1. Jane Plumb MBE, Chief Executive jplumb@gbss.org.uk Group B Strep Support

2.  Charity, set up in 1996  Key aim: stop preventable GBS infection Inform & support families Inform health professionals Support research  Independent  Medical advisory panel

3. Free Information Materials  Introductory leaflets  Detailed information  Posters  Stickers for notes  PowerPoint presentations  Free to download

4. Medical Advisory Panel Prof Philip Steer BSC MD FRCOG (Chair) Emeritus professor at Imperial College & consultant obstetrician at the Chelsea and Westminster Hospital, London Dr Alison Bedford Russell MRCP Clinical Director NICU, West Midlands Strategic Clinical Network Maternity & Newborn Clinical Director, Hon Assoc Clinical Professor Warwick Medical School, Birmingham Women's NICU Philippa Cox Consultant Midwife, Supervisor of Midwives, Homerton Hospital, London Dr Guduru Gopal Rao, OBE Consultant Microbiologist, North West London Hospitals NHS Trust

5. www.gbss.org.uk

6. Group B Streptococcus Streptococcus agalactiae  Colonisation Asymptomatic & intermittent Intestinal (<30% of adults) Vaginal (<25% of women)  Infection (1588 cases E,W & NI 2012) Babies Adults: the elderly, pregnant/postpartum women, others with underlying disease

7. GBS infection in babies  Most common cause of severe infection in newborn babies  Most common cause of meningitis in babies under 3 months  Most are early onset (0-6 days) 270 EO and 168 LO in EW&NI in 2012 (PHE)  10% mortality  Pneumonia, septicaemia, meningitis  50% GBS meningitis survivors suffer long term sequelae

8. UK GBS disease 0-90 days: Age at onset Source: Heath PT, Schuchat A. Perinatal group B streptococcal disease. Best Practice & Research Clin Obs Gynaec. Vol 21, No 3, 411-424. 2007.

9. Early onset GBS infection (0-6 days) ~ 75% cases  90% show symptoms 0-12 hours  Usually septicaemia & pneumonia  11% mortality  7% morbidity  0.36/1000 reported rate (unchanged since 2003)  90% preventable IV Penicillin

10. EOGBS prevention  Intrapartum Antibiotic Prophylaxis (IAP) reduces early onset GBS infection  Offer of IAP triggered by: Screening (most developed countries, including Australia*, Argentina, Belgium, Canada, Chile, Czech Republic, Dubai, France, Germany, Hong Kong, Italy, Japan, Kenya, Lithuania, New Zealand*, Oman, Poland, Spain, Slovenia, Switzerland & USA) Risk factors (UK, Denmark, Netherlands …)

11. UK RCOG 2012  First published 2003  Reviewed published 2012 Routine bacteriological screening for all pregnant women for antenatal GBS carriage is not recommended

12. UK RCOG 2012 – prompt IAP

13. UK RCOG 2012 – risk factors

14. NICE Antibiotics for Neonatal Infection CG149 (2012)  Offer IAP as RCOG plus: Consider IAP in preterm labour if prelabour rupture of membranes of any duration Consider IAP in preterm labour if suspected/ confirmed ROM >18 hours

15. PHE Standards for Tests Processing Swabs for GBS Carriage - B58 (2006, updated 2012, under review)  “…provides a standardised method for culture where clinicians decide to investigate specific patients …”  Rarely available in NHS Investigation of Genital Tract & Associated Specimens – B28 (2003, updated 2014, under review)  “… patients judged at high risk for the development of group B streptococcal infection may be screened for carriage. Optimum yield will be achieved by selective/enrichment procedures applied to swabs obtained from the vagina and the anorectum”

16. England & Wales GBS infection 2003 - 2012 RCOG guidelines introduced Nov 2003 PHE data, series online http://ow.ly/DHgZchttp://ow.ly/DHgZc

17. GBS Infection – USA EO & LO GBS disease 1997-2013 Source: Active Bacterial Core surveillance areas, series online http://www.cdc.gov/abcs/reports-findings/surv-reports.html http://www.cdc.gov/abcs/reports-findings/surv-reports.html

18. Reduction of EOGBS incidence in other countries  Australia 82% (Daley et al, 2004)  Spain 86% (Andreu et al, 2003)  France 71% (Albouy-Llaty et al, 2011)  USA 86% (Jordan et al, 2008)

19. EOGBS known risk factors  Previous GBS baby 10 x  GBS bacteriuria this pregnancy 4 x  GBS found current pregnancy 3 x  Maternal intrapartum fever 3 x  PROM >18 hours 3 x  Preterm labour 3 x 40% of EOGBS babies have no known risk factors

20. Countries routinely screening pregnant women for GBS Australia* Argentina Barbados Belgium Brazil Canada Chile Czech Republic Dubai France Germany Hong Kong Italy Japan Kenya Lithuania New Zealand* Oman Poland Spain Slovenia Switzerland USA Dual (screening or risk factors)

21. Concerns about increased use of antibiotics Page 58: A recent UK HTA found that about 22% of women had at least one risk factor, therefore if IAP were given to every woman with a risk factor, a similar number would be expected to be treated with IAP as would be expected if they had been screened

22. Would screening be too costly? BMJ. 2007 Sep 29;335(7621):655

23. Colbourn et al BMJ. 2007 Sep 29;335(7621) Baby life years saved Cost compared with current practice

24.  Current best practice (to treat only high risk women without prior testing for infection) was not a cost effective option  Immediate extension of current best practice to treat all women with preterm and high risk term deliveries without testing (11% treated) would result in substantial net benefits.  Currently, addition of culture testing for low risk term women, while treating all preterm and high risk term women, would be the most cost effective option (21% treated). BMJ. 2007 Sep 29;335(7621):655.

26. Daniels et al 2009  Modelling analysis revealed that the most cost-effective strategy was to provide routine intravenous antibiotic prophylaxis (IAP) to all women without screening.  Removing this strategy, which is unlikely to be acceptable to most women and midwives, resulted in screening at 35– 37 weeks’ gestation being most cost effective (assuming that all women in premature labour would receive IAP)

27. The most cost-effective strategy was shown to be the provision of routine intrapartum antibiotic prophylaxis to all women without prior screening. This is unlikely to be acceptable. In its absence, intrapartum antibiotic prophylaxis directed by screening with enriched culture becomes cost-effective. The current strategy of risk-factor-based screening is not cost- effective compared with screening based on culture.

28. Penicillin allergy?  True allergy (anaphylaxis) is rare – 1 in 10,000  Mortality very low when given in hospital with an I/V running  No deaths from anaphylaxis in 1.8M administrations in USA Law MR, Palomaki G, Alfirevic Z, et al. The prevention of neonatal group B streptococcal disease: a report by a working group of the Medical Screening Society. J Med Screen 2005;12:60-68.

29. Current RCOG/NSC approach is inconsistent GBS carriage found by chance =) offer IAP  Why should women with unknown status be denied the opportunity to find out if their baby is at raised risk?  Logically, either we should know everyone’s GBS status, or ignore it completely.  Risk based approach, if followed properly, would result in 21% of women being offered IAP (NSC report, 2012) with only 29% being GBS +ve Why not give IAP to those actually at risk, and not give it to those who are negative?

31. Before Idriss’s birth at Whittington Hospital in Archway on March 5, 2007, maternity staff had diagnosed her as being a carrier of GBS. The court heard that providing simple antibiotics during labour would have prevented it spreading to Idriss. He was unable to cope with the infection and the stresses of labour.

32. Five key principles underpin the recommendations in this guideline: 1. Unless it is dangerous, families should be offered choice. The guideline includes recommendations to support families in making choices through provision of information and, where appropriate, reassurance.

33. What do women want? Bounty Word of Mum™ Research Panel  Online questionnaires run bi-monthly  Women in early pregnancy to youngest aged 2-5  2013 (2102 interviews)  2010 (2226 interviews)

34. 59% of Mums heard of GBS from a non-medical source How/ where heard about GBS Base: All who are aware of GBS (1,277)

35. Group B Strep Knowledge Have been able to find sufficient information on GBS Base: All who are aware of GBS (1,277)

36. Group B Strep testing Base: All respondents (2,226)

37. Midwives/student midwives 2013 163 Midwives completed the survey  98% had heard of GBS and many had read the relevant guidelines: 46% their Hospital Trust’s GBS guidelines 35% NICE Antenatal Care guideline 20% NICE Antibiotics for Neonatal Infection 16% RCOG’s GBS guideline

38. Knowledge of GBS guidelines

39. Rate per 1000 live births of EOGBS infection in E&W 5% knew rate/1000 live births had increased by 465 in decade to 2010* *Lamagni paper, published summer 2013

40. Midwives/student midwives 2013 7% midwives optimal testing for GBS carriage was LVS + rectal swabs, cultured in enriched media

41. Midwives: testing for GBS  62% in favour; 9% against, 21% undecided

42. Midwives: information  56% said they had adequate information about GBS  51% said they felt sufficiently well informed enough to talk about GBS to families in their care

43. GBSS wants  All women should be offered sensitive testing for GBS carriage in the latter weeks of pregnancy  ‘Gold standard’ Enriched Culture Medium (ECM) test should be used when pregnant women are tested for group B Strep carriage and  Information about group B Strep should be given to all expectant and new parents, and their health professionals, to include: how to prevent EOGBS infections, what the signs of GBS infection in babies are, and what action to take in the event any signs develop.

44. GBSS will continue to  Be an active stakeholder on any guidelines affecting group B Strep  Ensure decision makers are provided with key evidence to improve prevention of EOGBS infection  Provide evidence-based information & support to families affected by GBS & their health professionals  Support research to improve prevention of GBS infection in babies  Call for better information to be given to expectant & new parents & their health professionals about GBS within the NHS

45. Change is long overdue Theo Plumb, 19-20 March 1996 Jane Plumb MBE Chief Executive Group B Strep Support 01444 416176 jplumb@gbss.org.uk