drome. The cause of the syndrome, the hanta virus, was quickly identified, followed by the rapid development and implementation of prevention guidelines. This development has encouraging implications for the prevention of emerging infections. Technological advances and greater community activism have contributed to this trend, as have improvements in behavioral science and medical communications. Managed care may also be a contributing factor, particularly as more of the at-risk populations for new and reemerging infections are included under managed Medicaid contracts.

The example of Group B streptococcal infection provides an illustration of ways in which managed care can provide new opportunities to implement and evaluate clinical practice guidelines for controlling infectious diseases. Twenty-five years ago, Group B streptococcus emerged as the principal cause of sepsis and meningitis among newborns in the United States, resulting in treatment costs of approximately $300 million per year. Clinical trials during the 1980s demonstrated that the use of antibiotics in high-risk mothers during labor was successful in preventing transmission of the streptococcus to neonates. However, this strategy was not implemented. Both logistical concerns and lack of public pressure accounted for this absence of a response. Cost-effectiveness studies conducted in the early 1990s provided further support for this approach. The formation of a parents' organization, the Group B Strep Association, placed pressure on the medical community to develop a new standard of care. In 1996, the Centers for Disease Control and Prevention collaborated with the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics to issue consensus guidelines for the prevention of neonatal Group B streptococcal infection. Evaluation of these new guidelines at the Group Health Cooperative of Puget Sound showed that changing the timing of prenatal screening and offering treatment to all carriers (i.e., the screening-based approach included in the consensus recommendations) was feasible and could be efficiently implemented. This approach significantly increased the proportion of women who received antibiotics during labor (Anne Schuchat, Chief, Respiratory Diseases Branch, CDC, personal communication, January 8, 1999). Adoption of Group B streptococcal prevention policies by hospitals throughout the United States has been accompanied by a significant decline in Group B streptococcal disease (CDC, 1998; Schuchat, 1999).

As managed care evolves it offers increased advantages for implementation and evaluation of clinical practice guidelines. Patient recruitment, systemwide implementation, and the surveillance and monitoring of infectious diseases with computerized databases are some of the tools available to managed care systems to help combat emerging infections. Information can be readily accessed when systems are well designed and integrated, allowing quicker responses to new recommendations. On the other hand, the challenges to be overcome are subscriber turnover, proprietary restrictions on access to data from managed care organizations, and the adoption of different guidelines across organizations. Until these challenges have been addressed for clinicians, patients, laboratory personnel, and public health officials, the systemwide implementation of standard



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