Inside The Mysterious Lung Illness Linked To Vaping

A teen uses a JUUL vaping device. (Jesse Costa/WBUR)

With Meghna Chakrabarti

We take a deep look at the mysterious lung disease associated with vaping.

Guests

Ilona Jaspers, deputy director at the University of North Carolina Center for Environmental Medicine, Asthma and Lung Biology. Professor in the Department of Pediatrics, Microbiology and Immunology, and the Department of Environmental Sciences and Engineering at the Gillings School of Global Public Health. Director of the Curriculum in Toxicology. (@UNCpublichealth)

Dr. Melodi Pirzada, chief of pediatric pulmonology at NYU Winthrop Hospital on Long Island. (@NYUWinthropHosp)

From The Reading List

Statement From Juul:

"We commend CDC for its investigation and we we will continue to vigilantly monitor all reports. We have no higher priority than product safety which is why we have implemented industry-leading quality controls and appropriately label our products with ingredient disclosures and health warnings. Our device and manufacturing facilities are subject to numerous quality and certification standards and we conduct extensive preclinical and toxicological testing of the ingredients and analytes in JUUL e-liquids and aerosols. Our testing is conducted through reputable, independent third-party laboratories.

"Reporting also suggests many patients were vaping THC (a Schedule 1, controlled substance that we do not sell). Regardless, those reports reaffirm the need to keep all tobacco and nicotine products out of the hands of youth through significant actions and regulation on access and enforcement. We also must ensure illegal counterfeit and copycat products which may be made with unknown ingredients and under unknown standards and those that deliver controlled substances, stay out of the market."

Joint Statement From Acting FDA Commissioner Ned Sharpless, M.D., and CDC Director Robert R. Redfield, M.D.

"Both the U.S. Food and Drug Administration and the U.S. Centers for Disease Control and Prevention are working tirelessly to investigate the distressing incidents of severe respiratory disease associated with use of e-cigarette products. We were deeply saddened last week to learn of the death of an adult in Illinois who had been hospitalized with a severe respiratory illness following the use of an e-cigarette product. We are working closely with state and local health officials to investigate these incidents as quickly as possible, and we are committed to taking appropriate actions as a clearer picture of the facts emerges.

"We’ve also made it a top priority to communicate with the public about our efforts.

Today, we are providing several updates about efforts between FDA, CDC and state health officials to investigate these incidents that have impacted both youth and adults across the country. First, we are updating the number of potential cases of respiratory illnesses reported after use of e-cigarette products. Additionally, we are sharing more details about the work CDC and FDA are undertaking as part of the investigation, including its current status. We are also providing the public and our health partners across the country with information to help mitigate the risk of additional incidents and what health officials and clinicians can do to help us gather as much data as possible to better understand these illness and potential causes.

"As of Aug. 27, 2019, 215 possible cases have been reported from 25 states, and additional reports of pulmonary illness are under investigation. States are completing their own investigations and verifications of cases based on CDC’s recently released standardized case definition. While some cases in each of the states are similar and appear to be linked to e-cigarette product use, more information is needed to determine what is causing the respiratory illnesses. In many cases, patients reported a gradual start of symptoms, including breathing difficulty, shortness of breath, and/or chest pain before hospitalization. Some cases reported mild to moderate gastrointestinal illness including vomiting and diarrhea, or other symptoms such as fevers or fatigue. In many cases, patients have also acknowledged recent use of tetrahydrocannabinol (THC)-containing e-cigarette products while speaking to healthcare personnel, or in follow-up interviews by health department staff.

"Even though cases appear similar, it is not clear if these cases have a common cause or if they are different diseases with similar presentations, which is why our ongoing investigation is critical. CDC and the FDA are providing consultation to state health departments and working closely with them to gather information on any products or substances used. For example, our agencies are working to standardize information collection at the state level to help build a more comprehensive picture of these incidents. This includes investigating the brand and types of e-cigarette products, whether any of them are products that would fall within the FDA’s regulatory authority, as well as where they were obtained.

"CDC is helping involved states investigate whether the illnesses may be linked to specific devices, ingredients or contaminants in the devices, or substances associated with e-cigarette product use, with the FDA’s assistance. Current assistance to states includes deploying CDC staff to Illinois and Wisconsin to assist their state health departments with the respective state investigations; releasing a Clinician Outreach and Communication Activity (COCA) Clinical Action Alert describing this investigation and asking providers to report possible cases to their state health departments; developing and distributing to involved states a standardized case definition, medical chart abstraction form, and case interview questionnaire with input from states who are running investigations; reviewing and providing feedback on data collection and health messaging tools for states; and facilitating information sharing between states with possible cases.

"In addition to daily meetings between our federal agencies, as well as frequent communication with state health officials, the FDA has been and will continue to provide laboratory assistance. The FDA has received about 80 samples and continues to receive requests from states to send more samples for the FDA to analyze. The samples represent a variety of different types of products and substances – a number of which contained incomplete information about the product. The FDA is analyzing those samples for their contents, whether they contain nicotine, substances, such as THC or other cannabinoids, or other chemicals and ingredients. The results of that testing will be shared with the respective states to aid in their investigations and will help inform the federal response.

"More information is needed to better understand whether there’s a relationship between any specific products or substances and the reported illnesses. At this time, there does not appear to be one product involved in all of the cases, although THC and cannabinoids use has been reported in many cases. At this time, the specific substances within the e-cigarette products that cause illness are not known and could involve a variety of substances. We continue to gather information about the names of the products used, where they were purchased, and how the products were used. That information is critical to help determine whether patterns emerge on which we can take additional action. While we continue to gather more information about these incidents and any specific products or substances involved, we also believe it’s important to provide the public with useful information to help protect themselves and their loved ones, as well as continue to notify health care professionals about the illnesses, what to watch for, and how to collect and report information on these cases. As part of that commitment, CDC today issued a Health Alert Network (HAN) Health Advisory. The advisory includes the recommendation that while this investigation is ongoing, if you are concerned about these specific health risks, consider refraining from the use of e-cigarette products.

"Anyone who does use e-cigarette products should not buy these products off the street (e.g., e-cigarette products with THC or other cannabinoids) and should not modify e-cigarette products or add any substances to these products that are not intended by the manufacturer. Regardless of the ongoing investigation, e-cigarette products should not be used by youth, young adults, pregnant women, and adults who do not currently use tobacco products. If you use e-cigarette products, monitor yourself for symptoms (e.g., cough, shortness of breaths, chest pain) and promptly seek medical attention if you have concerns about your health. CDC and the FDA will continue to advise and alert the public as more information becomes available. Adult smokers who are attempting to quit should use evidence-based treatments, including counseling and FDA-approved medications. If you need help quitting tobacco products, including e-cigarettes, contact your doctor. If you are concerned about harmful effects from e-cigarette products, call your local poison control center at: 1-800-222-1222. We also continue to encourage the public to submit detailed reports of any unexpected tobacco- or e-cigarette-related health or product issues to the FDA via the online Safety Reporting Portal.

"As this investigation continues, our agencies remain committed to working as quickly as possible, in collaboration with our state and local public health partners and the clinical community, to find out as much as we can about these cases and potential causes and communicating with the public about these efforts to protect and promote the public health. Our ongoing oversight and educational efforts related to e-cigarettes is critical to our public health mission and, especially, to protecting youth from the dangers of nicotine addiction and tobacco-related disease and death.

"The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation’s food supply, cosmetics, dietary supplements, products that give off electronic radiation, and for regulating tobacco products. CDC works 24/7 protecting America’s health, safety and security. Whether disease start at home or abroad, are curable or preventable, chronic or acute, or from human activity or deliberate attack, CDC responds to America’s most pressing health threats. CDC is headquartered in Atlanta and has experts located throughout the United States and the world."

Statement From Vaping Technology Association

"In light of the seriousness of reports regarding lung disease in youth, the Vapor Technology Association (VTA) strongly urges public officials to thoroughly investigate the circumstances which might have led to each reported hospitalization before making statements to the public as to whether certain products are implicated in these incidents.

To date, several public health agencies have failed to provide clear information and, instead, are unnecessarily frightening consumers by failing to distinguish between e-cigarettes and non-nicotine vaporizers.

"Recent reports increasingly indicate that these adverse events are linked to illicit substances such as THC and cannabis, not e-cigarettes. For example, the New Mexico Department of Health has clearly determined that products containing THC are likely responsible for the cases highlighted in New Mexico. Despite this, virtually every other public health official continues with their generalized and repeated references to “e-cigarettes.” Such inaccurate warnings will result in either (1) people continuing to use the risky products actually causing the harm about which they have not been specifically warned; or (2) many smokers using e-cigarettes becoming ‘scared’ by these reports and moving back to deadly combustible cigarettes.

"VTA condemns in the strongest possible terms the sale or use of black-market products and does not endorse the manipulation or adulteration of vapor products to consume THC, THC oil, marijuana, or synthetic products like K2. E-cigarettes and other nicotine-containing vapor products are designed for the consumption of nicotine to provide adult smokers an alternative to cigarettes; they are not intended to be used to consume illicit substances.

"E-cigarettes and nicotine-containing vapor products are used by millions of adults as an alternative to combustible cigarettes, and most vapor products on the market are of high-quality. Nonetheless, no person should: misuse or alter a vapor device designed for vaping nicotine-containing products by attempting to vape anything other than an e-liquid designed to be used with that device; use any products other than those purchased from a reputable establishment; and use a vapor product offered to them by someone else without knowing precisely what they are consuming.

"FDA has imposed regulatory requirements on nicotine-containing vapor products for more than three years, since August 8, 2016, including strict labeling and packaging restrictions that require vapor companies to, among other requirements, disclose all of the ingredients in the products sold.

"In stark contrast, none of the products designed for THC, cannabis and any other non-nicotine substances are regulated by the FDA.

"Importantly, major medical groups and governments have conclusively determined that vapor products are 95% safer than combustible cigarettes, and studies have shown that they are nearly twice as effective at helping adults quit smoking than traditional methods."

New York Times: "The Mysterious Vaping Illness That’s ‘Becoming an Epidemic’" — "An 18-year-old showed up in a Long Island emergency room, gasping for breath, vomiting and dizzy. When a doctor asked if the teenager had been vaping, he said no.

"The patient’s older brother, a police officer, was suspicious. He rummaged through the youth’s room and found hidden vials of marijuana for vaping.

"'I don’t know where he purchased it. He doesn’t know,' said Dr. Melodi Pirzada, chief pediatric pulmonologist at NYU Winthrop Hospital in Mineola, N.Y., who treated the young man. 'Luckily, he survived.'

"Dr. Pirzada is one of the many physicians across the country treating patients — now totaling more than 215 — with mysterious and life-threatening vaping-related illnesses this summer. The outbreak is 'becoming an epidemic,' she said. 'Something is very wrong.'

"Patients, mostly otherwise healthy and in their late teens and 20s, are showing up with severe shortness of breath, often after suffering for several days with vomiting, fever and fatigue. Some have wound up in the intensive care unit or on a ventilator for weeks. Treatment has been complicated by patients’ lack of knowledge — and sometimes outright denial — about the actual substances they might have used or inhaled."

Washington Post: "As vaping-related lung illnesses spike, investigators eye contaminants" — "State and federal health authorities are focusing on the role of contaminants or counterfeit substances as a likely cause of vaping-related lung illnesses — now up to 354 possible cases in 29 states, nearly double the number reported to be under investigation last week, The Washington Post has learned.

"Officials are narrowing the possible culprits to adulterants in vaping products purported to have THC, the component in marijuana that makes users high, as well as adulterants in nicotine vaping products.

"The sudden onset of these mysterious illnesses and the patients’ severe and distinctive symptoms have led investigators to focus on contaminants, rather than standard vaping products that have been in wide use for many years."

CNBC: "US health officials investigating 215 possible cases of severe lung disease associated with vaping" — "U.S. health officials are investigating 215 possible cases of severe lung disease associated with vaping across 25 states, the Centers for Disease Control and Prevention and the Food and Drug Administration said in a joint statement Friday.

"The agencies said they need more information to understand whether there’s a relationship between specific products or substances and the reported illnesses. As of now, it does not appear the cases are linked to one particular product, the agencies said, noting that in 'many' of the cases, patients reported using THC or CBD, compounds found in cannabis.

"'Even though cases appear similar, it is not clear if these cases have a common cause or if they are different diseases with similar presentations, which is why our ongoing investigation is critical,' CDC Director Robert Redfield and acting FDA Commissioner Ned Sharpless said in a joint statement."