Vaping-related illness update ProMED

[niman]

Media reports and comments on CDC Telebriefing, Mayo Clinic on chemical burns, and Black-market marijuana vape cartridges

https://www.promedmail.org/post/6708832

Edited October 5, 2019 by niman

[niman]

Date: Thu 3 Oct 2019
Source: The New York Times [edited]
https://www.nytimes.com/2019/10/03/health/vaping-illnesses-cdc.html


Illnesses and deaths linked to vaping continue to increase around the country, now totaling 1080 cases and 19 deaths, health officials said on [Thu 3 Oct 2019]. The Centers for Disease Control and Prevention said that cases had occurred in 48 states and the United States Virgin Islands. This week, Nebraska, Alabama, Delaware, Connecticut, Virginia, and New Jersey reported deaths, which brought the total to 19 in 16 states. The new case count reflects an increase of 275 in just the past week. About half of the 275 were hospitalized in the past 2 weeks, and the rest were older cases whose link to vaping was just recognized, Dr Anne Schuchat, principal deputy director of the CDC, said during a news briefing.

She described the outbreak as "continuing at a brisk pace," emphasized that the illnesses were serious and life-threatening and called the proportion of patients hospitalized and in intensive care "just terrible." "We know that additional deaths are under investigation," Dr Schuchat said. About 70 percent of the patients were male, 80 percent under 35 years old, and 16 percent younger than 18, she said. Among the patients who died, the median age was about 50, and the proportion of women was higher than in the overall group of patients.

In response to the outbreak of illnesses as well as the increasing rate of teenage vaping, several states have ordered bans on flavored e-cigarettes. The Trump administration has said that it would draft a ban on flavored e-cigarettes, too. But on [Thu 3 Oct 2019], a New York appeals court ordered a temporary stay of a statewide flavor ban that was to take effect on [Fri 4 Oct 2019]. Vaping groups had filed suit against the ban, contending that it would hurt retailers and adults who use the products. The vaping industry is also battling a more extensive ban of all vaping products in Massachusetts.

Dr Howard Zucker, the New York state health commissioner, called the outbreak a "public health emergency," adding: "It is undeniable that the vaping industry is using flavored e-cigarettes to get young people hooked on potentially dangerous and deadly products. While the court's ruling temporarily delays our scheduled enforcement of this ban, it will not deter us from using every tool at our disposal to address this crisis."

Symptoms of the illness include coughing and breathing trouble that can become severe enough to require that patients be attached to ventilators. Some also have nausea, vomiting, and fever. Many have vaped THC, the psychoactive ingredient in marijuana; some have vaped both THC products and nicotine. Some say they have vaped only nicotine.

It is not yet possible to tell whether the illness comes on quickly or is the cumulative effect of long-time vaping.

The exact cause of the illness is still not known, although CDC officials have been referring to "chemical exposure." The culprit could be one or more ingredients in the vaping fluids, or a toxin released from the materials used to make vaping devices, which contain heated coils that vaporize fluids or other substances. Many of the ingredients in the products are unknown. "I wish we had more answers regarding the specific harmful products or components that are causing these illnesses," Dr Schuchat said. She added: "I think we have the feeling right now that there may be a lot of different nasty things in e-cigarettes or vaping products, and they may cause different harms in the lungs."

In some cases, the injury to the lung tissue looks like a chemical burn, the same kind of damage that occurs from industrial accidents where chemicals spill and people inhale poisonous fumes, experts in lung pathology from the Mayo Clinic reported on [Wed 2 Oct 2019]. Their findings were based on studying samples of lung tissue from 17 patients, ages 19 to 67, who became ill after vaping. Most reported vaping THC.

Medical investigators are scrambling to find the cause of the illnesses, a task made more difficult by the booming market in vaping products, some legal and many not, from sources unknown. Some are concocted at home by users themselves. All the products are a stew of chemicals, often including flavorings, oils, and solvents that may react with one another when heated, to produce still more molecules that have yet to be identified.

The Food and Drug Administration is testing vaping products, and has obtained more than 440 samples from 18 states, Judy McMeekin, the agency's deputy associate commissioner for regulatory affairs said at the briefing on [Thu 3 Oct 2019]. So far, she said, no single product or substance has been identified as the source of the trouble. She said that the agency was particularly concerned about black-market sources, but that it was too soon to rule out other products.

During the briefing, Dr Schuchat was asked if THC vaping products could be considered safe if purchased from dispensaries in states that license them. She replied: "With all the data I've been seeing, I don't know what safe is now."

[Byline: Denise Grady, Andrea Salcedo]

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[niman]

Date: Thu 3 Oct 2019
Source: The New York Times [edited]
https://www.nytimes.com/2019/10/02/health/vaping-illnesses.html


Doctors at the Mayo Clinic examined samples of lung tissue from 17 patients, all of which looked as if the people had been exposed to toxic chemicals, the researchers said.

The lung damage in some people who have become ill after vaping nicotine or marijuana products looks like that seen in people exposed to some chemical weapons, a pathologist said.

The lung damage in some people who have become ill after vaping nicotine or marijuana products resembles a chemical burn, doctors from the Mayo Clinic reported on [Wed 2 Oct 2019].

Their findings are based on samples of lung tissue from 17 patients around the country whose biopsy specimens were sent to Mayo to be examined under the microscope by experts in lung pathology. 2 samples came from patients who died.

"All 17 of our cases show a pattern of injury in the lung looking like a toxic chemical exposure, a toxic chemical fume exposure, or a chemical burn injury," said Dr Brandon T Larsen, a surgical pathologist at the Mayo Clinic in Scottsdale, Arizona. "To be honest, they look like the kind of change you would expect to see in an unfortunate worker in an industrial accident where a big barrel of toxic chemicals spills, and that person is exposed to toxic fumes and there is a chemical burn in the airways."

The injuries also look like those seen in people exposed to poisons like mustard gas, a chemical weapon used in World War I, he said.

The findings were published on [Wed 2 Oct 2019] in The New England Journal of Medicine [1] and involved samples from 13 men and 4 women whose ages ranged from 19 to 67. About 70 percent had a history of vaping marijuana or cannabis oils. 11 were in Arizona, 5 in Minnesota, and 1 in Florida.

More than 800 cases of lung illness in 46 states have been linked to vaping, and 16 people have died. The majority have vaped THC, the psychoactive ingredient in marijuana, but some say they have vaped only nicotine.

Medical investigators have been unable to identify exactly what is causing the lung damage, or even how many harmful substances are involved. They do not know whether the source is the liquids being vaped, or a toxin released from the materials used to make vaping devices. It is also unclear whether some devices used in vaping may be defective.

Initial concerns have focused on the possibility that the lungs were clogged by oils being vaped, like THC oil itself, or other oils like vitamin E acetate being used sometimes to dilute or "cut" THC for sale.

But Dr Larsen said the Mayo researchers saw no signs of oil accumulating in the lung tissue. Instead, they saw many immune cells called macrophages with what he described as "the fine, foamy-looking appearance that is characteristic of chemical injuries."

"So maybe we need to look more closely at the chemical compounds, and not just oils, but the chemical constituents, to figure out which ones are injurious," Dr Larsen said.

He said patients with lung illness from vaping had tissue damage and cell death in the lining of their airways, and in the lungs themselves. As the body reacts and tries to heal, the tissue swells and can narrow the airways. Dead cells slough off into the airways, blocking them further, and fluids leak into the lungs' air sacs.

The swelling, tissue damage, and fluid buildup can make it impossible to breathe.

"The lung is not very functional when it's been damaged and is trying to repair itself," Dr Larsen said, adding that the lungs and airways have essentially been "torched."

"There's no reserve left while the body tries to heal itself, so people will be really sick, on a ventilator because they can't get enough oxygen in, or carbon dioxide out," he said. "Some patients will not recover, and will end up dying."

He said it was too soon tell whether the survivors' lungs would fully recover.

"Based on the severity of injury we see, at least in some of these cases, I wouldn't be surprised if we wind up with people down the road having chronic respiratory problems from this," Dr Larsen said. "Some seem to recover. I don't think we know what the long-term consequences will be."

Two of the cases included in the Mayo Clinic report occurred before 2019, and Dr Larsen said he suspected the condition had existed for some time, years perhaps, but the cases were scattered and the cause was not recognized.

For decades, doctors have asked patients whether they had a history of smoking traditional cigarettes, but until very recently, not about vaping. "As we become more attuned, I think we'll see more and more of this, and we may see more risks than we initially realized," he said.

The patients described in the Mayo report included a 31-year-old woman who died, despite extensive treatment with steroids and even a machine to pump oxygen directly into her bloodstream. Her lungs were so damaged even a ventilator could not give her enough air. She had a history of vaping, but there was no information about what she vaped. Another patient was a 21-year-old man who reported vaping nicotine for 5 years, and who became ill shortly after adding marijuana to it for the 1st time. He recovered well enough to leave the hospital.

A 28-year-old man listed in the report had, for a year, been vaping 20 to 30 cartridges a day and also vaping THC.

Last [27 Sep 2019], the Centers for Disease Control and Prevention identified several names of THC-related products in prefilled cartridges they said patients had reported using before becoming ill. Dank Vapes, Moon Rocks, Off White, and TKO were among those listed by health officials who interviewed patients in Wisconsin and Illinois.

But officials said they did not know if vaping illnesses or deaths in other parts of the country were related to the same THC labels identified in those 2 states.

Officials also said Dank Vapes was not an actual brand, but just a label and packaging anyone selling THC vaping liquid could buy and stick on a product.

The extensive use of prefilled THC cartridges suggests they might play an important role in the outbreak, the CDC said.

According to the CDC report last week [week of 23 Sep 2019], of 771 patients nationwide in the outbreak, 91 percent had been hospitalized; 69 percent were male; and a little more than 60 percent were between the ages of 18 and 34. Of the 13 known deaths at the end of last week, the CDC said nearly 60 percent were of men, and the median age was 50 years old.

Nebraska, Virginia, and New Jersey reported deaths this week, bringing the total to 16. Many of the patients who died were older with underlying illnesses, although few details about them have been released.

[Byline: Denise Grady]

[Reference
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1. Butt YM, Smith ML, Tazelaar HD, et al. Pathology of vaping-associated lung injury. N Engl J Med. 2019; https://www.nejm.org/doi/full/10.1056/NEJMc1913069.]

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[The substance, be it liquid nicotine, THC, flavors, or oils could certainly burn a lung or look like chemical damage, as the vapor is essentially a hot liquid minute particle being inhaled. It is warmer by some degrees than the body temperature and the lungs are sensitive organs. - Mod.TG]

[niman]

Date: Fri 27 Sep 2019 9:29 AM ET
Source: The Daily Beast [edited]
https://www.thedailybeast.com/vaping-marijuana-cartridges-test-positive-for-hydrogen-cyanide-nbc-news-test-report


Black-market marijuana vape cartridges have been found to contain hydrogen cyanide in laboratory testing commissioned by NBC News. The network reports it asked a California cannabis testing facility to examine a sample of 18 cartridges containing THC [tetrahydrocannabinol], the psychoactive ingredient in marijuana. The 3 purchased from legal dispensaries found no toxins, such as heavy metals or pesticides, but the other 15 samples from black-market THC cartridges gave troubling results. They all contained myclobutanil, a fungicide capable of transforming into hydrogen cyanide when burned. 13 out of the 15 contained vitamin E acetate, which some health officials have blamed for the deaths and lung illnesses linked to vape pens. 10 of the unregulated cartridges also tested positive for pesticides. "You certainly don't want to be smoking cyanide," Antonio Frazier, the vice president of operations at testing lab CannaSafe, told NBC News. "I don't think anyone would buy a cart that was labeled hydrogen cyanide on it."

The Centers for Disease Control and Prevention reported [Thu 26 Sep 2019] that 12 people have now died from mysterious illnesses believed to be related to vaping, with the number of confirmed cases at 275.

[Byline: Jamie Ross]

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[There is information in these articles eliciting both hope and questions. Regarding the fungicide myclobutanil decomposing or breaking down under correct circumstances to hydrogen cyanide could make sense as hydrogen cyanide in proper concentrations could produce death. There is no information regarding the concentrations possibly inhaled or even if the concentrations have been measured above the level of 'present'. So clearly there are more questions here and a lot more room for work on this issue.

Vitamin E has been mentioned several times in these and other articles. Why would vitamin E be vaped? It is an oily substance and burned oil (oil heated to high temperatures, as in vaping) may have other changes, some or all possibly being unhealthy in the lungs.

Clearly the main cause of these vaping deaths is not yet evident and work is ongoing. With the possibility of cyanide being involved, it is likely other substances in relationship to the high temperatures of vaping may be more thoroughly examined. - Mod.TG