21 Group B Streptococcus (GBS) is a major cause of neonatal invasive disease worldwide. In 22 the Netherlands, the incidence of the disease increased, despite the introduction of prevention 23 guidelines in 1999. This was accompanied by changes in pathogen genotype distribution, 24 with a significant increase in the prevalence of isolates belonging to clonal complex (CC) 17.25 To better understand the mechanisms of temporal changes in the epidemiology of GBS 26 genotypes that correlated with the rise in disease incidence, we applied whole genome 27 sequencing (WGS) to study a national collection of invasive GBS isolates. A total of 1345 28 isolates from patients aged 0 -89 days and collected between 1987 and 2016 in the 29 Netherlands were sequenced and characterised. The GBS population contained 5 major 30 lineages representing CC17 (39%), CC19 (25%), CC23 (18%), CC10 (9%), and CC1 (7%).31 There was a significant rise in the prevalence of isolates representing CC17 and CC23 among 32 cases of early-and late-onset disease, due to expansion of discrete sub-lineages. The most 33 prominent was shown by a CC17 sub-lineage, identified here as CC17-1A, which 34 experienced a major clonal expansion at the end of the 1990s. The CC17-1A expansion 35 correlated with the emergence of a novel phage carrying a gene encoding a putative adhesion 36 protein, named here StrP. The first occurrence of this phage (designated phiStag1) within the 37 collection in 1997, was followed by multiple, independent acquisitions by CC17 and parallel 38 clonal expansions of CC17-1A and another cluster, CC17-1B. The CC17-1A clone was 39 identified in external datasets, and represents a globally distributed invasive sub-lineage of 40 CC17. Our work describes how a sudden change in the epidemiology of specific GBS sub-41 lineages, in particular CC17-1A, correlates with the rise in the disease incidence, and 42 indicates a putative key role of a novel phage in driving the expansion of this CC17 clone. 43 3 44
Author summary45 Group B Streptococcus (GBS) is a commensal organism of the gastrointestinal and 46 genitourinary tracts. However, it is also an opportunistic pathogen and a major cause of 47 neonatal invasive disease, which can be classified into early-onset (0 -6 days of life) or late-48 onset (7 -89 days of life). Current disease prevention strategy involves intrapartum antibiotic 49 prophylaxis (IAP), which aims to prevent the transmission of GBS from mother to baby 50 during labour. Many developed countries adapted national IAP guidelines. In the 51 Netherlands, these were introduced in 1999. However, the incidence of GBS disease 52 increased after IAP introduction. In this study we applied whole genome sequencing to 53 characterise a nationwide collection of invasive GBS from cases of neonatal disease that 54 occurred between 1987 and 2016. Analysis of GBS population structure involving 55 phylogenetic partitioning of individual lineages revealed that the rise in disease incidence 56 involved the expansion of specific clusters from two ma...