SIOUX FALLS, S.D. — Health officials across the Midwest and the nation are on alert to more evidence of what federal and state officials are calling an outbreak of a lung illness possibly linked to vaping.

North Dakota officials on Wednesday, Sept. 4, said they received a report of someone falling sick with breathing issues, potentially in connection with vaping. They're asking health care workers to be on the lookout for more cases.

The North Dakota case the latest in a raft of reports from 25 states, including Minnesota, that have reported more than 200 potential cases of severe respiratory illness possibly linked to the use of e-cigarettes. South Dakota has issued updates about the matter to its health care providers, but has yet to report a case in the state.

“As people call in with these reports, we will continue to gather data in an effort to find answers and linkages,” said Dr. Tracy Miller, state epidemiologist with the North Dakota Department of Health, in a Wednesday news release. “We’re working closely with the CDC on the national outbreak.”

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The Centers for Disease Control and Prevention says its investigation into the string of incidents is ongoing. The CDC announced the first death related to the outbreak, in Illinois, on Aug. 23. By last week, 215 possible cases had been reported from 25 states, with more under investigation, the CDC said.

"We were deeply saddened last week to learn of the death of an adult in Illinois who had been hospitalized with a severe respiratory illness following the use of an e-cigarette product," said CDC Director Dr. Robert R. Redfield and Acting Food and U.S. Food and Drug Administration Commissioner Dr. Ned Sharpless on Friday. "We are working closely with state and local health officials to investigate these incidents as quickly as possible, and we are committed to taking appropriate actions as a clearer picture of the facts emerges."

The CDC said it is trying to gain a more comprehensive picture of all the incidents, including what devices were used, where they were bought and what substances were inhaled. It has tested 80 samples so far.

The American Vaping Association, a nonprofit lobbying organization supported by the vaping industry, said "street vapes" containing THC and other illegal drugs were responsible for the illnesses, including the Illinois death — not nicotine vaping products.

“It is incredibly irresponsible for media outlets and health authorities to continue to focus on vaping products generally when we know that tainted, black market THC products remain on the streets," said Gregory Conley, president of the AVA in an Aug. 23 statement.

The CDC said in "many cases," patients acknowledged recent use of e-cigarettes containing THC, the main psychoactive compound in marijuana. But health officials also reported use of nicotine-based products in the illness cases linked to vaping.

What to look for

Reported symptoms of the potentially vaping-linked illness include cough, fatigue, dizziness, fever, headache, vomiting and diarrhea, chest pain, and shortness of breath, say the CDC and health departments in North Dakota and Minnesota, with some patients requiring intensive care. Some patients who were administered antibiotics didn't have a "positive response," the North Dakota Department of Health Department said.

The CDC recommends all e-cigarette users who experience these symptoms to avoid e-cigarettes and other vaping products and should seek prompt medical attention. Health care providers are asked to be on the lookout for symptoms and histories similar to the reported cases, consider consulting a pulmonologist and refer potential cases to state health officials.

“The current cluster of pulmonary-related illnesses linked to vaping in multiple states is alarming and deeply concerning," said the American Lung Association Chief Medical Officer Dr. Albert Rizzo in an Aug. 23 statement. He noted the U.S. surgeon general had called youth use of e-cigarette an epidemic and the association has raised the alarm about e-cigarettes and their use for a decade.

In Minnesota, doctors 'deeply concerned'

The Minnesota Department of Health on Aug. 13 asked health care providers to be on alert for what it called "novel cases" of severe lung disease related to vaping.

Children's Minnesota reported four cases in the Minneapolis-St. Paul metro area, similar to cases reported in Wisconsin and Illinois, though the department said it was too early to say the cases were connected.

“We are deeply concerned by the severe cases of lung injury associated with vaping that we are currently seeing,” said Dr. Emily Chapman, chief medical officer at Children’s Minnesota, the Minneapolis-based pediatric health network, in a news release from the Minnesota Department of Health. “These cases are extremely complex to diagnose, as symptoms can mimic a common infection yet can lead to severe complications and extended hospitalization. Medical attention is essential; respiratory conditions can continue to decline without proper treatment.”

Nearly one in five high school students use e-cigarettes and two in five have tried them, according to the 2017 Minnesota Youth Tobacco Survey. About one-third of high school students and 15% of middle school students who use e-cigarettes have used an e-cigarette for recreational marijuana, THC or hash oil, or THC wax at least once, the survey found.

Effective Aug. 1, state law banned the use of e-cigarette and other vaping products where cigarette use is prohibited, including bars and restaurants.

In South Dakota, on alert but no cases yet

South Dakota has no confirmed cased to report, said Derrick Haskins, spokesman for the state Department of Health. But the department is passing on updates and information from the CDC to health care providers in the state through its health alert network.

Nearly one in five South Dakota high school students used e-cigarettes in 2015, while about one in 10 smoked traditional cigarettes, according to an informational handout from the Health Department. Only 2% of adults used e-cigarettes according to the handout.

South Dakota lawmakers this year passed legislation banning the use of e-cigarettes and other vaping products from nearly all workplaces and public buildings in the state. That law went into effect July 1.