MMRVAXPRO Powder and solvent for suspension for injection in pre-filled syringe

M-M-RvaxPro is indicated for simultaneous vaccination against measles, mumps and rubella in individuals from 12 months of age (see section 4.2).

M-M-RvaxPro can be administered to infants from 9 months of age under special circumstances (see sections 4.2, 4.4 and 5.1).

For use in measles outbreaks, or for post-exposure vaccination, or, for use in previously unvaccinated individuals older than 9 months who are in contact with susceptible pregnant women, and persons likely to be susceptible to mumps and rubella, see section 5.1.

M-M-RvaxPro is to be used on the basis of official recommendations.

Posology

• Individuals 12 months of age or older:

Individuals 12 months or older should receive one dose at an elected date. A second dose may be administered at least 4 weeks after the first dose in accordance with official recommendation. The second dose is intended for individuals who did not respond to the first dose for any reason.

• Infants between 9 and 12 months of age:

Immunogenicity and safety data show that M-M-RvaxPro can be administered to infants between 9 and 12 months of age, in accordance with official recommendations or when an early protection is considered necessary (e.g., day-care, outbreak situations, or travel to a region with high prevalence of measles). Such infants should be revaccinated at 12 to 15 months of age. An additional dose with a measles-containing vaccine should be considered according to official recommendations (see sections 4.4 and 5.1).

• Infants below 9 months of age:

No data on the efficacy and safety of M-M-RvaxPro for use in children below 9 months of age are currently available.

Method of administration

The vaccine is to be injected intramuscularly (IM) or subcutaneously (SC).

The preferred injection sites are the anterolateral area of the thigh in younger children and the deltoid area in older children, adolescents, and adults.

The vaccine should be administered subcutaneously in patients with thrombocytopenia or any coagulation disorder.

For precautions to be taken before handling or administering the medicinal product, and for instructions on reconstitution of the medicinal product before administration, see section 6.6.

DO NOT INJECT INTRAVASCULARLY.

Hypersensitivity to any measles, mumps, or rubella vaccine, or to any of the excipients listed in section 6.1, including neomycin (see sections 2 and 4.4).

Pregnancy. Furthermore, pregnancy should be avoided for 1 month following vaccination (see section 4.6).

Vaccination should be postponed during any illness with fever > 38.5 °C.

Active untreated tuberculosis. Children under treatment for tuberculosis have not experienced exacerbation of the disease when immunised with live measles virus vaccine. No studies have been reported to date on the effect of measles virus vaccines on children with untreated tuberculosis.

Blood dyscrasias, leukaemia, lymphomas of any type, or other malignant neoplasms affecting the haematopoietic and lymphatic systems.

Current immunosuppressive therapy (including high doses of corticosteroids). M-M-RvaxPro is not contraindicated in individuals who are receiving topical or low-dose parenteral corticosteroids (e.g., for asthma prophylaxis or replacement therapy).

Severe humoral or cellular (primary or acquired) immunodeficiency, e.g., severe combined immunodeficiency, agammaglobulinemia and AIDS or symptomatic HIV infection or an age-specific CD4+ T-lymphocyte percentage in children below 12 months: CD4+ < 25%; children between 12-35 months: CD4+ < 20%; children between 36-59 months: CD4+ < 15% (see section 4.4).

In severely immunocompromised individuals inadvertently vaccinated with measles-containing vaccine, measles inclusion body encephalitis, pneumonitis, and fatal outcome as a direct consequence of disseminated measles vaccine virus infection have been reported.

Family history of congenital or hereditary immunodeficiency, unless the immune competence of the potential vaccine recipient is demonstrated.

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.

As with all injectable vaccines, appropriate medical treatment should always be readily available in case of rare anaphylactic reactions following the administration of the vaccine (see section 4.8).

Adults and adolescents with a history of allergies may potentially be at increased risk of anaphylaxis or anaphylactoid reactions. Close monitoring is recommended following vaccination for the early signs of such reactions.

Since live measles vaccine and live mumps vaccine are produced in chick embryo cell culture, persons with a history of anaphylactic, anaphylactoid, or other immediate reactions (e.g., hives, swelling of the mouth and throat, difficulty breathing, hypotension, or shock) subsequent to egg ingestion may be at an enhanced risk of immediate type hypersensitivity reactions. The potential risk to benefit ratio should be carefully evaluated before considering vaccination in such cases.

Due caution should be employed in administration of M-M-RvaxPro to persons with individual or family history of convulsions, or a history of cerebral injury. The physician should be alert to the temperature elevation that may occur following vaccination (see section 4.8).

Infants from 9 to 12 months of age vaccinated with a measles-containing vaccine during measles outbreaks or for other reasons may fail to respond to the vaccine due to the presence of circulating antibodies of maternal origin and/or immaturity of the immune system (see sections 4.2 and 5.1).

Thrombocytopenia

This vaccine should be given subcutaneously to individuals with thrombocytopenia or any coagulation disorder because bleeding may occur following an intramuscular administration in these individuals.

Individuals with current thrombocytopenia may develop more severe thrombocytopenia following vaccination. In addition, individuals who experienced thrombocytopenia with the first dose of M-M-RvaxPro (or its component vaccines) may develop thrombocytopenia with repeat doses. Serologic status may be evaluated to determine whether or not additional doses of vaccine are needed. The potential risk to benefit ratio should be carefully evaluated before considering vaccination in such cases (see section 4.8).

Other

Vaccination may be considered in patients with selected immune deficiencies where the benefits outweigh the risks (asymptomatic HIV patients, IgG subclass deficiencies, congenital neutropenia, chronic granulomatous disease, and complement deficiency diseases).

Immunocompromised patients who have no contraindication for this vaccination (see section 4.3) may not respond as well as immunocompetent patients; therefore, some of these patients may acquire measles, mumps, or rubella in case of contact, despite appropriate vaccine administration. These patients should be monitored carefully for signs of measles, parotitis, and rubella.

Vaccination with M-M-RvaxPro may not result in protection in all vaccinees.

Transmission

Excretion of small amounts of the live attenuated rubella virus from the nose or throat has occurred in the majority of susceptible individuals 7 to 28 days after vaccination. There is no confirmed evidence to indicate that such virus is transmitted to susceptible persons who are in contact with the vaccinated individuals. Consequently, transmission through close personal contact, while accepted as a theoretical possibility, is not regarded as a significant risk; however, transmission of the rubella vaccine virus to infants via breast milk has been documented without any evidence of clinical disease (see section 4.6).

There are no reports of transmission of the more attenuated Enders' Edmonston strain of measles virus or the Jeryl Lynn strain of mumps virus from vaccinees to susceptible contacts.

Sodium

This medicinal product contains less than 1 mmol sodium (23 milligrams) per dose, that is to say essentially 'sodium-free'.

Potassium

This medicinal product contains less than 1 mmol potassium (39 milligrams) per dose, that is to say essentially 'potassium-free'.

Sorbitol (E 420)

This medicinal product contains 14.5 milligrams of sorbitol per dose. The additive effect of concomitantly administered products containing sorbitol (or fructose) and dietary intake of sorbitol (or fructose) should be taken into account.

Interference with laboratory tests: see section 4.5.

Immune globulin

Immune globulin (Ig) is not to be given concomitantly with M-M-RvaxPro.

Administration of immune globulins concomitantly with M-M-RvaxPro may interfere with the expected immune response. Vaccination should be deferred for at least 3 months following blood or plasma transfusions, or administration of human immune serum globulin.

Administration of measles, mumps, or rubella antibody-containing blood products, including immune globulin preparations, should be avoided within 1 month after a dose of M-M-RvaxPro unless considered to be essential.

Laboratory tests

It has been reported that live attenuated measles, mumps and rubella virus vaccines given individually may result in a temporary depression of tuberculin skin sensitivity. Therefore, if a tuberculin test is to be done, it should be administered either any time before, simultaneously with, or 4 to 6 weeks after vaccination with M-M-RvaxPro.

Concomitant administration with other vaccines

M-M-RvaxPro can be given concomitantly with a pneumococcal conjugate vaccine.

Published clinical data support concomitant administration of the previous formulation of the measles, mumps and rubella vaccine manufactured by Merck Sharp & Dohme LLC, Rahway, NJ 07065, USA (herein after MSD) with other childhood vaccinations, including DTaP (or DTwP), IPV (or OPV), HIB (Haemophilus influenzae type b), HIB-HBV (Haemophilus influenzae type b with Hepatitis B vaccine), and VAR (varicella).

Based on clinical studies with the quadrivalent measles, mumps, rubella and varicella vaccine and with the previous formulation of the combined measles, mumps and rubella vaccine manufactured by MSD, M-M-RvaxPro can be given concomitantly with a hepatitis A vaccine. In these clinical studies, it was demonstrated that the immune responses were unaffected and that the overall safety profiles of the administered vaccines were similar.

Since M-M-RvaxPro has been shown to have safety and immunogenicity profiles similar to the previous formulation of the combined measles, mumps and rubella vaccine manufactured by MSD, experience with this vaccine can be considered.

M-M-RvaxPro should be given concomitantly at separate injection sites, or one month before or after administration of other live virus vaccines.

Pregnancy

Pregnant women should not be vaccinated with M-M-RvaxPro.

Studies have not been conducted with M-M-RvaxPro in pregnant women.

In a review of more than 3,500 susceptible women who were unknowingly in early stages of pregnancy when vaccinated with a rubella-containing vaccine, no cases of congenital rubella syndrome were reported. Subsequent post-marketing surveillance identified congenital rubella syndrome associated with a rubella vaccine strain following inadvertent vaccination of a pregnant woman with a measles, mumps and rubella vaccine.

Foetal damage has not been documented when measles or mumps vaccines have been given to pregnant women.

Inadvertent vaccination of unknowingly pregnant women with measles-, mumps-, or rubella-containing vaccines should not be a reason for termination of pregnancy.

Pregnancy should be avoided for 1 month following vaccination. Women who intend to become pregnant should be advised to delay.

Breast-feeding

Studies have shown that breast-feeding postpartum women vaccinated with live attenuated rubella vaccines may secrete the virus in breast milk and transmit it to breast-fed infants. In the infants with serological evidence of rubella infection, none had symptomatic disease. It is not known whether measles or mumps vaccine virus is secreted in human milk; therefore, caution should be exercised when M-M-RvaxPro is administered to a breast-feeding woman.

Fertility

M-M-RvaxPro has not been evaluated in fertility studies.

No studies on the effects on the ability to drive and use machines have been performed. M-M-RvaxPro is expected to have no or negligible influence on the ability to drive and use machines.

a. Summary of the safety profile

In clinical trials, M-M-RvaxPro was administered to 1,965 children (see section 5.1), and the general safety profile was comparable to the previous formulation of the measles, mumps and rubella vaccine manufactured by MSD.

In a clinical trial, 752 children received M-M-RvaxPro, either intramuscularly or subcutaneously. The general safety profile of either administration routes were comparable, although injection site reactions were less frequent in the IM group (15.8%) compared with the SC group (25.8%).

All adverse reactions were evaluated in 1,940 children. Among these children, the vaccine-related adverse reactions, summarised in section b, were observed in individuals following vaccination with M-M-RvaxPro (excluding isolated reports with frequency < 0.2%).

In comparison to the first dose, a second dose of M-M-RvaxPro is not associated with an increase in the incidence and severity of clinical symptoms including those suggestive of hypersensitivity reaction.

Additionally, other adverse reactions reported with post-marketing use of M-M-RvaxPro and/or in clinical studies and post-marketing use of previous formulations of monovalent and of the combined measles, mumps and rubella vaccines manufactured by MSD without regard to causality or frequency are available and are summarised in section b. The frequency of these adverse events is qualified as "not known" when it cannot be estimated based on the available data. These data were reported based on more than 400 million doses distributed worldwide.

The most common adverse reactions reported with the use of M-M-RvaxPro were: fever (38.5 °C or higher); injection site reactions including pain, swelling and erythema.

b. Tabulated list of adverse reactions

Adverse reactions are ranked under headings of frequency using the following convention:

[Very common (≥ 1/10); Common (≥ 1/100 to < 1/10); Uncommon (≥ 1/1,000 to < 1/100); Not known (cannot be estimated from the available data)]

^† see section c

c. Description of selected adverse reactions

Aseptic meningitis

Cases of aseptic meningitis have been reported following measles, mumps and rubella vaccination. Although a causal relationship between other strains of mumps vaccine and aseptic meningitis has been shown, there is no evidence to link Jeryl Lynn mumps vaccine to aseptic meningitis.

Encephalitis and Encephalopathy

In severely immunocompromised individuals inadvertently vaccinated with measles-containing vaccine, measles inclusion body encephalitis, pneumonitis, and fatal outcome as a direct consequence of disseminated measles vaccine virus infection have been reported (see section 4.3); disseminated mumps and rubella vaccine virus infection has also been reported.

Subacute sclerosing panencephalitis

There is no evidence that measles vaccine can cause subacute sclerosing panencephalitis (SSPE). There have been reports of SSPE in children who did not have a history of infection with wild-type measles but did receive measles vaccine. Some of these cases may have resulted from unrecognised measles in the first year of life or possibly from the measles vaccination. The results of a retrospective case-controlled study conducted by the US Centers for Disease Control and Prevention suggest that the overall effect of measles vaccine has been to protect against SSPE by preventing measles with its inherent risk of SSPE.

Arthralgia and/or arthritis

Arthralgia and/or arthritis (usually transient and rarely chronic), and polyneuritis are features of infection with wild-type rubella and vary in frequency and severity with age and sex, being greatest in adult females and least in prepubertal children. Following vaccination in children, reactions in joints are generally uncommon (0-3%) and of brief duration. In women, incidence rates for arthritis and arthralgia are generally higher than those seen in children (12-20%), and the reactions tend to be more marked and of longer duration. Symptoms may persist for a matter of months or on rare occasions for years. In adolescent girls, the reactions appear to be intermediate in incidence between those seen in children and adult women. Even in older women (35-45 years), these reactions are generally well tolerated and rarely interfere with normal activities.

Chronic arthritis

Chronic arthritis has been associated with wild-type rubella infection and has been related to persistent virus and/or viral antigen isolated from body tissues. Only rarely have vaccine recipients developed chronic joint symptoms.

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.

Administration of a higher than recommended dose of M-M-RvaxPro was reported rarely and the adverse reaction profile was comparable to that observed with the recommended dose of M-M-RvaxPro.

Pharmacotherapeutic group: Viral vaccine, ATC code J07BD52

Evaluation of immunogenicity and clinical efficacy

A comparative study in 1,279 subjects who received M-M-RvaxPro or the previous formulation (manufactured with human serum albumin) of the measles, mumps and rubella vaccine manufactured by MSD demonstrated similar immunogenicity and safety between the 2 products.

Clinical studies of 284 triple seronegative children, 11 months to 7 years of age, demonstrated that the previous formulation of the measles, mumps and rubella vaccine manufactured by MSD is highly immunogenic and generally well tolerated. In these studies, a single injection of the vaccine induced measles haemagglutination-inhibition (HI) antibodies in 95%, mumps neutralising antibodies in 96%, and rubella HI antibodies in 99% of susceptible persons.

Evaluation of immunogenicity in children from 9 to 12 months of age at the time of first dose

A clinical study was conducted with the quadrivalent measles, mumps, rubella and varicella vaccine manufactured by MSD administered with a 2-dose schedule, the doses being given 3 months apart in 1,620 healthy subjects from 9 to 12 months of age at the time of first dose. The safety profile post-dose 1 and 2 was generally comparable for all age cohorts.

In the Full Analysis Set (vaccinated subjects regardless of their antibody titre at baseline), high seroprotection rates of > 99% were elicited to mumps and rubella post-dose 2, regardless of the age of the vaccinee at the first dose. After 2 doses, the seroprotection rates against measles were 98.1% when the first dose was given at 11 months compared to 98.9% when the first dose was given at 12 months (non-inferiority study objective met). After two doses, the seroprotection rates against measles were 94.6% when the first dose was given at 9 months compared to 98.9% when the first dose was given at 12 months (non-inferiority study objective not met).

The seroprotection rates to measles, mumps and rubella for the Full Analysis Set are given in Table 1.

Table 1: Seroprotection Rates to Measles, Mumps and Rubella 6 Weeks Post-Dose 1 and 6 Weeks Post-Dose 2 of the quadrivalent measles, mumps, rubella and varicella vaccine manufactured by MSD – Full Analysis Set

The post-dose 2 geometric mean titres (GMTs) against mumps and rubella were comparable across all age categories, while the GMTs against measles were lower in subjects who received the first dose at 9 months of age as compared to subjects who received the first dose at 11 or 12 months of age.

A comparative study in 752 subjects who received M-M-RvaxPro either by intramuscular route or subcutaneous route demonstrated a similar immunogenicity profile between both administration routes.

The efficacy of the components of the previous formulation of the measles, mumps and rubella vaccine manufactured by MSD was established in a series of double-blind controlled field trials, which demonstrated a high degree of protective efficacy afforded by the individual vaccine components. These studies also established that seroconversion in response to vaccination against measles, mumps and rubella paralleled protection from these diseases.

Post-exposure vaccination

Vaccination of individuals exposed to wild-type measles may provide some protection if the vaccine can be administered within 72 hours after exposure. If, however, the vaccine is given a few days before exposure, substantial protection may be afforded. There is no conclusive evidence that vaccination of individuals recently exposed to wild-type mumps or wild-type rubella will provide protection.

Effectiveness

More than 400 million doses of the previous formulation of the measles, mumps and rubella vaccine manufactured by MSD have been distributed worldwide (1978 to 2003). Widespread use of a 2-dose vaccination schedule in the United States and countries such as Finland and Sweden has led to a > 99% reduction in the incidence of each of the 3 targeted diseases.

Non-pregnant adolescent and adult females

Vaccination of susceptible non-pregnant adolescent and adult females of childbearing age with live attenuated rubella virus vaccine is indicated if certain precautions are observed (see sections 4.4 and 4.6). Vaccinating susceptible postpubertal females confers individual protection against subsequently acquiring rubella infection during pregnancy, which, in turn, prevents infection of the foetus and consequent congenital rubella injury.

Previously unvaccinated individuals older than 9 months who are in contact with susceptible pregnant women should receive live attenuated rubella-containing vaccine (such as M-M-RvaxPro or a monovalent rubella vaccine) to reduce the risk of exposure of the pregnant woman.

Individuals likely to be susceptible to mumps and rubella

M-M-RvaxPro is preferred for vaccination of persons likely to be susceptible to mumps and rubella. Individuals who require vaccination against measles can receive M-M-RvaxPro regardless of their immune status to mumps or rubella if a monovalent measles vaccine is not readily available.

Concomitant administration

In a double-blind, active comparator-controlled study (Protocol V114-029), 1,720 healthy infants were randomised to receive Vaxneuvance (a 15-valent pneumococcal conjugate vaccine (PCV)) or a 13-valent PCV. The infants also received standard paediatric vaccines, including M-M-RvaxPro which was administered concomitantly with a pneumococcal conjugate vaccine at 12 to 15 months of age.

Not applicable.

Non-clinical studies have not been conducted.

Powder

Sorbitol (E 420)

Sodium phosphate (NaH₂PO₄/Na₂HPO₄)

Potassium phosphate (KH₂PO₄/K₂HPO₄)

Sucrose

Hydrolysed gelatine

Medium 199 with Hanks' salts

Minimum Essential Medium, Eagle (MEM)

Monosodium L-glutamate

Neomycin

Phenol red

Sodium bicarbonate (NaHCO₃)

Hydrochloric acid (HCl) (to adjust pH)

Sodium hydroxide (NaOH) (to adjust pH)

Solvent

Water for injections

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

2 years.

After reconstitution, the vaccine should be used immediately; however, in-use stability has been demonstrated for 8 hours when refrigerated at 2 °C – 8 °C.

Store and transport refrigerated (2 °C – 8 °C).

Do not freeze.

Keep the vial of powder in the outer carton in order to protect from light.

For storage conditions after the reconstitution of the medicinal product, see section 6.3.

M-M-RvaxPro with solvent for reconstitution supplied in a vial:

Powder in a vial (Type I glass) with a stopper (butyl rubber) and solvent in a vial (Type I glass) with stopper (chlorobutyl rubber) in a pack size of 1, 5 and 10.

M-M-RvaxPro with solvent for reconstitution supplied in a pre-filled syringe:

Powder in a vial (Type I glass) with a stopper (butyl rubber) and solvent in a pre-filled syringe (Type I glass) with plunger stopper (bromo- or chlorobutyl rubber) and tip cap (styrene-butadiene rubber).

Pack sizes of 1, 10 and 20 pre-filled syringes, either without needles, with 1 separate needle, or with 2 separate needles.

Not all pack sizes may be marketed.

Before mixing with the solvent, the powder vaccine is a light yellow compact crystalline cake. The solvent is a clear colourless liquid. When completely reconstituted, the vaccine is a clear yellow liquid.

To reconstitute the vaccine, use the solvent supplied.

It is important to use a separate sterile syringe and needle for each patient to prevent transmission of infectious agents from one individual to another.

One needle should be used for reconstitution and a separate, new needle for injection.

Reconstitution instructions

M-M-RvaxPro with solvent for reconstitution supplied in a vial:

Withdraw the entire content of the solvent vial into a syringe to be used for reconstitution and injection. Inject the entire content of the syringe into the vial containing the powder. Gently agitate to mix thoroughly.

The reconstituted vaccine must not be used if any particulate matter is noted or if the appearance of the solvent or powder or of the reconstituted vaccine differs from that described above.

After reconstitution, it is recommended to administer the vaccine immediately to minimise loss of potency, or within 8 hours if stored in a refrigerator.

Do not freeze the reconstituted vaccine.

Withdraw the entire content of the reconstituted vaccine from the vial into a syringe, change the needle and inject the entire volume by subcutaneous or intramuscular route.

M-M-RvaxPro with solvent for reconstitution supplied in a pre-filled syringe:

To attach the needle, it should be firmly placed on the tip of the syringe and secured by rotating.

Inject the entire content of the solvent syringe into the vial containing the powder. Gently agitate to mix thoroughly.

The reconstituted vaccine must not be used if any particulate matter is noted or if the appearance of the solvent or powder or of the reconstituted vaccine differs from that described above.

After reconstitution, it is recommended to administer the vaccine immediately to minimise loss of potency, or within 8 hours if stored in a refrigerator.

Do not freeze the reconstituted vaccine.

Withdraw the entire content of the reconstituted vaccine from the vial into a syringe, change the needle and inject the entire volume by subcutaneous or intramuscular route.

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