2016 년공수병예방을위한국내동물교상환자감시현황 질병관리본부국립보건연구원감염병연구센터세균질환연구과이혜경, 한달무리, 이영선 * * 교신저자 : yslee07@nih.go.kr, 043-719-8460 Animal Bite Surveillance for Human Rabies Prevention in Korea, 2016 Lee Hae Kyung, Han Dalmuri, Lee Yeong Seon* Division of Bacterial Disease Research, Center for Infectious Disease Research, KNIH, KCDC BACKGROUND: In Korea, rabies has occurred mainly in the north of Han river since its re-emergence in 1993. However, in 2012 and 2013, rabies outbreaks occurred in Suwon and Hwaseong of the southern Han river, once again. To prevent and control human rabies in Korea, the national surveillance on animal bites has been implemented since 2011. METHODOLOGY: Information, such as demographic data, exposure status, animal bite, and post-exposure prophylaxis (PEP) treatment in 2016 were collected through a survey. The Excel software was used for statistical analysis. RESULTS: A total of 820 animal bite cases were reported through the surveillance system in 2016. By region, 474 cases from Gyeonggi province and 331 cases from Gangwon province, and 15 cases in other regions were reported respectively. Specifically, the higher number was reported from Yangpyeong county with 269 cases (56.8%) in Gyeonggi province and from Chuncheon city of 122 cases (36.9%) in Gangwon province. Although animal bites were occurred frequently high in June as 11.2% (92 cases), the cases occurred all the year. In demographic distribution, 449 cases (54.8%) of animal bites occurred in male and the highest in those aged 50-59 (203, 24.8%). 723 cases (88.2 %) of animal exposures were due to dogs and the major bite sites were hands and fingers (393, 44.6%). According to the WHO guideline for human rabies, category III cases was 695 (84.8%) of the total and only 69 (9.9%) of them received PEP treatment for category III. CONCLUSION: Human rabies by animal bite is one of the serious diseases in public health, but it is a preventable disease if we get the proper treatment after an animal bite. Therefore, in order to have a rabies free from South Korea, the surveillance for animal bites should be expanded and strengthened in the future. 들어가는말 동물교상에따른인체감염은동물의이빨이피부를관통하였을 때, 타액에있는다양한병원체가침투하면서발생한다. 미국에서는 매년 470 만건의동물교상환자가응급실에서치료를받으며, 이중약 2% 는입원치료가필요하다. 특히, 미국에서동물교상의 www.cdc.go.kr 688
85 90% 는개에의한것이며, 대부분어린이로주로머리와목을물린다. 고양이에의한교상은 5 10% 로, 대부분성인여성이교상을당한다고보고되고있다 [1]. 교상부위에서검출되는세균은주로 Pasteurella, Staphylococcus, Pseudomonas, Streptococcus, Capnocytophaga, Moraxella 등의호기성세균및 Bacteroides, Fusobacterium과같은혐기성세균이며, 이외에도 Bartonella 에의한고양이할큄에의한감염 (cat-scratch disease, CSD), 파상풍 (tetanus), 공수병 (rabies) 등감염병이발생할수있다 [2]. 이중에서사람공수병은공수병 (rabies) 바이러스에감염되어광견병에걸린동물에게물렸을때, 상처부위가동물의타액에의해오염되어전파되는인수공통감염병으로, 전세계 면역글로불린투여및백신접종과같은신속하고적절한치료를받지못하여모두사망함에따라, 동물교상환자의감시와신속한치료의중요성을인식하기시작하였다 [4]. 질병관리본부에서는 2005년에동물에의한교상환자감시체계를구축하였고, 2011년부터는국내에서공수병발생을예방하기위하여, 과거광견병또는공수병발생사례가있었던경기도와강원도주요지역을중심으로동물교상환자발생감시웹시스템을개발하여해당시도보건소와협력 운영하고있다 ( 교상환자발생실험실감시시스템, http://is1.cdc.go.kr). 또한매년동물교상환자감시결과를분석한자료를제공하고있으며, 본글에서는 2016년의동물교상환자감시현황을기술하고자한다. 150 개국이상에서매년 35,000 명 50,000 명이공수병으로 사망한다. 하지만, 공수병은동물교상후에도초기에면역글로불린과공수병예방백신접종으로적절한치료를받는다면, 충분히예방가능한감염병이다. 따라서동물에의한교상감시와교상후적절한치료는공수병예방에매우중요하다 [3]. 우리나라에서공수병발생은 1962년부터공식적인집계가이루어졌으며, 1984년까지간헐적으로발생된이후로발생보고가없었다. 그러나 1999년파주시에서공수병환자가발생된이후로 2004년까지화천군, 연천군, 포천군, 고양시에서 6명의환자가개또는너구리에의한교상으로발생하였다. 그러나환자들이 몸말 2016년에는총 820건의동물교상환자가발생하였으며, 이중에서경기도는 474건 (57.8%), 강원도는 331건 (40.4%), 기타지역이 15건 (1.8%) 이었다. 경기도에서는양평군이 269건 (56.8%) 으로교상환자가가장많이발생하였고그다음은연천군 52건 (11.0%) 이었다. 강원도에서는춘천시가 122건 (36.9%) 으로가장많이발생하였고, 그다음으로는속초시 80건 (24.2%) 이었다 (Figure 1). (A) (B) Pocheon, 4.0% Hwaseong, 3.2% Gaoyeong, 3.8% Others, 1.2% Dongducheon, Paju, 5.7% 3.0% Hongcheon, 4.2% Others, 1.2% Goseong, 13.9% Yeoju, 2.5% Yeoncheon, 11.0% Yangju, 9.9% Chuncheon, 36.9% Sokcho, 24.2% Yangpyeong, 56.8% Cheolwon, 12.1% Yanggu, 1.8% Yangyang, 3.6% Inje, 2.1% Figure 1. Frequency of animal bite cases in Gyeonggi (A) and Gangwon (B) provinces in Korea, 2016 www.cdc.go.kr 689
성별에따른교상환자는남자 449건 (54.8%), 여자 371건 (45.2%) 이었다. 연령별로는 50대 203건 (24.8%), 60대 131건 (16.0%), 40대 114건 (13.9%) 이었고 10세미만에서는 42건 (5.1%) 이발생하였으며, 평균연령은 50.6세이었다. 월별로는평균 506건 (85%) 이 4월 9월사이에발생하였다 (Figure 2). 교상동물은개 723건 (88.2%), 고양이 82건 (10.0%), 너구리 3건 (0.4%), 기타야생동물 3건 (0.4%) 순이었으며, 교상부위는손과손가락이 393건 (44.6%) 으로가장높았고이외에다리 272건 (30.8%), 팔 124건 (14.1%), 얼굴 30건 (3.4%) 순이었다. 치료형태로는상처소독만한경우가 568건 (69.3%) 으로가장많았고면역글로불린투여및백신접종은 88건 (10.7%), post-exposure prophylaxis(pep) 지침에따른백신접종은 92건 (11.2%), 상처소독및봉합은 36건 (4.4%) 이었으며, 36건 (4.4%) 이적절한처치를하지않았거나, 치료여부를확인할수없었다. 공수병은대부분광견병에걸린동물에게교상을당한경우에전파가능한질병으로, 세계보건기구 (WHO) 에서는동물교상에따라신체접촉유형을 3가지로구분하고그치료방법을 Table 1과같이권고하고있다 [5]. 2016년발생한교상환자의경우에는 category III에속하는유형이 696건 (84.8%) 이었고 category II는 103건 (12.6%) 이었으며, 22건 (2.7%) 은정보가기록되지않아알수없었다. 공수병에노출될위험도가높은 category III에속한경우에 69건 (9.9%) 이면역글로불린과백신을모두접종하였으며, 5회접종및 5회미만으로접종한경우는각각 46건 (6.6%) 이였다. 또한, 상처만소독한경우는 470건 (67.6%) 이었으며, 상처소독과 12.0 10.0 Percent of animal bite 8.0 6.0 4.0 2.0 0.0 Jan Feb Mar Apr May Jun Jlu Aug Sep Oct Nov Dec Month Figure 2. Frequency of animal bite cases according to months in Korea, 2016 Table 1. Categories of post-exposure prophylaxis after rabies-infected animal bites recommended by WHO Category Exposure wound Prophylaxis I II III Touching or feeding of animals, licks on intact skin, contact of intact skin with secretions or excretions of a rabid animal or human Minor scratches or abrasions without bleeding and/or nibbling of uncovered skin Single or multiple transdermal bites or scratches, licks on broken skin, contamination of mucous membrane with saliva (i.e. licks) and suspect contacts with bats These are not regarded as exposures, and no post-exposure prophylaxis is required. Vaccine should be injected as soon as possible. Vaccine and rabies immunoglobulin should be administered at distant sites as soon as possible. Immunoglobulin can be administered up to day 7 after injection of the first dose of vaccine www.cdc.go.kr 690
함께봉합을한경우는 31 건 (4.5%) 으로나타났다. 치료를하지않은 경우와조치여부를알수없는경우는각각 4 건 (0.6%), 29 건 (4.2%) 이었다. 치료, 교육및홍보는무엇보다중요하다. 국내에서 1999 년 2004 년에발생한공수병환자 6 명이 모두사망함에따라, 질병관리본부에서는보도자료배포, 지침 개선, 교육등을강화하였고공수병예방을위한대국민홍보를 맺음말 우리나라에서동물광견병발생은 1907년에공식적으로처음보고되었으며, 1945년까지매년 200 800건정도가보고되었다. 이후 1970년대까지매년 3 91건이보고되면서매년증가추세를보였으나, 1984년에강원도지역의개에서 1건발생된이후 1992년까지는광견병발생은보고되지않았다. 그러나 1993년 9월에강원도철원에서다시발생하면서증가하기시작하였고 적극적으로실시하고있다. 공수병예방을위하여사용되는공수병면역글로불린과공수병예방백신은 2006년 7월부터건강보험급여가적용되었다. 또한 2016년에동물교상환자감시시스템을개선하여교상환자의등록일기준으로만볼수있었던자료를교상일기준으로도볼수있도록하였다. 아울러동남아해외여행중교상발생증가, 강원도및경기도이외의지역에서교상발생사례증가에따라, 국내의교상환자감시를더욱강화하기위하여 2017년부터강원도와경기도중심으로운영되었던감시시스템을전국으로점차확대하여운영하고있다. 2002 년에는 90 여건의광견병발생보고가있었는데, 주로경기도 및강원도의한강북쪽지역에서개, 소, 너구리, 고양이에서발생하였다. 그러나 2012년, 2013년에는한강남쪽지역인경기도화성과수원에서재발생하여광견병에대한경각심을갖게되었다 [6-9]. 농림축산식품부 ( 농림축산검역본부 ) 는 2001년이후부터우리나라에서광견병을근절시키기위하여기존광견병발생지역이나휴전선접경지역의사육가축, 개, 소에게광견병백신을의무적으로접종하도록하고있다. 또한우리나라의주요광견병전파매개동물인야생너구리와같은야생동물에대한광견병감염실태조사와더불어미끼예방백신 (bait vaccine) 살포, 광견병에대한예방캠페인등을실시하여왔다 [10]. 이렇게다양한국가방역정책을능동적으로실시함에따라, 2014년부터광견병발생은보고되고있지않다 [11]. 사람에서공수병은광견병이의심되는동물에게교상을당하더라도, WHO 지침 [5] 이나질병관리본부의공수병예방 관리지침에따라, 교상부위에면역글로불린투여및공수병예방백신접종등신속하고적절한치료를받는다면, 예방가능한감염병이다. 우리나라에서공수병발생은 2004년발생이후로현재까지보고되고있지않다. 하지만, 최근들어유기견증가및야생화, 해외여행지에서교상환자발생증가등으로공수병발생가능성이증가되고있기때문에, 공수병예방을위한교상환자감시, 신속한 참고문헌 1. Ellis R and Ellis C. 2014. Dog and cat bites. Downloaded from the American Family Physician website at www.aafp.org/afp. 90:239-243. 2. Griego, RD, Rosen T, Orengo I F, and Wolf J E. 1995. Dog, cat, and human bites: A review. The American Academy of Dermatology, Inc. 3. WHO 2017. Human rabies: 2016 updates and call for data. Weekly epidemiological record. 92:77-88(http://www.who.int/rabies/ resource/who_wer9207/en. Accessed April 15, 2017). 4. Lee JB, Lee HJ, Hyun BH, Bang JH, Nam KO, Jeong YE, Shin YH. 2005. Epidmiology and prevention stragegies of rabies in Korea. Korea J Epidemiol. 27:53-68. 5. WHO Expert consultation on rabies. 2013. Second Report, WHO technical report series no. 982. Geneva: World Health Organization, Switzerland. 6. Kim CH, Lee CG, Yoon HC, Nam HM, Park CK, Lee JC, Kang MI, and Wee SH. 2006. Rabies, an emerging disease in Korea. J. Vet. Med. B. 53:111-115. 7. Lee KK. 2010. Outbreak and control of animal rabies in Korea. Infect. Chemother. 42(1):1-5. 8. Cheong YT, Kim B, Lee KJ, Park DH, Kim WY, Kim HC, Parj EY, Lee HC, Bae CW, Oh CG, Park SY, Song CS, Lee SW, Choi IS, and www.cdc.go.kr 691
Lee JB. 2013. Strategic model of national rabies control in Korea. Clin Exp Vac Res. 3:78-90. 9. Oem, JK, Kim, SH, Kim YH, Lee MH, and Lee KK. 2014. Reemergene of rabies in the southern Han river region, Korea. 50:681-688. 10. Yang DK, Kim SY, Oh YI, Lee JA, Cho SD, Lee KW, and Song JY. 2011. Epidemiological characteristics of rabies in South Korea from January 2004 to March 2011. J Bacteriol Virol. 41:165-171. 11. K AHIS 국가동물방역통합시스템. http://www.kahis.go.kr. Accessed April 13, 2017. www.cdc.go.kr 692