KUALA LUMPUR, June 30 – The Ministry of Health (MOH) has instructed doctors in the public and private sectors to notify health authorities of cases of lung disease related to the use of e-cigarettes or vaping.
Director General of Health Dr. Noor Hisham Abdullah said in a June 9 circular that cases of lung injury associated with the use of electronic cigarettes or vaping products (EVALI) are classified as confirmed EVALI and probable.
EVALI is a serious condition in which the lungs are damaged by substances in electronic cigarettes and vaping products.
Dr Noor Hisham’s circular – which came into effect on June 9 – stated that confirmed and probable cases of EVALI should be notified to the district health office within 48 hours of diagnosis by a medical specialist or physician.
Suspected cases of EVALI treated in a hospital or clinic emergency department should be referred to a medical specialist for further action.
Probable and confirmed cases of EVALI are defined as the patient using e-cigarettes or vaping within 90 days before the onset of symptoms and radiological changes on chest X-ray or CT scan (pulmonary infiltrate, e.g. opacities, on a plain chest x-ray
or ground glass opacities on chest CT). Opacities are fuzzy spots on the lungs that indicate tissue damage.
For probable cases, infection is identified by PCR or culture, but the clinical team treating the patient believes that the infection is not the primary cause of the lung injury or that the minimal criteria for lung infection do not are not fulfilled (the tests have not been carried out).
For confirmed cases, early examinations do not show a lung infection. The minimum criteria are that the patient is negative for a viral respiratory infection, that the PCR or rapid influenza test is negative and that all tests related to a respiratory infectious disease are negative (for example: urinary antigen for Streptococcus pneumoniae and Legionella, sputum culture if productive cough, culture if performed, blood culture, human immunodeficiency virus (HIV)-related opportunistic respiratory infections if applicable).
For probable and confirmed cases of EVALI, there is no evidence in the patient’s medical record for a reasonable alternative diagnosis (eg, heart disease, rheumatology, or cancer).
The Ministry of Health has also drafted guidelines for the control of EVALI cases, categorized into sporadic and cluster cases. A sporadic EVALI case is the notification of a single confirmed case, while a cluster involves two or more confirmed EVALI cases; one confirmed case and one probable case; or two probable cases.
Epidemiological links in EVALI clusters are defined as cases using the same brand and same lot of e-cigarette or vape.
The Ministry of Health notification form for cases of EVALI includes symptoms to be checked off by the doctor, such as difficulty breathing, cough, chest pain, nausea, vomiting, diarrhea, aches stomach and fever.
Dr Noor Hisham said that for symptoms other than EVALI disease, doctors who suspect these symptoms were caused by e-cigarette or vaping use can notify the district health office through a “syndromic notification”.
The DG Santé noted that in addition to causing EVALI, using e-cigarettes or vaping can cause other symptoms besides respiratory symptoms. He cited the National Poisons Center reporting symptoms related to e-cigarette use such as numbness, heart palpitations, sweating, vomiting, dizziness and hallucinations.
EVALI was first reported in the United States in October 2019. As of February 2020, as many as 2,807 cases and 68 deaths have been reported in America, according to Dr. Noor Hisham.
Malaysian experts, he said, identified two EVALI-related cases in Labuan and Kuching, Sarawak, involving two teenagers who were permanently disabled and forced to be on continuous oxygen.
“There are believed to be a number of possibly unreported cases, given the increase in e-cigarette or vaping users,” he said.
“In accordance with this, the Ministry of Health shall strengthen the surveillance of diseases related to the use of electronic cigarettes or vaping by imposing the notification of this disease to allow the implementation of immediate prevention and control measures and to long term.
“These notifications are also needed to identify the disease burden caused by e-cigarette or vaping use in Malaysia.”
The MOH clinical practice guidelines on the management of lung injury associated with the use of electronic cigarettes or vaping products (EVALI) can be found here.