Dennis Barry, Managing Director & Owner, MedCode Healthcare Service

I was having my morning coffee and reading the most topical news pieces and once again Vaping and its related illnesses are prominent. EVALI or “e-cigarette, or vaping, product use-associated lung injury” has fast become the most topical and potentially emergent public health scare in recent months.

Essentially E-cigarettes invented in 2003 are battery operated devices that heat a liquid and deliver an aerosolized nicotine product to the user. E-cigarettes have been considered safer than cigarettes and a step-down from smoking in people trying to break their tobacco addictions. Since the vaping products first appeared in the marketplace, there has been deep skepticism of their safety. Now along with the exponential growth in recreational use among young people there is increasing evidence of harm with the first deaths directly attributable to e-cigarettes this year it is now abundantly clear that much more needs to be done.

As of early November, the Centers for Disease Control and Prevention (CDC) in the US have listed 2,051 probable and confirmed cases of EVALI across the US of which 39 cases have been fatal to date.

Ongoing investigations have been elusive as to the chemical cause but most cases until now appear to be associated with the use of vaping products containing tetrahydrocannabinol (THC), the primary psychoactive ingredient in marijuana. In a most recent study with EVALI patients, however, while both nicotine and THC was evident in bronchoalveolar fluid samples, Vitamin E acetate (an oily additive used in lotions, shampoos, soaps, anti-aging creams and oral supplements) was the only substance tested that showed up in every sample, mainly from black market products. While vitamin E acetate does not cause harm when swallowed, its effects when inhaled have not been extensively studied. The Health Service Executive (HSE) in Ireland as a direct result of the US study is conducting a review of vaping product ingredients on the Irish market and thankfully so far none containing vitamin E acetate have been found.

The key to tracking any public health concern is through adequate data collection from health care providers, researchers, patients, public health officials and moreover through accurate ICD-10 coding. This has proved a dilemma here too at MedCode as there are currently no specific codes or a unique code set for vaping product related illnesses which would pose a barrier for public health surveillance. Various guidelines from various institutes were issued on how to report vaping related disorders but medical coders are still limited to combinations of existing and unspecified codes that cannot completely highlight the cause and effect relationship. In response to the situation in the US the World Health Organization issued immediate effective guidance to use an emergency use code for the reporting of acutely ill patients who have a vaping-related disorder with no other plausible cause for illness. While this is an emergency code it is not yet a specific vaping related disorder code and more guidance and possibly new codes are likely to be used as new clinical information emerges over time.

Looking at the evidence it could be that vitamin E acetate is associated with EVALI but it is also possible that more than one compound and toxicants are the contributory cause. More information will yield itself over time and better regulation on e-cigarette products is needed as is the crack down on unregulated black market “Dank Vapes”.

Public health awareness of the potential unsafe nature of vaping products is necessary but one also has to question the legitimacy of legalizing products with very little research on long-term consequences and its effect on our public health systems. Through data capture and accurate specific coding the actual cost and the changes that have to be identified and implemented in terms of patient care will be essential.