The problem was discovered during routine FSIS surveillance activities of imported products, and it was determined that the products were not presented for reinspection.

The products subject to recall bear Canadian establishment number “391” inside the Canadian mark of inspection. 

Recalled product:

FSIS is concerned that some products may be in consumers’, restaurants, and institutions’ freezers.

• 15-kg/33.07-lb. cases containing “Frozen Pork Front Hock” with case code 18019 and Cert. No. 251497 and best before dates between July 14-27, 2025.

As of the posting of this recall, there have been no reports of adverse reactions due to consumption of these products. Anyone concerned about a reaction should contact a healthcare provider.

These items were shipped to Hawaii and American Samoa distributors and exported to Palau.

Consumers who have purchased these products are urged not to consume them. Restaurants and institutions are urged not to serve these products. These products should be thrown away or returned to the place of purchase.

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People can be infected when they deliberately or accidentally eat a raw snail or slug containing the lungworm larvae or eat unwashed lettuce or other raw leafy vegetables that the slime of infected snails or slugs has contaminated.

Each of the 300+ PBS stations makes its own decision about when, where and if to air the film. It’s had good uptake in many markets, including Florida, Puerto Rico and various midwestern states. Programmers at other major stations have not yet aired the show because of the limitations of their schedules. The film’s distribution as an Accidental Host to PBS stations will continue through September 2025, and the content will undoubtedly hold up for at least that long, if not longer.

On the other hand, PBS Passport is an app available to anyone who supports their local PBS station at a basic level (usually $60/year). So whether or not their home station has already aired the show, a supporter can access the film at no additional charge through the PBS Passport streaming site.

Paznosian is an infectious disease specialist at UCLA and Food Safety News contributor. She is an expert in rat lungworm disease.

This public education approach comes after the best minds with the best science have concluded that Hawaii’s rat lungworm is not spreading beyond the state. In fact, Hawaii is the epicenter of rat lungworm disease which was first found in Asia.

According to Hawaii’s State Department of Health:

“Angiostrongyliasis, also known as neuroangiostrongyliasis or rat lungworm, is a disease that affects the brain and spinal cord. It is caused by a parasitic nematode (roundworm parasite) called Angiostrongylus cantonensis. The adult form of A. cantonensis is only found in rodents. However, infected rodents can pass larvae of the worm in their feces. Snails, slugs, and certain other animals (including freshwater shrimp, land crabs, and frogs) can become infected by ingesting this larvae; these are considered intermediate hosts. Humans can become infected with A. cantonensis if they eat (intentionally or otherwise) a raw or undercooked infected intermediate host, thereby ingesting the parasite.”

And the Hawaii Department of Health says this is what puts you at risk:

“You can get angiostrongyliasis by eating food contaminated by the larval stage of A. cantonensis worms. In Hawaii, these larval worms can be found in raw or undercooked snails or slugs. Sometimes people can become infected by eating raw produce that contains a small infected snail or slug, or part of one. It is not known for certain whether the slime left by infected snails and slugs are able to cause infection. Angiostrongyliasis is not spread person-to-person.”

With these results:

“This infection can cause a rare type of meningitis (eosinophilic meningitis).

The clinical presentation can vary. Symptoms can start with non-specific symptoms and evolve into more specific symptoms over the next following weeks. People may experience nausea, vomiting, and abdominal pain a few hours to a few days after ingestion. Symptoms can then progress to headache and other neurologic symptoms. Non-specific symptoms include fever, light sensitivity, muscle pain, fatigue, and insomnia. More specific symptoms may include constant headache, neck stiffness and pain, tingling or burning of the skin, double vision, bowel or bladder difficulties, and seizures.

Children may experience more fever, irritability, somnolence, lethargy, gastrointestinal symptoms, muscle twitching, convulsions, and extremity weakness. In addition, individuals may experience a few days to weeks of no symptoms followed by neurologic symptoms.

Although it varies from individual to individual, the symptoms usually last between two to eight weeks. Symptoms have also been reported to last for longer periods of time.

Risk in Hawaii
According to the Hawaii Health Department: “The majority of cases of rat lungworm that are identified in Hawaii have occurred on the Big Island, but cases, and infected intermediate hosts (snails and slugs), have also been identified on all of the major neighbor islands. Since the risk for infection is present statewide, the recommendations for preventing infection should be followed no matter where in the state you are.

Prevention:

To prevent angiostrongyliasis, the Hawaii Department of Health says don’t eat raw or undercooked snails or slugs, and if you handle snails or slugs, be sure to wear gloves and wash your hands. Eating raw or undercooked freshwater shrimp, land crabs and frogs may also result in infection, although, there have not been any documented cases in Hawaii.

You should thoroughly inspect and rinse produce using potable water. Leaves of leafy greens should be washed one by one under running potable water. Boil snails, freshwater prawns, crabs, and frogs for at least 3–5 minutes. Only drink potable water and do not drink from garden hoses.

Eliminating snails, slugs, and rats founds near houses and gardens might also help reduce risk exposure to A. cantonensis. Eliminating snails, slugs, and rats can be achieved through pesticide baits, traps, rodent proofing your home and sanitation.

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Those provisions provide that

— A farm may sell raw milk directly to the end consumer for personal consumption.

— A farm may not sell raw milk to a wholesaler or retail store for mass consumption under this chapter.

— The seller shall only sell milk within this state.

— The sale may not involve interstate commerce.

— Raw milk may not be donated.

With those provisions, the North Dakota Legislature sent the direct sale bill to Gov. Doug Burgum’s desk by overwhelming margins, 83 -to 10 in the House and 32-to-14 in the Senate.

House Bill 1515 permits dairy producers in North Dakota to sell raw milk on their farms, while continuing the state’s prohibition on sales through grocery stores or wholesalers. Raw milk sales are limited to direct transactions between a willing buyer and a willing seller.

North Dakota’s health and agriculture officials remain concerned about the pathogens contained in milk that are not pasteurized that often cause human illnesses. Those concerns may be why Gov. Burgum’s position on HB 1515 remains unknown.

Iowa Gov. Kim Reynolds also has a raw bill on her desk. Iowa Senate File 315 is like the North Dakota bill but appears to go a little further.

Milk producers would be able to sell raw, unpasteurized milk in Iowa if Gov. Reynolds signs SF315.

.Healthcare and agricultural groups, including the Iowa Public Health Association, Iowa Farm Bureau, and Iowa State Dairy Association, are on record as being opposed to the bill because of public health concerns.

The Iowa House made revisions to the bill after it first passed the Senate, but the margins have been large on final passage in both chambers, 64-to-35 in the House and 37-to-13 in the Senate.

The approved version requires that raw milk producers test dairy animals for bacteria. It does not require that the raw milk itself be tested for bacteria or viruses, which can allow contaminated milk to enter the stream of commerce.

In four other states, the current legislative sessions appear to be coming to an end with no changes for raw milk.

Hawaii 
The Hawaii Senate’s Committee on Agriculture and the Environment and the Committee on Health and Human Services deferred HB 521 and nothing has happened since then.

Some citizen testimony had earlier asked why it is okay for Hawaiians to consume risky raw shellfish, but not raw milk, but the state Health Department remains completely opposed to raw milk legalization.

Adjournment Sine Die for the Hawaii Legislature is May 4.

Illinois
SB 0152 authorizes a dairy farm to sell, distribute or otherwise sell or distribute unpasteurized milk or milk products for human use or consumption without being issued a permit if the animal is housed at the farm.

After it was introduced on Jan. 25, 2023, the Illinois raw milk bill was assigned to the Senate’s Public Health Committee. It took the assignment until March 10, 2023, when SB 0152 was sent back to the Assignments Committee, where it remains.

The Illinois Legislature adjourns on May 19 and runs up to that date with the usual bill-killing deadlines.

Rhode Island
The Rhode Island House Health and Human Services Committee has recommended the bill to legalize raw milk “be held for further study.”

That action was taken by a committee vote on March 10, 2023. In all likelihood, it spells the death neal for HB 5557 during the current legislative session which does not end until June 30.

HB 5557 would, if it is ever enacted, give raw milk the same status as pasteurized milk.

Minnesota
The Minnesota House Agriculture, Finance and Policy Committee on Feb. 1, 2023, got the assignment to review HF 1167, but it’s not held any hearings or moved the bill in any way. As drafted it would permit registered small dairy farms to sell fluid raw milk and fluid raw milk products to consumers under certain circumstances.

The Minnesota Legislature is scheduled to adjourn on May 22,

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Of the four states, only Illinois currently allows for herd share agreements, which means a person has to buy a share in a herd or a single animal to receive the raw milk. On-farm sales are allowed in Illinois and Minnesota and for milk prescriptions in Rhode Island.

Other than that, the four states are among those with controls on raw milk sales and distribution. Bills questioning that approach are currently before each state’s legislature.

But when your bill is re-referred to the assignments committee or after an extensive public hearing it gets deferred, it’s usually not a good sign. And for the handful of raw milk bills state legislatures are still considering this year, that’s how it’s going.

Bills to legalize raw milk are pending in Hawaii, Illinois, Minnesota, and Rhode Island. And it’s not really going well for any of the four. Here’s the status report:

Hawaii
After a third set of hearings Monday, the Hawaii Senate’s Committee on Agriculture and the Environment and the Committee on Health and Human Services, the best HB 521 got was a pair of deferral votes by the two committees. While some citizen testimony asked why it is okay for Hawaiians to consume risky raw shellfish, but not raw milk, the state Health Department remains completely opposed to raw milk legalization.

Without a floor vote, HB 521 could be dead shortly. Adjournment Sine Die for the Hawaii Legislature is May 4, but bill-killing deadlines come before that.

Illinois
SB 0152 authorizes a dairy farm to sell, distribute or otherwise sell or distribute unpasteurized milk or milk products for human use or consumption without being issued a permit if the animal is housed at the farm.

After it was introduced on Jan. 25, 2023, the Illinois raw milk bill was assigned to the Senate’s Public Health Committee. It took the assignment until March 10, 2023, when SB 0152 was sent back to the Assignments Committee, where it remains.

The Illinois Legislature adjourns on May 19 and runs up to that date with the usual bill-killing deadlines.

Rhode Island
The Rhode Island House Health & Human Services Committee has recommended the bill to legalize raw milk “be held for further study.”

That action was taken by a committee vote on March 10, 2023. In all likelihood it spells the death neal for HB 5557 during the current legislative session which does not end until June 30.

HB 5557 would, if it is ever enacted, give raw milk the same status as pasteurized milk.

Minnesota
The Minnesota House Agriculture, Finance & Policy Committee on Feb. 1, 2023, got the assignment to review HF 1167, but it’s not held any hearings or moved the bill in any way. As drafted it would permit registered small dairy farms to sell fluid raw milk and fluid raw milk products to consumers under certain circumstances.

The Minnesota Legislature is scheduled to adjourn on May 22, and it too has the usual set of deadlines that bills must make or be dead before the adjournment date.

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The recall was the result of a routine sampling program by the State of Hawaii which revealed that the finished products contained Listeria monocytogenes. 

According to the company announcement posted by the FDA, the recalled Enoki Mushroom product was distributed in California to small local produce distributors or wholesalers for further distribution to retail stores within California and Hawaii.

Recalled product:

• The Enoki Mushroom comes in a 200g/7.05oz clear plastic package with the following description “Taiwan Best Quality Enoki Natural Mushroom***Manufacturer: Changhua County Mushrooms Production Cooperative” in English. 
• There is a green lettered “Premium” Printed with two QR scan codes and UPC 8 51084 00835 8 on the back side of a package
•  There is a Lot Code #3779 outside of box.

As of the posting of this recall, no illnesses have been reported to date in connection with this problem. The distribution of the product is suspended.

This recall is being made with the knowledge of the U.S. Food and Drug Administration and the California Department of Public Health.

Consumers should return enoki packages to the place of purchase for a full refund. 

About Listeria infections
Food contaminated with Listeria monocytogenes may not look or smell spoiled but can still cause serious and sometimes life-threatening infections. Anyone who has eaten any of the recalled product and developed symptoms of Listeria infection should seek medical treatment and tell their doctors about the possible Listeria exposure.

Also, anyone who has eaten any of the recalled product should monitor themselves for symptoms during the coming weeks because it can take up to 70 days after exposure to Listeria for symptoms of listeriosis to develop. 

Symptoms of Listeria infection can include vomiting, nausea, persistent fever, muscle aches, severe headache, and neck stiffness. Specific laboratory tests are required to diagnose Listeria infections, which can mimic other illnesses. 

Pregnant women, the elderly, young children, and people such as cancer patients who have weakened immune systems are particularly at risk of serious illnesses, life-threatening infections, and other complications. Although infected pregnant women may experience only mild, flu-like symptoms, their infections can lead to premature delivery, infection of the newborn, or even stillbirth.

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The state Department of Health has embargoed raw milk products, which it says are not safe for human consumption, according to a public warning from the department.

Officials took action when they became aware of pet stores selling raw goat’s milk and marketing it for pets.

“The goat milk is being advertised as ‘pet food,’ but the sale of any form of raw fluid milk is a risk to public health because it is easily diverted for human consumption,” said Peter Oshiro, chief of the health department’s Food Safety Branch.

“There are many in our community that mistakenly believe that drinking raw milk is healthy, but this is simply untrue.”

Nearly 20 O’ahu pet stores have been caught selling the raw milk, according to a statement from the health department. The department is continuing to investigate the situation and could find more retailers selling the illegal product.

Under Hawaii law, only Grade A pasteurized milk and milk products may be sold to the final consumer or to restaurants.

Pet stores or any other retailer that has raw milk in their possession must remove the product from sale immediately and destroy or return the product to their supplier, the health department warned. Failure to do so may result in seizure and fines of up to $10,000 per day.

The health department has issued cease and desist orders across the state, ordering pet stores and find retailers to stop selling illegal unpasteurized goat milk.

“Drinking unpasteurized milk is unsafe because it may result in serious illnesses, hospitalizations and even death,” according to the health department’s public alert.

Raw milk has the potential to carry and transmit dangerous pathogens including E. Coli, Salmonella, and a host of other bacteria that can cause disease. It is especially dangerous for children, the elderly, or those with weakened immune systems to drink raw milk because they may not be able to fend off these pathogens as a normal healthy individual would, the health department warning states.

Drinking raw milk is particularly dangerous because children infected through consumption of raw milk can spread disease through microscopic amounts of fecal matter that can infect others. This can cause a serious disease outbreak among other people with whom they come into contact.

“Raw milk consumption by a few individuals has the potential to negatively impact our community at large by causing an outbreak of disease,” according to the health department’s warning.

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Parasitic flatworms were found to use several species of thiarid snails, commonly found in freshwater environments in Southeast Asia, as their first intermediate host.

“Trematode infections are major public health problems affecting humans in Southeast Asia. Trematode infections depend not only on the habit of people, but also on the presence of first and second intermediate host species, resulting in the endemic spread of parasites, such as intestinal and liver flukes in Thailand,” said scientists.

Snails belong to the genus Stenomelania, have elongated and pointed shells and can be found near and in the brackish water environment of estuaries from India to the Western Pacific islands, including Hawaii.

Studying snails to understand the scale of problem
The study, conducted by Thai and German researchers, was published in the journal Zoosystematics and Evolution.

Researchers collected 1,551 Stenomelania snails between February 2018 and 2019, identified as four species, from streams and rivers near the coastline of the south of Thailand in Krabi, Trang and Satun Provinces. Ten were infected with trematodes. The parasites were found at seven of the 13 studied locations and belonged to three different species. In Krabi Province, the team found all three species.

Scientists suspect their presence could be related to the circulation of sea currents, as the flow of water along the Andaman coast is affected by the monsoon season between January and May and August and October.

Previous research has found at least 70 species of foodborne and waterborne trematodes, such as blood, intestinal, liver and lung flukes, can be found in various animals.

The Food and Agriculture Organization of the United Nations (FAO) produced factsheets in 2020 on foodborne parasitic infections such as paragonimiasis, taeniasis and cysticercosis, cystic and alveolar echinococcosis, clonorchiasis and opisthorchiasis and fish liver flukes.

Researchers said information on the susceptibility of Stenomelania snails to foodborne zoonotic infections provides information on public health in the region.

They added further study of the snails will enhance understanding of the host-parasite relationship as the first intermediate host populations in Thailand. This will also determine the role of parasitic infections in humans and animals in Southeast Asia.

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“Tropical parasites in our food? No way!” most Americans think.

It’s time to think again.

In May Hawaii’s Department of Health announced three more cases of rat lungworm in recent visitors. Already endemic in Hawaii, Asia, Australia, Brazil and the Caribbean, the exotic foodborne menace is also emerging in Florida and other southeastern states.

Rat lungworm survives using clever, earthy tactics. Adult worms live in rats—snails and slugs get infected by eating rat droppings—rats get infected by eating parasite-laden snails and slugs. Humans are “dead-end hosts,” meaning we can’t transmit the disease to others. But we can still fall gravely ill when larvae migrate, grow and die in our brains.

Last year, ten people officially contracted rat lungworm in Hawaii, presumably from eating locally-grown greens harboring mollusks. But human cases are underreported, according to the state’s Department of Health. Consider the risk in fauna. In Hawaii, up to 70 percent of a newly-invasive semi-slug carry rat lungworm larvae, while a 2017 Florida study found the parasite in one in five rats and one in 50 snails. In Florida, it has killed or sickened zoo animals; in neighboring states, it has also sickened a handful of humans.

What if plants grown in Hawaii or the Southeast spread infected mollusks to new locales? If tiny, larval-laden snails enter the Salinas Valley—especially if temperatures and rainfall continue to climb—could California’s leafy greens someday spawn cases? We believe the answer is yes.

The risk to tourists is equally worrisome. More than 9 million visit Hawaii every year and visitors have developed the disease. Returning travelers face many diagnostic obstacles, including the lack of definitive blood tests.

In the 1980s, one of us saw toddlers in Taiwan initially diagnosed with bacterial meningitis before unusual cells in their spinal fluid pointed to rat lungworm. Thirty years later, the situation hasn’t changed. Unless a doctor thinks of it, then performs a spinal tap, requests special tests and prescribes the right medications, patients can suffer dire harm.

More lessons can be gleaned from a landmark outbreak. In 1999, 23 medical students traveled to Jamaica on spring-break and shared a final celebratory feast. Weeks later, eleven of the twelve who ate Caesar salad tested positive for rat lungworm at the CDC. Three sufferers were well enough to remain outpatients, while a fellow student was hospitalized for weeks and—despite intravenous steroids—required a dozen spinal taps to relieve sky-high pressure in her brain.

Saddest of all is the story of Sam Ballard from Australia. In 2010, while in Sydney, the 19-year old ate a slug on a dare, thus contracting rat lungworm. After awakening from a coma, Ballard was fully paralyzed, and in 2018, he died. Hawaii has witnessed similar tragedies.

What can be done?
In Hawaii, especially near Hilo, a non-native semi-slug with high larval loads likely accounts for worsening infections. This small species with a toenail-sized shell on its back enters gardens, houses and water tanks. Controlling the semi-slug and other intermediate hosts is an uphill but necessary battle.

Physicians on the mainland still lack knowledge about rat lungworm disease. Education is needed, as are better diagnostic tests.

Education is also needed for visitors to Hawaii, Florida and other places where the parasite is present. Sensible advice? Eat only local produce that has been thoroughly washed. Don’t throw fresh leafy greens into a blender for a Kermit-colored smoothie. Don’t drink from a hose where a snail or slug might hide. Don’t let children play with snails!

Finally, what rat lungworm teaches is the dynamic ecology of foodborne parasites and one more basic truth. Parasites are not just “over there” — but here.

Cyclospora, which causes diarrhea, is another example. Until last year, foodborne outbreaks in the U.S. were solely linked to produce imported from Central and South America. But in 2018, a salad mix from California caused more than 500 cases in people who ate at fast-food restaurants in 15 states and New York City. Not only was Cyclospora found in unopened bags of the salad mix, it was also detected for the first time in romaine grown on California farms.

Human infections due to foodborne parasites are preventable. We should all stay vigilant and informed, not just about rat lungworm, but the next emerging threat. And the next. After all, from a parasite’s point of view, it’s all about surviving and thriving, which is what the rat lungworm has done for millennia.

About the author: Claire Panosian Dunavan is an infectious diseases specialist at UCLA and a past-president of the American Society of Tropical Medicine and Hygiene. Stephen Ostroff most recently served as FDA’s deputy commissioner for food and veterinary medicine.

Publication note: This column originally appeared in The Hill and is republished here with permission.

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Hawaii’s health department director has released information provided to the state by the federal Centers for Disease Control and Prevention about the confirmation of the infected patients. Hawaii Gov. David Y. Ige joined Health Director Bruce Anderson in the announcement, which did not indcate when the federal agency contacted them. Cases of rat lungworm infections have received increasing coverage from news media across the country in recent years.

Specific tests are required to diagnose rat lungworm infections, which come from microscopic creatures that infect rats. Larvae infect the rats’ lungs and are then passed through their feces to animals that people eat, such as snails and frogs. The parasitic worms travel through the human body to the brain and can cause eosinophilic meningitis and/or damage the central nervous system.

“People also can get infected by accident, by eating raw produce such as lettuce that contains a small snail or slug or part of one,” according to the CDC. 

Certain animals such freshwater shrimp, crabs, or frogs, have been found to be infected with larvae of the parasite and can therefore infect people, according to CDC information. Eating undercooked or raw animals that are infected can result in people becoming infected. Fish do not spread this parasite. 

Some people become infected from drinking rain water collected from roofs and other untreated sources that are accessible to carrier animals, according to health care officials who have spoken to Food Safety News in recent years. Many homes in Hawaii are not connected to municipal water sources. Carrier animals can also contaminate traditional regional dishes that are often cooked outdoors. 

Children and other people who drink from garden hoses have also been infected, according to reports in the U.S. and Europe.

Transmission routes for recently confirmed patients
Two of the patients recently confirmed by CDC laboratory analysis became ill early this year. The third visited Hawaii in December 2018 and became ill later that month. All three visited Hawaii Island, also known as the Big Island, before becoming sick.

The person who became ill in December visited East Hawaii “and became infected by purposely eating a slug on a dare” according to the health director’s announcement. Statewide, 10 people were confirmed to have been infected with angiostrongyliasis, the scientific name for rat lungworm disease, in 2018. 

Some researchers and government officials in Hawaii say the disease is under-reported and often not diagnosed. Specific testing is necessary and many health care providers are not aware of the symptom set the disease causes and therefore do not order the appropriate tests.

The two people who became ill from the parasite in January and the December 2018 patient, were infected in unrelated scenarios. The January cases had traveled to the opposite side of Hawaii Island that did the patient from December 2018.

One of the people who became ill in early January recalls eating many homemade salads while on vacation on the Big Island. The state’s investigation could not determine for sure how the individual was infected, according to the health department statement. 

“The other individual became ill in late February and was hospitalized for a short time. The investigation was not able to identify an exact source of infection, but the individual likely became infected while ‘grazing,’ or eating unwashed raw fruits, vegetables and other plants straight from the land,” according to state health officials.

With the confirmation of the two patients, the state has logged five confirmed cases of angiostrongyliasis in 2019.

Action taken by state officials
To help minimize the number of people who become infected, the state has posted information on signs “in local airports and shopping centers.”

“It’s important that we ensure our visitors know the precautions to take to prevent rat lungworm disease, which can have severe long-term effects,” said Anderson in this week’s announcement. “Getting information to visitors about the disease is just as critical as raising awareness amongst our residents.”

The Hawaii Department of Health has posted tips for avoiding the parasitic disease, including:

• Wash all fruits and vegetables under clean, running water to remove any tiny slugs or snails. Pay close attention to leafy greens.
• Control snail, slug, and rat populations around homes, gardens and farms. Get rid of these vectors safely by clearing debris where they might live, and also using traps and baits. Always wear gloves for safety when working outdoors.
• Inspect, wash and store produce in sealed containers, regardless of whether it came from a local retailer, farmer’s market, or backyard garden.

In recent years victims have reported being infected after eating only in restaurants. Some have said they discovered snails or parts of snails in restaurant salads. Some have reported eating traditional dishes prepared outdoors, according to researchers and health care professionals in Hawaii.

To read previous Food Safety News coverage about rat lungworm disease, please see:

• https://www.foodsafetynews.com/2018/08/rat-lungworm-cases-linked-to-eating-centipedes-host-snails-increasing-in-us/
• https://www.foodsafetynews.com/2018/02/hawaii-reports-first-confirmed-rat-lungworm-case-of-2018/
• victim https://www.foodsafetynews.com/2018/01/parasitic-disease-from-hawaii-changes-couples-lives/
• victim profile https://www.foodsafetynews.com/2017/05/poisoned-in-paradise-rat-lungworm-nightmare-in-hawaii/
• https://www.foodsafetynews.com/2017/04/rat-lungworm-cases-spike-on-two-islands-maui-and-big-island/
• https://www.foodsafetynews.com/2012/01/minnesotan-recovering-from-rat-lungworm-disease/
• https://www.foodsafetynews.com/2011/11/hawaiis-big-islands-concerned-about-rat-lungworm/
• https://www.foodsafetynews.com/2011/07/hawaii-might-dish-new-food-safety-law/

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In 2018, Hawaii enacted legislation to ban chlorpyrifos beginning in 2022. Now, the New York Senate and Assembly have approved legislation that will ban chlorpyrifos from the Empire State beginning in 2021.

The New York legislation, which will prohibit the use of chlorpyrifos by aerial application as of Jan. 2, 2020, prohibits all use of the chemical except on apple tree trunks by Jan. 1, 2021. It also will prohibit any use of chlorpyrifos by Dec. 1, 2021. The bill will likely be signed into law by Gov. Andrew Cuomo.

Former Environmental Protection Agency Administrator Scott Pruitt two years ago reversed the agency’s decision to impose a national ban on the pesticide sought by the departing Obama administration. At that time, Pruitt said the EPA needed to provide regulatory certainty for American agriculture. He said farms that rely on chlorpyrifos do so while protecting human health and the environment.

Chlorpyrifos was first registered for use in the United States by Dow Chemical in 1965  to control leafage and ground insects. It was used extensively on residential lawns and golf course turf as a structural termite control agent. Banned from home use in the United States for about 17 years now, it is still allowed for agriculture uses so long as label instructions are followed.

Chlorpyrifos is one of the most widely used pesticides in the world. New York State apple growers are among the agricultural users, and they will get extended time for tree trunk applications. New York is second only to Washington state for apple production.

In defending the proposed national ban, outgoing Obama administration officials pointed to research that suggested farm workers and children, if exposed, are put at unnecessary risk.

Chlorpyrifos exposure can lead to developmental issues in children, according to some studies. Those have been “correlational studies,” meaning they don’t provide causal links. Causal links between chlorpyrifos and developmental issues in rodents do exist.

But, correlations between chlorpyrifos and developmental issues in children remain to be documented. Research does show chlorpyrifos poses a threat to human health, but the question remains whether that concern should warrant a complete ban of the insecticide.

Those who worked for it, see the ban in New York as a “major victory for human health.” Tyler Smith, an Earthjustice staff scientist, said “today, the New York Legislature decided not to wait on Donald Trump to protect children from a brain-damaging pesticide.”

In addition to the widespread use to control pests in human food and animal feed crops, products with chlorpyrifos in them are used on golf courses and used for public health purposes in controlling mosquitoes and fire ants. Products containing chlorpyrifos are also used to treat wood fences and utility poles to combat termites and extend the life of the wood.

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The FDA sent warning letters to the companies in September and August of 2018 and posted them for public view in recent days. Companies are allowed 15 working days to respond to FDA warning letters. Failure to promptly correct violations can result in legal action without further notice, including, without limitation, seizure and injunction.

Elwood International Inc., Copiague, NY

In a Sept. 27, 2018, warning letter to Founder, Owner and Chief Executive Officer Mr. Stuart Roll, and Vice-President Mr. Richard F. Roll, staff from the FDA discussed the inspection of the firm’s Copiague, NY warehouse facility, which revealed serious violations of the Current Good Manufacturing Practice, Hazard Analysis, and Risk-Based Preventive Controls for Human Food rule (CGMP & PC Rule) and the low-acid canned food regulations (LACF regulations).

“We determined that your food products are adulterated, in that they were prepared, packed or held under insanitary conditions whereby they may have been contaminated with filth or rendered injurious to health,” according to the warning letter.

The FDA investigator noted the following violations:

• During the inspection, the FDA collected a sample of the firm’s Elwood’s Fat-Free Low Sodium Ranch Dressing Artificial Flavor and found that it is a low-acid food product; “The inspection revealed serious violations of the LACF regulations.”

The FDA also acknowledged the firm’s voluntary recall of all lots of this product within expiry.

• The firm did not have personnel involved in retorts, thermal processing systems, aseptic processing and packaging systems, or other thermal processing systems, and container closure inspectors under the operating supervision of a person who has attended and satisfactorily completed a school approved by the Commissioner; “Specifically, you manufacture shelf stable RTE Elwood Fat-Free Low Sodium Ranch Dressing Artificial Flavor packaged in 12 g cups and no one at your firm has attended or completed a Better Process Control School.”
•  The firm failed to exclude pests from their food plant to protect against contamination of food;

Specifically, during the inspection of your facility, FDA investigators observed the following evidence of insect and rodent activity:

On 01/08/2018 at the 3 N Oak Street Facility in the Production Room/Kitchen, Production Office, and Electrical Closet Areas

• A.  One apparent dead rodent was observed to be approximately 3 feet from the West wall, in the middle of the floor, between both windows.
• B.  Two apparent dead rodents were each observed to be on a white sticky trap in the Northwest corner of the production office, in front of the window adjacent to a tall, white plastic cabinet.
• C.  Two apparent dead rodents were each observed to be on white sticky traps against the West wall, adjacent to the window in the Northwest corner.
• D.  One apparent dead rodent was observed to be on a white sticky trap in the Northeast corner between a tall, white metal cabinet and a low-standing, black metal cabinet.
• E.  One apparent dead rodent was observed to be on a white sticky trap in the Northeast corner in front of the low-standing black metal cabinet.
• F.  15 intermingled rodent excreta pellets (REPs) were observed behind the low-standing black metal cabinet in the Southwest corner.
• G.  10 REPs were observed on the white radiator next to the white plastic cabinet, in the Northwest corner.
• H.  Too numerous to count (TNTC) REPs were observed on the floor along the production office wall shared with the Production Room/Kitchen. There were REPs in front of the low-standing, black metal cabinet located under yellow organization bins hung on the East wall.
• I.  25 intermingled REPs were observed on the floor along the West wall of the Production Room/Kitchen between the door to the Employee Breakroom and the Batch Room area.
• J.  15 REPs were observed under a wooden pallet intermingled with unknown white powder. The wooden pallet was located along the west wall of the Production Room/Kitchen between the door to the Employee Breakroom and the Batch Room area. The wooden pallet held several bags of product.
• K.  Three intermingled REPs were observed to be on the windowsill located on the West wall of the Batch Room.
• L.  Intermingled TNTC REPs were observed in the Northeast corner between the tall, white metal cabinet and the low-standing black metal cabinet.
• M.  Two REPs were observed on the floor along the exterior North wall of the women’s bathroom, outside the door to the Production Office.

A physical sample was collected from the Production Room/Kitchen, Production Office, and Electrical Closet Areas during the inspection of the facility and was analyzed by the FDA’s laboratory; “The analysis of this sample confirmed the material collected consisted of rodent excreta pellets. The analytical results for this sample confirmed the presence of rodent activity within your facility.”

On 01/08/2018 at 89 Hudson Street – Food Warehouse

• A.  Three apparent dead insects and one apparent dead cockroach were observed on a white sticky trap along the South wall, approximately four feet east of two red wires protruding from the concrete floor.
• B.  13 apparent dead spiders and one apparent dead cockroach were observed on a white sticky trap located east of the door marked “EXIT” in the Southwest corner of the building.
• C.  Three apparent dead cockroaches were observed on a white sticky trap in the Southwest corner of the building along the west wall.

On 01/08/2018 at 99 Hudson Street – Food Warehouse and Unused Office Space

• A.  50 intermingled REPs were observed scattered throughout the ½ bathroom located in the Northwest corner, sharing a wall with the ¾ bathroom.
• B.  40 intermingled REPs were observed to be scattered throughout the hall closet located in the Northeast corner.
• C.  50 intermingled REPs were observed scattered under the approximate four-inch gap beneath the kitchenette cabinets.
• D.  One apparent dead rodent and seven apparent dead cockroaches, 15 cockroach excreta pellets, and approximately two dead insects were observed on a white sticky trap between the door of the ¾ bathroom and the North door leading to the Food Warehouse.
• E.  25 intermingled REPs were observed scattered throughout the ¾ bathroom.
• F.  Six apparent cockroach egg cases were observed along the West wall underneath and behind a wooden desk adjacent to the South door leading to the Food Warehouse.
• G.  Two apparent dead cockroaches were observed on a white sticky trap approximately three feet from the South door leading to the unused office space.
• H.  An unmarked box of orange-red colored powder was observed to have approximately five dead insects and four apparent egg cases inside. This unmarked box was located on a wooden pallet, on the floor along the West wall, four feet from the South wall garage door.

According to the warning letter, “the plant is not constructed in such a manner that drip or condensate from fixtures, ducts, and pipes does not contaminate food, food-contact surfaces, or food packaging materials.”

At the 3 N Oak Street Facility

• A. On 01/08/2018 condensation from the ceiling and ceiling pipes was observed dripping throughout the facility. The condensate was observed falling directly onto the clear lidding film used on both Single Process Lines while one of the processing lines was packing ready-to-eat (RTE) Tartar Sauce into plastic ½ oz. cups, and the other “Jelly Packing Line” was filling RTE Strawberry and Grape Jelly stamped “0098 16:28.”

• Again on 01/17/2018, condensation from the same area of the ceiling was observed dripping onto the “Jelly Packing Line,” on the metal surface immediately adjacent to where exposed plastic ½ oz. cups were being filled with RTE Grape Jelly.
• On 01/12/2018, the firm voluntarily destroyed (b)(4) of Elwood Reduced Sugar Jelly in strawberry and grape flavor with lot # E-678-10 200-10 GM 0098 16:28. However, this immediate correction does not address appropriate corrective actions needed to prevent recurrence of the observed deficiency.

• B.  On 01/08/2018 condensate was observed dripping onto the packaging film on the “Single Process Line” where RTE margarine was being packaged.
• C.  On 01/08/2018 condensate was observed accumulating on a black pipe directly above Kettle (b)(4) that was manufacturing Mayonnaise, and a liquid was observed falling from the ceiling between Kettle (b)(4) and Kettle (b)(4). Condensate and liquid were observed on at least 11 boxes of a pallet of a finished product of Winston Single Servings Mustard located at the Southeast corner in front of the garage adjacent to Kettle (b)(4).
• D.  On 01/08/2018 a spinning fan on the ceiling directly above the “Jelly Packing Line” was observed to spray an unknown wet substance throughout the facility, while the firm was packing RTE Grape and Strawberry Jelly. This appeared to be due to the spinning fan being located adjacent to a leaky pipe.
• E.  On 01/17/2018 condensate was observed dripping onto the lid of a sealed holding drum, into which RTE margarine was being pumped.
• F.  On 01/19/2018 condensation and apparent rust was observed on the ceiling and in the uncovered ceiling light in the Batch Room, directly above where clean utensils were stored.

The firm also failed to take effective measures to protect against the inclusion of metal or other extraneous material in food; “Specifically, the 3 N Oak Street Facility was not equipped with shatterproof lights or light fixtures in the food Production Room/Kitchen where food is exposed during manufacturing and packaging.”

The firm also failed to maintain buildings, fixtures, and other physical facilities of their plant in a clean and sanitary condition and in repair adequate to prevent food from becoming adulterated.

The plant did not have adequate sanitary facilities and accommodation for trash disposal; “Specifically, during the inspection, our investigators observed throughout the 3 N Oak Street Facility, an accumulation of overflowing trash in the Northeast corner of the Batch Room along the wall of the Employee Breakroom. The trash was observed to be overflowing onto a pallet of raw materials adjacent to the large, plastic, gray trash bin.”

The firm did not conduct operations in accordance with adequate sanitation principles and take adequate precautions to ensure that production procedures did not contribute to allergen cross-contact and to contamination;

• A.  Our investigators observed on 01/17/2018 that while the single process lines were cleaned while the packaging film was still installed on the machines, water and sanitizer were observed splashing onto the film, an RTE food contact surface. This practice was observed again on 01/19/2018.
• B.  Employees were observed on 01/17/2018 cleaning the lids of the holding drums used for storing mayonnaise, jelly, or salad dressing products by resting them on the floor and spraying them with steam water. The edges of the lid remained in contact with the floor during and after spraying with water. The floor had an accumulation of stagnant liquid and food residue which was observed directly contacting the lids.
• C.  Employees were observed on 01/17/2018 placing the outlets of product transferring hoses inside the drains on the floor, to flush out the residual product. The hoses were then flushed with steam and water after being in direct contact with the floor drains and wastewater. This practice was also observed on 01/19/2018.
• D.  On 01/19/2018 an employee was observed washing stainless steel buckets on the floor, directly on top of the floor drain. These buckets are used to weigh ingredients during manufacturing.

The FDA reminded the firm of their responsibility for ensuring that their facility operates in compliance with the Act, the LACF regulations, the CGMP & PC rule, and other applicable requirements.

Maui Preserved LLC, Haiku, HI

In an Aug. 10 warning letter to Mr. Anthony M. Labua-Keiser, the FDA described violations observed during an April 30 – May 3, 2018, inspection at the company’s facility where they manufacture shelf-stable, ready-to-eat hot sauces, which are acidified food products.

Acidified food processors are required by federal law to comply with Current Good Manufacturing Practices in Manufacturing, Packing, or Holding Human Food, which includes taking effective measures to keep conditions sanitary.

Some of the significant violations cited were:

• The firm failed to provide the FDA, before packing any new product, information on the scheduled process from a qualified processing authority filed with FDA for their Thai Chile Hot Sauce and Hot Hot Sauce. There is no scheduled process on file for this product.

“As a commercial processor engaged in the thermal processing of acidified foods, you must provide the FDA information as to the scheduled processes, including conditions for heat processing and control of pH, salt, sugar, and preservative level and source and date of the establishment of the process, for each acidified food in each container size,” according to the warning letter.

• The firm failed to mark their acidified product bottles with an identifying code permanently visible to the naked eye which specifies the establishment where the product was packed, the product contained therein, and the year, day, and period during which it was packed.

Specifically, the 8-digit code on the firm’s acidified food containers do not include the establishment where the product was packed, the name of the product and the date the product was processed; “Each container or product must be marked with an identifying code permanently visible to the naked eye. If the container does not permit the code to be embossed or inked, the label may be legibly perforated or otherwise marked, as long as the label is securely affixed to the product container. The required identification shall specify in code the establishment where the product was packed, the product contained therein, and the year, day, and the period during which it was packed. The packing period code shall be changed often enough to enable ready identification of lots during their sale and distribution. Codes may be changed periodically on one of the following bases: intervals of 4 to 5 hours; personnel shift changes; or batches, as long as the containers constituting the batch do not represent those processed during more than one personnel shift.”

The FDA reminded the firm that the violations cited in this warning letter are not intended to be an all-inclusive statement of violations that exist in connection with the firm’s products.

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“There is clear evidence that food produced at the Kea‘au facility may be contaminated and consumers may be at risk,” said Peter Oshiro, sanitation branch chief for the Hawaii Department of Health. “The Department of Health is working with the facility to ensure the safety of their drinking water and food production.”

No illnesses have been confirmed in relation to the recalled Mauna Loa nuts and cookies, according to state health officials and the U.S. Food and Drug Administration. Both agencies are warning the public to not eat any of the recalled products. They should be thrown away immediately or returned to the place of purchase.

Neither FDA nor the Hawaii health department reported whether the contaminated well water is used by any other food companies, retailers or restaurants.

“On Sept. 5, samples taken from facility’s water distribution system passed testing and showed no contamination,” according to a statement posted by the Hawaii health department. “On Sept. 21, the DOH was notified that a water distribution system sample at the production center tested positive for E. coli and the food production operations were closed by order of DOH.

  “The Mauna Loa macadamia nut facility will remain closed until it meets all DOH Sanitation Branch and Safe Drinking Water Branch requirements and standards.”

The Keaau company produced the recalled snacks between Sept. 6 and 21 and distributed them to retailers in Hawaii. Neither the state department nor the FDA posted any photos of the recalled products. The Mauna Loa company did not appear to have any information about the contaminated water or its recall on its website as of Sept. 27.

Products subject to the recall are as follows:

Anyone who has eaten or handled any of the recalled products and developed symptoms of E. coli infection should seek medical attention and tell their doctors about their possible exposure to the bacteria. It can take one to 10 days after exposure for symptoms to develop.

Symptoms often include severe stomach cramps, diarrhea (often bloody), and vomiting. Some people may have a fever, which usually is not very high, usually  less than 101 degrees F, according to the Centers for Disease Control and Prevention. Some infections are very mild, but others are severe or even life-threatening. Children younger than 5, elderly people, pregnant women and people with compromised immune systems are at much higher risk of developing severe illnesses.

About 5 percent to 10 percent of people who are diagnosed with E. coli infections develop a potentially life-threatening complication known as hemolytic uremic syndrome (HUS). HUS develops about 7 days after symptoms first appear, when diarrhea is improving. Signs that someone is developing HUS include decreased frequency of urination, feeling very tired, and losing pink color in cheeks and inside the lower eyelids. People with HUS should be hospitalized because their kidneys may stop working and they may develop other serious problems. Most people with HUS recover within a few weeks, but some suffer permanent damage or die.

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The National Weather Service has predicted Hurricane Lane would pass to the south-southeast of Hawaii’s Big Island by Wednesday night and then begin a turn northwest toward the other Hawaiian islands. The center of Hurricane Lane will track close to the islands Thursday through Saturday. Regardless of the exact track of the center, impacts are likely in some areas of the state. Tropical storm force winds could start as early as this afternoon or evening, with dangerous hurricane force winds possible by tonight. Excessive rainfall is possible, which could lead to major flash flooding, landslides, and mudslides. Flooding can occur even in areas not usually prone to flooding. Storm total rainfall amounts greater than 20 inches are possible.

Hurricanes present the possibility of power outages and flooding that can compromise the safety of stored food. Residents in the path of this storm should pay close attention to the forecast. FSIS recommends that consumers take the following steps to reduce food waste and the risk of foodborne illness during this and other severe weather events.

Steps to follow in advance of losing power:

• Keep appliance thermometers in both the refrigerator and the freezer to ensure temperatures remain food safe during a power outage. Safe temperatures are 40°F or lower in the refrigerator, 0°F or lower in the freezer.
• Freeze water in one-quart plastic storage bags or small containers prior to a storm. These containers are small enough to fit around the food in the refrigerator and freezer to help keep food cold. Remember, water expands when it freezes, so don’t overfill the containers.
• Freeze refrigerated items, such as leftovers, milk and fresh meat and poultry that you may not need immediately—this helps keep them at a safe temperature longer.
• Know where you can get dry ice or block ice.
• Have coolers on hand to keep refrigerator food cold if the power will be out for more than four hours.
• Group foods together in the freezer—this ‘igloo’ effect helps the food stay cold longer.
• Keep a few days’ worths of ready-to-eat foods that do not require cooking or cooling.

Steps to follow if the power goes out:

• Keep the refrigerator and freezer doors closed as much as possible. A refrigerator will keep food cold for about four hours if the door is kept closed. A full freezer will hold its temperature for about 48 hours (24 hours if half-full).
• Place meat and poultry to one side of the freezer or on a tray to prevent cross contamination of thawing juices.
• Use dry or block ice to keep the refrigerator as cold as possible during an extended power outage. Fifty pounds of dry ice should keep a fully-stocked 18-cubic-feet freezer cold for two days.

Food safety after a flood:

• Do not eat any food that may have come into contact with flood water—this would include raw fruits and vegetables, cartons of milk or eggs.
• Discard any food that is not in a waterproof container if there is any chance that it has come into contact with flood water. Food containers that are not waterproof include those packaged in plastic wrap or cardboard or those with screw‐caps, snap lids, pull tops and crimped caps. Flood waters can enter into any of these containers and contaminate the food inside. Also, discard cardboard juice/milk/baby formula boxes and home canned foods if they have come into contact with flood water because they cannot be effectively cleaned and sanitized.
• Inspect canned foods and discard any food in damaged cans. Can damage is shown by swelling, leakage, punctures, holes, fractures, extensive deep rusting or crushing/denting severe enough to prevent normal stacking or opening with a manual, wheel‐type can opener.

Steps to follow after a weather emergency:

• Check the temperature inside of your refrigerator and freezer. Discard any perishable food (such as meat, poultry, seafood, eggs or leftovers) that has been above 40°F for two hours or more.
• Check each item separately. Throw out any food that has an unusual odor, color or texture or feels warm to the touch.
• Check frozen food for ice crystals. The food in your freezer that partially or completely thawed may be safely refrozen if it still contains ice crystals or is 40°F or below.
• Never taste a food to decide if it’s safe.
• When in doubt, throw it out.

FSIS’ YouTube video “Food Safety During Power Outages” has instructions for keeping frozen and refrigerated food safe. The publication “A Consumer’s Guide to Food Safety: Severe Storms and Hurricanes” can be downloaded and printed for reference during a power outage. An infographic is also available outline steps you can take before, during and after severe weather, power outages, and flooding. FSIS provides relevant food safety information during disasters on Twitter @USDAFoodSafety and Facebook.

If you have questions about food safety during severe weather, or any other food safety topics, call the USDA Meat and Poultry Hotline at 1-888MPHotline or chat live with a food safety specialist at AskKaren.gov. These services are available in English and Spanish from 10 a.m. to 6 p.m. Eastern Time, Monday through Friday. Answers to the frequently asked question can also be found 24/7 at AskKaren.gov.

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Researchers from the Southern Medical University and Zhujiang Hospital in Guangzhou said it’s the first time the Angiostrongylus cantonensis parasite — often called rat lungworm — has been detected in a centipede species. Centipedes are used in traditional Chinese medicine, though usually in a dried or powder form, which does not transmit the parasite.

Mild infections with A. cantonensis may resolve on their own. But the parasite can penetrate the brain and spinal cord, which can lead to meningitis and, in some instances, paralysis and death.

“We don’t typically hear of people eating raw centipedes, but apparently these two patients believed that raw centipedes would be good for their health,” said Lingli Lu, a co-author of the report who works in the Department of Neurology in Zhujiang Hospital.

Lingli said the patients, a 78-year-old woman and her 46-year-old son, came from the rural countryside where it was believed that consuming raw centipedes offered potential health benefits. Both recovered with treatment.

According to the U.S. Centers for Disease Control and Prevention, A. cantonensis is mainly found in China and Southeast Asia and infections are usually linked to eating raw or undercooked snails. The parasite has been detected in the Caribbean, Hawaii, and more recently, in Louisiana and South Florida.

The Hawaii Department of Health has confirmed at least three cases of rat lungworm disease so far this year.

In Louisiana, it was found in the invasive apple snail, a freshwater snail native to South America that is sometimes consumed as food. In South Florida, the parasite was discovered in the invasive giant African land snail.

In 2017, there were 17 laboratory-confirmed cases of rat lungworm disease statewide.

The researchers in China purchased 20 centipedes from the agricultural market where the patients bought theirs. The immature, or larvae, form of A. cantonensis was detected in seven of them. They infected 20 centipedes with the parasite but the centipedes subsequently died.

Lingli said results could indicate that, while centipedes can be temporary hosts, it is not certain they are able to serve as intermediate hosts, a classification that indicates an ability to carry and spread the parasite over a long period of time.

A study in a Morbidity and Mortality Weekly Report (MMWR) published by the CDC looked at the epidemiologic and clinical features of 12 rat lungworm cases in the continental U.S. from January 2011 to 2017. Six were likely a result of transmission in the southern part of the country. Consumption of raw vegetables was reported in 55 percent of those cases.

In Hawaii, public health officials have said host animals, particularly snails, are frequently found in fresh lettuce and other salad ingredients that are served raw.

“Health care providers, especially those in the southern United States, need to consider angiostrongyliasis in patients with eosinophilic meningitis, particularly those with a history of ingestion of gastropods or raw vegetables contaminated with larvae,” said the report.

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The individual became seriously ill earlier this month and is being treated at a hospital. Laboratory results confirmed evidence of the rat lungworm parasite in the person’s spinal fluid.

The state health department has not been able to determine the specific source of the infection, according to a public alert. The department is unable to provide any additional specific information about the victim.

“This is a reminder for everyone to take precautions and control snail, slug, and rat populations in and around properties, and especially home and school gardens and farms,” according to a statement from Aaron Ueno, Hawaii District Health Office administrator.

“We know that slugs, snails, and rats in all counties carry the parasite that can cause rat lungworm disease, and rain with wet conditions often brings more of these garden pests.”

Rat lungworm disease, officially known as angiostrongyliasis, can have debilitating effects on an infected person’s brain and spinal cord. The disease is endemic to Hawaii and is contracted when a person becomes infected with the parasite Angiostongylus cantonensis.

In Hawaii, people become infected by eating raw or undercooked infected slugs or snails. The snails and slugs are often found in and on fresh produce. It is not uncommon for people to become infected from undetected snails or slugs in salads.

Slugs and snails eat rat feces and serve as intermediate hosts for the parasites. Since the parasite cannot mature or reproduce in humans, they eventually die, but can cause physical problems.  These include eosinophilic meningitis and ocular Angiostrongylus.

In Hawaii, 80 percent of the land snails are carriers of the parasite.

The most common symptoms of infection include severe headaches and neck stiffness, but symptoms may vary widely among cases. The most serious cases experience neurological problems, pain, and severe disability.

In 2017, there were 17 laboratory-confirmed cases of rat lungworm disease statewide.

The public is urged to take the following precautions to prevent rat lungworm disease:

• Inspect, wash and store produce in sealed containers, regardless of whether it came from a local retailer, farmer’s market, or backyard garden.
• Wash All fruits and vegetables under running water, especially leafy greens, to remove any tiny slugs or snails.
• Control snail, slug, and rat populations. Eliminate slugs, snails, and rats around properties, and especially around home gardens and farms.

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Ron and Darlene Fields had been married for 26 years when they decided to take a “free” 12-day trip to Hawaii in fall 2016.

Ron was 62 then, and his construction business in Sarasota, FL, was really taking off. Darlene, who does paperwork for the company, had saved up credit card reward points so they could fly to Los Angeles, spend a night there and then fly to Maui for five nights before moving on to the Big Island.

The only things they expected to pay for were food and an excursion from one side of the Big Island to the other.

The Fieldses, physically fit and devoted for the past dozen years to eating organically, were a couple of days away from heading home when Ron got sick.

“My husband woke up in the middle of the night and couldn’t quite describe what was going on with his skin,” Darlene said during a telephone interview from their Florida home. “It was worse in L.A., and more when we got home. … We arrived home on a Saturday and by Thursday, he laid down in the bed — and he couldn’t get up for months.

“He called it burning skin pain. Then he started to have bladder problems and couldn’t urinate.”

Ron and Darlene Fields would end up taking a journey longer than any they’d imagined when they booked their flight to Hawaii.

Along the way, they’d go to emergency rooms, a hospital in Gainesville, FL, and an integrated health center. They’d see neurologists and urologists, general practitioners and meningitis specialists, medical marijuana consultants and acupuncturists and hypnotists.

The cause
The likely culprit behind it all: a tiny slug hiding in one of the many salads the couple ate during their trip.

The slug likely was home to a disgusting little parasite called rat lungworm that is carried in rat feces, which slugs and snails eat. The slugs and snails serve as intermediate hosts for the rat lungworms, which can’t mature or reproduce in humans but can cause a host of physical problems including eosinophilic meningitis and ocular Angiostrongylus if people ingest them.

Rat lungworm infections typically come from eating raw or undercooked snails — or slugs — that can be in lettuce or other raw produce that hasn’t been washed thoroughly and/or cooked throughly. It has been endemic in Hawaii for at least the past 50 years, according to public health records.

Ron and Darlene Fields didn’t eat any snails, so they’re pretty sure Ron contracted the infection from a salad, which they ate every day of their vacation.

“You know, a Caesar salad or whatever they had in the restaurants,” Ron said in recent days.

Experts say early symptoms of rat lungworm infection can include headaches, neck stiffness, nausea and vomiting and that the illness might incubate for a single day or for as long as six weeks before symptoms appear. Infected people are not contagious. Recovery time varies in many cases from a couple of weeks to a couple of months.

Not so in the case of Ron Fields.

“We would go to the emergency room and to our family doctor. We tried acupuncture for the pain,” Darlene said. “During the couple of weeks after we arrived home, I could get him in the car and get him to the emergency room, but when he was home, he just lay in bed, too weak to walk, and any jostle in the car just caused excruciating pain.”

How they discovered the cause
A couple of weeks into the whole thing, Darlene’s mom was flipping through the TV channels one day and caught the words “Big Island” and “rat lungworm” on the Animal Planet network. That sent Darlene on an internet search that led them to the answer.

Rat lungworm disease is reported in about 30 countries in Asia, Africa and Caribbean and Pacific Islands. In Hawaii 80 percent of land snails carry the parasite, which has caused two deaths in the islands since 2007. The state typically experiences one to nine rat lungworm cases a year.

In 2017, however, the Hawaii Department of Health recorded 18 laboratory-confirmed cases, said Anna Koethe of the department’s communications office.

Ron Fields’ case is one of an unknown number not included in the public count because his illness, like other people who get sick after returning home, wasn’t reported to Hawaiian public health authorities.

In fact, despite dozens – if not hundreds – of medical tests, doctor visits and exams, Ron never got confirmation that he was infected by rat lungworm disease.

“We were confident of what it was, but they wanted to do another spinal tap to take more fluid, and my wife said no,” he said.

“It was confirmed that it was a parasitic form of meningitis, though.”

During all of their efforts to get a diagnosis and help, they encountered no one in Florida who had heard of the condition.

”They diagnosed all these silly things,” said Darlene. “We thought he was dying, and they said acid reflux, stress. It was just weird. Even after we found out what it was and told doctors, nobody had ever heard of it.

“We diagnosed it ourselves from the internet. I called the Big Island, the hospital, the CDC, I think, trying to get hold of a doctor who had treated it to see what we could do. … I finally called an emergency room in Honolulu and got a doctor who said it was  untreatable but it would go away eventually.

“I said, ‘How long?’ and she said, ‘A long, long time.’ She said, ‘months,’ and I said, ‘He won’t make it months.’ ”

In the end, Ron Fields spent 10 months with a catheter because he couldn’t urinate. He spent nine days he doesn’t remember in the Gainesville hospital. He had IV treatments of vitamin C and he had problems with his bowels. He developed meningitis and had to have a spinal tap.

The time in Gainesville was a nightmare, Darlene said.

“All I did was tell my story every day, all day long,” she said. “Students, neurologists, doctors – and nobody knew anything. They were giving him a lot of antibiotics … trying to eliminate kinds of meninigitis.

“There was nothing to do to help him. He was losing weight. He was getting weaker and sicker instead of better. We went home after nine days and between October 2016 and January or February 2017, he determined he was never going to get better.”

Good days and bad days
Ron is 64 now, and, most days, he goes to work but does less physical labor. He’s lost weight and agility.

“I don’t know if words can really describe (it),” he said. “It’s been challenging. As far as my balance and ability to be able to work every day without disability is about 90 percent.

“It took a while to get there. I still suffer from the neuropathy from the nerve damage that happened to me, and it’s just been a real struggle with that.”

Said Darlene: “Now, every morning he has to go through agony just to get his shirt on. It hurts so badly.”

Ron had to kick morphine, which doctors had him on for three or four months for the pain. He takes a nerve pain medication, but the Fields worry that it’s not good for him long-term. So, he uses medical marijuana, which has been legal in Florida since 2016.

The marijuana, which he uses in vaping form, makes life tolerable.

“We’re so thankful that medical marijuana is legal in Florida,” said Darlene, adding that it helps her husband sleep.

It doesn’t get him high.

“He doesn’t act drunk or high or anything but he’s not able to think as clearly,” she said.

“I thought it was wrong before,” she said of marijuana use. “But a neurologist recommended it and as a Christian he explained how he used to feel the same way, but as soon as we realized how many people it helped … it doesn’t bother us at all.

“Being able to sleep now is a big boost,” Darlene said.

The Fieldses have a type of alternative health insurance through Christian Healthcare Ministries for major medical expenses, but a lot of the treatment and pain relief they tried wasn’t covered.

It’s been challenging, Ron Fields said, but they’ve had help.

“I am a Christian, and if it wasn’t for the love of Jesus Christ and the relationship I have with him to give me the strength, I would never have made it.

“I have good days and I have bad days.”

Ron said he doesn’t rule out a return to Hawaii, but both he and his wife say they’d do things differently – no salads, and probably not even fruit or fruit juice.

“It’s changed our lives,” Darlene said. “We’ve lost hundreds of thousands of dollars. His business was really starting to thrive … and when we came back, he just couldn’t work.”

They considered seeking compensation through a lawsuit but since they don’t know where Ron picked up the parasite, there’s really no one to sue.

“We don’t want to sue,” she said. “That’s not the point. What bothered us is that nobody knew about it. We wouldn’t have gone to Hawaii in the first place, and we certainly wouldn’t have eaten like we did.

“We went to Hawaii because I always love to find ways to travel for free … I tell everybody it was the most expensive free trip ever.”

Public health action
The Hawaii Department of Health launched a statewide public education campaign to raise awareness and inform people about best practices they can implement into their daily routines to prevent the spread of rat lungworm disease.

The first initiative, launched late in 2017, included a statewide broadcast media component through a partnership with the Hawaii Association of Broadcasters.

The campaign consists of three radio and three television commercials currently airing on 40 radio stations and seven television stations through the end of June 2018.

The department also has large-scale graphic advertisements displayed in malls and shopping centers across the state. It’s educational materials include rack cards, door hangers and posters that are being distributed during community events and health fairs.

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Some cases do get more public attention than others. Two newlyweds from San Francisco went from their two-week honeymoon in the remote Hana area on Maui to contracting rat lungworm.

Symptoms of rat lungworm are said to be like being stabbed by a hot knife.   The parasite impacts the brain and spinal cord.   How do people become infected?   Typically, rat lungworm infections come from eating raw or undercooked snails and slugs.

Rat lungworm has been endemic in Hawaii for at least the past 50 years, according to Heather Stockdale Walden, assistant professor of infectious disease and pathology at the University of Florida.  If lettuce or other raw produce is not thoroughly washed on Hawaii, there’s the risk a snail or a slug carrying the parasites might slip through.

Early symptoms include headaches, neck stiffness, nausea and vomiting.   The illness might incubate in a single day or take six weeks.  The parasite does not make people contagious, and recovery from the illness typically takes from two weeks to two months.

Snugs and snails eat rat feces and serve as intermediate hosts for the parasites.  Since the parasite cannot mature or reproduce in humans, they eventually die, but can cause physical problems.  These include eosinophilic meningitis and ocular Angiostrongylus.

In Hawaii, 80 percent of the land snails are carriers of the parasite.  Rat lungworm was responsible for two deaths in the islands since 2007.

Both the Hawaii Department of Health and the federal Centers for Disease Control (CDC) and Prevention are monitoring the current cases.

Rat lungworm disease is reported in about 30 countries in Asia, Africa, and Caribbean and Pacific Islands. Hawaii typically experiences one to 9 rat lungworm cases a year.

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Raw milk efforts this legislative season have mostly gone sour, politically speaking. One possibility for why state politicians are stepping away from these bills is the timing of the deadly and ongoing Listeria outbreak linked to Vulto Creamery’s raw milk cheese. At least six people have been sickened and two are dead from that raw experience, according to the Centers for Disease Control and Prevention.

A state-by-state analysis, however, shows lawmakers are usually mostly moved by their own legislative processes, which often turn on testimony by public health officials and the mainstream dairy industry. Both of those groups want to restrict access to unpasteurized milk.

Here’s a rundown of the raw action across the country:

ALASKA — Raw milk was dropped from House Bill 46 when a substitute was inserted in the place of the original language. HB 46 is now about state and municipal procurement of agricultural products, including fish, sold under the “Alaska Grown” trademark.

HAWAII — House Bill 257 to permit the retail sale of unpasteurized milk was killed in the Hawaii House on Jan. 27 by a committee vote that the measure be deferred.

ILLINOIS — The General Assembly is considered three bills addressing the cottage food industry and farmer’s markets. Two are House bills, HBs 2820 and 3063, and there is one in Senate, SB1469. They were earlier seen as possible vehicles for changing  the state’s recently adopted raw milk regulations, but that has not happened.

IOWA — While the Iowa General Assembly does not adjourn for another month, the two raw milk bills that were introduced in January appear to be dead if for no other reason that they’ve missed deadlines for advancement. Technically both are assigned to subcommittees of the Senate Agriculture Committee.

MONTANA — The life or death of House Bill 325 now awaits a vote of the Senate Agriculture, Livestock & Irrigation Committee after a lively public hearing on Tuesday in Helena. The raw milk bill passed the House on a 69-30 vote. Sponsored by Rep. Nancy Ballance, R-Hamilton, the Montana bill would create a new category of “small dairies,” meaning those with no more than five milk-producing cows or ten goats or sheep. It would exempt those small dairies from a requirement that all milk must be pasteurized before being sold.

During the public hearing one Montana resident asked why he cannot purchase raw milk at a local dairy when “most dairy people that I know drink their own raw.” Under current law, drinking raw milk in Montana is perfectly legal, you just cannot sell it.

Joseph Russell, public health officer for the Flathead City-County Health Department, called raw milk “an inherently high-risk food.” He said there should be more labeling on it, so health officials could investigate if a disease outbreak did occur.

“We need to know where this milk is from, when it was produced and how to get it out of market,” he said.

MASSACHUSETTS — In January, Food Safety News reported on a rambling 7,300 word bill about promoting agriculture in the Commonwealth because it contained 780 words to permit raw milk sales.  It’s been assigned to the Joint Committee on State Administration and Regulatory Oversight, which has no meetings scheduled.

NORTH DAKOTA — The North Dakota Senate held a March 17 hearing on House Bill 1433, a bill that would allow producers to sell unpasteurized, raw milk directly to consumers who will “assume the risks.” The committee has yet to make its recommendation on the measure. It has already passed the House 69-21. Testimony in North Dakota tracks almost identically with Montana’s debate.

VIRGINIA — As previously reported by Food Safety News, House Bill 2030 to permit the sale of raw milk was killed in the Committee for Agriculture, Chesapeake and Natural Resources by a two-to-one, bipartisan margin. The Virginia Department of Agriculture and Consumer Services and the Virginia Health Department both played prominent roles in helping defeat the raw milk bill.

RHODE ISLAND — Senate Bill 247 to permit the sale and handling of raw milk in Rhode Island was assigned to the Senate Environment and Agriculture Committee on Feb. 22nd. Since then, it does not appear to have seen any action. Food Safety News previously reported that the bill will be dead without committee action by April 13.

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The order from the Hawaii State Department of Health on Monday will remain in effect until the company can prove its 2 percent reduced fat milk is safe. No other Meadow Gold products are implicated.

“Department of Health inspectors will work with Meadow Gold Dairies to investigate the possible source of contamination, approve a plan of correction, and conduct further testing to confirm the company meets the standards to resume two-percent reduced fat milk distribution and sale,” said Peter Oshiro, program director of the department’s sanitation branch, in a news release.

When the state tested samples of two-percent reduced fat milk taken from Meadow Gold Dairies on Jan. 19, Feb. 6 and 22, officials found “excessive Coliform counts” of more than 150/ml, 130/ml and more than 150/ml respectively, according to the news release.

“The maximum allowed Coliform limit for pasteurized milk is 10/ml. Coliform is used an indicator of post-pasteurization contamination,” according to the state health department.

The health department conducts monthly testing of samples of all Grade A raw and pasteurized milk produced at dairy farms and milk plants in Hawaii. State and federal regulations require that samples be taken a minimum of four out of every six months, though most jurisdictions in the nation, like Hawaii, conduct sampling every month.

If any milk product is in violation three times out of the most recent five consecutive samples on the first of three Critical Control Point (CCP) standards Hawaii state law allows the health department to suspend distribution and sale of the product. The Critical Control Point (CCP) standards are:

1. Temperature must be 45 degrees F or less;
2. Bacterial limits are 10,000/ml or less;
3. Coliform limits are 10.ml or less;
4. Phosphatase limit is 1 mcg/ml or less; and
5. Antibiotics residues are not allowed.

To resume distribution and sale of its 2 percent reduced fat milk, Meadow Gold Dairies must pass health inspections and undergo additional testing of product samples.

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More than two-and-a-half times as many people in Hawaii took Hepatitis A vaccinations this past year compared with 2015, mainly because of an outbreak traced to contaminated frozen scallops that sickened 292 people. Two outbreak victims died.

The Hepatitis A illnesses traced to frozen scallops harvested in November 2015 in the Philippines began June 10, 2016, and continued through Oct. 9, 2016, according to the Hawaii Department of Health. A fast food chain headquartered in Japan — Genki Sushi — served the scallops raw.

When state health officials announced the outbreak and impounded the scallops on Aug. 15, 2016, they began urging anyone who had eaten at any of the Genki Sushi locations in the state to take the post-exposure Hepatitis A vaccination or an immune globulin (IG) shot.

Public took advice to heart
From July through November this past year, health care providers reported administering 90,259 Hepatitis A vaccination injections, according to data from the Hawaii Immunization Registry.

For all of 2016, there were 101,876 Hepatitis A vaccinations recorded. Compared with the 29,347 vaccinations recorded for 2015, that’s an increase of almost 250 percent.

“The response from the community during the outbreak was tremendous,” Health Director Virginia Pressler said in a recent vaccination reminder notice.

“Healthcare providers, including pharmacists, played a key role in ensuring Hepatitis A vaccine was available for those needing and wanting to be vaccinated. They truly rose to the challenge of vaccinating a large number of people in a relatively short amount of time.”

Many of those same pharmacists and healthcare providers stand ready to administer the second dose of the two-injection vaccination, according to a recent statement from the health department.

Make it easy on yourself
State health officials are encouraging people to return to the same clinic, doctor’s office or pharmacy that administered their first dose of vaccine to receive their second dose. This allows people to use their existing prescription and helps ensure the second round of injections is administered at least six months after the first.

“While one dose of hepatitis A vaccine provides good protection, two doses are necessary for nearly 100 percent protection and lasting immunity,” Sarah Park, state epidemiologist Sarah Park said in the vaccination reminder notice.

“We’d like to remind people now, if they received their first dose during the outbreak, to get their second dose at least six months after the first one was administered.”

Those not returning to the same location for vaccination should provide documentation of their first dose, if possible, and contact their physician if a prescription is needed. To ensure vaccine availability, contact your healthcare provider or pharmacy in advance.

The state health department has a list of vaccinating pharmacies and clinics that can be accessed by clicking here. Hawaii residents can also call the Aloha United Way information and referral line at 2-1-1 for help finding a vaccination location.

Class action pending for vaccination reimbursements
A seafood importer, a distributor and Genki Sushi are facing a class action lawsuit filed specifically on behalf of people who did not get sick but did receive Hepatitis A vaccinations because of the outbreak.

Distributor Koha Foods and importer Sea Port Products Corp. are named along with the sushi fast-food restaurant as defendants in the civil lawsuit. When they filed the case Aug. 23, 2016, the attorneys representing the “class” said it could exceed 10,000 people.

“This is quickly becoming one of the largest Hepatitis A outbreaks in U.S. history. Given the number of people that consumed scallops at Genki Sushi and became ill and worked at other restaurants on the islands, we estimate that over 10,000 people needed to be vaccinated to prevent an even larger disaster,” said Bill Marler, a Seattle food safety attorney who joined with a Honolulu law firm to file the class action.

Marler, founding partner of the Marler Clark law firm, is working with the Honolulu firm Starn O’Toole Marcus & Fisher to help Bryan K. Cuelho, an Oahu resident who ate scallops and other food at the Waikele Genki Sushi restaurant on Aug. 6, and others who took the post-exposure injections.

The civil suit filed in Hawaii’s First Circuit Court seeks compensation for Cuelho and others for medical expenses, lost wages and other damages related to the post-exposure safety measures.

“This is a class action lawsuit brought on behalf of all persons who were exposed, by consumption of adulterated food and drink, to the Hepatitis A virus, HAV, at the defendant Genki Sushi USA Inc.’s restaurants during the exposure period from April through August 2016,” according to the complaint.

“The plaintiff and class-members were required for public health and personal safety reasons to obtain Hepatitis A vaccination or an IG shot — with some persons also getting an HAV blood test — because of their exposure at the defendant Genki Sushi USA Inc.’s restaurants.”

In addition to recovering direct costs incurred by those who received post-exposure injections, the lawsuit is expected to raise public and corporate awareness about Hepatitis A vaccinations, which Marler has been advocating for all foodservice workers for several years.

“As a premier tourist destination, we want Hawaii to have the highest standards in food safety so our guests feel secure. We also want our local people to be taken care of. This suit is a step toward that,” attorney Trevor Brown of Starn O’Toole Marcus & Fisher said in a news release after the civil case was filed.

Editor’s note: Attorney Bill Marler is the publisher of Food Safety News.

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“The legislature finds that consumers’ food preferences have shifted toward locally-produced food in recent years,” the bill states.

“Additionally, many small farms have the capability and desire to offer unpasteurized dairy products to consumers that seek locally-produced dairy products.”

The proposed legislation, House Bill 257, would allow dairies to sell shares of cows or herds to people who want raw milk. Producers could also sell raw milk for animal consumption if the bill earns approval.

Main sponsor Rep. Richard Creagan is joined by 10 fellow Democrats and two Republican co-sponsors. The bill made it through a first reading Jan. 20 and was assigned to two committees on Jan. 23 — the agriculture committee and the consumer protection and commerce committee.

Similar efforts to allow some form of raw milk sales failed to gain approval the past four years. This year’s bill includes a provision requiring producers to maintain records of everyone who buys unpasteurized raw milk.

The federal government and many state health departments warn against consuming raw milk because without the heat from pasteurization there is no kill step for bacteria such as E. coli, Listeria, Salmonella and Campylobacter.

Nationwide, statistics from the Centers for Disease Control and Prevention show at least 148 foodborne illness outbreaks traced to unpasteurized raw milk from 1998-2011. The outbreaks caused 2,384 confirmed illnesses, 284 hospitalizations and two deaths, the CDC reports.

Both the Food and Drug Administration and the CDC have raw milk fact sheets that debunk claims that unpasteurized raw milk is more nutritious than pasteurized. Only a dozen states allow retail sales of raw milk.

Sponsors of Hawaii’s HB 257 to legalize retail and herd share sales of unpasteurized raw milk are: Richard Creagan, Cindy Evans, Kaniela Ing, Mathew Lopresti, Nicole Lowen, Lynn DeCoite, Cedric Gates, Mark Nakashima, Joy San Buenaventura, Gregg Takayama, Cynthia Thielen, Chris Todd and Andria Tupola.

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In the ruling, the appellate court found that Hawaii’s pesticide laws are sufficiently comprehensive and preclude counties from regulating either pesticides or genetically modified crops.

Companies such as Monsanto and Syngenta have long made Hawaii a center for their seed production. After anti-GMO activists turned to local ballot measures to kill the industry, the industry turned to the courts for protection.

The ordinances were first overturned by the U.S. District Court for Hawaii, and they have now been upheld by appellate decision, so they will not go into effect.

Erased from the books are a Kauai ordinance that would have required disclosures on pesticide use from big companies, a Big Island ordinance banning new GMO crops, and a Maui measure for a moratorium on GMO farming.

The 9th Circuit ruling was hailed as good news for Hawaii’s entire agriculture industry by Bennette Misalucha, who heads a trade group for the seed companies.

“The Hawaii Crop Improvement Association welcomes the protection that this decision provides Hawaii’s hard-working farmers and growers for standing up for science and for supporting continued innovation in agriculture,” she said.

The industry’s 1,000 jobs are mostly on Maui, Molokai and Oahu.

Hawaii Department of Agriculture Director Scott Enright said that statewide voluntarily pesticide reporting is planned. He said he expects to make an announcement on that program by the end of this year and that changes were inspired by a recent pesticide study on Kauai.

GMO-free areas that have been set up by counties in Oregon, Washington and California are permitted under the high court’s ruling. However, federal law was found to preempt state and local laws when it comes to field trials or experimental GMO crops.

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Marine Agrifuture LLC of Kahuku, HI, is recalling its “Kahuku Ogo,” “Robusta Ogo” and “Kahuku Sea Asparagus” from distributors and other direct customers in Hawaii, California, Washington and Nevada. The products were also sold at farmers markets in Hawaii, as well as being exported to Tokyo, according to the recall notice on the Food and Drug Administration’s website.

As of Nov.  8, 14 people had been confirmed with Salmonella infections, with four of them having symptoms so severe that they required hospitalization. The sick people include adults and children who developed diarrheal illnesses from mid- to late October.

Preliminary investigations identified consumption of raw fish, specifically poke that contained limo — seaweed — as a common factor among the sick people.

Anyone who has eaten any of the recalled products and developed symptoms of Salmonella infection should seek medical attention and alert their doctor to the possible Salmonella exposure. Symptoms typically begin within 12 to 72 hours after exposure to the bacteria, according to the Hawaii health department.

Salmonella can cause serious and sometimes fatal infections in young children, frail or elderly people, and others with weakened immune systems. Healthy persons infected with Salmonella often experience fever, diarrhea that can be bloody, nausea, vomiting and abdominal pain. In rare circumstances, infection with Salmonella can result in the organism getting into the bloodstream and producing more severe illnesses such as arterial infections, endocarditis and arthritis.

State officials inspected the Marine Agrifuture farm on Nov. 2 and 7, according to a news release Thursday that detailed the cease and desist order.

“During the investigation, testing was conducted on environmental, processing area, and ogo samples. Laboratory tests identified Salmonella bacteria in the packing and processing tanks and in the farm environment,” the health department reported.

Consumers, distributors, retailers and others can identify the recalled products by the following information:

“The Ogo products come in a plastic bag of various weights from 0.5 LB to 35 LB, which were sold from November 2, 2016 and prior, and the Sea Asparagus in 4 Ounce, 1 LB clear plastic clamshell or in a 5 LB of plastic bag marked with a tracking number stamped on the lids or bags, which were sold from November 8, 2016 and prior. The corresponding UPC number for 4 OZ, 1 LB, and 5 LB of sea asparagus are 897680001010, 897680001027, and 897680001041 respectively.”

Anyone who has the recalled products is urged to dispose of them or return them to the place of purchase for a refund or credit. Consumers with questions may contact the company at 808-779-2885.

For additional details on the situation, please see:
“Hawaii names farm linked to outbreak; recall details sketchy“

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The cease and desist order from the Hawaii Department of Health’s sanitation branch was published two days after the health department announced the outbreak had been linked to seaweed from an Oahu farm.

Department officials did not name the farm Tuesday, but when test results came in positive, the state revealed the farm to be Marine Agrifuture LLC, which does business Olakai Hawaii. The farm is in Kahuku on Oahu.

“Distributors and retailers have been notified to remove the affected products from sale or distribution immediately,” said sanitation branch chief Peter Oshiro in a news release.

“We advise the public to discard any suspect product they may have.”

Products included in the cease and desist order are: Kahuku Ogo, Robusta Ogo, and Sea Asparagus.

The company had not posted a recall notice on its website or with the U.S. Food and Drug Administration as of 11 p.m. EST Friday.

The Hawaii health department did not indicate what retailers had received Olakai products. It also reported distribution details were incomplete.

“Marine Agrifuture is a major distributor of ogo and sea asparagus in Hawaii and its products may have been shipped to all islands as well as the mainland, (including) California and Washington state. The department is still confirming all locations and states the product may have been shipped to,” according to the health department release.

The Marine Agrifuture/Olakai Hawaii website lists retailers that carry its products. The list as of Friday was:

• Kailua Town Farmers Market;
• Whole Foods Market;
• Waipio Costco;
• Kokua Market;
• Ala Moana Farmer’s Market;
• Windard Mall Farmers Market;
• Kailua Farmer’s Market;
• Hawaii Kai Costco; and
• Hawaii Kai Farmer’s Market.

As of Tuesday, 14 people had been confirmed with Salmonella infections, with four of them having symptoms so severe that they required hospitalization. The sick people include adults and children who developed diarrheal illnesses from mid- to late October.

Preliminary investigations identified consumption of raw fish, specifically poke that contained limo — seaweed — as a common factor among the sick people.

Anyone who has eaten poke containing limo and developed symptoms of Salmonella infection should seek medical attention and alert their doctor to the possible Salmonella exposure. Symptoms typically begin within 12 to 72 hours after exposure to the bacteria, according to the Hawaii health department.

State officials inspected the farm on Nov. 2 and 7, according to the Thursday news release.

“During the investigation, testing was conducted on environmental, processing area, and ogo samples. Laboratory tests identified Salmonella bacteria in the packing and processing tanks and in the farm environment,” the health department reported.

“Marine Agrifuture will be allowed to resume their sale of Kahuku Ogo, Robusta Ogo, and Sea Asparagus once the farm demonstrates to DOH that the risk of contamination from pathogenic bacteria has been mitigated at the source and that sanitation practices have been implemented to preclude contamination during the processing of the food product. DOH will continue to work with the farm and will require retesting of areas and products to assure food safety.”

The company, founded in 2006 by scientist Wenhao Sun, uses a patented salt-water cultivation system, according to its website. It “systematically cultures, develops, and enhances seed-stock for production and provides Sea Asparagus, ogo, and other marine-grown products for local and national distribution.”

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In its weekly update Wednesday, the Hawaii Department of Health (HDOH) reported no new confirmed cases from Nov. 3 through 9. It recorded one new case the previous week, bringing the total number of sick people to 292.

About a fourth of the outbreak victims have had symptoms so severe that they required hospitalization. At least one death, a 68-year-old woman, is attributed to the outbreak that was traced to frozen scallops imported from the Philippines and served raw by the Genki Sushi fast food chain. Another outbreak victim died, but was terminally ill and in hospice care so health officials are not attributing that death to Hepatitis A.

“Although the 50-day maximum incubation period from the date of the scallops embargo has passed, HDOH continues to be alert for people who have had onset of illness earlier but may present late to a clinician, as well as possible secondary cases,” according to the health department update.

“Secondary cases have been rare in this outbreak and have been limited to household members of cases or close contacts of cases.”

All but 18 of the victims have been residents of Oahu. Seven victims are visitors who have returned to the mainland or overseas. Eleven outbreak victims live on the islands of Hawaii, Kauai or Maui. Only Genki Sushi locations on Oahu and Kauai served the implicated scallops.

As of early November, the state’s health department had spent more than $336,000 on its outbreak investigation and response, officials tole KHON-TV Channel 2. Of that, $304,600 went for normal staff hours, and an estimated $19,750 paid for 300 hours of overtime, KHON-TV reported. The balance was spent on vaccines and shipping specimens for testing.

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The 14 infected people include children and adults, with four victims have such severe symptoms that they required hospitalization, according to the Hawaii Department of Health.

“Although our investigation is still ongoing, our preliminary investigation has implicated limu, also known as ogo or seaweed, produced at a particular farm on Oahu,” said State Epidemiologist Sarah Park in a news release Monday.

“To protect the public’s health, the department stepped in to make sure this product is no longer being put on the market pending further investigation. At the same time, we want the public to be aware of the situation so they may seek medical care if needed.”

Although encouraging public awareness, the state health department did not release the name of the Oahu farm. The department ordered the farm “to halt operations and advise its customers to remove product from sale immediately,” according to the news release.

All of the infected people developed diarrheal illnesses from mid- to late October. Preliminary investigations identified consumption of raw fish, specifically poke that contained limu, as a common factor among the sick people.

Anyone who has eaten poke containing limo and developed symptoms of Salmonella infection should seek medical attention and alert their doctor to the possible Salmonella exposure. Symptoms typically begin within 12 to 72 hours after exposure to the bacteria, according to the Hawaii health department.

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A spokesman for the Hawaii Department of Health confirmed the two deaths Thursday. He said one of the deaths is not attributed to the victim’s Hepatitis A infection because the person was terminally ill and in hospice care.

The other death was reported to the state health department “earlier this week” and involved a woman in her 60s who developed liver failure after contracting the outbreak strain of the virus that was also found in samples of the scallops. Seattle food safety attorney Bill Marler, who represents the woman’s family and about 75 other outbreak victims said the woman died last week.

“She did develop Hepatitis, she did suffer from liver failure and she just frankly never recovered,” Marler said. “She developed a number of other complications and unfortunately she passed away last week.”

As of Wednesday, the outbreak victim count was holding stead at 291 people, 73 of whom had symptoms so severs that they had to be hospitalized. All but two of the victims are adults. The first person confirmed in the outbreak became sick June 12. The most recent case is a person who became ill Oct. 9.

Marler said the dead woman ate raw scallops at a Genki Sushi restaurant in July. State and federal officials did not identify the scallops as the source of the Hepatitis A until Aug. 15. At that point they impounded the scallops and closed the Genki Sushi restaurants for cleaning and sanitizing.

Reports of new illnesses have been slowing in recent weeks, with no new cases reported in the past week, according to the health department’s Wednesday update.

“It’s a good sign that the numbers aren’t going up anymore,” Marler said. “I’m sure the health department feels good about that. Unfortunately we’re now dealing a woman who died from eating food. And in the United States in 2016, that shouldn’t be how it is.”

Editor’s note: Bill Marler is a founding member of the Marler Clark law firm and publisher of Food Safety News.

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When the Hawaii Department of Health first informed the public of the outbreak, the cause was a mystery. People started getting sick with the virus on June 12. More than two months later officials identified frozen scallops from the Philippines and served raw at Genki Sushi restaurants as the source.

State health officials impounded the implicated scallops and closed down the restaurants for cleaning and sanitizing, but people kept getting sick. That was expected — and continues to be expected — because it can take up to 50 days for a person to develop symptoms after exposure. The most recent person to be confirmed as part of the outbreak became ill on Oct. 9.

Although it’s been more than 50 days since restaurants stopped serving the implicated scallops, additional cases can occur because infected people can spread the disease to their family and other people they are in close contact with, according to Hawaii Epidemiologist Sarah Park.

Also, there continues to be a risk that a handful of employees at other restaurants who have been confirmed with the outbreak strain may have exposed customers.

A list of the restaurants where at least one employee has been identified with the outbreak strain of Hepatitis A is posted on the health department’s website, along with the dates they worked when they were contagious.

“This list does not indicate these businesses are sources of this outbreak; at this time, no infections have been linked to exposure to these businesses,” according to the weekly update posted Wednesday.

“The likelihood that patrons of these businesses will become infected is very low. However, persons who have consumed food or drink products from these businesses during the identified dates of service should contact their healthcare provider for advice and possible preventive care.”

Following are the restaurants remaining on the list as of Wednesday:

For additional details on the outbreak and investigation, please see our previous coverage:

FDA confirms Hepatitis A in scallops; multi-state recall begins
228 Hepatitis A cases in Hawaii; lawsuit could include 10,000
A fourth of Hawaii’s Hepatitis A victims admitted to hospitals

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In addition to the weekly case count update, officials with Hawaii’s Department of Health reported Wednesday that a worker at McDonald’s of Kahala, at 4618 Kilauea Avenue in Honolulu, has the virus.

Officials identified raw, frozen scallops from the Philippines as the source of the outbreak and impounded them Aug. 15.

“This case (of the McDonald’s worker) was identified and reported to us later in their illness, but had their symptom onset within the 50-day maximum incubation period from the date the scallops were embargoed,” State Epidemiologist Sarah Park said in a news release.

“The department will continue to investigate all reported cases of Hepatitis A and remain alert for other late-presenting cases as well as secondary cases.”

Affected dates of service for the McDonald’s employee were Sept. 20, 21, 23, 24, 27–29, and Oct. 1, 4–5, 7, and 11. It is unlikely that any McDonald’s customers contracted the virus from the McDonald’s employee, according to state officials.

Post-exposure vaccines are effective, but only if taken within two weeks of exposure. A statewide list of vaccinating pharmacies is available at http://health.hawaii.gov/docd/files/2013/07/IMM_Adult_Resource_List.pdf or by calling the Aloha United Way information and referral line at 2-1-1.

Anyone who had anything to eat or drink from the restaurant on the specific dates listed should monitor themselves for symptoms of Hepatitis A infection. People who develop symptoms should immediately seek medical care and tell their doctors about their potential exposure to Hepatitis A.

Symptoms usually develop within two weeks but it can take up to 50 days for some people to become sick after exposure. Not everyone — especially children — has symptoms after they are infected and contagious.

If symptoms develop, they can include: fever, fatigue, headache and/or body aches, loss of appetite, nausea, stomach pain,vomiting, diarrhea, dark colored urine and pale colored stools. Yellow skin and eyes may develop several days to a week after other symptoms begin and indicate serious illness.

The outbreak has been in the headlines since a July 1 announcement from state officials who reported 12 confirmed cases at that point.

By Aug. 15, when Hawaii’s Department of Health identified raw, frozen scallops from the Philippines as the source, more than 200 people were confirmed infected with the virus.

A large majority of victims reported they ate at Genki Sushi restaurants on Oahu and Kauai before becoming sick. Many of them reported eating raw scallops at one of the fast food chain’s locations.

The first confirmed illness began June 12, with the most recent victim becoming ill on Oct. 9. Of the 291 victims, 73 had symptoms so severe that they had to be hospitalized.

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That additional illness brings the total of sick people to 289, with 71 of them having had symptoms so severe that they required hospitalization, according to the weekly update from the Hawaii Department of Health.

Previous reports from the state indicated all of the victims had been adults. That information was not included in the Wednesday update this week. Confirmed illnesses began June 12, with the most recent person becoming sick on Sept. 28.

It can take up to 50 days for Hepatitis A symptoms to develop after exposure. Some infected people do not develop symptoms but are contagious for a period of time.

The majority of the confirmed victims reported eating at Genki Sushi restaurants on Oahu or Kauai before becoming ill. On Aug. 15 Hawaiian officials linked the illnesses to frozen scallops from the Philippines that had been served raw at the restaurants.

Officials ordered the restaurants to close and embargoed the scallops.

“Although the 50-day maximum incubation period from the date of the scallops embargo has passed, HDOH continues to be alert for people who have had onset of illness earlier but may present late to a clinician, as well as possible secondary cases. Secondary cases have been rare in this outbreak and have been limited to household members of cases or close contacts of cases,” according to the update from the state health department.

Although the Centers for Disease Control and Prevention and the Food and Drug Administration are involved in the outbreak investigation, the federal agencies have not posted updates since Aug. 19 and 24, respectively.

What to watch for and what to do
The CDC reports some people — especially children — who are infected with Hepatitis A do not have any symptoms. If symptoms occur, they usually appear two to six weeks after exposure. Symptoms usually develop over a period of several days.

If you do have symptoms, they may include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, clay-colored bowel movements, joint pain, and a yellowing of the skin or eyes referred to as jaundice.

Symptoms usually last less than two months, although some people can be ill for as long as six months.

Almost all people who get Hepatitis A recover completely and do not have any lasting liver damage, although they may feel sick for months. Hepatitis A can sometimes cause liver failure and death, although this is rare and occurs more commonly in persons 50 years of age or older and persons with other liver diseases, such as Hepatitis B or C.

If you have had contact with an outbreak victim or consumed food or any beverages at one of the restaurants where an employee has been confirmed as a victim, consult a doctor immediately and specifically mention your possible exposure to Hepatitis A.

Public health officials are requesting that health care providers consider the outbreak when seeing patients with Hepatitis A symptoms and conduct appropriate tests.

People exposed to the virus who have not been vaccinated can receive a post-exposure shot that is effective at avoiding infection development. However, the shot must be administer within two weeks of exposure.

Information and resources from Hawaii health officials

• Frequently Asked Questions
• List of Vaccinating Pharmacies
• Information for Contacts of Cases
• Fact Sheet for Food Service Establishments
• Information for Healthcare Workers
• Centers for Disease Control and Prevention (CDC) Information

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