Tainted Hand Sanitizer Leads to Outbreak of Methanol Toxicity During SARS-CoV-2 Pandemic

To the Editor:

It is timely to notify the membership of an emerging public health crisis that parallels the ongoing fight against the severe acute respiratory syndrome coronavirus 2. The coronavirus pandemic has resulted in a severe supply-demand mismatch of many products, particularly personal protective equipment and sanitization products. Consumers and health care 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 health care systems have become frequent in the news. The most recent example in the US 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 because of low cost and availability relative to conventional drinking alcohols.¹ Hand sanitizer products have recently been indicated in methanol poisonings causing blindness in 2 New Mexicans and death in 7. Although methanol outbreaks are historically well established, associations with hand sanitizer consumption have been poorly reported in the peer-reviewed literature. Outbreaks tend to occur when access to alcohol is limited, as observed in the prohibition era and in resource-poor populations turning to alternative alcohol sources.² The Food and Drug Administration issued an advisory on June 19, 2020, to notify the public about the dangers of 9 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 article submission, our cases appear to align with hand sanitizer consumption, but not with products specifically identified thus far by the Food and Drug Administration.⁴ As such, noncommercial 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. Because methanol is less lipophilic than ethanol, toxicity can present without the typical intoxicating features of ethanol. An anion gap metabolic acidosis is commonly observed 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 out-of-hospital outcomes, with hemodialysis often necessary for toxin elimination.^{2 , 5}

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