In 2022, BWCH's infant and perinatal priorities focused on reducing infant mortality and morbidity and promoting equitable and optimal care and protective factors for mothers and infants before, during, and after pregnancy. All activities under each priority have been categorized using Levels of Public Participation (Inform, Consult, Involve, Collaborate, Empower) and can be found in Appendix H. Levels of Public Participation under the Perinatal/Infant Health section. The Perinatal/Infant Health population domain continued its work in Health Equity and Family Engagement. The Health Equity activities are identified in italics throughout this section of the report and information about Family Engagement can be found in the Family Partnership narrative. This narrative concludes with an overview of Arizona’s response to the nationwide infant formula shortage and pediatric surge in respiratory virus in 2022 and Title V program involvement.

To support NPM 4: Breastfeeding, the ADHS Bureau of Women’s and Children’s Health (BWCH) partnered with the ADHS Bureau of Nutrition and Physical Activity (BNPA) to support breastfeeding initiatives through training, technical assistance, policy and procedures, and direct support services. In addition, BNPA, through the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program, was able to provide ongoing training and support opportunities for International Board Certified Lactation Consultant (IBCLC) certification. Early childhood home visiting programs continued to educate families about infant toddler development, mental health, the critical importance of bonding, injuries in the home, safe sleep, immunizations, and the effects of Adverse Childhood Experiences (ACE). Arizona was also involved in efforts to monitor the incidence of neonatal abstinence syndrome (NAS) and work with child welfare and other state agencies on collaborative strategies to prevent and reduce opioid use and stigma reduction as part of the larger public health response to the opioid epidemic.

The Perinatal/infant Health Annual Report will include program updates addressing key activities and results from CY 2022 (January 1, 2022 - December 31, 2022), health equity and family & youth engagement strategies, challenges, and emerging issues, including any continued COVID-19 impact and the strategies implemented to sustain the programs/services. Cross-cutting strategies for children’s health domain will be addressed. The following sections detail 2022 implemented strategies and activities.

In 2022, BWCH continued to identify programmatic measures and indicators that apply to all BWCH home visiting programs, including MIECHV-funded home visiting programs, the state- and MIECHV-funded Health Start program, and the state- and Title V-funded High-Risk Perinatal Program (HRPP). MIECHV, Health Start, and HRPP Community Health Nursing have worked collectively with the Bureau of Assessment and Evaluation to continue coordinated efforts for the home visitation data management system, Efforts-To-Outcomes (ETO). During this year, two additional staff members were trained in administrative and report writing modules and began the development of the first bureau-wide report. Additional data management projects started include a report and variable library. Reports and libraries are anticipated to be completed in 2023.

In 2022, the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) in Arizona provided funding to these evidence-based home visiting programs: Healthy Families (through Arizona Department of Child Safety), Nurse-Family Partnership (through Maricopa County Department of Public Health, Pima County Health Department), Family Spirit (through Coconino County and San Carlos Apache Tribe), Parents as Teachers (provided by two Native American Tribes: Cocopah and Navajo Nation) and this year expanded to include SafeCare Augmented, an evidence-based home visiting program providing services to families with children over the age of eighteen (18) months. In addition, the AZ MIECHV grant continues to be approved to fund Arizona’s state-funded home visiting program, Health Start, as a promising approach. Through the home visiting programs listed above, MIECHV served 1,397 families in at-risk communities through 25,351 visits, coordinating services across Arizona’s early childhood system. MIECHV supported the 2021-2025 Title V priority needs by implementing various strategies. The strategies and outcomes for 2022 are included in the Children’s Health Annual Report.

Arizona’s Health Start Program, funded through MIECHV, state lottery funds, and MHIP, uses community health workers (CHWs) to conduct home visits. In 2022, the Health Start Program continued to train Health Start home visitors in developmental screening in support of ESM 6.1 (number of home visitors trained to provide ASQ3 and SE2 training over the next five years). In 2022, the program trained two new staff members virtually through trainers at their sites. Health Start continued to provide developmental screening for children ages 10-17 months to increase early identification and treatment of developmental delays. In 2022, Health Start completed 801 Ages and Stages Questionnaire (ASQ) screenings and 486 ASQ SE screenings. The number of children screened using the ASQ increased during 2022 as in-home visits increased. Health Start continued to provide the Arizona Survey on Children’s Health (ASCH) in 2022 at all 15 sites. There were 259 ASCH surveys completed with families with children ages 11-13 months. Health Start screened 850 prenatal and postpartum women for substance use, of which 35 were using tobacco. Of those using tobacco, 34 (97%) accepted education on quitting and referrals to the Arizona ASHline for cessation services. This is a significant increase from 55% in the previous reporting year. In 2022, the Health Start program continued working with internal partners in the Bureau of Chronic Disease and Health Promotion (BCDHP) to provide tobacco cessation training and referrals and with the Office of Epidemiology and Disease Control (Division of Preparedness) to mitigate the syphilis outbreak among women and babies through the promotion of increased testing. Additional activities can be found in the Women’s Health Annual Report.

The High-Risk Perinatal Program (HRPP) is Arizona's oldest home-visiting program. The HRPP's purpose is to reduce maternal and infant morbidity and mortality through a statewide regionalized system of coordinated perinatal care. The HRPP is a primarily state-funded program that leverages Title V funds to increase access and enhance services. The HRPP continued to provide early identification of women and children at risk of morbidity and mortality and educate health professionals, families, and communities on developmental care and the needs of medically fragile infants. The HRPP also continued to link pregnant women and infants to the appropriate level of care hospital and establish standards of care and education once families return home after discharge. The components of the program are a 24/7 Information and Referral Line, Maternal and Neonatal Transport Services, Hospital and Inpatient Physician Services, Community Nursing Services, and Hospital Developmental Care. As mentioned in the Children’s Health Annual Report, in 2022, over 4,363 infants were enrolled in HRPP, Community Health Nurses documented 7,977 visits to medically fragile infants and their families after they were discharged from the neonatal intensive care unit (NICU), and 691 critically ill pregnant women and 858 critically ill newborns were transported to the appropriate level of care hospital as determined by program contracted physicians.

The HRPP Community Health Nurses (CHNs) continued to support families through the COVID-19 pandemic by continuing to adapt to the circumstances. The CHNs continued to offer virtual visits for families to help mitigate the spread of COVID-19. The families receive educational materials, ASQ screenings, and Edinburgh Postnatal Depression surveys prior to the visit via email, mail, or dropping the materials off at the families’ home. Return to In-Person Visit guidelines were released in May 2021 for CHN agencies to begin the transition back to in-person home visits. In 2022 a hybrid of virtual and in-person was offered to best meet the needs of the families. CHNs continued to provide POST-BIRTH Warning Signs information to all families at the initial home visit to educate the families on signs and symptoms that would require the family to seek medical care after leaving the hospital.

In 2022, the HRPP CHNs completed 466 surveys for the National Survey of Children’s Health (NSCH), which is utilized to improve referrals for children identified as having special health care needs. The CHNs also completed 2,320 initial Ages and Stages Questionnaires (ASQ) and 1,800 Edinburgh Postnatal Depression Screenings (EPDS). Of these EPDS, 215 of the people screened had a score greater than 9, leading them to be referred to mental health services.

Infants diagnosed with Neonatal Abstinence Syndrome (NAS) are automatically eligible for HRPP home-visiting follow-up services. Of the 4,363 infants enrolled in 2022, 691 (15.8%) of these were diagnosed with NAS, and 880 home visits were provided to these infants over the course of the year. The HRPP expanded services to meet the needs of infants diagnosed with NAS and began contracting with Hushabye Nursery in July 2021 and in 2022 they provided care for 195 HRPP NAS-enrolled babies. The mission of Hushabye Nursery is to 'embrace substance-exposed babies and their caregivers with compassionate, evidence-based care that changes the course of their entire lives.' In September of 2022, HRPP contracted with Jacob’s Hope, a 501(C)(3), care center for newborns who are suffering from NAS or prenatal substance exposure located in Mesa, Arizona. After becoming contracted, they were able to provide services to 11 HRPP NAS-enrolled babies.

In 2022, the annual High-Risk Perinatal Program Conference was again combined with the Strong Families AZ Home Visiting Conference, an annual conference for home visitors in Arizona. The four-day conference included one day with a priority population focus specific to the High-Risk Perinatal Program population. The conference attendees for that day consisted of Community Health Nurses and Neonatal Intensive Care Nurses across the state of Arizona. This provided an opportunity for Community Health Nurses and Neonatal Intensive Care Nurses to receive professional development targeted to their role and the services that they provide to families.

BWCH continued to implement the Pregnancy Risk Assessment Monitoring System (PRAMS). BWCH leveraged Title V and other federal and non-federal funds to support its ongoing implementation further. In 2022, PRAMS continued to use data collected to describe the maternal and infant populations in Arizona and to assess possible associations between perinatal health outcomes and maternal characteristics. Additional information regarding PRAMS is mentioned in the Women's Health 2022 Annual Report and 2024 Application.

Information on Arizona's Child Fatality Review (CFR) program is included in the Children's Health section of the application, except for the Safe Sleep and Sudden Unexpected Infant Death (SUID) efforts listed here.

NPM 5: Safe Sleep was addressed through the ongoing partnership with the Office of Injury and Violence Prevention (within the Bureau of Chronic Disease and Health Promotion). The Office of Injury & Violence Prevention utilized Title V funds to carry out a variety of strategies dedicated to Safe Sleep. The Safe Sleep Task Force continued to partner with key stakeholders from around the state to accelerate improvements that prevent and reduce infant deaths. In 2022, the Safe Sleep Task Force met quarterly and continues to meet virtually. Partners included the Arizona Department of Child Safety (DCS), Arizona Chapter of the American Academy of Pediatrics (AzAAP), Arizona Health Care Cost Containment System, March of Dimes, partners from birthing and non-birthing hospitals, home visitors, Safe Kids coalitions, county health departments, South Phoenix Healthy Start, Child Care Licensing (within ADHS), Prevent Child Abuse Arizona and Candelen. Our partners have learned to pivot how education services and resources are provided to new parents ever since the COVID-19 pandemic. Most partners have moved education services to virtual platforms. However, not every partner had that success; some faced challenges due to staff being reassigned, or technology barriers. The task force aims to decrease the sudden unexpected infant death (SUID) mortality rate by 5% by promoting safe sleep practices. The task force also worked toward reducing SUID disparities between White and Non-Hispanic Black and between White and American Indian/Alaska Natives by 3%.

Arizona safe sleep work continues to focus on providing safe sleep education and support to families through birthing hospitals, home visiting programs, local county health departments, and licensed and unlicensed child care. Arizona's activities include: adding safe sleep modeling to annual skills training for nurses in hospitals; using safe sleep Bassinet Cards as visual reminders for nursery staff; standardizing safe sleep messages for all home visiting programs; standardizing education and training for home visitors on current American Academy of Pediatrics (AAP) guidelines; developing standardized, safe sleep messages at ADHS with input from community partners; partnering with community tribal elders on AAP guidelines; engaging grandparents and caregivers on the recommended AAP guidelines; providing training for nursing and medical schools and helping hospitals establish policies.

In 2022, using Title V funding, the Office of Injury and Violence Prevention partnered with the Strong Families home visiting alliance, housed within BWCH, to develop a Safe Sleep Toolkit that is easily accessible on the Strong Families website and also available on the ADHS website. The Safe Sleep Toolkit contains suggestions for partners and providers for social media posts, posters that can be printed, and commercials that can be added to individual or organizations’ social media pages. A media campaign supported by MIECHV and Title V with newly developed creative was pushed out through digital platforms and within healthcare provider waiting rooms. As a result of this campaign, 23.7 K unique users visited the strongfamiliesaz.com/abcsafesleep website. Through this partnership, there is now content in Spanish as well as an image that targets the Native American community. Also, in collaboration with our partners on the Strong Families website, community partners can have caregivers/parents take a short quiz on their knowledge of safe sleep practices. Once completed, families can receive a free safe sleep sack mailed directly to them. In 2022, 327 families received a free safe sleep sack (303 in English and 24 in Spanish).

In 2022, 23 out of Arizona’s 36 birthing hospitals participated in distributing and educating the Crib Cards. Crib Cards are still being distributed to all of our birthing hospitals and other community partners so that they can distribute them with their education. In 2022, 33,300 crib cards were distributed. Through the Safe Sleep Task Force and partnerships, there was consensus to recommend that all birthing hospitals participating in the distribution of the Crib Cards should also develop a safe sleep policy to educate staff and ensure the same standard of care. Lastly, AzAAP continued to offer computer-based training on Safe Sleep for pediatricians to improve professional practice in 2022. Providers can also earn credit for Maintenance of Certification (MOC) Part 4 by taking the training.

In 2022, 2,185 Pack ‘N Plays were purchased with Title V funds and distributed to County Health Departments, Safe Kids Coalitions, Hospitals, Tribal Partners, Indian Health Services, South Phoenix Healthy Start, Home Visiting Programs, and Community Resources Centers. To receive a pack ‘n play, families receive education about safe sleep and how to follow the ABCs of safe sleep before receiving a pack ‘n play. Education and pack ‘n plays are provided through the partner agencies that receive Title V funded pack ‘n plays.

In 2019 ADHS formed a partnership with Prevent Child Abuse of Arizona to help with the distribution, implementation, and dissemination of the All Babies Cry program. At this time, it is being distributed through birthing hospitals. The All Babies Cry program is a new, evidence-based media program designed to help prevent child abuse during the first year of life - when the highest proportion of incidents occur. Incorporating the protective factors of the Strengthening Families framework and other outcomes-based research. All Babies Cry empowers new mothers and fathers with practical demonstrations of infant soothing and clear strategies for managing normal stress in parenting. Currently, participating hospitals are Mount Graham, Yavapai Regional Birthing Center, Banner Gateway, Banner Desert, Carondelet St. Joseph's, Tucson Medical Center, and Kingman Regional Center. The Children's Trust of Massachusetts is currently undergoing leadership changes therefore we've decided to not onboard additional hospitals until decisions have been made.

In 2022, Arizona continued to support Neonatal Abstinence Syndrome (NAS) and Substance Exposed Newborn (SEN) prevention efforts through various collaborative efforts. In 2022, ADHS staff attended meetings and collaborated with stakeholders to discuss ideas and next steps around care coordination processes for substance-exposed newborns and their mothers. ADHS continued to prioritize two specific action steps identified in the NAS Strategic Plan that was developed in conjunction with other key state agencies and stakeholders as part of a Learning Lab project under the National Governors Association in 2018 (which has been sunsetted).

These two action steps include 1. the development of a stigma reduction media campaign for women using substances and 2. the improvement and enhancement of the NAS/SEN data collection and surveillance system.

The stigma reduction media campaign for women using substances was developed using Title V funds. It was initiated on September 7, 2021, and initially continued through 2022. The campaign targeted women, families, and providers, including radio spots, billboards and posters, digital media, and publications. Messages and information for pregnant people who use substances and their families are available at azhealth.gov/hopeheals, and messages and resources for providers who serve pregnant people with substance use disorder are available at azhealth.gov/seemedifferently. Stigma reduction is an ongoing strategy in Arizona, and we are working to continue to share the campaign messaging.

In 2021, an internal ADHS work group convened to review the definition of NAS and to evaluate NAS data collection and reporting processes to improve the accuracy and integrity of the data. Through this process, NAS Surveillance was moved from the Office of Injury and Violence Prevention to the Arizona Birth Defects Monitoring Program (ABDMP), with BWCH continuing to support these efforts; and also conduct and analyze reports based on Hospital Discharge Data. In 2022, BWCH and BAE developed an updated 5-year NAS surveillance report. This report was finalized in December 2022, published in early 2023, and highlights the concerns of NAS in Arizona. These processes and combined efforts continue to help ADHS and statewide partners better understand the incidence and distribution of NAS statewide to guide future prevention efforts. The Bureau continues to support ABDMP’s efforts, monitor the incidence of NAS, and work with child welfare and other state and local county agencies on collaborative strategies to prevent and reduce opioid use specifically, including stigma reduction, as part of the larger universe of efforts addressing the opioid epidemic.

In 2022, BWCH continued drafting the Arizona Fetal-Infant Mortality Action Plan (FIMAP) Report. In partnership with the Bureau of Assessment and Evaluation, a graduate intern was onboarded to help with completing research and writing the narrative report, and updating the action plan. Shawn Soumilas, an ASU MHI student, started in late fall and has worked with the Title V Director and Title V Assessment and Evaluation lead to accomplish the following:

• Review the proposed actions, problem statements, and milestones listed in the FIMAP to ensure alignment and clarity.
• Establish a timeline for writing the FIMAP Report.
• Draft a FIMAP report that is data-driven, outlining the purpose, goal statements, proposed actions, and milestones.
• Prepare a formal presentation on the FIMAP to seek stakeholder input/feedback.
• Incorporate insight and feedback from community partners and clinical and non-clinical professionals.
• Serve as a community member on the fetal infant mortality workgroup (FIMW) to reconvene in Summer 2023.

The Bureau of Nutrition and Physical Activity (BNPA) hosted a number of activities in 2022 related to the promotion of breastfeeding with new virtual opportunities to ensure support was not disrupted. In 2022, LATCH-AZ conferences were held in a virtual setting in both January and August. The intent of LATCH-AZ is to provide education and networking opportunities to breastfeeding promotion and support professionals. These sessions attracted a total of 685 Women, Infants, and Children (WIC) program staff, peer counselors, Strong Families home visitors, and community partners. In addition, the International Board of Certified Lactation Consultants (IBCLCs) Mentoring Program provided five (5) education sessions explicitly designed for the candidates to prepare for the examination. A total of four (4) five-day-long Virtual Breastfeeding Boot Camps were also held to educate more individuals on breastfeeding.

In 2022, the program conducted partner outreach and promoted breastfeeding courses for clinicians’ courses. There are 15 courses available, and outreach was conducted among hospital staff. This outreach was facilitated by ADHS and encouraged the Local WIC Agency Breastfeeding Coordinator to reach out to deepen the relationship and partnership between the organization and the birthing facility. By the conclusion of 2022, there were approximately 3,083 total online courses completed. Breastfeeding promotion and support related to child care centers, health care providers, and workplace accommodation programs were challenged in 2020-2022 due to the COVID-19 pandemic.

In 2020, through a partnership with the Maricopa County Department of Public Health, ADHS supported the Healthy Arizona Workplace Program (HAWP). HAWP is an evidence-based public health initiative that provides various resources to employers to develop and implement workplace plans to improve employee health and wellness using the CDC Worksite Health ScoreCard, which includes "Make It Work Arizona." The “Making It Work Arizona” toolkit materials were reprinted and updated in 2021 and can be requested online by employers to understand how to support breastfeeding mothers returning to work or school. The toolkit is designed to assist breastfeeding mothers and provide tools and information for businesses and families. In 2022, 10 employers requested toolkits and reported implementing workplace policies supporting breastfeeding.

To support families, children, and parents with newborns, Arizona’s Title V Program funds the Title V Toll-Free MCH Helplines, which BWCH and BNPA maintain. The dedicated service includes three helplines: 1. Breastfeeding; 2. Children Information Center; and 3. Women's, Infant, and Children (WIC) Program. Information is provided in English, Spanish, and Telecommunications Device for the Deaf (TDD). Title V Toll-Free MCH Helplines provided callers with information and resources about breastfeeding; the Women, Infants, and Children (WIC) Program; and other resources for children, including sliding fee scale sites for uninsured families and individuals. In 2022, the 24-hour Breastfeeding Helpline provided breastfeeding support to 7,344 calls.

The Children Information Center was enhanced and named the Strong Families AZ Helpline. Throughout 2022, the helpline was transitioned to a Google Voice platform which allows for voice and text correspondence; connected with the Strong Families AZ website chat box; and established an email address. The position of Community Support Coordinator was filled in June 2022. The individual in this position is bilingual, allowing for direct support of both English and Spanish-speaking individuals that inquire through the helpline. The use of Google Voice allows for easy access to translation services in other languages if inquiries are received. The Community Support Coordinator has been working closely with 211 to crosswalk and update available community resources with the 211 directory to eliminate the need to have a separate resource directory for those that access the Strong Families AZ Helpline. The Helpline will fully relaunch in 2023 with a rollout of the new phone number and features.

Newborn Screening (NBS) is a coordinated system of care with partners who collaborate to ensure every newborn receives a screening and the appropriate follow-up services, care, and intervention. While not within the BWCH, the Office of Newborn Screening (ONBS) partners with the BWCH on cross-cutting activities and initiatives. In the past, Title V funds were used to help support the work of the Newborn Screening Program.

The COVID-19 pandemic has continued to create numerous issues regarding timely and complete screening. For hearing screening, if a mother tests COVID-19 positive, no hearing screening is completed at all. This delay is compounded by limited to no availability to receive an outpatient hearing screening after discharge. The newborn screening program created guidance documents related to the timely collection of newborn screens and emphasized to partners that, as a public health standard of care, these timeframes should be maintained wherever possible. This guidance was sent to pediatricians by the AzAAP chapter and posted to the website under COVID-19 Guidance.

In addition, Arizona has experienced a rise in the number of out-of-hospital births over the last few years — and this number rose by 32% between 2019 and 2020, presumably due in part to the pandemic. The number of home births kept increasing in 2021 and 2022. Due to COVID-19, the number of home-birth babies receiving hearing screening decreased significantly in 2021. However, preliminary data shows a minor increase in this number in 2022.

The ONBS conducts a program to loan otoacoustic emissions (OAE) hearing screening equipment to midwives who attend home births. Since the beginning of the loan program, there has been a 50% increase in the number of infants born out of hospital who receive a hearing screening. In the summer of 2021, Title V funding was used to purchase an additional 6 OAE hearing screening kits. These kits have been deployed to high-volume urban practices and lower-volume, but rural, midwives to increase access to screening for these underserved communities. The minor increase in the number of home birth babies receiving hearing screening in 2022 can be due to the increase in loan equipment available to the midwives.

Figure 13. Newborn Screening of Out of Hospital Births, Arizona (2014-2022)

Despite the pandemic, newborns continued to be identified with conditions through newborn screening. The program added two additional conditions to the core panel: Spinal muscular atrophy (SMA) and X-linked adrenoleukodystrophy (X-ALD). Preliminary 2022 data documents that 102 newborns were identified with one of the 31 core bloodspot conditions and an additional 203 infants were incidentally identified with a condition through newborn screening. In addition, the program has identified 193 infants who were born in 2021, and 177 infants who were born in 2022 with permanent hearing loss. Preliminary data indicates 25 infants, who were born in 2023, with permanent hearing loss.

Laboratory analysis is a core function of the ONBS, and the program continued to provide bloodspot and hearing screening data to families and providers in 2022. The ONBS partnered with the CYSHCN Program on a project to lend out otoacoustic emissions (OAE) hearing screening equipment to midwives in the community to ensure that hearing screening is available to newborns born outside of a hospital. The program supports supplies needed to continue to offer this service.

The Title V program also planned to support the participation of ONBS staff at national conferences targeted at specific disorders identified through newborn screening, such as the annual National Cystic Fibrosis Conference. Again, due to COVID-19, conferences were either postponed, canceled, or virtual.

The Arizona Birth Defects Monitoring Program (ABDMP), housed within ADHS’ Business Intelligence Office (BIO), is a statewide, population-based, active surveillance program that collects and analyzes information on children with reportable birth defects diagnosed within the first year of life. Data is ascertained from hospitals and medical facilities throughout the state on liveborn children with potential birth defects and all stillborn children of Arizona residents. ABDMP works under the guidance of, and collaboratively with, the National Birth Defects Prevention Network (NBDPN) and CDC to compare data and trends, align prevention efforts, and improve referrals to services. With the support of the Title V program, ABDMP shares data to inform internal and external partners, including several programs within BWCH, BNPA, Office of Infectious Disease Services (OIDS), as well as March of Dimes, Arizona Perinatal Trust, and others.

One example is the relationship between ABDMP and BNPA. ABDMP provides annual data to BNPA to guide and support the state’s folic acid distribution program. ABDMP participated in the initial PowerMeA2Z focus groups and has continued to support and collaborate with the program. ABDMP promotes PowerMeA2Z at community events and designs projects to increase folic acid consumption, specifically highlighting PowerMeA2Z.

Highlights of ABDMP’s work are best seen through ongoing engagement with partners to foster community support and intervention for families and children with birth defects, promote prevention efforts statewide and nationally, and provide its unique perspective to partner meetings and collaborations. The Title V program funds a portion of ABDMP staff salaries, supporting ongoing birth defect surveillance, prevention, and intervention efforts.

Through continued engagement with its partners in the Division of Prevention within ADHS, as mentioned above, ABDMP assumed oversight of enhanced surveillance of NAS in 2021. Through improved and expanded surveillance and continued partnerships, we will have improved data and be better able to provide outreach and services to affected families.

Alongside the Perinatal/Infant Health activities and work headed by the OCH team and collaborators, the Office of Oral Health (OOH) and Primary Care Office (PCO) continued in their cross-cutting activities relating to Perinatal/Infant Health.

The Office of Oral Health implements a number of oral health programs and initiatives to improve the health of Arizona’s infants. It is essential that oral and dental health is addressed during pregnancy as it impacts perinatal/infant health. Lack of preventive services can lead to premature birth, low birth weight infants, and pre-eclampsia. HRSA’s Maternal and Child Health Bureau issued the Oral Health Care During Pregnancy: A National Consensus Statement on the provision of oral health services during pregnancy. Additional information about oral health activities can be found in the Women/Maternal Health 2022 Annual Report.

The Primary Care Office (PCO) within BWCH leads statewide efforts to improve access to care to all health services in Arizona’s rural and underserved communities through the State Loan Repayment Program (SLRP), the National Health Service Corps Loan Repayment Program (NHSC), and the Conrad 30 Waiver Program.

In 2022, 133 providers were obligated through SLRP. Of those providers who were awarded, 15 were Pediatric Providers (12 Physicians and 3 Nurse Practitioners), and 14 focused on Women's Health or specialized in Obstetrics and Gynecology, this included 9 Physicians, 4 Nurse Practitioners, and 1 Licensed Clinical Social Worker. The NHSC supported 41 providers who specialized in Pediatric Care (26 Physicians, 10 Nurse Practitioners, 3 Physician Assistants, and 2 Dentists). There were 25 Physicians who specialized in Obstetrics and Gynecology, 18 were Certified Nurse Midwives, and 25 additional providers specialized in Women’s Health (16 Nurse Practitioners and 9 Physician Assistants). Lastly, the Conrad 30 Waiver Program currently supports 124 Physicians, with 10 focused on Pediatrics (including specialization in Pediatric Emergency, Pediatric Pulmonology, Pediatric Genetics, & Pediatric Gastroenterology) and 2 Neonatologists.

Additional information about the Primary Care Office and Access to Care activities can be found in the Women/Maternal Health 2022 Annual Report section of the application.

In 2022, the Arizona Title V program was also called upon to participate in two of ADHS Arizona’s Health Emergency Operation Centers (HEOC) that were set up to address the nationwide formula recall and the pediatric surge in respiratory virus in Arizona.

In February 2022, Abbott, a global healthcare company, recalled all cans of powdered infant formula and shut down a formula manufacturing unit in Sturgis, Michigan due to news of cronobacter contamination of infant formula. This shutdown of the facility, combined with the pandemic-fueled difficulties in obtaining enough food and formula, led to a nationwide infant formula shortage. The shortage of formula limited the number of cans of formula available for purchase resulting in inadequate formula for infants in the country. ADHS responded by setting up three teams to address the formula shortage in Arizona. The teams included: Core Team, Information & Guidance Team, and Impact Monitoring Team. Arizona’s MCH and CYSHCN Director, Chief of the Office of Children’s Health, and the Children with Special Health Care Needs program participated on these teams. In addition, MCH Family Advisor, Dawn Bailey was also a key contributor to the Impact Monitoring Team. Weekly meetings were held for all teams and a task tracker was developed to monitor assignments, status, deadlines, and completion dates. The tracker was used to determine priorities for each task assigned. The leads of each team reported to the Core Team, made up of senior leadership, on a weekly basis to receive approvals and provide status reports. The Impact Monitoring Team focused on collecting, analyzing, and reporting data to monitor the impact on the state. The team utilized the Women’s, Infant, and Children’s data to monitor trends, and the following data sources were used to monitor the effects of the formula crisis in Arizona: Monthly redemption rate of WIC families (% of cans redeemed from those issued) each month; Weekly redemptions of top 20 formula brands and top 3 formula brands and the number purchased; and Number of cans of formula sold by WIC vendors by county and city. At the conclusion of the Formula Shortage HEOC, ADHS Impact Monitoring Team developed a Standard Work for Data Monitoring During Infant Formula Shortage Response. The standard work document includes a thorough report including background, data sources, links to resources developed, and opportunities for growth. ADHS prevention and preparedness teams also developed a GIS map, Infant Formula Shortage Preparedness to monitor and track data.

Several opportunities, contributions, and recommendations were identified as a result of AZ Title V’s participation in the formula shortage teams. The main gap identified during the formula shortage related to the impact on families with children with special healthcare needs that require specialty formulas. Some of the key contributions and recommendations as a result include:

• Improving surveillance to identify the impact on CYSHCN. The standard work document highlighted the following opportunity: “Several families with CYSHCN were identified in the Localized Hardship Tracker as having a difficult time finding formulas. The queries used in ESSENCE did not capture this population because they were mostly focused on infants 0-1 years of age. Expanding the age criteria in ESSENCE results in a minimal increase in ED events identified. ESSENCE was also limited in that it did not include data from Phoenix Children’s Hospital - a hospital routinely seeing CYSHCN. If more CYSHCN cases were identified, we could have altered the ESSENCE queries to capture these individuals. In future responses, the Impact Monitoring Team should prioritize the identification of other internal and external data sources to identify CYSHCN. In addition, we should engage AHCCCS in the data monitoring team to target impact for families that received formula as a prescription through their health plans.”
• Recommendation to include specific information directly targeting infants and children with complex medical needs on the ADHS Infant Formula landing page. The tab highlights a collection of information and resources for families who require specialty formulas through a prescription from their DME/Home Health company managed by their health plan. In addition, information for families that receive formula via the state Medicaid program, AHCCCS, could report concerns.
• Recommended utilizing funds to connect ZOIA Pharma (A current ADHS, Title V CYSHCN contractor) to apply to become an approved provider within AHCCCS so that health plans can source specialty formulas through ZOIA Pharma. This would increase access to specialty formula requests and allow for the formula to be billable through the families’ health plan. ZOIA Pharma was able to become an established vendor under one of the AHCCCS plans, Health Choice, to source some of the specialty formulas for families who are serviced under the AHCCCS plan. ADHS added 75K of Title V funding to the ZOIA Pharma contract in 2022 to support any additional specialty formula requests during that time period. This provided 56 formulas for 8 families.
• Recommend convening system partners including AHCCCS and Health Plans to understand health plan response regarding infant formula targeting a response and support of information, awareness, and education for families with Special Healthcare Needs and partners serving CYSHCN. This recommendation did not fully come to fruition as it was determined that AHCCCS was addressing this concern through their existing process to report concerns about the quality of care received via the Clinical Quality Management (CQM) online form, email, and phone number provided to members.

In November 2022, ADHS established a HEOC tasked with addressing the pediatric surge in respiratory virus affecting Arizona infants and children. Arizona, like most of the country, was experiencing high numbers of infants/children with respiratory illnesses, particularly respiratory syncytial virus, or RSV. There were national and local reports of pediatric surges in Arizona hospitals due to a severe respiratory season, driven by RSV, influenza, and COVID-19. The title V MCH & CYSHCN Director, Office Chief for Children’s Health, and MCH Family Advisor, Dawn Bailey participated in the Peds Surge Task Force and Pediatric Advisory Council. The ADHS Division of Preparedness was the lead for the HEOC and informed by key internal stakeholders including Arizona’s Title V Program. The ADHS Division of Preparedness convened the Pediatric Advisory Collaborative made up of internal and external stakeholders. The members developed and provided guidance on the following materials to support providers, acute care facilities, and families during the peds surge. The following materials were developed and shared with system partners:

• A Facilities Letter - Pediatric Resources and Considerations for Pediatric Hospital Surge for all acute care facilities.
• Key Messaging for Pediatric Respiratory Virus Season 2022-2023 for agencies, providers, and any community health workers.
• Resource Equity & Access Coordination Hub (REACH) 24/7 Centralized transfer center for Critical Access Hospitals, IHS, 638 facilities.
• Pediatric Critical Care Triage Flow Diagram and Worksheet.