Skip to main content

Military Health System

Morbidity Burdens Attributable to Various Illnesses and Injuries, Deployed Active and Reserve Component Service Members, U.S. Armed Forces, 2019

Image of A physician examines a patient. A physician examines and educates a patient. (U.S. Navy photo by Jacob Sippel, Naval Hospital Jacksonville/Released)

Recommended Content:

Medical Surveillance Monthly Report

What Are the New Findings?

Three categories of morbidity burdens (injury/poisoning, musculoskeletal diseases, and signs/symptoms and ill-defined conditions) accounted for more than half of the total burden in theater. In 2019, the percentages of encounters due to mental health disorders decreased to levels much lower than during earlier periods of combat engagements. Compared to garrison disease burden, deployed service members had higher proportions of encounters for respiratory infections, skin diseases, and infectious and parasitic diseases.

What Is the Impact on Readiness and Force Health Protection?

The similarities between the burden of disease and injury among deployed and non-deployed service members emphasize the continuing need for surveillance, research, and preventive measures for those ever-present health threats. The dissimilarities highlight those special health threats associated with the more austere environments of deployment areas and the needed area-specific preventive measures of importance.

Background

Every year, the MSMR estimates illness- and injury-related morbidity and health care burdens on the U.S. Armed Forces and the Military Health System (MHS) using electronic records of medical encounters from the Defense Medical Surveillance System (DMSS). These records document health care delivered in the fixed medical facilities of the MHS and in civilian medical facilities when care is paid for by the MHS. Health care encounters of deployed service members are documented in records that are maintained in the Theater Medical Data Store (TMDS), which is incorporated into the DMSS. This report updates previous analyses examining the distributions of illnesses and injuries that accounted for medical encounters ("morbidity burdens") of active component members in deployed settings in the U.S. Central Command (CENTCOM) and the U.S. Africa Command (AFRICOM) areas of operations during the 2019 calendar year.1

Methods

The surveillance population included all individuals who served in the active or reserve components of the U.S. Army, Navy, Air Force, or Marine Corps and who had records of health care encounters captured in the TMDS during the surveillance period. The analysis was restricted to encounters where the theater of care specified was CENTCOM or AFRICOM or where the theater of operation was missing or null; by default, this excluded encounters in the U.S. Northern Command, U.S. European Command, U.S. Indo-Pacific Command, or U.S. Southern Command theater of operations. In addition, TMDS-recorded medical encounters where the data source was identified as Shipboard Automated Medical System (e.g., SAMS, SAMS8, SAMS9) or where the military treatment facility descriptor indicated care was provided aboard a ship (e.g., USS George H.W. Bush or USS Dwight D. Eisenhower) were excluded from this analysis. Encounters from aeromedical staging facilities outside of CENTCOM or AFRICOM (e.g., the 779th Medical Group Aeromedical Staging Facility or the 86th Contingency Aeromedical Staging Facility) were also excluded. Inpatient and outpatient medical encounters were summarized according to the primary (first-listed) diagnoses (if reported with an International Classification of Diseases, 9th Revision [ICD-9] code between 001 and 999 or beginning with V27 or with an International Classification of Diseases, 10th Revision [ICD-10] code between A00 and T88 or beginning with Z37). Primary diagnoses that did not correspond to an ICD-9 or ICD-10 code (e.g., 1XXXX, 4XXXX) were not reported in this burden analysis.

In tandem with the methodology described on page 2 of this issue of the MSMR, all illness- and injury-specific diagnoses were grouped into 151 burden of disease-related conditions and 25 major categories based on a modified version of the classification system developed for the Global Burden of Disease (GBD) Study.2 The morbidity burdens attributable to various conditions were estimated on the basis of the total number of medical encounters attributable to each condition (i.e., total hospitalizations and ambulatory visits for the condition with a limit of 1 encounter per individual per condition per day) and the numbers of service members affected by the conditions. In general, the GBD system groups diagnoses with common pathophysiologic or etiologic bases and/or significant international health policymaking importance. For this analysis, some diagnoses that are grouped into single categories in the GBD system (e.g., mental health disorders) were disaggregated. Also, injuries were categorized by the affected anatomic sites rather than by causes because external causes of injuries are not completely reported in TMDS records. It is important to note that because the TMDS has not fully transitioned to ICD-10 codes, some ICD-9 codes appear in this analysis. In addition to the examination of the distribution of diagnoses by the 151 conditions and the 25 major categories of disease burden, a third analysis depicts the distribution of diagnoses according to the 17 traditional categories of the ICD system.

Results

In 2019, a total of 191,887 medical encounters occurred among 69,405 individuals while deployed to Southwest Asia/Middle East and Africa. A majority of the medical encounters (77.4%) and individuals affected (81.8%) occurred among males (Figures 1a, 1b).

Medical encounters/individuals affected, by burden of disease categories

During 2019, the percentages of total medical encounters by burden of disease categories in both deployed men and women were generally similar; in both sexes, more encounters were attributable to injury/poisoning, musculoskeletal diseases, and signs/symptoms (including ill-defined conditions) than any other categories (Figures 1a, 1b, 2a, 2b). Of note, females had a greater proportion of medical encounters for genitourinary diseases (5.6%) compared to males (1.2%). Females also had a higher proportion of medical encounters for mental health disorders (9.1%) compared to males (5.2%).

Among both males and females, 5 burden conditions (other back problems, arm and shoulder injuries, knee injuries, foot and ankle injuries, and upper respiratory infections) were among the top 6 burden conditions that accounted for the most medical encounters in 2019 (Figures 3a, 3b). The remaining burden conditions among the top 6 were organic sleep disorders (specifically, circadian rhythm disorders) among males and all other signs and symptoms among females.

The 4-digit ICD-10 code with the most medical encounters in the other back problems category during 2019 was for lumbago/low back pain (data not shown). For all other musculoskeletal diseases, the most common 4-digit ICD code for both males and females was for cervicalgia. The most common 4-digit ICD-10 code for arm and shoulder injuries among males and for knee injuries among males and females was for pain in the specified body part (e.g., pain in right or left shoulder or pain in right or left knee) (data not shown).

Of note, among males, less than 0.3% of all medical encounters during deployment were associated with any of the following major morbidity categories: other neoplasms, metabolic/immunity disorders, endocrine disorders, congenital anomalies, blood disorders, malignant neoplasms, nutritional disorders, diabetes, and perinatal conditions (Figure 1a). Among females, less than 0.3% of all medical encounters during deployment were associated with endocrine disorders, other neoplasms, blood disorders, nutritional disorders, maternal conditions, congenital anomalies, malignant neoplasms, metabolic/immunity disorders, perinatal conditions, and diabetes mellitus (Figure 1b).

Among both sexes in 2019, injury/poisoning, musculoskeletal diseases, and signs/symptoms were the top 3 categories that affected the most individuals; musculoskeletal diseases ranked second among males and third among females (Figures 1a, 1b).

Medical encounters, by major ICD-9/ICD-10 diagnostic category

In 2019, among the 17 major ICD-9/ICD-10 diagnostic categories, the largest percentages of medical encounters were attributable to musculoskeletal system and "other" (includes factors influencing health status and contact with health services as well as external causes of morbidity) (Figure 4). The percentage of medical encounters attributable to musculoskeletal system conditions increased from 2015 through 2019, and the percentage attributable to "other" decreased during the same period. Of note, the percentages of medical encounters attributable to mental health disorders decreased slightly from 6.4% in 2015 to 4.7% in 2019. However, the percentage of medical encounters attributable to disorders of the nervous system and sense organs more than doubled from 3.5% in 2015 to 7.8% in 2019. The percentages of medical encounters attributable to other major ICD-9/ICD-10 diagnostic categories were relatively similar during the years 2015, 2017, and 2019.

Editorial Comment

This report documents the morbidity and health care burden among U.S. military members while deployed to Southwest Asia/Middle East and Africa during 2019. Similar to results from earlier surveillance periods,1,3 3 burden categories—injury/poisoning, musculoskeletal diseases, and signs/symptoms—together accounted for more than 50% of the total health care burden in theater among both male and female deployers. However, the 2019 percentages of encounters due to mental health disorders among males and females (5.2% and 9.1%, respectively) were much smaller than the corresponding percentages during 2008–2014 (13.1% and 13.8%, respectively).3

Compared to the distribution of major burden of disease categories documented in garrison, this report demonstrates relatively greater proportions of in-theater medical encounters due to respiratory infections, skin diseases, and infectious and parasitic diseases. The lack of certain amenities and greater exposure to austere environmental conditions may have compromised hygienic practices and contributed to this finding. In contrast, compared to the distribution of burden of disease in garrison, a relatively lower proportion of in-theater medical encounters due to mental health disorders was observed.4 This finding may be due to a number of factors including reduced combat and operational stress in deployed settings and the continued emphasis on promoting psychological health and resilience in deployed service members.

However, 4 of the top 5 major burden of disease categories in-theater—injury/poisoning, musculoskeletal diseases, signs/symptoms, and mental health disorders—were the same as those reported in non-deployed settings.4 Injury and musculoskeletal diseases ranked first and second in both settings. In garrison settings, mental health disorders, signs/symptoms, and neurologic conditions ranked third through fifth.4 In contrast, sign/symptoms, respiratory infections, and mental health disorders ranked third through fifth in deployed settings. The similarity in these top conditions is likely attributable to the fact that both deployed and non-deployed populations generally comprise young and healthy individuals undergoing strenuous physical and mental tasks. Some of the similarity in the top conditions could also be attributed to service members receiving follow-up care once out of theater. For example, a service member medically evacuated out of theater for an injury could have encounters for injury recorded in both deployed and non-deployed (hospital or ambulatory care) settings.

Encounters for certain conditions are not expected to occur often in deployment settings. For example, the presence of some conditions (e.g., diabetes, pregnancy, or congenital anomalies) makes the affected service members ineligible for deployment. As a result of this selection process, deployed service members are generally healthier than their non-deployed counterparts and, specifically, less likely to require medical care for conditions that preclude deployment. The overall result of such predeployment medical screening is diminished health care burdens (as documented in the TMDS) related to certain disease categories.

Interpretation of the data in this report should be done with consideration of some limitations. Not all medical encounters in theaters of operation are captured in the TMDS. Some care is rendered by medical personnel at small, remote, or austere forward locations where electronic documentation of diagnoses and treatment is not feasible. As a result, the data described in this report likely underestimate the total burden of health care actually provided in the areas of operation examined. In particular, some emergency medical care provided to stabilize combat-injured service members before evacuation may not be routinely captured in the TMDS. Another limitation derives from the potential for misclassification of diagnoses due to errors in the coding of diagnoses entered into the electronic health record. Although the aggregated distributions of illnesses and injuries found in this study are compatible with expectations derived from other examinations of morbidity in military populations (both deployed and non-deployed), instances of incorrect diagnostic codes (e.g., coding a spinal cord injury using a code that denotes the injury was suffered as a birth trauma rather than using a code indicating injury in an adult) warrant care in the interpretation of some findings. Although such coding errors are not common, their presence serves as a reminder of the extent to which this study depends on the capture of accurate information in the sometimes austere deployment environment in which health care encounters occur.

References

  1. Armed Forces Health Surveillance Branch. Morbidity burdens attributable to various illnesses and injuries, deployed active and reserve component service members, U.S. Armed Forces, 2018. MSMR. 2019;26(5):34–39.
  2. Murray CJL and Lopez AD, eds. Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Cambridge, MA: Harvard University Press; 1996:120–122.
  3. Armed Forces Health Surveillance Branch. Morbidity burdens attributable to various illnesses and injuries in deployed (per Theater Medical Data Store [TMDS]) active and reserve component service members, U.S. Armed Forces, 2008–2014. MSMR. 2015;22(8):17–22.
  4. Armed Forces Health Surveillance Branch. Absolute and relative morbidity burdens attributable to various illnesses and injuries, active component, U.S. Armed Forces, 2019. MSMR. 2020;27(5): 2–9.

FIGURE 1a. Medical encountersa and individuals affected,b by burden of disease major category,c deployed male service members, U.S. Armed Forces, 2019

FIGURE 1b. Medical encountersa and individuals affected,b by burden of disease major category,c deployed female service members, U.S. Armed Forces, 2019

FIGURE 2a. Percentage of medical encounters,a by burden of disease major category,b deployed male service members, U.S. Armed Forces, 2019

FIGURE 2b. Percentage of medical encounters,a by burden of disease major category,b deployed female service members, U.S. Armed Forces, 2019

FIGURE 3a. Percentage and cumulative percentage distribution, burden of disease-related conditionsa that accounted for the most medical encounters, deployed male service members, U.S. Armed Forces, 2019

FIGURE 3b. Percentage and cumulative percentage distribution, burden of disease-related conditionsa that accounted for the most medical encounters, deployed female service members, U.S. Armed Forces, 2019

 FIGURE 4. Major ICD-9/ICD-10 diagnostic categories of in-theater medical encounters, active component, U.S. Armed Forces, 2015, 2017, and 2019

You also may be interested in...

MSMR Vol. 29 No. 10 - October 2022

Report
10/1/2022

A monthly publication of the Armed Forces Health Surveillance Division. This issue of the peer-reviewed journal contains the following articles: Surveillance trends for SARS-CoV-2 and other respiratory pathogens among U.S. Military Health System Beneficiaries, Sept. 27, 2020 – Oct. 2,2021; Establishment of SARS-CoV-2 genomic surveillance within the MHS during March 1 – Dec. 31 2020; Suicide behavior among heterosexual, lesbian/gay, and bisexual active component service members in the U.S. Armed Forces; Brief report: Phase I results using the Virtual Pooled Registry Cancer Linkage system (VPR-CLS) for military cancer surveillance.

Recommended Content:

Health Readiness & Combat Support | Public Health | Medical Surveillance Monthly Report

MSMR Vol. 29 No. 09 - September 2022

Report
9/1/2022

A monthly publication of the Armed Forces Health Surveillance Division. This issue of the peer-reviewed journal contains the following articles: Surveillance trends for SARS-CoV-2 and other respiratory pathogens among U.S. Military Health System Beneficiaries, Sept. 27, 2020 – Oct. 2,2021; Establishment of SARS-CoV-2 genomic surveillance within the MHS during March 1 – Dec. 31 2020; Suicide behavior among heterosexual, lesbian/gay, and bisexual active component service members in the U.S. Armed Forces; Brief report: Phase I results using the Virtual Pooled Registry Cancer Linkage system (VPR-CLS) for military cancer surveillance.

Recommended Content:

Health Readiness & Combat Support | Public Health | Medical Surveillance Monthly Report

MSMR Vol. 29 No. 08 - August 2022

Report
8/1/2022

A monthly publication of the Armed Forces Health Surveillance Division. This issue of the peer-reviewed journal contains the following articles: Surveillance trends for SARS-CoV-2 and other respiratory pathogens among U.S. Military Health System Beneficiaries, Sept. 27, 2020 – Oct. 2,2021; Establishment of SARS-CoV-2 genomic surveillance within the MHS during March 1 – Dec. 31 2020; Suicide behavior among heterosexual, lesbian/gay, and bisexual active component service members in the U.S. Armed Forces; Brief report: Phase I results using the Virtual Pooled Registry Cancer Linkage system (VPR-CLS) for military cancer surveillance.

Recommended Content:

Medical Surveillance Monthly Report

Musculoskeletal Injuries During U.S. Air Force Special Warfare Training Assessment and Selection, Fiscal Years 2019–2021.

Article
8/1/2022
U.S. Air Force Capt. Hopkins, 351st Special Warfare Training Squadron, Instructor Flight commander and Chief Combat Rescue Officer (CRO) instructor, conducts a military free fall equipment jump from a DHC-4 Caribou aircraft in Coolidge, Arizona, July 17, 2021. Hopkins is recognized as the 2020 USAF Special Warfare Instructor Company Grade Officer of the Year for his outstanding achievement from January 1 to December 31, 2020.

Musculoskeletal (MSK) injuries are costly and the leading cause of medical visits and disability in the U.S. military.1,2 Within training envi­ronments, MSK injuries may lead to a loss of training, deferment to a future class, or voluntary disenrollment from a training pipeline, all of which are impediments to maintaining full levels of manpower and resources for the Department of Defense.

Recommended Content:

Medical Surveillance Monthly Report

Brief Report: Pain and Post-Traumatic Stress Disorder Screening Outcomes Among Military Personnel Injured During Combat Deployment.

Article
8/1/2022
U.S. Air Force Airman 1st Class Miranda Lugo, right, 18th Operational Medical Readiness Squadron mental health technician and Guardian Wingman trainer, and Maj. Joanna Ho, left, 18th OMRS director of psychological health, discuss the suicide prevention training program, Guardian Wingman, at Kadena Air Base, Japan, Aug. 20, 2021. Guardian Wingman aims to promote wingman culture and early help-seeking behavior. (U.S. Air Force photo by Airman 1st Class Anna Nolte)

The post-9/11 U.S. military conflicts in Iraq and Afghanistan lasted over a decade and yielded the most combat casualties since the Vietnam War. While patient survivability increased to the high­est level in history, a changing epidemiology of combat injuries emerged whereby focus shifted to addressing an array of long-term sequelae, including physical, psychologi­cal, and neurological issues.

Recommended Content:

Medical Surveillance Monthly Report

Prevalence and Distribution of Refractive Errors Among Members of the U.S. Armed Forces and the U.S. Coast Guard, 2019.

Article
8/1/2022
Ophthamologist Air Force Maj. Thuy Tran evaluates a patient during an eye exam. (U.S. Air Force photo by Tech. Sgt. John Hughel)

During calendar year 2019, the estimated prevalence of myopia, hyperopia, and astigmatism were 17.5%, 2.1%, and 11.2% in the active component of the U.S. Armed Forces and 10.1%, 1.2%, and 6.1% of the U.S. Coast Guard, respectively.

Recommended Content:

Medical Surveillance Monthly Report

MSMR Vol. 29 No. 07 - July 2022

Report
7/1/2022

A monthly publication of the Armed Forces Health Surveillance Division. This issue of the peer-reviewed journal contains the following articles: Surveillance trends for SARS-CoV-2 and other respiratory pathogens among U.S. Military Health System Beneficiaries, Sept. 27, 2020 – Oct. 2,2021; Establishment of SARS-CoV-2 genomic surveillance within the MHS during March 1 – Dec. 31 2020; Suicide behavior among heterosexual, lesbian/gay, and bisexual active component service members in the U.S. Armed Forces; Brief report: Phase I results using the Virtual Pooled Registry Cancer Linkage system (VPR-CLS) for military cancer surveillance.

Recommended Content:

Health Readiness & Combat Support | Public Health | Medical Surveillance Monthly Report

Establishment of SARS-CoV-2 Genomic Surveillance Within the Military Health System During 1 March–31 December 2020.

Article
7/1/2022
Dr. Peter Larson loads an Oxford Nanopore MinION sequencer in support of COVID-19 sequencing assay development at the U.S. Army Medical Research Institute of Infectious Diseases, Fort Detrick, Maryland. (Photo by John Braun Jr., USAMRIID.)

This report describes SARS-CoV-2 genomic surveillance conducted by the Department of Defense (DOD) Global Emerging Infections Surveillance Branch and the Next-Generation Sequencing and Bioinformatics Consortium (NGSBC) in response to the COVID-19 pandemic. Samples and sequence data were from SARS-CoV-2 infections occurring among Military Health System (MHS) beneficiaries from 1 March to 31 December 2020.

Recommended Content:

Medical Surveillance Monthly Report

Surveillance Trends for SARS-CoV-2 and Other Respiratory Pathogens Among U.S. Military Health System Beneficiaries, 27 September 2020–2 October 2021.

Article
7/1/2022
Staff Sgt. Misty Poitra and Senior Airman Chris Cornette, 119th Medical Group, collect throat swabs during voluntary COVID-19 rapid drive-thru testing for members of the community while North Dakota Army National Guard Soldiers gather test-subject data in the parking lot of the FargoDome in Fargo, N.D., May 3, 2020. The guardsmen partnered with the N.D. Department of Health and other civilian agencies in the mass-testing efforts of community volunteers. (U.S. Air National Guard photo by Chief Master Sgt. David H. Lipp)

Respiratory pathogens, such as influenza and adenovirus, have been the main focus of the Department of Defense Global Respiratory Pathogen Surveillance Program (DoDGRPSP) since 1976.1. However, DoDGRPSP also began focusing on SARS-CoV-2 when COVID-19 was declared a pandemic illness in early March 2020.2. Following this declaration, the DOD quickly adapted and organized its respiratory surveillance program, housed at the U.S. Air Force School of Aerospace Medicine (USAFSAM), in response to this emergent virus.

Recommended Content:

Medical Surveillance Monthly Report

Suicide Behavior Among Heterosexual, Lesbian/Gay, and Bisexual Active Component Service Members in the U.S. Armed Forces.

Article
7/1/2022
  The DOD’s theme for National Suicide Prevention Month is “Connect to Protect: Support is Within Reach.” Deployments, COVID-19 restrictions, and the upcoming winter season are all stressors and potential causes for depression that could lead to suicidal ideations. Options are available to individuals who are having thoughts of suicide and those around them (Photo by Kirk Frady, Regional Health Command Europe).

Lesbian, gay, and bisexual (LGB) individuals are at a particularly high risk for suicidal behavior in the general population of the United States. This study aims to determine if there are differences in the frequency of lifetime suicide ideation and suicide attempts between heterosexual, lesbian/gay, and bisexual service members in the active component of the U.S. Armed Forces. Self-reported data from the 2015 Department of Defense Health-Related Behaviors Survey were used in the analysis.

Recommended Content:

Medical Surveillance Monthly Report

Brief Report: Phase I Results Using the Virtual Pooled Registry Cancer Linkage System (VPR-CLS) for Military Cancer Surveillance.

Article
7/1/2022
A patient at Naval Hospital Pensacola prepares to have a low-dose computed tomography test done to screen for lung cancer. Lung cancer is the leading cause of cancer-related deaths among men and women. Early detection can lower the risk of dying from this disease. (U.S. Navy photo by Jason Bortz)

The Armed Forces Health Surveillance Division, as part of its surveillance mission, periodically conducts studies of cancer incidence among U.S. military service members. However, service members are likely lost to follow-up from the Department of Defense cancer registry and Military Health System data sets after leaving service and during periods of time not on active duty.

Recommended Content:

Medical Surveillance Monthly Report

Morbidity Burdens Attributable to Various Illnesses and Injuries, Deployed Active and Reserve Component Service Members, U.S. Armed Forces, 2021

Article
6/1/2022
Morbidity Burdens Attributable to Various Illnesses and Injuries, Deployed Active and Reserve Component Service Members, U.S. Armed Forces, 2021

As in previous years, among service members deployed during 2021, injury/poisoning, musculoskeletal diseases and signs/symptoms accounted for more than half of the total health care burden during deployment. Compared to garrison disease burden, deployed service members had relatively higher proportions of encounters for respiratory infections, skin diseases, and infectious and parasitic diseases. The recent marked increase in the percentage of total medical encounters attributable to the ICD diagnostic category "other" (23.0% in 2017 to 44.4% in 2021) is likely due to increases in diagnostic testing and immunization associated with the response to the COVID-19 pandemic.

Recommended Content:

Medical Surveillance Monthly Report

Hospitalizations, Active Component, U.S. Armed Forces, 2021

Article
6/1/2022
Hospitalizations, Active Component, U.S. Armed Forces, 2021

The hospitalization rate in 2021 was 48.0 per 1,000 person-years (p-yrs), the second lowest rate of the most recent 10 years. For hospitalizations limited to military facilities, the rate in 2021 was the lowest for the entire period. As in prior years, the majority (71.2%) of hospitalizations were associated with diagnoses in the categories of mental health disorders, pregnancy-related conditions, injury/poisoning, and digestive system disorders.

Recommended Content:

Medical Surveillance Monthly Report

Surveillance snapshot: Illness and injury burdens, reserve component, U.S. Armed Forces, 2021

Article
6/1/2022
Surveillance snapshot: Illness and injury burdens, reserve component, U.S. Armed Forces, 2021

Recommended Content:

Medical Surveillance Monthly Report

Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Active Component, U.S. Armed Forces, 2021

Article
6/1/2022
Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Active Component, U.S. Armed Forces, 2021

In 2021, as in prior years, the medical conditions associated with the most medical encounters, the largest number of affected service members, and the greatest number of hospital days were in the major categories of injuries, musculoskeletal disorders, and mental health disorders. Despite the pandemic, COVID-19 accounted for less than 2% of total medical encounters and bed days in active component service members.

Recommended Content:

Medical Surveillance Monthly Report
<< < 1 2 3 4 5  ... > >> 
Showing results 1 - 15 Page 1 of 13
Refine your search
Last Updated: October 24, 2022
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on Twitter Follow us on YouTube Sign up on GovDelivery