#14,462
Every couple of years, but seemingly with increased frequency the past couple of decades, doctors around the globe are being challenged by new - or at least, re-emerging - diseases, which require new approaches to diagnosing, and managing, patients.
Whenever that happens - whether due to a novel flu like 2009's H1N1, an emerging coronavirus like MERS-CoV, or importation of a hemorrhagic fever like Ebola or Lassa - the CDC creates one or more working groups to compile, publish, and continuously revise interim guidelines for the healthcare industry.These are `works in progress', as early on the available data is sparse, and the results of various approaches have yet to be fully analyzed. Often, the CDC will adopt a `worst case' approach at first and then relax the guidance as more is learned.
Over the years we've looked at a number of these, including:
Updates Infection Control Guidance
CDC HAN Update On MERS-CoV
CDC HAN Advisory & Updates On Fungal Meningitis
CDC Updated Interim Guidance On Ebola
COCA Call - Interim Zika Virus Clinical Guidance : Webcast, Audio, Slides & TranscriptWith just under 1300 probable cases - and more than two dozen deaths - reported over the past few weeks, on Friday afternoon the CDC released - via the MMWR - a set of initial guidance for clinicians dealing with patients presenting with possible vaping-related lung injury symptoms.
The CDC also held a highly informative Telebriefing (Audio [MP3 – 7 MB) Friday afternoon on this interim guidance. Among the new information provided is the interim name/acronym being used for this new illness; EVALI (e-cigarette, or vaping, product use associated lung injury).The updated interim guidance (below) is lengthy, and geared primarily for clinicians and the public health community, but is worth scanning by a wide range of interested parties.
I've only included the summary and introduction, so follow the link the read it in its entirety.
Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury — United States, October 2019
Early Release / October 11, 2019 / 68
David A. Siegel, MD1; Tara C. Jatlaoui, MD1; Emily H. Koumans, MD1; Emily A. Kiernan, DO2,3; Mark Layer, MD3,4; Jordan E. Cates, PhD5,6; Anne Kimball, MD6,7; David N. Weissman, MD8; Emily E. Petersen, MD1; Sarah Reagan-Steiner, MD9; Shana Godfred-Cato, DO10; Danielle Moulia, MPH5,11; Erin Moritz, PhD4; Jonathan D. Lehnert, MPH9; Jane Mitchko, MEd1; Joel London, MPH1; Sherif R. Zaki, MD9; Brian A. King, PhD1; Christopher M. Jones, PharmD, DrPH12; Anita Patel, PharmD5; Dana Meaney Delman, MD10; Ram Koppaka, MD, PhD5; Lung Injury Response Clinical Working Group; Lung Injury Response Epidemiology/Surveillance Group
SummaryOn This Page
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.
Clinical Evaluation for Patients with Suspected EVALI
Management of Patients with Suspected EVALIClinical Care and Public Health Recommendations
Acknowledgments
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.
(Continue . . . )
With flu season just around the corner, the ability for clinicians to differentiate between a viral illness and EVALI will become more problematic. This is not unlike the dilemma we've seen in differentiating between flu and MERS-CoV or Avian Flu in the Middle East & Asia the during the winter.
While tobacco products still appear far more harmful than e-cigs and vaping (see UK PHE publishes independent expert e-cigarettes evidence review), it generally takes years - even decades - for serious illness to occur in tobacco users.With e-cigs and vaping - while the absolute number of cases remains small in comparison (n=1299) - many of the seriously ill are teenagers, or very young adults (median age was 24 years (range = 13–75 years)).
In toxicology, the old adage `The dose makes the poison' (Latin: "Sola dosis facit venenum'), reminds us that everything is toxic - including water and oxygen - given sufficient ingestion or exposure.
The $64 question for EVALI remains: what ingredient (or ingredients) in e-cigs are behind this rash of lung injuries, and at what dose do they make the poison?Stay tuned.
