Sex Differences in Tuberculosis Burden and Notifications in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis



Tuberculosis (TB) case notification rates are usually higher in men than in women, but notification data are insufficient to measure sex differences in disease burden. This review set out to systematically investigate whether sex ratios in case notifications reflect differences in disease prevalence and to identify gaps in access to and/or utilisation of diagnostic services.

Methods and Findings

In accordance with the published protocol (CRD42015022163), TB prevalence surveys in nationally representative and sub-national adult populations (age ≥ 15 y) in low- and middle-income countries published between 1 January 1993 and 15 March 2016 were identified through searches of PubMed, Embase, Global Health, and the Cochrane Database of Systematic Reviews; review of abstracts; and correspondence with the World Health Organization. Random-effects meta-analyses examined male-to-female (M:F) ratios in TB prevalence and prevalence-to-notification (P:N) ratios for smear-positive TB. Meta-regression was done to identify factors associated with higher M:F ratios in prevalence and higher P:N ratios. Eighty-three publications describing 88 surveys with over 3.1 million participants in 28 countries were identified (36 surveys in Africa, three in the Americas, four in the Eastern Mediterranean, 28 in South-East Asia and 17 in the Western Pacific). Fifty-six surveys reported in 53 publications were included in quantitative analyses. Overall random-effects weighted M:F prevalence ratios were 2.21 (95% CI 1.92–2.54; 56 surveys) for bacteriologically positive TB and 2.51 (95% CI 2.07–3.04; 40 surveys) for smear-positive TB. M:F prevalence ratios were highest in South-East Asia and in surveys that did not require self-report of signs/symptoms in initial screening procedures. The summary random-effects weighted M:F ratio for P:N ratios was 1.55 (95% CI 1.25–1.91; 34 surveys). We intended to stratify the analyses by age, HIV status, and rural or urban setting; however, few studies reported such data.


TB prevalence is significantly higher among men than women in low- and middle-income countries, with strong evidence that men are disadvantaged in seeking and/or accessing TB care in many settings. Global strategies and national TB programmes should recognise men as an underserved high-risk group and improve men’s access to diagnostic and screening services to reduce the overall burden of TB more effectively and ensure gender equity in TB care.

Author Summary

Why Was This Study Done?

  • Global health initiatives have tended to treat “gender” issues in health as being synonymous with women’s health. However, for infectious diseases, policy and practice need to be guided by epidemiological data and consideration of transmission dynamics.
  • Many more men than women are diagnosed with, and die from, tuberculosis (TB) globally.
  • Data from population-level surveys for undiagnosed TB, carried out in a number of countries during the last two decades, can be combined with data on diagnosed (notified) cases to provide more complete insight into the magnitude and nature of sex differences in TB.

What Did the Researchers Do and Find?

  • Surveys conducted to identify adult cases of TB in communities in low- and middle-income countries between 1993 and 2016 were analysed by sex.
  • TB prevalence among men was over twice as high as among women and was substantially higher even in settings with high HIV prevalence.
  • Case notification rates were also higher for men, and the ratio of prevalent-to-notified cases of TB—an indication of how long patients take to be diagnosed, on average—was 1.5 times higher among men than women, suggesting that men are less likely than women to achieve a timely diagnosis.

What Do These Findings Mean?

  • Given that undiagnosed TB is the key driver for transmission in communities, our data show that greater effort and investment are needed to improve awareness of TB in men as an individual and public health issue.
  • Policies on gender and TB should place greater emphasis on the high burden of disease in men and the need to invest in male-friendly diagnostic and screening services, with the aim of reducing undiagnosed TB.
By |2018-07-10T11:42:02+00:00July 10th, 2018|

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