Please note: An erratum has been published for this issue. To view the erratum, please click here.

Morbidity and Mortality Weekly Report

Weekly / Vol. 68 / No. 47 November 29, 2019

Status of HIV Case-Based

World AIDS Day —
Surveillance Implementation —
December 1, 2019
39 U.S. PEPFAR-Supported Countries,
World AIDS Day, observed annually on December 1,
draws attention to the status of the human immuno-
May–July 2019
deficiency virus/acquired immunodeficiency syndrome Joshua R. Holmes, MPH1; Thu-Ha Dinh, MD1;
(HIV/AIDS) epidemic. Approximately 37.9 million per- Nasim Farach, MA1; Eric-Jan Manders, PhD1;
sons worldwide are living with HIV infection, including James Kariuki, MPH1; Daniel H. Rosen, PhD1; Andrea A. Kim, PhD1;
PEPFAR HIV Case-Based Surveillance Study Group
1.7 million persons newly infected in 2018 (1).
With support from the U.S. President’s Emergency Human immunodeficiency virus (HIV) case-based surveil-
Plan for AIDS Relief (PEPFAR), several African coun- lance (CBS) systematically and continuously collects available
tries are on track to achieve HIV epidemic control. In demographic and health event data (sentinel events*) about
2017, an estimated 1,020,419 persons in the United persons with HIV infection from diagnosis and, if available,
States and dependent areas were living with diagnosed throughout routine clinical care until death, to character-
HIV infection; 37,832 new cases were diagnosed in ize HIV epidemics and guide program improvement (1,2).
2018 (2). The aim of the U.S. Department of Health and Surveillance signals such as high viral load, mortality, or
Human Services’ proposed Ending the HIV Epidemic: recent HIV infection can be used for rapid public health
A Plan for America initiative (3) is to end the U.S. HIV action. To date, few standardized assessments have been
epidemic within 10 years. conducted to describe HIV CBS systems globally (3,4). For
Through global efforts, including PEPFAR, in 2018, this assessment, a survey was disseminated during May–July
23.3 million persons worldwide received antiretroviral 2019 to all U.S. President’s Emergency Plan for AIDS Relief
therapy. A report in this issue of MMWR describes the
status of implementation of HIV case-based surveillance
systems in 39 PEPFAR-supported countries (4). * Sentinel events include various events throughout medical care for a client
with diagnosed HIV infection, such as HIV recency status (recent or long-term
infection at time of diagnosis), clinical laboratory values such as CD4 count
References and viral load, change in antiretroviral therapy regimens, and death.
1. Joint United Nations Programme on HIV/AIDS. Global HIV &
AIDS Statistics–2019 fact sheet. Geneva, Switzerland: Joint
United Nations Programme on HIV/AIDS; 2019. [Link]
[Link]/en/resources/fact-sheet
2. CDC. Diagnoses of HIV infection in the United States and INSIDE
dependent areas, 2018 (preliminary). HIV surveillance report. 1096 Characteristics of E-cigarette, or Vaping, Products
Vol. 30. Atlanta, GA: US Department of Health and Human
Services, CDC; 2019. [Link] Used by Patients with Associated Lung Injury and
reports/surveillance/[Link] Products Seized by Law Enforcement —
3. US Department of Health and Human Services. What is ‘ending Minnesota, 2018 and 2019
the HIV epidemic: a plan for America’? Washington, DC: US 1102 QuickStats
Department of Health and Human Services; 2019. [Link]
[Link]/federal-response/ending-the-hiv-epidemic/overview
4. Hughes JR, Dinh T-H, Farach N, et al. Status of HIV case-based
surveillance implementation in 39 U.S. PEPFAR-supported
Continuing Education examination available at
countries, May–July 2019. MMWR Morb Mortal Wkly Rep
[Link]
2019;68:1089–95.

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

(PEPFAR)–supported countries with CDC presence† (46) to implementing or planning for implementation of CBS, these
describe CBS implementation and identify facilitators and barriers need to be addressed to implement effective HIV CBS
barriers. Among the 39 (85%) countries that responded,§ 20 that can inform the national response to the HIV epidemic.
(51%) have implemented CBS, 15 (38%) were planning imple- In 2017, CDC initially assessed clinical surveillance among
mentation, and four (10%)¶ had no plans for implementation. CDC PEPFAR-supported countries (4). The survey was revised
All countries with CBS reported capturing information at in 2019 with feedback from stakeholders** to focus on CBS
the point of diagnosis, and 85% captured sentinel event data. and client-level HIV health information system as they relate
The most common characteristic (75% of implementation to CBS. Research Electronic Data Capture (REDCap) (5,6),
countries) that facilitated implementation was using a health an electronic data management tool hosted at CDC and dis-
information system for CBS. Barriers to CBS implementa- tributed to each PEPFAR-supported CDC country or regional
tion included lack of country policies/guidance on mandated office (representing 46 countries) during May–July 2019 was
reporting of HIV and on CBS, lack of unique identifiers to used to collect responses. CDC country office representatives
match and deduplicate patient-level data, and lack of data were asked to complete the survey in partnership with local
security standards. Although most surveyed countries reported government officials (ministries of health and implementing
partners). The protocol for this activity was reviewed in accor-
† PEPFAR-supported countries include Angola, Barbados, Botswana, Brazil, dance with CDC human research protection procedures and
Burma, Cambodia, Cameroon, Côte d’Ivoire, Democratic Republic of the
Congo, Dominican Republic, El Salvador, Eswatini, Ethiopia, Ghana,
was determined to be nonresearch.
Guatemala, Guyana, Haiti, Honduras, India, Jamaica, Kazakhstan, Kenya, The survey included questions on functional requirements,
Kyrgyzstan, Laos, Lesotho, Malawi, Mali, Mozambique, Namibia, Nicaragua, security measures, national policies and guidelines, and bar-
Nigeria, Panama, Papua New Guinea, Rwanda, Senegal, South Africa, South
Sudan, Tajikistan, Tanzania, Thailand, Trinidad and Tobago, Uganda, Ukraine, riers for CBS implementation (Supplementary table, https://
Vietnam, Zambia, and Zimbabwe. [Link]/view/cdc/82569). Answers were reported based
§ No data for Barbados, Burma, India, Cameroon, Kazakhstan, Kyrgyzstan,
on the country’s CBS status (currently implementing CBS,
or Tajikistan.
¶ Implementing countries include those that reported having an HIV case-based planning to implement, or not planning to implement). In one
surveillance system in their country at any scale (e.g., pilot or national) in which country, respondents reported uncertainty about future CBS
individual-level information on diagnosed HIV cases are reported for implementation, so this country was grouped with countries
surveillance purposes; planning countries include those that reported planning
to implement case-based surveillance; the not planning category includes
** World Health Organization (WHO), Joint United Nations Programme on
countries that reported not having plans to implement case-based surveillance;
HIV/AIDS, Global Fund, ministries of health, and CDC country offices.
and the unsure country reported uncertainty on future implementation.

The MMWR series of publications is published by the Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC),
U.S. Department of Health and Human Services, Atlanta, GA 30329-4027.
Suggested citation: [Author names; first three, then et al., if more than six.] [Report title]. MMWR Morb Mortal Wkly Rep 2019;68:[inclusive page numbers].
Centers for Disease Control and Prevention
Robert R. Redfield, MD, Director
Anne Schuchat, MD, Principal Deputy Director
Chesley L. Richards, MD, MPH, Deputy Director for Public Health Science and Surveillance
Rebecca Bunnell, PhD, MEd, Director, Office of Science
Barbara Ellis, PhD, MS, Acting Director, Office of Science Quality, Office of Science
Michael F. Iademarco, MD, MPH, Director, Center for Surveillance, Epidemiology, and Laboratory Services
MMWR Editorial and Production Staff (Weekly)
Charlotte K. Kent, PhD, MPH, Editor in Chief Martha F. Boyd, Lead Visual Information Specialist
Jacqueline Gindler, MD, Editor Maureen A. Leahy, Julia C. Martinroe,
Mary Dott, MD, MPH, Online Editor Stephen R. Spriggs, Tong Yang,
Terisa F. Rutledge, Managing Editor Visual Information Specialists
Douglas W. Weatherwax, Lead Technical Writer-Editor Quang M. Doan, MBA, Phyllis H. King,
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Technical Writer-Editors Information Technology Specialists
MMWR Editorial Board
Timothy F. Jones, MD, Chairman
Ileana Arias, PhD Jonathan E. Fielding, MD, MPH, MBA Stephen C. Redd, MD
Matthew L. Boulton, MD, MPH David W. Fleming, MD Patrick L. Remington, MD, MPH
Jay C. Butler, MD William E. Halperin, MD, DrPH, MPH Carlos Roig, MS, MA
Virginia A. Caine, MD Jewel Mullen, MD, MPH, MPA William Schaffner, MD
Katherine Lyon Daniel, PhD Jeff Niederdeppe, PhD Morgan Bobb Swanson, BS
Patricia Quinlisk, MD, MPH

1090 MMWR / November 29, 2019 / Vol. 68 / No. 47 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

not planning implementation. Functional requirements and remaining 17 sub-Saharan African countries, 13 were planning
facilitators included using unique identifiers†† to link and implementation, three had no plans for implementation, and
deduplicate patient data, having national policies for including one was unsure about plans for implementing CBS.
HIV infection as a notifiable disease, and reporting unique Among the 20 implementing countries, all collect the date
cases of HIV infection and sentinel events to a public health of diagnosis of HIV infection, and 17 (85%) collect sentinel
program for surveillance. Barriers to implementation included event data; however, only 10 of these countries reported using
lack of policies related to CBS, data security, confidentiality, a unique identifier for linking and deduplicating patient-level
and privacy of HIV information; criminalization laws; and data (Table 2). An electronic health information system was
stigmatization and criminalization of populations at great- used by 15 (75%) countries that have implemented CBS.
est risk for HIV infection.§§ Additional questions assessing Among the 18 implementing countries asked about electronic-
implementation barriers were asked of countries that were not based security measures, all reported having one or more
planning to implement CBS. such measures for transmitting data (if applicable), and 19 of
Several questions applied only to countries that had imple- 20 had such measures for storing data. Among 16 countries
mented or were planning to implement CBS. These included implementing paper-based CBS,††† 14 reported adopting one
whether the system captured (or will capture) date of diagnosis or more security measures.
of HIV infection and subsequent sentinel events data and Among the 15 countries planning to implement CBS, 13
security measures for transmitting paper-based data and for planned to collect date of diagnosis data, and 11 planned to
transmitting and storing electronic data. Implementing coun- collect sentinel event data with date of events (Table 2). Four
tries also reported information on whether they were using a countries planning implementation of CBS have the capability
health information system for CBS. to use unique identifiers to link and deduplicate patient-level
Among the 46 PEPFAR-supported countries surveyed, data. Similar to countries that have already implemented
39 (85%) completed the survey. Despite multiple follow-up CBS, all of the 14 countries planning to implement reported
attempts, seven countries did not complete the assessment. Skip planning for security measures for transmitting data (if appli-
patterns in the survey resulted in some questions not being cable), 14 of 15 reported planning for security measures for
asked of all responding countries. Descriptive statistics for storing data, and seven of eight reported planning to imple-
aggregated and country-level responses¶¶ for primary variables ment paper-based surveillance reported planning for security
were performed using SAS statistical software (version 9.4; measures (Table 2).
SAS Institute). Many countries reported barriers to implementation of CBS.
Overall, 20 (51%) countries reported implementing CBS, Stigmatization and criminalization of populations at high risk
15 (38%) were planning implementation, three (8%) were not of HIV infection were reported by six of 20 countries that had
planning implementation, and one (3%) was unsure of future implemented CBS, by six of 15 that were planning implemen-
implementation (Table 1). Implementation status substan- tation, and by all four that were not planning to implement.
tially varied among continents. All surveyed countries in the Ten of 15 countries planning to implement reported the lack
regions*** of Americas (11) and Europe (one) reported having of national policy/guidance for CBS as an important barrier to
implemented CBS. Among five surveyed countries in Asia, implementation. Barriers reported by countries not planning
three (Papua New Guinea, Thailand, and Vietnam) had imple- to implement CBS included lack of funding and dedicated
mented CBS, and two (Cambodia and Laos) were planning human resources. HIV was a nationally notifiable condition
implementation, whereas among 22 countries in sub-Saharan in 16 of 20 implementing countries, in five of 15 countries
Africa, only five (Botswana, Ethiopia, Rwanda, Senegal, and planning to implement CBS, and in none of the countries that
Zimbabwe) reported having implemented CBS. Among the did not have plans to implement CBS (Table 2).

†† Unique identifiers include health identifier, passport number, driver license, Discussion
biometrics, program-specific identifier (e.g., antiretroviral therapy number), Although 35 (90%) of 39 PEPFAR-supported countries that
civil identity card, and pseudo-identifier.
§§ Includes female sex workers, men who have sex with men, persons who inject responded to the survey have implemented HIV CBS or are
drugs, transgender persons, and persons incarcerated. planning implementation, barriers to implementation were
¶¶ The country-level indicator is the current state of case-based surveillance
implementation (implementing, planning implementation, not planning
identified in most countries, including absence of policies
implementation, and unsure).
††† Among countries reporting paper-based abstraction of case-based surveillance
*** WHO regions were used to group countries in the Americas, Europe, and
Africa. Countries in Asia were grouped into a single region, rather than the data or using a courier for sending paper case report forms to the above-site
two regions (Southeast Asia and Western Pacific) designated by WHO. level (n = 16).

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / November 29, 2019 / Vol. 68 / No. 47 1091
 Morbidity and Mortality Weekly Report

TABLE 1. Status of implementation of case-based surveillance for human immunodeficiency virus infection in 39 countries supported by the
U.S. President’s Emergency Plan for AIDS Relief, May–July 2019
Region*/Country Implementing Planning implementation Not planning implementation Unsure†
Africa (n = 22)
Angola — — Yes —
Botswana Yes — — —
Côte d’Ivoire — Yes — —
DRC — — Yes —
Eswatini — — — Yes
Ethiopia Yes — — —
Ghana — Yes — —
Kenya — Yes — —
Lesotho — Yes — —
Malawi — Yes — —
Mali — — Yes —
Mozambique — Yes — —
Namibia — Yes — —
Nigeria — Yes — —
Rwanda Yes — — —
Senegal Yes — —
South Africa — Yes — —
South Sudan — Yes — —
Tanzania — Yes — —
Uganda — Yes — —
Zambia — Yes — —
Zimbabwe Yes — — —
Americas (n = 11)
Brazil Yes — — —
Dominican Republic Yes — — —
El Salvador Yes — — —
Guatemala Yes — — —
Guyana Yes — — —
Haiti Yes — — —
Honduras Yes — — —
Jamaica Yes — — —
Nicaragua Yes — — —
Panama Yes — — —
Trinidad and Tobago Yes — — —
Asia (n = 5)
Cambodia — Yes — —
Laos — Yes — —
Papua New Guinea Yes — — —
Thailand Yes — — —
Vietnam Yes — — —
Europe (n = 1)
Ukraine Yes — — —
Total (N = 39) 20 15 3 1
Abbreviations: AIDS = acquired immunodeficiency syndrome; DRC = Democratic Republic of the Congo.
* World Health Organization (WHO) regions were used to group countries in the Americas, Europe, and Africa; countries in Asia were grouped into a single region,
rather than the two regions (Southeast Asia and Western Pacific) designated by WHO.
† The “unsure” and “not planning implementation” categories are reported separately here but were combined for analyses because of small sample size.

related to HIV reporting and CBS, nonuniversal adoption of Among the 39 participating countries, 22 (56%) were in
security measures for electronic-based and paper-based systems, sub-Saharan Africa; however, only 23% of these countries had
lack of unique identifiers, and no collection of postdiagnosis implemented CBS. This finding might be partly explained by
sentinel event data. The fact that only half of countries imple- the region’s high HIV prevalence, less developed health infor-
menting CBS use a unique identifier to match and deduplicate mation system infrastructure, and fewer resources compared
data highlights a need to improve understanding of the func- with countries with lower HIV prevalence or an epidemic
tional requirements of CBS. Ministries of health can request among specific populations, such as those in the Americas,
partners with surveillance, informatics, and policy expertise Asia, and Europe (7). Because HIV is a notifiable condition
to assist in identifying barriers to implementing effective HIV in most implementing countries, national policy changes
CBS and in developing solutions. could support CBS implementation. Implementing CBS

1092 MMWR / November 29, 2019 / Vol. 68 / No. 47 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

TABLE 2. Human Immunodeficiency virus (HIV) case-based surveillance functional requirements, security measures, national policies and
guidelines, and barriers, by implementation status,* in 39† countries supported by the U.S. President’s Emergency Plan for AIDS Relief,
May–July 2019
Case-based surveillance implementation status (no. of countries)
%§ (no./total no.¶)
Implementing Planning Not planning
Case-based surveillance characteristics (20) implementation (15) implementation** (4) Total (39)
Functional requirements
Use of unique identifiers†† 50 (10/20) 27 (4/15) 0 (0/4) 36 (14/39)
Captures (or will capture) diagnosis and date of diagnosis 100 (20/20) 87 (13/15) —§§ 94 (33/35)
Captures (or will capture) ≥1 sentinel event¶¶ with date 85 (17/20) 73 (11/15) — 80 (28/35)
Health information system integrated into 75 (15/20) — — 75 (15/20)
case-based surveillance***
Security measures
Paper-based††† 88 (14/16) 88 (7/8) — 88 (21/24)
Electronic-based: storage of data§§§ 95 (19/20) 93 (14/15) — 94 (33/35)
Electronic-based: transmission of data¶¶¶ 100 (18/18) 100 (14/14) — 100 (32/32)
National policies and guidelines
HIV infection is a notifiable condition 80 (16/20) 33 (5/15) 0 (0/4) 54 (21/39)
Mandated reporting of subsequent health events for 63 (10/16) 40 (2/5) — 57 (12/21)
diagnosed HIV-positive cases****
Mandated security measures for data storage 85 (17/20) 67 (10/15) — 77 (27/35)
Mandated reporting of HIV infection to a public health 85 (17/20) 40 (6/15) 0 (0/4) 59 (23/39)
surveillance system
Barriers to implementation and maintenance
No national policy/guidance for case-based surveillance 15 (3/20) 67 (10/15) 75 (3/4) 41 (16/39)
No policies for data security, confidentiality, or privacy 20 (4/20) 7 (1/15) 25 (1/4) 15 (6/39)
of HIV information
HIV criminalization laws 10 (2/20) 7 (1/15) 0 (0/4) 8 (3/39)
Stigmatization/Criminalization of populations at high risk†††† 30 (6/20) 40 (6/15) 100 (4/4) 41 (16/39)
No funding — — 50 (2/4) 50 (2/4)
No dedicated human resources — — 50 (2/4) 50 (2/4)
Not a current priority — — 25 (1/4) 25 (1/4)
No perceived need — — 0 (0/4) 0 (0/4)
Abbreviation: AIDS = acquired immunodeficiency syndrome.
* Implementing countries include those that reported having an HIV case-based surveillance system in which individual-level information on diagnosed HIV cases
is reported for surveillance purposes; planning countries include those that reported having plans to implement case-based surveillance; and the not planning
category includes countries that reported not having plans to implement case-based surveillance.
† Angola, Botswana, Brazil, Cambodia, Côte d’Ivoire, Democratic Republic of the Congo, Dominican Republic, El Salvador, Eswatini, Ethiopia, Ghana, Guatemala,
Guyana, Haiti, Honduras, Jamaica, Kenya, Laos, Lesotho, Mali, Malawi, Mozambique, Namibia, Nicaragua, Nigeria, Panama, Papua New Guinea, Rwanda, Senegal,
South Africa, South Sudan, Tanzania, Thailand, Trinidad and Tobago, Uganda, Ukraine, Vietnam, Zambia, and Zimbabwe.
§ Column percentages might not sum to 100% because of rounding.
¶ Total number might vary based on number of countries to which each question was asked.
** One country reported not having case-based surveillance and was unsure about future implementation. Because of small sample size, this country was grouped
with those that reported having no plans to implement case-based surveillance.
†† Unique identifiers include health identifier, passport number, driver license, biometrics, program specific identifier (e.g., antiretroviral therapy number), civil
identity card, and pseudo-identifier that can be used to connect and deduplicate patient data across facilities.
§§ Dashes indicate that some questions were not asked for countries based on self-reported status of case-based surveillance implementation.
¶¶ Sentinel events data include various events throughout medical care for a client with diagnosed HIV infection, such as HIV recency status (recent or long-term
infection at time of diagnosis), clinical laboratory values such as CD4 count and viral load, change in antiretroviral therapy regimens, and death.
*** Countries were asked if they reported using health information systems for case-based surveillance.
††† Among countries reporting paper-based abstraction of case-based surveillance data and/or using courier for sending paper case report forms to the above-site
level (implementing countries, n = 16; planning countries, n = 8). Paper-based security measures include at least one of the following: forms kept in a secure and
locked location or record retention policies.
§§§ Electronic-based security measures include one of more of the following steps: encryption of data; software barrier; limited personnel access; multifactor
authentication; periodic password changes and/or complex passwords; and laws, policies, guidelines, or standard operating procedures mandating security.
¶¶¶ Among countries reporting electronic transmission of case-based surveillance data (implementing countries, n = 18; planning countries, n = 14). Electronic-based
security measures include one of more of the following steps: encryption of data; software barrier; limited personnel access; multifactor authentication; periodic
password changes and/or complex passwords; and laws, policies, guidelines, or standard operating procedures mandating security.
**** Among countries in which HIV infection is a nationally notifiable condition (implementing countries, n = 14; planning countries, n = 7).
†††† Groups that have high risk of HIV infection, including female sex workers, men who have sex with men, persons who inject drugs, transgender persons, and
persons incarcerated.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / November 29, 2019 / Vol. 68 / No. 47 1093
 Morbidity and Mortality Weekly Report

for public health is an important policy consideration for

Summary
all PEPFAR-supported countries (2); however, the fact that
What is already known on this topic?
many countries have not yet implemented CBS underscores
the need for increased efforts to address policy barriers and Human immunodeficiency virus (HIV) case-based surveillance
continuously and systematically monitors HIV-positive
gaps in technical infrastructure so that comprehensive HIV patients throughout their clinical care and facilitates rapid
CBS systems that can inform national responses to the HIV public health action.
epidemic can be implemented. What is added by this report?
These findings are subject to at least four limitations. First,
Among 39 surveyed countries supported by the U.S. President’s
several countries did not complete the survey despite multiple Emergency Plan for AIDS Relief, 20 had implemented case-
follow-up attempts; thus, these results might not be representa- based surveillance, 15 were planning implementation, and four
tive of all PEPFAR-supported countries. Second, this assess- were not planning implementation. Challenges for most
ment might not have identified all potential facilitators and countries, particularly those in sub-Saharan Africa, include need
barriers for CBS implementation. Third, because the survey for unique identifiers to link data across systems, supportive
national policy environments, and data security standards.
was self-administered, the questions might have been inter-
preted differently by different respondents. Finally, although What are the implications for public health practice?
persons familiar with the country’s HIV surveillance systems Enhanced efforts are needed to address policy barriers and
gaps in technical infrastructure to implement comprehensive
were requested to complete the survey, not all responses were
HIV case-based surveillance that can inform national response
verified and were subject to reporting bias; in some cases, some to the HIV epidemic.
responses were confirmed through follow-up communication
with the respondent.
Despite these limitations, this is the first comprehensive References
global assessment of CBS implementation in PEPFAR- 1. World Health Organization. Consolidated guidelines on person-centred
supported countries. CBS is an effective system for countries to HIV patient monitoring and case surveillance. Geneva, Switzerland: World
Health Organization; 2017. [Link]
monitor their HIV epidemics in real time and to better inform person-centred-hiv-monitoring-guidelines/en/
responses. The assessment identified important barriers that 2. Office of the US Global AIDS Coordinator and Health Diplomacy,
need to be addressed to implement CBS effectively. Moving US Department of State. PEPFAR 2019 country operational plan
forward, annual deployments of this assessment can help moni- guidance for all PEPFAR countries. Washington, DC: US Department
of State; 2019. [Link]
tor countries’ progress toward successful CBS implementation. [Link]
3. Harklerode R, Schwarcz S, Hargreaves J, et al. Feasibility of establishing HIV
Acknowledgments case-based surveillance to measure progress along the health sector cascade:
Clinical Surveillance and Epidemiology Team, Staff members, situation assessments in Tanzania, South Africa, and Kenya. JMIR Public
Health Surveill 2017;3:e44. [Link]
Health Informatics, Data Management, and Statistics Branch, 4. Suthar AB, Khalifa A, Joos O, et al. National health information systems
Division of Global HIV and TB, Center for Global Health, CDC. for achieving the sustainable development goals. BMJ Open
Corresponding author: Joshua R. Holmes, jholmes3@[Link], 404-471-7348. 2019;9:e027689. [Link]
5. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research
1Division of Global HIV and TB, Center for Global Health, CDC. electronic data capture (REDCap)—a metadata-driven methodology and
workflow process for providing translational research informatics support.
All authors have completed and submitted the International J Biomed Inform 2009;42:377–81. [Link]
Committee of Medical Journal Editors’ form for disclosure of potential 6. Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O’Neal L; The
conflicts of interest. No potential conflicts of interest were disclosed. REDCap consortium. building an international community of software
partners. J Biomed Inform 2019;95:103208. [Link]
jbi.2019.103208
7. United Nations Programme on HIV/AIDS. UNAIDS data 2019. Geneva,
Switzerland: United Nations Programme on HIV/AIDS; 2019. https://
[Link]/en/resources/documents/2019/2019-UNAIDS-data

1094 MMWR / November 29, 2019 / Vol. 68 / No. 47 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

PEPFAR HIV Case-based Surveillance Study Group

Alean Frawley, CDC-Angola; Patrick Tema, Ministry of Health, Botswana; Kristen L. Hess, CDC-Botswana; Khuteletso Bagapi, CDC-
Botswana; Penh Sun Ly, Ministry of Health, Cambodia; Vanthy Ly, CDC-Cambodia; Rachel Albalak, CDC-Cambodia; Varough Deyde, CDC-
Caribbean Regional Office; Tyson Volkmann, CDC-Caribbean Regional Office; Martine Chase, CDC-Caribbean Regional Office; Rhonda A.
Moore, Ministry of Public Health, Guyana; Sasha E. Walrond, Ministry of Public Health, Guyana; Avery Hinds, Ministry of Health, Trinidad and
Tobago; Keven Antoine, Ministry of Health, Trinidad and Tobago; Nicola Skyers, Ministry of Health and Wellness, Jamaica; Jose Manuel Rodas,
CDC-Central America Regional Office; Sandra I. Juarez, CDC-Central America Regional Office; Tomasa Sierra Pineda, Ministry of Health,
Honduras; José Salvador Sorto, Ministry of Health, El Salvador; Maria Mastelari, Ministry of Health, Panama; Manuel Sagastume, Ministry of
Health, Guatemala; Ingrid Castillo, Ministry of Health, Guatemala; Luz Maria Romero, Unversidad del Valle de Guatemala; Enrique Beteta,
Ministry of Health, Nicaragua; Aka-Camara Aoua, Ministry of Health and Public Hygiene, Côte d’Ivoire; G. Laissa Ouedraogo, CDC-Côte
d’Ivoire; Legre Roger Lobognon, CDC-Côte d’Ivoire; Rinaldy Capellán, Direccíon General de Epidemiología, Dominican Republic; Luis Bonilla,
CDC-Dominican Republic; Jacob Dee, CDC-Democratic Republic of the Congo; Rogers Galaxy Ngalamulume, CDC-Democratic Republic
of Congo; Denis Yoka Ebengo, Ministry of Public Health, Democratic Republic of the Congo; Caroline Ryan, CDC-Eswatini; Munyaradzi
Pasipamire, CDC-Eswatini; Beyene Moges, Ethiopian Public Health Institute; Frehywot Eshetu, CDC-Ethiopia; Ayalew A. Haile, International
Centers for AIDS Care and Treatment Programs, Ethiopia; Silas Quaye, CDC-Ghana; Valerie Pelletier, CDC-Haiti; Joelle Deas Van Onacker,
Ministère de la Santé Publique et de la Population, Haiti; Timbila Jean Baptiste Koama, CDC-Haiti; Leonard Kingwara, Ministry of Health,
Kenya; Faith N. Ngari, Ministry of Health, Kenya; Catherine Ngugi, Ministry of Health, Kenya; Anthony Waruru, CDC-Kenya; Joseph L.
Barker, CDC-Kenya; Margaret Ndisha, CDC-Kenya; Peter Young, CDC-Kenya; Phouthone Southalack, Ministry of Health, Laos; Bouathong
Simanovong, Ministry of Health, Laos; Douangchanh Xaymounvong, CDC-Laos; Martha Conkling, CDC-Lesotho; Refiloe Mpholo, CDC-
Lesotho; Tigest Mekonnen, CDC-Malawi; Linda Mattocks, CDC-Malawi; Evelyn Kim, CDC-Malawi; Subrat Das, CDC-Mali; Mamadou B.
Traore, CDC-Mali; Sory Traore, Ministry of Health, Mali; Kristen Heitzinger, CDC-Mozambique; Maria Rein, CDC-Mozambique; Peter
Kerndt, CDC-Mozambique; Adam Wolkon, CDC-Namibia; Michael de Klerk, CDC-Namibia; Nicholus Mutenda, Ministry of Health and
Social Services, Namibia; Charles Nzelu, Federal Ministry of Health, Nigeria; Ibrahim Dalhatu, CDC-Nigeria; Stacie Greby, CDC-Nigeria;
Ibrahim Jahun, CDC-Nigeria; Mukhtar Ahmed, CDC-Nigeria; Victor Sebastian, CDC-Nigeria; Ademola Oladipo, CDC-Nigeria; Matthias
Alagi, CDC-Nigeria; Moyosola Bamidele, CDC-Nigeria; Mustapha Bello, CDC-Nigeria; Henry Debem, CDC-Nigeria; Raphael Akpan, CDC-
Nigeria; Aminu Yakubu, CDC-Nigeria; Ayodele Fagbemi, CDC-Nigeria; Nguhemen Tiger, CDC-Nigeria; Ifunanya Mgbakor, CDC-Nigeria;
Ibrahim Dangana, CDC-Nigeria; Abel Yamba, CDC-Papua New Guinea; Poruan Temu, CDC-Papua New Guinea; Peniel Boas, National
Department of Health, Papua New Guinea; Gene MacDonald, CDC-Rwanda; Janise Richards, CDC-Rwanda; Placidie Mugwaneza, Rwanda
Biomedical Center; Mboup Souleymane, Institut de Recherche en Santé, de Surveillance Epidémiologique et de Formations, Senegal; Astou
Guèye Gaye, Institut de Recherche en Santé, de Surveillance Epidémiologique et de Formations, Senegal; Safiatou Thiam, Conseils National de
Lutte Contre le SIDA, Senegal; Moussa Sarr, Westat, Senegal; Mireille Cheyip, CDC-South Africa; Zukiswa Edna Pinini, National Department
of Health, South Africa; Sarah Porter, CDC-South Africa; Shirley Nkone, CDC-South Africa; Richard Lino Loro Lako, Ministry of Health,
South Sudan; Moses Mutebi Nganda, Mbarara University of Science and Technology, Uganda; Sudhir Bunga, CDC-South Sudan; Alex Bolo,
CDC-South Sudan; George S. Mgomella, CDC-Tanzania; Jeremiah Mushi, Ministry of Health, Community Development, Gender, Elderly and
Children, Tanzania; Zaharani Kalungwa, CDC-Tanzania; Suvimon Tanpradech, CDC-Thailand; Kunjanakorn Phokhasawad, CDC-Thailand;
Thitipong Yingyong, Ministry of Public Health, Thailand; Herbert Kiyingi, CDC-Uganda; Muramuzi Bangizi Emmy, Ministry of Health,
Uganda; Edgar Kansiime, School of Public Health, Makerere University, Uganda; Musenge Kenneth, CDC-Uganda; Roksolana Kulchynska,
CDC-Ukraine; Ihor Kuzin, Public Health Center of the Ministry of Health, Ukraine; Nataliya Podolchak, CDC-Ukraine; Ezra J. Barzilay,
CDC-Ukraine; Violetta Martsynovska, Public Health Center of the Ministry of Health, Ukraine; Abu S. Abdul-Quader, CDC-Vietnam;
Vo Hai Son, Ministry of Health, Vietnam; Nguyen Tuan Anh, CDC-Vietnam; Suilanjo Sivile, Ministry of Health, Zambia; Andrew Banda,
University of Zambia; Stanley Kamocha, CDC-Zambia; Elizabeth Gonese, CDC-Zimbabwe; Brian Kumbirai Moyo, Ministry of Health and
Child Care, Zimbabwe; Kelsey Mirkovic, CDC-Zimbabwe.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / November 29, 2019 / Vol. 68 / No. 47 1095
 Morbidity and Mortality Weekly Report

Characteristics of E-cigarette, or Vaping, Products Used by Patients with

Associated Lung Injury and Products Seized by Law Enforcement —
Minnesota, 2018 and 2019
Joanne Taylor, PhD1,2; Terra Wiens, MPH2; Jason Peterson, MS2; Stefan Saravia, MPH2; Mark Lunda2; Kaila Hanson, MS2; Matt Wogen2;
Paige D’Heilly, MPH2; Jamie Margetta, MPH2; Maria Bye, MPH2; Cory Cole, MPH2,3; Erica Mumm, MPH2,3; Lauren Schwerzler, MPH2;
Roon Makhtal2; Richard Danila, PhD2; Ruth Lynfield, MD2; Stacy Holzbauer, DVM2,4; Lung Injury Response Task Force

On November 26, 2019, this report was posted as an MMWR contain THC or any e-cigarette, or vaping, products obtained
Early Release on the MMWR website ([Link] from informal sources. E-cigarette, or vaping, products should
During August 9–October 31, 2019, 96 patients were clas- never be used by youths, young adults, or pregnant women.*
sified as having e-cigarette, or vaping, product use–associated Until the relationship between inhaled vitamin E acetate and
lung injury (EVALI) by the Minnesota Department of Health lung health is better characterized, vitamin E acetate should not
(MDH); other patients are being investigated for case classifica- be added to e-cigarette, or vaping, products.
tion and exposures. Among 58 patients interviewed, 53 (91%) On August 12, the Minnesota Commissioner of Health
reported obtaining tetrahydrocannabinol (THC)–containing requested that patients with EVALI be reported. Medical
products from informal sources such as friends, family members, records of suspected cases were reviewed, and patients were
or in-person or online dealers. Using gas chromatography–mass classified using CDC case definitions.† EVALI patients or their
spectrometry (GCMS), the MDH Public Health Laboratory proxies (e.g., parents) were interviewed using an adaptation of
(PHL) analyzed 46 THC-containing e-cigarette, or vaping, a structured questionnaire developed in Illinois and Wisconsin
products obtained from 12 EVALI patients for various poten- in consultation with CDC during investigation of cases in
tial toxicants, including vitamin E acetate, which has recently those states. Patients were asked to provide product samples to
been detected in some THC-containing products and in MDH for testing. In addition, to explore whether the content
samples of lung fluid from EVALI patients (1–4). To explore of the local supply of illicit e-cigarette, or vaping, products was
whether vitamin E acetate is a recently added component in different before the outbreak, local law enforcement provided
THC-containing products, MDH tested ten products seized products to MDH from a raid of unregulated manufacturers
by law enforcement in 2018, before the EVALI outbreak, and and distributors of e-cigarette, or vaping, products in 2018
20 products seized in 2019, during the outbreak. Twenty-four and a comparison sample of products from a raid in 2019 that
products obtained from 11 EVALI patients from 2019 contained coincided with the current outbreak.
vitamin E acetate. Among the seized products tested by MDH, Product samples from EVALI patients and from the two law
none seized in 2018 contained vitamin E acetate, although all enforcement seizures were analyzed at MDH PHL using inter-
tested THC-containing products seized in 2019 tested posi- nally developed headspace GCMS and nontargeted GCMS
tive for vitamin E acetate. These chemical analyses of products methods and purchased reference materials. MDH PHL tested
obtained from EVALI patients and of products intended for for active compounds (cannabidiol [CBD], nicotine, and
the illicit market both before and during the outbreak support THC), toxicants of concern (glycerin, medium-chain triglyc-
a potential role for vitamin E acetate in the EVALI outbreak; eride [MCT], propylene glycol, and vitamin E acetate), and
however, the number of products tested was small, and further three vitamin E forms (alpha, beta, and gamma tocopherol).
research is needed to establish a causal link between exposure to Bronchoalveolar lavage (BAL) fluid samples from five EVALI
inhaled vitamin E acetate and EVALI. Collaboration between patients were analyzed at CDC for active compounds and
public health jurisdictions and law enforcement to characterize toxicants. MDH collaborated with the Minnesota Bureau of
THC-containing products circulating before the recognition Criminal Apprehension Forensic Drug Chemistry Department,
of the EVALI outbreak and during the outbreak might provide which had obtained six containers of bulk liquids, each labeled
valuable information about a dynamic market. These Minnesota with a different flavor, and 100 cartridges (all labeled “Cali
findings highlight concerns about e-cigarette, or vaping, products
that contain THC acquired from informal sources. Because local * [Link]
[Link].
supply chains and policy environments vary, CDC continues † [Link]
to recommend not using e-cigarette, or vaping, products that [Link].

1096 MMWR / November 29, 2019 / Vol. 68 / No. 47 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

Plugs Grape Punch”) from a spring 2018 raid. PHL tested five TABLE. E-cigarette, or vaping, product use characteristics of
bulk liquid samples and five cartridges held by the Minnesota interviewed e-cigarette, or vaping, product use–associated lung
injury (EVALI) patients (N = 58) — Minnesota, 2019
Bureau of Criminal Apprehension. In September 2019, local
Product use characteristics
law enforcement seized 75,000 cartridges intended for the illicit (no. with available information if <58) No. (%)
THC market (5). These cartridges were packaged inside boxes Illicit THC-containing products
bearing two market labels: “Dank Vapes” and “31 Flavors.” Any use* 53 (91)
Investigators used labeling to identify 31 different flavors of Exclusive use 13 (22)
Prefilled cartridges† 47 (81)
Dank Vapes and 19 different flavors of 31 Flavors. PHL evalu-
Nicotine-containing products
ated 10 different flavor cartridges labeled “Dank Vapes” and Any use 41 (71)
10 different flavor cartridges labeled “31 Flavors.” Exclusive use 2 (3)
Nicotine use, without illicit THC 3 (5)
As of October 31, 2019, 96 patients were classified as having
Any use, both illicit THC- and nicotine-containing products 37 (64)
confirmed or probable EVALI in Minnesota, and additional
Both illicit THC- and nicotine-containing products only 26 (45)
cases are being investigated. The median age of patients was CBD-containing products
21 years (range  =  15–71 years), and 58 (60%) were male. Any use 14 (24)
Eighty-seven (91%) patients were hospitalized, including 26 CBD oil products, with illicit THC and nicotine 8 (14)
CBD oil with illicit THC 3 (5)
(27%) in intensive care units. Three (3%) patients died. Among CBD and nicotine 1 (2)
58 (60%) interviewed EVALI patients, 53 (91%) reported Other product combinations§
using illicit THC-containing products obtained from informal Illicit THC brand usage
sources in the 3 months before illness onset,§ 41 (71%) used Any use Dank Vapes¶ 39 (67)
Used Dank Vapes exclusively, with no other THC brands 11 (19)
nicotine-containing products, and 14 (24%) used CBD oil Did not use Dank Vapes, but used other THC brands** 6 (10)
products (Table). Two patients reported using illicit THC, Solely used Dank Vapes, no other THC brand, nicotine, or CBD oil 2 (3)
medical cannabis, and nicotine-containing products. Thirty- Illicit THC- and nicotine-containing product use frequency††
Daily use of THC-containing products (49) 37 (76)
nine (67%) patients reported using Dank Vapes. Daily use of nicotine-containing products (40) 32 (80)
Sixteen (28%) patients submitted 265 products, 67 of which Illicit THC- and nicotine-containing product use duration††
were selected for testing because of available product volume >1-year use of THC-containing products (37) 19 (51)
and features that physically differentiated the cartridges; 46 >1-year use of nicotine-containing products (31) 22 (71)

contained THC, and 21 contained nicotine. Among the 46 Abbreviations: CBD = cannabidiol; THC = tetrahydrocannabinol.
* Three patients reported use of CBD and THC only. Two additional patients
assessed THC-containing products submitted by 12 patients, did not report THC during interview, but testing of bronchoalveolar lavage
the most commonly detected compounds were vitamin E fluid or product confirmed exposure to THC.
† Prefilled cartridge use was unknown for six respondents who used illicit THC.
acetate (24, 52%), MCT (20, 43%), CBD (20, 43%), and § Nicotine and unknown homemade oil (one, laboratory testing confirmed
alpha tocopherol (17, 37%). Eight (17%) THC-containing THC and vitamin E acetate present in bronchoalveolar lavage fluid); CBD and
unknown (one, laboratory testing of product confirmed THC and vitamin E
products did not contain either vitamin E acetate or MCT. acetate in unlabeled cartridge); and illicit THC, nicotine, and prescribed THC
THC-containing products used by 11 of 12 (92%) patients products supplied by a medical marijuana dispensary (two).
¶ Dank Vapes are a class of largely counterfeit THC-containing products of
contained vitamin E acetate, and products from seven (58%) unknown provenance that are marketed under a common name and
patients contained MCT. One patient who used medical can- distributed through informal sources.
nabis submitted illicit THC-containing products; one tested ** EVALI patients reported using these non-Dank Vapes brands: Banks Extracts
(one), Cannaclear (one), Chronic (one), Cookie Cart (one), Dabwoods (one),
product contained vitamin E acetate and another contained King Pin (one), Off White (two), Runtz (one), Sauce Extracts (one), TKO Extracts
MCT. THC-containing products from one patient did not (two), and West Coast Cure (one). Cartridge or brand use was unknown for
eight respondents who used illicit THC.
contain vitamin E acetate; however, this patient reported using †† Information on brand of THC-containing product and THC use duration and
multiple products daily, including Dank Vapes, which were not frequency was not available for all patients.
included among the products submitted for testing. Among
21 nicotine-containing products submitted by eight patients, Dank Vapes samples contained vitamin E acetate (Figure).
20 contained propylene glycol, and 15 contained glycerin but In five products labeled “Dr. Zodiak” and six labeled “TKO
not the other analytes. Extract,” vitamin E acetate, MCT, and alpha tocopherol were
Among the 21 patient-submitted THC-containing prod- variably detected.
ucts that were categorized by identifiable brands, two of two Vitamin E acetate was detected in all five patient BAL
fluid specimens. One of these patients submitted four THC-
§ THC-containing products were obtained from informal sources such as friends, containing cartridges labeled “TKO Extract” (two), “Rove”
family members, or in-person or online dealers, and were not obtained from (one), or “Dr. Zodiak” (one), all of which contained vitamin E
the Minnesota medical cannabis program ([Link]
people/cannabis/). acetate. Although the other patients were known to be exposed

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / November 29, 2019 / Vol. 68 / No. 47 1097
 Morbidity and Mortality Weekly Report

to THC based on interview or testing of the BAL fluid, none including five Minnesota patients, found vitamin E acetate in
of the other patients whose BAL fluid specimens were tested all specimens (1). Although the long-term stability of vitamin E
submitted THC-containing products for testing. acetate in THC-containing products is unknown, vitamin E
Among products seized during the 2018 raid, all five bulk acetate is reported to remain stable for at least 36 months in
liquid samples tested negative for vitamin E acetate and cosmetic products (6). Whereas vitamin E acetate was not
MCT; two tested positive for THC (Figure). The bulk liquids detected in the limited number of tested products seized in
appeared to be flavoring agents. All five Cali Plug cartridges 2018, it was detected in products seized in 2019, suggesting
tested contained THC and MCT, but not vitamin E acetate. that vitamin E acetate might have been introduced recently
Among the 20 tested cartridges seized during September 2019, as a diluent or filler. However, verification of this observation
all contained THC, vitamin E acetate, and MCT. In addition, requires testing of more products from Minnesota before 2019
five cartridges of 31 Flavors also contained gamma tocopherol. as well as products from other states.
All Dank Vapes tested, including those from patients and
Discussion
those confiscated by law enforcement in 2019, contained
This report evaluated e-cigarette, or vaping, products used vitamin E acetate. The majority of interviewed EVALI patients
by EVALI patients and products intended for the illicit market in Minnesota reported using Dank Vapes products: to date,
and seized by law enforcement both before and during the 87%–95% of EVALI patients in Illinois, Minnesota, Utah,
current EVALI outbreak. The findings support a potential and Wisconsin have reported using illicit THC-containing
role for vitamin E acetate in lung injury in EVALI patients. products, with 40%–75% of patients interviewed reporting
Vitamin E acetate has been detected in a high proportion using cartridges labeled “Dank Vapes” (3,7). In Illinois, EVALI
of THC-containing products associated with EVALI cases, patients aged 18–44 years had higher odds of reporting use of
including those tested at MDH PHL, New York (4), Utah (3), illicit THC-containing products and of using products labeled
and the Food and Drug Administration (from 25 states) (2). “Dank Vapes,” compared with persons aged 18–44 years who
In addition, evaluation at CDC of 29 BAL fluid specimens in an online survey reported use of THC-containing products
from a convenience sample of EVALI patients from 10 states, but who did not have EVALI (8).

FIGURE. Detection of vitamin E acetate and medium chain triglyceride (MCT) by mass spectrometry methods in tetrahydrocannabinol (THC)–
containing products obtained from e-cigarette, or vaping, product use–associated lung injury patients (N = 46) and law enforcement raids
(N = 27) — Minnesota, 2018 and 2019

Bulk liquids
2018
raid

Cali Plug Neither vitamin acetate nor MCT

MCT only
Dank Vapes
Vitamin E acetate and MCT
2019
raid

31 Flavors Vitamin E acetate only

Buddha Bear
Cali Cart
Chronic Cart
Product source

Dabwoods
2019 EVALI patients

Dank Vapes
Dr. Zodiak
Mario Cart
Rove
Sky High
Supreme
TKO Extract
Unknown brand of THC product

0 5 10 15 20 25 30
No. of products with compound detected

1098 MMWR / November 29, 2019 / Vol. 68 / No. 47 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

MCT was found in many of the THC-containing products

Summary
tested in Minnesota. Although the numbers are small, MCT
What is already known about this topic?
was not found in any of the 29 tested BAL fluid samples from
EVALI patients (1). MCT was found in products seized by law Tetrahydrocannabinol (THC)-containing e-cigarette, or vaping,
products also containing vitamin E acetate appear to be
enforcement during both 2018 and 2019, suggesting that per- associated with e-cigarette, or vaping, product use–associated
sons using illicit THC-containing products in Minnesota were lung injury (EVALI).
exposed to MCT before 2019. However, more information What is added by this report?
on MCT is needed. Alpha tocopherol and gamma tocopherol
Illicit THC-containing products submitted by 11 of 12 EVALI
were detected in some products. These forms of vitamin E patients in Minnesota contained vitamin E acetate. Twenty
can be naturally derived from plant products; whether these THC-containing products seized during September 2019
compounds have a role in EVALI is unknown (9). Additional contained vitamin E acetate; ten products seized during 2018,
work, including quantitative analysis of the various compounds before the EVALI outbreak, did not contain vitamin E acetate.
in products, assessment of interactions and changes occurring What are the implications for public health practice?
with heating, and assessment of the biologic activity of poten- These data further support a potential role for vitamin E acetate in
tial toxicants in animal models should be considered. EVALI. While potential toxicants continue to be evaluated, vitamin E
Because many EVALI patients used THC- and nicotine- acetate should not be added to e-cigarette, or vaping, products.
containing products, nicotine-containing products were evalu-
ated as well. None of the nicotine-containing products tested Although vitamin E acetate was detected in THC-
contained alpha tocopherol, gamma tocopherol, MCT, THC, containing products provided by 11 of 12 EVALI patients
or vitamin E acetate. and a convenience sample of confiscated products from 2019
Two EVALI-patients discussed here used medical cannabis in Minnesota, additional analyses are needed to establish
vaping products as well as illicit THC-containing e-cigarette, whether a causal link exists between inhaled vitamin E acetate
or vaping, products. One patient submitted illicit THC- exposure and EVALI. According to these and other published
containing e-cigarette, or vaping, products; one product tested data, using THC-containing products with vitamin E acetate
contained vitamin E acetate and another contained MCT. appears to be associated with EVALI; however, it is possible
Another EVALI-patient refused interview, but medical records that more than one compound or ingredient could be a cause
indicated that the patient was enrolled in the medical cannabis of lung injury, and evidence is not yet sufficient to rule out
program and also used illicit THC-containing e-cigarette, or contribution of other toxicants. The ongoing investigation in
vaping, products. After the analytic period covered by this Minnesota has shown that collaborating with law enforcement
report, MDH learned of two additional patients who used to obtain and test products confiscated before and during
medical cannabis products, one of whom reported use of mari- the current outbreak can provide valuable information on
juana. The type of medical cannabis used by these patients, as the potential changes in these products in a dynamic market.
analyzed by MDH PHL, does not contain vitamin E acetate or Such collaboration is encouraged elsewhere to provide insight
MCT. Another medical cannabis manufacturer in Minnesota into the national picture and an improved understanding of
had used MCT, but no longer uses this compound. Further THC-containing products. These findings from Minnesota
investigation of these patients is ongoing. highlight concerns about e-cigarette, or vaping, products that
The findings in this report are subject to at least six limita- contain THC acquired from informal sources such as friends,
tions. First, EVALI patients might have been misclassified. family members, or in-person or online dealers. Because local
Second, many EVALI patients did not agree to be interviewed supply chains and policy environments vary, CDC continues
or to provide products for testing, which might limit the gen- to recommend not to use e-cigarette, or vaping, products that
eralizability of these findings to other EVALI patients. Third, contain THC and not to use any e-cigarette, or vaping, prod-
products submitted by EVALI patients did not represent all ucts obtained from informal sources. Further, e-cigarette, or
THC- and nicotine-containing products they had recently vaping, products should never be used by youths, young adults,
used. Fourth, many products did not contain sufficient material or pregnant women. Until the relationship between vitamin E
to test. Fifth, mass spectrometric laboratory testing of products acetate and lung health is better characterized, vitamin E acetate
focused on 10 compounds for which reference materials were should not be added to e-cigarette, or vaping, products.
obtained; however, other toxicants might have been present but
not identified. Finally, only a limited number of products and
brands from law enforcement were tested, and these might not
be representative of available products in Minnesota.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / November 29, 2019 / Vol. 68 / No. 47 1099
 Morbidity and Mortality Weekly Report

Acknowledgments References
Deborah Anderson, PharmD, Minnesota Poison Control 1. Blount BC, Karwowski MP, Morel-Espinosa M, et al. Evaluation of
System; Elisabeth Bilden, MD, Saint Mary’s Medical Center, bronchoalveolar lavage fluid from patients in an outbreak of e-cigarette,
or vaping, product use–associated lung injury—10 states, August–October
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Minnesota Poison Control System; staff members and leadership and recommendation. Silver Spring, MD: US Department
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Drug Chemistry Department, Minnesota Bureau of Criminal 3. Lewis N, McCaffrey K, Sage K, et al. E-cigarette use, or vaping, practices
Apprehension; Anoka County Sheriff ’s Office, Andover, Minnesota; and characteristics among persons with associated lung injury—Utah,
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4. Sun L. New York to subpoena firms selling substances linked to illicit
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Benjamin C. Blount, PhD, Division of Laboratory Sciences, [Link]/health/2019/09/09/new-york-subpoena-firms-
National Center for Environmental Health, CDC; Mateusz P. selling-substances-linked-illicit-vaping-products/
5. Minnesota CBS. Officials: 75,000 vaping cartridges seized in Anoka
Karwowski, MD, Division of Laboratory Sciences, National Center County. CBS Minnesota. September 24, 2019. [Link]
for Environmental Health, CDC; Maria Morel-Espinosa, PhD, com/2019/09/24/officials-75000-vaping-cartridges-seized-in-anoka-county/
Division of Laboratory Sciences, National Center for Environmental 6. BASF Corporation. Technical information: vitamin E acetate. Florham
Health, CDC; Liza Valentin-Blasini, PhD, Division of Laboratory Park, NJ: BASF Corporation; 2006. [Link]
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7. Ghinai I, Pray IW, Navon L, et al. E-cigarette product use, or vaping,
Corresponding author: Joanne Taylor, okp2@[Link], 651-201-5193. among persons with associated lung injury—Illinois and Wisconsin,
1Epidemic Intelligence Service, CDC; 2Minnesota Department of Health;
April–September 2019. MMWR Morb Mortal Wkly Rep 2019;68:865–9.
3Council of State and Territorial Epidemiologists Fellowship Program, Atlanta, [Link]
8. Navon L, Jones CM, Ghinai I, et al. Risk factors for e-cigarette, or vaping,
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product use–associated lung injury (EVALI) among adults who use
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1100 MMWR / November 29, 2019 / Vol. 68 / No. 47 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

Erratum

Vol. 68, No. 43 provision of safe drinking water (1,2). The worldwide eradi-
In the report “Progress Toward Global Eradication of cation campaign began in 1980 at CDC. In 1986, with an
Dracunculiasis — January 2018–June 2019,” on page 979, a estimated 3.5 million cases† occurring each year in 20 African
sentence was omitted from the first paragraph. The paragraph and Asian countries§ (3), the World Health Assembly called
should have read as follows: for dracunculiasis elimination (4). The global Guinea Worm
“Dracunculiasis (also known as Guinea worm disease) is Eradication Program (GWEP), led by The Carter Center and
caused by the parasite Dracunculus medinensis and is acquired supported by the World Health Organization (WHO), CDC,
by drinking water containing copepods (water fleas) infected the United Nations Children’s Fund, and other partners, began
with D. medinensis larvae. The worm typically emerges through assisting ministries of health in countries with dracunculiasis.
the skin on a lower limb approximately 1 year after infection, This report, based on updated health ministry data, describes
resulting in pain and disability (1). There is no vaccine or progress to eradicate dracunculiasis during January 2018–
medicine to treat the disease; eradication efforts rely on case June 2019 and updates previous reports (2,4,5). With only five
containment* to prevent water contamination and other countries currently affected by dracunculiasis (Angola, Chad,
interventions to prevent infection, including health educa- Ethiopia, Mali, and South Sudan), achievement of eradication
tion, water filtration, chemical treatment of unsafe water with is within reach, but it is challenged by civil unrest, insecurity,
temephos (an organophosphate larvicide to kill copepods), and and lingering epidemiologic and zoologic questions.”

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / November 29, 2019 / Vol. 68 / No. 47 1101
 Morbidity and Mortality Weekly Report

QuickStats

FROM THE NATIONAL CENTER FOR HEALTH STATISTICS

Age-Adjusted Percentage* of Adults Who Had Ever Used an E-cigarette,†

by Race and Ethnicity — National Health Interview Survey,
United States, 2014 and 2018§

100
2014
2018
25

20
Percentage

15

10

0
All adults White, Black, Asian, Hispanic
non-Hispanic non-Hispanic non-Hispanic

Race/Ethnicity

* With 95% confidence intervals indicated by error bars.

† Based on the response of “yes” to the survey question “Have you ever used an e-cigarette even one time?”
Data on e-cigarette use were first collected in the 2014 National Health Interview Survey.
§ Estimates are based on household interviews of a sample of the civilian, noninstitutionalized U.S. population
and are derived from the National Health Interview Survey, Sample Adult component. The estimates are age-
adjusted to the projected 2000 U.S. population as the standard population using five age groups: 18–24,
25–34, 35–44, 45–64, and ≥65 years.

From 2014 to 2018, the percentage of all U.S. adults aged ≥18 years who had ever used an e-cigarette increased from 13.0%
to 15.7% overall and, by race/ethnicity, increased among non-Hispanic white, non-Hispanic black, non-Hispanic Asian, and
Hispanic adults. Non-Hispanic white adults were the most likely, in both years, to have ever used an e-cigarette. In 2018, 19.1%
of non-Hispanic white adults had ever used an e-cigarette, compared with 10.1% of non-Hispanic blacks and non-Hispanic
Asians and 10.2% of Hispanics.
Source: National Center for Health Statistics, National Health Interview Survey, 2014 and 2018 data. [Link]
Reported by: Florence C. Lee, MPH, kwn5@[Link], 301-458-4694; Shilpa Bengeri.

1102 MMWR / November 29, 2019 / Vol. 68 / No. 47 US Department of Health and Human Services/Centers for Disease Control and Prevention
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