Investigation Spotlight: Outbreak of e-cigarette or vaping product use-associated lung injury (EVALI)
Problem
In August 2019, CDPH first received reports of illness and death among people in California who had a history of vaping. The reports described severe breathing problems and lung damage. States throughout the country began to receive similar reports. By February 2020, more than 2,800 individuals were hospitalized across the U.S. and 68 individuals died.
Investigation
CDPH partnered with other public health agencies and organizations to understand why vaping was causing illness and death and to stop the unfolding outbreak. CDPH issued a health advisory to clinicians, local health departments, and the public about the severe health risks of vaping.
CDPH also worked with local health departments to conduct patient surveys, analyze samples of vaping products, and review patient medical records. CDPH and its partners across the country determined that most patients who were hospitalized or died had used vaping products that contained cannabis or cannabidiol (CBD) oils. They also determined that other chemicals in these vaping products likely contributed to the lung injuries.
Outcomes and impact
By February 2020, there was a sharp decline in illnesses and death among people who vaped. CDPH continues to receive and document case reports of people with serious illness from vapingā.
CDPH and its partners conducted and published several research projects related to EVALI. These studies identified a number of harmful chemicals in vaping products that can cause injury to the lungs:ā
- Vitamin E acetate was identified as an additive in many adulterated THC-containing vaping products that patients used. It was also found in lung fluid samples from these patients. The presence of vitamin E acetate in vaping products has been strongly linked to the EVALI outbreak.
- Vitamin E acetate in vaping products can produce a toxic reaction when the chemical is heated during vaping. This reaction, called ketene formation, can cause immediate and long-term injury to the lungs. Other acetates may also create ketene with exposure to heat, such as THC-O acetates.ā
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Heavy metals were found in vaping liquids and the vapor produced during vaping. These heavy metals, in the amounts found, are likely to increase the risk of cancer and other health problems. Vaping product design, including heating coils, are likely the main source of the harmful metals.
āāCDPH continues to investigate and publish its findings on harmful exposures from vaping.
Following this outbreak, CDPH established a
Toxicological Outbreak Programā to build California's capacity to identify and respond to toxicological outbreaks from exposure to chemicals and toxins.
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