Transcript Jhpiego Overview Slides

TB and gender: some of the evidence
Stacie Stender
14 January 2015
Outline
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Jhpiego background
Risk factors for TB
Sex distribution
Physiological hypotheses
and evidence
 Behavioural hypotheses
and evidence
 Gender related outcomes
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Reminder
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IJTLD 2008 Special Section
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The value of gender studies in TB control can be
enhanced by
1.the ongoing collection of accurate disaggregated
data
2.a balance in the collection and analysis of genderbased studies to capture not only the experiences
of men and women but also the dynamism of the
social relationships and interactions of other critical
social, cultural and environmental determinants of
health
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Jhpiego: Innovating to Save Lives
Jhpiego prevents the needless deaths
of women and their families.
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Founded 1973
Affiliate of Johns Hopkins University
Currently working in more than 50 countries
Experience working in 154 countries
More than 1500 employees worldwide
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Jhpiego’s Technical Expertise
 Jhpiego works on:
 Family planning
 Maternal and newborn health
 Malaria
 Cervical cancer
 HIV/AIDS and TB
 Infection Prevention
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Jhpiego’s Approach
 Jhpiego saves lives by:
 Building local human resource
capacity
 Working in partnerships with
government, NGOs, universities,
professional associations and
communities
 Strengthening health care systems
 Developing evidence-based
innovations & sharing best practices
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Risk factors for TB
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HIV
Malnutrition
Diabetes
Alcoholism
Silicosis
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Overcrowding
Poverty
Smoking
Male sex
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Sex distribution
 Varies by geographic location and year. Of 20 highburden countries with data, median male:female ratio is
1.8:1; only Afghanistan reported a ratio of <1:1 (WHO,
2013)
 A study in West Africa found male:female ratios of
2.03:1, with roughly even sex ratios among household
contacts and community controls (Lienhardt et al, 2005)
 A randomized household prevalence survey of 260,000
individuals in Bangladesh found male:female ratio of 3:1
(Salim et al., 2004)
 Male bias dose not arise until puberty
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Global age-sex distribution of TB incidence in
HIV-negative individuals in 2013
Murray et al., 2014
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Extrapulmonary TB (EPTB) is more
prevalent in women
 In the US, among 253,299 cases, compared with
pulmonary TB, extra-pulmonary TB was
associated with female sex (OR 1.7; 95% CI,
1.7-1.8). Being female was identified as
independent risk factor for EPTB
Lin, 2009; Yang, 2004;
Kingkaew, 2009; Lowieke, 2006
Tanzania Example
Male
Female
49%
51%
TB cases, all 59%
forms
41%
Population
Life
expectancy
58 years 61 years
 Notification rates:
1.8:1 ratio of
male:female*
 TB case mortality rate
higher among males
than females
*Neither the prevalence survey nor active case
finding efforts have diagnosed more females than
expected from the notification data
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Gender patterns of tuberculosis testing and
disease in South Africa
McLaren et al, 2015
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HIV is the strongest risk factor for TB, yet despite
higher HIV prevalence among women in sub-Saharan
Africa, incidence of TB is higher in men
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…except among specific populations
TB in women 15-24 years of age: in areas of high HIV
prevalence, women have TB rates 1.5-2-fold higher than men
DeLuca A et al, 2009
Physiology vs. behaviour
Physiology
 Biological differences
between sexes lead to
variable susceptibility
Behaviour
 Primarily related to sexspecific exposure to
infection
Nhamoyebonde and Leslie; JID
2014:209 (Suppl 3)
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Physiological effects
 Gonads may influence mycobacterial disease in
mammals
 Male mice more susceptible; less severe disease
among castrated; females treated with testosterone
increased susceptibility (Yamamoto et al., 1991)
 8.1% of institutionalized mentally ill, medically
castrated men died from TB compared with 20.6%
of intact males and 15.8% of intact females
(Hamilton et al., 1969)
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Physiological effects
 7% TB death rate among women who had
oophorectomy compared to country rate of 0.7%
(Svanberg, 1981)
 M. avium complex most common among postmenopausal women (Tsuyuguchi et al., 2001)
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Hypothesized physiological mechanisms
 X-linked genetics
 Differences in immune response and effects of
sex hormones
 Differences in anatomy
 Differences in nutrition
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Gender-related behaviour
 Differences in social roles, risk behaviors, and
activities
 Males may travel more frequently; have more social
contacts; spend more time in settings that may be
conducive to transmission; and work in settings
associated with a higher risk for TB, such as mining
(Narasimhan et al., 2013; Oni et al, 2012);
 Time spent in household – household contact does
not have gender bias (Grandjean et al., 2011)
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Gender-related behaviour
 In many countries smoking is more frequent among
men; a correlative analysis of cigarette smoking,
sex, and TB suggests that smoking might explain
up to one-third of the gender bias observed
(Watkins and Plant, 2006)
 Prevalence of alcohol consumption higher among
men in low-income settings (Nhamoyebonde and
Leslie, 2014)
 Meta-analysis of 29 surveys conducted in 14
countries suggests access to healthcare not a
confounding factor (Borgdorff et al., 2000)
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Gender related outcomes
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TB treatment outcomes stratified by gender
in Ebonyi state, Nigeria, 2011-2012
 Mean age of females lower than males (36.1 vs 40.2)
 Of the patients who had sputum smear done after 5
months of treatment, 1.5% of women still had a
positive smear compared to 4.3% of men (P=0.02)
 Similar treatment success rates
 Higher treatment failure rate among men - 2.2% vs
0.7% (P=0.01)
 HIV infection appeared to reverse the
‘immunoprotective effect’ of being female
Oshi et al., 2014
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Gender differences in delays in diagnosis
and treatment of TB in Bangladesh
 Both bivariate and multivariate analyses
revealed longer delays for women than for men
in total delay, total diagnostic delay and patients’
delay
 Older women and young men were less likely to
be diagnosed with TB through the existing TB
control interventions, necessitating special
drives to enhance case detection in these
particular groups.
Karim, et al., 2007
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Overall
 More males than females are diagnosed with TB
 Evidence that treatment success rates are better
for women than men in many settings (Nigeria,
Mexico, India, UK, Malaysia) and equivalent in
others (Brazil, Egypt, Syria)
 Evidence of better treatment adherence among
women than men
Gender, locally-specific strategies are
needed to improve TB control – limiting
transmission is essential
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The Three Delays Model of maternal mortality
applies to TB & HIV morbidity and mortality
Delay in
1) decision to seek care
2) reaching care
3) receiving care
Thaddeus S, Maine D. Too far to walk: maternal
mortality in context. Soc Sci Med 1994;38:1091-1110.
TB in Pregnancy
Prevalence of latent TB in pregnant women in HIVendemic areas can be high.
 In Tanzania, where antenatal prevalence of HIV was
5%, the prevalence of latent TB in pregnancy was
30% (Sheriff et al, 2010)
 High rates of latent TB (49%) have been reported in
antenatal clinics in South Africa (Nachega, 2003)
Tuberculosis in pregnancy: an estimate of
the global burden of disease among 22 HBC
Country
Mean
Rate per 1000 pregnant women
South Africa
8400
10.3
Zimbabwe
2400
7.9
DR Congo
16200
7.2
Afghanistan
6100
7.2
Vietnam
900
0.8
Brazil
800
0.4
Different epidemiology requires different
approaches to TB identification and control:
importance of pregnancy status
Sugarman et al., 2014
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Maternal TB/HIV important risk factor for
paediatric TB and mortality, Pune India
 HIV-infected mothers have 10-fold increase in TB
 Maternal TB/HIV increased risk of postpartum mortality by
2.2 fold and probability of infant death by 3.4 fold
Maternal death
aIRR 2.2
p=0.006
Infant death
aIRR = 3.4
p=0.02
715 HIV-infected
pregnant women in
Pune, India
TB incidence 5/100 pt-yr
(24 of 715 HIV+ women)
Gupta A et al., 2007
Programmatic challenges of TB symptom
screening in MNH services
Kenya
 no routine collection of
data in the monthly
summary sheets
 TB data summary sheet
does not specifically
capture referrals from
ANC
South Africa
 Provider bias of
screening women
perceived to have a
higher risk of TB*
 Poor clinical staff moral
and motivation*
 High rates of
extrapulmonary TB harder to screen and
diagnose
*Gounder et al. JAIDS 2011; 57: e77-384
Malawi pilot results
Total ANC Attendees
Women screened for signs/symptoms of TB in
ANC
5,474
3,920 (71.6%)
Women with signs/symptoms of TB
68 (1.7%)
Women with signs/symptoms of TB diagnosed
with TB
4 (5.9%)
Women with signs/symptoms of TB diagnosed
with HIV
8 (11.8%)
Number needed to screen to find one case
1369
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TB control requires implementation of locallyrelevant, evidence-based interventions to address
the special issues of both genders (including
pregnancy among wwomen) and all ages to
maximize effective access to the spectrum of
essential services
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Thank you
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