Mapping infant streptococcal mortality burden in low- and middle-income countries: temporal trends, geospatial...

Streptococcal mortality burden threatens children's health in low- and middle-income countries (LMICs), yet their temporal trends, geographic disparities, and socioeconomic determinants remain unclear. Using the MICROBE database and World Bank data, we conducted a cross-sectional study to assess infant mortality burden of group A Streptococcus (GAS), group B Streptococcus (GBS), Streptococcus pneumoniae, and other streptococci in LMICs. Joinpoint regression estimated the average annual percent change (AAPC). Frontier analysis assessed the potential reduction in antimicrobial resistance (AMR) mortality burden for Streptococcus. Random forest with SHapley Additive exPlanations (SHAP) identified key socioeconomic drivers. During 1990-2021, infant streptococcal mortality burden in LMICs declined from 798.8 to 241.1 per 100,000. However, a post-2016 increase in the mortality burden of early-onset neonatal GAS and GBS bacteremia (0-6 days) was observed (annual percent change, 1.9% and 1.7%). Streptococcal mortality burden declined most slowly, or increased, among neonates in sub-Saharan Africa and South Asia (AAPC, - 5.8 to 1.6%). Multiple LMICs in sub-Saharan Africa, South Asia, and Oceania exhibited a high AMR-related mortality burden from streptococcal infections. SHAP analysis indicated that increased health expenditure was associated with lower mortality burden across most streptococcal pathogens. WASH (Water, Sanitation, and Hygiene) and skilled birth attendance were linked to lower GAS/GBS mortality burden. Complete pneumococcal vaccination was negatively associated with pneumococcal mortality burden, mainly through reduced incidence.

Infant streptococcal mortality burden persists in LMICs, especially among neonates. Increasing health investment, strengthening WASH, improving perinatal care, promoting vaccination, and enhancing antibiotic stewardship are critical.

• Infant streptococcal mortality burden in low- and middle-income countries (LMICs) constitutes a major public health concern.

• Infant streptococcal mortality burden in LMICs declined by 69.8% (1990-2021), but remained concentrated in neonates, with rising early-onset GAS/GBS bacteremia mortality burden. • Infant streptococcal mortality burden is predominant in sub-Saharan Africa and South Asia, where resistance to penicillin and third-generation cephalosporins is relatively high. • Government health expenditure, WASH, tailored perinatal care, full-course pneumococcal vaccination, and antibiotic stewardship are key to reducing infant streptococcal mortality burden in LMICs.