Scientific Article
BY Allison E . James , DVM , MPH , PhD ; 1 , 2 Brandy Sutphin , MPH ; 2 Patrick Fleming , BS , TTS ; 2 Donald McCormick , MSHI ; 2 Appathurai Balamurugan , MD , DrPH , MPH 2 , 3 , 4
1
Epidemic Intelligence Service , Division of Scientific Education and Professional Development ; Centers for Disease Control and Prevention , Atlanta , GA ; 2 Arkansas Department of Health ,
3
Department of Epidemiology , UAMS ; 4 Department of Family and Preventive Medicine , UAMS
Characteristics of E-Cigarette , or Vaping , Product Use-Associated Lung Injury ( EVALI ) Patients
Disclaimer : The findings and conclusions in this report are those of the author ( s ) and do not necessarily represent the official position of the Centers for Disease Control and Prevention .
Abstract
DDuring August – December 2019 , 23 persons who received a diagnosis of e-cigarette , or vaping , product use-associated lung injury ( EVALI ) were reported to the Arkansas Department of Health ( ADH ); none died . Among Arkansas EVALI patients , most were aged < 25 years and white ; two-thirds were male . Approximately half of Arkansas EVALI patients were admitted to intensive care units . Among 18 patients who were interviewed , 61 % reported using both nicotine and tetrahydrocannabinol in an e-cigarette , or vaping , device during the 90 days preceding illness onset . Clinicians should remain vigilant for EVALI and continue to report cases to ADH .
Introduction
During July 2019 in Wisconsin and Illinois , the first cluster of persons with severe lung injury that was eventually termed e-cigarette , or vaping , product use-associated lung injury ( EVALI ) was identified . Common symptoms reported by patients were shortness of breath , nausea , and subjective fever . 1 Characteristic clinical findings included hypoxemia , neutrophilia , lack of evidence of bilateral pulmonary infiltrates on chest radiographs or chest computed tomography ( CT ) images , and an absence of infectious disease etiology . 1 Additional states subsequently reported patients with similar injuries , and on August 16 , 2019 , the Arkansas Department of Health ( ADH ) identified its first EVALI patient .
Since the outbreak started , state health departments , CDC , and the U . S . Food and Drug Administration have worked collaboratively to more fully understand causes , prevention , clinical features , and management of EVALI . This report describes the outbreak and response in
Arkansas to raise clinician awareness , optimize diagnosis and patient care , and promote public health reporting .
Methods
On August 30 , 2019 , ADH re-released CDC ’ s Health Advisory “ Severe Pulmonary Disease Associated with Using E-Cigarette Products ” to health care providers across the state using the voluntary ADH Health Alert Network ( HAN ) system . 2 , 3 In this HAN notification , clinicians were asked to report to ADH any patient with severe pulmonary disease of unclear etiology and a history of e-cigarette , or vaping , product ( EVP ) use during the past 90 days .
All cases summarized in this report have been classified according to CDC ’ s Lung Injury Surveillance Primary Case Definition released on September 18 , 2019 . 4 By definition , “ confirmed ” EVALI cases were patients who reported use of an EVP ≤90 days before symptom onset , had pulmonary infiltrates on chest radiographs or ground glass opacities on chest CT scans , had negative respiratory viral panel , influenza ( if local epidemiology supported influenza testing ), and all other clinically indicated respiratory infectious disease tests , and no alternative plausible diagnoses for pulmonary illness . “ Probable ” EVALI cases were those who met all aspects of the “ confirmed ” definition , except the patient did not have a full infectious disease workup , or a respiratory pathogen was identified but the clinical team believed the infectious agent was not the sole cause of illness .
For all reported cases , patient medical records were requested . Records were received by fax or mail and data regarding demographics , symptoms , clinical course , chest imaging , and infectious disease testing were abstracted and entered into a database ( Research Electronic Data Capture [ RedCap ]; version 8.8.0 ). When patients were available , they were interviewed by telephone about their history of EVP use . Data entered into RedCap were downloaded and descriptive statistics were computed using Microsoft Excel for Office 365 ( version 2002 ).
Results
In total , 23 persons with EVALI were reported to ADH ( eight confirmed and 15 probable cases ). Arkansas EVALI patients reported illness onset during August – December 2019 ; about half ( 12 , 52.2 %) had onset of illness in September ( Figure 1 ).
Table 1 summarizes demographic information ; median age at injury onset was 21 years ( range : 17 – 54 years ), 78.2 % of cases were among
Table 1 . Demographic Characteristics of Arkansas EVALI Patients ( N = 23 )
Age ( yrs )
Sex
No . (%)
< 18 2 ( 8.7 ) 18 – 24 13 ( 56.5 ) 25 – 34 5 ( 21.7 ) 35 – 44 2 ( 8.7 ) 45 – 54 1 ( 4.3 )
Male 15 ( 65.2 ) Female 8 ( 34.8 )
Race / Ethnicity Non-Hispanic White 18 ( 78.3 ) Hispanic , Any Race 4 ( 17.4 ) Non-Hispanic Black 1 ( 4.3 )
ADH Public Health Region of Residence a
Northwest 13 ( 56.5 ) Northeast 2 ( 8.7 ) Central 8 ( 34.8 ) Southwest 0 ( 0 ) Southeast 0 ( 0 ) a
Counties belonging to ADH Public Health Regions can be found at www . healthy . arkansas . gov / health-units
110 • The Journal of the Arkansas Medical Society www . ArkMed . org