KUALA LUMPUR, June 30 – The Ministry of Health (MOH) has instructed medical practitioners across the public and private sectors to notify health authorities about cases of lung disease related to the use of e-cigarettes or vape.
Health director-general Dr Noor Hisham Abdullah said in a circular last June 9 that e-cigarette or vaping product use-associated lung injury (EVALI) cases are categorised into confirmed and probable EVALI.
EVALI is a serious medical condition in which one’s lungs get damaged from substances contained in e-cigarettes and vaping products.
Dr Noor Hisham’s circular – which took effect last June 9 – stated that both confirmed and probable EVALI cases must be notified to the district health office within 48 hours after diagnosis by a medical specialist or a medical officer.
Suspected EVALI cases treated at the emergency department at a hospital or clinic must be referred to a medical specialist for further action.
Probable and confirmed EVALI cases are defined as the patient using e-cigarettes or vape within 90 days before symptoms show and radiological changes on the X-ray or chest CT scans (pulmonary infiltrate, for example opacities, on plain film chest radiograph
or ground-glass opacities on chest CT). Opacities are hazy spots on one’s lungs that indicate tissue damage.
For probable cases, infection is identified through PCR or culture, but the clinical team treating the patient believes that the infection is not the main cause of lung injury or the minimum criteria for lung infection are not fulfilled (tests were not done).
For confirmed cases, early examinations do not show pulmonary infection. The minimum criteria are the patient is negative for respiratory viral infection, PCR or rapid test influenza is negative, and all tests related to respiratory infectious disease are negative (for example: urine antigen for Streptococcus pneumoniae and Legionella, sputum culture if productive cough, culture if done, blood culture, human immunodeficiency virus (HIV)-related opportunistic respiratory infections if appropriate).
For both probable and confirmed EVALI cases, there is no evidence in the patient’s medical record for a reasonable alternative diagnosis (for example: heart disease, rheumatology, or cancer).
MOH has also drafted guidelines for control of EVALI cases, categorised into sporadic and cluster cases. A sporadic EVALI case is the notification of a single confirmed case, whereas a cluster involves two or more confirmed EVALI cases; one confirmed and one probable case; or two probable cases.
The epidemiological links in EVALI clusters are defined as cases using the same brand and batch of an e-cigarette or vape.
MOH’s notification form for EVALI cases includes symptoms to be ticked by the doctor, such as breathing difficulty, cough, chest pain, nausea, vomiting, diarrhoea, stomach ache, and fever.
Dr Noor Hisham said for symptoms besides EVALI disease, medical practitioners who suspect that those symptoms were caused by the use of e-cigarettes or vape can notify the district health office through “syndromic notification”.
The Health DG noted that besides causing EVALI, the use of e-cigarettes or vape can lead to other symptoms aside from respiratory symptoms. He cited the National Poisons Centre that reported symptoms related to the use of e-cigarettes like numbness, heart palpitations, sweating, vomiting, giddiness, and hallucination.
EVALI was first reported in the United States in October 2019. Until 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, have identified two EVALI-related cases in Labuan and Kuching, Sarawak, involving two teenagers who suffered permanent disability and are forced to be on continuous oxygen support.
“It is believed that there are a number of possibly unreported cases, given the rise in e-cigarette or vape users,” he said.
“In line with that, the Ministry of Health must increase surveillance for disease related to the use of e-cigarettes or vape by compelling the notification of this disease to enable the implementation of immediate and long-term prevention and control measures.
“Such notifications are also necessary to identify the burden of disease caused by the use of e-cigarettes or vape in Malaysia.”
MOH’s clinical practice guidelines on the management of e-cigarette or vaping product use-associated lung injury (EVALI) are found here.