# src: https://drive.google.com/file/d/13QvkPs5oK8MF_CWmO5SL9mCwUcTmFMwR/view
# orig: Dr. Briss response received 100121 to Evali letter.pdf
# date: 2021-09-22
# type: ocr
# q: 0.3

(,;~
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
v'~~
Public Health Service
Centers for Disease Control
and Prevention (CDC)
Atlanta GA 30329-4027

September 22, 2021
The Honorable Thomas J. Miller
Attorney General
Iowa Depattment of Justice
J305 E. Walnut Street
Des Moines, Iowa 50319


Dear Attorney General Miller:


Thank you for your Jetter to Dr.  Rochelle WaJensky, Director of the Centers
for Disease Control and Prevention (CDC), requesting that the agency rename
"E-cigarette, or Vaping, Product UseAssociated Lung Injury" (EV ALI).  I am
responding on Dr.  WaJensky's behalf.

From August 2019 to Februai·y 2020, CDC, the Food and Drug Administration, state and local
health departments, and other clinical and public health partners investigated a national outbreak
of EV ALI. Case peaked in September 2019, with a substantial decline thereafter. Though it has
been more than a year since the decline in cases and CDC stopped routinely collecting
information from states on EV ALI cases, the agency continues to monitor EV ALI-related trends
using syndromic surveiJlance. These data do not suggest a resurgence of EV ALI.

EV ALI was named in the early tage of the outbreak based on information that
was known, including case patient reports of the use of a wide range of
e-cigarette, or vaping, product .  CDC and others broadly communicated that
the outbreak investigation has shown most cases of EV ALI were linked to
Tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, products,
particularly from informal sources.  Vitamin E acetate, an additive in some
THC-containing ecigarette, or vaping, products, was strongly linked to the
EV ALI outbreak.  However, the evidence remains insufficient to rule out the
contribution of other chemicals of concern, including chemical s in either
THC or non-THC products, in some reported EV ALI cases.  As noted in the
January 24, 2020 Morbidity and Mortality Weekly Report, "Update:
Characteristics of a Nationwide Outbreak of E-cigarette, or Vaping, Product
Use-Associated Lung Injury United States, August 20 19-January 2020," 1 14
percent of EVALI patients reported exclusive use of nicotine-containing
producl .  The identification of EV ALI ca e patients reporting excJ u ive
use of nicotine-containing product i reported elsewhere.  2 · 3 .4

Given the lack of ev idence to rule out the contribution of other chemicals
of concern to the EV AU o utbreak, the pos ibility that chemicaL of concern
co uld be introduced into su pply chains of either THC o r
non-THC-containing product in the future, the prudence of assessing sub
tance use broadly where c linical ly indicated , and that some EV ALI cases
reported exclu 1ve u e of nicotine-containing product , CDC declines to
rename EV ALI.  CDC will continue to monitor EV ALI-related trend , provide
EV ALI-related help to state as needed, and provide nece sary update · to
the public.  5

We appreciate your letter and interest in thi important public health topic. 
Plea e share a copy of this re ponse with the co-sig ners of your letter. 
Sincere ly,



Peter Briss, MD, MPH
EV ALJ Incident Manager, 2019-2020
M edical Director, Nation al Center for Chronic
Di ease Preventio n and Health Promotio n
CDC





1: Krishnasamy VP, Hallowell BD. Ko JY. et al. Update: Characteristics of a Nationwide Outbreak of E-cigarene, or
Vaping, Product Use-Associated Lung Injury - Un ited States. August 20 19- Ja nuary 2020. MMWR Morb Mortal
Wkly Rep 2020;69:90-94. DOI: hllp://dx.doi .org/I O. I 5585/mmwr.mm690'.k

2: Ghinai r, Navon L. Gunn JK. e l al. Characteri Lies of Per on Who Report Using Onl y Nicotine-Containing
Products Among Interviewed Patients wiLh E-cigarcue. or Yaping, Product Use-Associated Lu ng Inj ury - Illinoi ,
August- December 2019. MMWR Morb Monal Wkly Rep 2020;69:84-89.
DOI: www.cdc.gov/mm wr/vo lumc!>/69/wr/mm6903c I .htm

3: Lozier MJ , Wallace 8 , Anderson K, ct al. Update: Demographic, Product. and Sub tance-Use Characteristics of
Ho pitalized Patient in a Nationwide Outbreak of E-cigareue, or Yaping, Product Use-Associated Lung Injuries United State . December 20 19. MMWR Morb Monal Wkly Rep 20 19;68: 11 42-1148.
DOI: http://dx.doi.org/ IO. I5585/mm wr.mm6849c I ·

4: Ell ington S. Salvat0re PP, Ko J. et al. Update: Product, Sub tance- Use, and Demographic Characteristics of
Hospitalized Patients in a Nationwide Outbreak of E-cigareue, or Yaping. Product U e- Associatcd Lung lnjury United States. Augu t 20 19- January 2020. MMWR Morb Mortal Wkly Rep 2020;69:44-49. DO£:
w v. w .cdc.gov/rnmwr/volurnes/69/wr/rn rn6902e2. htrn?s cid=mm6902c2 w

5: W\\ w.cdc.gov/Lunc lnjury