Vaping Injury 'May Be Leveling Off,' but Risk Still High: CDC

Troy Brown, RN

October 25, 2019

Cases of lung injury associated with vaping in the United States have been reported in every state except Alaska, but the "epidemic curve...may be leveling off or even declining," according to officials speaking at a telebriefing from the Centers for Disease Control and Prevention (CDC) and the US Food and Drug Administration (FDA).

As of October 22, the number of cases of e-cigarette, or vaping, product use associated lung injury (EVALI) had grown to 1604, Anne Schuchat, MD, RADM, USPHS, RET, principal deputy director, CDC, said.

Thirty-four deaths have been confirmed in 24 states (Alabama, California [3], Connecticut, Delaware, Florida, Georgia [2], Illinois [2], Indiana [3], Kansas [2], Massachusetts, Michigan, Minnesota [3], Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon [2], Pennsylvania, Tennessee, Texas, Utah, and Virginia). Cases have also been reported in the District of Columbia and the US Virgin Islands. Additional deaths are being investigated.

"This week's numbers represent an increase of 125 cases of lung injury, compared with what we reported last week," Schuchat said. "Although the epidemic curve...suggests that the trajectory may be leveling off or even declining, and you may wonder if the peak of cases has passed, this pattern may or may not be confirmed with additional time."

Several factors may be responsible for this possible decline, Schuchat added. "There may be less intensive investigation of possible cases by the health departments, fewer cases from earlier in the year being reported into the public health system, or lags in data reporting to the CDC," she explained.

Consumer warnings about the risks associated with the use of e-cigarette products containing THC may be paying off, and enforcement efforts by local and federal authorities may be affecting supply chains in certain geographic areas.

"We also don't know what the upcoming influenza and winter respiratory infection season may do to the risk of lung injury among users of...vaping products," Schuchat said.

Deaths

To date, those who have died from EVALI have ranged in age from 17 to 75 years but have frequently been older; the median age is 45 years. The median age of those who have survived lung injury is 23 years, a difference that is statistically significant. Approximately one quarter of deaths have been in patients younger than 35 years.

The vast majority of all patients with EVALI have been THC users. Of more than 860 patients, approximately 85% reported use of e-cigarette products containing THC. Ten percent of patients reported using nicotine-containing products only.

Multiple Products May Be Involved

Product history information was available for "a relatively small number" of patients who died, Schuchat said; most reported using THC-containing products.

Officials still don't know where most of these products were obtained, but a report from Utah published October 25 in Morbidity and Mortality Weekly Report suggests most were acquired from informal sources or online, as opposed to "brick and mortar" stores or dispensaries.

This is consistent with data from investigations in Illinois and Wisconsin, where approximately 89% of products involved in fatal cases were from informal sources, Schuchat explained.

The FDA and the CDC have been unable to identify a single compound, product, substance, or brand responsible for these lung injuries, and it may be that multiple products are involved.

The CDC and the FDA are working together to investigate these cases, Mitch Zeller, JD, director, Center for Tobacco Products, FDA, said at the telebriefing. The FDA is working with laboratories around the country to make sure a wide range of testing is conducted on these products, including analyzing the substances used with e-cigarette products and the aerosols they produce.

The CDC and the FDA continue to refine the receipt and collection of product samples and are using "state-of-the-art" methods to analyze chemicals contained in these products, including cannabinoids, nicotine, pesticides, cutting agents, poisons, and toxins.

The FDA has obtained more than 900 product samples from 25 states. In some cases, containers of vaping liquid are almost empty, and this limits the kinds of testing that can be conducted on them, Zeller explained.

Analysis of these substances alone is not sufficient for determining causality, he stressed. Connecting products and how they were used with specific patients is extremely important for determining, "to the extent possible," the cause of lung injuries.

Officials are also looking into possible illicit trafficking of these products through international mail facilities, and the FDA is prepared to use its authority to the fullest extent to contain this outbreak.

"It is critically important that we get answers to these supply chain questions," Zeller said.

Although THC-containing products are involved in most of the EVALI cases, Schuchat stressed that they still do not know what the risky product is; THC may be a marker for a way cartridges are produced or used that may also apply to e-cigarette products that are not used with THC.

Schuchat said they do have concerns about heavy metals that may be released during the heating that occurs with use of vaping products. Zeller said they are finding vitamin E acetate in approximately half of the cases in which they are testing THC products.

Call to Action

Schuchat said she hopes that with the help of social media, young people will learn from those who have experienced these lung injuries first hand, and she implored those who have developed EVALI not to resume vaping once they start feeling better. Their lungs are weakened, she said, which could make them more vulnerable to additional lung injury.

Schuchat urged everyone to avoid using e-cigarette or vaping products containing THC. The only way to protect oneself from EVALI is to stop using e-cigarette products altogether. Adults who are using these products to quit using tobacco should consider using other FDA-approved nicotine replacement products.

Schuchat said treatments are available to help people who are addicted to vaping nicotine- or THC-containing products, and she encouraged e-cigarette product users to talk with their primary care provider about quitting.

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