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Objective To determine the cost-effectiveness of alternative screening and prevention strategies, including rapid intrapartum testing, for prevention of early-onset neonatal group B streptococcus (GBS) infection in the UK. Design A decision model was developed to investigate the costeffectiveness of screening and prevention strategies for GBS. A strategy of doing nothing was also considered. Deterministic and probabilistic sensitivity analyses were carried out.Setting Two large UK based obstetric units.Participants Test accuracy data were obtained from a primary study of rapid tests at the onset of labour and risk factors from 1400 women.Main outcome measures Incremental health sector costs per case of early-onset GBS death avoided.Results Compared with a strategy of do nothing, the incremental cost-effectiveness ratio was £32,000 per Early-Onset GBS Disease avoided and £427,000 per Early-Onset GBS Death avoided for the strategy of providing routine intrapartum antibiotic prophylaxis to all women without prior screening; Based on their current sensitivity, specificity and cost, screening using rapid tests was dominated by other more cost-effective strategies.Conclusions The most cost-effective strategy was shown to be the provision of routine intrapartum antibiotic prophylaxis to all women without prior screening but, given broader concerns relating to antibiotic use, 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.Keywords Cost-effectiveness, group B streptococcus, labour, rapid tests.Please cite this paper as: Kaambwa B, Bryan S, Gray J, Milner P, Daniels J, Khan K, Roberts T. Cost-effectiveness of rapid tests and other existing strategies for screening and management of early-onset group B streptococcus during labour.

Point-of-care testing (POCT) is one of the fastest growing sectors of laboratory diagnostics. Most tests in routine use are haematology or biochemistry tests that are of low complexity. Microbiology POCT has been constrained by a lack of tests that are both accurate and of low complexity. We describe our experience of the practical issues around using more complex POCT for detection of Group B streptococci (GBS) in swabs from labouring women. We evaluated two tests for their feasibility in POCT: an optical immune assay (Biostar OIA Strep B, Inverness Medical, Princetown, NJ) and a PCR (IDI-Strep B, Cepheid, Sunnyvale, CA), which have been categorised as being of moderate and high complexity, respectively. A total of 12 unqualified midwifery assistants (MA) were trained to undertake testing on the delivery suite. A systematic approach to the introduction and management of POC testing was used. Modelling showed that the probability of test results being available within a clinically useful timescale was high. However, in the clinical setting, we found it impossible to maintain reliable availability of trained testers. Implementation of more complex POC testing is technically feasible, but it is expensive, and may be difficult to achieve in a busy delivery suite.

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Group B streptococci (GBS) have been recognized as a leading cause of serious early-onset neonatal sepsis for 30 years. Introduction of intrapartum antibiotic prophylaxis (IAP) has led to a decrease in neonatal early-onset GBS (EOGBS) disease and in early neonatal sepsis-related mortality in many countries. At present decisions concerning the administration of IAP are usually based on either the presence of risk factors at the time of labor, or on screening of women at 35-37 weeks gestation. A new generation of rapid test for GBS suitable for point of care use offer the prospect of accurately detecting GBS during labor, which might improve targeting of IAP. Looking further ahead, active immunization of women before or during pregnancy may become the mainstay of prevention of neonatal EOGBS disease. In this article the role of GBS as a neonatal pathogen, and current and possible future strategies for prevention of neonatal EOGBS disease, are reviewed.