Eight teenagers with lung injury, in the middle of a pandemic

In April 2020, eight patients were hospitalised in California with
e-cigarette, or vaping, product use-associated lung injury (EVALI).

**Nucleic acid testing for SARS-CoV-2 was performed on all of them at
admission. Every test was negative.** Seven were tested two or more times,
and lower respiratory tract specimens were tested from the two intubated
patients — a thoroughness that says how hard it was to believe the answer in
April 2020.

Why they nearly were not counted

EVALI peaked nationwide in September 2019 and fell steeply. **CDC
discontinued collection of EVALI case reports in February 2020.** California
had only four cases reported in February, so it **asked local
jurisdictions to keep reporting cases but stop active interviews and
follow-up.**

These April cases were the first reported since February, and the first
since widespread SARS-CoV-2 transmission was identified in the state.

The report is careful about what that means:

**It is unclear whether EVALI cases have continued to occur and were
underreported or missed, or whether these cases might represent the
background incidence of EVALI.**

Surveillance was wound down because cases fell, and cases might have fallen
partly because surveillance was wound down. Nobody can tell from here.

The collision

**Because EVALI and COVID-19 signs and symptoms can be similar (e.g., cough,
fever, and diarrhea), health care providers should maintain clinical
suspicion for EVALI during the COVID-19 pandemic.**

In April 2020, a young person arriving breathless with a cough and a fever was
a COVID-19 patient until proven otherwise. Four of these eight went to
intensive care, two onto ventilators — and none of them had it.

**In May 2020 California provisionally updated its EVALI case definition to
require a negative SARS-CoV-2 test** and suspended the probable case
definition. The two diseases had become impossible to separate on symptoms
alone, so the definition was rewritten around the test.

What to ask

**Ask patients with symptoms consistent with EVALI — especially teenagers and
young adults — about vaping, during COVID-19 evaluations.**

The underlying advice is unchanged: **refrain from using all e-cigarette or
vaping products**, and especially **do not use THC-containing products from
informal sources** — social contacts, online dealers, unlicensed retailers.
Of California's 210 EVALI hospitalisations through February 2020, **65 of 87
interviewed patients (75%) reported exactly that.**

Source: Centers for Disease Control and Prevention, MMWR.