Impact of the COVID‑19 Pandemic on Group A Streptococcal Infections, Acute Rheumatic Fever and Rheumatic Heart Disease in US Youth

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic affected exposure to infectious agents. We aimed to analyze changes in Group A streptococcal (GAS), acute rheumatic fever (ARF) and rheumatic heart disease (RHD) prevalence during the COVID-19 pandemic and assess associated social vulnerability indices (SVI). METHODS: Using the Epic Cosmos database, we performed a descriptive analysis of patients aged 2-21 in the United States from January 2016 through December 2023. We compared monthly GAS positivity rates and ARF/RHD diagnosis frequencies across pre-pandemic (January 2016-February 2020), early-pandemic (March 2020-August 2022), and late-pandemic (September 2022-December 2023) periods, incorporating Centers for Disease Control-derived SVI themes. RESULTS: GAS positivity significantly decreased from pre-pandemic (15.5%; 838 tests/100,000) to early pandemic (12.3%; 363; P < 0.001), then rebounded in the late pandemic (20.8%; 1340; P < 0.001). Among 412 ARF and 780 RHD patients, early pandemic diagnoses dropped significantly for ARF (0.87-0.56 per 100,000; P < 0.001) and RHD (0.54-0.43; P = 0.003). Neither showed a significant late-pandemic resurgence (ARF 0.60, P = 0.915; RHD 0.40, P = 0.182). Compared with >29 million controls, RHD patients showed higher vulnerability across all SVI themes, while ARF patients were more vulnerable in Racial and Ethnic Minority Status, Housing Type and Transportation. CONCLUSIONS: This study identifies a significant reduction in GAS, ARF and RHD during the pandemic. Despite a late-pandemic surge in GAS infections, ARF and RHD diagnoses remained stable. These findings highlight a potential decline in overall ARF and RHD diagnoses and identify specific social vulnerability targets for public health intervention in the United States.