[Federal Register: January 5, 2004 (Volume 69, Number 2)]
[Rules and Regulations]
[Page 255-267]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr05ja04-6]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration
21 CFR Parts 201 and 610
[Docket No. 1980N-0208]
Biological Products; Bacterial Vaccines and Toxoids;
Implementation of Efficacy Review
AGENCY: Food and Drug Administration, HHS.
ACTION: Final rule and final order.
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SUMMARY: The Food and Drug Administration (FDA) is amending the
biologics regulations in response to the report and recommendations of
the Panel on Review of Bacterial Vaccines and Toxoids with Standards of
Potency (the Panel). The Panel reviewed the safety, efficacy, and
labeling of bacterial vaccines and toxoids that have standards of
potency, bacterial antitoxins, and immune globulins. On the basis of
the Panel's findings and recommendations, FDA is classifying these
products as Category I (safe, effective, and not misbranded), Category
II (unsafe, ineffective, or misbranded), or Category IIIB (off the
market pending completion of studies permitting a determination of
effectiveness).
DATES: This rule is effective January 4, 2003. The final order on
categorization of products is effective January 5, 2004.
FOR FURTHER INFORMATION CONTACT: Astrid Szeto, Center for Biologics
Evaluation and Research (HFM-17), Food and Drug Administration, 1401
Rockville Pike, suite 200N, Rockville, MD 20852-1448, 301-827-6210.
SUPPLEMENTARY INFORMATION:
I. Introduction
The purposes of this document are:
1. To categorize those bacterial vaccines and toxoids licensed
before July 1972 according to the evidence of their safety and
effectiveness, thereby determining whether they may remain licensed and
on the market;
2. To issue a final response to recommendations made in the Panel's
report. These recommendations concern conditions relating to active
components, labeling, tests required before release of product lots,
product standards, or other conditions considered by the Panel to be
necessary or appropriate for assuring the safety and effectiveness of
the reviewed products;
3. To revise the standard for potency of Tetanus Immune Globulin in
Sec. 610.21 (21 CFR 610.21); and
4. To apply the labeling requirements in Sec. Sec. 201.56 and
201.57 (21 CFR 201.56 and 201.57) to bacterial vaccines and toxoids by
amending the implementation dates in Sec. 201.59 (21 CFR 201.59).
II. History of the Review
In the Federal Register of February 13, 1973 (38 FR 4319), FDA
issued procedures for the review by independent advisory review panels
of the safety, effectiveness, and labeling of biological products
licensed before July 1, 1972. This process was eventually codified in
Sec. 601.25 (21 CFR 601.25) (38 FR 32048 at 32052, November 20, 1973).
Under the panel assignments published in the Federal Register of June
19, 1974 (39 FR 21176), FDA assigned the biological product review to
one of the following groups: (1) Bacterial vaccines and bacterial
antigens with ``no U.S. standard of potency,'' (2) bacterial vaccines
and toxoids with standards of potency, (3) viral vaccines and
rickettsial vaccines, (4) allergenic extracts, (5) skin test antigens,
and (6) blood and blood derivatives.
Under Sec. 601.25, FDA assigned responsibility for the initial
review of each of the biological product categories to a separate
independent advisory panel consisting of qualified experts to ensure
objectivity of the review and public confidence in the use of these
products. Each panel was charged with preparing an advisory report to
the Commissioner of Food and Drugs which was to: (1) Evaluate the
safety and effectiveness of the biological products for which a license
had been issued, (2) review their labeling, and (3) identify the
biological products that are safe, effective, and not misbranded. Each
advisory panel report was also to
[[Page 256]]
include recommendations classifying the products reviewed into one of
three categories.
[sbull] Category I designating those biological products determined
by the Panel to be safe, effective, and not misbranded.
[sbull] Category II designating those biological products
determined by the Panel to be unsafe, ineffective, or misbranded.
[sbull] Category III designating those biological products
determined by the Panel not to fall within either Category I or
Category II on the basis of the Panel's conclusion that the available
data were insufficient to classify such biological products, and for
which further testing was therefore required. Category III products
were assigned to one of two subcategories. Category IIIA products were
those that would be permitted to remain on the market pending the
completion of further studies. Category IIIB products were those for
which the Panel recommended license revocation on the basis of the
Panel's assessment of potential risks and benefits.
In its report, the Panel could also include recommendations
concerning any condition relating to active components, labeling, tests
appropriate before release of products, product standards, or other
conditions necessary or appropriate for a biological product's safety
and effectiveness.
In accordance with Sec. 601.25, after reviewing the conclusions
and recommendations of the review panels, FDA would publish in the
Federal Register a proposed order containing: (1) A statement
designating the biological products reviewed into Categories I, II,
IIIA, or IIIB, (2) a description of the testing necessary for Category
IIIA biological products, and (3) the complete panel report. Under the
proposed order, FDA would propose to revoke the licenses of those
products designated into Category II and Category IIIB.
After reviewing public comments, FDA would publish a final order on
the matters covered in the proposed order.
In the Federal Register of December 13, 1985 (50 FR 51002), FDA
issued a proposed rule responding to the recommendations of the Panel
(the December 1985 proposal). In the December 1985 proposal, FDA
proposed regulatory categories (Category I, Category II, or Category
IIIB as defined previously in this document) for each bacterial vaccine
and toxoid under review by the Panel, and responded to other
recommendations made by the Panel. The public was offered 90 days to
submit comments in response to the December 1985 proposal.
The above stated definition of Category IIIA was applied at the
time of the Panel's review and served as the basis for the Panel's
recommendations. In the Federal Register of October 5, 1982 (47 FR
44062), FDA revised Sec. 601.25 and codified Sec. 601.26, which
established procedures to reclassify those products in Category IIIA
into either Category I or Category II based on available evidence of
effectiveness. The Panel recommended that a number of biological
products be placed into Category IIIA. FDA assigned the review of those
products previously classified into Category IIIA to the Vaccines and
Related Biological Products Advisory Committee. FDA has addressed the
review and reclassification of bacterial vaccines and toxoids
classified into Category IIIA through a separate administrative
procedure (see the Federal Register of May 15, 2000 (65 FR 31003), and
May 29, 2001 (66 FR 29148)). Therefore, FDA does not further identify
or discuss in this document any bacterial vaccines and toxoids
classified into Category IIIA.
III. Comments on the December 1985 Proposal and Our Response
FDA received four letters of comments in response to the December
1985 proposal. One letter from a licensed manufacturer of bacterial
vaccine and toxoid products concerned the confidentiality of
information it had submitted for the Panel's review. As provided in
Sec. 601.25(b)(2), FDA considered the extent to which the information
fell within the confidentiality provisions of 18 U.S.C. 1905, 5 U.S.C.
552(b) or 21 U.S.C. 331(j) before placing the information in the public
docket for the December 1985 proposal. Another comment from a member of
the Panel provided an update of important scientific information
related to bacterial vaccines and toxoids that had accrued since the
time of the Panel's review. The letter did not comment on the December
1985 proposal nor did it contend that the newly available information
should result in modification of the Panel's recommendations or FDA's
proposed actions. FDA's responses to the comments contained in the
remaining two letters of comment follows.
(Comment 1) One comment from a licensed manufacturer of bacterial
vaccines and toxoids objected to the proposed classification into
Category IIIA of several of its products for use in primary
immunization.
As described previously in this document, FDA is considering those
products proposed for Category IIIA in a separate rulemaking process.
This final rule does not take any action regarding the further
classification of those products proposed for Category IIIA, including
those proposed for Category IIIA for primary immunization. All
manufacturers and others in the general public have been offered
additional opportunity to comment on the final categorization of
specific category IIIA products in the above-noted process.
(Comment 2) In response to FDA's proposal that Pertussis Immune
Globulin (Human) be placed into category IIIA because of insufficient
evidence of efficacy, one comment stated that FDA should permit
manufacture of Pertussis Immune Globulin (Human) for export only. The
comment noted that medical practices in other countries may differ from
those in the United States and that in some countries Pertussis Immune
Globulin (Human) plays an important role in the augmentation of therapy
with antibiotics in young, very ill infants with pertussis.
Since that time, FDA has revoked all licenses for Pertussis Immune
Globulin (Human) at the requests of the individual manufacturers. The
FDA Export Reform and Enhancement Act of 1996 (Public Law 104-134, as
amended by Public Law 104-180) amended provisions of the Federal Food,
Drug, and Cosmetic Act (the act) pertaining to the export of certain
unapproved products. Section 802 of the act (21 U.S.C. 382) contains
requirements for the export of products not approved in the United
States. Under these provisions, products such as Pertussis Immune
Globulin (Human) could be exported to other countries, if the
requirements of section 802 are met.
(Comment 3) One comment concerned the generic order and wording for
product labeling recommended by the Panel and which FDA proposed to
adopt in its response to the Panel recommendation. The comment
recommended that a labeling section concerning ``Overdose'' be included
only when circumstances dictate. The comment stated that because all
biological products are prescription products administered by health
care providers, the risk of overdose should be greatly reduced.
FDA agrees that in many cases a labeling section ``Overdosage'' is
not necessary. Section 201.56(d)(3) of the labeling regulations
provides that the labeling may omit any section or subsection of the
labeling format (outlined in Sec. 201.56) if clearly inapplicable. The
``Overdosage'' section,
[[Page 257]]
provided for in Sec. 201.57(i) of the regulations, is omitted for many
bacterial vaccine and toxoid products.
(Comment 4) One letter of comment objected to several statements
made by the Panel and provided in the written report but did not object
to or comment on FDA's proposed responses to the Panel's
recommendations.
FDA is not considering comments on the Panel's report in this
rulemaking. The Panel's recommendations are not binding but represent
the scientific opinions of a Panel of experts. FDA believes that the
agency should not modify the statements and recommendations of the
Panel as provided in its report, including through public comment. The
purpose of the opportunity for comment was to allow comment on FDA's
responses to the Panel's report and not on the Panel's report directly.
IV. Categorization of Products--Final Order
Category I. Licensed biological products determined to be safe and
effective and not misbranded. Table 1 of this document is a list of
those products proposed in December 1985 by FDA for Category I. Under
the ``Comments'' column, FDA notes those products for which FDA's
proposed category differs from that recommended by the Panel. Products
for which the licenses were revoked before the December 1985 proposal
are not listed but were identified in the December 1985 proposal.
Products for which the licenses were revoked after the December 1985
proposal are identified in the ``Comments'' column. After review of the
comments and finding no additional scientific evidence to alter the
proposed categorizations, FDA adopts Category I as the final category
for the following products.
Table 1.--Category I
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Manufacturer/
License No. Products Comments
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Alpha Therapeutic Tetanus Immune Although the Panel recommended
Corp., License No. Globulin (Human) that Tetanus Immune Globulin
744 (Human), manufactured by
Alpha Therapeutic Corp., be
placed in category IIIB, FDA
proposed that it be placed in
Category I.\1\
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Advance Biofactures Collagenase ..............................
Corp., License No.
383
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Armour Tetanus Immune Manufacturer's licensed name
Pharmaceutical Globulin (Human) is now Centeon L. L. C. On
Co., License No. July 26, 1999, FDA revoked
149 the license for Tetanus
Immune Globulin (Human) at
the request of the
manufacturer.
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Connaught Diphtheria and On December 9, 1999, a name
Laboratories, Tetanus Toxoids change to Aventis Pasteur,
Inc., License No. and Pertussis Inc. with an accompanying
711 Vaccine Adsorbed, license number change to 1277
and Diphtheria was granted to Connaught
Antitoxin Laboratories, Inc. FDA
revoked the licenses for
these products at the request
of the manufacturer on July
6, 2001, and August 2, 2001,
respectively.
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Connaught BCG Vaccine, On February 24, 2000, a name
Laboratories, Botulism Antitoxin change to Aventis Pasteur,
Ltd., License No. (Types A, B, and Ltd. with an accompanying
73 E), Botulism license number change to 1280
Antitoxin (Type was granted. On December 21,
E), Tetanus Toxoid 2000, FDA revoked the license
for Tetanus Toxoid at the
request of the manufacturer.
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Cutter Plague Vaccine, On October 5, 1994, the
Laboratories, Tetanus Immune manufacturing facilities and
Inc., License No. Globulin (Human) process for Plague Vaccine
8 were transferred to Greer
Laboratories, Inc., License
No. 308. On May 24, 1995, FDA
revoked Cutter's license for
Plague Vaccine at the request
of Cutter, the previous
manufacturer; the license for
Greer Labs, Inc. remains in
effect. Bayer Corp. now holds
the license for Tetanus
Immune Globulin (Human) under
License No. 8.
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Eli Lilly & Co., Diphtheria and On December 2, 1985, FDA
License No. 56 Tetanus Toxoids revoked the license for
and Pertussis Diphtheria and Tetanus
Vaccine Adsorbed Toxoids and Pertussis Vaccine
Adsorbed at the request of
the manufacturer. FDA
inadvertently omitted this
information in the December
1985 proposal.
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Glaxo Laboratories, BCG Vaccine On July 17, 1990, FDA revoked
Ltd., License No. the license for BCG Vaccine
337 at the request of the
manufacturer.
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Istituto Diphtheria On July 17, 1990, FDA revoked
Sieroterapico Antitoxin, the license for Diphtheria
Vaccinogeno Diphtheria Toxoid Antitoxin at the request of
Toscano Sclavo, Adsorbed, Tetanus the manufacturer. On July 27,
License No. 238 Toxoid Adsorbed 1993, FDA revoked the
licenses for Diphtheria
Toxoid Adsorbed and Tetanus
Toxoid Adsorbed at the
request of the manufacturer.
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Lederle Cholera Vaccine, On December 23, 1992, FDA
Laboratories, Tetanus Immune revoked the license for
Division American Globulin (Human) Tetanus Immune Globulin
Cyanamid Co., (Human) at the request of the
License No. 17 manufacturer. On October 23,
1996, FDA revoked the license
for Cholera Vaccine at the
request of the manufacturer.
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[[Page 258]]
Massachusetts Diphtheria and Although the Panel recommended
Public Health Tetanus Toxoids that Tetanus Antitoxin be
Biologic Adsorbed, placed in Category IIIB, FDA
Laboratories, Diphtheria and proposed that it be placed in
License No. 64 Tetanus Toxoids Category I. On October 26,
and Pertussis 1988, FDA revoked the license
Vaccine Adsorbed, for Typhoid Vaccine at the
Tetanus and request of the manufacturer.
Diphtheria Toxoids On January 10, 1994, FDA
Adsorbed (For revoked the license for
Adult Use), Tetanus Antitoxin at the
Tetanus Antitoxin, request of the manufacturer.
Tetanus Immune On December 22, 1998, FDA
Globulin (Human), revoked the license for
Tetanus Toxoid Diphtheria and Tetanus
Adsorbed, Typhoid Toxoids and Pertussis Vaccine
Vaccine Adsorbed at the request of
the manufacturer. On August
3, 2000, FDA revoked the
license for Diphtheria and
Tetanus Toxoids Adsorbed at
the request of the
manufacturer.
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Merck Sharp & Tetanus Immune The manufacturer is now known
Dohme, Division of Globulin (Human) as Merck & Co., Inc. On
Merck & Co., Inc, January 31, 1986, FDA revoked
License No. 2 the license for Tetanus
Immune Globulin (Human) at
the request of the
manufacturer.
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Michigan Department Anthrax Vaccine The license for Typhoid
of Public Health, Adsorbed, Vaccine was revoked on June
License No. 99 Diphtheria and 25, 1985, at the request of
Tetanus Toxoids the manufacturer. FDA
and Pertussis inadvertently omitted this
Vaccine Adsorbed, information in the December
Pertussis Vaccine 1985 proposal. On November
Adsorbed, Typhoid 11, 1998, a name change to
Vaccine BioPort Corp. (BioPort) with
an accompanying license
number change to 1260 was
granted. The license for
Diphtheria and Tetanus
Toxoids and Pertussis Vaccine
Adsorbed was revoked at the
request of the manufacturer
(BioPort) on November 20,
2000. The license for
Pertussis Vaccine Adsorbed
was revoked at the request of
the manufacturer (BioPort) on
April 22, 2003.
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Parke-Davis, Tetanus Immune On November 19, 1983, FDA
Division of Warner- Globulin (Human) revoked the license for
Lambert Co., Tetanus Immune Globulin
License No. 1 (Human) at the request of the
manufacturer. FDA
inadvertently omitted this
information in the December
1985 proposal.
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Swiss Serum and Tetanus Antitoxin Although the Panel recommended
Vaccine Institute that Tetanus Antitoxin be
Berne, License No. placed in Category IIIB, FDA
21 proposed that it be placed in
Category I. On March 13,
1980, FDA revoked the license
for Tetanus Antitoxin at the
request of the manufacturer;
FDA inadvertently omitted
this information in the
December 1985 proposal.
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Travenol Tetanus Immune The manufacturer is now known
Laboratories, Globulin (Human) as Baxter Healthcare Corp. On
Inc., Hyland July 27, 1995, FDA revoked
Therapeutics the license for Tetanus
Division, License Immune Globulin (Human) at
No. 140 the request of the
manufacturer.
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University of BCG Vaccine On May 29, 1987, FDA revoked
Illinois, License the license for BCG Vaccine
No. 188 at the request of the
manufacturer.
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Wyeth Laboratories, Cholera Vaccine, On December 23, 1992, FDA
Inc, License No. 3 Tetanus Immune revoked the license for
Globulin (Human), Tetanus Immune Globulin
Typhoid Vaccine (Human) at the request of the
(acetone manufacturer. On September
inactivated), 11, 2001, FDA revoked the
Typhoid Vaccine licenses for Cholera Vaccine
(heat-phenol and Typhoid Vaccine (both
inactivated) forms) at the request of the
manufacturer.
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\1\ The Panel recommended that Tetanus Immune Globulin (Human)
manufactured by Alpha Therapeutic Corp. be placed in Category IIIB,
products for which available data are insufficient to classify their
safety and effectiveness and which should not continue in interstate
commerce. The agency disagreed with the Panel's recommendation as the
product was manufactured only as a partially processed biological
product and was intended for export and further manufacture (50 FR
51002 at 51007). The agency continues to agree with this approach
inasmuch as the manufacturer continues to export the product as a
partially processed biological. The product is not available as a
final product in the United States.
Category II. Licensed biological products determined to be unsafe
or ineffective or to be misbranded and which should not continue in
interstate commerce. FDA did not propose that any products be placed in
Category II and in this final rule does not categorize any products in
Category II.
Category IIIB. Biological products for which available data are
insufficient to classify their safety and effectiveness and should not
continue in interstate commerce. Table 2 of this document is a list of
those products proposed by FDA for Category IIIB. We have not listed
products for which FDA revoked the licenses before the December 1985
proposal but we identified them in the proposal. Products for which FDA
revoked the licenses after the December 1985 proposal are identified in
the ``Comments'' column.
FDA has revoked the licenses of all products proposed by FDA for
Category IIIB. After review of the comments and finding no additional
scientific evidence to alter the proposed categorization, FDA adopts
Category IIIB as the final category for the listed products.
[[Page 259]]
Table 2.--Category IIIB
------------------------------------------------------------------------
Manufacturer/
License No. Products Comments
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Istituto Diphtheria Toxoid On July 27, 1993, FDA
Sieroterapico revoked the license for
Vaccinogeno Diphtheria Toxoid at the
Toscano request of the
Sclavo, manufacturer.
License No.
238
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Connaught Diphtheria Toxoid, On June 21, 1994, FDA
Laboratories, Pertussis Vaccine revoked the license for
Inc., License Diphtheria Toxoid and on
No. 711 December 19, 1997, FDA
revoked the license for
Pertussis Vaccine, in
both cases at the request
of the manufacturer.
------------------------------------------------------------------------
Massachusetts Tetanus Toxoid On October 11, 1989, FDA
Public Health revoked the license for
Biologic Tetanus Toxoid at the
Laboratories, request of the
License No. 64 manufacturer.
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Merck Sharpe & Cholera Vaccine, Diphtheria On January 31, 1986, FDA
Dohme, and Tetanus Toxoids and revoked the licenses for
Division of Pertussis Vaccine all the listed products
Merke & Co., Adsorbed, Tetanus and at the request of the
Inc., License Diphtheria Toxoids manufacturer.
No. 2 Adsorbed (For Adult Use),
Tetanus Toxoid, Typhoid
Vaccine
------------------------------------------------------------------------
Michigan Diphtheria Toxoid Adsorbed On November 12, 1998, the
Department of name of the manufacturer
Public Health, was changed to BioPort,
License No. 99 and the license number
was changed to 1260. On
November 20, 2000, FDA
revoked the license for
Diphtheria Toxoid
Adsorbed at the request
of the manufacturer.
------------------------------------------------------------------------
Wyeth Diphtheria Toxoid, On May 19, 1987, FDA
Laboratories, Diphtheria Toxoid revoked the licenses for
Inc., License Adsorbed, Pertussis all listed products at
No. 3 Vaccine the request of the
manufacturer.
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V. Anthrax Vaccine Adsorbed
A. The Panel Recommendation that Anthrax Vaccine Adsorbed be Placed in
Category I (Safe, Effective, and Not Misbranded)
In its report, the Panel found that Anthrax Vaccine Adsorbed (AVA),
manufactured by Michigan Department of Public Health (MDPH now BioPort)
was safe and effective for its intended use and recommended that the
vaccine be placed in Category I. In the December 1985 proposal, FDA
agreed with the Panel's recommendation. During the comment period for
the December 1985 proposal, FDA received no comments opposing the
placement of AVA into Category I\2\.
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\2\ On October 12, 2001, a group of individuals filed a citizen
petition requesting that FDA find AVA, as currently manufactured by
BioPort, ineffective for its intended use, classify the product as
Category II, and revoke the license for the vaccine. The petitioners
complained that the December 1985 proposal that placed AVA in
Category I had not been finalized. FDA responded separately in a
written response to the petitioners and will not further address
those issues in this final rule.
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The Panel based its evaluation of the safety and efficacy of AVA on
two studies: A well controlled field study conducted in the 1950s,
``the Brachman study,'' (Ref. 1) and an open-label safety study
conducted by the National Center for Disease Control (CDC, now the
Centers for Disease Control and Prevention) (50 FR 51002 at 51058). The
Panel also considered surveillance data on the occurrence of anthrax
disease in the United States in at-risk industrial settings as
supportive of the effectiveness of the vaccine (50 FR 51002 at 51059).
In its determination that the data support the safety and efficacy of
AVA, FDA has identified points of disagreement with statements in the
Panel report. However, FDA has determined that the data do support the
safety and efficacy of the vaccine and, thus, the agency continues to
accept the Panel's recommendation and places AVA in Category I.\3\
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\3\ In October 2000, the Institute of Medicine (IOM) convened
the Committee to Assess the Safety and Efficacy of the Anthrax
Vaccine. In March 2002, the Committee issued its report: The Anthrax
Vaccine: Is It Safe? Does It Work? (Ref. 2). The report concluded
that the vaccine is acceptably safe and effective in protecting
humans against anthrax.
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B. Efficacy of Anthrax Vaccine Adsorbed
The Brachman study included 1,249 workers in four textile mills in
the northeastern United States that processed imported goat hair. Of
these 1,249 workers, 379 received anthrax vaccine, 414 received
placebo, 116 received incomplete inoculations of either vaccine or
placebo, and 340 received no treatment but were monitored for the
occurrence of anthrax disease as an observational group. The Brachman
study used an earlier version of the protective antigen-based anthrax
vaccine administered subcutaneously at 0, 2, and 4 weeks and 6, 12, and
18 months. During the trial, 26 cases of anthrax were reported across
the four mills: 5 inhalation and 21 cutaneous anthrax cases. Prior to
vaccination, the yearly average number of human anthrax cases was 1.2
cases per 100 employees in these mills. Of the five inhalation anthrax
cases (four of which were fatal), two received placebo and three were
in the observational group. Of the 21 cutaneous anthrax cases, 15
received placebo, 3 were in the observational group, and 3 received
anthrax vaccine. Of the three cases in the vaccine group, one case
occurred just prior to administration of the third dose, one case
occurred 13 months after the individual received the third of the six
doses (but no subsequent doses), and one case occurred prior to
receiving the fourth dose of vaccine.
In its report, the Panel stated that the Brachman study results
demonstrate ``a 93 percent (lower 95 percent confidence limit = 65
percent) protection against cutaneous anthrax'' and that ``inhalation
anthrax occurred too infrequently to assess the protective effect of
vaccine against this form of the disease'' (50 FR 51002 at 51058). On
the latter point, FDA does not agree with the Panel report. Because the
Brachman comparison of anthrax cases between the placebo and vaccine
groups included both inhalation and cutaneous cases, FDA has determined
that the calculated efficacy of the vaccine to prevent all types of
anthrax disease combined was, in fact, 92.5 percent
[[Page 260]]
(lower 95 percent confidence interval = 65 percent). The efficacy
analysis in the Brachman study includes all cases of anthrax disease
regardless of the route of exposure or manifestation of disease. FDA
agrees that the five cases of inhalation anthrax reported in the course
of the Brachman study are too few to support an independent statistical
analysis. However, of these cases, two occurred in the placebo group,
three occurred in the observational group, and no cases occurred in the
vaccine group. Therefore, the indication section of the labeling for
AVA does not specify the route of exposure, and the vaccine is
indicated for active immunization against Bacillus anthracis,
independent of the route of exposure.\4\
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\4\ The Panel noted that it would be very difficult, if not
impossible, to clinically study the efficacy of any anthrax vaccine
(50 FR 51058). Further study raises ethical considerations, and the
low incidence and sporadic occurrence of anthrax disease also makes
further adequate and well-controlled clinical studies of
effectiveness not possible.
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As stated previously in this document, the Panel also considered
epidemiological data--sometimes called surveillance data--on the
occurrence of anthrax disease in at-risk industrial settings collected
by the CDC and summarized for the years 1962-1974 as supportive of the
effectiveness of AVA. In that time period, individuals received either
vaccine produced by MDPH, now BioPort, or an earlier version of anthrax
vaccine. Twenty-seven cases of anthrax disease were identified. Three
cases were not mill employees but people who worked in or near mills;
none of these cases were vaccinated. Twenty-four cases were mill
employees; three were partially immunized (one with one dose, two with
two doses); the remainder (89 percent) were unvaccinated (50 FR 51002
at 51058). These data provide confirmation that the risk of disease
still existed for those persons who were not vaccinated and that those
persons who had not received the full vaccination series (six doses)
were susceptible to anthrax infection, while no cases occurred in those
who had received the full vaccination series.
In 1998, the Department of Defense (DoD) initiated the Anthrax
Vaccination Program, calling for mandatory vaccination of service
members. Thereafter, concerns about the vaccine caused the U.S.
Congress to direct DoD to support an independent examination of AVA by
the IOM. The IOM committee reviewed all available data, both published
and unpublished, heard from Federal agencies, the manufacturer, and
researchers. The committee in its published report concluded that AVA,
as licensed, is an effective vaccine to protect humans against anthrax
including inhalation anthrax (Ref. 2). FDA agrees with the report's
finding that studies in humans and animal models support the conclusion
that AVA is effective against B. anthracis strains that are dependent
upon the anthrax toxin as a mechanism of virulence, regardless of the
route of exposure.\5\
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\5\ For example: The Brachman study (Ref. 1); the CDC
epidemiological data described in the December 1985 proposal;
Fellows (2001) (Ref. 3); Ivins (1996) (Ref. 4); Ivins (1998) (Ref.
5).
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C. Safety of Anthrax Vaccine Adsorbed
CDC conducted an open-label study under an investigational new drug
application (IND) between 1967 and 1971 in which approximately 7,000
persons, including textile employees, laboratory workers, and other at-
risk individuals, were vaccinated with anthrax vaccine and monitored
for adverse reactions to vaccination. The vaccine was administered in
0.5 mL doses according to a 0, 2, and 4 week initial dose schedule
followed by additional doses at 6, 12, and 18 months with annual
boosters thereafter. Several lots, approximately 15,000 doses, of AVA
manufactured by MDPH were used in this study period. In its report, the
Panel found that the CDC data ``suggests that this product is fairly
well tolerated with the majority of reactions consisting of local
erythema and edema. Severe local reactions and systemic reactions are
relatively rare'' (50 FR 51002 at 51059).
Subsequent to the publication of the Panel's recommendations, DoD
conducted a small, randomized clinical study of the safety and
immunogenicity of AVA. These more recent DoD data as well as post
licensure adverse event surveillance data available from the Vaccine
Adverse Event Reporting System (VAERS) further support the safety of
AVA. These data were reviewed by FDA and provided the basis for a
description of the types and severities of adverse events associated
with administration of AVA included in labeling revisions approved by
FDA in January 2002 (Ref. 6).
D. The Panel's General Statement: Anthrax Vaccine, Adsorbed,
Description of Product
The Panel report states:
``Anthrax vaccine is an aluminum hydroxide adsorbed, protective,
proteinaceous, antigenic fraction prepared from a nonproteolytic,
nonencapsulated mutant of the Vollum strain of Bacillus anthracis'' (50
FR 51002 at 51058).
FDA would like to clarify that while the B. anthracis strain used
in the manufacture of BioPort's AVA is the nonproteolytic,
nonencapsulated strain identified in the Panel report, it is not a
mutant of the Vollum strain but was derived from a B. anthracis culture
originally isolated from a case of bovine anthrax in Florida.
E. The Panel's Specific Product Review: Anthrax Vaccine Adsorbed:
Efficacy
The Panel report states:
3. Analysis--a. Efficacy--(2) Human. The vaccine manufactured by
the Michigan Department of Public Health has not been employed in a
controlled field trial. A similar vaccine prepared by Merck Sharp &
Dohme for Fort Detrick was employed by Brachman * * * in a placebo-
controlled field trial in mills processing imported goat hair * * *.
The Michigan Department of Public Health vaccine is patterned after
that of Merck Sharp & Dohme with various minor production changes.
(50 FR 51002 at 51059).
FDA has found that contrary to the Panel's statement, the vaccine
used in the Brachman study was not manufactured by Merck Sharp & Dohme,
but instead this initial version was provided to Dr. Brachman by Dr. G.
Wright of Fort Detrick, U.S. Army, DoD (Ref. 1). The DoD version of the
anthrax vaccine used in the Brachman study was manufactured using an
aerobic culture method (Ref. 7). Subsequent to the Brachman trial, DoD
modified the vaccine's manufacturing process to, among other things,
optimize production of a stable and immunogenic formulation of vaccine
antigen and to increase the scale of manufacture. In the early 1960s,
DoD entered into a contract with Merck Sharp & Dohme to standardize the
manufacturing process for large-scale production of the anthrax vaccine
and to produce anthrax vaccine using an anaerobic method. Thereafter,
in the 1960s, DoD entered into a similar contract with MDPH to further
standardize the manufacturing process and to scale up production for
further clinical testing and immunization of persons at risk of
exposure to anthrax spores. This DoD-MDPH contract resulted in the
production of the anthrax vaccine that CDC used in the open-label
safety study and that was licensed in 1970.
While the Panel attributes the manufacture of the vaccine used in
the Brachman study to Merck Sharp & Dohme, FDA has reviewed the
historical development of AVA and concluded that DoD's continuous
involvement with, and intimate knowledge of, the formulation and
manufacturing processes of all of these versions of the anthrax vaccine
provide a foundation
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for a determination that the MDPH anthrax vaccine is comparable to the
original DoD vaccine. See Berlex Laboratories, Inc. v. FDA, 942 F.
Supp. 19 (D.D.C. 1996). The comparability of the MDPH anthrax vaccine
to the DoD vaccine has been verified through potency data that
demonstrate the ability of all three versions of the vaccine to protect
guinea pigs and rabbits against challenge with virulent B. anthracis.
In addition, there are data comparing the safety and immunogenicity of
the MDPH vaccine with the DoD vaccine. These data, while limited in the
number of vaccines and samples evaluated, reveal that the serological
responses to the MDPH vaccine and the DoD vaccine were similar with
respect to peak antibody response and seroconversion.
F. The Panel's Specific Product Review: Anthrax Vaccine Adsorbed:
Labeling
The Panel report states:
3. Analysis--d. Labeling. The labeling seems generally adequate.
There is a conflict, however, with additional standards for anthrax
vaccine. Section 620.24(a) (21 CFR 620.24(a)) defines a total
primary immunizing dose as 3 single doses of 0.5 mL. The labeling
defines primary immunization as 6 doses (0, 2, and 4 weeks plus 6,
12, and 18 months).
(50 FR 51002 at 51059).
The labeling of AVA since at least 1978 has described the
vaccination schedule as three ``primary'' doses followed by three
``booster'' doses for a total of six doses followed by annual boosters.
This labeling is not inconsistent with Sec. 620.24(a) before it was
revoked by FDA in 1996 as part of a final rule that revoked 21 CFR part
620 and other biologics regulations because they were obsolete or no
longer necessary (Ref. 8).
VI. FDA's Responses to Additional Panel Recommendations
In the December 1985 proposal, FDA responded to the Panel's general
recommendations regarding the products under review and to the
procedures involved in their manufacture and regulation. Below, FDA
responds in final to the general recommendations.
A. Generic Order and Wording of Labeling; Amendment of Sec. 201.59
The Panel recommended changes to the labeling of the biological
products under review. The Panel also recommended a generic order and
wording for information in the labeling of bacterial vaccines. FDA
agreed with the labeling changes recommended by the Panel.
In the December 1985 proposal, FDA proposed that 6 months after
publication of a final rule, manufacturers of products subject to this
Panel review submit, for FDA's review and approval, draft labeling
revised in conformance with the Panel's report and with the
regulations. FDA proposed to require that the revised labeling
accompany all products initially introduced or initially delivered for
introduction into interstate commerce 30 months after the date of
publication of the final rule. The proposed labeling review schedule
was consistent with the scheduling provided in Sec. 201.59 of the
regulations.
Since the time of the Panel's recommendation, FDA has made a number
of changes to the labeling regulations and related regulatory policies.
FDA has added or revised the requirements in Sec. 201.57 for including
in the labeling, in standardized language, the information concerning
use during pregnancy, pediatric use, and geriatric use. Section 201.57
requires a specific order and content for drug product labeling. A
number of labeling sections included in Sec. 201.57 were not included
in the Panel's recommended ordering and wording of the labeling but are
now required to help ensure clarity in the labeling. FDA has also
provided guidance regarding the wording of sections in which the agency
believes complete and consistent language is important. Because FDA
regularly monitors labeling for the products subject to this Panel
review to determine if the labeling is consistent with applicable
labeling requirements, the agency does not believe that a labeling
review is necessary at this time. Accordingly, FDA is amending the
table in Sec. 201.59 by providing that the labeling requirements in
Sec. Sec. 201.56, 201.57, and 201.100(d)(3) (21 CFR 201.100(d)(3))
become effective on the date 30 months after the date of publication of
this final rule. Because FDA regularly monitors the labeling of all
products on an ad hoc basis, FDA is also explaining in a footnote that
specification of a date for submission of revised product labeling
under Sec. 201.59 is unnecessary.
Section 314 of the National Childhood Vaccine Injury Act (NCVIA) of
1986 required FDA to review the warnings, use instructions, and
precautionary information that are distributed with each vaccine listed
in section 2114 of the Public Health Service Act and to determine
whether this information was adequate to warn health care providers of
the nature and extent of the dangers posed by such vaccine. Since the
December 1985 proposal, the agency has completed this review and
labeling has been revised accordingly. FDA is also taking this
opportunity to update the table in Sec. 201.59(a)(3) to include the
current mail codes for the review of labeling for various biological
products.
B. Periodic Review of Product Labeling
In its report the Panel noted a number of labeling deficiencies. To
improve the labeling, the Panel recommended that labeling be reviewed
and revised as necessary at intervals of no more than every 2 years.
As discussed in the December 1985 proposal, FDA believes the
current system of labeling review will adequately assure accurate
labeling. Periodic review of labeling on a set schedule is unnecessary.
Section 601.12(f) prescribes when revised labeling must be submitted,
either as a supplement for FDA's review or, if changes are minor, in an
annual report. In addition, the agency may request revision of labeling
when indicated by current scientific knowledge. FDA believes that, by
these mechanisms, product labeling is kept up to date, and a scheduled,
routine review of labeling is unnecessary and burdensome for both the
agency and manufacturers.
C. Improvement in the Reporting of Adverse Reactions
The Panel recommended that actions be taken to improve the
reporting and documentation of adverse reactions to biological
products. The Panel particularly noted the need to improve the
surveillance systems to identify adverse reactions to pertussis
vaccine.
Since publication of the Panel's report, the Vaccine Adverse Event
Reporting System (VAERS) was created as an outgrowth of the National
Childhood Vaccine Injury Act (NCVIA) and is administered by FDA and
CDC. VAERS accepts from health care providers, manufacturers, and the
public reports of adverse events that may be associated with U.S.-
licensed vaccines. Health care providers must report certain adverse
events included in a Reportable Events Table (Ref. 9) and any event
listed in the vaccine's package insert as a contraindication to
subsequent doses of the vaccine. Health care providers also may report
other clinically significant adverse events. FDA and CDC receive an
average of 800 to 1,000 reports each month under the VAERS program. A
guidance document is available which explains how to complete the VAERS
form (Ref. 10). To facilitate electronic reporting, FDA is currently
revising the reporting form.
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D. Periodic Review of Product Licenses
The Panel recommended that all licensed vaccines be periodically
reviewed to assure that data concerning the safety and effectiveness of
these products are kept current and that licenses be revoked for
products which have not been marketed for years or which have never
been marketed in the licensed form. The Panel noted that, by limiting
the period for which specific vaccines may be licensed, older products
would be assured periodic review, and new products for which additional
efficacy data are required could be provisionally licensed for a
limited time period during which additional data can be generated.
In its proposed response, FDA noted that licensing policies in
effect at the time of the review resulted in licenses being held for
some products which were never intended to be marketed as individual
products or which were no longer being marketed as individual products.
FDA had required that manufacturers licensed for a combination vaccine
also hold a license for each individual vaccine contained in the
combination. For example, a manufacturer of diphtheria, tetanus, and
pertussis (DTP) vaccine would also be required to have a license for
Diphtheria Toxoid, Tetanus Toxoid, and Pertussis Vaccines. Because this
policy is no longer in effect, most licenses are for currently marketed
products. In a few cases, there may be no current demand for a product
but, for public health reasons, a license continues to be held for the
product. There are some vaccines for which there is little current
demand but continued licensure could expedite the manufacture and
availability of the product in the event an outbreak of the targeted
disease should occur. FDA believes that the routine inspection of
licensed facilities adequately assures that the information held in
product licenses is current and that a routine review of safety and
efficacy data is unnecessary and burdensome. The Panel's recommendation
that some new vaccines be provisionally licensed for only limited
periods of time while additional data are generated is inconsistent
with the law that requires a determination that a biologic product is
safe, pure, and potent before it is licensed.
E. Compensation for Individuals Suffering Injury From Vaccination
The Panel recommended that compensation from public funds be
provided to individuals suffering injury from vaccinations that were
recommended by competent authorities, carried out with approved
vaccines, and where the injury was not a consequence of defective or
inappropriate manufacture or administration of the vaccines.
A compensation program has been implemented consistent with the
Panel's recommendation. The NCVIA established the National Vaccine
Injury Compensation Program (NVICP) designed to compensate individuals,
or families of individuals, who have been injured by childhood
vaccines, whether administered in the private or public sector. The
NVICP, administered under the Health Resources and Services
Administration, Department of Health and Human Services (DHHS), is a
no-fault alternative to the tort system for resolving claims resulting
from adverse reactions to routinely recommended childhood vaccines. The
specific vaccines and injuries covered by NVICP are identified in a
Vaccine Injury Table that may periodically be revised as new vaccines
come into use or new types of potential injuries are identified. The
NVICP has resulted in a reduction in the amount of litigation related
to injury from childhood vaccines while assuring adequate liability
coverage and protection. The NVICP applies only to vaccines routinely
recommended for infants and children. Vaccines recommended for adults
are not covered unless they are routinely recommended for children as
well, e.g., Hepatitis B Vaccine.
F. Public Support for Immunization Programs
The Panel recommended that both FDA and the public support
widespread immunization programs for tetanus, diphtheria, and
pertussis.
The National Immunization Program is part of CDC and was
established to provide leadership to health agencies in planning and
implementing immunization programs, to identify unvaccinated
populations in the United States, to assess vaccination levels in State
and local areas, and to generally promote immunization programs for
children, including vaccination against diphtheria, tetanus, and
pertussis. A recent survey shows that nearly 95 percent of children 19
to 35 months of age have received 3 or more doses of diphtheria and
tetanus toxoids (DTs) and the acellular pertussis vaccine (Ref. 11).
G. Assuring Adequate Supplies of Bacterial Vaccines and Toxoids;
Establishment of a National Vaccine Commission
The Panel recommended that FDA work closely with CDC and other
groups to assure that adequate supplies of vaccines and passive
immunization products continue to be available. The Panel recommended
establishment of a national vaccine commission to address such issues.
Since publication of the December 1985 proposal, the National
Vaccine Program was created by Congress (Public Law 99-660) with the
National Vaccine Program Office within DHHS designated to provide
leadership and coordination among Federal agencies as they work
together to carry out the goals of the National Vaccine Plan. The
National Vaccine Plan provides a framework, including goals,
objectives, and strategies, for pursuing the prevention of infectious
diseases through immunizations. The National Vaccine Program brings
together all of the groups that have key roles in immunizations, and
coordinates the vaccine-related activities, including addressing
adequate production and supply issues. Despite efforts to assure
vaccine availability, short-term shortages may occur (Ref. 12) for a
variety of reasons. FDA will continue to work with the National
Institutes of Health, CDC, and vaccine manufacturers to assure
continued vaccine availability making the establishment of a national
vaccine commission unnecessary.
H. Consistency of Efficacy Protocols
The Panel recommended that the protocols for efficacy studies be
reasonably consistent throughout the industry for any generic product.
To achieve this goal, the Panel recommended the development of industry
guidelines that provide standardized methodology for adducing required
information.
FDA believes that the standardization of clinical testing
methodology for a group of vaccines is often not practical or useful.
Because of the variety of possible vaccine types, e.g., live vaccines,
killed vaccines, toxoids, bioengineered vaccines, acellular vaccines,
and the diversity of populations in which the vaccine may be studied,
it is difficult to develop guidance that would apply to more than one
or two studies. FDA routinely meets with manufacturers before the
initiation of clinical studies to discuss the study and will comment on
proposed protocols for efficacy studies. FDA intends to continue to
allow flexibility in selecting appropriate tests, procedures, and study
populations for a clinical study while assuring that the necessary data
are generated to fulfill the intended objectives of the study.
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I. The Effect of Regulations Protecting and Informing Human Study
Subjects on the Ability to Conduct Clinical Trials
The Panel expressed concern that the regulations governing informed
consent and the protection of human subjects involved in clinical
investigations should not establish unnecessary impediments to the goal
of obtaining adequate evidence for the safety and effectiveness of a
product.
FDA believes that the regulations and policies applying to informed
consent and the protection of human subjects do not inhibit the
adequate clinical study of a product. FDA notes that whenever the
regulations or guidance documents related to these subjects are
modified or amended, FDA offers an opportunity for public comment on
the revisions. FDA particularly welcomes comments on how appropriate
informed consent and protection of human subjects can be maintained
while assuring that the development and study of useful products is not
inhibited.
J. Standards for Determining the Purity of DTs
The Panel recommended that standards should be established for
purity of both DTs in terms of limits of flocculation (Lf) content per
milligram (mg) of nitrogen.
In 1985, FDA agreed that standards should be set. FDA has since
determined that this approach is overly restrictive and does not allow
FDA to keep pace with advances in manufacturing and technology. The
Center for Biologics Evaluation and Research (CBER) establishes the
release specifications for the purity of DTs during the review of a
Biologics License Application (BLA). The purity of diphtheria toxoids
in currently licensed vaccines is usually at least 1,500 Lf/mg non-
dialyzable nitrogen. While there are no general standards for tetanus
toxoid purity in the United States, CBER has generally required a
purity specification of at least 1,000 Lf/mg of non-dialyzable nitrogen
for tetanus toxoids.
K. Immunogenic Superiority of Adsorbed Toxoids Over Fluid Toxoids
The Panel recommended that the immunogenic superiority of the
adsorbed DTs over the fluid (plain) preparations be strongly emphasized
in product labeling, especially with regard to the duration of
protection.
Tetanus Toxoid fluid, manufactured by Aventis Pasteur, Inc., is the
only fluid toxoid product that remains licensed in the United States in
2003. This product is licensed for booster use only in persons over 7
years of age. The current package insert for this product states that
``although the rates of seroconversion are essentially equivalent with
either type of tetanus toxoid, the adsorbed toxoids induce more
persistent antitoxin titers than fluid products.''
L. Laboratory Testing Systems for Determining Potency of Tetanus and
Diphtheria Toxoids
The Panel noted a need for further studies with tetanus toxoids in
a World Health Organization (WHO)-sponsored quantitative potency test
in animals to establish the conditions under which the test results are
reproducible, and to relate these results more closely to those
obtained in the immunization of humans. The Panel also recommended the
development of an animal or laboratory testing system for diphtheria
toxoid that correlates consistently, and with acceptable precision,
with primary immunogenicity in humans.
DT-containing vaccines are tested during the licensing process for
their ability to induce acceptable levels of protective antibodies in
clinical trials in the target populations. Properties of vaccines used
in these clinical trials, including potency, also are determined during
licensing. The acceptance criteria for commercial lots of these
vaccines are set at licensing on the basis of the properties of the
vaccines that induced acceptable quantitative/qualitative levels of
antibodies. The establishment of a correlation between a specific
antibody response and a given assay would require an efficacy trial
designed specifically to establish this correlation. This may call for
vaccination of humans with suboptimal doses of vaccine. Such an
efficacy study is not feasible for ethical reasons.
The animal potency tests currently required by the WHO, the
European Pharmacopoeia (EP), and FDA differ. Despite these differences,
the potency tests have been adequate to ensure sufficient immunogenic
activity of the vaccines to induce protective immunity in target
populations. However, international efforts to harmonize the diphtheria
and tetanus potency tests under development are based on immunogenicity
in animals. CBER is currently participating in these international
harmonization efforts.
M. Potency Testing of DTs for Pediatric Use
The Panel recommended that the agency require potency testing after
combination of the individual toxoid components in DTs for pediatric
use.
FDA agrees with the recommendation. All manufacturers and the FDA
testing laboratory follow this procedure on products submitted to the
agency for release.
N. Potency Requirements for Pertussis Vaccine
The Panel recommended that the regulations concerning the maximum
pertussis vaccine dose should be updated to reflect current
recommendations and practices. At the time of the Panel review, whole
cell pertussis vaccines were in use. Specifically, the Panel
recommended that pertussis vaccine have a potency of 4 protective units
per single human dose with the upper estimate of a single human dose
not to exceed 8 protective units. The Panel also recommended that the
total immunizing dose be defined as 4 doses of 4 units each, compared
to the 3 doses of 4 units each defined at the time of the
recommendation in the regulations.
FDA has removed the additional standard regulations applicable to
pertussis vaccine (61 FR 40153, August 1, 1996). As whole cell
pertussis vaccines are no longer licensed for human use in the United
States, this recommendation no longer applies to products available in
the United States.
O. Weight-Gain Test in Mice for Pertussis Vaccine
The Panel recommended that the weight-gain test in mice used to
determine toxicity of pertussis vaccines be revised to include a
reference standard and specifications regarding mouse strains to be
used.
At the time of the Panel's deliberations, only DTP vaccines
containing a whole-cell pertussis component were licensed in the United
States. The mouse weight-gain test was a toxicity test used for whole-
cell pertussis vaccines. Whole-cell pertussis vaccines are no longer
licensed in the United States for human use, thus the mouse weight-gain
test is no longer in use. Currently, only DTP vaccines containing an
acellular pertussis component (DTaP) are licensed in the United States.
These vaccines are tested specifically for residual pertussis toxin
activity.
Although not currently licensed in the United States, vaccines
containing a whole-cell pertussis component are still in use in other
countries. CBER continues to participate in international efforts to
improve the tests used to assess toxicity of whole-cell pertussis
vaccines, including the mouse weight-gain test. CBER is represented on
WHO committees and working groups with the goal of improving regulation
and testing of whole-cell pertussis vaccines.
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P. Agglutination Test to Determine Pertussis Vaccine Response in Humans
The Panel recommended that the agglutination test used to determine
pertussis vaccine response in humans be standardized and that a
reference serum be used for comparison. It also recommended that a
reference laboratory be available at FDA.
As stated previously in this document, at the time of the Panel's
deliberations, only whole-cell pertussis vaccines were licensed in the
United States. The agglutination test was used for the clinical
evaluation of DTP vaccines. Under the Panel's recommendations, FDA
(CBER) developed and distributed reference materials for the
agglutination assay and served as a reference laboratory. Currently,
only DTaP vaccines are licensed in the United States. For the clinical
evaluation of DTaP vaccines, the agglutination test was replaced by
antigen-specific immunoassays, specifically enzyme-linked immunosorbent
assays (ELISAs). As had been done with the agglutination assay, CBER
took an active role in standardization of the ELISAs used to measure
the specific antibody to the pertussis components of DTaP vaccines.
Specifically, CBER distributes reference and control materials for the
antigen-specific pertussis ELISA and has served as a reference
laboratory.
Q. Warnings in Labeling for Pertussis Vaccine
The Panel recommended that the pertussis vaccine label warn that if
shock, encephalopathic symptoms, convulsions, or thrombocytopenia
follow a vaccine injection, no additional injections with pertussis
vaccine should be given. The Panel also recommended that the label
include a cautionary statement about fever, excessive screaming, and
somnolence.
FDA agrees with the recommendation except that such information
should be included in product labeling, i.e., the package insert,
rather than the product label. Labeling applicable to the whole-cell
pertussis vaccine conformed to this recommendation. Because the
acellular form of pertussis vaccine has a different profile of
potential adverse events and contraindications, the product labeling is
worded consistent with available data.
R. Field Testing of Fractionated Pertussis Vaccines
The Panel recommended that any fractionated pertussis vaccine that
differs from the original whole cell vaccine be field tested until
better laboratory methods for evaluating immunogenicity are developed.
The Panel recommended that the field-testing include agglutination
testing and, if possible, evaluation of clinical effectiveness.
The currently approved vaccines containing an acellular pertussis
component were studied in the United States and abroad in human
populations with the antibody response being measured and clinical
effectiveness evaluated.
S. Use of Same Seed Lot Strain in Manufacturing Bacillus Calmette-
Guerin (BCG) Vaccine
The Panel recommended that all BCG vaccines be prepared from the
same seed lot strain with demonstrated efficacy, if available data
justify such action.
BCG vaccines are not recommended for routine immunization in the
United States. The two currently U.S.-licensed BCG vaccines are
produced using different seed strains. Most BCG vaccines produced
globally are manufactured using seed strains with a unique history.
Recent evidence suggests that these different BCG strains do differ
genetically and have slightly varying phenotypes. However, a meta
analysis of the current human BCG vaccination data performed in 1994 by
Harvard University concluded that no strain-to-strain differences in
protection could be detected. Although there have been differences in
immunogencity among strains demonstrated in animal models, no
significant differences have been seen in human clinical trials (Ref.
13). Thus, FDA does not find that available human data justify
requirement of a single BCG vaccine strain.
T. Development of an Improved Cholera Vaccine
The Panel recommended public support for development of an improved
cholera vaccine because unsatisfactory sanitary conditions in many
countries make it clear that control of the disease by sanitation alone
cannot be realized in the foreseeable future.
Cholera is not an endemic disease in the United States. However,
there is risk to U.S. travelers to certain countries where the disease
is endemic. FDA continues to cooperate with international health
agencies in efforts to evaluate new types of vaccines and to study the
pathogenesis of the disease. CBER personnel have chaired and
participated in the WHO Cholera Vaccine Standardization Committee and
have participated in drafting new WHO guidelines for immune measurement
of protection from cholera.
U. Plague Vaccine Immunization Schedule
The Panel recommended that the following plague vaccine
immunization schedule be considered:
1. A primary series of 3 intramuscular (IM) injections (1 mL, 0.2
mL, and 0.2 mL), 1 and 6 months apart, respectively;
2. Booster IM injections of 0.2 mL at 12, 18, and 24 months; and,
3. For persons achieving a titer of 1:128 after the third and fifth
inoculations, booster doses when the passive agglutination titer falls
below 1:32 and empirically every 2 years when the patient cannot be
tested serologically.
FDA agrees with the recommendation. The current recommendations of
the Advisory Committee on Immunization Practices (ACIP) (Ref. 14) are
consistent with the Panel's recommendation, and the currently licensed
vaccine is labeled consistent with these recommendations.
VII. FDA's Response to General Research Recommendations
In its report, the Panel identified many areas in which there
should be further investigation to improve existing products, develop
new products, develop new testing methodologies, and monitor the
population for its immune status against bacterial disease. In the
December 1985 proposal, FDA responded to these recommendations in the
responses identified as items 11, 17 (in part), 21, 25, and 27. As
discussed in the December 1985 proposal, FDA considered the Panel's
recommendations in defining its research priorities at the time the
recommendations were made. Because a considerable amount of time has
elapsed since these recommendations were made and FDA initially
responded to the recommendations, FDA is not providing specific
responses to each recommendation in this final rule. As in any area of
scientific research, new discoveries and new concerns require a
continual reevaluation of research priorities and objectives to assure
their relevance to current concerns.
FDA recognizes the Panel's desire to have FDA's research program
evolve with the significant issues and findings of medical science. In
order to assure the continued relevance of its research program, CBER's
research program for vaccines, including bacterial vaccines and related
biological products, is subject to peer review by the Panel's
successor, the Vaccines and Related Biological Products Advisory
Committee (see, for example, the
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transcripts from the meetings of June 11 (Ref. 15) and November 29,
2001 (Refs. 16 and 17), and March 6, 2002 (Ref. 18)). In addition, CBER
has defined as part of its mission statement a strategic goal of
assuring a high quality research program that contributes directly to
its regulatory mission. This goal includes a plan to assure that CBER's
research program continues to support the regulatory review of products
and timely development of regulatory policy, and to have a significant
impact on the evaluation of biological products for safety and
efficacy.
Because of limited resources, FDA also supports the leveraging of
resources to create effective collaborations in the advancement of
science. FDA has issued a ``Guidance for FDA Staff: The Leveraging
Handbook, an Agency Resource for Effective Collaborations.'' (Ref. 19).
Through cooperation with international, other Federal, and State health
care agencies and the industry and academia, the agency intends that
its research resources will reap the benefits of a wide range of
experience, expertise, and energy from the greater scientific community
while the agency maintains its legal and regulatory obligations. FDA
invites comment at any time on ways it may improve its research program
and set its objectives.
VIII. Proposed Amendment to the Regulations
In the December 1985 proposal, FDA proposed to amend Sec. 610.21
(21 CFR 610.21), limits of potency, by revising the potency
requirements for Tetanus Immune Globulin (Human) (TIG). FDA proposed to
amend the regulations to require a minimum potency of 250 units of
tetanus antitoxin per container for TIG. FDA advises that in this
discussion and in the regulation ``per container'' means that amount of
the contents of the container deliverable to the patient in normal use.
The current regulation provides for a minimum potency of 50 units of
tetanus antitoxin per milliliter of fluid. FDA proposed the change
because the concentration of antitoxin per milliliter has varied widely
in the past without any apparent effect on the performance of the
product. TIG is routinely manufactured consistently at a concentration
of 170 units per milliliter. However, there was no evidence upon which
to establish a revised minimum potency on a per milliliter basis.
Because the evidence of efficacy for TIG was based on use of product
administered consistently at doses of 250 units or larger and the
varying concentration of the product without any apparent adverse
effect, FDA found it more appropriate to regulate the potency on a per
vial basis, rather than by units per milliliter. The current licensed
product continues to be marketed at a potency no less than the minimum
dose (250 units), which historically has been shown to be clinically
effective.
FDA received no comments opposing the proposed revision to Sec.
610.21 and therefore is amending the regulations to require a minimum
potency of 250 units of tetanus antitoxin per container for TIG.
IX. Analysis of Impacts
A. Review Under Executive Order 12866, the Regulatory Flexibility Act,
and the Unfunded Mandates Reform Act of 1995
FDA has examined the impacts of the final rule under Executive
Order 12866, the Regulatory Flexibility Act (5 U.S.C 601-612), and the
Unfunded Mandates Reform Act of 1995 (Public Law 104-4). Executive
Order 12866 directs agencies to assess all costs and benefits of
available regulatory alternatives and, when regulation is necessary, to
select regulatory approaches that maximize net benefits (including
potential economic, environmental, public health and safety, and other
advantages: distributive impacts; and equity). The Regulatory
Flexibility Act requires agencies to analyze whether a rule may have a
significant economic impact on a substantial number of small entities
and, if it does, to analyze regulatory options that would minimize the
impact on small entities. The Unfunded Mandates Reform Act requires
that agencies prepare a written statement under section 202(a) of
anticipated costs and benefits before proposing any rule that may
result in an expenditure by State, local, or tribal governments, in the
aggregate, or by the private sector, of $100 million (adjusted annually
for inflation) in any one year.
The agency believes that this final rule is consistent with the
regulatory philosophy and principles identified in the Executive order.
In addition, this final rule is not a significant regulatory action as
defined by the Executive order and so is not subject to review under
the Executive order. Because this final rule does not impose new
requirements on any entity it has no associated compliance costs, and
the agency certifies that the rule will not have a significant economic
impact on a substantial number of small entities. Therefore, under the
Regulatory Flexibility Act, no further analysis is required. Because
this final rule does not impose mandates on State, local, or tribal
governments, in the aggregate, or the private sector, that will result
in an expenditure in any one year of $100 million or more, FDA is not
required to perform a cost benefit analysis under the Unfunded Mandates
Reform Act. The current inflation adjusted statutory threshold is
approximately $110 million.
B. Environmental Impact
The agency has determined under 21 CFR 25.31(h) that this action is
of a type that does not individually or cumulatively have a significant
effect on the human environment. Therefore, neither an environmental
assessment nor an environmental impact statement is required.
C. Paperwork Reduction Act of 1995
This final rule contains no collections of information. Therefore,
clearance by the Office of Management and Budget under the Paperwork
Reduction Act of 1995 is not required.
D. Federalism
FDA has analyzed this final rule in accordance with the principles
set forth in Executive Order 13132. FDA has determined that the rule
does not contain policies that have substantial direct effects on the
States, on the relationship between National Government and the States,
or on the distribution of power and responsibilities among the various
levels of government. Accordingly, the agency has concluded that the
rule does not contain policies that have federalism implications as
defined in the Executive order and, consequently, a federalism summary
impact statement is not required.
X. References
The following references have been placed on display in the
Division of Dockets Management (HFA-305), Food and Drug Administration,
5630 Fishers Lane, rm. 1061, Rockville, MD 20852, and may be seen by
interested persons between 9 a.m. and 4 p.m., Monday through Friday.
1. Brachman, P. S., H. Gold, S. Plotkin, F. R. Fekety, M.
Werrin, and N. R. Ingraham, ``Field Evaluation of a Human Anthrax
Vaccine,'' American Journal of Public Health, 52:632-645, 1962.
2. Lois M. Joellenbeck, Lee L. Zwanziger, Zane S. Durch, and
Brian L. Strom, Editors, Committee to Assess the Safety and Efficacy
of the Anthrax Vaccine, Medical Follow-Up Agency, The National
Academies Press, Washington, DC, http://www.nap.edu/catalog/10310.html.
(FDA has verified the Web site address, but we are not
responsible for subsequent changes to the Web site after this
document publishes in the Federal Register).
[[Page 266]]
3. Fellows, P. F., M. K. Linscott, B. E. Ivins, M. L. Pitt, C.
A. Rossi, P. H. Gibbs, and A. M. Friedlander, ``Efficacy of a Human
Anthrax Vaccine in Guinea Pigs, Rabbits, and Rhesus Macaques Against
Challenge by Bacillus Anthracis Isolates of Diverse Geographical
Origin,'' Vaccine, 19(23-24):3241-3247, 2001.
4. Irvins, B. E., P. F. Fellows, M. L. M. Pitt, J. E. Estep, S.
L. Welkos, P. L.Worsham & A. M. Friedlander, ``Efficacy of a
Standard Human Anthrax Vaccine Against Bacillus Anthracis Aerosol
Spore Challenge in Rhesus Monkeys,'' Salisbury Medical Bulletin
87(Suppl.):125-126, 1996.
5. Irvins, B. E., P. F. Fellows, J. W. Farchaus, B. E. Benner,
D. M. Waag, S. F. Little, G. W. Anderson, P. H. Gibbs, and A. M.
Friedlander, ``Comparative Efficacy of Experimental Anthrax Vaccine
Candidates Against Inhalation Anthrax in Rhesus Macaques,'' Vaccine,
16(11-12):1141-1148, 1998.
6. Anthrax Vaccine Adsorbed (BIOTHRAX) Package Insert (January
31, 2002).
7. Wright, G. G., et al, ``Studies on Immunity in Anthrax:
Immunizing Activity of Alum-Precipitated Protective Antigen,''
Journal of Immunology, 73:129-391, 1954.
8. 61 FR 40153, August 1, 1996.
9. ``Table of Reportable Events Following Vaccination,'' http://www.vaers.org/reportable.htm.
(FDA has verified the Web site
address, but we are not responsible for subsequent changes to the
Web site after this document publishes in the Federal Register).
10. Guidance for Industry: How to Complete the Vaccine Adverse
Reporting System Form (VAERS-1) - 9/8/1998, http://www.fda.gov/cber/gdlns/vaers-1.pdf.
(FDA has verified the Web site address, but we
are not responsible for subsequent changes to the Web site after
this document publishes in the Federal Register.)
11. ``Estimated Vaccination Coverage with Individual Vaccines
and Vaccination Series Among Children 10-35 Months of Age by Race/
Ethnicity--U.S. National Immunization Survey; Q3:2000--Q2/2001,''
http://www.cdc.gov/nip/coverage. (FDA has verified the Web site
address, but we are not responsible for subsequent changes to the
Web site after this document publishes in the Federal Register).
12. ``FDA's Role in Maintaining the Supply of Childhood
Vaccines--Testimony Before the Committee of Governmental Affairs;
June 12, 2002,'' http://www.cdc.gov/nip/news/testimonies/vac-shortages-walt-6-12-2002.htm.
(FDA has verified the Web site
address, but we are not responsible for subsequent changes to the
Web site after this document publishes in the Federal Register).
13. Colditz, et al., ``Efficacy of BCG Vaccine in the Prevention
of Tuberculosis: Meta Analysis of the Published Literature,''
Journal of the American Medical Association, 271:698-702, 1994.
14. Centers for Disease Control and Prevention, ``Prevention of
Plague: Recommendations of the Advisory Committee on Immunization
Practices (ACIP),'' Morbidity and Mortality Weekly Report, 45 (No.
RR-14), 1996.
15. http://www.fda.gov/ohrms/dockets/ac/01/transcripts/3755t1.pdf
16. http://www.fda.gov/ohrms/dockets/ac/01/transcripts/3805t2--
01.pdf
17. http://www.fda.gov/ohrms/dockets/ac/01/transcripts/3805t2_02.pdf
18. http://www.fda.gov/ohrms//dockets/ac/02/transcripts/
3842t1.pdf
19. http://www.fda.gov/cber/gdlns/leverhnbk.pdf
List of Subjects
21 CFR Part 201
Drugs, Labeling, Reporting and recordkeeping requirements.
21 CFR Part 610
Biologics, Labeling, Reporting and recordkeeping requirements.
0
Therefore, under the Federal Food, Drug, and Cosmetic Act, the Public
Health Service Act, and under authority delegated by the Commissioner
of Food and Drugs, 21 CFR parts 201 and 610 are amended as follows:
PART 201--LABELING
0
1. The authority citation for 21 CFR part 201 continues to read as
follows:
Authority: 21 U.S.C. 321, 331, 351, 352, 353, 355, 358, 360,
360b, 360gg-360ss, 371, 374, 379e; 42 U.S.C 216, 241, 262, 264.
0
2. Amend Sec. 201.59 in the table in paragraph (a)(3) to read as
follows:
a. In the BIOLOGICS section of the table, under ``Mail Routing
Code'' by removing ``HFB-240'' everywhere it appears and adding in its
place ``HFM-99'';
b. In the BIOLOGICS section of the table, under the headings
``Effective'' and ``Revised labeling due'' by revising the entries for
the drug classes ``Bacterial vaccines and toxoids with standards of
potency'' and ``Viral and rickettsial vaccines'' to read as follows;
c. In the NEW DRUG AND ANTIBIOTIC DRUGS section of the table for
the drug class ``Sulfonylurea blood glucose regulators'', under ``Mail
routing code,'' by removing ``HFN-130'' and adding in its place ``HFM-
99''.
Sec. 201.59 Effective date of Sec. Sec. 201.56, 201.57,
201.100(d)(3), and 201.100(e).
(a) * * *
(3) * * *
----------------------------------------------------------------------------------------------------------------
Effective Revised labeling due Drug class Mail routing code
----------------------------------------------------------------------------------------------------------------
Biologics
----------------------------------------------------------------------------------------------------------------
July 5, 2006 See footnote\3\ Bacterial vaccines and toxoids HFM-99
with standards of potency
* * * * * * *
Nov. 1, 1982\1\ Nov. 1, 1980\2\ Viral and rickettsial vaccines HFM-99
* * * * * * *
----------------------------------------------------------------------------------------------------------------
New Drugs and Antibiotic Drugs
----------------------------------------------------------------------------------------------------------------
* * * * * * *
Oct. 9, 1984 July 10, 1984 Sulfonylurea blood glucose HFM-99
regulators
* * * * * * *
----------------------------------------------------------------------------------------------------------------
\1\ Except the effective date for all biological products reviewed generically by the advisory panel is 30
months after a final order is published under Sec. 601.25(g) of this chapter.
\2\ Except the due date for all biological products reviewed generically by the advisory panel is 6 months after
a final order is published under Sec. 601.25(g) of this chapter.
\3\ FDA has determined that a review of product labeling under this section is unnecessary.
PART 610--GENERAL BIOLOGICAL PRODUCTS STANDARDS
0
3. The authority citation for 21 CFR part 610 continues to read as
follows:
Authority: 21 U.S.C. 321, 331, 351, 352, 353, 355, 360, 360c,
360d, 360h, 360i, 371, 372, 374, 381; 42 U.S.C. 216, 262, 263, 263a,
264.
0
4. Amend Sec. 610.21 to revise the entry ``Tetanus Immune Globulin
(Human), 50 units of tetanus antitoxin per milliliter'' under the
heading ``ANTIBODIES'' to read as follows:
Sec. 610.21 Limits of potency.
* * * * *
[[Page 267]]
ANTIBODIES
* * * * *
Tetanus Immune Globulin (Human), 250 units of tetanus antitoxin per
container.
* * * * *
Dated: December 23, 2003.
Jeffrey Shuren,
Assistant Commissioner for Policy.
[FR Doc. 03-32255 Filed 12-30-03; 3:23 pm]
BILLING CODE 4160-01-S