Women might be more likely to develop drug-resistant infections than men — an under-recognized aspect of the growing threat of antimicrobial resistance, according to a global review led by the World Health Organization (WHO). The report finds that more than 70% of countries do not recognize gender inequalities in national plans to tackle drug-resistant infections.
And last month, the WHO added four pathogens to its list of the drug-resistant bacteria it considers to be most dangerous to humans. The list, first published in 2017, helps nations to shape their action plans against antimicrobial resistance (AMR), which is caused by the overuse and misuse of antibiotics that leads to bacteria becoming resistant to the medications through mutations in their DNA.
The changes to the list were based on how commonly the bacteria cause infections, their deadliness and how easily infections can be prevented through measures such as handwashing, quarantine and vaccination. The WHO added three streptococcal bacteria — which cause conditions including a type of pneumonia and an influenza-like infection that can be fatal in extreme cases — and a highly resistant variety of tuberculosis (see ‘Dangerous drug resistance’). The streptococci are linked to a high burden of disease, especially in poor countries, and the tuberculosis strain is difficult to detect and very expensive to treat.
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Gender disparity
The gender review suggests that women, particularly those in low-resource settings, might be at a higher risk than men of contracting drug-resistant infections, owing to factors including menstrual-hygiene needs and gendered divisions of labour. The analysis will shape the first-ever WHO report on how policymakers can address gender inequalities in efforts to tackle the global threat, scheduled to be published in July.
“The majority of national action plans available have no mention of sex or gender, let alone consider this in the design of AMR interventions,” said Zlatina Dobreva, a technical officer focusing on AMR at the WHO in Geneva, Switzerland, when she presented the review last month at the European Society of Clinical Microbiology and Infectious Diseases conference in Barcelona, Spain.
“Gender influences exposure to infection, infection-prevention, health-care-seeking and self-treatment behaviours, as well as prescribing patterns,” she said. The WHO conducted the review in collaboration with researchers at the Global Strategy Lab in Toronto, Canada.
“It is imperative to study gender as it is one of the core social determinants of population health and health inequalities,” says Deepshikha Batheja at the One Health Trust in Bengaluru, India, who studies the factors that influence women’s participation and productivity in paid work in India, and provided feedback to the WHO and Global Strategy Lab teams on how the review was conducted. “This is an excellent and timely piece of work,” she says.
Many factors
The researchers analysed 130 English-language studies that focused on gender and antimicrobial resistance, published between 2000 and 2023. Around 20% of the studies focused on Africa, and nearly 15% focused on southeast Asia.
The team found that, in poor regions, inadequate access to clean water puts women and girls at a greater risk of drug-resistant urinary tract infections than men, because of menstrual-hygiene needs. In these settings, women and girls are also often responsible for fetching water, preparing food and doing farm work, which increases their exposure to pathogens such as antibiotic-resistant E. coli in water and food, and to antibiotics fed to animals.
Women are also more likely to encounter drug-resistant infections in hospitals and clinics, because they typically spend more time in them than men do. Globally, women make up 70% of health-care workers, and they tend to be responsible for making decisions about their children’s health and vaccinations, says Dobreva.
And higher rates of sexual violence against women compared with men also put them at a greater risk of drug-resistant sexually transmitted infections. In some regions, the lack of financial independence and decision-making power that result from cultural norms limit women’s access to treatments for infections. This makes them more likely to self-diagnose and use inappropriate treatments that allow microbes to persist and evolve drug resistance.
Dearth of data
Despite the many factors that put women at a greater risk of drug-resistant infections, it is not clear whether such infections are more common in women than in men. That’s because many countries do not collect data on sex and gender when tracking antimicrobial resistance, says Dobreva.
Filling this data gap is crucial to addressing gender inequality, she says. “When research studies are conducted, they need to consistently report on sex [and if possible, gender] and collect that data, because it’s a missed opportunity if you don’t do that,” says Dobreva.
Dobreva hopes that the review and upcoming WHO report will raise awareness of the need to discuss gender inequality at the United Nations General Assembly meeting on antimicrobial resistance in September. That meeting aims to encourage countries to make firm commitments on how to address the global threat. Since the WHO adopted a global action plan for antimicrobial resistance in 2015, more than 170 countries have drawn up plans — but none are legally binding.
The latest review struck a chord with antimicrobial-resistance researcher Charity Wiafe Akenten at the Kumasi Centre for Collaborative Research in Tropical Medicine, Ghana, who was at the microbiology meeting. “I have not thought of how gender and AMR overlap before,” she says.
This article is reproduced with permission and was first published on June 5, 2024.