Menu
Menu
Menu
Menu
Background: In the 6 months following our estimates from March 1, 2020, to April 30, 2021, the proliferation of new coronavirus variants, updated mortality data, and disparities in vaccine access increased the amount of children experiencing COVID-19-associated orphanhood. To inform responses, we aimed to model the increases in numbers of children affected by COVID-19-associated orphanhood and caregiver death, as well as the cumulative orphanhood age-group distribution and circumstance (maternal or paternal orphanhood). Methods: We used updated excess mortality and fertility data to model increases in minimum estimates of COVID-19-associated orphanhood and caregiver deaths from our original study period of March 1, 2020–April 30, 2021, to include the new period of May 1–Oct 31, 2021, for 21 countries. Orphanhood was defined as the death of one or both parents; primary caregiver loss included parental death or the death of one or both custodial grandparents; and secondary caregiver loss included co-residing grandparents or kin. We used logistic regression and further incorporated a fixed effect for western European countries into our previous model to avoid over-predicting caregiver loss in that region. For the entire 20-month period, we grouped children by age (0–4 years, 5–9 years, and 10–17 years) and maternal or paternal orphanhood, using fertility contributions, and we modelled global and regional extrapolations of numbers of orphans. 95% credible intervals (CrIs) are given for all estimates. Findings: The number of children affected by COVID-19-associated orphanhood and caregiver death is estimated to have increased by 90·0% (95% CrI 89·7–90·4) from April 30 to Oct 31, 2021, from 2 737 300 (95% CrI 1 976 100–2 987 000) to 5 200 300 (3 619 400–5 731 400). Between March 1, 2020, and Oct 31, 2021, 491 300 (95% CrI 485 100–497 900) children aged 0–4 years, 736 800 (726 900–746 500) children aged 5–9 years, and 2 146 700 (2 120 900–2 174 200) children aged 10–17 years are estimated to have experienced COVID-19-associated orphanhood. Globally, 76·5% (95% CrI 76·3–76·7) of children were paternal orphans, whereas 23·5% (23·3–23·7) were maternal orphans. In each age group and region, the prevalence of paternal orphanhood exceeded that of maternal orphanhood. Interpretation: Our findings show that numbers of children affected by COVID-19-associated orphanhood and caregiver death almost doubled in 6 months compared with the amount after the first 14 months of the pandemic. Over the entire 20-month period, 5·0 million COVID-19 deaths meant that 5·2 million children lost a parent or caregiver. Our data on children’s ages and circumstances should support pandemic response planning for children globally. Funding: UK Research and Innovation (Global Challenges Research Fund, Engineering and Physical Sciences Research Council, and Medical Research Council), Oak Foundation, UK National Institute for Health Research, US National Institutes of Health, and Imperial College London.
In this modelling study, we used new excess death and COVID-19 death data to examine the increase in global minimum estimates of orphanhood and caregiver loss from the 14-month period of our previous study2 (March 1, 2020–April 30, 2021) to the following 6-month period from May 1 to Oct 31, 2021. The appendix (p 2) gives the data sources. We defined orphanhood as the death of one or both parents;11 primary caregiver loss as the death of one or both parents, or of one or both co-residing custodial grandparents aged 60–84 years (household composition data only included grandparents or other kin 60 years or older); and secondary caregiver loss as the death of one or more co-residing grandparents or older kin; appendix p 3).2 We then estimated the age category and circumstance (maternal or paternal orphanhood) of these children by WHO region and globally (appendix p 4). We used the Guidelines for Accurate and Transparent Health Estimates Reporting.12 Using methods previously described,2 we extracted COVID-19 and excess deaths where disaggregated data were available between March 1, 2020, and Oct 31, 2021, for 21 study countries (Argentina, Brazil, Colombia, England and Wales, France, Germany, India, Iran, Italy, Kenya, Malawi, Mexico, Nigeria, Peru, Philippines, Poland, Russia, South Africa, Spain, the USA, and Zimbabwe). Compared with our previous study, our data for the entire 20-month period were improved by newly available mortality data for our 21 study countries, particularly for Peru, India, and Poland, and we therefore did new back calculations for the original 14-month period (March 1, 2020–April 30, 2021) as well as new calculations for the subsequent 6-month period (May 1–Oct 31, 2021; appendix p 2). For our back calculations and our new calculations, we used the maximum value between COVID-19 deaths and excess deaths for countries where age–sex disaggregates were available, and we applied an adjustment factor using age–sex-disaggregated COVID-19 deaths where only total excess deaths were available. We used the term COVID-19-associated deaths to describe the combination of deaths caused directly by COVID-19 or indirectly by associated causes (eg, decreased access to health services), reported as excess deaths. Excess deaths were derived by subtracting average deaths between 2015 and 2019 from average deaths during the same period in 2020–21. We used fertility data between 2003 and 2020 and child mortality data by 5-year age bands to calculate the average number of children per person of each age and sex. We then multiplied this estimate by the numbers of COVID-19-associated deaths in each 5-year age–sex band to calculate the number of children losing a parent. We adjusted for children who lost both parents (ie, double orphans) to avoid duplicate counts.2 We also included a sensitivity analysis examining potentially reduced fertility due to COVID-19 in 2021 (appendix p 6). Considering the loss of caregiving grandparents, we used UN household composition data for the proportion of adults older than 60 years co-residing with children aged younger than 18 years without a parent to define primary grandparent caregivers, and with a parent for secondary grandparent caregivers.13 Other co-residing kin (aged 60 years or older) could also be classed as secondary caregivers. We included co-residing grandparents because they provide substantial financial, psychosocial, and practical support to households, and their loss can place children at risk of institutional placement, poverty, mental health issues, and abuse.14 We multiplied these proportions by COVID-19-associated deaths to generate numbers of affected children, conservatively assuming one death resulted in only one child experiencing caregiver death. We used methods previously described2 to produce global extrapolations for COVID-19-associated orphanhood and caregiver death. This approach showed strong correlation between the ratio of orphanhood to deaths and total fertility rate (Pearson r2=0·93).2 We used logistic regression and further incorporated a fixed effect for western European countries into our model for the entire 20-month period, since the original model over-predicted caregiver loss in that region (appendix p 3): where TFR is the total fertility rate; e is the exponential function; western Europe is 1 if the country is within western Europe or 0 otherwise; and α, β, γ, and δ are constants to be fit, combined with bootstrapping, to address uncertainty. We then estimated the percentage increase in orphanhood and caregiver death for the recent 6-month study period compared with the original 14-month period. We adjusted our previous methods2 to estimate the age composition of children who lost mothers (maternal orphans), fathers (paternal orphans) for the entire period from March 1, 2020, to Oct 31, 2021. Instead of summing individual contributions to the average number of children an adult of each sex would have between 2003 and 2020, we estimated yearly fertility contributions separately (appendix p 5). Therefore, when multiplying by deaths, we obtained the average number of children for every year of age, between 0 and 17 years, that an adult would have in each adult age band. We assumed that fertility is negligible for both sexes for ages younger than 15 years, for females older than 50 years, and males older than 80 years. Our total number of countries for age-specific analyses was reduced to 20, because we excluded Russia due to scarcity of data on age of death. We classified children into age groups based on differing needs, risks, and response strategies: 0–4 years, 5–9 years, and 10–17 years. We used population data from the 2020 US Census Bureau and Office for National Statistics (for England and Wales) to calculate orphanhood cases per 1000 children aged 0–17 years.15, 16 We did not adjust for double orphans, as they accounted for 0·1% of all orphanhood. We used bootstrapping to calculate uncertainty around age-specific calculations (appendix p 6). Credible intervals (CrIs) are the 95% quantiles from 1000 samples. We further assessed whether risks of orphanhood among the 0–4 years age group increased compared with the first 14 months, potentially due to greater vulnerability of younger aged adults to deaths from delta variants. We fit a Bayesian multinomial logistic regression to our data from 20 study countries to estimate the proportion of orphans by age group and circumstance, using adult age proportions and gross domestic product (appendix p 6). We used the extrapolated number of orphans, combined with our Bayesian model, to estimate orphanhood by age group and circumstance from March 1, 2020, to Oct 31, 2021, for all countries that had reported COVID-19 deaths up to Oct 31, 2021, according to data from Johns Hopkins University of Medicine Coronavirus Resource Center (appendix p 6). Analyses were done with R (version 4.1.2). The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.
