title: Clusters of leprosy transmission and of late diagnosis in a highly endemic area in Brazil: focus on different spatial analysis approaches.
abstract: OBJECTIVE
  The Brazilian National Hansen's Disease Control Program recently identified clusters with high disease transmission. Herein, we present different spatial analytical approaches to define highly vulnerable areas in one of these clusters.
  
  
  METHODS
  The study area included 373 municipalities in the four Brazilian states Maranhão, Pará, Tocantins and Piauí. Spatial analysis was based on municipalities as the observation unit, considering the following disease indicators: (i) rate of new cases/100,000 population, (ii) rate of cases <15 years/100,000 population, (iii) new cases with grade-2 disability/100,000 population and (iv) proportion of new cases with grade-2 disabilities. We performed descriptive spatial analysis, local empirical Bayesian analysis and spatial scan statistic.
  
  
  RESULTS
  A total of 254 (68.0%) municipalities were classified as hyperendemic (mean annual detection rates >40 cases/100,000 inhabitants). There was a concentration of municipalities with higher detection rates in Pará and in the center of Maranhão. Spatial scan statistic identified 23 likely clusters of new leprosy case detection rates, most of them localized in these two states. These clusters included only 32% of the total population, but 55.4% of new leprosy cases. We also identified 16 significant clusters for the detection rate <15 years and 11 likely clusters of new cases with grade-2. Several clusters of new cases with grade-2/population overlap with those of new cases detection and detection of children <15 years of age. The proportion of new cases with grade-2 did not reveal any significant clusters.
  
  
  CONCLUSIONS
  Several municipality clusters for high leprosy transmission and late diagnosis were identified in an endemic area using different statistical approaches. Spatial scan statistic is adequate to validate and confirm high-risk leprosy areas for transmission and late diagnosis, identified using descriptive spatial analysis and using local empirical Bayesian method. National and State leprosy control programs urgently need to intensify control actions in these highly vulnerable municipalities.
authors.affiliation: Department of Community Health, School of Medicine, Federal University of Ceará, Fortaleza, Brazil.
authors.forename: Carlos H
authors.initials: CH
authors.lastname: Alencar
authors.forename: Alberto N
authors.initials: AN
authors.lastname: Ramos
authors.forename: Emerson S
authors.initials: ES
authors.lastname: dos Santos
authors.forename: Joachim
authors.initials: J
authors.lastname: Richter
authors.forename: Jorg
authors.initials: J
authors.lastname: Heukelbach
mesh_terms: D001938:Brazil / Q000453:epidemiology; D016000:Cluster Analysis; D003140:Communicable Disease Control / Q000458:organization & administration; D057210:Delayed Diagnosis / Q000706:statistics & numerical data*; D019353:Endemic Diseases / Q000706:statistics & numerical data*; D005260:Female; D006304:Health Status; D006801:Humans; D007918:Leprosy / Q000175:diagnosis / Q000453:epidemiology* / Q000635:transmission*; D008297:Male; D009166:Mycobacterium leprae / Q000302:isolation & purification; D011159:Population Surveillance; D018570:Risk Assessment; D012307:Risk Factors; D012424:Rural Population / Q000706:statistics & numerical data*