Whether state officials have downplayed the danger of rat lungworm parasites, the fact remains that Hawaii is in the midst of an outbreak that has given at least three people from the mainland lasting impressions of the island state.

The life cycle of the rat lungworm parasite, as depicted by the Hawaii Department of Health.
The life cycle of the rat lungworm parasite, as depicted by the Hawaii Department of Health.

The mainlanders — a California couple on their honeymoon and a Seattle woman who was set to begin classes at a school on Maui — are among at least 14 confirmed victims of the painful illness. People are exposed to the parasite by eating or drinking contaminated foods and beverages including raw or uncooked snails, slugs, frogs, some seafoods, fresh produce, certain homemade beverages and water from catchment systems.

The Hawaii Department of Health reports there are at least another four probable cases of infection. In humans, the parasite attacks the brain and the spinal cord, often causing eosinophilic meningitis with its severe headaches, random and intense body and joint pains, temporary paralysis and even death, according to public health officials.

In the most serious cases, people experience neurological problems, pain and severe disability. There is no medication or specific treatment for the infection, according to the Hawaii health department. Officials from the department did not accept invitations from Food Safety News for interview opportunities.

One victim’s story
“Morphine did nothing. It felt like someone was stabbing my brain,” said 24-year-old Seattle resident Tatum Larson.

Tatum Larson, left, and her mother posed for this photo in Hawaii days before Tatum began having symptoms of rat lungworm disease. Photo courtesy of Tatum Larson

Larson’s symptoms began March 1, the same day she left the Big Island where she had been visiting a friend. She headed Maui to set up housekeeping where she was scheduled to begin classes at a massage school. Her friend on the Big Island had told her about rat lungworm disease upon her arrival, but she didn’t make the connection at first.

The first symptoms for Larson were severe itching and burning in her hands and feet. After two weeks, she went to a clinic and was told it was nothing. She went to another clinic for a blood test when her bones started hurting. Crippling pain in her ankle sent her to an emergency room at 2 a.m., but she was sent away after she declined pain killers.

“The doctors didn’t know what the symptoms meant,” Larson said. “A nurse said my blood was OK and that I just wanted drugs, but I had already turned down pain killers.”

Next, a person specializing in natural medicine suggested Larson might have shingles, so she decided to return to the mainland for a short period because she could not attend school or go to work in the restaurant she’d been waitressing at because of the contagious nature of shingles.

Back in Seattle, Larson was still having symptoms so she went to a doctor there.

“He was stumped, but he knew it wasn’t shingles. He went to the CDC website and saw the symptoms and started putting things together,” she said.

A spinal tap later Larson was diagnosed with meningitis, admitted to a Seattle hospital for two days and treated like an experiment. “The doctors were excited because it was a strange and new thing for them, no literature on it and not much information about treatment,” Larson said.

Discharged from the Seattle hospital with more questions than answers, Larson flew back to Hawaii. During the flight she developed full-blown meningitis symptoms, including a rigid spine, and was immediately taken to a clinic upon landing.

The doctor at the clinic said he didn’t think it was rat lungworm, even though Larson provided her completely history. He sent her to another doctor who did believe it was the parasite, but did not know how to treat it. Larson finally got the doctor to give her anti-inflammatory medications to reduce the swelling in her brain so she could fly back to Washington.

Upon landing in Washington, Larson was wheelchair off her flight, straight to an ambulance and emergency room. She was in the hospital for five days and was well past the window of opportunity to take an anti-parasitical drug.

She’s still in pain and can’t work or go to school, but she is thankful.

“I had insurance. I’m getting treatment for the pain. I’m very grateful for that,” Larson said. “But I want people to know about this. People on the islands know about it, but no one talks about it.

“I’m pretty sure I got it at the Hilo Farmers Market. All the Department of Health needs to do is put up signs telling people about the possibility of it.

“I’m not saying ‘don’t go to Hawaii or don’t eat their produce.’ But people should be informed so they can make their own decisions.”

Officials with Whole Foods Markets have made the decision for their Hawaii customers. In April the grocery retailer announced it was switching from Hawaii-grown lettuce and greens to lettuce and greens from the mainland because of concerns about rat lungworm contamination.

State says don’t worry
Although the Hawaii Department of Health posted a news release April 19 on its website about the surge in cases this year — 11 confirmed at that time  compared to 11 in all of 2016 — criticism of the state’s response is coming from several directions.

State records show 76 cases have been reported since 2007 for an average of less than eight annually.

The situation is not an epidemic and “Hawaii is still a safe destination” said Hawaii Department of Health Director Virginia Pressler during a news conference April 19 with the head of the Hawaii Tourism Authority. Annually, tourism is a $15 billion industry in Hawaii.

Little information has come from the health department since the joint news conference.

“The Department of Health’s investigation is ongoing and with the heightened public awareness from the recent cases on Maui and Hawaii, we have seen more people come forward for evaluation and testing,” a health department spokeswoman said in an email to Food Safety News on April 28.

“We expect there may be additional cases due to the greater public awareness, and we hope more people will take to heart the message to wash their vegetables and fruits thoroughly before eating to not only prevent rat lungworm, but to also wash off any other contaminants — this is basic good health practice.”

Victim, legislator say worry
From the victim perspective, Larson said her friend on the Big Island explained that locals are aware of the rat lungworm parasite, particularly on the East part of the island where it is more common, especially in the Puna region.

Hawaii State Sen. Russell Ruderman, who represents the Puna district on the Big Island, has been trying to get the state legislature to fund research and public education efforts for at least three years. The bill made it further through the process this year than before, but it stalled suddenly.

The legislature decided in recent days to give $1 million in funding to the Department of Health (DOH). The allocation is contingent on full budget approval. The department has not yet decided how to spend the $1 million, which is split over two fiscal years.

“The DOH didn’t even ask for it,” said researcher Susan Jarvi who is a professor in the department of pharmaceutical studies at the University of Hawaii-Hilo.

Jarvis did ask, though, and has been asking for the state to fund research and public education efforts for years. She helped found the Rat Lungworm Working Group in 2011. She contends many state officials have turned a blind eye to the threat in the popular tourist destination.

Sen. Ruderman has told local media outlets in Hawaii that he believes the fact that most cases until now have involved residents of the Puna area made it easier for officials to ignore.

Jarvis agreed with that assessment, and said that the less than affluent demographic of the area combined with a high percentage of people using catchment methods for drinking water has resulted in many cases of rat lungworm disease that have gone undiagnosed, unreported and untreated in recent years.

Who’s doing what about it?
The Hawaii Department of Health is “continuing to monitor” the situation and working on figuring out how to spend half a million dollars in each of the coming two fiscal years. A department spokeswoman confirmed that the department had not asked for the funding and said “the appropriation came as a surprise to the department.”

“Legislators have expressed their concerns to us for the need for increasing public education and outreach about the disease, so much of the funding may go toward those efforts,” according to the spokeswoman.

“A local cable television company, Oceanic Cable, has stepped forward to donate production services and television airtime for a statewide public service announcement expected to begin airing in May in all counties. The  Department of Health is updating our print materials for distribution and posting on every island. This will also be completed this month.”

Meanwhile, Jarvi and other researchers at the Centers for Disease Control and Prevention and Mahidol University in Bangkok, Thailand, are closing in on a diagnostic blood test that will reveal not only whether a person is currently infected, but also whether they have ever been a host to rat lungworm parasites.

Jarvi and others at the university laboratory in Hilo are also working on the frontline of public education. Elementary school gardens have become popular in recent years, and they provide the perfect habitat for the snails and slugs that are the intermediary carriers of the parasite larvae, which can contaminate produce, catchment water and other foods and beverages.

By educating children about preventive measures, such as looking for snail and slug slime trails and chew marks on lettuce and other produce, Jarvi said the team is working on low-tech interventions while pursuing the diagnostic blood test.

The semi-slug, officially known as Parmarion martensi, is shown here on a nickel for scale. Photo courtesy of the Hawaii Department of Health
The semi-slug, officially known as Parmarion martensi, is shown here on a nickel for scale. Photo courtesy of the Hawaii Department of Health

She said 70 percent of semi-slugs — an invasive species introduced to Hawaii — tested positive for the larvae. The semi-slugs are more mobile than many other snail and slug species, climbing high and low for food and water.

Jarvi said one research project showed that the larvae escape from slugs that have drowned in catchment water containers, living in the water for up to three weeks and posing a threat to anyone who drinks it.

The state health department “has been in contact with” a researcher at the University of Hawaii, but not with the lab on the Hilo campus where Jarvi works.

“Our department recognizes the important value of research,” the health department spokeswoman said. “DOH is not a research facility and we defer decisions and advocacy on research to those organizations and academic institutions that conduct research.”

Advice to consumers and tourists
Jarvi said she would not discourage anyone from visiting Hawaii because of rat lungworm dangers. However, she also said she takes strict precautions with her own health in relation to the threat.

salad semi-slug
This salad, provided by a consumer, with a semi-slug was photographed by the Jarvi Lab at the University of Hawaii-Hilo.

The researcher lives in an area that does not have “city water” and uses a catchment system. She said she is careful to keep the water system secure from snails and slugs. She also takes care with her food.

“I only eat lettuce I have prepared personally,” Jarvi said, adding that thorough cooking or freezing can kill the parasite larvae.

Jarvi said the university lab at Hilo has had more than 10 people bring in salads or send in photos of salads bought at grocery stores and farmers markets that had snails or slugs in them.

Tips from the Hawaii Department of Health include:

  • Appropriately store, inspect and wash produce, especially leafy greens, no matter where they are grown;
  • Boil snails, freshwater prawns, crabs and frogs for at least 3 to 5 minutes;
  • Supervise young children while playing outdoors to prevent them from putting snails or slugs in their mouths; and
  • Control snail, slug and rat populations around the home, workplaces and other properties, especially if one maintains a home garden.


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