On October 11, 2019, this report was posted online as an MMWR Early Release.
CDC, the Food and Drug Administration (FDA), state and local health departments, and
public health and clinical partners are investigating a multistate outbreak of lung
injury associated with the use of electronic cigarette (e-cigarette), or vaping, products.
In late August, CDC released recommendations for health care providers regarding e-cigarette,
or vaping, product use associated lung injury (EVALI) based on limited data from the
first reported cases (
1
,
2
). This report summarizes national surveillance data describing clinical features
of more recently reported cases and interim recommendations based on these data for
U.S. health care providers caring for patients with suspected or known EVALI. It provides
interim guidance for 1) initial clinical evaluation; 2) suggested criteria for hospital
admission and treatment; 3) patient follow-up; 4) special considerations for groups
at high risk; and 5) clinical and public health recommendations. Health care providers
evaluating patients suspected to have EVALI should ask about the use of e-cigarette,
or vaping, products in a nonjudgmental and thorough manner. Patients suspected to
have EVALI should have a chest radiograph (CXR), and hospital admission is recommended
for patients who have decreased blood oxygen (O2) saturation (<95%) on room air or
who are in respiratory distress. Health care providers should consider empiric use
of a combination of antibiotics, antivirals, or steroids based upon clinical context.
Evidence-based tobacco product cessation strategies, including behavioral counseling,
are recommended to help patients discontinue use of e-cigarette, or vaping, products.
To reduce the risk of recurrence, patients who have been treated for EVALI should
not use e-cigarette, or vaping, products. CDC recommends that persons should not use
e-cigarette, or vaping, products that contain tetrahydrocannabinol (THC). At present,
CDC recommends persons consider refraining from using e-cigarette, or vaping, products
that contain nicotine. Irrespective of the ongoing investigation, e-cigarette, or
vaping, products should never be used by youths, young adults, or women who are pregnant.
Persons who do not currently use tobacco products should not start using e-cigarette,
or vaping, products.
As of October 8, 2019, 49 states, the District of Columbia, and one territorial health
department have reported 1,299 cases of EVALI to CDC, with 26 deaths reported from
21 states (median age of death = 49 years, range = 17–75 years). Among 1,043 patients
with available data on age and sex, 70% were male, and the median age was 24 years
(range = 13–75 years); 80% were aged <35 years, and 15% were aged <18 years. Among
573 patients who reported information on substances used in e-cigarette, or vaping,
products in the 90 days preceding symptom onset, 76% reported using THC-containing
products, and 58% reported using nicotine-containing products; 32% reported exclusive
use of THC-containing products, and 13% reported exclusive use of nicotine-containing
products.* No single compound or ingredient has emerged as the cause of these injuries
to date, and there might be more than one cause. Available data suggest THC-containing
products play a role in this outbreak, but the specific chemical or chemicals responsible
for EVALI have not yet been identified, and nicotine-containing products have not
been excluded as a possible cause.
Ongoing federal and state investigations have provided information about the clinical
characteristics of cases and a surveillance case definition for confirmed and probable
cases has been developed (
1
); this case definition
†
is not intended to guide clinical care. To inform CDC’s updated interim clinical guidance,
on October 2, 2019, CDC obtained individual expert perspectives on the evaluation
and treatment of patients with suspected EVALI. Discussions occurred with nine national
experts in adult and pediatric pulmonary medicine and critical care who were designated
by professional medical societies to participate (Lung Injury Response Clinical Working
Group). Evidence supporting CDC’s recommendations include data from medical abstractions
reported to CDC, previously published case series (
3
–
5
), and the aforementioned individual expert opinions.
Clinical Evaluation for Patients with Suspected EVALI
EVALI is considered a diagnosis of exclusion because, at present, no specific test
or marker exists for its diagnosis (Box 1). Health care providers should consider
multiple etiologies, including the possibility of EVALI and concomitant infection.
In addition, health care providers should evaluate alternative diagnoses as suggested
by clinical findings and medical history (e.g., cardiac, gastrointestinal, rheumatologic,
and neoplastic processes; environmental or occupational exposures; or causes of acute
respiratory distress syndrome) (
6
).
BOX 1
Clinical evaluation for patients with recent history of use of e-cigarette, or vaping,
products and suspected lung injury
History
Ask about respiratory, gastrointestinal, and constitutional symptoms (e.g., cough,
chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, and fever)
for patients who report a history of use of e-cigarette, or vaping, products.
Ask all patients about recent use of e-cigarette, or vaping, products.
Types of substances used (e.g., tetrahydrocannabinol [THC], cannabis [oil, dabs],
nicotine, modified products or the addition of substances not intended by the manufacturer);
product source, specific product brand and name; duration and frequency of use, time
of last use; product delivery system, and method of use (aerosolization, dabbing,
or dripping).
Physical exam
Assess vital signs and oxygen saturation via pulse-oximetry.
Laboratory testing
Infectious disease evaluation might include
Respiratory viral panel including influenza testing during flu season, Streptococcus
pneumoniae, Legionella pneumophila, Mycoplasma pneumoniae, endemic mycoses, and opportunistic
infections.
Initial laboratory evaluation
Consider complete blood count with differential, liver transaminases, and inflammatory
markers (e.g., erythrocyte sedimentation rate and C-reactive protein).
In all patients, consider conducting urine toxicology testing, with informed consent,
including testing for THC.
Imaging
Chest radiograph.
Consider chest computed tomography for evaluation of severe or worsening disease,
complications, other illnesses, or when chest x-ray result does not correlate with
clinical findings.
Other considerations
Further evaluation of patients meeting inpatient admission criteria might include
Consultation with pulmonary, critical care, medical toxicology, infectious disease,
psychology, psychiatry, and addiction medicine specialists.
Additional testing with bronchoalveolar lavage or lung biopsy as clinically indicated,
in consultation with pulmonary specialists.
Patient history. Based upon medical chart abstraction data submitted to CDC, 95% (323/339)
of patients diagnosed with EVALI initially experienced respiratory symptoms (e.g.,
cough, chest pain, and shortness of breath), and 77% (262/339) had gastrointestinal
symptoms (e.g., abdominal pain, nausea, vomiting, and diarrhea). Gastrointestinal
symptoms preceded respiratory symptoms in some patients (
1
–
3
). Respiratory or gastrointestinal symptoms were accompanied by constitutional symptoms
such as fever, chills, and weight loss among 85% (289/339) of patients (Table).
TABLE
Characteristics of patients (N = 342) with e-cigarette use, or vaping, product use
associated lung injury (EVALI),* from national EVALI surveillance reports to CDC —
United States, 2019
†
Characteristic
EVALI patients
No. (%)
Total no. used in calculation§
Age, median (range) (yrs)
22 (13–71)
338
Symptoms reported
Any respiratory
323 (95)
339
Any gastrointestinal
262 (77)
339
Any constitutional¶
289 (85)
339
Vital signs
Oxygen saturation <95% while breathing room air
143 (57)
253
Tachycardia (heart rate >100 beats/min)
169 (55)
310
Tachypnea (respiratory rate >20 breaths/min)
77 (45)
172
Clinical course
Admission to intensive care unit
159 (47)
342
Age group (yrs)
13–17
45 (56)
80
18–24
49 (38)
130
25–50
54 (47)
115
≥51
9 (69)
13
Past cardiac disease**
8 (50)
16
No past cardiac disease
151 (46)
326
Intubation and mechanical ventilation
74 (22)
338
Age group (yrs)
13–17
23 (29)
80
18–24
21 (16)
130
25–50
23 (20)
115
≥51
7 (54)
13
Past cardiac disease**
5 (31)
16
No past cardiac disease
70 (21)
326
Corticosteroids
252 (88)
287
Improved after corticosteroids
114 (82)
140
Duration of hospitalization (days)
Mean (median)
Range
Age group (yrs)
13–17
6.9 (6)
0–23
18–24
6.2 (5)
0–38
25–50
6.6 (6)
0–40
≥51
14.8 (12)
3–31
Past cardiac disease
8.9 (4)
3–31
No past cardiac disease
6.6 (5)
0–40
Average hospital stay
6.7 (5)
0–40
Abbreviation: E-cigarette = electronic cigarette.
* For cases that had full medical chart abstraction data available.
† Surveillance data through October 3, 2019, from the following 29 U.S states: Alabama,
Delaware, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine,
Maryland, Minnesota, Mississippi, Missouri, Montana, Nevada, New Jersey, New Mexico,
Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Texas, Vermont, Washington,
West Virginia, and Wisconsin.
§ Patients with missing data were excluded from denominators for selected characteristics.
¶ Self-reported fever, chills, and unexpected weight loss.
** Heart failure, heart attack, or other heart conditions.
All health care providers evaluating patients for EVALI should ask about the use of
e-cigarette, or vaping, products and ideally should ask about types of substances
used (e.g., THC, cannabis [oil, dabs], nicotine, modified products or the addition
of substances not intended by the manufacturer); product source, specific product
brand and name; duration and frequency of use, time of last use; product delivery
system, and method of use (aerosolization, dabbing, or dripping). Empathetic, nonjudgmental,
and private questioning of patients regarding sensitive information to assure confidentiality
should be employed. Standardized approaches should be used for interviewing adolescents.
Resources exist to guide patient interviews, including those of adolescents.
§
In some situations, asking questions over the course of the hospitalization or during
follow-up visits might elicit additional information about exposures, especially as
trust is established between the patient and clinicians.
Physical examination. For patients who report the use of e-cigarette, or vaping, products,
physical examination should include vital signs and pulse-oximetry. Tachycardia was
reported in 55% (169/310) of patients and tachypnea in 45% (77/172); O2 saturation
<95% at rest on room air was present for 57% (143/253) of patients reported to CDC
(Table), underscoring the need for routine pulse-oximetry. Among patients identified
to date, pulmonary findings on auscultation exam have often been unremarkable, even
among patients with severe lung injury (personal communication, Lung Injury Response
Clinical Working Group, October 2, 2019).
Laboratory testing. Laboratory testing should be guided by clinical findings. A respiratory
virus panel, including influenza testing during influenza season, should be strongly
considered. Additional testing should be based on published guidelines for evaluation
of community-acquired pneumonia.
¶
Infectious diseases to consider include Streptococcus pneumoniae, Legionella pneumophila,
Mycoplasma pneumoniae, endemic mycoses, and opportunistic infections; the likelihood
of infection by any of these varies by geographic prevalence and patient medical history.
Other abnormal laboratory tests reported in patients with EVALI include elevated white
blood cell (WBC) count, serum inflammatory markers (C-reactive protein, erythrocyte
sedimentation rate [ESR]), and liver transaminases. In a report of initial patients
from Illinois and Wisconsin, 87% had a WBC >11,000/mm3 and 93% had an ESR >30mm/hr;
50% of patients had elevated liver transaminases (aspartate aminotransferase or alanine
aminotransferase >35 U/L) (
3
). However, at this time, these tests cannot be used to distinguish EVALI from infectious
etiologies. In all patients, providers should consider conducting, with informed consent,
urine toxicology testing, including testing for THC.
Imaging. Radiographic findings consistent with EVALI include pulmonary infiltrates
on CXR and opacities on chest computed tomography (CT) scan (
1
,
7
). A CXR should be obtained on all patients with a history of e-cigarette, or vaping,
product use who have respiratory or gastrointestinal symptoms, particularly when accompanied
by decreased O2 saturation (<95%). Chest CT might be useful when the CXR result does
not correlate with clinical findings or to evaluate severe or worsening disease, complications
such as pneumothorax or pneumomediastinum, or other illnesses in the differential
diagnosis, such as pneumonia or pulmonary embolism. In some cases, chest CT has demonstrated
findings such as bilateral ground glass opacities despite a normal or nondiagnostic
CXR (
3
). Among patients with abnormal CXR findings and a clinical picture consistent with
EVALI, a chest CT scan might not be necessary for diagnosis. The decision to obtain
a chest CT should be made on a case-by-case basis depending on the clinical circumstances.
Consultation with specialists. Consultation with several specialists might be necessary
to optimize patient management. For patients being evaluated for possible EVALI, consideration
should be given to consultation with a pulmonologist, who can help guide further evaluation,
recommend empiric treatment, and review the indications for bronchoscopy. The decision
to perform bronchoscopy and bronchoalveolar lavage (BAL) to rule out alternative diagnoses
such as pulmonary infection should be made on a case-by-case basis. The value of staining
BAL cells or fresh lung biopsy tissue for lipid-laden macrophages (e.g., using oil
red O or Sudan Black) in the evaluation of EVALI remains unknown. In addition, there
should be a low threshold for consulting with critical care physicians, because, based
upon data submitted to CDC, 47% (159/342) of patients were admitted to an intensive
care unit and 22% (74/338) required endotracheal intubation and mechanical ventilation
(Table); critical care physicians should be consulted to determine optimal management
of respiratory failure. Consultation with medical toxicology, infectious disease,
psychology, psychiatry, addiction medicine, and other specialists should be considered
as warranted by patient circumstances.
Management of Patients with Suspected EVALI
Admission criteria and outpatient management. Several factors should be considered
when deciding whether to admit a patient with potential EVALI to the hospital (Box
2). Among 1,002 cases reported to CDC with available data as of October 8, 96% of
patients were hospitalized. Patients with suspected EVALI should be admitted if they
have decreased O2 saturation (<95%) on room air, are in respiratory distress, or have
comorbidities that compromise pulmonary reserve. Consider modifying factors such as
altitude to guide interpretation of measured O2 saturation.
BOX 2
Management of patients with suspected e-cigarette, or vaping, product use associated
lung injury (EVALI)
Admission criteria and outpatient management
Strongly consider admitting patients with potential lung injury, especially if respiratory
distress present, have comorbidities that compromise pulmonary reserve, or decreased
(<95%) O2 saturation (consider modifying factors such as altitude to guide interpretation).
Outpatient management for patients with suspected lung injury who have less severe
injury might be considered on a case-by-case basis.
Medical treatment
Consider initiation of corticosteroids.
Early initiation of antimicrobial coverage for community-acquired pneumonia should
be strongly considered in accordance with established guidelines.*
Consider influenza antivirals in accordance with established guidelines.
†
Patients not admitted to hospital
Recommend follow-up within 24–48 hours to assess and manage possible worsening lung
injury.
Outpatients should have normal oxygen saturation, reliable access to care and social
support systems, and be instructed to promptly seek medical care if respiratory symptoms
worsen.
Consider empiric use of antimicrobials and antivirals.
Post-hospital discharge follow-up
Schedule follow-up visit no later than 1–2 weeks after discharge that includes pulse-oximetry
testing.
Consider additional follow-up testing including spirometry and diffusion capacity
testing, and consider repeat chest radiograph in 1–2 months.
Consider endocrinology consultation for patients treated with high-dose corticosteroids.
Cessation services and preventive care
Strongly advise patients to discontinue use of e-cigarette, or vaping, products.
Provide education and cessation assistance for patients to aid nicotine addiction
and treatment or referral for patients with marijuana-use-disorder.
§
Emphasize importance of routine influenza vaccination.
¶
Consider pneumococcal vaccine.**
* https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST#readcube-epdf; https://academic.oup.com/cid/article/53/7/e25/424286/.
†
https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm; https://www.idsociety.org/practice-guideline/influenza/.
§ Substance Abuse and Mental Health Services Administrations treatment locator (https://www.samhsa.gov/find-treatment)to
find treatment in your area or call 1–800–662-HELP (4357).
¶
https://www.cdc.gov/flu/prevent/vaccinations.htm.
**
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6337a4.htm?s_cid.
Outpatient management of suspected EVALI might be considered on a case-by-case basis
for patients who are clinically stable, have less severe injury, and for whom follow-up
within 24–48 hours of initial evaluation can be assured. Candidates for outpatient
management should have normal O2 saturation (≥95%), reliable access to care, and strong
social support systems. For these patients, empiric use of antimicrobials, including
antivirals, if indicated, should be considered. Some patients who initially had mild
symptoms experienced a rapid worsening of symptoms within 48 hours. In Illinois and
Wisconsin, 72% of patients had either an outpatient or emergency department visit
before seeking additional medical care that resulted in hospital admission (
3
). Health care providers should instruct all patients to seek medical care promptly
if respiratory symptoms worsen.
Medical treatment. Corticosteroids might be helpful in treating this injury. Several
case reports describe improvement with corticosteroids, likely because of a blunting
of the inflammatory response (
3
–
5
). In a series of patients in Illinois and Wisconsin, 92% of 50 patients received
corticosteroids; the medical team documented in 65% of 46 patient notes that “respiratory
improvement was due to the use of glucocorticoids” (
3
). Among 140 cases reported nationally to CDC that received corticosteroids, 82% of
patients improved (Table). However, the natural progression of this injury is not
known, and it is possible that patients might recover without corticosteroids or by
avoiding use of e-cigarette, or vaping, products. In some circumstances, it would
be advisable to withhold corticosteroids while evaluating patients for infectious
etiologies, such as fungal pneumonia, that might worsen with corticosteroid treatment.
Nevertheless, because the diagnosis remains one of exclusion, aggressive empiric therapy
with corticosteroids, antimicrobial, and antiviral therapy might be warranted for
patients with severe illness. A range of corticosteroid doses, durations, and taper
plans might be considered on a case-by-case basis. Whenever possible, decisions on
the use of corticosteroids and dosing regimen should be made in consultation with
a pulmonologist.
Early initiation of antimicrobial treatment for community-acquired pneumonia in accordance
with established guidelines** should be strongly considered given the overlapping
of signs and symptoms in these conditions. During influenza season, health care providers
should consider influenza in all patients with suspected EVALI. Antivirals should
be considered in accordance with established guidelines.
††
Decisions on initiation or discontinuation of treatment should be based on specific
clinical features and, when appropriate, in consultation with specialists.
Follow-up from hospital admission. Patients discharged from the hospital after inpatient
treatment for EVALI should have a follow-up visit no later than 1–2 weeks after discharge
that includes pulse-oximetry, and clinicians should consider repeating the CXR. Additional
follow-up testing 1–2 months after discharge that might include spirometry, diffusion
capacity testing, and CXR should be considered. Long-term effects and the risk of
recurrence of EVALI are not known. Whereas many patients’ symptoms resolved, clinicians
report that some patients have relapsed during corticosteroid tapers after hospitalization,
underscoring the need for close follow-up (personal communication, Lung Injury Response
Clinical Working Group, October 2, 2019). Some patients have had persistent hypoxemia
(O2 saturation <95%), requiring home oxygen at discharge and might need ongoing pulmonary
follow-up. Patients treated with high-dose corticosteroids might require care from
an endocrinologist to monitor adrenal function.
It is unknown if patients with a history of EVALI are at higher risk for severe complications
of influenza or other respiratory viral infections if they are infected simultaneously
or after recovering from lung injury. Health care providers should emphasize the importance
of annual vaccination against influenza for all persons >6 months of age, including
patients with a history of EVALI. In addition, administration of pneumococcal vaccine
should be considered according to current guidelines.
§§
Addressing exposures. Advising patients to discontinue use of e-cigarette, or vaping,
products should be an integral part of the care approach during an inpatient admission
and should be re-emphasized during outpatient follow-up. Cessation of e-cigarette,
or vaping, products might speed recovery from this injury; resuming use of e-cigarette,
or vaping, products has the potential to cause recurrence of symptoms or lung injury.
Evidence-based tobacco product cessation strategies include behavioral counseling
and FDA-approved cessation medications.
¶¶
For patients who have addiction to THC-containing or nicotine-containing products,
cognitive-behavioral therapy, contingency management, motivational enhancement therapy,
and multidimensional family therapy have been shown to help, and consultation with
addiction medicine services should be considered (
8
–
10
).
Special considerations for groups at high risk. Patients with certain characteristics
or comorbidities, including older age, history of cardiac or lung disease, or pregnancy,
might be at higher risk for more severe outcomes. Among reported cases (Table), patients
aged >50 years experienced the highest percentage of endotracheal intubation and mechanical
ventilation (54%) and the longest mean inpatient stays (15 days). The mean first recorded
O2 saturations among those who did and did not require intubation were 87% and 92%,
respectively (data not shown). Among those with and without past cardiac disease,
31% and 21%, respectively, required intubation (Table). Special consideration might
need to be given to patients aged >50 years, because these patients might require
longer duration of hospitalization and have a higher risk of intubation (Figure).
Rapid identification of exposure, a high index of suspicion of EVALI, initiation of
corticosteroids, and specialist consultations might be lifesaving in this patient
population.
FIGURE
Percentage of persons needing intubation (N = 338) and hospitalization (N = 242) among
patients with e-cigarette, or vaping, product use associated lung injury (EVALI),
by age of patient — United States, February 1–October 3, 2019*,†<Fig_Large></Fig_Large>
Abbreviation: E-cigarette = electronic cigarette.
* Data reported through October 3, 2019, from the following 29 states: Alabama, Delaware,
Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland,
Minnesota, Mississippi, Missouri, Montana, Nevada, New Jersey, New Mexico, Oklahoma,
Oregon, Rhode Island, South Carolina, South Dakota, Texas, Vermont, Washington, West
Virginia, and Wisconsin.
† 95% confidence intervals indicated by error bars.
The figure consists of two bar charts showing the percentage of U.S. persons needing
intubation (N = 338) and hospitalization (N = 242) among patients with lung injury
associated with e-cigarette, or vaping, product use, by age of patient, based on reports
from 29 states during February 1–October 3, 2019.
Additional data might identify other groups at high risk, provide important information
about disparities in outcomes, and help guide clinical care. Certain patients, such
as adolescents and young adults, might benefit from specialized services, such as
addiction treatment services and providers who have experience with counseling and
behavioral health follow-up.
Clinical Care and Public Health Recommendations
Reporting cases to state, local, territorial, or tribal health departments is critical
for accurate surveillance of EVALI. Reporting cases and obtaining and sending products,
devices, and clinical and pathologic specimens for testing, can help health departments
and CDC determine the cause or causes of these lung injuries.*** CDC is developing
International Classification of Diseases, Tenth Edition, Clinical Modification coding
guidance for health care encounters related to EVALI. Updates, when available, can
be found at https://www.cdc.gov/lunginjury (Box 3).
BOX 3
Clinical Care and Public Health Reporting of e-cigarette, or vaping, product use associated
lung injury (EVALI)
Considerations at points of care
Examples include emergency departments, urgent care, doctors’ offices, etc.
Consider posting reminders or signage to encourage conversation between patients and
providers about use of e-cigarette, or vaping, products.*
Report cases of lung injury associated with use of e-cigarette, or vaping, products
within the past 90 days to state or local health department.
Determine whether any remaining product, including devices and liquids, is available
for testing. Testing can be coordinated with health departments.
CDC is developing International Classification of Diseases, Tenth Edition, Clinical
Modification (ICD-10-CM) coding guidance for healthcare encounters related to EVALI.
Updates, when available, will be at https://www.cdc.gov/lunginjury.
Clinical specimen testing by CDC
†
Consider submission of any collected specimens, including bronchoalveolar lavage,
blood, or urine, to CDC for evaluation.
Testing of pathologic specimens by CDC
§
If a lung biopsy or autopsy is performed on a patient suspected of lung injury related
to e-cigarette, or vaping, product use, consider submission of fixed lung biopsy tissues
or autopsy tissues to CDC for evaluation.
Testing can include evaluation for lipids on formalin-fixed (wet) lung tissues that
have not undergone routine processing.
Routine microscopic examination will be performed, as well as infectious disease testing,
if indicated, on formalin-fixed (wet) tissues, or formalin-fixed, paraffin-embedded
tissue specimens.
* https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/healthcare-providers/index.html.
†
https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/health-departments/index.html.
§
https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/health-departments/index.html.
Public health recommendations. At this time, FDA and CDC have not identified the cause
or causes of the lung injuries among EVALI cases, and the only commonality among all
cases is that patients report the use of e-cigarette, or vaping, products. This outbreak
might have more than one cause, and many different substances and product sources
are still under investigation. To date, national and state data suggest that products
containing THC, particularly those obtained off the street or from other informal
sources (e.g., friends, family members, or illicit dealers), are linked to most of
the cases and play a major role in the outbreak (
11
,
12
). Therefore, CDC recommends that persons should not use e-cigarette, or vaping, products
that contain THC. Persons should not buy any type of e-cigarette, or vaping, products,
particularly those containing THC, off the street. Persons should not modify or add
any substances to e-cigarette, or vaping, products that are not intended by the manufacturer,
including products purchased through retail establishments.
Given that the exclusive use of nicotine-containing products has been reported by
a small percentage of persons with EVALI, and that many persons with EVALI report
combined use of THC- and nicotine-containing products, the possibility that nicotine-containing
products play a role in this outbreak cannot be excluded. Therefore, at present, CDC
continues to recommend that persons consider refraining from using e-cigarette, or
vaping, products that contain nicotine. If adults are using e-cigarette, or vaping,
products to quit cigarette smoking, they should not return to smoking cigarettes;
they should use evidence-based treatments, including health care provider counseling
and FDA-approved medications.
†††
If persons continue to use these products, they should carefully monitor themselves
for symptoms and see a health care provider immediately if symptoms develop. Irrespective
of the ongoing investigation, e-cigarette, or vaping, products should never be used
by youths, young adults, or women who are pregnant. There is no safe tobacco product,
and the use of any tobacco products, including e-cigarettes, carries a risk. Therefore,
persons who do not currently use tobacco products should not start using e-cigarette,
or vaping, products.
This investigation is ongoing. CDC will continue to work in collaboration with FDA
and state and local partners to investigate cases and to update guidance, as appropriate,
as new data emerges from this complex outbreak.
Summary
What is already known about this topic?
Forty-nine states, the District of Columbia, and one U.S. territory have reported
1,299 cases of lung injury associated with the use of electronic cigarette (e-cigarette),
or vaping, products. Twenty-six deaths have been reported from 21 states.
What is added by this report?
Based on the most current data, CDC’s updated interim guidance provides a framework
for health care providers in their initial assessment, evaluation, management, and
follow-up of persons with symptoms of e-cigarette, or vaping, product use associated
lung injury (EVALI).
What are the implications for public health practice?
Rapid recognition by health care providers of patients with EVALI and an increased
understanding of treatment considerations could reduce morbidity and mortality associated
with this injury.