key: cord-300656-56sd6pnn
authors: Welle, Luke; Medoro, Amanda
title: Tainted hand sanitizer leads to outbreak of methanol toxicity during SARS-CoV-2 pandemic
date: 2020-07-08
journal: Ann Emerg Med
DOI: 10.1016/j.annemergmed.2020.07.011
sha: 
doc_id: 300656
cord_uid: 56sd6pnn

nan

Tainted hand sanitizer leads to outbreak of methanol toxicity during SARS-CoV-2 pandemic

To the Editor, We feel it is timely to notify the membership of an emerging public health crisis which parallels the ongoing fight against the SARS-CoV-2 virus. The coronavirus pandemic has resulted in a severe supply-demand mismatch of many products, particularly personal protective equipment and sanitization products. Consumers and healthcare entities alike are turning to alternative sources including the online marketplace to purchase products for workplace and personal safety. Instances of misrepresented materials purchased by governments and healthcare systems have become frequent in the news. The most recent example in the American Southwest is an outbreak of methanol poisonings from tainted hand sanitizer products.

Hand sanitizers typically containing high concentrations of ethanol or isopropanol have become increasingly recognized as a substance of abuse due to low cost and availability relative to conventional drinking alcohols. 1 Hand sanitizer products have recently been indicated in methanol poisonings causing blindness in two and death in seven New Mexicans. Although methanol outbreaks are historically well-established, associations to hand sanitizer consumption have been poorly reported in the peer-reviewed literature. Outbreaks tend to occur when access to alcohol is limited as seen in the prohibition-era and in resource-poor populations turning to alternative alcohol sources. 2 The Food and Drug Administration issued an advisory on 6/19/2020 to notify the public about the dangers of nine formulations of hand sanitizers marketed by a manufacturer in Mexico. These products were found to contain up to 81% methanol, which was not listed as an ingredient. 3 At the time of letter submission, our cases appear to align with hand sanitizer consumption, but not to products specifically identified thus far by the Food and Drug Administration. 4 As such, non-commercial sources of hand sanitizer and drinking alcohol are also being considered.

Emergency physicians must have a heightened awareness for methanol toxicity in at-risk populations given the possibility of this outbreak to spread geographically in this time of the online marketplace and heightened product demand. Methanol toxicity has been observed in doses as small as 15 mL and may lead to blindness and death if not promptly treated. Since methanol is less lipophilic than ethanol, toxicity can present without the typical intoxicating features of ethanol. An anion gap metabolic acidosis is commonly seen in large ingestions, but like serum osmolar gap, does not rule out toxic alcohol poisoning. 5 As soon as the diagnosis is suspected, treatment with fomepizole in tandem with Poison Center consultation is imperative. Ethanol is second-line for treatment when fomepizole is unavailable and has been shown to improve prehospital outcomes with hemodialysis often necessary for toxin elimination. 2, 5 

The rising incidence of intentional ingestion of ethanol-containing hand sanitizers

Use of Out-of-Hospital Ethanol Administration to Improve Outcome in Mass Methanol Outbreaks

FDA advises consumers not to use hand sanitizer products manufactured by Eskbiochem. U.S. Food & Drug Administration

We urge the emergency medicine community to remain vigilant to this developing threat. 
