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Vaping-Associated Respiratory Illness Outbreak Report Back to vaping and lung illness Colorado is one of multiple states investigating severe lung illness associated with vaping. In line with the Centers for Disease Control and Prevention, Colorado is reporting confirmed and probable cases. A confirmed case is someone who recently used a vaping product, developed a breathing illness, and for whom testing did not show an infection. Other common causes of illness have been ruled out as the primary cause. A probable case is someone who recently used a vaping product, developed a breathing illness, and for whom specific testing has not been not performed to rule out infection OR for whom an infection was identified, but the clinical team believes this is not the only cause of the breathing illness. Confirmed and probable cases in Colorado since August 2019 Values Number Percentage Age Mean 25.5 Median 18 Sex Male 6 75% Female 2 25% Total 8 100% County Boulder 2 25% Arapahoe 1 12.5% Denver 3 37.5% Jefferson 1 12.5% Weld 1 12.5% Total 8 100% Hospitalized Yes 6 75% No 2 25% Total 8 100% Substances vaped Marijuana only 2 25% Nicotine only 3 37.5% Both nicotine and marijuana 2 25% Under Investigation 1 12.5% Total 8 100% At a glance As of Sept. 25, 2019 8 outbreak cases 6 hospitalizations 0 deaths Colorado Vaping-Associated Respiratory Illness Outbreak Report | Last updated 092519

At a glance As of Sept. 25, 2019 8 outbreak cases 6 hospitalizations 0 deaths https://docs.google.com/document/d/e/2PACX-1vSM_x2Lls4ip-PDZT5LGVYYnwaTya-G4sBNlNM00XM_zs5RekMCbFkIjzzIUqkbxZoVitKg8OwlXhpm/pub

VAPING-RELATED LUNG ILLNESS INVESTIGATION The Arkansas Department of Health is warning Arkansans who use an electronic smoking device, e-cigarette, or vape about the risk of a potential lung illness. Further investigation is ongoing to determine the possible cause of the illnesses. Current Cases as of September 25, 2019 Confirmed 1* Probable 7 Under Investigation 6 Total 14 * Due to a change in case definitions, some previously confirmed cases have been reclassified. Symptoms may include shortness of breath, chest pain, coughing, and fatigue. A few patients also reported fever, nausea, and diarrhea. The symptoms may worsen over days and weeks. Of the confirmed cases, all patients had vaped in the weeks and months leading up their hospitalization. People who experience any type of chest pain or difficulty breathing after vaping should seek medical attention. Clinicians who become aware of cases are encouraged to report them to ADH Outbreak Response at 501-537-8969. Those interested in quitting tobacco and nicotine can call Be Well Arkansas at 833-283-WELL (9355). Wellness counselors help Arkansans quit tobacco through coaching and providing nicotine replacement therapy at no cost. The wellness counselors are available on weekdays Monday through Friday from 8 a.m. to 4 p.m. Downloads & Resources ADH News: Vaping Associated Illness Public Health Advisory: Vaping Associated Illness Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping Posted September 19, 2019 at 12:00pm ET CDC, the 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 lung injury associated with e-cigarette product (devices, liquids, refill pods, and/or cartridges) use. Key Facts about E-Cigarette Use, or Vaping Electronic cigarettes – or e-cigarettes — are also called vapes, e-hookahs, vape pens, and electronic nicotine delivery systems (ENDS). Using an e-cigarette product is commonly called vaping. E-cigarettes work by heating a liquid to produce an aerosol that users inhale into their lungs. The liquid can contain: nicotine, tetrahydrocannabinol (THC) and cannabinoid (CBD) oils, and other substances and additives. On This Page Key Facts about E-Cigarette Use, or Vaping What we know What we don’t know What CDC recommends Latest Outbreak Information on Lung Injury Associated with Electronic Cigarettes, or Vaping Map of Reported Cases device icon Digital Press Kit For the Public: What You Need to Know For Healthcare Providers For State and Local Health Departments Top of Page What we know There are 530* cases of lung injury reported from 38 states and 1 U.S. territory. Seven deaths have been confirmed in 6 states. CDC has received complete sex and age data on 373 of 530 cases. Nearly three fourths (72%) of cases are male Two thirds (67%) of cases are 18 to 34 years old 16% of cases are under 18 years and 17% are 35 years or older All reported cases have a history of e-cigarette product use or vaping. Based on initial data from certain states we know: Most patients have reported a history of using e-cigarette products containing THC. Many patients have reported using THC and nicotine. Some have reported the use of e-cigarette products containing only nicotine. What we don’t know We do not yet know the specific cause of these lung injuries. The investigation has not identified any specific e-cigarette or vaping product (devices, liquids, refill pods, and/or cartridges) or substance that is linked to all cases. Top of Page What CDC recommends CDC has released interim recommendations for healthcare providers, health departments, and the public. Until we know more, if you are concerned about these specific health risks, CDC recommends that you consider refraining from using e-cigarette or vaping products. If you are an adult who used e-cigarettes containing nicotine to quit cigarette smoking, do not return to smoking cigarettes. If you have recently used an e-cigarette or vaping product and you have symptoms like those reported in this outbreak see a healthcare provider. Regardless of the ongoing investigation: Anyone who uses an e-cigarette or vaping product should not buy these products (e.g., e-cigarette or vaping products with THC or CBD oils) off the street, and should not modify or add any substances to these products that are not intended by the manufacturer. Youth and young adults should not use e-cigarette products. Women who are pregnant should not use e-cigarette products. Adults who do not currently use tobacco products should not start using e-cigarette products. Top of Page Latest Outbreak Information on Lung Injury Associated with Electronic Cigarettes, or Vaping As of September 17, 2019 at 5pm, 530* cases of lung injury associated with the use of e-cigarette or vaping products have been reported to CDC from the following states and 1 U.S. territory: AR, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MD, MI, MN, NC, ND, NE, NJ, NM, NV, NY, OH, OR, PA, SC, SD, TN, TX, UT, VA, WA, WI, WV, WY, and USVI. These numbers may change frequently. CDC has received complete sex and age data on 373 of 530 cases. Nearly three fourths (72%) of cases are male Two thirds (67%) of cases are 18 to 34 years old 16% of cases are under 18 years and 17% are 35 years or older Seven deaths have been confirmed in California (2), Illinois, Indiana, Kansas, Minnesota, and Oregon. CDC worked with states to create a case definition to classify confirmed and probable cases in a consistent way. State investigators determine if cases are confirmed or probable after examining the medical records of suspected cases and consulting with the clinical care team to exclude other possible causes of illness. Unlike nationally reportable conditions, these cases are requiring clinicians and public health professionals to interview patients to determine product use and individual behaviors. CDC will report numbers of confirmed and probable cases once states have finalized their classification of cases. States are in the process of classifying cases. We expect that states and clinicians may look back for older cases based on CDC’s case definition. All patients have a reported history of e-cigarette product use, and no consistent evidence of an infectious cause has been discovered. Therefore, the suspected cause is a chemical exposure. Based on initial data from certain states we know: Most patients have reported a history of using e-cigarette products containing THC. Many patients have reported using THC and nicotine. Some have reported the use of e-cigarette products containing only nicotine. No consistent e-cigarette or vaping product, substance, or additive has been identified in all cases, nor has any one product or substance been conclusively linked to lung disease in patients. Initial published reports from the investigation point to clinical similarities among cases. Patients reported a history of e-cigarette use and had similar symptoms and clinical findings. These align with the CDC health advisory released August 30, 2019. These investigations are ongoing. CDC will provide updates when more information is available. *The increase in cases from last week represents both new cases and recent reporting of previously-identified cases to CDC. Top of Page Map of Reported Cases Top of Page Content provided and maintained by the US Centers for Disease Control and Prevention (CDC). Please see our system usage guidelines and disclaimer.

VAPING-RELATED LUNG ILLNESS INVESTIGATION The Arkansas Department of Health is warning Arkansans who use an electronic smoking device, e-cigarette, or vape about the risk of a potential lung illness. Further investigation is ongoing to determine the possible cause of the illnesses. Current Cases as of September 25, 2019 Confirmed 1* Probable 7 Under Investigation 6 Total 14 * Due to a change in case definitions, some previously confirmed cases have been reclassified. https://www.healthy.arkansas.gov/programs-services/topics/vaping-related-lung-illness

Vaping-Related Respiratory Illness Outbreak ADHS Home Public Health Prevention Tobacco & Chronic Disease Vaping-Related Respiratory Illness Outbreak - Home Vaping-Related Respiratory Illness Outbreak There have been 3 cases reported in Arizona. No deaths have been reported in Arizona. There have been 530 cases reported in nationwide in 38 states and 1 U.S. territory. Seven deaths have been reported from 6 states. If you are experiencing symptoms consistent with vaping-related respiratory illness, seek medical care immediately. Healthcare providers should report suspected cases of vaping-related respiratory illnesses in hospitalized patients to the Poison Control at 1-800-222-1222. Overview We join the CDC, the U.S. Food and Drug Administration (FDA), other state and local health departments, and other clinical and public health partners by investigating a multistate outbreak of lung disease associated with e-cigarette product (devices, liquids, refill pods, and/or cartridges) use. Patients have reported symptoms that include: cough, shortness of breath, or chest pain nausea, vomiting, or diarrhea fatigue, fever, or weight loss The investigation has not identified any specific substance or e-cigarette product that is linked to all cases. Vaping devices containing both nicotine and cannabinoid substances have been identified in this investigation. If you are experiencing symptoms consistent with vaping-related respiratory illness, seek medical care immediately. Healthcare providers should report suspected cases of vaping-related respiratory illnesses in hospitalized patients to the Poison Control at 1-800-222-1222. Resources Arizona Department of Health Services Announces Three Cases of Vaping-Related Respiratory Illness, September 17, 2019 ADHS Vape Prevention CDC Website: Outbreak of Lung Illness Associated with Using E-cigarette Products CDC Health Alert Network “Severe Pulmonary Disease Associated with Using E-Cigarette Products” (August 31, 2019) For the Public For Healthcare Providers Local Health Departments For the Public If you or your child is experiencing symptoms and you suspect it may be related to vaping, contact your healthcare provider. There is no safe level of nicotine for children, and they should never use any vape device. Parents should talk to their children about the dangers of vape. Women who are pregnant should not use e-cigarette products. If you do use vape, do not modify the device or add any substances to these products that are not intended by the manufacturer. If you do use vape and experience symptoms like those reported in this outbreak, seek medical care immediately. Resources CDC Outbreak Page for the Public ADHS Vape Prevention Arizona Youth Vape Awareness Campaign

Vaping-Related Respiratory Illness Outbreak There have been 3 cases reported in Arizona. No deaths have been reported in Arizona. https://www.azdhs.gov/prevention/tobacco-chronic-disease/vape-outbreak/index.php

Vaping Related Lung Illness: A Summary of the Public Health Risks and Recommendations for the Public Health Advisory (PDF) News Releases Audio Clips This health advisory seeks to inform the public about the imminent public health risks posed by vaping any product, including the use of electronic cigarettes (e‐cigarettes), as vaping has recently been linked to severe breathing problems, lung damage, and even death. Vaping is inhaling aerosol from an e-cigarette or other vaping device that heats a liquid that can contain nicotine, marijuana (THC), cannabidiol (CBD) or other substances. The shapes and sizes of these devices vary and include colorful vape pens, modified tank systems, and new pod-based devices that can look like USB flash drives, cell phones, credit card holders, and highlighters. These devices are frequently referred to as e-cigarettes, e‐cigs, vapes, vape pens, electronic vaporizers, pod mods, or pod systems. 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 98 people in California who have a history of vaping were hospitalized for severe breathing problems and lung damage, and two people have died. Across the U.S., there are over 500 reports of lung damage associated with vaping across 38 states and 1 U.S. territory, and more reports are coming in nearly every day. CDPH, along with other states, the Centers for Disease Control and Prevention (CDC), the U.S. Food and Drug Administration (FDA), local health departments, and healthcare providers are working hard to investigate what is in the vape materials that is making people sick. Although CDPH regulates manufacturers of cannabis vaping products to ensure they are as safe as possible for those who choose to vape, CDPH warns that individuals put themselves at risk any time they inhale a foreign substance into their lungs. The risk of vaping now includes death. CDC continues to warn that any tobacco product use, including e-cigarettes, is unsafe, especially for youth, pregnant, and breastfeeding women. Sudden lung damage from vaping is a new health problem. We are learning from this investigation that lung damage can happen very suddenly to people who vape, including people who have not been vaping for a long time, and young, healthy people who do not have lung disease or other health problems. This is different from most other health issues caused by vaping and smoking, which happen over a long time and can be worse in people who have other medical conditions. Additionally, most patients do not have a recent history of smoking regular cigarettes, suggesting these lung issues are exclusively related to vaping. Many types of vape products may be causing the lung damage from vaping. Almost all people with lung damage from vaping say that they vaped or "dabbed" the cannabis products THC and CBD in cartridges, waxes, oils, and other forms. Some people report vaping only nicotine. Many people report vaping a combination of both nicotine and cannabis products. The investigation is still in process, but the one thing that people with the lung illness have in common is a history of vaping. County health departments are contacting the people who had lung damage from vaping to find out which products they used, where they purchased the products, and to collect their vape products to test for harmful ingredients. The government does not ensure the safety of vaping devices through regulation. In California, licensed cannabis retailers are required to sell products obtained from a licensed cannabis manufacturer that have been tested (PDF) by a licensed laboratory. Cannabis products sold by licensed sources are tested for a variety of chemicals, pesticides, microbial impurities, and heavy metals. Illegal cannabis dispensaries sell unregulated and untested cannabis products and absolutely should not be used. People are hospitalized with breathing problems and other symptoms. People with lung damage from vaping typically have symptoms that start a few days to a few weeks before they go see a doctor. All people hospitalized developed some type of breathing problems, but many people also have other symptoms. The symptoms reported by those who have gotten sick are: Breathing symptoms: trouble catching their breath, coughing, chest pain Gastrointestinal symptoms: nausea, vomiting, diarrhea, abdominal pain Non-specific symptoms: feeling tired, fever, weight loss These symptoms are very similar to having a lung infection like pneumonia or bronchitis, so it can be hard to tell if the symptoms are from an infection or vaping the first time someone sees the doctor. There is no test that a doctor can do to know that breathing problems are from vaping right away. Laboratory blood tests and an x-ray or CT scan of the lungs may be necessary. People with vaping-related lung disease are usually admitted to the hospital because of their breathing problems. Teenagers and young adults make up almost half of the people hospitalized with breathing problems from vaping in California. 30% of people hospitalized in California had to be treated with a mechanical ventilator, or "life support," in the intensive care unit (ICU). Be Aware That Your Child's Respiratory Issues Could be Related to Vaping Parents should be aware that numerous cases involve children under age 18. Parents in particular should be aware that e-cigarettes and vaping devices are available in more than 15,000 flavors that may be attractive to children, such as mango, bubble gum, unicorn poop, mint. The secondhand aerosol typically smells sweet so it can be hard to detect. Be aware of the symptoms in case your middle or high school child develops symptoms, and seek medical attention. No one knows yet why this lung damage is happening from vaping. There are many different possible ingredients added to cannabis and nicotine to make the cartridges, waxes, and oils used for vaping. Multiple people who were diagnosed with lung damage from vaping say that they received the cannabis products from unlicensed smoke shops or individuals. Vape products sold by unlicensed retailers are not tested and can contain harmful ingredients. We do not know yet if all of the people in the country with this illness use the same vape products, or if the products were contaminated with the same substance. The long-term effects of vaping are still unknown, but these short-term effects are alarming. Recommendations for the Public 1. CDPH urges everyone to quit vaping altogether, no matter the substance or source. For those who continue, you are urged to avoid buying any vaping products on the street and never modify a store-bought vape product. 2. If you, or your child, have vaped at all in the past few months and are having new problems with breathing or other symptoms, you should seek medical care immediately and tell your healthcare provider about your history of vaping. 3. If you decide to stop vaping, do not replace vaping with smoking combustible cigarettes. Ask your doctor for FDA-approved quitting treatments. Resources CDPH Tobacco Free California Website. The California Smokers' Helpline offers vaping cessation services including telephone counseling, text messaging, web chat, and an online app to help all tobacco users quit. For more information and resources for youth, young adults and parents, call 1-800-NO BUTTS or visit their website. If you suspect your child is vaping, visit Flavors Hook Kids website for more information on the health effects and actions you can take. You can download the parent's guide (PDF) for information on how to talk to your child about vaping. For help on how to quit vaping marijuana, consult a doctor or contact the Substance Abuse and Mental Health Services Administration helpline at 1-800-662-4357. For additional information, please review the CDC's recommendations about the vaping-related lung injuries. https://www.cdph.ca.gov/Programs/CCDPHP/Pages/Vaping-Health-Advisory.aspx Page Last Updated : September 25, 2019

Vaping-Associated Pulmonary Illness Outbreak As of September 17, 2019, 530 cases of lung illness associated with the use of e-cigarette products have been reported to CDC from 38 states and one territory. Seven deaths have been confirmed in California, Illinois, Indiana, Kansas, Minnesota, and Oregon. No cases have been reported in Alaska. The case count includes only confirmed and probable cases reported by states to CDC after classification. State and federal agencies are actively working to identify the cause of the outbreak. Since no single product or substance has been linked to all of the cases in this outbreak, the U.S. Centers for Disease Control and Prevention (CDC) is advising people to consider not using e-cigarettes while this investigation is ongoing. This is particularly important for those e-cigarette products purchased from sources other than authorized retailers and products modified in a manner not intended by the manufacturer. If you do use e-cigarette products and you experience symptoms like those reported in this outbreak, seek medical care promptly. The CDC also recommends the following, regardless of the ongoing investigation: Youth and young adults should not use e-cigarette products. Women who are pregnant should not use e-cigarette products. Adults who do not currently use tobacco products should not start using e-cigarette products. If you do use e-cigarette products, you should not buy these products off the street (for example, e-cigarette products with THC or other cannabinoids). You should not modify e-cigarette products or add any substances to these products that are not intended by the manufacturer. Adult smokers who are attempting to quit should use evidence-based treatments, including counseling and FDA-approved medications. If you are an adult who used e-cigarettes containing nicotine to quit cigarette smoking, do not return to smoking cigarettes. If you need help quitting tobacco products, including e-cigarettes, contact your doctor, other medical provider, or Alaska's Tobacco Quit Line at 1-800-QUIT-NOW (1-800-784-8669). If you are concerned about your health after using an e-cigarette product, you can also call your poison control center at 1-800-222-1222. Health care providers should report cases of respiratory illness of unclear etiology among persons with a history of e-cigarette product use within the past 90 days to the Alaska Section of Epidemiology at (907) 269-8000 or 800-478-0084 (after hours). Resources For more information about this outbreak, please see the following resources: CDC’s webpage about this outbreak FDA’s webpage about this outbreak CDC’s Health Alert Network message (8/30/2019) Alaska Public Health Alert Network message (8/28/2019) CDC’s Clinician Outreach and Communication Activity Clinical Action message (9/19/2019) For general information about e-cigarettes and vaping, please see the following resources: Alaska Division of Public Health, Section of Chronic Disease Prevention and Health Promotion: E-cigarettes: Not Harmless. Not Healthy Not Buying It Facebook page (addresses e-cig and tobacco use) Information from CDC Information from FDA Information from the U.S. Surgeon General American Lung Association, The Vape Talk (for parents)

No cases have been reported in Alaska. The case count includes only confirmed and probable cases reported by states to CDC after classification. http://dhss.alaska.gov/dph/Epi/Pages/Vaping-Pulmonary-Illness.aspx

Vapes and E-Cigs E-cigarettes, also known as e-cigs, vapes, vape pens, and electronic nicotine delivery systems (ENDS), are experiencing rapid growth in popularity, especially among teens and young adults. They come in a variety of forms, sometimes looking like USB flash drives, pens, and other items that make them hard for parents and teachers to spot. Vape-Related Pulmonary Illnesses As of September 25, 2019, there are 16 Alabama residents under investigation for probable cases of lung disease associated with e-cigarette product use, or vaping. Alabama is currently not included in the national case numbers since we are in the process of investigating reports. ADPH is joining other state health departments in requesting health care providers to report any cases of suspected serious respiratory illness they treat among patients who use electronic cigarettes or other vaping devices. Vaping Illness Blamed for Deaths: What Parents Need to Know (al.com) (09/10/19) Health care providers asked to report pulmonary illnesses that may be associated with vaping (ADPH News Release) (08/23/19) New Vape Laws Changes in Alabama's vape laws as reflected in Act #2019-233 went into effect on August 1, 2019. The act introduces major changes for retailers who advertise and/or sell alternative nicotine products, including vape devices and liquids, in the state of Alabama. These changes are geared toward limiting marketing that targets minors, as well as limiting minors' access to alternative nicotine products. Major changes include: The sale of alternative nicotine products to anyone under the age of 19 is prohibited. The Alcohol Beverage Control Board is responsible for the regulation of e-cigarettes and vape products. Advertising cannot categorize alternative nicotine products as healthy options to replace smoking. Billboards advertising vaping liquid are limited to the advertisement of three flavors: tobacco, mint, or menthol. Vape shops are required to have a tobacco permit. Opening vape shops within 1,000 feet of a school, church, youth center, daycare center, or public library, playground or park is prohibited. Full text of Act #2019-233 is available online. JUUL JUUL Labs is the manufacturer of a line of e-cigarettes called JUUL. JUUL e-cigarettes are shaped like USB flash drives. These devices create a vapor by heating up cartridges or pods containing oils that come in a variety of flavors such as mint, mango, creme brulee, and more. In addition to flavored oils, each JUUL pod contains as much nicotine as a pack of cigarettes, or the equivalent of 200 cigarette puffs. According to a recent study published in Tobacco Control, teens are 16 times more likely to use JUUL devices than older age groups. The following resources contain more information on JUUL and similar e-cigarettes. E-Cigarettes Shaped Like USB Flash Drives (CDC) Teachers and Parents: That USB Stick Might Be an E-Cigarette (CDC) What is JUUL? (Truth Initiative) JUUL exposed: How Big Vape took a page from Big Tobacco's old playbook Health Effects of Vapes and E-Cigs Because e-cigarettes are still fairly new, scientists are still learning about the long-term health effects of their use. It is known that most e-cigarettes contain nicotine, which is highly addictive, toxic to developing fetuses, and can harm adolescent brain development. Other potential dangers include the ingestion of cancer-causing chemicals and heavy metals such as tin and lead. The following resources contain more information on the health effects of vapes and e-cigarettes: About E-Cigarettes (CDC) Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students — United States, 2011–2018 (CDC) The Real Cost (U.S. Department of Health and Human Services) FDA Youth Tobacco Prevention Plan FDA's Youth Tobacco Prevention Plan is a series of actions to stop youth use of tobacco products, especially e-cigarettes, with special focus on three key areas: Preventing youth access to tobacco products Curbing marketing of tobacco products aimed at youth; and Educating teens about the dangers of using any tobacco product, including e-cigarettes, as well as educating retailers about their key role in protecting youth For more information, visit the FDA Youth Tobacco Prevention Plan. Alabama Tobacco Quitline The Alabama Tobacco Quitline is a free telephone and online coaching service for any Alabamian who is ready to quit tobacco or e-cigarette use. Contact the Quitline for more information. American Lung Association E-Cigarette Resources American Lung Association's Statement on E-Cigarettes The Impact of E-Cigarettes on the Lungs E-Cigarettes, Vapes and JUULs: What Parents Should Know E-Cigarettes, Vapes and JUULs: What Teens Should Know E-Cigarettes, Vapes and JUULs: What Schools Should Know Additional Resources on E-Cigarettes Page last updated: September 25, 2019

Vape-Related Pulmonary Illnesses As of September 25, 2019, there are 16 Alabama residents under investigation for probable cases of lung disease associated with e-cigarette product use, or vaping. Alabama is currently not included in the national case numbers since we are in the process of investigating reports. http://alabamapublichealth.gov/tobacco/ecigs.html

Lung Disease Among E-cigarette Users – Sept. 24, 2019 DSHS has identified 54 Texas cases of severe lung disease in people who report vaping before developing symptoms. State health officials are gathering more information about 35 other possible cases to determine whether they are consistent with the symptoms and substance use seen in cases in Texas and 37 other states. About half of the Texas cases have been in teens, and more than half required hospitalization. Respiratory symptoms include difficulty breathing, shortness of breath and coughing. Some people have also experienced nausea, vomiting and diarrhea. Clinicians should ask patients with these symptoms about a history of vaping, gather as much information as possible about suspected cases, and report them to DSHS. Nationally, 530 cases have been reported, and DSHS is working with the Centers of Disease Control and Prevention, the Food and Drug Administration and other states to gather evidence about what the cases have in common and determine a cause. Until we know more about the cause, people should consider not using e-cigarettes. If you do vape and experience symptoms like those reported, seek medical care promptly. Regardless of the ongoing situation: Youth and young adults should not vape. Women who are pregnant should not vape. Adults who do not currently use tobacco products should not start vaping. Case counts will be updated each Tuesday. News Release Updated Health Alert Vaping-Associated Severe Lung Disease in Texas Public Health Region Number of Cases 1 (Panhandle) 0 2/3 (North Texas) 22 4/5N (East Texas) 2 6/5S (Southeast Texas) 14 7 (Central Texas) 5 8 (South Texas) 3 9/10 (West Texas) 2 11 (Rio Grande Valley) 6 Total 54 Figure 1: Cases of vaping-associated severe lung disease in Texas, as of 9/24/19

Vaping-Associated Severe Lung Disease in Texas Public Health Region Number of Cases 1 (Panhandle) 0 2/3 (North Texas) 22 4/5N (East Texas) 2 6/5S (Southeast Texas) 14 7 (Central Texas) 5 8 (South Texas) 3 9/10 (West Texas) 2 11 (Rio Grande Valley) 6 Total 54 https://www.dshs.texas.gov/news/updates.shtm#vaping

Vaping-Associated Pulmonary Illness The Tennessee Department of Health is asking health care providers across the state to report any cases of suspected serious respiratory illness they treat among patients who use electronic cigarettes or other vaping devices. Patients have had symptoms including cough, shortness of breath and fatigue, with symptoms growing worse over a period of days or weeks before admission to the hospital. Other symptoms may include fever, chest pain, nausea, abdominal pain and diarrhea. If you are experiencing these symptoms, see a health care provider. TDH will investigate any cases reported to look for common factors and collect information on specific components or brands of vaping products that may be the source of the illness. Cases reported in Tennessee (as of September 19, 2019): 26* *Evidence of respiratory illness, with no other cause identified, and report vaping in the last 90 days How can health care providers report potential cases? Contact your regional or metropolitan health department, or email TDH at [email protected] to report suspect cases as soon as possible. Please provide Patient’s home county Brief clinical description Reporting provider’s name, email address, telephone number Additional Resources Tennessee Tobacco Program Electronic Cigarettes TDH News Release “TDH Urges Providers to Report Cases of Vaping-associated Respiratory Illness” CDC - Outbreak of Severe Pulmonary Disease Associated with Using E-cigarette Products

Cases reported in Tennessee (as of September 19, 2019): 26* *Evidence of respiratory illness, with no other cause identified, and report vaping in the last 90 days https://www.tn.gov/health/cedep/vaping-illness.html

LUNG INJURY ASSOCIATED WITH E-CIGARETTE USE Summary Many states are investigating cases of patients with severe lung injury associated with e-cigarette product use or “vaping.” E-cigarettes are devices that heat a liquid to produce an aerosol that users inhale into their lungs. The liquid can contain nicotine, tetrahydrocannabinol (THC) and cannabinoid oils, and other substances and additives. As of September 19, 2019, 530 cases of lung injury from 38 states and 1 U.S. territory have been identified. All cases have a history of e-cigarette or vaping in the weeks to months before symptoms started. Nationally, most patients reported using products that contain THC. Many patients reported using both THC and nicotine. Some have reported using only products containing nicotine. The specific cause of these illnesses is unknown. Public health investigations are being conducted to better understand the patients, their illnesses, and possible causes. While these investigations are ongoing, people who are concerned about these health risks should refrain from using e-cigarette or vaping 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. People who use e-cigarette products 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. People who are concerned about their health after using an e-cigarette product should contact their healthcare provider or the local poison control center at 1-800-222-1222. Smokers who are attempting to quit should use evidence-based treatments, including counseling and FDA-approved medications, rather than e-cigarettes. If you need help quitting tobacco products, including e-cigarettes, contact your healthcare provider. Free cessation counseling may be obtained by contacting the VDH quitline at 1-800-QUIT NOW (1-800-784-8669) or QuitNow.net/Virginia. Clinicians are encouraged to report possible cases of vaping-associated illnesses to their local health department. General Information VDH Tobacco Free Living E-cigarettes Outbreak Resources VDH Commissioner Letter CDC Outbreak Resources CDC Health Alert Network Advisory FDA Outbreak Website Reporting and Surveillance Clinicians are encouraged to report cases of significant respiratory illness of unclear etiology and a history of "vaping" or "dabbing" to your local health department. If possible, inquire about the types of drugs (legal or illicit) used and methods of drug use (e.g. smoking, "vaping", "dabbing"). Virginia Situational Update As of September 19, 2019, there have been 16 confirmed cases, 7 probable cases, and 0 reported deaths associated with this cluster of illness in Virginia. Region Confirmed Probable Total Central Region 1 0 1 Eastern Region 5 1 6 Northern Region 6 4 10 Northwest Region 3 1 4 Southwest Region 1 1 2 Total 16 7 23 These data will be updated weekly every Thursday by close of business.

Virginia Situational Update As of September 19, 2019, there have been 16 confirmed cases, 7 probable cases, and 0 reported deaths associated with this cluster of illness in Virginia. Region Confirmed Probable Total Central Region 1 0 1 Eastern Region 5 1 6 Northern Region 6 4 10 Northwest Region 3 1 4 Southwest Region 1 1 2 Total 16 7 23 These data will be updated weekly every Thursday by close of business. http://www.vdh.virginia.gov/vdhlivewell/vaping/

Severe Lung Illness Associated with E-Cigarettes and Vaping Background The Maryland Department of Health is investigating cases of individuals who have developed severe lung illness with no clear infectious cause after using e-cigarettes, or “vaping.” Similar cases have been reported in other states across the United States. Cases of Vaping-Associated Lung Illness (as of September 24, 2019): 20 Symptoms of Vaping-Associated Lung Illness Patients report using e-cigarettes or vaping in the weeks or months prior to the onset of symptoms. Respiratory symptoms reported include: shortness of breath, chest pain, pain on breathing, wheezing, cough, and coughing up blood. Other symptoms reported by many patients include: fever, chills, nausea, weight loss, vomiting, diarrhea, or abdominal pain. Detailed descriptions of this illness, and clinical guidance that may aid identification, can be found in recent publications in the New England Journal of Medicine and Morbidity and Mortality Weekly Report. Causes of Vaping-Associated Lung Illness The cause of this cluster of illnesses is not known, and has not been definitively linked to any particular device, substance, or brand. People who became ill reported using a range of products, including both cannabis-derived products with THC or CBD, and nicotine-containing products Frequently Asked Question for the Public Q: What are e-cigarettes? What is vaping? A: E-cigarettes are devices that produce an aerosol by heating a liquid containing various chemicals. Users inhale the aerosol, including any additives, into their lungs. Commonly inhaled chemicals include nicotine, tetrahydrocannabinol (THC, the psychoactive component in cannabis/marijuana), cannabidiol (CBD, another chemical found in cannabis/marijuana), flavorings, and other additives like propellants, solvents, and oils. Vaping means using these products. Q: How can I keep myself safe from vaping-associated lung illness? A: The best way to keep yourself safe is to not use e-cigarettes or vapes. Q: I want to quit using e-cigarettes and vaping but I can’t. What should I do? A: If you want to stop using e-cigarettes, or any tobacco product, you can call the Quitline at 1-800-QUIT-NOW: Trained professionals are there 24/7 to help you. Q: I used e-cigarettes to help me quit smoking. What should I do? A: Don’t start smoking again. There are several FDA-approved quit aids like nicotine patches, gum, or lozenges that safely help smokers quit and reduce nicotine withdrawal. Use these products instead of vaping to help you stay quit. FDA-approved quit aids can be mailed to you for free through the Quitline (see above), or by your local health department. Q: I heard this illness is caused by marijuana or THC oils. Is that true? A: We do not know yet what causes this illness. Many, but not all, patients who developed this illness report that, in addition to nicotine, they vaped pre-filled cartridges of cannabis-derivative products like THC or CBD. Maryland Department of Health strongly advises against the use of these products. Q: I heard this illness is caused by Vitamin E. Is that true? A: We do not know yet. Testing at several national labs has identified a compound – vitamin E acetate – in some, but not all, of the THC product samples collected from people who became sick. However, we do not know if Vitamin E acetate was the cause, or even one of several causes, of the illness. There is also no way for you to test if a product you purchase contains vitamin E acetate or any other possibly harmful chemical. Q: I only use THC or CBD oils made with natural ingredients and safe extraction techniques that come in sealed cartridges. Is that safe? A: No product has yet been identified as safe, and there is no evidence to date that any set of ingredients or extraction techniques prevent this illness. Additionally, information about ingredients or extraction techniques listed on packaging may not be accurate. Ingredients that may be safe when eaten or applied to skin may not be safe when vaporized or inhaled. Q: Where can I learn more about the health-effects of vaping? A: The Maryland Department of Health has a website for youth and young adults – www.TheVapeExperiment.com – that describes the known and unknown hazards associated with vaping and e-cigarette use. Q: I’m enrolled in Maryland’s medical cannabis program. Should I stop or change what I’m using? A: Persons enrolled in Maryland’s medical cannabis program who vape and are concerned about this illness can contact their medical provider to discuss the risks and benefits of the products they are using. If you start to experience any of the symptoms listed above, seek immediate medical attention. If you think you became sick because of medical cannabis, you should report the incident by e-mail to [email protected]. Information for the Public MDH Center for Tobacco Prevention and Control Maryland Tobacco Quitline FDA, Center for Tobacco Products Know the Risks: E-cigarettes and Young People CDC: Smoking and Tobacco Use The Vape Experiment Information for Clinicians **NEW** Laboratory Clinical Specimen Collection and Storage Guidance For Lung Injury Related to e-Cigarette Related Exposures **NEW** NEJM Preliminary Report **NEW** MMWR CDC Interim Guidance MDH Clinician Letter on Vaping and Lung Injury MDQuit Resource Center CDC Clinical Outreach Alert

Severe Lung Illness Associated with E-Cigarettes and Vaping Background The Maryland Department of Health is investigating cases of individuals who have developed severe lung illness with no clear infectious cause after using e-cigarettes, or “vaping.” Similar cases have been reported in other states across the United States. Cases of Vaping-Associated Lung Illness (as of September 24, 2019): 20 https://phpa.health.maryland.gov/OEHFP/EH/Pages/VapingIllness.aspx

09/19/2019 Department of Public Health Reports two additional Cases of Severe Lung Injury Related to Vaping, for a total of 13 cases; one person currently hospitalized Consumers should avoid buying vaping products off the street or from another person, including a friend The Connecticut Department of Public Health (DPH) today is reporting that it has learned of two more Connecticut residents who have been hospitalized for severe lung injury possibly related to using e-cigarettes or vaping, bringing the total to 13 cases that have been reported to DPH. Twelve of the 13 patients have now been discharged from hospitals. The 13 cases involve residents from five of our counties: Fairfield (7), New Haven (3), New London (1), Tolland (1), and Windham (1). The Connecticut Department of Public Health (DPH) is participating in the national investigation of vaping-related lung illnesses that is being led by the Centers for Disease Control and Prevention (CDC). So far, DPH has interviewed 9 of the 13 patients with vaping-related lung injury. All nine reporting using vaping products containing tetrahydrocannabinol (THC), a psychoactive component of the marijuana plant. These products were purchased from another person (6 cases), bought from a dispensary (1 case), purchased but not from a dispensary (1 case), and given product by another person (1 case). Three of the nine reported using e-cigarette products containing nicotine, in addition to products containing THC. “I am asking Connecticut residents to consider not using e-cigarette or vaping products while the investigation is ongoing and the search for the exact causes of these lung illnesses continues,” said DPH Commissioner Renée D. Coleman-Mitchell. “If you chose to continue vaping, you should avoid buying vaping products off the street or from another person, including a friend.” As of September 17, 2019, 530 cases of lung injury associated with the use of e-cigarette or vaping products have been reported to the Centers for Disease Control and Prevention (CDC). Until more is known about the exact cause or causes of these illnesses: Anyone who uses an e-cigarette or vaping product should not buy these products (e.g., e-cigarette or vaping products with THC, other cannabinoids) off the street, and should not modify or add any substances to these products that are not intended by the manufacturer. Youth and young adults should not use e-cigarette or vaping products. Women who are pregnant should not use e-cigarette or vaping products. Adults who do not currently use tobacco products should not start using e-cigarette or vaping products. More information about the investigation can be found on CDC’s webpage: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#latest-outbreak-information

The Connecticut Department of Public Health (DPH) today is reporting that it has learned of two more Connecticut residents who have been hospitalized for severe lung injury possibly related to using e-cigarettes or vaping, bringing the total to 13 cases that have been reported to DPH. Twelve of the 13 patients have now been discharged from hospitals. The 13 cases involve residents from five of our counties: Fairfield (7), New Haven (3), New London (1), Tolland (1), and Windham (1). https://portal.ct.gov/DPH/Press-Room/Press-Releases---2019/DPH-Reports-two-additional-Cases-of-Severe-Lung-Injury-Related-to-Vaping

Florida reports first vaping-related death Posted: Wed 12:17 PM, Sep 25, 2019 | Updated: Wed 1:30 PM, Sep 25, 2019 TALLAHASSEE, Fla. (WCTV) – The Florida Department of Health is reporting the state's first death from a lung injury associated with vaping. It comes amid a nationwide outbreak of lung problems associated with e-cigarettes, marking the 10th reported death tied to vaping use. The Florida death is posted on the department’s public health statistics website, on a chart tracking cases of lung injury associated with e-cigarette use. The chart lists 27 reported cases of lung injury tied to vaping in Florida in 2019, and one death. It’s not clear when that death occurred, though the chart was last updated Tuesday. WCTV has reached out to the Department of Health for more details including where the patient was from, when they died, their age and gender. The health department website says the chart documents lung injury associated with vaping using an electronic device, electronic cigarette, e-cigarette, vaporizer, vape, vape pen, dab pen, or other to inhale substances including nicotine, marijuana, THC, THC concentrates, CBD, synthetic cannabinoids, flavorings, or other substances. We've also reached out for comment from the Florida Smoke-Free Association, an advocacy group for vaping businesses and consumers. Health officials say hundreds of people have fallen ill nationwide in recent months with lung injuries associated with e-cigarette use. Tuesday, testifying before congress, staff with the Centers for Disease Control and Prevention said the agency is struggling to keep up with the growing outbreak. "The epidemic is moving faster than our data gathering," said Dr. Anne Schuchat, "we really are losing people in the meantime." On Friday, the Florida Department of Health announced it was responding to the emerging public health issue. The department said it was coordinating with federal agencies to develop a disease case definition and report cases to the CDC as part of the national investigation. Florida DOH also said it's working with county health departments to identify and investigate reports, and monitoring and conducting surveillance of lung disease that is associated with electronic cigarette or vaping use. The department encourages health care providers to report cases to their county health department or the state DOH Bureau of Epidemiology. https://www.wctv.tv/content/news/Florida-reports-first-vaping-related-death-561332351.html

Lung Injury Associated with E-Cigarette Use, or Vaping* - Florida Year Reported Cases Year-to-Date Deaths Year-to-Date 2019 27 1 Report last updated on September 24, 2019 with data from January 1, 2019 - September 21, 2019. FLHealthCharts.com is provided by the Florida Department of Health, Division of Public Health Statistics & Performance Management. Data Source: Florida Department of Health, Division of Disease Control and Health Protection, Florida Bureau of Epidemiology. Data Note(s) The counts here represent the cases of Lung Injury Associated with E-Cigarette Use, or Vaping reported into Florida's reportable disease surveillance system, Merlin. Legal authority: Pursuant to section 381.0031(6), Florida Statutes, and Rule 64D- 3.041, Florida Administrative Code, the Department and its authorized representatives, when deemed necessary to protect the public’s health, may conduct epidemiological investigations and follow-up to confirm the diagnosis, treatment and causes of any disease or condition to determine appropriate methods of outbreak and communicable disease control. * Includes vaping using an electronic device (e.g., electronic nicotine delivery system (ENDS), electronic cigarette, e-cigarette, vaporizer, vape(s), vape pen, dab pen, or other) to inhale substances (e.g., nicotine, marijuana, THC, THC concentrates, CBD, synthetic cannabinoids, flavorings, or other substances), with or without smoking of any plant, chemical, or substance. http://www.flhealthcharts.com/ChartsReports/rdPage.aspx?rdReport=ChartsProfiles.LungInjuryE-CigaretteUse

E-Cigarette/Vaping Information for Parents, Teachers, Coaches & Healthcare Providers Until the CDC/FDA determines the cause of 530 confirmed and probable cases of lung illness associated with the use of e-cigarettes in 38 states and the U.S. Virgin Islands, the CDC is recommending people not use e-cigarettes. To date, there have been no cases of vaping-related lung issues that have been associated with products sold in New Jersey Medical Marijuana dispensaries. People should not buy products off the street or add substances not intended by the manufacturer. E-cigarettes are electronic devices that produce an aerosol by heating a liquid that usually contains nicotine (the addictive drug in regular cigarettes, cigars, and other tobacco products), flavorings, and other chemicals to help make the aerosol. Users inhale this aerosol into their lungs. Bystanders can also breathe in this aerosol when the user exhales into the air. E-cigarettes come in many shapes and sizes. They are sometimes called “e-cigs,” “e-hookahs,” “mods,” “vape pens,” “vapes,” “tank systems,” and “electronic nicotine delivery systems.” Using an e-cigarette is sometimes called “vaping” or “JUULing.” Some e-cigarettes looks like regular cigarettes, cigars, or pipes. Some look like USB flash drives, pens, and other everyday items. Many e-cigarettes and vaping materials contain harmful or potentially harmful substances, and it is difficult to know what each individual product contains. E-cigarettes can also be used to deliver marijuana and other drugs. Women who are pregnant, youth, young adults, or adults who are not currently using tobacco products should not start vaping or using e-cigarettes. Source: Centers for Disease Control and Prevention Risks of E-Cigarettes for Kids, Teens, and Young Adults Scientists are still learning about the long-term health effects of e-cigarettes. Some of the ingredients in e-cigarettes could also be harmful to the lungs in the long-term. It is difficult for consumers to know what e-cigarette products contain. The e-cigarette aerosol that users breathe from the device and exhale can contain harmful and potentially harmful substances. Defective e-cigarette batteries have caused fires and explosions, some of which have resulted in serious injuries. Children and adults have been poisoned by swallowing, breathing, or absorbing e-cigarette liquid through their skin or eyes. Source: Centers for Disease Control and Prevention Youth Vaping Rising Sharply, Displacing Traditional Cigarettes Cigarette use among New Jersey high school students has declined steadily since the Department of Health began measuring it in 1999. In 2012, the Department began measuring youth "vaping," or use of electronic cigarettes (e-cigarettes). In 2012, traditional cigarettes were used at a higher rate than e-cigarettes. The Department saw a sharp increase in e-cigarette use in 2014, when e-cigarettes surpassed traditional cigarettes among New Jersey high school students. In 2016, rates of e-cigarette use remained higher than traditional cigarettes. Nationally, youth vaping spiked in 2018, with more than 1 in 5 high school students and about 1 in 20 middle school students reporting e-cigarette use. (See infographics) E-Cigarettes and Vaping In The News At this time, the New Jersey Department of Health is investigating multiple reports from healthcare facilities of severe lung illness in people who report vaping. Cases in New Jersey have been primarily reported among persons between the ages of 16 to 45 with no significant past medical history. The Department has sent a statewide health alert to health care providers and local health departments following recent reports of severe lung disease in people who have used vaping products. No single product has been implicated. Patients have reported high variability in substances/products they used in vaping, including both tobacco and tetrahydrocannabinol (THC) containing products as well as other products. Walmart will stop selling e-cigarettes in the wake of vaping-related deaths (September 19) Contaminant found in vaping products linked to deadly lung illnesses, state and federal labs show (September 5) CVS launches $50M campaign to battle teen vaping (September 3) CDC/FDA Joint Statement on E-cigarette Related Respiratory Illnesses (August 30) I'm so hooked on vaping, I sleep with my JUUL, addicted teen says in lawsuit (August 24) Years Ago, This Doctor Linked a Mysterious Disease to Vaping (August 24)

Vaping-associated Illness* Total Confirmed Cases 9 Reports Under Investigation 34 Most Recent Report 9/20/19 Age Range 15-51 Gender 34 male, 9 female Regions of State Impacted Northern, Central * This chart is updated on Tuesdays. https://www.nj.gov/health/fhs/tobacco/vaping/index.shtml