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NEONATALABSTINENCESYNDROMEAnnual Surveillance Report 2016
GeorgiaDepartmentofPublicHealthDivisionofHealthPromotion
NAS
PREPAREDBY:GraceKang,RN/MaternalChildHealth
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CONTENTS
Introduction/Overview.............................................................................................................................2
StatewideDataSummary......................................................................................................................8
SubstanceData.....................................................................................................................................................
13
NASRegionalData...........................................................................................................................................18
Conclusion/NextStep.............................................................................................................................20
Acknowledgements.....................................................................................................................................20
Citations/References.................................................................................................................................2
1
Note:Thisreportcontainsdataobtainedthroughahospitalsurveillancesystem.Otheravailablesourcesofdatanotincludedinthisreportincludehospitaldischargedata,birthrecorddata,andpaymentdata.Allfindingsshouldbeinterpretedwithcaution.Thecasecountsinthissamplearesmallandmaybesta-tisticallyunreliable.
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INTRODUCTION
Neonatalabstinencesyndrome(NAS)isadrugwithdrawalsyndromethatresultsfromtheabruptdiscontinuationofchronicfetalexposuretosubstancesthatwereusedorabusedbythemotherduringpregnancy.Ithasprimarilybeenstudiedinopioid-exposedinfants;however,asimilarsyndromehasbeendescribedininfantsexposedtootherkindsofsubstances,bothprescriptionandillicit.
Inthelastdecade,ratesofopioidusehaveincreasedrapidlyintheUnitedStates,includingamongwomenofchildbearingage.Correspondingly,ratesofNAShavealsoincreased(Kocherlakota2014).
SOURCE:CDC/NCHS,NationalVitalStatisticsSystem,Mortality.CDCWONDER,Atlanta,GA:USDepartmentofHealthandHumanServices,ŁCDC;2016.https://wonder.cdc.gov/.
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OVERVIEW
Opioiduseandmisuse(abuse)havecontributedtotheriseofoverdosedeathsinGeorgia.Historically,motorvehiclecrashes(MVC)havebeenaleadingcauseofdeath,especiallyamongGeorgiansaged1-44.In2014,drugoverdosedeaths(n=1223)eclipsedMVCfatalities(n=1104)asaleadingcauseofdeathinGeorgia,followingthenationaltrend.
Thenumeratoristotalnumberofuniquecodesinagivenyear,andthedenominatoristotalnumberofGAhospitalbirthsinagivenyear.
InanefforttomorecloselymonitorNASwithinthestate,GeorgiaDepartmentofPublicHealthmadeNASareportableconditionasofJanuary1,2016.Reportsarecurrentlyreceivedelectronicallythroughtheweb-basedStateElectronicNotifiableDiseaseSurveillanceSystem(SENDSShttps://sendss.state.ga.us/).
Thedatasubmittedprovidesopportunitiesto:1)AssessthecurrentincidenceofNASinGeorgiaandtrendsovertime2)Identifyopportunitiesfortimelyinterventionandeducation3)BettercharacterizeriskfactorsforNASinGeorgia4)Assesscapacitytoaddressmaternaladdictionandprovidemultidisciplinarycare/supportforthefamily/childaffectedbysubstanceabuse.
CriteriaforaconfirmedcaseofNASareoneormoreofthefollowing:1)PresenceofoneormoreclinicalsymptomsofNASand/or2)Apositiveinfantsubstancetestresult.Providersarerequiredtoreportwithin7daysofdiagnosis.
ThedatainthisreportreflectsNASreportsreceivedbySendSSduringCY2016.
TheOfficeofHealthIndicatorsforPlanning(OHIP)attheGeorgiaDepartmentofPublicHealthconductedretrospectiveanalysisofhospitaldischargedataandnotedincreasingratesofNASbetween2010and2015.CodesusedforsurveillancewereforICD-9:779.5(drugwithdrawalsyndromeinanewborn)and760.72(noxiousinfluencesaffectingfetusornewbornviaplacentaorbreastmilk,narcotics),andforICD-10:P96.1(drugwithdrawal,infantofdependentmother)andP04.4(newbornaffectedbymaternaluseofdrugsofaddiction).
EventYear
Rate/1000births
2010 2011 2012 2013 2014 2015
2.21 2.53 3.13 4.08 4.77 6.10DEATHS FROM DRUG OVERDOSES &
MOTOR VEHICLE CRASHES, GEORGIA RESIDENTS, 1999-2015
200
0
400
600
800
1,000
1,200
1,400
1,600
1,800
Legend
DRUGOVERDOSE
MOTORVECHICLECRASH
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
2012 2013 2014 2015
DrugOverdoseusesunderlyingcauseICD-10CodesX40-X44,X60-X64,Y10-Y14,X85,F11-F16,F18andF19;Ł
MotorVehicleCrashesusesV02-V04,V09.0,V09.2,V12-V14,V19.0-V19.2,V19.4-V19.6,V20-V79,SOURCE:GeorgiaDepartmentofPublicHealth.OfficeofHealthIndicatorsforPlanning
(OHIP).OASIShttps://oasis.state.ga.us
Nu
mb
ero
fDea
ths
OVERVIEW (con't)
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STATEWIDE DATA SUMMARY
TOTALNUMBEROFCASESREPORTEDFORCY2016,aggregate
DuringCY2016,therewereatotalof522casesreportedwithinthestateofGeorgia,receivedfrom47ofthe74(64%)birthingfacilities.Ofthosereports,410metcasecriteriaforaconfirmedcase.Typicallycasesthatarenotconfirmeddonotmeetcasecriteria,butarestillreportedtoSendSSduetoevidenceorhistoryofmaternalsubstanceuse.Tworeportedcaseswereout-of-stateresidentswhogavebirthwithinaGeorgiahospital,andwereexcludedfromanalysis.Ofalltheneighboringstates,onlyTennesseeandFloridahaveformalizedreporting/surveillancesystemstomonitorNAS.BecauseofobstetricianprovidershortagesintheruralareasofGeorgia,includingareasthatborderotherstates,someGeorgiawomengivebirthoutsidethestate.ItisunknownatthistimehowmanyGeorgiaNAScasesgounreportedinneighboringstates.
NUMBEROFREPORTEDV.S.CONFIRMEDCASESPREVIOUS12MONTHS,quarterly
SincethebeginningofCY2016,theoverallnumberofcasesreported(n=522)andconfirmed(n=410)perquarterincreased.Thisincreaseislikelydueinparttoimprovedproviderawarenessofthemandatoryreportingrequirements.Bytheendof2016,only64%ofGeorgiahospitalshaveparticipatedinreportingNASviaSendSS;thenumberofreportedcaseswilllikelyincreaseasprovidersbecomemoreawareofNASreportingrequirements.TheGeorgiaDepartmentofPublicHealthisworkingwithpartnersthroughoutthestatetoconductongoingprovideroutreachandeducationefforts.Forexample,clinicaleducatorsattheRegionalPerinatalCentershavedevelopedacomprehensivecurriculumtoeducatefrontlinehealthcarepersonnelonNASandmaternalsubstanceuse.
STATEWIDE DATA SUMMARY
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STATEWIDE DATA SUMMARY (con't)
METHODOFCASECONFIRMATION
Forty-twopercentofcaseswereidentifiedbythepresenceofbothclinicalsymptomsandapositivesubstancetest.Theremainderwereconfirmedbypresenceofclinicalsymptomsonly(24.9%)orbypositivesubstancetestonly(32.9%).
Specimensthatmaybeusedforsubstancetestingincludeurine,meconium,cordbloodandhair.Whiledataonspecimentypeisnotcurrentlycollected,urineandmeconiumspecimensarelikelythemostcommonspecimenstestedduetoeaseofcollectionandrelativelylowcost.DataonspecimentypewillbecollectedinCY2017.
OCCURRENCEOFPOLYSUBSTANCEEXPOSUREAMONGCONFIRMEDCASES
Themajorityofinfantswithapositivesubstancetesthadknownexposuretoonlyonesubstance(72.1%);theremaininginfantswereexposedtotwoormoresubstances(28%).However,thisdatamustbeinterpretedwithcaution.Laboratorytestingmayfailtodetectsubstancesthatthefetuswasexposedtoformanyreasons(e.g.durationofexposure,amountoftimesinceexposure,specimentype,specimenquality,collection/storagetechnique,lablimitations).Urinespecimenshaveamuchshorterdetectionwindow(uptoafewdayspriortocollection)thanthatofcorrectlycollectedmeconiumspecimensorumbilicalcordspecimens(Kocherlakota,2014).Additionally,falsenegativesmayoccurassomesubstancesofpotentialabusearenotdetectablebycurrenttestingmethodsavailabletohospitals.
CONFIRMED CASES BY CONFIRMATION METHOD, GEORGIA, 2016
CLINICALSYMPTOM
24.9%SUBSTANCE
TEST
32.9%BOTH
42.2%
STATEWIDE DATA SUMMARY
72.1%
1SUBSTANCE
1.9%
4SUBSTANCES
3.9%
3SUBSTANCES
22.1%
2SUBSTANCES
CONFIRMED CASES & NUMBER OF SUBSTANCES IDENTIFIED,GEORGIA,
2016
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SUBSTANCE DATA
SUBSTANCESIDENTIFIEDINCONFIRMEDCASES,BYNUMBEROFSUBSTANCES
Thisgraphdisplaystheindividualsubstancesidentifiedbypositivesubstancetestamongtheconfirmedcases.Asinfantsmayhavepositiveresultsformultiplesubstances,thetotalnumberofsubstancesidentifieddoesnotequaltotalnumberofconfirmedcases.Cannabinoidswerebyfarthemostcommonlyidentifiedsubstance(n=120),followedbyOpioids-Other*(n=87),andAmphetamines(n=73).Limitationstolabora-torysubstanceidentificationcanbeduetothetypeofdrugpanelthatwasorderedbytheprovider(e.g.5drugpanelvs.10drugpanel)orbysubstanceused;notallpanelshavethecapabilitytodifferentiatebetweenspecificsubstancesandnotallsubstancescanbedetectedbytypicallaboratorymethods.
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METHODOFCASECONFIRMATION
Thisgraphdisplaysthesubstancecategoriesidentifiedamongtheconfirmedcasesbypositivesubstancetest.“Stimulants”wereidentifiedmostoften(33.5%),followedby“Opioids”(29.7%),and“Cannabinoids”(28.7%).
SUBSTANCE DATASUBSTANCE DATA
COMBINED CATEGORIES:
OPIOIDSIDENTIFIEDBYTYPEINCONFIRMEDCASES
Amongopioids,the“Opioids-Other”categorywasmostcommon(69.6%).ThenextmostcommonwasOxycodone(20.8%)andBuprenorphine(5.6%).Heroinmakesup4%oftheopioidsidentified.Theseresultsindicatethatprescriptionpainrelieverscontributedtothemajorityoftheopiate-relatedNAScases.Again,duetothelabcapabilityortypeofdrugpanel,thespecificopiatemaynotalwaysbeidentified.
(Seechartonnextpage).
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SUBSTANCE DATA (con't)
OPIOIDS BY TYPE, GEORGIA, 2016
HERO
IN
OXYCODONE
BU
PR
ENO
RP
HIN
E
69
.6
%
2
0.2
%
4%5.6
%
OTHERCodeine,Morphine,Methadone
Meperidine,PropoxypheneUnspecified
ONE
OR
PH
INE
OCodeine,Morphine,Me
Meperidine,PropoUns
TRAMADOL
0.0%
PRESENCEOFSYMPTOMSININFANTSIDENTIFIEDTOBEPOSITIVEFORMARIJUANA
Ofallinfantsidentifiedtobepositive
forthepresenceofmarijuana,69.2%
wereasymptomatic.Amonginfants
withonlymarijuanadetectedby
laboratorytesting,23.6%presented
withclinicalsymptomsofwithdrawal.
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NAS DISTRIBUTION IN GEORGIA
ThehighestnumbersofconfirmedNAScasereportsarefromCobbandChathamCounties.
However,thehighestratesofNASarefrommoreruralcountiesinGeorgia(numerator–confirmedcasesofNASwithinthecounty,denominator–numberofbirthswithinthecounty).
0
1 - 2
3 - 6
7 - 13
18 - 24
28 - 35
NAS CONFIRMED CASES BY COUNTY, GEORGIA, 2016
LEGEND
DADE
WALKER
CATOOSA
MURRAYGILMER
FANNIN
UNION
RABUN
HABER -SHAM
STEPHENSWHITE
DAWSON
PICKENS GORDON
FLOYD CHEROKEEFORSYTH
HALL
BANKS FRANKLIN HART
ELBERTMADISONJACKSON
BARROW CLARKE
OCONEE
WALTON
GWINNETT
DEKALB
POLK
HARALSON
CARROLL
COWETAFAYETTE
HENRY
NEWTON
MORGAN
PUTNAMJASPER
BUTTSSPALDING
MERIWETHERTROUP
HARRISTALBOT
UPSON
PIKE LAMAR
MONROE
BALDWIN
HANCOCKGLASCOCK
JEFFERSON
SCREVEN
BULLOCH EFFINGHAM CANDLER
EMANUEL
JOHNSON
WASHINGTON
WILKINSON
CRAWFORD
TAYLOR
MARION
SCHLEY
PEACH
BLECHLEY LAURENS TREUTLEN
TOOMBS
TATTNAIL
EVANS
LIBERTY
BRYAN
LONGAPPLINGJEFF DAVIS
WHEELER
TELFAIR
DODGEPULASKI
WILCOX
DOOLEY
MACON
STEWART
WEBSTER SUMTERCRISP
LEERANDOLPH TERRELL
QUITMAN
CLAY
CALHOUN DOUGHERTYWORTH
TURNER
TIFT
IRWIN
BEN HILL
COFFEEBACON
PIERCE
WARE
ATKINSON
CLINCH
COOK COLQUITMITCHELL
BAKEREARLY
MILLER
SEMINOLEDECATUR GRADY THOMAS
ECHOLS
CHARLETON
CAMDEN
BERRIEN
WAYNEMcINTOSH
GLYNN
BRANTLEY
JENKINS
BURKE
HEARD
OGELTHORPE
WILKES LINCOLN
McDUFFIE
WARREN
TALIAFERROGREENE
BARTOW
LUMPKIN
COLUMBIA
LANIER
BROOKS
PAULDING
RICHMOND
JONES
HOUSTON
BIBB
TWIGGS
MUSCOGEE
CHATTAHOOCHIE
DOUGLAS
CHATHAM
LOWNDES
TOWNS
CLAYTON
ROCKDALE
FULTON
WHITFIELD
CHATTOOGA
COBB
DADE
WALKER
CATOOSA
MURRAYGILMER
FANNIN
UNION
RABUN
HABER -SHAM
STEPHENSWHITE
DAWSON
PICKENS GORDON
FLOYD CHEROKEEFORSYTH
HALL
BANKS FRANKLIN HART
ELBERTMADISONJACKSON
BARROW CLARKE
OCONEE
WALTON
GWINNETT
DEKALB
POLK
HARALSON
CARROLL
COWETAFAYETTE
HENRY
NEWTON
MORGAN
PUTNAMJASPER
BUTTSSPALDING
MERIWETHERTROUP
HARRISTALBOT
UPSON
PIKE LAMAR
MONROE
BALDWIN
HANCOCKGLASCOCK
JEFFERSON
SCREVEN
BULLOCH EFFINGHAM CANDLER
EMANUEL
JOHNSON
WASHINGTON
WILKINSON
CRAWFORD
TAYLOR
MARION
SCHLEY
PEACH
BLECHLEY LAURENS TREUTLEN
TOOMBS
TATTNAIL
EVANS
LIBERTY
BRYAN
LONGAPPLINGJEFF DAVIS
WHEELER
TELFAIR
DODGEPULASKI
WILCOX
DOOLEY
MACON
STEWART
WEBSTER SUMTERCRISP
LEERANDOLPH TERRELL
QUITMAN
CLAY
CALHOUN DOUGHERTYWORTH
TURNER
TIFT
IRWIN
BEN HILL
COFFEEBACON
PIERCE
WARE
ATKINSON
CLINCH
COOK COLQUITMITCHELL
BAKEREARLY
MILLER
SEMINOLEDECATUR GRADY THOMAS
ECHOLS
CHARLETON
CAMDEN
BERRIEN
WAYNEMcINTOSH
GLYNN
BRANTLEY
JENKINS
BURKE
HEARD
OGELTHORPE
WILKES LINCOLN
McDUFFIE
WARREN
TALIAFERROGREENE
BARTOW
LUMPKIN
COLUMBIA
LANIER
BROOKS
PAULDING
RICHMOND
JONES
HOUSTON
BIBB
TWIGGS
MUSCOGEE
CHATTAHOOCHIE
DOUGLAS
CHATHAM
LOWNDES
TOWNS
CLAYTON
ROCKDALE
FULTON
WHITFIELD
CHATTOOGA
MOMOOONNOOONONTTGOMEGOMERRRRRRRRYY
COBB
0
0.2 - 3.2
3.6 - 7.6
7.8 - 13.2
14.9 - 21.6
23.1 - 34.9
LEGENDRATEPER1,000BIRTHS
DADE
WALKER
CATOOSA
MURRAYGILMER
FANNIN
UNION
RABUN
HABER -SHAM
STEPHENSWHITE
DAWSON
PICKENS GORDON
FLOYD CHEROKEEFORSYTH
HALL
BANKS FRANKLIN HART
ELBERTMADISONJACKSON
BARROW CLARKE
OCONEE
WALTON
GWINNETT
DEKALB
POLK
HARALSON
CARROLL
COWETAFAYETTE
HENRY
NEWTON
MORGAN
PUTNAMJASPER
BUTTSSPALDING
MERIWETHERTROUP
HARRISTALBOT
UPSON
PIKE LAMAR
MONROE
BALDWIN
HANCOCKGLASCOCK
JEFFERSON
SCREVEN
BULLOCH EFFINGHAM CANDLER
EMANUEL
JOHNSON
WASHINGTON
WILKINSON
CRAWFORD
TAYLOR
MARION
SCHLEY
PEACH
BLECHLEY LAURENS TREUTLEN
TOOMBS
TATTNAIL
EVANS
LIBERTY
BRYAN
LONGAPPLINGJEFF DAVIS
WHEELER
TELFAIR
DODGEPULASKI
WILCOX
DOOLEY
MACON
STEWARTWEBSTER SUMTER
CRISP
LEERANDOLPH TERRELL
QUITMAN
CLAY
CALHOUN DOUGHERTYWORTH
TURNER
TIFT
IRWIN
BEN HILL
COFFEEBACON
PIERCE
WARE
ATKINSON
CLINCH
COOK COLQUITMITCHELL
BAKEREARLY
MILLER
SEMINOLEDECATUR GRADY THOMAS
ECHOLS
CHARLETON
CAMDEN
BERRIEN
WAYNEMcINTOSH
GLYNN
BRANTLEY
JENKINS
BURKE
HEARD
OGELTHORPE
WILKES LINCOLN
McDUFFIE
WARREN
TALIAFERROGREENE
BARTOW
LUMPKIN
COLUMBIA
LANIER
BROOKS
PAULDING
RICHMOND
JONES
HOUSTON
BIBB
TWIGGS
MUSCOGEE
CHATTAHOOCHIE
DOUGLAS
CHATHAM
LOWNDES
TOWNS
CLAYTON
ROCKDALE
FULTON
WHITFIELD
CHATTOOGA
COBB
MONTGOMERY
NAS RATES BY COUNTY, GEORGIA, 2016
NAS DISTRIBUTION IN GEORGIA
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CONCLUSION
CONCLUSION&NEXTSTEPS
Hospitaldischargedatafortheyears2010-2015suggestthattheratesofNASwithinGeorgiahavebeenincreasing.SinceNASbecameareportableconditioninJanuary2016,410caseshavebeenconfirmed,providingadditionalevidenceoftheincreasingpublichealthimportanceofNASandtheopioidepidemic.
ACKNOWLEDGEMENTSTheGeorgiaDepartmentofPublicHealthwouldliketoacknowledgethereportinghospitalsandproviderswithinthestateofGeorgia,theRegionalPerinatalCenterOutreachCoordinators,andtheGeorgiaObGynSociety..
CITATIONS
CentersforDiseaseControl.OverdoseDeathsInvolvingOpioids,byTypeofOpioid,UnitedStates,2000-2015[Internet].CentersforDiseaseControlDrugOverdose,2017Feb9;[cited2017Jun1].Availablefrom:https://www.cdc.gov/drugoverdose/data/analysis.html
Kocherlakota,P.NeonatalAbstinenceSyndrome[Internet].Pediatrics,2014Aug;134(2)[cited2017Jun1].Availablefrom:http://pediatrics.aappublications.org/content/134/2/e547
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InformationandcontactsregardingNASandotherreportablediseases/conditionscanbefoundat:
dph.georgia.gov/NAS ordph.georgia.gov/disease-reporting
