E-cigarette, or vaping, product use-associated lung injury (Evali) remains a problem

ABSTRACT

Rationale The e-cigarette, or vaping, product use-associated lung injury (EVALI) outbreak of 2019 was the first broad public recognition of the risk of vaping. The CDC investigation that associated vitamin E acetate (VEA) with EVALI, followed by the onset of the COVID-19 pandemic, have led to an impression by the general public and many medical professionals that EVALI is no longer a problem. Although the CDC stopped collecting EVALI data as of February 2020, the state of Utah continued to identify new cases. Here, we describe the ongoing incidence of EVALI and provide a framework for categorizing EVALI. Methods: We included all patients with an EVALI diagnosis between June 24, 2019 and November 23, 2020 in the two largest healthcare systems in Utah. All EVALI diagnoses were confirmed by at least two pulmonologists in the Utah EVALI Taskforce using CDC diagnostic criteria. Starting on March 1, 2020, a negative SARS-CoV-2 test was added to the criteria for an EVALI diagnosis. Demographics and incidence of EVALI are reported. Results: 192 patients were diagnosed with EVALI between June 24, 2019 and November 23, 2020 (Figure). Most patients were young (mean age 30.7 ± 12.5), white (92%), and male (59%) reflecting the demographics of Utahns who vape. The fall 2019 peak of the EVALI outbreak, which was attributed to VEA adulteration of e-cigarettes, decreased with the subsequent removal of VEA from distribution. A robust cross-institutional reporting system continued to identify 38 EVALI cases between March 1, 2020, and November 23, 2020. Conclusion: EVALI remains a cause of acute lung injury in patients well after the fall 2019 outbreak and the elimination of VEA from e-cigarettes. EVALI is a syndrome, not a disease, with not one, but multiple causes and pathological patterns. Continued attention to vaping exposure history in patients with acute lung injury remains critical in making the diagnosis of EVALI.