Transcript of CDC Telebriefing: CDC Update on Pulmonary Illnesses

OPERATOR: Good morning, everyone.  Thanks for dialing in for today’s conference.  Please continue to stand by.  We’ll begin our conference momentarily.  Once again thanks for dialing in for today’s conference call.  Our conference will begin momentarily.

MODERATOR: Welcome everyone to today’s conference call.  At this time your lines have been placed on listen only for today’s conference until the question and answer portion are of our call at which time, you’ll be prompted to push star 1 on your touch tone phone.  Record your name and media affiliation.  To be introduced to ask your question.  Our conference is being recorded and if you have any objections you may disconnect at this time.  KD Hoskins.  You may proceed.

MODERATOR: Thank you for joining us on the update on investigation among people who use e-cigarettes or vape.  We’re joined today by Anne Schuchat, principal deputy director, CDC. Dr. Schuchat will provide us this week’s update on our support of the lung injury investigation.  We’re join today by Dr. Jennifer Layden, chief medical officer and state epidemiologist for the Illinois Department of Public Health. Also, Dr. Jon Meiman, chief medical officer with the Bureau of Environmental and Occupational Health for the Wisconsin Department of Health Services.  In addition, during our Q&A session Dr. Brian King who is our deputy incident manager for this response, and deputy director for research translation in CDC’s Office on Smoking and Health will join us to answer any additional questions that you may have.  I’ll now turn the call over to Dr. Schuchat.

Dr. Anne Schuchat: Thank you all for joining us for today’s briefing.  I want to provide a national update on lung injury associated with the use of e-cigarettes or vaping products, including the latest data on cases, death and a snap shot product use.  Much more detail will be provided on the experience of patients from my colleagues in Wisconsin and Illinois.  We are in the midst of a complex investigation that spans nearly all states, involving serious life threatening disease in young people who report use of wide variety of products and substance  in a dynamic marketplace for e-cigarettes or vaping products, which may have a mix of ingredients, complex packaging and supply chain, and includes potentially illicit substances in any given state.  Users do not know what is in their e-cigarette or e-liquid solution.  Moreover, many of the products and substances themselves can be modified by a supplier or user.  They can be obtained from brick-and-mortar stores, online retailers, on the street, or through social sources.  First, let me share the latest pictures.  As of September 24th, 805 confirmed and probable cases of lung injury associated with e-cigarette use or vaping were reported to us by 46 states and the U.S. Virgin Islands.  Sadly, 12 deaths have been confirmed in ten states.  More than two-thirds of patients are male, and the median age of cases is 23 years.  About 62% of patients were age 18 to 34 years, and 54% were under 25 years of age.  Two reports were released today.  One national and the other presenting data from Illinois and Wisconsin.  These reports suggest that THC containing products play a role in the recent cases.  On the national level out of 514 patients with exposure histories, we found 77% reported using THC containing products or using both THC containing products and nicotine containing products.  Information about substance use was self-reported by the 514 patients.  Of the patients that reported what products they used, THC containing products were the most prominent link across patients.  With only 16% reporting using only nicotine containing products.  We do not know at this time if the products linked with disease in Illinois and Wisconsin are also linked to cases in geographically remote parts of the country, and this is a key issue for further investigation.  We do not know yet what exactly is making people sick.  For example, whether solvents or adulterants are leading to lung injury or whether cases stem from a single supplier or multiple ones.  The illnesses we have been seeing are serious.  We are committed to share information as we learn more and update our guidance based on the latest data.  Based on the most recent reports, CDC recommends people consider refraining from use of e-cigarette or vaping products particularly those containing THC.  Because of the variety of chemicals that are present in e-cigarettes or vaping liquids and may be added to e-cigarettes or vaping liquid as well as the diversity of products in circulation, laboratory analysis may be complex, but these are ongoing.  We don’t want to see any more vaping related illnesses, and as such I want to stress that we at CDC are concerned about the occurrence of life-threatening illness in otherwise healthy young people reported from around the country.  I want to thank the clinicians and public health staff working hard to find answers and care for patients and their families.  And I now would like to invite Dr. Jon Meiman of Wisconsin to share key information that has emerged from the state investigation.

Dr. Jon Meiman: Thank you for the opportunity to speak today and discuss some of the findings in our articles being published.  As listeners may be aware Illinois and Wisconsin were at the forefront of this complex public health investigation.  We’ve been working very closely with clinicians, states, the CDC and other federal partners over the past two months.  The number of infected individuals continues to increase and sadly we’re seeing cases of severe lung injury in teenagers, young adults and other vulnerable groups.  So, it’s critical that state and federal public health agencies make every effort to determine the possible cause and prevent future cases.  As we outlined in our article today, Illinois and Wisconsin began conducting detailed interviews with patients with lung injury in July to better understand their use of e-cigarettes or vaping products.  Our main goals were to identify if one or more products or drugs were shared in common.  These interviews were conducted by both state and local health department staff and we obtained extensive information on these products using the three months before patients began experiencing symptoms.  We specifically focused on the type of drugs used, where they were obtained, names of specific brands and types of devices used.  It’s important to bear in mind these findings are based on self-report and may be limited by hesitancy to disclose information.  In total we interviewed 86 patients across both states.  Approximately two-thirds of patients were under 25 years of age and were predominantly male.  The illness among interviewed patients were severe with nearly 60% admitted to an intensive care unit.  We appreciate the willingness of these patients to work with public health about their use of e-cigarettes or vaping products and thank them for providing information that will hopefully help this investigation going forward.  I’ll hand this over to Dr. Jennifer Layden with Illinois Department of Public Health to discuss the findings in greater detail.

Dr. Jennifer Layden: Thank you Dr. Meiman.  I would like to reiterate the gratitude expressed by Dr. Meiman to patients and family members who have participated in these in-depth interviews.  Again, thank you to the clinicians, local health departments, and investigative teams who have tirelessly investigated these cases. We are grateful to the collaboration with our CDC colleagues and are committed to continuing our coordinated efforts on these investigations.  Similar to previous reports and national findings released today we continue to find most patients with vaping related lung injury report the use of THC based products with or without the use of nicotine-based products.  However there does remain a proportion of individuals who continue to report only using nicotine-based products.  Several new findings reported in this MMWR – we would like to highlight.  First, a large and diverse number of products and brands were reported by patients.  Among all 86 patients in our study, 234 unique e-cigarette or vaping products across 87 different brands were reported.  While no one brand was reported by all patients, pre-filled THC cartridges labelled under the brand name Dank Vapes was most common.  With 66% of all patients reporting this name. Second, despite not having consistency in product or brand names the vast majority of products used were pre-packaged, pre-filled cartridges.  Of all the THC base products that were used and reported to us, 96% were pre-packaged, pre-filled cartridges.  Patients did not report adding substances to their products.  Third, individual patients used numerous products and brands before becoming ill.  Patients who used THC based products on average used 2.1 different brands and patients who used nicotine-based products on average used 1.3 different brands with some reporting up to seven different THC products.  Majority of patients used products at least daily and often numerous time throughout the day.  Finally, THC products were most often acquired from informal sources such as on the street, from friends or from a dealer.  These findings do highlight predominant use of pre-packaged, pre-filled THC cartridges obtained through informal sources.  At this time, however, we can unfortunately not identify one product, brand, source or device that’s common across all patients.  Given the vast number and diversity of products and brands reported and without definitive lab testing results and continued uncertainty regarding the causative agents we in Illinois continue to recommend individuals to refrain from using e-cigarettes or vaping products particularly those that are THC based.  While this investigation is ongoing.  We encourage to you talk to your family, friends and children to ensure they are aware of the potential risks. Illinois and Wisconsin remain committed to this investigation in working with other key partners including the CDC in the efforts to identify the cause or causes of these severe lung injuries.  Thank you.

MODERATOR: Thank you to our speakers and now Jill we’re ready for our Q&A session.

OPERATOR: Thank you.  At this time, we would like to open up the lines for q and a.  If you would like to ask a question over the phone, please press star 1.  Record your names to be introduced and record your affiliation.  Please stand by for our first question.  Our first question is from Lena Sun from “the Washington post”.  Ma’am, your line is open.

Lena Sun, Washington Post: This is a question for Dr.  Layden.  Thank you very much for your information.  So, in the pre-filled THC cartridges that these kids said, these people said he they used what has the testing shown that was in them?  Were there specific adulterants and if so, did they include vitamin e acetate?

Dr. Jennifer Layden: At this time, we don’t know the substances found in products.  All products have been sent to the FDA for testing and those results are pending.

Lena Sun, Washington Post: I have a follow up question.  Did they say for the people who ordered the vape cartridges did they order them mostly online or get them mostly from friends or dealers?

Dr. Jennifer Layden:  The vast majority of patients received their products on the streets from friends or dealers.

MODERATOR: Next question, Jill.

OPERATOR: Our next question is from Mike with Associated Press.  Your line is open, sir.

Mike Stobbe, Associated Press: Thank you.  I had a couple of questions.  One is, it’s notable you all have been saying in previous weeks while this investigation is ongoing CDC recommend persons consider refraining from using e-cigarettes or vaping products and now the phrase added, particularly those containing THC.  You’ve added that this week.  I was wondering was it the information from Wisconsin and Illinois that prompted that change, that addition?  You mind saying what in the investigation is helping you narrow in and then I have a follow up question.

Dr. Anne Schuchat: Thanks, Mike.  This is Anne, responding.  The Illinois and Wisconsin data were very compelling, and the national snapshot, while less detailed than Illinois and Wisconsin provide a consistent set of information.  The CDC is committed to follow the evidence and update the information when we have more evidence, and the outbreak currently is pointing to a greater concern around THC containing products.  However, we do not know whether the only risky substance for lung injury is the THC containing products and we didn’t feel comfortable dropping the broader recommendation yet.  Certainly, the information that our colleagues in Illinois and Wisconsin have reported paints a compelling picture.

Mike Stobbe, Associated Press:  Okay.  Can I also ask, looking at the report, one of the reports provides an iffy curve.  What’s the explanation for it?  It looks like there was more of an increase in July and August and then is there a decrease lately?  What’s going on?  Is this subsiding?  What do you think is going on?  Thank you.

Dr. Anne Schuchat: Thanks.  I do not think that we can say a decrease is going on yet.  The last few weeks of the curve may reflect a delay in reporting.  It may reflect a delay in recognition of the condition on the part of clinicians, a delay in that information getting to the health department classification based on the record review and then reporting it to us and into the national picture.  So I think that I’m concerned that there are new cases every week with onset recently and that as the lag is caught up, we may see a continued brisk case — a brisk new cases and that’s one of the main reasons we want to warn the public that at this point, if you’re concerned about this very, very serious disease, consider refraining from vaping or using e-cigarette products especially those containing THC.

MODERATOR: Next question, Jill.

OPERATOR: Thank you.  Our next question from Angelica LaVito with CNBC.  Your line is open, ma’am.

Angelica LaVito CNBC:  Thank you for taking my question.  I also noticed the addition of particularly avoiding THC products and I wanted to ask if it’s fair to say at this point the CDC is now narrowing its investigation to THC containing vaping products?

Dr. Anne Schuchat: No, we are not narrowing the investigation.  There remain many questions.  We do not know even for the THC containing products that seem to be closely linked with cases in Illinois and Wisconsin – what the substance is within the products that’s causing harm.  We don’t know if .. we have many questions about the supply chain and the integrity of these products.  So, I think that we need to have an open mind and under a lot more about the supply chain as well as about the contents of various products that are used within e-cigarettes or vaping to understand which of many toxins might be leading to this type of lung injury.  You know, to have over 800 cases in this short period of time, many leading to intensive care unit hospitalizations and potentially longer-term lung damage, we really need to understand how many different kinds of products could be risky and how to stop their distribution.

Angelica LaVito CNBC:  What exactly is the CDC doing to understand the supply chain?  I know FDA has that criminal investigation, but how is CDC interacting with that?

Dr. Anne Schuchat:  Right.  This is Dr. Schuchat again.  The states are working closely with FDA and DEA and CDC is working closely as well.  The information about products is being, as well as products that exist are being provided for laboratory testing at FDA’s forensic laboratory, supply chain traced back would to be done either through FDA or DEA depending and CDC is basically in very close communication with our partners across government.  This may be more complicated than we think in terms of more than one product being risky, more than one label on the product and more than one substance within the product.  So, I think we have to have a very open mind and recognize how dynamic this marketplace is right now and really want consumers recognize it’s a difficult time and we want families talk to their kids and people trying to get these products understand the potential risks.

MODERATOR: Next question, please?

OPERATOR: Thank you.  Our next question from Allison Aubrey with NPR News.

Allison Aubrey, NPR News:  I’ve got two questions.  Wondering if you’ve found any commonality among the 12 deaths, those that have died.  Did they use THC only or a particular brand?  Second question is have you been testing your samples for hydrogen cyanide?

Dr. Anne Schuchat:  The information about commonality among the deaths we don’t have yet.  As we hear more deaths the age range that seems to occur seems to be broader, but we don’t have big enough numbers or detail yet on those patients to share.  The testing that FDA or forensic laboratory DEA is doing I believe, is broad and I don’t have information on the cyanide question but approach to testing is being designed based on use of scarce product, whatever product remains from those patients as well as testing other products that aren’t associated with patients.  So I don’t have results on a particular adulterant.  But I know there’s been testing done by the private-sector as well.

Allison Aubrey, NPR News:  When you said that the results are pending, do you know how many results — of the samples you have, how many are completed, how many are pending.  It does seem like it’s taking a while.

Dr. Anne Schuchat:  Yes.  Thank you.  I don’t have the information but one thing I can say is that as Dr. Layden described, there were a number of products even from one individual and so making their way through the different products and linking them to cases is taking some time.  In the beginning of this analysis you have scarce samples.  Our testing for substances and design a strategic testing plan and so I wish I had results that were compelling, but I think a message that I would have for the public, they are making more than one thing of risk within some of these products, and we need to follow the data to their conclusion.  At this time, we do not believe that consumers can tell what’s in the product and there’s not sufficient information on labels to know anyway.

Allison Aubrey, NPR News:  Thank you.

MODERATOR: Next question, Jill.

OPERATOR: Thank you, ma’am.  Our next question is from Mary with the Milwaukee Journal Sentinel paper.  Ma’am, your line is open.

Mary Spicuzza, Milwaukee Journal Sentinel:  Hi, thanks for taking my questions.  Two questions.  One is can one of you address the role that children’s hospital of Wisconsin played in uncovering this outbreak?  And the other is confirming it was the Illinois and Wisconsin cases combined where it was 66% involving pre-filled Dank Vapes.

Dr. Jon Meiman: This is Jon with the Wisconsin Department of Health Services.  Children’s hospital of Wisconsin and Milwaukee was integral to alerting us.  They had seen a small number of cases very early on back in early July over the previous few weeks where they really weren’t able — they thought unusual cases of this lung injury weren’t able to pin it on any specific cause so they reached out to us at which point we launched our investigation to look into this further.  But they were the ones that first brought to it our attention and really helped to get the whole public health investigation launched.

MODERATOR: Next question, Jill?

OPERATOR: Thank you, ma’am.  Our next is from Courtney Norris with the PBS News Hour.  Miss Norris your line is open.

Courtney Norris, PBS News Hour: I’m curious two quick questions in one.  Of the 514, is that number about people who self-reported substance use and two, with the 12 deaths, you know, that’s news.  I’m curious when you say intensive care do you expect more?

Dr. Anne Schuchat:  This is Dr. Schuchat.  The information out of the 514 patients about product use was self-reported.  I didn’t quite catch the second question, I think it was about intensive care is that what you were asking about?

Courtney Norris, PBS News Hour: Yes, just in terms of deaths we know 12 deaths across ten states.  We haven’t seen an uptick there in a few days but I’m curious about the condition when you say they are put into intensive care or requiring intensive care, sort of if that, you know, what that means, how serious that is, if you could elaborate on that.

Dr. Anne Schuchat:  Yes.  I think, again, this is Dr. Schuchat again:  I believe that Dr. Meiman described some of the results from the Illinois-Wisconsin investigation where they had more detailed information about the seriousness.  They found overall 59% or 42 out of 71 patients with the conditions were admitted to intensive care unit.  What that means is a person really has a life-threatening illness.  They may require being hooked up to a breathing machine to help them breathe or other supported measures.  It is too soon for us to say how well these individuals will do long term after discharges whether they will continue to have some difficulty breathing or weakened lungs that may not recover fully.  We’re in the early days but we know some people have been gravely ill.  In term of the deaths, we do know that other states continue to investigate patients to try to understand whether a recent death may have been due to this condition, and one of our messages for clinicians right now is when caring for people with respiratory illness to please remember to ask about smoking but about e-cigarette or vaping use, that’s not necessarily something clinicians typically ask about but in light of these severe patients presentations we think that type of information is very important to gather.

Courtney Norris, PBS News Hour: Thank you.

MODERATOR:  Next question, Jill?

OPERATOR: Thank you, ma’am.  Our next question is from Erika Edwards with NBC News.

Erika Edwards, NBC News: I was merely going to ask about the deaths as well.  You pretty much addressed it. Were they generally older adults?  Did they have any underlying conditions, anything else linking those cases?

Dr. Anne Schuchat:  I think it’s too early for us to say whether there will be significant differences.  But I think the preliminary assessment is they may be somewhat older.  But the range of ages is expanding right now.  So, I don’t think we can say with confidence that a young healthy person is immune from the risk of death from this condition.  We know that the x-rays and the lung function may be very, very damaged by the insult of the products.

MODERATOR: Jill, we can take one last question.

OPERATOR: Thank you.  Our last question will come from Mary Kekatos with Dailymail.com.  Your line is open.

Mary Kekatos, Dailymail.com: Hi.  Thank you for taking my question.  I also wanted to ask about the death toll.  In this meeting we heard that the death toll was at 12, however there have been some news reports that have put it at 13 and specifically coming from North Carolina.  Have this been confirmed yet by the CDC or is this going to be investigated at a later date?

Dr. Anne Schuchat:  We let the states. This is Dr. Schuchat again:  States do the initial investigation and classification and typically report publicly once they’ve confirmed that.  When they report to us, we’re updating our death numbers once a week.  Sadly, I do believe there will be additional ones.  You know this is a very serious threat right now to young people across the country and we don’t want there to be more death but that’s why our message is so critical.  A lot of this investigation is ongoing.  We do recommend people concerned about this disease consider not using e-cigarettes or vaping products especially ones containing THC.  So, thank you.  I believe that was the last question.  I really want to, again, thank Dr. Meiman and Dr. Layden for their teams’ incredible work and leadership and thank you all for covering this story.

MODERATOR: Thank you all for joining our call today and that concludes the telebriefing.  If reporters have additional questions, they can call the CDC at 404-639-3286 or email us.  Thank you.

OPERATOR: That does conclude today’s conference call.  We thank you all for participating.  You may disconnect and have a great rest of your day.

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