Consumer medicine information

Dukoral

Vibrio cholerae vaccine; Cholera toxin B subunit (recombinant)

BRAND INFORMATION

Brand name

Dukoral

Active ingredient

Vibrio cholerae vaccine; Cholera toxin B subunit (recombinant)

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Dukoral.

SUMMARY CMI

Dukoral®

Consumer Medicine Information (CMI) summary

The full CMI below has more details. If you are worried about using this medicine, speak to your doctor or pharmacist.

1. Why am I taking Dukoral®?

Dukoral® contains the active ingredients Vibrio cholerae (cholera) bacteria (inactivated) and cholera toxin B subunit (recombinant). Dukoral® is a vaccine used to help prevent cholera.
For more information, see Section 1. Why am I taking Dukoral®? in the full CMI.

2. What should I know before I take Dukoral®?

Do not use if you or your child have ever had an allergic reaction to Dukoral® or formaldehyde or any of the ingredients listed at the end of the CMI.

Talk to your doctor if you or your child have any other medical conditions, take any other medicines, or are pregnant or plan to become pregnant or are breastfeeding.

For more information, see Section 2. What should I know before I take Dukoral®? in the full CMI.

3. What if I am taking other medicines?

Some medicines may interfere with Dukoral® and affect how it works.

A list of these medicines is in Section 3. What if I am taking other medicines? in the full CMI.

4. How do I take Dukoral®?

  • Follow all directions given to you by your doctor or pharmacist carefully.
  • Avoid food and drink for 1 hour before and 1 hour after drinking the vaccine. Food and drink taken during this time may inactivate the vaccine.

More instructions can be found in Section 4. How do I take Dukoral®? in the full CMI.

5. What should I know while taking Dukoral®?

Things you or your child should do
  • Remind any doctor, dentist or pharmacist you visit that you are using Dukoral®.
  • Keep an updated record of your vaccinations.
  • Keep follow-up appointments with your doctor or clinic.
Things you or your child should not do
  • Do not have food or drink for 1 hour before and 1 hour after taking Dukoral®.
  • Do not have an oral typhoid vaccine for 8 hours after taking Dukoral®.
  • Do not have any other oral medicines for at least 1 hour before and 1 hour after taking Dukoral®.
Looking after your medicine
  • Store it in a refrigerator, between 2°C and 8°C.
  • Do not freeze. Freezing destroys the vaccine.
  • Drink within 2 hours of the vaccine dose being prepared.

For more information, see Section 5. What should I know while taking Dukoral®? in the full CMI.

6. Are there any side effects?

The most common side effects include, diarrhoea, loose stools, stomach discomfort, vomiting, nausea, headache, cough and runny or blocked nose.

Serious side effects include, severe diarrhoea, fainting, shortness of breath and allergic reactions.

For more information, including what to do if you have any side effects, see Section 6. Are there any side effects? in the full CMI.



FULL CMI

Dukoral®

Active ingredient(s): Vibrio cholerae (cholera) bacteria (inactivated), Recombinant cholera toxin B subunit.


Consumer Medicine Information (CMI)

This leaflet provides important information about using Dukoral®. You should also speak to your doctor or pharmacist if you would like further information or if you have any concerns or questions about using Dukoral®.

Where to find information in this leaflet:

1. Why am I taking Dukoral®?
2. What should I know before I take Dukoral®?
3. What if I am taking other medicines?
4. How do I take Dukoral®?
5. What should I know while taking Dukoral®?
6. Are there any side effects?
7. Product details

1. Why am I taking Dukoral®?

Dukoral® contains the active ingredient Vibrio cholerae (cholera) bacteria (inactivated) and recombinant cholera toxin B subunit. Dukoral® is a vaccine used to help prevent cholera.

Dukoral® is used to protect adults and children from two years of age who are traveling to an area where there is a risk of cholera.

Dukoral® works by causing your body to produce its own protection against cholera. It does this by making substances called antibodies in the intestine wall, which fight the cholera bacteria (Vibrio cholerae) and the cholera toxin. Cholera toxin causes diarrhoea and is produced by the cholera bacteria. If a vaccinated person comes into contact with cholera bacteria or cholera toxin, the body is usually ready to destroy it.

Your body usually takes two weeks after vaccination to develop protection against diarrhoea due to cholera.

Most people will produce enough antibodies to protect against diarrhoea due to cholera. However, as with all vaccines, 100% protection cannot be guaranteed. About 85% of people can expect to be protected against cholera in the 6 months following initial vaccination. This decreases to 52% at the end of the second year, when a booster should be given if ongoing protection is needed. If more than 2 years have passed, the primary course should be repeated.

The vaccine will not give you or your child cholera.

The chance of a severe reaction from Dukoral® is very small, but the risks from not being vaccinated against cholera may be very serious.

2. What should I know before I take Dukoral®?

Warnings

Do not take Dukoral® if:

  • you are allergic to Dukoral®, formaldehyde, or any of the ingredients listed at the end of this leaflet.
  • you have a high temperature.
  • you have symptoms such as vomiting, nausea, cramps or diarrhoea.

Always check the ingredients to make sure you can use this medicine.

Talk to your doctor or pharmacist if you are not sure whether you or your child should take Dukoral®.

Check with your doctor if you or your child:

  • have any other medical conditions, especially the following
    - a disease that weakens your immune system (e.g. HIV/AIDS)
    - low/weak immunity due to treatment with medicines such as corticosteroids, cyclosporine or other medicines used to treat autoimmune conditions or cancer (including radiation therapy)
    The vaccine may provide you with a lower level of protection than it does for people with healthy immune systems.
  • take any medicines for any other condition
  • have an infection or have been unwell. Your doctor may decide to delay vaccination until the illness has passed. A mild illness, such as a cold, is not usually a reason to delay vaccination.
  • are on a controlled sodium (low salt) diet. Dukoral® contains approximately 1,200 mg sodium per dose.
  • have allergies to any other medicines
  • have allergies to any other substances, such as foods, preservatives or dyes.

During treatment, you may be at risk of developing certain side effects. It is important you understand these risks and how to monitor for them. See additional information under Section 6. Are there any side effects?

Pregnancy and breastfeeding

Check with your doctor if you are pregnant or intend to become pregnant. Your doctor will discuss the possible risks and benefits of having Dukoral® during pregnancy.

Talk to your doctor if you are breastfeeding or intend to breastfeed. Your doctor will discuss the possible risks and benefits of having Dukoral® while you are breastfeeding.

Children

Do not give Dukoral® to a child under 2 years of age.
There is not enough information to recommend the use of Dukoral® in children under 2 years of age.

3. What if I am taking other medicines?

Tell your doctor or pharmacist if you or your child are taking any other medicines, including any medicines, vitamins or supplements that you buy without a prescription from your pharmacy, supermarket or health food shop.

Some medicines may interfere with Dukoral® and affect how it works.

Do not take any other oral medicines at the same time as Dukoral®.

Other oral medicines should not be taken for at least 1 hour before and 1 hour after you take Dukoral®.

Having other vaccines

Your doctor will tell you if you can have Dukoral® at the same time as another vaccine.

If you have to take Dukoral® and an oral typhoid vaccine, you should have the vaccines at least 8 hours apart.

Check with your doctor or pharmacist if you are not sure about what medicines, vitamins or supplements you are taking and if these affect Dukoral®.

4. How do I take Dukoral®?

How much to take

  • Follow the instructions provided to you by your doctor or pharmacist carefully. Your doctor or pharmacist will tell you how to take this vaccine.
  • Primary Course:
    Adults and children over 6 years of age:
    A total of two (2) doses:
    The second dose should be taken at least 1 week (and no more than 6 weeks) after the first dose.

    Children 2 to 6 years of age:
    A total of three (3) doses:
    Each dose should be taken at least 1 week (and no more than 6 weeks) apart.
  • Booster Dose:
    If there is an on-going risk of cholera or in the case of repeated travel an extra (booster) dose is recommended:
    Adults and children over 6 years of age:
    One (1) booster dose is recommended up to 2 years after the primary course. If more than 2 years have passed, the primary course should be repeated.

    Children 2 to 6 years of age:
    One (1) booster dose is recommended up to 6 months after the primary course. If more than 6 months have passed, the primary course should be repeated.
  • If you do not understand the instructions in this leaflet or on the box, ask your doctor or pharmacist for help.

When to take Dukoral®

For best protection against cholera the last dose of vaccine should be taken at least 2 weeks before arrival at your destination.

Each dose should be taken at least 1 week (and no more than 6 weeks) apart.

Do not take doses less than 1 week apart.

How to take Dukoral®

Please follow the instructions and diagrams below:

Avoid food and drink for 1 hour before and 1 hour after vaccination. Food and drink during this time may inactivate the vaccine.

  1. Dissolve the effervescent powder from the buffer sachet in a glass of cool water (approx. 150 mL).
This is the buffer solution.

If you are preparing the vaccine for a child 2-6 years of age: pour away (discard) half of the buffer solution leaving approximately 75 mL.
  1. Shake the vaccine vial gently (1 vial = 1 dose)

  1. Add the entire contents of the vaccine vial to the buffer solution. Mix well.

  1. The mixture should be drunk within 2 hours.

The vaccine must not be injected.

Do not use any liquid except water to make the buffer solution.

it is important to follow these instructions otherwise the vaccine will not work.

If you forget to take Dukoral®

If more than 6 weeks have passed between doses you should talk to your doctor or pharmacist. You may need to repeat the primary course.

If you are not sure what to do, ask your doctor or pharmacist.

If you take too much Dukoral®

If you think that you or anyone else may have used too much Dukoral®, you may need urgent medical attention.

You should immediately:

  • phone the Poisons Information Centre
    (by calling 13 11 26), or
  • contact your doctor, or
  • go to the Emergency Department at your nearest hospital.

You should do this even if there are no signs of discomfort or poisoning.

Urgent medical attention may be required.

As each vial of Dukoral® contains only one dose, overdosage is unlikely.

5. What should I know while taking Dukoral®?

Things you or your child should do

  • Keep an updated record of your vaccinations.
  • Keep follow-up appointments with your doctor or clinic.
    It is important to take your follow-up doses of Dukoral® at the appropriate times to make sure the vaccine has the best chance of providing protection against cholera.

Remind any doctor, dentist or pharmacist you visit that you are using Dukoral®.

Things you or your child should not do

  • Do not have food or drink for 1 hour before and 1 hour after taking Dukoral®.
    Food and drink taken during this time may inactivate the vaccine.
  • Do not have an oral typhoid vaccine for 8 hours after taking Dukoral®.
  • Do not have any other oral medicines for 1 hour after taking Dukoral®.

Things to be careful of

Dukoral® is not a sole measure of prevention against cholera. Clean hygiene practices are still required.

Looking after your medicine

Follow the instructions in the carton on how to take care of your medicine properly.

Store it in a refrigerator, between 2°C and 8°C.

Do not freeze Dukoral®.

Freezing destroys the vaccine.

Keep it where young children cannot reach it.

When to discard your medicine

Do not take Dukoral® if the packaging is torn or shows signs of tampering.

Do not take Dukoral® after the expiry date printed on the pack.

Getting rid of any unwanted medicine

If you no longer need to use this medicine or it is out of date, take it to any pharmacy for safe disposal.

Do not use this medicine after the expiry date.

6. Are there any side effects?

All medicines can have side effects. If you do experience any side effects, most of them are minor and temporary. However, some side effects may need medical attention.

See the information below and, if you need to, ask your doctor or pharmacist if you have any further questions about side effects.

Tell your doctor or pharmacist as soon as possible if you, or your child, do not feel well after having Dukoral®.

Less serious side effects

Less serious side effectsWhat to do
  • diarrhoea, loose stools, stomach symptoms such as pain, cramps, gurgling or bloating, gas or general stomach discomfort
  • headache
  • nausea, vomiting, indigestion
  • loss of appetite, dehydration
  • reduced sense of taste
  • fever, dizziness
  • difficulty sleeping or sleepiness
  • generally feeling unwell or tired
  • shortness of breath
  • flu-like symptoms such as sweating, shivering, feeling tired
  • runny or blocked nose, sneezing, cough, sore throat
  • high blood pressure
  • joint pain
  • swelling of the lymph glands
  • numbness or pins and needles
Speak to your doctor, nurse or pharmacist if you or your child have any of these less serious side effects and they worry you.

Serious side effects

Serious side effectsWhat to do
  • severe diarrhoea
  • fainting
  • shortness of breath
  • an allergic reaction: typical symptoms include rash, itching or hives on the skin, swelling of the face, lips, tongue, throat or other parts of the body.
Call your doctor straight away, or go straight to the Emergency Department at your nearest hospital if you or your child notice any of these serious side effects.

Tell your doctor or pharmacist if you notice anything else that may be making you feel unwell.

Other side effects not listed here may occur in some people.

Do not be alarmed by this list of possible side effects.
You or your child may not experience any of them.

Reporting side effects

After you have received medical advice for any side effects you experience, you can report side effects to the Therapeutic Goods Administration online at www.tga.gov.au/reporting-problems. By reporting side effects, you can help provide more information on the safety of this medicine.

Always make sure you speak to your doctor or pharmacist before you decide to stop taking any of your medicines.

7. Product details

This medicine is only available with a doctor's prescription.

What Dukoral® contains

Active ingredients
(main ingredients)
  • Bacteria from the following strains:
    - Vibrio cholerae O1 Inaba classic strain, heat inactivated
    - Vibrio cholerae O1 Inaba El Tor strain, formalin inactivated
    - Vibrio cholerae O1 Ogawa classic strain, formalin inactivated
    - Vibrio cholerae O1 Ogawa classic strain, heat inactivated
  • Recombinant cholera toxin B subunit.
Other ingredients
(inactive ingredients)
  • Sodium phosphate, monobasic dihydrate
  • Sodium phosphate, dibasic dihydrate
  • Sodium chloride
  • Water for injections.
Buffer sachet contains
  • Sodium bicarbonate
  • Citric acid, anhydrous
  • Raspberry flavour
  • Sodium carbonate - anhydrous
  • Sodium citrate
  • Saccharin sodium.
Dukoral® contains Sodium salts. Dukoral® contains approximately 1,200 mg sodium per dose.
Dukoral® does not contain lactose, sucrose, gluten, tartrazine or any other azo dyes.

Do not take this medicine if you are allergic to any of these ingredients.

What Dukoral looks like

Dukoral® is supplied as a small amount of whitish liquid in a glass vial. The vial is closed with a rubber stopper and a screw cap.

Each vial contains one dose of the vaccine.

Also supplied is one sachet of effervescent powder (buffer). The buffer is a dry powder which is white to off-white in colour.

Dukoral® may be supplied in a carton that contains:

One Dose: 1 vaccine vial and 1 sachet of buffer

Two Doses: 2 vaccine vials and 2 sachets of buffer

Aust R 94483.

Who distributes Dukoral

Seqirus Pty Ltd
ABN 26 160 735 035
63 Poplar Road
Parkville, VIC 3052
Australia

Telephone: 1800 642 865
www.seqirus.com.au

This leaflet was prepared in June 2022.

Dukoral® is a registered trademark of Valneva Sweden AB

Published by MIMS August 2022

BRAND INFORMATION

Brand name

Dukoral

Active ingredient

Vibrio cholerae vaccine; Cholera toxin B subunit (recombinant)

Schedule

S4

 

1 Name of Medicine

Vibrio cholerae.

2 Qualitative and Quantitative Composition

Dukoral is provided as a whitish oral liquid suspension (vaccine) in a single dose glass vial with white to off-white effervescent powder (buffer), in an accompanying sachet.
Each dose of vaccine suspension (3 mL) contains:

Active ingredients.

A total of 1.25 x 1011 bacteria of the following strains:
Vibrio cholerae O1 Inaba classic strain, heat inactivated ca. 31.25 x 109 bacteria*,
Vibrio cholerae O1 Inaba El Tor strain, formalin inactivated ca. 31.25 x 109 bacteria*,
Vibrio cholerae O1 Ogawa classic strain, formalin inactivated ca. 31.25 x 109 bacteria*,
Vibrio cholerae O1 Ogawa classic strain, heat inactivated ca. 31.25 x 109 bacteria*.
*Bacterial count before inactivation.
Recombinant cholera toxin B subunit 1 mg.
For the full list of excipients, see Section 6.1 List of Excipients.

3 Pharmaceutical Form

Dukoral is provided as a whitish oral liquid suspension (vaccine) in a single dose glass vial with white to off-white effervescent powder (buffer), in an accompanying sachet.
The vaccine suspension is filled to a volume of 3 mL in vials (type I glass) with a rubber stopper (bromobutyl rubber) and a screw cap.

4 Clinical Particulars

4.1 Therapeutic Indications

Dukoral is indicated for use in the prevention of cholera caused by serogroup O1 Vibrio cholerae. Dukoral can be used for active immunisation of adults and children from two years of age, who will be visiting areas epidemic or endemic for cholera and who are at high risk of infection.

4.2 Dose and Method of Administration

Dosage.

Primary immunisation consists of 2 doses for adults and children over the age of 6. Children from 2 to 6 years of age should receive 3 doses. Doses are to be administered at intervals of at least 1 week. If more than 6 weeks elapse between doses, the primary immunisation course should be re-started.

Booster dose.

For continuous protection against cholera a single booster dose is recommended within 2 years for adults and children from 6 years of age, and within 6 months for children aged 2 to below 6 years. No clinical efficacy data has been generated on repeat booster dosing. However, immunological and duration of protection data suggest that if up to 2 years have elapsed since the last vaccination for adults and children from 6 years of age, and up to 6 months for children aged 2 to below 6 years, a single booster dose should be given. If more than 2 years have elapsed since the last vaccination (more than 6 months for children aged 2 to below 6 years) the primary course should be repeated.
Satisfactory protection against cholera can be expected about two weeks after completing the primary immunisation course.
No clinical data on protective efficacy of Dukoral against cholera after administration of booster doses are available.

Administration.

The vaccine is intended for oral use. Before ingestion, the vaccine suspension should be mixed with a buffer (sodium hydrogen carbonate) solution prepared from the supplied effervescent powder.

Adults and children > 6 years of age.

Dissolve the effervescent powder in approximately 150 mL of cool water to make the buffer solution. Shake the vaccine vial gently and add the contents to the buffer solution. Mix well and drink the mixture.

Children 2 to 6 years of age.

After dissolving the effervescent powder in 150 mL of cool water, half the amount of buffer solution is poured away and the remaining part (approx. 75 mL) is mixed with the entire contents of the vaccine vial.

General considerations.

After the effervescent powder has been dissolved in water and the vaccine suspension has been added, the mixture should be drunk within 2 hours.
Food and drink should be avoided for 1 hour before and 1 hour after vaccine administration.
For administration with other oral medicinal products, see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions.
Dukoral should only be mixed with the supplied effervescent powder dissolved in water. In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.
Any unused product or waste material should be disposed of in accordance with local requirements.

4.3 Contraindications

Hypersensitivity to the active substances, to any of the excipients or to formaldehyde.
Administration of Dukoral should be postponed for subjects suffering from acute gastrointestinal illness or acute febrile illness.

4.4 Special Warnings and Precautions for Use

Identified precautions.

As with any vaccine, immunisation with Dukoral may not protect 100% of susceptible individuals. Dukoral confers protection specific to Vibrio cholerae serogroup O1. Immunisation with Dukoral does not protect against V. cholerae serogroup O139 or other species of Vibrio cholerae.
Dukoral is effective in providing protection against clinical cholera. Dukoral does not necessarily prevent the spread of cholera via a vaccinee exposed to V. cholerae bacteria.
Cholera vaccine is not a sole measure in prevention of cholera outbreaks and should be combined with good hygiene practices.
In subjects infected with HIV, limited data are available on immunogenicity and safety of Dukoral. Vaccine efficacy has not been assessed in these subjects. Immunisation of HIV infected subjects may result in transient increases of viral load. Dukoral may not induce protective antibody levels in subjects with advanced HIV disease.
The antibody response in Dukoral vaccinees with endogenous or iatrogenic immunosuppression may be insufficient.
Formaldehyde is used during the manufacturing process and trace amounts may be present in the final product. Caution should be taken in subjects with known hypersensitivity to formaldehyde.
Dukoral contains approximately 1,200 mg sodium per dose, which should be taken into consideration for patients on a controlled sodium diet.

Use in the elderly.

There are only very limited data on protective efficacy of the vaccine in subjects aged 65 years and over.

Paediatric use.

Dukoral has been administered to children between 1 and 2 years of age in safety and immunogenicity studies, but the protective efficacy has not been studied in this age group. Therefore, Dukoral is not recommended to be used in children less than 2 years of age.

Effects on laboratory tests.

No data available.

4.5 Interactions with Other Medicines and Other Forms of Interactions

Dukoral is acid labile. Food and/or drink will increase acid production in the stomach and the effect of the vaccine may be impaired. Consequently, food and drink should be avoided 1 hour before and 1 hour after vaccination. Oral administration of other medicinal products should also be avoided 1 hour before and 1 hour after administration of Dukoral.
Except for yellow fever vaccine, co-administration of Dukoral with other vaccines has not been sufficiently assessed in clinical studies. The administration of an encapsulated oral typhoid vaccine and Dukoral should be separated by at least 8 hours.
Dukoral has been administered concomitantly with yellow fever vaccine to 55 subjects. The yellow fever antibody response was similar to that seen in the 58 subjects who received the yellow fever vaccine alone. However, no results are available to evaluate the safety of concomitant administration of the two vaccines or to evaluate the immune response to Dukoral when administered with yellow fever vaccine.
No other vaccines/ medicinal products, including oral polio vaccine and antimalarials, have been given simultaneously with Dukoral in clinical studies.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

Dukoral has not been evaluated for impairment of fertility.
(Category B2)
No animal data on reproduction toxicity are available. Following careful benefit/ risk assessment the vaccine may be administered during pregnancy although no specific studies have been conducted to investigate the safety of Dukoral during pregnancy.
Following careful benefit/ risk assessment Dukoral may be administered to lactating women. It has been given to lactating women in several studies, although no specific studies have been conducted to investigate the safety of Dukoral during lactation.

4.7 Effects on Ability to Drive and Use Machines

There is no evidence of an effect on the ability to drive and use machines.

4.8 Adverse Effects (Undesirable Effects)

Adverse reactions are adverse events that were considered to be reasonably associated with the use of Dukoral based on the comprehensive assessment of the available adverse event information. A causal relationship with Dukoral cannot be reliably established in individual cases. Further, because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a vaccine cannot be directly compared to rates in the clinical trials of another vaccine and may not reflect the rates observed in clinical practice.

Clinical trial data.

The safety of Dukoral was assessed in clinical trials, including both adults and children, conducted in endemic and nonendemic countries for cholera and enterotoxigenic Escherichia coli (ETEC) producing heat labile enterotoxin (LT). Over 94,000 doses of Dukoral were administered during the clinical trials. Evaluation of safety varied between trials with respect to mode of surveillance, definition of symptoms and time of follow-up. In the majority of studies adverse events were assessed by passive surveillance. The most frequently reported adverse reactions, such as gastrointestinal symptoms including abdominal pain, diarrhoea, loose stools, nausea and vomiting, occurred at similar frequencies in vaccine and placebo groups.
Frequency classification: very common (≥ 1/10); common (≥ 1/100 to < 1/10); uncommon (≥ 1/1,000 to < 1/100); rare (≥ 1/10,000 to < 1/1,000); very rare (< 1/10,000); not known (cannot be estimated from the available data). See Table 1.

Post marketing data.

The following results were observed in a study of traveller's diarrhoea in tourists to Morocco where participants received either vaccine or killed E. coli K12 in sodium hydrogen carbonate buffer. See Table 2.
In this study other symptoms among placebo recipients included: oppressive feeling in diaphragm (N = 1), bump below chin (N = 1), itching red spots on back (N = 1), intestinal gas (N = 1), nausea (N = 1), ache in shoulder (N = 1), thirsty (N = 1), nervousness (N = 1). Other symptoms among vaccinees included: nausea (N = 4), fatigue (N = 1), sore throat (N = 1), intestinal gas (N = 2), shivers (N = 1), sense of fatigue (N = 2).

Safety surveillance.

Additional adverse reactions reported during postmarketing surveillance, are listed below. The frequency cannot be estimated from the available data.

Infections and infestations.

Gastroenteritis.

Blood and lymphatic system disorders.

Lymphadenitis.

Nervous system disorders.

Paraesthesia.

Vascular disorders.

Hypertension.

Respiratory, thoracic and mediastinal disorders.

Dyspnoea, increased sputum.

Gastrointestinal disorders.

Flatulence.

Skin and subcutaneous tissue disorders.

Urticaria, angioedema, pruritus.

General disorders and administration site conditions.

Pain, flu-like syndrome, asthenia, chills.

Reporting suspected adverse effects.

Reporting suspected adverse reactions after registration of the medicinal product is important. It allows continued monitoring of the benefit-risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions at www.tga.gov.au/reporting-problems.

4.9 Overdose

Data on overdose are limited. Adverse reactions reported following overdose have been consistent with those seen after the recommended dosing, see Section 4.8 Adverse Effects (Undesirable Effects).
For information on the management of overdose, contact the Poisons Information Centre on 13 11 26 (Australia).

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Pharmacotherapeutic group: Bacterial vaccines, ATC-code: J07AE01.
The protection against cholera is specific for biotype and serotype. O-antigens as well as toxin B subunit will induce immunity. Dukoral contains additional antigenic components in order to induce broad protection. The vaccine contains no somatic or capsular antigens from O139 serogroup Vibrio cholerae, or from non-O1, non-O139 serogroup Vibrio cholerae.
Most enterotoxigenic Escherichia coli (ETEC) strains produce an enterotoxin, which is structurally, pathophysiologically and immunologically similar to cholera toxin. The heat labile enterotoxin, designated LT, is neutralised by antibodies against cholera toxin subunit B.
Cholera infections are limited to the intestinal tract. Oral administration of Dukoral will induce local immunity.
Since the toxin B subunit is acid labile, the vaccine is mixed with a buffering sodium hydrogen carbonate solution.

Mechanism of action.

Dukoral contains killed whole V. cholerae O1 bacteria and the recombinant non-toxic B subunit of the cholera toxin (CTB). Bacterial strains of both Inaba and Ogawa serotypes and of El Tor and classical biotypes are included in the vaccine. Dukoral is taken orally with bicarbonate buffer, which protects the antigens from the gastric acid. The vaccine acts by inducing antibodies against both the bacterial components and CTB. The antibacterial intestinal antibodies prevent the bacteria from attaching to the intestinal wall thereby impeding colonisation of V. cholerae O1. The anti-toxin intestinal antibodies prevent the cholera toxin from binding to the intestinal mucosal surface thereby preventing the toxin-mediated diarrhoeal symptoms.
The heat-labile toxin (LT) of enterotoxigenic E. coli (ETEC) is structurally, functionally and immunologically similar to CTB. The two toxins cross-react immunologically.

Clinical trials.

Clinical results have revealed a protective efficacy against cholera of 85% for the first six months in all age categories although efficacy had fallen to 52% at the end of the second year and 19% at the end of the third year. Children under the age of 2 were not examined, but protective efficacy in the 2-6 year age range was satisfactory (100%) for the first six months. In this randomised, double blind, placebo controlled study in Bangladesh, 3 doses of vaccine were given, each separated by 6 weeks. Efficacy was measured 14 days after the 3rd dose. A cohort in this study received only two doses and the efficacy results were comparable with those who received three doses. The pivotal cholera efficacy studies were conducted in Bangladesh and Peru, where exposure to Vibrio cholerae prior to vaccination is likely to be greater than in Australia. See Table 3.
Protective effectiveness of Dukoral against cholera was evaluated during two mass-vaccination campaigns conducted in Mozambique (December 2003 - January 2004) and Zanzibar (February 2009 - May 2010).
In the case-control study conducted during the mass vaccination campaign in Mozambique, protective effectiveness of 2 doses of Dukoral was 84% (95% CI 43-95, per-protocol analysis; p=0.005) for the initial 5 months of follow-up. Protective effectiveness of one or more doses of the vaccine was 78% (95% CI 39-92, intention-to-vaccinate analysis; p=0.004) (Table 4).
An intention-to-vaccinate subgroup analysis was performed according to age selection and severity of cholera, where the effectiveness of the vaccine among those more than 15 years of age - an age group in which rates of HIV coinfection may be high - who have received one or more doses was 72% (95% confidence interval, 24 to 91%; p=0.03).
In the longitudinal cohort-analysis conducted during the mass-vaccination campaign in Zanzibar, protective effectiveness after 2 doses of Dukoral was 79% (95% CI, 47-92; p < 0.0001) for a follow-up period of 15 months. In addition to the direct protection, it was suggested that Dukoral provides indirect (herd) protection in the studied setting. (Table 5).

5.2 Pharmacokinetic Properties

Not applicable.

5.3 Preclinical Safety Data

Genotoxicity.

Dukoral has not been evaluated for mutagenicity.

Carcinogenicity.

Dukoral has not been evaluated for carcinogenicity.

6 Pharmaceutical Particulars

6.1 List of Excipients

Vaccine, 1 dose (3 mL) contains: sodium phosphate, monobasic dihydrate 1.95 mg; sodium phosphate, dibasic dihydrate 9.39 mg; sodium chloride 25.5 mg; water for injections to 3.0 mL.
Effervescent powder, one sachet (5.6 g) contains: sodium bicarbonate 3600 mg; citric acid, anhydrous 1450 mg; raspberry flavour 70.0 mg; sodium carbonate anhydrous 400 mg; sodium citrate 6.0 mg; saccharin sodium 30.0 mg.
See Section 2 Qualitative and Quantitative Composition.

6.2 Incompatibilities

Dukoral should only be mixed with the supplied effervescent powder dissolved in water. In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.

6.3 Shelf Life

In Australia, information on the shelf life can be found on the public summary of the Australian Register of Therapeutic Goods (ARTG). The expiry date can be found on the packaging.

6.4 Special Precautions for Storage

Store at 2° to 8°C. Refrigerate. Do not freeze.
Do not use after expiry date.
After the powder has been dissolved in water and the vaccine suspension added, the mixture should be drunk within 2 hours.

6.5 Nature and Contents of Container

Dukoral is available in the following pack sizes:

Single dose carton.

1 vaccine vial and 1 sachet of effervescent powder.

Two dose carton.

2 vaccine vials and 2 sachets of effervescent powder.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of in accordance with local requirements.

6.7 Physicochemical Properties

Chemical structure.

No data available.

CAS number.

Not applicable.

7 Medicine Schedule (Poisons Standard)

Prescription Only Medicine (S4).

Summary Table of Changes