By Sharon Atieno
Group B Streptococcus (GBS) remains a major global health threat, with an estimated one in five (some 18 million) pregnant women carrying these bacteria annually. It is responsible for approximately 400,000 cases of invasive disease annually in infants, including sepsis and meningitis and is linked to nearly 91,000 infant deaths and 46,200 stillbirths worldwide. Low and middle-income countries bear the brunt, with access to screening, preventive antibiotics during childbirth and advanced neonatal care remaining uneven.
Dr. Nelly Bosire, an obstetric/ gynaecologist, explains further about the burden of this bacteria in Kenya, its implications and management.
Q: What is the state of neonatal mortality in Kenya?
A: In Kenya, the neonatal mortality rate is 21 out of every 1,000 babies born within the first 28 days of life. This period is considered the most delicate in childhood. This rate signifies that 50% of all children who die before their fifth birthday do so within these first 28 days. If a child survives the first 28 days, their 50% chance of dying before they see their fifth birthday is spread over a five-year period. This highlights the critical importance of newborn or neonatal care in reducing infant death and enabling more children to reach their fifth birthday.
Q: What is the leading cause of neonatal deaths?
A: When we talk about neonatal health, we know that the leading cause of why our babies die is inability to breathe what we call birth asphyxia. But we also know that these babies who get asphyxia will have to end up in the newborn unit. Even when they may have had a chance of surviving that asphyxia, the likelihood of catching infections while in the newborn unit is so high that then the infection becomes a very key cause of death even when it may not have been the first reason why these babies were admitted in the ward anyway.
Q: What is the reason behind this infection?
A: Looking at the various reasons why the babies get infection, Group B Streptococcus (GBS) is actually ranking very highly. It is actually the leading bacterial cause in a lot of the studies that have been carried out, not only in the developed world, but also in our sub-Saharan Africa space.
Q:What is GBS and how is it transmitted?
A: GBS is bacteria that primarily resides in the gastrointestinal tract, from the mouth to the anus, where it typically maintains a symbiotic relationship, aiding digestion and nutrient absorption. However, a disruption in the balance between the bacteria’s presence and the immunity in the body can lead to disease.
GBS can exist in the female genital tract, often without symptoms, but can cause discomfort and discharge, requiring treatment. While it can be transmitted to male sexual partners, it is not classified as a sexually transmitted infection due to its diverse modes of transmission.
The challenge arises when GBS migrates from these natural habitats to other body systems. In adults, this can cause severe pneumonia, especially in immunocompromised individuals. For newborns, whose immunity is almost zero at birth, GBS is particularly dangerous as it can easily spread throughout the body, leading to severe infections such as meningitis and pneumonia. This vulnerability in infants is a key concern.
Q: What implications does GBS have on infants?
A: If a newborn survives such an infection, the damage, especially to the brain, can be irreversible, leading to lifelong developmental delays. This is due to the brain’s limited capacity to replace damaged cells.
Q: With evidence showing that GBS is a leading bacterial cause, how is it being managed?
A: Currently, our biggest way of being able to minimize this risk to the babies is what we call intrapartum antibiotic use. Intrapartum antibiotic use means that when the mother comes in labor, we are able to class her as a high risk mother and then we are able to start treatment. Treating the mom to protect the baby. If the mother is not infected, then she’s unable to pass on the infection to the baby.
Q: Is there a difference in how GBS cases are managed in developing countries like Kenya and the developed world?
A: In the world where resources are not the limitation, this screening is not done in labor. They actually screen mothers at about 37 weeks of pregnancy so that any mother who is found carrying this bacterium without symptoms is treated in advance and is birth ready so that they are not passing on this infection to their unborn baby. Worst case scenario, they will be screened immediately they show up in labor.
In our setting we know we don’t have the capacity to do generalized antenatal screening which is the ideal. We know how limited our resources are. Screening a woman who is pregnant or in labor requires what we call a swab culture. At the very least, and once the babies arrive, we want to do a blood culture. In our setup, doing a culture irrespective of which culture you’re doing is something that is beyond a lot of people’s affordability.
These are some of the conversations we must rethink when we talk about comprehensive maternity care because some of these are not thought about when we are looking at what does our package for antenatal care look like. If we’re not able to screen all mothers, can we screen the high-risk mothers? What does this mean? Who establishes who is a high-risk mother?
We don’t have a proper dissemination tool that even the midwife in a very remote area can look at a mother and check a box and say this mother meets a requirement for being a high risk mother for group B streptococcal infection. Even the referral systems for such a case, is challenging. We’re already struggling with getting appropriate referrals for other non-maternal and newborn complications. This is an additional burden that we have to think about.
Q: Immunization is one of the ways that is being recommended by researchers as a means of dealing with GBS, what’s your take on this?
A: We have vaccinated mothers for tetanus for years in this country. We know that it is easy, affordable, and sustainable. We have done this for tetanus toxoid for the last almost 40 years. We have been able to drastically reduce neonatal tetanus. People fail to understand that when we vaccinate the mum in pregnancy, it’s not for mum. It is for the baby, the unborn baby who at birth has even no capacity to create sufficient protection for themselves even if we gave them a vaccine at birth. There are very few vaccines we give at birth that the baby can actually effectively respond to them and create the protection they need. When we vaccinate the mum, she is able to make the antibodies and pass it to the baby while still in the womb. When we effectively do that, then the baby comes with some level of protection. That yes, it is going to wear away because it is what we call passive immunity. But it buys them time to get old enough to actually handle this disease better and minimize the impact of the severity of the disease should they actually get the infection.
