While leprosy remains rare in the U.S., more cases are popping up across the country, including in Florida, where the disease may have become endemic, experts say.  A disease is considered endemic when it is consistently present in a place. A pandemic, like COVID, can spread far and quickly.

While leprosy remains rare in the U.S., more cases are popping up across the country, including in Florida, where the disease may have become endemic, experts say. A disease is considered endemic when it is consistently present in a place. A pandemic, like COVID, can spread far and quickly. (Pratchaya Leelapatchayanont/Dreamstime/TNS)

MIAMI (Tribune News Service) — Leprosy, a disease of the skin and nerves, hearkens back centuries, all the way to its reference in the Bible in the Book of Leviticus.

People in Florida are talking about leprosy again — and not just in church or Sunday school.

While leprosy remains rare in the U.S., more cases are popping up across the country, including in Florida, where the disease may have become endemic, experts say. A disease is considered endemic when it is consistently present in a place. A pandemic, like COVID, can spread far and quickly.

Even though most people have natural immunity against the ancient bacteria that causes leprosy, thousands across the world get ill with the disease every year. And in the U.S., which sees about 150 cases a year, infections in the southeastern U.S. have more than doubled in the last decade, according to research published last year in the U.S. Centers for Disease Control and Prevention’s Emerging Infectious Diseases peer-reviewed journal.

The report was written by Central Florida doctors Aashni Bhukhan, Charles Dunn and Rajiv Nathoo.

But there is a cautionary tale at work here.

“The ultimate message for the general public, is do not panic,” Dunn, chief resident of the ADCS Orlando Dermatology Residency Program, said in a telephone interview with the Miami Herald. “This is a very rare disease process that is still very uncommon in the United States and something that is highly treatable if caught early, and not something that people need to be anxious or nervous about. It’s actually incredibly hard to contract — 95% of the population is genetically not susceptible to contracting it.”

The study, he said, was primarily aimed at educating the clinical community given the strong geographic predilection for leprosy. There’s still much to be learned about leprosy and why it is endemic in some states and wholly absent in others.

The bacteria that fuels the disease is slow growing and can take 5 to 20 years for symptoms to appear, which can make it slip under the radar in routine medical visits, Dunn said.

“There’s some misconceptions within the clinical community about how it’s contracted and how it’s transmitted,” he said.

Another takeaway from recent reports is to tell your doctor if you suspect something is wrong.

“If you have any questions about your skin, or if you have any clinical concerns about your exposure history that make you nervous, that you could potentially have it, find your local physician, find your local dermatologist, and ask them questions and we’ll be able to answer them. But this is not something that you need to panic about. It’s not something that is spreading or rampant or anything that the population needs to be concerned about,” Dunn said.

What the numbers reveal

In 2022, 136 leprosy cases were reported in the U.S., mostly in Florida, Texas, New York, California, Arkansas, Louisiana and Hawaii, according to the most recent data available through the National Hansen’s Disease Program in Baton Rouge, Louisiana.

Florida recorded eight cases in 2022, or about 6% of the cases reported in the country that year, and three of those cases were in Brevard County in East Central Florida, state data shows.

In 2020, Central Florida accounted for nearly one-fifth of the 159 cases reported in the country, according to the CDC report. Florida’s Reportable Diseases Frequency Report found that of the 27 cases that year in eight counties, 20 of those were in Brevard and none in South Florida.

There are just three cases of leprosy in Florida in 2024, through March 26, out of a population of nearly 23 million people, according to U.S. Census data — one leprosy case each in Polk, Sumter and Volusia counties, all in the Central Florida region.

“There’s this common misconception within the medical community that leprosy only occurs in people that were born in countries outside the United States,” Dunn said.

The majority of cases of leprosy are diagnosed and occur outside the United States. Most cases occur in India, Brazil, Indonesia, Nepal, Bangladesh, he said.

Here’s more to know about leprosy in modern times:

What is leprosy?

Hansen’s disease, or leprosy, is a disease that affects the nerves and skin. It’s one of the oldest infectious diseases in human history, and is caused by a slow-growing bacteria called Mycobacterium leprae. About 95% of people are naturally immune against the bacteria that causes leprosy, according to the Florida Department of Health.

▪ Symptoms: Leprosy causes discolored patches of skin, lumps and ulcers, and numbness in affected areas. If left untreated, leprosy can lead to paralysis, crippling of hands and feet, disfigurement and blindness.

▪ What to look for: Dunn says leprosy can appear as patches or plaques that are well marked. “I can take a pen and I can draw a circle around them perfectly,” he said. These skin patches or plaques tend to be lighter in color, but not always. And if you rub your finger over that area it tends to have less sensation than the surrounding skin, Dunn noted. “One mimicker of this is actually psoriasis. So it can look a little like a psoriatic plaque,” Dunn said. Other presenting signs to look for include a loss of the eyebrows and eyelashes and a kind of thickening or furrowing of the facial features. “The ear lobes can start to elongate a little bit as the nerves and the connective tissue kind of gets softer,” Dunn said.

▪ Treatment: Leprosy is typically treated with two or three antibiotics simultaneously for one to two years to help prevent the bacteria from developing resistance against the drugs, the U.S. Centers for Disease Control and Prevention says. While treatment can cure the disease and prevent the illness from getting worse, it cannot reverse nerve damage or physical disfiguration from the illness.

▪ The bottom line: “In the past, Hansen’s disease was feared as a highly contagious, devastating disease, but now we know that it’s hard to spread and it’s easily treatable once recognized,” according to the CDC. “Still, a lot of stigma and prejudice remains about the disease, and those suffering from it are isolated and discriminated against in many places where the disease is seen.”

How does leprosy spread?

Even though leprosy has ancient roots, doctors still don’t know how leprosy spreads between people. What they do know is that leprosy doesn’t spread easily and is easy to treat if detected early, according to the CDC.

Scientists believe leprosy can spread by inhaling infected respiratory droplets that are released when an infected person coughs or sneezes, similar to how flu and COVID spread. However, unlike with flu and COVID, you need to inhale these infected respiratory droplets over a long period.

“Prolonged, close contact with someone with untreated leprosy over many months is needed to catch the disease,” which means you cannot get leprosy through “casual contact,” such as by shaking hands, sitting next to each other on the bus or sitting together for a meal, according to the CDC. Leprosy is also not spread by sex nor can it be passed on to an unborn child during pregnancy.

How do armadillos factor in?

Some nine-banded armadillos in the southern United States, including in Florida, are also naturally infected with the bacteria that causes leprosy. The CDC say it’s possible that contact with the animal could cause a human to get infected although the risk “is very low” and unlikely. The public health agency still cautions people to avoid armadillos when possible.

“There are pockets where nine-banded armadillos appear to carry this particular strain of Mycobacterium leprae that also appears in humans but we don’t know how it gets from armadillos to people. But when they tested the armadillos in different pockets, they showed that for whatever reason, armadillos in Central Florida, as well as five or six other locations, harbored the strains of Mycobacterium leprae that people get,” said Dunn, the expert at the ADCS Orlando Dermatology Residency Program

But in some other U.S. locations where people and nine-banded armadillos also mingle, and where there are no reported cases of leprosy, those armadillos didn’t harbor the Mycobacterium leprae strain.

“The transmission is really poorly understood,” Dunn acknowledged.

Is leprosy endemic in Florida?

The research report published in the CDC journal indicates that there’s growing evidence leprosy has become endemic in Florida, according to a report published recently in Newsweek.

The report noted that many of the recent cases reported in the eastern United States, including Georgia and Central Florida, lacked typical transmission routes, such as traveling to a country where the disease is widespread and having contact with armadillos.

“Endemic in and of itself is a hot word,” Dunn said, concurring with the research report. “By definition, the CDC defines endemic disease as the constant presence of a disease or an infectious agent within a given geographic area or population group that is neither spiking nor decreasing. It’s just kind of like present. The idea of endemic leprosy looks like it is endemic in certain pockets of the United States and I would say that Central Florida is included in that.”

The report published in Newsweek noted that there “is some support for the theory that international migration of persons with leprosy is a potential source of autochthonous transmission.” It also noted that while leprosy cases are increasing, the rates of new diagnoses among people born outside of the U.S. have declined since 2022.

Who is most susceptible?

The age range of people diagnosed with leprosy in the research studies have been 9 to 75. But most patients tend to be older than 50, Dunn said. “As you get older, your immune system starts to shift and change and your susceptibility to particular things becomes increased.”

Why are most people immune?

Despite the biblical age of this disease, experts remain stumped as to why 95% of the population has a natural immunity to leprosy.

“The classic mantra for leprosy is that you need a susceptible patient, you need prolonged contact, and you need a sufficient bacterial load,” Dunn said. In the vast majority of patients, when the disease invades the body’s skin and nerves, the immune system recognizes the foreign entity and attacks it, nullifying it. In 5% of the population, these individuals don’t have the genetic makeup or the genes that are key to recognizing this bacteria and thus fight it, Dunn said. “It’s a genetic polymorphism or it’s a genetic trait that people inherently have, but we don’t know exactly why.”

Is there a vaccine for leprosy?

A vaccine can’t be formulated because the bacteria is so slow replicating that scientists have yet to even culture it in a petri dish, according to Dunn.

“It’s what’s called a non-culturable disease. We know it exists. We’re able to get what’s called a PCR and test and prove its existence, but we’ve never been able to culture it because it replicates so slowly, and that’s part of the challenge with these diagnoses that we have in the United States,” he said.

Is contact tracing possible?

Contact tracing, which became a household phrase during the COVID pandemic, is next to impossible to conduct for leprosy to pinpoint the origin of its transmission.

“We’re talking about an exposure that occurred years ago — 5, 10, 15, 20 years ago, right? So that’s different than something like COVID where you can walk back a week to two weeks and discover where it was that the contact occurred. But for leprosy, whenever you’re trying to figure out where it happened it’s hard to figure out exactly where it happened,” Dunn said.

Are there travel advisories?

The CDC has not issued any travel advisories for Florida or other states due to leprosy, the public health agency’s website states.

A breakdown of leprosy cases in Florida

Florida has confirmed 203 cases of leprosy since 2013 and 11 of them were in South Florida, according to the state’s web-based reportable disease surveillance system. While state officials still don’t know where many of the infections originated, they’ve determined that at least 63 of the 203 cases, or about 31% of the reported cases, were acquired in Florida. Nineteen of the cases, or 9%, were acquired in another country.

So far, Florida has confirmed three cases of leprosy this year, state data shows.

▪ One person in Sumter County who is between the ages of 20-24. State health officials don’t know if the person was infected in Florida, another state or another country.

▪ One person in Polk County who is between the ages of 25-29. State health officials say the person acquired the infection outside of the U.S.

▪ One person in Volusia County who is between the ages of 55-59. State health officials believe the person acquired the infection in Florida.

When was the last time South Florida recorded leprosy cases?

▪ In Miami-Dade, the most recent confirmed leprosy case was in 2014. A person between the ages of 50-54. State health officials don’t know where the person was infected.

▪ In Broward, the most recent confirmed leprosy case was in 2021. A person between the ages of 50-54 was infected outside of the U.S.

▪ In Palm Beach County, the most recent confirmed leprosy case was in 2023. A person between the ages of 65-69 was infected in Florida.

▪ Monroe County hasn’t recorded a leprosy case in more than 10 years. The last time a case was reported in the Florida Keys was in 2010. The case involved a person between the ages of 55-59 who acquired it in Florida.

©2024 Miami Herald.

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