Child mortality and COVID-19

The available evidence indicates the direct impact of COVID-19 on child, adolescent and youth mortality to be limited. However, there is concern that the indirect effects of the pandemic on mortality in these age groups stemming from strained health systems, household income loss, and disruptions to care-seeking and preventative interventions like vaccination may be more substantial.

The UN IGME undertook an analysis of excess mortality among children, adolescents and youth in 2020 for its most recent annual report: Levels and Trends in Child Mortality: Report 2021, which provides country, regional and global estimates of mortality for ages 0-24 years up to 2020. Importantly, excess mortality analysis considers all deaths that have occurred in a specific time and place, and thus should capture both direct COVID-19 deaths and any indirect deaths resulting from pandemic-related disruptions. That analysis, which included empirical data on mortality in 2020 from more than 80 countries and areas, found no evidence of significant excess mortality among those under age 25 for 2020.

While the evidence thus far does not point to any increase in child and youth mortality related to the COVID-19 pandemic in 2020, these data have limitations and caution must be taken with their interpretation. First, the available data for the excess mortality analysis disproportionally represents high-income countries and the pandemic may unfold differently in low- and middle-income countries. Likewise, some of these data may suffer from underreporting during the pandemic, thus data quality is also of concern. More quality data representing the widest array of country characteristics is greatly needed to better understand the full impact of the COVID-19 pandemic on mortality. Second, national level estimates can obscure subnational variation and the pandemic may unfold differently at subnational levels. Disaggregated data by age and subnational level will be critical to assessing the pandemic’s impact on child survival. Finally, caution should be taken in assuming 2021 will be like 2020. COVID-19 has shown its ability to change in unpredictable and unexpected ways. The surge of the Delta variant, the rollout and uneven access to vaccines both between and within countries, the relative decline in countrywide lockdown policies and personal precaution taking, and the economy in 2021 are just some of the pandemic’s evolving aspects that could result in a different mortality outcome for children and youth in 2021 compared to 2020. Moreover, some of the indirect mortality effects arising from disruptions to services like immunization for example, may not be apparent for some time.

Gains in child survival are dependent on the continued provision of essential health services to women and children around the world. While the full extent of COVID-19’s impact on economies, movement, and child health is not entirely clear, if life-saving interventions are disrupted, many more children could die of treatable and preventable conditions. This is a call to not only invest in women and children by continuing to provide critical services and supplies, but also to provide the evidence base for sound and informed decision-making. More data and research are urgently needed to foster a more nuanced understanding of how and why child mortality has changed since the pandemic began, and to ensure children and adolescents do not succumb to preventable deaths.

The UN Inter-agency Group for Child Mortality Estimation, led by UNICEF, will continue to assess the impact of COVID-19 on child and adolescent mortality in 2020 and beyond as more data become available. Timely, high-quality, and disaggregated data will be critical to achieving this goal. While UNICEF and its partners continue to monitor and report on this pandemic’s impact on children, please find below additional resources on COVID-19 and mortality. This list is to be updated as new resources become available.

Resources on COVID-19 and mortality

Latest update: 20 December 2021

Dashboards or databases on excess and COVID-19-related mortality

• COVID-19 confirmed cases and deaths by age and sex (based on COVerAGE database)
• The World Mortality Dataset: Tracking excess mortality across countries during the COVID-19 pandemic
• Our World in Data: Statistics and Research – Coronavirus Pandemic (COVID-19)
• European Centre for Disease Prevention and Control COVID-19 tracking
• European Monitoring of Excess Mortality for Public Health (EuroMOMO)
  Pooled weekly total number of deaths in the data-providing EuroMOMO partners for the past 4½ years, in four age groups.
• MPIDR/INED COVID-19 cases and deaths by age and sex
• Johns Hopkins University Center for Systems Science Engineering COVID-19 data repository
• Global 50/50 dashboard on COVID-19 age and sex disaggregated data
• The Economist Excess Death Tracker
• Human Mortality Database: Short-term fluctuations in mortality

Indirect deaths from COVID-19 pandemic

• Research articles comparing occurrence of neonatal mortality, stillbirth and other pregnancy outcomes during and prior to COVID-19, including regional/national lockdowns periods. Note that findings in these articles may not be nationally representative, as they are based on hospital or regional specific data with small sample sizes observed.
  • Stillbirths During the COVID-19 Pandemic in England, April-June 2020 (December 2020)
  • Changes in Preterm Birth Phenotypes and Stillbirth at 2 Philadelphia Hospitals During the SARS-CoV-2 Pandemic, March-June 2020 (December 2020)
  • Impact of the COVID-19 Pandemic on Excess Perinatal Mortality and Morbidity in Israel (November 2020)
  • Increase of stillbirth and decrease of late preterm infants in Italy during the COVID-19 pandemic lockdown (October 2020)
  • Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study (October 2020)

• Early Estimates of the Indirect Effects of the Coronavirus Pandemic on Maternal and Child Mortality in Low- and Middle-Income Countries: Johns Hopkins University – Bloomberg School of Public Health.
  An analysis of potential health intervention disruptions in 118 low and middle-income countries (representing almost 98 per cent of global under-five deaths) using the LiST model indicates under-five deaths in those countries could increase substantially due to the indirect effects of the COVID-19 pandemic.
• Estimates of the Potential Impact of the COVID-19 Pandemic on Sexual and Reproductive Health in Low- and Middle-Income Countries: Guttmacher Institute, New York.
  This commentary explores the impact of COVID-19 on maternal and newborn health through coverage of essential pregnancy-related and newborn care interventions in mostly low and middle-income countries using the Lives Saved Tool.
• COVID-19 Aftershocks: Secondary Impacts Threaten More Children’s Lives Than Disease Itself: World Vision.
  World Vision’s Aftershocks report considers what would happen if the devastating secondary impacts of the 2015-2016 Ebola outbreak on children were replicated in the 24 most fragile countries covered by the UN’s COVID-19 humanitarian appeal.
• Missing Deaths: Tracking the True Toll of the Coronavirus Crisis: New York Times.
• Routine childhood immunisation during the COVID-19 pandemic in Africa: a benefit–risk analysis of health benefits versus excess risk of SARS-CoV-2 infection (July 2020)
  An analysis highlighting estimating the potential impact on mortality and risk/benefit of trade-off of reducing or disrupting routine immunization services in Africa due to the pandemic.
• Estimating Excess Deaths due to Covid-19 in Brazil using the Cartorios Data
  Presentation of application of Cartorios data used for estimating subnational excess deaths in Brazil. Slides include links to download publicly available data.
• Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population-based cohort study (June 2020)
  Population based study in UK monitoring maternal, neonatal, and stillbirth outcomes in when infected with SAR-CoV-2. Initial data shows limited impact on stillbirth and neonatal deaths but note that monitoring for pregnancy outcomes is needed.
• How Many Infants May Have Died in Low-Income and Middle-Income Countries in 2020 Due to the Economic Contraction Accompanying the COVID-19 Pandemic? (August 2021) Mortality Projections Based on Forecasted Declines in Economic Growth.
• Indirect Effects on Maternal and Child Mortality from the COVID-19 Pandemic: Evidence from Disruptions in Healthcare Utilization in 18 Low- and Middle-Income Countries (September 2021)
• World Malaria Report 2021 (December 2021) WHO report showing modelled increase in child deaths from malaria based on data on service disruptions.

Direct deaths from COVID-19

• UNICEF/Innocenti works on the impact of COVID-19 on children
  Analysis of age-specific data and reporting of COVID-19 data. Highlights lack of COVID-19 case reporting, on children particularly in LMIC settings, as well some country-specific high rates of COVID observed among younger groups.
  • The Evolving Epidemiologic and Clinical Picture of SARS-CoV-2 and COVID-19 Disease in Children and Young People (July 2020)
  • Does COVID-19 Affect the Health of Children and Young People More Than We Thought? The case for disaggregated data to inform action (July 2020)
  • COVID-19 may pose greater risk to children than originally thought (July 2020)

• Exploring the young demographic profile of COVID-19 cases in Hong Kong: Evidence from migration and travel history data (June 2020)
  An analysis of the age and sex distribution of confirmed case data from Hong Kong’s Centre for Health Department and Immigration Department, with findings of high case reports among younger age groups, particularly those aged 15-24.
• Age-dependent effects in the transmission and control of COVID-19 epidemics
  A study to obtain estimates of susceptibility to SARS-CoV-2 infection in children using an age-structured mathematical modeling with data from China, Italy, Japan, Singapore, Canada and South Korea. Estimate that susceptibility to infection in individuals under 20 years of age is approximately half that of adults aged over 20 years.

Guidance

• Modelling the health impacts of disruptions to essential health services during COVID-19. Module 1: Understanding modelling approaches for sexual, reproductive, maternal, newborn, child and adolescent health, and nutrition
• Stillbirth Alliance: Advice on the Coronavirus (COVID-19) and pregnancy
• Healthy Newborn Network: COVID-19 Interim Guidance
• Revealing the Toll of COVID-19: A Technical Package for Rapid Mortality Surveillance and Epidemic Response
• CRVS Knowledge Gateway resources on civil registration and vital statistics (CRVS) system
  • Approaches and methods for estimating excess deaths due to COVID-19
    Guidance on challenges of and approaches to measuring excess mortality due to COVID-19 in systems with various levels of registration completeness.
  • Correctly certifying deaths due to COVID-19: Guidance for physicians
    Information for physicians on how to correctly certify deaths due to COVID-19.
  • Correctly coding deaths due to COVID-19: Guidance for Iris automated mortality coders
    Information for automated mortality coders to correctly code deaths due to COVID-19
  • Correctly coding deaths due to COVID-19: Guidance for manual mortality coders
    Information for manual mortality coders to correctly code deaths due to COVID-19.
  • Report on the experiences of CRVS Fellows early in the COVID-19 pandemic: What resources are needed to better support CRVS personnel?
    Report experiences of past CRVS Fellowship recipients during the early phases of the COVID-19 pandemic, and how to support CRVS personnel to better respond to COVID-19.
  • Video: How to certify and code COVID-19 deaths

• WHO guidance documents on COVID-19 related mortality reporting
  • Medical certification, ICD mortality coding, and reporting mortality associated with COVID-19
  • The WHO application of ICD-10 to deaths during pregnancy, childbirth and puerperium: ICD MM

Tools

• Estimating Excess Mortality From COVID-19 – Prevent Epidemics
  A guide for producing and presenting findings on mortality patterns related to COVID-19 within countries, states, and cities, including weekly and monthly excess mortality calculators (available in English, French, and Spanish)
  
• The Lives Saved Tool (LiST): Johns Hopkins Bloomberg School of Public Health
  LiST is a model that estimates the impact of changes in intervention coverage on child and maternal mortality in low- and middle-income countries. LiST can give researchers and policy makers critical information to assess the potential impact of health intervention policy or programs and can be used to conduct scenario-based projections to gage the impact of the reduction of intervention coverage due to COVID-19 on child and maternal mortality⁸.

References

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2. Sochas L, Channon AA, Nam S. Counting indirect crisis-related deaths in the context of a low-resilience health system: The case of maternal and neonatal health during the Ebola epidemic in Sierra Leone. Health Policy Plan 2017; 32: iii32–9.
3. Ribacke KJB, Saulnier DD, Eriksson A, Schreeb J von. Effects of the West Africa Ebola virus disease on health-care utilization – A systematic review. Front Public Heal 2016; 4: 1–12.
4. Chang HJ, Huang N, Lee CH, Hsu YJ, Hsieh CJ, Chou YJ. The Impact of the SARS Epidemic on the Utilization of Medical Services: SARS and the Fear of SARS. Am J Public Health 2004; 94: 562–4.
5. World Health Organization. Vaccination Must be Scaled up in Ebola-Affected Countries. 2015. [Last accessed on 2020 April 21]. http://www.who.int/mediacentre/news/releases/2015/vaccination-ebola-countries/en/
6. Takahashi S, Metcalf CJ, Ferrari MJ, Moss WJ, Truelove SA, Tatem AJ, et al. Reduced vaccination and the risk of measles and other childhood infections post-Ebola. Science. 2015; 347:1240–2.
7. World Health Organization. Liberia tackles measles as the Ebola epidemic comes to an end. June 2015. [Last accesed on 2020 April 21]. https://www.who.int/features/2015/measles-vaccination-liberia/en/
8. Roberton T, Carter ED, Chou VB, Stegmuller A, Jackson BD, Tam Y, Sawadogo-Lewis T, Walker N. Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. The Lancet Global Health. Published: May 12, 2020. DOI: https://doi.org/10.1016/S2214-109X(20)30229-1