Characteristics of a Multistate Outbreak of Lung Injury Associated with E-cigarette use, or Vaping — United States, 2019

Cria G. Perrine, PhD; Cassandra M. Pickens, PhD; Tegan K. Boehmer, PhD; Brian A. King, PhD; Christopher M. Jones, DrPH; Carla L. DeSisto, PhD; Lindsey M. Duca, PhD; Akaki Lekiachvili, MD; Brandon Kenemer, MPH; Mays Shamout, MD; Michael G. Landen, MD; Ruth Lynfield, MD; Isaac Ghinai, MBBS; Amy Heinzerling, MD; Nathaniel Lewis, PhD; Ian W. Pray, PhD; Lauren J. Tanz, ScD; Anita Patel, PharmD; Peter A. Briss, MD; Lung Injury Response Epidemiology/Surveillance Group

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(39):860-864. 

In This Article

Abstract and Introduction

Introduction

Electronic cigarettes (e-cigarettes), also called vapes, e-hookas, vape pens, tank systems, mods, and electronic nicotine delivery systems (ENDS), are electronic devices that produce an aerosol by heating a liquid typically containing nicotine, flavorings, and other additives; users inhale this aerosol into their lungs.[1] E-cigarettes also can be used to deliver tetrahydrocannabinol (THC), the principal psychoactive component of cannabis.[1] Use of e-cigarettes is commonly called vaping. Lung injury associated with e-cigarette use, or vaping, has recently been reported in most states.[2–4] CDC, the Food and Drug Administration (FDA), state and local health departments, and others are investigating this outbreak. This report provides data on patterns of the outbreak and characteristics of patients, including sex, age, and selected substances used in e-cigarette, or vaping, products reported to CDC as part of this ongoing multistate investigation. As of September 24, 2019, 46 state health departments and one territorial health department had reported 805 patients with cases of lung injury associated with use of e-cigarette, or vaping, products to CDC. Sixty-nine percent of patients were males, and the median age was 23 years (range = 13–72 years). To date, 12 deaths have been confirmed in 10 states. Among 514 patients with information on substances used in e-cigarettes, or vaping products, in the 30 days preceding symptom onset, 76.9% reported using THC-containing products, and 56.8% reported using nicotine-containing products; 36.0% reported exclusive use of THC-containing products, and 16.0% reported exclusive use of nicotine-containing products. The specific chemical exposure(s) causing the outbreak is currently unknown. While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC. CDC will continue to work in collaboration with FDA and state and local partners to investigate cases and advise and alert the public on the investigation as additional information becomes available.

State health departments, the Council of State and Territorial Epidemiologists (CSTE), and CDC have developed definitions for confirmed and probable cases* and medical chart abstraction and case interview forms. The case definition, forms, and instructions for reporting cases were disseminated to all state health departments in late August 2019. Patients with cases of lung injury associated with e-cigarette use, or vaping, had 1) a history of e-cigarette use, vaping, or dabbing (vaping concentrated marijuana) within 90 days before symptom onset; 2) imaging studies showing lung injury; 3) absence of evidence of infection (confirmed cases) or infection not thought to be the sole cause of the lung injury or infectious disease testing not performed (probable cases); and 4) absence of alternative plausible diagnoses. Most states are reporting case counts to CDC as case status is determined; however, it can take up to several weeks to complete and submit information from medical chart abstraction and interviews. Additional time might be required after the information is submitted to CDC to clean and standardize data submitted in different formats. This report summarizes patterns of the lung injury outbreak and characteristics of cases reported to CDC, including demographic characteristics and selected substances used by patients.

As of September 24, 2019, 805 cases of lung injury from 46 states and one territory had been reported to CDC (Figure 1). Among the 805 cases reported, basic patient data (i.e., demographics and dates of symptom onset and hospitalization) were received for 771 (96%) patients. Ninety-one percent of patients were hospitalized. Median duration between symptom onset and hospitalization was 6 days (range = 0–158 days) (Figure 2). Although some cases occurred during April–June 2019, the number of cases began increasing in early July. The decline in reporting of onset dates and hospitalizations in the most recent 3–4 weeks is the result, in part, of a lag in reporting; there is no evidence that occurrence of lung injury cases is declining.

Figure 1.

Number of cases of lung injury associated with e-cigarette use, or vaping (n = 805) — United States, including two territories, 2019*
Abbreviations: DC = District of Columbia, PR = Puerto Rico; VI = U.S. Virgin Islands.
*As of September 24, 2019, 1–9 cases had been reported by 23 states and one territory; 10–29 cases had been reported by 14 states; 30–49 cases had been reported by five states; 50–99 cases had been reported by four states, and 0 cases had been reported by four states and DC. Additional cases being investigated are not reflected on this map.

Figure 2.

Dates of symptom onset (n = 590) and hospital admission (n = 674) among patients with lung injury associated with e-cigarette use, or vaping — United States, March 31–September 21, 2019

Sixty-nine percent of patients were male (Table). Median age was 23 years (range = 13–72 years); 61.9% were aged 18–34 years, and 16.2% were aged <18 years. Among the 12 deaths reported to CDC, 58% occurred in men, and the median age was 50 years (range = 27–71 years). Among a subset of 514 patients (63.8%) for whom information on substances used in e-cigarettes, or vaping, products was available, 395 (76.9%) reported using THC-containing products, and 292 (56.8%) reported using nicotine-containing products in the 30 days preceding symptom onset; 210 patients (40.9%) reported using both THC-containing and nicotine-containing products, 185 (36.0%) reported exclusive use of THC-containing products, and 82 (16.0%) reported exclusive use of nicotine-containing products.

* https://www.cdc.gov/tobacco/basic_information/e-cigarettes/assets/2019-Lung-Injury-Surveillance-Case-Definition-508.pdf.
CDC determined the intent of this project to be public health practice for disease and injury control; thus, the activity is not research involving human subjects and Institutional Review Board approval was not required (OMB No. 0920–1011).

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