Invasive group A streptococcal disease in pregnant women and young children: a systematic review and meta-analysis

Abstract

Background: The incidence of invasive disease caused by group A streptococcus (GAS) has increased in multiple countries in the past 15 years. However, despite these reports, to the best of our knowledge, no systematic reviews and combined estimates of the incidence of invasive GAS have been done in key high-risk groups. To address this, we estimated the incidence of invasive GAS disease, including death and disability outcomes, among two high-risk groups-namely, pregnant women and children younger than 5 years.

Methods: We did a systematic review and meta-analyses on invasive GAS outcomes, including incidence, case fatality risks, and neurodevelopmental impairment risk, among pregnant women, neonates (younger than 28 days), infants (younger than 1 year), and children (younger than 5 years) worldwide and by income region. We searched several databases for articles published from Jan 1, 2000, to June 3, 2020, for publications that reported invasive GAS outcomes, and we sought unpublished data from an investigator group of collaborators. We included studies with data on invasive GAS cases, defined as laboratory isolation of Streptococcus pyogenes from any normally sterile site, or isolation of S pyogenes from a non-sterile site in a patient with necrotising fasciitis or streptococcal toxic shock syndrome. For inclusion in pooled incidence estimates, studies had to report a population denominator, and for inclusion in pooled estimates of case fatality risk, studies had to report aggregate data on the outcome of interest and the total number of cases included as a denominator. We excluded studies focusing on groups at very high risk (eg, only preterm infants). We assessed heterogeneity with I².

Findings: Of the 950 published articles and 29 unpublished datasets identified, 20 studies (seven unpublished; 3829 cases of invasive GAS) from 12 countries provided sufficient data to be included in pooled estimates of outcomes. We did not identify studies reporting invasive GAS incidence among pregnant women in low-income and middle-income countries (LMICs) nor any reporting neurodevelopmental impairment after invasive GAS in LMICs. In nine studies from high-income countries (HICs) that reported invasive GAS in pregnancy and the post-partum period, invasive GAS incidence was 0·12 per 1000 livebirths (95% CI 0·11 to 0·14; I²=100%). Invasive GAS incidence was 0·04 per 1000 livebirths (0·03 to 0·05; I²=100%; 11 studies) for neonates, 0·13 per 1000 livebirths (0·10 to 0·16; I²=100%; ten studies) for infants, and 0·09 per 1000 person-years (95% CI 0·07 to 0·10; I²=100%; nine studies) for children worldwide; 0·12 per 1000 livebirths (95% CI 0·00 to 0·24; I²=100%; three studies) in neonates, 0·33 per 1000 livebirths (-0·22 to 0·88; I²=100%; two studies) in infants, and 0·22 per 1000 person-years (0·13 to 0·31; I²=100%; two studies) in children in LMICs; and 0·02 per 1000 livebirths (0·00 to 0·03; I²=100%; eight studies) in neonates, 0·08 per 1000 livebirths (0·05 to 0·11; I²=100%; eight studies) in infants, and 0·05 per 1000 person-years (0·03 to 0·06; I²=100%; seven studies) in children for HICs. Case fatality risks were high, particularly among neonates in LMICs (61% [95% CI 33 to 89]; I²=54%; two studies).

Interpretation: We found a substantial burden of invasive GAS among young children. In LMICs, little data were available for neonates and children and no data were available for pregnant women. Incidences of invasive GAS are likely to be underestimates, particularly in LMICs, due to low GAS surveillance. It is essential to improve available data to inform development of prevention and management strategies for invasive GAS.

Funding: Wellcome Trust.

Figure 1

Data and extraction for invasive group A streptococcal disease in pregnancy and the post-natal period (up to 42 days after birth) and children (aged 0–5 years)

Figure 2

Incidence of invasive group A streptococcal infections worldwide and by income group, 2000–20 (A) Pregnancy and post-natal period (up to 42 days after birth). (B) Neonates (aged 0–27 days). (C) Infants (0–1 year). ABCs=Active Bacterial Core Surveillance System. HIC=high-income country. LMIC=low-income and middle-income country. *Weights are from random effects analysis and rounded to two significant figures. †Unpublished data.

Figure 3

Case fatality risk of invasive group A streptococcal infection worldwide and by income group, 2000–20 (A) Neonates (aged 0–27 days). (B) Infants (0–1 year) (C) Children (aged 1–5 years). (D) Children (aged 0–5 years). ABCs=Active Bacterial Core Surveillance System. HIC=high-income country. LMIC=low-income and middle-income country. *Weights are from random effects analysis and rounded to two significant figures. †Unpublished data.

Figure 3

Case fatality risk of invasive group A streptococcal infection worldwide and by income group, 2000–20 (A) Neonates (aged 0–27 days). (B) Infants (0–1 year) (C) Children (aged 1–5 years). (D) Children (aged 0–5 years). ABCs=Active Bacterial Core Surveillance System. HIC=high-income country. LMIC=low-income and middle-income country. *Weights are from random effects analysis and rounded to two significant figures. †Unpublished data.

Figure 4

Incidence of invasive group A streptococcal infections in children worldwide and by income group, 2000–20 (A) Children aged 1–5 years. (B) Children aged 0–5 years. ABCs=Active Bacterial Core Surveillance System. HIC=high-income country. LMIC=low-income and middle-income country. *Unpublished data. †Weights are from random effects analysis and rounded to two significant figures.