Municipal Health Secretariat of Rio de Janeiro

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Using Community Health Workers to provide
Home-based DOT in Rio de Janeiro favela
Solange Cesar Cavalcante

• Municipal Health Secretariat of Rio de Janeiro
• Research Institute Evandro Chagas IPEC/FIOCRUZ

2
Introduction

• 1999 DOTS strategy clinic-based DOT program
• Set the stage for city-wide DOTS which has now
  expanded to cover 80 of the population
• The DOT program has been largerly clinic-based,
  with treatment provided in municipal health
  centers

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Introduction

• Brazilian MOH new model of community-based
  health care for the country, the Family Health
  and the Community Health Workers Program
• (PSF/PACS) PSF/PACS teams consist of medical and
  nursing staff, social workers, and CHWs who
  provide selected health services and health
  education through home-based outreach and
  follow-up in the communities they serve

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Introduction

• The integration of DOTS into the PSF/PACS program
  has the potential to be highly successful
• Could improve the care of TB patients by
  facilitating DOT in the community, enhancing
  treatment adherence and meeting the goal of
  decentralization of TB control measures
• During the expansion of DOTS in one district of
  Rio the Janeiro, we decided to integrate TB
  treatment and follow-up into the PSF/PACS program
  in an impoverished urban slum community

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Introduction

• BRAZIL
• TB Incidence rate 38,2/100,000
• 16th WHOs high burden TB countries

Brazil 181 million pop

• RIO DE JANEIRO CITY
• Population 6 million
• 20 live in favelas
• TB Incidence93,7/100,000

Rio de Janeiro City
Sources WHO/HTM/TB/2007.376
Brazils Ministery of Health Health
Department of Rio de Janeiro City
South Zone of Rio
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Methods

• South zone (AP 2.1) 14 occupied by favelas
• Population area 634,966 inhabitantes
• TB incidence rates 140/100,000 (900 TB
  cases/year)
• Cure rates 70

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Rocinha population

• Population 56,338

• Population density 39,123 inh/km2

• Literacy 15 illiterate

• Inadequate access to basic sanitation

• Family income US 4,160/year

• Unemployment 17

Source Brazilian Institute of Geography and
Statistics (IBGE) Census 2000
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Rocinha favela
Copacabana
Ipanema
Lagoa
Rocinha
São Conrado
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Rocinha favela
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Rocinha favela
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The War
Rocinha in The Washington Post April 2007
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Rocinha favela
O Estadão - Victor Caivano Abril 2004
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TB Morbidity in Rocinha
Cases per 100,000
Source Health Department of Rio de Janeiro City
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Methods Intervention
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Establishment of partnerships
Jonhs Hopkins University
USAID
Catholic Church
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Rocinhas CHWs team
June 2003
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Community Health Workers (CHWs)

• Selection process written test and interviews

• 40 lay people were hired

• Residents of the community

• Training program

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Training material
TUBERCULOSE Manual de Treinamento para os
Agentes Comunitários de Saúde Secretaria
Municipal de Saúde do Rio de Janeiro Coordenação
de Doenças Transmissíveis Gerência de Pneumologia
Sanitária Coordenação de Saúde da
Comunidade Coordenação de Saúde da AP
2.1 Universidade Johns Hopkins 2003
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The core team

• 2 Nurses coordinators
• 1 Psychologist supervisor

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Church of Nossa Senhora da Boa Viagem
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(No Transcript)
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Mapping the community

• Fluxo que a própria população estabelece
• Vias de acesso, barreiras geográficas e de
  transporte
• Regularidades sócio-econômicas
• Aspectos urbanos comuns entre as moradias
• Padrão de distribuição geográfica dos casos de
  tuberculose

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DOTS Program
After the Intervention
Before the Intervention

• Regimen
• New cases 2 HRZ 4 H2R2
• Retreatment2 HRZE 4H2R2E2

• Regimen
• New cases 2 HRZ 4 HR
• Retreatment 2 HRZE 4 HRE

• Supervision
• All doses were supervised by the CHWs

• Supervision
• Self-administered
• Monthly supply of drugs

• Follow up
• Monthly medical attendance at a regional TB
  Clinic (same clinic)

• Follow up
• Monthly medical attendance at a regional TB
  Clinic (5 km distant from Rocinha)

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Directly observed treatment program (DOT)
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Home visits
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Directly Observed Treatment (DOT)
Doses register
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Supportive social network

• Visited the institutions
• Kept records of all sorts of organizations
• Established partnerships

Day Care Center
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Educational activities

• Institutions visited 29
• Total of people who attended the events 2,922

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NGO Colaboration - Transformarte
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Patients, families and HCWs meetings
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Other activities

• Collect sputum at home
• Monitor medical appointment attendance
• Send contacts for evaluation
• Accompany patients to hospitals

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Results - Treatment outcomes N 788 (Jun/03 à
Dez/05)
Transferência 19
2
Falência 11
Óbito 10
1
1
Abandono 43
6
Cura 705
90
Fonte Livro Preto
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(No Transcript)
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Contact evaluation (Jun/03 à Dez/05)
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Treatment outcomes
2003- 2007
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Active Case Finding

• Date of start June 2005
• Door-to-door symptom screen
• On the spot sputum collection

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Active Case Finding
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Mapping
Detailed map
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Active Case Finding

• Door to door
• Respiratory syntoms
• Sputum collection

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Active Case Finding
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Conclusion
A community based-DOTS model using indigenous
CHWs and incorporating social mobilization and
community support is a highly promising approach
to improve TB treatment outcomes in urban
favelas A community based- DOTS using CHWs is
feasible and sustainable and assures that the
most vulnerable populations receive high quality
care, which is essential to TB control in Rio and
Brazil
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Aknowledgments
Health Secretariat of Rio de Janeiro City, Rio de
Janeiro, RJ, Brazil E.C.C. Soares, Jussara, G B.
Durovni Rita de Cassia TB program staff Jonhs
Hopkins University, Baltimore, MD, United
States R.E. Chaisson J. E. Golub L.
Watkinson Center for TB Research staff
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Rocinhas CHWs team and the nurses
Adalgisa da Silva Adriana Isaías Adriana Maria
Freitas Alexandre dos Santos Mello Alice Maria
Rodrigues da Fonseca Ana Lúcia de Almeida Ana
Maria de Araújo Matias Campos Anderson Gomes de
Oliveira André Serafim Ferreira Ângela Coelho
Rodrigues Bueno Demétrio Aragão Carla Carolina
Amorim da Silva Catarina G. Oliveira Cecília
Caetano Pereira Cíntia Eva Machado Claudia Maria
Francisca da Silva Cristiano Chagas de
Farias Dayse Lúcia Rosa da Silva Débora Alcântara
da Silva Denise Ambrozina da Nóbrega Éden José
dos Santos Eliane Paiva Costa da Silva Eliete da
Silva Franquine Elisângela Andrade dos
Santos Elvis Pereira da Silva Fabiana dos Santos
Silva Fabiana Lopes do Nascimento Francilene de
Oliveira Lima Francisco Augusto Martins de
Souza Gabriela de Carvalho Ferreira Giliard Alves
Barreto Greice Fernandes de Oliveira
Gustavo Alves Pinto Henrique do Nascimento
Borges Izabel Barbosa da Silva João Amaral
Filho José Renato dos Santos Josefa da Costa
Brito Leandro dos Santos da Silva Lígia Maria
Mendes Gomes Lúcia Helena Vicente Marco Antônio
da Silva Maria da Conceição da Silva Maria da
conceição Titz F. de Oliveira Maria de Lourdes
Marques Marília Ferreira dos Santos Mirella
Ferreira Franco Natalia da Silva Dias Patrícia
Bernardo da Silva Patrícia de Macedo Patrícia
Malta de Campos Sá Brito Paula F. Alves da
Silveira Peter Daniel Lotti Olmedo Rita de Cássia
Vieira Smith Roberta Paiva Costa da Silva Ronaldo
Ferreira da Silva Sabrina dos Santos
Fonseca Sheila de Carvalho Ferreira Lima Shirley
Elias da Silva Solange Merlino Gomes Teresa
Rodrigues Anastácio Vanessa Silva Gomes Vera
Regina Soares de Santana Vilson Bezerra Rodrigues
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O Estadão - Alaor Filho