NAS NEONATAL ABSTINENCE SYNDROME Annual Surveillance Report 2017 Georgia Department of Public Health Division of Health Promotion Acknowledgements Georgia Department of Public Health Division of Health Protection Epidemiology Section Maternal and Child Health Epidemiology Unit Perinatal Epidemiology Team Newborn Surveillance Team Division of Health Promotion Maternal and Child Health Section Women's Health Unit Perinatal Quality Improvement J. Patrick O'Neal, MD Commissioner, State Health Officer J. Patrick O'Neal, MD Director Cherie L. Drenzek, DVM, MS State Epidemiologist J. Michael Bryan, PhD Chief Epidemiologist Tonia Calder, MPH Manager Jerusha E. Barton, MPH Manager LaToya Osmani, MPH Director Jeannine Galloway, MPH Director Diane Durrence, MSN, MPH Director Grace Kang, RN Manager 2 / NAS REPORT / 2017 ANNUAL CONTENTS Key Findings ...................................................................................................................................................................5 Summary. ............................................................................................................................................................................6 Key Recommendations...............................................................................................................................6 Introduction...................................................................................................................................................................... 7 NAS Distribution in Georgia .............................................................................................................. 10 NAS Rates by Urban-Rural Status .............................................................................................10 NAS Rates by Maternal County of Residence ............................................................... 11 Hospital Charges ................................................................................................................................................. 12 Length of Stay .......................................................................................................................................................... 13 Confirmed Case Summary ................................................................................................................ 15 Maternal Age ........................................................................................................................................................ 16 Maternal Race/Ethnicity ......................................................................................................................... 17 Infant Sex .................................................................................................................................................................. 18 Clinical Signs/Symptoms of Withdrawal .....................................................................18 Substance Exposure .................................................................................................................................... 20 Medications to Treat Infant ..................................................................................................................2 1 APPENDIX ........................................................................................................................................................................22 Appendix 1: Hospital Discharge Data by County .......................................................22 Appendix 2: Case Confirmation Process .......................................................................... 23 Appendix 3: Data Collection on the SendSS NAS Reporting Form ... 24 Appendix 4: Hospital Discharge Data by County: Frequency, Rate and Urban-Rural Status .......................................25 References ..................................................................................................................................................................... 30 Georgia Department of Public Health / 3 4 / NAS REPORT / 2017 ANNUAL KEY FINDINGS Reporting expanded to 52 Georgia birthing facilities. 1,053 suspected cases were reported, with 762 determined to meet the case definition of Neonatal Abstinence Syndrome (NAS). Among the 762 cases, 59% were reported to have the signs/symptoms consistent with NAS (with or without positive toxicology screening results), while 41% had positive toxicology only. Infants born to mothers who were 1529 years of age, especially 2529 (7.0 per 1,000 live births), and Non-Hispanic Whites (8.6 per 1,000 live births) had the highest rates of NAS. Small metropolitan, micropolitan, and non-core counties had higher NAS rates than large and medium metropolitan counties (17.519.8 vs. 9.913.0 per 1,000 live births, respectively). Hospital charges and length of stay increased substantially for infants with NAS compared with non-NAS newborns in the nursery. Charges and length of stay differed by $12,500 and nine days, respectively, for infants with NAS. Toxicology results are currently underreported, which impacts the ability to inform intervention and prevention efforts. Georgia Department of Public Health / 5 SUMMARY Key Recommendations Standardize protocols: Train hospital staff on standardized protocol for the identification, assessment, and management of NAS, such as education in Regional Perinatal Centers. a. Utilize existing NAS-specific toolkits and implement evidence-based quality improvement on existing services such as Georgia Perinatal Quality Collaborative (GaPQC). Promote primary prevention opportunities, such as responsible prescribing practices, reproductive planning, and access to contraception for women who do not intend to become pregnant. a. Utilize existing toolkits (e.g., Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain, 2016). Promote existing services and advocate for increased support for women with substance use disorder. Improve case identification and reporting: Increase awareness of NAS reporting requirements and continue outreach to birthing facilities to encourage participation in reporting suspected cases of NAS. Leverage resources to remove barriers that may keep hospitals from reporting: a. Enhance passive case identification capacity through integration with other data sources (e.g., Vital Records data). b. Advocate for resources to receive and review medical records. c. Expand toxicology screening reporting to include negative results. 6 / NAS REPORT / 2017 ANNUAL INTRODUCTION Substance abuse presents a significant threat to the health of women and young children in Georgia. From 2007 to 2017, the number of deaths due to drug overdoses nearly doubled among Georgia women of childbearing age (Figure 1). During that same timeframe, the number of opioid-specific overdose deaths more than tripled. In the most recent national estimates, 8.5% of pregnant women reported using at least one illicit substance during the past month. About 1.4% of pregnant women reported using either heroin or misusing an opioid pain reliever during the past month (Center for Behavioral Health Statistics and Quality, 2018). Newborns may be impacted by maternal use of licit and illicit substances. Neonatal abstinence syndrome (NAS) is a set of clinical withdrawal signs and symptoms present in a newborn infant who was exposed to illegal or prescription drugs while in the mother's womb. Nationally, the incidence of NAS tripled from 2000 (1.2 per 1,000 live births) to 2009 (3.4 per 1,000 live births) (Patrick et al., 2012) Georgia Department of Public Health / 7 INTRODUCTION (CON'T) In Georgia, the incidence of infants who experienced withdrawal signs/symptoms and/or were affected by maternal substance abuse increased from about 1 case per 1,000 live hospital births in 2007 to nearly 13 cases per 1,000 live hospital births in 2017 (Figure 2). The incidence among infants with withdrawal signs/symptoms alone was five times greater in 2017 than 2007. This increase was similar to the findings of a 28-state study that demonstrated NAS rose from 1.5 to 6.0 per 1,000 hospital births during 1999 to 2013 (Ko et al., 2016). See Appendix 1 for more information on the NAS case identification process in the hospital discharge data. 8 / NAS REPORT / 2017 ANNUAL INTRODUCTION (CON'T) The Georgia Department of Public Health (DPH) made NAS a notifiable condition January 1, 2016. Healthcare providers reported NAS cases through the State Electronic Notifiable Disease Surveillance System (SendSS). As part of NAS surveillance, the NAS reporting form in SendSS collects data to: 1. Assess the incidence of NAS in Georgia and monitor 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 for the child and family affected by substance abuse. This annual report, in accordance with Georgia Code Section 31-12-2, details the most recent NAS findings and recommendations on how to reduce the number of infants born with NAS in Georgia. Two data sources were used in this surveillance report. The distribution of NAS cases across the state, average lengths of hospital stay after birth, and average hospital charges were derived from hospital discharge data (HDD) maintained by DPH Office of Health Indicators for Planning (OHIP). Maternal demographic factors, occurrence of clinical signs/symptoms of NAS, substance exposure confirmed by infant toxicology screening results, and the use of medications to treat infants with NAS were summarized from case data collected through the NAS reporting form in SendSS. Georgia Department of Public Health / 9 NAS DISTRIBUTION RATES IN GEORGIA NAS Rates by Urban-Rural Status1 Non-metropolitan counties had higher rates of NAS compared to the larger, metropolitan counties (Map 1). The rate of NAS among micropolitan counties (19.8 per 1,000 live births) was double that of the large metropolitan counties (9.9 per 1,000 live births). NAS rates among small metropolitan, noncore, and micropolitan counties ranged from 17.5 to 19.8 per 1,000 live births. 10 / N AS R E P O RT / 20 17 A N N UA L NAS Rates by Maternal County of Residence The rates of NAS by county ranged from 0 to 73.5 cases per 1,000 live births (Map 2). In 20 counties there were no identified cases of NAS and each county had fewer than 250 live births in 2017. Thirteen counties had rates of 40 or more cases per 1,000 live births. Haralson County had the highest rate of NAS (73.5 cases per 1,000 live births). Appendix 4 contains the frequency, rate, and urban-rural status by county. Geo rgia Depa rtmen t of Pu blic H ea lth / 11 HOSPITAL CHARGES In 2017, hospital charges were nearly $12,500 more for infants exhibiting substance withdrawal symptoms in the nursery ($16,224) than infants with no indication of effects of addictive substances ($3,762)2. Infants who were affected only by maternal use of substances of addiction3 had about $1,500 more in hospital charges than infants with no indication of effects of addictive substances. Table 1A. Total charges among Nursery Infants by NAS Status, Georgia, 2017 Total Charges (USD) NURSERY NAS Infants4 Mean (95% CI) $7,236.22 ($6,639.06, $7,833.39) Non-NAS Infants Mean (95% CI) $3,762.96 ($3,737.31, $3,788.62) Table 1B. Total charges among Nursery Infants with NAS by ICD-10-CM Code, Georgia, 2017 1 Total Charges (USD) Infants Experiencing Withdrawal2 Mean (95% CI) Infants Exposed3 Mean (95% CI) NURSERY $16,224.68 ($13,521.95, $18,927.42) $5,269.34 ($4,973.36, $5,565.32) 1 Columns are mutually exclusive. 2 Infants experiencing withdrawal were identified with ICD-10-CM code P96.1. 3 Infants exposed were identified with ICD-10-CM code PO4.4 4 NAS infants are either of the two ICD-10-CM codes (P96.1 or PO4.4). 12 / N AS R E P O RT / 20 17 A N N UA L LENGTH OF STAY Among newborns in the nursery, those with substance withdrawal symptoms spent nearly nine more days in the hospital upon delivery than infants with no indication of effects of addictive substances (11.2 and 2.6 days, respectively). Infants affected only by maternal use of substances of addiction had an average length of stay half a day longer than infants with no indication of effects of addictive substances (3.0 and 2.6 days, respectively). Table 2A. Length of Stay among Nursery Infants by NAS Status, Georgia 2017 Length of Stay (DAYS) NAS Infants4 Mean (95% CI) Non-NAS Infants Mean (95% CI) NURSERY 4.47 (4.06, 4.87) 2.55 (2.54, 2.57) Table 2B. Length of Stay among Nursery Infants with NAS by ICD-10-CM Code, Georgia 20171 Length of Stay (DAYS) Infants Experiencing Withdrawal2 Mean (95% CI) Infants Exposed3 Mean (95% CI) NURSERY 11.17 (9.30, 13.04) 3.03 (2.86, 3.21) 1 Columns are mutually exclusive. 2 Infants experiencing withdrawal were identified with ICD-10-CM code P96.1. 3 Infants exposed were identified with ICD-10-CM code PO4.4 4 NAS infants are either of the two ICD-10-CM codes (P96.1 or PO4.4). Geo rgia Depa rtmen t of Pu blic H ea lth / 13 14 / N AS R E P O RT / 20 17 A N N UA L CONFIRMED CASE SUMMARY All data described in the remainder of this report were collected through the SendSS NAS reporting form. A confirmed case was defined as an infant reported with either a positive toxicology screen or clinical signs/symptoms compatible with NAS. Positive maternal toxicology screens were not used for case confirmation. In 2017, Georgia had 762 confirmed cases of NAS. Of these, clinical signs were present in 59% (Figure 3). The remaining confirmed cases (41%) had at least one positive toxicology screen. See Appendix 2 for a description of Georgia's case confirmation process. Tables listing the substances and signs/symptoms captured by the SendSS-based NAS reporting form can be found in Appendix 3. Geo rgia Depa rtmen t of Pu blic H ea lth / 15 MATERNAL AGE Infants born to mothers 25-29 years of age had the highest incidence of NAS (Figure 4). Over one in three infants with NAS were born to mothers 2529 years of age. Overall, the incidence of NAS was highest for infants born to mothers 15-29 years of age (6.6-7.0 cases per 1,000 live births). FIGURE 4. CONFIRMED NAS CASES + INCIDENCE BY MATERNAL AGE, GEORGIA, 2017 (N=750*) Incidence (per 1,000 live births) 300 6.7 250 7.0 6.6 263 LEGEND NUMBER 8 RATE 6 200 5.1 182 150 100 50 177 4.1 4 3.2 2 76 39 0 13 0 15-19 20-24 25-29 30-34 35-39 40-43 Maternal Age (years) *Maternal age was not available for all confirmed cases. SOURCE: State Electronic Notifiable Disease Surveillance System NAS reporting form (2017). Georgia Department of Public Health. Data pulled September 5, 2018. Frequency 16 / N AS R E P O RT / 20 17 A N N UA L MATERNAL RACE/ETHNICITY Nearly two-thirds of confirmed NAS cases had Non-Hispanic white mothers (Figure 5). Infants with Non-Hispanic White mothers had nearly twice the incidence of NAS as infants with Non-Hispanic Black mothers. Geo rgia Depa rtmen t of Pu blic H ea lth / 17 WITHDRAWAL SIGNS/SYMPTOMS Among confirmed cases, 451 infants (59%) were reported to have clinical signs/symptoms consistent with substance withdrawal; of these, about half were male (data not shown). Tremors (34.5%) were the most frequently reported sign/symptom (Figure 6). About a quarter of confirmed NAS cases were reported with hyperactive reflexes (26.5%), hyperirritability (25.1%), and excessive sucking (24.8%). Among confirmed NAS cases with any signs/symptoms, over 80% had multiple signs/symptoms reported (data not shown). 18 / N AS R E P O RT / 20 17 A N N UA L INFANT SEX In 2017, 52% of the confirmed NAS cases were male and 48% were female, yielding a rate of approximately six cases per 1,000 live births for each sex (data not shown). This minor variation by sex is contrary to recent research indicating males were disproportionately impacted by NAS (Warren et al., 2015; Miller et al., 2018). Geo rgia Depa rtmen t of Pu blic H ea lth / 19 SUBSTANCE EXPOSURE In recent years, opioid use and abuse, particularly among pregnant women, has gained increased attention. While this is warranted, opioids are not the only addictive substances that can cause NAS. In 2017, 8.5% of pregnant women reported using at least one illicit substance within the past month (Center for Behavioral Health Statistics and Quality, 2018). Marijuana was the substance most commonly reported by pregnant women, with 7% reporting use in the past month. In Georgia, three out of four confirmed NAS cases had positive toxicology screens for at least one substance (data not shown). Cannabinoids were the most commonly reported substance for which infants were positive (Figure 7). Over one in five confirmed NAS cases had positive toxicology screens for stimulants (n=197) or opioids (n=162). Infant toxicology results were not available for the majority of confirmed cases. FIGURE 7. TOXICOLOGY SCREENING RESULTS BY SUBSTANCE CLASS* AMONG CONFIRMED CASES, GEORGIA, 2017 (N=762) 800 552 561 430 696 600 LEGEND POSITIVE NEGATIVE NOT TESTED /REPORTED Frequency 400 19 200 0 13 197 Stimulants 39 162 OpioidsC 313 annabinoids 13 53 Depressants *Classes are not mutually exclusive, as an infant could have a positive toxicology screen for more than one substance/class. SOURCE: State Electronic Notifiable Disease Surveillance System NAS reporting form (2017). Georgia Department of Public Health. Data pulled September 5, 2018. 20 / N AS R E P O RT / 20 17 A N N UA L MEDICATIONS TO TREAT INFANTS About one in five confirmed NAS cases received pharmacological intervention (n=161) (data not shown). Among infants reported with signs/symptoms (N=451), about one in three received medication to treat withdrawal (n=159) (data not shown). Morphine was the most frequently reported pharmacological intervention (Figure 8). Geo rgia Depa rtmen t of Pu blic H ea lth / 21 APPENDIX 1 Hospital Discharge Data and NAS Burden Hospital discharge data (HDD) from 2007 to 2017 were used to determine the annual, de-duplicated incidence rate of neonatal abstinence syndrome (NAS) in infants born to mothers who were residents of Georgia at the time of delivery. The numerator consisted of infants younger than one year of age born in Georgia whose hospital discharge records contained at least one of four International Classification of Disease (ICD) codes that indicated an NAS diagnosis. From 2007 through the first three quarters of 2015, NAS cases were identified by ICD-9-CM codes 779.5 (drug withdrawal syndrome in a newborn) and 760.72 (narcotics affecting fetus or newborn via placenta or breast milk). For the last quarter of 2015 through 2017, NAS cases were identified with ICD-10-CM codes P96.1 (neonatal withdrawal symptoms from maternal use of drugs of addiction) and P04.4 (newborn affected by maternal use of drugs of addiction). Iatrogenic cases4 were ascertained using the methodology described by Patrick et al in "Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States, 20002009" (Patrick et al., 2012); and were excluded from the numerator. The denominator consisted of all hospital births among Georgia residents as identified with V and Z ICD codes. During 2007 through the first three quarters of 2015, hospital births were captured with the ICD-9-CM codes V30V39.01. For the last quarter of 2015 through 2017, the following ICD-10-CM codes were used: Z38.0, Z38.2, Z38.3, Z38.5, Z38.6, and Z38.8. The incidence rate of NAS was calculated by dividing the number of infants with NAS, as identified by one of the above ICD codes (779.5 or 760.72; P96.1 or P04.4), divided by the total hospital births, as identified by the V or Z ICD codes listed above; and multiplying by 1,000 to determine the number of cases per 1,000 hospital births among Georgia residents. The primary diagnosis rate of NAS is the number of infants with NAS, as identified by either the ICD-9-CM or ICD-10-CM codes, who exhibit withdrawal symptoms only, per 1,000 hospital births among Georgia residents (data not shown). These infants were identified by either ICD-9-CM code 779.5 or ICD-10-CM code P96.1. Because no standardized case definition for NAS has been implemented in the U.S., states have utilized a combination of the primary diagnosis and overall NAS incidence (i.e., using both signs/symptoms and positive toxicology ICD codes) rates to estimate the burden of NAS. The Centers for Disease Control and Prevention (CDC) and the Council for State and Territorial Epidemiologists (CSTE) surveyed states in late 2018 to collect detailed information on local NAS case criteria. This information will be used to develop a standardized NAS case definition in the coming year. 4 Latrogenic cases refer to infants experiencing withdrawal signs/symptoms related to medical treatment or surgery, not antenatal exposure to maternal substance use. 22 / N AS R E P O RT / 20 17 A N N UA L APPENDIX 2 Case Confirmation Process Healthcare providers reported suspected NAS cases to the Georgia Department of Public Health (DPH) by filling out an electronic reporting form in the State Electronic Notifiable Disease Surveillance System (SendSS). DPH reviewed the NAS case reports for completeness and accuracy. A reported case was confirmed if the infant met the case definition (Figure A2). To be considered a confirmed NAS case, a newborn must have been reported with clinical signs/symptoms consistent with NAS and/or a positive toxicology screen result. Clinical signs/symptoms included tremors, vomiting, hyperactive reflexes, and hyperirritability (a full list is presented in Appendix 3). Sixteen substances for which toxicology results could be reported were grouped into four classes: opioids, stimulants, cannabinoids, and depressants (see Appendix 3 for more information). Figure A2. NAS CASE CONFIRMATION DECISION REPORTED NAS Case Clinical Signs/Sx Present Only Positive Toxicology Only Clinical Signs/Sx and Positive Toxicology Neither Confirmed NAS Case Confirmed NAS Case Confirmed NAS Case Not a Case In 2017, 1,053 suspected cases of NAS were reported to DPH through SendSS from 52 of the 74 (70%) birthing facilities in Georgia. Three birthing hospitals in Tennessee also reported NAS cases among Georgia resident births in their facilities. Of the 1,053 suspected cases, 762 were confirmed. This was nearly twice the number of reported suspected (N=522) and confirmed NAS cases (N=410) in 2016. Data from the SendSS NAS reporting form has several limitations. First, despite the addition of NAS to the notifiable condition list in Georgia, cases may have been underreported. Incidence rates based on SendSS data may be an underestimate of the burden of NAS in the Georgia population as a whole and subpopulations therein. Second, data reported may be incomplete. For example, only the more severe signs/symptoms may have been regularly reported. Finally, data collection for toxicology screening may not provide the most effective information for informing prevention efforts. Although fewer than half of all confirmed cases were reported to have had toxicological screening for any substance class (Figure 7, range: 8.7%43.6%), the vast majority of toxicology screens reported to SendSS were positive (data not shown). The 2017 NAS case reporting form also did not collect information on the specimen type (e.g., urine, meconium, cord blood, etc.). Further, reported maternal substance exposure did not differentiate among licit or illicit use, abuse, or prescription of addictive substances, including whether medication-assisted treatment (MAT) was administered during pregnancy. The NAS case reporting form in SendSS has been revised to capture these data starting January 1, 2018. Geo rgia Depa rtmen t of Pu blic H ea lth / 23 APPENDIX 3 Data Collection on the SendSS NAS Reporting Form On the 2017 SendSS NAS case reporting form, providers could indicate one or more clinical signs/symptoms of NAS using 13 checkboxes (Table 3A). An additional checkbox gave providers the option to report asymptomatic infants. If "Other" was selected, a comment box appeared to collect signs/symptoms not otherwise listed. Reported "Other" symptoms included sleep and respiratory (e.g., apnea, tachypnea) abnormalities, and arrhythmias (e.g., tachycardia, bradycardia). Table 3A. CLINICAL SIGNS/SYMPTOMS OF NAS COLLECTED IN SENDSS Blotchy skin coloring Diarrhea Excessive crying Excessive sucking Fever/temperature instability Hyperactive reflexes Hyperirritability Other Poor/inability to feed Seizures Sweating Tremors Vomiting Like the signs/symptoms selections, the SendSS NAS reporting form had checkboxes for 16 substances (Table 3B). Providers could indicate whether mothers and/or infants (1) received toxicology screening and (2) the toxicology results (e.g., positive or negative) for each substance. Additionally, providers had a free-text option to list substances and toxicology results not otherwise captured by the 16 checkboxes. Four substances classes were created by grouping the 16 individual substances by their mechanisms of action and effects on the body. When "Other Opioids" was indicated, more granular information was not reported. The reporting form did not capture whether buprenorphine was associated with medication-assisted treatment (MAT). Ambien and butalbital (grouped into Depressants) were reported in free-text for infants, and kratom (grouped into Opioids) toxicology screening was reported in free-text for both infants and mothers. Table 3B. CLASS CATEGORIES FOR INFANT AND MOTHERS SUBSTANCES COLLECTED IN SENDSS Cannabinoids1 Marijuana or THC Depressants Alcohol Barbiturates Benzodiazepines Gabapentin (Neurontin)2 Phencyclidine (PCP) SSRI3 Opioids Buprenorphine Heroine Oxycodone Tramadol (Ultram) Other opioids Stimulants Amphetamines Cocaine Methamphetamine Tobacco (nicotine)4 1 SendSS listed one checkbox for cannabinoids: "Marijuana-THC-cannabinoids." 2 Gabapentin (Neurontin) toxicology screening was not reported for any mothers or infants. 3 SSRI: Selective serotonin reuptake inhibitors. SSRI toxicology screening was not reported for any infants. 4Tobacco (nicotine) toxicology screening was not reported for any infants. 24 / N AS R E P O RT / 20 17 A N N UA L APPENDIX 4 Hospital Discharge Data by County: Frequency, Rate, and Urban-Rural Status County Number of Live Births Number of NAS Cases Rate of NAS NCHS Urban-Rural Status Appling 213 * ** Noncore Atkinson 93 0 Bacon 175 * 0.0 Noncore ** Noncore Baker 34 0 Baldwin 358 * 0.0 Small Metropolitan ** Micropolitan Banks 189 * ** Noncore Barrow 886 * Bartow 1238 18 ** Large Metropolitan 14.5 Large Metropolitan Ben Hill 194 * Berrien 185 * Bibb 1919 52 ** Micropolitan ** Noncore 27.1 Small Metropolitan Bleckley 122 * Brantley 198 * ** Noncore ** Small Metropolitan Brooks 170 * Bryan 433 * Bulloch 839 10 ** Small Metropolitan ** Medium Metropolitan 11.9 Micropolitan Burke 305 * Butts 219 0 ** Medium Metropolitan 0.0 Large Metropolitan Calhoun 45 0 0.0 Noncore Camden 693 11 Candler 132 * 15.9 Micropolitan ** Noncore Carroll 1256 77 Catoosa 44 * 61.3 Large Metropolitan ** Medium Metropolitan Charlton 82 * ** Noncore Chatham 3430 43 Chattahoochee 62 * 12.5 Medium Metropolitan ** Medium Metropolitan Chattooga 246 * Cherokee 2677 21 Clarke 1349 17 ** Micropolitan 7.8 Large Metropolitan 12.6 Small Metropolitan Clay 17 0 Clayton 3914 33 0.0 Noncore 8.4 Large Metropolitan Clinch 82 0 Cobb 8793 74 Coffee 577 * 0.0 Noncore 8.4 Large Metropolitan ** Micropolitan Colquitt 496 * ** Micropolitan * Counts not displayed for counties with 19 NAS cases. ** NAS rates not calculated for counties with 19 cases of NAS. Geo rgia Depa rtmen t of Pu blic H ea lth / 25 APPENDIX 4 (CON'T) County Columbia Cook Coweta Crawford Crisp Dade Dawson Decatur DeKalb Dodge Dooly Dougherty Douglas Early Echols Effingham Elbert Emanuel Evans Fannin Fayette Floyd Forsyth Franklin Fulton Gilmer Glascock Glynn Gordon Grady Greene Gwinnett Habersham Hall Hancock Haralson Harris Hart Heard Number of Live Births Number of NAS Cases 1656 * 188 0 1364 10 121 * 257 * 0 0 217 * 355 18 10594 74 201 * 63 52 1179 13 1637 19 129 * 51 0 733 * 198 * 289 * 131 * 183 * 694 * 1188 28 2357 13 271 * 11578 143 278 * 22 0 891 18 560 24 286 * 161 * 11478 55 477 14 2063 26 51 * 313 23 290 * 210 * 109 * 26 / N AS R E P O RT / 20 17 A N N UA L Rate of NAS ** 0.0 7.3 ** ** 0.0 ** ** 7.0 ** ** 11.0 11.6 ** 0.0 ** ** ** ** ** ** 23.6 5.3 ** 12.4 ** 0.0 20.2 42.9 ** ** 4.8 29.4 12.6 ** 73.5 ** ** ** NCHS Urban-Rural Status Medium Metropolitan Noncore Large Metropolitan Small Metropolitan Micropolitan Medium Metropolitan Large Metropolitan Micropolitan Large Metropolitan Noncore Noncore Small Metropolitan Large Metropolitan Noncore Small Metropolitan Medium Metropolitan Noncore Noncore Noncore Noncore Large Metropolitan Small Metropolitan Large Metropolitan Noncore Large Metropolitan Noncore Noncore Small Metropolitan Micropolitan Noncore Noncore Large Metropolitan Micropolitan Small Metropolitan Micropolitan Large Metropolitan Medium Metropolitan Noncore Large Metropolitan APPENDIX 4 (CON'T) County Number of Live Births Number of NAS Cases Rate of NAS NCHS Urban-Rural Status Henry 2090 12 Houston 1856 37 Irwin 87 * Jackson 787 * Jasper 144 * Jeff Davis 197 * Jefferson 192 * Jenkins 87 * Johnson 106 * Jones 245 * Lamar 170 * Lanier 124 0 Laurens 609 11 Lee 315 * Liberty 616 14 Lincoln 80 0 Long 192 * Lowndes 1458 12 Lumpkin 248 * Macon 116 * Madison 317 * Marion 84 * McDuffie 267 * McIntosh 126 * Meriwether 214 10 Miller 66 * Mitchell 261 * Monroe 231 * Montgomery 94 * Morgan 210 * Murray 462 11 Muscogee 2371 51 Newton 1271 * Oconee 372 * Oglethorpe 169 0 Paulding 1788 27 Peach 285 * Pickens 301 * Pierce 223 * 5.7 19.9 ** ** ** ** ** ** ** ** ** 0.0 18.1 ** 22.7 0.0 ** 8.2 ** ** ** ** ** ** 46.7 ** ** ** ** ** 23.8 21.5 ** ** 0.0 15.1 ** ** ** Large Metropolitan Small Metropolitan Noncore Micropolitan Large Metropolitan Noncore Noncore Noncore Micropolitan Small Metropolitan Large Metropolitan Small Metropolitan Micropolitan Small Metropolitan Small Metropolitan Medium Metropolitan Small Metropolitan Small Metropolitan Noncore Noncore Small Metropolitan Medium Metropolitan Medium Metropolitan Small Metropolitan Large Metropolitan Noncore Noncore Small Metropolitan Micropolitan Large Metropolitan Small Metropolitan Medium Metropolitan Large Metropolitan Small Metropolitan Small Metropolitan Large Metropolitan Small Metropolitan Large Metropolitan Micropolitan * Counts not displayed for counties with 19 NAS cases. ** NAS rates not calculated for counties with 19 cases of NAS. Geo rgia Depa rtmen t of Pu blic H ea lth / 27 APPENDIX 4 (CON'T) County Pike Polk Pulaski Putnam Quitman Rabun Randolph Richmond Rockdale Schley Screven Seminole Spalding Stephens Stewart Sumter Talbot Taliaferro Tattnall Taylor Telfair Terrell Thomas Tift Toombs Towns Treutlen Troup Turner Twiggs Union Upson Walker Walton Ware Warren Washington Wayne Webster Number of Live Births Number of NAS Cases 162 * 536 13 71 * 183 * 19 0 126 * 85 * 2782 38 934 10 48 0 190 * 94 * 786 * 254 * 36 * 385 * 59 * 12 0 230 * 86 * 139 * 93 * 487 * 526 13 339 * 71 0 82 0 664 44 92 * 67 * 148 * 313 * 35 * 1010 * 452 * 65 0 198 * 331 * 24 * 28 / N AS R E P O RT / 20 17 A N N UA L Rate of NAS ** 24.3 ** ** 0.0 ** ** 13.7 10.7 0.0 ** ** ** ** ** ** ** 0.0 ** ** ** ** ** 24.7 ** 0.0 0.0 66.3 ** ** ** ** ** ** ** 0.0 ** ** ** NCHS Urban-Rural Status Large Metropolitan Micropolitan Small Metropolitan Noncore Noncore Noncore Noncore Medium Metropolitan Large Metropolitan Micropolitan Noncore Noncore Large Metropolitan Micropolitan Noncore Micropolitan Noncore Noncore Noncore Noncore Noncore Small Metropolitan Micropolitan Micropolitan Micropolitan Noncore Noncore Micropolitan Noncore Small Metropolitan Noncore Micropolitan Medium Metropolitan Large Metropolitan Micropolitan Noncore Noncore Micropolitan Noncore APPENDIX 4 (CON'T) County Wheeler White Whitfield Wilcox Wilkes Wilkinson Worth Number of Live Births Number of NAS Cases 68 0 233 * 1172 24 62 * 91 0 93 * 235 * Rate of NAS 0.0 ** 20.5 ** 0.0 ** ** NCHS Urban-Rural Status Noncore Noncore Large Metropolitan Noncore Noncore Noncore Large Metropolitan * Counts not displayed for counties with 19 NAS cases. ** NAS rates not calculated for counties with 19 cases of NAS. Geo rgia Depa rtmen t of Pu blic H ea lth / 29 REFERENCES Substance Abuse and Mental Health Services Administration. (2018). Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 8-5068, NSDUH Series H-53). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. [Cited 2018 Nov 9]. Available from: https://www.samhsa.gov/data/ Patrick, S. W., Schumacher, R. E., Benneyworth, B. D., Krans, E. E., McAllister, J. M., & Davis, M. M. Neonatal Abstinence Syndrome and Associated Health Care Expenditures United States, 20002009. [Internet]. Journal of the American Medical Association, 2012; 307(18), 19341940. [Cited 2018 Nov 9]. Available from: https://jamanetwork.com/journals/jama/fullarticle/1151530 doi:10.1001/jama.2012.3951 Ko, J. Y., Patrick, S. W., Tong, V. T., Patel, R., Lind, J. N., Barfield, W. D. Incidence of Neonatal Abstinence Syndrome--28 States, 19992013. [Internet]. Morbidity and Mortality Weekly Report, 2016; 65(31), 799802. [Cited 2018 Nov 9]. Available from: https://www.cdc.gov/mmwr/volumes/65/wr/mm6531a2.htm doi:10.15585/mmwr.mm6531a2 Ingram D. D., Franco S.J. 2013 NCHS UrbanRural Classification Scheme for Counties. National Center for Health Statistics. [Internet]. Vital Health Statistics 2(166). 2014. [Cited 2018 Nov 9]. Available from: https://www.cdc.gov/nchs/data/series/sr_02/sr02_166.pdf Warren, M. D., Miller, A. M., Traylor, J., Bauer, A., Patrick, S. W. Implementation of a Statewide Surveillance System for Neonatal Abstinence Syndrome--Tennessee, 2013. [Internet]. Morbidity and Mortality Weekly Report, 2015; 64(5), 125128. [Cited 2018 Nov 9]. Available from: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6405a4.htm Miller, A. M., McDonald M., Warren, M. D. Neonatal Abstinence Syndrome Surveillance Annual Report 2017. [Internet]. Tennessee Department of Health, 2018. [Cited 2018 Nov 9]. Available from: https://www.tn.gov/content/tn/health/nas/nas-update-archive.html 30 / N AS R E P O RT / 20 17 A N N UA L Special thanks to current and former members of the Georgia Department of Public Health team who contributed to the creation of this report: Elise Barnes, Britney Robinson, Michael Lo, Ankit Sutaria, Sabrina Johnston, the team of Information Technology professionals responsible for developing and maintaining the State Electronic Notifiable Disease Surveillance System, the Office of Health Indicators for Planning, and finally, we would like to thank each participating healthcare facility and provider who helped contribute information relevant to this report. Without their support, this report would not be possible. Geo rgia Depa rtmen t of Pu blic H ea lth / 31 Information and contacts regarding NAS and other reportable diseases/conditions can be found at: dph.georgia.gov/NAS or dph.georgia.gov/disease-reporting January 2019