The Rising Concern of Ethanol Intoxication from Easy Access to Hand Sanitizers: A Case Report.

BACKGROUND Ethanol intoxication is very common, and several forms of alcohol intoxication can lead to emergency department visits. Excessive alcohol users, when in withdrawal, might seek replacement alcoholic beverages; one of the common sources of ethanol is hand sanitizer, which contains 45-95% alcohol. It becomes even more challenging to deal with alcohol use disorder patients when they seek these replacement products inside hospital premises, and medical clinics and hospitals have increased their use of ethanol-based hand sanitizer since the start of the COVID-19 pandemic. CASE REPORT We report the case of a 26-year-old man with alcohol dependence presenting with a fictitious illness leading to hospital admission and consumption of ethanol-based hand sanitizer in the emergency department (ED). The patient initially presented reporting severe abdominal pain that persisted despite medications. The initial laboratory tests and imaging were non-significant. The patient was later caught stealing hand sanitizer bottles, consuming them within 4-6 h. The COVID-19 pandemic has increased alcohol intoxication, especially in EDs. Hand sanitizers, including ethanol, are toxic and hazardous when misused, mostly by adolescents and young adults. Treatments include glucose determination, dextrose infusion, and thiamine perfusion. Strategies to reduce ethanol intoxication include eliminating hand sanitizers, using wall-fixed sanitizers, and using sanitizer wipes. CONCLUSIONS Patients with alcohol use disorder are known to develop alcohol-seeking behaviors. This report has highlighted that healthcare professionals should be aware that the increased availability of ethanol-based hand sanitizers, some of which contain toxic antiviral chemical agents, may be targeted by individuals with alcohol dependency.

Methanol poisoning during COVID-19 pandemic; A systematic scoping review.

OBJECTIVE: In this systematic scoping review, it was aimed to assess the epidemiology of methanol poisoning, clinical findings and patients' management, causes, and recommendations regarding prevention or reduction of methanol poisoning during COVID-19 pandemic. METHODS: Three Electronic databases [Medline (accessed from PubMed), Scopus, and Science Direct] were searched systematically from December 01, 2019 to September 10, 2020, using MESH terms and the related keywords in English language. Considering the titles and abstracts, unrelated studies were excluded. The full texts of the remained studies were evaluated by authors, independently. Then, the studies' findings were assessed and reported. RESULTS: Total of 86 articles were obtained within the first step of searching, and 64 ones remained after removing the duplications. Through the title and abstract screening, 35 were removed. Finally, after reading the full text of the remained articles, 15 ones included in data extraction. Most of the previous reported evidence (13/15) were letter to editor, commentary and short reports. None of them were interventional, and none of them followed the patients. Findings were summarized in four categories: 1) epidemiology; 2) clinical findings and patients' management; 3) causes; and 4) recommendation regarding prevention or reduction of methanol poisoning during COVID-19 pandemic. CONCLUSION: The recent outbreak is the largest methanol mass poisoning outbreak throughout Iran and the world in recent decades. The causes of methanol poisoning during the COVID-19 pandemic are intertwined, and most of them are modifiable by health policy makers. Building trust, educating and warning, as well as controlling and monitoring are three main recommendation for prevention or reduction of methanol poisoning.

COVID-19 pandemic and methanol poisoning outbreak in Iranian children and adolescents: A data linkage study.

BACKGROUND: During the first wave of COVID-19, many Iranians were poisoned by ingesting hand sanitizers and/or alcoholic beverages to avoid viral infection. To assess whether the COVID-19 pandemic resulted in an increased prevalence of accidental hand sanitizer/alcoholic beverage exposure in children and adolescents, we compared pediatric hospitalization rates during COVID-19 and the previous year. For poisoning admissions during COVID-19, we also evaluated the cause by age and clinical outcomes. METHODS: This retrospective data linkage study evaluated data from the Legal Medicine Organization (reporting mortalities) and hospitalization data from nine toxicology referral centers for alcohol-poisoned patients (age 0 to 18 years) for the study period (February 23 to June 22, 2020) and the pre-COVID-19 reference period (same dates in 2019). RESULTS: Hospitalization rates due to ethanol and methanol exposure were significantly higher in 2020 (n = 375) than 2019 (n = 202; OR [95% CI] 1.9 [1.6, 2.2], p < 0.001). During COVID-19, in patients ≤15 years, the odds of intoxication from hand sanitizers were significantly higher than from alcoholic beverages, while in 15- to 18-year-olds, alcoholic beverage exposure was 6.7 times more common (95% CI 2.8, 16.1, p < 0.001). Of 375 children/adolescents hospitalized for alcoholic beverage and hand sanitizer exposure in 2020, six did not survive. The odds of fatal outcome were seven times higher in 15- to 18-year-olds (OR (95% CI) 7.0 (2.4, 20.1); p < 0.001). CONCLUSION: The Iranian methanol poisoning outbreak during the first wave of COVID-19 was associated with significantly increased hospitalization rates among children and adolescents-including at least six pediatric in-hospital deaths from poisoning. Public awareness needs to be raised of the risks associated with ingesting alcoholic hand sanitizers.

Death by hand sanitizer: syndemic methanol poisoning in the age of COVID-19.

BACKGROUND: The advent of COVID-19 increased attention to hand hygiene in prevention of disease transmission. To meet the increased demand for hand sanitizer during the pandemic, the US FDA issued an Emergency Use Authorization allowing new manufacturers and importers to enter the market. Some of the newly introduced hand sanitizer products contained methanol in lieu of ethanol or isopropanol. We describe five patients with fatal methanol poisoning resulting from hand sanitizers improperly containing methanol. CASE SUMMARY: Comparing a 5-month period from 2019 to the same time frame in 2020, the Arizona Poison and Drug Information Center has seen an increase of 124% in exposures to hand sanitizer. Of these cases, 28% involved methanol-contaminated hand sanitizer. Five of these patients died from methanol poisoning. All five cases had similar clinical features with severe high anion gap metabolic acidosis and, in four patients, elevated osmolal gap. Methanol concentrations were consistently very elevated, but these results were not available before the patients succumbed. Four of the patients received fomepizole and adjunctive care. Two patients received emergency extracorporeal therapy. All five died despite maximal treatment efforts. CONCLUSION: During the pandemic in 2020, there was a proliferation of alcohol-based hand sanitizers which contained methanol. Exposure to these products, which failed to meet regulatory standards, led to increased harm and death. Challenges to treatment of methanol poisoning, especially in rural areas, include lack of access to timely laboratory measurement of methanol concentrations and lack of available emergency hemodialysis without transfer of the patient.

COVID-19 and contamination: impact on exposures to alcohol-based hand sanitizers reported to Texas Poison Control Centers, 2020.

BACKGROUND: The COVID-19 pandemic has increased use of alcohol-based hand sanitizers (ABHS), creating shortages leading to additional production by new, non-traditional manufacturers. In June 2020, the Food and Drug Administration (FDA) issued warnings about methanol or 1-propanol contaminated brands of hand sanitizer. Exposure to methanol, including dermally, can cause kidney damage, blindness and death. Exposure to 1-propanol can cause severe acidosis and death. Chronic exposure may be more likely due to increased hand sanitizer use in 2020. METHODS: We used generic codes for ABHS to characterize exposures reported to the Texas Poison Control Network in 2019 and 2020. For 2020 cases, we also used case narratives to identify cases considered COVID-19 -related and cases where the caller reported exposure to unknown ABHS with safety concerns, specifically identified brands on the FDA warning list or before that warning was made in June 2020. RESULTS: Reported exposures to ABHS increased 72.5% between 2019 and 2020. In 2020, 10% of the cases were COVID-19 -related. COVID-19 -related cases in 2020 were likely to be older, to have a lower portion of young children exposed and to report chronic use of hand sanitizer. Similar trends were reported among cases who reported possible exposures to potentially unsafe ABHS products, including products on the FDA list. Most exposures were not referred for medical attention, and no deaths were reported among the Texas cases. DISCUSSION: Callers reporting exposures to ABHS related to use prompted by the novel severe acute respiratory syndrome coronavirus 2 (COVID-19) and specific exposure to unsafe products differ from the traditional callers in being older, reporting chronic use and in healthcare facility (HCF) referral. The 72.5% increase in 2020 calls compared to 2019 cases differ from typical exposures, which often involve young children. Changes in manufacturing processes by additional manufacturers have produced potential exposure to toxic alcohol-containing products and others in Texas.

A Geographically Distinct Case of Fatal Methanol Toxicity from Ingestion of a Contaminated Hand Sanitizer Product During the COVID-19 Pandemic.

The COVID-19 pandemic has triggered outbreaks of unanticipated toxicities, including methanol toxicity. Multiple methanol outbreaks have been described, including contaminated hand sanitizer in the southwest USA. In this case, we describe a fatal case of methanol toxicity from hand sanitizer ingestion, geographically separated from the outbreak in the southwest USA and prior to the announcement of nationwide warnings by the Food and Drug Administration (FDA). The product was identified as one later recalled by the FDA for methanol contamination. Additionally, the consumption in this case was related to a desire to conceal alcohol consumption from family members. This case of methanol toxicity should increase awareness of the ease of which contaminated products can be widely distributed and of the use of alternative ethanol-containing products to obscure relapse in alcohol use disorder.

Serious Adverse Health Events, Including Death, Associated with Ingesting Alcohol-Based Hand Sanitizers Containing Methanol - Arizona and New Mexico, May-June 2020.

Alcohol-based hand sanitizer is a liquid, gel, or foam that contains ethanol or isopropanol used to disinfect hands. Hand hygiene is an important component of the U.S. response to the emergence of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). If soap and water are not readily available, CDC recommends the use of alcohol-based hand sanitizer products that contain at least 60% ethyl alcohol (ethanol) or 70% isopropyl alcohol (isopropanol) in community settings (1); in health care settings, CDC recommendations specify that alcohol-based hand sanitizer products should contain 60%-95% alcohol (≥60% ethanol or ≥70% isopropanol) (2). According to the Food and Drug Administration (FDA), which regulates alcohol-based hand sanitizers as an over-the-counter drug, methanol (methyl alcohol) is not an acceptable ingredient. Cases of ethanol toxicity following ingestion of alcohol-based hand sanitizer products have been reported in persons with alcohol use disorder (3,4). On June 30, 2020, CDC received notification from public health partners in Arizona and New Mexico of cases of methanol poisoning associated with ingestion of alcohol-based hand sanitizers. The case reports followed an FDA consumer alert issued on June 19, 2020, warning about specific hand sanitizers that contain methanol. Whereas early clinical effects of methanol and ethanol poisoning are similar (e.g., headache, blurred vision, nausea, vomiting, abdominal pain, loss of coordination, and decreased level of consciousness), persons with methanol poisoning might develop severe anion-gap metabolic acidosis, seizures, and blindness. If left untreated methanol poisoning can be fatal (5). Survivors of methanol poisoning might have permanent visual impairment, including complete vision loss; data suggest that vision loss results from the direct toxic effect of formate, a toxic anion metabolite of methanol, on the optic nerve (6). CDC and state partners established a case definition of alcohol-based hand sanitizer-associated methanol poisoning and reviewed 62 poison center call records from May 1 through June 30, 2020, to characterize reported cases. Medical records were reviewed to abstract details missing from poison center call records. During this period, 15 adult patients met the case definition, including persons who were American Indian/Alaska Native (AI/AN). All had ingested an alcohol-based hand sanitizer and were subsequently admitted to a hospital. Four patients died and three were discharged with vision impairment. Persons should never ingest alcohol-based hand sanitizer, avoid use of specific imported products found to contain methanol, and continue to monitor FDA guidance (7). Clinicians should maintain a high index of suspicion for methanol poisoning when evaluating adult or pediatric patients with reported swallowing of an alcohol-based hand sanitizer product or with symptoms, signs, and laboratory findings (e.g., elevated anion-gap metabolic acidosis) compatible with methanol poisoning. Treatment of methanol poisoning includes supportive care, correction of acidosis, administration of an alcohol dehydrogenase inhibitor (e.g., fomepizole), and frequently, hemodialysis.

Reported Adverse Health Effects in Children from Ingestion of Alcohol-Based Hand Sanitizers - United States, 2011-2014.

Hand sanitizers are effective and inexpensive products that can reduce microorganisms on the skin, but ingestion or improper use can be associated with health risks. Many hand sanitizers contain up to 60%-95% ethanol or isopropyl alcohol by volume, and are often combined with scents that might be appealing to young children. Recent reports have identified serious consequences, including apnea, acidosis, and coma in young children who swallowed alcohol-based (alcohol) hand sanitizer (1-3). Poison control centers collect data on intentional and unintentional exposures to hand sanitizer solutions resulting from various routes of exposure, including ingestion, inhalation, and dermal and ocular exposures. To characterize exposures of children aged ≤12 years to alcohol hand sanitizers, CDC analyzed data reported to the National Poison Data System (NPDS).* The major route of exposure to both alcohol and nonalcohol-based (nonalcohol) hand sanitizers was ingestion. The majority of intentional exposures to alcohol hand sanitizers occurred in children aged 6-12 years. Alcohol hand sanitizer exposures were associated with worse outcomes than were nonalcohol hand sanitizer exposures. Caregivers and health care providers should be aware of the potential dangers associated with hand sanitizer ingestion. Children using alcohol hand sanitizers should be supervised and these products should be kept out of reach from children when not in use.

Acute alcohol intoxication in a child following ingestion of an ethyl-alcohol-based hand sanitizer.

While uncommon, ingestion of ethanol-based hand sanitizers by children may be associated with significant intoxication. We report the case of a 7-year-old with acute alcohol intoxication following hand sanitizer ingestion. Alcohol elimination in this patient followed zero-order kinetics with a clearance rate of 22.5 mg/kg/h, consistent with the limited pharmacokinetic information available for children who experience alcohol intoxication from more traditional sources.

Characteristics of hand sanitizer ingestions by adolescents reported to poison centers.

BACKGROUND: There had been reports of adolescents using hand sanitizers to obtain alcohol and ending up in emergency departments with alcohol poisoning. OBJECTIVE: This study aimed to describe the pattern of adolescent ingestions of hand sanitizers reported to a statewide poison center system. SUBJECTS: Our study subjects included patients aged 13-19 years who reported hand sanitizer ingestions as reported to Texas poison centers during 2000-2013. MATERIALS AND METHODS: The distribution of the ingestions was determined for various demographic and clinical factors. RESULTS: Of 385 total cases, 61% of the patients were male, and the mean age was 15.3 years. The ingestion reason was unintentional (61%), intentional abuse/misuse (18%), and malicious (10%). Ingestion site was most frequently reported to be the patient's own residence (53%), followed by school (35%). About 77% of the patients were managed on site. The medical outcome was serious (moderate effect or unable to follow-potentially toxic) in 5% of the cases. The most frequently reported adverse clinical effects were vomiting (5%), abdominal pain (4%), nausea (4%), throat irritation (4%), and drowsiness (2%). CONCLUSION: Adolescents who ingested hand sanitizers were more likely to be male and younger. One-third of the ingestions occurred at school, suggesting that school personnel might be made aware of the potential problem of hand sanitizer ingestions by adolescents. Nevertheless, despite the potential for serious outcomes from adolescent hand sanitizer ingestion, most of the ingestions reported to poison centers are not likely to be serious and can be successfully managed outside of a healthcare facility.

Death caused by ingestion of an ethanol-based hand sanitizer.

BACKGROUND: The use of hand sanitizer is effective in preventing the transmission of disease. Many hand sanitizers are alcohol-based, and significant intoxications have occurred, often in health care facilities, including the emergency department (ED). OBJECTIVES: We present this case to highlight potential toxicity after the ingestion of an ethanol-based hand sanitizer. CASE REPORT: A 36-year-old man presented to the ED with ethanol intoxication. Ethanol breath analysis was measured at 278 mg/dL. After 4 h, the patient was less intoxicated and left the ED. Thirty minutes later, he was found apneic and pulseless in the ED waiting room bathroom after having ingested an ethanol-based hand sanitizer. Soon after a brief resuscitation, his serum ethanol was 526 mg/dL. He never regained consciousness and died 7 days later. No other cause of death was found. CONCLUSION: The case highlights the potential for significant toxicity after the ingestion of a product found throughout health care facilities. Balancing the benefit of hand sanitizers for preventing disease transmission and their potential misuse remains a challenge.