Diversification without convergence: national childhood respiratory pathogen spectra diverge as they diversify, 1990–2023
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Background
National childhood respiratory pathogen spectra are diversifying nearly everywhere — within-country diversity rose in 203 of 204 countries between 1990 and 2023 — yet whether countries are diversifying toward a common spectrum or along divergent paths is unknown. We quantified between-country compositional distance of national pathogen spectra over the same period.
Methods
We built national pathogen share vectors from Global Burden of Disease Study 2023 lower respiratory infection etiologic attributions (26 pathogens, 204 countries, ages 0–19 years) at five timepoints spanning 1990–2023. Between-country distance was measured as all pairwise Jensen–Shannon divergences (JSD; primary) and Bray–Curtis dissimilarities, with Baselga and Jaccard decompositions; robustness was assessed across metrics, pathogen panels, low-count thresholds and a balanced panel of 107 countries.
Results
Mean pairwise JSD rose from 0.0084 in 1990 to 0.0283 in 2023 (+238%; trend p = 0.030), peaking in 2021 (+283%) with a partial 2023 pullback. Bray–Curtis dissimilarity rose +120% and the balanced panel +423%. Divergence was entirely balanced variation (share reallocation), with spectrum richness rising from 18.5 to 21.1 of 26 pathogens. Dispersion rose fastest for influenza (coefficient of variation 0.03 to 0.55) and respiratory syncytial virus (0.08 to 0.48). Within-region distance rose in every computable GBD super-region (five of seven): divergence occurs within regions, not between blocs.
Conclusions
National spectra are re-sorting along country-specific axes as vaccine-preventable dominance recedes at different speeds. Diversification is universal, but convergence is absent: the transition at the etiologic-spectrum level is asynchronous and path-dependent, with implications for empirical treatment policy and pathogen surveillance.
Summary box
What is already known on this topic
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Epidemiological transition theory and the global health convergence agenda imply that national cause-of-death structures become more alike as mortality declines, but this expectation has been tested mainly at the level of mortality rates and broad cause groups, not etiologic spectra.
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Within-country (alpha) diversity of the childhood respiratory pathogen spectrum rose in 203 of 204 countries between 1990 and 2023.
What this study adds
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Between-country (beta) compositional distance roughly tripled over the same period (mean pairwise Jensen–Shannon divergence +238%, 1990 to 2023), robust to distance metric, pathogen panel, COVID-19 exclusion, low-count threshold, and a fixed balanced panel.
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Divergence is driven entirely by reallocation of pathogen shares (balanced variation), is fastest for viral pathogens, and occurs within every GBD super-region, indicating that countries diversify along country-specific paths rather than toward a common spectrum.
