GARDASIL 9: Package Insert and Label Information (Page 3 of 5)

14.2 Clinical Trials for GARDASIL 9

Efficacy and/or immunogenicity of the 3-dose regimen of GARDASIL 9 were assessed in six clinical trials. Study 1 evaluated the efficacy of GARDASIL 9 to prevent HPV-related cervical, vulvar, and vaginal disease using GARDASIL as a comparator.

The analysis of efficacy for GARDASIL 9 was evaluated in the per-protocol efficacy (PPE) population of 16- through 26-year-old girls and women, who received all three vaccinations within one year of enrollment, did not have major deviations from the study protocol, and were naïve to the relevant HPV type(s) by serology and PCR of cervicovaginal specimens prior to dose one and who remained PCR negative for the relevant HPV type(s) through one month post-dose 3 (Month 7). Overall, approximately 52% of subjects were negative to all vaccine HPV types by both PCR and serology at Day 1.

The primary analysis of efficacy against HPV Types 31, 33, 45, 52, and 58 is based on a combined endpoint of Cervical Intraepithelial Neoplasia (CIN) 2, CIN 3, Adenocarcinoma in situ (AIS), invasive cervical carcinoma, Vulvar Intraepithelial Neoplasia (VIN) 2/3, Vaginal Intraepithelial Neoplasia (VaIN) 2/3, vulvar cancer, or vaginal cancer. Other endpoints evaluated include cervical, vulvar and vaginal disease of any grade, persistent infection, cytological abnormalities and invasive procedures. For all endpoints, the efficacy against the HPV Types 31, 33, 45, 52 and 58 in GARDASIL 9 was evaluated compared with GARDASIL. Efficacy of GARDASIL 9 against anal lesions caused by HPV Types 31, 33, 45, 52, and 58 was not assessed due to low incidence. Effectiveness of GARDASIL 9 against anal lesions was inferred from the efficacy of GARDASIL against anal lesions caused by HPV types 6, 11, 16 and 18 in men and antibody responses elicited by GARDASIL 9 against the HPV types covered by the vaccine.

Effectiveness against disease caused by HPV Types 6, 11, 16, and 18 was assessed by comparison of geometric mean titers (GMTs) of type-specific antibodies following vaccination with GARDASIL 9 with those following vaccination with GARDASIL (Study 1 and Study 3). The effectiveness of GARDASIL 9 in girls and boys 9 through 15 years old and in boys and men 16 through 26 years old was inferred based on a comparison of type-specific antibody GMTs to those of 16 through 26-year-old girls and women following vaccination with GARDASIL 9. Immunogenicity analyses were performed in the per-protocol immunogenicity (PPI) population consisting of individuals who received all three vaccinations within pre-defined day ranges, did not have major deviations from the study protocol, met pre-defined day range for serum collection for assessment of antibody response and were naïve [PCR negative (in girls and women 16 through 26 years of age; Studies 1 and 2) and seronegative (Studies 1, 2, 3, 5, 7 and 8)] to the relevant HPV type(s) prior to dose 1 and among 16- through 26-year-old girls and women (Studies 1 and 2) remained PCR negative to the relevant HPV type(s) through Month 7. Pre-defined day ranges for vaccinations were relative to Day 1 (dose 1). For the 3-dose schedule, dose 2 was at 2 months (± 3 weeks) and dose 3 was at 6 months (± 4 weeks). For the 2-dose schedule, dose 2 was at 6 or 12 months (± 4 weeks). Pre-defined day range for serum collection for assessment of antibody response was 21 to 49 days after the last dose.

Study 1 evaluated immunogenicity of GARDASIL 9 and efficacy to prevent infection and disease caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 in 16- through 26-year-old girls and women. Study 2 evaluated immunogenicity of GARDASIL 9 in girls and boys 9 through 15 years of age and women 16 through 26 years of age. Study 3 evaluated immunogenicity of GARDASIL 9 compared with GARDASIL in girls 9 through 15 years of age. Study 4 evaluated administration of GARDASIL 9 to girls and women 12 through 26 years of age previously vaccinated with GARDASIL. Study 5 evaluated GARDASIL 9 concomitantly administered with Menactra and Adacel in girls and boys 11 through 15 years of age. Together, these five clinical trials evaluated 12,233 individuals who received GARDASIL 9 (8,048 girls and women 16 through 26 years of age at enrollment with a mean age of 21.8 years; 2,927 girls 9 through 15 years of age at enrollment with a mean age of 11.9 years; and 1,258 boys 9 through 15 years of age at enrollment with a mean age of 11.9 years. Study 7 evaluated immunogenicity of GARDASIL 9 in boys and men, including 1,106 self-identified as heterosexual men (HM) and 313 self-identified as men having sex with men (MSM), 16 through 26 years of age at enrollment (mean ages 20.8 years and 22.2 years, respectively) and 1,101 girls and women 16 through 26 years of age at enrollment (mean age 21.3 years).

The race distribution of the 16- through 26-year-old girls and women in the clinical trials was as follows: 56.8% White; 25.2% Other; 14.1% Asian; and 3.9% Black. The race distribution of the 9- through 15-year-old girls in the clinical trials was as follows: 60.3% White; 19.3% Other; 13.5% Asian; and 7.0% Black. The race distribution of the 9- through 15-year-old boys in the clinical trials was as follows: 46.6% White; 34.3% Other; 13.3% Asian; and 5.9% Black. The race distribution of the 16- through 26-year-old boys and men in the clinical trials was as follows: 62.1% White; 22.6% Other; 9.8% Asian; and 5.5% Black.

One clinical trial (Study 8) assessed the 2-dose regimen of GARDASIL 9. Study 8 evaluated the immunogenicity of 2 doses of GARDASIL 9 in girls and boys 9 through 14 years of age and 3 doses of GARDASIL 9 in girls 9 through 14 years of age and women 16 through 26 years of age; (N=1,518; 753 girls; 451 boys and 314 women). The mean age for the girls and boys 9 through 14 years of age was 11.5 years; the mean age for girls and women 16 through 26 years of age was 21.0 years. In Study 8, the race distribution was as follows: 61.1% White; 16.3% Asian; 13.3% Other; and 8.9% Black.

14.3 Efficacy – HPV Types 31, 33, 45, 52 and 58 in Girls and Women 16 through 26 Years of Age

Studies Supporting the Efficacy of GARDASIL 9 against HPV Types 31, 33, 45, 52, and 58

The efficacy of GARDASIL 9 in 16- through 26-year-old girls and women was assessed in an active comparator-controlled, double-blind, randomized clinical trial (Study 1) that included a total of 14,204 women (GARDASIL 9 = 7,099; GARDASIL = 7,105) who were enrolled and vaccinated without pre-screening for the presence of HPV infection. Subjects were followed up with a median duration of 40 months (range 0 to 64 months) after the last vaccination.

The primary efficacy evaluation was conducted in the PPE population based on a composite clinical endpoint of HPV 31-, 33-, 45-, 52-, and 58-related cervical cancer, vulvar cancer, vaginal cancer, CIN 2/3 or AIS, VIN 2/3, and VaIN 2/3. Efficacy was further evaluated with the clinical endpoints of HPV 31-, 33-, 45-, 52-, and 58-related CIN 1, vulvar and vaginal disease of any grade, and persistent infection. In addition, the study also evaluated the impact of GARDASIL 9 on the rates of HPV 31-, 33-, 45-, 52-, and 58-related abnormal Papanicolaou (Pap) tests, cervical and external genital biopsy, and definitive therapy [including loop electrosurgical excision procedure (LEEP) and conization]. Efficacy for all endpoints was measured starting after the Month 7 visit.

GARDASIL 9 prevented HPV 31-, 33-, 45-, 52-, and 58-related persistent infection and disease and also reduced the incidence of HPV 31-, 33-, 45-, 52-, and 58-related Pap test abnormalities, cervical and external genital biopsy, and definitive therapy (Table 7).

Table 7: Analysis of Efficacy of GARDASIL 9 against HPV Types 31, 33, 45, 52, and 58 in the PPE * Population of 16- through 26-Year-old Girls and Women (Study 1)
Disease Endpoint GARDASIL 9N =7099 GARDASILN =7105 GARDASIL 9 Efficacy%(95% CI)
n Number of cases n Number of cases
CI=Confidence Interval
CIN=Cervical Intraepithelial Neoplasia, VIN=Vulvar Intraepithelial Neoplasia, VaIN=Vaginal Intraepithelial Neoplasia, AIS=Adenocarcinoma In Situ , ASC-US=Atypical squamous cells of undetermined significance
HR=High Risk
*
The PPE population consisted of individuals who received all three vaccinations within one year of enrollment, did not have major deviations from the study protocol, were naïve (PCR negative and seronegative) to the relevant HPV type(s) (Types 31, 33, 45, 52, and 58) prior to dose 1, and who remained PCR negative to the relevant HPV type(s) through one month post-dose 3 (Month 7); data from Study 1 (NCT00543543).
N=Number of individuals randomized to the respective vaccination group who received at least one injection
n=Number of individuals contributing to the analysis
§
Persistent infection detected in samples from two or more consecutive visits at least six months apart
Persistent infection detected in samples from two or more consecutive visits over 12 months or longer
#
Papanicolaou test
Þ
Including loop electrosurgical excision procedure (LEEP) and conization
HPV 31-, 33-, 45-, 52-, 58-related CIN 2/3, AIS, Cervical Cancer, VIN 2/3, VaIN 2/3, Vulvar Cancer, and Vaginal Cancer 6016 1 6017 30 96.7(80.9, 99.8)
HPV 31-, 33-, 45-, 52-, 58-related CIN 1 5948 1 5943 69 98.6(92.4, 99.9)
HPV 31-, 33-, 45-, 52-, 58-related CIN 2/3 or AIS 5948 1 5943 27 96.3(79.5, 99.8)
HPV 31-, 33-, 45-, 52-, 58-related Vulvar or Vaginal Disease 6009 1 6012 16 93.8(61.5, 99.7)
HPV 31-, 33-, 45-, 52-, 58-related Persistent Infection ≥6 Months § 5939 26 5953 642 96.2(94.4, 97.5)
HPV 31-, 33-, 45-, 52-, 58-related Persistent Infection ≥12 Months 5939 15 5953 375 96.1(93.7, 97.9)
HPV 31-, 33-, 45-, 52-, 58-related ASC-US HR-HPV Positive or Worse Pap # Abnormality 5881 35 5882 462 92.6(89.7, 94.8)
HPV 31-, 33-, 45-, 52-, 58-related Biopsy 6016 7 6017 222 96.9(93.6, 98.6)
HPV 31-, 33-, 45-, 52-, 58-related Definitive Therapy Þ 6012 4 6014 32 87.5(65.7, 96.0)

14.4 Immunogenicity of a 3-Dose Regimen

The minimum anti-HPV titer that confers protective efficacy has not been determined.

Type-specific immunoassays (i.e., cLIA) with type-specific standards were used to assess immunogenicity to each vaccine HPV type. These assays measured antibodies against neutralizing epitopes for each HPV type. The scales for these assays are unique to each HPV type; thus, comparisons across types and to other assays are not appropriate. Immunogenicity was measured by (1) the percentage of individuals who were seropositive for antibodies against the relevant vaccine HPV type, and (2) the Geometric Mean Titer (GMT).

Studies Supporting the Effectiveness of GARDASIL 9 against HPV Types 6, 11, 16, and 18

Effectiveness of GARDASIL 9 against persistent infection and disease related to HPV Types 6, 11, 16, or 18 was inferred from non-inferiority comparisons in Study 1 (16- through 26-year-old girls and women) and Study 3 (9- through 15-year-old girls) of GMTs following vaccination with GARDASIL 9 with those following vaccination with GARDASIL. A low number of efficacy endpoint cases related to HPV types 6, 11, 16 and 18 in both vaccination groups precluded a meaningful assessment of efficacy using disease endpoints associated with these HPV types. The primary analyses were conducted in the per-protocol population, which included subjects who received all three vaccinations within one year of enrollment, did not have major deviations from the study protocol, and were HPV-naïve. HPV-naïve individuals were defined as seronegative to the relevant HPV type(s) prior to dose 1 and among female subjects 16 through 26 years of age in Study 1 PCR negative to the relevant HPV type(s) in cervicovaginal specimens prior to dose 1 through Month 7.

Anti-HPV 6, 11, 16 and 18 GMTs at Month 7 for GARDASIL 9 among girls 9 through 15 years of age and young women 16 through 26 years of age were non-inferior to those among the corresponding populations for GARDASIL (Table 8). At least 99.7% of individuals included in the analyses for each HPV type became seropositive by Month 7.

Table 8: Comparison of Immune Responses (Based on cLIA) Between GARDASIL 9 and GARDASIL for HPV Types 6, 11, 16, and 18 in the PPI * Population of 9- through 26-Year-Old Girls and Women (Studies 1 and 3)
Population GARDASIL 9 GARDASIL GARDASIL 9/GARDASIL
N (n ) GMTmMU §/ mL N (n ) GMTmMU §/ mL GMTRatio (95% CI)
CI=Confidence Interval
GMT=Geometric Mean Titer
cLIA=competitive Luminex Immunoassay
*
The PPI population consisted of individuals who received all three vaccinations within pre-defined day ranges, did not have major deviations from the study protocol, met predefined criteria for the interval between the Month 6 and Month 7 visit, were naïve (PCR negative [among 16- through 26-year old girls and women] and seronegative) to the relevant HPV type(s) (types 6, 11, 16, and 18) prior to dose 1, and among 16- through 26-year-old girls and women remained PCR negative to the relevant HPV type(s) through one month post-dose 3 (Month 7). The data for 16- through 26-year-old girls and women are from Study 1 (NCT00543543), and the data for 9- through 15-year-old girls are from Study 3 (NCT01304498).
N=Number of individuals randomized to the respective vaccination group who received at least one injection
n=Number of individuals contributing to the analysis
§
mMU=milli-Merck Units
Demonstration of non-inferiority required that the lower bound of the 95% CI of the GMT ratio be greater than 0.67
Anti-HPV 6
9- through 15-year-old girls 300(273) 1679.4 300(261) 1565.9 1.07 (0.93, 1.23)
16- through 26-year-old girls and women 6792(3993) 893.1 6795(3975) 875.2 1.02 (0.99, 1.06)
Anti-HPV 11
9- through 15-year-old girls 300(273) 1315.6 300(261) 1417.3 0.93 (0.80, 1.08)
16- through 26-year-old girls and women 6792(3995) 666.3 6795(3982) 830.0 0.80 (0.77, 0.83)
Anti-HPV 16
9- through 15-year-old girls 300(276) 6739.5 300(270) 6887.4 0.97 (0.85, 1.11)
16- through 26-year-old girls and women 6792(4032) 3131.1 6795(4062) 3156.6 0.99 (0.96, 1.03)
Anti-HPV 18
9- through 15-year-old girls 300(276) 1956.6 300(269) 1795.6 1.08 (0.91, 1.29)
16- through 26-year-old girls and women 6792(4539) 804.6 6795(4541) 678.7 1.19 (1.14, 1.23)

Study Supporting the Effectiveness of GARDASIL 9 against Vaccine HPV Types in 9- through 15-Year-Old Girls and Boys

Effectiveness of GARDASIL 9 against persistent infection and disease related to vaccine HPV types in 9- through 15-year-old girls and boys was inferred from non-inferiority comparison conducted in the PPI population in Study 2 of GMTs following vaccination with GARDASIL 9 among 9- through 15-year-old girls and boys with those among 16- through 26-year-old girls and women. Anti-HPV GMTs at Month 7 among 9- through 15-year-old girls and boys were non-inferior to anti-HPV GMTs among 16- through 26-year-old girls and women (Table 9).

Table 9: Comparison of Immune Responses (Based on cLIA) between the PPI * Populations of 16- through 26-Year-Old Girls and Women, 9- through 15-Year-Old Girls, and 9- through 15-Year-Old Boys for All GARDASIL 9 Vaccine HPV Types (Study 2)
Population N n GMTmMU §/mL GMT Ratio relative to 16-through 26-year-old girls and women(95% CI)
cLIA=competitive Luminex Immunoassay
CI=Confidence Interval
GMT=Geometric Mean Titer
*
The PPI population consisted of individuals who received all three vaccinations within pre-defined day ranges, did not have major deviations from the study protocol, met predefined criteria for the interval between the Month 6 and Month 7 visit, were naïve (PCR negative [among 16- through 26-year old girls and women] and seronegative) to the relevant HPV type(s) prior to dose 1 and among 16- through 26-year-old girls and women remained PCR negative to the relevant HPV types through one month post-dose 3 (Month 7). The data are from Study 2 (NCT00943722).
N=Number of individuals randomized to the respective vaccination group who received at least one injection
n=Number of individuals contributing to the analysis
§
mMU=milli-Merck Units
Demonstration of non-inferiority required that the lower bound of the 95% CI of the GMT ratio be greater than 0.67
Anti-HPV 6
9- through 15-year-old girls 630 503 1703.1 1.89 (1.68, 2.12)
9- through 15-year-old boys 641 537 2083.4 2.31 (2.06, 2.60)
16- through 26-year-old girls and women 463 328 900.8 1
Anti-HPV 11
9- through 15-year-old girls 630 503 1291.5 1.83 (1.63, 2.05)
9- through 15-year-old boys 641 537 1486.3 2.10 (1.88, 2.36)
16- through 26-year-old girls and women 463 332 706.6 1
Anti-HPV 16
9- through 15-year-old girls 630 513 6933.9 1.97 (1.75, 2.21)
9- through 15-year-old boys 641 546 8683.0 2.46 (2.20, 2.76)
16- through 26-year-old girls and women 463 329 3522.6 1
Anti-HPV 18
9- through 15-year-old girls 630 516 2148.3 2.43 (2.12, 2.79)
9- through 15-year-old boys 641 544 2855.4 3.23 (2.83, 3.70)
16- through 26-year-old girls and women 463 345 882.7 1
Anti-HPV 31
9- through 15-year-old girls 630 506 1894.7 2.51 (2.21, 2.86)
9- through 15-year-old boys 641 543 2255.3 2.99 (2.63, 3.40)
16- through 26-year-old girls and women 463 340 753.9 1
Anti-HPV 33
9- through 15-year-old girls 630 518 985.8 2.11 (1.88, 2.37)
9- through 15-year-old boys 641 544 1207.4 2.59 (2.31, 2.90)
16- through 26-year-old girls and women 463 354 466.8 1
Anti-HPV 45
9- through 15-year-old girls 630 518 707.7 2.60 (2.25, 3.00)
9- through 15-year-old boys 641 547 912.1 3.35 (2.90, 3.87)
16- through 26-year-old girls and women 463 368 272.2 1
Anti-HPV 52
9- through 15-year-old girls 630 517 962.2 2.21 (1.96, 2.49)
9- through 15-year-old boys 641 545 1055.5 2.52 (2.22, 2.84)
16- through 26-year-old girls and women 463 337 419.6 1
Anti-HPV 58
9- through 15-year-old girls 630 516 1288.0 2.18 (1.94, 2.46)
9- through 15-year-old boys 641 544 1593.3 2.70 (2.40, 3.03)
16- through 26-year-old girls and women 463 332 590.5 1

Study Supporting the Effectiveness of GARDASIL 9 against Vaccine HPV Types in 16- through 26-Year-Old Boys and Men

Effectiveness of GARDASIL 9 against persistent infection and disease related to vaccine HPV types in 16- through 26-year-old boys and men was inferred from non-inferiority comparison conducted in the PPI population in Study 7 of GMTs following vaccination with GARDASIL 9 among 16- through 26-year-old HM with those among 16- through 26-year-old girls and women. Anti-HPV GMTs at Month 7 among 16- through 26-year-old HM were non-inferior to anti-HPV GMTs among 16- through 26-year-old girls and women (Table 10). Study 7 also enrolled 313 16- through 26-year-old HIV-negative MSM. At Month 7, anti-HPV GMT ratios for MSM relative to HM ranged from 0.6 to 0.8, depending on HPV type. The GMT ratios for MSM relative to HM were generally similar to those previously observed in clinical trials with GARDASIL.

Table 10: Comparison of Immune Responses (Based on cLIA) between the PPI * Populations of 16- through 26-Year-Old Girls and Women and 16- through 26-Year-Old Boys and Men Self-Identified as Heterosexual (HM) for All GARDASIL 9 Vaccine HPV Types (Study 7)
Population N n GMTmMU §/mL GMT Ratio relative to 16- through 26-year-old girls and women(95% CI)
cLIA=competitive Luminex Immunoassay
CI=Confidence Interval
GMT=Geometric Mean Titer
*
The PPI population consisted of individuals who received all three vaccinations within pre-defined day ranges, did not have major deviations from the study protocol, met predefined criteria for the interval between the Month 6 and Month 7 visit, and were seronegative to the relevant HPV type(s) (types 6, 11, 16, 18, 31, 33, 45, 52, and 58) prior to dose 1. The data are from Study 7 (NCT01651949).
Number of individuals randomized to the respective vaccination group who received at least one injection
Number of individuals contributing to the analysis
§
mMU=milli-Merck Units
Demonstration of non-inferiority required that the lower bound of the 95% CI of the GMT ratio be greater than 0.67
Anti-HPV 6
16- through 26-year-old HM 1103 847 782.0 1.11 (1.02, 1.21)
16- through 26-year-old girls and women 1099 708 703.9 1
Anti-HPV 11
16- through 26-year-old HM 1103 851 616.7 1.09 (1.00, 1.19)
16- through 26-year-old girls and women 1099 712 564.9 1
Anti-HPV 16
16- through 26-year-old HM 1103 899 3346.0 1.20 (1.10, 1.30)
16- through 26-year-old girls and women 1099 781 2788.3 1
Anti-HPV 18
16- through 26-year-old HM 1103 906 808.2 1.19 (1.08, 1.31)
16- through 26-year-old girls and women 1099 831 679.8 1
Anti-HPV 31
16- through 26-year-old HM 1103 908 708.5 1.24 (1.13, 1.37)
16- through 26-year-old girls and women 1099 826 570.1 1
Anti-HPV 33
16- through 26-year-old HM 1103 901 384.8 1.19 (1.10, 1.30)
16- through 26-year-old girls and women 1099 853 322.0 1
Anti-HPV 45
16- through 26-year-old HM 1103 909 235.6 1.27 (1.14, 1.41)
16- through 26-year-old girls and women 1099 871 185.7 1
Anti-HPV 52
16- through 26-year-old HM 1103 907 386.8 1.15 (1.05, 1.26)
16- through 26-year-old girls and women 1099 849 335.2 1
Anti-HPV 58
16- through 26-year-old HM 1103 897 509.8 1.25 (1.14, 1.36)
16- through 26-year-old girls and women 1099 839 409.3 1

Immune Response to GARDASIL 9 across All Clinical Trials

Across all clinical trials, at least 99.5% of individuals included in the analyses for each of the nine vaccine HPV types became seropositive by Month 7. Anti-HPV GMTs at Month 7 among 9- through 15-year-old girls and boys and 16- through 26-year-old boys and men were comparable to anti-HPV responses among 16- through 26-year-old girls and women in the combined database of immunogenicity studies for GARDASIL 9.

Persistence of Immune Response to GARDASIL 9

The duration of immunity following a 3-dose schedule of vaccination with GARDASIL 9 has not been established. The peak anti-HPV GMTs for each vaccine HPV type occurred at Month 7. Proportions of individuals who remained seropositive to each vaccine HPV type at Month 24 were similar to the corresponding seropositive proportions at Month 7.

Administration of GARDASIL 9 to Individuals Previously Vaccinated with GARDASIL

Study 4 evaluated the immunogenicity of 3 doses of GARDASIL 9 in 921 girls and women (12 through 26 years of age) who had previously been vaccinated with 3 doses of GARDASIL. Prior to enrollment in the study, over 99% of subjects had received three injections of GARDASIL within a one year period. The time interval between the last injection of GARDASIL and the first injection of GARDASIL 9 ranged from approximately 12 to 36 months.

Seropositivity to HPV Types 6, 11, 16, 18, 31, 33, 45, 52, and 58 in the per protocol population ranged from 98.3 to 100% by Month 7 in individuals who received GARDASIL 9. The anti-HPV 31, 33, 45, 52 and 58 GMTs for the population previously vaccinated with GARDASIL were 25-63% of the GMTs in the combined populations from Studies 1, 2, 3, and 5, who had not previously received GARDASIL, although the clinical relevance of these differences is unknown. Efficacy of GARDASIL 9 in preventing infection and disease related to HPV Types 31, 33, 45, 52, and 58 in individuals previously vaccinated with GARDASIL has not been assessed.

Concomitant Use of Hormonal Contraceptives

Among 7,269 female recipients of GARDASIL 9 (16 through 26 years of age), 60.2% used hormonal contraceptives during the vaccination period of clinical studies 1 and 2. Use of hormonal contraceptives did not appear to affect the type specific immune responses to GARDASIL 9.

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