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Investigation into vaping-related lung injuries intensifies

Anne Schuchat

As the number of confirmed and probable cases of lung injury associated with electronic cigarette use, or vaping, surges, CDC, FDA and state health departments have scaled up their joint investigation into identifying the cause of this outbreak, officials said today during a CDC telebriefing.

Specifically, CDC has activated its emergency operations center to enhance the current investigation and the FDA announced during the telebriefing that its Office of Criminal Investigations, the agency’s law enforcement arm, began parallel investigative efforts shortly after the outbreak began.

“This is a complex investigation. It spans many states and involves hundreds of cases and a wide variety of substances and products. States are classifying cases and reporting them to CDC on a regular basis, and CDC is working 24/7 with the states to try to find answers,” Anne Schuchat, MD, CDC principal deputy director, said during the telebriefing. “I’d like to stress how challenging this situation is, as many patients may have been exposed to a variety of products and substances, may not know the contents or sources of these products and, in some instances, may be reluctant or too ill to fully disclose all the details of interest.”

Investigative efforts

So far, many patients have reported use of vaping or e-cigarette products that contain tetrahydrocannabinol (THC) or use of both products that contain THC and products that contain nicotine, and some have reported use of products that contain nicotine only, Schuchat said.

As previously reported by Healio Pulmonology, the FDA has been working with officials at the federal and state levels to help test samples from the vaping or e-cigarette products used to determine whether there is a relationship between any specific product or substance and these cases of severe lung injury.

Although vitamin E acetate was found in several product samples, the FDA at this time has still not identified a specific product or substance that has been definitively linked to the respiratory illnesses in this outbreak, according to Mitch Zeller, JD, director of the Center for Tobacco Products at the FDA. However, he added that the agency has collected more than 150 vaping product samples from a number of states for analysis in its forensic chemical center, and the FDA is looking at the presence of a broad range of chemicals, including nicotine, THC, opioids, cutting agents, other additives, pesticides, poisons and toxins.

Regarding the involvement of the agency’s Office of Criminal Investigations, Zeller said the focus of their work is “to identify what is making people sick and focus on supply chain.” He emphasized, however, that the office is not pursuing any prosecutions associated with personal use of any controlled substances in these cases but is rather involved due to their unique set of investigative skills.

At the state level, Jennifer Layden, MD, PhD, chief medical officer and state epidemiologist for the Illinois Department of Public Health, and colleagues are planning to ask Illinois residents to fill out an anonymous survey on vaping habits and compare the potential differences in use or products used by people who have used e-cigarettes and become ill and those who have used e-cigarettes and not become ill, she said during the telebriefing. Hopefully, she noted, this will fill some gaps in knowledge.

“I know that this is very frustrating for the public and the media and is very frustrating for us,” Schuchat said. “It is a complex investigation, and I don’t think we should expect definitive answers immediately; this may take some time. That said, state and local public health departments, FDA and CDC are working around the clock to get as much information and answers soon. It may turn into finding multiple issues that are of concern rather than a single product or substance.”

In the meantime, she reiterated the CDC’s recommendations that people consider refraining from using vaping or e-cigarette products and that people should not buy products off the street or modify their e-cigarette or vaping devices in any way.

Updated numbers

As of Sept. 24, 805 confirmed and probable cases have been reported by 46 states and the U.S. Virgin Islands, including 12 confirmed deaths in 10 states. This number of confirmed and probable cases is significantly higher than previously reported, which may be due in part to catching prior cases in addition to finding new ones, according to Schuchat. However, she noted during the telebriefing that CDC thinks this is an ongoing outbreak, as there continues to be people with new symptom onset.

During the call, Schuchat also provided new demographic information regarding these cases. Based on currently available data, nearly three-quarters of the cases are male, two-thirds of the cases are in people aged 18 to 34 years, 16% are in patients younger than 18 years and 17% are in people aged at least 35 years. Overall, more than half of the cases are in people younger than 25 years. Typical symptoms include cough, shortness of breath or chest pain, and some patients have reported nausea, vomiting, diarrhea, fatigue, fever or abdominal pain, she said.

CDC plans to update the number of confirmed and probable cases each Thursday.

“I want to stress that we at CDC are very concerned about the occurrence of life-threatening illness in otherwise healthy young people reported from around the country,” Schuchat said. “We’re working closely with state and local health departments, FDA and the clinical community to learn as much as we can to try to stop this outbreak, and I wish we had more answers.” – by Melissa Foster

Editor's note: This story was updated on Sept. 26, 2019, to include new information from CDC on the number of confirmed and probable cases of lung injury and the number of confirmed deaths possibly related to e-cigarette use.