The Journal of School Nursing2024, Vol. 40(6) 688–695© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221138731journals.sagepub.com/home/jsn
Abstract
The circumstances and nature of concussions among youth who play tackle, flag, or touch football are not well understood. This study used data from Utah’s Student Injury Reporting System (SIRS) to explore suspected concussions among K-12 students sustained during participation in football-related activities (tackle, flag, or touch football). Descriptive statistics and chisquare analyses showed that 54.7% of suspected concussions due to football-related activity were among elementary and middle school and 41.3% were among high school students. Most suspected concussions resulted from being struck by or against something (81.9%) and occurred during school-sanctioned games and practices (37.9%), lunch, lunch recess, and recess (34.8%), or physical education class (22.7%). The type of school activity and context for suspected concussions varied by school level. School nurses and others in Utah may use study findings to customize concussion prevention efforts by school level and activity.
Keywordsinjuries, safety/injury prevention, concussion, football, K-12
School-based sports- and recreation-related (SRR) activities are not only beneficial to a student’s physical and mental health, but may also contribute to improved academic performance (Centers for Disease Control and Prevention, 2010; Marquez et al., 2020). However, prior studies note that injuries, including concussions and other traumatic brain injuries (TBI), commonly occur during both formal (physical education [PE], school sanctioned sports games and practices) and informal (recess, outdoor play) activities (Haarbauer-Krupa et al., 2018; Josse et al., 2009; Sarmiento et al., 2020; Yaramothu et al., 2019). Data from the Youth Risk Behavior Survey indicates that 18.2% of middle school students and 14.3% of high school students self-reported one or more sports- and physical activity-related concussions during the previous 12 months of the survey (Sarmiento et al., Under Review). Concussion rates among middle and high school athletes are highest in contact sports, in particular tackle football (Kerr et al., 2017, 2019; Pfister et al., 2016).
Several studies have examined the prevalence of concussions and other injuries among high school and college football student-athletes participating on school-based sports teams (Chandran et al., 2021; Kerr et al., 2018, 2019; Zuckerman et al., 2015). Much of that data is garnered from high school and college sports injury surveillance systems. For example, tackle football accounted for approximately 40% of the 1.2 million sports-related injuries sustained by high school student-athletes (Collins et al., 2021). However, these systems do not capture data on concussion and other injuries for football sustained during other school recreational activities, such as PE classes or intramural sports, or in youth under high school age.
Youth flag football is often promoted as a safer alternative to tackle football. Tackling and purposeful colliding with other athletes is not allowed in flag football as a means to advance and stop play. Instead, flag football athletes grab detachable flags hanging from opponents’ waists. Unlike tackle football, participation in flag football has grown in recent years (The Aspen Institute, 2019). The few published studies that compare flag football to tackle football provide limited insights into concussion and head impact risk. Two studies on head impact exposure in youth football showed that tackle football athletes experience substantially more head impacts than flag football athletes per game and practice (Lynall et al., 2019; Waltzman et al., 2021). However, Peterson and colleagues reported no differences in the rate of concussions between flag and tackle football athletes during practices and games (Peterson et al., 2017). Information about concussion and injury risk for touch football in youth is scarce. To our knowledge, the only published study (Zendler et al., 2021) that included data on touch football combined flag football with touch football to create a non-tackle football category and found that head injury rates were lower for non-tackle football (78.0 per 100,000 participant-years) compared with other sports (basketball (323.5), soccer (318.2), or tackle football (1478.6)).
No large-scale or national surveillance system currently exists for schools to capture concussion or other injuries among students under high school age. As such, unlike high school and college football, the circumstances and nature of concussions from playing tackle, flag, touch, and other football-related activities at the elementary and middle school levels are not well understood. This may inhibit how schools determine the need for injury mitigation (i.e., preventing injuries and increasing safety promotion) and for policy-related decisions. Thus, this study used Utah’s unique school-based injury surveillance system to gain insight into the circumstances of football-related concussions in schools and provide new information about the context of suspected concussions from tackle, flag, touch football and other football-related activities at elementary, middle, and high schools across the state. Differences in outcomes following a football-related concussion (e.g., absence from school, seen by a medical professional) were also examined.
Data from the school years 2011–2012 through 2019–2020 were collected using Utah’s Student Injury Reporting System (SIRS). SIRS is an online system that tracks injuries (e.g., suspected concussion, fracture/broken, abrasion/scrape) that occur in public schools among K-12 students in Utah (for a detailed description, please see (Waltzman et al., 2022)). Injuries are recorded on a standardized injury reporting form if the injury is severe enough to (a) cause the loss of one-half day or more of school, (b) warrant medical attention and treatment, and/or (c) require reporting according to school district policy. School nurses or others who enter data into SIRS are prompted to indicate the activity and circumstances surrounding the injury. While separate categories for tackle football, as well as flag/touch football (Supplemental Materials) are included in SIRS, the extent to which students followed football-related rules of play for tackle, flag, and touch football, outside of schoolsanctioned games and practices, is unclear. As such, for this analysis, the tackle and flag/touch football categories were collapsed into football-related activities, and these activities may be inclusive of unorganized play using a football. IRB approval was obtained from the Utah Department of Health.
Descriptive statistics were calculated for students with a suspected concussion for football-related activities by sex, school level, mechanism of injury (MOI), school period, days absent, and action taken (please see below for further definitions of the variables). Levels of certain variables were further reduced prior to the analysis due to low numbers or categories that shared common elements. MOI was condensed into a three-level variable (struck by or against, fall, and other/unknown), school period was condensed into an overall three-level variable (before or after school, during school hours, other), days absent was condensed as a three-level variable (1 day or less, 2 days, and 3 + days) and action taken was dichotomized as eight separate binary variables: yes and no for remained/returned to class, sent/taken home, seen by a medical professional, restricted school activity, called 911, admitted to hospital, and transported by ambulance; and no action taken (“Yes”) and action taken (“No”) for none of the above.
A chi-square (χ2 ) analysis that examined the association between characteristics of K-12 students and school level was also run. When there was statistical significance (p <.05), a post-hoc proportions test with a Bonferroni correction was used. To analyze the data, the statistical package SAS version 9.4 (Cary, North Carolina) and IBM SPSS Statistics Subscription were employed.
During the 9-year timeframe of the study, there were 739 suspected concussions among K-12 students during footballrelated activities in Utah. Nearly all students with a suspected concussion that occurred during football-related activities were male (90.9%) and the largest percentage occurred among students in high school (41.3% vs 24.1% in elementary school and 30.6% in middle/junior high school) (Table 1). Most students (81.9%) with a suspected concussion during football-related activities were identified as being struck by or against something. Fewer suspected concussions were due to a fall (17.3%) or another mechanism of injury (0.8%). A suspected concussion that occurred during participation in football-related activities occurred most frequently during school (59.5%) with lunch, lunch recess, and recess (34.8%) and PE class (22.7%) associated with most of these injuries. Following a suspected concussion, 11.6% of students were absent for 2 days and 12.7% were absent 3 or more days. Further, most of these students saw a medical professional (71.0%) with 92.7% (data not shown) of suspected concussions being diagnosed as a concussion by a medical professional. Smaller percentages of students with a suspected concussion resulting from participation in football-related activities had restricted school activities (21.1%), called 911 (4.1%), or were admitted to the hospital (1.4%), or transported by ambulance (3.4%). Conversely, no action (i.e., remained/returned to class, sent or taken home, seen by a medical professional, restricted school activity, called 911, admitted to the hospital, or transported by ambulance) was taken for 9.2% of these students with a suspected concussion. Table 1 provides a more detailed breakdown.
The chi-square analysis exploring school level (elementary school, middle/junior high, high school) by characteristics (Table 2) showed a significantly higher percentage of suspected concussions of struck by or against something for MOI while participating in football-related activities in high school (94.1%) compared to elementary school (68.5%) and middle/junior high school (78.3%). Conversely, more suspected concussions occurred due to a fall while participating in football-related activities in elementary school (31.5%) and middle/junior high school (21.2%) compared to high school (4.3%). Among suspected concussion experienced during specific school hours (i.e., lunch, lunch recess, recess, and PE class), a higher percentage of concussions for football-related activities occurred during lunch, lunch recess, and recess as school level decreased (93.6%, 41.7%, 18.0%, respectively); however, more occurred during PE class (6.4%, 58.3, 82.0%, respectively) as school level increased. Among school-sanctioned games and practices, there was a similar percentage of suspected concussion among middle/junior high school and high school students in games (57.6% vs. 61.8%, respectively) and practices (42.4% vs. 38.2% respectively). A greater percentage of high school students saw a medical professional following a suspected concussion (82.3%) as compared to elementary (66.3%) and middle/junior high school students (62.8%). Further details are provided in Table 2.
This study used data from the Utah SIRS to examine the circumstances and context of suspected concussions due to football-related activities at elementary, middle, and high schools to help inform possible injury mitigation efforts in the state. This analysis revealed that approximately 5 in 10 suspected concussions resulting from football-related activities were among elementary and middle school students. A substantial percentage of suspected concussions occurred during lunch, lunch recess, and recess (34.8%) and PE class (22.7%), although this varied by school level. Specifically, among suspected concussions that occurred during school hours, the percentage occurring during lunch, lunch recess, and recess decreased with school level; conversely, the percentage of suspected concussions during PE increased with school level.
Tackle football has been consistently documented to have one of the highest concussion rates among high schools sports (Collins et al., 2021; Kerr et al., 2019); however, concussions sustained by elementary school students and those sustained outside of school-sanctioned games and practices (at all school levels) have not previously been reported. Taken together, the novel findings from this study indicates that efforts to expand concussion prevention for footballrelated activities among K-12 schools in Utah might include a particular focus on younger children and in-school activities. Although these findings are not generalizable, other states may consider adopting SIRS, or a comparable surveillance system, to inform concussion prevention strategies among school children.
School nurses and or staff other school professionals (e.g., playground supervisors, educators, coaches, athletic trainers, etc.) in Utah may consider customizing prevention efforts by school level and activity versus implementing a one-sizefits-all approach. For example, our data demonstrates that falls during football-related activities accounted for one-third of suspected concussions for elementary school students. To support student safety at the elementary school level, schools in Utah may consider additional supervision during lunch, lunch recess, and recess to reduce injuries from falls and contact with the surface when possible. To promote concussion safety among middle and high school students, prevention efforts may include prohibiting tackling and tackle football and limiting aggressive play and roughhousing during PE class. Additional suggestions may include creating a social norm or a school culture that emphasizes safety and health as a priority around recess and PE. These strategies can be adapted based on the needs, resources, and funds of each school.
School-sanctioned tackle football games and practices are available to many high school students in Utah and to a lesser extent middle school students. This study, consistent with prior research (Kerr et al., 2017, 2019) showed that most or almost all suspected concussions among middle school (78.3%) and high school (94.1%) students reported in Utah SIRS resulted from being struck by or against something (e.g., tackling), respectively. To reduce concussion and head impact risk in organized middle school and high school tackle football practices and games, the state of Utah and Utah schools could consider the findings from studies on the effectiveness of contact restrictions (Broglio et al., 2016; Pfaller et al., 2019). For example, Broglio and colleagues found that limiting contact practices in high schools to 2 days per week reduced practice head impacts per player-season by 42% (Broglio et al., 2016). To the extent that they do not already do so, middle and high schools in Utah may consider exploring opportunities to implement and/or better enforce contact restrictions during school-sanctioned games and practices to promote football safety for students. Implementing contact restrictions among elementary school students is not relevant in Utah as elementary schools do not have school sanctioned games and practices. Additionally, creating a school environment with a positive and supportive culture may also help to prevent as well as identify and manage concussions. Some examples of fostering a safe concussion culture include limiting aggressive play, concussion communication between coaches, athletic trainers, parents, and children, positive messages about symptom reporting, and supporting sitting out of play if a suspect concussion has occurred (Centers for Disease Control and Prevention).
The Centers for Disease Control and Prevention’s (CDC) Pediatric Mild TBI Guideline states that children with a suspected concussion should be evaluated by a medical professional and that absence from school, for most children, should be limited to no more than 2 to 3 days (Lumba-Brown et al., 2018). In this study, three-quarters (75.7%) of students were absent between 1 day or less from school following a suspected concussion while participating in football-related activities and 71.0% were seen by a medical professional. These findings mirror those of a prior study that used Utah SIRS data and showed that 71.4% of students with a suspected concussion (from any activity) were absent 1 day or less from school and 68% were seen by a medical professional (Waltzman et al., 2022). While assessing recovery and symptom presentation among students with a suspected concussion was not possible in this study, limited school absences and high percentages of students seen by medical professionals may suggest that, in general, Utah schools promote positive care-seeking behaviors and can successfully integrate students back into the classroom following a concussion.
There were several limitations to this study. First, participating in SIRS is voluntary. The schools that submit data may be different from the ones that do not submit data, which might lead to results that are biased. However, SIRS has a high estimated yearly school participation rate (90%–95%) and only a few schools do not submit data. Second, suspected concussions during tackle and flag football were not able to be separated and compared for this analysis. While school nurses and others were able to indicate tackle or flag/touch football as separate activities during which the injury occurred in SIRS, those entering information into SIRS do not always know the specific football activity during which the injury occurred. As such, tackle and flag/touch football categories were collapsed into football-related activities and may be inclusive of unorganized play using a football. Third, the number of injuries reported during lunch and lunch recess was higher than expected. While this may be attributed to participation in physical activities during lunch time, more examination of activities during lunch may be needed. Fourth, SIRS is currently only available for schools in Utah and the data in SIRS may not be generalizable to states other than Utah. Fifth, data are only collected among public schools; injury experienced in other types of schools (e.g., private schools) may differ. Lastly, the number of suspected concussions within each school not captured by SIRS is unknown. Data captured in this study likely underestimate the true injury burden among K-12 students in Utah and the true number of concussions is unknown.
A school nurse is often the staff member who is trained to identify, track, and monitor every child who reports a concussion in the school setting. Additionally, school nurses may play a role in implementing a personalized return to school and play/activity plan that is shared among the school staff who are in contact with the injured student in order to help reduce any decline in school performance or altered behavior after a concussion (McGrath, 2010). However, as the ratio of school nurses to students was 1:2,789 in Utah in 2021, many may have to balance their time at multiple schools (Hinkson, 2021). As such, school nurses may not be present when a concussion is suspected. This is especially true when a suspected concussion occurs during a school sanctioned event before or after school hours. Increasing the number of non-clinical school professionals (e.g., teachers, coaches when appropriate) at each school may be beneficial. Non-clinical school professionals who observe possible concussion signs or symptoms can make the school nurse and students’ parents and guardians aware of the possible concussion- providing back up for school nurses. Through its HEADS UP campaign, the Centers for Disease Control and Prevention created an online training for school and healthcare professionals focused on improving concussion identification and management (Centers for Disease Control and Prevention, 2016). School nurses may complete HEADS UP trainings and working with school administrators to identify school staff who can serve as points-of-contact for concussion identification and response when they are not present.
This study used a unique injury surveillance system in Utah to assess the circumstances and context of suspected concussions due to football-related activities at elementary, middle/junior high, and high schools across the state. More than half the students in the study sustained a suspected concussion during school hours, but circumstances (school period), MOI, and care-seeking behavior (receiving medical attention) varied by school level. Schools are challenged with providing safe environments for students who participate in SRR activities while also minimizing the risk for injury. Data from surveillance systems, such as Utah’s SIRS, allow school nurses and other school professionals to customize prevention efforts by school level and activity versus implementing a one-size-fits-all approach to reduce the risk for concussion in football-related activities.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Dana Waltzman https://orcid.org/0000-0002-1708-0524
Broglio, S. P., Williams, R. M., O’Connor, K. L., & Goldstick, J. (2016). Football players’ head-impact exposure after limiting of full-contact practices. Journal of Athletic Training, 51(7), 511–518. https://doi.org/10.4085/1062-6050-51.7.04
Centers for Disease Control and Prevention. (2010). The association between school-based physical activity, including physical education, and academic performance. Atlanta, GA: U.S. Department of Health and Human Services.
Centers for Disease Control and Prevention. (2016). About Heads Up. https://www.cdc.gov/headsup/about/index.html
Centers for Disease Control and Prevention. HEADS UP concussion: Concussion at play. Opportunities to reshape the culture around concussion. Centers for Disease Control and Prevention. Retrieved October 21, 2022 from https://www.cdc.gov/headsup/pdfs/resources/concussion_at_play_playbook-a.pdf
Chandran, A., Morris, S. N., Powell, J. R., Boltz, A. J., Robison, H. J., & Collins, C. L. (2021). Epidemiology of injuries in national collegiate athletic association men’s football: 2014–2015 through 2018– 2019. Journal of Athletic Training, 56(7), 643–650. https://doi.org/10.4085/1062-6050-447-20
Collins, C., Robison, H., & Burus, T. (2021). National high school sports-related injury surveillance study, 2020–2021 school year.
Haarbauer-Krupa, J., Arbogast, K. B., Metzger, K. B., Greenspan, A. I., Kessler, R., Curry, A. E., Bell, J. M., DePadilla, L., Pfeiffer, M. R., Zonfrillo, M. R., & Master, C. L. (2018). Variations in mechanisms of injury for children with concussion. The Journal of Pediatrics, 197, 241–248.e1. https://doi.org/10.1016/j.jpeds.2018.01.075
Hinkson, E. (2021). Nursing services in utah public schools, 2020– 2021. https://utahchildren.org/images/Reports/School_Health_Survey_November_2021.pdf
Josse, J. M., MacKay, M., Osmond, M. H., & MacPherson, A. K. (2009). School injury among Ottawa-area children: A population-based study. Journal of School Health, 79(2), 45–50. https://doi.org/10.1111/j.1746-1561.2008.00375.x
Kerr, Z. Y., Chandran, A., Nedimyer, A. K., Arakkal, A., Pierpoint, L. A., & Zuckerman, S. L. (2019). Concussion incidence and trends in 20 high school sports. Pediatrics, 144(5), e20192180. https://doi.org/10.1542/peds.2019-2180
Kerr, Z. Y., Cortes, N., Caswell, A. M., Ambegaonkar, J. P., Hallsmith, K. R., Milbert, A. F., & Caswell, S. V. (2017). Concussion rates in U.S. Middle school athletes, 2015–2016 school year. American Journal of Preventive Medicine, 53(6), 914–918. https://doi.org/10.1016/j.amepre.2017.05.017
Kerr, Z. Y., Wilkerson, G. B., Caswell, S. V., Currie, D. W., Pierpoint, L. A., Wasserman, E. B., Knowles, S. B., Dompier, T. P., Comstock, R. D., & Marshall, S. W. (2018). The First decade of web-based sports injury surveillance: Descriptive epidemiology of injuries in United States high school football (2005–2006 through 2013–2014) and national collegiate athletic association football (2004–2005 through 2013–2014). Journal of Athletic Training, 54(2), 212–225. https://doi.org/10.4085/1062-6050-144-17
Lumba-Brown, A., Yeates, K. O., Sarmiento, K., Breiding, M. J., Haegerich, T. M., Gioia, G. A., Turner, M., Benzel, E. C., Suskauer, S. J., & Giza, C. C. (2018). Centers for disease control and prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatrics, 172(11), e182853–e182853. https://jamanetwork.com/journals/jamapediatrics/articlepdf/2698456/jamapediatrics_lumbabrown_2018_sc_180001.pdf https://doi.org/10.1001/jamapediatrics.2018.2853
Lynall, R. C., Lempke, L. B., Johnson, R. S., Anderson, M. N., & Schmidt, J. D. (2019). A comparison of youth flag and tackle football head impact biomechanics. Journal of Neurotrauma, 36(11), 1752–1757. https://doi.org/10.1089/neu.2018.6236
Marquez, D. X., Aguiñaga, S., Vásquez, P. M., Conroy, D. E., Erickson, K. I., Hillman, C., Stillman, C. M., Ballard, R. M., Sheppard, B. B., Petruzzello, S. J., King, A. C., & Powell, K. E. (2020). A systematic review of physical activity and quality of life and well-being. Translational Behavioral Medicine, 10(5), 1098–1109. https://doi.org/10.1093/tbm/ibz198
McGrath, N. (2010). Supporting the student-athlete’s return to the classroom after a sport-related concussion. Journal of Athletic Training, 45(5), 492–498. https://doi.org/10.4085/1062-6050-45.5.492
Peterson, A. R., Kruse, A. J., Meester, S. M., Olson, T. S., Riedle, B. N., Slayman, T. G., Domeyer, T. J., Cavanaugh, J. E., & Smoot, M. K. (2017). Youth football injuries: A prospective cohort. Orthopaedic Journal of Sports Medicine, 5(2), 2325967116686784. https://doi.org/10.1177/2325967116686784
Pfaller, A. Y., Brooks, M. A., Hetzel, S., & McGuine, T. A. (2019). Effect of a new rule limiting full contact practice on the incidence of sport-related concussion in high school football players. The American Journal of Sports Medicine, 47(10), 2294–2299. https://doi.org/10.1177/0363546519860120
Pfister, T., Pfister, K., Hagel, B., Ghali, W. A., & Ronksley, P. E. (2016). The incidence of concussion in youth sports: A systematic review and meta-analysis. British Journal of Sports Medicine, 50(5), 292–297. https://doi.org/10.1136/bjsports-2015-094978
Sarmiento, K., Daugherty, J., DePadilla, L., & Breiding, M. J. (2020). Examination of sports and recreation-related concussion among youth ages 12–17: Results from the 2018 YouthStyles survey. Brain Injury, 34(3), 357–362. https://doi.org/10.1080/02699052.2020.1723165
Sarmiento, K., Miller, G. F., & Jones, S. E. (2022). Sports-related concussions and adverse health behaviors among middle and high school students. American Journal of Sports Medicine.
The Aspen Institute. (2019). State of play: Trends and developments in youth sports. https://assets.aspeninstitute.org/content/uploads/2019/10/2019_SOP_National_Final.pdf
Waltzman, D., Daugherty, J., Sarmiento, K., Haarbauer-Krupa, J., Campbell, H., & Ferrell, D. (2022). Prevalence of suspected concussions among K-12 students in utah: Findings from Utah’s student injury reporting system. Journal of School Health, 92(3), 241–251. https://doi.org/10.1111/josh.13126
Waltzman, D., Sarmiento, K., Devine, O., Zhang, X., DePadilla, L., Kresnow, M.-j., & Borradaile, K. (2021). Head impact exposures among youth tackle and flag American football athletes. Sports Health. https://doi.org/10.1177/1941738121992324
Yaramothu, C., Goodman, A. M., & Alvarez, T. L. (2019). Epidemiology and incidence of pediatric concussions in general aspects of life. Brain Sciences, 9(10), 257. https://doi.org/10.3390/brainsci9100257
Zendler, J. M., Jadischke, R., Frantz, J.,Hall, S.,& Goulet, G. C. (2021). Emergency department visits from 2014 to 2018 for head injuries in youth non-tackle football compared with other sports. Orthopaedic Journal of Sports Medicine, 9(1), 2325967120975402. https://doi.org/10.1177/2325967120975402
Zuckerman, S. L., Kerr, Z. Y., Yengo-Kahn, A., Wasserman, E., Covassin, T., & Solomon, G. S. (2015). Epidemiology of sportsrelated concussion in NCAA athletes from 2009–2010 to 2013– 2014: Incidence, recurrence, and mechanisms. The American Journal of Sports Medicine, 43(11), 2654–2662. https://doi.org/10.1177/0363546515599634
Dana Waltzman, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention.
Kelly Sarmiento, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention.
Deanna Ferrell, Utah Department of Health (UDOH), Violence and Injury Prevention Program (VIPP). Vanonda Kern, Utah Department of Health (UDOH), Violence and Injury Prevention Program (VIPP).
Chloe Roghaar, MPH, Utah Department of Health (UDOH), Violence and Injury Prevention Program (VIPP).
1 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, Atlanta, GA, USA
2 Utah Department of Health (UDOH), Violence and Injury Prevention Program (VIPP), Salt Lake City, Utah, USA
Corresponding Author:Dana Waltzman, Division of Injury Prevention, National Center for Injury Prevention & Control, Centers for Disease Control & Prevention, 4770 Buford Highway, Mail Stop: F62, Atlanta, GA 30341, USA.Email: dwaltzman@cdc.gov
