO and UNICEF in North Korea, said, "If we are going to use the mRNA vaccines (such as) Pfizer or Moderna, (North Korea) will need ultra-cold refrigerators, which UNICEF can provide as they did with other countries."
In 2021, UNICEF delivered 800 ultra-cold storage units to about 70 countries to store COVID-19 mRNA vaccines.
The Gavi spokesperson told VOA's Korean Service on Friday that "regarding challenges of mRNA vaccines … that's something we'd only be able to comment on if/when (North Korea) submits an updated national vaccine deployment plan as part of a request for support."
VOA's Korean Service contacted North Korea's mission to the U.N., asking whether it is willing to accept mRNA vaccines if they are offered but did not receive a reply.
Turning to other vaccines
Due to the challenges of using mRNA vaccines, Moore said North Korea could resort to other vaccines.
"Chinese vaccines … are easier to use," Moore said. "Those vaccines are mediocre by our standards but would be able to reduce the incidence of severe and fatal infections." Sinopharm vaccines have an efficacy rate of 79%, and Sinovac vaccines are 51% effective, according to the WHO.
"There's also another highly effective Western vaccine called Novavax," which is "more potent" than Chinese vaccines, said Moore. Novavax vaccines have a 90% efficacy rate. In comparison, Pfizer and Moderna mRNA vaccines both have a 95% efficacy rate.
However, to be used properly, all these vaccines — particularly the mRNA vaccines — would require North Korea to accept outside medical experts who can administer immunizations, according to experts.
Country 'will need help'
"North Korea will need help from global partners to acquire all the necessary knowledge for the vaccination" as well as "technical experts to make sure the cold chain works properly," said Lee.
North Korea "would need few medical experts to administer the process of vaccination and storing vaccine," said Shafik.
Experts said Pyongyang would also need to obtain power sufficient to run cold storage units – for both mRNA and non-mRNA vaccines – throughout the nation of nearly 26 million people.
North Korea lacks a reliable power supply, often struggling to keep lights on. According to the CIA World Factbook, only 26% of its total population had access to electricity in 2019.
Lee said North Korea has "solar refrigeration and solar panels" that are available in case of interruption on the electricity supply. However, Shafik said, solar-powered cold units may need to be supplemented for mass immunization.
"UNICEF had provided some solar energy (powered) refrigerators and (they are) working well for a 'regular' vaccination program," Shafik said. "But for mass vaccination, there could be some modifications and other arrangement(s) to be considered before the campaign."