Our findings suggest a considerable male predominance in COVID-19 cases however a male advantage in terms of case fatality.
These trends are in contrast to what is currently being observed in many HICs. For instance, in Denmark and the Netherlands, women account for 58% and 63% of all cases, respectively. On the other hand, in the Netherlands the case fatality rate in men is more than double that of women (19.3% vs 9.1%), as of the 26th May 2020. Similarly, in Denmark, the case fatality rate in women was 3.7% in women and 6.6% on the 26th May 2020 (3).
These findings may have several explanations.
Firstly, socially constructed gender roles in this region may enable men better access to healthcare facilities and COVID-19 testing. Data from the Institute of Epidemiology Disease Control and Research (IEDCR) in Bangladesh shows considerable discrepancies in the rates of testing between men and women, whereby 65% of all tests performed in Bangladesh are in men (6). Despite this, it is still unclear whether differential testing by sex is associated with differences in the number of positive cases by sex in the remainder of South Asia.
Secondly, concomitant cardio-respiratory disorders and related risk factors (e.g., smoking and diabetes) tend to be more prevalent in South Asian men than women (7). For example, among Indian men, there is a higher proportion of mortality attributable to cardiovascular diseases (CVD), higher age-standardized CVD mortality rate and considerably higher smoking rates (among younger Indians, prevalence of smoking is 24% in men compared to 3% in women) (8). In terms of respiratory diseases, prevalence of asthma and chronic cough are considerably high in all South Asian countries. Although prevalence of asthma is generally higher among women, chronic cough is higher among men, particularly those who smoke (9).
Thirdly, women may have an amplified immune response to different lung diseases. For instance, significant sex differences exist in the development, course, and outcome of respiratory tract infections (RTIs), whereby most types of RTIs affect men more than women. In addition, more severe RTIs disproportionately impact men, leading to higher mortality. Research has repeatedly shown a stronger immune response to infections among women potentially due to enhanced capabilities of producing antibodies. The role of sex hormones in the regulation of the immune system may also contribute to reported sex differences in the incidence and severity of the various types of RTIs, especially in adolescents and adults (10). However, direct evidence related to COVID-19 is still lacking on this hypothesis.
Finally, the low men to women case-fatality-ratio could be driven by relatively conservative social structures that may restrict women’s access to both healthcare facilities. Women are less likely to seek appropriate and early care for most diseases. However, the frequency with which such care is required: burden of disease, maternal mortality, morbidity and the quality of care provided to women has not been well documented in South Asia. Diseases that generally have an equal prevalence in men and women are found to have affected women disproportionately in this region. This may explain the low rates of COVID-19 testing for women, resulting in (undocumented) deaths at home, or poorer prognosis at hospitals given the late stage admissions.
The main limitation of this report relates to the relatively low number of tests conducted in the region, suggesting that the total numbers may be considerably higher than what we report. Despite this, we do not expect the main message of this report to change considerably.
Our findings indicate a male predominance in the number of COVID-19 cases and hospitalisations; however, highlight a low men to women case-fatality-ratio compared to other world regions. These findings reinforce the need for 1) detailed research to quantify the extent to which sex and gender may contribute to COVID-19 outcomes among South Asians, and 2) context-specific public health strategies.