 This is Think Tech Hawai'i. Community Matters here. Welcome. This is Craig Thomas, your host on Much More on Medicine, part of Think Tech Hawai'i's live stream series, assisted as always by Cindy and Rich, our engineers, and joined by my friend Vernon Anstale. Great. And thanks for coming. And just a little back story. Vernon, you're going to learn more about Soon, but he's a professor of tropical medicine. And years ago, like 25, I'm tempted to say, you and I went to Vanuatu together. And I vividly remember you, Dapper as always, commenting on the rat that had shared your pillow one morning. And, you know, it's probably appropriate now that you are heading up this symposium on rat lungworm disease. So thanks for coming. Well, thanks for bringing that up again. Actually, I can barely remember the incident, but still. Well, you've been to many interesting places and are no doubt exposed to more interesting creatures than rats. And honestly, Vanuatu was a fascinating place. Before we dive into this, and I think it's both a timely and interesting topic, and I know that you're heading up a symposium and a board for what, at least a year, gathering the available information about this. But before we do that, I wanted to talk a little bit about a couple items in the news recently. And specifically, there's been quite a few different articles in the press relating the health benefits of exercise over pretty much anything else we can do, particularly if it's outdoors, and then looking at where states rank. And the benefits of outdoor exercise appear to be very high. And guess what? Hawaii has wonderful opportunities, and consequently, in a recent study, I had the highest average lifespan of any state at just over 81 years. I think that's fantastic. It's obviously one of the reasons it's great to live here. And in fact, I went for a little paddle this morning. It was fantastic. There is a disturbing piece to this also, Howard. And that is we live in a great state on a fantastic island. Access to many of the trails, and Cocoa Crater Trail, which is a really nice climb up if you haven't done it, and you can even make a great loop out of it, is in disarray. Sounds like there's a local group that is trying to own repairing and managing it, and I'm delighted about that. But there are a whole bunch of other trails that have been open and shut through the years that are now closed. And specifically, I know, and I thank you for it, that you've been leading the charge on the hiking stairs, which is probably the best trail in the entire state. You want to kind of tell us where that's at a little bit? Yeah. I mean, I think what you're saying, it's really disturbing. This list of hiking trails that are now forbidden, as it were, people can't enjoy them. And the list just seems to get longer and longer. And unfortunately, hike who stares is one of those situations. People cannot climb legally there. If they do try to sneak on and get caught, they can be fined up to $1,000. But this is such a fabulous experience that it needs to be reopened at some point for the general public to enjoy. I agree completely. I can't give you specifics, but let's just say I am fully aware of the joys on repeated occasions of climbing the hike who stares. So far, wallet is intact. In fact, he moved. Don't take your wallet. But it's a fantastic experience. I believe that things like the hike who stares, Cocoa Crater, Tom Tom Trail, if it could be safe enough, belong to us all. And that in truth, we should be expending some resource. In fact, I'll put out something else that's bugging me. You need a bike route over the Colows. The old poly highway works. It's closed off. So I would love to see recognition of the value of outdoor exercise and some support for infrastructure to make it happen. So I've admired you for years on this crusade. I hope that it works. And I'd love to help. Okay, so with that, we're going to switch gears a bit. Another item that's been in the news episodically, like every time somebody gets sick, for some years now, and is an issue on pretty much all the islands, I think, what you clue me up about that, but certainly both Oahu and Hilo, two islands I'm familiar, two areas I'm familiar with, is the whole rat lung disease, synophilic meningitis, whatever you want to call it thing. And it's a fascinating topic, honestly. And you're the world expert. I beg to differ on that. Well, you may not have been a year and a half ago, but I think you are now. Well, there's a whole core group of people who are now somewhat expert in the disease. And as you were saying, it's certainly present on the east side of Hawaii Island. Now they're getting cases on Maui, and we've had a handful of cases here recently on Oahu. So the potential, I think, is there for it to be on all the islands. Yeah, likely. And where else is it in the world? The main areas of infection are in Southeast Asia. So Thailand, China, Taiwan, they're seeing more cases. They're recognizing more cases in Vietnam and Laos. And then it's also been recognized on the mainland, the United States, and certainly in other countries in Africa and so on. So it's there. It's probably spreading. It'll probably spread more as with climate change. Climate change is a great uncontrolled experiment, sadly. And we're seeing, you know, we staff the winter side of the big island, and we're seeing more things longer than we have lefto, dengue. So anyway, yes, that will happen. My guess also is that, like most diseases, there's a big spectrum. And probably, you and I may have had it, we just didn't know it. And there's probably a whole lot of that or minor cases. And then, of course, the serious ones get real attention. So hopefully we can learn more about the true incidents. Let's talk about epidemiology of this a bit. Okay. Well, the basic life cycle is from rats to slugs and snails, and then back to rats. I think we have a picture of the slug and snail, and then I believe can also project an image of the whole deal. First of all, we don't need a picture of a rat. You're very familiar with rats. But if we could show our audience sort of what the slugs and snails look like, and then, Rich, if we could project the photo of the slugs and snails, or one of the two is up, and then we're going to switch to the life cycle. How does this work? So the basic life cycle is from rats to slugs and snails, and then back to rats. And that's the life cycle that the parasite would favor. That works best for the parasite. And interestingly, what you're just alluding to is that the parasites have their own life, and what they want to do is stick with the right host. So this is a little bit like the fish-tape worm thing. We are the wrong host. Bad for the fish-tape worm, they die. They could possibly make us sick and yonder. I mean, that's sort of the story here too, right? Yeah. So humans become infected as accidental hosts. And dogs and horses and other mammals can become infected as well. Again, accidental hosts. Interestingly, did you hear about the horses on the Big Island? I wonder. Yeah, yeah. I think a lot of things are possible, and it's probably not getting recognized too much in animals. Similar sort of problem to humans. It's an unusual disease. It's rare. But I think on the Big Island, it can be quite a problem. Yeah, it was, I think, a fairly isolated herd in the YPL Valley, which is certainly a place where this could be. Okay, so we're going to put up the actual life cycle, and maybe you can walk us through it. Bearing in mind, it's all aberrant for the long worm. Yeah, yeah. So again, basic life cycle is from rats to slugs and snails. Humans become infected in three made ways. One would be by deliberately eating a slug or a snail. Kids do that. And that happens. So do adult occasionally as a dare or a wager, and there have been cases of that. Let me guess, drunk men. Sorry, go on. I think often you're right, yeah. Another way of getting infected, and this is probably the most important way in Hawaii, is by inadvertently eating small slugs and snails that are contaminating green leafy vegetables, mainly sometimes fruits and things like that. So that's probably the main way that we get infected in Hawaii. And then the third way that's probably quite rare is through what they call transport hosts. So these are other creatures that can become infected, things like lizards, land crabs, frogs, shrimps and prawns. And if you eat those raw, you can become infected, and they're infected, humans can become infected. Not much of a problem here as far as we can tell, but in some countries where they eat raw frogs or raw lizards, as almost like a routine thing, then people can become infected. Or raw filter feeders. You're the one who introduced me to the possibilities of filter feeders and the many cooking them is a good idea. Yes. I mean, I think if you cook these things, even if you cook slugs and snails, if you cook them well, they are safe to eat. You have any recipes? Never mind. And that's part of a problem in some countries like Thailand. As you probably know, if you cook a slug or a snail well, it becomes very rubbery. So not very attractive to eat. So in some countries, they may cook these creatures, but they tend to undercook them. So some of the infection maybe survives and can. And hence, that's why you traveled to Thailand a couple of times to learn more about both presentation, but also diagnostic and therapeutic evidence, which we'll talk a little bit about. There's world experts in Thailand. They see a lot of the disease there, especially up in the north. And so actually talking to people who've seen a lot of cases has proved very helpful. We wanted to talk to people there about diagnosis and treatment of the disease. They tend to see milder cases there, which kind of muddies the waters a bit, but it was useful information to help us when we worked on our guidelines. You think they're milder because they're diagnosed earlier. I'm aware that their diagnosis algorithm is a little different, or it's a different disease, or a different spectrum of the disease. I think it's a different spectrum of disease. They see very severe cases, but that's really very rare, apparently. They see much milder cases there. And I think it's mainly because they're eating these partially cooked snails. And the snails themselves tend to have a low level of infection. Unlike what we have here, we have a semi-slug that's notorious for spreading infection. And those semi-slugs tend to... they're very susceptible to infection, and when they get infected, they have very high larval load, so-called. So if you inadvertently or deliberately eat one of those, you're going to get a big whole up of infection. Got it. Well, after the break, we're going to talk more about how to get it, how to keep getting it, and a better what to do about it. So, thanks. And we'll see you soon. Good morning, guys. They told me they were making music. Do you watch my show on Tuesday? Comfort Zone. I sang this song to you because I think you either are cool or have the potential to be seriously cool. And I want you to come watch my show where I bring in experts who talk all about easy strategies to be healthier, happier, build better relationships, and make your life a success. So come sit with the cool kids at Out of the Comfort Zone on Tuesdays at 1 p.m. Welcome back. This is Much More on Medicine. We discussed part of Think Tech Hawaii's live stream series, and I'm here with Dr. Vernon Anstahl, Professor of Tropical Medicine at UH, absent, actually, which is the School of Medicine. And before the break, we were talking about sort of the life cycle of this parasite, the rat lungworm. You've been spending, I think, at least a year working on collecting all aspects of information, how this is spread, how it makes people sick, how you diagnose it, what you might do about it, and tell us a little about the process because it sounds pretty interesting. We formed a subcommittee, part of the governor's task force on rat lungworm disease, and the subcommittee was addressing diagnosis and treatment, which in a way are the most controversial or difficult areas. So we put together this group of mainly physicians, Tropical Medicine specialists, Infectious Disease specialists, parasitologists, a group of about 15 people, I think, altogether, and started really looking into diagnosis and treatment with the goal of coming up with guidelines. And at first, we spent time looking through the human literature, and there's a moderate amount of literature about this. Some of it is more reliable than others. So if I hear what you're saying, in my experience, when little is known about something, somebody kind of pulls something out of the air, often 50 years ago, and it becomes gospel. Is there anything like that in here? You're absolutely right. And one of the things was the use of anti-worm medicine. I mean, you've got a worm crawling through your brain or worms crawling through your brain. I think there's a great temptation to think we have to kill it. Yes. But unfortunately, when the worm dies, it creates an inflammation, which itself can be quite dangerous and serious. So over decades, people have said, well, we don't know whether to use these anti-worm medicines because it's going to kill the worm, often all the worms at once, and create a lot of inflammation. So that keeps getting repeated. So it's like we reached a point where we need to fix this. We need to figure this out. And by the way, just so everybody knows, these worms are going to die. We are not their terminal host. And so whether we kill them, and I understand if you kill them all at once, it may be different than if they die off. On the other hand, they get bigger over time, too. If I got worms up there, kill them while they're little. It's my theory. Now, that's not based on science. I'll fully admit. So anyway, tell me about the process, what you've learned. You alluded to what you learned about the life cycle. What about how do you diagnose it? How do these cases present? Yeah, in terms of diagnosis, what would be ideal would be a simple blood test. So we could see a patient, we think might have it, just take a blood sample and make a diagnosis. I have a better idea. I have always wanted my patients to come in with on their forehead, I have appendicitis, or I have rat lung worms. Honestly, that would be just for dumb people like me, that would be perfect. But a blood test would be nice. A blood test would be nice. Unfortunately, the blood tests that are available are not the answer. We have a lot of what they call false positive tests. Somebody may have a positive test, but they don't actually have the disease right now. They may have had it years ago. There are all sorts of issues like that. So we have to resort to a spinal tap. And that's where we can actually do testing that will tell us to somebody have an active infection. Spinal taps are something that, it's been around for a long time. We've all done them. It's a pretty straightforward procedure, but it's the thought for a patient of having, people talk about lumbar punctures, or a lumbar puncture. But it's the right way to make the diagnosis. So this is a fascinating set of issues. The concept that tests, you think the test would say yes or no, and they'd never be wrong. And the truth is, a blood sugar determination, that's pretty much in that category. Almost none of the rest of our tests are. And some of them are bad enough that they're not very useful, as you've described. So in other words, if you have the disease, you want the test to say yes. And if it says no 30% of the time, it's not a very useful test. And again, if you don't have the disease, you want it to say no. And if, I don't know, 50% of the time it says yes, or even 20%, that's a real problem. Because you think the patient has something and they have something else. And then the last question of what do you have to do to perform the test? You're right. Lumbar punctures, honestly, well, I've never had one done on me. And so easy for me to say. But in truth, it's a routine test. It's really quite benign. But it's not a blood test either. And that's a barrier to both it being offered because it's a procedure. You have to fit it into your practice or refer them to somewhere where it can be done. And honestly, it's a procedure that it's very routine. It's not automatic. Sometimes they're harder to accomplish than they are technically tricky. And then the patient has to be okay with getting it done. So this is, I think, a significant challenge to diagnostics here. Yeah, I think spending time with the patient and explaining that it's critical to get this test. This is the only way I'm really going to be able to be able to make the diagnosis and plan a course of treatment for you. Yeah, and we call that shared decision making. Correct. You tell them, here's what I'm worried about. Here really seems to be the option to do it or not, the way to figure this out. Let's figure out together what a reasonable course it is. And then in the end, together you decide. Yeah. So, okay, so we've done that. Now, let's say my, I get my spinal tap. My test is positive. What lies ahead of me? Then it would be a course of treatment targeting this worm that's in the brain. And just simply doing a lumbar puncture action can relieve some of the pressure that's in the head and can help the severe headaches that these people have. But another way of relieving the inflammation that's there and relieving some of the pressure is corticosteroids. And so that's an important part of the treatment of the disease. Hidoscorticosteroids. But, and then the other arm, if you like, of treatment would be do we decide to treat the parasite, to kill the parasite or not? And as you mentioned earlier, when they're small, it sort of makes sense to kill them at that point, not let them thrive and grow to the point where when they finally do die, they're a much larger worm that's going to create more inflammation. How big do they get before they croak? That's a good question. You can see them with the naked eye when they're mature. As mature as they're going to get, yeah. The goal of the parasite is, they would much rather be in a rat's brain. And their goal is to go from the brain, then the final step for them is to go into the lungs. Then the rats cough them up in the end, right? Yeah, they mate and the worms mate and release eggs and then larvae are produced and excreted. So that's what they want to do. It's actually very rare probably for the larvae to get to the human lungs. So they die somewhere in the brain usually. Parasites are fascinating. They really are. As you allude to, there's some controversy about when or if and probably how much. I doubt so much how much. You use the anti-worm medicines. Is there likely to be a trial of this in the future, do you think? Well, in response really to all the work that we did, we realized we just don't have enough information. So we're hoping to put together a large multi-center trial which might involve working with people in Thailand and China and Taiwan, countries where they have a lot of disease because we just simply don't see enough cases here. It would take us 100 years to figure this out. Don't think that's helpful. But no, I hope that happens. That's exciting. You know, in the last minute or so, let's talk about what people can do to maintain a healthy diet because you don't want to eat a brown diet. A brown diet is something with no greens. But minimize your chances of this because honestly the risk of getting it is really low and the benefits from healthy diet is substantial. Yeah, so as I mentioned, one of the main ways that people in Hawaii seem to get infected is by inadvertently eating slugs and snails that are contaminating green leafy vegetables. So there's work being done looking at different ways of trying to wash these things off on green leafy vegetables. And it looks as if the best way is just simply pull off the leaves, inspect them, and wash them vigorously under running water. And if you do that, I mean sure it's a bit of a chore, but it seems to be a pretty effective way of making it safe to eat. You know, it must be pretty effective because the actual number of cases is very small. So a number of symptomatic cases, as one I should have said, is very small. And so I think we both want to leave the message of, sure, wash your stuff, then eat plenty of green things and fruits. You know, Vernon, it's been great having you here. I appreciate you coming. And best wishes at the symposium next month when you present the findings back in Baltimore, is it? New Orleans. New Orleans. Oh, even better. That's better. Well, thanks. I hope you get to do this multi-center trial. I think that would be fantastic. Thank you. Thank you. Thanks for listening. We appreciate you joining us on Much More Medicine and our guest, Dr. Vernon Anstow. Thank you.