Close collaboration with the US Centers for Disease Control and Prevention (CDC), US Food and Drug Administration (FDA),
Council of State and Territorial Epidemiologists (CSTE) and APHL member laboratories helped the public health community make great strides in identifying chemical agents associated with the E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI) multi-state outbreak. The Lung Injury Response Laboratory Working Group, a team of researchers from these organizations, has observed an association between Vitamin E Acetate (VEA) contaminants in vape product samples and EVALI – VEA was identified in 94% of the 51 case-associated bronchoalveolar lavage (BAL) samples tested. These findings were published in the
New England Journal of Medicine on February 20, 2020.
Federal Partner Recommendations and Actions
Both the CDC and FDA recommend that all individuals in the United States refrain from using tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, products, particularly those obtained informally. Those using e-cigarettes for smoking cessation purposes are encouraged to consider using
FDA-approved cessation medications. CDC warns against returning to smoking cigarettes and recommends contacting a health care provider for other options. CDC also warns that women who are pregnant and adults who do not currently use e-cigarettes should not begin using them.
FDA agents were deployed nationally to support outbreak response efforts by collecting vape pens and cartridges from consumers, hospitals, and APHL member PHLs, as well as interviewing consumers to assess patterns in product use and composition. FDA collated product-specific information and analyzed these products for a broad range of chemicals, including nicotine, THC and other cannabinoids, cutting agents/diluents, pesticides, opioids, poisons, heavy metals, toxins, and other potentially toxic additives.
Public Health Laboratory Response
APHL member PHLs shipped hundreds of product samples to support product sample investigations led by the FDA's Forensic Chemistry Center. Additionally, member PHLs conducted their own targeted and non-targeted analyses on select vape product samples and patient-associated clinical specimens. Of note, New York State Department of Health, Wadsworth Center first identified VEA in October 2019 and presented their findings publically on November 19, 2019, during an
ABC Good Morning America recorded interview with Wadsworth Center staff.
Through leveraging close relationships with epidemiologists at state and local health departments, PHLs provided invaluable contributions to outbreak response efforts in their jurisdictions. A September 6, 2019 article published in the New England Journal of Medicine provides a preliminary report on an example of a coordinated public health investigation in Illinois and Wisconsin.
In the summer and fall of 2019, APHL activated the Incident Command System in an effort to ensure that APHL member PHL needs were met throughout the outbreak response. Through this activation, APHL has supported members through a variety of activities, including assisting with sample triage and shipment, facilitating technical assistance requests, and disseminating news, guidance, and recommendations. APHL lead interagency communication brokering between partner organizations and members during national EVALI Community of Practice conference calls.
Incident Command System/Emergency Operations Center
An APHL Emergency Operations Center (EOC), stood up on September 12, 2019, was staffed 24/7 at the height of the outbreak response, with Julianne Nassif (Director, Environmental Health) serving as Science Officer. On December 10, 2019 the EOC officially deactivated as outbreak response efforts became more routine. Members are advised to direct any questions about ongoing APHL EVALI activities or requests for technical assistance to the APHL Environmental Health program mailbox,
EVALI Community of Practice
On September 13, 2019, APHL established an EVALI Community of Practice for state laboratories involved in the outbreak response. This consists of two primary modes of communication:
- A searchable electronic platform or discussion board, where members may post documents and events on the calendar. Such platforms have been used effectively in other topic areas and emergency incidents.
- Regular calls with members of this community of practice. Calls are intended for analysts to share what they are doing to support this response, questions for their peers, and best practices. Calls are restricted to APHL members and key public health partners.
APHL distributed a survey to all state and local laboratory directors on September 30, 2019 to determine activities, capabilities and needs related to the 2019 EVALI Response. Responses were due to APHL by October 7, 2019; summary results were rapidly shared with partners.
Laboratory Testing Guidance
A variety of laboratory testing guidance is hosted on the
CDC STLT webpage in the 'Laboratory Testing by CDC' and 'CDC FDA Product Sample Submission' sections. Please direct any questions about these guidance documents to the CDC or FDA e-mail addresses listed on the CDC STLT webpage.
Due to continued decline in incident EVALI cases and the identification of VEA as the primary cause of disease, the final CDC update on hospitalized EVALI cases and deaths was reported on
February 25, 2020. CDC and APHL will continue to provide assistance to public health laboratories as needed. Please reach out to
email@example.com with any technical assistance needs.