Abstract
Globally, men have a higher epidemiologic burden of tuberculosis (incidence, prevalence, mortality) than women do, possibly due to differences in disease incidence, treatment initiation, self-cure, and/or untreated-tuberculosis mortality rates. Using a simple, sex-stratified compartmental model, we employed a Bayesian approach to explore which factors most likely explain men’s higher burden. We applied the model to smear-positive pulmonary tuberculosis in Vietnam (2006–2007) and Malawi (2013–2014). Posterior estimates were consistent with sex-specific prevalence and notifications in both countries. Results supported higher incidence in men and showed that both sexes faced longer durations of untreated disease than estimated by self-reports. Prior untreated disease durations were revised upward 8- to 24-fold, to 2.2 (95% credible interval: 1.7, 2.9) years for men in Vietnam and 2.8 (1.8, 4.1) years for men in Malawi, approximately a year longer than for women in each country. Results imply that substantial sex differences in tuberculosis burden are almost solely attributable to men’s disadvantages in disease incidence and untreated disease duration. The latter, for which self-reports provide a poor proxy, implies inadequate coverage of case-finding strategies. These results highlight an urgent need for better understanding of gender-related barriers faced by men and support the systematic targeting of men for screening.
Highlights
Substantial gender disparity exists in the burden of tuberculosis, as indicated by incidence, prevalence and mortality estimates
Individuals are added to the pool of prevalent cases upon development of incident disease, and disease incidence rates could differ between men and women due to gender differences in exposure to infection and/or susceptibility to disease
Gender-specific tuberculosis incidence rates were based on 2015 World Health Organization (WHO) estimates of incident cases [17] and population estimates from the United Nations Department of Economic and Social Affairs [18, 19]
Summary
Substantial gender disparity exists in the burden of tuberculosis, as indicated by incidence, prevalence and mortality estimates. Prevalence surveys, which provide the most reliable source of data on tuberculosis burden [2], show even greater gender disparity, with a two-fold higher underlying burden of undiagnosed disease among men than among women in low- and middle-income countries [3]. Comparisons of these two measures using prevalence-tonotification ratios [4] imply that gaps in the detection and reporting of new cases are greater for men than for women [3, 5]. Little attention is placed on men’s burden of disease in current gender policies and programs [6,7,8,9], addressing gender imbalances in tuberculosis will benefit men, women and children
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