Skip to content

Pfs230D1M-EPA/AS01 Vaccine, a Transmission Blocking Vaccine Against Plasmodium Falciparum, in an Age De-Escalation Trial of Children and a Family Compound Trial in Mali

Safety, Immunogenicity and Efficacy of Pfs230D1M-EPA/AS01 Vaccine, a Transmission Blocking Vaccine Against Plasmodium Falciparum, in an Age De-Escalation Trial of Children and a Family Compound Trial in Mali

Status
Completed
Phases
Phase 2
Study type
Interventional
Source
ClinicalTrials.gov
Registry ID
NCT03917654
Enrollment
1301
Registered
2019-04-17
Start date
2019-04-24
Completion date
2022-10-31
Last updated
2024-10-22

For informational purposes only — not medical advice. Sourced from public registries and may not reflect the latest updates. Terms

Conditions

Malaria

Keywords

Randomized, Assays, Blood Smear, Antibody, Parasites

Brief summary

Background: Malaria affects many people in Mali and other parts of Africa. It is spread by mosquito bites. Malaria can make people sick or can lead to death. Scientists want to learn if a vaccine can stop it from spreading to other people. Objective: To test how well an experimental malaria vaccine works to decrease malaria infections. Eligibility: Healthy people ages 5 and older who live in Doneguebougou, Mali, and surrounding areas Design: Participants will be screened with: Medical history Physical exam Blood, urine, and heart tests EKG Participants will be randomly assigned to get either the experimental vaccine or an approved vaccine. They will not know which they are getting. Participants will have a visit about a week before their first vaccine. They will take a medicine that kills malaria. They will take it at the clinic the next 2 days. Participants ages 5-8 will take the drug again 2 weeks before their third vaccine. Participants get the vaccine through a needle in the arm. They will have visits 1, 3, 7, and 14 days after. They will have blood tests or finger pricks. Participants will get another vaccine 1 and 6 months later. Participants will have blood tests once a month. At these visits they may also have urines tests or mosquito feeds. For the feeds a cup full of mosquitoes will be placed on arms or legs for 15-20 minutes. Participants will have visits twice a month for 4 months after their last vaccine.

Detailed description

A vaccine to interrupt malaria transmission (VIMT), targeting disruption of both human and mosquito transmission, would be a valuable tool for local elimination or eradication of this disease. One strategy to design a VIMT is using components that block transmission of malaria to mosquitoes, such as Pfs230. Pfs230, a surface antigen of intracellular gametocytes, as well as extracellular gametes and zygotes in the mosquito stage of Plasmodium falciparum, is currently the leading candidate in clinical trials for a malaria transmission-blocking vaccine (TBV). Recombinant Pfs230D1M has been conjugated to a recombinant Pseudomonas aeruginosa ExoProtein A (EPA) and adjuvanted with AS01. When formulated in AS01, results from a recent first-in-human trial demonstrated that Pfs230-EPA induces functional transmission-reducing, and in a significant proportion of vaccinees, transmission-blocking serum activity that can be measured for months, the vaccine is well-tolerated and safe in adults, and our recent natural history data clearly indicate that children play a disproportionate role in malaria transmission. The next step in the development of Pfs230D1M-EPA as a TBV is therefore to conduct an age de-escalation trial to ensure that the vaccine is safe to administer to children and then to conduct a community clinical trial to assess efficacy in family groups. This Phase 2 study will first determine safety and tolerability of Pfs230D1M-EPA/AS01 in healthy Malian children of decreasing ages: 9-18 years old, followed by 5-8 years old. A total of 60 subjects will be enrolled in Doneguebougou, Mali, West Africa. Children will be recruited from compounds/family that have agreed to participate in the main phase of the study and will enroll in a staggered manner to receive either Pfs230D1M-EPA/AS01 vaccine or comparator as assigned by their compound block randomization. Prior to receipt of vaccination #1, all subjects will receive a full treatment course of artemether/lumefantrine (AL). Safety and tolerability will be monitored and reported as local and systemic adverse events (AEs) and serious adverse events (SAEs) and reviewed by DSMB, sponsor, medical monitors, and study team prior to proceeding with enrollment of the main phase. If there are no safety concerns, in a staggered manner, the main phase will begin enrollment of approximately 137 compounds/vaccine units (about 1500 vaccinees + about 400 under 5 years of age for parasite surveillance). Children enrolled during the pilot safety phase will join their main phase compounds/family for vaccination #3. Prior to receipt of first vaccination, all subjects will receive a full treatment course of AL. All vaccinated subjects will be monitored for safety and tolerability. Immunogenicity outcomes will be antibody responses as measured by enzyme-linked immunosorbent assay (ELISA) against recombinant Pfs230D1M. Functional activity of the induced antibodies will be assessed by standard membrane feeding assays in select samples. Vaccine activity will be measured in children 9-18 years of age who will undergo direct skin feeds (DSF) starting 2 weeks post vaccination #3 for a total of 8 DSFs. Prior to scheduled last vaccination in members of the compound/family, children 1-4 years of age and vaccinated children 5-8 years of age will receive a full treatment course of AL prior to the expected start of the transmission season and will then be followed every 2 weeks by blood smear (BS) along with all vaccinated children. Children 9-18 years of age will also be assessed for vaccine efficacy, but as a separate analysis from those 1-8 years of age. In Year 2, those who received vaccination during Year 1 (5 years of age and older at enrollment), if eligible and still on study, will receive a single fourth vaccination per their vaccine unit (VU) blinded arm assignment. No new individuals will be enrolled. Again, children 1-4 years of age and vaccinated children 5-8 years of age will receive a full treatment course of AL prior to the expected start of the transmission season and will then be followed every 2 weeks by BS along with all vaccinated children. Children 9-18 years of age will also be assessed for vaccine efficacy against parasitemia, but as a separate analysis from those 1-8 years of age. Immunogenicity outcomes will be antibody responses as measured by ELISA against recombinant Pfs230D1M. Functional activity of the induced antibodies will be assessed by standard membrane feeding assays in select samples. Vaccine activity will be measured in children 9-18 years of age who will undergo DSF starting 2 weeks post vaccination #4 for a total of 10 DSFs.

Interventions

BIOLOGICALPfs230D1M-EPA/AS01

The Pfs230D1M-EPA was formulated as conjugated Pfs230D1M in 4 mM phosphate-buffered saline (PBS) to a 2X dilution of the high dose (160 (Micro)g/mL in 0.5 mL volume) in cGMP compliance at Walter Reed Bioproduction facility in April 2016 and will be provided as a single use vial. AS01B adjuvant was manufactured for use in the SHINGRIX vaccine by GSK

BIOLOGICALHAVRIX

HAVRIX (Hepatitis A Vaccine; HAV) is produced by GSK and is a sterile suspension of inactivated virus for IM administration. The virus (strain HM175) is propagated in MRC-5 human diploid cells. HAVRIX is FDA approved for active immunization against disease caused by HAV for persons 12 months of age and older.

BIOLOGICALTYPHIM Vi (Salmonella typhi vaccine)

TYPHIM Vi (Typhoid Vi Polysaccharide Vaccine), produced by Sanofi Pasteur SA, for IM use, is a sterile solution containing the cell surface Vi polysaccharide extracted from Salmonella enterica serovar Typhi, S typhi Ty2 strain (inactivated, subunit vaccine). TYPHIM Vi vaccine is indicated for active immunization for the prevention of typhoid fever caused by S typhi and is FDA approved for use in persons 2 years of age or older

BIOLOGICALMenactra

Menactra (Sanofi Pasteur) is a sterile, intramuscularly administered vaccine that contains Neisseria meningitidis serogroup A, C, Y, and W-135 capsular polysaccharide antigens individually conjugated to diphtheria toxoid protein. No preservative or adjuvant is added during the manufacturing process. Menactra is FDA approved for active immunization to prevent invasive meningococcal disease caused by Neisseria meningitidis serogroups A, C, Y, and W-135 (but does not protect against serotype B) for use in individuals 9 months through 55 years of age.

BIOLOGICALAVAXIM

AVAXIM - Pediatric \[Hepatitis A Vaccine Inactivated\] is a sterile, whitish, cloudy suspension. The active ingredient is a purified and formaldehyde-inactivated hepatitis A virus (HAV) obtained from the GBM strain, cultured on MRC-5 human diploid cells. HAV is adsorbed onto aluminum.

Sponsors

National Institute of Allergy and Infectious Diseases (NIAID)
Lead SponsorNIH

Study design

Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
DOUBLE (Subject, Investigator)

Eligibility

Sex/Gender
ALL
Age
1 Years to No maximum
Healthy volunteers
No

Inclusion criteria

* INCLUSION CRITERIA FOR GROUPS 1,2,3: All of the following criteria must be fulfilled for a volunteer to participate in this trial: 1. Meets age requirements for Arm currently being enrolled. 2. Available for the duration of the trial. 3. Family compound known resident or long-term resident (more than 1 year) of Doneguebougou, Mali or surrounding villages. 4. Able to provide proof of identity to the satisfaction of the study clinician completing the enrollment process. 5. In good general health and without clinically significant medical history in the opinion of the investigator. 6. Females of childbearing potential must be willing to use reliable contraception from 21 days prior to Study Day 0 and until 1 month after the last vaccination. * A reliable method of birth control includes one of the following: <!-- --> 1. Confirmed pharmacologic contraceptives (parenteral) delivery; 2. Intrauterine or implantable device EXCEPTIONS to required pregnancy prevention includes the following: 1. Postmenopausal state: defined as no menses for 12 months without an alternative medical cause 2. Surgical sterilization 3. Unmarried AND not sexually active AND menstruating OR not menstruating females 12-17 years of age 4. NOTE: if a female of childbearing potential s status changes during the course of vaccination through 1 month post vaccination (e.g. they become \>=18 years of age, married, or sexually active), the female will be required to start reliable contraception 7\. Willing to have blood samples stored for future research. INCLUSION CRITERIA FOR GROUP 4: All of the following criteria must be fulfilled for a volunteer to participate in this trial: 1. Meets age requirements for Arm currently being enrolled. 2. Available for the duration of the trial. 3. Family compound known resident or long-term resident (more than 1 year) of Doneguebougou, Mali or surrounding villages. 4. Able to provide proof of identity to the satisfaction of the study clinician completing the enrollment process. 5. In good general health and without clinically significant medical history in the opinion of the investigator. 6. Willing to have blood samples stored for future research. Inclusion Criteria for Groups 1, 2, 3, (Year 2) All of the following criteria must be fulfilled for a volunteer to continue to participate in this trial: 1\. Previously enrolled in the study and has received at least 1 vaccination. 2. Available for the duration of the trial. 3\. In good general health and without clinically significant medical history in the opinion of the investigator. 4\. Females of childbearing potential must be willing to use reliable contraception from 21 days prior to scheduled vaccine dose #4 and until 1 month after the 4th vaccination. -A reliable method of birth control includes one of the following: 1. Confirmed pharmacologic contraceptives (parenteral) delivery; 2. Intrauterine or implantable device EXCEPTIONS to required pregnancy prevention includes the following: 1. Postmenopausal state: defined as no menses for 12 months without an alternative medical cause 2. Surgical sterilization 3. Unmarried AND not sexually active AND menstruatingOR not menstruating females 12-17 years of age 4. NOTE: if a female of childbearing potential s status changes during the course of vaccination through 1 month post vaccination (e.g. they become greater than or equal to 18 years of age, married, or sexually active), the female will be required to start reliable contraception 5. Willing to have blood samples stored for future research. Inclusion Criteria for Group 4 (Year 2): All of the following criteria must be fulfilled for a volunteer to continue to participate in this trial: 1. Previously enrolled in the study 2. Available for the duration of the trial. 3. In good general health and without clinically significant medical history in the opinion of the investigator. 4. Willing to have blood samples stored for future research.

Exclusion criteria

FOR GROUPS 1, 2, 3: An individual will be excluded from participating in this trial if any one of the following criteria is fulfilled: 1. Pregnant, as determined by a positive urine or serum beta human choriogonadotropin (beta-hCG) test (if female). NOTE: Pregnancy is also a criterion for discontinuation of any further vaccine dosing 2. Menstruating females 11 years of age and younger. (In order to avoid cultural implications of further assessing pregnancy potential i.e. sexual activity in this age group.) 3. Behavioral, cognitive, or psychiatric disease that in the opinion of the investigator affects the ability of the subject to understand and comply with the study protocol at a level appropriate for the subject s age. 4. Hemoglobin, white blood cell (WBC), absolute neutrophil count, or platelet levels outside the local laboratory defined limits of normal. (Subjects may be included at the investigator s discretion for not clinically significant values outside of normal range and \<= Grade 2.) 5. Alanine transaminase (ALT) or creatinine (Cr) level above the local laboratory defined upper limit of normal. (Subjects may be included at the investigator s discretion for not clinically significant values outside of normal range and \<= Grade 2.) 6. Infected with HIV 7. Evidence of clinically significant neurologic, cardiac, pulmonary, hepatic, endocrine, rheumatologic, autoimmune, hematological, oncologic, or renal disease by history, physical examination, and/or laboratory studies including urinalysis. 8. Clinically significant prolonged QTc (\>450 milliseconds) on screening EKG 9. History of receiving any investigational product within the past 30 days. 10. Current or planned participation in an investigational vaccine study until the last required protocol visit. 11. Medical, occupational, or family problems as a result of alcohol or illicit drug use during the past 12 months. 12. History of a severe allergic reaction or anaphylaxis. 13. Known: * Severe asthma, defined as asthma that is unstable or required emergent care, urgent care, hospitalization, or intubation during the past 2 years, or that has required the use of oral or parenteral corticosteroids at any time during the past 2 years. * Autoimmune or antibody-mediated disease including but not limited to: systemic lupus erythematosus, rheumatoid arthritis, multiple sclerosis, Sj(SqrRoot)(Delta)gren s syndrome, or autoimmune thrombocytopenia. * Immunodeficiency syndrome. * Seizure disorder (exception: history of simple febrile seizures) * Asplenia or functional asplenia. * Use of chronic (\>=14 days) oral or intravenous (IV) corticosteroids (excluding topical or nasal) at immunosuppressive doses (i.e., prednisone \>10 mg/day) or immunosuppressive drugs within 30 days of Study Day 0. * Allergy to latex or neomycin * Adverse reaction to hepatitis A and/or typhoid and/or meningococcal vaccine in the past * Adverse reaction to artemether/lumefantrine in the past 14. Receipt of: -Live vaccine within the past 4 weeks or a killed vaccine within the past 2 weeks to enrollment. * Immunoglobulins and/or blood products within the past 6 months. * Investigational malaria vaccine in the last 2 years. 15. Any other condition that in the opinion of the investigator would jeopardize the safety or rights of a subject participating in the trial, interfere with the evaluation of the study objectives, or would render the subject unable to comply with the protocol. Co-enrollment guidelines: Co-enrollment in other trials is restricted, other than enrollment on observational studies. Consideration for co-enrollment in trials evaluating the use of a licensed medication will require the approval of the PI. Study staff should be notified of co-enrollment on any other protocol as it may require the approval of the investigator.

Design outcomes

Primary

MeasureTime frameDescription
Number of Participants With Local and Systemic Adverse Events in Years 1 and 2Within 7 days after each vaccination at days, 0, 28, 126, 448 (for arms 1a, 1b, 2a, 2b), days 0, 28, 56, 392 (for arms 3a, 3b, 3c, 3d, 3e, 3f), days -14 and 385 (for arms 4a, 4b) and year 2 (for all arms)Number of participants with local and systemic adverse events (AEs) graded by severity occurring within 7 days after each vaccine

Countries

Mali

Participant flow

Participants by arm

ArmCount
Arm 1a
Pilot/safety: Dosing interval on days: 0, 28, 126, 448 Participants received 4 doses of 40 μg of Pfs230D1M-EPA/AS01 administered via intramuscular (IM) injection on days: 0, 28, 126, 448; receipt of artemether/lumefantrine (AL) on day -7
15
Arm 1b
Pilot/safety: Dosing interval on days: 0, 28, 126, 448 Participants received 4 doses administered via intramuscular (IM) injection on days 0, 448 to receive HAVRIX; day 28 to receove TYPHIM Vi; and day 126 to receive Menactra; receipt of AL on day -7
15
Arm 2a
Pilot/safety: Dosing interval on days: 0, 28, 126, 448 Participants received 4 doses administered via intramuscular (IM) injection on days 0, 28, 126, 448 to receive 40 μg of Pfs230D1M-EPA/AS01; receipt of AL on day -7,112, 441
15
Arm 2b
Pilot/safety: Dosing interval on days: 0, 28, 126, 448 Participants received 4 doses administered via intramuscular (IM) injection on days 0, 448 to receive HAVRIX; day 126 to receive Menactra; receipt of AL on day -7,112, 441
15
Arm 3a
Safety/efficacy: Dosing interval on days 0, 28, 56, 392 Participants received 4 doses administered via intramuscular (IM) injection on days 0, 28, 56, 392 to receive 40 μg of Pfs230D1M-EPA/AS01; receipt of AL on day -7, 42, 385
99
Arm 3b
Safety/efficacy: Dosing interval on days 0, 28, 56, 392 Participants received 4 doses administered via intramuscular (IM) injection on days 0, 392 to receive HAVRIX; day 28 TYPHIM Vi; day 56 to receive Menactra; receipt of AL on day -7, 42, 385
87
Arm 3c
Safety/efficacy: Dosing interval on days 0, 28, 56, 392 Participants received 4 doses administered via intramuscular (IM) injection on days 0, 28, 56, 392 to receive 40 μg of Pfs230D1M-EPA/AS01; receipt of AL on day -7
192
Arm 3d
Safety/efficacy: Dosing interval on days 0, 28, 56, 392 Participants received 4 doses administered via intramuscular (IM) injection on days 0, 392 to receive HAVRIX; day 28 TYPHIM Vi; day 56 to receive Menactra; receipt of AL on day -7
177
Arm 3e
Safety/efficacy: Dosing interval on days 0, 28, 56, 392 Participants received 4 doses administered via intramuscular (IM) injection on days 0, 28, 56, 392 to receive 40 μg of Pfs230D1M-EPA/AS01; receipt of AL on day -7
227
Arm 3f
Safety/efficacy: Dosing interval on days 0, 28, 56, 392 Participants received 4 doses administered via intramuscular (IM) injection on days 0, 392 to receive HAVRIX; day 28 TYPHIM Vi; day 56 to receive Menactra; receipt of AL on day -7
267
Arm 4a
AL treatment only; no vaccination Participants received AL on day -14, 385
97
Arm 4b
AL treatment only; no vaccination Participants received AL on day -14, 385
95
Total1,301

Withdrawals & dropouts

PeriodReasonFG000FG001FG002FG003FG004FG005FG006FG007FG008FG009FG010FG011
Year 1Death000000001100
Year 1Lost to Follow-up000000200000
Year 1Missed visits000000000011
Year 1Pregnancy000000010100
Year 1Spouse/Family member request001010020001
Year 1Subject moved away from site010000121003
Year 1Travel0110441082533
Year 1Withdrawal by Subject100001625310
Year 2Adverse Event000000000100
Year 2Death000001001100
Year 2Lost to Follow-up000000101001
Year 2Married100000110000
Year 2Spouse/family member request000000100000
Year 2Subject moved away from site100010230201
Year 2Travel100011210101
Year 2Withdrawal by Subject000000302500
Year 2Year 2 Screening failure0100204310211

Baseline characteristics

CharacteristicArm 1bTotalArm 4bArm 4aArm 3fArm 3eArm 3dArm 1aArm 3cArm 3bArm 3aArm 2bArm 2a
Age, Categorical
<=18 years
15 Participants783 Participants95 Participants97 Participants0 Participants0 Participants167 Participants15 Participants178 Participants87 Participants99 Participants15 Participants15 Participants
Age, Categorical
>=65 years
0 Participants37 Participants0 Participants0 Participants18 Participants19 Participants0 Participants0 Participants0 Participants0 Participants0 Participants0 Participants0 Participants
Age, Categorical
Between 18 and 65 years
0 Participants481 Participants0 Participants0 Participants249 Participants208 Participants10 Participants0 Participants14 Participants0 Participants0 Participants0 Participants0 Participants
Race/Ethnicity, Customized
Bambara
11 Participants575 Participants32 Participants41 Participants139 Participants115 Participants51 Participants9 Participants84 Participants34 Participants51 Participants2 Participants6 Participants
Race/Ethnicity, Customized
Bozo
0 Participants1 Participants0 Participants0 Participants0 Participants0 Participants0 Participants0 Participants1 Participants0 Participants0 Participants0 Participants0 Participants
Race/Ethnicity, Customized
Malinke
0 Participants15 Participants0 Participants5 Participants0 Participants6 Participants1 Participants0 Participants2 Participants0 Participants1 Participants0 Participants0 Participants
Race/Ethnicity, Customized
Other
0 Participants10 Participants2 Participants0 Participants2 Participants0 Participants4 Participants0 Participants0 Participants1 Participants0 Participants1 Participants0 Participants
Race/Ethnicity, Customized
Peulh
1 Participants38 Participants3 Participants5 Participants4 Participants8 Participants0 Participants0 Participants12 Participants1 Participants2 Participants1 Participants1 Participants
Race/Ethnicity, Customized
Sarakole
3 Participants661 Participants58 Participants45 Participants122 Participants98 Participants121 Participants6 Participants93 Participants51 Participants45 Participants11 Participants8 Participants
Race/Ethnicity, Customized
Sonrhai
0 Participants1 Participants0 Participants1 Participants0 Participants0 Participants0 Participants0 Participants0 Participants0 Participants0 Participants0 Participants0 Participants
Region of Enrollment
Mali
15 participants1301 participants95 participants97 participants267 participants227 participants177 participants15 participants192 participants87 participants99 participants15 participants15 participants
Sex: Female, Male
Female
8 Participants653 Participants43 Participants44 Participants147 Participants126 Participants91 Participants6 Participants84 Participants43 Participants50 Participants6 Participants5 Participants
Sex: Female, Male
Male
7 Participants648 Participants52 Participants53 Participants120 Participants101 Participants86 Participants9 Participants108 Participants44 Participants49 Participants9 Participants10 Participants

Adverse events

Event typeEG000
affected / at risk
EG001
affected / at risk
EG002
affected / at risk
EG003
affected / at risk
EG004
affected / at risk
EG005
affected / at risk
EG006
affected / at risk
EG007
affected / at risk
EG008
affected / at risk
EG009
affected / at risk
EG010
affected / at risk
EG011
affected / at risk
deaths
Total, all-cause mortality
0 / 150 / 150 / 150 / 150 / 991 / 870 / 1920 / 1772 / 2275 / 2670 / 970 / 95
other
Total, other adverse events
15 / 1514 / 1515 / 1515 / 1595 / 9984 / 87187 / 192170 / 177222 / 227253 / 26789 / 9784 / 95
serious
Total, serious adverse events
0 / 150 / 150 / 150 / 151 / 991 / 870 / 1922 / 1772 / 2277 / 2670 / 971 / 95

Outcome results

Primary

Number of Participants With Local and Systemic Adverse Events in Years 1 and 2

Number of participants with local and systemic adverse events (AEs) graded by severity occurring within 7 days after each vaccine

Time frame: Within 7 days after each vaccination at days, 0, 28, 126, 448 (for arms 1a, 1b, 2a, 2b), days 0, 28, 56, 392 (for arms 3a, 3b, 3c, 3d, 3e, 3f), days -14 and 385 (for arms 4a, 4b) and year 2 (for all arms)

ArmMeasureValue (COUNT_OF_PARTICIPANTS)
Arm 1aNumber of Participants With Local and Systemic Adverse Events in Years 1 and 215 Participants
Arm 1bNumber of Participants With Local and Systemic Adverse Events in Years 1 and 214 Participants
Arm 2aNumber of Participants With Local and Systemic Adverse Events in Years 1 and 215 Participants
Arm 2bNumber of Participants With Local and Systemic Adverse Events in Years 1 and 215 Participants
Arm 3aNumber of Participants With Local and Systemic Adverse Events in Years 1 and 296 Participants
Arm 3bNumber of Participants With Local and Systemic Adverse Events in Years 1 and 285 Participants
Arm 3cNumber of Participants With Local and Systemic Adverse Events in Years 1 and 2187 Participants
Arm 3dNumber of Participants With Local and Systemic Adverse Events in Years 1 and 2172 Participants
Arm 3eNumber of Participants With Local and Systemic Adverse Events in Years 1 and 2224 Participants
Arm 3fNumber of Participants With Local and Systemic Adverse Events in Years 1 and 2260 Participants
Arm 4aNumber of Participants With Local and Systemic Adverse Events in Years 1 and 289 Participants
Arm 4bNumber of Participants With Local and Systemic Adverse Events in Years 1 and 285 Participants

Source: ClinicalTrials.gov · Data processed: Feb 23, 2026