When the Massachusetts Department of Public Health started collecting reports of vaping-related lung illness from hospitals across the state mid-September, the national public health issue that would kill five Massachusetts residents and at least 68 others nationwide was still largely shrouded in mystery.
Today, the issue pales in comparison to the coronavirus pandemic that has killed more than 47,000 globally and continues to increase exponentially. But at the end of 2019, an observable increase in lung-related illnesses was plagued by questions health officials had few answers to — what was causing the illnesses, and what was the connection to vaping?
In January, roughly six months after the U.S. Centers for Disease Control and Prevention first reported a spike in the illnesses, the federal agency noted that emergency department visits associated with e-cigarette use was declining nationwide. Vitamin E acetate, sometimes used as a vape cartridge additive, is still “strongly linked” to the outbreak.
But none of the confirmed cases or deaths in Massachusetts has been linked to vitamin E acetate or any of the CDC’s chemicals of concern, and public health officials have been reluctant to share information about the nature and origins of the outbreak in Massachusetts, citing patient privacy concerns.
MassLive attempted to gain insight into the scope of the problem, requesting records from the Massachusetts Department of Public Health in October detailing the number of potential cases and the medical facilities from which they originated. After refusing to fulfill the request, claiming several exemptions under the Massachusetts public records law, DPH was twice-ordered by the Secretary of State’s office to provide the data.
DPH then provided a partial list noting numbers of potential cases of vaping-related illnesses at the state’s larger hospitals.
A breakdown of the hospitals’ reported cases shows that Southern Worcester County may have been hit hardest by the outbreak, particularly the communities served by Harrington Hospital, according to public records obtained by MassLive. The hospital reported 54 potential cases, the highest number of any hospital or health center in the state between Sept. 11, 2019 and Jan. 29, 2020.
After Harrington Hospital, Mass. General Hospital reported 43 potential cases, then UMass Memorial Medical Center in Worcester reported 15 cases. Boston Children’s Hospital reported 10, according to DPH’s data. To some experts, the disparity in possible cases came as no surprise.
“Harrington Hospital is a hotbed of vaping-related injury,” said Craig M. Lilly, vice chairman of critical care operations at UMass Memorial Medical Center, which is planning to acquire Harrington Hospital.
While the statistics do not represent the number of confirmed or even probable cases — DPH uses the hospital reporting to then classify the cases into those categories — they do shed light on regional patterns that could be tied to smoking rates, socioeconomic factors or illicit market activity.
The ‘smoking’ gun
Tina Grosowsky, project coordinator of the Central Massachusetts Tobacco-Free Community Partnership, said the vaping hospital data is not surprising given that the smoking rates in the communities surrounding Harrington Hospital are among the highest in the state.
“These are all older industrial communities leftover from the recession,” she said. “There’s not as much community-organized support for programs to help people quit” or to access mental health services.
The town of Southbridge, which is where Harrington Hospital is located, had the third-highest smoking rate, at just over 25%, of any municipality in Massachusetts between 2011 and 2015, according to data from DPH. The medium income in Southbridge during that period was $47,234.
Sturbridge, by comparison, which borders Southbridge to the west, had a smoking rate of 12%, with a medium income of $71,607.
Finding the black market
While the data on smoking rates is compelling enough for some experts to explain the high rates of potential injuries reported by Harrington Hospital, the growing consensus among health officials with respect to confirmed cases is that they’re tied to vitamin E acetate, an oil additive that has been found in THC-based vape products and is linked to the black market.
There have been no incidents of illegal vaping, or of illicit vaping-related activity, reported in Southbridge by town law enforcement, according to the town’s chief of police, Shane Woodson.
Woodson said after Mass. Gov. Charlie Baker instituted a four-month ban on the sale of vaping products in September, his department conducted a four-day sting operation to ensure all e-cigarette stores complied with the temporary prohibition.
“We didn’t have a single business selling illicit vapes,” Woodson said.
Woodson said he was surprised at Harrington’s numbers. He noted the hospital serves several surrounding municipalities, and that the figures may not be entirely representative of a problem in Southbridge.
But if there is black market or illicit activity in certain parts of Massachusetts dealing in the cannabis extract supply chain, it may not be on the radars of law enforcement agencies, according to David Downs, California bureau chief of Leafly, a cannabis news website.
“The challenge facing law enforcement is that they have made it a priority to interdict opioid transactions, because so many people are dying of opioid overdoses,” he said. “Attention wasn’t focused on what was happening in the cannabis extract space.”
Increasingly, however, police across the country have been cracking down on illicit vape production rings, Downs said. One of the more famous cases involved the arrests of two Wisconsin brothers, who oversaw an underground operation that produced between 3,000 to 5,000 counterfeit vaping cartridges a day, according to the Milwaukee Journal Sentinel.
Downs estimates the underground market in Massachusetts is “very large” because the legal market is not meeting the per capita demands of cannabis users across the state. According to data compiled by Verilife, which operates marijuana dispensaries in Massachusetts and other states, Massachusetts has one recreational store per 100,000 residents. Compared to states like Oregon and Oklahoma, which have 16.5 and 15.6, respectively, that figure seems low, according to Downs.
“Most cannabis consumers in Massachusetts do not yet have a viable option in terms of a store that’s close by with affordable, tested products,” he said.
If there’s anyone keeping tabs on what types of vaping products are changing hands in Southbridge, it’s Miguel Cepeda, store manager of VAPORSS, an e-cigarette store located several blocks away from Harrington Hospital.
Cepeda, an ex-smoker himself, said customers come into his store every day with counterfeit vape cartridges. The brands subject to counterfeiting include Dank Vapes, TKO and Mario Carts, which are THC vapes.
Cepeda said he sees many fake TKO carts in the hands of customers, and being exchanged around town, including in restaurants, other e-cigarette shops and on the streets.
“Most of the time it’s somebody in the area selling cartridges,” he said, “and the person selling them most likely doesn’t know” that it’s a counterfeit.
Cepeda says he tries to steer his customers away from street products for their own health and safety. He credits the switch to vaping products from combustible cigarettes with helping to drastically improve his own health. He said he’s lost more than 200 pounds thanks to lifestyle changes he’d made as a result of quitting smoking.
“I want people to be on the safer side,” he said.
So when customers come in looking for a 510 thread battery to screw into a TKO cartridge, he knows something is amiss. TKO only manufacturers disposable vapes now, with the battery and the tank fused together.
“TKO doesn’t sell 510 thread screw-in carts anymore, it’s all one piece,” Cepeda said. “So whenever someone shows me this black-tipped one with the TKO stamp on it I know it’s fake. So I go listen, don’t vape that, throw it out.”
Because of the scarcity of public data surrounding vaping-related lung illness, there are many questions still to answer about the causes of these injuries. Health departments across the country and the CDC haven’t released information on confirmed vaping-related deaths because of privacy laws and patient confidentiality, according to the Wall Street Journal.
This has left families with loved ones who’ve died or are sick desperate for information, the Journal reports, “driving hundreds of miles to deliver vaping oils to authorities, filing records requests and calling lawyers representing the state.”
After MassLive appealed the health department’s initial denial of records, officials noted in their response that the reports of injuries that have come in from hospitals showed “no observed, statistically significant geographic patterns.”
“However, the department takes this opportunity to state that reports of patients suspected of having EVALI have been received from hospitals, urgent care centers and individual healthcare providers,” health department officials wrote. “These reports have come from practitioners and facilities across the state with no observed, statistically significant, geographic patterns.”
Yet Lilly says doctors and medical professionals at UMass Memorial Medical Center are “very aware” of the higher rates of vaping illness observed at the Southbridge facility.
And while the numbers of injuries continues to substantially decline, the medical community is still seeing cases.
“We are very committed to trying to report every case to the DPH,” Lilly said.
At the end of February, a fifth vaping death was announced in Massachusetts. The man, who officials said was in his 40s and from Suffolk County, said he had vaped THC.