From routine data collection to policy design: sex and gender both matter in COVID-19.

Vaccine equity is a growing concern of COVID-19 vaccination roll-outs and uptake globally. Gender has a role in vaccine uptake but goes largely unrecognised in vaccine policies and programmes, undermining attempts to ensure equity. There is a wider gender blind spot that pervades national health responses to COVID-19 beyond vaccination, ranging from the way countries collect and report data to the commitments they make in pandemic health policies.

Socially constructed gender norms can mean that women's access to COVID-19 prevention, testing, and treatment, including vaccination, is hindered by unaffordable fees or inability to travel to services. In immunisation programmes before COVID-19, factors such as low autonomy, labour responsibilities, and unpaid care burdens were reasons for gendered barriers to vaccination that disadvantaged women. COVID-19 vaccine uptake may be impacted by poorer access to health services and information about vaccines or perceptions of lower risk, among other factors. Sex is thought to account for greater efficacy of some vaccines in women compared with men due to the different regulation of immune responses related to factors that include hormonal and chromosomal differences.

According to the Global Health 50/50 (GH5050) COVID-19 Sex-Disaggregated Data Tracker, among countries reporting COVID-19 vaccine uptake data, women comprise 53% of individuals receiving at least one dose. However, only 34 of the roughly 180 countries that have begun vaccination programmes reported sex-disaggregated data on vaccine coverage between mid-April and mid-May, 2021.

Poor recognition by governments of the importance of considering sex and gender is also evident in national policies designed to guide vaccine roll-out. The GH5050 Sex, Gender and COVID-19 Health Policy Portal shows only five (9%) of 58 vaccine policies available as of March, 2021, mentioned gender. England, India, and Lebanon were the only countries found to include gender in their COVID-19 vaccine policies and to publicly report on vaccine uptake by sex.6, 7 However, the inclusion of gender is just a starting point. In-depth analysis of the UK Government's COVID-19 Scientific Advisory Group for Emergencies (SAGE) meetings found that considerations of gender largely reproduced gendered stereotypes, including uneven distribution of domestic responsibilities, rather than engaging with ways to transform these norms.

Similarly, only 52% of countries reported sex-disaggregated COVID-19 data on testing, cases, hospitalisations, admissions to intensive care units, or deaths between mid-April and mid-May, 2021. Additionally, fewer than 33 (9%) of 388 policies relating to vaccination, public health messaging, clinical management, protection of health-care workers, and maintenance of essential health services acknowledged or addressed gender norms in some way.

These gender gaps persist despite an abundance of data showing sex differences in COVID-19 outcomes.9, 10, 11 GH5050's COVID-19 tracker shows that men are less likely to be vaccinated and tested for COVID-19, but more likely to be admitted to hospital with the disease, and more likely to die from COVID-19 than women.

Failure to include sex and gender in data collection and policy is not regionally specific. Although high-income countries are more likely to report sex-disaggregated COVID-19 data than low-income and middle-income countries, reporting rates are low even among the high-income group. As of mid-May, 2021, 54% of high-income countries had reported sex-disaggregated data for COVID-19 deaths for the past 3 months, compared with 34% of low-income countries. For data on COVID-19 cases and deaths, about one in three countries that had previously reported sex-disaggregated data were no longer reporting by May, 2021, suggesting that some countries have decided to discontinue such reporting.

There has been no shortage of calls for sex-disaggregated COVID-19 surveillance data,12, 13 and gender-responsive national public health policies. Moreover, as signatories of the 2030 Sustainable Development Goal (SDG) agenda, most countries have committed to sex-disaggregated reporting on SDG indicators, including the health goal. It is, therefore, concerning that so many countries, across regions and income levels, consistently fail to account for sex and gender in COVID-19 responses.

One factor could be low gender diversity throughout the chain of influence on public health decisions, including among researchers, pandemic policy advisers, and leaders. Evidence shows that women's leadership is associated with a higher likelihood of sex and gender being incorporated into research.15, 16 Yet women accounted for just 38% of first authors of COVID-19-related research published between February, 2020, and January, 2021, and of the 11 prominent research and surveillance organisations reviewed by GH5050 in 2021, only three (27%) were headed by women.

Policy processes that engage women, gender experts, and groups that are marginalised due to identities, such as disability, gender identity, ethnicity, and sexuality, are essential to the development of gender responsive and inclusive health responses.19, 20 However, decision making in relation to national COVID-19 responses has largely adopted an exclusionary, male-dominated approach: a UN Development Programme review found that only 24% of national COVID-19 task force members globally are women.

Pandemic responses that do not recognise the importance of sex and gender will always be less equitable and less effective. To realise the ambition of universal COVID-19 vaccination, governments must bring sex and gender to the fore. The longer calls to change course go unheeded, the greater will be the toll of the COVID-19 pandemic on everyone's health.