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      E-cigarette Product Use, or Vaping, Among Persons with Associated Lung Injury — Illinois and Wisconsin, April–September 2019

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          In July 2019, the Illinois Department of Public Health and the Wisconsin Department of Health Services launched a coordinated epidemiologic investigation after receiving reports of several cases of lung injury in previously healthy persons who reported electronic cigarette (e-cigarette) use, or vaping ( 1 ). This report describes features of e-cigarette product use by patients in Illinois and Wisconsin. Detailed patient interviews were conducted by telephone, in person, or via the Internet with 86 (68%) of 127 patients. Overall, 75 (87%) of 86 interviewed patients reported using e-cigarette products containing tetrahydrocannabinol (THC), and 61 (71%) reported using nicotine-containing products. Numerous products and brand names were identified by patients. Nearly all (96%) THC-containing products reported were packaged, prefilled cartridges, and 89% were primarily acquired from informal sources (e.g., friends, family members, illicit dealers, or off the street). In contrast, 77% of nicotine-containing products were sold as prefilled cartridges, and 83% were obtained from commercial vendors. The precise source of this outbreak is currently unknown ( 2 ); however, the predominant use of prefilled THC-containing cartridges among patients with lung injury associated with e-cigarette use suggests that they play an important role. While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC. Given the diversity of products reported and frequency of patients using both THC- and nicotine-containing e-cigarette products, additional methods such as product testing and traceback could help identify the specific cause of this outbreak. During July–September 2019, possible cases of lung injury associated with e-cigarette use in Illinois and Wisconsin were investigated to determine symptoms, exposures, and medical care history related to the outbreak. Patients were classified as having confirmed or probable cases of lung injury associated with e-cigarette use according to CDC’s interim outbreak case definitions ( 3 ). Interviews were conducted with patients or a proxy using a structured and scripted questionnaire that was developed jointly between Illinois and Wisconsin with guidance from CDC. The questionnaire asked detailed questions about e-cigarette use, including the names of e-cigarette, or vaping, products and devices, frequency of use, and product sources in the 3 months preceding illness onset. Most interviews were conducted by state or local health department staff members or in person by health care facility staff members during a patient’s hospitalization; a small number of patients completed the same survey online. In total, 86 (68%) interviews were completed among the 127 confirmed and probable patients that had been identified in Illinois (75) and Wisconsin (52) as of September 20, 2019. Among the 86 confirmed and probable patients that were interviewed, including 48 from Illinois and 38 from Wisconsin, 68 (79%) were male, and the median age was 21 years (range = 15–53 years) (Table 1). Hospitalization dates among patients were similar in Illinois and Wisconsin, ranging from April 24 to September 19, 2019, and closely reflected the national outbreak ( 2 ). Illinois cases predominantly occurred in the northeast region of the state (in Chicago and the surrounding counties, close to the Wisconsin border) but have since been reported in other regions of the state. Most Wisconsin cases were initially clustered in the southeastern region of the state but have since been reported throughout western and central Wisconsin as well. TABLE 1 Patient characteristics by type of electronic cigarette, or vaping, product used in the 3 months prior to illness onset — Illinois and Wisconsin, 2019 Characteristic n/N (%) THC-containing products only (N = 25) Nicotine-containing products only (N = 11) Both THC- and nicotine-containing products (N = 50) Total (N = 86) Age group (yrs) <18 5/25 (20) 3/11 (27) 11/50 (22) 19/86 (22) 18–24 7/25 (28) 4/11 (36) 27/50 (54) 38/86 (44) 25–34 7/25 (28) 3/11 (27) 9/50 (18) 19/86 (22) ≥35 6/25 (24) 1/11 (9) 3/50 (6) 10/86 (12) Gender Male 22/25 (88) 8/11 (73) 38/50 (76) 68/86 (79) Female 3/25 (12) 3/11 (27) 12/50 (24) 18/86 (21) Race/Ethnicity* White, non-Hispanic† 13/22 (59) 8/11 (73) 39/46 (85) 60/79 (76) Black, non-Hispanic† 2/22 (9) 2/11 (18) 3/46 (7) 7/79 (9) Other, non-Hispanic† 0/22 (0) 0/11 (0) 2/46 (4) 2/79 (3) Hispanic† 7/22 (32) 1/11 (9) 2/46 (4) 10/79 (13) Other characteristics Admitted to ICU§ 12/19 (63) 5/8 (63) 25/44 (57) 42/71 (59) Smoked combustible marijuana¶ 12/24 (50) 5/11 (45) 26/48 (54) 43/83 (52) Smoked combustible tobacco¶ 3/24 (13) 4/11 (36) 13/48 (27) 20/83 (24) Abbreviations: ICU = intensive care unit; THC = tetrahydrocannabinol. * Information missing for seven patients. † Blacks, whites, and persons of other races were non-Hispanic; Hispanic persons could be of any race. § Information missing for 15 patients. ¶ Information missing for three patients. Among the 86 interviewed patients, 75 (87%) reported using e-cigarette products containing THC, the principal psychoactive component of cannabis, during the 3 months preceding illness; 61 (71%) reported using nicotine-containing products; 50 (58%) reported using both THC- and nicotine-containing products. Twenty-five (29%) patients reported exclusive use of THC-containing products, whereas 11 (13%) reported exclusive use of nicotine-containing products (Table 2). Demographic characteristics of patients were similar among those who reported exclusive use of THC-containing products, exclusive use of nicotine-containing products, or use of both types of products (Table 1). TABLE 2 Electronic cigarette (e-cigarette), or vaping, product use behaviors in the 3 months prior to illness onset in patients with lung injury associated with e-cigarette use — Illinois and Wisconsin, 2019 Product use and behaviors No. (%) Illinois (n = 48) Wisconsin (n = 38) Total (N = 86) THC-containing product use Any use 39 (81) 36 (95) 75 (87) Exclusive use 13 (27) 12 (32) 25 (29) Dank Vapes use 33 (73) 24 (63) 57 (66) Nicotine-containing product use Any use 35 (73) 26 (68) 61 (71) Exclusive use 9 (19) 2 (5) 11 (13) Both THC- and nicotine-containing product use 26 (54) 24 (63) 50 (58) At least daily use of e-cigarette products* THC-containing products 29 (60) 20 (53) 49 (57) Nicotine-containing products 27 (56) 18 (47) 45 (52) Devices used with e-cigarette products† Device designed for prefilled cartridge use 43 (91) 35 (92) 78 (92) Tank designed to be filled with product 7 (15) 11 (29) 18 (21) Dab rig or a dab pen 7 (15) 7 (18) 14 (16) No. of e-cigarette product brands reported per product type user† THC brands per THC user,§ mean (range) 2.1 (1–7) 2.1 (1–7) 2.1 (1–7) Nicotine brands per nicotine user,¶ mean (range) 1.3 (1–3) 1.3 (1–4) 1.3 (1–4) Packaging of e-cigarette products used No./total of THC products (%) that were packaged, prefilled cartridges 69/72 (96) 80/83 (96) 149/155 (96) No./total of nicotine products (%) that were packaged, prefilled cartridges 32/35 (91) 29/44 (66) 61/79 (77) Abbreviation: THC = tetrahydrocannabinol. * The denominator used here is all patients, not just those who reported using THC- or nicotine-containing products. † Patients could report using more than one type of device or product, thus the percentage totals sum to >100%. § Patients were counted as THC users if they reported use of at least one THC-containing e-cigarette product in the past 3 months. ¶ Patients were counted as nicotine users if they reported use of at least one nicotine-containing e-cigarette product in the past 3 months. The chemical contents of reported THC-containing products are unknown. However, urinary THC screens were obtained for 32 patients who reported using THC-containing products, 29 (91%) of which were positive for THC; two patients who did not report using THC-containing e-cigarette products, out of four tested, also had positive urinary THC screens; one of these patients reported smoking combustible marijuana. Urinary THC levels for four patients who reported using THC-containing products exceeded 400 ng/ml, indicating intensive use of THC or THC-containing products ( 4 , 5 ). In Wisconsin, eight patients initially denied using THC-containing products in interviews, but five (63%) were later found to have used THC through review of medical charts, reinterview, or cross-referencing with friends who were also interviewed as patients. Among the 86 interviewed patients, 234 unique e-cigarette, or vaping, products labeled with 87 different brand names were reported. Nicotine-containing product users reported a mean of 1.3 different nicotine brands (range = 1–4), and THC-containing product users reported a mean of 2.1 different THC brands (range = 1–7). Among 155 THC-containing products reported, nearly all (149, 96%) were packaged, prefilled cartridges, whereas 61 (77%) of 79 nicotine-containing products were sold as prefilled cartridges or “pods.” No patients reported adding other ingredients to the e-cigarette products they used. Although no single brand name was reported by all patients, a prefilled THC cartridge sold under the brand name Dank Vapes was reported by 57 (66%) patients (Figure). In Wisconsin, two groups of friends (two patients in one group and three in the second group) who became ill after using THC-containing cartridges specifically reported sharing Dank Vapes cartridges. Dank Vapes was the only e-cigarette product reported by one of the patients. FIGURE Frequently reported brand names of tetrahydrocannabinol (THC)- and nicotine-containing electronic cigarette (e-cigarette), or vaping, products* ,†,§ reported by patients with lung injury¶ — Illinois and Wisconsin, 2019 * Two brands of cannabidiol are not shown (each brand reported by one patient). † 30 other THC-containing brands (including three brands of THC wax for “dabbing”) were only reported by one patient each. § 22 other nicotine-containing brands were only reported by one patient each. ¶ Data are presented from interviews conducted with 86 of 127 patients with lung injury associated with e-cigarette use, or vaping. The figure is a bar chart showing frequently reported brand names of tetrahydrocannabinol- and nicotine-containing electronic cigarette, or vaping, products reported by patients with lung injury in Illinois and Wisconsin during 2019. Among 112 THC-containing products for which the source was reported, 100 (89%) were acquired from informal sources (e.g., friends, family, school, dealers, or off the street). The remaining 12 were bought at an out-of-state cannabis dispensary (six), online (five), or from a vape or tobacco shop (one). In contrast, among 81 nicotine-containing products, 40 (49%) were obtained from a vape or tobacco shop, 22 (27%) from gas stations or convenience stores, 14 (17%) from friends or family, and five (6%) online. A variety of e-cigarette and vaping device types ( 6 ) were used by patients to aerosolize THC- or nicotine-containing products. Overall, 78 (92%) of 85 patients reported using a device designed to aerosolize prefilled cartridges or pods. Within this category of vaping devices, some were closed-pod systems (also known as “mods”) designed for use with proprietary nicotine-containing products (e.g., JUUL); however, most were universal “vape pens” that are adaptable to the prefilled THC cartridges reported by many patients. Use of devices with a tank designed to be filled with nicotine-containing liquid or THC oil was reported by 18 (21%) patients, and 14 (16%) reported aerosolizing THC concentrates, known as waxes or “dabs,” using either a “dab rig” or a “dab pen” device. † Patients reported frequent daily use of e-cigarette products; among 75 users of THC-containing products, 49 (65%) reported using these products at least daily, and 45 (74%) of 61 nicotine-containing product users reported at least daily use of these products. Where more detailed information on frequency of use was provided, 21 (41%) of 51 THC-containing product users and 30 (65%) of 46 nicotine-containing product users reported use of at least one such product five or more times a day. In addition to e-cigarette products, among 83 patients who provided information on combustible product use, 43 (52%) reported smoking combustible marijuana, and 20 (24%) reported smoking combustible tobacco. Only four (5%) of 86 interviewed patients reported prescription drug misuse or illicit drug use other than THC. Two patients reported using LSD, one reported misusing dextroamphetamine-amphetamine (Adderall), and one reported misusing oxycodone. Urinary toxicology screens were positive for substances other than THC (and for other substances that could not be explained by the medical treatment these patients had received) in six of 31 patients, including two patients who tested positive for benzodiazepines and opioids, one for benzodiazepines alone, one for opioids alone, one for amphetamines, and one for unspecified narcotics. Discussion In this series of in-depth interviews with 86 e-cigarette– or vaping-associated lung injury patients in Illinois and Wisconsin during July–September 2019, patients reported a wide range of e-cigarette products; however, the vast majority reported using illicit THC-containing products sold as prefilled cartridges and obtained from informal sources. Although no single brand or product was definitively identified, a high percentage of patients reported using Dank Vapes cartridges. Dank Vapes appears to be the most prominent in a class of largely counterfeit brands, with common packaging that is easily available online and that is used by distributors to market THC-containing cartridges with no obvious centralized production or distribution ( 7 ). Previous reports highlighted that patients with lung injury associated with e-cigarette use have used both THC- and nicotine-containing products ( 1 , 3 , 8 , 9 ). The additional information presented here regarding the range and diversity of brands used by patients, acquisition patterns, and frequency of use helps to formulate hypotheses about the possible etiology of this outbreak. In particular, the high level of use of prefilled THC cartridges, used in a range of different devices, suggests that the cartridges might play an important role. The findings in this report are subject to at least four limitations. First, interviews were not available for one third of patients; this nonresponse rate might introduce selection bias, although the demographics of the 86 interviewed patients were similar to those of all 127 patients. Second, because information was self-reported, there is the possibility that social desirability bias might affect reporting, particularly of illicit products; nonmedical THC use is currently illegal in both Illinois and Wisconsin. In this analysis, some patients did not disclose THC-containing product use to clinicians until late in their hospital admission or until a urinary THC screen was performed. Third, the time between urinary toxicology testing and last reported use of an e-cigarette product was not consistent and might explain the three negative results in patients who reported using THC-containing products. Finally, these data are largely drawn from patients living in the northeastern region of Illinois and southeastern region of Wisconsin, and therefore might not be generalizable to other states; however, the age and gender distribution of is consistent with nationwide trends ( 2 , 3 ). The findings document that many, but not all, patients with lung injury associated with use of an e-cigarette product reported using THC-containing products. Similar findings have been noted in the national data, which include some of the data presented here ( 2 ). These data also reveal a predominant use of prefilled THC cartridges sold through informal and unregulated markets, although the origin of these products further back in the production and distribution chain is unknown. In addition, these data do not elucidate whether the causative exposure is THC itself or a substance associated with prefilled THC cartridges, such as a cutting agent or adulterant. Ascertaining the importance of these products in contributing to the current outbreak will require data from multiple states and analysis at the national level. Given the number and diversity of products reported overall and by individual patients, as well as the high frequency of patients using both THC- and nicotine-containing products, the epidemiologic investigation could benefit from additional information, including product testing and traceback of e-cigarette products to identify the ultimate source of the outbreak. The Illinois Department of Public Health and the Wisconsin Department of Health Services are collaborating with CDC on a large nationwide public health response and with the Food and Drug Administration to coordinate laboratory testing of products associated with this outbreak. While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC. Summary What is already known about this topic? An outbreak of lung injury of unknown source associated with electronic cigarette (e-cigarette) use is ongoing in the United States. What is added by this report? Interviews about e-cigarette use were completed with 86 patients in Illinois and Wisconsin. Use of tetrahydrocannabinol (THC)-containing e-cigarette products, the majority of which were prefilled cartridges obtained from informal sources, was reported by 87% of patients during the 3 months preceding illness. What are the implications for public health practice? The cause of this outbreak is unknown but might be related to prefilled THC cartridges. While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC. Additional information from product testing and traceback could help to determine the source of the outbreak and prevent future illnesses.

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          Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Preliminary Report

          New England Journal of Medicine
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            Severe Pulmonary Disease Associated with Electronic-Cigarette–Product Use — Interim Guidance

            On September 6, 2019, this report was posted as an MMWR Early Release on the MMWR website (https://www.cdc.gov/mmwr). As of August 27, 2019, 215 possible cases of severe pulmonary disease associated with the use of electronic cigarette (e-cigarette) products (e.g., devices, liquids, refill pods, and cartridges) had been reported to CDC by 25 state health departments. E-cigarettes are devices that produce an aerosol by heating a liquid containing various chemicals, including nicotine, flavorings, and other additives (e.g., propellants, solvents, and oils). Users inhale the aerosol, including any additives, into their lungs. Aerosols produced by e-cigarettes can contain harmful or potentially harmful substances, including heavy metals such as lead, volatile organic compounds, ultrafine particles, cancer-causing chemicals, or other agents such as chemicals used for cleaning the device ( 1 ). E-cigarettes also can be used to deliver tetrahydrocannabinol (THC), the principal psychoactive component of cannabis, or other drugs; for example, “dabbing” involves superheating substances that contain high concentrations of THC and other plant compounds (e.g., cannabidiol) with the intent of inhaling the aerosol. E-cigarette users could potentially add other substances to the devices. This report summarizes available information and provides interim case definitions and guidance for reporting possible cases of severe pulmonary disease. The guidance in this report reflects data available as of September 6, 2019; guidance will be updated as additional information becomes available. Preliminary reports from state health department investigations, a published case series of patients in Illinois and Wisconsin ( 2 ), and three other published case series ( 3 – 5 ), describe clinical features of pulmonary illness associated with e-cigarette product use. According to these reports, the onset of respiratory findings, which might include a nonproductive cough, pleuritic chest pain, or shortness of breath, appears to occur over several days to several weeks before hospitalization. Systemic findings might include tachycardia, fever, chills, or fatigue; reported gastrointestinal findings, which have preceded respiratory findings in some cases, have included nausea, vomiting, abdominal pain, and diarrhea. Most identified patients have been hospitalized with hypoxemia, which, in some cases, has progressed to acute or subacute respiratory failure. Patients have required respiratory support therapies ranging from supplemental oxygen to endotracheal intubation and mechanical ventilation. Many patients initially received a diagnosis of infection and were treated empirically with antibiotics without improvement. In the largest cohort, 53 patients from Illinois and Wisconsin ( 2 ), the six-patient case series in Utah ( 4 ), and in the five North Carolina patients described in a report in this issue of MMWR ( 3 ), many of the patients who were treated with corticosteroids improved. All patients described in these reports to date have had abnormal radiographic findings, including infiltrates on chest radiograph and ground glass opacities on chest computed tomography scan. All patients have a reported history of e-cigarette product use, and no consistent evidence of an infectious etiology has been discovered. Therefore, the suspected cause is a chemical exposure. The type, extent, and severity of any chemical-related illness might depend on multiple factors including the chemical to which the user was exposed; chemical changes associated with heating, dose, frequency, and duration of exposure; product delivery methods; and behaviors and medical conditions of the user. The specific behaviors and exposures of identified patients have varied. Most have reported a history of using e-cigarette products containing cannabinoids such as THC, some have reported the use of e-cigarette products containing only nicotine, and others have reported using both. No consistent e-cigarette product, substance, or additive has been identified in all cases, nor has any one product or substance been conclusively linked to pulmonary disease in patients. Health care providers who cared for the five North Carolina patients diagnosed acute exogenous lipoid pneumonia in all patients based on history of e-cigarette use and clinical, radiographic, laboratory, and bronchoscopy findings. Specifically, the authors identified lipids within alveolar macrophages from the three bronchoalveolar lavage (BAL) specimens stained with oil red O. All five patients reported using marijuana oils or concentrates in e-cigarettes, and three also reported using nicotine ( 3 ). In a report describing the clinical course and outcomes of six patients from Utah, health care providers described the potential diagnostic utility of identification of lipid-laden macrophages from BAL specimens ( 4 ). Among the 53 cases from Illinois and Wisconsin, however, the pathologic findings were heterogeneous. Whereas almost half (24/53) of these patients underwent BAL, seven reports described the use of oil red O stain that identified lipid-laden macrophages ( 2 ). Additional pathologic analyses are in progress on specimens from some of these patients ( 2 ). The clinical significance of lipid-laden macrophages is currently unclear. It is not known whether the lipid is exogenous (from inhaled material) or endogenous (from altered lipid metabolism). In addition, it is not known whether lipid-laden macrophages are a marker of exposure to e-cigarette aerosol or they are central to the disease process. CDC is currently coordinating a multistate investigation. Investigations in affected states are focused on describing exposures and the epidemiologic, clinical, laboratory, and behavioral characteristics of cases. In conjunction with a task force from the Council for State and Territorial Epidemiologists and affected states, interim outbreak surveillance case definitions* (Table), data collection tools, and a database to collect relevant patient data have been developed and released. The interim outbreak case definitions will be updated as necessary as additional information becomes available. TABLE CDC surveillance case definitions* for severe pulmonary disease associated with e-cigarette use — August 30, 2019 Case classification Criteria Confirmed Using an e-cigarette (“vaping”) or dabbing† during the 90 days before symptom onset      AND Pulmonary infiltrate, such as opacities on plain film chest radiograph or ground-glass opacities on chest computed tomography      AND Absence of pulmonary infection on initial work-up: Minimum criteria include negative respiratory viral panel, influenza polymerase chain reaction or rapid test if local epidemiology supports testing. All other clinically indicated respiratory infectious disease testing (e.g., urine antigen for Streptococcus pneumoniae and Legionella, sputum culture if productive cough, bronchoalveolar lavage culture if done, blood culture, human immunodeficiency virus–related opportunistic respiratory infections if appropriate) must be negative      AND No evidence in medical record of alternative plausible diagnoses (e.g., cardiac, rheumatologic, or neoplastic process). Probable Using an e-cigarette (“vaping”) or dabbing† in 90 days before symptom onset      AND Pulmonary infiltrate, such as opacities on plain film chest radiograph or ground-glass opacities on chest computed tomography      AND Infection identified via culture or polymerase chain reaction, but clinical team§ believes this is not the sole cause of the underlying respiratory disease process OR minimum criteria to rule out pulmonary infection not met (testing not performed) and clinical team§ believes this is not the sole cause of the underlying respiratory disease process      AND No evidence in medical record of alternative plausible diagnoses (e.g., cardiac, rheumatologic, or neoplastic process). * These surveillance case definitions are meant for surveillance and not clinical diagnosis; they are subject to change and will be updated as additional information becomes available if needed. † Using an electronic device (e.g., electronic nicotine delivery system (ENDS), electronic cigarette (e-cigarette), vaporizer, vape(s), vape pen, dab pen, or other device) or dabbing to inhale substances (e.g., nicotine, marijuana, tetrahydrocannabinol, tetrahydrocannabinol concentrates, cannabinoids, synthetic cannabinoids, flavorings, or other substances). § Clinical team caring for the patient. CDC has provided technical assistance to states and has issued a Clinical Action alert through its Clinician Outreach and Communication Activity network on August 16, 2019 ( 6 ), and has initiated data collection from states. CDC staff members have deployed to Illinois and Wisconsin, the first states that identified patients, as part of an epidemiologic assistance investigation to assist with their state investigations and continue to work closely with affected states to characterize the exposures and the extent and progression of this illness. CDC is working closely with the Food and Drug Administration (FDA) to facilitate collection of information regarding recent e-cigarette product use among patients and to provide technical assistance related to product samples associated with patients for chemical analysis of remaining substances or chemicals within the e-cigarettes. FDA is focused on processing targeted product samples associated with clinical illness and will analyze samples if there is enough material to test. Those with questions regarding the collection of e-cigarette products for possible testing by FDA should use the following e-mail address: FDAVapingSampleInquiries@fda.hhs.gov. On August 30, 2019, CDC published recommendations for clinicians, public health officials, and the public based on preliminary information obtained from states and treating clinicians as a Health Advisory ( 7 ). CDC has created a website (https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html) ( 8 ) to disseminate up-to-date information and has created a dedicated e-mail address for clinicians and health officials to use to communicate about this public health emergency response (VapingAssocIllness@cdc.gov). Clinicians are encouraged to consider e-cigarette-associated pulmonary disease as one possible etiology in the broad differential diagnosis of patients with pulmonary disease and a history of e-cigarette product use. Clinicians should evaluate and treat for other possible cases of illness (e.g., infectious, rheumatologic, neoplastic, or other) as clinically indicated. They should report possible cases † to their local or state health department for further investigation. If e-cigarette product use is suspected as a possible etiology for a patient’s pulmonary disease, a detailed history of the substances used, the sources, and the devices used should be obtained, as outlined in the Health Advisory ( 7 ), and efforts should be made to determine if any remaining product, devices, or liquids are available for testing. Additional recommendations for clinicians, public health officials, and the public are available and will be updated as needed ( 6 – 8 ). Clinicians should contact their local or state health departments for further guidance as needed. State public health officials should promptly notify CDC about possible cases and refer to CDC for the most recent versions of the surveillance case definitions, reporting guidelines, and case investigation forms. Public health officials seeking these documents should e-mail CDC at eocevent101@cdc.gov. CDC will revise these tools as new information becomes available and disseminate them to state health departments. General questions regarding this outbreak can be answered by telephoning CDC-INFO (https://www.cdc.gov/cdc-info/index.html). While this investigation is ongoing and the definitive cause of reported illnesses remains uncertain, persons should consider not using e-cigarette products. Those who do use e-cigarette products should monitor themselves for symptoms (e.g., cough, shortness of breath, chest pain, nausea, vomiting, or other symptoms) and seek medical attention for any health concerns. Regardless of the ongoing investigation, persons who use e-cigarette products should not buy these products off the street and should not modify e-cigarette products or add any substances that are not intended by the manufacturer. E-cigarette products should never be used by youths, young adults, pregnant women, or by adults who do not currently use tobacco products. Adult smokers who are attempting to quit should use evidence-based smoking cessation treatments, including counseling and FDA-approved medications; those who need help quitting tobacco products, including e-cigarettes, should contact their medical provider. Persons who are concerned about harmful effects from e-cigarette products may call their local poison control center at: 1-800-222-1222. CDC will continue to advise and alert the public as more information becomes available. Summary What is already known about this topic? Twenty-five states have reported more than 200 possible cases of severe pulmonary disease associated with the use of electronic cigarettes (e-cigarettes). What is added by this report? Based on available information, the disease is likely caused by an unknown chemical exposure; no single product or substance is conclusively linked to the disease. What are the implications for public health practice? Until a definitive cause is known, persons should consider not using e-cigarettes. Those who use e-cigarettes should seek medical attention for any health concerns. Clinicians should report possible cases to their local or state health department.
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              Characteristics of a Multistate Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping — United States, 2019

              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. The figure is a U.S. map showing the number of cases of lung injury associated with e-cigarette use, or vaping in each of the 50 states and two territories in 2019. 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 The figure is an epidemiologic curve showing the dates of symptom onset and hospital admission among patients with lung injury associated with e-cigarette use, or vaping in the United States, during 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. TABLE Number of patients with lung injury associated with e-cigarette use, or vaping (n = 771), by demographic and substance use characteristics — United States, 2019 Characteristic No. (%) Demographic (n = 771)* Sex Male 531 (68.9) Female 234 (30.4) Missing 6 (0.8) Age group (yrs) <18 125 (16.2) 18–24 293 (38.0) 25–34 184 (23.9) 35–44 93 (12.1) ≥45 42 (5.5) Missing 34 (4.4) Substances used in e-cigarette, or vaping, products (n = 514)† THC-containing products Yes 395 (76.9) No 96 (18.7) Unknown/Missing 23 (4.5) Nicotine-containing products Yes 292 (56.8) No 173(33.7) Unknown/Missing 49 (9.5) Cannabidiol (CBD) Yes 89 (17.3) No 265 (51.6) Unknown/Missing 160 (31.1) Synthetic cannabinoids Yes 4 (0.8) No 289 (56.2) Unknown/Missing 221 (43.0) Flavored e-liquids § Yes 102 (19.8) No 132 (25.7) Unknown/Missing 280 (54.5) Abbreviation: THC = tetrahydrocannabinol. * Patients for whom basic demographic information was submitted to CDC. † Patients for whom information was available on use of either nicotine-containing or THC-containing substances. § Flavored products that contain water, food-grade flavoring, propylene glycol, vegetable glycerin, nicotine, THC, or CBD. Discussion E-cigarettes were introduced to the U.S. market in 2007 ( 1 ). In 2018, 20.8% of high school students reported current e-cigarette use ( 5 ). E-cigarette use is markedly lower among U.S. adults than among youths; in 2018, only 3.2% of adults currently used e-cigarettes, with higher prevalences among persons aged 18–24 years (7.6%) and 25–34 years (5.4%) than among older age groups ( 6 ). Approximately three fourths of patients in this investigation were aged <35 years. In the general U.S. adult population, current e-cigarette use is slightly higher among males than females for both adults and youths ( 6 ); in the present investigation, approximately seven in 10 cases occurred in males. In this investigation, 62% of patients were aged 18–34 years; this is consistent with the age group with highest reported prevalence of marijuana use in the preceding 30 days in the United States ( 7 ). THC-containing and nicotine-containing products were the most commonly reported substances used in e-cigarettes, or vaping products, by patients. Specific data on use of THC in e-cigarettes, or vaping products, in the general population is limited; among U.S. middle and high school students in 2016 who had ever used an e-cigarette, 30.6% reported using THC in an e-cigarette (33.3% among males and 27.2% among females) ( 8 ). Among adults who reported using marijuana in 2014, 9.9% reported consuming it via a vaporizer or other electronic device (11.5% among men and 7.8% among women) ( 9 ). In a recent study of college students, approximately 75% of those who had used substances other than nicotine in e-cigarettes reported using marijuana or THC-containing products in an e-cigarette ( 10 ). Because information about substance use in this investigation was self-reported, the information is not available for some cases because of the time required for completing and reporting patient interviews, inability to conduct interviews (e.g., patient refusal, loss to follow-up, persons who were too ill or died before they could be interviewed) and missing data for certain variables (e.g., patient refusal to answer certain questions). In addition, patients might not always know what substances they use or might be hesitant to reveal use of substances that are not legal in their state. Continued monitoring of patient case counts and characteristics, as well as substances used with e-cigarette, or vaping, products, is critical to informing the ongoing investigation and helping to identify the cause. CDC and state health departments continue to collect and analyze epidemiologic data to better understand what types of devices and products patients are using (e.g., cartridges and e-liquids), the source of products or location where they were obtained, and the patterns (e.g., duration and frequency) of specific product use. Given the vast number of chemicals used in e-cigarette, or vaping, products, it is important to link epidemiologic data with findings from laboratory analyses of products and clinical specimens from patients. Federal, state, and private laboratories are working to collect and analyze products obtained from patients with lung injury associated with e-cigarette use, or vaping. In addition, CDC, clinical, and public health laboratories are collecting clinical specimens for future targeted analyses of substances identified in product samples. The specific chemical exposure(s) causing this outbreak is unknown at this time. National data to date show that most lung injury patients with data on substance use report using THC-containing products with or without nicotine-containing products, although some patients report using only nicotine-containing products. While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC. Persons who continue to use e-cigarettes or vaping products should carefully monitor themselves and seek medical attention immediately if they have symptoms consistent with those described in this outbreak. § Regardless of the investigation, e-cigarettes, or vaping products, should never be used by youths, young adults, pregnant women, or by adults who do not currently use tobacco products ( 2 ). Adults who use e-cigarettes because they have quit smoking should not return to smoking combustible cigarettes. In addition, persons who use e-cigarettes or vaping products should not get them from informal sources or off the street and should not modify e-cigarette, or vaping, devices or add any substances that are not intended by the manufacturer. Both THC-containing and nicotine-containing e-cigarette, or vaping, products purchased legally within states might also contain harmful substances ( 1 ); it is difficult for consumers to know what is in these products, and full ingredient lists are typically not available. THC use has been associated with a wide range of health effects, particularly with prolonged heavy use. ¶ The best way to avoid potentially harmful effects is to not use THC, including through e-cigarette, or vaping, devices. Persons with marijuana use disorder should seek evidence-based treatment by a health care provider. This investigation is ongoing. 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. Summary What is already known about this topic? Lung injury associated with e-cigarette use, or vaping, has recently been reported in most states. CDC, the Food and Drug Administration, and others are investigating this outbreak. What is added by this report? Among 805 cases reported as of September 24, 2019, 69% were in males; 62% of patients were aged 18–34 years. Among patients with data on substances used in e-cigarettes, or vaping products, tetrahydrocannabinol (THC)-containing product use was reported by 76.9% (36.0% reported exclusive THC-product use); 56.8% reported nicotine-containing product use (16.0% reported exclusive nicotine-product use). What are the implications for public health practice? The cause of the outbreak is unknown. While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC.
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                Journal
                MMWR Morb Mortal Wkly Rep
                MMWR Morb. Mortal. Wkly. Rep
                WR
                Morbidity and Mortality Weekly Report
                Centers for Disease Control and Prevention
                0149-2195
                1545-861X
                04 October 2019
                04 October 2019
                : 68
                : 39
                : 865-869
                Affiliations
                Illinois Department of Public Health; Epidemic Intelligence Service, CDC; Wisconsin Department of Health Services; Division of State and Local Readiness, Center for Preparedness and Response, CDC; Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC; National Center for Environmental Health, CDC; Emory University School of Medicine, Atlanta, Georgia.
                Author notes
                Corresponding author: Isaac Ghinai, Isaac.Ghinai@ 123456Illinois.gov , 217-782-2016.
                Article
                mm6839e2
                10.15585/mmwr.mm6839e2
                6776374
                31581166
                aefc85f8-7367-4da5-864b-4fecfa87d7bd

                All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

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