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Vitamin E acetate may be major cause of vaping injuries — CDC

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Authorities at the US Centres for Disease Control and Prevention (CDC) are finally zeroing in on one of the substances in vapes that could be making people sick. According to a Mashable report, a new report identifies vitamin E acetate as a cause of the illness that has come to be identified as E-VALI. The CDC reached that determination after 29 E-VALI patients from 10 different states were tested, and the offending substance showed up in every result.

“Vitamin E acetate is used as an additive in the production of e-cigarette, or vaping, products,” the report notes. “This is the first time that we have detected a potential chemical of concern in biologic samples from patients with these lung injuries.”

The report says while this formal identification of vitamin E acetate as a cause of E-VALI represents a positive step, it’s not exactly surprising news. The vitamin supplement was identified in early September as a possible cause, after the US Food and Drug Administration found it in cannabis products used by a number of people who had fallen ill.

“While this is the first common element found in samples from across the country, health officials said it is too early to know whether this is causing the injuries,” the report said it was noted at the time.

The CDC test involved analysing fluid samples collected from patients’ lungs. Out of the 29 patients tested, THC (the psychoactive ingredient in cannabis) was found in 82% of the samples and nicotine was found in 62% of the samples. This suggests that, at this point, any vape poses a potential danger.

The CDC reflects that risk. “CDC continues to recommend that people should not use e-cigarette, or vaping, products that contain THC, particularly from informal sources like friends, or family, or in-person or online dealers,” it cautions. “We will continue to provide updates as more data become available.”

The report says it’s worth pointing out that the higher THC risk factor was first suspected and then later identified in October

Research continues, as it’s still possible that there’s more than one substance behind the E-VALI outbreak. The illness has now shown up in every state except Alaska, as well as Washington, DC and one US territory. In all, 39 deaths have been reported.

While the CDC continues to recommend staying away from vaping products entirely for the time being, the report says it acknowledges that some options are riskier than others. Since THC has popped up in most of the samples tested, the agency recommends avoiding any e-cigarettes or other vaping products that contain THC.

“For the first time we have detected a potential toxin of concern: vitamin E acetate,” CDC principal deputy director Anne Schuchat is quoted in a Business Insider report as saying.

The CDC has taken a look at lung samples taken from 29 patients across 10 different US states and found vitamin E acetate in all of them. “Vitamin E acetate is enormously sticky,” Jim Pirkle, from the CDC’s environmental health lab, said on the call. “You can think of it to be just like honey. And so, when it goes into the lung, it does hang around.”

The CDC said that vitamin E acetate is often found in illicit street-bought vapes. It’s used to dilute liquid in vapes, especially to water down THC, the psychoactive ingredient in dagga. Investigators still aren’t positive that vitamin E is causing harm, but there’s definitely a link between more vitamin E vapes and more injuries.

CDC report
New Laboratory Findings:
Analyses of bronchoalveolar lavage (BAL) fluid samples (or samples of fluid collected from the lungs) of patients with e-cigarette, or vaping, product use associated lung injury identified vitamin E acetate, an additive in some THC-containing products.
Recent CDC laboratory test results of BAL samples from 29 patients submitted to CDC from 10 states identified vitamin E acetate in all BAL fluid samples. THC was identified in 82% of the samples and nicotine was identified in 62% of the samples.

CDC tested for a range of other chemicals that might be found in e-cigarette, or vaping, products, including plant oils, petroleum distillates like mineral oil, MCT oil, and terpenes (which are compounds found in or added to THC products). None of these potential chemicals of concern were detected in the BAL fluid samples tested.

This is the first time that we have detected a potential chemical of concern in biologic samples from patients with these lung injuries. These findings provide direct evidence of vitamin E acetate at the primary site of injury within the lungs.

These findings complement the ongoing work of the FDA and some state public health laboratories to characterise e-liquid exposures and inform the ongoing multistate outbreak.

As the outbreak of lung injuries and deaths associated with vaping continues to spread across the US, researchers at Intermountain Healthcare in Salt Lake City have, meanwhile, effectively developed a best practice treatment guide to quickly identify and treat patients who develop the new and potentially fatal respiratory injury, according to a new study.

“This is still an ongoing outbreak, and not something we’ve seen with vaping before,” said Dr Denitza Blagev, a pulmonary and critical care physician at Intermountain Healthcare, who is the lead author of a new study that outlines best practices for treatment for patients with e-cigarette or vaping-associated lung injury (E-VALI).

The lung injury diagnosis and treatment guidelines developed by Intermountain Healthcare clinicians are based on the cumulative clinical experience of treating more than 60 patients throughout the health system’s 24 hospitals and 215 clinics.

The Intermountain guidelines recommend shorter courses of moderate-dose steroids for patients who are either treated as outpatients, or admitted to hospitals, and higher doses of intravenous steroids that are tapered more slowly for patients who are critically ill on admission. Clinicians also recommend close outpatient follow-up, as complications after initial recovery are recognised.

“Through sharing the guideline, we’re reaching clinicians and keeping e-cigarette or vaping-associated lung injury on everyone’s minds, especially as we enter flu season and diagnosing vaping associated lung injury becomes more challenging,” said Blagev. “We now have a standardised approach to treat these patients, and we’re starting to learn about what the recovery and complications are,” she added. “Time will show us the long-term outcomes and the cause of this new disease, but in the meantime, the surest way to prevent lung injuries associated with e-cigarettes, or vaping, is not to vape.”

In the study, Intermountain Healthcare researchers identified 60 E-VALI patients at 13 different Intermountain hospitals or clinics in Utah from 27 June, 2019, through 4 October, 2019. The diagnosis was defined by a history of vaping or e-cigarette use within 90 days prior to symptoms, abnormalities shown in chest imaging, and no other cause for these findings (such as pneumonia).

While the majority of E-VALI patients were admitted to an intensive care unit, many weren’t critically ill and recovered more quickly. These patients typically had flu-like symptoms, shortness of breath, cough, chest pain, and abdominal symptoms such as nausea, vomiting, and abdominal pain.

Most patients with lung injuries associated with e-cigarettes or vaping were treated with antibiotics (due to overlapping pneumonia symptoms), oxygen, and steroids. While specific infectious disease testing was negative for all of the patients, most received antibiotics, researchers reported.

The Intermountain clinicians attribute the clinical improvement of the patients’ health to the positive effect of the steroids they received. Most patients started to show improvement within days, researchers noted, however, six of the patients – or 10% of those enrolled in the study – relapsed and had complications that required hospital readmission.

The majority of patients who were re-admitted to the hospital had been critically ill when they initially came in for care, and half of them had resumed vaping after discharge, researchers reported.

In the first study to report follow-up findings for these patients, Intermountain clinicians performed a short follow-up exam after two weeks and found that, although most patients had improved significantly, many had residual abnormalities. Only 23% of the patients still needed supplementary oxygen, but most still showed some signs of lung abnormalities on their imaging and breathing tests.

These findings are helping physicians recognise what lung injuries associated with e-cigarettes or vaping look like – and helping them maintain a high degree of suspicion when they diagnose lung injuries in patients who’ve been vaping.

“Being vigilant about obtaining a patient’s vaping history when they’re admitted and keeping it in mind throughout their hospital stay, is essential,” said Blagev. “For some patients in our study, their vaping history didn’t emerge until they were well into the course of their disease.”

While the majority of E-VALI patients vaped THC, some reported only vaping nicotine. Intermountain researchers reported no clear pattern emerged in terms of vaping device or the source of the vaping liquids among the patients. Patients in the study reported obtaining vaping e-liquids from local dealers or vape shops, friends, or social medial apps.

Without a known cause of e-cigarette or vaping-associated lung injury, current recommendations are to avoid all e-cigarette or vaping exposure, Intermountain researchers advised in the study.

According to the CDC, 1,888 cases of e-cigarette or vaping-associated lung injury have been reported in the US, including 37 deaths in 24 states. In Utah, 109 cases of E-VALI have been confirmed, with another seven cases under investigation in the state, as of 28 October.

Blagev and her colleagues at Intermountain began to see E-VALI patients early last summer. The first case at Intermountain was recognised by pulmonologist Dr Dixie Harris, who, through her work in the Intermountain TeleHealth Critical Care service, noticed a cluster of patients seeking treatment at multiple Intermountain hospitals throughout Utah.

The Intermountain TeleHealth Critical Care service is a system-wide proactive monitoring and response centre where intensivist physicians and critical care nurses monitor data on large patient populations and provide clinical decision support remotely as bedside staff care for individual patients in hospitals throughout the Mountain West.

The Intermountain TeleHealth Critical Care service allowed the rapid formation of a centralised task force, which enabled tracking and public reporting of cases, and sharing of clinical expertise among clinicians, according to the study.

“The use of the TeleHealth Critical Care service allowed us to recognise the outbreak much earlier than if we had only relied on reports of separate cases in individual hospitals,” Blagev noted.

Abstract
Background: An ongoing outbreak of lung injury associated with e-cigarettes or vaping (also known as E-VALI or VALI) started in March, 2019, in the USA. The cause, diagnosis, treatment, and course of this disease remains unknown.
Methods: In this multicentre, prospective, observational, cohort study, we collected data on all patients with lung injury associated with e-cigarettes or vaping seen in Intermountain Healthcare, an integrated health system based in Utah, USA, between June 27 and Oct 4, 2019. Telecritical care, based in Salt Lake City, UT, USA, was used as the central repository for case validation, public reporting, and system-wide dissemination of expertise, which included a proposed diagnosis and treatment guideline for lung injury associated with e-cigarettes or vaping. We extracted data on patient presentation, treatment, and short-term follow-up (2 weeks after discharge) from chart review and interviews with patients undertaken by the Utah Department of Health (Salt Lake City, UT, USA).

Findings: 60 patients presented with lung injury associated with e-cigarettes or vaping at 13 hospitals or outpatient clinics in the integrated health system. 33 (55%) of 60 were admitted to an intensive care unit (ICU). 53 (88%) of 60 patients presented with constitutional symptoms, 59 (98%) with respiratory symptoms, and 54 (90%) with gastrointestinal symptoms. 54 (90%) of 60 were given antibiotics and 57 (95%) were given steroids. Six (10%) of 60 patients were readmitted to an ICU or hospital within 2 weeks, three (50%) of whom had relapsed with vaping or e-cigarette use. Of 26 patients who were followed up within 2 weeks, despite clinical and radiographic improvement in all, many had residual abnormalities on chest radiographs (ten [67%] of 15) and pulmonary function tests (six [67%] of nine). Two patients died and lung injury associated with e-cigarettes or vaping was thought to be a contributing factor, but not the cause of death, for both.
Interpretation: Lung injury associated with e-cigarettes or vaping is an emerging illness associated with severe lung injury and constitutional and gastrointestinal symptoms. Increased awareness has led to identification of a broad spectrum of severity of illness in patients who were treated with antibiotics and steroids. Despite improvement, at short-term follow-up many patients had residual abnormalities. Lung injury associated with e-cigarettes or vaping remains a clinical diagnosis with symptoms that overlap infectious and other lung diseases. Maintaining a high index of suspicion for this disease is important as work continues in understanding the cause or causes, optimal therapy, and long-term outcomes of these patients.

Authors
Denitza P Blagev, Dixie Harris, Angela C Dunn, David W Guidry, Colin K Grissom, Michael J Lanspa

Mashable report

Business Insider report

CDC report

Intermountain Medical Centre material

The Lancet abstract

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