Osong Public Health and Research Perspectives

Volume 5(Suppl); December 2014

Editorial

Is Tuberculosis Still the Number One Infectious Disease in Korea?: Hae-Wol Cho, Chaeshin Chu; Osong Public Health Res Perspect. 2014;5(Suppl):S1-S2. Published online December 31, 2014; DOI: https://doi.org/10.1016/j.phrp.2014.11.003

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Original Articles

Evaluation and Comparison of Molecular and Conventional Diagnostic Tests for Detecting Tuberculosis in Korea, 2013: Sang-Hee Park, Chang-Ki Kim, Hye-Ran Jeong, Hyunjin Son, Seong-Han Kim, Mi-Sun Park; Osong Public Health Res Perspect. 2014;5(Suppl):S3-S7. Published online December 31, 2014; DOI: https://doi.org/10.1016/j.phrp.2014.10.006

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Abstract PDF

Objectives
A fast and accurate diagnosis is necessary to control and eliminate tuberculosis (TB). In Korea, TB continues to be a serious public health problem. In this study, diagnostic tests on clinical samples from patients suspected to have TB were performed and the sensitivity and specificity of the various techniques were compared. The main objective of the study was to compare various diagnostic tests and evaluate their sensitivity and specificity for detecting tuberculosis.
Methods
From January 2013 to December 2013, 170,240 clinical samples from patients suspected to have TB were tested with smear microscopy, acid-fast bacilli culture, and real-time polymerase chain reaction (PCR). The test results were compared and data were analyzed.
Results
A total of 8216 cultures tested positive for TB (positive detection rate, 4.8%). The contamination rate in the culture was 0.6% and the isolation rate of nontuberculous mycobacteria was 1.0%. The sensitivity and specificity of smear microscopy were 56.8% and 99.6%, respectively. The concordance rate between the solid and liquid cultures was 92.8%. Mycobacterium isolates were not detected in 0.4% of the cases in the liquid culture, whereas no Mycobacterium isolates were detected in 6.8% of the cases in the solid culture. The sensitivity and specificity of real-time PCR for the solid culture were 97.2% and 72.4%, respectively, whereas the corresponding data for the liquid culture were 93.5% and 97.2%.
Conclusion
The study results can be used to improve existing TB diagnosis procedure as well as for comparing the effectiveness of the assay tests used for detecting Mycobacterium tuberculosis isolates.

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The Xpert® MTB/RIF diagnostic test for pulmonary and extrapulmonary tuberculosis in immunocompetent and immunocompromised patients: Benefits and experiences over 2 years in different clinical contexts
Ana Paula de Oliveira Tomaz, Sonia Mara Raboni, Gislene Maria Botão Kussen, Keite da Silva Nogueira, Clea Elisa Lopes Ribeiro, Libera Maria Dalla Costa, Padmapriya P. Banada
PLOS ONE.2021; 16(3): e0247185. CrossRef
Comparative performance of the laboratory assays used by a Diagnostic Laboratory Hub for opportunistic infections in people living with HIV
Narda Medina, Ana Alastruey-Izquierdo, Danicela Mercado, Oscar Bonilla, Juan C. Pérez, Luis Aguirre, Blanca Samayoa, Eduardo Arathoon, David W. Denning, Juan Luis Rodriguez-Tudela
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Multiplex PCR is a Rapid, Simple and Cheap Method for Direct Diagnosis of M. tuberculosis from Sputum Samples
Tarig M.S. Alnour, Faisel Abuduhier , Mohammed Khatatneh , Fahad Albalawi , Khalid Alfifi , Bernard Silvala
Infectious Disorders - Drug Targets .2020; 20(4): 495. CrossRef
Naked eye detection of the Mycobacterium tuberculosis complex by recombinase polymerase amplification—SYBR green I assays
Nuntita Singpanomchai, Yukihiro Akeda, Kazunori Tomono, Aki Tamaru, Pitak Santanirand, Panan Ratthawongjirakul
Journal of Clinical Laboratory Analysis.2019;[Epub] CrossRef
Retropharyngeal SOL: An unusual presentation of a multifaceted entity
Poojan Agarwal, Manju Kaushal, Shruti Dogra, Ankur Gupta, Nishi Sharma
CytoJournal.2018; 15: 12. CrossRef
Rapid Detection of Rifampicin- and Isoniazid-Resistant Mycobacterium tuberculosis using TaqMan Allelic Discrimination
Davood Darban-Sarokhalil, Mohammad J. Nasiri, Abbas A.I. Fooladi, Parvin Heidarieh, Mohammad M. Feizabadi
Osong Public Health and Research Perspectives.2016; 7(2): 127. CrossRef
Port site infection in laparoscopic surgery: A review of its management
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World Journal of Clinical Cases.2015; 3(10): 864. CrossRef

A Study on the Relapse Rate of Tuberculosis and Related Factors in Korea Using Nationwide Tuberculosis Notification Data: Hyungmin Lee, Jusang Kim; Osong Public Health Res Perspect. 2014;5(Suppl):S8-S17. Published online December 31, 2014; DOI: https://doi.org/10.1016/j.phrp.2014.11.001

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Abstract PDF

Objectives
From the perspective of public health, tuberculosis (TB) remains an important issue that threatens health. Korea is an intermediate burden country with a TB incidence of 97/100,000 individuals. Among many TB control measures, a relapse rate of TB is one indicator that can be used to indirectly assess the level of TB control in countries and in communities. Relapse TB has an approximately 12% yearly incidence in Korea. This study aims to estimate the relapse rate of TB and to investigate the associated factors by using nationwide TB notification data in Korea.
Methods
The nationwide TB notification data in 2005 was used with the exclusion criteria of duplicated reporting, foreign-born patients, outcome–died, and outcome–diagnosis changed. The data were double-checked as to whether they were reported again during 2006–2010 and the estimated relapse rate of TB. Associated factors were analyzed by multivariate logistic regression with the variables of age, sex, registration type, results of sputum smear test, medication, and outcome of treatment.
Results
Among 45,434 TB patients in 2005, 4,371 patients were again reported as TB patients from 2006 to 2010. Five hundred and sixty-four patients were reported more than twice and the cumulative number of relapses was 5,072 cases. The 5-year relapse rate was estimated as 9.62%. The relapse rate decreased yearly: 4.8% in 2006, 2.4% in 2007, 1.6% in 2008, 1.4% in 2009, and 1.0% in 2010. Age, sex, registration type, tuberculosis type, and medication were independently associated with a relapse of TB. In the multivariate logistic regression analysis, the following factors were related: male sex, 40–49 years old; registration type, relapse, treatment after failure, treatment after default, transfer in, and other, the sputum smear-positive pulmonary TB, and medications (including individuals taking 2–5 drugs).
Conclusion
This study has estimated a 5-year relapse rate of TB in Korea that is slightly lower than the rate of relapse TB in the annual reports. This study could be conducted and cross-checked with data from the National Health Insurance in the future.

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Sex differences in the impact of diabetes mellitus on tuberculosis recurrence: a retrospective national cohort study
Dararat Eksombatchai, Dawoon Jeong, Jeongha Mok, Doosoo Jeon, Hee-Yeon Kang, Hee Jin Kim, Hee-Sun Kim, Hongjo Choi, Young Ae Kang
International Journal of Infectious Diseases.2023; 127: 1. CrossRef
Recurrence of pulmonary tuberculosis in India: Findings from the 2019–2021 nationwide community-based TB prevalence survey
Prathiksha Giridharan, Sriram Selvaraju, Raghuram Rao, Kiran Rade, Kannan Thiruvengadam, Smita Asthana, Rakesh Balachandar, Sampada Dipak Bangar, Avi Kumar Bansal, Jyothi Bhat, Debjit Chakraborty, Vishal Chopra, Dasarathi Das, Shanta Dutta, Kangjam Rekha
PLOS ONE.2023; 18(12): e0294254. CrossRef
Risk factors associated with tuberculosis recurrence in South Korea determined using a nationwide cohort study
Hin Moi Youn, Moon-Kyung Shin, Dawoon Jeong, Hee-Jin Kim, Hongjo Choi, Young Ae Kang, Jun Hyeok Lim
PLOS ONE.2022; 17(6): e0268290. CrossRef
Facteurs de risque de récurrence de tuberculose pulmonaire bactériologique confirmé à Kisangani (République démocratique du Congo)
Catherine Marie Nomopuane Kabudri, Shadrack Kandala Ngianga II, Léon Okenge Ngongo
Santé Publique.2022; Vol. 34(4): 591. CrossRef
Predicting the impact of control strategies on the tuberculosis burden in South and North Korea using a mathematical model
Hyunwoo Cho, Youngmok Park, Jeongjoo Seok, Joon Sup Yeom, Jun Yong Choi, Hee Jin Kim, Young Ae Kang, Jeehyun Lee
BMJ Global Health.2021; 6(10): e005953. CrossRef
Preferred product characteristics for therapeutic vaccines to improve tuberculosis treatment outcomes: Key considerations from World Health Organization consultations
Johan Vekemans, Michael James Brennan, Mark Hatherill, Lewis Schrager, Bernard Fritzell, Kathryn Rutkowski, Beatrice De Vos, Matteo Zignol, Georges Thiry, Ann M. Ginsberg, Barry Walker
Vaccine.2020; 38(2): 135. CrossRef
Rate and risk factors of recurrent tuberculosis in Yemen: a 5-year prospective study
Mohammed Saif Anaam, Alian A. Alrasheedy, Saud Alsahali, Saeed O. Alfadly, Adel H. Aldhubhani
Infectious Diseases.2020; 52(3): 161. CrossRef
Small Animal Model of Post-chemotherapy Tuberculosis Relapse in the Setting of HIV Co-infection
Matthew B. Huante, Tais B. Saito, Rebecca J. Nusbaum, Kubra F. Naqvi, Sadhana Chauhan, Robert L. Hunter, Jeffrey K. Actor, Jai S. Rudra, Mark A. Endsley, Joshua G. Lisinicchia, Benjamin B. Gelman, Janice J. Endsley
Frontiers in Cellular and Infection Microbiology.2020;[Epub] CrossRef
Proteomic analysis of infected primary human leucocytes revealed PSTK as potential treatment-monitoring marker for active and latent tuberculosis
Benjawan Kaewseekhao, Sittiruk Roytrakul, Yodying Yingchutrakul, Kanin Salao, Wipa Reechaipichitkul, Kiatichai Faksri, HASNAIN SEYED EHTESHAM
PLOS ONE.2020; 15(4): e0231834. CrossRef
The association between proton pump inhibitor use and the risk of tuberculosis: A case‐control study
Hyun Jin Song, Haesuk Park, Susan Park, Jin‐Won Kwon
Pharmacoepidemiology and Drug Safety.2019; 28(6): 830. CrossRef
Recurrence of tuberculosis in a low-incidence setting: a retrospective cross-sectional study augmented by whole genome sequencing
Laila Parvaresh, Taryn Crighton, Elena Martinez, Andrea Bustamante, Sharon Chen, Vitali Sintchenko
BMC Infectious Diseases.2018;[Epub] CrossRef
Treatment Outcomes of Patients Treated for Pulmonary Tuberculosis after Undergoing Gastrectomy
In Young Jung, Moo Hyun Kim, Woo Yong Jeong, Mi Young Ahn, Yong Duk Jeon, Hea Won Ahn, Jin Young Ahn, Je Eun Song, Dong Hyun Oh, Yong Chan Kim, Eun Jin Kim, Su Jin Jeong, Nam Su Ku, June Myung Kim, Jun Yong Choi
The Tohoku Journal of Experimental Medicine.2016; 240(4): 281. CrossRef
Is Tuberculosis Still the Number One Infectious Disease in Korea?
Hae-Wol Cho, Chaeshin Chu
Osong Public Health and Research Perspectives.2014; 5: S1. CrossRef

The Usefulness of the Tuberculosis Skin Test and the Interferon-gamma Release Assay in the Diagnosis of Latent Tuberculosis Infection in South Korea: Ju Young Jang, In Won Park, Byoung Whui Choi, Jae Chol Choi; Osong Public Health Res Perspect. 2014;5(Suppl):S18-S23. Published online December 31, 2014; DOI: https://doi.org/10.1016/j.phrp.2014.10.009

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Abstract PDF

Objectives
South Koreans receive the bacillus Calmette-Guerin (BCG) vaccination, which influence the result of the tuberculin skin test (TST); however, only a few studies have described the usefulness of the TST and interferon-γ release assay (IGRA) for diagnosing latent TB infection (LTBI). Therefore, our aim was to determine the usefulness of the TST and IGRA for diagnosing LTBI in a household contacts investigation.
Methods
We reviewed the 329 household contacts who visited Chung-Ang University Hospital (Seoul, Korea) from May 1, 2011 to February 28, 2014. To evaluate the effectiveness of TST and IGRA for the diagnosis of LTBI, we examined the concordance rate between the two tests, based on age. We also evaluated the risk factors for LTBI.
Results
The concordance rate between the two tests in individuals 0–24 years, 25–54 years, and over 55 years were 82.6% (κ = 0.64, p < 0.01), 68.9% (κ = 0.40, p < 0.01), and 68.4% (κ = 0.35, p < 0.01), respectively. The ratio of positive TST to negative IGRA was higher in individuals 25–44 years old, whereas the ratio of negative TST to positive IGRA was higher in individuals older than 55 years old. Based on the TST, the risk factor for LTBI was a cavity (p < 0.01). When using IGRA, the risk factors were contact time (p = 0.04) and age over 55 years old (p = 0.02).
Conclusion
The concordance rate between TST and IGRA was not good after the age of 25 years. The IGRA test reflects the known risk factors more exactly.

Citations

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Household tuberculosis contact investigation in a tuberculosis-prevalent country
Jung Seop Eom, Insu Kim, Won-Young Kim, Eun-Jung Jo, Jeongha Mok, Mi-Hyun Kim, Kwangha Lee, Ki Uk Kim, Hye-Kyung Park, Min Ki Lee
Medicine.2018; 97(3): e9681. CrossRef
QuantiFERON-TB Gold In-tube test for the diagnosis of active and latent tuberculosis in selected health facilities of Addis Ababa, Ethiopia
Selam Niguse, Kassu Desta, Gebremdihin Gebremichael, Atsebeha Gebrezgeaxier, Mulluwork Getahun, Desta Kassa
BMC Research Notes.2018;[Epub] CrossRef
Predictors for false-negative QuantiFERON-TB Gold assay results in patients with extrapulmonary tuberculosis
Youn Jeong Kim, Ji Young Kang, Sang Il Kim, Mee Soo Chang, Yang Ree Kim, Yeon Joon Park
BMC Infectious Diseases.2018;[Epub] CrossRef

Utilization of Laboratory Tests for Tuberculosis and Mycobacterial Disease in Korea: Chang-Ki Kim, Sung Won Choi, Mi-Sun Park; Osong Public Health Res Perspect. 2014;5(Suppl):S24-S29. Published online December 31, 2014; DOI: https://doi.org/10.1016/j.phrp.2014.10.008

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Abstract PDF

Objectives
In Korea, a large portion of tuberculosis (TB) patients are diagnosed and treated in private institutes. Laboratory tests are crucial for TB control. There are many possible problems using laboratory tests in the private sector. In this study, we aimed to investigate the characteristics and trends of utilizing laboratory tests for TB and mycobacterial diseases in the private sector by analyzing the National Health Insurance (NHI) database.
Methods
After selecting TB or other mycobacteria-related test items, we searched the number and cost of each item on the website of the Health Insurance Review and Assessment Service using the code of each test from 2007 to 2012.
Results
Our data revealed that the number and cost of tests drastically increased between 2007 and 2012. Culture and molecular tests primarily contributed to the tremendous increases. For each year, concentrated smearing and fluorochrome staining were more commonly used. The number of serologic tests for latent TB infection stagnated, despite the expansion of contact investigation.
Conclusion
The NHI data could be considerably useful for understanding the utilization trends of laboratory tests for TB and mycobacterial diseases in Korea. Our data showed that TB laboratory systems have recently improved. In this study, many issues were noticed. Therefore, solutions to these issues are required and the continued monitoring of NHI data regarding laboratory diagnosis.

Citations

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Tuberculosis Surveillance and Monitoring under the National Public-Private Mix Tuberculosis Control Project in South Korea 2016–2017
Jinsoo Min, Hyung Woo Kim, Yousang Ko, Jee Youn Oh, Ji Young Kang, Joosun Lee, Young Joon Park, Sung-Soon Lee, Jae Seuk Park, Ju Sang Kim
Tuberculosis and Respiratory Diseases.2020; 83(3): 218. CrossRef
Is Tuberculosis Still the Number One Infectious Disease in Korea?
Hae-Wol Cho, Chaeshin Chu
Osong Public Health and Research Perspectives.2014; 5: S1. CrossRef

Results of Tuberculosis Contact Investigation in Congregate Settings in Korea, 2013: Yunhyung Kwon, So Jung Kim, Jieun Kim, Seol-yi Kim, Eun Mi Song, Eun Jung Lee, Yun Choi, Yejin Kim, Byoung ok Lim, Da Sul Kim, Duksun Choi, Hye Sung Kim, Ji Eun Park, Ji-eun Yun, Jin A. Park, Jong Rak Jung, Joo-kyoung Kim, Sang Hee Kang, Seo Yean Hong, Seung Jae Lee, Soo Jin Park, Sun Hwa Park, Sunhye Yoon, Yoonsun Kim, Yunjeong Choi, Yun Jeong Seo, Yul A Seo, Jiseon Park, Minhee Sung, Minjang Shin, Hyunjin Son, Yeonkyeng Lee, Unyeong Go, Geun-Yong Kwon; Osong Public Health Res Perspect. 2014;5(Suppl):S30-S36. Published online December 31, 2014; DOI: https://doi.org/10.1016/j.phrp.2014.10.010

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22 Download
6 Crossref

Abstract PDF

Objectives
This study aimed to check the status of the contact investigation in congregate settings to eradicate tuberculosis (TB) in the Republic of Korea.
Methods
The “Integrated System for Disease and Public Health Management” is used for care and follow-up for patients and contacts of TB. We downloaded data for contact investigations conducted from January to December 2013.
Results
A total of 1,200 contact investigations in congregate settings were carried out by 25 field investigators in 2013. We performed the status of contact investigation, TB, and LTBI rate by age, accept rate of LTBI treatment, and complete rate of LTBI treatment during 2013. A total of 1,547 index TB patients, 149,166 contacts, and 259 additional TB patients were found through the investigation. Kindergartens showed the highest LTBI rate, 19.8%, among educational facilities. The second highest was in elementary schools and the subtotal LTBI rate of educational facilities was 7.8%. Social welfare/correctional facilities and workplaces showed relatively high LTBI rates of 23.8% and 23.6%, respectively. By age, individuals >35 years showed the highest LTBI rate, followed by those aged 0–4 years, 30–34 years, and 5–9 years, with rates of 18.1%, 16.4%, and 15.4% respectively. When comparing the tuberculin skin test (TST) positive conversion ratio by facility, middle school and high school were relatively high compared to the others. The accept rate of LTBI treatment in the workplace was lowest at 63% and the complete rate in elementary schools was lowest at 76.5%.
Conclusion
TB contact investigation is considered as a meaningful strategy for preventing TB outbreaks in congregate settings and decreasing the prevalence of TB in young people. Results of this study could be used to establish the LTBI management policy.

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Latent Tuberculosis Cascade of Care Among Healthcare Workers: A Nationwide Cohort Analysis in Korea Between 2017 and 2018
Jinsoo Min, Hyung Woo Kim, Joon Young Choi, Ah Young Shin, Ji Young Kang, Yunhee Lee, Jun-Pyo Myong, Hyunsuk Jeong, Sanghyuk Bae, Hyeon-Kyoung Koo, Sung-Soon Lee, Jae Seuk Park, Hyeon Woo Yim, Ju Sang Kim
Journal of Korean Medical Science.2022;[Epub] CrossRef
Risk of active tuberculosis development in contacts exposed to infectious tuberculosis in congregate settings in Korea
Shin Young Park, Sunmi Han, Young-Man Kim, Jieun Kim, Sodam Lee, Jiyeon Yang, Un-Na Kim, Mi-sun Park
Scientific Reports.2020;[Epub] CrossRef
The risk of active tuberculosis among individuals living in tuberculosis-affected households in the Republic of Korea, 2015
Jiyeon Yang, Sodam Lee, Suhyeon Oh, Sunmi Han, Shin Young Park, Youngman Kim, Jieun Kim, Mi-sun Park, Philip C. Hill
PLOS ONE.2019; 14(12): e0225744. CrossRef
The Infectivity of Pulmonary Tuberculosis in Korean Army Units: Evidence from Outbreak Investigations
Chang-gyo Yoon, Dong Yoon Kang, Jaehun Jung, Soo Yon Oh, Jin Beom Lee, Mi-Hyun Kim, Younsuk Seo, Hee-Jin Kim
Tuberculosis and Respiratory Diseases.2019; 82(4): 298. CrossRef
Tuberculosis prevention and care in Korea: Evolution of policy and practice
Unyeong Go, Misun Park, Un-Na Kim, Sodam Lee, Sunmi Han, Joosun Lee, Jiyeon Yang, Jieun Kim, Shinyoung Park, Youngman Kim, Hyosoon Yoo, Jeongok Cha, Wonseo Park, Haeyoung Kang, Hwon Kim, Guri Park, Minjung Kim, Ok Park, Hyunjin Son, Enhi Cho, Kyoungin Na,
Journal of Clinical Tuberculosis and Other Mycobac.2018; 11: 28. CrossRef
The Prevalence and Risk Factors of Latent Tuberculosis Infection among Health Care Workers Working in a Tertiary Hospital in South Korea
Jae Seuk Park
Tuberculosis and Respiratory Diseases.2018; 81(4): 274. CrossRef

Trends and Characteristics of HIV Infection among Suspected Tuberculosis Cases in Public Health Centers in Korea: 2001–2013: Meekyung Kee, Kyoung-Ho Lee, Sae-Young Lee, Chun Kang, Chaeshin Chu; Osong Public Health Res Perspect. 2014;5(Suppl):S37-S42. Published online December 31, 2014; DOI: https://doi.org/10.1016/j.phrp.2014.11.002

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Abstract PDF

Objectives
The Republic of Korea reports approximately 35,000 new tuberculosis (TB) patients each year, and the number of HIV-infected individuals is steadily increasing. Public health centers (PHCs) conduct TB diagnosis and treatment for risk groups in communities. This study aimed to identify possible trends and characteristics of HIV infection among suspected TB cases in PHCs.
Methods
Study subjects were suspected TB cases in PHCs who agreed to be tested for HIV from 2001 to 2013. Trends in HIV seroprevalence were assessed through a series of annual cross-sectional analyses. We analyzed suspected TB cases, and HIV-infected individuals among suspected TB cases, by gender, age, nationality, and region.
Results
The number of suspected tuberculosis cases who took an HIV test in PHCs was approximately 6,000 each year from 2001 to 2013. Among the suspected TB cases who took an HIV test, the number of those aged 20–39 is gradually decreasing, while the number of those aged 50–69 is increasing. During this period, 32 HIV-infected individuals were identified; the majority were men (94%), aged 30–49 (68%), Korean (94%), and residents in a metropolitan area (53%). HIV seroprevalence decreased from 8.2 per 10,000 persons in 2001 to 1.9 per 10,000 persons in 2013.
Conclusion
This study has identified trends and characteristics of HIV infection among suspected tuberculosis cases in PHCs. This national data provides a basis for public health policy for HIV and tuberculosis infections.

Citations

Citations to this article as recorded by

Is Tuberculosis Still the Number One Infectious Disease in Korea?
Hae-Wol Cho, Chaeshin Chu
Osong Public Health and Research Perspectives.2014; 5: S1. CrossRef

Brief Report

Activities of the Korean Institute of Tuberculosis: Sungweon Ryoo, Hee Jin Kim; Osong Public Health Res Perspect. 2014;5(Suppl):S43-S49. Published online December 31, 2014; DOI: https://doi.org/10.1016/j.phrp.2014.10.007

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Abstract PDF

The Korean National Tuberculosis Association (KNTA) set up the Korean Institute of Tuberculosis (KIT) in 1970 to foster research and technical activities pertaining to tuberculosis (TB). The KNTA/KIT had successfully conducted a countrywide TB prevalence survey from 1965 to 1995 at 5-year intervals. The survey results (decline in TB rates) established Korea as a country that had successfully implemented national control programs for TB. The KIT developed the Korea Tuberculosis Surveillance System and the Laboratory Management Information System, both of which were transferred to the Korea Centers for Disease Control and Prevention after its establishment. The KIT functions as a central and supranational reference TB laboratory for microbiological and epidemiological research and provides training and education for health-care workers and medical practitioners. Recently, the KIT has expanded its activities to countries such as Ethiopia, Laos, and Timor-Leste to support TB control and prevention. The KIT will continue to support research activities and provide technical assistance in diagnosing the infection until it is completely eliminated in Korea.

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