Pneumo 23

Overdose

Overdose with Pneumo 23 13 is unlikely due to its presentation as a pre-filled syringe. However, in infants and children there have been reports of overdose with Pneumo 23 13 defined as subsequent doses administered closer than recommended to the previous dose. In general, adverse events reported with overdose are consistent with those that have been reported with doses given in the recommended paediatric schedules of Pneumo 23 13.

Overdose with Pneumo 23 is unlikely due to its presentation as a pre-filled syringe. However, in infants and children there have been reports of overdose with Pneumo 23 defined as subsequent doses administered closer than recommended to the previous dose. In general, adverse events reported with overdose are consistent with those that have been reported with doses given in the recommended paediatric schedules of Pneumo 23.

Contraindications

As with other vaccines, the administration of Pneumo 23 13 should be postponed in subjects suffering from acute, severe febrile illness. However, the presence of a minor infection, such as a cold, should not result in the deferral of vaccination.

As with other vaccines, the administration of Pneumo 23 should be postponed in subjects suffering from acute, severe febrile illness. However, the presence of a minor infection, such as a cold, should not result in the deferral of vaccination.

Incompatibilities

In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.

Pharmaceutical form

Undesirable effects

Analysis of postmarketing reporting rates suggests a potential increased risk of convulsions, with or without fever, and HHE when comparing groups which reported use of Pneumo 23 13 with

Infanrix hexa to those which reported use of Pneumo 23 13 alone.

Adverse reactions reported in clinical studies or from the postmarketing experience for all age groups are listed in this section per system organ class, in decreasing order of frequency and seriousness. The frequency is defined as follows: very common (> 1/10), common (> 1/100 to < 1/10), uncommon (> 1/1,000 to < 1/100), rare (> 1/10,000 to < 1/1,000), very rare (< 1/10,000), not known (cannot be estimated from available data).

Infants and children aged 6 weeks to 5 years

The safety of the vaccine was assessed in controlled clinical studies where 14,267 doses were given to 4,429 healthy infants from 6 weeks of age at first vaccination and 11-16 months of age at booster dose. In all infant studies, Pneumo 23 13 was co-administered with routine paediatric vaccines.

Safety in 354 previously unvaccinated children (7 months to 5 years of age) was also assessed.

The most commonly reported adverse reactions in children 6 weeks to 5 years of age were vaccination-site reactions, fever, irritability, decreased appetite, and increased and/or decreased sleep.

In a clinical study in infants vaccinated at 2, 3, and 4 months of age, fever > 38°C was reported at higher rates among infants who received Pneumo 23 (7-valent) concomitantly with Infanrix hexa (28.3% to 42.3%) than in infants receiving Infanrix hexa alone (15.6% to 23.1%). After a booster dose at 12 to 15 months of age, fever > 38°C was reported in 50.0% of infants who received Pneumo 23 (7-valent) and Infanrix hexa at the same time as compared to 33.6% of infants receiving Infanrix hexa alone. These reactions were mostly moderate (less than or equal to 39°C) and transient.

An increase in vaccination-site reactions was reported in children older than 12 months compared to rates observed in infants during the primary series with Pneumo 23 13.

Adverse reactions from clinical studies

In clinical studies, the safety profile of Pneumo 23 13 was similar to Pneumo 23. The following frequencies are based on adverse reactions assessed in Pneumo 23 13 clinical studies:

Adverse reactions from Pneumo 23 13 postmarketing experience

Although the following adverse drug reactions were not observed in the Pneumo 23 13 clinical studies in infants and children, the following are considered adverse drug reactions for Pneumo 23 13 as they were reported in the postmarketing experience. Because these reactions were derived from spontaneous reports, the frequencies could not be determined and are thus considered as not known.

Blood and lymphatic system disorders:

Lymphadenopathy (localised to the region of the vaccination-site)

Immune system disorders:

Anaphylactic/anaphylactoid reaction including shock; angioedema

Skin and subcutaneous tissue disorders:

Erythema multiforme

General disorders and administration site conditions:

Vaccination-site urticaria; vaccination-site dermatitis; vaccination-site pruritus; flushing

Additional information in special populations:

Apnoea in very premature infants (≤ 28 weeks of gestation).

Children and adolescents aged 6 to 17 years of age

Safety was evaluated in 592 children (294 children aged 5 to 10 years previously immunised with at least one dose of Pneumo 23 and 298 children aged 10 to 17 years who had not received a pneumococcal vaccine).

The most common adverse events in children and adolescents 6 to 17 years of age were:

Other adverse events previously observed in infants and children 6 weeks to 5 years of age may also be applicable to this age group but were not seen in this study possibly due to the small sample size.

Additional information in special populations

Children and adolescents with sickle cell disease, HIV infection, or an haematopoietic stem cell transplant have similar frequencies of adverse reactions, except that headaches, vomiting, diarrhoea, pyrexia, fatigue, arthralgia, and myalgia were very common.

Adults >18 years and the elderly

Safety was assessed in 7 clinical studies including 91,593 adults ranging in age from 18 to 101 years. Pneumo 23 13 was administered to 48,806 adults; 2,616 (5.4%) aged 50 to 64 years, and 45,291 (92.8%) aged 65 years and older. One of the 7 studies included a group of adults (n=899) ranging from 18 to 49 years who received Pneumo 23 13 and who were not previously vaccinated with 23-valent pneumococcal polysaccharide vaccine. Of the Pneumo 23 13 recipients 1,916 adults were previously vaccinated with the 23-valent pneumococcal polysaccharide vaccine at least 3 years prior to study vaccination, and 46,890 were 23-valent pneumococcal polysaccharide vaccine unvaccinated.

A trend to lower frequency of adverse reactions was associated with greater age; adults >65 years of age (regardless of prior pneumococcal vaccination status) reported fewer adverse reactions than younger adults, with adverse reactions generally most common in the youngest adults, 18 to 29 years of age.

Overall, the frequency categories were similar for all age groups, with the exception of vomiting which was very common (> 1/10) in adults aged 18 to 49 years and common (> 1/100 to < 1/10) in all other age groups, and pyrexia was very common in adults aged 18 to 29 years and common in all other age groups. Severe vaccination-site pain/tenderness and severe limitation of arm movement was very common in adults 18 to 39 years and common in all other age groups.

Adverse reactions from clinical studies

Local reactions and systemic events were solicited daily after each vaccination for 14 days in 6 studies and 7 days in the remaining study. The following frequencies are based on adverse reactions assessed in Pneumo 23 13 clinical studies in adults:

Overall, no significant differences in frequencies of adverse reactions were seen when Pneumo 23 13 was given to adults previously vaccinated with the pneumococcal polysaccharide vaccine.

Additional information in special populations

Adults with HIV infection have similar frequencies of adverse reactions, except that pyrexia and vomiting were very common and nausea common.

Adults with an haematopoietic stem cell transplant have similar frequencies of adverse reactions, except that pyrexia and vomiting were very common.

Higher frequency in some solicited systemic reactions was observed when Pneumo 23 13 was administered concomitantly with trivalent inactivated influenza vaccine (TIV) compared to TIV given alone (headache, chills, rash, decreased appetite, arthralgia, and myalgia) or Pneumo 23 13 given alone (headache, fatigue, chills, decreased appetite, and arthralgia).

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

Analysis of postmarketing reporting rates suggests a potential increased risk of convulsions, with or without fever, and HHE when comparing groups which reported use of Pneumo 23 with

Infanrix hexa to those which reported use of Pneumo 23 alone.

Adverse reactions reported in clinical studies or from the postmarketing experience for all age groups are listed in this section per system organ class, in decreasing order of frequency and seriousness. The frequency is defined as follows: very common (> 1/10), common (> 1/100 to < 1/10), uncommon (> 1/1,000 to < 1/100), rare (> 1/10,000 to < 1/1,000), very rare (< 1/10,000), not known (cannot be estimated from available data).

Infants and children aged 6 weeks to 5 years

The safety of the vaccine was assessed in controlled clinical studies where 14,267 doses were given to 4,429 healthy infants from 6 weeks of age at first vaccination and 11-16 months of age at booster dose. In all infant studies, Pneumo 23 was co-administered with routine paediatric vaccines.

Safety in 354 previously unvaccinated children (7 months to 5 years of age) was also assessed.

The most commonly reported adverse reactions in children 6 weeks to 5 years of age were vaccination-site reactions, fever, irritability, decreased appetite, and increased and/or decreased sleep.

In a clinical study in infants vaccinated at 2, 3, and 4 months of age, fever > 38°C was reported at higher rates among infants who received Prevenar (7-valent) concomitantly with Infanrix hexa (28.3% to 42.3%) than in infants receiving Infanrix hexa alone (15.6% to 23.1%). After a booster dose at 12 to 15 months of age, fever > 38°C was reported in 50.0% of infants who received Prevenar (7-valent) and Infanrix hexa at the same time as compared to 33.6% of infants receiving Infanrix hexa alone. These reactions were mostly moderate (less than or equal to 39°C) and transient.

An increase in vaccination-site reactions was reported in children older than 12 months compared to rates observed in infants during the primary series with Pneumo 23.

Adverse reactions from clinical studies

In clinical studies, the safety profile of Pneumo 23 was similar to Prevenar. The following frequencies are based on adverse reactions assessed in Pneumo 23 clinical studies:

Adverse reactions from Pneumo 23 postmarketing experience

Although the following adverse drug reactions were not observed in the Pneumo 23 clinical studies in infants and children, the following are considered adverse drug reactions for Pneumo 23 as they were reported in the postmarketing experience. Because these reactions were derived from spontaneous reports, the frequencies could not be determined and are thus considered as not known.

Blood and lymphatic system disorders:

Lymphadenopathy (localised to the region of the vaccination-site)

Immune system disorders:

Anaphylactic/anaphylactoid reaction including shock; angioedema

Skin and subcutaneous tissue disorders:

Erythema multiforme

General disorders and administration site conditions:

Vaccination-site urticaria; vaccination-site dermatitis; vaccination-site pruritus; flushing

Additional information in special populations:

Apnoea in very premature infants (≤ 28 weeks of gestation).

Children and adolescents aged 6 to 17 years of age

Safety was evaluated in 592 children (294 children aged 5 to 10 years previously immunised with at least one dose of Prevenar and 298 children aged 10 to 17 years who had not received a pneumococcal vaccine).

The most common adverse events in children and adolescents 6 to 17 years of age were:

Other adverse events previously observed in infants and children 6 weeks to 5 years of age may also be applicable to this age group but were not seen in this study possibly due to the small sample size.

Additional information in special populations

Children and adolescents with sickle cell disease, HIV infection, or an haematopoietic stem cell transplant have similar frequencies of adverse reactions, except that headaches, vomiting, diarrhoea, pyrexia, fatigue, arthralgia, and myalgia were very common.

Adults >18 years and the elderly

Safety was assessed in 7 clinical studies including 91,593 adults ranging in age from 18 to 101 years. Pneumo 23 was administered to 48,806 adults; 2,616 (5.4%) aged 50 to 64 years, and 45,291 (92.8%) aged 65 years and older. One of the 7 studies included a group of adults (n=899) ranging from 18 to 49 years who received Pneumo 23 and who were not previously vaccinated with 23-valent pneumococcal polysaccharide vaccine. Of the Pneumo 23 recipients 1,916 adults were previously vaccinated with the 23-valent pneumococcal polysaccharide vaccine at least 3 years prior to study vaccination, and 46,890 were 23-valent pneumococcal polysaccharide vaccine unvaccinated.

A trend to lower frequency of adverse reactions was associated with greater age; adults >65 years of age (regardless of prior pneumococcal vaccination status) reported fewer adverse reactions than younger adults, with adverse reactions generally most common in the youngest adults, 18 to 29 years of age.

Overall, the frequency categories were similar for all age groups, with the exception of vomiting which was very common (> 1/10) in adults aged 18 to 49 years and common (> 1/100 to < 1/10) in all other age groups, and pyrexia was very common in adults aged 18 to 29 years and common in all other age groups. Severe vaccination-site pain/tenderness and severe limitation of arm movement was very common in adults 18 to 39 years and common in all other age groups.

Adverse reactions from clinical studies

Local reactions and systemic events were solicited daily after each vaccination for 14 days in 6 studies and 7 days in the remaining study. The following frequencies are based on adverse reactions assessed in Pneumo 23 clinical studies in adults:

Overall, no significant differences in frequencies of adverse reactions were seen when Pneumo 23 was given to adults previously vaccinated with the pneumococcal polysaccharide vaccine.

Additional information in special populations

Adults with HIV infection have similar frequencies of adverse reactions, except that pyrexia and vomiting were very common and nausea common.

Adults with an haematopoietic stem cell transplant have similar frequencies of adverse reactions, except that pyrexia and vomiting were very common.

Higher frequency in some solicited systemic reactions was observed when Pneumo 23 was administered concomitantly with trivalent inactivated influenza vaccine (TIV) compared to TIV given alone (headache, chills, rash, decreased appetite, arthralgia, and myalgia) or Pneumo 23 given alone (headache, fatigue, chills, decreased appetite, and arthralgia).

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

Preclinical safety data

Non-clinical data revealed no special hazard for humans based on conventional studies of safety pharmacology, single and repeated dose toxicity, local tolerance, and reproduction and developmental toxicity.

Therapeutic indications

Active immunisation for the prevention of invasive disease, pneumonia and acute otitis media caused by Streptococcus pneumoniae in infants, children and adolescents from 6 weeks to 17 years of age.

Active immunisation for the prevention of invasive disease and pneumonia caused by Streptococcus pneumoniae in adults >18 years of age and the elderly.

1 for information on protection against specific pneumococcal serotypes.

The use of Pneumo 23 13 should be determined on the basis of official recommendations taking into consideration the risk of invasive disease and pneumonia in different age groups, underlying comorbidities as well as the variability of serotype epidemiology in different geographical areas.

Active immunisation for the prevention of invasive disease, pneumonia and acute otitis media caused by Streptococcus pneumoniae in infants, children and adolescents from 6 weeks to 17 years of age.

Active immunisation for the prevention of invasive disease and pneumonia caused by Streptococcus pneumoniae in adults >18 years of age and the elderly.

1 for information on protection against specific pneumococcal serotypes.

The use of Pneumo 23 should be determined on the basis of official recommendations taking into consideration the risk of invasive disease and pneumonia in different age groups, underlying comorbidities as well as the variability of serotype epidemiology in different geographical areas.

Pharmacotherapeutic group

Pharmacodynamic properties

Pharmacotherapeutic group: vaccines, pneumococcal vaccines; ATC code: J07AL02

Pneumo 23 13 contains the 7 pneumococcal capsular polysaccharides that are in Pneumo 23 (4, 6B, 9V, 14, 18C, 19F, 23F) plus 6 additional polysaccharides (1, 3, 5, 6A, 7F, 19A) all conjugated to CRM197 carrier protein.

Burden of disease

Infants and children aged 6 weeks to 5 years

Based on serotype surveillance in Europe performed before the introduction of Pneumo 23, Pneumo 23 13 is estimated to cover 73-100 % (depending on the country) of serotypes causing invasive pneumococcal disease (IPD) in children less than 5 years of age. In this age group, serotypes 1, 3, 5, 6A, 7F, and 19A account for 15.6 % to 59.7 % of invasive disease, depending on the country, the time period studied, and the use of Pneumo 23.

Acute otitis media (AOM) is a common childhood disease with different aetiologies. Bacteria can be responsible for 60-70 % of clinical episodes of AOM. S. pneumoniae is one of the most common causes of bacterial AOM worldwide.

Pneumo 23 13 is estimated to cover over 90% of serotypes causing antimicrobial-resistant IPD.

Children and adolescents aged 6 to 17 years

In children and adolescents aged 6 to 17 years, the incidence of pneumococcal disease is low, however, there is an increased risk of morbidity and mortality in those with underlying comorbidities.

Adults >18 years and the elderly

Pneumonia is the most common clinical presentation of pneumococcal disease in adults.

The reported incidence of community-acquired pneumonia (CAP) and IPD in Europe varies by country, increases with age from 50 years and is highest in individuals aged > 65 years. S. pneumoniae is the most frequent cause of CAP, and is estimated to be responsible for approximately 30% of all CAP cases requiring hospitalisation in adults in developed countries.

Bacteraemic pneumonia (approximately 80% of IPD in adults), bacteraemia without a focus, and meningitis are the most common manifestations of IPD in adults. Based on surveillance data following the introduction of Pneumo 23 but before the introduction of Pneumo 23 13 in childhood vaccination programmes, the pneumococcal serotypes in Pneumo 23 13 may be responsible for at least 50 - 76% (depending on country) of IPD in adults.

The risk for CAP and IPD in adults also increases with chronic underlying medical conditions, specifically, anatomical or functional asplenia, diabetes mellitus, asthma, chronic cardiovascular, pulmonary, kidney or liver disease, and it is highest in those who are immune-suppressed such as those with malignant haematological diseases or HIV infection.

Pneumo 23 13 immunogenicity clinical studies in infants, children and adolescents

The protective efficacy of Pneumo 23 13 against IPD has not been studied. As recommended by the World Health Organization (WHO) the assessment of potential efficacy against IPD in infants and young children has been based on a comparison of immune responses to the seven common serotypes shared between Pneumo 23 13 and Pneumo 23, for which protective efficacy has been proven (for Pneumo 23 (7-valent) efficacy in infants and children, see below). Immune responses to the additional 6 serotypes were also measured.

Immune responses following a three-dose primary infant series

Clinical studies have been conducted in a number of European countries and the US using a range of vaccination schedules, including two randomised non-inferiority studies (Germany using a 2, 3, 4 month primary series [006] and US using a 2, 4, 6 month primary series [004]). In these two studies pneumococcal immune responses were compared using a set of non-inferiority criteria including the percentage of subjects with serum anti-polysaccharide serotype-specific IgG > 0.35 μg/ml one month after the primary series and the comparison of IgG geometric mean concentrations (ELISA GMCs); in addition, functional antibody titres (OPA) between subjects receiving Pneumo 23 13 and Pneumo 23 were compared. For the six additional serotypes, these values were compared with the lowest response among all of the seven common serotypes in the Pneumo 23 recipients.

The non-inferiority immune response comparisons for study 006, based on the proportion of infants achieving anti-polysaccharide IgG concentrations > 0.35 μg/ml, are shown in Table 1. Results for study 004 were similar. Pneumo 23 13 non-inferiority (lower bound of the 95% CI for the difference in percentage of responders at 0.35 µg/ml between groups was >-10%) was demonstrated for all 7 common serotypes, except for serotype 6B in study 006 and serotypes 6B and 9V in study 004, which missed by a small margin. All seven common serotypes met pre-defined non-inferiority criteria for IgG ELISA GMCs. Pneumo 23 13 elicited comparable, although slightly lower, antibody levels than Pneumo 23 for the 7 common serotypes. The clinical relevance of these differences is not known.

Non-inferiority was met for the 6 additional serotypes based on the proportion of infants achieving antibody concentrations > 0.35 μg/ml and comparison of IgG ELISA GMCs in study 006 and was met for 5 out of the 6 serotypes, with the exception of serotype 3 for study 004. For serotype 3, the percentages of Pneumo 23 13 recipients with serum IgG > 0.35 μg/ml were 98.2% (study 006) and 63.5% (study 004).

Pneumo 23 13 elicited functional antibodies to all 13 vaccine serotypes in studies 004 and 006. For the 7 common serotypes there were no differences between groups in the proportion of subjects with OPA titres > 1:8. For each of the seven common serotypes, > 96% and > 90 % of the Pneumo 23 13 recipients reached an OPA titre > 1:8 one month after the primary series in studies 006 and 004, respectively.

For each of the 6 additional serotypes, Pneumo 23 13 elicited OPA titres > 1:8 in 91.4% to 100% of vaccinees one month after the primary series in studies 004/006. The functional antibody (OPA) geometric mean titres for serotypes 1, 3 and 5 were lower than the titres for each of the other additional serotypes; the clinical relevance of this observation for protective efficacy is unknown.

Immune responses following a two-dose primary infant series

The immunogenicity after two doses in infants has been documented in four studies. The proportion of infants achieving a pneumococcal anti-capsular polysaccharide IgG concentration > 0.35 μg/ml one month after the second dose ranged from 79.6% to 98.5% across 11 of the 13 vaccine serotypes. Smaller proportions of infants achieved this antibody concentration threshold for serotype 6B (27.9% to 57.3%) and 23F (55.8% to 68.1%) for all studies using a 2, 4 month regimen, compared to 58.4% for serotype 6B and 68.6% for 23F for a study using a 3, 5 month regimen. After the booster dose, all vaccine serotypes including 6B and 23F had immune responses consistent with adequate priming with a two-dose primary series. In a UK study, the functional antibody (OPA) responses were comparable for all serotypes including 6B and 23F in the Pneumo 23 and Pneumo 23 13 arms after the primary series at two and four months of age and after the booster dose at 12 months of age. For Pneumo 23 13 recipients, the proportion of responders with an OPA titre > 1:8 was at least 87% following the infant series, and at least 93% following the booster dose. The OPA geometric mean titres for serotypes 1, 3 and 5 were lower than the titres for each of the other additional serotypes; the clinical relevance of this observation is unknown.

Booster responses following two-dose and three-dose primary infant series

Following the booster dose, antibody concentrations increased from the pre-booster level for all 13 serotypes. Post-booster antibody concentrations were higher for 12 serotypes than those achieved after the infant primary series. These observations are consistent with adequate priming (the induction of immunologic memory). The immune response for serotype 3 following the booster dose was not increased above the levels seen after the infant vaccination series; the clinical relevance of this observation regarding the induction of serotype 3 immune memory is unknown.

Antibody responses to booster doses following two-dose or three-dose infant primary series were comparable for all 13 vaccine serotypes.

For children aged from 7 months to 5 years, age appropriate catch-up immunisation schedules (as described in section 4.2) result in levels of anti-capsular polysaccharide IgG antibody responses to each of the 13 serotypes that are at least comparable to those of a three-dose primary series in infants.

Antibody persistence and immunological memory were evaluated in a study in healthy children who received a single dose of Pneumo 23 13 at least 2 years after they had been previously immunised with either 4 doses of Pneumo 23, a 3-dose infant series of Pneumo 23 followed by Pneumo 23 13 at 12 months of age, or 4 doses of Pneumo 23 13.

The single dose of Pneumo 23 13, in children approximately 3.4 years of age regardless of previous vaccination history with Pneumo 23 or Pneumo 23 13, induced a robust antibody response for both the 7 common serotypes and the 6 additional serotypes in Pneumo 23 13.

Since the introduction of 7-valent Pneumo 23 in 2000, pneumococcal disease surveillance data have not shown that the immunity elicited by Pneumo 23 in infancy has waned over time.

Preterm Infants

Safety and immunogenicity of Pneumo 23 13 given at 2, 3, 4 and 12 months was assessed in approximately 100 prematurely born infants (mean Estimated Gestational Age [EGA], 31 weeks; range, 26 to 36 weeks) and compared with approximately 100 infants born at term (mean EGA, 39 weeks; range, 37 to 42 weeks).

Immune responses in preterm and term infants were compared using the proportion of subjects achieving a pneumococcal polysaccharide IgG binding antibody concentration >0.35 μg/ml 1 month after the infant series, the approach used for immunogenicity comparisons of Pneumo 23 13 to Pneumo 23 based on WHO guidelines.

More than 85% achieved a pneumococcal polysaccharide IgG binding antibody concentration >0.35 µg/ml 1 month after the infant series, except for serotypes 5 (71.7%), 6A (82.7%), and 6B (72.7%) in the preterm group. For these 3 serotypes, the proportion of responders among preterm infants was significantly lower than among term infants. Approximately one month after the toddler dose, the proportion of subjects in each group achieving this same antibody concentration threshold was >97%, except for serotype 3 (71% in preterm infants and 79% in term infants). It is unknown whether immunological memory to all serotypes is induced in pre-term infants. In general, serotype-specific IgG GMCs were lower for preterm infants than term infants.

After the infant series, OPA GMTs were similar in preterm infants compared to term infants except for serotype 5, which was lower in preterm infants. OPA GMTs after the toddler dose relative to those after the infant series were similar or lower for 4 serotypes (4, 14, 18C, and 19F) and were statistically significantly higher for 6 of 13 serotypes (1, 3, 5, 7F, 9V, and 19A) in preterm infants compared to 10 of 13 serotypes (1, 3, 4, 5, 6A, 7F, 9V, 18C, 19A, and 23F) in term infants.

Children (12-59 months) completely immunised with Pneumo 23 (7-valent)

Following administration of a single dose of Pneumo 23 13 to children (12-59 months) who are considered completely immunised with Pneumo 23 (7-valent) (either 2 or 3 dose primary series plus booster), the proportion achieving serum IgG levels >0.35 µg/ml and OPA titres >1:8 was at least 90%. However, 3 (serotypes 1, 5 and 6A) of the 6 additional serotypes showed lower IgG GMC and OPA GMT when compared with children who had received at least one previous vaccination with Pneumo 23 13. The clinical relevance of the lower GMCs and GMTs is currently unknown.

Unvaccinated Children (12-23 months)

Studies in unvaccinated children (12-23 months) with Pneumo 23 (7-valent) demonstrated that 2 doses were required to achieve serum IgG concentrations for 6B and 23F similar to those induced by a 3-dose infant series.

Children and Adolescents 5 to 17 years of age

In an open-label study in 592 healthy children and adolescents including those with asthma (17.4%) who may be predisposed to pneumococcal infection, Pneumo 23 13 elicited immune responses to all 13 serotypes. A single dose of Pneumo 23 13 was given to children 5 to 10 years of age previously vaccinated with at least 1 dose of Pneumo 23, and children and adolescents 10 to 17 years of age who had never received a pneumococcal vaccine.

In both the children 5 to 10 years of age and children and adolescents aged 10 to 17 years, the immune response to Pneumo 23 13 was non inferior to Pneumo 23 for the 7 common serotypes and to Pneumo 23 13 for the 6 additional serotypes compared to the immune response after the fourth dose in infants vaccinated at 2, 4, 6 and 12-15 months of age as measured by serum IgG.

In children and adolescents aged 10 to 17 years of age OPA GMTs 1 month after vaccination were noninferior to OPA GMTs in the 5 to 10 year old age group for 12 of the 13 serotypes (except serotype 3).

Immune responses after subcutaneous administration

Subcutaneous administration of Pneumo 23 13 was evaluated in a non-comparative study in 185 healthy Japanese infants and children who received 4 doses at 2, 4, 6 and 12-15 months of age. The study demonstrated that safety and immunogenicity were generally comparable with observations made in studies of intramuscular administration.

Pneumo 23 13 Effectiveness

Invasive Pneumococcal Disease

Data published by Public Health England showed that, four years after the introduction of Pneumo 23 as a two dose primary infant series with booster dose in the second year of life and with a 94% vaccine uptake, there was a 98% (95% CI 95; 99) reduction in disease caused by the 7 vaccine serotypes in England and Wales. Subsequently, four years following the switch to Pneumo 23 13, the additional reduction in incidence of IPD due to the 7 serotypes in Pneumo 23 ranged from 76% in children less than 2 years of age to 91% in children 5-14 years of age. The serotype specific reductions for each of the 5 additional serotypes in Pneumo 23 13 (no cases of serotype 5 IPD were observed) by age group are shown in Table 2 and ranged from 68% (serotype 3) to 100% (serotype 6A) for children less than 5 years of age. Significant incidence reductions were also observed in older age groups who had not been vaccinated with Pneumo 23 13 (indirect effect).

Otitis Media (OM)

In a published study performed in Israel, using a 2-dose primary series plus booster dose in the second year of life, the impact of Pneumo 23 13 on OM was documented in a population-based active-surveillance system with tympanocentesis culturing of middle ear fluid in Israeli children less than 2 years of age with OM.

Following the introduction of Pneumo 23 and subsequently Pneumo 23 13 there was a decline in incidence from 2.1 to 0.1 cases per 1000 children (95%) for the Pneumo 23 serotypes plus serotype 6A and a decline in incidence from 0.9 to 0.1 cases per 1000 children (89%) for the additional serotypes 1, 3, 5, 7F, and 19A in Pneumo 23 13. The annual overall pneumococcal incidence of OM declined from 9.6 to 2.1 cases per 1000 children (78%) between July 2004 (prior to the introduction of Pneumo 23) and June 2013 (post Pneumo 23 13 introduction).

Pneumonia

In a multicenter observational study in France comparing the periods before and after the switch from Pneumo 23 to Pneumo 23 13, there was 16% (2060 to 1725 cases) reduction in all community acquired pneumonia (CAP) cases in emergency departments in children 1 month to 15 years of age. Reductions were 53% (167 to 79 cases) (p<0.001) for CAP cases with pleural effusion and 63% (64 to 24 cases) (p<0.001) for microbiologically confirmed pneumococcal CAP cases. In the second year after the introduction of Pneumo 23 13 the total number of CAP cases due to the 6 additional vaccine serotypes in Pneumo 23 13 was reduced from 27 to 7 isolates (74%).

The decrease in all cause pneumonia cases was most pronounced in the younger vaccinated age groups with a decrease of 31.8% (757 to 516 cases) and 16.6% (833 to 695 cases) in the age groups <2 years and 2 to 5 years, respectively. The incidence in older, predominantly non-vaccinated children (>5 years) did not change over the duration of the study.

In an ongoing surveillance system (2004 to 2013) to document the impact of Pneumo 23 and subsequently Pneumo 23 13 on CAP in children less than 5 years in Southern Israel using a 2 dose primary series with a booster dose in the second year of life, there was a reduction of 68% (95% CI 73; 61) in outpatient visits and 32% (95% CI 39; 22) in hospitalizations for alveolar CAP following the introduction of Pneumo 23 13 when compared to the period before the introduction of Pneumo 23.

Effect on nasopharyngeal carriage

In a surveillance study in France in children presenting with acute otitis media, changes in nasopharyngeal (NP) carriage of pneumococcal serotypes were evaluated following the introduction of Pneumo 23 (7-valent) and subsequently Pneumo 23 13. Pneumo 23 13 significantly reduced NP carriage of the 6 additional serotypes (and serotype 6C) combined and individual serotypes 6C, 7F, 19A when compared with Pneumo 23. A reduction in carriage was also seen for serotype 3 (2.5% vs 1.1%; p=0.1). There was no carriage of serotypes 1 and 5 observed.

The effect of pneumococcal conjugate vaccination on nasopharyngeal carriage was studied in a randomised double-blind study in which infants received either Pneumo 23 13 or Pneumo 23 (7-valent) at 2, 4, 6 and 12 months of age in Israel. Pneumo 23 13 significantly reduced newly identified NP acquisition of the 6 additional serotypes (and serotype 6C) combined and of individual serotypes 1, 6A, 6C, 7F, 19A when compared with Pneumo 23. There was no reduction seen in serotype 3 and for serotype 5 the colonization was too infrequent to assess impact. For 6 of the remaining 7 common serotypes, similar rates of NP acquisition were observed in both vaccine groups; for serotype 19F a significant reduction was observed.

In this study, reductions of S. pneumoniae serotypes 19A, 19F, and 6A not susceptible to a number of antibiotics were documented. The reductions ranged between 34% and 62% depending on serotype and antibiotic.

Pneumo 23 (7-valent vaccine) protective efficacy in infants and children

The efficacy of 7-valent Pneumo 23 was evaluated in two major studies - the Northern California Kaiser Permanente (NCKP) study and the Finnish Otitis Media (FinOM) study. Both studies were randomised, double-blind, active-control studies in which infants were randomised to receive either Pneumo 23 or control vaccine (NCKP, meningococcal serogroup C CRM-conjugate [MnCC] vaccine; FinOM, hepatitis B vaccine) in a four-dose series at 2, 4, 6, and 12-15 months of age. The efficacy results from these studies (for invasive pneumococcal disease, pneumonia, and acute otitis media) are presented below (Table 3).

Pneumo 23 (7-valent) effectiveness

The effectiveness (both direct and indirect effect) of 7-valent Pneumo 23 against pneumococcal disease has been evaluated in both three-dose and two-dose primary infant series immunisation programmes, each with booster doses (Table 4). Following the widespread use of Pneumo 23, the incidence of IPD has been consistently and substantially reduced.

Using the screening method, serotype-specific effectiveness estimates for 2 doses under the age of 1 year in the UK were 66 % (-29, 91 %) and 100 % (25, 100 %) for serotype 6B and 23F, respectively.

Pharmacotherapeutic group: vaccines, pneumococcal vaccines; ATC code: J07AL02

Pneumo 23 contains the 7 pneumococcal capsular polysaccharides that are in Prevenar (4, 6B, 9V, 14, 18C, 19F, 23F) plus 6 additional polysaccharides (1, 3, 5, 6A, 7F, 19A) all conjugated to CRM197 carrier protein.

Burden of disease

Infants and children aged 6 weeks to 5 years

Based on serotype surveillance in Europe performed before the introduction of Prevenar, Pneumo 23 is estimated to cover 73-100 % (depending on the country) of serotypes causing invasive pneumococcal disease (IPD) in children less than 5 years of age. In this age group, serotypes 1, 3, 5, 6A, 7F, and 19A account for 15.6 % to 59.7 % of invasive disease, depending on the country, the time period studied, and the use of Prevenar.

Acute otitis media (AOM) is a common childhood disease with different aetiologies. Bacteria can be responsible for 60-70 % of clinical episodes of AOM. S. pneumoniae is one of the most common causes of bacterial AOM worldwide.

Pneumo 23 is estimated to cover over 90% of serotypes causing antimicrobial-resistant IPD.

Children and adolescents aged 6 to 17 years

In children and adolescents aged 6 to 17 years, the incidence of pneumococcal disease is low, however, there is an increased risk of morbidity and mortality in those with underlying comorbidities.

Adults >18 years and the elderly

Pneumonia is the most common clinical presentation of pneumococcal disease in adults.

The reported incidence of community-acquired pneumonia (CAP) and IPD in Europe varies by country, increases with age from 50 years and is highest in individuals aged > 65 years. S. pneumoniae is the most frequent cause of CAP, and is estimated to be responsible for approximately 30% of all CAP cases requiring hospitalisation in adults in developed countries.

Bacteraemic pneumonia (approximately 80% of IPD in adults), bacteraemia without a focus, and meningitis are the most common manifestations of IPD in adults. Based on surveillance data following the introduction of Prevenar but before the introduction of Pneumo 23 in childhood vaccination programmes, the pneumococcal serotypes in Pneumo 23 may be responsible for at least 50 - 76% (depending on country) of IPD in adults.

The risk for CAP and IPD in adults also increases with chronic underlying medical conditions, specifically, anatomical or functional asplenia, diabetes mellitus, asthma, chronic cardiovascular, pulmonary, kidney or liver disease, and it is highest in those who are immune-suppressed such as those with malignant haematological diseases or HIV infection.

Pneumo 23 immunogenicity clinical studies in infants, children and adolescents

The protective efficacy of Pneumo 23 against IPD has not been studied. As recommended by the World Health Organization (WHO) the assessment of potential efficacy against IPD in infants and young children has been based on a comparison of immune responses to the seven common serotypes shared between Pneumo 23 and Prevenar, for which protective efficacy has been proven (for Prevenar (7-valent) efficacy in infants and children, see below). Immune responses to the additional 6 serotypes were also measured.

Immune responses following a three-dose primary infant series

Clinical studies have been conducted in a number of European countries and the US using a range of vaccination schedules, including two randomised non-inferiority studies (Germany using a 2, 3, 4 month primary series [006] and US using a 2, 4, 6 month primary series [004]). In these two studies pneumococcal immune responses were compared using a set of non-inferiority criteria including the percentage of subjects with serum anti-polysaccharide serotype-specific IgG > 0.35 μg/ml one month after the primary series and the comparison of IgG geometric mean concentrations (ELISA GMCs); in addition, functional antibody titres (OPA) between subjects receiving Pneumo 23 and Prevenar were compared. For the six additional serotypes, these values were compared with the lowest response among all of the seven common serotypes in the Prevenar recipients.

The non-inferiority immune response comparisons for study 006, based on the proportion of infants achieving anti-polysaccharide IgG concentrations > 0.35 μg/ml, are shown in Table 1. Results for study 004 were similar. Pneumo 23 non-inferiority (lower bound of the 95% CI for the difference in percentage of responders at 0.35 µg/ml between groups was >-10%) was demonstrated for all 7 common serotypes, except for serotype 6B in study 006 and serotypes 6B and 9V in study 004, which missed by a small margin. All seven common serotypes met pre-defined non-inferiority criteria for IgG ELISA GMCs. Pneumo 23 elicited comparable, although slightly lower, antibody levels than Prevenar for the 7 common serotypes. The clinical relevance of these differences is not known.

Non-inferiority was met for the 6 additional serotypes based on the proportion of infants achieving antibody concentrations > 0.35 μg/ml and comparison of IgG ELISA GMCs in study 006 and was met for 5 out of the 6 serotypes, with the exception of serotype 3 for study 004. For serotype 3, the percentages of Pneumo 23 recipients with serum IgG > 0.35 μg/ml were 98.2% (study 006) and 63.5% (study 004).

Pneumo 23 elicited functional antibodies to all 13 vaccine serotypes in studies 004 and 006. For the 7 common serotypes there were no differences between groups in the proportion of subjects with OPA titres > 1:8. For each of the seven common serotypes, > 96% and > 90 % of the Pneumo 23 recipients reached an OPA titre > 1:8 one month after the primary series in studies 006 and 004, respectively.

For each of the 6 additional serotypes, Pneumo 23 elicited OPA titres > 1:8 in 91.4% to 100% of vaccinees one month after the primary series in studies 004/006. The functional antibody (OPA) geometric mean titres for serotypes 1, 3 and 5 were lower than the titres for each of the other additional serotypes; the clinical relevance of this observation for protective efficacy is unknown.

Immune responses following a two-dose primary infant series

The immunogenicity after two doses in infants has been documented in four studies. The proportion of infants achieving a pneumococcal anti-capsular polysaccharide IgG concentration > 0.35 μg/ml one month after the second dose ranged from 79.6% to 98.5% across 11 of the 13 vaccine serotypes. Smaller proportions of infants achieved this antibody concentration threshold for serotype 6B (27.9% to 57.3%) and 23F (55.8% to 68.1%) for all studies using a 2, 4 month regimen, compared to 58.4% for serotype 6B and 68.6% for 23F for a study using a 3, 5 month regimen. After the booster dose, all vaccine serotypes including 6B and 23F had immune responses consistent with adequate priming with a two-dose primary series. In a UK study, the functional antibody (OPA) responses were comparable for all serotypes including 6B and 23F in the Prevenar and Pneumo 23 arms after the primary series at two and four months of age and after the booster dose at 12 months of age. For Pneumo 23 recipients, the proportion of responders with an OPA titre > 1:8 was at least 87% following the infant series, and at least 93% following the booster dose. The OPA geometric mean titres for serotypes 1, 3 and 5 were lower than the titres for each of the other additional serotypes; the clinical relevance of this observation is unknown.

Booster responses following two-dose and three-dose primary infant series

Following the booster dose, antibody concentrations increased from the pre-booster level for all 13 serotypes. Post-booster antibody concentrations were higher for 12 serotypes than those achieved after the infant primary series. These observations are consistent with adequate priming (the induction of immunologic memory). The immune response for serotype 3 following the booster dose was not increased above the levels seen after the infant vaccination series; the clinical relevance of this observation regarding the induction of serotype 3 immune memory is unknown.

Antibody responses to booster doses following two-dose or three-dose infant primary series were comparable for all 13 vaccine serotypes.

For children aged from 7 months to 5 years, age appropriate catch-up immunisation schedules (as described in section 4.2) result in levels of anti-capsular polysaccharide IgG antibody responses to each of the 13 serotypes that are at least comparable to those of a three-dose primary series in infants.

Antibody persistence and immunological memory were evaluated in a study in healthy children who received a single dose of Pneumo 23 at least 2 years after they had been previously immunised with either 4 doses of Prevenar, a 3-dose infant series of Prevenar followed by Pneumo 23 at 12 months of age, or 4 doses of Pneumo 23.

The single dose of Pneumo 23, in children approximately 3.4 years of age regardless of previous vaccination history with Prevenar or Pneumo 23, induced a robust antibody response for both the 7 common serotypes and the 6 additional serotypes in Pneumo 23.

Since the introduction of 7-valent Prevenar in 2000, pneumococcal disease surveillance data have not shown that the immunity elicited by Prevenar in infancy has waned over time.

Preterm Infants

Safety and immunogenicity of Pneumo 23 given at 2, 3, 4 and 12 months was assessed in approximately 100 prematurely born infants (mean Estimated Gestational Age [EGA], 31 weeks; range, 26 to 36 weeks) and compared with approximately 100 infants born at term (mean EGA, 39 weeks; range, 37 to 42 weeks).

Immune responses in preterm and term infants were compared using the proportion of subjects achieving a pneumococcal polysaccharide IgG binding antibody concentration >0.35 μg/ml 1 month after the infant series, the approach used for immunogenicity comparisons of Pneumo 23 to Prevenar based on WHO guidelines.

More than 85% achieved a pneumococcal polysaccharide IgG binding antibody concentration >0.35 µg/ml 1 month after the infant series, except for serotypes 5 (71.7%), 6A (82.7%), and 6B (72.7%) in the preterm group. For these 3 serotypes, the proportion of responders among preterm infants was significantly lower than among term infants. Approximately one month after the toddler dose, the proportion of subjects in each group achieving this same antibody concentration threshold was >97%, except for serotype 3 (71% in preterm infants and 79% in term infants). It is unknown whether immunological memory to all serotypes is induced in pre-term infants. In general, serotype-specific IgG GMCs were lower for preterm infants than term infants.

After the infant series, OPA GMTs were similar in preterm infants compared to term infants except for serotype 5, which was lower in preterm infants. OPA GMTs after the toddler dose relative to those after the infant series were similar or lower for 4 serotypes (4, 14, 18C, and 19F) and were statistically significantly higher for 6 of 13 serotypes (1, 3, 5, 7F, 9V, and 19A) in preterm infants compared to 10 of 13 serotypes (1, 3, 4, 5, 6A, 7F, 9V, 18C, 19A, and 23F) in term infants.

Children (12-59 months) completely immunised with Prevenar (7-valent)

Following administration of a single dose of Pneumo 23 to children (12-59 months) who are considered completely immunised with Prevenar (7-valent) (either 2 or 3 dose primary series plus booster), the proportion achieving serum IgG levels >0.35 µg/ml and OPA titres >1:8 was at least 90%. However, 3 (serotypes 1, 5 and 6A) of the 6 additional serotypes showed lower IgG GMC and OPA GMT when compared with children who had received at least one previous vaccination with Pneumo 23. The clinical relevance of the lower GMCs and GMTs is currently unknown.

Unvaccinated Children (12-23 months)

Studies in unvaccinated children (12-23 months) with Prevenar (7-valent) demonstrated that 2 doses were required to achieve serum IgG concentrations for 6B and 23F similar to those induced by a 3-dose infant series.

Children and Adolescents 5 to 17 years of age

In an open-label study in 592 healthy children and adolescents including those with asthma (17.4%) who may be predisposed to pneumococcal infection, Pneumo 23 elicited immune responses to all 13 serotypes. A single dose of Pneumo 23 was given to children 5 to 10 years of age previously vaccinated with at least 1 dose of Prevenar, and children and adolescents 10 to 17 years of age who had never received a pneumococcal vaccine.

In both the children 5 to 10 years of age and children and adolescents aged 10 to 17 years, the immune response to Pneumo 23 was non inferior to Prevenar for the 7 common serotypes and to Pneumo 23 for the 6 additional serotypes compared to the immune response after the fourth dose in infants vaccinated at 2, 4, 6 and 12-15 months of age as measured by serum IgG.

In children and adolescents aged 10 to 17 years of age OPA GMTs 1 month after vaccination were noninferior to OPA GMTs in the 5 to 10 year old age group for 12 of the 13 serotypes (except serotype 3).

Immune responses after subcutaneous administration

Subcutaneous administration of Pneumo 23 was evaluated in a non-comparative study in 185 healthy Japanese infants and children who received 4 doses at 2, 4, 6 and 12-15 months of age. The study demonstrated that safety and immunogenicity were generally comparable with observations made in studies of intramuscular administration.

Pneumo 23 Effectiveness

Invasive Pneumococcal Disease

Data published by Public Health England showed that, four years after the introduction of Prevenar as a two dose primary infant series with booster dose in the second year of life and with a 94% vaccine uptake, there was a 98% (95% CI 95; 99) reduction in disease caused by the 7 vaccine serotypes in England and Wales. Subsequently, four years following the switch to Pneumo 23, the additional reduction in incidence of IPD due to the 7 serotypes in Prevenar ranged from 76% in children less than 2 years of age to 91% in children 5-14 years of age. The serotype specific reductions for each of the 5 additional serotypes in Pneumo 23 (no cases of serotype 5 IPD were observed) by age group are shown in Table 2 and ranged from 68% (serotype 3) to 100% (serotype 6A) for children less than 5 years of age. Significant incidence reductions were also observed in older age groups who had not been vaccinated with Pneumo 23 (indirect effect).

Otitis Media (OM)

In a published study performed in Israel, using a 2-dose primary series plus booster dose in the second year of life, the impact of Pneumo 23 on OM was documented in a population-based active-surveillance system with tympanocentesis culturing of middle ear fluid in Israeli children less than 2 years of age with OM.

Following the introduction of Prevenar and subsequently Pneumo 23 there was a decline in incidence from 2.1 to 0.1 cases per 1000 children (95%) for the Prevenar serotypes plus serotype 6A and a decline in incidence from 0.9 to 0.1 cases per 1000 children (89%) for the additional serotypes 1, 3, 5, 7F, and 19A in Pneumo 23. The annual overall pneumococcal incidence of OM declined from 9.6 to 2.1 cases per 1000 children (78%) between July 2004 (prior to the introduction of Prevenar) and June 2013 (post Pneumo 23 introduction).

Pneumonia

In a multicenter observational study in France comparing the periods before and after the switch from Prevenar to Pneumo 23, there was 16% (2060 to 1725 cases) reduction in all community acquired pneumonia (CAP) cases in emergency departments in children 1 month to 15 years of age. Reductions were 53% (167 to 79 cases) (p<0.001) for CAP cases with pleural effusion and 63% (64 to 24 cases) (p<0.001) for microbiologically confirmed pneumococcal CAP cases. In the second year after the introduction of Pneumo 23 the total number of CAP cases due to the 6 additional vaccine serotypes in Pneumo 23 was reduced from 27 to 7 isolates (74%).

The decrease in all cause pneumonia cases was most pronounced in the younger vaccinated age groups with a decrease of 31.8% (757 to 516 cases) and 16.6% (833 to 695 cases) in the age groups <2 years and 2 to 5 years, respectively. The incidence in older, predominantly non-vaccinated children (>5 years) did not change over the duration of the study.

In an ongoing surveillance system (2004 to 2013) to document the impact of Prevenar and subsequently Pneumo 23 on CAP in children less than 5 years in Southern Israel using a 2 dose primary series with a booster dose in the second year of life, there was a reduction of 68% (95% CI 73; 61) in outpatient visits and 32% (95% CI 39; 22) in hospitalizations for alveolar CAP following the introduction of Pneumo 23 when compared to the period before the introduction of Prevenar.

Effect on nasopharyngeal carriage

In a surveillance study in France in children presenting with acute otitis media, changes in nasopharyngeal (NP) carriage of pneumococcal serotypes were evaluated following the introduction of Prevenar (7-valent) and subsequently Pneumo 23. Pneumo 23 significantly reduced NP carriage of the 6 additional serotypes (and serotype 6C) combined and individual serotypes 6C, 7F, 19A when compared with Prevenar. A reduction in carriage was also seen for serotype 3 (2.5% vs 1.1%; p=0.1). There was no carriage of serotypes 1 and 5 observed.

The effect of pneumococcal conjugate vaccination on nasopharyngeal carriage was studied in a randomised double-blind study in which infants received either Pneumo 23 or Prevenar (7-valent) at 2, 4, 6 and 12 months of age in Israel. Pneumo 23 significantly reduced newly identified NP acquisition of the 6 additional serotypes (and serotype 6C) combined and of individual serotypes 1, 6A, 6C, 7F, 19A when compared with Prevenar. There was no reduction seen in serotype 3 and for serotype 5 the colonization was too infrequent to assess impact. For 6 of the remaining 7 common serotypes, similar rates of NP acquisition were observed in both vaccine groups; for serotype 19F a significant reduction was observed.

In this study, reductions of S. pneumoniae serotypes 19A, 19F, and 6A not susceptible to a number of antibiotics were documented. The reductions ranged between 34% and 62% depending on serotype and antibiotic.

Prevenar (7-valent vaccine) protective efficacy in infants and children

The efficacy of 7-valent Prevenar was evaluated in two major studies - the Northern California Kaiser Permanente (NCKP) study and the Finnish Otitis Media (FinOM) study. Both studies were randomised, double-blind, active-control studies in which infants were randomised to receive either Prevenar or control vaccine (NCKP, meningococcal serogroup C CRM-conjugate [MnCC] vaccine; FinOM, hepatitis B vaccine) in a four-dose series at 2, 4, 6, and 12-15 months of age. The efficacy results from these studies (for invasive pneumococcal disease, pneumonia, and acute otitis media) are presented below (Table 3).

Prevenar (7-valent) effectiveness

The effectiveness (both direct and indirect effect) of 7-valent Prevenar against pneumococcal disease has been evaluated in both three-dose and two-dose primary infant series immunisation programmes, each with booster doses (Table 4). Following the widespread use of Prevenar, the incidence of IPD has been consistently and substantially reduced.

Using the screening method, serotype-specific effectiveness estimates for 2 doses under the age of 1 year in the UK were 66 % (-29, 91 %) and 100 % (25, 100 %) for serotype 6B and 23F, respectively.

Pharmacokinetic properties

Not applicable.

Name of the medicinal product

Qualitative and quantitative composition

Special warnings and precautions for use

Pneumo 23 13 must not be administered intravascularly.

As with all injectable vaccines, appropriate medical treatment and supervision should always be readily available in case of a rare anaphylactic event following the administration of the vaccine.

This vaccine should not be given as an intramuscular injection to individuals with thrombocytopaenia or any coagulation disorder that would contraindicate intramuscular injection, but may be given subcutaneously if the potential benefit clearly outweighs the risks.

Pneumo 23 13 will only protect against Streptococcus pneumoniae serotypes included in the vaccine, and will not protect against other microorganisms that cause invasive disease, pneumonia, or otitis media. As with any vaccine, Pneumo 23 13 may not protect all individuals receiving the vaccine from pneumococcal disease. For the most recent epidemiological information in your country you should consult with the relevant national organisation.

Individuals with impaired immune responsiveness, whether due to the use of immuno-suppressive therapy, a genetic defect, human immunodeficiency virus (HIV) infection, or other causes, may have reduced antibody response to active immunisation.

Safety and immunogenicity data are available for a limited number of individuals with sickle cell disease, HIV infection, or with an haematopoietic stem cell transplant. Safety and immunogenicity data for Pneumo 23 13 are not available for individuals in other specific immuno-compromised groups (e.g., malignancy or nephrotic syndrome) and vaccination should be considered on an individual basis.

This medicinal product contains less than 1 mmol sodium (23 mg) per dose, i.e. essentially 'sodium-free'.

Infants and children aged 6 weeks to 5 years

In clinical studies, Pneumo 23 13 elicited an immune response to all thirteen serotypes included in the vaccine. The immune response for serotype 3 following the booster dose was not increased above the levels seen after the infant vaccination series; the clinical relevance of this observation regarding the induction of serotype 3 immune memory is unknown.

The proportions of functional antibody responders (OPA titres > 1:8) to serotypes 1, 3 and 5 were high. However, the OPA geometric mean titres were lower than those against each of the remaining additional vaccine serotypes; the clinical relevance of this observation for protective efficacy is unknown.

Limited data have demonstrated that Pneumo 23 7-valent (three-dose primary series) induces an acceptable immune response in infants with sickle cell disease with a safety profile similar to that observed in non-high-risk groups.

Children younger than 2 years old should receive the appropriate-for-age Pneumo 23 13 vaccination series. The use of pneumococcal conjugate vaccine does not replace the use of 23-valent pneumococcal polysaccharide vaccines in children > 2 years of age with conditions (such as sickle cell disease, asplenia, HIV infection, chronic illness, or those who are immuno-compromised) placing them at higher risk for invasive disease due to Streptococcus pneumoniae. Whenever recommended, children at risk who are > 24 months of age and already primed with Pneumo 23 13 should receive 23-valent pneumococcal polysaccharide vaccine. The interval between the 13-valent pneumococcal conjugate vaccine (Pneumo 23 13) and the 23-valent pneumococcal polysaccharide vaccine should not be less than 8 weeks. There are no data available to indicate whether the administration of 23-valent pneumococcal polysaccharide vaccine to unprimed children or to children primed with Pneumo 23 13 might result in hyporesponsiveness to further doses of Pneumo 23 13.

The potential risk of apnoea and the need for respiratory monitoring for 48-72h should be considered when administering the primary immunisation series to very premature infants (born ≤ 28 weeks of gestation), and particularly for those with a previous history of respiratory immaturity. As the benefit of vaccination is high in this group of infants, vaccination should not be withheld or delayed.

For vaccine serotypes, protection against otitis media is expected to be lower than protection against invasive disease. As otitis media is caused by many organisms other than pneumococcal serotypes represented in the vaccine, protection against all otitis media is expected to be low.

When Pneumo 23 13 is administered concomitantly with Infanrix hexa (DTPa-HBV-IPV/Hib), the rates of febrile reactions are similar to those seen with concomitant administration of Pneumo 23 (7-valent) and Infanrix hexa. Increased reporting rates of convulsions (with or without fever) and hypotonic hyporesponsive episode (HHE) were observed with concomitant administration of Pneumo 23 13 and Infanrix hexa.

Antipyretic treatment should be initiated according to local treatment guidelines for children with seizure disorders or with a prior history of febrile seizures and for all children receiving Pneumo 23 13 simultaneously with vaccines containing whole cell pertussis.

Pneumo 23 must not be administered intravascularly.

As with all injectable vaccines, appropriate medical treatment and supervision should always be readily available in case of a rare anaphylactic event following the administration of the vaccine.

This vaccine should not be given as an intramuscular injection to individuals with thrombocytopaenia or any coagulation disorder that would contraindicate intramuscular injection, but may be given subcutaneously if the potential benefit clearly outweighs the risks.

Pneumo 23 will only protect against Streptococcus pneumoniae serotypes included in the vaccine, and will not protect against other microorganisms that cause invasive disease, pneumonia, or otitis media. As with any vaccine, Pneumo 23 may not protect all individuals receiving the vaccine from pneumococcal disease. For the most recent epidemiological information in your country you should consult with the relevant national organisation.

Individuals with impaired immune responsiveness, whether due to the use of immuno-suppressive therapy, a genetic defect, human immunodeficiency virus (HIV) infection, or other causes, may have reduced antibody response to active immunisation.

Safety and immunogenicity data are available for a limited number of individuals with sickle cell disease, HIV infection, or with an haematopoietic stem cell transplant. Safety and immunogenicity data for Pneumo 23 are not available for individuals in other specific immuno-compromised groups (e.g., malignancy or nephrotic syndrome) and vaccination should be considered on an individual basis.

This medicinal product contains less than 1 mmol sodium (23 mg) per dose, i.e. essentially 'sodium-free'.

Infants and children aged 6 weeks to 5 years

In clinical studies, Pneumo 23 elicited an immune response to all thirteen serotypes included in the vaccine. The immune response for serotype 3 following the booster dose was not increased above the levels seen after the infant vaccination series; the clinical relevance of this observation regarding the induction of serotype 3 immune memory is unknown.

The proportions of functional antibody responders (OPA titres > 1:8) to serotypes 1, 3 and 5 were high. However, the OPA geometric mean titres were lower than those against each of the remaining additional vaccine serotypes; the clinical relevance of this observation for protective efficacy is unknown.

Limited data have demonstrated that Prevenar 7-valent (three-dose primary series) induces an acceptable immune response in infants with sickle cell disease with a safety profile similar to that observed in non-high-risk groups.

Children younger than 2 years old should receive the appropriate-for-age Pneumo 23 vaccination series. The use of pneumococcal conjugate vaccine does not replace the use of 23-valent pneumococcal polysaccharide vaccines in children > 2 years of age with conditions (such as sickle cell disease, asplenia, HIV infection, chronic illness, or those who are immuno-compromised) placing them at higher risk for invasive disease due to Streptococcus pneumoniae. Whenever recommended, children at risk who are > 24 months of age and already primed with Pneumo 23 should receive 23-valent pneumococcal polysaccharide vaccine. The interval between the 13-valent pneumococcal conjugate vaccine (Pneumo 23) and the 23-valent pneumococcal polysaccharide vaccine should not be less than 8 weeks. There are no data available to indicate whether the administration of 23-valent pneumococcal polysaccharide vaccine to unprimed children or to children primed with Pneumo 23 might result in hyporesponsiveness to further doses of Pneumo 23.

The potential risk of apnoea and the need for respiratory monitoring for 48-72h should be considered when administering the primary immunisation series to very premature infants (born ≤ 28 weeks of gestation), and particularly for those with a previous history of respiratory immaturity. As the benefit of vaccination is high in this group of infants, vaccination should not be withheld or delayed.

For vaccine serotypes, protection against otitis media is expected to be lower than protection against invasive disease. As otitis media is caused by many organisms other than pneumococcal serotypes represented in the vaccine, protection against all otitis media is expected to be low.

When Pneumo 23 is administered concomitantly with Infanrix hexa (DTPa-HBV-IPV/Hib), the rates of febrile reactions are similar to those seen with concomitant administration of Prevenar (7-valent) and Infanrix hexa. Increased reporting rates of convulsions (with or without fever) and hypotonic hyporesponsive episode (HHE) were observed with concomitant administration of Pneumo 23 and Infanrix hexa.

Antipyretic treatment should be initiated according to local treatment guidelines for children with seizure disorders or with a prior history of febrile seizures and for all children receiving Pneumo 23 simultaneously with vaccines containing whole cell pertussis.

Effects on ability to drive and use machines

Pneumo 23 13 has no or negligible influence on the ability to drive and use machines.“Undesirable effects” may temporarily affect the ability to drive or use machines.

Pneumo 23 has no or negligible influence on the ability to drive and use machines.“Undesirable effects” may temporarily affect the ability to drive or use machines.

Dosage (Posology) and method of administration

The immunisation schedules for Pneumo 23 13 should be based on official recommendations.

Posology

Infants and children aged 6 weeks to 5 years

It is recommended that infants who receive a first dose of Pneumo 23 13 complete the vaccination course with Pneumo 23 13.

Infants aged 6 weeks-6 months

Three-dose primary series

The recommended immunisation series consists of four doses, each of 0.5 ml. The primary infant series consists of three doses, with the first dose usually given at 2 months of age and with an interval of at least 1 month between doses. The first dose may be given as early as six weeks of age. The fourth (booster) dose is recommended between 11 and 15 months of age.

Two-dose primary series

Alternatively, when Pneumo 23 13 is given as part of a routine infant immunisation programme, a series consisting of three doses, each of 0.5 ml, may be given. The first dose may be administered from the age of 2 months, with a second dose 2 months later. The third (booster) dose is recommended between 11 and 15 months of age.

Preterm infants (< 37 weeks gestation)

In preterm infants, the recommended immunisation series consists of four doses, each of 0.5 ml. The primary infant series consists of three doses, with the first dose given at 2 months of age and with an interval of at least 1 month between doses. The first dose may be given as early as six weeks of age. The fourth (booster) dose is recommended between 11 and 15 months of age.

Unvaccinated infants and children > 7 months of age

Infants aged 7-11 months

Two doses, each of 0.5 ml, with an interval of at least 1 month between doses. A third dose is recommended in the second year of life.

Children aged 12-23 months

Two doses, each of 0.5 ml, with an interval of at least 2 months between doses.

Children and adolescents aged 2-17 years

One single dose of 0.5 ml.

Pneumo 23 13 vaccine schedule for infants and children previously vaccinated with Pneumo 23 (7-valent) (Streptococcus pneumoniae serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F)

Pneumo 23 13 contains the same 7 serotypes included in Pneumo 23, using the same carrier protein CRM197.

Infants and children who have begun immunisation with Pneumo 23 may switch to Pneumo 23 13 at any point in the schedule.

Young children (12-59 months) completely immunised with Pneumo 23 (7-valent)

Young children who are considered completely immunised with Pneumo 23 (7-valent) should receive one dose of 0.5 ml of Pneumo 23 13 to elicit immune responses to the 6 additional serotypes. This dose of Pneumo 23 13 should be administered at least 8 weeks after the final dose of Pneumo 23 (7-valent).

Children and adolescents 5-17 years

Children 5 to 17 years of age may receive a single dose of Pneumo 23 13 if they have been previously vaccinated with one or more doses of Pneumo 23. This dose of Pneumo 23 13 should be administered at least 8 weeks after the final dose of Pneumo 23 (7-valent).

Adults >18 years of age, and the elderly

One single dose.

The need for revaccination with a subsequent dose of Pneumo 23 13 has not been established.

Regardless of prior pneumococcal vaccination status, if the use of 23-valent pneumococcal polysaccharide vaccine is considered appropriate, Pneumo 23 13 should be given first.

Special Populations

Individuals who have underlying conditions predisposing them to invasive pneumococcal disease (such as sickle cell disease or HIV infection) including those previously vaccinated with one or more doses of 23-valent pneumococcal polysaccharide vaccine may receive at least one dose of Pneumo 23 13.

In individuals with an haematopoietic stem cell transplant (HSCT), the recommended immunisation series consists of four doses of Pneumo 23 13, each of 0.5 ml. The primary series consists of three doses, with the first dose given at 3 to 6 months after HSCT and with an interval of at least 1 month between doses. A fourth (booster) dose is recommended 6 months after the third dose.

Method of administration

The vaccine should be given by intramuscular injection. The preferred sites are the anterolateral aspect of the thigh (vastus lateralis muscle) in infants or the deltoid muscle of the upper arm in children and adults.

The immunisation schedules for Pneumo 23 should be based on official recommendations.

Posology

Infants and children aged 6 weeks to 5 years

It is recommended that infants who receive a first dose of Pneumo 23 complete the vaccination course with Pneumo 23.

Infants aged 6 weeks-6 months

Three-dose primary series

The recommended immunisation series consists of four doses, each of 0.5 ml. The primary infant series consists of three doses, with the first dose usually given at 2 months of age and with an interval of at least 1 month between doses. The first dose may be given as early as six weeks of age. The fourth (booster) dose is recommended between 11 and 15 months of age.

Two-dose primary series

Alternatively, when Pneumo 23 is given as part of a routine infant immunisation programme, a series consisting of three doses, each of 0.5 ml, may be given. The first dose may be administered from the age of 2 months, with a second dose 2 months later. The third (booster) dose is recommended between 11 and 15 months of age.

Preterm infants (< 37 weeks gestation)

In preterm infants, the recommended immunisation series consists of four doses, each of 0.5 ml. The primary infant series consists of three doses, with the first dose given at 2 months of age and with an interval of at least 1 month between doses. The first dose may be given as early as six weeks of age. The fourth (booster) dose is recommended between 11 and 15 months of age.

Unvaccinated infants and children > 7 months of age

Infants aged 7-11 months

Two doses, each of 0.5 ml, with an interval of at least 1 month between doses. A third dose is recommended in the second year of life.

Children aged 12-23 months

Two doses, each of 0.5 ml, with an interval of at least 2 months between doses.

Children and adolescents aged 2-17 years

One single dose of 0.5 ml.

Pneumo 23 vaccine schedule for infants and children previously vaccinated with Prevenar (7-valent) (Streptococcus pneumoniae serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F)

Pneumo 23 contains the same 7 serotypes included in Prevenar, using the same carrier protein CRM197.

Infants and children who have begun immunisation with Prevenar may switch to Pneumo 23 at any point in the schedule.

Young children (12-59 months) completely immunised with Prevenar (7-valent)

Young children who are considered completely immunised with Prevenar (7-valent) should receive one dose of 0.5 ml of Pneumo 23 to elicit immune responses to the 6 additional serotypes. This dose of Pneumo 23 should be administered at least 8 weeks after the final dose of Prevenar (7-valent).

Children and adolescents 5-17 years

Children 5 to 17 years of age may receive a single dose of Pneumo 23 if they have been previously vaccinated with one or more doses of Prevenar. This dose of Pneumo 23 should be administered at least 8 weeks after the final dose of Prevenar (7-valent).

Adults >18 years of age, and the elderly

One single dose.

The need for revaccination with a subsequent dose of Pneumo 23 has not been established.

Regardless of prior pneumococcal vaccination status, if the use of 23-valent pneumococcal polysaccharide vaccine is considered appropriate, Pneumo 23 should be given first.

Special Populations

Individuals who have underlying conditions predisposing them to invasive pneumococcal disease (such as sickle cell disease or HIV infection) including those previously vaccinated with one or more doses of 23-valent pneumococcal polysaccharide vaccine may receive at least one dose of Pneumo 23.

In individuals with an haematopoietic stem cell transplant (HSCT), the recommended immunisation series consists of four doses of Pneumo 23, each of 0.5 ml. The primary series consists of three doses, with the first dose given at 3 to 6 months after HSCT and with an interval of at least 1 month between doses. A fourth (booster) dose is recommended 6 months after the third dose.

Method of administration

The vaccine should be given by intramuscular injection. The preferred sites are the anterolateral aspect of the thigh (vastus lateralis muscle) in infants or the deltoid muscle of the upper arm in children and adults.

Special precautions for disposal and other handling

During storage, a white deposit and clear supernatant can be observed. This does not constitute a sign of deterioration.

The vaccine should be shaken well to obtain a homogeneous white suspension prior to expelling air from the syringe, and should be inspected visually for any particulate matter and/or variation of physical aspect prior to administration. Do not use if the content appears otherwise.

No special requirements for disposal.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.