As we learn more about the long-term effects of traumatic brain injuries (TBI), the public health focus is increasingly on prevention in youth sports. A recent study funded by the Robert Wood Johnson Foundation and published in the American Journal of Public Health found that while 44 states and Washington, D.C., have enacted youth sport TBI laws, they all deal with identifying and responding to the injuries—not preventing them.

NewPublicHealth recently spoke with Robert Faherty, VP and Commissioner of the Babe Ruth League Inc., about what the baseball league in particular—and youth sports in general—are doing to improve the prevention of and response to traumatic brain injuries. The league includes about 1 million players across its Cal Ripken and Babe Ruth divisions.

>>Read more in a related Q&A with the author of the youth sports TBI law study.

NewPublicHealth: How is the Babe Ruth League working to prevent primary traumatic brain injuries in youth baseball?

Robert Faherty: One of the things that we really pride ourselves on— and, first of all, our organizations are entirely made up of volunteers, from the league administration level right down to the coach—is providing that league with the best insurance program we possibly can. Through Babe Ruth League, you have the opportunity to buy accident, or liability insurance. That's because we wanted to make sure that there would be no reason that a player wouldn’t go get checked out or a league wouldn’t send a player to a doctor or to an emergency room. We weren’t worried about the parents having insurance, we weren’t worried about somebody’s liability being in question—you can go to the doctor and have it covered.

The second part of that would be our ongoing attempt to educate and prevent injuries right down to the simplest practices. In our coaching certification and coaching education courses, which are mandated, not only are there safety issues that we include that in our score books that we provide to the teams, but it’s also the smallest things about how to run a practice. One of the most common injuries is being hit by a baseball, but it’s not the batter being hit by a baseball or a fielder being hit by a baseball—it’s an overthrow by kids warming up improperly, and not throwing all in the same direction.

As school winds down and camps and sports prepare for the summer season, a new study funded by the Robert Wood Johnson Foundation and published in the American Journal of Public Health on sports-related traumatic brain injuries in youth sports, is generating deserved attention.

The study, by Hosea Harvey, JD, PhD, Assistant Professor of Law at the Temple University Beasley School of Law, found that while forty four states and Washington, D.C.,  passed youth sport TBI laws  between 2009 and 2012, none of the laws focus on preventing the injuries in the first place. The laws on the books deal primarily with increasing coaches’ and parents’ ability to identify and respond to traumatic brain injuries and reducing the immediate risk of multiple brain injuries.

>>Read more in a Q&A with the Babe Ruth League Inc. about how youth sports leagues are making strides to prevent injuries.

Harvey’s conclusion is that continued research and evaluation is needed to develop a more comprehensive reduction in youth sport traumatic brain injuries.

NewPublicHealth: What did your study address?

Hosea Harvey: I looked at traumatic brain injury (TBI) laws that were passed at the state level that purported to deal with the problem of youth TBIs in sports statewide. I looked at every related state law passed between 2009 through the end of 2012, though most states only had one law that they passed that dealt with youth sports TBIs during that period.

NPH: And your study found that no state that right now has a law that says this is what you have to do in order to prevent these concussions in the first place?

While a growing number of major league sports teams have policies on concussion assessment and return to play, many youth and school sports leagues and teams do not have similar rules, despite thousands of sports-related traumatic brain injuries (TBIs) reported in children and adolescents every year.

Hosea H. Harvey, PhD, JD, Assistant Professor of Law in Temple University’s Beasley School of Law, has just published an article in the American Journal of Public Health analyzing how this health issue is being addressed across the country. He found that there are laws dealing with concussions in youth sports in 44 states and D.C.—but none are focused on preventing the injuries. The laws only address detecting the injuries or preventing an additional injury after one has already occurred.

The study also revealed that many laws don’t draw on evidence around what works. For example, most state laws establish a minimum 24-hour period of youth athlete removal, but there is no scientific agreement about the optimal minimal time someone who has suffered a sports-related TBI should be removed from play. The study utilized an open source dataset from Robert Wood Johnson Foundation grantee Public Health Law Research called LawAtlas.

>>Read the full study.

NewPublicHealth previously spoke with Harvey and Kerri McGowan Lowrey, JD, MPH, Senior Staff Attorney with the Network for Public Health Law — Eastern Region, about legal and legislative approaches to addressing concussions in youth sports. The previous interview is included below:

Health Highlights of 2012
On this last day of the year, the news site HealthDay ticks off some significant health events of the last twelve months:

• The June Supreme Court ruling upholding most of the Affordable Care Act.
• The outbreak of deadly fungal meningitis linked to tainted steroid injections that began during the summer. As of December 17, the outbreak had infected 620 people and killed 39 people across 19 states. On Dec. 20, health officials from all fifty states met with U.S. Food and Drug Administration representatives to discuss proposed regulation to help prevent such events in the future.
• Autism incidence keeps rising. In March, the Centers for Disease Control and Prevention estimated the prevalence of the disorder at one in every 88 children, up from one in 110 in 2010. Cases were also five times more common in boys than girls, the agency found. While changes in how autism is spotted and reported may have played a role in the new numbers, other factors behind the increase are unclear.
• This year saw two major milestones in HIV testing and treatment. In July, the FDA approved OraQuick, the first at-home HIV test, which enables people to privately assess their infection status within 20 minutes. The same month the FDA approved Truvada, the first HIV drug aimed at preventing transmission of the virus to uninfected people who are at high risk.
• Two new diet drugs were approved by the U.S. Food and Drug Administration for the first time in thirteen years. Belviq was approved in July for obese adults with high blood pressure, Osymia, approved for the patient group, got the FDA’s nod a month later.

Read NewPublicHealth News Roundups.

IOM Committee to Explore Sports-related Concussions
Youth sports concussions will be a focus of an Institute of Medicine Committee next year. The committee will conduct a study on youth, from elementary school through young adulthood, including military personnel and their dependents. The committee will also review concussion risk factors; screening and diagnosis; treatment and management; and long-term consequences. Read more on injury prevention.

Scheduling Cardiac Rehab Soon After a Heart Attack Improves Compliance
A new study in Circulation found that scheduling cardiac rehabilitation to begin sooner rather than later following a heart attack increased the chance that patients show up for the first and subsequent sessions. Cardiac rehab, which includes supervised exercise and nutrition counseling, has been linked to a reduction in second heart attacks in patients who complete the multi-week programs. In the new study, patients whose first rehab session was scheduled within ten days of hospital discharge were more likely to come to the first session than were patients whose appointments were scheduled for within 35 days of discharge, which is a standard time frame in the United States. Read more on heart health.

New Report Finds Underage Drinking in all States
More than a quarter of Americans who are legally too young to drink are doing so anyway, according to a new report issued today by the Substance Abuse and Mental Health Services Administration (SAMHSA). The report says there has been progress in reducing the extent of underage drinking in recent years, especially among youth ages 17 and younger, but that the rates of underage drinking “are still unacceptably high.” Over 25 percent of people ages 12-20 report drinking in the month before they were surveyed, and 8.7 percent of them purchased their own alcohol the last time they drank. “Underage drinking should not be a normal part of growing up. It’s a serious and persistent public health problem that puts our young people and our communities in danger,” says SAMHSA Administrator Pamela S. Hyde. “Even though drinking is often glamorized, the truth is that underage drinking can lead to poor academic performance, sexual assault, injury, and even death.” All 50 states and the District of Columbia currently have laws prohibiting the purchase and use of alcoholic beverages by anyone under age 21. Find resources to prevent and treat underage drinking here. Read more on addiction.

Helmets Can Save Lives on the Slopes
Wearing a helmet while skiing or snowboarding can prevent injuries and reduce injury severity, according to a review article of 16 published studies in the Journal of Trauma and Acute Care Surgery. About 600,000 skiing and snowboarding injuries occur each year, according to reporting by Johns Hopkins researchers who wrote the new report. Up to 20 percent of those are head injuries, and 22 percent of those head injuries are severe enough to cause loss of consciousness, concussion or more serious injuries. Read more on injury prevention.

Study: Low-Level Air Pollution Impacts Fetal Growth
Exposure to low levels of air pollution seems to have a small effect on fetal growth, according to a study in the Puget Sound area by the University of Washington Schools of Public Health and Medicine and the Seattle Children’s Research Institute. The study looked at more than 367,000 births between 1997 and 2005 in the four-county Puget Sound region, including metropolitan areas Seattle and Tacoma, and estimated prenatal exposure to traffic-related air pollutants such as nitrogen oxide. The researchers found associations between increased levels of nitrogen dioxide exposures and an increased risk of small-for-gestational-age birth. Health problems for low birth weight babies can include decreased oxygen levels and low blood sugar, according to the researchers. Read more on maternal and infant health.

Public Health Law Research, a national program of the Robert Wood Johnson Foundation housed at the Temple University Beasley School of Law, recently released a new, comprehensive online portal called LawAtlas that allows users to explore variation in laws across U.S. states and over time. Having more information about state laws, and their effect on health over time, is a critical step toward understanding what works to improve health. LawAtlas offers:

• Interactive Law Maps to show how certain laws differ by state and how they have changed over time.
• Policy Surveillance Reports to summarize the state of various public health laws across the country
• Data that public health law researchers can work with to expand upon existing research

NewPublicHealth caught up with Damika Webb, JD, Law Fellow at the Center for Health Law Policy and Practice at Temple University, at last week’s APHA Annual Meeting to chat about LawAtlas and how it can be used to better understand why policy surveillance is critical, and what we can learn from a program like LawAtlas.

NewPublicHealth: Why is it important to conduct research to know whether particular laws and policies are working to improve public health?

Damika Webb: By measuring the dimensions of a law, you can figure out which components of the law are having a positive or negative effect on health outcomes.

NPH: Why is it important to track how public health laws and policies differ from state to state?

CDC: 14 Dead, 170 Sick in Meningitis Outbreak
Fourteen people have now died in a meningitis outbreak tied to apparently tainted steroid injections, according to the U.S. Centers for Disease Control and Prevention. There are 170 total cases so far. The methylprednisolone acetate was manufactured at the New England Compounding Center of Framingham, Mass. and given to as many as 13,000 people in 23 states. The outbreak has led many to question current compounding practices. "This incident raises serious concerns about the scope of the practice of pharmacy compounding in the United States and the current patchwork of federal and state laws," read a statement from Rep. Henry Waxman (D-Calif.), Rep. Diana DeGette (D-Colo.) and Rep. Frank Pallone Jr. (D-N.J.). Read more on infectious diseases.

Study: Concussion Diagnosis Inconsistent in College Athletics
Physicians who diagnose concussions in college athletes use inconsistent criteria that could hinder proper patient care, according to a new study in the Journal of Neurosurgery. Refined, universal standards would improve patient outcomes, according to researchers who analyzed 48 diagnosed concussions in 450 college athletes at Brown University, Dartmouth College and Virginia Tech. "The term 'concussion' means different things to different people, and it's not yet clear that the signs and symptoms we now use to make a diagnosis will ultimately prove to be the most important pieces of this complicated puzzle," said Ann-Christine Duhaime, MD, director of the pediatric brain trauma lab at Massachusetts General Hospital. "Some patients who receive a diagnosis of concussion go on to have very few problems, and some who are not diagnosed because they have no immediate symptoms may have sustained a lot of force to the head with potentially serious consequences," she explained. Read more on access to health care.

Researchers to Evaluate Umbilical Stem Cells’ Effect on Children with Autism
Scientists at the Sutter Neuroscience Institute, in Sacramento, Calif. will inject 30 children with autism with stem cells from their own umbilical cord blood to research whether the treatment can improve behavior and language skills. Michael Chez, MD, director of pediatric neurology at the institute, said researchers hope to find scientific support for anecdotal evidence. The 13-month study will involve children ages 2 to 7. One in 88 children are affected by autism, according to the U.S. Centers for Disease Control and Prevention. Read more on pediatrics.

Alan Schwarz spent the majority of his career as a baseball reporter before authoring dozens of stories for The New York Times unearthing the dangers of concussions in football at all levels—from the professional leagues down to kids’ leagues. He was working as a freelancer when first approached about the public health issue. The end result was a series that made him a Pulitzer Prize-finalist and helped change the face of football.

NewPublicHealth sat down with Schwarz before he delivered a keynote address at the 2012 Public Health Law Conference to discuss how his interest in sports-related concussions began and what he thinks about the impact he made on public health.

NewPublicHealth: How did you come to report on this issue?

Alan Schwarz:  Most regularly I was, along with David Leonhardt, the Keeping Score columnist for the Times sports section on Sundays, where every week we looked at some phenomenon through a statistical lens. But my beat was exclusively baseball. However, I came to know a fellow named Chris Nowinski, former Harvard football player turned professional wrestler, who had written a book about concussions and how serious they were. This was the summer of 2005.

Chris called me up. I got lots of calls from lots of young writers at that time and tried to be nice to them and Chris sent me the manuscript and it was incredible. It was really, really well done, and I thought “this is a very important book.” So I introduced him to a few people I knew here in New York in publishing, because I thought this was really good stuff. Well, no one really gave him the time of day, frankly. No one thought it was commercial enough to succeed as a book. And that was that. I didn't hear from him again, nor did I expect to.

NPH: Then what happened?

chool sports teams often start practicing in the late weeks of summer, so an upcoming webinar on August 7 (2:00 to 3:00 pm ET) from the Centers for Disease Control and Prevention on assessing and treating possible concussions in kids from kindergarten through high school, is timely and important.

Presenters include Julie Haarbauer-Krupa, PhD, B.R.A.I.N. Program Coordinator at Children’s Health Care of Atlanta and Karen McAvoy, PsyD, at Rocky Mountain Hospital for Children.

Webinar topics include the signs and symptoms of concussions and supporting kids returning to school after a concussion.

>>Register for the webinar.

Until very recently, concussions were often dismissed as relatively insignificant hazard of even pee wee sports. Emerging research shows that the injuries can cause life-long brain damage and that steps before and during play can prevent the injuries, or minimize harm after a concussion. Read news reports and interviews about concussions on NewPublicHealth.

CDC has also just released a concussion awareness public service announcement (PSA) featuring former NFL quarterback Kurt Warner. Find other CDC concussion awareness resources here.

>>Bonus Webinar Link: The Network for Public Health Law is co-sponsoring holding a webinar on Model Aquatic Code (Thursday August 16 from 1–2 p.m. ET). Register here by 1 p.m. ET on August 14. The model code is designed to prevent drowning, injuries and the spread of recreational water illnesses at public swimming pools and spas. Presenters will discuss the goals, outcomes and benefits of the code and the role of public health officials in implementing these water safety provisions.

United Health to Keep New Health Provisions Regardless of Supreme Court Ruling on Affordable Care Act

Reuters is reporting that UnitedHealth Group, a major U.S. health insurer, has announced it would retain new health coverage rules—such as dropping co-pays for some preventive care—regardless of how the Supreme Court rules on the legislation. The Court is expected to rule this month. Read more on access to health care.

USDA Promotes Free Summer Food Service this Week

The U.S. Department of Agriculture (USDA) is holding its second annual Summer Food Service Program Week June 11 through June 15 to promote awareness of summer food programs for millions of children who typically eat free or low cost breakfast and lunch at school during the school year.

In partnership with the advocacy group WhyHunger, USDA has developed downloadable Public Service Announcements to inform parents and guardians about summer meals sites for school-age children. To find a site in your community, call 1-866-3-HUNGRY (1-866-348-6479or 1-877-8-HAMBRE (1-877-842-6273.) Read more on community health.

Extreme Rest Very Soon After Concussion May Prevent Long Term Symptoms in Some Patients

A new study in the Journal of Pediatrics finds that taking a week off from nearly all mental and physical activity within a week after a concussion may lead to fewer symptoms, such as headaches, and better mental performance, months after the injury.

The researchers found that study participants who rested physically and mentally soon after their injuries had much improved symptoms compared with concussion patients who waited weeks to months before they started resting their bodies and brains, such as no socializing, no computer, no TV and no phone use. Read more on injury prevention.

Rise in Military Suicides Reported

The Associated Press (AP) is reporting that there have been 154 military suicides in the first 155 days of 2012, a higher number than military members killed in action in Afghanistan, based on Pentagon statistics the AP obtained. Among possible explanations: combat exposure, post-traumatic stress, misuse of prescription medications and personal financial problems. The AP reports that multiple deployments is a risk factor for suicide, but that a large number of suicides have been among soldiers who were never deployed. The number of suicides at this time last year was 130. The AP also reports that the Pentagon recently established a Defense Suicide Prevention Office. Read more on military health.