Centers for Disease Control offers updates on EVALI cases. Courtesy image

CDC News:

The Centers for Disease Control (CDC) has announced that as of Dec. 27, 2019 the number of hospitalized cases or deaths from e-cigarette, or vaping, product use associated lung injury (EVALI) was 2,561 nationwide.

More specifically, there have been 55 deaths confirmed in 27 state and the District of Columbia.

These states include: Alabama, California, Connecticut, Delaware, the 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.

More deaths are under investigation.

Current findings on the issue:

Syndromic data on emergency department visits suggest that the EVALI outbreak began in June 2019. Cases have been declining since a peak in September.

This 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 emergency department visits associated with possible EVALI have declined, they have not returned to levels before June 2019 and EVALI remains a concern.Laboratory data support previous findings that vitamin E acetate is closely associated with EVALI.

This 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.

Although progress in the investigation and response is being seen, the CDC encourages the public to remain vigilant. National data show that certain groups of EVALI patients released from the hospital are more likely to be rehospitalized or die.

Characteristics of EVALI patients who were readmitted or died following hospital discharge indicate that some chronic medical conditions, including cardiac disease, chronic pulmonary disease, and diabetes as well as increasing age might be risk factors leading to higher morbidity and mortality among some EVALI patients.

Based on the findings on EVALI patient rehospitalization and death, CDC has updated its guidance to clinicians to minimize these outcomes.

The updated clinical guidance recommends that hospitalized patients be documented as clinically stable for 24–48 hours prior to discharge.

Patients should have a follow-up visit with a primary care provider or pulmonary specialist, optimally within 48 hours of discharge—a shorter follow-up time than the previous recommendation of 1–2 weeks.

Healthcare providers should continue to report cases of EVALI to their state or local health department. CDC will continue to update guidance as we learn more about EVALI.

What We Know

Laboratory Findings Reported Dec. 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 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 (1 EVALI patient each).
• This study built upon a previously released using a large number of 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:

CDC is only reporting hospitalized EVALI cases and EVALI deaths regardless of hospitalization status
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.

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

While it appears that vitamin E acetate is associated with EVALI, there are many different substances and product sources that are being investigated, and there may be more than one cause.

What CDC Recommends

CDC and FDA recommend that people should not use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online sellers.

Vitamin E acetate should not be added to 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.

While it appears that vitamin E acetate is associated with EVALI, there are many different substances and product sources that are being investigated, and there may be more than one cause. Therefore, the best way for people to ensure that they are not at risk while the investigation continues is to consider refraining from the use of all e-cigarette, or vaping, products.

Adults using 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.

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.
Adults with ongoing cannabis (marijuana) use that leads to significant impairment or distress should seek out evidence-based behavioral treatment.

Effective treatments are available, and recovery is possible. A number of therapy-based treatments such as cognitive-behavioral therapy, contingency management, motivational enhancement therapy, and multi-dimensional family therapy have been shown to be effective.
Visit Substance Abuse and Mental Health Services Administration’s Treatment Locator to locate treatment in your area or call 1-800-662-HELP (4357).

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.

Regardless of the ongoing investigation:

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. There is no safe tobacco product. All tobacco products, including e-cigarettes, carry a risk.

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. Persons engaging in ongoing cannabis (marijuana) use that leads to significant impairment or distress should seek evidence-based treatment by a healthcare provider.
CDC will continue to update guidance, as appropriate, as new data becomes available from this complex outbreak.

For updates on this investigation, visit www.cdc.gov/lunginjury.