A va­p­ing ‘break­through’

Vi­ta­min E ac­etate found in pa­tients is seen as a likely cul­prit

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Health of­fi­cials say vi­ta­min E ac­etate is the likely cul­prit in the out­break that has killed 39.

Fed­eral health of­fi­cials have iden­ti­fied vi­ta­min E ac­etate in the lung flu­ids of 29 peo­ple sick­ened in the out­break of dan­ger­ous va­p­ing-re­lated lung in­juries. The dis­cov­ery points to the oil as a likely cul­prit in the out­break that has sick­ened more than 2,000 peo­ple and killed at least 39.

“These find­ings pro­vide di­rect ev­i­dence of vi­ta­min E ac­etate at the pri­mary site of in­jury within the lungs,” said Anne Schuchat, prin­ci­pal deputy di­rec­tor at the Cen­ters for Dis­ease Con­trol and Preven­tion. The lat­est in­for­ma­tion points to grow­ing ev­i­dence of vi­ta­min E ac­etate as “a very strong cul­prit of con­cern,” she said in a brief­ing with re­porters.

The find­ings an­nounced Fri­day do not rule out other pos­si­ble com­pounds or in­gre­di­ents that may be caus­ing the lung in­juries. But Schuchat de­scribed the lab re­sults as a “break­through” in the in­ves­ti­ga­tion. The CDC tested for a wide range of sub­stances that might be found in pa­tients’ lung flu­ids, in­clud­ing plant oils and petroleum dis­til­lates, such as min­eral oil.

But what they did not find was just as im­por­tant. “No other po­ten­tial tox­ins were de­tected,” Schuchat said.

CDC of­fi­cials found vi­ta­min E ac­etate, an oil de­rived from the vi­ta­min, in all 29 sam­ples of lung fluid col­lected from pa­tients who had fallen ill or died of lung in­juries. THC, the psy­choac­tive in­gre­di­ent in mar­i­juana, was also found in 23 pa­tients, in­clud­ing three who said they had not used THC prod­ucts. Nico­tine was de­tected in 16 of 26 pa­tients. Most pa­tients who have fallen ill in the out­break have vaped THC, of­fi­cials have said.

Vi­ta­min E ac­etate had al­ready been iden­ti­fied in pre­vi­ous test­ing by the Food and Drug Ad­min­is­tra­tion and state lab­o­ra­to­ries in vape prod­ucts that con­tain THC. New York state’s Wadsworth Cen­ter lab was the first to dis­cover it about two months ago in sam­ples from sick pa­tients. Of 595 va­p­ing prod­uct sam­ples linked to pa­tients that have been tested by the FDA, 70 per­cent con­tained THC. Half of those Thc-con­tain­ing prod­ucts also had vi­ta­min E ac­etate, with con­cen­tra­tions as high as 88 per­cent, the FDA said Fri­day.

Many of the Thc-con­tain­ing prod­ucts were ob­tained on the il­licit mar­ket, of­fi­cials have said. Vi­ta­min E ac­etate has been used in re­cent months as a cut­ting agent or ad­di­tive on the cannabis black mar­ket to stretch the amount of THC in vape car­tridges, of­fi­cials and in­dus­try ex­perts have said. Vi­ta­min E ac­etate is a pop­u­lar ad­di­tive be­cause it is col­or­less and odor­less, has sim­i­lar vis­cos­ity to THC oil and is much cheaper.

The find­ings are sig­nif­i­cant be­cause for the first time, sci­en­tists have been able to con­nect re­sults from prod­uct test­ing with clin­i­cal spec­i­mens from pa­tients, Schuchat said. The 29 pa­tients are from 10 states, rep­re­sent­ing a di­verse ge­o­graph­i­cal area, mak­ing the find­ings “much more ro­bust” than if all the pa­tients were from a sin­gle lo­ca­tion. Most of the pa­tients were male, with a me­dian age of 23. Two of the pa­tients died.

“They help us bet­ter un­der­stand the po­ten­tial com­pounds” that may con­trib­ute to the in­juries, Schuchat said. “They tell us what en­tered the lungs of some of these pa­tients.”

Vi­ta­min E ac­etate is found in many foods and in cos­met­ics, es­pe­cially skin-care prod­ucts. It is not known to cause harm when swal­lowed or ap­plied to the skin, Schuchat said. But when it is heated and in­haled, it may in­ter­fere with nor­mal lung func­tion. Its prop­er­ties could be as­so­ci­ated with the kinds of res­pi­ra­tory symp­toms that many pa­tients have re­ported — cough, short­ness of breath and chest pain, of­fi­cials and ex­perts have said.

Pub­lic health ex­perts wel­comed the news but cau­tioned that more test­ing needs to be com­pleted. “While this is a big step in help­ing us un­der­stand what may be caus­ing these in­juries, these find­ings do not rule out the po­ten­tial for other com­pounds or in­gre­di­ents as con­tribut­ing fac­tors,” said Scott Becker, ex­ec­u­tive di­rec­tor of the As­so­ci­a­tion of Pub­lic Health Lab­o­ra­to­ries. “There may be more than one cause of the out­break.”

The find­ings, de­tailed in a CDC re­port re­leased Fri­day, also re­in­forced of­fi­cial health warn­ings against us­ing e-cig­a­rette or va­p­ing prod­ucts that con­tain THC, es­pe­cially those bought off the street.

The CDC is main­tain­ing its rec­om­men­da­tion that con­sumers con­sider re­frain­ing from all va­p­ing and e-cig­a­rette prod­ucts, in­clud­ing those con­tain­ing nico­tine, be­cause a small pro­por­tion of pa­tients con­tinue to re­port exclusive use of nico­tine-con­tain­ing prod­ucts, Schuchat said.

Chem­istry pro­fes­sor Michelle Francl has de­scribed vi­ta­min E ac­etate as ba­si­cally grease. Its molec­u­lar struc­ture means that “you have to heat it up pretty hot” for it to va­por­ize, said Francl, a pro­fes­sor at Bryn Mawr Col­lege. Once the oil is heated enough to va­por­ize, it can po­ten­tially de­com­pose, and “now you’re breath­ing in who knows what,” Francl has said.

Of­fi­cials still need to test for the sub­stance in other peo­ple who vaped and who did not ex­pe­ri­ence these in­juries, Schuchat said. Of­fi­cials also want to test a broader num­ber of lung fluid sam­ples from pa­tients in dif­fer­ent lo­ca­tions, she said.

An­i­mal stud­ies also need to be un­der­taken to bet­ter un­der­stand how vi­ta­min E ac­etate might cause the harm in lungs, she said.

For the lung fluid test­ing, CDC sci­en­tists had drawn up a pri­or­ity list of chem­i­cals that had the po­ten­tial to be tox­ins. They in­cluded vi­ta­min E ac­etate; plant oils;

petroleum-based oils such as min­eral oil; and ter­penes, or­ganic com­pounds that give fra­grant aro­mas to plants and flow­ers, said Jim Pirkle, di­rec­tor of the lab­o­ra­tory sci­ence di­vi­sion at the CDC’S Na­tional Cen­ter for En­vi­ron­men­tal Health. Pirkle is over­see­ing much of the CDC’S out­break-re­lated lab test­ing.

“We haven’t found any of those” ex­cept for vi­ta­min E ac­etate, Pirkle said, but the sam­ples ac­count for only a small por­tion of the num­ber of peo­ple sick­ened, and more test­ing will con­tinue. Find­ing vi­ta­min E ac­etate in 29 out of 29 sam­ples of lung fluid is “a very strong sig­nal,” he said.

Vi­ta­min E ac­etate is a sticky sub­stance, like honey, Pirkle said. “When it goes into the lung,” he said, “it does hang around.” The oil can dis­rupt the abil­ity of the lungs to stay in­flated, of­fi­cials said.

THC, on the other hand, “is not some­thing you would ex­pect to be hang­ing around in the lung fluid,” Pirkle said. It is more likely to be found in urine, he said. That could ac­count for why it was not found in some sam­ples. It is also pos­si­ble that the vi­ta­min E ac­etate was part of dif­fer­ent kind of va­p­ing liq­uid, of­fi­cials said.

“These find­ings pro­vide di­rect ev­i­dence of vi­ta­min E ac­etate at the pri­mary site of in­jury within the lungs.” Anne Schuchat, prin­ci­pal deputy di­rec­tor at the CDC

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