Epidemiology Program

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E-cigarette, or Vaping, Product Use Associated Lung Injury

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Multiple reports of sudden, and severe lung illness associated with vaping began to be noticed by physicians across the United States in June of 2019.  E-cigarette, or Vaping, Product Use Associated Lung Injuries (EVALI) have now been reported by physicians in multiple states, including California, as well as here in San Diego County. EVALI is also known as Vaping-Associated Pulmonary Injury (VAPI). The specific cause of EVALI has not yet been identified, but is being investigated by local, state, and federal health officials.

As of November 27, 2019, there have been 35 confirmed and probable EVALI cases reported among San Diego County residents. All cases were hospitalized and there have been no deaths. Ages of patients have ranged from 17 to 70 years, with a median age of 31 years, and 57% have been male.

Most cases of EVALI, in California, reported vaping cannabis or cannabidiol (CBD) oils, though no specific common vaping products have been identified.  One pattern observed during investigations, to date, is the purchase of vape cartridges from “pop-up shops.” These temporary, unlicensed shops open for an undetermined amount of time, advertise by word of mouth, and move locations frequently. San Diego County cases have reported vaping cannabis products and/or CBD oils obtained from these and other unlicensed retailers and via the internet.  No infectious cause has been determined for these EVALI cases.

All cases in California have been hospitalized, with most requiring respiratory support. 

 

What is E-cigarette, or Vaping, Product Associated Lung Injury (EVALI)?

Lung injuries in people who have a history of using e-cigarette products or vaping.  Most people with EVALI have reported using vaping products that contain tetrahydrocannabinol, or what is more commonly known as THC.

 

How is E-cigarette, or Vaping, Product Associated Lung Injury acquired or transmitted?

These lung injuries are associated with vaping or the use of e-cigarettes.  The specific cause has not been identified; no specific e-cigarette or vaping product (devices, liquids, refill pods, and/or cartridges) or substance have been linked to the EVALI cases.

 

What are the Symptoms of EVALI?

People experiencing EVALI typically report a cough, difficulty breathing, fever, and sometimes vomiting and diarrhea. In many cases, the person is originally thought to have an infection, but no evidence of infection or other explanation for the pulmonary disease has been found.  However, the CDC has identified vitamin E acetate as a chemical of concern among people with EVALI.  Vitamin E is sometimes used as an additive, most notably as a thickening agent in THC containing vaping products.

If you have recently used a vaping or e-cigarette product and are experiencing any of the following symptoms, please get medical care for additional evaluation and treatment:

  • Cough, shortness of breath, and chest pain
  • Nausea or vomiting
  • Diarrhea
  • Fatigue
  • Fever
  • Weight loss

 

How can you protect yourself?

  • Anyone who does not currently use tobacco or vaping products should not start using e-cigarette or vaping products.
  • If you are concerned about the health risks associated with vaping, it is best to stop using e-cigarette or vaping products.
  • If you are an adult who uses e-cigarettes containing nicotine to help you quit smoking cigarettes, do not return to smoking cigarettes.
  • If you have recently used an e-cigarette or vaping product and have experienced symptoms like the ones mentioned above, contact a healthcare provider.
  • Anyone who uses an e-cigarette or vaping product should not buy these products (e.g., e-cigarette or vaping products with THC or CBD oils) off the street or in pop up shops and should not modify or add any substances to these products that are not intended by the manufacturer.

 

** REMINDER**

Although cannabis or CBD oil use is legal for adults in California, people who vape cannabis or CBD oil or a combination of both, should be aware of potential health risks associated with vaping and only purchase products from a licensed retailer.  You can visit the Bureau of Cannabis Control California at www.cannabis.ca.gov to make sure you are purchasing products from a licensed cannabis retailer.

 

Information for the Public

The long-term health consequences of vaping are unknown. Existing studies have found that vaping devices can expose people to hazardous compounds such as formaldehyde, acetaldehyde, and acrolein during use.

Youth and young adults should not vape or use e-cigarette products.

Women who are pregnant should not vape or use e-cigarette products.

 

Anyone who is using vaping products and wishes to stop can get FREE assistance through the following resources:

  • California Smokers’ Helpline, 1-800-NO-BUTTS, offers free telephone counseling, self-help materials, and online help in six languages.
  • CDC Quit Smoking Website, 1-800-QUIT-NOW (1-800-784-8669) for support in quitting, including free quit coaching, a free quit plan, free educational materials, and referrals to local resources.

FDA-approved medical treatments are available to assist smokers in quitting, with more information available from a healthcare provider or the FDA.   

For individuals who would benefit from substance use disorder treatment, the Access and Crisis Line (888) 724-7240 has more information about what resources are available.

 

Information for Health Professionals

The clinical presentation of EVALI can initially mimic other common pulmonary diagnoses like pneumonia, but patients typically do not respond to antibiotic therapy. High clinical suspicion is necessary to make the diagnosis of VAPI. In some cases, patients sought care at outpatient clinics in the days prior to hospital presentation and received antibiotics for presumed pneumonia or bronchitis, which did not improve their symptoms.

 

Action Items for Physicians:

1)  Ask patients presenting with respiratory complaints in both outpatient and inpatient settings about their use of vaping or “dabbing” devices, especially patients who had an initial diagnosis of pneumonia or bronchitis that did not respond to antibiotics. For patients who do vape, ask these follow-up questions:

Type of vape used     

—Do you vape nicotine-containing substances?           

—Do you vape substances that contain cannabis or cannabinoid compounds like THC and CBD?

Amount of use

—When was the last time you vaped?

—How often do you vape?

—How long have you been vaping?

Source

—Where do you purchase your vaping supplies?

—What brands are your vaping devices, cartridges, and oils?

 

2)  Report suspected cases to the local health department within one business day.

  • An official from the health department may interview the patient or family members.
  • The health department will contact the hospital lab to arrange the transfer of biospecimens remaining from the patient to the public health lab. You do not have to order any specific cultures or tests on blood or urine that you would not normally request for the care of the patient.
  • The health department may collect vape devices and cartridges from the patient or family for testing.

 

Suspected cases should be reported to the San Diego County Epidemiology Program at (619) 692-8499 during business hours, or by faxing a Confidential Morbidity Report to (858) 715-6458, during all hours. Record “vaping-associated pulmonary illness” as the disease being reported.

CAHAN San Diego Health Alert Update: Vaping-associated Pulmonary Injury (10/3/19)

CDPH Health Advisory: Health Advisory for Health Care Professionals Regarding Vaping Associated Pulmonary Injury (10/1/19)

CDPH Health Advisory: Vaping Related Lung Illness: A Summary of the Public Health Risks and Recommendations for the Public (9/24/19)

CDPH News Release: California Department of Public Health Issues Public Health Advisory Urging Everyone to Refrain from Vaping (9/24/19)

CAHAN San Diego Health Alert: Vaping-associated Pulmonary Injury (8/28/19)

CDPH Health Alert: Vaping Associated Pulmonary Injury (8/27/19)

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For more information, contact the Epidemiology Program at (619) 692-8499 or send us an e-mail.