Letter to the Editor

To the Editor:

The article from Hakimi and Armstrong, “Hand Sanitizer in a Pandemic: Wrong Formulations in the Wrong Hands,” reported two important findings: that the content of instructional YouTube videos often deviates from published scientific guidelines; and that an increase in cases of pediatric hand sanitizer exposures occurred in the United States in March 2020 (1). These findings were timely and independently interesting, but we feel the article is mistitled and inappropriately suggested a causal relationship between its findings and its conclusion.

First, the article did not demonstrate a connection between its two primary findings, as the title suggested it might. The reported disparity between the YouTube video content and World Health Organization guidelines focused mainly on the do-it-yourself formulation of the hand sanitizer, noting concerns for antimicrobial efficacy based on ingredients and their concentrations, not any potential for toxic exposure. The specific findings that 82% of the videos failed to address proper labeling and 69% encouraged use of fragrance-enhancers could theoretically have led to increased risk of accidental ingestion. However, the authors fail to provide any evidence that the noted increase in reported exposures by poison control centers was due to homemade sanitizer. Without this, no causal connection can be concluded. We consider the higher overall availability of hand sanitizer, both store-bought and homemade, similar to a concurrent increase in exposures to other store-bought disinfectants, such as bleaches, during the same period as the likelier reason for the increase in cases (2). Second, a poison center phone call does not prove there was toxicity; in fact, most calls are deemed nontoxic exposures. The authors did not address whether any of the calls resulted in toxicity, nor specifically, toxicity due to a do-it-yourself formulation.

We agree that health care providers must quickly act to recognize these toxicities, but found that the article only tangentially touched upon this. There was no comment that properly prepared U.S. Food and Drug Administration-approved hand-sanitizer formulations could result in toxicity, nor that pediatric patients are at a unique risk of hypoglycemia with ethanol ingestion, and that isopropanol ingestion is frequently associated with emesis (3). Although we acknowledge the authors for their innovative and timely approaches, we believe these findings should have been discussed in separate articles, each with a more clearly stated purpose, and should not be used to suggest a causal relationship as stated in its conclusion and implied in its title.