E-cigarette Product Use, or Vaping, Among Persons With Associated Lung Injury — Illinois and Wisconsin, April–September 2019

Isaac Ghinai; Ian W. Pray; Livia Navon; Kevin O'Laughlin; Lori Saathoff-Huber; Brooke Hoots; Anne Kimball; Mark W. Tenforde; Jennifer R. Chevinsky; Mark Layer; Ngozi Ezike; Jonathan Meiman; Jennifer E. Layden

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(39):865-869. 

In This Article

Discussion

In this series of in-depth interviews with 86 e-cigarette– or vaping-associated lung injury patients in Illinois and Wisconsin during July–September 2019, patients reported a wide range of e-cigarette products; however, the vast majority reported using illicit THC-containing products sold as prefilled cartridges and obtained from informal sources. Although no single brand or product was definitively identified, a high percentage of patients reported using Dank Vapes cartridges. Dank Vapes appears to be the most prominent in a class of largely counterfeit brands, with common packaging that is easily available online and that is used by distributors to market THC-containing cartridges with no obvious centralized production or distribution.[7]

Previous reports highlighted that patients with lung injury associated with e-cigarette use have used both THC- and nicotine-containing products.[1,3,8,9] The additional information presented here regarding the range and diversity of brands used by patients, acquisition patterns, and frequency of use helps to formulate hypotheses about the possible etiology of this outbreak. In particular, the high level of use of prefilled THC cartridges, used in a range of different devices, suggests that the cartridges might play an important role.

The findings in this report are subject to at least four limitations. First, interviews were not available for one third of patients; this nonresponse rate might introduce selection bias, although the demographics of the 86 interviewed patients were similar to those of all 127 patients. Second, because information was self-reported, there is the possibility that social desirability bias might affect reporting, particularly of illicit products; nonmedical THC use is currently illegal in both Illinois and Wisconsin. In this analysis, some patients did not disclose THC-containing product use to clinicians until late in their hospital admission or until a urinary THC screen was performed. Third, the time between urinary toxicology testing and last reported use of an e-cigarette product was not consistent and might explain the three negative results in patients who reported using THC-containing products. Finally, these data are largely drawn from patients living in the northeastern region of Illinois and southeastern region of Wisconsin, and therefore might not be generalizable to other states; however, the age and gender distribution of is consistent with nationwide trends.[2,3]

The findings document that many, but not all, patients with lung injury associated with use of an e-cigarette product reported using THC-containing products. Similar findings have been noted in the national data, which include some of the data presented here.[2] These data also reveal a predominant use of prefilled THC cartridges sold through informal and unregulated markets, although the origin of these products further back in the production and distribution chain is unknown. In addition, these data do not elucidate whether the causative exposure is THC itself or a substance associated with prefilled THC cartridges, such as a cutting agent or adulterant. Ascertaining the importance of these products in contributing to the current outbreak will require data from multiple states and analysis at the national level.

Given the number and diversity of products reported overall and by individual patients, as well as the high frequency of patients using both THC- and nicotine-containing products, the epidemiologic investigation could benefit from additional information, including product testing and traceback of e-cigarette products to identify the ultimate source of the outbreak. The Illinois Department of Public Health and the Wisconsin Department of Health Services are collaborating with CDC on a large nationwide public health response and with the Food and Drug Administration to coordinate laboratory testing of products associated with this outbreak. While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC.

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