Int J Adolesc Med Health 2015; 27(1): 69–72

Mathias B. Forrester*

Characteristics of hand sanitizer ingestions by adolescents reported to poison centers Abstract

Keywords: alcohol; ethanol; hand sanitizers; poison center.

Background: There had been reports of adolescents using hand sanitizers to obtain alcohol and ending up in emergency departments with alcohol poisoning. Objective: This study aimed to describe the pattern of adolescent ingestions of hand sanitizers reported to a statewide poison center system. Subjects: Our study subjects included patients aged 13–19  years who reported hand sanitizer ingestions as reported to Texas poison centers during 2000–2013. Materials and methods: The distribution of the ingestions was determined for various demographic and clinical factors. Results: Of 385 total cases, 61% of the patients were male, and the mean age was 15.3 years. The ingestion reason was unintentional (61%), intentional abuse/ misuse (18%), and malicious (10%). Ingestion site was most frequently reported to be the patient’s own residence (53%), followed by school (35%). About 77% of the patients were managed on site. The medical outcome was serious (moderate effect or unable to follow-potentially toxic) in 5% of the cases. The most frequently reported adverse clinical effects were vomiting (5%), abdominal pain (4%), nausea (4%), throat irritation (4%), and drowsiness (2%). Conclusion: Adolescents who ingested hand sanitizers were more likely to be male and younger. One-third of the ingestions occurred at school, suggesting that school personnel might be made aware of the potential problem of hand sanitizer ingestions by adolescents. Nevertheless, despite the potential for serious outcomes from adolescent hand sanitizer ingestion, most of the ingestions reported to poison centers are not likely to be serious and can be successfully managed outside of a healthcare facility.

DOI 10.1515/ijamh-2014-0014 Received March 1, 2014; accepted April 17, 2014; pre­ viously published online May 31, 2014

*Corresponding author: Mathias B. Forrester, BS, Epidemiology and Disease Surveillance Unit, Texas Department of State Health Services, 1100 W 49th Street, Austin, TX 78756, USA, Phone: +1-512-776-7111, Fax: +1-512-776-7689, E-mail: [email protected]

Introduction Hand sanitizers are antimicrobial agents supplied in liquid, gel, or foam formulations. The most common types of hand sanitizers used in the United States are alcoholbased, which contain 60% or more ethanol or isopropanol. They are fast-acting and significantly reduce microorganisms on the skin. Ingestion of hand sanitizers can have serious adverse effects. Acute ethanol intoxication can result in such effects as tachycardia, cardiac dysrhythmias, central nervous system depression, ataxia, tremors, seizures, nausea, vomiting, diarrhea, hepatic injury, hypothermia, and respiratory depression (1). Deaths due to hand sanitizer ingestion have been reported (2, 3). Much attention has been given to unintentional hand sanitizer ingestions by young children (4–6). However, intentional ingestions also occur. The literature on intentional ingestions of hand sanitizers has noted that these ingestions often occurred among at-risk populations in healthcare settings (2, 3, 7–9). Hand sanitizer abuse also has been observed among correctional facility inmates (10). One study that examined hand sanitizer exposures reported to United States poison centers during 2005–2009 found that the rate of intentional exposures increased during this time period (2). Concerns have been raised about intentional hand sanitizer ingestion among adolescents. There have been reports of teenagers ingesting hand sanitizers and ending up in emergency departments with alcohol poisoning (11). The products are inexpensive and readily accessible, even in schools. Moreover, instructions on how to distill alcohol from hand sanitizers can be found on the Internet. Meanwhile, published information on adolescent ingestions of hand sanitizers is limited. The intent of this study, therefore, was to describe such ingestions reported to a large, statewide poison center system.

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70      Forrester: Hand sanitizer ingestions

Materials and methods The data source for this retrospective investigation was the Texas Poison Center Network (TPCN), consisting of six poison centers that together cover the entire state. Currently, Texas has a population of over 25 million, of which almost 2.5 million are aged 13–19 years. The six poison centers use a single, common electronic database to collect demographic and clinical information on all calls in a consistent manner. The data fields and allowable data options are standardized by the American Association of Poison Control Centers (AAPCC) (12). Cases examined in this study were hand sanitizer ingestions reported to the TPCN during 2000–2013, where the patient’s age was 13–19  years or otherwise classified as “adolescent”. All cases for whatever exposure reason (unintentional, intentional, etc.) were included because some patients may not have been truthful when describing the circumstances of the exposure. Ingestions involving other substances, in addition to the hand sanitizer, and those cases not followed to a final medical outcome were included. Ingestions reported from outside of Texas were excluded. The distribution of cases was determined for year and month of exposure, patient age and gender, presence of additional substances in the exposure, exposure site and reason, management site, medical outcome, as well as most common adverse clinical effects and treatments. Often, it was impossible to identify the exact ingredients in the hand sanitizer involved in a particular ingestion, so no analysis by ingredients was performed. The medical outcome or severity of an exposure is assigned by the poison center staff and is based on the observed or anticipated adverse clinical effects. Medical outcome was classified according to the following criteria: no effect (no symptoms due to exposure), minor effect (some minimally troublesome symptoms), moderate effect (more pronounced, prolonged symptoms), major effect (lifethreatening symptoms or those that caused significant disability or disfigurement), and death. A portion of exposures were not followed to a final medical outcome because of resource constraints or the inability to obtain subsequent information on the patient. In these instances, the poison center staff recorded the expected outcome of the exposure. These expected outcomes were grouped into the following categories: not followed but judged as nontoxic exposure (symptoms not expected), not followed but minimal symptoms were possible (no more than minor symptoms possible), and unable to follow but judged as a potentially toxic exposure. Another medical outcome category was unrelated effect, where the exposure was probably not responsible for the symptoms. The Texas Department of State Health Services Institutional Review Board considers this analysis exempt from ethical review.

Results

Table 1 Monthly adolescent hand sanitizer ingestions reported to the Texas Poison Center Network during 2000–2013. Month



Number

January   February   March   April   May   June   July   August   September   October   November   December   Total  

26 38 31 42 38 31 15 21 35 38 44 26 385

                         

6.8 9.9 8.1 10.9 9.9 8.1 3.9 5.5 9.1 9.9 11.4 6.8

lowest during July and August, followed by December and January. The study sample consisted of 234 (60.8%) males and 151 (39.2%) females. Table 2 presents the distribution by patient age. Excluding those patients whose exact age was unknown, the mean age was 15.3 years, and patients aged 13–16 years accounted for 70.9% of the total sample. Most (203, 52.7%) exposures occurred at the patient’s own residence, while some (133, 34.5%) occurred at school. Other cases (49, 12.7%) occurred at other or unknown locations. The exposure was reported to be unintentional in 236 (61.3%) of the cases, intentional abuse or misuse in 71 (18.4%), tampering or malicious in 40 (10.4%), suspected attempted suicide in 23 (6.0%), and other and unknown in 15 (3.9%) cases. The preponderance (297, 77.1%) of patients were managed on site (non-healthcare facility), 34 (8.8%) were already at or en route to a healthcare facility when the poison center was contacted, 21 (5.5%) were referred to a healthcare facility by the poison center, and 33 (8.6%) were managed at other or unspecified locations. The

Table 2 Patient age of adolescent hand sanitizer ingestions reported to the Texas Poison Center Network during 2000–2013. Patient age, years

There were 385 adolescent ingestions of hand sanitizers reported to Texas poison centers during 2000–2013. Of these, six (4.2%) were reported to have involved other substances in addition to the hand sanitizer. The annual number of exposures increased from six in 2000 to 60 in 2009, before falling to 51 in 2013. Table 1 shows the monthly number of ingestions. The numbers of cases were

  Percent



Number

13   14   15   16   17   18   19   “Adolescent” unspecified  Total  

72 70 71 60 40 42 16 14 385

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  Percent                  

18.7 18.2 18.4 15.6 10.4 10.9 4.2 3.6

Forrester: Hand sanitizer ingestions      71

distribution by final medical outcome was 84 (21.8%) no effect, 41 (10.6%) minor effect, four (1.0%) moderate effect, 43 (11.2%) not followed but judged as nontoxic, 193 (50.1%) not followed but minimal symptoms possible, 15 (3.9%) unable to follow but judged as a potentially toxic exposure, and five (1.3%) unrelated effect. No major effects or deaths were reported. Table 3 lists the reported specific adverse clinical effects. The most commonly reported treatments were administered through dilution (269, 69.9%), food (127, 33.0%), and IV fluids (seven, 1.8%).

Discussion This investigation describes adolescent hand sanitizer ingestions reported to a large poison center system. Many hand sanitizers contain ethanol and are readily available to children. As a result, hand sanitizers pose a risk of causing acute ethanol intoxication in adolescents. The annual number of adolescent hand sanitizer ingestions increased during the first part of the study period, peaking in 2009 before dropping to a lower level during the next 4 years. One possible explanation for the peak in cases during 2009 was that the H1N1 influenza virus outbreak occurred that year, and frequent use of hand sanitizers was among the recommendations for reducing risk of infection. This was associated with an increase in hand sanitizer exposures reported to various poison centers, including those in Texas (13–15). In the Texas study, the total number of hand sanitizer exposures decreased the following year (13). The ingestions demonstrated a seasonal trend with fewer cases reported during December–January and July–August, which are the months when Texas children are usually out of school. This information as well as the Table 3 Most common specific adverse clinical effects with adolescent hand sanitizer ingestions reported to the Texas Poison Center Network during 2000–2013. Clinical effect



Number

Vomiting   Abdominal pain   Nausea   Throat irritation   Drowsiness/lethargy   Oral irritation/pain   Headache   Ocular irritation/pain   Total  

21 17 15 14 9 6 5 5 385

  Percent                  

5.5 4.4 3.9 3.6 2.3 1.6 1.3 1.3

observation that over one-third of the ingestions occurred at school suggest that school personnel might be made aware of the potential for abuse of hand sanitizers by their students. Efforts might also be made to monitor or restrict access to hand sanitizers in schools. The majority of patients were male. This was consistent with the nationwide poison center study of hand sanitizer exposures, which found that 60% of patients aged 6–19 years were male (2). Other recent studies using Texas poison center data found that adolescents who used synthetic cannabinoids and synthetic cathinones also tended to be male (16, 17). Most of the patients in the present investigation were aged 13–16 years. The phenomenon of younger teenagers ingesting hand sanitizers may be due to the fact that older adolescents have access to alternative sources of alcohol or other types of substances of abuse. The preponderance of ingestions was not known or expected to result in serious outcomes. Even the most commonly reported specific adverse clinical effects were observed in a fraction of the patients. These clinical effects tended to be gastrointestinal (vomiting, abdominal pain, nausea) or neurological (drowsiness, headache) in nature and have been reported with ethanol intoxication. As a consequence, it might be expected that the majority of adolescents would not need to be seen at a healthcare facility. In fact, 77% of the patients were managed on site. Moreover, most of the treatments tended to be some form of decontamination (e.g., via dilution or food) that can be performed outside of a healthcare facility. This study is subject to various limitations. Reporting of hand sanitizer ingestions to Texas poison centers is voluntary. Thus, those ingestions that are reported may not be representative of all adverse hand sanitizer ingestions that occur in the population. Moreover, because of the sensitive nature of alcohol abuse, particularly among children, a portion of those ingestions reported to the Texas poison centers for other reasons might actually have been abuse. As a result, the proportion of ingestions recorded as intentional misuse or abuse might be considered to be a lower limit.

Conclusion Adolescents who ingested hand sanitizers and were reported to Texas poison centers were more likely to be male and younger. Ingestions were more frequently reported during the school year, and one-third of the ingestions occurred at school, suggesting that school personnel might be made aware of the potential problem

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72      Forrester: Hand sanitizer ingestions of hand sanitizer ingestions by adolescents. Despite the potential for serious outcomes from adolescent hand sanitizer ingestion, such as alcohol poisoning, most of the ingestions reported to Texas poison centers were not likely to be serious and were successfully managed outside of a healthcare facility. Nevertheless, parents and professionals working in the education field might be made aware of the situation. Acknowledgments: There was no study sponsor or unique source of support. Conflict of interest statement: The author is aware of no conflict of interest.

References 1. Leikin JB, Paloucek FP, editors. Poisoning and toxicology compendium with symptoms index. Hudson, OH, USA: Lexi-Comp Inc., 1998;266–8. 2. Gormley NJ, Bronstein AC, Rasimas JJ, Pao M, Wratney AT, et al. The rising incidence of intentional ingestion of ethanol-containing hand sanitizers. Crit Care Med 2012;40:290–4. 3. Schneir A, Clark RF. Death from ingestion of an ethanol-based hand sanitizer in the emergency department waiting room. Clin Toxicol (Phila) 2012;50:711–2. 4. Forrester MB. Potential toxicity of hand sanitizers. TX Public Health J 2010;62:27. 5. Miller M, Borys D, Morgan D. Alcohol-based hand sanitizers and unintended pediatric exposures: a retrospective review. Clin Pediatr (Phila) 2009;48:429–31.

6. Alsop JA, Daubert GP. A two-year review of pediatric liquid hand sanitizer ingestions. Clin Toxicol (Phila) 2008;46:605. 7. Darracq MA, Ghafouri N, Pesce A, Cantrell FL. Significant hand sanitizer intoxication following crude extraction method with in vitro ethanol concentration analysis. Clin Toxicol (Phila) 2012;50:711. 8. Herbert JX, Cassidy N, Tracey JA. The need for prevention of intentional ingestion of alcohol hand gels in Irish hospitals. Clin Toxicol (Phila) 2009;47:481. 9. Bookstaver PB, Norris LB, Michels JE. Ingestion of hand sanitizer by a hospitalized patient with a history of alcohol abuse. Am J Health Syst Pharm 2008;65:2203–4. 10. Roche KM, Barko IR, McDonagh J, Bayer MJ, Sangalli B. Hand sanitizer abuse. Clin Toxicol (Phila) 2006;44:633–4. 11. Gorman A. A troubling trend in teens drinking hand sanitizer. Los Angeles Times April 24, 2012. Available at: http://www.latimes.com/news/local/la-me-hand-sanitizer-20120424,0,4801404.story. 12. Mowry JB, Spyker DA, Cantilena LR, Bailey JE, Ford M. 2012 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 30th Annual Report. Clin Toxicol (Phila) 2013;51:949–1229. 13. Forrester MB. Changes in Texas poison center call patterns in response to H1N1 influenza outbreak. TX Public Health J 2012;64:14–8. 14. Eronen AK, Mustonen H, Hoppu K. Pandemic hand hygiene recommendations increased inquiries related to alcoholic hand sanitizers in children under 6 years. Clin Toxicol (Phila) 2011;49:237. 15. Thrane EV, Skjerdal JW, Ziesler T, Borgeraas J. Pandemic flu increases risk of poisonings in children. Clin Toxicol (Phila) 2010;48:265. 16. Forrester MB. Adolescent synthetic cannabinoid exposures reported to Texas poison centers. Pediatr Emerg Care 2012;28:985–9. 17. Forrester MB. Adolescent synthetic cathinone exposures reported to Texas poison centers. Pediatr Emerg Care 2013;29:151–5.

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Characteristics of hand sanitizer ingestions by adolescents reported to poison centers.

There had been reports of adolescents using hand sanitizers to obtain alcohol and ending up in emergency departments with alcohol poisoning...
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