Transcript of August 23, 2019, Telebriefing on Severe Pulmonary Disease Associated with Use of E-cigarettes

OPERATOR: Welcome and thank you for standing by. All participants are in listen-only mode until the question-and-answer session. At that time, please press star-one. Please unmute your phone and record your name at the prompt. I would like to inform all parties that today’s conference is being recorded.  If you have any objections you may disconnect at this time.  I’ll turn the call over to kathy harben, thank you you may begin.

KATHY HARBEN: Thank you, Denise.  And thank you everyone for joining us today for an update on the investigation of severe pulmonary disease among people who use e-cigarettes.  We’re joined today by cdc’s Ileana Arias, senior scientific advisor and acting deputy director for non-infectious diseases at CDC, she will provide an update on cdc support for the investigation.  We’re also joined by Dr. Jennifer Layden, l-a-y-d-e-n, she’s chief medical officer and state epidemiologist with the illinois department of public health.  We’re also joined by Mitch Zeller, he’s director of the Center for Tobacco Products at FDA.  During our q&a session we’ll be joined by Dr. Brian King with CDC’s Office on smoking and health and by Dr. Josh Schier,  who’s with the division of unintentional injury prevention.  I’ll turn the call over to Dr. Arias.

DR. ILEANA ARIAS: thank you all for joining us to learn about what cdc knows, what it doesn’t know about the current situation and what it is we’re doing to try to learn more. Before i do that, i would like to extend cdc’s condolences to the family and friends upon the death of the illinois resident who had pulmonary illness with the use of e-cigarettes. The cdc understands and are concerned about the severity of the illnesses that appear to be associated with e-cigarettes and vaping and we’re happy to fill you in on what it is we’re planning to do in response.  Cdc is currently providing consultations to state health departments about a cluster of pulmonary illnesses having to do with vaping or e-cigarette use.  Many states have alerted to possible but not confirmed cases, and investigation into these cases are ongoing.  In addition, fda is working with cdc and state health officials to gather information on any products or substances used and providing technical and laboratory assistance, fda encourages the public to submit detailed records of any unexpected tobacco or e-cigarette health or product issues to the fda via the online reporting portal.  While some cases appear to be similar and linked to e-cigarette product use, more information is needed to determine what is causing the illnesses.  A little bit about the latest information that we have.

As of 5:00 p.m. yesterday, August 22nd, there were 193 potential cases, but again not all are confirmed of severe lung illness associated with e-cigarette product use reported by 22 states (CA, CT, IL, IN, IA, MN, MI, NC, NJ, NM, NY, PA, TX, UT, WI and additional states pending verification).  These were reported between June 28th and August 20th of this year.  One death has been reported in Illinois.  Cdc and states have not identified the cause, but reported cases have reported e-cigarette product use or vaping.  Available evidence does not suggest that an infectious disease is a principle cause of the illness.  Investigators haven’t identified any product or compound linked to all of the cases.  In many cases patients report a gradual start of symptoms, including breathing difficulty, shortness of breath and/or hospitalization before the cases.  Some have reported gastro intestinal illnesses as well.  In many cases patients have reported use of THC-containing products while speaking to health care professionals in follow-up interviews by health department staff.  However, no specific product has been identified in all cases nor has any product been conclusively linked to the illnesses.

Even though cases appear similar, it isn’t clear if these cases have a common cause or if they are different diseases with similar presentations.  The state departments of health are investigating the possible cause of the illness by testing patient specimens and e-cigarette products as well.  Specifically, the wisconsin and illinois departments of health have asked cdc for assistance investigating the illnesses in their states.  The investigation is ongoing and more information will be shared as it is available.  Cdc has notified u.s. health care systems and clinicians about the illnesses and what to do — and what to watch for via a clinician outreach and communication outreach activity message.  For information about a specific state we ask you to contact that state’s health department.  For information on electronic cigarettes we ask you to visit our website, www.cdc.gov/e-cigarettes.

Now I’ll turn the call over to Dr. Jennifer Layden with the illinois department of public health.

DR. JENNIFER LAYDEN: We here at illinois department of public health offer our condolences to the friends and family in the recent death of an illinois resident. Illinois is reporting 22 cases of individuals hospitalized with severe unexplained respiratory systems after reported vaping or e-cigarette use. The illinois department of public health is working across the state to investigate 12 additional individuals.  Yesterday we received a report of the death of an adult who had been hospitalized with unexplained illness after reported vaping or e-cigarette use.  We’re working with the cdc, fda to investigate products and devices that individuals have reportedly used.  In addition to interviewing individuals we are also working to educate our residents through community and public health partners and using social media.  Thank you.

MITCH ZELLER: This is Mitch Zeller from the food and drug administration.  I want to thank cdc and the illinois department of public health for their partnership in this investigation and ability to gather on the phone today.  The fda is saddened and concerned by the reported death related to the investigation of respiratory illnesses following the use of vaping products.  Our agency is committed to continuing to work closely with cdc and state health officials working as quickly as possible to gather more information about all of these cases.  In particular fda will continue to provide technical and laboratory assistance to help identify any products or substances used in these cases.  Our department of emergency operations is coordinating our activities and the agency is participating in regular meetings with cdc and all state health officials.  We have received some product samples, and we’re analyzing those samples to see whether they contain nicotine, substances such as THC, or other chemicals or ingredients.

The results of the testing will be shared with states to aid in their ongoing investigation.  Fda is also working to investigate the brand and type of vaping products and devices and whether any of them are products that would fall within fda’s regulatory authority, as well as where they were obtained.  We don’t have any information to share at this time, however the agency will continue to communicate with the public about this issue.  Let me close by saying as we work to protect the public health, fda encourages the public to submit as detailed reports as possible of any tobacco or e-cigarette product or health issues to our online reporting portal, and it’s www.safetyreporting.hhs.gov..  Thank you very much.

HARBEN: Thank you to all of our speakers.  Denise, we’re now ready for questions.

The first question comes from mike stoby with associated press, your line is open.

STOBBE/AP: hi, thank you for taking my call.  May i ask, the person who died in illinois can you say if it was a male or female and what his or her age was or at least whether they were in their 20s or 30s and what day did they die and what was he or she vaping?  Could you say whether that person had a preexisting condition that made them more susceptible to something like that and of the 193, how many were vaping thc?  Thank you.

LAYDEN: this is dr. Layden from illinois.  The illinois resident we are not providing additional information to help protect the identity and confidential health information.  The individual was an adult. Of our cases in Illinois the range of ages have been from 17 to 38 with a median age of 23, and the majority of cases have been men.  At this time we don’t have additional information as to the product that has been smoked.

>> the next question comes from sarah overmire with politico.  Your line is open.

OWERMOHLE/Politico: thank you for taking my question.  I wanted to know if among the cases there was a sense of how often the person was vaping, if they were vaping a certain amount each day or if they were new users, and among those 193 cases if there were other trends aside from them being teens and young adults?

SCHIER: This is josh schier.  Right now states are leading their own specific epidemiologic investigations and we’re providing assistance as needed. We’re currently assisting right now at the state’s request.  Cdc is working on a system to collect, aggregate, and analyze data at the national level to better characterize this illness, right now we refer you to specific states for details on their own specific investigations.

>> next question, please.

>> that comes from — one moment.  That comes from lena sun, your line is open.

SUN/Washington Post: hi, thanks for taking the call.  I know that every state is doing its own investigation but since they are reporting to cdc, the basic details, surely since you know there are 193 cases, you could break it down to how many were vaping ingredients with thc, how many were straight nicotine cartridges, and i have another question, which is how much investigation is there looking into the vape juice and possible aerosolized lipid droplets going into the lung.

SCHIER: Thank you for your question.  The first question, i would emphasize we’re working rights now with states to collect, aggregate and analyze that data, this is all specific state data, state-owned data, so we are currently right now developing a system and planning for collecting and analyzing this data at the national level but we don’t have it.  We don’t have it right now.  As to the second question, I would probably ask the fda to comment.

ZELLER: Fda is beginning laboratory analysis based upon some of the samples that have been sent.  Droplets and lung deposition and pulmonary delivery would require additional different kinds of studies, some of which we have in the field just to better understand how e-cigarettes and electronic nicotine delivery systems perform.  But as regards to these particular cases, our laboratory analysis is first simply trying to identify what the compounds are that are present in this product that will be one piece of the puzzle.  Won’t necessarily answer any questions about causality but it’s a starting point and an important piece of the puzzle.

>> next question, please.

>> matthew vitis from “reuters,”  your line is open.

LAVIETES/Reuters: can you explain why there’s a sudden up surge of these cases?  Some of these products have been around for better part of a decade.  So can you just explain, does the cdc know why there’s this sudden up surge?  And — yeah, that should be it.

>> dr. King, are you able to answer that?

KING: this is brian king.  We do know that e-cigarettes do not emit a harmless aerosol. they can include a variety of potential harmful ingredients, including ingredients that are harmful in terms of pulmonary illness. That said it’s possible that the reported cases could have been occurring before this investigation was even initiated in an event that we weren’t necessarily capturing them, but now there’s increased diligence in terms of the current investigation that we’re better able to capture those.  That being said, the available science does suggest that the constituents in the aerosol could be problematic. We know there’s a variety of intended and unintended constituents in these products so as we continue with the investigation it’s important to keep all option opens and identify a variety of ingredients. At present we haven’t isolated a specific source but we know there’s a variety of constituents in e-cigarette aerosol that could be problematic in terms of illness.

>> next question, please.

>> michael nedelman cnn.

NEEDLEMAN/CNN: thank you, i was curious to know the 192 number, including illinois seem to be reporting sort of, you know, concern versus — 22 and then another dozen.  So just curious what that really means since you haven’t necessarily confirmed to be related to any e-cigarette in particular.  Is there something applied to what we think as quote/unquote cases that are tainted?

SCHIER: This is josh schier from cdc, it was hard to hear your question.  Is there a possibility you could repeat it but focus it better?  There was a lot of background noise.

NEEDLEMAN/CNN: I can definitely repeat that.  The cdc is reporting these numbers in aggregate, the 193 number, a number of state health departments, including illinois, are reporting some sort of, you know, confirmed under investigation, or something of that nature, they haven’t necessarily confirmed due to a certain substance in e-cigarettes.  These are all under investigation in a sense, i’m curious if there’s a standard being applied to these numbers when we’re counting them as a potential case versus under investigation?  How that language is being applied.

SCHIER: Thank you.  That’s an excellent question.  Right now as we mentioned states are leading their own systems of epidemiologic investigations, but the cdc is working with states to harmonize that.  And we’re working to help states harmonize again their investigation and collect data so hopefully we can look at it in a more standardized fashion. Those data collection tools will be going out this weekend.

>> next question, please.

>> allison aubrey from npr, your line is open.

AUBREY/NPR: thanks a question for dr. Layden of the cases in your state can you say how many are linked to people using — vaping thc, how many people using nicotine, and also just circling back to you dr. King, if i heard you correctly, what you’re saying is, it’s possible this could have been happening all along but we’re just now hearing about it, just now capturing it, it’s possible in the ten years since vaping has become a big thing that it may have been happening and you didn’t know about it?  I just wanted to know if you could reiterate that to make sure i understand it correctly.  You mentioned there were multiple constituents that could cause lung harm, if you could name one or two.  Those are my questions.

>> go ahead, dr. King.

DR. KING: yes. So there’s a variety of harmful ingredients identified, including things like ultrafine particulates, heavy metals like lead and cancer causing chemicals. And flavoring used in e-cigarettes to give it a buttery flavor.  Diacetyl and it’s been related to severe respiratory illness.  That being said we haven’t specifically linked any of those specific ingredients to the current cases but we know that e-cigarette aerosol is not harmless.  In some cases these could have occurred but now we’re monitoring in such a fashion that we are picking them up. But we have to continue with the investigation to determine if they are intended or unintended in these particular cases.  We note that a variety of individuals use a number of substances, including THC, particularly young adults so we continue to investigate that as well.  But the bottom line is there’s a variety of things in e-cigarette aerosol that could have implications for lung health.  A review recently identified a number of adverse health effects associated with e-cigarette use.  It’s possible some of these cases were already occurring but we were not picking them up but we continue to investigate.

DR. LAYDEN: At this point unfortunately we have not identified a specific product that is consistent across all cases. The consistent information is that all patients have vaped in recent months.

>> next question, please.

>> courtney norris from tbs news hour your line is open.

NORRIS/PBS Newshour: thank you for doing this call.  I’m looking for a little bit more clarity in where you all are at, if you can say anything more on the concerns of THC vaping as well as nicotine and if the patients in illinois have done both or one or the other, just again any more distinction from you experts is helpful.

ZELLER: this is mitch zeller, from fda, i’ll start.  I think it’s important for everybody to understand that as closely as the federal agencies and the state health departments have been working together, we find ourselves in the early stages of these investigations trying to piece together the facts.  As illinois said in their press release, many of these cases have involved the presence of compounds like THC, and we need to get to the bottom of every single case.  And at times we are reliant on case reporting that is incomplete, and requires time to gather basic information like the name of the product that was used, where it was purchased, and then how the product was used.  Was it used as intended or was some other compound added?  And those kind of facts need to be strung together for every single one of these cases so that we can see if there are any kind of patterns that emerge.  So please understand that we’re at a relatively early stage in this ongoing investigation but that state government and the federal government are throwing a lot of resources at this to try to answer your questions, which are all good questions.

>> next question, please.

>> that comes from kate sayer with the chicago tribune.  Your line is open.

SAYER/Chicago Tribune:  hi, i actually think maybe some of that was covered, my question was covered.  But one more thing, any thoughts to the — there’s been some — the results of like a black market, amateur made vapes and not necessarily the ones people buy, can you speak to that at all?

>> dr. Layden or dr. Schier?

>> go ahead, dr. Layden.

DR. LAYDEN: This is dr. Layden, i can only speak to the illinois investigation. We have had cases that have reported the use of THC product oils, we are actively investigating to try to identify where purchased, but reiterate the message from the fda that these investigations are very time intensive and we rely on the information we gather from the affected individuals.

>> and dr. Schier?

SCHIER:  i want to emphasize that again these are state-led investigations. CDC is actively working right now to develop a — to develop a way to collect, aggregate and analyze that data at the national level because we think it will potentially help identify the illness and ideologies to inform laboratory testing. At this time we don’t have any information or ability to comment on that.

>> next question, please.

>> that comes from joy benedict with cbs news your line is open.

BENEDICT/CBS: yes, a couple of quick questions.  One, i was wondering as somebody else said we seem to be seeing a lot of cases very, very quickly, like they’re multiplying, do we have any idea how long the patients have been using these products or what their dosage was, were they using a different dosage when they all of a sudden become affected?  And finally of the 192 other patients i guess that have survived, do we have any idea what their conditions are?  Is this something they’re going to recover from, or do you expect — hopefully there aren’t any more deadly cases like the one in illinois but is that a possibility?

>> dr. Schier are you still on the line?  Or dr. Layden speaking specifically for illinois?

DR. LAYDEN: . Here in illinois we have seen some cases recover, we have individuals who are continuing to need medical care and attention. As to the frequency and type of use, that’s information that we’re trying to gather to understand what the potential risks are in association with this illness.

>> thank you.  We have time now for just two more questions.

>> the next question comes from erika edwards with nbc news.  Your line is open.

EDWARDS/NBC: thank you.  I’m wondering if you have a list of those 22 states you mentioned, as well as the numbers of confirmed and potential cases in each state, thank you.

>> we’ll see what we can provide.

>> next question.  The final question.

>> the last question.  Yes.  The last question comes from bryant furlough with lancet, your line is open.

FURLOW/Lancet: thank you.  Previously we were told 15 states were reporting hospitalizations, i believe you said earlier 22, i wanted to make sure a list will be provided which states those are, and secondly, are you testing for pesticide residue in the thc vaping fluid? lastly i understand not one model was used by the patients but what about classes of vaping products?  Were voltage known and were patient ct and imaging consistent with pulmonary burns.

ZELLER: this is mitch zeller let me take part of that related to product usage.  And the questions that you asked would be all part of our product-specific inquiry starting with how is the product being used, was it being used as intended, was it being modified or altered in some way, how is the product purchased.  The specific question pesticides we will have to get back to you on, i don’t know if those are being tested for in our laboratories or not.

HARBEN: i’m not sure that we have anyone on the phone who can address the clinical level of questions that you asked of the last part of your questions.  I think we would need to follow-up offline on that one.

HARBEN:  Thank you.  I want to give a special thanks to all of our speakers for joining us on very short notice this afternoon.  Thank you all also to the media who have joined us, if you have follow-up questions you can call us at 440-639-3286 or email us at media@cdc.gov.  We’ll be working to get a transcript up later tonight.  There’ll also be an audio recording available on our website.  Thank you very much.

>> that does conclude today’s conference.  Thank you for participating.  You may disconnect at this time.  Speakers allow a moment of silence and stand by for your post conference.

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