23 Apr EVALI: E-Cigarette & Vaping Lung Injury Hospitalizations and Deaths

MedicalResearch.com Interview with:

Dr. Werner

Angela K. Werner, PhD, MPH
Environmental Public Health Tracking Program
National Center for Environmental Health
CDC

MedicalResearch.com: What is the background for this study?

Response: In August 2019, emergency department (ED) visits related to e-cigarette, or vaping, product-associated lung injury (EVALI) increased sharply, followed by a peak in September. This was followed by a gradual but persistent decline in the number of cases.

As of February 18, 2020 (CDC’s latest and final published update), there were a total of 2,807 hospitalized EVALI cases or deaths reported to CDC from all 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands). Sixty-eight deaths were confirmed in 29 states and the District of Columbia. Although clinical presentations and outcomes of EVALI patients have been reported, data on patients who died are more limited. This article fills a gap by reporting on a national study assessing detailed demographic, substance use, and clinical characteristics of EVALI patients who have died, and comparing them to the characteristics of EVALI patients who survived.

MedicalResearch.com: What are the main findings?

• The first main finding is that those who died from EVALI were more likely to be older (≥35 years of age) and to have smoked cigarettes than those who did not die.
• Second, patients who died from EVALI were more likely to have certain chronic medical conditions compared to those who did not die from EVALI. Fatal cases were more likely to have a history of chronic obstructive pulmonary disease, asthma, cardiac disease, and any mental health condition (including depression or anxiety).
• Third, patients who died were more likely to have gone to outpatient care or an emergency department without admission prior to hospitalization.

MedicalResearch.com: What should readers take away from your report?

Response: It is important for all clinicians (in outpatient and hospital settings) to recognize that patients may have EVALI early so that they can provide appropriate clinical care and potentially reduce deaths. Patient characteristics that may help identify EVALI cases at higher risk for serious consequences, including death, are: older age (≥35 years), non-Hispanic white, current or former tobacco smoking, and history of chronic disease, and mental health conditions.

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: Our study showed that the percentage of patients who had obesity (BMI ≥30) was higher among those who died from EVALI than in the general population. While we only had data on body weight for those who died from EVALI, and not for those who did not die, more studies could be helpful to determine if there is an association between obesity and development of EVALI as well as whether obesity contributes to the severity of outcomes for those who develop EVALI. Further research will also be important to help determine the impact of early glucocorticoid administration on mortality among patients with EVALI. 

MedicalResearch.com: Is there anything else you would like to add?

Response: National and state data from patient reports and product sample testing show tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers, are linked to most EVALI cases and play a major role in the outbreak. Vitamin E acetate is strongly linked to the EVALI outbreak. Vitamin E acetate has been found in product samples tested by FDA and state laboratories and in patient lung fluid samples tested by CDC from geographically diverse states. Vitamin E acetate has not been found in the lung fluid of people that do not have EVALI. However, evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products, in some of the reported EVALI cases.

While Vitamin E acetate has been strongly linked to EVALI, and EVALI cases have markedly declined since the peak in September 2019, it is important for clinicians to be vigilant and aware of the risk factors associated with EVALI, including those associated with more severe outcomes of EVALI. CDC will continue to update guidance related to EVALI, including for clinicians, as appropriate.

Citation: 

Hospitalizations and Deaths Associated with EVALI

Angela K. Werner, Ph.D.,  Emilia H. Koumans, M.D., Kevin Chatham-Stephens, M.D., Phillip P. Salvatore, Ph.D., Christina Armatas, M.D., Paul Byers, M.D., Charles R. Clark, M.P.H., Isaac Ghinai, M.B., B.S., Stacy M. Holzbauer, D.V.M., Kristen A. Navarette, M.D., Melissa L. Danielson, M.S.P.H., Sascha Ellington, Ph.D., et al., for the Lung Injury Response Mortality Working Group
April 23, 2020
N Engl J Med 2020; 382:1589-1598
DOI: 10.1056/NEJMoa1915314 

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Last Updated on April 23, 2020 by Marie Benz MD FAAD