Transcript of CDC Telebriefing: Update on Lung Injury Associated with E-cigarette Use, or Vaping

OPERATOR>>> WELCOME AND THANK YOU FOR STANDING BY. YOUR LINES HAVE BEEN PLACED ON A LISTEN-ONLY MODE UNTIL THE QUESTION AND ANSWER SESSION. AT THAT TIME, IF YOU WOULD LIKE TO ASK A QUESTION, YOU MAY PRESS STAR ONE. TODAY’S CONFERENCE IS BEING RECORDED. IF YOU HAVE ANY OBJECTIONS YOU CAN DISCONNECT AT THIS TIME. I WILL NOW TURN THE CALL OVER TO K.D. HOSKINS. YOU MAY BEGIN.

HOSKINS>> THANK YOU. THANK YOU FOR JOINING OUR UPDATE ON THE INVESTIGATION AMONG PEOPLE WHO USE E-CIGARETTES OR VAPING PRODUCTS. WE’RE JOINED TODAY BY DR. ANNE SCHUCHAT, PRINCIPLE DEPUTY DIRECTOR OF THE CENTERS CONTROL OF DISEASE PREVENTION � AND DR. SCHUCHAT WILL PROVIDE THIS WEEK’S UPDATE. WE’RE ALSO JOINED BY DR. JENNIFER LAYDEN, STATE EPIDEMIOLOGIST AT THE ILLINOIS DEPARTMENT OF HEALTH. ALSO, DURING OUR Q AND A SESSION, DR. JIM PIRKLE FROM CDC’S ENVIRONMENTAL HEALTH LABS WILL ALSO BE AVAILABLE TO ANSWER YOUR QUESTIONS. I’LL NOW TURN THE CALL OVER TO DR. SCHUCHAT.

SCHUCHAT>> THANK YOU FOR JOINING US AS CDC CONTINUES INVESTIGATING THE OUTBREAK OF LUNG INJURY ASSOCIATED WITH THE USE OF E-CIGARETTE OR VAPING PRODUCTS, TOGETHER WITH THE STATE AND LOCAL HEALTH DEPARTMENTS AND FEDERAL PARTNERS SUCH AS FDA. THERE ARE NOW 2,051 CASES OF E-CIGARETTE OR VAPING PRODUCT ASSOCIATED LUNG INJURY REPORTED FROM 49 STATES, D.C. AND THE U.S. VIRGIN ISLANDS. UNFORTUNATELY, 39 PEOPLE HAVE DIED FROM THIS CONDITION AS OF NOVEMBER 5th AND WE ARE AWARE THAT ADDITIONAL INVESTIGATIONS ARE ONGOING. THE TREND IN CASES APPEARS TO BE DOWNWARD, BUT WE UNDERSTAND THAT SOME STATES ARE STILL HARD HIT AND THIS S CONTINUES TO BE A VERY ACTIVE INVESTIGATION. YOU WILL SHORTLY HEAR ABOUT SOME NEW RESULTS FROM A DETAILED STUDY OF RISK FACTORS FOR EVALI, OR THE E-CIGARETTE AND VAPING PRODUCT ASSOCIATED LUNG INJURY, PATIENTS IN ILLINOIS. BUT, FIRST, I’D LIKE TO PROVIDE SOME NEW DATA ON LABORATORY STUDIES THAT WERE CARRIED OUT AT THE CDC’S ENVIRONMENTAL HEALTH LABORATORY.

WHAT WE KNOW FROM THE LABORATORY METHODS THAT WE PUT IN PLACE TO LOOK FOR POTENTIAL TOXINS FROM E-CIGARETTE OR VAPING PRODUCTS COMES FROM BRONCHOALVEOLAR LAVAGE � OR BAL � FLUID SAMPLES FROM PATIENTS WHO SUFFERED THESE LUNG INJURIES. THESE ARE SAMPLES OF FLUID COLLECTED FROM THE LUNGS OF ILL PATIENTS. TODAY’S MMWR REPORT DESCRIBES LAB TESTING OF A CONVENIECE SAMPLE OF BAL SAMPLES FROM 29 PATIENTS WITH EVALI THAT WERE SUBMITTED TO CDC FROM TEN DIFFERENT STATES THROUGH THE END OF OCTOBER. THC AND A POTENTIAL TOXIN, VITAMIN E ACETATE, WERE DETECTED IN MANY. THE VITAMIN E ACETATE WAS FOUND IN ALL SAMPLES AND THC WAS IN 23 OF 28 SAMPLES THAT WERE TESTED. NICOTINE WAS FOUND IN 61%, OR 16 OF 26, SAMPLES THAT WERE TESTED. AND, AGAIN, VITAMIN E ACETATE WAS FOUND IN ALL 29 SAMPLES TESTED.

THESE NEW FINDINGS ARE SIGNIFICANT BECAUSE FOR THE FIRST TIME, WE HAVE DETECTED A POTENTIAL TOXIN OF CONCERN � VITAMIN E ACETATE � IN BIOLOGIC SAMPLES FROM PATIENTS WITH LUNG INJURIES ASSOCIATED WITH THE USE OF E-CIGARETTE OR VAPING PRODUCTS. THESE FINDINGS PROVIDE DIRECT EVIDENCE OF VITAMIN E ACETATE AT THE PRIMARY SITE OF INJURY WITHIN THE LUNGS. AND THE SAMPLES REFLECT PATIENTS FROM STATES ACROSS THE COUNTRY. TO DATE, VITAMIN E ACETATE HAS BEEN REPORTED IN PRODUCT SAMPLES USED BY PATIENTS WITH EVALI, INCLUDING AN E-LIQUID TESTING COMPLETED BY THE FDA AND BY SOME STATE PUBLIC HEALTH LABORATORIES, INCLUDING THE WADSWORTH LABORATORY IN NEW YORK STATE. CDC TESTED FOR A WIDE RANGE OF SUBSTANCES THAT MIGHT BE FOUND IN E-CIGARETTE OR VAPING PRODUCTS INCLUDING PLANT OIL, PETROLEUM DISTILLATES LIKE MINERAL OIL, MEDIUM-CHAIN TRIGLYCERIDE OILS � OR MCT OILS � AND TERPENES WHICH ARE COMPOUNDS FOUND IN OR ADDED TO THC PRODUCTS. NO OTHER POTENTIAL TOXINS WERE DETECTED IN THE TESTING CONDUCTED SO FAR. VITAMIN E ACETATE IS A VITAMIN FOUND IN MANY FOODS AND IS ALSO AVAILABLE IN SUPPLEMENTS AND COSMETIC PRODUCTS LIKE SKIN CREAM. VITAMIN E ACETATE IS ALSO A KNOWN ADDITIVE USED TO DILUTE LIQUID IN E-CIGARETTE OR VAPING PRODUCTS THAT CONTAIN THC. VITAMIN E ACETATE DOES USUALLY NOT CAUSE HARM WHEN SWALLOWED AS A VITAMIN SUPPLEMENT OR APPLIED TOPICALLY TO THE SKIN. HOWEVER, PREVIOUS NON-CDC RESEARCH SUGGESTS THAT WHEN VITAMIN E ACETATE IS INHALED, IT MAY INTERFERE WITH NORMAL LUNG FUNCTION. TO BETTER CHARACTERIZE THE EXPOSURE AMONG EVALI PATIENTS, CDC SCIENTISTS DEVELOPED 12 TARGETED LABORATORY METHODS TO ANALYZE SPECIFIC CHEMICALS OF CONCERN AND ACTIVE COMPOUNDS IN THE BAL FLUID FROM PATIENTS WITH EVALI.

THIS TYPE OF ACTIVE DEVELOPMENT AND CAREFUL VALIDATION TAKES TIME. BUT WE ARE PLEASED TO BE ABLE TO SHARE THE EARLY RESULTS OF THIS EFFORT, WHICH RELIED ON COLLABORATION FROM OUR CDC SCIENTISTS WORKING CLOSELY WITH EPIDEMIOLOGISTS, CLINICIANS AND PUBLIC HEALTH STAFF ACROSS THE COUNTRY. IT’S IMPORTANT TO NOTE THAT THESE FINDINGS DO NOT RULE OUT OTHER POSSIBLE COMPOUNDS OR INGREDIENTS THAT MAY BE CAUSING THESE LUNG INJURIES. THERE MAY BE MORE THAN ONE CAUSE OF THE OUTBREAK, HOWEVER, THEY HELP US BETTER UNDERSTAND THE POTENTIAL COMPOUNDS OR INGREDIENTS THAT MAY CONTRIBUTE TO THE CAUSE OF EVALI. SPECIFICALLY, THESE FINDINGS HELP US CONNECT THE EPIDEMIOLOGIC AND PRODUCT TESTING DATA WITH BIOLOGIC DATA FROM CLINICAL SPECIMENS TESTED FROM PATIENTS WITH EVALI. STATED SIMPLY, THESE FINDINGS TELL US WHAT ENTERED THE LUNGS OF SOME PATIENTS WITH THESE INJURIES. OUR WORK COMPLEMENTS THE ONGOING WORK OF FDA AND SOME STATE PUBLIC HEALTH LABS TO CHARACTERIZE E-LIQUID EXPOSURES AND HIGHLIGHTS THE EXTENSIVE COLLABORATION BETWEEN FEDERAL, STATE AND LOCAL PARTNERS.

THE RESULTS REINFORCED PREVIOUS CDC RECOMMENDATIONS TO NOT USE E-CIGARETTE OR VAPING PRODUCTS THAT CONTAIN THC, PARTICULARLY FROM INFORMAL SOURCES LIKE FRIENDS OR FAMILY, ONLINE DEALERS OR THE ILLICIT MARKET. UNTIL THE RELATIONSHIP BETWEEN VITAMIN E ACETATE AND LUNG HEALTH IS BETTER CHARACTERIZED, IT’S IMPORTANT THAT VITAMIN E ACETATE NOT BE ADDED TO E-CIGARETTE OR VAPING PRODUCTS. THOUGH VITAMIN E ACETATE WAS UNIVERSALLY DETECTED IN THESE 29 CASE-ASSOCIATED BAL SAMPLES, ADDITIONAL STUDIES ARE NEEDED TO ESTABLISH WHETHER A CAUSAL LINK EXISTS BETWEEN THE EXPOSURE AND EVALI. AND IT MAY BE THERE IS MORE THAN ONE CAUSE OF THE OUTBREAK. MANY DIFFERENT SUBSTANCES AND PRODUCTS ARE STILL UNDER INVESTIGATION, INCLUDING THOSE TESTED IN THESE SAMPLES. CAUTION SHOULD BE USED BEFORE SUBSTITUTING OTHER CUTTING AGENTS OR ADDITIVES FOR VITAMIN E ACETATE. CDC’S GOAL AND PRIORITY IS TO STOP THIS OUTBREAK AND TO PROVIDE THE AMERICAN PUBLIC WITH DATA-DRIVEN AND SCIENCE-BASED RECOMMENDATIONS.

WE’LL CONTINUE TO PROVIDE REGULAR UPDATES, BUT NOW I’D LIKE TO INVITE DR. JENNIFER LAYDEN, CHIEF MEDICAL OFFICER AND STATE EPIDEMIOLOGIST FROM ILLINOIS TO PROVIDE AN UPDATE. DR. LAYDEN?

LAYDEN>> THANK YOU, DR. SCHUCHAT. I WOULD LIKE TO START BY THANKING THE LEADERSHIP OF ILLINOIS DEPARTMENT OF PUBLIC HEALTH, OUR DIRECTOR, DR. EZIKE, FOR CONTINUING TO PRIORITIZE THIS INVESTIGATION, AND RESPONSE EFFORTS HERE IN ILLINOIS. AND WE ARE GRATEFUL FOR THE LEADERSHIP, COLLABORATION AND ONGOING SUPPORT FROM OUR COLLEAGUES AT THE CDC AS WE CONTINUE THIS IMPORTANT WORK TO UNDERSTAND WHAT IS CAUSING AND CONTRIBUTING TO THIS SEVERE LUNG INJURY THAT HAS AFFECTED SO MANY INDIVIDUALS IN A SHORT TIME. IN EARLIER PUBLISHED WORK, WE DESCRIBED THE USE HABITS AMONG EVALI CASES HERE IN ILLINOIS. WE FOUND SIMILAR TO WHAT HAS BEEN SEEN IN NATIONAL DATA, THAT THE MAJORITY OF CASES REPORTED USING THC-BASED E-CIGARETTE PRODUCTS. PARTICULARLY, WE FOUND A HIGH PROPORTION OF CASES REPORTED THE USE OF THC-BASED PRE-FILLED CARTRIDGES THAT THEY OBTAINED THROUGH INFORMAL SOURCES. IN CASES REPORTED A HIGH FREQUENCY OF USE AND USED NUMEROUS TYPES OF PRODUCTS.

A SIGNIFICANT LIMITATION OF EARLIER RESULTS HAS BEEN THE LACK OF A COMPARISON GROUP, WHICH PREVENTED THE ABILITY TO DESCRIBE WHETHER CERTAIN YOUTH HABITS OR THE USE OF CERTAIN PRODUCTS WERE ASSOCIATED WITH AN INCREASED RISK OR CHANCE OF BEING AFFECTED BY EVALI. TO ADDRESS THIS, IDPH DEVELOPED AN ONLINE PUBLIC SURVEY TARGETING ILLINOIS ADULTS WHO USE E-CIGARETTE OR VAPING PRODUCTS. THE PUBLIC SURVEY LINK WAS POSTED ON OUR WEBSITE IN SEPTEMBER AND OCTOBER OF THIS YEAR AND WAS PUBLICIZED THROUGH THE MEDIA, POSTED ON IDPH SOCIAL MEDIA ACCOUNTS AND PROMOTED BY OUR LOCAL HEALTH DEPARTMENTS. THIS SURVEY USED THE SAME QUESTIONS THAT WERE ASKED OF EVALI PATIENTS.

THE PURPOSE OF THIS SURVEY WAS TWO-FOLD: ONE, TO GATHER BASELINE INFORMATION FROM ILLINOIS ADULTS WHO USE E-CIGARETTE OR VAPING PRODUCTS REGARDING THE TYPE OF PRODUCTS THEY USED AND UNDERSTAND GENERAL USE HABITS, SUCH AS THE FREQUENCY OF USE AND WHERE SUCH PRODUCTS WERE OBTAINED. THE SECOND GOAL WAS TO COMPARE A SUBSET OF SURVEY RESPONDENTS WHO USED THC E-CIGARETTE OR VAPING PRODUCTS TO OUR INTERVIEWED EVALI PATIENTS TO IDENTIFY RISK FACTORS ASSOCIATED WITH AN INCREASED CHANCE OF BEING AN EVALI CASE. WE HAD A LARGE NUMBER OF RESPONDENTS AND ARE SO GRATEFUL TO ALL SURVEY RESPONDENTS WHO TOOK THE TIME TO HELP IN THE ADVANCEMENT OF THIS INVESTIGATION. ULTIMATELY, WE HAD 4,631 ADULT ILLINOIS RESIDENTS COMPLETE THE SURVEY WHO REPORTED THE RECENT USE OF E-CIGARETTE OR VAPING PRODUCTS AND WHO ARE NOT EVALI PATIENTS. AMONG THESE SURVEY RESPONDENTS, 94% USED NICOTINE CONTAINING PRODUCTS COMPARED TO IT 21% REPORTING THE USE OF THC-CONTAINING PRODUCTS. USE OF THC-CONTAINING PRODUCTS WAS MORE COMMON AMONG YOUNGER RESPONDENTS. THC USE DECREASED WITH AGE. FURTHER, AMONG YOUNGER SURVEY RESPONDERS, MALES REPORTED MORE FREQUENT USE, GREATER THAN FIVE TIMES PER DAY OF NICOTINE AND THC-CONTAINING E-CIGARETTES OR VAPING PRODUCTS COMPARED TO FEMALES.

WE THEN COMPARED THE SUBSET OF SURVEY RESPONDENTS WHO USED THC-CONTAINING PRODUCTS AND DID NOT HAVE EVALI TO ADULT EVALI PATIENTS OF THE SAME AGE GROUP. SEVERAL KEY FINDINGS WERE NOTED IN THIS COMPARISON. FIRST, EVALI PATIENTS WERE ROUGHLY TWO TIMES MORE LIKELY TO REPORT THE EXCLUSIVE USE OF THC-CONTAINING PRODUCTS COMPARED TO SURVEY RESPONDENTS. A HIGHER PROPORTION OF EVALI PATIENTS THAN SURVEY RESPONDENTS REPORTED USING THC-CONTAINING PRODUCTS FREQUENTLY, MORE THAN FIVE TIMES A DAY. COMPARE WITH THE SURVEY RESPONDENTS, EVALI CASES WERE ESTIMATED TO BE EIGHT TIMES MORE LIKELY TO REPORT THE USE OF [INDECIPHERABLE] VAPES COMPARED TO SURVEY RESPONDENTS. AND FINALLY, EVALI CASES WERE ROUGHLY NINE TIMES LIKELY TO CONTAIN THE THC-CONTAINING PRODUCTS FROM INFORMAL SOURCES SUCH AS A DEALER, OFF THE STREET OR FROM A FRIEND, COMPARED TO SURVEY RESPONDENTS.

OUR FINDINGS REINFORCED CURRENT RECOMMENDATIONS NOT TO USE E-CIGARETTE OR VAPING PRODUCTS THAT CONTAIN THC. AND NOT TO USE ANY E-CIGARETTE OR VAPING PRODUCTS OBTAINED FROM INFORMAL SOURCES. IN ADDITION, SINCE THE SPECIFIC COMPOUND OR INGREDIENT CAUSING LUNG INJURY IS NOT YET KNOWN, CDC CONTINUES TO RECOMMEND TO CONSIDER REFRAINING FROM THE USE OF ALL E-CIGARETTE OR VAPING PRODUCTS WHILE THE OUTBREAK INVESTIGATION CONTINUES. THANK YOU.

HOSKINS>> THANK YOU, DR. LAYDEN. I’M SHOWING WE ARE READY FOR QUESTIONS NOW.

OPERATOR>> THANKS, WE WILL NOW BEGIN THE QUESTION AND ANSWER SESSION. IF YOU WOULD LIKE TO ASK A QUESTION, PLEASE PRESS STAR ONE. YOU WILL BE PROMPTED TO RECORD YOUR NAME. TO WITHDRAW YOUR QUESTION, YOU MAY PRESS STAR 2. AGAIN, PRESS STAR 1 TO ASK A QUESTION AND ONE MOMENT PLEASE FOR OUR FIRST QUESTION. OUR FIRST QUESTION FROM LENA SUN WITH WASHINGTON POST. YOU MAY ASK YOUR QUESTION.

SUN>> THANK YOU VERY MUCH. THIS QUESTION IS FOR DR. SCHUCHAT. GOING BACK TO WHAT YOU WERE DESCRIBING, THE FINDINGS WERE IN 29 SAMPLES. AND, OF COURSE, YOU’RE SAYING THAT IT’S TOO EARLY TO FIGURE OUT WHETHER THIS IS THE CAUSATIVE AGENT. HOW MANY MORE SAMPLES WOULD CDC NEED AND WOULD YOU NEED TO FIND IT IN 100% OF THEM BEFORE YOU FELT COMFORTABLE SAYING THAT THIS IS THE THING THAT IS CAUSING THE HARM?

SCHUCHAT>> THANK YOU FOR THAT QUESTION. THE SAMPLES COME FROM 29 PATIENTS. AND THEY DO COME FROM PATIENTS FROM TEN DIFFERENT STATES. SO, WE THINK THIS IS MUCH MORE ROBUST INFORMATION THAN IF THEY WERE ALL FROM A SINGLE LOCATION WHERE PERHAPS A SINGLE COMMON SOURCE HAD LED TO THE CONCERN. WE BELIEVE THERE’S MORE WORK TO DO IN TERMS OF TESTING CONTROL, CLINICAL BIOLOGIC SPECIMENS, PEOPLE WHO DO NOT HAVE EVALI BUT HAVE OTHER EXPOSURES OR HAVE UNDERGONE BRONCHOSCOPIES AND THAT THERE’S PROBABLY IMPORTANT ANIMAL STUDIES TO DO TO UNDERSTAND WHAT MIGHT BE PATHOGENSIS. THAT SAID, IDENTIFYING A COLLECTION OF INFORMATION THAT POINTS TO VITAMIN E ACETATE AS A CONCERN FOR LUNG PATHOLOGY DOESN’T MEAN THAT THERE ARE NOT OTHER COMPONENTS CAUSING LUNG HARM. SO, WHAT I’M LOOKING FOR IS AN END TO THE OUTBREAK AND NOT CONTINUED LARGE NUMBERS OF NEW CASES ONGOING. SO I THINK WE BOTH WANT TO UNDERSTAND CAUSE OR CAUSES AND WE WANT TO MAKE SURE THAT CONTROL MEASURES ARE REACHED. SO I THINK THIS IS VERY IMPORTANT NEW INFORMATION. BUT THERE IS ADDITIONAL WORK TO DO ON VITAMIN E ACETATE AND THEN PROBABLY ADDITIONAL TESTING TO DO ON A BROADER NUMBER, NOT TO GIVE IT A PRECISE NUMBER, BUT A BROADER NUMBER OF PATIENT SPECIMENS FROM DIFFERENT LOCATIONS.

SUN>> THANK YOU.

OPERATOR>> THANK YOU. NEXT QUESTION COMES FROM EVAN BROWN WITH FOX NEWS. YOU MAY ASK YOUR QUESTION.

BROWN>> HI, GOOD MORNING. DO WE FIND THE VITAMIN E ACETATE IN NON-THC VAPE LIQUID? IS IT IN THE STUFF THAT IS LEGITIMATELY PRODUCED AND SOLD OR IS IT SOMETHING THAT SEEMS TO BE EXCLUSIVE TO THIS EITHER BLACK MARKET OR OFF-THE-STREET PRODUCT THAT MAY NOT BE LEGITIMATE?

SCHUCHAT>> THANK YOU FOR THAT QUESTION. IT’S POSSIBLE THAT VITAMIN E ACETATE IN VERY SMALL AMOUNTS MAY BE USED IN SOME E-LIQUID MATERIAL FOR A VARIETY OF REASONS. I THINK SOME OF THE OTHER LABORATORY REPORTS FROM FDA AND THE STATE LABS HAVE MENTIONED HIGH CONCENTRATIONS OF VITAMIN E ACETATE AND THAT MAY BE DONE FOR MORE THE ILLICIT PURPOSES OR THE PROFIT PURPOSES OF DILUTING THE MATERIALS AND MAKING IT LOOK NICE AND PERHAPS NOT HAVING TO USE AS MUCH THC OR OTHER ACTIVE INGREDIENTS. BUT IT COULD POTENTIALLY BE USED IN A VARIETY OF SUBSTANCES. IN THOSE THAT WERE TESTED SO FAR, IT’S PRIMARILY BEEN THC-CONTAINING E-LIQUIDS THAT HAVE THE VITAMIN E.

BROWN>>IF I COULD ASK ANOTHER QUICK FOLLOW-UP. IS VITAMIN E ACETATE, YOU MENTION THAT IT’S IN A LOT OF PRODUCTS. I MEAN, IS IT SOMETHING THAT PEOPLE CAN NORMALLY TAKE INTERNALLY IN EITHER WAYS WITHOUT HAVING ANY KIND OF ADVERSE EFFECTS? I MEAN, I DON’T WANT PEOPLE SCURRYING TO THEIR MEDICINE CABINETS AND BATHROOM CLOSETS LOOKING THROUGH EVERY SKIN CARE PRODUCT THEY HAVE AND FREAKING OUT IF THERE IS VITAMIN E ACETATE IN IT.

SCHUCHAT>> THANK YOU. THERE IS A BIG DIFFERENCE BETWEEN PUTTING VITAMIN E ACETATE-CONTAINING PRODUCTS ON ONE’S SKIN OR SWALLOWING A VITAMIN E PILL AND INHALING AERSOLIZED VITAMIN E ACETATE OILY MATERIAL IN AN E-LIQUID. SO I THINK THAT THERE ARE A NUMBER OF INGREDIENTS IN FLAVOR, FOR INSTANCE, THAT ARE APPROVED FOR INGESTION OR EATING THAT ARE NOT STUDIED FOR INHALATION. AND INHALATION, OF COURSE, RIGHT INTO THE LUNGS, INTO THE ALVEOLI. IT IS VERY DIFFERENT ROUTE OF EXPOSURE THAT COULD CAUSE LOCAL HARM AT THAT LUNG INTERFACE. SO, AGAIN, WE’RE NOT TALKING ABOUT THE VITAMIN E CAPSULES THAT PEOPLE TAKE BY MOUTH AND SWALLOW. THIS IS A QUESTION OF INHALED AEROSOL. OPERATOR.

OPERATOR>> THANK YOU. NEXT QUESTION FROM NAOMI MARTIN FROM BOSTON GLOBE. YOU MAY ASK YOUR QUESTION.

MARTIN>> HI. THANKS FOR TAKING MY QUESTION. DR. SCHUCHAT, I WAS JUST CURIOUS, IS THERE ANY INDICATION THAT VITAMIN E ACETATE HAS BEEN USED IN ANY STATE-LICENSED MARIJUANA DISPENSARY PRODUCTS? AND DO YOU HAVE ANY SENSE OF WHETHER ANY ILLNESSES HAVE BEEN LINKED TO STATE-LICENSED MARIJUANA DISPENSARIES?

SCHUCHAT>> THE STATES THAT HAVE DISPESARIES FOR MARIJUANA SET THEIR OWN REGULATORY MEASURES IN TERMS OF WHAT NEEDS TO BE DONE, WHAT INGREDIENTS ARE ALLOWABLE OR WHAT DOCUMENTATION ON THE QUALITY OF PRODUCTION, DISTRIBUTION AND HANDLING HAS BEEN MADE. IT IS POSSIBLE THAT VITAMIN E ACETATE MAY BE INCLUDED IN SOME DISPENSARY-SOLD PRODUCTS IN ONE STATE OR ANOTHER. AND IT’S POSSIBLE IT’S THERE INTENTIONALLY. IT IS POSSIBLE IT IS THERE UNINTENTIONALLY. I BELIEVE STATE REGULATORS ARE TAKING A LOOK AT THEIR REGULATIONS RIGHT NOW IN LIGHT OF THE ONGOING OUTBREAKS. I DIDN’T KNOW IF DR. LAYDEN WOULD LIKE TO MAKE ANY COMMENTS, OR DR. PIRKLE, BUT LET ME OFFER THEM.

LAYDEN>> SURE, HI, THIS IS DR. LAYDEN FROM ILLINOIS. I CAN CHIME IN TO SAY IN ILLINOIS WE HAD NOT HAD CASES ASSOCIATED WITH OUR MEDICAL MARIJUANA PROGRAM.

MARTIN>> OKAY, THANK YOU. AND DR. SCHUCHAT, DO YOU KNOW IF NATIONALLY YOU’VE SEEN ANY LINK TO LICENSED DISPENSARIES?

SCHUCHAT>> THE INFORMATION IS CONTINUING TO BE COLLECTED. MY UNDERSTANDING IS THERE’S SOME ANECDOTAL INFORMATION RIGHT NOW ABOUT INDIVIDUALS WHO ONLY REPORT GETTING PRODUCTS FROM LICENSED DISPENSARIES. AND EXACTLY WHAT THOSE PRODUCTS ARE AND WHETHER THEY WERE AS LABELED OR AS EXPECTED TO BE PRODUCED IS UNCLEAR. I THINK WE HAVE A FEW CASES THAT I’M AWARE OF, BUT I DON’T HAVE THE DETAILS.

MARTIN>> OKAY. THANK YOU.

SCHUCHAT>> AS DR. LAYDEN POINTED OUT IN THE ILLINOIS RESULTS AND WE SAWEARLIER IN UTAH, THERE SEEMS TO BE A STRONG ASSOCIATION WITH ACQUIRING PRODUCTS FROM INFORMAL SOCIAL SOURCES. IN UTAH THEY ALSO HAD ONLINE AS ONE OF THE ISSUES. BUT FRIENDS, FAMILY, DEALER RATHER THAN DISPENSARIES AS A STATISTICALLY SIGNIFICANT RISK FACTOR IN THE ILLINOIS STORY. BUT NOT SHOWING UP AS A MAJOR PART OF THE NATIONAL DATA YET.

MARTIN>> THANK YOU.

OPERATOR>> THANK YOU. NEXT QUESTION FROM DENISE GRADY WITH NEW YORK TIMES. YOU MAY ASK YOUR QUESTION.

GRADY>> HI. THANK YOU VERY MUCH. WOULD IT BE POSSIBLE AT THIS POINT TO SAY THAT PEOPLE WHO ARE VAPING ONLY NICOTINE WITHOUT FLAVORING MAY NOT BE AT RISK FOR EVALI?

SCHUCHAT>> I DON’T THINK WE CAN SAY THAT TODAY. WE CERTAINLY HAVE EVIDENCE THAT PEOPLE SHOULD NOT USE E-CIGARETTE OR VAPING PRODUCTS THAT CONTAIN THC, PARTICULARLY THOSE ACQUIRED FROM INFORMAL SOURCES. BUT WE CONTINUE TO HAVE A SMALL PROPORTION OF CASES THAT REPORT ONLY EXPOSURE TO NICOTINE-CONTAINING E-CIGARETTE OR VAPING PRODUCTS. AND BASED ON CONVERSATIONS WITH SOME HEALTH DEPARTMENT INVESTIGATORS, WE CONTINUE TO HAVE A SMALL NUMBER THAT BELIEVE THESE ARE ACCURATE REPORTS AND THEY REALLY WERE NOT USING THC-CONTAINING PRODUCTS. SO THAT’S WHY THE CDC CONTINUES TO RECOMMEND THAT WHILE THIS INVESTIGATION IS ONGOING, PEOPLE CONSIDER REFRAINING FROM USE OF ALL E-CIGARETTE OR VAPING PRODUCTS. I THINK WE STILL HAVE MORE TO LEARN TODAY. WE ARE IN A BETTER PLACE THAN WE WERE TWO WEEKS AGO IN TERMS OF HAVING ONE VERY STRONG CULPRIT OF CONCERN BASED ON THE LUNG FLUID TESTING. BUT I DON’T THINK WHILE THIS INVESTIGATION CONTINUES TO GIVE US SOME NEW INFORMATION, WE THINK THAT CONSIDERING REFRAINING FROM USE OF ALL E-CIGARETTE OR VAPING PRODUCTS. NEXT QUESTION?

OPERATOR>> THANK YOU. NEXT QUESTION COMES FROM MIKE STOBBE WITH ASSOCIATED PRESS. YOU MAY ASK YOUR QUESTION.

STOBBE>> HI, THANK YOU FOR TAKING MY CALL. I HAVE A QUESTION AND THEN A FOLLOW-UP AFTER. DR. SCHUCHAT, WOULD YOU CALL THE FINDINGS FROM THE BRONCHOALVEOLAR LAVAGE A BREAKTHROUGH IN THE INVESTIGATION?

SCHUCHAT>> YES, I WOULD.

STOBBE>> GREAT. THANK YOU. AND I JUST WANTED TO FOLLOW UP EVAN BROWN’S QUESTION. I WAS A LITTLE UNCLEAR. ALL 29 TESTED POSITIVE FOR THC, I’M SORRY, FOR VITAMIN E ACETATE, BUT NOT ALL THE SAMPLES TESTED POSITIVE FOR THC. COULD YOU EXPLAIN THAT? AND, ALSO, I WANTED TO MAKE SURE VITAMIN E ACETATE, SOME OF THESE INJURIES HAVE BEEN DESCRIBED AS CHEMICAL-LIKE BURNS. WOULD VITAMIN E ACETATE CAUSE THAT KIND OF INJURY? DOES THAT MAKE BIOLOGICAL SENSE? AND I’M SORRY, ONE MORE QUESTION. IN DESCRIBING THE PROCESS, THE BRONCHOALVEOLAR LAVAGE, WAS IT STERILE WATER THAT WAS SQUIRTED INTO THE LUNGS OR WAS IT SALINE? JUST A LITTLE DESCRIPTION OF THAT PROCESS. THANK YOU.

SCHUCHAT>> YES, THANK YOU. 23 OF THE 28 BRONCHOALVEOLAR LAVAG SAMPLES HAD THC DETECTED. THAT’S 82%. THE ISSUE OF WHETHER THERE HAD BEEN HAD BEEN THC PRESENT IN THE SUBSTANCES THAT WERE AEROSOLIZED AND THERE WAS NO LONGER REMAINING THC IS POSSIBLE OR THAT THERE WERE, THERE WAS VITAMIN E ACETATE USED IN THE DIFFERENT COMPONENTS. I THINK BOTH OF THOSE ARE POSSIBILITIES. DR. PIRKLE MAY WANT TO COMMENT ON THE LEVEL OF DETECTION OF THE TEST AND SO FORTH. I’LL JUST GO THROUGH, THE ISSUE OF IF VITAMIN E ACETATE IS THE CULPRIT IN MANY OF THESE CASES, WE DON’T KNOW YET THE MECHANISM OR PATHOGENESIS AND THERE MAY BE MULTIPLE. IT’S AN OILY SUBSTANCE, SO THAT COULD BE CONSISTENT WITH A LIKELY PNEUMONIA THAT SOME OF THE REPORTS HAVE MENTIONED. THERE ARE OTHER WAYS THAT VITAMIN E ACETATE CAN INTERFERE WITH LUNG FUNCTION, AS IS MENTIONED IN THE MMWR IN TERMS OF INTERFERING WITH THE [INDECIPHERABLE] FUNCTION, WHICH IS THE LUNG TENSION UP AND WHETHER A [INDECIPHERABLE] IS UNCLEAR. SO, I THINK ONE OF THE VALUES OF ANIMAL PATHOLOGY STUDIES ON A VARIETY OF CULPRITS, POTENTIAL SUSPECTS, IS TO UNDERSTAND WHAT KIND OF INJURY MIGHT BE CAUSED. NOW, IN TERMS OF BRONCHOALVEOLAR LAVAGES, I WANT TO CLARIFY, THOSE WERE NOT DONE. THE BRONCHOSCOPIES WERE NOT DONE FOR THE PURPOSE OF GATHERING DATA FOR THIS INVESTIGATION. THEY WERE PART OF CLINICAL MANAGEMENT OF THE PATIENTS. AND THOSE INVOLVED, YOU KNOW, A BROCHOSCOPY WHERE YOU PUT A TUBE IN THROUGH THE NOSE AND DEEP INTO THE LUNGS AND DO WASHINGS, AS WELL AS COLLECT A SMALL AMOUNT OF TISSUE FOR, YOU KNOW, EXPLORING UNDER THE MICROSCOPE. EXACTLY HOW THE WASHING WAS DONE IN TERMS OF WHAT FLUIDS ARE BATHED, I BELIEVE IT’S SALINE. BUT DR. PIRKLE MIGHT BE ABLE. HE COULD TALK A LITTLE BIT MORE ABOUT THE TESTING. JIM?

PIRKLE>> THIS IS JIM PIRKLE. LET ME COMMENT ON THE THC FIRST. THC IS NOT SOMETHING WE WOULD EXPECT TO BE HANGING AROUND IN THE LUNG FLUID. SO THAT WOULD NOT BE THE WAY THAT WE WOULD TAKE A LOOK TO SEE IF SOMEONE HAS HAD EXPOSURE TO THC. SO, FINDING 82% IS VERY NOTEWORTHY, BUT NOT FINDING IT IN 18% IS VERY EXPLAINABLE. IF WE REALLY WANT TO FIND OUT IF PEOPLE HAD THC EXPOSURE, THE VERY BEST DIAGNOSTIC WOULD BE A TEST IN URINE. SO, THAT CAN PARTIALLY EXPLAIN THAT FOR THOSE PEOPLE THAT WE DID NOT FIND THC. AND BY CONTRAST, VITAMIN E ACETATE IS ENORMOUSLY STICKY. YOU CAN THINK OF IT TO BE JUST LIKE HONEY. WHEN IT GOES INTO THE LUNG, IT DOES HANG AROUND. SO, BEING ABLE TO FIND VITAMIN E ACETATE IS A LITTLE BIT EASIER TO DO THAN THC. YOU SHOULDN’T INTERPRET THE LACK OF FINDING THC AS THE PERSON DID NOT USE THC. AND THEN ALSO IN THE BRONCHOALVEOLAR LAVAGE THEY DO SQUIRT NORMAL SALINE, SO IT’S KIND OF LIKE A SALT WATER, AND THE PROCEDURE ONCE THEY’VE WEDGED THE BRONCOSCOPE DOWN INTO THE LUNG IS THAT THEY’LL SQUIRT, SAY 100 MILLILITERS, OF NORMAL SALINE OUT AND THEN SUCK BACK WHAT THEY CAN GET AND THE PURPOSE IS TO SAMPLE THE FLUID LINING OF THE LUNG AND THEN THEY WILL SPIN THAT DOWN AND LOOK AT CYTOLOGY ANALYSES AND THEN WE WILL USE WHAT IS LEFT OVER AND TAKE A LOOK AT CHEMICAL ANALYSES.

HOSKINS>> WE’RE READY FOR OUR NEXT QUESTION.

OPERATOR>> THANK YOU. OUR NEXT QUESTION FROM CHLOE AIELLO WITH CHEDDAR, YOU MAY ASK YOUR QUESTION.

AIELLO>> THANK YOU FOR TAKING MY QUESTION. I WANTED TO DIG IN JUST SORT OF RETURN TO A QUESTION THAT WAS KIND OF ASKED EARLIER ABOUT THE THC VAPE SITUATION. THERE WAS A NUMBER THAT YOU MENTIONED, DR. LAYDEN, THAT THOSE WITH EVALI WERE NINE TIMES, I BELIEVE, MORE LIKELY TO HAVE USED VAPES PURCHASED FROM INFORMAL MEANS. I WAS WONDERING IF I WAS INTERPRETING THAT CORRECTLY. IF YOU COULD BREAK DOWN WHAT THAT NUMBER MEANS. AND THEN I HAVE A FOLLOW-UP AFTER THAT.

LAYDEN>> SURE. IN THE TYPE OF STUDY THAT WE DO WE’RE LOOKING TO SEE, TO COMPARE THE PROPORTION OF INDIVIDUALS WHO WERE CASES THAT USED OR ACQUIRE PRODUCTS FROM INFORMAL SOURCES TO INDIVIDUALS WHO ARE NOT CASES. AND, ALSO, ACQUIRE FROM INFORMAL SOURCES. AND THAT HELPS US TO IDENTIFY A RISK FACTOR OR AN ASSOCIATION BETWEEN THAT BEHAVIOR AND WHETHER OR NOT YOU ARE OR COULD BE A CASE. SO, IN THIS INSTANCE FOR THAT RISK FACTOR OF ACQUIRING IT FROM INFORMAL SOURCES, WE FOUND THAT EVALI CASES WERE NINE TIMES MORE LIKELY TO OBTAIN THC-CONTAINING PRODUCTS FROM INFORMAL SOURCES COMPARED TO THOSE THAT WERE NOT CASES.

AIELLO>> THANK YOU. AND THEN THE FOLLOW-UP. AND I THINK THIS WOULD PROBABLY BE BEST DIRECTED TO DR. SCHUCHAT. SO, I WAS WONDERING, YOU SAID THERE WERE SOME ANECDOTAL CASES OF PEOPLE ACQUIRING VAPE PRODUCTS FROM LICENSED DISPENSARIES THAT YOU’RE SORT OF LOOKING INTO RIGHT NOW. I KNOW MANY IN THE CANNABIS INDUSTRY HAVE BEEN TELLING ME THEY THINK THIS IS LARGELY AN ILLICIT MARKET PROBLEM. I AM WONDERING IF YOU’RE AT A POINT NOW WHERE YOU’D BE COMFORTABLE SAYING MAYBE NOT THAT IT’S NOT GETTING THESE THC PRODUCTS FROM LICENSED DISPENSARIES BUT THERE IS KIND OF A DIFFERENTIATOR THERE.

SCHUCHAT>> THE DATA SO FAR THAT HAVE BEEN CAREFULLY LOOKED THROUGH POINT TO A MUCH GREATER RISK ASSOCIATED WITH THE THC-CONTAINING PRODUCTS THAT ARE ACQUIRED FROM INFORMAL SOURCES AS OPPOSED TO LICENSED DISPENSARIES. MIGHT THERE BE SOME INFILTRATION OF THE LICENSED PRODUCT DISTRIBUTION SYSTEM IN TERMS OF SOME OF THE SUPPLIERS INTENTIONALLY OR INADVERTENTLY HAVING PROBLEMATIC INGREDIENTS? I THINK THAT’S POSSIBLE. BUT THE MAJORITY OF WHAT WE’RE SEEING RIGHT NOW IS GOING INTO THE INFORMAL SOURCES. I DO THINK AS DR. LAYDEN MENTIONED, THE STATES THAT HAVE REGULATORY OVERSIGHT OF MEDICAL OR RECREATIONAL MARIJUANA PRODUCTS RIGHT NOW ARE TAKING A LOOK AT THEIR REGULATIONS AND THEIR QUALITY CONTROL TO UNDERSTAND WHETHER THERE COULD BE STRENGTHENING OF THOSE EFFORTS. BUT, YOU KNOW, WE HAVE CASES NOW FROM 49 STATES, MANY OF WHICH HAVE LEGAL MARIJUANA MARKETS. THE DATA ARE POINTING TOWARDS THE ILLICIT SUPPLY, BUT THIS IS A VERY SEVERE DISEASE WHICH CAN BE FATAL AND I DON’T THINK WE KNOW ENOUGH YET TO COMPLETELY TAKE THE DISPENSARIES OUT OF THE QUESTION.

AIELLO>> THANK YOU.

SCHUCHAT>> OPERATOR.

OPERATOR>> THANK YOU. NEXT QUESTION COMES FROM BRIANNA ABBOT WITH WALL STREET JOURNAL. YOU MAY ASK YOUR QUESTION.

ABBOTT>> HI. THANKS FOR TAKING MY CALL. MY QUESTION IS DIRECTED AT DR. LAYDEN. SO, IN THE NEW SURVEY REPORT, YOU NOTED THAT ONLY 58% OF THE ILLINOIS EVALI PATIENTS AGE 18 TO 44 YEARS OLD HAVE BEEN INTERVIEWED. AND I’M SORT OF WONDERING WHY THAT PERCENTAGE ISN’T HIGHER.

LAYDEN>> SURE. THANK YOU FOR THAT QUESTION. THERE ARE MULTIPLE REASONS FOR THAT. THE NEWER CASES SOMETIMES IT TAKES TIME TO GET A HOLD OF THEM. THEY’RE REALLY ILL WHEN THEY’RE IN THE HOSPITAL. SO THOSE INTERVIEWS HAVE NOT BEEN COMPLETED. SOMETIMES PATIENTS REFUSE OR ARE UNABLE TO PARTICIPATE. SO, THERE’S A VARIETY OF FACTORS. WE TRY TO REACH PATIENTS MULTIPLE TIMES. BUT IT IS ULTIMATELY THEIR CHOICE TO PARTICIPATE IN THOSE INTERVIEWS.

ABBOTT>> ALL RIGHT, THANK YOU.

OPERATOR>> OUR NEXT QUESTION COMES FROM JAYNE O’DONNELL WITH USA TODAY. YOU MAY ASK YOUR QUESTION.

O’DONNELL>> HI. ONE OF MY QUESTIONS HAS BEEN ASKED AND ANSWERED. BUT I WAS CURIOUS ABOUT THE FREQUENCY. I’D LIKE TO ADDRESS THIS TO DR. LAYDEN. THE FIVE TIMES OR MORE PER DAY DOESN’T SOUND QUITE AS FREQUENT AS SOME OF WHAT WAS DESCRIBED TO ME BY SOME OF THE PATIENTS. YOU DON’T THINK SOME OF � DO YOU THINK SOME OF THEM WERE WAY HIGHER THAN FIVE TIMES PER DAY AND I’M JUST CURIOUS IF THERE’S ANYTHING ELSE YOU CAN SAY ABOUT THE FREQUENCY BECAUSE PULMONOLOGISTS I HAD ASKED BEFORE WEREN’T SURE THERE WAS A CUMULATIVE EFFECT. DOES THAT MEAN THERE IS A CUMULATIVE EFFECT?

LAYDEN>> SO, AS FAR AS THE FREQUENCY OF USE, IT’S VERY DIFFICULT TO QUANTIFY HOW FREQUENTLY THESE INDIVIDUALS ARE USING THESE PRODUCTS. WE DON’T HAVE A STANDARD WAY OF DOING THAT COMPARED TO OTHER SUBSTANCES WE STUDIED AND HOW WE LOOKED AT IT WAS MORE BASED ON GROUPINGS. SO, IF YOU USED MORE THAN FIVE TIMES A DAY, YOU WERE STILL IN THAT GROUP. I DO AGREE AND CONCUR THAT MANY TIMES PATIENTS REPORT USING THESE PRODUCTS MULTIPLE AND NUMEROUS TIMES A DAY AT VERY HIGH FREQUENCIES. AT THIS POINT, WE DON’T HAVE DATA THAT CAN SUPPORT OR ADDRESS THE QUESTION OF IF THERE IS A DOSE DEPENDENCY AS TO WHETHER IT MAKES YOU, YOU KNOW, MORE OR LESS LIKELY TO GET SEVERE OR MILD DISEASE.

O’DONNELL>> THANKS.

HOSKINS>> HI, SHIRLEY. WE HAVE TIME FOR ONE MORE QUESTION.

OPERATOR>> THANK YOU, OUR FINAL QUESTION COMES FROM GABY GALVIN WITH U.S. NEWS AND WORLD REPORT. YOU MAY ASK YOUR QUESTION.

GALVIN>> HI, THANK YOU. DR. SCHUCHAT, YOU HAD MENTIONED THERE COULD STILL BE OTHER COMPOUNDS OR INGREDIENTS THAT ARE CONTRIBUTING TO THE ILLNESSES AND I’M WONDERING IF THERE ARE ANY IN PARTICULAR THAT YOU’RE STILL LOOKING INTO OR IF VITAMIN E ACETATE REALLY IS THE BOTTOM LINE HERE.

SCHUCHAT>> YOU KNOW, E-CIGARETTES AND OTHER VAPING PRODUCTS CAN CONTAIN A VARIETY OF COMPOUNDS, SUBSTANCES, ADDITIVES, INGREDIENTS, INTENTIONALLY AS WELL AS UNINTENTIONALLY. AND SO THE TESTING IS QUITE BROAD, DR. PIRKLE DESCRIBED THE SET OF THINGS THAT WE HAVE ALREADY TESTED FOR. BUT LET ME OFFER HIM A CHANCE TO EXPAND ON OTHER THINGS THAT THE GROUP IS FOCUSED ON TESTING FOR. JIM?

PIRKLE>> OKAY. SO, WHEN WE TOOK A LOOK AT THIS, WE PRIORITIZED A GROUP OF CHEMICALS THAT WE FELT BASED ON THE INVESTIGATION HAD POTENTIAL TO BE A TOXICANT AND WHEN WE LOOKED AT THAT AND I THINK IT’S VERY IMPORTANT TO NOTE THAT WE DIDN’T FIND ANY OF THOSE. THOSE WERE PLANT OILS AND THERE’S A LOT OF CONCERN ABOUT PLANT OILS BEING USED IN THESE PRODUCTS. MCT OIL, PETROLEUM DISTILLATES LIKE MINERAL OIL AND DILUENT TERPENES THAT CAN BE PUT INTO THE PRODUCT. LOOKING AT ALL THE THINGS LIKE SOMETHING NEW HAD TO COME OUT THIS YEAR BECAUSE THE OUTBREAK IS THIS YEAR AND LOOKING AT ALL THE FACTORS ABOUT HOW THESE THINGS WERE ASSOCIATED WITH CASES, WE DEVELOPED THIS PRIORITY LIST AND PUT TOGETHER METHODS REALLY TO GO AFTER IT. AND IT WAS OUR MAIN PRIORITY LIST. BUT WE ARE GOING TO CONTINUE TO DO WORK LOOKING AT AEROSOLS AND LOOKING AT OTHER THINGS THAT COME FROM USE OF VAPING PRODUCTS. AND IT’S POSSIBLE THAT WE’LL COME ACROSS SOMETHING, YOU KNOW, OTHER TOXICANTS OF OTHER POSSIBILITY. TO SAY WE’VE GOT A LIST OF A TOP FIVE TO TAKE ON NEXT, WE ACTUALLY DON’T. WE REALLY PRIORITIZED OUR TOXICANTS AND WE WENT THROUGH THE LIST AND WE’LL BE TAKING A LOOK AT OTHER THINGS RIGHT NOW AND WE’LL CERTAINLY KEEP AN OPEN MIND. BUT WE HAVEN’T GOT FIVE ON THE TOP OF OUR LIST RIGHT NOW AND SAY WE REALLY NEED TO DIVE INTO THOSE NEXT.

HOSKINS>> THANK YOU, ALL, FOR JOINING OUR CALL TODAY. THAT CONCLUDES OUR TELEBRIEFING. IF YOU HAVE ANY ADDITIONAL QUESTIONS, YOU CAN CALL THE CDC MEDIA OFFICE AT 404-639-3286 OR YOU CAN E-MAIL US AT MEDIA@CDC.GOV.

OPERATOR>> THANK YOU. THIS WILL CONCLUDE TODAY’S CONFERENCE. WE THANK YOU FOR YOUR PARTICIPATION. AT THIS TIME, YOU MAY DISCONNECT YOUR LINE.

Source: Centers for Disease Control and Prevention

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