Sex differences in the case-fatality rates for COVID-19—A comparison of the age-related differences and consistency over seven countries

Manfred S. Green, Dorit Nitzan, Naama Schwartz, Yaron Niv, Victoria Peer

Research output: Contribution to journalArticlepeer-review


Background Early in the COVID-19 pandemic, it was noted that males seemed to have higher case-fatality rates than females. We examined the magnitude and consistency of the sex differences in age-specific case-fatality rates (CFRs) in seven countries. Methods Data on the cases and deaths from COVID-19, by sex and age group, were extracted from the national official agencies from Denmark, England, Israel, Italy, Spain, Canada and Mexico. Age-specific CFRs were computed for males and females separately. The ratio of the male to female CFRs were computed and meta-analytic methods were used to obtained pooled estimates of the male to female ratio of the CFRs over the seven countries, for all age-groups. Meta-regression and sensitivity analysis were conducted to evaluate the age and country contribution to differences. Results The CFRs were consistently higher in males at all ages. The pooled M:F CFR ratios were 1.71, 1.88, 2.11, 2.11, 1.84, 1.78 and 1.49, for ages 20–29, 30–39, 40–49, 50–59, 60–69, 70–79, 80+ respectively. In meta-regression, age group and country were associated with the heterogeneity in the CFR ratios. Conclusions The sex differences in the age-specific CFRs are intriguing. Sex differences in the incidence and mortality have been found in many infectious diseases. For COVID-19, factors such as sex differences in the prevalence of underlying diseases may play a part in the CFR differences. However, the consistently greater case-fatality rates in males at all ages suggests that sex-related factors impact on the natural history of the disease. This could provide important clues as to the mechanisms underlying the severity of COVID-19 in some patients.

Original languageEnglish
Article numbere0250523
JournalPLoS ONE
Issue number4
StatePublished - Apr 2021

Bibliographical note

Publisher Copyright:
© 2021 Green et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


  • Adolescent
  • Adult
  • Age Factors
  • Aged
  • Aged, 80 and over
  • COVID-19/epidemiology
  • Canada/epidemiology
  • Child
  • Child, Preschool
  • England/epidemiology
  • Europe/epidemiology
  • Female
  • Humans
  • Infant
  • Israel/epidemiology
  • Male
  • Mexico/epidemiology
  • Middle Aged
  • Retrospective Studies
  • SARS-CoV-2/isolation & purification
  • Sex Factors
  • Young Adult

ASJC Scopus subject areas

  • General


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