key: cord-0862306-qm6zn05d authors: Mousavi-Roknabadi, Razieh Sadat; Arzhangzadeh, Melika; Safaei-Firouzabadi, Hosain; Mousavi-Roknabadi, Reyhaneh Sadat; Sharifi, Mehrdad; Fathi, Nazanin; Jelyani, Najmeh Zarei; Mokdad, Mojtaba title: Methanol poisoning during COVID-19 pandemic; A systematic scoping review date: 2021-11-24 journal: Am J Emerg Med DOI: 10.1016/j.ajem.2021.11.026 sha: 2831532203b24e2506b67bdaec663a6bdff3da87 doc_id: 862306 cord_uid: qm6zn05d 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. The coronavirus disease 2019 (COVID-19) is an infectious disease that first appeared in December 2019 in China. Symptoms of the virus range from mild to severe disease, and in some cases can be fatal (1, 2) . The long-term effects of COVID-19 on physical and mental health are still under study (3) . This new health issue has clinical, psychological, and emotional consequences, the collapse of the health system, and economic slowdown for the international communities (4, 5) . The World Health Organization (WHO) has proposed preventive measures and a healthy lifestyle with an effective immune system to fight and protect against this infection. One of the best recommendations of this organization is to disinfect hands with soap or 60% alcohol disinfectant (6) . Also, Center for Disease Control and Prevention (CDC) has recommended the use of hand sanitizers with a greater than 60% ethanol or 70% isopropanol for hand hygiene (7). Although wide ranges of disinfection detergents are available, alcoholic disinfectants are the best for viruses (8) . But, some hand sanitizer products may contain unacceptable active ingredients (especially methanol) other than the recommended alcohols (ethanol or isopropyl alcohol), which can be toxic due to respiratory and dermal exposure, and it may lead death if swallowed (9) . Alcohol (ethanol) is a substance in alcoholic beverages, too. Other toxins that may have an ethanol odor may be added to fake beverages produced informally or illegally, or may be present in alcoholic beverages not intended for human consumption, such as hand sanitizers (10) . One of these similar substances is methanol (also known as methyl alcohol or wood alcohol), which is commonly available chemical with a variety of uses as a solvent, in chemical synthesis, and as a fuel (11, 12) . Although products containing methanol are easily available, but illicit and informal productions are responsible for most methanol poisoning (13) . Methanol is highly toxic with high mortality and morbidity (including vision problems, especially blindness, metabolic, cardiac, and extensive neurological disorders) even after hospital discharge (14) (15) (16) (17) . Hemorrhagic and non-hemorrhagic necrotic of basal ganglia, white matter necrosis and diffuse cerebral edema may lead to a serious prognosis (18, 19) . Methanol poisoning is mostly occurred by direct consumption in doses as small as 15 mL and rarely through inhalation or skin absorption that it has little toxicity. But when it was metabolized into products, it is highly toxic especially for central nerve and gastrointestinal systems (10, 12, 14, 15) . This substance is rapidly absorbed from the gastrointestinal tract in less than 10 minutes and reaches the peak plasma concentration in 30 minutes to one hour (13) . With the onset of the COVID-19 pandemic, misinformation about the alcohol's potential to neutralize this virus, led to a significant increase in methanol-induced mortality. Reports as of April 27, 2020 from the Ministry of Health of Iran showed 5011 patients with methanol poisoning, with 505 confirmed deaths. The total number of deaths from February to April 2020 was almost eight times higher than the corresponding number of confirmed deaths for the same period in 2019, but reports before 2019 show fewer mortality due to methanol poisoning (20). The recent and perhaps most important outbreak coincided with the COVID-19 pandemic (21). In some provinces in Iran, for example in Fars province, southern Iran, the total mortality rate from methanol poisoning was higher than COVID-19, which many reasons were presented in various studies. One reason was that the death from alcohol poisoning happens more quickly than death from . Also, outbreaks of methanol poisoning in Iran in 2007, 2013 and 2018, led to significant complications and mortality (19, 21, 23) . In Norway (2002) (2003) (2004) , 59 poisoned patients were reported with 17 deaths (14) . Likewise, outbreaks were reported in the Czech Republic, Estonia, Libya, Kenya, Malaysia, and other countries with fewer death (24-27). In this systematic scoping review, it was aimed to assess the epidemiology of methanol poisoning, clinical findings and patients' management, causes, as well as recommendations regarding prevention or reduction of methanol poisoning during COVID-19 pandemic. The present systematic scoping review was conducted based on the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) statement (28). As was shown in Figure 1 , a multi-step search strategy was performed. The electronic literature searches were conducted to identify all relevant studies on MEDLINE (accessed from PubMed), Science Direct, and Scopus electronic databases from December 01, 2019 to September 10, 2020, using MESH terms and the related keywords (Table 1) . Google Scholar and researchgate.net were also reviewed manually to explore the grey literature in English. To ensure literature saturation, the reference lists of the included studies or relevant reviews J o u r n a l P r e -p r o o f identified through the search were scanned. All the following searches were conducted by three authors [MA, RSM, HS]. We focused on the studies on the epidemiology, clinical findings and patients' management, causes, as well as recommendations regarding prevention or reduction of methanol poisoning during COVID-19 pandemic. Articles were excluded if they were not relevant, or were performed before the COVID-19 pandemic, through reading the titles and the abstracts [RSM, MA, RSM]. The target population were all patients around the world with methanol poisoning. Full texts of the studies were evaluated by three authors [RSM, MA, RSM]; they decided whether these met the inclusion criteria, independently. They resolved any disagreement through discussions, and finally the articles were selected based on consensus. Neither of the authors were blind to the journal titles or to the study authors or institutions. Then, the level of evidence of each study was determined (29). The following data were extracted from the included studies and recorded in a Microsoft Excel sheet, 2016: study authors, country, title, and main findings [RSM, MA, HS]. Ethical issues (including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors. In total, 86 (23 articles in Medline, 24 articles in Scopus, 16 article from Science Direct, and 23 articles from other resources) were achieved at the first step search. After initial assessment 22 duplications were found. After the identification and the screening, 29 articles were selected as potential studies. After reading the full text of these articles, 15 articles formed the final sample and considered for the final data extraction (5, 10, 19, 21, 22, (30) (31) (32) (33) (34) (35) (36) (37) (38) (39) . Inter-rater agreement following the first round of screening between the investigators was J o u r n a l P r e -p r o o f 95.31% (Cohen's k=0.89). Within the second round of screening, inter-rater agreement rose to 100%. Table 2 shows the summary of these studies. Fourteen (14/15) studies were peer-reviewed (5, 10, 19, 21, 22, (30) (31) (32) (33) (34) (35) (36) (37) (38) ) and 1/15 of them was in-review (39). Our investigation illustrated that the most of available reported evidences (13/15) were in the format of letter to editor, commentary and short reports (5, 10, 19, 21, 22, (30) (31) (32) (33) (34) (36) (37) (38) , and only 2/15 were original articles (35, 40). None of the studies were interventional, and none of them followed the patients. As was shown in Table 3 , most of the studies (12/15) were reported from Iran (5, 10, 19, 21, 22, 30, (32) (33) (34) (35) (36) (37) (38) (39) . We summarized the results 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. All studies mentioned the clinical and paraclinical findings in these patients, which were shown in Table 4 . Visual impairment, severe anion-gap metabolic acidosis, gastrointestinal symptoms, and death were the most suggestive findings in patients with methanol poisoning. The causes of methanol poisoning during COVID-19 pandemic were disused in 12/15 studies (5, 10, 19, 21, 22, 30, (32) (33) (34) (36) (37) (38) , which we categorized them in three areas (3P): a) public; b) physicians; and c) policy makers (Table 4) . Moreover, 13/15 studies had recommendations for prevention or reduction of methanol poisoning during COVID-19 pandemic (5, 10, 19, 21, 22, (30) (31) (32) (33) (34) (36) (37) (38) , which we categorized them in three areas (3P): a) public; b) physicians; and c) policy makers (Table 5 ). Figure 2 shows the mapping of recommendations for policy makers in three categories; a) building trust; b) educating and warning; and c) controlling and monitoring. In this systematic scoping review, fifteen studies were assessed, which that the obtained results were summarized in four areas. Here we will discuss the findings. (5) . It was reported that the age of poisoned patients in Iran ranged between 14 and 78 years (22). Only a study in Australia reported one patient with methanol poisoning due to ingestion of the contents of methylated with containing of more than 60% methanol (31). Two studies were from USA, that 9 patients with methanol poisoning in New Mexico in one of them (10) , and 15 patients in another one (38). It is worthy to mention that the reported patients and mortality are based on recognized and reported cases, and they certainly are not an accurate denominator due to many patients not receiving medical care or not being recognized by providers. The recent outbreak is the largest methanol mass poisoning outbreak throughout Iran and the world in recent decades. Methanol mass poisoning outbreak has previously been reported in In the reviewed studies, the reported poisoned patients and deaths were based on patients' histories, clinical symptoms, blood tests, toxicology tests, and autopsies. Morbidity and mortality in methanol poisoning are most prevalent amongst young and healthy people (30). Most of studies mentioned the clinical and paraclinical findings in patients with methanol poisoning. Visual impairment especially blindness, severe anion-gap metabolic acidosis, gastrointestinal symptoms (such as; abdominal pain, nausea, and vomiting), and death were the most suggestive findings in these patients (19, 21, 31-33, 38). It was documented that visual impairment, metabolic acidosis with an elevated anion gap, and acute kidney injury are reported very specific presentations of methanol poisoning. However, difficulty breathing, pupillary dilation, hypotension, agitation, confusion, headache, difficulty walking, stomachache, diarrhea, jaundice, nausea and sometimes blood vomiting, leg cramps, and weakness was not specific for methanol poisoning (41). These changes can be revealed in the brain computed tomography (CT) scan, but magnetic J o u r n a l P r e -p r o o f resonance imaging (MRI) can illustrate these in the best way (33). Taheri et al. reported that 66.6% of patients with acute methanol poisoning had abnormal findings in brain CT scan (42). They indicated that in addition to clinical and laboratory findings, the presence of putamen hemorrhage and subcortex white matter necrosis, which are detectable in brain CT scans of patients with acute methanol poisoning, are associated with poor outcomes. Therefore, this modality will be useful for physicians (14) . Sefidbakht et al. also stated that CT scans and MRI reveal changes in patients with methanol poisoning, which can be helpful for physicians (18) . Supportive care and correction of acidosis should be started for all patients (36, 38). Fomepizole as a competitive inhibitor of alcohol dehydrogenase, in tandem with Poison Center consultation is mandatory for these patients. On the other hand, ethanol is second-line for treatment when fomepizole is unavailable (10) . Also, hemodialysis can improve hospital outcomes with toxin elimination (33, 38, 43). (12) . Also, Hassanian-Moghaddam concluded that pH <7 and coma at the time of admission, as well as delayed hospital admission (>24 hours), are associated with poor prognosis in these patients (45). An issue that was mentioned is that many difficulties in the diagnosis and management of patients with alcohol poisoning because of lack of laboratory facilities to detect blood levels of toxic alcohols and their metabolites (ethanol, methanol, format, ethylene glycol, oxalate, and isopropanol concentrations), either gas chromatography with or without mass spectrometry confirmation (as gold standard method) or enzymatic assays; to measure plasma osmolality, chloride tests for calculating anion gap, and serum lactate level in most of teaching and referral hospitals in Iran, due to United States sanctions against this country. So, the toxicologists use blood gas analysis to detect these patients. In the management of methanol poisoning, administration of denatured ethanol with Bitrex (denatonium benzoate) orally or via a nasogastric tube as an antidote, folic acid as a cofactor, and hemodialysis for J o u r n a l P r e -p r o o f the elimination of toxic alcohols and its metabolites from the blood are recommended. It was reported that no intravenous ethanol, intravenous thiamine, Fomepizole (4-methylpyrazole), and Leucovorin (Folinic acid) are available in Iran for the management of these patients, which can result of poor prognosis and death (41). Multiple potential causes were raised by studies, which seems intertwined. Although there are wide ranges of disinfectant available, alcoholic disinfectants are the best disinfectants for viruses (46). By starting the COVID-19 pandemic, sale of alcohol was increased 14-30% in several countries for disinfecting purposes (47). Also, lack of public awareness about the prevention and treatment of COVID-19, different types of alcohol, hazards of toxic alcohol, and how to use it properly as well as fear and concern from being infected by the virus led to wide use of alcohol-based detergents, especially methanol (22, 32, 36-38). Methanol has few disinfectant properties, and oral methanol consumption is associated with severe intoxication, blindness, and death (17) . Many people thought drinking or gargling alcohol-based drinks may protect and disinfect their bodies against COVID-19, when some evidence suggested that people infected with COVID-19 have the virus on their stool and gastrointestinal system (5, 8, 22, 30, 32, 41, 47) . It is worth mentioning that transcutaneous methanol poisoning is rare, that its absorption depends on many factors such as its form, contact time, dose, concentration, as well as size of the exposure area (38). Although methanol poisoning outbreaks are historically described, relations to consumption of hand sanitizer have been rarely observed in the previous reports. Some of responsible organizations notified the public about the dangers of formulations of hand sanitizers marketed by some manufacturers, which used methanol and it was not listed as an ingredient (31, 48). Also, in this pandemic, people tend to rely upon rumors, myths and conflicting information, as well as harmful practices from unofficial communication channels and social media (21, 22, 30, 32, 34, 37), because they do not trust the organizations or agencies publishing the true information, and they will not follow their advice (22, 30, 34). Moreover, making consumed alcoholic drinks at home or unauthorized workrooms and repackaged in famous brands containers, and reduction in the amount of ethanol on the market because of the large industrial use of ethanol for the manufacturing of hand sanitizers led to shift the use of methanol instead of ethanol by individuals, who were previously using ethanol for the manufacturing of alcohol beverages (5, 22, 30, 32, 36, 37) . Furthermore, it is worth J o u r n a l P r e -p r o o f mentioning that increased unstructured leisure time, decreasing sports activity due to closure of gyms, and the mass advertisement to the public to remain home have all led to increased use of alcohol drinks (5) . In addition, poisoned patients fear from recognition or reporting to poison centers or state health departments and arresting them. Hence, they may be reported to a poison center late, and they may refuse to provide an accurate medical history (38). On the other hand, several studies reported the reasons at the policy makers' level. It seems that faulty understanding and mismanagement by the ruling authorities is one of the main cause of mass methanol poisoning (32). Almost all existence strategies have mainly focused on palliative care and treating alcohol poisoning secondary to the consumption of illegal methanol at individual levels, not prevention programs (36). Some studies mentioned that obtaining alcoholic drinks in some counties is far more difficult than in other countries in which selling, consuming, producing, and distributing of alcoholic beverages is illegal (5, 30) . Consequently, people only access smuggled or illegally homemade alcoholic beverages. Ethanol is commonly used of for the manufacturing of alcohol beverages. During the COVID-19 pandemic, the large industrial use of ethanol for the manufacturing of hand sanitizers, following the shortage of it, these people shift to use methanol instead, since it is cheaper and widely available in the markets (5, 36) . Some sellers of alcoholic beverages and disinfectants add bleach to methanol to discolor it, and sell it at a higher price instead of ethanol (22, 34, 37). Authorities are not taking the needed measures to address this issue, which led to the absence of public awareness. Importance of early identification and initiation of treatment, which is better to be complemented by "active case finding" was recommended by studies (19). But, sanctions on access to essential medicines and equipment, the shortage of medical care and diagnostic capacity, as well as not having proper laboratory equipment to determine the blood concentration of toxic alcohols were the main barriers (19, 32, 36). Also, few studies mentioned that challenge in the taking an exposure history in patients with altered mental status and unable to test for a blood methanol level in some hospitals, which were raised at the physicians' level (19). Studies recommended many solutions to decrease or prevent methanol poisoning during this pandemic, that we summarized them in 3P: People, Physicians, and Policy makers; however, they are intertwined. It was stated by Aghababaeian that effective risk communication can help to avoid rumor and prevent personal and public health risks (22). As was mentioned above, in this pandemic, people may rely upon rumors and and misleading information, and harmful practices from unofficial communication channels and social media which encouraged them to drink or gargle alcohol to prevent or cure COVID-19 (22, 30, 32, 34, 37). On the other hand, they did not trust the organizations or agencies publishing the true information. In this regard, building trust by policy makers is recommended (22). In the second step, in the situations of crisis, to raise public awareness, timely and accurate news and information about the fatal outcomes of consumption of fake alcohols, as well as using reliable disinfectants must be provided to the people, and the consequences of the false information must be taken into account (8, 36, 37) . Also, they should know about different types of alcohol and should be informed that the J o u r n a l P r e -p r o o f available ethanol might actually be methanol, so they should be sensitizers from reliable markets (9, 22, 37) . In this regard, social media should widely use to educate the public about risk, risk management, and health and safety issues (21, 22). It is worth mentioning that informing people that there is no policy in the hospitals to report alcohol users to the justice authorities and this information is considered highly confidential, is highly recommended In regards of controlling and monitoring, it is necessary to develop regulatory and monitoring mechanisms during the process of manufacturing of sanitizers to verify the purity of alcoholbased hand sanitizers (22, 32, 46). As was mentioned previously, methanol should not be used in hand sanitizers, because it is a highly toxic detergent, which can cause severe reactions when exposed to the skin, lungs or mouth (46). Methanol staining by manufacturers should be mandatory so that people can easily distinguish between it and ethanol, which is colorless (22, 32). Another recommendation was the improving the surveillance and early warning systems for alcohol poisoning in the purpose of better controlling and monitoring (23). Also, cooperation between authorities at the local, national, and international levels to combat the illicit alcohol should be more strengthen (22). Moreover, providing diagnostic and therapeutic facilities at least for referral hospitals by policy makers is essential (41). The policy makers should adhere to the WHO guidance on formulations of alcohol-based hand sanitizers, undertake a regular inspection of manufacturers and quality testing of sample hand sanitizers from the market, strength the supervision over pharmaceutical companies for production of alcohol containing products, as well as the sale of alcohol on the black markets (5, 9, 30, 37) . The main limitation of this systematic scoping review stems from the lack of high-quality evidence and interventional studies, and the provided causes and recommendations were based on the authors' experiences and opinions. None of the studies followed up the participants. The results showed that the recent outbreak is the largest methanol mass poisoning outbreak throughout Iran and the world in recent decades. It seems that the causes of methanol poisoning during the COVID-19 pandemic are intertwined, and most of them are modifiable J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f gargling alcohol-based in the hope of disinfecting the virus in the mouth or within their bodies and its protection against COVID-19.  Alcoholic beverage through unlawful means such as personal home production and illegal imports from some neighboring countries.  Making consumed alcoholic drinks at home or unauthorized workrooms and repackaged in famous brands containers.  Shifting the use of methanol instead of ethanol by individuals who were previously using ethanol for the manufacturing of alcohol beverages due to unprecedented shortage in ethanol because of the large industrial use of ethanol for the manufacturing of hand sanitizers.  Fear from recognition or reporting to poison centers or state health departments in poisoned patients and arresting them.  Decreasing sports activity due to closure of gyms and the mass advertisement to the public to remain home, which led to increase the use of alcohol drinks.  Challenge in the taking an exposure history in patients with altered mental status.  Unable to test for a blood methanol level in some hospitals.  Faulty understanding and mismanagement by the ruling authorities.  Reduction in the amount of ethanol on the market.  The large industrial using ethanol for the manufacturing of hand sanitizers during the COVID-19 pandemic, following the shortage of it, shift people to use methanol instead of ethanol for the manufacturing of alcohol beverages.  Legal prohibiting of the production, distribution, and drinking of alcoholic beverage in some countries.  Smuggled and illegally banding of selling, consuming, producing, and distributing alcoholic beverages in some counties.  Increased accessibility and consumption of mainly methanolcontaining homemade and bootleg types of alcohol.  Discoloring the industrial alcohol by 5% sodium hypochlorite solution (Vitex®) and sale it instead of ethanol or drinking alcohol by profiteers.  Access smuggled or illegally homemade alcoholic beverages that may use methanol instead of ethanol.  Using methanol instead of ethanol because of its lower price and availability  Sanctions on access to essential medicines and equipment.  The shortage of medical care and diagnostic capacity to prevent COVID-19.  Not having proper laboratory equipment to determine the blood concentration of toxic alcohols.  Importance of early identification and initiation of treatment, which can be supplemented by "active case finding" by treating physicians and public health agencies. J o u r n a l P r e -p r o o f  Developing appropriate scientific policies for the prevention of alcohol poisoning.  Making proper arrangement and policies for alcohol consumption and trade.  Raising public awareness about the fatal outcomes of consumption of counterfeit alcoholic beverages sold in the black market through broadcasting various educational programs.  Educating people about different types of alcohol and the related health impacts, even if consuming alcohol is prohibited.  Informing people that the available "ethanol" might actually be methanol.  Warning about specific hand sanitizers that contain methanol.  Alert people by internationally recognized references and guidelines to not to use methanol for disinfecting hands, skin, medical supplies, and surfaces (such as door handles, desks, floors, etc.).  Warning and controlling to add color to methanol by manufacturers, so people can easily differentiate between methanol and ethanol (colorless).  Making strengthen supervision over pharmaceutical companies for production of alcohol containing products by the Food and Drug Administration of Iran.  Controlling the quality of alcoholic beverages by Food and Drug Administration.  Monitoring rumors via mainstream media, hotlines, social media, SMS messages, focus groups, feedback from community influencers and community volunteers.  Adhering to the WHO guidance on formulations of alcohol-based hand rubs.  Informed people that there is no policy in the hospitals in Iran to report alcohol users to the justice authorities and that this information is considered highly confidential.  Making amendments to the law for production, sale, and consumption of alcohols in order to improve the society health and prevent the production of toxic alcohols as beverages by legislators in Iran.  Publishing updates of affected population by emergency management officials about risk management and health and safety issues to mitigate uncertainty and rumors.  Encouraging the public by emergency management officials to remain skeptical about information coming from unofficial channels. J o u r n a l P r e -p r o o f  Including social media strategy in effective communication plan.  Improvement the surveillance and early warning systems for alcohol poisoning.  Cooperation between authorities at the local, national, and international levels to combat the illicit alcohol.  Providing essential facilities for timely diagnosis and treatment of poisonings.  Providing proper training of poisoning course in medical education.  Prosecuting ruling authorities for the methanol outbreaks.  Increasing unstructured leisure time. A complementary critical appraisal on systematic reviews regarding the most efficient therapeutic strategies for the current COVID-19 (SARS-CoV-2) pandemic COVID-19 and Unfinished Mourning COVID-19: a review. Monaldi Arch Chest Dis Epub 2020/06/06 A Surge in Methanol Poisoning Amid Pandemic: Why Is This Occurring? WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care: World Health Organization; 2009. 7. Center for Disease Control and Prevention. CDC statement for healthcare personnel on hand hygiene during the response to the international emergence of COVID-19 Alcohol Consumption Under the Shadow of Coronavirus Pandemic Hand Sanitizers Marketed in the Streets of Addis Ababa, Ethiopia, in the Era of COVID-19: A Quality Concern Tainted Hand Sanitizer Leads to Outbreak of Methanol Toxicity During SARS-CoV-2 Pandemic Clinical Toxicology practice guidelines on the treatment of methanol poisoning Role of clinical and paraclinical manifestations of methanol poisoning in outcome prediction Investigating the epidemiology of methanol poisoning outbreaks: a scoping review protocol Methanol outbreak in Norway 2002-2004: epidemiology, clinical features and prognostic signs Methanol poisoning in Iran Methanol mass poisoning in Iran: role of case finding in outbreak management Visual Disturbances in Patients With Acute Methanol Poisoning: A Cross-sectional Study: Acute methanol poisoning and visual disturbances Methanol poisoning: acute MR and CT findings in nine patients  Warning about specific hand sanitizers that contain methanol.  Never ingestion of alcohol-based hand sanitizer.  Avoiding use of specific imported products found to contain methanol.  Continuing to monitor Food and Drugs Administration's guidance.  Having high index of suspicion for methanol poisoning by physicians when evaluating adult or pediatric patients with reported swallowing of an alcohol-based hand sanitizer product or with symptoms, signs, and laboratory findings compatible with methanol poisoning.  Obtaining medical management advice by physicians from their regional poison center.  Using all alcohol-based hand sanitizers only for disinfecting hands and should never be swallowed.  Stop using alcohol-based hand sanitizers containing methanol immediately and seek immediate medical attention if they experience any concerning symptoms by consumers.  Supervision on children using hand sanitizers, and keeping these products out of reach of children when not in use.  Not ingesting alcohol-based hand sanitizer products.  Evaluation for methanol poisoning in patients with compatible signs and symptoms or after having swallowed hand sanitize.