Hrev_master Abstract During coronavirus disease 2019 (COVID-19) pandemic, Iran experienced the largest methanol mass poisoning outbreak in the history. Despite advancements in the diagnosis and treatment of Methanol Poisoning (MP), mortality rates remain high. In light of the geographical location and increased travel to this northern province, coupled with the rising consumption of illicit and home- made alcoholic beverages and the associated incidence of methanol poisoning, we undertook an analysis of the demographic characteristics, diagnostic procedures, and treatment approaches among patients hospitalized in five designated hospitals within the region. The data collection period for this study spanned from March 2020 to September 2021. This retrospective and descriptive cross-sectional study is a multicenter study in the western part of Mazandaran province over the initial 18 months of the pandemic to provide a more comprehensive view on MP patients. The diag- nosis was based on several factors, including a history of alcohol consumption, visual impairment, altered level of consciousness, and the presence of metabolic acidosis in laboratory tests. The study included 82 patients diagnosed with MP, comprising 74 males (90.2%) and 8 females (9.8%), with an average age of 38.20 ±13.9 years. The majorities (76.8%) resided in urban areas, and most were self-employed. Blurred vision and metabolic acidosis were observed in the majority of the patients. Oral ethanol and dialysis were the primary treatment employed for our patients. Visual complications and severe metabolic acidosis are commonly linked to poor outcomes in MP. A comprehensive analysis of MP patients revealed no significant correlation between treatment type, patient demographics, and outcomes, highlighting the com- plex and multifaceted nature of this condition. Introduction During the initial months of the coronavirus disease 2019 (COVID-19) pandemic, there were reports of methanol mass poi- soning outbreaks in Iran, the United States, and Turkey.1-5 In Iran, at least 5,876 patients with a mortality rate of 13.61% were report- ed poisoned in over half of the country’s provinces, marking the largest Methanol Poisoning (MP) outbreak in the history.2, 6 Children were also reported as being affected by this outbreak.4 In Iran, the lack of access to legal and safe alcoholic beverages, along with the shortage of methanol-free sanitizers, and misconceptions about the preventive effects of consuming or gargling alcohol against COVID-19 are considered to be among the main caus- Emergency Care Journal 2025; volume 21:14009 [Emergency Care Journal 2025; 21:14009] [page 27] Methanol poisoning during COVID-19 pandemic: a multicenter study of northern Iran Jamileh Divsalar,1 Seyed Khosro Ghasempouri,2 Zahra Nekoukar,3 Amir-Hassan Bordbari,1 Zakaria Zakariaei4 1Student Research Committee, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari; 2Department of Forensic Medicine and Toxicology, School of Medicine, Mazandaran University of Medical Sciences, Sari; 3Department of Clinical Pharmacy, Faculty of Pharmacy, Shahid Sadoughi University of Medical Sciences, Yazd; 4Department of Forensic Medicine and Toxicology, Mazandaran Registry Center for Opioid Poisoning, Orthopedic Research Center, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran Correspondence: Zakaria Zakariaei, Department of Forensic Medicine and Toxicology, Mazandaran Registry Center for Opioid Poisoning, Orthopedic Research Center, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, P.O box: 48166- 33131, Iran. E-mail: ali.zakariaei@yahoo.com Key words: alcohol consumption, methanol poisoning, COVID-19, metabolic acidosis, dialysis. Conflicts of interest: the authors have no conflicts of interest to declare. Funding: the Mazandaran University of Medical Sciences funded the study. The funder had no role in designing the study, collecting, analyzing, and interpreting data, or writing the manuscript. Contributions: ZZ, JD are involved in the interpretation and collect- ing of data, writing, and editing of the manuscript. SKhGh, ZN were involved in editing and preparing the final version of the manuscript. AHB submitted of the manuscript. All authors reviewed the paper and approved the final version of the manuscript. Ethics approval: this research was approved by the Mazandaran University of Medical Science Ethics Committee (No: IR.MAZUMS.IMAMHOSPITAL.REC.1400.094) and was carried out in accordance with the Helsinki Declaration Principles. Informed Consent was obtained from all patients/participants and their legal guardian(s) for study participation. Data availability: the datasets used and/or analyzed during the cur- rent study are available from the corresponding author on reasonable request. Received: 19 May 2025. Accepted: 8 August 2025. Early view: 10 September 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Emergency Care Journal 2025; 21:14009 doi:10.4081/ecj.2025.14009 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. es.2,4,5,7-9 In the United States, MP occurred as a result of ingesting alcohol-based hand sanitizers.3 MP can occur through various routes, including ingestion, inhalation, and skin contact, although ingestion is the most com- mon.1,3,10,11 Methanol exerts toxic effects when ingested in quanti- ties as low as 7-8 mL. The estimated lethal dose ranges between 30 and 100 ml; however, cases have been documented in which death occurred following ingestion of only 5 ml, and conversely, recov- ery was observed in individuals who consumed up to 250-500 mL. The toxic methanol blood concentration is considered to be within the range of 0.2-0.3 mg/mL, while concentrations between 0.8-1 mg/mL are typically associated with a fatal outcome.12,13 MP clinical findings include gastrointestinal manifestations (nausea, vomiting and abdominal pain), Central Nervous System (CNS) symptoms such as confusion, drowsiness, ataxia, and seizures, dyspnea, hyperventilation, and uncompensated metabolic acidosis accompanied by visual disturbances.1,3,14 Methanol is rap- idly absorbed, distributing throughout the body fluids within 10 minutes.1,15 In the liver, methanol is converted to formaldehyde by Alcohol Dehydrogenase (ADH), and formaldehyde is further transformed to formic acid by aldehyde dehydrogenase.1 The meta- bolic process of methanol to formic acid takes time, therefore, after 6 to 24 hours, depending on the absorbed amount, uncompensated metabolic acidosis and visual disorders such as blurred vision, photophobia, diplopia, and blindness may begin.1,10 Methanol induces ataxia, mild inebriation, and lethargy, while formic acid is responsible for metabolic acidosis, blindness, putamen hemor- rhage, coma, and eventually death.1 The triad of visual impairment, gastrointestinal symptoms, and metabolic acidosis has been suggested as characteristic indicators of MP.16, 17 However, simultaneous ethanol consumption may alter the presentation and delay the onset of symptoms.14 Clinical diag- nosis of MP may be established when symptoms like visual distur- bances, headache, dizziness, nausea, vomiting, and increased osmolar and anion gap concentrations are present. Prompt inter- vention in cases of methanol poisoning is critical.15 Methanol tox- icity commonly leads to hypotension, primarily through vasodila- tion, and is often accompanied by vomiting. Consequently, fluid resuscitation with intravenous crystalloids is frequently required. Due to methanol’s rapid gastrointestinal absorption and its poor affinity for activated charcoal, gastrointestinal decontamination is generally not recommended.18 Nonspecific symptoms emphasize the significance of laboratory tests in diagnosing MP.14 Following initial resuscitation, the most crucial therapeutic measures involve correcting acidosis, administrating folic acid, inhibiting ADH, and, if necessary, resorting to hemodialysis.1,3,19 Inhibiting ADH with fomepizole and ethanol is possible; however, considering the fewer side effects, fomepizole is preferable.1,19 Indications for ini- tiating hemodialysis in methanol poisoning include the presence of severe metabolic acidosis (pH<7.25 and anion gap >30 mEq/L), evidence of end-organ damage such as visual disturbances, CNS involvement, or renal dysfunction, progressive deterioration of vital signs despite conservative management, significant elec- trolyte abnormalities, and methanol serum concentrations exceed- ing 50 mg/dL – even in the absence of acidosis or overt clinical symptoms.1 The combination of fomepizole and hemodialysis has been proven to be both safe and effective.15 Corticosteroids are rec- ommended to prevent visual complications and reduce mortality, although further research is warranted.1, 9 Despite advancements in the diagnosis and treatment of methanol poisoning, mortality rates remain high.9, 14 According to reports, there was a mass outbreak of MP in Mazandaran, Iran, with an initial mortality rate of 34.3%, ranking second-highest in the country within the first month of the COVID-19 pandemic. 2, 6 In this study, we conducted a multicenter cross-sectional survey in the western part of Mazandaran province over the initial 18 months of the pandemic to provide a more com- prehensive view. Materials and Methods This research is a retrospective and descriptive cross-sectional study that was approved by the Mazandaran University of Medical Science Ethics Committee (No. IR. MAZUMS. IMAM HOSPI- TAL. REC.1400.094) and carried out in accordance with the ethi- cal guidelines of the Helsinki Declaration Principles. Additionally, written informed consent was obtained from all participants or their legal guardians. Article Table 1. Demographic and clinical characteristics of patients. Demographic and Frequency (%) clinical features Mean±SD Age 38.20±13.9 Gender Male 74 (90.2) Female 8 (9.8) Marital status Single 29 (35.4) Married 53 (64.6) Education Illiterate 2 (2.4) Elementary 31 (37.8) Secondary (High school) 31 (37.8) Collegiate level 18 (22.0) Residence Rural 19 (23.2) Urban 63 (76.8) Occupation Unemployed 17 (20.7) Employee 9 (11.0) Self-employee 56 (68.3) Clinical findings Nausea/vomiting 31 (37.8) Blurred vision 76 (92.7) Decreased LOC 9 (11) Shortness of breath 24 (29.3) Seizure 5 (6.1) Headache 2 (2.4) Metabolic acidosis 82 (100) Laboratory tests pH 7.09±0.21 PCO2 36.25±17.2 HCO3 10.5±5.66 BS (mg / dL) 140±38 BUN (mg/dL) 28±14 Cr (mg/dL) 1.1±0.8 Na (mEq/L) 139±8 K (mEq/L) 3.8±1.03 Treatment Ethanol 55 (67.1) Dialysis 80 (97.5) BS, Blood sugar, BUN, Blood urea nitrogen, Cr, Creatinine, Na, Sodium, K, Potassium, LOC, level of consciousness [page 28] [Emergency Care Journal 2025; 21:14009] The selection of samples for this study involved patients who were diagnosed with MP. The diagnosis was based on several fac- tors, including a history of alcohol consumption, visual impair- ment, altered level of consciousness, and the presence of metabolic acidosis in laboratory tests. The study included patients admitted to five specific hospitals in the western region of Mazandaran province, which is located in northern Iran. The data was obtained for research purposes in the period from March 2020 to September 2021. All individuals with MP from March 2020 to September 2021 in the selected hospitals were included in the study through a cen- sus approach. Patients admitted to the hospital with a history of alcohol consumption and a diagnosis of MP was included in this study. The exclusion criteria were a diagnosis of ethanol toxicity or the unavailability of complete patient records. The study parame- ters were recorded based on a provided questionnaire and clinical symptoms, including visual impairment, altered level of con- sciousness, dyspnea, chest pain, nausea/vomiting, abdominal pain, and laboratory findings. Data analysis was performed using SPSS version 21, based on data from all patients entered into the study from the beginning. Initially, variables were categorized into quan- titative and qualitative categories, and then data from the study was analyzed using chi-squared and Fisher’s exact tests. Results In total, 82 patients with MP were enrolled in this study. Among the patients, 74 (90.2%) were male, and 8 (9.8%) were female, with an average age of 38.20±13.9 years. 53 patients (64.6%) were married, and 29 patients (35.4%) were single. Furthermore, 31 patients (37.8%) had under diploma, while 18 patients (22%) had a university education. Among them, 56 patients were self-employed, 9 were employed, and 17 patients were unemployed. It is noteworthy that 76.8% of the patients resided in urban areas, while 23.2% lived in rural areas (Table 1). In total, 31 patients (37.8%) presented with symptoms of nau- sea and vomiting, 76 patients (92.7%) experienced blurred vision, 9 patients (11%) exhibited altered level of consciousness, 24 patients (29.3%) reported shortness of breath, 5 patients (6.1%) had seizures, and 2 patients (2.4%) complained of headaches. All patients displayed metabolic acidosis and the laboratory tests revealed that the average blood pH of the patients was 7.09±0.21, with an average PCO2 of 36.25±17.2, and an average HCO3 of 10.5±5.66. In this study, 12 patients (14.6%) required intubation, while 80 patients (97.5%) underwent dialysis. Among the 82 patients evaluated, none received fomepizole therapy due to its unavailability. Treatment was administered to 55 patients (67.1%) based on symptomatic presentation and the availability of oral ethanol, as summarized in Table 1. Of the 82 patients enrolled in this study, 6 (7.3%) experienced visual complications, while 65 (79.3%) were discharged without any adverse outcomes. Unfortunately, 11 patients (13.4%) succumbed to the poisoning. No significant association was observed between the treatment type and patient outcomes and demographic characteristics (age, gender, education level, residency, and job status) (p>0.05) (Table 2). Discussion In this 18-month study, we reported cases of hospitalized patients diagnosed with MP across five selected hospitals in north- west of Iran. The reporting timeframe started from the beginning of the COVID-19 pandemic in Iran and likely included some patients as part of the MP outbreak. Given that Mazandaran province is a popular tourist destination in Iran, it is conceivable that some patients were travelers. The majority of our patients were male (90.2%), with visual impairments (92.7%), and resi- dents of urban areas (76.8%), aligning with previous studies in the country.2,6,7,9,20-23 All patients in our sample exhibited metabolic aci- dosis, but anion gap and osmolality were not reported, which were expected to be elevated.1 Western Mazandaran faces shortages in hospital and laboratory equipment, and some necessary tests, such as methanol and ethanol levels in the blood and medications for MP, like fomepizole and intravenous ethanol, are not readily avail- able in hospitals. Given various limitations in therapeutic options, all patients underwent dialysis. In our study, the majority of patients were discharged from the hospital without specific com- Article [Emergency Care Journal 2025; 21:14009] [page 29] Table 2. Methanol poisoning outcome and correlation between demographic characteristics. Demographic features Death (n=11) Visual complications (n=6) Without complication (n=65) p Gender Male 9 (12.1) 6 (8.1) 59 (79.7) 0.459 Female 2 (25) 0 (0.0) 6 (75) Marital status Single 1 (3.4) 1 (3.4) 27 (93.1) 0.70 Married 10 (18.8) 5 (13.1) 38 (71.6) Education Illiterate 0 (0) 0 (0.0) 2 (100) Elementary 6 (19.3) 1 (3.2) 31 (77.4) 0.578 Secondary (High school) 2 (6.4) 4 (12.9) 25 (80.6) Collegiate level 3 (16.6) 1 (5.5) 14 (77.7) Residence Urban 9 (14.2) 5 (7.9) 49 (77.7) 0.830 Rural 2 (10.5) 1 (5.2) 16 (84.2) Occupation Unemployed 2 (11.7) 1 (5.8) 14 (82.3) 0.906 Employee 2 (22.2) 1 (11.1) 6 (66.9) Self-employee 7 (12.5) 4 (7.1) 45 (80.3) plications, but 7.3% experienced visual complications, and 13.4% unfortunately passed away. The mortality rate and complications in the western part of the province were lower than in the central region, possibly due to the referral of critically ill patients from across the province to the central region.9 In Iran, access to official records on MP has consistently been limited.24 A study that analyzed forensic mortality data in Tehran clearly demonstrated a 16.5% increase in deaths related to MP dur- ing the first three months after the onset of the pandemic.25 Other studies reported 800 deaths were observed nationwide, with 22 deaths in the pediatric population.4,6 In mass outbreaks of MP, it is often observed that the peak of cases occurs in the early days. There have been reports of unpublished data indicating that a sin- gle emergency room experienced over 200 cases of MP within a single week. This highlights the urgency and importance of early identification and seeking assistance from relevant authorities.14,26 The MP outbreak in the early days of the COVID-19 pandemic is believed to have stemmed from two primary causes. Firstly, a rise in unstructured leisure time, decreased sports activity resulting from gym closures, and mass encouragement for the public to stay at home caused increased alcohol consumption. This led to a high- er incidence of MP in a country where legal and safe alcohol sales are prohibited.25,26 Furthermore, the extensive spread of misinfor- mation regarding the prevention of COVID-19—specifically the use of alcohol-based beverages and sanitizers through consump- tion or gargling—prompted individuals to adopt such hazardous practices. However, due to the legal prohibition of the production, distribution, and consumption of alcoholic beverages in Iran, along with the prevalence of illicit and homemade alternatives, many resorted to black market sources, thereby exposing themselves to severe health risks associated with methanol-contaminated sub- stances. Additionally, as the pandemic surged in the country, sani- tizers became scarce in the market. According to local news, the heightened demand for ethanol prompted bootleggers to eliminate the color from industrial alcohols containing pyridine (to discour- age consumption) using bleach, before selling them as regular ethanol to Iranians.2,3,5-8,26 It’s noteworthy that sanitizers containing methanol were not exclusive to Iran. In July 2020, the FDA recalled at least 75 sani- tizers containing methanol from across the United States.15 Furthermore, the prolonged use of methanol-containing sanitizers can be absorbed through the skin.11 MP is associated with numerous complications and high mor- tality, necessitating rapid diagnosis and treatment to prevent per- manent consequences and death.1 Various factors contribute to delayed diagnosis, including religious or societal taboos on alcohol consumption and nonspecific presentation of poisoning.14,27 In Iran, the lack of proper laboratory equipment for measuring toxic alcohol concentrations and their metabolites, as well as serum osmolality and chloride levels for calculating anion gap and serum lactate levels, also plays an effective role in diagnostic delays.1,24 Another factor during the early months of the pandemic was the fear of COVID-19, which likely deprived victims of alcohol poi- soning from timely diagnosis and treatment.6 Limited access to appropriate treatment is another reason, despite the addition of fomepizole to the essential drugs list of the World Health Organization (WHO), its availability in Iran is limited.24,28 Although COVID-19 may no longer dominate our concerns, the emergence of other widespread infectious diseases remains a possibility. In such circumstances, it is crucial for responsible gov- ernmental bodies to take decisive actions. This involves countering the circulation of misinformation and unsafe behaviors in society through education and increased public awareness. On one hand, they should strive to provide accurate information, and on the other hand, by supplying safe, methanol-free sanitizers, they can reduce the risk of MP. Moreover, MP outbreaks were prevalent in Iran long before the COVID-19 pandemic. Comprehensive education on toxic alcohols and MP, coupled with training healthcare profes- sionals for timely and effective responses, along with providing appropriate hospital equipment across all regions, can contribute significantly. Lastly, acknowledging the reality of alcohol con- sumption in Iran, the government must assume a responsible role in regulating its use. Implementing these measures is essential to prevent tragic events, such as the methanol mass poisoning out- break of 2020.5,14,21,22 Limitations The explicit and implicit legal restrictions on accessing and publishing hospital records of MP cases pose a significant barrier to conducting a thorough clinical evaluation and obtaining detailed imaging findings. The inability to obtain an accurate medical his- tory from patients, often stemming from fear of familial judgment and legal repercussions under country’s laws, significantly influ- ences the nature and urgency of their presentation at the emergency department. The inadequate availability of hospital laboratory equipment in the healthcare system has hindered the provision of comprehensive and precise diagnosis and treatment procedures for patients with MP. Conclusions MP poses a significant challenge to both individual and social health globally. Despite efforts to promptly diagnose and treat affected individuals, the mortality rate associated with MP remains a cause for concern. In Iran, one contributing factor to the morbid- ity and mortality related to MP is the delay in seeking treatment due to the fear of legal consequences. However, based on our study, no significant correlation was found between the type of treatment, patient outcomes, and demographic characteristics. It is worth noting that timely recognition of the outbreak and the involvement of experienced specialists can play a crucial role in mitigating the impact of visual complications and severe metabolic acidosis. References 1. Nekoukar Z, Zakariae Z, Taghizadeh F, et al. Methanol poison- ing as a new world challenge: A review. Ann Med Surg (Lond) 2021;66:102445. 2. Soltaninejad K. Methanol mass poisoning outbreak: a conse- quence of COVID-19 pandemic and misleading messages on social media. Int J Occup Environ Med 2020;11:148-50. 3. Yip L, Bixler D, Brooks DE, et al. Serious adverse health events, including death, associated with ingesting alcohol- based hand sanitizers containing methanol - Arizona and New Mexico, May-June 2020. MMWR Morb Mortal Wkly Rep 2020;69:1070-3. 4. Mahdavi SA, Kolahi AA, Akhgari M, et al. COVID-19 pan- demic and methanol poisoning outbreak in Iranian children and adolescents: A data linkage study. Alcohol Clin Exp Res 2021;45:1853-63. 5. Banagozar Mohammadi A, Vahabzadeh M. A concurrent out- break of COVID-19 and methanol poisoning in Iran: Is this the Article [page 30] [Emergency Care Journal 2025; 21:14009] time to make amendments to alcohol drinking laws? Eur J Clin Experimental Med 2020:252-3. 6. Hassanian-Moghaddam H, Zamani N, Kolahi AA, et al. Double trouble: methanol outbreak in the wake of the COVID- 19 pandemic in Iran-a cross-sectional assessment. Crit Care 2020;24:402. 7. Delirrad M, Mohammadi AB. New methanol poisoning out- breaks in Iran following COVID-19 pandemic. Alcohol Alcohol 2020;55:347-8. 8. Rafizadeh A, Kolahi AA, Shariati S, et al. The danger of the toxicity and inefficacy of alcohol-based hand rubs in Iran dur- ing COVID-19: a cross-sectional study. Antimicrob Resist Infect Control 2023;12:42. 9. Sadeghi M, Fakhar M, Hoseininejad SM, et al. The clinico-epi- demiological, diagnostic and therapeutic aspects of methanol poisoning: A five-year retrospective study, northern Iran. Drug Alcohol Dependence 2023;253:111024. 10. Sadeghi M, Zakariaei Z, Fakhar M, et al. Acute pancreatitis due to methanol toxicity during the COVID-19 pandemic. Clin Case Rep 2021;9:e04943. 11. Chan APL, Chan TYK. Methanol as an unlisted ingredient in supposedly alcohol-based hand rub can pose serious health risk. Int J Environ Res Public Health 2018;15. 12. Kurtas O, Imre KY, Ozer E, et al. The evaluation of deaths due to methyl alcohol intoxication. Biomed Re 2017;28:3680-7. 13. Ran M, Li Y, Zhang L, et al. Clinical features, treatment, and prognosis of acute methanol poisoning: experiences in an out- break. Int J Clin Exp Med 2019;12:5938-0. 14. Rostrup M, Edwards JK, Abukalish M, et al. The methanol poisoning outbreaks in Libya 2013 and Kenya 2014. PLoS One 2016;11:e0152676. 15. Krebs NP, Czarnecki L. A Cluster of five deaths due to methanol toxicity after apparent hand sanitizer ingestion in the setting of chronic alcoholism. Acad Forensic Pathol 2022;12:90-4. 16. Sefidbakht S, Lotfi M, Jalli R, et al. Methanol toxicity out- break: when fear of COVID-19 goes viral. Emerg Med J 2020;37:416. 17. Gallagher N, Edwards FJ. The diagnosis and management of toxic alcohol poisoning in the emergency department: a review article. Adv J Emerg Med 2019;3:e28. 18. Elwell RJ, Darouian P, Bailie GR, et al. Delayed absorption and postdialysis rebound in a case of acute methanol poison- ing. Am J Emerg Med 2004;22:126-7. 19. Barceloux DG, Bond GR, Krenzelok EP, et al. American Academy of Clinical Toxicology practice guidelines on the treatment of methanol poisoning. J Toxicol Clin Toxicol 2002;40:415-46. 20. Yousefinejad V, Moradi B, Mohammadi Baneh A, et al. Prognostic factors of outcome in methanol poisoning; an 8- year retrospective cross-sectional study. Arch Acad Emerg Med 2020;8:e69. 21. Aghababaeian H, Araghi Ahvazi L, Ostadtaghizadeh A. The methanol poisoning outbreaks in Iran 2018. Alcohol Alcoholism 2019;54:128-30. 22. Massoumi G, Saberi K, Eizadi-Mood N, et al. Methanol poi- soning in Iran, from 2000 to 2009. Drug Chem Toxicol 2012;35:330-3. 23. Shadnia S, Shojaei Arani L, Bahmani K, et al. Demographic and clinical characteristics of patients who died of methanol toxicity during COVID 19 period in Loghman-e Hakim Hospital in Tehran. Int J Med Toxicol Forensic Med 2021;12: 36171. 24. Banagozar Mohammadi A, Delirrad M. Problems with methanol poisoning outbreaks in Iran. Alcohol Alcoholism 2019;54:338. 25. Behnoush AH, Bazmi E, Forouzesh M, et al. Impact of COVID-19 on poisoning-related mortality in Iran: An inter- rupted time series study. Int J Drug Policy 2023;117:104051. 26. Arasteh P, Pakfetrat M, Roozbeh J. A Surge in Methanol Poisoning Amid COVID-19 Pandemic: Why Is This Occurring? Am J Med Sci 2020;360:201. 27. Hassanian-Moghaddam H, Nikfarjam A, Mirafzal A, et al. Methanol mass poisoning in Iran: role of case finding in out- break management. J Public Health (Oxf) 2015;37:354-9. 28. World Health Organization. Model list of essential medicines. 2023. Article [Emergency Care Journal 2025; 21:14009] [page 31]