Throughout the fall, health officials made a national push to intervene in an outbreak of vaping-related lung injuries.
Media reports about a crisis seemingly came out daily.
As suddenly as the outbreak began, it seems to have stopped.
The last notification the Missouri Department of Health and Senior Services provided, on Nov. 14, indicated a middle-age Missouri woman died after suffering lung injuries associated with vaping. But the woman had been fighting a chronic, long-standing lung condition before the injuries.
DHSS began requiring physicians to report the lung injuries shortly after the outbreak began, according to Kristi Campbell, director of the Cole County Health Department.
And, of late, DHSS has been busy monitoring the coronavirus in China and a large hepatitis A outbreak as well as updating information on those illnesses. As of Feb. 15, 655 Missouri cases have been linked to a hepatitis A outbreak (primarily in southern Missouri). Two deaths have also been connected to the hepatitis outbreak.
It's possible another disease has taken the spotlight from the lung injuries, Campbell said.
For a couple of months, vaping and the injuries were all we heard about.
The Children's Hospital of Wisconsin on July 10, 2019, notified state health officials it was treating five (previously healthy) adolescents - who had been admitted within the past month - for progressive difficulty breathing, low blood oxygen and fatigue. Doctors placed two of the children on ventilators.
About two weeks later, the Wisconsin Department of Health Services issued an alert to clinicians to be aware of similar pulmonary conditions associated with the use of e-cigarettes, or vapes, according to a report in the New England Journal of Medicine.
An Illinois physician contacted Wisconsin health officials, asking for guidance treating the same conditions for a patient. Wisconsin health officials notified their colleagues in Illinois, and the agencies began a joint public health investigation and consulted the Centers for Disease Control and Prevention, the report stated.
Before long, a CDC team was deployed to the Midwest states. It found some patients began experiencing symptoms in April.
On Aug. 30, the CDC released a health advisory concerning severe pulmonary disease associated with e-cigarette use.
E-cigarettes typically contain nicotine, and most also contain flavorings and other chemicals, the advisory stated. Some may contain marijuana or other substances.
"Additionally, some e-cigarette products are used to deliver illicit substances; may be acquired from unknown or unauthorized (i.e., 'street') sources; and may be modified for uses that could increase their potential for harm to the user," it said.
The CDC said health officials in 25 states reported 215 possible cases of vaping-related lung injuries by Aug. 27.
At that time, one patient in Illinois with a history of vape use had died after suffering severe pulmonary disease.
The number of lung-injury patients continued to climb and peaked in mid-September. By then, nine possible cases had been identified in Missouri, according to a state Department of Health and Senior Services news release.
Patient symptoms ranged from cough, shortness of breath, chest pain, nausea and vomiting or diarrhea, to fatigue, fever, weight loss or elevated heart rate. There seemed to be some common practices involved in the vaping use. And health officials warned e-cigarette products should not be bought off the street nor modified by adding substances, such as THC or other cannabinoids, not intended for the device by the manufacturer.
In early September, President Donald Trump asked the U.S. Food and Drug Administration to ban all fruit-flavored vapes. About Sept. 13, broadcasters stopped running ads for Juul brand e-cigarettes, which heat up a refillable cartridge containing oils to create vapor. On Oct. 7, the company announced it had stopped selling fruit-flavored pods because of their popularity with young users. On Nov. 17, it also stopped selling mint-flavored pods.
A Missouri man who died the week ending Sept. 22 was the state's first fatality associated with the lung injuries. By then, the state had conducted 22 investigations into cases of pulmonary disease possibly linked to vaping.
CDC data show the national outbreak was already on the decline in mid-October when Missouri Gov. Mike Parson called on state agencies to create and launch a "Clear the Air" campaign aimed at reducing youth vaping, which was skyrocketing at the same time that the outbreak of lung injuries was peaking. The number of reported cases was down about 50 percent from a month earlier.
CDC data indicate cases nationwide continued to fall. During the latest reported week (ending Jan. 26), health officials reported three potential cases of lung injuries nationwide.
What happened with the outbreak is unclear.
It became evident early on that use of THC in the vaping products was relatively common among people who suffered the lung injuries, according to a CDC report. The "Update: Characteristics of a Nationwide Outbreak of E-cigarette, or Vaping Product Use-Associated Lung Injury - United States, August 2019-January 2020" report showed 82 percent of the lung-injury patients verified they used THC in their e-cigarettes.
By then - Jan. 17 - 2,668 people had been hospitalized with symptoms associated with the lung injuries.
Additionally, there were strong indications the use of lipids (fatty acids like Vitamin E) contributed to the injuries.
Vitamin E acetate was not found in the lung fluids of people who do not have e-cigarette or vaping product use-associated lung injury (EVALI), Joel London, the senior press officer for the Office on Smoking and Health told the News Tribune in an email. But, it is commonly found in the lungs of people who suffer from EVALI.
A late-December report in the New England Journal of Medicine sampled bronchial fluids from 51 patients in 16 states. Researchers detected vitamin E acetate (which is sometimes used as a thickening agent for THC oil) in 48 of the patients.
"Vitamin E acetate is strongly linked to the EVALI outbreak and should not be added to any e-cigarette or vaping products," the CDC update stated. "However, evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC- or non-THC-containing products (in some cases)."
The CDC fell short of saying the outbreak has ended. Because of progress made in the investigation - including the identification of a strong link between EVALI and vitamin E acetate, as well as the marked decline in cases since September 2019 - addressing the public health threat no longer requires the same magnitude of scope of resources and personnel, London said.
"National emergency department data and active case reporting from state health departments around the country show a sharp rise in symptoms or cases of EVALI in August 2019, a peak in September 2019, and a gradual, but persistent decline since that time," London said. "Some cases and deaths continue to be reported to CDC; however, the extent of cases and deaths have considerably and consistently declined since the peak that occurred in September 2019."
The CDC continues to work with the FDA, individual states, public health partners and clinicians - providing consultation and technical assistance on communications, health alerts, outreach and surveillance.
"Investigations into EVALI are state-led, and individual states have been submitting data to CDC on EVALI cases and deaths on a routine basis since August 2019. CDC will stop collecting these data from states by the end of Feb. 28, but individual states may choose to continue collecting these data," London said. "However, although these data will no longer be requested from states, CDC will continue to conduct a variety of activities related to EVALI, including ongoing surveillance of emergency department visits related to e-cigarette, or vaping, products, technical assistance to states and clinicians, and updates to the public and others via the CDC's EVALI website, cdc.gov/lunginjury."