Vaping Lung Injury in Wisconsin: Friends Who Shared THC Cartridges Fell Ill Together

Several of these patients had been buying the same brands of THC vape cartridges from the same local dealers for up to a year. Nothing about their habits changed. Yet all of them fell ill within the same few weeks in the summer of 2019. That timing is one of the strongest clues in Wisconsin's investigation of e-cigarette, or vaping, product use–associated lung injury (EVALI): something in the illicit cartridges — very likely the additive vitamin E acetate — changed shortly before June 2019.

Three clusters

On July 10, 2019, the Wisconsin Department of Health Services was told of five previously healthy adolescents with severe lung injuries who had vaped. By December 31, 105 confirmed or probable EVALI cases had been reported in the state. Among them, investigators found three social clusters — groups of friends who shared products, bought from the same source, or used the same brands — totaling eight patients.

• All eight used THC cartridges daily in the month before they got sick, all bought from local illicit dealers, and all reported cartridges labeled "Dank Vapes" among other illicit brands.
• In each cluster, at least two members frequently shared cartridges.
• All eight also vaped nicotine daily.
• Symptoms began between June 18 and July 21, 2019.

When each patient began and stopped using nicotine and THC products, and when illness began. Credit: CDC.

What the tests found

Vitamin E acetate was found in a cartridge or in lung fluid from at least one patient in every cluster. Nationally it had been detected in lung fluid from 48 EVALI patients in 16 states. Law enforcement in Wisconsin had found counterfeit cartridges packaged under the same brand names the patients shared — a possible source.

Timing and heavy use

• Patients had started THC cartridges a median of 9 months before falling ill, from under a month to 12 months, with no change in brand or source.
• The shared onset fits the national spike in EVALI emergency visits in June 2019, and Minnesota seizures that found vitamin E acetate in every THC cartridge taken in a September 2019 raid but in none seized in 2018.
• Use was heavy: seven of eight used at least half of a 1-gram cartridge a day, which patients estimated at 300 to 500 inhalations per cartridge.
• Nicotine products did not appear to be the cause: every patient had used them for a long time, a median of 33 months, without change.

Six patients were hospitalized for a median of 6.5 days (6–20), five in intensive care and two on mechanical ventilation. One still had breathing symptoms three months after discharge.

The advice

CDC recommends that people not use THC-containing e-cigarette or vaping products, especially from informal sources such as friends, family or in-person or online dealers, and that vitamin E acetate never be added to vaping products. Adults using e-cigarettes to replace cigarettes should not go back to smoking, and youths, young adults and pregnant women should never vape.

Sources

Based on "E-cigarette, or Vaping, Product Use–Associated Lung Injury Among Clusters of Patients Reporting Shared Product Use — Wisconsin, 2019," by Ian W. Pray, Sukhshant K. Atti, Carrie Tomasallo and Jonathan G. Meiman, Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention; a work of the United States government in the public domain. Products were tested by the Food and Drug Administration and lung fluid by CDC.