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1 소아알레르기호흡기 : 제 22 권제 1 호, pp21~26, 2012 년 1) 신종인플루엔자 A 유행시발열시작과신속항원검사시행사이의시간간격에따른민감도 부산성모병원소아청소년과 박근화ㆍ박순빈ㆍ김성원 The Sensitivity according to the Time Gap between Fever Onset and the Performance of Rapid Antigen Test for 2009 H1N1 Influenza Geun Hwa Park, MD, Sun Bin Park, MD, Sung Won Kim, MD Department of Pediatrics, Busan St. Mary's Medical Center, Busan, Korea Purpose : Rapid antigen test (RAT) is used to screen influenza rapidly. The clinical sensitivity of RAT was poor for 2009 H1N1 influenza. The aim of this study was to identify the correlation of time gap (TG) between fever onset and the sensitivity of RAT for 2009 H1N1 influenza. Methods : Data were collected retrospectively during the pandemic H1N influenza season between October 2009 and February The RAT was done by using SD Bioline influenza antigen (Standard Diagnostics Inc.) in nasopharyngeal swab. The 2009 H1N1 influenza was confirmed by real- time reverse transcriptase polymerase chain reaction (rrt-pcr). Specimens were categorized according to the TG between fever onset and performance of RAT. They were classified into <24 hours (TG1), 24 to 48 hours (TG2), 48 to 72 hours (TG3), 72 to 96 hours (TG4), 96 to 120 hours (TG5), 120 hours (TG6). Results : The overall sensitivity of RAT was 69.9%. The TG dependent sensitivity of RAT at TG1, TG2, TG3, TG4, TG5, and TG6 was 64.3%, 73.3%, 61.1%, 88.9%, 83.3%, and 61.1% respectively. The sensitivity of RAT was the highest when the TG was 72 to 96 hours. But this result was not statistically significant. Conclusion : Correlation of TG between fever onset and the sensitivity of RAT for 2009 H1N1 influenza was not statistically significant. But our study suggested that 72 to 96 hours after fever onset is the most sensitive time of RAT. Timely optimal performance of the RAT could have a significant impact on improving results. Further evaluation for better sensitivity would be needed. [Pediatr Allergy Respir Dis(Korea) 2012;22:21-26] Key Words : Rapid antigen test, Sensitivity, Time gap, 2009 H1N1 influenza, rrt-pcr 서 신종인플루엔자 (influenza A/H1N1 2009) 는돼지에서 론 접수 : 2011 년 5 월 31 일, 수정 : 2011 년 7 월 15 일승인 : 2011 년 8 월 29 일책임저자 : 김성원, 부산광역시남구용호동 번지부산성모병원소아청소년과 Tel : 051) Fax : 051) sbdph1@paran.com 기원하여인간, 조류, 돼지인플루엔자바이러스의재조합에의해생긴바이러스이다. 2009년 3월과 4월초에미국과멕시코에서처음으로검출되었고빠르게사람에서사람으로전파되어전세계적으로퍼졌다. 1-3) 2009년 6월 11일세계보건기구 (World Health Organization, WHO) 에서신종인플루엔자대유행을경고를 6단계 (2개이상의 WHO 지역의최소 1개국이상에서지속적인지역사회에서의유행이

2 Geun Hwa Park, et al.:the Sensitivity of Rapid Antigen Test for 2009 H1N1 Influenza 있는단계 ) 로발표하였다. 4) 우리나라에서도 2009년 7월말부터발생이늘어나기시작하였다. 5) 미국질병통제예방센터 (Centers for Disease Control and Prevention, CDC) 에서신종인플루엔자 A (H1N1) 검출을위한실시간역전사중합효소연쇄반응검사 (real-time reverse transcriptase polymerase chain reaction, rrt-pcr) 를발표한후이를이용하여확진할수있게되었다. 6,7) 신종인플루엔자를빠르게진단하면항바이러스치료를적절한시기에시작하고감염의전파를막을수있기때문에진단의정확성과신속한결과확인이중요하다. 8-10) rrt-pcr은비교적정확한결과를얻을수있지만검사소요시간이길고숙련된검사자가필요하다 ) 반면신속항원검사 (rapid antigen test, RAT) 는조작이간편하고결과가나오기까지 15분정도의시간이소요되기때문에빠른시간내에결과를알수있다 ) 본연구에서는 RAT 를언제시행할경우민감도를높일수있는지를알아보기위해신종인플루엔자 A (H1N1) 에감염된소아에서발열시작과 RAT 시행사이의시간간격에따른민감도의차이를알아보았다. 대상및방법 1. 대상 2009년 10월에서 2010년 2월까지부산성모병원소아청소년과에신종인플루엔자 A로입원한환아를대상으로의무기록을후향적으로연구하였다. rrt-pcr 에서양성이나온 206 명의환아를대상으로 RAT 의결과와발열시작에서 RAT 시행까지의시간간격, 나이, 성별등을확인하였다. 2. 방법 RAT 는 SD Bioline Influenza A/B/A (H1N1) pandemic (Standard Diagnostics Inc., Yongin, Korea) 키트를이용하였다. 스폰지재질의면봉을콧구멍을통하여깊숙이코인두까지넣어면봉을살살돌리면서검체를채취하였다. 점적기를사용하여검사용튜브에추출용액 (tricine, NaCl, sodium aside, TritonX-100) 0.3 ml를떨어뜨린후환자의검체를추출용액에넣고충분히추출이일어날수있도록 5회정도이상돌려주고검사용스트립 (stipe) 을화살표가아래로가도록검사용튜브에넣어 10-15분후에결과를판독하였다. rrt-pcr 은 AccuPower New Influenza A (H1N1) real-time PT-PCR 키트 (Cat. No. SIV- 1111, Bioneer Co., Daejeon, Korea) 와 Exicycler 96 (Cat. No. A-2060, Bioneer Co.) 를사용하여 RAT 에사용한동일한검체로실험하였다. rrt-pcr 은바이오인포메틱분석을이용하여밝혀낸신종인플루엔자 A (H1N1) 바이러스전게놈 (total genome) 의특정부분을증폭한다. 증폭산물의양은 thermal cycling 동안신종인플루엔자 A (H1N1) 에특징적인프로브 (probe) (5 -FAM; 3 -BHQ1) 로부터발생하는형광량을실시간측정하고분석하여결정하였다. 검체는발열시작과 RAT 시행사이의시간간격에따라시간간격이 24시간이내인경우 TG1, 시간인경우 TG2, 시간인경우 TG3, 시간인경우 TG4, 시간인경우 TG5, 120시간이후인경우 TG6 의 6 개그룹으로분류하였다. rrt-pcr 이양성인경우신종인플루엔자에감염되었다고진단하였고 rrt-pcr 양성중 RAT 양성인검체의민감도를계산하여시간간격에따른차이를비교하였다. 3. 통계분석통계분석은 SPSS ver (IBM, New York, NY, USA) 프로그램을이용하여시행하였다. 시간간격에따른민감도의차이를알아보기위해일원분산분석 (one way analysis of variance) 을이용하였고성별과나이에따른 Table 1. The Age Dependent Sensitivity of Rapid Antigen Test (RAT) Age (yr) Negative RAT Positive Total, n (%) Sensitivity (%) Total (11.2) 94 (45.6) 69 (33.5) 19 (9.2) 206 (100)

박근화등 : 신종인플루엔자 A 에대한신속항원검사의민감도 민감도의차이를알아보기위해독립변수 T 검정 (independent T test) 를이용하였다. P 값이 0.05 미만인경우통계적으로의미가있다고하였다. 결과 rrt-pcr 에서양성이나온 206검체중 144검체에서 RAT 가양성으로나와전체민감도는 69.9% 였다.

3 박근화등 : 신종인플루엔자 A 에대한신속항원검사의민감도 민감도의차이를알아보기위해독립변수 T 검정 (independent T test) 를이용하였다. P 값이 0.05 미만인경우통계적으로의미가있다고하였다. 결과 rrt-pcr 에서양성이나온 206검체중 144검체에서 RAT 가양성으로나와전체민감도는 69.9% 였다. 환아의나이는 1개월부터 14세까지였으며 ( 평균 5.0 세 ), 1세이하 24명 (11.2%), 2-5 세 94명 (45.6%), 6-10세 69명 (33.5 %), 11 세이상 19 명 (9.2%) 이었다. 나이에따른 RAT 의민감도는 1세이하 87.5%, 2-5 세 70.2%, 6-10세 63.8%, 11세이상 68.4% 이었고민감도의차이는없었다.(Table 1) 환아의성별은남아 133명 (64.6%), 여아 73명 (35.4 %) 이었다. 성별에따른 RAT 의민감도는남아 67.8%, 여아 74.0% 이었고민감도의차이는없었다.(Table 2) 발열시작과 RAT 시행사이의시간간격에따른연령, 성별의차이는없었다.(Table 3) 발열시작과 RAT 시행사이의평균시간간격은 96 시간이었다. 시간간격을 6개의그룹으로나누어살펴본민감도는 TG1 64.3%, TG2 73.3%, TG3 61.1%, TG4 88.9%, TG5 83.3%, 그리고 TG6 61.1% 였다. 시간간격에따른 RAT 의민감도는통계학적으로의미가없었으나, 본연구에서는발열시작후 시간에민감도가가장높았다.(Fig. 1) 고찰 H1N 인플루엔자가유행하면서신종인플루엔자 A 감염을선별하여적절한치료를받기위해빠른진단이필요하였다. 신종인플루엔자 A 대유행시에 CDC 에서 rrt -PCR 를제시하여신종인플루엔자 A를확진할수있게되었다. 6) rrt-pcr 는민감도는높지만검사소요시간이길고숙련된검사자가필요하기때문에규모가큰병원이나검사전문기관에서시행할수있다. 반면 RAT 는조작이간편하고결과가나오기까지 15 분이내의시간이소요되기때문에빠른시간내에결과를알수있어응급실, 의원, 소규모병원등에서시행하고있으며불필요한검사를줄여주고, 항바이러스치료를적절한시기에할수있게하여부적절한항생제남용을감소시키는데도움을준다. 10,19,21) 그러나 RAT는 rrt-pcr 에비해민감도가낮으며바이러스의종류, 검체채취방법, 키트의종류, 검체채취시기등에따라다양한민감도를나타낸다. 계절인플루엔자 A와신종인플 Table 2. The Sex Dependent Sensitivity of Rapid Antigen Test (RAT) Sex Male Female Total Negative RAT Positive Total Sensitivity (%) Fig. 1. The time dependent sensitivity of rapid antigen test (RAT). Our result showed that 72 to 96 hours after fever onset was the most sensitive time for RAT, but there was no statistical significance. Table 3. Characteristics according to the Time Gap Between Fever Onset and Performance of Rapid Antigen Test (RAT) Time gap (hr) < >120 Total No. (%) Male/Total (%) Mean age (yr) 42 (20.4) (41.7) (17.5) (8.7) (2.9) (8.7) (100)

4 Geun Hwa Park, et al.:the Sensitivity of Rapid Antigen Test for 2009 H1N1 Influenza 루엔자 A에대한 RAT 의민감도는각각 10-95%, % 로보고되었으며전체적으로신종인플루엔자 A에서낮게나타났다. 10,12,22-24) 인플루엔자검사에사용될수있는검체는비강면봉검체 (nasal swabs), 비인두면봉검체 (nasopharyngeal swabs), 비인두세척검체 (nasopharyngeal aspirates) 가있다. 비강면봉검체, 비인두면봉검체, 비인두세척검체를채취하여 RAT 의민감도를비교한연구가있었고민감도는각각 78%, 85%, 69% 로비인두면봉검체의민감도가가장높았다. 25) RAT 의경우비인두면봉검체를이용할경우가장높은민감도를나타내어검체채취시이러한방법이권장되고있다. 9,25-27) RAT 에사용되는키트의종류는다양하며민감도또한 BD Directigen EZ Flu A+B test 46.7%, BinaxNOW Influenza A&B test 38.3%, QuickVue Influenza A+B Test 53.3 % 등으로다양하다. 19,28) 이러한키트들은인플루엔자 A와인플루엔자 B에대한감별만가능하여계절인플루엔자 A 와신종인플루엔자 A (H1N1) 를감별할수없다. 신종인플루엔자 A를감별할수있는새로운키트 (SD Bioline Influenza Ag A/B/A (H1N1) Pndemic, Standard Diagnostics Inc.) 가개발되어사용되고있고민감도는 77% 로보고하였다. 29) 인플루엔자바이러스에감염되었을경우발열, 기침, 인후통, 비염, 근육통, 피로, 구토등의다양한임상증상이나타날수있다. 7) 이러한임상증상이시작된후언제검체를채취할때민감도가가장높을것인지에대한연구들이있었는데, 임상증상이발생한후 시간에검체를채취할경우민감도가가장높았다고보고하였다. 30,31) 본연구에서는신종인플루엔자 A 유행시발열시작과 RAT 시행사이의시간간격에따른민감도를살펴보았고통계학적으로유의하지는않았지만 시간에가장높게나타났다. RAT 시행을다양한임상증상을기준으로한이전연구들과는달리본연구에서는발열만을기준으로했기때문에민감도가가장높은시간의차이가나타나는것으로생각된다. RAT 는다양한민감도를보이며이러한민감도는검체채취방법, 시기, 키트종류를적절하게선택할경우높아질수있으며이러한것에대한더많은연구가필요할것이다. 요약목적 : 인플루엔자신속항원검사 (rapid antigen test, RAT) 는인플루엔자를빠르게선별하는검사로많이사용되고있다. 저자들은신종인플루엔자 A 유행시소아에서 RAT 의민감도와발열시작과 RAT 시행사이의시간간격에따른민감도의차이를알아보았다. 방법 : 2009 H1N1 인플루엔자유행시기인 2009 년 10 월에서 2010년 2월까지신종인플루엔자 A 감염으로입원한환아를대상으로하였다. RAT 는비인두면봉검체 (nasopharyngeal swab) 를이용하여 SD 바이오라인인플루엔자항원 (Standard diagnostics Inc., Yongin, Korea) 으로시행하였다. 신종인플루엔자 A는 RAT 와같은시기에시행한동일한검체를이용하여실시간역전사종합효소연쇄반응검사 real-time reverse transcriptase polymerase chain reaction) 로확진하였다. 검체는발열시작과 RAT 시행시기의시간간격에따라 6개의그룹으로분류하였다. 시간간격이 24 시간이내인경우 TG1, 시간인경우 TG2, 48-72시간인경우 TG3, 72-96시간인경우 TG4, 시간인경우 TG5, 120시간이후인경우 TG6 로분류하였다. 각각의그룹에서 RAT 의민감도를계산하여시간간격에따른차이를비교하였다. 결과 : 채취한모든검체에대한 RAT 의민감도는 69.9 % 였다. 시간간격에따른 RAT 의민감도는 TG1 64.3%, TG2 73.3%, TG3 61.1%, TG4 88.9%, TG5 83.3%, 그리고 TG6 61.1% 였으며통계학적으로차이가없었다. 결론 : 본연구에서신종인플루엔자 A 유행시발열시작과 RAT 시행까지의시간간격에따른 RAT 민감도가통계학적으로는의미가없었으나, RAT 를발열시작후 시간에시행하였을경우민감도가가장높았다. 소아에서언제 RAT 를시행할경우민감도를높일수있을지에대한추가적인연구가필요할것이다. 참고문헌 1. Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team, Dawood FS, Jain S, Finelli L, Shaw MW, Lindstrom S, et al. Emergence of a novel swine-origin influenza A (H1N1) virus in humans. N Engl J Med 2009;360: World Health Organization [Internet]. Geneva: May 18]. First confirmed case of influenza A (H1N1) in Republic of Korea. Available from: ED_News_or_Press_Release.aspx?NRMODE=P ublished&nrnodeguid=%7b25ef48d3-dd8 F-4AE4-B247-11D7EFA2EB0E%7D&NRORIG INALURL=%2Fmedia_centre%2Fnews%2Fne

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Korean J Lab Med 2010;30: DOI /kjlm Original Article Clinical Microbiology Evaluation of the Efficacies of Rapid Antigen Te

Korean J Lab Med 2010;30: DOI /kjlm Original Article Clinical Microbiology Evaluation of the Efficacies of Rapid Antigen Te Korean J Lab Med 2010;30:147-52 DOI 10.3343/kjlm.2010.30.2.147 Original Article Clinical Microbiology Evaluation of the Efficacies of Rapid Antigen Test, Multiplex PCR, and Real-time PCR for the Detection