International Group B Strep Awareness Month: What Should I Know About GBS Disease?

July is International Group B Strep Month. This blog post gives an overview of the illness and its impact on pregnant women around the globe.

Group B Streptococcus bacteria (GBS), also known as Streptococcus agalactiae, typically colonize the gastrointestinal and genitourinary tracts, the throat, and the skin. GBS disease is caused when bacteria enter a normally sterile site such as the blood, bone, or spinal fluid. Both children and adults can develop GBS disease. The disease usually develops in infants that are 0-90 days old and adults that are 60 years of age and older with underlying chronic illnesses. There is currently no vaccine for GBS disease.

Although GBS may come from unknown sources, one out of four pregnant women are carrying the bacteria in their vagina or rectum and can vertically transmit an infection to their newborns. Infections occur during labor (“early-onset disease” or EOD) or within the first week of life through three months of age (“late-onset disease” or LOD). Symptoms can be difficult to distinguish from other infections and range from fever, difficulty breathing, lethargy, and “blue” skin. Severe symptoms that can develop in newborns and infants include sepsis and pneumonia. Meningitis is more likely to occur in infants or newborns with LOD. Complications from GBS disease may result in preterm delivery and lead to developmental disabilities or death. According to the Centers for Disease Control and Prevention (CDC), risk factors for pregnant women include:

  • Testing positive for group B strep bacteria late in the current pregnancy (35-37 weeks pregnant)
  • Detecting group B strep bacteria in urine (pee) during the current pregnancy
  • Delivering early (before 37 weeks of pregnancy) 
  • Developing a fever during labor
  • Having a long time between water breaking and delivering (18 hours or more)
  • Having a previous baby who developed early-onset disease

Since 1970, GBS disease has been a topic of concern in health care, research, and public health circles. In 1989, the death of three newborns from GBS disease led to the development of public awareness campaigns that called for improved education, detection, and preventive resources in the U.S. Furthermore, around this time, data collected by the CDC revealed that GBS disease was the leading cause of death in newborns. Parents and advocacy groups actively demanded guidance that would allow for routine screening and the development of an effective vaccine for pregnant moms, globally. Below is a timeline of how advocacy efforts led to research, policy change, and the implementation of effective interventions:

Brief Timeline of GBS Disease Awareness, Education, and Prevention Efforts

  • 1990 Group B Strep Association US/International is created. Its primary goals are to:
    • Educate the public about GBS infections.
    • Promote prevention of neonatal GBS infections through routine prenatal screening.
    • Promote the development of a GBS vaccine.
  • 1991 GBS researchers awarded a 5-year grant to begin research on a vaccine for  GBD disease
  • 1992 American College of Obstetrics and Gynecology and American Academy of Pediatrics publish position papers for members
  • 1996 CDC Call for Content on GBS Prevention Protocol in (January MMWR)
  • 1996 CDC, ACOG, AAP published first consensus statement on GBS National Prevention Guideline in June
  • 1997 Group B Strep Association launches its first website
  • 2002 The National Consensus Guidelines recommending routine screening for all pregnant woman was published
  • 2008 The CDC Active Bacterial Surveillance Core published data that showed an 80% drop in GBS neonatal morbidity and mortality
  • 2014 WHO convened the first meeting of the Product Development for Vaccines Advisory Committee (PDVAC); GBS and RSV identified as pathogens that cause a large burden of disease

Globally, it is estimated that EOD makes up 60-90% of GBS disease cases. The mean incidence of GBS disease in infants 0-89 days old is estimated to be .53 cases of GBS infection/1000 live births. The highest incidence of cases is reported to be in the continent of Africa, however, additional studies need to be conducted in low-income countries to better assess the true burden of disease. Prevention methods worldwide include providing prophylactic treatment (antibiotics) to women that are either high-risk or have tested positive for GBS, during labor. With treatment, there is only a 1/4000 chance of the baby becoming infected compared to a 1/200 chance if no treatment is given. In order to identify those who qualify for treatment, a culture-based method can be used to screen all pregnant women between 35-37 weeks for vaginal or rectal colonization of GBS. On the other hand, a risk-based method identifies pregnant women with risk factors for EOD such as fever, preterm delivery, and being in labor for 18 or more hours.

Although the administration of antibiotics during labor reduced EOD from .75 cases of GBS infection/100 live births to .23 cases of GBS infection/100 live births, GBS disease morbidity in infants and mothers is still significant and likely underreported. Antibiotic treatment and GBS disease education are more accessible to pregnant women in high-income countries than those in low-middle income countries. It is likely that challenges related to access to care and health system deficiencies limit the use of antibiotic treatment in low-middle income countries. As a result, the development of a cost-effective vaccine may be able to help bridge an awareness gap.

According to the World Health Organization (WHO), developing a vaccine for maternal immunization is a priority when it comes to GBS disease. In 2016, the WHO Product Development for Vaccines Advisory Committee held a technical consultation to discuss vaccine development. Ultimately, the committee determined that the global burden of GBS disease cases that result in stillbirths needs to be assessed. In addition, standardized antibody assays need to be developed in order to find correlates of protection. Vaccine targets such as the type III capsular polysaccharide (CPS) and proteins on the GBS bacterial surface have also been identified. As new vaccine development ideas for GBS disease are being discussed, here are some foundational components that the Group B Strep Association (US/International) and Group B Strep Support (UK/EU) groups feel have an important role to play in the introduction of the vaccine to pregnant women across the globe:

  • Standardized definition of disease worldwide.
  • Standardized monitoring of disease worldwide.
  • Routine prenatal care widely available in which a vaccine can be delivered.
  • Education of health professionals and parents and expectant parents about group B Strep and the vaccine.

Check out these CDC podcasts, if you want to learn additional information about GBS disease during International GBS Awareness Month!

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The Dire State of Reproductive Rights Worldwide

Each day, an estimated 830 women die of preventable causes related to pregnancy and childbirth. Disproportionately affected are adolescent girls and women living in rural and impoverished areas. Providing women with universal access to family planning is one important and cost-effective way to help reduce maternal deaths. Doing so would decrease maternal deaths by a third. In developing countries, investing in family planning would lead to 2.4 million fewer unsafe abortions (one of the top causes of maternal deaths worldwide according to the WHO) and 5600 fewer maternal deaths related to unintended pregnancies. In addition, it would decrease infant mortality by anywhere from 10 to 20%.

Availability of family planning services has clear benefits in protecting the health of women and children, but it also offers so much more than that. When women can plan the timing and spacing of their pregnancies, women are more likely to attend and finish school; achieve higher levels of education; gain access to better job opportunities; contribute positively to her community; and improves the chances that she will invest in her children’s health, education, and well-being. In short, when women do better, societies do better.

This is all at grave risk now. As part of Trump’s first executive order, he reinstated the global gag rule which when implemented, states that the US can withhold family planning foreign assistance to any foreign non-governmental organization that so little as provides information on abortions, and that’s even if the organization receives funding from other sources. It’s important to note that the US already prohibits any foreign assistance from funding abortions under the Helms Amendment, which has been in place since 1973.

The re-enactment of the global gag rule comes as no surprise, as historically it has been re-enacted by every Republican president since Reagan then overturned by every Democratic president. Ironically although it has been argued that the gag role was put into place to decrease the number of abortions, a Stanford study found that abortions actually increased in years that the gag rule was in effect. It has also been shown that cutting off family planning funding to these organizations severely limits and in some cases, completely ceases, their ability to provide contraceptives and reproductive health services, thus increasing unintended pregnancies and unsafe abortions and further worsening maternal health outcomes.

The newest reinstatement of this rule however, extends far beyond the scope of the original rule and withholds all US global health assistance, not just family planning foreign assistance, to organizations that perform or provide any counseling, referrals, information, or advocacy on abortions. This revision of the global gag rule will not only hurt the millions of women in some of the poorest areas of the world who heavily rely on US-funded organizations which provide family planning services like contraception, but now impacts vulnerable men, women, and children alike. That’s because many of these organizations provide so much more than reproductive health services. Many of these organizations are hospitals and clinics, which in addition to reproductive health services, provide the full spectrum of medical care including life-saving childhood vaccinations, treatment for survivors of gender-based violence, HIV prevention and care, prenatal and postnatal care, and play a vital role in preventing the spread of infectious diseases like Zika and Ebola.

This is an unprecedented setback for the global health community and a huge threat to the advances that we have made in the fight against emerging infectious diseases, HIV/AIDS, and maternal and child mortality to name a few. We cannot let the progress we’ve worked so hard for be eradicated. Let us always remember that progress is something we must work for everyday, a call to action that is becoming more imperative in the precarious times ahead of us.

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US support for family planning foreign assistance currently stands at $575 million to 40 countries. With the institution of this new rule, $9 billion of global health assistance to 60 countries is currently at stake.

Here are a few ways to get involved:

Read APHA’s statement opposing reinstatement of the global gag rule.