 Back with the Department of Health, we want to be healthy, not only individually, but as a community. Sarah Park is our guest today, my co-host, Kisha King. Sarah Park is, can I say this, the state epidemiologist? Oh, very good. Yeah, not bad, you know. Pretty good. Yeah, you got to study that word. Yes, you do. Sarah, what is an epidemiologist? Well, so I should start and say it's not tied to a specific subject matter in that a lot of people, because of my role and what I do, they tend to think that an epidemiologist only works on infectious disease issues. But an epidemiologist basically just studies disease trends, how those conditions are impacted in the population, you know, in individuals and how the differences occur in individuals, why they occur in particular individuals, but not in others. It's basically understanding what's going on, you know, with those diseases. It's not particularly to infectious disease. There are chronic disease epidemiologists. There are environmental health epidemiologists, maternal child health. I just tend to focus on infectious disease. Okay. But it sounds to me like epidemiology is only one of your roles to do other things as well in our state. So we're here to talk about, what are we here to talk about, Kisha? Today we're going to talk about rat lungworm disease. We're going to talk about why it's here. There are so many cases here. Why? Well, it's not so many cases, but it's more cases definitely than we'd like to see. I remember when this first came up and it was in the early 2000s. I call it the odd years. Yeah, we don't know what to call those years. No. They were a dark hole. Maybe this is a dark hole too, this one, this decade. Anyway, so here we are in the early 2000s and some cases come up on the big island and we're all kind of shocked by how this disease progresses. And it's kind of a Hawaii-specific kind of disease, isn't it? We have more than our fair share. Hawaii-specific compared with the rest of the United States, yes, but not Hawaii-specific compared with the rest of the world. In the South Pacific and the sort of Southeast Asian and Southern Asian areas, those countries or regions, they've definitely seen rat lungworm or angiostrongeliasis much more frequently than we have. They have probably greater risk factor in certain cultural aspects in that it's in their culture actually, some of them to eat raw snails or undercooked snails and such as part of their diet and so that's how they get more readily exposed in some cases. Yeah, it's not something we like to see here in Hawaii. Unfortunately, we are endemic for it. It probably came over either the slugs or snails being brought over or the rats, infected rats came over. No one's really clear how it came over. Which one brought, which is the original vector? Right. It most likely was introduced to Hawaii so you could call it an invasive species. You know what I like about rat lungworm? There's not too much to like about rat lungworm. I can't find a single thing. The only thing is if I had rat lungworm, I could not pass it directly to you. No. I could not do that. It's not a person to person. It's not really infectious. No, it's not infectious in the sense it's not a person to person infection. It has to be consumed. So you have to accidentally or intentionally, as we've seen in some cases, surprisingly, consume either an infected snail or a slug or there are a few other potentially, they call it paratonic hosts. But generally speaking, we're talking about slugs or snails. You ate a rat. You'd be at risk. No, not necessarily. So more snails are worse than rats then? Right. Because rats are generally, they're infected with a different stage of the parasite. So the parasite goes through various stages of its life cycle. And the stage it's in, in the slug or snail, is the stage that's perfect for us to get infected. Whereas the stage it's in, in the rat, not necessarily so. So I think most people are not going to be eating rats where they're obviously infected with parasite worms. I knew it probably would take away the green pass in the restaurant. They were serving rats. I think most people will be turning up their noses and be a little bit wary of any place that had rats around in their eating establishment. So it's a circle. It's a cycle, right? In all seriousness, yes. And the cycle between humans and rats. Well, so it's not between humans. Humans, we fall into the life cycle. So the life cycle is... Oh, we're not part of it. We're not part of the life cycle. The regular life cycle is slug, snails or mollusks and rats. And they go on this current, you know, constant cycling around where rats are the definitive hosts. What we mean by definitive host is that's where the parasite reproduces itself. Whereas the slug or snail is what we call an intermediate host. They just sort of carry one stage of the parasite, but the parasite actually can't reproduce in the snail or slug. So if you imagine, you could, if we ever, by any miracle, eliminated all mollusks, we could potentially affect the life cycle to a certain extent. But more effective would be to get rid of rats or to limit or control the population rats. Because as I said, they're the definitive hosts. You cut out the cycle that way. They're the ones that the parasite reproduces constantly in. So if you cut out that ability to reproduce itself, you know, you control the rats, then you can control the potential for us to get infected. We fall into that life cycle because slugs or snails, anyone of us who lives in Hawaii knows, you know, in the morning, in the early evening, you've seen the snail trails, the slug trails, right? And if you've got a home garden or even just any vegetation, you can see those slugs or snails going into the leaves and getting into the crevices. Or, you know, even around your property, if you happen to have, like, in a pail or something that's overturned and making a nice dark sort of shade with maybe a little moisture underneath, you overturn that, even some tarp, right? If you overturn those, you'll find plenty of these slugs or snails. But where I was going with the home garden and such is that slugs or snails. Well, not the slime, the slugs or snails. It's not the slime because I have a reference to Ghostbusters, the movie, when they said, oh, I've been slimed. Okay, but no, it's the slug or snail. So the tissue of these slugs or snail are just totally teeming, can be teeming with this parasite. We accidentally ingested it. If we didn't wash our lettuce or these days a lot of people are into kale and you imagine, so when you wash your lettuce, your head of lettuce, when you get it home from the farmer's market or you grew it in your backyard, do you take it apart leaf by leaf and inspect it? Because that's what we recommend in the state of Hawaii, is that if you're home, you have homegrown vegetation, you should be inspecting that leaf, especially the leafy greens, leaf by leaf and rinsing it with your hands mechanically. The natural and organic is not the way to go. Well, it can be, we're still saying healthy greens are healthy for you, but you just need to be careful. They just need to have it out of the ground, not clean it. I mean, that's what happened in the odd years. They would grow it in the backyard and then they wouldn't clean it right and then they would eat it and bingo. A lot of people, their practice, when we've interviewed folks, we find that a lot of people just run and take the head of lettuce or a few leaves and they put it under running water, shake it off and then put it on the counter or on the cutting board and proceed to make their salad or whatnot. But we've also found that by doing that, you could potentially miss some of the slugs or stales. Here's my big question, Sarah. Falled into those corners. Big question. I was thinking about what big question I would ask you. This is a big question. I go into a restaurant and I order a salad. This is not unusual or wonderful because that's mostly what I order. Salad. So do I. It shows on you, it doesn't show on me. Anyway, how do I know that the people who have prepared that salad are doing the right thing? In any restaurant in this state, there could be somebody who doesn't do the right thing. So it's not a matter of looking at the small towns on the big island or anything like that. It could be anywhere, right? Sure. So the risk is here in the state of Hawaii and it's all about, it's not necessarily homegrown or whatnot. We're finding also, likely, there's a suggestion that it's also how you store your food. So as far as eating establishments, you mentioned that the placard system that our environmental health colleagues in the department have instituted several years ago. And so that is one way to be assured that our eating establishments are following the food code correctly, making sure that things are handled appropriately. It's anecdotal though. The inspector goes in, he makes sure that at that moment in time, and he may have a surprise inspection. I know that. Sure. But at that moment in time, everybody's doing it right. But then next day, maybe somebody doesn't do the right thing. Well, there's always that risk, right? But I think many of the establishments, I mean, this is their reputation. If the word gets out about something, their reputation is down to it. The end of that restaurant. That's the end of their business, exactly. So there's, nothing is 100%, but it is a means to have some reassurance that people are acting accordingly in the eating establishments. The other thing to think about is that we're not talking about produce from the mainland. And the amount of produce that is required to supply these establishments, a lot of them are getting their supplies and most of them are getting them from the mainland. Now, there is the Farm to Table movement where there's local produce, but what we've seen is that a lot of these eating establishments, I mean, they're very well aware of this risk factor, as well as a lot more common foodborne diseases like E. coli, Salmonella, Shigella and such. Taking pains to make sure the produce that they serve is well washed, you know, go through several rinses and such before they actually serve, you know. And again, it's the reputation. It's not just that someone becomes ill. Can you imagine that you're in an eating establishment and someone says, waiter, I've got a slug in my snail. Everybody reads. Yeah, everyone's, it's not just the disease. It's the fact that there was something in the salad that can cause an issue for the reputation. So these are things that I'm sure are many of the eating establishments in our state consider. So what I get out of this is that if you knock off the rats and you don't fool around with snails, you just don't fool around with snails. Or slugs. Or slugs. Or slime. Well. Slug, slime, snail slime, right? That's more of a precaution, but it's not been proven that the slime is actually... Oh, okay. I didn't know that. Right. So if you, you know, knock off the rats, don't deal with snails or slugs. And you watch out in restaurants for the green pass sign. That helps to reduce the risk. You're reasonably sure that you're not going to get this disease. Right. Reasonably sure. Reasonably sure. I can't guarantee anything 100%. If you don't go to restaurants and you go to a food market that only has... You go to a food stand on the side of the road where there's no placard and there's no running water and you don't know what the food source is and they're serving kale smoothies and such. I would not order those. Let's just put it that way. You know, so I'd want to make sure, I'd want to actually see them hand washing everything before I actually ate it, you know. So those are the establishments that, you know, you have to be a little bit more questioning of. I know there are people, especially our visitors, like to think it's quaint, roadside stand and things like this. This is not the place to be quaint. No. And it's your body. It's your health. Right. So I know what you're burning to ask, Keisha. Oh, please tell us, what am I burning to ask? I know you're burning to ask. So if I get it, and there's not that many cases in Hawaii, three I think this year, total? You know, honestly, I'd have to look at the latest counts. Less than one hand. Less than one hand. That's the residents. We have some non-resident cases too. Oh, my goodness. Okay. So if I get it, two questions that I'm sure you're going to ask. One is, what happens to me? And two is, what can I do about it, comma, if anything? I hear you asking that. That is my question. I did want to know what the symptoms are, because from what I read, it does seem as though the symptoms are much like the flu initially. Sort. Not really, actually. The flu, remember, is a respiratory infection, and so you're going to have coughing and sneezing. That's not part of RAT lungworm, a disease or angiological. Headache and bodyache, though. Headache. Yeah. Bodyache is not the same as the kind of body aches you get with the flu, necessarily. So if you think about it, the way this worm causes symptoms is that it likes to go to your central nervous system. Okay. So when it invades our body, we accidentally ingest it, it gets into our bloodstream, and it travels to our central nervous system. And there is no, what's the word I'm looking for? No specific area that they're really targeting in your central nervous system, and so it can go anywhere. It's just basically trying to find its home, and we're not it. So it keeps moving around until it dies, because it will die in us because we're not their home. We can't provide it what it needs to survive. But while it's alive and it's moving, that's what's causing damage. The physical actual damage it's causing as it migrates, as well as- Does it grow in size? Right. Well, no, no. But it's like a having, I've said this before to others, it's like having a slow-moving bullet moving around your central nervous system. Plus, it's because it's foreign to our body, our body's recognizing it's foreign, there's this huge inflammatory response. So a lot of inflammation swelling and such. So those two things, that physical movement plus the inflammation combined are what's causing the symptoms. Now, where it migrates to in your central nervous system is what dictates in terms of the specific symptoms that you might get. Some people complain of having odd skin sensations, tingling, burning, sensation in their skin. Other people have weakness in their limbs. Other people have facial, what we call facial palsies. They all have headache though because that inflammation, that, you know, there's blockage going on- This is hard to diagnose. Is it hard to test? Yes. Do doctors in the state of Hawaii know what it looks like? We're constantly hoping that more and more of them do know. And I think that those doctors who are, and other healthcare providers who practice in Hawaii regularly, I like to think most of them by now have at least heard about the disease and know where to call if they need help. I think our challenge at times are those temporary doctors and nurses, so to speak. The temporary healthcare providers sometimes have to fill in sometimes when there's a shortage in a healthcare facility or someone's on vacation or, you know, you see this a lot in the emergency department sometimes. Some of our neighbor island hospitals sometimes. Because there's not that much of it. They have health care providers. Health care providers, right? Right. It's not something that they're familiar with on the mainland. A lot of them are coming from the mainland, remember, and they're not going to be familiar with this. So it's a constant challenge to try and educate those healthcare providers, not just doctors but nurses and other folks who are, you know, the traveling doctors, shall we call them traveling nurses, right? Making sure that they're aware. So that leaves it to the individuals, to be sure. It does. Well, it does to a certain extent. But, you know, on our part in the Department of Health, we try to make sure that there's a website that has a lot of information that is available for the public but also for healthcare providers to reference. There is now a clinical work group that's a subgroup of the governor's task force, which I'm a part of as well. And we as clinicians are getting together to try and, we've already developed preliminary guidelines and we provide a link to that preliminary clinical guidelines for doctors and nurses and such on our website. The clinical work group is working on a, you know, a final guideline that, a more complete guideline for healthcare providers. These are all tools to help a healthcare provider in terms of recognizing and management. Management. That's the question you have to ask it. The big thing, though, is the headache. You know, and it's severe enough headache that a lot of healthcare providers or physicians will consider the diagnosis of meningitis. Because it's that severe. It's not just headache, stiffness in the neck, you know, various other things that would sort of clue into a healthcare provider that there's something more than just a regular headache. And that usually triggers to do what we call lumbar puncture, to collect cerebral spinal fluid. And that sounds scary to the average person. There's actually a routine part of a diagnostic workup if you're thinking about something neurological and it can offer a lot of information. So you take the spinal fluid and you look, and you can see it under a microscope. You can't see the parasite. I've probably, like, rarely see the parasite, because the parasite really doesn't hang out in that fluid that's bathing your brain and your spinal cord. It's hanging out in the brain. What you'll see is cells, white blood cells that fight infection right in our body. There's a particular type of white blood cell called eosinophils. And those start getting produced in large numbers when we have this parasitic infection. It can be produced in response to other things, but in the state of Hawaii, when we have CSF, or lumbar puncture fluid, where you have this case of person with severe headache and potentially other neurological findings, and now you see in that CSF that the eosinophil level is high, that they have white blood cells and it's predominantly eosinophils. That's a huge, you know, ding, ding, ding, you know, this is probably going to be industrialized. So now I have it. And it sounds, no, I miss a wild guess. I'd like to make a wild guess. So we know that it's going to create an inflammatory reaction. We also know, I think I heard you say that after a while it doesn't find a home and it's got nowhere to go and it burns itself out. Right. So the idea is to wait it out and avoid the, manage the inflammation while we're waiting it out. Right. So there's a spectrum like all infectious diseases, there's a spectrum of clinical presentation or disease, right? Symptoms, and so some people are going to be lucky enough to have mild symptoms, mild being severe headache, which some people would argue is not mild. And then others are going to have more sort of complications and neurological symptoms and such that last for a few weeks or longer. And others unfortunately, very few, but there are going to be some unfortunately will have severe disease even as severe as coma and even a couple instances of death. Now this is why it's so important that they're under medical care that a physician is following them, is checking their labs, potentially treating them. The preliminary guidelines that I mentioned earlier, we've recommended that clinicians should consider in these patients providing steroid therapy as long as they've excluded all other. Managing the inflammation. Right. As long as they've excluded all other infectious disease causes. Because you never want to give steroids to someone who has like a bacterial infection. If you do that, you're just going to make things worse. So you have to first exclude all the other potential causes of infection. Then you're pretty sure that you have this parasitic infection. The treatment right now of recommending as steroid therapy, high dose steroids, for at least a couple of weeks and monitoring while on those steroids. Because if you're on high dose steroids, if you're diabetic, that could be a problem because it throws your sugars off, for example. And then there is a potential that we're actually discussing right now. The clinical worker is discussing about the utility of using antiparasitic medication. And the jury is really out. The research that's been done and there's very limited research out there because it's not like this is so common. That would be experimental at this point. Yeah. So what's definitive, we definitely say steroid therapy. Cluster minus what we call anti-helmets or antiparasitic drugs and monitoring the patient very important. Now to back up to the diagnosis. So simple rule of thumb is, as I mentioned, that cerebral spinal fluid. But please also report to the state of Hawaii because then what we can do is help to do what we call a PCR test, a polymerase chain reaction test. And that's to look for the DNA of this parasite in the CSF. Now, We can do some testing on that and maybe even solve it. Right. So it just to give definitive diagnosis. Most of the time, like I said, if you have a patient with all the clinical symptoms, they've been in Hawaii. They've now got eosinophils in their CSF greater than 10% eosinophils. That's pretty much likelihood this is this parasitic infection because we don't really have other conditions that will cause that. Ideally, somebody even here and japs them, you know, because they talk about these DNA things, finds a way to neutralize, you know, the worm. That would be nice. That would be nice and we would be famous here in Hawaii if we solved this problem. Not just for this parasite but many other, I mean, there are many cousins of this parasite that cause problems in other parts of the world so that would be an amazing find if you could figure that out. If you manage it, this is my last question before I ask you to take a break. If you manage it and now you don't have such an inflammatory reaction and your body's immune system is dealing properly, however that might be and the parasite is like, you know, not finding a home. It's getting tired. It dies. It dies. Can it come back? No. It cannot come back. Once it's dead, it's dead. So at some point, people will recover if you're going to recover except as I mentioned, the few that might go on to more severe disease. And the other thing to keep in mind is that you may recover from the infection but you could have long-term complications because again, it's moving through your exactly, it's moving through your central nervous system causing damage. So if it caused some irreparable damage, you're going to have to recover, rehabilitate from that if at all possible. So there are other long-term potential effects. Not a happy thing. You know, and my neurological system, I just suggest that we take a break. We don't have time for a break. We're going to go right in. But we have to make it clear to our audience that we've been talking about rat lungworm with Sarah Park, state epidemiologist, and more. And we're going to stop talking about rat lungworm. Now we're going to talk about measles. Make a note. This is going to be on the final exam. Measles. This is the measles part. Measles. Let me just open the discussion by saying, you know, this thing about anti-vax is so ridiculous that it's like sliding back into the 12th century. I do not understand for a moment why responsible institutions actually encourage this. And yet they do, even here, even in Hawaii, you should go out with a baseball bat and fix this. I don't know if that's the appropriate response. And I'm not sure which institutions are actually supporting. I hope not. But because generally it's not a good idea to support pseudoscience. You know, the data is clear. Measles is a severe disease. I think this, in this day and age, our population is healthier. So, okay, one could argue we're a healthier population. We get hit with measles. Maybe not as bad, you know, severity-wise compared with, you know, early 1900s or, you know, late 1800s where nutrition was always, you know, potentially challenging issue for a large part of the population. Other issues in terms of, you know, not as well protected against other diseases and such. Am I right to say that in a comparative analysis, if you have a lot of childhood diseases out there, although this isn't really limited to childhood, there's a lot of childhood diseases out there and some of them are really bad. Some are fatal even childhood diseases. And measles can be fatal. Measles can be fatal, but, you know, in years past, 50 years ago, 50, 60, 70, 100 years ago, measles was among an array of things. And it actually was not the worst kid on the block. Small pugs was, right? Or the neurological thing, I forget the name of it, you know, where you get an infection in your nervous system. Which one? I forget. Measles can do that too. Yeah. Measles can do that too. So all I'm saying is that now, we've beat back most of those other ones. Right. And measles stand alone and it is quite serious. It is serious not only on an individual basis, but on an epidemiological basis. And you are so terribly inconsiderate if you allow your kid. Oh. I thought you're telling me I'm inconsiderate. I'll make my point. Okay. You are very inconsiderate to the community. If you care at all about the community, you have your kid vaccinated. Right. It's not only him, it's everyone in school. I would actually just correct you and say, measles doesn't stand alone. What is interesting about measles and what makes measles stand out is it's because it's so communicable, so infectious that it is essentially sort of the beacon of all these other infectious diseases coming back. It basically shows us if this most infectious of all the diseases that we're vaccinated against right now is coming back now, it's an indicator of how low our vaccination levels are in our communities. How long? And the likelihood that we will see other infectious diseases that we can vaccinate against. Measles is just, it's obvious. Because the vaccine covers more than measles. Well, the MMR does cover more than measles, but what I'm talking about is we have a whole array of childhood vaccinations and I say a whole array, but really we're talking about a handful of vaccines, a handful of tools to fight against thousands of pathogens out there. We'd only touch on defending against a handful of them. So measles, the MMR vaccine protects against measles, mumps, and rubella, or what used to be called German measles. And rubella being a problem for pregnant women because we saw devastating impacts on their unborn children, the fetus. Mumps being a problem as we've seen with our mumps outbreak in the past a couple years in terms of swelling and potential for sterility in males and females as well as potential for other things here in impairment and potentially encephalitis in the past. That's the one I was trying to think of in encephalitis. So measles can cause encephalitis. In fact, you know George in the giant peach, Roald Dahl, the famous author. Unfortunately, his four-year-old daughter died from measles and she had measles and encephalitis. She succumbed and died. He wrote about it. It's extremely tragic. And she was healthy before she succumbed. So it just shows that there is no rhyme or reason this virus can happen. The other thing... We've got to stop it. I just want to add to is people don't realize that when you get measles infection it also messes up your immune system in general. And there have been studies in the past to show that once someone recovers from measles for some time afterwards your immune system is not the same and you are more vulnerable to infectious diseases in general than if you had not had measles. That's definitely going to be in the final exam. Yeah. So what do you say to parents who are concerned about their children getting autism because of vaccines? Sure. There have been so many studies now to demonstrate that the safety of these vaccines, I know that some of the arguments that have been made in terms of additives and whatnot, I mean, think about the technology advances these days and that and compared with when these vaccines were first on the market. There is so far fewer less additives if you will in these vaccines and they were and there were when these vaccines were first made. On top of that our technology so precise that we can even limit it to a small amount of the protein that we put or the weakened virus in this case that we put in the vaccine just enough to induce immunity to teach your how to fight off this infection whereas back in the day there was loads more of protein or virus weakened virus or whatnot included in the vaccine so even all of us who were vaccinated in our day probably got more additive more of the what we call antigen in our vaccine that we receive than what the kids now are getting if in a way it's a much cleaner vaccine but I would also encourage parents to talk to your healthcare provider talk to your pediatrician you know express your concerns have that dialogue I think honestly one of my concerns in Hawaii is that unfortunately our healthcare providers are weighed down with a lot of requirements billing requirements and such as our healthcare providers elsewhere so oftentimes they're very much constrained about time limits with their patients when they really would love nothing better to spend as much time talking to these parents you know and so a lot of times there is some I will acknowledge there are some limitations in terms of being able to do that perfect segue for the end of the show we hate time limitations yes we would like to spend all day with you but I think I think we're out of time so Kisha it's up to you to make some kind of final statement about this okay I don't envy you that but can you make a closing statement I certainly will and Sarah if you disagree she says speak up sorry I would say the number one thing that a person can do to help themselves is to wash your produce that is because of the rat lungworm disease we know that if you wash your produce thoroughly the same way we teach you to wash your hands to prevent the flu if you do that I think you would really help yourselves and the community also keep the area around your home clean that way you can prevent rat carry the germ or carry the worm who give it to the slugs because the slugs eat the poop from the rats too technical for me and it's also gross but wash your produce wash your fruit you don't need any special things to do this any special chemicals just water use your hands or even a brush that will help with that and then I would have to agree with the doctor get the vaccines for your kids it's just that simple it's much cleaner now it's much healthier and it helps us all do you agree? I would agree awesome alright nice job Pisa thank you Sarah thank you it's great to have you down thank you you take care bye loja