Lessons Learned From the E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) Outbreak Response, Minnesota, 2019-2020.

OBJECTIVE: Electronic cigarette (e-cigarette), or vaping, product use-associated lung injury (EVALI) is a novel noncommunicable disease with an unknown cause. The objective of this analysis was to describe the Minnesota Department of Health's (MDH's) outbreak response to EVALI, including challenges, successes, and lessons learned. METHODS: MDH began investigating EVALI cases in August 2019 and quickly coordinated an agencywide response. This response included activating the incident command system; organizing multidisciplinary teams to perform the epidemiologic investigation; laboratory testing of e-cigarette, or vaping, products (EVPs) and clinical specimens; and collaborating with partners to gather information and develop recommendations. RESULTS: MDH faced numerous investigational challenges during the outbreak response of EVALI, including the need to gather information on unregulated and illicit substances and their use and collecting information from minors and critically ill people. MDH laboratorians faced methodologic challenges in characterizing EVPs. Despite these challenges, MDH epidemiologists successfully collaborated with the MDH public health laboratory, law enforcement, partners with clinical and toxicology expertise, and local and national public health partners. PRACTICE IMPLICATIONS: Lessons learned included ensuring the state public health agency has legal authority to conduct noncommunicable disease outbreak investigations and the necessity of cultivating and using internal and external partnerships, specifically with laboratories that can analyze clinical specimens and unknown substances. The lessons learned may be useful to public health agencies responding to similar public health emergencies. To improve preparedness for the next outbreak of EVALI or other noncommunicable diseases, we recommend building and maintaining partnerships with internal and external partners.

Biosurveillance of Drug Overdoses and Substance Misuse Treated in Selected Emergency Departments in Minnesota, 2017-2020.

OBJECTIVES: Increasing knowledge about the toxicology of drug overdose and substance misuse (DOSM) is important in improving our understanding of the epidemic. We describe the Minnesota Drug Overdose and Substance Use Pilot Surveillance Activity, which started collecting data on emergency department (ED) visits attributable to DOSM in 2017, with a focus on the toxicology results of a subset of clinical encounters. METHODS: From November 1, 2017, through January 30, 2020, we collected near-real-time data on DOSM-related ED encounters. The Minnesota Department of Health Public Health Laboratory tested leftover clinical specimens (blood and/or urine) for the presence of various substances for patients who died, were hospitalized, had an atypical clinical presentation, or were part of a local drug overdose cluster. Testing looked for >250 drugs or their metabolites, including those commonly misused (eg, methamphetamine, cocaine), prescription medications, synthetic cannabinoids and cathinones, and opioids. We describe characteristics of the overall group and a subgroup of clinical encounters with toxicology results. RESULTS: Specimens submitted from 6 EDs during the study period represented 239 clinical encounters. Methamphetamine was the most frequently detected substance (67.4%) but was suspected in only 45.6% of encounters. At least 1 opioid was detected in 42.5% of encounters but suspected in only 29.7%. Testing also detected potential adulterants and additives (eg, fentanyl, fentanyl analogues, levamisole) and showed frequent patient exposure to substances not reported by patients or suspected by clinicians. Nearly half (44.4%) of clinical encounters had >1 substance detected. CONCLUSIONS: ED surveillance for DOSM encounters, enhanced by toxicology testing, can provide local situational awareness on overdoses, prevent potential mischaracterization of the true drug overdose epidemic, and inform harm reduction and drug overdose prevention efforts.

Characteristics of E-cigarette, or Vaping, Products Used by Patients with Associated Lung Injury and Products Seized by Law Enforcement - Minnesota, 2018 and 2019.

During August 9-October 31, 2019, 96 patients were classified as having e-cigarette, or vaping, product use-associated lung injury (EVALI) by the Minnesota Department of Health (MDH); other patients are being investigated for case classification and exposures. Among 58 patients interviewed, 53 (91%) reported obtaining tetrahydrocannabinol (THC)-containing products from informal sources such as friends, family members, or in-person or online dealers. Using gas chromatography-mass spectrometry (GCMS), the MDH Public Health Laboratory (PHL) analyzed 46 THC-containing e-cigarette, or vaping, products obtained from 12 EVALI patients for various potential toxicants, including vitamin E acetate, which has recently been detected in some THC-containing products and in samples of lung fluid from EVALI patients (1-4). To explore whether vitamin E acetate is a recently added component in THC-containing products, MDH tested ten products seized by law enforcement in 2018, before the EVALI outbreak, and 20 products seized in 2019, during the outbreak. Twenty-four products obtained from 11 EVALI patients from 2019 contained vitamin E acetate. Among the seized products tested by MDH, none seized in 2018 contained vitamin E acetate, although all tested THC-containing products seized in 2019 tested positive for vitamin E acetate. These chemical analyses of products obtained from EVALI patients and of products intended for the illicit market both before and during the outbreak support a potential role for vitamin E acetate in the EVALI outbreak; however, the number of products tested was small, and further research is needed to establish a causal link between exposure to inhaled vitamin E acetate and EVALI. Collaboration between public health jurisdictions and law enforcement to characterize THC-containing products circulating before the recognition of the EVALI outbreak and during the outbreak might provide valuable information about a dynamic market. These Minnesota findings highlight concerns about e-cigarette, or vaping, products that contain THC acquired from informal sources. Because local supply chains and policy environments vary, CDC continues to recommend not using e-cigarette, or vaping, products that contain THC or any e-cigarette, or vaping, products obtained from informal sources. E-cigarette, or vaping, products should never be used by youths, young adults, or pregnant women.* Until the relationship between inhaled vitamin E acetate and lung health is better characterized, vitamin E acetate should not be added to e-cigarette, or vaping, products.

Public Health and Law Enforcement Joint Investigation of Unknown Suspicious Substances and Potential Threat Evaluations, Minnesota, 2007-2016.

From the Field is a semi-regular column that explores what it means to be a local health professional on the front lines of an emergency. Typically, National Association of County and City Health Officials (NACCHO) members share their stories of preparing for and responding to disasters, epidemics, and other major health issues. This month's column features a submission from a state health department that describes their experience in investigating white powder incidents. Through exploring the analysis of the challenges faced and the solutions developed, readers can learn how these public health champions keep their communities safe even in extreme situations. Readers may submit topics of interest to the column's editor, Meghan McGinty, PhD, MPH, MBA, at mmcginty@naccho.org.

High throughput quantitative analysis of the ß-lyase sulfur mustard metabolite, 1,1'-sulfonylbis[2-(methylsulfinyl)ethane] in urine via high performance liquid chromatography tandem mass spectrometry.

Sulfur Mustard (HD) has a 100year history of use as a chemical warfare agent and recent events in the Middle East are causing it to once again be a potential concern. We report a new high-throughput method for the determination of HD exposure by the analysis of the ß-lyase metabolite 1,1'-sulfonylbis[2-(methylsulfinyl)ethane] (SBMSE) in human urine. This method features a hydrogen peroxide (H2O2) oxidative conversion of the ß-lyase metabolites to SBMSE, followed by sample extraction and concentration using solid phase extraction in 96-well plate format. Subsequent high performance liquid chromatography tandem mass spectrometry (HPLC-MS/MS) analysis gave linear quantitation over a calibration range of 0.1-100ng/mL, with a method detection limit of 0.03ng/mL. Liquid chromatographic separation was achieved using a hydrophilic interaction liquid chromatography (HILIC) column with an analyte retention time of 0.9min and method time of 1.5min (cycle time=2.0min). Users of this method could prepare and analyze approximately 650 samples in 24h which would be important for an emergency response.

A performance assessment of airborne infection isolation rooms.

BACKGROUND: Airborne infection isolation rooms (AIIRs) help prevent the spread of infectious agents in hospitals. The performance of 678 AIIRs was evaluated and compared with construction design guidelines. METHODS: The pressure differentials (DeltaP) between the isolation rooms and adjacent areas were measured, and ventilation and construction details were recorded for each room. Ultrafine particle concentrations were evaluated in the rooms, surrounding areas, and ventilation systems serving the rooms. Measurements were analyzed as a function of room parameters. RESULTS: Only 32% of the isolation rooms achieved the recommended DeltaP of -2.5 Pascals (Pa) relative to surrounding areas. AIIRs with solid ceilings had an average DeltaP of -4.4 Pa, which was significantly higher than the average DeltaP of -2.0 Pa for rooms with dropped ceilings (P = .0002). Isolation room ultrafine particle concentrations were more highly correlated with particle levels in surrounding areas (R(2) = 0.817) than in the ventilation systems serving the rooms (R(2) = 0.441). Almost all ventilation filters serving AIIRs collected fewer particles than anticipated. CONCLUSION: The results indicate that hospitals are not all maintaining AIIRs to correspond with current guidelines. The findings also support the contention that having tightly sealed rooms helps maintain appropriate pressure differentials.