Trial Outcomes & Findings for Efficacy and Safety of Omalizumab in Children (6 - < 12 Years) With Moderate-severe, Inadequately Controlled Allergic Asthma (NCT NCT00079937)

NCT ID: NCT00079937

Last Updated: 2012-04-11

Results Overview

A clinically significant asthma exacerbation was defined as a worsening of asthma symptoms, as judged clinically by the investigator, requiring doubling of the baseline inhaled corticosteroid dose and/or treatment with systemic rescue corticosteroids for at least 3 days. The exacerbations rate per patient was derived using Poisson model adjusted by time at risk and the following covariates: country, exacerbation history, and dose schedule. A patient's person-days at risk was taken as the total amount of time (in days) he/she spent in the 24-week fixed-dose steroid treatment period.

Recruitment status

COMPLETED

Study phase

PHASE3

Target enrollment

628 participants

Primary outcome timeframe

Baseline to end of the fixed-dose steroid treatment period (Week 24)

Results posted on

2012-04-11

Participant Flow

Participant milestones

Participant milestones
Measure
Omalizumab
Participants received omalizumab administered by subcutaneous injection every 2 or 4 weeks for a duration of 52 weeks. The omalizumab dose was based on the patient's body weight and total serum IgE level at Screening. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Placebo
Placebo was administered by subcutaneous injection every 2 or 4 weeks depending on the dosing schedule in the protocol for a total of 52 weeks. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Overall Study
STARTED
421
207
Overall Study
COMPLETED
352
175
Overall Study
NOT COMPLETED
69
32

Reasons for withdrawal

Reasons for withdrawal
Measure
Omalizumab
Participants received omalizumab administered by subcutaneous injection every 2 or 4 weeks for a duration of 52 weeks. The omalizumab dose was based on the patient's body weight and total serum IgE level at Screening. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Placebo
Placebo was administered by subcutaneous injection every 2 or 4 weeks depending on the dosing schedule in the protocol for a total of 52 weeks. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Overall Study
Adverse Event
2
1
Overall Study
Unsatisfactory therapeutic effect
1
2
Overall Study
Subject no longer requires study drug
3
0
Overall Study
Protocol Violation
8
6
Overall Study
Withdrawal by Subject
21
7
Overall Study
Lost to Follow-up
12
5
Overall Study
Administrative problems
22
11

Baseline Characteristics

Efficacy and Safety of Omalizumab in Children (6 - < 12 Years) With Moderate-severe, Inadequately Controlled Allergic Asthma

Baseline characteristics by cohort

Baseline characteristics by cohort
Measure
Omalizumab
n=421 Participants
Participants received omalizumab administered by subcutaneous injection every 2 or 4 weeks for a duration of 52 weeks. The omalizumab dose was based on the patient's body weight and total serum IgE level at Screening. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Placebo
n=207 Participants
Placebo was administered by subcutaneous injection every 2 or 4 weeks depending on the dosing schedule in the protocol for a total of 52 weeks. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Total
n=628 Participants
Total of all reporting groups
Age Continuous
8.7 years
STANDARD_DEVIATION 1.7 • n=5 Participants
8.4 years
STANDARD_DEVIATION 1.7 • n=7 Participants
8.6 years
STANDARD_DEVIATION 1.7 • n=5 Participants
Sex: Female, Male
Female
134 Participants
n=5 Participants
69 Participants
n=7 Participants
203 Participants
n=5 Participants
Sex: Female, Male
Male
287 Participants
n=5 Participants
138 Participants
n=7 Participants
425 Participants
n=5 Participants
Race (NIH/OMB)
American Indian or Alaska Native
0 Participants
n=5 Participants
0 Participants
n=7 Participants
0 Participants
n=5 Participants
Race (NIH/OMB)
Asian
0 Participants
n=5 Participants
2 Participants
n=7 Participants
2 Participants
n=5 Participants
Race (NIH/OMB)
Native Hawaiian or Other Pacific Islander
0 Participants
n=5 Participants
0 Participants
n=7 Participants
0 Participants
n=5 Participants
Race (NIH/OMB)
Black or African American
69 Participants
n=5 Participants
30 Participants
n=7 Participants
99 Participants
n=5 Participants
Race (NIH/OMB)
White
249 Participants
n=5 Participants
128 Participants
n=7 Participants
377 Participants
n=5 Participants
Race (NIH/OMB)
More than one race
0 Participants
n=5 Participants
0 Participants
n=7 Participants
0 Participants
n=5 Participants
Race (NIH/OMB)
Unknown or Not Reported
103 Participants
n=5 Participants
47 Participants
n=7 Participants
150 Participants
n=5 Participants

PRIMARY outcome

Timeframe: Baseline to end of the fixed-dose steroid treatment period (Week 24)

Population: Modified intent-to-treat population: All patients who were randomized, excluding patients from 2 sites due to Good Clinical Practice non-compliance. Excluded patients were replaced with patients at other sites to maintain statistical power.

A clinically significant asthma exacerbation was defined as a worsening of asthma symptoms, as judged clinically by the investigator, requiring doubling of the baseline inhaled corticosteroid dose and/or treatment with systemic rescue corticosteroids for at least 3 days. The exacerbations rate per patient was derived using Poisson model adjusted by time at risk and the following covariates: country, exacerbation history, and dose schedule. A patient's person-days at risk was taken as the total amount of time (in days) he/she spent in the 24-week fixed-dose steroid treatment period.

Outcome measures

Outcome measures
Measure
Omalizumab
n=384 Participants
Participants received omalizumab administered by subcutaneous injection every 2 or 4 weeks for a duration of 52 weeks. The omalizumab dose was based on the patient's body weight and total serum IgE level at Screening. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Placebo
n=192 Participants
Placebo was administered by subcutaneous injection every 2 or 4 weeks depending on the dosing schedule in the protocol for a total of 52 weeks. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Rate of Clinically Significant Asthma Exacerbations Per Patient in the 24-week Fixed-dose Steroid Treatment Period
0.45 Exacerbations per patient per 24-weeks
Interval 0.36 to 0.55
0.64 Exacerbations per patient per 24-weeks
Interval 0.49 to 0.83

PRIMARY outcome

Timeframe: Baseline to end of the study (Week 68)

Population: Safety population: All patients who received any study drug and had at least 1 post-baseline safety assessment.

See Adverse Events module for details.

Outcome measures

Outcome measures
Measure
Omalizumab
n=421 Participants
Participants received omalizumab administered by subcutaneous injection every 2 or 4 weeks for a duration of 52 weeks. The omalizumab dose was based on the patient's body weight and total serum IgE level at Screening. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Placebo
n=207 Participants
Placebo was administered by subcutaneous injection every 2 or 4 weeks depending on the dosing schedule in the protocol for a total of 52 weeks. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Percentage of Participants With at Least 1 Adverse Event
90.3 Percentage of participants
93.7 Percentage of participants

SECONDARY outcome

Timeframe: Baseline to the end (last 4 weeks) of the 24-week fixed-dose steroid treatment period

Population: Modified intent-to-treat population: All patients who were randomized, excluding patients from 2 sites due to Good Clinical Practice non-compliance. Excluded patients were replaced with patients at other sites to maintain statistical power.

Nocturnal asthma symptom was measured daily on a scale of 0 to 4 in response to the question "How did you sleep last night?", with 0 as the best response and 4 as the worst response. The mean of the last 4 weeks of the 24-week fixed-dose steroid treatment period was calculated; for patients who discontinued prematurely, the mean of the last 28 days before discontinuation was calculated. A negative change in mean score indicated improvement.

Outcome measures

Outcome measures
Measure
Omalizumab
n=382 Participants
Participants received omalizumab administered by subcutaneous injection every 2 or 4 weeks for a duration of 52 weeks. The omalizumab dose was based on the patient's body weight and total serum IgE level at Screening. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Placebo
n=191 Participants
Placebo was administered by subcutaneous injection every 2 or 4 weeks depending on the dosing schedule in the protocol for a total of 52 weeks. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Change in Mean Nocturnal Asthma Symptom Score From Baseline to the End (Last 4 Weeks) of the 24-week Fixed-dose Steroid Treatment Period
-0.63 Units on a scale
Standard Deviation 0.72
-0.50 Units on a scale
Standard Deviation 0.71

SECONDARY outcome

Timeframe: Baseline to end of the treatment period (Week 52)

Population: Modified intent-to-treat population: All patients who were randomized, excluding patients from 2 sites due to Good Clinical Practice non-compliance. Excluded patients were replaced with patients at other sites to maintain statistical power.

A clinically significant asthma exacerbation was defined as a worsening of asthma symptoms, as judged clinically by the investigator, requiring doubling of the baseline inhaled corticosteroid dose and/or treatment with systemic rescue corticosteroids for at least 3 days. The exacerbations rate per patient was derived using Poisson model adjusted by time at risk and the following covariates: country, exacerbation history, and dose schedule. A patient's person-days at risk was taken as the total amount of time (in days) he/she spent in the 52-week treatment period.

Outcome measures

Outcome measures
Measure
Omalizumab
n=384 Participants
Participants received omalizumab administered by subcutaneous injection every 2 or 4 weeks for a duration of 52 weeks. The omalizumab dose was based on the patient's body weight and total serum IgE level at Screening. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Placebo
n=192 Participants
Placebo was administered by subcutaneous injection every 2 or 4 weeks depending on the dosing schedule in the protocol for a total of 52 weeks. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Rate of Clinically Significant Asthma Exacerbations Per Patient in the 52-week Treatment Period
0.78 Exacerbations per patient per year
Interval 0.65 to 0.94
1.36 Exacerbations per patient per year
Interval 0.92 to 1.71

SECONDARY outcome

Timeframe: Baseline to the end (last 4 weeks) of the 24-week fixed-dose steroid treatment period

Population: Modified intent-to-treat population: All patients who were randomized, excluding patients from 2 sites due to Good Clinical Practice non-compliance. Excluded patients were replaced with patients at other sites to maintain statistical power.

Patients were instructed to record the number of puffs of rescue medication they took twice daily in a diary. The mean daily number of puffs during the last 4 weeks of the 24-week fixed-dose steroid treatment period was calculated; for patients who discontinued prematurely, the mean of the last 28 days before discontinuation was calculated. A negative change in mean daily number of puffs indicated reduced use of rescue medication.

Outcome measures

Outcome measures
Measure
Omalizumab
n=381 Participants
Participants received omalizumab administered by subcutaneous injection every 2 or 4 weeks for a duration of 52 weeks. The omalizumab dose was based on the patient's body weight and total serum IgE level at Screening. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Placebo
n=191 Participants
Placebo was administered by subcutaneous injection every 2 or 4 weeks depending on the dosing schedule in the protocol for a total of 52 weeks. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Change in Mean Daily Number of Puffs of Asthma Rescue Medication From Baseline to the End (Last 4 Weeks) of the 24-week Fixed-dose Steroid Treatment Period
-1.3 Puffs
Standard Deviation 2.84
-1.0 Puffs
Standard Deviation 2.50

SECONDARY outcome

Timeframe: Baseline to the end of the 24-week fixed-dose steroid treatment period (Week 24)

Population: Modified intent-to-treat population: All patients who were randomized, excluding patients from 2 sites due to Good Clinical Practice non-compliance. Excluded patients were replaced with patients at other sites to maintain statistical power.

PAQLQ measures functional problems that are most troublesome to children with asthma. PAQLQ has 23 questions in 3 domains (activity limitation=5, emotional function=8, symptoms=10). Patients responded to each question on a 7-point Likert scale. Overall PAQLQ score is mean of 23 questions; each domain score is mean of questions in that domain. Minimum possible value is 1 (maximum impairment); maximum possible value is 7 (no impairment). Positive change indicated improvement. The analysis included country, baseline PAQLQ value, and dosing schedule (2-weekly/4-weekly) as factors and covariates.

Outcome measures

Outcome measures
Measure
Omalizumab
n=375 Participants
Participants received omalizumab administered by subcutaneous injection every 2 or 4 weeks for a duration of 52 weeks. The omalizumab dose was based on the patient's body weight and total serum IgE level at Screening. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Placebo
n=187 Participants
Placebo was administered by subcutaneous injection every 2 or 4 weeks depending on the dosing schedule in the protocol for a total of 52 weeks. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Change in Pediatric Asthma Quality of Life Questionnaire (Standardized) [PAQLQ(S)] Scores From Baseline to the End of the 24-week Fixed-dose Steroid Treatment Period (Week 24)
Activity limitation
0.85 Units on a scale
Interval 0.72 to 0.99
0.76 Units on a scale
Interval 0.59 to 0.93
Change in Pediatric Asthma Quality of Life Questionnaire (Standardized) [PAQLQ(S)] Scores From Baseline to the End of the 24-week Fixed-dose Steroid Treatment Period (Week 24)
Emotional function
0.89 Units on a scale
Interval 0.76 to 1.03
0.91 Units on a scale
Interval 0.74 to 1.09
Change in Pediatric Asthma Quality of Life Questionnaire (Standardized) [PAQLQ(S)] Scores From Baseline to the End of the 24-week Fixed-dose Steroid Treatment Period (Week 24)
Symptoms
0.99 Units on a scale
Interval 0.85 to 1.13
0.93 Units on a scale
Interval 0.76 to 1.1
Change in Pediatric Asthma Quality of Life Questionnaire (Standardized) [PAQLQ(S)] Scores From Baseline to the End of the 24-week Fixed-dose Steroid Treatment Period (Week 24)
Overall (total)
0.92 Units on a scale
Interval 0.8 to 1.05
0.89 Units on a scale
Interval 0.73 to 1.05

Adverse Events

Omalizumab

Serious events: 27 serious events
Other events: 374 other events
Deaths: 0 deaths

Placebo

Serious events: 26 serious events
Other events: 194 other events
Deaths: 0 deaths

Serious adverse events

Serious adverse events
Measure
Omalizumab
n=421 participants at risk
Participants received omalizumab administered by subcutaneous injection every 2 or 4 weeks for a duration of 52 weeks. The omalizumab dose was based on the patient's body weight and total serum IgE level at Screening. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Placebo
n=207 participants at risk
Placebo was administered by subcutaneous injection every 2 or 4 weeks depending on the dosing schedule in the protocol for a total of 52 weeks. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Gastrointestinal disorders
Diarrhoea
0.00%
0/421
0.48%
1/207
Gastrointestinal disorders
Duodenal ulcer
0.00%
0/421
0.48%
1/207
Immune system disorders
Drug hypersensitivity
0.24%
1/421
0.00%
0/207
Infections and infestations
Acute sinusitis
0.24%
1/421
0.00%
0/207
Infections and infestations
Appendicitis
0.71%
3/421
0.48%
1/207
Infections and infestations
Bronchitis
0.48%
2/421
0.48%
1/207
Infections and infestations
Bronchitis bacterial
0.24%
1/421
0.00%
0/207
Infections and infestations
Croup infectious
0.24%
1/421
0.00%
0/207
Infections and infestations
Gastroenteritis shigella
0.48%
2/421
0.00%
0/207
Infections and infestations
Lower respiratory tract infection
0.00%
0/421
0.48%
1/207
Infections and infestations
Meningitis
0.00%
0/421
0.48%
1/207
Infections and infestations
Otitis media
0.24%
1/421
0.00%
0/207
Infections and infestations
Pneumonia
0.71%
3/421
2.9%
6/207
Infections and infestations
Respiratory syncytial virus infection
0.24%
1/421
0.00%
0/207
Infections and infestations
Sinusitis
0.00%
0/421
0.48%
1/207
Infections and infestations
Upper respiratory tract infection
0.24%
1/421
0.00%
0/207
Infections and infestations
Upper respiratory tract infection bacterial
0.00%
0/421
0.97%
2/207
Injury, poisoning and procedural complications
Head injury
0.24%
1/421
0.00%
0/207
Injury, poisoning and procedural complications
Joint dislocation
0.24%
1/421
0.00%
0/207
Injury, poisoning and procedural complications
Upper limb fracture
0.24%
1/421
0.00%
0/207
Metabolism and nutrition disorders
Dehydration
0.24%
1/421
0.00%
0/207
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Medulloblastoma
0.00%
0/421
0.48%
1/207
Nervous system disorders
Convulsion
0.24%
1/421
0.48%
1/207
Nervous system disorders
Syncope vasovagal
0.24%
1/421
0.00%
0/207
Pregnancy, puerperium and perinatal conditions
Pregnancy
0.00%
0/421
0.48%
1/207
Psychiatric disorders
Bipolar disorder
0.24%
1/421
0.00%
0/207
Psychiatric disorders
Suicide attempt
0.24%
1/421
0.00%
0/207
Psychiatric disorders
Tic
0.24%
1/421
0.00%
0/207
Respiratory, thoracic and mediastinal disorders
Asthma
4.0%
17/421
8.7%
18/207
Respiratory, thoracic and mediastinal disorders
Pneumonitis
0.24%
1/421
0.00%
0/207

Other adverse events

Other adverse events
Measure
Omalizumab
n=421 participants at risk
Participants received omalizumab administered by subcutaneous injection every 2 or 4 weeks for a duration of 52 weeks. The omalizumab dose was based on the patient's body weight and total serum IgE level at Screening. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Placebo
n=207 participants at risk
Placebo was administered by subcutaneous injection every 2 or 4 weeks depending on the dosing schedule in the protocol for a total of 52 weeks. The first 24 weeks of the treatment period was a fixed steroid phase where the steroid dose was maintained constant; in the following 28 weeks the steroid dose was adjustable, depending on the patient's condition. Following the 52-week treatment period, patients were followed up for an additional 16 weeks.
Gastrointestinal disorders
Abdominal pain
5.5%
23/421
5.8%
12/207
Gastrointestinal disorders
Diarrhoea
4.8%
20/421
5.8%
12/207
Gastrointestinal disorders
Vomiting
8.1%
34/421
11.6%
24/207
General disorders
Pyrexia
14.0%
59/421
9.7%
20/207
Infections and infestations
Bronchitis
8.6%
36/421
14.0%
29/207
Infections and infestations
Ear infection
5.2%
22/421
5.3%
11/207
Infections and infestations
Gastroenteritis
4.5%
19/421
7.2%
15/207
Infections and infestations
Gastroenteritis viral
5.5%
23/421
3.4%
7/207
Infections and infestations
Influenza
12.1%
51/421
13.5%
28/207
Infections and infestations
Nasopharyngitis
27.8%
117/421
27.1%
56/207
Infections and infestations
Pharyngitis
8.6%
36/421
8.7%
18/207
Infections and infestations
Pharyngitis streptococcal
4.5%
19/421
6.3%
13/207
Infections and infestations
Rhinitis
5.9%
25/421
9.7%
20/207
Infections and infestations
Sinusitis
16.6%
70/421
18.4%
38/207
Infections and infestations
Tonsillitis
1.7%
7/421
5.3%
11/207
Infections and infestations
Upper respiratory tract infection
16.2%
68/421
22.2%
46/207
Infections and infestations
Viral upper respiratory tract infection
8.1%
34/421
12.6%
26/207
Nervous system disorders
Headache
13.8%
58/421
15.9%
33/207
Respiratory, thoracic and mediastinal disorders
Asthma
68.9%
290/421
82.1%
170/207
Respiratory, thoracic and mediastinal disorders
Cough
10.5%
44/421
12.1%
25/207
Respiratory, thoracic and mediastinal disorders
Pharyngolaryngeal pain
7.8%
33/421
7.7%
16/207
Respiratory, thoracic and mediastinal disorders
Rhinitis allergic
8.3%
35/421
9.2%
19/207

Additional Information

Study Director

Novartis Pharmaceuticals

Phone: 862-778-8300

Results disclosure agreements

  • Principal investigator is a sponsor employee The terms and conditions of Novartis' agreements with its investigators may vary. However, Novartis does not prohibit any investigator from publishing. Any publications from a single-site are postponed until the publication of the pooled data (ie, data from all sites) in the clinical trial.
  • Publication restrictions are in place

Restriction type: OTHER