Rebound Phenotypes of Childhood Respiratory Infectious Causes After the COVID-19 Perturbation: A 29-Cause, 204-Country Mortality Atlas, 2019–2023

Background Post-pandemic resurgence of childhood respiratory pathogens has been documented by case-based surveillance, but case counts are sensitive to testing behaviour. Whether the mortality rebound is uniform or structured is unknown. We phenotyped the 2019–2023 collapse and rebound of modelled childhood deaths from 29 respiratory infectious causes across 204 countries.Methods We assembled a country × cause panel of Global Burden of Disease Study 2023 death estimates at ages 0–19 years (26 lower-respiratory-infection aetiologies, tuberculosis, pertussis and COVID-19). For each cell we defined collapse (2019→2021), rebound (2021→2023) and net change (2019→2023), classified the 1,917 stable cells (2019 deaths ≥20; 1,800 non-COVID-19 and 117 COVID-19) into six phenotypes using declared thresholds, and handled COVID-19 separately as a peak-fade metric. Reporting follows GATHER.Findings The rebound was phenotypically structured, not uniform. Pertussis rebounded in 85 of 87 evaluable countries (98%; median +168%) yet only 32% exceeded their 2019 baseline—a rebound without overshoot, excess concentrated in sub-Saharan Africa. Influenza and respiratory syncytial virus showed a near-universal V-with-shortfall: fast rebound in 70.5% and 72.5% of countries, but median net change near −50%. Only Latin America and the Caribbean sat above baseline, marginally (+0.9%), against −17.0% in high-income countries. COVID-19 deaths faded by a median 73%, resurging in six countries, five late-exit settings. Pneumococcal rebound was uncorrelated with conjugate-vaccine coverage (ρ = 0.00).Interpretation Post-pandemic mortality rebounded as distinct, geographically structured phenotypes, not a single global wave; mortality readouts complement incidence surveillance and locate where the rebound window remains open.