Cases of Vaping-Related Lung Illness Surge, Vitamin E Acetate One of Many Possible Causes

Indiana announced a third death linked to the illness on Friday. State and federal health officials are working urgently to understand the causes.

By Matt Richtel and Denise Grady / New York Times / Sept. 6, 2019

Federal health officials reported on Friday that the number of people sickened with a severe lung illness linked to vaping has more than doubled to 450 possible cases in 33 states, including three deaths and a possible fourth.

The Indiana Department of Health announced the third death on Friday, saying only that the victim was older than 18.

“There is clearly an epidemic that begs for an urgent response,” Dr. David C. Christiani of the Harvard T.H. Chan School of Public Health wrote in an editorial published on Friday afternoon in The New England Journal of Medicine.

The editorial called on doctors to discourage their patients from using e-cigarettes and for a broader effort to increase public awareness about “the harmful effects of vaping.”

Officials from the Centers for Disease Control and Prevention echoed that call in a briefing.

“While this investigation is ongoing, people should consider not using e-cigarette products,” said Dr. Dana Meaney-Delman, who is leading the C.D.C.’s investigation into the illness.

C.D.C. officials said they believe that some “chemical” is involved as the cause but they have not identified a single responsible “device, product or substance,” Dr. Meaney-Delman said.

Dr. Christiani, author of the New England Journal article, wrote that it was not yet clear which substances in vaping were causing the damage. E-cigarette fluids alone contain “at least six groups of potentially toxic compounds,” the editorial said, and suggested that the mixed-up stew of chemicals might create new toxins. The journal also published today a study of two large clusters of 53 cases in Wisconsin and Illinois.

The first case of the mysterious lung illness, in Illinois, came in April, indicating that the syndrome emerged earlier than the mid-June date that has been often cited by federal officials as the time the afflictions began.

A keener look at the patient base and syndrome came from details of 53 patients from Illinois and Wisconsin described in the article in the New England Journal of Medicine. The patients were typically “healthy, young, with a median age of 19 years and a majority have been men,” said Dr. Jennifer Layden, chief medical officer and state epidemiologist for the Illinois Department of Public Health.

She said that 98 percent were hospitalized, half required admission to the intensive care unit, and a third required ventilation. The majority, Dr. Layden said, vaped a product including T.H.C., the high-inducing chemical in marijuana, but a majority also used a “nicotine-based product,” noting that there were “a range of products and devices.”

“The focus of our investigation is narrowing but is still faced with complex questions,” said Ileana Arias, the C.D.C.’s acting deputy director for noninfectious diseases. She added: “We are working tirelessly and relentlessly.”

Dr. Mitch Zeller said particular concern is developing around products that are jury-rigged by vaping retailers, or tampered with or mixed by consumers themselves. “Think twice,” he said, urging consumers to avoid vaping products purchased off the street or purchasing informally mixed or made devices.

Public health officials have underscored one fundamental point: that the surge in illnesses is a new phenomenon and not merely a recognition of a syndrome that may have been developing for years.

Before health officials in Indiana confirmed the third death from a severe lung illness linked to vaping, two other people — one in Illinois, the other in Oregon, both of whom were adults — have died from what appears to be the same type of illness, health officials in those states have said. State and federal health officials are scrambling to find a cause, possibly a particular chemical or adulterant contained in some vaping products.

What looked like a few scattered cases in mid-June has become a full-fledged and widespread public health scare, leaving some otherwise healthy teenagers and young adults so severely ill that they have been placed on ventilators.

Those afflicted typically show up in emergency rooms with shortness of breath after several days of flulike symptoms, including high fever.

The state of New York, where 34 people have become ill, said on Thursday that vaping samples from eight of its cases showed high levels of a compound called vitamin E acetate. Investigators there are focusing on the possibility that the oily substance might be playing a key role in the illness.

However, some of the more than 100 vaping samples being tested by the federal government did not prove positive for vitamin E acetate, so that compound remains only one of many possible causes of the heavy lung inflammation.

As with a food poisoning outbreak, the search for a cause of the vaping syndrome involves a multiparty investigation that can feel slow to the public and industry. The challenge with this particular investigation is amplified by the many possible chemicals involved in vaping liquids and by the haphazard nature of industry regulation, leaving a vast black and gray market of e-cigarettes and marijuana products.

Vaping, a wholesale change in how nicotine and marijuana is inhaled, involves the use of high heat to create aerosolized versions of nicotine and marijuana. In the case of e-cigarettes, which deliver nicotine, the industry and a vast range of supporters have positioned the devices as a much safer alternative to the lethal habit of traditional smoking; that’s because smoking involves the combustion and inhalation of countless carcinogens that pepper the delicate lung tissue, whereas e-cigarettes deliver many fewer chemicals and none through fiery combustion.