“To change is difficult. Not to change is fatal.” William Pollard
Guidelines for group B Strep screening and education.
First and foremost, we must remind everyone that routine screening of all pregnant women for group B Strep carriage is not recommended by the UK National Screening Committee nor the Royal College of Obstetricians & Gynaecologists. Screening for the most common cause of life-threatening infections in newborn babies and babies under three months is not currently recommended. Screening does however routinely take place in countries like Australia, Argentina, Belgium, Canada, Chile, Czech Republic, Dubai, France, Germany, Hong Kong, Italy, Japan, Kenya, Lithuania, New Zealand, Oman, Poland, Spain, Slovenia, Switzerland and the USA. Just so we’re clear at how far behind the UK is on this issue.
The current UK policy is centred around a ‘risk factor’ approach to determining which babies are at-risk. Risk factors include Mum carrying GBS this pregnancy, high temperature during labour, labour starting or waters breaking prematurely and having previously had a baby infected with GBS. The hope was that this strategy would reduce the rate of early-onset GBS infections in babies by up to 50%. Unfortunately these hopes have been dashed by the fact that the rate has barely changed. Furthermore, up to 40% of babies who do become infected are born to mothers without any of these clinical risk factors. So then how is this particular strategy working for us? It simply is not.
In those countries that do offer universal screening to pregnant women to identify group B Strep carriage, including the US, they have seen much progress. Rates of infection have reduced by up to 86%! What’s even more frustrating is the fact that the current risk based strategy here in the UK was introduced in 2003 after research came out in 2002 stating that antenatal screening strategies would prevent more cases of group B Strep infection in newborn babies than risk-based strategies. So then why would one opt for the less successful approach? We simply do not know.
These risk factors are showing us time and again that they are not accurate predictors of GBS infection in newborn babies. In a UK study from 2011** we learned that 21% of women carried group B Strep at delivery. 19% of women with NO risk factors still were GBS carriers. 71% of women WITH risk factors did not carry group B Strep. Again, how is it not clear that this strategy is epically failing us? There is, of course, the argument that the reason the rate of infection has not changed much is because of better reporting; i.e more group B Strep cases are being documented since 2003. Well, that may be, but if the risk based approach was actually worth its salt then wouldn’t we see some marked difference/decrease?
The other argument would be that of cost. Surely the amount of money that is being spent on treating avoidable infections (due to lack of screening) is more expensive than a simple ECM swab test? Last year Public Health England estimated the cost per test was only £11. £11! And isn’t it interesting that the NHS will fund tests for smoking in pregnancy, but not the cause of life threatening infections? They also recently introduced Maple Syrup Urine Disease testing for all newborns, a condition that affects an estimated 1/116,000 babies born. Clearly it’s important to identify and treat those babies as well. But why then are we not also screening for something that 2-3 out of every ten women carry, a bacterium that produces a 1/300 chance of baby developing a group B Strep infection, an infection that kills 1/10 of these sick babies?!
To add insult to injury, there seems to be a stalwart resistance to change and education across the board.
- Public Health England has had since 2006 a standard for processing swabs that test specifically for group B Strep in their UK Standards for Microbiology Investigations B 58.
- NICE: The 2008 and 2011 reviews of the guidelines for ‘Antenatal care: Routine care for the healthy pregnant woman’ did not update the sections relating to group B Strep in the light of new evidence since 2003, despite requests by a number of stakeholders. The NICE ‘Induction of Labour’ and ‘Postnatal Care’ guidelines contain no mention at all of babies born to women carrying group B Strep.
- UK National Screening Committee: During the 2012 public consultation, 212 written responses were received and 207 were published on their website. Of these, 93% were in favour of introducing screening for group B Strep in pregnancy and fewer than 4% were against. To say this decision, which went against the opinions of the overwhelming majority who took the time to comment, was hugely disappointing would be the understatement of the year.
This topic is especially pertinent as we near the end of 2014, because between the New Year and 2016 these guidelines will be coming up for review by the UK National Screening Committee. The Royal College of Obstetricians and Gynaecologists will also be reviewing their group B Strep guidelines. We move forward into 2015 with the firm belief that “We seem to gain wisdom more readily through our failures than through our successes. We always think of failure as the antithesis of success, but it isn’t. Success often lies just the other side of failure.” Leo F. Buscaglia
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**(Intrapartum tests for group B streptococcus: accuracy and acceptability of screening Daniels JP, Gray J, Pattison HM, Gray R, Hills RK, Khan KS; GBS Collaborative Group. BJOG. 2011 Jan;118(2):257-65. Epub 2010 Oct 13. Full article at http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2010.02725.x/pdf)