Vaping Associated Lung Injury

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Investigation

What's happening?

The Washington State Department of Health (DOH) is working with local health jurisdictions as well as the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) to investigate an outbreak of lung injury associated with e-cigarettes and vapor products.

Vapor products — also known as JUULs, e-cigarettes, e-cigs, vapes, e-hookahs, vape pens, mods, tanks, or electronic nicotine delivery systems — can contain nicotine, marijuana, and/ or other substances like flavoring agents and other chemicals.

What's the cause?

The latest national findings suggest THC-containing vapor products, particularly those from informal sources like friends, family, or in-person or online dealers, are linked to most patients with vaping-associated lung injury and play a major role in the outbreak. In addition, vitamin E acetate, an additive in some THC-containing vapor products, is closely associated with vaping-associated lung injury.

About 13 percent of patients nationally and about half of patients in Washington report only using non-THC vapor products. It is unclear if these patients are not fully disclosing THC use, are being exposed to a substance that is also in THC products, or have lung injury unrelated to vaping. Additionally, it is possible that there may be multiple substances in multiple vapor products that cause lung injury.

Why now?

Reported lung injuries emerged in June and peaked in September 2019. Since then, the number of cases occurring per week has fallen, but cases continue to be detected.

The leading hypothesis for why cases are occurring now is that a new diluting agent, vitamin E acetate, was recently added to some THC-containing products. This hypothesis is supported by the fact that vitamin E acetate was found in samples taken from lung injury patients at the site of their injury, but not in samples from healthy people's lungs.

In addition, products seized by law enforcement in Minnesota in 2019 at the same time as the lung injury outbreak tested positive for vitamin E acetate, but products seized in 2018 tested negative.

Why don't we know more?

Several factors make the investigation into the outbreak cause complicated. Some patients may not be able or willing to share products or product use information. When products have been available for testing, very often there have been very small amounts of liquid available for testing. This can result in not being able to conduct all the tests that would help determine similar ingredients across all products.

Tracking ingredients can be very difficult, especially for products that weren't bought at a licensed retailer in Washington. Even for products sold at licensed retailers, we don't know all the ingredients included and have limited research about how some ingredients affect people's health when inhaled.

What is the state doing?

DOH and local health officials are working closely with health care providers to identify cases. Case investigations involve reviewing medical records, talking with providers, and interviewing patients about their vapor product use.

Until recently, samples of vapor products the patient used were collected and sent for testing at FDA and CDC. Going forward, vapor product analysis will be more targeted. Vapor products will only be analyzed if a certain kind of sample taken from patients' lungs (bronchoalveolar lavage specimens) is also available for study.

DOH and local health have developed and sent out messaging related to the outbreak, as well as links to quit resources.

Health officials are also concerned about the ongoing epidemic of vapor product use among Washington youth. DOH has developed education and outreach materials to increase awareness of the potential dangers of vaping and is promoting resources to specifically help youth quit using nicotine and cannabis.

DOH also offers several quit resources for tobacco, vapor products, and marijuana.

Case information

Since April 2019, there have been 27 cases of vaping associated lung injury reported in Washington, including two deaths. 52 percent of the patients are male.

We confirmed the two deaths meet the probable case definition after reviewing medical records and autopsy reports. In both cases, testing identified a respiratory pathogen, but medical personnel did not believe the infection was the sole cause of the lung injury and vaping was identified as contributing to the death. These deaths show how much we still need to learn about the health impacts of vaping, and whether people who vape are at increased risk of complications from respiratory infections.

This page will be updated when we have new cases. Note that increases in case numbers may represent new patients or new reports of previously-identified patients.

Last update: Feb 24, 2020

County Cases Deaths
Clark 2
King 8
Kitsap 2
Klickitat 1
Mason 1
Pierce 1
Snohomish 5
Spokane 4 1
Thurston 1 1
Yakima 2
Age Cases
10 to 19 years old 5
20 to 29 years old 9
30 to 39 years old 7
40 to 49 years old 3
50 to 59 years old 0
60 to 69 years old 0
70 to 79 years old 3
Reported use of products Cases
THC products only 5
Nicotine products only 11
THC and nicotine products 7
Other 1
Unknown 3
Not Yet Released* 0

*To protect patient privacy, reported use of products will be updated each time we have multiple new cases with product information.

Recommendations to the public

DOH recommends that people should not use THC-containing vapor products, particularly those from informal sources like friends, family, or in-person or online sellers. Additionally, people should not add any other substances not intended by the manufacturer to products, including products purchased through retail stores.

While it appears that vitamin E acetate is associated with lung injury, there are many different substances and product sources that are being investigated, and there may be more than one cause. Therefore, the best way for people to ensure they are not at risk while the investigation continues is to consider refraining from the use of all e-cigarette, or vaping, products.

Adults using e-cigarettes or vaping products as an alternative to cigarettes should not go back to smoking. They should weigh all available information and consider using evidence-based treatments including counseling and FDA-approved medications. If you need help quitting tobacco, e-cigarettes or vapor products, contact your health care provider or access online resources to quit tobacco and/or marijuana.

Adults who continue to use vapor products should carefully monitor themselves for symptoms and see a healthcare provider immediately if they develop symptoms like those reported in this outbreak.

Regardless of the ongoing investigation, we know that if you don't use e-cigarettes or vapor products, you should not start doing so, and youth, young adults and pregnant or breastfeeding women should never use them.

Vaping, like smoking cigarettes or using marijuana, has never been completely safe. The healthiest option for everyone is to not smoke or vape.

Healthcare providers and tribes
Health care providers - read cdc interim guidance on vaping associated lung injury

Healthcare providers should contact your local health departments to report cases of vaping-associated lung injury and for any questions related to the vaping-associated lung injury investigation.

Local health jurisdictions

Local health jurisdictions can use these forms for investigating and reporting possible cases to DOH.

Emergency rule on vapor products

On September 27, 2019, Governor Inslee issued an executive order (PDF) on vaping and e-cigarette use. The State Board of Health passed an emergency rule on vapor products and flavors, which took effect October 10, 2019 for 120 days. The original sections of the rule expired on February 7, 2020.

On November 18, 2019, the Board added a new section to the rule banning the sale of vapor products containing vitamin E acetate. The new section became effective on November 20, 2019. On March 19, 2020, the rule banning the sale of vapor products containing vitamin E acetate was extended for another 120 days.

You may find information on the rule from the Board of Health, and information on implementation from the Liquor and Cannabis Board.

Contact

For media and public information inquiries, please use the department's standard media contacts. Members of the public can also call the DOH consumer assistance line at 360-236-4501.

Questions about implementation of the emergency rule banning flavored vapor products should be directed to the Liquor and Cannabis Board.