For the 20th straight year—as it has since persecution watchdog Open Doors began its annual World Watch List—North Korea again bears the title of the most dangerous country for Christians to live in.

Open Doors released its World Watch List during a press conference Wednesday. A comprehensive research-based report, the annual list ranks the top 50 countries where it is most dangerous to be Christian.

According to the report, 340 million Christians now suffer high levels of persecution for their faith, representing one in eight Christians worldwide. Open Doors identified several trends driving this year’s numbers, not the least of which was COVID-19.

“The COVID-19 pandemic has turned a bad situation into an unbearable one,” said David Curry, president and CEO of Open Doors USA. “This public health crisis created an opportunity to expand faith-based discrimination and violence in regions where religious persecution had already reached alarming rates.”

In one country, 80% of Christians said they had been turned away from food distribution points because of their faith. Others reported they’d been passed over for employment. Other hot spots where Christians face discrimination while seeking COVID-19 relief include Myanmar, Nepal, Vietnam, Bangladesh, Pakistan, Central Asia, Malaysia, North Africa, Yemen and Sudan, according to the report.

“We’ve definitely seen that both extremists and governments are taking advantage of or using this opportunity to justify an increase in persecution,” Curry told Religion News Service.

“The global pandemic made persecution more obvious than ever—simply because so many people needed help,” according to Open Doors’ report accompanying its annual World Watch List. “The clear discrimination and oppression suffered by Christians in 2021 must not be forgotten, even after the COVID-19 crisis fades into our collective memory.”

Other top-10 countries, in addition to North Korea, are Afghanistan, Somalia, Libya, Pakistan, Eritrea, Yemen, Iran, Nigeria and India.

Sudan fell from the top 10 after abolishing the death penalty for apostasy and guaranteeing—on paper at least—freedom of religion in its new constitution after three decades of Islamic rule. Yet it remains No. 13 on the list, as Open Doors researchers noted Christians from Muslim backgrounds still face attacks, ostracization and discrimination from their families and communities, while Christian women face sexual violence.

The list added four new countries: Mexico at No. 37, Democratic Republic of Congo at 40, Mozambique at No 45, and Camoros at No. 50. It also dropped four nations: Sri Lanka, Russia, United Arab Emirates and Niger.

China re-entered the top 20 for the first time in a decade, the report says.

Most of the countries in the top 10 have been there since 2015, which at the time Open Doors proclaimed to be the “worst year in modern history for Christian persecution.”

“I’m afraid I could repeat that same statement [this year],” Curry said before the 2021 report’s release.

In the 50 countries on the World Watch list, 309 million Christians experience “very high” or “extreme” levels of persecution and discrimination, according to Open Doors. That’s one in eight Christians worldwide, it said.

More Christians are murdered for their faith in Nigeria than in any other country, Open Doors says. The organization blames violent attacks by Islamic extremist groups like Boko Haram and the Fulani, which Curry said mimic the rise of ISIS in Iraq.

Open Doors defines persecution as “any hostility experienced as a result of one’s identification with Christ. This can include hostile attitudes, words and actions toward Christians.” It creates its ranking by measuring and tracking reports of violence, as well as surveying field staff about pressures Christians face from governments, family and other institutions in each country.