Orphanhood and caregiver death among children in the United States due to all-cause mortality 2000-2021: A Modeling Study (preprint)

Importance: Deaths of parents and grandparent caregivers linked to social and health crises threaten child wellbeing due to losses of nurturance, financial support, physical safety, family stability, and care. Little is known about the full burden of all-causes and leading cause-specific orphanhood and caregiver death beyond estimates from select causes. Objective: To estimate 2000-2021 prevalence and incidence trends of all-cause orphanhood and caregiver death among children <18, by cause, age, race/ethnicity, and state. Data Sources: National Center for Health Statistics (NCHS) birth, death, race/ethnicity, and population data to estimate fertility rates and identify causes of death; 1983-1998 ICD-9 causes-of-death harmonized to ICD-10 classifications; 1999-2021 ICD-10 causes-of-death; CDC WONDER for state-specific estimates; and American Community Survey for grandparent population estimates. Data extraction and synthesis: We extracted U.S. population-level death, birth, population size, race, and ethnicity data from NCHS and attributed to each deceased individual the average number of children left behind according to subgroup-specific fertility rates in the previous 0-17 years. We examined prevalence and incidence of orphanhood by leading causes-of-death, including COVID-19, the leading 5 causes-of-death for 1983-2021, and additional leading causes for ages 15-44. We extended these to obtain state-level outcome estimates. Main outcome measures: National incidence and prevalence of orphanhood and caregiver death from 2000-2021, with orphanhood by year, parental cause-of-death and sex, child age, race/ethnicity, and state. Results: From 2000-2021, orphanhood and custodial/co-residing grandparent caregiver loss annual incidence and prevalence trends increased 49.2% and 8.3%, respectively. By 2021, 2.9 million children (4% of all children) had experienced prevalent orphanhood and caregiver death. Populations disproportionately affected by orphanhood included 5.0% of all adolescents; 6.5%, 4.8%, and 3.9% respectively of non-Hispanic American Indian/Alaska Native, non-Hispanic Black, and non-Hispanic White children; and children in New Mexico and Southern and Eastern States. Parental death due to drug overdose during 2020-2021 surpassed COVID-19 as the leading cause of incident and prevalent orphanhood during the COVID-19 pandemic. Conclusions and Relevance: Policies, programs, and practices aimed at orphanhood prevention, identification, and linkage to services and support of nearly 3 million bereaved children are needed, foremost prioritizing rapidly increasing overdose-linked orphanhood.

Covid-19 is a leading cause of death in children and young people ages 0-19 years in the United States (preprint)

Covid-19 has caused more than 1 million deaths in the US, including at least 1,433 deaths among children and young people (CYP) aged 0-19 years. Deaths among US CYP are rare in general, and so we argue here that the mortality burden of Covid-19 in CYP is best understood in the context of all other causes of CYP death. Using publicly available data from the National Center for Health Statistics, and comparing to mortality in 2019, the immediate pre-pandemic period, we find that Covid-19 is a leading cause of death in CYP aged 0-19 years in the US, ranking #9 among all causes of deaths, #5 in disease related causes of deaths (excluding accidents, assault and suicide), and #1 in deaths caused by infectious / respiratory diseases. Due to the impact of mitigations such as social distancing and our comparison of a single disease (Covid-19) to groups of causes such as deaths from pneumonia and influenza, these rankings are likely conservative lower bounds. Our findings underscore the importance of continued vaccination campaigns for CYP over 5 years of age in the US and for effective Covid-19 vaccines for under 5 year olds.

COVID-19-Associated Orphanhood and Caregiver Death in the United States (preprint)

Background: Most COVID-19 deaths occur among adults, not children, and attention has focused on mitigating COVID-19 burden among adults. However, a tragic consequence of adult deaths is that high numbers of children might lose their parents and caregivers to COVID-19-associated deaths. Methods: We quantified COVID-19-associated caregiver loss and orphanhood in the US and for each state using fertility and excess and COVID-19 mortality data. We assessed burden and rates of COVID-19-associated orphanhood and deaths of custodial and co-residing grandparents, overall and by race/ethnicity. We further examined variations in COVID-19-associated orphanhood by race/ethnicity for each state. Results: We found that from April 1, 2020 through June 30, 2021, over 140,000 children in the US experienced the death of a parent or grandparent caregiver. The risk of such loss was 1.1 to 4.5 times higher among children of racial and ethnic minorities, compared to Non-Hispanic White children. The highest burden of COVID-19-associated death of parents and caregivers occurred in Southern border states for Hispanic children, Southeastern states for Black children, and in states with tribal areas for American Indian/Alaska Native populations. Conclusions: We found substantial disparities in distributions of COVID-19-associated death of parents and caregivers across racial and ethnic groups. Children losing caregivers to COVID-19 need care and safe, stable, and nurturing families with economic support, quality childcare and evidence-based parenting support programs. There is an urgent need to mount an evidence-based comprehensive response focused on those children at greatest risk, in the states most affected.

Report 46: Factors driving extensive spatial and temporal fluctuations in COVID-19 fatality rates in Brazilian hospitals (preprint)

The SARS-CoV-2 Gamma variant spread rapidly across Brazil, causing substantial infection and death waves. We use individual-level patient records following hospitalisation with suspected or confirmed COVID-19 to document the extensive shocks in hospital fatality rates that followed Gamma’s spread across 14 state capitals, and in which more than half of hospitalised patients died over sustained time periods. We show that extensive fluctuations in COVID-19 in-hospital fatality rates also existed prior to Gamma’s detection, and were largely transient after Gamma’s detection, subsiding with hospital demand. Using a Bayesian fatality rate model, we find that the geographic and temporal fluctuations in Brazil’s COVID-19 in-hospital fatality rates are primarily associated with geographic inequities and shortages in healthcare capacity. We project that approximately half of Brazil’s COVID-19 deaths in hospitals could have been avoided without pre-pandemic geographic inequities and without pandemic healthcare pressure. Our results suggest that investments in healthcare resources, healthcare optimization, and pandemic preparedness are critical to minimize population wide mortality and morbidity caused by highly transmissible and deadly pathogens such as SARS-CoV-2, especially in low- and middle-income countries. Note The following manuscript has appeared as ‘Report 46 - Factors driving extensive spatial and temporal fluctuations in COVID-19 fatality rates in Brazilian hospitals’ at https://spiral.imperial.ac.uk:8443/handle/10044/1/91875 . One sentence summary COVID-19 in-hospital fatality rates fluctuate dramatically in Brazil, and these fluctuations are primarily associated with geographic inequities and shortages in healthcare capacity.

Regularised B-splines projected Gaussian Process priors to estimate time-trends of age-specific COVID-19 deaths related to vaccine roll-out (preprint)

The COVID-19 pandemic has caused severe public health consequences in the United States. In this study, we use a hierarchical Bayesian model to estimate the age-specific COVID-19 attributable deaths over time in the United States. The model is specified by a novel non-parametric spatial approach, a low-rank Gaussian Process (GP) projected by regularised B-splines. We show that this projection defines a new GP with attractive smoothness and computational efficiency properties, derive its kernel function, and discuss the penalty terms induced by the projected GP. Simulation analyses and benchmark results show that the spatial approach performs better than standard B-splines and Bayesian P-splines and equivalently well as a standard GP, for considerably lower runtimes. The B-splines projected GP priors that we develop are likely an appealing addition to the arsenal of Bayesian regularising priors. We apply the model to weekly, age-stratified COVID-19 attributable deaths reported by the US Centers for Disease Control, which are subject to censoring and reporting biases. Using the B-splines projected GP, we can estimate longitudinal trends in COVID-19 associated deaths across the US by 1-year age bands. These estimates are instrumental to calculate age-specific mortality rates, describe variation in age-specific deaths across the US, and for fitting epidemic models. Here, we couple the model with age-specific vaccination rates to show that lower vaccination rates in younger adults aged 18-64 are associated with significantly stronger resurgences in COVID-19 deaths, especially in Florida and Texas. These results underscore the critical importance of medically able individuals of all ages to be vaccinated against COVID-19 in order to limit fatal outcomes.

Age groups that sustain resurging COVID-19 epidemics in the United States (preprint)

Following initial declines, in mid 2020, a resurgence in transmission of novel coronavirus disease (COVID-19) has occurred in the United States and parts of Europe. Despite the wide implementation of non-pharmaceutical interventions, it is still not known how they are impacted by changing contact patterns, age and other demographics. As COVID-19 disease control becomes more localised, understanding the age demographics driving transmission and how these impacts the loosening of interventions such as school reopening is crucial. Considering dynamics for the United States, we analyse aggregated, age-specific mobility trends from more than 10 million individuals and link these mechanistically to age-specific COVID-19 mortality data. In contrast to previous approaches, we link mobility to mortality via age-specific contact patterns and use this rich relationship to reconstruct accurate transmission dynamics. Contrary to anecdotal evidence, we find little support for age-shifts in contact and transmission dynamics over time. We estimate that, until August, 63.4% [60.9%-65.5%] of SARS-CoV-2 infections in the United States originated from adults aged 20-49, while 1.2% [0.8%-1.8%] originated from children aged 0- 9. In areas with continued, community-wide transmission, our transmission model predicts that re-opening kindergartens and elementary schools could facilitate spread and lead to additional COVID-19 attributable deaths over a 90-day period. These findings indicate that targeting interventions to adults aged 20-49 are an important consideration in halting resurgent epidemics and preventing COVID-19-attributable deaths when kindergartens and elementary schools reopen.