Persisting leprosy transmission despite increased control measures in an endemic cluster in Brazil: the unfinished agenda

To provide an evidence base for improvement of leprosy control in Brazil's high transmission areas. We obtained data from municipalities in a major disease cluster from databases for notifiable diseases of four states (Maranhão, Parâ, Tocantins, Piauí), including notifications from 2001 to 2009. Indicators for monitoring and evaluation of leprosy according to the World Health Organization were evaluated with emphasis on the rates of new cases presenting grade-2 disabilities and among children < 15 years of age, indicating late diagnosis and active transmission, respectively. A total of 82,463 leprosy cases were detected in the area (mean annual case detection rate: 95.9/100,000; RR = 4.56 as compared to the rest of Brazil; 95% CI: 4.45-4.66, P < 0.0001). There was a steady decrease of detection rates in the study period, from 100.8 to 75.6/100,000 inhabitants. In children