 This is Think Tech Hawaii. Immunity matters here. Trees and loose things in the background. Well, here we are. Welcome back to Think Tech. I'm Jay Fiedel. This is Community Matters. That's Sarah Park. Dr. Sarah Park. She's the state epidemiologist with the Department of Health. And she's here to talk about epidemiology. Say that five times in a fashion. Anyway, the epidemiological question we want to talk to you today about is something that was on the radar and then got quiet. And it'll come up again, I think. And that's rat lungworm. So let's begin by defining what it is, Sarah. Yeah, so rat lungworm is the common name for the scientific name is angiostrongilis cantinensis. Or the disease is called angiostrongilisis. It's quite a mouthful. Yeah, it's quite a mouthful. So rat lungworm is definitely easy to say, easy to remember. Essentially, it's a parasitic infection. So parasites, they can't survive without a host. We're not their definitive host. It's a worm. And the scientific side, they call it a roundworm. But it's a worm, essentially. It can be visible. The adults can be visible to the human eye. It's little babies. The larvae can be barely visible. It really can really distinguish the features in a microscope. So it just gives you an idea. But they're definitely bigger than, say, bacteria or viruses, which are definitely very microscopic, even beyond that, some of them. But at any rate, this parasite has been, in the state of Hawaii, documented to at least like the 1940s and such. Definitely well-documented all through the 1960s. A lot of research was done. And interestingly, if you talk to some old-timer physicians, old-timer farmers, people who were here way back when, they all talk about, they're like, we knew about this disease. The disease has been here. And what's disconcerting is, it's like so many things. It's in the public mind's eye. But unfortunately, when something isn't really evident to people, they move on to other things. And then the memory is lost, unfortunately. And we get so many new people, new residents that, and they don't learn about what's. I think it's a new thing. But it's not a new thing. But it's not a new thing. It's unfortunate. And so the real struggle is, how do we keep up that awareness, just like with leptosporosis, another one of our lovely endemic diseases? So we have a few, unfortunately in Hawaii, we have a few, what we call endemic diseases, diseases that are here in Hawaii that can cause infection and make people sick. And how do we make sure that the public, everyone knows about these? We can safeguard ourselves against them. And we should be. So you said microscopic is some questions to follow up when you said microscopic. I can look, I can see, if I look closely with the worm, I can see it. How long is it? Is it longer than thinner? It's more longer than thinner, yeah. I mean, it varies in size, depending upon. You're talking about adults versus its babies, larvae. Like I said, the adults are visible to the human eye. Grossly visible, they're not microscopic. Whereas the babies, you kind of need a microscope to really distinguish the details. Although if you've got a bunch of them swimming around, you can kind of, as was described by one person to me, was you can see a shimmering effect from their swimming around. So you can kind of tell them out, even the larvae, but really need the microscope to look at them. As far as the size, I can't quote you. I'm not the parasitologist, so I can't quote you exact. You know, nanometers and such and centimeters. But just from that description, I think it gives you a little idea. Here's the hill that I am getting at. So I get my lettuce, my lettuce. And we'll talk about the cycle, the life cycle. I was going to say, we should back up a little and just talk about, like, what is the host and things like that. If I get the lettuce, and it's there, the little bugger is there on the lettuce. Well, you won't see it on the lettuce. You won't see it on the lettuce. So this is probably where we should talk about the life cycle. So the rat, I mean, where does that name come from? It's because the rat is the definitive host. It's home, essentially. That's where the parasite likes to live. It basically loves to be a parasite off of the rat. And it really loves to be in the lungs. It causes lung disease, essentially, in the rats, among other things. And that's where that name, rat lungworm, comes from. The rat doesn't like it at all. It's not helpful to the rat. I'm not a veterinarian, but I would guess that it's probably not a good thing for the rats. I mean, that's a whole nother question as far as what's going on there. So the rat's a definitive host. It goes through their system and basically, they poop it out to be really blunt. They poop it out. And then along comes a snail or a slug. And they eat the feces. And then they get infected. So we call the snails or slugs. They would eat the feces anyway, right? They would anyway. It just happens to be that the parasite is in the feces. Right, exactly. And we assume, actually, I can't say we know, because we haven't had comprehensive ongoing rat surveillance ever, really. But assumption is that many of our rats probably carry it, especially maybe in some areas, maybe more heavily infested. We don't know. But assuming they're infected, they poop out the larvae of this parasite. The snail slugs come along. They become what we call the intermediate host. And essentially, they become infected. Then we all, everyone in Hawaii, anyone who's grown up here, everyone who lives here, everyone of us is seeing the snails and slugs. They love to be in the shady areas. They love to get into anything leafy. That's where they hang out. So how big are they? The snails and slug. Well, you need to talk to the Malacologist, like Dr. Rob Cowey at UH Manoa. That's a great resource. So I understand the size really ranges. We have that iconic picture. If you look at our website, one of our investigators took a picture on the head of a nickel, the babies of one of the semi-slugs, this new invasive species of slug. It's really tiny versus the giant African snail. It's not that inch-to-inch-long kind slug. Or some of the bigger slugs that are out there. And actually, believe it or not, there have been some usually young adult male, not to stereotype, but it's interesting that among our cases, there's a handful, usually young adult male, who have purposely eaten one of these, a slug or a snail, usually on a dare. But it really underscores why we need to make sure people understand, because Hawaii is not the place to do fear factor or dares or things like this. And it's essentially, we need to be aware of the potential for these slugs and snails to be in our produce, because that's where they like to be. And for us to potentially accidentally get involved in the life cycle. So we're not part of the normal life cycle, but we can fall into it by accidentally ingesting, eating one of the slugs or snails. So if I go out in the garden and I find a slug and I eat a slug, is there a substantial chance I'm going to get ill from this? It's really hard to say. Again, we don't have comprehensive ongoing surveillance of either rats or slugs or snails. We know from past studies, past sort of samplings of slugs and snails, as well as rats in different areas, that it is prevalent on every island, essentially, in the state, to what degree, what percentage, and also what percentage in each species of snail or slug or even among the rats, we don't know. We have many species, don't we? It's not just one thing. But the assumption is that the risk is there. And so we just want to make sure that everyone understands that risk and takes precautions to wash their produce. I thought it was all about organic farming, natural farming in the wild and subsistence farming, if you will, or in your backyard, where you didn't realize that you had the snails and slugs around and they slither across your lettuce in some way and presto-digital, you have it on the lettuce. But we don't know about the slime at this point, if that's what you were asking. But you don't know if it's in the slime. Right. I mean, there have been studies to demonstrate there's a small amount, potentially a small amount of parasite that's excreted in the slime. But is it enough to cause infection? How long do they actually survive outside of a home? Remember, these are parasites. The whole idea of being a parasite is you need a home to survive. So how long do they survive long enough to cause problems for anyone else? Do they die soon after? Like I said, how much is actually in the slime? Is it enough? But it just underscores that no matter what, inspect your produce, wash it thoroughly, store it properly. We've had some issues where there's a question of how well the produce was actually stored, food prep. We've had issues where we've seen cases where there was a question of they kept all their food prep a blender, for example, out overnight. And essentially, their way of washing the blender was slush it out with some water and toss it. And we all know how sticky these slugs and snails, just slushing something is not going to make them fall off necessarily. So if I'm one of those subsistence guys and it doesn't clean off my salad, so to speak, then whatever is there. Potentially is an increased risk. I mean, it's not just a risk for rat lung, worm, or angistrongilus. It's also a risk for other pathogens, right? If you're not washing your produce. So you should always wash produce, because you're not cooking produce. When you're not cooking produce, you better wash it. And cooking is, I'm glad you brought that up, because we haven't asked, well, what about cooking? Obviously, if you cook anything, we've always said that about anything. You cook anything, you kill pathogens in parasites, bacteria, whatnot. So cooking is always a great thing. But if you're going to eat produce raw, which we all think is produce is healthy, just take some extra measures, or actually, regular measures, really. These aren't really extra measures. It's just regular measures, inspecting your produce, washing them. Just water? Yeah. So you don't have to do anything. You don't have to put any fancy chemicals or. So there was a study that folks from UH Manoa actually did to actually look at, does it make a difference using certain solutions and things like this? And they didn't really find any difference. And they found that the actual mechanical washing, not just rinsing under a faucet, but actually rubbing the produce and inspecting it made the difference. So that's what we were advocating for. After this came up, and I've been following it since, oh, God, 10 years anyway when it started hitting the news, I go and I go to a restaurant. I order a salad, and I look deeply into the eyes of the person who was going to deliver me the salad. And I'm asking, is this person care to wash that lettuce? I mean, is the risk, is there any significant risk from a restaurant, a licensed restaurant, a restaurant with a past sticker on the front from your department, right? Is there any significant risk that they won't do this? Is there any significant restaurant risk that they won't clean the salad? I'll defer the particulars to our sanitation folks. Of course. But I would say that we have not seen that. And as far as we understand it, from our partners the Department of Ag, from our partners in sanitation, at the farm level, at the restaurant level, there are many safeguards that are taken to assure the safety of food products. And so it's really, those of us at home, if we have a home garden, especially school gardens, there's been a lot of education done with the schools by many different partners, just trying to make sure people understand what they need to do. Because here in Hawaii, especially, because we know this parasite is here. And again, a reminder, this isn't something new. This is, I mean, again, if you talk to the old timers, physicians, some of the older physicians I talked to who've been here since their families have been here. And they say, they remember when they were young physicians, and everyone knew what to look for, everyone knew what tests to do, which was basically, you have to do a lumbar puncture, that spinal tap. Oh my goodness. Yeah, to see what the cells are, they knew that people coming in with severe headache, they need to assess for this. They knew this. The locals, they knew that this was a possibility. So really, from the epi question is, OK, so I'm hearing from the old timers, this was much more sort of a known thing, a more common thing, understood thing. What happened in the interim for people, what changed? And what is changing now that we're becoming more aware of it again? So there's conditions that are contributing. Oh yeah. So there's a lot of, right. Those are great questions for right after our break. That's cliffhanger kind of questions. We're going to try to answer those questions. Well, I don't know about answering. Maybe somewhat we're going to answer those questions. We're also going to talk about the human experience to have this disease. And we'll talk about where it is, if I could ask you, politically where it is, what people think about it, and how the government reacts. We'll take a short break. When we come back, don't go away. This is the best part, yeah. This is Think Tech Hawaii, raising public awareness. Ted Rawlsson here, folks. You're a host on Where the Drone Leads, our weekly show at noon on Thursdays here on Think Deck. We talk about drones. Anything to do about drones, drones, remotely piloted aircraft, unmanned aircraft systems, whatever you want to call them, emerging into Hawaii's economy, educational framework, and our public life. We talk about things associated with the use, the misuse, technology, engineering, legislation with local experts, as well as people from across the country. Please join us noon on Thursdays and catch the latest on what's taking place in the world of drones that might affect you. Hello, everyone. I'm DeSoto Brown, the co-host of Human Humane Architecture, which is seen on Think Tech Hawaii every other Tuesday at 4 p.m. And with the show's host, Martin Desbang, we discuss architecture here in the Hawaiian Islands and how it not only affects the way we live, but other aspects of our life, not only here in Hawaii, but internationally as well. So join us for Human Humane Architecture every other Tuesday at 4 p.m. on Think Tech Hawaii. You should have been here during the break. What can I say? As Dr. Sarah Park, she's a state epidemiologist with the State Department of Health, and we are really happy to have her here yet again. And he was saying we're growing old together, except it shows more on me. Thank you. Must be doing something right today. I run a lot. Okay, good, good move. But anyway, so we're talking about rat lungworm and the fact that it's been here a long time. It's here now. It's probably gonna be here in the future. Is it indigenous to Hawaii? Is this something only happening in Hawaii? No, it's not indigenous. Well, I suppose it's indigenous in the fact that it's here. It definitely is here. It's not something that was imported recently, but it was likely imported years and years ago. It's not really clear how it was imported. Old theories have been that it was brought over on the ships via the rats, because we all know on ships there are rats. There were no native rats here. I guess not, but the rats, I mean, we do a lot of trade with Southeast Asia where this is very prevalent on other Pacific islands, other areas of the world. But essentially, this is a parasite of the sort of tropical regions. So, and with trade going back and forth, it's not too surprising whether it was the rats that brought it here or the mollusks themselves, you know, snails and slugs that hitched a ride on a plant that came over here. It doesn't really matter because it is here. It's been here for many years. I think the bottom line for people to remember is it does cause potentially serious disease. We don't know actually how much mild disease there is out there, because obviously, if you have a mild symptoms, you have infection, but only mild symptoms, minor headache, and then it resolves, you're never gonna see the doctor. We're never gonna know about it. You know, so- The body has an immune system and actually deals with it. Right, or some other condition, you know, maybe you only ate one worm and the one worm didn't go anywhere, you know, and died. We don't know what the situation is that, yeah, we don't know what it is. What is, where are the conditions that make someone have much more severe infection, severe disease compared with someone else, and how many people are having of the proportion? You know, when you look at numbers of people and severity of disease, are we seeing a curve where this side, the left side is mild disease and the right side being severe disease? Are we seeing a heavy curve towards the left with a lot of mild infection? Or is it really more, are we seeing more of the heavy curve to the right? Well, it's hard to say. If you have it and you don't know it, then you're not even on the curve at all. Right, and I think the important thing to point out is what we monitor for in public health are the severe cases, because obviously those are the ones we're trying to prevent, especially so, but prevent any infection in general. And so remembering the prevention messages about washing your produce, good hygiene, food hygiene prep, inspecting and good storage of food, produce of your equipment, food equipment, preparation equipment, things like this. These are all essentially smart things, and not just for rat lungworm, but for a lot of other pathogens. For everything, right. Food is, food is, it bears problems sometimes. Right, but I think it's also important to note that compared with something like salmonellosis or E. coli infection or Shigella or Campylobacter, where we see hundreds, literally hundreds of cases a year. You know, it's balancing it out in terms of, I've heard that people are reluctant to eat produce when all their life they've been eating produce. So what's changed for you right now? So think about that, because in terms of how common is this, it's definitely here in Hawaii. How many cases? I've lost count for this year. I think we're at 17, but I'm not sure I should have left the office. This isn't something that multiplies like an infectious disease. It's not an infectious disease. You get it and it's just you. Well, we call it an infectious disease because it's an infection, but it's not transmitted person to person. You basically fall into the life cycle by accidentally ingesting a slug or a snail, or even part of one that happens to be infected. So you really have to get into that. Like I mentioned earlier, there have been cases where they've deliberately eaten the slug or snail. Again, not to stereotype, but it seems to be when we look at our cases as young adult male on non-commonly. We've also seen, unfortunately, and as a pediatrician, this is where I tend to worry most, honestly, is for the cakey. Because if you think about developmentally, one to four-year-olds, very well-known, any parent knows this, not just pediatricians. You know, what do we let them do? We let them crawl around. And there are some people that advocate for letting them eat dirt. Sometimes people, I know, some people don't, that's a whole nother conversation, but some people will say, oh yeah, I saw grass in their mouth. So clearly they've been putting things, or pebbles, or things like this, and so this is where in Hawaii we have to be really cognizant of our cakey out there and make sure they're not putting things in their mouth. They don't, some of these, they don't know any better. We as adults think, oh, Ick factor, this is really gross. They don't know that. But they don't know that. They're really curious, and they should be about their vulnerabilities. Are they more vulnerable to getting serious cake? Potentially. The thought is potentially they're more vulnerable to serious infection because they're smaller, they have, you know, their immune system is a little different, it's naive compared with ours, maybe actually even more so in that response to an infection like this, it might be over-exuberant, and part of the problem of the infection is actually not just the actual physical worm going through the brain, it's that the inflammation, your own immune response is this huge, basically you have this huge immune response and you can imagine, you already have one or two worms or maybe 10 worms going through the brain now and they're small, but then you have this intense inflammation wherever they are affecting the brain. That's not very good and a lot of questions are, how much is the result of the huge amount of inflammation? How much of it is the actual physical worm? They both clearly play a role, but you know, how much is- Parasitic, they're gonna live off body fluids like blood, right? They're gonna try, but unfortunately, they're starving to death from the moment they actually enter our body because again, remember, we're not the definitive host, they're looking for their definitive host, they're looking for the rat, they, we're not it, we don't provide whatever chemicals or whatever that they need to survive. So from day one essentially that they enter us, they're dying. They will start, you know, they'll start off, we adjust them, they get into our bloodstream very briefly and shoot up to our brain and that's where they seem to like to be. But from the moment that they're in our body, they are dying. So in the worst case- When they die is the big question. Yeah, so how long does it take? I mean, any idea? We're not sure and it seems, we don't know what the conditions are to have more, you know, the worms maybe die off sooner or later, there's just a lot that's not known and it's not exactly ethical to, you can't open someone's brain up and take a look. You can't do biopsies and honestly, when we do imaging studies, even though we know it's in there, we may not see signs of it on the imaging study. So there's a lot of questions. We know that from certain observations and anecdotal sort of experience that are we supposed that potentially you, the incubation period, you know, that time from when you actually might be infected, ingested, infected, mollusk or, to the time that you actually have symptoms could be as short as a week, could be as long as a month. So it's really unclear. But the cakey- Is it ever fatal? Or something that is the group that I worry about most. It can be fatal. And in fact, we had one cakey, unfortunately pass away a report of, and that's the other thing. On public health side of this, you know, the only way we know about outcome is if it's reported back to us because we don't actually follow out, we follow incidents of disease. We're counting disease as it occurs, but we're not actually, we're not researchers, so we're not following every single person who has a disease, whether it's E. coli or, angestrangeless rat lungworm or other things, so flu all the way to the outcome. And your approach would be different with a truly infectious human-to-human disease than with this. Right, exactly. You don't have to worry about, you know, thousands of cases. Right. This is more linear than that. Right, right. So what about the worst case analysis? If you catch, and I mean, I don't wanna make gory here, but if you catch this disease and it gets to your brain, which is where it likes to go, then it's gonna eat your brain and it's gonna come out your eyes. Am I right about that? No, no, no, don't. This is a bad movie. Don't start stories. Don't start stories, please. Tell me I'm wrong, that's okay. What it's doing, again, we are not the definitive host, so it's fine, it's searching, essentially. So it's meandering around until it dies eventually of starvation, essentially. And our own immune system is trying to fight it off, even as it's traveling, and that's why that big inflammatory response. But it doesn't extrude from orifices. It doesn't cause any crazy things that Hollywood might put together. So it's ultimately a matter of inflammation. It's gonna inflame wherever it goes. And the thing that's very common among all cases is, pretty much, is that they'll complain about headache, because if you can imagine, it's causing the inflammation so the cerebral spinal fluid, that fluid that bays your brain and meninges, it's building up pressure, and that's causing tremendous about a headache. And that's why, actually, sometimes doing a spinal tap can actually be therapeutic. It can actually, because it's relieving the pressure, and a lot of the cases often comment that they feel better. Their headaches feel better, and other symptoms may feel, especially their headache, though, feel better after the lumbar puncture. So you get remission, though. If you can weight out the worm, you get remission. But we'll oftentimes see that a lot of the clinicians will use steroid therapy to try and help calm down that inflammation, while monitoring the clinical signs and keeping those steroids on and then potentially tapering them off or stopping them at some point, really to try and deal with that inflammation, because a lot of that is causing a lot of the problems, pain, potentially, other neurological problems, maybe weakness, maybe tingling, odd tingling in your fingers. What's the other case where somebody went through a coma? There's potential. So again, this is talking about your brain, and so depending upon where the worms go in your brain, that will dictate what symptoms you really have. The only thing that's really, really common among all the cases that we've seen is everyone has a very severe headache. Yeah, any permanent damage to the brain by this? There can be, but it varies. There can be, people can resolve completely, and we've certainly heard of this. There are those, unfortunately, who, and these tend to be the more severe cases who have unfortunately long-term complications, and so it really runs a gamut, and so really wanna impress upon people. This is a serious disease, but there's something you can do about it. So tell them, they're right there. It's camera one, those are the people. Tell them what they should do. Yeah, so I mean, basically, again, we know that it's in them all, so we know it's snails and slugs. We know that snails and slugs will have to be in the produce, so being mindful here in Hawaii about inspecting your produce, washing it well, leaf by leaf, and then making sure that your food prep, everything that you do in terms of utilizing your equipment, your storage from start to finish is very hygienic, and that is really the most important thing, really, in Hawaii, just to be aware that, for those people who are, they've been eating produce all their life and then suddenly to change their habits because they've heard this thing and they're scared, think about that a little bit. You must've been doing something right because this parasite is prevalent throughout the state, and so we need to think about that. Okay, we're thinking about it. Is there, one last question, and we gotta go, is what can the community do? I mean, you're talking about what individuals can do, what can the community do? What can the government do? What can public health structures do to minimize the risk or to ameliorate it? I think, again, what's been curious to me is that, like I said, when I talk to old-timer physicians and locals and such, they all, to one, they all say, oh yeah, I know about this. They may have called it something else, but they all know about it. They knew about it from back then, and they're surprised that people now don't know anything about it, and what it really speaks volumes about is, how do we keep the awareness going in perpetuity? Because I don't see, unfortunately, unless we completely eradicate the rats from the entire state, which, by the way, would not just solve this problem, but leptosporosis, typhus, bunch of other problems as it is, all connected, but unless we eradicate the rats, we're not likely to see this disease go away, this parasite go away, and the risk go away, and so it's really about increasing the awareness and maintaining that awareness, so how do we do that? Oh, I have an answer for you, Sarah. Oh yeah, keep you guys going, and educating everyone. That's right, you come on, think, take Hawaii, do public outreach and information, and we do it more than once, so I hope you'll come back and talk to us again about this kind of public health issue, and others. Sure. And Sarah Park, she is the epidemiologist, the state epidemiologist for the Department of Health, and we really like having her on the show. Thank you so much, Sarah. Good seeing you. Aloha. Aloha.