Mayor and Council
Meeting No. 33- 16 September 26, 2016 7:00 PM
6:00 pm
1. Convene in Open Session to vote on motion to go into Executive Session pursuant to sections 3-305(b)(1)(i) and 3-305(b)(7) of the General Provisions Article of the Annotated Code of Maryland to 1) discuss the appointment of an appointee, employee, or official over whom it has jurisdiction; and 2) consult with counsel to obtain legal advice regarding ex parte communications.
2. Executive Session
7:00 pm
3. Reconvene into Open Session
4. Pledge of Allegiance
5. Agenda Review
7:05 pm
6. City Manager's Report
7:15 pm
7. Proclamation Declaring October 6, 2016 as German-American Day
7:20 pm
8. Proclamation Declaring September 27, 2016 as National Voter Registration Day
7:25 pm
9. Appointments/Reappointments and Announcements of Boards and Commissions Vacancies
7:35 pm
10. Community Forum
This time is set aside to hear from any community member who wishes to address the Mayor and Council. Citizens are asked to keep their remarks to three minutes. Priority will be given to speakers who have signed up in advance by calling the city Clerk's Office at 240-314-8280 by 4:00 p.m. on the day of the meeting and those who are speaking on an agenda item.
11. Mayor and Council's Response to Community Forum and Announcements
12. Mayor and Council Reports 7:50 pm
13. Presentation - Rockville Economic Development, Inc. Quarterly Report
8:05 pm
14. Consent Agenda
A. Authorize the City Manager to Execute a Lease Agreement Between the Mayor and Council of Rockville and New Cingular Wireless PCS, LLC (doing business as AT&T)
B. Authorization to Dispose of City-Collected Materials at the Montgomery County Transfer Station
C. Approval of Minutes
D. Approval of Amended Minutes - February and March 2016
E. Authorize the Acting City Manager to Execute a Memorandum of Understanding between the Mayor and Council of Rockville, the City of Takoma Park and the Maryland Municipal Channel for Use of a Shared High Definition Television Channel.
8:10 pm
15. Financial Advisory Board Action Plan for FY 2017
9:10 pm
16. Discussion and Instructions - Senior Needs Assessment Implementation Plan
9:55 pm
17. Discussion and Instructions - Safety of Youth Sports - Traumatic Brain Injuries (TBI)
10:40 pm
18 Presentation - FY 2016 Annual Procurement Report
10:55 pm
19. Review and Comment - Mayor and Council Action Report
20. Review and Comment - Future Agendas
21. Old/New Business
11:10 pm
22. Adjournment
NOTE: Times given for agenda items are estimates only. Matters may be considered at times other than those indicated. Please check the upcoming Mayor and Council calendar listed after this evening's agenda for future meeting and Drop-in information, including Community' Forum.
THERE WILL BE A COMMUNITY FORUM AT EVERY MEETING, UNLESS OTHERWISE INDICATED. When listed, Drop-in will be held in the Council offices from 5:30 pm to 6:30 pm. All meetings are on Monday evenings unless otherwise indicated. Worksessions in City Hall will be televised.
Please check with the City Clerk's office at 240-314-8280 for any further information.
Any person who requires assistance in order to attend this meeting should call the ADA Coordinator at 240-314-8100. Proclamation Declaring October 6, 2016 as German-American Day
Mayor and Council
For the meeting on: September 26, 2016 Department: City Clerk Responsible staff: Kathleen Conway, City Clerk/Director of Council Operations phone: (240) 314 - [email protected]
Subject Proclamation Declaring October 6, 2016 as German-American Day
Recommendation Staff recommends that the Mayor and Council read, approve and present the Proclamation declaring October 6, 2016 as German-American Day to Drew Powell, President of Rockville Sister Cities Corporation.
Discussion German-American Day (Deutsch-Amerikanischer) is a holiday in the United States, observed annually on October 6 each year. This day commemorates the date in 1683 when 13 German families from Krefeld, near the Rhine, landed in Philadelphia. Those families subsequently founded Germantown, Pennsylvania, the first German settlement and organized the first petition in the colonies to abolish slavery in 1688.
At a 1987 formal ceremony in the White House Rose Garden, President Ronald Reagan issued the proclamation declaring October 6 as German-America Day to honor the 300th anniversary of German-American immigration and culture to the United States.
Mayor and Council History This is the first time this item has been brought before the Mayor and Council.
Public Notification and Engagement Rockville Sister City Corporation (RSSC) promotes and facilitates international cultural relations between the City of Rockville and Rockville's Sister City Pinneberg, Germany and Rockville's Friendship City, Jiaxing, China.
Everyone is invited to learn more about the Rockville Sister City Corporation (RSSC) and the 60th Anniversary Celebration of Rockville's Sister City relationship with Pinneberg, Germany during the RSSC Annual Meeting at Rockville's historic Glenview Mansion on September 29, 2016. The Annual Meeting will begin with light refreshments at 6:30pm followed by the general meeting at 7:30pm. The meeting will include reports from RSSC Directors and a video highlighting RSSC activities over the past year.
RSSC will host its annual German-American Day Dinner and celebration at Normandie Farm Restaurant in Potomac, MD, on Sunday, October 9, 2016 between 4:30pm and 7:00pm. This event is in recognition of German-American Day and Rockville Sister City Corporation's thirtieth anniversary as it facilitates the nearly sixty year relationship between the cities of Rockville, MD and Pinneberg, Germany. For details, contact [email protected].
Additional RSSC information can be found at rockvillesistercities.org.
Attachments
https://rockmail.rockvillemd.gov/...egenda.nsf/d5c6a20307650f4a852572f9004d38b8/a0ac369d1738d2358525802e00579916?OpenDocument[6/30/2017 5:45:26 PM] Proclamation Declaring October 6, 2016 as German-American Day
2016 Proclamation German-American Day.pdf
Department Head:
Kathleen Conway, City Clerk/Director of Council Operations Approved on: 09/21/2016
https://rockmail.rockvillemd.gov/...egenda.nsf/d5c6a20307650f4a852572f9004d38b8/a0ac369d1738d2358525802e00579916?OpenDocument[6/30/2017 5:45:26 PM] WHEREAS, German-American Day commemorates the date in 1683 when 13 German families from Krefeld landed in Philadelphia, founded the first German settlement named Germantown, Pennsylvania, organized the first petition in the colonies to abolish slavery in 1688; and now over one-fourth of all Americans can trace their ancestry back to German roots and have proven our Nation's diversity makes our society ever stronger; and
WHEREAS, in 1983, President Ronald Reagan proclaimed October 6th as German American Day to celebrate and honor the anniversary of German American immigration and culture to the United States; and
WHEREAS, in 1957, Rockville became a Sister City with Pinneberg, Germany to promote international peace through people-to-people relationships between our Nations; and in 2017, Rockville will celebrate the 60th anniversary of this Sister City relationship, and the educational and charitable programs between the citizens of Rockville and Pinneberg, Germany; and
NOW, THEREFORE, the Mayor and Council of Rockville do hereby proclaim October 6, 2016 as German-American Day and encourage everyone to explore other cultures and the opportunities to participate in cultural exchanges.
~L . ~ Beryl L. F~lnberg. Councolnw r Vir inoa D. Onley. Councilm~ OJ\W?~ Mlork Poerzchala. Counc:dmember September 26, 2016 Proclamation Declaring September 27, 2016 as National Voter Registration Day
Mayor and Council
For the meeting on: September 26, 2016 Department: City Clerk Responsible staff: Kathleen Conway, City Clerk/Director of Council Operations phone: (240) 314 - 8282 [email protected]
Subject Proclamation Declaring September 27, 2016 as National Voter Registration Day
Recommendation Staff recommends that the Mayor and Council read, approve and present the Proclamation to Dr. Lois Neuman, Rockville Board of Supervisors of Elections Chair.
Discussion National Voter Registration Day occurs on the fourth Tuesday each September. Hundreds of local, state and national organizations help to coordinate nationwide events to bring awareness to elections, ballot initiatives, voter registration and voter registration updates.
Maryland residents can use Maryland's Online Voter Registration System (OLVR) or submit a voter registration application to their local Board of Elections or the State Board of Elections at any time. However, an application must be postmarked by the voter registration deadline in order to vote in the next scheduled election.
One can also register to vote during early voting. To make the voting process quicker, registering to vote by the close of voter registration is encouraged. If one cannot register by the date, one can go to an early voting center in the county where one lives. Additional information for Early Voting can be found athttp://www.elections.state.md.us/voting/early_voting.html. Montgomery County, MD voter information can be found at www.777vote.org or by calling 240.777.VOTE.
Mayor and Council History This is the first time this item has been brought before the Mayor and Council.
Public Notification and Engagement Register to vote, update voter registration information if needed and Vote on November 8, 2016!
Attachments
2016 Proclamation National Voter Registration Day.pdf
Department Head:
Kathleen Conway, City Clerk/Director of Council Operations Approved on: 09/21/2016
https://rockmail.rockvillemd.gov/...egenda.nsf/d5c6a20307650f4a852572f9004d38b8/c82cb07bdacb10438525803500479651?OpenDocument[6/30/2017 5:46:13 PM] Proclamation Declaring September 27, 2016 as National Voter Registration Day
https://rockmail.rockvillemd.gov/...egenda.nsf/d5c6a20307650f4a852572f9004d38b8/c82cb07bdacb10438525803500479651?OpenDocument[6/30/2017 5:46:13 PM] WHEREAS, the right to vote is a cornerstone of what it means to be a free people: it represents the bedrock tenets of equality and civic participation upon which our Nation was founded and many have fought to obtain and protect; and
WHEREAS, many people are unaware that they may need to update their voter registration when they change their address or change their name; and
WHEREAS, the City of Rockville is committed to strengthening democracy by encouraging voter registration and increasing participation in all elections; and
WHEREAS, the strength of our democracy depends on the willingness of citizens to participate in the election process, by choosing our leaders and by voicing their opinions on important matters that come before the voters on Election Day; and
NOW, THEREFORE, the Mayor and Council of Rockville do hereby proclaim September 27, 2016 as National Voter Registration Day and encourage everyone to register or update their registration information and exercise their right to vote.
Vir inia D. Onley. Councilmember o~w?~ Mark P~em:hala. Counolmembi!r
September 26, 20 16 Appointments/Reappointments and Announcements of Boards and Commissions Vacancies
Mayor and Council
For the meeting on: September 26, 2016 Department: City Clerk Responsible staff: Kathleen Conway, City Clerk/Director of Council Operations phone: (240) 314 -8282 [email protected]
Subject Appointments/Reappointments and Announcements of Boards and Commissions Vacancies
Recommendation Animal Matters Board Megan Conway - New appointment as an alternate member to serve until October 1, 2019
Board of Appeals Alan Frankle - New appointment as a member to serve until October 1, 2019
Board of Supervisors of Elections Stephen Weiner - Reappointment as a member to serve until July 1, 2020
Cultural Arts Commission Mary Baltimore - New appointment as a member to serve an unexpired term until July 1, 2019
Financial Advisory Board Robert Wright - New appointment as a member to serve until October 1, 2019
Historic District Commission Matthew Goguen - New appointment as a member to serve an unexpired term until May 1, 2017
Human Rights Commission David Kenton - New appointment as a member to serve until October 1, 2019 Harry Iceland - New appointment as a member to serve an unexpired term until March 1, 2018
Human Services Advisory Commission Denise Thomas - New appointment as a Caregiver Representative to serve until October 1, 2019
Landlord/Tenant Affairs Commission Jessica Ornsby - New appointment as a Tenant Representative to serve until October 1, 2019
Sign Review Board Joseph Anastasi - New appointment as a member to serve until October 1, 2019
Attachments
Attachment A - Boards_and_Commissions_Vacancies_09_26_2016.pdf
Department Head:
https://rockmail.rockvillemd.gov/...egenda.nsf/d5c6a20307650f4a852572f9004d38b8/bd8518b5fdb155ce852580200063a6cd?OpenDocument[6/30/2017 5:46:31 PM] Appointments/Reappointments and Announcements of Boards and Commissions Vacancies
Kathleen Conway, City Clerk/Director of Council Operations Approved on: 09/21/2016
https://rockmail.rockvillemd.gov/...egenda.nsf/d5c6a20307650f4a852572f9004d38b8/bd8518b5fdb155ce852580200063a6cd?OpenDocument[6/30/2017 5:46:31 PM] Attachment A
Boards and Commissions Vacancies as of 9/26/2016
1-Board of Appeals (Alternate) 1-Ethics Commission 1-Historic District Commission (Alternate) 1-Human Services Advisory Commission (Caregiver) 1-Sign Review Board (Alternate) 2-Compensation Commission 2-Human Rights Commission 2-Landlord Tenant Affairs Commission (1 Landlord Representative/1 Alternate At-Large Representative) 2-Senior Citizens Commission 4-Planning Commission
A - 1 Rockville Ecnomic Development, Inc. Quarterly Report
Mayor and Council
For the meeting on: September 26, 2016 Department: City Manager Responsible staff: Jenny Kimball, Deputy City Manager phone: (240) 314 - 8104 [email protected]
Subject Rockville Ecnomic Development, Inc. Quarterly Report
Recommendation Receive a quarterly update on Rockville Economic Development, Inc. (REDI)
Discussion Laurie Boyer, REDI's executive director, will present the Mayor and Council with an update on REDI's activities and accomplishments.
Assistant City Manager:
Jenny Kimball, Deputy City Manager Approved on: 09/19/2016
City Manager: Approved on: 09/19/2016
https://rockmail.rockvillemd.gov/.../egenda.nsf/d5c6a20307650f4a852572f9004d38b8/1f8a250983cb9b5f85257fe9004ee480?OpenDocument[6/30/2017 5:46:56 PM] Authorize the City Manager to Execute a Lease Agreement Between the Mayor and Council of Rockville and New Cingular Wireless PCS, LLC (doing business as ...
Mayor and Council
For the meeting on: September 26, 2016 Department: City Manager Responsible staff: Jenny Kimball, Deputy City Manager phone: (240) 314 - 8104 [email protected]
Subject Authorize the City Manager to Execute a Lease Agreement Between the Mayor and Council of Rockville and New Cingular Wireless PCS, LLC (doing business as AT&T).
Recommendation Staff recommends that the Mayor and Council authorize the City Manager to execute the lease agreement between the Mayor and Council of Rockville and New Cingular Wireless PCS, LLC (doing business as AT&T), in a form acceptable to the City Attorney.
Discussion The City of Rockville owns the property at 13890 Glen Mill Road for the primary purpose of operating a water storage tank, commonly known as the Hunting Hill tank. The City and New Cingular Wireless PCS, LLC are parties to an existing lease agreement that allows for antenna to be attached to the tank and for ground space adjacent to the tank for ground communications equipment.
New Lease Agreement The new agreement is largely consistent with the existing agreement with New Cingular Wireless for the antenna and ground communications equipment currently in place at the Hunting Hill tank. It is updated to reflect a new antenna mounting structure and a one-time attachment fee of $40,000 to be paid to the City by New Cingular Wireless. The new mounting structure will allow space for additional carriers to install antennae on the tank under lease agreements with the city, therefore generating additional revenue. At this time, one other carrier has expressed interest and staff is preparing to engage them in discussions of a lease. The amendment is also updated to reflect a generator at the site for emergency use during power failures. There will be 432 square feet (SF) of ground space occupied (377 SF for the existing equipment shelter plus 55 SF for the proposed generator).
The initial lease term is for five (5) years and will commence when the antenna structure is ready for use. The Agreement will automatically renew for three (3) additional successive five (5) year renewal terms unless either party notifies the other of its intention not to renew. Rental payments will be due in equal monthly installments of $3,900 or $46,800 annually. Rent will increase annually by three percent (3%) of the previous year's amount.
The Agreement specifies that the City's uses of the Property shall have priority, and the Lessee shall make necessary accommodations to permit the City's uses of the Property to operate safely and efficiently. New Cingular Wireless PCS, LLC will maintain all required insurance policies as approved by the City's risk manager. The lease agreement indicates that New Cingular Wireless PCS, LLC will indemnify and hold the City harmless against any claim of liability or loss from personal injury or property damage. The lease also allows the City to terminate the agreement after a finding that the lease is contrary to the public safety, health and/or welfare.
Water Tank Improvement Project The existing New Cingular Wireless antenna must be temporarily relocated to complete a Water Tank Improvements project included in the FY17 Adopted CIP (Attachment A.) The CIP project
https://rockmail.rockvillemd.gov/...egenda.nsf/d5c6a20307650f4a852572f9004d38b8/34e15006d5baed36852580190076cb34?OpenDocument[6/30/2017 5:47:05 PM] Authorize the City Manager to Execute a Lease Agreement Between the Mayor and Council of Rockville and New Cingular Wireless PCS, LLC (doing business as ...
includes design, inspection and rehabilitation of the Hunting Hill and Carr Avenue tanks. Rehabilitation involves interior and exterior coating and structural/safety repairs to these tanks. The project also includes installation of an antenna mounting structure on Hunting Hill tank for wireless carrier antenna. This mounting structure will allow for antenna installation in a manner that protects the rehabilitated water tank. It also provides the opportunity for additional leases and associated revenue from rental payments by the carriers.
During the rehabilitation work, New Cingular Wireless' existing antenna on Hunting Hill tank will be temporarily located on the site on ground equipment. Smartlink, on behalf of New Cingular Wireless PCS, LLC, has filed a Special Exception application for the temporary relocation of their antenna which is required during tank rehabilitation. A Zoning Ordinance Waiver Request for the temporary cell tower height is forthcoming for Mayor and Council approval.
Upon project completion, the New Cingular Wireless antenna will be relocated to the tank's new antenna mounting structure. At that time, the existing agreement between the City and New Cingular Wireless will be terminated and replaced with the updated agreement that the Mayor and Council is authorizing the Acting City Manager to execute.
Mayor and Council History This is the first time this item has been brought before the Mayor and Council.
Public Notification and Engagement Smartlink, on behalf of New Cingular Wireless PCS, LLC, conducted a community meeting on July 12, 2016, which was required as part of the Special Exception for the temporary relocation of the antenna during water tank rehabilitation. Smartlink informed area citizens about the temporary cell tower. Five people attended this meeting. Department of Public Works staff will notify the surrounding community, as is typical for a CIP project, before work begins on the tank rehabilitation project.
Fiscal Impact The new lease agreement for the antenna and ground equipment at the Hunting Hill water tank result in a one-time payment to the City of $40,000 for an attachment fee. The current lease also generates monthly rental income of $3,900, or $46,800 annually. Those monthly rental payments will continue under the new agreement and will increase three percent (3%) each year. The one- time attachment fee and the monthly lease payments for the Hunting Hill tank site are included in the Water Fund.
Next Steps Upon Mayor and Council approval, the City Manager will execute the lease agreement with New Cingular Wireless PCS, LLC in a form acceptable to the City Attorney.
Attachments
Attachment A - FY17 Water Tank Improvements CIP Project Sheet.pdf
Assistant City Manager:
Jenny Kimball, Deputy City Manager Approved on: 09/21/2016
City Manager: https://rockmail.rockvillemd.gov/...egenda.nsf/d5c6a20307650f4a852572f9004d38b8/34e15006d5baed36852580190076cb34?OpenDocument[6/30/2017 5:47:05 PM] Authorize the City Manager to Execute a Lease Agreement Between the Mayor and Council of Rockville and New Cingular Wireless PCS, LLC (doing business as ...
Approved on: 09/21/2016
https://rockmail.rockvillemd.gov/...egenda.nsf/d5c6a20307650f4a852572f9004d38b8/34e15006d5baed36852580190076cb34?OpenDocument[6/30/2017 5:47:05 PM] Attachment A
City of Rockville, Maryland FY 2017 Adopted Budget
Water Tank Improvements (7 A34) Description: This project funds work on three water tanks: Hunting Hill, Carr Avenue, and Talbott Street. The Hunting Hill and Carr Avenue tank work includes design, inspection, and rehabilitation. Rehabilitation work includes interior and exterior coating, structural/safety repairs, and antennae mounting structure for wireless carriers. The Talbott Tank work, which was completed in FY 2014, included taking the tank out of service and creating two new pressure zones to improve fire flow along Rockville Pike.
Changes from Previous Year: None.
Current Project Appropriations Critical Success Factor: Stewardship of Infrastructure and Env. Prior Appropriations: 6,128,923 Mandate/Plan: 2011 Tank Inspection Reports; EPA Stage 2 Less Expended as of 5/3/16: 2,355,337 Disinfection Byproducts Rule; 2012 Water Quality Study; 2012 Total Carryover: 3,773,586 Twinbrook Rezoning Report New Funding: Total FY 2017 Appropriations: 3,773,586 Anticipated Project Outcome: Fully rehabilitated water storage tanks to extend life 40 to 50 years. Project Timeline and Total Cost by Type: Original project only included over-coating of the tanks; however, tank studies in 2011 identified the need for extensive rehabilitation. In addition to increased scope, funding was added in FY 2016 for construction cost escalation. Estimated Start Estimated Completion Estimated Cost Type Original Current Original Current Original Current $Change %Change Planning I Design FY 2009 FY 2009 FY 2014 FY 2016 150,000 377,000 227,000 151% Construction FY 2011 FY 2016 FY 2012 FY 2017 500,000 5,751,923 5,251,923 1050% Other
Project Total ($): 650,000 6,128,923 5,478,923 843%
Project Funding: This project is fully funded. Source Prior FY 2017 FY 2018 FY 2019 FY 2020 FY 2021 Future Total Paygo (Wtr) 2,428,923 2,428,923 Bonds (Wtr) 3,700,000 3,700,000 Total Funded ($) 6,128,923 6,128,923 Unfunded (Wtr) Total w/Unfunded ($) 6,128,923 6,128,923
Operating Cost Impact: No measurable impact. Fund Prior FY 2017 FY 2018 FY 2019 FY 2020 FY 2021 Future Total Water
Project Manager: Ilene Lish, Senior Civil Engineer, 240-314-8516.
Notes: This project first appeared in the FY 2007 CIP. FY 2017 work includes rehabilitation of the Hunting Hill and Carr Avenue water storage tanks.
373 A - 1 Authorization to Dispose of City-Collected Materials at the Montgomery County Transfer Station
Mayor and Council
For the meeting on: September 26, 2016 Department: Public Works Division: Environmental Management Responsible staff: Mark Charles, Chief of Environmental Management phone: (240) 314 - 8871 [email protected]
Subject Authorization to Dispose of City-Collected Materials at the Montgomery County Transfer Station
Recommendation Staff recommends that the Mayor and Council authorize the Acting City Manager to expend funds to dispose of City-collected materials at the Montgomery County Transfer Station without a formal agreement, until such time that the Acting City Manager determines that this arrangement is no longer in the best interest of the City.
Discussion Rockville has transported its solid waste to the County's transfer station for decades. The transfer station is located just outside the City at 16101 Frederick Road, Derwood, Maryland 20855. Staff is unable to locate any previous approval by Mayor and Council to utilize this service, and this approval is sought primarily as a formality to continue the arrangement and expend funds for this service in accordance with City Code.
The County currently charges the City a tipping or "dump" fee of $56.00 per ton of refuse and $46.00 per ton of yard waste, including storm debris and street leaves collected in the spring and fall. The County charges the City the same prices as the general public and has historically reserved the right to increase fees, as needed. Since the dump fees are based on the weight of the refuse material delivered to the County, the actual payments can vary from year to year. However, the annual cost of this service is more than $100,000 and therefore requires Mayor and Council authorization. The close proximity of the site to Rockville makes this arrangement the best value to the City.
While the City Code requires a written agreement for services over a certain monetary threshold, Staff believes that an agreement with Montgomery County for this service is not in the best interest of the City. The City would not be receiving any preferential price or services from the County that is not being offered to the public. Also, locking into a term or promising to utilize the county transfer facility might limit City options in the future. If the City had an agreement in place it might have impacted our previous decision to stop taking recyclable materials to the county transfer station. There is simply no City interest in signing an agreement or contract for this service.
Mayor and Council History This is the first known time this item has been brought before the Mayor and Council.
Procurement Information The Procurement Code states that "except for the purchase of goods and equipment, formal written contracts signed by the City Manager and the contractor shall be required for procurements exceeding thirty thousand dollars ($30,000.00), including requirements contracts estimated to exceed thirty thousand dollars ($30,000.00) in any given fiscal year". (City Code section 17-38).
https://rockmail.rockvillemd.gov/.../egenda.nsf/d5c6a20307650f4a852572f9004d38b8/421ccc242fcaa46485258028006103ed?OpenDocument[6/30/2017 5:47:31 PM] Authorization to Dispose of City-Collected Materials at the Montgomery County Transfer Station
As a result of implementing recommendations of the purchasing study and based on the amount of the expenditure of funds, staff now recommends that these types of arrangements be brought before the Mayor and Council for authorization as they are discovered.
The Procurement Code also states that "nothing in this chapter shall be construed as prohibiting or limiting the council's right to make appointments under the City's Charter or to authorize any procurement it deems to be in the best interest of the City, or the City's right to employ its own personnel for the construction or reconstruction of public improvements or for any other purpose without competitive solicitation". (City Code section 17-3(c))
Fiscal Impact Funding for this service is subject to annual appropriation by the Mayor and Council and is in the Department of Public Works, Recycling and Refuse Cost Center. The FY 2017 adopted budget for this service equals $900,400.
Next Steps If the Mayor and Council authorizes the action, the City will continue to utilize Montgomery County for the disposal of our collected solid waste.
Department Head:
Judy Ding, Acting Director of Public Works Approved on: 09/13/2016
City Manager: Approved on: 09/21/2016
https://rockmail.rockvillemd.gov/.../egenda.nsf/d5c6a20307650f4a852572f9004d38b8/421ccc242fcaa46485258028006103ed?OpenDocument[6/30/2017 5:47:31 PM] Approval of Minutes
Mayor and Council
For the meeting on: September 26, 2016 Department: City Clerk Responsible staff: Kathleen Conway, City Clerk/Director of Council Operations phone: (240) 314 - [email protected]
Subject Approval of Minutes
Recommendation To approve the following minutes:
July 18, 2016 General Session (Meeting No. 28-16) July 18, 2016 Executive Session (Meeting No. 28-16) August 1, 2016 General Session (Meeting No. 29-16
Department Head:
Kathleen Conway, City Clerk/Director of Council Operations Approved on: 09/21/2016
https://rockmail.rockvillemd.gov/...egenda.nsf/d5c6a20307650f4a852572f9004d38b8/35432eab8804ae5e8525803500466a18?OpenDocument[6/30/2017 5:47:43 PM] Approval of Amended Minutes - February and March 2016
Mayor and Council
For the meeting on: September 26, 2016 Department: City Clerk Responsible staff: Sara Taylor-Ferrell, Acting Deputy City Clerk phone: (240) 314 - 8283 [email protected]
Subject Approval of Amended Minutes - February and March 2016
Recommendation To approve the following minutes
February 22, 2016 Executive Session (Meeting No. 06-16) February 22, 2016 General Session (Meeting No. 06-16) February 25, 2016 Executive Session (Meeting No. 07-16) February 25, 2016 General Session (Meeting No. 07-16) February 26, 2016 Executive Session (Meeting No. 08-16) February 29, 2016 Executive Session (Meeting No. 09-16) March 7, 2016 Executive Session (Meeting No. 10-16) March 14, 2016 General Session (Meeting No. 11-16)
Department Head:
Kathleen Conway, City Clerk/Director of Council Operations Approved on: 09/21/2016
https://rockmail.rockvillemd.gov/...genda.nsf/d5c6a20307650f4a852572f9004d38b8/eb912b48971823b785258035004c7448?OpenDocument[6/30/2017 5:47:52 PM] Authorize the Acting City Manager to Execute a Memorandum of Understanding between the Mayor and Council of Rockville, the City of Takoma Park and the Ma...
Mayor and Council
For the meeting on: September 26, 2016 Department: City Manager Division: Cable TV Responsible staff: Marylou Berg, Director of Communications phone: (240) 314 - 8105 [email protected]
Subject Authorize the Acting City Manager to Execute a Memorandum of Understanding between the Mayor and Council of Rockville, the City of Takoma Park and the Maryland Municipal Channel for Use of a Shared High Definition Television Channel.
Recommendation Staff recommends that the Mayor and Council authorize the acting city manager to execute a memorandum of understanding between the City of Rockville, the City of Takoma Park and the Maryland Municipal Channel for use of a shared High Definition channel, in a form acceptable to the city attorney.
Discussion On May 23, 2016, the Mayor and Council of Rockville approved a franchise agreement with Comcast of Potomac, LLC, effective April 1, 2016 - December 31, 2021. Under that agreement, Comcast will continue to provide Rockville with a Standard Definition television channel (channel 11) and will now provide one High Definition (HD) channel to be shared between the cities of Rockville and Takoma Park and the Montgomery Municipal Channel (MMC). The new HD channel will start airing on October 1. The shared channel will be known as the Montgomery Broadcast Network (MBN), and will be broadcast on Comcast channel 99 and RCN channel 1057.
The MOU will set forth the terms and conditions upon which the parties will operate and coordinate programming for the shared HD channel and work with Montgomery County's department of technology services, office of cable and communication services, which will provide operation support. Attorneys from Rockville, Takoma Park and MMC have been involved in drafting the MOU.
The MOU specifies a programming schedule that can be changed by a majority vote of the three entities. Generally, programming will be shared equally between the three parties during prime time (6 p.m. - 1 a.m.) and shared equally between Rockville and Takoma Park all other times. The MOU allows for Takoma Park and Rockville to air their regular Mayor and Council meetings live each week. The MOU includes a process for the parties to request preemption of the program schedule to accommodate special events and emergency situations. The programming schedule will be displayed on Comcast programming guides. The MOU may be terminated by any party with 30 days written notice.
Mayor and Council History The Mayor and Council approved the Comcast franchise agreement that provides for the shared HD channel on May 23, 2016.
Next Steps Upon the Mayor and Council's approval, the acting city manager will execute the memorandum of understanding with Takoma Park and the Montgomery Municipal Channel board in a form acceptable to the city attorney.
https://rockmail.rockvillemd.gov/...egenda.nsf/d5c6a20307650f4a852572f9004d38b8/6e31a57894218e548525803000474f04?OpenDocument[6/30/2017 5:48:05 PM] Authorize the Acting City Manager to Execute a Memorandum of Understanding between the Mayor and Council of Rockville, the City of Takoma Park and the Ma...
Assistant City Manager:
Jenny Kimball, Deputy City Manager Approved on: 09/19/2016
City Manager: Approved on: 09/19/2016
https://rockmail.rockvillemd.gov/...egenda.nsf/d5c6a20307650f4a852572f9004d38b8/6e31a57894218e548525803000474f04?OpenDocument[6/30/2017 5:48:05 PM] Financial Advisory Board Action Plan for FY 2017
Mayor and Council
For the meeting on: September 26, 2016 Department: Finance Division: Budget Responsible staff: Stacey Webster, Deputy Director of Finance phone: (240) 314 - 8407 [email protected]
Subject Financial Advisory Board Action Plan for FY 2017
Recommendation The Financial Advisory Board ("Board") recommends that the Mayor and Council:
1) Review and approve the Board's Action Plan for FY 2017, and
2) Consider changing the City Code to increase the number of Board members from five to seven.
Discussion The Financial Advisory Board held a meeting on August 23, 2016, where they unanimously approved an Action Plan for FY 2017. The Board would like the Mayor and Council to review and approve the Action Plan. The Board believes that the Action Plan (Attachment A) is consistent with the "Duties and Responsibilities" outlined in the City Code (Section 2-241) as shown below:
Section 2-241. - Duties and Responsibilities
a) The Board shall provide minutes of its meetings as well as related reports in support of its duties as enumerated below. The format of any reports shall be decided by the Board. The Board may also be provided time to orally present to the Mayor and Council. All members of the Board shall familiarize themselves with the financial affairs of the City.
(b) Review and evaluate the financial consequences of any program or proposal, as may be requested by the Mayor and Council. The Board may be asked to analyze, research, and assess alternatives, consult with the Finance Department, and make appropriate recommendations to the Mayor and Council.
(c) Annually review the City's Comprehensive Annual Financial Report (CAFR), the Single Audit Report, and all other reports issued by the auditors and published in final form. The review should encompass and include any management letters and audit findings, as appropriate.
(d) Annually review the City's Financial Management Policies published in the City's budget document to evaluate whether those policies are appropriate.
(e) Annually review the City's investment policy to evaluate whether that policy is appropriate.
(f) Review the City's cash and investment report when published.
(g) Review the City's quarterly financial reports to assess whether spending and revenue collection are tracking with adopted and amended budgets, analyzing
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variances, and to highlight problem areas, if any.
(h) Annually provide comments and recommendations, as appropriate, regarding the next fiscal year's operating and capital budgets.
(i) Review and report on such matters as bonding requests, the practices and/or policies of other jurisdictions, or any other matter as may be requested by the Mayor and Council.
In addition to the Mayor and Council approving the FY 2017 Action Plan, the Board recommends that the Mayor and Council consider changing the City Code (Section 2-238) to increase the size of the Board from five to seven members. Below is the language from the City Code related to the "Structure and Qualifications" of the Board:
Section 2-238. - Structure and Qualifications
(a) Composition. The Financial Advisory Board shall consist of five (5) members, appointed by the Mayor subject to confirmation by the Council.
(b) Term. The Board members shall serve three-year terms. Notwithstanding the foregoing, the initial terms of two (2) members appointed shall be for one (1) year or until their respective successors are appointed and confirmed, so that the terms of two (2) members shall be staggered with respect to the terms of the other three (3) members.
(c) Chairperson. The Board shall elect its own chairperson from among its appointed members. The chairperson shall serve for a term of one (1) year and is eligible for reelection.
(d) Qualifications. The Board shall consist of at least three (3) residents of the City and any two (2) others who, in the opinion of the Mayor and Council, can demonstrate a stakeholder position, ideally with at least one (1) member from the Rockville business community. If possible, one (1) member should be a certified public accountant licensed to practice or retired, and at least one (1) other member should have experience with financial matters related to larger employers or governmental agencies. All members shall demonstrate experience directly in, or related to finance or accounting. Board members will be able to read and understand governmental financial statements sufficiently to be able to recognize inconsistencies and report on variances that require explanation and reporting to the Mayor and Council.
Attachments Attachment A - Financial Advisory Board Action Plan
AttachA_FAB Action Plan for 2017 final.pdf
Department Head:
Gavin Cohen, Chief Financial Officer Approved on: 09/06/2016
City Manager:
https://rockmail.rockvillemd.gov/...k/egenda.nsf/d5c6a20307650f4a852572f9004d38b8/aa17c930ff5c3abc8525801a004bfae5?OpenDocument[6/30/2017 5:48:17 PM] Financial Advisory Board Action Plan for FY 2017
Approved on: 09/16/2016
https://rockmail.rockvillemd.gov/...k/egenda.nsf/d5c6a20307650f4a852572f9004d38b8/aa17c930ff5c3abc8525801a004bfae5?OpenDocument[6/30/2017 5:48:17 PM] ATTACHMENT A
August 24, 2016
MEMORANDUM TO THE MAYOR AND COUNCIL OF THE CITY OF ROCKVILLE, MD
FROM: Jack Kelly, Chair Financial Advisory Board
SUBJECT: Proposed Financial Advisory Board Action Plan for FY 2017
Since its inauguration in FY 2013, the Financial Advisory Board (FAB or Board) has worked under the supervision of the Mayor and Council and provided its recommendations directly to that body. However, for FY 2017, the FAB proposes an Action Plan based on closer collaboration with certain City departments whose work has strong financial implications for the City. The activities that the FAB proposes to undertake in FY 2017 are presented below by Department. The Attachment to this memo lists all of the issues that the Board has undertaken in the past as well as those that are proposed for this Action Plan. When the lead for an issue has been assigned to a specific FAB member, this assignment is shown with the Issue Description. A few issues remain unassigned.
Finance Department
Almost all of the formal responsibilities assigned to the FAB by the amendment to the City Code that created it deal with reviewing the financial reports and policy documents prepared by the staff of this Department as well as by the independent auditor hired to prepare the Comprehensive Annual Financial Report, the Single Audit Report, and other audit findings. During my almost two-years on the Board, we have reviewed and commented on several of these documents, but not on all of them and not annually as directed by the Code. The City Manager would like to see the Board’s proposed Action Plan address all of its responsibilities under the Code and this proposed draft does so.
Recently, for the first time, Finance Department staff provided the FAB with the Department’s priority tasks for FY 2017. These tasks are in addition to producing the annual financial reports, but include updating some of the financial management policies. The Department has invited the Board to review and comment on the work products of any of the tasks on which it wishes to do so. The activities listed below include the annual reviews of the City’s financial reports required by the Code, tasks from the Department’s priority list, as well as additional activities that the Board would like to undertake.
• Review and comment on the following financial reports prepared by the City’s independent auditor and provide comments to City staff in time for the Board’s views to be reflected in the submissions of those reports to the Mayor and Council: o The City’s Comprehensive Annual Financial Report (CAFR)
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o The Single Audit Report and all other reports issued by the independent auditors, including any management letters and audit findings, as appropriate • Review and comment on early drafts of the following documents prepared by City staff and provide comments to City staff in time for the Board’s views to be reflected in the submissions of those reports to the Mayor and Council: o The City’s Financial Management Policies including, among other topics, the City’s cost recovery policy o The City’s investment policy to evaluate whether that policy is appropriate o The City’s cash and investment report o The City’s quarterly financial reports (QFRs) o The format of the FY 2018 Operating and Capital Budgets o The City’s Popular Annual Financial Report (PAFR) • The Board will also review and comment on: o The financial consequences of any program or proposal as requested by the Mayor and Council o Bonding requests, the practices and/or policies of other jurisdictions, or any other matter as may be requested by the Mayor and Council. o Documents associated with the selection of the new independent auditor, specifically, an initial draft of the RFP and Statement of Work used to solicit the new audit firm. o Documents associated with updating the CAP analysis in FY 2017, specifically: An initial draft of the Statement of Work used to solicit the consultant assistance to update the CAP analysis An initial draft of the consultant’s initial work products, including the final report and implementation plan.
Procurement Division
The FAB had a strong role in the design and execution of the Purchasing Study that was completed last year and would like to continue to add value to the implementation of the Study Report’s recommendations. Based on previous communications by the FAB to the Mayor and Council as well as conversations with Finance Division staff, the FAB would like to undertake the following activities in FY 2017:
• Review the status of the City’s actions to implement the Purchasing Action Plan (PAP). • Review PAP work products that require approval by the Mayor and Council, e.g., changes to the City Code, Purchasing performance measures, etc. • Review early drafts of changes to the City’s financial management system proposed by the Finance Department and Procurement Division to develop automated work flow tracking processes and to make maximum use of available financial system functionality to develop spend analyses and other reports.
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Community Planning and Development Services (CPDS) Department
Ordinarily, the work done by this department would fall outside the purview of the FAB’s usual interests. However, this year this department will be hiring a consultant to develop a model for assessing the financial impacts of various development scenarios on the City’s revenues and costs. Because of the significant impact that this model can have on decisions that affect the City’s financial situation, the FAB would like to offer a similar level of involvement in reviewing and commenting on the draft RFP for this work and reviewing the consultant’s work products as it did for the Purchasing Study conducted last year. The specific work tasks are listed below.
• Review and comment on an initial draft of the RFP prepared by CPDS for hiring a consultant to develop a model that will allow the City to project and analyze the fiscal (i.e., revenue and cost) and economic (e.g., jobs, population changes, other?) impacts of different development scenarios. • Review and comment on early drafts of the consultant’s work products, including the final report and implementation plan.
Next Steps
Preliminary conversations with the City Manager and representatives of the affected Departments indicate willingness for the Board to carry out the action plan items described above. Consequently, members of the Board have already begun contacting the appropriate City staff to develop milestone plans for addressing each of the issues identified in this Proposed Action Plan. The Board also invites the Mayor and Council to suggest additional issues on which they would like the Board to work during the upcoming fiscal year. Whenever the Mayor and Council suggest additional issues for the Board, the Board will revise its Action Plan accordingly.
Concerns
During the course of preparing FAB comments to the M&C regarding the status of the Purchasing Action Plan, I was informed that the Maryland Open Meetings Act prohibited City Boards and Commissions from sending “official” Board communications to M&C that hadn’t been approved during an open, in-person meeting of the Board. As you may know, we have traditionally finalized many of the Board’s memos to the M&C via email. This has permitted us to react quickly to various issues and send our comments to the M&C as soon as we could get our comments together. Even though the Board has increased its meeting frequency from four times per year to six times, it will be difficult, if not impossible, to coordinate scheduled meetings with deadlines for providing Board comments on various City financial documents. Our fallback option is always to provide informal comments during the Citizen Forums at M&C meetings, as I did with comments on the Purchasing Action Plan; however, this falls way short of the goal of incorporating formal Board comments in the staff memos that accompany the agendas for M&C meetings. We hope to find a satisfactory solution to this problem and would welcome your thoughts on a solution.
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Attachment
Financial Advisory Board Issue Summary
Active Issues
Issue Description Board Actions and Status Purchasing Study [Kelly has Memos to M&C – many actions taken consistent with lead] FAB recommendations; FAB reviews of Purchasing Action Plan work products are proposed as part of FY 2017 FAB Action Plan. Salary Lapse [Kelly has Memo to M&C – no response from M&C; but continued lead] interest by at least one Councilmember. Justifying CIP Projects [lead Presentation to M&C – no response from M&C; unclear not yet assigned] as to continuing FAB interest; may be dropped. Format and Content of QFR Discussions held within FAB; no formal recommendation [Dawson has lead] made to M&C as yet. Proposed for FY 2017 FAB Action Plan. Cost Allocation Plan Memo to M&C – Per FAB recommendation, FY 2017 [Dawson has lead] funds were approved for updated CAP study. Proposed for FY 2017 FAB Action Plan.
Proposed Issues
Issue Description Status Format and Content of CAFR [Turner has Proposed for FY 2017 FAB Action Plan lead] Format and Content of PAFR [lead not yet Proposed for FY 2017 FAB Action Plan assigned] Format of FY 2018 Operating and Capital Proposed for FY 2017 FAB Action Plan Budgets [Kelly has lead] Proposed updates to the City’s investment Proposed for FY 2017 FAB Action Plan policy [Onyemelukwe has lead] Proposed changes to the City’s cash and Proposed for FY 2017 FAB Action Plan investment report [Onyemelukwe has lead] Proposed changes to the City’s Financial Proposed for FY 2017 FAB Action Plan Management policies, including the cost recovery policy. [lead not yet assigned] Provide input to the CPDS in selecting a Proposed for FY 2017 FAB Action Plan consultant to develop a model that will allow the City to analyze the fiscal (i.e., revenue and cost) and economic impacts of different development scenarios. [Kelly has
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lead] Selecting the new independent auditor Proposed for FY 2017 FAB Action Plan [Turner has lead] Reviewing and commenting on reports Proposed for FY 2017 FAB Action Plan prepared by the independent auditor [Turner has lead] Performance Measures in Budget Not yet proposed Projecting Future Impacts of Current Not yet proposed Budget Decisions Validate 5-year financial projections Not yet proposed Maintain financial data series over x year Not yet proposed planning horizon
Previous Issues – Not Currently Being Pursued
Issue Description Board Actions and Status Fixing Pension Shortfalls Memo to M&C – no initial response. FAB reviewed latest actuary report and determined that pension shortfall is on track to be resolved without further City action. Issue dropped 4/26/16. Water and Sewer Rates Presentation to M&C – no response; FAB would like to remain involved in updates to the rate analyses and recommendations. Reserve Policies Dropped from issue list on 2/16/2016 Financial Ratios Dropped from issue list on 2/16/2016 Prior Period Adjustments Dropped from issue list on 2/16/2016 FY 2015 Budget Presentation to M&C – no response FY 2016 Budget Unclear – need Board comments FY 2017 Budget Unclear – need Board comments
5 A - 5 Senior Needs Assessment Implementation Plan
Mayor and Council
For the meeting on: September 26, 2016 Department: Recreation and Parks Division: Senior Center Responsible staff: Terri Hilton, Manager phone: (240) 314 - 8802 [email protected]
Subject Senior Needs Assessment Implementation Plan
Recommendation Staff recommends that the Mayor and Council discuss and provide guidance on the proposed action items in the Senior Needs Assessment Implementation Plan.
Discussion Overview
The Senior Needs Assessment and Gap Analysis study was identified as a priority by Mayor and Council during the 2015 budget process. RTI International conducted the study on the City's behalf, and made a presentation to Mayor and Council on April 18, 2016. The study consisted of an inventory of existing services, a web survey, focus groups, and stakeholder interviews. Several themes emerged from this study and serve as the primary structure for the Senior Needs Assessment Implementation Plan (Implementation Plan). The themes identified included barriers to participation in programs and services, under served populations, gaps in senior programs and services, a need for more affordable housing, and a desire for the villages approach to be added to our scope of services. In this Implementation Plan, these themes are addressed through the following categories: Awareness of Programs and Services, Barriers to Participating in 60+ Programs and Services, Aging in Place and Villages, and Programming.
A copy of the Senior Needs Assessment and Gap Analysis study can be found online at: http://www.rockvillemd.gov/seniorstudy
Goal
The goal of the Implementation Plan is to help improve the City of Rockville’s services to our older residents. The City of Rockville will continue to remain age friendly through creating opportunities that enhance healthy aging, and identifying and developing new programs and services that will meet the current and future needs of Rockville seniors.
The action steps that are presented in this plan are intended to move the City of Rockville forward by giving older adults the necessary tools, programs and services to support healthy aging, and aging in place.
Why is this important?
It is estimated that by the year 2040 Rockville’s senior population will total 19,140 seniors, equaling 22% of the total population. The City faces significant challenges to not only maintain existing service levels for this diverse population, but also to develop and fund new programs addressing the evolving needs of the population. Strategic planning will help the City accommodate the needs of all its seniors. More and more of our aging population indicate that their preference is to age-in-place. To help senior’s age-in-place and preserve their independence, the City currently offers a variety of successful services and programs. As the City’s senior population continues to
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expand, the demand for senior services will also increase, stretching the City’s resources and facilities beyond their current capacity.
How will the Implementation Plan be used?
This plan is intended to present the proposed action strategies to Mayor and Council for discussion and instruction, as well as to establish the initial goals and guidelines for addressing the study findings.
This plan will be a living document, and continue to evolve as we learn more about the needs and challenges of aging, and as we devise new strategies for supporting the needs of this population. It is our hope that the lead organizations, including Rockville Senior Citizens Commission, Rockville Seniors Inc., the Villages Advisory Committee, Rockville senior service providers, Rockville seniors, and City of Rockville staff, will work together to implement these items, add action items as needed, and evolve and change the plans as necessary to continue to meet the needs of Rockville seniors.
A complete list of proposed action items and additional detail can be found in Attachment A.
Mayor and Council History The Senior Needs Assessment Implementation Plan was proposed by the Mayor and Council following the Senior Needs Assessment and Gap Analysis presentation on April 18, 2016.
Boards and Commissions Review The implementation plan has been reviewed with the chair of the Rockville Senior Citizens Commission, Rockville Seniors Inc., and the Villages Advisory Committee. All three committee chairs favored the implementation plan and look forward to working with City staff and their board members to accomplish the proposed action items.
Fiscal Impact Attachment B is a summary of the action items recommended in the Implementation Plan. Staff will review these items in the context of the FY 2018 budget process, and will make recommendations to the Mayor and Council via the City Manager’s proposed operating budget. Included in the attachment is a brief detail on each item, the projected expenditure and/or revenue associated with each item, and a column that references the action item from the Implementation Plan.
Next Steps Staff will provide additional information to the Mayor and Council as needed. Staff is implementing the action items funded in the FY17 budget. Based on Mayor and Council direction, new items that do not require funding will also be implemented. Action items not currently funded will be examined through the city's budget process.
Attachments Attachment A - Senior Needs Assessment Implementation Plan
Senior Needs Assessment Implementation Plan Attachment A.pdf
Attachment B - Senior Needs Assessment Implementation Plan Funding Chart
Attachment B Senior Needs Assessment Implementation Plan funding chart .pdf
Attachment C - Implementation Plan Powerpoint Presentation
Attachment C - Implementation plan power point .pdf
https://rockmail.rockvillemd.gov/.../egenda.nsf/d5c6a20307650f4a852572f9004d38b8/e02e7bf07764ca6285257ffc00599606?OpenDocument[6/30/2017 5:48:47 PM] Senior Needs Assessment Implementation Plan
Department Head:
Tim Chesnutt, Director of Recreation and Parks Approved on: 09/16/2016
City Manager: Approved on: 09/21/2016
https://rockmail.rockvillemd.gov/.../egenda.nsf/d5c6a20307650f4a852572f9004d38b8/e02e7bf07764ca6285257ffc00599606?OpenDocument[6/30/2017 5:48:47 PM] Attachment A
2016 Implementation Plan Rockville Senior Needs Assessment and Gap Analysis
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Attachment A
“Older people are wonderful resources for their families, communities and in the formal and informal workforce. They are a repository of knowledge. They can help us avoid making the same mistakes again. Indeed, if we can ensure older people live healthier as well as longer lives, if we can make sure that we are stretching life in the middle and not just at the end, these extra years can be as productive as any others. The societies that adapt to this changing demographic and invest in Healthy Aging can reap a sizeable "longevity dividend", and will have a competitive advantage over those that don't.”
World Health Organization – “About Aging and Life Course”
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Attachment A
Table of Contents
Page #
Overview 4-5
1. Awareness of Programs and Services 5 1.1 Marketing 5-6 1.2 Community Outreach 7 1.3 Senior Service Providers 7 2. Barriers to participating in Programs and Services 8 2.1 Isolation and Homebound 8 2.2 Low and Middle Income 9 2.3 Language and Cultural 9-10 3. Aging in Place and Villages 10 3.1 Aging in Place 10-11 3.2 Village Movement 11-12 3.3 Transportation 12 4. Programming 13 4.1 Community Centers 13 4.2 Senior Programs 13-14 4.3 Stigma of the Title “Senior” and “Senior Programs” 14
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Attachment A
Overview
The Senior Needs Assessment and Gap Analysis study was identified as a priority from Mayor and Council in the 2015 budget year. RTI International conducted the study with a final presentation to Mayor and Council on April 18, 2016. The study consisted of an inventory of existing services, web survey, focus groups, and stakeholder interviews. Overall common themes presented in the study findings include barriers to participation, underserved populations, gaps in senior programs and services, affordable housing, and the villages approach. These themes are broken out further and placed into detailed categories for the action plan that will be presented for discussion and information at the September 26, 2016 Mayor and Council meeting. Staff is pleased to present this plan that includes innovative approaches, programs and services to address the gaps and needs identified in the study.
Goal
The goal of this action plan is to help improve the City of Rockville’s services to our older residents. The City of Rockville will continue to remain age friendly through creating opportunities that enhance healthy aging and identifying and developing new programs and services that will meet the current and future needs of Rockville seniors.
The action steps that are presented in this plan are intended to move the City of Rockville forward by giving older adults the necessary tools, programs and services to support healthy aging, and aging in place.
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Attachment A
Why is this important?
Planning for an aging population is critical. The City of Rockville has made a significant investment in tracking the quality of life and services provided to its senior population. To help senior’s age-in-place and preserve their independence, the City currently offers a variety of successful services and programs. It is estimated that by the year 2040 Rockville’s senior population will total 19,140 seniors, equaling 22% of the total population. As the City’s senior population surges, the demand for senior services will also increase, causing strain to the City’s current resources and facilities. The City faces significant challenges to not only maintain existing service levels for the evolving population, but also develop and fund new programs addressing the diverse needs of the population. Strategic planning will help the city accommodate the needs of all its seniors.
How this action plan will be used
This plan is intended as a tool to gather the proposed action strategies together for discussion and instruction with the Mayor and Council, as well as establish guidelines to implement the study findings.
This action plan will continue to evolve as we improve our knowledge and new understandings are gained. It is our hope that the lead organizations, including Rockville Senior Citizens Commission, Rockville Seniors Inc. (RSI), the Villages Advisory Committee, Rockville seniors and City of Rockville staff work together to implement these items, and continuously adjust as necessary to continue to meet the needs of Rockville seniors.
The action areas included in this report are: Awareness of Programs and Services, Barriers to Participating in 60+ Programs and Services, Villages, Aging in Place Initiatives and Programming. Action Area 1: Awareness of Programs and Services
To increase the knowledge and awareness of senior residents and senior services providers of the resources, services, and program opportunities available to improve the quality of life and make the city a more livable and desirable retirement location for its older residents.
Action Item 1.1: Marketing - Increase knowledge and awareness of senior programs and services by improving marketing strategies, introducing new marketing opportunities, and updating and creating new marketing material.
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Attachment A
1. Create Channel 11 news stories on the benefits of leading an active lifestyle and participating in programs and services for those age 60 and older. This item will begin in October 2016, will be implemented by Senior Services and Chanel 11 staff, and will require no additional funding. 2. Produce four yearly recreation guides targeting residents ages 60 and up. Continue to cross promote in the main recreation guide. This item will begin in FY 2017, will be implemented by Senior Services and Public Information Office (PIO) staff, and will cost $6,000, which was budgeted in the FY 17 adopted budget. 3. Continue to promote programs and services for ages 60 and older in Rockville Reports. This item will begin October 2017, will be implemented by Senior Services and PIO staff, and will require no additional funding. 4. Improve targeted marketing materials for all areas of senior services to attract the younger cohort of senior. This item will be implemented by Senior Services and PIO staff and will require a $1,000 budget each year. 5. Improve Senior Services webpages. This item will be completed by March 2017, will be implemented by Senior Services and PIO staff, and will require no additional funding. 6. Install digital monitors at the three Senior Center entrances to display information on classes, programs, and events. This item will be implemented by the Manager of Senior Services and Information and Technology (IT) staff and will require a $5,000 budget. 7. Create an internet “meet up” group to assist seniors in planning social activities with other seniors. This item will begin November 2016, will be implemented by Senior Services staff and will require no additional funding. 8. Send out bi-monthly email newsletters to highlight upcoming programs, special events and services. This item will begin September 2017, will be implemented by the Facility Coordinator for Senior Services and will require no additional funding. 9. Develop a “Welcome Guide” of programs and services for ages 60 and older. We will place the “Welcome Guide” in all “New Resident Guides”. This item will be implemented by Senior Services and PIO staff and will require a $1,000 budget. 10. Create a brochure, webpage, channel 11 news coverage, social media coverage and Rockville Reports article on transportation options for seniors. This item will be completed by June 2017, will be implemented by the Support Services Supervisor, Senior Services and PIO staff, and will require no additional funding. 11. Create an A-Z guide of programs and services for the website. This item will be completed by November 2016, will be implemented by the Facility Coordinator for Senior Services and will require no additional funding.
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Attachment A
Action Item 1.2: Community Outreach - Increase awareness of programs and services by creating tailored outreach strategies aimed to reach all Rockville Seniors.
1. Develop a training program on outreach strategies for village leaders and Senior Services volunteers, as well as prepare them to share basic knowledge of senior programs and services. This item will be completed by March 2017, will be implemented by the Village Facilitator, and will require no additionalfunding . 2. Develop an “Ambassador Program”. Ambassador volunteers will promote the senior center, senior programs and services. This item will begin March 2017, will be implemented by the Manager of Senior Services, volunteers, Senior Citizens Commission and RSI, and will require no additional funding for FY 17 and $2,200 per year in future years. This proposed budget will include name tags for all volunteers, information cards for all ambassadors to carry and supplies for ambassador training. 3. Conduct presentations and provide direct outreach to senior housing sites, churches, neighborhood associations and civic associations. This item will begin March 2017, will be implemented by Senior Services staff, and will require no additional funding. 4. Senior Services Outreach staff will host regular hours at City of Rockville community centers and the Swim and Fitness Center (S&FC). This item will begin October 2017, will be implemented by outreach staff and will require no additional funding.
Action Item 1.3: Awareness of Senior Service Providers – Facilitate the collaboration of Montgomery County senior service providers, including government, nonprofit and private businesses, in an effort to gain knowledge and increase awareness of the programs and services each provides as well as gain a better understanding of the problems and challenges facing each provider.
1. Support and share information through coordinatingbi annual meetingsof senior service providers in Montgomery County. This item will be completed March 2017, will be implemented by Senior Services staff, and will require no additional funding.
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Attachment A
Action Area 2: Barriers to Participating in Programs and Services
To minimize the multiple perceived or actual barriers to participating in programs and services for residents ages 60 and older.
Action Item 2.1: Isolation and Homebound Seniors – Older adults who are not able to leave their homes and are not connected to family, friends, social groups or churches are of particular concern. If they cannot pay for services, basic needs often go unmet. This action plan creates opportunities for homebound seniors to receive socialization, support and services, and provides the foundation for future programs to be developed.
1. Develop and continuously update a contact list of home bound seniors in Rockville. Encourage residents to refer seniors to Senior Services staff for outreach services. This item will be completed by March 2017, will be implemented by Support Services staff, and will require no additional funding. 2. Develop and implement a volunteer visitor and phone call program. This item will begin July 2017, will be implemented by Support Services staff and volunteers, and will require no additional funding. 3. Create a caregiver support group to assist those caring for homebound seniors. This item will begin October 2016, will be implemented by Support Services staff, and will require no additional funding.
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Attachment A
Action Item 2.2: Low and Middle Income Seniors The lack of financial resources can be a barrier to participating in programs and services. While the median income for the City is above the national average, 7.9% of those 65 and older in Rockville are living below the poverty line.* As a result, seniors often choose services or programs based on what they can afford. *U.S. Census Bureau, 2010-2014 American Community Survey
1. Work with the Villages program to create a list of volunteer services available within each community that could alleviate financial strain from seniors who struggle to pay for chore services such as grass cutting, transportation, home maintenance, shopping, and snow removal and are not in an area of Rockville with an active Village. This item will be ongoing and will be implemented by the Home Maintenance Coordinator and Support Services Staff, and will require no additional funding. 2. Increase awareness of the Senior Assistance Fund by changing the name of the fund to better relate to what the fund is used for: subsidizing Senior Services classes, trips, special events and senior center memberships. Adjust qualification levels to serve middle income seniors who are also in need of financial assistance. This item will be completed in winter 2017, will be implemented by the Support Services Supervisor and Manager for Senior Services, and will require no additional funding. 3. Offer a variety of senior classes, special events and trips at varying prices to assist low and middle income seniors with financial concerns. This item will be ongoing beginning in winter 2017, will be implemented by Senior Services staff and will require no additional funding.
Action Item 2.3: Language and Cultural barriers - 33.2% of individuals ages 65 and over speak a language other than English at home, and 22.1% indicate they speak English less than very well.* *U.S. Census Bureau – 2010-2014 American Community Survey
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Attachment A
1. Translate all Senior Services and Senior Center marketing material into Chinese and Spanish. This item will be implemented by the Facility Coordinator, PIO staff and translation services, and will require a $1,500 budget. 2. Increase multicultural programming. This item will be implemented by all Senior Services staff and will require a $3,400 expenditure budget and will bring in $2,800 in revenue. 3. Hire multilingual class instructors and offer classes in different languages. This item will be implemented by all Senior Services staff and will require a $4,600 expenditure budget, but will recover 100% of the cost.
Action Area 3: Aging in Place and Villages
To help seniors age in place and preserve their independence, the City currently offers a variety of successful programs and services. Examples of Aging in Place services currently offered include Home Maintenance, Transportation, Call and Ride and Health and Wellness Programs as well as Outreach and Counseling. The Village program represents an innovative approach that facilitates neighbors working together to fulfil unmet needs and will further support positive aging in place.
Action Item 3.1: Aging in Place - Aging in Place is defined as “the ability to live in one’s own home and community safely, independently, and comfortably, regardless of age, income or ability level.” (Center for Disease Control and Prevention)
1. Encourage the development of volunteer programs through each Village to deliver affordable chore services, homemaker services and personal services. Examples include but are not limited to: grass cutting, home maintenance, laundry, house cleaning, and grooming. This item will be ongoing and specific to each Village, will be implemented by
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Attachment A
the Village Facilitator, Home Maintenance Coordinator and Outreach staff. A $5,000 budget will also be needed for those occasions when a senior in one of the Rockville villages has an emergency need and a volunteer or other community/non-profit resource is not available to assist. 2. Advocate for Aging in Place initiatives at all levels of government. This item will be ongoing, will be implemented by Rockville Senior Citizens Commission and will require no additional funding. 3. Research and implement a computerized program allowing volunteers to connect with residents who need snow shoveling assistance. This item will be implemented by July 2017, will be implemented by Senior Services and PIO staff, and will require no additional cost. 4. Educate Rockville businesses about the benefits of hiring older workers through a resource employment webpage, and develop a process for older workers to put their names on an employment eligible list for businesses to access. This item will be completed by March 2017, will be implemented by Senior Services and PIO staff, and will require no additional cost. 5. Hire and train additional staff to assist with ADA accommodations at City Senior Programs and Senior Center. As the older population continues to expand, so will the need for accommodations. This item will be ongoing according to the need, will be implemented by the Manager for Senior Services and will require a $7,800 budget per year for a part time staff to work 10 hours per week in the programs we have the most need.
Action Item 3.2: Village Movement –Setting up Villages in Rockville will allow neighbors to remain in their homes for as long as they are able. Villages will reach the isolated and homebound, promote a strong sense of community, and provide a greater opportunity to engage older adults in volunteer opportunities. As each Village takes root, needed programs, services and events will be identified by the volunteers of each Village. The Village movement will allow seniors to find solutions to some of the challenges they are facing right in their own neighborhoods. Senior Services will be there to facilitate and complement the services each Village provides.
1. Recruit, hire and train Village Facilitator. This item will begin with interviews in September 2016, will be implemented by Support Services Supervisor and Human Resources staff, and is included in the FY 17 adopted budget. 2. Coordinate annual Rockville Villages meeting to support emerging and established villages and promote new participation. This item is ongoing, will be implemented by Rockville Village Advisory Committee, Support Services staff, PIO and Village Facilitator, and will require no additionalfunding . 3. Attend village advisory committee meetings. This item will be ongoing, will be implemented by the Village Facilitator and will require no additional funding. 4. Develop village webpage and marketing materials. This item will be implemented by the Village Facilitator and PIO staff and will require no additional funding for the
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Attachment A
development of a city webpage and will require an $800 budget for printing marketing materials. 5. Translate village marketing information to encourage diverse participation. This item will be implemented by the Village Facilitator, with advice from each Village and the Montgomery County Village Coordinator, and will require a $1,200 budget. 6. Develop and provide start up resources and funding for emerging villages. This item is ongoing, will be implemented by the Village Facilitator and village volunteers, and will require a $5,000 budget. Start-up resources may include training for village organizers, neighborhood mailings about the village program, events to promote the village program, and supplies.
Action Item 3.3: Transportation - Specialized and individualized door to door transportation options are needed for seniors to feel independent. Awareness will be increased through educating seniors on transportation options.
1. Expand the Call and Ride program in response to the need for high priority transportation that volunteer ride programs cannot accommodate. This item will be implemented by the Support Service Supervisor, Village Facilitator, and Outreach staff, and will require a $5,000 expenditure budget, while generating $750 in revenue. 2. Support the Village Ride program through encouraging Rockville seniors to volunteer. Investigate Rockville’s own volunteer ride program for door to door transportation. This item will be completed by July 2017, will be implemented by the Support Services Supervisor, Village Facilitator, and Outreach staff, and will require no additionalfu nding. 3. Offer additional bus service to local shopping areas and other local venues. This item will be implemented by the Support Services Supervisor and bus drivers, and will require a $7,800 budget. 4. Offer classes on transportation options that provide instructions on how to use the metro, bus and new ride options such as Uber. This item will be ongoing beginning Winter of 2017, will be implemented by Senior Services staff and will require no additional funding.
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Attachment A
Action Area 4: Programming
Rockville Senior Services offers recreation programs in many areas of interest. With the leading edge of baby boomers turning 70 this year, the need is high for programs in the areas of health, fitness and specialized classes. The study data recommended using community centers as satellite locations for senior programs and services. The data also indicated the title “senior” is stigmatizing to the younger cohort of senior and needs to be addressed.
Action Item 4.1: Community Centers – The recommendation for a more decentralized programming approach emerged from the study. While several senior programs currently operate out of our community centers, the study suggests that older adults are increasingly likely to utilize community centers in their own neighborhoods and that enhanced programming at the centers should occur.
1. Offer senior programs and services at city community centers and the S&FC. This item will begin Fall 2016, will be implemented by Senior Services staff and will cost $7,900 which is included in the FY 17 adopted budget. 2. Senior Services Staff will provide outreach to community centers and the S&FC. This item will be ongoing, will be implemented by Senior Services staff and will require no additional cost.
Action Item 4.2: Senior Programs – The need for additional senior classes and programs, as well as extended hours, was identified in the report.
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Attachment A
1. Offer at least one additional overnight trip (2 night/3 day trip). This item will be implemented by the Senior Recreation staff, will require an $11,640 expenditure budget, and will recover 100% of the cost. 2. Offer additional high level classes, such as lifelong learning lectures, taught by experts in the respective topic. This item will be implemented by Senior Services staff and require an $8,800 expenditure budget, and will recover 100% of the cost. 3. Expand senior center hours Monday-Friday, 5-7pm and Saturdays from 7am-3pm. This item will be implemented by the Manager for Senior Services, will require a $12,000 expenditure budget. 4. Expand classes, events and trips into the early evening. This item will be implemented by Senior Services Supervisors, will require an $8,160 expenditure budget and will recover 100% of the cost. 5. Increase health and wellness offerings to include alternative healing therapies. This item will be implemented by the Health and Wellness Coordinator for Senior Services and will require a $7500 expenditure budget and will bring in $9000 in revenue. 6. Explore funding a feasibility study to open up vehicular access to the Senior Center from Gude Drive. The one-time cost of this study is to be determined.
Action Item 4.3: Stigma in the title “Senior” and “Senior Programs” - The word “senior” is stigmatizing to the younger cohort of adults ages 60 and up. Participants mention a lack of association with the word “senior” and as a result do not view the “senior center” as a place for them. A change in the perception of “Senior Services” is needed in order to not repel the younger seniors and make the current programs and services attractive to all older adults.
1. Change the name of “Senior Center” to a title that deletes the word “senior” such as Rockville 60+ Center, The Rockville Center, Rockville Active Adult Center, Rockville 60+ Activity Center, and Rockville Center for Active Adults. This item will be implemented by the Manager for Senior Services, Senior Citizens Commission and RSI, and will require a $2,550 budget for updated signage. 2. Design and update all non-renovated areas of the Senior Center to be engaging and appealing to all older adults (includes an update of furniture and room functions). This item will be implemented by Senior Services Supervisors and price quotes are being obtained. 3. Create a large event for ages 60 and up that helps to change the stigma of a typical senior activity, for example a fun run and walk for seniors. This item will be implemented by Senior Services Supervisors, will require a $2,600 expenditure budget, and will recover 100% of the cost.
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Attachment B Senior Needs Assessment Implementation Plan - Expenditure/Revenue Chart
Item Details Exp Rev Funding Item #
New Recreation Guide for Senior programs and services Senior Guide Included in FY 17 $ - ongoing 1.1-2 in FY 2017 adopted budget - $6000 Marketing Materials Print 5 new brochures for Senior Services (color) $ 1,000 $ - ongoing 1.1-4 TV Monitors Install 3 new monitors for Senior Center entrances $ 5,000 $ - one time 1.1-6 Welcome Guide Print 1,000 new welcome guides (color) $ 1,000 $ - ongoing 1.1-9 This is a new program and includes funding for program Ambassador Program $ 2,200 $ - ongoing 1.2-2 supplies Translate Marketing Translate 5 new senior services brochures, welcome $ 1,500 $ - one time 2.3-1 Material guide, and transportation flyer into Chinese and Spanish Increase Multicultural 3 new programs per year $ 3,400 $ 2,800 ongoing 2.3-2 programs Multilingual class Funding to hire new instructors $ 4,600 $ 4,600 ongoing 2.3-3 instructors Emergency Chore Funding for emergency chore services, homemaker Services (If volunteers $ 5,000 $ - ongoing 3.1-1 services, and personal services are not available) Additional ADA staff For Senior Center services and programs $ 7,800 $ - ongoing 3.1-5 Print Village marketing Print 2,000 pieces of marketing material $ 800 $ - ongoing 3.2-4 material Translate Village Translate 4 brochures into Spanish and Chinese $ 1,200 $ - one time 3.2-5 marketing materials Startup funding for Funding for emerging Villages – training, supplies, $ 5,000 $ - ongoing 3.2-6 emerging Villages events, mailings Expand existing 'Call Expand 'Call and Ride' program to accommodate $ 5,000 $ 750 ongoing 3.3-1 and Ride' program current needs and emergency transportation Hire 1 additional bus driver to expand current bus Additional bus service transporation to include additional shopping routes, $ 7,800 $ - ongoing 3.3-3 local venues and new senior class locations Overnight Trip To NYC – lodging, food, tour, and transportation $ 11,640 $ 11,640 ongoing 4.2-1 Offer 10 additional new classes in higher learning, such High level classes $ 8,800 $ 8,800 ongoing 4.2-2 as art, science and history lectures Hire new temp staff to cover the registration office Expand hours during the hours of Monday-Friday from 5pm-7pm and $ 12,000 $ - ongoing 4.2-3 Saturdays from 7am-3pm Expand program offerings in the evening by hiring staff Expand evening classes or contractors to offer 2 new art classes, 1 evening trip, $ 8,160 $ 8,160 ongoing 4.2-4 3 one day events and 2 big dances. Expand health and Hire staff or contractors to offer alternative healing $ 7,500 $ 9,000 ongoing 4.2-5 wellness offerings health and wellness offerings Change the name of Replace 3 existing building signs and all street $ 2,550 $ - one time 4.3-1 the Senior Center directional signs Promote and change the stigma of senior programs by Create New event offering one new large special event such as a Fun Run $ 2,600 $ 2,600 ongoing 4.3.3 and walk that ends up at the Senior Center. $ 104,550.00 $ 48,350.00
1-1 Senior Needs Assessment Implementation Plan
Senior Services Division Department of Recreation and Parks September 26, 2016
www.rockvillemd.gov Implementation Plan Page 1
Presentation Outline
• Introduction and Overview
• Overview of Action Areas
• Overview of Action Items
• Discussion with Mayor and Council Implementation Plan Page 2
Introduction and Overview • RTI International was hired to complete the Senior Needs Assessment and Gap Analysis Study. RTI presented study results to Mayor and Council on April 18th, 2016.
• This proposed action plan is based on study results, best practices and innovative approaches to address the gaps and needs identified in the study.
• It is our hope that the lead organizations, Rockville Senior Citizens Commission, Rockville Seniors Inc. (RSI), and the Villages Advisory Committee and interested seniors work together with city staff to implement these items. Implementation Plan Page 3
Action Plan Areas
Action Area 1: Awareness of Programs and Services
Action Area 2: Barriers to Participating in Programs and Services
Action Area 3: Aging in Place and Villages
Action Area 4: Programming Implementation Plan Page 4
Action Area 1: Awareness of Programs and Services
To increase the knowledge and awareness of the resources, services and program opportunities available to residents ages 60 and up.
Marketing-1.1 Community Outreach-1.2 Senior Services Provider Outreach-1.3 Implementation Plan Page 5 Overview of Action Items for Area 1: Awareness of Programs and Services • Create an A-Z guide of • Develop a training programs and services. program on outreach • Develop a “Welcome strategies for village Guide” of programs and leaders and Senior services. Services volunteers. • Create an internet “meet • Develop an “Ambassador up” group. Program.” • Install digital monitors at • Coordinate meetings of the three Senior Center senior service providers in entrances. Montgomery County. Implementation Plan Page 6
Action Area 2: Barriers to participating in Programs and Services
To minimize the multiple perceived or actual barriers to participating in programs and services for residents ages 60 and older.
Isolation and Homebound Seniors-2.1 Low and Middle Income Seniors-2.2 Language and Cultural barriers-2.3 Implementation Plan Page 7 Overview of Action Items for Area 2: Barriers to participating in Programs and Services • Develop and update a • Offer a variety of senior contact list of home classes, special events and bound seniors. trips at varying prices. • Develop and implement a • Translate all Senior volunteer visitor and Services and Senior Center phone call program. marketing material. • Increase awareness of the • Hire multilingual class Senior Assistance Fund by instructors and offer changing the name of the classes in languages other fund. then English. • Create a caregiver • Increase multicultural support group. programming. Implementation Plan Page 8
Action Area 3: Aging in Place and Villages
To help seniors age in place and preserve their independence, the City currently offers a variety of successful programs and services. The village movement represents an innovative approach that facilitates neighbors working together to fulfil unmet needs and will further support positive aging in place.
Aging in Place-3.1 Village Movement-3.2 Transportation-3.3 Implementation Plan Page 9 Overview of Action Items for Area 3: Aging in Place and Villages • Encourage the development • Expand the Call and Ride of volunteer programs program in response to the through each Village to need for high priority deliver affordable chore transportation that volunteer services, homemaker services ride programs cannot and personal services. accommodate. • Educate Rockville businesses • Support the Village Ride about the benefits of hiring program through encouraging older workers. Rockville seniors to volunteer. • Develop and provide start up • Offer additional bus service to resources and funding for local shopping areas and other emerging villages. local venues. Implementation Plan Page 10
Action Area 4: Programming
Rockville Senior Services offers recreation programs in many areas of interest. The study data recommended using community centers as satellite locations for senior programs and services. The data also indicated the title “senior” is stigmatizing to the younger cohort of senior and needs to be addressed.
Community Centers-4.1 Recreation Programs-4.2 Stigma in the title “Senior” and “Senior Programs”-4.3 Implementation Plan Page 11 Overview of Action Items for Area 4: Programming • Offer senior programs and • Expand classes, events and services at city community trips into the early evening. centers and the S&FC. • Change the name of “Senior • Senior Services Staff will Center” to a title that deletes provide outreach to community the word “senior” such as centers and the S&FC. “Rockville 60+ Center.” • Offer one additional overnight • Design and update all non- trip. renovated areas of the Senior • Offer additional high level Center. classes, such as lifelong learning • Discuss opening up access to lectures, taught by experts in Senior center from Gude drive. the respective topic. Implementation Plan Page 12
Discussion with Mayor and Council
•Questions, concerns, comments or guidance on these action areas or items?
•Any action items not included in this plan that the Mayor and Council would like staff to address? Safety of Youth Sports - Traumatic Brain Injuries (TBI)
Mayor and Council
For the meeting on: October 17, 2016 Department: Recreation and Parks Division: Recreation Responsible staff: Andrew Lett, Superintendent of Recreation phone: (240) 314 - 8627 [email protected]
Subject Safety of Youth Sports - Traumatic Brain Injuries (TBI)
Recommendation
Staff recommends that the Mayor and Council discuss the issues related to participant safety in youth sports, and provide guidance in further enhancing the safety guidelines and procedures related to traumatic brain injuries and consider staff recommendations.
Discussion Sports and Recreation-Related Traumatic Brain Injury
Sports and recreational (SR) activities help to foster important social and team-building skills, enhance decision making and self-confidence, and contribute to improving health and quality of life. Unfortunately, participation in SR activity also involves some risk and comes with the possibility of injury. According to the Centers for Disease Control (CDC), an estimated 2.6 million children aged ≤19 years were treated each year in emergency departments (ED) for SR-related injuries during 2001–2009. 173,285 (6.5%) of the 2.6 million injuries annually were diagnosed as suspected Traumatic Brain Injury (TBI) (Attachment A)
TBI is a serious public health concern (Attachment C) that has recently received increased media attention, especially related to professional athletes. Children and adolescents are considered to have a higher risk for sustaining TBI, have the potential for increased severity of the injury, and can take longer to recover when compared to adults. Policies and practices are being established to help protect youth athletes from the dangers of SR-related TBI with 50 states and the District of Columbia adopting laws to help improve the recognition and response to suspected brain injuries among school-aged children (http://www.ncsl.org/research/health/traumatic-brain-injury-legislation.aspx).
What Is a TBI?
A TBI is any head injury that disrupts normal brain function and can be caused by a blow, jolt, or bump to the head or penetrating head injury.(Attachment B) The severity of TBIs can range anywhere from a “mild” TBI with a momentary change in mental status to “severe” with an extended period of unconsciousness or amnesia after the injury (http://www.cdc.gov/traumaticbraininjury/get_the_facts.html). The majority of TBIs that occur each year in the US are concussions or other mild TBI.
What Is a Concussion?
Concussions are a type of TBI that can occur from a fall or blow to the body that causes the brain to move rapidly back and forth within the skull. A concussion may be described as a “mild” TBI by health care professionals because they are typically not life-threatening; however, their effects can be serious. Depending on the severity of the injury, potential short- or long-term consequences can result in disturbances to the way a person thinks, their emotional well-being, general sensation such as sight and touch, and general language comprehension (Attachment D) (https://youtu.be/zCCD52Pty4A).
Who Is at Risk?
TBIs can occur in any SR-related activity. The highest rates for SR-related TBI visits occurred among those ages 10–19, with males accounting for 71% of TBIs amongst all age groups. It is essential that staff, parents, coaches, and the public understand that TBIs do not only occur during contact sports.
The table below provides data on ED visits by type of activity. Bicycling was the activity associated with the highest estimated number of ED visits for TBI followed by football, playground falls, basketball, and soccer. Additionally, TBIs
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sustained during activities such as horseback riding, all-terrain vehicle riding, and tobogganing/sledding accounted for greater than 10% of all injury ED visits for these. Among males aged 10–19, playing football or bicycling were associated with the highest number of SR-related TBI ED visits. Females of the same age had the highest rates of visits for SR-related TBI while playing soccer, basketball, or while bicycling. While these findings emphasize the need for prevention, they also highlight the importance of recognizing the signs and symptoms of TBI, as well as how to respond when one is suspected (Attachment A.)
Estimated annual number of emergency department visits for all nonfatal injuries and nonfatal traumatic brain injuries (TBIs) related to sports and recreation activities among persons aged ≤19 years, by type of activity --- National Electronic Injury Surveillance System--All Injury Program, United States, 2001--2009 % of all visits for All visits for sports and TBIs injuries Activity recreation--related injuries that were TBIs Number Number Bicycling 26,212 323,571 8.1 Football 25,376 351,562 7.2 Playground 16,706 210,979 7.9 Basketball 13,987 375,601 3.7 Soccer 10,436 135,988 7.7 Baseball 9,634 121,309 7.9 All-terrain vehicle riding 6,337 59,533 10.6 Skateboarding 6,004 101,577 5.9 Swimming 4,557 62,745 7.3 Hockey 4,427 45,450 9.7
The CDC has been taking the lead nationally in attempting to understand, prevent and develop protocols for responding to TBI. Their core programmatic response to date is titled “Heads Up”. The Heads Up initiative focuses on: 1. Using prevention strategies to help reduce the risk for concussion and other injuries; 2. Stopping participation in an activity if a concussion is suspected and seeking medical evaluation and approval before returning to play; and 3. Learning concussion signs and symptoms and encouraging athletes and others to report a suspected concussion.
CDC’s concussion Web site includes links to additional resources with further information regarding TBI and concussions.
How to Recognize a Possible Concussion
To recognize a possible concussion, watch for two main things: 1. A forceful bump, blow, or jolt to the head or body that results in rapid movement of the head, AND 2. Any changes in the injured person’s behavior, physical functioning, or thinking.
Concussion signs and symptoms, listed in the table below, typically fall under four categories.
Thinking/ Emotional/ Physical Sleep Remembering Mood Headache Sleeping Difficulty Fuzzy or Irritability more thinking clearly blurry than usual vision Nausea or vomiting Feeling slowed Sleeping less (early Sadness down than usual on) Dizziness Sensitivity to Trouble Difficulty noise or light, More falling concentrating Balance emotional asleep problems Difficulty Feeling tired, Nervousness remembering having no or new energy anxiety information
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These symptoms may not always be apparent immediately after the injury. In some cases, people who have sustained a concussion may not present any symptoms/effects until days or even months later, or when they return to everyday life where more stressors are placed upon them. Concussion symptoms may be difficult to identify initially as a person may seem fine, although they may be acting or feeling differently than normal. A majority of those who sustain a concussion recover quickly and fully, while some have symptoms that last for several days or longer. A list of concussion signs and symptoms specifically related to concussions in sports can be found at http://www.cdc.gov/traumaticbraininjury/symptoms.html.
Concussion Prevention
Concussions can occur in any SR activity and are a risk inherent to physical activity. Here are a few steps to take that will minimize the risk for concussions during SR: 1. Teach the importance of good sportsmanship and following rules of the game at all times. 2. Ensure that protective equipment is worn at all times (e.g., a bicycle helmet). 3. Coach safe and proper sport/recreation-specific skills and techniques.
Additional SR-related concussion prevention information is available at http://www.cdc.gov/headsup/basics/concussion_prevention.html.
What to do if a Concussion is Suspected
Coaches, parents and participants play a key role in identifying and responding in the event a concussion occurs. All of those involved in SR must know the importance of recognizing the signs and symptoms, and of responding quickly and appropriately to a suspected concussion. To ensure early identification and proper management of concussions, the CDC recommends that you develop an action plan before activities begin. They promote a “Heads Up” five-step action plan. (http://www.cdc.gov/traumaticbraininjury/response.html).
HEADS UP Action Plan
If an individual is suspected of having sustained a concussion, the CDC recommends that you take the following steps: 1. Remove the athlete from play. When in doubt, sit them out! 2. Keep an athlete with a possible concussion out of play until cleared by a health care provider. Do not try to judge the severity of the injury yourself. Only a health care provider should assess an athlete for a possible concussion. 3. Record and share information about the injury, such as how it happened and the athlete’s symptoms, to help a health care provider assess the athlete. 4. Inform the athlete’s parent(s) or guardian(s) about the possible concussion and refer them to CDC’s website for concussion information. 5. Ask for written instructions from the athlete’s health care provider about the steps you should take to help the athlete safely return to play. Before returning to play an athlete should:
Be back to doing their regular school activities; Not have any symptoms from the injury when doing normal activities; and Have the green-light from their health care provider to begin the return to play process.
You cannot see a concussion, and some people may not exhibit signs or symptoms until much later. Information about the signs and symptoms of concussion and emergency contacts must be readily available in the event an injury occurs. Coaches, staff, children, teens, and their parents or guardians must also be educated about the dangers of concussions.
State Concussion Legislation
Since the passage of the Zachery Lystedt Law in Washington State in 2009, 50 states and the District of Columbia have passed similar laws addressing youth sports concussions among student-athletes. Maryland’s "Concussions or head injuries in youth sports program" law Md. HEALTH-GENERAL Code Ann. § 14-501 (Attachment E) was enacted in 2013. Much like the Washington State's Lystedt Law, a majority of youth sports concussion laws include three key components: 1) education for coaches, parents, students, etc. regarding concussion among youth athletes; 2) removal from participation of any athlete suspected of sustaining a concussion during a practice or competition; and 3) return to participation only after the athlete has been evaluated and cleared for return by an appropriate health care professional. Each state law is unique and differs in various ways, including who is considered a “youth athlete”. In accordance with Maryland's state legislation, the Maryland State Department of Education (MSDE) was tasked with developing policies and providing recommendations for the implementation of concussion awareness programs throughout the state of Maryland. From MSDE's policies, various Maryland jurisdictions have developed their own policies and/or concussion plans. Several are included as Attachments G-J.
Recommendations
Staff recommends that the City of Rockville ensure that SR activities meet or exceed all CDC recommendations for prevention and response to TBI and concussions through the adoption and implementation of the following:
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1. Require mandatory CDC Heads Up certification of all coaches using City of Rockville fields and facilities (http://www.cdc.gov/HeadsUp/youthsports/training/index.html); 2. Modify ‘Notification of Suspected Concussion or Head Injury Return to Play Requirement’ form and ‘Medical Clearance for Return to Athletic Participation Following Suspected Concussion or Head Injury’ form to match Maryland State Department of Education; 3. Develop a concussion plan similar to Howard County Recreation and Parks (Attachment J); and 4. Require sports league partners (RBBA and RFL) via the MOU to:
a. Provide concussion information on their respective website; b. Incorporate concussion awareness in the league rules and specify processes to follow if a participant is suspected of suffering a concussion; and c. Require head injury tracking processes.
Mayor and Council History Youth Sports- TBI was proposed as a discussion item on March 14, 2016. The September 26 discussion was moved to October 17. Attachment K includes responses to questions from council members prior to the previously scheduled meeting.
Attachments
Attachment A - Non fatal sport and recreation related traumatic brain injuries among children and adolescents 2001- 2009.pdf
Attachment B - Consensus statement on concussion in sport – The 3rd International Conference.pdf
Attachment C - Report to Congress on mild traumatic brain injury in the United States.pdf
Attachment D - Traumatic brain injury; Hope through Research.pdf Attachement E - Maryland Law § 14-501.pdf
Attachment F - Point of health care entry.pdf Attachment G - MSDE Policies Programs Concussions 2011.pdf
Attachment H - Montgomery County Public School Concussion Plan.pdf
Attachment I - Montgomery County Maryland - New concussion policy.pdf
Attachment J - Howard County Recreation and Parks Concussion and Sudden Cardiac Arrest Information Plan of Action.pdf
Attachment K- Councilmember questions related to TBI discussion.pdf
Department Head:
Tim Chesnutt, Director of Recreation and Parks Approved on: 07/15/2016
City Manager: Approved on: 09/20/2016
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Morbidity and Mortality Weekly Report Weekly / Vol. 60 / No. 39 October 7, 2011
Nonfatal Traumatic Brain Injuries Related to Sports and Recreation Activities Among Persons Aged ≤19 Years — United States, 2001–2009
Traumatic brain injuries (TBIs) from participation in ED (5). NEISS-AIP provides data on approximately 500,000 sports and recreation activities have received increased public injury-related cases each year. awareness, with many states and the federal government For this analysis, sports and recreation–related injuries considering or implementing laws directing the response to included those injuries among children and adolescents aged suspected brain injury (1,2). Whereas public health programs ≤19 years that occurred during organized and unorganized promote the many benefits of sports and recreation activities, sports and recreation activities (e.g., bicycling, skating, or those benefits are tempered by the risk for injury. During playground activities). Each case was initially classified into 2001–2005, an estimated 207,830 emergency department one of 39 mutually exclusive sports and recreation–related (ED) visits for concussions and other TBIs related to sports groups on the basis of an algorithm using both the consumer and recreation activities were reported annually, with 65% of products involved (e.g., bicycles, swing sets, or in-line skating TBIs occurring among children aged 5–18 years (3). Compared equipment) and the narrative description of the incident with adults, younger persons are at increased risk for TBIs obtained from the medical record. For the analysis, 30 of the with increased severity and prolonged recovery (4). To assess categories were examined separately and the remaining nine and characterize TBIs from sports and recreation activities were combined into the “other specified” category. Persons with among children and adolescents, CDC analyzed data from sports and recreation–related injuries were classified as having the National Electronic Injury Surveillance System–All Injury a TBI if the primary body part injured was the head and the Program (NEISS-AIP) for the period 2001–2009. This report principal diagnosis was either concussion or internal organ summarizes the results of that analysis, which indicated that injury. Sports and recreation–related cases were excluded if the an estimated 173,285 persons aged ≤19 years were treated in injury was violence-related (e.g., intentional self-harm, assault, EDs annually for nonfatal TBIs related to sports and recreation activities. From 2001 to 2009, the number of annual TBI- INSIDE related ED visits increased significantly, from 153,375 to 248,418, with the highest rates among males aged 10–19 years. 1343 Acute Illness and Injury from Swimming Pool By increasing awareness of TBI risks from sports and recreation, Disinfectants and Other Chemicals — United States, 2002–2008 employing proper technique and protective equipment, and 1348 Health Plan Implementation of U.S. Preventive quickly responding to injuries, the incidence, severity, and Services Task Force A and B Recommendations long-term negative health effects of TBIs among children and — Colorado, 2010 adolescents can be reduced. 1351 Vital Signs: Alcohol-Impaired Driving Among NEISS-AIP is operated by the U.S. Consumer Product Adults — United States, 2010 Safety Commission and contains data on initial visits for all 1357 Multistate Outbreak of Listeriosis Associated with injuries in patients treated in U.S. hospital EDs. NEISS-AIP Jensen Farms Cantaloupe — United States, data are drawn from a nationally representative subsample August–September 2011 of 66 of 100 NEISS hospitals that are selected as a stratified 1359 Announcements probability sample of hospitals in the United States and its 1361 QuickStats territories that have a minimum of six beds and a 24-hour
U.S. Department of Health and Human Services Centers for Disease Control and Prevention
A-1 Morbidity and Mortality Weekly Report Attachment A or legal intervention). Additionally, data regarding persons who What is already known on this topic? were dead on arrival or who died in the ED were excluded. Each case of sports and recreation–related injury was assigned Risk for traumatic brain injury (TBI) is inherent to participation in sports and recreation activities; compared with adults, children a sample weight based on the inverse probability of selection; and adolescents have an increased risk for TBIs with increased these weights were added to provide national estimates of severity and prolonged recovery. sports and recreation–related injuries. National estimates were What is added by this report? based on weighted data for 453,655 ED visits for all sports From 2001 to 2009, the estimated number of sports and and recreation–related injuries (of which 36,230 were TBIs) recreation–related TBI visits to emergancy departments (EDs) during 2001–2009. Confidence intervals were calculated using increased from 153,375 to 248,418, and the estimated rate of a direct variance estimation procedure that accounted for the TBI visits increased from 190 per 100,000 population to 298. The sample weights and complex sample design (5). Significance two most common sports and recreation activities associated of trends over time was assessed using weighted least squares with ED treatment for TBI were bicycling and playing football. regression analysis. What are the implications for public health practice? During 2001–2009, an estimated 2,651,581 children aged To minimize TBI in sports and recreation activities, prevention ≤19 years were treated annually for sports and recreation– strategies should be implemented, including practicing skills, strength and conditioning, and sportsmanship, and using related injuries. Approximately 6.5%, or 173,285 of these protective equipment (e.g., bicycle helmets). Secondary injuries, were TBIs (Table 1). Approximately 71.0% of all strategies include knowing the signs and symptoms of TBI, sports and recreation–related TBI ED visits were among responding to suspected TBI appropriately, and permitting males; 70.5% were among persons aged 10–19 years. An return to activity only after evaluation and clearance by an estimated 2.5% of children and adolescents with sports and experienced health-care provider. recreation–related injuries were hospitalized or transferred to other facilities, compared with an estimated 6.6% of those hospitalization ranged from 9,300 to 14,000 annually but did with sports and recreation–related TBIs. From 2001 to 2009, not show a significant trend over time. the estimated number of sports and recreation–related TBI Overall, the activities associated with the greatest estimated visits to EDs increased 62%, from 153,375 to 248,418, and number of TBI-related ED visits were bicycling, football, the estimated rate of TBI visits increased 57%, from 190 playground activities, basketball, and soccer (Table 2). per 100,000 population to 298. During this same period, Activities for which TBI accounted for >10% of the injury the estimated number of ED visits for TBIs that resulted in
The MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333. Suggested citation: Centers for Disease Control and Prevention. [Article title]. MMWR 2011;60:[inclusive page numbers]. Centers for Disease Control and Prevention Thomas R. Frieden, MD, MPH, Director Harold W. Jaffe, MD, MA, Associate Director for Science James W. Stephens, PhD, Director, Office of Science Quality Stephen B. Thacker, MD, MSc, Deputy Director for Surveillance, Epidemiology, and Laboratory Services Stephanie Zaza, MD, MPH, Director, Epidemiology and Analysis Program Office MMWR Editorial and Production Staff Ronald L. Moolenaar, MD, MPH, Editor, MMWR Series John S. Moran, MD, MPH, Deputy Editor, MMWR Series Martha F. Boyd, Lead Visual Information Specialist Robert A. Gunn, MD, MPH, Associate Editor, MMWR Series Maureen A. Leahy, Julia C. Martinroe, Teresa F. Rutledge, Managing Editor, MMWR Series Stephen R. Spriggs, Terraye M. Starr Douglas W. Weatherwax, Lead Technical Writer-Editor Visual Information Specialists Donald G. Meadows, MA, Jude C. Rutledge, Writer-Editors Quang M. Doan, MBA, Phyllis H. King Information Technology Specialists MMWR Editorial Board William L. Roper, MD, MPH, Chapel Hill, NC, Chairman Virginia A. Caine, MD, Indianapolis, IN Patricia Quinlisk, MD, MPH, Des Moines, IA Jonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA Patrick L. Remington, MD, MPH, Madison, WI David W. Fleming, MD, Seattle, WA Barbara K. Rimer, DrPH, Chapel Hill, NC William E. Halperin, MD, DrPH, MPH, Newark, NJ John V. Rullan, MD, MPH, San Juan, PR King K. Holmes, MD, PhD, Seattle, WA William Schaffner, MD, Nashville, TN Deborah Holtzman, PhD, Atlanta, GA Anne Schuchat, MD, Atlanta, GA John K. Iglehart, Bethesda, MD Dixie E. Snider, MD, MPH, Atlanta, GA Dennis G. Maki, MD, Madison, WI John W. Ward, MD, Atlanta, GA
1338 MMWR / October 7, 2011 / Vol. 60 / No. 39 A-2 Morbidity and Mortality Weekly Report Attachment A
TABLE 1. Estimated annual number and rate* of emergency department visits for all nonfatal injuries and nonfatal traumatic brain injuries (TBIs) related to sports and recreation activities among persons aged ≤19 years, by selected characteristics — National Electronic Injury Surveillance System–All Injury Program, United States, 2001–2009 All visits for sports and TBIs recreation–related injuries % of all visits for injuries that Characteristic No.† Rate 95% CI No.† Rate 95% CI were TBIs Age group (yrs) ≤4 14,406 71 (48–93) 158,876 778 (642–914) 9.1 5–9 36,756 184 (136–231) 529,481 2,646 (2,232–3,060) 6.9 10–14 60,272 291 (226–357) 1,084,041 5,242 (4,391–6,092) 5.6 15–19 61,851 294 (226–361) 879,184 4,177 (3,561–4,793) 7.0 Sex Male 122,970 292 (225–360) 1,810,260 4,302 (3,664–4,940) 6.8 Female 50,310 126 (96–155) 840,838 2,098 (1,757–2,439) 6.0 Disposition Treated and released 159,010 194 (148–239) 2,569,161 3,127 (2,645–3,610) 6.2 Hospitalized/Transferred 11,477 14 (9–19) 67,277 82 (66–98) 17.1 Observed 1,954 2 (1–4) 4,946 6 (4–9) 39.5 Other/Unknown§ 844 1 (0.6–1.5) 10,196 12 (9–16) 8.3 Year 2001 153,375 190 (137–242) 2,784,375 3,440 (3,057–3,823) 5.5 2002 143,744 177 (134–220) 2,669,721 3,287 (2,756–3,818) 5.4 2003 152,882 188 (138–237) 2,647,990 3,250 (2,673–3,826) 5.8 2004 148,651 182 (133–230) 2,619,490 3,202 (2,623–3,780) 5.7 2005 162,371 198 (148–248) 2,592,682 3,159 (2,621–3,697) 6.3 2006 172,463 209 (158–261) 2,659,199 3,228 (2,672–3,783) 6.5 2007 184,424 223 (168–277) 2,637,890 3,184 (2,621–3,746) 7.0 2008 193,235 232 (180–284) 2,615,004 3,143 (2,611–3,675) 7.4 2009 248,418 298 (216–379) 2,637,881 3,162 (2,590–3,734) 9.4 Total 173,285 211 (162–260) 2,651,581 3,228 (2,737–3,719) 6.5 Abbreviation: CI = confidence interval. * Per 100,000 population. † Numbers might not sum to totals because of rounding. § Includes patients who left against medical advice or without being examined by attending physician, or those with unknown disposition.
ED visits for that activity included horseback riding (15.3%), Editorial Note ice skating (11.4%), golfing (11.0%), all-terrain vehicle riding The findings in this report indicate that, from 2001 to (10.6%), and tobogganing/sledding (10.2%). 2009, the number of sports and recreation–related ED visits Activities associated with the greatest estimated number of for TBI among persons aged ≤19 years increased 62% and sports and recreation–related TBI ED visits varied by age group the rate of TBI visits increased 57%. These increases might and sex (Table 3). For males and females aged ≤9 years, TBIs reflect an increased participation in sports and recreation, an most commonly occurred during playground activities or when increased incidence of TBI among participants, and/or an bicycling. For persons aged 10–19 years, males sustained TBIs increased awareness of the importance of early diagnosis of most often while playing football or bicycling, whereas females TBI. Because the number of ED visits for TBIs that resulted sustained TBIs most often while playing soccer or basketball, in hospitalization did not trend upward significantly, increased or while bicycling. awareness likely contributed to the increasing number of ED Reported by visits for TBI. Additionally, this report highlights that the rates of sports and recreation–related TBI visits were higher Julie Gilchrist, MD, Div of Unintentional Injury Prevention, among persons aged 10–19 years than among younger persons. Karen E. Thomas, MPH, Likang Xu, MD, Lisa C. McGuire, This finding might be associated with age-related increases in PhD, Victor Coronado, MD, Div of Injury Response, National participation in higher-risk activities (e.g., competitive contact Center for Injury Prevention and Control, CDC. Corresponding sports) or increases in participants’ weight and speed, leading contributor: Julie Gilchrist, [email protected], 770-488-1178. to greater momentum and force of impact (6).
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TABLE 2. Estimated annual number of emergency department visits for all nonfatal injuries and nonfatal traumatic brain injuries (TBIs) related to sports and recreation activities among persons aged ≤19 years, by type of activity — National Electronic Injury Surveillance System–All Injury Program, United States, 2001–2009 All visits for sports and TBIs recreation–related injuries % of all visits for injuries that Activity No.* 95% CI (±) No.* 95% CI (±) were TBIs Bicycling 26,212 (6,809) 323,571 (48,566) 8.1 Football 25,376 (4,845) 351,562 (47,448) 7.2 Playground 16,706 (5,198) 210,979 (37,050) 7.9 Basketball 13,987 (3,077) 375,601 (47,607) 3.7 Soccer 10,436 (3,736) 135,988 (39,167) 7.7 Baseball 9,634 (2,401) 121,309 (22,175) 7.9 All-terrain vehicle riding 6,337 (3,481) 59,533 (14,061) 10.6 Skateboarding 6,004 (2,455) 101,577 (31,907) 5.9 Swimming 4,557 (1,699) 62,745 (14,500) 7.3 Hockey† 4,427 (2,749) 45,450 (24,405) 9.7 Miscellaneous ball games§ 4,065 (1,477) 66,543 (15,306) 6.1 Horseback riding 3,638 (1,266) 23,842 (5,169) 15.3 Moped/Dirt bike riding¶ 3,370 (978) 39,363 (9,209) 8.6 Scooter riding 3,336 (779) 54,561 (11,784) 6.1 Gymnastics** 3,319 (948) 71,248 (13,881) 4.7 Combative sports†† 2,981 (786) 50,639 (10,941) 5.9 Softball 2,735 (756) 49,345 (10,002) 5.5 Exercising 2,406 (825) 77,069 (11,731) 3.1 Tobogganing/Sledding 2,377 (948) 23,306 (8,383) 10.2 Trampolining 2,323 (823) 86,584 (17,540) 2.7 Golf§§ 1,887 (609) 17,078 (3,510) 11.0 Ice skating 1,673 (631) 14,608 (4,241) 11.4 Volleyball 1,396 (483) 34,513 (7,568) 4.0 Amusement attractions¶¶ 1,266 (470) 15,781 (3,844) 8.0 Roller skating/Unspecified skating 1,126 (316) 34,717 (8,280) 3.2 Go-cart riding 875 (308) 11,078 (2,280) 7.9 In-line skating 853 (335) 25,350 (7,515) 3.4 Track and field 449 (171) 15,553 (3,003) 2.9 Racquet sports*** 323 (125) 9,306 (1,984) 3.5 Bowling 153 (74) 6,574 (1,524) 2.3 Other specified††† 9,059 (4,630) 136,210 (44,511) 6.7 Total 173,285 (40,284) 2,651,581 (403,378) 6.5 Abbreviation: CI = confidence interval. * Estimates might not sum to totals because of rounding. † Includes ice hockey, field hockey, roller hockey, and street hockey. § Includes lacrosse, rugby, handball, and tetherball. ¶ Includes other two-wheeled, powered, off-road vehicles and dune buggies. ** Includes cheerleading and dancing. †† Includes boxing, wrestling, martial arts, and fencing. §§ Includes injuries related to golf carts. ¶¶ Includes rides and water slides (not swimming pool slides). *** Includes tennis, badminton, and squash. ††† Includes water skiing, surfing, personal watercraft, snow skiing, snowmobiling, snowboarding, camping, fishing, archery, darts, table tennis, nonpowder/BB guns, and billiards.
Risk for TBI is inherent to physical activity and can occur prevention strategies include increasing awareness of the signs during any activity at any age. To minimize TBI in sports and symptoms of TBI and recognizing and responding quickly and recreation activities, primary and secondary prevention and appropriately to suspected TBI. strategies should be implemented. Primary prevention Participants suspected of having a TBI should be removed strategies include: 1) using protective equipment (e.g., a from play, never returned to play the same day, and allowed bicycle helmet) that is appropriate for the activity or position, to return only after evaluation and clearance by a health-care fits correctly, is well maintained, and is used consistently and provider who is experienced in diagnosing and managing TBI correctly; 2) coaching appropriate sport-specific skills with an (4). Return to play is a critical decision because children and emphasis on safe practices and proper technique; 3) adhering adolescents are at increased risk for both repeat concussion to rules of play with good sportsmanship and strict officiating; during sports and recreation–related activities and for long- and 4) attention to strength and conditioning (7). Secondary term sequelae, delayed recovery, and cumulative consequences
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TABLE 3. Five most common activities associated with emergency department visits for nonfatal traumatic brain injuries related to sports or recreation activities, by age group and sex — National Electronic Injury Surveillance System–All Injury Program, United States, 2001–2009 Age group (yrs) ≤4 5–9 10–14 15–19 ≤19 total Sex/Rank No. (%) No. (%) No. (%) No. (%) No. (%) Male 1 Playground Bicycling Football Football Football 3,187 (35.3*) 5,997 (23.6) 8,988 (20.7) 13,667 (30.3) 24,431 (19.9) 2 Bicycling Playground Bicycling Bicycling Bicycling 1,608 (17.8) 4,790 (18.9) 8,302 (19.1) 4,377 (9.7) 20,285 (16.5) 3 Baseball Baseball Basketball Basketball Playground 656 (7.3) 2,227 (8.8) 4,009 (9.2) 4,049 (9.0) 9,568 (7.8) 4 Scooter riding Football Baseball Soccer Basketball 460 (5.1) 1,657 (6.5) 3,061 (7.0) 3,013 (6.7) 9,372 (7.6) 5 Swimming Basketball Skateboarding ATV riding Baseball 429 (4.8) 1,133 (4.5) 2,613 (6.0) 2,546 (5.6) 8,030 (6.5) Other 2,680 (29.7) 9,558 (37.7) 16,476 (37.9) 17,488 (38.7) 51,284 (41.7) Total 9,020 25,362 43,449 45,140 122,970 Rate† (95% CI) 86 (61–112) 248 (182–313) 410 (316–504) 417 (323–512) 292 (225–360) Female 1 Playground Playground Bicycling Soccer Playground 2,297 (47.8) 3,455 (30.3) 2,051 (12.2) 2,678 (16.0) 7,136 (14.2) 2 Bicycling Bicycling Basketball Basketball Bicycling 775 (14.4) 2,361 (20.7) 1,863(11.1) 2,446 (14.6) 5,928 (11.8) 3 Baseball Baseball Soccer Gymnastics§ Soccer 321 (6.0) 541 (4.7) 1,843 (11.0) 1,513 (9.1) 4,767 (9.5) 4 Trampolining Scooter riding Horseback riding Softball Basketball 261¶ (4.8) 525 (4.6) 1,301 (7.7) 1,171 (7.0) 4,615 (9.2) 5 Swimming Swimming Playground Horseback riding Horseback riding 257 (4.8) 504 (4.4) 1,041 (6.2) 1,028 (6.2) 2,853 (5.7) Other 1,275 (23.7) 4,006 (35.2) 8,724 (51.9) 7,872 (47.1) 25,011 (49.7) Total 5,386 11,391 16,824 16,709 50,310 Rate† (95% CI) 54 (34–74) 117 (87–146) 167 (130–203) 163 (122–204) 126 (96–155) Abbreviations: ATV = all-terrain vehicle; CI = confidence interval. * Percentages might not sum to 100% because of rounding. † Per 100,000 population. § Includes cheerleading and dancing. ¶ Estimate might be unstable because the coefficient of variation is >30%. of multiple TBIs (e.g., increased severity of future TBIs and with concussion achieve optimal recovery and reduce or avoid increased risk for depression and dementia) (8,9). significant sequelae. To promote the prevention of, recognition of, and The findings in this report are subject to at least five appropriate responses to TBI, CDC has developed the Heads limitations. First, injury rates for specific activities could not Up initiative, a program that provides concussion and mild TBI be calculated because of a lack of national participation and education to specific audiences such as health-care providers, exposure data. Therefore, the estimates cannot be used to coaches, athletic trainers, school nurses, teachers, counselors, calculate the relative risks for TBI associated with any particular parents, and student athletes. The newest addition to this sport or activity. Second, NEISS-AIP only includes injuries initiative is Heads Up to Clinicians: Addressing Concussion in recorded by hospital EDs and excludes persons who sought Sports Among Kids and Teens, an online course for health-care care in other settings or who did not seek care. Therefore, this professionals that was developed with support from the CDC report underestimates the actual burden of TBI from sports and Foundation and the National Football League.* This course, recreation among children and adolescents. Third, NEISS-AIP which offers free continuing education credits, addresses the includes only the principal diagnosis and primary body part appropriate diagnosis, management, and referral of TBI, and injured and therefore cannot capture TBIs that were secondary education about TBI that is critical for helping young athletes diagnoses. For example, skull fractures, which commonly involve TBI, are listed as fractures of the head, and not as * Available at http://preventingconcussions.org.
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TBIs, resulting in underestimation of the number of sports References and recreation–related TBI ED visits. Fourth, NEISS-AIP 1. Schatz P, Moser RS. Current issues in pediatric sports concussion. Clin narrative descriptions do not provide detailed information Neuropsychol 2011;25:1042–57. 2. Zhao L, Han W, Steiner C. Sports related concussions, 2008. Statistical about injury circumstances (e.g., whether the activity was brief no. 114. Rockville, MD: Agency for Healthcare Research and Quality, organized, whether the injury occurred during training or Healthcare Cost and Utilization Project; 2011. Available at http://www. competition, or whether protective equipment was used), hcup-us.ahrq.gov/reports/statbriefs/sb114.jsp. Accessed October 5, 2011. so NEISS-AIP cannot be used to assess the impact of these 3. CDC. Nonfatal traumatic brain injuries from sports and recreation activities—United States, 2001–2005. MMWR 2007;56:733–7. factors. Finally, the available data do not allow for assessment 4. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on of whether the increased number of ED visits from 2001 to concussion in sport—the 3rd International Conference on Concussion 2009 resulted from an increase in incidence or an increase in in Sport, held in Zurich, November 2008. J Clin Neurosci 2009;16:755–63. awareness of TBI and concussion, or from shifts in location 5. Schroeder T, Ault K, eds. The NEISS sample (design and implementation): of medical care, or other reasons. 1997 to present. Bethesda, MD: US Consumer Product Safety The frequency of TBIs and the wide variety of activities Commission; 2001. Available at http://www.cpsc.gov/neiss/2001d011-6b6. pdf. Accessed October 4, 2011. associated with them underscore the need to prevent, recognize, 6. Proctor MR, Cantu RC. Head and neck injuries in young athletes. Clin and respond to sports and recreation–related TBIs. Additional Sports Med 2000;19:693–715. information and resources regarding TBI and the Heads Up 7. CDC. Concussion in sports: what can I do to prevent concussions? initiative, including tool kits and on-line trainings, are available Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cdc.gov/concussion/sports/prevention. at http://www.cdc.gov/concussion. html. Accessed October 3, 2011. 8. Buzzini SR, Guskiewicz KM. Sport-related concussion in the young athlete. Curr Opin Pediatr 2006;18:376–82. 9. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury. J Head Trauma Rehabil 2006;21:375–8.
1342 MMWR / October 7, 2011 / Vol. 60 / No. 39 A-6 Morbidity and Mortality Weekly Report Attachment A
Acute Illness and Injury from Swimming Pool Disinfectants and Other Chemicals — United States, 2002–2008
Swimming pools require disinfectants and other chemicals (Table 1). State cases categorized as definite, probable, possible, to maintain water quality and prevent swimmers from and suspicious and California Department of Pesticide acquiring infections (1). When these chemicals are stored Regulation cases categorized as definite, probable, and possible or used improperly or when they are handled or applied by were included in the analysis. NEISS cases† were those persons not using appropriate personal protective equipment involving exposure to swimming pool chemicals (product (PPE), illness or injury can result (2). To assess the frequency code 938). State cases were excluded if the event occurred of illness and injury related to pool chemicals, CDC analyzed during crop farming activities. Neither state nor NEISS cases data for the period 2002–2008 from six states participating were included if the illness or injury was not directly caused in the Sentinel Event Notification System for Occupational by pool chemicals.§ Data were analyzed for demographic Risk (SENSOR)–Pesticides surveillance program and from the characteristics, event location, health effects, outcomes (e.g., National Electronic Injury Surveillance System (NEISS). This hospitalization), and factors contributing to illness or injury. report describes the results of that analysis, which identified Data from the SENSOR-Pesticides states also were analyzed for 584 cases of illness or injury associated with pool chemicals in reporting source, illness or injury severity,¶ chemical toxicity,** the six SENSOR-Pesticides states and indicated an estimated active ingredients, work-relatedness, and time lost from work. national total of 28,071 cases (based on 688 NEISS cases) For the period 2002–2008, a total of 584 cases were during that period. For the 77% of state cases and 49% of identified in the six SENSOR-Pesticides states (Table 2); NEISS cases that had sufficient information to determine most cases occurred in California (306 [52%]). Most cases factors contributing to illness or injury, the most common reported by the states (65%) were identified through poison contributing factors included mixing incompatible products, control centers, followed by cases indentified from workers’ spills and splashes of chemicals, lack of appropriate PPE use, compensation claims (28%). The number of cases from NEISS and dust clouds or fumes generated by opening a chemical for the period 2002–2008 was 688, which yields a weighted container. Adhering to existing CDC recommendations national estimate of 28,071 cases (Table 2). A substantial can prevent some of the reported illnesses and injuries, but additional measures (e.g., improving package design to limit † NEISS is a probability sample of emergency departments based on a sampling the release of dust clouds and fumes when a container is frame of 100 emergency departments in the United States and its territories. Each case is assigned a weight based on the sample design. The national opened, making containers child-proof, and making product estimate is the sum of weights. labels easier to understand) might reduce them further. § NEISS cases that did not meet the case definition for inclusion in this analysis did not directly involve the pool chemical, did not have acute symptoms In the six SENSOR-Pesticides states (California, Iowa, related to pool chemicals, or involved intentional exposure (e.g., drug use). Louisiana, Michigan, North Carolina, and Texas),* a case Examples of cases that were excluded include a case in a person who injured of poisoning associated with pool disinfectants was defined his back while lifting a bucket of pool chlorine, a case in a person who sprained their ankle when they fell into the pool while adding pool chemicals to the as two or more acute adverse health effects resulting from pool water, cases in persons who had symptoms because they were drowning, exposure to any pool disinfectant. Cases were categorized by cases in persons who lived in a home where chlorine, fertilizer, or muriatic certainty of exposure, reported health effects, and consistency acid was stored but did not have any symptoms, and cases in other persons whose illnesses or injuries did not directly involve pool chemicals or for whom of health effects with known toxicology of the chemical (3) no symptoms after exposure were reported. A total of 55 NEISS cases with product code 938 occurred during 2002–2008 that did not meet the case * Currently, 12 states conduct surveillance of pesticide-related illness and injury, definition for this analysis. If these cases were included, the national estimate and these states comprise the SENSOR-Pesticides program. Of these states, for illnesses and injuries associated with pool chemicals during that period would be 30,235 cases. only California, Louisiana, Michigan, and Texas collected data on illnesses and ¶ injuries related to disinfectants for the period 2002–2008. The North Carolina Severity of illness or injury of cases was categorized into four groups using Department of Health and Human Services Division of Public Health began standardized criteria for state-based surveillance programs. In low-severity collecting data on illnesses and injuries related to disinfectants in 2008. The cases, illness or injury usually resolves without treatment and <3 days are lost Iowa Department of Public Health has a collaborative relationship with the from work. In moderate-severity cases, illness or injury is non–life-threatening poison control centers in Iowa and was able to identify pesticide poisoning but requires medical treatment and <6 days are lost from work. In high-severity cases associated with swimming pool disinfectants for the period 2005–2008. cases, illness or injury is life-threatening and requires hospitalization and >5 The California Department of Public Health provided data for the period days are lost from work. The category for fatal poisonings is death. ** The toxicity category of a pesticide is determined by the Environmental 2006–2008 (14 cases), and the California Department of Pesticide Regulation Protection Agency under guidance from Code of Federal Regulations Title provided data for the period 2002–2008 (292 cases). The numbers of cases 40 Part 156. Pesticides in category I have the greatest toxicity, and pesticides contributed by each state were as follows: California, 306; Louisiana, 138; in category IV have the least toxicity. Texas, 57; Michigan, 43; North Carolina, 25; and Iowa, 15.
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TABLE 1. Case classification matrix for acute illnesses and injuries associated with pool disinfectants — six Sentinel Event Notification What is already known on this topic? System for Occupational Risk (SENSOR)–Pesticides states, 2002–2008 Swimming pools require frequent application of disinfectants Classification category* and other pool chemicals, and exposure to these chemicals can Classification cause illness and injury. criteria† Definite Probable Possible Suspicious Exposure 1 1 2 2 1 or 2 What is added by this report? Health effects 1 2 1 2 1 or 2 During 2002–2008, an estimated 28,071 cases of illness or injury Causal relationship 1 1 1 1 4 associated with pool disinfectants and other pool chemicals Source: CDC. Case definition for acute pesticide-related illness and injury cases occurred nationally (an average of 4,010 cases per year). Most reportable to the national public health surveillance system. Cincinnati, OH: US cases occurred at private residences. In the six states Department of Health and Human Services, CDC, National Institute for participating in the Sentinel Event Notification System for Occupational Safety and Health; 2005. Available at http://www.cdc.gov/niosh/ Occupational Risk (SENSOR)–Pesticides surveillance program, topics/pesticides/pdfs/casedef2003_revapr2005.pdf. * Case classifications are slightly different between the SENSOR-Pesticides 40% of cases were work-related, 9% of which involved loss of 1 program and the California Department of Pesticide Regulation (CDPR) or more days from work. The most frequently identified causes Pesticide Illness Surveillance system. CDPR classifies cases as definite, probable, of illness or injury were mixing incompatible chemicals, spills and possible based on the relationship between exposure and health effects: and splashes of pool chemicals, lack of appropriate personal definite = both physical (e.g., disinfectant residue on clothing) and medical evidence document exposure and consequent health effects; probable = protective equipment (PPE) use, lack of proper training and limited or circumstantial evidence supports a relationship to pesticide supervision, and dust clouds or fumes generated by opening a exposure; and possible = evidence neither supports nor contradicts a pool chemical container. relationship. Additional information available at http://www.cdpr.ca.gov/docs/ whs/pisp/brochure.pdf. What are the implications for public health practice? † Cases are classified as definite, probable, possible, or suspicious based on Some of the identified illnesses and injuries resulted from failure scores for exposure, health effects, and causal relationship. Exposure score: to follow CDC recommendations to prevent illnesses and 1 = laboratory, clinical, or environmental evidence for exposure; 2 = evidence of exposure based solely on written or oral report from the patient, a witness, injuries associated with pool chemicals. Additional measures to or applicator. Health effects scores: 1 = two or more new postexposure signs reduce exposures to pool chemicals that are suggested by these or laboratory findings reported by a licensed health professional; 2 = two or findings include altering pool chemical container design and more postexposure symptoms reported by the patient. Causal relationship modifying labels to make them easier to understand, including scores: 1 = the observed health effects are consistent with the known toxicology of the disinfectant; 4 = insufficient toxicologic information available using pictograms to depict appropriate PPE use. to determine the causal relationship. or fumes generated by opening a chemical container (15% of proportion of cases were in children aged <15 years (25% of state and NEISS cases) (Table 3). Factors that contributed to state cases and 34% of NEISS cases). Cases were most frequently worker illness or injury included spills and splashes of liquid or poisonings at private residences (48% of state cases and 56% of dust (33%), lack of appropriate PPE use (24%), and equipment NEISS cases) followed by nonmanufacturing facilities, which failure (19%). Among state and NEISS cases, 9% occurred included hotels, health clubs, and other facilities (28% of state when a child gained access to chemicals not securely stored, cases and 14% of NEISS cases). Symptoms most frequently and 6% of state cases and 2% of NEISS cases involved other reported were respiratory symptoms, such as cough, upper improper storage. Of cases that involved storage within reach respiratory irritation, and dyspnea (65% of state cases and of a child, 14% of state cases involved children aged 4–11 years 24% of NEISS cases), eye injuries (33% of state cases and who opened containers. 42% of NEISS cases), and skin injuries (18% of state cases and Five high-severity cases were identified by the six SENSOR- 19% of NEISS cases). In the six SENSOR-Pesticides states, Pesticides states. One case occurred in a man aged 39 years the active ingredients most frequently associated with acute in Louisiana with no pertinent medical history. He was in a illness or injury were sodium hypochlorite (31%), triazine public recreational swimming pool when chlorine was added compounds (22%), and calcium hypochlorite (16%). Most of to shock chlorinate it. He inhaled fumes and developed the disinfectants were toxicity category I (87%). The majority nausea, headache, cough, upper respiratory irritation, of state cases (85%) involved low-severity illnesses or injuries. dyspnea, wheezing, hypoxia, and tachycardia. He was Forty percent of state cases were work-related, 9% of which diagnosed with chlorine inhalation and ingestion, and was involved loss of 1 or more days from work. A small proportion hospitalized for 4 days. The second case occurred in a boy of cases involved hospitalization (2% of state cases and 4% of aged 5 years in Louisiana who stuck his face in a bucket of NEISS cases). pool shock treatment (65% calcium hypochlorite). Cyanosis Factors most frequently associated with illness or injury and dyspnea were documented, and the boy was admitted to included mixing incompatible products (21% of state cases the critical-care unit, where he was hospitalized for 4 days. and 6% of NEISS cases), spills and splashes of pool chemicals The third case involved a previously healthy woman aged 61 (18% of state cases and 33% of NEISS cases), and dust clouds
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TABLE 2. Number and percentage of acute illnesses and injuries TABLE 2. (Continued) Number and percentage of acute illnesses and associated with pool chemicals, by selected characteristics — six injuries associated with pool chemicals, by selected characteristics Sentinel Event Notification System for Occupational Risk (SENSOR)– — six Sentinel Event Notification System for Occupational Risk Pesticides states and the National Electronic Injury Surveillance (SENSOR)–Pesticides states and the National Electronic Injury System (NEISS), 2002–2008* Surveillance System (NEISS), 2002–2008* SENSOR states NEISS SENSOR states NEISS U.S. U.S. Characteristic No. (%)† No. estimate§ (%)† Characteristic No. (%)† No. estimate§ (%)† Total cases 584 (100) 688 28,071 — Active ingredient†† §§ Year of exposure Sodium hypochlorite 189 (31) — — — 2002 103 (18) 95 3,753 (13) Triazines 133 (22) — — — 2003 49 (8) 116 4,813 (17) Calcium hypochlorite 99 (16) — — — 2004 42 (7) 64 3,111 (11) Chlorine 72 (12) — — — 2005 45 (8) 121 4,015 (14) Other 111 (18) — — — 2006 97 (17) 79 3,507 (12) Illness severity 2007 99 (17) 109 4,508 (16) Fatal — — — — — 2008 149 (26) 104 4,364 (16) High 5 (1) — — — Age group (yrs) Moderate 78 (13) — — — 0–5 43 (7) 109 3,619 (13) Low 499 (85) — — — 6–14 106 (18) 186 5,960 (21) Missing/Unknown 2 (<1) — — — 15–24 121 (21) 89 3,580 (13) Body part/System 25–44 175 (30) 171 8,389 (30) affected †† ¶¶ ≥45 125 (21) 133 6,523 (23) Respiratory 379 (65) 193 6,846 (24) Unknown 14 (2) — — — Eye 194 (33) 271 11,813 (42) Sex Skin 103 (18) 125 5,216 (19) Male 360 (62) 388 15,986 (57) Neurologic 94 (16) 24 732 (3) Female 218 (37) 300 12,086 (43) Gastrointestinal 95 (16) 59 1,686 (6) Unknown 6 (1) — — — Cardiovascular 28 (5) 6 256 (1) Other 18 (3) 6 333 (1) Status Unknown — — 57 2,592 (9) Definite 89 (15) — — — Probable 246 (42) — — — Hospitalization Possible 246 (42) — — — Yes 14 (2) 32 1,062 (4) Suspicious 3 (1) — — — * Case classifications are slightly different between the SENSOR-Pesticides Work-related program and the California Department of Pesticide Regulation (CDPR) Yes 233 (40) — — — Pesticide Illness Surveillance system. CDPR classifies cases as definite, probable, Lost time from work and possible based on the relationship between exposure and health effects: Yes 51 (9) — — — definite = both physical (e.g., disinfectant residue on clothing) and medical evidence document exposure and consequent health effects; probable = Reporting source limited or circumstantial evidence supports a relationship to pesticide Physician report 32 (5) — — — exposure; and possible = evidence neither supports nor contradicts a Poison control center 377 (65) — — — relationship. Additional information available at http://www.cdpr.ca.gov/docs/ Workers’ 165 (28) — — — whs/pisp/brochure.pdf. compensation † Percentages might not sum to 100 because of rounding. State health 4 (1) — — — § Weighted national estimate. department ¶ The injury occurred when a horse ranch maintenance worker applied chlorine Other 6 (1) — — — to a pool for horses. Event location ** Toxicity categories are classified by the Environmental Protection Agency Agriculture¶ 1 (<1) — — — based on established criteria, with I being the most toxic and IV the least. †† Private residence 281 (48) 339 15,699 (56) The total might exceed the number of cases because multiple active Institutions 29 (5) 3 115 (<1) ingredients or body parts/systems might have been involved in a single case. §§ Information was not available to identify active ingredients in 19 cases in the Manufacturing facility 2 (<1) — — — six SENSOR-Pesticides states. Nonmanufacturing 161 (28) 145 4,021 (14) ¶¶ Symptoms were derived from narratives of the illness or injury included in facility the NEISS dataset and were coded using SENSOR criteria. Narratives that Other 68 (12) — — — lacked specific symptoms were coded as “Unknown.” Unknown/Missing 42 (7) 201 8,236 (29) Toxicity** I-Danger 510 (87) — — — II-Warning 5 (1) — — — III-Caution 6 (1) — — — Missing/Unknown 63 (11) — — —
MMWR / October 7, 2011 / Vol. 60 / No. 39 1345 A-9 Morbidity and Mortality Weekly Report Attachment A
TABLE 3. Number and percentage of acute illnesses and injuries associated with pool chemicals, by contributing factor — six Sentinel Event Notification System for Occupational Risk (SENSOR)–Pesticides states and the National Electronic Injury Surveillance System (NEISS), 2002–2008* SENSOR states Total Workers Nonworkers NEISS§ Contributing factor† No.¶ (%) No.¶ (%) No.¶ (%) No.¶ U.S. estimate** (%) One or more contributing factors identified†† 451 — 183 — 267 — 335 14,412 — Mixing incompatible products 94 (21) 21 (11) 73 (27) 21 832 (6) Spill or splash of liquid or dust 80 (18) 61 (33) 19 (7) 90 4,728 (33) Required PPE not worn/PPE inadequate 75 (17) 44 (24) 31 (12) — — — Not properly trained or supervised 68 (15) 19 (10) 49 (18) — — — Application equipment failure 50 (11) 35 (19) 15 (6) 19 301 (2) Dust cloud or fumes generated upon opening container 68 (15) 13 (7) 55 (21) 39 2,164 (15) Stored within reach of child 42 (9) — — 42 (16) 41 1,359 (9) Other improper storage 29 (6) 13 (7) 16 (6) 9 343 (2) Exposure to fumes/dust during application 30 (7) 10 (5) 20 (7) 31 1,636 (11) Illegal pesticide used/Illegal dumping 12 (3) 12 (7) — — — — — Inadequate ventilation 12 (3) 5 (3) 7 (3) 41 946 (7) Decontamination not adequate or timely 8 (2) 7 (4) 1 (<1) 8 329 (2) Early reentry 5 (1) 2 (1) 3 (1) 25 1,369 (10) Persons in treated area 8 (2) 2 (1) 6 (2) 10 479 (3) Excessive application 10 (2) 4 (2) 6 (2) 23 817 (6) Label violation not otherwise specified 8 (2) 3 (2) 5 (2) 1 77 (1) Person poisoned but no label violation identified 8 (2) 6 (3) 2 (1) — — — Abbreviation: PPE = personal protective equipment. * Case classifications are slightly different between the SENSOR-Pesticides program and the California Department of Pesticide Regulation (CDPR) Pesticide Illness Surveillance system. CDPR classifies cases as definite, probable, and possible based on the relationship between exposure and health effects: definite = both physical (e.g., disinfectant residue on clothing) and medical evidence document exposure and consequent health effects; probable = limited or circumstantial evidence supports a relationship to pesticide exposure; and possible = evidence neither supports nor contradicts a relationship. Additional information available at http:// www.cdpr.ca.gov/docs/whs/pisp/brochure.pdf. † For 133 cases (23%) in the six SENSOR-Pesticides states and 353 (51%) cases in NEISS, information was not available to determine contributing factors. § Because there was no product-identifying information available in NEISS, label information about directions for use and required PPE could not be determined. ¶ A case can have multiple contributing factors that resulted in illness or injury; thus, the sum of the categories exceed the total number of cases with sufficient information to determine contributing factors, and the total percentage exceeds 100%. ** Weighted national estimate. †† The denominator for the proportions was the total cases that had sufficient information to determine contributing factors. years in California who mixed two pool chemicals, calcium Reported by hypochlorite and cyanuric acid, in her kitchen sink. The Louise Mehler, MD, PhD, California Dept of Pesticide Regulation; chemicals reacted and created fumes in the poorly ventilated John Beckman, California Dept of Public Health. Roshan kitchen. She reported cough, upper respiratory irritation, Badakhsh, MPH, Louisiana Dept of Health and Hospitals. and dyspnea, and was treated with oxygen. The next day, she Brienne Diebolt-Brown, MA, Texas Dept of State Health Svcs. was wheezing and was diagnosed with pulmonary edema and Abby Schwartz, MPH, Michigan Dept of Community Health. hospitalized for 6 days. The fourth case occurred in a woman Sheila Higgins, MPH, Div of Public Health, North Carolina aged 42 years in Iowa who had asthma. She inhaled dust while Dept of Health and Human Svcs. Rita Gergely, MA, Iowa Dept applying chlorinating granules, resulting in cough, dyspnea, of Public Health. Geoffrey M. Calvert, MD, Div of Surveillance, and lower respiratory pain and irritation. She received a Hazard Evaluations, and Field Studies, National Institute for diagnosis of asthma exacerbation caused by chemical exposure Occupational Safety and Health; Naomi L. Hudson, DrPH, EIS and was admitted to an intensive-care unit, where she was Officer, CDC. Corresponding contributor: Naomi L. Hudson, hospitalized for 4 days. The fifth case occurred in a woman [email protected], 513-841-4424. aged 54 years in Michigan who had allergies. She was exposed to chlorine fumes when an excessive amount of chlorine was Editorial Note added to a pool in which she was swimming. She had cough, Chlorine-based disinfectants are the most commonly used dyspnea, wheezing, and vomiting. She received a diagnosis of disinfectants for treating swimming pool water. A total of 36 chemical pneumonitis and was hospitalized for 7 days. pool chemical–associated events were reported in New York during 1983–2007, of which 31 events were attributed to
1346 MMWR / October 7, 2011 / Vol. 60 / No. 39 A-10 Morbidity and Mortality Weekly Report Attachment A chlorine gas exposure, which most often resulted from mixing available at http://www.cdc.gov/healthywater/swimming/ sodium hypochlorite solutions (e.g., household chlorine pools/preventing-pool-chemical-injuries.html. These bleach) with acid (4). In England and Wales, 13 events recommendations address contributing factors related to involving pool chemicals were reported during June–October application equipment failure, storage within reach of a child 2007, of which 10 events involved sodium hypochlorite and other improper storage, illegal dumping, and inadequate and nine events resulted from equipment failure or mixing PPE used by workers. In addition to the existing CDC incompatible chemicals (5). Several individual cases of illness recommendations, the findings described in this report suggest or injury attributed to pool disinfectants have been reported that pool chemical manufacturers should design containers so and include respiratory illness and eye and skin injury (6,7). that dust clouds or fumes are minimized when containers are The findings in this report are subject to at least five opened and should make the containers child-proof. Label limitations. First, illnesses and injuries related to pool chemicals information on appropriate PPE usage should be easy to likely are underreported. Case identification by states relies on find and understand; the addition of pictograms depicting a passive surveillance system, so cases in persons experiencing appropriate PPE might increase the likelihood of correct use. minor symptoms who do not seek medical treatment or advice Instructions for consumers to point the container away from from poison control centers are not reported. Also, cases their face while opening might also reduce illness and injury reported in NEISS only involve persons who sought treatment from pool chemicals. in a hospital emergency department. Second, cases might have References been excluded because insufficient information was provided to meet the case definition. Third, symptoms for illness or 1. World Health Organization. Guidelines for safe recreational waters. Volume 2: swimming pools and similar recreational-water environments. injury associated with pool chemicals are nonspecific and Geneva, Switzerland: World Health Organization; 2006. Available at not pathognomonic, so false-positives might have occurred. http://www.who.int/water_sanitation_health/bathing/bathing2. Fourth, some cases that were not work-related might have Accessed September 26, 2011. 2. CDC. Healthy swimming/recreational water: recommendations for been missed in Iowa, Louisiana, Michigan, North Carolina, preventing pool chemical-associated injuries. US Department of Health and Texas because CDC’s National Institute for Occupational and Human Services, CDC; 2011. Available at http://www.cdc.gov/ Safety and Health advises these states to prioritize work-related healthywater/swimming/pools/preventing-pool-chemical-injuries.html. cases when staffing limitations preclude follow-up of all cases. Accessed September 26, 2011. 3. Calvert GM, Mehler LN, Alsop J, De Vries A, Besbelli N. Surveillance Finally, the NEISS dataset had limited information, which of pesticide-related illness and injury in humans. In: Krieger R, ed. for some cases precluded the identification of symptoms and Hayes’ handbook of pesticide toxicology. 3rd ed. London, England: contributing factors. Furthermore, no product-identifying Academic Press; 2010:1313–69. 4. CDC. Pool chemical–associated health events in public and residential information was available in NEISS. Thus, whether illnesses settings—United States, 1983–2007. MMWR 2009;58:489–93. and injuries were caused by nondisinfectant pool chemicals 5. Thomas HL, Murray V. Review of acute chemical incidents involving or whether noncompliance with product labels contributed exposure to chlorine associated with swimming pools in England and Wales, June–October 2007. J Public Health (Oxf) 2008;30:391–7. to the reported illnesses and injuries could not be determined. 6. Vohra R, Clark RF. Chlorine-related inhalation injury from a swimming However, most NEISS cases are thought to be disinfectant- pool disinfectant in a 9-year-old girl. Pediatr Emerg Care 2006;22:254–7. related, based on the pool chemical–associated events reported 7. Martinez TT, Long C. Explosion risk from swimming pool chlorinators in New York and England and Wales (4,5). Pool disinfectant and review of chlorine toxicity. J Toxicol Clin Toxicol 1995; 33:349–54. byproducts, such as chloramines, are responsible for many 8. CDC. Ocular and respiratory illness associated with an indoor swimming illnesses and injuries reported (8–10). No cases from the six pool—Nebraska, 2006. MMWR 2007;56:929–32. SENSOR-Pesticides states were attributed to chloramines; 9. Dang B, Chen L, Mueller C, et al. Ocular and respiratory symptoms among lifeguards at a hotel indoor waterpark resort. J Occup Environ however, chloramines might have contributed to some NEISS Med 2010;52:207–13. injuries, but their involvement could not be discerned given 10. Bowen AB, Kile JC, Otto C, et al. Outbreaks of short-incubation ocular the limited product and event information. and respiratory illness following exposure to indoor swimming pools. Current CDC recommendations to reduce illness and Environ Health Perspect 2007;115:267–71. injury from pool chemicals, including disinfectants, are
MMWR / October 7, 2011 / Vol. 60 / No. 39 1347 A-11 Morbidity and Mortality Weekly Report Attachment A
Health Plan Implementation of U.S. Preventive Services Task Force A and B Recommendations — Colorado, 2010
The Patient Protection and Affordable Care Act (PPACA) benefit is moderate or there is moderate certainty that the net is aimed at expanding access to health care and lowering benefit is moderate to substantial (grade B recommendation) cost barriers to seeking and receiving care, particularly high- (3). The survey questions focused only on those USPSTF value preventive care. The legislation requires Medicare and recommendations pertaining to chronic disease prevention, all qualified commercial health plans (except grandfathered screening, and management. The survey inquired about individual and employer-sponsored plans) to cover routine cardiovascular disease and cancer screening, obesity screening preventive services graded A and B by the U.S. Preventive and intervention, and tobacco screening and cessation. Medical Services Task Force (USPSTF) at no cost to the consumer, directors were questioned about benefit availability across each along with recommended immunizations and additional coverage type provided by the health plan (i.e., individual versus preventive care and screenings for women (1). In 2009, group market) and limits on coverage (i.e., age, frequency, Colorado passed a law with similar USPTF A and B service annual or lifetime limits). In addition, directors were questioned coverage requirements (2). To determine how Colorado health regarding how they had communicated these benefit changes plans had interpreted the state and federal law, the Colorado to their consumers and providers. Department of Public Health and Environment (CDPHE) The vast majority of A and B recommendations addressed in interviewed representatives of commercial health plans serving the survey were interpreted consistently across all health plans. Colorado residents. The results of those interviews indicated However, health plans interpreted and designed their coverage that different health plans interpreted certain USPSTF around some A and B recommendations differently. One recommendations differently, including tobacco screening USPSTF A recommendation encourages clinicians to ask all and pharmacotherapy, colorectal cancer screening, and obesity adult patients about tobacco use and provide tobacco cessation screening and counseling. One health plan communicated the interventions for adults who use tobacco products (4). Colorado scope, eligibility criteria, and content of the new preventive health plans reported some restrictions and variability in the services coverage to its members or providers. The differences provided coverage for tobacco screening and pharmacotherapy. in interpretation of the USPSTF recommendations and Three of the eight plans restricted reimbursement for tobacco limited communication to consumers or health-care providers use screening to primary-care providers. One plan restricted the in Colorado might be repeated in other states. To ensure optimal frequency that providers could be reimbursed for screening to consumer and health-care provider utilization of preventive the annual visit plus one other visit per year. Only one heath service benefits, the preventive services supported by USPSTF plan offered all Food and Drug Administration–approved A and B recommendations should be clearly defined in health tobacco cessation medications with no restrictions. The most plan benefit language, with processes put in place for consistent consistent areas of pharmacotherapy benefit limitation were implementation and eligibility criteria communicated to both with varenicline and buproprion SR. Two plans did not cover consumers and providers. The experience in Colorado shows that these medications, and five plans offered the medications with public health organizations can play a key role in successfully restrictions, such as frequency (annual or lifetime limits), step implementing PPACA prevention services provisions. therapy requirements, copays, deductibles, or coinsurance. During June–July 2010, CDPHE staff members used a In addition to the different interpretations regarding tobacco standardized survey protocol to interview seven of the eight cessation and counseling, the benefit design for colorectal cancer local medical directors or quality improvement directors of each screening reflected different interpretations of how coverage of the major commercial health plans in Colorado about their for such benefits should be structured. USPSTF advises, as an coverage of USPSTF recommended services. USPSTF reviews A recommendation, screening for colorectal cancer using fecal the most current evidence of effectiveness of clinical preventive occult blood testing, sigmoidoscopy, or colonoscopy in adults health-care services and grades the strength of the evidence. beginning at age 50 years and continuing until age 75 years USPTF recommends that primary-care practitioners and health (4). Not all health plans consistently interpreted colonoscopies systems offer or provide their clients preventive services when as a preventive benefit rather than a diagnostic service when there is high certainty that the net benefit is substantial (grade performed either as a primary screening or secondary screening A recommendation) or when there is high certainty that the net after an abnormal fecal occult blood test. Four health plans
1348 MMWR / October 7, 2011 / Vol. 60 / No. 39 A-12 Morbidity and Mortality Weekly Report Attachment A
disease) was made. One plan indicated use of an authorized What is already known on this topic? but unlisted CPT code. To request reimbursement, providers The Patient Protection and Affordable Care Act requires would have to call the health plan directly for the CPT code commercial health plans to cover services recommended for routine use (A and B recommendations) by the U.S. Preventive to bill and, when the claim form was submitted, the claim was Services Task Force (USPSTF) at no cost to the consumer. subject to an automatic review by health plan staff, increasing What is added by this report? the likelihood of denial. Interviews conducted by the Colorado Department of Public When asked whether health plans had communicated the Health and Environment with representatives of seven of eight new, no-cost, covered benefits to consumers or health-care health plans operating in the state determined that USPSTF providers, one plan indicated such communication occurred recommendations are not written in health plan language and via e-mail and letters. The rest indicated that they had not certain A and B recommendations are not being uniformly promoted the benefit plan changes to their members. interpreted by health plan administrators. This can create confusion for the consumer and health-care provider and might Reported by result in underuse of the recommended services. Sara Russell Rodriguez, MSN, MPH, Deb Osborne, MPH, What are the implications for public health practice? Prevention Svcs Div; Jillian Jacobellis, PhD, Colorado Dept of Public health organizations can assist health plans in Public Health and Environment. Corresponding contributor: interpreting federal health-care reform regulations and can work with health plans to define minimum baseline standards Jillian Jacobellis, [email protected], 303-692-2504. for all USPSTF recommended services required by the Patient Editorial Note Protection and Affordable Care Act. Health-care reform advances individual and population defined a colonoscopy after an abnormal fecal occult blood prevention goals by requiring coverage of services supported test as diagnostic rather than preventive, making colonoscopy by evidence. Variance in health plan interpretation of the subject to all applicable copays and deductibles. Three of USPSTF recommendations coupled with health-care provider the health plans indicated that the cost to the patient would uncertainty regarding coverage and coding and lack of clarity depend on whether the clinician coded the service as preventive among consumers regarding benefits might affect their use of or diagnostic. One plan indicated that colonoscopies were services and impinge on optimal health outcomes. covered with no cost sharing only so long as consumers used Although USPSTF provides clinical guidance on how to the preferred facility within their plan. implement recommendations within health-care provider Obesity screening and counseling was the last area where practices, it does not define the recommendations in language plans reported the greatest variations in eligibility requirements that can be applied readily to the delivery of health insurance and in how provided services would be covered. USPSTF benefits (4). To ensure optimal consumer and health-care recommends that clinicians screen all adult patients for obesity provider utilization of preventive benefits, implementation and offer intensive counseling and behavioral interventions to of these benefits must be consistent across health plans and promote sustained weight loss for obese adults. In addition, understood by both health-care providers and consumers. The USPSTF recommends that clinicians screen children aged ≥6 A and B recommendations should be translated clearly into years for obesity and offer or refer them to comprehensive, health plan benefit language, and processes should be put in intensive behavioral interventions for weight control (4). Both place for consistent implementation; public health agencies can are B recommendations. All health plans identified the lack assist in this effort. CDPHE has taken the lead in identifying of specific Current Procedural Terminology (CPT) codes for gaps in preventive services and addressing these inconsistencies obesity screening as a barrier. Two health plans indicated no through collaboration with the major commercial and public restrictions on the type of clinician that could be reimbursed health plans in Colorado. for screening and counseling for obesity and also reported no Colorado has formed a prevention council, where health limits on how often clients could be screened or counseled. Two plan representatives can share best practices and come to health plans indicated that the counseling CPT code could be agreement on minimum benefit standards for the A and B used only by a registered dietitian. One health plan responded recommendations. Colorado has had previous success in that the consumer could receive two counseling sessions within working with health plans on tobacco cessation coverage and the year unless a determination of medical necessity such as counseling and was able to gain agreement on minimum an obesity-related comorbidity (e.g., diabetes or cardiovascular benefits. Creating constructive relationships with health plans
MMWR / October 7, 2011 / Vol. 60 / No. 39 1349 A-13 Morbidity and Mortality Weekly Report Attachment A will be critical to successful implementation of federal health- References care reform. Public health agencies also can provide useful data 1. Patient Protection and Affordable Care Act. Available at http://www.gpo. regarding the return on investment from many public health gov/fdsys/pkg/PLAW-111publ148/content-detail.html. Accessed September 30, 2011. initiatives and can connect health plans with population-based 2. Colorado General Assembly. House Bill 09-1204: first regular session, strategies to increase preventive service use. 67th General Assembly (Colo. 2009). Available at http://www.state.co.us/ gov_dir/leg_dir/olls/sl2009a/sl_344.htm. Accessed October 3, 2011. Acknowledgments 3. US Preventive Services Task Force. Methods and processes. Rockville, MD: US Preventive Services Task Force; 2011. Available at http://www. Claire Brockbank, Segue Consulting. Ben Price, Colorado uspreventiveservicestaskforce.org/methods.htm. Accessed September 30, 2011. Association of Health Plans. The following health plans: Aetna, 4. US Preventive Services Task Force. USPSTF A and B recommendations. Anthem, Cigna, Denver Health Medical Plan, Humana, Kaiser Rockville, MD: US Preventive Services Task Force; 2010. Available at Permanente, and Rocky Mountain Health Plan. http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm. Accessed September 30, 2011.
1350 MMWR / October 7, 2011 / Vol. 60 / No. 39 A-14 Morbidity and Mortality Weekly Report Attachment A
Vital Signs: Alcohol-Impaired Driving Among Adults — United States, 2010
On October 4, 2011, this report was posted as an MMWR Early Release on the MMWR website (http://www.cdc.gov/mmwr).
Abstract
Background: Alcohol-impaired driving crashes account for nearly 11,000 crash fatalities, or about one third of all crash fatalities in the United States. Methods: CDC analyzed data from the 2010 Behavioral Risk Factor Surveillance System survey to obtain the prevalence, episodes, and rates of alcohol-impaired driving (defined as driving “when you’ve had perhaps too much to drink” in the past 30 days) among U.S. adults aged ≥18 years who responded to the survey by landline telephone. Results: In 2010, an estimated 4 million U.S. adult respondents reported at least one episode of alcohol-impaired driving, for an estimated total of approximately 112 million alcohol-impaired driving episodes or 479 episodes per 1,000 adult population. From a peak in 2006, such episodes decreased 30% through 2010. Men accounted for 81% of all episodes with young men aged 21–34 years accounting for 32% of all episodes. Additionally, 85% of alcohol-impaired driving episodes were reported by persons who also reported binge drinking, and the 4.5% of the adult population who reported binge drinking at least four times per month accounted for 55% of all alcohol-impaired driving episodes. Episode rates were nearly four times higher among persons who reported not always wearing seatbelts compared with persons who reported always wearing seatbelts. Conclusions: Rates of self-reported alcohol-impaired driving have declined substantially in recent years. However, rates remain disproportionally high among young men, binge drinkers, and those who do not always wear a seat belt. Implications for Public Health: States and communities should continue current evidence-based strategies, such as sobriety checkpoints and enforcement of 0.08 g/dL blood alcohol concentration laws to deter the public from driving while impaired. Additionally, all states should consider requiring ignition interlocks on the vehicles of all persons convicted of alcohol-impaired driving. States without primary seatbelt laws should consider enacting them to reduce fatalities in alcohol-impaired driving crashes.
Introduction (DC). The median Council of American Survey and Research Approximately one third of all motor vehicle crash fatalities Organizations (CASRO) response rate for the 2010 BRFSS involve alcohol-impaired driving. In 2009, a total of 10,839 survey was 55% (3). persons died in crashes in which at least one driver had a blood One question on alcohol-impaired driving is included alcohol concentration (BAC) of ≥0.08 g/dL, the illegal level periodically on the BRFSS survey of each state. Respondents for adult drivers in the United States (1). A 0.08 g/dL BAC who report having had at least one alcoholic beverage in the corresponds to four drinks in 1 hour for a 160-pound (73 kg) man past 30 days are asked, “During the past 30 days, how many and three drinks in 2 hours for a 120-pound (55 kg) woman (2). times have you driven when you’ve had perhaps too much to drink?” Annual estimates of alcohol-impaired driving episodes Methods per respondent were calculated by multiplying the reported For this report, CDC used data from the 2010 Behavioral Risk episodes in the preceding 30 days by 12. These numbers of Factor Surveillance System (BRFSS) survey to provide estimates episodes were summed to obtain state and national estimates of the prevalence, episodes, and rates of alcohol-impaired driving of alcohol-impaired driving episodes. Annual rates of alcohol- among adults aged ≥18 years by selected characteristics, state, impaired driving episodes then were calculated by dividing the and Census region. BRFSS is a state-based, landline, random- annual number of alcohol-impaired driving episodes by the digit–dialed telephone survey that collects information on respective weighted population estimate from BRFSS for 2010. health-related behaviors from a representative sample of civilian, Annual alcohol-impaired driving episodes for 2004, 2006, and noninstitutionalized adults aged ≥18 years. Data from the 2010 2008, which had not been described previously, were produced, BRFSS survey included all 50 states and the District of Columbia and estimates of alcohol-impaired driving episodes for the
MMWR / October 7, 2011 / Vol. 60 / No. 39 1351 A-15 Morbidity and Mortality Weekly Report Attachment A years 1993, 1995, 1997, 1999, and 2002 were obtained from FIGURE 1. Number of self-reported episodes of alcohol-impaired driving among adults — Behavioral Risk Factor Surveillance System, an earlier study (4) and used to report the alcohol-impaired United States, 1993–2010 driving trend over time. 180 Alcohol-impaired driving prevalence in 2010 was stratified 160 by sex and reported by age, race/ethnicity, education level, 140 marital status, household income, number of binge drinking 120 episodes per month, seatbelt use, and Census region. Binge 100 drinking was defined as consuming ≥5 drinks on one occasion 80 for men and consuming ≥4 drinks on one occasion for women. 60 Seat belt use was dichotomized as always wear or less than 40 Episodes (millions) always wear. All data were weighted according to age-, race/ 20 ethnicity-, and sex-specific state population counts and to the 0 respondent’s probability of selection to produce population- 1993 1995 1997 1999 2002 2004 2006 2008 2010 based estimates. T-tests were used to determine differences Year between subgroups, with differences considered statistically significant at p<0.05. only allows police to issue seat belt tickets if drivers were stopped from some other violation) or no seatbelt law (New Hampshire) Results reported always wearing a seatbelt. In 2010, 1.8% of respondents reported at least one episode The Midwest Census region had the highest annual rate of of alcohol-impaired driving in the past 30 days. These four alcohol-impaired driving episodes at 643 per 1,000 population, million adults reported an estimated 112,116,000 episodes which was significantly higher than the rates in all other regions of alcohol-impaired driving in the United States for the year. (Figure 2). Excluding 12 states and DC with small sample sizes This is the lowest percentage of drinking drivers and lowest and potentially unstable rates, four of the seven states with rates number of episodes reported since 1993, the first year for which of alcohol-impaired driving that were significantly higher than the published national BRFSS estimates are available. Since the U.S. rate overall were in the Midwest (Table 2). The Midwest also peak in 2006, alcohol-impaired driving episodes have declined had the highest prevalence of binge drinking at 16.5%, which was 30%, from 161 million to 112 million (Figure 1). Sixty percent significantly higher than the prevalence in the Northeast (15.1%), of those who reported driving while impaired indicated one West (14.3%), or South (12.6%). episode in the past 30 days; however, some respondents reported that they drove while impaired daily. Men accounted Conclusions and Comment for 81% of 2010 alcohol-impaired driving episodes. Young Since 2006, self-reported alcohol-impaired driving episodes men aged 21–34 years, who represented 11% of the U.S. adult have declined 30%, reaching a low of an estimated 112 million population, reported 32% of all 2010 episodes. episodes in 2010. Neither self-reported alcohol consumption Binge drinking was strongly associated with alcohol-impaired nor binge drinking in the past 30 days, as reported by BRFSS, driving; 85% of all alcohol-impaired driving episodes were declined significantly over this period. Reasons for the decline in reported by persons who also reported binge drinking. Frequent alcohol-impaired driving are not well understood, but possible binge drinkers contributed disproportionately to the alcohol- factors include less discretionary driving as a result of the current impaired driving rates; the 4.5% of the adult population who economic downturn (5) and possible changes in drinking location reported binge drinking ≥4 times per month accounted for 55% to places where driving is not required such as at home (6). of all alcohol-impaired driving episodes (Table 1). Alcohol-impaired driving fatalities declined 20% from Persons who reported not always using seatbelts had alcohol- 13,491 to 10,839 from 2006 to 2009, the most recent year for impaired driving rates nearly four times higher than persons which fatality data are available (7). However, the proportion who reported always using seatbelts. Among respondents who of all motor vehicle fatalities that involve at least one alcohol- reported driving while impaired, seatbelt use varied significantly impaired driver has remained stable at about 33%, because by the type of state seatbelt law in effect; 76% of persons living non-alcohol-impaired driving fatalities have declined at the same in states with a primary seatbelt law (which allows police to rate as alcohol-impaired fatalities (7). This study indicated that stop drivers and ticket them solely because occupants are alcohol-impaired driving rates remain disproportionally high unbelted) reported always wearing a seatbelt, whereas 58% of among young men, binge drinkers, persons who do not always their counterparts living in states with a secondary law (which wear a seatbelt, and persons living in the Midwest.
1352 MMWR / October 7, 2011 / Vol. 60 / No. 39 A-16 Morbidity and Mortality Weekly Report Attachment A
TABLE 1. Percentage of adults reporting alcohol-impaired driving episodes in preceding 30 days and rate of episodes, by sex and selected characteristics — Behavioral Risk Factor Surveillance System, United States, 2010 Total Men Women % % % respondents respondents respondents reporting reporting reporting alcohol- Episode alcohol- Episode alcohol- Episode impaired rate per impaired rate per impaired rate per driving in 1,000 driving in 1,000 driving in 1,000 Characteristic past 30 days population (95% CI) past 30 days population (95% CI) past 30 days population (95% CI) Total 1.8 479 (425–533) 2.8 800 (691–908) 0.8 175 (152–197) Age (yrs) 18–20 2.2 626 (314–939) 3.0 919 (408–1,430) —* — — 21–24 3.6 1,037 (578–1,496) 4.5 1,543 (651–2,434) 2.8 517 (360–675) 25–34 2.6 811 (566–1,056) 4.2 1,379 (890–1,868) 1.1 256 (179–334) 35–54 1.9 460 (410–509) 3.0 733 (641–824) 0.9 191 (154–229) ≥55 0.8 231 (202–260) 1.4 425 (366–484) 0.3 69 (47–91) Race/ethnicity White, non-Hispanic 1.9 473 (435–510) 3.0 779 (705–853) 0.9 185 (164–207) Black, non-Hispanic 1.2 331 (242–420) 2.0 570 (383–756) 0.6 140 (83–197) Hispanic 1.7 580 (346–814) 2.7 1,002 (540–1,464) 0.6 165 (76–254) Other, non-Hispanic — — — — — — — — — Education Less than high school — — — — — — — — — High school graduate 1.6 472 (396–548) 2.6 800 (659–941) 0.6 151 (92–209) Some college 1.9 501 (427–575) 3.1 868 (713–1,024) 0.9 196 (157–235) College graduate 1.9 422 (376–467) 2.9 645 (558–731) 1.0 196 (167–225) Marital status Married 1.4 332 (297–368) 2.2 538 (473–603) 0.6 119 (93–146) Unmarried couple 2.6 684 (406–962) 3.8 1,134 (594–1,673) 1.4 217 (139–295) Previously married 1.6 581 (416–746) 3.5 1,358 (871–1,846) 0.7 203 (144–262) Never married 2.9 852 (629–1,075) 3.9 1,257 (862–1,651) 1.7 338 (273–403) Annual household income($) <25,000 1.3 418 (329–507) 2.3 782 (588–976) 0.5 126 (87–165) 25,000–49,999 1.8 543 (410–676) 2.8 918 (651–1,186) 0.8 189 (135–243) 50,000–74,999 1.9 598 (335–862) 2.8 977 (460–1,494) 1.1 209 (156–261) ≥75,000 2.3 527 (469–586) 3.3 776 (675–878) 1.2 232 (190–274) Binge drinking None per month 0.8 168 (144–192) 1.0 216 (176–256) 0.6 119 (94–144) 1 time per month 5.1 1,030 (714–1,346) 6.3 1,390 (880–1,901) 3.2 463 (353–574) 2–3 times per month 9.6 2,041 (1,728–2,355) 11.3 2,372 (1,982–2,763) 6.6 1,408 (884–1,932) ≥4 times per month 15.8 5,814 (4,768–6,860) 17.4 6,746 (5,358–8,134) 11.4 3,103 (2,504–3,703) Seatbelt use Less than always 3.8 1,387 (1,034–1,740) 5.1 1,963 (1,412–2,514) 1.6 384 (269–498) Always 1.5 357 (322–392) 2.3 587 (516–658) 0.7 159 (136–182) Abbreviation: CI = confidence interval. * Sample size <50 or relative standard error >0.30.
Effective strategies to reduce alcohol-impaired driving are premises) legally responsible for harms caused by serving underutilized in the United States (8). Examples include alcohol to minors or visibly intoxicated patrons (10). sobriety checkpoints, enforcement of 0.08 BAC laws Two thirds of all fatalities in alcohol-impaired driving crashes and minimum legal drinking age laws, multicomponent in the United States occur among alcohol-impaired drivers community-based programs, and ignition interlock programs themselves (1). In 2009, seatbelt status was known for 93% for all convicted alcohol-impaired driving offenders (9). Given of fatally injured alcohol-impaired passenger vehicle drivers; of the strong association between binge drinking and alcohol- those drivers, 72% were unbelted. In the states with secondary impaired driving, programs to reduce alcohol impaired driving seatbelt laws, 81% of fatally injured alcohol-impaired passenger should consider adding effective strategies to reduce excessive vehicle drivers were unbelted (Tonja Lindsey, National Highway drinking. These strategies include increasing alcohol taxes, Traffic Safety Administration, personal communication, 2011). regulating alcohol outlet density, and dram shop liability In this report, always using seatbelts was 18 percentage points laws, which hold alcohol retailers (both on premises and off higher among alcohol-impaired drivers in states with primary
MMWR / October 7, 2011 / Vol. 60 / No. 39 1353 A-17 Morbidity and Mortality Weekly Report Attachment A
FIGURE 2. Rates of self-reported alcohol-impaired driving episodes* TABLE 2. Rates of self-reported alcohol-impaired driving episodes among adults — Behavioral Risk Factor Surveillance System, United among adults, by U.S. Census region and state — Behavioral Risk States, 2010 Factor Surveillance System, United States, 2010 Episodes per Region/State 1,000 population (95% CI) National 479 (425–533) Northeast 396 (329–463) Connecticut 567 (427–708) Maine 295* (226–364) Massachusetts 835† (552–1,118) DC New Hampshire 309* (225–393) New Jersey 270* (150–390) New York 237* (169–305) Pennsylvania 419 (311–527) Rhode Island —§ — Vermont 462 (352–572) South 460 (345–574) Alabama 621 (282–960) 586–988 Arkansas — — 441–585 Delaware 843† (533–1,153) 237–440 District of Columbia — — Sample size <50 or relative Florida 446 (364–529) standard error >0.30 Georgia — — Kentucky — — * Per 1,000 population. Louisiana 728† (585–870) Maryland 379 (250–507) Mississippi — — seatbelt laws compared with those from states with secondary North Carolina 309* (196–421) laws. This finding is important because seatbelts are 48%–61% Oklahoma 321* (251–390) effective in preventing driver fatalities in crashes (11). South Carolina 582 (335–829) Tennessee — — The findings in this report confirm those from the most Texas 605 (444–765) recent National Roadside Survey, which in 2007 found that Virginia — — only a small percentage of adult drivers are alcohol-impaired. West Virginia — — West 422 (349–495) That survey showed that 2.2% of drivers on the road on Friday Alaska — — afternoon or Friday or Saturday night had a BAC of ≥0.08 g/dL Arizona 316* (250–383) (12). Additionally, the findings in this report are consistent California 461 (356–565) Colorado 375 (262–488) with alcohol-impaired driving fatality data. Men accounted Hawaii 492 (389–596) for 81% of all alcohol-impaired driving episodes in 2010 and Idaho — — 82% of all alcohol-impaired drivers involved in fatal crashes Montana 603 (468–739) Nevada 443 (319–567) in 2009 (1). Likewise, men aged 21–34 accounted for 32% New Mexico 256* (114–399) of alcohol-impaired driving episodes and 35% of all alcohol- Oregon 470 (240–701) Utah — — impaired drivers involved in fatal crashes (Tonja Lindsey, Washington 441 (383–498) National Highway Traffic Safety Administration, personal Wyoming 586 (401–771) communication, 2011). Midwest 643 (516–766) The findings in this report are subject to at least seven Illinois 513 (356–669) Indiana 400 (280–521) limitations. First, BRFSS surveys only those aged ≥18 years, so Iowa 620 (423–817) alcohol-impaired driving episodes of younger drivers are not Kansas 450 (367–534) Michigan 689† (506–871) included, which underestimates episodes. Second, an increasing Minnesota 474 (332–616) proportion of adults use wireless telephones exclusively; as of Missouri 701† (496–905) the second half of 2010, 28% of adults lived in wireless-only Nebraska 832† (598–1,065) North Dakota 988† (713–1,262) households (13). These adults are younger and report a higher Ohio 585 (467–703) prevalence of binge drinking compared with adults with landline South Dakota 623 (406–839) phones (14). Given the association among binge drinking, Wisconsin — — younger persons, and alcohol-impaired driving, omitting Abbreviation: CI = confidence interval. * Significantly lower than national rate. wireless-only households likely results in underestimating † Significantly higher than national rate. alcohol-impaired driving episodes. Third, a social stigma is § Sample size <50 or relative standard error >0.30.
1354 MMWR / October 7, 2011 / Vol. 60 / No. 39 A-18 Morbidity and Mortality Weekly Report Attachment A attached to alcohol-impaired driving; therefore, self-reports Key Points might be spuriously low. Fourth, self-reported alcohol-impaired driving as defined by the BRFSS survey cannot be equated to a specific BAC; however 85% of alcohol-impaired driving episodes • Alcohol-impaired driving accounts for about one third were reported by persons who also reported binge drinking. of U.S. motor vehicle fatalities, nearly 11,000 deaths Fifth, the alcohol-impaired driving prevalence estimates for 12 per year. states and DC were potentially unstable because of small sample • In 2010, 1.8% of U.S. adults (4 million men and sizes and/or high relative standard errors. Therefore, this report women) reported over 112 million episodes of alcohol included only the stable state estimates. Sixth, this report uses impaired driving. one month self-reported estimates of alcohol-impaired driving to • Men reported 81% of episodes of alcohol-impaired calculate an annual estimate. However, BRFSS is administered driving year-round, eliminating potential bias from seasonal fluctuations • About 5% of adults reported binge drinking at least in alcohol-impaired driving. Additionally, using a 5-week recall four times per month, yet accounted for 55% of all period to estimate injuries has been found to result in a more alcohol-impaired driving episodes. accurate estimate than longer recall periods (15). Finally, the • Although the prevalence of alcohol impaired driving CASRO response rate for the 2010 BRFSS was only 55%, which has declined, it continues to cause thousands of deaths increases the risk for response bias; although the large sample each year. Effective interventions such as sobriety size might decrease this risk. checkpoints and ignition interlocks can reduce alcohol Public support for preventing alcohol-impaired driving impaired driving. is strong. For example, 75% of respondents in a recent Department of Transportation survey endorsed weekly or monthly sobriety checkpoints; only 6% believed that sobriety In recent decades, the United States has lagged behind most checkpoints should not be used at all (16). However, sobriety other high-income countries in reducing the rate of motor checkpoints are not conducted in 12 states and are conducted vehicle crash deaths (18). Because alcohol-impaired driving at intervals varying from weekly to a few times a year in the crashes account for about one third of all crash fatalities, any remaining 38 states and DC (17). An estimated 1,500 to successful strategy for reducing overall crash deaths must 3,000 lives might be saved annually through widespread use of address alcohol-impaired driving. To decrease alcohol-impaired frequent sobriety checkpoints (18), which produce an estimated driving, states and communities should consider expanding $6.80 in total benefits (i.e., reductions in medical costs, work use of sobriety checkpoints, strictly enforcing 0.08 BAC laws loss, and lost quality of life) for each $1.00 spent (19). Public and minimum legal drinking age laws, and requiring ignition support for ignition interlock programs is also strong. These interlocks for all persons convicted of alcohol-impaired driving, programs install ignition interlock devices in the vehicles of whether it is their first offense or a subsequent offense. To persons convicted of alcohol-impaired driving to prevent them reduce the excessive drinking associated with alcohol-impaired from operating the vehicle if they have been drinking. In a driving, states and communities should consider increasing recent survey, 90% of respondents supported requiring ignition alcohol taxes, regulating alcohol outlet density, and enacting interlocks for drivers with multiple alcohol-impaired driving dram shop liability laws. States without primary seatbelt laws convictions, and 69% supported this requirement for drivers should consider enacting them to help reduce fatalities in upon their first conviction (20). Historically, ignition interlock alcohol-impaired driving crashes. programs have targeted persons with multiple alcohol-impaired driving convictions. As of August 2011, 14 states had passed Reported by legislation requiring or strongly encouraging use of ignition Gwen Bergen, PhD, Ruth A. Shults, PhD, Rose Ann Rudd, interlocks for persons upon their first alcohol-impaired driving MSPH, Div of Unintentional Injury Prevention, National Center conviction (21). Ignition interlocks reduce alcohol-impaired for Injury Prevention and Control, CDC. Corresponding driving rearrest rates by a median 67% while installed (9) and contributor: Gwen Bergen, [email protected], 770-488-1394. are estimated to result in a 6.6 benefit:cost ratio (19); however, only about 20% of eligible offenders currently are enrolled in Acknowledgment ignition interlock programs (9,22). Tonja Lindsey, National Highway Traffic Safety Administration, Washington, DC.
MMWR / October 7, 2011 / Vol. 60 / No. 39 1355 A-19 Morbidity and Mortality Weekly Report Attachment A
References 13. Blumberg SJ, Luke JV. Wireless substitution: early release of estimates from the National Health Interview Survey, July–December 2010, 1. National Highway Traffic Safety Administration. Traffic safety facts Hyattsville, MD: National Center for Health Statistics; 2011. Available 2009: alcohol-impaired driving. Washington, DC: US Department of at http:/www.cdc.gov/nchs/data/nhis/earlyrelease/wireless201106.pdf. Transportation, National Highway Traffic Safety Administration; 2010. Accessed August 1, 2011. Available at http://www-nrd.nhtsa.dot.gov/pubs/811385.pdf. Accessed 14. CDC. Vital signs: binge drinking among high school students and July 20, 2011. adults—United States, 2009. MMWR 2010;59:1274–9. 2. Miller WR, Munoz RF. How to control your drinking. Albuquerque, 15. Warner M, Schenker N, Heinen MA, Fingerhut LA. The effects of recall NM: University of Mexico Press; 1982:8–11. on reporting injury and poisoning episodes in the National Health 3. Behavioral Risk Factor Surveillance System. 2010 Summary data quality Interview Survey. Inj Prev 2005;11:282–7. report. May 2011. Available at ftp://ftp.cdc.gov/pub/data/brfss/2010_ 16. Moulton BE, Peterson A, Haddix D, Drew L. National survey of drinking summary_data_quality_report.pdf. Accessed August 2, 2011. and driving attitudes and behaviors: 2008. Volume II: findings report. 4. Quinlan KP, Brewer RD, Siegel P, et al. Alcohol-impaired driving among Washington, DC: National Highway Traffic Safety Administration; U.S. adults, 1993–2002. Am J Prev Med 2005:28;4:346–50. 2010. Available at http://www.nhtsa.gov/staticfiles/nti/pdf/811343.pdf. 5. Sivak M, Schoettle B. Toward understanding the recent large reductions Accessed August 1, 2011. in U.S. road fatalities. Traffic Inj Prev 2010;11:561–6. 17. Governors Highway Safety Administration. Sobriety checkpoint laws, 6. Evans L. Do increases in the cost of fuel reduce traffic fatalities? October August 2011. Available at http://www.statehighwaysafety.org/html/ 2008. Available at http://scienceservingsociety.com/p/X/07.htm. stateinfo/laws/checkpoint_laws.html. Accessed August 29, 2011. Accessed August 12, 2011. 18. Transportation Research Board of the National Academies. Achieving 7. National Highway Traffic Safety Administration. Traffic safety facts traffic safety goals in the United States: lessons from other nations. Special 2009: a compilation of motor vehicle crash data from the Fatality Analysis report 300. Washington, DC: Transportation Research Board of the Reporting System and the General Estimates System. Early edition. National Academies; 2011. Available at http://onlinepubs.trb.org/ Washington, DC: US Department of Transportation, National Highway onlinepubs/sr/sr300.pdf. Accessed August 3, 2011. Traffic Safety Administration; 2010. Available at http://www-nrd.nhtsa. 19. Children’s Safety Network. Injury prevention: what works? A summary dot.gov/pubs/811385.pdf. Accessed July 20, 2011. of cost-outcome analysis for impaired driving (2010 update). Calverton, 8. Williams AF. Alcohol-impaired driving and its consequences in the MD: Children’s Safety Network; 2010. Available at http://www. United States: the past 25 years. J Safety Res 2006;37:123–38. childrenssafetynetwork.org/publications_resources/pdf/data/ 9. The Task Force on Community Preventive Services. Motor vehicle- injurypreventionwhatworks_impaireddriving.pdf. Accessed related injury prevention: reducing alcohol-impaired driving. Atlanta, August 12, 2011. GA: Task Force on Community Preventive Services; 2011. Available at 20. American Automobile Association Foundation for Traffic Safety. 2010 traffic http://www.thecommunityguide.org/mvoi/aid/index.html. Accessed safety culture index. Washington, DC: American Automobile Association August 2, 2011. Foundation for Traffic Safety; 2010. Available at http://www.aaafoundation. 10. The Task Force on Community Preventive Services. Preventing excessive org/pdf/2010tscindexfinalreport.pdf. Accessed August 1, 2011. alcohol consumption. Atlanta, GA: Task Force on Community 21. Insurance Institute for Highway Safety. DUI/DWI laws: August 2011. Preventive Services; 2011. Available at http://www.thecommunityguide. Arlington, VA: Insurance Institute for Highway Safety; 2011. Available org/alcohol/index.html. Accessed August 2, 2011. at http://www.iihs.org/laws/dui.aspx. Accessed August 12, 2011. 11. Kahane C. Fatality reduction by safety belts for front-seat occupants of 22. Marques PR, Voas RB. Key features for ignition interlock programs. cars and light trucks, technical report. Washington, DC: National Washington, DC: National Highway Traffic Safety Administration. Highway Traffic Safety Administration; 2000. Available at http://www- March 2010. Publication No. DOT-HS-811-262. Available at http:// nrd.nhtsa.dot.gov/pubs/809199.pdf. Accessed August 1, 2011. www.nhtsa.gov/staticfiles/nti/impaired_driving/pdf/811262.pdf. 12. Lacey J, Kelley-Baker T, Furr-Holden D, et al. 2007 National roadside Accessed August 12, 2011. survey of alcohol and drug use by drivers: alcohol results. Washington, DC: National Highway Traffic Safety Administration; 2009. Available at http://www.nhtsa.gov/DOT/NHTSA/Traffic%20Injury%20Control/ Articles/Associated%20Files/811248.pdf. Accessed August 2, 2011.
1356 MMWR / October 7, 2011 / Vol. 60 / No. 39 A-20 Morbidity and Mortality Weekly Report Attachment A
Multistate Outbreak of Listeriosis Associated with Jensen Farms Cantaloupe — United States, August–September 2011
On September 30, 2011, this report was posted as an MMWR cantaloupe. Isolates with this pattern were then also considered Early Release on the MMWR website (http://www.cdc.gov/mmwr). to be among the outbreak strains. By September 29, 84 cases Listeriosis is caused by Listeria monocytogenes, a gram-positive with one of the four outbreak PFGE pattern combinations had bacillus common in the environment and acquired by humans been reported from 19 states,† including 83 with information primarily through consumption of contaminated food. Infection on the date of illness onset (Figure). Among the patients, 88% causes a spectrum of illness, ranging from febrile gastroenteritis were aged ≥60 years (range: 35–96 years); 55% were female, to invasive disease, including sepsis and meningoencephalitis. and two were pregnant. Fifteen deaths were reported. Ninety- Invasive listeriosis occurs predominantly in older adults and two percent (57 of 62 with information on food consumption) persons with impaired immune systems. Listeriosis in pregnant reported eating cantaloupe in the month before illness began. women is typically a mild “flu-like” illness, but can result in All four outbreak strains of L. monocytogenes were isolated fetal loss, premature labor, or neonatal infection. Listeriosis is from whole and cut cantaloupe samples from patients’ homes treated with antibiotics. On September 2, 2011, the Colorado or from samples of Jensen Farms cantaloupe collected from Department of Public Health and Environment (CDPHE) grocery stores and the farm. On September 14, the farm issued notified CDC of seven cases of listeriosis reported since a voluntary recall of its cantaloupe. August 28. On average, Colorado reports two cases of listeriosis This outbreak has several unusual features. First, this is the annually in August. By September 6, all seven Colorado patients first listeriosis outbreak associated with melon. Second, four interviewed with the Listeria Initiative* questionnaire reported widely differing PFGE pattern combinations and two serotypes eating cantaloupe in the month before illness began, and three (1/2a and 1/2b) have been associated with the outbreak. Third, reported eating cantaloupe marketed as “Rocky Ford.” this outbreak is unusually large; only two U.S. listeriosis A case was defined as illness with one of the outbreak outbreaks, one associated with frankfurters (108 cases) and strains isolated on or after August 1. Outbreak strains initially one with Mexican-style cheese (142), have had more cases were defined as clinical isolates of L. monocytogenes with 1) (1,2). Additional cases likely will be reported because of the specimen collection dates in August, and 2) a two-enzyme, long incubation period (usually 1–3 weeks, range: 3–70 days) pulsed-field gel electrophoresis (PFGE) pattern combination and the time needed for diagnosis and confirmation. Fourth, that occurred in two or more persons and matched any of the this outbreak has the highest number of deaths of any U.S. three pattern combinations found among Colorado residents foodborne outbreak since a listeriosis outbreak in 1998 (1). in August. Analysis of Listeria Initiative data comparing CDC recommends that persons do not eat cantaloupes from the first 19 outbreak-associated cases in 2011 with 85 cases Jensen Farms. This recommendation is especially important among persons aged ≥60 years with sporadic listeriosis for persons at greater risk for listeriosis, including older adults, identified during August of the years 2004–2010 indicated persons with weakened immune systems, and pregnant women. that cantaloupe consumption was strongly associated with Not all of the recalled cantaloupes are individually labeled with illness caused by the outbreak strains: 19 of 19 (100%) versus stickers to indicate production by Jensen Farms. Consumers 54 of 85 (64%); (odds ratio = 14.9; 95% CI = 2.4–∞). Initial should consult the retailer or discard any cantaloupe of tracebacks of cantaloupe purchased by patients converged on uncertain origin. Recommendations for preventing listeriosis Jensen Farms in Colorado. from other foods are available at http://www.cdc.gov/listeria. After cantaloupe was implicated, PulseNet, the national Reported by molecular subtyping network for foodborne bacterial disease surveillance, detected a multistate cluster with a fourth PFGE Shaun Cosgrove, Alicia Cronquist, Colorado Dept of Public Health pattern combination; a sample of cantaloupe collected from and Environment. Gail Wright, Boulder County Public Health. the implicated farm yielded L. monocytogenes with this pattern, Tista Ghosh, Richard Vogt, Tri-County Health Department. Paul and interviews with patients revealed that most had consumed Teitell, Investigations Br, Food and Drug Administration (FDA)
* The Listeria Initiative is a CDC-led, enhanced surveillance system that has † Colorado (17 cases), Texas (14), New Mexico (13), Oklahoma (11), Nebraska routinely collected data on food consumption from all patients with listeriosis (6), Kansas (5), Missouri (3), Indiana (2), Wisconsin (2), Wyoming (2), Alabama since 2004. Additional information is available at http://www.cdc.gov/ (1), Arkansas (1), California (1), Illinois (1), Maryland (1), Montana (1), North nationalsurveillance/listeria_surveillance.html. Dakota (1), Virginia (1), and West Virginia (1).
MMWR / October 7, 2011 / Vol. 60 / No. 39 1357 A-21 Morbidity and Mortality Weekly Report Attachment A
FIGURE. Number of infections with outbreak-associated strains of Listeria monocytogenes (n = 83), by date of illness onset* — United States, July–September 2011 8
Additional illnesses with onset during this period likely not yet reported 7
6
5
cases 4 No. of of No. 3
2
1
0 28 2 7 12 17 22 27 1 6 11 16 21 26 Jul Aug Sep
Date of illness onset * Among persons for whom information on illness onset was reported to CDC by September 29, 2011.
Denver District. Allen Gelfius, Charlotte Spires, Tracy Duvernoy, Acknowledgments Sheila Merriweather, FDA Coordinated Outbreak Response and State and local health departments in the 19 states with cases. Evaluation (CORE) Network. Molly Freeman, Patricia M. Griffin, Kelly A. Jackson, Lavin A. Joseph, Barbara E. Mahon, References Karen Neil, Benjamin J. Silk, Cheryl Tarr, Robert Tauxe, Eija 1. Mead PS, Dunne EF, Graves L, et al. Nationwide outbreak of listeriosis Trees, Div of Foodborne, Waterborne, and Environmental due to contaminated meat. Epidemiol Infect 2006;134:744–51. 2. Linnan, MJ, Mascola L, Lou XD, et al. Epidemic listeriosis associated Diseases, National Center for Emerging and Zoonotic Infectious with Mexican-style cheese. N Engl J Med 1988;319:823–8. Diseases; Mam Ibraheem, Maho Imanishi, Neena Jain, Jeffrey McCollum, Katherine A. O’Connor, EIS officers, CDC. Corresponding contributor: Kelly A. Jackson, [email protected], 404-639-4603.
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Announcements
National Breast Cancer Awareness Month — World Arthritis Day — October 12, 2011 October 2011 In 2003, the European League Against Rheumatism, in October is National Breast Cancer Awareness Month, a collaboration with worldwide organizations representing time to increase awareness of the most common cancer among persons with arthritis and other rheumatic diseases, created women and the second leading cause of cancer-related deaths World Arthritis Day. This observance aims to increase among women in the United States (1). In 2007, the most awareness of arthritis and to influence policies that can reduce recent year for which data are available, 202,964 women the burden of arthritis. received a diagnosis of breast cancer, and 40,598 women died The theme of this year’s World Arthritis Day (October 12, from the disease (1). 2011) is Move to Improve. Physical activity is a key self- Mammography can detect breast cancer at its earliest, most management strategy for persons with arthritis and is proven treatable stage, up to 3 years before lumps can be detected to reduce pain and improve function and quality of life during breast self-examination or clinical examination. For (1,2). The 2008 Physical Activity Guidelines for Americans (3) 21 years, CDC’s National Breast and Cervical Cancer Early recommends that adults, including those with arthritis, engage Detection Program has helped low-income, uninsured, and in 150 minutes or more per week of at least moderate-intensity underserved women gain access to breast and cervical cancer aerobic physical activity and do muscle-strengthening exercises screening and follow-up services. The program has assisted at least 2 days per week. Adults with arthritis who cannot meet approximately 3.9 million women, provided approximately these recommendations are encouraged to do what physical 9.8 million screening examinations, and diagnosed nearly activity they can, because some is better than none. 53,000 cases of breast cancer. Additional information about Additional information on World Arthritis Day is CDC activities that promote early detection and treatment of available at http://www.worldarthritisday.org. Information breast cancer is available at http://www.cdc.gov/cancer/breast. about how to use physical activity to reduce arthritis pain is available at http://www.fightarthritispain.org. A list of Reference CDC-recommended exercise classes proven safe and effective 1. US Cancer Statistics Working Group. United States Cancer Statistics: for arthritis is available at http://www.cdc.gov/arthritis/ 1999–2007 incidence and mortality web-based report. Atlanta, GA: US Department of Health and Human Services, CDC and National Cancer interventions/physical_activity.htm. Institute; 2010. Available at http://www.cdc.gov/uscs. Accessed September 29, 2011. References 1. Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee report, 2008. Washington, DC: US Department of Health and Human Services; 2008. Available at http:// www.health.gov/paguidelines/report/pdf/committeereport.pdf. Accessed September 26, 2011. 2. Kelley GA, Kelley KS, Hootman JM, Jones DL. Effects of community- deliverable exercise on pain and physical function in adults with arthritis and other rheumatic diseases: a meta-analysis. Arth Care Res 2011;63:79–93. 3. US Department of Health and Human Services. Physical activity guidelines for Americans, 2008. Washington, DC: US Department of Health and Human Services; 2008. Available at http://www.health.gov/ paguidelines. Accessed September 26, 2011.
MMWR / October 7, 2011 / Vol. 60 / No. 39 1359 A-23 Morbidity and Mortality Weekly Report Attachment A
TABLE 2. Reported cases of notifiable diseases, by geographic Errata division and area — United States, 2010 Streptococcus pneumoniae, invasive disease* Vol. 60 / No. 32 Area All ages Age <5 yrs United States 16,569 2,186 In the Notice to Readers, “Final 2010 Reports of Nationally New England 942 107 Connecticut 389 30 Notifiable Infectious Diseases,” multiple errors occurred in Maine 130 10 the introductory text and in Table 2. In the introductory text, Massachusetts 71 47 New Hampshire 145 6 on page 1088, “poliomyelitis, paralytic” was omitted from Rhode Island 123 8 the statement specifying diseases with no cases reported. The Vermont 84 6 Mid. Atlantic 1,701 262 sentence should read, “Because no cases of anthrax; diphtheria; New Jersey 754 64 New York (Upstate) 155 120 eastern equine encephalitis virus disease, non-neuroinvasive; New York City 792 78 poliomyelitis, paralytic; poliovirus infection, nonparalytic; Pennsylvania N N E.N. Central 3,299 375 Powassan virus disease, non-neuroinvasive; rubella, congenital Illinois N 100 Indiana 781 55 syndrome; severe acute respiratory syndrome–associated Michigan 744 82 Ohio 1,227 100 coronavirus disease; smallpox; western equine encephalitis Wisconsin 547 38 virus disease, neuroinvasive and non-neuroinvasive; or yellow W.N. Central 875 157 Iowa N N fever were reported in the United States during 2010, these Kansas N N diseases do not appear in these early release tables.” Minnesota 649 87 Missouri N 40 For Table 2, “Reported cases of notifiable diseases, by Nebraska 139 16 North Dakota 87 3 geographic division and area — United States, 2010,” on page South Dakota N 11 1089, “poliomyelitis, paralytic” was omitted from the footnote S. Atlantic 4,282 577 Delaware 50 2 that lists the diseases with no cases reported. On page 1097, in District of Columbia 78 9 Florida 1,509 204 the section for territories, “Guam’s Q Fever, total, and Guam’s Georgia 1,461 162 Q Fever, acute” are incorrectly reported as not reportable; it Maryland 526 53 North Carolina N N should have been displayed as “—” (no reported cases). On South Carolina 519 56 Virginia N 59 page 1099, under “Streptococcus pneumoniae, invasive disease” West Virginia 139 32 the number of reported cases, by geographic division and area, E.S. Central 1,289 126 Alabama N N should read as follows: Kentucky 205 12 Mississippi N 19 Tennessee 1,084 95 W.S. Central 2,263 331 Arkansas 194 22 Louisiana 157 28 Oklahoma N 55 Texas 1,912 226 Mountain 1,804 234 Arizona 823 105 Colorado 546 63 Idaho N 8 Montana N N Nevada N N New Mexico 174 20 Utah 232 34 Wyoming 29 4 Pacific 114 17 Alaska 110 17 California N N Hawaii 4 — Oregon N N Washington N N Territories American Samoa N — C.N.M.I. — — Guam — — Puerto Rico — — U.S. Virgin Islands — — N: Not reportable. U: Unavailable. —: No reported cases. C.N.M.I.: Commonwealth of Northern Mariana Islands. * The previous categories of invasive pneumococcal disease among children less than 5 years and invasive, drug-resistant Streptococcus pneumoniae were eliminated. All cases of invasive Streptococcus pneumoniae disease, regardless of age or drug resistance are reported under a single disease code.
1360 MMWR / October 7, 2011 / Vol. 60 / No. 39 A-24 Morbidity and Mortality Weekly Report Attachment A
QuickStats
FROM THE NATIONAL CENTER FOR HEALTH STATISTICS
Percentage of Adults Aged ≥18 Years with a Complex Activity Limitation,* by Race/Ethnicity† — National Health Interview Survey, United States, 2003–2009§
25
20
¶ 15
Percentage 10
5
0 Overall White, Black, American Indian/ Asian, Hispanic non-Hispanic non-Hispanic Alaska Native, non-Hispanic non-Hispanic Race/Ethnicity
* A complex activity limitation is a limitation in the tasks and organized activities that, when executed, make up numerous social roles, such as working, attending school, or maintaining a household. Adults are defined as having a complex activity limitation if they have one or more of the following types of limitations: self-care limitation, social limitation, or work limitation. † Race/ethnicity categories are limited to persons who indicated only a single race, except for the overall category, which includes persons of other and multiple races. Persons of Hispanic ethnicity might be of any race or combination of races. Non-Hispanic refers to persons who are not of Hispanic ethnicity, regardless of race. § Estimates are based on household interviews of a sample of the civilian, noninstitutionalized U.S. population and are derived from the National Health Interview Survey sample adult component. ¶ 95% confidence interval.
During 2003–2009, 14.7% of U.S. adults had one or more complex activity limitation. Among racial/ethnic populations, non- Hispanic Asian adults (6.8%) were least likely to have this limitation, and non-Hispanic American Indian/Alaska Native adults (21.3%) were most likely to have a complex activity limitation. Sources: National Health Interview Survey, 2003–2009. Available at http://www/cdc/gov/nchs/nhis.htm. Ward BW, Schiller JS. Prevalence of complex activity limitations among racial/ethnic groups and Hispanic subgroups of adults: United States, 2003–2009. Data brief 2011;73. Available at http://www.cdc.gov/nchs/data/databriefs/db73.pdf.
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Notifiable Diseases and Mortality Tables
TABLE I. Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) — United States, week ending October 1, 2011 (39th week)* 5-year Total cases reported for previous years Current Cum weekly States reporting cases Disease week 2011 average† 2010 2009 2008 2007 2006 during current week (No.) Anthrax — — — — 1 — 1 1 § ¶ Arboviral diseases , : California serogroup virus disease — 80 2 75 55 62 55 67 Eastern equine encephalitis virus disease — 3 0 10 4 4 4 8 Powassan virus disease — 12 — 8 6 2 7 1 St. Louis encephalitis virus disease — 1 0 10 12 13 9 10 Western equine encephalitis virus disease — — — — — — — — Babesiosis 4 421 1 NN NN NN NN NN NY (3), MD (1) Botulism, total — 66 3 112 118 145 144 165 foodborne — 8 0 7 10 17 32 20 infant — 50 2 80 83 109 85 97 other (wound and unspecified) — 8 0 25 25 19 27 48 Brucellosis 3 66 2 115 115 80 131 121 FL (1), OK (1), CA (1) Chancroid 1 11 0 24 28 25 23 33 NJ (1) Cholera — 27 0 13 10 5 7 9 § Cyclosporiasis 1 129 2 179 141 139 93 137 FL (1) Diphtheria — — — — — — — — Haemophilus influenzae,** invasive disease (age <5 yrs): serotype b — 5 1 23 35 30 22 29 nonserotype b 1 84 2 200 236 244 199 175 WV (1) unknown serotype 1 178 2 223 178 163 180 179 FL (1) Hansen disease§ 1 34 2 98 103 80 101 66 NV (1) § Hantavirus pulmonary syndrome — 18 1 20 20 18 32 40 § Hemolytic uremic syndrome, postdiarrheal 7 126 8 266 242 330 292 288 OH (2), OK (2), ID (2), CA (1) § †† Influenza-associated pediatric mortality , — 112 2 61 358 90 77 43 Listeriosis 23 503 20 821 851 759 808 884 ME (1), NY (2), OH (3), IA (1), VA (1), NC (1), FL (3), LA (1), OK (1), TX (3), WY (2), CO (2), CA (2) §§ Measles — 197 1 63 71 140 43 55 Meningococcal disease, invasive¶¶: A, C, Y, and W-135 — 136 5 280 301 330 325 318 serogroup B 1 72 2 135 174 188 167 193 VA (1) other serogroup — 11 0 12 23 38 35 32 unknown serogroup 1 304 8 406 482 616 550 651 FL (1) Novel influenza A virus infections*** — 6 0 4 43,774 2 4 NN Plague — 2 0 2 8 3 7 17 Poliomyelitis, paralytic — — — — 1 — — — § Polio virus Infection, nonparalytic — — — — — — — NN § Psittacosis — 2 0 4 9 8 12 21 § Q fever, total 2 84 2 131 113 120 171 169 acute 1 64 2 106 93 106 — — MD (1) chronic 1 20 0 25 20 14 — — NY (1) Rabies, human — 1 0 2 4 2 1 3 ††† Rubella — 3 0 5 3 16 12 11 Rubella, congenital syndrome — — — — 2 — — 1 SARS-CoV§ — — — — — — — — Smallpox§ — — — — — — — — § Streptococcal toxic-shock syndrome 1 98 2 142 161 157 132 125 NY (1) §§§ Syphilis, congenital (age <1 yr) — 142 8 377 423 431 430 349 Tetanus — 6 1 26 18 19 28 41 § Toxic-shock syndrome (staphylococcal) — 62 1 82 74 71 92 101 Trichinellosis — 8 0 7 13 39 5 15 Tularemia 1 101 2 124 93 123 137 95 NY (1) Typhoid fever 3 274 11 467 397 449 434 353 NY (1), CA (2) § Vancomycin-intermediate Staphylococcus aureus 1 52 1 91 78 63 37 6 NY (1) § Vancomycin-resistant Staphylococcus aureus — — — 2 1 — 2 1 § Vibriosis (noncholera Vibrio species infections) 6 556 16 846 789 588 549 NN MD (1), FL (2), AZ (2), CA (1) Viral hemorrhagic fever¶¶¶ — — — 1 NN NN NN NN Yellow fever — — — — — — — — See Table 1 footnotes on next page.
1362 MMWR / October 7, 2011 / Vol. 60 / No. 39 A-26 Morbidity and Mortality Weekly Report Attachment A
TABLE I. (Continued) Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) — United States, week ending October 1, 2011 (39th week)* —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. * Case counts for reporting years 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. † Calculated by summing the incidence counts for the current week, the 2 weeks preceding the current week, and the 2 weeks following the current week, for a total of 5 preceding years. Additional information is available at http://www.cdc.gov/osels/ph_surveillance/nndss/phs/files/5yearweeklyaverage.pdf. § Not reportable in all states. Data from states where the condition is not reportable are excluded from this table except starting in 2007 for the arboviral diseases, STD data, TB data, and influenza-associated pediatric mortality, and in 2003 for SARS-CoV. Reporting exceptions are available at http://www.cdc.gov/osels/ph_surveillance/nndss/phs/infdis.htm. ¶ Includes both neuroinvasive and nonneuroinvasive. Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ArboNET Surveillance). Data for West Nile virus are available in Table II. ** Data for H. influenzae (all ages, all serotypes) are available in Table II. †† Updated weekly from reports to the Influenza Division, National Center for Immunization and Respiratory Diseases. Since October 3, 2010, 116 influenza-associated pediatric deaths occurring during the 2010-11 influenza season have been reported. §§ No measles cases were reported for the current week. ¶¶ Data for meningococcal disease (all serogroups) are available in Table II. *** CDC discontinued reporting of individual confirmed and probable cases of 2009 pandemic influenza A (H1N1) virus infections on July 24, 2009. During 2009, four cases of human infection with novel influenza A viruses, different from the 2009 pandemic influenza A (H1N1) strain, were reported to CDC. The four cases of novel influenza A virus infection reported to CDC during 2010, and the six cases reported during 2011, were identified as swine influenza A (H3N2) virus and are unrelated to the 2009 pandemic influenza A (H1N1) virus. Total case counts for 2009 were provided by the Influenza Division, National Center for Immunization and Respiratory Diseases (NCIRD). ††† No rubella cases were reported for the current week. §§§ Updated weekly from reports to the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. ¶¶¶ There was one case of viral hemorrhagic fever reported during week 12 of 2010. The one case report was confirmed as lassa fever. See Table II for dengue hemorrhagic fever.
FIGURE I. Selected notifiable disease reports, United States, comparison of provisional 4-week totals October 1, 2011, with historical data
CASES CURRENT DISEASE DECREASE INCREASE 4 WEEKS
Giardiasis 871
Hepatitis A, acute 51
Hepatitis B, acute 151
Hepatitis C, acute 52
Legionellosis 276
Measles 5
Meningococcal disease 12
Mumps 12
Pertussis 481
0.25 0.5 1 2 4 Ratio (Log scale)* Beyond historical limits
* Ratio of current 4-week total to mean of 15 4-week totals (from previous, comparable, and subsequent 4-week periods for the past 5 years). The point where the hatched area begins is based on the mean and two standard deviations of these 4-week totals.
Notifiable Disease Data Team and 122 Cities Mortality Data Team Jennifer Ward Deborah A. Adams Rosaline Dhara Willie J. Anderson Pearl C. Sharp Lenee Blanton Michael S. Wodajo
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TABLE II. Provisional cases of selected notifiable diseases, United States, weeks ending October 1, 2011, and October 2, 2010 (39th week)* Chlamydia trachomatis infection Coccidioidomycosis Cryptosporidiosis Previous 52 weeks Previous 52 weeks Previous 52 weeks Current Cum Cum Current Cum Cum Current Cum Cum Reporting area week Med Max 2011 2010 week Med Max 2011 2010 week Med Max 2011 2010 United States 12,763 26,084 31,142 976,768 968,092 83 352 568 13,516 NN 137 134 334 6,329 7,191 New England 412 862 2,043 32,225 30,984 — 0 1 1 NN 1 5 55 260 422 Connecticut — 213 1,557 7,106 8,111 — 0 0 — NN — 0 49 49 77 Maine† — 59 100 2,337 1,933 — 0 0 — NN — 1 4 37 83 Massachusetts 376 419 860 16,721 15,581 — 0 0 — NN — 2 7 89 137 New Hampshire 3 53 82 2,012 1,783 — 0 1 1 NN — 1 5 49 50 Rhode Island† 33 76 154 3,004 2,620 — 0 0 — NN — 0 1 1 15 Vermont† — 26 84 1,045 956 — 0 0 — NN 1 1 4 35 60 Mid. Atlantic 2,059 3,400 5,069 127,388 126,820 — 0 1 3 NN 11 16 37 694 677 New Jersey 182 542 938 21,470 19,775 — 0 0 — NN — 0 4 21 37 New York (Upstate) 770 715 2,099 26,785 25,243 — 0 0 — NN 10 4 15 175 173 New York City 251 1,129 2,612 40,581 46,487 — 0 0 — NN — 1 6 55 71 Pennsylvania 856 966 1,240 38,552 35,315 — 0 1 3 NN 1 9 26 443 396 E.N. Central 1,013 3,971 7,039 145,603 153,566 — 0 5 37 NN 52 32 134 1,932 2,029 Illinois — 1,066 1,320 35,989 45,301 — 0 0 — NN — 3 24 139 285 Indiana 210 482 3,376 19,913 15,069 — 0 0 — NN — 4 14 180 234 Michigan 460 929 1,412 35,565 37,163 — 0 3 22 NN 2 6 13 246 267 Ohio 189 1,002 1,134 37,306 38,549 — 0 3 15 NN 47 9 95 888 382 Wisconsin 154 458 559 16,830 17,484 — 0 0 — NN 3 8 55 479 861 W.N. Central 355 1,448 1,667 53,974 54,304 — 0 2 6 NN 10 19 82 1,057 1,592 Iowa 15 210 254 7,918 7,925 — 0 0 — NN 1 6 18 288 337 Kansas 30 195 288 7,713 7,339 — 0 0 — NN — 0 8 25 90 Minnesota — 273 368 8,995 11,648 — 0 0 — NN — 0 10 — 349 Missouri 286 544 759 20,941 19,517 — 0 0 — NN 8 4 63 438 478 Nebraska† 24 112 218 4,574 3,707 — 0 2 6 NN 1 4 12 162 221 North Dakota — 43 77 1,490 1,777 — 0 0 — NN — 0 12 28 19 South Dakota — 63 93 2,343 2,391 — 0 0 — NN — 1 13 116 98 S. Atlantic 3,292 5,212 6,685 204,852 195,018 — 0 2 3 NN 16 21 37 889 822 Delaware 91 85 128 3,196 3,294 — 0 0 — NN — 0 1 7 7 District of Columbia — 107 180 4,030 4,065 — 0 0 — NN — 0 1 5 5 Florida 1,006 1,494 1,698 57,276 57,052 — 0 0 — NN 13 8 17 352 307 Georgia 793 979 2,384 38,536 33,204 — 0 0 — NN 1 5 11 217 209 Maryland† 633 464 1,125 17,744 18,171 — 0 2 3 NN 2 1 6 52 31 North Carolina — 852 1,688 35,909 33,036 — 0 0 — NN — 0 13 36 73 South Carolina† — 515 946 20,533 19,699 — 0 0 — NN — 2 8 106 91 Virginia† 769 648 965 24,578 23,647 — 0 0 — NN — 2 8 98 83 West Virginia — 78 121 3,050 2,850 — 0 0 — NN — 0 5 16 16 E.S. Central 1,808 1,804 3,314 71,773 69,241 — 0 0 — NN 19 6 17 257 261 Alabama† 594 524 1,567 21,504 20,134 — 0 0 — NN 2 3 13 107 131 Kentucky 390 268 2,352 11,726 11,527 — 0 0 — NN 17 1 4 45 65 Mississippi 498 398 696 15,771 16,381 — 0 0 — NN — 1 3 32 17 Tennessee† 326 593 795 22,772 21,199 — 0 0 — NN — 1 6 73 48 W.S. Central 2,169 3,387 4,338 131,874 132,671 — 0 1 5 NN 9 7 62 362 383 Arkansas† 287 309 440 12,257 11,814 — 0 0 — NN — 0 3 16 27 Louisiana — 477 1,052 16,372 19,980 — 0 1 5 NN — 0 9 37 61 Oklahoma — 222 850 7,557 10,671 — 0 0 — NN 1 2 34 66 69 Texas† 1,882 2,415 3,107 95,688 90,206 — 0 0 — NN 8 4 34 243 226 Mountain 877 1,650 2,155 63,487 62,741 71 275 457 10,756 NN 11 11 30 473 485 Arizona — 507 698 17,840 20,510 69 271 455 10,630 NN 1 1 4 35 30 Colorado 569 416 848 18,239 14,647 — 0 0 — NN 4 3 12 132 110 Idaho† — 78 235 2,895 3,017 — 0 0 — NN 4 2 9 90 81 Montana† 50 61 89 2,482 2,308 — 0 2 3 NN 1 1 6 59 39 Nevada† 211 200 380 8,127 7,650 2 1 5 72 NN — 0 2 7 36 New Mexico† 47 196 1,183 7,810 8,071 — 0 4 38 NN 1 2 7 97 108 Utah — 126 175 4,662 4,980 — 0 2 10 NN — 1 5 33 60 Wyoming† — 38 90 1,432 1,558 — 0 2 3 NN — 0 5 20 21 Pacific 778 3,916 6,559 145,592 142,747 12 62 143 2,705 NN 8 11 29 405 520 Alaska — 108 157 4,173 4,641 — 0 0 — NN — 0 3 10 4 California 778 2,949 5,763 113,488 109,187 12 62 143 2,698 NN 8 7 19 245 274 Hawaii — 108 135 3,677 4,608 — 0 0 — NN — 0 0 — 1 Oregon — 270 524 10,048 8,409 — 0 1 7 NN — 2 11 93 172 Washington — 416 522 14,206 15,902 — 0 0 — NN — 1 9 57 69 Territories American Samoa — 0 0 — — — 0 0 — NN N 0 0 N N C.N.M.I. — — — — — — — — — NN — — — — — Guam — 6 81 189 691 — 0 0 — NN — 0 0 — — Puerto Rico 180 102 349 4,063 4,659 — 0 0 — NN N 0 0 N N U.S. Virgin Islands — 15 27 539 444 — 0 0 — NN — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. † Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
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TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending October 1, 2011, and October 2, 2010 (39th week)* Dengue Virus Infection† Dengue Fever§ Dengue Hemorrhagic Fever¶ Previous 52 weeks Previous 52 weeks Current Cum Cum Current Cum Cum Reporting area week Med Max 2011 2010 week Med Max 2011 2010 United States — 3 20 104 589 — 0 1 1 9 New England — 0 3 1 6 — 0 0 — — Connecticut — 0 0 — — — 0 0 — — Maine** — 0 2 — 3 — 0 0 — — Massachusetts — 0 0 — — — 0 0 — — New Hampshire — 0 0 — — — 0 0 — — Rhode Island** — 0 0 — 1 — 0 0 — — Vermont** — 0 1 1 2 — 0 0 — — Mid. Atlantic — 1 4 24 200 — 0 0 — 5 New Jersey — 0 3 — 25 — 0 0 — — New York (Upstate) — 0 1 — 29 — 0 0 — 2 New York City — 0 2 10 128 — 0 0 — 3 Pennsylvania — 0 2 14 18 — 0 0 — — E.N. Central — 0 4 7 57 — 0 0 — 1 Illinois — 0 2 1 16 — 0 0 — — Indiana — 0 1 1 12 — 0 0 — — Michigan — 0 1 2 9 — 0 0 — — Ohio — 0 1 1 14 — 0 0 — — Wisconsin — 0 2 2 6 — 0 0 — 1 W.N. Central — 0 6 4 24 — 0 1 — — Iowa — 0 1 3 2 — 0 0 — — Kansas — 0 1 1 4 — 0 0 — — Minnesota — 0 1 — 13 — 0 0 — — Missouri — 0 1 — 4 — 0 0 — — Nebraska** — 0 6 — — — 0 0 — — North Dakota — 0 0 — 1 — 0 0 — — South Dakota — 0 0 — — — 0 1 — — S. Atlantic — 1 6 43 209 — 0 1 1 2 Delaware — 0 0 — — — 0 0 — — District of Columbia — 0 0 — — — 0 0 — — Florida — 1 6 32 163 — 0 0 — 2 Georgia — 0 1 3 11 — 0 0 — — Maryland** — 0 0 — — — 0 0 — — North Carolina — 0 1 1 6 — 0 0 — — South Carolina** — 0 0 — 13 — 0 0 — — Virginia** — 0 1 7 14 — 0 1 1 — West Virginia — 0 0 — 2 — 0 0 — — E.S. Central — 0 1 1 5 — 0 0 — — Alabama** — 0 1 — 2 — 0 0 — — Kentucky — 0 0 — 2 — 0 0 — — Mississippi — 0 0 — — — 0 0 — — Tennessee** — 0 1 1 1 — 0 0 — — W.S. Central — 0 2 6 25 — 0 0 — 1 Arkansas** — 0 0 — — — 0 0 — 1 Louisiana — 0 1 3 4 — 0 0 — — Oklahoma — 0 1 — 4 — 0 0 — — Texas** — 0 1 3 17 — 0 0 — — Mountain — 0 2 3 17 — 0 0 — — Arizona — 0 2 2 7 — 0 0 — — Colorado — 0 0 — — — 0 0 — — Idaho** — 0 1 — 2 — 0 0 — — Montana** — 0 1 — 3 — 0 0 — — Nevada** — 0 0 — 4 — 0 0 — — New Mexico** — 0 0 — 1 — 0 0 — — Utah — 0 1 1 — — 0 0 — — Wyoming** — 0 0 — — — 0 0 — — Pacific — 0 4 15 46 — 0 0 — — Alaska — 0 0 — 1 — 0 0 — — California — 0 2 5 32 — 0 0 — — Hawaii — 0 4 5 — — 0 0 — — Oregon — 0 0 — — — 0 0 — — Washington — 0 1 5 13 — 0 0 — — Territories American Samoa — 0 0 — — — 0 0 — — C.N.M.I. — — — — — — — — — — Guam — 0 0 — — — 0 0 — — Puerto Rico — 29 291 794 9,200 — 0 10 10 217 U.S. Virgin Islands — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. † Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ArboNET Surveillance). § Dengue Fever includes cases that meet criteria for Dengue Fever with hemorrhage, other clinical and unknown case classifications. ¶ DHF includes cases that meet criteria for dengue shock syndrome (DSS), a more severe form of DHF. ** Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
MMWR / October 7, 2011 / Vol. 60 / No. 39 1365 A-29 Morbidity and Mortality Weekly Report Attachment A
TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending October 1, 2011, and October 2, 2010 (39th week)* Ehrlichiosis/Anaplasmosis† Ehrlichia chaffeensis Anaplasma phagocytophilum Undetermined Previous 52 weeks Previous 52 weeks Previous 52 weeks Current Cum Cum Current Cum Cum Current Cum Cum Reporting area week Med Max 2011 2010 week Med Max 2011 2010 week Med Max 2011 2010 United States 3 7 109 583 566 11 16 44 456 1,464 — 2 13 86 76 New England — 0 2 4 4 — 2 15 109 81 — 0 1 1 2 Connecticut — 0 0 — — — 0 5 — 32 — 0 0 — — Maine§ — 0 1 1 2 — 0 2 13 14 — 0 0 — — Massachusetts — 0 0 — — — 0 10 49 — — 0 0 — — New Hampshire — 0 1 2 2 — 0 4 14 13 — 0 1 1 2 Rhode Island§ — 0 1 1 — — 0 10 30 21 — 0 0 — — Vermont§ — 0 0 — — — 0 1 3 1 — 0 0 — — Mid. Atlantic 1 1 7 53 78 10 4 27 238 217 — 0 2 11 9 New Jersey — 0 1 — 48 — 0 3 — 59 — 0 0 — 1 New York (Upstate) 1 0 7 46 24 9 3 25 207 146 — 0 2 11 6 New York City — 0 1 7 5 — 0 5 28 11 — 0 0 — — Pennsylvania — 0 1 — 1 1 0 1 3 1 — 0 1 — 2 E.N. Central — 0 3 21 41 — 0 9 14 450 — 1 4 36 40 Illinois — 0 2 11 15 — 0 2 6 6 — 0 1 2 3 Indiana — 0 0 — — — 0 0 — — — 0 3 28 14 Michigan — 0 2 4 2 — 0 1 — 3 — 0 2 4 — Ohio — 0 1 6 6 — 0 1 5 2 — 0 1 1 — Wisconsin — 0 1 — 18 — 0 9 3 439 — 0 1 1 23 W.N. Central — 1 18 145 115 — 0 20 31 642 — 0 11 15 9 Iowa N 0 0 N N N 0 0 N N N 0 0 N N Kansas — 0 1 2 6 — 0 1 2 1 — 0 0 — — Minnesota — 0 12 — — — 0 20 1 631 — 0 11 — — Missouri — 1 18 141 107 — 0 7 26 10 — 0 7 14 9 Nebraska§ — 0 1 1 2 — 0 0 — — — 0 1 1 — North Dakota N 0 0 N N N 0 0 N N N 0 0 N N South Dakota — 0 1 1 — — 0 1 2 — — 0 0 — — S. Atlantic — 3 33 201 220 — 1 8 47 54 — 0 1 9 5 Delaware — 0 2 15 17 — 0 1 1 4 — 0 0 — — District of Columbia N 0 0 N N N 0 0 N N N 0 0 N N Florida — 0 3 13 8 — 0 3 8 3 — 0 0 — — Georgia — 0 3 16 19 — 0 2 7 1 — 0 1 1 1 Maryland§ — 0 3 23 19 — 0 2 4 13 — 0 0 — 2 North Carolina — 0 17 55 82 — 0 6 17 21 — 0 0 — — South Carolina§ — 0 1 1 4 — 0 0 — 1 — 0 0 — — Virginia§ — 1 14 78 69 — 0 3 10 11 — 0 1 7 2 West Virginia — 0 1 — 2 — 0 0 — — — 0 1 1 — E.S. Central 1 0 8 64 85 1 0 2 12 18 — 0 3 10 8 Alabama§ — 0 2 3 10 — 0 1 3 7 N 0 0 N N Kentucky — 0 3 10 16 — 0 0 — — — 0 0 — 1 Mississippi — 0 1 3 3 — 0 0 — 2 — 0 0 — 1 Tennessee§ 1 0 6 48 56 1 0 1 9 9 — 0 3 10 6 W.S. Central 1 0 87 95 22 — 0 9 3 2 — 0 0 — 1 Arkansas§ — 0 12 38 4 — 0 2 2 — — 0 0 — — Louisiana — 0 0 — 1 — 0 0 — — — 0 0 — — Oklahoma 1 0 82 56 14 — 0 7 1 2 — 0 0 — — Texas§ — 0 1 1 3 — 0 1 — — — 0 0 — 1 Mountain — 0 0 — — — 0 0 — — — 0 1 3 — Arizona — 0 0 — — — 0 0 — — — 0 1 3 — Colorado N 0 0 N N N 0 0 N N N 0 0 N N Idaho§ N 0 0 N N N 0 0 N N N 0 0 N N Montana§ N 0 0 N N N 0 0 N N N 0 0 N N Nevada§ N 0 0 N N N 0 0 N N N 0 0 N N New Mexico§ N 0 0 N N N 0 0 N N N 0 0 N N Utah — 0 0 — — — 0 0 — — — 0 0 — — Wyoming§ — 0 0 — — — 0 0 — — — 0 0 — — Pacific — 0 1 — 1 — 0 1 2 — — 0 1 1 2 Alaska N 0 0 N N N 0 0 N N N 0 0 N N California — 0 1 — 1 — 0 0 — — — 0 1 1 2 Hawaii N 0 0 N N N 0 0 N N N 0 0 N N Oregon — 0 0 — — — 0 1 2 — — 0 0 — — Washington — 0 0 — — — 0 0 — — — 0 0 — — Territories American Samoa N 0 0 N N N 0 0 N N N 0 0 N N C.N.M.I. — — — — — — — — — — — — — — — Guam N 0 0 N N N 0 0 N N N 0 0 N N Puerto Rico N 0 0 N N N 0 0 N N N 0 0 N N U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. † Cumulative total E. ewingii cases reported for year 2010 = 10, and 13 cases reported for 2011. § Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
1366 MMWR / October 7, 2011 / Vol. 60 / No. 39 A-30 Morbidity and Mortality Weekly Report Attachment A
TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending October 1, 2011, and October 2, 2010 (39th week)* Haemophilus influenzae, invasive† Giardiasis Gonorrhea All ages, all serotypes
Current Previous 52 weeks Cum Cum Current Previous 52 weeks Cum Cum Current Previous 52 weeks Cum Cum Reporting area week Med Max 2011 2010 week Med Max 2011 2010 week Med Max 2011 2010 United States 199 294 456 10,781 14,955 3,130 5,902 7,484 221,911 228,434 20 64 141 2,356 2,284 New England 17 23 42 888 1,281 56 100 206 3,872 4,199 — 4 12 141 134 Connecticut — 4 9 131 234 — 42 150 1,592 1,896 — 1 6 37 25 Maine§ 10 3 10 135 158 — 3 17 170 133 — 0 2 17 10 Massachusetts — 11 21 343 550 47 48 80 1,719 1,802 — 2 6 62 71 New Hampshire — 2 6 85 135 3 2 7 102 111 — 0 2 11 10 Rhode Island§ — 1 10 56 53 6 7 16 252 209 — 0 2 9 11 Vermont§ 7 3 11 138 151 — 0 8 37 48 — 0 3 5 7 Mid. Atlantic 52 58 103 2,165 2,507 497 763 1,121 29,071 26,504 4 13 32 533 426 New Jersey — 5 20 134 368 52 137 225 5,653 4,256 — 2 7 79 80 New York (Upstate) 33 22 72 820 849 145 114 271 4,299 4,137 1 3 18 141 110 New York City 2 16 29 630 707 53 246 497 9,037 8,946 — 3 6 123 70 Pennsylvania 17 16 26 581 583 247 263 363 10,082 9,165 3 4 11 190 166 E.N. Central 40 46 78 1,742 2,550 260 1,016 2,091 38,027 42,189 3 11 22 414 371 Illinois — 9 16 297 570 — 262 369 9,045 11,627 — 3 10 123 129 Indiana — 6 14 189 317 39 114 1,018 4,803 4,245 — 2 7 75 75 Michigan 5 10 25 349 542 115 236 491 9,039 10,221 2 1 4 49 25 Ohio 31 17 29 624 628 60 315 394 11,778 12,400 1 2 7 114 92 Wisconsin 4 8 17 283 493 46 93 127 3,362 3,696 — 1 5 53 50 W.N. Central 15 24 54 846 1,644 121 300 363 11,290 10,988 — 3 10 115 167 Iowa 3 5 15 212 227 4 37 53 1,418 1,314 — 0 0 — 1 Kansas 1 2 7 71 176 9 39 57 1,522 1,573 — 0 2 16 16 Minnesota — 0 26 — 653 — 36 53 1,233 1,639 — 0 5 — 59 Missouri 5 8 23 322 317 98 150 184 5,697 5,145 — 1 5 62 65 Nebraska§ 6 4 11 150 172 9 24 49 905 841 — 1 3 25 16 North Dakota — 0 12 34 18 1 4 8 141 154 — 0 6 11 10 South Dakota — 1 6 57 81 — 11 20 374 322 — 0 1 1 — S. Atlantic 24 54 100 2,009 2,999 833 1,456 1,862 55,030 57,900 8 15 31 567 593 Delaware 1 0 2 24 26 10 16 31 607 750 — 0 2 3 5 District of Columbia — 1 3 29 45 — 39 69 1,460 1,587 — 0 1 — 3 Florida 20 24 56 904 1,617 282 377 465 14,757 15,412 3 5 12 184 139 Georgia — 13 51 555 587 242 313 874 11,653 11,502 — 3 7 105 128 Maryland§ 3 4 13 202 214 157 117 246 4,268 5,265 1 2 5 68 52 North Carolina N 0 0 N N — 284 535 11,608 11,070 — 1 7 56 107 South Carolina§ — 2 7 83 116 — 145 257 5,845 6,081 — 1 5 59 70 Virginia§ — 7 32 190 364 142 110 185 4,239 5,842 1 1 8 75 69 West Virginia — 0 8 22 30 — 16 29 593 391 3 0 9 17 20 E.S. Central 3 4 11 132 162 512 495 1,007 19,638 18,764 1 3 11 148 136 Alabama§ 3 4 11 132 162 187 159 409 6,585 5,843 — 1 4 44 22 Kentucky N 0 0 N N 118 69 712 3,219 2,996 — 0 4 21 27 Mississippi N 0 0 N N 137 118 197 4,309 4,613 — 0 3 12 10 Tennessee§ N 0 0 N N 70 142 223 5,525 5,312 1 2 5 71 77 W.S. Central 6 5 15 190 312 571 918 1,319 34,122 36,572 2 2 26 104 108 Arkansas§ 2 2 9 90 95 100 90 138 3,669 3,582 1 0 3 27 15 Louisiana 4 3 10 100 155 — 133 372 4,677 6,118 — 1 4 37 24 Oklahoma — 0 0 — 62 — 59 254 2,169 3,193 1 1 19 39 61 Texas§ N 0 0 N N 471 599 867 23,607 23,679 — 0 4 1 8 Mountain 17 26 51 961 1,365 89 191 253 7,535 7,215 1 5 12 201 240 Arizona — 3 8 97 126 — 69 110 2,733 2,395 — 2 6 75 88 Colorado 11 12 25 466 543 45 44 89 1,690 2,085 1 1 5 48 67 Idaho§ 1 3 9 108 164 — 2 14 90 83 — 0 2 15 13 Montana§ 3 2 5 60 81 1 1 4 60 86 — 0 1 2 2 Nevada§ 2 1 6 44 80 39 37 103 1,551 1,390 — 0 2 14 6 New Mexico§ — 2 6 66 83 4 28 98 1,207 887 — 1 4 32 32 Utah — 3 9 101 245 — 4 10 174 261 — 0 3 14 26 Wyoming§ — 0 5 19 43 — 1 3 30 28 — 0 1 1 6 Pacific 25 49 128 1,848 2,135 191 611 791 23,326 24,103 1 3 10 133 109 Alaska — 2 7 70 80 — 20 34 731 1,004 — 0 3 19 20 California 20 33 67 1,252 1,296 191 504 695 19,394 19,676 1 0 6 34 16 Hawaii — 0 4 24 47 — 13 26 474 554 — 0 3 19 18 Oregon 5 7 20 250 388 — 25 40 978 776 — 1 6 58 50 Washington — 8 57 252 324 — 49 86 1,749 2,093 — 0 2 3 5 Territories American Samoa — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 0 — 3 — 0 10 6 72 — 0 0 — — Puerto Rico 1 1 7 33 69 7 6 14 244 226 — 0 0 — 1 U.S. Virgin Islands — 0 0 — — — 2 7 83 108 — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. † Data for H. influenzae (age <5 yrs for serotype b, nonserotype b, and unknown serotype) are available in Table I. § Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
MMWR / October 7, 2011 / Vol. 60 / No. 39 1367 A-31 Morbidity and Mortality Weekly Report Attachment A
TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending October 1, 2011, and October 2, 2010 (39th week)* Hepatitis (viral, acute), by type A B C Previous 52 weeks Previous 52 weeks Previous 52 weeks Current Cum Cum Current Cum Cum Current Cum Cum Reporting area week Med Max 2011 2010 week Med Max 2011 2010 week Med Max 2011 2010 United States 11 22 74 831 1,213 24 48 167 1,776 2,460 15 18 39 731 627 New England 1 1 4 39 82 — 1 8 47 44 — 1 4 40 45 Connecticut — 0 3 9 22 — 0 4 10 18 — 0 3 25 30 Maine† 1 0 2 6 7 — 0 2 7 11 — 0 2 6 2 Massachusetts — 0 2 16 43 — 0 6 29 8 — 0 2 5 12 New Hampshire — 0 1 — 1 — 0 1 1 5 N 0 0 N N Rhode Island† — 0 1 3 9 U 0 0 U U U 0 0 U U Vermont† — 0 2 5 — — 0 0 — 2 — 0 1 4 1 Mid. Atlantic 2 4 12 152 204 2 5 12 196 227 — 1 6 63 80 New Jersey — 1 4 21 59 — 1 4 32 62 — 0 4 1 18 New York (Upstate) 1 1 4 38 44 1 1 9 37 36 — 0 4 36 39 New York City — 1 6 51 58 — 1 5 59 69 — 0 2 2 3 Pennsylvania 1 1 3 42 43 1 2 4 68 60 — 0 4 24 20 E.N. Central 1 4 8 145 159 2 5 38 248 386 2 3 12 137 72 Illinois — 1 4 38 42 — 1 6 50 99 — 0 2 6 — Indiana — 0 3 12 11 — 1 3 37 59 — 1 5 48 24 Michigan — 1 6 58 54 — 1 6 63 102 1 2 7 77 33 Ohio 1 1 3 32 37 2 1 30 78 84 1 0 1 5 8 Wisconsin — 0 2 5 15 — 0 3 20 42 — 0 1 1 7 W.N. Central 1 1 25 33 63 — 2 16 99 89 — 0 6 7 13 Iowa — 0 1 4 9 — 0 1 7 13 — 0 0 — — Kansas — 0 2 3 10 — 0 2 9 6 — 0 1 3 1 Minnesota — 0 22 9 13 — 0 15 9 6 — 0 6 2 6 Missouri — 0 1 10 16 — 2 5 62 53 — 0 1 — 4 Nebraska† 1 0 1 5 14 — 0 3 11 10 — 0 1 2 2 North Dakota — 0 3 — — — 0 0 — — — 0 0 — — South Dakota — 0 2 2 1 — 0 1 1 1 — 0 0 — — S. Atlantic 2 5 13 171 267 10 12 54 493 669 7 4 11 181 142 Delaware — 0 1 2 6 — 0 1 1 22 U 0 0 U U District of Columbia — 0 0 — 1 — 0 0 — 3 — 0 0 — 2 Florida 2 1 6 60 106 6 4 11 157 221 1 1 4 46 43 Georgia — 1 4 33 33 1 2 8 71 135 — 1 3 28 21 Maryland† — 0 4 21 18 — 1 4 41 48 — 0 2 27 19 North Carolina — 0 3 20 41 1 2 12 85 80 4 1 7 44 32 South Carolina† — 0 2 9 22 1 1 4 26 46 — 0 1 1 1 Virginia† — 0 3 18 38 — 1 7 48 67 — 0 2 14 10 West Virginia — 0 5 8 2 1 0 43 64 47 2 0 6 21 14 E.S. Central 1 0 6 37 33 2 9 14 319 272 5 3 7 132 119 Alabama† — 0 2 4 6 1 2 5 82 53 1 0 2 11 5 Kentucky 1 0 6 8 13 — 2 6 79 96 2 1 6 56 82 Mississippi — 0 1 7 2 — 1 3 34 26 U 0 0 U U Tennessee† — 0 5 18 12 1 3 7 124 97 2 1 5 65 32 W.S. Central 3 2 15 90 100 7 7 67 224 433 — 2 11 67 53 Arkansas† — 0 1 — 2 — 1 4 38 48 — 0 0 — 1 Louisiana — 0 1 2 8 — 1 4 23 44 — 0 2 5 2 Oklahoma — 0 4 3 1 5 1 16 57 76 — 1 10 34 19 Texas† 3 2 11 85 89 2 3 45 106 265 — 0 3 28 31 Mountain — 1 5 52 122 — 1 5 56 111 1 1 4 44 51 Arizona — 0 2 14 52 — 0 3 13 19 U 0 0 U U Colorado — 0 2 17 33 — 0 3 15 39 — 0 3 14 12 Idaho† — 0 1 6 6 — 0 1 2 6 1 0 2 8 9 Montana† — 0 1 2 4 — 0 0 — — — 0 1 3 2 Nevada† — 0 3 5 12 — 0 3 16 34 — 0 1 6 5 New Mexico† — 0 1 5 3 — 0 2 5 5 — 0 1 10 13 Utah — 0 2 1 9 — 0 1 5 7 — 0 1 1 10 Wyoming† — 0 1 2 3 — 0 1 — 1 — 0 1 2 — Pacific — 3 15 112 183 1 3 25 94 229 — 1 12 60 52 Alaska — 0 1 2 1 — 0 1 4 3 U 0 0 U U California — 2 15 81 145 1 1 22 40 151 — 1 4 25 20 Hawaii — 0 2 7 7 — 0 1 5 5 U 0 0 U U Oregon — 0 2 5 15 — 0 4 27 35 — 0 3 11 14 Washington — 0 4 17 15 — 0 4 18 35 — 0 5 24 18 Territories American Samoa — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 5 8 4 — 0 8 28 64 — 0 4 10 52 Puerto Rico — 0 2 6 12 — 0 3 7 19 N 0 0 N N U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. † Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
1368 MMWR / October 7, 2011 / Vol. 60 / No. 39 A-32 Morbidity and Mortality Weekly Report Attachment A
TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending October 1, 2011, and October 2, 2010 (39th week)* Legionellosis Lyme disease Malaria Previous 52 weeks Previous 52 weeks Previous 52 weeks Current Cum Cum Current Cum Cum Current Cum Cum Reporting area week Med Max 2011 2010 week Med Max 2011 2010 week Med Max 2011 2010 United States 68 53 128 2,356 2,443 324 361 1,667 22,007 25,527 16 27 114 973 1,300 New England — 3 15 126 196 2 72 295 3,634 7,730 1 1 20 53 83 Connecticut — 0 6 25 32 — 28 173 1,438 2,615 — 0 20 6 2 Maine† — 0 2 10 10 — 9 53 458 561 1 0 1 4 5 Massachusetts — 1 9 58 98 — 16 50 494 2,974 — 1 5 33 64 New Hampshire — 0 3 14 17 — 12 62 643 1,130 — 0 2 2 2 Rhode Island† — 0 4 9 30 — 1 31 110 155 — 0 4 2 7 Vermont† — 0 2 10 9 2 5 66 491 295 — 0 1 6 3 Mid. Atlantic 30 15 57 779 649 285 152 1,182 14,424 9,061 3 7 17 208 397 New Jersey — 2 18 105 100 107 53 557 5,979 3,155 — 0 6 8 83 New York (Upstate) 11 5 25 258 198 72 35 214 2,791 2,085 2 1 4 36 63 New York City 1 3 17 122 120 — 1 17 69 595 — 3 10 117 206 Pennsylvania 18 5 28 294 231 106 62 491 5,585 3,226 1 1 4 47 45 E.N. Central 15 10 51 544 540 1 20 96 1,033 3,464 5 3 7 117 135 Illinois — 1 9 75 131 — 1 18 123 125 — 1 4 43 52 Indiana — 1 5 67 46 — 0 15 83 77 — 0 2 8 11 Michigan 2 2 15 131 138 1 1 12 92 84 1 0 4 26 27 Ohio 13 4 34 270 170 — 1 9 41 24 4 1 4 34 34 Wisconsin — 0 4 1 55 — 15 63 694 3,154 — 0 2 6 11 W.N. Central 1 2 9 64 88 — 2 32 95 1,943 1 1 45 26 57 Iowa — 0 2 8 14 — 0 11 70 82 — 0 3 15 10 Kansas — 0 2 7 9 — 0 2 10 10 1 0 2 7 9 Minnesota — 0 8 — 23 — 0 31 — 1,825 — 0 45 — 3 Missouri 1 1 5 42 26 — 0 0 — 4 — 0 1 — 17 Nebraska† — 0 1 4 8 — 0 2 8 8 — 0 1 3 15 North Dakota — 0 1 1 3 — 0 10 4 13 — 0 1 — — South Dakota — 0 2 2 5 — 0 1 3 1 — 0 1 1 3 S. Atlantic 16 9 26 360 408 32 52 164 2,563 3,031 5 8 23 337 343 Delaware — 0 2 11 13 5 11 46 654 553 — 0 3 6 2 District of Columbia — 0 3 9 16 — 0 2 11 34 — 0 1 5 11 Florida 7 3 9 122 126 1 2 7 87 70 1 2 7 79 102 Georgia 1 1 4 28 46 — 0 3 17 10 1 1 5 65 58 Maryland† 7 1 13 72 88 7 17 108 916 1,269 3 2 13 88 74 North Carolina — 1 7 52 49 — 0 8 51 64 — 0 6 34 39 South Carolina† — 0 4 13 11 — 0 6 24 27 — 0 1 4 3 Virginia† 1 1 9 47 48 6 17 76 735 916 — 1 8 56 51 West Virginia — 0 2 6 11 13 0 14 68 88 — 0 1 — 3 E.S. Central 3 2 10 122 106 — 1 5 45 39 — 1 4 26 24 Alabama† 1 0 2 19 15 — 0 2 13 2 — 0 3 6 6 Kentucky 1 0 3 26 23 — 0 1 1 5 — 0 1 6 6 Mississippi — 0 3 11 12 — 0 1 3 — — 0 1 1 2 Tennessee† 1 1 8 66 56 — 0 3 28 32 — 0 3 13 10 W.S. Central — 3 13 92 127 — 1 29 32 89 1 1 18 27 79 Arkansas† — 0 2 9 16 — 0 0 — — — 0 1 4 4 Louisiana — 0 3 13 9 — 0 1 1 3 — 0 1 1 3 Oklahoma — 0 3 9 11 — 0 0 — — 1 0 1 5 5 Texas† — 2 11 61 91 — 1 29 31 86 — 0 17 17 67 Mountain 2 2 5 67 135 — 0 4 31 25 — 1 4 50 51 Arizona — 1 3 22 47 — 0 2 8 2 — 0 4 19 23 Colorado — 0 2 4 25 — 0 1 1 2 — 0 3 18 16 Idaho† — 0 1 5 5 — 0 2 3 8 — 0 1 2 1 Montana† — 0 1 1 4 — 0 2 8 4 — 0 1 1 2 Nevada† 1 0 2 12 18 — 0 1 3 1 — 0 2 7 5 New Mexico† — 0 2 7 7 — 0 2 6 5 — 0 1 2 1 Utah — 0 2 13 22 — 0 1 1 3 — 0 1 1 3 Wyoming† 1 0 1 3 7 — 0 1 1 — — 0 0 — — Pacific 1 5 21 202 194 4 3 11 150 145 — 4 10 129 131 Alaska — 0 0 — 2 — 0 2 6 6 — 0 2 5 3 California 1 4 15 170 165 4 2 9 125 92 — 2 8 91 88 Hawaii — 0 1 1 1 N 0 0 N N — 0 1 5 3 Oregon — 0 3 13 11 — 0 2 13 38 — 0 4 12 9 Washington — 0 6 18 15 — 0 4 6 9 — 0 3 16 28 Territories American Samoa N 0 0 N N N 0 0 N N — 0 1 1 — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 1 — — — 0 0 — — — 0 0 — — Puerto Rico — 0 1 — 1 N 0 0 N N — 0 0 — 5 U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. † Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
MMWR / October 7, 2011 / Vol. 60 / No. 39 1369 A-33 Morbidity and Mortality Weekly Report Attachment A
TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending October 1, 2011, and October 2, 2010 (39th week)* Meningococcal disease, invasive† All serogroups Mumps Pertussis Previous 52 weeks Previous 52 weeks Previous 52 weeks Current Cum Cum Current Cum Cum Current Cum Cum Reporting area week Med Max 2011 2010 week Med Max 2011 2010 week Med Max 2011 2010 United States 2 15 53 523 595 3 6 47 211 2,400 95 281 2,925 10,117 16,469 New England — 0 3 24 14 — 0 1 6 24 5 8 18 332 401 Connecticut — 0 1 3 2 — 0 0 — 11 — 1 3 30 91 Maine§ — 0 1 4 3 — 0 1 — 1 5 2 8 111 38 Massachusetts — 0 2 11 4 — 0 1 3 9 — 3 10 99 214 New Hampshire — 0 1 1 — — 0 0 — 3 — 1 7 58 13 Rhode Island§ — 0 1 — — — 0 1 2 — — 0 3 18 34 Vermont§ — 0 3 5 5 — 0 1 1 — — 0 4 16 11 Mid. Atlantic — 1 6 59 62 — 1 23 26 2,059 27 31 125 1,160 1,083 New Jersey — 0 1 5 19 — 0 2 9 342 — 3 7 105 127 New York (Upstate) — 0 4 19 9 — 0 2 7 660 20 13 81 517 370 New York City — 0 3 22 16 — 0 22 9 1,033 — 0 19 38 66 Pennsylvania — 0 2 13 18 — 0 16 1 24 7 14 70 500 520 E.N. Central — 2 7 71 100 1 1 7 54 48 15 61 198 2,096 3,718 Illinois — 0 3 21 19 — 1 3 30 17 — 15 50 541 653 Indiana — 0 2 11 22 — 0 1 — 3 — 4 26 142 525 Michigan — 0 4 9 16 — 0 1 9 17 1 15 57 516 1,060 Ohio — 0 2 20 25 1 0 5 12 9 8 17 80 561 1,139 Wisconsin — 0 2 10 18 — 0 1 3 2 6 10 25 336 341 W.N. Central — 1 4 37 42 — 0 4 31 79 6 23 501 881 1,525 Iowa — 0 1 9 9 — 0 1 5 37 — 5 36 142 430 Kansas — 0 1 2 6 — 0 1 4 4 1 2 10 73 140 Minnesota — 0 2 — 3 — 0 4 1 4 — 0 469 326 450 Missouri — 0 2 13 17 — 0 3 12 9 4 7 43 235 294 Nebraska§ — 0 2 10 5 — 0 1 5 23 1 1 11 44 146 North Dakota — 0 1 1 2 — 0 3 4 — — 0 10 37 38 South Dakota — 0 1 2 — — 0 0 — 2 — 0 6 24 27 S. Atlantic 2 2 8 109 108 — 0 3 21 47 19 30 106 1,018 1,326 Delaware — 0 1 1 1 — 0 0 — — — 0 5 21 10 District of Columbia — 0 1 1 1 — 0 0 — 3 — 0 2 3 8 Florida 1 1 5 42 49 — 0 2 7 8 6 6 17 253 246 Georgia — 0 1 12 8 — 0 2 4 2 1 3 13 128 190 Maryland§ — 0 1 11 7 — 0 1 1 10 1 2 6 61 101 North Carolina — 0 3 13 12 — 0 2 7 8 3 3 35 140 242 South Carolina§ — 0 1 9 11 — 0 0 — 4 2 3 25 108 294 Virginia§ 1 0 2 13 17 — 0 2 2 10 — 7 41 246 173 West Virginia — 0 3 7 2 — 0 0 — 2 6 0 41 58 62 E.S. Central — 0 3 20 32 — 0 1 4 9 5 9 28 276 599 Alabama§ — 0 2 9 6 — 0 1 1 6 — 3 11 109 160 Kentucky — 0 2 2 14 — 0 0 — 1 — 1 16 56 211 Mississippi — 0 1 2 3 — 0 1 3 — — 0 10 24 60 Tennessee§ — 0 2 7 9 — 0 1 — 2 5 2 10 87 168 W.S. Central — 1 12 43 65 2 1 15 51 81 7 23 297 687 2,299 Arkansas§ — 0 1 8 5 — 0 1 1 5 — 2 16 48 168 Louisiana — 0 2 9 12 — 0 2 — 5 — 0 3 15 33 Oklahoma — 0 2 7 15 2 0 1 3 — — 0 92 29 51 Texas§ — 0 10 19 33 — 1 14 47 71 7 19 187 595 2,047 Mountain — 1 4 36 45 — 0 2 6 18 9 41 100 1,344 1,146 Arizona — 0 1 10 11 — 0 0 — 5 — 14 29 557 343 Colorado — 0 1 8 16 — 0 1 3 7 7 9 63 304 176 Idaho§ — 0 1 5 5 — 0 1 1 1 1 2 11 104 165 Montana§ — 0 2 4 1 — 0 0 — — — 2 16 71 61 Nevada§ — 0 1 1 8 — 0 0 — 1 — 0 5 20 29 New Mexico§ — 0 1 1 3 — 0 2 2 — 1 2 10 98 102 Utah — 0 2 7 1 — 0 0 — 3 — 5 16 182 258 Wyoming§ — 0 1 — — — 0 0 — 1 — 0 1 8 12 Pacific — 4 26 124 127 — 0 3 12 35 2 71 1,710 2,323 4,372 Alaska — 0 1 2 1 — 0 1 1 1 — 0 4 21 35 California — 2 17 89 83 — 0 3 5 23 — 56 1,569 1,648 3,753 Hawaii — 0 1 4 1 — 0 1 2 3 — 1 9 72 59 Oregon — 0 3 16 25 — 0 1 4 2 2 5 14 213 231 Washington — 0 8 13 17 — 0 1 — 6 — 9 131 369 294 Territories American Samoa — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 0 — — — 2 9 12 457 — 0 14 31 2 Puerto Rico — 0 1 — 2 — 0 1 1 1 — 0 1 2 2 U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. † Data for meningococcal disease, invasive caused by serogroups A, C, Y, and W-135; serogroup B; other serogroup; and unknown serogroup are available in Table I. § Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
1370 MMWR / October 7, 2011 / Vol. 60 / No. 39 A-34 Morbidity and Mortality Weekly Report Attachment A
TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending October 1, 2011, and October 2, 2010 (39th week)* Rabies, animal Salmonellosis Shiga toxin-producing E. coli (STEC)† Previous 52 weeks Previous 52 weeks Previous 52 weeks Current Cum Cum Current Cum Cum Current Cum Cum Reporting area week Med Max 2011 2010 week Med Max 2011 2010 week Med Max 2011 2010 United States 46 60 119 2,186 3,481 674 972 1,755 34,039 39,816 58 92 264 3,607 3,897 New England 1 3 13 131 244 4 25 351 1,313 1,977 — 2 36 142 180 Connecticut — 0 9 28 109 — 0 330 330 491 — 0 36 36 60 Maine§ — 1 6 52 49 4 3 8 109 98 — 0 3 24 15 Massachusetts — 0 0 — — — 17 38 554 1,048 — 0 10 44 69 New Hampshire — 0 3 17 15 — 3 8 132 143 — 0 3 22 18 Rhode Island§ — 0 4 15 27 — 1 62 135 141 — 0 2 4 3 Vermont§ 1 0 2 19 44 — 1 5 53 56 — 0 3 12 15 Mid. Atlantic 22 16 35 702 857 62 94 205 4,197 4,661 7 9 32 438 440 New Jersey — 0 0 — — — 20 48 787 953 — 2 6 67 98 New York (Upstate) 9 7 20 292 404 36 25 67 1,086 1,122 7 3 12 160 147 New York City — 0 3 9 140 2 20 41 871 1,056 — 1 6 65 56 Pennsylvania 13 8 21 401 313 24 32 111 1,453 1,530 — 3 18 146 139 E.N. Central 3 2 16 149 214 41 86 150 3,365 4,755 8 12 45 644 673 Illinois — 1 6 46 110 — 27 56 1,114 1,610 — 2 11 127 128 Indiana — 0 6 20 — — 10 19 349 618 — 2 8 86 109 Michigan 1 1 6 47 60 12 14 31 621 774 — 2 18 125 132 Ohio 2 0 5 36 44 29 21 46 966 1,044 8 2 10 147 115 Wisconsin N 0 0 N N — 8 44 315 709 — 3 20 159 189 W.N. Central 1 2 40 67 214 42 47 95 1,832 2,337 11 12 39 552 708 Iowa — 0 1 — 24 3 9 19 351 422 — 2 15 144 139 Kansas 1 0 4 27 53 8 7 21 337 348 — 2 8 77 55 Minnesota — 0 34 — 25 — 0 16 — 598 — 0 8 — 237 Missouri — 0 1 — 59 24 16 45 784 635 7 4 14 199 187 Nebraska§ — 0 3 29 43 6 4 13 198 185 4 1 7 83 60 North Dakota — 0 6 11 10 1 0 15 33 30 — 0 10 11 5 South Dakota — 0 0 — — — 3 17 129 119 — 1 4 38 25 S. Atlantic 8 18 93 816 909 328 279 719 10,354 10,920 7 14 29 499 513 Delaware — 0 0 — — — 3 10 123 141 — 0 2 13 4 District of Columbia — 0 0 — — 3 1 5 47 78 — 0 1 3 9 Florida — 0 84 84 121 172 107 226 4,065 4,408 3 3 15 111 163 Georgia — 0 0 — — 46 42 126 1,844 2,163 1 2 8 90 81 Maryland§ — 6 13 204 301 28 18 39 717 838 — 1 8 35 69 North Carolina — 0 0 — — 47 34 251 1,598 1,104 2 2 11 96 47 South Carolina§ N 0 0 N N 23 30 99 1,088 1,194 — 0 4 15 20 Virginia§ 8 11 27 459 430 9 21 68 829 849 1 3 9 133 104 West Virginia — 0 30 69 57 — 0 14 43 145 — 0 4 3 16 E.S. Central — 2 7 93 144 46 60 188 2,886 2,951 2 4 22 205 195 Alabama§ — 1 7 67 60 19 18 70 866 762 — 1 15 68 39 Kentucky — 0 2 12 16 9 9 21 355 451 1 1 5 34 50 Mississippi — 0 1 1 — 1 20 66 920 930 — 0 12 17 14 Tennessee§ — 0 4 13 68 17 17 49 745 808 1 2 11 86 92 W.S. Central 6 1 31 60 682 107 134 515 4,434 5,072 2 6 151 228 240 Arkansas§ 6 0 10 47 23 26 14 51 641 577 — 0 5 35 44 Louisiana — 0 0 — — 5 14 52 565 1,031 — 0 2 7 15 Oklahoma — 0 20 13 41 15 11 95 500 495 2 1 55 44 20 Texas§ — 0 30 — 618 61 85 381 2,728 2,969 — 5 95 142 161 Mountain 2 0 4 31 60 11 47 91 1,804 2,263 14 11 30 430 487 Arizona N 0 0 N N 1 14 34 546 763 — 2 14 73 48 Colorado — 0 0 — — 4 10 24 421 454 3 2 11 90 179 Idaho§ 1 0 1 5 11 2 3 8 118 131 3 3 6 87 69 Montana§ N 0 0 N N 3 2 10 104 80 — 1 5 34 36 Nevada§ 1 0 2 9 5 1 3 8 106 250 1 0 7 27 29 New Mexico§ — 0 2 10 10 — 6 22 239 254 — 1 6 34 34 Utah — 0 2 7 10 — 5 15 224 283 — 1 7 62 73 Wyoming§ — 0 0 — 24 — 1 9 46 48 7 0 3 23 19 Pacific 3 3 15 137 157 33 106 288 3,854 4,880 7 13 46 469 461 Alaska — 0 2 9 12 — 1 6 44 67 — 0 1 3 2 California 3 3 10 118 131 24 75 232 2,969 3,573 7 8 36 299 207 Hawaii — 0 0 — — 6 7 14 264 260 — 0 1 6 27 Oregon — 0 2 10 14 3 5 14 185 432 — 1 11 66 74 Washington — 0 14 — — — 12 42 392 548 — 2 16 95 151 Territories American Samoa N 0 0 N N — 0 0 — 2 — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 0 — — — 0 3 6 8 — 0 0 — — Puerto Rico — 0 6 25 36 1 6 25 158 461 — 0 0 — — U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. † Includes E. coli O157:H7; Shiga toxin-positive, serogroup non-O157; and Shiga toxin-positive, not serogrouped. § Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
MMWR / October 7, 2011 / Vol. 60 / No. 39 1371 A-35 Morbidity and Mortality Weekly Report Attachment A
TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending October 1, 2011, and October 2, 2010 (39th week)* Spotted Fever Rickettsiosis (including RMSF)† Shigellosis Confirmed Probable Previous 52 weeks Previous 52 weeks Previous 52 weeks Current Cum Cum Current Cum Cum Current Cum Cum Reporting area week Med Max 2011 2010 week Med Max 2011 2010 week Med Max 2011 2010 United States 153 227 742 7,944 10,552 6 2 16 148 118 20 25 245 1,398 1,291 New England — 2 29 135 291 — 0 0 — — — 0 1 3 3 Connecticut — 0 28 28 69 — 0 0 — — — 0 0 — — Maine§ — 0 4 19 5 — 0 0 — — — 0 0 — 2 Massachusetts — 1 6 76 193 — 0 0 — — — 0 1 1 — New Hampshire — 0 2 2 12 — 0 0 — — — 0 1 1 1 Rhode Island§ — 0 4 6 11 — 0 0 — — — 0 1 1 — Vermont§ — 0 1 4 1 — 0 0 — — — 0 0 — — Mid. Atlantic 20 15 74 583 1,360 — 0 2 11 2 — 1 5 35 86 New Jersey — 3 8 89 316 — 0 0 — 1 — 0 3 — 50 New York (Upstate) 18 3 18 201 176 — 0 1 3 1 — 0 2 6 13 New York City — 5 13 202 246 — 0 0 — — — 0 3 15 11 Pennsylvania 2 3 56 91 622 — 0 2 8 — — 0 3 14 12 E.N. Central 7 15 40 531 1,306 — 0 2 7 3 1 1 6 78 74 Illinois — 4 10 116 743 — 0 1 1 2 — 0 3 26 33 Indiana§ — 1 4 43 50 — 0 1 2 1 — 0 4 38 20 Michigan 1 3 10 125 205 — 0 1 1 — — 0 1 1 1 Ohio 6 5 27 247 246 — 0 2 3 — 1 0 2 13 14 Wisconsin — 0 4 — 62 — 0 0 — — — 0 1 — 6 W.N. Central 8 7 38 236 1,785 — 0 7 24 13 2 4 30 298 248 Iowa — 0 4 13 45 — 0 0 — — — 0 2 5 5 Kansas§ 3 1 12 43 212 — 0 0 — — — 0 0 — — Minnesota — 0 4 — 45 — 0 0 — — — 0 2 — — Missouri 3 5 18 163 1,447 — 0 4 17 10 1 4 30 288 240 Nebraska§ 2 0 10 13 29 — 0 3 5 3 1 0 1 4 2 North Dakota — 0 0 — — — 0 1 2 — — 0 0 — 1 South Dakota — 0 2 4 7 — 0 0 — — — 0 1 1 — S. Atlantic 48 68 133 2,764 1,845 4 1 8 77 73 2 6 54 380 403 Delaware§ — 0 1 3 36 — 0 1 1 1 — 0 4 17 17 District of Columbia — 0 2 12 27 — 0 1 1 — — 0 1 1 — Florida§ 34 42 98 1,962 770 — 0 1 3 3 — 0 2 7 8 Georgia 9 12 25 426 593 4 0 5 45 52 — 0 0 — — Maryland§ 1 2 7 74 103 — 0 1 2 — 1 0 3 23 39 North Carolina 4 4 36 168 138 — 0 4 12 13 — 0 49 201 210 South Carolina§ — 1 4 37 55 — 0 2 10 1 — 0 2 17 14 Virginia§ — 2 8 78 108 — 0 1 3 3 1 2 9 111 115 West Virginia — 0 66 4 15 — 0 0 — — — 0 1 3 — E.S. Central 14 13 29 450 542 2 0 3 9 17 3 5 27 309 352 Alabama§ 9 4 15 163 126 — 0 1 3 4 2 1 8 59 71 Kentucky 2 1 6 38 193 — 0 1 1 6 — 0 0 — — Mississippi 2 2 9 121 40 — 0 0 — 1 — 0 4 12 17 Tennessee§ 1 4 14 128 183 2 0 2 5 6 1 4 21 238 264 W.S. Central 39 57 503 1,866 1,946 — 0 8 6 4 12 1 235 266 112 Arkansas§ 2 2 7 57 48 — 0 2 3 — 9 0 39 217 70 Louisiana — 4 21 175 211 — 0 0 — — — 0 2 4 2 Oklahoma 19 2 161 101 219 — 0 5 2 3 3 0 202 41 22 Texas§ 18 46 338 1,533 1,468 — 0 1 1 1 — 0 5 4 18 Mountain 11 16 41 610 616 — 0 5 13 2 — 0 6 29 12 Arizona 5 6 27 250 331 — 0 4 12 — — 0 6 15 1 Colorado§ 3 1 8 78 77 — 0 1 — — — 0 1 2 1 Idaho§ — 0 3 15 22 — 0 1 1 — — 0 1 1 5 Montana§ — 1 15 117 7 — 0 0 — 2 — 0 1 1 1 Nevada§ 3 0 4 26 37 — 0 0 — — — 0 0 — — New Mexico§ — 3 9 85 104 — 0 0 — — — 0 1 1 1 Utah — 1 4 37 38 — 0 0 — — — 0 1 1 3 Wyoming§ — 0 1 2 — — 0 0 — — — 0 2 8 — Pacific 6 22 63 769 861 — 0 2 1 4 — 0 0 — 1 Alaska — 0 2 5 1 N 0 0 N N N 0 0 N N California 6 20 59 626 689 — 0 2 1 4 — 0 0 — — Hawaii — 1 3 41 38 N 0 0 N N N 0 0 N N Oregon — 1 4 32 46 — 0 0 — — — 0 0 — 1 Washington — 1 7 65 87 — 0 1 — — — 0 0 — — Territories American Samoa — 1 1 1 2 N 0 0 N N N 0 0 N N C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 1 1 5 N 0 0 N N N 0 0 N N Puerto Rico — 0 1 — 4 N 0 0 N N N 0 0 N N U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. † Illnesses with similar clinical presentation that result from Spotted fever group rickettsia infections are reported as Spotted fever rickettsioses. Rocky Mountain spotted fever (RMSF) caused by Rickettsia rickettsii, is the most common and well-known spotted fever. § Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
1372 MMWR / October 7, 2011 / Vol. 60 / No. 39 A-36 Morbidity and Mortality Weekly Report Attachment A
TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending October 1, 2011, and October 2, 2010 (39th week)* Streptococcus pneumoniae,† invasive disease All ages Age <5 Syphilis, primary and secondary Previous 52 weeks Previous 52 weeks Previous 52 weeks Current Cum Cum Current Cum Cum Current Cum Cum Reporting area week Med Max 2011 2010 week Med Max 2011 2010 week Med Max 2011 2010 United States 94 298 937 10,250 11,352 9 23 101 747 1,388 79 255 363 9,306 10,345 New England 1 17 79 554 617 — 1 5 29 79 3 7 16 273 369 Connecticut — 6 49 235 246 — 0 3 6 22 — 1 8 39 79 Maine§ — 2 13 98 89 — 0 1 3 7 — 0 3 11 22 Massachusetts — 0 3 21 55 — 0 3 8 37 1 5 9 166 225 New Hampshire — 2 8 74 84 — 0 1 5 4 — 0 3 14 16 Rhode Island§ — 2 8 73 80 — 0 1 2 5 2 0 7 36 25 Vermont§ 1 1 6 53 63 — 0 2 5 4 — 0 2 7 2 Mid. Atlantic — 33 81 1,014 1,162 — 3 27 84 172 11 29 51 1,105 1,289 New Jersey — 13 35 474 517 — 1 4 28 43 — 4 13 143 186 New York (Upstate) — 1 10 60 115 — 1 9 34 85 7 3 20 143 101 New York City — 13 42 480 530 — 0 14 22 44 2 15 31 557 726 Pennsylvania N 0 0 N N N 0 0 N N 2 6 13 262 276 E.N. Central 14 67 113 2,219 2,303 1 4 10 121 209 2 30 48 1,120 1,495 Illinois N 0 0 N N — 0 0 57 73 — 13 22 449 714 Indiana — 16 32 502 535 — 0 4 21 43 2 3 8 116 140 Michigan 3 15 29 492 528 — 1 4 25 66 — 5 12 190 192 Ohio 10 26 45 903 875 1 2 7 62 72 — 9 21 324 412 Wisconsin 1 9 24 322 365 — 0 3 13 28 — 1 5 41 37 W.N. Central 1 4 35 129 615 — 0 4 9 87 2 6 13 216 269 Iowa N 0 0 N N N 0 0 N N — 0 2 12 17 Kansas N 0 0 N N N 0 0 N N — 0 3 19 17 Minnesota — 0 24 — 467 — 0 3 — 71 — 2 8 88 104 Missouri N 0 0 N N — 0 0 26 30 2 2 6 91 121 Nebraska§ 1 2 9 86 98 — 0 2 8 14 — 0 2 5 6 North Dakota — 0 25 43 50 — 0 1 1 2 — 0 1 1 — South Dakota N 0 0 N N — 0 0 9 8 — 0 0 — 4 S. Atlantic 42 72 170 2,879 3,089 6 7 22 217 385 27 65 178 2,440 2,381 Delaware — 1 6 37 28 — 0 1 — — — 0 4 16 4 District of Columbia — 1 3 28 58 — 0 1 4 7 — 3 8 123 108 Florida 14 24 68 1,034 1,131 4 3 13 95 152 2 23 36 837 864 Georgia 7 22 54 770 992 1 2 7 55 121 11 13 130 518 517 Maryland§ 4 10 32 412 398 — 1 4 29 44 2 8 19 333 232 North Carolina N 0 0 N N N 0 0 N N 9 8 21 299 320 South Carolina§ 3 8 25 343 390 — 0 3 20 44 — 4 10 154 107 Virginia§ N 0 0 N N — 0 0 26 44 3 4 16 158 223 West Virginia 14 1 48 255 92 1 0 6 14 17 — 0 1 2 6 E.S. Central 3 19 36 671 770 — 1 4 44 73 10 15 34 551 669 Alabama§ N 0 0 N N N 0 0 N N — 4 11 151 192 Kentucky N 0 0 N N N 0 0 N N 1 2 16 81 98 Mississippi N 0 0 N N — 0 0 8 13 9 3 16 138 160 Tennessee§ 3 19 36 671 770 — 1 4 44 73 — 5 11 181 219 W.S. Central 20 31 368 1,367 1,396 2 4 30 130 189 16 35 59 1,308 1,602 Arkansas§ 4 3 26 169 130 — 0 3 13 14 2 4 10 151 164 Louisiana — 3 11 121 86 — 0 2 11 20 — 7 24 274 427 Oklahoma N 0 0 N N — 0 0 29 39 — 1 6 42 75 Texas§ 16 25 333 1,077 1,180 2 3 27 106 155 14 23 33 841 936 Mountain 13 32 72 1,298 1,315 — 3 8 103 178 2 12 20 399 456 Arizona 4 12 45 617 626 — 1 5 50 80 — 4 8 151 171 Colorado 8 10 23 407 399 — 0 4 28 54 — 2 8 81 103 Idaho§ N 0 0 N N — 0 0 5 8 — 0 4 11 2 Montana§ N 0 0 N N N 0 0 N N — 0 1 4 3 Nevada§ N 0 0 N N N 0 0 N N 2 2 9 95 83 New Mexico§ — 3 13 180 122 — 0 2 13 15 — 1 4 49 38 Utah — 2 8 74 157 — 0 3 12 26 — 0 2 8 56 Wyoming§ 1 0 15 20 11 — 0 1 — 3 — 0 0 — — Pacific — 3 11 119 85 — 0 1 10 16 6 51 66 1,894 1,815 Alaska — 3 11 115 85 — 0 1 8 16 — 0 1 1 3 California N 0 0 N N N 0 0 N N 6 42 57 1,568 1,544 Hawaii — 0 3 4 — — 0 1 2 — — 0 5 10 28 Oregon N 0 0 N N N 0 0 N N — 2 10 120 52 Washington N 0 0 N N N 0 0 N N — 5 13 195 188 Territories American Samoa N 0 0 N N — 0 0 — — — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 0 — — — 0 0 — — — 0 0 — — Puerto Rico — 0 0 — — — 0 0 — — 15 4 13 183 179 U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. † Includes drug resistant and susceptible cases of invasive Streptococcus pneumoniae disease among children <5 years and among all ages. Case definition: Isolation of S. pneumoniae from a normally sterile body site (e.g., blood or cerebrospinal fluid). § Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
MMWR / October 7, 2011 / Vol. 60 / No. 39 1373 A-37 Morbidity and Mortality Weekly Report Attachment A
TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending October 1, 2011, and October 2, 2010 (39th week)* West Nile virus disease† Varicella (chickenpox) Neuroinvasive Nonneuroinvasive§ Previous 52 weeks Previous 52 weeks Previous 52 weeks Current Cum Cum Current Cum Cum Current Cum Cum Reporting area week Med Max 2011 2010 week Med Max 2011 2010 week Med Max 2011 2010 United States 166 275 367 9,207 11,523 — 1 51 289 584 — 0 19 143 383 New England 5 21 49 783 853 — 0 3 11 13 — 0 1 2 5 Connecticut — 4 16 169 267 — 0 2 7 7 — 0 1 1 4 Maine¶ — 5 16 147 163 — 0 0 — — — 0 0 — — Massachusetts — 5 18 260 213 — 0 1 2 5 — 0 1 1 1 New Hampshire — 3 9 102 104 — 0 0 — 1 — 0 0 — — Rhode Island¶ — 0 6 30 31 — 0 1 1 — — 0 0 — — Vermont¶ 5 2 10 75 75 — 0 1 1 — — 0 0 — — Mid. Atlantic 42 37 71 1,715 1,282 — 0 10 25 122 — 0 6 16 62 New Jersey 17 14 62 1,017 442 — 0 1 1 14 — 0 1 3 14 New York (Upstate) N 0 0 N N — 0 4 12 56 — 0 4 11 30 New York City — 0 0 — — — 0 4 9 33 — 0 1 1 9 Pennsylvania 25 18 41 698 840 — 0 1 3 19 — 0 1 1 9 E.N. Central 40 67 118 2,078 3,694 — 0 11 46 76 — 0 4 19 30 Illinois 1 15 31 534 957 — 0 3 13 42 — 0 2 5 16 Indiana¶ 5 4 18 184 290 — 0 2 4 6 — 0 1 3 7 Michigan 8 20 38 656 1,083 — 0 6 22 24 — 0 1 1 4 Ohio 26 21 58 703 971 — 0 2 7 4 — 0 3 9 1 Wisconsin — 0 22 1 393 — 0 0 — — — 0 1 1 2 W.N. Central 1 8 42 282 682 — 0 6 20 30 — 0 4 19 75 Iowa N 0 0 N N — 0 2 4 4 — 0 1 2 4 Kansas¶ — 2 15 81 283 — 0 1 — 3 — 0 2 — 15 Minnesota — 0 0 — — — 0 1 1 4 — 0 0 — 4 Missouri — 4 24 143 328 — 0 1 2 3 — 0 1 3 — Nebraska¶ 1 0 5 4 11 — 0 4 12 10 — 0 3 11 29 North Dakota — 0 10 31 33 — 0 1 1 2 — 0 1 3 7 South Dakota — 1 7 23 27 — 0 0 — 4 — 0 0 — 16 S. Atlantic 22 34 64 1,318 1,698 — 0 8 42 33 — 0 3 12 21 Delaware¶ — 0 3 6 26 — 0 1 1 — — 0 0 — — District of Columbia — 0 2 12 17 — 0 1 1 3 — 0 0 — 3 Florida¶ 16 15 38 662 811 — 0 5 16 7 — 0 2 2 2 Georgia N 0 0 N N — 0 1 5 4 — 0 1 3 9 Maryland¶ N 0 0 N N — 0 4 9 15 — 0 2 7 6 North Carolina N 0 0 N N — 0 1 2 — — 0 0 — — South Carolina¶ — 0 9 12 75 — 0 1 — — — 0 0 — — Virginia¶ 6 8 25 330 419 — 0 2 7 4 — 0 0 — 1 West Virginia — 7 32 296 350 — 0 1 1 — — 0 0 — — E.S. Central 3 5 15 196 237 — 0 7 38 7 — 0 5 26 10 Alabama¶ 3 4 14 184 230 — 0 1 1 1 — 0 0 — 2 Kentucky N 0 0 N N — 0 1 2 2 — 0 1 1 1 Mississippi — 0 3 12 7 — 0 4 24 2 — 0 4 22 5 Tennessee¶ N 0 0 N N — 0 3 11 2 — 0 1 3 2 W.S. Central 43 43 258 1,898 2,165 — 0 5 12 95 — 0 1 6 19 Arkansas¶ 2 4 17 184 155 — 0 1 1 6 — 0 0 — 1 Louisiana 1 2 6 65 60 — 0 2 5 17 — 0 1 3 7 Oklahoma N 0 0 N N — 0 1 — — — 0 0 — — Texas¶ 40 39 247 1,649 1,950 — 0 4 6 72 — 0 1 3 11 Mountain 10 18 65 853 822 — 0 8 36 145 — 0 3 15 122 Arizona 3 3 50 385 — — 0 7 21 95 — 0 2 8 56 Colorado¶ 7 4 31 181 311 — 0 0 — 26 — 0 1 2 54 Idaho¶ N 0 0 N N — 0 1 1 — — 0 0 — 1 Montana¶ — 2 28 111 160 — 0 1 1 — — 0 0 — — Nevada¶ N 0 0 N N — 0 3 10 — — 0 1 3 2 New Mexico¶ — 1 3 31 87 — 0 1 2 21 — 0 0 — 4 Utah — 3 26 137 250 — 0 0 — 1 — 0 0 — 1 Wyoming¶ — 0 3 8 14 — 0 1 1 2 — 0 1 2 4 Pacific — 2 6 84 90 — 0 12 59 63 — 0 7 28 39 Alaska — 1 4 41 33 — 0 0 — — — 0 0 — — California — 0 2 9 29 — 0 12 59 63 — 0 7 28 38 Hawaii — 1 4 34 28 — 0 0 — — — 0 0 — — Oregon N 0 0 N N — 0 0 — — — 0 0 — — Washington N 0 0 N N — 0 1 — — — 0 0 — 1 Territories American Samoa N 0 0 N N — 0 0 — — — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 4 16 23 — 0 0 — — — 0 0 — — Puerto Rico — 5 21 137 487 — 0 0 — — — 0 0 — — U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. † Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ArboNET Surveillance). Data for California serogroup, eastern equine, Powassan, St. Louis, and western equine diseases are available in Table I. § Not reportable in all states. Data from states where the condition is not reportable are excluded from this table, except starting in 2007 for the domestic arboviral diseases and influenza- associated pediatric mortality, and in 2003 for SARS-CoV. Reporting exceptions are available at http://www.cdc.gov/osels/ph_surveillance/nndss/phs/infdis.htm. ¶ Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
1374 MMWR / October 7, 2011 / Vol. 60 / No. 39 A-38 Morbidity and Mortality Weekly Report Attachment A
TABLE III. Deaths in 122 U.S. cities,* week ending October 1, 2011 (39th week) All causes, by age (years) All causes, by age (years) All P&I† Reporting area All P&I† Reporting area Ages ≥65 45–64 25–44 1–24 <1 Total (Continued) Ages ≥65 45–64 25–44 1–24 <1 Total
New England 579 392 135 29 12 11 46 S. Atlantic 1,100 699 272 76 31 22 64 Boston, MA 142 86 38 7 3 8 11 Atlanta, GA 122 77 25 13 1 6 5 Bridgeport, CT 27 22 3 1 1 — 6 Baltimore, MD 122 78 29 10 4 1 12 Cambridge, MA 12 9 3 — — — 3 Charlotte, NC 112 73 26 8 3 2 9 Fall River, MA 24 15 6 3 — — 1 Jacksonville, FL 134 83 39 7 3 2 5 Hartford, CT 58 43 15 — — — 3 Miami, FL 135 88 35 9 2 1 6 Lowell, MA 24 16 6 1 1 — 1 Norfolk, VA 60 42 13 2 2 1 — Lynn, MA 11 8 3 — — — — Richmond, VA 60 34 14 6 4 2 3 New Bedford, MA 25 18 5 2 — — 2 Savannah, GA 49 29 11 5 2 2 5 New Haven, CT 42 29 10 2 — 1 3 St. Petersburg, FL 48 30 11 — 5 2 2 Providence, RI 77 51 20 4 1 1 2 Tampa, FL 143 101 35 4 1 2 4 Somerville, MA 1 1 — — — — — Washington, D.C. 108 62 31 10 4 1 11 Springfield, MA 35 21 11 1 1 1 2 Wilmington, DE 7 2 3 2 — — 2 Waterbury, CT 33 24 5 1 3 — 1 E.S. Central 908 592 216 59 20 21 51 Worcester, MA 68 49 10 7 2 — 11 Birmingham, AL 150 106 32 8 2 2 9 Mid. Atlantic 2,147 1,472 470 124 44 36 90 Chattanooga, TN 74 48 17 6 1 2 2 Albany, NY 39 27 8 — — 4 3 Knoxville, TN 106 71 25 9 — 1 6 Allentown, PA 29 18 6 3 2 — — Lexington, KY 66 43 12 8 2 1 4 Buffalo, NY 72 54 14 3 — 1 5 Memphis, TN 189 110 53 13 8 5 19 Camden, NJ 26 17 4 4 1 — 1 Mobile, AL 124 83 31 5 3 2 3 Elizabeth, NJ 19 11 7 1 — — 2 Montgomery, AL 35 29 4 — — 2 2 Erie, PA 58 52 4 2 — — 2 Nashville, TN 164 102 42 10 4 6 6 Jersey City, NJ 15 14 1 — — — 1 W.S. Central 1,148 730 269 74 35 40 56 New York City, NY 1,103 769 234 63 22 14 43 Austin, TX 87 52 22 9 4 — 6 Newark, NJ 19 14 3 — 1 1 1 Baton Rouge, LA 65 43 12 5 3 2 — Paterson, NJ 12 7 3 1 1 — — Corpus Christi, TX 42 33 7 1 — 1 2 Philadelphia, PA 456 261 128 36 17 14 22 Dallas, TX 191 98 66 12 9 6 4 Pittsburgh, PA§ 44 34 7 3 — — 2 El Paso, TX 118 89 23 4 1 1 11 Reading, PA 29 25 4 — — — 1 Fort Worth, TX U U U U U U U Rochester, NY 93 62 26 5 — — 2 Houston, TX 149 84 27 15 2 21 11 Schenectady, NY 13 9 4 — — — 1 Little Rock, AR 74 54 10 4 4 2 1 Scranton, PA 26 19 4 2 — 1 1 New Orleans, LA U U U U U U U Syracuse, NY 41 34 6 — — 1 1 San Antonio, TX 230 151 55 17 5 2 9 Trenton, NJ 15 12 3 — — — — Shreveport, LA 103 65 26 4 3 5 10 Utica, NY 18 16 2 — — — — Tulsa, OK 89 61 21 3 4 — 2 Yonkers, NY 20 17 2 1 — — 2 Mountain 1,114 721 248 85 31 24 58 E.N. Central 1,975 1,293 487 109 42 44 126 Albuquerque, NM 114 77 25 8 3 1 — Akron, OH 54 32 17 4 1 — 3 Boise, ID 49 33 11 2 2 1 3 Canton, OH 32 24 5 2 1 — 1 Colorado Springs, CO 97 66 22 6 2 1 3 Chicago, IL 224 148 57 13 6 — 11 Denver, CO 72 49 13 7 3 — 5 Cincinnati, OH 88 60 18 5 — 5 9 Las Vegas, NV 280 171 70 24 10 3 22 Cleveland, OH 247 175 51 9 7 5 9 Ogden, UT 31 23 5 3 — — 1 Columbus, OH 243 150 68 14 6 5 14 Phoenix, AZ 165 93 45 8 6 12 13 Dayton, OH 127 90 25 4 4 4 11 Pueblo, CO 28 20 5 1 1 1 1 Detroit, MI 159 85 52 11 6 5 4 Salt Lake City, UT 116 79 21 10 2 4 5 Evansville, IN 50 39 7 2 — 2 4 Tucson, AZ 162 110 31 16 2 1 5 Fort Wayne, IN 50 29 16 2 1 2 3 Pacific 1,599 1,108 335 91 31 34 135 Gary, IN 17 11 4 1 1 — 1 Berkeley, CA 14 7 4 3 — — 1 Grand Rapids, MI 57 41 6 5 1 4 7 Fresno, CA 111 73 28 8 — 2 10 Indianapolis, IN 220 135 61 16 3 5 14 Glendale, CA 35 24 7 2 1 1 6 Lansing, MI 58 35 18 5 — — 6 Honolulu, HI 62 48 10 2 — 2 8 Milwaukee, WI 74 49 17 5 1 2 4 Long Beach, CA 49 29 11 4 3 2 6 Peoria, IL 38 25 11 1 1 — 6 Los Angeles, CA 243 168 52 9 7 7 28 Rockford, IL 56 42 11 2 — 1 1 Pasadena, CA 19 14 2 2 — 1 2 South Bend, IN 36 25 9 2 — — 5 Portland, OR 114 80 25 8 — 1 4 Toledo, OH 99 62 26 6 2 3 7 Sacramento, CA 215 147 48 12 5 3 17 Youngstown, OH 46 36 8 — 1 1 6 San Diego, CA 169 123 32 5 3 6 14 W.N. Central 817 525 195 51 28 18 51 San Francisco, CA 110 77 25 4 2 2 10 Des Moines, IA 148 98 33 11 5 1 8 San Jose, CA 178 136 29 8 2 3 16 Duluth, MN 30 25 5 — — — 5 Santa Cruz, CA 20 14 5 1 — — 1 Kansas City, KS 19 8 6 2 1 2 2 Seattle, WA 109 66 31 8 2 2 2 Kansas City, MO 98 56 28 11 2 1 5 Spokane, WA 61 35 14 7 3 2 6 Lincoln, NE 56 44 8 3 1 — 3 Tacoma, WA 90 67 12 8 3 — 4 Minneapolis, MN 51 31 12 3 2 3 5 Total¶ 11,387 7,532 2,627 698 274 250 677 Omaha, NE 93 73 15 1 3 1 10 St. Louis, MO 185 92 56 14 13 10 5 St. Paul, MN 45 32 11 2 — — 5 Wichita, KS 92 66 21 4 1 — 3 U: Unavailable. —: No reported cases. * Mortality data in this table are voluntarily reported from 122 cities in the United States, most of which have populations of >100,000. A death is reported by the place of its occurrence and by the week that the death certificate was filed. Fetal deaths are not included. † Pneumonia and influenza. § Because of changes in reporting methods in this Pennsylvania city, these numbers are partial counts for the current week. Complete counts will be available in 4 to 6 weeks. ¶ Total includes unknown ages.
MMWR / October 7, 2011 / Vol. 60 / No. 39 1375 A-39 Morbidity and Mortality Weekly Report Attachment A
The Morbidity and Mortality Weekly Report (MMWR) Series is prepared by the Centers for Disease Control and Prevention (CDC) and is available free of charge in electronic format. To receive an electronic copy each week, visit MMWR’s free subscription page at http://www.cdc.gov/mmwr/mmwrsubscribe. html. Paper copy subscriptions are available through the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402; telephone 202-512-1800. Data presented by the Notifiable Disease Data Team and 122 Cities Mortality Data Team in the weekly MMWR are provisional, based on weekly reports to CDC by state health departments. Address all inquiries about the MMWR Series, including material to be considered for publication, to Editor, MMWR Series, Mailstop E-90, CDC, 1600 Clifton Rd., N.E., Atlanta, GA 30333 or to [email protected]. All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of these sites. URL addresses listed in MMWR were current as of the date of publication.
U.S. Government Printing Office: 2012-523-043/21082 Region IV ISSN: 0149-2195
A-40 Attachment B
Journal of Clinical Neuroscience 16 (2009) 755–763
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience
journal homepage: www.elsevier.com/locate/jocn
Communication Consensus statement on concussion in sport – The 3rd International Conference on concussion in sport, held in Zurich, November 2008 q
P. McCrory a,*, W. Meeuwisse b, K. Johnston c, J. Dvorak d, M. Aubry e, M. Molloy f, R. Cantu g a Centre for Health, Exercise and Sports Medicine, University of Melbourne, 202 Berkeley Street, Victoria 3010, Australia b Sport Medicine Centre, Faculty of Kinesiology and Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Alberta, Canada c Sport Concussion Clinic, Toronto Rehabilitation Institute, Toronto, Ontario, Canada d FIFA Medical Assessment and Research Center (F-MARC) and Schulthess Clinic, Zurich, Switzerland e Ottawa Sport Medicine Centre, Ottawa, Canada f Huguenot House, Dublin, Ireland g Emerson Hospital, Concord, Massachusets, USA article info a b s t r a c t
Article history: Received 23 February 2009 Ó 2009 Paul McCrory. Published by Elsevier Ltd. All rights reserved. Accepted 24 February 2009
Keywords: Concussion Sport
PREAMBLE ment on an individualized basis. Readers are encouraged to copy and distribute freely the Zurich Consensus Statement and/or the This paper is a revision and update of the recommendations Sports Concussion Assessment Tool (SCAT2)(Supplementary Figs. 1 developed following the 1st (Vienna) and 2nd (Prague) Interna- and 2). Neither is subject to any copyright restriction. The authors tional Symposia on Concussion in Sport.1,2 This Zurich Consensus request, however, that the Zurich Consensus Statement and/or the Statement on Concussion in Sport (the ‘‘Zurich Consensus State- SCAT2 (Supplementary Figs. 1 and 2) be distributed in their full and ment”) is designed to build on the principles outlined in the complete format. original Vienna and Prague documents and to further develop The following focus questions formed the foundation for the conceptual understanding of this problem using a formal Zurich Consensus Document: consensus-based approach. A detailed description of the consen- sus process is outlined in the Statement on Background to Consen- Acute simple concussion sus Process section (see Section 11). This document is developed Which symptom scale and which sideline assessment tool is for use by physicians, therapists, certified athletic trainers, health best for diagnosis and/or follow up? professionals, coaches and other people involved in the care of How extensive should the cognitive assessment be in elite injured athletes, whether at the recreational, elite or professional athletes? level. How extensive should clinical and neuropsychological (NP) While agreement exists pertaining to principal messages con- testing be at non-elite level? veyed within this document, the authors acknowledge that the sci- Who should do/interpret the cognitive assessment? ence of concussion is evolving and therefore management and Is there a gender difference in concussion incidence and return to play (RTP) decisions remain in the realm of clinical judg- outcomes?
q Consensus panelists in addition to the authors (in alphabetical order): S Broglio, Return to play issues G Davis, R Dick, R Echemendia, G Gioia, K Guskiewicz, S Herring, G Iverson, J Kelly, Is provocative exercise testing useful in guiding RTP? J Kissick, M Makdissi, M McCrea, A Ptito, L Purcell, M Putukian. What is the best RTP strategy for elite athletes? Also invited but not in attendance: R Bahr, L Engebretsen, P Hamlyn, B Jordan, What is the best RTP strategy for non-elite athletes? P Schamasch. Is protective equipment (e.g. mouthguards, helmets) useful * Corresponding author. Tel.: +61 3 8344 3773; fax: +61 3 8344 3771. E-mail address: [email protected] (P. McCrory). in reducing concussion incidence and/or severity?
0967-5868/$ - see front matter Ó 2009 Paul McCrory. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jocn.2009.02.002 B-1 Attachment B
756 P. McCrory et al. / Journal of Clinical Neuroscience 16 (2009) 755–763
Complex concussion and long-term issues 1.2. Classification of concussion Is the Simple versus Complex classification a valid and useful differentiation? There was unanimous agreement to abandon the Simple versus Are there specific patient populations at risk of long-term Complex terminology that had been proposed in the Prague agree- problems? ment statement as the panel felt that the terminology itself did not Is there a role for additional tests (e.g. structural and/or func- fully describe the entities. The panel, however, unanimously re- tional MRI, balance testing, biomarkers)? tained the concept that most (80–90%) concussions resolve in a Should athletes with persistent symptoms be screened for short period (7–10 days), although the recovery time frame may depression/anxiety? be longer in children and adolescents.2
Paediatric concussion Which symptoms scale is appropriate for this age group? 2. CONCUSSION EVALUATION Which tests are useful and how often should baseline testing be performed in this age group? 2.1. Symptoms and signs of acute concussion What is the most appropriate RTP guideline for elite and non- elite child and adolescent athletes? The panel agreed that the diagnosis of acute concussion usually involves the assessment of a range of domains including clinical Future directions symptoms, physical signs, behavior, balance, sleep and cognition. What is the best method of knowledge transfer and Furthermore, a detailed concussion history is an important part education? of the evaluation both in the injured athlete and when conducting Is there evidence that new and novel injury prevention strat- a pre-participation examination. The detailed clinical assessment egies work (e.g. changes to rules of the game, fair play of concussion is outlined in the SCAT2 form (Supplementary Fig. 1). strategies)? The suspected diagnosis of concussion can include one or more of the following clinical domains: The Zurich Consensus Document additionally examines the (a) symptoms: somatic (e.g. headache), cognitive (e.g. feeling management issues raised in the previous ‘‘Prague” and like in a fog) and/or emotional symptoms (e.g. lability) ‘‘Vienna” documents and applies the consensus questions to these (b) physical signs (e.g. loss of consciousness, amnesia) areas. (c) behavioral changes (e.g. irritablity) (d) cognitive impairment (e.g. slowed reaction times) (e) sleep disturbance (e.g. drowsiness). SPECIFIC RESEARCH QUESTIONS AND CONSENSUS DISCUSSION If any one or more of these components is present, a concussion 1. CONCUSSION should be suspected and the appropriate management strategy instituted. 1.1. Definition of concussion 2.2. On-field or sideline evaluation of acute concussion Panel discussion regarding the definition of concussion and its separation from mild traumatic brain injury (mTBI) was held. When a player shows any features of a concussion: Although there was acknowledgement that the terms refer to dif- ferent injury constructs and should not be used interchangeably, (a) The player should be medically evaluated onsite using stan- it was not felt that the panel would define mTBI for the purpose dard emergency management principles and particular of this document. There was unanimous agreement, however, that attention should be given to excluding a cervical spine concussion is defined as follows: injury. (b) The appropriate disposition of the player must be deter- Concussion is defined as a complex pathophysiological process mined by the treating healthcare provider in a timely man- affecting the brain, induced by traumatic biomechanical forces. ner. If no healthcare provider is available, the player Several common features that incorporate clinical, pathologic and should be safely removed from practice or play and urgent biomechanical injury constructs that may be utilized in defining referral to a physician arranged. the nature of a concussive head injury include: (c) Once the first aid issues are addressed, then an assessment of the concussive injury should be made using the SCAT2 1. Concussion may be caused either by a direct blow to the head, (Supplementary Figs. 1 and 2) or other similar tool. face or neck or a blow elsewhere on the body with an ‘‘impul- (d) The player should not be left alone following the injury and sive’’ force transmitted to the head. serial monitoring for deterioration is essential over the ini- 2. Concussion typically results in the rapid onset of short-lived tial few hours following injury. impairment of neurologic function that resolves spontaneously. (e) A player with diagnosed concussion should generally not be 3. Concussion may result in neuropathological changes but the allowed to RTP on the day of injury. Occasionally in adult acute clinical symptoms largely reflect a functional disturbance athletes, there may be RTP on the same day as the injury rather than a structural injury. (see Section 4.2). 4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clin- It was unanimously agreed that sufficient time for assessment ical and cognitive symptoms typically follows a sequential and adequate facilities should be provided for the appropriate course. In a small percentage of cases, however, post-concussive medical assessment both on and off the field for all injured ath- symptoms may be prolonged. letes. In some sports this may require a rule change to allow an 5. No abnormality on standard structural neuroimaging studies is off-field medical assessment to occur without affecting the flow seen in concussion. of the game or unduly penalizing the injured player’s team. B-2 Attachment B
P. McCrory et al. / Journal of Clinical Neuroscience 16 (2009) 755–763 757
Sideline evaluation of cognitive function is an essential compo- of various MRI abnormalities that may be incidentally discovered nent in the assessment of this injury. Brief NP test batteries that is not established at the present time. assess attention and memory function have been shown to be Other imaging modalities such as functional MRI (fMRI) demon- practical and effective. Such tests include the Maddocks strate activation patterns that correlate with symptom severity questions3,4 and the Standardized Assessment of Concussion and recovery in concussion.9–13 While not part of routine assess- (SAC).5–7 Standard orientation questions (e.g. time, place, person) ment at the present time, they nevertheless provide additional in- have been shown to be unreliable in the sporting situation when sight into pathophysiological mechanisms. Alternative imaging compared with memory assessment.4,8 It is recognized, however, technologies (e.g. positron emission tomography, diffusion tensor that abbreviated testing paradigms are designed for rapid concus- imaging, magnetic resonance spectroscopy, functional connectiv- sion screening on the sidelines and are not meant to replace com- ity), while demonstrating some compelling findings, are still in prehensive NP testing, which is sensitive to detect subtle deficits the early stages of development and cannot be recommended that may exist beyond the acute episode; nor should they be used other than in a research setting. as a stand-alone tool for the ongoing management of sports concussions. 3.2. Objective balance assessment It should also be recognized that the appearance of symptoms might be delayed several hours following a concussive Published studies, using both sophisticated force plate technol- episode. ogy, as well as those using less sophisticated clinical balance tests (e.g. the Balance Error Scoring System), have identified postural 2.3. Evaluation in emergency room or office by medical stability deficits lasting approximately 72 hours following a personnel sport-related concussion. It appears that postural stability testing provides a useful tool for objectively assessing the motor domain An athlete with concussion may be evaluated in the emergency of neurologic functioning, and should be considered a reliable room or doctor’s office as a point of first contact following injury or and valid addition to the assessment of athletes suffering from may have been referred from another care provider. In addition to concussion, particularly where symptoms or signs indicate a bal- the points outlined above, the key features of this exam should ance component.14–20 include: 3.3. Neuropsychological assessment (a) A medical assessment encompassing a comprehensive his- tory and detailed neurological examination including a thor- The application of NP testing in concussion has been shown to ough assessment of mental status, cognitive functioning and be of clinical value and continues to contribute significant infor- gait and balance. mation in concussion evaluation.21–26 Although in most cases (b) A determination of the clinical status of the patient including cognitive recovery largely overlaps with the time course of symp- whether there has been improvement or deterioration since tom recovery, it has been demonstrated that cognitive recovery the time of injury. This may involve seeking additional infor- may occasionally precede or more commonly follow clinical mation from parents, coaches, teammates and eyewitnesses symptom resolution, which suggests that the assessment of cog- to the injury. nitive function should be an important component in any RTP (c) A determination of the need for emergent neuroimaging in protocol.27,28 It must be emphasized, however, that NP assess- order to exclude a more severe brain injury involving a ment should not be the sole basis of management decisions; structural abnormality. rather it should be seen as an aid to the clinical decision-making process in conjunction with a range of clinical domains and In large part, these points above are included in the SCAT2 investigational results. assessment (Supplementary Figs. 1 and 2), which forms part of Neuropsychologists are in the best position to interpret NP tests the Zurich Consensus Document. by virtue of their background and training. However, there may be situations where neuropsychologists are not available and other 3. CONCUSSION INVESTIGATIONS medical professionals may perform or interpret NP screening tests. The ultimate RTP decision should remain a medical one in which a A range of additional investigations may be utilized to assist in multidisciplinary approach, when possible, has been taken. In the the diagnosis and/or exclusion of other injury. These include the absence of NP and other testing (e.g. formal balance assessment), following. a more conservative RTP approach may be appropriate. In most cases, NP testing will be used to assist RTP decisions and will not be done until the patient is symptom free.29,30 There may 3.1. Neuroimaging be situations (e.g. child and adolescent athletes) where testing may be performed early, while the patient is still symptomatic, to assist It was recognized by the panelists that conventional structural in determining management. This will normally be determined neuroimaging is normal in concussive injury. Given that caveat, best in consultation with a trained neuropsychologist.31,32 the following suggestions are made: brain CT scans (or where available, brain MRI) contribute little to concussion evaluation but should be employed whenever suspicion of an intracerebral 3.4. Genetic testing structural lesion exists. Examples of such situations may include a prolonged disturbance of the conscious state, a focal neurological The significance of apolipoprotein (Apo) E4, ApoE promotor deficit or worsening symptoms. gene, Tau polymerase and other genetic markers in the manage- Newer structural MRI modalities including gradient echo, perfu- ment of sports concussion risk or injury outcome is unclear at this sion and diffusion imaging have greater sensitivity for structural time.33,34 Evidence from human and animal studies in more severe abnormalities. However, the lack of published studies as well as traumatic brain injury demonstrates induction of a variety of absent pre-injury neuroimaging data limits the usefulness of this genetic and cytokine factors such as: insulin-like growth factor-1 approach in clinical management. In addition, the predictive value (IGF-1), IGF binding protein-2, fibroblast growth factor, copper– B-3 Attachment B
758 P. McCrory et al. / Journal of Clinical Neuroscience 16 (2009) 755–763 zinc superoxide dismutase-1 (SOD-1), nerve growth factor, glial the stepwise program, then the patient should drop back to the fibrillary acidic protein (GFAP) and S-100. Whether such factors previous asymptomatic level and try to progress again after a fur- are affected in sporting concussion is not known at this stage.35–42 ther 24-hour period of rest has passed.
3.5. Experimental concussion assessment modalities 4.2. Same day return to play
Different electrophysiological recording techniques (e.g. evoked With adult athletes, in some settings, where there are team response potential, cortical magnetic stimulation and electroen- physicians experienced in concussion management and sufficient cephalography) have demonstrated reproducible abnormalities in resources (e.g. access to neuropsychologists, consultants, neuroim- the post-concussive state; however, not all studies reliably differ- aging) as well as access to immediate (i.e. sideline) neurocognitive entiated concussed athletes from controls.43–49 The clinical signif- assessment, RTP management may be more rapid. The RTP strategy icance of these changes remains to be established. must still follow the same basic management principles; namely, In addition, biochemical serum and cerebrospinal fluid markers full clinical and cognitive recovery before consideration of RTP. of brain injury (including S-100, neuron specific enolase, myelin This approach is supported by published guidelines, such as the basic protein, GFAP, tau) have been proposed as means by which American Academy of Neurology, US Team Physician Consensus cellular damage may be detected if present.50–56 There is insuffi- Statement, and US National Athletic Trainers’ Association Position cient evidence, however, to justify the routine use of these bio- Statement.58–60 This issue was extensively discussed by the con- markers clinically. sensus panelists and it was acknowledged that there is evidence that some professional American football players are able to return 4. CONCUSSION MANAGEMENT to play more quickly, with even same day RTP supported by National Football League studies without a risk of recurrence or The cornerstone of concussion management is physical and cog- sequelae.61 There are data, however, demonstrating that at the col- nitive rest until symptoms resolve and then a graded program of legiate and high school level, athletes allowed to RTP on the same exertion prior to medical clearance and RTP. The recovery and out- day may demonstrate NP deficits post-injury that may not be evi- come of this injury may be modified by a number of factors that dent on the sidelines and are more likely to have delayed onset of may require more sophisticated management strategies. These symptoms.62–68 It should be emphasized, however, that the young are outlined in the section on modifiers (see Section 5). (<18 years) elite athlete should be treated more conservatively As described above, the majority of injuries will recover sponta- even though the resources may be the same as for an older profes- neously over several days. In these situations, it is expected that an sional athlete (see Section 6.1). athlete will proceed progressively through a stepwise RTP strat- egy.57 During this period of recovery while symptomatic following 4.3. Psychological management and mental health issues an injury, it is important to emphasize to the athlete that physical and cognitive rest is required. Activities that require concentration In addition, psychological approaches may have potential appli- and attention (e.g. scholastic work, video games, text messaging) cation in this injury, particularly with the modifiers listed in may exacerbate symptoms and possibly delay recovery. In such Section 5.69,70 Care givers are also encouraged to evaluate the cases, apart from limiting relevant physical and cognitive activities concussed athlete for affective symptoms such as depression as (and other risk-taking opportunities for re-injury) while symptom- these symptoms may be common in concussed athletes.57 atic, no further intervention is required during the period of recov- ery and the athlete typically resumes sport without further 4.4. The role of pharmacological therapy problem. Pharmacological therapy in sports concussion may be applied in 4.1. Graduated return to play protocol two distinct situations. The first of these situations is the manage- ment of specific prolonged symptoms (e.g. sleep disturbance, The RTP protocol following a concussion follows a stepwise anxiety). The second situation is where drug therapy is used to process as outlined in Table 1. modify the underlying pathophysiology of the condition with the With this stepwise progression, the athlete should continue to aim of shortening the duration of concussion symptoms.71 In broad proceed to the next level if asymptomatic at the current level. terms, this approach to management should be considered only by Generally each step should take 24 hours so that an athlete would clinicians experienced in concussion management. take approximately one week to proceed through the full rehabil- An important consideration in RTP is that concussed athletes itation protocol once they are asymptomatic at rest and with pro- should not be only symptom free but also should not be taking vocative exercise. If any post-concussion symptoms occur while in any pharmacological agents/medications that may mask or modify
Table 1 Graduated return to play protocol
Rehabilitation stage Functional exercise at each stage of rehabilitation Objective of each stage 1. No activity Complete physical and cognitive rest Recovery 2. Light aerobic Walking, swimming or stationary cycling keeping intensity <70% MPHR. No resistance training. Increase HR exercise 3. Sport-specific Skating drills in ice hockey, running drills in soccer. No head impact activities. Add movement exercise 4. Non-contact training Progression to more complex training drills (e.g. passing drills in football and ice hockey). May Exercise, coordination, cognitive load drills start progressive resistance training). 5. Full contact practice Following medical clearance, participate in normal training activities Restore confidence, assessment of functional skills by coaching staff 6. Return to play Normal game play
HR = heart rate, MPHR = maximum predicted heart rate. B-4 Attachment B
P. McCrory et al. / Journal of Clinical Neuroscience 16 (2009) 755–763 759 the symptoms of concussion. Where antidepressant therapy may ance assessment, and neuroimaging. It is envisioned that athletes be commenced during the management of a concussion, the deci- with such modifying features would be managed in a multidisci- sion to RTP while still on such medication must be considered care- plinary manner coordinated by a physician with specific expertise fully by the treating clinician. in the management of concussive injury. The role of female gender as a possible modifier in the manage- 4.5. The role of pre-participation concussion evaluation ment of concussion was discussed at length by the panel. There was not unanimous agreement that the published research evi- Recognizing the importance of a concussion history, and appre- dence is conclusive that this should be included as a modifying fac- ciating that many athletes will not recognize all the concussions tor, although it was accepted that gender may be a risk factor for that they may have suffered, a detailed concussion history is of injury and/or influence injury severity.76–78 value.72–75 Such a history may pre-identify athletes who fit into a high-risk category and provides an opportunity for the healthcare 5.1. The significance of loss of consciousness provider to educate the athlete in regard to the significance of concussive injury. A structured concussion history should include In the overall management of moderate to severe TBI, duration specific questions as to previous symptoms of a concussion; not of loss of consciousness (LOC) is an acknowledged predictor of out- just the perceived number of past concussions. It is also worth not- come.79 While published findings in concussion describe LOC asso- ing that dependence upon the recall of concussive injuries by ciated with specific early cognitive deficits, it has not been noted as teammates or coaches has been demonstrated to be unreliable.72 a measure of injury severity.80,81 Consensus discussion determined The clinical history should also include information about all pre- that prolonged (>1 minute duration) LOC would be considered as a vious head, face or cervical spine injuries as these may also have factor that may modify management. clinical relevance. It is worth emphasizing that in the setting of maxillofacial and cervical spine injuries, coexistent concussive 5.2. The significance of amnesia and other symptoms injuries may be missed unless specifically assessed. Questions per- taining to disproportionate impact versus symptom severity There is renewed interest in the role of post-traumatic amnesia matching may alert the clinician to a progressively increasing vul- and its role as a surrogate measure of injury severity.67,82,83 Pub- nerability to injury. As part of the clinical history, it is advised that lished evidence suggests that the nature, burden and duration of details regarding protective equipment employed at the time of clinical post-concussive symptoms may be more important than injury be sought, both for recent and remote injuries. The benefit the presence or duration of amnesia alone.80,84,85 Further, it must of a comprehensive pre-participation concussion evaluation is that be noted that retrograde amnesia varies with the time of measure- it allows for modification and optimization of protective behavior ment post-injury and hence is poorly reflective of injury and an opportunity for education. severity.86,87
5. MODIFYING FACTORS IN CONCUSSION MANAGEMENT 5.3. Motor and convulsive phenomena
The consensus panel agreed that a range of ‘‘modifying” factors A variety of immediate motor phenomena (e.g. tonic posturing) may influence the investigation and management of concussion or convulsive movements may accompany a concussion. Although and, in some cases, may predict the potential for prolonged or per- dramatic, these clinical features are generally benign and require sistent symptoms. These modifiers would also be important to con- no specific management beyond the standard treatment of the sider in a detailed concussion history and are outlined in Table 2. underlying concussive injury.88,89 In this setting, there may be additional management consider- ations beyond simple RTP advice. There may be a more important 5.4. Depression role for additional investigations including: formal NP testing, bal-
Mental health issues (e.g. depression) have been reported as a Table 2 long-term consequence of TBI including sports-related concussion. Concussion modifiers Neuroimaging studies using fMRI suggest that a depressed mood Factors Modifier following concussion may reflect an underlying pathophysiological Symptoms Number abnormality consistent with a limbic-frontal model of depres- Duration (>10 days) sion.52,90–100 Severity Signs Prolonged LOC (>1 minute), amnesia 6. SPECIAL POPULATIONS Sequelae Concussive convulsions Temporal Frequency – repeated concussions over time Timing - injuries close together in time 6.1. The child and adolescent athlete ‘‘Recency” – recent concussion or TBI Threshold Repeated concussions occurring with progressively less impact There was unanimous agreement by the panel that the evalua- force or slower recovery after each successive concussion tion and management recommendations contained herein could Age Child and adolescent (<18 years old) be applied to children and adolescents down to the age of 10 years. Below that age children report concussion symptoms different from Comorbidity Migraine, depression or other mental and health disorders, ADHD, LD, sleep disorders adults and would require age-appropriate symptom checklists as a premorbidity component of assessment. An additional consideration in assessing Medication Psychoactive drugs, anticoagulants the child or adolescent athlete with a concussion is that in the clin- ical evaluation by the healthcare professional there may be the Behavior Dangerous style of play need to include both patient and parent input, as well as teacher Sport High-risk activity, contact and collision sport, high sporting level and school input, when appropriate.101–107 ADHD = attention deficit hyperactivity disorder, LD = learning disabilities, The decision to use NP testing is broadly the same as the LOC = loss of consciousness, TBI = traumatic brain injury. adult assessment paradigm. However, timing of testing may B-5 Attachment B
760 P. McCrory et al. / Journal of Clinical Neuroscience 16 (2009) 755–763 differ in order to assist planning in school and home manage- mechanical studies have shown a reduction in impact forces to ment (and may be performed while the patient is still symptom- the brain with the use of head gear and helmets, but these findings atic). If cognitive testing is performed then it must be have not been translated to show a reduction in concussion inci- developmentally sensitive until the late teen years due to the dence. For skiing and snowboarding there are studies to suggest ongoing cognitive maturation that occurs during this period that helmets provide protection against head and facial injury which, in turn, makes the utility of comparison to either the per- and hence should be recommended for participants in alpine son’s own baseline performance or to population norms lim- sports.113–116 In specific sports such as cycling, motor and eques- ited.20 In this age group it is more important to consider the trian sports, protective helmets may prevent other forms of head use of trained neuropsychologists to interpret assessment data, injury (e.g. skull fracture) that are related to falling on hard road particularly in children with learning disorders and/or attention surfaces and these may be an important injury prevention issue deficit hyperactivity disorder who may need more sophisticated for those sports.116–128 assessment strategies.31,32,101 The panel strongly endorsed the view that children should not 7.2. Rule change be returned to practice or play until clinically completely symptom free, which may require a longer time frame than for adults. In Consideration of rule changes to reduce the head injury inci- addition, the concept of ‘‘cognitive rest” was highlighted with spe- dence or severity may be appropriate where a clear-cut mecha- cial reference to a child’s need to limit exertion with activities of nism is implicated in a particular sport. An example of this is in daily living and to limit scholastic and other cognitive stressors football (soccer) where research studies demonstrated that upper (e.g text messaging, video games) while symptomatic. School limb-to-head contact in heading contests accounted for approxi- attendance and activities may also need to be modified to avoid mately 50% of concussions.129 As noted earlier, rule changes also provocation of symptoms. may be needed in some sports to allow an effective off-field med- Because of the different physiological response and longer ical assessment to occur without compromising the athlete’s wel- recovery after concussion and specific risks (e.g. diffuse cerebral fare, affecting the flow of the game or unduly penalizing the swelling) related to head impact during childhood and adoles- player’s team. It is important to note that rule enforcement may cence, a more conservative RTP approach is recommended. It is be a critical aspect of modifying injury risk in these settings and appropriate to extend the amount of time of asymptomatic rest referees play an important role in this regard. and/or the length of the graded exertion in children and adoles- cents. It is not appropriate for a child or adolescent athlete with 7.3. Risk compensation concussion to RTP on the same day as the injury regardless of the level of athletic performance. Concussion modifiers apply even An important consideration in the use of protective equipment more to this population than adults and may mandate more is the concept of risk compensation.130 This is where the use of pro- cautious RTP advice. tective equipment results in behavioral change such as the adop- tion of more dangerous playing techniques, which can result in a 6.2. Elite vs non-elite athletes paradoxical increase in injury rates. This may be a particular con- cern in child and adolescent athletes where head injury rates are 131–133 The panel unanimously agreed that all athletes regardless of often higher than in adult athletes. level of participation should be managed using the same treatment and RTP paradigm. A more useful construct was agreed whereby 7.4. Aggression versus violence in sport the available resources and expertise in concussion evaluation were of more importance in determining management than a sep- The competitive/aggressive nature of sport that makes it fun to aration between elite and non-elite athlete management. Although play and watch should not be discouraged. However, sporting formal baseline NP screening may be beyond the resources of organizations should be encouraged to address violence that may many sports or individuals, it is recommended that in all organized increase concussion risk.134,135 Fair play and respect should be sup- high-risk sports consideration be given to having this cognitive ported as key elements of sport. evaluation regardless of the age or level of performance.
6.3. Chronic traumatic brain injury 8. KNOWLEDGE TRANSFER
Epidemiological studies have suggested an association between As the ability to treat or reduce the effects of concussive injury repeated sports concussions during a career and late-life cognitive after the event is minimal, education of athletes, colleagues and impairment. Similarly, case reports have noted anecdotal cases the general public is a mainstay of progress in this field. Athletes, where neuropathological evidence of chronic traumatic encepha- referees, administrators, parents, coaches and healthcare providers lopathy was observed in retired football players.108–112 A panel dis- must be educated regarding the detection of concussion, its clinical cussion was held and no consensus was reached on the significance features, assessment techniques and principles of safe RTP. Meth- of such observations at this stage. Clinicians need to be mindful of ods to improve education including web-based resources, educa- the potential for long-term problems in the management of all tional videos and international outreach programs are important athletes. in delivering the message. In addition, concussion working groups plus the support and endorsement of enlightened sports groups such as Fédération Internationale de Football Association (FIFA), 7. INJURY PREVENTION International Ice Hockey Federation (IIHF), International Olympic Commission (IOC) and the International Rugby Board (IRB) who ini- 7.1. Protective equipment – mouthguards and helmets tiated this endeavor have enormous value and must be pursued vig- orously. Fair play and respect for opponents are ethical values that There is no good clinical evidence that currently available pro- should be encouraged in all sports and sporting associations. Simi- tective equipment will prevent concussion, although mouthguards larly coaches, parents and managers play an important part in have a definite role in preventing dental and orofacial injury. Bio- ensuring these values are implemented on the field of play.57,136–148 B-6 Attachment B
P. McCrory et al. / Journal of Clinical Neuroscience 16 (2009) 755–763 761
9. FUTURE DIRECTIONS researchers in clinical medicine, sports medicine, neurosci- ence, neuroimaging, athletic training and sports science. The consensus panelists recognize that research is needed 2. These experts presented data in a public session, followed across a range of areas in order to answer some critical research by inquiry and discussion. The panel then met in an execu- questions. The key areas for research identified include: tive session to prepare the consensus statement. 3. Specific questions were prepared and posed in advance to validation of the SCAT2 (see Supplementary Figs. 1 and 2) define the scope and guide the direction of the conference. gender effects on injury risk, severity and outcome The principle task of the panel was to elucidate responses pediatric injury and management paradigms to these questions. These questions are outlined in the virtual reality tools in the assessment of injury preamble. rehabilitation strategies (e.g. exercise therapy) 4. A systematic literature review was prepared and circulated novel imaging modalities and their role in clinical in advance for use by the panel in addressing the conference assessment questions. concussion surveillance using consistent definitions and out- 5. The Consensus statement is intended to serve as the scien- come measures tific record of the conference. clinical assessment where no baseline assessment has been 6. The Consensus statement will be widely disseminated to performed achieve maximum impact on both current healthcare prac- ‘‘best-practice” NP testing tice and future medical research. long-term outcomes on-field injury severity predictors. The panel chairperson (WM) did not identify with any advocacy position. The chairperson was responsible for directing the consen- 10. MEDICAL LEGAL CONSIDERATIONS sus session and guiding the panel’s deliberations. Panelists were drawn from clinical practice, academic and research in the field This consensus document reflects the current state of knowledge of sports related concussion. They do not represent organizations and will need to be modified according to the development of new per se but were selected for their expertise, experience and under- knowledge. It provides an overview of issues that may be of impor- standing of this field. tance to healthcare providers involved in the management of sports-related concussion. It is not intended as a standard of care, APPENDIX A. SUPPLEMENTARY DATA and should not be interpreted as such. This document is only a guide, and is of a general nature, consistent with the reasonable Supplementary data associated with this article can be found, in practice of a healthcare professional. Individual treatment will de- the online version, at doi:10.1016/j.jocn.2009.02.002. pend on the facts and circumstances specific to each individual case. 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Report to Congress on Mild Traumatic Brain Injury in the United States:
Steps to Prevent a Serious Public Health Problem
September 2003
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The Report to Congress on Mild Traumatic Brain Injury in the United States: Steps to Prevent a Serious Public Health Problem is a publication of the National Center for Injury Prevention and Control, part of the Centers for Disease Control and Prevention.
Centers for Disease Control and Prevention Julie Louise Gerberding, M.D., M.P.H. Director
National Center for Injury Prevention and Control Sue Binder, M.D. Director
Suggested Citation: National Center for Injury Prevention and Control. Report to Congress on Mild Traumatic Brain Injury in the United States: Steps to Prevent a Serious Public Health Problem. Atlanta, GA: Centers for Disease Control and Prevention; 2003.
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Dear Colleague:
Traumatic brain injury is frequently referred to as the silent epidemic because the problems that result from it (e.g., impaired memory) often are not visible. Mild traumatic brain injury (MTBI) accounts for at least 75 percent of all traumatic brain injuries in the United States. However, it is clear that the consequences of MTBI are often not mild.
In response to these concerns, Congress passed the Children’s Health Act of 2000 (Public Law 106-310), which required the Centers for Disease Control and Prevention (CDC) to submit a report to Congress on appropriate methodological strategies to obtain data on the incidence and prevalence of MTBI. To that end, CDC formed the Mild Traumatic Brain Injury Work Group, composed of brain injury experts, to determine appropriate and feasible methods for assessing the incidence and prevalence of MTBI in the United States.
This report, Mild Traumatic Brain Injury (MTBI) in the United States: Steps to Prevent a Serious Public Health Problem, presents the significant findings and recommendations of the members of the MTBI Work Group, which are the product of numerous discussions and a thorough review of the scientific litera ture. It describes the public health significance of MTBI and makes recommen dations on how to better measure the magnitude of the problem of MTBI in this country. Incorporating the recommendations of this report into public health policy and public health practice will help the nation to better understand the full impact and the long-term consequences of MTBI.
Julie Louise Gerberding, M.D., M.P.H. Director Centers for Disease Control and Prevention Department of Health and Human Services
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Contents
I. Preface
II. Executive Summary 1
III. Body of the Report
Introduction 7
Formation and Objectives of the CDC 13 Mild Traumatic Brain Injury Work Group
Findings and Recommendations of the 15 CDC Mild Traumatic Brain Injury Work Group
Conclusion 26
References 27 Appendices
A. CDC Mild Traumatic Brain Injury 31 Work Group
B. Criteria Used to Evaluate Proposed, 35 Ongoing Surveillance Systems to Identify Persons with Mild Traumatic Brain Injury in the United States
C. Descriptions of Recommended 37 Mild Traumatic Brain Injury Databases
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Preface
In recent decades, public health and health care communities have become increasingly aware that the consequences of mild traumatic brain injury (MTBI) may not, in fact, be mild. Epidemiologic research has identified MTBI as a public health problem of large magnitude, while clinical research has provided evidence that these injuries can cause serious, lasting problems.
In response to public health concerns, Congress passed the Children’s Health Act of 2000, which required the Centers for Disease Control and Prevention (CDC) to determine how best to measure the rate at which new cases of MTBI occur (i.e., incidence) and the proportion of the U.S. population at any given time that is experiencing the effects of a MTBI (i.e., prevalence) and to report the findings to Congress. To that end, CDC formed the Mild Traumatic Brain Injury Work Group, composed of experts in the field of brain injury, to determine appropriate and feasible methods for assessing the incidence and prevalence of MTBI in the United States.
This report presents the significant findings and recommendations of the members of the CDC MTBI Work Group, which are the product of numerous discussions and a thorough review of the scientific literature. It describes the public health significance of MTBI and recommends how to better measure the magnitude of the problem of MTBI in this country.
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Executive Summary
Background According to existing data, more than 1.5 million people experience a traumatic brain injury (TBI) each year in the United States. Of them, as many as 75 percent sustain a mild traumatic brain injury—or MTBI. These injuries may cause long-term or permanent impairments and disabilities. Many people with MTBI have difficulty returning to rou tine, daily activities and may be unable to return to work for many weeks or months. In addition to the human toll of these injuries, MTBI costs the nation nearly $17 billion each year.
These data, however, likely underestimate the problem of MTBI in this country—for several reasons. First, no standard definitions exist for MTBI and MTBI-related impair ments and disabilities. The existing Centers for Disease Control and Prevention (CDC) definition for TBI surveillance is designed to identify cases of TBI that result in hospital ization, which tend to be more severe. MTBI is most often treated in emergency depart ments or in non-hospital medical settings, or it is not treated at all. Few states conduct emergency department-based surveillance, and current efforts do not capture data about persons with MTBI who receive no medical treatment. Additionally, neither hospital- nor emergency department-based data can provide estimates of the long-term consequences of MTBI.
In response to concerns about this public health problem, Congress passed the Children’s Health Act of 2000, which required CDC to determine how best to measure the incidence (i.e., rate at which new cases of MTBI occur) and the prevalence (i.e., proportion of the U.S. population at any given time that is experiencing the effects) of MTBI and to report the findings to Congress. To that end, CDC formed the Mild Traumatic Brain Injury Work Group to determine appropriate and feasible methods for assessing the incidence and prevalence of MTBI in the United States.
The Mild Traumatic Brain Injury Work Group The Mild Traumatic Brain Injury Work Group brought together 17 external experts from fields including epidemiology, neurology, neurosurgery, neuropsychology, statistics, and an organization representing the brain injury community. The work group was divided into two subgroups. The Definitions Subgroup developed a conceptual definition of MTBI based on clinical signs, symptoms, and neuroimaging; and an operational defini tion to be used in identifying cases of MTBI in administrative databases, medical records, and survey and interview results. The Methods Subgroup evaluated surveillance databases and identified those that would best capture the types of data needed to deter- mine the full magnitude of MTBI and related impairments and disabilities.
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Recommended Definitions for Mild Traumatic Brain Injury
Incident Cases of MTBI The conceptual definition of MTBI is an injury to the head as a result of blunt trauma or acceleration or deceleration forces that result in one or more of the following conditions:
● Any period of observed or self-reported:
◆ Transient confusion, disorientation, or impaired consciousness;
◆ Dysfunction of memory around the time of injury;
◆ Loss of consciousness lasting less than 30 minutes.
● Observed signs of neurological or neuropsychological dysfunction, such as:
◆ Seizures acutely following injury to the head;
◆ Among infants and very young children: irritability, lethargy, or vomiting following head injury;
◆ Symptoms among older children and adults such as headache, dizziness, irritability, fatigue or poor concentration, when identified soon after injury, can be used to support the diagnosis of mild TBI, but cannot be used to make the diagnosis in the absence of loss of consciousness or altered consciousness. Research may provide additional guidance in this area.
Based on this conceptual definition, separate operational definitions of MTBI are recommended for cases identified from interviews and surveys, administrative health care data sets, and patient medical records. These operational definitions are described in detail in the Definitions Subgroup Findings and Recommendations section (pages 15–21).
Prevalent Cases of MTBI-Related Impairments, Functional Limitations, Disabilities, and Persistent Symptoms The conceptual definition of a prevalent case of MTBI is any degree of neurological or neuropsychological impairment, functional limitation, disability, or persistent symptom attributable to an MTBI.
The operational definition of a prevalent case of MTBI-related impairment, functional limitation, disability, or persistent symptoms is any case in which current symptoms are
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reported consequent to MTBI or made worse in severity or frequency by the MTBI, or in which current limitations in functional status are reported consequent to MTBI. Symptoms and limitations are described on pages 19-21.
Recommended Methods for Mild Traumatic Brain Injury Surveillance To obtain data on the incidence and prevalence of MTBI, established methods such as hospital emergency department- and hospital-based data collection and analysis should be the first priority. The other methods provided in this report can serve as additional sources of good information as resources and capacity will allow.
Priority Recommendations to Obtain Data on the Incidence and Prevalence of MTBI
● Increase the number of states conducting emergency department- and hospital-based TBI surveillance, and apply the recommended operational definitions of MTBI to improve detection of cases in these and national systems.
● Explore using large, national hospital discharge databases that have not been used previously for injury surveillance.
Additional Recommendations – Detection and Surveillance of New Cases of Medically-Treated MTBI
● Routinely analyze data from CDC health and medical care surveys to estimate incidence and external causes of MTBIs treated in hospital outpatient settings and those treated outside hospitals and hospital emergency departments.
● Analyze data from a collegiate sports surveillance system to assess the incidence of MTBI among participants in selected college sports.
Detection and Surveillance of New Cases (Incidence) of MTBI Not Receiving Medical Care
● Explore adding MTBI-related questions to large, existing, state-based surveys.
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● Determine the feasibility of using existing, national health surveys to identify people with MTBI who do not receive medical care.
Identifying and Assessing Prevalent Cases of MTBI-Related Impairment, Functional Limitation, Disability, and Persistent Symptoms
● Explore adding MTBI-related questions to existing surveys and sur veillance systems to determine the prevalence of individuals with MTBI-related functional and cognitive impairments or disabilities.
● Explore determining the occurrence of MTBI-related disabilities and impairments among children by adding MTBI-related questions to large, longitudinal studies.
● Collaborate with the Defense and Veterans Head Injury Program to use their databases to determine the occurrence of MTBI-related disabilities.
● Use existing TBI surveillance systems and registries to develop pro spective follow-up studies to determine what percentage of persons with MTBI become disabled or experience persistent symptoms, and to improve linkage of brain-injury persons with appropriate services.
Establishing the Natural History of MTBI-Related Impairments and Disabilities
● Collaborate with the Defense and Veterans Brain Injury Program to use their databases to determine the natural history of MTBIs experienced by military personnel and to identify pre-existing,acute, and chronic factors that predict the likelihood of disabilities, impair ments, and persistent symptoms.
● Explore adding questions to longitudinal studies to track the evolution of impairments, functional limitations, disabilities, and persistent symptoms associated with MTBI.
● Support the development of state-based TBI registries with the ability to track acute MTBI cases longitudinally.
● Develop methods to determine how pre-injury and post-injury conditions affect MTBI outcomes.
● Research how symptoms and their resolution relate to the presence of biological markers.
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Documenting the Prevalence of Individuals with MTBI-Related Disabilities in Special Populations The Methods Subgroup determined that information about special populations (e.g., persons in mental health institutions and educational settings) is not of sufficient quantity or quality to recommend MTBI surveillance methods at this time. They recom mended that stakeholders coordinate activities to promote research and standardize data collection instruments and methods.
Conclusion Evidence indicates that MTBI is a public health problem, the magnitude and impact of which are underestimated by current surveillance systems. Much research is needed to determine the full magnitude of MTBI, to identify preventable and modifiable risk factors, and to develop and test strategies to reduce MTBIs and to improve outcomes for those who sustain these injuries. Such research will inform the development of more effective primary prevention strategies and policies to address the service and rehabili tation needs of persons with MTBI. The recommendations in this report can help shape that research.
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Introduction
Mild Traumatic Brain Injury: Signs, Symptoms, and Diagnosis Historically, clinicians and investigators have classified traumatic brain injury as mild, moderate, and severe by using the scores of the Glasgow Coma Scale, a widely-used scoring system to assess coma and impaired consciousness (Teasdale and Jennett 1974; Rimel, Giordani, Barth, et al. 1981, 1982). Patients with scores of 8 or less are classified as “severe”; scores of 9 to 12 are “moderate”; and scores of 13 to 15 are “mild.”
Mild traumatic brain injury or MTBI—also called concussion, minor head injury, minor brain injury, minor head trauma, or minor TBI (Rimel, Giordani, Barth, et al. 1981; Tellier, Della Malva, Cwinn, et al. 1999; Rutherford 1989)—is one of the most common neurologic disorders (Kurtzke and Jurland 1993). It occurs when an impact or forceful motion of the head results in a brief alteration of mental status, such as confusion or disorientation, loss of memory for events immediately before or after the injury, or brief loss of consciousness. In contrast, more severe traumatic brain injuries are associated with extended periods of unconsciousness (more than 30 minutes), prolonged post- traumatic amnesia (more than 24 hours), or penetrating skull injury. Although the distinction between MTBI and more severe TBI seems straightforward, establishing definitive, measurable criteria to identify and quantify the occurrence of MTBI has proven challenging because clinicians and investigators have been using different diagnostic criteria and methodologies to study this condition (Ruff and Jurica 1999; American Congress of Rehabilitation Medicine 1993).
A variety of radiological and laboratory techniques have been used to diagnose TBI, including X-rays of the skull, computed tomography of the brain, MRI (magnetic reso nance imaging), and SPECT (single photon emission computed tomography) (De Kruijk, Twijnstra and Leffers 2001; Bigler and Snyder 1995). To monitor the severity of brain damage, several biological markers, such as Serum S-100, that indicate damage to brain cells are under investigation (De Kruijk, Twijnstra and Leffers 2001; Ingebrigtsen, Romner, Marup-Jensen, et al. 2000). Although these imaging and laboratory techniques help to rule out more serious TBIs, some patients with MTBI do not present abnormali ties, or the markers are not sensitive enough to accurately diagnose the condition (De Kruijk, Twijnstra and Leffers 2001; Ingebrigtsen, Romner, Marup-Jensen, et al. 2000). Thus, additional research is needed about using these and other more advanced techniques to accurately diagnose MTBI.
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Consequences of Mild Traumatic Brain Injury People with MTBI and their health care providers may fail to recognize the potential severity of a brief period of unconsciousness or memory loss caused by a blow to the head (Alexander 1995; Swift and Wilson 2001). Many individuals with MTBI do not receive medical care at the time of the injury and may later present to their primary care physician days, weeks, or even months after the injury with complaints of persistent symptoms (Alexander 1995; Kushner 1998).
A person with MTBI may manifest brief symptoms or experience persistent and dis abling problems (Kushner 1998). The clinical consequences of such an injury can, for example, affect one’s ability to return to work and complete routine, daily activities. In one study, employed persons who were hospitalized for MTBI lost an average of nearly four weeks of work after injury (Binder, Rohling and Larrabee 1997). Other researchers reported unemployment rates among previously employed MTBI victims of 34 percent at 3 months and 9 percent at 12 months after injury (Rimel, Giordani, Barth, et al. 1981; Guthkelch 1980). Also, people with MTBI may return to work despite incomplete recovery (Russell 1971).
Despite widespread agreement that MTBI may be associated with substantial neuro psychological problems, there is disagreement about how often and for how long such problems persist. Some researchers suggest that pre-injury factors such as age, alcohol abuse, educational level, and neuropsychiatric history, and post-injury factors such as stress, litigation, and compensation claims may affect the recovery of persons with MTBI and contribute to their disabilities (Kibby and Long 1996). However, findings in the literature are inconsistent, possibly resulting from study design limitations (Bernstein 1999) such as the lack of a control group and the absence of a standard definition for MTBI (Culotta, Sementilli, Gerold and Watts 1996; Dikmen and Levin 1993).
Knowledge about the natural clinical history of MTBI is incomplete. Impaired attention, concentration, information processing speed, and memory are the most common, persis tent complaints following MTBI; others include headaches, dizziness, nausea, fatigue, and emotional problems such as impulsiveness and mood swings (Barth, Macciocchi, Giordani, et al. 1983; Bohnen, Twijnstra and Jolles 1992; Alves, Macciocchi and Barth 1993; Macciocchi, Barth and Littlefield 1998). However, these symptoms are not spe cific to MTBI and commonly occur in the general population (Barsky and Borus 1999; Wessely, Nimnuan and Sharpe 1999; Iverson and McCracken 1997). Moreover, consider- able variability exists in the frequency with which persons with MTBI report post-injury complaints (Steadman and Graham 1970; Rutherford, Merrett and McDonald 1978;
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Alves, Macciocchi and Barth 1993; Bohnen, Twijnstra and Jolles 1992; Deb, Lyons and Koutzoukis 1998). The lack of certainty about out-comes suggests a need for follow-up studies to assess the prevalence of symptoms and disabilities in representative populations.
The Burden of All Traumatic Brain Injury in the United States TBI, including all levels of severity, is a major cause of death and life-long disability in the United States. Each year, an estimated 1.5 million Americans sustain a TBI (Sosin, Sniezek and Thurman 1996); 50,000 die from these injuries; and 80,000 to 90,000 experience onset of long-term disability (CDC 1999). An estimated 5.3 million Americans live with a permanent TBI-related disability today (CDC 1999).
Magnitude of Mild Traumatic Brain Injury in the United States Of the 1.5 million people who survived a TBI, 392,000 (25 percent) were hospitalized; 543,000 (35 percent) were treated in emergency departments (EDs) and released; 221,000 (14 percent) were treated in clinics and physicians’ offices; and 381,000 (25 percent) did not receive medical care (Sosin, Sniezek and Thurman 1996). Of those who were hospitalized, 146,000 stayed in the hospital for only one night. These data suggest that as many as 75 percent of traumatic brain injured persons sustain mild trau matic brain injury (MTBI). Using hospital and ED data, the TBI Surveillance Program of the South Carolina Department of Health (SC DOH) identified 56,780 new cases of TBI in the state from 1996 to 2000. Of them, 86 percent (49,099) were mild injuries; of these, 85 percent were identified through ED surveillance (Table 1, page 10). Both national surveillance systems and the SC DOH data underestimate the occurrence of TBI because they do not include injured people who received medical care in other facilities, such as outpatient clinics, or those who received no medical care for their injuries.
The incidence of MTBI in EDs appears to have increased—almost doubling from 216 per 100,000 in 1991 (Sosin, Sniezek and Thurman 1996) to 392 per 100,000 in 1995–1996 (Guerrero, Thurman and Sniezek 2000). In contrast, MTBI hospitalizations appear to have declined from 130 per 100,000 to 51 per 100,000 between 1980 and 1994 (Thurman and Guerrero 1999). These findings may reflect changes in hospital practices that shift the care of persons with less severe forms of TBI from hospital inpatient care to ED and outpatient treatment. Such changes indicate a growing need to document and study MTBIs treated in EDs and outpatient settings.
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Table 1. Frequency and Distribution (Percent) of Traumatic Brain Injury in South Carolina by Severity and Level of Care, 1996–2000
Level of Care Injury Severity EDs Only Hospitalization Total
Mild TBI 41,734 7,365 49,099 (85 percent) (15 percent) (100 percent)
Moderate and — 7,681 7,681 Severe TBI (100 percent) (100 percent)
TOTAL 41,734 15,046 56,780 (74 percent) (26 percent) (100 percent)
Source: Selassie A. 1996–2000 South Carolina Department of Health Traumatic Brain Injury Surveillance Program. Unplublished Data.
Mild Traumatic Brain Injury: Special Considerations We need to further explore issues related to MTBI among children and among sports participants. Very few population-based studies have examined MTBI among children (Kraus, Fife and Conroy 1987). However, existing data indicate that the rates of hospital admissions and ED visits for head injuries are several times higher among children than the general adult population (Jennett 1996), with the highest rates among children under age five (Beattie 1997) and among children in lower socioeconomic groups (Adelson and Kochanek 1998). Further research is needed to assess the magnitude of MTBI among this population and to guide prevention efforts.
Sports-related injuries accounted for 20 percent (306,000) of the 1.5 million TBIs in the United States in 1991 (Sosin, Sniezek and Thurman 1996). Of persons with sports- related TBI, 12 percent (35,000) were hospitalized; 55 percent (168,000) received out- patient care only; and 34 percent (103,000) received no medical care (Sosin, Sniezek and Thurman 1996; Thurman, Branche and Sniezek 1998). These data suggest that most sports-related traumatic brain injuries fall into the mild or moderate category. While it is important to the health of children to be physically active, we must further investigate the relationship that sports may pose on the injuries one incurs, especially if the injury occurs at a young age.
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Economic Burden of Mild Traumatic Brain Injury Max and colleagues (1991) analyzed U.S. incidence and cost data for all TBIs that resulted in hospitalization or death in 1985. MTBI accounted for $16.5 billion or 44 percent of the estimated total lifetime cost ($37.8 billion) of TBIs that year. CDC updated these estimates using incidence data from 1995 and adjusting for inflation to yield an estimated total cost of $56 billion, $16.7 billion of which was for MTBI (Thurman 2001). For several reasons, this figure underestimates the economic burden MTBI poses on the United States. First, it does not include injuries treated in EDs; this omission is significant, given the decreasing trend to hospitalize persons with TBI. Additionally, it excludes injured persons treated in other, non-hospital medical care settings, such as private physicians’ offices; the costs of lost productivity and lost quality of life; and indirect costs borne by family members and friends who care for persons with MTBI. Because our knowledge about the current cost to society from TBI and MTBI is limited (Thurman 2001), these additional costs need to be quantified and need to be studied to address the impact of the changes in health care practices that shifted the care of less severe forms of TBI from inpatient care to ED and outpatient treatment and follow-up (Thurman and Guerrero 1999).
Limitations in Defining the Problem of Mild Traumatic Brain Injury in the United States MTBI has been studied in great detail from a clinical perspective, by looking at its signs, symptoms, and management, mainly among hospitalized patients. Few studies have described the magnitude and impact of MTBI from a population perspective that includes persons who are not hospitalized (Kraus, McArthur and Silberman 1994).
Complicating efforts to establish true measures of this problem are a lack of an accepted, standard definition for MTBI; a limited understanding of the consequences of MTBI; and inadequate methods of collecting data about MTBI and its outcomes (Kraus, McArthur and Silberman 1994).
Lack of a Standard Definition Definitions of MTBI used by clinicians and investigators vary significantly (Culotta, Sementilli, Gerold and Watts 1996; Dikmen and Levin 1993). The current CDC case definition used for TBI surveillance activities is designed to identify cases of TBI that are treated in hospitals—cases that tend to be more severe. To address this limitation, CDC recognizes a need for standard surveillance case definitions to assist in identifying new MTBI cases and cases with impairments, functional limitations, disabilities, or persistent symptoms.
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Limited Understanding of Consequences of MTBI Many health care providers fail to recognize the potential impact of MTBI (Alexander 1995; Kushner 1998; Swift and Wilson 2001). Greater awareness of the problems experi enced by persons with MTBI is needed to improve recognition of the condition, to reduce the extent of MTBI-related disability, and to ensure that injured persons get the services they need to allow them to resume their societal roles.
Limitations in Surveillance Currently, most TBI surveillance relies on hospitalization data; only a few states conduct ED-based surveillance.1 With hospitalization rates for cases of MTBI declining and more patients with these injuries receiving care in EDs or non-hospital settings, traditional inpatient, hospital-based surveillance identifies only a small percentage of persons with MTBI. Moreover, current surveillance does not capture data about persons who receive no medical care (Thurman and Guerrero 1999).
Neither hospital discharge nor ED data can estimate the number of individuals living with the consequences of MTBI or determine the full spectrum of long-term symptoms and disabilities associated with this type of injury. Some studies have attempted to assess prognosis and sequelae of MTBI. However, because these studies were conducted in small, selected clinical samples using different methodologies, their findings cannot be generalized to the U.S. population (Dikmen and Levin 1993; Bohnen, Twijnstra and Jolles 1992).
Accurate estimates of the prevalence of MTBI-related impairments, functional limita tions, disabilities, and persistent symptoms require follow-up assessments among representative samples of the brain-injured population after recovery from the acute phase of injury: for example, three months, six months, and one year or longer after injury. However, population-based studies of MTBI prevalence may have substantial limitations. For example, attrition (number of persons lost to follow-up during a study) is likely to increase as the follow-up interval increases. Also, detailed or face-to-face examinations to assess neurological impairments common after MTBI may be impracti cal for large, population-based samples; the amount and quality of disability-related information gathered might be limited by necessary cost-saving methods such as tele phone interviewing. Research is needed to address these issues that make it difficult to estimate the prevalence of disabilities resulting from MTBI.
1 CDC funds 12 states to conduct hospital discharge- based TBI surveillance and 2 states to conduct ED-based TBI surveillance.
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Formation and Objectives of the CDC Mild Traumatic Brain Injury Work Group
To address the challenges outlined previously and to meet the objectives set by Congress in the Children’s Health Act of 2000, CDC formed the Mild Traumatic Brain Injury (MTBI) Work Group, composed of 17 external experts from diverse fields, including epidemiology, neurology, neurosurgery, neuropsychology, statistics, and an organization representing the brain injury community. The Work Group’s objectives were as follows:
● Recommend standard MTBI surveillance case definitions to help detect:
◆ Persons receiving medical care for MTBI in hospitals, EDs, or other health care settings;
◆ Persons experiencing MTBIs who do not receive immediate medical care;
◆ Persons who experience MTBI-related impairments, functional limitations, disabilities, or persistent symptoms.
● Recommend the best ways to measure the incidence ofacute cases of MTBI among persons who:
◆ Receive inpatient hospital care;
◆ Receive treatment in EDs or other outpatient settings;
◆ Do not receive immediate medical care.
● Recommend the best ways to assess the prevalence of persons experiencing long-term impairments, functional limitations, disabilities, or persistent symptoms resulting from MTBI.
● Recommend approaches to better establish the natural clinical history of MTBI-related impairments, functional limitations, disabilities, and persistent symptoms.
● Recommend approaches to identify prevalence of MTBI-related impairments, functional limitations, disabilities, and persistent symptoms among special populations, including persons in school, special education classes, mental health institutions, and prisons.
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To achieve these objectives, the Work Group was divided into the MTBI Surveillance Case Definition Subgroup (the Definitions Subgroup) and the MTBI Surveillance Methods and Database Subgroup (the Methods Subgroup). As a foundation for the subgroups’ activities, CDC conducted a systematic literature review that found more than 400 articles relevant to MTBI to be reviewed by subgroup members.
Definitions Subgroup The Definitions Subgroup reviewed key literature from 1980 to 2001 to summarize clinical case definitions and diagnostic criteria for MTBI as a foundation for developing a conceptual definition of MTBI and for formulating operational definitions for important surveillance measures, such as incidence of medically-treated and non-treated cases and prevalence of disabilities.
Methods Subgroup The Methods Subgroup reviewed key literature and data to identify potential surveillance databases and surveys to gather data about MTBI and its consequences. Subgroup mem bers interviewed experts on databases and surveillance and evaluated systems using standard public health surveillance criteria (Teutsch 2000; CDC 2001); a summary of the evaluation criteria is found in Appendix B. They considered validity and reliability of data in making final recommendations. They also reviewed information about special populations, such as persons in school, special education classes, mental health institu tions, and prisons.
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Findings and Recommendations of the CDC Mild Traumatic Brain Injury Work Group
The subgroups met twice per month by teleconference from June 2001 to November 2001 to share information and to develop a plan for producing the Report to Congress. In late November 2001, the MTBI Work Group met with CDC staff in Atlanta to review find ings and to formulate recommendations.
Definitions Subgroup Findings and Recommendations The Definitions Subgroup found wide variation in the clinical case definitions and criteria used to identify MTBIs. As a foundation for developing operational definitions for MTBI, the subgroup developed conceptual definitions.
A conceptual case definition provides criteria to identify a case of MTBI for surveil- lance purposes based on selected clinical signs, symptoms, and neuroimaging. This definition is necessary as a reference standard for the evaluation of operational or working definitions of MTBI used by surveillance systems.
An operational case definition provides quantifiable criteria to consistently identify cases of MTBI for surveillance purposes when reviewing coded health care adminis trative databases, abstracting information from medical records, or analyzing data from surveys and personal interviews. Operational definitions should be designed to approxi mate the conceptual definition as closely as possible.
The Definitions Subgroup used the Traumatic Brain Injury (TBI) definition found in CDC’s Guidelines for Surveillance of Central Nervous System Injury (Thurman, Sniezek, Johnson, Greenspan and Smith 1995) as the foundation for its definitions. However, that definition does not categorize injuries by severity and is not well suited for surveillance of less severe injuries that may not be treated in hospital settings.
The recommended definitions for MTBI were developed with the following premises in mind:
● TBI severity refers to the degree of brain trauma as it is assessed during the acute phase of injury. TBI severity assessment focuses on acute signs and symptoms indicating brain pathophysiology.
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● TBI severity should be distinguished from TBI outcome (Dikmen and Levin 1993). Assessment of TBI outcome focuses on subacute or chronic signs and symptoms related to impairment and disability. TBI outcome is most relevant to measures of TBI prevalence.
● Major criteria for distinguishing levels of TBI severity are based primarily on the immediate effects of TBI on consciousness or cognition. In addition, focal signs and intracranial pathology (demonstrable on neuroimaging studies such as computed tomography) are considered.
● An incident case should meet either conceptual or operational definition criteria within the surveillance period.
● Some criteria for distinguishing grades of severity await further clinical study and more conclusive evidence.
Recommended Conceptual Definition of Incident Cases of MTBI A case of MTBI is an occurrence of injury to the head resulting from blunt trauma or acceleration or deceleration forces with one or more of the following conditions attribut able to the head injury during the surveillance period:
● Any period of observed or self-reported transient confusion, disorientation, or impaired consciousness;
● Any period of observed or self-reported dysfunction of memory (amnesia) around the time of injury;
● Observed signs of other neurological or neuropsychological dysfunction, such as—
◆ Seizures acutely following head injury;
◆ Among infants and very young children: irritability, lethargy, or vomiting following head injury;
◆ Symptoms among older children and adults such as headache, dizziness, irritability, fatigue, or poor concentration, when identified soon after injury, can be used to support the diagnosis of mild TBI, but cannot be used to make the diagnosis in the absence of loss of consciousness or altered con sciousness. Further research may provide additional guidance in this area.
● Any period of observed or self-reported loss of consciousness lasting 30 minutes or less.
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More severe brain injuries were excluded from the definition of MTBI and include one or more of the following conditions attributable to the injury:
● Loss of consciousness lasting longer than 30 minutes;
● Post-traumatic amnesia lasting longer than 24 hours;
● Penetrating craniocerebral injury.
A wide range of severity and the possibility of further gradation exists within this defini tion. The Definitions Subgroup identified additional criteria that may further distinguish degrees of severity within the spectrum of mild TBI. Under this recommended definition, TBI cases with intracranial lesions demonstrated by neuroimaging studies (e.g., com puted tomography) or with focal neurological deficits (e.g., hemiplegia) may still be considered mild if the criteria described previously are met. Some evidence, although inconsistent, indicates that such cases may have poorer outcomes (Williams, Levin and Eisenberg 1990; Dikmen and Temkin, unpublished data, 2001). To the extent allowed by data sources, TBI surveillance systems and epidemiological studies should obtain information about the presence of intracranial lesions, focal findings, and duration of unconsciousness in reported cases. Mild TBI cases with such abnormalities should be distinguished from cases without them in analyses of MTBI outcome. The value of such findings to predict outcome may be better defined by future research.
Recommended Operational Definitions of Incident Cases of MTBI Three operational definitions are recommended for case ascertainment based on interviews and surveys; health care administrative data sets, such as hospital billing data; and clinical records, such as hospital medical record reviews or trauma registry data.
Interview/survey definition A case of MTBI is recognized when a person surveyed or interviewed (or his or her proxy respondent) affirms the occurrence, within the period under surveillance, of a nonfatal injury to the head that is accompanied by:
● Criteria consistent with the recommended conceptual case definition (above);
● Loss of consciousness or altered consciousness;
● Loss of memory for events immediately before, during, or after the injury.
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Surveys and interviews should ask whether health care professionals evaluated such injuries and, if so, what level of care was received. Where possible, analyses of data should distinguish between injuries receiving no medical care, non-hospital-based care, hospital ED care, inpatient hospital care of 24 hours or less, and inpatient hospital care of more than 24 hours. Occurrences of brain injury with inpatient hospital care of more than 24 hours may be classified as more severe (i.e., they do not meet the criteria for MTBI).
Administrative data definition for surveillance or research (ICD-9-CM) A case of MTBI is recognized among persons treated in health care facilities who are assigned the following ICD-9-CM diagnostic codes (International Classification of Diseases 1989):
ICD-9-CM First Four Digits = ICD-9-CM Fifth Digit = 800.0, 800.5, 801.0, 801.5, 0, 1, 2, 6, 9, or Missing 803.0, 803.5, 804.0, 804.5, 850.0, 850.1, 850.5 or 850.9
854.0 1, 2, 6, 9, or Missing
959.0* 1
*The current inclusion of code 959.01 (i.e., head injury, unspecified) in this definition is provisional. Although a recent clarification in the definition of this code is intended to exclude concussions, there is evidence that nosologists have been using it to code TBIs. Accordingly, this code may be removed from the recommended definition of mild TBI when there is evidence that in common practice nosologists no longer assign this code for TBI.
The codes in this table represent one possible approach for identifying MTBI using ICD-9-CM codes obtained from administrative records. Research is needed to determine the reliability and validity of these codes for defining MTBI. The full range of ICD-9- CM codes consistent with TBI of any severity is published in the CDC Guidelines for Surveillance of Central Nervous System Injury (Thurman, Sniezek, Johnson, Greenspan and Smith 1995).
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Clinical records data definition A case of MTBI is recognized when medical records document any one of the following:
● Criteria consistent with the recommended conceptual case definition (page 16);
● Glasgow Coma Scale (GCS) score between 13 and 15 assigned at the time of first medical evaluation at a health care facility (Teasdale and Jennett 1974; 1976);2
● Abbreviated Injury Severity (AIS) Scale score of 2 for the head region (Association for the Advancement of Automotive Medicine 1998).
Injuries accompanied by indicators of neurological deterioration during the course of acute care, such as cases in which subsequent GCS scores fall below 13 are excluded.
Recommended Conceptual Definition of Prevalent Cases of MTBI-Related Impairments, Functional Limitations, Disabilities, and Persistent Symptoms A prevalent case of MTBI-related impairment, functional limitation, disability, or persistent symptoms is recognized among persons with a history of MTBI who are experiencing any degree of neurological or neuropsychological problem attributable to the MTBI.
Recommended Operational Definitions of Prevalent Cases of MTBI-Related Impairments, Functional Limitations, Disabilities, and Persistent Symptoms Measuring the prevalence of MTBI-related impairments, functional limitations, disa bilities, and persistent symptoms requires follow-up assessments after recovery from the acute phase of injury: for example, at three months, six months, and one year or longer after injury. Follow-up studies of representative samples of persons who
2 The Glasgow Coma Scale is widely used in clinical practice to distinguish degrees of TBI severity. The routine recording of GCS scores by clinicians and the collection of GCS data by surveillance systems are strongly recommended. Among children under 36 months, a pediatric coma scale can be used. Some scales are intended to approximate the GCS, with a score of 13 to 15 indicating a mild injury. See Hahn YS, Chyung C, Barthel MJ, et al. Head injuries in children under 36 months of age: demography and outcome. Child’s Nervous System 1988;4:34–40. See also Simpson DA, Cockington RA, Hanieh A, et al. Head injuries in infants and young children: The value of the pediatric coma scale. Review of the literature and report on a study. Child’s Nervous System 1991;7:183–90.
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No widely accepted, standard assessment tool currently exists to identify prevalent cases of MTBI-related impairment, functional limitation, disability, and persistent symptoms in population-based surveys. CDC proposes the following limited criteria for construct ing an operational definition for such surveys, when respondents are persons with a history of MTBI or reliable proxy respondents:
● Current symptoms reported consequent to MTBI not present before injury or those made worse in severity or frequency by the MTBI:
◆ Problems with memory
◆ Problems with concentration
◆ Problems with emotional control
◆ Headaches
◆ Fatigue
◆ Irritability
◆ Dizziness
◆ Blurred vision
◆ Seizures
● Current limitations in functional status reported consequent to MTBI:
◆ Basic activities of daily living (e.g., personal care, ambulation, travel)
◆ Major activities (e.g., work, school, homemaking)
◆ Leisure and recreation
◆ Social integration
◆ Financial independence
Most of these symptoms and limitations are associated with many other conditions in addition to MTBI. This lack of specificity for MTBI places some limitations on the validity of studies of the prevalence of MTBI-related impairments, functional limitations, disabilities, and persistent symptoms. However, these limitations may be minimized by
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appropriate selection of comparison groups and cautious interpretation of findings, and by assessing pre- and post-injury symptom occurrence. If pre-existing symptoms cannot be “attributable” to the MTBI, these data should also be documented for further study and interpretation.
Methods Subgroup Findings and Recommendations The Methods Subgroup reviewed a wide range of databases and surveys to identify those that would be most appropriate for measuring the incidence of MTBI; to determine the prevalence of MTBI-related impairments and disabilities; to determine underlying causes of MTBIs; and to identify population groups at risk regardless of age. Most of these databases and surveys were set up largely to provide information about other medical issues, but together, and with additional questions added, they can provide a more complete picture of MTBI. To obtain data on the incidence and prevalence of MTBI, established methods such as hospital emergency department- and hospital-based data collection and analysis should be the first priority. As resources and capacity will allow, the other methods provided in this report can serve as additional sources of good information. A summary of the subgroup’s review and findings follows.
Detection and Surveillance of New Cases (Incidence) of Medically-Treated MTBI In making recommendations for measuring the incidence of medically-treated MTBIs, the Methods Subgroup was primarily concerned with including data sources that are accessible, valid, and reliable. The recommendations focused largely on enhancing capabilities to conduct TBI surveillance in emergency departments (EDs), because many more MTBIs are diagnosed and treated in EDs than in hospital inpatient settings and because such ED data systems already exist in some states and at the national level. However, the subgroup also recognized the need to improve surveillance of hospitalized cases of MTBI. Specific recommendations include:
Priority Recommendations to Obtain Data on the Incidence and Prevalence of MTBI
● Increase the number of states conducting ED-based TBI surveillance using the South Carolina Department of Health (SC DOH) TBI Surveillance Program as a model.
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● Routinely analyze data from CDC’s National Hospital Ambulatory Medical Care Survey (NHAMCS) and National Ambulatory Medical Care Survey (NAMCS) to estimate incidence of, study external causes related to, and identify trends in MTBIs treated in, outpatient settings.
● Increase the number of states conducting MTBI surveillance using hospital discharge data.
● Consider using large, national hospital discharge databases, such as the Nation- wide Inpatient Sample database [conducted by the Agency for Health Care Research and Quality (AHRQ)/Healthcare Cost and Utilization Project (HCUP)] that have not been used previously for injury surveillance.
● Explore using data from the National Electronic Injury Surveillance System (NEISS) to assess the incidence and external causes of MTBI in the United States among persons treated in EDs.
Additional Recommendations
● Routinely analyze data collected by CDC’s National Health Interview Survey (NHIS) to estimate the incidence of MTBI among persons who receive medical care outside of hospitals and hospital EDs.
● Analyze data from the National Collegiate Athletic Association Injury Surveillance System (NCAAISS) to assess the incidence of MTBI among participants in selected college sports.
● Apply the recommended operational definition of MTBI to enhance the capability of current CDC-funded state TBI Surveillance Systems and other national and state hospital discharge databases to detect and monitor MTBI incidence.
● Routinely analyze data from the National Hospital Discharge Survey (NHDS) to assess hospitalization patterns due to MTBI.
● Collaborate with the Defense and Veterans Head Injury Program to use use their database and the Defense and Medical Surveillance System databases to determine the occurrence of MTBI in these systems.
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Detection and Surveillance of New Cases (Incidence) of MTBI Not Receiving Medical Care Measuring the incidence of MTBIs that are not treated medically is difficult because the injuries are not documented in any routinely-collected health information system. To the extent possible, the Methods Subgroup considered ways to add modules to existing surveys or studies. Specific recommendations include the following:
● Explore adding MTBI-related questions to large, existing state-based surveys, such as those conducted through CDC’s Behavioral Risk Factor Surveillance System (BRFSS) and Youth Risk Behavior Surveillance System (YRBSS).
● Explore adding a module to CDC’s National Health Interview Survey (NHIS) to study the incidence, external causes, and the consequences of MTBI among persons in the community, including those who did not receive medical care.
● For a sample of individuals self-reporting the receipt of medical care as a result of MTBI (identified via NHIS-DS and BRFSS), special follow-up studies with health care providers will be considered to determine the accuracy of self-reporting.
Identifying and Assessing Prevalent Cases of MTBI-Related Impairment, Functional Limitation, Disability, and Persistent Symptoms Identifying individuals disabled by the effects of a MTBI presents a challenge not only because they are not routinely documented in current health information systems, but also because many of the impairments, functional limitations, disabilities, and persistent symptoms experienced by persons with MTBI, may result from other conditions. Most existing health information systems and surveys are inadequate for this type of surveil- lance. Thus, documenting who and how many people are disabled by MTBI-related problems will be more costly than the surveillance and study of acute, medically-treated cases. With these considerations in mind, the Methods Subgroup recommended the following:
● Explore adding MTBI-related questions to existing surveys, such as the National Health Interview Survey–Disability Supplement (NHIS-DS), to determine the prevalence of individuals with MTBI-related functional and cognitive impairments or disabilities.
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● Determine the feasibility of adding MTBI disability questions to state-based surveillance systems or surveys, such as BRFSS.
● For a sample of individuals self-reporting the receipt of medical care as a result of MTBI (identified via NHIS-DS and BRFSS), special follow-up studies with health care providers should be considered to determine the accuracy of self-reporting.
● Consider determining the occurrence of MTBI-related disabilities and impairments among children by adding questions to large, longitudinal studies such as the 30-year follow-up National Children’s Study (http://nationalchildrensstudy.gov).
● Collaborate with the Defense and Veterans Head Injury Program to use their database and the Defense and Medical Surveillance System data- bases to determine the occurrence of MTBI-related disabilities.
● Use existing TBI surveillance systems and registries to develop prospective follow-up studies to determine what percentage of persons with MTBI become disabled or experience persistent symptoms, to identify which cases receive appropriate services, and to link brain-injured persons with appropriate rehabilitation support and other services.
Establishing the Natural History of MTBI-Related Disabilities and Impairments Health care providers need a better understanding of the progression of acute injury into long-term disability to identify brain-injured persons at greatest risk for lasting problems and to determine when to intervene to ensure the best possible outcomes. This knowledge will be gained through studying patients with MTBI over time. To this end, the Methods Subgroup focused on using existing or proposed databases and studies capable of track ing MTBI cases from occurrence to two or more years after injury. Specific recommen dations include the following:
● Collaborate with the Defense and Veterans Head Injury Program to use their database to determine the natural history of MTBIs experienced by military personnel and to identify pre-existing, acute, and chronic factors that predict the likelihood of disabilities, impairments, and persistent symptoms.
● Explore adding MTBI-related questions to longitudinal studies, such as the National Children’s Study to track the evolution of symptoms and disabilities associated with MTBI.
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● Support the development of state-based TBI registries with the ability to track acute MTBI cases longitudinally.
● Develop methods to determine the effects of pre-injury conditions, such as learning disabilities and psychiatric problems, and post-injury conditions and circumstances, such as depression, substance abuse, and compensation.
The relationship of symptoms and their resolution to the presence of biological markers that may be developed in the future, is an important research question that also needs to be addressed.
Documenting the Prevalence of Individuals with MTBI-Related Disabilities in Special Populations Documenting the prevalence of individuals impaired by MTBIs in special populations— such as those in school programs, mental health institutions, and prisons—is difficult for several reasons. First, there is a lack of standardized definitions for special populations. Second, no health data systems exist for these populations specifically. Finally, in many cases, no data of any kind exist about MTBI among these groups. For these reasons, the Methods Subgroup determined that information about special populations is not of sufficient quantity or quality to make recommendations at this time. Given the current knowledge in these areas, stakeholders should coordinate activities to promote research and to standardize data collection instruments and methods.
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Conclusion
Evidence indicates that MTBI is a public health problem, the magnitude and impact of which are underestimated by current surveillance systems. Much research is needed to determine the full magnitude of MTBI, to identify preventable and modifiable risk factors, and to develop and test strategies to reduce MTBIs and to improve outcomes for those who sustain these injuries. Such research will inform the development of more effective primary prevention strategies and policies to address the service and reha bilitation needs of persons with MTBI. The recommendations in this report can help shape that research.
Already, the definitions of MTBI recommended in this report have received support from the public health community. The World Health Organization’s Task Force on Mild Traumatic Brain Injury reviewed the definitions, and, at the time this report was prepared, recommended that these definitions be used worldwide for surveillance purposes. This recommendation is an important first step in establishing acceptance of uniform definitions of MTBI.
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Appendix A: CDC Mild Traumatic Brain Injury Work Group
Senior Editor Victor G. Coronado, M.D., M.P.H. Medical Epidemiologist Division of Injury and Disability Outcomes and Programs National Center for Injury Prevention and Control Centers for Disease Control and Prevention Atlanta, Georgia
Editor Bruce Jones, M.D., M.P.H. Acting Team Leader Disability and Rehabilitation Team Division of Injury and Disability Outcomes and Programs National Center for Injury Prevention and Control Centers for Disease Control and Prevention Atlanta, Georgia
Executive Secretary Victor G. Coronado, M.D., M.P.H. Medical Epidemiologist Division of Injury and Disability Outcomes and Programs National Center for Injury Prevention and Control Centers for Disease Control and Prevention Atlanta, Georgia
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Definitions Subgroup Jeffrey J. Bazarian, M.D. Assistant Professor University of Rochester Medical Center Department of Emergency Medicine Rochester, New York
Kathleen R. Bell, M.D. Associate Professor Department of Rehabilitation Medicine University of Washington Medical Center Seattle, Washington
Jörgen Borg, M.D. Associate Professor, Neurology, Karolinska Institutet Head, Department of Rehabilitation Medicine Stockholm, Sweden
Sureyya Dikmen, Ph.D. Professor, Department of Rehabilitation Medicine Neurological Surgery and Psychiatry and Behavioral Sciences University of Washington Seattle, Washington
Jess F. Kraus, Ph.D., M.P.H. Director, Southern California Injury Prevention Research Center UCLA School of Public Health Los Angeles, California
Charles J. Long, Ph.D. Chair, Director, MS Graduate Psychology Program Psychology Department The University of Memphis Memphis, Tennessee
David Thurman, M.D. Medical Epidemiologist National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention Atlanta, Georgia
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Methods Subgroup Robert C. Cantu, M.D. Medical Director National Center for Catastrophic Sports Injury Research University of North Carolina Chief, Neurosurgery Service Emerson Hospital Concord, Massachusetts
J. David Cassidy, Ph.D. Associate Professor, Epidemiology and Medicine Alberta Centre for Injury Control and Research Department of Public Health Sciences Faculty, Medicine and Dentistry University of Alberta Edmonton, Alberta, Canada
John D. Corrigan, Ph.D. Professor, Department of Physical Medicine and Rehabilitation The Ohio State University Columbus, Ohio
Virginia M. Lesser, Dr.P.H., M.S. Assistant Professor, Statistics Director, Survey Research Center Oregon State University Corvallis, Oregon
Gregory O’Shanick, M.D. Co-Chair, U.S. Mild Traumatic Brain Injury (MTBI) Guideline Development Work Group National Medical Director, Brain Injury Association of America Medical Director, Center for Neuro-Rehabilitation Services Midlothian, Virginia
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Peter Patrick, Ph.D. Associate Professor, Clinical Pediatrics School of Medicine, University of Virginia Director, Pediatric Psychology/Neuropsychology Children’s Medical Center Kluge Children’s Rehabilitation Center Charlottesville, Virginia
Karen Schwab, Ph.D. Assistant Director for Statistics Defense and Veterans Head Injury Program Department of Neurology Walter Reed Army Medical Center Gaithersburg, Maryland
Anbesaw W. Selassie, Dr.P.H. Chair, Department of Biometry and Epidemiology Medical University of South Carolina Charleston, South Carolina
Nancy Temkin, Ph.D. Associate Professor, Neurological Surgery and Biostatistics Department of Neurological Surgery University of Washington Seattle, Washington
Barbara Weissman, M.D. Associate Professor Pediatrics (Neurology) Emory University School of Medicine Medical Director, Rehabilitation Services Children’s Healthcare of Atlanta at Egleston Medical Director, Day RehabilitationProgram Children’s Healthcare of Atlanta Atlanta, Georgia
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Appendix B: Criteria Used to Evaluate Proposed, Ongoing Surveillance Systems to Identify Persons with Mild Traumatic Brain Injury in the United States
The following criteria are summarized from CDC guidelines for evaluating public health surveillance systems (CDC 2001).
Simplicity. Structure and ease of operating the surveillance system. Is the operational case definition easy to apply? Are cases easily ascertained? How much time and how many resources are or will be required to maintain the system?
Flexibility. System’s ability to adapt as information needs or operating conditions change, given limited availability of personnel and/or funds.
Data Quality. Completeness and accuracy of the data collected. What is the proportion of unknown and missing responses?
Acceptability. Willingness of the survey population to participate in the surveillance system. What are the participation rates? What are the interview completion rates and refusal rates?
Sensitivity. System’s ability to detect true cases of MTBI. What is the proportion of cases detected? How well can the system track changes and trends over time?
Predictive Value Positive. Proportion of reported cases that actually experienced the health event or have the health condition under surveillance.
Representativeness. Accuracy of a system to describe the occurrence of a health event or condition under surveillance over time and its distribution in the population by place and person.
Timeliness. Speed between steps in public health surveillance from the occurrence of the event to feedback to clinicians, investigators, legislators, and the public.
Stability. System’s ability to collect, manage, and report data properly without failure.
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Appendix C: Descriptions of Recommended Mild Traumatic Brain Injury Databases
South Carolina Department of Health (SC DOH) TBI Surveillance System Characteristics: Statewide surveillance system conducted by the SC DOH with CDC funds since 1995 to characterize the epidemiology of TBI in this state. Targets all state residents, regardless of age, who receive health care in hospitals and in self-standing or hospital-based EDs. Data are abstracted from coded hospital discharge and ED adminis trative databases. Medical records are reviewed for a sample. Data are unduplicated (thus, it is a true patient-level). Coded mortality data is also collected. It requires $300,000 to $370,000 a year ($150,000 to $200,000 for ED data and $150,000 to $170,000 for hospital and vital statistics data).
Strengths: Population-based. State representative. Targets all ages. Timely. Economical. Includes ED-based data. Reports true, unduplicated cases. Uses International Classifica tion of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) rubrics to code medical diagnoses.
Limitations: If implemented in other states, a law requiring all self-standing and hospital- based EDs to report in standard format may be necessary.
Recommendations: Use as model to be implemented in selected states. Allows the yearly study of incidence, trends, demographics, external causes, and selected risk factors in the population. Potential use for follow-up studies to improve understanding of the natural history of MTBI.
National Electronic Injury Surveillance System (NEISS) Characteristics: Nationally-representative, probability sample surveillance system of all U.S. hospitals with EDs conducted by the U.S. Consumer Product Safety Commission since 1972 and expanded through collaboration with CDC in July 2000. Targets all persons regardless of age who receive health care in 100 representative hospital-based EDs. NEISS collects data for over 500,000 cases per year, visiting selected EDs. Trained NEISS staff abstract data daily from eligible records. Subsequent telephone or on-site follow-back interviews yield clues about the causes of injury. Only first-time-visit data are reported. Routine analysis of NEISS data costs $100,000 to $150,000 per year.
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Strengths: Nationally representative. Large population under study may allow better estimates. Targets all ages. Timely. Economical. Has a follow-back system. Identifies unduplicated cases. Provides patient-level data.
Limitations: Coding accuracy varies by variable from 27 percent (for adverse effects) to 92 percent (for transportation-related cases). Has its own special coding system different from that of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).
Recommendations: Analyze routinely to study incidence, external causes, occupation and type of industry, and risk factors. Potential uses for follow-up or follow-back studies to assess the natural history of MTBI.
National Hospital Ambulatory Medical Care Survey (NHAMCS) – Emergency Department and Outpatient Department Modules Characteristics: Nationally-representative, four-stage probability sample survey of visits to hospital EDs and outpatient departments (ODs) of non-federal, short-stay general hospitals in the United States. Conducted by CDC’s National Center for Health Statistics since 1992. Targets all persons regardless of age who receive health care in hospital- based EDs and ODs. Hospital staff collects health care information for all visits to EDs and ODs during a randomly assigned four week reporting period. Sample data are weighted to produce annual, nationally-representative estimates. Routine analysis of NHAMCS data costs $100,000 to $150,000 per year. Adding more variables to obtain two more diagnostic codes costs $100,000 per year.
Strengths: Nationally representative. Targets all ages. Timely. Economical. Uses International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) rubrics to code medical diagnoses.
Limitations: Only three diagnostic codes are collected; thus, MTBI cases may be missed (estimated missing cases range from 25 to 30 percent). Production of more precise estimates requires aggregating data from at least two survey years.
Recommendations: Analyze routinely (at intervals of at least two years) to study inci dence, trends, demographics, external causes of injury, service use, hospital character istics, expected source of payment, chief complaint and diagnosis, medications, type of provider, and disposition of MTBI-related visits to EDs and ODs. Additional funds will be necessary to collect at least five diagnostic codes; this will allow detection of 90 to 95 percent of all MTBIs.
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National Ambulatory Medical Care Survey (NAMCS) Characteristics: Nationally-representative, multistage probability sample survey of visits to the offices of non-federally employed physicians (excluding those in anesthesiology, radiology, and pathology), including visits to non-hospital-based clinics and health maintenance organizations. Conducted by CDC’s National Center for Health Statistics since 1973. Targets all persons regardless of age who receive health care from selected office-based physicians. Health data for a systematic random sample of office visits occurring during a randomly assigned one-week reporting period are abstracted by sampled physicians (1,088 in 1999). Routine analysis of the NAMCS costs $100,000 to $150,000 yearly.
Strengths: Nationally representative. Targets persons of all ages. Economical. Uses International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) rubrics to code medical diagnoses.
Limitations: Only three diagnostic codes are collected; thus, MTBI cases may be missed. Excludes specialties of radiology, anesthesiology, and pathology. Precise estimates require aggregating data from at least two consecutive years.
Recommendations: Analyze routinely (at intervals of at least two years) to study inci dence, trends, demographics, reasons for visits, place of injury, use of preventive services (including violence and injury prevention), medications, and disposition of MTBI-related visits.
National Health Interview Survey (NHIS) Characteristics: Population-based, nationally-representative, face-to-face area proba bility sample survey conducted by CDC’s National Center for Health Statistics since 1957. Used to assess public health issues among the civilian, non-institutionalized U.S. population. Respondents are household residents ages 18 years and older. Data is obtained for all members of the family residing in the household; respondents are the proxies for younger persons living in the household. Topical data (e.g., disability) are collected. In 1997, data from 40,000 households were collected; 103,5000 persons responded to the interview. The Injury Section of the Core NHIS Instrument identifies injuries requiring medical attention occurring in the three months preceding the interview among respondents or family members residing in the household at the time of the interview. Causes and consequences of each injury episode are also collected. Routine analysis of the NHIS data costs $100,000 to $150,000 per year.
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Strengths: Population based. Nationally representative. Targets all ages. Economical. Potential use for follow-up; costs for this aspect were not estimated at this time. Uses International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) rubrics to code medical diagnoses.
Limitations: Current care-of-injury eligibility criteria exclude people who did not receive health care or advice. Current time-of-injury eligibility criteria (i.e., injuries requiring medical attention occurring in the three months preceding the interview) limit study of the natural history and sample size. Any proposed follow-up study requires funding and up to two to three years for implementation.
Recommendations: Analyze routinely to study incidence, trends, and demographics. Data from the Disability Supplement can also be analyzed routinely. Findings can also be compared with methods of contemporaneous surveillance of health events and can serve as a validation system. Propose modifying current care-of-injury eligibility criteria to allow for identification and interview of persons who had a MTBI but did not receive medical care or advice. Extend current time-of-injury eligibility criteria to generate a larger sample. Follow-up studies can be proposed and implemented, provided that questions regarding natural history and associated disability are included in the instrument.
National Collegiate Athletic Association Injury Surveillance System (NCAAISS) Characteristics: Population-based, nationally-representative sports-related injury surveillance system that has collected data from a representative sample of colleges that are members of the National Collegiate Athletic Association (NCAA) since 1982 (450 of 977 in 2000). Final selection of participant colleges is random and includes at least 10 percent of each NCAA division. Data are used to reduce injury through changes in rules, protective equipment, and coaching techniques. Targets college students prac ticing spring football; wrestling; baseball; ice and field hockey; women’s volleyball and softball; and men’s and women’s soccer, basketball, gymnastics, and Lacrosse. Data on at least one sport are collected in a standardized questionnaire by certified and student athletic trainers from the first official day of pre-season practice to the final tournament contest.
Strengths: Population based. NCAA representative. Conducted at no cost to CDC. Can produce regional and state-level estimates. Potential use for follow-up studies.
Limitations: Excludes all non-NCAA colleges. Does not include some contact sports (e.g., karate). Data are not validated.
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Recommendations: Analyze routinely to assess the incidence of MTBI in selected college sports. Follow-up/follow-back studies can be added; these enhancements will allow clinicians and investigators to characterize natural history, adverse outcomes, and associated disability.
CDC Traumatic Brain Injury Surveillance System Characteristics: Statewide, representative surveillance system conducted in selected states receiving CDC funding since 1996. This system is the only ongoing, population- based TBI surveillance system in the United States. It has two aspects: core surveillance, which relies on International Classification of Diseases, Version 9, Clinical Modification codes found in hospital discharge and vital statistics data; and extended surveillance, which relies on abstraction of relevant health information via medical record review. Targets hospitalized persons regardless of age. During the funding cycle that ended in 2000, 15 states received funds to conduct the core aspect; 14 of these also conducted the expanded aspect. In the cycle that began in late 2000, only 12 states were funded to conduct core TBI surveillance; of these, six were funded to conduct expanded surveillance. This system requires $140,000 to $180,000 per state per year ($80,000 to $100,000 to conduct the core aspect and $60,000 to $80,000 to conduct the expanded surveillance aspect).
Strengths: Representative at the state level. Economical. Targets persons of all ages. Uses International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) rubrics to code medical diagnoses. Potential use for follow-up studies.
Limitations: Not timely. Current TBI definition is not suitable for detecting cases of MTBI. Does not include ED data.
Recommendations: Analyze routinely to assess incidence, external causes, and risk factors of MTBI among persons who are hospitalized. Apply the recommended definitions for MTBI to enhance the system’s ability to detect and monitor MTBI in the United States. Increase the number of states conducting TBI surveillance.
National Hospital Discharge Survey (NHDS) Characteristics: Nationally-representative, three-stage stratified sample survey of inpa tient records acquired from a representative probability sample of about 500 non-federal, short-stay hospitals (average length of stay of 30 days or shorter) having six or more beds in the United States. Conducted by CDC’s National Center for Health Statistics (NCHS)
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42 since 1965. The NHDS is designed to provide information about characteristics of inpa tients (regardless of age) hospitalized and discharged from the hospitals in the survey. Medical and administrative data—including date of birth, sex, race, ethnicity, marital status, ZIP codes, dates of admission and discharge, discharge status, expected source of payment, procedures, diagnoses, size of hospital, and hospital ownership—for approxi mately 300,000 hospital discharges are obtained from two sources. The first source uses data that is manually-abstracted and transcribed by hospital and U.S. Bureau of the Census staff from a manually-selected sample of hospital discharge records. Completed forms are coded, computerized, and edited by NCHS. The second source uses a system atic sample of electronic hospital discharge files containing medical record data selected from electronic files purchased from public and private organizations authorized by the states. Approximately 10 percent of the abstracts are independently recoded with an overall error of 0.6 percent for medical coding and 0.3 percent for administrative coding. Approximately 40 percent of respondent hospitals provided data through the automated system. Sample data are weighted to produce annual, nationally-representative estimates. Routine analysis of NHDS data costs $100,000 to $150,000 per year.
Strengths: Nationally representative. Targets all ages. Excellent quality. Timely. Economical. Uses International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) rubrics to code medical diagnoses.
Limitations: Does not include ED data. Cannot distinguish first admissions from read- missions in some states; thus, allowing for discharge rates, not injury rates. Measures discharges and not individual patients (potential duplicates).
Recommendations: Analyze routinely to study incidence, trends, demographics, external causes of injury, service use, hospital characteristics, expected source of payment, chief complaint and diagnosis, medications, type of provider, and disposition of MTBI-related hospitalizations in non-federal, short-stay hospitals in the United States.
Nationwide Inpatient Sample (NIS) Characteristics: Nationally-representative, multi-state health data system based on all hospital discharges from a stratified probability sample of non-federal, short-stay hospitals (994 in 28 participant states in 2000). Sponsored by the Agency for Health- care Research and Quality since 1988. Designed to approximate a 20 percent sample of all non-federal, short-term, general and other specialty hospitals in the United States. The NIS 2000 is a sample of hospitals that comprise about 80 percent of all hospital discharges in the United States. States voluntarily report allowable electronic, coded discharge data from all persons hospitalized regardless of age. Analysis of NIS data costs $100,000 to $150,000 annually.
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Strengths: Representative at the participant state and national levels. Economical. Targets persons of all ages. Contains data on discharge disposition, procedures, service use, length of hospitalization, source of payment, and costs among hospitalized persons with MTBI at the national level. Contains 7 million records (in contrast, the National Hospital Discharge Survey (NHDS) contains 300,000). Uses International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) rubrics to code medical diagnoses.
Limitations: Does not include ED data. Reporting is not uniform: small hospitals are underrepresented in some states; hospitals in some states report only a subset of their discharges. Cannot distinguish first admissions from readmissions in some states; thus, allowing for discharge rates, not injury rates. Measures discharges and not individual patients (potential duplicates).
Recommendations: Analyze routinely to study the incidence of MTBI-related hospitalization and discharge in non-federal, short-stay hospitals in the United States.
Behavioral Risk Factor Surveillance System (BRFSS) and the South Carolina Department of Health Interagency Office of Disability and Health Disability Surveillance (SC DOH IODH-DS) Characteristics: CDC-sponsored, population-based, random digit dialing telephone surveillance system that collects topical data about varying health issues, including disability, among persons in the community. Includes persons who did not seek medical care. SC DOH IODH-DS has used BRFSS since the early 1990s, including a question about the likely cause of any disability in the “Quality of Life and Care Giving” module. BRFSS targets primarily people ages 18 years and older; however, some states collect infor-mation about children from parents or legal guardians. Costs vary with the number of questions added to the data collection instrument. Adding questions and administering them to the target population costs $35,000 to $50,000 per question. Routine data analy sis costs $50,000 to $70,000 per year.
Strengths: Population based. Representative at the state level; nationally representative if questions are administered by all participating states. Relatively economical. Allows identification of cases of persons with MTBI who did not receive health care. Potential use for follow-up studies among both adults and children.
Limitations: Nationally representative only if questions are administered by all states. Question about the likely cause of any disability in the “Quality of Life and Care Giving” module has low completion rates; thus, it needs to be re-written and tested. Does not cover population of persons in households without phones.
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Recommendations: Injury-related questions or module can be added to the data collection instrument and used to study MTBI incidence in the community, especially among those who did not receive health care (requires pre-testing of proposed questions before admin istering them in states). Follow-up studies can also be proposed.
National Children’s Study (NCS) Characteristics: Planned, population-based, nationally-representative, longitudinal cohort study of 100,000 children (from birth to adulthood) to measure exposure of risks for asthma, unintentional injuries, cancer, and developmental disorders; to assess out- comes of such health and safety problems; and to identify factors for improving children’s health and well being. Children will be recruited, measured, and followed-up in geographically-distributed centers using sampling techniques. Special populations will be oversampled. The National Institute of Child Health and Human Development (part of the National Institutes of Health), the Environmental Protection Agency (EPA), and CDC are leading a consortium of federal and non-federal partners. It includes children, their families, and their environment, physical, chemical, biological, and psychosocial influences. Biomarkers and exposure measurements will be collected and evaluated. Methodological development and pilot studies began in FY 2001 and will run through FY 2003; the study should begin in 2004 and is expected to end by 2035.
Strengths: Population based. Nationally representative. Targets children and their families. Hypothesis driven. Longitudinal design allows for determining causality and natural history. Biomarkers will be used. Special populations will be oversampled. Study design allows pilot tests to recommend standard tests or measures. CDC will incur no costs.
Limitations: Not a tested system. Excludes intentional injuries. Preliminary finding and results will not be available until 2010.
Recommendations: CDC should ensure the inclusion of a follow-up component to study the incidence and the natural history of MTBI among children in the United States. A pilot study could develop an injury severity scale to measure the long-term cognitive outcomes for MTBI, especially the cumulative effects of repetitive injuries (e.g., multiple minor concussions). In addition, a scale could distinguish between acute and chronic injuries; however, this distinction does not relate to outcome.
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Defense and Veterans Head Injury Program (DVHIP) Characteristics: Military and VA beneficiary TBI registry, based on patient information from seven lead sites and 20 network sites in the DVHIP. Conducted by the Department of Defense (DoD) and the Department of Veterans Affairs (VA) sites of the DVHIP since 1992. Data collected include those from standardized evaluation batteries, randomized trials, and data from the Defense National Databases. Components considered to study MTBI are primarily found among military patients included in the TBI registry and the DoD and VA national discharge databases for incidence studies, a helmet study in a paratrooper population, and a proposed follow-up study for prevalence and outcomes. Targets primarily adults who are hospitalized or receive health care in emergency depart ments and out-patient departments in the military and VA systems. Hospital discharge, ED, and outpatient data are used to identify cases of TBI (including MTBI). Routine analysis of the DVHIP registry data will cost $100,000 to $150,000 per year.
Strengths: Military- and VA-based. Military- and VA-representative. Timely. Economical. Contains baseline data (i.e., prior to injury), such as drug use and prior medical history. Includes ED data. Reports unduplicated cases; thus, allowing for study of MTBI inci dence. Military cases generally healthy pre-injury. Excellent potential to follow-up adults with MTBI to characterize outcomes and the natural history of this condition; no costs for this option have been determined at this time. Includes wartime injuries. Uses Inter- national Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) rubrics to code medical diagnoses.
Limitations: Does not represent the entire U.S. population. In general, younger adult males are over-represented in this database, consistent with TBI in the general popu lation. Population in the VA system is older than the U.S. population as a whole.
Recommendations: Collaborative routine analysis with DVHIP to assess incidence, risk factors, external causes, service needs and use, and long-term consequences of MTBI and its associated disabilities in the military system. Excellent option for implementing follow-up and tracking systems for persons with MTBI (through personal interviews and medical record reviews). Because military hospitals serve enlisted personnel and their families, children constitute a small proportion of the population in these databases. Any proposed, large follow-up study would target mainly adults; findings for non-wartime injuries can be extrapolated to the general population. Special follow-up studies that target children can be proposed. Follow-up studies will allow for the characterization of the natural history of MTBI among adults. No costs have been determined for the use of these resources at this point.
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N O T E S
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N O T E S
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C-56 Attachment D Hope Through Research Traumatic Brain Injury
National Institute of Neurological Disorders and Stroke National Institutes of Health
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NINDS health-related material is provided for information purposes only and does not necessarily represent endorsement by or an official position of the National Institute of Neurological Disorders and Stroke or any other Federal agency. Advice on the treatment or care of an individual patient should be obtained through consultation with a physician who has examined that patient or is familiar with that patient’s medical history. All NINDS-prepared information is in the public domain and may be freely copied. Credit to the NINDS or the NIH is appreciated.
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Table of Contents
Introduction ...... 1 What is a TBI? ...... 3 How does TBI affect the brain? ...... 4 What are the leading causes of TBI? ...... 9 What are the signs and symptoms? ...... 11 Effects on consciousness ...... 14 How is TBI diagnosed? ...... 15 How is TBI treated? ...... 19 Treating mild TBI ...... 19 Treating severe TBI ...... 21 Other factors that influence recovery ...... 23 i Can a TBI be prevented? ...... 25 What research is NINDS funding? ...... 26 Clinical trials ...... 28 Animal models ...... 31 How is NINDS coordinating research efforts? .....32 How can I support TBI research? ...... 34 Where can I get more information? ...... 38 Glossary ...... 41
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Introduction
Traumatic brain injury (TBI) is the leading cause of death and disability in children and young adults in the United States. TBI is also a major concern for elderly individuals, with a high rate of death and hospitalization due to falls among people age 75 and older. Depending on the severity of injury, TBI can have a lasting impact on quality of life for survivors of all ages — impairing thinking, decision making and reasoning, concentration, memory, movement, and/or sensation (e.g., vision or hearing), and causing emotional problems (personality changes, impulsivity, anxiety, and depression) and epilepsy. Annually, TBI injuries cost an estimated $76 billion in direct and indirect medical expenses. According to the U.S. Centers for Disease Control and Prevention: 1 • TBIs were a factor in the deaths of more than 50,000 people in the United States • More than 280,000 people with TBI were hospitalized • 2.2 million people with TBI visited an emergency department1. These figures are likely an underestimate of the true number of TBIs as they exclude people who did not seek medical attention at the emergency room. Although approximately 75 percent of brain injuries are considered mild (not life-threatening),
1 Traumatic Brain Injury in the United States Fact Sheet. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. January 12, 2015.
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According to the CDC, 2.2 million people with TBI visited an emergency department in one year.
as many as 5.3 million people in the United States are estimated to be living with the challenges of long- term TBI-related disability. Not every TBI is alike. Each injury is unique and 2 can cause changes that affect a person for a short period of time, or sometimes permanently. The majority of people will completely recover from symptoms related to concussion2, a mild type of TBI. However, persistent symptoms do occur for some people and may last for weeks or months. The long-term effects of TBI may vary depending on the number and nature of “hits” to the head, the age and gender of the individual, the speed with which the person received medical attention, and genetic and other factors. Over the past few decades preventive measures, such as seatbelts and helmets, and better critical care have substantially increased survival from severe TBI.
2 Words in Italic appear in a Glossary at the end of this document. D-6 Attachment D
Recently, research has expanded from a singular focus on severe TBI to a greater awareness about potential long-term consequences and the need to find better ways to diagnose, treat, and prevent all forms of TBI. Many questions remain unanswered regarding the impact of TBIs, the best treatments, and the most effective methods for promoting recovery of brain function. This publication outlines what is known about TBI, as well as directions for future research.
What is a TBI?
A TBI occurs when physical, external forces impact the brain either from a penetrating object or a bump, blow, or jolt to the head. Not all blows or jolts to the head result in a TBI. For the ones 3 that do, TBIs can range from mild (a brief change in mental status or consciousness) to severe (an extended period of unconsciousness or amnesia after the injury). There are two broad types of head injuries: penetrating and non-penetrating. Penetrating TBI (also known as open TBI) occurs when the skull is pierced by an object (for example, a bullet, shrapnel, bone fragment, or by a weapon such as hammer, knife, or baseball bat). With this injury, the object enters the brain tissue. Non-penetrating TBI (also known as closed head injury or blunt TBI) is caused by an external force that produces movement of the brain within the skull. Causes include falls, motor vehicle crashes, sports injuries, or being struck by an object. Blast
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injury due to explosions is a focus of intense study but how it causes brain injury is not fully known. Some accidents such as explosions, natural disasters, or other extreme events can cause both penetrating and non-penetrating TBI in the same person.
How does TBI affect the brain?
TBI-related damage can be confined to one area of the brain, known as a focal injury, or it can occur over a more widespread area, known as a diffuse injury. The type of injury is another determinant of the effect on the brain. Some injuries are considered primary, meaning the damage is immediate. Other consequences of TBI can be secondary, meaning they can occur gradually over the course of hours, 4 days, or weeks. These secondary brain injuries are the result of reactive processes that occur after the initial head trauma. There are a variety of immediate effects on the brain, including various types of bleeding and tearing forces that injure nerve fibers and cause inflammation, metabolic changes, and brain swelling. • Diffuse axonal injury (DAI) is one of the most common types of brain injuries. DAI refers to widespread damage to the brain’s white matter. White matter is composed of bundles of axons (projections of nerve cells that carry electrical impulses). Like the wires in a computer, axons connect various areas of the brain to one another. DAI is the result of shearing forces, which stretch or tear these axon bundles. This
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damage commonly occurs in auto accidents, falls, or sports injuries. It usually results from rotational forces (twisting) or sudden deceleration. It can result in a disruption of neural circuits and a breakdown of overall communication among nerve cells, or neurons, in the brain. It also leads to the release of brain chemicals that can cause further damage. These injuries can cause temporary or permanent damage to the brain, and recovery can be prolonged. • Concussion — a type of mild TBI that may be considered a temporary injury to the brain but could take minutes to several months to heal. Concussion can be caused by a number of things, including a bump, blow, or jolt to the head, sports injury or fall, motor vehicle accident, 5 weapons blast, or a rapid acceleration or deceleration of the brain within the skull (such as the person having been violently shaken).
Concussions can have a number of causes including motor vehicle accidents.
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The individual either suddenly loses consciousness or has sudden altered state of consciousness or awareness, and is often called “dazed” or said to have his/her “bell rung.” A second concussion closely following the first one causes further damage to the brain — the so-called “second hit” phenomenon — and can lead to permanent damage or even death in some instances. • Hematomas — a pooling of blood in the tissues outside of the blood vessels. Hematomas can develop when major blood vessels in the head become damaged, causing severe bleeding in and around the brain. Different types of hematomas form depending on where the blood collects relative to the meninges. The meninges are the protective membranes surrounding the brain, which consist of three layers: dura mater (outermost), arachnoid 6 mater (middle), and pia mater (innermost). — Epidural hematomas involve bleeding into the area between the skull and the dura mater. These can occur with a delay of minutes to hours after a skull fracture damages an artery under the skull, and are particularly dangerous. — Subdural hematomas involve bleeding between the dura and the arachnoid mater, and, like epidural heamatomas, exert pressure on the outside of the brain. Their effects vary depending on their size. They are very common in the elderly after a fall. — Subarachnoid hemorrhage is bleeding that occurs between the arachnoid mater and the pia mater and their effects vary depending on their size.
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— Bleeding into the brain itself is called an intracerebral hematoma and damages the surrounding tissue. • Contusions — a bruising or swelling of the brain that occurs when very small blood vessels bleed into brain tissue. Contusions can occur directly under the impact site (i.e, a coup injury) or, more often, on the complete opposite side of the brain from the impact (i.e., a contrecoup injury). They can appear after a delay of hours to a day. • Coup/Contrecoup lesions — contusions or subdural hematomas that occur at the site of head impact as well as directly opposite the coup lesion. Generally they occur when the head abruptly decelerates, which causes the brain to bounce back and forth within the skull (such as
in a high-speed car crash). This type of injury 7 also occurs in shaken baby syndrome, a severe head injury that results when an infant or toddler is shaken forcibly enough to cause the brain to bounce back and forth against the skull. • Skull fractures — breaks or cracks in one or more of the bones that form the skull. They are a result of blunt force trauma and can cause damage to the underlying areas of the skull such as the membranes, blood vessels, and brain. One main benefit of helmets is to prevent skull fracture. Skull fractures result from blunt force trauma and can cause damage to underlying areas of the skull. D-11 Attachment D
The first 24 hours after mild TBI are particularly important because subdural hematoma, epidural hematoma, contusion, or excessive brain swelling (edema) are possible and can cause further damage. For this reason doctors suggest watching a person for changes for 24 hours after a concussion. • Hemorrhagic progression of a contusion (HPC) contributes to secondary injuries. HPCs occur when an initial contusion from the primary injury continues to bleed and expand over time. This creates a new or larger lesion — an area of tissue that has been damaged through injury or disease. This increased exposure to blood, which is toxic to brain cells, leads to swelling and further brain cell loss. • Secondary damage may also be caused by a
8 breakdown in the blood-brain barrier. The blood-brain barrier preserves the separation between the brain fluid and the very small capillaries that bring the brain nutrients and oxygen through the blood. Once disrupted, blood, plasma proteins, and other foreign substances leak into the space between neurons in the brain and trigger a chain reaction that causes the brain to swell. It also causes multiple biological systems to go into overdrive, including inflammatory responses which can be harmful to the body if they continue for an extended period of time. It also permits the release of neurotransmitters, chemicals used by brain cells to communicate, which can damage or kill nerve cells when depleted or over-expressed. • Poor blood flow to the brain can also cause secondary damage. When the brain sustains
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a powerful blow, swelling occurs just as it would in other parts of the body. Because the skull cannot expand, the brain tissue swells and the pressure inside the skull rises; this is known as intracranial pressure (ICP). When the intracranial pressure becomes too high it prevents blood from flowing to the brain, which deprives it of the oxygen it needs to function. This can permanently damage brain function. Additional information about TBI and its causes can be found on the U.S. Centers for Disease Control and Prevention TBI website: http://www.cdc.gov/ TraumaticBrainInjury/.
What are the leading causes of TBI?
9 According to data from the Centers for Disease Control and Prevention (CDC), falls are the most common cause of TBIs and occur most frequently among the youngest and oldest age groups. From 2006 to 2010 alone, falls caused more than half (55 percent) of TBIs among children aged 14 and younger. Among Americans age 65 and older, falls accounted for more than two-thirds (81 percent) of all reported TBIs. The second and third most common causes of TBI are unintentional blunt trauma (accidents that involved being struck by or against an object), followed closely by motor vehicle accidents. Blunt trauma is especially common in children younger than 15 years old, causing nearly a quarter of all TBIs. Assaults account for an additional 10 percent of TBIs, and include abuse-related TBIs, such
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as head injuries that result from shaken baby syndrome. Unintentional blunt trauma includes sports- related injuries, which are also a major cause of TBI. Overall, bicycling, football, playground Among girls, TBI occurs most often while activities, basketball, playing sports such as soccer or basketball. and soccer result in the most TBI-related emergency room visits. The cause of these injuries does vary slightly by gender. According to the CDC, among children age 10 to 19, boys are most often injured while playing football or bicycling. Among girls, TBI occur most often while playing soccer or basketball or while bicycling. 10 Anywhere from 1.6 million to 3.8 million sports- and recreation-related TBIs are estimated to occur in the United States annually. TBIs caused by blast trauma from roadside bombs became a common injury to service members in recent military conflicts. From 2000 to 2014 more than 320,000 military service personnel sustained TBIs, though these injuries were not all conflict related. The majority of these TBIs were classified as mild head injuries and due to similar causes as those that occur in civilians. Adults age 65 and older are at greatest risk for being hospitalized and dying from a TBI, most likely from a fall. TBI-related deaths in children aged 4 years and younger are most likely the result of assault. In young adults aged 15 to 24 years, motor vehicle accidents are the most likely cause. In every age
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group, serious TBI rates are higher for men than for women. Men are more likely to be hospitalized and are nearly three times more likely to die from a TBI than women.
What are the signs and symptoms?
The effects of TBI can range from severe and permanent disability to more subtle functional and cognitive difficulties that often go undetected during initial evaluation. These problems may emerge days later. Headache, dizziness, confusion, and fatigue tend to start immediately after an injury, but resolve over time. Emotional symptoms such as frustration and irritability tend to develop later on during the recovery period. Many of the signs and symptoms can be easily missed as people may appear healthy 11 even though they act or feel different. Many of the symptoms overlap with other conditions, such as depression or sleep disorders. If any of the following symptoms appear suddenly or worsen over time following a TBI, especially within the first 24 hours after the injury, people should immediately see a medical professional. People should seek immediate medical attention if they experience any of the following symptoms: • loss of or change in consciousness anywhere from a few seconds to a few hours • decreased level of consciousness, i.e., hard to awaken • convulsions or seizures
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• unequal dilation in the pupils of the eyes or double vision • clear fluids draining from the nose or ears • nausea and vomiting • new neurologic deficit, i.e., slurred speech; weakness of arms, legs, or face; loss of balance. Other common symptoms that should be monitored include: • mild to profound confusion or disorientation • problems remembering, concentrating, or making decisions • headache • light-headedness, dizziness, vertigo, or loss of balance or coordination 12 • sensory problems, such as blurred vision, seeing stars, ringing in the ears, bad taste in the mouth • sensitivity to light or sound • mood changes or swings, agitation (feeling sad or angry for no reason), combativeness, or other unusual behavior • feelings of depression or anxiety • fatigue or drowsiness; a lack of energy or motivation • changes in sleep patterns (e.g., sleeping a lot more or having difficulty falling or staying asleep); inability to wake up from sleep.
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TBI symptoms including headache, dizziness, confusion, and fatigue generally start immediately after an injury, but resolve over time.
Diagnosing TBI in children can be challenging because they may be unable to let others know that 13 they feel different. A child with a TBI may display the following signs or symptoms: • changes in eating or nursing habits • persistent crying, irritability, or crankiness; inability to be consoled • changes in ability to pay attention; lack of interest in a favorite toy or activity • changes in the way the child plays • changes in sleep patterns • sadness or depression • loss of a skill, such as toilet training • loss of balance or unsteady walking • vomiting.
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In some cases, repeated blows to the head can cause chronic traumatic encephalopathy (CTE) — a progressive neurological disorder associated with a variety of symptoms, including cognition and communication problems, motor disorders, problems with impulse control and depression, confusion, and irritability. CTE occurs in those with extraordinary exposure to multiple blows to the head and as a delayed consequence after many years. Studies of retired boxers have shown that repeated blows to the head can cause a number of issues, including memory problems, tremors, and lack of coordination and dementia. Recent studies have demonstrated rare cases of CTE in other sports with repetitive mild head impacts (e.g., soccer, wrestling, football, and rugby). A single, severe TBI also may lead to a disorder called post-traumatic 14 dementia (PTD), which may be progressive and share some features with CTE. Studies assessing patterns among large populations of people with TBI indicate that moderate or severe TBI in early or mid-life may be associated with increased risk of dementia later in life.
Effects on consciousness
A TBI can cause problems with arousal, consciousness, awareness, alertness, and responsiveness. Generally, there are four abnormal states that can result from a severe TBI: • Brain death — The lack of measurable brain function and activity after an extended period of time is called brain death and may be confirmed by studies that show no blood flow to the brain.
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• Coma — A person in a coma is totally unconscious, unaware, and unable to respond to external stimuli such as pain or light. Coma generally lasts a few days or weeks after which an individual may regain consciousness, die, or move into a vegetative state. • Vegetative state — A result of widespread damage to the brain, people in a vegetative state are unconscious and unaware of their surroundings. However, they can have periods of unresponsive alertness and may groan, move, or show reflex responses. If this state lasts longer than a few weeks it is referred to as a persistent vegetative state. • Minimally conscious state — People with severely altered consciousness who still display
some evidence of self-awareness or awareness 15 of one’s environment (such as following simple commands, yes/no responses).
How is TBI diagnosed?
Although the majority of TBIs are mild they can still have serious health implications. Of greatest concern are injuries that can quickly grow worse. All TBIs require immediate assessment by a professional who has experience evaluating head injuries. A neurological exam will assess motor and sensory skills and the functioning of one or more cranial nerves. It will also test hearing and speech, coordination and balance, mental status, and changes in mood or behavior, among other abilities.
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The most common imaging technology used to evaluate people with suspected TBI is computed tomography or CT.
Screening tools for coaches and athletic trainers can identify the most concerning concussions for 16 medical evaluation. Initial assessments may rely on standardized instruments such as the Acute Concussion Evaluation (ACE) form from the Centers for Disease Control and Prevention or the Sport Concussion Assessment Tool 2, which provide a systematic way to assess a person who has suffered a mild TBI. Reviewers collect information about the characteristics of the injury, the presence of amnesia (loss of memory) and/or seizures, as well as the presence of physical, cognitive, emotional, and sleep-related symptoms. The ACE is also used to track symptom recovery over time. It also takes into account risk factors (including concussion, headache, and psychiatric history) that can impact how long it takes to recover from a TBI.
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When necessary, medical providers will use brain scans to evaluate the extent of the primary brain injuries and determine if surgery will be needed to help repair any damage to the brain. The need for imaging is based on a physical examination by a doctor and a person’s symptoms. Computed tomography (CT) is the most common imaging technology used to assess people with suspected moderate to severe TBI. CT scans create a series of cross-sectional x-ray images of the skull and brain and can show fractures, hemorrhage, hematomas, hydrocephalus, contusions, and brain tissue swelling. CT scans are often used to assess the damage of a TBI in emergency room settings. Magnetic resonance imaging (MRI) may be used after the initial assessment and treatment as it is a more sensitive test and picks up subtle changes in 17 the brain that the CT scan might have missed. Unlike moderate or severe TBI, milder TBI may not involve obvious signs of damage (hematomas, skull fracture, or contusion) that can be identified with current neuroimaging. Instead, much of what is believed to occur to the brain following mild TBI happens at the cellular level. Significant advances have been made in the last decade to image milder TBI damage. For example, diffusion tensor imaging (DTI) can image white matter tracts, more sensitive tests like fluid-attenuated inversion recovery (FLAIR) can detect small areas of damage, and susceptibility-weighted imaging very sensitively identifies bleeding. Despite these improvements, currently available imaging technologies, blood tests, and other measures remain inadequate for
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detecting these changes in a way that is helpful for diagnosing the mild concussive injuries. Neuropsychological tests to gauge brain functioning are often used in conjunction with imaging in people who have suffered mild TBI. Such tests involve performing specific cognitive tasks that help assess memory, concentration, information processing, executive functioning, reaction time, and problem solving. The Glasgow Coma Scale is the most widely used tool for assessing the level of consciousness after TBI. The standardized 15-point test measures a person’s ability to open his or her eyes and respond to spoken questions or physical prompts for movement. A total score of 3-8 indicates a severe head injury; 9-12 indicates moderate injury; and 13-15 is classified as mild injury. (For more information about the scale, see 18 http://glasgowcomascale.org/). Many athletic organizations recommend establishing a baseline picture of an athlete’s brain function at the beginning of each season, ideally before any head injuries have occurred. Baseline testing should begin as soon as a child begins a competitive sport. Brain function tests yield information about an individual’s memory, attention, and ability to concentrate and solve problems. Brain function tests can be repeated at regular intervals (every 1 to 2 years) and also after a suspected concussion. The results may help health care providers identify any effects from an injury and allow them make more informed decisions about whether a person is ready to return to their normal activities.
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How is TBI treated?
Many factors, including the size, severity, and location of the brain injury, influence how a TBI is treated and how quickly a person might recover. One of the critical elements to a person’s prognosis is the severity of the injury. Although brain injury often occurs at the moment of head impact, much of the damage related to severe TBI develops from secondary injuries which happen days or weeks after the initial trauma. For this reason, people who receive immediate medical attention at a certified trauma center tend to have the best health outcomes.
Treating mild TBI
Individuals with mild TBI, such as concussion, should focus on symptom relief and “brain rest.” 19 In these cases, headaches can often be treated with over-the-counter pain relievers. People with mild TBI are also encouraged to wait to resume normal activities until given permission by a doctor. People with a mild TBI should: • Make an appointment for a follow-up visit with their health care provider to confirm the progress of their recovery. • Inquire about new or persistent symptoms and how to treat them. • Pay attention to any new signs or symptoms even if they seem unrelated to the injury (for example, mood swings, unusual feelings of irritability). These symptoms may be related even if they occurred several weeks after the injury.
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Even after symptoms resolve entirely, people should return to their daily activities gradually. Brain functionality may still be limited despite an absence of outward symptoms. Very little is known about the Individuals with mild TBI should focus on symptom relief and “brain rest,” and are encouraged to wait to long-term effects of resume normal activities until given permission from concussions on brain their health care provider. function. There is no clear timeline for a safe return to normal activities although there are guidelines such as those from the American Academy of Neurology and the American Medical Society for Sports Medicine to help determine when athletes can return to 20 practice or competition. Further research is needed to better understand the effects of mild TBI on the brain and to determine when it is safe to resume normal activities. Preventing future concussions is critical. While most people recover fully from a first concussion within a few weeks, the rate of recovery from a second or third concussion is generally slower. In the days or weeks after a concussion, a minority of individuals may develop post-concussion syndrome (PCS). People can develop this syndrome even if they never lost consciousness. The symptoms include headache, fatigue, cognitive impairment, depression, irritability, dizziness and balance trouble, and apathy. These symptoms usually improve without medical treatment within one to a few weeks but some people can have longer lasting symptoms.
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In some cases of moderate to severe TBI, persistent symptoms may be related to conditions triggered by imbalances in the production of hormones required for the brain to function normally. Hormone imbalances can occur when certain glands in the body, such as the pituitary gland, are damaged over time as result of the brain injury. Symptoms of these hormonal imbalances include weight loss or gain, fatigue, dry skin, impotence, menstrual cycle changes, depression, difficulty concentrating, hair loss, or cold intolerance. When these symptoms persist 3 months after their initial injury or when they occur up to 3 years after the initial TBI, people should speak with a health care provider about their condition.
Treating severe TBI 21 Immediate treatment for the person who has suffered a severe TBI focuses on preventing death; stabilizing the person’s spinal cord, heart, lung, and other vital organ functions; and preventing further brain damage. Persons with severe TBI generally require a breathing machine to ensure proper oxygen delivery and breathing. During the acute management period, health care providers monitor the person’s blood pressure, flow of blood to the brain, brain temperature, pressure inside the skull, and the brain’s oxygen supply. A common practice called intracranial pressure ICP monitoring involves inserting a special catheter through a hole drilled into the skull. Doctors frequently rely on ICP monitoring as a way to determine if and when medications or surgery are needed in order to prevent secondary
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brain injury from swelling. People with severe head injury may require surgery to relieve pressure inside the skull, get rid of damaged or dead brain tissue (especially for penetrating TBI), or remove hematomas. In-hospital strategies for managing people with severe TBI aim to prevent conditions including: • infection, particularly pneumonia • deep vein thrombosis (blood clots that occur deep within a vein; risk increases during long periods of inactivity) . People with TBIs may need nutritional supplements to minimize the effects that vitamin, mineral, and other dietary deficiencies may cause over time. Some individuals may even require tube feeding to maintain the proper balance of nutrients. 22 Following the acute care period, people with severe TBI are often transferred to a rehabilitation center where a multidisciplinary team of health care providers help with recovery. The rehabilitation team includes neurologists, nurses, psychologists, nutritionists, as well as physical, occupational, vocational, speech, and respiratory therapists. Cognitive rehabilitation therapy (CRT) is a strategy aimed at helping individuals regain their normal brain function through an individualized training program. Using this strategy, people may also learn compensatory strategies for coping with persistent deficiencies involving memory, problem solving, and the thinking skills to get things done. CRT programs tend to be highly individualized and their success varies. A 2011 Institute
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In-hospital strategies for managing people with severe TBI focus on preventing infection and deep vein thrombosis or blood clots (like the one shown above) that occur deep within a vein. of Medicine report concluded that cognitive rehabilitation interventions need to be developed and assessed more thoroughly. 23
Other factors that influence recovery
Genes Evidence suggests that genetics play a role in how quickly and completely a person recovers from a TBI. For example, researchers have found that apolipoprotein E ε4 (ApoE4) — a genetic variant associated with higher risks for Alzheimer’s disease — is associated with worse health outcomes following a TBI. Much work remains to be done to understand how genetic factors, as well as how specific types of head injuries in particular locations, affect recovery processes. It is hoped that this research will lead to new treatment strategies and improved outcomes for people with TBI.
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Age Studies suggest that age and the number of head injuries a person has suffered over his or her lifetime are two critical factors that impact recovery. For example, TBI-related brain swelling in children can be very different from the same condition in adults, even when the primary injuries are similar. Brain swelling in newborns, young infants, and teenagers often occurs much more quickly than it does in older individuals. Evidence from very limited CTE studies suggest that younger people (ages 20 to 40) tend to have behavioral and mood changes associated with CTE, while those who are older (ages 50+) have more cognitive difficulties. Compared with younger adults with the same
24 TBI severity, older adults are likely to have less complete recovery. Older people also have more medical issues and are often taking multiple medications that may complicate treatment (e.g., blood-thinning agents when there is a risk of bleeding into the head). Further research is needed to determine if and how treatment strategies may need to be adjusted based on a person’s age. Researchers are continuing to look for additional factors that may help predict a person’s course of recovery.
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Can a TBI be prevented?
The best treatment for TBI is prevention. Unlike most neurological disorders, head injuries can be prevented. According to the CDC, doing the following can help prevent TBIs: • Wear a seatbelt when you drive or ride in a motor vehicle. • Wear the correct helmet and make sure it fits properly when riding a bicycle, skateboarding, and playing sports like hockey and football. • Install window guards and stair safety gates at home for young children. • Never drive under the influence of drugs or alcohol. • Improve lighting and remove rugs, clutter, and 25 other trip hazards in the hallway.
Wearing a seatbelt when you drive or ride in a motor vehicle can help prevent TBI.
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• Use nonslip mats and install grab bars next to the toilet and in the tub or shower for older adults. • Install handrails on stairways. • Improve balance and strength with a regular physical activity program. • Ensure children’s playgrounds are made of shock-absorbing material, such as hardwood mulch or sand.
What research is NINDS funding?
The mission of the National Institute of Neurological Disorders and Stroke (NINDS) is to seek fundamental knowledge about the brain 26 and nervous system and use that knowledge to reduce the burden of neurological disease. The NINDS is a component of the National Institutes of Health (NIH), the leading supporter of biomedical research in the world. NINDS funds research on the full range of severity of TBI to understand the mechanisms that result in immediate and delayed effects in the brain and to develop therapies that can prevent or reverse brain damage. NINDS-supported researchers are working to better understand the factors that contribute to chronic traumatic encephalopathy (CTE). Brain tissue studies suggest that people with CTE have abnormal microscopic deposits of a protein known as tau. Accumulations of tau are also found in the brains of people known to have other neurodegenerative disorders such as Alzheimer’s disease. NINDS-
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funded researchers are working to define a clear set of criteria for the various stages of CTE and to distinguish it from Alzheimer’s and other NINDS funds a wide range of TBI research in neurodegenerative an effort to find better ways to safely detect, disorders in post- treat, and ultimately prevent TBI. mortem brain tissue. Once researchers characterize CTE in brain tissue they may then be able to correlate certain changes with findings from advanced brain scanning technologies. If this were possible then individuals with CTE would be able to be diagnosed while they are still alive. One promising research strategy uses 27 a radioactive biochemical substance known as a ligand to bind to tau, which can then be detected using positron emission tomography (PET scan). It is currently not known how many people either have CTE or are at greatest risk for developing the condition. Researchers are conducting studies to better understand the lasting effects of a single head injury vs. repetitive injuries to the brain, how repetitive TBI might lead to CTE, and how commonly these changes occur among adults. A key objective is to identify and develop noninvasive ways of detecting and monitoring brain injuries. For example, NINDS researchers are currently working to develop consensus criteria for diagnosis as well as objective biomarkers (signs that may indicate risk of a disease and aid in diagnosis) for CTE in order to detect this and similar disorders in living people.
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NIH has also funded research to develop sensors to determine the type of acceleration and rotation that can lead to brain injuries. Researchers hope these sensors can help determine the effect of head injuries over time on cognitive performance and aid in new ways to diagnose concussions. NINDS, along with the NIH’s National Institute of Mental Health and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, supports the NIH NeuroBioBank (NBB) (https://neurobiobank.nih.gov). The repository brings together multiple stakeholders to enable and advance research by collecting and distributing human post-mortem brain tissue. This research improves our understanding of the long-term consequences of brain trauma and the development of conditions such as CTE. 28 Other studies focus on substances found in the body or in nature that are believed to prevent cell death and inflammation. For example, naturally occurring substances in plants called flavonoids have been shown to reduce inflammation and cell toxicity.
Clinical trials
Despite recent progress in understanding what happens in the brain following TBI, more than 30 large clinical trials have failed to identify specific treatments that make a dependable and measurable difference in people with TBI. A key challenge facing doctors and scientists is the fact that each person with a TBI has a unique set of circumstances
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based on such multiple variables as the location and severity of the injury, the person’s age and overall heath, and the time between the injury and the initiation of treatment. These factors, along with differences in care across treatment centers, highlight the importance of coordinating research efforts so that the results of potential new treatments can be confidently measured. Among such efforts to coordinate researchers worldwide is the International Initiative for Brain Injury Research (InTBIR), a collaboration between the NIH, the European Commission, and the Canadian Institutes of Health Research. The U.S. Department of Defense (DOD) also participates. InTBIR’s goal is to advance TBI research by establishing and promoting the use of consistent standards for TBI clinical data collection. 29 One component of InTBIR that NINDS supports is the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study. This large, multi-center study aims to test, refine, and develop standards and best practices for TBI research across the entire spectrum of TBI severity among adults. TRACK-TBI has a sister study in Europe called Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI). Researchers hope that these projects have the potential to substantially advance and revolutionize TBI clinical research. InTBIR is also building a large registry of people with TBI to track the results of various treatment strategies over time.
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NIH has funded research to develop sensors to determine NINDS-funded the type of acceleration and researchers are also rotation that can lead to coordinating a large brain injuries. international study aimed at evaluating treatments for children with moderate to severe TBI. Most of the treatments for TBI are based on studies involving adults. Children are rarely included in research studies so the best course of treatment in pediatric TBI cases is often not clear. The five-year study, called the Approaches and Decisions for Acute Pediatric TBI (ADAPT) Trial, aims to develop evidence-based guidelines that can immediately improve recovery and disability rates among children with TBI. The study will include 1,000 children from more than 36 locations in the United States and abroad. Researchers are looking 30 at the effectiveness of immediate interventions, such as lowering intracranial pressure, as well as strategies to prevent secondary injuries and deliver nutrients to the brain. NINDS is also leading the establishment of a collaborative emergency care research network, Strategies to Innovate EmeRgENcy Care Clinical Trials (SIREN). SIREN will be responsible for simultaneously conducting at least four large clinical trials that focus on improving care in emergency room settings for individuals suffering from traumatic and medical conditions, including TBI. Other participating NIH organizations are the National Heart, Lung and Blood Institute, the National Center for Advancing Translational Science, and the Office of Emergency Care Research in the National Institute of General Medical Sciences.
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Animal models
NINDS-supported researchers conduct numerous studies using animal models in order to test potential new therapies and to better understand the nature of TBI. One major challenge to delivering drug therapies for TBI is dealing effectively with the blood-brain barrier. This important barrier plays a key role in protecting the brain from potentially harmful substances. However, it also limits the ability of potentially beneficial agents from reaching the brain. Researchers are exploring ways of combining neuroprotective agents with membrane transporters that are able to carry medications across the blood- brain barrier. Other researchers are exploring ways to promote 31 the brain’s innate ability to adapt and repair itself, known as neuroplasticity. For example, they are stimulating deep brain structures with electricity or magnetic fields and combining such therapy with exercises to see if it improves functionality in animals with TBI. A newly developed mouse model of TBI is enabling researchers to look at potential treatments for concussion. Using the model, they found that applying glutathione (an antioxidant that is normally found in our cells) directly on the skull surface after brain injury reduced the amount of brain cell death. In addition to NINDS, other NIH Institutes fund research on TBI. Among them, the National Center for Medical Rehabilitation Research (NCMRR)
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coordinates rehabilitation research; the National Institute on Drug Abuse supports investigations into TBI and drug abuse; the National Institute of Biomedical Imaging and Bioengineering funds studies on head impact detection technologies, imaging technologies, regenerative medicine, and prosthetics; and the National Institute of Mental Health supports research on post-traumatic stress disorder associated with TBI. Research projects on TBI and other disorders can be found using NIH RePORTER (http://projectreporter.nih.gov), a searchable database of current and past research projects supported by NIH and other federal agencies. RePORTER also includes links to publications from these projects and other resources.
32 How is NINDS coordinating research efforts?
Harnessing the efforts of the many physicians and scientists working on developing better treatments for TBI requires everyone to collect the same types of information from people including details about injuries and treatment results. To lay the groundwork for these studies, NINDS started the Common Data Elements project. This effort brings the research community together to develop data collection standards. Closely linked to the Common Data Elements project is the data sharing platform, Federal Interagency Traumatic Brain Injury The NINDS Common Data Elements Project brings the research community together to develop data collection standards.
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Research (FITBIR). Born out of a partnership between DOD and NIH, the database provides a central repository for information on TBI and allows researchers to compare study results worldwide. With FITBIR researchers can collectively pursue answers to common problems. Together, FITBIR and the Common Data Elements project provide the tools that make large-scale research on TBI possible. NINDS also works with DOD and the Departments of Health and Human Services, Veterans Affairs, and Education to coordinate TBI research for military members. This National Research Action Plan (NRAP) aims to improve prevention, diagnosis, and treatment of TBI and other mental health conditions such as PTSD that effect veterans and their families. The findings resulting from 33 NRAP will be rapidly translated into new effective prevention strategies and clinical innovations, as well as identify biomarkers to detect these disorders early and accurately.
Expediting the development of better treatments for TBI also requires collaboration between private and public organizations dedicated to preventing and managing the consequences of TBI. NIH, through its Foundation for NIH, has built an innovative private-public partnership known as the Sports and Health Research Program (SHRP). Through SHRP, the National Football League has committed millions of dollars to furthering TBI research to improve the lives of all athletes.
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SHRP projects include developing and testing a portable eye tracking instrument that can be used on the sidelines to help diagnose concussions and monitor injury progression. SHRP-funded investigators also are looking at other options for detecting mild TBI brain changes with biomarkers such as those on imaging or by measuring levels of substances in the blood. The potential to improve TBI care through these projects will extend beyond the athletic field and be of value to anyone who sustains a TBI.
How can I support TBI research?
If you or someone you know has been diagnosed with a TBI, enrolling in a clinical trial or brain bank 34 are the best ways to support research toward new and better treatment options. Clinical trials are research studies that involve people. Studies involving individuals with TBI and healthy individuals offer researchers the opportunity to greatly increase our knowledge of TBI and find better ways to safely detect, treat, and ultimately prevent TBI. By participating in a clinical study, healthy individuals and those with TBI can greatly benefit the lives of those living with this disorder. Talk with your doctor about clinical studies and help to make the difference in the quality of life for all people with TBI. Trials take place at medical centers across the United States and elsewhere. For information about NINDS- funded studies on TBI, see www.clinicaltrials.gov
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Clinical research studies involving healthy people and those with TBI give researchers the opportunity to greatly increase our knowledge of TBI.
and search for “TBI AND NINDS.” For additional studies on TBI and information about participating in clinical studies, visit the “NIH Clinical Trials and 35 You” website at (www.nih.gov/health/clinicaltrials). Always talk with your health care provider before enrolling in a clinical trial. People with a TBI also can support TBI research by designating the donation of brain tissue before they die. The study of human brain tissue is essential to increasing the understanding of how the nervous system functions. The NIH NeuroBioBank is an effort by the National Institutes of Health to coordinate the network of brian banks it supports in the United States to facilitate advances in research through the collection and distribution of post-mortem brain tissue. Stakeholder groups include brain and tissue repositories, researchers, NIH program staff,
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information technology experts, disease advocacy groups, and most importantly individuals seeking information about opportunities to donate. It ensures protection of the privacy and wishes of donors. Creating a network of these centers makes it more likely that precious tissue can be made available to the greatest number of scientists. Six current brain and tissue repositories include: University of Miami Brain Endowment Bank University of Miami Department of Neurology 1951 N.W. 7th Avenue, Suite 240 Miami, FL 33136 305-243-6219 800-862-7246 brainbank.med.miami.edu University of Maryland Brain and Tissue Bank
36 (formerly NICHD Brain and Tissue Bank for Developmental Disorders) University of Maryland, School of Medicine 655 West Baltimore Street, Room 13-0313 BRB Baltimore, MD 21201-1559 410-706-1755 800-847-1559 www.medschool.umaryland.edu/BTBank/ Harvard Brain Tissue Resource Center McLean Hospital 115 Mill Street Belmont, MA 02478 617-855-2400 800-272-4622 www.brainbank.mclean.org
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The Human Brain and Spinal Fluid Resource Center (HBSFRC) Building 212, Room 16 West Los Angeles Health Care Center 11301 Wilshire Blvd. (127A) Los Angeles, CA 90073 310-268-3536 Pager: 310-636-5199 brainbank.ucla.edu Mount Sinai NIH Brain and Tissue Repository James J. Peters VA Medical Center 130 West Kingsbridge Road Room 4F-33A Bronx, NY 10468 718-584-9000 x6083 icahn.mssm.edu/research/labs/neuropathology-and- brain-banking 37 Brain Tissue Donation Program at the University of Pittsburgh Translational Neuroscience Program Biomedical Service Tower 1654 3811 O’Hare Street Pittsburgh, PA 15213-2582 412-383-8548 www.tnp.pitt.edu
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Where can I get more information?
For more information on neurological disorders or research programs funded by the National Institute of Neurological Disorders and Stroke, contact the Institute’s Brain Resources and Information Network (BRAIN) at: BRAIN P.O. Box 5801 Bethesda, MD 20824 301-496-5751 800-352-9424 www.ninds.nih.gov Additional information about TBI is available from the following organizations: Brain Injury Association of America 38 1608 Spring Hill Road, Suite 110 Vienna, VA 22182 703-761-0750 800-444-6443 www.biausa.org Brain Injury Resource Center P.O. Box 84151 Seattle, WA 98124 206-621-8558 www.headinjury.com
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Brain Trauma Foundation 1 Broadway, 6th Floor New York, NY 10004-1007 212-772-0608 www.braintrauma.org Uniformed Services University of the Health Sciences (USUHS) Center for Neuroscience and Regenerative Medicine (CNRM) NIH-USUHS TBI Center 4301 Jones Bridge Road Bethesda, MD 20814-4799 www.usuhs.mil/cnrm U.S. Centers for Disease Control and Prevention Heads Up to Concussion National Center for Injury Prevention and
Control (NCIPC) 39 Division of Unintentional Injury Prevention 1600 Clifton Road Atlanta, GA 30329-4027 800-232-4636 TTY: 888-232-6348 http://www.cdc.gov/headsup/index.html National Rehabilitation Information Center 8400 Corporate Drive, Suite 500 Landover, MD 20785 800-346-2742 www.naric.com
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ThinkFirst National Injury Prevention Foundation 1801 N. Mill Street, Suite F Naperville, IL 60563 630-961-1400 800-844-6556 www.thinkfirst.org National Library of Medicine National Institutes of Health 8600 Rockville Pike Bethesda, MD 20894 301-594-5983 888-346-3656 www.nlm.nih.gov
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Glossary
blood-brain barrier — a protective barrier around brain blood vessels designed to keep the environment in the brain as stable as possible brain death — a lack of measurable brain function activity and blood flow after an extended period of time chronic traumatic encephalopathy (CTE) — brain damage caused by cumulative and repetitive head trauma cognitive rehabilitation therapy (CRT) — a strategy aimed at helping individuals with severe TBI regain their normal brain function through an individualized training program
coma — a state of unconsciousness in which a 41 person cannot be wakened and does respond to external stimuli, such as pain or light concussion — injury to the brain caused by a hard blow or violent shaking of the brain within the skull, which produces a sudden and temporary impairment of brain function, such amnesia, short loss of consciousness, or disturbance of vision and equilibrium contrecoup lesions — contusions or subdural hematomas that occur directly opposite the point of head impact contusion — a distinct area of swollen or bruised brain tissue mixed with blood released from broken blood vessels
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coup injury — a head injury that occurs under the site of impact with an object diffuse axonal injury (or traumatic axonal injury) — widespread damage to the brain’s white matter; the result of shearing forces that stretch or tear the nerve fibers that connect brain regions diffuse injury — a brain injury that covers a widespread area; most often associated with injuries resulting from rapid acceleration or deceleration of the skull such as in a car crash or to a blast injury epidural hematomas — bleeding into the area between the skull and the dura focal injury — a brain injury that occurs in a specific area; most often associated with an injury in which the head strikes or is struck by an object
42 Glasgow Coma Scale — a widely-used clinical tool used to assess the degree of consciousness and neurological functioning after a brain injury by testing motor responsiveness, ability to respond to verbal questions, and eye opening hematoma(s) — heavy bleeding in or around the brain caused by damage to a large blood vessel in the head hemorrhagic progression of a contusion (HPC) — occurs when an initial contusion from the primary injury continues to bleed and expand over time, creating a new or larger lesions. This contributes to secondary injuries. intracerebral hematoma — bleeding within the brain caused by damage to a major blood vessel
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increased intracranial pressure (ICP) — buildup of pressure in the brain as a result of swelling and/or bleeding in the brain meninges — the protective membranes surrounding the brain, which consist of three layers: dura mater (outermost), arachnoid mater (middle), and pia mater (innermost) minimally conscious state — people with severely altered consciousness who still display some evidence of self-awareness or awareness of one’s environment neuron(s) — nerve cells that process and transmit information through electrical and chemical signals; these cells are core components of the brain and nervous system neuroplasticity — ability of the brain to adapt to 43 deficits and injury by creating new connections to uninjured brain regions non-penetrating head injury or (closed head injury) — an injury that occurs when the head suddenly and violently hits an object but the object does not break through the skull penetrating head injury (or open head injury) — a brain injury in which an object pierces the skull and enters the brain tissue persistent vegetative state — an ongoing state of severely impaired consciousness, in which the patient is incapable of voluntary motion primary injury — an injury that occurs during the initial brain trauma
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post-concussion syndrome (PCS) — a set of symptoms that may occur after a concussion, including cognitive impairment, depression, irritability, persistent sensory problems, anger, apathy, or paranoia post-traumatic dementia (PTD) — a condition with symptoms that are very similar to those of chronic traumatic encephalopathy (CTE) except that it caused by a single, severe TBI that results in a coma. post-traumatic stress disorder (PTSD) — a condition that may develop after a person has experienced or witnessed a traumatic or terrifying event in which serious physical harm occurred or was threatened. PTSD can be caused by a number of different events including war, assaults, car
44 crashes, and natural disasters. secondary injury — a gradual injury that occurs in the hours and days following a primary head injury; these injuries are a major factor in TBI-related brain damage and death shaken baby syndrome — a severe form of head injury that occurs when an infant or small child is shaken forcibly enough to cause the brain to bounce against the skull; the degree of brain damage depends on the extent and duration of the shaking. Minor symptoms include irritability, lethargy, tremors, or vomiting; major symptoms include seizures, coma, stupor, or death. shearing — forces that stretch or tear axons as a result of the head rapidly accelerating or decelerating; the cause of diffuse axonal injuries (DAIs)
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skull fractures — breaks or cracks in one or more of the bones that form the skull, which can damage the underlying areas of the skull including the brain, membranes, and blood vessels subdural hematoma — bleeding confined to the area between the dura and the arachnoid membranes subarachnoid hemorrhage — bleeding that occurs between the arachnoid mater and the pia mater vegetative state — a condition in which people are unconscious and unaware of their surroundings, but can have periods of alertness and may groan, move, or show reflex responses
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NIH . . . Turning Discovery Into Health
Prepared by: Office of Communications and Public Liaison National Institute of Neurological Disorders and Stroke National Institutes of Health Bethesda, Maryland 20892
NIH Publication No. 16-158 September 2015
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Article - Health - General §14–501.
(a) (1) In this section the following words have the meanings indicated.
(2) “Concussion” means a traumatic injury to the brain causing an immediate and, usually, short–lived change in mental status or an alteration of normal consciousness resulting from:
(i) A fall;
(ii) A violent blow to the head or body; or
(iii) The shaking or spinning of the head or body.
(3) “Sudden cardiac arrest” means a condition in which the heart suddenly and unexpectedly stops beating.
(4) “Youth athlete” means an individual who participates in an athletic activity in association with a youth sports program conducted:
(i) At a public school facility; or
(ii) By a recreational athletic organization.
(5) “Youth sports program” means a program organized for recreational athletic competition or instruction for participants who are under the age of 19 years.
(b) (1) A youth sports program shall make available information on concussions, head injuries, and sudden cardiac arrest developed by the State Department of Education under §§ 7– 433 and 7–436 of the Education Article to coaches, youth athletes, and the parents or guardians of youth athletes.
(2) A coach of a youth sports program shall review the information provided in paragraph (1) of this subsection.
(c) (1) A youth athlete who is suspected of sustaining a concussion or other head injury in a practice or game shall be removed from play at that time.
(2) A youth athlete who has been removed from play may not return to play until the youth athlete has obtained written clearance from a licensed health care provider trained in the evaluation and management of concussions.
(d) Before a youth sports program may use a facility owned or operated by a local government, the local government shall provide notice to the youth sports program of the requirements of this section.
E-1 Research Attachment F
Original Investigation Point of Health Care Entry for Youth With Concussion Within a Large Pediatric Care Network
Kristy B. Arbogast, PhD; Allison E. Curry, PhD; Melissa R. Pfeiffer, MPH; Mark R. Zonfrillo, MD, MSCE; Juliet Haarbauer-Krupa, PhD; Matthew J. Breiding, PhD; Victor G. Coronado, MD, MPH; Christina L. Master, MD
IMPORTANCE Previous epidemiologic research on concussions has primarily been limited to patient populations presenting to sport concussion clinics or to emergency departments (EDs) and to those high school age or older. By examining concussion visits across an entire pediatric health care network, a better estimate of the scope of the problem can be obtained.
OBJECTIVE To comprehensively describe point of entry for children with concussion, overall and by relevant factors including age, sex, race/ethnicity, and payor, to quantify where children initially seek care for this injury.
DESIGN, SETTING, AND PARTICIPANTS In this descriptive epidemiologic study, data were collected from primary care, specialty care, ED, urgent care, and inpatient settings. The initial concussion-related visit was selected and variation in the initial health care location (primary care, specialty care, ED, or hospital) was examined in relation to relevant variables. All patients aged 0 to 17 years who received their primary care from The Children’s Hospital of Philadelphia’s (CHOP) network and had 1 or more in-person clinical visits for concussion in the CHOP unified electronic health record (EHR) system (July 1, 2010, to June 30, 2014) were selected.
MAIN OUTCOMES AND MEASURES Frequency of initial concussion visits at each type of health care location. Concussion visits in the EHR were defined based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes indicative of concussion.
RESULTS A total of 8083 patients were included (median age, 13 years; interquartile range, 10-15 years). Overall, 81.9% (95% CI, 81.1%-82.8%; n = 6624) had their first visit at CHOP within primary care, 5.2% (95% CI, 4.7%-5.7%; n = 418) within specialty care, and 11.7% (95% CI, 11.0%-12.4%; n = 947) within the ED. Health care entry varied by age: 52% (191/368) of children aged 0 to 4 years entered CHOP via the ED, whereas more than three-quarters of those aged 5 to 17 years entered via primary care (5-11 years: 1995/2492; 12-14 years: 2415/2820; and 15-17 years: 2056/2403). Insurance status also influenced the pattern of health care use, with more Medicaid patients using the ED for concussion care (478/1290 Medicaid patients [37%] used the ED vs 435/6652 private patients [7%] and 34/141 self-pay Author Affiliations: Center for Injury Research and Prevention, The patients [24%]). Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (Arbogast, CONCLUSIONS AND RELEVANCE The findings suggest estimates of concussion incidence based Curry, Pfeiffer, Zonfrillo); University solely on ED visits underestimate the burden of injury, highlight the importance of the of Pennsylvania Perelman School of Medicine, Philadelphia (Arbogast, primary care setting in concussion care management, and demonstrate the potential for EHR Zonfrillo, Master); National Center for systems to advance research in this area. Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia (Haarbauer-Krupa, Breiding, Coronado); Sports Medicine and Performance Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (Master). Corresponding Author: Kristy B. Arbogast, PhD, Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, 3535 Market St, Ste 1150, JAMA Pediatr. doi:10.1001/jamapediatrics.2016.0294 Philadelphia, PA 19104 Published online May 31, 2016. ([email protected]).
F-1 (Reprinted) E1 Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a Stephen B. Thacker CDC Library User on 06/01/2016 Research Original Investigation Point of Health Care EntryAttachment for Youth Concussion F
oncussion in youth has received heightened attention owing to emerging evidence that this common injury Key Points can affect academics and cause behavioral changes and C Question Across a broad health care network, where do children neurocognitive deficits in working memory,concentration, pro- initially seek health care for concussion? cessing speed, and eye and motor function.1-3 Reported esti- Findings In this descriptive epidemiology study, 82% of patients mates of the number of youth with concussion have in- sought initial care for concussion with primary care and only 12% creased in recent years, likely owing in part to increased within the emergency department. Younger children and those involvement in youth sports, introduction of return-to-play insured by Medicaid were more likely to use the emergency legislation, and increased awareness of concussion by clini- department as their initial point of health care entry. cians, parents, and youth themselves.1,4-6 Meaning Efforts to measure the incidence of concussion cannot Concussion diagnosis remains symptom-based and does solely be based on emergency department visits, and primary care 7 not require advanced diagnostic tools such as imaging. Thus, clinicians must be trained in concussion diagnosis and unlike many other types of traumatic injuries, children with management. concussion potentially enter the health care system through a variety of portals, including primary care or specialty care such as sports medicine or neurology, in addition to the emer- gency department (ED) and urgent care. A previous study high- medicine, neurology, and trauma care clinicians at CHOP evalu- lighted the diversity of health care use for youth with concus- ate and manage concussions using a linked EHR system (Epic- sion and minor head injury based on private insurance data, Care; Epic Systems Inc). The EHR is used for all aspects of clini- emphasizing the importance of primary care clinicians.8 How- cal care, from inpatient to outpatient settings, as well as initial ever, pediatricians noted that they lack up-to-date concus- and follow-up office visits. sion training and/or resources needed for timely and accu- This study was reviewed and approved by the CHOP in- rate diagnosis and ongoing case management.9 A more stitutional review board. Consent was waived because the re- complete understanding of the distribution of point of health search was limited to existing data and involved no more than care entry for children with concussion is needed to guide both minimal risk to the patient, and the research could not be health care networks and clinicians where targeted training and practicably carried out without the waiver. resources need to be deployed. In addition, an Institute of Medicine (IOM) report high- Case Identification lighted the lack of data on concussions treated outside the ED We queried CHOP’s EHR database to identify all CHOP primary setting or sustained outside organized high school or colle- care patients who were aged 0 to 17 years and who had an ini- giate athletics.1,10-12 Prior efforts have either focused on a single tial in-person medical visit at CHOP related to concussion from sport, used EDs as the sole site of identification, or studied a July 1, 2010, through June 30, 2014. Concussion visits were de- broader spectrum of head injury.13-22 In response to the IOM fined as those assigned an International Classification of Dis- report, several initiatives are under way that are attempting eases, Ninth Revision, Clinical Modification (ICD-9-CM) diagno- to better estimate youth concussion incidence. To give guid- sis code indicative of concussion (Table 1). Primary care patients ance as to the needed breadth of those efforts and to identify were identified as those with at least 1 primary care visit to a locations in the health care system that need to be skilled in CHOP primary care network location during the study period; concussion diagnosis and initial management, we leveraged the study was limited to patients whose primary care is nor- the linked electronic health record (EHR) system at The mally delivered by the CHOP network because we expect the Children’s Hospital of Philadelphia (CHOP) to comprehen- distribution of entry locations for this group to be a more accu- sively describe point of entry into a large, regional, pediatric rate representation of patient behavior in using the CHOP health health care network for CHOP primary care patients who care system for concussion than all patients of the CHOP health sustained concussions from July 2010 through June 2014; care network. Initial visits were defined as the first clinical en- distributions were assessed over time across broad age, demo- counter for a concussion as determined by date and time of the graphic, and socioeconomic characteristics. encounter. Because we could not separate multiple concus- sions that may have been sustained by an individual patient owing to limitations of CHOP’s EHR system, each patient was Methods counted only once in analyses. Given that the focus of this analysis was on patients whose Description of CHOP Network concussion was their only traumatic brain injury, as well as to The CHOP network encompasses more than 50 locations minimize concussion misclassification, we excluded pa- throughout southeastern Pennsylvania and southern New Jer- tients who were also assigned an ICD-9-CM code for a more se- sey, including 31 primary care centers, 14 specialty care cen- vere traumatic brain injury (codes included the following key ters, a 535-bed inpatient hospital, 2 EDs, and 2 urgent care cen- words/phrases: contusion, laceration, subarachnoid, subdu- ters supporting more than 1 million visits annually. The CHOP ral, epidural, other and unspecified intracranial hemorrhage, network serves a socioeconomically and racially/ethnically di- and moderate or prolonged loss of consciousness) within 2 weeks verse population and accepts most insurance plans, includ- of the initial concussion visit (n = 20). In addition, patients with ing Medicaid. In addition to primary care clinicians, sports clinically important injuries to body regions other than the
E2 JAMA Pediatrics Published online May 31, 2016 (Reprinted) F-2 jamapediatrics.com Copyright 2016 American Medical Association. All rights reserved.
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Table 1. Concussion-Related ICD-9-CM Codes Table 2. Patient Characteristics at Time of Initial Concussion Visit to CHOP Health Care Network ICD-9-CM Code Description CHOP Primary 800.02 Fracture of vault of skull with brief (< 1 h) LOC Care Patients Characteristic (N = 8083), No. (%) 800.09 Closed fracture of vault of skull without mention of intracranial injury, with concussion, unspecified Age at first concussion-related encounter, y 800.52 Open fracture of vault of skull without mention of 0-4 368 (4.6) intracranial injury, with brief (< 1 h) LOC 5-11 2492 (30.8) 800.59 Open fracture of vault of skull without mention of intracranial injury, with concussion, unspecified 12-14 2820 (34.9) 801.02 Closed fracture of base of skull without mention of 15-17 2403 (29.7) intracranial injury, with brief (< 1 h) LOC 801.09 Closed fracture of base of skull without mention of Sex intracranial injury, with concussion, unspecified Male 4494 (55.6) 801.39 Closed fracture of base of skull with concussion, unspecified Female 3589 (44.4) 801.52 Open fracture of base of skull without mention of Race/ethnicity intracranial injury with brief (< 1 h) LOC Non-Hispanic white 5729 (70.9) 801.56 Open fracture of base of skull without mention of intracranial injury with LOC of unspecified duration Non-Hispanic black 1383 (17.1) 801.59 Open fracture of base of skull without mention of Hispanic 257 (3.2) intracranial injury, with concussion, unspecified Non-Hispanic Asian/Asian Pacific 134 (1.7) 803.02 Other and unqualified skull fractures with brief (<1 h) LOC Islander/other/multiple race 803.09 Other and unqualified skull fractures with concussion, Unknown 580 (7.2) unspecified 803.52 Other open skull fracture without mention of intracranial Payor of encounter injury with brief (<1 h) LOC Private 6652 (82.3) 803.59 Other open skull fracture without mention of intracranial injury, with concussion, unspecified Medicaid 1290 (16.0) 804.02 Closed fractures involving skull or face with other bones, Self-pay 141 (1.7) without mention of intracranial injury, with brief (<1 h) LOC 804.09 Closed fractures involving skull of face with other bones, Abbreviation: CHOP, The Children’s Hospital of Philadelphia. without mention of intracranial injury, with concussion, unspecified 804.52 Open fractures involving skull or face with other bones, tion were calculated using the surveyfreq procedure in SAS. without mention of intracranial injury, with brief (<1 h) LOC 850 Concussion In addition, during May and June 2012, extensive training was 850.0 Concussion with no LOC provided to CHOP primary care clinicians on the current stan- 850.1 Concussion with brief LOC dard of care and approach for diagnosing and managing con- 850.10 Concussion with brief LOC cussions. Therefore, analyses were conducted looking both at 850.11 Concussion, with LOC of ≤30 min the overall 4-year period, as well as stratified by date of initial 850.5 Concussion with LOC of unspecified duration concussion visit: July 2010 to June 2012 and July 2012 to June 850.9 Concussion, unspecified 2014. All analyses were conducted in SAS version 9.3 (SAS
Abbreviations: ICD-9-CM, International Classification of Diseases, Ninth Revision, Institute Inc). Clinical Modification; LOC, loss of consciousness.
brain were excluded (n = 298); this was assessed by identify- Results ing ICD-9-CM codes corresponding to other injuries on the same day as the initial concussion visit. Last, patients who were re- A total of 8083 children aged 17 years and younger had an ini- ceiving ongoing concussion treatment during the study pe- tial in-person clinical visit for concussion (without a more se- riod but whose initial concussion visit occurred prior to July vere head injury or other clinically significant injury) within 1, 2010, were excluded (n = 121). the CHOP network during the 4-year study period. The fre- quency and proportion of relevant characteristics at the time Variable Definitions of initial concussion visit are shown in Table 2. The median age Potential points of entry within the CHOP health care network of patients was 13 years (interquartile range, 10-15 years); 4.6% included (1) 1 of the primary care network offices; (2) outpa- (n=368)wereaged0to4years,30.8%(n=2492)wereaged tient specialty care, including orthopedics/sports medicine, 5 to 11 years, 34.9% (n = 2820) were aged 12 to 14 years, and trauma, and neurology; (3) 1 of 2 EDs or 2 urgent care centers; 29.7% (n = 2403) were aged 15 to 17 years. Most were non- and (4) direct admission to the hospital. Race/ethnicity, sex, age, Hispanic white (n = 5729; 70.9%) and had private insurance and payor (Medicaid, private, vs self-pay) at time of initial con- (n = 6652; 82.3%). Almost two-thirds of all visits occurred from cussion visit were ascertained from the EHR. July 2012 to June 2014 (n = 5026). Overall, 81.9% (95% CI, 81.1%-82.8%; n = 6624) of pa- Statistical Analysis tients had their first concussion visit at CHOP within primary The distribution of initial concussion visit location was de- care, 5.2% (95% CI, 4.7%-5.7%; n = 418) within specialty care, scribed by age, sex, payor, and race/ethnicity; Wald 95% CIs 11.7% (95% CI, 11.0%-12.4%; n = 947) within the ED, and 1.2% based on a normal approximation to the binomial distribu- (95% CI, 0.9%-1.4%; n = 94) direct admit to the hospital
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(Table 3). The proportion of CHOP primary care patients who ture research ensuring validated, age-appropriate diagnostic sought care at their primary care office increased 13% be- and treatment strategies are available across the entire pedi- tween July to September 2010 and April to June 2014 (72.4%, atric age range. 184/254 to 81.7%, 503/616), while the proportion seeking care Second, our results illustrate that more than three- at the ED decreased 16% over the same period (15.4%, 39/254 fourths of the patients (6624/8083) had their first concus- to 13.0%, 80/616) (Figure). sion visit within the CHOP network with primary care and Table 3 illustrates the distribution of health care entry lo- just over 10% (947/8083) within the ED, suggesting that con- cation by age, sex, race/ethnicity, payor, and period. Location cussion estimates based solely on ED visits likely substan- of entry varied significantly by age. More than half of chil- tially underestimate the true incidence of this injury in chil- dren aged 0 to 4 years entered the CHOP network via the ED dren. A study linking multiple population-based health (51.9%; 95% CI, 46.8%-57.0%; 191/368), a significantly higher administration databases in Canada25 and a study using data proportion than for older children (14.9% [371/2492] of those on private insurance claims in Massachusetts8 documented aged 5-11 years [95% CI, 13.5%-16.3%]; 7.9% [222/2820] of those a similar increase over time in concussions and minor head aged 12-14 years [95% CI, 6.9%-8.9%]; and 6.8% [163/2403] of injuries treated during office visits (eg, primary care and spe- those aged 15-17 years [95% CI, 5.8%-7.8%]). Conversely, more cialty care) compared with treatment within EDs. Our study than three-quarters of those aged 5 to 17 years (5-11 years: 1995/ uniquely extends these findings in 2 ways. First, we used a 2492; 12-14 years: 2415/2820; and 15-17 years: 2056/2403) ini- stricter definition of concussion by excluding minor head tially sought care at CHOP via primary care. There were also injuries that were not diagnosed as concussions. More important differences by race/ethnicity and payor: 42.4% (95% importantly, by capturing cases across broad demographics CI, 39.8%-45.0%; 586/1383) of non-Hispanic black patients en- and socioeconomics throughout an entire health care net- tered via the ED compared with 4.9% (95% CI, 4.3%-5.4%; 280/ work, we identified important variations in health care use 5729) of non-Hispanic white patients. Similarly, 37.1% (95% CI, by insurance payor and other demographic subgroups. 34.4%-39.7%; 478/1290) of children insured by Medicaid and Our results highlight the critical importance of primary care 24.1% (95% CI, 17.1%-31.2%; 34/141) who were self-pay en- clinicians in concussion care. This may be driven in part by in- tered through the ED compared with 6.5% (95% CI, 5.9%- surance reasons or the fact that patients can often be sched- 7.1%; 435/6652) with private insurance. uled for office appointments in the primary care setting sooner and at lesser expense than in specialty care or the ED. Regard- less of the reason, these data provide critical guidance to health Discussion care networks, alerting them that the primary care setting is increasingly being used for concussion care and those clini- While our understanding of concussion as an important pub- cians may be in need of augmented training or increased re- lic health issue among children has grown tremendously over sources. For primary care clinicians, these data provide evi- the last decade, as highlighted in a recent IOM report,1 the epi- dence they can use to advocate for concussion clinical decision demiology of youth concussion has been limited primarily to support tools in their health care system. Because special- those who are high school age or older, participate in orga- ized equipment is currently not needed for diagnosis, nized sports, and/or are treated in EDs. In this study, we lev- primary care clinicians can be well positioned to provide the eraged the strength of a linked EHR system throughout a large initial evaluation for most patients with concussion. In some health care network to provide a comprehensive description geographic areas, they may be the only available clinical re- of the point of health care entry specific for pediatric concus- source. Preliminary findings suggest that primary care clini- sion across the developmental age spectrum—the first such US cians can in fact provide quality care to children with assessment to include a diverse demographic and socioeco- concussion.26 The care partnership between specialists and pri- nomic sample. By doing so, we discovered important insights mary care that has occurred in the diagnosis and treatment of into the variations in point of entry by age, payor, and race/ pediatric mental health disorders, such as attention-deficit/ ethnicity that will provide guidance to the future develop- hyperactivity disorder, suggests there are models for success- ment of youth concussion surveillance systems being de- ful clinical collaboration. signed to provide national incidence estimates. In addition, our We also observed important variations in health care results highlighted the potential of EHR systems to facilitate use among different subgroups. Children younger than 5 research in this field. years old were more likely than older children to have the First, the findings confirmed that concussions occur among ED as their initial point of entry into the CHOP system for children of all ages: approximately one-third of patients (2860/ concussion. This aligns with previous research describing 8083) were younger than 12 years. In contrast, most pediatric high rates of ED use for injuries in younger children.27 Con- concussion research has focused on youth of high school age, cussion is challenging to diagnose in infants and toddlers as resulting in limited knowledge about the natural history of con- they are often unable to reliably relay their symptoms to the cussion in a middle or elementary school population.23 Ow- clinician, which may make their parents more likely to seek ing to the evolving neuropsychology and neurophysiology ED care for more urgent evaluation and concern for more across the pediatric age range, it is likely that children mani- serious brain injuries. Others have noted that ED use can be fest concussion symptoms differently across the age influenced by parental understanding of the primary care continuum.24 Our findings underscore the critical need for fu- clinician as a comprehensive source of care,28 parental anxi-
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Downloaded From: http://archpedi.jamanetwork.com/ by a Stephen B. Thacker CDC Library User on 06/01/2016 Point of Health Care Entry for Youth Concussion OriginalAttachment Investigation Research F Specialty Outpatient Primary Care Hospital Encounter No. (%) ED/Urgent Care No. Specialty Outpatient Primary Care Hospital Encounter No. (%) ED/Urgent Care No. Specialty Outpatient Primary Care Hospital Encounter No. (%) ED/Urgent Care 368 191 (51.9) 16 (4.3) 158 (42.9) 3 (0.8) 183 103 (56.3) 9 (4.9) 69 (37.7)134 24 (17.9) 2 (1.1) 2 (1.5) 185 88 (47.6) 99 (73.9) 7 (3.8) 9 (6.7) 89 (48.1) 39 1 (0.5) 9 (23.1) 2 (5.1) 26 (66.7) 2 (5.1) 95 15 (15.8) 0 (0) 73 (76.8) 7 (7.4) Overall (N = 8083)No. July 2010-June 2012 (n = 3057) July 2012-June 2014 (n = 5026) 2492 371 (14.9)2820 222 (7.9) 45 (1.8)2403 163 (6.8) 18 (0.6) 1995 (80.1)4494 15 (0.6) 604 (13.4) 2415 81 (85.6) (3.3) 56 2056 (1.2) 165 (85.6) (5.9) 8535729 169 (7.0) 1036 168 3601 280 (19.7) (80.1) (4.9)1383 27 93 233 (3.2) (9.0) (5.2) 985 32 586 (0.6) (42.4) 11 81 (1.1) (8.2) 1822 55 (4.0) 613 (71.9) 5073 291 (88.5) (16.0) 11 (1.1) 45 845 (5.3) 36 344 (81.6) (2.0) (6.0) 698 (50.5) 1639 87 798 (8.4) (81.0) 2144 1361 (74.7) 44 (3.2) 203 (12.4) 133 1784 95 (6.2) 134 (9.6) (7.4) 18 (1.1) 129 (7.2) 20 585 1418 (0.9) 2672 1382 284 (84.3) (48.5) 313 (11.7) 7 82 (0.4) (5.8) 1794 (83.7) 32 (5.5) 36 20 (2.2) (0.7) 197 (9.2) 1570 (88.0) 4 (0.3) 2240 (83.8) 249 3585 (42.6) 78 (4.4) 1258 (88.7) 99 147 (3.7) (4.1) 20 (3.4) 74 (5.2) 12 (0.3) 798 3279 302 (91.5) (37.8) 147 (4.1) 23 (2.9) 449 (56.3) 24 (3.0) All age groups0-4 80835-11 947 (11.7)12-14 94 (1.2)15-17 6624 (81.9)Male 418 (5.2)Female 3057 445 (14.6)Non-Hispanic 58 (1.9)white 3589 343Non-Hispanic (9.6) 2325black (76.1) 229 38Hispanic (7.5) (1.1)Non-Hispanic 5026Asian/Asian 3023 (84.2) 502Pacific (10.0) 185 257Islander/other/ (5.2) 36 (0.7)multiple race 32 (12.5) 1235Unknown 4299 (85.5) 154 (12.5) 3 189 (1.2) (3.8) 22 (1.8)Private 580Medicaid 215 (83.7) 25 964 (4.3) (78.1)Self-pay 7 6652 95 (2.7) (7.7) 2 1290 435 (0.3) (6.5) 478 2354 (37.1) 141 97 47 189 (0.7) 45 (8.0) (3.5) 539 (92.9) 34 14 (24.1) (14.4) 16 (0.7) 5789 14 (87.0) (2.4) 2 2 735 (2.1) (1.4) (57.0) 2059 381 (87.5) (5.7) 32 192 (2.5) 90 (3.8) 2502 100 77 (70.9) (79.4) 208 5 (8.3) (2.6) 499 4 5 (4.1) (3.5) 225 31 (45.1) (1.2) 2 (1.0) 26 (5.2) 160 2057 (82.2) 56 179 (93.2) 206 18 (8.2) (11.3) 229 12 (45.9) (21.4) 6 4150 1 (3.1) (0.6) 19 (3.8) 1 (1.8) 227 (5.5) 388 138 791 (86.3) 16 (0.4) 39 253 (69.6) 20 (32.0) (5.2) 3 (1.9) 3732 19 (89.9) (2.4) 4 (7.1) 0 175 (0) (4.2) 506 (64.0) 85 360 13 (92.8) (1.6) 22 (25.9) 8 (2.1) 1 (1.2) 61 (71.8) 1 (1.2) Factor Race/ethnicity Payor of encounter Sex Age at first concussion-related encounter, y Table 3. Distribution of Health Care Location of Initial Concussion Visit, Overall and by Relevant Factors, for CHOP Primary Care Patients Only (N = 8083) Abbreviations: CHOP, The Children’s Hospital of Philadelphia; ED, emergency department.
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Figure. Proportion of Concussion Visits by Initial Point of Health Care Entry Over Time Among The Children’s Hospital of Philadelphia Primary Care Patients (N = 8083)
100 90 80 70
60 Primary care 50 Emergency department/urgent care Specialty outpatient 40 Hospital encounter 30 Proportion of Visits, % 20 10 0 2010-Q3 2010-Q4 2011-Q1 2011-Q2 2011-Q3 2011-Q4 2012-Q1 2012-Q2 2012-Q3 2012-Q4 2013-Q1 2013-Q2 2013-Q3 2013-Q4 2014-Q1 2014-Q2
Period Q indicates quarter.
ety during the relatively high-stress period of infancy,29 or ED rather than another community ED. Despite being more misperceptions of illness/injury severity.30 Our findings likely to be minority and receiving Medicaid than the entire suggest the need for specialized training for concussion sample, 69% of these patients first sought care at their pri- diagnosis and/or development of special screening tools in mary care office, reinforcing our primary findings. Previous EDs for this difficult-to-diagnose population. These assess- analyses indicated that the CHOP primary care population is ments may need to be age modified as evidence suggests similar in key demographic variables to the Philadelphia met- different symptom constellations among pediatric age ropolitan area32 and likely is representative of the general pa- groups.24 Enhancement of the triage process that occurs in tient population in the Mid-Atlantic region. Second, this as- most primary care settings via telephone nurse triage may sessment did not take into account those who did not seek care be advantageous in reassuring parents that many instances for their concussion, either because they did not recognize or of minor head trauma, even in the very young, can be want to disclose their symptoms or because their family did appropriately managed by primary care. Future work might not perceive their injury required medical care. As high- focus on delineation of concussion characteristics in this lighted by the IOM, this “culture of resistance” is prevalent and, youngest age group aimed at providing the foundation for although not the focus of this analysis, is a significant soci- these interventions. etal issue in need of further study. Third, only the initial CHOP Patterns of health care entry point also varied by payor and visit for the first concussion occurring during the study pe- race/ethnicity, a finding congruent with previous research re- riod was identified for each patient. Certainly, some propor- lated to pediatric injuries in general.27,31 Patients with Medic- tion of patients experienced multiple concussions during the aid were disproportionately more likely to use the ED setting study period. Unfortunately, the EHR was not set up to sys- as an initial point of entry into the CHOP network for concus- tematically separate multiple concussions within a given pa- sion, as were non-Hispanic black patients. This may be owing tient’s record. To estimate the extent to which we underesti- to the fact that specific state-level Medicaid provisions may mated the number of unique concussions, we selected 3% of direct the patient where they can seek care, or it may be ow- concussion patients (n = 218) for manual medical record re- ing to existing beliefs as to the appropriateness of the ED for view; we randomly selected patients within strata based on the injury care for particular demographic subgroups. This sug- number of concussion visits and the length of time between gests that concussion epidemiology based on ED records may the first and last visits; patients with more visits and a longer overestimate the incidence of concussion among these groups time between the first and last visits were more likely to be se- and underestimate the incidence among other groups. lected. Based on this review, we estimated that 16% of our pa- There were several limitations of this study. First, inher- tients (1289/8083) sought treatment for more than 1 concus- ent to the use of a single health care network’s EHR system as sion during the study period, indicating that we likely a data source is the fact that visits outside that network are not underestimated the true number of unique concussions by that included. Some patients may have had a prior visit at a com- percentage over the 4-year period. A more complete assess- munity ED or non-CHOP provider before seeking care at CHOP ment of the patterns of health care use for the entire course of and, therefore, this analysis may not fully characterize the care, including subsequent concussions, is under way to health care use of a well-defined underlying population. To ex- complement the analyses contained herein. Last, it is impor- plore the extent of this limitation, we conducted sensitivity tant to note that these analyses were conducted on patients analyses that limited the sample only to patients of primary with a primary care clinician; the distribution of health care care practices that were within 20 miles driving distance from location initially used for concussion may be different in those the CHOP ED as these might be more likely to use the CHOP without a primary care clinician.
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ing and clinical decision support tools to these clinicians. Conclusions Important variations in the point of health care entry by age, race/ethnicity, and payor also suggest the accuracy of inci- In summary, using a novel method to leverage rich data cap- dence estimates based on a single point of health care entry may tured in a unified EHR system on a diverse demographic and vary for these different subgroups. These differences may lead socioeconomic population, this study suggests that incidence to targeted interventions to improve recognition and manage- estimates of pediatric concussion that rely solely on ED ment of concussion in these populations. In addition, the in- records substantially underestimate the true incidence of this creased use of EHRs may provide an opportunity to leverage injury. Most pediatric patients with concussion sought their ini- health records for research into the natural history of concus- tial concussion care within the CHOP network with a primary sion that may lead to improvements in the prevention, diagno- care clinician, illustrating the need to provide up-to-date train- sis, and management of this common childhood injury.
ARTICLE INFORMATION Washington, DC: Institute of Medicine and National 15. O’Kane JW, Schiff MA. Concerns about Accepted for Publication: January 27, 2016. Research Council of the National Academies; 2013. concussion rates in female youth soccer-reply. JAMA Pediatr. 2014;168(10):968. Published Online: May 31, 2016. 2. Ransom DM, Vaughan CG, Pratson L, Sady MD, doi:10.1001/jamapediatrics.2016.0294. McGill CA, Gioia GA. Academic effects of 16. Bakhos LL, Lockhart GR, Myers R, Linakis JG. concussion in children and adolescents. Pediatrics. Emergency department visits for concussion in Author Contributions: Drs Arbogast and Curry had 2015;135(6):1043-1050. young child athletes. Pediatrics. 2010;126(3):e550- full access to all of the data in the study and take e556. responsibility for the integrity of the data and the 3. Corwin DJ, Wiebe DJ, Zonfrillo MR, et al. accuracy of the data analysis. Vestibular deficits following youth concussion. 17. Meehan WP III, Mannix R. Pediatric concussions Study concept and design: Arbogast, Curry, J Pediatr. 2015;166(5):1221-1225. in United States emergency departments in the Zonfrillo, Haarbauer-Krupa, Breiding, Coronado, 4. Metzl JD. Concussion in the young athlete. years 2002 to 2006. J Pediatr. 2010;157(6):889-893. Master. Pediatrics. 2006;117(5):1813. 18. Marin JR, Weaver MD, Yealy DM, Mannix RC. Acquisition, analysis, or interpretation of data: 5. Zonfrillo MR, Kim KH, Arbogast KB. Emergency Trends in visits for traumatic brain injury to Arbogast, Curry, Pfeiffer, Haarbauer-Krupa, department visits and neuroimaging for concussion emergency departments in the United States. JAMA. Coronado, Master. patients from 2006-2011. Acad Emerg Med.2015; 2014;311(18):1917-1919. Drafting of the manuscript: Arbogast, Curry, 22(7):872-877. 19. Howard AF, Costich JF, Mattacola CG, Slavova S, Pfeiffer, Master. 6. Chrisman SP, Schiff MA, Chung SK, Herring SA, Bush HM, Scutchfield FD. A statewide assessment Critical revision of the manuscript for important of youth sports- and recreation-related injuries intellectual content: Arbogast, Curry, Pfeiffer, Rivara FP. Implementation of concussion legislation and extent of concussion education for athletes, using emergency department administrative Zonfrillo, Haarbauer-Krupa, Breiding, Coronado, records. J Adolesc Health. 2014;55(5):627-632. Master. parents, and coaches in Washington State. Am J Statistical analysis: Curry, Pfeiffer. Sports Med. 2014;42(5):1190-1196. 20. Stewart TC, Gilliland J, Fraser DD. An Obtained funding: Arbogast, Master. 7. Master CL, Balcer L, Collins M. In the clinic: epidemiologic profile of pediatric concussions: Administrative, technical, or material support: concussion. Ann Intern Med. 2014;160(3):ITC2-1. identifying urban and rural differences. J Trauma Acute Care Surg. 2014;76(3):736-742. Zonfrillo, Haarbauer-Krupa, Coronado, Master. 8. Taylor AM, Nigrovic LE, Saillant ML, et al. Trends Study supervision: Arbogast, Curry, Master. in ambulatory care for children with concussion and 21. Gilchrist J, Thomas KE, Xu L, McGuire LC, Conflict of Interest Disclosures: None reported. minor head injury from eastern Massachusetts Coronado V; Centers for Disease Control and Prevention. Nonfatal traumatic brain injuries Funding/Support: This research was supported by between 2007 and 2013. J Pediatr. 2015;167(3): 738-744. related to sports and recreation activities among an intergovernmental personnel act agreement persons aged Յ19 years: United States, between the US Department of Health and Human 9. Zonfrillo MR, Master CL, Grady MF, Winston FK, 2001-2009. MMWR Morb Mortal Wkly Rep. 2011;60 Services (HHS) Centers for Disease Control and Callahan JM, Arbogast KB. Pediatric providers’ (39):1337-1342. Prevention (CDC) and The Children’s Hospital of self-reported knowledge, practices, and attitudes Philadelphia. about concussion. Pediatrics. 2012;130(6):1120-1125. 22. Dompier TP, Kerr ZY, Marshall SW, et al. Incidence of concussion during practice and games Role of the Funder/Sponsor: Beyond the 10. Kerr ZY, Dompier TP, Snook EM, et al. National in youth, high school, and collegiate American coauthors, the CDC had no role in the design and Collegiate Athletic Association Injury Surveillance football players. JAMA Pediatr. 2015;169(7):659-665. conduct of the study; collection, management, System: review of methods for 2004-2005 analysis, and interpretation of the data; through 2013-2014 data collection. JAthlTrain. 23. Davis GA, Purcell LK. The evaluation and preparation, review, or approval of the manuscript; 2014;49(4):552-560. management of acute concussion differs in young children. Br J Sports Med. 2014;48(2):98-101. and decision to submit the manuscript for 11 . Covassin T, Swanik CB, Sachs ML. publication. Epidemiological considerations of concussions 24. Sady MD, Vaughan CG, Gioia GA. Psychometric Disclaimer: This article does not reflect the official among intercollegiate athletes. Appl Neuropsychol. characteristics of the postconcussion symptom policy or opinions of the CDC or the US Department 2003;10(1):12-22. inventory in children and adolescents. Arch Clin Neuropsychol. 2014;29(4):348-363. of HHS and does not constitute an endorsement of 12. Hootman JM, Dick R, Agel J. Epidemiology of the individuals or their programs—by the CDC, HHS, collegiate injuries for 15 sports: summary and 25. Macpherson A, Fridman L, Scolnik M, Corallo A, or other components of the federal government— recommendations for injury prevention initiatives. Guttmann A. A population-based study of and none should be inferred. JAthlTrain. 2007;42(2):311-319. paediatric emergency department and office visits Additional Contributions: We thank Ronni Kessler, for concussions from 2003 to 2010. Paediatr Child 13. Mannix R, O’Brien MJ, Meehan WP III. The Health. 2014;19(10):543-546. MS, and Julia Vanni for their role in project epidemiology of outpatient visits for minor head coordination and Marianne Chilutti, MS, for her data injury: 2005 to 2009. Neurosurgery. 2013;73(1): 26. Lott A, Zonfrillo MR, Wiebe DW, Arbogast KB, management (The Children’s Hospital of 129-134. Grady MF, Master CL. Post-intervention study of Philadelphia). Ms Chilutti and Ms Kessler received concussion education and clinical support compensation from a funding sponsor. 14. Kontos AP, Elbin RJ, Fazio-Sumrock VC, et al. implementation with primary care providers. Poster Incidence of sports-related concussion among presented at: Pediatric Academic Societies Annual REFERENCES youth football players aged 8-12 years. J Pediatr. Meeting; April 27, 2015; San Diego, California. 2013;163(3):717-720. 1. Institute of Medicine. Sports-Related Concussions 27. Alpern ER, Clark AE, Alessandrini EA, et al; in Youth: Improving the Science, Changing the Culture. Pediatric Emergency Care Applied Research
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Network (PECARN). Recurrent and high-frequency services in infancy: a prospective study. J Pediatr States: focus on injury-related emergency use of the emergency department by pediatric Psychol. 1994;19(3):369-381. department utilization and expenditures. Ambul patients. Acad Emerg Med. 2014;21(4):365-373. 30. Fieldston ES, Alpern ER, Nadel FM, Shea JA, Pediatr. 2008;8(4):219-240.e17. 28. Romaire MA, Bell JF, Grossman DC. Health care Alessandrini EA. A qualitative assessment of 32. Feemster KA, Li Y, Grundmeier R, Localio AR, use and expenditures associated with access to the reasons for nonurgent visits to the emergency Metlay JP. Validation of a pediatric primary care medical home for children and youth. Med Care. department: parent and health professional network in a US metropolitan region as a 2012;50(3):262-269. opinions. Pediatr Emerg Care. 2012;28(3):220-225. community-based infectious disease surveillance 29. Goldman SL, Owen MT. The impact of parental 31. Owens PL, Zodet MW, Berdahl T, Dougherty D, system. Interdiscip Perspect Infect Dis. 2011;2011: trait anxiety on the utilization of health care McCormick MC, Simpson LA. Annual report on 219859. health care for children and youth in the United
E8 JAMA Pediatrics Published online May 31, 2016 (Reprinted) F-8 jamapediatrics.com Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a Stephen B. Thacker CDC Library User on 06/01/2016 Attachment G
Policies and Programs on Concussions for Public Schools and Youth Sport Programs
G-1 Attachment G
Introduction
In accordance with SB 771 and HB858 which amended sections 7-432 and 14-501 of the Annotated Code of Maryland, the Maryland State Department of Education (MSDE) has developed policies and provided recommendations for the implementation of concussion awareness programs throughout the state of Maryland for student-athletes, their parents or guardians, and their coaches. The Department has also developed recommendations on the management and treatment of student-athletes suspected or diagnosed with having sustained a concussion. These recommendations, in addition to the accompanying recommended forms, provide guidance for both the student-athlete’s exclusion from play as well as their return to the classroom. Finally, the Department addresses the concussion education and tracking requirements of non-school related athletic programs and provides guidance and suggestions for those programs.
The provisions of the policies and plan call for training of every public high school coach as well as providing awareness to all student-athletes and their parents or guardians on:
• The nature and risk of a concussion or head injury • The criteria for removal from and return-to-play • The risk of not reporting injury • Appropriate academic accommodations
The provisions also mandate written verification of:
• The coach receiving concussion awareness training • The student-athlete and parent or guardian acknowledging receipt of concussion awareness information
In addition, schools shall extend appropriate procedures for academic accommodations to student-athletes who have been diagnosed with a concussion.
Finally, non-school youth athletic activities conducted on school property must provide assurances that concussion information has been provided to all participants and their parents or guardians.
This document has been formulated in conjunction with the Maryland Department of Health and Mental Hygiene, Local County Departments of Education, Maryland Public Secondary Schools Athletic Association, Maryland Athletic-Trainers’ Association, Brain Injury Association of Maryland and Health Care Providers who treat concussions.
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G-2 Attachment G
Definitions
Concussion is a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head that can change the way the brain normally works. Concussions can also occur from a blow to the body that causes the head to move rapidly back and forth. Even a "ding," or what seems to be a mild bump or blow to the head can result in a concussion.
Licensed health care provider means a licensed physician or physician assistant, a licensed psychologist with specialty training in neuropsychology (neuropsychologist); or a licensed nurse practitioner.
Return to play means participation in a non-medically supervised practice or athletic competition after a period of exclusion.
Student-athlete means a student participating in any try-out, practice or contest of a school team.
School personnel means those directly responsible for administrating or coaching interscholastic athletic programs within a school or county and those employees of the school or school system with overall responsibility for student-athletes’ academic performance and medical well-being.
Youth sports program means a program organized for recreational athletic competition or instruction for participants who are under the age of 19 years. Coach’s Education
The Maryland State Department of Education will alert each local school system of its responsibility to assure that each coach is trained in concussion risk and management. At a minimum, the coach’s training shall include:
• The nature of the risk of a brain injury • The risk of not reporting a brain injury • Criteria for removal and return to play
One of the following programs is recommended to be used for coach’s concussion awareness training:
The National Federation of State High School Associations’ (NFHS) online coach education course, Concussion in Sports-What You Need to Know. This Center for Disease Control’s (CDC)-endorsed program provides a guide to understanding,
2
G-3 Attachment G
recognizing and properly managing concussions in high school sports. It is available at www.nfhslearn.com.
The Center for Disease Control’s (CDC) tools for youth and high school sports coaches, parents, athletes, and health care professionals provide important information on preventing, recognizing, and responding to a concussion, and are available at http://www.cdc.gov/concussion/HeadsUp/online_training.html. These include Heads Up to Schools: Know Your Concussion ABCs; Heads Up: Concussion in Youth Sports; and Heads UP: Concussion in High School Sports.
Funded by the National Institutes of Health, developed by leading researchers, and validated in a clinical trial, the Oregon Center for Applied Science (ORCAS) ACTive® course, provides an online training and certification program that gives sports coaches the tools and information to protect players from sports concussions. Information about the course is available at:
http://www.orcasinc.com/wp-content/uploads/2011/03/concussion.pdf.
If the above mentioned programs are not used, at a minimum, the concussion awareness training programs shall include the following components:
• Understanding Concussions • Recognizing Concussions • Signs & Symptoms • Responses and Action Plan
Proof of Completion
Presentation of a certificate of completion from a coaches training course as a condition of coaching employment provides a simple and clear mechanism for local school systems to assure compliance. (Figure 1)
Best Practices
The following are a list of resources that should be at every practice or competition where a student-athlete could possibly sustain a concussion.
• On field quick reference guide kept in team medical kit or other accessible area • A CDC clipboard or CDC clipboard sticker (http://www.cdc.gov/concussion/pdf/Clipboard_Sticker~a.pdf) or a clipboard sticker containing the same information • Copies of the “MSDE Notification of Probable Head Injury” form
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G-4 Attachment G
Concussion Awareness for Student-Athletes, Parents or Guardians and School Personnel
Each Maryland public school district shall develop policies that assure student-athletes, parents or guardians, and school personnel receive an informational sheet describing:
• The nature and risk of a concussion or head injury • The criteria for removal from play and return to play • The risks of not reporting injury and continuing to play • Appropriate academic accommodations for diagnosed concussion victims
Informational materials used shall emanate from programs such as, but not limited to:
The Center for Disease Control’s (CDC) tools for youth and high school sports coaches, parents, athletes, and health care professionals provide important information on preventing, recognizing, and responding to a concussion, and are available at http://www.cdc.gov/concussion/HeadsUp/online_training.html. These include Heads Up to Schools: Know Your Concussion ABCs; Heads Up: Concussion in Youth Sports; and Heads UP: Concussion in High School Sports.
The Maryland Public Secondary Schools Athletic Association (MPSSAA) has posted parent and student-athlete information sheets as well as other CDC material on its website: www.mpssaa.org. (Figures 2 and 3)
Best Practices
Suggested opportunities to provide concussion information include but are not limited to:
• In-service training • Team meetings or practice segment • Team pre-participation documents • Student-athlete/Parent orientation • Coach/Parent preseason meeting • Athletic trainer tips • Formal/informal seminars
Required Acknowledgement
4
G-5 Attachment G
Every student-athlete and at least one parent or guardian must verify in writing that they have received information on concussion and sign a statement acknowledging receipt of the information. A recommended verification sheet follows. (Figure 4)
Removal and Return-to Play
After an appropriate medical assessment, any student-athlete suspected of sustaining a concussion shall immediately be removed from practice or play. The student-athlete shall not return until cleared by a licensed health care provider authorized to provide sports physical examinations and trained in the evaluation and management of concussions.
To assist student-athletes, parents and school personnel the following sample forms are provided on the MPSSAA website: www.mpssaa.org.
• Notification of possible head injury (Figure 5) • Medical clearance for gradual return to sports participation Following concussion (Figure 6) • Graduated return to play protocols (Figures 7, 8, 9)
Note: As of this writing, there are no formally approved or licensed certifications of concussion management. As a result, and until such time as a certification exists, each medical professional authorizing return to play must determine whether they are aware of current medical guidelines on concussions evaluation and if concussion evaluation and management fall within their own scope of practice. Any medical professional’s concussion education should include at least the following:
• 2010 AAP Sport Related Concussion in Children and Adolescents http://aappolicy.aappublications.org/cgi/reprint/pediatrics;126/3/597.pdf • 2008 Zurich Concussion in Sport Group Consensus http://sportconcussions.com/html/Zurich%20Statement.pdf
Youth Sports Programs use of School Property
Youth sports programs seeking to use school facilities must verify distribution of concussion information to parents or guardians and receive verifiable acknowledgement of receipt. In addition, each youth sports program will annually affirm to the local school system of their intention to comply with the concussion information procedures. Materials for use for youth sports are available on the CDC website: http:// www.cdc.gov. (Figure 10)
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G-6 Attachment GFigure 1
(
Your NameName has successfully completed
Concussion in Sports - What You Need To Know
6/9/2Q1_Q Maryland Date of completion State of completion
V(,{.v.tf!>~ NFHS Executive Director Completion code
G-7 Attachment G
A FACT SHEET FOR ATHLETES HEADSIN HIGHUP SCHOOL CONCUSSION SPORTS What is a concussion? What should I do if I think I have a concussion? A concussion is a brain injury that: • Tell your coaches and your parents. Never ignore a • Is caused by a bump, blow, or jolt to the head bump or blow to the head even if you feel fine. Also, or body. tell your coach right away if you think you have a • Can change the way your brain normally works. concussion or if one of your teammates might have a • Can occur during practices or games in any sport concussion. or recreational activity. • Get a medical check-up. A doctor or other health • Can happen even if you haven’t been knocked out. care professional can tell if you have a concussion • Can be serious even if you’ve just been “dinged” and when it is OK to return to play. or “had your bell rung.” • Give yourself time to get better. If you have a concussion, your brain needs time to heal. While your All concussions are serious. A concussion can affect brain is still healing, you are much more likely to have your ability to do schoolwork and other activities (such another concussion. Repeat concussions can increase as playing video games, working on a computer, the time it takes for you to recover and may cause studying, driving, or exercising). Most people with a more damage to your brain. It is important to rest and concussion get better, but it is important to give your not return to play until you get the OK from your brain time to heal. health care professional that you are symptom-free.
What are the symptoms of a concussion? How can I prevent a concussion? You can’t see a concussion, but you might notice Every sport is different, but there are steps you can one or more of the symptoms listed below or that you take to protect yourself. “don’t feel right” soon after, a few days after, or even • Use the proper sports equipment, including personal weeks after the injury. protective equipment. In order for equipment to • Headache or “pressure” in head protect you, it must be: • Nausea or vomiting - The right equipment for the game, position, or activity • Balance problems or dizziness - Worn correctly and the correct size and fit • Double or blurry vision - Used every time you play or practice • Bothered by light or noise • Follow your coach’s rules for safety and the rules • Feeling sluggish, hazy, foggy, or groggy of the sport. • Difficulty paying attention • Practice good sportsmanship at all times. • Memory problems • Confusion If you think you have a concussion: Don’t hide it. Report it. Take time to recover.
It’s better to miss one game than the whole season. For more information and to order additional materials free-of-charge, visit: www.cdc.gov/Concussion.
U.S. DEPARTMENTOF HEALTHANDG-8 HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION June 2010 Attachment G
A FACT SHEET FOR PARENTS HEADSIN HIGHUP SCHOOL CONCUSSION SPORTS What is a concussion? • Ensure that they follow their coaches' rules for safety and A concussion is a brain injury. Concussions are caused by the rules of the sport. a bump, blow, or jolt to the head or body. Even a “ding,” • Encourage them to practice good sportsmanship at all times. “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious. What should you do if you think your teen has a concussion? What are the signs and symptoms? 1. Keep your teen out of play. If your teen has a concussion, You can’t see a concussion. Signs and symptoms of concussion her/his brain needs time to heal. Don’t let your teen can show up right after the injury or may not appear or be return to play the day of the injury and until a health noticed until days after the injury. If your teen reports one care professional, experienced in evaluating for concussion, or more symptoms of concussion listed below, or if you notice says your teen is symptom-free and it’s OK to return to the symptoms yourself, keep your teen out of play and seek play. A repeat concussion that occurs before the brain medical attention right away. recovers from the first—usually within a short period of time (hours, days, or weeks)—can slow recovery or increase Signs Observed Symptoms Reported the likelihood of having long-term problems. In rare cases, by Parents or Guardians by Athlete repeat concussions can result in edema (brain swelling), permanent brain damage, and even death. • Appears dazed or stunned • Headache or “pressure” • Is confused about in head 2. Seek medical attention right away. A health care profes- assignment or position • Nausea or vomiting sional experienced in evaluating for concussion will be able to decide how serious the concussion is and when it is safe • Forgets an instruction • Balance problems or for your teen to return to sports. • Is unsure of game, score, dizziness or opponent • Double or blurry vision 3. Teach your teen that it’s not smart to play with a concussion. Rest is key after a concussion. Sometimes athletes wrongly • Moves clumsily • Sensitivity to light believe that it shows strength and courage to play injured. or noise • Answers questions slowly Discourage others from pressuring injured athletes to play. • Loses consciousness • Feeling sluggish, hazy, Don’t let your teen convince you that s/he’s “just fine.” (even briefly) foggy, or groggy 4. Tell all of your teen’s coaches and the student’s school nurse • Concentration or memory • Shows mood, behavior, about ANY concussion. Coaches, school nurses, and other problems or personality changes school staff should know if your teen has ever had a concussion. • Can’t recall events prior • Confusion Your teen may need to limit activities while s/he is recovering to hit or fall • Just not “feeling right” from a concussion. Things such as studying, driving, working • Can’t recall events after or is “feeling down” on a computer, playing video games, or exercising may cause hit or fall concussion symptoms to reappear or get worse. Talk to your health care professional, as well as your teen’s coaches, school nurse, and teachers. If needed, they can help adjust How can you help your teen prevent a concussion? your teen’s school activities during her/his recovery. Every sport is different, but there are steps your teens can take to protect themselves from concussion and other injuries. If you think your teen has a concussion: • Make sure they wear the right protective equipment for their activity. It should fit properly, be well maintained, and be Don’t assess it yourself. Take him/her out of play. worn consistently and correctly. Seek the advice of a health care professional. It’s better to miss one game than the whole season. For more information and to order additional materials free-of-charge, visit: www.cdc.gov/Concussion.
U.S. DEPARTMENTOF HEALTHANDG-9 HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION June 2010 Attachment G
Figure 4
For official use only: Name of Athlete______Sport/season______Date Received______
Concussion Awareness Parent/Student-Athlete Acknowledgement Statement
I ______, the parent/guardian of ______, Parent/Guardian Name of Student-Athlete acknowledge that I have received information on all of the following:
The definition of a concussion
The signs and symptoms of a concussion to observe for or that may be reported by my athlete
How to help my athlete prevent a concussion
What to do if I think my athlete has a concussion, specifically, to seek medical attention right away, keep my athlete out of play, tell the coach about a recent concussion, and report any concussion and/or symptoms to the school nurse.
Parent/Guardian______Parent/Guardian______Date ______PRINT NAME SIGNATURE
Student Athlete______Student Athlete______Date ______PRINT NAME SIGNATURE
It’s better to miss one game than the whole season. For more information visit:G-10 www.cdc.gov/Concussion. Attachment G
Student-Athlete Date of injury Sport Parent/guardian name Home Phone Notification of Probable Head Injury Dear Parent: Based on our observations and/or incident described below, we believe your son/daughter exhibited signs and symptoms of a concussion while participating in ______. Since your son/ daughter has not been evaluated by a physician at school, it is important that you seek a physician’s care as soon as possible. It is important to recognize that blows to the head can cause a variety of injuries other than concussions (e.g., neck injuries, more serious brain injuries). Please be sure to see your doctor as soon as possible for any other medical concerns. Description of Incident/ Injury:
When to Seek Care Urgently. If you observe any of the following signs, call your doctor or go to your emergency department immediately. Headaches that worsen Very drowsy, can't be awakened Can't recognize people or places Seizures Repeated vomiting Increasing confusion Neck pain Slurred speech Weakness/numbness in arms/legs Unusual behavior change Significant irritability Less responsive than usual
Common Signs & Symptoms. It is common for a student with a concussion to have one or many symptoms. Physical Cognitive Emotional Sleep Headache Visual Problems Feeling mentally foggy Irritability Drowsiness Nausea/Vomiting Fatigue/ Feeling tired Feeling slowed down Sadness Sleeping less than usual Dizziness Sensitivity to light/ noise Difficulty remembering More emotional Sleeping more than usual Balance Problems Numbness/Tingling Difficulty concentrating Nervousness Trouble falling asleep
Please feel free to contact me if you have any questions. I can be reached at:
Employee Name and Title Date
TO BE COMPLETED BY THE AUTHORIZED HEALTH CARE PROVIDER:
Name:______Signature Date: Diagnosis: Please be advised that your son/daughter will not be allowed to return to play until they have no symptoms and have been cleared in writing by an authorized health care provider (physician, neuropsychologist, nurse practitioner, physician’s assistant) for this type of injury.
Distribution: __Parent __AD __School Health Room G-11 Attachment G
Student-Athlete Date of injury Today’s Date
Sport
Medical Clearance for Gradual Return to Sports Participation Following Concussion To be completed by the Licensed Health Care Provider
The above-named student-athlete sustained a concussion. The purpose of this form is to provide initial medical clearance before starting the Gradual Return to Sports Participation. Criteria for Medical Clearance for Gradual Return to Play (Check each) The student-athlete must meet all of these criteria to receive medical clearance. 1. No symptoms at rest/ no medication use to manage symptoms (e.g., headaches) 2. No return of symptoms with typical physical and cognitive activities of daily living 3. Neurocognitive functioning at typical baseline 4. Normal balance and coordination 5. No other medical/ neurological complaints/ findings Detailed Guidance 1. Symptom checklist: None of these symptoms should be present. Assessment of symptoms should be broader than athlete report alone. Also consider observational reports from parents, teachers, others. Physical Cognitive Emotional Sleep Headaches Sensitivity to light Feeling mentally foggy Irritability Drowsiness Nausea Sensitivity to noise Problems concentrating Sadness Sleeping more than usual Fatigue Numbness/ tingling Problems remembering Feeling more emotional Sleeping less than usual Visual problems Vomiting Feeling more slowed down Nervousness Trouble falling asleep Balance Problems Dizziness
2. Exertional Assessment (Check): The student-athlete exhibits no evidence of return of symptoms with: __ Cognitive activity: concentration on school tasks, home activities (e.g. TV, computer, pleasure reading) __ Physical activity: walking, climbing stairs, activities of daily living, endurance across the day 3. Neurocognitive Functioning (Check): The student’s cognitive functioning has been determined to have returned to its typical pre-injury level by one or more of the following: __ Appropriate neurocognitive testing __ Reports of appropriate school performance/ home functioning (concentration, memory, speed) in the absence of symptoms listed above 4. Balance & Coordination Assessment (Check): Student-athlete is able to successfully perform: __ Romberg Test OR SCAT2 (Double leg, single leg, tandem stance, 20 secs, no deviations fr proper stance) __ 5 successive Finger-to-Nose repetitions < 4 sec
I certify that: I am a Licensed Health Care Provider with training in concussion evaluation and management in accordance with current medical evidence (2010 AAP Sport-Related Concussion in Children and Adolescents, 2008 Zurich Concussion in Sport Group Consensus). The above-named student-athlete has met all the above criteria for medical clearance for his/her recent concussion, and as of this date is ready to return to a progressive Gradual Return to Sports Participation program (typically lasting minimum of 5 days).
Provider Name
Signature Date: Distribution: __Parent __AD __School Health Room G-12 Attachment G
Name______Date of Injury______School/Sport______Date of AHCP RTP Clearance______
Graduated Return to Play Protocol
With no symptoms, a gradual return to play program can be initiated. Follow these gradual progressive steps of the training sequence. There should be approximately 24 hours (or longer) in between each step. If any symptoms return at any time during these activities, stop the work out. Rest until symptom-free for 24 hours. Return to the previous asymptomatic step. If symptoms return or worsen, seek medical attention.
Step Date Activity Tolerance/Comments 1.Light General Begin with sport specific warm up. Do 15-20 minute Conditioning Exercises workout: stationary bicycle, fast paced walking or light (Goal: Increase HR) jog, rowing or freestyle swimming. 2. Moderate General Sport specific warm-up. Slowly increase intensity and Conditioning and Sport duration of workout to 20-30 minutes. Specific Skill Work; - Begin sport specific skill work within the workout. No Individually (Goal: Add spins, dives or jumps. Movement, individual skill work) 3. Heavy General Continue with general conditioning up to 60 minutes. conditioning, skill work; Increase intensity and duration. Begin interval training. individually and with team- - Continue individual skill work. mate. NO CONTACT - Begin skill work with a partner but with no contact. (Goal: Add Movement, Continue with individual skill work as per Step 2. teammate skill work) - Begin beginner level spins, dives, jumps. 4. Heavy General Resume regular conditioning and duration of practice. conditioning, skill work and - Increase interval training and skill work as required. team drills. No live scrimmages. - Gradually increase skill level of spins, dives & jumps. VERY LIGHT CONTACT. - Review team plays with no contact. (Goal: Team skill work, light - Very light contact and low intensity on dummies. static contact) 5. Full Team Practice with - Participate in a full practice. Body Contact -If a full practice is completed with no symptoms, return to competition is appropriate. Discuss with the coach about getting back in the next game.
G-13 Attachment G
Step 1: Light General Conditioning Exercises: • Begin with a sport specific warm up. • Do a (15-20 minute) workout which can include: stationary bicycle, fast paced walking or light jog, rowing or freestyle swimming. Step 2: General Conditioning and Sport Specific Skill Work; Individually: • Continue with the sport specific warm-up. • Slowly increase intensity and duration of workout (20-30 minutes). • Begin sport specific skill work within the workout. No spins, dives, or jumps. STEP 3: General conditioning, skill work; individually and with a team-mate: • NO CONTACT • Continue with general conditioning (up to 60 minutes). Increase intensity and duration. Begin interval training. • Continue with individual skill work. • May begin skill work with a partner. • May start beginner level spins, dives and jumps. STEP 4: General conditioning, skill work and team drills:: • Do not play live scrimmages. NO CONTACT • Resume regular conditioning, duration of practice, and team drills. • Increase interval training and skill work as required. • Gradually increase skill level of spins, dives and jumps. • Review team plays with no contact. Step 5: Full Team Practice with Body Contact: • Participate in a full practice. If it is completed with no symptoms, you are ready to return to competition. Discuss with the coach about getting back in the game.
G-14 Attachment G
Name______Date of Injury______School/Sport______Date of AHCP RTP Clearance______
Graduated Return to Football Protocol
With no symptoms, a gradual return to play program can be initiated. Follow these gradual progressive steps of the training sequence. There should be approximately 24 hours (or longer) in between each step. If any symptoms return at any time during these activities, stop the work out. Rest until symptom-free for 24 hours. Return to the previous asymptomatic step. If symptoms return or worsen, seek medical attention.
Step Date Activity Tolerance/Comments 1.Light General Begin with sport specific warm up. Do 15-20 minute Conditioning Exercises workout: stationary bicycle, fast paced walking or light (Goal: Increase HR) jog, rowing or freestyle swimming. 2. Moderate General Sport specific warm-up. Slowly increase intensity and Conditioning and Sport duration of workout to 20-30 minutes. Specific Skill Work; - Begin skill work within the workout. Individually (Goal: Add - Begin footwork drills, running drills, running patterns Movement, individual skill with cones and dummies. work) - Stationary throwing and catching a football. 3. Heavy General Continue with general conditioning up to 60 minutes. conditioning, skill work; Increase intensity and duration. Begin interval training. individually and with team- - Begin drills with a partner but with no contact. mate. NO CONTACT Continue with individual skill work as per Step 2. (Goal: Add Movement, - Begin dynamic throwing and catching, taking handoffs, teammate skill work) one on one (receiver vs. defensive backs) with no contact. - Begin walk-throughs on offense and defense. 4. Heavy General Resume regular conditioning and duration of practice. conditioning, skill work and - Practice passing shell drills (8 or 6) with no contact. team drills. No live scrimmages. - Continue with walk-throughs, skill work (patterns, VERY LIGHT CONTACT. dynamic catching and throwing, handoffs). Review (Goal: Team skill work, light blocking and tackling techniques, focus on skill. static contact) - Very light contact and low intensity on dummies. 5. Full Team Practice with - Participate in a full practice. Body Contact -If a full practice is completed with no symptoms, return to competition is appropriate. Discuss with the coach about getting back in the next game.
G-15 Attachment G
Step 1: Light General Conditioning Exercises (Goal: Increase HR) • Begin with a sport specific warm up. • Do a (15-20 minute) workout which can include: stationary bicycle, fast paced walking or light jog, rowing or freestyle swimming. Step 2: General Conditioning and Sport Specific Skill Work; Individually: • Continue with the sport specific warm-up. • Slowly increase intensity and duration of workout (20-30 minutes). • Begin skill work within the workout. • Begin footwork drills, running drills, running patterns with cones and dummies. • Stationary throwing and catching a football. STEP 3: General conditioning, skill work; individually and with a team-mate: • NO CONTACT • Continue with general conditioning (up to 60 minutes). Increase intensity and duration. Begin interval training. • Begin drills with a partner but with no contact. Continue with individual skill work as per Step 2. • Begin dynamic throwing and catching, taking handoffs, one on one (receiver vs. defensive backs) with no contact. • Begin walk-throughs on offense and defense. STEP 4: General conditioning, skill work and team drills:: • Do not play live scrimmages. NO CONTACT • Resume regular conditioning and duration of practice. • Practice passing shell drills (8 or 6) with no contact. • Continue with walk-throughs, skill work (patterns, dynamic catching and throwing, handoffs). Review blocking and tackling techniques, focus on skill, very light contact and low intensity on dummies. Step 5: Full Team Practice with Body Contact: • Join team in a full practice to get yourself back in the lineup. If a full practice is completed with no symptoms, you are ready to return to competition. Discuss with the coach about getting back in the next game.
G-16 Attachment G
Name______Date of Injury______School/Sport______Date of AHCP RTP Clearance______
Graduated Return to Soccer Protocol
With no symptoms, a gradual return to play program can be initiated. Follow these gradual progressive steps of the training sequence. There should be approximately 24 hours (or longer) in between each step. If any symptoms return at any time during these activities, stop the work out. Rest until symptom-free for 24 hours. Return to the previous asymptomatic step. If symptoms return or worsen, seek medical attention.
Step Date Activity Tolerance/Comments 1.Light General Begin with sport specific warm up. Do 15-20 minute Conditioning Exercises workout: stationary bicycle, fast paced walking or light (Goal: Increase HR) jog, rowing or freestyle swimming. 2. Moderate General Sport specific warm-up. Slowly increase intensity and Conditioning and Sport duration of workout to 20-30 minutes. Specific Skill Work; - Begin skill work within the workout. Individually (Goal: Add - Begin running drills, static and dynamic foot dribbling, Movement, individual skill use cones, individual kicking. work) 3. Heavy General Continue with general conditioning up to 60 minutes. conditioning, skill work; Increase intensity and duration. Begin interval training. individually and with team- - Begin drills with a partner but with no contact. mate. NO CONTACT Continue with individual skill work as per Step 2. (Goal: Add Movement, - Begin partner passing and kicking on goalie drills. teammate skill work) - Begin walk-throughs on offense and defense. 4. Heavy General Resume regular conditioning and duration of practice. conditioning, skill work and - Practice passing shell drills (8 or 6) with no contact. team drills. No live scrimmages. - Practice team passing and kicking drills, practice VERY LIGHT CONTACT. offensive, defensive and counter attack tactical (Goal: Team skill work, light schemes with no contact to the player. static contact) - Review heading the ball techniques. Do a few reps of low intensity with limited height and distance. 5. Full Team Practice with - Participate in a full practice. Body Contact -If a full practice is completed with no symptoms, return to competition is appropriate. Discuss with the coach about getting back in the next game.
G-17 Attachment G
Step 1: Light General Conditioning Exercises: • Begin with a sport specific warm up. • Do a (15-20 minute) workout which can include: stationary bicycle, fast paced walking or light jog, rowing or freestyle swimming.
Step 2: General Conditioning and Sport Specific Skill Work; Individually: • Continue with the sport specific warm-up. • Slowly increase intensity and duration of workout (20-30 minutes). • Begin skill work within the workout. • Begin running drills, static and dynamic foot dribbling, use cones, individual kicking.
STEP 3: General conditioning, skill work; individually and with a team-mate: • NO CONTACT • Continue with general conditioning (up to 60 minutes). Increase intensity and duration. Begin interval training. • Begin drills with a partner but with no contact. Continue with individual skill work as per Step 2. • Begin partner passing and kicking on goalie drills. • Begin walk-throughs on offense and defense.
STEP 4: General conditioning, skill work and team drills:: • Do not play live scrimmages. NO CONTACT • Resume regular conditioning and duration of practice. • Practice team passing and kicking drills, practice offensive, defensive and counter attack tactical schemes with no contact to the player. • Review heading the ball techniques. Do a few reps of low intensity with limited height and distance.
Step 5: Full Team Practice with Body Contact: • Join team in a full practice to get yourself back in the lineup. If a full practice is completed with no symptoms, you are ready to return to competition. Discuss with the coach about getting back in the next game.
G-18 Figure 10 Attachment G
Heads Up: Concussion in Youth Sports
Spanish version (/concussion/HeadsUp/spanish/youth.html) It’s Better to Miss One Game Than the Whole Season To help ensure the health and safety of young athletes, CDC developed the Heads Up: Concussion in Youth Sports initiative to offer information about concussions to coaches, parents, and athletes involved in youth sports. The Heads Up initiative provides important information on preventing, recognizing, and responding to a concussion. Heads Up Tool Kit for Youth Sports
• Activity Report [PDF 2MG] (/concussion/pdf/Heads_Up_Activity_Report_Final-a.pdf)
• See also Heads Up: Concussion in High School Sports (/concussion/headsup/high_school.html) .
For additional resources (videos, promotional materials, etc.) and to order free materials, click here (/concussion/sports/resources.html) Information for Coaches Online Training Course for Youth Sports (/concussion/HeadsUp/online_training.html) Fact Sheet [PDF 206KB] (/concussion/pdf/coaches_Engl.pdf) Clipboard [PDF 202KB] (/concussion/pdf/clipboard_Eng.pdf) Poster [PDF 328KB] (/concussion/pdf/poster_Eng.pdf) Quiz [PDF 170KB] (/concussion/pdf/quiz_Eng.pdf) Information for Athletes Fact Sheet [PDF 201KB] (/concussion/pdf/athletes_Eng.pdf) Poster [PDF 328KB] (/concussion/pdf/poster_Eng.pdf) Quiz [PDF 170KB] (/concussion/pdf/quiz_Eng.pdf) Information for Parents Fact Sheet [PDF 250KB] (/concussion/pdf/parents_Eng.pdf) Magnet [PDF 106KB] (/concussion/pdf/magnet_Eng.pdf) Quiz [PDF 170KB] (/concussion/pdf/quiz_Eng.pdf)
If you think your athlete has sustained a concussion…don’t assess it yourself. Take him/her out of play, and seek the advice of a health care professional.
Page last reviewed: December 8, 2009 Page last updated: December 8, 2009 G-19 Attachment H
Concussion Plan
Montgomery County Public Schools (MCPS) Guidelines and Procedures Regarding Concussions/Head Injuries
MCPS guidelines and procedures for student-athletes who sustain head injuries/concussions conform to recommendations by the Department of Health and Human Services Centers for Disease Control and Prevention (CDC), the National Federation of High Schools (NFHS), the Maryland Public Secondary Schools Athletics Association (MPSSAA), and the Maryland State Department of Education (MSDE). Information and forms referenced in the MCPS Concussion Plan are located under Concussions in the Health and Safety section of the MCPS Athletics web page at the following address: (http://www.montgomeryschoolsmd.org/departments/athletics).
The MCPS Concussion Plan includes the following elements:
A. Education 1. Coaches 2. Players/Parents B. Baseline Testing C. Athletic Trainers D. Procedures 1. General Procedures 2. Coach Procedures 3. Nurse Procedures E. Return-to-Play F. Forms and Documents G. Limitations on Full Contact
A. Education
1. MCPS coaches will:
a) Review annually the MCPS Concussion Plan b) Receive training and instruction regarding head injuries in Prevention and Care of Athletic Injuries, a course required for coaching certification at Maryland public schools. c) Complete every two years the NFHS Coaches’ Education Course: Concussions in Sports— What You Need to Know. d) Review Coach Resource Materials in the Health and Safety section of the MCPS Atheltics web page. e) Have available at practices and contests the MCPS Concussion Quick Reference Card. f) Receive relevant guidance and information at school and systemwide coaches’ meetings. g) Inform parents and players of guidelines and procedures regarding concussions. h) Present a PowerPoint to players on health and safety information, including concussions.
Revised July 2016 H-1 Attachment H
2. Players and parents will:
a) Receive a letter describing the MCPS Concussion Plan. b) Receive an information sheet published by the CDC on symptoms and procedures regarding concussions (Head’s Up—A Fact Sheet for Parents). c) Be encouraged to review additional health and safety materials regarding concussions in the Health and Safety section of the on the MCPS Athletics web page d) Sign/Submit the MPSSAA forms Pre-participation Head Injury/Concussion Reporting Form and Concussion Awareness (Parent/Student-Athlete Acknowledgement Statement). e) Receive verbal instruction from coaches at practices (players) and/or parent preseason meetings (parents) regarding concussions. f) Indicate on the MCPS Student-Parent Athletic Participation Contract that they have reviewed safety and health-related information made available by the school system, including concussions.
B. Baseline Testing
1. All MCPS student-athletes will participate in baseline concussion testing at the beginning of the season. Student-athletes must take a baseline test every two years. 2. Parents will receive a letter describing the MCPS Baseline Testing Plan. 3. Details regarding ImPACT baseline concussion testing are described in the Baseline Testing Plan in the Health and Safety section of the MCPS Athletics web page.
C. Athletic Trainers
1. Athletic trainers are assigned to all 25 MCPS high schools. 2. Athletic trainers will be available at practices and contests. The “home” team athletic trainer will assist with injuries sustained by both the home and visiting team. 3. Athletic trainers will assist in implementing baseline concussion testing and “gradual return- to-play” protocol after a student is cleared by to resume participation after a concussion.
D. Procedures
1. General Procedures
a) Any player who exhibits signs or symptoms consistent with a concussion shall be removed from the practice or contest and shall not return to play until cleared by an authorized health care provider—the clearance must be signed. b) The player’s parents shall be informed that their son or daughter may have suffered a concussion and shall be advised to take their child to an authorized health care provider as soon as possible. The parent will be issued the MPSSAA form Medical Clearance for Suspected Head Injury. c) Appropriate school personnel, including administrators, athletic director, athletic trainer, and school nurse, will be informed of the injury. Appropriate follow-up will be initiated, including potential academic accommodations. d) If the player suffered a concussion, he/she may begin a supervised gradual return to play process on the date indicated on the form Medical Clearance for Suspected Head Injury.
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Revised July 2016 H-2 Attachment H
e) The player’s gradual return to full activity is supervised by school staff over a five-day period, according to the MPSSAA form Graduated Return to Play Protocol. Generally, the school athletic trainer will supervise gradual return to play protocol. f) The player may resume full participation after he or she successfully completes a supervised, gradual return-to-play protocol.
2. Coach / Athletic Trainer / Athletic Director Procedures
When a student-athlete suffers a potential concussion:
a) The coach or athletic trainer removes the student-athlete from the practice or contest. b) The coach, designee, or athletic trainer calls 911 and/or student-athlete’s parent (Emergency Cards should always be available for this purpose). c) In instances when it is fairly clear that the student-athlete has suffered a concussion, the coach/designee/athletic trainer calls emergency personnel (911) and the student-athlete’s parents. d) In instances where the student-athlete displays only mild symptoms, the coach/designee/athletic trainers calls the parent, and asks whether the parent wants to pick the student-athlete up immediately or whether to call 911. e) If the parent cannot be contacted, the coach/designee/athletic trainer calls the emergency contact person designated on the Emergency Medical Card. f) A coach/designee/athletic trainer should remain with the student-athlete at all times until either a parent or emergency personnel arrive. g) A student-athlete should not be allowed to go home unless accompanied by a parent or an adult designated by the parent. h) The coach or athletic trainer presents to the parent the MPSSAA form Medical Clearance for Suspected Head Injury. This form provides instructions to parents, including that the parent or student-athlete must take the form to an appropriate health care provider, and bring the completed form to the school nurse as soon as possible after the injury. i) The coach follows school protocol in notifying appropriate school staff that a potential concussion (or serious injury) has occurred. At a minimum, the coach notifies the athletic director the afternoon or evening after the practice or contest ends when a student-athlete has been removed from participation because of a potential concussion. The athletic director then informs the athletic trainer and school nurse (unless the athletic trainer is already aware). j) The coach, with assistance from the athletic trainer, completes and submits a Student Accident Report to the athletic director the next school day. k) The athletic director informs the school nurse of the injury on or before the start of the next school day following the injury. l) The school nurse follows-up with the student-athlete, and notifies the athletic director when the student may resume participation. The athletic director informs the athletic trainer and coach. m) The athletic director and the athletic trainer retain copies of the completed Medical Clearance for Suspected Head Injury and the athletic trainer enters on the applicable database that a concussion has occurred. n) If the injury was a concussion, the coach and athletic trainer initiate procedures described in the form Graduated Return to Play Protocol.
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Revised July 2016 H-3 Attachment H
3. Nurse Procedures
a) The school nurse implements follow-up procedures described in High School Student- Athlete Probable Head Injury Flow Chart. b) These procedures include separate courses of action based on whether the injury occurred during the school day or after school. c) These procedures also include separate courses of action based on whether or not the student-athlete has suffered a concussion. d) After following the procedures described in the flow chart, the student-athlete may resume a supervised gradual return to play once the nurse returns to the athletic director a copy of the medical clearance (Medical Clearance for Suspected Head Injury).
E. Return-to-Play
1. Student-athletes who are removed from a practice or contest because they exhibit signs or symptoms consistent with a concussion must have written medical clearance before they may return to play. The medical clearance shall be indicated on the MPSSAA form titled Medical Clearance for Suspected Head Injury. 2. The form is given to parents of student-athletes who have potentially suffered a concussion, and includes procedures on how the student-athlete may obtain clearance to resume participation. The form must be completed and signed by an authorized health care provider. 3. The completed form is returned to the school nurse when the student-athlete returns to school. 4. The form includes two separate clearances. If a student-athlete has not suffered a concussion, the health care provider indicates such at the top of the form and there is no need for a follow- up examination. 5. If the top portion of the form indicates that the student-athlete has suffered a concussion, the student-athlete may not resume participation until receiving clearance from a health care provider (bottom portion of form). 6. The school nurse informs the athletic director when the student-athlete may initiate a gradual return to play program, and provides a copy of the completed form Medical Clearance for Suspected Head Injury. The athletic trainer informs the coach and athletic trainer. 7. The coach or athletic trainer monitors Gradual Return to Play Protocol over a five day period. 8. If the student-athlete remains symptom-free, he or she may return to full participation after the five-day gradual return-to-play period. 9. The school files and retains copies of all of the forms associated with the student-athlete’s concussion for a period of five years.
F. Forms and Documents
1. Concussion / Baseline Testing Information for Players and Parents a) Concussion Information for Parents b) Baseline Testing Information for Parents c) Head’s Up - A Fact Sheet for Parents d) Head’s Up - A Fact Sheet for Students
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Revised July 2016 H-4 Attachment H
2. Concussion / Baseline Testing Forms a) Consent Form – ImPACT Baseline Concussion Testing b) Pre-Participation Head Injury/Concussion Report Form for Extracurricular Activities c) Concussion Awareness (Parent/Student-Athlete Acknowledgement Statement) form d) Medical Clearance for Suspected Head Injury e) Graduated Return to Play Protocol
3. Concussion Administrative Information a) MCPS Concussion Plan b) MCPS Baseline Testing Plan c) Concussions in Sports – What You Need to Know [NFHS Course] d) High School Student-Athlete Probable Head Injury Flow Chart
G. Limitations on Full Contact
1. The MSDE has categorized sports in one of three categories: collision, contact, and non- contact. In turn, the MSDE has provided recommendations on limiting exposures to head injuries in collision and contact sports, including basketball, field hockey, football, boys’ lacrosse, girls’ lacrosse, soccer, and wrestling.
2. MCPS coaches of basketball, field hockey, football, boys’ lacrosse, girls’ lacrosse, soccer, and wrestling will follow MSDE recommendations included in the document Identification of Collision, Contact, and Non-Contact Sports and Recommended Concussion Injury Mitigation and Limitations of Contact Exposure.
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Revised July 2016 H-5 Attachment I
ATTENTION COACHES
New Concussion Policy
On May 19, 2011, Governor O’Malley signed into law “Education—Public Schools and Youth Sports Programs—Concussions” to protect the state’s student- athletes from the dangers of a concussion—a medical condition which can cause permanent harm. This law, now supported with the Maryland State Department of Education (MSDE) concussion policy, applies to youth sports programs organized for recreational athletic competition or instruction for participants under the age of 19.
While most of the bill focuses on school sponsored programs, it also includes provisions for community groups.
Effective July 1, 2011, the law requires: “Youth sports programs seeking to use school facilities must verify distribution of concussion information to parents or guardians and receive verifiable acknowledgement of receipt. In addition, each youth sports program will annually affirm to the local school system or agent of their intention to comply with the concussion information procedures.”
This provision applies to instructional and competitive youth athletic groups scheduled through CUPF. Look for the following statement in CUPF Permits issued after 1/1/12 which affirms your intent to comply with every time you request school or park use: “By accepting this permit I agree to comply with all applicable provisions of the MSDE Policies and Programs on Concussions for Public Schools and Youth Sports Programs and affirm that youth and parents/guardians will be provided concussion information.”
Please see important information on other side >>>
I-1 Attachment I
In addition to retaining documentation demonstrating your compliance with distribution of this information, coaches or sport activity leaders are encouraged to complete one of the State recommended on-line training programs and use the many forms and hand- outs available in the MSDE policy and USDHHS Centers for Disease Control and Prevention (CDC) web site. Program organizers are advised to retain documentation of coaches’ training and parent notifications in their records. To help you meet this requirement links to the CDC resources are listed below:
Main CDC Concussion link: http://www.cdc.gov/concussion/sports/index.html Youth Sports Page: http://www.cdc.gov/concussion/HeadsUp/youth.html Coach Handout: http://www.cdc.gov/concussion/pdf/Coach_Guide-a.pdf Parent/Guardian Fact/Acknowledgement Sheet: http://www.cdc.gov/concussion/headsup/pdf/Parent_Athlete_Info_Sheet-a.pdf
Free On-line CDC Training Class (Click on HEADS UP icon) http://www.cdc.gov/concussion/HeadsUp/online_training.html Completion of this 30-minute class (also available in Spanish) is mandatory for all Montgomery County Recreation Department (MCRD) coaches, who must submit a copy of the completion certificate to MCRD. All non-MCRD coaches should keep completion certificates and Parent Acknowledgement Forms for their own records.
Even if you are not sponsoring a competitive or instructional activity with the risk of physical contact between players, it is still a good idea to be informed. Sports with the highest risk include basketball, soccer, and football.
Other best practices include:
• Require coaches/volunteers to complete an on-line Concussion Training Course. • Immediately remove youth athletes from play (game or practice) if you think they may have sustained a concussion; require clearance from their doctors before the youth may be returned to play. • Require all coaches/activity leaders to inform their athletes’ parents or guardians about the potential of concussion injuries during an activity and provide them with a fact sheet about concussions in conjunction with your notification. • Provide youth and parents/guardians information at time of registration, and document that this information was provided. • Have information about the signs and symptoms of concussion at EVERY event where a head injury is possible. • Follow appropriate safety protocols whatever the activity.
Want More Information?
Maryland Department of Education Policies and Programs on Concussions for Public Schools and Youth Sports Programs: http://www.marylandpublicschools.org/NR/rdonlyres/FCB60C1D-6CC2-4270-BDAA- 153D67247324/29630/MSDEPoliciesProgramsConcussions2011_2.pdf Senate Bill 771: http://mlis.state.md.us/2011rs/billfile/sb0771.htm House Bill 858: http://mlis.state.md.us/2011rs/chapters_noln/Ch_549_hb0858E.pdf
Montgomery County Recreation
I-2 Attachment J
Howard County Recreation and Parks Concussion and Sudden Cardiac Arrest Information Plan of Action (2/13/2015)
This plan provides concussion and sudden cardiac arrest information electronically and in seasonal brochures, and communicates a firm expectation that parents and guardians who register for department sponsored youth sports programs shall acknowledge receipt of the concussion and sudden cardiac arrest information.
Though this acknowledgement is required by law only for programs conducted on public school property, Howard County Recreation and Parks will require such acknowledgement regardless of the site, with respect to department sponsored programs. Additionally, through the permit process, user groups providing youth sports will be notified and required to comply with State law.
For the purpose of this plan, the department will use the concussion and sudden cardiac arrest information made available from the State Board of Education with edits that reflect a non- school space where appropriate. The plan of action is as follows:
1.0 Sponsorship & Purpose 1.01 Recreation and Parks recognizes that concussions are a serious injury to the brain resulting from a force or jolt applied directly or indirectly to the head producing a set of signs and symptoms reflecting the brain’s dysfunction. Recreation and Parks also recognizes sudden cardiac arrest is a potentially fatal condition in which the heart suddenly and unexpectedly stops beating. 1.02 Recreation and Parks, as part of its GoodSports effort that includes provisions for player safety, desires a Concussion and Sudden Cardiac Arrest Compliance Plan that educates parents, sport administrators, athletes, coaches and officials about the nature and risks of concussions and sudden cardiac arrest. Procedures to detect and treat suspected / possible concussions prior to safe return to play are established. 1.03 Recognizing that much of the on-field oversight of recreational sports occurs under the supervision by the many volunteers representing their club or organization, the primary key to this Plan’s effectiveness will depend on the teamwork of coaches, parents, athletes, game officials and subsequent medical caregivers. 1.04 Recreation and Parks recognizes that unlike the public school atmosphere, the off the field oversight of recreational sports athletes is the primary responsibility of the parent and other care givers under the parents’ direction. This is especially true for athletes involved in multiple sports. 1.05 Therefore, the goal of the Plan is for this team of Recreation and Parks, coaches, parents, athletes, game officials and subsequent medical caregivers to work together to identify possible concussion and to ensure a safe return to play.
Howard County Recreation and Parks Concussion Compliance Plan revised Spring 2015 Page 1
J-1 Attachment J
1.06 The Plan is also intended to be consistent with the County’s “Healthy Howard” campaign to assure a healthy and safe Howard County. 1.07 The Plan includes many features such as the coach’s online concussion education component popular with local high school associations. 2.0 Definition of Terms for this policy 2.01 “Coach” refers to any Howard County paid employee or volunteer that is a member of the Coaches Registry and thus assigned to coach, lead or instruct in a youth sport program. For the purposes of department sport camps – this includes Camp Director and all subsequent coaches assigned to the camp. 2.02 “Roster Coach” refers to a program of team registration. In these instances the coach may be required to be a member of the Coaches Registry but is not a volunteer or employee of the department. 2.03 Unless otherwise exempted from this plan, “youth sports program” refers specifically 2.03.1 To any competitive sport program sponsored by the department 2.03.2 Any instructional sport program that specifically prepares a child for competition or fine tunes his / her skills for competitive play. This includes afterschool or camp programs with a focus on sports. This Plan does not apply to activities the department deems for adventure / outdoor recreation participation. This includes mountain bike (unless a race), paddling programs (unless a race), climbing activities, fishing activities, skateboarding (unless a competition) and martial arts (unless a competition), etc. 2.04 For the purpose of this plan, the term “parent” includes parents, any step parents or any other legal guardian of the participating child. 2.05 “Program Coordinator” refers to the department employee assigned as the league commissioner, program coordinator or camp coordinator. This is usually a Coordinator, Supervisor or Manager. 2.06 The “Youth Sports Leagues Manager” is the manager of the division’s youth sports leagues. 3.0 Administration of Concussion and Sudden Cardiac Arrest Compliance Plan 3.01 The Youth Leagues Manager will maintain a chart and files of all youth sports concussion related incidents. 3.01.1 A file on each concussion incident to include copies of subsequent incident reports, parent compliance with online concussion education courses and copies of written clearance of play will be maintained in accordance with Recreation & Parks’ confidentiality and record retention protocols. 3.01.2 Department staff (Assistants to Chiefs and Director) will provide the Youth Sports Leagues Manager copies of any concussion and sudden cardiac arrest related incident / accident reports submitted. Howard County Recreation and Parks Concussion Compliance Plan revised Spring 2015 Page 2
J-2 Attachment J
3.01.3 The Youth Leagues Manager will work with the Sports and Adventure Services Division representative with the Registration Office to temporarily suspend the registration activity in youth sports activities during the rehabilitation / clearance time period. This effort is limited only to those programs offered by the department where registration occurs through the office on an individual registration basis. 3.01.4 It is the parent’s ultimate responsibility as stated in 5.02.4 in situations where a child may be involved in multiple activities simultaneously or where the child doesn’t get clearance before the end of the current season, to keep their child out of youth sport programs until all return to play provisions have been met. 3.02 All program coordinators involved with league and tournament (competitions) will include provisions of this plan in their league / tournament rules. 3.03 Promotions and Registration details include: 3.03.1 Effective with the Spring/Summer 2015 Seasonal Activity Guide, the department will dedicate one page each on concussion and sudden cardiac arrest information. 3.03.2 Both Concussion Information and Sudden Cardiac Arrest Information are posted online.at www.howardcountymd.gov/concussion.htm and www.Howardcountymd.gov/suddencardiacarrest.htm. Effective with programs advertised in the Spring/Summer 2015 Seasonal Activity Guide, the following language will be included throughout the sports program section. “Read concussion and sudden cardiac arrest information on pages xxx of the xxx Activity Guide or online at www.howardcountymd.gov/concussion.htm, www.howardcountymd.gov/suddencardiacarrest.htm.Your family's review of this information is required by law before you are allowed to register for sports programs” 3.03.3 Effective with all future program flyers, the above sentence will be included. “Read concussion and sudden cardiac arrest information on pages xxx of the xxx Activity Guide or online at www.howardcountymd.gov/concussion.htm, www.howardcountymd.gov/suddencardiacarrest.htm Your family's review of this information is required by law before you are allowed to register for sports programs” 3.03.4 Effective with sport programs starting on or after September 1, 2015, the following language is added to the waiver – 3.03.4.1 For the Activity Guide Waiver - I have read the concussion and sudden cardiac arrest information on pages xxxx (if this registration is for a youth sports program).
Howard County Recreation and Parks Concussion Compliance Plan revised Spring 2015 Page 3
J-3 Attachment J
3.03.4.2 For phone registration (if a youth sports program), the waiver indicated on the receipt includes – If this is a registration for a youth sport program, I attest that my child and his / her parents have received information on concussions and sudden cardiac arrest on pages xxx or online at www.howardcountymd.gov/concussion.htm and www.howardcountymd.gov/suddencardiacarrest.htm. 3.03.4.3 For registration via flyer – I attest that my child and his / her parents have received information on concussions and sudden cardiac arrest on pages xxx of xxx Activity Guide or online at www.howardcountymd.gov/concussion.htm and www.howardcountymd.gov/suddencardiacarrest.htm. 3.03.4.4 For online registration, to complete the registration process, the customer must agree to the following statement - I attest that my child and his / her parents have received information on concussions and sudden cardiac arrest online at www.howardcountymd.gov/concussion.htm and www.howardcountymd.gov/suddencardiacarrest.htm. 3.03.5 For programs involving team registrations (certain leagues and tournaments), the Roster Coach shall indicate on the roster – “I attest that the Howard County Recreation and Parks Concussion and Sudden Cardiac Arrest Information has been received by players and their parents on this roster, and that these players and parents have acknowledged receipt of the Department’s Concussion and Sudden Cardiac Arrest Information.” 3.03.6 Effective with Fall 2015 Athletic Facility permits (Gyms, Courts, Fields, etc) . all permit guidelines include the language – “State Law (Health – General Article, Section 14-501, Annotated Code of Maryland) implemented July 1, 2011 requires all organizations sponsoring Youth Sports to provide mandatory concussion awareness information to all coaches, youth athletes and their parents, with a signed acknowledgment from each young athlete and parent that they have received the concussion awareness information. With application for a field permit and any subsequent issue of field permit(s), the applicant agrees to fully enforce the provisions of this law. The required concussion awareness can be accessed at www.howardcountymd.gov/concussion.htm. This site provides a sample acknowledge format that must be completed and signed.” Additionally, state law requires all organizations sponsoring Youth Sports to provide mandatory sudden cardiac arrest awareness information to all coaches, youth athletes and their parents, with a signed acknowledgment from each young athlete and parent that
Howard County Recreation and Parks Concussion Compliance Plan revised Spring 2015 Page 4
J-4 Attachment J
they have received the sudden cardiac arrest awareness information. With application for a field permit and any subsequent issue of field permit(s), the applicant agrees to fully enforce the provisions of this law. The required sudden cardiac arrest awareness can be accessed at www.howardcountymd.gov/suddencardiacarrest.htm. This site provides a sample acknowledge format that must be completed and signed.”
4.0 Coaches & Parents 4.01 All coaching candidates approved for assignments must be members of the Coaches & Administrators Registry. Registry application requires prospective member to acknowledge receiving both concussion information and cardiac arrest information. Members of this registry have successfully demonstrated that they have: 4.01.1 Completed the required American Sport Education Program. 4.01.2 Completed an online concussion education program through either the Centers for Disease Control and Prevention or the National Federation of State High School Athletic Associations or other sources approved by the State Board of Education. 4.01.3 Completed an annual background check in accordance with the Department’s standards for volunteers. 4.02 All parents will be provided via email or program participant welcoming letters access and encouragement to the same online concussion training resources. 4.02.1 Per 5.02, before any young athlete can return to play from a suspected concussion or other head injury, parents must demonstrate successful completion of one of the online education training courses and provide the required Howard County Recreation and Parks Medical Clearance for Return to Athletic Participation Following Suspected Concussion or Other Head Injury form.. 5.0 Removal and Return to Action after a suspected concussion or other head injury
5.01 Any athlete that exhibits any sign of concussion or reports any symptom of concussion or will be removed from the practice or play. Parents, coaching staff and Game Officials have the authority to invoke this safety precaution. If an athlete has a suspected concussion and is removed from play, the parent/guardian will be issued the Notification of Suspected Concussion or Other Head Injury and Return to Play Requirements form by a Recreation and Parks representative.
5.01.1 The coach of the athlete will file a report with the program coordinator within 24 hours to include verification that a parent has been informed.
Howard County Recreation and Parks Concussion Compliance Plan revised Spring 2015 Page 5
J-5 Attachment J
5.01.2 If the situations results in emergency medical attention – the program coordinator must be notified immediately in accordance with department policy (includes faxing of incident report to Risk Management). 5.01.3 From the time of the reported incident, an athlete is considered ineligible for youth sports program participation with the Department until all conditions are met for a full return to play. The Program Coordinator(s) will ensure the athlete does not continue to participate in the program(s) in which he/she is currently enrolled. The Youth Sports Leagues Manager will contact the Registration Office Supervisor and request to temporarily suspend the account of the athlete until he/she has met all return to play requirements. Once clear for a full return to play, the athlete can return to his/her current sports program(s) and register for additional youth sports programs. Registration overrides will be granted for non-sports based programs during the suspension period. 5.02 Before any athlete can return to action 5.02.1 During the athlete’s rehabilitation (under the direction of the parent and appropriate medical care), the parent must keep the coach abreast of the athlete’s status. 5.02.2 The parents must provide documentation that they’ve successfully completed one of the online concussion education programs. 5.02.3 The parents must provide the Howard County Recreation and Parks Medical Clearance for Return to Athletic Participation Following Suspected Concussion or Other Head Injury form from a licensed healthcare provider trained in the evaluation and management of concussions. The parent assumes the responsibility to assure that the licensed health care provider has the above-mentioned training. 5.02.4 For concussion rehabilitations that carryover beyond the season or beyond the program where the concussion symptoms were first noticed, it’s the responsibility of the parent to ensure enforcement of this subsection. This honor system includes notifying the subsequent coach and program coordinator of any concussion related issues of their child. 5.03 Receipt of the written clearance by a coach must be communicated immediately to the Program Coordinator with the original eventually getting to the program coordinator for filing (see administration) 5.04 Upon receipt of the online concussion certificate online certificate and notification from the coach regarding receipt of the written clearance for play, the program coordinator shall notify parent and coach the player may return to play. 5.05 If a coach, parent, or game official see a re-occurrence of concussion symptoms, the process repeats.
Howard County Recreation and Parks Concussion Compliance Plan revised Spring 2015 Page 6
J-6 Attachment K
Councilmember Palakovich Carr What ages can participate in City-sponsored youth tackle football (i.e. through RFL)? RFL offers options for Kindergarten through Eighth grade.
Is tackling taught for all ages? For instance, say an 8 year old can participate in RFL. Is an 8 year old engaging in tackling or this reserved for older children? Our understanding is that RFL teaches tackle football for all age divisions. We can confirm when we get with the RFL representative this evening.
Attachment G says that under Maryland state law, the child and parent have to acknowledge receipt of concussion awareness information. Would it be possible to see a copy of the materials provided to participants of City-sponsored sports? Attached is an example of the City of Rockville’s League Participation Information form with participant agreement and waiver agreements. In the example under “I understand… 2)” participants and parents acknowledge the risk and hazards associated with f) concussions in sports. For more information, participants/parents are directed to view our online concussion information at http://www.rockvillemd.gov/index.aspx?NID=1931. The online information allows for participants/parents/coaches/officials to download additional information like the attached Heads Up Concussion Fact Sheet for parents (http://www.cdc.gov/headsup/pdfs/custom/headsupconcussion_fact_sheet_for_parents.pdf). There is also a link for individuals who would like to take the “Heads Up Online Training”.
K-1 Attachment K
Are parents provided with information about the risk of sustaining a TBI while playing a sport prior to enrolling their child? The materials in attachment G are specific to recognizing a concussion and not about the risk of sustaining one while playing a sport. Parents are not currently provided the information prior to registration unless they go to our website. Once they register they are directed to the additional information.
Does RFL have a zero tolerance policy for head-first hits? Our understanding is that RFL has a zero tolerance policy towards head-first hits. We will confirm that with the RFL representative this evening.
Is there a City-sponsored non-tackling youth football league? RFL also offers NFL Flag-Football for ages 5-6, 7-8, and 9-11 years old.
Councilmember Pierzchala I read through item 17. It provides extensive information on Traumatic Brain Injury. This is a well-known and documented concern as noted in the materials.
I am more interested in the cumulative effects of repetitive head contact. I found this article: http://www.momsteam.com/sub-concussive/sub-concussive-hits-growing-concern-in-youth-sports
Would you have anyone available to discuss this part of the issue?
Recreation and Parks can search for a physician with expertise in neurology/sports medicine.
Here is a list of articles related to sub-concussive studies:
1. Functionally-Detected Cognitive Impairment in High School Football Players Without Clinically Diagnosed Concussion: http://www.icnapedia.org/content/journal- watch/ezproxy.online.journal/20883154.pdf 2. Measuring Head Impact Exposure and Mild Traumatic Brain Injury in Humans: https://vtechworks.lib.vt.edu/bitstream/handle/10919/23815/Cobb.pdf?sequence=1 3. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes: https://www.impacttest.com/ArticlesPage_images/Articles_Docs/7DHSvsCollege%20AthleteJPe diatrics2003.pdf 4. Traumatic Injury to the Immature Brain Results in Progressive Neuronal Loss, Hyperactivity, and Delayed Cognitive Impairments: http://www.safar.pitt.edu/archive/content/grant/jc/2006/1201%20Bayir.pdf
K-2 Attachment K
5. Long-term Consequences of Repetitive Brain Trauma: Chronic Traumatic Encephalopathy: http://www.bu.edu/cte/files/2011/11/Stern-et-al-2011-PMR-Long-term-Consequences-of- Repetitive-Brain-Trauma1.pdf 6. Head Impact Exposure in Youth Football: Elementary School Ages 9–12 Years and the Effect of Practice Structure: https://www.triaxtec.com/sports/wp-content/uploads/2013/08/BMES- study.pdf 7. The clinical spectrum of sport-related traumatic brain injury: http://www.burke.org/docs/TBI%20sports%20Jordan%202013.pdf
K-3 FY 2016 Annual Procurement Report
Mayor and Council
For the meeting on: October 24, 2016 Department: City Manager Division: Procurement Responsible staff: Jessica Blow, Director of Procurement phone: (240) 314 - 240-314-8432 [email protected]
Subject FY 2016 Annual Procurement Report
Recommendation Staff recommends that the Mayor and Council receive this report.
Discussion On October 13, 2014, the Mayor and Council requested that a procurement report be produced within ninety days of the end of the fiscal year (June 30). This is the second annual procurement report prepared for the Mayor and Council.
This procurement report documents the procurement activities of the City of Rockville from July 1, 2015 to June 30, 2016. The report summarizes information from the City's financial system and internally maintained spreadsheets. Additional information can become available for reporting as the procurement database is developed further.
Mayor and Council History This is the second time this report has been brought before the Mayor and Council. The FY 2015 report was presented to the Mayor and Council on October 5, 2015.
Boards and Commissions Review At their meeting on October 11, 2016, the Financial Advisory Board reviewed and commented on the FY 2016 Annual Procurement Report. A revised version of the Board’s comments can be found as Attachment B to this agenda item. City staff reviewed the Board’s comments and agreed to address many of the Board’s recommendations in the FY 2017 Procurement Report. Staff is currently researching ways to better track procurement information in order to produce more relevant, subsequent annual reports. The Board recommends that City staff obtain input from the Board in the creation of the FY 2017 Annual Procurement Report, and that staff prepare an early draft for the Board’s review and comment. The Board recommends that these milestones be included in the Purchasing Action Plan.
Attachments
Attachment A - FY16 Annual Procurement Report.pdf
Attachment B - FAB Comments on FY16 Annual Procurement Report final.pdf
Department Head:
https://rockmail.rockvillemd.gov/.../egenda.nsf/d5c6a20307650f4a852572f9004d38b8/7a2d7e4a0c87831585257ff50064817c?OpenDocument[6/30/2017 5:53:43 PM] FY 2016 Annual Procurement Report
-- Craig Simoneau, Acting City Manager -- Approved on: 09/20/2016 ------City Manager: Approved on: 09/20/2016 ~- ~-
https://rockmail.rockvillemd.gov/.../egenda.nsf/d5c6a20307650f4a852572f9004d38b8/7a2d7e4a0c87831585257ff50064817c?OpenDocument[6/30/2017 5:53:43 PM] Attachment A
FY 2016 Annual Procurement Report
Introduction
On October 13, 2014, the Mayor and Council requested that a procurement report be produced within ninety days of the end of the fiscal year (June 30). This is the second annual procurement report prepared for the Mayor and Council.
This procurement report documents the procurement activities of the City of Rockville from July 1, 2015 to June 30, 2016. The report summarizes information from the City’s financial system and internally maintained spreadsheets. Additional information can become available for reporting as the procurement database is developed further.
FY 2016 Summary
FY 2016 has proven to be an extraordinary year of transition and positive change. As a new division of the City Manager’s Office, we have made a commitment to ensure continuous development and improvement of the Procurement Division. I am extremely humbled and honored to serve as the recently titled Director of Procurement and to lead a staff of talented procurement professionals. An abundance of positive change has already occurred within the Division with more changes to come. In summary, some of the highlights of FY 2016 include:
Transition of the Procurement Division to the City Manager’s Office Implementation a hybrid structure with departmental focus Revamped Purchase Card (P-card) Manual and Training Program Implementation of the auto-release function of Purchase Orders - allows electronic distribution of purchase orders Implementation of the Requisition to Payment Process - identifies the appropriate procurement and payment methods and when they should be used (including GAX payments) Development of the Minority, Female, Disabled (MFD) Outreach Program Successful year end process - significantly improved processing of solicitations and contract awards
The items highlighted have increased Procurement’s efficiency, effectiveness, and partnership with departments that utilize our services. These highlights are only the beginning of real strategic changes that are forthcoming from Procurement. We continuously seek areas of development that will encourage overall improvement and efficiencies. I would like to thank my staff for their hard work and diligence as we continue to serve the citizens of Rockville. I extend sincere appreciation to the Finance Department who remain instrumental in future improvements. In addition, I would also like to give special thanks to the Mayor and Council and the City Manager for their support as the Procurement Division continues to reach new heights in the years to come.
1
A-1 Attachment A
FY 2016 Procurement Statistics
The total amount spent, excluding payroll, across all departments and funds through accounts payable between July 1, 2015 and June 30, 2016 was $91,434,332.70. Tables 1, 2, and 3 reflect this spending by fund, by department, and by payment type respectively.
The City’s largest fund is the General Fund. It is predominantly taxpayer supported and accounted for 39% of City spending in FY 2016. When combined with the Capital Projects Fund (420) and Debt Service Fund (550), taxpayer supported spending accounted for 58% or $53,043,946.59 of total City spending. Enterprise fund spending accounted for 36% or $32,892,045.60 of total City spending. The enterprise fund with the least amount of spending was RedGate Golf at $4,546.97, while Sewer’s spending was the highest at $13,207,841.65.
Table 1: Total City Spending by Fund FY 2016
FUND SPENDING GENERAL (110) $ 35,577,601.85 SEWER (220) $ 13,207,841.65 CAP. PROJECTS (420) $ 11,650,624.46 WATER (210) $ 9,312,900.97 DEBT SERVICE (550) $ 5,815,720.28 SWM (330) $ 5,056,533.74 REFUSE (230) $ 3,809,342.01 BROKERED BENEFITS (640) $ 2,491,017.83 SPEED (380) $ 1,521,805.47 PARKING (320) $ 1,500,880.26 SPEC. ACTIVITIES (350) $ 883,720.34 INVENTORY (630) $ 409,425.14 CDBG (360) $ 192,371.73 GOLF (340) $ 4,546.97 TOTALS $ 91,434,332.70
Source: Infoadvantage - FY16 Operating and CIP Expense Detail
2
A-2 Attachment A
When one looks at spending by department, the most spending took place in a non-operational department called Non-Departmental due to debt service payments, transfers, and depreciation for enterprise funds. The operating department with the highest spending level was Public Works at 36% or $33,291,296.18, followed by Recreation and Parks and Police. Combined, these three largest departments accounted for 54% or $49,938,987.34 of the total City spending in FY 2016. If one excludes non-departmental spending, the Public Works, Recreation and Parks, and Police departments represented 87% of total operating department City spending.
Table 2: Total City Spending by Department FY 2016
DEPARTMENT TRANSACTIONS VALUE OF TRANSACTIONS * NON-DEPARTMENT 597 $ 34,144,961.14 PUBLIC WORKS 5,185 $ 33,291,296.18 RECREATION & PARKS 6,514 $ 13,720,534.80 POLICE 1,057 $ 2,927,156.36 CITY MANAGER'S OFFICE 700 $ 2,286,489.36 IT 520 $ 1,748,087.67 FINANCE 511 $ 1,144,766.96 CPDS 552 $ 1,142,894.37 HUMAN RESOURCES 316 $ 401,938.30 MAYOR & COUNCIL 298 $ 380,582.94 CITY ATTORNEY 165 $ 245,624.62 TOTALS $ 91,434,332.70
* Non-Departmental expenditures include but are not limited to debt service payments, inter-fund transfers, depreciation, and amortization.
Source: Infoadvantage - FY 16 Operating and CIP Expense Detail
3
A-3 Attachment A
In Table 3, the spending by payment type reflects the different ways that a payment gets made. The payment document is what initiates a payment in the City’s financial system. The City makes payments by way of issuing checks, sending bank wires (EFT/ACH), direct debits, and purchasing cards (p-cards). Payments are made against current year contracts and previously issued contracts. The payment type with the highest spending level was Master Agreement/Purchase Orders at $37,002,312.21. The payment type with the lowest spending level was Travel Reimbursements at $61,568.75.
Table 3: Total Spending by Payment Instrument FY 2016
DOCUMENT PAYMENT TYPE TOTAL PRC/MRC MASTER AGREEMENTS / PURCHASE ORDERS $ 37,002,312.21 JVA WIRES / ACH, DIRECT DEBITS AND NONCASH EXPENSES $ 32,414,231.10 GAX SINGLE ITEM DISBURSEMENT $ 18,997,246.04 JVA CC P-CARD TRANSACTIONS $ 2,585,670.22 OC/SN STOCKROOM TRANSACTIONS $ 373,304.38 TP TRAVEL REIMBURSEMENTS $ 61,568.75 TOTALS $ 91,434,332.70
Source: Infoadvantage - FY 16 Operating and CIP Expense Detail
Tables 4 and 5 reflect the core procurement activities taking place during the year. Spending may or may not occur against these instruments during the year the contract is established and executed. The highest level of spending occurred through purchase orders at $34,700,827.48 and the lowest through rider contracts at $5,167,741.14.
Table 4: Procurement Activity by Procurement Type Award FY 2016
NUMBER OF VALUE OF AVERAGE VALUE OF TRANSACTIONS TRANSACTIONS TRANSACTIONS PURCHASE ORDERS ISSUED 306 $ 34,700,827.48 $ 113,401.40 MASTER AGREEMENTS ISSUED 74 $ 6,161,094.28 $ 83,258.03 RIDER CONTRACTS ISSUED 160 $ 5,167,741.14 $ 32,298.38 TOTALS 540 $ 46,029,662.90 $ 85,240.12
Source: Internal Spreadsheet based on comments recorded.
4
A-4 Attachment A
Table 5 represents solicitation instruments that the City utilizes during the year. Solicitations are governed by City Code. The instrument with the highest transaction value is the formal competitive Invitation for Bid (IFB) at $24,389,895.22. The instrument with the largest number of transactions is the rider contract at 160 totaling $5,167,741.14. By using a rider contract, the City can take advantage of another public entity’s competitive bid process, which is an efficient means of procurement when like goods or services are being sought.
Table 5: Procurements by City Code Section Utilized during FY 2016
TYPE OF PROCUREMENT ACTIVITY BY CODE SECTION NUMBER OF TRANSACTIONS VALUE OF TRANSACTION COMPETITIVE SEALED IFB (17-61) 62 $ 24,389,895.22 COMPETITIVE SEALED RFP (17-62) 55 $ 5,739,788.09 RIDER CONTRACTS USED (17-71) 160 $ 5,167,741.14 EXEMPTIONS (17-87) 96 $ 1,909,786.70 EMERGENCY (17-84) 10 $ 911,295.59 SPECIAL PROCUREMENTS (17-88) 9 $ 489,292.66 SOLE SOURCE ISSUED (17-82) 12 $ 328,948.91 INFORMAL (17-63) 33 $ 224,686.74 PUBLIC ENTITIES (17-72) 6 $ 103,102.50 SMALL PROCUREMENT (17-81) 19 $ 26,731.21 PROTESTS (17-171) 0 $ -
Source: Internal Spreadsheet based on comments recorded.
5
A-5 Attachment A
In accordance with City Code Section 17-39, procurements with a value above $100,000 are awarded by the Mayor and Council. Table 6 represents the awards that were made by the Mayor and Council during the year listed by department and award size. Where there is no value reflected, an award was made without a defined dollar amount to the contract.
Table 6: Procurements Awarded by Mayor and Council above $100,000
CONTRACT DESCRIPTION CONTRACTOR CONTRACT VALUE DEPARTMENT COR1787 TEMPORARY LABOR SERVICES LABOR READY NORTHEAST, INC. $ 215,000.00 PUBLIC WORKS 18-13 SIDEWALK, CURB AND DRIVEWAY CONSTRUCTION MULTIPLE AWARDS $ 800,000.00 PUBLIC WORKS BALCOB-349 ATHLETIC COURT MAINTENANCE/INSTALLATION AMERICAN TENNIS COURTS $ 224,100.00 REC & PARKS 44-15 WATER MAIN REHABILITATION SERVICES MULTIPLE AWARDS $ 13,000,000.00 PUBLIC WORKS MC6506030178BB CUSTODIAL SERVICES CERTIFIED BUILDING SERVICES, INC. $ 224,149.53 REC & PARKS FRDCO09MISC10 PLAYGROUND EQUIPMENT PLAYGROUND SPECIALIST $ 264,393.14 REC & PARKS 26-15 STREET CLEANING SERVICES EAST COAST SWEEPING, INC. $ 115,000.00 PUBLIC WORKS 47-15 WATER TREATMENT CHEMICALS MULTIPLE AWARDS $ 359,188.28 PUBLIC WORKS 04-16 ASPHALT REHABILITATION SERVICES MULTIPLE AWARDS $ 2,500,000.00 PUBLIC WORKS 06-16 ACCESSIBLE PEDESTRIAN SIGNALS FORT MYER CONSTRUCTION $ 452,848.15 PUBLIC WORKS 27-15 STREAM RESTORATION SERVICES MEADVILLE LAND SERVICE, INC. $ 655,735.80 PUBLIC WORKS 24-15 SOUTH POOL DECK CHANGE ORDER STEVEN GOODRICH CITY CONST. $ 45,540.00 REC & PARKS 02-16 EAST ROCKVILLE SANITARY SEWER IMPROVEMENTSFORT MYER CONSTRUCTION $ 2,960,965.55 PUBLIC WORKS 30-15 FROG RUN STORM DRAIN REPAIR COASTAL GUNITE CONSTRUCTION $ 438,595.00 PUBLIC WORKS 23-15 WOOTTON BRIDGE REHABILITATION TITAN INDUSTRIAL SERVICES $ 704,941.00 PUBLIC WORKS 07-16 SIDEWALK, CURB AND DRIVEWAY CONSTRUCTION MULTIPLE AWARDS $ 3,000,000.00 PUBLIC WORKS COR1788 SINGLE STREAM RECYCLING SERVICES WASTE MANAGEMENT $ 400,000.00 PUBLIC WORKS 41-11 BRIDGE ENGINEERING SERVICES MULTIPLE AWARDS $ 500,000.00 PUBLIC WORKS MD001IT820002 LAW ENFORCEMENT VEHICLES HERTRICH FLEET SERVICES $ 161,428.00 PUBLIC WORKS NJPA060612-ESG REFUSE LOADER CONVERSIONS MID-ATLANTIC WASTE SYSTEMS, INC. $ 181,530.76 PUBLIC WORKS NJPA060612-ODB TRUCK MOUNTED DEBRIS COLLECTORS OLD DOMINION BRUSH CO. $ 113,889.20 PUBLIC WORKS 19-16 JANITORIAL SERVICES CERTIFIED BUILDING SERVICES, INC. $ 250,000.00 REC & PARKS MCOES-3-2015 ELECTRICITY WGL ENERGY SERVICES $ - PUBLIC WORKS VASCUPP4394459JC BROADCAST EQUIPMENT HUMAN CIRCUIT, INC. $ 242,998.21 CITY MANAGER NJPA102811-NAF DUMP TRUCKS WITH SNOW EQUIPMENT JOHNSON TRUCK CENTER, LLC $ 441,360.00 PUBLIC WORKS 12-16 DOGWOOD PARK STREAM RESTORATION EQR, INC. $ 968,106.20 PUBLIC WORKS 31-16 CIVIC CENTER ADA PARKING LOT CONSTRUCTION MANUEL LUIS CONSTRUCTION $ 557,938.53 REC & PARKS 25-16 WATKINS POND SWM RETROFIT AVON CORPORATION $ 1,198,014.98 PUBLIC WORKS 13-16 FIRST STREET BRIDGE REPLACEMENT CONCRETE GENERAL, INC. $ 1,730,470.00 PUBLIC WORKS 32-16 STREET LIGHT MAINTENANCE SERVICES LIGHTING MAINTENANCE, INC. $ 116,081.62 PUBLIC WORKS LGIT INSURANCE SERVICES LGIT $ - HUMAN RESOURCES 18-16 INSURANCE SERVICES AON $ - HUMAN RESOURCES
Source: City agenda management system.
Minority, Female, Disabled (MFD) Outreach Program In FY 2016, about 34% of Mayor and Council award items, including multiple award contracts, were awarded to MFD businesses. During FY 2016, the Procurement Division was able to place more focus on the MFD outreach efforts for the City of Rockville. We remain proactive to ensure that MFD businesses are educated on the procurement processes and are made aware of opportunities to compete on City solicitations. Efforts are also facilitated by attending various conferences, seminars, workshops and networking functions with focus on MFD outreach. Some of the outreach program highlights include:
Attendance at 15 MFD networking events Attendance at 4 individual meetings with local jurisdictions Facilitated 8 formal, technical one-on-one meetings Identification and purchase of road show exhibit materials Established text/email alert notifications of new City bids Ongoing population of the City’s vendor database by MFD category As we proceed, we remain dedicated in carrying out the functions of the program. We value the importance of our outreach efforts and continue to explore ideas to measure performance and overall success of the program.
6
A-6 Attachment B
October 14, 2016
MEMORANDUM TO THE MAYOR AND COUNCIL OF THE CITY OF ROCKVILLE, MD
FROM: Financial Advisory Board
SUBJECT: FAB Comments on FY 2016 Annual Procurement Report
Summary
The Board met with City staff to review the FY 2016 Annual Procurement Report. The meeting was productive, and resulted in a useful exchange of information between the Board and City staff. City staff recognizes the shortcomings in the current format of the Annual Procurement Report. The Board encouraged City staff to also consider the improvements we recommend below when preparing the FY 2017 Annual Procurement Report. We also request that staff provide us with an early draft of the FY 2017 report for our review and comment. Finally, the Board recommends that the milestones associated with these actions be included in the Purchasing Action Plan.
The Board thanks Mayor & Council for postponing the presentation of this report so that we had time to review it and have our comments included in the staff issue paper that transmits the report to you. We realize our comments could not be reflected in the FY 2016 report, but ask that they be considered when formulating the report for FY 2017.
Ways to Improve Current Reports
We applaud City staff for including in the FY 2016 Annual Procurement Report highlights of the actions taken during the past year to implement many of the Calyptus recommendations and make other improvements. We hope that City staff will continue the practice of highlighting improvement made during the year in future Annual Procurement Reports. In the event that no improved sources of procurement data become available for the FY 2017 report, the current report format could be improved by taking the following steps:
1. To the maximum extent possible, only report procurement dollars in Tables 1 through 3. a. Review the JVA transactions to identify all non-procurement transactions and remove them from the JVA transactions reported in Tables 1 though 3. Non-procurement transactions of which we are aware include debt service payments (i.e., principal and interest); depreciation and amortization in the Enterprise Funds; and intradepartmental/intra-fund transfers. If other non-procurement JVA transactions are known, they should be removed too, and the adjustments to the JVA totals footnoted in each Table.
1 B-1 Attachment B
b. To the extent that Stockroom Transactions and Travel Reimbursements don’t reflect payments to vendors, they should also be removed from the amounts reported on Tables 1 through 3. For example, travel reimbursements to employees should not be included; payments directly to hotels, airlines, restaurants, rental car companies, and other providers should. 2. Once both of the above adjustments have been made, the resulting totals shown in the first three tables should still be equal and will more closely approximate true procurement spending. However, there may still be differences between the totals reported in Tables 1 through 3 and the totals reported in Tables 4 and 5. The report should explain clearly the reasons for any differences in those totals. 3. Group the Procurements by City Code Section in Table 5 into two categories according to the risk associated with each type of procurement. The first category should be “Competitive Awards” and should include transactions that have followed “normal,” low-risk procurement rules, e.g., competitive awards, informal RFQ, and rider contracts. The second category should be “Non- Competitive Awards” and include those that are inherently more risky, e.g., exemptions, sole source procurements, and emergency procurements. City staff agreed with this suggestion. 4. Add a new Table 6 that compares the totals in Tables 3, 4, and 5 for the current and two previous fiscal years and explains any significant differences in those totals over that three-year period. 5. Include the fiscal year-end performance measures as a separate section of the report. These data should already be available.
Useful Lessons from the Calyptus Purchasing Study
Calyptus was able to take data available from the City’s CGI/AMS financial management system and produce a number of credible and compelling reports on the City’s purchasing activities. In some cases, this required Calyptus to analyze detailed transaction sets to distinguish between initial contracts, change orders, and contract extensions; also between initial awards of Master Contracts, contract extensions, and spending against those contracts. Calyptus was also able to use available data and to report expenditures by category (e.g., construction, insurance, purchased services, etc. (see p. 59 in the Calyptus report), but they had to run “multiple custom data reports from the CGI-AMS system” to do so. Although City staff agree with the value of these additional reports, they do not believe it feasible to replicate the Calyptus approach. They prefer instead to explore ways to tweak the current financial management system to produce some of the desired information and to examine other systems that might provide the more complete set of data provided by Calyptus and requested in Councilmember Feinberg’s motion for an annual procurement report.
2 B-2 Mayor and Council Action Report
Mayor and Council
For the meeting on: September 26, 2016 Department: City Manager Responsible staff: Jenny Kimball, Deputy City Manager phone: (240) 314 - 8104 [email protected]
Subject Mayor and Council Action Report
Recommendation Review and comment on the Action Report
Attachments
Attachment A - M&C Action Report for 9-26-16.pdf
Assistant City Manager:
Jenny Kimball, Deputy City Manager Approved on: 09/21/2016
City Manager: Approved on: 09/21/2016
https://rockmail.rockvillemd.gov/.../egenda.nsf/d5c6a20307650f4a852572f9004d38b8/ea3f5dd0baf928ca85258017005a20d0?OpenDocument[6/30/2017 5:54:05 PM] Attachment A Blue - new items to the list. Red - latest changes. Mayor and Council Action Report Ref. # Meeting Staff/ Response Direction to Staff / Action Taken / Status Estimated Date Dep Method Completion or Agenda Item date FA-2013-7 4/22/13 CMO / Agenda item Town Center Parking October 17, 2016 CPDS Status: The Mayor and Council discussed Town Center parking on February 25, 2016, June 13, 2016, and August 1, 2016. As directed by the Mayor and Council on August 1, 2016, staff has established free 15 minute meter spaces for customer pick up, implemented a new lunchtime concert series on E. Montgomery Avenue, and installed three additional portable parking signs in Town Center. Other follow up items will be presented to the Mayor and Council in October 17, 2016. FA-2014-23 9/8/11 R&P Future King Farm Farmstead – Next Steps Ongoing agenda Status: The King Farm Farmstead house is currently being advertised for rent for $3,000/month. The King Farm Task Force has been established, and a meeting has been scheduled for September 27, 2016. FA-2014-25 9/8/14 CPDS Future Southlawn Industrial Area Study October 10, 2016 agenda Status: The Mayor and Council completed review of the Southlawn Study recommendations at their meeting on August 1, 2016. Staff will return to the Mayor and Council in the fall with the list of the accepted recommendations along with anticipated implementation schedules, preliminary costs and next steps. A community meeting will also be held in the fall to inform stakeholders about the Mayor and Council’s decisions. FA-2015-14 7/13/15 CMO Future Purchasing Study Response February 2017 agenda Status: On October 19, 2015, the Mayor and Council received a presentation by Calyptus Consulting. The City Manager distributed an action plan responding to the Calyptus report on January 16, 2016 and presented the plan to the Mayor and Council on February 1, 2016. Public updates will be provided every six months. The first six month presentation was presented at the August 1, 2016 Mayor and Council meeting. FA-2016-1 3/14/16 R&P Future Youth Sports September 26, 2016 Agenda Schedule a worksession with stakeholders to discuss safety in the City’s youth sports activities that could result in head injuries. FA-2016-2 3/14/16 R&P Future Grants for Watts Branch Fishing TBD Agenda Research Federal and State grant opportunities to introduce trout to Watts Branch and pursue designation as a youth and blind fishing area. Status: The Chief of the Environmental Management Division met with the residents to learn more about their proposal. Staff is in the process of researching and evaluating options. The residents shared their proposal in the Rockshire Newsletter and announced it at the May 11, 2016 Rockshire HOA meeting. They have received some feedback, both positive and negative. FA-2016-4 4/18/16 R&P Future Senior Study Action Plan September 26, 2016 agenda Prepare an action plan in response to the Senior Services Needs Assessment and Gap Analysis A-1
Attachment A Ref. # Meeting Staff/ Response Direction to Staff / Action Taken / Status Estimated Date Dep Method Completion or Agenda Item date Study, and incorporate the plan into the implementation of the Mayor and Council’s priority initiative to “Receive Senior Service Study and develop a multi-year implementation plan.” FA-2016-5 3/21/16 Finance Future Budget Calendar and Process Complete agenda Status: A Discussion and Instruction worksession on the operating budget process was held on September 12, 2016, and Discussion and Instruction on the CIP budget process was held on September 19, 2016. FA-2016-6 4/25/16 Police / Future Police Staffing November 21, 2016 Human agenda Schedule a Mayor and Council discussion to follow up on the April 25, 2016 presentation on Resources Rockville City Police Roles and Responsibilities. Include the following topics in the discussion: succession planning, over hire or temporary overages hiring approach, and drop program. FA-2016-7 7/11/16 DPW Future Montgomery County Bike Gap Analysis October 24, 2016 agenda Invite the planning coordinator from M-NCPPC to an October meeting for a briefing on the County’s Bike Gap Analysis in preparation for the Mayor and Council taking up the Bikeway Master Plan. Staff will select a meeting date based on the M-NCPPC staff availability. FA-2016-8 7/18/16 CMO / Future Smoking Ban at Eating Establishments October 2016 Legal agenda Discuss establishing a smoking ban at all eating establishments with outdoor seating within the City limits. FA-2016-9 7/18/16 R&P Future Cultural Arts Commission October 24, 2016 agenda Schedule a discussion with the Cultural Arts Commission to include the topic of gateway art projects. FA-2016-10 7/18/16 CMO Future Annual Procurement Report September 26, 2016 agenda Present annually to the Mayor and Council a report of City procurement activities. FA-2016-11 9/12/16 R&P Memo 9-11 Remembrance Ceremony TBD Explore how the City can be more formally involved in future 9-11 remembrance ceremonies at the Courthouse Square/9-11 Memorial Park
COMPLETED / CLOSED OUT ITEMS MC-2014-1 1/27/14 CMO Memo Neighborhood Communication Initiative Complete Implement neighborhood communication initiative. Status: In an April 15, 2016 memo to the Mayor and Council, staff recommended using the Nextdoor tool to facilitate the Neighborhood Communication Initiative. Staff began using the tool on September 1, 2016, and will provide more information about the implementation by memo to the Mayor and Council.
A-2
Future Agendas
Mayor and Council
For the meeting on: September 26, 2016 Department: City Clerk Responsible staff: Sara Taylor-Ferrell, Acting Deputy City Clerk phone: (240) 314 - 8283 [email protected]
Subject Future Agendas
Recommendation
Attachments
Attachment A - Mock Agenda 10.10.16.pdf[attachment "Attachment B - Future Agendas
09.26.16.pdf" deleted by Sara Taylor-Ferrell/RKV] Attachment B - Future Agendas 09.26.16.pdf
Department Head:
Kathleen Conway, City Clerk/Director of Council Operations Approved on: 09/21/2016
https://rockmail.rockvillemd.gov/...egenda.nsf/d5c6a20307650f4a852572f9004d38b8/a5aeebd16542a7bb85258035005d3012?OpenDocument[6/30/2017 5:54:11 PM] Attachment A
-Tentative- Mayor and Council Meeting October 10, 2016 Meeting No. 34-16 7:00 pm
7:00 pm
1. Convene
2. Pledge of Allegiance
3. Agenda Review
7:05 pm
4. City Manager's Report
7:15 pm
5. Proclamation Declaring October 2016 as Breast Cancer Awareness Month.
7:20 pm
6. Proclamation Declaring October 2016 as Bullying Prevention Month in Rockville.
7:25 pm
7. Proclamation Declaring October 2016 as National Community Planning Month in Rockville.
7:30 pm
8. Community Forum
9. Mayor and Council's Response to Community Forum and Announcements
10. Mayor and Council Reports
A - 1 Attachment A
7:45 pm
11. Consent Agenda
A. Award of Rider on Baltimore County Contract #B700, Environmental Restoration, Design/Build, On-Call, to Environmental Quality Resources, LLC, in an Annual Amount Not to Exceed $420,000.
B. Award of Recycling Hauling Contract
C. Approval - Resolution Appointing Reliant as Trustee
D. Authorization and Approval for the City Manager to Sign a CSXT Construction Agreement in the Amount of $200,000
E. Award of Contract Extension to Dukes Sales and Services in the Amount Not to Exceed $90,000 Through December 18, 2017
7:50 pm
12. Discussion and Instruction on an Ordinance to Adopt Zoning Text Amendment to Allow Installation of Small Cell Antennas for Wireless Facilities (TXT2016-00244, Verizon Wireless, Applicant)
8:05 pm
13. Discussion and Instructions - Public Property Naming and Commemoration Policy
8:20 pm
14. Approval of Southlawn Study Recommendations and Review of Next Steps
8:50 pm
15. Veirs Mill Road Bus Rapid Transit alternatives - MDOT presentation
9:35 pm
16. Review and Comment - Mayor and Council Action Report
17. Review and Comment - Future Agendas
18. Old/New Business
9:50 pm
19. Adjournment
A - 2 Future Agendas September 26, 2016 Attachment B
Type of Item Subject
October 17, 2016 Introduction Introduction of an Ordinance to repeal in its entirety and re-enact Chapter 10 of the Rockville City Code entitled “Floodplain Management” so as to comply with the new Federal and State floodplain management provisions and to create a formal permitting process to track floodplain activities Discussion Proposed FY17 Strategy and Plan for School Construction Advocacy Adoption Adoption - Public Property Naming and Commemoration Policy Award Award of Baltimore County contract #B-973, for Playground Equipment, Pavilions and Site Furnishings for the new installation, replacements and repair of playgrounds for a period of five years in the aggregate amount of $1,250,000. Review and Mayor and Council Action Report Comment Proclamation Proclamation for the 2016 Rockville Holiday Drive Kick-Off Discussion and Town Center Parking Follow Up Instructions Rockville's Human Services Grant Process October 24, 2016 Authorization Authorization to File a Zoning Text Amendment To Reorganize and Revise the Provisions for Historic Preservation in the Zoning Ordinance Introduction Introduction of an Ordinance to Approve Zoning Text Amendment TXT2016-00244 - to Allow Installation of Small Cell Antennas for Wireless Facilities; Cellco Partnership dba Verizon Wireless, Applicant Adoption Adoption of Resolution to Revise the Statement of Investment Policy for the investment of the City’s operating and capital funds Review and Fourth Quarter FY 2016 Financial Report Comment Introduction and Introduction, and Possible Adoption, of an Ordinance to Amend Ordinance #05-16 Adoption to Appropriate Funds and Levy Taxes for Fiscal Year 2017 (Budget Amendment #1) Review and Mayor and Council Action Report Comment Approval Police Body-Worn Camera System and In-Car Video Cameras Worksession Worksession with the Cultural Arts Commission Proclamation Proclamation Declaring November, 2016 Emancipation Day in Rockville Montgomery County Bike Gap Analysis placeholder Presentation Presentation of the Montgomery County Bicycle Gap Analysis November 1, 2016 Public Hearing FY 2018 Budget Public Hearing November 14, 2016 Adoption Adoption of Ordinance for Zoning Text Amendment TXT2016-00244 - to Allow Installation of Small Cell Antennas for Wireless Facilities; Cellco Partnership, dba Verizon Wireless, Applicant
B - 1 Future Agendas September 26, 2016 Attachment B
Type of Item Subject
Discussion Minimum wage increases and the impacts of compression Award Award of IFB #01-16, Water Storage Tank Rehabilitation Various Locations, to (vendor) in the Amount Not to Exceed ($xxx) Review and Mayor and Council Action Report Comment November 21, 2016 Public Hearing Public Hearing for Ordinance to repeal in its entirety and re-enact Chapter 10 of the Rockville City Code entitled “Floodplain Management” so as to comply with the new Federal and State floodplain management provisions and to create a formal permitting process to track floodplain activities Award Award of Structural Repairs to King Farm Farmstead Dairy Barns Discussion Police Staffing Review and Mayor and Council Action Report Comment Presentation Part II Presentation on Fireside Recapitalization Strategy December 5, 2016 Public Hearing Public hearing on Zoning Text Amendment TXT2017-00xxx, to relocate and clarify the procedures for historic preservation designation and certificates of approval Presentation Presentation - Good Neighbor Awards Presentation Fiscal Year 2016 Audited Financial Reports Presentation Fiscal Year 2016 Popular Annual Financial Report (PAFR) Review and First Quarter FY 2017 Financial Report Comment Review and Mayor and Council Action Report Comment December 12, 2016 Review and Mayor and Council Action Report Comment 2017 January 9, 2017 Adoption Discussion and Instruction and Possible Adoption of an Ordinance to repeal in its Discussion and entirety and re-enact Chapter 10 of the Rockville City Code entitled “Floodplain Instructions Management” so as to comply with the new Federal and State floodplain management provisions and to create a formal permitting process to track floodplain activities Discussion and Discussion and Instructions to Staff on Zoning Text Amendment TXT2017-000XX - Instructions to Reorganize and Revise the Provisions for Historic Preservation in the Zoning Ordinance; Mayor and Council of Rockville, applicant Presentation Cost Allocation Plan (CAP) January 23, 2017 Introduction Introduction of Ordinance for Zoning Text Amendment TXT2017-000XX - to Reorganize and Revise the Provisions for Historic Preservation in the Zoning Ordinance; Mayor and Council of Rockville, applicant Adoption Adoption of an Ordinance to repeal in its entirety and re-enact Chapter 10 of the Rockville City Code entitled “Floodplain Management” so as to comply with the new Federal and State floodplain management provisions and to create a formal permitting process to track floodplain activities B - 2