Update

Demographic, Product, and Substance-Use Characteristics of Hospitalized Patients in a Nationwide Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injuries

United States, December 2019

Matthew J. Lozier, PhD; Bailey Wallace, MPH; Kayla Anderson, PhD; Sascha Ellington, PhD; Christopher M. Jones, PharmD, DrPH; Dale Rose, PhD; Grant Baldwin, PhD; Brian A. King, PhD; Peter Briss, MD; Christina A. Mikosz, MD

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(49):1142-1148. 

In This Article

Abstract and Introduction

Introduction

CDC, the Food and Drug Administration (FDA), state and local health departments, and public health and clinical stakeholders continue to investigate a nationwide outbreak of e-cigarette, or vaping, product use–associated lung injury (EVALI).[1] This report updates demographic and self-reported product-use and substance-use characteristics of hospitalized EVALI patients reported to CDC from available interview or medical record abstraction data. As of December 3, 2019, all 50 states, the District of Columbia (DC), and two U.S. territories (Puerto Rico and U.S. Virgin Islands) reported 2,291 patients hospitalized with EVALI. A total of 48 (2% of total reported cases) deaths occurred in 25 states and DC. Median patient age was 24 years, 67% were male, and the largest number of weekly hospitalized cases occurred during the week of September 15, 2019; weekly hospitalized cases since then have steadily declined. Among all hospitalized EVALI patients reported to CDC weekly, the percentage of recent cases (patients hospitalized within the preceding 3 weeks) declined from 58% reported November 12 to 30% reported December 3. Overall, 80% of hospitalized EVALI patients reported using tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, products. "Dank Vapes," a class of largely counterfeit THC-containing products of unknown origin, were the most commonly reported THC-containing branded products nationwide and among all major U.S. Census regions. However, regional differences in THC-containing product use were noted; TKO and Smart Cart brands were more commonly reported by patients in the West region compared with other regions. 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. The nationwide diversity of THC-containing products reported by patients suggests it is unlikely a single brand is responsible for the EVALI outbreak, and regional differences in THC-containing products might be related to product sources. Although it appears that vitamin E acetate is associated with EVALI, many substances and product sources are being investigated, and there might be more than one cause. Therefore, while the investigation continues, persons should consider refraining from the use of all e-cigarette, or vaping, products.

CDC has worked with state health departments and a task force formed by the Council of State and Territorial Epidemiologists to develop and disseminate surveillance case definitions* and data collection tools to monitor and track cases beginning in August 2019. States and jurisdictions voluntarily report the number of confirmed and probable hospitalized EVALI cases and all EVALI-associated deaths to CDC on a weekly basis. This report is limited to data on hospitalized EVALI patients and all EVALI-associated deaths reported to CDC as of December 3, 2019,[2] and updates patient demographic characteristics, the number and diversity of self-reported substances, and brands used in e-cigarette, or vaping, products. Distribution of THC-containing brands is reported nationally and by U.S. Census region.§ 2018 U.S. Census population estimates were used to calculate rates (hospitalized EVALI cases per 1 million population) by state. Because of the time required to investigate cases, weekly reports to CDC include recent EVALI cases (patients hospitalized within the preceding 3 weeks) and past EVALI cases (those hospitalized earlier). To assess the recent trajectory of the EVALI outbreak, this report examined the percentage of all hospitalized EVALI patients reported weekly who had been hospitalized within the preceding 3 weeks.

As of December 3, 2019, all 50 states, DC, Puerto Rico, and the U.S. Virgin Islands reported 2,291 hospitalized EVALI cases to CDC (Table). Overall, a total of 48 (2% of total reported cases) EVALI-associated deaths occurred in 25 states and DC, which include one nonhospitalized case and two cases with unknown hospitalization status. Among hospitalized EVALI patients for whom data were available, 67% were male, and the median age was 24 years (range = 13–77 years); 78% of patients were aged <35 years and 16% were <18 years. Most EVALI patients were non-Hispanic white (75%), and 16% were Hispanic. Among the 48 deaths, 54% of patients were male, and the median age was 52 years (range = 17–75 years).

Since February 2019, the largest number of hospitalized EVALI patients (217) was reported during the week of September 15, 2019 (Figure 1). Since September 15, there has been a steady decline in hospitalized EVALI patients reported weekly to CDC. Among all hospitalized EVALI patients reported weekly to CDC by states since November 5, 2019, the percentage of recent EVALI cases declined from 58% reported November 12 to 30% reported December 3. Although EVALI cases have been reported in all states, DC, and two US territories, population-based prevalence rates varied widely across states (Figure 2).

Figure 1.

Number of patients (N = 2,163) with lung injury associated with e-cigarette, or vaping, product use, by week of hospital admission and percentage of patients hospitalized in last 3 weeks* — United States, February 10–December 3, 2019
*Percentage hospitalized within 3 weeks preceding the date reported to CDC.

Figure 2.

Prevalence* of hospitalized cases of e-cigarette, or vaping, product use–associated lung injury (N = 2,291) — United States, August–December 2019
Abbreviations: DC = District of Columbia; PR = Puerto Rico; VI = U.S. Virgin Islands.
*Number of cases per 1 million population. The U.S. Census population from 2010 was used to calculate prevalence for U.S. Virgin Islands, and U.S. Census population estimates from 2018 were used to calculate prevalence for all other states, the District of Columbia, and territories.

As of December 3, among 1,782 hospitalized EVALI patients with information on substances used in e-cigarette, or vaping, products in the 3 months preceding symptom onset, 80% and 35% reported any and exclusive use, respectively, of THC-containing products (Table). This compared with 54% and 13% of hospitalized EVALI patients who reported any and exclusive use, respectively, of nicotine-containing products and 12% and 1% who reported any and exclusive use, respectively, of cannabidiol (CBD)-containing products. Among 214 hospitalized patients who reported using CBD-containing products, 80% also reported using THC-containing products. Among 770 hospitalized patients who reported using THC-containing products and had frequency reported, 75% reported using THC-containing products daily.

Among hospitalized EVALI patients who reported using THC-containing e-cigarette, or vaping, products and had complete data on product use, 482 reported using 152 different products (861 observations; median = 2; range = 1–25). Dank Vapes, the most frequently reported product brand, was used by 56% of hospitalized EVALI patients nationwide (Figure 3). TKO (15%), Smart Cart (13%), and Rove (12%) were the next most commonly reported product brands. When stratified by U.S. Census regions, Dank Vapes remained the most commonly reported THC-containing product in all regions and was reported by >60% of hospitalized EVALI patients in the Northeast and South regions. Regional differences were seen in reported use of many products, including Smart Cart, which was reportedly used by a higher proportion of hospitalized EVALI patients in the West (24%) compared with those in the South (14%), Midwest (14%) and Northeast (6%). TKO was reported by more than twice as many hospitalized EVALI patients in the West (29%) as in the Northeast (14%), Midwest (12%), and South (2%) regions.

Figure 3.

Percentage of hospitalized EVALI patients (N = 482) who reported brand names of THC-containing e-cigarettes, or vaping, products,* by U.S. Census region — United States, August–December 2019
Abbreviations: EVALI = e-cigarette, or vaping, product use–associated lung injury; THC = tetrahydrocannabinol.
*"Other products" included 146 unique products. Dabwood and Brass Knuckles were reported by 10% of patients in the Northeast and West regions. Off White, Moon Rocks, Chronic Carts, Mario Carts, Cereal Carts, Runtz, Dr. Zodiac, Eureka, Supreme G, and CaliPlug were reported by 1%–5% of patients nationwide. Use of 134 other products were reported by <1% of hospitalized patients.
Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming. Puerto Rico and U.S. Virgin Islands were included in the South region.

*https://www.cdc.gov/tobacco/basic_information/e-cigarettes/assets/2019-Lung-Injury-Surveillance-Case-Definition-508.pdf.
https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/healthcare-providers/pdfs/National-Case-Report-Form-v01.pdf.
§ Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming. Puerto Rico and U.S. Virgin Islands were included in the South region.
https://www.census.gov/.

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