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| Credit CDC |
#14,512
While it is not a slam dunk - and there may be other, as-yet unidentified contributing factors - yesterday the CDC announced a prime (and not wholly unexpected) suspect in the outbreak of vaping-related lung injuries around the country.
In an early release MMWR published yesterday, researchers reported finding evidence of Vitamin E Acetate - sometimes used as a `carrier fluid' for vaping products - in alveolar lavage fluids drawn from 29 of 29 known cases.
A high percentage (but not all) also showed evidence of THC at the injury site. While not found in 100% of cases, this does not eliminate THC as a potential causative agent, as detectable levels of THC are less likely to remain in the alveolar sacs over an extended period of time.A link and some excerpts from the MMWR Report follow:
Evaluation of Bronchoalveolar Lavage Fluid from Patients in an Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injury — 10 States, August–October 2019
Early Release / November 8, 2019 / 68
Benjamin C. Blount, PhD1*; Mateusz P. Karwowski, MD1*; Maria Morel-Espinosa, PhD1; Jon Rees, PhD1; Connie Sosnoff, MA1; Elizabeth Cowan, PhD1; Michael Gardner, MS1; Lanqing Wang, PhD1; Liza Valentin-Blasini, PhD1; Lalith Silva, PhD1; Víctor R. De Jesús, PhD1; Zsuzsanna Kuklenyik, PhD1; Cliff Watson, PhD1; Tiffany Seyler, PhD1; Baoyun Xia, PhD1; David Chambers, PhD1; Peter Briss, MD2; Brian A. King, PhD3; Lisa Delaney, MS4; Christopher M. Jones, PharmD, DrPH5; Grant T. Baldwin, PhD6; John R. Barr, PhD1; Jerry Thomas, MD1; James L. Pirkle, MD, PhD1
(Excerpt)
Vitamin E acetate was detected in all 29 patient BAL samples. Among 23 patients for whom self-reported THC use information was available, 20 reported using THC-containing products. THC or its metabolites were detected in 23 of 28 patient BAL samples, including in those of three patients who said they did not use THC products. Nicotine metabolites were detected in 16 of 26 patient BAL specimens. Results for plant oils, MCT oil, petroleum distillates, and diluent terpenes were all below analyte-specific levels of detection (typically in the low ng/mL range).
This is the first reported identification of a potential toxicant of concern (vitamin E acetate) in biologic specimens obtained from EVALI patients. These findings provide direct evidence of vitamin E acetate at the primary site of injury among EVALI patients and are consistent with FDA product testing and media reports of state public health laboratory testing documenting vitamin E acetate in product samples used by EVALI patients (2,3) (Personal communication, D.T. Heitkemper, FDA Forensic Chemistry Center, November 2019). Other diluents and additives of concern (e.g., plant oils, MCT oil, petroleum distillates, and diluent terpenes) were notably not detected in BAL fluid specimens from EVALI patients.
(Continue . . . )
A second MMWR Report on Risk Factors was also released:
Risk Factors for E-Cigarette, or Vaping, Product Use–Associated Lung Injury (EVALI) Among Adults Who Use E-Cigarette, or Vaping, Products — Illinois, July–October 2019(EXCERPT)
Early Release / November 8, 2019 / 68
Livia Navon, MS1,2; Christopher M. Jones, PharmD, DrPH3; Isaac Ghinai, MBBS1,4; Brian A. King, PhD5; Peter A. Briss, MD5; Karen A. Hacker, MD5; Jennifer E. Layden, MD, PhD1 (View author affiliations)
Compared with survey respondents aged 18–44 years reporting using of THC-containing e-cigarette, or vaping, products, EVALI patients aged 18–44 years had higher odds of reporting exclusive and frequent use of THC-containing products and obtaining these products from informal sources, such as a dealer, off the street, or from a friend, and of using Dank Vapes, a class of largely counterfeit THC-containing products.(Continue . . . )
Yesterday afternoon the CDC held a Telebriefing and Q&A on these two studies, which you can listen to, or read the transcript, at the following link:
Transcript of CDC Telebriefing: Update on Lung Injury Associated with E-cigarette Use, or Vaping
Press Briefing Transcript
Friday, November 8, 2019
Audio recording media icon[MP3 – 6 MB]
Please Note: This transcript is not edited and may contain errors.
Next, we have the latest updated figures from the CDC on acute lung injury due to vaping.
Updated every Thursday
- This complex investigation spans almost all states, involves over 2,000 patients, and a wide variety of brands and substances and e-cigarette, or vaping, products.
- As of November 5, 2019, 2,051* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 1 U.S. territory.
- Thirty nine deaths in 24 states and the District of Columbia: Alabama, California (3), Connecticut, Delaware, District of Columbia, Florida, Georgia (3), Illinois (3), Indiana (3), Kansas (2), Massachusetts (2), Michigan, Minnesota (3), Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon (2), Pennsylvania, Tennessee (2), Texas, Utah, and Virginia.
- The median age of deceased patients was 53 years and ranged from 17 to 75 years (as of November 5, 2019).
- More deaths are under investigation.
- Among 1,378 patients with data on sex (as of October 15, 2019):
- 70% of patients are male.
- Among 1,364 patients with data on age (as of October 15, 2019):
- The median age of patients is 24 years and ages range from 13 to 75 years.
- 79% of patients are under 35 years old.
- By age group category:
- 14% of patients are under 18 years old;
- 40% of patients are 18 to 24 years old;
- 25% of patients are 25 to 34 years old; and
- 21% of patients are 35 years or older.
- Among 867 patients with information on substances used in e-cigarette, or vaping, products in the 3 months prior to symptom onset** (as of October 15, 2019):
- About 86% reported using THC-containing products; 34% reported exclusive use of THC-containing products.
- About 64% reported using nicotine-containing products; 11% reported exclusive use of nicotine-containing products.
While Vitamin E Acetate may not be alone in causing lung injury, this does appear to be an important breakthrough in the investigation. Additional tests are being performed on literally dozens of other substances used in various `vape juice' concoctions, and more suspects may turn up.
In the meantime, the CDC advises:
What CDC Recommends
CDC recommends that you do not use e-cigarette, or vaping, products that contain THC.
CDC also recommends that people should not:
Adults using e-cigarettes to quit smoking should not go back to smoking; they should weigh all risks and benefits and consider utilizing FDA-approved nicotine replacement therapiesexternal icon..
- Buy any type of e-cigarette, or vaping, products, particularly those containing THC, off the street.
- Modify or add any substances to e-cigarette, or vaping, products that are not intended by the manufacturer, including products purchased through retail establishments.
- Since the specific compound or ingredient causing lung injury are not yet known, the only way to assure that you are not at risk while the investigation continues is to consider refraining from use of all e-cigarette, or vaping, products.
If people continue to use an e-cigarette, or vaping, product, carefully monitor yourself for symptoms and see a healthcare provider immediately if you develop symptoms like those reported in this outbreak.
Irrespective of the ongoing investigation:
- E-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant.
- Adults who do not currently use tobacco products should not start using e-cigarette, or vaping, products. There is no safe tobacco product. All tobacco products, including e-cigarettes, carry a risk.
- 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.
