Flucelvax

Description

FLUCELVAX QUADRIVALENT (Influenza Vaccine), a vaccine for intramuscular injection, is a subunit influenza vaccine prepared from virus propagated in Madin Darby Canine Kidney (MDCK) cells, a continuous cell line. These cells were adapted to grow freely in suspension in culture medium. The virus is inactivated with β-propiolactone, disrupted by the detergent cetyltrimethylammonium bromide and purified through several process steps. Each of the 4 virus strains is produced and purified separately then pooled to formulate the quadrivalent vaccine.

FLUCELVAX QUADRIVALENT is a sterile, slightly opalescent suspension in phosphate buffered saline. FLUCELVAX QUADRIVALENT is standardized according to United States Public Health Service requirements for the 2017-2018 influenza season and is formulated to contain a total of 60 micrograms (mcg) hemagglutinin (HA) per 0.5 mL dose in the recommended ratio of 15 mcg HA of each of the following four influenza strains: A/Singapore/GP1908/2015 IVR-180 (H1N1) (an A/Michigan/45/2015-like virus); A/Singapore/GP2050/2015 (H3N2) (an A/Hong Kong/4801/2014 – like virus); B/Utah/9/2014 (a B/Phuket/3073/2013-like virus); B/Hong Kong/259/2010 (a B/Brisbane/60/08- like virus). Each dose of FLUCELVAX QUADRIVALENT may contain residual amounts of MDCK cell protein (≤8.4 mcg), protein other than HA (≤160 mcg), MDCK cell DNA (≤10 ng), polysorbate 80 (≤1500 mcg), cetyltrimethlyammonium bromide (≤18 mcg), and β-propiolactone (<0.5 mcg), which are used in the manufacturing process.

FLUCELVAX QUADRIVALENT 0.5 mL pre-filled syringes contain no preservative or antibiotics.

FLUCELVAX QUADRIVALENT 5 mL multi-dose vial formulation contains thimerosal, a mercury derivative, added as a preservative. Each 0.5 mL dose from the multi-dose vial contains 25 mcg mercury. FLUCELVAX QUADRIVALENT 5 mL multi-dose vial formulation contains no antibiotics. The tip caps and plungers of the prefilled syringes and the multi-dose vial stopper are not made with natural rubber latex.

FLUCELVAX QUADRIVALENT is an inactivated vaccine indicated for active immunization for the prevention of influenza disease caused by influenza virus subtypes A and type B contained in the vaccine. FLUCELVAX QUADRIVALENT is approved for use in persons 4 years of age and older. For children and adolescents 4 through 17 years of age, approval is based on the immune response elicited by FLUCELVAX QUADRIVALENT. Data demonstrating a decrease in influenza disease after vaccination of this age group with FLUCELVAX QUADRIVALENT are not available. [see Clinical Studies]

Dosage And Administration

For intramuscular injection only.

Dosage And Schedule

Administer FLUCELVAX QUADRIVALENT as a single 0.5 mL intramuscular injection preferably in the region of the deltoid muscle of the upper arm. Do not inject the vaccine in the gluteal region or areas where there may be a major nerve trunk.

Table 1: Dosage and Schedule

Administration

Shake the syringe vigorously before administering and shake the multi-dose vial preparation each time before withdrawing a dose of vaccine. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration whenever solution and container permit. [see DESCRIPTION] If either condition exists, do not administer the vaccine. Between uses, return the multidose vial to the recommended storage conditions between 2° and 8°C (36° and 46°F). Do not freeze. Discard if the vaccine has been frozen.

Attach a sterile needle to the pre-filled syringe.

For the multi-dose vial, a separate sterile syringe and needle must be used for each injection to prevent transmission of infectious agents from one person to another. Needles should be disposed of properly and not recapped. It is recommended that small syringes (0.5 mL or 1 mL) should be used to minimize any product loss.

Administer intramuscularly only. Do not administer this product intravenously, intradermally or subcutaneously.

How Supplied

Dosage Forms And Strengths

FLUCELVAX QUADRIVALENT is a suspension for injection supplied in two presentations:

• a 0.5 mL single-dose pre-filled Luer Lock syringe
• a 5 mL multi-dose vial containing 10 doses (each dose is 0.5mL).

Storage And Handling

FLUCELVAX QUADRIVALENT product presentations are listed in Table 9 below:

Table 9: Flucelvax Product Presentations

Store this product refrigerated at 2°C to 8°C (36°F to 46°F). Between uses, return the multi-dose vial to the recommended storage conditions. Do not freeze. Protect from light. Do not use after the expiration date.

Manufactured by: Seqirus Inc. Holly Springs, NC 27540, USA, US License No. 2049. Distributed by: Seqirus USA Inc. 25 Deforest Avenue, Summit, NJ 07901, USA. Revised: Apr 2017

Clinical Trials Experience

The most common (≥10%) local and systemic reactions in adults 18-64 years of age were injection site pain (45.4%) headache (18.7%), fatigue (17.8%) and myalgia (15.4%), injection site erythema (13.4%), and induration (11.6%).

The most common (≥10%) local and systemic reactions in adults ≥65 years of age were injection site pain (21.6%), and injection site erythema (11.9%).

The most common (≥10%) local and systemic reactions in children 4 to <6 years of age after first dose of vaccine were tenderness at the injection site (46%), injection site erythema (18%), sleepiness (19%), irritability (16%), injection site induration (13%) and change in eating habits (10%). The most common (≥10%) local and systemic reactions in children 6 through 8 years of age after first dose of vaccine were pain at the injection site (54%), injection site erythema (22%), injection site induration (16%), headache (14%), fatigue (13%) and myalgia (12%).

The most common (≥10%) local and systemic reactions in children and adolescents 9 through 17 years of age were pain at the injection site (58%), headache (22%), injection site erythema (19%), fatigue (18%) myalgia (16%), and injection site induration (15%).

Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a vaccine cannot be directly compared to rates in clinical studies of another vaccine, and may not reflect rates observed in clinical practice.

Adults 18 Years Of Age And Older

The safety of FLUCELVAX QUADRIVALENT in adults was evaluated in a randomized, double-blind, controlled study conducted in the US (Study 1). The safety population included a total of 2680 adults 18 years of age and older; 1340 adults 18 through 64 years of age and 1340 adults 65 years of age and older.

In this study, subjects received FLUCELVAX QUADRIVALENT or one of the two formulations of comparator trivalent influenza vaccine (TIV1c and TIV2c) (FLUCELVAX QUADRIVALENT (n=1335), TIV1c, n=676 or TIV2c n= 669). The mean age of subjects who received FLUCELVAX QUADRIVALENT was 57.4 years of age; 54.8% of subjects were female and 75.6% were Caucasian, 13.4% were Black, 9.1% were Hispanics, 0.7% were American Indian and 0.3%, 0.1% and 0.7% were Asian, Native Hawaiian and others, respectively. The safety data observed are summarized in Table 2.

In this study, solicited local injection site and systemic adverse reactions were collected from subjects who completed a symptom diary card for 7 days following vaccination.

Solicited adverse reactions for FLUCELVAX QUADRIVALENT and comparator are summarized in Table 2.

Table 2: Incidence of Solicited Adverse Reactions in the Safety Population¹ Reported Within 7 Days of Vaccination (Study 1)

Unsolicited adverse events were collected for 21 days after vaccination. In adults 18 years of age and older, unsolicited adverse events were reported in 16.1% of subjects who received FLUCELVAX QUADRIVALENT, within 21 days after vaccination.

In adults 18 years of age and older, serious adverse events (SAEs) were collected throughout the study duration (until 6 months after vaccination) and were reported by 3.9%, of the subjects who received FLUCELVAX QUADRIVALENT. None of the SAEs were assessed as being related to study vaccine.

Children And Adolescents 4 Through 17 Years Of Age

The safety of FLUCELVAX QUADRIVALENT in children was evaluated in a randomized, doubleblind, controlled study conducted in the US (Study 2). The safety population included a total of 2332 children 4 through 17 years of age; 1161 children 4 through 8 years of age and 1171 children 9 through 17 years of age.

In this study, subjects received FLUCELVAX QUADRIVALENT or one of the two formulations of comparator trivalent influenza vaccine (FLUCELVAX QUADRIVALENT n=1159, TIV1c, n=593 or TIV2c n= 580). Children 9 through 17 years of age received a single dose of FLUCELVAX QUADRIVALENT or comparator vaccine. Children 4 through 8 years of age received one or two doses (separated by 4 weeks) of FLUCELVAX QUADRIVALENT or comparator vaccine based on determination of the subject’s prior influenza vaccination history. The mean age of subjects who received FLUCELVAX QUADRIVALENT was 9.6 years of age; 48% of subjects were female and 53% were Caucasian. The safety data observed are summarized in Table 3 and Table 4.

In this study, solicited local injection site and systemic adverse reactions were collected from subjects who completed a symptom diary card for 7 days following vaccination.

Solicited adverse reactions for FLUCELVAX QUADRIVALENT and comparator are summarized in Table 3 and Table 4.

Table 3: Incidence of Solicited Adverse Reactions in the Safety Population¹ (4 through 5 years of age) Reported Within 7 Days of the Firs t dos e of Vaccination (Study 2)

Table 4: Incidence of Solicited Adverse Reactions in the Safety Population¹ (Children 6 through 17 years of age) Reported Within 7 Days of Vaccination (Study 2)

In children who received a second dose of FLUCELVAX QUADRIVALENT, TIV1c, or TIV2c, the incidence of adverse reactions following the second dose of vaccine were similar to those observed with the first dose.

Unsolicited adverse events were collected for 21 days after last vaccination. In children 4 through 17 years of age, unsolicited adverse events were reported in 24.3 of subjects who received FLUCELVAX QUADRIVALENT, within 3 weeks after last vaccination.

In children 4 through 17 years of age, serious adverse events (SAEs) were collected throughout the study duration (until 6 months after last vaccination) and were reported by 0.5%, of the subjects who received FLUCELVAX QUADRIVALENT. None of the SAEs were assessed as being related to study vaccine.

Postmarketing Experience

The safety experience with FLUCELVAX (trivalent influenza vaccine) is relevant to FLUCELVAX QUADRIVALENT, because both vaccines are manufactured using the same process and have overlapping compositions.

The following additional adverse events have been identified during post-approval use of FLUCELVAX. Because these events are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to the vaccine.

Immune system disorders: Anaphylactic reaction, angioedema.

Skin and subcutaneous tissue disorders: Generalized skin reactions including pruritus, urticaria or nonspecific rash.

Nervous systems disorders: Syncope, Presyncope

General disorders and administration site conditions: Extensive swelling of injected limb.

Drug Interactions

Concomitant Use With Other Vaccines

No data are available to assess the concomitant administration of FLUCELVAX QUADRIVALENT with other vaccines.

Included as part of the PRECAUTIONS section.

Precautions

Guillain-Barré Syndrome

The 1976 swine influenza vaccine was associated with an elevated risk of Guillain-Barré syndrome (GBS). Evidence for a causal relation of GBS with other influenza vaccines is inconclusive; if an excess risk exists, it is probably slightly more than 1 additional case per 1 million persons vaccinated.¹ If GBS has occurred after receipt of a prior influenza vaccine, the decision to give FLUCELVAX QUADRIVALENTshould be based on careful consideration of the potential benefits and risks.

Preventing And Managing Allergic Reactions

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

Syncope

Syncope (fainting) can occur in association with administration of injectable vaccines, including Flucelvax. Syncope can be accompanied by transient neurological signs such as visual disturbance, paresthesia, and tonic-clonic limb movements. Procedures should be in place to avoid falling injury and to restore cerebral perfusion following syncope by maintaining a supine or Trendelenburg position.

Altered Immunocompetence

After vaccination with FLUCELVAX QUADRIVALENT, immunocompromised individuals, including those receiving immunosuppressive therapy, may have a reduced immune response.

Limitations Of Vaccine Effectiveness

Vaccination with FLUCELVAX QUADRIVALENT may not protect all vaccine recipients against influenza disease.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment Of Fertility

FLUCELVAX QUADRIVALENT has not been evaluated for carcinogenic or mutagenic potential, or for impairment of male fertility in animals. Administration of Flucelvax vaccine (45 mcg HA/dose) did not affect female fertility in a rabbit reproductive and developmental toxicity study.

Use In Specific Populations

Pregnancy

Pregnancy Exposure Registry

There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to FLUCELVAX QUADRIVALENT during pregnancy. Women who are vaccinated with FLUCELVAX QUADRIVALENT during pregnancy are encouraged to enroll in the registry by calling 1-855-358- 8966 or sending an email to Seqirus at us.medicalinformation@seqirus.com.

Pregnancy Category B

The developmental and reproductive toxicity study performed with the trivalent formulation of FLUCELVAX is relevant to FLUCELVAX QUADRIVALENT because both vaccines share the same manufacturing process and route of administration. A reproductive and developmental toxicity study has been performed in rabbits with FLUCELVAX, with a dose level that was approximately 11 times the human dose based on body weight. The study revealed no evidence of impaired female fertility or harm to the fetus. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this vaccine should be used during pregnancy only if clearly needed.

In a reproductive and developmental toxicity study, the effect of FLUCELVAX containing 45 mcg HA/dose on embryo-fetal and post-natal development was evaluated in pregnant rabbits. Animals were administered vaccine by intramuscular injection 3 times prior to gestation, during the period of organogenesis (gestation day 7) and later in pregnancy (gestation day 20), 0.5 mL/rabbit/occasion (approximately 11-fold excess relative to the projected human dose on a body weight basis). No adverse effects on mating, female fertility, pregnancy, embryo-fetal development, or post-natal development were observed. There were no vaccine-related fetal malformations or other evidence of teratogenesis.

Nursing Mothers

FLUCELVAX QUADRIVALENT has not been evaluated in nursing mothers. It is not known whether FLUCELVAX QUADRIVALENT is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when FLUCELVAX QUADRIVALENT is administered to a nursing woman.

Pediatric Use

Safety and effectiveness have not been established in children less than 4 years of age.

Geriatric Use

Of the total number of subjects who received one dose of FLUCELVAX QUADRIVALENT in clinical studies and included in the safety population (2493), 26.47% (660) were 65 years of age and older and 7.7% (194) were 75 years of age or older.

Antibody responses to FLUCELVAX QUADRIVALENT were lower in the geriatric (adults 65 years and older) population than in younger subjects. [see Clinical Studies]

REFERENCES

1. Lasky T, Terracciano GJ, Magder L, et al. The Guillain-Barré syndrome and the 1992-1993 and 1993-1994 influenza vaccines. N Engl J Med 1998; 339(25):1797-1802.

No information provided.

Contraindications

Do not administer FLUCELVAX QUADRIVALENTto anyone with a history of severe allergic reaction (e.g. anaphylaxis) to any component of the vaccine [see DESCRIPTION].

Mechanism Of Action

Influenza illness and its complications follow infection with influenza viruses. Global surveillance and analysis of influenza virus isolates permits identification of yearly antigenic variants. Since 1977, antigenic variants of influenza A (H1N1 and H3N2) viruses and influenza B viruses have been in global circulation. Specific levels of hemagglutination inhibition (HI) antibody titers induced by vaccination with inactivated influenza virus vaccine have not been correlated with protection from influenza illness. In some studies, HI antibody titers of ≥1:40 have been associated with protection from influenza illness in up to 50% of subjects.^2,3

Antibody against one influenza virus type or subtype confers little or no protection against another. Furthermore, antibody to one antigenic variant of influenza virus might not protect against a new antigenic variant of the same type or subtype. Frequent development of antigenic variants through antigenic drift is the virologic basis for seasonal epidemics and the reason for the usual change of one or more strains in each year’s influenza vaccine. Therefore, inactivated influenza vaccines are standardized to contain the hemagglutinin of influenza virus strains representing the influenza viruses likely to circulate in the United States in the upcoming winter.

Annual influenza vaccination is recommended by the Advisory Committee on Immunization Practices because immunity declines during the year after vaccination, and because circulating strains of influenza virus change from year to year.⁴

Clinical Studies

Efficacy Against Culture-Confirmed Influenza

The efficacy experience with FLUCELVAX is relevant to FLUCELVAX QUADRIVALENT because both vaccines are manufactured using the same process and have overlapping compositions. A multinational (US, Finland, and Poland), randomized, observer-blind, placebo-controlled trial was performed to assess clinical efficacy and safety of FLUCELVAX during the 2007-2008 influenza season in adults aged 18 through 49 years. A total of 11,404 subjects were enrolled to receive  FLUCELVAX (N=3828), AGRIFLU (N=3676) or placebo (N=3900) in a 1:1:1 ratio. Among the overall study population enrolled, the mean age was 33 years, 55% were female, 84% were Caucasian, 7% were Black, 7% were Hispanic, and 2% were of other ethnic origin.

FLUCELVAX efficacy was assessed by the prevention of culture-confirmed symptomatic influenza illness caused by viruses antigenically matched to those in the vaccine and prevention of influenza illness caused by all influenza viruses compared to placebo. Influenza cases were identified by active and passive surveillance of influenza-like illness (ILI). ILI was defined as a fever (oral temperature ≥100.0°F / 38°C) and cough or sore throat. Nose and throat swab samples were collected for analysis within 120 hours of onset of an influenza-like illness in the period from 21 days to 6 months after vaccination. Overall vaccine efficacy against all influenza viral subtypes and vaccine efficacy against individual influenza viral subtypes were calculated (Tables 5 and 6, respectively).

Table 5: Vaccine Efficacy against Culture-Confirmed Influenza

Table 6: Efficacy of FLUCELVAX against Culture-Confirmed Influenza by Influenza Viral Subtype

There are no data demonstrating prevention of influenza disease after vaccination with FLUCELVAX in the pediatric age group.

Immunogenicity Of FLUCELVAX QUADRIVALENT In Adults 18 Years Of Age And Above

Immunogenicity of FLUCELVAX QUADRIVALENT was evaluated in adults 18 years of age and older in a randomized, double-blind, controlled study conducted in the US (Study 1). In this study, subjects received FLUCELVAX QUADRIVALENT or one of the two formulations of comparator trivalent influenza vaccine (FLUCELVAX QUADRIVALENT (N=1334), TIV1c, N=677 or TIV2c N= 669). In the per protocol set, the mean age of subjects who received FLUCELVAX QUADRIVALENT was 57.5 years; 55.1% of subjects were female and 76.1% of subjects were Caucasian, 13% were black and 9% were Hispanics. The immune response to each of the vaccine antigens was assessed, 21 days after vaccination.

The immunogenicity endpoints were geometric mean antibody titers (GMTs) of hemagglutination inhibition (HI) antibodies response and percentage of subjects who achieved seroconversions, defined as a pre-vaccination HI titer of <1:10 with a post-vaccination titer ≥1:40 or a pre-vaccination HI titer >1:10 and at least 4-fold increase in serum HI antibody titer.

FLUCELVAX QUADRIVALENT was noninferior to TIVc. Noninferiority was established for all 4 influenza strains included in the QIVc, as assessed by ratios of GMTs and the differences in the percentages of subjects achieving seroconversion at 3 weeks following vaccination. The antibody response to influenza B strains contained in FLUCELVAX QUADRIVALENT was superior to the antibody response after vaccination with TIVc containing an influenza B strain from the alternate lineage. There was no evidence that the addition of the second influenza B strain resulted in immune interference to other strains included in the vaccine. (See Table 7)

Table 7: Noninferiority of FLUCELVAX QUADRIVALENT relative to TIVc in adults 18 Years of Age and Above- Per Protocol Analys is Set [Study 1]

Immunogenicity In Children And Adolescents 4 Through 17 Years Of Age

Immunogenicity of FLUCELVAX QUADRIVALENT was evaluated in children 4 through 17 years of age in a randomized, double-blind, controlled study conducted in the US (Study 2). (See section 6.1) In this study, 1159 subjects received FLUCELVAX QUADRIVALENT. In the per protocol set, the mean age of subjects who received FLUCELVAX QUADRIVALENT was 9.8 years; 47% of subjects were female and 54% of subjects were Caucasian, 22% were black and 19% were Hispanics. The immune response to each of the vaccine antigens was assessed, 21 days after vaccination.

The immunogenicity endpoints were the percentage of subjects who achieved seroconversion, defined as a pre-vaccination hemagglutination inhibition (HI) titer of <1:10 with a post-vaccination HI titer ≥1:40 or at least a 4-fold increase in serum HI titer; and percentage of subjects with a post-vaccination HI titer ≥1:40.

In subjects receiving FLUCELVAX QUADRIVALENT, for all four influenza strains, the 95% LBCI seroconversion rates were ≥40% and the percentage of subjects who achieved HI titer ≥1:40 post vaccination were ≥70% (95%LBCI). (See Table 8)

Table 8: The Percentage of Children and Adolescents 4 through 17 years of Age with Seroconversion and HI Titers ≥ 1:40 post vaccination with FLUCELVAX QUADRIVALENT- Per-Protocol Analysis Set3 [Study 2]

REFERENCES

2. Hannoun C, Megas F, Piercy J. Immunogenicity and protective efficacy of influenza vaccination. Virus Res 2004;103:133-138.

3. Hobson D, Curry RL, Beare A, et.al. The role of serum hemagglutinin-inhibiting antibody in protection against challenge infection with influenza A2 and B viruses. J Hyg Camb 1972; 767-777.

4. Centers for Disease Control and Prevention. Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011; 60(33): 1128-1132.