GEOGRAPHICAL AND TEMPORAL VARIATIONS IN

OUTPATIENT MORBIDITY

AT U. S. NAVY OVERSEAS FACILITIES

'mm

N

C. G. BLOOD

C. B. NIRONA

OTICSELECTES JAN I0 199133

EUREPORT NO. 90-13

Approved tor public release: distribution unlimited.

NAVAL HEALTH RESEARCH CENTERP.O. BOX 85122

SAN DIEGO, CALIFORNIA 92186-5122

NAVAL MEDICAL RESEARCH AND DEVELOPMENT COMMAND

BETHESDA, MARYLAND - .

1. j,

GEOGRAPHICAL AND TEIPI@A VALIATIONS IN O(TPATIF2T M1ORBIDITY

AT U.S. NAVY OVERSEAS FACILITIES

Accession For

NTIS GRA&IDTIC TABUnannounced []Justificatio

Christopher G. Blood _ _

Corazon B. Nirona Distribution/

Availability CodesjAvail and/or

Dist Special

Medical Decisions Support Department

Naval Health Research Center

P.O. Box 85122

San Diego, CA 92186-5122

Report No. 90 - 13, supported by the Naval Medical Research and Development

Command, Department of the Navy, under work unit No. M0095.005-6004. The

views expressed in this article are those of the authors and do not reflect

the official policy or position of the Department of Defense, nor the U.S.

government. Approved for public release, distribution unlimited.

Sumary

Problem

Delineation of factors which impact on the incidence of disease and

non-battle injuries is requisite to Navy medical resource planning.

Previous investigations at Naval Health Research Center have examined the

effect of geographical region, ship size, and combat support status on

shipboard outpatient illness rates.

Objective

,-The present investigation seeks to assess the seasonal and geographical

variations among the overseas regions at which the U.S. Navy has a presence4

Approach

.&AMorbidity reports recorded during 1984 were compiled and examined by

quarters for seven geographical regions which have Navy medical facilities.

Illness rates per 1,000 per day were computed and reported with 95%

confidence limits.

Results

Overall rates of illness in East Asia were higher than those in Europe.

The highest outpatient rate among individual countries occurred in Bahrain.

A progressive increase in illness rate was seen at duty stations from

Northeast Asia to Southwest Asia (Japan-Philippines-Bahrain). The greatest

seasonal variations in morbidity rates within regions were seen for Bahrain

and Iceland; minor fluctuations by quarter were evident for Japan,

Philippines, Diego Garcia, European continent, and the United Kingdom.,

Conclusions

In general, the increases in illness rates between and within Asiatic

locales corresponded to shifts in greater humidity and or rainfall.

Morbidity rates in the Atlantic region evidenced minor elevations

corresponding to cool or wet weather. Slight increases among several

categories of illness, rather than epidemics within a single category,

appeared to be responsible for the seasonal variations in overall rates.

Illness rate differences between geographical areas were much greater than

the minor seasonal fluctuations in rates observed within regions.

2

GEOGRAPHICAL AND TEPUOAL VARIATICNS IN OUTPATIENT MRBIDITY AT

U.S. NAVY OVERSEAS FACILITIES

Recent investigations have examined the effects of various factors on

U.S. Navy disease and non-battle injury (DNBI) rates. This research has

indicated variations in outpatient disease rates by deployment area l, size

of vessel2 , and combat support status3 . These studies indicated higher

outpatient rates among ships deployed to the Western Pacific when compared

with the Atlantic region, elevated rates among destroyers and frigates when

contrasted with cruisers and carriers, and no increase in rates among ships

providing combat support during the Vietnam conflict. All factors which

influence DNBI rates are of interest to medical and manpower policy planners

due to their potential impact on required medical resources and personnel

considerations during military conflicts.

Though the aforementioned studies have focused mainly on shipboard rates

of illness, rates for shore facilities around the world are of interest

because they indicate the disease incidence likely to be incurred by ground

troops should they be deployed to similar regions. Geographical variability4

in blood pressure as well as higher rates of fatal circulatory system

diseases and malignant tumors among Eastern European countries than those of

West Europe5 establish that regional health differences do exist.

Moreover, because geopolitical conflicts adhere to no pre-arranged

schedules, any seasonal variations in illness incidence are likewise

important to assess. Seasonal fluctuations have previously been observed for

various enteropathogens among children worldwide . Rotavirus, a common

etiologic agent of diarrheal disease, was found to be prevalent in winter

months in temperate zones with less well-defined seasonality in tropical9 10areas. Likewise, seasonal influences on pertussis , measles , and the less

well understood Sudden Infant Death Syndrome11 have been evidenced. While

most of the aforementioned studies have dealt with young children, there is

clearly a temporal component to certain health problems, in particular

communicable disorders. The U.S. Navy has personnel stationed around the

3

world and subject to numerous environmental, climatological, and social

influences. Information concerning the combined influence of time of year

and region on DNBI rates may be used to augment medical readiness in times

of war.

The purpose of the present investigation is to assess the geographical

and temporal variations in outpatient disease incidence at overseas

facilities. Rates of illness will be examined for units from all of the

overseas countries in which the U.S. Navy has a medical facility. Further,

rates for the various geographical locations will be analyzed by quarters of

the year to determine the existence of seasonal variations. All categories

of disease will be examined with particular attention paid to the more

readily transmittable categories of infective/parasitic, respiratory, and

digestive disorders.

Method

The illness data analyzed is a product of the Medical Services and12

Outpatient Morbidity Reporting System . The monthly morbidity reports, as

they are commonly known, are completed by each reporting facility and

maintained at the Naval Medical Data Services Center, Bethesda, Maryland.

The overseas facilities filing the outpatient reports in this study included

Naval clinics, branch facilities, and medical centers. The monthly

morbidity reports record visits in accordance with the major disease

categories within the International Classification of Diseases, Ninth

Revision (ICD-9).

Shore facilitics in Japan, Republic of the Philippines, Bahrain, Diego

Garcia, Europe (Greece, Spain, Italy), United Kingdom, and Iceland were used

in the analysis. Population serviced by each medical facility was surveyed

to insure adequate size and service homogeneity; all populations selected

with the exception of Bahrain exceeded one hundred in strength and all were

composed of at least 80% active duty Navy personnel (with the remainder

being Marines). Table 1 displays the strengths and service composition of

each analyzed geographical area for the study year of 1984.

4

TABLE 1. STRENGTHS AND COMPOSITIONS OF OVERSEAS FACILITIES REPORTING UNITS

AVERAGE STRENGTH PERCENT NAVY MANDAYS

JAPAN 4,443 91.0 1,626,172

PHILIPPINES 5,852 83.7 2,141,689

BAHRAIN 92 100.0 33,530

DIEGO GARCIA 1,679 91.5 560,799

EUROPE 9,199 93.9 3,366,881

UNITED KINGDOM 2,325 90.0 851,034

ICELAND 1,746 94.2 639,153

Outpatient visit rates are computed per 1000 strength per day. Only

the initial visi4 for a specific illness per individual was entered into the

rate calculations; revisits and follow-ups were not included in the illness

totals. Ninety-five percent confidence limits were computed to indicate the

degree which a rate might fluctuate. The Dunn method of adjusting the

significance level for multiple comparisons13 has been applied.

Results

Table 2 is a display of the rates of individual categories of illness

for the seven overseas regions under investigation (Tables 2-10 follow

text). Overall rates of illness in East Asia (Japan, Philippines) were

higher than those in Europe. The highest rate among individual countries

occurred in Bahrain. Figure 1 is a graphical presentation of the total

outpatient rates by region. Among the various subcategories of illness,

infective/parasitic diseases incidence was highest in the Philippines;

respiratory, digestive, skin, and musculoskeletal disorder rates were

highest in Bahrain; accidents and injuries were at their highest rate of

inci,' nce in Japan.

Figure 2 is a display of the quarterly rates for each of the seven

geographical regions. Only Bahrain exhibits a seasonal trend of substantial

magnitude, with rates increasing in the second quarter followed by an even

larger increase in outpatient incidence during the July through September

quarter. When all regions were combined, little variation was evidenced

among quarterly illness rates: January-March, 12.12; April-June, 12.72;July-September, 12.18; October-December, 12.13. Illness rates by quarter

for the individual regions are displayed in Tables 3 through 9.

5

21

20.01

19-

17- 16.35

>- 14.99

15

z

13-

LUj

11 10.35

9.16 9.28

9- 8.47

7

5JAPAN PHILIPPINES BAH-RAIN DIEGOGARCLA EL.CP U)NrTEDK1WJGOOM ICELAND

U.S. NAVY OVERSEAS SHORE FACILMTES

Fig. I. Rwtes of Outpatient Illness at U.S. Navy Overseas Shore Facilities

6

40- 1 -.-- JAPAN-i- PHILIPPINES

-- A- BAHRAIN

351 DIEGO GARCIA

-0 aFOP

-a- UNITED KINGDOM

-a--ICEAND

30-

25

U

15

10 - ......

5

0-JAN-MAR APR-JUN JUL-SEPT OCT-DEC

Fig. 2. Outpatient Illness rates by quarter: U.S. Navy Overseas Shore Facilities. 1984.

7

JAPAN

Table 3 indicates minor fluctuations in the overall illness rates among

the first three quarters in Japan. However, a small but statistically

significant increase in the overall illness rate is seen in the fourth

quarter. Individual categories of disease that were significantly higher in

the final quarter were musculoskeletal disorders, and symptoms and

ill-defined diseases.

Republic of the Philippines

Table 4 is a display of the quarterly illness rates in the Philippines

and shows that the first three month period had a significantly lower

overall morbidity rate than the last three quarters. The highest outpatient

rates were evidenced between April and September with the third quarter

being the highest. Among individual disease categories, infective and

parasitic disorders were significantly higher in the third quarter than in

the first two quarters while the rate of genitourinary disorders was

significantly higher in the third quarter when compared with the other three

time periods.

Bahrain

Among all geographical regions, the greatest variations in illness rates

by quarter were in Bahrain. Table 5 shows that the lowest quarterly rate

was for January - March and differed significantly from the final two

quarters. The quarter spanning July through September was by far the

highest and was significantly greater than the first two quarters. It

should be noted that the Bahrain facility services a particularly small duty

station (average strength = 92) and therefore, relatively small changes in

illness frequencies result in rather wide fluctuations in the morbidity

rates.

Diego Garcia

Outpatient morbidity rates by quarter for Diego Garcia are shown in

Table 6 and indicate very little variation in illness rate over the course

of the year. The lowest overall rate (7.793) was evidenced for the final

quarter while the highest rate (9.902) was seen in the time period from

April to June. These two quarterly rates yielded a significant difference

but were the only time periods that such a difference was seen. Lower rates

8

within the subcategories of infective and parasitic disorders and

respiratory diseases were evident in the October to December time period and

were partially responsible for the decrease in the overall morbidity rate in

the final quarter.

European Continent

Though the quarterly rates in Europe ranged from a high of 11.774 per

1,000 per day to a low of 9.418, Table 7 indicates that the overall illness

rates in the first two quarters were significantly higher than in the second

half of the year. The overall morbidity rate was highest in the first

quarter and this time frame had significantly higher rates of behavioral

disorders, respiratory system diseases, and symptoms and ill-defined

conditions when compared with the other three quarters.

United Kingdom

Like the European continent, the United Kingdom showed but minor

fluctuations in the quarterly rates (7.666 - 9.270) as seen in Table 8.

Though relatively minor, the rate difference between the first and third

quarters was significant with the July to September quarter being the lowest

of the year. The only subcategory of disease that was significantly lower

in the third quarter when compared with the first quarter was respiratory

system disorders.

Iceland

There was considerable variability in overall morbidity rates across

quarters in Iceland as indicated in Table 9. The overall rate for the

second quarter (April to June) was the highest among quarters and differed

significantly from the other three. Further, the rate for the last quarter

(October - December) was significantly lower than the first three time

periods. None of the specific categories of illness in the April - June

time period were significantly higher than all other quarters; likewise, no

category of disease in the fourth quarter was significantly lower when

compared with all other quarters.

9

t. Japan Rates Per 1,000 Strength Per Day10.

45.-

44'

137

50.

I.5

to

00

I.

25.

1

.5

2 10

40 Japan Rates Per 1,000 Strength Per Day

(15

Philippine,

Diego Garcia

10.

jIN AO A MAY AN* Am ALE] mNt A

1011

'Japan Rater Per 1,000 Stxengmn Per Day

a a

I %

10

I 0 edKngo

10 2

Figure 3 is a graphical presentation of the infective and parasitic

rates by month for each region except Bahrain, which has been omitted due to

its artifactual fluctuations. It is quite clear that the highest incidence

was in the East Asia regions and that the area of greatest variability was

the Philippines. Figure 4 presents the monthly rates of respiratory

disorders for the same regions. There are much larger month to month

fluctuations among respiLatory disorders than seen with infective diseases,

and though generally stable, the Philippines region has the highest

incidence. A trend which was evidenced among all three Atlantic regions was

a decrease in respiratory rates during June, July, and August. Figure 5 is

a display of the monthly rates of digestive disorders for the overseas shore

stations. Fluctuations in digestive rates do not appear to be systematic

with the possible exception of increases during May, June, and July in Japan

an the Philippines.

Figure 6 is a bar chart indicating the rates of disease categories

across all the investigated shore facilities. Respiratory diseases had the

highest rate among all categories followed ')y infectious/parasitic disorders

and skin diseases. Rank orderings of the prevalence of individual disease

categories among the geographical regions are displayed in Table 10.

Although each region had its own unique distribution of disease

predominance, several of the sixteen disorder categories were consistently

responsible for higher projpotions of the outpatient visits across areas.

These categories included: respiratory disorders, which was the foremost or

second most prevalent disorder within all regions except Japan where it

ranked fourth; skin and subcutaneous diseases which ranked second or third

in all areas except Europe (5th) and Iceland (6th), and accidents which was

one of the top three categories of outpatient visits in all regions except

Bahrain and the Philippines where it ranked eighth and ninth.

Discussion

Overall outpatient morbidity in this study adhered to a previously

documented illness trend which indicated a higher rate of illness amrng

duty stations in Asia when compared with Europe. A progressive increase in

illness rate was seen at duty stations from Northeast to Southwest Asia

(Japan - Philippines - Bahrain). These morbidity differences may be tied to

climatological shifts occurring among these regions.

13

t6INFECTIVE

NEOPLASMS

0.14ENDOCRINE

0.01BLOOD DISORDERS

BEHAVIORAL

0.77NERVOUS SYSTEM

CIRCLATORY

2.01RESPIRATORY

DIGESTIVE

1.05GENITCURINARY

PREGNANCY

MUSCULOS<ELETAL

0.02COtNGENITAL

0.94SYMAPTOMS & ILL DEFINED

1.39ACCIDENTS

0.0 0.2 0.4 0.6 0.8 1.0 1 2 1.4 1.6 1 8 2 0 2 2 2 4

RATES PER 1 ,000) STRENGTH PER DAY

Fig. 6. Outpatient Illness Rates by Disease Category Across Overseas Shore Facilities.

14

Japan is characterized as having a humid continental climate with

temperatures ranging from subtropical to cool; the sunmmers are warm and wet

and the winters are dry and cool. The moderate nature of this climate is

reflected in its stable illness rates with a slight increase in morbidity

seen in the fourth quarter. A slight but nonsignificant increase in

respiratory Late was seen in this final quarter along with a significant

increase in the rather nebulous category of symptoms and ill-defined. The

Philippines has a wet equatorial climate with the heaviest rainfall between

June and November. The highest illness rates in the Philippines occurred in

the quarters corresponding to April through September. Both infective

disorders and genitourinary disease rates were significantly higher between

July and September than in other quarters. Bahrain has a tropical dry

climate which is typically hot and humid from April through October and

temperate from November through March; the highest illness rate was

witnessed in the July - September quarter and was quadruple that seen

between January and March. Categories of illness rates that increased

substantially in the July-September quarter included infective, respiratory,

and digestive disorders.

In general, it appears that the increases in illness rates between

Asiatic locales as well as the intra-regional increases corresponded to

shifts in greater humidity and or rainfall. It is quite likely that it is

not the weather per se that is responsible for increases in communicable

diseases but rather that warm moist mediums which accompany this type of

weather are more conducive to the growth of various bacteria and viruses. An

additional factor possibly contributing to higher rates is the greater

likelihood of spending time indoors in this weather thereby facilitating

disease transmission.

Duty stations in the Atlantic region yielded illness rates which were

substantially lower than those of the Pacific and Persian Gulf regions. The

duty stations comprised by the European continent region included Spain

(Rota), Italy (Naples, Sigonella), and Greece (Nea Makri, Souda Bay). These

areas generally have a Mediterranean climate consisting of mild, wet winters

and hot, dry summuers; illness rates were lowest during the July through

September quarters and then increased with a peak in the January through

March quarter. The United Kingdom facilities were located in Thurso,

15

Brawdy, Edzell, and London; the climate is temperate and equable with

winters typically cool and moist, and summrs mild and moist. The U.K.

illness rates fluctuated little, but were at their lowest in the July to

September period and then rose through the January - March quarter. Iceland

has damp, cool summers and relatively mild but extremely windy winters; the

highest illness rates were seen between April and June and the lowest rates

were in the October through December quarter. Morbidity rates in the

Atlantic region, though generally quite stable, evidenced minor elevations

corresponding to periods of cool, wet weather. The only consistent trend in

communicable illnesses seen throughout the region was that of lower rates of

respiratory diseases during the summer months.

No single illness category contributed to the fluctuations in rates seen

across all duty stations. In the Philippines infectious disorders and

genitourinary diseases were highest in the peak periods of humidity. In

Europe, higher rates of respiratory disorders, and behavioral problems were

witnessed during the first quarter of the year and may be attributed to

weather conditions forcing more time spent -4- indoor closed environments.

Generally, when the overall illness rates rose in a region for a time period

it was the result of slight increases within several disease categories

rather than an epidemic within a single disease category. Those regions

which had the highest outpatient rates, specifically those in Asia, were

most prone to fluctuations in illness incidence. Outpatient rates at the

treatment facilities were generally low and stable in all but the Bahrain

facility, which had rates based on a small number of personnel, and

therefore, were subject to greater variability.

Medical planners are most concerned with those illnesses incurred in

wartime which require hospitalization. In times of combat, however, due to

the scarcity of beds some personnel that in peacetime would be treated on an

outpatient basis and sent to their quarters will require evacuation to a14rear echelon facility 1

. The present findings, though based on peacetime

data, indicate the minimal effects of time of year on outpatient illness

rates which would be evident during times of conflict in these regions. The

effect of regir' on illness rates at these shore facilities was much greater

and more consistent than the observed seasonal influences on health.

16

References

1. Blood, C.G., Pugh, W.M., Griffith, D.K., Nirona, C.B., Medical Resource

Planning: Rates of Illness for Various Operational Theaters. Report No.

88-42. Naval Health Research Center, San Diego, CA 1988.

2. Blood, C.G., Griffith, D.K., Ship Size as a Factor in Illness Incidence.

Report No. 88-48. Naval Health Research Center, San Diego, CA 1988.

3. Blood, C.G., Nirona, C.B., Outpatient Illness Incidence Aboard U.S. Navy

hips During and Following the Vietnam Conflict. Report No. 89-15. Naval

Health Research Center, San Diego, CA 1989.

4. Bruce, N.G., Cook, D.G., Shaper, A.G., Thomson, A.G. Geographical

Variations in Blood Pressure in British Men and Women. Journal of Clinical

Epidemiology, 43, 385-398, 1990.

5. Forster, D.P., Jozan, P. Health in Eastern Europe. Lancet, 335,

458-460, 1990.

6. Cook, S.M., Glass, R.I., LeBaron, C.W., Mei-Shang, H. Global Seasonality

of Rotavirus Infections. Bulletin of the World Health Organization, 68,

171-177, 1990.

7. Konno, T., Suzuki, H., Katsushima, A.I., Tazawa, F., Kutsuzawa, S.K.,

Sakamoto, M., Yazaki, N., Ishida, N. Influence of Temperature and Relative

Humidity on Human Rotavirus Infection in Japan. Journal of Infectious

Disease, 147, 125-128, 1983.

8. Stintzing, G., Back, E., Tufvesson, B., Johnsson, T., Wadstrom, T.,

Habte, D. Seasonal Fluctuations in the Occurrence of Enterotoxigenic

Bacteria and Rotavirus in Pediatric Diarrhea in Addis Ababa. Bulletin of the

World Health Organization, 59, 67-73, 1981.

9. Fine, P.E.M., Clarkson, J.A. Seasonal Influences on Pertussis.

International Journal of Epidemiology, 15, 237-247, 1986.

17

10. Fine, P.E.M., Clarkson, J.A. Measles in England and wales: An Analysis

of Factors Underlying Seasonal Patterns. International Journal of

Epidemiology, 11, 5-14, 1982.

11. Helweg-Larsen, K., Bay, H., Mac, F. A Statistical Analysis of the

Seasonalit' in Sudden Infant Death Syndrome. International Journal of

Epidemiology, 14, 566-574, 1985.

12. BUMEDINST 6300.2A Medical Services and Outpatient Morbidity Reporting

System. Instructions for completing the Medical Services and Outpatient

Morbidity Report (NAVMED 6300/1). December 1979.

13. Dunn, O.J., On Multiple Tests and Confidence Intervals. Communications

in Statistics, 3, 101-103, 1974.

14. Pugh, W.M., White, M.R., Blood, C.G., Disease and Non-Battle Injury

Pates for Navy Enlisted Personnel Duriny Peacetime. Report No. 89-51.

Naval Health Research Center, San Diego, CA 1989.

18

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27

UNCLASSIFIED

SECURITY CLASSIFICATION OF THIS PAGE

REPORT DOCUMENTATION PAGEla REPORT SECURITY CLASSIFjCAT!ON lb RESTRICTIVE MARKINGS

UNCLASSIFIED NONE2a SECURITY CLASSIFCATiON AUTHORITY 3 DISTRIBUTION /AVAILABILITY OF REPORT

N/A Approved for public release; distribution2b DECLASSrICA

TtON / DOWNGRADING SCHEDULE unl i mi tedN/A

4 PERFORMiNG ORGANIZATION REPORT NUMBER(S) 5 MONITORING ORGANIZATION REPORT NUMBER(S)

NHRC Report No. 90- 13

6a NAME OF PERFORMING ORGANIZATION 6o OFFICE SYMBOL 7a NAME OF MONITORING ORGANIZATION

Naval Health Research Center (if applicable) Chief

I Code 20 Bureau of Medicine and Surgery

6c. ADDRESS (City, State, and ZIPCode) 7b. ADDRESS (City State, and ZIP Code)

P.O. Box 85122 Department of the NavySan Diego, CA 92186-5122 Washington, D.C. 20372

Sa NAME OP FUNDING, SPONSORING 8b OFFICE SYMBOL 9 PROCUREMENT INSTRUMENT IDENTIFICATION NUMBER

ORGANIZAT'ON Naval Medical (if applicable)

Research and Development Commar8( ADDRESS(Cty, State, and ZIP Code) 10 SOURCE OF FUNDING NUMBERS

NNt4C PROGRAM PROJECT TASK WORK UNITBethesda, MD 20814-5044 ELEMENT NO NO NO ACCESSION NO63706N M0095 005 DN249506

1 TITLE (Include Security Classification)

(U) GEOGRAPHICAL AND TEMPORAL VARIATIONS IN OUTPATIENT MORBIDITY AT U.S. NAVY OVERSEAS

FACILITIES!2 PERSONAL AUTHOR(S)

BLOOD, C.G., NIRONA, C.B.1Ta TYPE OF REPORT 13b TIME COVERED 1 DATEOFREORT (Year,Month, Day) 15 PAGE COUNT

Final FROM 10 190 July16 SUPPLEMENTARY NOTATION

1 7 COSATI CODES 18 SUBJECT TERMS (Continue on reverse if necessary and identify by block number)

FIELD GROUP SUBGROUP U.S. Navy disease rates, DNBI, geographical, seasonalillness incidence, morbidity

19 ABSTRACT (Continue on reverse if necessary and identify by block number)

Differences in outpatient morbidity were found to exist between shore stations in EastAsia and Europe. The facilities in Europe consistently yielded lower illness rates than

those in the Pacific region. The highest rate among the seven regions investigated was

seen in Bahrain. Minor fluctuations in illness incidence by quarter were evidenced forJapan and the Philippines while Bahrain showed considerable variation by time period.Increases in disease rates were quite stable across quarters for facilities in Europe andthe United Kingdom. The minor elevations in morbidity rates for the Europpan reqionsparalleled increases in rainfall or decreases in temperature. Outpatient rates fluctuatedmuch more by region than they did by season within regions.

20 DISTPRBIT 'In AVAILABILITY OF ABSTRACT 21 ABSTRACT SECURITY CLASSIFICATION

K3 UNCIASit'ED,UNLIMITED E- SAME AS RPT 1 OTtUC USERS UNCLASSIFIED22a NAME O RESPONSIBLE INDIVIDUAL 22b TELEPHONE (Include Area Code) 22c OFFICE SYMBOL

CHRISTOPHER G. BLOOD (619) 553-8404 Code 20

DD FORM 1473, 84 MAR 83 APR ed:ton may be used until exhausted SECURITY CLASSIFICATION OF THIS PAGEAll other editions are obsolete

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