Utah health officials have confirmed 42 cases of serious, vaping-related illnesses — a per-capita rate that no other state has come close to matching, according to a Salt Lake Tribune review of government health announcements and news reports from the other states.

Meanwhile, the U.S. Centers for Disease Control and Prevention (CDC) on Thursday drastically increased its estimated number of confirmed cases nationwide, from 380 to 530.

Here’s what we know about the outbreak so far.

Do I need to worry about getting sick from nicotine vape products? Or are the illnesses only connected to illegal THC vape juice, bought on the street?

Most of Utah’s patients — about 90%— reported vaping THC products, either alone or along with nicotine products, said Keegan McCaffrey, the state epidemiologist who is leading Utah’s investigation into vaping-related illnesses. (THC is the intoxicating element of marijuana.) That’s consistent with national data collected by the CDC and the Food and Drug Administration. As a result, some researchers are looking at popular additives in street THC vape products as a possible culprit in lung injuries.

But a number of patients reported vaping only nicotine products, purchased in stores and online, McCaffrey said. Substances found only in THC products do not account for those cases.

Some patients might not immediately disclose THC use because it is illegal in Utah, said Scott Aberegg, a critical care pulmonologist at University of Utah Health; some patients have claimed they were vaping nicotine, and only acknowledged THC use after their families were no longer in earshot, he said.

But other patients tested negative for THC use, Aberegg said. One patient described suddenly becoming ill after vaping something purchased from the same local vape shop the patient had been visiting for seven years, said Dixie Harris, a pulmonology and critical care specialist with Intermountain Healthcare.

"That makes me ask the question, is there something different in the materials the vape shops are getting?" Harris said. "This patient was going for seven years, and this is the first time the patient got sick. It's not like the patient was getting it from all these crazy places."

(Christopher Cherrington | The Salt Lake Tribune)
(Christopher Cherrington | The Salt Lake Tribune)

THC and nicotine users alike have reported becoming severely ill, some requiring life support and extensive hospital stays. At this time, health officials are warning against all vaping, regardless of the product.

“It’s not safe to vape with this illness going around,” Aberegg said. “It appears to be less safe to vape THC, but any vaping appears to be capable of causing this illness.”

Did the patients notice anything strange about the products they were using before they became sick?

A few patients said they noticed small differences in flavor and in the packaging, Harris said. “It was very clear the quality of the cartridge and containers had changed,” she said — including “one of the very popular brands,” she added.

“I heard this from several patients: There are variances in what they are buying,” she said. That may speak to a need for more regulation, she added.

“If you buy — whatever, Chobani yogurt: The blueberry is packaged the same, the flavor is the same. You know when you buy Tylenol, or Oreo cookies: They look the same, they taste the same,” Harris said. “When things get regulated, that’s where all that happens. How well are things replicated in the [vape product] manufacturing process? ... What are they mixing them with? What’s the shelf life? What temperature does it need to be?"

So what is supposed to go into vape juice? How is that regulated?

Nicotine vape products normally include vegetable glycerine, propylene glycol, nicotine and usually a flavoring, said Ryan Bartlett, spokesman for tobacco prevention and control with the Utah Department of Health. Vape products are required to carry labels identifying ingredients, said Tom Hudachko, also a department spokesman.

Of the 20 nicotine samples submitted by patients, none tested positive for any unexpected substances, McCaffrey said.

State rules that went into effect this year limit the amount of nicotine in e-cigarette products sold in Utah, and they require sellers to obtain certifications from the manufacturer that the fluids don’t exceed that limit. But the rules don’t apply to “closed” cartridge vape products, like the popular JUUL brand. (Some cartridges are closed and disposable; others are open and can be refilled.) And the state rules don’t address other substances in the products.

The CDC has reported finding in some vape products trace metals that have been shown to be potentially carcinogenic, such as nickel and lead, Bartlett said.

“It could be something that at some point in the future is potentially harmful,” Bartlett said. “With the limited research at this time, people who are vaping are pretty much conducting an experiment on their own health and well-being.”

Last week, Rep. Paul Ray, R-Clearfield, pointed to testing by a private lab, which he said showed opioids and other illicit drugs were present in nearly 85% of the nicotine vape products that researchers obtained in Utah stores. However, the lab’s CEO told The Tribune that the test it used was so inaccurate for vape products that it effectively amounted to a “coin toss,” and the results are not scientifically valid. Health department officials have not identified opioids or other drugs in the nicotine samples patients have submitted, McCaffrey said.

The state rules also required vaping products sold in Utah to have FDA approval as of Aug. 8. But that rule was written in anticipation of FDA guidelines that were projected to be in effect by August, Hudachko said. The FDA still has not established “approval” mechanisms for e-cigarette products, so that rule has not been enforced by local health departments, Hudachko said.

THC products, meanwhile, are illegal to possess or sell in Utah, so there are no regulations about what they can contain.

Why do I keep hearing about vitamin E? Is that in all vape products?

Vitamin E acetate is a cutting agent used in some THC products, generally those sold on the black market. It was found in all 19 THC product samples submitted by Utah vapers who fell ill, McCaffrey said.

It also was found in nearly all THC vape products tested in New York, the state health department there reported. The FDA also has found significant amounts of vitamin E acetate in “most” of the samples it has tested.

The ingredient is used to dilute THC products, and it’s not typically found in legal medical or recreational cannabis products, McCaffrey said.

It’s not known how or even whether the chemical may relate to illnesses — and not all cases of vaping-related illness involved products containing Vitamin E acetate.

“No one substance, including Vitamin E acetate, has been identified in all of the samples tested,” the CDC reported last week.

It’s also possible that not all patients are reacting to the same chemical, Harris said. Changes to THC products may have caused the sudden outbreak that caught doctors’ attention — and the new focus on vaping may have enabled doctors to also identify nicotine-related cases that previously would have flown under the radar or been diagnosed as more run-of-the-mill respiratory problems.

“Is one thing causing all of these problems, or is it multiple things?” she asked. “There’s so many different products being used, you have to think there’s probably multiple causes.”

Since vitamin E acetate is mostly used in black market products, are THC products safe if they're from dispensaries in states where it's legal?

In Utah, where THC products are illegal, some patients have initially reported the product they were using came from a dispensary in another state, such as California, Colorado or Nevada, Harris and Aberegg said.

But pressed further, those patients conceded that they themselves had not bought their supplies out-of-state, but obtained them from friends or dealers who claimed the products originated in a legal dispensary.

“What I’m hearing from our [THC] cases — and they’re being cagey — it sounds like they’re getting it from friends, who get it from the back of a gas station, from the back of someone’s car,” Harris said. “It sounds more black market.”

But at least one person has died, in Oregon, after vaping a THC product bought legally in a dispensary, The Oregonian reported.

Because scientists don’t know whether vitamin E acetate or some other substance is to blame, health officials are recommending that no one vape anything until more is known.

Are public officials looking at banning or further regulating vape products?

In Utah, some legislators have called for a statewide ban on flavored e-cigarette products — a measure adopted in Michigan, and proposed in New York and in Washington, D.C. In San Francisco, city officials banned e-cigarettes altogether; voters there in 2018 had approved a ban on flavored e-cigarettes and tobacco products.

Sen. Mitt Romney, R-Utah, has joined Sen. Jeff Merkley, D-Ore., in drafting a ban on flavored e-cigarettes. The proposed legislation would also require electronic nicotine delivery systems to be tamper-proof. Romney has urged the FDA to recall e-cigarettes amid the outbreak of lung disease.