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Last Wednesday, Dr. Virginia Pressler had some grim news to share.
Earlier that day, Pressler, who directs the Hawaii Department of Health, learned that two more people on the Big Island had tested positive for rat lungworm disease, and four others were also likely suffering from the parasitic infection.
Within hours, Pressler held a press conference, telling reporters that, less than four months into the year, the department has already confirmed as many rat lungworm cases as it did in all of last year.
But Pressler was also quick to point out that the situation is nowhere near an “epidemic” level, stressing that “Hawaii is still a safe destination” for tourists. To hammer home the message, Pressler had a representative from Hawaii’s tourism industry sitting next to her.
In many ways, the episode illustrates what state officials have to navigate through whenever a public health crisis hits tourism-dependent Hawaii: As they go about sharing updates and educating the public about the risks, they tread carefully not to fuel any hysteria.
“We want to raise awareness but not fear,” Pressler told Civil Beat. “That’s why we try to put things in context … What we don’t want to see is people panicking. ‘Six more cases on the Big Island. Oh, my god!'”
But the state’s cautious approach has frustrated some critics.
State Sen. Russell Ruderman, who represents the Puna district of the Big Island, says the state is playing a catch-up, when it should have addressed the issue a long time ago.
Ruderman, whose district is the “ground zero” of rat lungworm disease, says he’s tried for years to bring attention to the issue. In 2015 and 2016, he introduced a bill that would have pumped state funds into a range of efforts to curb the spread of infections — but to no avail.
“If I may be frank, I think it was ignored for a long time by our state agencies for a couple of reasons,” Ruderman said. “One reason is, it was perceived as a Puna problem — that it wasn’t going to affect other people. Number two, it was thought that, if we talk about this, it might scare tourists away.
“Now, it’s kind of clearly no longer just a Puna issue. And it’s clearly spreading, and tourists have gotten it. It’s a national story now, and I believe it’s reached a certain critical mass where we can’t ignore it,” Ruderman said.
Rat lungworm disease is caused by a parasitic worm called Angiostrongylus cantonensis, which reproduces itself in the lungs of rats. The larvae of the worm, released in rat feces, gets passed on to the carriers — slugs and snails, as well as freshwater shrimp, land crabs and frogs. Humans, in turn, can contract the disease by eating contaminated produce — or ingesting the carriers themselves.
The disease, once contracted, attacks the brain and the spinal cord, causing eosinophilic meningitis and leaving the victims with long-lasting effects — ranging from severe headaches and neck stiffness to temporary paralysis and even death.
Hawaii is no stranger to rat lungworm — reported cases of infections go back decades.
But given the number of infections, the chances of contracting rat lungworm disease in Hawaii appear to be slim. According to the Health Department, 76 cases have been reported since 2007 — an average of fewer than eight a year.
Still, the department has seen a spike in infections in recent years — going from seven cases in 2015 to 12 in 2016 and 15 so far this year.
In response, state officials say they’re embarking on an “aggressive” public awareness campaign, spending $15,000 to $20,000 to print out education materials — such as brochures, door hangers, flyers and posters — and to run some messages on the radio.
“We’ll have the message out to everybody in the state,” Pressler said. “We need to make sure everyone is fully aware of the disease.”
George Szigeiti, executive director of the Hawaii Tourism Authority, which represents the $15 billion a year industry, shared the same concern. “There’s no reason to feel differently about Hawaii or fear getting a disease as long as you … use good common sense when eating and storing food.”
Brian Miyamoto, executive director of Hawaii Farm Bureau, says he’s also working with the Ige administration to develop other resources for local farmers.
“We want to make sure that our farmers are producing safe food, so the consumers have confidence in the local product,” Miyamoto said. “The last thing we want is people to stop buying local produce. It’s really going to impact the farmers if they do.”
However, Whole Foods said in a written statement that “out of an abundance of caution,” its Maui store was only using greens and lettuce from the mainland in its prepared foods.
“We are closely monitoring this issue and working with the Hawaii Department of Agriculture to develop a plan that allows us to continue to support local agriculture while ensuring the safety of our customers and team members,” the company said.
Bill Marler, a Seattle attorney specializing in food safety, says the whole exercise can be a tricky balancing act.
“It is a hard decision on the part of the public health (officials) to figure out when and how you alert the public of the risk,” said Marler, who is representing dozens of victims of the hepatitis A outbreak that hit Hawaii last year. “If it doesn’t seem like the risk is large, is it worth going out to the public and saying, ‘Don’t eat salad in a restaurant unless you go wash it in the sink yourself’?”
Susan Jarvi, professor of pharmaceutical sciences at the University of Hawaii at Hilo, says all this public attention comes too late for many victims on the Big Island.
“If the state had taken an interest in protecting the people of Hawaii Island years ago, we could’ve maybe curbed this problem,” said Jarvi, who co-founded the Hawaii Island Rat Lungworm Working Group in 2011. “Meanwhile, dozens of people have suffered from rat lungworm disease — that’s just really, really sad.”
“There may be more cases of dengue fever, but every case of rat lungworm is a hundred times worse than the case of dengue fever,” Ruderman said. “When you factor in the severity, rat lungworm has been a very serious problem for our state for a long time.”
Last year, after Ruderman’s bill failed to gain much support in the Legislature, Gov. David Ige created a task force on rat lungworm disease — an effort to draw on the knowledge of experts like Jarvi to find ways to curb the spread of infections.
But Jarvi says the task force has met only three times and taken no concrete actions — beyond agreeing on the need for a better public awareness campaign.
Ruderman says the recent spike in infections has at least brought the issue to the fore and helped secure more support for Senate Bill 272 — a virtually identical measure to what Ruderman introduced before.
“This issue didn’t come up 10 years ago and then go away. It came up 10 years ago and got worse. We can no longer ignore it,” Ruderman said.
Dr. Sarah Park, state epidemiologist, also sees a silver lining.
“It is a constant struggle to get people to be aware of all kinds of diseases that could potentially impact us,” Park said.
“If anyone remembers anything out of this, (it’s) how to protect yourself and your loved ones. It’s not very different from many of the other diseases, which quite frankly are much more common.”
“Whatever passes through your mouth, wash it appropriately and prepare it appropriately … know where food and drinks are coming from. If you do that, anywhere — not just in Hawaii but anywhere else — you’re protecting yourself and your family, and that’s the best thing you can do.”
Read about the Hana School’s DIY effort to control spread of the parasite.