Global and Super-Regional Burden of Mycoplasma pneumoniae–Attributable Lower Respiratory Infection Deaths in Children Aged 0–19 Years, 1990–2023: A Systematic Analysis of the Global Burden of Disease Study 2023

Background. Mycoplasma pneumoniae, the archetypal agent of “walking pneumonia”, causes predominantly self-limited infection peaking in school-age children and adolescents, and is regarded as rarely fatal. After near-disappearance under pandemic non-pharmaceutical interventions in 2020–2021, re-emergence was delayed relative to other respiratory pathogens but was well established by 2023–2024. No standalone global estimate of M. pneumoniae–attributable mortality spanning the pandemic window has been reported to contextualise this resurgence. Methods. We analysed Global Burden of Disease (GBD) Study 2023 estimates (release v8352), which attribute lower respiratory infection (LRI) deaths to 26 pathogens through a counterfactual, population-attributable-fraction framework. Attributable deaths (the only available measure) were extracted globally and for seven super-regions, 1990–2023, for children aged 0–19 years (under 5, 5–9, 10–14, and 15–19 years). Trends were summarised by estimated annual percentage change (EAPC); 95% uncertainty intervals (UIs) were propagated conservatively. Reporting follows the GATHER statement. Results. In 2023, an estimated 26,382 deaths (95% UI 18,984–36,012) in children aged 0–19 years were attributable to M. pneumoniae, ranking ninth among 26 LRI aetiologies and accounting for 3.71% of all-pathogen LRI deaths. Deaths fell by 50.7% from 1990 to 2023 (EAPC −2.45% per year, 95% CI −2.66 to −2.23). Sub-Saharan Africa and South Asia carried 81.6% of the 2023 total. The 5–14 year share of attributable deaths was 15.0%, versus 2.2% for respiratory syncytial virus. Children under 5 years accounted for 80.6% of attributable deaths. Across the pandemic window, deaths fell only 17.1% in 2019–2021—versus 62.6% for influenza and 65.2% for respiratory syncytial virus—then rebounded 16.1% by 2023, exceeding the no-pandemic trend extrapolation by 19.2%. The crude mortality rate fell faster than counts (EAPC −2.93% per year), and estimates were stable across GBD rounds (≤2.6% difference for under-5 deaths).Conclusions. Modelled M. pneumoniae mortality concentrates where macrolide-resistance data and diagnostics are scarcest; its school-age skew and post-pandemic rebound are coherent with surveillance. These estimates provide baselines for age-targeted empirical-treatment guidance and resistance-aware stewardship.