Outcome Disparities Among Men and Women With COVID-19: An Analysis of the New York City Population Cohort

Abstract

Background: Growing evidence suggests a possible sex disparity in COVID-19 disease related outcomes. Objective: To explore the sex disparity in COVID-19 cases and outcomes using New York City (NYC) population level data. Setting: NYC surveillance data from February 29 to June 12, 2020. Participants: Individuals tested for COVID-19 in metropolitan NYC. Outcome Measurements and Statistical Analysis: Outcomes of interest included rates of COVID-19 case positivity, hospitalization and death. Relative risks and case fatality rates were computed for all outcomes based on sex and were stratified by age groups. Results and Limitations: 911,310 individuals were included, of whom 434,273 (47.65%) were male and 477,037 (52.35%) were female. Men represented the majority of positive cases (n=106,275, 51.36%), a majority of hospitalizations (n=29,847, 56.44%), and a majority of deaths (n=13,054, 59.23%). Following population level adjustments for age and sex, testing rates of men and women were equivalent. The majority of positive cases and hospitalizations occurred in men for all age groups except age >75 years, and death was more likely in men of all age groups. Men were at a statistically significant greater relative risk of case positivity, hospitalization, and death across all age groups except those <18 years of age. The most significant difference for case positivity was observed in the 65-74 age group (RR 1.22, 95%CI 1.19-1.24), for hospitalization in the 45-65 age group (RR 1.85, 95% 1.80-1.90), and for death in the 18-44 age group (RR 3.30, 95% CI 2.82-3.87). Case fatality rates were greater for men in all age-matched comparisons to women. Limitations include the use of an evolving surveillance data set and absence of further demographic characteristics such as ethnographic data. Conclusion: Men have higher rates of COVID-19 positivity, hospitalization, and death despite greater testing of women; this trend remains after stratification by age.

The impact of SARS-CoV-2 and COVID-19 on male reproduction and men’s health

“…Based on our knowledge of other viral illnesses (e.g., mumps), SARS-CoV-2 may affect male reproduction. Older age (>65 years), male sex, African-American or Asian race, diabetes, and hypertension are among many well established risk factors for more severe symptoms and death from COVID-19 (31)(32)(33). However, 5% of all cases of severe COVID-19 are in younger healthy adults (32).…”

“…However, 5% of all cases of severe COVID-19 are in younger healthy adults (32). Regardless of the known risk factors, men are more likely to have more severe disease and clinical courses (33). Some hypotheses, which are discussed later, relate to differential expression of ACE2/TMPRSS2 (which have higher expression levels in the male-specific organs), an androgen-dependent relationship with higher levels possibly conferring worse FIGURE 2 SARS-CoV-2 viral entry in host cell.…”

National Population-Level Disparities in COVID-19 Mortality Across the Intersection of Race/Ethnicity and Sex in the United States

“…We focus the attention of this paper on quantifying disparities in population-level COVID-19 mortality. Substantial scientific research has uncovered disparities in COVID-19 mortality outcomes in the U.S. by race/ethnicity (e.g., (3, 4, 5, 6, 7, 8, 9, 10, 11)), as well as between males and females (e.g., (12, 13, 14, 15, 16, 17, 18, 19)). However, research on U.S. population-level disparities in COVID-19 mortality outcomes across the intersection of race/ethnicity and sex has been limited, largely due to the absence of requisite publicly available data, which represents a critical research gap in the quantification and understanding of the nature of population-level disparities in COVID-19 mortality outcomes between subgroups.…”

Androgens and COVID-19: exploring the role of testosterone replacement therapy

“…Numerous reports have attempted to understand the sexdifference observed in COVID-19, whether secondary to an innate sex-variable physiology or acquired from lifestyle and behavior [3,8]. Initially, it was hypothesized that the presence of receptors on male-specific tissue was contributory to some of the observed differences, including some clinical presentations such as orchitis.…”

“…Since its discovery, an abundance of studies have been conducted to better understand the complex pathophysiology of the disease, its consequences to the human body and epidemiologic trends to elucidate groups that are at greatest risk. A multitude of evidence was available early in the pandemic highlighting a clear sexdifference with greater burdens of disease in men including worse outcomes (both hospitalization and death) even when considering known COVID-19 risk factors, such as age [3]. In an effort to better understand this trend many studies have proposed hypotheses to explain these differences, one of which has included the possible role of androgens [4,5].…”