Fatality, Not Exposure, Divides Child Pneumonia Deaths: The Global Episode-Fatality Gradient at Ages 0–19 Years, 1990–2023

Background: Lower respiratory infections (LRIs) remain the leading infectious cause of child death, yet global frameworks focus on under-5s and the 5–19-year burden lacks systematic quantification. We analyzed the 0–19-year LRI burden in the Global Burden of Disease Study (GBD) 2023.Methods: We extracted deaths, DALYs, YLDs, incidence and prevalence for 204 countries, 1990–2023, from the GBD 2023 Results Tool for the official <5-year aggregate plus three older pediatric bands. We computed trends, Socio-demographic Index (SDI) gradients and pandemic-window changes; defined a national episode-fatality ratio proxy (EFR; deaths per 1,000 incident episodes); extrapolated trends to 2030; tested whether school-age mortality divergence tracks pediatric tuberculosis burden; and decomposed deaths into the 26 etiologic fractions.Results: In 2023, LRIs caused 711,713 deaths (95% UI 579,607–843,819), 62.49 million DALYs and 81.05 million incident episodes at ages 0–19 years. The EFR varied 75.6-fold across countries—three times the 25.9-fold national range of incidence—tracked income and, independently, inequality, and widened between low- and high-SDI settings over 1990–2023; incidence and fatality were positively correlated across countries (r = 0.66), and a best-quartile counterfactual implied 80.1% of deaths avertable (upper bound). The global EFR rose silently by 30.4% between 2010 and 2019. Improvement was age-asymmetric: in crude-rate terms, mortality fell 69.1% under 5 years but 39.4% at ages 5–19 years; the 5–19-year share of deaths rose from 6.7% to 14.4%, reaching 16.5% by 2030. Divergence was widest where under-5 progress was fastest and did not track pediatric tuberculosis burden. Streptococcus pneumoniae caused 32.0% of 2023 deaths (47.8% in 1990); influenza and RSV deaths collapsed into 2021 and rebounded fastest thereafter, remaining below 2019. Low-SDI countries carried 61.7% of deaths at 22 times the high-SDI rate. Post-2021 patterns were directional only.Conclusions: Fatality inequality—wider than, and positively correlated with, exposure inequality—now defines the divide, and progress has concentrated under age 5, leaving school-age children and adolescents behind. We propose the EFR as a monitorable indicator, with layered responses: surveillance extension to ages 5–19 years, clinical targeting of high-risk groups, and case-management strengthening in high-burden regions—without routine adolescent vaccine expansion, which current data do not support.