Robert Redfield, MD, has been at the helm of the CDC for 18 months. He recently spoke at the Health Connect South conference in Atlanta about his tenure at the agency and his plans for tackling several major public health threats -- including the snowballing cases of severe lung injuries tied to vaping.
WebMD: Have your investigators been able to find out if there was a discrete event -- a change to e-cigarette cartridges or an explosion of black market e-liquids, for example -- that started this? Or has this been happening all along, with a case here and a case there and nobody connected them?
Redfield: My own sense is that this didn’t just all of a sudden happen. What has happened is it’s been recognized. We now have a good case definition. It’s out among all the health departments. I think you’re going to see people start to go backwards and try to see when this happened. My instinct is that this has been going on for a while, but misdiagnosed as a pneumonia or an exacerbation of a chronic health condition, but, as I said, we’re not really an opinion organization, so I’ve got to hang in there and look at the data and the investigation.
I will say it’s a very serious public health threat. We have asked people that are using these products to not use these products. Particularly, for example, nonsmokers don’t need to start. There’s no role for adolescents to be using this product. Pregnant women shouldn’t. If you are an ex-cigarette smoker that has converted to these products, we’re now recommending that you seriously consider switching to an FDA-approved nicotine cessation product, because there are a number of those, and to refrain while we’re trying to understand.
I do not believe this is a single causation. I think there is something intuitive about allowing a lot of foreign products to get deeply into your lungs that may have changed their nature because of a very high temperature before they go into your lungs that could cause damage to your lungs. I don’t think it’s rocket science to think that may be the case.
I caution people from jumping to conclusions that they know that it’s THC or that they know it’s vitamin E acetate. I think until we complete a really extensive evaluation, we should assume that the different particulates that may be associated with the current vaping products carry a significant health risk.
WebMD: The FDA said in congressional testimony yesterday that they’re going to start enforcement actions against flavored e-cigarettes. Why just flavors? Is that enough? For that matter, what about cigarettes?
Redfield: For us, right now, and we’ve been part of it, a lot of this action is based on our youth survey. There was an assumption that these e-cigarette products had a significant public health benefit by allowing cigarette smokers an off-ramp, but I want to stress that’s an assumption. There really isn’t any comprehensive data to show that they’re somehow safer than combustible cigarettes. I think that’s the first thing to highlight.
What was disconcerting about the first survey, when we added these questions the first year I was CDC director, is the number of middle schoolers and high schoolers who are now using these products. It’s now over 6 million. These products deliver much more nicotine than cigarettes do.
We’re in the public health crisis of our time with the drug use disorder and opioid epidemic. Nicotine is also an addictive drug. Our concern is that we have a whole generation of literally children -- I’m going to call them children -- using these products who are now becoming nicotine-addicted. When we did these surveys, the data shows the flavor of choice was menthol/mint. There was a lot of push to take off the juicy fruit and the bubble gum products. Menthol and mint, there was this issue where there are a lot of adults who were using those, it might dissuade adults from transitioning, although there’s no evidence that that’s necessarily safer. We would argue that adults should transition to FDA-approved products.
I think this is a stepwise process, clearly going to where we have data that these products are negatively influencing individuals under the age of 18. I think our biggest interest is to stop our next generation from becoming chronically addicted to nicotine. As I said, nicotine has a negative impact on development of the brain. It is poison. So that’s why the initiative is all flavored products.
Whether it goes further than that or not is going to depend on these investigations. I won’t be surprised that the overall waiver for these products, I think there’s a timeline when that waiver comes to an end, then there will be a requirement to show public benefit and safety.
I actually think this is the most important public health decision that’s been made to date by our administration, to get these products off the market.
WebMD: So just to be clear, in getting these products off the market, you’re trying to protect kids. Kids are the ones using the flavored e-cigarette products, according to the data you have.
Redfield: The data we have right now is that these products are being used inappropriately because they’re not supposed to be sold to children. But clearly they are an attraction. When we look at the data by users, if I did cigarette smoking and I took a group of 14-, 15-, 16-, 17-year-olds, there would be more males using these products than females. For e-cigarettes, it would be equal. For vapers, men and women are equal. They’re equal across the country. They’re equal by race. They’re equal by socioeconomic status. This is very different than if you were to look at other tobacco-containing products.
In general, this should teach us all a lesson that we shouldn’t assume things are safe. We should probably want to have data to show that there’s public benefit and safety before we have wide-scale distribution. CDC is not a regulator, so we defer to the FDA. Our role is basically gathering the data.
WebMD: How long-lasting are these injuries? Do we have any sense of the prognosis for kids who come in, basically, in crisis?
Redfield: The answer is that we’re trying to gather that information. Obviously, a number of these kids have been so sick that they’ve had to be in the intensive care unit requiring respiratory support. Some have died. Whether this lung injury is reversible or not, I would just be speculating, and that’s not my role. We’re going to get the data to try to determine this.
About a week after I became CDC director, one of my grandsons, Jack, who was 13, put his finger in my chest and said “Granddad, you’re the CDC director. You need to get vaping out of my school. Half the kids are vaping.” I didn’t even know what vaping was. He told me the school had changed because they were using these new devices that looked like a jump drive, and the teachers didn’t know who had a vaping device, who didn’t. His brother has cystic fibrosis, so we’re very cognizant of trying to maintain lung function.
WebMD: Do we have any sense of what kind of flu season we might be in store for?
Redfield: It’s very difficult to predict flu. I think I’m just going to say that the best thing we can all do is make sure to get the vaccine. We work very hard, all year long, trying to figure out what the right viruses are to put in that vaccine. We have virus sampling sites all over the world. CDC plays a critical role in helping figure out what three or four viruses are in the vaccine.
So it’s frustrating for us when we do all that and half the American people don’t even choose to get vaccinated. I can only just continue to urge the American people to get vaccinated. Some of them say they don’t get vaccinated because the vaccine doesn’t work all the time, and they’re right. The vaccine efficacy has been as low as 25% and as high as 60% for different types. So that means you still might get the flu, but people miss that it could influence the severity of the flu. Among children, we have very strong data that it could prevent children from dying from the flu. So, a lot of people don’t realize that in the last 10 years, we had 360,000 people die of the flu in this country. So I keep trying to tell people to get vaccinated.
But I can’t predict. Who would have predicted that last year’s flu season would have lasted so long? We finally got a second wave, and the season went all the way to May. It’s time to get vaccinated. It’s the perfect time to do it this week.
WebMD: I was going to ask you about that. It’s so early this year. I got a text back in August by my pediatrician’s office saying ‘It’s time to get your child a flu shot.’ It’s flu season already?
Redfield: It’s flu season already.
WebMD: Why so early this year?
Redfield: I really do think this is the right time to get vaccinated. The last 2 weeks of September through the end of October. There’s a lot of debate about it. If it’s a late flu season, will the antibody be as protective later? I think really this is the time to get vaccinated. My wife got vaccinated 2 weeks ago. I think if you watch the news tonight, you might see somebody else very prominent got vaccinated today in public.
WebMD: Who decides when it’s flu season? Or flu shot season? Who makes that call?
Redfield: That’s a good question. In general, we look at vaccination time frame from late August to October. I am an advocate that this is the time to get vaccinated.
WebMD: I want to ask you about measles and the possibility that we could lose our measles-free status. What’s the process for determining whether transmission is endemic here again?
Redfield: If we have ongoing transmission in this country for greater than 1 year, then we could lose our measles elimination status.
WebMD: I think we’re close in New York.
Redfield: We’re very close. Great Britain lost theirs a couple of weeks ago. We’re very close. October 2 or October 4. New York state is where the eyeballs are.
WebMD: What will it mean if we do lose it?
Redfield: It’s a step backwards. It’s what I talk about all the time, about having the tools on the shelf and we’re not effectively utilizing them. There’s no reason for us to have measles. It’s preventable. We need to operationalize. It’s a warning sign. If we lose measles, we could lose other things. We really need to use this as a high sign that we need to really get serious about reengaging the American public and the advantage of vaccination as the key to preventing or eliminating disease. My own view is to change the hearts and minds of all people that they don’t want to leave vaccination on the shelf. They want to put that science into action to protect themselves and their communities.