For Healthcare Providers

The Department of Health and Senior Services (DHSS) requires reporting under 19 CSR 20-20.020 1(c) of possible cases of e-cigarette, or vaping, product use associated lung injury (EVALI) to DHSS or their local health department for further investigation.

If e-cigarette, or vaping, product use is suspected as a possible cause for a patient’s lung injury, using the Case Report Form, a detailed history of the substances used, the sources of products, and the devices used should be obtained, as outlined in the Health Update. Efforts should also be made to collect clinical samples and to determine if any remaining product, devices, and liquids are available for testing. Additionally, CDC has developed International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM)-Supplement coding guidance for healthcare encounters related to EVALI.

DHSS recommends:

1. All patients with serious respiratory illness of unknown etiology be asked about recent use of electronic cigarettes and vaping,
2. Ruling out infectious and non-infectious etiology in patients with unexplained serious respiratory illness and vaping exposures,
3. A urinary toxicology screen (including tetrahydrocannabinol [THC], quantified as necessary) be obtained for these patients if a reliable vaping history is unavailable, or if otherwise clinically indicated,
4. Specialty case consultation be considered in severe cases of vaping associated lung injury,
5. Systemic steroid use in clinical management, although data on its effectiveness are limited. When possible, decisions on the use of corticosteroids should be made in consultation with a pulmonologist,
6. Advising all patients with vaping-associated lung injury to stop vaping and offering evidence-based cessation support, and
7. Follow-up with all patients with vaping-associated lung injury within 1-2 weeks of hospital discharge.

DHSS asks:

1. That patients with unexplained serious respiratory illness and recent vaping be reported to DHSS using the attached new case report form,
2. That providers ask and encourage patients with vaping associated lung injury to complete the attached patient survey,
3. That clinical samples from bronchoalveolar lavage (BAL) and /or tissue biopsies be saved and work with the Tobacco Prevention and Control Program to facilitate shipment of these specimens to the Missouri State Public Health Laboratory (MSPHL) for routing to the CDC, and
4. That remaining vaping product or devices from case-patients be retained for testing (only full to half full cartridges will be accepted), and work with the Tobacco Prevention and Control Program to facilitate shipment of these specimens to the MSPHL.

Clinicians routinely consider multiple possible etiologies when evaluating and treating patients presenting with respiratory symptoms. In some cases, treatment directed at one or more of these etiologies must be initiated before the results of diagnostic testing, or other clinical features enable the list of possibilities to be narrowed.

• For the coming flu season, CDC recommends that healthcare providers strongly consider respiratory infections as well as lung injury associated with use of e-cigarette, or vaping, products in all patients presenting with respiratory symptoms and a history of using these products.
• CDC recommends that everyone 6 months of age and older should get a flu vaccine every year by the end of October, including people who use e-cigarette, or vaping, products. Check out Key Facts About Seasonal Flu Vaccine for more information.

• EVALI Lung Injury Case Report
• EVALI Lung Injury Patient Survey

DHSS EVALI Related Health Updates

Update 2: Lung Injuries Associated with E-cigarette, or Vaping, Product Use (11.14.19)
Severe Lung Disease Associated with Using E-Cigarette Products (9.12.19)
Severe Lung Disease Associated with Vaping (8.20.19)

CDC Guidelines

Lung Injury CDC Laboratory Clinical Sample Collection Guidelines

Lung Injury CDC Biopsy Submission Guidelines

ICD-10 CM Coding Guidelines for EVALI

Case Definitions

Primary Cases

Out-of-Hospital Cases

Publications

CDC MMWR – Interim Guidance for HealthCare Providers, October 2019

CDC MMWR First Analysis of Lung Injury Deaths

Fact Sheets and Posters

Fact Sheet for Evaluating the Care of EVALI Patients

Educate Young Patients About the Risks of E-Cigarettes

Poster for Clinical Settings (English, Spanish)

Training

Product Use Associated Lung Injury Presentation.

COCA Webinar – Outbreak of Lung Injury Associated with E-cigarette Product Use or Vaping: Information for Clinicians Presentation.

Clinician Outreach and Communication Activity (COCA) Webinar – Update: Interim Guidance for Healthcare Providers Evaluating and Caring for Patients with Suspected E-cigarette or Vaping Product Use Associated Lung Injury Presentation.