Gender Disparities in Tuberculosis Epidemiology and Treatment Outcomes

Global data consistently demonstrate that men experience higher rates of active tuberculosis (TB), more severe pulmonary disease and poorer treatment outcomes than women. This disparity arises from a complex interplay of biological factors—such as sex hormone–modulated immune responses—and socio‐cultural drivers including differential exposure to risks, health‐seeking behaviours and access to care. Men often present later in the course of disease, with more extensive lung pathology and a higher likelihood of cavitation, which in turn increases transmission. Women, by contrast, are more prone to extrapulmonary forms during reproductive ages and tend to achieve faster bacteriological conversion under standard regimens. Yet women may face barriers related to stigma or caregiving responsibilities, influencing latent infection detection and adherence. A comprehensive understanding of these patterns is critical for tailoring public health strategies, improving case finding amongst men, and ensuring gender‐sensitive interventions to advance equity in TB control worldwide.

Research from Nature Portfolio

Recent analyses of a national TB registry revealed that the proportion of extrapulmonary TB differs by sex across the lifespan, with women in their forties to sixties exhibiting a relative predisposition to extrapulmonary manifestations, while men consistently dominate pulmonary case notifications. This work further showed that male patients in mid‐life were more likely to present with cavitation and positive sputum smears, reflecting sex‐specific patterns in disease severity. Foundational experimental studies in a common murine model have since illuminated mechanistic underpinnings of male susceptibility: male mice developed accelerated disease progression, higher bacterial loads and exacerbated inflammatory lung pathology, linked to differential cytokine profiles and impaired macrophage activation. Together, these laboratory and registry investigations bridge clinical observations with immune‐pathological pathways, underscoring the importance of sex as a biological variable in TB research.

Gender Disparities in Tuberculosis Epidemiology and Treatment Outcomes publication trend

The graph below shows the total number of articles in gender disparities in tuberculosis epidemiology and treatment outcomes across all publications each year (not limited to Nature Index journals).

Technical terms

Extrapulmonary tuberculosis: Disease caused by Mycobacterium tuberculosis affecting organs other than the lungs, such as lymph nodes or bones.

Cavitation: Formation of air‐filled cavities in lung tissue due to necrosis, often associated with higher bacillary loads and transmission risk.

Culture conversion: Transition from positive to negative mycobacterial culture in respiratory specimens, indicating response to therapy.

Latent tuberculosis infection (LTBI): A state in which individuals harbour live bacilli without clinical disease or contagiousness, detectable only by immunological tests.

Sex hormones: Biochemical mediators (e.g., testosterone, oestrogen) that modulate immune cell function and influence susceptibility to infection.

References

1. Sex Differences in Tuberculosis Burden and Notifications in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis. PLOS Medicine (2016).
2. The Influence of Sex Steroid Hormones in the Immunopathology of Experimental Pulmonary Tuberculosis. PLOS ONE (2014).
3. Differential effects of sex on tuberculosis location and severity across the lifespan. Scientific Reports (2023).
4. Early Release - Influence of Sex and Sex-Based Disparities on Prevalent Tuberculosis, Vietnam, 2017–2018 - Volume 29, Number 5—May 2023 - Emerging Infectious Diseases journal - CDC. Emerging Infectious Diseases (2023).
5. Gender differences in tuberculosis treatment outcomes: a post hoc analysis of the REMoxTB study. BMC Medicine (2018).