CDC says they are looking at heavy metals from battery in the aerosol (maybe they read the hypothesis by Colorado Green Labs), but then they also say they are focusing on the liquid. And they are only now doing enhanced testing and new, more in-depth assays.
My question: What the hell took them so long to take this seriously and do “enhanced” testing?
So far I don’t have much faith in the CDC and FDA to figure this out. They seem to be flailing around and have no idea what to do. They have received over 900 samples, but of those, only a limited number had enough liquid for testing. It seems to me the CDC and FDA just keep doing the same tests over and over again (GC/MS) on liquid. I suspect they just aren’t looking for the right analytes, they just keep looking for the same analytes over and over again.
Here’s what Utah is looking for in terms of analytes, from this week’s MMWR. The CDC and FDA won’t specifically say what analytes they are looking for:
Nicotine, THC, vitamin E acetate, diazion, phorate, terbuphos, tetramine, paraoxon parathion, pentazocine, scopolamine, codeine, strychnine, aldrin, endrin, dichlorodiphenyltrichloroethane (DDT), fentanyl, dichlorodiphenyldichloroethylene (DDE), arecoline, pilocarpine, and morphine.
Here’s the full MMWR from this week:
mm6842e1-H-2.pdf (161.6 KB)
Some Q&A from yesterday’s CDC telebriefing:
MIKE STOBBE, ASSOCIATED PRESS : Thanks for taking my call. This is for Dr. Schuchat. You said at the beginning you were talking about the epi curve. What proportion of the 125 cases reported in the last week had a recent onset of symptoms and is that proportion different than the weekly updates previously or is the proportion getting larger and larger or smaller and smaller of new cases, new illnesses in the mix? Second question is – I think you mentioned of the deaths you only have information for a small percentage on what they vaped. Can you say of the 34 how many do you have information on how many of them do you know what they vaped? And, I’m sorry, one more. You said something about we are intensifying the lab investigations. Could you be more specific? What’s going on? What’s the intensification? Thank you.
DR. ANNE SCHUCHAT: Thanks so much for those questions. In the past weeks, we were seeing about half of the cases that we were hearing about were of recent onset. I don’t have those data for this week. We are working, trying to get them. The second question was about the — history. We’ve only got exposure history for about 19 fatal illnesses at this point. And so, it’s fairly small numbers but the data so far look quite similar to the overall picture. And then in terms of an intensification, as we have mentioned, we have been — our laboratory has been standardizing some assays in order to be able to measure the components of aerosols. We have also been standardizing some assays in order to measure pathology specimens. So, what our current portfolio is to test for specific vaping-related substances in body fluids including lung fluid from biopsies or blood or urine, to test pathology specimens including lung biopsy or autopsy specimens from patients with lung injury. And then we have a backdrop of control specimens. To offer the aerosol emission testing of the EVALI-associated products from the liquids as well as the full products. That complements what FDA is doing which is testing the liquids themselves or the devices. Whether — you know, we are going to need to put the pieces of the story together around an individual patient’s lung injury. Obviously, the clinical records have information on x-rays and lab tests and the imaging. CTs and so forth. But we’re hoping that our aerosol testing, and enhanced pathology testing will round out the picture. I need to caution that these results may come in slowly and will be important to interpret carefully. That’s why there’s been an effort to validate assays as well as get control specimens for comparison. Thank you.
DAWN KOPECKI, CNBC: Thank you. My question is what are your theories as to why this cropped up out of nowhere in March with no prior real knowledge of this being a problem? Vaping has been going on for years. Is it something that was making people sick that doctors just weren’t catching or do you suspect some sort of change in the supply chain that made this a factor all of the sudden in March and nowhere in the world except for the U.S.? Thank you.
DR. ANNE SCHUCHAT: Thanks. There are a number of good questions in your comments. We are aware of older cases that look similar to what we are seeing now. But we do not believe that this outbreak or surge in cases is due to better recognition. We think that something riskier is in much more frequent use. There are a couple of factors to consider. One is that the supply chain now has a lot of risky product. They may be locally produced or produced centrally, and we don’t have information to say it’s all one way or the other. It may end up being a mix of them. We know that there has been practices around use of cutting agents to essentially increase the profit from selling cartridges and that the practice may have become more widespread. Anecdotally, there is information about YouTube videos showing people how to do this that might have skyrocketed that practice. I also need to point out that the backdrop — this outbreak is occurring in a backdrop of skyrocketing use of nicotine-containing e-cigarettes among youth and the frequency of their use is substantial and has increased greatly over the past two years. And so, whether individuals who are more frequently using e-cigarettes and become addicted to nicotine start experimenting with other products and are vaping with THC now as well, that may be sort of laying a fertile ground for the expanded use of risky products. There have been a couple of things that have changed. Obviously in the past year increased use of the nicotine-containing e-cigarettes that can be used very discreetly, and we believe a diversified supply chain of other vaping products. But those are theories. I think we need to learn more. As you heard, the FDA is working hard on supply chain issues, as are other authorities in the state and local areas. So, with that, I think that’s the best I can say with why now. I don’t know if Mitch wants to add anything.
IVAN COURONNE, AFP: Thank you very much. A question for Mitch Zeller. I understand there is no single substance or cause found yet, but do you have a short list, and have you made progress in narrowing the list of potential targets?
MITCH ZELLER: No. We do not have a short list. On prior calls we have reported within the world of the THC cases the frequency with which for the samples that we have been able to do the analysis on which is a subset of all samples and a subset of all cases, the frequency with which we are seeing Vitamin E acetate for the samples that we have been able to do sufficient analysis, Vitamin E acetate is showing up in roughly half of the cases where the person reported that they used a THC product and we were testing a THC product. We know that percentage has been higher at a state level, as a couple of the states have reported. But there is no short list of compounds. We continue to do all of the chemistry and all of the analysis as we try to figure out what’s going on causing these illnesses.
DR. ANNE SCHUCHAT: Thanks. This is Dr. Schuchat and then FDA may have additional comments. We do have concerns about the devices themselves and whether heavy metals or other dangerous compounds may be released in the process of the heating that occurs or the battery-operated device. So, the CDC has developed some assays to be testing the aerosols which would be testing both what is coming from the device as well as what is in the liquid. FDA has other work, I think, that they could describe.
MITCH ZELLER: What I would add to that is you have heard both agencies say now on these calls that at the end of the day there could be multiple causes and that when we complete our chemistry analysis of the substances and the compounds, we have tried to describe that as just one piece of the puzzle. There could be other factors and other causes. We know that for the THC products, as you have heard Dr. Schuchat describe and has been reported, a whole bunch of these products are being purchased off the street. We don’t know what kind of modifications are being made to those devices on top of the compounds that are being inserted and inhaled. Modifications to the devices themselves by the intermediary who is selling the device off the street or the end user themselves. We are trying to unravel all of that as product analysis and sample analysis continues. We don’t have anything definitive to share with you. All of that remains ongoing work.