Methanol Contamination of Romanian Home-Distilled Alcohol.
Transcript of Methanol Contamination of Romanian Home-Distilled Alcohol.
ARTICLE
Methanol Contamination of Romanian Home-Distilled Alcohol
P. Levy,1,* A. Hexdall,1 P. Gordon,1 C. Boeriu,2 M. Heller,3 and L. Nelson1,3
1Bellevue Hospital Center/NYU Medical Center, New York, New York, USA2Mures County Poison Control Center, Romania
3New York City Poison Control Center, New York, New York, USA
INTRODUCTION
Epidemic methanol poisoning from the consumption
of illicitly manufactured alcohol is a well-recognized
entity within the United States (1,2). Although large-
scale toxicity was a common occurrence in the mid-
twentieth century, it is rarely encountered today (1). In
fact, the last major epidemic of this nature occurred in
1981, and involved 44 inmates at the State Prison of
Southern Michigan (3). This change may relate to a
general decline in domestic production of moonshine
over the past 30 years (4). Methanol exposure does
remain an important issue though, with approximately
2300 presumed cases reported annually to U.S. regional
poison control centers (5,6). The vast majority are
unintentional, resulting from the inadvertent ingestion of
household or industrial products, such as windshield
washer fluid, paint removers/thinners, and shellacs (5,6).
On a global scale, however, illicit alcohol production and
consumption remains a significant source of methanol
poisoning. In Kenya, for example, chang’aa, or “kill me
quick,” is a regionally brewed bootleg alcohol
notorious for its methanol content and is widely
known to be responsible for hundreds of deaths each
year. (see Table 1)
In Mures County, Romania (see Fig. 1), the regional
poison control center (MCPCC) has linked several cases
of lethal methanol toxicity to a regionally produced,
distilled spirit known as Tuica (pronounced Tsweeka).
Tuica is a sweet-tasting, clear alcohol made from locally
available fruits, primarily plums and apples, and is
consumed throughout the country. Since production is
neither sanctioned nor regulated by the Romanian
government, data are nonexistent on the ethanol or
methanol contents of Romanian Tuica. This study was
specifically undertaken to characterize the methanol
content of Tuica and better understand the potential for
epidemic methanol poisoning in Romania.
METHODS
During a one-month period, accessible local Tuica
distilleries were visited throughout Mures County,
Romania. After obtaining verbal permission from the
distillery operators, 5-mL samples of Tuica were
extracted from production storage vessels using a sterile
10 cc syringe with an attached 18 gauge needle and
transferred into individual sterile, additive-free, sealed
vacuum collection tubes. Data were collected from
23
DOI: 10.1081/CLT-120018267 0731-3810 (Print); 1097-9875 (Online)
Copyright q 2003 by Marcel Dekker, Inc. www.dekker.com
*Correspondence: Phil Levy, Bellevue Hospital Center, 462 First Avenue, New York, NY 10016, USA; E-mail:
Journal of Toxicology
CLINICAL TOXICOLOGY
Vol. 41, No. 1, pp. 23–28, 2003
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the distillery operators regarding the type of fruits or
grains used in the distillation process. The samples were
stored at room temperature until transportation to a
reference laboratory (Department of Health, New York
City) where all samples were analyzed for their methanol
and ethanol contents using gas chromatography. The
methanol analyisis was performed using 5-mL aliquots
on a Carbopak B/carbowax 20M column at 2508C using
helium as a carrier gas and a flame ionization detector.
The laboratory staff was blinded to the source of all
Table 1. Recent global epidemic methanol poisonings (7–21).
Location Year Total cases Deaths Methanol source
Temixco; Mexico 1994 N/A 28 Mezcal
Phnom Penh; Cambodia 1998 .400 60 Rice wine
Murang’a; Kenya 1998 N/A .20 Chang’aa
Nis; Serbia 1998 29 9 Brandy
Shanxi Province; China 1998 .200 27 N/A
Mai Mahiu; Kenya 1999 N/A .100 Chang’aa
Embu; Kenya 1999 N/A 24 Chang’aa
Narsingdi; Bangladesh 1999 N/A 121 Whiskey
Nairobi; Kenya 2000 661 137 Chang’aa
Feni; Bangladesh 2000 .100 56 Whiskey
San Salvador; El Salvador 2000 .200 117 Rum variant
San Vincente; El Salvador 2000 19 19 Rum variant
Thika; Kenya 2001 N/A 120 Kumi-Kumi
Parnu; Estonia 2001 178 67 Vodka
Mecca/Jizan Province; Saudi Arabia 2002 N/A 19 Cologne
Antananarivo; Madagascar 2002 40 11 N/A
Figure 1. Map of Romania (with Mures County circled).
Levy et al.24
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samples and the nature of the study. By convention,
ethanol and methanol concentrations were reported in
grams percent (gm/dL). A sample was considered
positive for methanol if any methanol was detected; a
positive sample was considered to contain clinically
significant methanol if the level exceeded 0.35 gm/dL;
this corresponds to the safety threshold established for
distilled spirits by the U.S. Bureau of Alcohol, Tobacco
and Firearms (ATF) (3). Mean, median, and proportional
values were calculated and reported with their corre-
sponding standard deviations (SD) and 95% confidence
intervals (CI) where applicable. All data comparisons
were performed with the student’s t-test.
RESULTS
Thirty-one distilleries were visited yielding 35
individual samples (Table 2). On two occasions, more
than one sample was obtained from the same distillery
(samples 23 and 24 and samples 27–30). Each of these
samples was from a distinct, individual batch of Tuica.
Twenty-six samples contained detectable methanol
levels (74%). The mean methanol level for these positive
samples was 0.66 gm/dL (SD 1.64 gm/dL) with a range
of 0.06–8.6 gm/dL. The median level was 0.25 gm/dL.
The overall mean ethanol concentration was 26.0 gm/dL
(SD 12.1 gm/dL) with a range of 0.10–49.07 gm/dL. The
median level was 27.5 gm/dL. One sample contained
negligible levels (,0.1 gm/dL) of ethanol and no
detectable methanol.
Nine samples (26%, 95% CI ¼ 12:5–43:3%) had
methanol levels exceeding 0.35 gm/dL. One sample
(2.9%, 95% CI ¼ 0:07%–14:9%) contained a methanol
concentration of 8.6 gm/dL. The mean methanol level of
these nine samples was 1.53 gm/dL (SD 2.66) and the
mean ethanol level was 34.64 gm/dL (SD 11.48; 95% CI
27.09–42.18). The mean ethanol level for the remaining
26 samples with no detectable methanol or positive
methanol levels ,0.35 gm/dL was 23.06 gm/dL (SD
11.01, 95% CI 18.62–27.50). The difference between the
ethanol levels of these two groups was significant ðp ¼
0:011Þ; indicating an association between methanol
contamination and higher ethanol levels.
Fruit was the principle ingredient in 25 samples
(71%), 4 (11%) were grain based, and 1 (3%) was
distilled from industrial-grade ethanol. Ingredient data
were not available for 5 (14%) samples. Data were
available for all 9 samples with clinically significant
methanol levels. Eight (89%, SD 31.4%) were fruit based
(4 mixed, 2 plums, 1 grape, and 1 pear) and 1 (11%) was
grain-based. Of the 26 samples with negative or
nonclinically significant levels, data was available for
21. Seventeen (81%, SD 39.3%) were fruit-based, 3
(14.3%) were grain-based, and 1 (4.8%) was industrial-
grade ethanol. There was no statistically significant
correlation between the proportion of fruit-based
samples in either group ðp ¼ 0:28Þ.
DISCUSSION
Although data on the prevalence of clinical
methanol toxicity in Romania has not been compiled,
physicians in the Mures County region have noted that
methanol poisoning is a relatively common entity and is
associated with Tuica consumption. Because
Table 2. Data from analysis of 35 Tsuica samples.
Sample
number
Methanol
concentrationa
Ethanol
concentrationa
Sample
ingredients
1 0 39.52 Fruits
2 0 20.16 Cereal grains
3 0 28.23 Industrial ethanol
4 0 18.55 N/A
5 0.4 15.32 Plums
6 0 39.79 Cereal grains
7 0 12.24 Cereal grains
8 0 3.83 Apples
9 0.09 29.07 Apples
10 0.2 0.23 Mixed fruits
11 0.1 30.74 Mixed fruits
12 0.2 23.5 Mixed fruits
13 0.3 35.3 Apples, plums
14 0.7 49.7 Pplums
15 0.1 30.5 Pprunes, fruits
16 0.7 27.6 Mixed fruits
17 0.2 27.6 Prunes, fruits
18 8.6 40.5 Prunes, fruits
19 0.2 15.6 Apples, plums
20 0.3 22.7 Plums, prunes
21 0.2 19.9 Apples, plums
22 0.2 20.7 N/A
23 0 0.1 Mixed fruits
24 0.6 41.3 Grains
25 1.0 47 Mixed fruits
26 0.4 38.3 Mixed fruits
27 0.8 23.7 Grapes
28 0.6 28.3 Pears
29 0.06 14.5 Cherries
30 0.2 29.1 Oranges, apricots
31 0.3 22.2 Mixed fruits
32 0.3 29.1 Mixed fruits
33 0.2 40.6 N/A
34 0.08 27.5 N/A
35 0 18.4 N/A
a In gms/dL
Methanol Contamination of Alcohol 25
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elimination of the practice of home distillation is
unlikely to be easily achieved, surveillance for potential
toxins and community awareness campaigns may be
more practical. In the United States for example, trace
element evaluation of illicit whiskey in the 1970s
resulted in the identification of lead, zinc, copper and
arsenic in potentially toxic quantities (21,22). Sub-
sequent screening of consumers of illicit alcohol helped
delineate an at-risk population and create a situation
amenable to regional public health intervention (23–
26). Unfortunately, only limited data exist on the degree
and extent of methanol contamination in illegally
produced alcohol. Prior investigations have assessed
serum methanol levels in those affected during epidemic
outbreaks as well as frequent consumers of methylated
spirits, with evaluation of the methanol content of the
culprit alcohol as a secondary, retrospective consider-
ation (1,2,4,27). Our analysis is the first to prospectively
evaluate the potential for methanol poisoning by
sampling the home-distilled spirits themselves, enabling
the potential prevention of an epidemic event.
Our finding of elevated methanol levels in 74%
(26/35) of Romanian Tuica samples is clinically
relevant. Of particular concern is the fact that nine of
the samples tested had levels exceeding the U.S. ATF
limit of 0.35%, traditionally considered the threshold of
safety. However, an exact correlation between an
ingested quantity of methanol and clinical methanol
poisoning does not exist (5), making the effects of
consuming Tuica difficult to predict. Fatalities have
been noted with the intake of as little as 15 cc of a 40%
solution (1). Presumptive serum levels can be estimated
based on known pharmacokinetic parameters, allowing
for some rough calculations. Using the accepted
methanol serum action level for hemodialysis of
25 mg/dL and the volume of distribution for methanol
as 0.6 L/kg (5), a 70 kg individual will likely manifest
consequential clinical effects by ingesting 10.5 grams of
methanol. This would require the intake of at least 3 L
of Tsuica with a methanol concentration of 0.35 gm/dL.
To attain this same serum level however, consumption
of only 1.6 L of a sample containing 0.66 gm/dL of
methanol (the mean value for our nine samples
exceeding the U.S. ATF threshold of safety) and only
120 cc of a sample containing 8.6 gm/dL (our maxi-
mum) would be required. Chronic moonshine drinkers
are known to consume in excess of 1 L per day (21),
making the potential for toxicity quite real.
Of additional concern, the samples with methanol
levels .0.35 gm/dL were associated with a 50% increase
in mean ethanol content. Although the effects of chronic
ethanol administration on methanol kinetics are not
completely understood, this may have critical impli-
cations for the development of methanol poisoning.
Since ethanol decreases the rate of methanol elimination,
chronic concomitant ingestion of both ethanol and
methanol may potentially result in higher than expected
serum methanol concentrations. This may be particularly
consequential when the patient reduces or stops self-
administration of ethanol, which would allow methanol
metabolism to proceed, producing a more profound,
delayed toxicity (28–30).
Several sources, either alone or in combination,
may explain the methanol content of Romanian Tuica.
Although fermentation and distillation of fruit leads to
the production of small amounts of methanol (31), we
found no statistical correlation between fruit-based
ingredients and the presence of potentially intoxicating
methanol levels. It is possible that improper distillation
techniques allowed for the accumulation of methanol.
The basic principle of distillation, fractional separation
by boiling point, requires the appropriate equipment and
techniques to assure purity. Alterations in the pro-
duction method, such as premature collection of the
distillate or added length to the precipitation tubing may
increase the percentage of unwanted byproducts, such as
methanol. Consideration must also be given to the
possibility of intentional adulteration of the final
product with industrial methanol. Unscrupulous bootleg
alcohol producers in China, Kenya, and Bangladesh
have allegedly engaged in this type of behavior in an
effort to increase the potency of their products. While
we cannot rule this out, our suspicion is low.
Adulterated alcohol typically contains methanol at
much greater concentrations than we found in most of
the samples analyzed in this study and is often
associated with mass epidemics.
LIMITATIONS
Our study is limited by several factors. Our sample
size was relatively small and represents Tuica from one
single region in Romania. Generalizations on all
Romanian Tuica should not be extrapolated from our
data. Larger sampling is needed to accurately portray the
true prevalence of methanol contamination. This may be
difficult however, as the fear of legal ramifications may
preclude some Tuica producers from allowing access to
their stills. Additionally, this study did not seek to
correlate the specific Tuica sampled with individual
clinical outcomes. Future studies should characterize the
relationship between the consumption of potentially
contaminated Tuica and the resultant incidence of
Levy et al.26
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methanol toxicity. Detailed analysis of the distillation
techniques would be useful and may help elucidate the
source of the methanol contamination. Finally, the goal
of our study was to merely characterize the extent of
methanol-tainted Tuica in Mures County. Unfortunately,
a more noble extension to public health policy
intervention was not the intent. While we feel strongly
that closer regulation of the process on Tuica distillation
should be adopted, it is difficult to enforce outside views
on an established cultural practice. The possibility for a
public awareness campaign in the future using available
local media resources including newspaper, television
and radio advertisements is under consideration.
CONCLUSIONS
Methanol existed in potentially toxic quantities in a
significant proportion of Romanian Tuica sampled in this
prospective evaluation. Although overall ethanol
concentrations varied greatly, there was a significant
association between elevated methanol levels and higher
ethanol levels. Changes in Romanian public health
policies may be necessary with strategies to address the
population health risks associated with illicit alcohol
consumption.
ACKNOWLEDGMENTS
All funding for the conduction of this research was
provided by a grant obtained from the Open Society
Institute.
We wish to express our gratitude and appreciation to
the staff of the MCPCC for their assistance with the
sample collection. In addition, we would like to thank the
laboratory staff at the New York City Department of
Health for assisting with the sample analysis.
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