As the year draws to a close, the precise cause of the mysterious outbreak of vaping-related illness, or EVALI, that has swept through the United States, isn’t yet fully settled. And the numbers are bleak: As of December 17, more than 2,500 people have been hospitalized for EVALI in all 50 states, the District of Columbia, Puerto Rico, and the US Virgin Islands. Fifty-four people have died — and more deaths are being investigated.
But two pieces of the complex puzzle seemed to find their place Friday: when it all started, and what’s causing the majority of the cases.
A new analysis out of the Centers for Disease Control and Prevention, published in the New England Journal of Medicine, suggests the disease may have actually surfaced in January 2017, long before June 2019, when the current outbreak began.
The authors of the paper used data from the National Syndromic Surveillance Program — a post-9/11 system that was developed to detect bioterrorism attacks — to try to root out when e-cigarettes or vaping were first mentioned as the reason for visiting emergency departments across the country. They overlaid those findings with data from Google searches and cases reported to the Centers for Disease Control and Prevention to see if the trends lined up.
They found e-cigarettes began to be mentioned as the reason for emergency room visits as early as January 2017 — the earliest date the researchers looked at. Though the authors couldn’t say whether or not these cases were EVALI, the trend in emergency rooms continued and increased for more than two years, until June 2019 — when the number began rising sharply, and finally peaking in September. The sharp increase and peak mirrors data CDC was using to track EVALI. It also coincides with the first known “cluster” of the disease — or sign there was a widespread problem.
In a second new study, also published in NEJM Friday, researchers found vitamin E acetate — an oily substance added to some THC vaping liquids to thicken or dilute them — in lung fluid samples taken from 48 of 51 EVALI patients from 16 states. The chemical wasn’t present in the lung samples taken from a variety of comparison patient groups.
These data suggest two things: First, “The number of cases had been increasing prior to this spike, suggesting some level of under-detection prior to the outbreak in June,” said David Hammond, a public health researcher at the University of Waterloo in Ontario who studies the North American vaping market, and who was not involved in the studies. Second, that some contaminant — most likely THC oils like vitamin e acetate — became more widely vaped last summer, and that it’s likely responsible for the cases. “If the cases are primarily caused by the general effects of vaping, one would not see this type of spike,” Hammond added.
Kathleen Hartnett, a lead author on the study and epidemiologist at CDC, warned that while the outbreak may have peaked, it’s still not over. “Hospitalizations associated with the use of e-cig or vaping products continue at higher rates than before the summer and really do remain a concern.”
Vitamin E acetate is playing a key role in the outbreak
Since the last fall, health officials have said THC vape products are playing a major role and the main chemical contender has been Vitamin E acetate. The chemical is a synthetic form of vitamin E, and it’s used — safely — in nutritional supplements and skin creams. But it isn’t safe to inhale. Sticky and honey-like, it can hang around in the lungs, interfering with how they function.
“We are confident vitamin E acetate is strongly linked to the EVALI outbreak,” said Anne Schuchat, principal deputy director of the Centers for Disease Control and Prevention, in a press briefing Friday timed with the release of the NEJM papers.
The new study pointing to vitamin E acetate builds on prior research, also indicating the chemical is a key culprit. Samples taken from 29 patients in 10 states, for a recent CDC Mortality and Morbidity Weekly report, found the chemical in all samples, while other potential toxins — such as plant and mineral oils — weren’t.
Of the 419 THC-containing products the Food and Drug Administration has tested, 50 percent contained the sticky substance as of November 8. Recent data from Utah found the chemical in 89 percent of the THC-containing cartridges tested there. New York State — where health officials were first to signal concern about vitamin E acetate — found vitamin E acetate in many of the THC vaping cartridges used by patients suffering respiratory illness.
For now, CDC is advising people not use THC-containing vaping products, especially those from informal sources, and that vitamin E acetate shouldn’t be added to e-cigarettes.
Schuchat warned, “This doesn’t meant there aren’t other substances that are causing lung injury.” There’s still a small number of EVALI patients who don’t use THC, so it’s possible that there may be other substances that are sickening people. But the vitamin E exposure appears to explain the majority of cases.
Black market cannabis suppliers have been known to use vitamin E acetate — but legitimate suppliers may be using the chemical, too
State and federal investigations have also found many of the THC products people reported using were cartridges purchased through informal or black market sources. And vitamin E acetate has reportedly been used as a cheap cutting agent by illicit cannabis suppliers.
Even in states where cannabis vaping products are manufactured by legitimate sources, regulators haven’t necessarily been checking for the presence of vitamin E acetate.
Cannabis is subject to a patchwork of state-level health regulations where it’s legal or decriminalized. As I reported recently, these regulations are generally weak and inadequate, revealing a problem in cannabis oversight in this country.
So in Washington state, for example, the Liquor and Cannabis Board regulates the recreational cannabis marketplace, and products are tested for “potency, moisture, foreign matter, microbiological, mycotoxins (fungi), and residual solvents,” according to a spokesperson there. But only medical-grade products are also tested for pesticides and heavy metals. The list of tests also doesn’t include checking for chemicals, such as vitamin E acetate, that have emerged as a health threat. “Until only recently with the outbreak of the vapor associated lung injury crisis, no one suspected additional safety tests should be considered,” a spokesperson for the board said.
That’s why, with the mounting death toll, some experts are calling for more stringent oversight.
“How confident [are state regulators] that some of the ingredients used in vape oils are safe?” Hammond told Vox. “I don’t know if anyone knows that. It’s the manufacturer’s job to make sure products don’t include harmful chemicals. But the whole concept of vaping from liquids is fairly new and we don’t have a lot of certainty.”