Adult Influenza VaccinationsSOPNCT01868334

SOP Toolkit in Diverse Practices Implemented & Tested With RE-AIM

A study testing Pillar 1: Convenient Vaccination Services, Pillar 2: Patient notification and Pillar 3: Enhanced Office Systems in people with Adult Influenza Vaccinations and Adult PPSV Vaccinations, run by University of Pittsburgh at 2 sites in United States.

Completed

Finished. The study has ended and is not enrolling. Results may be posted on the official record.

Official record

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Trial summary

Who is it for?: Ages 18 years and olderHealthy volunteers can take part
Conditions the study is for: Adult Influenza Vaccinations, Adult PPSV Vaccinations, Adult Tdap/Td Vaccinations
What is being tested?: Pillar 1: Convenient Vaccination Services, Pillar 2: Patient notification and Pillar 3: Enhanced Office Systems
Type of treatment: Vaccines, Lifestyle or therapy programme
Could I receive a placebo?: No, everyone receives an active treatment
How many people: 70,549 participants
Where: 2 sitesUnited States
Study dates: Apr 2013to Dec 2015
Phase: Interventional
Are there results?: Yes, posted in the registrySummary in the doctors' view

Key requirements

Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.

Ages 18 years and older
All sexes
Healthy volunteers accepted
Adult, Older adult

Who may be able to join

Site inclusion criteria:
1) an appropriate adult population: e.g., adults aged 50 years and older;
2) currently using an EMR that has prompt ability, such as EpicCare;
3) having and keeping immunization data within this EMR
Patient-level inclusion criteria:
1) Adults (18 years and above) who are active patients of the enrolled practices (e.g., active patients are those with a visit within the last 12 months)
2) All unvaccinated adults without a contraindication are eligible to receive Td/Tdap and influenza, regardless of age and at age 65 years or older are eligible for PPSV.

Who cannot join

Site exclusion criteria:
1) consistent SOP use for the 3 vaccines being studied or high vaccination rates (e.g., 80%)
Patient-level exclusion criteria:
1) those with a true contraindication, following the CDC's Guide to Contraindications (attached with the US Recommended Adult Immunization Schedule), such as prior vaccine anaphylaxis.

Trial locations and contacts

2 sites in 1 country.

United States2 sites

Baylor Colllege of Medicine
Houston, Texas, 77030
University of Pittsburgh, School of Medicine, Department of Family Medicine
Pittsburgh, Pennsylvania, 15213

Other trials in United States

About this study

Official title: A Vaccination SOP Toolkit in Diverse Practices Implemented & Tested With RE-AIM

The purpose of this study is to test whether or not the 4 Pillars Toolkit increases adult Influenza, pneumococcal polysaccharide vaccine (PPSV), tetanus, adult diphtheria and acellular pertussis vaccine (Tdap/Td) vaccination rates. The vaccines are all FDA licensed vaccines and to be used according to national guidelines. The investigators will conduct a randomized cluster trial of this toolkit in diverse primary care practice with electronic medical records (EMRs).

Read the detailed description

This intervention is a two-region, two-year, stratified randomized cluster trial in 24 primary care practices with EMRs. These practices will be randomly assigned to be intervention or control sites to test this 4 Pillars Toolkit intervention package of evidence-based techniques tailored to their practice structure and culture; one set of practices randomized to intervention in year 1 and the other to control. In year 2, the other set of practices will receive the intervention and community controls may be sought.

These diverse practices consist of: 18 diverse practices from UPMC in western Pennsylvania and 6 diverse practices from large community health centers in a PBRN in Texas.

Conditions: Adult Influenza Vaccinations, Adult PPSV Vaccinations, Adult Tdap/Td Vaccinations
Being tested: Pillar 1: Convenient Vaccination Services, Pillar 2: Patient notification, Pillar 3: Enhanced Office Systems, Pillar 4: Motivation
Keywords: influenza vaccine, PPSV, Tdap, vaccination, adult
Medical subject headings: Influenza, Human

What participants receive

What participants receive. In a randomised study each person is assigned to one group by chance.

Pillar 1: Convenient Vaccination ServicesBehavioural
Extend Vaccination Season: Begin vaccinating for influenza as soon as vaccine arrives; use every visit as opportunity to vaccinate; extend the season for influenza by vaccinating in January and beyond.
Use Express Vaccination services such as influenza vaccination clinics, Open access vaccine scheduling (for all vaccines), or dedicated vaccination station. When giving influenza vaccination, screen for need for PPSV/Tdap.
Pillar 2: Patient notificationBehavioural
Patient Education: notifying patients of doctor recommendations for vaccination; providing information on express vaccination services via email, autodialer, "on-hold" messages, clinic websites, and/or social media
Pillar 3: Enhanced Office SystemsBehavioural
Routine assessment for office systems flow to ensure staff consistently promoting vaccination: utilization of EMR prompts, review of Immunization tabs within EMR, and/or checking vaccination status as part of vital signs when rooming. Empower staff to vaccinate by use of a standing orders program (SOP). Order a sufficient supply of vaccination to cover increased rates
Pillar 4: MotivationBehavioural
Utilization of an Office Immunization Champion who will track overall progress towards their goal - setting a goal of increased rates of 20 to 25% for influenza vaccine; monitoring and sharing progress with staff regularly; and changing office systems flow as needed to increased vaccination rates.

Study groups in NCT01868334
Study group	Role	What they receive
Intervention with the Toolkit	Experimental	Pillar 1: Convenient Vaccination Services Pillar 2: Patient notification Pillar 3: Enhanced Office Systems Pillar 4: Motivation 13 clinical practices (intervention sites) will receive the Toolkit in Year 1 to increase their adult influenza, PPSV, Tdap/Td vaccination rates. In Year 2, those who choose to continue will "maintain" use of the Toolkit and online resources available but will receive no active intervention from study staff. Receives: Behavioral: Pillar 1: Convenient Vaccination Services; Behavioral: Pillar 2: Patient notification; Behavioral: Pillar 3: Enhanced Office Systems; Behavioral: Pillar 4: Motivation
12 clinical practices (control sites)	No intervention	12 diverse clinical practices will receive no additional assistance in Year 1 to increase their adult influenza, PPSV, Tdap/Td vaccination rates, they will follow guidelines for usual care. In Year 2 however they will become intervention sites and receive the 4 Pillars Toolkit for use in increasing vaccination rates

What is being measured

The primary outcome is the main question the study is designed to answer.

Year 1 RCCT: Change From Baseline in the Percentage of Participants Who Were Vaccinated at the End of Year 1
Outcome listed is total percentage point difference in vaccination rates from baseline to end of year 1
Measured: % vaccinated by 5/31/2014 (Tdap, Pneumococcal); % vaccinated by 1/31/2014 (Influenza)

Secondary outcomes (1)

Year 2 Pre-post Study: Change From Year 1 in the Percentage of Participants Who Were Vaccinated at the End of Year 2
Outcome listed is total percentage point difference in vaccination rates from end of year 1 to end of year 2
Measured: % vaccinated by 1/31/2015

Timeline

From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.

Apr 2013Dec 2015

First posted4 Jun 2013 (estimated)
Study startApr 2013
Primary completionMay 2015
Study completionDec 2015

Resources

Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
Posted resultsParticipant flow, outcome measures and adverse events reported by the sponsor.
Publications (3)Papers the sponsor has linked to this study.
Other trials for Adult Influenza VaccinationsStudies of the same condition, open and under way.
More trials run by University of PittsburghThe sponsor's other registered studies.
What the trial phases meanHow a treatment moves from first tests in people to approval.

More details

For doctors and researchers: how the study is designed, who runs it, and its registry IDs.

Study design

Study type: Interventional
Phase: Phase N/A
Primary purpose: Health services research
Allocation: Randomised
Intervention model: Single group
Masking: None (open label)
Enrolment: 70,549 participants (actual)

IDs, dates and publications

ClinicalTrials.gov ID: NCT01868334
Sponsor's protocol ID: CDC-1U01IP000662-01
Acronym: SOP
Status last verified: Oct 2023
First submitted: 20 Mar 2013
Last updated: 6 Oct 2023
Results posted: Yes, on ClinicalTrials.gov
Data monitoring committee: No
Individual data sharing: No

Publications

Lin CJ, Nowalk MP, Pavlik VN, Brown AE, Zhang S, Raviotta JM, Moehling KK, Hawk M, Ricci EM, Middleton DB, Patel S, South-Paul JE, Zimmerman RK. Using the 4 pillars practice transformation program to increase adult influenza vaccination and reduce missed opportunities in a randomized cluster trial. BMC Infect Dis. 2016 Nov 3;16(1):623. doi: 10.1186/s12879-016-1940-1.
PubMed 27809793
Zimmerman RK, Brown AE, Pavlik VN, Moehling KK, Raviotta JM, Lin CJ, Zhang S, Hawk M, Kyle S, Patel S, Ahmed F, Nowalk MP. Using the 4 Pillars Practice Transformation Program to Increase Pneumococcal Immunizations for Older Adults: A Cluster-Randomized Trial. J Am Geriatr Soc. 2017 Jan;65(1):114-122. doi: 10.1111/jgs.14451. Epub 2016 Oct 18.
PubMed 27755655
Nowalk MP, Lin CJ, Pavlik VN, Brown AE, Zhang S, Moehling KK, Raviotta JM, South-Paul JE, Hawk M, Ricci EM, Middleton DB, Patel SA, Ahmed F, Zimmerman RK. Using the 4 Pillars Practice Transformation Program to increase adult Tdap immunization in a randomized controlled cluster trial. Vaccine. 2016 Sep 22;34(41):5026-5033. doi: 10.1016/j.vaccine.2016.07.053. Epub 2016 Aug 26.
PubMed 27576073

Want to know more?

The sponsor has not listed a contact. The official record may have more details.

Talk to your doctor first and take this page with you. Only the study team can confirm whether you can join.

Questions to ask the study team

What is the study trying to find out?
What would I need to do, and how often would I visit?
Could I receive a placebo instead of the treatment?
What are the possible risks and benefits for me?
Will it cost me anything? Are travel or time paid for?
Can I keep seeing my own doctor during the study?
What happens when the study ends?

See locations

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All Adult Influenza Vaccinations trials

Study at a glance

From the registry record, last updated by the sponsor on 6 Oct 2023. Recruitment status is as the sponsor reported it: confirm with the study team.

Official title: A Vaccination SOP Toolkit in Diverse Practices Implemented & Tested With RE-AIM
ClinicalTrials.gov ID: NCT01868334
Acronym / sponsor ID: SOP / CDC-1U01IP000662-01
Conditions: Adult Influenza Vaccinations, Adult PPSV Vaccinations, Adult Tdap/Td Vaccinations
Keywords: influenza vaccine, PPSV, Tdap, vaccination, adult
Study type: Interventional
Recruitment status: Completed
Enrolment: 70,549 participants (actual)
Lead sponsor: University of PittsburghUniversity, hospital or other
Collaborators: Centers for Disease Control and Prevention, Baylor College of Medicine
Study start: Apr 2013
Primary completion: May 2015 (actual)
Study completion: Dec 2015 (actual)
First posted: 4 Jun 2013 (estimated)
Results: Posted 2 Oct 2017

Clinical summary

The research question as the sponsor registered it. This describes what the study plans to test, not what it found.

Detailed description

These diverse practices consist of: 18 diverse practices from UPMC in western Pennsylvania and 6 diverse practices from large community health centers in a PBRN in Texas.

Study design

Primary purpose: Health services research
Allocation: Randomised
Intervention model: Single group
Masking: None (open label)
Number of arms: 2

Arm	Type	Receives
Intervention with the Toolkit	Experimental	Behavioral: Pillar 1: Convenient Vaccination Services, Behavioral: Pillar 2: Patient notification, Behavioral: Pillar 3: Enhanced Office Systems, Behavioral: Pillar 4: MotivationPillar 1: Convenient Vaccination Services Pillar 2: Patient notification Pillar 3: Enhanced Office Systems Pillar 4: Motivation 13 clinical practices (intervention sites) will receive the Toolkit in Year 1 to increase their adult influenza, PPSV, Tdap/Td vaccination rates. In Year 2, those who choose to continue will "maintain" use of the Toolkit and online resources available but will receive no active intervention from study staff.
12 clinical practices (control sites)	No intervention	–12 diverse clinical practices will receive no additional assistance in Year 1 to increase their adult influenza, PPSV, Tdap/Td vaccination rates, they will follow guidelines for usual care. In Year 2 however they will become intervention sites and receive the 4 Pillars Toolkit for use in increasing vaccination rates

Who may qualify

Ages: 18 years and older
Sex: All
Healthy volunteers: Accepted
Age groups: Adult, Older adult

Key inclusion criteria (7 listed)

1) an appropriate adult population: e.g., adults aged 50 years and older;
2) currently using an EMR that has prompt ability, such as EpicCare;
3) having and keeping immunization data within this EMR
1) Adults (18 years and above) who are active patients of the enrolled practices (e.g., active patients are those with a visit within the last 12 months)
2) All unvaccinated adults without a contraindication are eligible to receive Td/Tdap and influenza, regardless of age and at age 65 years or older are eligible for PPSV.

Key exclusion criteria (4 listed)

1) consistent SOP use for the 3 vaccines being studied or high vaccination rates (e.g., 80%)
1) those with a true contraindication, following the CDC's Guide to Contraindications (attached with the US Recommended Adult Immunization Schedule), such as prior vaccine anaphylaxis.

Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.

Interventions

Intervention	Type	Arms
Pillar 1: Convenient Vaccination ServicesExtend Vaccination Season: Begin vaccinating for influenza as soon as vaccine arrives; use every visit as opportunity to vaccinate; extend the season for influenza by vaccinating in January and beyond. Use Express Vaccination services such as influenza vaccination clinics, Open access vaccine scheduling (for all vaccines), or dedicated vaccination station. When giving influenza vaccination, screen for need for PPSV/Tdap.	Behavioural	Intervention with the Toolkit
Pillar 2: Patient notificationPatient Education: notifying patients of doctor recommendations for vaccination; providing information on express vaccination services via email, autodialer, "on-hold" messages, clinic websites, and/or social media	Behavioural	Intervention with the Toolkit
Pillar 3: Enhanced Office SystemsRoutine assessment for office systems flow to ensure staff consistently promoting vaccination: utilization of EMR prompts, review of Immunization tabs within EMR, and/or checking vaccination status as part of vital signs when rooming. Empower staff to vaccinate by use of a standing orders program (SOP). Order a sufficient supply of vaccination to cover increased rates	Behavioural	Intervention with the Toolkit
Pillar 4: MotivationUtilization of an Office Immunization Champion who will track overall progress towards their goal - setting a goal of increased rates of 20 to 25% for influenza vaccine; monitoring and sharing progress with staff regularly; and changing office systems flow as needed to increased vaccination rates.	Behavioural	Intervention with the Toolkit

Primary outcome

Year 1 RCCT: Change From Baseline in the Percentage of Participants Who Were Vaccinated at the End of Year 1
Time frame: % vaccinated by 5/31/2014 (Tdap, Pneumococcal); % vaccinated by 1/31/2014 (Influenza)
Outcome listed is total percentage point difference in vaccination rates from baseline to end of year 1

1 secondary outcome

Year 2 Pre-post Study: Change From Year 1 in the Percentage of Participants Who Were Vaccinated at the End of Year 2
Time frame: % vaccinated by 1/31/2015

Results and safety

Results posted to the registry on 2 Oct 2017, as reported by the sponsor. Figures are copied from the record, not re-analysed. Full results on ClinicalTrials.gov.

Participant flow

Group	Started	Completed
Pittsburgh Intervention Sites	13,186	13,186
Pittsburgh Control/Maintenance Sites	17,185	17,185
Houston Intervention Sites	19,274	19,274
Houston Control/Maintenance Sites	20,904	20,904

Primary outcome: Year 1 RCCT: Change From Baseline in the Percentage of Participants Who Were Vaccinated at the End of Year 1

Time frame: % vaccinated by 5/31/2014 (Tdap, Pneumococcal); % vaccinated by 1/31/2014 (Influenza). Number. Unit: percent change in vaccination rates

Measure	Year 1 RCCT Pittsburgh Intervention Sites - Tdap Vaccination n = 13,186	Year 1 RCCT Pittsburgh Control Sites - Tdap Vaccination n = 17,185	Year 1 RCCT Pittsburgh Intervention Sites - Pneumococcal Vacc n = 6,095	Year 1 RCCT Pittsburgh Control Sites - Pneumococcal Vaccine n = 6,223	Year 1 RCCT Pittsburgh Intervention Sites - Influenza Vaccine n = 13,186	Year 1 RCCT Pittsburgh Control Sites - Influenza Vaccine n = 17,185	Year 1 RCCT Houston Intervention Sites - Tdap Vaccination n = 19,274	Year 1 RCCT Houston Control Sites - Tdap Vaccination n = 20,904	Year 1 RCCT Houston Intervention Sites - Pneumococcal Vaccine n = 3,010	Year 1 RCCT Houston Control Sites - Pneumococcal Vaccine n = 2,779	Year 1 RCCT Houston Intervention Sites - Influenza Vaccination n = 19,274	Year 1 RCCT Houston Control Sites - Influenza Vaccination n = 20,904
Value	7.7	6.4	6.5	6.6	5.0	6.5	9.9	7.6	8.7	6.5	2.7	5.2

Year 1 RCCT Pittsburgh Intervention Sites - Tdap Vaccination vs Year 1 RCCT Pittsburgh Control Sites - Tdap Vaccination vs Year 1 RCCT Pittsburgh Intervention Sites - Pneumococcal Vacc vs Year 1 RCCT Pittsburgh Control Sites - Pneumococcal Vaccine vs Year 1 RCCT Houston Intervention Sites - Tdap Vaccination vs Year 1 RCCT Houston Control Sites - Tdap Vaccination vs Year 1 RCCT Houston Intervention Sites - Pneumococcal Vaccine vs Year 1 RCCT Houston Control Sites - Pneumococcal Vaccine: p = 0.05, Chi-squared
Year 1 RCCT Pittsburgh Intervention Sites - Influenza Vaccine vs Year 1 RCCT Pittsburgh Control Sites - Influenza Vaccine vs Year 1 RCCT Houston Intervention Sites - Influenza Vaccination vs Year 1 RCCT Houston Control Sites - Influenza Vaccination: p = 0.05, Cochran-Armitage trend test

1 secondary outcome is reported in the full results.

Adverse events

Time frame: 3 years (Baseline, Year 1, Year 2). Other adverse events reported at 0% frequency or more

Group	Serious adverse events	Other adverse events	Deaths
Year 1 RCCT Pittsburgh Intervention Sites - Tdap Vaccination	0 of 13,186 (0%)	0 of 13,186 (0%)	0 of 13,186
Year 1 RCCT Pittsburgh Control Sites - Tdap Vaccination	0 of 17,185 (0%)	0 of 17,185 (0%)	0 of 17,185
Year 1 RCCT Pittsburgh Intervention Sites - Pneumococcal Vacc	0 of 6,095 (0%)	0 of 6,095 (0%)	0 of 6,095
Year 1 RCCT Pittsburgh Control Sites - Pneumococcal Vaccine	0 of 6,223 (0%)	0 of 6,223 (0%)	0 of 6,223
Year 1 RCCT Pittsburgh Intervention Sites - Influenza Vaccine	0 of 13,186 (0%)	0 of 13,186 (0%)	0 of 13,186
Year 1 RCCT Pittsburgh Control Sites - Influenza Vaccine	0 of 17,185 (0%)	0 of 17,185 (0%)	0 of 17,185
Year 1 RCCT Houston Intervention Sites - Tdap Vaccination	0 of 19,274 (0%)	0 of 19,274 (0%)	0 of 19,274
Year 1 RCCT Houston Control Sites - Tdap Vaccination	0 of 20,904 (0%)	0 of 20,904 (0%)	0 of 20,904
Year 1 RCCT Houston Intervention Sites - Pneumococcal Vaccine	0 of 3,010 (0%)	0 of 3,010 (0%)	0 of 3,010
Year 1 RCCT Houston Control Sites - Pneumococcal Vaccine	0 of 2,779 (0%)	0 of 2,779 (0%)	0 of 2,779
Year 1 RCCT Houston Intervention Sites - Influenza Vaccination	0 of 19,274 (0%)	0 of 19,274 (0%)	0 of 19,274
Year 1 RCCT Houston Control Sites - Influenza Vaccination	0 of 20,904 (0%)	0 of 20,904 (0%)	0 of 20,904

Limitations and caveats (from the sponsor): The limitations of this study included late delivery of influenza vaccine in Year 1 in the Pittsburgh sites, delay of EMR data for reporting study progress to sites (all vaccines) and vaccine increases in control arm (Tdap and PPSV) during Year 1.

Loading the posted results from ClinicalTrials.gov…

Research links

Official record on ClinicalTrials.govLast updated by the sponsor 6 Oct 2023.
Posted resultsParticipant flow, baseline, all outcome measures and adverse events.
Results publication: PubMed 27809793Lin CJ, Nowalk MP, Pavlik VN, Brown AE, Zhang S, Raviotta JM, Moehling KK, Hawk M, Ricci EM, Middleton DB, Patel S, South-Paul JE, Zimmerman RK. Using the 4 pillars practice transformation program to increase adult influenza vaccination and reduce missed opportunities in a randomized cluster trial. BMC Infect Dis. 2016 Nov 3;16(1):623. doi: 10.1186/s12879-016-1940-1.
Results publication: PubMed 27755655Zimmerman RK, Brown AE, Pavlik VN, Moehling KK, Raviotta JM, Lin CJ, Zhang S, Hawk M, Kyle S, Patel S, Ahmed F, Nowalk MP. Using the 4 Pillars Practice Transformation Program to Increase Pneumococcal Immunizations for Older Adults: A Cluster-Randomized Trial. J Am Geriatr Soc. 2017 Jan;65(1):114-122. doi: 10.1111/jgs.14451. Epub 2016 Oct 18.
Results publication: PubMed 27576073Nowalk MP, Lin CJ, Pavlik VN, Brown AE, Zhang S, Moehling KK, Raviotta JM, South-Paul JE, Hawk M, Ricci EM, Middleton DB, Patel SA, Ahmed F, Zimmerman RK. Using the 4 Pillars Practice Transformation Program to increase adult Tdap immunization in a randomized controlled cluster trial. Vaccine. 2016 Sep 22;34(41):5026-5033. doi: 10.1016/j.vaccine.2016.07.053. Epub 2016 Aug 26.
Individual participant dataSharing planned: No

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Referral and contact

AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.

Mary Patricia Nowalk, PhD, RD study director

University of Pittsburgh, School of Medicine, Department of Family Medicine

Anthony E Brown, MD MPH study director

Baylor College of Medicine

2 sites in 1 country: see every site and its status.

Questions about this trial

What is this clinical trial studying?

The full registered description is in the About this study section and the official record.

Who may be eligible to take part?

The sponsor lists 7 inclusion and 4 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.

Is this clinical trial currently recruiting?

The record says: finished, as of the sponsor's last update on 6 Oct 2023. Status can change between updates, so confirm with the study contact before making plans.

Where is the study taking place?

The record lists 2 sites in United States. Whether a site is taking part right now should be confirmed with that site. See every site.

What are the possible benefits and risks?

They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.

Are results available for this study?

Yes. Results are posted in the registry (first posted 2 Oct 2017). A summary is in the For doctors view, and the full results are on ClinicalTrials.gov.

How can a doctor refer a patient or contact the research team?

The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.

What does the primary outcome measure?

Year 1 RCCT: Change From Baseline in the Percentage of Participants Who Were Vaccinated at the End of Year 1 (time frame: % vaccinated by 5/31/2014 (Tdap, Pneumococcal); % vaccinated by 1/31/2014 (Influenza)). It is what the study was designed to measure, not a finding.

Where can I read the original study information?

On the ClinicalTrials.gov record for NCT01868334, which also lists 3 linked publications.

Does a listing mean the treatment is approved or proven to work?

No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.

How often is this information updated?

AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 6 Oct 2023.