Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin - Final Report.

BACKGROUND: E-cigarettes are battery-operated devices that heat a liquid and deliver an aerosolized product to the user. Pulmonary illnesses related to e-cigarette use have been reported, but no large series has been described. In July 2019, the Wisconsin Department of Health Services and the Illinois Department of Public Health received reports of lung injury associated with the use of e-cigarettes (also called vaping) and launched a coordinated public health investigation. METHODS: We defined case patients as persons who reported use of e-cigarette devices and related products in the 90 days before symptom onset and had pulmonary infiltrates on imaging and whose illnesses were not attributed to other causes. Medical record abstraction and case patient interviews were conducted with the use of standardized tools. RESULTS: There were 98 case patients, 79% of whom were male; the median age of the patients was 21 years. The majority of patients presented with respiratory symptoms (97%), gastrointestinal symptoms (77%), and constitutional symptoms (100%). All case patients had bilateral infiltrates on chest imaging. A total of 95% of the patients were hospitalized, 26% underwent intubation and mechanical ventilation, and two deaths were reported. A total of 89% of the patients reported having used tetrahydrocannabinol products in e-cigarette devices, although a wide variety of products and devices was reported. Syndromic surveillance data from Illinois showed that the mean monthly rate of visits related to severe respiratory illness in June through August of 2019 was twice the rate that was observed in the same months in 2018. CONCLUSIONS: Case patients presented with similar clinical characteristics. Although the definitive substance or substances contributing to injury have not been determined, this initial cluster of illnesses represents an emerging clinical syndrome or syndromes. Additional work is needed to characterize the pathophysiology and to identify the definitive causes.

Characterization of Carbon Monoxide Exposure During Hurricane Sandy and Subsequent Nor'easter.

OBJECTIVE: Carbon monoxide (CO) is an odorless, colorless gas produced by fossil fuel combustion. On October 29, 2012, Hurricane Sandy moved ashore near Atlantic City, New Jersey, causing widespread morbidity and mortality, $30 to $50 billion in economic damage, and 8.5 million households to be without power. The combination of power outages and unusually low temperatures led people to use alternate power sources, placing many at risk for CO exposure. METHODS: We examined Hurricane Sandy-related CO exposures from multiple perspectives to help identify risk factors and develop strategies to prevent future exposures. This report combined data from 3 separate sources (health departments, poison centers via the National Poison Data System, and state and local public information officers). RESULTS: Results indicated that the number of CO exposures in the wake of Hurricane Sandy was significantly greater than in previous years. The persons affected were mostly females and those in younger age categories and, despite messaging, most CO exposures occurred from improper generator use. CONCLUSIONS: Our findings emphasize the continued importance of CO-related communication and ongoing surveillance of CO exposures to support public health response and prevention during and after disasters. Additionally, regional poison centers can be a critical resource for potential on-site management, public health promotion, and disaster-related CO exposure surveillance. (Disaster Med Public Health Preparedness. 2017;11:562-567).

Hepatotoxicity associated with weight loss or sports dietary supplements, including OxyELITE Pro™ - United States, 2013.

In September 2013, the Hawaii Department of Health (HDOH) was notified of seven adults who developed acute hepatitis after taking OxyELITE Pro™, a weight loss and sports dietary supplement. CDC assisted HDOH with their investigation, then conducted case-finding outside of Hawaii with FDA and the Department of Defense (DoD). We defined cases as acute hepatitis of unknown etiology that occurred from April 1, 2013, through December 5, 2013, following exposure to a weight loss or muscle-building dietary supplement, such as OxyELITE Pro™. We conducted case-finding through multiple sources, including data from poison centers (National Poison Data System [NPDS]) and FDA MedWatch. We identified 40 case-patients in 23 states and two military bases with acute hepatitis of unknown etiology and exposure to a weight loss or muscle building dietary supplement. Of 35 case-patients who reported their race, 15 (42.9%) reported white and 9 (25.7%) reported Asian. Commonly reported symptoms included jaundice, fatigue, and dark urine. Twenty-five (62.5%) case-patients reported taking OxyELITE Pro™. Of these 25 patients, 17 of 22 (77.3%) with available data were hospitalized and 1 received a liver transplant. NPDS and FDA MedWatch each captured seven (17.5%) case-patients. Improving the ability to search surveillance systems like NPDS and FDA MedWatch for individual and grouped dietary supplements, as well as coordinating case-finding with DoD, may benefit ongoing surveillance efforts and future outbreak responses involving adverse health effects from dietary supplements. This investigation highlights opportunities and challenges in using multiple sources to identify cases of suspected supplement associated adverse events. Published 2016. This article is a U.S. Government work and is in the public domain in the USA.

Notes from the Field: Kratom (Mitragyna speciosa) Exposures Reported to Poison Centers - United States, 2010-2015.

Kratom (Mitragyna speciosa) is a plant consumed throughout the world for its stimulant effects and as an opioid substitute (1). It is typically brewed into a tea, chewed, smoked, or ingested in capsules (2). It is also known as Thang, Kakuam, Thom, Ketum, and Biak (3). The Drug Enforcement Administration includes kratom on its Drugs of Concern list (substances that are not currently regulated by the Controlled Substances Act, but that pose risks to persons who abuse them), and the National Institute of Drug Abuse has identified kratom as an emerging drug of abuse (3,4). Published case reports have associated kratom exposure with psychosis, seizures, and deaths (5,6). Because deaths have been attributed to kratom in the United States (7), some jurisdictions have passed or are considering legislation to make kratom use a felony (8). CDC characterized kratom exposures that were reported to poison centers and uploaded to the National Poison Data System (NPDS) during January 2010-December 2015. The NPDS is a national database of information logged by the country's regional poison centers serving all 50 United States, the District of Columbia, and Puerto Rico and is maintained by the American Association of Poison Control Centers. NPDS case records are the result of call reports made by the public and health care providers.

Severe Illness Associated with Reported Use of Synthetic Cannabinoids - Mississippi, April 2015.

On April 2, 2015, four patients were evaluated at the University of Mississippi Medical Center (UMMC) in Jackson, Mississippi, for agitated delirium after using synthetic cannabinoids. Over the next 3 days, 24 additional persons went to UMMC with illnesses suspected to be related to synthetic cannabinoid use; one patient died. UMMC notified the Mississippi State Department of Health, which issued a statewide alert via the Health Alert Network on April 5, requesting that health care providers report suspected cases of synthetic cannabinoid intoxication to the Mississippi Poison Control Center (MPCC). A suspected case was defined as the occurrence of at least two of the following symptoms: sweating, severe agitation, or psychosis in a person with known or suspected synthetic cannabinoid use. A second statewide alert was issued on April 13, instructing all Mississippi emergency departments to submit line lists of suspected patients to MPCC each day. By April 21, 16 days after the first alert was issued, MPCC had received reports of approximately 400 cases, including eight deaths possibly linked to synthetic cannabinoid use; in contrast, during April 2012­March 2015, the median number of telephone calls to MPCC regarding synthetic cannabinoid use was one per month (range = 0­11). The Mississippi State Department of Health, with the assistance of CDC, initiated an investigation to better characterize the outbreak, identify risk factors associated with severe illness, and prevent additional illnesses and deaths.

Notes from the Field: Increase in Reported Adverse Health Effects Related to Synthetic Cannabinoid Use - United States, January-May 2015.

On April 6, 2015, CDC received notification of an increase in telephone calls to U.S. poison centers related to synthetic cannabinoid use. Monthly calls to all poison centers are tracked by the National Poison Data System, which reported that adverse health effects or concerns about possible adverse health effects related to synthetic cannabinoid use increased 330% from 349 in January 2015 to 1,501 in April 2015. Synthetic cannabinoids include various psychoactive chemicals or a mixture of such chemicals that are sprayed onto plant material, which is then often smoked or ingested to achieve a "high." These products are sold under a variety of names (e.g., synthetic marijuana, spice, K2, black mamba, and crazy clown) and can be sold in retail outlets as herbal products. Law enforcement agencies have regulated a number of these substances; however, manufacturers of synthetic cannabinoids frequently change the formulation to avoid detection and regulation. After the initial notification, CDC analyzed information from the National Poison Data System on reported adverse health effects related to synthetic cannabinoid use for the period January-May 2015.

National surveillance for radiological exposures and intentional potassium iodide and iodine product ingestions in the United States associated with the 2011 Japan radiological incident.

BACKGROUND: In March of 2011, an earthquake struck Japan causing a tsunami that resulted in a radiological release from the damaged Fukushima Daiichi nuclear power plant. Surveillance for potential radiological and any iodine/iodide product exposures was initiated on the National Poison Data System (NPDS) to target public health messaging needs within the United States (US). Our objectives are to describe self-reported exposures to radiation, potassium iodide (KI) and other iodine/iodide products which occurred during the US federal response and discuss its public health impact. METHODS: All calls to poison centers associated with the Japan incident were identified from March 11, 2011 to April 18, 2011 in NPDS. Exposure, demographic and health outcome information were collected. Calls about reported radiation exposures and KI or other iodine/iodide product ingestions were then categorized with regard to exposure likelihood based on follow-up information obtained from the PC where each call originated. Reported exposures were subsequently classified as probable exposures (high likelihood of exposure), probable non-exposures (low likelihood of exposure), and suspect exposure (unknown likelihood of exposure). RESULTS: We identified 400 calls to PCs associated with the incident, with 340 information requests (no exposure reported) and 60 reported exposures. The majority (n = 194; 57%) of the information requests mentioned one or more substances. Radiation was inquired about most frequently (n = 88; 45%), followed by KI (n = 86; 44%) and other iodine/iodide products (n = 47; 24%). Of the 60 reported exposures, KI was reported most frequently (n = 25; 42%), followed by radiation (n = 22; 37%) and other iodine/iodide products (n = 13; 22%). Among reported KI exposures, most were classified as probable exposures (n = 24; 96%); one was a probable non-exposure. Among reported other iodine/iodide product exposures, most were probable exposures (n = 10, 77%) and the rest were suspect exposures (n = 3; 23%). The reported radiation exposures were classified as suspect exposures (n = 16, 73%) or probable non-exposures (n = 6; 27%). No radiation exposures were classified as probable exposures. A small number of the probable exposures to KI and other iodide/iodine products reported adverse signs or symptoms (n = 9; 26%). The majority of probable exposures had no adverse outcomes (n = 28; 82%). These data identified a potential public health information gap regarding KI and other iodine/iodide products which was then addressed through public health messaging activities. CONCLUSION: During the Japan incident response, surveillance activities using NPDS identified KI and other iodine/iodide products as potential public health concerns within the US, which guided CDC's public health messaging and communication activities. Regional PCs can provide timely and additional information during a public health emergency to enhance data collected from surveillance activities, which in turn can be used to inform public health decision-making.

Using poison center data for national public health surveillance for chemical and poison exposure and associated illness.

The National Poison Data System (NPDS) is a national near-real-time surveillance system that improves situational awareness for chemical and poison exposures, according to data from US poison centers. NPDS is the successor to the Toxic Exposure Surveillance System. The Centers for Disease Control and Prevention (CDC) use these data, which are owned and managed by the American Association of Poison Control Centers, to improve public health surveillance for chemical and poison exposures and associated illness, identify early markers of chemical events, and enhance situational awareness during outbreaks. Information recorded in this database is from self-reported calls from the public or health care professionals. In 2009, NPDS detected 22 events of public health significance and CDC used the system to monitor several multistate outbreaks. One of the limitations of the system is that exposures do not necessarily represent a poisoning. Incorporating NPDS data into the public health surveillance network and subsequently using NPDS to rapidly identify chemical and poison exposures exemplifies the importance of the poison centers and NPDS to public health surveillance. This integration provides the opportunity to improve the public health response to chemical and poison exposures, minimizes morbidity and mortality, and serves as an important step forward in surveillance technology and integration.