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U.S. health officials are investigating what might be causing hundreds of serious lung illnesses in people who use e-cigarettes and other vaping devices. They have identified about 380 confirmed and probable cases in 36 states, including six deaths.

At a Sept. 6, 2019, press briefing including officials from the Centers of Disease Control and Prevention and the Food and Drug Administration, Dr. Dana Meaney Delman, the CDC's Incident Manager for the outbreak, summarized what was known about the vaping illnesses so far. 

“No specific e-cigarette device or substance has been linked to all cases, and e-cigarettes include a variety of chemicals and additives; consumers may not know what these products contain. Particularly, products obtained from social sources or off the street, it is difficult to know what is contained in these e-cigarette products,” she said. 

“Based on the clinical and laboratory evidence to date, we believe that a chemical exposure is likely associated with these illnesses,” Meany Delman said. “However, and I really want to stress this, more information is needed to determine which specific products or substances are involved. We are aware that some laboratories have identified vitamin E acetate in product samples, and we have connected those laboratories with the FDA forensic laboratories to compare results. At this time, no one device, product, or substance has been linked to all cases.”

Mitch Zeller, Director of the Center for Tobacco Products at the FDA noted in the press briefing that his agency is collecting samples of vaping products for analysis. “The samples we're continuing to evaluate show a mix of results and no one substance or compound, including vitamin E acetate has been identified in all of the samples tested,” he said.

A look at what is known so far about the outbreak as the investigation continues:

What are the Symptoms?

Patients are coming into hospitals with cough, chest pain, shortness of breath, fatigue, and vomiting.

How Serious are These Illnesses?

Many of the reports involve severe, life-threatening respiratory illnesses in previously healthy people. Many patients received oxygen. Some required assistance from ventilators before they recovered. Antibiotics didn't work, and it's not clear yet whether steroid drugs helped.

What Vaping Products are Involved?

No single device, ingredient or additive has been identified. Most of the patients say they vaped products containing THC, the intoxicating ingredient in marijuana. Others say they vaped only nicotine and others say they vaped both THC and nicotine.

Doctors do not believe a germ caused the hundreds of respiratory illnesses. Investigations have focused on additives that might be in marijuana and nicotine vapes, such as vitamin E acetate or cutting agents including propylene glycol (PG) and vegetable glycerin, as possibly related to the health emergencies. (Gina Coleman/Weedmaps)

Is There a Common Thread?

Doctors believe this isn't caused by a germ. Instead, they suspect chemical exposure. And vape juice contains many possible culprits.

After testing products, New York has focused its investigation on vitamin E acetate, which recently has been used as a thickener, particularly in illicit vape cartridges. Suppliers say it dilutes vape oils without making them look watery. Vitamin E is safe as a vitamin pill or to use on the skin, but inhaling oily vitamin E droplets into the lungs can trigger pneumonia.

Immune cells containing oily droplets have been found in the lungs of some patients. These large cells, called macrophages, are the cleanup crew of the immune system. University of Utah doctors think this could be a marker for vaping injury. They wrote up their findings about six patients in the New England Journal of Medicine in response to a preliminary report by Illinois and Wisconsin physicians about 53 cases in summer 2019 in the two states.

What Else is in Vape Liquids?

Most e-cigarettes contain colorless, flavorless cutting agents such as propylene glycol and vegetable glycerin, which create an inhalable vapor when heated. The chemicals are considered safe as food additives, but their long-term effects when inhaled have not been studied.

Researchers have found cancer-causing chemicals in e-cigarette vapor, such as formaldehyde. However, it's not yet clear whether those chemicals are present in high enough amounts to cause harm.

E-cigarette vapor contains tiny particles that carry flavorings. Some early-stage laboratory and animal studies suggest these flavor particles can damage the lungs, airways, and blood vessels, but more research is needed to better understand how human bodies react to them.

Much less is known about the contents of THC oils and how those chemicals behave when heated.

“I wouldn't rule anything out at this point because we know so little,” said Dr. David Christiani of Harvard T.H. Chan School of Public Health.

Is This Brand New?

There have been occasional reports of similar illnesses, including one from 2000 that was tied to inhaling homemade marijuana-infused oil vapor. In that case, the patient had smoked a homemade preparation two to 10 times a day for more than a decade. The patient mixed hydroponically grown marijuana leaves with isopropyl alcohol, which she then burned for a short period to eliminate the alcohol. After mixing in petroleum jelly, vitamin E, or another oil-based substance, she heated the oily substance again and inhaled the vapors, according to a report published in the Canadian Respiratory Journal.

The large number of cases is new and alarming to public health officials.

Who is Investigating and What are They Doing?

State and federal health officials are testing products and analyzing cases for clues.

New York is issuing subpoenas to three companies that sell vaping additives made from vitamin E acetate. The state wants to know more about the ingredients, the quality of the raw materials, any safety testing performed, sales of the products during the past three years, and what other additives the companies sell.

Are Products from State-Licensed Dispensaries Safe?

Most of the cases involve products purchased on the street, not in dispensaries in states with legal adult-use or medical marijuana sales. One person who died in Oregon had used an e-cigarette containing marijuana oil purchased from a dispensary. Health officials there don't know whether the product was contaminated, or whether the victim may have added something to the liquid in the device after buying it.

What's the Best Advice Right Now?

Health officials are urging people to stop vaping and to get medical care if they have trouble breathing or chest pain after vaping.

— Carla K. Johnson

Weedmaps News contributed to this article.

Featured Image: Most of the cases of respiratory illnesses involving THC and nicotine vapes have involved devices purchased off the street, not in dispensaries in states where marijuana is legal. (Gina Coleman/Weedmaps)