Vaccine Information: PNEUMOVAX 23 (Page 2 of 3)

6.2 Post-Marketing Experience

The following list of adverse reactions includes those identified during post approval use of PNEUMOVAX 23. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or their causal relationship to product exposure.

General disorders and administration site conditions
Cellulitis
Malaise
Fever (>102°F)
Warmth at the injection site
Decreased limb mobility
Peripheral edema in the injected extremity

Digestive System
Nausea
Vomiting

Hematologic/Lymphatic
Lymphadenitis
Lymphadenopathy
Thrombocytopenia in patients with stabilized idiopathic thrombocytopenic purpura
Hemolytic anemia in patients who have had other hematologic disorders
Leukocytosis

Hypersensitivity reactions including
Anaphylactoid reactions
Serum Sickness
Angioneurotic edema

Musculoskeletal System
Arthralgia
Arthritis

Nervous System
Paresthesia
Radiculoneuropathy
Guillain-Barré syndrome
Febrile convulsion

Skin
Rash
Urticaria
Cellulitis-like reactions
Erythema multiforme

Investigations
Increased serum C-reactive protein

7 DRUG INTERACTIONS

7.1 Concomitant Administration with Other Vaccines

In a randomized clinical study, a reduced immune response to ZOSTAVAX® as measured by gpELISA was observed in individuals who received concurrent administration of PNEUMOVAX 23 and ZOSTAVAX compared with individuals who received these vaccines 4 weeks apart. Consider administration of the two vaccines separated by at least 4 weeks. [See Clinical Studies (14.3).]

Limited safety and immunogenicity data from clinical trials are available on the concurrent administration of PNEUMOVAX 23 and vaccines other than ZOSTAVAX.

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

Risk Summary

All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.

Available human data from clinical trials of PNEUMOVAX 23 in pregnancy have not established the presence or absence of a vaccine-associated risk.

Developmental toxicity studies have not been conducted with PNEUMOVAX 23 in animals.

8.2 Lactation

Risk Summary

It is not known whether PNEUMOVAX 23 is excreted in human milk. Data are not available to assess the effects of PNEUMOVAX 23 on the breastfed infant or on milk production/excretion.

The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for PNEUMOVAX 23 and any potential adverse effects on the breastfed child from PNEUMOVAX 23 or from the underlying maternal condition. For preventive vaccines, the underlying maternal condition is susceptibility to the disease prevented by the vaccine.

8.4 Pediatric Use

PNEUMOVAX 23 is not approved for use in children less than 2 years of age. Children in this age group do not develop an effective immune response to the capsular types contained in this polysaccharide vaccine.

The ACIP has recommendations for use of PNEUMOVAX 23 in children 2 years of age or older, who have previously received pneumococcal vaccines, and who are at increased risk for pneumococcal disease.

8.5 Geriatric Use

In one clinical trial of PNEUMOVAX 23, conducted post-licensure, a total of 629 subjects who were aged ≥65 years and 201 subjects who were aged ≥75 years were enrolled.

In this trial, the safety of PNEUMOVAX 23 in adults 65 years of age and older (N=629) was compared to the safety of PNEUMOVAX 23 in adults 50 to 64 years of age (N=379). The subjects in this study had underlying chronic illness but were in stable condition; at least 1 medical condition at enrollment was reported by 86.3% of subjects who were 50 to 64 years old, and by 96.7% of subjects who were 65 to 91 years old. The rate of vaccine-related systemic adverse experiences was higher following revaccination (33.1%) than following primary vaccination (21.7%) in subjects ≥65 years of age, and was similar following revaccination (37.5%) and primary vaccination (35.5%) in subjects 50 to 64 years of age.

Since elderly individuals may not tolerate medical interventions as well as younger individuals, a higher frequency and/or a greater severity of reactions in some older individuals cannot be ruled out.

Post-marketing reports have been received in which some elderly individuals had severe adverse experiences and a complicated clinical course following vaccination. Some individuals with underlying medical conditions of varying severity experienced local reactions and fever associated with clinical deterioration requiring hospital care.

8.6 Immunocompromised Individuals

Persons who are immunocompromised, including persons receiving immunosuppressive therapy, may have a diminished immune response to PNEUMOVAX 23.

11 DESCRIPTION

PNEUMOVAX 23 (Pneumococcal Vaccine Polyvalent) is a sterile, liquid vaccine consisting of a mixture of purified capsular polysaccharides from Streptococcus pneumoniae types (1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, and 33F).

PNEUMOVAX 23 is a clear, colorless solution. Each 0.5-mL dose of vaccine contains 25 micrograms of each polysaccharide type in isotonic saline solution containing 0.25% phenol as a preservative. The vaccine is used directly as supplied. No dilution or reconstitution is necessary.

The vial stoppers, syringe plunger stopper and syringe tip cap are not made with natural rubber latex.

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

PNEUMOVAX 23 induces type-specific antibodies that enhance opsonization, phagocytosis, and killing of pneumococci by leukocytes and other phagocytic cells. The levels of antibodies that correlate with protection against pneumococcal disease have not been clearly defined.

14 CLINICAL STUDIES

14.1 Effectiveness

The protective efficacy of pneumococcal vaccines containing six (types 1, 2, 4, 8, 12F, and 25) or twelve (types 1, 2, 3, 4, 6A, 8, 9N, 12F, 25, 7F, 18C, and 46) capsular polysaccharides was investigated in two controlled studies in South Africa in male novice gold miners ranging in age from 16 to 58 years, in whom there was a high attack rate for pneumococcal pneumonia and bacteremia. In both studies, participants in the control groups received either meningococcal polysaccharide serogroup A vaccine or saline placebo. In both studies, attack rates for vaccine type pneumococcal pneumonia were observed for the period from 2 weeks through about 1 year after vaccination. Protective efficacy was 76% and 92%, respectively, for the 6- and 12-valent vaccines, for the capsular types represented.

Three similar studies in South African young adult male novice gold miners were carried out by Dr. R. Austrian and associates using similar pneumococcal vaccines prepared for the National Institute of Allergy and Infectious Diseases, with pneumococcal vaccines containing a 6-valent formulation (types 1, 3, 4, 7, 8, and 12) or a 13-valent formulation (types 1, 2, 3, 4, 6, 7, 8, 9, 12, 14, 18, 19, and 25) capsular polysaccharides. The reduction in pneumococcal pneumonia caused by the capsular types contained in the vaccines was 79%. Reduction in type-specific pneumococcal bacteremia was 82%.

A prospective study in France found a pneumococcal vaccine containing fourteen (types 1, 2, 3, 4, 6A, 7F, 8, 9N, 12F, 14, 18C, 19F, 23F, and 25) capsular polysaccharides to be 77% (95%CI: 51% to 89%) effective in reducing the incidence of pneumonia among male and female nursing home residents with a mean age of 74 (standard deviation of 4 years).

In a study using a pneumococcal vaccine containing eight (types 1, 3, 6, 7, 14, 18, 19, and 23) capsular polysaccharides, vaccinated children and young adults aged 2 to 25 years who had sickle cell disease, congenital asplenia, or undergone a splenectomy experienced significantly less bacteremic pneumococcal disease than patients who were not vaccinated.

In the United States, one post-licensure randomized controlled trial, in the elderly or patients with chronic medical conditions who received a 14-valent pneumococcal polysaccharide vaccine (types 1, 2, 3, 4, 6A, 8, 9N, 12F, 14, 19F, 23F, 25, 7F, and 18C), did not support the efficacy of the vaccine for nonbacteremic pneumonia.

A retrospective cohort analysis study based on the U.S. Centers for Disease Control and Prevention (CDC) pneumococcal surveillance system, showed 57% (95%CI: 45% to 66%) overall protective effectiveness against invasive infections caused by serotypes included in PNEUMOVAX 23 in persons ≥6 years of age, 65 to 84% effectiveness among specific patient groups (e.g., persons with diabetes mellitus, coronary vascular disease, congestive heart failure, chronic pulmonary disease, and anatomic asplenia) and 75% (95%CI: 57% to 85%) effectiveness in immunocompetent persons aged ≥65 years of age. Vaccine effectiveness could not be confirmed for certain groups of immunocompromised patients.

14.2 Immunogenicity

The levels of antibodies that correlate with protection against pneumococcal disease have not been clearly defined.

Antibody responses to most pneumococcal capsular types are generally low or inconsistent in children less than 2 years of age.

Sequential Administration of Prevnar 13 and PNEUMOVAX 23

In a randomized, double-blind, placebo-controlled, multicenter study, healthy adults, 50 years of age and older, received Prevnar 13 followed by PNEUMOVAX 23 either 8 weeks later (Group 1) or 26 weeks later (Group 2). Four hundred subjects were randomized 1:1 into Group 1 or Group 2, all of whom were initially vaccinated with Prevnar 13; of these, 188 subjects received PNEUMOVAX 23 (Group 1) and 185 subjects received placebo (Group 2) at Week 8, and 172 subjects received placebo (Group 1) and 164 subjects received PNEUMOVAX 23 (Group 2) at Week 26.

Opsonophagocytic activity (OPA) titers were measured at prevaccination, at Week 12 and at Week 30 for the 12 shared serotypes contained in both PNEUMOVAX 23 and Prevnar 13 (1, 3, 4, 5, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F), 2 of the 11 serotypes unique to PNEUMOVAX 23 (22F and 33F), and 1 serotype unique to Prevnar 13 (6A). OPA testing was performed on evaluable serum samples from all subjects at baseline (Day 1) and Week 12, and on sera from a random subset of subjects (approximately 50% of subjects) at Week 30. Estimated GMTs, GMT ratio, and 95% confidence intervals were obtained from a constrained Longitudinal Data Analysis model {1}.

For each of the shared serotypes, Week 12 OPA geometric mean titers (GMTs) in Group 1 were noninferior to those of Group 2, as the lower bounds of the 95% CIs for the OPA GMT ratios were >0.5 for all 12 shared serotypes. For serotypes 22F and 33F, OPA GMTs in Group 1 at Week 12 were superior to those of Group 2 at Week 12, as the lower bounds of the 95% CIs for the OPA GMT ratios were >2.0 for both serotypes.

The OPA GMTs to the 12 shared serotypes and 2 unique serotypes (22F and 33F) when measured 4 weeks after dosing with PNEUMOVAX 23 were generally similar between Group 1 (Week 12) and Group 2 (Week 30 subset).

14.3 Concomitant Administration with Other Vaccines

In a double-blind, controlled clinical trial, 473 adults, 60 years of age or older, were randomized to receive ZOSTAVAX and PNEUMOVAX 23 concomitantly (N=237), or PNEUMOVAX 23 alone followed 4 weeks later by ZOSTAVAX alone (N=236). At four weeks postvaccination, the varicella-zoster virus (VZV) antibody levels following concomitant use were significantly lower than the VZV antibody levels following nonconcomitant administration (GMTs of 338 vs. 484 gpELISA units/mL, respectively; GMT ratio = 0.70 (95% CI: [0.61, 0.80]).

Limited safety and immunogenicity data from clinical trials are available on the concurrent administration of PNEUMOVAX 23 and vaccines other than ZOSTAVAX.

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