Vaping, lung injury, and mental health Minnesota 2018-2019.

This report describes and contextualizes the high prevalence of mental health conditions (MHC) among Minnesota 2019 EVALI patients by examining the prevalence of MHC and associations between MHC and e-cigarette or vaping product (EVP) use in Minnesota population surveys. Investigators reviewed medical records for 140 EVALI patients to determine history of MHC. History of MHC and EVP use in the general population was estimated using self-reported measures and screening tools from two population-based surveys, the 2019 Minnesota Student Survey (MSS) and the 2018 Minnesota Behavioral Risk Factor Surveillance Survey (MN-BRFSS). Some 64.3% of EVALI patients had an MHC. In both Minnesota population surveys, MHCs were common among people who used EVP. The odds of MHC among youth aged <18 were higher among those who reported current EVP use compared with those did not report EVP use. Similarly, the odds of depression were higher among adults who reported current EVP use compared with those who did not. Clinicians treating patients with EVALI should consider evaluating the need for, and providing indicated referrals to, post-discharge mental health services for their patients.

Characteristics of E-cigarette, or Vaping, Products Used by Patients with Associated Lung Injury and Products Seized by Law Enforcement - Minnesota, 2018 and 2019.

During August 9-October 31, 2019, 96 patients were classified as having e-cigarette, or vaping, product use-associated lung injury (EVALI) by the Minnesota Department of Health (MDH); other patients are being investigated for case classification and exposures. Among 58 patients interviewed, 53 (91%) reported obtaining tetrahydrocannabinol (THC)-containing products from informal sources such as friends, family members, or in-person or online dealers. Using gas chromatography-mass spectrometry (GCMS), the MDH Public Health Laboratory (PHL) analyzed 46 THC-containing e-cigarette, or vaping, products obtained from 12 EVALI patients for various potential toxicants, including vitamin E acetate, which has recently been detected in some THC-containing products and in samples of lung fluid from EVALI patients (1-4). To explore whether vitamin E acetate is a recently added component in THC-containing products, MDH tested ten products seized by law enforcement in 2018, before the EVALI outbreak, and 20 products seized in 2019, during the outbreak. Twenty-four products obtained from 11 EVALI patients from 2019 contained vitamin E acetate. Among the seized products tested by MDH, none seized in 2018 contained vitamin E acetate, although all tested THC-containing products seized in 2019 tested positive for vitamin E acetate. These chemical analyses of products obtained from EVALI patients and of products intended for the illicit market both before and during the outbreak support a potential role for vitamin E acetate in the EVALI outbreak; however, the number of products tested was small, and further research is needed to establish a causal link between exposure to inhaled vitamin E acetate and EVALI. Collaboration between public health jurisdictions and law enforcement to characterize THC-containing products circulating before the recognition of the EVALI outbreak and during the outbreak might provide valuable information about a dynamic market. These Minnesota findings highlight concerns about e-cigarette, or vaping, products that contain THC acquired from informal sources. Because local supply chains and policy environments vary, CDC continues to recommend not using e-cigarette, or vaping, products that contain THC or any e-cigarette, or vaping, products obtained from informal sources. E-cigarette, or vaping, products should never be used by youths, young adults, or pregnant women.* Until the relationship between inhaled vitamin E acetate and lung health is better characterized, vitamin E acetate should not be added to e-cigarette, or vaping, products.

Lessons Learned From the E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) Outbreak Response, Minnesota, 2019-2020.

OBJECTIVE: Electronic cigarette (e-cigarette), or vaping, product use-associated lung injury (EVALI) is a novel noncommunicable disease with an unknown cause. The objective of this analysis was to describe the Minnesota Department of Health's (MDH's) outbreak response to EVALI, including challenges, successes, and lessons learned. METHODS: MDH began investigating EVALI cases in August 2019 and quickly coordinated an agencywide response. This response included activating the incident command system; organizing multidisciplinary teams to perform the epidemiologic investigation; laboratory testing of e-cigarette, or vaping, products (EVPs) and clinical specimens; and collaborating with partners to gather information and develop recommendations. RESULTS: MDH faced numerous investigational challenges during the outbreak response of EVALI, including the need to gather information on unregulated and illicit substances and their use and collecting information from minors and critically ill people. MDH laboratorians faced methodologic challenges in characterizing EVPs. Despite these challenges, MDH epidemiologists successfully collaborated with the MDH public health laboratory, law enforcement, partners with clinical and toxicology expertise, and local and national public health partners. PRACTICE IMPLICATIONS: Lessons learned included ensuring the state public health agency has legal authority to conduct noncommunicable disease outbreak investigations and the necessity of cultivating and using internal and external partnerships, specifically with laboratories that can analyze clinical specimens and unknown substances. The lessons learned may be useful to public health agencies responding to similar public health emergencies. To improve preparedness for the next outbreak of EVALI or other noncommunicable diseases, we recommend building and maintaining partnerships with internal and external partners.

Biosurveillance of Drug Overdoses and Substance Misuse Treated in Selected Emergency Departments in Minnesota, 2017-2020.

OBJECTIVES: Increasing knowledge about the toxicology of drug overdose and substance misuse (DOSM) is important in improving our understanding of the epidemic. We describe the Minnesota Drug Overdose and Substance Use Pilot Surveillance Activity, which started collecting data on emergency department (ED) visits attributable to DOSM in 2017, with a focus on the toxicology results of a subset of clinical encounters. METHODS: From November 1, 2017, through January 30, 2020, we collected near-real-time data on DOSM-related ED encounters. The Minnesota Department of Health Public Health Laboratory tested leftover clinical specimens (blood and/or urine) for the presence of various substances for patients who died, were hospitalized, had an atypical clinical presentation, or were part of a local drug overdose cluster. Testing looked for >250 drugs or their metabolites, including those commonly misused (eg, methamphetamine, cocaine), prescription medications, synthetic cannabinoids and cathinones, and opioids. We describe characteristics of the overall group and a subgroup of clinical encounters with toxicology results. RESULTS: Specimens submitted from 6 EDs during the study period represented 239 clinical encounters. Methamphetamine was the most frequently detected substance (67.4%) but was suspected in only 45.6% of encounters. At least 1 opioid was detected in 42.5% of encounters but suspected in only 29.7%. Testing also detected potential adulterants and additives (eg, fentanyl, fentanyl analogues, levamisole) and showed frequent patient exposure to substances not reported by patients or suspected by clinicians. Nearly half (44.4%) of clinical encounters had >1 substance detected. CONCLUSIONS: ED surveillance for DOSM encounters, enhanced by toxicology testing, can provide local situational awareness on overdoses, prevent potential mischaracterization of the true drug overdose epidemic, and inform harm reduction and drug overdose prevention efforts.

Campylobacter jejuni genotypes are associated with post-infection irritable bowel syndrome in humans.

Campylobacter enterocolitis may lead to post-infection irritable bowel syndrome (PI-IBS) and while some C. jejuni strains are more likely than others to cause human disease, genomic and virulence characteristics promoting PI-IBS development remain uncharacterized. We combined pangenome-wide association studies and phenotypic assays to compare C. jejuni isolates from patients who developed PI-IBS with those who did not. We show that variation in bacterial stress response (Cj0145_phoX), adhesion protein (Cj0628_CapA), and core biosynthetic pathway genes (biotin: Cj0308_bioD; purine: Cj0514_purQ; isoprenoid: Cj0894c_ispH) were associated with PI-IBS development. In vitro assays demonstrated greater adhesion, invasion, IL-8 and TNFα secretion on colonocytes with PI-IBS compared to PI-no-IBS strains. A risk-score for PI-IBS development was generated using 22 genomic markers, four of which were from Cj1631c, a putative heme oxidase gene linked to virulence. Our finding that specific Campylobacter genotypes confer greater in vitro virulence and increased risk of PI-IBS has potential to improve understanding of the complex host-pathogen interactions underlying this condition.

Law enforcement practices in the first two states in U.S. to legalize recreational marijuana.

BACKGROUND: There is a lack of research regarding law enforcement practices where recreational marijuana sales are legal. Given that legalization of recreational marijuana is expanding, lessons learned from areas with existing legalization can help inform future practices. This pilot study is an evaluation of enforcement of marijuana laws in the first two states in the U.S. to legalize sales of recreational marijuana, Colorado and Washington, several years post legalization. METHODS: We surveyed a random sample of local law enforcement agencies in the two states (25 agencies per state). We also attempted to survey the state-level marijuana enforcement agency but only Washington responded. Surveys focused on youth marijuana use, youth access to marijuana, and impaired driving but included other topics. Chi-square tests assessed differences between states (p < .05). RESULTS: All local agencies reported underage use was somewhat or very common in their jurisdictions. Thirty percent of local agencies conducted enforcement targeting underage use/possession. Twenty percent of agencies overall conducted underage compliance checks at licensed stores, with more agencies conducting checks in Colorado (32%) than Washington (8%; p = .03). Most agencies in both states reported marijuana-impaired driving was somewhat or very common in their jurisdictions. One local agency in each state specifically targeted marijuana-impaired driving. The state-level agency in Washington reported that their agency is the one primarily responsible for enforcing marijuana retail laws and they conducted routine underage compliance checks at all licensed marijuana stores three times per year. CONCLUSION: Our findings indicate that marijuana enforcement can be improved regarding sales/provision to underage youth and impaired driving in these states, particularly given that underage use and impaired driving are perceived to be common. Larger studies with additional jurisdictions and types of agencies (e.g., highway patrol) are warranted.