This article is part of the special report: The Big Vaping Dilemma.
The patient was gasping for air and the emergency room doctors werent sure why.
The 34-year old woman entered Birmingham Heartlands Hospital in England in respiratory distress, breathing fast and hard as she tried to move oxygen through her lungs. She winded easily and had been coughing a lot over the past few months. Sometimes her phlegm was white. Sometimes it was streaked with blood.
When Gareth Walters, the National Health Service respiratory doctor assigned to her case, listened to her lungs, everything sounded normal. There was none of the tell-tale “crackling” — akin to the sound of walking in fresh snow — to indicate inflammation. Blood tests showed her kidney and liver function were normal, and none of her existing health problems could explain why she couldnt take a full breath.
But then there was the fact that she had recently quit smoking cigarettes.
The woman had smoked up to 40 cigarettes a day for five years but switched to e-cigarettes a few years earlier. After several months and an array of tests, Walters and his colleagues found her lungs were “filled with little fat particles” — a condition known as lipoid pneumonia. Previous cases had been reported in circus performers who eat fire, but for this patient there was one likely source: the liquid in her e-cigarettes.
More than 7 million people will die from tobacco-related causes this year, equivalent to the population of Bulgaria.
The womans ailment — what Walters described as an extremely rare consequence of vaping — is an illustration of the dilemma facing policymakers are they grapple with e-cigarettes. How should they approach a technology thats safer than traditional cigarettes but with possible harmful effects of its own. Are e-cigarettes helpful or harmful?
The answer, it turns out, depends largely on whos doing the vaping.
“There are a variety of weird and wonderful lung diseases that any exposure [to chemicals] can cause, but generally there are small numbers of people [affected],” said Walters. “For the most part, these chemicals and substances [in e-cigarettes] at low and controlled levels, for most of the population, are relatively safe.”
Its that word — “relatively” — thats come to dominate the debate over e-cigarettes.
A man exhales a cloud of vapors | Niklas Hallen/AFP via Getty Images
Proponents of vaping technology describe it as a “less harmful” alternative that could improve the health and quality of life of the worlds smokers — 1.1 billion ticking time bombs for chronic heart and lung diseases, cancers and premature death. More than 7 million people will die from tobacco-related causes this year, equivalent to the population of Bulgaria.
Critics respond that, while theres some evidence they could help smokers quit, the overall risk to society — particularly to youth and non-smokers who stand to become addicted — is too great.
E-cigarettes may not contain tar or rat poison or a host of other chemicals found in cigarettes, but they do contain nicotine, a highly addictive substance, which could turn many users into lifelong vapers.
There are also concerns that vaping could renormalize smoking, undoing decades of tobacco cessation efforts from governments and health care campaigners.
The response by policymakers, so far, is fragmented. While the U.K.s health system is pushing e-cigarettes as a smoking cessation tool, U.S. regulators have declared youth vaping an “epidemic” and cracked down on sales to kids, and Australia and Japan have imposed bans.
Research scientists, epidemiologists and public health experts studying e-cigarettes are equally divided.
The (uncertain) promise
Much of the harm from cigarettes is the result of combustion. Along with their nicotine hit, smokers inhale clouds of toxins and carcinogens, as the cigarette burns at up to 900 degrees Celsius.
E-cigarettes work differently, heating a tank of liquid to around 200 degrees Celsius, forming tiny aerosolized particles the user inhales as a vapor. The liquid contents varies depending on the manufacturer, but the main components are generally nicotine, propylene glycol, vegetable glycerin and added flavoring.
“Its not rocket science that vaping causes less damage to the lungs than inhaling radioactivity from tobacco,” said David Nutt, a neuropsychopharmacology professor at Imperial College London.
In 2013 Nutt convened a meeting in London to evaluate the relative harms of a range of nicotine-containing products, using whats known as a multi-criteria decision analysis. The group evaluated each product along 14 weighted harm criteria — the possibility of causing disease counted significantly more than the potential for lost relationships with family or friends.
There is evidence that people who used e-cigarettes for six months had significantly lower levels of carcinogenic substances in their systems than people smoking combustible cigarettes.
“This process is remarkably powerful. That is why companies, businesses and governments use it to make decisions where there isnt as much evidence as they would like. There is no better way of estimating uncertainty,” Nutt said. “Its the best way of directing policy.”
The number Nutts group came up with — that vaping is 95 percent “less harmful” than smoking combustible cigarettes — was later endorsed by Public Health England, a government agency that advises on health care issues. Its a powerful conclusion that has loudly resonated.
But the conclusion is not without its share of critics, who have taken aim at the process and questioned the disclosed ties to the e-cigarette industry of one of the participants, as well as the funding.
“Its total bullshit,” said Stanton Glantz, a professor who runs the Center for Tobacco Control Research and Education at the University of California San Francisco. “It was 12 people, who got in a room and scratched their butts and came up with that number. Theres no data in that paper.”
A man exhales vapour | Justin Sullivan/Getty Images
Still, there is evidence that people who used e-cigarettes for six months had significantly lower levels of carcinogenic substances in their systems than people smoking combustible cigarettes.
Lion Shahab, a professor of behavioral science and health at University College of London, and his colleagues recruited smokers, vapers and people using nicotine replacement therapies to compare the levels of known carcinogens and toxins found in cigarettes, such as NNAL, a chemical found in the body after exposure to tobacco that is linked to lung cancer.
The results, published in the Annals of Internal Medicine, showed long-term e-cigarette users had a more than 97 percent reduction in levels of NNAL. The vapers also showed much lower levels of several other toxins specific to tobacco, ranging from 57 percent to 89 percent less than smokers.
These so-called biomarkers function as a “proxy for disease” in the absence of long-term data, Shahab said.
“When you look at these indices of subsequent disease risk, theyre much lower in people who use e-cigarettes than people who continue to smoke,” he said.
Looking scarier every day
Biomarkers offer a picture of whats happening inside individual patients. Epidemiological studies indicate whats happening across the population at large — and some of those have flagged worrying trends.
There arent yet any long-term studies tracking the health of cohorts of e-cigarette smokers, but researchers can use a different method — comparing recent users with people who smoke and those who abstain — to come up with an approximation of the relative risk.
Glantz, a well-known vaping critic, developed a model showing people who use e-cigarettes daily are at greater odds of having a heart attack by a factor of 1.79. The study, published in the American Journal of Preventive Medicine, found an association but didnt prove a causal link.
Anti-tobacco campaigners worry that e-cigarettes will roll back their efforts.
“These things are very dangerous,” Glantz said. “Theyre exposing people to nicotine, ultra-fine particles, to agents, aldehydes, like formaldehyde.”
Glantz said other studies have highlighted the possibility of increased risks of strokes, asthma and other respiratory and cardiovascular diseases among people who use e-cigarettes.
“Science takes a long time, and people are always very skeptical,” he said. “But to me, the picture thats emerging is very consistent and looking scarier every day.”
Critics also point to a societal cost of introducing a new, addictive product, even one thats likely less harmful than tobacco.
Anti-tobacco campaigners have worked for decades to get smoking banned from airports, offices, restaurants and bars. They worry that e-cigarettes will roll back their efforts. Smoke from combustible cigarettes is obvious — you can smell it, see it and it lingers in your hair and clothes. Vaping is largely invisible. E-cigarettes are odorless except for occasional whiffs of some of the flavorings, which is like standing next to someone sucking on a cherry lollipop.
Tobacco companies are taking a different approach toward regulators with e-cigarettes than they did with traditional cigarettes | Fabrice Coffrini/AFP via Getty Images
Others point to vapings allure to young people, as products, such as Juul, which resemble a USB stick, sweep through schools in the United States.
Nearly 21 percent of U.S. high school students said they had used an e-cigarette atRead More – Source
Spain’s coronavirus incidence rate falls for the first time this year, but pressure on ICUs rises
The third wave of the coronavirus has pushed Spain to the breaking point. According to the Spanish Health Ministry’s latest report, released on Thursday, the country has started to flatten the curve of new infections, but it has done so at crisis levels, with pressure on hospitals, especially in intensive care units (ICUs), close to unbearable. This pressure continues to rise across almost all of Spain.
The last 10 months of the pandemic have shown that there is not one but various peaks in a wave. The first is the number of new infections. The second is the spike in hospital admissions, which tends to happen a week later, and takes a little longer to be reflected in ICU figures. The final peak, which indicates a change in trend, is the number of deaths. The Health Ministry added 515 fatalities to the official count on Thursday, a terrible toll that is likely to remain at these levels for days to come while Spain transitions from peak to peak.
The latest data indicates that Spain is starting to see the other side of the peak of new infections in the third wave. A week ago, the Health Ministry reported a record-high 44,357 new coronavirus figures. On Thursday, that figure fell to 34,899. It is also the first day this year that the national incidence rate has fallen: the 14-day cumulative number of cases per 100,000 inhabitants now stands at 890, down from 900 on Wednesday.
Hospital admissions fell for the first time this year on Wednesday, with the percentage of Covid-19 patients in hospital wards dropping to 24.10%, down slightly from 24.03% on Tuesday. This data point fell again on Thursday, although the drop was again only marginal. But pressure continues to mount in Spain’s ICUs, which are the last line of defense of the healthcare system. If they are overwhelmed, authorities may be forced to introduce tougher restrictions, such as home confinement. Making matters worse, the pressure on ICUs is rising amid the uncertainty over how the emergence of new, more contagious strains of the coronavirus, such as the B.1.1.7 variant detected in the United Kingdom, will impact the pandemic in Spain.
“According to the data we have, we can expect that it [the B.1.1.7 variant] will be the dominant one in Spain by the end of February or the first fortnight of March. This has some implications because the strain is more transmittable,” said Fernando Simón, the director of the Health Ministry’s Coordination Center for Health Alerts (CCAES), at a government press conference on Thursday. The health official previously said this would not happen until a later date.
Simón admitted that there are small areas in Spain where the new strain already accounts for 20% of cases, but said nationally this figure was “around 8%.” With respect to restrictions, the health official said that “the measures that must be taken” are the same for the new and old variants of the coronavirus. “More measures can still be implemented without modifying the state of alarm,” he said, in reference to the emergency decree that gives regional governments – which are responsible for managing the health crisis – the power to introduce measures such as perimetral lockdowns, but not home confinement.
The figures released on Thursday also do not reflect how the coronavirus situation differs between each of Spain’s 17 regions. Indeed, the fall in hospitalizations over the past two weeks is mainly due to improvements in two regions: Valencia (which, despite this, remains in a “very critical situation,” said Simón) and Catalonia, which reported 466 fewer occupied beds on Thursday than on Tuesday. In Castilla y León, Galicia and Andalusia, there continue to be more hospital admissions than discharges.
“There are 11 regions where the situation is stabilizing or on a downward trend, but this is not the same as a fall in the hospital occupancy rate. The pressure on hospitals will continue over the coming days,” said Simón.
Andalusia and Galicia, as well as Murcia and Valencia, are some of the regions that are being hardest hit by the third wave of the pandemic, with the situation even worse than what it was during the first wave.
The big problem continues to be in ICUs. On Thursday, the Health Ministry reported 97 more ICU admissions than on Wednesday, and no region has managed to clearly reverse the upward trend. In other words, the peak of ICU pressure is still to come. In more than half of Spain, Covid-19 patients occupy more than 40% of all ICU beds – a similar figure to all other diseases combined. In the Balearic Islands, Castilla y León and Extremadura, the occupancy rate is more than 40%; in Castilla-La Mancha, Catalonia, Madrid and La Rioja, it is more than 50%; and in Valencia, it is 63%, a record high not seen since April last year, during the first wave.
As experts warned, the source of the problem is that Spain entered the third wave – which started after the December 6 long weekend – before the second wave was over. This meant that the ICU occupancy rate of Covid-19 patients, which was below 15% in October when the number of new cases began to rise, was already at around 30% in some regions when the third wave hit.
Covid-19 vaccine doses going to waste in some of Spain’s regions due to unsuitable syringes
Spanish regions such as Andalusia, Catalonia and Madrid are wasting thousands of doses of the Pfizer-BioNTech Covid-19 vaccine by not injecting patients with the sixth dose contained in the vials. Since January 8, when the European Medicines Agency granted authorization, the five initial doses contained in the vials are now officially six, increasing the number of potential recipients.
But this change has not been exploited by a number of Spain’s territories, who are in charge of their own vaccination campaigns. Speaking on Thursday in the regional parliament, Andalusia’s health chief Jesús Aguirre admitted that this was the case. “You could take out up to five doses and there was a wee drop left, and that little bit is used to administer that sixth dose,” he said. “But we are talking about 20% more vaccinations.”
The Andalusian regional government has blamed the failure to use this dose on a “deficit of 0.1-millimeter syringes,” the type that is usually used to inject insulin or in pediatrics, and has promised to solve the issue. The extraction of the sixth dose is more difficult with the 0.2-millimeter syringes also being used to administer the vaccines.
Based on the information offered by Spain’s regions, it is impossible to calculate how much of the vaccine has been wasted. Catalonia, for its part, has admitted it is only using the sixth dose from “two-thirds” of the vials. The region has administered more than 165,000 doses of the Pfizer-BioNTech vaccine so far, which would suggest wastage of around 10,000 doses.
A similar situation is playing out in Madrid, which on Thursday announced the purchase of 280,000 syringes in order to take advantage of this sixth dose. This is a low amount, however, compared to the millions of suitable syringes that have been purchased by regions with a much smaller population, such as Murcia and the Balearic and Canary Islands. The Madrid region has stated that in “the majority of cases” it is managing to use the sixth dose, but it has offered little extra information.
Aragón, which purchased 1,870,000 syringes in September, says that it has managed to use “100% of the first five doses from each vial and 81% of the sixth, which is 97% of the total.” Castilla-La Mancha, meanwhile, puts the percentage at 90%, while Asturias, Castilla y León and the Basque Country opted not to provide figures when consulted by EL PAÍS. The rest of the regions, however, stated that the use of the sixth dose is widespread across their territories.
Meanwhile, Spain’s regions are having to improvise a response to news that politicians, retired health workers and relatives of medical staff are jumping the line and receiving the Covid-19 vaccine ahead of their time. Currently, Spain is still in the first stage of the vaccination campaign, which is focussing on senior home residents, their carers, front-line medical workers and adults with serious disabilities.
The Health Ministry and the country’s regions have been working on the vaccination plan since September, but the scheme has failed to adequately set out how the order of the vaccinations should be supervised, and whether there should be some kind of sanction or punishment for those who jump the line or indeed what to do with unused doses.
The excuses offered so far by those who have got the vaccine early range from “wanting to boost confidence” in the vaccination, to claims of making use of “leftover doses.”
EL PAÍS has requested information from the country’s health departments as to the measures being taken against these irregularities. The majority have not responded. Extremadura, Madrid and Navarre claim that they are observing protocols, while Valencia, La Rioja, Andalusia and the Basque Country explain that they are cross-referencing databases: anyone who is found to have been given the vaccine despite not being on the list of phase one recipients must offer an explanation.
Health Minister Salvador Illa said this week that “proper planning” must be put in place to avoid wasting injections, adding that any sanctions for breaking protocol are the responsibility of the regions. For now, none of Spain’s regional governments have confirmed whether or not they have levied sanctions against offenders.
No second dose
One decision that has been made, however, is that Valencia is opting not to administer the second vaccine dose to anyone who has jumped the line. This includes, for example, the Socialist Party (PSOE) mayors of the municipalities of El Verger, Els Poblets and Rafelbuñol, who were found to have skipped the protocol and were given the vaccines in senior homes.
The PSOE premier of the region, Ximo Puig, has taken the decision not to administer the second dose to the 150 to 185 people thought to have jumped the line. They will instead be fully vaccinated when it is their turn, he insisted.
But Fernando Simón, the director of the Health Ministry’s Coordination Center for Health Alerts (CCAES) and the government’s most visible face during the coronavirus crisis, criticized the approach. “I understand that people who were vaccinated when they shouldn’t have been should admit their responsibility,” he said when asked by reporters about the incidents. “But from my point of view, I believe it would committing two errors: vaccinating people ahead of time and not administering the second vaccine.”
The issue is whether it is worse to waste the first dose by not giving the second one 21 to 42 days later, as stipulated by the manufacturer, or to fully immunize those who jumped the line. The Pfizer-BioNTech vaccine needs two doses for the recipient to develop 94% immunity to Covid-19, according to clinical trials. The regional government has said that it respects Simón’s opinion but that this was “a matter of institutional credibility.” The aforementioned mayors who jumped the line have been suspended from the party and their local councils will be deciding whether or not they should be fired.
Coronavirus cases in Spain officially top two million
The number of coronavirus cases recorded in Spain since the beginning of the pandemic officially exceeded two million on Thursday, amid warnings of difficult weeks ahead. According to the Health Ministry’s latest report, all data points clearly indicate that the pandemic continues to follow an upward trend. Thursday’s report – which also included figures from Wednesday as it was a public holiday (the Health Ministry does not release data on holidays or over the weekend) – registered 42,360 new coronavirus cases. The 14-day cumulative number of cases per 100,000 inhabitants now stands at 321, up from 296 on Tuesday. The number of Covid-19 patients in hospital and intensive care units (ICUs) rose by 1,514 and 134, respectively. Thursday’s report added 245 Covid-19-related deaths to the official toll.
But the Health Ministry does not believe the rising trend will impact the return to school, which has already happened in some regions, and will begin on Monday in others. When asked about the possibility of closing schools on Thursday, health official María José Sierra replied: “We do not recommend it.”
“It [schools] is one of the areas that have worked best, where there has been the most control. There were no outbreaks,” said Sierra, from the Health Ministry’s Coordination Center for Health Alerts (CCAES), who was standing in for the center’s director, Fernando Simón. The health official highlighted the enormous social and learning impact of closing schools and said that any new measures would target sectors that are hubs for contagions.
On the question of a new home lockdown, which has been introduced in countries like the United Kingdom, Sierra replied: “There are many measures to take before a strict confinement.” The health official defended the use of partial restrictions, like perimetral lockdowns and limits on social gatherings, which “proved their effectiveness” during the second wave of the pandemic. On November 9, Spain recorded its highest incidence rate when the 14-day cumulative number of cases per 100,000 inhabitants reached 529. The incidence rate began to fall after that date until rising again at the beginning of December.
It is important to note that Thursday’s report recorded a 25-point rise in Spain’s incidence rate even though the 14-day cumulative number includes three public holidays (Christmas, New Year’s Day, King’s Day), when there is typically underreporting. What’s more, fewer PCR and antigen tests have been carried out: while 140,000 tests were being done every day in the middle of December, between December 28 and January 3 – the last week with complete data – only 110,000 tests were administered in the entire week.
With fewer tests being done – most of which are carried out on patients with symptoms –, the positivity rate i.e. the percentage of tests that come back positive out of the total, has also risen. While 20 days ago this figure stood at 8%, it rose to 13.5% last week and to 15.6% on January 4. But experts warn the rise suggests that many chains of transmission are going undetected.
“It is a trend that is worrying us,” said Sierra on Thursday, who added that the weekly positivity rate exceeded 15% in five regions and 20% in three. “Among suspected cases diagnosed in primary healthcare centers, [the positivity rate] is already close to 30%,” she added.
According to Thursday’s report, Extremadura has the highest incidence rate in Spain, recording a 14-day cumulative number of cases per 100,000 inhabitants of 717. It is followed by the Balearic Islands (529) and Madrid (452). Asturias, Andalusia and the Canary Islands are the only regions where the incidence rate is below 200.
Hospital and ICU admissions – considered one of the most objective indicators of the pandemic – also rose significantly since Tuesday. A total of 14,543 Covid-19 patients are currently admitted to hospital, occupying 11.9% of all hospital beds. The occupancy rate in ICUs is 24%, with 2,307 patients in intensive care.
Sierra confirmed that Spain has detected nearly 50 cases of the new, more contagious strain of the coronavirus that was discovered in the United Kingdom, while many more cases are being studied.
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