EVALI Advisory for Healthcare Providers

Update: E-Cigarette or Vaping-Associated Lung Injury (EVALI)

Posted Feb. 13, 2020. Past health advisories and alerts are archived for historical purposes and are not maintained or updated.

Situation Update:

As of February 4, 2020, a total of 2,758 hospitalized e-cigarette or vaping-associated lung injury (EVALI) cases or deaths have been reported from all 50 states, the District of Columbia, and two U.S. territories, including 64 deaths. The Washington State Health Officer has requested provisional reporting of EVALI cases for an additional 120 days.  

Vitamin E acetate is strongly linked to the EVALI outbreak; however, evidence is not sufficient to rule out the contribution of other chemicals of concern. Emergency department visits related to e-cigarette, or vaping, products continue to decline after peaking in September 2019. According to the Centers for Disease Control & Prevention, reasons for the decline may be related to the following:

  • Increased public awareness of the risk associated with THC-containing e-cigarette, or vaping, product use as a result of the rapid public health response.
  • Removal of vitamin E acetate from some products.
  • Law enforcement actions related to elicit products.

Requested Actions:

  • Be aware that the State Health Officer is requesting provisional reporting of vaping-associated lung injury cases for an additional 120 days.
  • Ask about the use of e-cigarette or vapor products when evaluating patients with respiratory symptoms (e.g., cough, chest pain, and shortness of breath), gastrointestinal symptoms (e.g., abdominal pain, nausea, vomiting, stomach pain, and diarrhea), or nonspecific constitutional symptoms (e.g., fever, chills, and weight loss).
  • Ask patients about recent use of e-cigarette or vapor products. If confirmed, the types of substances used (e.g., THC and nicotine) and where they were obtained should be ascertained.
  • Please report patients who meet the following criteria to Spokane Regional Health District Epidemiology (509-324-1442 phone, 509-324-3623 fax) within three days:
    Any hospitalized patient who
    • Reports vaping or dabbing in the 90 days prior to symptom onset
    • Has a chest X-ray with pulmonary infiltrates or a chest CT scan with ground-glass opacities
    • Has no pulmonary infection (i.e., negative respiratory viral panel, negative flu test, and other clinically-indicated respiratory infectious disease testing negative) or an infection has been identified, but you feel this is not the sole cause of the lung injury or complete infectious disease testing was not performed, but you feel an infection is not the sole cause of the lung injury
    • There is no other alternative plausible diagnosis such as a cardiac, rheumatologic or neoplastic process.
      Note: For more information, see the full CDC case definition.
  • If e-cigarette or vaping product use is suspected as a possible etiology of a patient’s lung injury, obtain a detailed history regarding
    • Substance(s) used
    • Substance source(s)
    • Device(s) used
    • Where the product(s) were purchased
    • Method of substance use 


While the multi-state outbreak of vaping-associated lung injury has waned nationally, the Centers for Disease Control and Prevention (CDC) and public health agencies in Washington State continue to investigate vaping-associated lung injury to better understand its prevalence and cause(s). The latest information about the outbreak can be found on the CDC and Department of Health websites.   

National data from patient reports and product sample testing show tetrahydrocannabinol (THC)-containing vapor products, particularly from informal sources like friends, family, or in-person or online dealers, are linked to most EVALI cases and play a major role in the outbreak. Vitamin E acetate, a product used to produce THC-containing vapor products, is also strongly linked to the EVALI outbreak. Vitamin E acetate has been found in product samples tested by FDA and state laboratories and inpatient lung fluid samples tested by CDC from geographically diverse states. Evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products, in some of the reported EVALI cases. 

Additional Resource

For additional clinical considerations and additional resources for healthcare providers, please see: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/healthcare-providers/index.html  

For patients who want to quit vaping nicotine the best practices are described here:  https://www.drugabuse.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/what-are-treatments-tobacco-dependence and local resources are listed here: https://srhd.org/media/documents/CessationSheet.pdf