he had no recurrence. A 20-year-old student received a single dose of JE vaccine (Biken, batch EJN 094A). After 24 hours she developed dizziness, nausea, and described influenza-like symptoms. 4 days after immunisation she developed a widespread urticarial rash affecting all limbs,trunk, face, and lips, with angio-oedema of the limbs. She was admitted to her local hospital and the rash subsided over 5 days. Photographs of both subjects showed the rashes to be very similar in distribution and morphology. One estimate. suggests that severe adverse events occur with a frequency of 1-104 per 10000 vaccinees. In the UK, of an estimated 35 120 JE immunised travellers, 8 severecutaneous reactions (including our 2 patients) have been reported (P Murray, Cambridge Selfcare Diagnostics, personal communication), giving an incidence of 0-02%. The numbers of cases reported to the vaccine distributor by passive surveillance may be a considerable underestimate. The vaccine predominantly used in the UK is produced by the Research Institute of Osaka University (Biken) and is aninactivated virus derived from infected mouse brain. The total number of cases of JE disease in travellers, summarised by Wittesjo and colleagues, is around 25 cases in 14 years in several million European and North American visitors to Asia. This risk should be weighed against that of severe vaccine reactions occurring in about 1 per 4000 vaccinees. To propose any wider use of JE vaccine in thiscontext could be hazardous. JE vaccine should be offered to travellers with high-risk itineraries." Typically, these will be those spending a month or more in rural or agricultural areas of Asia where transmission of JE is known to take place.
Alec Bonington, Marcus Harbord, Robert N Davidson, Ian Cropley, *Ron H Behrens
Department of Infection and Tropical Medicine, Northwick Park and *Hospital forTropical Diseases, London NW1 0PE, UK
Figure: Comparison of red-blood-cell cholinesterase (ChE) patients with and without miosis
cholinesterase activity ranged between 0-3 and 2-0 U (1-2-2-0). Tests for red-cell cholinesterase are more sensitive than those for serum cholinesterase (data not shown). All patients with decreased red-cell cholinesterase activity showed miosis (figure).Data for the effect of nerve gas in man were previously obtained in healthy volunteers,l,2 and few data in patients have been recorded. Because more than 5000 people were treated for the effects of sarin poisoning in the Tokyo incident, we think that the opportunity for investigation of such effects should not be lost.
*Naoki Masuda, Masami Takatsu, Testuma Ozawa
Departments of *Internal MedicineChiyoda-Ku, Tokyo 102 Japan
Ophthalmology, Tokyo Teishin Hospital,
Grob D, Harvey AM. The effects and
of nerve gas
Ruff TA, Eisen D, Fuller A, Kass R. Adverse reactions to Japanese encephalitis vaccine. Lancet 1991; 338: 881-82. 2 Andersen MM, Ronne T. Side-effects with Japanese encephalitis vaccine. Lancet 1991; 337:1044. 3 Robinson HC, Russell ML, Csokonay WM. Japanese encephalitis vaccine and adverse effects among travellers. Can Dis Wkly Rep 1991; 17: 173-74; 177.
4 Inactivated Japanese encephalitis virus vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morb Mortal Wkly Rep 1993; 42: 1-15.
poisoning. Am J Med 1953; 14: 52-63. Grob D, Harvey JC. Effects in man of theanticholinesterase compound sarin (isopropyl methyl phosphonofluoridate). J Clin Invest
1958; 37: 350-68.
SiR-Your correspondents report (April 15, p 980) an attack with the nerve gas sarin in Tokyo on March 20, 1995, with several deaths and more than 5000 people injured. After this accident 71 patients attended our hospital, and 43 were admitted....