The Methanol Poisoning Outbreaks in Libya 2013 and Kenya 2014

RESEARCH ARTICLE The Methanol Poisoning Outbreaks in Libya 2013 and Kenya 2014 Morten Rostrup1,2,3, Jeffrey K. Edwards4,5, Mohamed Abukalish6, Masoud Ezzabi7, David Some4, Helga Ritter4, Tom Menge8, Ahmed Abdelrahman9, Rebecca Rootwelt1, Bart Janssens10, Kyrre Lind11, Raido Paasma12, Knut Erik Hovda11,13* 1 Department of Acute Medicine, Oslo University Hospital, Oslo, Norway, 2 Médecins Sans Frontières International, Geneva, Switzerland, 3 Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway, 4 Médecins Sans Frontières, Nairobi, Kenya, 5 Department of International Health, School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America, 6 Libyan Emergency Medicine Association, Tripoli Medical Center, Tripoli, Libya, 7 Medical Department, Tripoli Central Hospital, Tripoli, Libya, 8 Department of Pharmacy, Kenyatta National Hospital, Nairobi, Kenya, 9 Médecins Sans Frontières, Libya Mission, Tripoli, Libya, 10 Médecins Sans Frontières Operational Centre, Brussels, Belgium, 11 Médecins Sans Frontières, Oslo, Norway, 12 Department of Anesthesiology and ICU, Pärnu County Hospital, Pärnu, Estonia, 13 The Norwegian CBRNe Centre of Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway * OPEN ACCESS Citation: Rostrup M, Edwards JK, Abukalish M, Ezzabi M, Some D, Ritter H, et al. (2016) The Methanol Poisoning Outbreaks in Libya 2013 and Kenya 2014. PLoS ONE 11(3): e0152676. doi:10.1371/journal.pone.0152676 Editor: Imti Choonara, Nottingham University, UNITED KINGDOM Received: November 27, 2015 Accepted: March 17, 2016 Published: March 31, 2016 Abstract Background Outbreaks of methanol poisoning occur frequently on a global basis, affecting poor and vulnerable populations. Knowledge regarding methanol is limited, likely many cases and even outbreaks go unnoticed, with patients dying unnecessarily. We describe findings from the first three large outbreaks of methanol poisoning where Médecins Sans Frontières (MSF) responded, and evaluate the benefits of a possible future collaboration between local health authorities, a Non-Governmental Organisation and international expertise. Copyright: © 2016 Rostrup et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Methods Data Availability Statement: Exact data on how many patients were treated with ethanol are not publicly available due to ethical and security concerns. All original data referred to in the paper will be made available by contacting the Corresponding Author. Findings Funding: Study expenses were supported from the regular operation budgets of the MSF Kenya and Libyan missions as well as Oslo University Hospital. Thus no specific funding was received for this work. Competing Interests: The authors have declared that no competing interests exist. Retrospective study of three major methanol outbreaks in Libya (2013) and Kenya (May and July 2014). Data were collected from MSF field personnel, local health personnel, hospital files, and media reports. In Tripoli, Libya, over 1,000 patients were poisoned with a reported case fatality rate of 10% (101/1,066). In Kenya, two outbreaks resulted in approximately 341 and 126 patients, with case fatality rates of 29% (100/341) and 21% (26/126), respectively. MSF launched an emergency team with international experts, medications and equipment, however, the outbreaks were resolving by the time of arrival. Interpretation Recognition of an outbreak of methanol poisoning and diagnosis seem to be the most challenging tasks, with significant delay from time of first presentations to public health warnings PLOS ONE | DOI:10.1371/journal.pone.0152676 March 31, 2016 1 / 10 The Methanol Poisoning Outbreaks in Libya 2013 and Kenya 2014 being issued. In spite of the rapid response from an emergency team, the outbreaks were nearly concluded by the time of arrival. A major impact on the outcome was not seen, but large educational trainings were conducted to increase awareness and knowledge about methanol poisoning. Based on this training, MSF was able to send a local emergency team during the second outbreak, supporting that such an approach could improve outcomes. Basic training, simplified treatment protocols, point-of-care diagnostic tools, and early support when needed, are likely the most important components to impact the consequences of methanol poisoning outbreaks in these challenging contexts. Introduction Methanol is a common organic solvent mainly used for industrial purposes. It is sometimes mixed with ethanol in alcoholic beverages either by mistake or more commonly, as an inexpensive substitute for ethanol to increase profit. Despite effective treatment, morbidity and mortality from methanol remains high, disproportionately affecting people in the developing countries,[1–7] but also regularly seen in the developed part of the world.[8–10] Symptoms usually appear within 12–24 hours after ingestion, but can be significantly delayed if ethanol is ingested simultaneously. Methanol itself is not toxic, but is metabolized by alcohol dehydrogenase to formic acid, which is responsible for the severe toxicity. Clinical features are nonspecific, with gastrointestinal symptoms, dyspnoea, chest pain and hyperventilation dominating along with visual disturbances.[11, 12] The lack of characteristic symptoms highlights the importance of analytical tools for diagnosis, which are absent in most places. Furthermore, limited knowledge of basic toxicological principles in areas where these poisonings are endemic, leaves many victims untreated and without a correct diagnosis. Incidents where dozens or even hundreds of patients are affected, are often solely reported in the media. [13, 14] Sodium bicarbonate, antidote (fomepizole or ethanol), [15] folinic acid and dialysis are key components of treatment. Correctly diagnosed, early treatment can potentially save all victims, but availability of adequate facilities is variable and often scarce or totally lacking. The fact that methanol is often added to either illegal liquor[1, 8, 9] or even original bottles of spirit,[10] frequently creates the appearance of an epidemic. The number of victims within a short timespan often overwhelm resources. Further, lack of specific training for healthcare personnel and a delay in notification to the public, all play a role in the high fatality rates typically seen.[3] Médecins Sans Frontières (MSF) operates in contexts where these poisonings are frequently seen. In 2013, a Memorandum of Understanding was signed between MSF and Oslo University Hospital (“The Methanol Poisoning Initiative”), aiming to quickly respond to suspected outbreaks, bringing experts of toxicology and intensive care as well as diagnostic tools, medications and simplified tr (...truncated)