Interim Guidance for Health Care Professionals Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use–Associated Lung Injury and for Reducing the Risk for Rehospitalization and Death Following Hospital Discharge — United States, December 2019

Mary E. Evans, MD; Evelyn Twentyman, MD; Eleanor S. Click, MD, PhD; Alyson B. Goodman, MD; David N. Weissman, MD; Emily Kiernan, DO; Susan Adkins Hocevar, MD; Christina A. Mikosz, MD; Melissa Danielson, MSPH; Kayla N. Anderson, PhD; Sascha Ellington, PhD; Matthew J. Lozier, PhD; Lori A. Pollack, MD; Dale A. Rose, PhD; Vikram Krishnasamy, MD; Christopher M. Jones, PharmD, DrPH; Peter Briss, MD; Brian A. King, PhD; Jennifer L. Wiltz, MD


Morbidity and Mortality Weekly Report. 2020;68(5152) 

In This Article

Abstract and Introduction


CDC, the Food and Drug Administration, 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).[1–4] Clinical guidance from CDC and state partners for EVALI continues to evolve as more information about EVALI becomes available.[5–8] Among EVALI patients who were rehospitalized or who died after discharge for an EVALI-related hospitalization, a recent study found a high rate of comorbidities and a median interval from discharge to readmission of 4 days and a median interval from discharge to death of 3 days; at least one quarter of rehospitalizations and deaths occurred within 2 days of discharge.[9] The study findings prompted CDC, in consultation with the Lung Injury Response Clinical Working Group, to update guidance regarding timing of the initial postdischarge follow-up of hospitalized EVALI patients and other EVALI patient management. Updates to current clinical guidance include recommendations for discharge planning and optimized follow-up and case management after discharge that might reduce risk of rehospitalization and avert postdischarge mortality among patients hospitalized for EVALI. Specifically, guidance updates include 1) confirming no clinically significant fluctuations in vital signs for at least 24–48 hours before discharge; 2) ensuring outpatient primary care or pulmonary specialist follow-up, optimally within 48 hours of discharge (previously recommended within 2 weeks of discharge); 3) planning for discharge care, early follow-up, and management of any comorbidities; 4) arranging posthospitalization specialty care; 5) following best practices for medication adherence; and 6) ensuring social support and access to mental and behavioral health and substance use disorder services.

As of December 10, 2019, a total of 2,409 hospitalized EVALI cases have been reported to CDC, including 52 (2%) deaths among EVALI patients. Among 1,139 reported cases with patient hospital discharge by October 31, 2019, 31 (2.7%) patients were rehospitalized after initial discharge (median time to readmission: 4 days [interquartile range: 2–20 days]), and seven patients died following discharge after an EVALI hospitalization (median time to death: 3 days [interquartile range 2–13 days]).[9] Characteristics of EVALI patients who were rehospitalized or died following hospital discharge indicate that some chronic medical conditions, including cardiac disease, chronic pulmonary disease (e.g., chronic obstructive pulmonary disease and obstructive sleep apnea), and diabetes, and increasing age are risk factors leading to higher morbidity and mortality among some EVALI patients. For example, 70.6% of patients who were rehospitalized and 83.3 (five of six) of patients who died had one or more chronic conditions, compared with 25.6% of patients who were neither rehospitalized nor died.[9] EVALI patients who were rehospitalized or died after discharge were older: the median ages of patients who died, were rehospitalized, and who neither died nor were rehospitalized were 54, 27, and 23 years, respectively.[9]

Confirming stability of certain clinical parameters without clinically significant fluctuations in vital signs (Box) (Supplementary Figure, https://stacks.cdc.gov/view/cdc/83554) before discharge and careful hospital discharge and transition planning might help prevent rehospitalization or death, particularly among those patients with cardiac or chronic respiratory comorbidities who are at higher risk for rehospitalization or death.[9] In addition, anxiety, depression, attention-deficit/hyperactivity disorder, and other mental or behavioral health conditions were common among all EVALI patients.[9] Based on the high prevalence of these conditions, appropriate engagement with social and behavioral health services during care transition from hospital to the outpatient setting is also important.