IN 1996, CONGRESS PASSED PUBLIC LAW 104-166 mandating the Centers for Diseases Control and Prevention (CDC) to engage in work focused on reducing the incidence of traumatic brain injury (TBI) in the United States. The TBI Act, which has been amended and renewed 3 times since then, specifies certain activities around which the TBI work at the CDC should be focused. The CDC's National Center for Injury Prevention and Control has remained responsive to Congress by conducting surveillance to better understand the burden of TBI, conducting research to better explore the full range of TBI outcomes, identifying prevention strategies, implementing education initiatives, and providing technical assistance to states and other key partners. As the field evolved, new priorities emerged and the CDC revised its strategic plan for measuring and reducing the public health burden of TBI in the United States. The articles included in this special issue fit within this newly developed strategic plan.

The public health model emphasizes a framework by which a health condition of interest is defined and systematically studied to describe the overall public health burden, identify modifiable risk and protective factors, implement effective prevention strategies, and carry out widespread dissemination to increase adoption of evidence-based practices. The CDC's strategic plan for TBI aims to anchor work to the public health model with the intent of achieving maximum impact in reducing TBI-related morbidity and mortality. The CDC's strategic plan for TBI is organized into 4 pillars: (1) improving the understanding of the public health burden of TBI; (2) reducing the incidence of TBI through primary prevention; (3) improving the recognition and management of mild TBI; and (4) promoting healthy lifestyles and improving health outcomes for persons living with TBI.

Surveillance is the cornerstone of all epidemiologic work and primary prevention activities at the CDC. Improving TBI surveillance is essential to determining whether progress is being made to reduce the public health burden of TBI. Four articles in the special issue are focused on TBI surveillance. The first article by Taylor et al examines the ability of a new data source to improve monitoring and characterization of the burden of TBI in the United States. Data from the Healthcare Cost and Utilization Project (HCUP) were examined and compared with the data sources traditionally used by the CDC to produce estimates of TBI-related medical encounters. HCUP data sets were found to be a comparable data source for these statistics, with the added benefit of having a larger sample size that will enhance our ability to examine TBI in population subgroups.

The second article by Cuthbert et al examines unemployment after TBI among persons 16 to 60 years of age who have received inpatient rehabilitation. This article demonstrates that TBI can have substantial socioeconomic impacts, as 60.4% of persons in the cohort were unemployed 2 years postinjury. Furthermore, a substantial proportion (35%) of those who were employed were employed only in a part-time capacity. As noted by Cuthbert et al, additional analyses are needed to identify modifiable factors that can maximize the potential for employment after TBI.

Motor vehicle crashes were the third overall leading cause of TBI and the second leading cause of TBI-related deaths in the United States during 2006-2010.1 However, differences in state-based incidence estimates are unknown and likely vary. Elucidating the epidemiology of TBI on a state level is informative for prevention planning. Toward this end, Harmon et al examined statewide emergency department (ED) visits and hospitalizations due to injuries from traffic-related motorcycle crashes in North Carolina. Their work revealed that persons who sustained a TBI as the result of a motorcycle crash consumed more healthcare resources and were 3 times as likely to die in the ED compared with patients who suffered motorcycle injuries not involving a TBI.

The fourth and fifth articles by Coronado et al and Parker et al, respectively, focus on sports- and recreation-related TBI, topics that have generated considerable public interest and have influenced state-based public policy (eg, Return to Play legislation). Coronado et al examined sports- and recreation-related ED visits for TBI among persons of all ages. Their analyses found that TBIs accounted for approximately 7% of all sports- and recreation-related injuries treated in United States EDs-approximately 3.4 million TBIs over the 12-year study period-and they identify the leading activities responsible for sports- and recreation-related ED visits involving a TBI. At the same time, Coronado et al highlight some of the limitations of the data set in identifying the true incidence of sports- and recreation-related TBIs. These are some of the same limitations that prompted a report by the Institute of Medicine, Sports-Related Concussion in Youth, to task the CDC with developing a comprehensive surveillance system that captures TBI incidence data for those 5 to 21 years of age. The CDC has been working to address this challenge by identifying potential data sources that can overcome deficiencies in current surveillance systems, particularly the challenge of capturing sports-related TBIs that occur outside of organized sports as well as sports-related TBIs that are not captured by current healthcare data systems.

Finally, Parker et al describe a component of the CDC's Heads Up educational campaign that aims to improve the recognition and management of mild TBI through an online course. The course, "Concussion in Sports: What You Need to Know," was taken by more than 600 000 people from all 50 states and the District of Columbia in the first 3 years following its launch in 2010. Posttest scores indicated that the course was effective in increasing concussion-related knowledge across a wide range of individuals, including coaches of more than 20 sports.

This special issue highlights some of the key areas of focus in this rapidly evolving field of study that also fit within the CDC's strategic plan for TBI. First, the articles in this special issue emphasize the importance of understanding the public health burden of TBI through surveillance. Second, this special issue draws attention to the need for strategies to prevent TBI and mitigate the substantial physical, psychological, economic, and social impacts of TBI. Finally, there is currently great interest in the intersection of surveillance and prevention as it relates to sports-related TBI. Decision makers are looking to the growing body of science to inform and suggest solutions for a problem that is of significant concern to the public. At this time, continued scientific progress has great potential to be translated into real-world impacts.

-Jeneita M. Bell, MD, MPH

Christopher A. Taylor, PhD

Issue Co-editors

Matthew J. Breiding, PhD

Division of Unintentional Injury Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Atlanta, Georgia

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