Review Korean J Health Promot 2012;12(1):1-12 pissn: 2234-2141 eissn: 2093-5676 성인예방접종의일반적인원칙과최신지견 유선미 인제대학교의과대학해운대백병원가정의학과 General Recommendations and Recent Update in Adult Immunization Sunmi Yoo Department of Family Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea Backgrounds: Vaccination is the primary prevention strategy which aims to prevent various vaccine-preventable diseases and its complications. Although immunization practice had been centered on children in Korea, recent epidemic of several vaccine-preventable diseases such as hepatitis A and novel influenza H1N1 made people pay more attention on adult immunization since 2000. Methods: This article reviews the general recommendations of adult immunization based on the recent report from the US Advisory Committee on Immunization Practices in 2011. New vaccines which have been introduced or will be introduced are briefly reviewed. Results: Following topics are included: 1) principles for vaccine scheduling, 2) spacing of vaccines and antibody-containing products, 3) vaccination in altered immunocompetence, 4) vaccination in special situations, 5) contraindications and precautions, and 6) preventing and managing adverse reactions. Brief information on various influenza vaccines, adult pertussis vaccine, meningococcal vaccine, and zoster vaccine are reviewed and provided. Conclusions: Updated general recommendations and information on the new vaccines are intended for clinicians and other health-care providers who vaccinate patients. Korean J Health Promot 2012;12(1):1-12 Keywords: Vaccination, Immunization, Adult, Guidelines 서 론 예방접종은백신으로예방할수있는질병발생및합병증을예방하기위한 1차예방전략이다. 국내에서예방접종은주로소아를대상으로시행되었지만 2000년대에들어서면서발생한전국적인 A형간염유행과 2009/2010년에걸친 H1N1 인플루엔자의대유행으로성인예방접종의중요성이새롭게부각되었다. 그동안대한가정의학회, 1) 대한감염학회 2) 등학술단체와질병관리본부 3) 에서는개별적인 Received:December 21, 2011 Accepted:March 5, 2012 Corresponding author:sunmi Yoo, MD, PhD Department of Family Medicine, Inje University Haeundae Paik Hospital, 875 Haeun-daero, Haeundae-gu, Busan 612-030, Korea Tel: +82-51-797-3220, Fax: +82-797-0589 Email: syoo@paik.ac.kr 백신에대한성인예방접종권고안을제시하였는데예방접종을시행할때적용하는일반적인원칙에대해서는별로소개되지않았다. 병 의원이나학교에서실제로예방접종을시행할때는적응증에해당하는사람에게표준적인접종을제공하는것외에도다양한상황이발생할수있는데이때는일반적인원칙을충분히이해하고적용하는것이필요하다. 또비교적최근에국내에도입된성인용파상풍 -백일해- 디프테리아백신이나 2012년에도입될것으로예상되는수막알균백신, 대상포진백신등은청소년이나성인을대상으로한것으로이러한새로운예방접종에대한지식과경험이필요하다. 이글에서는최근발표된미국예방접종자문위원회 (Advisory Committee on Immunization Practices, ACIP) 의예방접종의일반원칙에대한권고 4) 와새롭게국내에도입되었거나도입될예정인백신을소개하고자한다.
2 Korean J Health Promot Vol. 12, No. 1, 2012 본론 1. 예방접종의기본원칙 1) 제조방법에따른백신분류예방접종에사용되는백신은제조방법에따라크게약독화생백신 (live attenuated vaccine) 과불활성화사백신 (inactivated vaccine) 으로나뉜다. 생백신과사백신은기대하는면역효과, 부작용, 투여방법, 다른치료제투여시반응등이다르므로각백신이어디에속하는지잘알고있어야한다 (Table 1). 약독화생백신은병원체를실험실에서반복배양하여인위적으로약화시킨것으로체내에서증식하지만질병을일으키지못하고, 면역체계만을자극해서능동면역을유도한다. 약독화생백신은실제질병에걸렸을때얻는능동면역과유사한면역반응을보이며, 소량으로도면역유도가가능하다는장점이있으나, 열이나빛등에노출되어백신에포함된병원체가손상되거나, 인체내에항체가존재하는경우에는증식이방해되어충분한면역유도효과를기대할수없다. 드물게백신주 (vaccine strain) 가돌연변이를일으켜서독성을회복하게되면질병을유발할수있다는단점이있다. 불활성화사백신은병원체를배양시킨후열이나화학약품으로불활성화시킨백신이다. 불활성화사백신은인체내에서증식하지못하기때문에면역을얻기위해서는생백신에비해서많은양의항원이필요하고여러번접종하여야하는반면생백신과같이독성을회복하거나질병을일으키지않으며, 인체내항체의영향을받지않는다. 그러나생백신에비해서면역효과가오래지속되지않기때문에추가접종이필요하고, 생성되는항체가질병방어와무관한것일수도있다는단점이있다. 불활성화사백신에는전세포바이러스백신 ( 인플루엔자, 주사용폴리오, 공수병, A형간염, B형간염 ), 전세포세균백신 ( 콜레라 ), 세포분획백신 (Pre S2 B형간염, 인플루엔자, 개량백일해, Vi 장티푸스 ), 톡소이드 ( 디프테리아, 파상풍 ) 와유전자재조합백신 ( 유전자재조합 B형간염 ) 등이있다. 다당질백신은불활성화사백신의특수한형태중의하나로 b형헤모필루스인플루엔자, 폐렴사슬알균, 수막알균등의세포막에있는다당질로만든세포분획백신이다. 그러나다당질백신은 2세미만의영유아에게접종시항체형성이잘안되고, 추가접종후에도항체가의상승효과가없다. 따라서이러한결점을보완하기위해다당질에특수한단백을결합한단백결합백신 (protein conjugate vaccine; b형헤모필루스인플루엔자, 7가폐렴사슬알균, 수막알균 ) 이개발되어접종되고있다. 2) 백신의접종간격가. 동일백신의접종간격예방접종후적절한반응을얻기위해서는권장하는백신접종대상자와스케줄을정확하게지키는것이중요하다. 여러차례접종해야하는백신의경우해외여행이나새로운유행발생등의이유로예방접종을빨리시행할수있으나이경우에도최소연령과최소간격은지켜야한다 (Table 2). 백신간격이너무짧거나너무어린연령에접종한경우적절한항체반응을얻기어렵다. 그러나최소간격이나연령에도달하기까지 4일정도남아있다면접종을시행해도무방하다는의견도있다. 권장하는접종최소연령까지 5일이상남아있는데 1차접종을시행했다면이를무시하고최소연령에도달한이후에다시접종한다. 예를들어생후 10개월에수두 1차접종을했다면이를무시하고만 1세에도달한이후에접종을다시시작한다. 생후 11 개월 2주째에 1차접종을했다면만 1세가되었더라도 4주 Table 1. Characteristics of live attenuated vaccines and inactivated vaccines Immunological action Adverse events Examples Live attenuated vaccines Close to a natural infection and often confer lifelong immunity Elicit strong cellular and antibody responses Could revert to a virulent form and cause disease Can be severe for individuals with altered immunocompetence Need to be refrigerated to stay potent BCG, MMR, varicella vaccine, herpes zoster vaccine, Ty21a oral typhoid, rotavirus vaccine, yellow fever vaccine, live, attenuated influenza vaccine Inactivated vaccines Persist relatively short periods Need to take several additional doses or booster shots Elicit antibody response only Fever, shock, and encephalopathy can occur by the component of vaccines Local adverse events can increase as the number of shots increase HepB, Td, Tdap, JEV, influenza, killed typhoid vaccine, Hib, HepA, cholera, pneumococcal vaccine, rabies vaccine, MCV4 Abbreviations: BCG, bacille Calmette Guerin; MMR, measles, mumps, and rubella; HepB, hepatitis B; Td, tetanus and diphtheria toxoid; Tdap, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; JEV, Japanese encephalitis vaccine; Hib, Haemophilus influenzae type b; HepA, hepatitis A; MCV4, quadrivalent meningococcal conjugate vaccine.
Sunmi Yoo. General Recommendations and Recent Update in Adult Immunization 3 Table 2. Recommended and minimum ages and intervals between vaccine doses used for adults a (Modified from General Recommendations on Immunization from National Centers for Immunization and Respiratory Diseases 4) ) b Disease Vaccination and dose Recommended age for Minimum age for Recommended Minimum interval number this dose this dose interval to next dose to next dose Hepatitis B Hepatitis B #1 Birth Birth 1-4 mo 4 wk Hepatitis B #2 1-2 mo 4 wk 2-17 mo 8 wk Hepatitis B #3 c 6-18 mo 24 wk - - Diphtheria, tetanus, Td 11-12 y 7 y 10 y 5 y pertussis Tdap d 11 y 7 y - - Measles, mumps, rubella MMR #1 12-15 mo 12 mo 3-5 y 4 wk MMR #2 4-6 y 13 mo - - Influenza Influenza, inactivated e 6 mo 6 mo f 1 mo 4 wk LAIV (intranasal) e 2-49 y 2 y 1 mo 4 wk Chickenpox Varicella #1 12-15 mo 12 mo 3-5 y 12 wk g Varicella #2 4-6 y 15 mo - - PPSV #1-2 y 5 y 5 y infection PPSV #2 h - 7 y - - Hepatitis A Hepatitis A #1 2 y 2 y 6-18 mo 6 mo Hepatitis A #2 30 mo 30 mo - - Meningococcal meningitis MCV4 #1 i 11-12 y 2 y 5 y 8 wk MCV4 #2 16 y 11 y (+8 wk) - - Abbreviations: Td, tetanus and diphtheria toxoid; Tdap, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; MMR, measles, mumps, and rubella; LAIV, live, attenuated influenza vaccine; PPSV, pneumococcal polysaccharide vaccine; MCV4, quadrivalent meningococcal conjugate vaccine. a Combination vaccines are available. Use of licensed combination vaccines is generally preferred to separate injections of their equivalent component vaccines. When administering combination vaccines, the minimum age for administration is the oldest age for any of the individual components; the minimum interval between doses is equal to the greatest interval of any of the individual components. b Modified from table on page 36-7 in the General Recommendations on Immunization. c Hepatitis B #3 should be administered at least 8 weeks after hepatitis B #2 and at least 16 weeks after hepatitis B #1 and should not be administered before age 24 weeks. d Only 1 dose of Tdap is recommended. Subsequent doses should be given as Td. For the brand of Tdap currently available in Korea, the minimum age is 11 years. For management of a tetanus-prone wound in persons who have received a primary series of tetanus-toxoid-containing vaccine, the minimum interval after a previous dose of any tetanus-containing vaccine is 5 years. e One dose of influenza vaccine per season is recommended for most persons. Children aged <9 years who are receiving influenza vaccine for the first time or who received only 1 dose the previous season (if it was their first vaccination season) should receive 2 doses this season. f The minimum age for inactivated influenza vaccine varies by vaccine manufacturer. See package insert for vaccine-specific minimum ages. g The minimum interval from Varicella #1 to Varicella #2 for persons beginning the series at age 13 years is 4 weeks. h A second dose of PPSV 5 years after the first dose is recommended for persons aged 65 years at highest risk for serious pneumococcal infection and those who are likely to have a rapid decline in pneumococcal antibody concentration. i Revaccination with meningococcal vaccine is recommended for previously vaccinated persons who remain at high risk for meningococcal disease. 이상간격을두고접종을다시시작한다. 여러번의접종이필요한백신의경우접종간격이미루어진다고해서예방효과가감소하지는않는다. 따라서 B 형간염예방접종을 1개월간격으로 2회시행한뒤 1년이지나서방문한경우라도이전접종력 (2회) 은유효하므로처음부터다시접종할필요는없고 3차접종만시행하면된다. 나. 서로다른백신의동시접종동시접종이란두가지이상의백신을같은날다른부위에한주사기에섞지않은상태로투여하는것을말한다. 대부분의생백신과불활성화백신은동시에접종하더라도각백신에대한항체반응이저하되거나이상반응이증가하지않으므로짧은기간동안여러개의백신을접종해야할때는동시접종을최대한활용하는것이좋다. 최근까지의연구결과를볼때피접종자의연령과백신의종류에 따라서 B형간염, 경구용폴리오, 주사용폴리오, 디프테리아-파상풍-개량백일해백신 (diphtheria and tetanus toxoids and acelluar pertussis, DTaP), 홍역- 볼거리 -풍진(measles- mumps-rubella, MMR), 수두, A형간염, b형헤모필루스인플루엔자 (Haemophilus influenzae type b, Hib) 백신은동시접종이가능하다. 단, 콜레라백신과황열백신을동시에접종하면두백신에대한항체생성률이모두떨어진다. 따라서콜레라백신과황열백신은서로 3주이상의간격을두고접종하여야한다. 두가지이상의백신을동시에접종할때에는서로다른주사기를이용해서다른부위에접종하여야한다. 또한같은사지에두가지이상의예방접종을할때는국소반응을구별하기위해주사부위는적어도 2.5-5 cm 이상떨어져야한다.
4 Korean J Health Promot Vol. 12, No. 1, 2012 다. 동시에접종하지않는서로다른백신의접종간격불활성화사백신과불활성화사백신, 불활성화사백신 과생백신은특별히지켜야할최소접종간격은없다. 그러나생백신과생백신은 4주이상의간격을두고접종하여 Table 3. Guidelines for administering antibody-containing products a and vaccines (Modified from General Recommendations on Immunization from National Centers for Immunization and Respiratory Diseases 4) ) b Type of administration Products administered Recommended minimum interval between doses Simultaneous (during the same office visit) Antibody-containing products and inactivated antigen Antibody-containing products and live antigen Can be administered simultaneously at different anatomic sites or at any time interval between doses Should not be administered simultaneously. c If simultaneous administration of measles-containing vaccine or varicella vaccine is unavoidable, administer at different sites and revaccinate or test for seroconversion after the recommended interval (see Table 4) Nonsimultaneous Administered first Administered second Antibody-containing products Inactivated antigen No interval necessary Inactivated antigen Antibody-containing products No interval necessary Antibody-containing products Live antigen Dose related c,d Live antigen Antibody-containing products 2 wk c a Blood products containing substantial amounts of immune globulin include intramuscular and intravenous immune globuline, specific hyperimmune globulin (e.g., hepatitis B immune globulin, tetanus immune globulin, varicella zoster immune globulin, and rabies immune globulin), whole blood, packed red blood cells, plasma, and platelet products. b Modified from table on page 38 in the General Recommendations on Immunization. c Yellow fever vaccine, rotavirus vaccine, oral Ty21a typhoid vaccine, live, attenuated influenza vaccine, and zoster vaccine are exceptions to these recommendations. d The duration of interference of antibody-containing products with the immune response to the measles component of measles-containing vaccine, and possibly varicella vaccine, is does related (see Table 4). Table 4. Recommended intervals between administration of antibody-containing products and measles- or varicella-containing vaccine, by products and indication for vaccination (Modified from General Recommendations on Immunization from National Centers for Immunization and Respiratory Diseases 4) ) a Recommended interval before Product/Indication Dose and route measles- or varicella-containing vaccine administration (mo) Tetanus IG 250 units (10 mg IgG/kg) IM 3 Hepatitis A IG Contact prophylaxis International travel 0.02 ml/kg (3.3 mg IgG/kg) IM 0.06 ml/kg (10 mg IgG/kg) IM 3 3 Hepatitis B IG 0.06 ml/kg (10 mg IgG/kg) IM 3 Rabies IG 20 IU/kg (22 mg IgG/kg) IM 4 Varicella IG 125 units/10 kg (20-39 mg IgG/kg) IM, maximum 625 units 5 Measles prophylaxis IG Standard (i.e., nonimmnunocompromised) contact Immunocompromised contact Blood transfusion RBCs, washed RBCs, adenine-saline added Packed RBCs (hematocrit 65%) Whole blood (hematocrit 35-50%) Plasma/platelet products 0.25 ml/kg (40 mg IgG/kg) IM 0.50 ml/kg (80 mg IgG/kg) IM 10 ml/kg, negligible IgG/kg IV 10 ml/kg (10 mg IgG/kg) IV 10 ml/kg (60 mg IgG/kg) IV 10 ml/kg (80-100 mg IgG/kg) IV 10 ml/kg (160 mg IgG/kg) IV Cytomegalovirus IG (intravenous) 150 mg/kg maximum 6 Intravenous IG Replacement therapy for immune deficiency ITP treatment Postexposure varicella prophylaxis Kawasaki disease 300-400 mg IgG/kg IV 400 mg/kg IV 1000 mg/kg IV 2 g/kg IV 8 8 10 11 Monoclonal antibody to RSV F protein 15 mg/kg IM None Abbreviations: IG, immune globulin; IgG, immune globulin G; IM, intramuscular; RBCs, red blood cells; IV, intravenous; ITP, immune thrombocytopenic purpura; RSV, respiratory syncytial virus. a Modified from table on page 39 in the General Recommendations on Immunization. 5 6 None 3 6 6 7
Sunmi Yoo. General Recommendations and Recent Update in Adult Immunization 5 야한다. 예를들어 MMR과수두백신은동시에접종할수있으나, 동시접종을하지못하였을때에는 4주간의간격을두고접종하여야한다. 홍역백신단독접종후황열백신은 4주이내에접종해도상관없다. 그러나일본뇌염생백신과다른생백신은동시에접종할수없다. 경구용생백신 (Ty21a 장티푸스백신, 경구용폴리오백신등 ) 과인플루엔자생백신은주사용활성화사백신또는생백신과지켜야할간격이없다. 또한경구용생백신과인플루엔자생백신끼리도특별히지켜야할간격은없다. 라. 면역글로불린및수혈과백신접종 (Table 3, 4) 특정질환의면역글로불린은생백신에대한면역반응을저하시키는항체를가지고있을가능성이있다. 따라서혈액제제 (whole blood, packed red blood cells, plasma) 나항체를포함하는제제 (antibody-containing products: 면역글로불린, 과다면역글로불린, 정주용면역글로불린등 ) 를투여하였다면항체가파괴될때까지생백신투여를연기하여야한다. 생백신중에서경구용장티푸스백신 (Ty21a typhoid), 인플루엔자생백신, 로타바이러스백신, 황열백신등은항체를포함하는제제투여전, 후또는동시에접종해도문제가되지않는다. MMR 이나수두백신접종후에항체를포함하는제제투여가필요한경우에도면역반응에대한방해가일어날수있다. 백신바이러스의복제와면역반응자극은백신접종후 1-2주에일어나기때문에백신접종후항체를포함하는제제투여까지 14일미만의간격이있었다면적절한시간이경과한후에재접종해야한다. 생백신에비해불활성화사백신, 톡소이드, 다당류백신은항체를포함하는제제와잘반응하지않으므로별문제없이동시또는전, 후에투여할수있다. 단, 투여부위는달라야한다. 3) 면역력이변화한사람의예방접종면역억제 (immunosuppression) 또는면역약화 (immunocompromise) 상태에있는사람은감염에취약하기때문에인플루엔자백신이나폐렴사슬알균백신등특정예방백신이권장된다. 면역억제또는면역약화는일차적인면역결핍 (immunodeficiency) 과다른원인에의한이차적인면역결핍으로구분할수있다. 일차적인면역결핍은면역력을제공하는체액면역이나세포면역력이없거나양적으로부족한경우이며대부분유전질환이다. 선천성면역결핍질환인 X-linked agammaglobulinemia, chronic granulomatous disease 등이그예이다. 이차적인면역결핍은다른질병의경과또는치료때문에체액면역이나세포면역력을상실하거나양적으로부족해지는경우로대부분후천적이다. HIV 감염, 조혈계악성종양, 방사선치료, 알킬화약물 (alkylating agents) 또는항대사물질 (antimetabolites) 등의면역억제제로치료한경우가그예이다. 무비증, 만성신질환, 단일클론항체약제치료 (tumor necrosis factor inhibitors), 장기간의고용량스테로이드치료도면역결핍상태에해당한다. 면역력이변화한경우에는예방접종의효과가감소할수있다. 면역기능이회복될때까지생백신접종은연기하는것이좋다. 불활성화사백신을면역력이변화한기간에투여하였다면면역기능이회복된뒤에다시접종해야한다. 약독화생백신접종후에병원체의비억제복제때문에부작용위험도증가한다. 면역억제정도는의사가판단한다. 체액면역이나세포면역에영향을미치는질병이나약물이무엇인지파악하고, 특정백신이필요한경우나사용에주의가필요한지를추론하여결정한다. 판단이어려울때는감염질환이나면역학의전문가에게상의하는것이좋다. 면역상태를평가하는검사실검사를시행하여판단에도움을받을수있다. 체액면역평가에는면역글로불린과혈청항체가 ( 파상풍, 디프테리아 ), 세포면역상태는림프구수 (CBC with differential), B/T 림프구, CD4+/CD8+ T 림프구, lymphocyte proliferation assay 등을검사할수있다. 면역력이변화한사람에게는일반적으로인플루엔자사백신, 연령에적합한다당질백신 ( 폐렴사슬알균백신, 수막알균백신, Hib 등 ) 접종을권장한다 (Table 5). 면역력이변화한사람을접촉하는가족이나다른접촉자는두창백신을제외한대부분의백신접종이가능하다. MMR 백신바이러스는접촉으로전염되지않으며수두백신의전파는가능하나매우드물다. 1 불활성화백신전세포백신, 세포분획백신, 톡소이드, 다당질, 다당질단백결합백신등어떤형태의불활성화백신이라도면역력이변화한사람에게안전하게투여할수있다. 접종시에는통상적인용량과접종간격을지키면되지만그효과가적정선이하일수있다. 불활성화인플루엔자백신을제외하면항암요법이나방사선치료를받는동안에는항체반응이잘나타나지않을수있으므로예방접종을하지않는것이낫다. 면역억제치료중이거나치료시작하기전 14일이내에접종을했다면치료후 3개월이상경과하여면역상태가정상으로돌아간뒤에재접종한다. 2 생백신면역력이변화한사람에게생백신을접종하면심각한합병증이발생할수있기때문에생백신인비씨지 (bacille Calmette Guerin, BCG), MMR, 수두, Ty21a typhoid, 로타바이러스, 황열, 인플루엔자생백신, 대상포진백신접종을하지않아야한다.
6 Korean J Health Promot Vol. 12, No. 1, 2012 Table 5. Vaccination of persons with primary and secondary immunodeficiencies (Modified from General Recommendations on Immunization from National Centers for Immunization and Respiratory Diseases 4) ) a Primary Specific immunodeficiency Contraindicated vaccines b Risk-specific recommended vaccines b B-lymphocyte (humoral) T-lymphocyte (cell-mediated and humoral) Complement Phagocyte function Severe antibody deficiencies (e.g., X-linked agammaglobulinemia) Less severe antibody deficiencies (e.g., selective IgA deficiency and IgG subclass deficiency) Complete defects (e.g., severe combined immunodeficiency [SCID] disease, complete DiGeorge syndrome) Partial defects (e.g., most patients with DiGeorge syndrome, Wiskott- Aldrich syndrome, ataxia- telangiectasia) Persistent complement, properdin, or factor B deficiency Chronic gramulomatous disease, leukocyte adhesion defect, and myeloperoxidase deficiency LAIV BCG Ty21a (oral, live) Yellow fever BCG Yellow fever Other liver vaccines appear to be safe Consider measles and varicella vaccination Effectiveness and comments The effectiveness of any vaccine is uncertain if it depends only on the humoral response (e.g., PPSV, MPSV4) IGIV interferes with the immune response to measles vaccine and possibly varicella vaccine All vaccines likely effective; immune response might be attenuated All live vaccines c,d,e Vaccines might be ineffective All live vaccines c,d,e None Secondary HIV/AIDS BCG LAIV Withhold MMR and varicella in severely immunocompromised persons Yellow fever vaccine might have a contraindication or a precaution depending on clinical parameters of immune function g Malignant neoplasm, transplantation, immunosuppressive or radiation therapy Meningococcal Hib (if not administered in infancy) Meningococcal Effectiveness of any vaccine depends on degree of immune suppression All routine vaccines likely effective Live bacterial vaccines c f All inactive vaccines safe and likely effective Live viral vaccines likely safe and effective Consider Hib (if not administered in infancy) and meningococcal vaccination MMR, varicella, rotavirus, and all inactivated vaccines including inactivated influenza, might be effective h Live viral and bacterial, depending Effectiveness of any vaccine on immune status c,d depends on degree of immune suppression Asplenia None Meningococcal Hib (if not administered in infancy) Chronic renal disease LAIV Hepatitis B i All routine vaccines likely effective All routine vaccines likely effective Abbreviations: LAIV, live, attenuated influenza vaccine; BCG, bacilli Calmette-Guerin; PPSV, pneumococcal polysaccharide vaccine; MPSV4, quadrivalent meningococcal polysaccharide vaccine; IGIV, immune globulin intravenous; IgA, immune globulin A; IgG, immune globulin G; HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency syndrome; Hib, Haemophilus influenzae type b; MMR, measles, mumps, and rubella. a Modified from table on page 48 in the General Recommendations on Immunization. b Other vaccines that are universally or routinely recommended should be given if not contraindicated. c Live bacterial vaccines: BCG and oral Ty21a Samonella Typhi vaccine. d Live viral vaccines: MMR, LAIV, yellow fever, zoster, rotavirus, and varicella. e Regarding T-lymphocyte immunodeficiency as a contraindication for rotavirus vaccine, data exist only for severe combined immunodeficiency. f vaccine is not indicated for children with chronic granulomatous disease beyond age-based universal recommendations for pneumococcal conjugate vaccine. Children with chronic granuolmatous disease are not at increased risk for pneumococcal disease. g Symptomatic HIV infection or CD4+ T-lymphocyte count of <200/mm 3 or <15% of total lymphocytes for children aged <6 years is a contraindication to yellow fever vaccine administration. Asymptomatic HIV infection with CD4+ T-lymphocyte count of 200-499/mm 3 for persons aged 6 years or 15-24% of total lymphocytes for children aged <6 years is a precaution for yellow fever vaccine administration. h HIV-infected children should receive immunoglobulin after exposure to measles and may receive varicella and measles vaccine if CD4+ T-lymphocyte count is 15%. i Indicated based on the risk from dialysis-based bloodborne transmission.
Sunmi Yoo. General Recommendations and Recent Update in Adult Immunization 7 4) 특별한경우의예방접종가. 조혈모세포이식치료조혈모세포이식치료는조혈모세포이식전처치, 이식편대숙주반응 (graft versus host disease) 의예방 / 치료를위해사용하는약물, 조혈모세포이식이필요한기존질환때문에면역억제상태를초래한다. 자가이식또는동종이식후에는재접종을받지않으면백신으로예방하는질병 ( 파상풍, 폴리오, 홍역, 볼거리, 풍진, 피막을가진세균인폐렴사슬알균, 수막알균, Hib 감염 ) 의항체가가 1-4년간에걸쳐감소한다. 따라서조혈모세포이식을받은사람은연령에무관하게, 줄기세포가본인의것이든공여자의것이든무관하게재접종을받아야한다. 그러나예방접종을받지않은조혈모세포수용자에비해접종을받은사람에게서감염이감소하였다는근거는아직까지는제한적이며간접적이다. 1 인플루엔자사백신 : 이식후적어도 6개월경과후에시작하여매년접종한다. 이식후 4개월이내에접종했거나처음으로인플루엔자접종을받는어린이는 2회접종을받아야한다. 2 폐렴사슬알균백신 : 이식후 3-6개월이후부터폐렴사슬알균단백결합백신을 3회접종하고다당질백신을 1회더접종한다. 단백결합백신은다당질백신에비해항체생성률이높지만적은혈청형 (7/10/13 가 vs. 23가 ) 을포함하고있기때문이다. 3 Hib 백신 : 이식후 6개월이상경과한후에 3회접종한다. 4 MMR 백신 : 이식후 24개월에조혈모세포수용자의면역능이회복되었을때접종한다. 5 DTaP 백신 : 이식후 6-12개월에 DTaP 3회접종을선호한다. 디프테리아톡소이드용량을줄이면항체반응이약화될수있고, 용량을줄인백일해백신을사용한경우에도항체반응이낮았다는보고가있기때문이다. 성인에서 DTaP 사용이허가되지않은경우에는성인형파상풍- 디프테리아-개량백일해백신 (tetanus toxoid and reduced diphtheria toxoid, and acellular pertussis, Tdap) 을접종한다. 6 수두백신 : 조혈모세포이식환자에서수두백신접종이많이시행되지않았기때문에각환자의감염위험을평가하여시행을고려한다. 접종을한다면이식후 24개월이후에시행한다. 대상포진백신은바이러스역가가높기때문에사용을금한다. 7 B형간염백신 : 이식후 6-12개월에일반인처럼유전자재조합백신을 3회접종한다. HBsAg 양성이거나 HBcAb 양성인수용자의경우접종을하면역혈청전환의위험을줄일수있다. 나. 무비증선천적으로비장이없거나수술로제거한해부학적무비증과기능적무비증이있을때피막이있는세균인폐렴사슬알균, 수막알균, Hib 감염의위험이증가한다. 비장절제술을시행할예정인경우적어도 14일이전에접종을시행해야한다. 수술전에접종을하지못했다면환자의상태가안정된후에가급적빨리접종한다. 1 폐렴사슬알균백신 : 5세미만의어린이가무비증에해당하면단백결합백신을이용하여연령에맞게접종하고, 2세이상인경우다당질백신을 5년간격으로 2회접종한다. 2 수막알균백신 : 2012 년에국내도입될예정이며백신종류에따라허가연령이다르기때문에확인후접종을권유한다. 수막알균접종후면역이지속되는기간은확실하지않지만고위험군인사람에게는재접종이필요하다. 2-6 세사이에 1차접종을받은고위험군소아는 3년후에재접종한다. 7세이후에 1차접종을받은고위험군소아는 5년후에재접종을권유한다. 3 Hib 백신 : 59개월이상의소아및성인에서 Hib 감염의위험이증가하는만성질병이있을때시행하는예방접종의효과에대한자료는아직없지만전에 Hib 백신을받지않았던사람에게 1회접종을고려한다. 다. 단일클론항체치료를받은경우특히항종양괴사인자치료제인 adalimumab, infliximab, etanercept 등을사용하면잠재된결핵감염과결핵에의한질병이활성화될수있으며다른기회감염도증가하므로이런약제를사용하는사람에게생백신을사용할때는주의가필요하다. 라. 스테로이드치료원래정상면역기능을가진사람에게서면역저하를유발하는스테로이드용량과투여기간이확실하게정해진것은아니다. 일반적으로체중 10 kg 이상인사람에게체중 1 kg당 2 mg 이상또는하루 20 mg 이상의 prednisolone을 14일이상사용하면면역저하상태가되어생백신투여시안전성에문제가있을것으로볼수있다. 1) 단기간 (14일미만 ), 2) 저용량또는중간용량 ( 하루 prednisolone 20 mg 미만 ) 사용시, 3) 작용기간이짧은속효성스테로이드를격일로장기간사용시, 4) 생리적용량을유지요법으로사용시, 5) 국소 ( 피부, 눈 ), 흡입, 관절강내, 윤활낭, 힘줄에주입하는치료중일때는바이러스생백신투여의금기가아니다. 마. 결핵반응검사홍역, 심한급만성감염, HIV 감염, 영양불량상태일때투베르쿨린피부반응검사를하면 anergy state가되어위음
8 Korean J Health Promot Vol. 12, No. 1, 2012 성결과를보일수있다. 홍역예방접종 ( 또는 MMR) 을하면이론적으로투베르쿨린피부반응검사의반응을억제할수있으나실제홍역감염일때보다는덜억제할것으로생각된다. 피부반응검사가필요할때는홍역예방접종과동시에시행하고 48-72 시간후에결과를판독하는것이가장좋다. 최근에홍역예방접종을한경우에는 4주이상피부반응검사를연기한다. 결핵이의심되면홍역예방접종을시행하지않는다. 피부반응검사가수두백신이나황열백신에미치는영향에대해서는자료가불충분하지만홍역예방접종에대한가이드라인에준하여시행하되이론적인가능성때문에예방접종시기를놓치지않도록주의해야한다. 바. 백신성분에대한알레르기알레르기반응은백신항원, 남아있는동물단백질 ( 예, 계란 ), 항생제 ( 예, 네오마이신 ), 보존제 ( 예, 치메로살 ), 기타백신성분 ( 예, 젤라틴 ) 에의해일어날수있다. 인플루엔자백신과황열백신생산에사용되는계란에대한알레르기가가장흔하다. 일반적으로계란이나계란으로만든음식을먹을수있고이전에인플루엔자접종을안전하게받았다면백신접종이가능하고, 아나필락시스반응이있었던사람은접종을금한다. 계란과민성이있더라도알레르기전문가의감독하에백신성분으로피부반응검사를시행해보거나백신용량의 1/10을먼저투여하고 30분간관찰한뒤나머지용량을투여함으로써심각한부작용없이인플루엔자접종을시행한보고가있으므로예방접종으로얻는이득이클것으로예상되는경우에는시행할수있다. 5) 사. 출혈경향이있는사람출혈경향이있는사람에게백신을근주하면혈종발생의위험이증가하기때문에근주대신피하주사또는피내주사를시행하는경우가있다. 그러나연구에따르면혈우병이있는환자에게 B형간염백신을접종할때 23게이지미만의주사기를사용하고주사후 1-2분간꽉누르도록했을때멍이든경우도적었고 (4%) 응고인자를보충하는치료가필요한경우도없어안전하였다. 따라서투여방법을바꾸지말고근주하되의사가출혈위험을판단하여접종을하고가능하면출혈경향에대한치료제를사용한직후에접종하는것을고려한다. 5) 예방접종금기사항 (contraindication) 과주의해서접종해야하는경우 (precaution) (Table 5) 가. 예방접종의금기사항백신접종의심각한이상반응발생위험이높은경우로, 백신접종을하지말아야한다. 모든백신에적용할수있는금기사항은이전백신접종후또는백신의성분에대 해아나필락시스 (anaphylaxis) 와같은심한알레르기반응이있었던경우뿐이다. 그외에도심각한면역약화상태에있거나임신한경우에는생백신을접종하면안된다. 백일해백신 (DTP, DTaP, Tdap) 접종후 7일이내에원인을알수없는뇌증 (encephalopathy) 이발생한경우에는백일해백신성분이포함된예방접종을하지말아야한다. 나. 주의해서접종해야하는경우백신접종의심각한이상반응발생위험이증가할수있거나면역형성이잘안되는경우를말한다. 수혈로홍역에대한수동면역이생긴사람에게홍역백신을접종하거나, 이전인플루엔자백신접종후 6주내에길랑- 바레증후군이발생했던경우등이이에해당한다. 이때는백신접종을미루는것이좋지만백신에서얻는이득이이상반응의위험을능가한다면접종을할수있다. 예를들면이전에 DTaP 백신접종후길랑 -바레증후군이발생했던사람이라도지역사회에백일해가유행하고있다면 DTaP 를접종할수있다. 중등도및중증급성질병이있을때 ( 열이있든없든 ) 도모든백신에대해주의해서접종해야하는경우이다. 설사, 가벼운상기도감염, 이전접종후경도및중등도국소부작용발생, 항생제치료중이거나급성질병의회복기는금기사항이아니며증상의심각도나원인등환자의상태를판단하여예방접종을시행할수있다. 가벼운상기도감염때문에예방접종을연기하지않는것이좋다. 금기사항이나주의해서접종해야하는경우에해당하는지예방접종전에예진설문지를이용하여확인할수있다 (Table 6). 그러나건강해보이는사람에게접종전신체진찰이나체온측정이반드시필요한것은아니다. 본인이나보호자에게접종당사자가아픈지물어보고중등도또는중증질병이있으면접종을연기한다. 6) 예방접종후이상반응접종후에생길수있는이상반응은국소이상반응, 중추신경계를포함한전신이상반응과알레르기성이상반응으로나눌수있다. 국소이상반응이가장많지만경미하고, 알레르기성이상반응은발생이가장적으나심각할수있다. 국소이상반응은접종부위의통증, 종창, 발적등이며주로사백신접종후수시간에나타난다. 전신이상반응은발열, 권태감, 근육통, 두통, 식욕부진등이며사백신보다는생백신접종 1-3주 ( 백신바이러스잠복기 ) 후에나타난다. 알레르기성이상반응은백신항원, 세포배양물질, 안정제, 보존제또는항생제등백신성분에의하여나타나며, 심한알레르기성이상반응은 1/500,000-1,000,000 도스접종미만의빈도로매우드물지만치명적일수있다. 백신접종후혈관미주신경실신이발생할수있는데, 청
Sunmi Yoo. General Recommendations and Recent Update in Adult Immunization 9 Table 6. Contraindications and precautions a to commonly used vaccines for adults (Modified from General Recommendations on Immunization from National Centers for Immunization and Respiratory Diseases 4) ) b Vaccine Contraindications Precautions Td Tdap MMR c Severe allergic reaction (e.g., anaphylaxis) after a previous Severe allergic reaction (e.g., anaphylaxis) after a previous Encephalopathy (e.g., coma, decreased level of consciousness, or prolonged seizures), not attributable to another identifiable cause, within 7 days of administration of previous dose of DTP, DTaP, or Td Severe allergic reaction (e.g., anaphylaxis) after a previous Pregnancy Known severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, or long-term immunosuppressive therapy d or patients with HIV infection who are severely immunocompromised) c GBS <6 weeks after previous dose of tetanus toxoid-containing vaccine History of arthus-type hypersensitivity reactions after a previous dose of tetanus toxoid-containing vaccine; defer vaccination until at least 10 years have elapsed since the last tetanus toxoid-containing vaccine GBS <6 weeks after previous dose of tetanus toxoid-containing vaccine Progressive neurologic disorder, including infantile spasms, uncontrolled epilepsy, progressive encephalopathy; defer DTaP until neurologic status clarified and stabilized History of arthus-type hypersensitivity reactions after a previous dose of tetanus toxoid-containing vaccine; defer vaccination until at least 10 years have elapsed since the last tetanus toxoid-containing vaccine Recent ( 11 mo) receipt of antibody-containing blood product (specific interval depends on product) e History of thrombocytopenia of thrombocytopenic purpura Need for tuberculin skin testing f Hib Severe allergic reaction (e.g., anaphylaxis) after a previous Hepatitis B Severe allergic reaction (e.g., anaphylaxis) after a previous Hepatitis A Severe allergic reaction (e.g., anaphylaxis) after a previous Pregnancy Varicella Severe allergic reaction (e.g., anaphylaxis) after a previous Pregnancy Recent ( 11 mo) receipt of antibody-containing blood product (specific interval depends on product) g Known severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, or long-term immunosuppressive therapy d or patients with HIV infection who are severely immunocompromised) c Inactivated influenza vaccine Severe allergic reaction (e.g., anaphylaxis) after a previous GBS <6 weeks after previous dose of influenza vaccine Live, attenuated influenza Severe allergic reaction (e.g., anaphylaxis) after a previous GBS <6 weeks after previous dose of influenza vaccine vaccine Pregnancy Immunosuppression Certain chronic medical conditions h PPSV, MCV4, Severe allergic reaction (e.g., anaphylaxis) after a previous MPSV4 HPV Severe allergic reaction (e.g., anaphylaxis) after a previous Pregnancy Zoster Severe allergic reaction (e.g., anaphylaxis) after a previous Substantial suppression of cellular immunity Pregnancy Abbreviations: Td, tetanus and diphtheria toxoid; GBS, Guillian-Barre syndrome; Tdap, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; DTP, diphtheria toxoid, tetanus toxoid, and pertussis; DTaP, diphtheria and tetanus toxoids and acelluar pertussis; MMR, measles, mumps, and rubella; Hib, Haemophilus influenzae type b; PPSV, pneumococcal polysaccharide vaccine; MCV4, quadrivalent meningococcal conjugate vaccine; MPSV4, quadrivalent meningococcal polysaccharide vaccine; HPV, human papillomavirus. a Events or conditions listed as precautions should be reviewed carefully. Benefits of and risks for administering a specific vaccine to a person under these circumstances should be considered. If the risk from the vaccine is believed to outweigh the benefit, the vaccine should not be administered. If the benefit of vaccination is believed to outweigh the risk, the vaccine should be administered. b Modified from table on page 40-1 in the General Recommendations on Immunization. c MMR and varicella vaccines can be administered on the same day. If not administered on the same day, these vaccines should be separated by at least 28 days. d Substantially immunosuppressive steroid dose is considered to be 2 weeks of daily receipt of 20 mg or 2 mg/kg body weight of prednisolone or equivalent. e See text and Table 4 for details. f Measles vaccination might suppress tuberculin reactivity temporarily. Measles-containing vaccine can be administered on the same day as tuberculin skin testing. If testing cannot be performed until after day of MMR vaccination, the test should be postponed for 4 weeks after the vaccination. If an urgent need exists to skin test, do so with the understanding that reactivity might be reduced by the vaccine. g Vaccines should be deferred for the appropriate interval if replacement immune globulin products are being administered (see Table 4). h Asthma, chronic lung diseases, cardiovascular diseases (except simple hypertension), kidney diseases, liver diseases, neuromuscular diseases, hematologic disorders, metabolic diseases.
10 Korean J Health Promot Vol. 12, No. 1, 2012 소년및성인에게흔히발생한다. 미국백신이상반응보고시스템에따르면인유두종바이러스백신, 수막알균백신 (quadrivalent meningococcal vaccine, MCV4), Tdap 허가후실신이증가하는경향이있었다. 실신후두개골골절이나뇌출혈등의이차손상이발생할수있으므로예방을위한주의가필요하다. 청소년및젊은성인은앉거나누워서접종을하고, 접종후에는어지러운증상이있는지 15 분정도병원에서관찰하다가귀가하는것이바람직하다. 아나필락시스반응은드물지만일단발생하면치명적일수있으므로신속하게대처하기위해서는백신접종시응급장비, 산소, 에피네프린등의약품이항상준비되어있어야한다. 아나필락시스는보통접종후수분내에발생하므로빨리진단하여처치하는것이중요하다. 안면홍조및부종, 두드러기, 가려움증, 구강및목부종, 천명음, 호흡곤란등의증상이나증후가있으면환자의다리를올린자세로눕힌다. 에피네프린이일차치료제이며, 성인은 1:1000 용액을 0.01 mg/kg 에서시작하여 0.5 mg 까지 (0.01 ml/kg/dose 에서시작하여 0.5 ml 까지 ) 10-20 분마다 3회까지근주한다. 주사부위의발적이나부종, 발열, 근육통, 피부발진등은백신종류에따라다르지만비교적흔히발생할수있다. 대부분 24-48시간내에저절로없어지기때문에특별한치료가필요하지는않으나증상완화를위해 acetaminophen이나항히스타민제를사용할수있다. 2. 최근에국내에도입되었거나도입예정인백신 1994년대한가정의학회에서발간한 < 성인예방접종 > 에 서국내최초로성인예방접종에대한체계적인접근이시작되었다. 1) 최근성인예방접종의중요성이부각되면서 2006년질병관리본부-대한의사협회의권장안이발표되었고 3) 2011년개정판이발간될예정이다. 대한감염학회에서도최근경향과국내의감염질환실태, 예방접종현황을감안하여 2007년에성인예방접종권고안을발표하였다 (Table 7). 2) 이를바탕으로성인예방접종의주요각론에대해서는이미다루어졌으므로 6) 여기서는최근에국내에도입되었거나도입예정인백신에대해소개한다. 1) 인플루엔자백신그간국내에서사용해온불활성화사백신은유행바이러스와항원이일치할경우 65세미만성인에서 70-90% 정도의인플루엔자예방효과를보인다. 노인에대한예방효과는이보다는적어 60세이상지역사회거주노인에대한무작위대조군연구에따르면 58% 의인플루엔자예방효과가있었고요양원거주노인에서는 20-40% 의급성호흡기질환예방효과를보였다. 7) 노인에서의면역원성을강화하기위해면역증강제인 MF59를포함한백신 (FLUAD, Norvatis Korea, Seoul, Korea) 이 2009년부터국내에출시되었고면역원성강화와접종편이를위해제작된피내접종백신 (ID FLU, Sanofi Pasteur Korea, Seoul, Korea) 이 2010년도입되어국내에서사용할수있다. 2-49 세의면역기능이정상인사람에게코에분무하는생백신도 2009년에도입되었다. 8) 새로운인플루엔자백신의면역원성과안정성에대한자료가계속축적되면다양한인플루엔자백신을사용할수있을것이다. Table 7. Current adult immunization schedule recommended by Korean Society of Infectious Diseases 2007 (From Vaccination for Adult 2) ) Vaccine Age, y 19-29 30-39 40-49 50-64 65 All adults Td 1 dose every 10 years 1 dose every 10 years after completion of a primary series (3 doses: 0, 1, 6-12 months) Adult pertussis (Tdap) Substitute 1 dose of Tdap for Td Vaccination for young adults HAV 2 doses Anti-HAV IgG HBV Anti-HBs Ab and HBsAg Measles/mumps/rubella a Anti-mumps Ab (anti-rubella IgG in women) Varicella a Anti-VZV IgG Human Papilloma virus Women ( 26 y) Menigococcal b Military recruits Vaccination for elderly Influenza Annually 1 dose Abbreviations: Td, tetanus and diphtheria toxoid; Tdap, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; HAV, hepatitis A; IgG, immune globulin G; HBV, hepatitis B; HBs Ab, hepatitis B surface antibody; HBsAg, hepatitis B surface antigen; VZV, varicella zoster virus. a Primarily indicated to persons at risk for acquisition or transmission. b Currently not available in Korea.
Sunmi Yoo. General Recommendations and Recent Update in Adult Immunization 11 2) Tdap 백일해는적극적인백신접종으로발생이많이감소하였지만미국의보고에의하면 1980년대이후청소년과성인을중심으로발생이증가하는추세이다. 청소년은백일해보균원으로작용하여합병증및사망위험이높은영아 ( 특히백일해에대한면역생성전 ) 에게감염을전파시키는역할을한다. 성인용파상풍 -디프테리아톡소이드 (tetanus and reduced diphtheria toxoids, Td) 에개량백일해백신 (acellular pertussis vaccine) 을추가한 Tdap은청소년과성인의백일해유병률을감소시키고영유아에게감염전파를막기위해도입되었다. 국내에는 2009년이후성인용흡착디프테리아파상풍톡소이드및정제백일해혼합백신 (Adacel TM, Sanofi Pasteur Korea; Boostrix, GlaxoSmithKline, Seoul, Korea) 이 11-64 세청소년및성인에게사용되고있다. 1회의 Tdap 접종에대한항체반응은영아의 DTaP 3회접종과비슷하며임상효과도비슷하다고판단되어 Tdap 는 1회만접종한다. 11-18 세청소년이소아기에시행하는 DTaP 5회를모두완료한경우 Td 대신에 Tdap를 1회접종한다. 11-18 세청소년이 Td를접종받았는데백일해에대한예방접종이불완전한경우 Tdap를사용하여따라잡기접종을시행한다. 1세미만의고위험군과접촉이예상되는성인에게접종을권고하는데, DTaP 접종력이없는성인은 Td 0.5 ml을 4-8주간격으로 2회접종하고, 2차접종후 6-12개월에 3차접종을시행하면되고, 이중한번은 Tdap으로접종하면된다. 상처를입은후파상풍예방이필요할때 Td 대신에 Tdap을 1회접종할수있다. 과거에는마지막 Td 백신접종후 2년이내접종을피할것을권장했지만, 최근권고안에서는백일해예방이더중요하다면간격제한이필요없고국소부작용증가에대해설명한뒤접종하도록권고한다. 9) 과거에는임신중태아에대한안전성이확보되지않았고임신부에게 Tdap을접종하면태반을통해태아에게항체가전달되어출생후 DTaP 접종시항체생성이억제될수있다는가능성때문에가급적임신전이나분만직후에접종하는것을권장하였다. 그러나 2011년미국 ACIP는임신중 Tdap 접종의안전성을확인하였고, 임신부가 Tdap을접종한경우출생한아기의항백일해항체생성이약화되지만감염예방효과는충분하기때문에신생아의백일해감염예방을위하여재태 20주이후 ( 임신 2-3분기 ) 에 Tdap 접종을권고한다. 10) 수유중에도접종이가능하다. 3) 대상포진백신국내연구에따르면대상포진의유병률은인구 1,000명당 7.9-12.5명이며 70대에서가장발생빈도가높다. 대상포진및포진후신경통예방을위해개발된대상포진백신 (Zostavax, Merck South Korea, Seoul, Korea) 은 2011년에국내에도입되었고 50세이상을대상으로허가를받아발매될예정이다. 60세이상을대상으로대상포진백신의효능에대한 3상임상연구에서대상포진발생감소 (51.3%) 및포진후신경통감소 (66.5%) 효과가있었다. 11) 그러나국내에대상포진백신을적용할때백신의효능및효과에대한자료가없고, 대상포진백신이비용-효과적인지에대해서는아직논란의여지가있다. 생백신으로 1회상완에피하주사하며, 대상포진을앓은적이있는사람에게도접종할수있다. 그러나수두백신접종을받은사람에게는접종하지않는다. 4) 수막알균백신수막알균에의한패혈증을예방하기위하여고위험군에게접종을권장한다. 수막알균감염의고위험군은대학기숙사거주신입생, 수막알균을통상다루는미생물실험실담당자, 신입훈련병, 수막알균이유행인지역여행자나체류자 ( 아프리카수막염벨트여행자, 사우디아라비아메카순례여행자포함 ), 비장절제또는기능저하인경우, 보체결핍질환이있을때, 유행시뇌수막염에노출된사람등이다. 국내수막알균감염의역학에대한자료가적어적절한적응대상이정해지지않은상태이다. 미국 ACIP 에서는 11-12세청소년에게기초접종을하고 16세에추가접종을권장한다. 미국의경우 17-20세에감염위험이높으며, 1회접종을한경우 5년이상경과하면면역력이감소하기때문에감염위험에계속노출된경우추가접종이필요하기때문이다. 기초접종은 1회시행하나보체결핍, 비장절제또는기능저하인경우, HIV 감염자는기초접종으로 2 개월간격 2회접종을권고한다. 12) 국내에서는 2011년군훈련소에서발생한패혈증때문에관심이높아져서곧백신도입이예상된다. 현재국내에서유통되지않지만희귀의약품센터를통해단백결합백신 (Menveo, Novartis Korea, Seoul, Korea) 을구입하여접종할수있다. 다른단백결합백신 (Menactra, Sanofi Pasteur Korea, Seoul, Korea) 도 2012년에국내시판될예정이다. 8) 둘다 4개의혈청군 (A, C, Y, W-135) 을포함하는 4가백신이다. 단백결합백신은 0.5 ml 근육주사하며접종후 7-10 일이면항체가형성된다. 국내에서유행하는수막알균감염질환의혈청군에대한역학자료가거의없고, 수막알균백신은비용에비해효과가낮은편이기때문에일반적인백신접종의기대효과는판단하기어렵다. 결 론 2011 년미국 ACIP 에서발표한예방접종에대한전반적
12 Korean J Health Promot Vol. 12, No. 1, 2012 인권고안을중심으로성인예방접종에서적용할수있는원칙을기술하였다. 구체적으로백신의접종간격, 면역글로불린및수혈과백신접종, 면역력이변화한사람의예방접종, 특별한임상상황에서의예방접종, 예방접종금기사항과주의해서접종해야하는경우, 예방접종후이상반응에대한내용이포함되었다. 또최근국내에도입되었거나도입될것으로예상되는다양한인플루엔자백신, 성인용파상풍 -백일해-디프테리아백신, 수막알균백신, 대상포진백신에대해간단히소개하였다. 이글에서다루어지지않은예방접종의원칙이나구체적인예방접종에대해서는대한감염학회의 성인예방접종 ( 제2판, 2012) 과 2011년말에발간된질병관리본부의 예방접종대상전염병의역학과관리 를참고하기바란다. 요약 연구배경 : 예방접종은백신으로예방할수있는질병발생및합병증을예방하기위한 1차예방전략이다. 국내에서성인예방접종은주로소아를대상으로시행되었지만 2000년대이후백신으로예방할수있는질병이유행하면서성인예방접종의중요성이새롭게부각되었다. 그러나백신접종에일반적으로적용하는최신원칙에대해서는강조되지않았다. 방법 : 2011년미국예방접종자문위원회에서발표한예방접종에대한전반적인권고안을중심으로성인예방접종에서적용할수있는원칙을기술하였다. 또최근국내에도입되었거나도입될것으로예상되는백신에대해간단히소개하였다. 결과 : 2011년미국예방접종자문위원회에서발표한예방접종에대한전반적인권고안에따라백신의접종간격, 면역글로불린및수혈과백신접종, 면역력이변화한사람의예방접종, 특별한임상상황에서의예방접종, 예방접종금기사항과주의해서접종해야하는경우, 예방접종후이상반응에대한내용이포함되었다. 그동안사용되었던인플루엔자사백신외에다양한인플루엔자백신, 성인용파상풍-백일해- 디프테리아백신, 수막알균백신, 대상포진백신에대한정보를소개하였다. 결론 : 예방접종의일반적인원칙과최근도입된다양한백신에대한정보를숙지함으로써의료인들이최신원칙에입각한예방접종을시행하는데도움이될것으로기대한다. REFERENCES 1. The Korean Academy of Family Medicine. Vaccination for Adults. Seoul:Gimm-Young Publishers, Inc;1994. 2. The Korean Society of Infectious Diseases. Vaccination for Adult. Seoul:Koonja Publishing, Inc;2007. 3. Korea Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable disease. Seoul: Korea Centers for Disease Control and Prevention. 2006. http://nip. cdc.go.kr/reference.do?mnlv1=2. Accessed December 16, 2011. 4. National Centers for Immunization and Respiratory Diseases. General recommendations on immunization --- recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2011;60(2):1-64. 5. Gruenberg DA, Shaker MS. An update on influenza vaccination in patients with egg allergy. Curr Opin Pediatr 2011;23(5): 566-72. 6. Yoo S. Recent Update in adult immunization. Korean J Fam Med 2010;31(5):345-54. 7. Fiore AE, Uyeki TM, Broder K, Finelli L, Euler GL, Singleton JA, et al; Centers for Disease Control and Prevention (CDC). Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Recomm Rep 2010;59(RR-8):1-62. 8. Choi JH. Newly introduced vaccines. 2011 Annual Meeting of the Korean Society of Infectious Diseases and the Korean Society for Chemotherapy. Seoul: the Korean Society of Infectious Diseases; 2011. Workshop. 9. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) Vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR Morb Mortal Wkly Rep 2011;60(1):13-5. 10. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) in pregnant women and persons who have or anticipate having close contact with an infant aged <12 months --- Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep 2011;60(41):1424-6. 11. Harpaz R, Orteqa-Sanchez IR, Seward JF; Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2008;57(5):1-30; quiz CE2-4. 12. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of meningococcal conjugate vaccines --- Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep 2011;60(3):72-6. 중심단어 : 백신, 예방접종, 성인, 가이드라인