Cervarix is a vaccine for use from the age of 9 years for the prevention of premalignant ano-genital lesions (cervical, vulvar, vaginal, and anal) and cervical and anal cancers causally related to certain oncogenic Human Papillomavirus (HPV) types. See sections 4.4 and 5.1 for important information on the data that support this indication.

The use of Cervarix should be in accordance with official recommendations.

Posology

*If the second vaccine dose is administered before the 5^th month after the first dose, a third dose should always be administered.

**If flexibility in the vaccination schedule is necessary, the second dose can be administered between 1 month and 2.5 months after the first dose and the third dose between 5 and 12 months after the first dose.

The need for a booster dose has not been established (see section 5.1).

It is recommended that subjects who receive a first dose of Cervarix complete the vaccination course with Cervarix (see section 4.4).

Paediatric population (children < 9 years of age)

Cervarix is not recommended for use in children below 9 years of age due to limited data on safety and immunogenicity in this age-group.

Method of administration

Cervarix is for intramuscular injection in the deltoid region (see also sections 4.4 and 4.5).

Cervarix should under no circumstances be administered intravascularly or intradermally. No data are available on subcutaneous administration of Cervarix (see section 4.4).

If Cervarix is to be given at the same time as another injectable vaccine, the vaccines should always be administered at different injection sites (see section 4.5).

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

Syncope (fainting) can occur following, or even before, any vaccination especially in adolescents as a psychogenic response to the needle injection. This can be accompanied by several neurological signs such as transient visual disturbance, paraesthesia and tonic-clonic limb movements during recovery. It is important that procedures are in place to avoid injury from faints.

Administration of Cervarix should be postponed in subjects suffering from an acute severe febrile illness. However, the presence of a minor infection, such as a cold, is not a contraindication for immunisation.

The vaccine should under no circumstances be administered intravascularly or intradermally.

No data are available on subcutaneous administration of Cervarix.

As with other vaccines administered intramuscularly, Cervarix should be given with caution to individuals with thrombocytopenia or any coagulation disorder since bleeding may occur following an intramuscular administration to these subjects.

As with any vaccine, a protective immune response may not be elicited in all vaccinees.

Cervarix will only protect against diseases that are caused by HPV types 16 and 18 and to some extent against diseases caused by certain other oncogenic related HPV types (see section 5.1). Therefore, appropriate precautions against sexually transmitted diseases should continue to be used.

The vaccine is for prophylactic use only and has no effect on active HPV infections or established clinical disease. The vaccine has not been shown to have a therapeutic effect. The vaccine is therefore not indicated for treatment of cervical cancer or cervical intraepithelial neoplasia (CIN). It is also not intended to prevent progression of other established HPV-related lesions or existing HPV infections with vaccine or non-vaccine types (see section 5.1 “Efficacy against HPV-16/18 in women with evidence of HPV-16 or HPV-18 infection at study entry.”).

Vaccination is not a substitute for routine cervical screening. Since no vaccine is 100% effective and Cervarix will not provide protection against every HPV type, or against existing HPV infections, routine cervical screening remains critically important and should follow local recommendations.

Duration of protection has not fully been established. Timing and need of booster dose(s) has not been established.

Except for asymptomatic human immunodeficiency virus (HIV) infected subjects for whom immunogenicity data are available (see section 5.1), there are no data on the use of Cervarix in subjects with impaired immune responsiveness such as patients receiving immunosuppressive treatment. As with other vaccines, an adequate immune response may not be elicited in these individuals.

There are no safety, immunogenicity or efficacy data to support interchangeability of Cervarix with other HPV vaccines.

This vaccine contains less than 1 mmol sodium (23 mg) per dose, that is to say essentially ‘sodium-free’.

Traceability

In order to improve the traceability of biological medicinal products, the name and the batch number

of the administered product should be clearly recorded.

In all clinical trials individuals who had received immunoglobulin or blood-derived products within 3 months prior to the first vaccine dose were excluded.

Use with other vaccines

Cervarix may be administered concomitantly with a combined booster vaccine containing diphtheria (d), tetanus (T) and pertussis [acellular] (pa) with or without inactivated poliomyelitis (IPV), (dTpa, dTpa-IPV vaccines), with no clinically relevant interference with antibody response to any of the components of either vaccine. The sequential administration of combined dTpa-IPV followed by Cervarix one month later tended to elicit lower anti-HPV-16 and anti-HPV-18 GMTs as compared to Cervarix alone. The clinical relevance of this observation is not known.

Cervarix may also be administered concomitantly with meningococcal serogroups A, C, W-135, Y tetanus toxoid conjugate vaccine (MenACWY-TT); with combined hepatitis A (inactivated) and hepatitis B (rDNA) vaccine (Twinrix) or with hepatitis B (rDNA) vaccine (Engerix B).

Administration of Cervarix at the same time as Twinrix has shown no clinically relevant interference in the antibody response to the HPV and hepatitis A antigens. Anti-HBs geometric mean antibody concentrations were significantly lower on co-administration, but the clinical relevance of this observation is not known since the seroprotection rates remain unaffected. The proportion of subjects reaching anti-HBs ≥ 10mIU/ml was 98.3% for concomitant vaccination and 100% for Twinrix given alone. Similar results were observed when Cervarix was given concomitantly with Engerix B with 97.9% of subjects reaching anti-HBs ³ 10mIU/ml compared to 100% for Engerix B given alone.

If Cervarix is to be given at the same time as another injectable vaccine, the vaccines should always be administered at different injection sites.

Use with hormonal contraceptive

In clinical studies, approximately 60% of women who received Cervarix used hormonal contraceptives. There is no evidence that the use of hormonal contraceptives has an impact on the efficacy of Cervarix.

Use with systemic immunosuppressive medicinal products

See section 4.4.

Pregnancy

Specific studies of the vaccine in pregnant women were not conducted. Data in pregnant women collected as part of pregnancy registries, epidemiological studies and inadvertent exposure during clinical trials are insufficient to conclude whether or not vaccination with Cervarix affects the risk of adverse pregnancy outcomes including spontaneous abortion.

However, during the clinical development program, a total of 10,476 pregnancies were reported including 5,387 in women who had received Cervarix. Overall, the proportions of pregnant subjects who experienced specific outcomes (e.g., normal infant, abnormal infants including congenital anomalies, premature birth, and spontaneous abortion) were similar between treatment groups.

Animal studies do not indicate direct or indirect harmful effects with respect to fertility, pregnancy, embryonal/foetal development, parturition or post-natal development (see section 5.3).

As a precautionary measure, it is preferable to avoid the use of Cervarix during pregnancy. Women who are pregnant or trying to become pregnant, are advised to postpone or interrupt vaccination until completion of pregnancy.

Breast-feeding

The effect on breast-fed infants of the administration of Cervarix to their mothers has not been evaluated in clinical studies.

Cervarix should only be used during breast-feeding when the possible advantages outweigh the possible risks.

Fertility

No fertility data are available.

No studies on the effects on the ability to drive or use machines have been performed. However, some of the effects mentioned under section 4.8 “Undesirable effects” may temporarily affect the ability to drive or use machines.

Summary of the safety profile

In clinical studies that enrolled girls and women aged from 10 up to 72 years (of which 79.2% were aged 10-25 years at the time of enrolment), Cervarix was administered to 16,142 females whilst 13,811 females received control. These subjects were followed for serious adverse events over the entire study period. In a pre-defined subset of subjects (Cervarix = 8,130 versus control = 5,786), adverse events were followed for 30 days after each injection. In two clinical studies that enrolled males aged 10 to 18 years, 2,617 males received Cervarix and were followed-up with active safety surveillance.

The most common adverse reaction observed after vaccine administration was injection site pain which occurred after 78% of all doses. The majority of these reactions were of mild to moderate severity and were not long lasting.

Tabulated list of adverse reactions

Adverse reactions considered as being at least possibly related to vaccination have been categorised by frequency.

Frequencies are reported as:

Very common (³1/10)

Common (³1/100 to <1/10)

Uncommon (³1/1,000 to <1/100)

*Because these events were reported spontaneously, it is not possible to reliably estimate their frequency

In clinical trials a similar safety profile has been observed in subjects with prior or current HPV infection as compared to subjects negative for oncogenic HPV DNA or seronegative for HPV-16 and HPV-18 antibodies.

For any information about this medicinal product, please contact: ​

GSK- Head Office, Jeddah​

·          Tel:  +966-12-6536666​

·          Mobile: +966-56-904-9882​

·          Email: gcc.medinfo@gsk.com​

·          Website: https://gskpro.com/en-sa/ ​

·          P.O. Box 55850, Jeddah 21544, Saudi Arabia​

To report any side effect(s):​

Kingdom of Saudi Arabia​

-National Pharmacovigilance centre (NPC)​

·       Reporting Hotline: 19999

·       E-mail: npc.drug@sfda.gov.sa​

·       Website: https://ade.sfda.gov.sa ​

-GSK - Head Office, Jeddah​

·          Tel:  +966-12-6536666​

·          Mobile: +966-56-904-9882​

·          Email: saudi.safety@gsk.com  ​

·          Website: https://gskpro.com/en-sa/ ​

·          P.O. Box 55850, Jeddah 21544, Saudi Arabia

No case of overdose has been reported.

Pharmacotherapeutic group: Vaccines, Papillomavirus vaccines, ATC code: J07BM02

Mechanism of action

Cervarix is an adjuvanted non-infectious recombinant vaccine prepared from the highly purified virus-like particles (VLPs) of the major capsid L1 protein of oncogenic HPV types 16 and 18. Since the VLPs contain no viral DNA, they cannot infect cells, reproduce or cause disease. Animal studies have shown that the efficacy of L1 VLP vaccines is largely mediated by the development of a humoral immune response.

HPV-16 and HPV-18 are estimated to be responsible for approximately 70% of cervical cancers, 90% of anal cancers, 70% of HPV-related high grade vulvar and vaginal intraepithelial neoplasia and 78% of HPV related high-grade anal (AIN 2/3) intraepithelial neoplasia.

Other oncogenic HPV types can also cause ano-genital cancers (approximately 30%). HPV 45, -31 and -33 are the 3 most common non-vaccine HPV types identified in squamous cervical carcinoma (12.1%) and adenocarcinoma (8.5%).

The term “premalignant ano-genital lesions” in section 4.1 corresponds to high-grade Cervical Intraepithelial Neoplasia (CIN2/3), high-grade vulvar intraepithelial neoplasia (VIN2/3), high-grade vaginal intraepithelial neoplasia (VaIN2/3). and high-grade anal intraepithelial neoplasia (AIN 2/3).

Clinical studies

Clinical efficacy in women aged 15 to 25 years

The efficacy of Cervarix was assessed in two controlled, double-blind, randomised Phase II and III clinical trials that included a total of 19,778 women aged 15 to 25 years.

The phase II trial (study 001/007) enrolled only women who:

-             Were tested negative for oncogenic HPV DNA of types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68

-             Were seronegative for HPV-16 and HPV-18 and

-             Had normal cytology

The primary efficacy endpoint was incident infection with HPV-16 and/or HPV-18. Twelve-month persistent infection was evaluated as additional efficacy endpoint.

The phase III trial (study 008) enrolled women without pre-screening for the presence of HPV infection, i.e. regardless of baseline cytology and HPV serological and DNA status.

The primary efficacy endpoint was CIN2+ associated with HPV-16 and/or HPV-18 (HPV-16/18). Cervical Intraepithelial Neoplasia (CIN) grade 2 and 3 (CIN2/3) and cervical adenocarcinoma in situ (AIS) were used in the clinical trials as surrogate markers for cervical cancer.

The secondary endpoints included 6- and 12-month persistent infection.

Persistent infection that lasts for at least 6 months has also been shown to be a relevant surrogate marker for cervical cancer in women aged 15 to 25 years.

Prophylactic efficacy against HPV-16/18 infection in a population naïve to oncogenic HPV types

Women (N=1,113) were vaccinated in study 001 and evaluated for efficacy up to month 27. A subset of women (N=776) vaccinated in study 001 was followed in study 007 up to 6.4 years (approximately 77 months) after the first dose (mean follow-up of 5.9 years). There were five cases of 12-month persistent HPV-16/18 infection (4 HPV-16; 1 HPV-18) in the control group and one HPV-16 case in the vaccine group in study 001. In study 007 the efficacy of Cervarix against 12-month persistent HPV-16/18 infection was 100% (95% CI: 80.5; 100). There were sixteen cases of persistent HPV-16 infection, and five cases of persistent HPV-18 infection, all in the control group.

In study HPV-023, subjects from the Brazilian cohort (N=437) of study 001/007 were followed up to a mean of 8.9 years (standard deviation 0.4 years) after the first dose. At study completion, there were no cases of infection or histopathological lesions associated with HPV-16 or HPV-18 in the vaccine group in study HPV-023.  In the placebo group, there were 4 cases of 6-month persistent infection and 1 case of 12-month persistent infection. The study was not powered to demonstrate a difference between the vaccine and the placebo group for these endpoints.

Prophylactic efficacy against HPV-16/18 in women naïve to HPV-16 and/or HPV-18

In study HPV-008, the primary analyses of efficacy were performed on the According to Protocol cohort (ATP cohort: including women who received 3 vaccine doses and were DNA negative and seronegative at month 0 and DNA negative at month 6 for the HPV type considered in the analysis). This cohort included women with normal or low-grade cytology at baseline and excluded only women with high-grade cytology (0.5% of the total population). Case counting for the ATP cohort started on day 1 after the third dose of vaccine.

Overall, 74% of women enrolled were naïve to both HPV-16 and HPV-18 (i.e. DNA negative and seronegative at study entry).

Two analyses of study HPV-008 have been performed: an event-triggered analysis performed once at least 36 CIN2+ cases associated with HPV-16/18 were accrued in the ATP cohort and an end-of study analysis.

Vaccine efficacy against the primary endpoint CIN2+at the end of study is presented in Table 1. In a supplemental analysis, the efficacy of Cervarix was evaluated against HPV-16/18-related CIN3+.

Table 1: Vaccine efficacy against high grade cervical lesions associated with HPV-16/18 (ATP cohort)

At the event-triggered analysis the efficacy was 92.9% (96.1% CI: 79.9;98.3) against CIN2+ and 80% (96.1% CI: 0.3;98.1) against CIN3+. In addition, statistically significant vaccine efficacy against CIN2+ associated with HPV-16 and HPV-18 individually was demonstrated.

Further investigation of the cases with multiple HPV types considered the HPV types detected by Polymerase Chain Reaction (PCR) in at least one of the two preceding cytology samples, in addition to types detected in the lesion to distinguish the HPV type(s) most likely responsible to the lesion (HPV type assignment). This post-hoc analysis excluded cases (in the vaccine group and in the control group) which were not considered to be causally associated with HPV-16 or HPV-18 infections acquired during the trial.

Based on the HPV type assignment post-hoc analysis, there was 1 CIN2+ case in the vaccine group versus 92 cases in the control group (Efficacy 98.9% (95% CI: 93.8;100)) and no CIN3+ case in the vaccine group versus 22 cases in the control group (Efficacy 100% (95% CI: 81.8;100)) at the end of study analysis.

In the event-triggered analysis, vaccine efficacy against CIN1 associated with HPV 16/18 observed in the ATP cohort was 94.1% (96.1% CI: 83.4;98.5). Vaccine efficacy against CIN1+ associated with HPV 16/18 observed in the ATP cohort was 91.7% (96.1% CI: 82.4;96.7). At the end of study analysis, vaccine efficacy against CIN1 associated with HPV 16/18 observed in the ATP cohort was 92.8% (95% CI: 87.1;96.4).

At end of study analysis, there were 2 cases of VIN2+ or VaIN2+ in the vaccine group and 7 cases in the control group in the ATP cohort associated with HPV-16 or HPV-18. The study was not powered to demonstrate a difference between the vaccine and the control group for these endpoints.

Vaccine efficacy against virological endpoints (6-month and 12-month persistent infection) associated with HPV-16/18 observed in the ATP cohort at the end of study is presented in Table 2.

Table 2: Vaccine efficacy against virological endpoints associated with HPV-16/18 (ATP cohort)

The efficacy results at the event-triggered analysis were 94.3% (96.1% CI: 91.5;96.3) against 6-month persistent infection and 91.4% (96.1% CI: 89.4;95.4) against 12-month persistent infection.

Efficacy against HPV-16/18 in women with evidence of HPV-16 or HPV-18 infection at study entry.

There was no evidence of protection from disease caused by the HPV types for which subjects were HPV DNA positive at study entry. However, individuals already infected (HPV DNA positive) with one of the vaccine-related HPV types prior to vaccination were protected from clinical disease caused by the other vaccine HPV type.

Efficacy against HPV types 16 and 18 in women with and without prior infection or disease.

The Total Vaccinated Cohort (TVC) included all subjects who received at least one dose of the vaccine, irrespective of their HPV DNA status, cytology and serostatus at baseline. This cohort included women with or without current and/or prior HPV infection. Case counting for the TVC started on day 1 after the first dose.

The efficacy estimates are lower in the TVC as this cohort includes women with pre-existing infections/lesions, which are not expected to be impacted by Cervarix.

The TVC may approximate to the general population of women in the age range of 15-25 years.

Vaccine efficacy against high grade cervical lesions associated with HPV-16/18 observed in TVC at end of study is presented in Table 3.

Table 3: Vaccine efficacy against high grade cervical lesions associated with HPV-16/18 (TVC)

Vaccine efficacy against virological endpoints (6-month and 12-month persistent infection) associated with HPV-16/18 observed in TVC at end of study is presented in Table 4.

Table 4: Vaccine efficacy against virological endpoints associated with HPV-16/18 (TVC)

Overall impact of the vaccine on cervical HPV disease burden

In study HPV-008, the incidence of high grade cervical lesions was compared between the placebo and vaccine group irrespective of the HPV DNA type in the lesion. In the TVC and TVC-naïve cohorts, the vaccine’s efficacy was demonstrated against high-grade cervical lesions at end of study (Table 5).

The TVC-naïve is a subset of the TVC that includes women with normal cytology, and who were HPV DNA negative for 14 oncogenic HPV types and seronegative for HPV-16 and HPV-18 at baseline.

Table 5: Vaccine efficacy against high-grade cervical lesions irrespective of the HPV DNA type in the lesion

At the end of study analysis, Cervarix reduced definitive cervical therapy procedures (includes loop electrosurgical excision procedure [LEEP], cold-knife Cone, and laser procedures) by 70.2% (95% CI: 57.8;79.3) in TVC-naïve and 33.2% (95% CI: 20.8;43.7) in TVC.

Cross-protective efficacy

The cross-protective efficacy of Cervarix against histopathological and virological endpoints (persistent infection) has been evaluated in study HPV-008 for 12 non-vaccine oncogenic HPV types. The study was not powered to assess efficacy against disease caused by individual HPV types. The analysis against the primary endpoint was confounded by multiple co-infections in the CIN2+ lesions.  Unlike histopathological endpoints, virological endpoints are less confounded by multiple infections.

HPV-31, 33 and 45 showed consistent cross-protection for 6-month persistent infection and CIN2+ endpoints in all study cohorts.

End of study vaccine efficacy against 6-month persistent infection and CIN2+ associated with individual non-vaccine oncogenic HPV types is presented in Table 6 (ATP cohort).

Table 6: Vaccine efficacy for non-vaccine oncogenic HPV types

Clinical efficacy in women aged 26 years and older

The efficacy of Cervarix was assessed in a double-blind, randomised Phase III clinical trial (HPV-015) that included a total of 5,778 women aged 26-72 years (median: 37.0 years). The study was conducted in North America, Latin America, Asia Pacific and Europe. Final analysis was performed at study conclusion, 7 years after 1^st vaccination.

The primary endpoint was a combination of a virological and a histopathological endpoint: HPV-16/18 related 6-month persistent infection and/or CIN1+. The primary analyses of efficacy were performed on the ATP cohort for efficacy and the TVC which included a subset of up to 15% of women with a history of HPV-associated infection or disease (defined as two or more abnormal smears in sequence, abnormal colposcopy, or biopsy or treatment of the cervix after abnormal smear or colposcopy findings). Inclusion of this subset allowed assessment of prophylactic efficacy in a population that is thought to reflect a real-world setting, as adult women are the age group generally targeted for cervical screening.

Vaccine efficacy at study conclusion is summarised in the following table.

There is no evidence whether prevention of persistent infection that lasts for at least 6 months is a relevant surrogate marker for cervical cancer prevention in women aged 26 years and above.

Table 7 - Vaccine efficacy at study conclusion in study HPV-015

Efficacy against ≥ASC-US (abnormal cytology) associated with oncogenic non-vaccine types was 37.2% (96.2% CI [21.3; 50.1]) (ATP).

Efficacy against CIN1+ irrespective of the HPV type detected in the lesion was 22.9% (96.2% CI [4.8; 37.7]) (TVC). 

There was no evidence of protection from disease caused by HPV in subjects aged 25 years and above who were DNA positive and/ or with abnormal cytology at study entry.

Immunogenicity

Immune response to Cervarix after the primary vaccination course

No minimal antibody level associated with protection against CIN of grade 2 or 3 or against persistent infection associated with vaccine HPV types has been identified for HPV vaccines.

The antibody response to HPV-16 and HPV-18 was measured using a type-specific direct ELISA (version 2, MedImmune methodology, modified by GSK) which was shown to correlate with the pseudovirion-based neutralisation assay (PBNA).

The immunogenicity induced by three doses of Cervarix has been evaluated in 5,465 female subjects from 9 to 55 years of age and over 800 male subjects aged 10 to 18 years.

In clinical trials, more than 99% of initially seronegative subjects had seroconverted to both HPV types 16 and 18 one month after the third dose. Vaccine-induced IgG Geometric Mean Titres (GMT) were well above titres observed in women previously infected but who cleared HPV infection (natural infection). Initially seropositive and seronegative subjects reached similar titres after vaccination.

Persistence of Immune Response to Cervarix

Study 001/007, which included women from 15 to 25 years of age at the time of vaccination, evaluated the immune response against HPV-16 and HPV-18 up to 76 months after administration of the first vaccine dose. In study 023 (a subset of study 001/007), the immune response continued to be evaluated up to 113 months. 92 subjects in the vaccine group had immunogenicity data at the [M107-M113] interval after the first vaccine dose with a median follow-up of 8.9 years. Of these subjects, 100% (95% CI: 96.1;100) remained seropositive for HPV-16 and HPV-18 in the ELISA assay.

Vaccine-induced IgG GMTs for both HPV-16 and HPV-18 peaked at month 7 and then declined to reach a plateau from month 18 up to the [M107-M113] interval with ELISA GMTs for both HPV-16 and HPV-18 at least still 10-fold higher than the ELISA GMTs observed in women who cleared a natural HPV infection.

In study 008, immunogenicity up to month 48 was similar to the response observed in study 001. A similar kinetic profile was observed with the neutralising antibodies.

In another clinical trial (study 014) performed in women aged 15 to 55 years, all subjects seroconverted to both HPV types 16 and 18 after the third dose (at month 7).  The GMTs were, however, lower in women above 25 years. 470 subjects (142 aged 15-25 years, 172 aged 26-45 years and 156 aged 46-55 years) who completed study HPV-014 and received the 3-dose schedule were followed-up for up to 10 years in the extension study HPV-060. Ten years after administration of the first dose, 100% of subjects in the 15-25 years group, 99.2% in the 26-45 years group and 96.3% in the 46-55 years group were still seropositive for HPV-16, and 99.2%, 93.7% and 83.8% for HPV-18, respectively. In all age groups, GMTs remained at least 5- to 32-fold for HPV-16 and 3- to 14-fold for HPV-18 above those elicited in women who cleared a natural infection for both antigens.

Evidence of Anamnestic (Immune Memory) Response

In study 024 (a subset of study 001/007), a challenge dose of Cervarix was administered to 65 subjects at a mean interval of 6.8 years after the administration of the first vaccine dose. An anamnestic immune response to HPV-16 and HPV-18 (by ELISA) was observed one week and one month after the challenge dose, GMTs one month after the challenge dose exceeded those observed one month after the primary 3-dose vaccination.

Bridging the efficacy of Cervarix from young adult women to adolescents

In a pooled analysis (HPV-029,-30 & -48), 99.7% and 100% of females aged 9 years seroconverted to HPV types 16 and 18, respectively after the third dose (at month 7) with GMTs at least 1.4-fold and 2.4-fold higher as compared to females aged 10-14 years and 15 to 25 years, respectively.

In two clinical trials (HPV-012 & -013) performed in girls aged 10 to 14 years, all subjects seroconverted to both HPV types 16 and 18 after the third dose (at month 7) with GMTs at least 2-fold higher as compared to women aged 15 to 25 years.

In clinical trials (HPV-070 and HPV-048) performed in girls aged 9 to 14 years receiving a 2-dose schedule (0, 6 months or 0, 12 months) and young women aged 15-25 years receiving Cervarix according to the standard 0, 1, 6 months schedule, all subjects seroconverted to both HPV types 16 and 18 one month after the second dose. The immune response after 2 doses in females aged 9 to 14 years was non-inferior to the response after 3 doses in women aged 15 to 25 years.

On the basis of these immunogenicity data, the efficacy of Cervarix is inferred from 9 to 14 years of age.

Duration of the immune response in women aged 26 years and older

In the Phase III study (HPV-015) in women 26 years and older all subjects seroconverted one month after the third dose. At the 84-month time point, i.e. 78 months after completion of the full vaccination course, 99.3% and 95.9% of initially seronegative women remained seropositive for anti-HPV-16 and anti-HPV-18 antibodies, respectively. All initially seropositive women remained seropositive for both anti-HPV-16 and anti-HPV-18 antibodies. Antibody titers peaked at month 7 then gradually declined up to month 18 and stabilized to reach a plateau up to month 84.

Immunogenicity in males aged 10 to 18 years

Immunogenicity in males was assessed in 2 clinical trials HPV-011 (N=173) and HPV-040 (N=556). The data showed comparable immunogenicity in males and females. In study HPV-011, all subjects seroconverted to both HPV-16 and 18 and GMT levels were non inferior to those observed in females aged 15 to 25 years in study HPV-012.

Bridging of clinical efficacy against anal lesions and cancers

No efficacy study against anal premalignant lesions has been conducted with Cervarix. However, studies conducted in girls aged 9 to 14 years (study HPV-071) and in women aged 18 to 45 years (study HPV-010) have consistently shown a higher immune response with Cervarix than with the comparator for which efficacy data against anal premalignant lesions are conclusive and have shown protection.

Immunogenicity in HIV infected women

Two clinical studies assessed safety and immunogenicity of Cervarix:

1. In study HPV-020, conducted in South Africa, 22 HIV uninfected and 42 HIV infected subjects (WHO clinical stage 1; ATP cohort for immunogenicity) received Cervarix.
2. Study HPV-019, a comparative study of Cervarix and quadrivalent HPV vaccine was conducted in 289 (ATP cohort = 157) HIV uninfected and 257 (ATP cohort = 166) HIV infected female subjects aged 15-25 years in Brazil, Estonia, India and Thailand.

At study entry, HIV infected subjects in both studies had to: be asymptomatic regardless of their prior clinical stage; have undetectable viral load (i.e., viral load < 400 copies/ml) for at least six months if on antiretroviral therapy (ART) (HPV-020) or highly active antiretroviral therapy (HAART) for at least one year (HPV-019); not be diagnosed with active tuberculosis (TB) or on TB therapy;  in HPV-019 only - have a CD4 cell count > 350 cells/mm3.

In both studies, seroconversion at month 7 in HIV infected subjects receiving Cervarix was 100% for both antigens in the ATP cohort. In HPV-019, seropositivity at month 24 after Cervarix vaccination was 100% for HPV-16 antibodies and >96% for HPV-18 antibodies with a Geometric Mean Concentration (GMC) level more than 12 times higher than the response to natural HPV infection.

In both studies, the antibody GMCs in HIV infected subjects appeared lower than in the HIV negative subjects (non-overlapping 95% confidence interval). In HPV-019, superiority of immune responses (neutralizing antibodies GMT ratios) to both HPV-16 and HPV-18 antigens was demonstrated with Cervarix compared to quadrivalent HPV vaccine, at month 7 in HIV infected subjects. The clinical relevance of these observations is unknown. No clinical efficacy data exist about protection against persistent infection or precancerous lesions among HIV infected women.

The observed reactogenicity and safety profile of Cervarix in HIV infected women was in line with the known safety profile in healthy subjects (see section 4.8).

Not applicable.

Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, acute and repeated dose toxicity, local tolerance, fertility, embryo-foetal and postnatal toxicity (up to the end of the lactation period).

Serological data suggest a transfer of anti-HPV-16 and anti-HPV-18 antibodies via the milk during the lactation period in rats. However, it is unknown whether vaccine-induced antibodies are excreted in human breast milk.

Sodium chloride (NaCl)

Sodium dihydrogen phosphate dihydrate (NaH₂PO₄.2 H₂O)

Water for injections

For adjuvants, see section 2.

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

Store in a refrigerator (2°C – 8°C).

Do not freeze.

Store in the original package in order to protect from light.

Multidose vial

For storage after first opening, see section 6.3.

Pre-filled syringe

0.5 ml of suspension in a pre-filled syringe (type I glass) with a plunger stopper (rubber butyl) with or without needles.

Pack sizes of 1 and 10 pre-filled syringes with or without needles.

Vial

0.5 ml of suspension in a vial (type I glass) for 1 dose with a stopper (rubber butyl).

Pack sizes of 1, 10 and 100 vials.

Multidose vial

1 ml of suspension in a vial (type I glass) for 2 doses with a stopper (rubber butyl).

Pack sizes of 1, 10 and 100 vials.

Not all pack sizes may be marketed.

Pre-filled syringe

A fine white deposit with a clear colourless supernatant may be observed upon storage of the syringe. This does not constitute a sign of deterioration.

The content of the syringe should be inspected visually both before and after shaking for any foreign particulate matter and/or abnormal physical appearance prior to administration.

In the event of either being observed, discard the vaccine.

The vaccine should be well shaken before use.

Vial

A fine white deposit with a clear colourless supernatant may be observed upon storage of the vial. This does not constitute a sign of deterioration.

The content of the vial should be inspected visually both before and after shaking for any foreign particulate matter and/or abnormal physical appearance prior to administration.

In the event of either being observed, discard the vaccine.

The vaccine should be well shaken before use.

Multidose vial

A fine white deposit with a clear colourless supernatant may be observed upon storage of the vial. This does not constitute a sign of deterioration.

The content of the vial should be inspected visually both before and after shaking for any foreign particulate matter and/or abnormal physical appearance prior to administration.

In the event of either being observed, discard the vaccine.

The vaccine should be well shaken before use.

When using a multidose vial, each 0.5 ml dose should be withdrawn using a sterile needle and syringe; precautions should be taken to avoid contamination of the contents.

Disposal

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

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