Peer-reviewed / Modelling/ People
**Country-level data is available via Imperial College London’s Global Orphanhood Calculator—see notes to editors**
**Infographics available—see notes to editors**
- Modelling study estimates at least 5.2 million children under age 18 years have experienced the death of a parent or caregiver due to COVID-19.
- Study updates previous estimates from July 2021 based on new mortality data from 20 countries (including the US, India, England, and Peru) from 1 March 2020 to 31 October 2021.
- Although large numbers of children age 0-4 (nearly 500,000 children) and 5-9 (740,000 children) experienced COVID-19-associated orphanhood, adolescents age 10-17 are worst affected (2.1 million children), accounting for almost two out of three children who lost a parent due to COVID-19.
- Authors call for urgent actions to prioritise children affected by deaths of parents and caregivers as part of national and global pandemic responses, including economic strengthening, enhanced community and family support, and education.
The number of children estimated to have experienced the death of a parent or caregiver as a result of the COVID-19 pandemic has surged to more than 5.2 million globally, according to a new modelling study published in The Lancet Child & Adolescent Health journal.
Estimates of the numbers of children affected by COVID-19-associated orphanhood and caregiver death nearly doubled in the six months from 1 May 2021 through 31 October 2021, compared with the amount after the first 14 months of the pandemic (March 1, 2020 through April 30, 2021).
Globally, the new study suggests that two out of three children orphaned from COVID-19 are adolescents aged 10 to 17 years. Additionally, in line with evidence that COVID-19 deaths disproportionally affect men , three out of four children worldwide who experienced the death of a parent during the pandemic lost their fathers.
Overall, children who experience the loss of a caregiver have an increased risk of poverty, exploitation and sexual violence or abuse, HIV infection, mental health challenges and severe distress, and in some contexts, increased vulnerability to gang involvement and violent extremism. The researchers call for evidence-based programs for children experiencing orphanhood to be urgently incorporated into pandemic response efforts, including programs that support economic strengthening, enhanced community and family support, and programs that avoid placing children in institutional care. The findings can aid national responses tailored to age and circumstances of affected children.
“We estimate that for every person reported to have died as a result of the COVID-19 pandemic, one child is left orphaned or loses a caregiver. That is the equivalent of one child every six seconds facing a heightened risk of lifelong adversity unless given appropriate support in time. Thus, support for orphaned children must be immediately integrated into every national COVID-19 response plan. Such support should focus on three core components: preventing caregiver death through equitable COVID-19 vaccine coverage, containment, and treatment; preparing families that are safe and nurturing to support affected children (such as through kinship care, foster care, and adoption); and protecting children using evidence-based strategies to reduce risks of poverty, childhood adversity, and violence. These strategies will help save lives now and put the programmatic and financial infrastructure in place on a global scale to secure a better future for children and families around the world,” says lead author Dr Susan Hillis, who completed this work during her tenure at the US Centers for Disease Control and Prevention (CDC). 
Dr Juliette Unwin, lead author from Imperial College London (UK), adds, “sadly, as high as our estimates of orphanhood and caregiver deaths are, they are likely to be underestimates, and we expect these numbers to grow as more global data on COVID-19 deaths becomes available. For example, WHO estimates accurate data for COVID-19 deaths in Africa are limited, and the real estimates are likely to be 10 times higher than what is currently being reported. Consequently, these under-reported deaths mean that COVID-19-related orphanhood and caregiver loss is also drastically underestimated. Real-time updated data suggests the true totals reached 6.7 million children as of January 2022. While our current study looked at estimates through October 2021, the pandemic is still raging worldwide, which means COVID-19 related orphanhood will also continue to surge.” 
Prior to the COVID-19 pandemic, there were an estimated 140 million orphaned children worldwide. COVID-19’s impact on orphanhood was first revealed in a study published in July 2021, which estimated that 1.5 million children had experienced the death of a parent or caregiver between March 2020 and April 2021 as a result of COVID-19 .
The new study increases this estimate to more than 2.7 million children for the same time period, by re-calculating the figures from updated COVID-19 death figures along with excess mortality data to account for indirect deaths associated with the pandemic (July 2021 estimates: 1,562,000 children vs latest estimates: 2,737,300 children).
Using the same methodology, the researchers extended their analysis to 31 October 2021, analysing mortality and fertility data from countries that accounted for the largest proportion of COVID-19 deaths  and using mathematical modelling to extrapolate their findings for global estimates. This approach has previously shown a strong correlation between the ratio of orphanhood to deaths and total fertility rate.
As before, the team estimated the loss of caregiver grandparents using United Nations household composition data for the proportion of adults aged over 60 years co-residing with children under 18 years, with or without a parent. These proportions were multiplied by COVID-19 associated deaths in the relevant age group to estimate the number of children affected, conservatively estimating that one death resulted in only one child experiencing caregiver death.
For the entire 20-month period of the study, the team estimates a minimum of 3,367,000 children were orphaned worldwide, experiencing the loss of a parent. A further 1,833,300 children were affected by the death of a grandparent or older adult caregiver living in their own home. Overall, the number of children affected by the death of a caregiver due to COVID-19 exceeded the number of reported COVID-19 deaths (5.2 million children compared to 5 million COVID-19 deaths).
“It took 10 years for 5 million children to be orphaned by HIV/AIDS, whereas the same number of children have been orphaned by COVID-19 in just two years. These figures do not account for the latest wave of the omicron COVID-19 variant, which may push the true toll even higher. We need to act swiftly to identify the children behind these numbers, so they can be given the support they need to thrive,” says senior author Prof Lorraine Sherr from University College London (UK). 
The number of children affected in the 20 countries  studied ranged from 2,400 in Germany to more than 1.9 million in India. Calculations of estimated orphanhood cases per capita showed the highest rates were in Peru and South Africa, with 8 and 7 out of every 1000 children affected, respectively.
In all countries, children were more likely to have lost a father than a mother, with more than three times as many children experiencing the death of a father than losing a mother (76.5% or 2,581,300/3,374,900 of children lost fathers as compared to 23.5% or 793,600/3,374,900 who lost mothers).
The researchers also calculated the ages of children who lost a parent in each of the countries studied, by estimating yearly fertility contributions separately to obtain the average number of children for every year of age between birth and 17 years. Mathematical modelling was again used to extrapolate these findings for all countries in the world that had reported COVID-19 deaths up to 31 October 2021. Adolescents accounted for a far greater proportion of those orphaned (Ages 10-17 years represented 63.6% or 2,146,700/3,374,900 of orphaned children) than younger children in all countries. (Ages 5-9 years: 21.8%, 736,800/3,374,900; ages 0-4 years: 14.6%, 491,300/3,374,900).
“The global health community must build upon the two decades experience supporting vulnerable children through the HIV/AIDS epidemic to offer that same support for children experiencing loss due to COVID-19. Losing a parent or grandparent is a distressing experience for any child, however, the specific needs and vulnerabilities of orphanhood vary dramatically with age and developmental stage. We know that different age groups benefit from tailored, evidence-based support packages that include strengthening family-based and community support networks, and economic support while avoiding placing children in institutional care wherever possible. Our findings show the urgent need to invest in response plans focused on children at greatest risk and in the locations most affected. We have seen that timely, responsive, and supportive intervention transforms damage into lifelong dividends. Hesitation is a luxury we cannot afford,” says study author Prof Chris Desmond of University of KwaZulu-Natal (South Africa). 
The authors note some limitations. Most notably, their estimates are generated by mathematical modelling and cannot measure actual numbers of children affected by a parent or caregiver’s death. They say future pandemic responses should include surveillance systems to monitor the numbers of children affected for every parental and caregiver death, in order to track needs for services and provide referral platforms that help point families towards appropriate support.
They also note that their analysis is based on the best available data, but many countries do not have robust reporting systems for deaths or fertility. However, by using a stable COVID-19 infection fatality ratio, they say it is unlikely this limitation substantially biased their results.
Writing in a linked Comment, lead author Dr Michael Goodman of the University of Texas Medical Branch (USA), who was not involved in the study, says, “[The] modelling represents an ongoing attempt to hit a moving target—heart-wrenching and unavoidably incomplete. Beyond updating earlier estimates, the authors add value through describing orphanhood ‘by time, person, and place’. In doing so, they draw attention to the importance of dynamic, multilevel systems in shaping the crisis. Orphanhood increases a range of economic, social, educational, and health risks. To best protect children, we must consider the individual, family, community, national, and global factors that affect their wellbeing, and how these can be integrated into an adaptive response… COVID-19 orphanhood confronts us at a time nearing resource exhaustion across multiple systems. The consequences of orphanhood linger throughout the course of a lifetime, affecting the futures of families, communities, and societies. We determine how long our communities will suffer the effects of COVID-19 by urgently determining the quality and force of our concern for orphaned young people.”
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. The authors have also developed an updated evidence-based strategy for action as described in the paper, which can be found in a policy report authored by the Global Reference Group for Children Affected by COVID: “Joint Estimates and Action. Children: The hidden pandemic, February 2022 - updated interim estimates.” 
NOTES TO EDITORS
The study was carried out by researchers from the CDC COVID-19 Response Team, U.S. Centers for Disease Control and Prevention (USA); Imperial College London (UK); University of Oxford (UK); University of Copenhagen (Denmark); University of KwaZulu-Natal (South Africa); University of Cape Town (South Africa); World Health Organization; University College London (UK); Maestral International; Office of Global HIV/AIDS, U.S. Agency for International Development (USA); World Without Orphans; World Bank Group; Harvard Medical School (USA); and Boston Children’s Hospital (USA).It was funded by 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.
 Quote direct from author and cannot be found in the text of the Article.
 S.D. Hillis et al. Global minimum estimates of children affected by COVID-19-associated orphanhood and deaths of caregivers: a modelling study. The Lancet, 2021. https://doi.org/10.1016/S0140-6736(21)01253-8
 The countries are Argentina, Brazil, Colombia, England and Wales, France, Germany, India, Islamic Republic of Iran, Italy, Kenya, Malawi, Mexico, Nigeria, Peru, Philippines, Poland, South Africa, Spain, USA and Zimbabwe. NB The initial study also included data from the Russian Federation, but this was excluded from the latest study because of limited age of mortality data.
 Fertility rates were calculated from country-specific data for male and female and fertility (UK), figures reported in the Demographic and Health Survey (https://dhsprogram.com/), or figures from the UN World Prospects (https://population.un.org/wpp/) and UN Statistics Division (https://unstats.un.org/home/), alongside population estimates.
 Imperial College London's Calculator for up-to-date minimum estimates by country of children affected by COVID-19 orphanhood and death of caregivers: https://imperialcollegelondon.github.io/orphanhood_calculator
 The Global Reference Group on Children Affected by COVID-19: Joint Estimates and Action. Children: The hidden pandemic, February 2022 - updated interim estimates. https://www.spi.ox.ac.uk/the-global-reference-group-on-children-affected-by-covid-19#collapse3410246.
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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
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CAD reports grants from the UK Medical Research Council and grants from NIHR during the conduct of the study. LC reports grants from UK Research and Innovation (UKRI) Global Challenges Research Fund during the conduct of the study. All other authors declare no competing interests.