Report To Congress On Traumatic Brain Injury In The United .

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Report to Congress onTraumatic Brain Injuryin the United States:Understanding the Public HealthProblem among Current and FormerMilitary PersonnelJune 2013

The Report to Congress on Traumatic Brain Injury in the United States: Understanding the Public Health Problemamong Current and Former Military Personnel is a publication of the Centers for Disease Control and Prevention(CDC) and the National Institutes of Health (NIH) in collaboration with the Department of Defense (DOD) and theDepartment of Veterans Affairs (VA).Centers for Disease Control and PreventionNational Center for Injury Prevention and ControlThomas R. Frieden, M.D., M.P.H.Director, Centers for Disease Control and PreventionNational Institutes of HealthNational Institute of Neurological Disorders and StrokeNational Center for Medical Rehabilitation Research,Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentFrancis S. Collins, M.D., Ph.D.Director, National Institutes of HealthThe inclusion of individuals, programs, or organizations in this report does not constitute endorsement bythe U.S. federal government, DHHS, DoD, or DVA.Suggested Citation: The CDC, NIH, DoD, and VA Leadership Panel. Report to Congress on TraumaticBrain Injury in the United States: Understanding the Public Health Problem among Current and FormerMilitary Personnel. Centers for Disease Control and Prevention (CDC), the National Institutes of Health(NIH), the Department of Defense (DoD), and the Department of Veterans Affairs (VA). 2013.ii

Dear Colleague:Since the mid-2000s, public health and heath care-communities have become aware of the increased ratesof traumatic brain injury (TBI) among active duty U.S. military personnel. In response to these publichealth concerns, Congress passed the Traumatic Brain Injury Act of 2008, which requires the Centers forDisease Control and Prevention (CDC) and the National Institutes of Health (NIH), in consultation withthe Department of Defense (DoD) and the Department of Veterans Affairs (VA), to determine how best toimprove the collection and dissemination of information on the incidence and the prevalence of TBIamong persons who sustained these injuries while in the military; and to make recommendations on themanner in which CDC, NIH, DoD, and VA can collaborate further on the development and improvementof TBI diagnostic tools and treatments.This report, Traumatic Brain Injury in the United States: Understanding the Public Health Problemamong Current and Former Military Personnel, presents the major findings and recommendations of themembers of the CDC, NIH, DoD, and VA Leadership Panel. These findings and recommendations are theproduct of a review of relevant scientific literature and a thorough examination of current TBI-relatedactivities and programs conducted by the four agencies/departments. The report describes the publichealth importance of military service-related TBI, recommends how better to measure the magnitude ofits medical and socio-economic impact, and suggests ways in which the four agencies/departments cancollaborate further on the development and improvement of TBI-related diagnostic tools and treatments.Incorporating the recommendations of this report into public health policy and public health and clinicalpractice will help our nation to address the full impact and long-term consequences of TBI, will informthe development of more effective primary prevention strategies and policies, diagnostic tools andtherapeutic interventions, and will allow for improved rehabilitation and reintegration of military andcivilian TBI survivors in the United States.Thomas R. Frieden, M.D., M.P.H.Director, Centers for Disease Control and PreventionAdministrator, Agency for Toxic Substances and Disease RegistryDepartment of Health and Human ServicesFrancis S. Collins, M.D., Ph.D.Director, National Institutes of HealthDepartment of Health and Human Servicesiii

PrefaceSince the beginning of Operation Enduring Freedom (OEF) (Afghanistan) and Operation Iraqi Freedom(OIF), public health and health care-communities have become aware of the increased rates of traumaticbrain injury (TBI) among active duty U.S. military personnel. Epidemiologic and clinical studies suggestthat many of these military service-related injuries have serious long-term health and socioeconomicconsequences.In response to these public health and medical concerns, Congress passed the Traumatic Brain Injury Actof 2008 (TBI Act of 2008), which requires the Centers for Disease Control and Prevention (CDC) and theNational Institutes of Health (NIH), in consultation with the Department of Defense (DoD) andDepartment of Veterans Affairs (VA), to determine how best to improve the collection and disseminationof information on the incidence and prevalence of TBI among persons who were formerly in the military;and to make recommendations on the manner in which CDC, NIH, DoD, and VA can collaborate furtheron the development and improvement of TBI diagnostic tools and treatments. To that end, the CDC, NIH,DoD, and VA formed a Leadership Panel of experts with extensive experience in epidemiologic andclinical research, and in treating and managing TBI and its consequences.This report presents the major findings and recommendations of the Leadership Panel and a review ofrelevant scientific literature and a thorough examination of current TBI-related activities and programsconducted by the four agencies/departments. It describes the public health importance of military servicerelated TBI, recommends how to measure the magnitude of the health and socioeconomic impact of TBIand suggests ways in which the four agencies/departments can collaborate further on the development andimprovement of TBI diagnostic tools and treatments.Goals of the ReportTo respond to the mandate of the TBI Act of 2008 and to accomplish the goals of this report, CDC, NIH,DoD, and VA formed a Leadership Panel comprising representatives from each of these fouragencies/departments. These persons were researchers and investigators with extensive experience inTBI-related epidemiologic and clinical research and in treating and providing rehabilitation for TBIsurvivors. To prepare their respective contributions to the report, members of the panel reviewed allcurrent TBI-related activities and programs conducted by the four agencies/departments and relevantscientific literature.This report represents the culmination of the Leadership Panel’s deliberations and summarizes findingsand recommendations. By sharing the results of this effort, CDC, NIH, DoD and VA aim to:iv

Raise Awareness: Describe the public health importance of TBI among people currently orformerly in the military; Improve Surveillance: Recommend how to better measure the magnitude and impact of thiscondition in this population and the country; and Strengthen Collaboration: Suggest how the four agencies/departments can collaborate furtheron the development and improvement of TBI-related diagnostic and prognostic tools, treatment,management, and rehabilitation.v

Members of the Leadership PanelCenters for Disease Control and Prevention Victor G. Coronado, M.D., M.P.H., Executive SecretaryMedical OfficerDivision of Injury ResponseNational Center for Injury Prevention and ControlCenters for Disease Control and Prevention4770 Buford Highway NEAtlanta, GA 30341 Vikas Kapil, D.O.Associate Director for SciencesDivision of Injury ResponseNational Center for Injury Prevention and ControlCenters for Disease Control and PreventionAtlanta, GA 303334770 Buford Highway NEAtlanta, GA 30341National Institutes of Health Beth Ansel, Ph.D.Program DirectorNational Center for Medical Rehabilitation ResearchThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of Health6100 Executive Blvd Room 2A03, MSC 7510Bethesda MD. 20892-7510vi

Ramona Hicks, Ph.D.Program DirectorNational Institute of Neurological Disorders and StrokeNational Institutes of HealthNeuroscience Center, Room 22066001 Executive Blvd MSC 9525Bethesda, MD. 20892-9525 Walter Koroshetz, M.D., Ph.D.Deputy DirectorNational Institute of Neurological Disorders and StrokeNational Institutes of HealthBuilding 31, Room 8A5231 Center Dr. MSC 2540Bethesda, MD. 20892 Michael Weinrich, M.D.DirectorNational Center for Medical Rehabilitation ResearchThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of Health6100 Executive Blvd Room 2A03, MSC 7510Bethesda, MD. 20892-7510Department of Defense COL Jamie Grimes, M.D.National DirectorDefense and Veterans Brain Injury Center, National Headquarters1135 East-West Highway, Suite 6-100Silver Spring, MD. 20910vii

COL Michael S. Jaffee, M.D.Pulmonary Clinic, Pulmonary Rehab (COPD), & Sleep MedicineWilford Hall Ambulatory Surgical CenterSan Antonio Military Medical Center59 MDW/SGO5PS2200 Bergquist Dr Ste 1Lackland AFB, TX. 78236 Kimberly Meyer, M.S.N., A.R.N.P.Neurotrauma ClinicianDefense and Veterans Brain Injury Center, National Headquarters1135 East-West Highway, Suite 6-100Silver Spring, MD 20910 Brian Ivins, M.P.S.Senior AnalystDefense and Veterans Brain Injury Center1135 East-West Highway, Suite 6-100Silver Spring, MD 20910Department of Veterans Affairs David W. Chandler, Ph.D.Deputy Chief Consultant, Office of Rehabilitation ServicesU.S. Department of Veterans Affairs810 Vermont Ave, NWWashington, DC 20420 David X. Cifu, M.D.Department of Veterans AffairsChief, Physical Medicine & Rehabilitation Service (PM&RS)McGuire VA Medical CenterActing National Director for PM&R ServicesVeterans Health AdministrationRichmond, VA 23249viii

Kyle D. Dennis, Ph.D.U.S. Department of Veterans AffairsAudiology & Speech Pathology National Program Office (10P4RA)50 Irving Street NWWashington, DC 20422 Stuart W. Hoffman, Ph.D.Scientific Program Manager for Brain InjuryRehabilitation Research and Development ServiceOffice of Research and DevelopmentU.S. Department of Veterans Affairs810 Vermont Avenue (10P9R)Washington DC 20240 Alexander Ommaya, Sc.D.Director - Translational ResearchOffice of Research and Development (12)U.S. Department of Veterans Affairs810 Vermont Ave., NWWashington, DC 20420 Dr. Aaron I. Schneiderman, Ph.D., M.P.H., R.N.Acting DirectorDepartment of Veterans Affairs (10P3A)Epidemiology Program810 Vermont Avenue, NWWashington DC 20420 Jay M. Uomoto, Ph.D.Formerly with Department of Veterans AffairsFormer Deputy DirectorDepartment of Veterans AffairsDefense Centers of Excellence for Psychological Health and Traumatic Brain Injury1335 East West HighwaySilver Spring, MD 20910ix

Senior Editor Victor G. Coronado, M.D., M.P.H.Medical OfficerDivision of Unintentional Injury PreventionNational Center for Injury Prevention and ControlCenters for Disease Control and Prevention4770 Buford Highway NEAtlanta, GA 30341Editors Vikas Kapil, D.O.Associate Director for ScienceFormerly with Division of Injury ResponseNational Center for Injury Prevention and ControlCenters for Disease Control and PreventionAtlanta, GA 303334770 Buford Highway NEAtlanta, GA 30341 Arlene Greenspan, DrPH, MPH, PTAssociate Director for ScienceNational Center for Injury Prevention and ControlCenters for Disease Control and PreventionAtlanta, GA 303334770 Buford Highway NEAtlanta, GA 30341 Lynn Jenkins, PhDSenior AdvisorNational Center for Injury Prevention and ControlCenters for Disease Control and PreventionAtlanta, GA 303334770 Buford Highway NEAtlanta, GA 30341x

Suzanne M. Hewitt, MPAMedical Writer/Editor404-636-8283 (office)404-798-6555 (cell)Contributors Julie Gilchrist, MD, MPHMedical OfficerDivision of Unintentional Injury PreventionNational Center for Injury Prevention and ControlCenters for Disease Control and Prevention4770 Buford Highway NEAtlanta, GA 30341 Lisa McGuire, PhDPsychologistDivision of Unintentional Injury PreventionNational Center for Injury Prevention and ControlCenters for Disease Control and Prevention4770 Buford Highway NEAtlanta, GA 30341xi

Table of ContentsPreface. ivGoals of the Report . ivMembers of the Leadership Panel . viExecutive Summary . xivI.Introduction . 1Definition of TBI . 1II.Pathophysiology and Mechanisms . 3Primary Injury. 3Secondary Injury. 3Diffuse and Focal Injury . 4Research Relevant to Active Duty Personnel and Veterans . 7III.Diagnosis. 11Pre-Deployment Neurocognitive Baseline Testing . 11In-Theater Screening . 12Post-Deployment . 13VA Clinical Screening and Diagnosis Tools . 13Civilian Clinical Screening and Diagnosis Tools . 14Clinical Presentation/Symptoms . 15Severity . 16IV.Treatment . 20Acute Care . 20Long-Term Care . 22VA’s Vet Centers. 23VA’s Polytrauma System of Care. 24Care in the Civilian Health System . 29Rehabilitation. 30V.Prognosis and Recovery . 32Recovery from TBI . 32Post-Concussive syndrome (PCS) . 34Posttraumatic Stress Disorder (PTSD) . 34Long-term Health Outomes or Disability . 35Risk of Neurodegenerative Disease Following TBI . 36VI.Surveillance . 38Case Definition Background. 38Definition of TBI based on ICD Diagnostic Coding . 41Case Ascertainment by Severity . 43Data Sources . 47Department of Defense . 50VA . 51Challenges/Limitations . 52VII.Epidemiology. 54Incidence: Traumatic Brain Injury. 54Prevalence: Traumatic Brain Injury. 59xii

The Economic Costs of TBI . 64Estimating the Cost of TBI . 67VIII. Prevention . 68Preventing TBI . 68Preventing TBI Associated with Motor Vehicle Traffic Crashes . 69Preventing TBI Associated with Falls . 70Preventing TBI Caused by Striking or Being Struck . 70Preventing TBI Associated with Intentional Injury . 70Prevention of Secondary Brain Injury . 71IX.Recommendations. 72General Recommendations . 72Recommendations to Improve TBI Diagnosis and Treatment . 73Methodological Concerns and Research Priorities . 76Recommendations to Improve TBI Surveillance. 77Methods for Detecting TBI Incidence and Prevalence . 78Recommendations to Improve TBI Prevention . 80References . 82List of Acronyms . 110xiii

Executive SummaryBackground and Key FindingsTraumatic brain injury (TBI) is one of the highest priorities in public health and medicine because of itsmagnitude, cost, and consequences (e.g., death and disability), and because it is often preventable. TheCenters for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control(NCIPC) estimates that each year approximately 1.7 million civilians in the United States sustain a TBI.Of these TBI injuries, which can occur alone or in combination with other injuries, about 1.36 million aretreated and released from emergency departments (EDs), 275,000 are hospitalized, and 52,000 die.However, not all of these ED visits, hospitalizations and deaths are attributable to TBI, but might be dueto other co-occurring injuries. These data suggest that the majority of TBIs (approximately 80%;Coronado, Thurman, Greenspan, and Weissman, 2009) are mild. These figures might not reflect the trueincidence of TBI because they do not include people who are treated in physicians’ offices or outpatientfacilities or those seeking medical care in non-civilian facilities (Faul, Xu, Wald, and Coronado, 2010).TBI among U.S. military personnel is a critically important health concern for veterans of the currentOperation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF); these operations compriseseveral subordinate operations in Afghanistan, Horn of Africa, Trans Sahara, Philippines, Kyrgyzstan, aswell as earlier theaters of military operations. According to a Defense and Veterans Brain Injury Center(DVBIC) analysis of surveillance data released by the Department of Defense (DoD), 33,149 U.S.military personnel were diagnosed with a TBI in 2011 alone. This number includes service members(SMs) from the Army, Navy, Marine Corps, Air Force, and from the active duty and reserve componentsof the National Guard. (U.S. Dept. of Defense: http://www.health.mil/Research/TBI Numbers.aspx). TheU.S. Department of Veterans Affairs (VA) estimates that of the 771,874 veterans who sought care from aVA Medical Center from the start of OEF in October 1, 2001 to December 31, 2011, a total of 59,218unique OEF and OIF veterans were evaluated or treated for a condition possibly related to a TBI (U.S.Dept. of Veterans Affairs, 2012: ealthcareutilization-report-fy2012-qtr1.pdf ).In response to these public health and medical concerns, Congress reauthorized the Traumatic BrainInjury (TBI) Act of 1996 with the passage of the Traumatic Brain Injury (TBI) Act of 2008 (P.L. 110206; U.S. GPO 2008), which requires CDC and the National Institutes of Health (NIH), in consultationwith the Department of Defense and the Veteran’s Administration, toxiv

Determine how best to improve the collection and dissemination of information on the incidence(rate at which new cases of a condition occur in the population) and the prevalence (proportion ofa population at any given time that is experiencing the effects of a condition) of TBI amongpersons who were formerly in the military; and Make recommendations on the manner in which CDC, NIH, DoD, and VA can collaboratefurther on the development and improvement of TBI diagnostic tools and treatments.This report responds to these mandates. It was developed through a collaborative effort of a LeadershipPanel made up of representatives from the four participating agencies/departments and was reviewed,cleared, and approved by the participating agencies/departments. Members of this Leadership Panel wereclinicians, researchers, investigators, and science administrators with extensive experience inepidemiologic and clinical research and in treating and managing persons with TBI.Advances in TBI research in the past 30 years have created new opportunities for improved surveillanceand for effective, acute and long-term medical care and rehabilitation; however, as detailed in this report,many important data and knowledge gaps persist. Several critical concerns and challenges related to thepopulation of U.S. SMs who have sustained a TBI while in military service drive the recommendationsincluded in this report. Although DoD and VA have made substantial progress in helping militarypersonnel who have sustained a TBI, critical gaps remain in surveillance, epidemiology, clinicaldiagnosis, management, and rehabilitation, including a need to continue developing standard surveillancedefinitions, clinical definitions, and data collection methods as new knowledge and technology emerge.Some recent and current challenges include the following: The annual rate of TBI among active duty personnel increased substantially from 2000 to 2011. Amajority of the increases occurred from 2006 through 2008 (U.S. Department of Defense,unpublished data). As is experienced in the general population, the actual rate of TBI among military personnel ispotentially underestimated by existing TBI surveillance efforts. This is especially true foridentification of personnel who have sustained a mild TBI. The total burden of TBI among current and former military personnel, including medical costs,rehabilitation costs and lost productivity/income, is difficult to determine from existing datasources.xv

Evidence on the effectiveness of acute and post-acute treatment is limited. Although someguidelines and recommendations exist for the acute and post-acute treatment and rehabilitation ofpersons sustaining a TBI, they are generally derived from expert consensus or case series studies,as evidence-based scientific knowledge is sparse or is less than optimal to justify the strongestclinical recommendations. The influence of blast exposure on the risk for later developing neurodegenerative disorders isunknown.RecommendationsThe following general recommendations were developed in response to these concerns and to thequestions posed in the TBI Act of 2008: IMPROVE IDENTIFICATION: Strengthen the identification of military service-related TBIamong current military SMs and veterans, including those who do not seek care from the militaryor VA health-care systems. Emphasis will be given to improving data-collection initiatives anddata sources to obtain a more comprehensive picture of the problem and impacts of TBI in thispopulation. All four participating agencies should continue to foster and strengthen collaborationto this aim. STANDARDIZE DEFINITIONS: Use standard clinical and surveillance definitions and severityclassification of TBI among U.S. military and civilian health-care providers and researchers toimprove reporting. Update these definitions periodically as more precise, sensitive, and validterms and definitions are available. STANDARDIZE CLASSIFICATION: Improve the coding and classification of TBI by workingacross agencies. All four participating agencies should continue to meet with professional,academic, health care, and coding organizations to discuss improvements in ICD-10-CM and TBIseverity measures that can allow comparison of cases and outcomes. ENHANCE DISSEMINATION: Promote dissemination of information to non-VA facilitiesregarding TBI services available through the VA health-care system since 2007 includingbaseline screening and follow-up assessment and evaluation. STRENGTHEN RESEARCH: Continue research into the consequences of deployment-relatedTBI, including prospective investigation of the impact of single or multiple insults to the brainxvi

and risk for cognitive decline or other health conditions later in life, which might occur amongSMs and veterans. Share findings with civilian health-care providers. FOLLOW EVIDENCE-BASED PREVENTION STRATEGIES: Continue reducing risk factors,improving quality of protective equipment, and ensuring adherence to evidence-based strategiesand guidelines.Evidence indicates that TBI in the U.S. population, including among those who served in the military, is apublic health problem, the magnitude and impact of which are underestimated by current civilian andmilitary surveillance systems. Much research is needed to determine the full magnitude of TBI, identifypreventable and modifiable risk factors, develop and test strategies to reduce TBIs in civilian and militarylife, and improve health and social outcomes and quality of life for those who sustain these injuries. Suchresearch will inform the development of more effective primary prevention strategies and policies,diagnostic tools, and therapeutic interventions and will allow for improved rehabilitation and recovery ofTBI survivors.More details on each of the recommendations, including the rationale and potential benefits, can be foundin this document. Imperative in planning for the future is recognizing that the public health and medicalcommunities’ understanding of TBI is evolving, with many gaps in knowledge for both military andcivilian populations. This report offers recommendations for future TBI-related epidemiologic andclinical research; however, refinement and periodic review of the recommendations and their impact willbe necessary.xvii

I. IntroductionIn response to public health concerns, Congress passed the TBI Act of 2008 (P.L. 110-206; U.S.Government Printing Office 2008), requiring the Secretary of the U.S. Department of Health and HumanServices (DHHS), acting through the Directors of CDC and NIH, in consultation with the Secretary ofDefense and the Secretary of Veterans Affairs, to submit a report on TBI to the relevant committees ofCongress. It will contain the findings derived from an evaluation of activities and procedures that can beimplemented by CDC to improve the collection and dissemination of compatible epidemiologic studieso

Dr. Aaron I. Schneiderman, Ph.D., M.P.H., R.N. Acting Director Department of Veterans Affairs (10P3A) Epidemiology Program 810 Vermont Avenue, NW Washington DC 20420 Jay M. Uomoto, Ph.D. Formerly with Department of Veterans Affairs Former Deputy Director Department of Veterans AffairsFile Size: 1MB

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