2019 Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping
National Vaping Associated Lung Injury Situation
On yesterday’s call, CDC provided an update on the national situation as of November 5, 2019. This information is also updated on their website and will be updated each Thursday:
- 2,051 cases of lung injury associated with vaping (EVALI) have been reported to CDC from 49 states (all except Alaska), DC, and US Virgin Islands
- 39 deaths confirmed from 24 states with additional deaths under investigation
- CDC reports the trend in the number of new patients per week appears downward, but several states are still reporting very active investigation.
- An MMWR article posted on the CDC website today reports on results of testing potential toxins from bronchoalveolar lavage (BAL) fluid samples from EVALI patients. CDC tested 29 samples from 10 states and in all 29 samples found Vitamin E acetate. This is very significant as it is the first time a potential toxicant of concern has been identified in biological samples from patients as well as from the site of injury. In 23/28 samples THC was identified and in 16/26 samples nicotine was identified. CDC conducted testing on a wide range of potential toxicants including plant oils, petroleum distillates like mineral oil, medium chain triglycerides (MCT oils) and terpenes that can be present in THC products or added to products. No other potential toxicants were detected in the samples.
- CDC is making it clear that Vit E Acetate exists in a variety of products used on skin or ingested, and has not been shown to be harmful for ingestion or topical application. However, inhalation of this compound may interfere with normal lung function, and it is the inhaled aerosol that is of concern. There’s still a lot we don’t know about the impact of inhalation exposures.
- CDC notes it is possible Vit E Acetate may be present in other e liquid materials intentionally or unintentionally and at different concentrations.
- A second MMWR article reports results from Illinois. Earlier outbreak report from Illinois is here. This week’s report focuses on results from an online public survey targeting Illinois adults who use e-cigarettes or vapor products. The survey was both to gather baseline information on the type, frequency and source of vapor products used as well as to compare the subset of respondents who reported using THC products to EVALI patients from Illinois. Key findings show that EVALI patients were 9 times as likely as controls to obtain THC from informal sources and 8 times as likely to report using Dank Vapes. This underscores the import of the illegal/informal market as a key component of this outbreak in Illinois.
- Another MMWR with clinical guidance is being developed and should address guidance related to flu and EVALI.
- CDC new case form has been circulated, and their new reporting platform DCIPHER will extend to all 50 states next week.
Washington Vaping Associated Lung Injury Situation
- Reported cases of EVALI in Washington has increased to 14 cases this week and is posted on DOH website.
- Characteristics of the WA cases is similar to that nationally – 64% of patients are male; 29% are 19 or younger.
- Of the 12 cases we have the reported substance vaped (we will update again when we have 15 cases)
o 6 (50%) reported using THC containing products, 2 (17%) reported exclusive use of THC containing products, 4 (33%) reported both THC and Nicotine containing products
o 8 (67%) reported using Nicotine containing products, 4 (33%) reported exclusive use of Nicotine containing products
o 2 (17%) we do not know what product was vaped
- We have been able to send products or devices to FDA for 5 of the 14 cases.
- We have not sent any clinical specimens to CDC to date.
- We have formatted the new CDC case form for Washington use and have added it to WDRS. It is available here. We are in the process of testing the WDRS module and are transferring information from our existing cases into the new reporting form on WDRS. This will greatly facilitate our ability to pull out and summarize WA information as well as to contribute to the national data.
- We have added a lung injury evaluation worksheet to our website for use by local health for provider reports to help determine when additional case investigation is needed.
- CDCs 2-page fact sheet for evaluating and caring for patients with suspected EVALI is also posted to our website along with the full MMWR Interim Guidance.
- There are additional possible cases under investigation in Washington.
- Please continue to use firstname.lastname@example.org for questions or reports regarding the investigation.
- Media and public information inquiries should use DOH media contacts.