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Notes from CSTE’s Vaping-Associated Pulmonary Injury (VAPI) Outbreak Response

Posted By Ruth Lynfield, MD and Landen, MD, Friday, July 17, 2020
Updated: Friday, July 17, 2020

Notes from CSTE’s Vaping-Associated Pulmonary Injury (VAPI) Outbreak Response. 

In July 2019, Illinois and Wisconsin were the first states to call attention to a then-unidentified severe lung illness among previously healthy individuals reporting use of vapes and e-cigarettes. Shortly thereafter, Minnesota also began reporting a similar outbreak, and Utah, California, and Massachusetts quickly followed suit. On August 21, 2019, CSTE activated its Incident Command System (ICS) to support state and local epidemiologists responding to the multi-state outbreak of e-cigarette use, or vaping, associated lung injury (EVALI). In conjunction with the Centers for Disease Control and Prevention (CDC), CSTE coordinated the Vaping-Associated Pulmonary Illness (VAPI) Task Force consisting of state and local epidemiologists. 


The CSTE VAPI Epidemiology Task Force operated between August 2019 and February 2020 and was instrumental in assisting CDC to develop case definitions and data collection tools. The VAPI Task Force quickly grew to over 100 members, and CSTE established a Leadership Group comprised of members in California, Illinois, Minnesota, New Mexico, North Carolina, Utah, and Wisconsin to guide the overall Task Force. Ruth Lynfield and Mike Landen, State Epidemiologists in Minnesota and New Mexico chaired the VAPI Task Force. The Task Force and Leadership Group met weekly with CDC ICS leadership to discuss data and surveillance issues, typically centered on providing feedback on CDC materials. The VAPI Task Force input on the CDC case reporting and interview forms, as well as the EVALI outbreak case definition and DCIPHER platform for reporting cases highlighted the critical impact that CSTE members can have during a national outbreak response. 


Several smaller groups emerged, led by CSTE members on various epidemiology studies of interest: the CDC National YouGov survey, a multi-state EVALI severity analysis, and an analysis of cases in states with legalized recreational THC. CSTE collaborated with national partners at the Association of Public Health Labs (APHL) and the Food and Drug Administration (FDA) regularly as we navigated how to best support our members as laboratory data began to demonstrate that vitamin E acetate, an additive in some THC-containing vaping products, is strongly linked to the EVALI outbreak. CSTE members discussed strategies for communicating warnings to the public against the use of THC products, particularly those sold in illegal and informal markets, such as through family, friends, and in-person or online dealers. 


In January 2020, CSTE developed brief EVALI questionnaire to all 50 states, the District of Columbia, and the affected territories of Puerto Rico and the U.S. Virgin Islands to learn more about ongoing challenges and response capacity. The results of this questionnaire informed CDC efforts to stand down their response in early February, shortly followed by CSTE’s deactivation and incorporation into normal daily operations under the Substance Use and Injury programsCDC reports that as of February 18, 2020 (the last day for DCIHPER reporting), a total of 2,807 hospitalized EVALI cases or deaths have been reported. While CSTE has several major takeaways from our EVALI response, there was little opportunity to implement changes or host an in-person After Action Review (AAR) due to the rapid escalation of COVID-19 across the U.S. As CSTE navigates the current pandemic, we will not forget the lessons learned from EVALI and what it means to respond to a non-infectious disease outbreak. 

Ruth Lynfield, MD, is Minnesota’s State Epidemiologist, and Michael Landen, MD, is now retired as State Epidemiologist of New Mexico. Dr. Lynfield and Dr. Landen served as CSTE’s VAPI Task Force chairs during the outbreak response. 


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