연구논문, Research article 2017 년만 1-3 세어린이정기예방접종의완전접종률현황 질병관리본부감염병관리센터예방접종관리과박광숙, 이재영, 최연화, 공인식 * * 교신저자 : insik.kong@korea.kr, 043-719-6810 National Vaccination Coverage Among Children Aged 1-3 Years in the Republic of Korea, 2017 Park Kwangsuk, Lee Jaeyoung, Choi Yeonhwa, Kong Insik Division of VPD Control & NIP, Center for Infectious Disease Control, KCDC Background: The most effective way to prevent communicable vaccine-preventable diseases (VPD) is to achieve and maintain vaccination coverage level above the threshold of disease transmission prevention. In the Republic of Korea, the government established a strategy for achieving more than 95% of immunization coverage through routine vaccinations and/or supplemental immunization activities. The national level of vaccination coverage is a critical performance process indicator of the National Immunization Program (NIP). The Korea Centers for Disease Control and Prevention (KCDC) publicly reported the national level of vaccination coverage since 2015. Methods/results: This report details the vaccination coverage for the year 2017, using 1.29 million data of children from the National Registration Information System. The calculations of vaccine coverages are modeled on birth cohorts at ages of (born in 2016), (born in 2015), and (born in 2014). The complete vaccination coverage of subjects aged,, and in 2017 were 96.6%, 94.1%, and 90.4%, respectively. According to the birth cohorts, the vaccination coverages of NIP were higher than 95%, except for Japanese encephalitis (92.9%). Conclusion: Vaccination coverage in the Republic of Korea was higher than that in many developed countries. netheless, more investment and research are needed to identify vaccination hesitancy and refusal groups, as well as all VPD group. Keywords: Vaccination, Immunization, Coverage, Vaccination hesitancy 들어가는말 국가예방접종사업은개인의건강과생명을보호할뿐만아니라, 일정수준의접종률을달성할경우집단면역력형성 (herd immunity) 으로감염병전파를차단함으로써감염병유행을 예방한다. 예방접종은 $1 투자하면 $16 이득이생기는가장비용- 효과적인감염병예방관리전략이다 [1]. 우리나라의국가예방접종사업은 감염병의예방및관리에관한법률 제조및제25조에의거하여예방접종대상감염병을예방하기위해 1954년전후부터실시하고있다. 1996년 www.cdc.go.kr 1410
이전까지는아동의보호자에게반드시예방접종을받도록하는책임을부여하였으나, 1999년규제정비계획에의해보호자의강제예방접종규정과벌금조항이폐지되었으며, 현재까지기초지자체장의책임하에국가예방접종을실시하고있다 [2]. 우리나라의국가예방접종사업은 2020년까지예방접종률을감염병퇴치수준인 95% 이상으로높이기위해국가사업대상백신과접종대상자의확대, 민간의료기관접종에대한비용지원등양적 질적확대를통해국민의접종비용에대한부담을낮추고, 접종의편의성을향상시키고있다. 2014년도부터는 세이하어린이에대해국가예방접종을민간의료기관까지확대하여무료로실시하고있으며, 2018년현재총 17종의백신접종에대해국가지원을하고있다. 또한, 미접종자관리, 예방접종기록의효율적관리를위한예방접종통합관리시스템의구축 운영, 실시간으로개인별접종정보및접종일정안내정보제공, 지연접종알림등을지속적으로실시하고있다 [3]. 우리나라의전국예방접종률현황통계는 2013년통계청의국가승인통계 (117093 호 ) 로지정받았으며, 2015년부터만3세어린이전수에대한접종률을산출하고있다. 전국예방접종률현황산출은최신의집단면역수준을확인하여, 예방접종대상감염병발생시신속한유행예방관리를위한대응전략마련을위해매우중요하다. 이글에서는국가예방접종사업의성과를파악할수있는중요한지표인우리나라의 2017년만1~3세어린이예방접종률현황에대해자료의수집, 산출및분석방법과결과, 통계산출의발전방향에대해기술하고자한다. Integration System, 이하 전산시스템 이라함 ) 에전산등록한자료를이용하였다. 질병관리본부에서는전산등록된자료에대해지속적으로품질관리를실시하고있으며, 행정안전부의출생 사망정보및주소지정보와법무부의이중국적및출 입국정보를연계하였으며, 접종률분석을실시하여예방접종통계분야전문가회의를통해최종자문을받았다. 우리나라는 2015년부터만3세어린이의전국예방접종률현황을전산시스템에등록된기록을분석해전수통계로매년산출하고있으며, 2016년까지는만3세 1개년출생코호트 (2013년생) 에과거 개월, 개월, 개월시기의접종률을산출하였다. 2017년부터는최근시점의접종률을산출하기위해연도말기준만1 3 세어린이로산출대상출생코호트를 3개년으로확대하고그에따라각출생코호트의연도말기준만1세, 2세, 3세각각의백신별접종률과해당연령시기의접종률을산출하는방식으로변경하였다. 산출방식의변경으로전년도 개월과 개월의접종률추이비교는곤란해졌으나, 최근시점의접종률을확인할수있게되었다는점에서큰의의가있다. 2017년만1 3세어린이전국예방접종률은대한민국국적을보유하고국내에거주하는 2017년말기준만1 3세아동인 2014 2016 년출생아를대상으로감염병의예방을위해 예방접종실시기준및방법 ( 보건복지부고시제2016-80 호 ) 에따라권장하는예방접종횟수를모두완료한아동의비율로산출하였다 (Figure 1). 접종대상자인분모에서사망자와외국의영주권을취득하고영주목적으로외국에거주하는것으로확인된아동은제외하였다. 접종자인분자에대해서는질병관리본부의전산시스템에전산 몸말 1. 예방접종률자료의수집및산출방법 예방접종기록은보건소및의료기관에서예방접종을실시한후질병관리본부의예방접종통합관리시스템 (Immunization Registry 등록된기록만인정하였으며, 동일한예방접종을중복으로접종한경우는첫번째접종을인정하고, 그외의중복접종기록은제외하였으며, 예방접종실시기준보다이른접종을실시한경우에는접종력을인정하지않으므로제외하였다. 또한예방접종실시기준에서인정하지않는교차접종 1) 을한경우해당감염병의예방을위한접종을완료하기위해최종선택한백신의예방접종기록을인정하고, 그외교차접종의기록은제외하였다 (Figure 2)[4]. 1) 교차접종 : 동일한감염병을예방하기위해두개이상의백신을교차하여접종을실시한예방접종 ( 일본뇌염약독화생백신과불활성화백신간의교차접종 ) www.cdc.go.kr 1411
Selection process of denominator Population data registered in the Ministry Survival status Excluding target Check overseas resident with dual citizenship Denominator Figure 1. Flowchart of the selection process of denominator Selection process of numerator Immunization records registered in the Immunization Registry Integration System (IRIS) Early-vaccination (Minimum age & immunization interval) Excluding early vaccination records Duplication Excluding 2 nd duplicate vaccination records Cross-vaccination BCG & JE excludes later cross -vaccination records Completion of vaccination by age N o Incomplete vaccination Numerator Figure 2. Flowchart of the selection process of numerator www.cdc.go.kr 14
2. 예방접종률산출결과및해석 2014 2016 년출생아로서 2017년 월 31일기준행정안전부주민등록전산센터에주민등록된예방접종대상자는 9만명으로다음과같았다 (Table 1). 연령시기별예방접종률은생후 개월까지접종완료를권장하는예방접종 (6종, 16회접종 ) 2) 을모두접종한아동은 96.6%, 생후 개월까지권장되는예방접종 (8종, 21회접종 ) 3) 을모두접종한아동은 94.1%, 생후 개월까지권장하는예방접종 (9종, 23 회접종 ) 4) 을모두완료한아동은 90.4% 로각각나타났다 (Figure 3). 지역별완전접종률중 개월까지 (6종, 16회접종 ) 권장하는예방접종을모두완료한아동은울산 98.1%, 전남 97.8%, 광주 97.7% 의순서로높았고, 개월까지 (8종, 21회접종 ) 권장하는접종에대해서는울산과충남이 95.7%, 충북 95.3% 로높았으며, 개월까지 (9종, 23 회접종 ) 권장하는접종에대해서는울산 93.2%, 강원과충북이 92.1% 의순으로높았다 (Figure 4). 백신별로는생후 개월, 개월, 개월까지각각권장하는예방접종의백신별예방접종률이 92.9% 98.2% 로일본뇌염을제외하고모든백신의예방접종률이 95.0% 이상으로나타났다. 각연령별로는 BCG 백신접종이 98.0% 이상으로가장높았다 (Table 2). 백일해 ) 백신과 Hib(b형헤모필루스인플루엔자 ) 백신, 생후 23개월에첫접종을하고 개월후추가접종해가장늦은시기까지접종하는 JE( 일본뇌염 ) 백신의예방접종률이낮게나타났다. 일본뇌염백신은표준접종일정보다늦게접종하여아직다음접종시기가도래하지않은경우에도미접종자로분류되어다른백신보다낮은것으로보인다. 올해처음접종률을산출한 PCV( 폐렴구균 ) 백신의예방접종률은연령별로 96.8 97.4% 로다른백신과비슷한접종률을보였다. 지역별예방접종률차이는현재시점의주소지기준, 해외거주자등인구이동요인으로해석의한계는있으나지자체별로미접종자개별우편안내등접종독려방법의노력도차이가있는것으로보인다. 그러나 2017년만3세아동의 개월접종률은국가예방접종백신에 PCV가추가되어접종횟수가 4회증가하였음에도불구하고전년에비해 89.2% 에서 90.4% 로 1.2%p 증가되어 2015년이후지속적으로증가하고있으며, 우리나라의백신별완전접종률은접종률현황을공개하고있는해외주요국가와비교한결과국가별로동일한접종기준이적용되고있는 DTaP, IPV, MMR, Var, Hib 등 5종백신의평균이한국 96.9% 로미국 87.8%, 호주 95.1%, 영국 94.0% 등에비해평균약 2 9%p 가량높은것으로파악되어 (Figure 5)[5,6,7], 세계최고수준으로우리나라의어린이건강보호수준이높은것으로나타났다. 예방접종률은연령이높아질수록접종완료해야하는누적 접종횟수가많아져완전접종률이낮아졌으며, 백신별예방접종률은 만 3 세까지총 4 회로접종횟수가많은 DTaP( 디프테리아, 파상풍, Table 1. Subjects of birth cohorts used as denominator, 2017 Unit: n, % Total number of children Male Female of age (born in 2016) of age (born in 2015) of age (born in 2014) 409,170 209,508 199,662 442,257 226,726 215,531 438,726 2,801 213,925 2) 6 종백신 : BCG 1 회, HepB 3 회, DTaP 3 회, IPV 3 회, Hib 3 회, PCV 3 회를모두완료한아동 3) 8 종백신 : BCG 1 회, HepB 3 회, DTaP 4 회, IPV 3 회, Hib 4 회, PCV 4 회, MMR 1 회, Var 1 회를모두완료한아동 4) 9 종백신 : BCG 1 회, HepB 3 회, DTaP 4 회, IPV 3 회, Hib 4 회, PCV 4 회, MMR 1 회, Var 1 회및 JE 불활성화백신 3 회또는약독화생백신 2 회를모두완료한아동 www.cdc.go.kr 1413
100 96.6% Vaccination coverages (%) 95 90 85 94.1% 90.4% 80 75 (born in 2016) (born in 2015) (born in 2014) (16 doses required) (21 doses required) (23- doses required) Figure 3. Completed vaccination coverages by,, and of age (16 (16 doses doses required) vaccine) (21 (21 doses doses required) vaccine) (23- (23~ doses doses required) vaccine) 100 90 97.7 98.1 96.2 96.6 96.7 97.0 97.4 97.6 96.7 97.3 97.6 97.3 97.8 97.3 97.0 96.4 94.9 95.7 93.3 94.1 94.2 94.6 94.4 94.4 94.3 95.2 95.3 95.7 94.0 94.7 94.9 93.2 94.5 92.3 92.7 90.9 91.6 91.2 90.8 92.1 92.1 91.8 89.8 90.2 90.8 90.3 89.1 89.7 88.9 89.6 89.2 Vaccination coverages (%) 80 70 60 50 Figure 4. Completed vaccination coverages by age cohort and region, 2017 www.cdc.go.kr 1414
Table 2. Completed vaccination coverage of selected vaccines by region, 2017 Unit: n, % BCG HepB DTaP IPV Hib PCV MMR Var JE Total 98.2 98.1 98.0 97.8 97.8 97.6 97.7 96.2 96.6 97.6 97.7 97.7 97.7 95.9 95.7 97.4 96.9 96.8 97.6 97.7 97.5 97.6 92.9 Seoul 96.8 96.7 96.4 96.3 96.3 95.9 96.5 94.9 95.0 96.4 96.4 96.2 96.4 94.5 94.2 96.2 95.5 95.3 96.4 96.5 96.2 96.3 92.0 Busan 98.0 97.9 97.8 97.4 97.3 97.2 97.4 95.4 96.1 97.3 97.2 97.2 97.4 95.2 95.3 97.1 96.2 96.2 97.2 97.3 97.0 97.1 91.9 Daegu 98.3 98.3 98.0 98.0 98.1 97.9 97.9 96.5 96.7 97.8 97.9 97.9 97.7 95.7 95.6 97.5 97.1 96.9 97.9 98.0 97.8 97.7 92.7 Incheon 98.2 98.2 98.0 97.9 98.0 97.7 97.9 96.7 96.8 97.8 98.0 97.9 97.8 95.9 95.7 97.6 97.2 96.8 97.9 97.9 97.7 97.8 93.6 Gwangju 99.1 98.9 98.9 98.6 98.6 98.5 98.4 96.9 97.1 98.4 98.5 98.5 98.3 96.2 95.7 98.1 97.7 97.3 98.5 98.4 98.3 98.2 91.3 Daejeon 98.6 98.6 98.6 97.9 98.2 98.1 97.9 96.4 97.1 97.8 98.1 98.2 97.9 96.3 96.4 97.7 97.3 97.4 98.0 98.2 97.7 97.8 93.7 Ulsan 99.0 99.0 99.0 98.8 98.8 98.8 98.7 97.3 98.1 98.7 98.8 98.8 98.8 96.9 97.3 98.6 98.1 98.3 98.6 98.9 98.4 98.7 94.9 Sejong 99.0 98.6 98.9 98.5 98.4 98.3 98.4 96.5 97.5 98.2 98.3 98.6 98.4 96.3 96.5 98.1 97.2 97.6 98.1 98.8 98.0 98.6 93.8 Gyeonggi 98.2 98.0 97.9 97.9 97.7 97.6 97.8 96.4 96.7 97.7 97.7 97.7 97.7 95.9 95.6 97.5 97.0 96.9 97.7 97.9 97.6 97.6 93.4 Gangwon 98.8 98.5 98.6 98.5 98.1 98.2 98.5 96.7 97.4 98.5 98.1 98.2 98.4 96.6 96.6 98.1 97.4 97.6 97.9 98.2 97.8 97.9 94.0 Chungbuk 98.7 98.8 98.6 98.2 98.4 98.2 98.1 96.9 97.5 98.0 98.3 98.4 98.1 96.8 96.7 97.9 97.6 97.6 98.4 98.4 98.3 98.2 94.2 Chungnam 98.9 98.9 98.7 98.5 98.7 98.2 98.4 97.3 97.5 98.3 98.6 98.3 98.5 97.1 96.6 98.2 97.9 97.5 98.6 98.4 98.5 98.3 94.2 Jeonbuk 98.7 98.4 98.4 98.3 98.2 98.0 98.1 96.3 96.9 98.1 98.1 98.1 98.1 96.8 96.8 97.8 97.5 97.3 97.1 97.1 97.5 97.4 92.8 Jeonnam 99.1 98.9 98.9 98.9 98.5 98.4 98.6 96.7 97.2 98.6 98.5 98.4 98.6 96.5 96.1 98.3 97.5 97.4 98.4 98.4 98.3 98.2 91.9 Gyeongbuk 98.7 98.5 98.5 98.3 98.3 98.2 98.2 96.9 97.1 98.1 98.2 98.2 98.2 96.5 96.2 97.9 97.4 97.5 98.1 98.3 97.9 98.1 93.1 Gyeongnam 98.7 98.8 98.8 98.2 98.4 98.4 98.0 96.5 97.1 97.9 98.2 98.4 97.9 96.7 96.8 97.6 97.4 97.6 97.5 97.7 97.6 97.9 92.6 Jeju 98.3 98.1 98.3 97.7 97.8 97.9 97.6 95.4 96.3 97.5 97.6 97.8 97.6 95.2 95.0 97.1 96.4 96.6 97.5 97.7 97.0 97.4 92.2 *Abbreviation: BCG, Bacille Calmette-Gúerin; HepB, Hepatitis B; DTaP, Diphtheria-Tetanus-acellular-Pertussis; IPV, Inactivated Polio Vaccine; Hib, Haemophilus influenza type b; PCV, Pneumococcal Conjugate Vaccine; Var, Varicella; MMR, Measles-Mumps-Rubella; JE, Japanese Encephalitis Vaccination coverages (%) 100 95 90 85 80 96.4 83.4 97.5 97.6 97.4 96.4 96.3 95.0 95.0 95.3 91.9 91.1 Korea America Australia U.K. U.S.A 92.8 90.6 92.7 92.1 95.5 81.8 94.8 95.0 75 70 DTaP IPV MMR Var Hib Figure 5. Completed vaccination coverages by country www.cdc.go.kr 1415
맺는말 전국예방접종률현황은주민등록상주소지를기준으로집계함에따라인구이동등으로접종당시지역또는현재거주하고있는지역사회의예방접종률과다소차이가있을수있다. 국외거주하거나장기출국이확인된아동에대해서는예방접종대상자에서제외하고있으나, 일부확인되지않은아동을포함하고있어, 이들아동의비율이높은지역의경우실제 국가예방접종사업의성과를지속적으로분석하고, 저소득층, 다문화가족등취약계층의접종현황과백신거부, 지연자등미접종사유조사등을통한현황조사와그에따른관리체계를수립할필요가있다. 또한, 장기적으로만4 6 세와만11 세추가접종에대한접종률분석등분석연령을지속적으로확대하고, 미접종자의사회경제적특성등심층분석을통해미접종자의접종률제고를위한노력이필요하며, 연구자원으로써예방접종빅데이터를활용할수있는체계를마련할필요가있다. 지역사회의접종률보다낮게산출되었을가능성이있다. 또한, 수두 예방접종률은수두감염자의경우면역력획득으로예방접종제외대상이나, 감염및면역획득여부확인의한계로수두감염자를예방접종대상자에포함하여집계하였으며, 예방접종완료자에서제외하지않아실제수두예방접종률보다낮게산출되었을가능성이있다. 결핵예방접종률은결핵을예방하는 BCG 경피용백신이국가예방접종으로도입되지않은백신이나, 질병관리본부전산시스템에등록된 BCG 경피용예방접종기록을예방접종률산출에포함하였으며, 일부예방접종기록이전산등록누락되었을수있어실제결핵예방접종률보다낮게산출되었을가능성이있다. 예방접종률은국가예방접종사업의성과를파악할수있는중요한지표로서, 접종률결과에따라사업의문제점을발견하여대응방안을마련할수있는유용한지표이다. 이에각나라들은예방접종률의측정방법을개발하고, 그측정주기나자료원등과같은사항들에대하여많은연구와노력을경주하고있다. 2017년만1 3세어린이의전국예방접종률현황통계는 참고문헌 1. Ozawa S. Clark S. et al. Return On Investment From Childhood Immunization In Low- And Middle-Income Countries, 2011-20. Health Aff. 2016;35(2):199-207. 2. 보건복지부. 20 경제발전경험모듈화사업 : 어린이예방접종사업. 2013. 3. 질병관리본부. 2017년취학아동예방접종확인사업추진결과. 주간건강과질병. 2018;11(17);533-537. 4. 질병관리본부. 2017 전국예방접종률현황. 2017. 5. Hill HA, Elam-Evans LD, et al. Vaccination Coverage Among Children Aged 19-35 Months-United States, 2016. Morb Mortal Wkly Rep. 2017;66:1171-1177. 6. Alexandra H, Brynley H. et al. NSW Annual Immunisation Coverage Report, 2016. 7. National Statistics. Childhood Vaccination Coverage Statistics, England, 2016-2017, 2017. 8. Choe YJ, Park K et al. School entry vaccination requirement program: Experience from the Republic of Korea. Vaccine. 2018;(37)5497-5499. 2014 2016년에출생한 9만명을대상으로질병관리본부의전산시스템에등록된접종기록을분석해산출하여, 가장최신의연령별접종률산출을통해집단면역수준을확인한통계라는점과, 여러분야에서예방접종빅데이터를활용할수있는정확한통계자료를제공하였다는것에큰의의가있다. 우리나라어린이의높은예방접종률은단체생활에의한유행을막을수있는수준의높은집단면역보호체계를갖췄다는것을의미한다. 이러한높은접종률유지를위해서는향후매년전수등록자료를이용해접종률을분석함으로써우리나라 www.cdc.go.kr 1416