Publication date: May 21, 2025

Background and Objectives: Group A Streptococcus (GAS) is a leading cause of acute pharyngitis with seasonal outbreaks. The coronavirus disease 2019 (COVID-19) pandemic significantly altered respiratory infection trends; however, its impact on GAS pharyngitis (GAS-P) incidence remains unclear. Additionally, data on co-infections with GAS and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are limited. In this study, temporal trends in GAS-P incidence and characteristics of GAS-SARS-CoV-2 co-infections in Japan were examined. Materials and Methods: In this observational study, data from patients who visited the Tokyo Shinagawa Hospital between January 2019 and December 2024 were retrospectively analyzed. Data on GAS and SARS-CoV-2 test results and patient demographics were extracted from medical records. The study period was categorized based on COVID-19-related public health measures as follows: pre-COVID-19 social period (January 2019-April 2020), restricted social period (May 2020-April 2023), and post-restriction period (May 2023-December 2024). GAS incidence stratified by sex, age, and period was calculated. Clinical characteristics of patients co-infected with GAS and SARS-CoV-2 were analyzed. Results: Among 4837 GAS tests, 463 (9. 6%) were positive. GAS positivity rates varied significantly: 11. 4% (pre-COVID-19), 7. 1% (restricted social period), and 12. 6% (post-restriction period; p < 0. 001). The proportion of pediatric cases decreased significantly during the restricted social period (24. 8-5. 3%) before rising sharply in the post-restriction period (47. 1%, p < 0. 001). Among 151 patients tested for GAS and SARS-CoV-2, 14 (9. 3%) had co-infections, which were identified exclusively after July 2022. Most patients exhibited mild symptoms, primarily fever and sore throat, with decreased lymphocyte counts despite normal white blood cell counts. Conclusions: In our cohort, the incidence of GAS pharyngitis temporarily declined during COVID-19-related public health measures and subsequently increased, particularly among children, after restrictions were lifted. Limited testing may contribute to the underdiagnosis of GAS-SARS-CoV-2 co-infections. Further large-scale studies are warranted to assess microbial interactions, disease severity, and long-term outcomes.

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