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DuPage County Health Department News

Posted on: October 10, 2019

Outbreak of Lung Injury Associated with E-Cigarettes, Vaping

CDC Image of USB E Cigarettes

UPDATED by CDC on January 16, 2020 at 1:00 p.m. (EST)

Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products

The Centers for Disease Control and Prevention (CDC), the U.S. Food and Drug Administration (FDA), state and local health departments, and other clinical and public health partners are investigating a national outbreak of lung injury associated with use of e-cigarette, or vaping, product use-associated lung injury (EVALI).

If you have questions about CDC’s investigation into the lung injuries associated with use of e-cigarette, or vaping, products, contact CDC-INFO or call 1-800-232-4636.

What is New

  • CDC, FDA, and state health authorities have made progress in identifying substances of concern in EVALI, and in characterizing the outbreak.
  • A new study, coupled with previous state-based evidence, strengthens the association between EVALI and the use of tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, products obtained from informal sources.
    • 82 percent of hospitalized patients with data on substance use reported using THC-containing products; 34 percent reported exclusive use of THC-containing products.
    • 50 percent of EVALI patients who reported using THC-containing products provided data on product source.
      • 16 percent reported acquiring products only from commercial sources (recreational and/or medical dispensaries, vape or smoke shops, stores, and pop-up shops).
      • 78 percent reported acquiring products only from informal sources (family/friends, dealers, online, or other sources).
      • 6 percent reported acquiring products from both commercial and informal sources.
    • This study reinforces existing CDC and FDA recommendations that people not use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers.
  • Vitamin E acetate is strongly linked to the EVALI outbreak. Vitamin E acetate has been found in product samples tested by FDA and state laboratories and in patient lung fluid samples tested by CDC from geographically diverse states. Vitamin E acetate has not been found in the lung fluid of people that do not have EVALI.
  • However, evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products, in some of the reported EVALI cases.

CDC will continue to update guidance as we learn more about EVALI.

What We Know

Laboratory Findings Reported December 20, 2019:

  • Laboratory data show that vitamin E acetate, an additive in some THC-containing e-cigarette, or vaping, products, is closely associated with EVALI.
    • A recent study analyzed samples from 51 EVALI cases from 16 states and a comparison group of samples from 99 healthy people for vitamin E acetate, plant oils, medium chain triglyceride (MCT) oil, coconut oil, petroleum distillates, and diluent terpenes.
    • Vitamin E acetate was identified in bronchoalveolar lavage (BAL) fluid samples (fluid samples collected from the lungs) from 48 of the 51 EVALI patients, but not in the BAL fluid from the healthy comparison group.
    • No other toxicants were found in BAL fluid from either group, except for coconut oil and limonene (one EVALI patient each).
    • This study built upon a previously released CDC report, using a large number of BAL fluid samples from EVALI patients, and added healthy controls, and yielded the same finding.
    • These findings complement the ongoing work of FDA and some state public health laboratories to characterize e-liquid exposures and inform the ongoing multistate outbreak.

About the Outbreak:

  • About the Outbreak:
    • CDC is only reporting hospitalized EVALI cases and EVALI deaths regardless of hospitalization status. CDC has removed non-hospitalized cases from previously reported case counts. See Public Health Reporting for more information.
    • As of January 14, 2020, a total of 2,668 hospitalized EVALI cases or deaths have been reported to CDC from all 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands).
      • Sixty deaths have been confirmed in 27 states and the District of Columbia (as of January 14, 2020).
    • Syndromic data on emergency department (ED) visits suggest that the EVALI outbreak began in June 2019. Cases have been declining since a peak in September.
      • Data suggest two distinct periods: a gradual increase in ED visits associated with e-cigarette use since 2017, followed by a sharp rise in June 2019.
      • Data suggest that that the EVALI outbreak began in the summer of 2019, and has been on the decline since September 2019.
      • These data align with recently released CDC national epidemiologic data among EVALI patients suggesting that the number of new hospitalized EVALI cases has also been declining since a peak in September.
      • While ED visits associated with possible EVALI have declined, they have not returned to levels before June 2019 and EVALI remains a concern.
    • Although the number of reported cases appears to be declining, states are still reporting new hospitalized EVALI cases to CDC on a weekly basis and should remain vigilant with EVALI case finding and reporting.

About Patient Exposure:

  • All EVALI patients have reported a history of using e-cigarette, or vaping, products.
    • Vitamin E acetate has been identified as a chemical of concern among people with e-cigarette, or vaping, product use-associated lung injury (EVALI).
    • THC is present in most of the samples tested by FDA to date, and most patients report a history of using THC-containing products.
    • The latest national and state findings suggest THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers, are linked to most of the cases and play a major role in the outbreak.
  • CDC has analyzed national data on use of THC-containing product brands by EVALI patients.
    • Overall, 152 different THC-containing product brands were reported by EVALI patients.
    • Dank Vapes, a class of largely counterfeit THC-containing products of unknown origin, was the most commonly reported product brand used by patients nationwide, although there are regional differences. While Dank Vapes was most commonly reported in the Northeast and South, TKO and Smart Cart brands were more commonly reported by patients in the West and Rove was more common in the Midwest.
    • The data further support that EVALI is associated with THC-containing products and that it is not likely associated with a single THC-containing product brand.

What We Don’t Know

Vitamin E acetate is strongly linked to the EVALI outbreak. However, evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products, in some of the reported EVALI cases.

What CDC Recommends

  • CDC and FDA recommend that people not use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers.
  • Vitamin E acetate should not be added to any e-cigarette, or vaping, products. Additionally, people should not add any other substances not intended by the manufacturer to products, including products purchased through retail establishments.
  • Adults using nicotine-containing e-cigarettes or vaping products as an alternative to cigarettes should not go back to smoking; they should weigh all available information and consider utilizing FDA-approved cessation medications. They should contact their healthcare provider if they need help quitting tobacco products, including e-cigarettes, as well as if they have concerns about EVALI.
  • E-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant. Adults who do not currently use tobacco products should not start using e-cigarette, or vaping, products.
  • THC use has been associated with a wide range of health effects, particularly with prolonged frequent use. The best way to avoid potentially harmful effects is to not use THC-containing e-cigarette, or vaping, products.
  • Adults who continue to use an e-cigarette, or vaping, product should carefully monitor themselves for symptoms and see a healthcare provider immediately if they develop symptoms like those reported in this outbreak.
  • If you are an adult trying to quit smoking:

    • Contact a healthcare provider for help quitting tobacco products, including e-cigarettes.
    • Use evidence-based treatments, including counseling and FDA-approved cessation medications.
  • If you are concerned about your health after using an e-cigarette, or vaping, product, contact your healthcare provider or local poison control center at 1-800-222-1222.

    Persons engaging in ongoing cannabis (marijuana) use that leads to significant impairment or distress should seek out evidence-based treatment by a healthcare professional.

  • For adults currently using marijuana/THC-containing e-cigarette, or vaping, products for medical use: We do not know if there are different health effects of using different forms of marijuana, such as smoking, vaping, and edibles, or whether transitioning from one form to another might reduce harm. Talk with your healthcare provider about other available treatment options for the conditions.

    CDC will continue to update guidance, as appropriate, as new data becomes available from this complex outbreak.

Key Facts about Use of E-Cigarette, or Vaping, Products

  • Electronic cigarettes—or e-cigarettes—are also called vapes, e-hookahs, vape pens, tank systems, mods, and electronic nicotine delivery systems (ENDS).
  • Using an e-cigarette product is commonly called vaping.
  • E-cigarettes work by heating a liquid to produce an aerosol that users inhale into their lungs.
  • The liquid can contain: nicotine, tetrahydrocannabinol (THC) and cannabinoid (CBD) oils, and other substances and additives. THC is the psychoactive mind-altering compound of marijuana that produces the “high”.

Latest Outbreak Information (Updated by CDC every Thursday)

  • his complex investigation spans all states, involves over 2,600 patients, and a wide variety of brands and substances and e-cigarette, or vaping, products.
  • As of December 3, 2019, CDC is only reporting hospitalized EVALI cases and EVALI deaths regardless of hospitalization status. CDC has removed nonhospitalized cases from previously reported case counts. See Public Health Reporting for more information.
  • As of January 14, 2020, a total of 2,668 hospitalized e-cigarette, or vaping, product use-associated lung injury (EVALI) cases or deaths have been reported to CDC from 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands).
  • Sixty deaths have been confirmed in 27 states and the District of Columbia (as of January 14, 2020):
    • Alabama, California, Connecticut, Delaware, District of Columbia, Florida, Georgia, Illinois, Indiana, Kansas, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, and Virginia
    • The median age of deceased patients was 51 years and ranged from 15 through 75 years (as of January 14, 2020).
    • More deaths are currently under investigation.
  • Data suggest the outbreak peaked in September 2019. However, states continue to report new cases, including deaths, to CDC on a weekly basis.
  • Among the 2,602 hospitalized EVALI cases or deaths reported to CDC with available data (as of January 7, 2020):
    • 67 percent were male
    • By age group category:
      • 15 percent of patients were under 18 years old;
      • 37 percent of patients were 18 to 24 years old;
      • 24 percent of patients were 25 to 34 years old; and
      • 24 percent of patients were 35 years or older.
  • 1,979 hospitalized patients had data on substance use, of whom (as of January 7, 2020):
    • 82 percent reported using THC-containing products; 34 percent reported exclusive use of THC-containing products.
    • 57 percent reported using nicotine-containing products; 13 percent reported exclusive use of nicotine-containing products.
  • 50 percent of EVALI patients who reported using THC-containing products provided data on product source.
    • 16 percent reported acquiring products only from commercial sources (recreational and/or medical dispensaries, vape or smoke shops, stores, and pop-up shops).
    • 78 percent reported acquiring products only from informal sources (family/friends, dealers, online, or other sources).
    • 6 percent reported acquiring products from both commercial and informal sources.
  • 54 percent of EVALI patients who reported using nicotine-containing products provided data on product source.
    • 69 percent reported acquiring products only from commercial sources.
    • 17 percent reported acquiring products only from informal sources.
    • 15 percent reported acquiring products from both commercial and informal sources.
  • Younger patients, aged 13–17 years, were significantly more likely to obtain THC and nicotine products from informal sources.
    • 94 percent of EVALI patients aged 13–17 years acquired THC-containing products only from informal sources versus 62 percent of those aged 45 years or older.
    • 42 percent of EVALI patients aged 13–17 years acquired nicotine-containing products only from informal sources versus 12 percent of those aged 45 years or older.

What CDC is doing

Public Health Response:

  • CDC’s Lung Injury response efforts are committed to:
    • Identify and define the risk factors and the source for lung disease associated with e-cigarette product use, or vaping.
    • Detect and track confirmed and probable cases in the US.
    • Communicate actionable recommendations to state, local, and clinical audiences.
    • Establish lab procedures that can assist with the public heath investigation and patient care.

Partnerships:

  • CDC is working 24/7 to identify the cause or causes of this outbreak.
  • CDC continues to work closely with FDA, states, public health partners, and clinicians on this investigation by providing consultation and technical assistance to states on communication, health alerts, public outreach, and surveillance.
  • CDC has activated the Emergency Operations Center (EOC) to coordinate activities and provide assistance to states, public health partners and clinicians around the nation.
  • CDC worked with states to create case definitions to classify confirmed and probable cases in a consistent way. States are in the process of classifying patients.
    • CDC will report numbers of confirmed and probable lung injury cases once states have finalized their classification of cases.
  • By invitation, CDC has deployed Epidemic Intelligence Service (EIS) officers and other CDC staff to support states.
  • CDC has been communicating with international public health partners. Currently, there is a very small number of similar lung injuries outside the U.S. and not close to the magnitude in the U.S.

Media and Communication:

  • CDC is maintaining an outbreak webpage with key messages and weekly updates on case counts, deaths, and resources available to healthcare providers, health departments, and the public.
  • CDC is holding congressional briefings, media telebriefings, and regular calls with health departments, clinicians to provide timely updates.

Laboratory Testing:

  • CDC is currently testing bronchoalveolar lavage (BAL) fluid samples as well as blood or urine samples paired to BAL fluid samples.
  • CDC is testing pathologic specimens, including lung biopsy or autopsy specimens, associated with patients.
  • CDC is offering aerosol emission testing of case-associated product samples from e-cigarette, or vaping, products, and e-liquids. For more information about submission, see Product Sample Submission Information.
  • Results can help provide insight into the nature of chemical exposure(s) contributing to this outbreak.
  • CDC developed guidance documents to assist public health laboratories, healthcare providers, pathologists, and others with specimen collection, storage, and submission to CDC for testing.
  • For more information and resources, visit For the Public, For Healthcare Providers and For State and Local Health Departments as well as our Publications and Resources page.

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