Health Advisory
UPDATED INTERIM GUIDANCE FOR HEALTH CARE PROVIDERS MANAGING VAPING-ASSOCIATED LUNG ILLNESS DURING FLU SEASON

The Delaware Division of Public Health (DPH) is issuing this health advisory to provide health care providers updated interim guidance from the Centers for Disease Control and Prevention (CDC) regarding management of cases of vaping associated lung illness during influenza season.

Summary

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.

Background

CDC, the Food and Drug Administration (FDA), state and local health departments, and public health and clinical stakeholders continue to investigate a nationwide outbreak of VAPI/EVALI. A total of 2,172 U.S. VPAI/EVALI cases have been reported to CDC, including 18 in Delaware. Vitamin E acetate and tetrahydrocannabinol appear to be associated with the outbreak; however, no single causative agent has been identified.

Recommendations/Reporting

VAPI/EVALI remains a diagnosis of exclusion because, at present, no specific test or marker exists for its diagnosis, and evaluation should be guided by clinical judgment. Because patients with VAPI/EVALI can experience symptoms similar to those associated with influenza or other respiratory infections (e.g., fever, cough, headache, myalgias, or fatigue), it might be difficult to differentiate VAPI/EVALI from influenza or community-acquired pneumonia on initial assessment; VAPI/EVALI might also co-occur with respiratory infections.

Recommendations for health care providers managing patients with suspected or known VAPI/EVALI when respiratory infections such as influenza are more prevalent in the community than they have been in recent months include:

• Asking patients with respiratory, gastrointestinal, or constitutional symptoms about the use of e-cigarette, or vaping, products;
• Evaluating those suspected to have VAPI/EVALI with pulse oximetry and obtaining chest imaging, as clinically indicated;
• Considering outpatient management for clinically stable VAPI/EVALI patients who meet certain criteria;
• Testing patients for influenza, particularly during influenza season, and administering antimicrobials, including antivirals, in accordance with established guidelines;
• Using caution when considering prescribing corticosteroids for outpatients, because this treatment modality has not been well studied among outpatients, and corticosteroids could worsen respiratory infections;
• Recommending evidence-based treatment strategies, including behavioral counseling, to help patients discontinue using e-cigarette, or vaping, products; and
• Emphasizing the importance of annual influenza vaccination for all persons aged ≥6 months, including patients who use e-cigarette, or vaping products.
• Clinicians should report cases of significant respiratory illness of unclear etiology and a history of vaping to the Delaware Division of Public Health, Bureau of Epidemiology (24/7) at 1-888-295-5156.

Additional Information

Interim Updated Clinical Guidance: CDC Morbidity and Mortality Weekly Report (MMWR)

An algorithm for VAPI/EVALI patient management (diagnosis and treatment) is available on the CDC website: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/healthcare-providers/pdfs/Algorithm-EVALI-Nov-2019.pdf

Clinician Resources: cdc.gov/LungInjuryHCP

Clinician Questions about VAPI/EVALI: LungDiseaseOutbreak@cdc.gov

Delaware specific information on VAPI and e-cigarettes: dhss.delaware.gov/DPH

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