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DE Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping

The Delaware Division of Public Health continues to participate in a multi-state investigation into a national outbreak of severe pulmonary disease. As of Jan. 7, 2020, the CDC reports 2,602 probable or confirmed cases of lung injury associated with the use of e-cigarettes – also called vaping. The investigation includes such vaping-associated products as devices, liquids, refill pods, and cartridges. Those cases included 57 deaths in 27 states. Additional details on the national investigation can be found on the CDC’s website.

E-Cigarettes Smoke Content

This webpage will provide ongoing updates regarding the outbreak, Delaware’s response to it, and our recommendations.

Delaware has 19 cases of vaping-associated lung injury (VAPI) that meet the CDC’s case definition of either probable or confirmed. Sadly, in one of the cases associated with this national outbreak, an individual died. Some information about Delaware’s 19 cases:

  • 12 are male, 7 are female
  • The age range of patients is between 15 to 65 years old. *Note: This doesn’t mean the youngest is 15 and the oldest is 65, but that the patient’s ages fall within this range.
  • The average age range of the patients is 28 years old
  • Eleven of the individuals are from New Castle County, three are from Kent and five are from Sussex
  • Five of the patients report using e-cigarette products containing THC alone; eight report using THC in combination with nicotine e-cigarettes (One of the reported uses of THC products included vaping medical marijuana.) Six of the 19 persons reported using e-cigarette products containing nicotine only.

The Latest

All VAPI patients have reported a history of using e-cigarettes, or vaping, products.

  • While ED visits associated with possible VAPI have declined since a peak in September, they have not returned to levels before June 2019 and VAPI remains a concern.
  • Although CDC is seeing progress in the investigation and response, they indicate we must remain vigilant. National data show that certain groups of EVALI patients (some with chronic medical conditions, including cardiac disease, chronic pulmonary disease, and diabetes as well as those of increasing age) who are released from the hospital are more likely to be re-hospitalized or die. CDC has updated its clinical guidance to recommend that hospitalized patients be documented as clinically stable for 24–48 hours prior to discharge. Also, patients should have a follow–up visit with a primary care provider or pulmonary specialist, optimally within 48 hours of discharge–a shorter follow–up time than the previous recommendation of 1–2 weeks.
  • Vitamin E Acetate, an additive in some THC–containing e–cigarette, or vaping, products, is closely associated with EVALI. Vitamin E acetate is used most notably as a thickening agent in THC-containing e-cigarette, or vaping, products. However, evidence is not yet sufficient to rule out contribution of other chemicals of concern. There may be more than one cause of this outbreak.
  • THC is present in most, but not all, of the samples tested by FDA to date, and most patients report a history of using THC-containing e-cigarette, or vaping, products. For more information on the health effects of marijuana in the body visit:
  • National and state findings suggest products containing THC, particularly from informal sources like friends, or family, or in-person or online dealers, play a major role in the outbreak. CDC recommends that people should not use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, or family, or in-person or online dealers. In addition, people should not add any substance to e-cigarette, or vaping, products that are not intended by the manufacturer, including products purchased through retail establishments.
  • While this investigation is ongoing, vitamin E acetate should not be added to e-cigarette, or vaping, products.

Since the specific cause or causes of lung injury are not yet known, the only way to assure that you are not at risk while the investigation continues is to refrain from using all e-cigarette, or vaping, products.

What is Vaping-Associated Lung Illness?

As seen in this outbreak, vaping can be deadly. VAPI symptoms typically develop over a period of days, but sometimes can manifest over several weeks. Symptoms include:

Health effects of vaping on the lungs

  • Rapid heart beat (regular or irregular)
  • Shortness of breath
  • Nonproductive cough
  • Pleuritic chest pain
  • Fever
  • Chills
  • Fatigue
  • Gastrointestinal distress: nausea, vomiting, abdominal pain, diarrhea
  • Hypoxemia (abnormally low blood-oxygen level)
  • Acute or subacute respiratory failure

As in the national cases, no single product or device in Delaware has been identified in all cases, but we do know that use of vaping or e-cigarette products containing either THC alone or in combination with nicotine products is reported in most cases.

Although vaping proponents advocate that these products have helped them quit using combustible cigarettes, these products are not recognized by federal health agencies as approved smoking cessation devices. Many people falsely believe that vaping is healthier than smoking, when in fact neither is considered safe.

According to the Centers for Disease Control and Prevention (CDC), although e-cigarette aerosol generally contains fewer toxic chemicals than regular cigarettes, e-cigarette aerosol can contain harmful and potentially harmful substances, like nicotine, heavy metals like lead, volatile organic compounds, and cancer-causing agents. Additionally, some e-cigarette products contain as much nicotine as 20 cigarettes.

What is DPH Doing?

On August 20, DPH began sharing the CDC’s information on this evolving outbreak to health care providers through Health Advisory Notices (HANs). Recommendations to providers included asking them to report suspected cases to DPH for investigation. A small number of reports began coming in the next day. DPH appointed a lead epidemiologist to follow up on suspect cases, and additional epidemiologists are searching medical databases for possible cases.

On August 28, DPH started reporting cases that met the CDC case definition of "probable" to the CDC. A second HAN with updated CDC information was shared with the medical community on Aug. 30. DPH issued a press release on Sept. 9, announcing the investigation of three possible cases, and issued a follow-up release on Sept. 25. On Oct. 3, DPH held a media call to provide an update and announce Delaware’s first death associated with this outbreak.

Delaware has submitted samples of vaping devices to the FDA for testing. DPH does not have any results at this time from FDA testing.

Vaping can be hazardous to your health

We also have asked the state’s medical marijuana compassion centers to post signage advising patients to consider if vaping is the best option for their medical use, and to have a thoughtful conversation with their health care provider or compassion center staff about possibly safer alternatives to vaping.


Recommendations for the Public

  • DPH strongly encourages people not to use e-cigarette products, particularly those containing THC, whether the THC products are legal or illegal. The use of regulated THC products has been reported in cases of severe lung injury in other states.
  • People who continue to use e-cigarette products should monitor themselves for symptoms including: coughing, shortness of breath, chest pain, nausea, vomiting, abdominal pain, and fever – and promptly seek medical attention for any health concerns.
  • People with underlying chronic respiratory conditions are particularly susceptible to increased effects or impacts of using e-cigarette products, and should stop using them immediately, or not start using e-cigarette products in the first place.

Woman walking away from cigarettes

  • Although there is risk with any vaping product, people should not buy e-cigarette products off the street and should not modify those products or add any substances that are not intended for use by the manufacturer.
  • E-cigarette products should never be used by youth, young adults, pregnant women, or adults who do not currently use tobacco products.
  • Those individuals who switched from combustible cigarettes to e-cigarettes and discontinue vaping, should not return to smoking combustible cigarettes. The Division of Public Health recognizes that there are people who have chosen to use e-cigarette products as a step-down from using combustible tobacco products, but the FDA does not recognize the use of e-cigarette products as an approved smoking cessation product.
  • Instead if you are an adult who needs help quitting tobacco products, including e-cigarettes, call the Delaware Quitline at 1-866-409-1858. Youth who smoke or vape can contact the American Lung Association’s N-O-T (Not on Tobacco) Cessation Program for teens at 1-800-LUNGUSA. The Truth Initiative also operates a text cessation program for youth. To participate, text "DITCHJUUL" to 887-09.
  • If you are using vape-/e-cigarette products with THC for medical purposes, contact your health care provider and have a conversation about potentially safer alternatives for you.
  • If you are vaping illegal THC products and need help stopping the use of marijuana, contact the Division of Substance Abuse and Mental Health’s Crisis Line. In New Castle County, the number is 1-800-652-2929 and in Kent and Sussex counties, it is 1-800-345-6785.

For Health Care Providers

The CDC issued updated interim guidance in late November to guide health care providers as rates of influenza in the community increase. The CDC advises providers evaluating patients with respiratory illnesses to ask them about e-cigarette, or vaping, product use; evaluate whether patients require hospital admission; and consider empiric use of antimicrobials, including antivirals, as well as possible corticosteroids. Vaping associated lung injury (VAPI) is a diagnosis of exclusion; rapid recognition of VAPI (also known as EVALI) patients by health care providers is critical to reducing severe outcomes. This information was published as a CDC Morbidity and Mortality Weekly Report (MMWR), which includes an algorithm for management of patients with respiratory, gastrointestinal, or constitutional symptoms and e-cigarette, or vaping, product use.

DPH and the CDC recommend health care providers:

  • Report cases of lung injury of unclear etiology and a history of e-cigarette or vaping product use within the past 90 days to DPH at 1-888-295-5156. Reporting of lung injury cases may help the CDC and state health departments determine the cause of these lung injuries.
  • Screen all patients for e-cigarette or vaping product use, including nicotine and THC containing products.

View additional recommendations here:

Medical Professional

For the coming flu season, CDC recommends that clinicians strongly consider respiratory infections such as influenza, as well as lung injury associated with e-cigarette use, or vaping, in all patients presenting with respiratory symptoms and a history of e-cigarette use, or vaping.

Clinicians are further advised that it may not be possible to distinguish definitively between respiratory infection and lung injury associated with use of e-cigarettes, or vaping, using available testing. Therefore, therapy directed at both may be necessary. Decisions on the initiation or discontinuation of treatment should be based on specific clinical features and, when appropriate, in consultation with specialists.

DPH also asks that providers download this poster (Spanish available too) and place it in their waiting and patient rooms as space allows:

CDC Lung Injury posterCDC Lung Injury poster in Spanish


Additionally, providers can remain informed about the latest updates via the CDC’s lung injury webpage:

The risks of e-cigarette use:

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