Regional and national estimates of children affected by all-cause and COVID-19-associated orphanhood and caregiver death in Brazil, by age and family circumstance: a modeling study.

Background: Orphanhood and caregiver death can have severe consequences for children. Timely and accurate data can guide policy, particularly during health crises like COVID-19. The aim of our study is to present national and subnational analysis of both all-cause and COVID-19-associated orphanhood and caregiver death in Brazil and compare our model outputs with bespoke administrative datasets. Methods: We use publicly available national datasets to estimate the number of Brazilian children experiencing parent and caregiver loss due to all causes and COVID-19 in 2020-2021. Findings: An estimated 1,300,000 (95% uncertainty interval, 1,190,000, 1,430,000) children in Brazil experienced loss of one or multiple parents and/or co-residing caregivers. 673,000 (652,000, 690,000) were estimated to have lost one or both parents, of which 149,000 (144,000, 154,000) were COVID-19 associated; 635,000 (534,000, 758,000) children were estimated to have lost a co-residing grandparent or other kin, of which 135,000 (85,900, 199,000) were COVID-19 associated. Orphanhood varied substantially across states, with the rate of all cause parental orphanhood highest in Roraima at 17.5 (15.6, 20.6) per 1000 children and the lowest in Santa Catarina at 9.5 (8.7, 10.4) per 1000 children. COVID-19-associated orphanhood was also unevenly distributed, with Mato Grosso experiencing the greatest rate, at 4.4 (3.9, 5.3) per 1000 children, while Pará experienced the lowest rate of 1.4 (1.2, 1.8) per 1000 children. Comparisons with limited data from Brazil's civil registry offices and (manually reviewed death certificates in Campinas found a similar demographic distribution of orphanhood. However, our estimates suggested that administrative sources undercount orphanhood. Interpretation: Our findings highlight the extent of orphanhood in Brazil and large inequalities between states. Comparisons between administrative data and model estimates show similar temporal patterns and proportions of maternal and paternal orphanhood but different magnitudes. This suggests that strengthening vital registration systems can put children at the center of public health responses globally. Funding: This study was funded by "Building Global Public Health Capacity to Link Real-Time Modelling Data on COVID-19-associated Orphanhood and Caregiver Deaths to Inform Prevention, Preparedness and Protection from COVID-19 consequences" (2023 CDC/WHO grant) and the Moderna Charitable Foundation.