More than 1.5 million children around the world have lost a parent, grandparent, or other caregiver to COVID-19, according to the first global study of its kind.

In the study, published yesterday in The Lancet, a team led by US Centers for Disease Control and Prevention (CDC) scientists used death and fertility data to model minimum estimated COVID-19–related deaths of primary or secondary caregivers of children 18 years and younger in 21 countries. Indirect coronavirus deaths, such as those related to lockdowns or decreased access to medical care, were also included.

The countries, which represent 77% of global COVID-19 deaths in 2020 and early 2021, were Argentina, Brazil, Colombia, England and Wales, France, Germany, India, Iran, Italy, Kenya, Malawi, Mexico, Nigeria, Peru, the Philippines, Poland, Russia, South Africa, Spain, the United States, and Zimbabwe.

Parents and custodial grandparents were considered primary caregivers, and grandparents or other relatives 60 to 84 years old living with a child were classified as secondary caregivers.

‘The tragic overlooked consequence’

From Mar 1, 2020, to Apr 30, 2021, an estimated 1,042,000 children were orphaned; 1,134,000 lost a primary caregiver, including at least one parent or custodial grandparent; and 1,562,000 lost at least one primary or secondary caregiver.

Countries with primary caregiver death rates of 1 or more per 1,000 children were Peru (10.2 per 1,000 children), South Africa (5.1), Mexico (3.5), Brazil (2.4), Colombia (2.3), Iran (1.7), the United States (1.5), Argentina (1.1), and Russia (1.0). Amid a COVID-19 surge in India, researchers identified an 8.5-fold rise in newly orphaned children in April over March (43,139 vs 5,091, respectively).

Because men—particularly those who were middle-aged or older—died of COVID-19 at higher rates than women in every country except South Africa, two to five times more children lost fathers than mothers.

In a Lancet news release, lead study author Susan Hillis, PhD, a member of the CDC COVID-19 Response Team, said, “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.”

A cascade of pain

Grandparents, who are especially susceptible to COVID-19, often support their grandchildren’s psychosocial, practical, or financial needs—particularly when they live in increasingly common multigenerational households, the authors wrote.

For example, in the United States, 40% of grandparents who share a household with their grandchildren are their primary caregivers, and 70% of children in Brazil receive financial support from their grandparents. Their loss is tied to the need for parents to work, poor school attendance, lower educational attainment, and poor communication skills, the researchers said.

Further, “up to 23% of children in countries considered in this analysis are raised by single parents, whose death can have extreme consequences for children,” they wrote. “Increases in orphanhood that are associated with COVID-19 occur against a backdrop of more than 140 million existing orphans in need of global health and social care prioritisation.”

The authors also noted that children who are orphaned or are grieving their caregivers often are also subject to poverty, abuse, mental illness, institutionalization, and physical, emotional, and sexual violence. These experiences can in turn lead to teen pregnancy, infections (eg, HIV/AIDS), and chronic diseases, and institutionalization or foster care placement can result in developmental delays and more abuse.

In a National Institute on Drug Abuse (NIDA) news release, co-senior author Charles Nelson, III, PhD, of Boston Children’s Hospital, said that caregiver loss can upend children’s lives and affect their development. “If we take into consideration variants of concern or possible severity of illness among youth, we must not forget that the pandemic continues to pose a threat to parents and caregivers—and their children,” he said.

NIDA, part of the US National Institutes of Health, helped fund the study.

‘Orphanhood does not go away’

The authors called for support for extended or foster families of orphaned children, including economic support, parenting programs, school access, and vaccination of caregivers of children.

“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,” Hillis said in the Lancet release.

In a commentary in the same journal, Rachel Kentor, PhD, of Baylor College of Medicine, and Amanda Thompson, PhD, of Inova Schar Cancer Institute, said that while the number of children who lost caregivers amid the pandemic may seem small compared with the 140,000 million total orphans worldwide, they constitute a large group of children in need of support.

“By answering the authors’ call to expand our worldwide pandemic response to include caring for children, the global community can capitalise on this momentum,” they wrote.

“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.”