[Source: US Centers for Disease Control and Prevention (CDC), MMWR Morbidity and Mortality Weekly Report, full page: (LINK). Abstract, edited.]
Serious Adverse Health Events, Including Death, Associated with Ingesting Alcohol-Based Hand Sanitizers Containing Methanol — Arizona and New Mexico, May–June 2020
Early Release / August 5, 2020 / 69
Luke Yip, MD1; Danae Bixler, MD1; Daniel E. Brooks, MD2; Kevin R. Clarke, MD1; S. Deblina Datta, MD1; Steven Dudley Jr., PharmD3; Kenneth K. Komatsu4; Jennifer N. Lind, PharmD1; Annaliese Mayette, PhD5; Michael Melgar, MD1; Talia Pindyck, MD1; Kristine M. Schmit, MD1; Steven A. Seifert, MD6; Farshad Mazda Shirazi, MD, PhD3; Susan C. Smolinske, PharmD7; Brandon J. Warrick, MD6; Arthur Chang, MD1
Corresponding author: Luke Yip, email@example.com.
1CDC COVID-19 Response Team; 2Banner Poison and Drug Information Center, Phoenix, Arizona; 3Arizona Poison and Drug Information Center, Tucson, Arizona; 4Division of Public Health Preparedness, Arizona Department of Health Services; 5Epidemiology and Response Division, New Mexico Department of Health; 6University of New Mexico School of Medicine, Albuquerque, New Mexico; 7New Mexico Poison and Drug Information Center, Albuquerque, New Mexico.
All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Steven Seifert reports personal fees from Taylor & Francis as Editor-in-Chief of Clinical Toxicology and from UpToDate as a paid author. Susan Smolinske reports grants from Health Resources and Services Administration for poison centers. No other potential conflicts of interest were disclosed.
Suggested citation for this article: 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. ePub: 5 August 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6932e1
- What is already known about this topic?
- Alcohol-based hand sanitizers should only contain ethanol or isopropanol, but some products imported into the United States have been found to contain methanol.
- What is added by this report?
- From May 1 through June 30, 2020, 15 cases of methanol poisoning were reported in Arizona and New Mexico, associated with swallowing alcohol-based hand sanitizers. Four patients died, and three were discharged with visual impairment.
- What are the implications for public health practice?
- Alcohol-based hand sanitizer products should never be ingested. In patients with compatible signs and symptoms or after having swallowed hand sanitizer, prompt evaluation for methanol poisoning is required. Health departments in all states should coordinate with poison centers to identify cases of methanol poisoning.
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.
Keywords: SARS-CoV-2; COVID-19; Toxic chemicals; Arizona; New Mexico; USA.