Hansen's Disease Trends in Florida

BACKGROUND:  Hansen’s disease epidemiology is evolving with increased molecular testing tools, identification of armadillos as potential sentinels or reservoirs, and evidence of possible short-term environmental persistence of the pathogen. Travel outside the U.S. and contact with infected people have been the major risk factors identified for Hansen’s disease historically. A summary of 10 years of Hansen’s disease cases reported in Florida is presented to describe recent trends in Florida as well as gaps in current data collection tools.

METHODS:  Case notes and laboratory data for 89 confirmed Hansen’s disease cases reported in Florida from January 1, 2005 through December 31, 2014 were reviewed in the Florida Department of Health’s (DOH) reportable disease database. Genetic typing was performed by the National Hansen’s Disease Program (NHDP).

RESULTS: Males (66%), those of Asian/Pacific Islanders race (7%) and those of Hispanic ethnicity (39%) were over-represented in comparison to statewide population demographics. Median age of cases was 54 years with most cases being over 40 years of age. Average time from symptom onset to diagnosis was 21 months. Only two cases reported contact with an infected person, both with likely exposure outside the U.S. Eight cases reported direct contact with an armadillo including three with armadillo contact outside the U.S. Genetic typing matched armadillo variants for three cases reporting armadillo contact and five cases reporting no armadillo contact. Fifty-four cases (61%) reported residence outside the continental U.S., while 32 (36%) reported no lifetime international residence. Twelve cases reported residence in Alabama, Georgia, Texas and Mississippi, all states that have leprosy in armadillos. Since 2005 at least three cases were reported to the NHDP but not to DOH. Case numbers for 2015 are incomplete but are at least 50% higher than the 10 year average. Three additional 2015 cases do not meet national case criteria but are polymerase chain reaction (PCR) positive on testing performed at the NHDP 

CONCLUSIONS:  

• There are significant delays in identification of Hansen’s disease cases as well as gaps in reporting to the state or county health departments.
• Although most cases have a history of international residence, over a third do not and few of these cases recall direct contact with armadillos.
• More detailed Hansen’s disease risk information should be collected including factors such as case immune status and soil contact; validated molecular testing should be added to national case definition laboratory criteria.