INT J TUBERC LUNG DIS 17(12):1581–1586 © 2013 The Union http://dx.doi.org/10.5588/ijtld.13.0152 Tuberculosis control in a socially vulnerable area: a community intervention beyond DOT in a Brazilian favela E. C. C. Soares,* W. M. Vollmer, † S. C. Cavalcante,* ‡ A. G. Pacheco, ‡ V. Saraceni,* J. S. Silva,* G. R. Neves,* J. E. Golub, § A. R. Efron, § B. Durovni,* R. E. Chaisson § * City of Rio de Janeiro Health Secretariat, Rio de Janeiro, Rio de Janeiro, Brazil; † Kaiser Permanente Center for Health Research, Portland, OR, USA; ‡ IPEC-Fiocruz, Rio de Janeiro, Rio de Janeiro, Brazil; § Johns Hopkins University, Center for Tuberculosis Research, Baltimore, MD, USA Correspondence to: Elizabeth C C Soares, Health Secretariat of the City of Rio de Janeiro, Rua Afonso Cavalcanti, 455/803 Cidade Nova, 20211-901, Rio de Janeiro, RJ, Brazil. Tel: (+55) 21 2439 8938. Fax: (+55) 21 2420 9208. e-mail: eccsoares@ gmail.com; elizabethc.soares@smsdc.rio.rj.gov.br Article submitted 1 March 2013. Final version accepted 29 July 2013. SUMMARY IN 2008, for the frst time in history, the world’s urban population exceeded its rural population. 1 This trend has been most dramatic in developing countries, where high rates of population growth have resulted in the establishment of informal settlements or slums in most urban settings. 2 Rio de Janeiro is a city with a population of 6 million located in south-east Brazil. It is the second largest city in the country and the fourteenth largest in the world. Nineteen per cent of Rio’s population lives in favelas, poor, overcrowded slums with few basic public services. 3 These conditions pose signifcant challenges to human health and create a breeding ground for social problems as well as com- municable diseases such as tuberculosis (TB). 4–8 Rocinha is a densely populated favela where resi- dents have low levels of literacy, high rates of poverty and inadequate access to basic sanitation. 3 Com- pounding the poor living conditions, Rocinha has a large and lucrative illegal drug trade which creates a violent environment. Poverty and the gap between rich and poor are important factors contributing to a high incidence of TB in many countries, 9 and the Rocinha favela is a clear example of this. Rocinha comprises 1% of the city population, but accounts for a disproportionate 5% of TB cases in the city. With a population of more than 56 000, from the year 2000 to 2002 the reported annual TB case notifcation rate was more than 500 per 100 000 population, which is fve times higher than that for the city as a whole. 10 Despite successful clinic-based implementation of TB control in selected areas of Rio de Janeiro, the city has not yet reached the World Health Organiza- tion goal of curing 85% of incident cases, 11 indicat- ing that a clinic-based DOTS model alone, at least in cities such as Rio, will not suffce to achieve the 2015 TB-related Millennium Development Goals. 12,13 In June 2003, the city’s TB Control Program began the implementation of a comprehensive community intervention in the favela, where the annual TB noti- fcation rate was estimated to be 570/100 000. The intervention began with supervised treatment in the community, followed by a door-to-door active case OBJECTIVES: To evaluate the population-based impact of a comprehensive intervention to strengthen tubercu- losis (TB) control in Rocinha, the largest urban slum in Rio de Janeiro, Brazil. DESIGN: In July 2003, 40 lay persons were hired and trained as community health workers to supervise treat- ment, implement educational activities and establish a supportive social network for anti-tuberculosis treat- ment. Between July 2005 and June 2008, a door-to-door active case finding campaign was conducted. Data were obtained from the Brazilian National Reporting System, which collects information from the TB notification form for every reported case. RESULTS: Between January 2001 and December 2008, 2623 TB cases were reported, 852 before and 1771 after the start of the program. Following the intervention, treatment success rates increased (67.6% vs. 83.2%, P < 0.001) and default rates dropped (17.8% vs. 5.5%, P < 0.001). Compared to the pre-intervention period, the TB case rate declined by an average of 39 cases per 100 000 population per 6 months (P = 0.003) in the post-intervention period, although this may have been due to secular trends already in place at the start of the intervention. Case rates declined from 591/100 000 in 2001 to 496/100 000 in 2008. CONCLUSION: With proper planning and effective community involvement, a successful intervention can lead to high cure rates and may contribute to a decrease in TB notification rates. KEY WORDS: TB case notification rate; slum; commu- nity health workers; incidence rate