Autochthonous leprosy in the eastern United States is from international migration, not from armadillos.

To the Editor: Domozych et al1Domozych R. Kim E. Hart S. Greenwald J. Increasing incidence of leprosy and transmission from armadillos in Central Florida: a case series.JAAD Case Rep. 2016; 2: 189-192Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar reported 4 cases of leprosy in a single medical dermatology practice in central Florida in a report entitled Increasing incidence of leprosy and transmission from armadillos in Central Florida: A case series. This title is misleading and would lead the reader to assume that their data have identified armadillos as the source of transmission of leprosy in this cluster of central Florida autochthonous cases when, in fact, they had no molecular data linking their cases to armadillos. In a place where just less than a third of the population was born in state, Florida continues to be dominated by people from elsewhere in the country and in the world. The foreign-born population in Orlando is at 14.2% (408,137 immigrants) of a total population of 2,875,341 in 2013 (http://immigrationforum.org). In a recent report, Ramos et al2Ramos J.M. Romero D. Belinchón I. Epidemiology of leprosy in Spain: the role of the international migration.PLoS Negl Trop Dis. 2016; 10: e0004321Google Scholar emphasized the role of international migration on leprosy in Spain, a country of low prevalence similar to the that of United States, by analyzing Spanish immigration statistics and World Health Organization leprosy statistics on the countries of origin. They concluded that the registered incidence of leprosy was lower than expected every year, often more than 50% and as high as 90% per year.2Ramos J.M. Romero D. Belinchón I. Epidemiology of leprosy in Spain: the role of the international migration.PLoS Negl Trop Dis. 2016; 10: e0004321Google Scholar We reported autochthonous leprosy cases in New York City,3Levis W.R. Vides E.A. Cabrera A. Leprosy in the eastern United States.JAMA. 2000; 283: 1004-1005Crossref PubMed Google Scholar including proof with molecular techniques.4Keo T. Martiniuk F. Latkowski J. Cabrera A. Rom W. Levis W.R. Molecular origin of endemic leprosy in New York City.Clin Infect Dis. 2008; 46: 899-901Crossref PubMed Scopus (5) Google Scholar In our original epidemiologic evaluation of leprosy in New York City, we found an average lag from onset of symptoms to diagnosis of leprosy of 4.8 years with some cases going undiagnosed for more than 30 years,5Levis W.R. Schuman J.S. Friedman S.M. Newfield S.A. An epidemiologic evaluation of leprosy in New York City.JAMA. 1982; 247: 3221-3226Crossref PubMed Scopus (15) Google Scholar findings that tend to confirm the lower incidence than expected in the Ramos study. Although the transmission of leprosy is still poorly understood, it stands to reason that the international migration of patients with leprosy is playing a role in what has been identified as a secondary attack of leprosy in New York City, and New York City is well above the armadillo belt. For this reason, additional autochthonous cases of leprosy being reported from the Eastern United States should not be assumed to be from armadillos, especially if there is no history of armadillo exposure. Increasing incidence of leprosy and transmission from armadillos in Central Florida: A case seriesJAAD Case ReportsVol. 2Issue 3PreviewLeprosy, or Hansen's disease, is caused by the acid-fast bacillus Mycobacterium leprae. Leprosy is transmitted by human-to-human contact, although zoonotic transmission has been described, and contact with the nine-banded armadillo (Dasypus novemcinctus) is a risk factor for development of leprosy.1-4 Cases 1 and 2 in this case series show zoonotic transmission from armadillos. An additional source of M leprae infection may be soil or land contaminated by leprosy-infected armadillos.3,5,6 Cases 3 and 4 support this potential mode of transmission. Full-Text PDF Open AccessArmadillos: An emerging zoonosis in FloridaJAAD Case ReportsVol. 3Issue 4PreviewTo the Editor: We read with considerable puzzlement Dr Levis' critique of our case report conclusion that armadillos infected with Mycobacterium leprae were the likely source of our patients' Hansen's disease. We believe that both the clinical and genotypic evidence that the armadillo is an important vector for Hansen's disease in Florida is quite overwhelming. Full-Text PDF Open Access