TABLE 2. Features of state-led surveillance of neonatal abstinence syndrome in states with mandated reporting* — six states, 2018–2021.

Program feature	Surveillance findings reported by health officials†	States implementing surveillance feature
Ongoing challenges with initial case reporting§
Resource-intensive activities (surveillance-related activities requiring the most state resources)	Collecting missing information (infant)	Arizona, Georgia, Tennessee, Virginia
	Collecting missing information (mother)	Arizona, Georgia, Tennessee, Virginia
	Assessing data accuracy (medical record abstraction)	Florida
	Sharing reports with local, state, and federal agencies	Tennessee
	Deduplicating data received from multiple facilities and medical providers	Georgia, Kentucky, Virginia
	Tracking and reconnecting with families of infants relocating within state	Arizona, Virginia
Barriers to initial case reporting	Lack of capacity to carry out medical record abstractions	Tennessee
	Limited awareness of surveillance efforts by facilities, medical providers, or staff turnover	Georgia, Kentucky
	Variability in case identification and reporting by facility	Georgia
	Passive surveillance registry limits timeliness, accuracy, and data completeness	Florida
	Challenges with criteria or implementation of NAS case definition	Arizona, Georgia
Activities beyond initial case reporting†
Health-related outcomes¶ (e.g., maternal OUD or SUD, initiation or retention in MOUD program, infant hospitalization rates and comorbidities)	Monitoring comorbidities in infants with NAS	Kentucky
	Monitoring infant hospitalization rates	Kentucky
	Monitoring rates of infant preventative health maintenance visit, vaccine information	Kentucky
Social services-related outcomes¶ (e.g., linkage to housing, transportation, food or nutrition, child welfare, legal assistance, or juvenile courts services)	N/A	None
Development-related outcomes¶ (e.g., linkage or retention in Head Start, early intervention, home nursing visitation services)	N/A	None
Program development or improvement activities informed by state NAS surveillance** (to serve identified needs of opioid or substance-exposed mother-infant dyads)	OUD education campaign (e.g., stigma reduction) for providers and families	Arizona, Kentucky, Tennessee
	Expand MOUD programs for pregnant or postpartum women	Arizona, Florida
	Educational outreach to local MOUD providers and jails for expanded access to contraception for persons voluntarily seeking contraception	Tennessee
	Educational or training outreach to hospitals participating in quality improvement program initiative to improve care management for NAS	Georgia
	Teleconsultation program for providers on maternal substance use prevention and treatment	Virginia
	Plan of Safe Care program designed specifically to identify OUD in pregnancy and link to MOUD	Florida
	Expand reimbursement for OUD screening or intervention	Florida
Policy enactment informed by state NAS surveillance** (to address needs of opioid or substance-exposed mother-infant dyads)	Broadened same-day long-term contraception availability through state Medicaid program	Tennessee
Barriers to follow-up of initial case reports	Lack of infrastructure within agency to conduct follow-up with families of infants with reported cases of NAS	Arizona, Florida, Georgia, Tennessee, Virginia
	Lack of infrastructure at outside agencies that provide services to families of infants	Arizona, Virginia
	Lack of access to necessary infrastructure or services in rural communities	Kentucky, Tennessee
Quality assurance measures and resources as reported by health officials§,††
Institution of required data fields	+ Collecting missing data	Kentucky, Tennessee
Link case report data to vital records	+ Collecting missing data	Kentucky, Tennessee
Health official review of reported cases	- Requiring more resources to carry out activity	Kentucky, Tennessee
Request additional or missing information	- Collecting missing data; burdensome, inefficient	Georgia, Tennessee
Reporter education on best practices to complete case report	+ Collecting missing data and data quality	Georgia, Tennessee
Partnering with national laboratories to receive positive toxicology for infant via ELR	+ Enabling confirmation of select reported results and identification of cases that may have been otherwise missed	Georgia
	- Laborious to set up
Tools or resources used (local or community or state-level resources used in conducting surveillance)	+ Partnering with reporting hospital staff	Georgia, Tennessee
	+ Using web-based electronic reporting tools	Georgia, Kentucky, Tennessee
	- Faxing reports	Kentucky
	+ Partnering with state perinatal quality collaborative	Florida, Georgia, Kentucky, Tennessee, Virginia
	+ Using existing state disease reporting system streamlines hospital reporting	Arizona
	+ State mandate for NAS public health reporting	Arizona, Georgia, Tennessee, Virginia

Abbreviations: ELR = electronic laboratory reporting; MOUD = medication for opioid use disorder; NAS = neonatal abstinence syndrome; OUD = opioid use disorder; SUD = substance use disorder; + = most helpful; − = least helpful.

* Arizona, Florida, Georgia, Kentucky, Tennessee, and Virginia.

^† Surveillance findings listed are summarized from responses to questionnaires and semistructured interviews completed by state health departments.

^§ Including and extending beyond initial case reporting; surveillance features listed are summarized from question items detailed in both questionnaire and semistructured interview completed by state health departments.

^¶ Monitoring of specified outcomes since enactment of state-mandated NAS case reporting.

** Programs developed or policies enacted since institution of state-mandated NAS case reporting.

^†† Quality assurance measures enacted to improve completeness of case reporting.