- Email: [email protected]
Immunological preparations
B. Hofman and H.R Lansberg
34
Immunological preparations
BACTERIOLOGICAL VACCINES
Cholera Masengo Bwanga vaccinated in Zaire 12,000 persons with oral passage Institute Pasteur anticholera vaccine. Side effects mentioned in the report are limited to 2 c a s e s o f diarrhea occurring less than 24 hours after administration (1R). A case is reported of a patient suffering from a syndrome similar to immune complex disease following cholera vaccination. The clinical symptoms subsided within 2 weeks (2c).
Cholera typhoid A previously healthy person died 8 hours after a cholera typhoid vaccination. The chnical course and necropsy findings suggest that death was the result of a slowly evolving systemic anaphylactic reaction that terminated in hypotension and right heart failure. The deceased was probably atopic (3c).
Diphtheria tetanus typhoid AB (DTTAB) A new case of hemolytic uremic syndrome (HUS) after DTTAB vaccination has been reported. The cause was probably typhoid factor but the diphtheria toxoid may have been responsible for the allergic phenomenon (4c).
hours after receiving the largest vaccine dose (5r).
Meningocoeci A new tetravalent meningococcal polysaccharide vaccine containing Groups A, C, W 135 and Y was administered to 40 healthy adults. The side effects of the vaccine were similar to those associated with monovalent and bivalent vaccines containing Group A and C meningococcal polysaccharides (6r).
Pneumococci During a pneumococcal vaccine study of 20 children with nephrotic syndrome, 5 (25 % ) suffered moderate or severe local reactions and another 5 (25%) developed O fever of >38.3 C. The reactions correlated with antibody response (7 R). After vaccination with pneumococcal vaccine a woman developed keratoacanthoma at the injection site (8c). A series of 79 children (aged 2 - 5 years), 52 of whom had had prior immunization with pneumococcal vaccine, received pneumococcal vaccine. Local reactions including erythema, induration and/or swelling around Table 1. Side effects of tetravalent meningococcal polysaccharide vaccine in 40 healthy volunteers Sign or symptom
Dysentery Nineteen volunteers were vaccinated with Form 1 antigen of Shigetta sonnei transferred to the avirulent Salmonella typhi strain 21a. One person developed mild abdominal cramp and diarrhea within 2
Side Effects of Drugs Annual 9 M.N.G. Dukes, editor 9 Elsevier Science Publishers B.V., 1985 ISBN 0 444 90394 1 $0.85 per article per page (transactional system) $0.20 per article per page (licensing system)
General reactions Fever Headache Chills Fatigue Gastrointestinal symptoms Local reactions Soreness Erytbema Induration
Incidence
Duration (days)
No.
%
2 15 1 5 1
5.0 37.5 2.5 12.5 2.5
1-2 1-3 1 1-2 1
9 4 2
22.5 10.0 5.0
1* 1-2 1
*One patient reported soreness lasting for 2 days, and one for 4 days.
Immunological preparations Chapter34 the injection site were significantly greater in the reimmunized group (9r).
283 Tetanus A 60-year-old woman developed a calcifying dermatomyositis, probably due to an
Pneumococcal influenza vaccine A patient who had been vaccinated for several years in succession with influenza vaccine developed small vessel vasculitis after combined influenza-pneumococcal vaccination. This side effect is known for influenza vaccine but not for pneumococcal vaccine; however, in this case the pneumococcal vaccine may have been the trigger (lOC).
anti-tetanus vaccination ( 14 c). A 20-year-old soldier developed neuralgic amyotrophy after a 'booster shot' of tetanus toxoid (15c). Another recent case report relates to polyradiculoneuritis with paresis of the urinary bladder and bowel following administration of tetanus and diphtheria toxoid to a 22-year-old male. Neurological reactions to tetanus toxoid are known, but none so far to DT vaccine; this case appears most likely to have been caused by the tetanus portion of the vaccine (16 c).
Pertussis The literature on the whooping cough controversy subsequent to the publication of the DHSS report in 1981 has been reviewed by Christina Harding. No real new problems of a somatic nature have appeared in the last 2 years, although Christina Harding emphasizes a side effect of a psychological nature in that young mothers are often left to make the difficult decision all by themselves whether to have their children vaccinated or nor. Those who are experts in the field should occasionally remember the suffering that they cause these mothers (11 R) by shirking their professional responsibility to give clear advice and explanation. A child developed paroxysmal supraventricular tachycardia during a febrile illness at 5 weeks of age. This paroxysmal supraventricular tachycardia was repeatedly precipitated by the administration of DTP vaccine. There are implications that the pertussis component is the precipitating factor (12c). Following Cody's and Baraff's paper reviewed in SEDA-8 additional data have been provided by Baraff et al. Local reactions appeared to be less common when immunization was given in the buttocks than in the thigh. Local redness, temperature in excess of 39~ and persistent crying for more than half-an-hour were 2 - 3 times more frequent on subsequent immunization in cases where they had been present at a prior vaccination than if not previously present. Children receiving half doses had significantly less serious local reactions as well as notable differences in temperature, drowsiness and persistent crying than those receiving full dose.s ( 13 R ).
Tuberculosis A girl with normal cellular and humoral immunity vaccinated at 7 months of age with BCG developed after a year lupus vulgaris in which BCG bacteria were found (17c). Two cases of fatal BCG histiocytosis have been reported in babies with immune defects vaccinated shortly after birth (18c). After describing 2 cases of local complications in immune normal infants after BCG vaccination, Nagashima et al offer the impression, but without concrete evidence, that complications to BCG vaccination have increased in frequency in Japan since 1978 (18c).
VIRAL VACCINES Hepatitis B After administration of hepatitis-B vaccine to hospital employees, 7 of 16 women vaccinated experienced menstrual abnormalities, such as hypomenorrhea, oligomenorrhea, and polymenorrhea which lasted for 3 - 6 months. None of these women was married or had ever taken hormone contraceptives (20 c). A case of inflammatory polyradiculopathy was described in a 29-year-old man, 10 days after the second intramuscular injection of hepatitis-B vaccine. In many respects the picture was similar to the Guillain-Barr6 syndrome. Recovery was uneventful (2 lC).
284
Influenza A case of optic neuritis in a 10-year-old boy with onset 4 days after influenza vaccination has been described. Moreover the electroencephalogram showed an abnormal basic activity pattern, possibly reflecting an acute disseminated encephalomyelitis (22c). A 17-year-old girl who had already been suffering from systemic lupus erythematosus developed a recurrent aseptic meningitis after the administration of influenza vaccine (23c).
Measles Severe local reactions defined as redness and swelling at the injection site which persisted for 72 hours after receiving the vaccine were described in 9 junior highschool students vaccinated with live measles virus vaccine in the course of a school vaccination program. The symptoms appeared within a few days after vaccination (24r). Fifteen reactions between 3 and 30 minutes after injection of live measles virus vaccine in Australia have been reviewed. The main symptoms observed were color changes o f the skin, cough, pallor and vomiting. The age of the children
Chapter 34
B. Hofman and H.P. Lansberg
involved ranged from 12 to 22 months (25r). Convulsions within 30 days after measles vaccination have been described (26r). Allergic reactions in patients hypersensitive to egg protein may occur after administration of measles vaccine prepared in chick embryo tissue cultures (27c). A combined vaccine against measles, parotitis and rubella may, like any of its components, give rise to thrombocytopenic purpura. Such a case in a 20-month-old girl with onset 2 weeks after the vaccination has been described (28 c ). Poliomyelitis Some recent publications from the Federal Republic of Germany mention for the Cologne area a frequency of oral polio vaccine associated paralytic polio cases of 5 per million doses (29r).
Yellow fever A case of meningoencephalitis occurred in a 1-month-old boy, 13 days after vaccination with 17D yellow fever vaccine. The course of the disease was favorable. Although the risks are very slight, it is suggested that vaccination with this preparation be avoided in the first year of life (30c).
REFERENCES 1. Bwanga M (1984) Premiers essais control6s du vaccin antichol6rique oral au cours de l'6pid6mie de cholera dans la zone de Malemba-Nkulu (Shaba-Zaire). Bull. Soc. PathoL, 77, 13. 2. Mall Th, Gyr K (1984) Episode resembling immune complex disease after cholera vaccination. Trans. R. Soc. Trop. Med. Hyg., 78, 106. 3. Pounder DJ (1984) Sudden, unexpected death following typhoid-cholera vaccination. Forensic Sci. lnt., 24, 95. 4. Delacour JL, Daoudal P e t al (1983) Syndr6me h6molytique et ur6mique: complication rare de la vaccination antityphoparatyphofdique. M~d. MaL Infect., 13, 550. 5. Tramont EC, Chung R et al (1984) Safety and antigenicity of Typhoid-Shigella sonnei vaccine. J. Infect. Dis., 149, 133. 6. Ambrosch F, Wiedermann G e t al (1983) Immunogenicity and side effects of a new tetravalent meningococcal polysaccharide vaccine. Bull. WHO, 61, 317. 7. Halsey NA, Spika JS et al (1982) Adverse reactions to pneumococcal polysaccharide vaccine in children. Pediatr. Infect. Dis., 1, 34,
8. Bart RS, Lagin S (1983) Keratoacanthoma following pneumocoecal vaccination. J. Derm. Surg. Oncol., 9, 381. 9. Lawrence EM, Edwards KM et al (1983) Pneumococcal vaccine in normal children. Am. J. Dis. Child., 137, 846. 10. Houston ThP (1983) Small-vessel vasculitis following simultaneous influenza and pneumococcal vaccination. N Y State J. Med., 1182. 11. Harding CM (1983) Whooping cough vaccination: a review of the controversy since the 1981 DHSS report. Child Care, Health Dev., 9, 257. 12. Park JM, Ledbetter EO et al (1983) Paroxysmal supraventricular tachycardia precipitated by pertussis vaccine. Clin. Lab. Observ., 102, 883. 13. Baraff LJ, Cody CL et al (1984) DTP-associated reactions: an analysis by injection site, manufacturer, prior reactions and dose. Pediatrics, 73,31. 14. Albert JM, Ott HJ (1983) Calcifying dermatomyositis following antitetanus vaccination. Arch. lntern. Med., 143, 1457. 15. Kiwit JCW (1984) Neuralgic amyotrophy
Immunological preparations Chapter 34 after administration of tetanus toxoid. J. Neurol.
Neurosurg. Psychiatry, 4 7, 320. 16. Holliday PL, Bauer RB (1983) Polyradiculoneuritis secondary to immunization with tetanus and diphtheria toxoids. Arch. Neurol., 40, 56. 17. Lassale C, Lemerle Gruson S et al (1983) Lupus vulgaire de la face ~ BCG. Arch. Fr. Pediatr., 40, 643. 18. Baum WF, Wessel H et al (1983) Die BCGHistiozytose - eine Form der generalisierten BCG-Infektion. Dtsch. Gesundheitswes., 38, 699. 19. Nagashima K, Harasawa N e t al (1983) Complications of BCG vaccination: report of two cases. Kitakanto Med. J., 33/3, 250. 20. Shingu T, Uchida T et al (1982) Menstrual abnormalities after hepatitis B-vaccine. Kurume Med. J., 29, 123. 21. Ribera EF, Dutka AJ (1983) Polyneuropathy associated with administration o f hepatitis B vaccine. N. Engl. J. Med., 309, 614. 22. Hara Y, Wakano I e t al (1983) A case of optic neuritis after influenza vaccination. Folia Ophthalmol. Jpn., 34, 1980. 23. lchikawa N, Takase S, Kogure K (1983) Recurrent aseptic meningitis after influenza
285 vaccination in a case with systemic lupus erythematosus. Clin. Neurol., 23, 570. 24. 8tetler HC, Gens RD et al (1983) Severe local reactions to live measles virus vaccine following an immunization program. Am. J. Publ. Health, 73, 899. 25. McEwen J (1983) Early-onset reaction after measles vaccination: further Australian reports. Med. J. Aust., 2, 503. 26. Berlin BS (1983) Convulsions after measles immunisation. Lancet, 1, 1380. 27. Herman JH, Radin R, Schneiderman R (1983) Allergic reactions to measles (rubeola) vaccine in patients hypersensitive to egg protein. J. Pediatr., 102, 196. 28. Neiderud J (1983) Thrombocytopenic purpura after a combined vaccine against morbilli, parotitis and rubella. Acta Paediatr. Seand., 72, 613. 29. Mertens Th, Schiirmann W e t al (1984) Two cases of vaccine-induced poliomyelitis. Acta Paediatr. Scand., 73, 133. 30. Louis JJ, Chopard Ph, Larbre F (1981) Un cas d'enc6phalite apr~s vaccination anti-amarile par la souche 17D. P~diatrie, 36, 547.
34
Immunological preparations
BACTERIOLOGICAL VACCINES
Cholera Masengo Bwanga vaccinated in Zaire 12,000 persons with oral passage Institute Pasteur anticholera vaccine. Side effects mentioned in the report are limited to 2 c a s e s o f diarrhea occurring less than 24 hours after administration (1R). A case is reported of a patient suffering from a syndrome similar to immune complex disease following cholera vaccination. The clinical symptoms subsided within 2 weeks (2c).
Cholera typhoid A previously healthy person died 8 hours after a cholera typhoid vaccination. The chnical course and necropsy findings suggest that death was the result of a slowly evolving systemic anaphylactic reaction that terminated in hypotension and right heart failure. The deceased was probably atopic (3c).
Diphtheria tetanus typhoid AB (DTTAB) A new case of hemolytic uremic syndrome (HUS) after DTTAB vaccination has been reported. The cause was probably typhoid factor but the diphtheria toxoid may have been responsible for the allergic phenomenon (4c).
hours after receiving the largest vaccine dose (5r).
Meningocoeci A new tetravalent meningococcal polysaccharide vaccine containing Groups A, C, W 135 and Y was administered to 40 healthy adults. The side effects of the vaccine were similar to those associated with monovalent and bivalent vaccines containing Group A and C meningococcal polysaccharides (6r).
Pneumococci During a pneumococcal vaccine study of 20 children with nephrotic syndrome, 5 (25 % ) suffered moderate or severe local reactions and another 5 (25%) developed O fever of >38.3 C. The reactions correlated with antibody response (7 R). After vaccination with pneumococcal vaccine a woman developed keratoacanthoma at the injection site (8c). A series of 79 children (aged 2 - 5 years), 52 of whom had had prior immunization with pneumococcal vaccine, received pneumococcal vaccine. Local reactions including erythema, induration and/or swelling around Table 1. Side effects of tetravalent meningococcal polysaccharide vaccine in 40 healthy volunteers Sign or symptom
Dysentery Nineteen volunteers were vaccinated with Form 1 antigen of Shigetta sonnei transferred to the avirulent Salmonella typhi strain 21a. One person developed mild abdominal cramp and diarrhea within 2
Side Effects of Drugs Annual 9 M.N.G. Dukes, editor 9 Elsevier Science Publishers B.V., 1985 ISBN 0 444 90394 1 $0.85 per article per page (transactional system) $0.20 per article per page (licensing system)
General reactions Fever Headache Chills Fatigue Gastrointestinal symptoms Local reactions Soreness Erytbema Induration
Incidence
Duration (days)
No.
%
2 15 1 5 1
5.0 37.5 2.5 12.5 2.5
1-2 1-3 1 1-2 1
9 4 2
22.5 10.0 5.0
1* 1-2 1
*One patient reported soreness lasting for 2 days, and one for 4 days.
Immunological preparations Chapter34 the injection site were significantly greater in the reimmunized group (9r).
283 Tetanus A 60-year-old woman developed a calcifying dermatomyositis, probably due to an
Pneumococcal influenza vaccine A patient who had been vaccinated for several years in succession with influenza vaccine developed small vessel vasculitis after combined influenza-pneumococcal vaccination. This side effect is known for influenza vaccine but not for pneumococcal vaccine; however, in this case the pneumococcal vaccine may have been the trigger (lOC).
anti-tetanus vaccination ( 14 c). A 20-year-old soldier developed neuralgic amyotrophy after a 'booster shot' of tetanus toxoid (15c). Another recent case report relates to polyradiculoneuritis with paresis of the urinary bladder and bowel following administration of tetanus and diphtheria toxoid to a 22-year-old male. Neurological reactions to tetanus toxoid are known, but none so far to DT vaccine; this case appears most likely to have been caused by the tetanus portion of the vaccine (16 c).
Pertussis The literature on the whooping cough controversy subsequent to the publication of the DHSS report in 1981 has been reviewed by Christina Harding. No real new problems of a somatic nature have appeared in the last 2 years, although Christina Harding emphasizes a side effect of a psychological nature in that young mothers are often left to make the difficult decision all by themselves whether to have their children vaccinated or nor. Those who are experts in the field should occasionally remember the suffering that they cause these mothers (11 R) by shirking their professional responsibility to give clear advice and explanation. A child developed paroxysmal supraventricular tachycardia during a febrile illness at 5 weeks of age. This paroxysmal supraventricular tachycardia was repeatedly precipitated by the administration of DTP vaccine. There are implications that the pertussis component is the precipitating factor (12c). Following Cody's and Baraff's paper reviewed in SEDA-8 additional data have been provided by Baraff et al. Local reactions appeared to be less common when immunization was given in the buttocks than in the thigh. Local redness, temperature in excess of 39~ and persistent crying for more than half-an-hour were 2 - 3 times more frequent on subsequent immunization in cases where they had been present at a prior vaccination than if not previously present. Children receiving half doses had significantly less serious local reactions as well as notable differences in temperature, drowsiness and persistent crying than those receiving full dose.s ( 13 R ).
Tuberculosis A girl with normal cellular and humoral immunity vaccinated at 7 months of age with BCG developed after a year lupus vulgaris in which BCG bacteria were found (17c). Two cases of fatal BCG histiocytosis have been reported in babies with immune defects vaccinated shortly after birth (18c). After describing 2 cases of local complications in immune normal infants after BCG vaccination, Nagashima et al offer the impression, but without concrete evidence, that complications to BCG vaccination have increased in frequency in Japan since 1978 (18c).
VIRAL VACCINES Hepatitis B After administration of hepatitis-B vaccine to hospital employees, 7 of 16 women vaccinated experienced menstrual abnormalities, such as hypomenorrhea, oligomenorrhea, and polymenorrhea which lasted for 3 - 6 months. None of these women was married or had ever taken hormone contraceptives (20 c). A case of inflammatory polyradiculopathy was described in a 29-year-old man, 10 days after the second intramuscular injection of hepatitis-B vaccine. In many respects the picture was similar to the Guillain-Barr6 syndrome. Recovery was uneventful (2 lC).
284
Influenza A case of optic neuritis in a 10-year-old boy with onset 4 days after influenza vaccination has been described. Moreover the electroencephalogram showed an abnormal basic activity pattern, possibly reflecting an acute disseminated encephalomyelitis (22c). A 17-year-old girl who had already been suffering from systemic lupus erythematosus developed a recurrent aseptic meningitis after the administration of influenza vaccine (23c).
Measles Severe local reactions defined as redness and swelling at the injection site which persisted for 72 hours after receiving the vaccine were described in 9 junior highschool students vaccinated with live measles virus vaccine in the course of a school vaccination program. The symptoms appeared within a few days after vaccination (24r). Fifteen reactions between 3 and 30 minutes after injection of live measles virus vaccine in Australia have been reviewed. The main symptoms observed were color changes o f the skin, cough, pallor and vomiting. The age of the children
Chapter 34
B. Hofman and H.P. Lansberg
involved ranged from 12 to 22 months (25r). Convulsions within 30 days after measles vaccination have been described (26r). Allergic reactions in patients hypersensitive to egg protein may occur after administration of measles vaccine prepared in chick embryo tissue cultures (27c). A combined vaccine against measles, parotitis and rubella may, like any of its components, give rise to thrombocytopenic purpura. Such a case in a 20-month-old girl with onset 2 weeks after the vaccination has been described (28 c ). Poliomyelitis Some recent publications from the Federal Republic of Germany mention for the Cologne area a frequency of oral polio vaccine associated paralytic polio cases of 5 per million doses (29r).
Yellow fever A case of meningoencephalitis occurred in a 1-month-old boy, 13 days after vaccination with 17D yellow fever vaccine. The course of the disease was favorable. Although the risks are very slight, it is suggested that vaccination with this preparation be avoided in the first year of life (30c).
REFERENCES 1. Bwanga M (1984) Premiers essais control6s du vaccin antichol6rique oral au cours de l'6pid6mie de cholera dans la zone de Malemba-Nkulu (Shaba-Zaire). Bull. Soc. PathoL, 77, 13. 2. Mall Th, Gyr K (1984) Episode resembling immune complex disease after cholera vaccination. Trans. R. Soc. Trop. Med. Hyg., 78, 106. 3. Pounder DJ (1984) Sudden, unexpected death following typhoid-cholera vaccination. Forensic Sci. lnt., 24, 95. 4. Delacour JL, Daoudal P e t al (1983) Syndr6me h6molytique et ur6mique: complication rare de la vaccination antityphoparatyphofdique. M~d. MaL Infect., 13, 550. 5. Tramont EC, Chung R et al (1984) Safety and antigenicity of Typhoid-Shigella sonnei vaccine. J. Infect. Dis., 149, 133. 6. Ambrosch F, Wiedermann G e t al (1983) Immunogenicity and side effects of a new tetravalent meningococcal polysaccharide vaccine. Bull. WHO, 61, 317. 7. Halsey NA, Spika JS et al (1982) Adverse reactions to pneumococcal polysaccharide vaccine in children. Pediatr. Infect. Dis., 1, 34,
8. Bart RS, Lagin S (1983) Keratoacanthoma following pneumocoecal vaccination. J. Derm. Surg. Oncol., 9, 381. 9. Lawrence EM, Edwards KM et al (1983) Pneumococcal vaccine in normal children. Am. J. Dis. Child., 137, 846. 10. Houston ThP (1983) Small-vessel vasculitis following simultaneous influenza and pneumococcal vaccination. N Y State J. Med., 1182. 11. Harding CM (1983) Whooping cough vaccination: a review of the controversy since the 1981 DHSS report. Child Care, Health Dev., 9, 257. 12. Park JM, Ledbetter EO et al (1983) Paroxysmal supraventricular tachycardia precipitated by pertussis vaccine. Clin. Lab. Observ., 102, 883. 13. Baraff LJ, Cody CL et al (1984) DTP-associated reactions: an analysis by injection site, manufacturer, prior reactions and dose. Pediatrics, 73,31. 14. Albert JM, Ott HJ (1983) Calcifying dermatomyositis following antitetanus vaccination. Arch. lntern. Med., 143, 1457. 15. Kiwit JCW (1984) Neuralgic amyotrophy
Immunological preparations Chapter 34 after administration of tetanus toxoid. J. Neurol.
Neurosurg. Psychiatry, 4 7, 320. 16. Holliday PL, Bauer RB (1983) Polyradiculoneuritis secondary to immunization with tetanus and diphtheria toxoids. Arch. Neurol., 40, 56. 17. Lassale C, Lemerle Gruson S et al (1983) Lupus vulgaire de la face ~ BCG. Arch. Fr. Pediatr., 40, 643. 18. Baum WF, Wessel H et al (1983) Die BCGHistiozytose - eine Form der generalisierten BCG-Infektion. Dtsch. Gesundheitswes., 38, 699. 19. Nagashima K, Harasawa N e t al (1983) Complications of BCG vaccination: report of two cases. Kitakanto Med. J., 33/3, 250. 20. Shingu T, Uchida T et al (1982) Menstrual abnormalities after hepatitis B-vaccine. Kurume Med. J., 29, 123. 21. Ribera EF, Dutka AJ (1983) Polyneuropathy associated with administration o f hepatitis B vaccine. N. Engl. J. Med., 309, 614. 22. Hara Y, Wakano I e t al (1983) A case of optic neuritis after influenza vaccination. Folia Ophthalmol. Jpn., 34, 1980. 23. lchikawa N, Takase S, Kogure K (1983) Recurrent aseptic meningitis after influenza
285 vaccination in a case with systemic lupus erythematosus. Clin. Neurol., 23, 570. 24. 8tetler HC, Gens RD et al (1983) Severe local reactions to live measles virus vaccine following an immunization program. Am. J. Publ. Health, 73, 899. 25. McEwen J (1983) Early-onset reaction after measles vaccination: further Australian reports. Med. J. Aust., 2, 503. 26. Berlin BS (1983) Convulsions after measles immunisation. Lancet, 1, 1380. 27. Herman JH, Radin R, Schneiderman R (1983) Allergic reactions to measles (rubeola) vaccine in patients hypersensitive to egg protein. J. Pediatr., 102, 196. 28. Neiderud J (1983) Thrombocytopenic purpura after a combined vaccine against morbilli, parotitis and rubella. Acta Paediatr. Seand., 72, 613. 29. Mertens Th, Schiirmann W e t al (1984) Two cases of vaccine-induced poliomyelitis. Acta Paediatr. Scand., 73, 133. 30. Louis JJ, Chopard Ph, Larbre F (1981) Un cas d'enc6phalite apr~s vaccination anti-amarile par la souche 17D. P~diatrie, 36, 547.