Abstract
BackgroundBangladesh, India, and Nepal aim for the elimination of Visceral Leishmaniasis (VL), a systemic parasitic infectious disease, as a public health problem by 2020. For decades, male patients have comprised the majority of reported VL cases in this region. By comparing this reported VL sex ratio to the one observed in population-based studies conducted in the Indian subcontinent, we tested the working hypothesis that mainly socio-cultural gender differences in healthcare-seeking behavior explain this gender imbalance.Methodology/Principal findingsWe compared the observed sex ratio of male versus female among all VL cases reported by the health system in Nepal and in the two most endemic states in India with that observed in population-based cohort studies in India and Nepal. Also, we assessed male sex as a potential risk factor for seroprevalence at baseline, seroconversion, and VL incidence in the same population-based data. The male/female ratio among VL cases reported by the health systems was 1.40 (95% CI 1.37–1.43). In the population cohort data, the age- and study site-adjusted male to female risk ratio was 1.27 (95% CI 1.08–1.51). Also, males had a 19% higher chance of being seropositive at baseline in the population surveys (RR 1.19; 95% CI 1.11–1.27), while we observed no significant difference in seroconversion rate between both sexes at the DAT cut-off titer defined as the primary endpoint.Conclusions/SignificanceOur population-based data show that male sex is a risk factor for VL, and not only as a socio-cultural determinant. Biological sex-related differences likely play an important role in the pathogenesis of this disease.
Highlights
Visceral leishmaniasis (VL) is on the verge of being eliminated as a public health problem in Bangladesh, India, and Nepal
The majority of Visceral Leishmaniasis (VL) patients attending the health services are male, and this is usually attributed to unequal access to health care for men and women in this sociocultural context
Thereby we minimized any potential differences in access to health care between both sexes, as every suspect VL case occurring in the community received a full diagnostic work-up, and the research project facilitated transport to treatment centers if needed
Summary
Visceral leishmaniasis (VL) is on the verge of being eliminated as a public health problem in Bangladesh, India, and Nepal. A more recent study in India confirmed the low prioritization of women’s health as an important factor of delayed treatment seeking among females [9] If this is the case in India and Nepal, with a higher proportion of women remaining undiagnosed and underreported, this would be an essential issue to address. Bangladesh, India, and Nepal aim for the elimination of Visceral Leishmaniasis (VL), a systemic parasitic infectious disease, as a public health problem by 2020. Male patients have comprised the majority of reported VL cases in this region By comparing this reported VL sex ratio to the one observed in population-based studies conducted in the Indian subcontinent, we tested the working hypothesis that mainly socio-cultural gender differences in healthcare-seeking behavior explain this gender imbalance
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