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The Colorado Department of Public Health and Environment is investigating what could be the state’s first vaping-related death. It likely will take at least six weeks for autopsy results to confirm whether the death of an 18-year-old man from the Denver area stemmed from the mysterious vaping-related illness that has been detected across the country, a department spokeswoman said. https://www.denverpost.com/2019/10/24/colorado-vaping-related-death/

DC Health @_DCHealth The District of Columbia Department of Health (DC Health) has confirmed one death associated with vaping.

Thread for tallying EVALI vaping cases.

2019 Lung Injury in Illinois Cases* Individuals needing more investigation Deaths ** 153 41 2 Updated October 24, 2019 *Case means evidence of respiratory illness, with no other cause identified, and report vaping in the last 90 days. ** Death included in the number of cases Cases in Chicago and Bureau, Cass, Champaign, Cook, DeKalb, DuPage, Fulton, Henry, Kane, Kendall, Knox, Lake, LaSalle, Macoupin, Madison, Marion, McHenry, Peoria, Perry, Rock Island, Sangamon, St. Clair, Tazewell, Vermilion, Wabash, Whiteside, Will, Winnebago, and Woodford counties. Ages - 13-66 years. Median age - 22 years. Updates will be posted by end of day on Thursdays. http://www.dph.illinois.gov/topics-services/prevention-wellness/tobacco/e-cigarettes-and-vapes

Updated October 23, 2019. This information is updated on Thursday each week. REPORTS CASES Number investigated 26 Confirmed 3 Probable 0 Pending classification 0 Not a case 23 https://www.healthvermont.gov/response/infectious-disease/lung-injury-associated-e-cigarette-use-2019

The median age of patients who have died is 49 years, ranging from 17 to 75 years old https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#latest-outbreak-information

What CDC is Doing Public Health Response: CDC’s Lung Injury response efforts are committed to: Identify and define the risk factors and the source for lung disease associated with e-cigarette product use, or vaping. Detect and track confirmed and probable cases in the US. Communicate actionable recommendations to state, local, and clinical audiences. Establish lab procedures that can assist with the public heath investigation and patient care. Partnerships: CDC is working 24/7 to identify the cause or causes of this outbreak through partnerships with states and other federal agencies. CDC continues to work closely with FDA, states, public health partners, and clinicians on this investigation by providing consultation and technical assistance to states on communication, health alerts, public outreach, and surveillance. CDC has activated the Emergency Operations Center (EOC) to coordinate activities and provide assistance to states, public health partners and clinicians around the nation. CDC worked with states to create primary and out-of-hospital case definitions to classify confirmed and probable cases in a consistent way. States are in the process of classifying patients. We expect that states and clinicians may look back for past lung injury cases based on CDC’s case definition CDC will report numbers of confirmed and probable lung injury cases once states have finalized their classification of cases. By invitation, CDC has deployed Epidemic Intelligence Service (EIS) officers and other CDC staff to support states. Media and Communication: CDC is maintaining an outbreak webpage with key messages and weekly updates on case counts, deaths, and resources. CDC is holding congressional briefings, media telebriefings, and regular calls with health departments, clinicians to provide timely updates. Laboratory Testing: CDC and FDA are expanding the range of available laboratory testing. CDC is currently testing bronchoalveolar lavage (BAL) fluid samples, as well as blood or urine samples paired to BAL fluid samples. CDC is testing pathologic specimens, including lung biopsy or autopsy specimens, associated with patients. CDC is offering aerosol emission testing of case-associated product samples from e-cigarette, or vaping, products and e-liquids. Analysis of aerosol emissions will augment FDA’s ongoing work to characterize e-liquid and will improve our understanding of exposure among case-patients associated with the Lung Injury outbreak. CDC is coordinating e-cigarette, or vaping, product analysis with FDA. Results may provide insight into the nature of the chemical exposure(s) contributing to this outbreak. CDC developed guidance documents for were created to assist public health laboratories, healthcare providers, and pathologists, and others, with specimen collection, storage, and submission. For more information and resources visit For the Public, For Healthcare Providers and For State and Local Health Departments as well as our Publications and Resources page. * The increase in lung injury cases from last week represents both new patients and recent reporting of previously-identified patients to CDC. ** Based on complete reports received.

Latest Outbreak Information Updated every Thursday This complex investigation spans almost all states, involves over a thousand patients, and a wide variety of brands and substances and e-cigarette, or vaping, products. Case counts continue to increase and new cases are being reported, which makes it more difficult to determine the cause or causes of this outbreak. As of October 22, 2019, 1,604* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 1 U.S. territory. Thirty-four deaths have been confirmed in 24 states: Alabama, California (3), Connecticut, Delaware, Florida, Georgia (2), Illinois (2), Indiana (3), Kansas (2), Massachusetts, Michigan, Minnesota (3), Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon (2), Pennsylvania, Tennessee, Texas, Utah, and Virginia. More deaths are under investigation. The median age of deceased patients was 49 years and ranged from 17 to 75 years. Data on age, sex, and substances used in e-cigarette, or vaping, products will be updated in the MMWR report being released on Friday, October 25, 2019. See CDC’s Lung Injury cases map and bar chart of dates of symptoms onset and hospital admission for Patients with e-cigarette, or vaping, product use associated lung injury (EVALI) for more details. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html

Media Statement For Immediate Release Thursday, October 24, 2019 Contact: CDC Media Relations (404) 639-3286 CDC, states update number of cases of lung injury associated with use of e-cigarette, or vaping, products CDC today announced the updated* number of confirmed and probable lung injury cases and deaths associated with the use of e-cigarette, or vaping, products. Patients with Lung Injury As of October 22, 2019, 1,604 confirmed and probable lung injury cases associated with use of e-cigarette, or vaping, products were reported by 49 states (all except Alaska), the District of Columbia, and the U.S. Virgin Islands. Data on age, sex, and substances used in e-cigarette, or vaping, products will be updated in a CDC MMWR report being released on Friday, October 25, 2019. Deaths 34 deaths have been confirmed in 24 states: Alabama, California (3), Connecticut, Delaware, Florida, Georgia (2), Illinois (2), Indiana (3), Kansas (2), Massachusetts, Michigan, Minnesota (3), Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon (2), Pennsylvania, Tennessee, Texas, Utah, and Virginia. The median age of patients who have died is 49 years, ranging from 17 to 75 years old. For updates on this investigation, visit: www.cdc.gov/lunginjury. For information about the collection of e-cigarette products for possible testing by FDA, contact:[email protected]. For information about collection and submission of clinical specimens for possible testing by CDC, see CDC’s Healthcare Provider web page. For information about collection and submission of e-cigarette, or vaping, products and e-liquids associated with confirmed or probable cases for possible aerosol emissions testing by CDC, contact:[email protected]. Clinicians and health officials who have questions about this outbreak can contact:[email protected]. All others, including the general public, who have questions about this outbreak can contact CDC-INFO at 800-232-4636, or visit wwwn.cdc.gov/dcs/ContactUs/Form. *This update will be posted online later today.

34 deaths have been confirmed in 24 states: Alabama, California (3), Connecticut, Delaware, Florida, Georgia (2), Illinois (2), Indiana (3), Kansas (2), Massachusetts, Michigan, Minnesota (3), Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon (2), Pennsylvania, Tennessee, Texas, Utah, and Virginia. The median age of patients who have died is 49 years, ranging from 17 to 75 years old https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#latest-outbreak-information

As of October 22, 2019, 1,604* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 1 U.S. territory. Thirty-four deaths have been confirmed in 24 states: Alabama, California (3), Connecticut, Delaware, Florida, Georgia (2), Illinois (2), Indiana (3), Kansas (2), Massachusetts, Michigan, Minnesota (3), Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon (2), Pennsylvania, Tennessee, Texas, Utah, and Virginia. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#latest-outbreak-information

Interview on 9/23/19 discussing lead based solder use in vaping devices (initially at 5:00 and in detail at 18:30) http://mediaarchives.gsradio.net/rense/special/rense_092319_hr1.mp3

Confirmed or probable cases: 78Confirmed deaths: 3Cases under review: 35Updated Wednesday, 23-Oct-2019 10:06:45 CDT https://www.health.state.mn.us/diseases/lunginjuries/index.html

Virginia Situational Update As of October 22, 2019, there have been 67 cases including 1 reported death, associated with this outbreak in Virginia. Region Confirmed Probable Total Central Region 2 1 3 Eastern Region 10 9 19 Northern Region 15 13 28 Northwest Region 3 8 11 Southwest Region 5 1 6 Total 35 32 67 These case counts are based on the September 18, 2019 CDC case definition. http://www.vdh.virginia.gov/vdhlivewell/vaping/

As of 10/24/2019, 61 cases have been reported in individuals in North Carolina ranging in age from 13 to 72 years. (Note: We plan to update case counts by 4:00 pm on Thursdays.) Patients experienced severe respiratory symptoms including cough and shortness of breath. Patients also reported experiencing fever, fatigue, chest pain, nausea, vomiting, and diarrhea. Most cases have been hospitalized and have required respiratory support. No deaths have been reported. https://www.tobaccopreventionandcontrol.ncdhhs.gov/ecigs/

Cases of Vaping-related Lung Disease in New Mexico: 17 (The case count is updated weekly, on Thursdays) Of those interviewed (N=12), ten reported THC use. Two patients reported only nicotine use. This is similar to national exposure information. All 17 cases in New Mexico were hospitalized with 12 cases requiring intensive care. Age ranges of cases: 13 – 46 years Counties with cases include: Bernalillo, Santa Fe, Los Alamos, Curry, Sandoval, San Juan, Valencia, and Quay. https://nmhealth.org/about/erd/eheb/vri/

As of 10/18/2019, the Michigan Department of Health and Human Services has identified 39 (21 confirmed and 18 probable) cases of severe lung disease associated with vaping. The department is investigating an additional twelve possible cases that have been reported by health care providers. Starting the week of October 26, 2019, case counts will be updated once a week on Fridays rather than every weekday. https://www.michigan.gov/mdhhs/0,5885,7-339-71550_5104_53072---,00.html

Cases of Vaping-Associated Lung Injury (as of October 22, 2019): 38 https://phpa.health.maryland.gov/OEHFP/EH/Pages/VapingIllness.aspx

'A gigantic uncontrolled experiment' Dumas de Rauly, CEO of vape company The Blinc Group, said testing labs looking for contaminants might not have the right equipment, including "puff" machines to replicate real-world use. He also noted testing by different labs has yielded wildly divergent results for identical products made by his company. An assortment of vape cartridges purchased by Queens, New York resident Gregory Rodriguez before he fell ill in September and was hospitalized with breathing failure. (Photo: Gregory Rodriguez) "When you change states, you have different molecules in play. When things are heated and transported as aerosols, they can become toxic," said Dumas de Rauly, who also serves as chairman of the International Organization for Standardization standards committee on vaping products. The Swiss-based ISO is a non-profit group that establishes standards for everything from food safety to shipping containers and the strength of bolts used on railroads. Dumas de Rauly said standardized testing would go a long way to helping regulators understand the causes behind the outbreak. "Who knows what's happening," Hilpert, the Columbia University professor said. "It's like a gigantic uncontrolled experiment where the people it's tested on include millions of young people." Narasimhan, who has seen the lung illnesses firsthand, said there are no clear answers now. Millions of people vaped without incident for years, she noted. "A year ago, the same number of people vaped, and we weren't seeing this. Something has changed. Something has changed in the product and I wish I knew what it was," she said. "We don't know how to stop it because we don't know what's causing it."

The case for vaping regulation In the majority of aerosol samples analyzed, the researchers found levels of carcinogenic metals in fumes above the minimal risk levels for safe air set by the Department of Health and Human Services. Those levels are not contained in regulations for the devices, and manufacturers trying to cut corners might be using lead or cadmium-based solder and other dangerous metals, experts consulted by USA TODAY said. Frank Conrad, who owns the cannabis testing facility Colorado Green labs, suggested recently that cadmium has “the motive, means, and opportunity to cause the illness.” Heavy metal particles can be easily carried on a stream of vapor, he said and don’t need to hit the melting point of the metals. Devin Alvarez, founder and CEO of Straight Hemp Products, said his products use ceramic heating coils and other premium components because they’re believed to be safer than metal coils can dissolve under high heat. “Looking at the hardware is critical as it can be a source of harm for the user if not chosen properly,” said Alvarez. He recommends regulation of the industry, including the hardware, perhaps through UL, a global safety certification company overseen by the Food and Drug Administration. “Vaping is a nascent technology and the cannabis industry has the knowledge, but not the infrastructure to regulate itself,” said Alvarez. “That’s why we’re looking to partner with the federal government and anyone else regulating.”

What's in the 'juice'? The federal Food and Drug Administration said it has more than 725 samples, including vaping devices and products that contain liquid, packaging and nearly empty containers to test and the Centers for Disease Control and Prevention is also developing standards for how to test what users inhale. While most people who've been sickened were consuming marijuana-based products, a few said they consumed only nicotine-based vape juice. Vape pens can be used for THC or other cannabis-based oil or nicotine liquid. The "juice" comes either in a bottle that users can top up their tank with, or in pre-packaged cartridges, depending on the design. Despite the name, the devices don't actually vaporize the liquid, but rather turn it into an aerosol. Substances that might be perfectly safe to eat or rub on your skin become something entirely different when heated on a metal or ceramic coil, experts say. And the devices themselves may also be emitting toxic chemicals, particularly if they are held together with lead or cadmium solder. Markus Hilpert is an associate professor of environmental health sciences at Columbia University's Mailman School of Public Health (Photo: Columbia University) The heating coil itself is the likely source of most inhaled metals, Johns Hopkins University environmental health professor Ana Rule concluded in a February 2018 report. Her study examined refillable vape devices with metal coils. The coils, she wrote, are typically composed of “complex metal alloys” but she noted other parts of the device may contribute metals. Additional sources could be the machines used to extract the THC from marijuana plants, or even the solder used to connect metal parts within the vape devices. In her report, Rule said the results suggest “several metals are being transferred from the device to the e-liquid in the tank as well as to the aerosol that is inhaled by the user.” Columbia University associate professor of environmental health sciences Markus Hilpert said metal coils on tested refillable devices often lacked the shine they started with after a few weeks of use, suggesting they'd become oxidized. Metals can then become combined with the e-liquid after the devices are heated. Hilpert's group uses a method for the collection of aerosol directly from devices, which is needed to differentiate ingredients inhaled from the liquids.

While many vape pens are manufactured in sophisticated factories, others are cobbled together by online retailers, mom-and-pop shops or vaping enthusiasts. The devices, known as vape pens or e-cigarettes, have been around for more than a decade, and hundreds of different styles and types have flooded the market in recent years, with clunkier, refillable devices being replaced by smaller, harder-to-hack models with scant regulation of how they are made or what they might release when heated. “If you’re buying cheap hardware from China, you never know what’s going on there,” said Arnaud Dumas de Rauly, a vaping expert helping develop international regulations. “In a certain sense, I’m happy we are having this vaping crisis. It points the finger at some things that should not be in these products.”

Dr. Mangala Narasimhan carefully inserted the long, thin probe down Gregory Rodriguez's throat, snaking it past his vocal cords and deep into his damaged lungs. A ventilator breathed for the 22-year-old college student as Narasimhan began sucking out the yellow, jelly-like clots that had nearly killed him. "It really was gross," said Narasimhan, a lung specialist and director of critical care medicine at Northwell Health in New Hyde Park, New York. Rodriguez`s case is an extreme example of the variety of lung illnesses that have sickened an estimated 1,479 people and killed at least 33 who vaped THC, nicotine or a combination. His lungs had failed so badly last month Narasimhan's team had to oxygenate his blood for several days by pumping it out through his neck and into an artificial lung. Queens, New York resident Gregory Rodriguez is shown in this selfie before he fell ill in September and was hospitalized with breathing failure connected to vaping. (Photo: Gregory Rodriguez) Rodriguez got sick after vaping an average of one “cart” a day of, among others, Dank Vapes brand marijuana extract he bought illegally online. That counterfeit brand is cited in many of the lung injuries studied, but there is no one device, brand or ingredient linked to all the cases. "I guess I put too much trust in them. They just seemed so legit," said Rodriguez, now recovering at home. "I never thought that someone would put poisons inside a vape cart, never thought they would put a person's life at risk to save a few bucks." Government doctors and scientists are racing to uncover the cause of the outbreak, which initially was blamed on tainted vape oil containing cannabis or nicotine extracts. But researchers and regulators also are scrutinizing the myriad of vape devices themselves, many of which are manufactured in China without U.S. government or third-party safety checks. Vapers, who often see the devices as safer and healthier than cigarettes, are potentially inhaling a toxic stew of atomized oils, an aircraft de-icing chemical, and toxic heavy metals leaching from the heating elements used to create the "smoke." “This appears to be an unforeseeable mixture of elements resulting from the combination of metal, heat, THC and liquid, causing very different lung injuries,” said Dr. Tony Casolaro, a former clinical chief of the pulmonary medicine branch at the National Institutes of Health, who is now a clinical professor at Georgetown University’s medical school. Government doctors and scientists are racing to uncover the cause of the outbreak, which initially was blamed on tainted vape oil containing cannabis or nicotine extracts. But researchers and regulators also are scrutinizing the myriad of vape devices themselves, many of which are manufactured in China without U.S. government or third-party safety checks. Vapers, who often see the devices as safer and healthier than cigarettes, are potentially inhaling a toxic stew of atomized oils, an aircraft de-icing chemical, and toxic heavy metals leaching from the heating elements used to create the "smoke." “This appears to be an unforeseeable mixture of elements resulting from the combination of metal, heat, THC and liquid, causing very different lung injuries,” said Dr. Tony Casolaro, a former clinical chief of the pulmonary medicine branch at the National Institutes of Health, who is now a clinical professor at Georgetown University’s medical school.

STORY HIGHLIGHTS The Centers for Disease Control has linked vaping to nearly 1,500 lung illnesses and 33 deaths. The vaping device’s heating coil is the likely source of most inhaled metals, according to a February 2018 report. Columbia University associate professor: “It’s like a gigantic uncontrolled experiment where the people it’s tested on include millions of young people.”