  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.
