The availability of new excess mortality data enables us to update global minimum estimates of COVID-19 orphanhood and caregiver death among children.1-4 Consequences for children can be devastating, including institutionalization, abuse, traumatic grief, mental health problems, adolescent pregnancy, poor educational outcomes, and chronic and infectious diseases.4,5 Global totals and country comparisons were previously hampered by inconsistencies in COVID-19 testing and incomplete death reporting. The new orphanhood estimates derived here based on excess deaths provide a comprehensive measure of COVID-19’s long-term impact on orphanhood and caregiver loss.
Using previous methodology for combining age-specific death and fertility rates,4 we use Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) reporting guideline for this epidemiologic modeling study to update COVID-19 estimates of parent and caregiver loss. We computed excess mortality-derived estimates for bereft children in every country, using data from the World Health Organization (WHO), The Economist, and the Institute for Health Metrics and Evaluation (IHME).1-3,6 We replaced COVID-19 deaths in previous logistic models with excess deaths (except when excess deaths were negative) to generate composite deaths for January 1, 2020, through December 31, 2021, and for January 1, 2020, through May 1, 2022 (eMethods in the Supplement; Table). We used bootstrapping to calculate uncertainty around estimates from fertility and death data. We present regional and national estimates using WHO-based mortality methods.
Using WHO excess mortality (more conservative than findings from IHME and The Economist), we estimate that 10 500 000 children lost parents or caregivers (Table), and 7 500 000 children experienced COVID-19–associated orphanhood through May 1, 2022. Greater numbers affected by orphanhood by primary and/or secondary caregiver loss were found in the Africa (24.3% [95% credible interval [CI], 19.3%-27.6%]) and Southeast Asia (40.6% [95% CI, 35.3%-46.2%]) WHO regions, compared with the Americas (14.0% [95% CI, 12.6%-15.8%]), Eastern Mediterranean (14.6% [95% CI, 12.9%-16.2%]), European (4.7% [95% CI, 4.4%-5.3%]) and Western Pacific (1.8% [95% CI, 1.7%-1.9%]) regions through May 1, 2022 (Figure A). Similarly, variation in estimates arises at national levels, with India (3 490 000 [95% CI, 2 430 000-4 730 000]), Indonesia (660 000 [95% CI, 390 000-1 020 000]), Egypt (450 000 [95% CI, 360 000-540 000]), Nigeria (430 000 [95% CI, 40 000-900 000]), and Pakistan (410 000 [95% CI, 80 000-770 000]) worst affected through May 1, 2022 (Figure B). Among the WHO regions most affected, countries with the highest numbers of bereaved children in Southeast Asia included Bangladesh, India, Indonesia, Myanmar, and Nepal and in Africa included Democratic Republic of Congo, Ethiopia, Kenya, Nigeria, and South Africa. Our updated Orphanhood Calculator6 provides these new numbers for every country.
COVID-19–associated orphanhood and caregiver death has left an estimated 10.5 million children bereaved of their parents and caregivers. While billions of dollars are invested in preventing COVID-19–associated deaths, little is being done to care for children left behind. However, billions of dollars invested in supporting AIDS-orphaned children showcase successful solutions ready for replication.4 Only 2 countries, Peru and the US, have made national commitments to address COVID-19–associated orphanhood. At the 2nd Global COVID-19 Summit (May 12, 2022), President Biden emphasized the urgency of caring for the millions of children orphaned. Urgently needed pandemic responses can combine equitable vaccination with life-changing programs for bereaved children. An important limitation is that modeling estimates cannot measure actual numbers of children affected by caregiver death; future pandemic surveillance should include such children. Given the magnitude and lifelong consequences of orphanhood, integration into every national pandemic response plan of timely care for these children will help mitigate lasting adverse consequences. Evidence highlights 3 essential components: (1) prevent death of caregivers by accelerating vaccines, containment, and treatment; (2) prepare families to provide safe and nurturing alternative care; and (3) protect orphaned children through economic support, violence prevention, parenting support, and ensuring school access. Effective, caring action to protect children from immediate and long-term harms of COVID-19 is an investment in the future and a public health imperative.
Accepted for Publication: June 28, 2022.
Published Online: September 6, 2022. doi:10.1001/jamapediatrics.2022.3157
Corresponding Authors: Joel-Pascal Ntwali N’konzi, MSc, African Institute for Mathematical Sciences, KN 3 Rd, Kigali, Rwanda (firstname.lastname@example.org); Susan Hillis, PhD, University of Oxford, 32 Wellington Square, OX1 1NF, Oxford, United Kingdom (email@example.com).
Correction: This article was corrected on October 3, 2022, to fix an error in the Table.
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Hillis S et al. JAMA Pediatrics.
Author Contributions: Dr Unwin and Mr Ntwali N’konzi had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Hillis, Villaveces, Flaxman, Unwin.
Acquisition, analysis, or interpretation of data: Hillis, Ntwali N’konzi, Msemburi, Villaveces, Flaxman, Unwin.
Drafting of the manuscript: Hillis, Villaveces, Flaxman, Unwin.
Critical revision of the manuscript for important intellectual content: Hillis, Ntwali N’konzi, Msemburi, Villaveces, Flaxman, Unwin.
Statistical analysis: Hillis, Ntwali N’konzi, Flaxman, Unwin.
Obtained funding: Flaxman.
Administrative, technical, or material support: Hillis, Msemburi, Villaveces.
Conflict of Interest Disclosures: Dr Cluver reports grants from UK Research and Innovation, Oak Foundation, and Wellspring Philanthropic Fund during the conduct of the study. No other disclosures were reported.
Funding/Support: We acknowledge the following sources of funding support: UKRI Global Challenges Research Fund (L.C. and J.-P.N.N.), Wellspring Philanthropic Fund (L.C.), Oak Foundation (L.C.), and Engineering and Physical Sciences Research Council (S.F.). Dr Unwin acknowledges funding from the MRC Centre for Global Infectious Disease Analysis (grant MR/R015600/1), jointly funded by the UK Medical Research Council (MRC) and the UK Foreign, Commonwealth & Development Office (FCDO), under the MRC/FCDO concordant agreement and is also part of the EDCTP2 programme supported by the European Union and acknowledges funding by Community Jameel. Dr Cluver thanks an anonymous family foundation for their support for the University of Oxford.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention or of the World Health Organization.
Additional Contributions: We acknowledge Jon Wakefield, PhD, University of Washington, with permission, for his help with accessing data and comments on the manuscript. Dr Wakefield did not receive compensation.
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