Route of | Dosage Form / Strength | Clinically |
Intramuscular | Suspension for injection 1 dose (0.5 mL pre-filled syringe) contains: Pneumococcal polysaccharide serotype 1 2.2 µga Pneumococcal polysaccharide serotype 3 2.2 µga Pneumococcal polysaccharide serotype 4 2.2 µga Pneumococcal polysaccharide serotype 5 2.2 µga Pneumococcal polysaccharide serotype 6A 2.2 µga Pneumococcal polysaccharide serotype 6B 4.4 µga Pneumococcal polysaccharide serotype 7F 2.2 µga Pneumococcal polysaccharide serotype 9V 2.2 µga Pneumococcal polysaccharide serotype 14 2.2 µga Pneumococcal polysaccharide serotype 18C 2.2 µga Pneumococcal polysaccharide serotype 19A 2.2 µga Pneumococcal polysaccharide serotype 19F 2.2 µga Pneumococcal polysaccharide serotype 23F 2.2 µga | Sodium Chloride, |
a conjugated to CRM197 carrier protein and adsorbed on aluminum phosphate (0.125 mg aluminum)
)Route of | Dosage Form / Strength | Clinically |
Intramuscular | Suspension for injection 1 dose (0.5 mL pre-filled syringe) contains: Pneumococcal polysaccharide serotype 1 2.2 µga Pneumococcal polysaccharide serotype 3 2.2 µga Pneumococcal polysaccharide serotype 4 2.2 µga Pneumococcal polysaccharide serotype 5 2.2 µga Pneumococcal polysaccharide serotype 6A 2.2 µga Pneumococcal polysaccharide serotype 6B 4.4 µga Pneumococcal polysaccharide serotype 7F 2.2 µga Pneumococcal polysaccharide serotype 9V 2.2 µga Pneumococcal polysaccharide serotype 14 2.2 µga Pneumococcal polysaccharide serotype 18C 2.2 µga Pneumococcal polysaccharide serotype 19A 2.2 µga Pneumococcal polysaccharide serotype 19F 2.2 µga Pneumococcal polysaccharide serotype 23F 2.2 µga | Sodium Chloride, |
a conjugated to CRM197 carrier protein and adsorbed on aluminum phosphate (0.125 mg aluminum)
Prevnar 13 is indicated for active immunization of infants and children from 6 weeks to 5 years of age (prior to the 6th birthday) for the prevention of invasive pneumococcal disease (including sepsis, meningitis, bacteraemic pneumonia, pleural empyema and bacteraemia) and acute otitis media caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F.
Prevnar 13 is indicated for active immunization of children from 6 years to 17 years of age (prior to the 18th birthday) for the prevention of invasive pneumococcal disease (including sepsis, meningitis, bacteraemic pneumonia, pleural empyema and bacteraemia) caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F.
Prevnar 13 is indicated for active immunization of adults 18 years of age and older for the prevention of pneumonia and invasive pneumococcal disease (including sepsis, meningitis, bacteraemic pneumonia, pleural empyema and bacteraemia) caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F.
Hypersensitivity to any component of the vaccine, including diphtheria toxoid.
(For a complete listing, see DOSAGE FORMS, COMPOSITION AND PACKAGING section)
A reproduction study has been performed in female rabbits at doses equal to the human dose and has revealed no evidence of impaired fertility or harm to the fetus due to Prevnar 13. There are, however, no adequate and well controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this vaccine should be used during pregnancy only if clearly needed.
Safety during lactation has not been established.
It is not known whether vaccine antigens or antibodies are excreted in human milk.
The safety and immunogenicity of Prevnar 13 in children below the age of 6 weeks have not been established.
Prevnar 13 has been studied in the geriatric population (see PART II, CLINICAL TRIALS section).
The safety of the vaccine was assessed in 13 controlled clinical trials where approximately 15,000 doses were given to 4,729 healthy infants in ages ranging from 6 weeks to 16 months of age. In all trials, Prevnar 13 was co-administered with routine pediatric vaccines.
In a catch-up study, 354 children (7 months to 5 years of age) receiving at least 1 dose of Prevnar 13 were also assessed for safety.
In a clinical study (0887X-100811) with pneumococcal 7-valent conjugate vaccine in infants vaccinated at 2, 3 and 4 months of age, fever ≥38°C was reported at higher rates among infants who received pneumococcal 7-valent conjugate vaccine concomitantly with Infanrix hexa (28.3% to 42.3%) than in infants receiving Infanrix hexa alone (15.6% to 23.1%). After a booster dose at 12-15 months of age, the rate of fever ≥38°C was 50.0% in infants who received pneumococcal 7-valent conjugate vaccine and Infanrix hexa at the same time as compared to 33.6% in infants receiving Infanrix hexa alone. These reactions were mostly moderate (less than or equal to 39°C) and transient.
Analysis of postmarketing reporting rates suggests a potential increased risk of convulsions, with or without fever, and hypotonic-hyporesponsive episode when comparing groups which reported use of Prevnar 13 with Infanrix hexa to those which reported use of Prevnar 13 alone.
Safety was evaluated in 592 healthy children and adolescents, including 17.4% of subjects with a history of asthma. Two hundred and ninety-four (294) children aged 5 to <10 years had previously been immunized with at least 1 dose of Prevnar (7-valent) vaccine and 298 children aged 10-17 years had not previously been vaccinated with a pneumococcal vaccine.
Safety was assessed in 7 clinical studies including 91,593 adults ranging in ages from 18 to 101 years. Prevnar 13 was administered to 48,806 adults; 2,616 adults were aged 50-64 years and 45,291 adults were 65 years and older. Of the Prevnar 13 recipients, 1,916 adults were previously vaccinated with PPSV23 at least 3 years prior, and 46,890 adults were PPSV23 unvaccinated. One of the 7 studies included a group of adults (n=899) ranging from 18-49 years who received Prevnar 13 and who were not previously vaccinated with PPSV23.
Immunogenicity Studies
Two of the 6 clinical studies supporting safety were randomized trials comparing the safety and immunogenicity of Prevnar 13 with PPSV23 as a single dose in PPSV23 unvaccinated adults aged 50-64 years (study 6115A1-004) and in adults ≥70 years PPSV23 previously vaccinated (≥5 years prior to enrollment) (study 6115A1-3005). Study 6115A1-004 also included a cohort of PPSV23 unvaccinated adults aged 18-49 years. One study was randomized comparing the safety and immunogenicity of a single dose of Prevnar 13 compared to a single dose of PPSV23 in PPSV23 unvaccinated adults aged 60-64 years (study 6115A1-3010). One clinical safety study (study 6115A1-3000) of Prevnar 13, conducted in PPSV23 previously vaccinated (≥ 3 years prior to enrollment) adults aged ≥ 68 years was a single arm study. Two studies, 1 in the US (study 6115A1-3001) in adults aged 50-59 years and the other in Europe (study 6115A1-3008) in adults aged ≥65 years, evaluated the concomitant administration of Prevnar 13 with trivalent inactivated influenza vaccine (TIV) in these 2 age groups in PPSV23 unvaccinated adults.
A trend to lower frequency of adverse reactions was associated with increasing age; adults >65 years of age (regardless of pneumococcal vaccination status) reported fewer adverse reactions than younger adults, with adverse reactions generally more common in adults 18-29 years of age.
Overall, the frequency categories were similar in adults 18-49 years of age compared to adults >50 years of age, with the exception of vomiting which was very common (≥ 1/10) in adults aged 18-49 years and common (≥ 1/100 to < 1/10) in adults >50 years of age.
Efficacy Study
Study 6115A1-3006, conducted in the Netherlands in adults aged 65 years and older, was a randomized, double-blind, placebo-controlled study. A single dose of Prevnar 13 was compared to placebo for efficacy in prevention of the first episodes of vaccine-type (VT) pneumococcal community-acquired pneumonia (CAP) and VT-IPD. 84,496 subjects received either Prevnar 13 (42,240) or placebo (42,256) in a 1:1 randomization.
For 1,006 Prevnar 13 vaccinated subjects, solicited adverse events were monitored by recording local and systemic events using electronic diaries for 7 days after vaccination; adverse events were collected for 28 days after vaccination, and serious adverse events were collected for 6 months after vaccination. For the remaining 41,234 Prevnar 13 vaccinated subjects, serious adverse events were collected for 28 days after vaccination.
Subjects with pre-existing medical conditions (heart disease, lung disease or asthma, diabetes mellitus with or without insulin use, liver disease and splenectomy) as well as subjects with a history of smoking were enrolled, except those with immunocompromising conditions.
These data are from clinical trials in which Prevnar 13 was administered simultaneously with other routine childhood vaccines. Expected frequency of adverse reactions is presented in CIOMS frequency categories:
System Organ Class | 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 |
Immune System Disorders | Hypersensitivity reaction including face edema, dyspnea, bronchospasm | |||
Metabolism and Nutrition Disorders | Decreased appetite | |||
Psychiatric Disorders | Irritability | Crying | ||
Nervous System Disorders | Drowsiness/increased sleep; restless sleep/decreased sleep | Seizures (including febrile seizures) | Hypotonic-hyporesponsive episode | |
Gastrointestinal Disorders | Diarrhea; vomiting | |||
Skin and Subcutaneous Tissue Disorders | Rash | Urticaria or urticaria-like rash | ||
General Disorders and Administration Site Conditions | Fever; any vaccination-site erythema, induration/swelling or pain/tenderness; vaccination-site erythema or induration/swelling 2.5 cm – 7.0 cm (after toddler dose and in older children [age 2-5 years]) | Fever greater than 39°C; vaccination-site erythema or induration/swelling 2.5 cm – 7.0 cm (after infant series); vaccination-site pain/tenderness interfering with movement | Vaccination-site induration/swelling or erythema greater than 7.0 cm |
During the 13 controlled clinical trials, SAEs that the investigator considered related to study vaccine were reported for 11 out of 7,489 total subjects (0.1%); 6 out of 4,729 subjects (0.1%) in the Prevnar 13 group and 5 out of 2,760 (0.2%) in the Prevnar (7-valent) group. Of these 11 cases, there were 3 cases of febrile convulsions and 4 cases of fever. Out of the 4 cases with fever, 1 subject had diffuse body rash, 1 subject had respiratory distress, and 1 subject had tense fontanelle. The remaining related SAE cases were crying (1), bronchitis (1), infantile spasms (1) and nephroblastoma (1).
During the 13 controlled clinical trials, death occurred in 4 (out of 7,489) infants. All 4 cases were attributable to Sudden Infant Death Syndrome (SIDS). Three (out of 4,729 cases receiving 15,739 doses) cases were among Prevnar 13 recipients, and 1 (out of 2,760 cases receiving 9,030 doses) was in the Prevnar (7-valent) group. None of these cases were assessed by the investigator as causally related to vaccination.
The incidence and severity of solicited adverse events that occurred within 7 days following 1 dose of Prevnar 13 administered to children and adolescents 5-17 years of age are shown in Tables 2 and 3.
Local Reaction | Study 6096A1-3011 Vaccine Group (as Administered) | |||||
Prevnar 13 (5 to <10 years) | Prevnar 13 (10-17 years) | |||||
Nb | nc | % | Nb | nc | % | |
Tenderness | ||||||
Any | 265 | 230 | 86.8 | 283 | 252 | 89.0 |
Significantd | 221 | 43 | 19.5 | 242 | 106 | 43.8 |
Swelling | ||||||
Any | 226 | 85 | 37.6 | 233 | 86 | 36.9 |
Milde | 220 | 48 | 21.8 | 221 | 50 | 22.6 |
Moderatee | 219 | 48 | 21.9 | 226 | 48 | 21.2 |
Severee | 211 | 7 | 3.3 | 214 | 4 | 1.9 |
Redness | ||||||
Any | 233 | 100 | 42.9 | 232 | 70 | 30.2 |
Milde | 226 | 63 | 27.9 | 226 | 48 | 21.2 |
Moderatee | 218 | 48 | 22.0 | 221 | 31 | 14.0 |
Severee | 212 | 7 | 3.3 | 213 | 4 | 1.9 |
Any of the above | 270 | 242 | 89.6 | 285 | 258 | 90.5 |
a All reported local reactions, regardless of causality. b N = Number of subjects reporting yes for at least 1 day or no for all days. | ||||||
Systemic Event | Study 6096A1-3011 Vaccine Group (as Administered) | |||||
Prevnar 13 (5 to <10 years) | Prevnar 13 (10-17 years) | |||||
Nb | nc | % | Nb | nc | % | |
Fever ≥38°C but ≤39°C | 212 | 9 | 4.2 | 214 | 11 | 5.1 |
Fever >39°C but ≤40°C | 212 | 5 | 2.4 | 212 | 1 | 0.5 |
Fever >40°C | 210 | 1 | 0.5 | 212 | 1 | 0.5 |
Decreased appetite | 227 | 52 | 22.9 | 223 | 51 | 22.9 |
Irritability | 234 | 73 | 31.2 | 234 | 59 | 25.2 |
Increased sleep | 226 | 48 | 21.2 | 229 | 61 | 26.6 |
Decreased sleep | 212 | 12 | 5.7 | 224 | 42 | 18.8 |
Hives (urticaria) | 213 | 4 | 1.9 | 214 | 3 | 1.4 |
Use of medication to treat symptoms | 232 | 88 | 37.9 | 232 | 66 | 28.4 |
Use of medication to prevent symptoms | 225 | 58 | 25.8 | 225 | 47 | 20.9 |
Use of medication to treat or to prevent symptoms | 237 | 107 | 45.1 | 236 | 78 | 33.1 |
Use of medication to treat and to prevent symptoms | 220 | 35 | 15.9 | 221 | 29 | 13.1 |
Any systemic eventd | 250 | 118 | 47.2 | 253 | 130 | 51.4 |
a All reported systemic adverse events, regardless of causality. b N = Number of subjects reporting yes for at least 1 day or no for all days. | ||||||
Other adverse reactions observed in other age groups may also be applicable in this age group but due to the small sample size in this study (6096A1-3011) were not seen.
In a single-arm study (6096A1-3014) conducted in 158 children and adolescents 6-17 years of age with sickle cell disease (see Part II, CLINICAL TRIALS), the frequencies of solicited local reactions after the first or second doses of Prevnar 13 were comparable to those reported after a single Prevnar 13 dose in healthy children and adolescents 5-17 years of age from study 6096A1-3011 (see Table 2). All solicited systemic events were reported by ≥10% of subjects in study 6096A1-3014. Frequencies after the first and second doses of Prevnar 13, respectively, were muscle pain (74.8% and 75.5%), fatigue (66.1% and 62.5%), headache (53.6% and 59.3%), joint pain (39.8% and 44.9%), vomiting (15.4% and 13.4%) fever ≥38°C but ≤38.4°C (13.6% and 9.5%) and diarrhea (13.3% and 25.0%).
In a single-arm study (6115A1-3002) which included 150 HIV-infected children and adolescents 6-17 years of age not previously vaccinated with a pneumococcal vaccine (see Part II, CLINICAL TRIALS), the frequencies of solicited local reactions reported within 14 days after the first, second or third dose of Prevnar 13(range across the 3 doses) were: redness (8.3-20.7%), swelling (18.0-29.9%), and pain at the injection site (52.9-68.4%). Frequencies of solicited systemic events reported within 14 days of each dose (range across the 3 doses) were: fever ≥38ºC (10.6-19.1%), fatigue (25.0-47.7%), headache (18.2-39.3%), vomiting (8.2-18.0%), diarrhea (4.9-25.5%), muscle pain (37.4-48.1%), and joint pain (24.2-34.0%).
In children and adolescents 2-17 years of age with a hematopoietic stem cell transplant (N=59) vaccinated with up to 4 doses of Prevnar 13 in single-arm study 6115A1-3003 (see Part II, CLINICAL TRIALS), the frequencies of solicited local reactions reported within 14 days after each study vaccination (range across the 4 doses) were: redness (21.1-71.4%), swelling (25.0-66.7%), and pain (70.3-86.7%). Frequencies of solicited systemic events (range across the 4 doses) were: fever ≥38ºC (12.8-27.8%), fatigue (48.6-67.9%), headache (32.3-52.4%), vomiting (6.3-21.4%), diarrhea (15.4-31.8%), muscle pain (44.4-58.3%), and joint pain (25.0-32.3%).
The incidence and severity of solicited adverse events that occurred within 14 days following each dose of Prevnar 13 or PPSV23 administered to adults in 4 immunogenicity studies (safety data presented from 2 studies in PPSV23 unvaccinated adults and 2 studies in PPSV23 pre-vaccinated adults), and within 7 days following the dose of Prevnar 13 or placebo administered to PPSV23 unvaccinated adults in the efficacy study, are shown in Tables 4 and 5.
| Study 6115A1-004 (PPSV23Unvaccinated Adults) | Study 6115A1-3010 (PPSV23 Unvaccinated Adults) | Study 6115A1-3006 (PPSV23 Unvaccinated Adults) | Study 6115A1-3005 (PPSV23 Pre-Vaccinated Adults) | Study 6115A1-3000b (PPSV23 Pre-Vaccinated Adults) | ||||||
Age in Years | 18-49 | 50-59 | 60-64 | 60-64 | ≥ 65 | ≥70 | ≥ 68 | ||||
Local Reaction | Prevnar 13b Nc= % | Prevnar 13b Nc= % | Prevnar 13 193-331 % | PPSV23 190-301 % | Prevnar 13 270-370 % | PPSV23 134-175 % | Prevnar 13 Nc= 886-914 % | Placebo Nc= 859-865 % | Prevnar 13 306-362 % | PPSV23 324-383 % | Prevnar 13 664-777 % |
Rednessd | |||||||||||
Any | 30.5 | 15.8 | 20.2 | 14.2 | 12.2 | 11.2 | 4.9* | 1.2 | 10.8 | 22.2* | 14.3 |
Mild | 26.4 | 15.2 | 15.9 | 11.2 | 8.3 | 9.7 | 3.7* | 0.8 | 9.5 | 13.5 | 12.6 |
Moderate | 11.9 | 5.0 | 8.6 | 4.9 | 6.4 | 3.9 | 1.7* | 0.3 | 4.7 | 11.5* | 6.5 |
Severe | 2.8 | 0.7 | 1.7 | 0.0 | 1.2 | 0.8 | 0.5 | 0.1 | 1.7 | 4.8* | 1.1 |
Swellingd | |||||||||||
Any | 39.4 | 21.7 | 19.3 | 13.1 | 10.0 | 10.4 | 6.8* | 1.2 | 10.4 | 23.1* | 12.8 |
Mild | 37.2 | 20.6 | 15.6 | 10.1 | 8.2 | 6.1 | 5.5* | 0.7 | 8.9 | 14.0* | 10.9 |
Moderate | 15.1 | 4.3 | 8.2 | 4.4 | 3.8 | 7.6 | 2.6* | 0.6 | 4.0 | 13.6* | 5.5 |
Severe | 1.4 | 0.0 | 0.6 | 1.1 | 0.0 | 0.0 | 0.1 | 0.1 | 0.0 | 4.8* | 0.6 |
Paine | |||||||||||
Any | 96.7 | 88.8 | 80.1 | 73.4 | 69.2* | 58.3 | 36.1* | 6.1 | 51.7 | 58.5 | 51.0 |
Mild | 93.2 | 85.9 | 78.6* | 68.6 | 66.1* | 52.9 | 32.9* | 5.6 | 50.1 | 54.1 | 49.4 |
Moderate | 77.1 | 39.5 | 23.3 | 30.0 | 20.1 | 21.7 | 7.7* | 0.6 | 7.5 | 23.6* | 9.0 |
Severe | 16.0 | 3.6 | 1.7 | 8.6* | 2.3 | 0.8 | 0.3 | 0.1 | 1.3 | 2.3 | 0.2 |
Limitation of arm movementf | |||||||||||
Any | 75.2 | 40.7 | 28.5 | 30.8 | 23.5 | 28.2 | 14.1* | 3.2 | 10.5 | 27.6* | 16.2 |
Mild | 71.5 | 38.6 | 26.9 | 29.3 | 22.7 | 26.1 | 12.4* | 2.5 | 10.3 | 25.2* | 14.8 |
Moderate | 18.5 | 2.9 | 2.2 | 3.8 | 1.2 | 3.1 | 1.7* | 0.5 | 0.3 | 2.6* | 1.6 |
Severe | 15.6 | 2.9 | 1.7 | 4.3 | 1.1 | 2.3 | 1.2 | 0.7 | 0.7 | 3.0* | 1.6 |
† All studies in this table reported local reactions within 14 days after vaccination, except Study 6115A1-3006, which reported local reactions within 7 days. * Statistically significant difference p < 0.05. a All reported local reactions, regardless of causality assessment. b Open label administration of Prevnar 13. c Number of subjects with known values for any local reaction. d Mild = 2.5 to 5.0 cm, moderate = 5.1 to 10.0 cm, and severe is >10.0 cm. | |||||||||||
| Study 6115A1-004 (PPSV23 Unvaccinated Adults) | Study 6115A1-3010 (PPSV23 Unvaccinated Adults) | Study 6115A1-3006 (PPSV23 Unvaccinated Adults) | Study 6115A1-3005 (PPSV23 Pre-Vaccinated Adults) | Study 6115A1-3000b (PPSV23 Pre-Vaccinated Adults) | ||||||
Age in Years | 18-49 | 50-59 | 60-64 | 60-64 | ≥ 65 | ≥70 | ≥68 | ||||
Systemic Event | Prevnar 13b Nc= 221-561 % | Prevnar 13b Nc= 137-248 % | Prevnar 13 Nc= 180-277 % | PPSV23 Nc= 185-273 % | Prevnar 13 Nc= 263-324 % | PPSV23 Nc= 127-173 % | Prevnar 13 Nc= 881-896 % | Placebo Nc= 859-878 % | Prevnar 13 Nc= 299-350 % | PPSV23 Nc= 304-367 % | Prevnar 13 Nc= 638-733 % |
Fever | |||||||||||
Any (≥38°C) | 7.2 | 1.5 | 4.0 | 1.1 | 4.2 | 1.6 | 2.9* | 1.3 | 1.0 | 2.3 | 1.1 |
≥38°C but <38.5°C | 4.2 | 1.5 | 4.0 | 1.1 | 3.8 | 0.8 | 1.1 | 0.6 | 1.0 | 2.0 | 0.8 |
≥38.5°C but <39°C | 1.9 | 0.0 | 0.6 | 0.0 | 0.8 | 0.0 | 0.6 | 0.2 | 0.0 | 0.0 | 0.0 |
≥39°C but ≤40°C | 1.4 | 0.0 | 0.0 | 0.0 | 0.4 | 0.8 | 0.7 | 0.2 | 0.0 | 0.3 | 0.3 |
>40°C | 0.5 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.8 | 0.3 | 0.0 | 0.0 | 0.0 |
Fatigue | 80.5 | 63.3 | 63.2 | 61.5 | 50.5 | 49.1 | 18.8* | 14.8 | 34.0 | 43.3* | 34.4 |
Headache | 81.4 | 65.9 | 54.0 | 54.4 | 49.7 | 46.1 | 15.9 | 14.8 | 23.7 | 26.0 | 26.1 |
Chills | 38.1 | 19.6 | 23.5 | 24.1 | 19.9 | 26.9 | 9.4 | 8.4 | 7.9 | 11.2 | 7.5 |
Rash | 21.3 | 14.2 | 16.5 | 13.0 | 8.6 | 13.4 | 3.3* | 0.8 | 7.3 | 16.4* | 8.4 |
Vomiting | 15.0 | 6.9 | 3.9 | 5.4 | 3.1 | 3.1 | 0.3 | 0.9 | 1.7 | 1.3 | 0.9 |
Diarrhea | NA | NA | NA | NA | NA | NA | 5.7 | 8.7 | NA | NA | 14.5 |
Decreased appetite | 55.6 | 25.3 | 21.3 | 21.7 | 14.7 | 23.0* | 5.3 | 3.7 | 10.4 | 11.5 | 11.2 |
Generalized new muscle pain | 82.0 | 61.8 | 56.2 | 57.8 | 46.9 | 51.5 | 18.4* | 8.4 | 36.8 | 44.7* | 25.3 |
Generalized aggravated muscle pain | 55.9 | 39.9 | 32.6 | 37.3 | 22.0 | 32.5* | 9.1* | 4.4 | 20.6 | 27.5* | 12.3 |
Generalized new joint pain | 41.7 | 31.5 | 24.4 | 30.1 | 15.5 | 23.8* | 7.4 | 5.4 | 12.6 | 14.9 | 12.8 |
Generalized aggravated joint pain | 28.6 | 25.6 | 24.9 | 21.4 | 14.0 | 21.1 | 5.2 | 4.2 | 11.6 | 16.5 | 9.7 |
† All studies in this table reported systemic events within 14 days after vaccination, except Study 6115A1-3006, which reported systemic events within 7 days. * Statistically significant difference p < 0.05. a All reported systemic events, regardless of causality assessment. b Open label administration of Prevnar 13. c Number of subjects with known values for any systemic event. NA = not applicable | |||||||||||
The safety of concomitant administration of Prevnar 13 with seasonal trivalent influenza vaccine (TIV) was assessed in 2 studies in PPSV23 unvaccinated adults. The incidence of solicited local and systemic adverse events that occurred within 14 days following Prevnar 13 administered concomitantly with TIV compared to Prevnar 13 or TIV administered alone are shown in Tables 6 and 7, respectively.
Local Reaction | Adults Aged 50-59 Years (Study 6115A1-3001) | Adults Aged ≥65 Years (Study 6115A1-3008) | ||
Prevnar 13 +TIV Nc=262-469 % | Prevnar 13b Nc=241-453 % | Prevnar 13 +TIV Nc=428-480 % | Prevnar 13b Nc=420-470 % | |
Rednessd | ||||
Any | 16.3 | 12.1 | 16.6 | 12.3 |
Mild | 15.7 | 10.2 | 14.4* | 9.7 |
Moderate | 4.2 | 5.6 | 6.0 | 6.1 |
Severe | 0.4 | 1.2 | 0.7 | 1.0 |
Swellingd | ||||
Any | 18.4 | 14.7 | 13.8 | 10.2 |
Mild | 17.0 | 12.3 | 11.8 | 8.1 |
Moderate | 5.7 | 6.4 | 4.2 | 5.0 |
Severe | 0.4 | 0.4 | 0.2 | 0.0 |
Paine | ||||
Any | 86.8 | 84.5 | 40.0 | 43.4 |
Mild | 82.8 | 82.1 | 34.3 | 37.9 |
Moderate | 39.2 | 41.1 | 14.8 | 19.7 |
Severe | 4.1 | 4.8 | 1.4 | 2.6 |
Limitation of Arm Movementf | ||||
Any | 35.6 | 42.5 | 13.9 | 14.8 |
Mild | 32.6* | 41.1 | 13.1 | 13.4 |
Moderate | 5.2 | 5.2 | 1.4 | 1.0 |
Severe | 3.4 | 2.9 | 1.9 | 1.4 |
* Statistically significant difference p < 0.05 – Prevnar 13 + TIV versus Prevnar 13. a All reported local reactions, regardless of causality assessment. b TIV and placebo were administered 1 month prior to Prevnar 13. c Number of subjects with known values for any local reaction. d Mild is 2.5-5.0 cm. moderate is 5.1-10.0 cm and severe is > 10.0 cm. e Mild = awareness of symptom but easily tolerated, moderate = discomfort enough to cause interference with usual activity, and severe = incapacitating with inability to do usual activity. f Mild = some limitation of arm movement, moderate = unable to move arm above head but able to move arm above shoulder, and severe = unable to move arm above shoulder. | ||||
Systemic Event | Adults Aged 50-59 Years (Study 6115A1-3001) | Adults Aged ≥65 Years (Study 6115A1-3008) | ||||
Prevnar 13 +TIV Nd=261-399 % | Prevnar 13c Nd=240-350 % | TIVb Nd=257‑382 % | Prevnar 13 +TIV Nd=428-476 % | Prevnar 13c Nd=420-456 % | TIVb Nd=431‑483 % | |
Fever | ||||||
Any (≥38°C) | 3.4 | 2.5 | 1.2 | 4.2 | 3.6 | 3.2 |
≥38°C but <38.5°C | 1.5 | 1.2 | 1.2 | 3.0 | 3.1 | 1.9 |
≥38.5°C but <39°C | 1.5† | 0.8 | 0.0 | 1.4 | 1.0 | 1.2 |
≥39°C but <40°C | 0.4 | 0.4 | 0.0 | 0.0 | 0.0 | 0.2 |
>40°C | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 |
Fatigue | 58.1 | 51.8 | 52.4 | 37.4* | 28.5 | 31.9 |
Headache | 65.9*,† | 50.9 | 56.5 | 32.6* | 24.7 | 29.7 |
Chills | 31.4† | 24.6 | 21.0 | 13.8*,† | 9.1 | 9.1 |
Rash | 12.6† | 9.5 | 4.9 | 6.9† | 6.8 | 3.4 |
Vomiting | 5.3 | 6.1 | 3.4 | 3.0 | 1.7 | 3.4 |
Decreased appetite | 30.2† | 25.8 | 22.6 | 16.9* | 11.3 | 14.6 |
Generalized new muscle pain | 65.5† | 59.1 | 37.7 | 26.9† | 23.4 | 16.7 |
Generalized aggravated muscle pain | 34.7† | 36.7 | 24.1 | 18.7 | 15.0 | 14.0 |
Generalized new joint pain | 33.0† | 27.4 | 24.7 | 16.2* | 11.5 | 13.1 |
Generalized aggravated joint pain | 21.2 | 23.8 | 18.0 | 15.7* | 8.6 | 13.0 |
* Statistically significant difference p < 0.05 – Prevnar 13 + TIV versus Prevnar 13. † Statistically significant difference p < 0.05 – Prevnar 13 + TIV versus TIV a All reported systemic events, regardless of causality assessment. b TIV was administered with placebo. c TIV and placebo were administered 1 month prior to Prevnar 13. d Number of subjects with known values for any systemic event. | ||||||
In a single-arm study (6115A1-3017) conducted in 329 HIV-infected adults ≥ 18 years of age previously vaccinated with PPSV23, and in a single-arm study (6115A1-3002) conducted in 151 HIV-infected adults ≥18 years of age not previously vaccinated with PPSV23 (see Part II, CLINICAL TRIALS), the frequencies of solicited local reactions and systemic adverse events after the first, second or third doses of Prevnar 13 were comparable to those reported after a single Prevnar 13 dose in healthy adults ≥18 years of age from study 6115A1-004 (see Tables 4 and 5), except that fever was very common (11.0-17.9% across the 3 doses) in study 6115A1-3002.
In adults ≥18 years of age with a hematopoietic stem cell transplant (N=188) vaccinated with up to 4 doses of Prevnar 13 in single-arm study 6115A1-3003 (see Part II, CLINICAL TRIALS), the frequencies of solicited local reactions and systemic events after the first, second, third, or fourth doses of Prevnar 13 were comparable to those reported after a single Prevnar 13 dose in healthy adults ≥18 years of age from study 6115A1-004 (see Tables 4 and 5), except that fever was very common (4.3-15.4% across the 4 doses) in study 6115A1-3003.
Immunogenicity Studies: Adults 50 Years and Older
Across the 6 studies, serious adverse events within 1 month of vaccination were reported in 0.2% to 1.7% of 5,667 persons vaccinated at any time during the study with Prevnar 13 and in 0.4% to 1.7% of 1,391 persons vaccinated at any time during the study with PPSV23. From 1 month to 6 months postvaccination, serious adverse events were reported in 1.2% to 5.8% of persons vaccinated at any time during the study with Prevnar 13 and in 2.4% to 5.5% of persons vaccinated at any time during the study with PPSV23.
Twelve of 5,667 (0.21%) Prevnar 13 recipients and 4 of 1,391 (0.29%) PPSV23 recipients died; none of the deaths were considered related to vaccination. Deaths occurred between day 3 and day 309 after study vaccination with Prevnar 13 or PPSV23. Two of 12 deaths occurred within 30 days of vaccination and both deaths were in subjects >65 years of age. One death due to cardiac failure occurred 3 days after receiving placebo. This subject had received Prevnar 13 and TIV 1 month earlier. The other death was due to peritonitis 20 days after receiving Prevnar 13. The reported causes of the 10 remaining deaths occurring greater than 30 days after receiving Prevnar 13 were cardiac disorders (4), neoplasms (4), Mycobacterium avium complex pulmonary infection (1) and septic shock (1).
Immunogenicity Study: Adults 18-49 Years of Age
Serious adverse events occurring within 1 month of vaccination and considered possibly related to vaccination were reported in 0.1% of 899 subjects vaccinated. There were no deaths or adverse events that led to withdrawal from the study.
Efficacy Study: Adults 65 Years and Older
Serious adverse events within 1 month of vaccination were reported in 0.8% of 42,237 Prevnar 13 recipients and in 0.7% of 42,225 placebo recipients in the safety population. In the subset of subjects where serious adverse events were monitored for 6 months, 7% of 1,006 Prevnar 13 vaccinated subjects and 6% of 1,005 placebo vaccinated subjects reported serious adverse events.
Although the following adverse drug reactions were not observed in the clinical trials, they are considered adverse drug reactions for Prevnar 13 as they were reported in the postmarketing experience. Because these reactions were derived from spontaneous reports, the frequencies could not be determined and are thus considered as not known.
System Organ Class | Frequency Not Known (cannot be estimated from available data)* |
Blood and lymphatic system disorders | Lymphadenopathy localized to the region of the vaccination-site |
Immune system disorders | Anaphylactic/anaphylactoid reaction including shock |
Skin and subcutaneous tissue disorders | Angioedema; erythema multiforme |
General disorders and administration site conditions | Vaccination-site dermatitis; vaccination-site urticaria; vaccination-site pruritus |
*Adverse drug reaction identified post-marketing
Infants and Children Aged 6 Weeks to 5 Years
Prevnar 13 can be given, at a different vaccination-site, with any of the following vaccine antigens, either as monovalent or combination vaccines: diphtheria, tetanus, acellular pertussis, Haemophilus influenzae type b, inactivated poliomyelitis, hepatitis B, meningococcal serogroup C, measles, mumps, rubella and varicella.
In the clinical trials, some infants and children were given rotavirus vaccine (oral administration) or hepatitis A vaccine (at a different site) with Prevnar 13. The safety profiles were comparable for these children but immunogenicity data were not available.
Prevnar 13 can also be given concomitantly with the tetanus toxoid conjugated meningococcal polysaccharide serogroups A, C, W and Y vaccine, administered between 12-23 months of age in children who have previously received the infant series of Prevnar 13 (see PART II, CLINICAL TRIALS section).
Data from a postmarketing clinical study evaluating the impact of prophylactic use of antipyretics (ibuprofen and acetaminophen) on the immune response to Prevnar 13 suggest that prophylactic administration of acetaminophen may reduce the immune response to Prevnar 13 after the infant series. Responses to the booster dose administered at 12 months were unaffected. The clinical significance of this observation is unknown.
Children and Adolescents 6 to 17 Years of Age
In children and adolescents, data are insufficient to assess the concomitant administration of Prevnar 13 with other routinely administered vaccines in this age group, including human papillomavirus vaccine (HPV), meningococcal protein conjugate vaccine (MCV4), influenza vaccine and tetanus, diphtheria and pertussis vaccine (Tdap).
Adults 18 to 49 Years of Age
No data are currently available regarding concomitant use with other vaccines.
Adults 50 Years and Older
Concomitant administration of Prevnar 13 and a trivalent inactivated influenza vaccine (TIV) has been studied in adults 50 years and older. Concomitant administration of Prevnar 13 and quadrivalent inactivated influenza vaccine (QIV) has been studied in adults 50 years of age and older who had previously received the 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least one year prior (see PART II, CLINICAL TRIALS section).
Some of the effects mentioned under the ADVERSE REACTIONS section may temporarily affect the ability to drive or use machines.
For intramuscular use only.
The dose is 0.5 mL given intramuscularly, with care to avoid injection into or near nerves and blood vessels. The preferred sites are the anterolateral aspect of the thigh in infants or the deltoid muscle of the upper arm in older children and adults. The vaccine should not be injected in the gluteal area. Do not administer Prevnar 13 intravascularly.
The vaccine should not be injected intradermally, subcutaneously or intravenously, since the safety and immunogenicity of these routes have not been evaluated.
Parenteral products should be inspected visually for particulate matter or discoloration prior to use.
The vaccine is not to be mixed with other vaccines/products in the same syringe.
Data on the interchangeability of Prevnar 13 with other pneumococcal conjugate vaccines containing a protein carrier different from CRM197 are not available.
It is recommended that infants who receive a first dose of Prevnar 13 complete the vaccination course with Prevnar 13.
Primary Immunization:
For infants, the recommended immunization series of Prevnar 13 consists of 3 doses of 0.5 mL each, at approximately 2-month intervals, followed by a fourth dose (booster) of 0.5 mL at 12-15 months of age (3+1 schedule). The customary age for the first dose is 2 months of age, but it can be given as young as 6 weeks of age. The recommended dosing interval is 4-8 weeks. The fourth dose should be administered at approximately 12-15 months of age, and at least 2 months after the third dose.
Dose | Dose 1 a | Dose 2 b | Dose 3 b | Dose 4 c |
Age at Dose
| 2 months | 4 months | 6 months | 12-15 months |
a. Dose 1 may be given as early as 6 weeks of age. b. The recommended dosing interval is 4-8 weeks. c. The fourth dose should be administered at approximately 12-15 months of age, and at least 2 months after the third dose. | ||||
Preterm infants in stable condition should be immunized with Prevnar 13 at the same chronological age and according to the same schedule as full-term infants (see Table 9, WARNINGS AND PRECAUTIONS – Infants and Children Aged 6 Weeks to 5 Years, and PART II, CLINICAL TRIALS – Preterm Infants).
For children who are beyond the age of the routine infant schedule, the following Prevnar 13 schedule applies:
Age at First Dose | Total Number of 0.5 mL Doses |
7-11 months of age | 3a |
12-23 months of age | 2b |
≥24 months to 5 years of age | 1 |
a. 2 doses at least 4 weeks apart; third dose after the 1-year birthday, separated from the second dose by at least 2 months. b. 2 doses at least 2 months apart. | |
If Prevnar 13 is given as part of a routine infant immunization program, a 3-dose (2+1) schedule may be considered. The first dose may be given from the age of 2 months, with a second dose 2 months later, and a third (booster) dose is recommended between 11-12 months of age. Lower immunogenicity responses for serotypes 6B and 23F were observed when Prevnar 13 is given as a 2-dose (e.g., at 2 and 4 months of age, or at 3 and 5 months of age) schedule in infants up to 6 months of age. After the booster dose, all vaccine serotypes had immune responses consistent with adequate priming with a 2-dose primary series (See PART II, CLINICAL TRIALS section).
Infants and Children Previously Vaccinated with Prevnar (7-valent) (Streptococcus pneumoniae Serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F):
Prevnar 13 contains the same 7 serotypes contained in Prevnar (7-valent) and is manufactured based on the same conjugate technology using the CRM197 carrier protein. A booster dose of Prevnar 13 in children (n = 100) previously vaccinated with 3 doses of Prevnar (7-valent) elicited anti-capsular antibody levels (GMCs) to each of the seven common serotypes that were comparable to those elicited by 4 doses of Prevnar (7-valent) (see Table 15 of PART II, CLINICAL TRIALS section).
Children who have completed the infant series with Prevnar (7-valent) can receive a single dose of Prevnar 13 in the second year of life. A single dose of Prevnar 13 in children >1 year of age elicits immune responses to the 6 additional serotypes that are comparable to those elicited by a 3-dose infant series of Prevnar 13, but are generally lower than those elicited by a 3 infant doses + 1 toddler dose schedule of Prevnar 13.
Children 6 years to 17 years of age may receive a single dose of Prevnar 13. If Prevnar (7-valent) was previously administered, then at least 8 weeks should elapse before receiving Prevnar 13.
Prevnar 13 is to be administered as a single dose of 0.5 mL to adults 18 years and older including those previously vaccinated with a pneumococcal polysaccharide vaccine.
Regardless of prior pneumococcal vaccination status, if sequential administration of Prevnar 13 and pneumococcal polysaccharide vaccine is considered, Prevnar 13 should be given first.
The need for re-vaccination with a subsequent dose of Prevnar 13 has not been established.
(Also see WARNINGS AND PRECAUTIONS – General, and PART II, CLINICAL TRIALS – Immune Responses in Special Populations)
Individuals who may be at higher risk of pneumococcal infection (e.g., individuals with sickle cell disease or HIV infection), including those previously vaccinated with 1 or more doses of 23-valent pneumococcal polysaccharide vaccine (PPSV23), may receive 1 dose of Prevnar 13.
In individuals aged ≥ 2 years with a hematopoietic stem cell transplant (HSCT), the recommended immunization series consists of 4 doses of Prevnar 13, each of 0.5 mL. The primary series consists of 3 doses, with the first dose given 3 to 6 months after HSCT and with an interval of at least 1 month between doses. A booster dose is recommended 6 months after the third dose.
Based on the National Advisory Committee on Immunization (NACI) recommendations, if sequential administration of Prevnar 13 and pneumococcal polysaccharide vaccine is considered, it is recommended that Prevnar 13 be given first.11
Overdose with Prevnar 13 is unlikely due to its presentation as a pre-filled syringe. However, in infants and children there have been reports of overdose with Prevnar 13 defined as subsequent doses administered closer than recommended to the previous dose. In general, adverse reactions reported with overdose are consistent with those that have been reported with doses given in the recommended pediatric schedules of Prevnar 13.
Prevnar 13 contains the 7 pneumococcal capsular polysaccharides that are in Prevnar (7-valent) (4, 6B, 9V, 14, 18C, 19F, 23F) plus 6 additional polysaccharides (1, 3, 5, 6A, 7F, 19A) all conjugated to CRM197 carrier protein. B-cells produce antibodies in response to antigenic stimulation via T-dependent and T-independent mechanisms. The immune response to most antigens is T-dependent and involves the collaboration of CD4+ T-cells and B-cells, recognizing the antigen in a linked fashion. CD4+ T-cells (T-helper cells) provide signals to B-cells directly through cell surface protein interactions, and indirectly through the release of cytokines. These signals result in proliferation and differentiation of the B-cells, and production of high-affinity antibodies. CD4+ T-cell signaling is a requisite for the generation of long-lived B-cells called plasma cells, which continuously produce antibodies of several isotypes (with an IgG component) and memory B-cells that rapidly mobilize and secrete antibodies upon re-exposure to the same antigen.
Bacterial capsular polysaccharides (PSs), while varied in chemical structure, share the common immunological property of being largely T-independent antigens. In the absence of T-cell help, PS stimulated B-cells predominantly produce IgM antibodies; there is generally no affinity maturation of the antibodies, and no memory B-cells are generated. As vaccines, PSs are associated with poor or absent immunogenicity in infants less than 24 months of age and failure to induce immunological memory at any age. Conjugation of PSs to a protein carrier overcomes the T-cell–independent nature of PS antigens. Protein carrier-specific T-cells provide the signals needed for maturation of the B-cell response and generation of B-cell memory. Conversion of Streptococcus pneumoniae PSs to a T-cell-dependent antigen by covalent coupling to the immunogenic protein carrier CRM197 enhances the antibody response and induces immune memory. This has been demonstrated to elicit booster responses on re-exposure in infants and young children to pneumococcal polysaccharides.
Prior to the licensure of 7-valent pneumococcal conjugate vaccine (Prevnar) in Canada in 2001, the observed incidence rates of invasive pneumococcal disease (IPD) among children <2 years of age and <5 years of age were 58.8-112.2 per 100,000 and 35.0-63.8 per 100,000 per year, respectively. The overall fatality rate was 2.0%. The incidence rate of pneumococcal meningitis among children <2 years of age was 9.0 per 100,000 per year, with a case fatality rate of 5.9%.
Since the introduction of Prevnar (7-valent) in Canada in 2001, it has been shown that the incidence of IPD caused by Prevnar (7-valent) serotypes decreased by 92% in Vancouver, 94% in Calgary and by 72% in Quebec.
While the effect of routine use of Prevnar (7-valent) in infants and young children has been dramatic, with a near-total elimination of the serotypes contained in this vaccine, an increase in other serotypes causing IPD has been observed (as an increasing percentage of residual disease). Data from Canadian surveillance systems (National Centre for Streptococcus [NCS]; Immunization Monitoring Program, Active [IMPACT]; and Institut National de Santé Publique du Québec [INSPQ]) showed that serotypes 19A, 6A and 3 have emerged as the predominant pneumococcal serotypes causing IPD in Canadian children, accounting for approximately one-third of the residual IPD in 2007 in children <5 years of age. Compounding the issue of the predominance of emerging serotype 19A is that it is increasingly likely to be nonsusceptible to commonly used first-line antimicrobial agents.
Serotype surveillance of invasive S. pneumoniae performed by the National Microbiology Laboratory in 2010 to establish a baseline serotype distribution in Canada during introduction of Prevnar 13 revealed that serotypes 19A, 7F and 3 were the most common serotypes in children, accounting for 57% of all invasive isolates in <2 year olds, 62% in 2-4 year olds and 45% in 5-14 year olds. Prevnar 13 serotypes represented 65%, 71% and 61% of pneumococci isolated from <2 year olds, 2-4 year olds, and 5-14 year olds, respectively.
Following Prevnar 13 introduction in the Calgary area in mid 2010, the overall pneumococcal nasopharyngeal colonization rate in healthy children declined from 19% in 2003-2006 to 13% in 2010-2012 (p<0.001), and colonization with serotype 19A decreased from 18% of all serotypes in 2010 to 4% in 2012. Children who received 2 or more doses of either Prevnar (7-valent) or Prevnar 13 had reduced odds of colonization with any pneumococcus in adjusted logistic regression (Odds ratio: 0.75; 95% CI: 0.63-0.9).
Prior to the introduction of Prevnar (7-valent) into the National Immunization Program (NIP), the IPD incidence for Canadian adults aged 65 years and older ranged from 16 to 31 per 100,000. A ten-year population-based surveillance of all cases of invasive pneumococcal infection occurring in the Calgary Health Region reported a decrease of 92% in 2007 vs. 1998-2001 in Prevnar (7-valent) serotypes among adults 65 years and older suggesting a herd immunity, a phenomenon that occurs via interruption of transmission of disease to otherwise susceptible populations. However, the incidence of IPD in adults, especially the elderly, has remained high, ranging from 23 per 100,000 to 29.4 per 100,000. Although the incidence estimates among adults younger than 65 are lower than those among adults older than 65, IPD represents a major public health burden among younger adults as well.
Canadian serotype surveillance performed by the National Microbiology Laboratory in 2010 revealed that serotypes 19A, 7F and 3 were the most common serotypes in adults, accounting for 44% of invasive S. pneumoniae isolates in 15-49 year olds, 41% in 50-64 year olds and 36% in ≥65 year olds. Prevnar 13 serotypes represented 60%, 53% and 49% of pneumococci isolated from 15-49 year olds, 50-64 year olds, and ≥65 year olds, respectively.
Store refrigerated at +2 °C to +8 °C.
Do not freeze. Discard if the vaccine has been frozen.
Store in original package.
Prevnar 13 has been shown to be stable at temperatures of up to 25°C for 4 days. Cumulative multiple temperature excursions between 8°C and 25°C are permitted, as long as the total time does not exceed 4 days (96 hours). These data are not recommendations for shipping or storage, but may guide decisions for use in case of temporary temperature excursions.
Do not use after the expiry date shown on the label.
Prevnar 13 is a suspension containing an adjuvant. The vaccine should be shaken well to obtain a homogeneous white suspension prior to expelling air from the syringe, and should be inspected visually for any particulate matter and/or variation of physical aspect prior to administration. Do not use if the content appears otherwise.
The vaccine is not to be mixed with other vaccines/products in the same syringe.
Each 0.5 mL dose of the vaccine is formulated to contain approximately 2.2 µg of each saccharide for Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 7F, 9V, 14, 18C, 19A, 19F and 23F, 4.4 µg of saccharide for serotype 6B, 34 µg CRM197 carrier protein, 4.25 mg sodium chloride, 100 µg polysorbate 80, 295 µg succinic acid and 125 µg aluminum as aluminum phosphate adjuvant.
The vaccine is a white suspension for injection and provided in a single-dose, pre-filled syringe (0.5 mL). Pack sizes of 1 and 10, without needles. The tip cap and rubber plunger of the pre-filled syringe do not contain latex.
Control #: 219617
August 8, 2019
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