Group A Streptococcus (GAS) continues to be a substantial worldwide public health issue, being responsible for a broad range of illnesses that span from minor infections like pharyngitis and impetigo to severe, life-threatening invasive conditions and subsequent complications such as rheumatic heart disease (RHD). Annually, GAS causes over 18 million serious illnesses and more than 500,000 fatalities globally. RHD, a major consequence, impacts an estimated 40.5 million individuals, with sub-Saharan Africa seeing a 23% contribution to cases and a prevalence of 10.31 per 1,000. The disease burden is exceptionally high in low- and middle-income nations, including sub-Saharan Africa, where RHD is prevalent among children aged 5–14 years (5.7–15 per 1,000) and where surveillance and control strategies are insufficient. This paper reviews current publications concerning GAS throat carriage in healthy children, highlighting key socio-environmental risk factors such as a large household size (adjusted odds ratio 4.64) and a family history of pharyngitis (adjusted odds ratio 2.51), and trends in antimicrobial susceptibility, with a specific focus on Anambra State, Nigeria. In Nigerian school children, the rates of asymptomatic throat colonization vary from 3.3% to 10.6%, primarily involving non-GAS beta-hemolytic streptococci. However, worldwide meta-analyses suggest a 5.9% GAS carriage rate in low/middle-income regions, which increases to 10–24% in symptomatic pharyngitis cases. This review incorporates global and local data on GAS epidemiology, molecular mechanisms of disease, spread patterns, and the development of antimicrobial resistance. This resistance includes tetracycline resistance in 8–58% of African strains and erythromycin resistance reaching 70% in some areas. Nevertheless, penicillin maintains high efficacy, showing >95% susceptibility. The analysis identifies significant gaps in knowledge, notably the scarcity of information on asymptomatic carriage rates, the distribution of local emm types (emm1, emm12, and emm89 are globally dominant but poorly documented in Nigeria), and the mechanisms driving resistance. Filling these informational voids is crucial for enhancing monitoring efforts, establishing successful prevention and control strategies, and reducing the health impact of GAS-associated illnesses in Nigeria and comparable resource-constrained environments.