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Post Operations Desert Shield/Desert Storm (ODS/DS) Medical
Issues
Filename:623rpt.93s
15 September 1993
INFORMATION PAPER
SUBJECT: Post Operations Desert Shield/Desert Storm (ODS/DS)
Medical Issues
1. PURPOSE: To provide information on the above subject.
2. FACTS:
a. Background.
(1) Many preventive measures were taken to protect U.S.
service personnel from diseases and environmental threats
known to exist in the Persian Gulf area.
(2) For protection against infectious diseases endemic to
Southwest Asia, deployment recommendations by the Army Medical
Department were that soldiers be current with polio, typhoid,
diphtheria tetanus, influenza and meningococcal immunizations.
In addition, soldiers were given immune serum globulin to
protect against infectious hepatitis and some soldiers were
given chloroquine chemoprophylaxis to protect against malaria.
All of the above products are licensed by the Food and Drug
Administration (FDA).
(3) Preventive medicine guidance was published (e.g., "The
Threat of Disease and Non Battle Injury to U.S. Military
Personnel on Operation Desert Shield") and widely distributed
in order to minimize disease and non battle injury (DNBI). A
second book, "Diagnosis and Treatment of Diseases of Tactical
Importance to U.S. CENTCOM Forces," was distributed to assist
medical personnel in the early diagnosis and treatment of the
diseases found in Southwest Asia (SWA).
(4) Preventive medicine assets were deployed to SWA to monitor
the incidence of DNBI. The DNBI rate during Operation Desert
Shield (1 Sept 90 through 15 Jan 91) was 0.34 hospital
admissions per 1000 soldiers per day and during Operation
Desert Storm (16 Jan 91 through 3 Jun 91) was 0.40/1000/day.
These rates were dramatically lower than reported during
previous exercises and conflicts. Four leading causes of
admissions in theater included non battle trauma, heat injury
(however, no death was attributed to heat injury), diarrhea,
and respiratory problems. There were 31 cases of leishmaniasis
(some of which were diagnosed after returning from SWA, see
below for additional details), 7 malaria, 2 meningococcal
disease (including one death) and 1 case of Q fever. No cases
of sandfly fever, hepatitis A, schistosomiasis, plague,
rabies, brucellosis, toxoplasmosis, trachoma, or anthrax were
diagnosed.
5. (U) No confirmed CBW detections.
The determination that CW is present is a two step process:
detection and confirmation. Detection is characterized by
alarms sounding. The equipment is very sensitive by design,
causing the resulting problem of many false alarms. A
conservative estimate of the number of false alarms during the
Gulf War crisis would number in the hundreds, if not,
thousands. It is very important to point out that despite this
large number of supposed detections, the second step,
confirmation, using simple wet chemlstry equipment and
techniques available at the platoon level, never resulted in a
single confirmation, except for the Czech reports on 19 and 24
January 91. In this case, the U.S. can not independently
verify these events, and essentially, is taking the Czechs at
their word based on assessments of their technical competence
and sensitivity of equipment.
6. (U) Advanced laboratory analysis of suspected CW samples
all proved negative. Before, during, and after the war, a
variety of soil, liquid and air samples were analyzed. This
analysis took place at state of the art labs in the U.S. and
UK. All samples were found negative.
7. (U) Long term low level exposure defies the laws of
physics.
A popular theory suggests the cause of the mystery illness to
be long term exposure of our troops to low, i.e. undetectable,
levels of CW. The law of diffusion states that any substance,
particularly a gas or liquid, naturally moves from an area of
greater concentration to lesser concentration. If in one area
or time the concentration is low as in the Czech detection
at some other area or time the concentration must be high.
Therefore, other detections would be expected near by,
possibly resulting in casualties; this did not happen.
Further, the only possible explanation for long term low level
exposure below detection range is the deliberate, continuous,
release of very small amounts of agent throughout the area
where exposure was to have occurred; in this case, much of the
Saudi Arabian peninsula. The facts simply do not support this
theory.
8. The Czech detection was not the result of a release from
bombed CBW targets. In addition to the law of diffusion, the
weather during the time further argues against this
possibility. The winds were in the wrong direction and it
rained throughout the region the day before the detection.
Even under ideal conditions, our models indicate that 80 tons
of nerve agent would have to have been released from the
closest known bombed CBW target, An Nasiriyah, to register at
the low levels detected by the Czechs 140 miles away. Such an
80 ton release of nerve agent in Iraq would have resulted in
an area of certain death or casualty that covers hundreds of
square kilometers. Also, detection equipment all over the area
would have alarmed and some additional confirmations would
have been expected; neither happened. Even a release caused by
a bomb from coalition aircraft striking a secondary target
an unknown CW storage site or convoy near the border for
example must still obey the law of diffusion. People nearby
would die or become casualties, detection alarms would sound
and confirmations would be made. As stated before, this simply
did not happen.
RECOMMENDATION: (U) None.
Prepared by: (b)(6)
.
POSITION PAPER
SUBJECT:: (U) Gulf War Health Issue; Evidence against use of
chemical or biological warfare (CBW) during Desert Storm
PURPOSE: (U) To provide the Secretary of Defense the basis of
DIA's assessment that no chemical or biological weapons were
used during Desert Storm, and are therefore not the cause of
the Gulf War Mystery Illness.
MAJOR POINTS: (U) DIA's assessment that no chemical or
biological weapons were used during Desert Storm/Shield is
based on the following:
1. (b)(1) sec 1.3(a)(4)
During its war with Iran, Iraq moved chemical munitions from
production and filling facilities in Samarra, to intermediate
storage areas in southern Iraq, and finally, to forward
deployment areas. This activity was accomplished within a
relatively short period (roughly 2 3 weeks), just prior to
Iraqi use of CW on the battlefield. The Iraqis operated in
this way in order to overcome a short shelf life problem
due to low purity levels they had with their nerve agent.
2. Unanimous statements of (b)(1) sec 1.3(a)(4) POWs
stating no intent. (b)(1) sec 1.3(a)(4) POW's
unanimously opined that there was no intent to use CBW against
the coalition for two main reasons: the fear of massive
retaliation we created the ambiguity of possible
retaliation with nuclear weapons and, their belief that the
coalition was far better prepared to fight in a CBW
environment than Iraq, thus there was no advantage in their
using CW.
3. (U) No CBW munitions found in the Kuwaiti Theater of
Operations (KTO) to this day. Immediately after the ground
war, a massive effort to collect and destroy remaining Iraqi
equipment was underway. Thorough searches of the entire
occupied Iraqi territory and Kuwait were accomplished. Not one
chemical munition nor any bulk agent was ever found. Moreover,
the Tampa based firm CMS Inc., primary U.S. contractor for
unexploded ordinance removal in Kuwait, stated recently that
to date, the company had discovered and removed over 14,000
tons of all types of ordinance (including 350,000 mines) and
found no CBW weapons.
4. (U) No CBW related casualties reported.
(U) During the entire Persian Gulf crisis, not one soldier,
sailor or airman was treated, hospitalized, or died, as a
result of CBW exposure. If CBW had been used, even on a
limited basis, this most certainly would not be the case. The
army private, mentioned on the recent NBC news program NOW,
who received the Bronze Star after experiencing burns while
searching bunkers, is the only known case with symptoms
similar to CBW exposure. However, advanced laboratory analysis
of his flak jacket, shirt, the swab used to clean his wound,
and subsequent urinalysis indicate conclusively that this was
not a CW event.
Subject: Technical procedures used to Detect Chemical Agent
during Desert Shield/Desert Storm
1. Detection of nerve agent during Desert Storm was accomplished using a
biochemical technique, while determination of mustard agent
depended on wet
chemical qualitative annlytical procedures
2. Detection of nerve agent on the 19th of January, 1991
occurred at three separate locations by two separate
Czechoslovak NBC Detachments. The first Chemical detachment
detected a G type agent while on convoy about 37 kilometers
north west of Hafr al Batin and 40 kilometers from the Iraqi
border. This unit detected chemical agents at two separate
locations. The second NBC detachment was located
approximately 45 kilometers north east of Hafr al Batin and 40
kilometers from the Kuwait border.
3. Both units detected the initial presence of nerve agent
using (b)(1) sec 1.3(a)(4) monitor/alarm which
detects only organophosphate type agents. (b)(1) sec
1.3(a)(4) , and were operating in a semi continuous mode.
This unit uses a wet chemical/colohmetric procedure by which
the enzyme system Butyryl Cholinesterase (BChE) containing
solution is deposited on a cotton tape, which is then drawn
through an air aspiration port exposing the enzyme to the
possible agent. Following this exposure, the tape is then
transported to another station, where a solution with the
indicator phenyl red is deposited on the tape. Presence of a
chemical agent in the air inhibits the enzyme from further
reaction which results in no color change; absence of an agent
causes a reaction which is registered as a color change from
red to yellow. As operated, this unit has a reported
sensitivity to nerve agent of 3.0 x 10 6 mg/l (of air
sampled).
4. Following the initial alarm by the (b)(1) sec
1.3(a)(4) , the troops donned their protective gear and
made follow up tests using the (b)(1) sec 1.3(a)(4)
unit. While this unit also uses BChE enzyme inhibition for
subsequent identification, the unit is somewhat more sensitive
due to the means of air sampling. However, because the basic
chemistry is identical to the (b)(1) sec 1.3(a)(4)
does not independently confirm the first nerve agent. This
system could register a positive result for any cholinesterase
inhibiting organophosphate compound, which would include many
agricultural insecticides. There were no other independent
tests performed at the site of the detection to indicate that
the chemical detected was in fact a nerve agent. An air sample
was collected on a dried silica gel substrate and preserved
for subsequent testing at a field laboratory located in King
Kahlid Military City (KKMC).At present there is no information
whether the enzyme testing was also used in this subsequent
testing, however, it is likely that it was.
5. The (b)(1) sec 1.3(a)(4) could be operated for
either a one minute or a three minute sample interval. When
operated for a one minute interval the sensitivity of this
unit is reported to be 5.0 x 105 mg/l. When operated for the
three minute interval, the sensitivity of this unit is
reported to be 5.0 x 0 7 mg/l (of air sample). When the
Czechoslovaks initially attempted to verify the (b)(1)
sec 1.3(a)(4) alarm using the one minute sample time, the
results were negative, and it was only after subsequent air
sampling for three minutes that they obtained the positive
results. This would place the concetration of the suspected
nerve agent in the air between 5.0 x 10 5 5.0 x 10 7 mg/1.
These concentraticns are so low that they are not felt to
represent any threat to personnel.
6. Following the initial alarm, there were four subsequent
(b)(1) sec 1.3(a)(4) , and subsequent processing and
refitting the unit lasted perhaps another 7 minutes. The first
three of these tests continued to register positive for
chemical agent. The fourth test was negative, at which point
the all clear was sounded. A total time of appfoximately 40
minutes elapsed between the initial alarm and the all clear.
The time between the initial detections at the 1st and 2nd NBC
detachments was about 30 minutes.
7. The reporting of these determinations was made through
proper channels, up through the brigade headquarters to the
joint command in KKMC. A situation report was also forwarded
through Saudi military to Riyadh.
8. Some four to five days following the detection of the nerve
agents north of Hafr al Batin, the 3rd detachment located at
KKMC was approached by the Saudi Liaison Officer with a
request for them to bring their reconnaissance vehicle out
into the desert to inspect an area. The location which they
were taken to was about one to two kilometers north or west of
KKMC. When approaching the actural location, they were
asked by the Saudi Liaison Officer if they shouldn't suit up
in their protective gear. The Czechoslovaks thought this was
strange but they did suit up. Upon disembarking their vehicles
they found a "wet area" on the desert floor which was
irregular in shape and measured about 60 centimeters by 200
centimeters (60 cm x 200 cm), much like a "puddle" of liquid
which is poured onto the ground and then seeps into the earth.
This area was tested using the (b)(1) sec 1.3(a)(4)
unit and mustard agent was identified as present. They then
used the (b)(1) sec 1.3(a)(4) portable laboratory
which used a complex chemical molecule based on benzoic acid,
phenol, and other aromatic chemicals. This test confirmed the
initial detection of the mustard agent by the (b)(1)
sec 1.3(a)(4) . Because these tests used different
chemical indicators for the determination, it is likely that
this detection of mustard was accurate and that the
contamination of this oil was with mustard age.
9. The situation report of this action was forwarded through
the joint headquarters KKMC, as were the previous reports.
There were no indications that this contamination was the
result of any military action; there was no debris, impact
crater or any other visible evidence that anyone had been to
this site previously. There was no previous, nor subsequent,
request like this one by the Saudi's. There was no follow up
action beyond the filing of the SITREP, and the notification
of the Czechoslovak Ministry of Defense.
10. Czechoslovak unit did not experience any problems with
their detectors, in particular (b)(1) sec 1.3(a)(4)
, as a result of environmental contaminants. The Czech unit
tested this equipment subsequently to determine its
sensitivity after the time of the burning oil fires. However,
the chemical agents were detected prior to the oil fires.
Morever, in a test, the Czechoslovak, set up the (b)(1)
sec 1.3(a)(4) on a lab bench located less than 2 feet
from the top of a 55 gallon oil drum containing burning oil.
The results of this test indicated that there were no problems
with the equipment, and that the emissions caused from these
units did not result in any false positive detections.
(12) REPORTED DISEASE CLUSTERS BY TUSKEEGEE VA MEDICAL CENTER:
Two clusters of illness (Hepatitis B and HTLV I/II) were the
subjects of media reports about veterans seen at the
Tuskeegee, Alabama VA Medical Center. A team from the VA
central office and a Navy epidemiologist investigated and
found no evidence to support the reports.
(13) MULTIPLE CHEMICAL SENSITIVITY:
The Army Medical Department (AMEDD) is evaluating the role of
multiple chemical sensitivity in causing some of the
unexplained symptoms reported by ODS/DS veterans and has
requested funding for a research facility to study mulLiple
chemical sensitivity.
c. The military health care system has sought extensive
consultation from within and with outside agencies and
individual experts in addressing the issue of post ODS/DS
medical symptoms. The health and well being of our service
personnel is of paramount concern to the military leadership
and the Army Medical Department and the Department of Veterans
Affairs will continue their investigations and treatment of
symptomatic veterans who served in Southwest Asia in support
of Operations Desert Shield/Desert Storm.
Prepared by: Office Of The Army Surgeon General,
(i) In order to determine the existence and prevalence of
chronic long term illnesses, conditions or symptomatology
directly related to or associated with service in SWA, the
Office of The Surgeon General sent out a worldwide message in
August 1992 to active duty medical treatment facilities
(07100Z AUG 92. Subject: New Operations Desert Shield/Desert
Storm (ODS/DS) Requirement for special Telegraphic Reporting
System MED 16). This message required that clinicians who
identify or suspect that a chronic medical or psychiatric
condition is related to service in SWA must notify the local
Preventive Medicine Service for assistance in gathering
epidemiological information and in preparing the electronic
report to be sent to OTSG.
(ii) Since August 1992, a total of 89 case reports (as of 14
September 1993) have been received at OTSG.
(iii) The cumulative data gathered through this surveillance
system will be tabulated and published at appropriate
intervals.
(10) POST TRAUMATIC STRESS DISORDER:
(a) The Conference Report on the FY 92 Defense Appropriations
Act directed the Department of Defense to study the effects of
the Gulf War on active duty, guard, and reserve personnel and
their families who are located in Greensburg, Pennsylvania,
and in the State of Hawaii. This is to specifically determine
if personnel are showing signs of significant psychological
distress brought on by abrupt changes in their lives. The
Walter Reed Army Institute of Research (WRAIR) has already
completed a similar study on Army active duty, guard, and
reserve personnel and their families during the pre
deployment, deployment, and post deployment phases of the Gulf
War. DOD asked WRAIR to perform its survey on this focused
population to determine what its mental health needs may be as
a result of the war. WRAIR will use the data base from the
former study which is derived from a larger population to
assess this particular population's needs.
(b) Between March and May 1993, WRAIR surveyed units and
individuals in Hawaii and Pennsylvania. Also the Department of
Veterans affairs will collect additional data on ODS/DS
veterans using local DVA facilities in the target area. The
final report of the study will be completed by November 1993.
(11) EXPOSURE TO LOW LEVEL CHEMICAL WARFARE AGENTS:
A press report quoting Senator Donald W. Riegle, Jr. in the 10
Sept 1993 Washington Post concerning alleged low level
exposure to chemical agents emitted from destroyed Iraqi
facilities ties these alleged exposures to post ODS/DS medical
symptoms. This matter is being investigated but as of this
date the AMEDD has no information to confirm this.
the private petroleum industry. The panel concluded that
"there is no scientifically supportable reason to believe that
the unexplained illnesses are related to petroleum exposure"
(for several reasons: diversity of complaints; delayed onset
of symptoms; lack of common exposure; and lack of similar
cases in long term oil industry workers).
( 9 ) MYSTERY ILLNESS:
(a) "Unexplained" or "Mystery Illnesses" have been widely
publicized. There have been media reports of individuals and
groups of individuals with symptoms of fatigue, joint pain,
hair loss, bleeding gums, headaches, rashes, and memory loss .
These have been investigated. Some are due to common medical
and dental problems expected in any civilian population; some
are difficult to diagnosis specifically even after extensive
civilian, Department of Veterans Affairs and/or military
medical center diagnostic workups.
(b) Active duty soldiers are evaluated through existing
medical channels. Reservists and other veterans with ODS/DS
related symptoms are eligible for care at Department of
Veterans Affairs (VA) medical treament facilities and are
added to the VA Persian Gulf Registry. Approximately 8000
ODS/DS veterans (all services) have had medical evaluations at
VA facilities and 3800 are on the Persian Gulf Registry.
Approximately 250 of these service personnel may be in the
category of "Mystery Illness". Each VA medical facility has
appointed an "Environmental Physician" point of contact for
ODS/DS related medical problems to facilitate patient
management.
(c) Working Group (b)(6)
( i) A working group of nationally recognized physician
experts, headed by (b)(6) is being assembled to review
and analyze medical records of ODS/DS veterans with
unexplained symptoms. This workirg group will collaborate with
the three services and the VA.
( ii) The working group will establish a working "case def
inition" for post ODS/DS unexplained illness .
(iii) (b)(6) in New Orleans and review his diagnostic
and therapeutic approach to post ODS/DS unexplained illness
and chronic fatigue syndrome.
(d) Summary Results of Special Surveillance Program.
DU. They are undergoing medical evaluation at the Boston VA
Medical Center. If all of their medical tests are negative, we
will conclude that all other category two soldiers needn't be
tested, because their exposures were less than the exposures
of the 144th S&S Company. In this category, 24 hour urine
specimens are also being collected to test for uranium
exposure. If any of the 144th S&S Company soldiers test
positive, the medical evaluation program for category two
soldiers will be broadened.
(4) VACCINES AGAINST BIOLOGICAL WARFARE AGENTS: The anthrax
vaccine, which is licensed by the FDA, was given to
approximately 150,000 individuals. The botulinum toxoid
vaccine, which is not FDA licensed but which has been used
safely for over 25 years, was given to approximately 8,000
individuals. Both may cause minor local or systemic side
effects, but no long term adverse health effects have been
documented.
MEDICATION AGAINST CHEMICAL WARFARE AGENTS: Pyridostigmine
bromide (PB) has been licensed in the U.S. (as Mestinon and
Regonol) since 1955 for treatment of myasthenia gravis. It can
be used prophylactically as a nerve agent antidote and was
used by tens of thousands of soldiers during the Gulf War.
There are some minor side effects but no known long term
adverse effects have been documented.
(6) MICROWAVE: It was widely reported in the news media that
microwave exposure from communications equipment was the cause
of unusual symptoms being reported by some individuals. That
was quickly discounted by experts in the field because of the
late onset of symptoms; no eye or skin injury; and no
indication that equipment was not used in a safe manner.
(7) OIL WELL FIRES: Smoke from the Kuwaiti oil well fires
caused some acute respiratory tract irritation, bronchitis,
and wheezing. The potential for long term health effects was
recognized early and the U.S. Army Environmental Hygiene
Agency began conducting two large scientific studies, while
the fires were still burning, to determine the level of
exposure to the smoke (Quantitative Health Risk Assessment
Study) and to estimate future long term health effects, if any
(llth Armored Cavalry Regiment Medical Surveillance Study).
The final report is due out in 1993, but at this point no
significant long term health effects have been identified or
are expected.
(8) PETROCHEMICAL EXPOSURE: Petrochemical toxicity as a cause
of the unusual symptoms reported by some veterans was
suggested by several clinical ecologists and was widely
publicized. The Army Surgeon General's office in August 1992
convened an expert panel on petroleum eXposure composed of
experts in toxicology, occupational medicine, internal
medicine, and epidemiology from governmental and academic
institutions and from
b. Post ODS/DS Medical Issues.
(l) LEISHMANIASIS (19 Cutaneous, 12 Viscerotropic): The
last case of viscerotropic leishmaniasis was diagnosed at
Walter
Reed Army Medical Center in May 1993 and the last case of
cutaneous
leishmaniasis in April 1993. In addition to the 31 cases of
leishmaniasis reported above, there are another 50 to 100
individuals from all services who have been evaluated and had
bone
marrow examinations at Walter Reed Army Medical Center. Even
though viscerotropic leishmaniasis may be suspected, the
parasite
has not been identified. Most of these individuals continue to
be
followed or have recovered. A system for getting suspected
active
duty or reserve component cases into Walter Reed Army Medical
Center was established early and has generally worked well.
The
risk of transmitting the parasite by blood transfusion is
thought to be low and the DOD moratorium on donations from
Gulf War veterans was lifted 1 January 1993. Civilian blood
banks also
lifted their ban on that date. No case of transfusion caused
leishmaniasis has been reported since lifting the moratorium.
(2) TUBERCULOSIS: Tuberculosis skin testing was recommended
for returnees. This office received reports of positive skin
tests in 1 5 of individuals in some returning units, but
it was felt that most were probably positive before departure.
Predeployment skin testing was not required. No cases of
active tuberculosis secondary to service in SWA have been
documented.
(3) DEPLETED URANIUM: Soldiers who received unusual exposures
to depleted uranium (DU) fall into two categories: (l) those
who were inside battlefield vehicles when hit by a DU
munition, and (2) those who received less significant
exposures (e.g., through vehicle recovery operations or by
fighting fires in which DU munitions were involved).
(a) Within category one, thirty five soldiers received
injuries; twenty two of the thirty five soldiers are suspected
of retaining DU fragments. No significant long term adverse
health effects are expected, but those 35 soldiers, and their
crewmembers who were not injured, are being offered
participation in a program through which they will undergo
periodic medical evaluation (at least annually) for five
years. After five years, a review will be made of the test
results and decisions will be made regarding continued medical
evaluation. As the first step in the investigation of these
soldiers, 24 hour urine specimens are being collected to test
for uranium exposure.
(b) Within category two, twenty seven soldiers of the 144th
Supply and Services Company (Army National Guard) are being
used as a sentinel population, because they incurred the
greatest potential in catgory two for receiving significant
exposures to
XDATE:1955
XDATE:1 SEPT 90
XDATE:JANUARY, 1991
XDATE:15 JAN 91
XDATE:16 JAN 91
XDATE:24 JANUARY 91
XDATE:3 JUN 91
XDATE:AUGUST 1992
XDATE:1993
XDATE:1 JANUARY 1993
XDATE:APRIL 1993
XDATE:MAY 1993
XDATE:10 SEPT 1993
XDATE:14 SEPTEMBER 1993
XDATE:15 SEPTEMBER 1993
XDATE:NOVEMBER 1993
XDATE:950925
PERSON:AL BATIN
PERSON:WALTER REED
PERSON:DONALD W. RIEGLE
FACIL:ARMY MEDICAL DEPARTMENT
FACIL:TUSKEEGEE VA MEDICAL CENTER
FACIL:ALABAMA VA MEDICAL CENTER
FACIL:DEPARTMENT OF VETERANS AFFAIRS
FACIL:ACTIVE DUTY MEDICAL TREATMENT FACILITIES
FACIL:ARMY INSTITUTE OF RESEARCH
FACIL:MEDICAL TREAMENT FACILITIES
FACIL:VA MEDICAL FACILITY
FACIL:BOSTON VA MEDICAL CENTER
FACIL:U.S. ARMY ENVIRONMENTAL HYGIENE AGENCY
EQUIP:CHEMICAL AGENT
EQUIP:NERVE AGENT
EQUIP:STORM 1
EQUIP:RECONNAISSANCE VEHICLE
COUNTRY:U.S.
COUNTRY:IRAQ
COUNTRY:KUWAIT
COUNTRY:IRAN
MILUNIT:BRIGADE HEADQUARTERS
MILUNIT:OFFICE OF THE ARMY
MILUNIT:LLTH ARMORED CAVALRY REGIMENT
MILUNIT:ARMY NATIONAL GUARD
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