On October 11, 2019, this report was posted online as an MMWR Early Release. 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 ( 100 beats/min) 169 (55) 310 Tachypnea (respiratory rate >20 breaths/min) 77 (45) 172 Clinical course Admission to intensive care unit 159 (47) 342 Age group (yrs) 13–17 45 (56) 80 18–24 49 (38) 130 25–50 54 (47) 115 ≥51 9 (69) 13 Past cardiac disease** 8 (50) 16 No past cardiac disease 151 (46) 326 Intubation and mechanical ventilation 74 (22) 338 Age group (yrs) 13–17 23 (29) 80 18–24 21 (16) 130 25–50 23 (20) 115 ≥51 7 (54) 13 Past cardiac disease** 5 (31) 16 No past cardiac disease 70 (21) 326 Corticosteroids 252 (88) 287 Improved after corticosteroids 114 (82) 140 Duration of hospitalization (days) Mean (median) Range Age group (yrs) 13–17 6.9 (6) 0–23 18–24 6.2 (5) 0–38 25–50 6.6 (6) 0–40 ≥51 14.8 (12) 3–31 Past cardiac disease 8.9 (4) 3–31 No past cardiac disease 6.6 (5) 0–40 Average hospital stay 6.7 (5) 0–40 Abbreviation: E-cigarette = electronic cigarette. * For cases that had full medical chart abstraction data available. † Surveillance data through October 3, 2019, from the following 29 U.S states: Alabama, Delaware, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Minnesota, Mississippi, Missouri, Montana, Nevada, New Jersey, New Mexico, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Texas, Vermont, Washington, West Virginia, and Wisconsin. § Patients with missing data were excluded from denominators for selected characteristics. ¶ Self-reported fever, chills, and unexpected weight loss. ** Heart failure, heart attack, or other heart conditions. All health care providers evaluating patients for EVALI should ask about the use of e-cigarette, or vaping, products and ideally should ask about types of substances used (e.g., THC, cannabis [oil, dabs], nicotine, modified products or the addition of substances not intended by the manufacturer); product source, specific product brand and name; duration and frequency of use, time of last use; product delivery system, and method of use (aerosolization, dabbing, or dripping). Empathetic, nonjudgmental, and private questioning of patients regarding sensitive information to assure confidentiality should be employed. Standardized approaches should be used for interviewing adolescents. Resources exist to guide patient interviews, including those of adolescents. § In some situations, asking questions over the course of the hospitalization or during follow-up visits might elicit additional information about exposures, especially as trust is established between the patient and clinicians. Physical examination. For patients who report the use of e-cigarette, or vaping, products, physical examination should include vital signs and pulse-oximetry. Tachycardia was reported in 55% (169/310) of patients and tachypnea in 45% (77/172); O2 saturation 11,000/mm3 and 93% had an ESR >30mm/hr; 50% of patients had elevated liver transaminases (aspartate aminotransferase or alanine aminotransferase >35 U/L) ( 3 ). However, at this time, these tests cannot be used to distinguish EVALI from infectious etiologies. In all patients, providers should consider conducting, with informed consent, urine toxicology testing, including testing for THC. Imaging. Radiographic findings consistent with EVALI include pulmonary infiltrates on CXR and opacities on chest computed tomography (CT) scan ( 1 , 7 ). A CXR should be obtained on all patients with a history of e-cigarette, or vaping, product use who have respiratory or gastrointestinal symptoms, particularly when accompanied by decreased O2 saturation ( 6 months of age, including patients with a history of EVALI. In addition, administration of pneumococcal vaccine should be considered according to current guidelines. §§ Addressing exposures. Advising patients to discontinue use of e-cigarette, or vaping, products should be an integral part of the care approach during an inpatient admission and should be re-emphasized during outpatient follow-up. Cessation of e-cigarette, or vaping, products might speed recovery from this injury; resuming use of e-cigarette, or vaping, products has the potential to cause recurrence of symptoms or lung injury. Evidence-based tobacco product cessation strategies include behavioral counseling and FDA-approved cessation medications. ¶¶ For patients who have addiction to THC-containing or nicotine-containing products, cognitive-behavioral therapy, contingency management, motivational enhancement therapy, and multidimensional family therapy have been shown to help, and consultation with addiction medicine services should be considered ( 8 – 10 ). Special considerations for groups at high risk. Patients with certain characteristics or comorbidities, including older age, history of cardiac or lung disease, or pregnancy, might be at higher risk for more severe outcomes. Among reported cases (Table), patients aged >50 years experienced the highest percentage of endotracheal intubation and mechanical ventilation (54%) and the longest mean inpatient stays (15 days). The mean first recorded O2 saturations among those who did and did not require intubation were 87% and 92%, respectively (data not shown). Among those with and without past cardiac disease, 31% and 21%, respectively, required intubation (Table). Special consideration might need to be given to patients aged >50 years, because these patients might require longer duration of hospitalization and have a higher risk of intubation (Figure). Rapid identification of exposure, a high index of suspicion of EVALI, initiation of corticosteroids, and specialist consultations might be lifesaving in this patient population. FIGURE Percentage of persons needing intubation (N = 338) and hospitalization (N = 242) among patients with e-cigarette, or vaping, product use associated lung injury (EVALI), by age of patient — United States, February 1–October 3, 2019*,† Abbreviation: E-cigarette = electronic cigarette. * Data reported through October 3, 2019, from the following 29 states: Alabama, Delaware, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Minnesota, Mississippi, Missouri, Montana, Nevada, New Jersey, New Mexico, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Texas, Vermont, Washington, West Virginia, and Wisconsin. † 95% confidence intervals indicated by error bars. The figure consists of two bar charts showing the percentage of U.S. persons needing intubation (N = 338) and hospitalization (N = 242) among patients with lung injury associated with e-cigarette, or vaping, product use, by age of patient, based on reports from 29 states during February 1–October 3, 2019. Additional data might identify other groups at high risk, provide important information about disparities in outcomes, and help guide clinical care. Certain patients, such as adolescents and young adults, might benefit from specialized services, such as addiction treatment services and providers who have experience with counseling and behavioral health follow-up. Clinical Care and Public Health Recommendations Reporting cases to state, local, territorial, or tribal health departments is critical for accurate surveillance of EVALI. Reporting cases and obtaining and sending products, devices, and clinical and pathologic specimens for testing, can help health departments and CDC determine the cause or causes of these lung injuries.*** CDC is developing International Classification of Diseases, Tenth Edition, Clinical Modification coding guidance for health care encounters related to EVALI. Updates, when available, can be found at https://www.cdc.gov/lunginjury (Box 3). BOX 3 Clinical Care and Public Health Reporting of e-cigarette, or vaping, product use associated lung injury (EVALI) Considerations at points of care Examples include emergency departments, urgent care, doctors’ offices, etc. Consider posting reminders or signage to encourage conversation between patients and providers about use of e-cigarette, or vaping, products.* Report cases of lung injury associated with use of e-cigarette, or vaping, products within the past 90 days to state or local health department. Determine whether any remaining product, including devices and liquids, is available for testing. Testing can be coordinated with health departments. CDC is developing International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) coding guidance for healthcare encounters related to EVALI. Updates, when available, will be at https://www.cdc.gov/lunginjury. Clinical specimen testing by CDC † Consider submission of any collected specimens, including bronchoalveolar lavage, blood, or urine, to CDC for evaluation. Testing of pathologic specimens by CDC § If a lung biopsy or autopsy is performed on a patient suspected of lung injury related to e-cigarette, or vaping, product use, consider submission of fixed lung biopsy tissues or autopsy tissues to CDC for evaluation. Testing can include evaluation for lipids on formalin-fixed (wet) lung tissues that have not undergone routine processing. Routine microscopic examination will be performed, as well as infectious disease testing, if indicated, on formalin-fixed (wet) tissues, or formalin-fixed, paraffin-embedded tissue specimens. * https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/healthcare-providers/index.html. † https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/health-departments/index.html. § https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/health-departments/index.html. Public health recommendations. At this time, FDA and CDC have not identified the cause or causes of the lung injuries among EVALI cases, and the only commonality among all cases is that patients report the use of e-cigarette, or vaping, products. This outbreak might have more than one cause, and many different substances and product sources are still under investigation. To date, national and state data suggest that products containing THC, particularly those obtained off the street or from other informal sources (e.g., friends, family members, or illicit dealers), are linked to most of the cases and play a major role in the outbreak ( 11 , 12 ). Therefore, CDC recommends that persons should not use e-cigarette, or vaping, products that contain THC. Persons should not buy any type of e-cigarette, or vaping, products, particularly those containing THC, off the street. Persons should not modify or add any substances to e-cigarette, or vaping, products that are not intended by the manufacturer, including products purchased through retail establishments. Given that the exclusive use of nicotine-containing products has been reported by a small percentage of persons with EVALI, and that many persons with EVALI report combined use of THC- and nicotine-containing products, the possibility that nicotine-containing products play a role in this outbreak cannot be excluded. Therefore, at present, CDC continues to recommend that persons consider refraining from using e-cigarette, or vaping, products that contain nicotine. If adults are using e-cigarette, or vaping, products to quit cigarette smoking, they should not return to smoking cigarettes; they should use evidence-based treatments, including health care provider counseling and FDA-approved medications. ††† If persons continue to use these products, they should carefully monitor themselves for symptoms and see a health care provider immediately if symptoms develop. Irrespective of the ongoing investigation, e-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant. There is no safe tobacco product, and the use of any tobacco products, including e-cigarettes, carries a risk. Therefore, persons who do not currently use tobacco products should not start using e-cigarette, or vaping, products. This investigation is ongoing. CDC will continue to work in collaboration with FDA and state and local partners to investigate cases and to update guidance, as appropriate, as new data emerges from this complex outbreak. Summary 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.
