2019–2020 vaping lung illness outbreak 2019–2020 vaping lung illness outbreak an outbreak of e-cigarette, or vaping, product use-associated lung injury (evali) started in 2019 among users of illegal, unregulated cannabis vaping products, almost exclusively in the united states. the first cases of this particular outbreak were identified in illinois and wisconsin in april 2019; as of 18 february 2020, a total of 2,807 hospitalized cases, including 68 deaths, have been confirmed. according to the u.s centers for disease control (cdc), "vitamin e acetate is strongly linked to the evali outbreak...evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either thc or non-thc products, in some of the reported evali cases". 2019–2020 vaping lung illness outbreaksome of the illegal and unregulated (black market) cannabis vaping products were found to contain large amounts of vitamin e acetate, including dank vapes pictured here. map of reported hospitalized cases or deaths in the us and us territories.diseasevaping-associated pulmonary injurylocationunited statesfirst outbreak2019 (2019)first reportedapril 2019 (2019-04)confirmed cases2,711deaths61 cases peaked in september 2019, and have slowly declined since. the cdc stopped reporting on evali cases in february 2020, due to the decline in cases, but as of december 2020, continues to monitor cases that may arrive in emergency departments. some states continue to record new evali cases. as of january 2022, the state of california has reported at least 40 cases on their update page, that were diagnosed after february 2020. according to an article in the radiological society of north america news published in march 2022, evali cases continue to be diagnosed. "evali has by no means disappeared," dr. kligerman said. "we continue to see numerous cases, even during the pandemic, many of which are initially misdiagnosed as covid-19." there have been at least 73 cases diagnosed in utah after the last cdc update of february 2020. cdc investigators identified direct exposure to chemicals present in illegal cannabis vaping products as a likely culprit for the outbreak, but the cdc did not rule out other chemicals in nicotine vapes as possible causes. vitamin e acetate is a very strong culprit of concern in the lung illnesses related to thc-based vaping products but according to the cdc, "no specific e-cigarette device or substance has been linked to all cases, and e-cigarettes include a variety of chemical and additives; consumers may not know what these products contain." though patients have reported using vaping products containing thc, nicotine, or both types, 84% of patients studied by the cdc admitted thc use. the majority of those affected were young adults aged 18–34, which is the group with the greatest prevalence of cannabis use in the u.s. nicotine-containing products are regulated in the u.s. by the food and drug administration (fda) which has not approved any vape product for sale; thc products are illegal under federal law, but allowed and regulated by many states. prior to the outbreak, vitamin e acetate was used in low concentrations, lower than 20% of the formula in vape cartridges, as a thickening agent. as a result of a limited availability of cannabis in california, as well as high demand, illicit sellers had used about 50% or higher of diluent thickeners in their formulas to bulk up tiny potency vape cartridges to create the illegal and dangerous products, and vitamin e acetate is a common choice because it resembles thc oil. some jurisdictions took action to restrict the sale of products containing vitamin e acetate and other chemicals in response to the outbreak, but thc products in states where it is illegal are produced unlawfully (and sometimes obtained illegally in jurisdictions where legal, by uninformed consumers). in 2021, researchers at johns hopkins university analyzed the vape aerosols of popular brands such as juul and vuse, and found "nearly 2,000 chemicals, the vast majority of which are unidentified." the cdc has not ruled out nicotine vapes as a possible additional cause of some cases of evali. public health recommendations the cdc recommends that the public should consider not using any vaping products during their investigation, particularly those containing thc from informal sources like friends, family, or in-person or online dealers as of 20 november 2019. the u.s. fda considers it prudent to avoid inhaling vitamin e acetate. on 6 september 2019, the u.s. fda stated that because consumers cannot be sure whether any thc vaping products may contain vitamin e acetate, consumers are urged to avoid buying vaping products on the street, and to refrain from using thc oil or modifying/adding any substances to products purchased in stores. the cdc recommends that e-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant. adults who do not currently use tobacco products should not start using e-cigarettes or vaping products, according to the cdc. background according to a systematic review article, "initial case reports of vaping-related lung injury date back to 2012, but the ongoing outbreak of evali began in the summer of 2019..." at least 19 cases of vaping-associated pulmonary injuries had been reported worldwide prior to 2019. the first case of e-cigarettes inducing lipid pneumonia was documented in the medical literature in 2012, though the causative agent was identified as glycerin, not vitamin e acetate. glycerin was long thought to be a safe additive in e-cig liquid. however, the carcinogen formaldehyde is known as a product of propylene glycol and glycerol vapor degradation, and these ingredients may also cause lung inflammation. lipid pneumonia is known to cause lung inflammation, with exogenous and endogenous factors that cause this disease. united states cases involved in the outbreak of severe vaping-associated pulmonary injury were first identified in illinois and wisconsin in april 2019. as of 18 february 2020, a total of 2,807 hospitalized cases of lung illness associated with the use of vaping products have been reported to the centers for disease control and prevention (cdc) from 50 states, the district of columbia, and two us territories (puerto rico and us virgin islands). the potential cases of severe lung illness have been associated with the use of vaping products such as devices, liquids, refill pods, and cartridges. on 12 september 2019, the cdc no longer reported possible cases. the cdc changed its reporting methodology from counting possible cases, to reporting probable and confirmed cases where patients recently vaped, developed a breathing illness, and either had some tests that were performed to rule out infection, or testing did not show an infection. the cdc stated the possible cases are still under investigation at the state level. as of 3 december 2019, the cdc is only reporting hospitalized vaping-associated lung illness cases and vaping-associated lung illness deaths, regardless of hospitalization status. as of 15 october 2019, the cdc has reported on 1,358 people with data on age and gender: 70% of people are male. the median age of persons is 24 years, and ages range from 13 to 75 years. 79% of persons are under 35 years old. prevalence of lung disease attributable to vaping is likely under reported, as cases brought to the cdc are some of the most severe. symptoms typically develop over a period of days, but can sometimes manifest over several weeks. in many cases, patients reported a gradual start of symptoms, including: breathing difficulty, shortness of breath, and/or chest pain before being admitted to a hospital for more deliberate treatment by professional medical experts. based on reports from several states, patients have experienced respiratory symptoms (cough, shortness of breath, or chest pain), while some have also experienced gastrointestinal symptoms (nausea, vomiting, or diarrhea) or non-specific symptoms (fatigue, fever, or weight loss). some cases reported mild to moderate gastrointestinal illness. some patients have reported that their symptoms developed over a few days, while others have reported that their symptoms developed over several weeks. some patients have reported that their gastrointestinal symptoms began before their respiratory symptoms. fever, elevated heart rate, and elevated white blood cell count have been reported, even though no infectious disease has been identified. many patients sought medical care in ambulatory settings, sometimes over several visits, before they were admitted to the hospital. percentage of persons needing intubation and hospitalization among persons with vaping-associated lung injury. many patients have required medical treatment with supplemental oxygen, including some who required assisted ventilation. some patients have been treated with corticosteroids with demonstrated improvement. evidence does not suggest an infectious disease is the cause of the severe pulmonary disease. antibiotic therapy alone has not consistently been associated with clinical improvement. a handful of individuals have been re-admitted for clinical care after discharge for lung injury. the cdc does not know whether individuals who were re-admitted continued or restarted use. the range of time that the cdc is aware of for these re-admissions ranges from approximately five days after discharge, to 55 days after discharge. as of 5 september 2019, the new york state department of health reported 34 cases of severe lung illness in patients who were reportedly using different vaping products. tests conducted by the wadsworth center found exceedingly high amounts of vitamin e acetate in most of the cannabis e-cigarette products. "at least one vape product containing vitamin e acetate has been linked to each patient who submitted a product for testing," the new york state department of health stated. none of the nicotine-based product samples contained vitamin e acetate. according to the reports from illinois and wisconsin, the onset of respiratory findings appeared to have occurred over several days to several weeks before hospitalization. as of 5 september 2019, the illinois department of public health reported 42 cases of lung illness, seven that were still being investigated, and one death. severe lung illness among young adults and youth who used vaping products required hospitalization in 11 cases in wisconsin, and others were being investigated in august 2019. symptoms were difficulty breathing, tiredness, chest pain, cough, and reduced weight. some required assistance to breathe. on 9 august 2019, the california department of public health issued a statement regarding a cluster of seven healthy adults in kings county, california, all of whom required hospitalization. since june 2019, at least seven cases of severe acute pulmonary illness in previously healthy adults were reported from a hospital in kings county, california. cases were among residents of multiple counties. the patients presented with progressive respiratory distress, sometimes initially diagnosed with pneumonia or bronchitis, and some with preceding fevers and gastrointestinal symptoms. all cases failed to respond to an initial course of antibiotic treatment. all patients required admission to the hospital with significant respiratory support, including high-flow oxygen, bilevel positive airway pressure (bipap), or intubation with mechanical ventilation. diagnoses included pneumonitis and acute respiratory distress syndrome (ards). several cases of vaping-associated pulmonary injury (vapi) and acute respiratory distress syndrome (ards) in california were connected to vaping cannabis products that were traced back to pop-up retailers. patients have improved with systemic steroids. evaluation for infectious etiologies has been negative to date in all patients. all patients reported vaping in the weeks prior to hospital admission, and a reported common exposure among these patients is that they have been vaping cannabis or cbd oils. deaths a total of 68 deaths linked to vaping products have been confirmed as of 18 february 2020 among 27 states and the district of columbia. at least one death linked to a vaping product. at least two deaths linked to a vaping product. at least three deaths linked to a vaping product. at least four deaths linked to a vaping product. at least five deaths linked to a vaping product. hospitalizations but no confirmed deaths. as of 18 february 2020, there were a recorded number of 68 deaths. many of these deaths have been linked to illegal (black market) cannabis vaping products, which have been confirmed in 27 states and the district of columbia: alabama, california (4), connecticut, delaware, district of columbia, florida, georgia (3), illinois (5), indiana (4), kansas (2), louisiana, massachusetts (3), michigan, minnesota (3), mississippi, missouri (2), montana, nebraska, new jersey, new york (2), oregon (2), pennsylvania, rhode island, south carolina, tennessee (2), texas, utah, and virginia. the median age of deceased persons was 51 years, and ranged from 15 to 75 years, as of 14 january 2020. canada on 18 september 2019, a case of severe