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

To the Editor: Domozych et al 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 al 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. We reported autochthonous leprosy cases in New York City, including proof with molecular techniques. 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, 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.