disposable e-cigarette penore admission, and some of them have seen multiple visits. The results of radiological examinations vary and are not present in all patients when they are first presented. According to reports, bilateral lung infiltration and diffuse ground glass opacity. Many patients require supplemental oxygen, some require assisted ventilation and oxygenation, and some require intubation. Some patients have been treated with corticosteroids and have improved. Antimicrobial therapy alone has not always been associated with clinical improvement. Many patients have completed the assessment of the cause of the infection, but there is no definite cause of the infection. Several patients from one state were diagnosed with lipoid pneumonia based on clinical manifestations and detected lipids in bronchoalveolar lavage samples that were specifically stained to detect oil. All patients reported using e-cigarette products, and the time of appearance of symptoms ranged from a few days to several weeks after e-cigarette use. In both states, many patients have recently inhaled cannabinoid products, THC or cannabidiol. So far, no single substance or e-cigarette product has always been associated with disease. CDC is working closely with state health departments to facilitate the collection of product samples for testing at the FDA Forensic Chemistry Center. Recommendations to clinicians Report severe lung disease of unknown etiology and a history of e-cigarette product use to your state or local health department in the past 90 days. Reporting cases may help the CDC and state health departments determine the cause of these lung diseases. Ask all patients who have reported the use of e-cigarette products in the past 90 days to understand the signs and symptoms of lung diseases. If you suspect that the use of e-cigarette products may be the cause of the patient鈥檚 severe lung disease, please understand the following in detail: Substances used: nicotine, cannabinoids (e.g., cannabis, THC, THC concentrate, CBD, CBD oil, synthetic cannabinoids [e.g., K2 or spice], hash oil, Dank vapes), spice or other substances. Sources of substances: commercially available liquids (i.e. bottles, cartridges or pods), homemade liquids, and use of homemade or commercially purchased liquids to reuse old cartridges or pods. The device: manufacturer; brand; product name; model; product, device or e-liquid serial number; if the device can be customized by the user; and any product modification of the user (for example, exposure of the atomizer or heating coil) to purchase the product Local substance usage method: atomization, light application or dripping. Other potential cases: sharing e-cigarette products (equipment, liquid, refill box or ink cartridge) with others to determine if there are any remaining products (including equipment and liquid) available for testing. The testing can be coordinated with the local or state health department. Consider all possible causes of illness in patients reporting respiratory and gastrointestinal symptoms and e-cigarette product use. Evaluate and treat other possible causes of diseases based on clinical indications (for example, infectious diseases, rheumatism, tumors). Consider consulting a specialist as appropriate (pulmonary, infectious diseases, intensive care, medical toxicology). The clinical improvement of the use of corticosteroids in the treatment of patients with severe lung diseases associated with e-cigarettes has been reported. The decision to use corticosteroids should be made on a case-by-case basis based on the risks and benefits and the likelihood of other causes. Based on the detection of lipid-loaded alveolar macrophages obtained by bronchoalveolar lavage (BAL) and lipid staining, lipoid pneumonia associated with the inhalation of lipids in aerosols produced by electronic cigarettes has been reported. The decision on whether to proceed with BAL should be based on the individual's clinical situation. Lung biopsies have been performed on some patients. If a lung biopsy is obtained, lipid staining can be considered during the pathological examination, and it is best to perform it on fresh tissue. Routine pathological tissue processing (including formalin fixation and paraffin embedding) can remove lipids. Routine tissue processing and histopathological evaluation are still important. Consider consulting pulmonary medicine and pathology experts to help inform any evaluation plans. Patients who have received treatment for severe lung diseases related to e-cigarette products should undergo follow-up evaluation as indicated by the clinical practice to monitor lung function. Advice to Public Health Officials State public health officials should notify the CDC of possible cases through VapingAssocIllness@cdc.gov. For case classification standards, reporting guidelines, case investigation forms, and questions about the outbreak, please contact the CDC at VapingAssocIllness@cdc.gov. Consider using existing data sources for case discovery activities (for example, local poison control centers, coroner and medical examiner offices, and other applicable surveillance systems, including syndrome surveillance). The CDC has developed two effective definitions of syndrome surveillance (one with specific symptoms, the other focusing on the use of e-cigarette products). CDC will program these definitions in the BioSense/ESSENCE platform of the CDC's National Syndrome Surveillance Program for case detection within the platform. Consider asking the medical examiner or coroner's office and other pathologists to report possible cases, especially those for which there are no other possible diagnoses. If an individual is found to show signs of severe lung disease as described above after death or an autopsy, the medical examiner and coroner are encouraged to report the case to the local or state health department. It is recommended to thoroughly sample the trachea, bronchus and lung parenchyma, collect fresh lung tissue for staining lipids (such as oil red O), provide formalin fixation, and paraffin-embed the tissue for routine histopathological examination. For further consultation, public health officials can contact the Infectious Disease Pathology Department of the Centers for Disease Control and Prevention at pathology@cdc.gov. State health department officials seeking technical assistance in epidemiological investigations can contact the CDC at VapingAssocIllness@cdc.gov. State health department officials seeking technical assistance in laboratory testing can discuss with state health department laboratories or contact CDC at VapingAssocIllness@cdc.gov. Recommendations to the public Although this investigation is still ongoing, if you are concerned about these specific health risks, please consider avoiding e-cigarette products. Regardless of the ongoing investigation, anyone who uses e-cigarette products should not buy these products on the street (for example, e-cigarette products with THC, other cannabinoids), and should not modify e-cigarette products or add any substances to them. These products are not the intention of the manufacturer. Regardless of ongoing investigations, adolescents, young adults, pregnant women, and adults who currently do not use tobacco products should not use e-cigarette products. If you use e-cigarette products, please monitor your symptoms (such as cough, shortness of breath, chest pain), and if you have concerns about your health, please seek medical attention immediately. As more information becomes available, the CDC and FDA will continue to provide advice and warnings to the public. Adult smokers trying to quit smoking should use evidence-based treatment, including counseling and FDA-approved drug treatment. If you need help quitting tobacco products, including e-cigarettes, please contact your doctor. If you are concerned about the harmful effects of e-cigarette products, please call your local poison control center: 1-800-222-1222. We encourage the public to submit detailed reports of any accidental tobacco or e-cigarette-related health or product issues to the FDA through the online safety reporting portal." />

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On September 4, the U.S. Centers for Disease Control and Prevention (CDC) recently issued an update on the death of respiratory diseases caused by the use of suspected e-cigarette products in Illinois. The following is the full text of the statement: The Centers for Disease Control and Prevention (CDC) provided: 1) background information on the form of e-cigarette products, 2) and the use of e-cigarette products (equipment, liquid, refill container and cartridge), and 3) patients with severe lung disease Clinical characteristics. The health consultation also provides advice to clinicians, public health officials and the public based on currently available information. General background Electronic cigarettes usually contain nicotine, most also contain flavorings and other chemicals, and some may contain marijuana or other substances. They are known by many different names and have many shapes, sizes and types of equipment. The device can be called “electronic cigarette”, “vapes”, “e-hookahs”, “vape pen”, “mods”, or electronic nicotine delivery system (ENDS). Some e-cigarette devices are similar to other tobacco products, such as cigarettes; some are similar to ordinary household items, such as USB flash drives, pens and flashlights; and others have unique shapes. The use of electronic cigarettes is sometimes referred to as "vaping" or "juuling". E-cigarettes may contain harmful or potentially harmful substances, including nicotine, heavy metals (such as lead), volatile organic compounds, and carcinogenic chemicals. In addition, some e-cigarette products are used to transport illegal substances; they can be obtained from unknown or unauthorized (ie "street") sources; and they can be modified for potential uses that may increase their harm to users. For example, some electronic cigarette cases or boxes for single use can be refilled with illegal or unknown substances. In addition, some e-cigarette products are used for “drip water” or “tap”. Dripping involves dropping the e-cigarette liquid directly onto the hot coil of the e-cigarette, which results in high concentrations of compounds (for example, tetrahydrocannabinol [THC]] and cannabinoid compounds). Adolescents, young adults, pregnant women and adults who currently do not use tobacco products should not use e-cigarettes. Electronic cigarettes containing nicotine may help some individual adult smokers reduce their use and transition of cigarettes. However, e-cigarettes have not yet been approved by the U.S. Food and Drug Administration (FDA) as a smoking cessation aid, and existing science has not yet determined whether e-cigarettes are effective for smoking cessation. Background of the outbreak As of August 27, 2019, 25 states have reported 215 possible cases, and another report of lung disease is under investigation. One patient (Illinois) had a recent history of e-cigarette use, was hospitalized for severe lung disease, and then died. Although the etiology of e-cigarette-related lung diseases has not yet been determined, epidemiological investigations in affected countries are underway to better describe patients鈥 exposure, demographics, clinical and laboratory characteristics and behaviors. All patients reported using e-cigarette products. The exact number is currently unknown, but many patients report using e-cigarettes containing cannabinoid products such as THC or CBD. According to reports from several states, patients have respiratory symptoms (cough, shortness of breath, or chest pain), and some people have gastrointestinal symptoms (nausea, vomiting, or diarrhea) or non-specific physical symptoms (fatigue, fever, or weight loss). Symptoms usually develop within a few days, but can sometimes last for several weeks. Gastrointestinal symptoms sometimes appear as respiratory symptoms. In the absence of identifiable infectious diseases, fever, tachycardia and elevated white blood cell counts have been reported. Many patients have sought initial care in an outpatient setting before admission, and some of them have seen multiple visits. The results of radiological examinations vary and are not present in all patients when they are first presented. According to reports, bilateral lung infiltration and diffuse ground glass opacity. Many patients require supplemental oxygen, some require assisted ventilation and oxygenation, and some require intubation. Some patients have been treated with corticosteroids and have improved. Antimicrobial therapy alone has not always been associated with clinical improvement. Many patients have completed the assessment of the cause of the infection, but there is no definite cause of the infection. Several patients from one state were diagnosed with lipoid pneumonia based on clinical manifestations and detected lipids in bronchoalveolar lavage samples that were specifically stained to detect oil. All patients reported using e-cigarette products, and the time of appearance of symptoms ranged from a few days to several weeks after e-cigarette use. In both states, many patients have recently inhaled cannabinoid products, THC or cannabidiol. So far, no single substance or e-cigarette product has always been associated with disease. CDC is working closely with state health departments to facilitate the collection of product samples for testing at the FDA Forensic Chemistry Center. Recommendations to clinicians Report severe lung disease of unknown etiology and a history of e-cigarette product use to your state or local health department in the past 90 days. Reporting cases may help the CDC and state health departments determine the cause of these lung diseases. Ask all patients who have reported the use of e-cigarette products in the past 90 days to understand the signs and symptoms of lung diseases. If you suspect that the use of e-cigarette products may be the cause of the patient鈥檚 severe lung disease, please understand the following in detail: Substances used: nicotine, cannabinoids (e.g., cannabis, THC, THC concentrate, CBD, CBD oil, synthetic cannabinoids [e.g., K2 or spice], hash oil, Dank vapes), spice or other substances. Sources of substances: commercially available liquids (i.e. bottles, cartridges or pods), homemade liquids, and use of homemade or commercially purchased liquids to reuse old cartridges or pods. The device: manufacturer; brand; product name; model; product, device or e-liquid serial number; if the device can be customized by the user; and any product modification of the user (for example, exposure of the atomizer or heating coil) to purchase the product Local substance usage method: atomization, light application or dripping. Other potential cases: sharing e-cigarette products (equipment, liquid, refill box or ink cartridge) with others to determine if there are any remaining products (including equipment and liquid) available for testing. The testing can be coordinated with the local or state health department. Consider all possible causes of illness in patients reporting respiratory and gastrointestinal symptoms and e-cigarette product use. Evaluate and treat other possible causes of diseases based on clinical indications (for example, infectious diseases, rheumatism, tumors). Consider consulting a specialist as appropriate (pulmonary, infectious diseases, intensive care, medical toxicology). The clinical improvement of the use of corticosteroids in the treatment of patients with severe lung diseases associated with e-cigarettes has been reported. The decision to use corticosteroids should be made on a case-by-case basis based on the risks and benefits and the likelihood of other causes. Based on the detection of lipid-loaded alveolar macrophages obtained by bronchoalveolar lavage (BAL) and lipid staining, lipoid pneumonia associated with the inhalation of lipids in aerosols produced by electronic cigarettes has been reported. The decision on whether to proceed with BAL should be based on the individual's clinical situation. Lung biopsies have been performed on some patients. If a lung biopsy is obtained, lipid staining can be considered during the pathological examination, and it is best to perform it on fresh tissue. Routine pathological tissue processing (including formalin fixation and paraffin embedding) can remove lipids. Routine tissue processing and histopathological evaluation are still important. Consider consulting pulmonary medicine and pathology experts to help inform any evaluation plans. Patients who have received treatment for severe lung diseases related to e-cigarette products should undergo follow-up evaluation as indicated by the clinical practice to monitor lung function. Advice to Public Health Officials State public health officials should notify the CDC of possible cases through VapingAssocIllness@cdc.gov. For case classification standards, reporting guidelines, case investigation forms, and questions about the outbreak, please contact the CDC at VapingAssocIllness@cdc.gov. Consider using existing data sources for case discovery activities (for example, local poison control centers, coroner and medical examiner offices, and other applicable surveillance systems, including syndrome surveillance). The CDC has developed two effective definitions of syndrome surveillance (one with specific symptoms, the other focusing on the use of e-cigarette products). CDC will program these definitions in the BioSense/ESSENCE platform of the CDC's National Syndrome Surveillance Program for case detection within the platform. Consider asking the medical examiner or coroner's office and other pathologists to report possible cases, especially those for which there are no other possible diagnoses. If an individual is found to show signs of severe lung disease as described above after death or an autopsy, the medical examiner and coroner are encouraged to report the case to the local or state health department. It is recommended to thoroughly sample the trachea, bronchus and lung parenchyma, collect fresh lung tissue for staining lipids (such as oil red O), provide formalin fixation, and paraffin-embed the tissue for routine histopathological examination. For further consultation, public health officials can contact the Infectious Disease Pathology Department of the Centers for Disease Control and Prevention at pathology@cdc.gov. State health department officials seeking technical assistance in epidemiological investigations can contact the CDC at VapingAssocIllness@cdc.gov. State health department officials seeking technical assistance in laboratory testing can discuss with state health department laboratories or contact CDC at VapingAssocIllness@cdc.gov. Recommendations to the public Although this investigation is still ongoing, if you are concerned about these specific health risks, please consider avoiding e-cigarette products. Regardless of the ongoing investigation, anyone who uses e-cigarette products should not buy these products on the street (for example, e-cigarette products with THC, other cannabinoids), and should not modify e-cigarette products or add any substances to them. These products are not the intention of the manufacturer. Regardless of ongoing investigations, adolescents, young adults, pregnant women, and adults who currently do not use tobacco products should not use e-cigarette products. If you use e-cigarette products, please monitor your symptoms (such as cough, shortness of breath, chest pain), and if you have concerns about your health, please seek medical attention immediately. As more information becomes available, the CDC and FDA will continue to provide advice and warnings to the public. Adult smokers trying to quit smoking should use evidence-based treatment, including counseling and FDA-approved drug treatment. If you need help quitting tobacco products, including e-cigarettes, please contact your doctor. If you are concerned about the harmful effects of e-cigarette products, please call your local poison control center: 1-800-222-1222. We encourage the public to submit detailed reports of any accidental tobacco or e-cigarette-related health or product issues to the FDA through the online safety reporting portal.US Centers for Disease Control and Prevention responds to suspected deaths caused by e-cigarettes: Three suggestions are made

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US Centers for Disease Control and Prevention responds to suspected deaths caused by e-cigarettes: Three suggestions are made

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US Centers for Disease Control and Prevention responds to suspected deaths caused by e-cigarettes: Three suggestions are made

On September 4, the U.S. Centers for Disease Control and Prevention (CDC) recently issued an update on the death of respiratory diseases caused by the use of suspected e-cigarette products in Illinois. The following is the full text of the statement: The Centers for Disease Control and Prevention (CDC) provided: 1) background information on the form of e-cigarette products, 2) and the use of e-cigarette products (equipment, liquid, refill container and cartridge), and 3) patients with severe lung disease Clinical characteristics. The health consultation also provides advice to clinicians, public health officials and the public based on currently available information. General background Electronic cigarettes usually contain nicotine, most also contain flavorings and other chemicals, and some may contain marijuana or other substances. They are known by many different names and have many shapes, sizes and types of equipment. The device can be called “electronic cigarette”, “vapes”, “e-hookahs”, “vape pen”, “mods”, or electronic nicotine delivery system (ENDS). Some e-cigarette devices are similar to other tobacco products, such as cigarettes; some are similar to ordinary household items, such as USB flash drives, pens and flashlights; and others have unique shapes. The use of electronic cigarettes is sometimes referred to as "vaping" or "juuling". E-cigarettes may contain harmful or potentially harmful substances, including nicotine, heavy metals (such as lead), volatile organic compounds, and carcinogenic chemicals. In addition, some e-cigarette products are used to transport illegal substances; they can be obtained from unknown or unauthorized (ie "street") sources; and they can be modified for potential uses that may increase their harm to users. For example, some electronic cigarette cases or boxes for single use can be refilled with illegal or unknown substances. In addition, some e-cigarette products are used for “drip water” or “tap”. Dripping involves dropping the e-cigarette liquid directly onto the hot coil of the e-cigarette, which results in high concentrations of compounds (for example, tetrahydrocannabinol [THC]] and cannabinoid compounds). Adolescents, young adults, pregnant women and adults who currently do not use tobacco products should not use e-cigarettes. Electronic cigarettes containing nicotine may help some individual adult smokers reduce their use and transition of cigarettes. However, e-cigarettes have not yet been approved by the U.S. Food and Drug Administration (FDA) as a smoking cessation aid, and existing science has not yet determined whether e-cigarettes are effective for smoking cessation. Background of the outbreak As of August 27, 2019, 25 states have reported 215 possible cases, and another report of lung disease is under investigation. One patient (Illinois) had a recent history of e-cigarette use, was hospitalized for severe lung disease, and then died. Although the etiology of e-cigarette-related lung diseases has not yet been determined, epidemiological investigations in affected countries are underway to better describe patients鈥 exposure, demographics, clinical and laboratory characteristics and behaviors. All patients reported using e-cigarette products. The exact number is currently unknown, but many patients report using e-cigarettes containing cannabinoid products such as THC or CBD. According to reports from several states, patients have respiratory symptoms (cough, shortness of breath, or chest pain), and some people have gastrointestinal symptoms (nausea, vomiting, or diarrhea) or non-specific physical symptoms (fatigue, fever, or weight loss). Symptoms usually develop within a few days, but can sometimes last for several weeks. Gastrointestinal symptoms sometimes appear as respiratory symptoms. In the absence of identifiable infectious diseases, fever, tachycardia and elevated white blood cell counts have been reported. Many patients have sought initial care in an outpatient setting before admission, and some of them have seen multiple visits. The results of radiological examinations vary and are not present in all patients when they are first presented. According to reports, bilateral lung infiltration and diffuse ground glass opacity. Many patients require supplemental oxygen, some require assisted ventilation and oxygenation, and some require intubation. Some patients have been treated with corticosteroids and have improved. Antimicrobial therapy alone has not always been associated with clinical improvement. Many patients have completed the assessment of the cause of the infection, but there is no definite cause of the infection. Several patients from one state were diagnosed with lipoid pneumonia based on clinical manifestations and detected lipids in bronchoalveolar lavage samples that were specifically stained to detect oil. All patients reported using e-cigarette products, and the time of appearance of symptoms ranged from a few days to several weeks after e-cigarette use. In both states, many patients have recently inhaled cannabinoid products, THC or cannabidiol. So far, no single substance or e-cigarette product has always been associated with disease. CDC is working closely with state health departments to facilitate the collection of product samples for testing at the FDA Forensic Chemistry Center. Recommendations to clinicians Report severe lung disease of unknown etiology and a history of e-cigarette product use to your state or local health department in the past 90 days. Reporting cases may help the CDC and state health departments determine the cause of these lung diseases. Ask all patients who have reported the use of e-cigarette products in the past 90 days to understand the signs and symptoms of lung diseases. If you suspect that the use of e-cigarette products may be the cause of the patient鈥檚 severe lung disease, please understand the following in detail: Substances used: nicotine, cannabinoids (e.g., cannabis, THC, THC concentrate, CBD, CBD oil, synthetic cannabinoids [e.g., K2 or spice], hash oil, Dank vapes), spice or other substances. Sources of substances: commercially available liquids (i.e. bottles, cartridges or pods), homemade liquids, and use of homemade or commercially purchased liquids to reuse old cartridges or pods. The device: manufacturer; brand; product name; model; product, device or e-liquid serial number; if the device can be customized by the user; and any product modification of the user (for example, exposure of the atomizer or heating coil) to purchase the product Local substance usage method: atomization, light application or dripping. Other potential cases: sharing e-cigarette products (equipment, liquid, refill box or ink cartridge) with others to determine if there are any remaining products (including equipment and liquid) available for testing. The testing can be coordinated with the local or state health department. Consider all possible causes of illness in patients reporting respiratory and gastrointestinal symptoms and e-cigarette product use. Evaluate and treat other possible causes of diseases based on clinical indications (for example, infectious diseases, rheumatism, tumors). Consider consulting a specialist as appropriate (pulmonary, infectious diseases, intensive care, medical toxicology). The clinical improvement of the use of corticosteroids in the treatment of patients with severe lung diseases associated with e-cigarettes has been reported. The decision to use corticosteroids should be made on a case-by-case basis based on the risks and benefits and the likelihood of other causes. Based on the detection of lipid-loaded alveolar macrophages obtained by bronchoalveolar lavage (BAL) and lipid staining, lipoid pneumonia associated with the inhalation of lipids in aerosols produced by electronic cigarettes has been reported. The decision on whether to proceed with BAL should be based on the individual's clinical situation. Lung biopsies have been performed on some patients. If a lung biopsy is obtained, lipid staining can be considered during the pathological examination, and it is best to perform it on fresh tissue. Routine pathological tissue processing (including formalin fixation and paraffin embedding) can remove lipids. Routine tissue processing and histopathological evaluation are still important. Consider consulting pulmonary medicine and pathology experts to help inform any evaluation plans. Patients who have received treatment for severe lung diseases related to e-cigarette products should undergo follow-up evaluation as indicated by the clinical practice to monitor lung function. Advice to Public Health Officials State public health officials should notify the CDC of possible cases through VapingAssocIllness@cdc.gov. For case classification standards, reporting guidelines, case investigation forms, and questions about the outbreak, please contact the CDC at VapingAssocIllness@cdc.gov. Consider using existing data sources for case discovery activities (for example, local poison control centers, coroner and medical examiner offices, and other applicable surveillance systems, including syndrome surveillance). The CDC has developed two effective definitions of syndrome surveillance (one with specific symptoms, the other focusing on the use of e-cigarette products). CDC will program these definitions in the BioSense/ESSENCE platform of the CDC's National Syndrome Surveillance Program for case detection within the platform. Consider asking the medical examiner or coroner's office and other pathologists to report possible cases, especially those for which there are no other possible diagnoses. If an individual is found to show signs of severe lung disease as described above after death or an autopsy, the medical examiner and coroner are encouraged to report the case to the local or state health department. It is recommended to thoroughly sample the trachea, bronchus and lung parenchyma, collect fresh lung tissue for staining lipids (such as oil red O), provide formalin fixation, and paraffin-embed the tissue for routine histopathological examination. For further consultation, public health officials can contact the Infectious Disease Pathology Department of the Centers for Disease Control and Prevention at pathology@cdc.gov. State health department officials seeking technical assistance in epidemiological investigations can contact the CDC at VapingAssocIllness@cdc.gov. State health department officials seeking technical assistance in laboratory testing can discuss with state health department laboratories or contact CDC at VapingAssocIllness@cdc.gov. Recommendations to the public Although this investigation is still ongoing, if you are concerned about these specific health risks, please consider avoiding e-cigarette products. Regardless of the ongoing investigation, anyone who uses e-cigarette products should not buy these products on the street (for example, e-cigarette products with THC, other cannabinoids), and should not modify e-cigarette products or add any substances to them. These products are not the intention of the manufacturer. Regardless of ongoing investigations, adolescents, young adults, pregnant women, and adults who currently do not use tobacco products should not use e-cigarette products. If you use e-cigarette products, please monitor your symptoms (such as cough, shortness of breath, chest pain), and if you have concerns about your health, please seek medical attention immediately. As more information becomes available, the CDC and FDA will continue to provide advice and warnings to the public. Adult smokers trying to quit smoking should use evidence-based treatment, including counseling and FDA-approved drug treatment. If you need help quitting tobacco products, including e-cigarettes, please contact your doctor. If you are concerned about the harmful effects of e-cigarette products, please call your local poison control center: 1-800-222-1222. We encourage the public to submit detailed reports of any accidental tobacco or e-cigarette-related health or product issues to the FDA through the online safety reporting portal.

On September 4, the U.S. Centers for Disease Control and Prevention (CDC) recently issued an update on the death of respiratory diseases caused by the use of suspected e-cigarette products in Illinois. The following is the full text of the statement: The Centers for Disease Control and Prevention (CDC) provided: 1) background information on the form of e-cigarette products, 2) and the use of e-cigarette products (equipment, liquid, refill container and cartridge), and 3) patients with severe lung disease Clinical characteristics. The health consultation also provides advice to clinicians, public health officials and the public based on currently available information. General background Electronic cigarettes usually contain nicotine, most also contain flavorings and other chemicals, and some may contain marijuana or other substances. They are known by many different names and have many shapes, sizes and types of equipment. The device can be called “electronic cigarette”, “vapes”, “e-hookahs”, “vape pen”, “mods”, or electronic nicotine delivery system (ENDS). Some e-cigarette devices are similar to other tobacco products, such as cigarettes; some are similar to ordinary household items, such as USB flash drives, pens and flashlights; and others have unique shapes. The use of electronic cigarettes is sometimes referred to as "vaping" or "juuling". E-cigarettes may contain harmful or potentially harmful substances, including nicotine, heavy metals (such as lead), volatile organic compounds, and carcinogenic chemicals. In addition, some e-cigarette products are used to transport illegal substances; they can be obtained from unknown or unauthorized (ie "street") sources; and they can be modified for potential uses that may increase their harm to users. For example, some electronic cigarette cases or boxes for single use can be refilled with illegal or unknown substances. In addition, some e-cigarette products are used for “drip water” or “tap”. Dripping involves dropping the e-cigarette liquid directly onto the hot coil of the e-cigarette, which results in high concentrations of compounds (for example, tetrahydrocannabinol [THC]] and cannabinoid compounds). Adolescents, young adults, pregnant women and adults who currently do not use tobacco products should not use e-cigarettes. Electronic cigarettes containing nicotine may help some individual adult smokers reduce their use and transition of cigarettes. However, e-cigarettes have not yet been approved by the U.S. Food and Drug Administration (FDA) as a smoking cessation aid, and existing science has not yet determined whether e-cigarettes are effective for smoking cessation. Background of the outbreak As of August 27, 2019, 25 states have reported 215 possible cases, and another report of lung disease is under investigation. One patient (Illinois) had a recent history of e-cigarette use, was hospitalized for severe lung disease, and then died. Although the etiology of e-cigarette-related lung diseases has not yet been determined, epidemiological investigations in affected countries are underway to better describe patients鈥 exposure, demographics, clinical and laboratory characteristics and behaviors. All patients reported using e-cigarette products. The exact number is currently unknown, but many patients report using e-cigarettes containing cannabinoid products such as THC or CBD. According to reports from several states, patients have respiratory symptoms (cough, shortness of breath, or chest pain), and some people have gastrointestinal symptoms (nausea, vomiting, or diarrhea) or non-specific physical symptoms (fatigue, fever, or weight loss). Symptoms usually develop within a few days, but can sometimes last for several weeks. Gastrointestinal symptoms sometimes appear as respiratory symptoms. In the absence of identifiable infectious diseases, fever, tachycardia and elevated white blood cell counts have been reported. Many patients have sought initial care in an outpatient setting before admission, and some of them have seen multiple visits. The results of radiological examinations vary and are not present in all patients when they are first presented. According to reports, bilateral lung infiltration and diffuse ground glass opacity. Many patients require supplemental oxygen, some require assisted ventilation and oxygenation, and some require intubation. Some patients have been treated with corticosteroids and have improved. Antimicrobial therapy alone has not always been associated with clinical improvement. Many patients have completed the assessment of the cause of the infection, but there is no definite cause of the infection. Several patients from one state were diagnosed with lipoid pneumonia based on clinical manifestations and detected lipids in bronchoalveolar lavage samples that were specifically stained to detect oil. All patients reported using e-cigarette products, and the time of appearance of symptoms ranged from a few days to several weeks after e-cigarette use. In both states, many patients have recently inhaled cannabinoid products, THC or cannabidiol. So far, no single substance or e-cigarette product has always been associated with disease. CDC is working closely with state health departments to facilitate the collection of product samples for testing at the FDA Forensic Chemistry Center. Recommendations to clinicians Report severe lung disease of unknown etiology and a history of e-cigarette product use to your state or local health department in the past 90 days. Reporting cases may help the CDC and state health departments determine the cause of these lung diseases. Ask all patients who have reported the use of e-cigarette products in the past 90 days to understand the signs and symptoms of lung diseases. If you suspect that the use of e-cigarette products may be the cause of the patient鈥檚 severe lung disease, please understand the following in detail: Substances used: nicotine, cannabinoids (e.g., cannabis, THC, THC concentrate, CBD, CBD oil, synthetic cannabinoids [e.g., K2 or spice], hash oil, Dank vapes), spice or other substances. Sources of substances: commercially available liquids (i.e. bottles, cartridges or pods), homemade liquids, and use of homemade or commercially purchased liquids to reuse old cartridges or pods. The device: manufacturer; brand; product name; model; product, device or e-liquid serial number; if the device can be customized by the user; and any product modification of the user (for example, exposure of the atomizer or heating coil) to purchase the product Local substance usage method: atomization, light application or dripping. Other potential cases: sharing e-cigarette products (equipment, liquid, refill box or ink cartridge) with others to determine if there are any remaining products (including equipment and liquid) available for testing. The testing can be coordinated with the local or state health department. Consider all possible causes of illness in patients reporting respiratory and gastrointestinal symptoms and e-cigarette product use. Evaluate and treat other possible causes of diseases based on clinical indications (for example, infectious diseases, rheumatism, tumors). Consider consulting a specialist as appropriate (pulmonary, infectious diseases, intensive care, medical toxicology). The clinical improvement of the use of corticosteroids in the treatment of patients with severe lung diseases associated with e-cigarettes has been reported. The decision to use corticosteroids should be made on a case-by-case basis based on the risks and benefits and the likelihood of other causes. Based on the detection of lipid-loaded alveolar macrophages obtained by bronchoalveolar lavage (BAL) and lipid staining, lipoid pneumonia associated with the inhalation of lipids in aerosols produced by electronic cigarettes has been reported. The decision on whether to proceed with BAL should be based on the individual's clinical situation. Lung biopsies have been performed on some patients. If a lung biopsy is obtained, lipid staining can be considered during the pathological examination, and it is best to perform it on fresh tissue. Routine pathological tissue processing (including formalin fixation and paraffin embedding) can remove lipids. Routine tissue processing and histopathological evaluation are still important. Consider consulting pulmonary medicine and pathology experts to help inform any evaluation plans. Patients who have received treatment for severe lung diseases related to e-cigarette products should undergo follow-up evaluation as indicated by the clinical practice to monitor lung function. Advice to Public Health Officials State public health officials should notify the CDC of possible cases through VapingAssocIllness@cdc.gov. For case classification standards, reporting guidelines, case investigation forms, and questions about the outbreak, please contact the CDC at VapingAssocIllness@cdc.gov. Consider using existing data sources for case discovery activities (for example, local poison control centers, coroner and medical examiner offices, and other applicable surveillance systems, including syndrome surveillance). The CDC has developed two effective definitions of syndrome surveillance (one with specific symptoms, the other focusing on the use of e-cigarette products). CDC will program these definitions in the BioSense/ESSENCE platform of the CDC's National Syndrome Surveillance Program for case detection within the platform. Consider asking the medical examiner or coroner's office and other pathologists to report possible cases, especially those for which there are no other possible diagnoses. If an individual is found to show signs of severe lung disease as described above after death or an autopsy, the medical examiner and coroner are encouraged to report the case to the local or state health department. It is recommended to thoroughly sample the trachea, bronchus and lung parenchyma, collect fresh lung tissue for staining lipids (such as oil red O), provide formalin fixation, and paraffin-embed the tissue for routine histopathological examination. For further consultation, public health officials can contact the Infectious Disease Pathology Department of the Centers for Disease Control and Prevention at pathology@cdc.gov. State health department officials seeking technical assistance in epidemiological investigations can contact the CDC at VapingAssocIllness@cdc.gov. State health department officials seeking technical assistance in laboratory testing can discuss with state health department laboratories or contact CDC at VapingAssocIllness@cdc.gov. Recommendations to the public Although this investigation is still ongoing, if you are concerned about these specific health risks, please consider avoiding e-cigarette products. Regardless of the ongoing investigation, anyone who uses e-cigarette products should not buy these products on the street (for example, e-cigarette products with THC, other cannabinoids), and should not modify e-cigarette products or add any substances to them. These products are not the intention of the manufacturer. Regardless of ongoing investigations, adolescents, young adults, pregnant women, and adults who currently do not use tobacco products should not use e-cigarette products. If you use e-cigarette products, please monitor your symptoms (such as cough, shortness of breath, chest pain), and if you have concerns about your health, please seek medical attention immediately. As more information becomes available, the CDC and FDA will continue to provide advice and warnings to the public. Adult smokers trying to quit smoking should use evidence-based treatment, including counseling and FDA-approved drug treatment. If you need help quitting tobacco products, including e-cigarettes, please contact your doctor. If you are concerned about the harmful effects of e-cigarette products, please call your local poison control center: 1-800-222-1222. We encourage the public to submit detailed reports of any accidental tobacco or e-cigarette-related health or product issues to the FDA through the online safety reporting portal.

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On September 4, the U.S. Centers for Disease Control and Prevention (CDC) recently issued an update on the death of respiratory diseases caused by the use of suspected e-cigarette products in Illinois. The following is the full text of the statement: The Centers for Disease Control and Prevention (CDC) provided: 1) background information on the form of e-cigarette products, 2) and the use of e-cigarette products (equipment, liquid, refill container and cartridge), and 3) patients with severe lung disease Clinical characteristics. The health consultation also provides advice to clinicians, public health officials and the public based on currently available information. General background Electronic cigarettes usually contain nicotine, most also contain flavorings and other chemicals, and some may contain marijuana or other substances. They are known by many different names and have many shapes, sizes and types of equipment. The device can be called “electronic cigarette”, “vapes”, “e-hookahs”, “vape pen”, “mods”, or electronic nicotine delivery system (ENDS). Some e-cigarette devices are similar to other tobacco products, such as cigarettes; some are similar to ordinary household items, such as USB flash drives, pens and flashlights; and others have unique shapes. The use of electronic cigarettes is sometimes referred to as "vaping" or "juuling". E-cigarettes may contain harmful or potentially harmful substances, including nicotine, heavy metals (such as lead), volatile organic compounds, and carcinogenic chemicals. In addition, some e-cigarette products are used to transport illegal substances; they can be obtained from unknown or unauthorized (ie "street") sources; and they can be modified for potential uses that may increase their harm to users. For example, some electronic cigarette cases or boxes for single use can be refilled with illegal or unknown substances. In addition, some e-cigarette products are used for “drip water” or “tap”. Dripping involves dropping the e-cigarette liquid directly onto the hot coil of the e-cigarette, which results in high concentrations of compounds (for example, tetrahydrocannabinol [THC]] and cannabinoid compounds). Adolescents, young adults, pregnant women and adults who currently do not use tobacco products should not use e-cigarettes. Electronic cigarettes containing nicotine may help some individual adult smokers reduce their use and transition of cigarettes. However, e-cigarettes have not yet been approved by the U.S. Food and Drug Administration (FDA) as a smoking cessation aid, and existing science has not yet determined whether e-cigarettes are effective for smoking cessation. Background of the outbreak As of August 27, 2019, 25 states have reported 215 possible cases, and another report of lung disease is under investigation. One patient (Illinois) had a recent history of e-cigarette use, was hospitalized for severe lung disease, and then died. Although the etiology of e-cigarette-related lung diseases has not yet been determined, epidemiological investigations in affected countries are underway to better describe patients鈥 exposure, demographics, clinical and laboratory characteristics and behaviors. All patients reported using e-cigarette products. The exact number is currently unknown, but many patients report using e-cigarettes containing cannabinoid products such as THC or CBD. According to reports from several states, patients have respiratory symptoms (cough, shortness of breath, or chest pain), and some people have gastrointestinal symptoms (nausea, vomiting, or diarrhea) or non-specific physical symptoms (fatigue, fever, or weight loss). Symptoms usually develop within a few days, but can sometimes last for several weeks. Gastrointestinal symptoms sometimes appear as respiratory symptoms. In the absence of identifiable infectious diseases, fever, tachycardia and elevated white blood cell counts have been reported. Many patients have sought initial care in an outpatient setting before admission, and some of them have seen multiple visits. The results of radiological examinations vary and are not present in all patients when they are first presented. According to reports, bilateral lung infiltration and diffuse ground glass opacity. Many patients require supplemental oxygen, some require assisted ventilation and oxygenation, and some require intubation. Some patients have been treated with corticosteroids and have improved. Antimicrobial therapy alone has not always been associated with clinical improvement. Many patients have completed the assessment of the cause of the infection, but there is no definite cause of the infection. Several patients from one state were diagnosed with lipoid pneumonia based on clinical manifestations and detected lipids in bronchoalveolar lavage samples that were specifically stained to detect oil. All patients reported using e-cigarette products, and the time of appearance of symptoms ranged from a few days to several weeks after e-cigarette use. In both states, many patients have recently inhaled cannabinoid products, THC or cannabidiol. So far, no single substance or e-cigarette product has always been associated with disease. CDC is working closely with state health departments to facilitate the collection of product samples for testing at the FDA Forensic Chemistry Center. Recommendations to clinicians Report severe lung disease of unknown etiology and a history of e-cigarette product use to your state or local health department in the past 90 days. Reporting cases may help the CDC and state health departments determine the cause of these lung diseases. Ask all patients who have reported the use of e-cigarette products in the past 90 days to understand the signs and symptoms of lung diseases. If you suspect that the use of e-cigarette products may be the cause of the patient鈥檚 severe lung disease, please understand the following in detail: Substances used: nicotine, cannabinoids (e.g., cannabis, THC, THC concentrate, CBD, CBD oil, synthetic cannabinoids [e.g., K2 or spice], hash oil, Dank vapes), spice or other substances. Sources of substances: commercially available liquids (i.e. bottles, cartridges or pods), homemade liquids, and use of homemade or commercially purchased liquids to reuse old cartridges or pods. The device: manufacturer; brand; product name; model; product, device or e-liquid serial number; if the device can be customized by the user; and any product modification of the user (for example, exposure of the atomizer or heating coil) to purchase the product Local substance usage method: atomization, light application or dripping. Other potential cases: sharing e-cigarette products (equipment, liquid, refill box or ink cartridge) with others to determine if there are any remaining products (including equipment and liquid) available for testing. The testing can be coordinated with the local or state health department. Consider all possible causes of illness in patients reporting respiratory and gastrointestinal symptoms and e-cigarette product use. Evaluate and treat other possible causes of diseases based on clinical indications (for example, infectious diseases, rheumatism, tumors). Consider consulting a specialist as appropriate (pulmonary, infectious diseases, intensive care, medical toxicology). The clinical improvement of the use of corticosteroids in the treatment of patients with severe lung diseases associated with e-cigarettes has been reported. The decision to use corticosteroids should be made on a case-by-case basis based on the risks and benefits and the likelihood of other causes. Based on the detection of lipid-loaded alveolar macrophages obtained by bronchoalveolar lavage (BAL) and lipid staining, lipoid pneumonia associated with the inhalation of lipids in aerosols produced by electronic cigarettes has been reported. The decision on whether to proceed with BAL should be based on the individual's clinical situation. Lung biopsies have been performed on some patients. If a lung biopsy is obtained, lipid staining can be considered during the pathological examination, and it is best to perform it on fresh tissue. Routine pathological tissue processing (including formalin fixation and paraffin embedding) can remove lipids. Routine tissue processing and histopathological evaluation are still important. Consider consulting pulmonary medicine and pathology experts to help inform any evaluation plans. Patients who have received treatment for severe lung diseases related to e-cigarette products should undergo follow-up evaluation as indicated by the clinical practice to monitor lung function. Advice to Public Health Officials State public health officials should notify the CDC of possible cases through VapingAssocIllness@cdc.gov. For case classification standards, reporting guidelines, case investigation forms, and questions about the outbreak, please contact the CDC at VapingAssocIllness@cdc.gov. Consider using existing data sources for case discovery activities (for example, local poison control centers, coroner and medical examiner offices, and other applicable surveillance systems, including syndrome surveillance). The CDC has developed two effective definitions of syndrome surveillance (one with specific symptoms, the other focusing on the use of e-cigarette products). CDC will program these definitions in the BioSense/ESSENCE platform of the CDC's National Syndrome Surveillance Program for case detection within the platform. Consider asking the medical examiner or coroner's office and other pathologists to report possible cases, especially those for which there are no other possible diagnoses. If an individual is found to show signs of severe lung disease as described above after death or an autopsy, the medical examiner and coroner are encouraged to report the case to the local or state health department. It is recommended to thoroughly sample the trachea, bronchus and lung parenchyma, collect fresh lung tissue for staining lipids (such as oil red O), provide formalin fixation, and paraffin-embed the tissue for routine histopathological examination. For further consultation, public health officials can contact the Infectious Disease Pathology Department of the Centers for Disease Control and Prevention at pathology@cdc.gov. State health department officials seeking technical assistance in epidemiological investigations can contact the CDC at VapingAssocIllness@cdc.gov. State health department officials seeking technical assistance in laboratory testing can discuss with state health department laboratories or contact CDC at VapingAssocIllness@cdc.gov. Recommendations to the public Although this investigation is still ongoing, if you are concerned about these specific health risks, please consider avoiding e-cigarette products. Regardless of the ongoing investigation, anyone who uses e-cigarette products should not buy these products on the street (for example, e-cigarette products with THC, other cannabinoids), and should not modify e-cigarette products or add any substances to them. These products are not the intention of the manufacturer. Regardless of ongoing investigations, adolescents, young adults, pregnant women, and adults who currently do not use tobacco products should not use e-cigarette products. If you use e-cigarette products, please monitor your symptoms (such as cough, shortness of breath, chest pain), and if you have concerns about your health, please seek medical attention immediately. As more information becomes available, the CDC and FDA will continue to provide advice and warnings to the public. Adult smokers trying to quit smoking should use evidence-based treatment, including counseling and FDA-approved drug treatment. If you need help quitting tobacco products, including e-cigarettes, please contact your doctor. If you are concerned about the harmful effects of e-cigarette products, please call your local poison control center: 1-800-222-1222. We encourage the public to submit detailed reports of any accidental tobacco or e-cigarette-related health or product issues to the FDA through the online safety reporting portal.

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US Centers for Disease Control and Prevention responds to suspected deaths caused by e-cigarettes: Three suggestions are made

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