Update

Characteristics of Patients in a National Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injuries

United States, October 2019

Erin D. Moritz, PhD; Lauren B. Zapata, PhD; Akaki Lekiachvili, MD; Emily Glidden, MPH; Francis B. Annor, PhD; Angela K. Werner, PhD; Emily N. Ussery, PhD; Michelle M. Hughes, PhD; Anne Kimball, MD; Carla L. DeSisto, PhD; Brandon Kenemer, MPH; Mays Shamout, MD; Macarena C. Garcia, DrPH; Sarah Reagan-Steiner, MD; Emily E. Petersen, MD; Emily H. Koumans, MD; Matthew D. Ritchey, DPT; Brian A. King, PhD; Christopher M. Jones, DrPH; Peter A. Briss, MD; Lisa Delaney, MS; Anita Patel, PharmD; Kara D. Polen, MPH; Katie Sives, MPH; Dana Meaney-Delman, MD; Kevin Chatham-Stephens, MD; Lung Injury Response Epidemiology/Surveillance Group

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(43):985-989. 

In This Article

Abstract and Introduction

Introduction

CDC, the Food and Drug Administration, state and local health departments, and other public health and clinical stakeholders are investigating a national outbreak of electronic-cigarette (e-cigarette), or vaping, product use–associated lung injury (EVALI).[1] As of October 22, 2019, 49 states, the District of Columbia (DC), and the U.S. Virgin Islands have reported 1,604 cases of EVALI to CDC, including 34 (2.1%) EVALI-associated deaths in 24 states. Based on data collected as of October 15, 2019, this report updates data on patient characteristics and substances used in e-cigarette, or vaping, products[2] and describes characteristics of EVALI-associated deaths. The median age of EVALI patients who survived was 23 years, and the median age of EVALI patients who died was 45 years. Among 867 (54%) EVALI patients with available data on use of specific e-cigarette, or vaping, products in the 3 months preceding symptom onset, 86% reported any use of tetrahydrocannabinol (THC)-containing products, 64% reported any use of nicotine-containing products, and 52% reported use of both. Exclusive use of THC-containing products was reported by 34% of patients and exclusive use of nicotine-containing products by 11%, and for 2% of patients, no use of either THC- or nicotine-containing products was reported. Among 19 EVALI patients who died and for whom substance use data were available, 84% reported any use of THC-containing products, including 63% who reported exclusive use of THC-containing products; 37% reported any use of nicotine-containing products, including 16% who reported exclusive use of nicotine-containing products. To date, no single compound or ingredient used in e-cigarette, or vaping, products has emerged as the cause of EVALI, and there might be more than one cause. Because most patients reported using THC-containing products before symptom onset, CDC recommends that persons should not use e-cigarette, or vaping, products that contain THC. In addition, because the specific compound or ingredient causing lung injury is not yet known, and while the investigation continues, persons should consider refraining from the use of all e-cigarette, or vaping, products.

State health departments, the Council of State and Territorial Epidemiologists Vaping Associated Pulmonary Injury Epidemiology Task Force, and CDC developed and disseminated surveillance case definitions* and data collection tools (i.e., patient interview and medical record abstraction forms) to monitor and track cases beginning in August 2019. Some states are using these tools, whereas others elected to use state-specific tools. States and jurisdictions routinely report the number of confirmed and probable EVALI cases to CDC on a voluntary basis and, when available, include data from medical record abstractions and patient interviews. Proxies (e.g., spouses or parents) were interviewed if patients were too ill or if they had died. Most states and jurisdictions report the number of cases to CDC as case status is determined; however, it can take up to several weeks to complete and submit information from interview and medical record abstraction. This report provides updated data on patient demographic characteristics; substances used in e-cigarette, or vaping, products; and characteristics of EVALI patients who died, based on cases reported to CDC with available interview and medical record abstraction data as of October 15, 2019. The median ages of patients were compared across groups using the Wilcoxon rank-sum test. SAS statistical software (version 9.4; SAS Institute) was used for the analysis.

As of October 22, 2019, 49 states, DC, and the U.S. Virgin Islands had reported 1,604 cases of EVALI to CDC, including 34 (2.1%) EVALI-associated deaths in 24 states. Among 1,378 patients with confirmed or probable EVALI reported to CDC by October 15, 2019, with available data, 964 (70%) were male (Table). No cases in pregnant women were reported. Among 1,364 patients with information on age, the median age was 24 years (range = 13–75 years) and was similar among males (23 years) and females (25 years); 737 (54%) patients were aged <25 years, and 1,081 (79%) were aged <35 years. Among 383 EVALI patients with available information on race/ethnicity, 298 (78%) were non-Hispanic white, and 62 (16%) were Hispanic. Among 867 patients with available data on substances used, 749 (86%) reported any use of THC-containing products, and 552 (64%) reported any use of nicotine-containing products in the 3 months preceding symptom onset; 455 patients (52%) reported use of both THC-containing products and nicotine-containing products, 294 (34%) reported exclusive use of THC-containing products, and 97 (11%) reported exclusive use of nicotine-containing products. Twenty-one (2%) patients reported no use of THC- or nicotine-containing products.

Among the 29 EVALI-associated deaths reported to CDC as of October 15, 2019, 59% (17) were male; the median age was 45 years (range = 17–75 years) overall (Table), 55 years (range = 17–71 years) among males, and 43 years (range = 27–75 years) among females; the age difference between males and females was not statistically significant (p = 0.5). Patients who died were older than patients who survived (p<0.01). Among 19 EVALI patients who died and for whom data on substance use was available, the use of any THC-containing products was reported by patients or proxies for 84% (16), including 63% (12) who exclusively used THC-containing products. Use of any nicotine-containing products was reported for 37% (seven), including 16% (three) who exclusively used nicotine-containing products. Use of both THC- and nicotine-containing products was reported in four decedents.

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