A Hawaii public education programme for rat lungworm disease prevention.

Education is essential for lowering cases of Angiostrongyliasis in Hawaii. A professional development course on rat lungworm disease (RLWD) prevention was offered to Hawaii K-12 teachers during the 2018-2019 school year. Fourteen teachers, 11 from Hawaii Island and three from Maui, representing grades K, 2, 6-8, and 10-12, completed workshops and activities and received course credit. Teachers reached 652 students and educated 86 teachers and staff and approximately 900 community members including parents. A pre-course survey showed 55% of teachers agreed to a basic understanding of rat lungworm and its impact on Hawaii; this increased to 100% post-course. A sixth-grade class was the first to document the arrival of a highly competent intermediate host of the rat lungworm in a new location, an important discovery that initiated community awareness and control efforts. Six, 1-day workshops were held in 2018-2019, each on one of the main Hawaiian Islands. These were attended by 106 participants including teachers, community educators, and interested individuals from agencies, non-profits, businesses and the private sector. Of participants surveyed, 100% responded the workshop improved their overall understanding of RLWD. Efforts are being made to continue these programmes.

In vitro comparison of treatments and commercially available solutions on mortality of Angiostrongylus cantonensis third-stage larvae.

On Hawai'i Island, an increase in human neuroangiostrongyliasis cases has been primarily associated with the accidental ingestion of Angiostrongylus cantonensis L3 in snails or slugs, or potentially, from larvae left behind in the slug's slime or feces. We evaluated more than 40 different treatments in vitro for their ability to kill A. cantonensis larvae with the goal of identifying a safe and effective fruit and vegetable wash in order to reduce the risk of exposure. Our evaluation of treatment lethality was carried out in two phases; initially using motility as an indicator of larval survival after treatment, followed by the development and application of a propidium iodide staining assay to document larval mortality. Treatments tested included common household products, consumer vegetable washes and agricultural crop washes. We found minimal larvicidal efficacy among consumer-grade fruit and vegetable washes, nor among botanical extracts such as those from ginger or garlic, nor acid solutions such as vinegar. Alkaline solutions, on the other hand, as well as oxidizers such as bleach and chlorine dioxide, did show larvicidal potential. Surfactants, a frequent ingredient in detergents that lowers surface tension, had variable results, but dodecylbenzene sulfonic acid as a 70% w/w solution in 2-propanol was very effective, both in terms of the speed and the thoroughness with which it killed A. cantonensis L3 nematodes. Thus, our results suggest promising directions for future investigation.

Adolescent Exposure to Violence and Intimate-Partner Violence Mediated by Mental Distress.

Adolescent exposure to violence (ETV) is associated with multiple negative health outcomes. Despite evidence linking adolescent ETV with later experiences of physical, sexual and psychological intimate partner violence (IPV) victimization, more longitudinal evidence is needed, and potential explanatory mechanisms should be tested. We examine data collected over 17 years to analyze the mediating effects of mental distress and substance use on the association between cumulative ETV in adolescence and IPV in adulthood. Adolescent (M ages=15-18 years) ETV was associated with IPV outcomes in adulthood (M age=32 years). In parallel mediation models, mental distress in emerging adulthood (M ages=20-23 years) fully mediated the effect of adolescent ETV on later IPV outcomes. Although substance use predicted experience of IPV, it did not mediate the association between ETV and IPV. These findings have implications for understanding trajectories of risk following violence exposure and inform intervention work through identifying developmental periods where ETV contributes to later IPV victimization.

Inadequate Systems to Support Breast and Cervical Cancer Screening in Primary Care Practice.

BACKGROUND: Despite substantial resources devoted to cancer screening nationally, the availability of clinical practice-based systems to support screening guidelines is not known. OBJECTIVE: To characterize the prevalence and correlates of practice-based systems to support breast and cervical cancer screening, with a focus on the patient-centered medical home (PCMH). DESIGN: Web and mail survey of primary care providers conducted in 2014. The survey assessed provider (gender, training) and facility (size, specialty training, physician report of National Committee for Quality Assurance (NCQA) PCMH recognition, and practice affiliation) characteristics. A hierarchical multivariate analysis clustered by clinical practice was conducted to evaluate characteristics associated with the adoption of practice-based systems and technology to support guideline-adherent screening. PARTICIPANTS: Primary care physicians in family medicine, general internal medicine, and obstetrics and gynecology, and nurse practitioners or physician assistants from four clinical care networks affiliated with PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium research centers. MAIN MEASURES: The prevalence of routine breast cancer risk assessment, electronic health record (EHR) decision support, comparative performance reports, and panel reports of patients due for routine screening and follow-up. KEY RESULTS: There were 385 participants (57.6 % of eligible). Forty-seven percent (47.0 %) of providers reported NCQA recognition as a PCMH. Less than half reported EHR decision support for breast (48.8 %) or cervical cancer (46.2 %) screening. A minority received comparative performance reports for breast (26.2 %) or cervical (19.7 %) cancer screening, automated reports of patients overdue for breast (18.7 %) or cervical (16.4 %) cancer screening, or follow-up of abnormal breast (18.1 %) or cervical (17.6 %) cancer screening tests. In multivariate analysis, reported NCQA recognition as a PCMH was associated with greater use of comparative performance reports of guideline-adherent breast (OR 3.23, 95 % CI 1.58-6.61) or cervical (OR 2.56, 95 % CI 1.32-4.96) cancer screening and automated reports of patients overdue for breast (OR 2.19, 95 % CI 1.15-41.7) or cervical (OR. 2.56, 95 % CI 1.26-5.26) cancer screening. CONCLUSIONS: Providers lack systems to support breast and cervical cancer screening. Practice transformation toward a PCMH may support the adoption of systems to achieve guideline-adherent cancer screening in primary care settings.

Provider Attitudes and Screening Practices Following Changes in Breast and Cervical Cancer Screening Guidelines.

BACKGROUND: Changes to national guidelines for breast and cervical cancer screening have created confusion and controversy for women and their primary care providers. OBJECTIVE: To characterize women's primary health care provider attitudes towards screening and changes in practice in response to recent revisions in guidelines for breast and cervical cancer screening. DESIGN, SETTING, PARTICIPANTS: In 2014, we distributed a confidential web and mail survey to 668 women's health care providers affiliated with the four clinical care networks participating in the three PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium breast cancer research centers (385 respondents; response rate 57.6 %). MAIN MEASURES: We assessed self-reported attitudes toward breast and cervical cancer screening, as well as practice changes in response to the most recent revisions of the U.S. Preventive Services Task Force (USPSTF) recommendations. KEY RESULTS: The majority of providers believed that mammography screening was effective for reducing cancer mortality among women ages 40-74 years, and that Papanicolaou (Pap) testing was very effective for women ages 21-64 years. While the USPSTF breast and cervical cancer screening recommendations were widely perceived by the respondents as influential, 75.7 and 41.2 % of providers (for mammography and cervical cancer screening, respectively) reported screening practices in excess of those recommended by USPSTF. Provider-reported barriers to concordance with guideline recommendations included: patient concerns (74 and 36 % for breast and cervical, respectively), provider disagreement with the recommendations (50 and 14 %), health system measurement of a provider's screening practices that use conflicting measurement criteria (40 and 21 %), concern about malpractice risk (33 and 11 %), and lack of time to discuss the benefits and harms with their patients (17 and 8 %). CONCLUSIONS: Primary care providers do not consistently follow recent USPSTF breast and cervical cancer screening recommendations, despite noting that these guidelines are influential.

Efficacy of X-Ray Phytosanitary Irradiation on the Infectivity and Reproduction of Angiostrongylus cantonensis in Experimentally Infected Rats.

Angiostrongylus cantonensis is a globally distributed nematode and the leading cause of eosinophilic meningitis in humans. As a global hotspot for this disease, Hawaii's agricultural exports may be contributing to the spread of A. cantonensis. Phytosanitary irradiation doses of 150 or 400 Gy provide quarantine security against multiple insect pests. We evaluated the in vitro and in vivo effects of phytosanitary irradiation on infectious, third-stage, A. cantonensis larvae. In vitro experiments directly exposed larvae to irradiation doses ranging from 200 to 1,000 Gy. Results showed low mortality and no dose response across all treatments 27 days post-irradiation. In vivo studies isolated larvae from wild-caught Parmarion martensi after exposure to x-ray irradiation at doses of 0, 150, and 400 Gy and infected them into laboratory rats. Fourteen rats were assigned to each treatment and infected with 50 larvae from their assigned irradiation dose. Results at 3 and 6 weeks post-infection demonstrated a significant negative dose response in regard to the number of larvae that migrated to the brain and adults found in the pulmonary artery. No irradiated larvae that grew into adults were able to produce eggs. These findings indicate that x-ray irradiation does not result in the direct mortality of A. cantonensis larvae; however, it does affect the infectivity and reproduction of A. cantonensis within its definitive host, the rat. Phytosanitary irradiation at doses ≥150 Gy appears to be an effective means of preventing the establishment of viable populations of A. cantonensis, thus reducing the potential for global spread due to agricultural exports from Hawaii.

Clinical Characteristics of Long-Term Complications of Severe Rat Lung Worm Disease in Hawai'i: A Survey of 4 Cases.

Rat lung worm disease (RLWD) is endemic to Hawai'i, and cases of severe RLWD with long-term sequelae have been reported in Hawai'i. However, there are limited data on clinical features of the RLWD survivors with the long-term sequelae. The authors conducted a survey to report on clinical characteristics of RLWD survivors with the long-term sequelae. Four RLWD survivors had severe RLWD with persistent, neurological symptoms for years after RLWD. In conclusion, long-term sequelae of severe RLWD exist. The most common long-term consequence among participants was severe skin pain, which may relate to damage of the nerves or spinal cord.

Workshop on research priorities for management and treatment of angiostrongyliasis(1).

In a concluding session of the workshop, the participants developed a list of 115 research and outreach needs, outlining the top 5-7 needs in each of 8 areas (Table). For complete information, including presenter details and abstracts, visit the workshop website at www.hawaii.edu/cowielab/Angio%20website%20home.htm.

Management of Rat Lungworm Disease (Neuroangiostrongyliasis) Using Anthelmintics: Recent Updates and Recommendations.

While there have been legitimate concerns in the past regarding the use of anthelmintics for the management of neuroangiostrongyliasis (rat lungworm disease), recent studies demonstrate that they can be considered safe and efficacious, particularly albendazole, which is regarded as the choice anthelmintic for its management. However, physician hesitancy to prescribe, as well as problems of availability persist, at least in Hawaii, which is considered the epicenter of this disease in the US. As a result, many patients suffer a diminished quality of life or even death. Here, we discuss recent studies that provide insights into new treatments and preventative interventions, which can be more rigorously used for the management of neuroangiostrongyliasis. In summary, results from recent studies suggest that albendazole and avermectins are beneficial for post-exposure management, pyrantel pamoate is beneficial as a post-exposure prophylactic, and levamisole is deserving of further study for the treatment of neuroangiostrongyliasis.

In vivo efficacy of pyrantel pamoate as a post-exposure prophylactic for rat lungworm (Angiostrongylus cantonensis).

Rat lungworm (Angiostrongylus cantonensis) is a neurotropic nematode, and the leading cause of eosinophilic meningitis worldwide. The parasite is usually contracted through ingestion of infected gastropods, often hidden in raw or partially cooked produce. Pharmaceutical grade pyrantel pamoate was evaluated as a post-exposure prophylactic against A. cantonensis. Pyrantel pamoate is readily available over-the-counter in most pharmacies in the USA and possesses anthelmintic activity exclusive to the gastrointestinal tract (GIT). Administering pyrantel pamoate immediately after exposure should theoretically paralyze the larvae in the GIT, causing the larvae to be expelled via peristalsis without entering the systemic circulation. In this study, pyrantel pamoate (11 mg/kg) was orally administered to experimentally infected rats at 0, 2-, 4-, 6-, or 8-h post-infection. The rats were euthanized six weeks post-infection, and worm burden was evaluated from the heart-lung complex. This is the first in vivo study to evaluate its efficacy against A. cantonensis. This study demonstrates that pyrantel pamoate can significantly reduce worm burden by 53-72% (P = 0.004), and thus likely reduce the severity of infection that is known to be associated with worm burden. This paralyzing effect of pyrantel pamoate on the parasite may also be beneficial for delaying the establishment of infection until a more suitable anthelmintic such as albendazole is made available to the patient.

Rat Lung Worm Disease Caused by Angiostrongylus cantonensis: A Review of Clinical and Diagnostic Characteristics and Lessons from a Severe Case in Hawaii.

Severe rat lung worm disease (RLWD) is an uncommon condition, but it can result in severe complications and can be difficult to diagnose, necessitating awareness on the part of physicians everywhere. We review the clinical manifestations and diagnostic dilemmas of severe RLWD based on a case in Hawaii. A 50-year-old man developed mild headache, a burning sensation in the limbs, fever, and strained urination nine days after consuming lettuce contaminated with parasitic nematodes (Angiostrongylus cantonensis [A. cantonensis]). In time, his headache became more severe, and he developed purple semi-circular stripes at the base of nail beds. He sought medical attention, but the diagnosis was delayed, likely due to unfamiliarity with the condition by the initial treating clinician. The diagnosis was eventually based on evidence of cerebrospinal fluid (CSF), eosinophils, and positive polymerase chain reaction (PCR) of CSF for A. cantonensis. Corticosteroid treatment was delayed, and albendazole was not administered due to a lack of availability. A greater awareness of RLWD on the part of physicians may have prevented these delays.

Estimating Human Exposure to Rat Lungworm (Angiostrongylus cantonensis) on Hawai'i Island: A Pilot Study.

Angiostrongylus cantonensis is a zoonotic, parasitic nematode causing angiostrongyliasis or rat lungworm disease. Clinical diagnosis in humans is currently confirmed by detection of parasite DNA in cerebrospinal fluid. This study estimated human exposure to A. cantonensis in volunteer participants solicitated via public venues on east Hawai'i Island using blood-based tests. Antibodies were screened in sera by crude antigen ELISA, followed by a 31-kDa dot-blot test developed and validated in Thailand. Human participants (n = 435) donated blood samples and completed a questionnaire to self-report relevant symptomology or clinical diagnosis. Among symptoms reported by participants diagnosed by licensed clinicians, headaches, high eosinophil counts, stiff neck, fatigue, and joint pain were most severe during the initial 3 months of infection. ELISA results revealed 22% of the serum samples as positive, 46% as equivocal, and 32% as negative. A subset of 186 samples was tested by dot blot, with 30% testing positive and 70% testing negative. A significantly higher mean ELISA value was found among recently (2014-2015) clinically diagnosed participants as than among those with a diagnosis before 2010 (P = 0.027). All dot-blot positives were also ELISA positive and were significantly associated with higher ELISA values compared with dot-blot negatives (P = 0.0001). These results suggest that an ELISA using crude antigen isolated from adult A. cantonensis from Hawai'i may be an effective initial screening method for estimating exposure to A. cantonensis in Hawai'i and likewise suggest that dot-blot tests using the 31-kDa antigen exhibit efficacy as a diagnostic for exposure.

Water transmission potential of Angiostrongylus cantonensis: Larval viability and effectiveness of rainwater catchment sediment filters.

Neuroangiostrongyliasis, caused by Angiostrongylus cantonensis, has been reported in Hawai'i since the 1950's. An increase in cases is being reported primarily from East Hawai'i Island, correlated with the introduction of the semi-slug Parmarion martensi. Households in areas lacking infrastructure for water must use rainwater catchment as their primary domestic water supply, for which there is no federal, state, or county regulation. Despite evidence that slugs and snails can contaminate water and cause infection, regulatory bodies have not addressed this potential transmission route. This study evaluates: 1) the emergence of live, infective-stage A. cantonensis larvae from drowned, non-native, pestiforous gastropods; 2) larvae location in an undisturbed water column; 3) longevity of free-living larvae in water; and 4) effectiveness of rainwater catchment filters in blocking infective-stage larvae. Larvae were shed from minced and whole gastropods drowned in either municipal water or rainwater with ~94% of larvae recovered from the bottom of the water column 72-96 hours post drowning. Infective-stage larvae were active for 21 days in municipal water. Histological sectioning of P. martensi showed proximity of nematode larvae to the body wall of the gastropod, consistent with the potential for shedding of larvae in slime. Gastropod tissue squashes showed effectivity as a quick screening method. Live, infective-stage larvae were able to traverse rainwater catchment polypropylene sediment filters of 20 µm, 10 µm, 5 µm, and 1 µm filtration ratings, but not a 5 µm carbon block filter. These results demonstrate that live, infective-stage A. cantonensis larvae emerge from drowned snails and slugs, survive for extended periods of time in water, and may be able to enter a catchment user's household water supply. This study illustrates the need to better investigate and understand the potential role of contaminated water as a transmission route for neuroangiostrongyliasis.

Increasing patient/physician communications about colorectal cancer screening in rural primary care practices.

BACKGROUND: Rural populations as well as less educated people in the United States are less likely to receive colorectal cancer (CRC) screening than people living in urban areas and more educated people. METHODS: We tested a computer tablet, Patient/Provider Communication Assistant (PPCA), which collected data, educated patients, and printed personalized notes to patients and providers encouraging conversation about CRC screening. Mixed model analyses using a prepost quasi-experimental design compared patient results during the comparison and intervention periods in 5 rural primary care practices on provider discussion about CRC screening, provider recommendation, and patient intention to be screened. Models including age, education, and literacy measures as covariates were examined. RESULTS: Providers talked with patients about CRC screening in general, and colonoscopy specifically more frequently after the PPCA than with the comparison group (P values = 0.04 and 0.01, respectively). Providers recommended CRC screening more often to patients in the intervention group than to the comparison group (P = 0.02). Patients planned to be screened, specifically with colonoscopy, more frequently after the intervention than in the comparison group (P = 0.003). There were no interactions between group and any of the covariates. Ninety-five percent of the patients, regardless of age or education, found the PPCA easy to use. CONCLUSIONS: Results indicated increased provider discussion and recommendation, and patients' intentions to obtain CRC screening, and in particular colonoscopy, for patients exposed to the intervention, regardless of the patients' age or literacy levels. The PPCA is a promising intervention method that is acceptable to rural patients.

Reducing Rat Lungworm Disease in Hawai'i Through a Collaborative Partnership With K-12 School Garden and Agriculture Projects.

A recent increase in serious cases of rat lungworm disease impacts Hawai'i's agriculture and human health. Slugs and snails, agricultural pests, are intermediate hosts of Angiostrongylus cantonensis the rat lungworm. Infection by this parasitic nematode is the leading cause of eosinophilic meningitis globally. Infection can result from ingestion of infected produce and has caused chronic neurological problems, disability, coma, and death. There are over 200 K-12 school and youth garden, and agriculture projects throughout the Hawaiian Islands. This existing network provides an avenue for teacher and student involvement in community health education and host control programs. We collaborated with five Hawai'i Island schools connected with the Hawai'i Island School Garden Network to develop an integrated pest management plan for the control of invasive, intermediate hosts of A. cantonensis. Curricula relating to rat lungworm for grades 5-8 that support student academic achievement with a focus on science, technology, engineering, art, and math were developed. The management plan trialed the use of five different materials for shelters, which provided refuge for and easy removal of unwanted slugs and snails. Over 4,000 invasive slugs and snails were removed. Students learned how to safely dispatch pests and they collected data on species found, numbers of species removed, and shelter-type capture rates. Using the arts, students shared information at school and within their family and community. A written management plan, eleven lesson plans, and auxiliary materials are now available online. A concerted effort is needed to reduce parasite hosts if we are to reduce human cases of disease and restore public faith in local agriculture. Use of the established school garden network is an ideal avenue through which to educate the public and develop solutions for this public health problem.

Angiostrongyliasis (Rat Lungworm Disease): Viewpoints from Hawai'i Island.

Hawai'i, particularly east Hawai'i Island, is the epicenter for angiostrongyliasis in the United States. Case numbers have been increasing and appear to parallel the introduction and spread of the semislug (Parmarion martensi) to east Hawai'i. The infective larvae in rainwater catchment as a source for household and agricultural water may also play a role. The spread of Angiostrongylus cantonensis as well as the potential introduction of the semislug P. martensi should be a concern to the mainland United States. The State of Hawai'i should recognize the seriousness of this growing problem and thus collaborate to fund studies to address the growing challenges surrounding angiostrongyliasis.

High prevalence of Angiostrongylus cantonensis (rat lungworm) on eastern Hawai'i Island: A closer look at life cycle traits and patterns of infection in wild rats (Rattus spp.).

The nematode Angiostrongylus cantonensis is a zoonotic pathogen and the etiological agent of human angiostrongyliasis or rat lungworm disease. Hawai'i, particularly east Hawai'i Island, is the epicenter for angiostrongyliasis in the USA. Rats (Rattus spp.) are the definitive hosts while gastropods are intermediate hosts. The main objective of this study was to collect adult A. cantonensis from wild rats to isolate protein for the development of a blood-based diagnostic, in the process we evaluated the prevalence of infection in wild rats. A total of 545 wild rats were sampled from multiple sites in the South Hilo District of east Hawai'i Island. Adult male and female A. cantonensis (3,148) were collected from the hearts and lungs of humanely euthanized Rattus rattus, and R. exulans. Photomicrography and documentation of multiple stages of this parasitic nematode in situ were recorded. A total of 45.5% (197/433) of rats inspected had lung lobe(s) (mostly upper right) which appeared granular indicating this lobe may serve as a filter for worm passage to the rest of the lung. Across Rattus spp., 72.7% (396/545) were infected with adult worms, but 93.9% (512/545) of the rats were positive for A. cantonensis infection based on presence of live adult worms, encysted adult worms, L3 larvae and/or by PCR analysis of brain tissue. In R. rattus we observed an inverse correlation with increased body mass and infection level of adult worms, and a direct correlation between body mass and encysted adult worms in the lung tissue, indicating that larger (older) rats may have developed a means of clearing infections or regulating the worm burden upon reinfection. The exceptionally high prevalence of A. cantonensis infection in Rattus spp. in east Hawai'i Island is cause for concern and indicates the potential for human infection with this emerging zoonosis is greater than previously thought.

Detection of Angiostrongylus cantonensis in the Blood and Peripheral Tissues of Wild Hawaiian Rats (Rattus rattus) by a Quantitative PCR (qPCR) Assay.

The nematode Angiostrongylus cantonensis is a rat lungworm, a zoonotic pathogen that causes human eosinophilic meningitis and ocular angiostrongyliasis characteristic of rat lungworm (RLW) disease. Definitive diagnosis is made by finding and identifying A. cantonensis larvae in the cerebral spinal fluid or by using a custom immunological or molecular test. This study was conducted to determine if genomic DNA from A. cantonensis is detectable by qPCR in the blood or tissues of experimentally infected rats. F1 offspring from wild rats were subjected to experimental infection with RLW larvae isolated from slugs, then blood or tissue samples were collected over multiple time points. Blood samples were collected from 21 rats throughout the course of two trials (15 rats in Trial I, and 6 rats in Trial II). In addition to a control group, each trial had two treatment groups: the rats in the low dose (LD) group were infected by approximately 10 larvae and the rats in the high dose (HD) group were infected with approximately 50 larvae. In Trial I, parasite DNA was detected in cardiac bleed samples from five of five LD rats and five of five HD rats at six weeks post-infection (PI), and three of five LD rats and five of five HD rats from tail tissue. In Trial II, parasite DNA was detected in peripheral blood samples from one of two HD rats at 53 minutes PI, one of two LD rats at 1.5 hours PI, one of two HD rats at 18 hours PI, one of two LD rats at five weeks PI and two of two at six weeks PI, and two of two HD rats at weeks five and six PI. These data demonstrate that parasite DNA can be detected in peripheral blood at various time points throughout RLW infection in rats.

A severe case of rat lungworm disease in Hawa'i.

A 23-year-old man living on the island of Hawa'i developed a life threatening case of eosinophilic meningitis caused by infection with Angiostrongylus cantonensis (rat lungworm disease: RLWD). He was comatose for 3 months, incurring brain and nerve damage sufficiently extensive that he was not expected to recover. The case was complicated by secondary infections of methicillin-resistant Staphylococcus aureus, Clostridium difficile, and pneumonia, which resulted in an empyema requiring a thoracoscopy and decortication. He was treated with prednisone, mebendozal, and pain medication for RLWD, and antibiotics and antifungal medications for the secondary infections. The administration of herbal supplements was requested by the family and approved, and these were administered through a gastric tube. Less than a month after being declared in a persistent vegetative state the man was able to talk, eat, and had regained some muscle functions. After release from the hospital he continued the use of supplements and received treatments of intravenous vitamin therapy. Four years after onset of the illness he is able to ride a bicycle, is a part time student, plays guitar, and is fluent in two foreign languages. RLWD is an emerging tropical disease of growing importance in Hawa'i.

Control measures for slug and snail hosts of Angiostrongylus cantonensis, with special reference to the semi-slug Parmarion martensi.

Slugs and snails (class Gastropoda) are the obligate intermediate hosts of the rat lungworm, Angiostrongylus cantonensis. This nematode is the causative agent of human angiostrongyliasis and the most common cause of human eosinophilic meningoencephalitis. Humans can become infected by accidental consumption of slugs or snails and possibly flatworms (or a portion of one of these animals) in fresh produce, but the slime from these animals can contain nematodes and may also constitute a disease risk. Gastropod carriers in Hawa'i include, among other species, giant African snails, veronicellid slugs, and the semi-slug Parmarion martensi. This latter species was first discovered on the island of Hawa'i in 2004 and is now common in the area where the majority of the state's documented cases of human angiostrongyliasis occurred between 2005 and 2011. This species is considered a high risk carrier of A. cantonensis because of its climbing behavior, abundance around human dwellings, and high worm burdens. One individual collected from east Hawa'i Island contained >6,800 infective third stage A. cantonensis larvae. Common and efficient control methods for slugs and snails include sanitation (eg, removal of objects that serve as hiding places) and the use of poison food baits, such as those containing metaldehyde and iron. An iron-containing bait that is relatively safe to non-target organisms was effective in controlling semi-slugs in cage experiments, although it killed more slowly than a metaldehyde-containing bait and the majority of slugs affected did not die until 1-2 weeks following ingestion.