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At this time, the Montana Department of Public Health and Human Services (DPHHS) has one confirmed case in Montana. https://dphhs.mt.gov/publichealth/mtupp/vapingpulmonarydisease

As of 9/26/2019, the Michigan Department of Health and Human Services has identified 20 (13 confirmed and seven probable) cases of severe lung disease associated with vaping. The department is investigating an additional 10 possible cases that have been reported by health care providers.

What It Is The Centers for Disease Control and Prevention, U.S. Food and Drug Administration, state and local health departments and other clinical and public health partners are investigating a multistate outbreak of severe pulmonary disease associated with e-cigarette product (devices, liquids, refill pods and/or cartridges) use. This investigation is ongoing and has not identified a cause, but all reported cases have a history of using e-cigarette products. E-cigarettes are devices that deliver an aerosol to the user by heating a liquid that usually contains nicotine, flavorings and other chemicals. E-cigarettes also can be used to deliver marijuana or other substances. Clinicians should report suspected cases to the Kentucky Department of Public Health (DPH) using the Kentucky Reportable Disease Form. Documentation Kentucky Reportable Disease Form (EPID 200) Clinician Alert, Severe Pulmonary Disease Related to Use of E-cigarettes or Vaping Fact Sheet on E-cigarettes and Severe Pulmonary Disease - 09272019 Pulmonary Disease Associated with Vaping Cases Reported for Investigation: 20 Ruled Out Cases: 2* Probable Cases: 3 Confirmed Cases: 1 Ruled out cases were reported but during investigation were determined not to include a documented history of vaping, or otherwise do not meet the case definition. Updated: Friday, September 27, 2019 at 3:00 pm. Additional Information CDC Severe Lung Disease Information Contact Information Phone:(502) 564-7212, ext. 4427 Mailing Address 275 E. Main St. Frankfort, KY 40621 MA, Director : Gary L. Kupchinsky [email protected] Related Agencies Department for Public Health Division of Maternal and Child Health Child and Family Health Improvement Branch Early Childhood Development Branch Health Promotions Branch Nutrition Services Branch

Pulmonary Disease Associated with Vaping Cases Reported for Investigation: 20 Ruled Out Cases: 2* Probable Cases: 3 Confirmed Cases: 1 Ruled out cases were reported but during investigation were determined not to include a documented history of vaping, or otherwise do not meet the case definition. Updated: Friday, September 27, 2019 at 3:00 pm. https://chfs.ky.gov/agencies/dph/dmch/hpb/Pages/pd-information.aspx

Iowa Weekly Case Information (Numbers are cumulative) August 30, 2019 - 7 cases (young to middle-age adults); 5 of 7 cases reported vaping THC September 6, 2019 - 8 cases (young to middle-age adults); 7 of 8 cases reported vaping THC September 13, 2019 - 13 cases (young to middle-age adults); 12 of 13 reported vaping THC September 20, 2019 - 15 cases (young to middle-age adults); 14 of 15 cases reported vaping THC September 27, 2019 - 23 cases (ages range from 17 to 60); 18 of 23 cases reported vaping THC

Severe Respiratory Illness Associated With Vaping – Idaho update Last updated: September 27, 2019 Cases among Idaho residents: 6 This page will be updated each Friday by 2:00pm MT Public health district of residence Number of cases Central District Health 2 Panhandle Health District 1 Southwest District Health 1 South Central District Health 1 Southeastern Idaho Public Health 1 https://healthandwelfare.idaho.gov/LinkClick.aspx?fileticket=nwItu85SJbc%3d&tabid=111&portalid=0&mid=17980

The California Department of Public Health (CDPH) urges everyone to refrain from vaping, no matter the substance or source, until current investigations are complete. Since June 2019, CDPH has received reports that 100 people in California who have a history of vaping were hospitalized for severe breathing problems and lung damage, and two people have died

THC Products May Play a Role in Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping Investigation ongoing, no single product linked to all cases, but patterns emerge Press Release Embargoed Until: Friday, September 27, 2019, 1:00 p.m. ET Contact: Media Relations (404) 639-3286 The latest findings from the investigation into lung injuries associated with e-cigarette use, or vaping, suggest THC products play a role in the outbreak. Most of the people (77%) in this outbreak reported using THC-containing products, or both THC-containing products and nicotine-containing products, according to a report published today in the CDC’s Morbidity and Mortality Weekly Report (MMWR). Though the investigation is ongoing and the cause remains unknown at this time, today’s report provides the first national comprehensive data on the characteristics of cases reported to CDC, including sex, age, and select substances used in e-cigarette, or vaping products. A second MMWR released today from Wisconsin and Illinois had similar findings regarding THC use and contains more details on the characteristics of cases in those states, including demographics, as well as substances and product types used. Based on this recent data, CDC recommends people consider refraining from use of e-cigarette or vaping products, particularly those containing THC. “CDC is committed to finding out what is causing this outbreak of lung injury and death among individuals using vaping products” said Robert R. Redfield, MD, director of the Centers for Disease Control and Prevention. “We continue to work with FDA and state partners to protect the nation from this serious health threat.” More information is needed to know whether a single product, substance, or brand is responsible for the lung injuries. Unraveling outbreaks such as this requires the collection and analysis of complex information. This epidemiologic investigation is particularly challenging given that it involves hundreds of cases across the country, and patients report use of a wide variety of products and substances. According to CDC’s national-level report, data about substances used in e-cigarettes, or vaping, products were self-reported by 514 patients. Of the patients who reported what products they used: About 77% reported using THC-containing products, with or without nicotine-containing products; 36% reported exclusive use of THC-containing products; and 16% reported exclusive use of nicotine-containing products. In addition, the report from Illinois and Wisconsin showed that nearly all THC-containing products reported were packaged, prefilled cartridges that were primarily acquired from informal sources such as friends, family members, illicit dealers, or off the street. As of September 24, 2019, 805 confirmed and probable cases of lung injury associated with e-cigarette product use, or vaping, have been reported to CDC by 46 states and the U.S. Virgin Islands. Those cases included 12 deaths in 10 states (CA (2), GA, FL, IL, IN, KS (2), MN, MO, MS, OR). More than two-thirds of patients are male. The median age of cases is 23 years, with about 62 % of patients aged 18-34 years, according to the new report. More information about the investigation is available on the CDC website at www.cdc.gov/lunginjury. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html

Transcript of CDC Telebriefing: CDC Update on Pulmonary Illnesses Press Briefing Transcript Friday, September 27th, 2019 Audio recording media icon[MP3 – 5 MB] Please Note: This transcript is not edited and may contain errors. OPERATOR: Good morning, everyone. Thanks for dialing in for today’s conference. Please continue to stand by. We’ll begin our conference momentarily. Once again thanks for dialing in for today’s conference call. Our conference will begin momentarily. MODERATOR: Welcome everyone to today’s conference call. At this time your lines have been placed on listen only for today’s conference until the question and answer portion are of our call at which time, you’ll be prompted to push star 1 on your touch tone phone. Record your name and media affiliation. To be introduced to ask your question. Our conference is being recorded and if you have any objections you may disconnect at this time. KD Hoskins. You may proceed. MODERATOR: Thank you for joining us on the update on investigation among people who use e-cigarettes or vape. We’re joined today by Anne Schuchat, principal deputy director, CDC. Dr. Schuchat will provide us this week’s update on our support of the lung injury investigation. We’re join today by Dr. Jennifer Layden, chief medical officer and state epidemiologist for the Illinois Department of Public Health. Also, Dr. Jon Meiman, chief medical officer with the Bureau of Environmental and Occupational Health for the Wisconsin Department of Health Services. In addition, during our Q&A session Dr. Brian King who is our deputy incident manager for this response, and deputy director for research translation in CDC’s Office on Smoking and Health will join us to answer any additional questions that you may have. I’ll now turn the call over to Dr. Schuchat. Dr. Anne Schuchat: Thank you all for joining us for today’s briefing. I want to provide a national update on lung injury associated with the use of e-cigarettes or vaping products, including the latest data on cases, death and a snap shot product use. Much more detail will be provided on the experience of patients from my colleagues in Wisconsin and Illinois. We are in the midst of a complex investigation that spans nearly all states, involving serious life threatening disease in young people who report use of wide variety of products and substance in a dynamic marketplace for e-cigarettes or vaping products, which may have a mix of ingredients, complex packaging and supply chain, and includes potentially illicit substances in any given state. Users do not know what is in their e-cigarette or e-liquid solution. Moreover, many of the products and substances themselves can be modified by a supplier or user. They can be obtained from brick-and-mortar stores, online retailers, on the street, or through social sources. First, let me share the latest pictures. As of September 24th, 805 confirmed and probable cases of lung injury associated with e-cigarette use or vaping were reported to us by 46 states and the U.S. Virgin Islands. Sadly, 12 deaths have been confirmed in ten states. More than two-thirds of patients are male, and the median age of cases is 23 years. About 62% of patients were age 18 to 34 years, and 54% were under 25 years of age. Two reports were released today. One national and the other presenting data from Illinois and Wisconsin. These reports suggest that THC containing products play a role in the recent cases. On the national level out of 514 patients with exposure histories, we found 77% reported using THC containing products or using both THC containing products and nicotine containing products. Information about substance use was self-reported by the 514 patients. Of the patients that reported what products they used, THC containing products were the most prominent link across patients. With only 16% reporting using only nicotine containing products. We do not know at this time if the products linked with disease in Illinois and Wisconsin are also linked to cases in geographically remote parts of the country, and this is a key issue for further investigation. We do not know yet what exactly is making people sick. For example, whether solvents or adulterants are leading to lung injury or whether cases stem from a single supplier or multiple ones. The illnesses we have been seeing are serious. We are committed to share information as we learn more and update our guidance based on the latest data. Based on the most recent reports, CDC recommends people consider refraining from use of e-cigarette or vaping products particularly those containing THC. Because of the variety of chemicals that are present in e-cigarettes or vaping liquids and may be added to e-cigarettes or vaping liquid as well as the diversity of products in circulation, laboratory analysis may be complex, but these are ongoing. We don’t want to see any more vaping related illnesses, and as such I want to stress that we at CDC are concerned about the occurrence of life-threatening illness in otherwise healthy young people reported from around the country. I want to thank the clinicians and public health staff working hard to find answers and care for patients and their families. And I now would like to invite Dr. Jon Meiman of Wisconsin to share key information that has emerged from the state investigation. Dr. Jon Meiman: Thank you for the opportunity to speak today and discuss some of the findings in our articles being published. As listeners may be aware Illinois and Wisconsin were at the forefront of this complex public health investigation. We’ve been working very closely with clinicians, states, the CDC and other federal partners over the past two months. The number of infected individuals continues to increase and sadly we’re seeing cases of severe lung injury in teenagers, young adults and other vulnerable groups. So, it’s critical that state and federal public health agencies make every effort to determine the possible cause and prevent future cases. As we outlined in our article today, Illinois and Wisconsin began conducting detailed interviews with patients with lung injury in July to better understand their use of e-cigarettes or vaping products. Our main goals were to identify if one or more products or drugs were shared in common. These interviews were conducted by both state and local health department staff and we obtained extensive information on these products using the three months before patients began experiencing symptoms. We specifically focused on the type of drugs used, where they were obtained, names of specific brands and types of devices used. It’s important to bear in mind these findings are based on self-report and may be limited by hesitancy to disclose information. In total we interviewed 86 patients across both states. Approximately two-thirds of patients were under 25 years of age and were predominantly male. The illness among interviewed patients were severe with nearly 60% admitted to an intensive care unit. We appreciate the willingness of these patients to work with public health about their use of e-cigarettes or vaping products and thank them for providing information that will hopefully help this investigation going forward. I’ll hand this over to Dr. Jennifer Layden with Illinois Department of Public Health to discuss the findings in greater detail. Dr. Jennifer Layden: Thank you Dr. Meiman. I would like to reiterate the gratitude expressed by Dr. Meiman to patients and family members who have participated in these in-depth interviews. Again, thank you to the clinicians, local health departments, and investigative teams who have tirelessly investigated these cases. We are grateful to the collaboration with our CDC colleagues and are committed to continuing our coordinated efforts on these investigations. Similar to previous reports and national findings released today we continue to find most patients with vaping related lung injury report the use of THC based products with or without the use of nicotine-based products. However there does remain a proportion of individuals who continue to report only using nicotine-based products. Several new findings reported in this MMWR – we would like to highlight. First, a large and diverse number of products and brands were reported by patients. Among all 86 patients in our study, 234 unique e-cigarette or vaping products across 87 different brands were reported. While no one brand was reported by all patients, pre-filled THC cartridges labelled under the brand name Dank Vapes was most common. With 66% of all patients reporting this name. Second, despite not having consistency in product or brand names the vast majority of products used were pre-packaged, pre-filled cartridges. Of all the THC base products that were used and reported to us, 96% were pre-packaged, pre-filled cartridges. Patients did not report adding substances to their products. Third, individual patients used numerous products and brands before becoming ill. Patients who used THC based products on average used 2.1 different brands and patients who used nicotine-based products on average used 1.3 different brands with some reporting up to seven different THC products. Majority of patients used products at least daily and often numerous time throughout the day. Finally, THC products were most often acquired from informal sources such as on the street, from friends or from a dealer. These findings do highlight predominant use of pre-packaged, pre-filled THC cartridges obtained through informal sources. At this time, however, we can unfortunately not identify one product, brand, source or device that’s common across all patients. Given the vast number and diversity of products and brands reported and without definitive lab testing results and continued uncertainty regarding the causative agents we in Illinois continue to recommend individuals to refrain from using e-cigarettes or vaping products particularly those that are THC based. While this investigation is ongoing. We encourage to you talk to your family, friends and children to ensure they are aware of the potential risks. Illinois and Wisconsin remain committed to this investigation in working with other key partners including the CDC in the efforts to identify the cause or causes of these severe lung injuries. Thank you. MODERATOR: Thank you to our speakers and now Jill we’re ready for our Q&A session. OPERATOR: Thank you. At this time, we would like to open up the lines for q and a. If you would like to ask a question over the phone, please press star 1. Record your names to be introduced and record your affiliation. Please stand by for our first question. Our first question is from Lena Sun from “the Washington post”. Ma’am, your line is open. Lena Sun, Washington Post: This is a question for Dr. Layden. Thank you very much for your information. So, in the pre-filled THC cartridges that these kids said, these people said he they used what has the testing shown that was in them? Were there specific adulterants and if so, did they include vitamin e acetate? Dr. Jennifer Layden: At this time, we don’t know the substances found in products. All products have been sent to the FDA for testing and those results are pending. Lena Sun, Washington Post: I have a follow up question. Did they say for the people who ordered the vape cartridges did they order them mostly online or get them mostly from friends or dealers? Dr. Jennifer Layden: The vast majority of patients received their products on the streets from friends or dealers. MODERATOR: Next question, Jill. OPERATOR: Our next question is from Mike with Associated Press. Your line is open, sir. Mike Stobbe, Associated Press: Thank you. I had a couple of questions. One is, it’s notable you all have been saying in previous weeks while this investigation is ongoing CDC recommend persons consider refraining from using e-cigarettes or vaping products and now the phrase added, particularly those containing THC. You’ve added that this week. I was wondering was it the information from Wisconsin and Illinois that prompted that change, that addition? You mind saying what in the investigation is helping you narrow in and then I have a follow up question. Dr. Anne Schuchat: Thanks, Mike. This is Anne, responding. The Illinois and Wisconsin data were very compelling, and the national snapshot, while less detailed than Illinois and Wisconsin provide a consistent set of information. The CDC is committed to follow the evidence and update the information when we have more evidence, and the outbreak currently is pointing to a greater concern around THC containing products. However, we do not know whether the only risky substance for lung injury is the THC containing products and we didn’t feel comfortable dropping the broader recommendation yet. Certainly, the information that our colleagues in Illinois and Wisconsin have reported paints a compelling picture. Mike Stobbe, Associated Press: Okay. Can I also ask, looking at the report, one of the reports provides an iffy curve. What’s the explanation for it? It looks like there was more of an increase in July and August and then is there a decrease lately? What’s going on? Is this subsiding? What do you think is going on? Thank you. Dr. Anne Schuchat: Thanks. I do not think that we can say a decrease is going on yet. The last few weeks of the curve may reflect a delay in reporting. It may reflect a delay in recognition of the condition on the part of clinicians, a delay in that information getting to the health department classification based on the record review and then reporting it to us and into the national picture. So I think that I’m concerned that there are new cases every week with onset recently and that as the lag is caught up, we may see a continued brisk case — a brisk new cases and that’s one of the main reasons we want to warn the public that at this point, if you’re concerned about this very, very serious disease, consider refraining from vaping or using e-cigarette products especially those containing THC. MODERATOR: Next question, Jill. OPERATOR: Thank you. Our next question from Angelica LaVito with CNBC. Your line is open, ma’am. Angelica LaVito CNBC: Thank you for taking my question. I also noticed the addition of particularly avoiding THC products and I wanted to ask if it’s fair to say at this point the CDC is now narrowing its investigation to THC containing vaping products? Dr. Anne Schuchat: No, we are not narrowing the investigation. There remain many questions. We do not know even for the THC containing products that seem to be closely linked with cases in Illinois and Wisconsin – what the substance is within the products that’s causing harm. We don’t know if .. we have many questions about the supply chain and the integrity of these products. So, I think that we need to have an open mind and under a lot more about the supply chain as well as about the contents of various products that are used within e-cigarettes or vaping to understand which of many toxins might be leading to this type of lung injury. You know, to have over 800 cases in this short period of time, many leading to intensive care unit hospitalizations and potentially longer-term lung damage, we really need to understand how many different kinds of products could be risky and how to stop their distribution. Angelica LaVito CNBC: What exactly is the CDC doing to understand the supply chain? I know FDA has that criminal investigation, but how is CDC interacting with that? Dr. Anne Schuchat: Right. This is Dr. Schuchat again. The states are working closely with FDA and DEA and CDC is working closely as well. The information about products is being, as well as products that exist are being provided for laboratory testing at FDA’s forensic laboratory, supply chain traced back would to be done either through FDA or DEA depending and CDC is basically in very close communication with our partners across government. This may be more complicated than we think in terms of more than one product being risky, more than one label on the product and more than one substance within the product. So, I think we have to have a very open mind and recognize how dynamic this marketplace is right now and really want consumers recognize it’s a difficult time and we want families talk to their kids and people trying to get these products understand the potential risks. MODERATOR: Next question, please? OPERATOR: Thank you. Our next question from Allison Aubrey with NPR News. Allison Aubrey, NPR News: I’ve got two questions. Wondering if you’ve found any commonality among the 12 deaths, those that have died. Did they use THC only or a particular brand? Second question is have you been testing your samples for hydrogen cyanide? Dr. Anne Schuchat: The information about commonality among the deaths we don’t have yet. As we hear more deaths the age range that seems to occur seems to be broader, but we don’t have big enough numbers or detail yet on those patients to share. The testing that FDA or forensic laboratory DEA is doing I believe, is broad and I don’t have information on the cyanide question but approach to testing is being designed based on use of scarce product, whatever product remains from those patients as well as testing other products that aren’t associated with patients. So I don’t have results on a particular adulterant. But I know there’s been testing done by the private-sector as well. Allison Aubrey, NPR News: When you said that the results are pending, do you know how many results — of the samples you have, how many are completed, how many are pending. It does seem like it’s taking a while. Dr. Anne Schuchat: Yes. Thank you. I don’t have the information but one thing I can say is that as Dr. Layden described, there were a number of products even from one individual and so making their way through the different products and linking them to cases is taking some time. In the beginning of this analysis you have scarce samples. Our testing for substances and design a strategic testing plan and so I wish I had results that were compelling, but I think a message that I would have for the public, they are making more than one thing of risk within some of these products, and we need to follow the data to their conclusion. At this time, we do not believe that consumers can tell what’s in the product and there’s not sufficient information on labels to know anyway. Allison Aubrey, NPR News: Thank you. MODERATOR: Next question, Jill. OPERATOR: Thank you, ma’am. Our next question is from Mary with the Milwaukee Journal Sentinel paper. Ma’am, your line is open. Mary Spicuzza, Milwaukee Journal Sentinel: Hi, thanks for taking my questions. Two questions. One is can one of you address the role that children’s hospital of Wisconsin played in uncovering this outbreak? And the other is confirming it was the Illinois and Wisconsin cases combined where it was 66% involving pre-filled Dank Vapes. Dr. Jon Meiman: This is Jon with the Wisconsin Department of Health Services. Children’s hospital of Wisconsin and Milwaukee was integral to alerting us. They had seen a small number of cases very early on back in early July over the previous few weeks where they really weren’t able — they thought unusual cases of this lung injury weren’t able to pin it on any specific cause so they reached out to us at which point we launched our investigation to look into this further. But they were the ones that first brought to it our attention and really helped to get the whole public health investigation launched. MODERATOR: Next question, Jill? OPERATOR: Thank you, ma’am. Our next is from Courtney Norris with the PBS News Hour. Miss Norris your line is open. Courtney Norris, PBS News Hour: I’m curious two quick questions in one. Of the 514, is that number about people who self-reported substance use and two, with the 12 deaths, you know, that’s news. I’m curious when you say intensive care do you expect more? Dr. Anne Schuchat: This is Dr. Schuchat. The information out of the 514 patients about product use was self-reported. I didn’t quite catch the second question, I think it was about intensive care is that what you were asking about? Courtney Norris, PBS News Hour: Yes, just in terms of deaths we know 12 deaths across ten states. We haven’t seen an uptick there in a few days but I’m curious about the condition when you say they are put into intensive care or requiring intensive care, sort of if that, you know, what that means, how serious that is, if you could elaborate on that. Dr. Anne Schuchat: Yes. I think, again, this is Dr. Schuchat again: I believe that Dr. Meiman described some of the results from the Illinois-Wisconsin investigation where they had more detailed information about the seriousness. They found overall 59% or 42 out of 71 patients with the conditions were admitted to intensive care unit. What that means is a person really has a life-threatening illness. They may require being hooked up to a breathing machine to help them breathe or other supported measures. It is too soon for us to say how well these individuals will do long term after discharges whether they will continue to have some difficulty breathing or weakened lungs that may not recover fully. We’re in the early days but we know some people have been gravely ill. In term of the deaths, we do know that other states continue to investigate patients to try to understand whether a recent death may have been due to this condition, and one of our messages for clinicians right now is when caring for people with respiratory illness to please remember to ask about smoking but about e-cigarette or vaping use, that’s not necessarily something clinicians typically ask about but in light of these severe patients presentations we think that type of information is very important to gather. Courtney Norris, PBS News Hour: Thank you. MODERATOR: Next question, Jill? OPERATOR: Thank you, ma’am. Our next question is from Erika Edwards with NBC News. Erika Edwards, NBC News: I was merely going to ask about the deaths as well. You pretty much addressed it. Were they generally older adults? Did they have any underlying conditions, anything else linking those cases? Dr. Anne Schuchat: I think it’s too early for us to say whether there will be significant differences. But I think the preliminary assessment is they may be somewhat older. But the range of ages is expanding right now. So, I don’t think we can say with confidence that a young healthy person is immune from the risk of death from this condition. We know that the x-rays and the lung function may be very, very damaged by the insult of the products. MODERATOR: Jill, we can take one last question. OPERATOR: Thank you. Our last question will come from Mary Kekatos with Dailymail.com. Your line is open. Mary Kekatos, Dailymail.com: Hi. Thank you for taking my question. I also wanted to ask about the death toll. In this meeting we heard that the death toll was at 12, however there have been some news reports that have put it at 13 and specifically coming from North Carolina. Have this been confirmed yet by the CDC or is this going to be investigated at a later date? Dr. Anne Schuchat: We let the states. This is Dr. Schuchat again: States do the initial investigation and classification and typically report publicly once they’ve confirmed that. When they report to us, we’re updating our death numbers once a week. Sadly, I do believe there will be additional ones. You know this is a very serious threat right now to young people across the country and we don’t want there to be more death but that’s why our message is so critical. A lot of this investigation is ongoing. We do recommend people concerned about this disease consider not using e-cigarettes or vaping products especially ones containing THC. So, thank you. I believe that was the last question. I really want to, again, thank Dr. Meiman and Dr. Layden for their teams’ incredible work and leadership and thank you all for covering this story. MODERATOR: Thank you all for joining our call today and that concludes the telebriefing. If reporters have additional questions, they can call the CDC at 404-639-3286 or email us. Thank you. OPERATOR: That does conclude today’s conference call. We thank you all for participating. You may disconnect and have a great rest of your day. https://www.cdc.gov/media/releases/2019/t0927-update-pulmonary-illnesses.html

Audio https://www.cdc.gov/media/releases/2019/t0927-lung-injury.html.mp3

What: The Centers for Disease Control and Prevention (CDC) and state partners will give updates on the investigation into cases of lung injury associated with e-cigarette use, or vaping. Who: Anne Schuchat, MD (RADM, USPHS, RET), principal deputy director, CDC Jennifer Layden, MD, PhD, chief medical officer and state epidemiologist, Illinois Department of Public Health Jon Meiman, MD, chief, Bureau of Environmental and Occupational Health, Wisconsin Department of Health Services When Friday, September 27, at 12:00 p.m.. ET Dial-In Media: 888-795-0855 Non-Media: 888-972-6892 INTERNATIONAL: 1-517-308-9298 PASSCODE: CDC Media Important Instructions If you would like to ask a question during the call, press *1 on your touchtone phone. Press *2 to withdraw your question. You may queue up at any time. You will hear a tone to indicate your question is pending. TRANSCRIPT A transcript and audio will be available following the briefing at CDC’s web site: www.cdc.gov/media.

CDC Telebriefing: Update on Lung Injury Associated with E-cigarette Use, or Vaping - 09-27-2019 Media Advisory For Immediate Release: Friday, September 27, 2019 Contact: Media Relations (404) 639-3286 https://www.cdc.gov/media/releases/2019/a0927-lung-injury.html

Indiana father says daughter died after a history of vaping THC POSTED 4:09 PM, SEPTEMBER 27, 2019, BY KELLY REINKE PEKIN, Ind.– A Hoosier father in southern Indiana says his daughter, Megan Eagle, died after a history of vaping THC, the main psychoactive compound in marijuana. Earlier this month, Indiana health officials confirmed the state’s first vaping-related death. Steve Dillon said they are talking about his 31-year-old daughter. “It truly is a parent’s worst nightmare,” said Dillon. “And it is a nightmare I even occasionally have, seen her death.” Dillon lives about two hours south of Indianapolis. He was supposed to be celebrating Megan’s 32nd birthday last week. It all changed after a trip to the emergency room in August. “She became ill, had flu like symptoms, had a fever, an upset stomach,” he said. “She vomited and was short of breath.” He said her sickness kept getting worse and doctors could not stop it. One night, Dillon said doctors decided to put her on a ventilator. Less than a week later, Megan passed away at the hospital. Dillon said her doctor believes her illness was likely related to vaping. “He told me in the cases he has seen in this region that they all look exactly like Megan,” he said. Dillon still has one of her vape pens. He believes Megan started vaping THC about a year ago to manage pain and she was getting her supply from California. “Nobody knows what you are smoking, nobody knows what is going into your lungs, what you are sucking into your lungs,” he said. Right now, Indiana State Department of Health is investigating at least 50 cases of severe lung injury. More than 15 of those cases are confirmed. A spokesperson for ISDH said cases are confirmed using the case definition set by the Centers of Disease Control and Prevention. ISDH said a majority of the cases are people ages 18 to 29 with a history of vaping. THC has been reported in a majority of cases. Patients have experienced respiratory symptoms, including cough, shortness of breath and chest pain. This week, the CDC said there are more than 800 lung injury cases reported and all patients have a history of vaping. Physicians at IU Methodist and Riley Hospital said they are also seeing illnesses that could be linked to vaping. “We are seeing people the ages of 18 to 34 mostly coming in with vague cough, fever and general difficulty breathing,” said Tommy Eales, an emergency medicine physician at IU Methodist. Dr. Eales said it is becoming more routine for doctors to ask patients about vaping. Health officials still do not know what is causing these mysterious illnesses. It is a mystery Dillon wants to be solved so another family does not experience his pain. “I will never get my baby back. That is over. But I would like to know what killed her,” he said. https://fox59.com/2019/09/27/indiana-father-says-daughter-died-after-a-history-of-vaping-thc/

Posted: Sep 27, 2019 / 05:26 PM PDT / Updated: Sep 27, 2019 / 05:26 PM PDT INDIANAPOLIS, IN (CNN) — Indiana health officials confirmed the state’s first vaping related death earlier this month. Now, a father says it was his 32-year-old daughter and is sharing her story. It’s a smile family can now only see in a picture. Everything seemed good with Megan Eagle and then one day, it wasn’t. “It truly is a parent’s worst nightmare, and it is a nightmare I even occasionally have, seen her death,” said the woman’s father, Steve Dillon. Dillon lives about two hours outside Indianapolis. He was supposed to be celebrating Eagle’s 32nd birthday last week. It all changed after a trip to the emergency room in August. “She became ill, had flu-like symptoms. Had a fever, an upset stomach. She vomited and was short of breath,” Dillon said. He says he sickness kept getting worse and doctors could not stop it. “So they decided Saturday night to ventilate her and she did not want it. She was afraid she was going to die,” the dad said. Eagle passed away at the hospital less than a week later. Dillon says he doctor believes her illness was likely related to vaping. “He told me in the cases he has seen in this region that they all look exactly like Megan,” Dillon said. Dillon still has one of his daughter’s vape pens. He thinks Eagles started vaping THC about a year ago to manage pain and she was getting her supply from California. “Nobody knows what you are smoking, nobody knows what is going into your lungs what you are sucking into your lungs,” Dillon said. Right now, Indiana’s State Department of Health is investigating at least 50 cases of severe lung injury. Physicians at IU Methodist and Riley Hospital say they’re also seeing illnesses that could be linked to vaping. “We are seeing people the ages of 18 to 34 mostly coming in with vague cough, fever and general difficulty breathing,” said Tommy Eales, emergency medicine physician at IU Methodist. A majority of patients have reported vaping THC, yet health officials still do not know what is causing these mysterious illnesses. It’s a mystery Dillon wants to be solved, so another family doesn’t experience his pain. “I will never get my baby back. That’s over. But I would like to know what killed her,” he said. The CDC says at least 805 lung injury cases have been reported 46 states and the U.S. Virgin Islands and 13 deaths have been reported in 10 states. https://www.kron4.com/news/national/indiana-father-says-daughters-death-linked-to-vaping/

Lung Injury Associated with E-Cigarette Use or Vaping The Indiana State Department of Health (ISDH) began investigating vaping-related severe lung injuries in early August 2019. The number of vaping-related lung injuries continues to rise steadily in Indiana and nationwide. Vaping is the only common factor in these injuries to date. Most individuals have reported vaping THC, the ingredient in marijuana, or other substances, but it’s unknown what specific products, brand or substance is causing these injuries. More information is being learned as new cases are investigated and data analyzed. This is a rapidly changing situation, and ISDH continues to gather data on cases and collaborate with local partners and healthcare providers, the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) to learn more about these lung injuries and determine potential causes. The CDC recommends that until more is known, people consider refraining from using e-cigarette or vaping products if they are concerned about these specific health risks. Patients have experienced respiratory symptoms, including: Cough Shortness of breath Chest pain Fatigue Fever Weight loss, nausea, abdominal pain and diarrhea Some patients have reported that their symptoms developed over a few days, while others have reported that their symptoms developed over several weeks. Anyone who experiences these symptoms should see their healthcare provider right away. In Indiana, the use of e-cigarettes and vaping among youth has risen more than 350 percent among high school and middle school students since 2012. Gov. Eric J. Holcomb and State Health Commissioner Dr. Kris Box have announced a plan to address youth vaping in Indiana. This approach includes education and training for parents, teachers and students; a youth-focused text messaging program; and a statewide media campaign. Visit Vape-Free Indiana for more information. Click here for a fact sheet on e-cigarettes. Resources: The CDC has developed a webpage that has resources for the public, healthcare providers and health departments. Learn more about e-cigarettes and vaping products, including what they look like and how to talk to kids about them, by visiting Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults, as well as Vape-Free Indiana. Call the Indiana Tobacco Quitline at 1-800-QUIT-NOW (1-800-784-8669) to talk to a quit coach or visit www.QuitNowIndiana.com if you are interested in quitting smoking, vaping or other tobacco use. For Providers: ISDH and the Indiana Poison Control Center have partnered to improve case reporting efficiency. To report suspected cases, please call ISDH at 317-233-7125 or the Indiana Poison Center at (800) 222-1222. To submit vape product, or for additional questions, please call ISDH at (317) 233-7125, or the ISDH epidemiologist on call after hours at (317) 233-1325. Resources: The following CDC publications have more information regarding the outbreak: Severe Pulmonary Disease Associated with Electronic-Cigarette–Product Use — Interim Guidance Outbreak of Electronic-Cigarette–Associated Acute Lipoid Pneumonia — North Carolina, July–August 2019 Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Preliminary Report Case definition

Lung Injury Associated with E-Cigarette Use or Vaping The Indiana State Department of Health (ISDH) began investigating vaping-related severe lung injuries in early August 2019. The number of vaping-related lung injuries continues to rise steadily in Indiana and nationwide. Vaping is the only common factor in these injuries to date. Most individuals have reported vaping THC, the ingredient in marijuana, or other substances, but it’s unknown what specific products, brand or substance is causing these injuries. More information is being learned as new cases are investigated and data analyzed. This is a rapidly changing situation, and ISDH continues to gather data on cases and collaborate with local partners and healthcare providers, the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) to learn more about these lung injuries and determine potential causes. The CDC recommends that until more is known, people consider refraining from using e-cigarette or vaping products if they are concerned about these specific health risks. https://www.in.gov/isdh/28337.htm

References Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. New Engl J Med 2019. Epub September 6, 2019. https://www.nejm.org/doi/full/10.1056/NEJMoa1911614external icon Perrine CG, Pickens CM, Boehmer TK, et al. Characteristics of a multistate outbreak of lung injury associated with e-cigarette use or vaping—United States, 2019. MMWR Morb Mortal Wkly Rep 2019;68(39). Schier JG, Meiman JG, Layden J, et al.; CDC 2019 Lung Injury Response Group. Severe pulmonary disease associated with electronic-cigarette-product use—interim guidance. MMWR Morb Mortal Wkly Rep 2019;68:787–90. CrossRefexternal icon PubMedexternal icon Spindle T, Cone E, Schlienz N, et al. Urinary excretion profile of 11-nor-9-carboxy Δ9-tetrahydrocannabinol (THCCOOH) following smoked and vaporized cannabis administration in infrequent cannabis users. Journal of Analytical Toxicology, 2019;43:233–58. CrossRefexternal icon Johansson E, Halldin M. Urinary excretion half-life of Δtetrahydrocannabinol-7-oic acid in heavy marijuana users after smoking. Journal of Analytical Toxicology, 1989;13:218–223. CrossRefexternal icon Kirkham C, Dastin J. Explainer: one possible culprit in vaping lung illnesses–“dank vapes.” Washington, DC: Reuters; 2019. https://www.reuters.com/article/us-health-vaping-industry-explainer/explainer-one-possible-culprit-in-vaping-lung-illnesses-dank-vapes-idUSKCN1VY2ETexternal icon US Department of Health and Human Services. Surgeon General’s advisory on e-cigarette use among youth. Washington, DC: US Department of Health and Human Services, CDC; 2018. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/surgeon-general-advisory/index.html Davidson K, Brancato A, Heetderks P, et al. Outbreak of electronic-cigarette-associated acute lipoid pneumonia—North Carolina, July–August 2019. MMWR Morb Mortal Wkly Rep 2019;68:784–6. CrossRefexternal icon PubMedexternal icon Maddock S, Cirulis M, Callahan A, et al. Pulmonary lipid-laden macrophages and vaping. New Engl J Med 2019. Epub September 6, 2019. https://www.nejm.org/doi/full/10.1056/NEJMc1912038external icon

TABLE 2. Electronic cigarette (e-cigarette), or vaping, product use behaviors in the 3 months prior to illness onset in patients with lung injury associated with e-cigarette use — Illinois and Wisconsin, 2019 Product use and behaviors No. (%) Illinois (n = 48) Wisconsin (n = 38) Total (N = 86) THC-containing product use Any use 39 (81) 36 (95) 75 (87) Exclusive use 13 (27) 12 (32) 25 (29) Dank Vapes use 33 (73) 24 (63) 57 (66) Nicotine-containing product use Any use 35 (73) 26 (68) 61 (71) Exclusive use 9 (19) 2 (5) 11 (13) Both THC- and nicotine-containing product use 26 (54) 24 (63) 50 (58) At least daily use of e-cigarette products* THC-containing products 29 (60) 20 (53) 49 (57) Nicotine-containing products 27 (56) 18 (47) 45 (52) Devices used with e-cigarette products† Device designed for prefilled cartridge use 43 (91) 35 (92) 78 (92) Tank designed to be filled with product 7 (15) 11 (29) 18 (21) Dab rig or a dab pen 7 (15) 7 (18) 14 (16) No. of e-cigarette product brands reported per product type user† THC brands per THC user,§ mean (range) 2.1 (1–7) 2.1 (1–7) 2.1 (1–7) Nicotine brands per nicotine user,¶ mean (range) 1.3 (1–3) 1.3 (1–4) 1.3 (1–4) Packaging of e-cigarette products used No./total of THC products (%) that were packaged, prefilled cartridges 69/72 (96) 80/83 (96) 149/155 (96) No./total of nicotine products (%) that were packaged, prefilled cartridges 32/35 (91) 29/44 (66) 61/79 (77) Abbreviation: THC = tetrahydrocannabinol. * The denominator used here is all patients, not just those who reported using THC- or nicotine-containing products. † Patients could report using more than one type of device or product, thus the percentage totals sum to >100%. § Patients were counted as THC users if they reported use of at least one THC-containing e-cigarette product in the past 3 months. ¶ Patients were counted as nicotine users if they reported use of at least one nicotine-containing e-cigarette product in the past 3 months.

TABLE 1. Patient characteristics by type of electronic cigarette, or vaping, product used in the 3 months prior to illness onset — Illinois and Wisconsin, 2019 Characteristic n/N (%) THC-containing products only (N = 25) Nicotine-containing products only (N = 11) Both THC- and nicotine-containing products (N = 50) Total (N = 86) Age group (yrs) <18 5/25 (20) 3/11 (27) 11/50 (22) 19/86 (22) 18–24 7/25 (28) 4/11 (36) 27/50 (54) 38/86 (44) 25–34 7/25 (28) 3/11 (27) 9/50 (18) 19/86 (22) ≥35 6/25 (24) 1/11 (9) 3/50 (6) 10/86 (12) Gender Male 22/25 (88) 8/11 (73) 38/50 (76) 68/86 (79) Female 3/25 (12) 3/11 (27) 12/50 (24) 18/86 (21) Race/Ethnicity* White, non-Hispanic† 13/22 (59) 8/11 (73) 39/46 (85) 60/79 (76) Black, non-Hispanic† 2/22 (9) 2/11 (18) 3/46 (7) 7/79 (9) Other, non-Hispanic† 0/22 (0) 0/11 (0) 2/46 (4) 2/79 (3) Hispanic† 7/22 (32) 1/11 (9) 2/46 (4) 10/79 (13) Other characteristics Admitted to ICU§ 12/19 (63) 5/8 (63) 25/44 (57) 42/71 (59) Smoked combustible marijuana¶ 12/24 (50) 5/11 (45) 26/48 (54) 43/83 (52) Smoked combustible tobacco¶ 3/24 (13) 4/11 (36) 13/48 (27) 20/83 (24) Abbreviations: ICU = intensive care unit; THC = tetrahydrocannabinol. * Information missing for seven patients. † Blacks, whites, and persons of other races were non-Hispanic; Hispanic persons could be of any race. § Information missing for 15 patients. ¶ Information missing for three patients.

FIGURE. Frequently reported brand names of tetrahydrocannabinol (THC)- and nicotine-containing electronic cigarette (e-cigarette), or vaping, products*,†,§ reported by patients with lung injury¶ — Illinois and Wisconsin, 2019 * Two brands of cannabidiol are not shown (each brand reported by one patient). † 30 other THC-containing brands (including three brands of THC wax for “dabbing”) were only reported by one patient each. § 22 other nicotine-containing brands were only reported by one patient each. ¶ Data are presented from interviews conducted with 86 of 127 patients with lung injury associated with e-cigarette use, or vaping.

Discussion In this series of in-depth interviews with 86 e-cigarette– or vaping-associated lung injury patients in Illinois and Wisconsin during July–September 2019, patients reported a wide range of e-cigarette products; however, the vast majority reported using illicit THC-containing products sold as prefilled cartridges and obtained from informal sources. Although no single brand or product was definitively identified, a high percentage of patients reported using Dank Vapes cartridges. Dank Vapes appears to be the most prominent in a class of largely counterfeit brands, with common packaging that is easily available online and that is used by distributors to market THC-containing cartridges with no obvious centralized production or distribution (7). Previous reports highlighted that patients with lung injury associated with e-cigarette use have used both THC- and nicotine-containing products (1,3,8,9). The additional information presented here regarding the range and diversity of brands used by patients, acquisition patterns, and frequency of use helps to formulate hypotheses about the possible etiology of this outbreak. In particular, the high level of use of prefilled THC cartridges, used in a range of different devices, suggests that the cartridges might play an important role. The findings in this report are subject to at least four limitations. First, interviews were not available for one third of patients; this nonresponse rate might introduce selection bias, although the demographics of the 86 interviewed patients were similar to those of all 127 patients. Second, because information was self-reported, there is the possibility that social desirability bias might affect reporting, particularly of illicit products; nonmedical THC use is currently illegal in both Illinois and Wisconsin. In this analysis, some patients did not disclose THC-containing product use to clinicians until late in their hospital admission or until a urinary THC screen was performed. Third, the time between urinary toxicology testing and last reported use of an e-cigarette product was not consistent and might explain the three negative results in patients who reported using THC-containing products. Finally, these data are largely drawn from patients living in the northeastern region of Illinois and southeastern region of Wisconsin, and therefore might not be generalizable to other states; however, the age and gender distribution of is consistent with nationwide trends (2,3). The findings document that many, but not all, patients with lung injury associated with use of an e-cigarette product reported using THC-containing products. Similar findings have been noted in the national data, which include some of the data presented here (2). These data also reveal a predominant use of prefilled THC cartridges sold through informal and unregulated markets, although the origin of these products further back in the production and distribution chain is unknown. In addition, these data do not elucidate whether the causative exposure is THC itself or a substance associated with prefilled THC cartridges, such as a cutting agent or adulterant. Ascertaining the importance of these products in contributing to the current outbreak will require data from multiple states and analysis at the national level. Given the number and diversity of products reported overall and by individual patients, as well as the high frequency of patients using both THC- and nicotine-containing products, the epidemiologic investigation could benefit from additional information, including product testing and traceback of e-cigarette products to identify the ultimate source of the outbreak. The Illinois Department of Public Health and the Wisconsin Department of Health Services are collaborating with CDC on a large nationwide public health response and with the Food and Drug Administration to coordinate laboratory testing of products associated with this outbreak. While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC. Top Acknowledgments Staff members and leadership of the Illinois Department of Public Health and Wisconsin Department of Health Services; local health departments in Illinois and Wisconsin; CDC 2019 Lung Injury Response Group; all interviewed patients. Top Corresponding author: Isaac Ghinai, [email protected], 217-782-2016. Top 1Illinois Department of Public Health; 2Epidemic Intelligence Service, CDC; 3Wisconsin Department of Health Services; 4Division of State and Local Readiness, Center for Preparedness and Response, CDC; 5Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC; 6National Center for Environmental Health, CDC; 7Emory University School of Medicine, Atlanta, Georgia. Top All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed. Top * These authors contributed equally. † Dabbing is a process that allows the user to inhale a high concentration of THC by vaporizing extracts of a concentrate that has been placed on a hot surface.

In July 2019, the Illinois Department of Public Health and the Wisconsin Department of Health Services launched a coordinated epidemiologic investigation after receiving reports of several cases of lung injury in previously healthy persons who reported electronic cigarette (e-cigarette) use, or vaping (1). This report describes features of e-cigarette product use by patients in Illinois and Wisconsin. Detailed patient interviews were conducted by telephone, in person, or via the Internet with 86 (68%) of 127 patients. Overall, 75 (87%) of 86 interviewed patients reported using e-cigarette products containing tetrahydrocannabinol (THC), and 61 (71%) reported using nicotine-containing products. Numerous products and brand names were identified by patients. Nearly all (96%) THC-containing products reported were packaged, prefilled cartridges, and 89% were primarily acquired from informal sources (e.g., friends, family members, illicit dealers, or off the street). In contrast, 77% of nicotine-containing products were sold as prefilled cartridges, and 83% were obtained from commercial vendors. The precise source of this outbreak is currently unknown (2); however, the predominant use of prefilled THC-containing cartridges among patients with lung injury associated with e-cigarette use suggests that they play an important role. While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC. Given the diversity of products reported and frequency of patients using both THC- and nicotine-containing e-cigarette products, additional methods such as product testing and traceback could help identify the specific cause of this outbreak. During July–September 2019, possible cases of lung injury associated with e-cigarette use in Illinois and Wisconsin were investigated to determine symptoms, exposures, and medical care history related to the outbreak. Patients were classified as having confirmed or probable cases of lung injury associated with e-cigarette use according to CDC’s interim outbreak case definitions (3). Interviews were conducted with patients or a proxy using a structured and scripted questionnaire that was developed jointly between Illinois and Wisconsin with guidance from CDC. The questionnaire asked detailed questions about e-cigarette use, including the names of e-cigarette, or vaping, products and devices, frequency of use, and product sources in the 3 months preceding illness onset. Most interviews were conducted by state or local health department staff members or in person by health care facility staff members during a patient’s hospitalization; a small number of patients completed the same survey online. In total, 86 (68%) interviews were completed among the 127 confirmed and probable patients that had been identified in Illinois (75) and Wisconsin (52) as of September 20, 2019. Among the 86 confirmed and probable patients that were interviewed, including 48 from Illinois and 38 from Wisconsin, 68 (79%) were male, and the median age was 21 years (range = 15–53 years) (Table 1). Hospitalization dates among patients were similar in Illinois and Wisconsin, ranging from April 24 to September 19, 2019, and closely reflected the national outbreak (2). Illinois cases predominantly occurred in the northeast region of the state (in Chicago and the surrounding counties, close to the Wisconsin border) but have since been reported in other regions of the state. Most Wisconsin cases were initially clustered in the southeastern region of the state but have since been reported throughout western and central Wisconsin as well. Among the 86 interviewed patients, 75 (87%) reported using e-cigarette products containing THC, the principal psychoactive component of cannabis, during the 3 months preceding illness; 61 (71%) reported using nicotine-containing products; 50 (58%) reported using both THC- and nicotine-containing products. Twenty-five (29%) patients reported exclusive use of THC-containing products, whereas 11 (13%) reported exclusive use of nicotine-containing products (Table 2). Demographic characteristics of patients were similar among those who reported exclusive use of THC-containing products, exclusive use of nicotine-containing products, or use of both types of products (Table 1). The chemical contents of reported THC-containing products are unknown. However, urinary THC screens were obtained for 32 patients who reported using THC-containing products, 29 (91%) of which were positive for THC; two patients who did not report using THC-containing e-cigarette products, out of four tested, also had positive urinary THC screens; one of these patients reported smoking combustible marijuana. Urinary THC levels for four patients who reported using THC-containing products exceeded 400 ng/ml, indicating intensive use of THC or THC-containing products (4,5). In Wisconsin, eight patients initially denied using THC-containing products in interviews, but five (63%) were later found to have used THC through review of medical charts, reinterview, or cross-referencing with friends who were also interviewed as patients. Among the 86 interviewed patients, 234 unique e-cigarette, or vaping, products labeled with 87 different brand names were reported. Nicotine-containing product users reported a mean of 1.3 different nicotine brands (range = 1–4), and THC-containing product users reported a mean of 2.1 different THC brands (range = 1–7). Among 155 THC-containing products reported, nearly all (149, 96%) were packaged, prefilled cartridges, whereas 61 (77%) of 79 nicotine-containing products were sold as prefilled cartridges or “pods.” No patients reported adding other ingredients to the e-cigarette products they used. Although no single brand name was reported by all patients, a prefilled THC cartridge sold under the brand name Dank Vapes was reported by 57 (66%) patients (Figure). In Wisconsin, two groups of friends (two patients in one group and three in the second group) who became ill after using THC-containing cartridges specifically reported sharing Dank Vapes cartridges. Dank Vapes was the only e-cigarette product reported by one of the patients. Among 112 THC-containing products for which the source was reported, 100 (89%) were acquired from informal sources (e.g., friends, family, school, dealers, or off the street). The remaining 12 were bought at an out-of-state cannabis dispensary (six), online (five), or from a vape or tobacco shop (one). In contrast, among 81 nicotine-containing products, 40 (49%) were obtained from a vape or tobacco shop, 22 (27%) from gas stations or convenience stores, 14 (17%) from friends or family, and five (6%) online. A variety of e-cigarette and vaping device types (6) were used by patients to aerosolize THC- or nicotine-containing products. Overall, 78 (92%) of 85 patients reported using a device designed to aerosolize prefilled cartridges or pods. Within this category of vaping devices, some were closed-pod systems (also known as “mods”) designed for use with proprietary nicotine-containing products (e.g., JUUL); however, most were universal “vape pens” that are adaptable to the prefilled THC cartridges reported by many patients. Use of devices with a tank designed to be filled with nicotine-containing liquid or THC oil was reported by 18 (21%) patients, and 14 (16%) reported aerosolizing THC concentrates, known as waxes or “dabs,” using either a “dab rig” or a “dab pen” device.† Patients reported frequent daily use of e-cigarette products; among 75 users of THC-containing products, 49 (65%) reported using these products at least daily, and 45 (74%) of 61 nicotine-containing product users reported at least daily use of these products. Where more detailed information on frequency of use was provided, 21 (41%) of 51 THC-containing product users and 30 (65%) of 46 nicotine-containing product users reported use of at least one such product five or more times a day. In addition to e-cigarette products, among 83 patients who provided information on combustible product use, 43 (52%) reported smoking combustible marijuana, and 20 (24%) reported smoking combustible tobacco. Only four (5%) of 86 interviewed patients reported prescription drug misuse or illicit drug use other than THC. Two patients reported using LSD, one reported misusing dextroamphetamine-amphetamine (Adderall), and one reported misusing oxycodone. Urinary toxicology screens were positive for substances other than THC (and for other substances that could not be explained by the medical treatment these patients had received) in six of 31 patients, including two patients who tested positive for benzodiazepines and opioids, one for benzodiazepines alone, one for opioids alone, one for amphetamines, and one for unspecified narcotics.

E-cigarette Product Use, or Vaping, Among Persons with Associated Lung Injury — Illinois and Wisconsin, April–September 2019 Early Release / September 27, 2019 / 68 Isaac Ghinai1,2*; Ian W. Pray2,3*; Livia Navon1,4; Kevin O’Laughlin2; Lori Saathoff-Huber1; Brooke Hoots5; Anne Kimball2; Mark W. Tenforde2; Jennifer R. Chevinsky2; Mark Layer6,7; Ngozi Ezike1; Jonathan Meiman3; Jennifer E. Layden1 (View author affiliations) View suggested citation Summary What is already known about this topic? An outbreak of lung injury of unknown source associated with electronic cigarette (e-cigarette) use is ongoing in the United States. What is added by this report? Interviews about e-cigarette use were completed with 86 patients in Illinois and Wisconsin. Use of tetrahydrocannabinol (THC)-containing e-cigarette products, the majority of which were prefilled cartridges obtained from informal sources, was reported by 87% of patients during the 3 months preceding illness. What are the implications for public health practice? The cause of this outbreak is unknown but might be related to prefilled THC cartridges. While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC. Additional information from product testing and traceback could help to determine the source of the outbreak and prevent future illnesses. https://www.cdc.gov/mmwr/volumes/68/wr/mm6839e2.htm?s_cid=mm6839e2_w

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TABLE. Number of patients with lung injury associated with e-cigarette use, or vaping (n = 771), by demographic and substance use characteristics — United States, 2019 Characteristic No. (%) Demographic (n = 771)* Sex Male 531 (68.9) Female 234 (30.4) Missing 6 (0.8) Age group (yrs) <18 125 (16.2) 18–24 293 (38.0) 25–34 184 (23.9) 35–44 93 (12.1) ≥45 42 (5.5) Missing 34 (4.4) Substances used in e-cigarette, or vaping, products (n = 514)† THC-containing products Yes 395 (76.9) No 96 (18.7) Unknown/Missing 23 (4.5) Nicotine-containing products Yes 292 (56.8) No 173(33.7) Unknown/Missing 49 (9.5) Cannabidiol (CBD) Yes 89 (17.3) No 265 (51.6) Unknown/Missing 160 (31.1) Synthetic cannabinoids Yes 4 (0.8) No 289 (56.2) Unknown/Missing 221 (43.0) Flavored e-liquids§ Yes 102 (19.8) No 132 (25.7) Unknown/Missing 280 (54.5) Abbreviation: THC = tetrahydrocannabinol. * Patients for whom basic demographic information was submitted to CDC. † Patients for whom information was available on use of either nicotine-containing or THC-containing substances. § Flavored products that contain water, food-grade flavoring, propylene glycol, vegetable glycerin, nicotine, THC, or CBD.