J Korean Med Sci.  2025 Mar;40(10):e36. 10.3346/jkms.2025.40.e36.

The Vaccine Cold Chain in North Korea: Assessing the Capacity to Store Routine Vaccines and Potential to Support Pandemic Vaccination Activities

• Sempungu JK
• Choi M
• Lee EH
• Kim MH
• Han JH
• Lee YH

• KMID: 2565806
• DOI: http://doi.org/10.3346/jkms.2025.40.e36

Abstract

Background
The health system's capacity to store vaccines in North Korea has been less studied. In this study, we aimed to investigate if the current vaccine cold chain in North Korea can store routine vaccines and if it has the storage capacity to handle pandemic vaccination activities (PVAs) without interrupting the country’s successful routine immunization program.
Methods
We used tables extracted from an evaluation report of The Global Alliance for Vaccines and Immunization (GAVI)’ Health Systems Strengthening program in North Korea from 2007 to 2014. We then used the World Health Organization’s Immunization Supply Chain Sizing Tool to estimate gaps and the cost of scaling up cold chain storage.
Results
We found that the vaccine cold chain in North Korea has adequate storage capacity for routine vaccines. While we found a deficit of 7,172 L at the central medical warehouse (CMW) and 14,256 L at the provincial medical warehouses (PMWs), the storage at the county warehouses (CoMW) had a surplus. When assessed for PVA, we found an aggregated deficit of 115,574 L (CMW), 113,160 L (PMW), and 25,133 L (CoMW). To fill the gaps, investments of 229,917 USD, and 2,262,211 USD were estimated for routine and PVA vaccination programs, respectively.
Conclusion
As countries and the international community work to improve systems in preparation for future pandemics, there is a need to scale up the North Korean vaccine cold chain to a pandemic-ready state.

Keyword

North Korea; Vaccine; Cold Chain; GAVI; Supplementary Immunization Activities

Figure

• 

  Fig. 1 The vaccine deployment strategy used in North Korea.

• 

  Fig. 2 Estimation of the available and needed additional cold chain storage for storage of supplementary vaccines at provincial- and county-level medical warehouses. (A) Provincial-level estimation. (B) County-level estimation.

Reference

1. Chattu VK, Chami G. Global health diplomacy amid the COVID-19 pandemic: a strategic opportunity for improving health, peace, and well-being in the CARICOM region-a systematic review. Social Sciences-Basel. 2020; 9(5):16.

2. Fleming M, Okebukola P, Skiba K. Port to Patient: Improving Country Cold Chains for COVID-19 Vaccines. White Paper. Chicago, IL, USA: McKinsey & Company;2021. p. 14.

3. Boro E, Stoll B. Barriers to COVID-19 health products in low-and middle-income countries during the COVID-19 pandemic: a rapid systematic review and evidence synthesis. Front Public Health. 2022; 10:928065. PMID: 35937225.

4. World Health Organization. WHO country cooperation strategy Democratic People’s Republic of Korea: 2014-2019. Geneva, Switzerland: World Health Organization;2016.

5. Park KB, Ham EI. North Korea’s surprisingly robust healthcare system. Glob Asia. 2021; 16(3):66–72.

6. UNICEF East Asia and Pacific Regional Office. Country Profiles for Immunization Version 2.0. Bangkok, Thailand: UNICEF East Asia and Pacific Regional Office;2017. p. 7–8.

7. World Health Organization. Evaluation of the GAVI Health Systems Strengthening Support to the Democratic People’s Republic of Korea. Geneva, Switzerland: World Health Organization;2018.

8. Shafik NM, Ryder CY, Park KB. North Korea’s Vaccination Capabilities: Implications for a COVID-19 Campaign. Updated 2021. Accessed December 4, 2023. https://www.38north.org/2021/08/north-koreas-vaccination-capabilities-implications-for-a-covid-19-campaign/ .

9. World Health Organization Regional Office for South-East Asia. Joint National/International Expanded Programme on Immunization and Vaccine Preventable Disease Surveillance Review Democratic People’s Republic of Korea, 2–9 July 2018. New Delhi, India: World Health Organization Regional Office for South-East Asia;2018.

10. DPRK Ministry of Public Health. Sustaining Equitable & Quality Immunization Coverage through Development of Health System Management and Delivery Systems. Pyongyang: DPRK Ministry of Public Health;2013.

11. World Health Organization. Nationwide catch-up immunization campaign in DPR Korea. Updated 2023. Accessed January 8, 2024. https://www.who.int/dprkorea/news/detail/26-04-2023-nationwide-catch-up-immunization-campaign-in-dpr-korea .

12. Biersteker TJ, Frank R, Ham E, Hecker SS, Hudáková Z, Jo D, et al. Understanding Kim Jong-un’s North Korea: Regime Dynamics, Negotiation, and Engagement. Lanham, MD, USA: Rowman & Littlefield;2022.

13. Stangatrone T. North Korea’s COVID-19 Vaccine Cold Chain Challenge. Washington, D.C., USA: Korea Economic Institute of America;2021.

14. Choi SH. From Storage to Transport, Hurdles to Getting COVID Vaccine to North Koreans. London, UK: Reuters;2022.

15. World Health Organization. Immunization Supply Chain Sizing Tool. Updates 2023. Accessed January 8, 2023. https://cdn.who.int/media/docs/default-source/immunization/supply-chain/supply_chain_sizing_tool_2020.xlsx?sfvrsn=2a731174_42&download=true .

16. World Health Organization. WHO PQS Catalogue. Geneva, Switzerland: World Health Organization;2020.

17. GAVI. Cold Chain Equipment Optimization Platform. Geneva, Switzerland: GAVI;2022.

18. World Health Organization. How to Calculate Vaccine Volumes and Cold Chain Capacity Requirements. Geneva, Switzerland: World Health Organization;2017.

19. World Bank. Population Estimates and Projections. Washington, D.C.: World Bank;2023.

20. Central Bureau of Statistics. DPR Korea 2008 Population Census. Pyongyang, DPR Korea: Central Bureau of Statistics;2009.

21. Centers for Disease Control and Prevention. Child and adolescent immunization schedule by age. Updated 2024. Accessed April 2, 2023. https://www.cdc.gov/vaccines/hcp/imz-schedules/child-adolescent-age.html .

22. Hart T. Kosovo Cold Chain System Assessment. New York, NY, USA: UNICEF;2020.

23. Hwang S, Kwon J. North Korea’s Response to Its COVID-19 Outbreak and the International Community’s Support to North Korea. Seoul, Korea: Korea Institute for National Unification;2023.

24. Grundy J, Biggs BA, Hipgrave DB. Public health and international partnerships in the Democratic People’s Republic of Korea. PLoS Med. 2015; 12(12):e1001929. PMID: 26714189.

25. World Health Organization. WHO and UNICEF Estimates of Immunization Coverage: 2022 Revision. Democratic People's Republic of Korea. Geneva, Switzerland: World Health Organization;2023.

26. Anupindi R, Gursel M. Vaccine supply chains: priority areas of action emerging from the COVID-19 pandemic. Vaccine Insights. 2023; 2(2):59–66.

27. Prosser W, Sagar K, Seidel M, Alva S. Ensuring vaccine potency and availability: how evidence shaped Gavi’s Immunization Supply Chain Strategy. BMC Health Serv Res. 2022; 22(1):1237. PMID: 36207724.

28. Berkley S. COVAX Explained. Updated 2020. Accessed March 17, 2024. https://www.gavi.org/vaccineswork/covax-explained .

29. Kim DJ, Kim AI. Global health diplomacy and North Korea in the COVID-19 era. Int Aff. 2022; 98(3):915–932.

30. Bremer I. UNICEF receives exemption to send North Korea equipment for ‘routine’ vaccines. NK News;Updated 2022. Accessed April 3, 2023. https://www.nknews.org/2022/03/unicef-receives-exemption-to-send-north-korea-equipment-for-routine-vaccines/ .