NAS NEONATAL ABSTINENCE SYNDROME Annual Surveillance Report 2016 Georgia Department of Public Health Division of Health Promotion PREPARED BY: Grace Kang, RN / Maternal Child Health CONTENTS Introduction / Overview 2 .............................................................................................................................. Statewide Data Summary 8 ....................................................................................................................... Substance Data 13 ...................................................................................................................................................... NAS Regional Data 18 ........................................................................................................................................... Conclusion/Next Step 20 ............................................................................................................................. Acknowledgements 20 ...................................................................................................................................... Citations/References 2 1 ................................................................................................................................. Note: This report contains data obtained through a hospital surveillance system. Other available sources of data not included in this report include hospital discharge data, birth record data, and payment data. All findings should be interpreted with caution. The case counts in this sample are small and may be statistically unreliable. 2 / NAS REPORT / 2016 ANNUAL Georgia Department of Public Health / 3 INTRODUCTION Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome that results from the abrupt discontinuation of chronic fetal exposure to substances that were used or abused by the mother during pregnancy. It has primarily been studied in opioid-exposed infants; however, a similar syndrome has been described in infants exposed to other kinds of substances, both prescription and illicit. In the last decade, rates of opioid use have increased rapidly in the United States, including among women of childbearing age. Correspondingly, rates of NAS have also increased (Kocherlakota 2014). SOURCE: CDC/NCHS, National Vital Statistics System, Mortality. CDC WONDER, Atlanta, GA: US Department of Health and Human Services,L CDC; 2016. https://wonder.cdc.gov/. Georgia Department of Public Health / 5 OVERVIEW Opioid use and misuse (abuse) have contributed to the rise of overdose deaths in Georgia. Historically, motor vehicle crashes (MVC) have been a leading cause of death, especially among Georgians aged 1-44. In 2014, drug overdose deaths (n=1223) eclipsed MVC fatalities (n=1104) as a leading cause of death in Georgia, following the national trend. DEATHS FROM DRUG OVERDOSES & MOTOR VEHICLE CRASHES, GEORGIA RESIDENTS, 1999-2015 Number of Deaths 1,800 1,600 1,400 1,200 1,000 800 600 400 200 0 Legend DRUG OVERDOSE MOTOR VECHICLE CRASH 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Drug Overdose uses underlying cause ICD-10 Codes X40-X44, X60-X64, Y10-Y14, X85, F11-F16, F18 and F19;L Motor Vehicle Crashes uses V02-V04, V09.0, V09.2, V12-V14, V19.0-V19.2, V19.4-V19.6, V20-V79, SOURCE: Georgia Department of Public Health. Office of Health Indicators for Planning (OHIP). OASIS https://oasis.state.ga.us The Office of Health Indicators for Planning (OHIP) at the Georgia Department of Public Health conducted retrospective analysis of hospital discharge data and noted increasing rates of NAS between 2010 and 2015. Codes used for surveillance were for ICD-9: 779.5 (drug withdrawal syndrome in a newborn) and 760.72 (noxious influences affecting fetus or newborn via placenta or breastmilk, narcotics), and for ICD-10: P96.1 (drug withdrawal, infant of dependent mother) and P04.4 (newborn affected by maternal use of drugs of addiction). 6 / NGAS MR EAPNOURATL // 2G0e1o6rgAiNa N2U0A17L OVERVIEW (con't) The numerator is total number of unique codes in a given year, and the denominator is total number of GA hospital births in a given year. Event Year Rate/1000 births 2010 2011 2012 2013 2014 2015 2.21 2.53 3.13 4.08 4.77 6.10 In an effort to more closely monitor NAS within the state, Georgia Department of Public Health made NAS a reportable condition as of January 1, 2016. Reports are currently received electronically through the webbased State Electronic Notifiable Disease Surveillance System (SENDSS https://sendss.state.ga.us/). The data submitted provides opportunities to: 1) Assess the current incidence of NAS in Georgia and trends over time 2) Identify opportunities for timely intervention and education 3) Better characterize risk factors for NAS in Georgia 4) Assess capacity to address maternal addiction and provide multidisciplinary care/support for the family/child affected by substance abuse. Criteria for a confirmed case of NAS are one or more of the following: 1) Presence of one or more clinical symptoms of NAS and/or 2) A positive infant substance test result. Providers are required to report within 7 days of diagnosis. The data in this report reflects NAS reports received by SendSS during CY2016. Georgia Department of Public Health / 7 STATEWIDE DATA SUMMARY TOTAL NUMBER OF CASES REPORTED FOR CY 2016, aggregate During CY2016, there were a total of 522 cases reported within the state of Georgia, received from 47 of the 74 (64%) birthing facilities. Of those reports, 410 met case criteria for a confirmed case. Typically cases that are not confirmed do not meet case criteria, but are still reported to SendSS due to evidence or history of maternal substance use. Two reported cases were out-of-state residents who gave birth within a Georgia hospital, and were excluded from analysis. Of all the neighboring states, only Tennessee and Florida have formalized reporting/surveillance systems to monitor NAS. Because of obstetrician provider shortages in the rural areas of Georgia, including areas that border other states, some Georgia women give birth outside the state. It is unknown at this time how many Georgia NAS cases go unreported in neighboring states. STATEWIDE DATA SUMMARY 8 / NAS REPORT / 2016 ANNUAL NUMBER OF REPORTED V.S. CONFIRMED CASES PREVIOUS 12 MONTHS, quarterly Since the beginning of CY2016, the overall number of cases reported (n=522) and confirmed (n=410) per quarter increased. This increase is likely due in part to improved provider awareness of the mandatory reporting requirements. By the end of 2016, only 64% of Georgia hospitals have participated in reporting NAS via SendSS; the number of reported cases will likely increase as providers become more aware of NAS reporting requirements. The Georgia Department of Public Health is working with partners throughout the state to conduct ongoing provider outreach and education efforts. For example, clinical educators at the Regional Perinatal Centers have developed a comprehensive curriculum to educate frontline healthcare personnel on NAS and maternal substance use. Georgia Department of Public Health / 9 STATEWIDE DATA SUMMARY (con't) METHOD OF CASE CONFIRMATION Forty-two percent of cases were identified by the presence of both clinical symptoms and a positive substance test. The remainder were confirmed by presence of clinical symptoms only (24.9%) or by positive substance test only (32.9%). Specimens that may be used for substance testing include urine, meconium, cord blood and hair. While data on specimen type is not currently collected, urine and meconium specimens are likely the most common specimens tested due to ease of collection and relatively low cost. Data on specimen type will be collected in CY2017. CONFIRMED CASES BY CONFIRMATION METHOD, GEORGIA, 2016 24.9% CLINICAL SYMPTOM 32.9% SUBSTANCE TEST 42.2% BOTH OCCURRENCE OF POLYSUBSTANCE EXPOSURE AMONG CONFIRMED CASES The majority of infants with a positive substance test had known exposure to only one substance (72.1%); the remaining infants were exposed to two or more substances (28%). However, this data must be interpreted with caution. Laboratory testing may fail to detect substances that the fetus was exposed to for many reasons (e.g. duration of exposure, amount of time since exposure, specimen type, specimen quality, collection/storage technique, lab limitations). Urine specimens have a much shorter detection window (up to a few days prior to collection) than that of correctly collected meconium specimens or umbilical cord specimens (Kocherlakota, 2014). Additionally, false negatives may occur as some substances of potential abuse are not detectable by current testing methods available to hospitals. 10 / N AS R E P O RT / 20 16 A N N UA L STATEWIDE DATA SUMMARY CONFIRMED CASES & NUMBER OF SUBSTANCES IDENTIFIED, GEORGIA, 2016 72.1% 1 SUBSTANCE 3.9% 3 SUBSTANCES 22.1% 2 SUBSTANCES 1.9% 4 SUBSTANCES Georgia Depa r t m e nt of Pub l i c H eal t h / 11 SUBSTANCE DATA SUBSTANCES IDENTIFIED IN CONFIRMED CASES, BY NUMBER OF SUBSTANCES This graph displays the individual substances identified by positive substance test among the confirmed cases. As infants may have positive results for multiple substances, the total number of substances identified does not equal total number of confirmed cases. Cannabinoids were by far the most commonly identified substance (n= 120), followed by Opioids-Other* (n=87), and Amphetamines (n=73). Limitations to laboratory substance identification can be due to the type of drug panel that was ordered by the provider (e.g. 5 drug panel vs. 10 drug panel) or by substance used; not all panels have the capability to differentiate between specific substances and not all substances can be detected by typical laboratory methods. 12 / N AS R E P O RT / 20 16 A N N UA L Georgia Depa r t m e nt of Pub l i c H eal t h / 13 SUBSTANCE DATA METHOD OF CASE CONFIRMATION This graph displays the substance categories identified among the confirmed cases by positive substance test. "Stimulants" were identified most often (33.5%), followed by "Opioids" (29.7%), and "Cannabinoids" (28.7%). SUBSTANCE DATA COMBINED CATEGORIES: OPIOIDS IDENTIFIED BY TYPE IN CONFIRMED CASES Among opioids, the "Opioids-Other" category was most common (69.6%). The next most common was Oxycodone (20.8%) and Buprenorphine (5.6%). Heroin makes up 4% of the opioids identified. These results indicate that prescription pain relievers contributed to the majority of the opiate-related NAS cases. Again, due to the lab capability or type of drug panel, the specific opiate may not always be identified. (See chart on next page). 14 / N AS R E P O RT / 20 16 A N N UA L Georgia Depa r t m e nt of Pub l i c H eal t h / 15 20.2 % % SUBSTANCE DATA (con't) OPIOIDS BY TYPE, GEORGIA, 2016 TRAMADOL 0.0% 5.6% 4% BUPRENORPHINE HEROIN OXYCODONE OTHER Codeine, Morphine, Methadone Meperidine, Propoxyphene Unspecified 69.6 16 / N AS R E P O RT / 20 16 A N N UA L PRESENCE OF SYMPTOMS IN INFANTS IDENTIFIED TO BE POSITIVE FOR MARIJUANA Of all infants identified to be positive for the presence of marijuana, 69.2% were asymptomatic. Among infants with only marijuana detected by laboratory testing, 23.6% presented with clinical symptoms of withdrawal. Georgia Depa r t m e nt of Pub l i c H eal t h / 17 NAS DISTRIBUTION IN GEORGIA NAS CONFIRMED CASES BY COUNTY, GEORGIA, 2016 LEGEND DADE CATOOSA WALKER WHITFIELD MURRAY CHATTOOGA GORDON FLOYD BARTOW FANNIN UNION TOWNS RABUN GILMER PICKENS CHEROKEE LUMPKIN WHITE HABER SHAM STEPHENS DAWSON FORSYTH HALL BANKS FRANKLIN HART JACKSON MADISON ELBERT 28 - 35 18 - 24 7 - 13 3 - 6 1 - 2 0 POLK COBB GWINNETT BARROW CLARKE OGELTHORPE HARALSON PAULDING CARROLL DOUGLAS FULTON DEKALB CLAYTON WALTON ROCKDALE NEWTON OCONEE MORGAN WILKES LINCOLN GREENE TALIAFERRO COLUMBIA McDUFFIE HEARD COWETA FAYETTE HENRY SPALDING BUTTS JASPER PUTNAM WARREN HANCOCK GLASCOCK RICHMOND TROUP MERIWETHER PIKE LAMAR MONROE JONES BALDWIN WASHINGTON JEFFERSON BURKE HARRIS MUSCOGEE TALBOT UPSON BIBB WILKINSON CRAWFORD TWIGGS TAYLOR PEACH HOUSTON BLECHLEY LAURENS JOHNSON JENKINS EMANUEL TREUTLEN CANDLER SCREVEN BULLOCH EFFINGHAM CHATTAHOOCHIE MARION SCHLEY MACON DOOLEY STEWART WEBSTER SUMTER CRISP PULASKI WILCOX DODGE MONTGOMERY WHEELER TOOMBS TELFAIR EVANS TATTNAIL BRYAN LIBERTY CHATHAM QUITMAN RANDOLPH TERRELL LEE TURNER BEN HILL JEFF DAVIS APPLING LONG CLAY CALHOUN DOUGHERTY EARLY MILLER BAKER MITCHELL SEMINOLE DECATUR GRADY WORTH IRWIN TIFT COFFEE BERRIEN ATKINSON COLQUIT COOK LANIER CLINCH THOMAS BROOKS LOWNDES ECHOLS BACON WAYNE PIERCE WARE BRANTLEY CHARLETON McINTOSH GLYNN CAMDEN The highest numbers of confirmed NAS case reports are from Cobb and Chatham Counties. 18 / N AS R E P O RT / 20 16 A N N UA L NAS DISTRIBUTION IN GEORGIA NAS RATES BY COUNTY, GEORGIA, 2016 LEGEND DADE CATOOSA WALKER WHITFIELD MURRAY CHATTOOGA GORDON FLOYD BARTOW FANNIN UNION TOWNS RABUN GILMER PICKENS CHEROKEE LUMPKIN WHITE HABER SHAM STEPHENS DAWSON FORSYTH HALL BANKS FRANKLIN HART JACKSON MADISON ELBERT RATE PER 1,000 BIRTHS 23.1 - 34.9 14.9 - 21.6 7.8 - 13.2 3.6 - 7.6 0.2 - 3.2 0 POLK COBB GWINNETT BARROW CLARKE OGELTHORPE HARALSON PAULDING CARROLL DOUGLAS FULTON DEKALB CLAYTON WALTON ROCKDALE NEWTON OCONEE MORGAN WILKES LINCOLN GREENE TALIAFERRO COLUMBIA McDUFFIE HEARD COWETA FAYETTE HENRY SPALDING BUTTS JASPER PUTNAM WARREN HANCOCK GLASCOCK RICHMOND TROUP MERIWETHER PIKE LAMAR MONROE JONES BALDWIN WASHINGTON JEFFERSON BURKE HARRIS MUSCOGEE TALBOT UPSON CRAWFORD BIBB WILKINSON TWIGGS TAYLOR PEACH HOUSTON BLECHLEY LAURENS JOHNSON JENKINS EMANUEL TREUTLEN CANDLER SCREVEN BULLOCH EFFINGHAM CHATTAHOOCHIE MARION SCHLEY MACON DOOLEY STEWART WEBSTER SUMTER CRISP PULASKI WILCOX DODGE MONTGOMERY WHEELER TOOMBS TELFAIR EVANS TATTNAIL BRYAN LIBERTY CHATHAM QUITMAN RANDOLPH TERRELL LEE TURNER BEN HILL JEFF DAVIS APPLING LONG CLAY CALHOUN DOUGHERTY EARLY BAKER MILLER MITCHELL SEMINOLE DECATUR GRADY WORTH IRWIN TIFT COFFEE BERRIEN ATKINSON COLQUIT COOK LANIER CLINCH THOMAS BROOKS LOWNDES ECHOLS BACON WAYNE PIERCE WARE BRANTLEY CHARLETON McINTOSH GLYNN CAMDEN However, the highest rates of NAS are from more rural counties in Georgia (numerator confirmed cases of NAS within the county, denominator number of births within the county). Georgia Depa r t m e nt of Pub l i c H eal t h / 19 CONCLUSION CONCLUSION & NEXT STEPS Hospital discharge data for the years 2010-2015 suggest that the rates of NAS within Georgia have been increasing. Since NAS became a reportable condition in January 2016, 410 cases have been confirmed, providing additional evidence of the increasing public health importance of NAS and the opioid epidemic. ACKNOWLEDGEMENTS The Georgia Department of Public Health would like to acknowledge the reporting hospitals and providers within the state of Georgia, the Regional Perinatal Center Outreach Coordinators, and the Georgia ObGyn Society. . 20 / N AS R E P O RT / 20 16 A N N UA L CITATIONS Centers for Disease Control. Overdose Deaths Involving Opioids, by Type of Opioid, United States, 2000-2015 [Internet]. Centers for Disease Control Drug Overdose, 2017 Feb 9; [cited 2017 Jun 1]. Available from: https:// www.cdc.gov/drugoverdose/data/analysis.html Kocherlakota, P. Neonatal Abstinence Syndrome [Internet]. Pediatrics, 2014 Aug; 134(2) [cited 2017 Jun 1]. Available from: http://pediatrics.aappublications.org/content/134/2/e547 Georgia Depa r t m e nt of Pub l i c H eal t h / 21 Information and contacts regarding NAS and other reportable diseases/conditions can be found at: dph.georgia.gov/NAS or dph.georgia.gov/disease-reporting