- 1. Name of the medicinal product
- 2. Qualitative and quantitative composition
- 3. Pharmaceutical form
- 4. Clinical particulars
- 4.1 Therapeutic indications
- 4.2 Posology and method of administration
- 4.3 Contraindications
- 4.4 Special warnings and precautions for use
- 4.5 Interaction with other medicinal products and other forms of interaction
- 4.6 Fertility, pregnancy and lactation
- 4.7 Effects on ability to drive and use machines
- 4.8 Undesirable effects
- 4.9 Overdose
- 5. Pharmacological properties
- 5.1 Pharmacodynamic properties
- 5.2 Pharmacokinetic properties
- 5.3 Preclinical safety data
- 6. Pharmaceutical particulars
- 6.1 List of excipients
- 6.2 Incompatibilities
- 6.3 Shelf life
- 6.4 Special precautions for storage
- 6.5 Nature and contents of container
- 6.6 Special precautions for disposal and other handling
- 7. Marketing authorisation holder
- 8. Marketing authorisation number(s)
- 9. Date of first authorisation/renewal of the authorisation
- 10. Date of revision of the text
PosologyIndividuals should receive a single dose (0.65 mL).The need for a booster dose is not known. See sections 4.8 and 5.1.
Paediatric populationThe safety and efficacy of ZOSTAVAX in children and adolescents have not been established. No data are available.There is no relevant use of ZOSTAVAX in children and adolescents for prevention of primary varicella infection (chickenpox).
Method of administrationThe vaccine can be injected subcutaneously (SC) or intramuscularly (IM), preferably in the deltoid region (see sections 4.8 and 5.1).The vaccine should be administered subcutaneously in patients with severe thrombocytopenia or any coagulation disorder (see section 4.4).
The vaccine should under no circumstances be injected intravascularly.For precautions to be taken before handling or administering the medicinal product see section 6.6.For instructions on reconstitution of the medicinal product before administration see section 6.6.
TransmissionIn clinical trials with ZOSTAVAX, transmission of the vaccine virus has not been reported. However, post-marketing experience with varicella vaccines suggests that transmission of vaccine virus may occur rarely between vaccinees who develop a varicella-like rash and susceptible contacts [for example, varicella-zoster virus (VZV) susceptible infant grandchildren]. Transmission of vaccine virus from varicella vaccine recipients who do not develop a varicella-like rash has also been reported. This is a theoretical risk for vaccination with ZOSTAVAX. The risk of transmitting the attenuated vaccine virus from a vaccinee to a susceptible contact should be weighed against the risk of developing natural zoster and potentially transmitting wild-type VZV to a susceptible contact.
PregnancyThere are no data on the use of ZOSTAVAX in pregnant women. Traditional non-clinical studies are insufficient with respect to reproductive toxicity (see section 5.3). However naturally-occurring varicella-zoster virus infection is known to sometimes cause foetal harm. ZOSTAVAX is not recommended to be administered to pregnant women. In any case, pregnancy should be avoided for one month following vaccination (see section 4.3).
Breast-feedingIt is unknown whether VZV is secreted in human milk. A risk to the newborns/infants cannot be excluded. A decision must be made whether to discontinue breast-feeding or to not administer ZOSTAVAX taking into account the benefit of breast feeding for the child and the benefit of vaccination for the woman.
FertilityZOSTAVAX has not been evaluated in fertility studies.
a. Summary of the safety profileThe most common adverse reactions reported in pivotal clinical trials were injection-site reactions. Headache and pain in the extremity were the most common systemic adverse reactions. Most of these local and systemic adverse reactions were reported as mild in intensity. Vaccine-related serious adverse reactions were reported for 0.01% subjects vaccinated with ZOSTAVAX and subjects who received placebo.Data from a clinical trial (n=368) demonstrated that the current refrigerated formulation has a safety profile comparable to that of the frozen formulation.
b. Tabulated summary of adverse eventsIn clinical trials, general safety has been evaluated in more than 57000 adults vaccinated with ZOSTAVAX.Table 1 presents vaccine-related injection-site and systemic adverse reactions reported at a significantly greater incidence in the vaccine group versus the placebo group within 42 days postvaccination in the ZOSTAVAX Efficacy and Safety trial (ZEST) study and in the Adverse Event Monitoring Substudy of Shingles Prevention Study (SPS).Additional adverse reactions, spontaneously reported through post-marketing surveillance, are also included in Table 1. As these events are reported voluntarily from a population of uncertain size, it is not possible to reliably calculate their frequency or establish a causal relationship to vaccine exposure. Consequently, the frequencies of these adverse reactions have been estimated based on the adverse events reported in SPS and ZEST (regardless of vaccine relationship assigned by the investigator).The adverse reactions are assigned frequency categories using the following convention: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)
Table 1: Adverse Reactions from Clinical Trial Experience and Post-Marketing Surveillance
|MedDRA System Organ Class||Adverse reaction terms||Frequency|
|Infections and infestations||Varicella, Herpes zoster (vaccine strain)||Very rare|
|Blood and lymphatic system disorders||Lymphadenopathy (cervical, axillary)||Uncommon|
|Immune system disorders||Hypersensitivity reactions including anaphylactic reactions||Rare|
|Nervous system disorders||Headache1||Common|
|Eye Disorders||Necrotizing retinitis (patients on immunosuppressive therapy)||Very rare|
|Skin and subcutaneous tissue disorders||Rash||Common|
|Musculoskeletal and connective tissue disorders||Arthralgia, Myalgia, Pain in extremity1||Common|
|General disorders and administration site conditions||Injection site: Erythema 1,2, Pain/tenderness1,2 , Pruritus1,2, Swelling1,2Injection site: Induration1, Haematoma1, Warmth1,Rash Pyrexia Injection site urticaria||Very common Common Rare|
c. Description of selected adverse reactions
Injection site reactionsVaccine-related injection-site adverse reactions were significantly greater for subjects vaccinated with ZOSTAVAX versus subjects who received placebo. In SPS, the overall incidence of vaccine-related injection-site adverse reactions were 48% for ZOSTAVAX and 17% for placebo in subjects 60 years of age and older.In ZEST, the overall incidence of vaccine-related injection site adverse reactions were 63.9% for ZOSTAVAX and 14.4% for placebo in subjects 50 to 59 years of age. Most of these adverse reactions were reported as mild in intensity.In other clinical trials evaluating ZOSTAVAX in subjects 50 years of age or older, including a study of concomitantly administered inactivated influenza vaccine, a higher rate of injection-site adverse experiences of mild-to-moderate intensity was reported among subjects 50-59 years of age compared with subjects ≥60 years of age (see section 5.1).ZOSTAVAX was administered either subcutaneously (SC) or intramuscularly (IM) in subjects 50 years of age or older (see section 5.1). The general safety profiles of the SC and IM routes were otherwise comparable, but injection-site adverse reactions were significantly less frequent in the IM group (34%) compared with the SC group (64%).
Herpes zoster/herpes zoster-like rashes and Varicella/varicella-like rashes in clinical trialsIn clinical trials the number of herpes zoster/herpes zoster-like rashes within the 42-day postvaccination was low in both ZOSTAVAX and placebo groups. The majority of rashes have been rated as mild to moderate; no complications from rash have been observed in the clinical setting. Most of the reporting rashes that were VZV positive by PCR analysis were associated with wild-type VZV.In SPS and ZEST, the number of subjects who reported herpes zoster/herpes zoster-like rashes was less than 0.2% for ZOSTAVAX and placebo groups, with no significant difference observed between the two groups. The number of subjects who reported varicella/varicella-like rashes was less than 0.7% for ZOSTAVAX and placebo.The Oka/Merck strain of VZV was not detected from any specimens in SPS or ZEST. VZV was detected in one (0.01%) specimen from a ZOSTAVAX recipient reporting a varicella/varicella-like rash; however, the virus strain (wild type or Oka/Merck strain) could not be determined. Across all other clinical trials, the Oka/Merck strain was identified by PCR analysis from the lesion specimens of only two subjects who reported varicella-like rashes (onset on Day 8 and 17).
d. Special populations
Adults with a history of herpes zoster (HZ) prior to vaccinationZOSTAVAX was administered to subjects 50 years of age or older with a history of herpes zoster (HZ) prior to vaccination (see section 5.1). The safety profile was generally similar to that seen in the Adverse Event Monitoring Substudy of the SPS.
Adults on chronic/maintenance systemic corticosteroidsIn subjects 60 years of age or older who were receiving chronic/maintenance systemic corticosteroid therapy at a daily dose equivalent of 5 to 20 mg of prednisone for at least 2 weeks prior to enrollment, and 6 weeks or more following vaccination, the safety profile was generally comparable to that seen in the Adverse Event Monitoring Substudy of the SPS (see sections 4.3 and 5.1).
HIV-infected adults with conserved immune functionIn a clinical trial, ZOSTAVAX was administered to HIV-infected adults (18 years of age or older, CD4+ T cell count ≥ 200 cells/µL) (see section 5.1). The safety profile was generally similar to the Adverse Event Monitoring Substudy of the SPS. Adverse events were followed up to Day 42 post vaccination and serious adverse events throughout the entire study period (i.e. through Day 180). Of the 295 ZOSTAVAX recipients, one case of serious vaccine related maculo-papular rash was reported on Day 4 following Dose 1 of ZOSTAVAX (see section 4.3).
VZV-seronegative adultsBased on limited data from 2 clinical trials that enrolled VZV-seronegative or low seropositive subjects (30 years of age or older) receiving live attenuated zoster vaccine, injection site and systemic adverse experiences were generally similar to those reported by other subjects who received ZOSTAVAX in clinical trials, with 2 of the 27 subjects reporting fever. No subjects reported varicella-like or herpes zoster-like rashes. No serious vaccine-related adverse experiences were reported.
e. Other studies
Adults receiving additional doses/revaccinationIn a clinical study, adults 60 years of age or older received a second dose of ZOSTAVAX 42 days following the initial dose (see section 5.1). The frequency of vaccine-related adverse experiences after the second dose of ZOSTAVAX was generally similar to that seen with the first dose.In another study, ZOSTAVAX was administered as a booster dose to HZ history-negative subjects 70 years of age or older who had received a first dose approximately 10 years previously, and as a first dose to HZ history-negative subjects 70 years of age or older (see section 5.1). The frequency of vaccine-related adverse experiences after the booster dose of ZOSTAVAX was generally similar to that seen with the first dose.
Reporting of suspected adverse reactionsReporting 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 national reporting system.
In IrelandHPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: firstname.lastname@example.org.
In the UKYellow Card Scheme at www.mhra.gov.uk/yellowcard.
Mechanism of actionAnyone who has been infected with VZV, including those without a clinical history of varicella, is at risk for developing zoster. This risk appears to be causally related to a decline in VZV-specific immunity. ZOSTAVAX was shown to boost VZV-specific immunity, which is thought to be the mechanism by which it protects against zoster and its complications (See Immunogenicity).
Clinical EfficacyThe protective clinical efficacy of ZOSTAVAX was demonstrated in two large, randomised, placebo controlled clinical trials where subjects received ZOSTAVAX subcutaneously (see Tables 2 and 3).
ZOSTAVAX Efficacy and Safety Trial (ZEST) in subjects 50 to 59 years of age:The ZEST study was a placebo-controlled, double-blind clinical trial in which 22,439 subjects were randomised to receive a single dose of either ZOSTAVAX or placebo and were followed for the development of zoster for a median of 1.3 years (range 0 to 2 years). Final determination of zoster cases was made by Polymerase Chain Reaction (PCR) [86%], or in the absence of virus detection, as determined by a clinical evaluation committee [14%]. ZOSTAVAX significantly decreased the incidence of zoster compared to placebo (see Table 2).
Table 2: Efficacy of ZOSTAVAX on zoster incidence compared with placebo in the ZEST trial in subjects 50 to 59 years of age*
|ZOSTAVAX||Placebo||Vaccine efficacy(95% CI)|
|Number of subjects||Number of zoster cases||Incidence rate of zoster per 1,000 person years||Number of subjects||Number of zoster cases||Incidence rate of zoster per 1,000 person years|
|11,211||30||2.0||11,228||99||6.6||70% (54%, 81%)|
Table 3: Efficacy of ZOSTAVAX on zoster incidence compared with placebo in the SPS in subjects 60 years of age and older*
|Age group||ZOSTAVAX||Placebo||Vaccine efficacy(95% CI)|
|Number of subjects||Number of zoster cases||Incidence rate of zoster per 1,000 person years||Number of subjects||Number of zoster cases||Incidence rate of zoster per 1,000 person years|
|≥ 60||19254||315||5.4||19247||642||11.1||51% (44%, 58%)|
|60-69||10370||122||3.9||10356||334||10.8||64% (56%, 71%)|
|≥ 70||8884||193||7.2||8891||308||11.5||38% (25%, 48%)|
|70-79||7621||156||6.7||7559||261||11.4||41% (28%; 52%)|
|Age group||ZOSTAVAX||Placebo||Vaccine efficacy (95% CI)|
|Number of subjects||Number of PHN cases||Incidence rate of PHN per 1,000 person years||Number of subjects||Number of PHN cases||Incidence rate of PHN per 1,000 person years|
|≥ 60||19254||27||0.5||19247||80||1.4||67%§(48%, 79%)|
|60-69||10370||8||0.3||10356||23||0.7||66% (20%, 87%)|
|≥ 70||8884||19||0.7||8891||57||2.1||67% (43%, 81%)|
|70-79||7621||12||0.5||7559||45||2.0||74% (49%, 87%)|
|Age group||ZOSTAVAX||Placebo||Vaccine efficacy (95% CI)|
|Number of subjects||Number of zoster confirmed cases||Mean BOI score||Number of subjects||Number of zoster confirmed cases||Mean BOI score|
|≥ 60||19254||315||2.21||19247||642||5.68||61% (51%, 69%)|
|60-69||10370||122||1.5||10356||334||4.33||66% (52%, 76%)|
|≥ 70||8884||193||3.47||8891||308||7.78||55% (40%, 67%)|
|70-79||7621||156||3.04||7559||261||7.43||59% (43%, 71%)|
Prevention of HZ cases with severe pain in the entire SPS study populationZOSTAVAX reduced the incidence of zoster with severe and long-lasting pain (severity-by-duration score >600) by 73% (95% CI: [46 to 87%]) compared with placebo (11 vs. 40 cases, respectively).
Reduction of zoster pain severity-by-duration in vaccinated individuals who developed zosterWith regard to the acute pain (pain between 0-30 days) there was no statistically significant difference between the vaccine group and the placebo group. However, among vaccinated individuals who developed PHN, ZOSTAVAX significantly reduced PHN-associated (chronic) pain compared with placebo. In the period from 90 days after rash onset to the end of follow-up, there was a 57% reduction in the severity-by-duration score (average scores of 347 for ZOSTAVAX and 805 for placebo; p=0.016).Overall, among vaccinated individuals who developed zoster, ZOSTAVAX significantly reduced overall acute and chronic zoster-associated pain compared with placebo. Over the 6-month (acute and chronic) follow-up period, there was a 22% reduction (p =0.008) in the severity-by-duration score and a 52% (95% CI: [7 to 74%]) reduction (from 6.2% to 3.5%) in the risk of having zoster with severe and long-lasting pain (severity-by-duration score of >600).
Zostavax persistence of protectionThe persistence of protection following vaccination has been evaluated through longer-term follow-up in Short-term Persistence Substudy (STPS) and Long-term Persistence Substudy (LTPS) and supports the continued benefit of ZOSTAVAX throughout the follow-up periods studied. The STPS was initiated to accrue additional information on the persistence of vaccine efficacy for subjects who received ZOSTAVAX in SPS.Persistence of ZOSTAVAX efficacy was studied 4 to 7 years postvaccination in the STPS, which included 7,320 subjects previously vaccinated with ZOSTAVAX and 6,950 subjects previously vaccinated with placebo in the SPS (mean age at enrollment was 73.3 years); and 7 to 10 years postvaccination in the Long-term Persistence Substudy (LTPS), which included 6,867 subjects previously vaccinated with ZOSTAVAX (mean age at enrollment into the LTPS was 74.5 years). The median follow-up was ~1.2 years (range is one day to 2.2 years) and ~3.9 years (range is one week to 4.75 years) in STPS and LTPS, respectively. During the course of the STPS, placebo recipients were offered ZOSTAVAX, at which time they were considered to have completed the STPS. A concurrent placebo control was not available in the LTPS; data from prior placebo recipients were used to estimate vaccine efficacy.In the STPS, there were 84 evaluable zoster cases [8.4/1000 person-years] in the ZOSTAVAX group and 95 evaluable cases [14.0/1000 person-years] in the placebo group. The estimated vaccine efficacy during the STPS follow-up period was 40% (95% CI: [18 to 56%]) for zoster incidence, 60% (95% CI: [-10 to 87%]) for PHN incidence and 50% (95% CI: [14 to 71%]) for zoster BOI.In the LTPS, there were 263 evaluable zoster cases reported among 261 patients [10.3/1000 person-years]. The estimated vaccine efficacy during the LTPS follow-up period was 21% (95% CI: [11 to 30%]) for zoster incidence, 35% (95% CI: [9 to 56%]) for PHN incidence and 37% (95% CI: [27 to 46%]) for zoster BOI.
Immunogenicity of ZOSTAVAXShingles Prevention Study (SPS)Within SPS, immune responses to vaccination were evaluated in a subset of the enrolled subjects (N=1395). ZOSTAVAX elicited significanlty higher VZV-specific immune responses at 6 weeks postvaccination compared with placebo.
ZOSTAVAX Efficacy and Safety Trial (ZEST)Within ZEST, immune responses to vaccination were evaluated in a random 10% subcohort (n=1,136 for ZOSTAVAX and n=1,133 for placebo) of the subjects enrolled in the ZEST. ZOSTAVAX elicited significantly higher VZV-specific immune responses at 6 weeks postvaccination compared with placebo.When evaluated at 4 weeks postvaccination, the immunogenicity of the current refrigerator-stable formulation was shown to be similar to the immunogenicity of the earlier frozen formulation of ZOSTAVAX.
Subjects who received ZOSTAVAX by SC (subcutaneous) or IM (intramuscular) routeIn an open-label, randomised, controlled clinical trial, ZOSTAVAX was administered either by SC route or by IM route to 353 subjects 50 years of age or older. Subjects with severe thrombocytopaenia or any other coagulation disorder were excluded.The VZV specific immune responses to ZOSTAVAX at Week 4 post-vaccination were comparable whether administered by SC or IM route.Concomitant administrationIn a double-blind, controlled clinical trial, 762 adults 50 years of age and older were randomised to receive a single dose of ZOSTAVAX administered either concomitantly (N=382) or nonconcomitantly (N=380) with inactivated split influenza vaccine. The VZV-specific immune responses to both vaccines at 4 weeks postvaccination were similar, whether administered concomitantly or nonconcomitantly.In a double-blind, controlled clinical trial, 473 adults, 60 years of age or older, were randomised to receive a single dose of ZOSTAVAX either concomitantly (N=237), or nonconcomitantly with 23-valent pneumococcal polysaccharide vaccine (N=236). At four weeks postvaccination, the VZV-specific immune responses following concomitant use were not similar to the VZV-specific immune responses following nonconcomitant administration. Therefore consider administration of the two vaccines separated by at least 4 weeks. Subjects with a history of herpes zoster (HZ) prior to vaccinationIn a double-blind, placebo-controlled, randomised clinical trial, ZOSTAVAX was administered to 100 subjects 50 years of age or older with a history of herpes zoster prior to vaccination to assess immunogenicity and safety (see section 4.8) of ZOSTAVAX. ZOSTAVAX induced a significantly higher VZV-specific immune response at 4 weeks postvaccination, compared with placebo. VZV-specific immune responses were generally similar in subjects 50 to 59 compared to subjects ≥60 years of age.Adults receiving additional doses/revaccinationThe need for, or timing of, a booster dose with ZOSTAVAX has not yet been determined. In an open-label study, ZOSTAVAX was administered as: (1) a booster dose to 201 zoster history-negative subjects 70 years of age or older who had received a first dose approximately 10 years previously as participants in the SPS, and (2) a first dose to 199 zoster history-negative subjects 70 years of age or older. The VZV-specific immune responses to vaccine 6 weeks postvaccination was comparable in the booster dose and first dose group.
Subjects on chronic/maintenance systemic corticosteroidsIn a double-blind, placebo-controlled, randomised clinical trial, ZOSTAVAX was administered to 206 subjects 60 years of age or older who were receiving chronic/maintenance systemic corticosteroid therapy at a daily dose equivalent of 5 to 20 mg of prednisone for at least 2 weeks prior to enrollment, and 6 weeks or more following vaccination to assess the immunogenicity and safety profile of ZOSTAVAX. Compared with placebo, ZOSTAVAX induced a higher VZV-specific immune response at 6 weeks postvaccination. HIV-infected adults with conserved immune functionIn a double-blind, placebo-controlled randomised clinical trial, ZOSTAVAX was administered to HIV-infected adults (18 years of age or older; median age 49 years) on appropriate antiretroviral therapy with conserved immune function (CD4+ T cell count ≥ 200 cells/µL). Although, ZOSTAVAX is indicated as a single dose regimen (see section 4.2), a two-dose regimen was used. 286 subjects received two doses and 9 subjects received only one dose. The VZV specific immune responses following Doses 1 and 2 were similar (see section 4.3).
Immunocompromised subjectsThe vaccine has not been studied in subjects with impaired immunity.The European Medicines Agency has waived the obligation to submit the results of studies with ZOSTAVAX in all the subsets of paediatric population (see section 4.2 for information on paediatric use).
Powder:SucroseHydrolysed gelatinSodium chloridePotassium dihydrogen phosphatePotassium chlorideMonosodium L-glutamate monohydrateDisodium phosphateSodium hydroxide (to adjust pH)Urea
Solvent:Water for injections
ZOSTAVAX with solvent for reconstitution supplied in a vial:Powder in a vial (glass) with a stopper (butyl rubber) and flip off cap (aluminium) and solvent in a vial (glass) with a stopper (chlorobutyl rubber) and flip off cap (aluminium) in a pack size of 1 or 10.
ZOSTAVAX with solvent for reconstitution supplied in a pre-filled syringe:Powder in a vial (glass) with a stopper (butyl rubber) and flip off cap (aluminium) and solvent in a pre-filled syringe (glass) with plunger stopper (chlorobutyl rubber) and tip cap (styrene-butadiene rubber) with one or two unattached needles in a pack size of 1, 10 or 20.Powder in a vial (glass) with a stopper (butyl rubber) and flip off cap (aluminium) and solvent in a pre-filled syringe (glass) with plunger stopper (chlorobutyl rubber) and tip cap (styrene-butadiene rubber) without needle in pack size of 1, 10 or 20.Powder in a vial (glass) with a stopper (butyl rubber) and flip off cap (aluminium) and solvent in a pre-filled syringe (glass) with plunger stopper (chlorobutyl rubber) and needle shield (natural rubber), in a pack size of 1 or 10.Not all pack sizes may be marketed.
ZOSTAVAX with solvent for reconstitution supplied in a vial:Withdraw the entire contents of the solvent vial into a syringe.Inject all the solvent into the vial of lyophilised vaccine.Gently agitate to dissolve completely.Withdraw the entire content of the reconstituted vaccine using the same syringe. Inject the vaccine.The reconstituted vaccine should be inspected visually for any foreign particulate matter and/or abnormal physical appearance prior to administration. In the event of either being observed, discard the vaccine.
ZOSTAVAX with solvent for reconstitution supplied in a pre-filled syringe:If two needles are provided, separate needles should be used for the reconstitution and administration of the vaccine.To reconstitute the vaccine, inject all the solvent in the pre-filled syringe into the vial of lyophilized vaccine and gently agitate to mix thoroughly. Withdraw the entire contents of the reconstituted vaccine using the same syringe. Inject the vaccine.One or 2 separate needles may be available in the secondary packaging of the presentation containing the pre-filled syringe without attached needle.The needle should be pushed into the extremity of the syringe and rotated a quarter of a turn (90°) to secure the connection.The reconstituted vaccine should be inspected visually for any foreign particulate matter and/or abnormal physical appearance prior to administration. In the event of either being observed, discard the vaccine.It is recommended that the vaccine be administered immediately after reconstitution, to minimize loss of potency. Discard reconstituted vaccine if it is not used within 30 minutes.Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
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