Vaccine Information: RotaTeq

ROTATEQ- human rotavirus a type g1p7(5) strain wi79 live antigen, human rotavirus a type g2p7(5) strain sc2 live antigen, human rotavirus a type g3p7(5) strain wi78 live antigen, human rotavirus a type g4p7(5) strain brb live antigen and human rotavirus a type g6p1a(8) strain wi79 live antigen solution
Merck Sharp & Dohme LLC

1 INDICATIONS AND USAGE

RotaTeq® is indicated for the prevention of rotavirus gastroenteritis in infants and children caused by types G1, G2, G3, G4, and G9 when administered as a 3-dose series to infants between the ages of 6 to 32 weeks. The first dose of RotaTeq should be administered between 6 and 12 weeks of age [see Dosage and Administration (2)].

2 DOSAGE AND ADMINISTRATION

FOR ORAL USE ONLY. NOT FOR INJECTION.

The vaccination series consists of three ready-to-use liquid doses of RotaTeq administered orally starting at 6 to 12 weeks of age, with the subsequent doses administered at 4- to 10-week intervals. The third dose should not be given after 32 weeks of age [see Clinical Studies (14)].

There are no restrictions on the infant’s consumption of food or liquid, including breast milk, either before or after vaccination with RotaTeq.

Do not mix the RotaTeq vaccine with any other vaccines or solutions. Do not reconstitute or dilute [see Dosage and Administration (2.2)].

For storage instructions [see How Supplied/Storage and Handling (16.1)].

Each dose is supplied in a container consisting of a squeezable plastic dosing tube with a twist-off cap, allowing for direct oral administration. The dosing tube is contained in a pouch [see Dosage and Administration (2.2)].

2.1 Use with Other Vaccines

In clinical trials, RotaTeq was administered concomitantly with other licensed pediatric vaccines [see Adverse Reactions (6.1), Drug Interactions (7.1), and Clinical Studies (14)].

2.2 Instructions for Use

To administer the vaccine:
	Tear open the pouch and remove the dosing tube.
	Clear the fluid from the dispensing tip by holding tube vertically and tapping cap.
	Open the dosing tube in 2 easy motions:
	1. Puncture the dispensing tip by screwing cap clockwise until it becomes tight.
	2. Remove cap by turning it counterclockwise .
	Administer dose by gently squeezing liquid into infant’s mouth toward the inner cheek until dosing tube is empty. (A residual drop may remain in the tip of the tube.)
	If for any reason an incomplete dose is administered (e.g., infant spits or regurgitates the vaccine), a replacement dose is not recommended, since such dosing was not studied in the clinical trials. The infant should continue to receive any remaining doses in the recommended series.
	Discard the empty tube and cap in approved biological waste containers according to local regulations.

3 DOSAGE FORMS AND STRENGTHS

RotaTeq, 2 mL for oral use, is a ready-to-use solution of live reassortant rotaviruses, containing G1, G2, G3, G4 and P1A[8] which contains a minimum of 2.0 – 2.8 x 10⁶ infectious units (IU) per individual reassortant dose, depending on the reassortant and not greater than 116 x 10⁶ IU per aggregate dose.

Each dose is supplied in a container consisting of a squeezable plastic dosing tube with a twist-off cap, allowing for direct oral administration. The dosing tube is contained in a pouch.

4 CONTRAINDICATIONS

4.1 Hypersensitivity

A demonstrated history of hypersensitivity to any component of the vaccine.

Infants who develop symptoms suggestive of hypersensitivity after receiving a dose of RotaTeq should not receive further doses of RotaTeq.

4.2 Severe Combined Immunodeficiency Disease

Infants with Severe Combined Immunodeficiency Disease (SCID) should not receive RotaTeq. Post-marketing reports of gastroenteritis, including severe diarrhea and prolonged shedding of vaccine virus, have been reported in infants who were administered RotaTeq and later identified as having SCID [see Adverse Reactions (6.2)].

4.3 History of Intussusception

Infants with a history of intussusception should not receive RotaTeq.

5 WARNINGS AND PRECAUTIONS

5.1 Managing Allergic Reactions

Appropriate medical treatment and supervision must be available to manage possible anaphylactic reactions following administration of the vaccine.

5.2 Immunocompromised Populations

No safety or efficacy data are available from clinical trials regarding the administration of RotaTeq to infants who are potentially immunocompromised including:

• Infants with blood dyscrasias, leukemia, lymphomas of any type, or other malignant neoplasms affecting the bone marrow or lymphatic system.
• Infants on immunosuppressive therapy (including high-dose systemic corticosteroids). RotaTeq may be administered to infants who are being treated with topical corticosteroids or inhaled steroids.
• Infants with primary and acquired immunodeficiency states, including HIV/AIDS or other clinical manifestations of infection with human immunodeficiency viruses; cellular immune deficiencies; and hypogammaglobulinemic and dysgammaglobulinemic states. There are insufficient data from the clinical trials to support administration of RotaTeq to infants with indeterminate HIV status who are born to mothers with HIV/AIDS.
• Infants who have received a blood transfusion or blood products, including immunoglobulins within 42 days.

Vaccine virus transmission from vaccine recipient to non-vaccinated contacts has been reported [see Warnings and Precautions (5.5)].

5.3 Intussusception

Following administration of a previously licensed live rhesus rotavirus reassortant vaccine, an increased risk of intussusception was observed.{1}

In a post-marketing observational study in the US cases of intussusception were observed in temporal association within 21 days following the first dose of RotaTeq, with a clustering of cases in the first 7 days. [See Adverse Reactions (6.2).]

In worldwide passive post-marketing surveillance, cases of intussusception have been reported in temporal association with RotaTeq. [See Adverse Reactions (6.2).]

5.4 Gastrointestinal Illness

No safety or efficacy data are available for administration of RotaTeq to infants with a history of gastrointestinal disorders including infants with active acute gastrointestinal illness, infants with chronic diarrhea and failure to thrive, and infants with a history of congenital abdominal disorders, and abdominal surgery. Caution is advised when considering administration of RotaTeq to these infants.

5.5 Shedding and Transmission

Shedding of vaccine virus was evaluated among a subset of subjects in the Rotavirus Efficacy and Safety Trial (Study 006, also known as REST) 4 to 6 days after each dose and among all subjects who submitted a stool antigen rotavirus positive sample at any time. RotaTeq was shed in the stools of 32 of 360 [8.9%, 95% CI (6.2%, 12.3%)] vaccine recipients tested after dose 1; 0 of 249 [0.0%, 95% CI (0.0%, 1.5%)] vaccine recipients tested after dose 2; and in 1 of 385 [0.3%, 95% CI (<0.1%, 1.4%)] vaccine recipients after dose 3. In phase 3 studies, shedding was observed as early as 1 day and as late as 15 days after a dose. Transmission of vaccine virus was not evaluated in phase 3 studies.

Transmission of vaccine virus strains from vaccinees to non-vaccinated contacts has been observed post-marketing.

The potential risk of transmission of vaccine virus should be weighed against the risk of acquiring and transmitting natural rotavirus.

Caution is advised when considering whether to administer RotaTeq to individuals with immunodeficient close contacts such as:

• Individuals with malignancies or who are otherwise immunocompromised;
• Individuals with primary immunodeficiency; or
• Individuals receiving immunosuppressive therapy.

5.6 Febrile Illness

Febrile illness may be reason for delaying use of RotaTeq except when, in the opinion of the physician, withholding the vaccine entails a greater risk. Low-grade fever (<100.5°F [38.1°C]) itself and mild upper respiratory infection do not preclude vaccination with RotaTeq.

5.7 Incomplete Regimen

The clinical studies were not designed to assess the level of protection provided by only one or two doses of RotaTeq.

5.8 Limitations of Vaccine Effectiveness

RotaTeq may not protect all vaccine recipients against rotavirus.

5.9 Post-Exposure Prophylaxis

No clinical data are available for RotaTeq when administered after exposure to rotavirus.

6 ADVERSE REACTIONS

6.1 Clinical Studies Experience

71,725 infants were evaluated in 3 placebo-controlled clinical trials including 36,165 infants in the group that received RotaTeq and 35,560 infants in the group that received placebo. Parents/guardians were contacted on days 7, 14, and 42 after each dose regarding intussusception and any other serious adverse events. The racial distribution was as follows: White (69% in both groups); Hispanic-American (14% in both groups); Black (8% in both groups); Multiracial (5% in both groups); Asian (2% in both groups); Native American (RotaTeq 2%, placebo 1%); and Other (<1% in both groups). The gender distribution was 51% male and 49% female in both vaccination groups.

Because clinical trials are conducted under conditions that may not be typical of those observed in clinical practice, the adverse reaction rates presented below may not be reflective of those observed in clinical practice.

Serious Adverse Events

Serious adverse events occurred in 2.4% of recipients of RotaTeq when compared to 2.6% of placebo recipients within the 42-day period of a dose in the phase 3 clinical studies of RotaTeq. The most frequently reported serious adverse events for RotaTeq compared to placebo were:

bronchiolitis (0.6% RotaTeq vs. 0.7% Placebo),

gastroenteritis (0.2% RotaTeq vs. 0.3% Placebo),

pneumonia (0.2% RotaTeq vs. 0.2% Placebo),

fever (0.1% RotaTeq vs. 0.1% Placebo), and

urinary tract infection (0.1% RotaTeq vs. 0.1% Placebo).

Deaths

Across the clinical studies, 52 deaths were reported. There were 25 deaths in the RotaTeq recipients compared to 27 deaths in the placebo recipients. The most commonly reported cause of death was sudden infant death syndrome, which was observed in 8 recipients of RotaTeq and 9 placebo recipients.

Intussusception

In Study 006, 34,837 vaccine recipients and 34,788 placebo recipients were monitored by active surveillance to identify potential cases of intussusception at 7, 14, and 42 days after each dose, and every 6 weeks thereafter for 1 year after the first dose.

For the primary safety outcome, cases of intussusception occurring within 42 days of any dose, there were 6 cases among RotaTeq recipients and 5 cases among placebo recipients (see Table 1). The data did not suggest an increased risk of intussusception relative to placebo.

Table 1: Confirmed cases of intussusception in recipients of RotaTeq as compared with placebo recipients during Study 006

* Relative risk and 95% confidence interval based upon group sequential design stopping criteria employed in Study 006.
	RotaTeq (n=34,837)	Placebo (n=34,788)
Confirmed intussusception cases within 42 days of any dose	6	5
Relative risk (95% CI) *	1.6 (0.4, 6.4)
Confirmed intussusception cases within 365 days of dose 1	13	15
Relative risk (95% CI)	0.9 (0.4, 1.9)

Among vaccine recipients, there were no confirmed cases of intussusception within the 42-day period after the first dose, which was the period of highest risk for the rhesus rotavirus-based product (see Table 2).

Table 2: Intussusception cases by day range in relation to dose in Study 006

	Dose 1		Dose 2		Dose 3		Any Dose
Day Range	RotaTeq	Placebo	RotaTeq	Placebo	RotaTeq	Placebo	RotaTeq	Placebo
1-7	0	0	1	0	0	0	1	0
1-14	0	0	1	0	0	1	1	1
1-21	0	0	3	0	0	1	3	1
1-42	0	1	4	1	2	3	6	5

All of the children who developed intussusception recovered without sequelae with the exception of a 9-month-old male who developed intussusception 98 days after dose 3 and died of post-operative sepsis. There was a single case of intussusception among 2,470 recipients of RotaTeq in a 7-month-old male in the phase 1 and 2 studies (716 placebo recipients).

Hematochezia

Hematochezia reported as an adverse experience occurred in 0.6% (39/6,130) of vaccine and 0.6% (34/5,560) of placebo recipients within 42 days of any dose. Hematochezia reported as a serious adverse experience occurred in <0.1% (4/36,150) of vaccine and <0.1% (7/35,536) of placebo recipients within 42 days of any dose.

Seizures

All seizures reported in the phase 3 trials of RotaTeq (by vaccination group and interval after dose) are shown in Table 3.

Table 3: Seizures reported by day range in relation to any dose in the phase 3 trials of RotaTeq

Day range	1-7	1-14	1-42
RotaTeq	10	15	33
Placebo	5	8	24

Seizures reported as serious adverse experiences occurred in <0.1% (27/36,150) of vaccine and <0.1% (18/35,536) of placebo recipients (not significant). Ten febrile seizures were reported as serious adverse experiences, 5 were observed in vaccine recipients and 5 in placebo recipients.

Kawasaki Disease

In the phase 3 clinical trials, infants were followed for up to 42 days of vaccine dose. Kawasaki disease was reported in 5 of 36,150 vaccine recipients and in 1 of 35,536 placebo recipients with unadjusted relative risk 4.9 (95% CI 0.6, 239.1).

Most Common Adverse Events

Solicited Adverse Events

Detailed safety information was collected from 11,711 infants (6,138 recipients of RotaTeq) which included a subset of subjects in Study 006 and all subjects from Studies 007 and 009 (Detailed Safety Cohort). A Vaccination Report Card was used by parents/guardians to record the child’s temperature and any episodes of diarrhea and vomiting on a daily basis during the first week following each vaccination. Table 4 summarizes the frequencies of these adverse events and irritability.

Table 4: Solicited adverse experiences within the first week after doses 1, 2, and 3 (Detailed Safety Cohort)

* Temperature ≥100.5°F [38.1°C] rectal equivalent obtained by adding 1 degree F to otic and oral temperatures and 2 degrees F to axillary temperatures
Adverse experience	Dose 1		Dose 2		Dose 3
	RotaTeq	Placebo	RotaTeq	Placebo	RotaTeq	Placebo
Elevated temperature *	n=5,61617.1%	n=5,07716.2%	n=5,21520.0%	n=4,72519.4%	n=4,86518.2%	n=4,38217.6%
	n=6,130	n=5,560	n=5,703	n=5,173	n=5,496	n=4,989
Vomiting	6.7%	5.4%	5.0%	4.4%	3.6%	3.2%
Diarrhea	10.4%	9.1%	8.6%	6.4%	6.1%	5.4%
Irritability	7.1%	7.1%	6.0%	6.5%	4.3%	4.5%

Other Adverse Events

Parents/guardians of the 11,711 infants were also asked to report the presence of other events on the Vaccination Report Card for 42 days after each dose.

Fever was observed at similar rates in vaccine (N=6,138) and placebo (N=5,573) recipients (42.6% vs. 42.8%). Adverse events that occurred at a statistically higher incidence (i.e., 2-sided p-value <0.05) within the 42 days of any dose among recipients of RotaTeq as compared with placebo recipients are shown in Table 5.

Table 5: Adverse events that occurred at a statistically higher incidence within 42 days of any dose among recipients of RotaTeq as compared with placebo recipients

Adverse event	RotaTeqN=6,138	PlaceboN=5,573
	n (%)	n (%)
Diarrhea	1,479 (24.1%)	1,186 (21.3%)
Vomiting	929 (15.2%)	758 (13.6%)
Otitis media	887 (14.5%)	724 (13.0%)
Nasopharyngitis	422 (6.9%)	325 (5.8%)
Bronchospasm	66 (1.1%)	40 (0.7%)

Safety in Pre-Term Infants

RotaTeq or placebo was administered to 2,070 pre-term infants (25 to 36 weeks gestational age, median 34 weeks) according to their age in weeks since birth in Study 006. All pre-term infants were followed for serious adverse experiences; a subset of 308 infants was monitored for all adverse experiences. There were 4 deaths throughout the study, 2 among vaccine recipients (1 SIDS and 1 motor vehicle accident) and 2 among placebo recipients (1 SIDS and 1 unknown cause). No cases of intussusception were reported. Serious adverse experiences occurred in 5.5% of vaccine and 5.8% of placebo recipients. The most common serious adverse experience was bronchiolitis, which occurred in 1.4% of vaccine and 2.0% of placebo recipients. Parents/guardians were asked to record the child’s temperature and any episodes of vomiting and diarrhea daily for the first week following vaccination. The frequencies of these adverse experiences and irritability within the week after dose 1 are summarized in Table 6.

Table 6: Solicited adverse experiences within the first week of doses 1, 2, and 3 among pre-term infants

* Temperature ≥100.5°F [38.1°C] rectal equivalent obtained by adding 1 degree F to otic and oral temperatures and 2 degrees F to axillary temperatures
	Dose 1		Dose 2		Dose 3
Adverse event	RotaTeq	Placebo	RotaTeq	Placebo	RotaTeq	Placebo
	N=127	N=133	N=124	N=121	N=115	N=108
Elevated temperature *	18.1%	17.3%	25.0%	28.1%	14.8%	20.4%
	N=154	N=154	N=137	N=137	N=135	N=129
Vomiting	5.8%	7.8%	2.9%	2.2%	4.4%	4.7%
Diarrhea	6.5%	5.8%	7.3%	7.3%	3.7%	3.9%
Irritability	3.9%	5.2%	2.9%	4.4%	8.1%	5.4%