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Background  Vivax malaria was successfully eliminated from the Republic of Korea (ROK) in the late 1970s but re-emerged in 1993. Two decades later as the ROK enters the final stages of malaria elimination, dedicated surveillance of the local  P .  vivax  population is critical. We apply a population genetic approach to gauge  P .  vivax  transmission dynamics in the ROK between 2010 and 2012.    Methodology/Principal Findings   P .  vivax  positive blood samples from 98 autochthonous cases were collected from patients attending health centers in the ROK in 2010 ( n  = 27), 2011 ( n  = 48) and 2012 ( n  = 23). Parasite genotyping was undertaken at 9 tandem repeat markers. Although not reaching significance, a trend of increasing population diversity was observed from 2010 ( H  E  = 0.50 ± 0.11) to 2011 ( H  E  = 0.56 ± 0.08) and 2012 ( H  E  = 0.60 ± 0.06). Conversely, linkage disequilibrium declined during the same period:  I  AS  = 0.15 in 2010 ( P  = 0.010), 0.09 in 2011 ( P  = 0.010) and 0.05 in 2012 ( P  = 0.010). In combination with data from other ROK studies undertaken between 1994 and 2007, our results are consistent with increasing parasite divergence since re-emergence. Polyclonal infections were rare (3% infections) suggesting that local out-crossing alone was unlikely to explain the increased divergence. Cases introduced from an external reservoir may therefore have contributed to the increased diversity. Aside from one isolate, all infections carried a short MS20 allele (142 or 149 bp), not observed in other studies in tropical endemic countries despite high diversity, inferring that these regions are unlikely reservoirs.    Conclusions  Whilst a number of factors may explain the observed population genetic trends, the available evidence suggests that an external geographic reservoir with moderate diversity sustains the majority of  P .  vivax  infection in the ROK, with important implications for malaria elimination.

Further Evidence of Increasing Diversity of Plasmodium vivax in the Republic of Korea in Recent Years