2.1 Immunization Series

DAPTACEL is to be administered as a 5 dose series at 2, 4 and 6 months of age (at intervals of 6-8 weeks), at 15-20 months of age and at 4-6 years of age. The first dose may be given as early as 6 weeks of age. Four doses of DAPTACEL constitute a primary immunization course for pertussis. The fifth dose is a booster for pertussis immunization. Three doses of DAPTACEL constitute a primary immunization course for diphtheria and tetanus. The fourth and fifth doses are boosters for diphtheria and tetanus immunization. [See Clinical Studies (14.1, 14.2, 14.3).]

2.2 Administration

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. If either of these conditions exist, the product should not be administered.

Just before use, shake the vial well, until a uniform, white, cloudy suspension results.

Withdraw and administer a single 0.5 mL dose of DAPTACEL intramuscularly. Discard unused portion. Use a separate sterile needle and syringe for each injection. Changing needles between withdrawing the vaccine from the vial and injecting it into a recipient is not necessary unless the needle has been damaged or contaminated. In infants younger than 1 year, the anterolateral aspect of the thigh provides the largest muscle and is the preferred site of injection. In older children, the deltoid muscle is usually large enough for injection. The vaccine should not be injected into the gluteal area or areas where there may be a major nerve trunk.

Do not administer this product intravenously or subcutaneously.

DAPTACEL should not be combined through reconstitution or mixed with any other vaccine.

4.1 Hypersensitivity

A severe allergic reaction (e.g., anaphylaxis) after a previous dose of DAPTACEL or any other tetanus toxoid, diphtheria toxoid, or pertussis-containing vaccine, or any other component of this vaccine is a contraindication to administration of DAPTACEL. [See Description (11).] Because of uncertainty as to which component of the vaccine may be responsible, none of the components should be administered. Alternatively, such individuals may be referred to an allergist for evaluation if further immunizations are to be considered.

4.2 Encephalopathy

Encephalopathy (e.g., coma, decreased level of consciousness, prolonged seizures) within 7 days of a previous dose of a pertussis containing vaccine that is not attributable to another identifiable cause is a contraindication to administration of any pertussis-containing vaccine, including DAPTACEL.

4.3 Progressive Neurologic Disorder

Progressive neurologic disorder, including infantile spasms, uncontrolled epilepsy, or progressive encephalopathy is a contraindication to administration of any pertussis-containing vaccine, including DAPTACEL. Pertussis vaccine should not be administered to individuals with such conditions until a treatment regimen has been established and the condition has stabilized.

5.1 Management of Acute Allergic Reactions

Epinephrine hydrochloride solution (1:1,000) and other appropriate agents and equipment must be available for immediate use in case an anaphylactic or acute hypersensitivity reaction occurs.

5.2 Adverse Reactions Following Prior Pertussis Vaccination

If any of the following events occur within the specified period after administration of a whole-cell pertussis vaccine or a vaccine containing an acellular pertussis component, the decision to administer DAPTACEL should be based on careful consideration of potential benefits and possible risks. [See Dosage and Administration (2.1).]

• Temperature of ≥40.5°C (105°F) within 48 hours, not attributable to another identifiable cause.
• Collapse or shock-like state (hypotonic-hyporesponsive episode [HHE]) within 48 hours.
• Persistent, inconsolable crying lasting ≥3 hours within 48 hours.
• Seizures with or without fever within 3 days.

5.3 Guillain-Barré Syndrome and Brachial Neuritis

A review by the Institute of Medicine found evidence for a causal relation between tetanus toxoid and both brachial neuritis and Guillain-Barré syndrome. (1) If Guillain-Barré syndrome occurred within 6 weeks of receipt of a prior vaccine containing tetanus toxoid, the risk for Guillain-Barré syndrome may be increased following DAPTACEL.

5.4 Infants and Children with a History of Previous Seizures

For infants or children with a history of previous seizures, an appropriate antipyretic may be administered (in the dosage recommended in its prescribing information) at the time of vaccination with a vaccine containing an acellular pertussis component (including DAPTACEL) and for the following 24 hours, to reduce the possibility of post-vaccination fever.

5.5 Limitations of Vaccine Effectiveness

Vaccination with DAPTACEL may not protect all individuals.

5.6 Altered Immunocompetence

If DAPTACEL is administered to immunocompromised persons, including persons receiving immunosuppressive therapy, the expected immune response may not be obtained. [See Immunosuppressive Treatments (7.2).]

5.7 Apnea in Premature Infants

Apnea following intramuscular vaccination has been observed in some infants born prematurely. The decision about when to administer an intramuscular vaccine, including DAPTACEL, to an infant born prematurely should be based on consideration of the individual infant's medical status and the potential benefits and possible risks of vaccination.

5.8 Syncope

Syncope (fainting) has been reported following vaccination with DAPTACEL. Procedures should be in place to avoid injury from fainting.

6.1 Data from Clinical Studies

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a vaccine cannot be directly compared to rates in the clinical trials of another vaccine and may not reflect the rates observed in practice. The adverse reaction information from clinical trials does, however, provide a basis for identifying the adverse events that appear to be related to vaccine use and for approximating rates of those events.

Approximately 18,000 doses of DAPTACEL have been administered to infants and children in 9 clinical studies. Of these, 3 doses of DAPTACEL were administered to 4,998 children, 4 doses of DAPTACEL were administered to 1,725 children, and 5 doses of DAPTACEL were administered to 485 children. A total of 989 children received 1 dose of DAPTACEL following 4 prior doses of Pentacel.

In a randomized, double-blinded pertussis vaccine efficacy trial, the Sweden I Efficacy Trial, conducted in Sweden during 1992-1995, the safety of DAPTACEL was compared with DT and a whole-cell pertussis DTP vaccine. A standard diary card was kept for 14 days after each dose and follow-up telephone calls were made 1 and 14 days after each injection. Telephone calls were made monthly to monitor the occurrence of severe events and/or hospitalizations for the 2 months after the last injection. There were fewer of the solicited common local and systemic reactions following DAPTACEL than following the whole-cell pertussis DTP vaccine. As shown in Table 1, the 2,587 infants who received DAPTACEL at 2, 4 and 6 months of age had similar rates of reactions within 24 hours as recipients of DT and significantly lower rates than infants receiving whole-cell pertussis DTP.

The incidence of serious and less common selected systemic events in the Sweden I Efficacy Trial is summarized in Table 2.

In the Sweden I Efficacy Trial, one case of whole limb swelling and generalized symptoms, with resolution within 24 hours, was observed following dose 2 of DAPTACEL. No episodes of anaphylaxis or encephalopathy were observed. No seizures were reported within 3 days of vaccination with DAPTACEL. Over the entire study period, 6 seizures were reported in the DAPTACEL group, 9 in the DT group and 3 in the whole-cell pertussis DTP group, for overall rates of 2.3, 3.5 and 1.4 per 1,000 vaccinees, respectively. One case of infantile spasms was reported in the DAPTACEL group. There were no instances of invasive bacterial infection or death.

In a US study, children received 4 doses of DAPTACEL at 2, 4, 6 and 15-17 months of age. A total of 1,454 children received DAPTACEL and were included in the safety analyses. Of these, 51.7% were female, 77.2% Caucasian, 6.3% Black, 6.5% Hispanic, 0.9% Asian and 9.1% other races. The use of DAPTACEL as a fifth dose of DTaP vaccine was evaluated in 2 subsequent US clinical studies. In one study, a total of 485 children received DAPTACEL at 4-6 years of age following 4 prior doses of DAPTACEL in infancy (DAPTACEL-primed). In a separate study, a total of 989 children received DAPTACEL at 4-6 years of age following 4 prior doses of Pentacel in infancy (Pentacel-primed). The children included in these fifth dose studies were non-random subsets of participants from previous DAPTACEL or Pentacel studies. The subsets were representative of all children who received 4 doses of DAPTACEL or Pentacel in the earlier studies with regard to frequencies of solicited local and systemic adverse events following the fourth dose.

In the US 4-dose DAPTACEL study, at 2, 4, and 6 months of age, DAPTACEL was administered concomitantly with Haemophilus influenzae type b (Hib) conjugate vaccine (tetanus toxoid conjugate) (Sanofi Pasteur SA), inactivated poliovirus vaccine (IPV) (Sanofi Pasteur SA), and 7-valent pneumococcal conjugate vaccine (Wyeth Pharmaceuticals Inc.). Infants had received the first dose of hepatitis B vaccine at 0 months of age. At 2 and 6 months of age, hepatitis B vaccine (recombinant) (Merck & Co., Inc.) was also administered concomitantly with DAPTACEL. Based on random assignment, the fourth dose of DAPTACEL was administered either alone; concomitantly with Hib conjugate (tetanus toxoid conjugate) vaccine; or concomitantly with Hib conjugate (tetanus toxoid conjugate) vaccine, 7-valent pneumococcal conjugate vaccine, measles, mumps, rubella (MMR) vaccine (Merck & Co., Inc.), and varicella vaccine (Merck & Co., Inc.). In the fifth dose studies, DAPTACEL was administered concomitantly with IPV (all DAPTACEL-primed subjects and 47% of Pentacel-primed subjects) and MMR vaccine.

In the US studies, the occurrence of solicited local and systemic adverse events listed in Table 3 was recorded daily by parents or guardians for Days 0-7 following vaccination. For Days 0 and 1 following the first three doses of DAPTACEL, signs and symptoms of HHE also were solicited. Periodic telephone calls were made to inquire about adverse events. Serious adverse events were monitored during the three studies, through 6 months following the last dose of DAPTACEL.

The incidence and severity of selected solicited local and systemic adverse events that occurred within 3 days following each dose of DAPTACEL are shown in Table 3. The incidence of redness, tenderness and swelling at the DAPTACEL injection site increased with the fourth and fifth doses, with the highest rates reported after the fifth dose. The incidence of redness, tenderness and swelling at the DAPTACEL injection site was similarly increased when DAPTACEL was given as a fifth dose of DTaP vaccine in Pentacel-primed children.

In the US study in which children received 4 doses of DAPTACEL, of 1,454 subjects who received DAPTACEL, 5 (0.3%) subjects experienced a seizure within 60 days following any dose of DAPTACEL. One seizure occurred within 7 days post-vaccination: an infant who experienced an afebrile seizure with apnea on the day of the first vaccination. Three other cases of seizures occurred between 8 and 30 days post-vaccination. Of the seizures that occurred within 60 days post-vaccination, 3 were associated with fever. In this study, there were no reported cases of HHE following DAPTACEL. There was one death due to aspiration 222 days post-vaccination in a subject with ependymoma. Within 30 days following any dose of DAPTACEL, 57 (3.9%) subjects reported at least one serious adverse event. During this period, the most frequently reported serious adverse event was bronchiolitis, reported in 28 (1.9%) subjects. Other serious adverse events that occurred within 30 days following DAPTACEL include three cases of pneumonia, two cases of meningitis and one case each of sepsis, pertussis (post-dose 1), irritability and unresponsiveness.

In the US study in which DAPTACEL was administered as a fifth DTaP dose in DAPTACEL-primed subjects, within 30 days following the fifth consecutive dose of DAPTACEL, 1 (0.2%) subject reported 2 serious adverse events (bronchospasm and hypoxia). In the US study in which DAPTACEL was administered as a fifth DTaP dose in Pentacel-primed subjects, within 30 days following DAPTACEL, 4 (0.4%) subjects reported one or more serious adverse events (asthma and pneumonia; idiopathic thrombocytopenic purpura; vomiting; cellulitis not at the injection site). In these two studies, there were no reports of seizures within 30 days following DAPTACEL in either the DAPTACEL-primed subjects or Pentacel-primed subjects.

In another study (Sweden II Efficacy Trial), 3 DTaP vaccines and a whole-cell pertussis DTP vaccine, none of which are licensed in the US, were evaluated to assess relative safety and efficacy. This study included HCPDT, a vaccine made of the same components as DAPTACEL but containing twice the amount of detoxified PT and four times the amount of FHA (20 mcg detoxified PT and 20 mcg FHA). HHE was observed following 29 (0.047%) of 61,220 doses of HCPDT; 16 (0.026%) of 61,219 doses of an acellular pertussis vaccine made by another manufacturer; and 34 (0.056%) of 60,792 doses of a whole-cell pertussis DTP vaccine. There were 4 additional cases of HHE in other studies using HCPDT vaccine for an overall rate of 33 (0.047%) in 69,525 doses.

In a randomized, parallel-group, US multi-center clinical trial conducted in children 4 through 6 years of age, DAPTACEL was administered as follows: concomitantly with IPV (Sanofi Pasteur SA) followed 30 days later by Menactra® [Meningococcal (Groups A, C, Y and W-135) Polysaccharide Diphtheria Toxoid Conjugate vaccine, Sanofi Pasteur Inc.] [Group A]; concomitantly with Menactra followed 30 days later by IPV [Group B]; or 30 days after concomitant administration of Menactra and IPV [Group C]. Solicited injection site and systemic reactions were recorded in a diary card for 7 consecutive days after each vaccination. For all study groups, the most frequently reported solicited local reaction at the DAPTACEL injection site was pain: 71.7%, 69.4% and 52.1% of subjects in Groups A, B and C, respectively. For all study groups, the most frequently reported systemic reaction after DAPTACEL vaccination was myalgia: 46.2%, 37.3% and 25.8% of subjects in Groups A, B and C, respectively. Fever >39.5ºC occurred at <1.0% in all groups.

6.2 Postmarketing Experience

The following adverse events have been spontaneously reported during the postmarketing use of DAPTACEL in the US and other countries. Because these events are reported voluntarily from a population of uncertain size, it may not be possible to reliably estimate their frequency or establish a causal relationship to vaccine exposure.

The following adverse events were included based on one or more of the following factors: severity, frequency of reporting, or strength of evidence for a causal relationship to DAPTACEL.

• Blood and lymphatic disorders
  Lymphadenopathy
• Cardiac disorders
  Cyanosis
• Gastro-intestinal disorders
  Nausea, diarrhea
• General disorders and administration site conditions
  Local reactions: injection site pain, injection site rash, injection site nodule, injection site mass, extensive swelling of injected limb (including swelling that involves adjacent joints).
• Infections and infestations
  Injection site cellulitis, cellulitis, injection site abscess
• Immune system disorders
  Hypersensitivity, allergic reaction, anaphylactic reaction (edema, face edema, swelling face, pruritus, rash generalized) and other types of rash (erythematous, macular, maculo-papular)
• Nervous system disorders
  Convulsions: febrile convulsion, grand mal convulsion, partial seizures
  HHE, hypotonia, somnolence, syncope
• Psychiatric disorders
  Screaming

7.1 Concomitant Administration with Other Vaccines

In clinical trials, DAPTACEL was administered concomitantly with one or more of the following US licensed vaccines: Hib conjugate vaccine, IPV, hepatitis B vaccine, pneumococcal conjugate vaccine, Meningococcal (Groups A, C, Y and W-135) Polysaccharide Diphtheria Toxoid Conjugate vaccine, MMR vaccine, and varicella vaccine. [See Adverse Reactions (6.1) and Clinical Studies (14.4).] When DAPTACEL is given at the same time as another injectable vaccine(s), the vaccines should be administered with different syringes and at different injection sites.

In cases where DAPTACEL and Menactra are to be administered to children 4 through 6 years of age, the two vaccines should be administered concomitantly or Menactra should be administered prior to DAPTACEL. Administration of Menactra one month after DAPTACEL has been shown to reduce meningococcal antibody responses to Menactra. [See Adverse Reactions (6.1) and Clinical Studies (14.4).]

7.2 Immunosuppressive Treatments

Immunosuppressive therapies, including irradiation, antimetabolites, alkylating agents, cytotoxic drugs and corticosteroids (used in greater than physiologic doses), may reduce the immune response to DAPTACEL.

8.4 Pediatric Use

DAPTACEL is not indicated for use in infants below 6 weeks of age or children 7 years of age or older. Safety and effectiveness of DAPTACEL in these age groups have not been established.

12.1 Mechanism of Action

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

DAPTACEL has not been evaluated for carcinogenic or mutagenic potential or impairment of fertility.

14.1 Diphtheria

In a US study in which children received 4 doses of DAPTACEL at 2, 4, 6 and 15-17 months of age, after the third dose, 100% (N = 1,099) achieved diphtheria antitoxin levels of ≥0.01 IU/mL and 98.5% achieved diphtheria antitoxin levels of ≥0.10 IU/mL. Among a random subset of children who received the fourth dose of DAPTACEL at 15-16 months of age, 96.5% (N = 659) achieved diphtheria antitoxin levels of ≥1.0 IU/mL after the fourth dose.

14.2 Tetanus

In a US study in which children received 4 doses of DAPTACEL at 2, 4, 6 and 15-17 months of age, after the third dose, 100% (N = 1,037) achieved tetanus antitoxin levels of ≥0.10 IU/mL. Among a random subset of children who received the fourth dose of DAPTACEL at 15-16 months of age, 98.8% (N = 681) achieved tetanus antitoxin levels of ≥1.0 IU/mL after the fourth dose.

14.3 Pertussis

A randomized, double-blinded, placebo-controlled efficacy and safety study was conducted in Sweden during 1992-1995 (Sweden I Efficacy Trial) under the sponsorship of the National Institute of Allergy and Infectious Diseases. A total of 9,829 infants received 1 of 4 vaccines: DAPTACEL (N = 2,587); another investigational acellular pertussis vaccine (N = 2,566); whole-cell pertussis DTP vaccine (N = 2,102); or DT vaccine as placebo (Swedish National Bacteriological Laboratory, N = 2,574). Infants were immunized at 2, 4 and 6 months of age. The mean length of follow-up was 2 years after the third dose of vaccine. The protective efficacy of DAPTACEL against pertussis after 3 doses using the World Health Organization (WHO) case definition (≥21 consecutive days of paroxysmal cough with culture or serologic confirmation or epidemiologic link to a confirmed case) was 84.9% (95% confidence interval [CI] 80.1 to 88.6). The protective efficacy of DAPTACEL against mild pertussis (≥1 day of cough with laboratory confirmation) was 77.9% (95% CI 72.6 to 82.2). Protection against pertussis by DAPTACEL was sustained for the 2-year follow-up period.

In order to assess the antibody response to the pertussis antigens of DAPTACEL in the US population, 2 lots of DAPTACEL, including the lot used in the Sweden I Efficacy Trial, were administered to US infants in the US Bridging Study. In this study, antibody responses following 3 doses of DAPTACEL given to US children at 2, 4 and 6 months of age were compared to those from a subset of the infants enrolled in the Sweden I Efficacy Trial. Assays were performed in parallel on the available sera from the US and Swedish infants. Antibody responses to all the antigens were similar except for those to the PRN component. For both lots of DAPTACEL, the geometric mean concentration (GMC) and percent response to PRN in US infants (Lot 006, N = 107; Lot 009, N = 108) were significantly lower after 3 doses of vaccine than in Swedish infants (N = 83). In separate US and Canadian studies in which children received DAPTACEL at 2, 4 and 6 months of age, with a fourth dose at either 17-20 months (Canadian study) or 15-16 months (random subset from US study) of age, antibody responses to each pertussis antigen following the fourth dose (Canadian study N = 275; US study N = 237-347) were at least as high as those seen in the Swedish infants after 3 doses. While a serologic correlate of protection for pertussis has not been established, the antibody response to all antigens in North American infants after 4 doses of DAPTACEL at 2, 4, 6 and 15-20 months of age was comparable to that achieved in Swedish infants in whom efficacy was demonstrated after 3 doses of DAPTACEL at 2, 4 and 6 months of age.

In the US Study 005, infants were randomized to receive 3 doses of VAXELIS at 2, 4, and 6 months of age and DAPTACEL and PedvaxHIB [Haemophilus b Conjugate Vaccine (Meningococcal Protein Conjugate)] at 15 months of age, or Control group vaccines (3 doses of Pentacel vaccine at 2, 4, and 6 months of age + RECOMBIVAX HB [Hepatitis B Vaccine (Recombinant)] at 2 and 6 months of age and DAPTACEL and ActHIB [Haemophilus b Conjugate Vaccine (Tetanus Toxoid Conjugate)] at 15 months of age). All subjects received concomitant Prevnar 13 (Pneumococcal 13-valent Conjugate Vaccine [Diphtheria CRM197 Protein]) at 2, 4, 6, and 15 months of age. To complete the 4-dose pertussis primary vaccination series, participants in both groups received DAPTACEL at 15 months of age and were evaluated for immune responses to pertussis antigens one month later.

The non-inferiority criteria for vaccine response rates and GMCs for all pertussis antigens were met following the fourth dose. (8)

14.4 Concomitantly Administered Vaccines

In the US Bridging study, DAPTACEL was given concomitantly with Hib conjugate vaccine (Sanofi Pasteur SA) according to local practices. Anti-PRP immune response was evaluated in 261 infants who received 3 doses of Hib conjugate vaccine. One month after the third dose, 96.9% achieved anti-PRP antibody levels of at least 0.15 mcg/mL and 82.7% achieved antibody levels of at least 1.0 mcg/mL.

In the US study in which infants received DAPTACEL concomitantly with Hib conjugate (tetanus toxoid conjugate) vaccine, IPV, 7-valent pneumococcal conjugate vaccine, and hepatitis B vaccine [see Adverse Reactions (6.1)], at 7 months of age, 100.0% of subjects (N = 1,050-1,097) had protective neutralizing antibody levels (≥1:8 1/dil) for poliovirus types 1, 2 and 3; and 92.4% (N = 998) achieved anti-hepatitis B surface antigen levels ≥10.0 mIU/mL. Although there is no established serologic correlate of protection for any of the pneumococcal serotypes, at 7 months of age 91.3%-98.9% (N = 1,027-1,029) achieved anti-pneumococcal polysaccharide levels ≥0.5 mcg/mL for serotypes 4, 9V, 14, 18C, 19F and 23F and 80.7% (N = 1,027) achieved an anti-pneumococcal polysaccharide level ≥0.5 mcg/mL for serotype 6B. The mumps seroresponse rate was lower when DAPTACEL was administered concomitantly (86.6%; N = 307) vs. non-concomitantly (90.1%; N = 312) with the first dose of MMR vaccine [upper limit of 90% confidence interval for difference in rates (non-concomitant minus concomitant) >5%]. There was no evidence for interference in the immune response to the measles, rubella, and varicella antigens or to the fourth dose of the 7-valent pneumococcal conjugate vaccine with concomitant administration of DAPTACEL.

In a randomized, parallel-group, US multi-center clinical trial conducted in children 4 through 6 years of age, DAPTACEL was administered as follows: concomitantly with IPV (Sanofi Pasteur SA) followed 30 days later by Menactra [Group A]; concomitantly with Menactra followed 30 days later by IPV [Group B]; or 30 days after concomitant administration of Menactra and IPV [Group C]. Sera were obtained approximately 30 days after each respective vaccination. When DAPTACEL was administered concomitantly with Menactra [Group B], antibody responses to PT, FHA and PRN (GMC), tetanus (% participants with antibody concentrations ≥1.0 IU/mL), and diphtheria (%participants with antibody concentrations ≥1.0 IU/mL) were non-inferior to those observed when DAPTACEL (and IPV) were administered [Group A]. The anti-FIM GMCs were marginally lower when DAPTACEL and Menactra were administered concomitantly but the clinical significance is unknown because there are no established serological correlates of protection for pertussis. When DAPTACEL (and IPV) were administered 30 days prior to Menactra [Group A], significantly lower serum-bactericidal assay-human complement (SBA-H) GMTs to all 4 meningococcal serogroups were observed compared to when Menactra (and IPV) were administered 30 days prior to DAPTACEL [Group C]. When DAPTACEL was administered concomitantly with Menactra [Group B], SBA-H GMTs to meningococcal serogroups A, C, and W-135 were non-inferior to those observed when Menactra (and IPV) were administered [Group C]. The non-inferiority criterion was marginally missed for meningococcal serogroup Y. [See Drug Interactions (7.1).]

DAPTACEL should be stored at 2° to 8°C (35° to 46°F). DO NOT FREEZE. Product which has been exposed to freezing should not be used. Do not use after expiration date shown on the label.