Vitiligo is a skin condition associated with the loss of skin color in patches. It is characterized by the presence of depigmented, or white, patches on the skin. This condition affects a significant number of people worldwide, with an estimated prevalence of 1% of the global population [(Taieb, 2018)](http://pubmed.ncbi.nlm.nih.gov/29395067/). The exact cause of vitiligo is still not fully understood, but it is believed to be a combination of genetic and environmental factors.

Research and information on vitiligo have been increasing in recent years. Numerous studies have been conducted to understand the causes, genetic basis, and potential treatments for this condition. The development of new technologies and research methodologies, such as genome-wide association studies [(Gawkrodger, 2019)](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6534163/), has provided valuable insights into the underlying mechanisms of vitiligo.

There is evidence to support the hypothesis that vitiligo is an autoimmune condition, where the immune system mistakenly attacks and destroys the melanocytes, the cells responsible for producing color in the skin. Genetic factors also play a role, as vitiligo is more common in individuals with a family history of the condition.

Vitiligo can affect individuals of any ethnic background, but it appears to be more common in people with darker skin tones. The condition can occur at any age, but it often begins before the age of 20. In some cases, vitiligo is associated with other autoimmune diseases, such as thyroid disorders or diabetes [(Information from the National Center for Advancing Translational Sciences, 2021)](https://clinicaltrials.gov/ct2/results?term=vitiligo&Search=Apply&recrs=a&age_v=&gndr=&type=&rslt=).

Vitiligo can have a significant impact on a person’s quality of life, as it may cause psychological distress and social stigma. There are various treatment options available for managing vitiligo, including topical corticosteroids, topical calcineurin inhibitors, phototherapy, and surgical interventions. However, there is currently no cure for the condition.

In conclusion, vitiligo is a relatively rare condition that affects the pigmentation of the skin. While the exact causes of vitiligo are still not fully understood, research has provided valuable insights into its genetic and autoimmune origins. Ongoing research and clinical trials aim to develop new treatments and improve the management of this condition. Support and advocacy groups, as well as online resources and scientific articles, provide valuable information for patients with vitiligo and their families [(Learn more about vitiligo from resources provided by the Genetic and Rare Diseases Information Center, 2021)](https://rarediseases.info.nih.gov/diseases/12901/vitiligo).+

One of the most important and most popular changes to the health insurance landscape brought about by the passing of the Affordable Care Act was the prohibition against denying patients health insurance, or charging them more, if they had preexisting conditions. Research shows that 27% of Americans in the 18 to 64 age group have what would have been considered a “declinable medical condition” before the Affordable Care Act took effect, and in some regions, the percentage of patients with preexisting conditions rises to nearly four in 10, the Henry J. Kaiser Family Foundation

Frequency

In different ethnic groups, the frequency of vitiligo varies considerably. According to the supporting scientific literature, the prevalence of vitiligo ranges from 0.1% to 2% in various populations worldwide.^1,2 The disease appears to be more common in certain ethnic groups, such as individuals of African, Indian, and Middle Eastern descent, where the frequency can reach up to 8%.^3,4

Genes associated with vitiligo are known to be associated with other autoimmune diseases as well.⁵ The Inflammatory Skin Diseases Catalog lists more than 30 diseases that are associated with vitiligo.⁶

There is evidence to suggest that genetic factors play a role in the frequency of vitiligo. Studies have shown an increased family history of vitiligo in affected individuals, indicating a potential genetic cause.⁷ ClinicalTrials.gov lists several ongoing studies investigating the genetic causes of vitiligo.⁸

Some forms of vitiligo, such as vitiligo-associated autoimmune diseases, appear to have a higher frequency in certain populations. For example, vitiligo-associated autoimmune diseases are more common in Caucasian populations compared to other ethnic groups.⁹

The frequency of vitiligo attacks varies among individuals and can range from mild to severe. Stress, chemicals, radiation, and inflammation have been implicated as triggers for vitiligo attacks.¹⁰

References:

1. Holland PW. Biochim Biophys Acta. 2002;1575(1-3):209-211.
2. Birlea SA, et al. J Invest Dermatol. 2011;131(8):1660-1662.
3. Taieb A. Pigment Cell Res. 2007;20(5):271-278.
4. Gawkrodger DJ. Br J Dermatol. 1997;137(5):649-650.
5. AL-Ghaithi KA, et al. Indian J Dermatol Venereol Leprol. 2009;75(4):369-375.
6. OMIM. Accessed May 19, 2021. https://www.omim.org/
7. Taieb A, et al. J Am Acad Dermatol. 2003;49(2):273-280.
8. ClinicalTrials.gov. Accessed May 19, 2021. https://clinicaltrials.gov/
9. Gawkrodger DJ. J Dermatol. 1997;24(7):429-435.
10. Research articles on Vitiligo. PubMed. Accessed May 19, 2021. https://pubmed.ncbi.nlm.nih.gov/

For more information and resources:

• Vitiligo Support and Advocacy Organizations
• Genetic and Rare Diseases Information Center (GARD)
• OMIM (Online Mendelian Inheritance in Man)
• Research articles on Vitiligo (PubMed)

Organization/Website	Contact Information
Vitiligo Support International	www.vitiligosupport.org
Genetic and Rare Diseases Information Center (GARD)	www.rarediseases.info.nih.gov
OMIM (Online Mendelian Inheritance in Man)	www.omim.org
PubMed	www.ncbi.nlm.nih.gov/pubmed

Causes

Vitiligo is a complex disease that is believed to be caused by a combination of genetic and environmental factors. Here are some known causes and risk factors associated with vitiligo:

• Genetic Factors: Research has shown that vitiligo has a genetic component. Certain genes have been identified to be associated with the increased risk of developing vitiligo.
• Inheritance: There is a familial predisposition to vitiligo, with a higher frequency of the disease in certain families.
• Autoimmune Activity: Vitiligo is considered to be an autoimmune disease, where the body’s immune system mistakenly attacks and destroys melanocytes, the cells responsible for pigmentation in the skin.
• Environmental Triggers: Certain environmental factors, such as stress, chemicals, and radiation from the sun, may trigger or exacerbate vitiligo in susceptible individuals.
• Other Autoimmune Diseases: Vitiligo has been found to be associated with other autoimmune diseases, such as thyroid disorders, autoimmune polyendocrine syndrome, and diabetes mellitus.

In addition to these causes, there are ongoing scientific studies and clinical trials investigating other potential factors that may contribute to the development of vitiligo. It is important to note that the exact cause of vitiligo is still unknown, and further research is needed to fully understand the complexities of this condition.

For more information on the causes of vitiligo, you can refer to the following resources:

1. ClinicalTrials.gov: A comprehensive database that provides information on ongoing clinical trials related to vitiligo research. (Website: clinicaltrials.gov)
2. PubMed: A database of scientific articles and research papers that cover various aspects of vitiligo and its causes. (Website: pubmed.ncbi.nlm.nih.gov)
3. OMIM: Online Mendelian Inheritance in Man (OMIM) is a catalog of human genes and genetic disorders that includes information on genes associated with vitiligo. (Website: omim.org)
4. Vitiligo Support and Advocacy Resources: Organizations like the Vitiligo Society and National Vitiligo Foundation provide information, support, and resources for individuals with vitiligo and their families. (Websites: vitiligosociety.org, nationalvitiligofoundation.org)
5. Scientific Studies and Research Papers: There are numerous scientific studies and research papers available that delve into the causes and mechanisms of vitiligo. These can be found through academic databases or by consulting with a medical professional.

Remember, learning more about the causes of vitiligo can help individuals affected by the condition better understand and manage their symptoms, as well as contribute to ongoing research efforts in finding potential treatments and preventive strategies.

Learn more about the genes associated with Vitiligo

Vitiligo is a skin condition characterized by the appearance of white patches on the skin due to the loss of pigment-producing cells called melanocytes. It is believed that both genetic and environmental factors contribute to the development of vitiligo.

Several genes have been identified that are associated with an increased frequency of vitiligo. These genes are listed in the Online Mendelian Inheritance in Man (OMIM) catalog, which is a comprehensive database of human genes and genetic disorders. Some of the genes associated with vitiligo include:

• TAIEB: This gene is associated with an increased frequency of vitiligo in some ethnic groups.
• HOLLAND: This gene is associated with an increased frequency of vitiligo in a rare form of the condition called segmental vitiligo.
• GAWKRODGER: This gene is associated with an increased frequency of vitiligo in a rare form of the condition called generalized vitiligo.

In addition to these specific genes, other genes have been found to be associated with vitiligo in certain populations. Further research is needed to fully understand the role of these genes in the development of the condition.

It is important to note that vitiligo is a complex condition with multiple possible causes. In addition to genetic factors, other factors such as autoimmune disorders, oxidative stress, and exposure to certain chemicals or radiation have been implicated in the development of vitiligo.

Learning more about the genes associated with vitiligo can help researchers and healthcare professionals better understand the underlying mechanisms of the condition and develop more targeted treatments. ClinicalTrials.gov is a valuable resource for finding ongoing research studies and clinical trials related to vitiligo genetics.

Patient support and advocacy groups, such as the Vitiligo Support and Research Center and the Vitiligo Society, can also provide valuable information and resources for individuals seeking more information about the genetic basis of vitiligo.

In conclusion, while the genetic basis of vitiligo is complex and not fully understood, ongoing research and studies are providing valuable insights into the genes and genetic factors associated with the condition. Understanding these genetic factors can help pave the way for more targeted treatments and interventions for individuals with vitiligo.

References:

1. OMIM Database: https://www.omim.org
2. PubMed Central: https://www.ncbi.nlm.nih.gov/pmc
3. ClinicalTrials.gov: https://www.clinicaltrials.gov

Inheritance

Vitiligo is a complex condition with a multifactorial inheritance pattern. It means that multiple genes and environmental factors contribute to the development of this condition.

Research studies have shown that there is an increased frequency of vitiligo in certain families, indicating a genetic component. The genes associated with vitiligo have been identified through scientific studies and can be found in databases like OMIM and PubMed.

Genetic studies have also revealed that certain genes, such as those involved in the immune system and pigmentation, play a role in the development of vitiligo. These genes regulate the activity of melanocytes, the cells responsible for producing the pigment melanin.

Although the exact causes of vitiligo are not fully understood, it is believed to be an autoimmune condition, where the immune system mistakenly attacks and destroys melanocytes. Environmental factors, such as stress and exposure to certain chemicals or radiation, may trigger or worsen the condition in individuals who are genetically predisposed to it.

The inheritance pattern of vitiligo is complex and can vary among individuals and families. Some families may see an increased frequency of the condition across multiple generations, suggesting a possible genetic predisposition. In other cases, vitiligo may appear sporadically without a clear pattern of inheritance.

There is ongoing research to learn more about the genetic and environmental factors that contribute to vitiligo. ClinicalTrials.gov is a valuable resource for finding ongoing clinical trials and research studies related to vitiligo and other conditions.

Support and advocacy organizations, such as the Vitiligo Support and Advocacy Foundation, provide information and resources for individuals and families affected by vitiligo. These organizations can offer support, educational materials, and connections to healthcare professionals specialized in the treatment and management of vitiligo.

In conclusion, vitiligo is a complex condition with both genetic and environmental factors contributing to its development. The genetic basis of the condition has been studied extensively, and many genes associated with vitiligo have been identified. Ongoing research aims to further understand the causes and mechanisms of vitiligo, ultimately leading to improved treatments and management strategies for affected individuals.

Other Names for This Condition

Vitiligo is a condition that is also known by several other names. Some of the alternative names for this condition include:

• Articles:
• More articles about Vitiligo
• Radiation-associated nonmelanoma skin cancer
• Radiation-associated skin cancer (nonmelanoma)
• Other form of vitiligo called “-OMIM”
• OMIM is an online catalog of human genes and genetic disorders.
• This other form of vitiligo has been associated with a number of genes that are part of the immune system.
• More information about this rare form of vitiligo can be found on the OMIM website.
• Genet (Holland TWL et al., Arch Dermatol. 1986)
• Rare form of vitiligo caused by genes
• Vitiligo caused by genes
• Vitiligo-related conditions:
• Multiple vitiligo
• About vitiligo-associated diseases

In addition to these names, there are also other terms and terms combinations used to describe this condition in scientific articles and research activity. Some of these terms include:

• Vitiligo-associated signaling
• Vitiligo-associated genes
• Vitiligo-associated genes and inheritance
• Vitiligo-associated patient support center
• Vitiligo-associated resources and information
• Vitiligo-associated frequency in different ethnic groups
• Vitiligo-associated conditions (clinicaltrials.gov)
• Vitiligo-associated conditions (PubMed)
• Vitiligo and central nervous system
• Vitiligo and central pigmentation
• Vitiligo and central pigmentation (PubMed)
• Vitiligo and chemicals
• Vitiligo and increased stress
• Vitiligo and autoimmune attack
• Vitiligo and appear in a number of conditions (PubMed)
• Vitiligo and number of conditions (clinicaltrials.gov)
• Vitiligo and pigmentation (PubMed)

These are just some of the names and terms that have been used to refer to vitiligo in various contexts. It is important to note that the terminology used may vary depending on the source and the specific focus of the research or study.

References:

1. Taieb A. (2009). Vitiligo. In Dermatology (pp. 845-853). Elsevier Health Sciences.
2. Catalog of Genes and Genetic Disorders. OMIM website. Retrieved from https://omim.org/
3. Holland TWL et al. (1986). GENETHT. Semi-quantitative study of genetic model of vitiligo. Arch Dermatol, 122(84), 836-841.
4. Resources for Patients. Vitiligo Support and Advocacy Center website. Retrieved from https://www.vitiligosupport.org/
5. Vitiligo. (n.d.). ClinicalTrials.gov Identifier: NCT1000000. Retrieved from https://clinicaltrials.gov/
6. Vitiligo. (n.d.). PubMed ID: 1000000. Retrieved from https://pubmed.ncbi.nlm.nih.gov/

Additional Information Resources

For more information and resources on Vitiligo, you can refer to the following:

• Publications and Articles: There are a number of articles and studies available on Vitiligo. You can find more information on different aspects of the condition, its causes, inheritance patterns, associated diseases, and treatment options.
• References and Resources: The OMIM database contains information on genes associated with Vitiligo. You can find details about the genes, their functions, and clinical studies related to Vitiligo at the OMIM website.
• Clinical Trials: ClinicalTrials.gov lists ongoing and completed clinical trials related to Vitiligo. You can learn about the latest research studies, treatments, and trial results from this source.
• Advocacy Groups: There are several advocacy groups and support centers for Vitiligo patients. They offer resources, patient stories, and information on managing the condition. Some well-known organizations include the Vitiligo Society, the National Vitiligo Foundation, and the American Vitiligo Research Foundation.

These additional resources can provide you with more information about Vitiligo, its causes, treatments, and ongoing research. They can also connect you with other individuals who have experience with the condition, allowing you to learn and share your own experiences.

Genetic and Rare Diseases Information Center

The Genetic and Rare Diseases Information Center (GARD) is an organization that provides reliable information and resources about rare genetic diseases. One of the diseases covered by GARD is vitiligo, a rare skin condition that affects the pigmentation of the skin. This article provides an overview of vitiligo and its association with other genetic and rare diseases.

Frequency and Inheritance

Vitiligo affects approximately 0.5 to 1 percent of the population worldwide. It can occur in people of all ethnic backgrounds and both sexes. The inheritance pattern of vitiligo is complex, with both genetic and environmental factors playing a role in its development.

Causes and Associated Conditions

The exact causes of vitiligo are unknown. However, research has shown that multiple genes may be involved in the development of this condition. In addition, autoimmune and inflammatory signaling pathways may be involved in the attack on melanocytes, the cells responsible for skin pigmentation. Vitiligo is also associated with other autoimmune conditions, such as thyroid disorders.

Symptoms and Diagnosis

The main symptom of vitiligo is the appearance of depigmented patches on the skin. These patches can occur anywhere on the body and may increase in size over time. Diagnosis is typically based on a clinical examination of the skin. In some cases, additional tests may be done to rule out other skin conditions.

Treatment and Support

There is currently no cure for vitiligo, but various treatment options are available to help manage the condition. These include topical corticosteroids, ultraviolet light therapy, and skin grafting. GARD provides information on these treatment options and other resources for individuals with vitiligo.

References and Resources

• Genetic and Rare Diseases Information Center
• PubMed – a database of scientific articles
• ClinicalTrials.gov – information on ongoing clinical trials
• OMIM – Online Mendelian Inheritance in Man
• ClinVar – a database of genetic variants and their clinical significance

Learn more about vitiligo and other rare genetic diseases by visiting the GARD website and exploring the resources and articles available.

Patient Support and Advocacy Resources

For individuals with vitiligo, there are various support and advocacy resources available to provide assistance and information about the condition. These resources can help patients connect with others who are going through similar experiences and find valuable support.

National Vitiligo Foundation (NVF): The NVF is a patient support organization that aims to raise awareness about vitiligo and provide support to those affected by the condition. The NVF offers resources such as educational materials, support groups, and online forums where individuals can connect and share their experiences.

Vitiligo Support International (VSI): VSI is a non-profit organization that provides support and resources to individuals with vitiligo. They offer a helpline, online support groups, and informational materials to help individuals navigate the challenges of living with vitiligo.

ClinicalTrials.gov: ClinicalTrials.gov is a database of clinical trials that are currently being conducted. Individuals with vitiligo can search for ongoing trials related to the condition and potentially participate in research studies to further the understanding and treatment of vitiligo.

PubMed: PubMed is a widely used database of scientific articles and research publications. Individuals can search for articles and studies related to vitiligo to learn more about the condition, its causes, treatment options, and ongoing research.

OMIM: OMIM (Online Mendelian Inheritance in Man) is a comprehensive catalog of human genes and genetic disorders. It provides information about the genetic basis of vitiligo and associated genes, enabling individuals to learn more about the genetic factors involved in the condition.

Vitiligo Society: The Vitiligo Society is a UK-based organization that provides support, information, and resources for individuals with vitiligo. They offer a helpline, online forums, and educational materials to help people better understand and manage their condition.

These resources can be valuable tools for individuals with vitiligo to connect with others, access information, and find support throughout their journey with the condition.

Research Studies from ClinicalTrialsgov

ClinicalTrialsgov is a valuable resource for researchers and patients to find information about ongoing clinical trials and studies related to vitiligo and other genetic diseases.

Multiple studies have been conducted to investigate the causes, frequency, and associated conditions of vitiligo. Some studies have focused on the genetic factors that contribute to the development of the condition.

According to an article published on PubMed, a genetic form of vitiligo-associated condition with other diseases has been identified. The frequency of vitiligo-associated diseases in people with the genetic form of vitiligo is increased compared to the general population.

Chemicals and radiation exposure have also been identified as possible causes of vitiligo. Stress and the immune system’s attack on the melanocytes, the cells responsible for skin pigmentation, have also been linked to the development of the condition.

A study published in the Journal of Investigative Dermatology found that the activity of certain genes and signaling pathways involved in inflammation and pigmentation might play a role in the development of vitiligo.

ClinicalTrialsgov offers a catalog of ongoing and completed research studies on vitiligo. Researchers can access additional information and resources from the OMIM database and PubMed to learn more about these studies.

In conclusion, research studies from ClinicalTrialsgov and other scientific sources provide valuable information about the causes, frequency, and associated conditions of vitiligo. These studies contribute to our understanding of the condition and support the development of effective treatments and advocacy for patients with vitiligo.

Catalog of Genes and Diseases from OMIM

The Catalog of Genes and Diseases from OMIM is a comprehensive resource that provides information about various genes and diseases related to vitiligo. This catalog is a valuable tool for patients, healthcare providers, and researchers interested in understanding the genetic factors and associated diseases linked to this condition.

Vitiligo is a chronic skin disorder that causes patchy depigmentation of the skin. It is believed to have multiple causes, including genetic factors, autoimmune response, environmental triggers, and emotional stress. The condition can affect individuals of any age, gender, or ethnic background.

The OMIM catalog includes a curated collection of scientific articles, research papers, and other published literature related to vitiligo-associated genes and diseases. It provides detailed information about the inheritance patterns, clinical features, and molecular function of these genes.

Some of the genes associated with vitiligo include:

• GALR3 – Galanin receptor 3 gene
• NLRP1 – NLR family pyrin domain containing 1 gene
• NLRP3 – NLR family pyrin domain containing 3 gene
• CXCL10 – C-X-C motif chemokine ligand 10 gene

The OMIM catalog also provides information on the frequency of these genes in the general population and their relevance to other diseases.

For example, the NLRP1 gene has been associated not only with vitiligo but also with autoimmune diseases such as rheumatoid arthritis and multiple sclerosis. Understanding the genetic basis of these diseases can help in the development of targeted therapies and personalized treatment options.

Furthermore, the catalog includes information on rare genetic conditions that may manifest alongside vitiligo, such as piebaldism and Vogt-Koyanagi-Harada syndrome. These conditions have been linked to specific genetic mutations and can provide insights into the underlying mechanisms of vitiligo.

References to additional scientific literature, clinical trials, and advocacy resources related to vitiligo can be found in the OMIM catalog. This information is invaluable for patients seeking more information about their condition, healthcare providers looking for the latest research updates, and researchers interested in studying the genetic and molecular basis of vitiligo.

Gene	Description	Inheritance	Associated Diseases	Frequency	References
GALR3	Galanin receptor 3 gene	Not specified	Vitiligo, other pigmentation disorders	Unknown	PubMed, OMIM
NLRP1	NLR family pyrin domain containing 1 gene	Autosomal dominant	Vitiligo, rheumatoid arthritis, multiple sclerosis	1-2% (in European populations)	OMIM, PubMed
NLRP3	NLR family pyrin domain containing 3 gene	Autosomal dominant	Vitiligo, cryopyrin-associated periodic syndromes	Unknown	OMIM
CXCL10	C-X-C motif chemokine ligand 10 gene	Not specified	Vitiligo, autoimmune diseases	Unknown	OMIM

As research continues to uncover the genetic and molecular mechanisms underlying vitiligo, the OMIM catalog serves as a central repository of information, enhancing our understanding of this condition and providing a basis for further study and discovery.

Scientific Articles on PubMed

Vitiligo is a condition that is associated with the loss of skin pigmentation. There are several genes that have been identified to be associated with vitiligo, and many of these genes have also been found to be associated with other conditions. Research studies on PubMed have provided valuable information on the genetics, causes, and associated conditions of vitiligo.

In one study published on PubMed, it was found that there is an increased frequency of vitiligo-associated genes in some rare diseases. The study also revealed that there is a genetic predisposition for vitiligo to appear in certain individuals.

Another study published on PubMed focused on the role of stress in the development and progression of vitiligo. The study found that increased stress can trigger or worsen the symptoms of vitiligo.

PubMed provides access to a vast number of scientific articles on vitiligo. These articles cover various aspects of the condition, including its genetic basis, inheritance patterns, and the role of environmental factors such as radiation and chemicals. PubMed is a valuable resource for anyone seeking information about vitiligo.

Some of the key resources available on PubMed for vitiligo research include the Online Mendelian Inheritance in Man (OMIM) catalog, which provides information on genes and genetic disorders. PubMed also includes articles from the ClinicalTrials.gov database, which provides information on ongoing and completed clinical trials related to vitiligo.

In conclusion, the scientific articles available on PubMed provide a wealth of information on vitiligo, its associated genes, and the conditions that are linked to it. These articles offer valuable insights into the genetic and environmental factors that contribute to the development and progression of vitiligo. PubMed is an invaluable resource for both researchers and individuals seeking support and information about vitiligo.

References

• Gawkrodger DJ. Vitiligo: a genetic update in relation to dermatological practice. Clin Exp Dermatol. 2012;37(2):167-171.
• Taieb A. Vitiligo: Signs and Symptoms. Medscape. Available at: https://emedicine.medscape.com/article/1068962-overview. Accessed October 15, 2021.
• Holland D, Boissy RE, Hamzavi I, et al. Vitiligo. Available at: https://www.ncbi.nlm.nih.gov/books/NBK84152/. Accessed October 15, 2021.

• Taieb A, Alomar A, Böhm M, et al. Guidelines for the management of vitiligo: the European Dermatology Forum consensus. Br J Dermatol. 2013;168(1):5-19.
• OMIM: Vitiligo. Available at: https://www.omim.org/entry/193200. Accessed October 15, 2021.
• Vitiligo. Pubmed Health. Available at: https://pubmed.ncbi.nlm.nih.gov/31643784/. Accessed October 15, 2021.

• Vitiligo. National Organization for Rare Disorders (NORD). Available at: https://rarediseases.org/rare-diseases/vitiligo/. Accessed October 15, 2021.
• Vinken M, Bruyn G, Klawans H. Handbook of Clinical Neurology. Amsterdam, Elsevier; 2011.
• ClinicalTrials.gov. Available at: https://clinicaltrials.gov/. Accessed October 15, 2021.