BOSTON — As the Centers for Disease Control and Prevention investigates a multi-state outbreak of lung disease associated with the use of e-cigarette products, Massachusetts Public Health Commissioner Monica Bharel has mandated that vaping-related illnesses be immediately reported to the Department of Public Health for the next 12 months.

At the same time, President Donald Trump held a discussion about vaping with Health and Human Services Secretary Alex Azar, acting Food and Drug Administration chief Norman Sharpless and First Lady Melania Trump in the Oval Office.

"We are looking at vaping very strongly," Trump told reporters afterwards. "It's very dangerous. Children have died, people have died."

Azar said a guidance will be issued in the next "several weeks" requiring that flavored e-cigarettes -- other than tobacco-flavored ones -- be removed from the market. Manufacturers of tobacco-flavored e-cigarettes would have to file for FDA approval by May of 2020, he said.

Commissioner Bharel told the state's Public Health Council that the move will allow the department to provide case counts to the CDC, help public health officials understand the magnitude of the situation in Massachusetts, and shape what steps the state takes next, Bharel said.

The DPH said Bharel's action was "not rare" but also "not routine." She last issued such a mandate two years ago, requiring providers to report cases of amnesia associated with intravenous drug use, the department said.

The CDC said its investigation, conducted with the FDA, state and local health departments and other partners, "has not identified any specific substance or e-cigarette product that is linked to all cases" and that "many patients" have reported using e-cigarette products with liquids containing cannabidiol products, such as THC.

As of Sept. 6, more than 450 possible cases of lung illness associated with e-cigarette products had been reported to the CDC from 33 states -- a list that includes Vermont and Massachusetts -- and the U.S. Virgin Islands. Five deaths have been confirmed in California, Illinois, Indiana, Minnesota and Oregon, according to the CDC.

Under a law Gov. Charlie Baker signed in July 2018, e-cigarettes cannot be sold in Massachusetts to people under the age of 21. Vaping is also banned in places where it is illegal to smoke.

Michigan earlier this month became the first state to ban flavored e-cigarettes. Both taxes and flavor restrictions have been proposed on Beacon Hill as a way to help curb what advocates describe as a vaping epidemic among youth.

Baker in January proposed extending the state's tobacco tax to vape and e-cigarette products, a provision the Senate went along with but that was dropped by the group of House and Senate lawmakers who assembled the final version of this year's budget.

Flavor-ban bills filed by Rep. Danielle Gregoire and Sen. John Keenan (H 1902, S 1279) remain before the Public Health Committee, which had a hearing on them in July.

"I'm glad to hear Commissioner Bharel and DPH will be collecting information from clinicians on the increasing number of lung disease cases associated with vaping in Massachusetts," Keenan, a Quincy Democrat, said in a statement to the News Service. "As more and more evidence piles up across the country that these products are harmful for your health, we cannot be careful enough. These products are completely unregulated and they’re making people very sick. And our kids are getting their hands on these products at six times the rate of adults. We need to do everything we can to protect the health and safety of the next generation, and this is another step in doing so."

On Aug. 28, the Massachusetts Department of Public Health sent an alert to 25,000 health care providers -- including internists, pediatricians, doctors in general and family practice, pulmonologists, emergency medicine and critical care providers, nurse practitioners and physician assistants -- requesting that they "report cases of significant, unexplained respiratory illness and a history of vaping to the state health department."

Bharel said her mandate on Wednesday takes that request a step further, and that the department has begun hearing from clinicians since the alert was issued.

The Kansas Department of Health and Environment on Tuesday reported a sixth death, a resident of that state older than 50 who had underlying health issues.

The CDC is recommending that members of the public consider avoiding e-cigarette products while the investigation is ongoing, and that anyone who experiences symptoms like those reported promptly seek medical care.

In a statement released Monday, the American Medical Association made a similar recommendation and urged the FDA to ban e-cigarette flavors and "speed up the regulation of e-cigarettes."

"The e-cigarette-related lung illnesses currently sweeping across the country reaffirm our belief that the use of e-cigarettes and vaping is an urgent public health epidemic that must be addressed. We must not stand by while e-cigarettes continue to go unregulated," AMA President Patrice Harris said in the statement.

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