Brevard has had half of Florida's leprosy cases in the past decade. Why?
Relative to the rest of Florida, in Brevard County leprosy has reached biblical proportions.
Almost half the state's leprosy cases over the past decade happened in Brevard, with the disfiguring disease infecting 85 people between 2012 and 2021, Florida Department of Health data shows. As COVID-19 raged in 2020, Brevard saw a spike of 20 leprosy cases, three-quarters of the 27 cases in the state that year.
Leprosy remains exceedingly rare in the United States, even in Brevard. Still the increasing numbers, while tiny, have puzzled scientists.
Now researchers warn that the state, especially Central Florida, is seeing more leprosy cases "lacking traditional risk factors" such as exposure to armadillos or extended travel outside the United States. That trend, coupled with fewer foreign-born residents getting the disease, brings mounting proof that leprosy is now endemic in Florida and the southeastern U.S., the authors conclude in their recent report in the Centers for Disease Control and Prevention's Emerging Infectious Diseases.
Leprosy, also called Hansen’s disease, is caused byslow-growing genus of bacteria called Mycobacterium leprae. Roughly 95% of people are genetically resistant to the pathogen, so it's not easy to catch.
The disease is believed to be transmitted mainly from person-to-person via direct contact and/or infectious aerosols. Armadillos also carry the pathogen and can infect humans. In years gone by, those with leprosy were often exiled to "leper colonies." Today, the disease is treated with antibiotics.
It primarily infects the skin and the nerves in the skin, according to the Florida Department of Health. But it can sometimes cause infections in other parts of the body including the lining of the airway passages in the nose.
Scientists are stumped as to why there's so much more leprosy on the Space Coast than anywhere else in Florida.
While the Bible points to punishment for sin and uncleanliness, scientists speculate reasons could include ample habitat conducive to more armadillos and the leprosy pathogen they carry, possibly bolstered by climate change. Or maybe there's more gardening and landscaping in Brevard. Or maybe leprosy is just more on local dermatologists' radar. No one knows why, only that it's getting worse.
"From our data, it's probably an increasing health problem," said Jeffrey Greenwald, a dermatologist and volunteer faculty member with the University of Central Florida's College of Medicine. "I don't think this is all just people are reporting it more."
Whatever the reasons, Central Florida has become leprosy central. The region accounted for 81% of cases reported in Florida and almost one fifth of nationally reported cases, researchers at Kansas City University–Graduate Medical Education/Advanced Dermatology and Cosmetic Surgery Consortium in Orlando, wrote in this months' CDC's Journal Emerging Infectious Diseases.
While leprosy in the U.S. previously affected those who had immigrated from leprosy-endemic areas, about 34% of new patients during 2015–2020 locally acquired the disease, the authors found. And several cases in central Florida show no clear evidence of exposure to armadillos or other traditionally known risk factors, including the case of a 54-year-old Central Florida man who the researchers highlighted.
He sought treatment at a dermatology clinic for a painful and progressive rash, which involved lesions on his trunk and face. "He denied any domestic or foreign travel, exposure to armadillos, prolonged contact with immigrants from leprosy-endemic countries, or connections with someone known to have leprosy," the authors wrote.
A lifelong Central Florida resident, the patient is a landscaper who spends long periods outdoors, indicating a possible local environmental reservoirs for the pathogen that causes leprosy, such as soils, which can contain armadillo waste.
Traditional risk factors for leprosy include travel to countries where the disease is prevalent, direct exposure to armadillos or close contacts with persons already infected. "The absence of traditional risk factors in many recent cases of leprosy in Florida, coupled with the high proportion of residents, like our patient, who spend a great deal of time outdoors, supports the investigation into environmental reservoirs as a potential source of transmission," the authors wrote.
International migrants in North America increased from 27.6 million people in 1990 to 58.7 million in 2020, the authors note, so a link to migration "may account for the increase in incidence of leprosy in historically nonendemic areas," they added.
But reports to CDC also show that, although the incidence of leprosy has been increasing, the rates of new diagnoses in people born outside of the U.S. has been declining since 2002.
The authors called for more research in Florida into how humans spread leprosy to each other and recommended that travel to Florida be considered when conducting leprosy contact tracing in any state.
How much leprosy is there?
Leprosy has been historically rare in the U.S. Cases peaked around 1983 and dropped drastically from the 1980s through 2000, the authors note. Since then, cases gradually increased, more than doubling in the southeastern states over the past decade.
According to the National Hansen’s Disease Program, 159 new cases were reported in the U.S. in 2020. Florida was among the top reporting states, with 27 of those cases, 20 of which were in Brevard County, according to state health department data.
Susan Hammerling-Hodgers, a certified physician assistant and master of physician assistant studies at Brevard Skin and Cancer, estimates she's treated about a dozen leprosy patients in the county over the past 22 years. They weren't all gardeners, she said. There was one who had cancer, so was immune-suppressed.
"I had a variety of people that had the diagnosis," Hammerling-Hodgers said. "Other people were perfectly healthy that got it."
Greenwalds's patients have included hunters who ate armadillo meat, a UPS driver who ran over an armadillo and cleaned it up from under the hood of his vehicle. A majority were avid gardeners.
"There's lots of evidence that it's respiratory," Greenwald said.
With human and armadillo numbers increasing, Florida and Brevard's leprosy scourge isn't likely to go away anytime soon, Greenwald says, and is something the public and doctors need to keep an eye out for.
"This is becoming a real problem," said Greenwald, who just had a patient who's toe had to be amputated because of leprosy. "I think it really is a health problem. I think the answer is going to be educating doctors."
Where can I learn more about leprosy?
The Florida Department of Health has information about leprosy here: https://www.floridahealth.gov/diseases-and-conditions/leprosy/index.html
The CDC has a leprosy page here: https://www.cdc.gov/leprosy/
FWC has an armadillo page.
Early signs of leprosy include pale or slightly red areas or rash on the body that is often associated with a loss of sensation in the affected area, according to the FDOH.
Other symptoms include:
Loss of feeling in hands and feet
Dry, stiff and sometimes painful skin in the affected area
Thinning of the eyebrows and eyelashes (if the face is involved)
Nasal congestion is sometimes reported
If the disease goes untreated, weakness in the muscles of the hands and feet can also occur.
How is leprosy transmitted or contracted?
How leprosy is transmitted isn't fully known due to how uncommon it is. Scientists do know it's not spread through casual contact, sexual transmission or from mother to fetus. The prevailing theory is that high levels of the bacteria are developed in a person's nose and are spread to others not immune through prolonged contact.
Exposure to soil contaminated by armadillos also can transmit the disease, so health officials recommend wearing gloves and a mask while gardening, then washing thoroughly afterward.
Source: Florida Department of Health; Florida Today research
This article originally appeared on Florida Today: Why is Brevard County 'leprosy central' in Florida?
