Outbreak of Lung Injury Associated with E-Cigarettes/Vaping

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The Oklahoma State Department of Health (OSDH) participated in a national investigation of an outbreak of severe lung injury associated with e-cigarette product (devices, liquids, refill pods, and/or cartridges) use. This page provides data on the number of confirmed and probable cases in Oklahoma as well as information regarding the result of the national investigation. Cases included patients with e-cigarette, or vaping, product use-associated lung injury (EVALI) who died or were hospitalized. Please see below for final case counts and outbreak information. Providers are encouraged to visit the Centers for Disease Control and Prevention's (CDC) information for health care professionals page for recommendations and clinical resources. The CDC closed data collection on February 18, 2020. 

Number of Reported Cases of Severe Lung Injury Associated with E-Cigarette Use or Vaping, Oklahoma 

Cumulative number of confirmed or probable cases	Cumulative number of confirmed or probable deaths
6	0

Case details

Of the six patients,

• Two (33%) are under the age of 18, two (33%) are 18 to 34 years of age, and two (33%) are 35 years of age or older.
• Patients are residents of: Oklahoma County (2), Tulsa County (1), the Central region (1), the Northeast region (1), and the Northwest region of the state (1). 

Symptoms

Symptoms resulted in hospitalizations lasting from days to weeks, with some patients admitted to intensive care units. Symptoms included shortness of breath, fever, cough, chest pain, vomiting, abdominal pain, and diarrhea. Some patients reported that their symptoms developed over a few days, while others reported that their symptoms developed over several weeks. A lung infection did not appear to be causing the symptoms. Therefore, the suspected cause was a chemical exposure.

Background

• Electronic cigarettes – or e-cigarettes — are also called vapes, e-hookahs, vape pens, tank systems, mods, and electronic nicotine delivery systems (ENDS).
• Using an e-cigarette product is commonly called vaping.
• E-cigarettes work by heating a liquid to produce an aerosol that users inhale into their lungs.
• The liquid can contain: nicotine, tetrahydrocannabinol (THC) and cannabinoid (CBD) oils, and other substances and additives.

What we know

• As of February 18, 2020, there have been 2,807 hospitalized EVALI cases or deaths reported from all 50 states, the District of Columbia, and two U.S. territories. Sixty-eight deaths have been confirmed in 29 states and the District of Columbia.
• As of January 14, 2020, CDC has received complete sex and age data on 2,668 hospitalized cases.
  • 66% of patients are male.
  • The median age of patients is 24 years and ranges from 13 to 85 years.
  • 76% of patients are under 35 years old.
    • 15% of patients are under 18 years.
    • 37% of patients are 18 to 24 years old.
• All reported cases had a history of e-cigarette product use or vaping.
• Most patients (82%) reported a history of using THC-containing products. 
• Most patients using THC products obtained them from informal sources like friends, family, or in-person or online dealers; most patients using nicotine-containing products obtained them from commercial sources (medical dispensaries, vape and smoke shops, stores and pop-up shops).
• National data suggests EVALI to be associated with 152 different brands of THC use.
  • Dank Vapes, TKO, Smart Cart and Rove are the most commonly used THC-containing products.
• In addition, vitamin E acetate has been identified as a chemical of concern among people with EVALI.
• Recent CDC laboratory testing of bronchoalveolar lavage (BAL) fluid samples (fluid samples collected from the lungs) from 51 EVALI patients submitted to CDC from 16 states found vitamin E acetate in 48 of the 51 samples. Vitamin E acetate is used as an additive, most notably as a thickening agent in THC-containing e-cigarette, or vaping, products. 
• The OSDH is in the process of investigating suspected cases reported by health care providers. We expect that clinicians may look back for older cases.

 

What the OSDH recommends

• The CDC released recommendations for health care providers, health departments, and the public.
• While it appears that vitamin E acetate is associated with EVALI, many different substances wereinvestigated, and  there may be more than one cause.
• It is recommended not to use THC-containing e-cigarette, or vaping, products, particularly from informal sources (e.g., friends, family members or online dealers).
• Vitamin E acetate should not be added to any e-cigarette, or vaping, products. Additionally, people should not add any other substances not intended by the manufacturer to products, including products purchased through retail establishments.
• If you are an adult who used e-cigarettes containing nicotine to quit cigarette smoking, do not return to smoking cigarettes.
  • For help quitting e-cigarettes/vaping, contact your health care provider or the Oklahoma Tobacco Helpline at 1-800-QUIT-NOW (784-8669) or utilize the resources included at the bottom of the page.
• People experiencing lung symptoms after vaping should seek clinical care and avoid e-cigarettes or other vaping products, as continued use may lead to worsening symptoms. People should avoid vaping non-medical cannabis-based products, as the ingredients in these products are unknown.
• Regardless of the ongoing investigation:
  
  • Youth and young adults should not use e-cigarette products.
  • Women who are pregnant should not use e-cigarette products.
  • Adults who do not currently use tobacco products should not start using e-cigarette products.
  • 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, products. Persons with marijuana use disorder should seek evidence-based treatment by a health care provider.
• Submit detailed reports of any unexpected health or product issues related to tobacco or e-cigarette products to the FDA via the online Safety Reporting Portal.

 Resources

• Centers for Disease Control and Prevention Response
• U.S. Food and Drug Administration Response
• E-Cigarette Microlearning Video - Long Version (Tobacco Control Network)
• Exchange Lab: Evidence-Based Tobacco Education Print Materials, Web Content, and Video for Your Organization (U.S. Food and Drug Administration)
• Talk with Your Teen About E-Cigarettes: A Tip Sheet for Parents (Centers for Disease Control and Prevention)
• How FDA is Regulating E-Cigarettes (U.S. Food and Drug Administration)
• Smokefree.gov (U.S. Department of Health and Human Services)