Lung disease. We heard testimony from centers for Disease Control and prevention experts held by a House Oversight subcommittee. It is about two hours 40 minutes. Good morning. Sorry for the delay. The subcommittee will come to order. Without objection the chairs are authorized to declare a recess of the committee at any time. Without objection id like to have a few members waived onto the committee. Congressman jordan, congressman meadows and congressman cox. Shall be permitted to join the subcommittee on the dias. Without objection so ordered. I now recognize myself for five minutes to give an opening statement. We are here to amplify the recent Health Warnings issued by the centers for Disease Control related to 530 ecigarette related incidents of lung disease in 38 states and the u. S. Virgin islands. First, i want to make clear that we did not plan to have this emergency hearing at the beginning of this congress, let alone this time last month. But on august 23rd, officials from my home state of illinois reported the first death due to a mysterious vaping related illness. And since then, a total of eight individuals have tragically died in this outbreak. In response to this crisis, cdc is warning the American Public to consider not using ecigarettes of any kind. Because the subcommittee has investigated the youth vaping epidemic and the companies behind it, we feel its our duty to draw attention to recent government Health Warnings about the dangers of ecigarette use. The longterm Health Effects of continued vaping is unknown. But what we do know should give us all pause. State Health Departments continue to conduct retroactive analyses of patient records to better understand exactly when this outbreak began. As they do, the number of affected people will grow. Unfortunately, illness related to e cigarettes is not new. The fda has received 127 reports of seizures and other neurological conditions caused by ecigarettes. When a product is released onto the market without safety testing or clinical trials, this is what we fear. This is a problem exacerbated by eCigarette Companies that take what appear to be unfounded and illegal claims that their products are safer and healthier than combustible cigarettes. People trust and rely on those claims even when theres no evidence to back them up. Thats why this subcommittee wrote a detailed letter to the fda outlining our findings about juul illegally marketing its products as safe, healthy and a Smoking Cessation device. Fda agreed with us and days later responded with a letter declaring that juul had broken the law. The response is due on april 30th. The fda will have the opportunity to act. I encourage you all of you to develop that development closely. We certainly will. Just days after the fda responded to our letter, the administration in part citing our investigation announced it would move to ban all ecigarette flavors, including mint and menthol. The fact that flavors hook kids is a point this subcommittee hammered home over our two days of hearings in july. The administration cited our hearings in rolling out its proposal. We should all be encouraged that democrats and republicans are coming together when the health of our nations youth comes under attack. Today, as we focus on the tragic outcomes of this lung disease outbreak, we must view it as a chance to come together to protect Public Health. At the heart of the recent vaping related outbreak are families are being blindsided. Joining us is ruby johnson. A mother of seven from near chicago. This august as she prepared to drop her oldest daughter off to start college, already a stressful time, the Johnson Family faced a terrifying health scare. Instead of moving into a dorm room, her daughter moved into a hospital bed far from home where she stayed for what would have been her first week of classes. Rubys daughter could have died. Thankfully she recovered enough from her bout of lung disease to be released, but she still has trouble breathing and doctors cannot tell her how much longer that may last. Mrs. Johnson, thank you for coming to share your familys harrowing experience. Were also joined by leaders from the Public Health community to provide a neutral assessment of the outbreak and provide their advice to the public they serve. We have a doctor from the cdc, a doctor of the Illinois Department of Public Health and dr. Albert rizzo of the American Lung association. Thank you all for joining us today. We look forward to learning more about how we can avoid more preventible deaths. And with that, i recognize the Ranking Member, mr. Cloud of texas, for five minutes for an opening statement. Thank you, mr. Chairman. Over the last several weeks its been clear that users of certain vaping products have become very ill. Some tragically to the point of death. Mr. Chairman, i do greatly appreciate your desire to hold this meeting. In the center for Disease Control prevention september 19th update, the number of those sick reached 530 and 8 deaths have been confirmed. This is very concerning and it is clear that we need to examine the cause and what can be done to prevent it. To the best information of available, many of these cases seem linked to the use of products that are something they are not. Based on the limited Data Available, about those impacted by this mysterious lung illness, approximately 16 are under 18 years of age. And while each life is affected is important these incidents also serve to bring attention to what has become an epidemic increase in teen vaping. With currently 20 of High School Students vaping. Add to that the decades long epidemic of addiction to traditional tobacco smoking that will leave five people dead by the end of these opening statements. As a father of three, this is very concerning. I wish we had a quick fix to insure that each child is protected, that no american finds themselves bound by a substance and that all of us are able to find complete personal fulfillment in experiencing the purpose for which we were created. Were here to discuss what should be the appropriate response to the lung illnesses associated with certain vaping products. Complicating this discussion is a lack of Scientific Data and studies available. Counterfeit products, untraceable supply lines. Lack of enforcement that allows players to pass the buck of accountability. For example, Data Available leads us to believe that many of the recently reported 530 cases involve vaping products. I hope were able to do the good work for which this Investigative Committee exists. I believe theres a lot of bipartisan support for addressing this situation. I appreciate the chairmans heart in this and to the point of examining this to find the solution and our desire to end teen vaping, there is unity. Police know my heart goes out to those impacted and my condolences to those who have lost loved ones. Again, i appreciate the chairmans work on this issue and look forward to productive discussion today. Thank you, mr. Cloud. I should say we recently started a bipartisan, bicameral youth antivaping caucus and, mr. Cloud, thank you for joining and today happens to be a National Recovery day. A bipartisan endeavor to recognize the folks in our lives who may be affected by Substance Use disorders and our attempts to try to wean them off their addictions. I hope vaping is not that next Substance Use disorder. Today were joined on panel one by dr. Anne schuchat, the Principle Deputy director of the cdc. If you would please rise and raise your right hand. Ill swear you in. Do you swear or affirm the testimony youre about to give is the truth, the whole truth and nothing but the truth, so help you god . I do. Let the record show the witness answered in the affirmative. Thank you very much and please be seated. The microphones are sensitive, so please speak directly into them. Without objection, your written statement will be made part of the record. With that dr. Schuchat, youre now recognized for five minutes. Thank you. Good morning, chairman, Ranking Member cloud, and members of the subcommittee. Thank you for the opportunity to testify today about cdcs investigation into lung injury associated with using ecigarettes or vaping products. Today, ill discuss with you what we know and dont know and what were doing to address this outbreak of lung injury. Ill also discuss our efforts to address the epidemic of youth ecigarette use or vaping. I want to make four key points. First, as soon as we learned about the initial cases of lung injury, cdc has been working 24 7 hand in hand with the fda and our state and local Public Health partners to find the cause. Secondly, our ability to do this type of investigation relies on a critical underlying Public Health infrastructure, including data systems that need modernization and a trained Public Health workforce. Third, the cdc has made important recommendations to the public, including the following. While this investigation is ongoing, people who are concerned about lung disease associated with ecigarette use or vaping should consider refraining from using ecigarette products or vaping. People should not buy these products off the street and should not modify them further. Adults who use ecigarettes or vaping products because they have quit cigarette smoking should not return to smoking cigarettes. We have a need to address the epidemic of youth use of ecigarettes. Reinforces the need to address the broader youth ecigarette epidemic. So what do we know so far . As youve heard, several hundred cases have been reported from nearly all states. Weve had a number of deaths. The cases are occurring in young people. One half of all cases are less than 25 years old. People present with cough, shortness of breath, chest pain, and sometimes with systems like nausea and vomiting, fatigue or fever. Most of the cases with information so far have reported use of thc or thc and nicotine containing products. Some have reported nicotine only. There may be some challenges with the histories of exposure in some subset of the patients. What do we not know so far . Probably the most important thing, we dont know the cause. No single product, brand, substance or additive has been linked to all cases. This investigation is ongoing and its very dynamic. What are we doing to respond . Cdc is working closely with state and local Public Health with the fda and Clinical Community to get to the bottom of this. Weve deployed staff to help states with their investigations. Weve provided technical assistance, developed a Case Definition, standardized clinical guidance, and a reporting system and are working every day on coordinating the parts of the investigation in response. We set up a system and activated our Emergency Operation center as we do in other Public Health urgent situations. Weve convened the Public Health clinical and media numerous times to share what we know and dont know and how they can be part of the solution. One such example is a clinical outreach and communication activity call we held in the past few days that had 2,500 lines and clinicians around the country listening to the latest information. Were working very closely with the fda on the Laboratory Aspects of trying to trace back and study the products from affected patients. There are challenges with this response, including the nature of the outbreak itself. Many states, some of the cases report using illicit products. And may not be fully forthcoming. The marketplace for ecigarettes is wide and diverse with a multitude of products and it might be complicated to tease out the problematic exposures. And our Public HealthData Collection systems are in need of an upgrade. In terms of youth ecigarette use were seeing an epidemic and to go into the details about that. The most recent data is to being to be concerning. Ill just leave you with this. Cdc is dedicated to working around the clock together with fda and the state and local Health Officials to identify the cause or causes of the outbreak and will continue to update you during the course of the investigation. Thank you very much, dr. Schuchat. I now recognize myself for five minutes of questioning. Dr. Schuchat, thank you for the work youre doing. The cdc has been clear its not yet possible to determine the cause of the vaping related lung disease outbreak. Cdc has recommended that people consider not using any ecigarettes. From that we gather that nothing is off the table as a possible cause. Lets first describe the general types of ecigarettes out there. From what i understand theres two major categories. First there are nicotine ecigarettes, which have been the focus of this subcommittees hearings up to this point. Second, there are ecigarettes that replicate the effects of marijuana. You are examining both of those products as factors in the current outbreak of lung illness. Is it correct to say you cannot rule out either as contributing to the outbreak . Thats correct at this point. Were getting new information in every day. We think its very important until we know that our recommendations be broad. Separate from this outbreak, we are quite concerned about the rise in nicotine containing ecigarette use among youth which is an epidemic. We dont know yet what the product or products are or whether theyre components of the products that might be contained in both nicotine and thc containing devices. I want to focus on the nicotine ecigarettes for a second. In the illinois and wisconsin published analysis, almost 20 of the victims there were using only nicotine ecigarettes and overall 61 of the victims were using among other ecigarettes nicotine ecigarettes, as well. So, doctor, there may be people out there for this to be a thc only problem so they can go back to vaping nicotine ecigarettes. If almost 20 of victims are using only nicotine ecigarettes, do we still need to be concerned about all ecigarettes at this point . At this point, i think caution for all products is recommended. It may not even be the thc or nicotine part. It may be additives. Or substances that may be common. It may be material thats not labelled appropriately. And so, we really do think surms need to be quite cautious right now. Got it. You cant rule out any brand at this point, right . No single brand, product or additive has been ruled out as of today. Id like to better understand the possible contributing factors to the outbreak youre considering. First of all, on august 22nd, cdc said, quote, even though the cases seem similar, its not clear if these cases have a common cause or if theyre different diseases with similar presentations. Does that mean that it could be multiple separate problems with ecigarettes that are causing similar results . Thats right. The respiratory systems are nonspecific and the xray findings are diverse. We also have cases in nearly all states at this point, whether the products in one state are the same as the problematic products in another or whether manipulation of the products is going on we dont know so i think we have to have a very open mind. We dont know the full impacts of vaping. If so many vaping products are causing the same result, could the common link be the process of vaping itself . Inhaling aerosolized liquid particles into our lungs . We dont know enough about the aerosol that vaping produces or that ecigarettes produces in terms of the short and longer Term Health Impacts and products may it may be that the process itself is risky. All ecigarettes include solvents. While theyre considered safe in food, a recent baylor study found those solvents when inhaled reduced the lungs ability to fight infection, increase the chances of getting flu and dying from it. Dr. Schuchat, these supplements are in all e cigarettes. Can the cdc rule them out as a factor in the current outbreak . We have not ruled out any substance yet. Many of the victims were using flavored products. To add flavor to an ecigarette requires additional chemicals on top of the solvents we just talked about. Can the cdc rule out the chemicals and flavors as a factor in the current outbreak . No, we cant. Dr. Schuchat, the cdc advises the public not the use any ecigarettes at this point. They also advice that those who do not vape not to start. That children and pregnant women never use ecigarettes. For those trying to quit smoking to use an fda approved cessation device. Ecigarettes are not approved by fda for Smoking Cessation. With that, thank you. Now i recognize mr. Cloud for five minutes of questioning. Thank you. Dr. Schuchat, previously the cdc has said that the illnesses that were seeing arent a result of this but Chemical Exposure. Do you maintain that the distinction or is it possible that the Chemical Exposure is leading to reduced immune system, therefore, leading to infection . Part of the Case Definition is to rule out infections as a cause. Certainly people presenting with cough, shortness of breath and abnormal xrays often have an infection. In this episodes, we dont believe infection is causing the problem. We think its one or more Chemical Exposure. Okay. Do the patients have systems immediately after vaping, or is it after