Roflumilast in Chronic Obstructive Pulmonary Disease (COPD) Patients Treated With Fixed Dose Combinations of Long-acting β2-agonist (LABA) and Inhaled Corticosteroid (ICS)

Phase 4

Completed

• Conditions: COPD; Respiratory Disorders; Pulmonary Disease; Lung Diseases; Chronic Obstructive Lung Diseases; COPD Exacerbation; Chronic Obstructive Airway Disease
• Interventions: Drug: Roflumilast; Drug: Placebo

• Registration Number: NCT01443845
• Lead Sponsor: AstraZeneca

Brief Summary

To demonstrate the additional benefit of roflumilast when added on to fixed-dose combination (FDC) LABA/ICS in the reduction of exacerbations in subjects with severe to very severe COPD.

Detailed Description

Not available

Study Timeline

• Study First Submitted: 2011-09-28
• Study First Submitted QC: 2011-09-28
• Study Start: 2011-09-30
• Study First Posted: 2011-09-30
• Primary Completion: 2015-11-30
• Study Completion: 2016-01-31
• Results First Submitted: 2016-11-30
• Results First Submitted QC: 2016-11-30
• Results First Posted: 2017-01-25
• Status Verified: 2017-03
• Last Update Submitted: 2017-03-16
• Last Update Posted: 2017-04-13

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 2354

Inclusion Criteria

• 1. Male or female patients at least 40 years of age
• 2. History of COPD (according to Global Initiative for Chronic Obstructive Lung Disease [GOLD] 2010) for at least 12 months prior to Screening (Visit 1) associated with chronic productive cough for 3 months in each of 2 consecutive years (with other causes of productive cough excluded). Only patients with chronic bronchitis will be included (concomitant emphysema is permitted)
• 3. Forced expiratory volume after 1 second (FEV1)/forced vital capacity (FVC) ratio (postbronchodilator) < 70% at Screening (Visit 1)
• 4. FEV1 (postbronchodilator) ≤ 50% of predicted at Screening (Visit 1)
• 5. At least two documented moderate or severe COPD exacerbations within 12 months prior to Screening (Visit 1)
• 6. Patients must be on FDC LABA/ICS treatment ≥ 3 months prior to Screening (Visit 1)
• 7. Former smokers (defined as smoking cessation at least 1 year ago) or current smokers (including patients who ceased smoking within the past year) both with a smoking history of at least 20 pack-years

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Exclusion Criteria

• 1. Moderate or severe COPD exacerbation and/or COPD exacerbations treated with antibiotics or systemic glucocorticosteroids within 4 weeks of Screening (Visit 1) (ie, patients must be clinically stable)
• 2. Known alpha-1-antitrypsin deficiency
• 3. Current diagnosis of asthma (either controlled or uncontrolled) (Note: History of childhood asthma is not exclusionary.)
• 4. Body mass index (BMI) ≥ 45 kg/m2
• 5. Patients with a history (within 5 years) or current diagnosis of cancer other than basal or squamous cell skin cancer

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Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
1	Roflumilast	Roflumilast
2	Placebo	Placebo

Primary Outcome Measures

Name	Time	Method
Rate of Moderate or Severe COPD Exacerbations Per Patient Per Year.	Baseline to Week 52	Rate of moderate or severe COPD exacerbations, defined as requiring oral or parenteral glucocorticosteroids (moderate) or requiring hospitalization and/or leading to death (severe), during the double-blind treatment period.

Secondary Outcome Measures

Name	Time	Method
Rate of COPD Exacerbations That Led to Hospitalization or Death (ie, Severe COPD Exacerbations)	Week 0 (Visit 2) to Week 52	Rate of moderate or severe COPD exacerbations, defined as requiring hospitalization and/or leading to death (severe), during the double-blind treatment period.
Rate of Moderate or Severe COPD Exacerbations or COPD Exacerbations Treated With Antibiotics	Week 0 (Visit 2) to Week 52	Rate of moderate or severe COPD exacerbations treated with antibiotics during the double-blind treatment period.
Mean Change in Predose Forced Expiratory Volume in 1 Second (FEV1)	Week 0 (Visit 2) to Week 52	Mean change from randomization (Visit 2) over 52 weeks of treatment in predose forced expiratory volume in 1 second (FEV1)

Trial Locations

Locations (338)

Forest Investigative Site 612; 🇷🇺 St. Petersburg, Russian Federation

Forest Investigative Site 600; 🇷🇺 St Petersburg, Russian Federation

Forest Investigative Site 248; 🇺🇸 Baltimore, Maryland, United States

Forest Investigative Site 205; 🇺🇸 Philadelphia, Pennsylvania, United States

Forest Investigative Site 364; 🇺🇸 Pittsburgh, Pennsylvania, United States

Forest Investigative Site 344; 🇺🇸 Pittsburgh, Pennsylvania, United States

Forest Investigative Site 312; 🇺🇸 Houston, Texas, United States

Forest Investigative Site 027; 🇺🇸 Miami, Florida, United States

Forest Investigative Site 604; 🇷🇺 St. Petersburg, Russian Federation

Forest Investigative Site 611; 🇷🇺 St. Petersburg, Russian Federation

Forest Investigative Site 607; 🇷🇺 Tomsk, Russian Federation

Forest Investigative Site 622; 🇷🇸 Belgrade, Serbia

Forest Investigative Site 624; 🇷🇸 Belgrade, Serbia

Forest Investigative Site 690; 🇺🇦 Ivano-Frankivsk, Ukraine

Forest Investigative Site 692; 🇺🇦 Donetsk, Ukraine

Forest Investigative Site 681; 🇺🇦 Lviv, Ukraine

Forest Investigative Site 708; 🇺🇦 Mykolayiv, Ukraine

Forest Investigative Site 662; 🇹🇭 Hat Yai, Songkhla, Thailand

Forest Investigative Site 301; 🇺🇸 Wichita, Kansas, United States

Forest Investigative Site 211; 🇺🇸 Phoenix, Arizona, United States

Forest Investigative Site 404; 🇦🇷 Mendoza, Argentina

Forest Investigative Site 442; 🇨🇴 Bogota, Colombia

Forest Investigative Site 108; 🇺🇸 Lincoln, Nebraska, United States

Forest Investigative Site 270; 🇺🇸 Henderson, Nevada, United States

Forest Investigative Site 233; 🇺🇸 Gaffney, South Carolina, United States

Forest Investigative Site 501; 🇲🇾 Kuala Lumpur, Malaysia

Forest Investigative Site 504; 🇲🇾 Kuala Lumpur, Malaysia

Forest Investigative Site 300; 🇺🇸 Pelzer, South Carolina, United States

Forest Investigative Site 410; 🇦🇷 Florencio Varela, Argentina

Forest Investigative Site 505; 🇲🇾 Batu Caves, Malaysia

Forest Investigative Site 524; 🇲🇽 Guadalajara, Mexico

Forest Investigative Site 545; 🇵🇪 Lima, Peru

Forest Investigative Site 584; 🇷🇴 Bucharest, Romania

Forest Investigative Site 618; 🇷🇺 Kemerovo, Russian Federation

Forest Investigative Site 327; 🇺🇸 Clifton, New Jersey, United States

Forest Investigative Site 197; 🇺🇸 Bellevue, Nebraska, United States

Forest Investigative Site 008; 🇺🇸 Coeur d' Alene, Idaho, United States

Forest Investigative Site 124; 🇺🇸 Newark, Delaware, United States

Forest Investigative Site 029; 🇺🇸 Missoula, Montana, United States

Forest Investigative Site 079; 🇺🇸 Henderson, Nevada, United States

Forest Investigative Site 333; 🇺🇸 Butte, Montana, United States

Forest Investigative Site 208; 🇺🇸 Fort Smith, Arkansas, United States

Forest Investigative Site 331; 🇺🇸 Stamford, Connecticut, United States

Forest Investigative Site 335; 🇺🇸 Charleston, West Virginia, United States

Forest Investigative Site 091; 🇺🇸 Peoria, Arizona, United States

Forest Investigative Site 119; 🇺🇸 Eagle, Idaho, United States

Forest Investigative Site 273; 🇺🇸 Lafayette, Louisiana, United States

Forest Investigative Site 502; 🇲🇾 Kuantan, Malaysia

Forest Investigative Site 526; 🇲🇽 Merida, Yucatan, Mexico

Forest Investigative Site 586; 🇷🇴 Bucharest, Romania

Forest Investigative Site 625; 🇷🇸 Beograd, Serbia

Forest Investigative Site 663; 🇹🇭 Bangkok, Thailand

Forest Investigative Site 689; 🇺🇦 Donetsk, Ukraine

Forest Investigative Site 337; 🇺🇸 Fremont, Nebraska, United States

Forest Investigative Site 257; 🇺🇸 Fort Mill, South Carolina, United States

Forest Investigative Site 544; 🇵🇪 Lima, Peru

Forest Investigative Site 407; 🇦🇷 Parana, Entre Rios, Argentina

Forest Investigative Site 416; 🇦🇷 Ciudad Autonoma de Buenos Aires, Argentina

Forest Investigative Site 567; 🇵🇭 Iloilo City, Philippines

Forest Investigative Site 562; 🇵🇭 Quezon City, Philippines

Forest Investigative Site 605; 🇷🇺 Novosibirsk, Russian Federation

Forest Investigative Site 319; 🇺🇸 Morgantown, West Virginia, United States

Forest Investigative Site 235; 🇨🇦 Calgary, Alberta, Canada

Forest Investigative Site 050; 🇺🇸 Fayetteville, Tennessee, United States

Forest Investigative Site 405; 🇦🇷 La Plata, Buenos Aires, Argentina

Forest Investigative Site 185; 🇨🇦 Montreal, Quebec, Canada

Forest Investigative Site 421; 🇨🇱 Talcahuano, Chile

Forest Investigative Site 564; 🇵🇭 Quezon City, Philippines

Forest Investigative Site 409; 🇦🇷 Rosario, Santa Fe, Argentina

Forest Investigative Site 406; 🇦🇷 Lanús Este, Provincia de Buenos Aires, Argentina

Forest Investigative Site 414; 🇦🇷 Ciudad Autonoma de Buenos Aires, Argentina

Forest Investigative Site 419; 🇦🇷 Ciudad Autonoma de Buenos Aires, Argentina

Forest Investigative Site 551; 🇵🇪 Lima, Peru

Forest Investigative Site 565; 🇵🇭 Manila, Philippines

Forest Investigative Site 563; 🇵🇭 Pasig City, Philippines

Forest Investigative Site 566; 🇵🇭 Quezon City, Philippines

Forest Investigative Site 619; 🇷🇺 St. Petersburg, Russian Federation

Forest Investigative Site 610; 🇷🇺 St. Petersburg, Russian Federation

Forest Investigative Site 606; 🇷🇺 St.Petersburg, Russian Federation

Forest Investigative Site 629; 🇷🇸 Knez Selo, Nišava District, Serbia

Forest Investigative Site 661; 🇹🇭 Muang, Thailand

Forest Investigative Site 706; 🇺🇦 Poltava, Ukraine

Forest Investigative Site 695; 🇺🇦 Sumy, Ukraine

Forest Investigative Site 412; 🇦🇷 Rosario, Santa Fe, Argentina

Forest Investigative Site 127; 🇨🇦 Saskatoon, Saskatchewan, Canada

Forest Investigative Site 722; 🇨🇳 Taipei, Taiwan

Forest Investigative Site 617; 🇷🇺 Moscow, Russian Federation

Forest Investigative Site 724; 🇨🇳 Puzih City, Taiwan

Forest Investigative Site 601; 🇷🇺 St. Petersburg, Russian Federation

Forest Investigative Site 620; 🇷🇺 Yaroslavl, Russian Federation

Forest Investigative Site 623; 🇷🇸 Belgrade, Serbia

Forest Investigative Site 725; 🇨🇳 Taipei, Taiwan

Forest Investigative Site 688; 🇺🇦 Zaporizhzhia, Ukraine

Forest Investigative Site 167; 🇺🇸 Oklahoma City, Oklahoma, United States

Forest Investigative Site 281; 🇺🇸 Oklahoma City, Oklahoma, United States

Forest Investigative Site 289; 🇺🇸 Portland, Oregon, United States

Forest Investigative Site 218; 🇺🇸 Portland, Oregon, United States

Forest Investigative Site 101; 🇺🇸 Little Rock, Arkansas, United States

Forest Investigative Site 272; 🇺🇸 Mesa, Arizona, United States

Forest Investigative Site 081; 🇺🇸 Anniston, Alabama, United States

Forest Investigative Site 074; 🇺🇸 Bellflower, California, United States

Forest Investigative Site 065; 🇺🇸 Athens, Alabama, United States

Forest Investigative Site 245; 🇺🇸 Fullerton, California, United States

Forest Investigative Site 310; 🇺🇸 Garden Grove, California, United States

Forest Investigative Site 034; 🇺🇸 Phoenix, Arizona, United States

Forest Investigative Site 247; 🇺🇸 Phoenix, Arizona, United States

Forest Investigative Site 188; 🇺🇸 Phoenix, Arizona, United States

Forest Investigative Site 060; 🇺🇸 Fresno, California, United States

Forest Investigative Site 329; 🇺🇸 Fresno, California, United States

Forest Investigative Site 299; 🇺🇸 Northridge, California, United States

Forest Investigative Site 268; 🇺🇸 Pismo Beach, California, United States

Forest Investigative Site 085; 🇺🇸 Los Angeles, California, United States

Forest Investigative Site 196; 🇺🇸 Brandon, Florida, United States

Forest Investigative Site 025; 🇺🇸 Riverside, California, United States

Forest Investigative Site 116; 🇺🇸 Long Beach, California, United States

Forest Investigative Site 213; 🇺🇸 Palo Alto, California, United States

Forest Investigative Site 352; 🇺🇸 San Diego, California, United States

Forest Investigative Site 038; 🇺🇸 San Diego, California, United States

Forest Investigative Site 187; 🇺🇸 Ormond Beach, Florida, United States

Forest Investigative Site 069; 🇺🇸 Pensacola, Florida, United States

Forest Investigative Site 357; 🇺🇸 Saint Petersburg, Florida, United States

Forest Investigative Site 224; 🇺🇸 Brandon, Florida, United States

Forest Investigative Site 326; 🇺🇸 San Jose, California, United States

Forest Investigative Site 077; 🇺🇸 Kissimmee, Florida, United States

Forest Investigative Site 023; 🇺🇸 Jacksonville, Florida, United States

Forest Investigative Site 209; 🇺🇸 Torrance, California, United States

Forest Investigative Site 123; 🇺🇸 Clearwater, Florida, United States

Forest Investigative Site 017; 🇺🇸 Waterbury, Connecticut, United States

Forest Investigative Site 358; 🇺🇸 Brandon, Florida, United States

Forest Investigative Site 239; 🇺🇸 DeFuniak Springs, Florida, United States

Forest Investigative Site 330; 🇺🇸 Kissimmee, Florida, United States

Forest Investigative Site 229; 🇺🇸 Miami, Florida, United States

Forest Investigative Site 121; 🇺🇸 St. Petersburg, Florida, United States

Forest Investigative Site 165; 🇺🇸 Fort Walton Beach, Florida, United States

Forest Investigative Site 001; 🇺🇸 Fort Lauderdale, Florida, United States

Forest Investigative Site 003; 🇺🇸 Hollywood, Florida, United States

Forest Investigative Site 115; 🇺🇸 Miami, Florida, United States

Forest Investigative Site 339; 🇺🇸 Miami, Florida, United States

Forest Investigative Site 087; 🇺🇸 Port Orange, Florida, United States

Forest Investigative Site 002; 🇺🇸 Tamarac, Florida, United States

Forest Investigative Site 109; 🇺🇸 St. Cloud, Florida, United States

Forest Investigative Site 348; 🇺🇸 Winter Park, Florida, United States

Forest Investigative Site 103; 🇺🇸 Canton, Georgia, United States

Forest Investigative Site 292; 🇺🇸 Dawsonville, Georgia, United States

Forest Investigative Site 140; 🇺🇸 Gainesville, Georgia, United States

Forest Investigative Site 139; 🇺🇸 Oak Lawn, Illinois, United States

Forest Investigative Site 334; 🇺🇸 Springfield, Illinois, United States

Forest Investigative Site 350; 🇺🇸 Pittsfield, Massachusetts, United States

Forest Investigative Site 056; 🇺🇸 Fridley, Minnesota, United States

Forest Investigative Site 042; 🇺🇸 Duluth, Georgia, United States

Forest Investigative Site 206; 🇺🇸 Downers Grove, Illinois, United States

Forest Investigative Site 030; 🇺🇸 Lawrenceville, Georgia, United States

Forest Investigative Site 263; 🇺🇸 Elwood, Indiana, United States

Forest Investigative Site 293; 🇺🇸 Michigan City, Indiana, United States

Forest Investigative Site 142; 🇺🇸 Charlotte, North Carolina, United States

Forest Investigative Site 342; 🇺🇸 Lafayette, Indiana, United States

Forest Investigative Site 051; 🇺🇸 Bowling Green, Kentucky, United States

Forest Investigative Site 128; 🇺🇸 Lewiston, Maine, United States

Forest Investigative Site 158; 🇺🇸 West Seneca, New York, United States

Forest Investigative Site 303; 🇺🇸 Edina, Minnesota, United States

Forest Investigative Site 053; 🇺🇸 Owensboro, Kentucky, United States

Forest Investigative Site 020; 🇺🇸 Columbia, Maryland, United States

Forest Investigative Site 341; 🇺🇸 Detroit, Michigan, United States

Forest Investigative Site 072; 🇺🇸 Towson, Maryland, United States

Forest Investigative Site 106; 🇺🇸 Fall River, Massachusetts, United States

Forest Investigative Site 044; 🇺🇸 North Dartmouth, Massachusetts, United States

Forest Investigative Site 328; 🇺🇸 Kalamazoo, Michigan, United States

Forest Investigative Site 149; 🇺🇸 Cincinnati, Ohio, United States

Forest Investigative Site 313; 🇺🇸 Asheville, North Carolina, United States

Forest Investigative Site 280; 🇺🇸 Cincinnati, Ohio, United States

Forest Investigative Site 259; 🇺🇸 Charlotte, North Carolina, United States

Forest Investigative Site 353; 🇺🇸 Dayton, Ohio, United States

Forest Investigative Site 186; 🇺🇸 St. Louis, Missouri, United States

Forest Investigative Site 226; 🇺🇸 Brooklyn, New York, United States

Forest Investigative Site 267; 🇺🇸 Fremont, Nebraska, United States

Forest Investigative Site 236; 🇺🇸 Tulsa, Oklahoma, United States

Forest Investigative Site 314; 🇺🇸 Winston Salem, North Carolina, United States

Forest Investigative Site 019; 🇺🇸 Elizabeth City, North Carolina, United States

Forest Investigative Site 105; 🇺🇸 Zanesville, Ohio, United States

Forest Investigative Site 067; 🇺🇸 Cherry Hill, New Jersey, United States

Forest Investigative Site 071; 🇺🇸 New York, New York, United States

Forest Investigative Site 066; 🇺🇸 Syracuse, New York, United States

Forest Investigative Site 078; 🇺🇸 Shelby, North Carolina, United States

Forest Investigative Site 285; 🇺🇸 Medford, Oregon, United States

Forest Investigative Site 086; 🇺🇸 Altoona, Pennsylvania, United States

Forest Investigative Site 228; 🇺🇸 Johnston, Rhode Island, United States

Forest Investigative Site 340; 🇺🇸 Beaver, Pennsylvania, United States

Forest Investigative Site 230; 🇺🇸 Philadelphia, Pennsylvania, United States

Forest Investigative Site 277; 🇺🇸 Norristown, Pennsylvania, United States

Forest Investigative Site 064; 🇺🇸 Uniontown, Pennsylvania, United States

Forest Investigative Site 093; 🇺🇸 Easley, South Carolina, United States

Forest Investigative Site 110; 🇺🇸 Greenville, South Carolina, United States

Forest Investigative Site 177; 🇺🇸 Boerne, Texas, United States

Forest Investigative Site 237; 🇺🇸 Houston, Texas, United States

Forest Investigative Site 090; 🇺🇸 Corsicana, Texas, United States

Forest Investigative Site 021; 🇺🇸 Spartanburg, South Carolina, United States

Forest Investigative Site 172; 🇺🇸 Dallas, Texas, United States

Forest Investigative Site 058; 🇺🇸 Rapid City, South Dakota, United States

Forest Investigative Site 024; 🇺🇸 Arlington, Texas, United States

Forest Investigative Site 370; 🇺🇸 Houston, Texas, United States

Forest Investigative Site 195; 🇺🇸 Houston, Texas, United States

Forest Investigative Site 332; 🇺🇸 Huntsville, Texas, United States

Forest Investigative Site 125; 🇺🇸 Abingdon, Virginia, United States

Forest Investigative Site 181; 🇺🇸 Colchester, Vermont, United States

Forest Investigative Site 232; 🇺🇸 Longview, Texas, United States

Forest Investigative Site 049; 🇺🇸 Tyler, Texas, United States

Forest Investigative Site 184; 🇺🇸 Spokane, Washington, United States

Forest Investigative Site 418; 🇦🇷 Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina

Forest Investigative Site 402; 🇦🇷 Florida, Buenos Aires, Argentina

Forest Investigative Site 411; 🇦🇷 Ciudad Autonoma de Buenos Aires, Argentina

Forest Investigative Site 401; 🇦🇷 San Miguel de Tucuman, Argentina

Forest Investigative Site 146; 🇺🇸 West Allis, Wisconsin, United States

Forest Investigative Site 543; 🇵🇪 Bellavista, Peru

Forest Investigative Site 302; 🇨🇦 Burlington, Ontario, Canada

Forest Investigative Site 413; 🇦🇷 Mar del Plata, Buenos Aires, Argentina

Forest Investigative Site 403; 🇦🇷 Buenos Aires, Argentina

Forest Investigative Site 420; 🇦🇷 Mendoza, Argentina

Forest Investigative Site 415; 🇦🇷 Derqui Pilar - Buenos Aires, Argentina

Forest Investigative Site 408; 🇦🇷 Santa Fe, Argentina

Forest Investigative Site 464; 🇮🇹 Roma, Italy

Forest Investigative Site 162; 🇨🇦 North Vancouver, British Columbia, Canada

Forest Investigative Site 443; 🇨🇴 Bogota, Colombia

Forest Investigative Site 522; 🇲🇽 Monterrey, Nuevo León, Mexico

Forest Investigative Site 461; 🇮🇹 Chieti, Italy

Forest Investigative Site 550; 🇵🇪 Lima, Peru

Forest Investigative Site 549; 🇵🇪 Lima, Peru

Forest Investigative Site 568; 🇵🇭 Iloilo City, Philippines

Forest Investigative Site 585; 🇷🇴 Brasov, Romania

Forest Investigative Site 587; 🇷🇴 Bucharest, Romania

Forest Investigative Site 627; 🇷🇸 Sremska Kamenica, Serbia

Forest Investigative Site 608; 🇷🇺 Barnaul, Russian Federation

Forest Investigative Site 602; 🇷🇺 Kazan, Russian Federation

Forest Investigative Site 609; 🇷🇺 Krasnodar, Russian Federation

Forest Investigative Site 614; 🇷🇺 Krasnoyarsk, Russian Federation

Forest Investigative Site 628; 🇷🇸 Kragujevac, Serbia

Forest Investigative Site 723; 🇨🇳 Kaohsiung Hsien, Taiwan

Forest Investigative Site 664; 🇹🇭 Bangkok, Thailand

Forest Investigative Site 699; 🇺🇦 Cherkasy, Ukraine

Forest Investigative Site 697; 🇺🇦 Kharkiv, Ukraine

Forest Investigative Site 691; 🇺🇦 Dnipropetrovsk, Ukraine

Forest Investigative Site 693; 🇺🇦 Kharkiv, Ukraine

Forest Investigative Site 682; 🇺🇦 Kharkiv, Ukraine

Forest Investigative Site 709; 🇺🇦 Kremenchuk, Ukraine

Forest Investigative Site 698; 🇺🇦 Kyiv, Ukraine

Forest Investigative Site 684; 🇺🇦 Kyiv, Ukraine

Forest Investigative Site 687; 🇺🇦 Kyiv, Ukraine

Forest Investigative Site 683; 🇺🇦 Kyiv, Ukraine

Forest Investigative Site 685; 🇺🇦 Kyiv, Ukraine

Forest Investigative Site 707; 🇺🇦 Vinnitsa, Ukraine

Forest Investigative Site 696; 🇺🇦 Zaporizhzhya, Ukraine

Forest Investigative Site 694; 🇺🇦 Zaporizhzhya, Ukraine

Forest Investigative Site 705; 🇺🇦 Zaporizhzhya, Ukraine

Forest Investigative Site 641; 🇪🇸 Cadiz, Spain

Forest Investigative Site 647; 🇪🇸 Loja, Spain

Forest Investigative Site 644; 🇪🇸 Salt, Spain

Forest Investigative Site 131; 🇺🇸 Florence, Alabama, United States

Forest Investigative Site 073; 🇺🇸 Mobile, Alabama, United States

Forest Investigative Site 082; 🇺🇸 Rochester, Minnesota, United States

Forest Investigative Site 345; 🇺🇸 Omaha, Nebraska, United States

Forest Investigative Site 033; 🇺🇸 Chesterfield, Missouri, United States

Forest Investigative Site 098; 🇺🇸 St. Charles, Missouri, United States

Forest Investigative Site 288; 🇺🇸 St. Louis, Missouri, United States

Forest Investigative Site 287; 🇺🇸 Tampa, Florida, United States

Forest Investigative Site 318; 🇺🇸 Shelby, North Carolina, United States

Forest Investigative Site 241; 🇺🇸 Los Angeles, California, United States

Forest Investigative Site 166; 🇺🇸 Chiefland, Florida, United States

Forest Investigative Site 092; 🇺🇸 Naples, Florida, United States

Forest Investigative Site 297; 🇺🇸 Lakewood, California, United States

Forest Investigative Site 346; 🇺🇸 Toledo, Ohio, United States

Forest Investigative Site 120; 🇺🇸 Downingtown, Pennsylvania, United States

Forest Investigative Site 010; 🇺🇸 Tipton, Pennsylvania, United States

Forest Investigative Site 174; 🇺🇸 Spokane, Washington, United States

Forest Investigative Site 062; 🇺🇸 Erie, Pennsylvania, United States

Forest Investigative Site 315; 🇺🇸 Lincoln, Nebraska, United States

Forest Investigative Site 336; 🇺🇸 Pittsburgh, Pennsylvania, United States

Forest Investigative Site 144; 🇺🇸 Hackensack, New Jersey, United States

Forest Investigative Site 143; 🇺🇸 Roseville, California, United States

Forest Investigative Site 291; 🇺🇸 Coral Gables, Florida, United States

Forest Investigative Site 111; 🇺🇸 Clearwater, Florida, United States

Forest Investigative Site 161; 🇺🇸 Ponte Vedra, Florida, United States

Forest Investigative Site 052; 🇺🇸 Tampa, Florida, United States

Forest Investigative Site 011; 🇺🇸 Winter Park, Florida, United States

Forest Investigative Site 075; 🇺🇸 Crescent Springs, Kentucky, United States

Forest Investigative Site 256; 🇺🇸 Iowa City, Iowa, United States

Forest Investigative Site 264; 🇺🇸 Muncie, Indiana, United States

Forest Investigative Site 322; 🇺🇸 Saint Joseph, Michigan, United States

Forest Investigative Site 097; 🇺🇸 Sunset, Louisiana, United States

Forest Investigative Site 199; 🇺🇸 Great Neck, New York, United States

Forest Investigative Site 117; 🇺🇸 Springfield, Missouri, United States

Forest Investigative Site 193; 🇺🇸 Burlington, North Carolina, United States

Forest Investigative Site 040; 🇺🇸 Cincinnati, Ohio, United States

Forest Investigative Site 176; 🇺🇸 Wilmington, North Carolina, United States

Forest Investigative Site 009; 🇺🇸 Columbus, Ohio, United States

Forest Investigative Site 164; 🇺🇸 Canton, Ohio, United States

Forest Investigative Site 365; 🇺🇸 Providence, Rhode Island, United States

Forest Investigative Site 253; 🇺🇸 Shelbyville, Tennessee, United States

Forest Investigative Site 271; 🇺🇸 Houston, Texas, United States

Forest Investigative Site 217; 🇺🇸 Tacoma, Washington, United States

Forest Investigative Site 561; 🇵🇭 Quezon City, Philippines

Forest Investigative Site 417; 🇦🇷 La Plata, Argentina

Forest Investigative Site 569; 🇵🇭 Cavite, Philippines

Forest Investigative Site 521; 🇲🇽 Monterrey, Mexico

Forest Investigative Site 546; 🇵🇪 Lima, Peru

Forest Investigative Site 541; 🇵🇪 Pueblo Libre, Peru

Forest Investigative Site 581; 🇷🇴 Iasi, Romania

Forest Investigative Site 588; 🇷🇴 Bucharest, Romania

Forest Investigative Site 583; 🇷🇴 Iasi, Romania

Forest Investigative Site 582; 🇷🇴 Bucharest, Romania

Forest Investigative Site 104; 🇺🇸 Sacramento, California, United States

Forest Investigative Site 004; 🇺🇸 Orlando, Florida, United States

Forest Investigative Site 088; 🇺🇸 Louisville, Kentucky, United States

Forest Investigative Site 157; 🇺🇸 Ann Arbor, Michigan, United States

Forest Investigative Site 305; 🇺🇸 Charleston, South Carolina, United States

Forest Investigative Site 282; 🇺🇸 Winston-Salem, North Carolina, United States

Forest Investigative Site 102; 🇺🇸 Gainesville, Florida, United States

Forest Investigative Site 202; 🇺🇸 Richmond, Virginia, United States

Forest Investigative Site 231; 🇺🇸 Richmond, Virginia, United States

Forest Investigative Site 045; 🇺🇸 Richmond, Virginia, United States

Forest Investigative Site 068; 🇺🇸 Lexington, Kentucky, United States

Forest Investigative Site 013; 🇺🇸 Rochester, New York, United States

Forest Investigative Site 227; 🇺🇸 Peoria, Illinois, United States

Forest Investigative Site 136; 🇺🇸 Elk Grove Village, Illinois, United States

Forest Investigative Site 135; 🇺🇸 Council Bluffs, Iowa, United States

Forest Investigative Site 351; 🇺🇸 Hazard, Kentucky, United States

Forest Investigative Site 201; 🇺🇸 Bolingbrook, Illinois, United States

Forest Investigative Site 061; 🇺🇸 Cincinatti, Ohio, United States

Forest Investigative Site 154; 🇺🇸 Marion, Ohio, United States

Forest Investigative Site 063; 🇺🇸 Livonia, Michigan, United States

Forest Investigative Site 316; 🇺🇸 Topeka, Kansas, United States

Forest Investigative Site 317; 🇺🇸 Summit, New Jersey, United States

Forest Investigative Site 059; 🇺🇸 Marion, Ohio, United States

Forest Investigative Site 283; 🇺🇸 Lincoln, Rhode Island, United States

Forest Investigative Site 204; 🇺🇸 Rock Hill, South Carolina, United States

Forest Investigative Site 321; 🇺🇸 Woodstock, Georgia, United States

Forest Investigative Site 214; 🇺🇸 Olathe, Kansas, United States

Forest Investigative Site 070; 🇺🇸 Opelousas, Louisiana, United States

Forest Investigative Site 012; 🇺🇸 Union, South Carolina, United States

Forest Investigative Site 223; 🇺🇸 Bristol, Tennessee, United States