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Severe Acute Pulmonary Disease Associated with Cannabis Vaping

TO:         Healthcare Providers 
FROM:   Karen Relucio, MD, Public Health Officer
               
Key Messages

  • Since June 2019, seven cases of severe acute pulmonary disease requiring hospitalization and respiratory support among previously healthy adults have been reported to the Kings County Health Officer. This number of cases greatly exceeds the number otherwise expected since June.
  • A reported common exposure among these patients is that they have been vaping cannabis or cannabidiol (CBD) oils. At this time, no infectious cause has been identified.
  • Clinicians who become aware of cases similar to those described above are asked to report them to them to Napa County Public Health by calling 707-253-4231.
  • If the patient has product in hand, please collect, hold, and contact Napa County Public Health.


Current Situation

Since June 2019, at least 7 cases of severe acute pulmonary disease in previously healthy adults were reported from a Kings County hospital. Cases were among residents of multiple counties. The patients presented with progressive respiratory distress, sometimes initially diagnosed with pneumonia or bronchitis, and some with preceding fevers and gastrointestinal symptoms. All cases failed to respond to an initial course of antibiotic treatment. All patients required admission to the hospital with significant respiratory support, including high-flow oxygen, bilevel positive airway pressure (BIPAP), or intubation with mechanical ventilation. Diagnoses included pneumonitis and acute respiratory distress syndrome (ARDS). Patients have improved with systemic steroids. Evaluation for infectious etiologies has been negative to date in all patients.
 
The Kings County Health Department is currently investigating the cause of these illnesses. All patients reported vaping in the weeks prior to hospital admission, and a reported common exposure between these patients is that they have been vaping cannabis or CBD oils. The names and types of products used remain unknown, and patient interviews are ongoing. Other states have reported recent similar cases. CDPH is supporting Kings County’s investigation.

Background

Vaping refers to the increasingly popular practice of inhaling vapor from an e-cigarette device, which works by heating a liquid that can contain nicotine, marijuana, or other drugs. The long-term health impacts of vaping are unknown. The liquids used in e- cigarettes are largely unregulated, and they can contain toxic chemicals that can cause lung damage.
 
Case Definition
A case is defined as meeting the following criteria:
  • Severe acute pulmonary disease (including but not limited to pneumonitis and ARDS);
  • Requiring admission to a hospital and respiratory support (including but not limited to high-flow oxygen, BIPAP, or intubation with mechanical ventilation);
  • No infectious etiology defined;
  • Recent history of vaping;
  • Symptom onset on or after June 1, 2019.
Recommendations for Providers
  • Clinicians are asked to remain alert for potential cases among persons presenting with severe acute pulmonary symptoms, and ask these patients about their recent history of vaping.
  • Patients were seen in primary care and initially diagnosed with pneumonia or bronchitis, but did not respond to antibiotics.
  • Clinicians who become aware of cases similar to those described above are encouraged to report them to Napa County Public Health at 707-253-4231.

TRAVEL ASSOCIATED DISEASES:
EBOLA, DENGUE, MALARIA, AND
MEASLES


Napa County Public Health receives reports of malaria, dengue, and measles in persons with a history of international travel. Ebola Virus Disease (EVD) has also re-emerged in an outbreak in the Democratic Republic of the Congo. As the early symptoms of these diseases are non-specific, travel history is essential for timely diagnosis. Patients may not be aware of pre-travel recommendations for measles immunization or malaria chemoprophylaxis.  Proactive questioning about planned or recent travel assists with prevention, appropriate infection control, and diagnosis.  Please refer to the table in full advisory below (red button) for features of EVD, dengue fever, malaria, and measles.

EVD: The World Health Organization (WHO) has declared the ongoing Ebola outbreak in the Democratic Republic of the Congo to be a Public Health Emergency of International Concern. As of 7/28/2019, 2687 confirmed and probable cases and 1803 deaths were reported. The WHO does not currently recommend closure of borders, restrictions on travel or trade, or entry screening at airports or other ports of entry. Although the risk of importation of EVD to Napa County is low, health care providers should institute protocols to obtain travel history to ensure early consideration of EVD and immediate infection control. If there is suspicion of EVD in a patient based on travel history and clinical presentation, immediately isolate the patient in a private room with in-room bathroom or a covered bedside commode and rapidly report to Napa County Public Health.

DENGUE: The incidence of dengue in the US has increased in recent decades. Most cases in the US are imported, although dengue is endemic in some parts of the US, including Puerto Rico and the US Virgin Islands. From 2013-2018, there was 1 confirmed and 4 probable cases in Napa County. Dengue can be caused by four related viruses (dengue virus 1-4). 

MALARIA: Malaria transmission typically occurs in tropical and subtropical regions where Anopheles mosquitoes are found. Although the risk of malaria to Napa County is low, health care providers should institute protocols to ask about recent or planned travels to ensure early consideration of malaria and immediate infection control. Malaria can be prevented through chemoprophylaxis and by avoiding mosquito bites.

MEASLES: Measles is a highly contagious disease that has caused several outbreaks in Europe, the Philippines, and parts of Africa in 2019. As of 7/25/2019, 1164 cases have been confirmed in the US in 2019, the greatest number of cases reported in this country since 1992. Several outbreaks have occurred in California this year, and while there has not been a confirmed case in Napa County, there is ongoing risk and need for clinician vigilance and immediate reporting of suspected cases to Napa County Public Health before the patient leaves the health care facility. Before international travel, clinicians should confirm that patients are up to date on measles immunizations; infants 6-11 months old should receive one dose of MMR, and persons 12 months of age and older should receive 2 doses of MMR. Infants who get one dose before 12 months of age should receive two more doses of MMR at 12-15 months and another separated by at least 28 days.

Health Advisory for Ebola and other travel associated diseases
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NCHO · 2751 Napa Valley Corporate Drive · Building B · Napa, Ca 94558 · USA

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