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

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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. Health sciences/Risk factors Health sciences/Diseases Figures Figure 1 Figure 2 Figure 3 Introduction Deaths of parents and co-residing/custodial grandparent caregivers, in the context of intersecting social and health crises, threaten child wellbeing 1 due to losses of nurturance, financial support, housing, and care. 2–4 Orphanhood (death of one or both parents) 5,6 and caregiver loss (death of co-resident/custodial grandparents) are considered Adverse Childhood Experiences (ACEs), 7,8 and may have enduring consequences that persist well into adulthood. 9–12 ACE’s are associated with increased chronic stress and lifelong risks of mental health illness, suicide, post-traumatic stress disorder, violence, insecure housing, 13 and chronic and infectious diseases. 14,15 These impacts often lead to ongoing needs for mental health, parenting, educational, and economic support for affected children, and for foster care or adoption services for children bereft of care. 15 In the United States, mortality data informs public health prevention and response policies according to leading causes-of-death. 16 However, one disproportionately affected population often remains largely invisible – those children left behind by adult deaths. 2,6,17 One exception are children experiencing COVID-19-associated orphanhood, where real-time incidence estimates 18–20 led to policies to support children, including recommendations in the National COVID-19 Pandemic Preparedness Plan 21 and investments in some states, 22 such as financial, bereavement, and mental health support for bereaved children and surviving caregivers. These established frameworks raise the possibility that new standards of care can be extended for any child experiencing orphanhood, regardless of cause. 23 To inform evidence-based, compassionate prevention and response strategies for affected children and families, understanding the numbers, time-trends, causes, locations and disparities in all-cause orphanhood is essential. Reports show COVID-19 excess deaths caused a surge in orphanhood and caregiver death, affecting over 10.5 million children globally. 24 In the U.S., the pandemic was linked to increased challenges including substance use, economic crises, mental health distress, and may have been linked to deaths due to overdose, suicide, and excessive alcohol use. 25,26 Though reports have described the U.S. orphanhood burden related to HIV, 27 maternal cancers, 23 COVID-19, 15 and child bereavement, 28 up-to-date estimates on all-cause orphanhood do not exist. Therefore, we estimate prevalence, incidence, and trends from 2000–2021 in all-cause orphanhood and caregiver death among children in the U.S. We further characterize leading causes of orphanhood and caregiver loss and identify whether the compound crises of the COVID-19 pandemic and drug overdose epidemic in 2020 and 2021 were associated with escalating orphanhood. We aim to identify populations disproportionately affected, by age, race/ethnicity, and state, to strengthen evidence-based response strategies. Our findings can contribute to identifying children at risk among population subgroups and geographic areas, and to targeting effective prevention and protection programming for affected children and parents/caregivers. Such strategic programming may form a blueprint for more comprehensive global public health responses. Methods Overview We adapted methods from Hillis et al 19 to estimate the magnitude of orphanhood and caregiver loss among children ages 0–17 from all causes of deaths, according to Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). We extracted subgroup-specific individual live birth and death data from National Center for Health Statistics (NCHS), along with population size estimates. We then attributed to each deceased individual the average number of children orphaned using subgroup-specific fertility rates in the previous 0–17 years. Our outcomes were orphanhood incidence and prevalence from 2000 through 2021, disaggregated by year, child age, and sex, race/ethnicity, cause-of-death of the deceased parent (numbers and percent of child population). We extended these estimates to include loss of co-residing/custodial grandparent caregivers, and state-level estimates of incidence and prevalence of orphanhood and grandparent caregiver loss (Supplementary Text S1, Fig. S2). We calculated 95% uncertainty intervals around estimates using bootstrap resampling (Supplementary Text S1). National mortality data We extracted mortality data of U.S. residents by underlying cause-of-death from NCHS Vital Statistics for 1983-2021. 29 The World Health Organization (WHO) defines underlying cause-of-death as "the disease or injury which initiated the train of events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury". 30 Mortality records 29 were mapped and aggregated to one of 53 caregiver loss causes-of-death that are closely related to the 52 rankable causes-of-death in the NCHS 113 cause-of-death list 31 , or `Other' caregiver loss cause-of-death (Supplementary Text S1). Cause-of-death classifications changed with the Tenth Revision of the International Classification of Disease (ICD-10), and we harmonized 1983–1998 cause-of-death data to ICD-10 classifications to avoid discontinuities in orphanhood estimates from 1998–1999 (Supplementary Text S1). Our cause-specific analyses for orphanhood estimates focused on leading causes of death in 2021: COVID-19, drug overdose, the remaining top five causes-of-death overall (heart disease, cancer, unintentional injuries, cerebrovascular diseases, chronic lung disease), and any additional causes of death in the top five for men and women ages 15–44 (suicide and homicide), as these ages include those more likely to be parents. We used a hierarachical approach for classifying cause of death; therefore, we consistently excluded drug overdose from each of these three categories: suicide, homicide, and unintentional injuries. Race and ethnicity in death certificates are typically reported by next of kin. We converted data that were incrementally reported by multiple races to standardised race categories (Supplementary Table S7). National orphanhood estimates To estimate the number of children each death leaves behind, we obtained age, race, and ethnicity data of fathers and mothers from NCHS live birth records. 29,31 We used corresponding 1990–2021 population sizes 32 to calculate annualized age- and sex-specific national-level fertility rates by standardised race/ethnicity categories (Supplementary Text S1). Before 1990, we assumed fertility rates of 1990 because population sizes by race/ethnicity were unavailable before 1990, and report corresponding sensitivity analyses (Supplementary Text S2). Incidence We estimated annual incidence of orphanhood for a given year among children by multiplying the number of cause-specific deaths among adults stratified by sex, race/ethnicity, and five-year age bands in each year 1983–2021, with the expected number of children aged 0–17 born to each adult, with the corresponding characteristics in the same year. Calculations were performed by race/ethnicity groups and then aggregated to U.S. totals due to correlations between mortality and fertility rates by race/ethnicity (Supplementary Text S1). Age of child was attributed by considering fertility rates in each of the current and preceding 17 years, after adjustment for pediatric survival probabilities (Supplementary Table S4). Prevalence We estimated annual prevalence of orphanhood among children in any given year in 2000–2021 by cumulatively summing incidence estimates by one-year age of child in the current and previous 17 years, excluding children who would have since turned 18; calculations of orphanhood prevalence for 2000–2015 required including annual orphanhood incidence estimates for 1983–1999, in order to include the cumulative prior 17-year risk for experiencing prevalent parental death. We removed duplicate orphanhood counts by adjusting for those who had lost both parents Supplementary Text S1, Supplementary Table S5). Incidence and prevalence rates were calculated relative to child population sizes in the corresponding year. National grandparent caregiver loss We estimated annual incidence of children losing grandparent caregivers in 1983–2021 by multiplying the number of cause-specific deaths in each year in adults aged 30 years and above stratified by sex and race/ethnicity with the corresponding proportions of adults co-residing with their grandchild(ren) and providing some or all basic needs for grandchild(ren), using U.S. Census American Community Surveys (ACS) 2010–2021 data (Supplementary Text S1). 33 We assumed only one child was affected by each grandparent caregiver death. We also developed estimates for the age of children affected (Supplementary Fig S21). State-level orphanhood and grandparent caregiver death estimates We generated state-level estimates of cause-specific incidence and prevalence of orphanhood and caregiver death for 2021, using data from CDC WONDER. 34,35 (Supplementary Text S1). State-level orphanhood and caregiver death were calculated as above, with exceptions for male fertility rates for 2005–2015 (Supplementary Text S1). We developed correction factors to adjust for bias resulting from data not stratified by race and ethnicity (Supplementary Text S1). Results All-cause orphanhood and caregiver loss In 2021, we estimate 498,249 (95% CI, 496,938 − 499,639) childr experienced incident orphanhood or caregiver death from any cause (0.72% of children, Table 1 , Fig. S2). Most children lost a parent (81.6%), while the remainder lost a grandparent caregiver (18.4%). Before the COVID-19 pandemic, incidence of orphanhood, and of orphanhood/caregiver loss (combined) increased rapidly from 2000 to 2019 by 11.4% and 11.7%, respectively (Table 1 ). Through the pandemic, incidence of orphanhood, and of orphanhood/caregiver loss (combined) increased further from 2019 to 2021 by 39.5% and 33.6%, respectively. Prevalence of orphanhood, and of orphanhood/caregiver loss decreased slightly by 2.4% and 0.9% from 2000 to 2019, then increased by 10.1% and 9.3% during the period spanning the pandemic years (2019 to 2021). In 2021, we estimate 2,966,008 (95%CI, 2,963,030 − 2,968,931) children experienced prevalent orphanhood or caregiver death, representing 4.0% of all children. Table 1 Trends in All-cause Orphanhood and Caregiver (Co-Residing/custodial Grandparent) Loss from 2000 to 2021, before and during the COVID-19 pandemic Before the COVID-19 pandemic Since the COVID-19 pandemic 2000 2019 2000–2019 2020 2021 2019–2021 2000–2021 (Number (Number change (Number (Number change change of of of of Children) Children) Children) Children) Incidence (n, (95% uncertainty interval)) Orphanhood 261,633 (260,485, 262,656) 291,574 (290,613, 292,657) + 11.4% (+ 10.9%, + 12.1%) 359,431 (358,301, 360,531) 406,733 (405,437, 407,928) + 39.5% (+ 38.8%, + 40.1%) + 55.5% (+ 54.7%, + 56.3%) Orphanhood and Caregiver Loss 333,959 (332,701, 335,049) 372,869 (371,737, 374,132) + 11.7% (+ 11.2%, + 12.2%) 454,403 (453,107, 455,706) 498,249 (496,938, 499,639) + 33.6% (+ 33.1%, + 34.2%) + 49.2% (+ 48.5%, + 49.9%) Incidence rate per 100 children (rate, (95% uncertainty interval)) Orphanhood 0.36 (0.36, 0.36) 0.40 (0.40, 0.40) + 10.2% (+ 9.9%, + 11.1%) 0.49 (0.49, 0.50) 0.59 (0.58, 0.59) + 46.9% (+ 46.2%, + 47.6%) + 62.2% (+ 61.3%, + 63.1%) Orphanhood and Caregiver Loss 0.46 (0.46, 0.46) 0.51 (0.51, 0.51) + 10.6% (+ 10.2%, + 11.1%) 0.62 (0.62, 0.63) 0.72 (0.72, 0.72) + 40.8% (+ 40.1%, + 41.3%) + 55.6% (+ 54.9%, + 56.3%) Prevalence (n, (95% uncertainty interval)) Orphanhood 2,228,940 (2,225,912, 2,232,100) 2,174,707 (2,172,340, 2,177,566) -2.4 (-2.6, -2.3) 2,266,808 (2,264,259, 2,269,533) 2,394,604 (2,391,948, 2,397,308) + 10.1% (+ 10.0%, + 10.2%) + 7.4% (+ 7.2%, + 7.6%) Orphanhood and Caregiver Loss 2,738,807 (2,735,607, 2,742,282) 2,712,927 (2,710,251, 2,715,769) -0.9 (-1.1, -0.8) 2,824,422 (2,821,579, 2,827,337) 2,966,008 (2,963,030, 2,968,931) + 9.3% (+ 9.3%, + 9.4%) + 8.3% (+ 8.1%, + 8.5%) Prevalence rate per 100 children (rate, (95% uncertainty interval)) Orphanhood 3.08 (3.08, 3.08) 2.98 (2.97, 2.98) -3.4 (-3.6, -3.2) 3.11 (3.11, 3.12) 3.45 (3.45, 3.45) + 16.0% (+ 15.9%, + 16.1%) + 12.0% (+ 11.8%, + 12.3%) Orphanhood and Caregiver Loss 3.78 (3.78, 3.79) 3.71 (3.71, 3.72) -1.9 (-2.1, -1.8) 3.88 (3.87, 3.88) 4.27 (4.27, 4.28) + 15.1% (+ 15.1%, + 15.2%) + 12.9% (+ 12.8%, + 13.1%) Cause-specific trends From 2000–2021, orphanhood caused by drug overdose increased markedly, as did orphanhood due to COVID-19 between 2019–2021. Orphanhood due to suicide decreased until 2010 and subsequently increased. Orphanhood due to unintentional injuries and homicide decreased until 2019, then increased until 2021; orphanhood due to diseases of the heart remained relatively unchanged until 2019, then increased. Only orphanhood due to malignant neoplasms consistently decreased from 2000–2021. By 2021, both incidence and prevalence of orphanhood due to fatal injuries – including drug overdose, suicide, homicide, and unintentional injuries (e.g. motor vehicle crashes) – exceeded orphanhood due to chronic diseases (Fig. 1 A, B and, Table S1 ). Orphanhood caused by drug overdose rose substantially from 2012–2019, then jumped sharply during 2020–2021 (Fig. 1 C). From 2000–2019, orphanhood incidence due to drug overdose increased from an estimated 0.015% of children in 2000, to 0.06% in 2019, 0.085% in 2020 after the pandemic onset, and 0.09% in 2021. Drug overdose was the leading cause of orphanhood incidence and prevalence in 2020 and 2021, surpassing both chronic diseases and COVID-19 (Fig. 1 C, D). The disproportionate impact of fatal injuries on orphanhood was evident in 2021, with drug overdose contributing 17.5% to orphanhood incidence, yet only 3.1% to adult mortality (Fig. 1 E); similarly, unintentional injuries, suicide, and homicide contributed 8.3%, 5.0%, and 3.7% to orphanhood, versus 3.6%, 1.2% and 0.7%, respectively, to adult deaths. Disparities by age and race/ethnicity From 2000–2021, children ages 10–17 years were 5.4 times more likely than children ages 0–4 to experience prevalent orphanhood (Fig. 2 A, Table S2). By 2021, orphanhood prevalence among ages 10–17 was 5.0%, affecting 1,704,671 children. Substantial disparities across race and ethnicity occurred, accentuated by the COVID-19 pandemic. By 2021, orphanhood affected 6.5% of non-Hispanic American Indian or Alaska Native children, 4.8% of non-Hispanic Black children, 3.9% of non-Hispanic White children, 1.7% of Hispanic children, and 1.9% of non-Hispanic Asian children (Fig. 2 C). Causes underpinning these disparities differed by parental race/ethnicity and sex (Fig. 2 D, Table S3). Among non-Hispanic American Indian or Alaska Native children, leading causes of maternal orphanhood in 2021 were, in order, COVID-19, drug overdose, and chronic liver disease and cirrhosis; while leading causes of paternal orphanhood were chronic liver disease and cirrhosis, unintentional injuries, and diseases of the heart – all of which increased as causes of orphanhood since 2000. Among non-Hispanic Black children, leading causes of maternal orphanhood were COVID-19, diseases of heart, and drug overdose; while paternal orphanhood was primariy caused by diseases of heart, drug overdose, and homicide. In non-Hispanic White children, drug overdose deaths among fathers increased substantially over the past two decades; in Hispanic children, COVID-19 deaths among fathers predominated. In non-Hispanic Asian children, primary causes of orphanhood were heart disease, malignant neoplasms, and COVID-19. State-level Estimates In 2021, 33 states had > 3% of all children experiencing prevalent orphanhood; Southeastern, Northeastern, Southern Border, and Midwest states were most affected (Table 2 , Fig. 3 , and Tables S4-S6). California, Texas, and Florida had the highest numbers of children experiencing orphanhood incidence and prevalence in 2021. West Virginia and New Mexico had the highest incidence (0.8–0.9%) and prevalence rates (4.5-5.0%) of orphanhood in 2021. Injury-associated parental deaths – including overdose, suicide, and/or unintentional injury – were among the top two causes of orphanhood prevalence in 47 states (Table 2 ). Drug overdose was the leading cause of orphanhood prevalence in 30 states, particularly affecting Southeastern, Southwestern, Southern Border, and Midwest states, and Southwestern States with large American Indian and Alaska Native populations. Table 2 Primary contributors to orphanhood in each US state in 2021. Orphanhood in 2021 Orphanhood Incidence in 2021 Orphanhood Prevalence in 2021 U.S. state Incidence Incidence First ranked Second ranked Prevalence Prevalence First ranked Second ranked rate cause cause rate cause cause per 100 per 100 children (name , (name , children (name , (name , (n, 95% UI) (rate, 95% UI) % contribution) % contribution) (n, 95% UI) (rate, 95% UI) % contribution) % contribution) Alabama 7,991 (7,585, 8,397) 0.71 (0.68, 0.75) Diseases of heart (16.4%) COVID-19 (16.2%) 45,696 (42,504, 49,079) 4.07 (3.79, 4.37) Diseases of heart (16.9%) Unintentional injuries excluding drug overdose (14.0%) Alaska 1,122 (795, 1,478) 0.63 (0.44, 0.82) Drug overdose (16.0%) Unintentional injuries excluding drug overdose (15.2%) 5,922 (3,970, 9,170) 3.30 (2.21, 5.11) Unintentional injuries excluding drug overdose (23.8%) Suicide excluding drug overdose (10.7%) Arizona 10,898 (10,511, 11,250) 0.68 (0.65, 0.70) COVID-19 (17.8%) Drug overdose (16.5%) 59,002 (55,837, 62,261) 3.66 (3.46, 3.86) Drug overdose (16.4%) Unintentional injuries excluding drug overdose (12.9%) Arkansas 4,461 (4,053, 4,945) 0.63 (0.58, 0.70) Diseases of heart (15.2%) COVID-19 (13.2%) 25,644 (22,348, 29,481) 3.65 (3.18, 4.19) Unintentional injuries excluding drug overdose (16.6%) Diseases of heart (15.4%) California 45,004 (45,713, 44,534) 0.51 (0.52, 0.51) COVID-19 (16.5%) Drug overdose (14.6%) 264,622 (268,326, 261,397) 3.02 (3.06, 2.98) Malignant neoplasms (16.8%) Diseases of heart (12.8%) Colorado 6,587 (6,178, 6,985) 0.53 (0.50, 0.56) Drug overdose (18.0%) COVID-19 (10.4%) 37,868 (34,890, 41,412) 3.05 (2.81, 3.33) Drug overdose (16.6%) Suicide excluding drug overdose (13.5%) Connecticut 3,330 (2,922, 3,741) 0.46 (0.40, 0.51) Drug overdose (29.0%) Malignant neoplasms (13.3%) 20,874 (17,911, 24,220) 2.86 (2.45, 3.32) Drug overdose (26.5%) Malignant neoplasms (14.9%) Delaware 962 (667, 1,279) 0.46 (0.32, 0.61) Drug overdose (34.4%) Malignant neoplasms (9.7%) 5,467 (3,582, 7,985) 2.62 (1.72, 3.83) Drug overdose (29.4%) Unintentional injuries excluding drug overdose (10.2%) District of Columbia 612 (432, 823) 0.49 (0.34, 0.65) Drug overdose (18.3%) Diseases of heart (10.8%) 3,828 (2,465, 5,519) 3.04 (1.96, 4.39) Diseases of heart (13.0%) Drug overdose (12.4%) Florida 28,456 (28,600, 28,393) 0.66 (0.67, 0.66) Drug overdose (19.0%) COVID-19 (17.9%) 159,629 (159,761, 159,719) 3.72 (3.72, 3.72) Drug overdose (18.2%) Malignant neoplasms (14.1%) Georgia 15,723 (15,459, 16,039) 0.62 (0.61, 0.64) COVID-19 (16.5%) Diseases of heart (15.2%) 87,557 (84,749, 90,515) 3.47 (3.36, 3.59) Diseases of heart (15.6%) Malignant neoplasms (13.0%) Hawaii 1,231 (950, 1,580) 0.40 (0.31, 0.52) Malignant neoplasms (16.2%) Diseases of heart (15.4%) 7,692 (5,510, 10,706) 2.53 (1.81, 3.52) Diseases of heart (15.3%) Malignant neoplasms (15.3%) Idaho 1,940 (1,544, 2,372) 0.41 (0.33, 0.51) COVID-19 (14.5%) Drug overdose (13.0%) 10,474 (7,785, 14,079) 2.23 (1.66, 3.00) Unintentional injuries excluding drug overdose (20.3%) Suicide excluding drug overdose (13.0%) Illinois 13,831 (13,528, 14,158) 0.49 (0.48, 0.51) Drug overdose (16.4%) Diseases of heart (13.9%) 89,775 (87,129, 92,407) 3.20 (3.11, 3.30) Drug overdose (16.5%) Malignant neoplasms (15.1%) Indiana 9,148 (8,705, 9,532) 0.58 (0.55, 0.60) Drug overdose (22.6%) Diseases of heart (11.9%) 54,889 (51,659, 58,427) 3.46 (3.26, 3.68) Drug overdose (20.2%) Diseases of heart (13.0%) Iowa 2,784 (2,381, 3,218) 0.38 (0.32, 0.44) Diseases of heart (14.8%) Malignant neoplasms (12.5%) 16,673 (13,710, 20,323) 2.26 (1.86, 2.76) Unintentional injuries excluding drug overdose (15.7%) Malignant neoplasms (14.5%) Kansas 3,455 (3,041, 3,947) 0.49 (0.43, 0.56) Drug overdose (14.4%) COVID-19 (13.1%) 19,915 (16,740, 23,836) 2.83 (2.38, 3.39) Unintentional injuries excluding drug overdose (15.8%) Malignant neoplasms (12.5%) Kentucky 7,183 (6,792, 7,634) 0.71 (0.67, 0.75) Drug overdose (24.3%) Diseases of heart (13.9%) 42,002 (38,999, 45,578) 4.13 (3.84, 4.49) Drug overdose (22.9%) Diseases of heart (14.0%) Louisiana 8,108 (7,719, 8,511) 0.75 (0.71, 0.79) Drug overdose (23.3%) Diseases of heart (12.7%) 46,778 (43,522, 50,175) 4.32 (4.02, 4.63) Drug overdose (17.3%) Diseases of heart (14.2%) Maine 1,347 (1,056, 1,679) 0.53 (0.42, 0.67) Drug overdose (30.1%) Diseases of heart (10.8%) 7,245 (5,099, 9,975) 2.88 (2.02, 3.96) Drug overdose (26.8%) Unintentional injuries excluding drug overdose (13.6%) Maryland 7,419 (6,996, 7,815) 0.54 (0.51, 0.57) Drug overdose (23.5%) Diseases of heart (13.8%) 48,147 (44,993, 51,637) 3.53 (3.30, 3.79) Drug overdose (22.7%) Diseases of heart (14.6%) Massachusetts 6,038 (5,612, 6,457) 0.44 (0.41, 0.47) Drug overdose (27.6%) Malignant neoplasms (14.7%) 41,234 (38,098, 44,636) 3.03 (2.80, 3.28) Drug overdose (27.4%) Malignant neoplasms (15.8%) Michigan 12,179 (11,820, 12,509) 0.57 (0.55, 0.58) Drug overdose (17.0%) Diseases of heart (13.6%) 75,255 (72,209, 78,059) 3.49 (3.35, 3.62) Drug overdose (17.9%) Diseases of heart (14.4%) Minnesota 5,403 (4,951, 5,883) 0.41 (0.38, 0.45) Drug overdose (17.6%) Malignant neoplasms (13.8%) 30,442 (27,178, 34,423) 2.31 (2.06, 2.61) Malignant neoplasms (16.8%) Drug overdose (14.6%) Mississippi 5,251 (4,791, 5,668) 0.76 (0.69, 0.82) COVID-19 (15.0%) Diseases of heart (14.7%) 30,280 (26,942, 33,913) 4.37 (3.89, 4.89) Unintentional injuries excluding drug overdose (16.7%) Diseases of heart (15.5%) Missouri 8,128 (7,727, 8,525) 0.59 (0.56, 0.62) Drug overdose (18.3%) Diseases of heart (13.5%) 49,665 (46,695, 52,986) 3.59 (3.37, 3.83) Drug overdose (18.1%) Diseases of heart (13.9%) Montana 1,216 (912, 1,568) 0.52 (0.39, 0.67) Unintentional injuries excluding drug overdose (17.3%) Suicide excluding drug overdose (10.7%) 6,553 (4,473, 9,605) 2.79 (1.90, 4.09) Unintentional injuries excluding drug overdose (24.6%) Suicide excluding drug overdose (12.7%) Nebraska 1,809 (1,412, 2,261) 0.37 (0.29, 0.47) Malignant neoplasms (13.7%) Unintentional injuries excluding drug overdose (12.1%) 10,680 (8,043, 14,384) 2.21 (1.67, 2.98) Unintentional injuries excluding drug overdose (18.6%) Malignant neoplasms (14.3%) Nevada 4,034 (3,650, 4,450) 0.58 (0.52, 0.64) COVID-19 (19.3%) Diseases of heart (13.6%) 21,946 (18,876, 25,409) 3.14 (2.70, 3.64) Drug overdose (15.5%) Diseases of heart (14.8%) New Hampshire 1,094 (814, 1,405) 0.43 (0.32, 0.55) Drug overdose (25.4%) Malignant neoplasms (10.9%) 6,869 (4,778, 9,552) 2.68 (1.86, 3.73) Drug overdose (30.8%) Malignant neoplasms (11.4%) New Jersey 9,644 (9,235, 10,114) 0.48 (0.46, 0.50) Drug overdose (21.9%) Malignant neoplasms (13.7%) 63,595 (60,303, 67,269) 3.14 (2.98, 3.32) Drug overdose (21.5%) Malignant neoplasms (15.3%) New Mexico 4,137 (3,701, 4,558) 0.87 (0.78, 0.96) Drug overdose (16.7%) COVID-19 (16.2%) 21,632 (18,554, 25,154) 4.57 (3.92, 5.32) Drug overdose (17.6%) Unintentional injuries excluding drug overdose (15.1%) New York 19,199 (19,000, 19,436) 0.47 (0.46, 0.47) Drug overdose (19.2%) Malignant neoplasms (14.8%) 124,546 (122,607, 126,477) 3.03 (2.98, 3.07) Malignant neoplasms (17.8%) Drug overdose (15.9%) North Carolina 14,097 (13,786, 14,457) 0.61 (0.60, 0.63) Drug overdose (20.5%) COVID-19 (12.4%) 79,120 (76,394, 82,029) 3.44 (3.32, 3.56) Drug overdose (17.7%) Malignant neoplasms (12.6%) North Dakota 695 (469, 1,081) 0.37 (0.25, 0.58) Unintentional injuries excluding drug overdose (15.0%) Drug overdose (10.2%) 3,808 (2,409, 6,887) 2.05 (1.30, 3.71) Unintentional injuries excluding drug overdose (17.7%) Suicide excluding drug overdose (7.9%) Ohio 15,767 (15,525, 16,051) 0.61 (0.60, 0.62) Drug overdose (24.9%) Diseases of heart (12.2%) 97,161 (94,914, 99,413) 3.73 (3.64, 3.82) Drug overdose (26.0%) Diseases of heart (12.9%) Oklahoma 6,119 (5,684, 6,576) 0.64 (0.59, 0.68) COVID-19 (16.9%) Diseases of heart (14.3%) 36,240 (32,901, 39,983) 3.77 (3.42, 4.16) Unintentional injuries excluding drug overdose (14.8%) Diseases of heart (14.7%) Oregon 4,153 (3,757, 4,561) 0.48 (0.44, 0.53) Drug overdose (15.7%) Malignant neoplasms (13.3%) 22,994 (19,901, 26,282) 2.67 (2.31, 3.05) Malignant neoplasms (14.9%) Unintentional injuries excluding drug overdose (13.6%) Pennsylvania 14,609 (14,349, 14,918) 0.55 (0.54, 0.56) Drug overdose (24.7%) Malignant neoplasms (12.0%) 95,425 (93,303, 97,704) 3.57 (3.49, 3.65) Drug overdose (26.3%) Malignant neoplasms (13.2%) Rhode Island 791 (565, 1,048) 0.38 (0.27, 0.50) Drug overdose (35.7%) Diseases of heart (9.6%) 4,826 (3,084, 7,091) 2.31 (1.48, 3.40) Drug overdose (30.3%) Malignant neoplasms (11.3%) South Carolina 7,274 (6,907, 7,638) 0.65 (0.62, 0.68) Drug overdose (18.1%) COVID-19 (14.6%) 39,654 (36,661, 42,890) 3.55 (3.28, 3.84) Drug overdose (14.8%) Unintentional injuries excluding drug overdose (14.7%) South Dakota 1,093 (794, 1,510) 0.50 (0.36, 0.69) Chronic liver disease and cirrhosis (17.7%) Unintentional injuries excluding drug overdose (11.7%) 5,552 (3,631, 9,040) 2.52 (1.65, 4.10) Unintentional injuries excluding drug overdose (19.5%) Suicide excluding drug overdose (8.6%) Tennessee 11,908 (11,590, 12,260) 0.77 (0.75, 0.80) Drug overdose (23.3%) COVID-19 (13.5%) 63,260 (60,342, 66,515) 4.11 (3.92, 4.32) Drug overdose (18.8%) Diseases of heart (14.5%) Texas 40,272 (40,738, 39,926) 0.54 (0.54, 0.53) COVID-19 (23.2%) Diseases of heart (12.0%) 224,453 (226,165, 223,024) 3.00 (3.03, 2.98) Malignant neoplasms (13.9%) Diseases of heart (13.7%) Utah 3,772 (3,283, 4,293) 0.40 (0.35, 0.45) Drug overdose (14.5%) COVID-19 (14.2%) 24,529 (20,856, 29,053) 2.59 (2.20, 3.07) Drug overdose (19.9%) Suicide excluding drug overdose (15.6%) Vermont 479 (308, 678) 0.41 (0.26, 0.58) Drug overdose (32.8%) Unintentional injuries excluding drug overdose (10.4%) 2,394 (1,244, 4,255) 2.05 (1.06, 3.64) Drug overdose (21.0%) Unintentional injuries excluding drug overdose (11.3%) Virginia 9,638 (9,245, 10,045) 0.51 (0.49, 0.53) Drug overdose (18.6%) Diseases of heart (13.9%) 56,961 (53,825, 60,501) 3.02 (2.86, 3.21) Drug overdose (16.2%) Malignant neoplasms (15.3%) Washington 7,386 (6,998, 7,814) 0.44 (0.42, 0.47) Drug overdose (17.8%) Malignant neoplasms (13.6%) 42,455 (39,491, 46,039) 2.53 (2.36, 2.75) Drug overdose (15.9%) Malignant neoplasms (15.6%) West Virginia 3,142 (2,754, 3,552) 0.88 (0.77, 0.99) Drug overdose (35.2%) COVID-19 (10.6%) 17,888 (15,069, 21,094) 4.98 (4.20, 5.88) Drug overdose (32.8%) Unintentional injuries excluding drug overdose (11.2%) Wisconsin 4,913 (4,528, 5,358) 0.39 (0.36, 0.42) Drug overdose (21.6%) Malignant neoplasms (12.1%) 29,802 (26,821, 33,307) 2.34 (2.10, 2.61) Drug overdose (19.9%) Malignant neoplasms (14.7%) Wyoming 542 (348, 880) 0.41 (0.26, 0.66) Unintentional injuries excluding drug overdose (13.5%) Suicide excluding drug overdose (10.3%) 3,021 (1,734, 5,830) 2.28 (1.31, 4.40) Unintentional injuries excluding drug overdose (25.4%) Suicide excluding drug overdose (11.2%) Discussion Over the past two decades, prevalence of all-cause orphanhood and caregiver death decreased slightly until 2019 and then increased markedly during 2020–2021 with intersecting crises of the overdose epidemic and COVID-19 pandemic. 36,37 Parental death due to drug overdose was the leading cause of orphanhood incidence and prevalence during the pandemic. By 2021, over 2.9 million children – 4.0% of all children in the U.S. – had lost a parent or caregiver in their lifetime. Populations disproportionately affected by orphanhood included over 1.7 million adolescents ages 10–17 years (1 of every 20 adolescents); and children of non-Hispanic American Indian or Alaska Native, non-Hispanic Black, and non-Hispanic White race/ethnicities (approximately 1 of 15, 1 of 20, and 1 of 25 children, respectively). Orphanhood prevalence was highest in West Virginia, New Mexico, Mississippi, Louisiana, and Kentucky, affecting 1 of every 25 children. Compared to previous cause-specific reports (an estimated 97,376 children orphaned by HIV/AIDS (1998), 27 157,183 by maternal cancers (2020), 23 and 218,800 by COVID-19 in 2020-2022 38 ), data on all-cause orphanhood and co-residing grandparent caregiver death are over ten times greater, quantifying the full burden. By 2021, orphanhood incidence and prevalence due to fatal injuries (drug overdose, suicide, homicide, and unintentional injuries), exceeded those linked to chronic diseases. Together, injuries and chronic diseases accounted for over half of all children orphaned. Fatalities due to injuries and chronic diseases among minoritized populations, are more common among younger adults still caring for children. For 47 states, drug overdose, suicide, and/or unintentional injuries were among the top two causes of orphanhood. Although drug overdose deaths were increasing before 2020, pandemic-linked increases of these deaths exceeded those forecasted; and the pandemic appeared to increase drug overdose risk. 39,40 The evolving nature of drug supply, including the proliferation of illegally made fentanyl and resurgence of stimulants such as methamphetamine, has affected almost every state. 41,42 By 2021, our data show drug overdose contributed 17.5% to orphanhood compared to 3.1% to mortality; establishing comprehensive care programs for children orphaned due to drug overdose could better mitigate the long-term negative effects that these children are disproportionately facing. Our findings reveal social and health disparities in orphanhood rates and leading caregiver causes-of-death between age, sex, and racial/ethnic groups, and across geographies. These results can inform and contextualize prevention and response programming for children affected by orphanhood. For non-Hispanic American Indian or Alaska Native persons, for example, alcohol-related deaths were a leading cause, while non-Hispanic Black populations showed homicide among fathers as a leading cause. Many of these disparities are related to historical racism and derived practices that foster inequitable access to housing, education, and employment. Populations most affected in different states may have been exposed to such inequalities. 43 In parts of the northeastern and midwestern U.S., rising unemployment, limited access to health and social services during the pandemic, increased access to a more lethal supply of illicit drugs or availability of other substances such as alcohol particularly among affected white men, may be linked to drug overdose emerging as the top cause of incident orphanhood in these regions. 44 Circumstances of parental death influence grief-related psychopathology in surviving children, 45 and evidence-based responses can improve short- and long-term outcomes. 9,11,12 It is paramount to keep children in their families, whenever possible. This requires ensuring bereaved families receive support, and those needing kinship or foster care are served rapidly. 46 Child resilience after parental loss can be strengthened by programs and policies that promote safe, stable, and nurturing relationships and environments, and that address childhood adversity, including preventing violence and abuse. 46 Despite serious risks for bereaved children, 47 timely, multifactored responses using an age- and life-stage approach may restore hope and build resilience. 48 As grief is an immediate reaction that can extend years after parental loss, healing and support are urgent needs for children, who may be less equipped to recover than adults, particularly when the loss is sudden and unexpected. 11,27 The governor of Utah 49 and others 50 have called for the addition to the death certificate of a checkbox to identify children living in the home of the deceased, so that bereaved children can be linked to support and services. Such responses typically provide parenting, economic, and education support, and are consistent with the WHO INSPIRE package for ending violence against children. 51,52 Our study has several limitations. First, cause-specific estimates of children experiencing orphanhood and caregiver deaths are derived from mortality statistics on underlying causes-of-death, and may be underestimates 53 for causes associated with erroneous or incomplete reporting, uncertainty in the chain of events preceding death, or coding limitations - such as for COVID-19, drug overdose, or suicide. 54 Second, as we attributed only one child per grandparent caregiver death, our estimates of grandparent caregiver loss are minimum estimates. Third, we assumed current mortality is unrelated to historic fertility for years before 1990, and sensitivity analyses suggest this may lead to inaccuracies in orphanhood prevalence estimates until 2007 (Supplementary Text S2). Fourth, publicly available state-specific data were partly suppressed due to small counts; therefore, we cannot exclude bias in state-specific orphanhood estimates. Finally, to characterise orphanhood prevalence in 2000–2021, we had to consider vital statistics since 1983 and consolidate changes in cause-of-death and race/ethnicity coding. Our sensitivity analyses, including detailed comparisons of NCHS death data to CDC WONDER vital statistics for each of the 21 years’ calculations (Supplementary Text S2), suggest our incidence and prevalence estimates are robust, and should be interpreted as minimum estimates of orphanhood and caregiver death. In conclusion, evidence-based policies and programs that provide healing and support for nearly 3 million children and adolescents in the U.S. who have experienced orphanhood and caregiver loss are urgently needed to reduce longterm negative affectsof this adverse childhood experience. This is especially relevant given unprecedented rates of drug overdoses, increasing the possibility that children who are living in a household where a parent or caregiver is negatively affected by substance use, may also experience the loss of a parent. 52,55 Evidence highlights three essential components of orphanhood prevention and response that effectively promote their recovery and resilience: ( 1 ) prevent death of parents and caregivers through timely prevention and treatment of leading causes of death and ensured access to affordable compassionate health and mental health care for all; ( 2 ) prepare families to provide safe and nurturing alternative care; and ( 3 ) protect children affected by orphanhood and vulnerabilities, through grief and mental health counseling, and parenting, economic, and educational support that can be contextualized and delivered at scale. 19,56 Declarations Disclaimer: The findings in this report are those of the authors. They do not necessarily represent the official position of the US Centers for Disease Control and Prevention. For the purpose of open access, the authors have applied a `Creative Commons Attribution’ (CC-BY) license to any Author Accepted Manuscript version arising. Question : What are U.S. trends in all-cause and cause-specific orphanhood and caregiver death among children <18? Findings : From 2000-2021, orphanhood and caregiver loss incidence and prevalence increased 49.2% and 8.3%, respectively. By 2021, 2.9 million children (4% of all children) were affected. Populations disproportionately affected by orphanhood included 1.7 million adolescents ages 10-17; 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, Southern and Eastern States. Drug overdose was the leading cause of orphanhood during the COVID-19 pandemic. Meaning : Evidence-based programs and policies are needed to prevent orphanhood and support these bereaved children. Ethical approval: All data used for this study are publicly available through U.S. Government websites. Data sharing statement: All data used to calculate estimates of mortality and orphanhood are publicly available. Mortality and natality data were sourced from NCHS (https://www.cdc.gov/nchs/data_access/vitalstatsonline.htm). Mortality, natality data after year 2005 at the state level were sourced from CDC WONDER (https://wonder.cdc.gov/). Population data from 1969 to 1989 were sourced from https://seer.cancer.gov/popdata/singleages.html. Population data from 1990 to 2020 were sourced from CDC WONDER (https://wonder.cdc.gov/bridged-race-population.html). Child mortality data were sourced from United Nations (https://population.un.org/wpp/Download/Standard/Mortality/). Household data from 2010 to 2021 were sourced from American Community Survey (https://data.census.gov/table/ACSST5Y2019.S1002). Code availability: Code to reproduce all analyses is freely available on Github version 1.1.2 under the GNU General Public License version 3.0 at the repository (https://github.com/MLGlobalHealth/orphanhood-caregiver-death-in-US-from-all-causes-of-mortality). Acknowledgements: We thank the Global Reference Group for Children In Crisis, reviewers at the CDC and NCHS especially Dr. Robert Anderson for his helpful suggestions on interpreting and classifying disease groups and race groups using existing NCHS data. We also thank Prof. Chris Desmond for his comments on early versions of this work. We thank the Imperial College Research Computing Service (https://doi.org/10.14469/ hpc/2232) for providing the computational resources to perform this study; and Zulip for sponsoring team communications through the Zulip Cloud Standard chat app. This study was supported by the Oak Foundation (to LC, LS); the Moderna Charitable Foundation (to OR); the World Health Organisation (to SF); the Engineering and Physical Sciences Research Council (EPSRC) through the EPSRC Centre for Doctoral Training in Modern Statistics and Statistical Machine Learning at Imperial College London and Oxford University (EP/S023151/1 to A. Gandy); the Imperial College London President’s PhD Scholarship fund to YC; Imperial College London Undergraduate Research Bursaries to LG and VKM; and London Mathematical Society Undergraduate Research Bursary to DW (URB-2023-86). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Competing interests: OR reports grants from the Bill & Melinda Gates Foundation, the EPSRC, the AIDSFonds, and the NIH during the conduct of this study. Copyright statement: For the purpose of open access, the authors have applied a ‘Creative Commons Attribution’ (CC BY) license to any Author Accepted Manuscript version arising. Author contributions: AV, SH and OR designed the study; AV, YC, ST, AB, LG, VKM, DW, SH and OR performed the analysis; YC led coding; LG, VKM, DW, JTU and SF checked analysis and code; AV, LC, LS, FA, GM, JL, LR, RN, CAN, SF, JTU, SH and OR oversaw data interpretation; AV, YC, ST, SH and OR wrote the first draft; All authors discussed the first draft and contributed to the final manuscript. References Bhutta ZA, Bhavnani S, Betancourt TS, Tomlinson M, Patel V. 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Predicting the social consequences of orphanhood in South Africa. Afr J AIDS Res . 2003;2(1):39-55. doi:10.2989/16085906.2003.9626558 Children’s Collaborative. Utah Children’s Collaborative. Children’s Collaborative. Accessed Sep 20, 2023. https://www.childrenscollaborative.us/utah Flaxman S, Kasonka L, Cluver L, et al. List child dependents on death certificates. Science . 2023;380(6644):467-467. doi:doi:10.1126/science.adh8784 World Health Organization. INSPIRE: Seven strategies for Ending Violence Against Children. Accessed Sep 9, 2020. https://www.who.int/publications/i/item/inspire-seven-strategies-for-ending-violence-against-children U.S. Centers for Disease Control and Prevention. Adverse childhood experiences prevention: Resource for Action. A compilation of the best available evidence . Prevention DoV; 2019:35. https://www.cdc.gov/violenceprevention/pdf/ACEs-Prevention-Resource_508.pdf Institute for Health Metrics and Evaluation. Estimation of total mortality due to COVID-19. Institute for Health Metrics and Evaluation (IHME). Accessed June 24, 2021. http://www.healthdata.org/special-analysis/estimation-excess-mortality-due-covid-19-and-scalars-reported-covid-19-deaths Peppin JF, Coleman JJ, Paladini A, Varrassi G. What Your Death Certificate Says About You May Be Wrong: A Narrative Review on CDC's Efforts to Quantify Prescription Opioid Overdose Deaths. Cureus . Sep 2021;13(9):e18012. doi:10.7759/cureus.18012 Winstanley EL, Stover AN. The Impact of the Opioid Epidemic on Children and Adolescents. Clin Ther . Sep 2019;41(9):1655-1662. doi:10.1016/j.clinthera.2019.06.003 Hillis S, Unwin J, Cluver L, et al. Children : the hidden pandemic 2021 : a joint report of COVID-19- associated orphanhood and a strategy for action . 2021. July 19. https://stacks.cdc.gov/view/cdc/108199 Additional Declarations Yes there is potential Competing Interest. OR reports grants from the Bill & Melinda Gates Foundation, the EPSRC, the AIDSFonds, and the NIH during the conduct of this study. Supplementary Files USallcausesOrphansSupplementaryMaterialsSUBMITNATMED.pdf Cite Share Download PDF Status: Published Journal Publication published 10 Jan, 2025 Read the published version in Nature Medicine → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4208475","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":288802468,"identity":"8e6a91c5-1fb5-48f2-829e-51afecfbcf55","order_by":0,"name":"Andres Villaveces","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAlUlEQVRIiWNgGAWjYJACgw8MzCRqKZxBspbPPCRpMZfuPbjZpsZanoF/8TEJorRYzjmXbJxzLN2wQeJZGnFaDG7kmBnnNhxOYJA4Y2xArBbz35akajEwZgRp4e8xfECklrwEwx6gX9ok2BKJ1ZJ7wOAHMMT4+Q8fOECUFgYGHgjFJpFApAa4FgZ+Yu0YBaNgFIyCEQcABVEsGb6vu/EAAAAASUVORK5CYII=","orcid":"","institution":"US Centers for Disease Control and Prevention","correspondingAuthor":true,"prefix":"","firstName":"Andres","middleName":"","lastName":"Villaveces","suffix":""},{"id":288802469,"identity":"c6374e3f-f5c8-40f5-a941-240a09e77bbe","order_by":1,"name":"Yu Chen","email":"","orcid":"https://orcid.org/0000-0002-7528-2298","institution":"Department of Mathematics, Imperial College London","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Chen","suffix":""},{"id":288802470,"identity":"302e1584-77b5-495e-a292-acf8b7f19ed8","order_by":2,"name":"Sydney Tucker","email":"","orcid":"","institution":"Imperial College London","correspondingAuthor":false,"prefix":"","firstName":"Sydney","middleName":"","lastName":"Tucker","suffix":""},{"id":288802471,"identity":"ffdbe856-2658-43e6-bf96-f9788398f5f8","order_by":3,"name":"Alexandra Blenkinsop","email":"","orcid":"https://orcid.org/0000-0002-2328-8671","institution":"Imperial College London","correspondingAuthor":false,"prefix":"","firstName":"Alexandra","middleName":"","lastName":"Blenkinsop","suffix":""},{"id":288802472,"identity":"c6ee5a0c-dad3-4ff9-9ec5-0428d2545980","order_by":4,"name":"Lucie Cluver","email":"","orcid":"","institution":"Oxford University","correspondingAuthor":false,"prefix":"","firstName":"Lucie","middleName":"","lastName":"Cluver","suffix":""},{"id":288802473,"identity":"9f58ad92-753c-4fa7-bf3d-b06f2e193468","order_by":5,"name":"Lorraine Sherr","email":"","orcid":"","institution":"University College 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Prevention","correspondingAuthor":false,"prefix":"","firstName":"Rita","middleName":"","lastName":"Noonan","suffix":""},{"id":288802477,"identity":"0542201a-f30c-4d8c-b1fc-add08e72ad38","order_by":9,"name":"Francis Annor","email":"","orcid":"","institution":"US Centers for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Francis","middleName":"","lastName":"Annor","suffix":""},{"id":288802478,"identity":"4faa77ff-9c6f-47a2-be17-e54619d0020d","order_by":10,"name":"Victor Kojey-Merle","email":"","orcid":"","institution":"Imperial College London","correspondingAuthor":false,"prefix":"","firstName":"Victor","middleName":"","lastName":"Kojey-Merle","suffix":""},{"id":288802479,"identity":"5c45be3d-4ceb-445b-b06b-3bf621ec2a51","order_by":11,"name":"Douhan Wang","email":"","orcid":"","institution":"Imperial College London","correspondingAuthor":false,"prefix":"","firstName":"Douhan","middleName":"","lastName":"Wang","suffix":""},{"id":288802480,"identity":"a5580898-b476-45d2-a66f-01c525190b59","order_by":12,"name":"Greta Massetti","email":"","orcid":"","institution":"US Centers for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Greta","middleName":"","lastName":"Massetti","suffix":""},{"id":288802481,"identity":"835b8518-1956-40b8-b3e0-6a8e3bc8c52d","order_by":13,"name":"Laura Rawlings","email":"","orcid":"","institution":"World Bank","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Rawlings","suffix":""},{"id":288802482,"identity":"6f8eecf3-b732-43b4-8f3b-dc0160ce1fd5","order_by":14,"name":"Charles Nelson","email":"","orcid":"","institution":"Harvard Medical School","correspondingAuthor":false,"prefix":"","firstName":"Charles","middleName":"","lastName":"Nelson","suffix":""},{"id":288802483,"identity":"8c19a206-3ca9-4291-8483-ff5cb1389550","order_by":15,"name":"H. Juliette Unwin","email":"","orcid":"https://orcid.org/0000-0002-9120-4003","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"H.","middleName":"Juliette","lastName":"Unwin","suffix":""},{"id":288802484,"identity":"de52e045-3755-404b-b0bf-380c8d32501a","order_by":16,"name":"Susan Hillis","email":"","orcid":"","institution":"Imperial College London","correspondingAuthor":false,"prefix":"","firstName":"Susan","middleName":"","lastName":"Hillis","suffix":""},{"id":288802485,"identity":"222f8cd8-1393-4835-875c-ec5b3831ee60","order_by":17,"name":"Oliver Ratmann","email":"","orcid":"","institution":"Imperial College London","correspondingAuthor":false,"prefix":"","firstName":"Oliver","middleName":"","lastName":"Ratmann","suffix":""}],"badges":[],"createdAt":"2024-04-02 18:55:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4208475/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4208475/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41591-024-03343-6","type":"published","date":"2025-01-10T05:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":54372339,"identity":"35f064ec-ef8a-4db5-8c9a-765e0ae507d1","added_by":"auto","created_at":"2024-04-09 13:19:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":217379,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMagnitude of children experiencing orphanhoodin the United States.\u003c/strong\u003e (\u003cstrong\u003eA\u003c/strong\u003e) Estimated number of U.S. children newly experiencing orphanhood by any cause and over time. (\u003cstrong\u003eB\u003c/strong\u003e) Estimated number of U.S. children experiencing orphanhood in their lifetime (over the past 18 years) by any cause and over time. (\u003cstrong\u003eC\u003c/strong\u003e) Incidence rates of orphanhood among US children. (\u003cstrong\u003eD\u003c/strong\u003e) Prevalence rates of orphanhood among US children. (\u003cstrong\u003eE\u003c/strong\u003e) Main contributors to children experiencing orphanhood (parental death) versus the main contributors to adult deaths in 2021. Incidence estimates for 2000-2021 are based on at least n=2,357,714 mortality records and n=3,610,887 natality records per year. Cause-specific incidence estimates for 2000-2021 are based on at least n=14,854 mortality records per year. Prevalence estimates are based on aggregating incidence estimates among children over the previous 17 years, while accounting for ageing. Corresponding uncertainty ranges are detailed in Table 1.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4208475/v1/4cfa29ca0a3707a57d9108cb.png"},{"id":54372332,"identity":"0d110d91-d84a-4f99-b30c-4bf293d1ad4a","added_by":"auto","created_at":"2024-04-09 13:19:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":211605,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTime trends in orphanhood in the United States by age of child, standardized\u003c/strong\u003e \u003cstrong\u003erace \u0026amp; ethnicity, and cause.\u003c/strong\u003e (\u003cstrong\u003eA\u003c/strong\u003e) Estimated prevalence rates of orphanhood among US children aged 0-4 years, 5-9 years, and 10-17 years. Age-specific estimates for 2000-2021 are based on at least n=2,321,339 age-specific mortality records and n=70,308,824 natality records per year. (\u003cstrong\u003eB\u003c/strong\u003e) Estimated prevalence rates of orphanhood among children by race and ethnicity of the deceased parent. Race \u0026amp; ethnicity-specific estimates for 2000-2021 are based on at least n=148,850 race \u0026amp; ethnicity-specific mortality records and n=642,737 race \u0026amp; ethnicity-specific natality records per year. (\u003cstrong\u003eC\u003c/strong\u003e) Prevalence rate of all-cause orphanhood by age and standardized race \u0026amp; ethnicity in 2021. (\u003cstrong\u003eD\u003c/strong\u003e) Time trends in sex and cause-specific incidence rates of orphanhood according to race \u0026amp; ethnicity among US children. \u0026nbsp;On the y-axis are shown 2021 incidence rates of orphanhood among US children, by sex and cause of death of the deceased parent. On the x-axis are shown the differences in incidence rates in 2021 minus those in 2000, with positive differences indicating increases in incidence rates and negative differences indicating decreases in incidence rates. Numbers show the cause of orphanhood. Shapes show the sex of the deceased parent. The size of points indicates the contribution of each cause to new cases of orphanhood respectively among US children in 2021. Incidence estimates for 2021 are based on an average of n=7,733 sex-, cause- and race \u0026amp; ethnicity-specific mortality records, and an average of n=707,651 race \u0026amp; ethnicity-specific natality records. Corresponding uncertainty ranges are detailed in Supplementary Tables S2-S3.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4208475/v1/abe11b03ed9366aa10daca57.png"},{"id":54372342,"identity":"c3afefca-a251-42a5-bb7f-f14dd04d92a7","added_by":"auto","created_at":"2024-04-09 13:19:24","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":360438,"visible":true,"origin":"","legend":"\u003cp\u003eSpatial distribution of US children experiencing orphanhood in 2021. (\u003cstrong\u003eA\u003c/strong\u003e) Estimated number of U.S. children newly experiencing parental death as the sum of orphanhood, by state and cause. (\u003cstrong\u003eB\u003c/strong\u003e) Estimated number of U.S. children experiencing parental death in their lifetime (over the past 18 years), by state and cause. Throughout (A) and (B), the leading cause of orphanhood in each state is indicated with hatch marks. (\u003cstrong\u003eC\u003c/strong\u003e) Map of orphanhood incidence rates per 100 children, by state and leading cause. (\u003cstrong\u003eD\u003c/strong\u003e) Map of orphanhood prevalence rate per 100 children, by state and leading cause. State- and cause-specific incidence estimates for 2021 are based on an average of n=5,071 state- and cause-specific mortality records and n=71,791 state-specific natality records. Prevalence estimates are based on aggregating incidence estimates among children over the previous 17 years, while accounting for ageing. Corresponding uncertainty ranges are detailed in Supplementary Table S4.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4208475/v1/7722a9b1cc9a0073e3926c0e.png"},{"id":73547485,"identity":"78eb5347-7dd9-4481-ac16-ec09a9604b4a","added_by":"auto","created_at":"2025-01-11 08:08:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2773060,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4208475/v1/8aa0af04-48ae-47ec-910e-0d774d9517f0.pdf"},{"id":54372328,"identity":"b37857b4-614d-49ed-88b5-c17f1bf64ab4","added_by":"auto","created_at":"2024-04-09 13:19:14","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1358804,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"USallcausesOrphansSupplementaryMaterialsSUBMITNATMED.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4208475/v1/48560c7acc714a6912ac42e6.pdf"}],"financialInterests":"\u003cb\u003eYes\u003c/b\u003e there is potential Competing Interest.\nOR reports grants from the Bill \u0026 Melinda Gates Foundation, the EPSRC, the AIDSFonds, and the NIH during the conduct of this study.","formattedTitle":"\u003cp\u003eOrphanhood and caregiver death among children in the United States due to all-cause mortality 2000-2021: A Modeling Study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDeaths of parents and co-residing/custodial grandparent caregivers, in the context of intersecting social and health crises, threaten child wellbeing\u003csup\u003e1\u003c/sup\u003e due to losses of nurturance, financial support, housing, and care.\u003csup\u003e2\u0026ndash;4\u003c/sup\u003e Orphanhood (death of one or both parents)\u003csup\u003e5,6\u003c/sup\u003e and caregiver loss (death of co-resident/custodial grandparents) are considered Adverse Childhood Experiences (ACEs),\u003csup\u003e7,8\u003c/sup\u003e and may have enduring consequences that persist well into adulthood.\u003csup\u003e9\u0026ndash;12\u003c/sup\u003e ACE\u0026rsquo;s are associated with increased chronic stress and lifelong risks of mental health illness, suicide, post-traumatic stress disorder, violence, insecure housing,\u003csup\u003e13\u003c/sup\u003e and chronic and infectious diseases.\u003csup\u003e14,15\u003c/sup\u003e These impacts often lead to ongoing needs for mental health, parenting, educational, and economic support for affected children, and for foster care or adoption services for children bereft of care.\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn the United States, mortality data informs public health prevention and response policies according to leading causes-of-death.\u003csup\u003e16\u003c/sup\u003e However, one disproportionately affected population often remains largely invisible \u0026ndash; those children left behind by adult deaths.\u003csup\u003e2,6,17\u003c/sup\u003e One exception are children experiencing COVID-19-associated orphanhood, where real-time incidence estimates\u003csup\u003e18\u0026ndash;20\u003c/sup\u003e led to policies to support children, including recommendations in the National COVID-19 Pandemic Preparedness Plan\u003csup\u003e21\u003c/sup\u003e and investments in some states,\u003csup\u003e22\u003c/sup\u003e such as financial, bereavement, and mental health support for bereaved children and surviving caregivers. These established frameworks raise the possibility that new standards of care can be extended for any child experiencing orphanhood, regardless of cause.\u003csup\u003e23\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTo inform evidence-based, compassionate prevention and response strategies for affected children and families, understanding the numbers, time-trends, causes, locations and disparities in all-cause orphanhood is essential. Reports show COVID-19 excess deaths caused a surge in orphanhood and caregiver death, affecting over 10.5\u0026nbsp;million children globally.\u003csup\u003e24\u003c/sup\u003e In the U.S., the pandemic was linked to increased challenges including substance use, economic crises, mental health distress, and may have been linked to deaths due to overdose, suicide, and excessive alcohol use.\u003csup\u003e25,26\u003c/sup\u003e Though reports have described the U.S. orphanhood burden related to HIV,\u003csup\u003e27\u003c/sup\u003e maternal cancers,\u003csup\u003e23\u003c/sup\u003e COVID-19,\u003csup\u003e15\u003c/sup\u003e and child bereavement,\u003csup\u003e28\u003c/sup\u003e up-to-date estimates on all-cause orphanhood do not exist.\u003c/p\u003e \u003cp\u003eTherefore, we estimate prevalence, incidence, and trends from 2000\u0026ndash;2021 in all-cause orphanhood and caregiver death among children in the U.S. We further characterize leading causes of orphanhood and caregiver loss and identify whether the compound crises of the COVID-19 pandemic and drug overdose epidemic in 2020 and 2021 were associated with escalating orphanhood. We aim to identify populations disproportionately affected, by age, race/ethnicity, and state, to strengthen evidence-based response strategies. Our findings can contribute to identifying children at risk among population subgroups and geographic areas, and to targeting effective prevention and protection programming for affected children and parents/caregivers. Such strategic programming may form a blueprint for more comprehensive global public health responses.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eOverview\u003c/h2\u003e \u003cp\u003eWe adapted methods from Hillis et al\u003csup\u003e19\u003c/sup\u003e to estimate the magnitude of orphanhood and caregiver loss among children ages 0\u0026ndash;17 from all causes of deaths, according to Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). We extracted subgroup-specific individual live birth and death data from National Center for Health Statistics (NCHS), along with population size estimates. We then attributed to each deceased individual the average number of children orphaned using subgroup-specific fertility rates in the previous 0\u0026ndash;17 years. Our outcomes were orphanhood incidence and prevalence from 2000 through 2021, disaggregated by year, child age, and sex, race/ethnicity, cause-of-death of the deceased parent (numbers and percent of child population). We extended these estimates to include loss of co-residing/custodial grandparent caregivers, and state-level estimates of incidence and prevalence of orphanhood and grandparent caregiver loss (Supplementary Text S1, Fig. S2). We calculated 95% uncertainty intervals around estimates using bootstrap resampling (Supplementary Text S1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eNational mortality data\u003c/h2\u003e \u003cp\u003eWe extracted mortality data of U.S. residents by underlying cause-of-death from NCHS Vital Statistics for 1983-2021.\u003csup\u003e29\u003c/sup\u003e The World Health Organization (WHO) defines underlying cause-of-death as \"the disease or injury which initiated the train of events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury\".\u003csup\u003e30\u003c/sup\u003e Mortality records\u003csup\u003e29\u003c/sup\u003e were mapped and aggregated to one of 53 caregiver loss causes-of-death that are closely related to the 52 rankable causes-of-death in the NCHS 113 cause-of-death list\u003csup\u003e31\u003c/sup\u003e, or `Other' caregiver loss cause-of-death (Supplementary Text S1). Cause-of-death classifications changed with the Tenth Revision of the International Classification of Disease (ICD-10), and we harmonized 1983\u0026ndash;1998 cause-of-death data to ICD-10 classifications to avoid discontinuities in orphanhood estimates from 1998\u0026ndash;1999 (Supplementary Text S1).\u003c/p\u003e \u003cp\u003eOur cause-specific analyses for orphanhood estimates focused on leading causes of death in 2021: COVID-19, drug overdose, the remaining top five causes-of-death overall (heart disease, cancer, unintentional injuries, cerebrovascular diseases, chronic lung disease), and any additional causes of death in the top five for men and women ages 15\u0026ndash;44 (suicide and homicide), as these ages include those more likely to be parents. We used a hierarachical approach for classifying cause of death; therefore, we consistently excluded drug overdose from each of these three categories: suicide, homicide, and unintentional injuries. Race and ethnicity in death certificates are typically reported by next of kin. We converted data that were incrementally reported by multiple races to standardised race categories (Supplementary Table S7).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eNational orphanhood estimates\u003c/h2\u003e \u003cp\u003eTo estimate the number of children each death leaves behind, we obtained age, race, and ethnicity data of fathers and mothers from NCHS live birth records.\u003csup\u003e29,31\u003c/sup\u003e We used corresponding 1990\u0026ndash;2021 population sizes\u003csup\u003e32\u003c/sup\u003e to calculate annualized age- and sex-specific national-level fertility rates by standardised race/ethnicity categories (Supplementary Text S1). Before 1990, we assumed fertility rates of 1990 because population sizes by race/ethnicity were unavailable before 1990, and report corresponding sensitivity analyses (Supplementary Text S2).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eIncidence\u003c/h2\u003e \u003cp\u003eWe estimated annual incidence of orphanhood for a given year among children by multiplying the number of cause-specific deaths among adults stratified by sex, race/ethnicity, and five-year age bands in each year 1983\u0026ndash;2021, with the expected number of children aged 0\u0026ndash;17 born to each adult, with the corresponding characteristics in the same year. Calculations were performed by race/ethnicity groups and then aggregated to U.S. totals due to correlations between mortality and fertility rates by race/ethnicity (Supplementary Text S1). Age of child was attributed by considering fertility rates in each of the current and preceding 17 years, after adjustment for pediatric survival probabilities (Supplementary Table S4).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePrevalence\u003c/h2\u003e \u003cp\u003eWe estimated annual prevalence of orphanhood among children in any given year in 2000\u0026ndash;2021 by cumulatively summing incidence estimates by one-year age of child in the current and previous 17 years, excluding children who would have since turned 18; calculations of orphanhood prevalence for 2000\u0026ndash;2015 required including annual orphanhood incidence estimates for 1983\u0026ndash;1999, in order to include the cumulative prior 17-year risk for experiencing prevalent parental death. We removed duplicate orphanhood counts by adjusting for those who had lost both parents Supplementary Text S1, Supplementary Table S5). Incidence and prevalence rates were calculated relative to child population sizes in the corresponding year.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eNational grandparent caregiver loss\u003c/h2\u003e \u003cp\u003eWe estimated annual incidence of children losing grandparent caregivers in 1983\u0026ndash;2021 by multiplying the number of cause-specific deaths in each year in adults aged 30 years and above stratified by sex and race/ethnicity with the corresponding proportions of adults co-residing with their grandchild(ren) and providing some or all basic needs for grandchild(ren), using U.S. Census American Community Surveys (ACS) 2010\u0026ndash;2021 data (Supplementary Text S1).\u003csup\u003e33\u003c/sup\u003e We assumed only one child was affected by each grandparent caregiver death. We also developed estimates for the age of children affected (Supplementary Fig S21).\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eState-level orphanhood and grandparent caregiver death estimates\u003c/h2\u003e \u003cp\u003eWe generated state-level estimates of cause-specific incidence and prevalence of orphanhood and caregiver death for 2021, using data from CDC WONDER.\u003csup\u003e34,35\u003c/sup\u003e (Supplementary Text S1). State-level orphanhood and caregiver death were calculated as above, with exceptions for male fertility rates for 2005\u0026ndash;2015 (Supplementary Text S1). We developed correction factors to adjust for bias resulting from data not stratified by race and ethnicity (Supplementary Text S1).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eAll-cause orphanhood and caregiver loss\u003c/h2\u003e\n \u003cp\u003eIn 2021, we estimate 498,249 (95% CI, 496,938\u0026thinsp;\u0026minus;\u0026thinsp;499,639) childr experienced incident orphanhood or caregiver death from any cause (0.72% of children, Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig. S2). Most children lost a parent (81.6%), while the remainder lost a grandparent caregiver (18.4%). Before the COVID-19 pandemic, incidence of orphanhood, and of orphanhood/caregiver loss (combined) increased rapidly from 2000 to 2019 by 11.4% and 11.7%, respectively (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Through the pandemic, incidence of orphanhood, and of orphanhood/caregiver loss (combined) increased further from 2019 to 2021 by 39.5% and 33.6%, respectively. Prevalence of orphanhood, and of orphanhood/caregiver loss decreased slightly by 2.4% and 0.9% from 2000 to 2019, then increased by 10.1% and 9.3% during the period spanning the pandemic years (2019 to 2021). In 2021, we estimate 2,966,008 (95%CI, 2,963,030\u0026thinsp;\u0026minus;\u0026thinsp;2,968,931) children experienced prevalent orphanhood or caregiver death, representing 4.0% of all children.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTrends in All-cause Orphanhood and Caregiver (Co-Residing/custodial Grandparent) Loss from 2000 to 2021, before and during the COVID-19 pandemic\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\" rowspan=\"5\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eBefore the COVID-19 pandemic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eSince the COVID-19 pandemic\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2000\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2019\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2000\u0026ndash;2019\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2019\u0026ndash;2021\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2000\u0026ndash;2021\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e(Number\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e(Number\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003echange\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e(Number\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e(Number\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003echange\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003echange\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eof\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eof\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eof\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eof\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChildren)\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChildren)\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChildren)\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChildren)\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"9\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncidence (n, (95% uncertainty interval))\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOrphanhood\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e261,633 (260,485, 262,656)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e291,574 (290,613, 292,657)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;11.4% (+\u0026thinsp;10.9%, +\u0026thinsp;12.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e359,431 (358,301, 360,531)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e406,733 (405,437, 407,928)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;39.5% (+\u0026thinsp;38.8%, +\u0026thinsp;40.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;55.5% (+\u0026thinsp;54.7%, +\u0026thinsp;56.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOrphanhood and Caregiver Loss\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e333,959 (332,701, 335,049)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e372,869 (371,737, 374,132)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;11.7% (+\u0026thinsp;11.2%, +\u0026thinsp;12.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e454,403 (453,107, 455,706)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e498,249 (496,938, 499,639)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;33.6% (+\u0026thinsp;33.1%, +\u0026thinsp;34.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;49.2% (+\u0026thinsp;48.5%, +\u0026thinsp;49.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"9\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncidence rate per 100 children (rate, (95% uncertainty interval))\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOrphanhood\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.36 (0.36, 0.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.40 (0.40, 0.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;10.2% (+\u0026thinsp;9.9%, +\u0026thinsp;11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.49 (0.49, 0.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.59 (0.58, 0.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;46.9% (+\u0026thinsp;46.2%, +\u0026thinsp;47.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;62.2% (+\u0026thinsp;61.3%, +\u0026thinsp;63.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOrphanhood and Caregiver Loss\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.46 (0.46, 0.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.51 (0.51, 0.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;10.6% (+\u0026thinsp;10.2%, +\u0026thinsp;11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.62 (0.62, 0.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.72 (0.72, 0.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;40.8% (+\u0026thinsp;40.1%, +\u0026thinsp;41.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;55.6% (+\u0026thinsp;54.9%, +\u0026thinsp;56.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"9\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevalence (n, (95% uncertainty interval))\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOrphanhood\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,228,940 (2,225,912, 2,232,100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,174,707 (2,172,340, 2,177,566)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-2.4 (-2.6, -2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,266,808 (2,264,259, 2,269,533)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,394,604 (2,391,948, 2,397,308)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;10.1% (+\u0026thinsp;10.0%, +\u0026thinsp;10.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;7.4% (+\u0026thinsp;7.2%, +\u0026thinsp;7.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOrphanhood and Caregiver Loss\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,738,807 (2,735,607, 2,742,282)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,712,927 (2,710,251, 2,715,769)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.9 (-1.1, -0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,824,422 (2,821,579, 2,827,337)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,966,008 (2,963,030, 2,968,931)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;9.3% (+\u0026thinsp;9.3%, +\u0026thinsp;9.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;8.3% (+\u0026thinsp;8.1%, +\u0026thinsp;8.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"9\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevalence rate per 100 children (rate, (95% uncertainty interval))\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOrphanhood\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.08 (3.08, 3.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.98 (2.97, 2.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-3.4 (-3.6, -3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.11 (3.11, 3.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.45 (3.45, 3.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;16.0% (+\u0026thinsp;15.9%, +\u0026thinsp;16.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;12.0% (+\u0026thinsp;11.8%, +\u0026thinsp;12.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOrphanhood and Caregiver Loss\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.78 (3.78, 3.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.71 (3.71, 3.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-1.9 (-2.1, -1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.88 (3.87, 3.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.27 (4.27, 4.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;15.1% (+\u0026thinsp;15.1%, +\u0026thinsp;15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+\u0026thinsp;12.9% (+\u0026thinsp;12.8%, +\u0026thinsp;13.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eCause-specific trends\u003c/h2\u003e\n \u003cp\u003eFrom 2000\u0026ndash;2021, orphanhood caused by drug overdose increased markedly, as did orphanhood due to COVID-19 between 2019\u0026ndash;2021. Orphanhood due to suicide decreased until 2010 and subsequently increased. Orphanhood due to unintentional injuries and homicide decreased until 2019, then increased until 2021; orphanhood due to diseases of the heart remained relatively unchanged until 2019, then increased. Only orphanhood due to malignant neoplasms consistently decreased from 2000\u0026ndash;2021. By 2021, both incidence and prevalence of orphanhood due to fatal injuries \u0026ndash; including drug overdose, suicide, homicide, and unintentional injuries (e.g. motor vehicle crashes) \u0026ndash; exceeded orphanhood due to chronic diseases (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eA, B and, Table \u003cspan class=\"InternalRef\"\u003eS1\u003c/span\u003e). Orphanhood caused by drug overdose rose substantially from 2012\u0026ndash;2019, then jumped sharply during 2020\u0026ndash;2021 (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eC). From 2000\u0026ndash;2019, orphanhood incidence due to drug overdose increased from an estimated 0.015% of children in 2000, to 0.06% in 2019, 0.085% in 2020 after the pandemic onset, and 0.09% in 2021. Drug overdose was the leading cause of orphanhood incidence and prevalence in 2020 and 2021, surpassing both chronic diseases and COVID-19 (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eC, D). The disproportionate impact of fatal injuries on orphanhood was evident in 2021, with drug overdose contributing 17.5% to orphanhood incidence, yet only 3.1% to adult mortality (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eE); similarly, unintentional injuries, suicide, and homicide contributed 8.3%, 5.0%, and 3.7% to orphanhood, versus 3.6%, 1.2% and 0.7%, respectively, to adult deaths.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eDisparities by age and race/ethnicity\u003c/h2\u003e\n \u003cp\u003eFrom 2000\u0026ndash;2021, children ages 10\u0026ndash;17 years were 5.4 times more likely than children ages 0\u0026ndash;4 to experience prevalent orphanhood (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eA, Table S2). By 2021, orphanhood prevalence among ages 10\u0026ndash;17 was 5.0%, affecting 1,704,671 children. Substantial disparities across race and ethnicity occurred, accentuated by the COVID-19 pandemic. By 2021, orphanhood affected 6.5% of non-Hispanic American Indian or Alaska Native children, 4.8% of non-Hispanic Black children, 3.9% of non-Hispanic White children, 1.7% of Hispanic children, and 1.9% of non-Hispanic Asian children (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eC).\u003c/p\u003e\n \u003cp\u003eCauses underpinning these disparities differed by parental race/ethnicity and sex (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eD, Table S3). Among non-Hispanic American Indian or Alaska Native children, leading causes of maternal orphanhood in 2021 were, in order, COVID-19, drug overdose, and chronic liver disease and cirrhosis; while leading causes of paternal orphanhood were chronic liver disease and cirrhosis, unintentional injuries, and diseases of the heart \u0026ndash; all of which increased as causes of orphanhood since 2000. Among non-Hispanic Black children, leading causes of maternal orphanhood were COVID-19, diseases of heart, and drug overdose; while paternal orphanhood was primariy caused by diseases of heart, drug overdose, and homicide. In non-Hispanic White children, drug overdose deaths among fathers increased substantially over the past two decades; in Hispanic children, COVID-19 deaths among fathers predominated. In non-Hispanic Asian children, primary causes of orphanhood were heart disease, malignant neoplasms, and COVID-19.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eState-level Estimates\u003c/h2\u003e\n \u003cp\u003eIn 2021, 33 states had\u0026thinsp;\u0026gt;\u0026thinsp;3% of all children experiencing prevalent orphanhood; Southeastern, Northeastern, Southern Border, and Midwest states were most affected (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e, and Tables S4-S6). California, Texas, and Florida had the highest numbers of children experiencing orphanhood incidence and prevalence in 2021. West Virginia and New Mexico had the highest incidence (0.8\u0026ndash;0.9%) and prevalence rates (4.5-5.0%) of orphanhood in 2021. Injury-associated parental deaths \u0026ndash; including overdose, suicide, and/or unintentional injury \u0026ndash; were among the top two causes of orphanhood prevalence in 47 states (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Drug overdose was the leading cause of orphanhood prevalence in 30 states, particularly affecting Southeastern, Southwestern, Southern Border, and Midwest states, and Southwestern States with large American Indian and Alaska Native populations.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePrimary contributors to orphanhood in each US state in 2021.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"8\"\u003e\n \u003cp\u003eOrphanhood in 2021\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eOrphanhood Incidence in 2021\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eOrphanhood Prevalence in 2021\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003eU.S. state\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIncidence\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIncidence\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFirst ranked\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSecond ranked\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePrevalence\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePrevalence\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFirst ranked\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSecond ranked\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003erate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ecause\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ecause\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003erate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ecause\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ecause\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eper 100\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eper 100\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003echildren\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e(name\u003c/strong\u003e,\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e(name\u003c/strong\u003e,\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003echildren\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e(name\u003c/strong\u003e,\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e(name\u003c/strong\u003e,\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e(n, 95% UI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e(rate, 95% UI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% contribution)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% contribution)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e(n, 95% UI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e(rate, 95% UI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% contribution)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% contribution)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlabama\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,991 (7,585, 8,397)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.71 (0.68, 0.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(16.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45,696 (42,504, 49,079)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.07 (3.79, 4.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(16.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlaska\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,122 (795, 1,478)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.63 (0.44, 0.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(16.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,922 (3,970, 9,170)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.30 (2.21, 5.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(23.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuicide\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(10.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArizona\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10,898 (10,511, 11,250)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.68 (0.65, 0.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(17.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(16.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59,002 (55,837, 62,261)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.66 (3.46, 3.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(16.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(12.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArkansas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,461 (4,053, 4,945)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.63 (0.58, 0.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(13.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25,644 (22,348, 29,481)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.65 (3.18, 4.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(16.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCalifornia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45,004 (45,713, 44,534)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.51 (0.52, 0.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(16.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e264,622 (268,326, 261,397)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.02 (3.06, 2.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(16.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(12.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eColorado\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,587 (6,178, 6,985)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.53 (0.50, 0.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(18.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(10.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37,868 (34,890, 41,412)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.05 (2.81, 3.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(16.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuicide\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(13.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConnecticut\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,330 (2,922, 3,741)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.46 (0.40, 0.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(29.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20,874 (17,911, 24,220)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.86 (2.45, 3.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(26.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(14.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDelaware\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e962 (667, 1,279)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.46 (0.32, 0.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(34.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(9.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,467 (3,582, 7,985)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.62 (1.72, 3.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(29.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(10.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDistrict of Columbia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e612 (432, 823)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.49 (0.34, 0.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(18.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(10.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,828 (2,465, 5,519)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.04 (1.96, 4.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(13.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(12.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFlorida\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28,456 (28,600, 28,393)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.66 (0.67, 0.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(19.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(17.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e159,629 (159,761, 159,719)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.72 (3.72, 3.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(18.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(14.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGeorgia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15,723 (15,459, 16,039)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.62 (0.61, 0.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(16.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87,557 (84,749, 90,515)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.47 (3.36, 3.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(15.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(13.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHawaii\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,231 (950, 1,580)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.40 (0.31, 0.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,692 (5,510, 10,706)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.53 (1.81, 3.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(15.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(15.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIdaho\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,940 (1,544, 2,372)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.41 (0.33, 0.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(14.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(13.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10,474 (7,785, 14,079)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.23 (1.66, 3.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(20.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuicide\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(13.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIllinois\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13,831 (13,528, 14,158)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.49 (0.48, 0.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(16.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(13.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89,775 (87,129, 92,407)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.20 (3.11, 3.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(16.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(15.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndiana\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9,148 (8,705, 9,532)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.58 (0.55, 0.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(22.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(11.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54,889 (51,659, 58,427)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.46 (3.26, 3.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(20.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(13.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIowa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,784 (2,381, 3,218)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.38 (0.32, 0.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(14.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16,673 (13,710, 20,323)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.26 (1.86, 2.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(15.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(14.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKansas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,455 (3,041, 3,947)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.49 (0.43, 0.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(14.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(13.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19,915 (16,740, 23,836)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.83 (2.38, 3.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(15.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKentucky\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,183 (6,792, 7,634)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.71 (0.67, 0.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(24.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(13.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42,002 (38,999, 45,578)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.13 (3.84, 4.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(22.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLouisiana\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8,108 (7,719, 8,511)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.75 (0.71, 0.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(23.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(12.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46,778 (43,522, 50,175)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.32 (4.02, 4.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(17.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(14.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMaine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,347 (1,056, 1,679)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.53 (0.42, 0.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(30.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(10.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,245 (5,099, 9,975)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.88 (2.02, 3.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(26.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMaryland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,419 (6,996, 7,815)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.54 (0.51, 0.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(23.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(13.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48,147 (44,993, 51,637)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.53 (3.30, 3.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(22.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMassachusetts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,038 (5,612, 6,457)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.44 (0.41, 0.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(27.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(14.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41,234 (38,098, 44,636)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.03 (2.80, 3.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(27.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(15.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMichigan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12,179 (11,820, 12,509)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.57 (0.55, 0.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(17.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75,255 (72,209, 78,059)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.49 (3.35, 3.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(17.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(14.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMinnesota\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,403 (4,951, 5,883)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.41 (0.38, 0.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(17.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(13.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30,442 (27,178, 34,423)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.31 (2.06, 2.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(16.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMississippi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,251 (4,791, 5,668)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.76 (0.69, 0.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(15.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(14.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30,280 (26,942, 33,913)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.37 (3.89, 4.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(15.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissouri\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8,128 (7,727, 8,525)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.59 (0.56, 0.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(18.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(13.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49,665 (46,695, 52,986)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.59 (3.37, 3.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(18.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(13.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMontana\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,216 (912, 1,568)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.52 (0.39, 0.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(17.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuicide\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(10.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,553 (4,473, 9,605)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.79 (1.90, 4.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(24.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuicide\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(12.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNebraska\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,809 (1,412, 2,261)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.37 (0.29, 0.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(13.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(12.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10,680 (8,043, 14,384)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.21 (1.67, 2.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(18.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNevada\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,034 (3,650, 4,450)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.58 (0.52, 0.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(19.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21,946 (18,876, 25,409)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.14 (2.70, 3.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(15.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(14.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNew Hampshire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,094 (814, 1,405)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.43 (0.32, 0.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(25.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(10.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,869 (4,778, 9,552)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.68 (1.86, 3.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(30.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(11.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNew Jersey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9,644 (9,235, 10,114)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.48 (0.46, 0.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(21.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(13.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63,595 (60,303, 67,269)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.14 (2.98, 3.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(21.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(15.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNew Mexico\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,137 (3,701, 4,558)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.87 (0.78, 0.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21,632 (18,554, 25,154)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.57 (3.92, 5.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(17.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(15.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNew York\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19,199 (19,000, 19,436)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.47 (0.46, 0.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(19.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(14.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e124,546 (122,607, 126,477)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.03 (2.98, 3.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(17.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(15.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNorth Carolina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14,097 (13,786, 14,457)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.61 (0.60, 0.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(20.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(12.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79,120 (76,394, 82,029)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.44 (3.32, 3.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(17.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(12.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNorth Dakota\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e695 (469, 1,081)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.37 (0.25, 0.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(15.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(10.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,808 (2,409, 6,887)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.05 (1.30, 3.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(17.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuicide\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(7.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOhio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15,767 (15,525, 16,051)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.61 (0.60, 0.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(24.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(12.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97,161 (94,914, 99,413)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.73 (3.64, 3.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(26.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(12.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOklahoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,119 (5,684, 6,576)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.64 (0.59, 0.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(16.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36,240 (32,901, 39,983)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.77 (3.42, 4.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(14.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(14.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOregon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,153 (3,757, 4,561)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.48 (0.44, 0.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(15.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22,994 (19,901, 26,282)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.67 (2.31, 3.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(14.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePennsylvania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14,609 (14,349, 14,918)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.55 (0.54, 0.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(24.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(12.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95,425 (93,303, 97,704)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.57 (3.49, 3.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(26.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(13.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRhode Island\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e791 (565, 1,048)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.38 (0.27, 0.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(35.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(9.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,826 (3,084, 7,091)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.31 (1.48, 3.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(30.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(11.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSouth Carolina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,274 (6,907, 7,638)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.65 (0.62, 0.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(18.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39,654 (36,661, 42,890)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.55 (3.28, 3.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(14.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(14.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSouth Dakota\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,093 (794, 1,510)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.50 (0.36, 0.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChronic liver disease and cirrhosis\u003c/p\u003e\n \u003cp\u003e(17.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(11.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,552 (3,631, 9,040)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.52 (1.65, 4.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(19.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuicide\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(8.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTennessee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,908 (11,590, 12,260)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.77 (0.75, 0.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(23.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(13.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63,260 (60,342, 66,515)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.11 (3.92, 4.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(18.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(14.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTexas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40,272 (40,738, 39,926)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.54 (0.54, 0.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(23.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(12.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e224,453 (226,165, 223,024)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.00 (3.03, 2.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(13.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(13.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUtah\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,772 (3,283, 4,293)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.40 (0.35, 0.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(14.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(14.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24,529 (20,856, 29,053)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.59 (2.20, 3.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(19.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuicide\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(15.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVermont\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e479 (308, 678)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.41 (0.26, 0.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(32.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(10.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,394 (1,244, 4,255)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.05 (1.06, 3.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(21.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(11.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVirginia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9,638 (9,245, 10,045)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.51 (0.49, 0.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(18.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of heart\u003c/p\u003e\n \u003cp\u003e(13.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56,961 (53,825, 60,501)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.02 (2.86, 3.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(15.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWashington\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,386 (6,998, 7,814)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.44 (0.42, 0.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(17.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42,455 (39,491, 46,039)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.53 (2.36, 2.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(15.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(15.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWest Virginia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,142 (2,754, 3,552)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.88 (0.77, 0.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(35.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003cp\u003e(10.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17,888 (15,069, 21,094)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.98 (4.20, 5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(32.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(11.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWisconsin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,913 (4,528, 5,358)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.39 (0.36, 0.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(21.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(12.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29,802 (26,821, 33,307)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.34 (2.10, 2.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrug overdose\u003c/p\u003e\n \u003cp\u003e(19.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant neoplasms\u003c/p\u003e\n \u003cp\u003e(14.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWyoming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e542 (348, 880)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.41 (0.26, 0.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(13.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuicide\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(10.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,021 (1,734, 5,830)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.28 (1.31, 4.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnintentional injuries\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(25.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuicide\u003c/p\u003e\n \u003cp\u003eexcluding drug overdose\u003c/p\u003e\n \u003cp\u003e(11.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOver the past two decades, prevalence of all-cause orphanhood and caregiver death decreased slightly until 2019 and then increased markedly during 2020\u0026ndash;2021 with intersecting crises of the overdose epidemic and COVID-19 pandemic.\u003csup\u003e36,37\u003c/sup\u003e Parental death due to drug overdose was the leading cause of orphanhood incidence and prevalence during the pandemic. By 2021, over 2.9\u0026nbsp;million children \u0026ndash; 4.0% of all children in the U.S. \u0026ndash; had lost a parent or caregiver in their lifetime. Populations disproportionately affected by orphanhood included over 1.7\u0026nbsp;million adolescents ages 10\u0026ndash;17 years (1 of every 20 adolescents); and children of non-Hispanic American Indian or Alaska Native, non-Hispanic Black, and non-Hispanic White race/ethnicities (approximately 1 of 15, 1 of 20, and 1 of 25 children, respectively). Orphanhood prevalence was highest in West Virginia, New Mexico, Mississippi, Louisiana, and Kentucky, affecting 1 of every 25 children. Compared to previous cause-specific reports (an estimated 97,376 children orphaned by HIV/AIDS (1998),\u003csup\u003e27\u003c/sup\u003e 157,183 by maternal cancers (2020),\u003csup\u003e23\u003c/sup\u003e and 218,800 by COVID-19 in 2020-2022\u003csup\u003e38\u003c/sup\u003e), data on all-cause orphanhood and co-residing grandparent caregiver death are over ten times greater, quantifying the full burden.\u003c/p\u003e \u003cp\u003eBy 2021, orphanhood incidence and prevalence due to fatal injuries (drug overdose, suicide, homicide, and unintentional injuries), exceeded those linked to chronic diseases. Together, injuries and chronic diseases accounted for over half of all children orphaned. Fatalities due to injuries and chronic diseases among minoritized populations, are more common among younger adults still caring for children. For 47 states, drug overdose, suicide, and/or unintentional injuries were among the top two causes of orphanhood. Although drug overdose deaths were increasing before 2020, pandemic-linked increases of these deaths exceeded those forecasted; and the pandemic appeared to increase drug overdose risk.\u003csup\u003e39,40\u003c/sup\u003e The evolving nature of drug supply, including the proliferation of illegally made fentanyl and resurgence of stimulants such as methamphetamine, has affected almost every state.\u003csup\u003e41,42\u003c/sup\u003e By 2021, our data show drug overdose contributed 17.5% to orphanhood compared to 3.1% to mortality; establishing comprehensive care programs for children orphaned due to drug overdose could better mitigate the long-term negative effects that these children are disproportionately facing.\u003c/p\u003e \u003cp\u003eOur findings reveal social and health disparities in orphanhood rates and leading caregiver causes-of-death between age, sex, and racial/ethnic groups, and across geographies. These results can inform and contextualize prevention and response programming for children affected by orphanhood. For non-Hispanic American Indian or Alaska Native persons, for example, alcohol-related deaths were a leading cause, while non-Hispanic Black populations showed homicide among fathers as a leading cause. Many of these disparities are related to historical racism and derived practices that foster inequitable access to housing, education, and employment. Populations most affected in different states may have been exposed to such inequalities.\u003csup\u003e43\u003c/sup\u003e In parts of the northeastern and midwestern U.S., rising unemployment, limited access to health and social services during the pandemic, increased access to a more lethal supply of illicit drugs or availability of other substances such as alcohol particularly among affected white men, may be linked to drug overdose emerging as the top cause of incident orphanhood in these regions.\u003csup\u003e44\u003c/sup\u003e Circumstances of parental death influence grief-related psychopathology in surviving children,\u003csup\u003e45\u003c/sup\u003e and evidence-based responses can improve short- and long-term outcomes.\u003csup\u003e9,11,12\u003c/sup\u003e It is paramount to keep children in their families, whenever possible. This requires ensuring bereaved families receive support, and those needing kinship or foster care are served rapidly.\u003csup\u003e46\u003c/sup\u003e Child resilience after parental loss can be strengthened by programs and policies that promote safe, stable, and nurturing relationships and environments, and that address childhood adversity, including preventing violence and abuse.\u003csup\u003e46\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDespite serious risks for bereaved children,\u003csup\u003e47\u003c/sup\u003e timely, multifactored responses using an age- and life-stage approach may restore hope and build resilience.\u003csup\u003e48\u003c/sup\u003e As grief is an immediate reaction that can extend years after parental loss, healing and support are urgent needs for children, who may be less equipped to recover than adults, particularly when the loss is sudden and unexpected.\u003csup\u003e11,27\u003c/sup\u003e The governor of Utah\u003csup\u003e49\u003c/sup\u003e and others\u003csup\u003e50\u003c/sup\u003e have called for the addition to the death certificate of a checkbox to identify children living in the home of the deceased, so that bereaved children can be linked to support and services. Such responses typically provide parenting, economic, and education support, and are consistent with the WHO INSPIRE package for ending violence against children.\u003csup\u003e51,52\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOur study has several limitations. First, cause-specific estimates of children experiencing orphanhood and caregiver deaths are derived from mortality statistics on underlying causes-of-death, and may be underestimates\u003csup\u003e53\u003c/sup\u003e for causes associated with erroneous or incomplete reporting, uncertainty in the chain of events preceding death, or coding limitations - such as for COVID-19, drug overdose, or suicide.\u003csup\u003e54\u003c/sup\u003e Second, as we attributed only one child per grandparent caregiver death, our estimates of grandparent caregiver loss are minimum estimates. Third, we assumed current mortality is unrelated to historic fertility for years before 1990, and sensitivity analyses suggest this may lead to inaccuracies in orphanhood prevalence estimates until 2007 (Supplementary Text S2). Fourth, publicly available state-specific data were partly suppressed due to small counts; therefore, we cannot exclude bias in state-specific orphanhood estimates. Finally, to characterise orphanhood prevalence in 2000\u0026ndash;2021, we had to consider vital statistics since 1983 and consolidate changes in cause-of-death and race/ethnicity coding. Our sensitivity analyses, including detailed comparisons of NCHS death data to CDC WONDER vital statistics for each of the 21 years\u0026rsquo; calculations (Supplementary Text S2), suggest our incidence and prevalence estimates are robust, and should be interpreted as minimum estimates of orphanhood and caregiver death.\u003c/p\u003e \u003cp\u003eIn conclusion, evidence-based policies and programs that provide healing and support for nearly 3\u0026nbsp;million children and adolescents in the U.S. who have experienced orphanhood and caregiver loss are urgently needed to reduce longterm negative affectsof this adverse childhood experience. This is especially relevant given unprecedented rates of drug overdoses, increasing the possibility that children who are living in a household where a parent or caregiver is negatively affected by substance use, may also experience the loss of a parent.\u003csup\u003e52,55\u003c/sup\u003e Evidence highlights three essential components of orphanhood prevention and response that effectively promote their recovery and resilience: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) prevent death of parents and caregivers through timely prevention and treatment of leading causes of death and ensured access to affordable compassionate health and mental health care for all; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) prepare families to provide safe and nurturing alternative care; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) protect children affected by orphanhood and vulnerabilities, through grief and mental health counseling, and parenting, economic, and educational support that can be contextualized and delivered at scale.\u003csup\u003e19,56\u003c/sup\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDisclaimer:\u003c/strong\u003e The findings in this report are those of the authors. They do not necessarily represent the official position of the US Centers for Disease Control and Prevention. For the purpose of open access, the authors have applied a `Creative Commons Attribution\u0026rsquo; (CC-BY) license to any Author Accepted Manuscript version arising.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuestion\u003c/strong\u003e: \u0026nbsp;What are U.S. trends in all-cause and cause-specific orphanhood and caregiver death among children \u0026lt;18?\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings\u003c/strong\u003e: From 2000-2021, orphanhood and caregiver loss incidence and prevalence increased 49.2% and 8.3%, respectively. \u0026nbsp;By 2021, 2.9 million children (4% of all children) were affected. Populations disproportionately affected by orphanhood included 1.7 million adolescents ages 10-17; 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, Southern and Eastern States. Drug overdose was the leading cause of orphanhood during the COVID-19 pandemic.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeaning\u003c/strong\u003e: Evidence-based programs and policies are needed to prevent orphanhood and support these bereaved children.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data used for this study are publicly available through U.S. Government websites.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData sharing statement:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data used to calculate estimates of mortality and orphanhood are publicly available. Mortality and natality data were sourced from NCHS (https://www.cdc.gov/nchs/data_access/vitalstatsonline.htm). Mortality, natality data after year 2005 at the state level were sourced from CDC WONDER (https://wonder.cdc.gov/). \u0026nbsp; Population data from 1969 \u0026nbsp;to 1989 were sourced from https://seer.cancer.gov/popdata/singleages.html. Population data from 1990 to 2020 were sourced from CDC WONDER (https://wonder.cdc.gov/bridged-race-population.html). Child mortality data were sourced from United Nations (https://population.un.org/wpp/Download/Standard/Mortality/). Household data from 2010 to 2021 were sourced from American Community Survey (https://data.census.gov/table/ACSST5Y2019.S1002).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCode to reproduce all analyses is freely available on Github version 1.1.2 under the GNU General Public License version 3.0 at the repository (https://github.com/MLGlobalHealth/orphanhood-caregiver-death-in-US-from-all-causes-of-mortality).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements: \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the Global Reference Group for Children In Crisis, reviewers at the CDC and NCHS especially Dr. Robert Anderson for his helpful suggestions on interpreting and classifying disease groups and race groups using existing NCHS data. We also thank Prof. Chris Desmond for his comments on early versions of this work. We thank the Imperial College Research Computing Service (https://doi.org/10.14469/ hpc/2232) for providing the computational resources to perform this study; and Zulip for sponsoring team communications through the Zulip Cloud Standard chat app. This study was supported by the Oak Foundation (to LC, LS); the Moderna Charitable Foundation (to OR); the World Health Organisation (to SF); the Engineering and Physical Sciences Research Council (EPSRC) through the EPSRC Centre for Doctoral Training in Modern Statistics and Statistical Machine Learning at Imperial College London and Oxford University (EP/S023151/1 to A. Gandy); the Imperial College London President\u0026rsquo;s PhD Scholarship fund to YC; Imperial College London Undergraduate Research Bursaries to LG and VKM; and London Mathematical Society Undergraduate Research Bursary to DW (URB-2023-86). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOR reports grants from the Bill \u0026amp; Melinda Gates Foundation, the EPSRC, the AIDSFonds, and the NIH during the conduct of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCopyright statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor the purpose of open access, the authors have applied a \u0026lsquo;Creative Commons Attribution\u0026rsquo; (CC BY) license to any Author Accepted Manuscript version arising.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAV, SH and OR designed the study; AV, YC, ST, AB, LG, VKM, DW, SH and OR performed the analysis; YC led coding; LG, VKM, DW, JTU and SF checked analysis and code; AV, LC, LS, FA, GM, JL, LR, RN, CAN, SF, JTU, SH and OR oversaw data interpretation; AV, YC, ST, SH and OR wrote the first draft; All authors discussed the first draft and contributed to the final manuscript.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBhutta ZA, Bhavnani S, Betancourt TS, Tomlinson M, Patel V. 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July 19. https://stacks.cdc.gov/view/cdc/108199\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"nature-portfolio","isNatureJournal":true,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"","title":"Nature Portfolio","twitterHandle":"","acdcEnabled":false,"dfaEnabled":false,"editorialSystem":"ejp","reportingPortfolio":"","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4208475/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4208475/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eImportance: \u003c/strong\u003eDeaths 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: To estimate 2000-2021 prevalence and incidence trends of all-cause orphanhood and caregiver death among children \u0026lt;18, by cause, age, race/ethnicity, and state.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Sources\u003c/strong\u003e: 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData extraction and synthesis\u003c/strong\u003e: 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMain outcome measures\u003c/strong\u003e: 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eFrom 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions and Relevance: \u003c/strong\u003ePolicies, 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.\u003c/p\u003e","manuscriptTitle":"Orphanhood and caregiver death among children in the United States due to all-cause mortality 2000-2021: A Modeling Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-09 13:17:57","doi":"10.21203/rs.3.rs-4208475/v1","editorialEvents":[],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"nature-medicine","isNatureJournal":true,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"nm","sideBox":"Learn more about [Nature Medicine](http://www.nature.com/nm/)","snPcode":"","submissionUrl":"","title":"Nature Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature Research","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"70871592-2c8b-411f-baa3-084373bad0a6","owner":[],"postedDate":"April 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":30438442,"name":"Health sciences/Risk factors"},{"id":30438443,"name":"Health sciences/Diseases"}],"tags":[],"updatedAt":"2025-01-11T08:08:01+00:00","versionOfRecord":{"articleIdentity":"rs-4208475","link":"https://doi.org/10.1038/s41591-024-03343-6","journal":{"identity":"nature-medicine","isVorOnly":false,"title":"Nature Medicine"},"publishedOn":"2025-01-10 05:00:00","publishedOnDateReadable":"January 10th, 2025"},"versionCreatedAt":"2024-04-09 13:17:57","video":"","vorDoi":"10.1038/s41591-024-03343-6","vorDoiUrl":"https://doi.org/10.1038/s41591-024-03343-6","workflowStages":[]},"version":"v1","identity":"rs-4208475","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4208475","identity":"rs-4208475","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}