Merck announces availability of GARDASIL 9 HPV vaccine in Canada

Helps Protect Against Nine HPV types – Including Types that Cause About 90% of Cervical Cancer Cases

Merck (NYSE: MRK), known as MSD outside the United States and Canada, announced today that GARDASIL^®9 (Human Papillomavirus 9-valent Vaccine, Recombinant), Merck's 9-valent human papillomavirus (HPV) vaccine, is now available in Canada. GARDASIL^®9 is indicated for use in girls and women 9 to 45 years of age for the prevention of cervical, vulvar, vaginal, and anal cancers caused by HPV types 16, 18, 31, 33, 45, 52 and 58, pre-cancerous or dysplastic lesions caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58, and genital warts caused by HPV types 6 and 11. GARDASIL^®9 is also approved for use in boys and men 9 to 26 years of age for the prevention of anal cancer caused by HPV types 16, 18, 31, 33, 45, 52 and 58, precancerous or dysplastic lesions caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58, and genital warts caused by HPV types 6 and 11. GARDASIL^®9 is contraindicated in individuals with hypersensitivity, including after a previous dose of GARDASIL^®9 or GARDASIL^® [Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recombinant Vaccine].

"With GARDASIL^®9, the medical and public health community now has the potential to help prevent 90 percent of cervical cancers caused by HPV," said Chirfi Guindo, President and Managing Director Merck Canada. "This is an extraordinary opportunity to even further reduce the burden of HPV-related diseases and cancers in males and females in Canada."

"The human papillomavirus (HPV) is the most common sexually transmitted infection in Canada and worldwide. It is estimated that 75% of sexually active Canadian men and women will have at least one anogenital HPV infection in their lifetime," explained Dr. Vivien Brown, Family Doctor and Board Member of Immunize Canada. "Vaccination remains the best method to prevent HPV infection and to protect yourself from the risk of HPV-related diseases."

GARDASIL^®9 includes the greatest number of HPV types in any available HPV vaccine. After HPV types 16 and 18, the five additional HPV types in GARDASIL^®9 are the most common cervical cancer-causing types worldwide. The nine HPV types in GARDASIL^®9 (HPV 6, 11, 16, 18, 31, 33, 45, 52 and 58) cause approximately 90 percent of cervical cancer cases and approximately 75-85 percent of high-grade cervical lesions (cervical precancers, defined as CIN 2, CIN 3 and AIS) worldwide. These seven HPV types also cause 85-90 percent of HPV-related vulvar cancers, 80-85 percent of HPV-related vaginal cancers, and 90-95 percent of HPV-related anal cancers. HPV types 6 and 11 cause approximately 90 percent of genital warts cases. In addition, approximately 50-60 percent of cases of low-grade cervical lesions (CIN 1) are caused by the nine HPV types included in the vaccine.

In clinical studies, GARDASIL^®9 demonstrated high efficacy against the five additional HPV types
The clinical trial program for GARDASIL^®9 was designed to build upon the efficacy established in clinical trials with GARDASIL^® [Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recombinant Vaccine]. The initial clinical program that supported the licensure of GARDASIL^®9 began in 2007 and included six trials that evaluated more than 12,000 individuals who received GARDASIL^®9.

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. Participants were followed up with a median duration of 40 months (range 0 to 64 months) after the last vaccination. The primary comparison between GARDASIL^®9 and GARDASIL^® was clinical efficacy for the five additional HPV types. Effectiveness of GARDASIL^®9 against persistent infection and disease related to the original four HPV types (6, 11, 16, or 18) was inferred from non-inferiority comparisons. The primary efficacy analysis was conducted in those who received all three doses of vaccine within one year of enrollment, did not have major deviations from the study protocol, were negative (PCR negative and seronegative) to the relevant HPV type(s) prior to dose 1, and who remained PCR negative to the relevant HPV type(s) through Month 7 (per-protocol efficacy, or PPE, population).

The primary efficacy evaluation was based on a composite clinical endpoint of
HPV 31-, 33-, 45-, 52-, and 58-related cervical, vulvar, and vaginal cancer, and high-grade cervical/vulvar/vaginal disease [CIN 2/3 (cervical intraepithelial neoplasia 2/3) or AIS (adenocarcinoma in situ), VIN 2/3 (vulvar intraepithelial neoplasia 2/3), and VaIN 2/3 (vaginal intraepithelial neoplasia 2/3)]. Additional secondary endpoints related to HPV 31, 33, 45, 52,
and 58 were also evaluated. Efficacy for all endpoints was measured starting after the
Month 7 visit. In the PPE population, GARDASIL^®9 (Human Papillomavirus 9-valent Vaccine, Recombinant) demonstrated:

• 96.7 percent efficacy (95% CI; 80.9, 99.8) against the combined incidence of cervical, vaginal, and vulvar cancers, CIN 2/3, AIS, VIN 2/3, and VaIN 2/3 caused by HPV types 31, 33, 45, 52, 58 (1 case in the group that received GARDASIL^®9 vs. 30 cases in the group that received GARDASIL^®).
• 98.6 percent efficacy (95% CI; 92.4, 99.9) against CIN 1 caused by HPV types 31, 33, 45, 52, 58 (1 case in the group that received GARDASIL^®9 vs. 69 cases in the group that received GARDASIL^®).
• 96.3 percent efficacy (95% CI; 79.5, 99.8) against CIN 2/3 or AIS caused by HPV types 31, 33, 45, 52, 58 (1 case in the group that received GARDASIL^®9 vs. 27 cases in the group that received GARDASIL^®).
• 93.8 percent efficacy (95% CI; 61.5, 99.7) against vulvar or vaginal disease caused by HPV types 31, 33, 45, 52, 58 (1 case in the group that received GARDASIL^®9 vs. 16 cases in the group that received GARDASIL^®).
• 96.0 percent efficacy (95% CI; 94.4, 97.2) against persistent HPV infection 6 months or longer with HPV types 31, 33, 45, 52, 58 (35 cases in the group that received GARDASIL^®9 vs. 810 cases in the group that received GARDASIL^®).
• 96.3 percent efficacy (95% CI; 94.4, 97.7) against persistent HPV infection
  12 months or longer with HPV types 31, 33, 45, 52, 58 (21 cases in the group that received GARDASIL^®9 vs. 544 cases in the group that received GARDASIL^®).
• 92.6 percent efficacy (95% CI; 89.7, 94.8) against abnormal Pap tests (ASC-US HR-HPV positive or worse) caused by HPV types 31, 33, 45, 52, 58 (35 cases in the group that received GARDASIL^®9 vs. 462 cases in the group that received GARDASIL^®).
• 96.9 percent efficacy (95% CI; 93.6, 98.6) against biopsy caused by HPV types 31, 33, 45, 52, 58 (7 cases in the group that received GARDASIL^®9 vs. 222 cases in the group that received GARDASIL^®).
• 87.5 percent efficacy (95% CI; 65.7, 96.0) against definitive therapy related to HPV types 31, 33, 45, 52, 58 (4 cases in the group that received GARDASIL^®9 vs. 32 cases in the group that received GARDASIL^®).

Effectiveness of GARDASIL^®9 against persistent infection and disease related to HPV types 6, 11, 16, or 18 was inferred from non-inferiority comparisons of geometric mean titers (GMTs) in 16- through 26-year-old girls and women following vaccination with GARDASIL^®9 with those following vaccination with GARDASIL^® [Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recombinant Vaccine]. Antibody responses for HPV 6, 11, 16, and 18 (measured by GMTs and seroconversion rates at Month 7) for GARDASIL^®9 among young women 16 to 26 years of age were non-inferior to those who received GARDASIL^®. At least 99.7 percent of individuals included in the analysis for each HPV type became seropositive by Month 7.

Immunogenicity of GARDASIL^®9 (Human Papillomavirus 9-valent Vaccine, Recombinant)
Prior vaccination strategies have shown that the ideal time to administer a vaccine is before exposure to the infection. Immunogenicity studies for GARDASIL^®9 were used for the adolescent population (9- to 15-year-old girls and boys) because adolescents are not likely to have been exposed to genital HPV types. Immunogenicity studies for GARDASIL^®9 in adolescents (9- to 15-year-olds) are similar to that previously established and used in the clinical program for GARDASIL^® as a basis for licensure in this population.

Merck conducted two immunogenicity studies to support effectiveness of GARDASIL^®9 in adolescents. In Study 2, 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 of GMTs following vaccination with GARDASIL^®9 among 9- to 15-year-old girls and boys with those among 16- through 26-year-old girls and women. The primary analyses were conducted in the per-protocol population, which included individuals who received all three vaccinations within one year of enrollment, did not have major deviations from the study protocol, and were HPV-naïve (seronegative to the relevant HPV type(s) prior to dose 1 and among female subjects 16 through 26 years of age, PCR negative to the relevant HPV type(s) prior to dose 1 through Month 7). In this study, anti-HPV GMTs at Month 7 for GARDASIL^®9 among 9- through 15-year-old girls and boys were non-inferior to anti-HPV GMTs among 16- through 26-year-old women for all nine HPV types.

In Study 3, effectiveness of GARDASIL^®9 against persistent infection and disease related to HPV types 6, 11, 16, or 18 was inferred from non-inferiority comparisons of GMTs in 9- through 15-year-old girls following vaccination with GARDASIL^®9 with those following vaccination with GARDASIL^® [Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recombinant Vaccine]. In the per-protocol population, anti-HPV 6, 11, 16, and 18 GMTs at Month 7 for GARDASIL^®9 among girls 9 through 15 years of age were non-inferior to those who received GARDASIL^®. At least 99.7 percent of individuals included in the analyses for each HPV type became seropositive by Month 7.

Across all clinical trials with GARDASIL^®9, at least 99.5 percent 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 were comparable to anti-HPV responses among 16- through 26-year-old women in the combined database of immunogenicity studies for GARDASIL^®9.