Good afternoon, everyone, I'm Kellee Waters, a health communication specialist in CDC’s Center for Preparedness and Response, Division of Emergency Operations. Thank you for joining us for today's EPIC webinar titled An Update on CDC's response to E-Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI). If you do not wish for your participation to be recorded, please exit at this time. 

You can earn continuing education by completing this webinar. Instructions on how to earn continuing education can be found on our website, emergency.cdc.gov/epic. The course access code is EPIC1204 with all letters capitalized. To repeat, the course code to recieve continuing edication is, in all caps EPIC1204.

Today's webinar is interactive. To make a comment, click the chat button on your screen and then enter your thoughts. 

To ask a question. please use the Q&A button. The Q&A session will begin after our presenter has finished. 

Closed captions are available for this webinar. We're fortunate today to have Teresa Wang with us to discuss this public health emergency. Dr. 

Wang serves as a subject matter expert on tobacco product use surveillance among U. S. youth and adults. 

She's a lieutenant commander in U. S. public health service commission core. 

She holds a Ph. D. and masters in bioinformatics from Boston university and bachelors in biomedical engineering from University of Michigan, Ann Arbor. 

Dr. Wang, please begin. 

     Hi, everyone, thank you for joining us today and for your interest in learning about this emergency response. As you may be aware, CDC has been partnering with colleagues at the U. S. 

Food and Drug Administration, state and local health departments and other public health and clinical stakeholders to investigate and gain a comprehensive understanding of e-cigarette or vaping product use associated lung injury. Next slide, please. First off, this outbreak is occurring in the context of a dynamic marketplace. 

For ecigarettes or vaping products. So. here's a very brief overview of these tobacco products. 

Ecigarettes or vaping products first entered the U. S. marketplace around Ecigarettes have rapidly diversified and come in many different shapes. 

You may hear them described as vapes, e-hookahs, vape pens, tank systems, mods and electronic nicotine delivery systems. Ecigarettes work by heating a liquid to produce an aerosol that users inhale. Liquids can contain nicotine, as well as Tetrahydrocannabinol and cannabinoid oils. 

As well as other substances and additives we'll talk about later. CDC's mission is to save lives and protect people from health threats. In responding to public health emergencies, CDC's first steps are to understand what is happening, establish where it's happening and collect as rapidly, as feasible relevant data to inform next steps. 

With regard to valley, CDC has been working 24/7 to identify root causes of this outbreak. In August 2019, Wisconsin alerted CDC about pulmonary injury among young adults in that area of the country. CDC has been working to address this public health crisis. 

On August 26th, CDC implemented an incident command structure. Then. on September 16th, CDC activated its Emergency Operations Center or EOC to enable it to dedicate more resources to this investigation. 

And. to date, approximately 300 staff from across the agency have been engaged in response efforts, including multiple staff who have been deployed to assist health departments in investigating these lung injuries. CDC's lung injury response efforts have been multifaceted and in addition to being committed to identifying, defining the risk factors or causes of EVALI, CDC is detecting and tracking cases of EVALI in the U. 

S. Through information collected and committed to communicating actionable recommendations, to state, local and clinical audiences. Next slide, please. 

What are symptoms associated with EVALI? Based on data submitted to CDC, patients in this investigation have reported respiratory, gastrointestinal and constitutional symptoms. Respiratory symptoms have included cough, shortness of breath or chest pain, gastrointestinal symptoms include nausea, vomiting, abdominal pain or diarrhea, and constitutional symptoms have included fever, chills, or weight loss. Next slide, please? Some patients reported that their symptoms developed over a few days, while others reported symptoms developed over several weeks. 

In some patients, gastrointestinal symptoms preceded respiratory symptoms. Next slide? To date. this complex investigation spans almost all states and involves over 2,000 patients, as well as a wide variety of brands, substances and e-cigarette or vaping products. 

Specifically, as of November 20th, 2,290 cases of EVALI have been reported to CDC from 49 states. The District of Columbia, Puerto Rico and U. S. 

Virgin Islands. 47 deaths confirmed in 25 states and District of Columbia. All patients have reported a history of using ecigarettes or vaping products. 

You can check for the latest data on CDC. gov/lunginjury. Next slide. 

Here you can see the distribution of the cases, geographically, by U. S. , state, and territory. 

Again. EVALI cases have been reported to CDC from 49 states, all accept Alaska and two territories, with the highest counts in dark green in California, Texas and Illinois. Next slide, please? Hospital admission for patients with EVALI in blue. 

The most-recent set of data points may suggest that the number of cases is declining. However. it's also important to take into account additional factors, such as reporting lag. 

This is a state-led investigation and. it can take time for states and providers to report their cases to CDC. Next slide. 

CDC recently updated the characteristics of EVALI cases. Among the 2016 cases of EVALI reported to CDC with available data on hospitalization status as of November 5th, 95% of patients were hospitalized and 5% were not hospitalized. 68% were male and 77% were under the age of 35 years. 

With a median of 24 years and age range from 13 to 78 years. Next slide. So. 

here's a more-detailed break down by age group. 15% of patients were under the age of 18. 38% of patients were between the ages of 18 to 24. 

24% of patients were between the ages of 25 to 34 and 23% of patients were 35 years or older. Next slide. CDC has also examined the information on substances used in e-cigarette or vaping products in the three months prior to symptom onset. 

Among EVALI patients with these information, 83% reported using THC-containing products, with 35% reporting exclusive use of THC-containing products. 61% reported using nicotine-containing products, with 13% reporting exclusive use of nicotine-containing products. 48% reported both THC and nicotine-containing product use and 4% reported no THC or nicotine-containing product use. 

Additionally, available data suggests that nonhospitalized EVALI patients have similar demographic and e-cigarette or vaping product use characteristics as do the hospitalized EVALI patients. Next slide. At this time, we know that most patients report a history of using THC-containing products. 

And that THC is present in most of the samples tested by FDA to date. Furthermore, the latest national and state findings suggest products containing THC, particularly those obtained off the street or from informal sources, such as friends, family members, or in-person or online dealers are linked to most of the cases and may play a major role in the outbreak. Next slide. 

For this response. CDC is aggregating data from its epidemiologic investigations with findings from laboratory testing of clinical and tobacco product samples in collaboration with FDA. To really try to fit the puzzle pieces together and identify who is most at-risk and the specific substances or ingredients causing these lung injuries. 

Specifically, as you see listed here, CDC is currently testing samples of fluid from the lung, which are also known as bronchoalveolar lavage samples from the lungs of EVALI patients. CDC is offering testing of state's pathologic specimens, including lung biopsy or autopsy specimens identified with the patients. Aerosol emission of case-associated product samples as well. 

Analysis of aerosol emissions is being used to improve our understanding of case patients associated with the lung injury outbreak. And together, these results can provide insight to what entered the lung of patients with these injuries and give us additional information about the nature of the chemical exposures contributing to this outbreak. Next slide? So. 

speaking of laboratory testing. CDC announced a break-through finding a little over two weeks ago on November 15th that vitamin E acetate was found in all 29 BAL samples tested among patients from ten states. This convenient sample represents specimens collected in the course of clinical care from patients with EVALI. 

Although vitamin E acetate was deducted in all samples, additional studies are needed to establish whether a causal link exists between this exposure and EVALI. Of note. CDC also tested for a range of other chemicals that might be found in e-cigarette or vaping product, including plant oils, petroleum distillates like mineral oil, compounds found in or added to THC products. 

None of these other potential chemicals of concern were detected in those BAL fluid samples tested. These findings provide direct evidence of vitamin E acetate at the primary site of injury within the lungs. This is the first time a potential chemical concern has been detected from samples with EVALI. 

More research is needed to establish whether this apparent association is causal. Here are some key facts about vitamin E acetate. Vitamin E acetate is an oily substance and might be used as an additive, most-notably as a thickening agent or dilutant in THC vaping products. 

It's found in vegetable oils, meats, fruits, vegetables, and available as a dietary supplement and found in many cosmetic products. It's generally regarded as safe when ingested as a supplement or applied topically to the skin. However. 

previous basic science research suggests that inhaled vitamin E acetate might interfere with normal lung functioning by disrupting fluid secreted by tiny air sacs in the lungs. Next slide. It's important to note that while it appears vitamin E acetate is associated with EVALI, evidence is not yet sufficient to rule out contributions of other chemicals of concern to EVALI. 

Many different substances and product sources are still under investigation and it may be that there is more than one cause of this outbreak. However, these findings help us to better understand the potential compounds or ingredients that may contribute to the cause or causes of EVALI. Next slide. 

As this investigation continues, CDC is dedicated to providing evidence-based recommendations as guidance. These are a few of CDC's recommendations for Health Care providers. CDC encourages clinicians to report possible cases of EVALI to their state or local health departments for further investigation. 

The most-critical step in assessing EVALI is to ask patients about recent use of e-cigarette or vaping products. If confirmed, the types of substances used, such as THC and nicotine and where they were obtained should be noted. Next slide. 

EVALI is a diagnosis of exclusion since, at present, no specific test or marker exists for its diagnosis in a patient. Health Care providers are recommended to consider all possible causes of illness in patients reporting respiratory and gastrointestinal symptoms. They should evaluate and treat for other possible causes of illness as clinically indicated and consider consultation with specialists, such as those in pulmonology, infectious disease, critical care medicine, medical toxicology, psychology, psychiatry and addiction medicine as a problem. 

For patients who report e-cigarette or vaping products, evaluation should include assessment of vital signs. Patients should be submitted to the hospital if they have decreased oxygen saturation while breathing room air or are in respiratory distress. Next slide. 

An algorithm for patient management is available to clinicians and can also be found on CDC's lung injury website. In terms of post discharge follow-up. patient's discharged from the hospital after impatient treatment should follow-up no later than one to two weeks after discharge. 

Not all patients with signs and symptoms concerning for EVALI need to be hospitalized. Some patients with recent history of e-cigarette or vaping product use were evaluated for respiratory, gastrointestinal or constitutional symptoms, might be candidates for out-patient management. And. 

EVALI symptoms can progress rapidly, so. follow-up within 24 to 48 hours is an important part of out-patient management. Additional follow-up might be indicated based on clinical findings. 

Patients should be advised to return immediately if they develop new or worsening respiratory symptoms. That being said, hospital admissions should be strongly-considered for patients with concurrent illness, such as influenza and potential EVALI, especially if respiratory distress, comorbidities that compromise pulmonary reserve or decrease oxygenation preservation are present. Given flu season, Health Care providers should emphasize the importance of routine influenza vaccinations for all persons age six months or older, including patients who use e-cigarette or vaping products. 

Next slide? Advising patients to discontinue the use of e-cigarette or vaping products should be integral to the care approach. Health Care providers should offer or connect services to stop using e-cigarette or vaping products and resuming use of these products has the potential to cause recovery or recurrence of symptoms or further lung injury. Patients should be provided with evidence-based interventions, including behavioral counseling, and FDA-approved cessation medications. 

Adults and -- adolescents and young adults might benefit from specialized services, such as addiction treatment services and providers who have experience with counseling and. behavioral health follow-up. Persons with ongoing marijuana use, that causes significant impairment or distress might have a cannabis use disorder. 

And persons with cannabis use disorder should receive evidence-based interventions. And consultation with addiction medicine services should be considered. Next slide. 

The CDC wants its partners to quickly share what they know about possible cases of EVALI. Health Care professionals are advised to report cases of lung injury of unclear etiology and a history of e-cigarette or vaping product use within the past three months to state, tribal, local, or territorial health departments. Public health officials should notify CDC about possible cases of lung injury from e-cigarette and vaping products. 

State, tribal, local, territorial health departments that need correction tools, reporting guidelines, case investigation forms and technical assistance can also contact CDC at that address. Next slide. Of note, states have been asked to only report hospitalized EVALI cases to CDC starting last Tuesday, November 26th. 

Further collection of data on nonhospitalized cases will be at the discretion of individual states, tribal, local, and territorial health departments. CDC stopped the collection of data on nonhospitalized cases of EVALI for several reasons. First. 

patients with EVALI may have similar symptoms to flu or other respiratory illness and it might be difficult to distinguish EVALI from other respiratory illnesses. Second. the finding and reporting of nonhospitalized patients could become more difficult and burdensome given the potential for large numbers of respiratory illness during the emerging flu season and may be of value to the ongoing investigation. 

Moreover. recent information regarding the characteristics of hospitalized and nonhospitalized EVALI patients were released in the CDC report published in MMWR on November 22nd. Next slide. 

In terms of recommendations for the public. CDC recommends that people should not use e-cigarette or vaping products that contain THC, particularly from informal sources like friends or family or in-person or online dealers. Until the relationship of vitamin E acetates and lung health is better-understood, vitamin E acetate shouldn't be added to e-cigarettes or vaping products. 

In addition, people shouldn't modify or add any substance to e-cigarette or vaping products that aren't intended by the manufacturer. This also applies to products purchased through retail establishments. Next slide. 

I mention this previously on one of the other slides, but. another key message CDC is reiterating to the public is that these findings still do not rule out other possible compounds or ingredients that may be contributing to this lung injury. More information is needed to link patterns of use to e-cigarette with vaping products, and one or more products, substance or brands responsible for the lung injury. 

The only way to assure you're not at risk while the investigation continues is to consider refraining from the use of all e-cigarette or vaping products. CDC is also recommending to the public, if you continue to use an e-cigarette or vaping product and have symptoms of lung injury, see a Health Care provider and report your e-cigarette or vaping product use. Importantly, adults using e-cigarettes to quit smoking combustible cigarettes shouldn't go back to smoking. 

They should weigh all risks and benefits and consider using all FDA-approved medications. Irrespective of the ongoing investigation, CDC has consistently reinforced, there are certain populations that shouldn't be using e-cigarette or vaping products, specifically e-cigarettes should never be used by youth, young adults or pregnant women. There's no safe tobacco product and all tobacco products, including e-cigarettes carry a risk. 

Adults who do not currently use tobacco products shouldn't start using e-cigarette or vaping products. Next slide. For adults who have ongoing problematic marijuana use leading to distress, effective treatments are available and recovery is possible for people who have this disorder. 

A number of therapy-based treatments such as cognitive behavioral therapy, contingency management, motivational enhancement therapy, and. multidimensional family therapy have been shown to help people who are addicted to marijuana. Here. 

we've linked the Substance Abuse and Mental Health Services Administration's treatment locator and the number 1-800-662-HELP. In terms of outreach, CDC ensures that the findings from this investigation are provided in a timely manner and communicates regularly with consumers, clinicians, and public health professionals through a combination of traditional media, social media and other channels. So. 

here are some ways to stay connected through Twitter, Facebook, LinkedIn and Instagram. Next slide. This is a very dynamic investigation and CDC is in close communication with states and FDA to ensure that they're providing tools and resources that facilitate streamline data collection, as well as data linkage to help continue to identify the cause or causes of these lung injuries. 

And to provide recommendations for state health departments, clinicians and the public. For instance, in collaboration with the FDA, CDC convenes a weekly national call with state and local health partners, during which, hundreds of participants can hear updates from the response and pose questions and. additionally, as you see here, FDA and CDC have jointly-developed resources that outline the process by which states can submit case-associated product samples to FDA and CDC for testing and detailed information from product-testing can be found on the lung injury response website and through these respective e-mail addresses. 

Next slide. In terms of scientific publications, here, on your left is a snapshot of some CDC-led or co-authored reports published since the beginning of the response. Most of these have been disseminated through CDC's morbidity and mortality weekly report or MMWR. 

If you're unaware, this is CDC's way to get out timely and helpful information and recommendations. Helping reinforce key public health recommendations to prevent EVALI based on the epidemiologic, laboratory, and clinical data being analyzed by CDC. Next slide? So. 

before icon -- I conclude, we have updated case counts, deaths and resources. Go to cdc. gov/lunginjury. 

You can also contact CDC info through their online e-mail form or by dialing 1-800-232-4636. Thanks for listening in and I think we can open it up to discussion and questions. 

     We will do that in just a second. We are going to transition to our Q&A session, first. I want to welcome your colleague, Brian King, CDC senior official for the lung injury response and he's also joined us by telephone to help answer questions. 

Jonathan, can you read the first question? 

     Sorry, folks. I think we're waiting for Jonathan to get reconnected to audio. So. 

please bear with us for one second. I think he cut out for a second there. He's going to pull up the question as soon as he's ready. 

So. thanks, again, please stand by. 

     Apologies, everyone, my audio spontaneously died. Little awkward, but I apologize for that. Our first question is for clarification. 

From Lisa Johnson. She's asking, do you want individual providers to report suspected EVALI cases or do you request that only hospitalized cases be reported by health departments? 

     Thanks for your question. I'll, I'll just speak briefly back to what I alluded to in the presentation, but I'll also, if Brian King wants to chime in as well. We did release a statement saying that states have been asked to report hospitalized EVALI cases to CDC starting last Tuesday on November 26th and the further collection of data on nonhospitalized cases will be at the discretion of local, territorial health departments. 

     That's correct. These are state-led investigations and we defer to states to make decisions about what that is, that's done to inform respective investigations. In terms of CDC's role, given that we know 95% of patient cases are indeed hospitalized, there wasn't marked variability in terms of characteristics of those patients, we're only requesting the hospitalized patient data, but we certainly continue to reinforce the importance of clinician reporting and so. 

we'd encourage you all to continue to do that reporting to your respective state health departments, based on their individual directives. 

     Teresa: Thank you, Brian. 

     Jonathan: Our next question is from Charla Haley who asks any idea whether EVALI patients have completely recovered or if they're still having respiratory issues? 

     Teresa: I'll defer to Brian on that if he knows anything in terms of the recovery of these patients. 

     Brian: We ultimately do know there's a lot of variability depending upon the individual patient. We do know that there's also disparity in the disease, but the vast majority are, indeed, being hospitalized, some to the point of intubation and admitted to the intensive care unit. In terms of recover, it does vary by a variety of factors, but. 

what we are concerned about is that we have seen instances of recurrence, particularly among individuals who have gone back to using e-cigarette or vaping products. We've ultimately reinforced the importance, particularly among those for which symptoms have been alleviated through corticosteroids and other recommendations that are clearly outlined in our clinical guidance, that those individuals do not return to using the products. But. 

in general, there's variability in terms of the long-term onset of injury, but corticosteroids have alleviated symptoms. 

     Jonathan: Great, thank you. The next question comes from RC Showers who asks since vitamin E has become a suspect culprit, what does that have to do with the connection to THC-based products? What is the connection between vitamin E and THC? 

     Teresa: So. again, really quickly, I think it'd be helpful to -- when we -- one of the slides I presented was based on the data where CDC examined information on substances used in e-cigarette or vaping products in the three months prior to onset and I believe those numbers were that, among EVALI patients with those complete data, 83% reported using THC products, the majority with 35% reporting exclusive use of THC-containing products, as well as, still, there being 61% reporting nicotine-containing products. In terms of those BAL findings, all of them tested positive for vitamin E acetate and we know that vitamin E acetate can be used as a diluent for THC-containing products. 

This isn't the only substance currently undergoing investigation, there may be more than one cause related to this. But. Brian, do you have anything else to add with regards to the THC-component of these findings? 

     Brian: Yeah. sure, I think that Teresa hit the nail on the head in terms of response. It's important to note that these products can be used to deliver a variety of substances. 

Typically with nicotine-containing products, you don't necessarily have the same types of substance or the need for a diluent which is basically what we're seeing with THC-containing products. Particularly, for the elicit market, we're seeing that people are cutting the product, the liquid with certain diluents and that can include vitamin E or other things, but. basically, that allows you to get higher volume for a lower cost. 

And so. it would make sense, in terms of, you know. informal sources and elicit sale, that this type of substance could potentially be added to the product. 

It's very much, you know, something that's squarely focused with the use of THC-containing products. I'll reinforce, it could be used for other types of substances, including CBD as well. But. 

at present, vitamin E is primarily a cutting agent, used for THC-containing products and we continue to investigate other potential causes as well, but. that certainly emerges as a chemical concern in the current investigation. 

     Jonathan: Thank you, the next question comes from Eric, a good follow-up question to that one. Are there indications that the products on the informal market still contain vitamin E acetate or have produced response by stopping the practice of adding this diluent? 

     Teresa:  Brian? 

     Brian: Yeah. it's hard to say because. we're still in the throngs of an outbreak investigation. 

There's been a lot of dialogue around vitamin E acetate since CDC, FDA and others have reinforced this as a potential chemical concern. We found it in the bronchoalveolar samples, the limited number of patients for which we presently have data. There's a variety of other communities and states that have implemented policies, aimed at prohibiting the inclusion of this particular diluent in these products. 

It's too premature for us to know what that ultimate impact of those efforts will be, at the present point, we're in the middle of an ongoing multi-state investigation. Our number one priority is warning the American public about it based on the best-available data that we have. Right now, we certainly know that most of the cases are using THC-containing products and vitamin E acetate is cause for concern. 

I can't reinforce enough, there's a variety of substances that can be put into these devices to serve in the same capacity as vitamin E acetate is being used, in terms of a diluent to cut these products and although some of these things may be safe to put on the skin or to otherwise ingest, that doesn't necessarily mean that they're safe to inhale and so. it's really important that we remain vigilant around continuing to investigate potential causes, but. at present, there's a lot of efforts to broach that vitamin E acetate directly, but we don't have the data yet to know long-term impact of what those efforts will be, but. 

in the meantime, we're definitely warning people using the best available data we've got. 

     Jonathan: Thank you. The next question comes from Aubrey Adams. Is vaping THC and CBD at a higher temperature a factor? To expand that question, if it's those chemicals or anything else. 

does a higher temperature make it more risky? 

     Teresa: I think that's a good question -- I'm not aware of the science that's out there -- but I know there are ongoing studies trying to tease this out a bit further. I'd imagine that the, the jury is still out in terms of the exact clinical effects, depending on the nuances of temperature and other factors, what they mean in terms of implications physiologically, as opposed to, for instance, in the basic lab research setting. Those are things that I believe many people are interested in looking at and continuing to do so as this investigation evolves and we continue to disseminate more information. 

     Jonathan: A question related to reporting. Is it possible that the spike in reported cases is due to a lack of consistent reporting before the first reported death in Wisconsin? And in general, can you comment on the possibility that there may have been someone inconsistent reporting at either end? 

     Teresa: I'll just speak to that briefly and maybe Brian can chime in. I think, certainly, as with any response, when you're trying to rapidly coordinate across multiple states and standardize definitions, as well as the tools, this may, in fact, be a factor, in terms of when you're looking at that, the dates and being able to track these cases. Now that we're more so in a steady state of being able to give out information in a consistent manner, I think we're able to get a better sense of what's happening realtime, but. 

certainly, I think that may be a factor, so. I don't know if Brian has anything else to add with that. 

     Brian: The only thing I'd add, as part of CDC's role on this investigation, we have a cadre of world class epidemiologists using a variety of surveillance tools to answer a lot of key questions related to this investigation. One is the one you posed. Is this a new phenomenon or occurring at levels undetected for awhile? So. 

in addition to the self-reported surveys we've been using with data from the states, which Teresa mentioned, in terms of collecting information on substances used in products, we also use something called [indiscernible] surveillance. This allows us to look, historically back, at hospitalization for severe lung injuries that mirror EVALI and also are associated with the use of e-cigarette or vaping products. By using that andromic surveillance, it shows us that we've always had an underlying level of hospitalizations and reports of signs and symptoms similar to EVALI, related to e-cigarette or vaping products for a couple years. 

Something new, definitely happened, this summer, particularly around June and July and so. we're continuing to investigate those data, you know. this could be because of -- in part, because of the increased attention by the media and that clinicians and even the general public were likely more diligent in reporting these things, but. 

it's quite apparent to us, that something new, definitely happened. Within the past few months, but. it's important to note, we've always seen an underlying level of these signs and symptoms, a markedly lower level than recent months. 

That could be the result of multiple factors, including lower levels of use of the potential problematic agent or. it could also be the use of other types of e-cigarette or vaping products. We know that the e-cigarette landscape in particular has evolved over time, including nicotine-containing products, including those that deliver nicotine salt, which could contain higher hit and use to individual and have potential higher risk of respiratory, strictly for younger people, primarily affected by this outbreak. 

The jury is still out in terms of all the different factors, but we haven't ruled out the fact that there could potentially be multiple causes of this outbreak investigation. We know THC is at the forefront and certainly something new that's happened within the past couple months. There could be multifactor etiology. 

The other important question we can ask as well, are things starting to attenuate in more-recent weeks? We've always had a reporting lag from cases, but. that data will also help inform whether we're making progress in terms of reducing case counts. I can assure you, we're in the process of writing those data up and getting them out to the public as soon as possible to answer these key questions. 

Up until now, we didn't have the data to answer, now we're getting to the point where we are and as we noted several times, CDC is a data-driven agency and we use the data to inform our recommendation, that's what we've always done and will continue to do for this investigation as well. 

     Jonathan: Thank you so much. The next question asks do we have information regarding the mechanism of toxicity of vitamin E acetate? 

     Teresa: There's been accommodation of basic science research, as well as things that are trying to mirror more-closely what's going on physiologically-speaking in the lungs. Given this particular investigation and what we're finding, I think this is -- we're still getting -- in the process of getting a confluence of information before we can pen down a specific mechanism. I think there are theories and hypotheses about things to follow-up on in terms of what exactly is happening at that interplay of where the vitamin E acetate is, what exactly it's doing to the lungs. 

I imagine there's basic science research published, disclosing how it may be disrupting the normal lung function of lungs [indiscernible] within the lungs. With other types of specific mechanisms, I think that's still being followed up on. 

     Thank you. We've gotten multiple questions asking if vitamin E acetate is present in the official licensed products as well. Do we know the answer to that question? 

     Teresa: Brian, have you heard anything about that? 

     Brian: Yeah. it's too premature to say that exactly. We continue to get information from self-reports from a variety of different channels in a variety of different states. 

At present, we do have self-reports of individuals obtaining THC-containing products from both informal as well as formal sources, including license dispensaries, but it's important to note that in some cases, these people obtained products from a variety of different sources and ultimately need more data on this. We're currently working with a variety of different states, particularly those with both legalized, recreational and medicinal cannabis as well as those without to get the data out to inform the types of discussions around answering that specific question. Right now. 

CDC's recommendation is very broad in terms of, you know. we definitely recommend that people do not use THC-containing products, but. particularly those from informal sources. 

You'll note, it's not just informal sources. Until we have the data to definitively say that those formal sources haven't potentially been a contributor to the outbreak, we're not prepared to diminish that current recommendation, which, right now. is very much to not use any THC-containing e-cigarette or vaping products. 

     Jonathan: We got one comment asking about Poison Control Centers. I was wondering if you guys could comment on how Health Care providers or public health officials should work with Poison Control Centers or if there's some appropriate source of information for Poison Control Centers, specifically. 

     Teresa: I'm not personally sure of the exact protocol that Poison Control Centers -- the exact role that they're currently playing, but. I think this is something where Health Care providers can work closely with their local community, health departments and also, we have a page dedicated to information for Health Care providers on the CDC. gov/lunginjury site. 

In which case, I believe there are several resources there that may be able to answer your question a little more-fully in terms of how, the role they're playing. We know that traditionally, Poison Control Centers have also played a key role in terms of e-cigarettes more broadly, where people have reported nicotine poisonings and what not. I believe this is something to be cognizant of. 

Unless Brian has other thoughts about the Poison Control Centers, specifically, I'd just advise them to visit the lung injury website. 

     Brian: Yeah. absolutely. I echo Teresa there. 

CDC. gov/lunginjury. We do recommend in our information to the general public that if you're concerned about your health after using an e-cigarette or vaping product, contact the Poison Control Center. 

1-800-222-1222. We're working very closely with the Poison Control Center. They've been instrumental in monitoring calls related to e-cigarettes or vaping products for years. 

We're directing the public to those resources for immediate concerns about health, but. it's critical that these entities work -- people with suspected EVALI contact their Health Care professionals as well. 

     Jonathan: Thank you, we've gotten multiple questions about comparing the outbreak, occurrence of cases in the U. S. to global data. 

Can you comment more on what we know and what comparisons there are? Of course. CDC is focused, primarily, on the United States. We wouldn't know as much as some other organizations. 

     Teresa: I'll let Brian take that one. 

     Brian: Good question, I can assure you that CDC is working closely with our international counterparts, including the World Health Organization, as well as individual country governments. At present, it doesn't appear that any country has near the situation that we're facing currently in the United States. The closest is Canada. 

Which has reported some cases of EVALI, but significantly lower magnitude than what we're seeing in the United States. Otherwise, there've been sporadic cases reported internationally, but. again, I'll reinforce that we continue to believe that EVALI likely has multiple causes. 

And so. the ultimate root of the map spike that we've seen in the United States could very well be different from some of the cases that we're necessarily seeing internationally. In terms of the geographic variation that we're seeing, I think it's quite interesting that the only place where we're seeing cases, you know. 

even a slightly elevated level are in Canada. If you look at some of the domestic information as well, geographic outliers that haven't been impacted by the outbreak, including Alaska and Puerto Rico, only recently added to cases. This reinforces unique geographic precision around where this outbreak has occurred. 

And that's something that we continue to investigate here at CDC through a variety of avenues. One potential etiology could indeed point towards supply chain, around particularly elicit products and how those have been distributed or used across the United States. In terms of international cases, we are carefully monitoring it with a variety of partners. 

At present, there's no country that has anywhere near the magnitude of cases that we're seeing in the United States. 

     Jonathan: Thank you, Brian. To follow-up with some of the previous questions about legitimate distributors and vitamin E acetate, we've had some industry people log on and comment as well, that's kind of not our focus and not something that we would get into -- can you comment on the mechanism of communication about this concern to the legitimate industry? I do understand there is some communication going on. 

     Teresa: I'll quickly say that CDC has been partnering and working closely with FDA as well. CDC itself isn't a regulatory agency, but FDA has been following up on the manufacturing, distributing side of this investigation but. in terms of any late-breaking information, I don't know if Brian has anything to add with regard to that? 

     Brian: Nothing further. CDC's angle on this, we're a Public Health Agency and work 24/7 to protect people's health. We have complementary and distinct roles in this investigation. 

We ultimately defer to the enforcement agencies to address that. That includes FDA, DEA and also irrespective of state agencies. In terms of CDC's role, we're responsible for ensuring that we continue to coordinate with states and collect the data to inform evidence-based recommendations that are made to protect the American public's health. 

     Jonathan: It looks like we're running near the end of time here, we've gone through most of the questions focused on this topic. I will mention that we have somebody in the QA section, Gayle Thompson has commented that there's just now been reported, a first case in Alaska, so. as you can see with all outbreaks, it's constantly updating event. 

We report the latest information as we can. But. that's it for our submitted questions. 

I'm going to punt it back to you, Kellee. 

     Kellee: Thank you, again, Teresa, Brian, Jonathan and everyone that joined today's webinar. If you do have additional questions, if you had a question that didn't get answered. you can e-mail them to EPIC@CDC. 

gov and as a reminder, today's presentation has been recorded. You can earn continuing education for your participation. Please follow the instructions found on emergency.cdc.gov/epic. The course access code is EPIC1204. 

With all letters capitalized. Thank you, again, everyone. Bye-bye.