Abstract

Abstract

During the first wave of COVID‐19 pandemic, Iran experienced the worldwide biggest methanol outbreak recorded to date. The outbreak triggered by consumption of toxic alcoholic beverages or hand sanitizers, partially motivated by the belief that ingestion would protect against COVID‐19 infection. Our study shows that children and adolescents were also affected, with 22 deaths due to methanol exposure recorded in 2020. These were significantly higher in Feb‐June 2020 (during COVID‐19), compared to the corresponding time period in 2019.

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INTRODUCTION

On February 19, 2020, Iran reported the first confirmed case of COVID‐19 infection in Qom, almost a month before the World Health Organization declared a global pandemic on March 11, 2020 (Soltaninejad, 2020; WHO, 2020a, 2020b). Lack of adequate diagnostic tools, prior training of healthcare professionals and the community on how to manage airborne viruses, and measures to prevent the viral spread facilitated a sharp increase in the rate of COVID‐19 infections in Iran. By March 28, 2020, about 35,408 COVID‐19 cases had been reported, including 2517 deaths (Soltaninejad, 2020).

The United States Centers for Disease Control and Prevention (CDC) recommended hand sanitization as the first method of disease prevention (CDC, 2019). Also, guidelines recommended the disinfection of frequently touched surfaces and objects to prevent the spread of the virus (CDC, 2019; Emmanuel et al., 2020), resulting in high demand for hand sanitizers in the general population.

In Iran, this led to a serious shortage of these products (Kampf, et al., 2020), and counterfeit and nonstandardized hand sanitizers entered the black market, some of which contained less than 60% ethanol (EtOH) or contained methanol (Jairoun et al., 2021). This coincided with the rapid spread of COVID‐19 misinformation via social media at the beginning of the COVID‐19 pandemic.

One of the misleading suggestions via social media was to drink or gargle alcoholic beverages to disinfect the mouth and prevent COVID‐19 infection (Delirrad & Mohammadi, 2020; Soltaninejad, 2020). Other recommendations involved household cleaning agents and disinfectants, leading to excessive exposure. This COVID‐19 misinformation caused a steep increase in household poisonings, including a major methanol poisoning outbreak in the population (Gharpure et al., 2020; Hassanian‐Moghaddam et al., 2020; Chang et al., 2020).

The Iranian methanol poisoning outbreak in adults involved 5876 hospitalizations and about 800 deaths registered by the Legal Medicine Organization (LMO) between February and May 2020, equivalent to an estimated mortality rate of 9 to 14% (Hassanian‐Moghaddam et al., 2020). This outbreak was five times greater than the second largest methanol outbreak in history, with 1066 hospitalizations reported in Libya in March 2013 (Rostrup et al., 2016). However, the scale of methanol poisoning during COVID‐19 in children and adolescents is unknown to date. To address this gap in the literature, we conducted a multicenter data linkage study of pediatric hospitalization and mortality data.

We aimed to compare the prevalence rates during the first wave of COVID‐19 versus the previous year (2019; “pre‐COVID”) for children and adolescents hospitalized with EtOH and methanol poisoning. For pediatric poisoning during COVID‐19, we also aimed to evaluate the cause of exposure by age and the clinical outcome.

METHODS

Participants

Inclusion criteria

All children and adolescents aged 0 to 18 years (McGoldrick, 1991) with (a) hospitalization due to alcohol (EtOH or methanol) exposure and/or (b) postmortem diagnosis of methanol poisoning during the study period were included.

Hospitalized cases at the nine referral toxicology centers were eligible if they had taken the sold product of alcoholic beverages usually used for recreational purposes and/or hand sanitizers used in an attempt to disinfect the body. History obtained from the patient or accompanying relatives determined the product that the patient was exposed to. In‐hospital diagnosis of EtOH poisoning was based on history and clinical presentation, as serum EtOH concentration cannot be routinely measured in an emergency condition.

The LMO established postmortem diagnosis of methanol poisoning (toxic alcohol) based on two criteria: (a) a serum methanol level >6.24 mmol/L (20 mg/dl) and/or (b) a high clinical suspicion of methanol exposure (gastrointestinal symptoms, visual disturbances, dyspnea, central nervous system signs/symptoms) with pH < 7.3 and serum bicarbonate <20 mmol/L (Hassanian‐Moghaddam et al., 2019).

Exclusion criteria

Patients with caustic ingestion and consumption of unknown substances were excluded. Hospitalized cases with duplicate, inaccurate, and missing data as well as outpatients with alcohol exposure were excluded (Figure ​(Figure1,1, see below).

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FIGURE 1

STROBE statement

Case matching

To identify fatal cases among those hospitalized, LMO data were matched to data from the clinical toxicology centers using the following patient identifiers: name, date of birth, and national identification number. Cases that could not be matched were either (1) out‐of‐hospital deaths (LMO data only) or (2) patients who were discharged from hospital (toxicology center data only) and thus survivors.

RESULTS

DISCUSSION

Our findings show that the rate of pediatric exposure from ingestion of alcoholic beverages and hand sanitizers was significantly increased in Iran during the first 4 months of the COVID‐19 pandemic, compared to the same period in the previous year. In total, 22 children and adolescents died of methanol poisoning during the COVID‐19 pandemic in Iran, of whom 20 died in hospitals and two died in the community before arriving at a treatment center.

Methanol outbreaks during the COVID‐19 pandemic were not confined to Iran. In the United States, the CDC reported that between May and June 2020, 15 adult patients in Arizona and New Mexico had ingested alcohol‐based hand sanitizers and were subsequently admitted to a hospital. Four patients died and three were discharged with vision impairment (Yip et al., 2020). There were also reports of a methanol poisoning outbreak in Turkey with 63 deaths within 11 days, likely from counterfeit alcohol (Dağ & Kara Aydın, 2020). However, to the best of our knowledge, no pediatric cases of methanol poisoning during COVID‐19 have been reported outside of Iran.

The pediatric exposures in our study co‐occurred with the spread of misinformation on Iranian social media at the start of the pandemic, suggesting that ingesting alcohol or hand sanitizers to “wash” the gastrointestinal tract could protect against COVID‐19. Most poisoned children and adolescents were referred during the initial 2 months of the COVID‐19 epidemic in Iran (February 23 to April 22), and, not surprisingly, most patients died during this period. The prevalence of exposures decreased after the Iranian methanol outbreak (which affected adults, adolescents, and children) received substantial media attention in March/April 2020.

Among the pediatric exposure cases in our study, almost two‐thirds (62%) were younger than 15 years old, with the remainder (38%) being 15 to 18 years old. The odds of hand sanitizer exposure were higher in those younger than 15 years, whereas alcohol poisoning and fatal outcome were more common in 15‐ to 18‐year‐olds.

Our high rates of hand sanitizer exposure among under 15‐year‐olds may reflect the fact that households were stockpiling hand sanitizers at the start of COVID‐19, which may have posed increased risk for unintentional toxicity among children (Hakimi & Armstrong, 2020). Disinfectant represents a common source of pediatric exposure, as many hand sanitizers contain up to 60 to 95% EtOH or isopropyl alcohol and often have artificially added scents that might be appealing to young children (Santos et al., 2017). For instance, a total of 70,669 hand sanitizer exposures in children aged ≤12 years were reported to the National Poison Data System in the United States during 2011 to 2014 (Santos et al., 2017).

Children are prone to experiencing complications from unintentional/accidental poisoning. Children are naturally curious and unaware of the consequences of exposure to toxic agents. Compared to adults (and adolescents), young children generally have a lower body weight and are therefore more vulnerable to exposure to such products, resulting in more severe intoxications (Peden et al., 2008; Yip et al., 2020).

It is generally assumed that young children, including infants, are at greater risk of developing complications from alcohol intoxication than older children and teenagers. Young children have decreased liver glycogen stores, which increase their risk of developing hypoglycemia, and have various pharmacokinetic parameters that make them more susceptible to development of alcohol toxicity (Madsen, 1990).

However, in our study, 15‐ to 18‐year‐olds, although fewer in number, had worse prognosis than under 15‐year‐olds. This is possibly because under 15‐year‐olds were exposed unintentionally to a lower amount of hand sanitizers and admitted sooner as they were under the care of adults, whereas 15‐ to 18‐year‐olds deliberately ingested alcoholic beverages (and in larger volume) and were admitted later. These prognostic factors have already been discussed in the literature (Kalkan et al., 2003). We could detect only 1 death due to hand sanitizers in the current study. The possibility of more EtOH concentrations in hand sanitizers, less ingested volume, and early admission through caring parents may explain lower mortality rate in nine referral centers (one out of 103 = 1%) in children under 15.

Accordingly, five out of the six cases who reported suicidal intent were in the 15‐ to 18‐year age category, including one fatal case (age: 17 years). The fatality rate of this group was five out of 53 cases (9.4%), which is similar to the average mortality of 9 to 14% in the current outbreak in the whole population (Hassanian‐Moghaddam et al., 2020). The higher metabolic acidosis in older children, the more evidence in favor of methanol poisoning with need for hemodialysis and higher mortality rate.

Our results support early findings by Gormley et al. who showed that older children were more likely to report intentional ingestion and to have adverse health effects and worse outcomes compared to younger children (Gormley et al., 2012).

Our study has several limitations. We requested data from 12 academic centers, but only nine centers agreed to cooperate with us. Our data are therefore likely not representative of the entire country. Also, due to the retrospective nature of the study, we had to contend with missing data. Another limitation concerned the lack of measurement of serum methanol and EtOH levels in most cases, even though we tried to compensate by evaluating VBGs and patients’ clinical presentation.

Acute methanol and EtOH intoxication may be indistinguishable early on, which suggests a risk of misclassification bias. Future research should focus on how monitoring of alcohol products and early warning systems can be established to prevent further toxic alcohol outbreaks.

CONCLUSION

COVID‐19 misinformation at the start of the pandemic in Iran was associated with poisonings from alcoholic beverage and hand sanitizers in children and adolescents, resulting in at least 22 fatalities in this age group. Parents need to be educated about the correct use of alcoholic sanitizers, with adult supervision and proper child safety precautions to prevent unintended adverse consequences.

Physicians should be trained to recognize the clinical manifestations of poisoning from toxic alcohols in order to initiate timely treatment and prevent long‐term morbidity or mortality.

CONFLICT OF INTEREST

The authors have no conflict of interest to declare.

ACKNOWLEDGMENTS

Notes

Mahdavi, S. A. , Kolahi, A.‐A. , Akhgari, M. , Gheshlaghi, F. , Gholami, N. , Moshiri, M. , Mohtasham, N. , Ebrahimi, S. , Ziaeefar, P. , McDonald, R. , Tas, B. , Kazemifar, A. M. , Amirabadizadeh, A. , Ghadirzadeh, M. , Jamshidi, F. , Dadpour, B. , Mirtorabi, S. D. , Farnaghi, F. , Zamani, N. , & Hassanian‐Moghaddam, H. (2021). COVID‐19 pandemic and methanol poisoning outbreak in Iranian children and adolescents: A data linkage study. Alcoholism: Clinical and Experimental Research, 45, 1853–1863. 10.1111/acer.14680 [Europe PMC free article] [Abstract] [CrossRef] [Google Scholar]

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