In the post, Johnson claimed that two weeks previously, her daughter became ill during a journey to college in Colorado and reported difficulty breathing. At some point during the journey, she was taken to an urgent care clinic. According to Johnson, she believed it “would be a quick visit,” and that she possibly had bronchitis “and she’d be fixed up quick and moving into her dorm the next day.”
However, Johnson said, her daughter’s condition remained severe:
The nurses and I had to wear masks to protect us from whatever virus or bacteria had begun to literally wreak havoc on her body. She cried to her nurse that it hurt too bad to take a breath. She was getting IV fluids, antibiotics, pain meds, anti-nausea meds and a diuretic to help clear fluid from her badly inflamed lungs. She continued to need more and more oxygen. The pain meds barely took the edge off. Tests were run, more meds were ordered, she was eventually transferred to a room on the ICU floor in case her oxygen needs became even more severe.
According to Johnson, Piper’s illness was due solely from vaping:
How does a healthy 18 year old become a VERY sick patient whose oxygen needs just keep increasing?
VAPING. That’s how.
She became Colorado’s first confirmed case of what was called a “sudden and severe lung illness due to vaping.”
Johnson went on to urge readers to support restrictions on all related products.
One day before Johnson’s post, the Colorado Department of Public Health and Environment tweeted that two cases of “sudden and severe lung illness associated with vaping” had been confirmed in the state:
Colorado now has two confirmed cases of sudden and severe lung illness associated with vaping. We will provide regular case updates on our website.https://t.co/DURa4uNebh
— CDPHE (@CDPHE) August 29, 2019
A statement last updated on August 30 2019 reiterated that two cases of “sudden and severe lung illness associated with vaping” had been documented in Colorado. A portion of the release suggested that the illnesses were not necessarily due to standard use of products as intended. In a section titled “what people should avoid,” two of CDPHE’s advisories stood out:
Do not buy e-cigarette products off the street (for example, e-cigarette products with THC or other cannabinoids).
Do not modify e-cigarette products or add any substances to these products that are not intended by the manufacturer.
Local news reports made little effort to determine why cases presented in August 2019 when the practice of vaping or use of e-cigarettes had been fairly regular in the United States since at least 2006. Scattered reports of “sudden and severe lung illness associated with vaping” began cropping up in the summer of 2019, but very few articles went into detail about what may have changed.
On August 31 2019, the New York Times published a far more in-depth article about clusters of “sudden and severe lung illness associated with vaping.” It began:
An 18-year-old showed up in a Long Island emergency room, gasping for breath, vomiting and dizzy. When a doctor asked if the teenager had been vaping, he said no.
The patient’s older brother, a police officer, was suspicious. He rummaged through the youth’s room and found hidden vials of marijuana for vaping.
“I don’t know where he purchased it. He doesn’t know,” said Dr. Melodi Pirzada, chief pediatric pulmonologist at NYU Winthrop Hospital in Mineola, N.Y., who treated the young man. “Luckily, he survived.”
Patients, mostly otherwise healthy and in their late teens and 20s, are showing up with severe shortness of breath, often after suffering for several days with vomiting, fever and fatigue. Some have wound up in the intensive care unit or on a ventilator for weeks. Treatment has been complicated by patients’ lack of knowledge — and sometimes outright denial — about the actual substances they might have used or inhaled.
That introduction was notable for two reasons: That the patient denied vaping overall, and that the patient was vaping products adulterated to contain cannabis in a state where such products are not available for regulated sale. The piece goes on to reiterate that patients were often unable or unwilling to disclose which substances they may have vaped before falling ill — understandably, if the substances were illicit or illegal.
Instances of “sudden and severe lung illness associated with vaping” did not appear to be striking older vapers, many of whom have long used mainstream vaping products. The cases highlighted by the New York Times appeared to affect largely teenagers and young adults, and modification of vaping equipment to vape cannabis products was frequently cited.
The article cited oils as a factor in many of the cases:
“Inhaling oil into your lungs is extremely dangerous behavior that could result in death,” said Thomas Eissenberg, who studies vaping at Virginia Commonwealth University. “That is probably the biggest message we can get out of this.”
Many vaping ingredients are not listed on the products. Vitamin E oil appears to have been a common substance associated with the severe and sudden respiratory problems in some of the New York cases, according to state health officials. It is not known how it was used. Vitamin E is sometimes advertised as a supplement in cannabidiol oil, which is not designed for vaping but has been used that way.
Mainstream e-cigarette solutions for vaping, commonly known as “e-juice” or “juice,” does not use oil as a carrier due to the danger inherent in vaping oils. Products purchased in stores contain nicotine, flavoring, propylene glycol, and/or vegetable glycerin. E-cigarette manufacturers are presumably aware that vaping oil is dangerous and exclude it from their carrier solutions, whereas users modifying juices or delivery devices may not be aware of the risks when adulterating products in order to vape THC.
Suspected modification of e-cigarettes to vape cannabis products is always present in reports on outbreaks of “sudden and severe lung illness associated with vaping.” The Times article quoted a public safety expert:
Dr. Scott Gottlieb, the former commissioner of the Food and Drug Administration, said he suspected a link to illicit products — perhaps related to ingredients including THC — because the main manufacturers of e-cigarettes had not suddenly altered their ingredients on a wide scale. “It’s probably something new that has been introduced into the market by an illegal manufacturer, either a new flavor or a new way to emulsify THC that is causing these injuries,” he said.
Another public health expert consulted for the article interviewed a number of patients about the products they had inhaled before falling ill. She said “interviews with patients suggested they were getting the marijuana liquid from friends in states with legal supplies of the drug, like California and Colorado.” The article goes on to highlight the intersection of regulated nicotine vaping products with the largely unregulated, federally illegal topic of cannabis products:
The F.D.A. oversees CBD products sold as dietary supplements, but does not regulate THC, which is illegal under federal law. Liquid nicotine and THC, sometimes sold in cartridges for use in vaping devices, can each contain oils that may be safe to swallow but can damage the lung when vaporized into a mix of unknown chemicals.
On August 30 2019, the Centers for Disease Control issued a public health advisory about cases of “sudden and severe lung illness associated with vaping.” In it, the CDC noted that “many patients have reported using e-cigarettes containing cannabinoid products such as THC or CBD” before falling ill.
In a section advising the public, the CDC recommended not modifying e-cigarette products and not buying them “off the street”:
Regardless of the ongoing investigation, anyone who uses e-cigarette products should not buy these products off the street (e.g., e-cigarette products with THC, other cannabinoids) and should not modify e-cigarette products or add any substances to these products that are not intended by the manufacturer.
Twitter user Amelia Howard shared an annotated version of the CDC advisory, noting portions where vague or confusing language obfuscated aspects of the notice:
I used Hypothesis to make some annotations on The CDC's heath advisory on "Severe Pulmonary Disease Associated with Using E-Cigarette Products" You can read the advisory with my notes here: https://t.co/TXTC5lb8Vg Click on the arrow at the top right to expand the comments.
— Amelia Howard (@Amelia_RH) September 2, 2019
Howard noted in part that no commercial product had been implicated, and that with the exception of one state, the cases were in states where THC products were not legally marketed or sold, and thus unregulated:
The term “e-cigarettes” is commonly understood to mean nicotine vaping products, not THC oil pens/cartridges. Based on the available evidence, it is quite clear that the majority, if not all of the observed cases are associated with the use of THC oils, most of which were accessed through the black market. Conversely, there is currently no evidence that any commercial nicotine vaping product has caused any one of the cases of pulmonary disease in the outbreak.
By and large (and with the exception of California) the cases are clustered in states with no legal recreational cannabis market, and either extremely restrictive medical cannabis regulations, or no legal market for medical cannabis. In other words, the cases are happening in places where the black market is the only option for people who use cannabis recreationally.
Howard referenced remarks from Dr. Michael Siegel, Professor in the Department of Community Health Sciences at the Boston University School of Public Health. Siegel explained that conflating common use of e-cigarettes with the illnesses likely caused by black-market products poses a risk to public health:
This is a public health crisis and I think that any physician who makes public statements about these cases has a responsibility to provide accurate information that will actually help to prevent further cases from occurring. Scaring people into thinking that any vaping product can cause respiratory failure is not only inaccurate, but it is irresponsible because it doesn’t provide useful information that can help youth avoid the specific products that are responsible for the observed cases.
As an trained epidemiologist, it was immediately clear to me that these cases are not being caused by vaping products generally because these products have been on the market for years without any significant problems and because the reports are clustered in specific geographic areas. Now that further information is available, it is clear that the majority of the observed cases are associated with the use of THC oils that were obtained from unlicensed sellers. It is also likely that cases occurring among people using nicotine-containing e-liquids without THC are due to a contaminant that is appearing in products being sold on the black market, not in retail stores.
In a disease outbreak such as this one, responsible public warnings need to be as specific as possible about the risk. In an outbreak of E. coli caused by a contaminated batch of lettuce, we don’t tell the public that the disease is associated with eating, or even that it is associated with eating lettuce. People need much more specific guidance if they are to take appropriate action to avoid or reduce the risk of further spread of the outbreak.
Here, we need to start telling the public the truth. However much physicians or anti-nicotine groups may not like it, the truth is that the outbreak we are seeing is not due to the risks of using standard vaping products. It appears much more likely that the outbreak is mostly, if not completely attributable to illicit products–especially THC extracts–that are being sold by unlicensed sellers on the black market. Unless people are provided with this specific information, they will not take action to avoid the products that could put them at risk.
Some reporting on the outbreak mentioned a company — Dank Vapes — and its link to some of the cases. A Wisconsin man sickened by vaping black market items identified a cartridge from Dank Vapes as the possible culprit. A Rolling Stone article referenced Dank Vapes as a “black market brand of ambiguous origins,” and referenced the case on Long Island and a vitamin E oil adulterant:
Lab testing of [Dr. Melodi ] Pirzada’s patient’s cartridge revealed that it tested positive for not just THC, but also vitamin E. If inhaled, oils like Vitamin E can cause lipoid pneumonitis, a rare condition that results from fat particles being inhaled into the lungs, says Pirzada. When she submitted the results to the Department of Health, it informed her that there were two other cases of THC cartridges testing positive for vitamin E oil, though she says the cartridge is currently being retested for other substances.
The viral Facebook post from the parent of a teenager hospitalized in Colorado due to “sudden and severe lung illness associated with vaping” was a clearly emotional plea shared due to the illness of the girl in the photograph. Misinformation about sudden and severe lung illness associated with vaping was rampant on social media in August 2019, due to clusters of the illness reported in several states.
Although the poster said that it is not only unregulated products causing illness (which public health officials continue to investigate), all available information suggested that the illnesses indeed were likely attributable to adulterated vape products and not commercial e-cigarette components or juices. We have been so far unable to locate any reports associated solely with standard vaping or e-cigarette usage, and the illness seemed to strike young users. The nature of the mechanism of injury (suspected vaping of cannabis in states where it is illegal) suggests that some patients might not be willing to disclose that activity to doctors or parents.
Cases of sudden and severe lung illness associated with vaping are real, and there is no reason to suspect that the Facebook post did not reference one such case. However, its focus on all vaping and e-cigarette products was misguided when read in contrast with commentary by public health experts. Although investigators struggled to identify a highly specific common factor in all the cases, most seemed to agree that e-cigarette cartridges and juice adulterated with oil and/or cannabis products in states without legal dispensaries were likely to blame. Commercial vaping products existed for well over a decade in the United States before sudden and severe lung illness associated with vaping cases began popping up, but few if any illnesses linked directly to those products followed before the 2019 cases appeared.
Update: September 5 2019, 4:48 PM
On September 5 2019, the Washington Post reported that investigators identified a common thread in samples of cannabis products used by many patients with sudden and severe lung illness associated with vaping — vitamin E oil:
State and federal health officials investigating mysterious lung illnesses linked to vaping have found the same chemical in samples of marijuana products used by people sickened in different parts of the country and who used different brands of products in recent weeks.
The chemical is an oil derived from vitamin E. Investigators at the U.S. Food and Drug Administration found the oil in cannabis products in samples collected from patients who fell ill across the United States. FDA officials shared that information with state health officials during a telephone briefing this week, according to several officials who took part in the call.
That same chemical was also found in nearly all cannabis samples from patients who fell ill in New York in recent weeks, a state health department spokeswoman said.
… “We knew from earlier testing by New York that they had found vitamin E acetate, but to have FDA talk about it from their overall testing plan, that was the most remarkable thing that we heard,” said one official who took part in the briefing but was not authorized to speak publicly.
The Washington Post further reported that state and federal health authorities said they were “focusing on the role of contaminants or counterfeit substances as a likely cause” of the illnesses in question. Federal findings aligned with those in New York State, where “very high levels of vitamin E acetate in nearly all” samples tested, and “vitamin E acetate is now a key focus” in the New York investigation. What makes the presence of vitamin E acetate so worrisome boils down to its unsuitable nature for inhalation:
Unlike the human digestive tract, which can break down and get rid of foreign substances, the lungs aren’t designed to handle anything except gases, experts said.
When oils are inhaled, they are temporarily heated and vaporized. That heated and vaporized substance returns to its original state after it is inhaled, coating the inside of the user’s lungs with oils. Inhaling products adulterated with oils such as vitamin E acetate can lead to a rare but serious condition known as lipoid pneumonia (less commonly called cholesterol pneumonia.)
Although authorities said they had not yet ruled out adulterants in nicotine-only samples, the Food and Drug Administration thus far has analyzed “12 viable nicotine samples and 18 viable THC products,” adding that “Vitamin E acetate was found in 10 of the 18 THC products.” By contrast, FDA lab tests found “nothing unusual in nicotine products that had been collected from sick patients.”
In a September 2019 bulletin issued in Oregon, health officials indicated that one sudden and severe lung illness associated with vaping death occurred in an individual who had recently used “an e-cigarette or vaping device containing cannabis.”