title: Risk factors for differential outcome following directly observed treatment (DOT) of slum and non-slum tuberculosis patients: a retrospective cohort study.
abstract: Brazil's National Tuberculosis Control Program seeks to improve tuberculosis (TB) treatment in vulnerable populations. Slum residents are more vulnerable to TB due to a variety of factors, including their overcrowded living conditions, substandard infrastructure, and limited access to healthcare compared to their non-slum dwelling counterparts. Directly observed treatment (DOT) has been suggested to improve TB treatment outcomes among vulnerable populations, but the program's differential effectiveness among urban slum and non-slum residents is not known.
  
  
  
  We retrospectively compared the impact of DOT on TB treatment outcome in residents of slum and non-slum census tracts in Rio de Janeiro reported to the Brazilian Notifiable Disease Database in 2010. Patient residential addresses were geocoded to census tracts from the 2010 Brazilian Census, which were identified as slum (aglomerados subnormais -AGSN) and non-slum (non-AGSN) by the Census Bureau. Homeless and incarcerated cases as well as those geocoded outside the city's limits were excluded from analysis.
  
  
  
  In 2010, 6,601 TB cases were geocoded within Rio de Janeiro; 1,874 (27.4 %) were residents of AGSN, and 4,794 (72.6 %) did not reside in an AGSN area. DOT coverage among AGSN cases was 35.2 % (n = 638), while the coverage in non-AGSN cases was 26.2 % (n = 1,234). Clinical characteristics, treatment, follow-up, cure, death and abandonment were similar in both AGSN and non-AGSN TB patients. After adjusting for covariates, AGSN TB cases on DOT had 1.67 (95 % CI: 1.17, 2.4) times the risk of cure, 0.61 (95 % CI: 0.41, 0.90) times the risk of abandonment, and 0.1 (95 % CI: 0.01, 0.77) times the risk of death from TB compared to non-AGSN TB cases not on DOT.
  
  
  
  While DOT coverage was low among TB cases in both AGSN and non-AGSN communities, it had a greater impact on TB cure rate in AGSN than in non-AGSN populations in the city of Rio de Janeiro.
authors.affiliation: Division of Infectious Diseases and Vaccinology and Division of Epidemiology, School of Public Health, University of California, Berkeley, 94720, CA, USA.
authors.forename: Robert E
authors.initials: RE
authors.lastname: Snyder
authors.affiliation: Division of Infectious Diseases and Vaccinology and Division of Epidemiology, School of Public Health, University of California, Berkeley, 94720, CA, USA.
authors.forename: Mariel A
authors.initials: MA
authors.lastname: Marlow
authors.affiliation: Rush Medical College, 600 S Paulina St, Chicago, 60612, IL, USA.
authors.forename: Melissa E
authors.initials: ME
authors.lastname: Phuphanich
authors.affiliation: Division of Infectious Diseases and Vaccinology and Division of Epidemiology, School of Public Health, University of California, Berkeley, 94720, CA, USA.
authors.forename: Lee W
authors.initials: LW
authors.lastname: Riley
authors.affiliation: Laboratory of Epidemiology, Universidade Federal do Espírito Santo, Avenida Marechal Campos, 1468 Maruípe, Vitória, ES, Brazil. ethel.maciel@gmail.com.
authors.forename: Ethel Leonor Noia
authors.initials: EL
authors.lastname: Maciel
mesh_terms: D000328:Adult; D000995:Antitubercular Agents / Q000627:therapeutic use*; D001938:Brazil; D023801:Directly Observed Therapy; D005260:Female; D006703:Ill-Housed Persons; D006801:Humans; D008297:Male; D011204:Poverty Areas; D015397:Program Evaluation; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D014376:Tuberculosis / Q000188:drug therapy* / Q000453:epidemiology; D014397:Tuberculosis, Pulmonary / Q000188:drug therapy / Q000453:epidemiology
chemical_list: D000995:Antitubercular Agents
keywords: Directly observed treatment; Slum; Tuberculosis cure; Tuberculosis treatment outcome; Urban poverty