Characteristics of Hospitalized and Nonhospitalized Patients in a Nationwide Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injury — United States, November 2019

CDC, the Food and Drug Administration (FDA), state and local health departments, and public health and clinical stakeholders are investigating a nationwide outbreak of e-cigarette, or vaping, product use–associated lung injury (EVALI) (1). As of November 13, 2019, 49 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands) have reported 2,172 EVALI cases to CDC, including 42 (1.9%) EVALI-associated deaths. To inform EVALI surveillance, including during the 2019–20 influenza season, case report information supplied by states for hospitalized and nonhospitalized patients with EVALI were analyzed using data collected as of November 5, 2019. Among 2,016 EVALI patients with available data on hospitalization status, 1,906 (95%) were hospitalized, and 110 (5%) were not hospitalized. Demographic characteristics of hospitalized and nonhospitalized patients were similar; most were male (68% of hospitalized versus 65% of nonhospitalized patients), and most were aged <35 years (78% of hospitalized versus 74% of nonhospitalized patients). These patients also reported similar use of tetrahydrocannabinol (THC)-containing products (83% of hospitalized versus 84% of nonhospitalized patients). Given the similarity between hospitalized and nonhospitalized EVALI patients, the potential for large numbers of respiratory infections during the emerging 2019–20 influenza season, and the potential difficulty in distinguishing EVALI from respiratory infections, CDC will no longer collect national data on nonhospitalized EVALI patients. Further collection of data on nonhospitalized patients will be at the discretion of individual state, local, and territorial health departments. Candidates for outpatient management of EVALI should have normal oxygen saturation (≥95% while breathing room air), no respiratory distress, no comorbidities that might compromise pulmonary reserve, reliable access to care, strong social support systems, and should be able to ensure follow-up within 24–48 hours of initial evaluation and to seek medical care promptly if respiratory symptoms worsen. Health care providers should emphasize the importance of annual influenza vaccination for all persons aged ≥6 months, including persons who use e-cigarette, or vaping, products (2,3).

State health departments, the Council of State and Territorial Epidemiologists Vaping Associated Pulmonary Injury Epidemiology Task Force, and CDC developed and disseminated surveillance case definitions and data collection tools (i.e., patient interview and medical record abstraction forms) to monitor and track cases beginning in August 2019.* Some states are using these tools, whereas others elected to use state-specific tools. States and jurisdictions routinely report the number of confirmed and probable EVALI cases to CDC on a voluntary basis and, when available, include data from patient interviews and medical record abstractions. Some states have restricted case finding to hospitalized patients. Proxies (e.g., spouses or parents) were interviewed if patients were too ill or if they had died. Most states and jurisdictions report the number of cases to CDC as case status is determined; however, completing and submitting information from interviews and medical record abstraction can take up to several weeks.

This report provides updated data on patient demographic characteristics and substances used in e-cigarette, or vaping, products among hospitalized and nonhospitalized patients, as well as clinical characteristics observed among nonhospitalized patients, according to cases reported to CDC with available interview data, medical record abstraction data, or both as of November 5, 2019. Nonhospitalized EVALI patients were defined as those receiving care in an outpatient clinic, urgent care, or emergency department without report of hospitalization. Demographic and product use characteristics were compared across groups using the chi-square test, and the median ages of patients were compared using the Wilcoxon rank-sum test. SAS statistical software (version 9.4; SAS Institute) was used for the analysis.

Among 2,016 EVALI patients with available data on hospitalization status, 1,906 (95%) were hospitalized, and 110 (5%) were not hospitalized (Table 1). The nonhospitalized patients were reported from 27 states. Demographic characteristics of hospitalized and nonhospitalized patients were similar; most were male (68%; [1,228 of 1,797] of hospitalized versus 65% [70 of 108] of nonhospitalized patients; p = 0.4) and non-Hispanic white (79% [830 of 1,048] of hospitalized versus 82% [46 of 56] of nonhospitalized patients; p = 0.5). A similar age distribution was observed: 78% (1,395 of 1,800) of hospitalized and 74% (78 of 106) of nonhospitalized patients were aged <35 years (p = 0.3), and median age was 24 years for both hospitalized and nonhospitalized patients (p = 0.9). A higher percentage of hospitalized (55%; 1,039 of 1,896) patients compared with nonhospitalized (12%; 13 of 110) were classified with confirmed cases rather than probable cases (p<0.01). Hospitalized and nonhospitalized patients reported similar use of THC-containing products (83% [932 of 1,122] versus 84% [52 of 62], respectively; p = 0.9) and nicotine-containing products (60% [678 of 1,122] versus 73% [45 of 62], respectively; p = 0.06).

According to medical chart abstraction data reported to CDC on nonhospitalized EVALI patients’ initial outpatient medical visit, 85% (47 of 55) experienced respiratory symptoms (e.g., cough, chest pain, and shortness of breath), 57% (27 of 47) had gastrointestinal symptoms (e.g., abdominal pain, nausea, vomiting, and diarrhea), and 76% (41 of 54) had constitutional symptoms (e.g., fever, chills, and weight loss) (Table 2). Very few patients reported only one symptom type (e.g., 9% [four of 47] reported having only respiratory symptoms). Initial oxygen saturation <95% (while breathing room air) was reported among 30% (eight of 27) of patients and tachycardia among 40% (10 of 25); no patients had tachypnea. Twenty-one (81%) of 26 patients with available data were reportedly prescribed corticosteroids. Among 34 patients with results reported for initial chest radiographs (CXR), 28 (82%) had abnormal findings, and 76% (19 of 25) had bilateral findings; three cases had missing information and were excluded. All 28 patients with results reported for chest computed tomography (CT) scans had abnormal findings, including 27 (96%) with bilateral findings. Six of 16 (38%) patients with information on both a CXR and chest CT had an initial normal CXR but abnormal chest CT; 10 (63%) had both an abnormal CXR and chest CT.

Acknowledgments

Sarah Khalidi, Sondra Reese, Alabama Department of Public Health; Emily M. Carlson, Tiana Galindo, Arizona Department of Health Services; Appathurai Balamurugan, Allison James, Brandy Sutphin, Arkansas Department of Health; Ellora Karmarkar, Svetlana Smorodinsky, California Department of Public Health; Elyse Contreras, Katelyn E. Hall, Colorado Department of Public Health and Environment; Sydney Jones, Jaime Krasnitski, Connecticut Department of Public Health; Amanda Bundek, Caroline Judd, Delaware Department of Health and Social Services, Division of Public Health; Adrienne Sherman, Kenan Zamore, District of Columbia Department of Health; Heather Rubino, Thomas Troelstrup, Florida Department of Health; Georgia Department of Public Health Lung Injury Response Team; Hawaii Department of Health; Eileen M. Dunne, Kathryn A. Tuer, Idaho Division of Public Health; Dawn Nims, Lori Saathoff-Huber, Illinois Department of Public Health; Sara Hallyburton, Kathryn Gaub, Charles R. Clark, Indiana State Department of Health; Chris Galeazzi, Rob Ramaekers, Iowa Department of Public Health; Amie Cook, Justin Blanding, Kansas Department of Health and Environment; Kentucky Department for Public Health; Louisiana Department of Health; Maine Center for Disease Control and Prevention; Kenneth A Feder, Clifford S. Mitchell, Maryland Department of Health; Daniel Church, MaryKate Martelon, Massachusetts Department of Public Health; Rita Seith, Eden V. Wells, Michigan Department of Health and Human Services; Stacy Holzbauer, Terra Wiens, Minnesota Department of Health; Paul Byers, Kathryn Taylor, Mississippi State Department of Health; Valerie Howard, George Turabelidze, Missouri Department of Health and Senior Services; Isaiah Reed, Montana Department of Public Health and Human Services; Matthew Donahue, Tom Safranek, Nebraska Department of Health and Human Services; Ashleigh Faulstich, Victoria LeGarde, Melissa Peek-Bullock, Nevada Department of Health and Human Services; Pascal Kalin, Suzann Beauregard, New Hampshire Department of Health and Human Services; Stephen Perez, Lisa McHugh, New Jersey Department of Health; Alex Gallegos, Joseph T. Hicks, New Mexico Department of Health; Adam Helman, Kristen Navarette, New York State Department of Health; Dana Dandeneau, Kendall Knuth, North Carolina Division of Public Health; Tracy Miller, Kodi Pinks, North Dakota Department of Health; Courtney Dewart, Kirtana Ramadugu, Ohio Department of Health; Claire B. Nguyen, Tracy Wendling, Oklahoma State Department of Health; Amanda Faulkner, Tasha Poissant, Oregon Health Authority; Barry Miller, Laurel Harduar Morano, Pennsylvania Department of Health; Ailis Clyne, Morgan Orr, James Rajotte, Rhode Island Department of Health; Sharon Biggers, Virginie Daguise, Daniel Kilpatrick, South Carolina Department of Health & Environmental Control; Joshua L. Clayton, Jonathan Steinberg, South Dakota Department of Health; Kelly Squires, Julie Shaffner, Tennessee Department of Health; Emily Hall, Varun Shetty, Texas Department of State Health Services; Esther M. Ellis, US Virgin Islands Department of Health; Deanna Ferrell, Jordan Green, Nathaniel Lewis, Keegan McCaffrey, Utah Department of Health; Julia Brennan, Vermont Department of Health; Jonathan Falk, Lilian Peake, Virginia Department of Health; Melanie Payne, Cathy Wasserman, Washington State Department of Health; Shannon McBee, Christy Reed, West Virginia Department of Health and Human Resources; Jonathan Meiman, Ian Pray, Wisconsin Department of Health Services; Melissa Taylor, Wyoming Department of Health.

Corresponding author: Kevin Chatham-Stephens, kchathamstephens@cdc.gov.

¹National Center on Birth Defects and Developmental Disabilities, CDC; ²National Center for Emerging and Zoonotic Infectious Diseases, CDC; ³National Center for Immunization and Respiratory Disease, CDC; ⁴National Center for Chronic Disease Prevention and Health Promotion, CDC; ⁵National Center for Environmental Health, CDC; ⁶National Center for Injury Prevention and Control, CDC; ⁷National Institute for Occupational Safety and Health, CDC.

References

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Abbreviation: THC = tetrahydrocannabinol.
* For cases reported as of November 5, 2019.
^† Percentages might not sum to 100% because of rounding.
^§ To assess for statistically significant differences between the hospitalized and nonhospitalized patients, a chi-square test was performed for comparing categorical data and Wilcoxon rank-sum test for the comparison of the median ages.
^¶ Whites, blacks or African Americans, American Indians or Alaska Natives, Asians, Native Hawaiians or other Pacific Islanders, and Others were non-Hispanic. Hispanic persons could be of any race.
** Data on both THC- and nicotine-containing product use required to be included.
^†† In the 3 months preceding symptom onset.
^§§ Comparison of the mutually exclusive categories of “Both THC- and nicotine-containing product use,” “THC-containing product use only,” “Nicotine-containing product use only,” and “No THC- or nicotine-containing product use reported.”

Abbreviation: CT = computed tomography.
* For cases reported as of November 5, 2019.
^† Percentages might not sum to 100% because of rounding.
^§ Self-reported symptoms (e.g., cough, chest pain, and shortness of breath).
^¶ Self-reported symptoms (e.g., abdominal pain, nausea, vomiting, and diarrhea).
** Self-reported symptoms (e.g., fever, chills, and weight loss).
^†† Three cases had missing chest radiograph information on unilateral versus bilateral findings and were excluded from this calculation.
^§§ Dates of chest radiographs and CT scans were not consistently reported, so it is unknown whether they were performed on the same or subsequent days, which could explain, in part, why the findings for the imaging tests were inconsistent among some patients.