Epidemiology and co-infection networks of pediatric respiratory pathogens in eastern China after COVID-19 restriction relaxation: a retrospective study

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Objectives To characterize the epidemiology, seasonal fluctuations, and co-infection networks of pediatric respiratory pathogens in eastern China following the relaxation of COVID-19 non-pharmaceutical interventions (NPIs). Methods We conducted a retrospective analysis of 7,473 throat swab samples collected from children (≤18 years) presenting with acute respiratory tract infections (ARTIs) at a tertiary hospital in Nanjing between January 2024 and May 2025. Samples were tested for 13 common pathogens using a multiplex RT-PCR assay. Pathogen detection rates, temporal trends, and co-infection dynamics were analyzed using Kruskal-Wallis tests, time-series smoothing, and network analysis. Results The overall pathogen detection rate was 61.8% (4,618/7,473), with no significant sex disparity (p = 0.267). Preschoolers (4–6 years) experienced the highest burden (68.3%), significantly exceeding other age groups (p < 0.008). Rhinovirus (RV, 16.9%), Mycoplasma pneumoniae (12.4%), and Respiratory Syncytial Virus (RSV, 9.0%) were the most prevalent pathogens. Distinct seasonal signatures were observed: RSV peaked in winter (25.3% in March 2025), M. pneumoniae dominated in mid-summer (22.8% in August 2024), and RV maintained high year-round activity. Co-infections occurred in 17.5% of positive samples, with M. pneumoniae-RV and Adenovirus-RV being the most frequent combinations. Network analysis identified RV and M. pneumoniae as central connectors within the intricate co-infection landscape. Conclusions Pediatric respiratory pathogens have returned with strong, age-specific patterns in post-NPI eastern China. The pronounced “immunity debt” among preschoolers and the high rate of co-infections underscore the urgent need for enhanced multiplex surveillance and the expansion of vaccination programs for RSV and influenza.

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