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E-cigarette and Vaping-Associated Lung Injury (EVALI) in Maryland
The Comptroller’s Task Force on Electronic Smoking DevicesClifford S. Mitchell, MS, MD, MPH
Kenneth A Feder, PhDPrevention and Health Promotion Administration
January 9, 2020
BackgroundE-Cigarettes and Vaping
An e-cigarette or vape is a devicethat produces an aerosol by heating a liquid containing chemicals to be inhaled.
3
Background
E-cigarettes and vaping
•Nicotine •Cannabis derivatives like
•Tetrahydrocannabinol (THC)•Cannabidiol (CBD)
•Flavorings•Whatever else is in there…?
4
Background
What substances do people vape?
5
Devices come in many shapes and sizes.Background
Image: New Hampshire Department of Health and Human Services
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Background
Image: Pexel Image Ganjawalk dispensary
Popular products for nicotine and THC
\\\
Smoking Cigarettes
Any Marijuana
Vaping Nicotine
Vaping Marijuana
0%
5%
10%
15%
20%
25%
30%
35%
2012 2013 2014 2015 2016 2017 2018
Lifetime prevalence of nicotine and cannabis product use, grades 8, 10, and 12, United States, 2012-2018
Source: Monitoring the Future Study http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2018.pdf
Smoking is declining.Vaping is increasing.
Lung injury and deaths associated with vaping
8
Outbreak
Timeline of Events
14-Jul 3-Aug 23-Aug 12-Sep 2-Oct 22-Oct 11-Nov 1-Dec 21-Dec
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Maryland investigates
Case definition:1. Vaping in 90 days before illness2. Lung disease visible on chest x-ray3. No other explanation (e.g., infection)
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Vaping-Associated Lung Illness
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Outbreak
Maryland issues press release.
12
Outbreak
CDC issues clinician outreach
New York: Vitamin E acetate implicated.
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Outbreak
Safe to eat
Safe to inhale
Maryland designates reportable disease
Patients with the following presentation must be reported:• Use of any e-cigarette (“vaping”) or dabbing in 90 days
prior to symptom onset AND• Pulmonary infiltrate, including opacities on plain film
chest radiograph or ground-glass opacities on chest CT AND• No alternative plausible diagnoses (e.g., infectious,
cardiac, rheumatologic, or neoplastic process).
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Vaping-Associated Lung Illness
CDC: THC > nicotine.
15
Outbreak
77%any THC.
36%only THC.
57%any nicotine.
16%only nicotine.
VS
Perrine, C. G. (2019). Characteristics of a Multistate Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping—United States, 2019. MMWR. Morbidity and Mortality Weekly Report, 68. https://doi.org/10.15585/mmwr.mm6839e1
Vitamin E acetate found in lung fluid
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Outbreak
10 states submitted lung fluid
from 29 patients who became
sick after vaping. 100% test positive for vitamin E acetate.
Current ScienceWhere are we now?
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Source: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html
Vitamin E acetate (VEA) implicated
WI announces first case
VEA foundin lung fluid
As of 12/27/19, CDC reports 2,561 hospitalized cases or deaths related to EVALI. Includes 55 deaths.
As of 12/24/19, Maryland has ID’d 57 cases.
19
Current Science
70%Male
89%Used nicotine
82%Hospitalized
16%Used CBD
21%Under 18
74%Used THC
What Do We Know?
• Confident that Vitamin E Acetate is a significant contributing factor in the recent surge in events
• Likely that there are some other conditions and/or contributing factors involved in at least some of the cases reported (13% of cases reported vaping ONLY nicotine products)
• Not clear about long-term health implications, either of post-EVALI complications, or of chronic vaping without EVALI
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Acknowledgments
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• Dawn Berkowitz• David Blythe• Monique Duwell• Brian Bauchus• Heather Peters• Laboratories Administration
• Reporting physicians
• Local health department epis
• Hospital infection preventionists
• Patients who completed interviews
