Transcript of CDC Telebriefing: Update on Lung Injury Associated with E-cigarette Product Use, or Vaping

Operator: Welcome and thank you all for standing by.  All participants will be on the listen-only mode until the question and answer session of today’s call.  At that time you can press star 1 to ask a question from the phone lines.  I’d also like to inform parties that the call is being recorded.  If you have any objections, you may disconnect at this time, and I would now like to turn your call over to moderator KD Hoskins.

Moderator:  Thank you for all of you for joining us for an update on the update lung injury among people who use e-cigarettes or vape.  We are joined today by CDC Dr. Anne Schuchat, principal deputy director, who will provide an update on our support of the investigation.  We are also joined today by Mitch Zeller, who is director of the FDA center for tobacco products, and also Dr. Jennifer Layden, chief medical officer and state epidemiologist for the Illinois department of public health.  In addition, during our Q&A session today, Dr. Ileana Arias, PhD., senior scientific advisor and acting deputy director for non-infectious diseases at CDC, along with Dr. Brian King, who is the chief science officer for the response, and deputy director for research translation in office of smoking and health.  I’ll now turn the call over to Dr. Schuchat.

Dr. Schuchat: Thanks so much.  Thank you, all for joining us today for this briefing.  I’d like to update you on the national public health investigation and CDC’s efforts so far.  I want to stress that we at CDC are very concerned about the occurrence of life-threatening illness in otherwise healthy young people reported from around the country.  We’re working closely with state and local health departments, FDA, and the clinical community to learn as much as we can to try to stop this outbreak.  And I wish we had more answers.  We plan to update our national numbers on cases every Thursday but realize this is a very dynamic investigation and we are committed to sharing new key information as it emerges.  As of September 17th, 530 confirmed and probable cases of lung injury associated with e-cigarette product use, or vaping, were reported to us by 38 states and one territory.  Sadly, seven deaths have been confirmed in and reported to us from six states, California, Illinois, Indiana, Kansas, Minnesota, and Oregon.  And we do expect others.  As you know, this past Monday, September 16th, CDC activated our emergency operations center.  We did this to enhance the inter-agents response and strengthen coordination of this multistate outbreak of cases of lung injury associated with e-cigarette product use, or vaping.  This is a complex investigation.  It spans many states, involves hundreds of cases, and a wide variety of substances and products.  States are classifying cases and reporting them to CDC on a regular basis.  CDC is working 24/7 with the states to try to find on answers.  I’d like to stress how challenging this situation is, as patients may have been exposed to a variety of products and substances, may not know the contents or sources of these products, and in some instances may be reluctant or too ill to fully disclose all the details of interest.  CDC has made it a priority to find out what is causing this outbreak of vaping-related injuries and deaths.  As such, we have been working with states and the FDA to collect information about recent e-cigarette product use among patients and to test the substances or chemicals within vaping products used by the patients.  And you will hear more about that from Mitch Zeller at the FDA.  Although the investigation continues, no consistent e-cigarette or vaping product, substance, additive, or brand has been identified in all cases, nor has any one product or substance been conclusively linked to lung injury in patients.  Based on available data to date, nearly three-quarters of the cases are male.  Two-thirds of the cases are in people between the ages of 18 and 34 years.  16% are younger than 18 years of age and 17% are 35 years or older.  In all, based on what we have to date, more than half of the cases are under 25 years of age.  Patients typically report symptoms such as cough, shortness of breath, or chest pain.  Some also describe nausea, vomiting, or diarrhea, fatigue, fever, or abdominal pain.  As I said, we have not identified the cause of the lung injury in this outbreak.  And note that many patients have described use of multiple types of products.  Initial published data from select states show most patients have reported a history of using e-cigarette products containing THC.  Many patients have reported using products containing THC and products containing nicotine.  And some have reported the use of e-cigarette products containing only nicotine.  CDC is still working to understand more about the exposures of these patients and if this trend is reflected in the full National picture of cases in addition to the earlier reports.  Clearly more information is needed to better understand whether there’s a relationship between any specific products product or substance and the reported lung injuries and deaths.  Until we know more, if you are concerned about these specific health risks, CDC recommend that you consider not using e-cigarette or vaping products.  If you have recently used an e-cigarette or vaping product and you have symptoms like those reported in this outbreak, we recommend you see a health care provider as soon as possible.  Anyone who uses an e-cigarette or vaping product should not use or buy these products off the street and should not modify or add any substances to these products.  Regardless of this investigation, certain people should not use e-cigarettes or vaping products.  In particular, youth and young adults, women who are pregnant, and adults who do not currently use tobacco products.  If you are an adult who is using e-cigarettes containing nicotine to quit cigarette smoking, do not return to smoking cigarettes.  Contact your health care provider to discuss the range of evidence-based treatments, including counseling and FDA-approved medications.  The e-cigarette or vaping-related lung injuries we have been describing are serious.  People are dying.  And CDC wants to protect Americans to keep you healthy and safe.  We ask you to take these recommendations seriously.  Now i would like to invite Mitch Zeller to share more information about FDA’s work so far.

Mitch Zeller: Thanks so much, Dr. Schuchat, for those important updates and for the continued strong collaboration between the Centers for Disease Control and Prevention, FDA and our state health partners.  FDA continues to work closely with those partners at the federal and state level and as quickly as possible to gather more information about these distressing incidents.  In particular, we’re keenly focused on better understanding whether there is a relationship between any specific products or substances and the reported illnesses.  As previously noted, there does not currently appear to be one product or one substance involved in all of the cases.  For example, in many cases, but not all, patients have acknowledged recent use of products containing THC.  Some reported the use of e-cigarettes containing nicotine.  Where both THC products and nicotine products.  That’s why our work includes collecting critical details about the products or substances involved, where they were purchased and how they were had he being used.  Today, I’d like to provide you a snapshot of FDA’s work to help gather as much information as possible about these cases.  First in recent, the office of emergency operations activated an Incident Management Group, IMG.  This group serves as the agency’s focal point for emergency management and staffed by experts from across the agency.  This group also coordinates information gathering and sharing within the agency and between FDA, CDC, and the states.  Second, FDA has now collected more than 150 vaping product samples from a number of states for analysis in our forensic chemistry center.  And that number of samples continues to grow.  FDA is analyzing these samples for the presence of a broad range of chemicals, including nicotine, THC and other cannabinoids, along with opioids, cutting agents or dilutants and other additives, pesticides, poisons and toxins.  Please note identifying any compounds present in the samples is but one piece of the puzzle and will not necessarily answer questions about causality, and that remains the focus of our ongoing work.  We are leaving no stone unturned in following all potential leads regarding any particular product, constituent or compound that may be at issue.  In that spirit, FDA’s Office of Criminal Investigations, or OCI, which is FDA’s law enforcement arm, began parallel investigative efforts shortly after the emergence of the associated illnesses.  OCI has special investigative skills, and the focus of their work is to identify what is making people sick, as well as a focus on the supply chain.  Let me be clear, OCI is not pursuing any prosecutions associated with personal use of any controlled substances in these cases.  Lastly, we understand everyone’s interest in the specifics of FDA’s investigation, and we are committed to providing updates to the public without unintentionally compromising this ongoing active investigation.  With that in mind, FDA has set up a landing page on our website at FDA.gov to provide public information about our work, as well as resources for consumers, health care providers, and state health departments.  Finally, FDA continues to encourage the public to submit detailed reports of any unexpected tobacco or e-cigarette related health or product issues via FDA’s online safety reporting portal and the Url is www.safetyreporting.hhs.gov.  Getting to the bottom of these respiratory illnesses is top priority for all federal and state agencies involved and we are committed to taking appropriate actions as the facts emerge.  Thank you all for your time and I will now turn the call over to Dr. Layden.

Dr. Jennifer Layden:  Thank you, Mitch.  I want to start off by thanking our federal partners, the CDC and the FDA, in their leadership for the coordination of this multistate outbreak.  Here in Illinois I want to thank the Illinois department of public health director Dr. Ezike to allow us to conduct this investigation, as well as a staff who have worked so hard on this investigation, along with the local health departments and clinicians who have been essential partners in this team effort to identify cases and provide meaningful data to help us identify the cause or causes of these serious illness.  This investigation continues to be a top priority for our state.  As of today, Illinois is reporting 69 cases, which unfortunately includes one individual who has died.  This is up from 52 cases that we reported last week, and we continue to get new reports of cases daily.  This is an extremely complex and novel investigation.  The patients are quite ill, and case patients are using numerous products and devices prior to becoming ill.  No one product or type of products have been definitively linked with these illnesses.  Adding to the difficulty is that some individuals are unable to talk with public health professionals because of the severity of their illness or there’s hesitancy about sharing information about the products they have used, especially if they are illicit products.  This investigation requires an all-hands-on-deck approach.  This is a complicated investigation, and data from states across the country are critical to helping us identify the potential causative substances.  In Illinois, and here at IDPH, we continue to use all our available resources to continue with this investigation.  To help us identify potential sources, we are asking Illinois residents who have recently vaped to fill out an anonymous online survey about their vaping habits.  Identifying differences among people who vape and have become ill and those who have not may help us to advance this investigation.  And to facilitate reporting to health departments, we have simplified the reporting form for clinicians and hospitals and we ask them to continue their efforts to report suspect cases to public health.  This partnership between clinicians and public health has and will continue to be critically important.  And i would like to end, again, by thanking public health officials at all levels and clinicians to for working so hard to identify cases and report to this investigation.  Thank you.

Moderator: And now, Sarah, we’re ready to take questions.

Operator: Thank you.  At this time if you would like to ask a question, please ask star 1.  You will be prompted to unmute your phone and provide your name.  To withdraw your request, press star 2.  One moment, please, for the questions to queue up.  The first question from Helen Branswell with STAT.  Your line is open.

Helen Branswell, STAT: Hi.  Thanks for taking my question.  I was hoping I could ask a couple, please.  This is a fairly big jump in numbers.  And I’m wondering if you think that’s because now people are retrospectively going back and finding case, or do you think some of this is happening in real-time?  And my second question is for Mitch Zeller from FDA.  You mentioned the criminal — the Office of Criminal Investigations becoming involved.  Can you tell us more about what triggers their involvement in something like this?  It seems to imply that somebody thinks something illicit may have been happening?

Dr. Schuchat: Thank you, Helen.  Let me begin, and then we will turn it over to the FDA.  The states continue to get new cases reported in addition to catching up from prior cases.  I think this is an ongoing outbreak and not something that we can consider completed.  Some of the additional cases that are in the numbers this week are of course from several weeks ago.  But there continue to be people with new symptom onset.  That is why we are so keen to get the word out to people.  If you do have concerns about your health risk, please consider from refraining using e-cigarettes or vaping products at this time.  Mitch, would you like to answer the second question?

Mitch Zeller: Sure.  And thanks for the question about our Office of Criminal Investigations.  In cases like this, we typically turn to OCI, as I said in my remarks, because they have special investigative skills, and there are leads to track down.  I want to reiterate that, yes, they are the law enforcement arm of the FDA, but they are not pursuing any leads for personal use of any of these substances.  These are trained and skilled investigators.  And what you’re hearing from CDC, FDA and the states is we are in desperate need of facts and answers to questions.  And the trained investigators in our office of criminal investigations typically get involved in cases like this.  They have been involved from the beginning because they have unique skills that will help us all get answers to the questions that we’re desperately seeking.  Thank you.

Moderator: Next question, Sarah.

Operator: Our next question comes from Matt Richtel with New York Times.  Your line is open.

Matt Richtel, New York Times: Guys, thanks for taking my question.  Mitch, my first question is for you, and I’m wondering, given that many of the cases you’ve confirmed appear to be associated with THC in some way.  Have you considered any enforcement action such as either making it just flatly illegal to sell THC vaping devices or liquid, or those with certain additives which seems to be under your purview under multiple federal law?  And, Mitch, is there a reason you have not provided more concrete numbers of percentages given the enormous concern from consumers and industry about the correct behavior to pursue?

Mitch Zeller: Well, this is Mitch.  I’ll start with your first question, Matt.  At this stage in this ongoing investigation, with all of the levels and the layers of complexity that you have heard us all describe, and at this point an ongoing investigation that has way more questions than answers, it’s really premature for me as a regularity to talk about any possible actions or regulatory authorities that could be called into play until we get more answers to these questions and have a better sense of cause and effect for either licit or illicit products.  In general, though, when it comes to the enforcement side, there are certain enforcement tools and authorities that could come into play but only down the road and only after we have a much stronger sense of what the causative factors are when it comes to products and substances.  And when we have those more definitive answers, then we will be in a better position to answer what is a very fair question, which is how could you possibly use any of your authorities, including enforcement authorities down the road?  When we’re in a position to better answer that question, we will.

Dr. Schuchat:  Yeah, thanks.  And let me answer the question about providing more detail about exposures.  We absolutely want to do that.  We are gathering the data from the states.  As you can imagine, it takes a bit more time to get the details of exposures.  And as i mentioned, many people have been exposed to multiple products.  We don’t want to prematurely reassure people that anything in particular in case it were to turn out to have been quite risky.  You know, that has happened before in some outbreaks where we said a certain kind of food and it turned out to be a different kind of food.  In this one, CDC hopes to be able to share more details about the exposures that people reported in the near future.

Matt Richtel, New York Times: Sorry.  Who was speaking there?

Dr. Anne Schuchat: Sorry.  That was Anne Schuchat.

Matt Richtel, New York Times: Thanks.  Okay.  Thanks, guys.

Moderator: Next question, Sarah.

Operator: Our next question is from Evan Brown from Fox News.  Your line is open.

Evan Brown, Fox News: Thank you very much for doing the call.  I think my question might echo one that was previously answered.  But I’ll try anyway.  Is there a belief or what belief do you have that these products may be tampered with in any way?  Vaping has been around for quite a while.  But it just seems like more recently people are getting sick.  Is that — with the involvement of the office of criminal investigations at FDA, is there a belief that something has just gone wrong, or is that no one has really ever looked into this before?

Mitch Zeller: This is Mitch.  I’ll start.  And then defer to colleagues at CDC and Dr. Layden as well if she has perspective from the state level.  I think what you’ve heard from all of us on each of the calls that we have done is that there is no consistent pattern when it comes to what product is being used, practice products, plural, are being used, how they are being used, where they might have been purchased, and/or what might have happened to the products along the way from the time that they were put into the hands of the end user to the moment of aerosolization and inhalation.  There are multiple ways in which multiple different products have been used.  But it’s why part of the advice that you’re hearing from the agencies is be very careful about buying products like this, especially the THC-laced products, off the street.  A number of these cases involve THC.  And in a jurisdiction where the only way that someone can get their hands on a product like that is literally buying it in an alley or on the street, we’re telling you to be very, very careful about doing that because we are all alarmed by the reports involving THC-containing products even if we don’t have THC present in each and every one of the cases that have presented themselves in the dozens of states that have reported illnesses.  And it goes back to the nature of this ongoing investigation.  We need to see what common threads emerge as we do the product analysis.  As the interviews with the patients continue, and as agencies at the federal and state level put their heads together and try to see what is the primary cause and what might the other causes might be.  And we do these calls with you, not because we have brand-new answers to the most important questions, but because we want to update you on where things stand.  CDC giving their latest numbers, our role in an ongoing investigation.  Because it’s important for you all to be able to accurately communicate to the public what’s known and just as importantly, what remains unknown and uncertain.  And I’ll turn it over to CDC and the state at this point.

Dr. Jennifer Layden: Yeah.  Just quickly, I would say that we don’t know if there’s a single exposure that’s the problem or multiple.  So I think the variety of hypotheses are being considered.  At this point it’s a national outbreak, and there may be problematic source material or modifications that are occurring in different places.  So we really need to use caution at this time in terms of our consumer recommendations and have an open mind in terms of the investigation.  Next question, operator?

Operator: Our next question comes from Mike Stobbe with Associated Press.  Your line is open.

Mike Stobbe, Associated Press:  Hi.  Thank you for taking my questions.  If I could ask one for Dr.  Schuchat and one for Mr. Zeller and one for Dr. Layden.  Dr. Schuchat, you gave us demographics, age profiles and a certain percentage are men.  Are the demographics of the cases similar to the demographics of vapors in general?  Is it mostly men, most live those age groups, or is it different in some way?  Mr. Zeller, could you say a little more generally about what the OCI is doing?  Are they interviewing patients?  Are they going to certain types of companies and interviewing or asking for records?  Dr. Layden, you mentioned sometime that one of the challenges is that individuals may be reluctant to talk.  Can you quantify of the 69 cases, how many of those were you unable to get information because the person got sick won’t answer that question.  Thank you.

Dr. Anne Schuchat: Mike, let me take — this is Dr. Schuchat.  Let me take your first question.  The demographics of e-cigarette users and the demographics of people who vape other products may not be identical in terms of nicotine versus THC or other things.  And we have a higher proportion of male in the preliminary data than you see among e-cigarette users where it’s a little closer.  Males have a — are more likely to use e-cigarettes than female in all ages.  It is not as big a discrepancy as the three-fourths we are seeing here.  I want to caution you that the data numbers continue to come in and the numbers are fluid.  I’ll let Mitch do the next question.

Mitch Zeller: I certainly understand the interest in more details.  But we’re trying to balance the need to be transparent with an appropriate position for a regulatory agency with the law enforcement arm to take.  And that is to not discuss the specifics of any ongoing criminal investigation.  We’re using all available resources, and that includes our criminal investigators because of the special skills that they have to first and foremost try to identify as quickly as possible what is making these people sick.  And it’s — it’s just using the investigative skills and training that our OCI investigators have.  Apologies that I can’t go into any more detail than that.

Dr. Jennifer Layden: Okay.  This is Jen Layden from Illinois.  To answer the specific question you asked, I don’t think i can give you an exact percent.  What i can see is with time, as the investigation as evolved, we are having more success in conducting interviews with patients.  Sometimes it requires numerous calls to get a hold of a patient.  And complicating that is they are had he very sick.  They have been sick for several days, two weeks by the time we talk to them.  So, the recall of what they have used, factoring in they have used numerous products, numerous times throughout the day, it is difficult to identify and recall all the products.  But overall, I would say that we have seen reluctance.  But with time, and as the investigation continues, there is more willingness for patients to provide information.

Moderator: Thank you.  Sarah, next question.

Operator: Our next question comes from Lena Sun with Washington Post.  Your line is open.

Lena Sun, Washington Post:  Thank you.  I have a question for Mitch and a question for Dr. Layden.  Mitch, you said that you have now over 150 samples.  I think the last one was 120 samples.  What else have you found in those samples?  Initially you mentioned there was vitamin e acetate.  Is that continuing to be found, or are you finding other possible clues?  And for Dr. Layden, in the Illinois survey that you’re doing, can you talk — explain a little bit more about how you are reaching people and what you are asking them to do and has that started and what are the results you’re seeing.

Mitch Zeller: Well, thanks for the question, Lena.  I’ll go first and then turn it over to Dr. Layden.  There’s not much more i can add to what was previously said on this.  Yes, we are seeing vitamin e acetate in some of the samples.  But our laboratory analysis continues to show a mix of results.  And there’s no one compound, ingredient, constituent, including vitamin e acetate showing up in all the samples tested.  And I’ll just have to leave it at that more general level.

Lena, Sun, Washington Post: You said that before, there was vitamin e as state samples.  Are you seeing more vitamin e acetate now that you are seeing more samples?

Mitch Zeller: I can’t answer that question.

Dr. Jennifer Layden: Hi.  Jen Layden from Illinois.  With regard to our survey, what we are trying to have had is gather more information from people who may also vape but may have not been ill with the goal to compare habits which may help us advance the investigation.  We are using social media efforts to try to reach Illinois residents who are using such products.

Lena, Sun, Washington Post:  Well, are you concerned if they are — if people who have gone sick are reluctant to talk to you because they are worried maybe they will get arrested for using, you know, illicit substances?  Are you concerned that you’re going to get people to take you up on this other offer to let you know what they have been vaping?

Dr. Jennifer Layden: It is certainly possible.  It is an anonymous survey.  We are not collecting any patient identifiers in the hopes that individuals will want to help advance this investigation.

Lena, Sun, Washington Post: Thank you.

Moderator: Next question, Sarah.

Operator: Our next question comes from Kathleen Doney with WebMD.  your line is open.

Kathleen Doney, WebMD:  You can’t say what substance to stay away from.  Is there an expected timeline for that information to become available or evident?

Dr. Anne Schuchat: Thank you.  This is Dr. Schuchat again.  I know that this is very frustrating for the public and the media.  It’s very frustrating for us.  This is a complex investigation.  And i don’t think that we should expect definitive answers imminently.  This may take some time.  That said, the state and local public health, CDC, FDA are working around the clock to get as much information and as many answers as we can soon.  This may turn into finding multiple issues that are of concern rather than a single product or substance.  And so we ask for your patience.  In the meantime, if you are concerned about these health risks, we recommend up consider refraining from using e-cigarettes or vaping products.  Thank you for joining us and thank you for participating in the call.  I believe that was the last question.

Moderator: and if any reporters have follow-up questions, you can call us at 404-639-3286 or email us at media@CDC.gov.  This concludes our call.

Operator: Thank you.  Once again, that does conclude today’s coverages.  Thank you all for participating.  You may disconnect your lines at this time.

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