Volume 101, Issue 3
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Angiostrongyliasis, caused by the roundworm, became reportable in the state of Hawaii in 2007. We confirmed 82 reported cases between 2007 and 2017. There was a median of seven cases per year, and the majority (57%) of cases occurred between January and April. Most (83%) cases were found on the island of Hawaii, with geographic information system (GIS) analysis identifying hot spots on the east side of the island. However, cases were identified on the other major islands as well, suggesting the risk of exposure is present statewide. Comparisons of cases from 2007 to 2017 with cases from previous assessments found no statistical differences in cerebrospinal fluid results, peripheral blood results, or ages of cases. However, differences in geographic distribution of the cases were statistically significant. Improved testing and increasing awareness of the disease have contributed to our efforts to better understand the general risk factors and modes of transmission present in Hawaii and also helped improve our prevention efforts, although we still do not fully understand the specific causes of cases being concentrated in certain parts of the state over others. Continued outreach efforts, including public forums and publication of preliminary clinical guidelines, aim to inform and improve our public health response and efforts to prevent angiostrongyliasis.

[open-access] This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


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  1. Alicata JE, , 1965. Biology and distribution of the rat lungworm, Angiostrongylus cantonensis, and its relationship to eosinophilic meningoencephalitis and other neurological disorders of man and animals. Adv Parasitol 3: 223248. [Google Scholar]
  2. Wallace GD, Rosen L, , 1969. Studies on eosinophilic meningitis. V. Molluscan hosts of Angiostrongylus cantonensis on Pacific Islands. Am J Trop Med Hyg 18: 206216. [Google Scholar]
  3. Wallace GD, Rosen L, , 1965. Studies on eosinophilic Meningitis. I. Observations on the geographic distribution of Angiostrongylus cantonensis in the pacific area and its prevalence in wild rats. Am J Epidemiol 81: 5262. [Google Scholar]
  4. Campbell BG, Little MD, , 1988. The finding of Angiostrongylus cantonensis in rats in New Orleans. Am J Trop Med Hyg 38: 568573. [Google Scholar]
  5. Yong HS, Eamsobhana P, , 2013. Definitive rodent hosts of the rat lungworm Angiostrongylus cantonensis. Raffles Bull Zool 29: 111115. [Google Scholar]
  6. Graeff-Teixeira C, da Silva ACA, Yoshimura K, , 2009. Update on eosinophilic meningoencephalitis and its clinical relevance. Clin Microbiol Rev 22: 322348, [Google Scholar]
  7. Wang QP, Wu ZD, Wei J, Owen RL, Lun ZR, , 2012. Human Angiostrongylus cantonensis: an update. Eur J Clin Microbiol Infect Dis 31: 389395. [Google Scholar]
  8. Wang QP, Lai DH, Zhu XQ, Chen XG, Lun ZR, , 2008. Human angiostrongyliasis. Lancet Infect Dis 8: 621630. [Google Scholar]
  9. Hidelaratchi MD, Riffsy MT, Wijesekera JC, , 2005. A case of eosinophilic meningitis following monitor lizard meat consumption, exacerbated by anthelminthics. Ceylon Med J 50: 8486. [Google Scholar]
  10. Bowden DK, , 1981. Eosinophilic meningitis in the New Hebrides: two outbreaks and two deaths. Am J Trop Med Hyg 30: 11411143. [Google Scholar]
  11. Beaver PC, Rosen L, , 1964. Memorandum on the first report of Angiostrongylus in man, by Nomura and Lin, 1945. Am J Trop Med Hyg 13: 589590. [Google Scholar]
  12. Aguiar PH, Morera P, Pascual J, , 1981. First record of Angiostrongylus cantonensis in Cuba. Am J Trop Med Hyg 30: 963965. [Google Scholar]
  13. Caldeira RL, Mendonca CL, Goveia CO, Lenzi HL, Graeff-Teixeira C, Lima WS, Mota EM, Pecora IL, Medeiros AM, Carvalho Odos S, , 2007. First record of molluscs naturallyinfected with Angiostrongylus cantonensis (Chen, 1935) (Nematoda: Metastrongylidae) in Brazil. Mem Inst Oswaldo Cruz 102: 887889. [Google Scholar]
  14. Lindo JF, 2002. Enzootic Angiostrongylus cantonensis in rats and snails after an outbreak of human eosinophilic meningitis, Jamaica. Emerg Infect Dis 8: 324326. [Google Scholar]
  15. Lo Re V, 3rd Gluckman SJ, , 2001. Eosinophilic meningitis due to Angiostrongylus cantonensis in a returned traveler: case report and review of the literature. Clin Infect Dis 33: e112e115. [Google Scholar]
  16. Bartschi E, Bordmann G, Blum J, Rothen M, , 2004. Eosinophilic meningitis due to Angiostrongylus cantonensis in Switzerland. Infection 32: 116118. [Google Scholar]
  17. Leone S, De Marco M, Ghirga P, Nicastri E, Esposito M, Narciso P, , 2007. Eosinophilic meningitis in a returned traveler from Santo Domingo: case report and review. J Travel Med 14: 407410. [Google Scholar]
  18. Slom TJ, 2002. An outbreak of eosinophilic meningitis caused by Angiostrongylus cantonensis in travelers returning from the Caribbean. N Engl J Med 346: 668675. [Google Scholar]
  19. Rosen L, Laigret J, Bories S, , 1961. Observations on an outbreak of eosinophilic meningitis on Tahiti, French Polynesia. Am J Hyg 74: 2642. [Google Scholar]
  20. Rosen L, Loison G, Laigret J, Wallace GD, , 1967. Studies on eosinophilic meningitis. 3. Epidemiologic and clinical observations on Pacific islands and the possible etiologic role of Angiostrongylus cantonensis. Am J Epidemiol 85: 1744. [Google Scholar]
  21. York EM, Creecy JP, Lord WD, Caire W, , 2015. Geographic range expansion for rat lungworm in North America. Emerg Infect Dis 21: 12341236. [Google Scholar]
  22. Stockdale Walden HD, Slapcinsky JD, Roff S, Mendieta Calle J, Diaz Goodwin Z, Stern J, Corlett R, Conway J, McIntosh A, , 2017. Geographic distribution of Angiostrongylus cantonensis in wild rats (Rattus rattus) and terrestrial snails in Florida, USA. PLoS One 12: e0177910. [Google Scholar]
  23. Liu EW, 2018. Rat lungworm infection associated with central nervous system disease–eight U.S. States, January 2011–January 2017. MMWR Morb Mortal Wkly Rep 67: 825828. [Google Scholar]
  24. Al Hammoud R, Nayes SL, Murphy JR, Heresi GP, Butler IJ, Perez N, , 2017. Angiostrongylus cantonensis meningitis and myelitis, Texas, USA. Emerg Infect Dis 23: 10371038. [Google Scholar]
  25. Foster CE, 2016. Angiostrongylus cantonensis infection: a cause of fever of unknown origin in pediatric patients. Clin Infect Dis 63: 14751478. [Google Scholar]
  26. Hochberg NS, Park SY, Blackburn BG, Sejvar JJ, Gaynor K, Chung H, Leniek K, Herwaldt BL, Effler PV, , 2007. Distribution of eosinophilic meningitis cases attributable to Angiostrongylus cantonensis, Hawaii. Emerg Infect Dis 13: 16751680. [Google Scholar]
  27. Hochberg NS, Blackburn BG, Park SY, Sejvar JJ, Effler PV, Herwaldt BL, , 2011. Eosinophilic meningitis attributable to Angiostrongylus cantonensis infection in Hawaii: clinical characteristics and potential exposures. Am J Trop Med Hyg 85: 685690. [Google Scholar]
  28. Qvarnstrom Y, 2016. Real-time polymerase chain reaction detection of Angiostrongylus cantonensis DNA in cerebrospinal fluid from patients with eosinophilic meningitis. Am J Trop Med Hyg 94: 176181. [Google Scholar]
  29. Giambelluca T, Chen Q, Frazier A, Price J, Chen Y-L, Chu P-S, Eischeid J, Delparte D, , 2013. Online rainfall atlas of Hawaii. Bull Am Meteorol Soc 94: 313316. [Google Scholar]
  30. Giambelluca T, 2014. Evapotranspiration of Hawaii. Final Report Submitted to the U.S. Army Corps of Engineers—Honolulu District, and the Commission on Water Resource Management, State of Hawaii.
  31. Kim JR, Wong TM, Curry PA, Yeung NW, Hayes KA, Cowie RH, , 2019. Modelling the distribution in Hawaii of Angiostrongylus cantonensis (rat lungworm) in its gastropod hosts. Parasitology 146: 4249. [Google Scholar]
  32. Hollingsworth R, Kaneta R, Sullivan JJ, Bishop H, Qvarnstrom Y, da Silva AC, Robinson DG, , 2007. Distribution of Parmarion cf. martensi (Pulmonata: Helicarionidae), a new semi-slug pest on Hawai‘i island, and its potential as a vector for human angiostrongyliasis. Pac Sci 61: 457467. [Google Scholar]
  33. Cowie RH, Hayes KA, Kim JR, Bustamente KM, Yeung NW, , 2018. Parmarion martensi Simroth, 1893 (Gastropoda: Ariophantidae), an intermediate host of Angiostrongylus cantonensis (rat lungworm), on Maui. Bishop Mus Occas Pap 123: 710. [Google Scholar]
  34. Kim JR, Hayes KA, Yeung NW, Cowie RH, , 2014. Diverse gastropod hosts of Angiostrongylus cantonensis, the rat lungworm, globally and with a focus on the Hawaiian Islands. PLoS One 9: e94969. [Google Scholar]
  35. Wilkins PP, Qvarnstrom Y, Whelen AC, Saucier C, da Silva AJ, Eamsobhana P, , 2013. The current status of laboratory diagnosis of Angiostrongylus cantonensis infections in humans using serologic and molecular methods. Hawaii J Med Public Health 72: 5557. [Google Scholar]
  36. Clinical Subcommittee of the Hawaii Governor’s Joint Task Force on Rat Lungworm Disease, 2018. Preliminary Guidelines for the Diagnosis and Treatment of Human Neuroangiostrongyliasis (Rat Lungworm Disease) in Hawaii. Available at: https://health.hawaii.gov/docd/files/2018/08/RLWD_Preliminary_Clinical_Guidelines_FINAL_082918.pdf. Accessed November 1, 2018. [Google Scholar]

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Supplemental materials

  • Received : 12 Apr 2019
  • Accepted : 06 Jun 2019
  • Published online : 08 Jul 2019

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