Sex disparities of the effect of the COVID-19 pandemic on mortality among patients living with tuberculosis in the United States

<title>Abstract</title> <bold>Background：</bold> We aimed to determine the trend of tuberculosis (TB)-related deaths during the pandemic, with focus on the impact of the epidemic on mortality in males and females. <bold>Methods：</bold> Using data from the Centers for Disease Control and Prevention and the U.S. Census Bureau, TB-related mortality data of decedents aged ≥ 25 years from 2006-2021 were analyzed. Excess TB-related deaths were estimated by determining the difference between observed and projected mortality rates during the pandemic. The mortality trends were then quantified with Joinpoint regression analysis. <bold>Results：</bold> A total of 18,626 TB-related deaths were documented among adults aged 25 years and older from 2006-2021. A downward trend was noted in TB-related mortality rates before the pandemic, followed by an increase during the pandemic. TB-related age-standardized mortality rates (ASMRs) were 0.51 in 2020 and 0.52 in 2021, corresponding to an excess mortality of 10.22% and 9.19%, respectively. Increased TB-related mortality was observed across all age and sex subgroups, but female with TB demonstrated a higher relative increase in mortality (26.33% vs. 2.17% in 2020; 21.48% vs.3.23% in 2021) during the pandemic when compared to male. Furthermore, female with TB and aged 45-64 years old showed a surge in mortality, with an annual percent change (APC) of -2.2% pre-pandemic to 22.8% (95% CI: -1.7% to 68.7%) during the pandemic, corresponding to excess mortalities of 62.165% and 99.16% in 2020 and 2021, respectively; these excess mortality rates were higher than those observed in the overall female population ages 45-64 years in 2020 (17.53%) and 2021 (33.79%). <bold>Conclusions：</bold> The steady decline in TB-related mortality in the United States has been reversed by COVID-19. Female patients with TB were disproportionately affected by the pandemic, largely owing to care gaps and health disparities experienced by this population.