- Study offers first global estimates of the number of children who experienced the death of a parent, grandparent, or primary caregiver from COVID-19.
- Researchers estimated figures based on COVID-19 mortality data from March 2020 through April 2021, and national fertility statistics for 21 countries, and extrapolated findings to produce global estimates.
- Findings suggest 1 million children have lost a parent, 1.1 million have lost a parent or custodial grandparent, and more than 1.5 million have lost a parent, custodial grandparent, or other secondary familial caregiver from COVID-19.
- Authors call for urgent investments in services to support children who have lost their parents and caregivers.
An estimated 1.5 million children worldwide have experienced the death of a parent, custodial grandparent, or other relative who cared for them, as a result of COVID-19, according to a new study published in The Lancet.
Of those, more than 1 million children experienced the death of one or both parents during the first 14 months of the pandemic, and another half a million experienced the death of a grandparent caregiver living in their own home, the study estimates.
Children who have lost a parent or caregiver are at risk of profound short- and long-term adverse effects on their health, safety, and wellbeing, such as increasing the risk of disease, physical abuse, sexual violence, and adolescent pregnancy. The researchers call for urgent action to address the impact of caregiver deaths on children into COVID-19 response plans.
Dr Susan Hillis, one of the lead authors on the study, from the U.S. Centers for Disease Control and Prevention COVID-19 Response Team says: "For every two COVID-19 deaths worldwide, one child is left behind to face the death of a parent or caregiver. By April 30, 2021, these 1.5 million children had become the tragic overlooked consequence of the 3 million COVID-19 deaths worldwide, and this number will only increase as the pandemic progresses . Our findings highlight the urgent need to prioritize these children and invest in evidence-based programs and services to protect and support them right now and to continue to support them for many years into the future - because orphanhood does not go away." 
Before the pandemic, there were an estimated 140 million orphaned children worldwide. These children have greater risks of mental health problems, family poverty, and physical, emotional, and sexual violence. They are also more likely to die by suicide or develop a chronic disease, such as heart disease, diabetes, cancer, or stroke.
The COVID-19 pandemic has resulted in more children facing the loss of a parent or caregiver. In addition, as older adults are the most vulnerable to COVID-19, many children living in multigenerational families will have experienced the death of a grandparent. Evidence shows that grandparents are increasingly playing key roles in providing care and financial support for their grandchildren worldwide. 
Study author Professor Lucie Cluver, Oxford University, UK, and the University of Cape Town, South Africa, says: "We have strong evidence from HIV and Ebola to guide solutions. We need to support extended families or foster families to care for children, with cost-effective economic strengthening, parenting programs, and school access. We need to vaccinate caregivers of children - especially grandparent caregivers. And we need to respond fast because every 12 seconds a child loses their caregiver to COVID-19." .
Before this report, there were no global figures to quantify how many children have been affected by the loss of a caregiver during the COVID-19 pandemic, either directly (due to the virus) or indirectly (due to another condition that was exacerbated due to the pandemic). The study's researchers developed mathematical models using the best available data as an initial attempt to estimate the magnitude of this hidden impact of the pandemic on children.
Implementing methods similar to those used by the UNAIDS Reference Group on Estimates, Modelling and Projections for estimating the number of children orphaned by AIDS , the authors based the COVID-19 orphanhood estimates on mortality data for 21 countries that account for 77% of global COVID-19 deaths . The analysis included both reported COVID-19 deaths between 1 March 2020 and 30 April 2021 and the number of excess deaths (when such data were available), during the same time-period, to account for variations in country-specific reporting systems.
The researchers linked COVID-19 death rates to fertility data for males and females from those 21 countries  to estimate the number of children who had lost a parent as a consequence of COVID-19. Loss of both parents was accounted for so that children were not counted twice.
The researchers extended their analysis to include deaths of grandparents or other older adults aged 60 to 84 years who were living in the same household as the children, based on United Nations Population Division's statistics on household composition. These figures take into account custodial grandparents (living with grandchildren in absence of parents), who have primary responsibility for their grandchildren's care, as well as co-residing grandparents and other older family members, who live in the same household (with grandchildren and parents) and have secondary, but not primary caring responsibilities.
Mathematical modelling was used to extrapolate the findings from these 21 countries to the rest of the world, using country-level data on COVID-19 deaths and fertility rates. The model showed a high correlation between female fertility rate and the ratio of orphans to deaths.
The findings suggest that at least 1,134,000 children experienced the death of their mother, father, or custodial grandparents, as a consequence of COVID-19. Of these, an estimated 1,042,000 lost their mother or father, or both. Overall, 1,562,000 children are estimated to have experienced the death of at least one parent or a custodial or other co-residing grandparent (or other older relative).
Countries with the highest rates of children losing their primary caregiver (parent or custodial grandparent) included: Peru (1 child per 100, totalling 98,975 children), South Africa (5 children per 1,000, totalling 94,625 children), Mexico (3 children per 1000, totalling 141,132 children), Brazil (2 children per 1,000, totalling 130,363 children), Colombia (2 children per 1,000, totalling 33,293 children), Iran (>1 child per 1,000, totalling 40,996 children), USA (>1 child per 1,000, totalling 113,708 children), and Russian Federation (1 child per 1,000, totalling 29,724 children).
In April 2021, in India, the researchers estimate an 8.5-fold increase in the numbers of children newly orphaned (43,139) compared to March 2021 (5,091).
For almost every country, deaths were greater in men than women, particularly in middle and older ages. Overall, up to five times more children lost their fathers than lost their mothers.
The authors note that children experiencing COVID-19-associated deaths of parents or caregivers are at greater risk of family separation and institutionalization, such as being placed in orphanages or care homes. They argue this should be avoided because it has negative effects on social, physical, and mental development.
Dr Seth Flaxman, one of the study's lead authors, from Imperial College London, UK, says: "The hidden pandemic of orphanhood is a global emergency, and we can ill afford to wait until tomorrow to act. Out of control COVID-19 epidemics abruptly and permanently alter the lives of the children who are left behind. Tomorrow is too late for the child institutionalized in an orphanage, who will grow up profoundly damaged by the experience. We urgently need to identify the children behind these numbers and strengthen monitoring systems, so that every child can be given the support they need to thrive." 
The researchers say their findings are likely underestimates because figures for a number of countries included in the study were based on COVID-19 mortality only and excess death data were unavailable. COVID-19 deaths may be underreported because of variability in SARS-CoV-2 testing and reporting systems.
Dr Juliette Unwin, another lead author from Imperial College London, UK, adds, "Our study establishes minimum estimates--lower bounds--for the numbers of children who lost parents and /or grandparents. Tragically, many demographic, epidemiological, and healthcare factors suggest that the true numbers affected could be orders of magnitude larger. In the months ahead variants and the slow pace of vaccination globally threaten to accelerate the pandemic, even in already incredibly hard-hit countries, resulting in millions more children experiencing orphanhood." 
The authors note some limitations to their results. Their study is based on the best available data, but many countries do not have robust reporting systems for deaths or fertility. Additionally, data on country-specific prevalence of orphans before the pandemic was lacking, so their estimates of double orphans are limited to deaths of both parents during the pandemic.
Writing in a linked Comment, Assistant Professor Rachel Kentor of Baylor College of Medicine, USA and Amanda Thompson of Inova Schar Cancer Institute, USA, (who were not involved in the study), say: "By answering the authors' call to expand our worldwide pandemic response to include caring for children, the global community can capitalise on this momentum; we can harness the current global attention on children bereaved by the pandemic to mobilise resources and implement systemic, sustainable supports for bereaved youth around the world."
As part of this work, the authors developed a real-time COVID-19 calculator , providing ongoing updated estimates of COVID-19-associated orphanhood and death of caregivers for every country in the world. These estimates as of the end of April 2021, along with an evidence-based strategy for action as described in the paper, can also be found in a policy report authored by the Global Reference Group for Children Affected by COVID: "Children: The Hidden Pandemic 2021 - A joint report of COVID-19-associated mortality and a strategy for action." 
Peer-reviewed / Modelling
NOTES TO EDITORS
This study was funded by UK Research and Innovation (UKRI) Global Challenges Research Fund Accelerator Hub, UKRI Medical Research Council, UKRI Engineering and Physical Sciences Research Council, UK National Institute for Health Research, Imperial College COVID-19 Research Fund and the US National Institutes of Health. It was conducted by researchers from the Centers for Disease Control COVID-19 Response Team (USA), Imperial College London (UK), the University of Oxford (UK), University of Copenhagen (Denmark), University of Cape Town (South Africa), the World Health Organization, University College London (UK), Maestral International, US Agency for International Development, World Without Orphans, World Bank Group and Harvard Medical School.
 Johns Hopkins University Coronavirus Resource Center. https://coronavirus.jhu.edu/
 Quote direct from author and cannot be found in the text of the Article.
 Chamie J. Increasingly Indispensable Grandparents. 2018. https://archive-yaleglobal.yale.edu/content/increasingly-indispensable-grandparents
 UNAIDS, UNICEF, USAID. Children on the Brink 2004. A Joint Report of New Orphan Estimates and a Framework for Action: UNICEF, 2004.
 The 21 countries are: Argentina, Brazil, Colombia, England and Wales, France, Germany, India, Islamic Republic of Iran, Italy, Kenya, Malawi, Mexico, Nigeria, Peru, Philippines, Poland, Russian Federation, South Africa, Spain, USA and Zimbabwe.
 Fertility rates were calculated from country-specific data for male and female and fertility (UK), figures reported in the Demographic and Health Survey, or figures from the UN World Prospects and UN Statistics Division, alongside population estimates.
 For Imperial College's Calculator giving up-to-date minimum estimates by country of minimum estimates of children affected by COVID-19 orphanhood and death of caregivers: https://imperialcollegelondon.github.io/orphanhood_calculator
For Imperial College's Interactive Visualization enabling comparisons between countries and over time of minimum estimates of children affected by COVID-19 orphanhood and death of caregivers: https://imperialcollegelondon.github.io/orphanhood_trends
 Children: The Hidden Pandemic 2021 - A joint report of COVID-19-associated orphanhood and a strategy for action (CDC, USAID, World Bank, WHO, University College London, University of Oxford, Imperial College, University of Cape Town) For embargoed access, please see: https://drive.google.com/file/d/1_wJnjGCtLFYC4LIGoT7L24xIr4vvmkpa/view?usp=sharing
Post-embargo it will be available via: https://www.cdc.gov/coronavirus/2019-ncov/downloads/community/orphanhood-report.pdf
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