Temporal trends and regional heterogeneity of leprosy in an Amazonian Brazilian state: Tocantins, 2014–2024

Tendências temporais e heterogeneidade regional da hanseníase em um estado amazônico brasileiro: Tocantins, 2014-2024

Abstract

Leprosy remains a persistent public health challenge in Brazil, particularly in the Legal Amazon, where its distribution reflects social inequities, environmental vulnerabilities, and heterogeneous access to health services. This study analyzed the sociodemographic profile, temporal trends, and regional heterogeneity of leprosy in the state of Tocantins between 2014 and 2024. A total of 15,734 confirmed cases were obtained from the Brazilian national surveillance system. Annual detection rates and temporal trends were assessed using log-linear regression models to estimate the Annual Percent Change, and regional heterogeneity was examined across the eight health regions of the state. The disease predominantly affected men, adults aged 30–59 years, individuals with low educational attainment, and persons self-identified as of mixed race. Despite year-to-year fluctuations, including a marked decline during the COVID-19 pandemic, detection rates remained consistently high throughout the study period. Substantial heterogeneity was observed across health regions, with persistently high detection rates in Capim Dourado, Amor Perfeito, and Cantão, while statistically significant decreasing trends were identified in Bico do Papagaio, Médio Norte Araguaia, and Ilha do Bananal. The continuous detection of cases among individuals under 15 years of age and the increase in relapse proportions in recent years indicate ongoing transmission and operational challenges in early diagnosis and surveillance. These findings highlight the need for regionally tailored strategies, strengthened contact tracing, and prioritization of high-risk territories to advance leprosy control in the Brazilian Amazon.

Keywords:
leprosy; temporal trends; regional heterogeneity; Amazon region; public health surveillance

Resumo

A hanseníase permanece como um persistente desafio de saúde pública no Brasil, particularmente na Amazônia Legal, onde sua distribuição reflete desigualdades sociais, vulnerabilidades ambientais e acesso heterogêneo aos serviços de saúde. Este estudo analisou o perfil sociodemográfico, as tendências temporais e a heterogeneidade regional da hanseníase no estado do Tocantins entre 2014 e 2024. Um total de 15.734 casos confirmados foi obtido a partir do sistema nacional de vigilância em saúde. As taxas anuais de detecção e as tendências temporais foram avaliadas por meio de modelos de regressão log-linear para estimar a Variação Percentual Anual (Annual Percent Change), e a heterogeneidade regional foi examinada nas oito regiões de saúde do estado. A doença afetou predominantemente homens, adultos de 30 a 59 anos, indivíduos com baixa escolaridade e pessoas autodeclaradas pardas. Apesar das flutuações anuais, incluindo uma redução acentuada durante a pandemia de COVID-19, as taxas de detecção permaneceram consistentemente elevadas ao longo do período estudado. Observou-se heterogeneidade substancial entre as regiões de saúde, com taxas de detecção persistentemente altas em Capim Dourado, Amor Perfeito e Cantão, enquanto tendências de redução estatisticamente significativas foram identificadas em Bico do Papagaio, Médio Norte Araguaia e Ilha do Bananal. A detecção contínua de casos em indivíduos menores de 15 anos e o aumento das proporções de recidiva nos anos recentes indicam transmissão ativa e desafios operacionais no diagnóstico precoce e na vigilância epidemiológica. Esses achados destacam a necessidade de estratégias regionalmente orientadas, do fortalecimento da vigilância de contatos e da priorização de territórios de alto risco para avançar no controle da hanseníase na Amazônia brasileira.

Palavras-chave:
hanseníase; tendências temporais; heterogeneidade regional; região amazônica; vigilância em saúde pública

1. Introduction

Leprosy remains an important public health problem in several low- and middle-income countries, particularly in contexts marked by social inequality, limited access to healthcare services and persistent barriers to early diagnosis. Although the global prevalence of the disease has declined following the introduction of multidrug therapy (MDT), transmission continues in hyperendemic areas where poverty, household overcrowding, delayed case detection and insufficient contact investigation sustain the circulation ofMycobacterium leprae. Brazil consistently reports the highest number of new leprosy cases in the Americas, with the North and Northeast regions accounting for a substantial proportion of the national burden (WHO, 2023; Barbosa-Lima et al., 2025).

The state of Tocantins, located in the Brazilian Legal Amazon, has historically presented some of the highest leprosy detection rates in the country. Surveillance data indicate persistent transmission, marked heterogeneity across health regions and frequent detection of cases among individuals under 15 years of age, suggesting ongoing bacillary circulation and limitations in timely diagnosis. National reports also point to structural challenges related to population mobility, unequal distribution of primary healthcare services and pronounced social vulnerability, which may influence the maintenance of endemicity in the state (Jesus et al., 2023; Sczmanski et al., 2025).

The analysis of temporal trends in leprosy detection is a key component of epidemiological surveillance, as it allows the identification of increases or declines in incidence over time and supports the evaluation of control strategies and program performance. Additionally, the assessment of regional heterogeneity contributes to identifying priority areas, operational weaknesses and inequalities in access to diagnosis and treatment within health systems. Indicators such as detection rates in children under 15 years of age and the distribution of clinical and operational characteristics reported by surveillance systems are widely used to monitor transmission intensity and the effectiveness of control measures (Chen et al., 2022; Santos et al., 2023).

Despite the epidemiological importance of Tocantins, few studies have examined leprosy trends in the state using an integrated approach that combines temporal analysis with the evaluation of regional heterogeneity and operational indicators. The period from 2014 to 2024 encompasses significant changes in the Brazilian health system, including the COVID-19 pandemic, which substantially disrupted the detection and follow-up of chronic infectious diseases and may have affected routine surveillance activities (Butala et al., 2024). The availability of data disaggregated by health region provides an opportunity to examine variations in endemicity and to explore the resilience of the surveillance system during this interval.

In this context, the present study aimed to analyze temporal trends in leprosy detection rates in the state of Tocantins between 2014 and 2024, describing regional heterogeneity across health regions and examining selected epidemiological and operational indicators reported by the surveillance system.

2. Methods

2.1. Study design and setting

A population-based ecological time-series study was conducted using secondary surveillance data to characterize temporal trends and regional heterogeneity of leprosy in the state of Tocantins, Brazil, between 2014 and 2024. Tocantins is in the Brazilian Legal Amazon and comprises 139 municipalities grouped into eight health regions, which present heterogeneous sociodemographic profiles and persistent endemic transmission of leprosy. The state was selected due to its historical contribution to the national leprosy burden and sustained high detection rates over the study period.

2.2. Data sources

Data on newly diagnosed leprosy cases were obtained from the Notifiable Diseases Information System (SINAN), including year of diagnosis, sex, age group, race/colour, educational level, type of entry in the surveillance system, and health region of notification. Annual population estimates by municipality and health region were retrieved from the Brazilian Institute of Geography and Statistics (IBGE, 2024). Only anonymized, publicly available aggregated datasets were used, in accordance with national open-data standards.

2.3. Variables and epidemiological indicators

Analyses incorporated sociodemographic and epidemiological variables relevant for characterizing the profile of reported cases and assessing temporal trends in leprosy detection. Sociodemographic variables included sex, age group (<15; 15–29; 30–59; ≥60 years), race/colour (pardo, preto, branca, amarela, indígena), and educational level.

From an epidemiological perspective, the study focused on newly diagnosed cases, which constituted the numerator for the calculation of detection rates. The proportion of cases occurring in individuals under 15 years of age was used as a sensitive indicator of ongoing transmission and potential delays in diagnosis. Other types of entry recorded in the surveillance system (e.g., relapse or transfer) were described for contextual and operational purposes but were not included in the calculation of detection rates.

Epidemiological indicators included the annual number of new cases, crude annual detection rates per 100,000 inhabitants, and mean detection rates across health regions for the period 2014–2024, allowing assessment of temporal evolution and regional heterogeneity.

2.3.1. Calculation of epidemiological rates

Annual detection rates were calculated using the Formula 1:

$\text{Detection rate}=\frac{\text{Number of new case in the year}}{\text{Population in the same year}}\text{X}\mathrm{100,000}$ (1)

The proportion of cases diagnosed in individuals under 15 years of age was calculated annually as an indicator of transmission intensity.

2.3.2. Temporal trend analysis

Temporal trends in leprosy detection rates were assessed using log-linear regression models. For each unit of analysis (state and health regions), the following model was applied Formula 2:

$\ln \left(rat{e}_t\right)=\beta 0+\beta 1t$ (2)

where$t$represents calendar year. Annual Percent Change (APC) was estimated as Formula 3:

$APC=\left(e\beta 1-1\right)\times 100$ (3)

Trends were classified as increasing (APC > 0 and p < 0.05), decreasing (APC < 0 and p < 0.05), or stable (p ≥ 0.05).

2.3.3. Regional stratification

All analyses were stratified by the eight health regions of Tocantins. For each region, annual detection rates, mean detection rates for the 2014–2024 period, and temporal trend estimates were calculated to identify regions with persistent transmission, epidemiological decline, or heterogeneous patterns over time.

2.4. Data management and statistical analysis

Datasets were harmonized, validated, and aggregated prior to analysis. Descriptive statistics and epidemiological indicators were calculated using Python (pandas). Temporal trend models were fitted using generalized linear models with Poisson distribution and robust standard errors.

2.5. Ethical considerations

This study used secondary, anonymized, publicly available data. According to Resolution No. 510/2016 of the Brazilian National Health Council, research based on aggregated epidemiological data without individual identifiers is exempt from ethical review.

3. Results

Between 2014 and 2024, a total of 15,734 leprosy notifications were recorded in the state of Tocantins. The sociodemographic profile of reported cases is presented in Table 1. Most notifications occurred among males (55.8%), and individuals aged 30–59 years accounted for the largest proportion of cases (56.2%). Children under 15 years of age represented 6.0% of all notifications, indicating ongoing transmission. With respect to race/colour, pardo individuals predominated (65.6%), followed by black (13.4%) and white (13.3%) groups. Nearly half of the cases were reported among individuals with low educational attainment (48.1%), highlighting the social vulnerability associated with disease occurrence.

Table 1
Sociodemographic characteristics of reported leprosy cases in Tocantins, Brazil, 2014–2024 (N = 15,734).

Variable	Category	N	%
Sex	Male	8,787	55.8
	Female	6,947	44.2
Age group	<15 years	951	6.0
	15–29 years	2,453	15.6
	30–59 years	8,848	56.2
	≥60 years	3,482	22.1
Race/colour	Brown	10,329	65.6
	Black	2,105	13.4
	White	2,093	13.3
	Asian	754	4.8
	Indigenous	144	0.9
	Unknown	309	2.0
Schooling	Low schooling	7,567	48.1
	High schooling	5,187	33.0
	Ignored	2,886	18.3
Entry type	New cases	12,174	77.4
	Transfers	1,214	7.7
	Relapse	447	2.8
	Others	1,974	12.5

• Notes.Percentages were calculated using the total number of reported cases. Totals may not sum to 100% due to rounding.

Annual numbers of newly diagnosed cases and crude detection rates are shown in Table 2. The number of new cases ranged from 1,085 in 2015 and 2021 to a peak of 2,205 cases in 2018. Detection rates varied between 70.1 and 145.9 cases per 100,000 inhabitants, with a mean annual crude detection rate of 94.2 per 100,000 over the study period. Temporal trend analysis at the state level revealed a non-significant decreasing pattern, with an Annual Percent Change (APC) of –3.1% per year (95% CI: –7.7 to 1.7; p ≈ 0.20), indicating relative stability of transmission over the decade.

Table 2
Annual new leprosy cases and detection rates in Tocantins, Brazil, 2014–2024.

Year	New Cases (n)	Population	Crude detection rate (per 100,000)
2014	1,268	1,456,210	87.1
2015	1,085	1,471,416	73.7
2016	1,734	1,485,416	116.7
2017	1,691	1,498,537	112.8
2018	2,205	1,511,702	145.9
2019	1,956	1,525,148	128.2
2020	1,130	1,537,886	73.5
2021	1,085	1,548,514	70.1
2022	1,106	1,557,580	71.0
2023	1,334	1,567,191	85.1
2024	1,140	1,577,342	72.3

• Notes. Detection rates were calculated as the number of newly diagnosed cases divided by the population in the same year, multiplied by 100,000. Temporal trends were assessed using log-linear regression models; the estimated Annual Percent Change (APC) for the period was –3.1% per year (95% CI: –7.7 to 1.7; p ≈ 0.20).

Marked heterogeneity was observed across health regions (Table 3). The highest mean detection rates for the 2014–2024 period were identified in Capim Dourado (157.9 per 100,000), Amor Perfeito (116.4 per 100,000), and Cantão (98.2 per 100,000), characterizing areas of persistent high endemicity. Statistically significant decreasing trends were observed in the regions of Bico do Papagaio (APC –8.7%; p < 0.001), Ilha do Bananal (APC –6.9%; p = 0.001), and Médio Norte Araguaia (APC –4.4%; p = 0.021). Other regions exhibited stable temporal patterns, while Amor Perfeito showed a non-significant increasing trend over the study period.

Table 3
Mean detection rates and temporal trends by health region (CIR), Tocantins, 2014–2024.

Health region (CIR)	Mean detection rate (per 100,000), 2014–2024	APC (% per year)	95% CI for APC	p-value	Trend interpretation
Médio Norte Araguaia	71.8	–4.4	–7.9 to –0.7	0.021	Significant decrease
Bico do Papagaio	37.3	–8.7	–12.3 to –4.9	<0.001	Significant decrease
Sudeste	53.4	–2.4	–7.3 to 2.9	0.372	Stable
Cerrado Tocantins Araguaia	69.4	–1.0	–2.6 to 0.7	0.257	Stable
Ilha do Bananal	80.9	–6.9	–10.7 to –2.9	0.001	Significant decrease
Capim Dourado	157.9	–3.4	–12.7 to 6.8	0.494	Stable (high endemicity)
Cantão	98.2	1.4	–3.0 to 5.9	0.545	Stable
Amor Perfeito	116.4	4.3	–1.4 to 10.3	0.138	Non-significant increase

• Notes.Mean detection rates were calculated using crude annual detection rates for the period 2014–2024. APC: Annual Percent Change estimated using log-linear regression models. Trends were classified as increasing or decreasing when APC was statistically significant (p < 0.05). Endemicity levels follow Brazilian Ministry of Health thresholds, with rates >40 per 100,000 inhabitants indicating high endemicity.

Despite the observed reductions in selected regions, all health regions remained above the thresholds established for low endemicity, indicating sustained transmission and reinforcing the need for strengthening surveillance and early diagnosis strategies throughout the state.

4. Discussion

The findings of this study demonstrate that leprosy remains a persistent public health challenge in the state of Tocantins, Brazil, with sustained transmission throughout the 11-year period and marked heterogeneity across demographic groups and health regions. Despite long-standing national control efforts, the magnitude of detection rates remained consistently high, reinforcing Tocantins’ position among the Brazilian states with the greatest leprosy burden in recent years (WHO, 2023; Brasil, 2024).

The sociodemographic profile of reported cases revealed a predominance among males and adults aged 30–59 years, a pattern consistently described in recent national and international studies. This distribution has been associated with greater exposure among economically active populations, delayed health-seeking behavior among men, and occupational or mobility-related risk factors that increase the likelihood of late diagnosis (Alves et al., 2021). The predominance of individuals self-identified as Brown reflects both the demographic composition of Tocantins and the well-documented intersection between social vulnerability, limited access to healthcare services, and increased risk of delayed detection of leprosy (Brasil, 2023; WHO, 2022). Furthermore, the high proportion of cases among individuals with low educational attainment underscores the role of reduced health literacy and structural barriers in sustaining endemic transmission, as consistently highlighted in recent epidemiological analyses (Alves et al., 2021; Lopes et al., 2021).

Temporal analysis revealed substantial oscillations in detection rates over the study period, with pronounced peaks in 2016, 2018, and 2019, followed by a sharp decline during the COVID-19 pandemic. Although the overall trend suggested a non-significant decrease, the absolute magnitude of detection rates remained well above the thresholds for high endemicity throughout the decade. Similar patterns have been described across Brazil and other endemic countries, where reductions during 2020 and 2021 largely reflected disruptions in routine surveillance, reduced healthcare utilization, and reallocation of health system resources rather than true declines in transmission (WHO, 2022; Butala et al., 2024). The partial rebound observed in 2023 and 2024 is consistent with the gradual restoration of surveillance activities and the identification of cases that may have accumulated during periods of reduced detection (Brasil, 2024).

Marked heterogeneity across health regions highlights the localized nature of leprosy transmission in Tocantins. Regions such as Capim Dourado, Amor Perfeito, and Cantão exhibited persistently high mean detection rates, indicating chronic endemicity. Despite their elevated burden, Capim Dourado and Cantão showed statistically stable temporal trends, suggesting long-term maintenance of transmission rather than effective epidemiological decline. Amor Perfeito presented a non-significant increasing trend, which, although not statistically conclusive, is epidemiologically relevant and may indicate operational weaknesses in early detection or sustained exposure in vulnerable populations. Recent studies emphasize that stable or increasing trends in highly endemic settings often reflect persistent diagnostic delays and limited reach of active case-finding strategies rather than biological changes in transmission dynamics (Freitas and Duarte, 2024).

Conversely, statistically significant reductions in detection rates were observed in the regions of Bico do Papagaio, Ilha do Bananal, and Médio Norte Araguaia. These declines may be indicative of improvements in primary healthcare coverage, strengthened surveillance capacity, or localized programmatic gains. However, caution is warranted in interpreting these reductions, as recent evidence suggests that apparent declines in remote or socioeconomically vulnerable areas may also reflect under-detection and persistent barriers to healthcare access, particularly in large territorial units with dispersed populations (Silva et al., 2017; Brasil, 2024).

The sustained detection of leprosy cases among children under 15 years of age throughout the study period constitutes a robust epidemiological marker of recent and active transmission within households and communities. Proportions consistently exceeding 3% and surpassing 6% in several years are incompatible with the expected epidemiological pattern of a declining endemic disease and signal ongoing failures in interrupting transmission chains. Recent studies reinforce that pediatric leprosy remains one of the most sensitive indicators of hidden prevalence and delayed diagnosis in endemic areas (Costa et al., 2024; WHO, 2023).

Taken together, these findings reaffirm Tocantins as a critical hotspot for leprosy in Brazil and highlight the complex interplay between social vulnerability, heterogeneous regional contexts, and operational challenges within the health system. While environmental and geographic characteristics typical of the Amazon region may exacerbate difficulties in access and surveillance, recent evidence emphasizes that social determinants and health system performance remain the central drivers sustaining transmission (WHO, 2022; Brasil, 2024). Strengthening primary healthcare services, expanding active case-finding and contact surveillance, and reducing diagnostic delays are essential components for interrupting transmission and reducing disease burden in high-endemicity regions.

This study has limitations inherent to the use of secondary surveillance data. Incomplete availability of certain clinical and operational variables and reporting inconsistencies across years restricted more detailed analyses and the evaluation of additional programmatic indicators. Nonetheless, the use of comprehensive, state-wide surveillance data over an extended period provides a robust and updated overview of leprosy dynamics in Tocantins, allowing for the identification of temporal trends and regional disparities of direct relevance to public health planning.

Despite these limitations, the present study contributes timely and policy-relevant evidence on the persistence of leprosy in a historically hyperendemic Amazonian state. The results underscore the urgent need for region-specific strategies that integrate epidemiological surveillance with social and operational interventions, reinforcing the importance of sustained investment in early diagnosis, surveillance quality, and equity-oriented public health actions to effectively interrupt transmission.

5. Conclusion

This study provides a comprehensive assessment of the temporal trends and regional distribution of leprosy in the state of Tocantins over an 11-year period. The findings demonstrate that the disease remains widely distributed across all health regions, with persistently high detection rates and continuous occurrence of cases among children under 15 years of age, indicating ongoing active transmission.

Despite annual fluctuations and a temporary decline during the COVID-19 pandemic, detection rates remained above thresholds for high endemicity throughout the study period. These results highlight the persistence of leprosy as a public health challenge in Tocantins and underscore the need to strengthen epidemiological surveillance, particularly in regions with sustained high burden.

Prevention and control strategies should prioritize early diagnosis, systematic contact tracing, and expansion of active case-finding activities, especially in hyperendemic areas. Strengthening primary healthcare services and improving surveillance sensitivity are essential to reduce diagnostic delays and interrupt transmission chains.

The findings also point to the need for future studies aimed at identifying environmental, social, and operational factors associated with the persistence of leprosy in the region. Such investigations may support the development of more targeted and effective control strategies in Tocantins and other endemic areas of the Brazilian Amazon.

Data Availability Statement

The datasets analyzed in this study are publicly available from the Brazilian Ministry of Health through the Notifiable Diseases Information System (SINAN), accessed via DATASUS (http://datasus.saude.gov.br), and from the Brazilian Institute of Geography and Statistics (IBGE). The processed datasets and statistical codes used in the analyses are available from the corresponding author upon reasonable request.

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Edited by

• Editor:
  Takako Matsumura Tundisi

Publication Dates

• Publication in this collection
  23 Mar 2026
• Date of issue
  2026

History

• Received
  03 Jan 2026
• Accepted
  30 Jan 2026