주간건강과질병 제 10 권제 29 호 2016 년큐열환자의역학적특성 질병관리본부감염병관리센터감염병감시과이신영, 이지연, 박현정, 이동한 * * 교신저자 : Epidemiological characteristics of

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1 2016 년큐열환자의역학적특성 질병관리본부감염병관리센터감염병감시과이신영, 이지연, 박현정, 이동한 * * 교신저자 : Idhmd@korea.kr, Epidemiological characteristics of Q fever cases in South Korea, 2016 Lee Shin Young, Lee Ji Yun, Bahk Hyun Jung, Lee Dong Han Division of Infectious Disease Surveillance, Center for Infectious Diseases Surveillance and Response, KCDC Q fever is a disease caused by the bacteria Coxiella burnetii that infects some animals such as goats, sheep and cattle. Human infections are made by breathing in dust that has been contaminated by infected animal feces, urine, milk, and birth products. Typical symptoms are fever, chills, fatigue, and muscle pain etc. A small percentage of those who became infected with Q fever develops to chronic Q fever that requires antibiotic treatment. Q fever is classified as one of the Group IV mandatory notifiable infectious diseases in Korea. In national infectious disease surveillance system, an annual number of reported patients of Q fever was less than 10 cases every year until Thereafter, it has been on increase from 27 cases in 2015 to 81 cases in Chronic cases accounted for 6(7.4%) among 81 cases in Annually the highest incidence was observed in November. 16% of patients was reported from high risk jobs such as farmers, livestock hygiene controller, veterinary drug delivery and meat by-product handler. we could not identify transmission routes in 54.3% of reported Q fever cases. Further efforts are needed to identify the transmission routes of Q fever. 큐열은 Coxiella burnetii가원인이되어발생하는인수공통감염병으로가축및야생동물, 진드기등에서확인된다. 주요숙주는소, 양, 염소이며사람은큐열에감염된숙주등으로부터분무 (aerosol) 흡입에의해주로발생한다. 동물의태반및배설물에오염된환경에서오랫동안생존하므로가축과접촉이잦은축산업자및수의사, 도축관련종사자등이고위험군으로알려져있고, 사람간전파나오염된식품섭취에의한감염은매우드물다. 원인병원체는 μm크기로 [1], 분무 (aerosol) 는바람을 통해 2-5 km[2] 까지확산될수있고최고 18 km까지전파되었다는연구도있다 [3]. 큐열병원체는감염력이높아균한마리로도사람에게감염을유발하며 [4], 병원성이낮아감염자의 60% 이상에서무증상이다. 급성감염의경우, 발열, 폐렴, 간염증상이있고환자의 38% 는치료하지않아도수개월안에회복되며 2% 정도가입원치료를받고 2% 이하에서사망할수있다 [5]. 만성감염의주요증상은심내막염으로급성환자의 5% 이하에서발생하고치료가부적절하여심내막염등의합병증이발생할경우 65% 이상에서 754

2 사망한다 [6]. 큐열예방접종은사백신으로호주에서고위험군을대상으로제한적으로사용하며, 부작용을우려하여우리나라를포함한대부분의나라에서시행하지않는다 [7]. 큐열은전세계에서산발적으로발생하며국내의경우 2006년제4군법정감염병으로지정하여관리하고있다. 매년 10명이내에서환자가신고되었으나 2015년에는 27명, 2016년에는 81명의환자가국가감염병감시체계에신고되었다 [8]. 외국의경우발생환자의 79% 가고위험직업과무관하고, 60% 는가축접촉력이확인되지않는등도시에서발생한큐열은가축접촉력이없거나취미정도의소규모축산을하는경우가많았다 [3]. 국내의경우 년역학적특성조사에서 87.5% 의환자가고위험직업군과관련이없었다 [9]. 이글에서는 2016년역학조사서를분석하여큐열발생추이, 위험요인및임상양상에대하여기술하고자한다. 2016년도국가감염병감시체계에신고된큐열중법정감염병진단 신고기준의검사기준에부합하는확진환자와추정환자를 포함한큐열환자는 81 명이었고, 이중만성환자는 6 명 (7.4%), 해외유입사례는 1 명 (1.2%) 이었다 [10] (Table 1) 년에는 11 월 20 명 (24.7%) 으로가장많은환자가 발생하였고, 9 월 11 명 (13.6%), 6 월 9 명 (11.1%) 순이었다 (Figure 1). 시 도별로는세종이인구 10 만명당 1.32 건으로가장 많이발생하였고, 충북 (1.13 건 ), 충남 (0.57 건 ), 전남 (0.37 건 ) 순을 보였으며 (Table 2), 시 군 구별로는충북청주에서 10 명으로신고가 Table 2. Incidence rates per 100,000 by province, South Korea, 2016 Province No. of reported cases Incidence rate per 100,000 Seoul Pusan Daegu Gkwangju Daejeon Ulsan Sejong Gyenggi Gangwon Chungbuk Chungnam Jeonbuk Jeonnam Gyeongbuk Figure 1. Percent of Q fever cases reported to KCDC by month of onset, South Korea, 2016 Gyengnam Total Table 1. Number of Q fever cases reported to KCDC, South Korea, 2016 Case classification No. of reported cases % Incidence rate per 100,000 Confirmed case Probable case Acute case Chronic case <0.01 Imported case <0.01 Local acquired

가장많았다 (Figure 2). 환자중 13명 (16.0%) 은축산업자, 가축위생방역사, 동물약품배달업무등고위험직업군이었다 (Table 3). 고위험직업군에서는보호장구없이가축접촉및가축유산장소에방문한경우가각각 3명 (23.1%) 으로가장많았다. 저위험직업군은접촉력이확인되지않은경우가 44명 (64.7%) 이고, 24명 (35.

3 가장많았다 (Figure 2). 환자중 13명 (16.0%) 은축산업자, 가축위생방역사, 동물약품배달업무등고위험직업군이었다 (Table 3). 고위험직업군에서는보호장구없이가축접촉및가축유산장소에방문한경우가각각 3명 (23.1%) 으로가장많았다. 저위험직업군은접촉력이확인되지않은경우가 44명 (64.7%) 이고, 24명 (35.3%) 의저위험직업군환자가야외활동및애완견접촉, 도살장에서포장육운반력등의위험요인이있었던것으로확인되었다 (Table 4). 큐열환자에서가장흔한증상은발열 72건 (88.9%) 이었고, 기저질환으로는고혈압 9건 (11.1%) 이가장많았으나심장질환 ( 협심증, 심내막염, 심장판막이식 ) 및혈관성질환 ( 대동맥류, 복부대동맥이식술, 심부정맥혈전증 ) 등중증질환이확인되었다 (Table 5). 국내의경우, 2015년이후매년큐열환자발생이증가하고 Figure 2. Geographic distribution of reported Q fever cases, South Korea, 2016 Table 3. Percentage of reported Q fever cases among risk group, 2016 Classification No. of reported cases % Farmer Risk group Livestock hygiene controller Veterinary drug delivery Meat by-product handler Others None of risk group Total

4 Table 4. Percentage of reported Q fever cases* by risk factors, 2016 Risk factor Low risk job High risk job Total (n = 13) (n = 68) Out door activity 8(11.8) - 8( 9.9) Ingestion of raw meat 6( 8.8) 2(15.4) 8( 9.9) Contact to animal without PPE 2( 2.9) 3(23.1) 5( 6.2) Contact with Dog and Pet 5( 7.4) - 5( 6.2) Visiting to livestock farm 3( 4.4) 2(15.4) 5( 6.2) Tick bites 2( 2.9) 1( 7.7) 3( 3.7) Packing meat handling at slaughter house 1( 1.5) - 1( 1.2) Direct contact of infected animal 1( 1.5) 1( 7.7) 2( 2.5) Visiting to place of animal abortion and delivery - 3(23.1) 3( 3.7) Killing of animal - 1( 7.7) 1( 1.2) Unknown 44(64.7) - 44(54.3) * The above table was made by multiple choice questions that respondents could select. Take a walk at the Park, climbing, mow the grass etc. Personal Protect Equipment Table 5. Clinical findings and underlying diseases among reported Q fever cases*, 2016 Clinical finding Underlying disease Fever 72(88.9) Hypertension 9(11.1) Chill 45(55.6) Cancer 7( 7.4) Headache 27(33.3) Diabetic Mellitus 5( 6.2) fatigue 22(27.2) Heart Disease 4( 4.9) Myalgia 21(25.9) Vascular disease 3( 3.7) Anorexia 20(24.7) Liver disease 3( 3.7) Diaphoresis 9(11.1) Benign Prostatic hyperplasia 3( 3.7) Arthralgia 9(11.1) Chronic respiratory disease 2( 2.5) Weight loss 6( 7.4) Rhinitis 1( 1.2) Abdominal pain & diarrhea 5( 6.2) Gastritis 1( 1.2) Backache 3( 3.7) Depression 1( 1.2) Hepatitis 3( 3.7) Alteration in mental status 2( 2.5) Vomiting 1( 1.2) Pneumonia 1( 1.2) Arthritis 1( 1.2) * The above table was made by multiple choice questions that respondents could select

5 있으나감염경로가확인되지않은경우가 54% 이었다. 큐열은도축장종사자, 수의사, 축산업종사자와같은동물관련직업군과관련된감염병으로알려져있으나, 미국에서도 79% 가고위험직업과무관하였으며 60% 가가축접촉력과연관성이없었고, 도시의경우 11. Frederika Dijkstra. et al The Q fever epidemic in the Netherlands: characteristics of notified acute Q fever patients and the association with dairy goat farming. Pathogens and Disease. 64;1:3-12. 접촉력이없거나취미정도의소규모축산을하였다 [3]. 2007년부터 3년간네덜란드에서보고된 3,000건이상큐열사례를분석한연구에서도농업 (3.2%), 도축장 (0.5%), 양모가공 (0.1%), 가축및농작물이동 (0.5%), 수의사 (0.8%) 등 5% 이하만이직업적연관성이있었다 [11]. 큐열병원체는감염력이높아균한마리로도분무를통해사람에게감염을유발하므로도시거주자들이교외에서바람에의해날라온분무에의해감염되었을수있을것으로추정된다 [5]. 동물은큐열에감염되어도무증상이대부분이므로유산하는가축검사를통해확인하는경우가많아감염된동물을인지하지못하는경우가많다. 위험요인이확인되지않는큐열사례중많은수는분무의확산에의한건으로추정되나분무에의해서감염될경우에는감염경로가사실상확인하기가어려우므로추가적인연구가필요하다. 참고문헌 1. Arbeitskreis Blut. et al Coxiella burnetii-pathogenic agent of Q(Query) Fever. Transfus Med Hemother. 204;41: Schimmer B. et al The use of a geographic information system to identify a dairy goat farm as the most likely source of an urban Q-fever outbreak. BMC Infect Dis. 10: Alica Anderson. et al Diagnostic and Management of Q Fever-United States, MMWR. Vol.62;No 유진홍, 김남중, 김미나, 김윤정. et al 감염학. section 3:721 pp. 5. Kerry O Cleveland Q fever. Available URL: medscape.com/article/ overview#a3. 6. Technical report, Risk assessment on Q fever Available URL: 7. David M. Waag. Review, Coxiella burnetii Host and bacterial responses to infection. Vaccine. 25, 질병관리본부 년도큐열관리지침. 9. 질병관리본부 년도감염병역학조사연보. 10. 보건복지부 법정감염병진단 신고기준

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°Ç°�°úÁúº´6-2È£ K O R E A C E N T E R S F O R D I S E A S E C O N T R O L & P R E V E N T I O N PHWR Vol. 6 No. 2 www.cdc.go.kr 2013 1 11 6 2 ISSN:2005-811X Flavivirus surveillance in mosquitoes collected from the quarantine