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New Case of Vaping-Associated Pulmonary Injury Reported in Long Beach

KEY MESSAGES
  • As of November 4, 2019, there have been three total cases of serious vaping-associated pulmonary injury (VAPI) in Long Beach residents. No deaths have been reported.
  • All three cases reported vaping with THC products prior to becoming ill.
  • Providers are reminded to report cases of severe respiratory illness among patients who recently used vaping products by calling the Long Beach Department of Health and Human Services at 562.570.4302 during regular business hours.
  • Statewide, cases continue. Since October 29, 2019, there have been 144 cases and three deaths reported in California, and 1,888 cases reported nationwide. 
SITUATION
As of November 5, 2019, there have been 150 cases of VAPI, also known as e-cigarette, or vaping product use associated lung injury (EVALI), reported in California, including three cases in Long Beach. There have been no deaths reported in Long Beach thus far. Nationwide, over 1,800 cases have been reported in 49 states, including 37 deaths. 

The California Department of Public Health (CDPH) is updating their VAPI Weekly Public Report regularly, and the Centers for Disease Control and Prevention is updating their outbreak page weekly as well.

All patients have reported use of e-cigarette products, or vaping, prior to illness, and the most recent data show that THC products, particularly those obtained from informal sources such as friends, family, or illicit dealers, play a major role in this outbreak. 

There has not been a single identified cause of the lung injury other than the common use of e-cigarette, or vaping products. CDC and the Food and Drug Administration (FDA) continue to investigate. 
CLINICAL PRESENTATION
Primary Clinical Presentations and Findings
  • Cough
  • Pleuritic chest pain
  • Shortness of breath
  • Fever
  • Headache
  • Fatigue
  • Nausea
  • Diarrhea
  • Anorexia
  • Weight Loss
In general, the majority of patients are under 30 years of age and in otherwise good health. In many cases, the initial diagnosis was presumed to be infectious, but no evidence of infection or other process to explain the pulmonary disease was found. Symptom onset has ranged from days to weeks prior to presentation to a health care provider, and all patients reported use of various vape products. Many patients were seen in an outpatient setting one or more times prior to hospitalization. At the time of hospital presentation, patients are often hypoxic and meet systemic inflammatory response syndrome (SIRS) criteria, including high fever. All cases in California have been hospitalized, with most requiring respiratory support with supplemental oxygen, high-flow oxygen, or bi-level positive airway pressure (BiPAP). Approximately 30 percent of patients had respiratory failure requiring mechanical ventilation.

Radiography
  • Abnormal findings may or may not be present on initial imaging, but develop eventually.
  • Chest radiographs have demonstrated bilateral opacities or infiltrates. Computed tomography (CT) imaging of the chest has shown diffuse bilateral ground-glass opacities, often with sub pleural sparing.
Lab Findings
Non-specific laboratory abnormalities have been reported:
  • Leukocytosis with neutrophil predominance
  • Elevated markers of inflammation (e.g., ESR, CRP)
  • Transient, mild elevation in serum transaminases
  • Elevated procalcitonin
Frequently Performed Diagnostic Evaluations
  • Evaluation for infectious etiologies is often completed without an identified cause
  • Pulmonary function tests (PFTs)
  • Some patients are evaluated for lung injury with bronchoscopy with bronchoalveolar lavage or lung biopsy
Diagnosis
VAPI is a clinical diagnosis of exclusion when infectious, rheumatologic, neoplastic, cardiac, or other processes cannot explain an acute pulmonary illness in a patient known to vape cannabinoids and/or nicotine. The diagnosis is commonly suspected when the patient does not respond to antibiotic therapy, and testing does not reveal an alternative diagnosis. Some, but not all, patients have been evaluated with
bronchoscopy with bronchoalveolar lavage, but findings are not pathognomonic and performing this evaluation is not a requirement for diagnosis.

Treatment
Guidelines for treatment of VAPI are not yet available.
  • Many patients experience sub-acute or acute hypoxemic respiratory failure requiring supplemental oxygenation and at times ventilator support, including mechanical ventilation or extracorporeal membrane oxygenation.
  • Treating physicians have used corticosteroids with possible benefit. The dosing, administration route, duration, and timing have varied.
  • Follow-up plan has been determined on a case by case basis.

Clinical Specimen Collection, Storage, and Shipping
  • CDPH and the Long Beach Healthe Department are asking that blood, urine, and BAL specimens obtained from patients during the course of evaluation for VAPI be saved for possible future analysis by CDPH or CDC. Plans for this testing are underway, but not yet finalized.
  • Hospital laboratories should contact their local public health department to report that the hospital lab has remnant patient biospecimens. Until further guidance from the CDC is available, the hospital lab or local health department should store the biospecimens according to their existing protocols.
  • CDC is updating their guidance on VAPI specimen collection, storage, and shipping; we expect to share this updated guidance with providers, laboratories, and public health departments very soon.
REPORTING
Reporting of VAPI 
  • Reports of suspect VAPI cases can be reported to the Long Beach Health Department's Communicable Disease Control Program at 562.570.4302 during regular business hours, from Monday to Friday, or by emailing LBEpi@longbeach.gov.                                      
ADDITIONAL RESOURCES
CDPH Outbreak Updates
CDC Outbreak Updates
California Smokers' Helpline
Click to Sign Up for Long Beach Provider Alerts
Facebook
Twitter
Link
Copyright © 2019 Long Beach Department of Health and Human Services, All rights reserved.

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