INT J TUBERC LUNG DIS 4(2):123–132

© 2000 IUATLD

Gender and tuberculosis: a comparison of prevalence

surveys with notification data to explore sex differences
in case detection

M. W. Borgdorff,* N. J. D. Nagelkerke,* C. Dye,† P. Nunn‡

* Royal Netherlands Tuberculosis Association, The Hague, The Netherlands; † Communicable Diseases Prevention
and Control, World Health Organization, ‡ Stop TB Initiative, World Health Organization, Geneva, Switzerland

SUMMARY

OBJECTIVE: To explore whether lower tuberculosis
notification rates among women are due to a reduced
access to health care, particularly diagnostic services, for
women.
M E T H O D S : Age- and sex-specific tuberculosis preva-
lence rates of smear-positive tuberculosis were obtained
from tuberculosis prevalence surveys reported to the
WHO or published in the literature. Age- and sex-
specific notification rates from the same countries in
1996 were used.
R E S U L T S : Prevalence data and notifications from 29 sur-
veys in 14 countries were used. Notification rates varied
strongly among countries, but the female/male ratio was
below 1 and decreased with increasing age in almost all.
The female/male (F/M) prevalence ratios were less than
0.5 in surveys in the South-East Asia and Western Pacific
Region, and approximately 1 in the African Region.
C O N C L U S I O N : In most countries the F/M sex ratio in
prevalent cases was similar or lower than that in notified
cases, suggesting that F/M differences in notification
rates may be largely due to epidemiological differences
and not to differential access to health care. However,
available data are limited as the prevalence surveys in
Africa were carried out many years ago, and in Asia
notification rates may be distorted by a large private sec-
tor with deficiencies in notification.
K E Y W O R D S : tuberculosis; gender; prevalence surveys;
notification; case detection

ANNUALLY approximately 2 million people die per se or to differences in exposure as a consequence

from tuberculosis,1 yet effective chemotherapy could
cure a vast majority of cases and, in combination with
high case detection rates, lead to eventual elimination
from the community of the role of Mycobacterium
tuberculosis as a major pathogen. This has been the
experience in many industrialised countries. To date,
however, low detection rates and poor cure rates have
prevented a repetition of this achievement in many
developing countries.2 Understanding factors which
impact on case detection and cure rates is therefore
key in effective disease control. One conspicuous fac-
tor is gender: notification rates of tuberculosis are
higher in men than in women in most countries.3
Differences in notification rates may reflect gender
differences in TB epidemiology, and/or gender differ-
ences in access to care.4–6 If the latter possibility were
true, this would need urgent redress. One way to
either corroborate or vitiate this hypothesis is by
studying the epidemiology of TB in relation to gender.
Gender differences in tuberculosis epidemiology
may arise either as a consequence of differences in
biological functioning, i.e., as a consequence of sex
of differences in the societal roles of men and women,
i.e., to gender differences. Sometimes these differ-
ences are hard to distinguish. For example, observed
differences in progression from infection to disease4–6
may be due to differences in the balance between bio-
logical need for (micro) nutrients and the gender-
specific access to these nutrients provided by society.
Evidence seems to suggest that women of repro-
ductive age have a higher disease progression than
men.4 Thus, lower notification rates for women
appear not to be due to a lower disease progression.
Hence, differences in notification rates appear to con-
stitute prima facie evidence for differences in access to
health care. Such differences, if real, would form a
major source of gender inequity.
For various diseases other than tuberculosis, gen-
der differences in access to health care have been
described.7,8 For tuberculosis, differences in access to
diagnosis and treatment are found in some, but not
all, studies. For instance, in a recent study on the
diagnosis of tuberculosis by sputum smear micros-
copy in Benin, Malawi, Nicaragua, and Senegal, it

Correspondence to: Dr Martien W Borgdorff, Royal Netherlands Tuberculosis Association, P O Box 146, 2501 CC The
Hague, The Netherlands. Tel: (31) 70 416 7222. Fax: (31) 70 358 4004. e-mail: martien.borgdorff@kncvtbc.nl
Article submitted 17 May 1999. Final version accepted 14 October 1999.
[A version in French of this article is available from the IUATLD Secretariat in Paris.]
124 The International Journal of Tuberculosis and Lung Disease

Table 1 List of prevalence surveys reviewed

Cases by Notification
Survey age and data Accept/
Country year(s) Scope sex* present? Reject Ref
AFRO
Ghana 1957 National Y Y A 12
Kenya Nairobi 1958–1959 Regional Y Y A 13
Kenya Not-Nairobi 1958–1959 Regional Y Y A 14
Gambia 1958–1959 National N R 15
Liberia 1959–1960 National N R 16
Malawi 1960 National N R 17
Mauritius 1957–1958 National Y N R 18
Mozambique 1961 Regional Y Y A 19
Nigeria 1973 Regional N R 20
South Africa (Bophuthatswana) 1980 Regional N R 21
South Africa (KwaZulu) 1974 Regional N R 22
South Africa (Transkei) 1982 Regional N R 23
South Africa (Transkei) 1977 Regional N R 24
South Africa (Transkei) 1972 Regional N R 25
Sierra Leone 1958 National Y Y A 26
Somalia 1956 National N R 27
Tanzania 1957 Regional Y Y A 28
Uganda 1958 National Y Y A 29
Zambia 1980 Regional N R 30
EMRO
Pakistan 1959–1961 National N R 31
Syria 1960 Regional Y Y A 32
Tunisia 1961 Regional Y N R 33
SEARO
Bangladesh 1973 National Y Y A 34
Bangladesh 1987 National Y Y A 35
India (South) rural 1950–1955 Regional Y Y A 36
India Tumkur 1960–1961 Regional Y Y A 37
India (South) 1961–1977 Regional Y Y A 38
India Chingleput 1968–1980 Regional Y Y A 39
India Tumkur 1972–1973 Regional Y Y A 40
India Kashmir 1978 Regional N R 41
India Bangalore 1979 Regional N R 42
India (South) 1981–1983 Regional Y Y A 43
India Bangalore 1984–1986 Regional Y Y A 44
India Review TB in workers 1996 Y Y R 45
Indonesia East Kalimantan 1989–1990 Regional N R 46
(continued)

was found that the number of sputum smears exam-
ined was similar among women and men.9 The higher
number of positive sputum smears among men
reflected a higher prevalence of tuberculosis among
suspected cases.9 Whether women and men had equal
access, given the presence of symptoms, could not be
answered by the study, as it was not determined
whether the presence of symptoms was similar among
men and women. A study in Nepal comparing active
and passive case-finding methods found a female-to-
male ratio of 1:1.2 in active tuberculosis case-finding
and of 1:2.6 in self-referred patients, suggesting an
access problem among women.10 Another study in
Nepal found that special ‘microscopy camps’ bring-
ing diagnostic services closer to the population also
detected a significantly higher percentage of women
than did routine services.11 It seems that this issue
merits further investigation.
This paper aims to determine to what extent gender-
related differences in tuberculosis notification rates can
be attributed to gender-related differences in the prev-
alence of disease, and to what extent to gender-related
differences in access to public TB care, by comparing
TB prevalence data with TB notification data.
METHODS
We restrict our attention to direct sputum smear-pos-
itive pulmonary tuberculosis, as sputum smear micros-
copy is the most widely used and available diagnostic
tool. Thus, tuberculosis always refers to smear-positive
tuberculosis unless stated otherwise.
Data sources
Notification rates of new smear-positive tuberculosis
cases in 1996 by age, sex, country and World Health
Organization (WHO) region have been published.3
Tuberculosis prevalence surveys were obtained from
the published literature and from unpublished reports
available at the WHO. The list of surveys identified is
presented in Table 1. Surveys carried out in a part of
a country only were included and treated as if they
 Gender and tuberculosis 125

Table 1 (continued)

Cases by Notification
Survey age and data Accept/
Country year(s) Scope sex* present? Reject Ref
SEARO
Indonesia West Nusa Tenggara 1991–1992 Regional N R 47
Indonesia West Java 1992–1993 Regional N R 48
Indonesia Oost Java 1992–1993 Regional N R 49
Indonesia West Sumatra 1994–1995 Regional N R 50
Myanmar 1972 National N R 51
Sri Lanka 1970–1971 National N R 52
WPRO
China Taiwan Province 1957–1958 Regional Y Y A 53
China 1990 National Y Y A 54
China 1984–1985 National N Y R 55
Japan 1953 National N R 56
Japan 1953 National N R 57
Japan 1953-1958 National N R 58
Japan 1954 National N R 59
Japan 1958 National N R 60
Japan 1963 National N R 61
Japan 1964 National N R 62
Republic of Korea 1965 National N R 63
Republic of Korea 1970 National Y Y R† 64
Republic of Korea 1975 National N R 65
Republic of Korea 1980 National N R 66
Republic of Korea 1985 National Y Y R† 67
Republic of Korea 1990 National Y Y A 68
Republic of Korea 1995 National Y Y A 69
Malaysia West 1970 Regional Y Y A 70
Philippines 1981–1983 National Y Y A 71
Philippines 1997 National Y Y A 72
Samoa 1975 National Y Y A 73
Vietnam 1962 Regional N R 74
AMRO
Colombia 1988 Regional N R 75
EURO
Turkey 1971 Regional Y N R 76
* Smear-positive cases only.
† From Korea only the latest two surveys were included (1990 and 1995), as the prevalence survey methodology was similar in all surveys (representative national

samples) and these two were nearest in time to the notification rates used (1996).
AFRO  African Regional Office; EMRO  Eastern Mediterranean Regional Office; SEARO  South-East Asian Regional Office; WPRO  Western Pacific
Regional Office; AMRO  American Regional Office; EURO  European Regional Office.

were national surveys. Surveys were excluded from
analysis if they did not provide a breakdown of prev-
alence rates by age and sex. If no notification data
were available by age and sex, these countries were
excluded from the analysis as well. For Korea only the
two most recent (1990, 1995) surveys were included as
they were national and considered adequate for the
prevalence situation near the time of notification. All
other surveys were accepted (Table 1). All included
surveys used statistical sampling methods (e.g., cluster,
multi-stage) to ensure that the sample would be repre-
sentative for the population under consideration.
Data analysis
The ratio of TB notification rates among women and
men was calculated by age group and summarised as
age-standardised rate ratios. Prevalence surveys
turned out to be highly heterogeneous in the age
groups used. In order to allow comparison by age and
sex of results from prevalence surveys and notifica-
tion data, prevalence survey results were re-grouped
into the age groups used in the notification data: 15–
24, 25–34, 35–44, 45–54, 55–64, 65. Regrouping
was done using the assumption that the population
examined and cases found were distributed evenly
over the age range reported. For instance, if the sur-
vey reported results on the age group 20–29, numbers
were divided equally over the age groups 15–24 and
25–34. The age group below 15 years was excluded
as very few smear-positive cases are found at these
ages. As the age group of 65 years and older was fre-
quently not covered by the prevalence surveys, this
group was excluded to facilitate comparisons between
countries.
Though prevalence surveys covered a long period
(from the late 1950s to 1997), for comparison with
the notification data it was assumed that the relative
age and sex distribution of prevalent cases did not
change over this period. However, in order to assess
the effect of the HIV/AIDS epidemic on the sex ratio
of tuberculosis cases, we explored changes of the sex
ratios in notification data over the past 6–9 years in
Kenya, Malawi, and Tanzania. Over this time period,
there has been a strong increase in HIV prevalence
126 The International Journal of Tuberculosis and Lung Disease

and in the number of notified tuberculosis cases in

15–64

0.6
0.6
0.7
0.6
0.6
0.7

0.5

0.4
0.5

0.6
0.5
0.5
0.3
8.3
these three countries. All three countries have a well-
established tuberculosis surveillance system.

65

0.2
0.3
0.2
0.3
0.2
0.4

0.5

0.1
0.2

0.2
0.4
0.3
0.3
0.0
Notified incident cases derive from the population
of prevalent cases. Prevalent TB cases are diagnosed

55–64
and notified at a certain rate, which may vary by age

0.4
0.4
0.3
0.5
0.4
0.5

0.6

0.2
0.2

0.3
0.3
0.4
0.2
0.0
Female/Male ratio
and sex. We will refer to this rate as patient detection
rate (PDR). For those countries from which preva-

45–54

0.4
0.4
0.5
0.5
0.4
0.5

0.5

0.3
0.3

0.4
0.3
0.4
0.3
n.d
lence survey reports were available for analysis, we
estimated these (age- and sex-specific) patient detec-

35–44
tion rates as:

n.d.
0.5
0.4
0.7
0.7
0.5
0.6

0.5

0.4
0.3

0.6
0.3
0.4
0.3
PDR  [notification rate]/[prevalence rate].

25–34

n.d.
The PDR among females was divided by the corre-

0.7
0.6
0.9
0.6
0.7
0.8

0.4

0.5
0.5

0.8
0.5
0.5
0.4
sponding male PDR for each age group. The resulting
rate ratios were used as a measure for age-specific

15–24
Notification rates (per 100 000) of smear-positive tuberculosis by age, sex, and country in countries with prevalence survey report*

n.d.
0.8
0.9
0.9
0.8
0.9
1.2

0.5

0.7
0.7

0.9
0.9
0.7
0.4

AFRO  African Regional Office; EMRO  Eastern Mediterranean Regional Office; SEARO  South-East Asian Regional Office; WPRO  Western Pacific Regional Office.
gender-related differences in notification and by impli-
cation as evidence for differences in access to public

15–64
TB care.

123
17
86
89
72
97

12

13
19
31

18
6
1

0
To arrive at an overall (i.e., not age-specific) rate
ratio we used a crude patient detection rate ratio and
65

15
26
23
31
46
61

14

10
51
60
2
0

1
0
two standardised rate ratios obtained by direct and in-
direct standardisation. For direct standardisation we
55–64

120
17
53
60
49
81

17

13
18
47
6
0

0
0
used, arbitrarily, the population of India in 1991 as
the reference population to which notification rates
and prevalence rates were applied. For indirect stan-
45–54

138
19
69
90
61
87

14

12
13
42

40
7
0

1
dardisation, the expected annual number notified—
Female

E(ann)—from the prevalence survey sample was cal-

35–44

culated for each age group, using age-specific notifica-

113
103
110
149
23
79

12
13
29

29
9

7
1

0
tion rates in the total population. The gender-specific
total E(ann) was then divided by the total number of
25–34

125
112

135
158
21

93

10

15
20
29

30
8
1

0
prevalent cases observed in the prevalence survey to
arrive at a gender-specific PDR. The female-to-male
15–24

ratios of these PDRs were presented as indirectly

10
76
64
49
67
74

13

13
24
25
4
1

0
0
standardised age-adjusted rate ratios.
15–64

145
129
116
170
176
31

24

15

21
38
69
1

1
2

RESULTS
Reports of 69 prevalence surveys were obtained,12–76
65

107

186
163

114
238
66
84

93

29

23

39

67
1

* Source: reference 3. Combined age groups (15-64) are standardised for age.

36 of which provided a breakdown by age and sex

(Table 1). From five countries, no notification data
55–64

121
181

212
231

134
49

92

28

28

38
72

25
2

were available by age and sex, leaving 31 surveys

from 14 countries (Table 1). As only the two most
45–54

recent surveys were used for Korea, only 29 surveys

156
179
133
211
256

105
47

25

21

28
47
2

2
0

were actually used for analysis.

Male

Notification rates of smear-positive tuberculosis

35–44

179
171
154
243
248
44

17

20

22
39
74
2

1
0

per 100 000 population by age and sex in these 14

countries showed a large variation, ranging from 0.7
25–34

to 176 among men, and from 0.2 to 61 among

202
127
156
206
206
29

26

15

19
36
63
1

1
0

women (Table 2). The female/male ratio was less than

1 in all countries except Samoa. The female/male
15–24

notification rate ratio decreased with increasing age

71
13
82

63
72
64

25

15
27
38
5
1

0
0

in all countries except Syria (Table 2).

From Table 3 it appears that in Kenya, Malawi, and
Mozambique
Sierra Leone

Bangladesh

Philippines

Tanzania the HIV epidemic, although accounting for an

Tanzania

Malaysia
Age group

Uganda

overall substantial increase in TB case-load, has led to

Samoa
Ghana
Kenya

China
Korea
Table 2

India
Syria
SEARO

WPRO
EMRO

only a minor shift in the female/male notification ratio.

AFRO

Crude prevalence rates of tuberculosis varied

 Gender and tuberculosis 127

Table 3 Gender specific notification rates per 100,000 population in Tanzania (1987 and 1996),
Kenya (1989 and 1996), and Malawi (1990 and 1996)*

Country
Age group Male Female F/M ratio Male Female F/M ratio
1989 1996
Kenya
15–24 37 26 0.7 82 76 0.9
25–34 89 44 0.5 202 125 0.6
35–44 95 42 0.4 171 79 0.5
45–54 99 59 0.6 179 69 0.4
55–64 105 55 0.5 181 53 0.3
65 78 34 0.4 107 26 0.2

1990 1996
Malawi
15–24 44 57 1.3 59 93 1.6
25–34 139 114 0.8 218 179 0.8
35–44 164 104 0.6 236 164 0.7
45–54 162 91 0.6 197 114 0.6
55–64 139 62 0.4 137 69 0.5
65 108 35 0.3 96 25 0.3

1987 1996
Tanzania
15–24 47 30 0.6 71 67 0.9
25–34 130 54 0.4 206 135 0.7
35–44 147 61 0.4 243 110 0.5
45–54 160 66 0.4 211 87 0.4
55–64 137 58 0.4 212 81 0.4
65 67 21 0.3 186 46 0.2
* Sources: WHO report for 1996 notification data. Annual reports of National Tuberculosis Programmes of Kenya,
Malawi and Tanzania for earlier (1990) notification data.

strongly between surveys, ranging from 0.5 to 16.2
per 1000 among men and from 0.0 to 8.7 per 1000
among women (Table 4). The crude female/male
prevalence ratio varied considerably between surveys,
which is likely to be due in part to the small sample
size in some of the surveys. When sex ratios are sum-
marised by WHO region, they are found to be
approximately 0.3 in South-East Asia (SEARO: India
and Bangladesh), approximately 0.5 in the Western
Pacific region (WPRO: China, Korea, Malaysia, Phil-
ippines, Samoa), and approximately 1.0 in sub-
Saharan Africa (AFRO: Ghana, Kenya, Mauritius,
Mozambique, Sierra Leone, Tanzania, Uganda) (Table
4). Age-adjusted prevalence ratios were similar to the
crude numbers.
On the assumption that notified cases arise at a
certain rate from prevalent cases, patient detection
rates (Table 5) and their confidence intervals (Figure)
were calculated. The (directly and indirectly) standar-
dised female/male ratios of PDRs were well above 1
in India (SEARO). Thus, female cases appeared more
likely to be notified than male cases. The rate ratio
was somewhat higher than 1 in WPRO and below 1
in various countries in AFRO. If the TB situation is
steady, and if all cases were eventually notified, the
PDR would be the inverse of the duration of illness
before diagnosis. A PDR of 50/100 would thus corre-
spond to a duration of illness of 2 years. In many
countries these PDRs were well below 50/100, imply-
ing that many cases may not have been notified. This
applied in particular to India and the Philippines,
which had PDRs of less than 1/100 (Table 5).
DISCUSSION
A striking feature of TB, which is apparent in preva-
lence surveys from most parts of the world, is that TB
is more a disease of men than of women. Thus, gender
is an important aspect of TB epidemiology. The differ-
ence between men and women appears to be larger in
Asia, especially in the SEARO region and to a lesser
extent in the WPRO region, than in sub-Saharan
Africa (AFRO region). It is unclear why male-female
differences in tuberculosis prevalence appear to be
larger in many Asian surveys than in those from Africa.
Whether this reflects, for example, lower (re)infection
rates of Asian women due to more restricted participa-
tion in society, or higher breakdown rates in African
women due to inadequate nutrition, is unknown. To
answer these questions the role of gender in TB epide-
miology needs to be better studied. Epidemiological
field studies looking at potentially confounding vari-
ables related to exposure and immunity may give clues.
This study suggests that overall gender differences
in TB notification rates may be largely due to gender
differences in TB prevalence. If anything, female TB
cases are more likely to be notified than male cases,
except perhaps in the AFRO region, where some
countries have PDRs smaller than 1. It is however dif-
ficult to make definitive statements on this region as
128 The International Journal of Tuberculosis and Lung Disease

Table 4 Tuberculosis prevalence rates in the age group 15–64 years by age and sex

F/M prevalence
Prev/1000 Prev/1000 ratio
Year
survey Male Age- Female Age- Age-
Country completed cases Population Crude adjusted cases Population Crude adjusted Crude adjusted Ref
AFRO 57 12 985 4.4 45 10 496 4.2 0.97
Ghana 1958 5 912 5.5 5.4 3 1016 3.0 3.3 0.54 0.62 12
Kenya 1959 6 5976 1.0 1.0 7 1809 3.9 3.9 3.85 3.94 13
Kenya 1961 17 1605 10.6 10.8 13 2404 5.2 5.3 0.49 0.49 14
Mozambique 1961 15 895 16.8 16.7 6 1352 4.4 4.7 0.26 0.28 19
Sierra Leone 1958 4 1040 3.8 3.0 3 1237 2.4 2.8 0.63 0.93 26
Tanzania 1960 5 847 5.9 5.3 3 995 3.0 3.0 0.51 0.57 28
Uganda 1958 5 1710 2.9 3.0 10 1683 5.9 5.3 2.03 1.73 29
EMRO 1 557 1.8 0 623 0.0 0.00
Syria 1960 1 557 1.8 1.7 0 623 0.0 0.0 0.00 0.00 32
SEARO 1475 159 614 9.2 447 156 352 2.9 0.31
Bangladesh 1973 24 7265 3.3 3.3 3 5879 0.5 0.5 0.15 0.15 34
Bangladesh 1987 189 13 716 13.8 11.8 92 10 783 8.5 10.0 0.62 0.84 35
India 1950 60 7470 8.0 8.0 21 6555 3.2 3.3 0.40 0.41 36
India 1960 54 8684 6.2 6.1 22 8425 2.6 2.6 0.42 0.43 37
India 1977 31 3653 8.5 8.2 5 3468 1.4 1.5 0.17 0.18 38 (1)
India 1977 30 3373 8.9 8.4 7 3263 2.1 2.2 0.24 0.26 38 (2)
India 1977 18 3285 5.5 5.2 7 3120 2.2 2.3 0.41 0.44 38 (3)
India 1977 22 3217 6.8 6.3 7 3155 2.2 2.2 0.32 0.34 38 (4)
India 1977 25 2815 8.9 6.8 10 3030 3.3 2.8 0.37 0.42 38 (5)
India 1969 856 79 471 10.8 9.9 216 82 168 2.6 2.5 0.24 0.25 39
India 1973 66 10 300 6.4 5.7 28 9929 2.8 2.9 0.44 0.50 40
India 1983 30 7422 4.0 4.0 12 7764 1.5 1.5 0.38 0.38 43
India 1986 70 8943 7.8 6.7 17 8813 1.9 1.7 0.25 0.25 44
WPRO 1128 481 635 2.3 589 491 894 1.2 0.51
China–Taiwan 1958 161 12 450 12.9 12.4 60 13 689 4.4 4.4 0.34 0.35 53
China 1990 765 410 000 1.9 1.8 441 410 000 1.1 1.0 0.58 0.59 54
Korea 1990 44 16 139 2.7 2.3 13 18 565 0.7 0.7 0.26 0.30 59
Korea 1995 28 21 728 1.3 1.0 13 25 218 0.5 0.5 0.40 0.49 60
Malaysia 1970 20 7184 2.8 2.7 5 7795 0.6 0.7 0.23 0.24 61
Philippines 1983 69 4570 15.1 16.0 40 5350 7.5 7.3 0.50 0.45 62
Philippines 1997 36 4876 7.4 7.4 11 5223 2.1 1.9 0.29 0.26 63
Samoa 1975 5 4688 1.1 1.1 6 6054 1.0 1.0 0.93 0.89 64
AFRO  African Regional Office, EMRO  Eastern Mediterranean Regional Office, SEARO  South-East Asian Regional Office, WPRO  Western Pacific
Regional Office.

all surveys from AFRO region were small in terms of
the number of TB cases observed. Thus, generally, our
findings do not seem to support the hypothesis that
gender differences in notification rates are due to
gender inequalities in access to health care. However,
this conclusion cannot be generalised to individual
regions or countries, as in some countries PDRs are
not inconsistent with values 1.
This does not imply the absence of gender inequal-
ities in access to health care. First, our findings do not
disprove gender inequalities in access to health care in
some countries. Unfortunately, the quality of the data
does not allow firm conclusion to be drawn about
individual countries. Second, access to notification
(i.e., diagnosis) does not necessarily imply access to
effective treatment. Third, our analysis only takes
into account notified incident cases. In many coun-
tries the private sector treats a substantial proportion
of TB cases and may not notify many cases that come
to its attention, in particular if notification is not
mandatory. Women may have less access to this form
of health care, especially where it is expensive. Thus,
gender inequities in access to this form of health care
are ‘invisible’ in analyses such as ours that make use
of notification data as a measure of access to health
care. Therefore, if Asian women tend to seek care in
the public sector and Asian men in the private sector,
then our results are biased. Fourth, the use of data
from prevalence surveys may also cause another form
of bias. If the average duration of smear positivity in
men is longer than in women, for example because
they have higher defaulting rates, then prevalence
may inadequately reflect the incidence of new cases,
i.e., those eligible for notification.
A limitation of many prevalence surveys is that
they were carried out many years ago. If TB preva-
lence has changed over time, but not equally so for
both sexes, then our approach is fallible. This limita-
tion applies in particular to surveys in Africa which
were carried out before the widespread introduction
of chemotherapy. Moreover, some of these countries
have a substantial HIV burden, where typically HIV
prevalence among young women is higher than among
men of the same age. However, data from Kenya,
 Gender and tuberculosis 129

Table 5 Age-standardised notification rates, prevalence rates, and patient detection rates (PDR) in the age group 15–64 years
in 29 prevalence surveys from 14 countries

Notification rates Prevalence rates PDRs

(1996) per 100 000 per 1000 per 100 prevalent
population population cases F/M ratio of PDRs
Country Male Female Male Female Male Female Ref Direct Indirect
AFRO
Ghana 30.6 17.5 5.4 3.3 5.7 5.2 12 0.92 1.08
Kenya 144.9 86.2 1.0 3.9 147.9 22.3 13 0.15 0.16
Kenya 144.9 86.2 10.8 5.3 13.4 16.4 14 1.22 1.24
Mozambique 128.6 88.8 16.7 4.7 7.7 19.1 19 2.47 2.60
Sierra Leone 116.3 72.4 3.0 2.8 38.4 25.7 26 0.67 0.97
Tanzania 170.1 96.7 5.3 3.0 32.0 31.9 28 1.00 1.08
Uganda 176.0 122.6 3.0 5.3 58.1 23.4 29 0.40 0.34
EMRO
Syria 24.2 12.1 1.7 0.0 14.7 Undefined 32 Undefined Undefined
SEARO
Bangladesh 14.7 6.1 3.3 0.5 4.4 12.1 34 2.73 2.74
Bangladesh 14.7 6.1 11.8 10.0 1.2 0.6 35 0.49 0.63
India 1.4 0.6 8.0 3.3 0.2 0.2 36 1.13 1.14
India 1.4 0.6 6.1 2.6 0.2 0.2 37 1.07 1.10
India 1.4 0.6 8.2 1.5 0.2 0.4 38 (1) 2.57 2.61
India 1.4 0.6 8.4 2.2 0.2 0.3 38 (2) 1.75 1.84
India 1.4 0.6 5.2 2.3 0.3 0.3 38 (3) 1.05 1.09
India 1.4 0.6 6.3 2.2 0.2 0.3 38 (4) 1.34 1.36
India 1.4 0.6 6.8 2.8 0.2 0.2 38 (5) 1.10 1.09
India 1.4 0.6 9.9 2.5 0.1 0.3 39 1.84 1.81
India 1.4 0.6 5.7 2.9 0.2 0.2 40 0.92 1.02
India 1.4 0.6 4.0 1.5 0.3 0.4 43 1.21 1.18
India 1.4 0.6 6.7 1.7 0.2 0.4 44 1.87 1.75
WPRO
China–Taiwan 21.1 13.3 12.4 4.4 1.7 3.1 53 1.79 1.84
China 21.1 13.3 1.8 1.0 12.0 12.8 54 1.06 1.06
Korea 38.5 18.7 2.3 0.7 16.9 27.1 68 1.60 1.76
Korea 38.5 18.7 1.0 0.5 37.4 37.4 69 1.00 1.05
Malaysia 68.7 31.0 2.7 0.7 25.1 47.8 70 1.89 1.96
Philippines 1.1 0.3 16.0 7.3 0.1 0.0 71 0.73 0.69
Philippines 1.1 0.3 7.4 1.9 0.1 0.2 72 1.28 1.23
Samoa 2.2 18.5 1.1 1.0 2.1 19.1 73 9.24 4.16
AFRO  African Regional Office, EMRO  Eastern Mediterranean Regional Office, SEARO  South-East Asian Regional Office, WPRO  Western Pacific
Regional Office.

Malawi and Tanzania suggest that, despite substan- Another limitation is the variable size and quality of
tial increases in notification rates over the past decade, TB surveys. Some surveys were very small and detected
the female/male notification ratio has remained few prevalent cases. Most were carried out regionally,
largely unaltered. whereas we compared them to national notification

Figure Female/male ratio of patient detection rates. Indirect standardisation for age.
130 The International Journal of Tuberculosis and Lung Disease
data. While the instrument of a prevalence survey may
be the best available for estimating the TB disease bur-
den, it may not be entirely free of gender bias if, for
example, women with symptoms manage to avoid
being screened by the survey from fear of being diag-
nosed as a TB patient. An even stronger limitation of
TB surveys is that they have only been carried out in a
limited number of countries. Clearly, this study could
not assess gender-related problems of access to public
TB care in countries that had not carried out a preva-
lence survey. Finally, our analysis was restricted to
smear-positive tuberculosis cases and did not assess
possible gender inequities in access to care for smear-
negative or extra-pulmonary TB.
In view of these limitations, additional research
would be instrumental in obtaining firmer conclu-
sions on gender bias in tuberculosis case detection.
Gender bias may be related to health seeking behav-
iour and/or to steps within the health systems in sus-
pecting and diagnosing TB. Gender bias within the
health system may be examined rapidly by comparing
sex- and age-specific 1) prevalence of respiratory
complaints among out-patients, 2) probabilities that
TB suspects actually undergo sputum examination, 3)
probabilities that TB patients being diagnosed are put
on treatment, and 4) cure rates. Such research could
be combined with social science research on perceived
gender-related barriers among patients and staff.
Gender-related problems of access to health care
are more difficult to assess and may need a combina-
tion of epidemiological research (population-based
prevalence survey) and social science research on
health seeking behaviour. Alternatively, at the time of
diagnosis, smear-positive patients could be requested
to bring in all other household members for sputum
smear examination. In the absence of gender bias, one
would expect the female/male ratio among smear-
positive household members to be approximately
equal to that among index patients. This may apply in
particular to spouses, who are likely to share possibly
confounding characteristics (such as approximate
age) with the index patient. Thus, if in the majority of
cases the index patient in double-positive couples is
the husband, gender bias, either in access to health
care or within the health system, can be suspected.
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O B J E C T I F : Explorer dans quelle mesure les taux de
déclaration plus bas de tuberculose observés chez les
femmes sont dus à une accessibilité réduite des soins de
santé et en particulier des services de diagnostic.
M E T H O D E S : Les taux de prévalence de tuberculose
spécifiques pour l’âge et le sexe et concernant les tuber-
culoses à bacilloscopie positive ont été obtenus à partir
d’enquêtes de prévalence de la tuberculose signalées à
l’OMS ou publiées dans la littérature. Les taux de décla-
ration spécifiques pour l’âge et le sexe pour les mêmes
pays en 1996 ont été utilisés.
R É S U L T A T S : On a utilisé les données de prévalence et de
déclaration provenant de 29 enquêtes dans 14 pays. Les
taux de déclaration varient fortement entre pays, mais le
ratio femmes/hommes (F/M) est inférieur à 1 et diminue
avec les progrès de l’âge dans presque tous les pays. Les
O B J E T I V O : Investigar si la notificación más baja de
tuberculosis en las mujeres es debida a un acceso redu-
cido a los centros de salud, en especial a los servicios de
diagnóstico.
M É T O D O S : Se obtuvieron las tasas de prevalencia de
tuberculosis, sexo y edad, de los tuberculosos con esputo
positivo obtenidas de las encuestas de tuberculosis
comunicadas a la OMS o publicadas en la literatura. Se
utilizaron las tasas de notificación de edad y sexo de los
mismos países, de 1996.
R E S U L T A D O S : Se usaron los datos de prevalencia y noti-
ficaciones de 28 encuestas en 14 países. Las tasas de noti-
ficación variaron fuertemente entre los países, pero la re-
lación mujer/hombre fue inferior a 1, y disminuyó con el
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RÉSUMÉ
ratios F/M de prévalence furent inférieurs à 0,5 dans
les enquêtes d’Asie du Sud-est et de la Région du Paci-
fique Occidental ; ils sont approximativement de 1 dans
la Région Afrique.
C O N C L U S I O N : Dans la plupart des pays, les ratios de
sexe F/M des cas prévalents sont similaires ou plus bas
que ceux des cas déclarés, ce qui suggère que les dif-
férences F/M dans les taux de déclaration peuvent être
dues largement à des différences épidémiologiques et
non à un accès différentiel aux services de santé. Toute-
fois, les données disponibles sont limitées, puisque les
enquêtes de prévalence en Afrique ont été conduites il y
a de nombreuses années, et puisqu’en Asie les taux de
déclaration peuvent être perturbés par l’existence d’un
vaste secteur privé où les déclarations sont déficientes.
RESUMEN
aumento de la edad en casi todos. Las relaciones de pre-
valencia mujer/hombre (M/H) eran inferiores a 0,5 en
encuestas en el Sud-Este Asiático y en la región del Pacífico
Occidental y aproximadamente 1 en la Región Africana.
C O N C L U S I Ó N : En la mayoría de los países la relación
M/H en los casos prevalentes fue similar o inferior a la
de los casos notificados, sugiriendo que las diferencias
M/H en las tasas notificadas son más bien debidas a
diferencias epidemiológicas que a diferencias en el
acceso a los centros de salud. Sin embargo, los datos
accesibles son limitados y las encuestas de prevalencia en
Africa fueron llevadas a cabo hace muchos años y las
tasas de notificación en Asia pueden ser influenciadas por
un gran sector privado con deficiencias en la notificación.