The government's failure to institute a national screening program to detect Streptococcus is causing needless deaths of babies.
By JUDY SIEGEL-ITZKOVICHbaby 88(photo credit: )
Nearly every pregnant woman knows about Down syndrome, congenital heart defects, spina bifida, rubella, Tay Sachs and many other diseases that cause newborn babies to die or be severely disabled. Yet very few have heard about GBS - group B Streptococcus - infection, the leading cause of life-threatening disease in the early neonatal period.
This condition can be detected with rectal or vaginal cultures during the 35th to 37th week of pregnancy, or even just before delivery, and serious damage to or death of the baby can be prevented by intravenous antibiotics during labor. But the plodding, budget-cutting Health Ministry hasn't taken the logical step of requiring all pregnant women in Israel to undergo simple swabs a few weeks before delivery - even though the US Centers for Disease Control and Prevention (CDC) in Atlanta recommended this practice several years ago and its adoption has quickly brought down the deaths and disease of newborns in the US. The CDC's policy was endorsed by the American College of Obstetricians and Gynecologist, and by the American Academy of Pediatrics without hesitation.
GBS is found in the lower intestine of 10% to 35% of all healthy adults, and in the vagina and/or lower intestine of 10% to 35% of all healthy women. It is not considered a sexually transmitted disease, and should not be confused with group A strep, which causes strep throat or tonsillitis. A person who carries GBS bacteria but does not show signs of infection is said to be "colonized" or to be a carrier. GBS colonization is not contagious, as the bacteria are a normal part of the human body. Normally, the presence of GBS doesn't cause problems, but in certain circumstances, the bacteria can cause serious infection. Typically, babies are exposed to GBS during labor and delivery; they may also be after the mother's water breaks. Babies can come in contact with bacteria that move from the mother's vagina into the uterus. Babies may also be exposed while passing through the birth canal if they swallow or inhale the bacteria. GBS may also cross intact membranes to expose the baby while it is still in the womb; there it may cause preterm births, stillbirths or miscarriages. Giving a baby high doses of penicillin after GBS is diagnosed doesn't offer much protection, so early action is vital.
UNTIL THIS policy change took effect in the US, about 8,000 American babies contracted serious GBS disease each year. Up to 800 died from it; and about a fifth those who survived GBS-related meningitis were left permanently handicapped. Today, the annual numbers of infant GBS infections and deaths in the US have been cut by over 70%, even though the number of women who carry the bacteria remains the same.
This policy change was largely the result of lobbying by US parents whose babies were victims of this infection. United in the Group B Strep Association, they lobbied the medical establishment for prevention standards while promoting routine screening and vaccine development. Parents took their GBS-disabled children to members of Congress and distributed hundreds of thousands of educational pamphlets. They appeared on talk shows and ran marathons to raise money and awareness.
None of this took place in Israel.
The Health Ministry in Jerusalem - citing statistics about lower GBS infection and death rates here than in the US (perhaps due to less-virulent bacterial strains) - has not taken action or questioned last year's recommendation by the National Council for Obstetrics, Genetics and Neonatology against changing guidelines. So GBS is tested for only in "high-risk" women rather than in every pregnant woman.
"This is a panel of highly qualified experts, and we accepted their recommendation," says Prof. Yona Amitai, a toxicologist who heads the ministry's department of maternal, child and adolescent health. "One doesn't zigzag on public health policy. You have to count on expert opinion," he told The Jerusalem Post.
But Amitai had still not read the expert opinion published in the Israel Medical Association Journal (IMAJ) last October, of Prof. Michael Schimmel, director of Shaare Zedek Medical Center's neonatal intensive care unit, former chief of pediatrics Prof. Arthur Eidelman, Dr. Vered Eisenberg of the hospital's obstetrics and gynecology department and colleagues in Jerusalem. In that article, titled "Prevention of Early-Onset Nenatal Group B Streptococcal Infection: Is Universal Screening by Culture Universally Applicable?" the authors noted that the carrier rate of GBS in pregnant women is more common than it was, and stated: "We now recommend routine prenatal screening for GBS."
After The Jerusalem Post pointed out an article in the December 2006 issue of Harefuah on the subject by Drs. Zalman Weintraub, Leonid German and colleagues at Western Galilee Government Hospital in Nahariya, Amitai commented: "In view of the research in Harefuah at Nahariya Hospital, we will ask the national council to discuss the subject again."
Asked for statistics on neonatal GBS cases in Israel, Amitai checked the records and found that "43 newborns" were reported to have contracted group B Streptococcus infections in 2004, out of 144,00 babies born that year. Of these, three died.
Many experts think that is three too many - three healthy children who went to their graves with a preventible condition.
THERE ARE dozens of GBS support groups based in the US, which for five years has marked Group B Strep Awareness Month. One of them is on a Web site called The Jesse Cause (www.thejessecause.org/pages/home.html), established by Chris and Shelene Keith, whose son Jesse was born with GBS and then got meningitis, sepsis and hydrocephalus, resulting in three brain operations.
"The Jesse Cause," they wrote, "was founded in hopes of sparing other families the devastating effects of GBS. Our mission is to distribute our brochure about GBS to pregnancy-related medical centers nationwide and worldwide to promote GBS awareness. A woman with GBS can pass it on to her fetus when she is pregnant or to her baby during delivery or after birth. But with testing, monitoring and treatment, 86% of GBS cases can be prevented."
When a Canadian baby named Hannah died of GBS complications, friends of her mother Pam made special T-shirts and wore them whenever they went out. Each time a colleague, friend, family member or stranger asked what the shirt was about, they would offer details about GBS and Hannah. "I don't think most women know how serious this can be, and I'm happy to be able to do something in Hannah's memory that could help prevent other tragedies," says one mother, Tory Tanaka.
"I had 10 women come up to me the first day I wore the shirt, and only one had a doctor that was cautious with GBS," says another mother, Teresa Thomas. "One in 20 babies with GBS die because of the infection. Babies who survive often have long-term problems, such as blindness, hearing loss or learning disabilities. It is shocking to me how many women have no idea what GBS is or how dangerous it can be. You might save someone from a lifetime of heartache just by taking that one minute to share," says a third, Kara Stewart.
THE AWARENESS level is undoubtedly much lower in Israel.
Schimmel, who just two weeks ago was elected chairman of the Israel Neonatology Society, told The Post in no uncertain terms that he favors universal screening. "I would that all pregnant women undergo a culture during the 35th to 37th week, but until then, high-risk women must be screened."
High-risk cases involve premature labor, or when the membranes rupture ("water breaks") more than two hours before the baby is born; if the mother has a fever before or during labor; and when women have a history of GBS in previous births.
Shaare Zedek's study in IMAJ showed that the GBS rate is higher in Jerusalem than in most parts of the country, and highest among immigrants from North America and the former Soviet Union. These two groups alone constitute almost 15% of the population.
"The rate has long been higher than average in Jerusalem," says Schimmel. "We don't know why. Now we learn from another study that the GBS rate in Beersheba is increasing, and that it is higher in Arab women. Now Harefuah shows it is higher in the north. Our Jerusalem study sampled 629 women admitted for labor and delivery to Shaare Zedek during five months in 2002. The GBS carrier rate was 13.7%, with 21% among women of North American origin. Eight newborns had early-onset GBS," according to Schimmel, whose findings raise questions about the accuracy of the 43 figure given by Amitai for all of 2004 in all the country's hospitals. "We looked at sub-groupings, but it's a hassle to ask women where they come from. The logical thing is to do national screening of all pregnant women so nobody falls between the chairs," Schimmel declared.
WITH ALL the tests and ultrasound scans that Israeli women undergo during pregnancy, some of them unnecessary, Schimmel said he didn't understand why all are not sent for a vaginal and rectal culture "at negligible cost. Giving antibiotics intravenously during labor can prevent sepsis and meningitis in not a few cases. These infections can cause damage for life." Although there are reports that giving intravenous antibiotics might increase resistance of bacteria to penicillin or raise the risk of childhood asthma, Schimmel said he was not convinced, and that studies have proven otherwise. "I can't explain why the advisory committee didn't recommend universal screening to the Health Ministry."
Rabin Medical Center Prof. Marek Glezerman, who headed the advisory council that in 2004 advised the Health Ministry not to institute universal screening, told The Post that the senior experts "struggled with the issue. We decided according to evidence-based medicine. The Cochrane Library on which this is based does not recommend universal screening, but testing only of high-risk patients and those in certain areas. Policy abroad is not necessarily relevant to Israel, as the number of GBS cases here is way below that in the US." Asked about the 43 GBS cases and three deaths in 2004, Glezerman said he does not know who they are.
"Maybe they were Beduin who did not get to the hospital for delivery and treatment? Universal screening might not have saved them." But he said that if impressive new evidence is presented, he would be willing as a council member to reconsider.
Eidelman, who although retired is now planning Shaare Zedek's children's hospital and whose research studies are frequently quoted in the Harefuah article, says: "The rule of thumb is that you do screening when the percentage of carriers is significant. Past surveys excluding Jerusalem showed the rate did not exceed 10%, but new studies show it is going higher. The GBS issue should be put on the agenda again, even though it has come up many times."
He can't say for sure what causes higher rates, or why it is higher in Jerusalem than elsewhere. In women of English-speaking or Western European backgrounds, GBS rates are higher, maybe because of greater use of oral contraceptives or more sexual activity. But the screening test costs less than a dollar. There are some false negatives but no false positives [women who don't have it but who come up positive]. We have brought the issue up with the ministry, which says there is no justification for testing outside Jerusalem. If higher rates are found in other parts of the country, national screening would be justified. Personally, I recommend screening every pregnant woman in the third trimester. Most obstetricians at Shaare Zedek routinely screen their patients."
Researchers are working to develop a GBS vaccine that would stimulate the immune system to create antibodies which could cross the placenta later in pregnancy and protect the baby. Although widespread use of a vaccine is still years away, vaccination will one day protect babies and others from this bacterial infection.
Let's hope the health establishment wakes up before that.
