TUBERCULOSIS

Gender differentials of pulmonary tuberculosis transmission and reactivation in an endemic area

M-E Jiménez-Corona¹, L García-García¹, K DeRiemer², L Ferreyra-Reyes¹, M Bobadilla-del-Valle³, B Cano-Arellano¹, S Canizales-Quintero¹, A Martínez-Gamboa³, P M Small⁴, J Sifuentes-Osornio³, A Ponce-de-León³

¹ Instituto Nacional de Salud Pública (INSP), Cuernavaca Morelos, México
² Stanford University, Palo Alto, California, USA
³ Instituto Nacional de Ciencias Médicas y de Nutrición "Salvador Zubirán" (INCMNSZ) México, DF, México
⁴ Bill and Melinda Gates Foundation, Seattle, Washington, USA

Correspondence to:
Dr L García-García
Director of the Tuberculosis Unit, Instituto Nacional de Salud Pública, 7^a Cerrada de Fray Pedro de Gante No 50; Col. Sección XVI, Deleg Tlalpan, México, DF México; C.P. 14000; garcigar{at}correo.insp.mx

Background: In most low income countries there are twice as many cases of tuberculosis (TB) reported among men than among women, a difference commonly attributed to biological and epidemiological characteristics as well as socioeconomic and cultural barriers in access to health care. The World Health Organization has encouraged gender specific comparisons in TB rates to determine whether women with TB are less likely than men with TB to be diagnosed, reported, and treated. A study was undertaken to identify gender based differences in patients with pulmonary TB and to use this information to improve TB control efforts.

Methods: Individuals with a cough for more than 2 weeks in southern Mexico were screened from March 1995 to April 2003. Clinical and mycobacteriological information (isolation, identification, drug susceptibility testing and IS6110 based genotyping, and spoligotyping) was collected from those with bacteriologically confirmed pulmonary TB. Patients were treated in accordance with official norms and followed to ascertain treatment outcome, retreatment, and vital status.

Results: 623 patients with pulmonary TB were enrolled. The male:female incidence rate ratio for overall, reactivated, and recently transmitted disease was 1.58 (95% CI 1.34 to 1.86), 1.64 (95% CI 1.36 to 1.98), and 1.41 (95% CI 1.01 to 1.96), respectively. Men were more likely than women to default from treatment (adjusted OR 3.30, 95% CI 1.46 to 7.43), to be retreated (hazard ratio (HR) 3.15, 95% CI 1.38 to 7.22), and to die from TB (HR 2.23, 95% CI 1.25 to 3.99).

Conclusions: Higher rates of transmitted and reactivated disease and poorer treatment outcomes among men are indicators of gender differentials in the diagnosis and treatment of pulmonary TB, and suggest specific strategies in endemic settings.

Abbreviations: AFB, acid fast bacilli; DOTS, directly observed therapy; TB, tuberculosis

Keywords: tuberculosis; gender; epidemiology; molecular; transmission

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