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Clinical Trial Details — Status: Completed

Administrative data

NCT number NCT00226499
Other study ID # 100388
Secondary ID 104105 (EXT FU Y
Status Completed
Phase Phase 3
First received
Last updated
Start date September 1, 2005
Est. completion date October 12, 2006

Study information

Verified date August 2019
Source GlaxoSmithKline
Contact n/a
Is FDA regulated No
Health authority
Study type Interventional

Clinical Trial Summary

An observer-blind study to evaluate GlaxoSmithKline Biologicals' live attenuated varicella vaccine and GlaxoSmithKline Biologicals' combined measles-mumps-rubella-varicella vaccine in the prevention of varicella disease in children. The Protocol Posting has been updated in order to comply with the FDA Amendment Act, Sep 2007.


Description:

According to treatment group allocation, participants will receive study vaccines and be followed for antibody titres and occurrence of varicella disease.

This study is conducted in 2 phases. Phase A includes the vaccination period and an observation period for efficacy. The efficacy endpoints will be evaluated over at least two years after vaccination. During this period, the immunogenicity endpoints will be evaluated with respect to the immune response 43 days after vaccination and the persistence of antibodies over two years to varicella (for all subjects) and to measles, mumps and rubella (for a subset of subjects). Regarding the safety endpoints, SAEs (including any complicated varicella cases if observed) will be assessed for all subjects during the whole Phase A duration, whereas, solicited (local and general) and unsolicited adverse events will be assessed in a subset of subjects within a 43-day period after vaccination.

Phase B is an extension of Phase A. It is a long-term follow-up until Year 10 to examine the long-term efficacy of the study vaccines against clinical varicella disease as well as the long-term persistence of antibodies to varicella (for all subjects) and to measles, mumps and rubella (in a subset of subjects) after vaccination.


Recruitment information / eligibility

Status Completed
Enrollment 5803
Est. completion date October 12, 2006
Est. primary completion date October 12, 2006
Accepts healthy volunteers Accepts Healthy Volunteers
Gender All
Age group 11 Months to 22 Months
Eligibility Inclusion criteria:

- Subjects for whom the investigator believes that their parents/guardians can and will comply with the requirements of the protocol for the whole duration of the study.

- Male or female subject between 12 and 22 months of age at the time of the first vaccination.

- Subjects free of obvious health problems, as established by medical history and physical examination before entering the study.

- Written informed consent obtained from the parents/guardians of the subject after they have been informed on the risks and benefits of the study, in a language they clearly understand and before performance of any study procedure.

- Subjects whose parents/guardians have direct access to telephone/mobile phone.

- Subjects:

1. with at least one sibling (with negative history of varicella disease/vaccination) at home, or

2. attending day care center, or

3. attending childminders, i.e. someone taking care of several children, or

4. who are in contact for at least once a week with other children without a known positive history of varicella disease/vaccination, while playing in close physical contact for more than 5 minutes.

Exclusion criteria:

- Previous vaccination against measles, mumps, rubella and/or varicella.

- History of previous measles, mumps, rubella and/or varicella/ herpes zoster diseases.

- Known exposure to measles, mumps, rubella and/or varicella/herpes zoster within 30 days prior to the start of the study.

- Chronic administration (defined as more than 14 days) of immunosuppressants or other immune-modifying drugs within six months prior to the first vaccine dose.

- Administration of immunoglobulins and/or any blood products within three months prior to the first vaccine dose or planned administration during the study period.

- Any confirmed or suspected immunosuppressive or immunodeficient condition, based on medical history and physical.

- Family history of congenital or hereditary immunodeficiency.

- History of allergic diseases or reactions likely to be exacerbated by any component of the vaccines, including systemic allergy to egg proteins or neomycin.

- Major congenital defects or serious chronic illness.

- Residence in the same household as newborns (0-4 weeks of age), pregnant women who are varicella-susceptible, persons with a known immunodeficiency or any other persons at high risk for varicella.

- History of any neurologic disorders or seizures.

- Use of any investigational or non-registered product (drug/vaccine other than the study vaccines) within 14 days prior to vaccination and planned use during the study period.

Additional exclusion criteria for subjects included in the subset:

- Administration of a licensed vaccine within 14 days prior to vaccination and planned use until approximately 42 days after the last study vaccine dose (Day 84) with the exception of oral polio vaccine (OPV).

Study Design


Intervention

Biological:
Priorix-tetra™
2 doses administered subcutaneously, one at Day 0 and the other at Day 42 to subjects in MMRV Group
Priorix™
2 doses administered subcutaneously, one at Day 0 and the other at Day 42 to subjects in MMR Group and one dose administered subcutaneously at Day 0 to subjects in OKAH Group
Varilrix™
1 dose administered subcutaneously at Day 42 to subjects in OKAH Group

Locations

Country Name City State
Czechia GSK Investigational Site Brno
Czechia GSK Investigational Site Chomutov
Czechia GSK Investigational Site Decin
Czechia GSK Investigational Site Havlickuv Brod
Czechia GSK Investigational Site Hradec Kralove
Czechia GSK Investigational Site Humpolec
Czechia GSK Investigational Site Jindrichuv Hradec
Czechia GSK Investigational Site Kolin
Czechia GSK Investigational Site Liberec
Czechia GSK Investigational Site Moravska Ostrava
Czechia GSK Investigational Site Nachod
Czechia GSK Investigational Site Ostrava
Czechia GSK Investigational Site Pardubice
Czechia GSK Investigational Site Plzen
Czechia GSK Investigational Site Praha 4
Czechia GSK Investigational Site Praha 4
Czechia GSK Investigational Site Praha 5
Czechia GSK Investigational Site Praha 6
Czechia GSK Investigational Site Praha 9
Czechia GSK Investigational Site Znojmo
Greece GSK Investigational Site Arta
Greece GSK Investigational Site Athens
Greece GSK Investigational Site Athens
Greece GSK Investigational Site Athens
Greece GSK Investigational Site Giannitsa
Greece GSK Investigational Site Karditsa
Greece GSK Investigational Site Komotini
Greece GSK Investigational Site Ptolemaida
Greece GSK Investigational Site Thessaloniki
Greece GSK Investigational Site Tripolis
Greece GSK Investigational Site Veria
Italy GSK Investigational Site Alghero (SS) Sardegna
Italy GSK Investigational Site Ferrara Emilia-Romagna
Italy GSK Investigational Site Firenze Toscana
Italy GSK Investigational Site Genova Liguria
Italy GSK Investigational Site Milano Lombardia
Italy GSK Investigational Site Novara Piemonte
Italy GSK Investigational Site Ozieri (SS) Sardegna
Italy GSK Investigational Site Quarto (NA) Campania
Italy GSK Investigational Site Udine Friuli-Venezia-Giulia
Lithuania GSK Investigational Site Alytus
Lithuania GSK Investigational Site Kaunas
Lithuania GSK Investigational Site Klaipeda
Lithuania GSK Investigational Site Panevezys
Lithuania GSK Investigational Site Siauliai
Lithuania GSK Investigational Site Vilnius
Lithuania GSK Investigational Site Vilnius
Lithuania GSK Investigational Site Vilnius
Norway GSK Investigational Site Bekkestua
Norway GSK Investigational Site Moelv
Norway GSK Investigational Site Paradis
Norway GSK Investigational Site Skien
Norway GSK Investigational Site Trondheim
Poland GSK Investigational Site Bydgoszcz
Poland GSK Investigational Site Debica
Poland GSK Investigational Site Krakow
Poland GSK Investigational Site Olesnica
Poland GSK Investigational Site Poznan
Poland GSK Investigational Site Siemianowice Slaskie
Poland GSK Investigational Site Tarnow
Poland GSK Investigational Site Trzebnica
Poland GSK Investigational Site Wesola
Poland GSK Investigational Site Wroclaw
Romania GSK Investigational Site Brasov
Romania GSK Investigational Site Bucharest
Romania GSK Investigational Site Bucharest
Romania GSK Investigational Site Bucharest
Romania GSK Investigational Site Bucharest
Romania GSK Investigational Site Cluj-Napoca
Romania GSK Investigational Site Constanta
Romania GSK Investigational Site Sibiu
Romania GSK Investigational Site Timisoara
Russian Federation GSK Investigational Site Ekaterinburg
Russian Federation GSK Investigational Site Ekaterinburg
Russian Federation GSK Investigational Site Ivanteevka Moscow Region
Russian Federation GSK Investigational Site Moscow
Russian Federation GSK Investigational Site Moscow
Russian Federation GSK Investigational Site Moscow
Russian Federation GSK Investigational Site Murmansk
Russian Federation GSK Investigational Site Novokuznetsk
Russian Federation GSK Investigational Site Novosibirsk
Russian Federation GSK Investigational Site Samara
Russian Federation GSK Investigational Site Sankt-Peterburg
Russian Federation GSK Investigational Site Saratov
Russian Federation GSK Investigational Site Tomsk
Russian Federation GSK Investigational Site Volgograd
Slovakia GSK Investigational Site Bratislava
Slovakia GSK Investigational Site Bratislava
Slovakia GSK Investigational Site Dlha nad Oravou
Slovakia GSK Investigational Site Dolny Kubin
Slovakia GSK Investigational Site Dubnica Nad Vahom
Slovakia GSK Investigational Site Nova Dubnica
Slovakia GSK Investigational Site Nove Mesto nad Vahom
Slovakia GSK Investigational Site Nove Zamky
Slovakia GSK Investigational Site Puchov
Slovakia GSK Investigational Site Ruzomberok
Slovakia GSK Investigational Site Sturovo
Slovakia GSK Investigational Site Surany
Slovakia GSK Investigational Site Trencin
Sweden GSK Investigational Site Linköping
Sweden GSK Investigational Site Malmö
Sweden GSK Investigational Site Norrköping
Sweden GSK Investigational Site Örebro
Sweden GSK Investigational Site Umeå

Sponsors (1)

Lead Sponsor Collaborator
GlaxoSmithKline

Countries where clinical trial is conducted

Czechia,  Greece,  Italy,  Lithuania,  Norway,  Poland,  Romania,  Russian Federation,  Slovakia,  Sweden, 

References & Publications (3)

Carryn S, Feyssaguet M, Povey M, Di Paolo E. Long-term immunogenicity of measles, mumps and rubella-containing vaccines in healthy young children: A 10-year follow-up. Vaccine. 2019 Aug 23;37(36):5323-5331. doi: 10.1016/j.vaccine.2019.07.049. Epub 2019 Jul 22. — View Citation

Henry O, Brzostek J, Czajka H, Leviniene G, Reshetko O, Gasparini R, Pazdiora P, Plesca D, Desole MG, Kevalas R, Gabutti G, Povey M, Innis B. One or two doses of live varicella virus-containing vaccines: Efficacy, persistence of immune responses, and safety six years after administration in healthy children during their second year of life. Vaccine. 2018 Jan 8;36(3):381-387. doi: 10.1016/j.vaccine.2017.11.081. Epub 2017 Dec 7. Erratum in: Vaccine. 2018 Oct 29;36(45):6894. — View Citation

Prymula R, Bergsaker MR, Esposito S, Gothefors L, Man S, Snegova N, Stefkovicova M, Usonis V, Wysocki J, Douha M, Vassilev V, Nicholson O, Innis BL, Willems P. Protection against varicella with two doses of combined measles-mumps-rubella-varicella vaccine versus one dose of monovalent varicella vaccine: a multicentre, observer-blind, randomised, controlled trial. Lancet. 2014 Apr 12;383(9925):1313-24. doi: 10.1016/S0140-6736(12)61461-5. Epub 2014 Jan 29. — View Citation

Outcome

Type Measure Description Time frame Safety issue
Primary Phase A: Number of Subjects With Confirmed Varicella Case Confirmed varicella case = A case that met the clinical case definition [an illness with acute onset of diffuse, generalized maculopapulovesicular rash (i.e. spots, papules and/or vesicles) without other apparent cause] at least in the opinion of the investigator and was confirmed by laboratory test [Polymerase Chain Reaction (PCR) (+)] OR a case that met the clinical definition confirmed by the Independent Data Monitoring Committee (IDMC) and was epidemiologically linked [Epi (+)] to a valid index case. From 42 days post dose 2 until the end of Phase A
Secondary Phase A: Number of Subjects With Moderate or Severe Confirmed Varicella Case Confirmed varicella case: A case that met the clinical case definition at least in the opinion of the investigator and was confirmed by laboratory test [PCR (+)] OR a case that met the clinical definition confirmed by the IDMC and was epidemiologically linked [Epi (+)] to a valid index case. Moderately severe disease: 8-15 points; severe disease: = 16 points (scored by IDMC using the modified Vázquez scale). From 42 days post dose 2 until the end of Phase A
Secondary Phase A: Number of Subjects With Probable or Confirmed Varicella Case Probable or confirmed varicella case = A case that met the clinical case definition (as determined by the IDMC) but was not laboratory confirmed [PCR (-)] AND was not epidemiologically linked [Epi (-)] to another probable or confirmed case. From 42 days post dose 2 until the end of Phase A
Secondary Phase A: Immune Response to Varicella Vaccine With Respect to Anti-Varicella Zoster Virus (Anti-VZV) Antibody Concentrations Anti-VZV antibody concentrations are presented as Geometric Mean Concentrations (GMCs), expressed in milliinternational units per milliliter (mIU/mL). At Day 0, Day 42, Day 84, Year 1 and Year 2 time points
Secondary Phase A: Number of Subjects With Seroconversion/Seroresponse to VZV Seronegative (S-) = Subjects with antibody concentration less than (<) 25 mIU/mL prior to vaccination. Seropositive (S+) = Subjects with antibody concentration greater than or equal to (=) 25 mIU/mL prior to vaccination. Seroconversion was defined as the appearance of antibodies (i.e. titer greater than or equal to the cut-off value) in the serum of subjects seronegative before vaccination. At Day 0, Day 42, Day 84, Year 1 and Year 2 time points
Secondary Phase A: Immune Response to Measles With Respect to Anti-measles Antibody Concentrations in a Subset of Subjects Anti-measles antibody concentrations are presented as Geometric Mean Concentrations (GMCs), expressed in milliinternational units per milliliter (mIU/mL). At Day 0, Day 42, Day 84, Year 1 and Year 2 time points
Secondary Phase A: Number of Subjects With Seroconversion/Seroresponse to Measles in a Subset of Subjects Seronegative (S-) = Subjects with antibody concentration < 150 mIU/mL prior to vaccination. Seropositive (S+) = Subjects with antibody concentration = 150 mIU/mL prior to vaccination. Seroconversion was defined as the appearance of antibodies (i.e. titer greater than or equal to the cut-off value) in the serum of subjects seronegative before vaccination. At Day 0, Day 42, Day 84, Year 1 and Year 2 time points
Secondary Phase A: Immune Response to Mumps With Respect to Anti-mumps Antibody Concentrations in a Subset of Subjects Anti-mumps antibody concentrations are presented as Geometric Mean Concentrations (GMCs), expressed in units per milliliter (U/mL). At Day 0, Day 42, Day 84, Year 1 and Year 2 time points
Secondary Phase A: Number of Subjects With Seroconversion/Seroresponse to Mumps in a Subset of Subjects Seronegative (S-) = Subjects with antibody concentration < 231 U/mL prior to vaccination. Seropositive (S+) = Subjects with antibody concentration = 231 U/mL prior to vaccination. Seroconversion was defined as the appearance of antibodies (i.e. titer greater than or equal to the cut-off value) in the serum of subjects seronegative before vaccination. At Day 0, Day 42, Day 84, Year 1 and Year 2 time points
Secondary Phase A: Immune Response to Rubella With Respect to Anti-rubella Antibody Concentrations in a Subset of Subjects Anti-rubella antibody concentrations are presented as Geometric Mean Concentrations (GMCs), expressed in International Units per milliliter (IU/mL). At Day 0, Day 42, Day 84, Year 1 and Year 2 time points
Secondary Phase A: Number of Subjects With a Seroconversion/Seroresponse to Rubella in a Subset of Subjects Seronegative (S-) = Subjects with antibody concentration < 4 IU/mL prior to vaccination. Seropositive (S+) = Subjects with antibody concentration = 4 IU/mL prior to vaccination. Seroconversion was defined as the appearance of antibodies (i.e. titer greater than or equal to the cut-off value) in the serum of subjects seronegative before vaccination. At Day 0, Day 42, Day 84, Year 1 and Year 2 time points
Secondary Phase A: Number of Subjects With Confirmed Cases of Herpes Zoster The number of subjects with confirmed cases of herpes zoster is reported. From Day 0 until the end of Phase A (Year 2)
Secondary Phase A: Number of Subjects Reporting Fever All fever = Occurrence of any fever (measured rectally) regardless of its intensity grade or relationship to vaccination. Related = fever (measured rectally) assessed by the investigator to be causally related to the study vaccination. Medical Advice = seek for medical advice. Within 43 days (Day 0-42) post-vaccination period following each dose
Secondary Phase A: Number of Subjects Reporting Fever All fever = Occurrence of any fever (measured rectally) regardless of its intensity grade or relationship to vaccination. Related fever = fever (measured rectally) assessed by the investigator to be causally related to the study vaccination. Medical Advice = seek for medical advice. Within 15 days (Day 0-14) post-vaccination period following each dose
Secondary Phase A: Number of Subjects Reporting Solicited Local Symptoms Solicited local symptoms assessed were pain, redness and swelling. Any solicited local symptom = Occurrence of any local symptom regardless of their intensity grade. Grade 3 pain = Cried when limb was moved/spontaneously painful. Grade 3 redness and swelling = greater than (>) 20 mm. 4 days post-vaccination period following each dose
Secondary Phase A: Number of Subjects Reporting Meningism Any = Occurrence of meningism regardless of its intensity grade. Grade 3 meningism = Prevented normal, everyday activities. Related = Assessed by the investigator to be causally related to the study vaccination. Within 43 days (Day 0-42) post-vaccination period following each dose
Secondary Phase A: Number of Subjects Reporting Parotitis Any = Occurrence of parotitis regardless of its intensity grade. Grade 3 parotitis = Swelling with accompanying general symptoms. Related = Assessed by the investigator to be causally related to the study. Within 43 days (Day 0-42) post-vaccination period following each dose
Secondary Phase A: Number of Subjects Reporting Rash Any = Occurrence of rash regardless of its intensity grade. Grade 3 rash = 101-500 lesions. Grade 4 rash = > 500 lesions. Related rash = Assessed by the investigator to be causally related to the study vaccination. Within 43 days (Day 0-42) post-vaccination period following each dose
Secondary Phase A: Number of Subjects With Suspected Sign of Meningism Including Febrile Convulsions Any = Occurrence of meningism including febrile convulsions regardless of intensity grade. Within 43 days (Day 0-42) post-vaccination period following each dose
Secondary Phase A: Number of Subjects Reporting Unsolicited Adverse Events (AEs) Unsolicited AE assessed included any AE reported in addition to those solicited during the clinical study and any solicited symptom with onset outside the specified period of follow-up for solicited symptoms. Any = Occurrence of any unsolicited symptom regardless of intensity grade or relation to vaccination. Within 43 days (Day 0-42) post-vaccination period following each dose
Secondary Phase A: Number of Subjects Reporting Serious Adverse Events (SAEs) SAEs assessed included medical occurrences that resulted in death, were life-threatening, required hospitalisation or prolongation of hospitalisation or resulted in disability/incapacity. Any SAE = occurrence of SAE regardless of intensity grade or relation to vaccination. From Day 0 until the end of Phase A (Year 2)
Secondary Phase A: Health Economics Analysis of Factors Leading to Indirect Costs Due to Varicella Illness Parameters assessed: 1. Number of hours lost from work by parents/guardians as a result of taking care of their child due to varicella. 2. Number of hours the child lost attendance in: day care/childminder, school, or in any extra-curricular activities (e.g. sports or recreation or any type of organised leisure activities) due to varicella. 3. Number of hours spent by a nurse, a babysitter or any type of existing paid caregiver to look after the child (if applicable). During Phase A (from Day 0 up to Year 2)
Secondary Phase B: Number of Subjects With Confirmed Varicella Case Confirmed varicella case = A case that met the clinical case definition at least in the opinion of the investigator and was confirmed by laboratory test [PCR (+)] OR a case that met the clinical definition confirmed by the IDMC and was epidemiologically linked [Epi (+)] to a valid index case. From the beginning of Phase B (Year 2) up to study end (Year 10)
Secondary Phase B: Number of Subjects With Moderate or Severe Confirmed Varicella Case Confirmed varicella case = A case that met the clinical case definition at least in the opinion of the investigator and was confirmed by laboratory test [PCR (+)] OR a case that met the clinical definition confirmed by the IDMC and was epidemiologically linked [Epi (+)] to a valid index case. Moderately severe disease = 8-15 points; severe disease: = 16 points (scored by IDMC using the modified Vázquez scale). From the beginning of Phase B (Year 2) up to study end (Year 10)
Secondary Phase B: Number of Subjects With Probable or Confirmed Varicella Case Probable or confirmed varicella = A case that met the clinical case definition (as determined by the IDMC) but was not laboratory confirmed [PCR (-)] AND was not epidemiologically linked [Epi (-)] to another probable or confirmed case. From the beginning of Phase B (Year 2) up to study end (Year 10)
Secondary Phase B: Characteristics of Varicella Cases Varicella cases were characterized by type, number and character of lesions, duration of rash, incidence of fever, systemic signs, the assessment by investigator, complications, treatment, outcome and intensity of severity. From the beginning of Phase B (Year 2) up to study end (Year 10)
Secondary Phase B: Immune Response to Varicella Vaccine With Respect to Anti-Varicella Zoster Virus (Anti-VZV) Antibody Concentrations Anti-VZV antibody concentrations are presented as Geometric Mean Concentrations (GMCs), expressed in milliinternational units per milliliter (mIU/mL). At Year 4, Year 6, Year 8 and Year 10 time points
Secondary Phase B: Number of Subjects With Anti-VZV Antibody Concentrations Above the Cut-off Value The anti-VZV antibody concentration cut-off value assessed was greater than or equal to (=) 25 mIU/mL, in the sera of subjects seronegative before vaccination. At Year 4, Year 6, Year 8 and Year 10 time points
Secondary Phase B: Immune Response to Measles With Respect to Anti-measles Antibody Concentrations Anti-measles antibody concentrations are presented as Geometric Mean Concentrations (GMCs), expressed in milliinternational units per milliliter (mIU/mL). At Year 4, Year 6, Year 8 and Year 10 time points
Secondary Phase B: Number of Subjects With Anti-measles Antibody Concentrations Above the Cut-off Value The anti-measles antibody concentration cut-off value assessed was = 150 mIU/mL, in the sera of subjects seronegative before vaccination. At Year 4, Year 6, Year 8 and Year 10 time points
Secondary Phase B: Immune Response to Mumps With Respect to Anti-mumps Antibody Concentrations Anti-mumps antibody concentrations are presented as Geometric Mean Concentrations (GMCs), expressed in units per milliliter (U/mL). At Year 4, Year 6, Year 8 and Year 10 time points
Secondary Phase B: Number of Subjects With Anti-mumps Antibody Concentrations Above the Cut-off Value The anti-mumps antibody concentration cut-off value assessed was = 231 U/mL, in the sera of subjects seronegative before vaccination. At Year 4, Year 6, Year 8 and Year 10 time points
Secondary Phase B: Immune Response to Rubella With Respect to Anti-rubella Antibody Concentrations Anti-rubella antibody concentrations are presented as Geometric Mean Concentrations (GMCs), expressed in international units per milliliter (IU/mL). At Year 4, Year 6, Year 8 and Year 10 time points
Secondary Phase B: Number of Subjects With Anti-rubella Antibody Concentrations Above the Cut-off Value The anti-rubella antibody concentration cut-off value assessed was = 4 IU/mL, in the sera of subjects seronegative before vaccination. At Year 4, Year 6, Year 8 and Year 10 time points
Secondary Phase B: Characteristics of Zoster Cases Zoster cases were characterized by number and character of lesions, duration of rash, incidence of fever, systemic signs, the assessment by investigator, complications, treatment, outcome and intensity of severity. From 6 weeks after Dose 2 until study end (Year 10)
Secondary Phase B: Number of Subjects Reporting Serious Adverse Events (SAEs) SAEs assessed included medical occurrences that resulted in death, were life-threatening, required hospitalisation or prolongation of hospitalisation or resulted in disability/incapacity. Any SAE = occurrence of SAE regardless of intensity grade or relation to vaccination. From the beginning of Phase B (Year 2) up to study end (Year 10)
Secondary Phase B: Health Economics Analysis of Factors Leading to Indirect Costs Due to Varicella Illness Parameters assessed: 1. Number of hours lost from work by parents/guardians as a result of taking care of their child due to varicella. 2. Number of hours the child lost attendance in: day care/childminder, school, or in any extra-curricular activities (e.g. sports or recreation or any type of organised leisure activities) due to varicella. 3. Number of hours spent by a nurse, a babysitter or any type of existing paid caregiver to look after the child (if applicable). During Phase B
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