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As of 9/25/2019, the Michigan Department of Health and Human Services has identified 15 (10 confirmed and five probable) cases of severe lung disease associated with vaping. The department is investigating an additional 14 possible cases that have been reported by health care providers. https://www.michigan.gov/mdhhs/0,5885,7-339-71550_5104_53072---,00.html

Vaping illnesses soar past 1,000 with investigators no closer to pinpointing cause Two new vaping-related deaths reported in Florida and Georgia. The acting commissioner of the Food and Drug Administration said he expects a nationwide ban on flavored e-cigarettes in the coming weeks. Andrew Burton / Getty Images file Sept. 25, 2019, 4:12 PM EDT / Updated Sept. 25, 2019, 9:53 PM EDT By Erika Edwards The Food and Drug Administration should have acted sooner to curb the surge in youth vaping, the acting head of the agency, Dr. Ned Sharpless, told a House subcommittee Wednesday in his first appearance before Congress since news of severe lung illnesses linked to vaping began to circulate this summer. State health departments in nearly every state tell NBC News that they are actively investigating more than 1,000 cases of the illnesses. That's higher than the Centers for Disease Control and Prevention's official case count, currently at 530, which only includes confirmed or probable cases. Eleven people have died: Two in California, two in Kansas, plus deaths in Illinois, Indiana, Minnesota, Missouri and Oregon. Georgia confirmed its first death Wednesday, and Florida confirmed a death Tuesday. Juul CEO steps down as company agrees to stop advertising SEPT. 25, 201901:25 But despite investigations by hundreds of physicians, state health officials, the FDA and the CDC, no single ingredient or product has been identified as the cause of the illnesses. The FDA has received 300 vape product samples, and has tested about half for the presence of nicotine, THC (the psychoactive ingredient in marijuana), painkillers, cutting agents, pesticides and toxins. About half of the products that contained THC also contained an ingredient vitamin E acetate, Sharpless said. That's an oil that has "no business being in lungs." But there's no evidence that one ingredient can explain all of the lung illnesses. Health investigators say it's likely there are multiple causes. "There may be a particular problematic source in California, and something different going on on the East Coast," said Dr. Anne Schuchat, the CDC's principal deputy director. Schuchat also testified before the subcommittee Wednesday. She said the tedious investigation cannot keep up with the fast-moving spate of illnesses. "The data are coming in as we speak," Schuchat said. "I’m extremely frustrated with the pace of our investigation." 9th vaping-related death confirmed SEPT. 24, 201900:32 Sharpless also told legislators that the FDA is finalizing plans to remove flavored electronic cigarettes from the marketplace, and will begin enforcing the "existing law that limits the marketing of such products" in the coming weeks. Recommended U.S. NEWSFlorida man with Down syndrome dies in hot car after caregiver takes drug, falls asleep NIGHTLY-NEWSTwo more people killed by rare mosquito-borne illness That means flavored e-cigarettes would essentially be banned from being sold, unless companies can provide evidence their products would benefit public health. Some states have already enacted temporary bans on flavored vapes, including Michigan, New York and Rhode Island. Massachusetts went one step further, banning all vaping devices for four months. Related HEALTH What is in a vape? Everything you need to know But Sharpless could not guarantee mint and menthol — favored by a third of young people who vape — will be part of the Trump administration's anticipated enforcement action. The plan of action that comes after years of skyrocketing rates of kids and teenagers using e-cigarettes. "In retrospect, the FDA should have acted sooner," Sharpless said. Others in public health say they, too, are impatiently waiting for answers, but insist a thorough and careful investigation is crucial. "We understand it’s a broad and deep analysis, and we want to make sure we go after the correct substance," Dr. Lee Norman, secretary of the Kansas Department of Health and Environment, told NBC News. But he added, "The sooner the better." "This is an epidemic," he said, "and it's getting worse." https://www.nbcnews.com/health/vaping/vaping-illnesses-soar-past-1-000-investigators-no-closer-pinpointing-n1058531

Written Testimony House Committee on Energy and Commerce Subcommittee on Oversight and Investigations ___________________________________________________________________________ September 25th, 2019 Statement of Anne Schuchat, M.D. (RADM, USPHS, RET) Principal Deputy Director Centers for Disease Control and Prevention Department of Health and Human Services For Release on Delivery Expected at 10:00 am On Wednesday, September 25, 2019 Page 1 of 10 Good morning, Chairwoman DeGette, Ranking Member Guthrie, and members of the Subcommittee. I am Dr. Anne Schuchat, the Principal Deputy Director of the Centers for Disease Control and Prevention (CDC). Thank you for the opportunity to testify before you regarding CDC’s investigation into lung disease associated with using e-cigarette or vaping products, and for your continued commitment to supporting CDC’s work in protecting public health. Introduction On August 1, 2019, Wisconsin first alerted CDC to a cluster of pulmonary illness among young adults that began in July 2019. As of September 18, 2019, 38 states and one territory have reported 530 confirmed and probable cases of lung disease associated with e-cigarette use or vaping. Six states (California, Illinois, Indiana, Kansas, Minnesota, and Oregon) have reported the death of a patient who had been hospitalized with lung disease with a history of recent e-cigarette or other vaping product use. As of September 18, there have been seven reported deaths. These tragic deaths reinforce the urgency of efforts by CDC, in coordination with the U.S. Food and Drug Administration (FDA), to identify the cause of this illness and to equip states with the necessary resources to address this emerging public health issue. As you know, CDC’s mission is to protect America from health, safety and security threats. CDC leverages cutting edge science and experience in preparedness and response to effectively protect Americans from public health threats. Consistent with what we do for other emergency investigations, CDC implemented an incident command structure in August and, on September 16, activated its Emergency Operations Center to enable it to dedicate more resources to this investigation. CDC works directly with state and local health departments as they identify cases, better describe illnesses, and search for causes and risk factors. CDC facilitates information sharing between state health departments and clinicians, analyzes data and conducts investigations, coordinates national communication activities such as updates on the status of the investigation, and provides health messaging tools for states. Epidemiology Summary The ongoing investigation into the cause of lung injury associated with e-cigarette or vaping product use Page 2 of 10 is challenging for a variety of reasons. First, the investigation covers a large number of states. Second, the investigation is complicated by the diversity of the e-cigarette or vaping product marketplace, with a multitude of products, a wide array of ingredients, and the intersection with potentially illicit substances such as marijuana. Users do not know what is in their e-cigarette or vape solutions. Moreover, many of the products and substances themselves can be modified by the user. They can be obtained from brick and mortar stores, online retailers, on the street, or through social sources. Our preliminary results are from data collected from dozens of states. In addition, data collection on the products used relies on self-reporting, and interviewees may be hesitant to share information about their use of illicit substances such as marijuana. According to data collected in two states and recently published in the New England Journal of Medicine, most patients (around 80 percent) reported using e-cigarette or vaping product liquids containing tetrahydrocannabinol, or THC (a psychoactive compound of marijuana), and more than half (around 60%) reported using liquids with nicotine, while around 10-20 percent reported using products with nicotine only. No single e-cigarette or vaping product, brand or specific substance has been definitively linked to the outbreak. CDC has received complete sex and age data on 373 of 530 cases. Nearly three-fourths of cases are male. Two-thirds of cases are 18 to 34 years old. Sixteen percent of cases are under 18 years and 17 percent are 35 years or older. Patients reported use of e-cigarette or other vaping products which could include devices, liquids, refill pods, and/or cartridges. The lung injuries observed in this outbreak does not appear to be due to infection. The pathologic appearance and absence of infectious diagnoses suggests chemical exposure(s). Patients first experienced their symptoms from a few days to several weeks after they most recently used ecigarette or vaping products. Most patients reported a gradual onset of difficulty breathing, shortness of breath, or chest pain before hospitalization. Some patients reported mild to moderate gastrointestinal illness, sometimes preceding respiratory symptoms. Some patients have reported other symptoms, such as fatigue, fever, and weight loss. Investigators have not identified any specific product or compound that is linked to all cases thus far. Page 3 of 10 CDC’s Collaboration with States CDC and FDA are working closely with and providing a coordinating function to state and local health officials to investigate these incidents as quickly as possible and aggregate information across states. CDC activated its Emergency Operations Center on September 16. CDC’s incident command structure comprises more than 80 staff from across the agency to coordinate activities, develop investigation tools and guidance, and provide assistance to states, public health partners, and clinicians around the nation. Shortly after Wisconsin first alerted CDC on August 1, 2019, to a cluster of pulmonary illness among young adults that began in July 2019, CDC learned that there also were possible similar cases in Illinois. Wisconsin and Illinois state health departments requested an “Epi Aid,” a formal assistance mechanism, from CDC on August 14, and August 16 respectively. Four CDC staff, including two Epidemic Intelligence Service Officers, were deployed to Illinois and Wisconsin on August 20, 2019, to assist with their respective state investigations. Building on the tools that were developed in Wisconsin and Illinois, CDC staff worked with all the states and the Council of State and Territorial Epidemiologists to help develop a standardized surveillance case definition and medical data collection tools to allow for more consistency across the states as they complete their own investigations and verify and classify their cases. When state investigators learn of suspected cases, they examine the medical records and consult with the clinical care team for each case. Using the standard case definition that has been developed, the state investigators then determine which cases are confirmed and which are probable. In both confirmed and probable cases, the patient recently used an e-cigarette product or vaped, developed a breathing illness, and other common causes of illness were ruled out as the primary cause of the illness. Confirmed and probable cases differ in the certainty with which an infectious cause is ruled out. But because the differences between these definitions are subtle, CDC reports confirmed and probable cases together for simplicity. In addition to approaching the investigation from this clinical perspective, clinicians and public health departments are also interviewing patients to gather more information about the devices and substances used as well as individual Page 4 of 10 behaviors. CDC has established a data reporting system which has been made available for states to enter data or to send data to CDC in an effort to describe the outbreak and define causes. CDC also reaches out to state health departments when it receives anecdotal reports of possible cases from clinicians and other sources. The reported information will allow CDC to aggregate and analyze the data across states to provide a better national picture of this emerging health issue. CDC is coordinating regular multi-state conference calls with health officials, laboratory personnel, and others to exchange information and is leading outreach to state health departments and clinicians, as well as coordinating efforts with FDA to gather information on devices or substances used, to help build a more comprehensive picture of these incidents. CDC is gathering reports of the types and brands of e-cigarette or vaping products used, the substances used, any modifications of the products, and where the products and liquids were obtained. This information will be shared with FDA to help FDA assess which of the products fall within FDA’s regulatory authority. CDC also developed interim guidance for clinicians and the public in support of the investigation. Based on CDC’s expertise in evaluation of e-cigarette or vaping devices and solutions, additional investigations are in development to help identify the potential chemical cause or causes of lung disease associated with use of e-cigarettes and vaping products. Because of the variety of chemicals that are present in e-cigarettes or vaping liquids and that may be added to e-cigarette or vaping liquids, as well as the diversity of products in circulation, laboratory analyses may be complex. In addition, users can modify the products, and the heating process can also influence the types and amounts of chemicals a user is exposed to. Thus, the identification of the cause or causes for the outbreak may take substantial time and continuing effort. CDC’s Outreach CDC is the source of public health information on this investigation and ensures that the findings from the investigation, as well as evidence-based interim recommendations, are provided to the public, health care providers, and others as soon as possible. CDC has communicated to consumers, clinicians, and public health Page 5 of 10 professionals through scientific publications, web products, social media, traditional media, and other channels. On August 16, 2019, CDC released a Clinician Outreach and Communication Activity (COCA) Clinical Action Alert describing this investigation and asking providers to report possible cases to their state health departments. CDC released a Health Alert Network (HAN) Health Advisory on August 30, 2019, with specific recommendations for clinicians, health officials, and the public. On September 6, 2019, CDC released additional information through the Morbidity and Mortality Weekly Reports (MMWRs), a summary from clinicians in North Carolina of clinical characteristics and e-cigarette or vaping product use exposures among five identified cases in that state, as well as CDC guidance for public health officials, clinical providers, and the public about prevention, case identification, and reporting. The New England Journal of Medicine article by authors from the Illinois and Wisconsin health departments in collaboration with CDC authors was also published on September 6. The article summarized the clinical characteristics and e-cigarette or vaping product use exposures among 53 Wisconsin and Illinois cases. Many of the patients, but not all, reported recent use of products containing THC, and some reported using both THC- and nicotine-containing products. Around 10-20 percent of cases report using nicotine-containing products only. CDC and FDA are working tirelessly to investigate whether the disease may be linked to specific ingredients or contaminants in the devices or substances associated with e-cigarette or vaping product use. Challenges This investigation has posed a number of challenges. First, most public health data collection and reporting systems are antiquated and fragmented, making it challenging to assure timely, actionable information while continuing to safeguard patient privacy. This investigation is emblematic of a challenge to all our work that requires rapid collection and analysis of public health data but is often reliant on paper-based systems and fax machines rather than electronic reporting and systems that are not interoperable. Second, the nature of the investigation includes inherent challenges, as reports of use of illicit drugs may complicate data collection from patients. State laws vary regarding THC and cannabis use, which may make standardized and Page 6 of 10 consistent data collection challenging. Finally, the e-cigarette and vaping marketplace is wide and diverse, with a multitude of substances that can be used with the devices. This can complicate toxicology testing (when there are a limited number of samples) and the interpretation of results (when there are many chemicals and substances that may be found across a wide variety of products). Despite these challenges, CDC has released interim recommendations for healthcare providers, health departments, and the public, and CDC will continue to provide evidence-based recommendations as we learn more. CDC’s Efforts to Address the Epidemic of E-cigarettes This outbreak comes in the middle of epidemic-level use of e-cigarettes by young people in the United States and reinforces the need to address the broader e-cigarette epidemic in the United States. Youth are much more likely than adults to use e-cigarettes. In fact, e-cigarettes are the most commonly used tobacco product among youth and their increased use has erased recent progress in reducing overall use of tobacco among youth. Preliminary data from the 2019 National Youth Tobacco Survey show a continued rise in rates of youth ecigarette use. The data show that in 2019, more than a quarter of high school students were current (past 30 day) e-cigarette users, a substantial increase in e-cigarette use among youth since 2017. E-cigarette use among high school students increased by 77.8 percent from 2017 to 2018, and more than one in four high school students reported current use of any tobacco product. As a result, the U.S. Surgeon General in December 2018 called the use of e-cigarettes among youth an epidemic in the United States. CDC is engaged in multifaceted efforts to prevent and reduce use of all tobacco products, including ecigarettes, among young people. In collaboration with our partners and other Federal agencies, CDC collects data and conducts research on youth use of tobacco products, including e-cigarettes. CDC and FDA jointly administer the National Youth Tobacco Survey (NYTS), an annual survey to monitor trends in the use of tobacco products among U.S. students in grades 6 through 12. CDC complements its routine surveillance efforts with novel, rapid response monitoring that captures emerging trends concerning e-cigarettes, such as the rise of ecigarette sales from 2013 to 2017. In addition, the Tobacco Laboratory in CDC’s Environmental Health Page 7 of 10 Laboratory provides critical laboratory science, including measuring harmful and addictive constituents in ecigarette solutions and aerosol, and measuring chemicals in the blood and urine of people who use e-cigarettes or are exposed to secondhand aerosol. CDC also educates the public about the harms of tobacco products, including e-cigarettes. For example, in 2016, CDC collaborated with the Surgeon General to release a Surgeon General’s Report entitled “E-Cigarette Use Among Youth and Young Adults.” This was the first comprehensive report on e-cigarettes among young people released by the U.S. government. Since, then, CDC has continued to promote the findings of the Report to educate parents, influencers of youth, and youth themselves. In response to compelling data about the sales and increased market share of JUUL, reports of widespread teen use of this and similar products, and mounting public concerns, CDC launched a partner initiative to expand the reach of CDC public health warnings. CDC developed plain-language infographics and social media posts for public health organizations and consumer audiences about e-cigarettes and has conducted back-to-school social media campaigns. CDC was the primary federal agency that assisted the Office of the Surgeon General in writing and launching a December 2018 ecigarette advisory to bring awareness to relevant audiences (teachers, parents, clinicians) about e-cigarette use by young people. CDC also developed promotional materials to support the release of the advisory, which was the first such advisory on a tobacco related topic released by the Office of the Surgeon General. Through the National Tobacco Control Program, CDC provides funding and technical support to all 50 states, the District of Columbia, 8 U.S. territories, 12 tribal support organizations, and 8 national networks representing priority populations, which are essential for coordinating the public health response to prevent tobacco initiation among youth and young adults, promote quitting among youth and adults, eliminate secondhand exposure to smoke and e-cigarette emissions, and identify and eliminate tobacco-related disparities. With funding from CDC, state and territorial health departments have taken a number of approaches to reduce youth access and exposure to e-cigarettes, including preparing nicotine health advisories and tobaccofree school toolkits, conducting surveillance of tobacco product use among youth, and creating and disseminating evidence-based educational materials to the public through social media and other mechanisms. Page 8 of 10 CDC’s Efforts to Understand the Harms Associated with Marijuana Use CDC is working to monitor cannabis use, identify associated health effects, and increase the surveillance capacity of CDC and state/local jurisdictions. The exposure to e-cigarettes or vaping products containing THC in many patients in this outbreak suggests the need to understand the health effects of increasing marijuana use in the United States and the changing marketplace as states continue to pursue legalization of marijuana for medical or recreational use. In 2018, an estimated 16 percent of the population age 12 and older reported using marijuana in the past year. The potency of THC in marijuana and the different products available have significantly increased over the last two decades. CDC Interim Outbreak Recommendations for Providers, States and the Public CDC has released interim recommendations for healthcare providers, health departments, and the public to supplement its existing e-cigarette and vaping product messaging. As we learn more about this outbreak, CDC will continue to provide evidence-based recommendations. While this investigation is ongoing, CDC recommends that individuals who are concerned about lung disease associated with e-cigarette use or vaping consider refraining from vaping or using e-cigarette products. CDC recommends that, regardless of the ongoing investigation, anyone who uses an e-cigarette or vaping products should not buy these products (such as e-cigarettes or vaping products with THC or other cannabinoids) off the street and should not modify or add any substances to these products that are not intended by the manufacturer. In addition, regardless of the ongoing investigation, e-cigarette products should not be used by youth, young adults, pregnant women, or adults who do not currently use tobacco products. CDC recommends adults who use e-cigarette products or vape because they have quit cigarette smoking should not return to smoking cigarettes. Those who need help quitting tobacco products, including e-cigarettes, should contact their doctor. Adult smokers who are attempting to quit should use evidence-based treatments, including counseling and FDA-approved medications. People who have recently used e-cigarette or vaping products should seek medical attention if they experience symptoms associated with this outbreak, such as cough, shortness of breath, or chest pain. Page 9 of 10 https://docs.house.gov/meetings/IF/IF02/20190925/110008/HHRG-116-IF02-Wstate-SchuchatMDRADMUSPHSRETA-20190925.pdf

LUNG ILLNESS ASSOCIATED WITH E-CIGARETTE USE OVERVIEW The Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and state and local health departments, including the Vermont Department of Health, are investigating a multistate outbreak of severe pulmonary illness associated with e-cigarette use. The investigation is ongoing and a cause has not been identified, but all reported cases have a history of using e-cigarette products. Many patients report using e-cigarette products with liquids that contain cannabinoid products, such as tetrahydrocannabinol (THC). Get the most recent case counts and information from CDC.(link is external) Until we know more about the cause of these illnesses, do not vape, dab or use e-cigarette products. What are e-cigarettes? What are the symptoms reported by some patients in this outbreak? VERMONT CASES This information is updated on Thursday each week. REPORTS CASES Number investigated 14 Confirmed 3 Probable 0 Pending classification 3 Not a case 8 INFORMATION FOR VERMONTERS Until we know more about the cause of these illnesses, do not vape, dab or use e-cigarette products. If you do use e-cigarette products and you experience symptoms(link is external) like those reported in this outbreak, seek medical care right away. The CDC and FDA encourage the public to submit detailed reports of any unexpected health or product issues related to tobacco or e-cigarette products to the FDA through the Safety Reporting Portal(link is external). Get Help Quitting If you need help quitting nicotine, including e-cigarettes, visit 802Quits(link is external). If you want to stop using marijuana and need help, call 2-1-1 or go to healthvermont.gov/find-treatment to find treatment options near you. INFORMATION FOR HEALTH CARE PROFESSIONALS Report possible cases to the Health Department. Report cases of significant respiratory illness of unclear etiology and a history of inhalational drug use (including vaping or smoking of any plant or chemical) in the 90 days prior to symptom onset to the Health Department at 802-863-7240 (available 24/7). Ask all patients if they vape or use e-cigarettes. Encourage patients to stop using these products. If e-cigarette product use is suspected as a possible cause for a patient’s lung disease, get a detailed history of the substances used, the sources, and the devices used as outlined in the CDC Health Advisory(link is external). For management of patients suspected of having illness related to recreational, illicit, or other drugs, call the Poison Control Center at 1-800-222-1222. Offer patients counseling and medication treatment. You can download the fax referral form(link is external) or send one electronically during the apointment(link is external). Get more information on how to refer patients at 802Quits(link is external). Resources: Upcoming CDC Webinar: Outbreak of Pulmonary Disease Associated with E-cigarette Product Use or Vaping: Information for Clinicians (Thursday, September 19, 2019, 2-3 p.m. EST)(link is external) Health Advisory: First Case of Severe Vaping-associated Pulmonary Illness Confirmed (Vermont Department of Health, September 16, 2019) Health Advisory: Severe Vaping-associated Pulmonary Illness (Vermont Department of Health, August 29, 2019) Health Advisory: Severe Pulmonary Disease Associated with Using E-Cigarette Products (CDC, August 30, 2019)(link is external) MMWR: Outbreak of Electronic-Cigarette–Associated Acute Lipoid Pneumonia — North Carolina, July–August 2019 (CDC, September 6, 2019)(link is external) MMWR: Severe Pulmonary Disease Associated with Electronic-Cigarette–Product Use — Interim Guidance (CDC, September 6, 2019)(link is external) LAST REVIEWED: SEPTEMBER 24, 2019

VERMONT CASES This information is updated on Thursday each week. REPORTS CASES Number investigated 14 Confirmed 3 Probable 0 Pending classification 3 Not a case 8 https://www.healthvermont.gov/response/infectious-disease/lung-illness-associated-e-cigarette-use

Severe Lung Disease/Injuries Associated with Vaping The New Hampshire Department of Health and Human Services, Division of Public Health Services (DPHS), is closely following the reports of severe lung illness potentially related to vaping among teens and adults across the United States. As part of these efforts, DPHS is partnering with the U.S. Centers for Disease Control and Prevention (CDC) to investigate any such cases that occur in New Hampshire so we can understand how to prevent and treat these illnesses. WMUR Health Headlines: Severe Lung Disease/Injuries Associated with Vaping (length 3:19 minutes) What are e-cigarettes/vaping? E-cigarettes are a diverse group of battery-powered devices that mimic the act of smoking by producing an aerosol. The aerosol is created by heating a liquid mixture containing nicotine and/or cannabis, flavorings, and other chemicals, which are inhaled (called “vaping.”) The aerosol that users inhale contain harmful and potentially harmful substances, including: Nicotine Ultrafine particles that can be inhaled deep into the lungs Flavoring such as diacetyl, a chemical linked to a serious lung disease Volatile organic compounds Cancer-causing chemicals Heavy metals such as nickel, tin, and lead Situation At the beginning of August, CDC announced that a cluster of patients in the mid-West were hospitalized with a respiratory illness associated with vaping. Since those reports, other states around the country have identified more people with possible vaping-associated respiratory illness. The cause of these illnesses is still under investigation, but all of these persons have reported vaping in the weeks and months prior to going into the hospital. There has not been one chemical or vaping product used by all individuals. Most patients who have become ill had progressive respiratory symptoms including difficulty breathing, cough, and chest pain with breathing. Some people have even reported gastrointestinal symptoms such as nausea, vomiting, and diarrhea. Medical evaluations have not shown that an infectious disease is the cause of a person’s symptoms. It is still unclear the best treatment for patients when they present with these vaping-associated respiratory illnesses.What can New Hampshire residents do to protect themselves and their families?E-cigarette use and vaping among youth and young adults is a major public health issue with e-cigarette use now the most commonly used tobacco product among youth. Almost a quarter (24%) of all high school aged adolescents in New Hampshire reported recently using electronic vapor products (the U.S. average is approximately 13%). Parents, guardians, and youth should be aware of the risk that e-cigarette use and vaping poses to their health and take steps to stop or prevent use of vaping and/or other tobacco products. People experiencing respiratory symptoms after vaping should seek medical care.Investigating Possible Connection with Vaping Because the cause of the these illnesses are being investigated around the country, if a healthcare provider suspects his/her patient might have a vaping-associated respiratory illness, it is important for that healthcare provider to obtain more information about the person’s use of vaping and e-cigarette use, including: Type of product and device used (e.g. liquids, refill pods, and/or cartridges Sharing and re-use of old cartridges or pods Types of drugs (e.g. nicotine and/or cannabis) Method(s) of heating and inhaling drug (e.g., smoking, vaping, “dabbing”) Whether there may be retained product, device, or chemical for further public health testing CDC recommends that clinicians report cases of significant respiratory illness of unclear etiology and a history of vaping to the appropriate state and/or local health department. For additional information, healthcare providers should consult the NH Health Alert messages. US Food and Drug Safety Reporting Tool The US Food and Drug Administration (FDA) is continuing to investigate a possible link between e-cigarettes and seizures or other neurologic symptoms. FDA "strongly" encourages health providers and the public to report details of any incidents of seizures following e-cigarette use via its Safety Reporting Portal. Additional Information CDC Outbreak of Severe Pulmonary Disease Associated with Using E-cigarette Products CDC Electronic Cigarettes NH Tobacco Prevention and Cessation Program E-Cigarettes/Vape Coming October 1: My Life, My Quit – New Hampshire’s Tobacco Quitline for Teens If you have additional questions, please contact the NH Tobacco Prevention and Cessation Program by email at [email protected].

The New Hampshire Department of Health and Human Services, Division of Public Health Services (DPHS), is closely following the reports of severe lung illness potentially related to vaping among teens and adults across the United States. As part of these efforts, DPHS is partnering with the U.S. Centers for Disease Control and Prevention (CDC) to investigate any such cases that occur in New Hampshire so we can understand how to prevent and treat these illnesses. https://www.dhhs.nh.gov/dphs/tobacco/lung-disease-vaping.htm

FOR IMMEDIATE RELEASE Date: September 20, 2019 Contact: Jon Ebelt, Public Information Officer, DPHHS, (406) 444-0936, (406) 461-3757, [email protected] Chuck Council, Communications Specialist, DPHHS, (406) 444-4391, (406) 461-8367, [email protected] Barbara Schneeman, RiverStone Health, Vice President, Communication and Public Affairs, (406) 651-6420 [email protected] Health officials confirm first Montana case of severe pulmonary disease associated with vaping RiverStone Health and the Department of Public Health and Human Services (DPHHS) have identified the first confirmed case of severe pulmonary disease associated with vaping in connection with the ongoing national investigation. The confirmed case is a Yellowstone County resident in their 30s with a history of vaping nicotine and THC. This individual was hospitalized in August, and is now home recovering. Eight deaths associated with severe pulmonary illness have occurred. As of September 17, 2019, there were 530 confirmed and probable cases of lung disease associated with e-cigarette product use, or vaping, reported by 38 states and the U.S. Virgin Islands. Two thirds (67%) of cases in this investigation are people 18 to 34 years old, and 16% are younger than 18 years old. Montana’s first confirmed case adds to the growing number of cases in this national investigation. “This is deeply concerning, especially given the rapid increase in young people using e-cigarettes,” said Governor Steve Bullock. “Montana is supporting the national investigation to determine what is making people sick, while also looking at options on how we can take action without waiting on Washington.” State Medical Officer Dr. Greg Holzman said DPHHS is working directly with local health officials on the investigation and is urging state residents to take into account the current situation both in Montana and in other states and respond accordingly. “I urge Montanans to refrain from using e-cigarettes, considering the existing unknown health consequences,” Holzman said. “If you’re having difficulties quitting these highly addictive nicotine products contact your healthcare provider or the Montana Tobacco Quit Line.” The CDC reports that products used could include a number of substances, including THC, CBD, nicotine, flavorings, and other chemicals. John Felton, President/CEO of RiverStone Health and Yellowstone County’s health officer, thanked the individual associated with the first confirmed case for providing valuable information about their illness. “In order to solve what is causing these illnesses, it’s imperative that people impacted cooperate with the investigation so that accurate information can be gathered,” he said. “These investigative efforts are happening around the country, and we appreciate those in Montana who are assisting.” Regardless of the ongoing investigation, health officials state that e-cigarette products should never be used by youth, young adults, pregnant women, or adults who do not currently use tobacco products. DPHHS states that adding to the concern is the high rate of e-cigarette use among youth. In Montana, e-cigarettes are now the most commonly used tobacco product among high school students. The 2019 Montana Youth Risk Behavior Survey showed nearly a third (30%) of Montana high school students currently use e-cigarettes and more than half (58%) have tried them. CDC states that all patients reported using e-cigarette products in the weeks and months prior to becoming ill. To date, no single substance, e-cigarette product, or additive has been consistently associated with the illness. Symptoms include coughing, shortness of breath, chest pain, and fatigue. Nausea, vomiting, and diarrhea are also common. Symptoms worsen over a period of days or weeks and do not appear to be caused by a pulmonary infection. Anyone who vapes and is experiencing respiratory issues should promptly consult their provider. Healthcare providers treating patients with respiratory illness with no apparent infectious cause and who have a history of e-cigarette use are asked to notify their local health department. Current recommendations for the public include: Until more information is known, CDC and DPHHS are advising people not to use any type of e-cigarette product. Anyone who uses e-cigarette products and is experiencing respiratory issues should promptly consult their provider. If it is a medical emergency call 9-1-1 or the Poison Control Center (1-800-222-1222). Anyone who uses e-cigarette products should not buy them off the street and should not modify these products or add any substances that are not intended by the manufacturer. Current tobacco users, including e-cigarette users, trying to quit should use evidence-based strategies, which include counseling, FDA-approved medications, and calling the Montana Tobacco Quit Line at 1-800-QUIT-NOW (1-800-784-8669). Youth (anyone under the age of 18) who need help quitting tobacco, including e-cigarettes, can text “Start my Quit” to 1-855-891-9989 or visit mylifemyquit.com. Anyone experiencing unexpected health or product issues related to tobacco or e-cigarettes should submit this information via FDA’s online Safety Reporting Portal. More information about the investigation is available on the DPHHS website at dphhs.mt.gov.

RiverStone Health and the Department of Public Health and Human Services (DPHHS) have identified the first confirmed case of severe pulmonary disease associated with vaping in connection with the ongoing national investigation. The confirmed case is a Yellowstone County resident in their 30s with a history of vaping nicotine and THC. This individual was hospitalized in August, and is now home recovering. https://dphhs.mt.gov/aboutus/news/2019/pulmonarydiseaseconfirmed

Earlier this month, I used my authority as Commissioner of Public Health to declare any suspected cases of vaping-associated pulmonary disease to be immediately reportable to the Department for the next 12 months. During the first two weeks of this mandated reporting, clinicians reported 46 suspected cases. We are receiving up to 10 suspected cases a day. https://docs.house.gov/meetings/IF/IF02/20190925/110008/HHRG-116-IF02-Wstate-BharelMDMPHM-20190925.pdf

Potential and probable cases have been coming into the State Public Health Laboratory at an alarming rate– on average of 5-10 per day since it was made a reportable condition just a short time ago. Massachusetts is taking this action now because it is prudent to response quickly, before we have large numbers and deaths. https://www.mass.gov/guides/vaping-public-health-emergency

Maine DHHS Press / News Release September 20, 2019 Maine reports a case of lung illness related to e-cigarette use Individuals who show symptoms are urged to consult a health care provider AUGUSTA – The Maine Center for Disease Control and Prevention (CDC) today reported a case of acute lung illness related to the use of e-cigarettes. The case involves an adult who reported symptoms similar to those identified in other states. Symptoms have included cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, fatigue, fever, and abdominal pain. Individuals who have recently used an e-cigarette or vaping product and experience similar symptoms should see a health care provider. "This case highlights the risks and uncertainty about the short- and long-term effects of e-cigarette use," said Maine CDC Director Nirav D. Shah. "People who do not vape should not start and people who do should seriously consider the health risks in using e-cigarette products." To date, federal public health authorities have reports of 530 cases in 38 other states and one U.S. territory. Seven deaths in six states have been attributed to the illness. The case reported to the U.S. Centers for Disease Control and Prevention today is the first case of the illness identified in Maine. No deaths from the illness have been recorded in Maine. The specific cause of this illness is being investigated by health officials across the country. No specific e-cigarette product or substance is linked to all cases. In other states, most patients reported a history of using e-cigarette products containing tetrahydrocannabinol (THC), the active ingredient in cannabis. Other patients reported using both THC and nicotine, while a third group reported using e-cigarettes containing only nicotine. Protecting Maine residents from the harmful effects of e-cigarettes is a priority for Maine CDC. In addition to investigating other potential cases of severe lung illness associated with e-cigarette use, Maine CDC continues its work with partners across the state to help prevent people from initiating use of and exposure to e-cigarettes. What can you do? If you vape and have symptoms of lung illness, see your health care provider. If you are a health care provider and suspect a case meets the lung illness criteria, call 1-800-821-5821 or email [email protected]. Please do not include personally identifying patient information. Schools needing policy or education assistance related to e-cigarettes/vaping may contact a local tobacco prevention provider ctimaine.org/resources/local-prevention-partners/. Learn more about e-cigarettes in this toolkit. If you've never smoked or used other tobacco products or e-cigarettes, don't start. If you use these products, help is available. Free support to quit or help someone quit: Phone:Call the Maine Tobacco HelpLine at 1-800-207-1230 to talk with a quit coach. Web:Visit thequitlink.com for support, whether you are ready to quit or just thinking about it. Support includes developing a plan to quit, texts, advice, and a supportive community of tobacco users who have quit. Text:The Truth Initiative offers free text message programs for youth and young adults who want to quit vaping or smoking. It presents content by age group to give appropriate advice about quitting. It is also a resource for parents looking to help their children. Text Quit to 202-804-9884 to quit JUUL or e-cigs. Text QUITNOW to 202-759-6436 to quit cigarettes. For more information: U.S. CDC updates on lung disease associated with vaping www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html Additional resources:ctimaine.org/resources/ends-vaping/ Maine CDC Tobacco and Substance Use Prevention and Control Program: (207)287-4627 or [email protected] Surgeon General's Advisory, e-cigarettes.surgeongeneral.gov/documents/surgeon-generals-advisory-on-e-cigarette-use-among-youth-2018.pdf.

September 20, 2019 Maine reports a case of lung illness related to e-cigarette use Individuals who show symptoms are urged to consult a health care provider AUGUSTA – The Maine Center for Disease Control and Prevention (CDC) today reported a case of acute lung illness related to the use of e-cigarettes. The case involves an adult who reported symptoms similar to those identified in other states. Symptoms have included cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, fatigue, fever, and abdominal pain. https://www.maine.gov/dhhs/press-release.shtml?id=1555233

Vaping in Louisiana Outbreak Background What are E-Cigarettes Recommendations How Many Cases are in Louisiana Resources Information for Healthcare Providers Outbreak Background CDC, U.S. Food and Drug Administration (FDA), 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. Although the etiology of e-cigarette-associated pulmonary disease is undetermined, epidemiologic investigations in affected states are ongoing to better characterize the exposures, demographic, clinical, and laboratory features and behaviors of patients. All patients have reported using e-cigarette products. The exact number is currently unknown, but many patients have reported using e-cigarettes containing cannabinoid products such as THC or CBD. The Louisiana Department of Health is asking physicians and other healthcare providers to report severe respiratory illnesses among patients that report a history of e-cigarette use to state health officials. top What are E-Cigarettes? 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 can also be used to deliver marijuana or other substances. E-cigarettes are not safe for youth, young adults, pregnant women, or adults who do not currently use tobacco products. top Recommendations for the public If you are concerned about the health risks associated with e-cigarettes, consider discontinuing the products. E-cigarette products should not be bought off the street and should not be modified or have substances not intended for use by the manufacturer added. Youth, young adults and pregnant women, as well as adults who do not currently use tobacco products, should not use e-cigarettes. Monitor for symptoms of severe side effects if you do use e-cigarettes. If you do develop symptoms, seek medical attention. These symptoms include: Cough Shortness of breath Chest pain Nausea Vomiting Diarrhea Fatigue Fever Weight loss Adult smokers who are looking to quit smoking can call 1-800-QUIT-NOW or visit www.quitwithusla.org for information on FDA-approved counseling and medications. top How Many Cases are There in Louisiana Outbreak Cases Deaths Age Range 18 0 17-45 years There are 18 cases reported in Louisiana 18 cases of pulmonary illness were reported to health officials between August and September of 2019. Those cases were reported from throughout the state with the ages ranging from 17-45. There have been no deaths in Louisiana associated with this illness. Click here for Outbreak of Lung Disease Associated with E-Cigarette Use, or Vaping Information from the CDC Site top Resources for the Public Information on electronic cigarettes and similar devices: CDC Press Statement CDC Clinical Outreach and Communication Activity announcement: CDC’s National Syndromic Surveillance Program’s BioSense/ESSENCE For more information, visit CDC Info Louisiana Department of Health Press Release on Vaping-Related Illness Strike Out Vaping Well-Ahead Youth Resources top Information for Healthcare Providers Health care providers should report cases of severe pulmonary disease of unclear etiology and a history of e-cigarette product use to the Louisiana Department of Health’s Infectious Disease Epidemiology Section at 1-800-256-2748 within one business day. Reporting of cases may help CDC and state health departments determine the cause or causes of these pulmonary illnesses. Ask all patients who report e-cigarette product use within the last 90 days about signs and symptoms of pulmonary illness.

How Many Cases are There in Louisiana Outbreak Cases Deaths Age Range 18 0 17-45 years There are 18 cases reported in Louisiana 18 cases of pulmonary illness were reported to health officials between August and September of 2019. Those cases were reported from throughout the state with the ages ranging from 17-45. There have been no deaths in Louisiana associated with this illness. Click here for Outbreak of Lung Disease Associated with E-Cigarette Use, or Vaping Information from the CDC Site http://ldh.la.gov/index.cfm/page/3724

Severe Lung Disease Associated with Vaping Several states have recently reported cases of severe respiratory illness among teenagers and young adults with a history of vaping. Reported symptoms include cough, fatigue, dizziness, headache, vomiting and diarrhea, chest pain, and worsening difficulty breathing, sometimes requiring intensive care. A variety of vaping products associated with the illnesses have been reported across states, but THC has been commonly associated with these illnesses. Youth should be discouraged from using vaping and e-cigarette products of any kind as the long-term health impacts for youth using these products are unknown. Patients with a history of vaping who are experiencing breathing problems should seek medical care. Health care providers should ask patients with respiratory illness about the use of vaping and e-cigarette products. Health care providers are asked to report severe respiratory illness in patients with a history of vaping or e-cigarette use to the Iowa Department of Public Health (1-800-362-2736). This is an emerging health issue that is still under investigation. Below you will find links to information from the CDC and IDPH. Weekly case counts will be posted to this page on Fridays. 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 Press Releases Vaping-related Illnesses Reported among Iowa Young Adults (8/22/19) New Vaping and Tobacco Cessation Program for Teens (9/9/19) Recommendations for the Public While this investigation is ongoing, if you are concerned about these specific health risks, consider refraining from using e-cigarette products. Regardless of the ongoing investigation, anyone who uses e-cigarette products should not buy these products off the street (e.g., e-cigarette products with THC, other cannabinoids) and should not modify e-cigarette products or add any substances to these products that are not intended by the manufacturer. Regardless of the ongoing investigation, e-cigarette products should not be used by youth, young adults, pregnant women, as well as adults who do not currently use tobacco products. If you use e-cigarette products, monitor yourself for symptoms (e.g., cough, shortness of breath, chest pain) and promptly seek medical attention if you have concerns about your health. IDPH, CDC and FDA will continue to advise and alert the public as more information becomes available. Adult smokers who are attempting to quit should use evidence-based treatments, including counseling and FDA-approved medications. If you who need help quitting tobacco products, including e-cigarettes, call 1-800-QUIT-NOW or visit Quitline Iowa. If you are concerned about harmful effects from e-cigarette products, call your local poison control center at1-800-222-1222. We encourage the public to submit detailed reports of any unexpected tobacco or e-cigarette-related health or product issues to the FDA via the online Safety Reporting Portal: https://www.safetyreporting.hhs.gov. CDC Information CDC Investigation Webpage Initial Federal, State Findings Point to Clinical Similarities in Illnesses Among People Who Use E-cigarettes (9/6/19) CDC Health Advisory: Severe Pulmonary Disease Associated with Using E-Cigarette Products (8/30/19) CDC Director's statement on the first death related to the outbreak of severe lung disease in people who use e-cigarette or "vaping" devices (8/23/19) Transcript of August 23, 2019, Telebriefing on Severe Pulmonary Disease Associated with Use of E-cigarettes

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 https://idph.iowa.gov/ehi/lung-disease-vaping

Severe Respiratory Illness Associated With Vaping – Idaho update Last updated: September 20, 2019 Cases among Idaho residents: 6 This page will be updated each Friday by 2:00pm MT The Idaho Division of Public Health (DPH) is currently working together with local public health districts statewide to investigate reports and identify cases of severe pulmonary illnesses associated with e-cigarette use, also known as vaping, juuling, or dabbing. Idaho DPH is also coordinating with federal and state partners in the investigation of this nationwide outbreak. Neighboring states including Utah and Oregon have reported multiple cases, including one fatality. Nationwide, patients have experienced respiratory symptoms including cough, shortness of breath, and chest pain. Other signs and symptoms included fever, fatigue, weight loss, nausea, vomiting and diarrhea. Many patients reported symptoms worsening over time. Many patients were otherwise healthy young adults. Products used by patients may contain THC, CBD, nicotine, flavors, and other chemicals. No single substance or product has been consistently associated with the illnesses. Whom to call If you or someone you know is experiencing any of these symptoms, please contact your healthcare provider. If it is a medical emergency call 9-1-1. Healthcare providers treating patients with unexplained serious respiratory illness in patients who mention e-cigarette use, vaping, or dabbing should notify DPH Epidemiologists at 208-334-5939 (Fax: 208-332-7307). Resources (also on www.epi.idaho.gov) Outbreak of Severe Pulmonary Disease Associated with Using E-cigarette Products (CDC) Severe Pulmonary Disease Associated with Electronic-Cigarette–Product Use — Interim Guidance (MMWR) E-cigarettes- what's the bottom line? (CDC) Know the risks- E-cigarettes & young people (Surgeon General) Project Filter- Idaho Fights Tobacco

Severe Respiratory Illness Associated With Vaping – Idaho update Last updated: September 20, 2019 Cases among Idaho residents: 6 This page will be updated each Friday by 2:00pm MT http://healthandwelfare.idaho.gov/Portals/0/Health/Epi/Hot Topic Idaho page 20190920.pdf

Severe Respiratory Illness Associated with E-cig/Vaping – Resource for Clinicians The Hawaii Department of Health has confirmed its first case of severe respiratory illness associated with e-cigarette use (also known as “vaping”). The case fell ill in August presenting with tactile fevers, cough, nonspecific gastrointestinal symptoms, and hemoptysis, and required brief intubation. If you suspect a patient under your care may have respiratory illness caused by vaping complete, please the case report form: Preliminary Vaping Case Report Form (pdf) Fax to the Disease Outbreak Control Division at (808)586-8347 or email to [email protected] using encryption or password protection. ACTION ITEMS FOR HAWAII CLINICIANS: INPATIENT SETTING: Assess patients for a vaping history for THC, nicotine, and/or any other products in the 90 days before illness onset. Consider this syndrome in patients with severe respiratory disease and vaping history, especially those with no explicative etiology. Consider consulting a pulmonologist to guide additional diagnostics and management. OUTPATIENT SETTING: Assess patients for recent or prior use of vaping products. Consider potential for worsening disease progression if risk factors present. ALL SETTINGS: Educate all patients on the risks associated with vaping nicotine and other products. Advise patients to seek care if symptoms worsen or return after initial resolution. While the national investigation is ongoing, persons should consider not using e-cigarette products, especially those purchased from sources other than authorized retailers (e.g., e-cigarette products with THC) and those modified in a manner not intended by the manufacturer. Contact the Disease Outbreak Control Division immediately (refer to contact information below) if you suspect you are managing a case of vaping associated severe respiratory illness. If e-cigarette product use is suspected as a possible cause for a patient’s respiratory disease, please obtain a detailed history of the substances used, the sources, and the devices used. Determine also if any remaining product, devices, and liquids are available for testing. We are advising the public to contact their physician should they have any concerns. E-cigarettes should never be used by youths, young adults, pregnant women, and adults who do not currently use tobacco products. If you have any questions or need to report a suspect case of vaping associated severe respiratory illness, please contact the Department of Health immediately. Oahu (Disease Reporting Line)………………………………. (808) 586-4586 Maui District Health Office…………………………………….. (808) 984-8213 Kauai District Health Office……………………………………. (808) 241-3563 Big Island District Health Office (Hilo)……………………. (808) 933-0912 Big Island District Health Office (Kona)……………………(808) 322-4877 After hours on Oahu……………………………………………….(808) 600-3625 After hours on neighbor islands……………………………..(800) 360-2575 (toll free) LINKS AND RESOURCES: Hawai’i Medical Advisory: Probable Vaping Associated Severe Respiratory Illness Case (9/10/19) CDC Health Alert for Vaping CDC’s resources for healthcare providers Preliminary Report in the New England Journal of Medicine

Severe Respiratory Illness Associated with E-cig/Vaping – Resource for Clinicians The Hawaii Department of Health has confirmed its first case of severe respiratory illness associated with e-cigarette use (also known as “vaping”). The case fell ill in August presenting with tactile fevers, cough, nonspecific gastrointestinal symptoms, and hemoptysis, and required brief intubation. http://health.hawaii.gov/docd/vaping-resources-for-clinicians/

DPH Provides Update on Vaping-Related Lung Illnesses in Delaware Delaware Health and Social Services | Division of Public Health | News | Date Posted: Wednesday, September 25, 2019 ListenListen with webReader DOVER – The Delaware Division of Public Health (DPH) continues to participate in a multi-state investigation into an outbreak of severe pulmonary disease reported across the country. As of today, 38 states, including Delaware, have reported cases of lung injury associated with use of e-cigarette products (e.g., devices, liquids, refill pods, and cartridges). The Centers for Disease Control and Prevention (CDC) classifies cases as probable or confirmed based on case definition. Since DPH released its initial Sept. 9, 2019, press release announcing three possible cases of vaping-related lung illnesses under investigation in Delaware, two of the three cases were identified as meeting the CDC case definition of “probable.” Four additional cases have since been classified as probable, resulting in a total of six probable cases as of today. Currently, Delaware does not have any cases classified as confirmed. There are an additional five cases under investigation. Of the six probable cases, the individuals range from ages 15 to 45. Five are New Castle County residents, and one is from Kent County. Four of the six individuals are men and two are women. Some individuals reported use of e-cigarette products containing THC, as well as e-cigarette products containing nicotine, and some reported using e-cigarette products containing only THC. As of Thursday, Sept. 19, 2019, there were 530 probable or confirmed cases of lung injury associated with the use of e-cigarette or vaping products reported throughout the United States, according to the CDC. Seven deaths related to this outbreak have been reported in six states. “As we continue to investigate additional cases of lung injury associated with the use of e-cigarette products, we strongly recommend that individuals avoid using e-cigarette products,” said DPH Director Dr. Karyl Rattay. “These illnesses can be life-threatening.” More research needs to be done on the long-term impacts, but the CDC has stated that the aerosol used in e-cigarettes contains harmful substances such as nicotine, lead products and cancer-causing agents. The CDC launched its investigation into the lung illnesses on Aug. 1, 2019, and has worked closely since then with the Food and Drug Administration, states and other public health partners, and clinicians to determine the cause. No evidence of infectious diseases has been identified in these patients, therefore lung illnesses are likely associated with a chemical exposure. The investigation has not yet identified any specific substance or e-cigarette product that is linked to all cases. Many patients report using e-cigarette products with liquids that contain cannabinoid products, such as tetrahydrocannabinol (THC). Based on reports from several states, patients have experienced respiratory symptoms (cough, shortness of breath, or chest pain), and some have also experienced gastrointestinal symptoms (nausea, vomiting, or diarrhea) or non-specific symptoms such as fatigue, fever, or weight loss. Symptoms typically develop over a period of days but sometimes can manifest over several weeks. Gastrointestinal symptoms sometimes preceded respiratory symptoms. Fever, tachycardia, and elevated white blood cell count have been reported in the absence of an identifiable infectious disease. What the public can do: While this investigation is ongoing, DPH strongly encourages people not to use e-cigarette products. People who do use e-cigarette products should monitor themselves for symptoms (e.g., cough, shortness of breath, chest pain, nausea, vomiting, abdominal pain, fever) and promptly seek medical attention for any health concerns. Although there is risk with any vaping product, people should not buy these products off the street and should not modify e-cigarette products or add any substances that are not intended by the manufacturer. E-cigarette products should never be used by youth, young adults, pregnant women, or adults who do not currently use tobacco products. Individuals who may be concerned about their health after using an e-cigarette product should contact their health care provider, or the local poison control center at 1-800-222-1222. Adult smokers who are attempting to quit should use evidence-based treatments, including counseling and FDA-approved medications. If you who need help quitting tobacco products, including e-cigarettes, call the Delaware Quitline at 1-866-409-1858. Youth who smoke or vape can contact the American Lung Association’s NOT on Tobacco Cessation Program (NOT) for teens (1-800-LUNGUSA). The Truth Initiative also operates a text cessation program. To participate text “DITCHJUUL” to 887-09. DPH recently issued a health alert to Delaware medical providers advising them of the CDC outbreak investigation and providing guidance for reporting possible cases. Clinicians should report cases of significant respiratory illness of unclear etiology and a history of vaping to the Delaware Division of Public Health, Bureau of Epidemiology (24/7) at 1-888-295-5156. Health care providers should also ask all patients who report e-cigarette product use within the last 90 days about signs and symptoms of pulmonary illness. If e-cigarette product use is suspected as a possible cause for a patient’s lung disease, a detailed history of the substances used, the sources, and the devices used should be obtained, and efforts should be made to determine if any remaining product, devices, and liquids are available for testing. Among teenagers, experimentation with electronic or e-cigarettes became very popular, starting about 2015. According to the 2017 Youth Risk Behavior Survey of public high school students, 38 percent reported ever trying e-cigarettes, 13.6 percent of students had used e-cigarettes in the past month, and 1.9 percent were smoking or “vaping” e-cigarettes daily. E-cigarette use is also catching on with adults. According to the 2017 Behavioral Risk Factor Survey, about 4.8 percent of Delaware adults currently use e-cigarettes, about the same prevalence as the 2016 survey. However, 12.7 percent of 18- to 24-year-old adults and 21.3 percent of males age 18-24 are “current users” of e-cigarettes. In 2017, more than half of the adults who “vaped” e-cigarettes (56.4 percent) also were current smokers, thereby increasing potential harm. Among current smokers, 28.6 percent also used e-cigarettes at least some days of the week. According to the CDC, while e-cigarettes have the potential to benefit some people and harm others, scientists still have a lot to learn about whether e-cigarettes are effective for quitting smoking. For more information and updates on the CDC’s multi-state investigation, go to https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html. A person who is deaf, hard-of-hearing, deaf-blind or speech-disabled can call the DPH phone number above by using TTY services. Dial 7-1-1 or 800-232-5460 to type your conversation to a relay operator, who reads your conversation to a hearing person at DPH. The relay operator types the hearing person’s spoken words back to the TTY user. To learn more about TTY availability in Delaware, visit http://delawarerelay.com.

The Centers for Disease Control and Prevention (CDC) classifies cases as probable or confirmed based on case definition. Since DPH released its initial Sept. 9, 2019, press release announcing three possible cases of vaping-related lung illnesses under investigation in Delaware, two of the three cases were identified as meeting the CDC case definition of “probable.” Four additional cases have since been classified as probable, resulting in a total of six probable cases as of today. Currently, Delaware does not have any cases classified as confirmed. There are an additional five cases under investigation. Of the six probable cases, the individuals range from ages 15 to 45. Five are New Castle County residents, and one is from Kent County. Four of the six individuals are men and two are women. Some individuals reported use of e-cigarette products containing THC, as well as e-cigarette products containing nicotine, and some reported using e-cigarette products containing only THC. https://news.delaware.gov/2019/09/25/dph-provides-update-on-vaping-related-lung-illnesses-in-delaware/

DPH Identifies First Death From Vaping-Associated Illness DPH has identified the state’s first death from a vaping-associated illness. The patient had a history of heavy nicotine vaping, but no reported history of vaping THC. DPH has identified nine cases, including the death, of vaping-associated illness in Georgia, and other possible cases are being reviewed. All patients were hospitalized and developed pneumonia with no known infectious cause. Cases range in age from 18 to 68 years (median age 26 years), 78% are male. The Centers for Disease Control and Prevention (CDC) is working with states to investigate more than 500 cases of vaping-associated illness. No specific e-cigarette device or substance has been linked to all cases. Most patients have reported a history of using vaping products containing THC. Many patients have reported using THC and nicotine. Some have reported the use of e-cigarette products containing only nicotine. Governor Brian P. Kemp and DPH Commissioner Kathleen E. Toomey, M.D., M.P.H. urge individuals to follow the CDC recommendation that individuals not use e-cigarettes or other vaping devices while this investigation is ongoing. Without knowing the specific cause of the vaping-associated illness, discontinuing use of e-cigarettes and vaping devices is the best prevention against becoming ill. E-cigarettes and other vaping devices are not safe for youth, young adults, pregnant women or adults who do not currently use tobacco products. People who use e-cigarette products should not buy vaping products off the street and should not modify or add any substances to e-cigarette products. Symptoms of vaping-associated illness, which worsen over time, include cough, shortness of breath, fatigue, chest pain, nausea, vomiting and diarrhea. People with a history of vaping who are experiencing breathing problems or any of these symptoms should seek medical care. For more information about e-cigarettes and vaping, visit https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#latest-outbreak-information.

DPH Identifies First Death From Vaping-Associated Illness DPH has identified the state’s first death from a vaping-associated illness. The patient had a history of heavy nicotine vaping, but no reported history of vaping THC. DPH has identified nine cases, including the death, of vaping-associated illness in Georgia, and other possible cases are being reviewed. All patients were hospitalized and developed pneumonia with no known infectious cause. Cases range in age from 18 to 68 years (median age 26 years), 78% are male. https://dph.georgia.gov/