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TB and gender: some of the evidence

This article explores the relationship between gender and tuberculosis (TB), focusing on the sex distribution of TB cases, physiological hypotheses and evidence, and gender-related behavioral patterns. It highlights the importance of collecting accurate disaggregated data and conducting gender-based studies to address the social, cultural, and environmental determinants of health.

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TB and gender: some of the evidence

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  1. TB and gender: some of the evidence Stacie Stender 14 January 2015

  2. Outline • Jhpiego background • Risk factors for TB • Sex distribution • Physiological hypotheses and evidence • Behavioural hypotheses and evidence • Gender related outcomes

  3. Reminder

  4. IJTLD 2008 Special Section

  5. The value of gender studies in TB control can be enhanced by • the ongoing collection of accurate disaggregated data • a balance in the collection and analysis of gender-based studies to capture not only the experiences of men and women but also the dynamism of the social relationships and interactions of other critical social, cultural and environmental determinants of health

  6. Jhpiego: Innovating to Save Lives Jhpiego prevents the needless deaths of women and their families. • Founded 1973 • Affiliate of Johns Hopkins University • Currently working in more than 50 countries • Experience working in 154 countries • More than 1500 employees worldwide

  7. Jhpiego’s Technical Expertise • Jhpiego works on: • Family planning • Maternal and newborn health • Malaria • Cervical cancer • HIV/AIDS and TB • Infection Prevention

  8. Jhpiego’s Approach • Jhpiego saves lives by: • Building local human resource capacity • Working in partnerships with government, NGOs, universities, professional associations and communities • Strengthening health care systems • Developing evidence-based innovations & sharing best practices

  9. Risk factors for TB • HIV • Malnutrition • Diabetes • Alcoholism • Silicosis • Overcrowding • Poverty • Smoking • Male sex

  10. Sex distribution • Varies by geographic location and year. Of 20 high-burden countries with data, median male:female ratio is 1.8:1; only Afghanistan reported a ratio of <1:1 (WHO, 2013) • A study in West Africa found male:female ratios of 2.03:1, with roughly even sex ratios among household contacts and community controls (Lienhardt et al, 2005) • A randomized household prevalence survey of 260,000 individuals in Bangladesh found male:female ratio of 3:1 (Salim et al., 2004) • Male bias dose not arise until puberty

  11. Global age-sex distribution of TB incidence in HIV-negative individuals in 2013 Murray et al., 2014

  12. Extrapulmonary TB (EPTB) is more prevalent in women • In the US, among 253,299 cases, compared with pulmonary TB, extra-pulmonary TB was associated with female sex (OR 1.7; 95% CI, 1.7-1.8). Being female was identified as independent risk factor for EPTB Lin, 2009; Yang, 2004; Kingkaew, 2009; Lowieke, 2006

  13. Tanzania Example • Notification rates: 1.8:1 ratio of male:female* • TB case mortality rate higher among males than females *Neither the prevalence survey nor active case finding efforts have diagnosed more females than expected from the notification data

  14. Gender patterns of tuberculosis testing and disease in South Africa McLaren et al, 2015

  15. HIV is the strongest risk factor for TB, yet despite higher HIV prevalence among women in sub-Saharan Africa, incidence of TB is higher in men

  16. …except among specific populations TB in women 15-24 years of age: in areas of high HIV prevalence, women have TB rates 1.5-2-fold higher than men DeLuca A et al, 2009

  17. Physiology vs. behaviour Physiology Behaviour Primarily related to sex-specific exposure to infection • Biological differences between sexes lead to variable susceptibility Nhamoyebonde and Leslie; JID 2014:209 (Suppl 3)

  18. Physiological effects • Gonads may influence mycobacterial disease in mammals • Male mice more susceptible; less severe disease among castrated; females treated with testosterone increased susceptibility (Yamamoto et al., 1991) • 8.1% of institutionalized mentally ill, medically castrated men died from TB compared with 20.6% of intact males and 15.8% of intact females (Hamilton et al., 1969)

  19. Physiological effects • 7% TB death rate among women who had oophorectomy compared to country rate of 0.7% (Svanberg, 1981) • M. avium complex most common among post-menopausal women(Tsuyuguchi et al., 2001)

  20. Hypothesized physiological mechanisms • X-linked genetics • Differences in immune response and effects of sex hormones • Differences in anatomy • Differences in nutrition

  21. Gender-related behaviour • Differences in social roles, risk behaviors, and activities • Males may travel more frequently; have more social contacts; spend more time in settings that may be conducive to transmission; and work in settings associated with a higher risk for TB, such as mining (Narasimhan et al., 2013; Oni et al, 2012); • Time spent in household – household contact does not have gender bias (Grandjean et al., 2011)

  22. Gender-related behaviour • In many countries smoking is more frequent among men; a correlative analysis of cigarette smoking, sex, and TB suggests that smoking might explain up to one-third of the gender bias observed (Watkins and Plant, 2006) • Prevalence of alcohol consumption higher among men in low-income settings (Nhamoyebonde and Leslie, 2014) • Meta-analysis of 29 surveys conducted in 14 countries suggests access to healthcare not a confounding factor (Borgdorff et al., 2000)

  23. Gender related outcomes

  24. TB treatment outcomes stratified by gender in Ebonyi state, Nigeria, 2011-2012 • Mean age of females lower than males (36.1 vs 40.2) • Of the patients who had sputum smear done after 5 months of treatment, 1.5% of women still had a positive smear compared to 4.3% of men (P=0.02) • Similar treatment success rates • Higher treatment failure rate among men - 2.2% vs 0.7% (P=0.01) • HIV infection appeared to reverse the ‘immunoprotective effect’ of being female Oshi et al., 2014

  25. Gender differences in delays in diagnosis and treatment of TB in Bangladesh • Both bivariate and multivariate analyses revealed longer delays for women than for men in total delay, total diagnostic delay and patients’ delay • Older women and young men were less likely to be diagnosed with TB through the existing TB control interventions, necessitating special drives to enhance case detection in these particular groups. Karim, et al., 2007

  26. Overall • More males than females are diagnosed with TB • Evidence that treatment success rates are better for women than men in many settings (Nigeria, Mexico, India, UK, Malaysia) and equivalent in others (Brazil, Egypt, Syria) • Evidence of better treatment adherence among women than men Gender, locally-specific strategies are needed to improve TB control – limiting transmission is essential

  27. The Three Delays Model of maternal mortality applies to TB & HIV morbidity and mortality Delay in • decision to seek care • reaching care • receiving care Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 1994;38:1091-1110.

  28. TB in Pregnancy Prevalence of latent TB in pregnant women in HIV-endemic areas can be high. • In Tanzania, where antenatal prevalence of HIV was 5%, the prevalence of latent TB in pregnancy was 30% (Sheriff et al, 2010) • High rates of latent TB (49%) have been reported in antenatal clinics in South Africa (Nachega, 2003)

  29. Tuberculosis in pregnancy: an estimate of the global burden of disease among 22 HBC Different epidemiology requires different approaches to TB identification and control: importance of pregnancy status Sugarman et al., 2014

  30. Maternal TB/HIV important risk factor for paediatric TB and mortality, Pune India • HIV-infected mothers have 10-fold increase in TB • Maternal TB/HIV increased risk of postpartum mortality by 2.2 fold and probability of infant death by 3.4 fold 715 HIV-infected pregnant women in Pune, India TB incidence 5/100 pt-yr (24 of 715 HIV+ women) Maternal death aIRR 2.2 p=0.006 Infant death aIRR = 3.4 p=0.02 Gupta A et al., 2007

  31. Programmatic challenges of TB symptom screening in MNH services Kenya South Africa Provider bias of screening women perceived to have a higher risk of TB* Poor clinical staff moral and motivation* High rates of extrapulmonary TB  - harder to screen and diagnose • no routine collection of data in the monthly summary sheets • TB data summary sheet does not specifically capture referrals from ANC *Gounder et al. JAIDS 2011; 57: e77-384

  32. Malawi pilot results

  33. TB control requires implementation of locally-relevant, evidence-based interventions to address the special issues of both genders (including pregnancy among wwomen) and all ages to maximize effective access to the spectrum of essential services

  34. Thank you stacie.stender@jhpiego.org

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