Global, regional, and national minimum estimates of children affected by COVID-19-associated orphanhood and caregiver death, by age and family circumstance up to Oct 31, 2021: an updated modelling study
20 min readSummary
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.
Introduction
modelling studies estimated that, globally, more than 1·5 million children had lost a parent or caregiver by April, 2021.
Racial and ethnic disparities in orphanhood have also been identified in the USA.
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For children, the potential consequences of parent or caregiver loss are devastating and enduring, including institutionalisation, abuse, mental health problems, adolescent pregnancy, and chronic and infectious diseases.
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Because of such consequences in the HIV/AIDS epidemic, the multibillion-dollar US President’s Emergency Plan for AIDS Relief (PEPFAR) provides 10% of bilateral funding to support orphans and vulnerable children.
Research suggests that the types of programmes these PEPFAR investments build, including economic strengthening and positive parenting, are effective and cost-effective, thus supporting their widespread application to orphaned and vulnerable children in the COVID-19 pandemic.
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As rates of COVID-19-associated orphanhood surge, an evidence-based emergency response is becoming increasingly urgent.
Evidence before this study
We searched PubMed, PsycINFO, Google Scholar, Web of Science, JSTOR, Academic Search Premier, and Public Library of Science for research articles published between Jan 1, 2020, and Nov 30, 2021, using the search terms “COVID-19*”, “coronavirus*”, “pandemic*”, “orph* mort* death”, “child* parent* grand* caregiver* coresid*”, “household*”, “bereave*”, and “foster*”, and found two publications that examined national estimates and one that estimated global numbers of children who have experienced orphanhood or death of a caregiver due to COVID-19. New evidence from the COVID-19 pandemic and past evidence from previous epidemics, including HIV/AIDS and Ebola virus disease, and the 1918 influenza pandemic indicates that large numbers of children were affected by orphanhood or death of their caregivers. Evidence related to COVID-19-associated deaths and orphanhood is accruing at a fast rate.
Added value of this study
This new modelled analysis updates previous global estimates with mortality data from 21 countries, and it adjusts estimations on the magnitude of children experiencing the death of a parent, custodial grandparent, or co-residing grandparent or kin due to the COVID-19 pandemic. With these new estimates for the study period from March 1, 2021, to Oct 31, 2021, we found that during the 20 months of the pandemic until the end of that period, more than 5·2 million children experienced the death of a primary or secondary caregiver. In that time, 5·0 million deaths due to COVID-19 were reported globally. Progression of COVID-19 pandemic associated orphanhood and death of caregivers has continued to accelerate globally, with the number of children affected increasing by 90% from April 30 to Oct 31, 2021. Our study further finds that globally, a larger proportion of adolescents (age 10–17 years) have experienced the death of parents or caregivers, relative to children of younger ages. We also find that in most countries, the death of a father has occurred with greater frequency than the death of a mother. Paternal and maternal deaths increase the risks of physical, emotional, and sexual violence, mental health problems, and family economic hardship, and the death of a father or mother can affect children differently.
Implications of all the available evidence
National and global implementations of evidence-based responses to the COVID-19 pandemic are urgently needed within a framework that comprehensively addresses first-order and second-order effects of the disease. Effective responses are key and should combine equitable vaccine access with evidence-based programmes for bereaved children, tailored to burden, location, age, and the circumstances of loss. We propose integrating care for children into every national COVID-19 response plan. This approach includes three components: prevent the death of caregivers by accelerating equitable COVID-19 vaccine delivery; prepare families to be safe and nurturing; and protect orphaned children using evidence-based strategies that address their increased risks of poverty, childhood adversity and violence, and strengthen their recovery.
As this rapidly evolving pandemic progresses with new variants, shifting locations, vaccine disparities, and new data, an adequate response for children will depend on epidemiological characterisation of COVID-19-associated orphanhood and caregiver death, by time, person, and place. Data on changes over time across regions and nations will help to prioritise responses. Data on rates of orphanhood by age group and the circumstances of maternal or paternal orphanhood are required to implement developmentally appropriate, evidence-based interventions. Finally, an understanding by region and nation of the burden and surges in orphanhood and caregiver death will help governments and development partners to focus investments on the children at greatest risk, in the locations most affected.
Loss of grandparents was included in that report, given their crucial role in care of children, particularly in lower-income settings.
The percentage of children living in extended family households that include grandparents is 38% worldwide and nearly 50% in the Asia Pacific region.
Using new excess mortality and COVID-19 mortality data, we aimed to estimate the increase in the number of children affected by COVID-19-associated orphanhood and caregiver death during the 6 months immediately following our original report. We further sought to model global distributions of orphanhood by age group and circumstance (maternal or paternal orphanhood) for every region and nation, and to link our findings to an evidence-based strategy for COVID-19 emergency response programming.
Results
Table 1Extrapolations for global minimum estimates of children affected by COVID-19-associated orphanhood and caregiver deaths, March 1, 2020–Oct 31, 2021
Data in parentheses are 95% credible intervals. All extrapolations are based on our set of 21 study countries, which together accounted for 76% of COVID-19 mortality between March 1, 2020, and April 30, 2021: Argentina, Brazil, Colombia, England and Wales, France, Germany, India, Iran, Italy, Kenya, Malawi, Mexico, Nigeria, Peru, the Philippines, Poland, Russia, South Africa, Spain, the USA, and Zimbabwe. All comparisons in Discussion section are based on these extrapolations using newly available updated data.
Figure 1Global (A) and regional (B) estimates of COVID-19-associated orphanhood and caregiver loss and reported COVID-19 deaths, March 1, 2020–Oct 31, 2021
The shading shows 95% credible interval for our estimation. The dashed vertical line shows the division between the first 14-month and second 6-month periods of our studies.
Table 2Estimated numbers of children orphaned in three age groups and maternal versus paternal orphanhood, for 20 study countries, and global extrapolation, March 1, 2020–Oct 31, 2021
Data in parentheses are 95% credible intervals. Totals for 20 study countries and global extrapolation are also given alongside the percentages of each category in the extrapolation.
Figure 2COVID-19-associated orphanhood by age category and circumstance in each study country, March 1, 2020–Oct 31, 2021
All estimates are based on newly available excess death and COVID-19 death reports. Percentages of orphanhood in the three age categories and two circumstances (maternal or paternal orphanhood), with error bars indicating 95% credible intervals. Boxes within each chart represent the proportion of orphanhood that would be expected if maternal or paternal orphanhood were equally likely.
Figure 3Global (A) and regional (B) percentages of maternal and paternal orphanhood by age category, March 1, 2020–Oct 31, 2021
Discussion
had showed a minimum estimate of more than 1·5 million children affected by COVID-19-associated death of parents and caregivers based on real-time mortality data for the first 14 months of the pandemic. Compared with that estimate, the use of new excess mortality data updated this minimum estimate to more than 2·7 million children, using back calculations. National COVID-19-associated mortality data, however, help to form the basis for minimum estimates, and for regions such as Africa, such estimates remain often vastly under-reported.
Consequently, we expect that future reports of minimum estimates will also increase as the quality of excess mortality and COVID-19 mortality data improves. New WHO mortality estimates show that the African region has under-reporting of death rates by a factor of 10.
Consequently, the real-time global minimum estimate for the number of children affected by COVID-19-associated orphanhood and caregiver death reached more than 6·7 million children by Jan 15, 2022, after adjustment for this under-reporting in the COVID-19 calculator. As new variants such as omicron emerge, it will also be important to assess their effect on caregiver deaths.
Two noteworthy findings were the elevated proportions of paternal compared with maternal loss (three of every four children affected by orphanhood lost their fathers), and the disproportionate orphanhood among young adolescents (accounting for two of every three children whose parents died). Increased risks for children of paternal death appear to be linked to trends of later fertility and greater risk of death from COVID-19.
Although increased risks of paternal and adolescent orphanhood occurred in every country and region, the numbers of children affected in all subgroups are disturbing. Globally, we estimated that nearly 500 000 children aged younger than 5 years, more than 735 000 children aged 5–9 years, and more than 2·1 million children aged 10–17 years were estimated to be orphaned during the pandemic until Oct 31, 2021. Nearly 800 000 children have experienced the death of their mothers, and almost 2·6 million children are estimated to have experienced the death of their fathers. The largest share of orphanhood among children aged 0–4 years and 5–9 years are in the African region and region of the Americas, whereas the largest share among those aged 10–17 years is in European and Eastern Mediterranean regions. For South Africa, at least one in every 200 children in every age group has experienced COVID-19-associated orphanhood.
HIV infection,
suicide, child labour, adolescent pregnancy, separation from family, household poverty, and leaving school to care for younger siblings.
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Our finding that adolescents were most likely to lose a parent or caregiver can inform priorities for national plans. This age group benefits from parenting or caregiving approaches focused on communication, connection, and supervision,
and good parenting or caregiving increases confidence, resilience, and reduces risk behaviour.
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Evidence-based interventions for adolescents, combining positive parenting with economic strengthening, education, life skills, and services, are effective for preventing violence, other social vulnerabilities, adolescent pregnancy, child marriage, and HIV infection.
Both the PEPFAR DREAMS programme and the WHO INSPIRE package endorse these evidence-based approaches, using a life-course approach to support individual, familial, community, and societal programmes and policies.
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For example, studies in sub-Saharan Africa show that paternal death is associated with decreased monitoring, guidance, and boundary setting;
increased risks of sexual violence, adolescent pregnancy, and early marriage for girls.
Loss of a primary socio-emotional caregiver can decrease social connectedness and family cohesion, and studies have shown such effects on maternally orphaned children.
These effects are mediated by varying family compositions—eg, single, dual, multigenerational, blended, traditional, and non-traditional—and by differing cultural approaches to adolescence, such as child marriage as a response to severe poverty. Adolescent girls affected by orphanhood have particularly heightened risks of school non-enrolment, non-attendance, sexual violence, and exploitation. Evidence confirms that parental monitoring reduces such risks.
Building parenting skills for remaining caregivers and life skills for adolescents can promote recovery by strengthening agency, self-esteem, and peer relationships.
Support for such interventions by governmental, civil society, and faith sectors can divert accumulated stressors, alleviate escalating suffering, and help children to find strength, experience growth, and develop new abilities.
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Two decades of coordinated HIV/AIDS programming for orphans and vulnerable children have demonstrated that investments in evidence-based programmes (eg, cash transfers, parenting support, and safe schools) promotes resilience for children, families, communities, and nations.
Thus, the care received after caregiver death shapes the consequences of that death.
We found that globally, the heart-breaking hidden pandemic of over 5·2 million children affected by orphanhood and caregiver death, has outpaced the 5·0 million COVID-19 deaths. These data identify an almost one-to-one correspondence in the magnitude of COVID-19 deaths and that of children’s COVID-19-associated loss of parents and caregivers. At the current rate, one child faces parental or caregiver death every 6 s. Our data suggest the surge of orphanhood and caregiver deaths must be urgently addressed with sustainable and scalable solutions, and integrated into coordinated and collaborative global, regional, and national strategies.
We propose immediate integration of care for children into every national COVID-19 response plan, as described in the joint report Children: the hidden pandemic, February 2022—updated interim estimates, prepared through the collaboration of the US Centers for Disease Control and Prevention, WHO, US Agency for International Development, the World Bank, the University of Oxford (Oxford, UK), Imperial College London (London, UK, Harvard University (Boston, MA, USA), and University College London (London, UK).
Care for children includes three components: prevent death of caregivers by accelerating equitable COVID-19 vaccine delivery; prepare families to be safe and nurturing; and protect children using evidence-based strategies to reduce risks of poverty, childhood adversity and violence, and strengthen their recovery.
HJTU and ABl guided and performed all the statistical and modelling analysis, and verified the underlying data. HJTU and SF wrote the entire appendix. Additional authors contributing to the formal analysis included SB, CAD, and OR, and these authors had full access to the data. HJTU and SH guided the conceptualisation and investigation, and wrote the first draft. SH guided the review and editing. LC, PSG, ABu, GB, LR, PG, CAN, CD, AV, and LS commented on the manuscript, and HJTU, SH, AV and LS had final responsibility for the decision to submit to publication.
