1. Immunogenicity of Pentacel Theresa Finn, Ph.D. OVRR, CBER

2. 2 Overview of presentation Clinical Studies Immunogenicity: –Endpoints –Diphtheria toxoid –Tetanus toxoid –Polioviruses –Hib –Pertussis Serology bridge to DAPTACEL in Sweden I Comparison to DAPTACEL in US-children Concurrent Prevnar (Concomitant Vaccines) Summary

3. 3 Controlled Studies 494-01 (U.S.) –Pentacel compared to HCPDT (DTaP) + POLIOVAX + ActHIB (doses 1-4) P3T06 (U.S.) –Pentacel compared to DAPTACEL + IPOL + ActHIB (doses 1-3) –Pentacel compared to DAPTACEL + ActHIB (dose 4)

4. 4 Pentacel Studies which did not include a group receiving control vaccines 494-03 (U.S.) dose 1-4 5A9908 (Canada) dose 4 M5A07 (U.S.)

5. 5 Immunogenicity Population: Pentacel Studies Population for primary immunogenicity analyses: Per Protocol for Immunogenicity (PPI) Population: –Eligible subjects, blood draws and vaccines within protocol specified windows, and serology result for at least one antigen post- dose 3 or 4

6. 6 Statistical considerations Non-inferiority analyses –Previously, CBER used 90% CI for difference in sero-protection/seroconversion rates and for ratio of GMCs –Currently, CBER recommends 95% CI for difference in rates and for ratio of GMCs

7. 7 Immunogenicity of Diphtheria, Tetanus, Polio and Hib components Post dose 3 endpointAssay Diphtheria% >0.01 IU/mLVERO Tetanus% >0.1 IU/mLELISA Poliovirus types 1, 2 and 3% >1:8Neutralization assay PRP% >0.15 ug/mL % >1.0 ug/mL GMC RIA

8. Immune response to Diphtheria and Tetanus Toxoids

9. 9 Study P3T06: Diphtheria and Tetanus seroprotection rates post dose 3 EndpointPentacelDAPTACEL N = 331- 345N = 1037- 1099 Diphtheria % >0.01 IU/mL 100.0 Tetanus % >0.1 IU/mL 99.7100.0

10. Immune response to Poliovirus types 1, 2 and 3

11. 11 P3T06: Polio seroprotection rates post dose 3 PentacelIPOL N = 338-350N = 1050-1097 Polio type 1 % > 1:8 99.4100 Polio type 2 % > 1:8 100 Polio type 3 % > 1:8 100

12. Immune response to PRP-T

13. 13 Study 494-01: PRP antibody levels post-dose 3 Pentacel N = 1127 ActHIB N = 401 Non-inferiority analyses Anti-PRPActHIB - Pentacel (90% CI) 1 % >0.15 ug/mL 95.498.32.87 (1.38, 4.36) % >1.0 ug/mL 79.188.89.63 (6.36, 12.90) ActHIB/Pentacel (90% CI) 2 GMC3.196.231.95 (1.68, 2.26) 1 Non-inferiority: UL 90% CI difference <10% 2 Non-inferiority: UL 90% CI ratio <1.5

14. 14 Study P3T06: PRP antibody levels post-dose 3 Pentacel N = 365 ActHIB N = 1128 Non-inferiority analyses Anti-PRPActHIB – Pentacel (90% CI) 1 % >0.15 ug/mL92.393.30.93 (-1.67, 3.53) % >1.0 ug/mL72.170.8-1.22 (-5.68, 3.24) ActHIB/Pentacel GMC2.312.290.99 (0.84, 1.17) 2 1 Non-inferiority: UL 90% CI difference <10% 2 Non-inferiority criteria not specified in the protocol

15. 15 Study 494-01 and Study P3T06: Exploratory analysis – PRP antibody levels pre-dose 4 Anti-PRPStudy 494-01Study P3T06 PentacelActHIBPentacelActHIB* N = 829N = 276N = 335N = 323 % >0.15ug/mL (95% CI) 68.6 (65.4, 71.8) 80.8 (75.6, 85.3) 65.4 (60.0, 70.5) 60.7 (55.1, 66.0) *Study P3T06 Group 1 (DAPTACEL + ActHIB)

16. Immune response to PT, FHA, Fimbriae 2&3 and Pertactin

17. 17 Efficacy of Pertussis Component Serology bridge: –Pentacel Study 494-01 compared to DAPTACEL Sweden I Comparison to DAPTACEL in US children: –Study P3T06 Endpoints: –% >4-fold rise relative to pre-dose 1 antibody levels –GMC

18. 18 Sweden I Efficacy Trial –March 1992-January 1995 –~ 2500 infants administered DAPTACEL at 2, 4 and 6 months of age –Compared to DT control vaccine efficacy of three doses of DAPTACEL against WHO defined pertussis (> 21 days cough with culture/serologic confirmation/epi link 84.9% (95% CI 80.1, 88.6)

19. 19 Basis for DAPTACEL efficacy in U.S. Serology bridge post-dose 3 DAPTACEL in US children to post-dose 3 Sweden I: –pertactin seroconversion rates and GMCs significantly lower in US infants –response to PT, FHA and FIM similar in US and Swedish infants Serology bridge post-dose 4 DAPTACEL in Canada to post-dose 3 Sweden I: –post-dose 4 GMCs were at least as high as those of Swedish infants

20. 20 Serology bridge: Non-inferiority of GMCs Antigen Post dose 3 DAPTACEL Sweden I GMC (EU/mL) Post dose 4 Pentacel Study 494-01 GMC (EU/mL) Non-inferiority DAPTACEL/Pentacel (90% CI) 1 N = 80N = 553-554 PT87.50195.100.45 (0.38, 0.53) FHA40.70129.850.31 (0.27, 0.36) FIM339.31506.570.67 (0.54, 0.82) PRN111.2690.821.23 (1.01, 1.49) 1 Non-inferiority: UL 90% CI ratio <1.5

21. 21 Serology bridge: Non-inferiority of seroconversion rates Antigen Post dose 3 DAPTACEL Sweden I % ≥4-fold rise 1 Post dose 4 Pentacel Study 494-01 % ≥4-fold rise 2 Non-Inferiority DAPTACEL - Pentacel % (95% CI) 3 N = 80N = 507-508 PT86.394.9-8.63 (-16.42, -0.85) FHA68.891.7-22.97 (-33.40, -12.53) FIM86.391.5-5.27 (-13.20, 2.66) PRN98.889.29.60 (5.96, 13.24) 1 Post dose 3/pre-dose 1, 2 Post dose 4/pre-dose 1, 3 Non-inferiority: UL 95% CI <10%

22. 22 Serology bridge: CBER Exploratory Analyses - Seroconversion rates post-dose 3 Antigen Post dose 3 DAPTACEL Sweden I % ≥ 4 fold rise Post dose 3 Pentacel Study 494-01 % ≥4 fold rise Difference DAPTACEL – Pentacel % (95% CI)* N = 80N = 650-652** PT86.389.7-3.44 (-12.89, 3.04) FHA68.879.8-11.0 (-22.23, -1.32) FIM86.386.5-0.23 (-9.75, 6.38) Pertactin98.874.424.36 (18.44, 28.20) *CBER generated 95% CI (STAT EXACT) **Subjects in Study 494-01 had 3 concurrently administered doses of Prevnar with Pentacel

23. 23 Serology bridge: CBER Exploratory Analysis - GMCs post-dose 3 Antigen Post dose 3 DAPTACEL Sweden I EU/mL Post dose 3 Pentacel Study 494-01 EU/mL Ratio DAPTACEL/Pentacel (90% CI)* N = 80N =730-731 PT87.50 93.380.94 (0.80, 1.09) FHA40.7071.460.57 (0.50, 0.65) FIM339.31265.021.28 (1.04, 1.58) Pertactin111.2638.112.92 (2.50, 3.40) *CBER generated 90% CI (STAT EXACT) **Subjects in Study 494-01 had 3 concurrently administered doses of Prevnar with Pentacel

24. Comparison to DAPTACEL in Study P3T06

25. 25 Comparison to DAPTACEL, Study P3T06: Non-inferiority of seroconversion rates post dose 3 Antigen Post dose 3 DAPTACEL % ≥ 4-fold rise 1 Post dose 3 Pentacel % ≥ 4-fold rise 1 Non-inferiority DAPTACEL - Pentacel %(90% CI) 2 N = 712-724N = 218-221 PT86.193.6-7.51 (-10.97, -4.06) FHA60.981.9-20.99 (-26.19, -15.79) FIM86.391.7-5.47 (-9.19, -1.74) PRN75.474.21.21 (-4.31, 6.73) 1 Post-dose3/pre-dose1 2 Non-inferiority: UL 90% CI difference <10%

26. 26 Comparison to DAPTACEL, Study P3T06: Non-inferiority of GMCs post-dose 3 Antigen Post dose 3 DAPTACEL GMC (EU/mL) Post dose 3 Pentacel GMC (EU/mL) Non-inferiority DAPTACEL/Pentacel (90% CI) 1 N = 1015-1016N = 318 PT63.8289.980.71 (0.66, 0.76) FHA29.2273.680.40 (0.37, 0.43) FIM267.18268.151.00 (0.91, 1.09) PRN43.2536.051.20 (1.08, 1.33) 1 Non-inferiority is demonstrated when UL 90% CI ratio <1.5

27. 27 Comparison to DAPTACEL, Study P3T06: Non-inferiority of seroconversion rates post-dose 4 Antigen Post dose 4 DAPTACEL % ≥ 4-fold rise 1 Post dose 4 Pentacel % ≥ 4-fold rise 1 Non-inferiority DAPTACEL - Pentacel (90% CI) 2 N=237-242N = 230-232 PT97.197.4-0.34 (-2.84, 2.15) FHA79.388.4-9.02 (-14.53, -3.52) FIM91.693.5-1.92 (-5.92, 2.08) PRN98.392.75.67 (2.55, 8.79) 1 Post-dose4/pre-dose1 2 Non-inferiority is demonstrated when UL 90% CI difference <10%

28. 28 Comparison to DAPTACEL, Study P3T06 : Non-inferiority of GMCs post-dose 4 Pertussis Antigen Post dose 4 DAPTACEL GMC (EU/mL) Post dose 4 Pentacel GMC (EU/mL) Non-inferiority DAPTACEL/Pentacel (90% CI) 1 N = 345-347N = 366-367 PT168.48174.030.97 (0.87, 1.08) FHA64.02107.940.59 (0.54, 0.66) FIM513.54553.390.93 (0.81, 1.06) PRN186.0793.591.99 (1.76, 2.25) 1 Non-inferiority is demonstrated when UL 90% CI ratio <1.5

29. 29 Effect of Prevnar Study 494-01 exploratory analyses Post-dose 4 across pivotal studies

30. 30 Effect of Prevnar: Pertussis GMCs following four doses of Pentacel in pivotal studies # of concurrent Prevnar doses: 5A9908494-01P3T06494-03 N=191N = 853-854N = 366-367 Group 1 N = 203 Group 3 N = 202 at 2, 4 and 6 months 00-3333 at 15 months 00001 PT (EU/mL) 249.85202.18174.03161.87138.83 FHA (EU/mL) 172.42134.59107.94134.47128.12 FIM (EU/mL) 833.37514.19553.39434.35324.96 Pertactin (EU/mL) 187.5294.9193.5976.4469.63

31. 31 Effect of Prevnar Study M5A07 –Pentacel + Prevnar at 2, 4, 6, 15 months of age –Pentacel at 2, 4, 6 and 15 months of age, Prevnar at 3, 5, 7 and 12 months of age –Summary post-dose 3 data in BLA

32. 32 Effect of Prevnar, Study M5A07: Non-inferiority of seroconversion rates post-dose 3 Antigen Pentacel + Prevnar % ≥ 4-fold rise 1 Pentacel staggered Prevnar % ≥ 4-fold rise 1 Non-inferiority Group 2 - Group 1 % (95% CI) 2 N = 422-445N = 436-438 PT89.790.40.73 (-3.23, 4.68) FHA81.681.90.25 (-4.86, 5.36) FIM87.687.70.11 (-4.24, 4.47) PRN73.671.7-1.96 (-7.84, 3.92) 1 The fold rise Post-Dose 3/Pre-Dose 1 antibody level (EU/mL). ²Non-inferiority: UL 95% CI <10%

33. 33 Effect of Prevnar, Study M5A07: Non-inferiority of GMCs post-dose 3 Antigen Pentacel + Prevnar GMC (EU/mL) Pentacel staggered Prevnar GMC (EU/mL) Non-Inferiority Group 2/Group 1 (90% CI) 1 N = 446-447N = 439 PT103.58102.780.99 (0.93, 1.06) FHA82.4177.800.94 (0.87, 1.02) FIM272.47280.971.03 (0.93, 1.14) PRN45.7044.280.97 (0.86, 1.09) 1 Non-inferiority: UL 90% CI ratio is <1.5.

34. 34 Response to concomitantly administered vaccines Hepatitis B –% >10mIU/mL and GMC similar when given with Pentacel or Control vaccines Prevnar –Post dose 3: % >0.15 ug/mL, >0.5ug/mL and GMC similar when given with Pentacel or Control vaccines –Post-dose 4: Non-inferiority demonstrated (% >0.15 ug/mL, >0.5 ug/mL and GMC) when given with Pentacel or MMR + Varivax (Study 494-03) MMR Varicella Non-inferiority demonstrated for seroresponse rates

35. 35 Summary Pentacel immunogenicity concerns: PRP-T PRP-T component: –Study 494-01: diminished % >1.0 ug/mL vs. ActHIB diminished GMC vs. ActHIB –Study P3T06: similar % >1.0 ug/mL vs. ActHIB similar GMC vs. ActHIB

36. 36 Summary Pentacel immunogenicity concerns: Pertussis antigens Post dose 3: – Serology bridge to Sweden I (exploratory): diminished anti-FIM (GMC), diminished anti-pertactin (4x rise and GMC) Post dose 4: –Serology bridge to Sweden I: diminished anti-pertactin (4x rise) –Study P3T06: diminished anti-pertactin (GMC)

37. 37 Questions and Discussion Items 1.Are the available data adequate to support the safety of four doses of Pentacel administered at 2, 4, 6 and 15-18 months of age? (Voting Item) If the available data are not adequate, what additional data are needed?

38. 38 Questions and Discussion Items cont’d. 2.Please discuss whether the available data are adequate to support the efficacy of: a) The diphtheria, tetanus and polio components of Pentacel, b) The Hib (PRP-T) component of Pentacel, and c) The pertussis component of Pentacel. Are the available data adequate to support the efficacy of Pentacel? (Voting Item) If the available data are not adequate, what additional data are needed?

39. 39 Questions and Discussion Items cont’d. 3.If Pentacel is licensed, please identify any issues which should be addressed in post-licensure studies.