2017-Metanolinitiativet

Metanolinitiativet– fraforskning
oginnovasjontilintensivmedisin
oghumanitærtarbeid
MortenRostrup
AkuttmedisinskAvdOUS,UiO&MSF
KnutErikHovda
NasjonalBehandlingstjenesteforCBRNE-medisin
(CBRNE-senteret)
AkuttmedisinskAvd OUS&MSF
2017– Metanolinitiativet– FredagsmøtetAHUS
2017– Metanolinitiativet– FredagsmøtetAHUS
2017– Metanolinitiativet– FredagsmøtetAHUS
2017– Metanolinitiativet– FredagsmøtetAHUS
2017– Metanolinitiativet– FredagsmøtetAHUS
2017– Metanolinitiativet– StabsmøtetRH
1
Methanol poisonings 1998-2002
Year
Location
Affected
Fatalities
Notes
1998
Madagascar
?
200
BBCNews(2002)
1998
Nis,Serbia
>90
43
TOL.org(1998)
Business.Highbeam.com(1998)
1998
?
Murang´a,Kenya
?
>100
1998
ShanxiProvince,China
>200
27
1998
PhnomPenh,Cambodia
>400
60
Levyetal.(2003)
1998
Vietnam
34
5
ProMED-mail(1999)
1999
MaiMahiu,Kenya
34
5
Levyetal.(2003)
1999
Embu,Kenya
?
24
1999
Narsingdi,Bangladesh
?
121
Levyetal.(2003)
2000
Nairobi,Kenya
661
140
Levyetal(2003),Ahmad(2000)
2000
SanSalvador,ElSalvador
>200
117
2000
SanVincente,ElSalvador
19
19
Levyetal.(2003)
2000
Newfoundland,Canada
>12
2
CBCNews(2000)
2000
Feni,Bangladesh
>100
56
Location
Affected
2003
Botswana
>45
9
BBCNews(2009)
2004
Istanbul,Turkey
?
21
ProMED-mail(2004)
>60
2004
Shiraz,Iran
Multan,Pakistan
2004
Mumbai,Pakistan
Levyetal.(2003)
Levyetal.(2003)
Thika,Kenya
?
120
Levyetal.(2003)
2001
Pärnu,Estonia
154
68
Paasmaetal.(2007)
2001
Bombay,India
>120
27
2002
Mecca/JizanProvince,SaudiArabia
?
19
2002
Antananarivo,Madagascar
40
11
2002
Taiwan
?
9
2002-2004
Norway
59
17
Levyetal.(2003)
Levyetal.(2003)
Hovdaetal.(2005)
2017– Metanolinitiativet– FredagsmøtetAHUS
Methanolpoisonings2003-2008
2004
Levyetal.(2003)
2001
2017– Metanolinitiativet– FredagsmøtetAHUS
Year
BBCNews(1998)
Fatalities
Notes
17
ProMED-mail(2004)
36
Archives.dawn.com(2004)
Methanolpoisonings2009-2011
Year
Location
2009
CentralUganda
77
27
ProMED-mail(2009)
2009
Kolkata,India
26
23
Expressindia(2009)
2009
Dailytimes.com.pk(2004)
Delhi,India
Affected Fatalities
?
>30
?
170
Notes
Pandey(2009)
128
45
2004
Kenya
?
23
2009
OrissaBolangir,India
?
8
Pandey(2009)
2004
Vikhroli,India
>300
87
"TheVikhroliHoochTragedy"
2009
Gujarat/Ahmedabad,India
>275
136
Sify.com(2009)
23
Bali/Lombok,Indonesia
2009
Karnataka,India
Tribune(2011)
2005
Istanbul,Turkey
ProMED-mail(2004),BBCNews(2004)
2009
45
25
TheAustralian(2009)
2005
Magadan,Russia
?
33
FoxNews(2005)
2009
Karachi,Pakistan
?
>40
Voanews.com(2009)
2005
Kenya
>500
140
Groups.yahoo.com(2005)
2010
UttarPradesh,India
?
10
2005
Tezpur,India
>100
25
Tribuneindia.com(2005)
2010
Kampala,Uganda
189
89
2006
Nicaragua
801
48
PAHO(2006)
2010
Nairiobi,Kenya
>35
24
BBCNews(2010)
2006
Urals,Russia
60
3
2010
Bangladesh
23
10
Chowdhury,FRetal.APJMT2014
2006
IrkutskRegion,Russia
?
13
2010
Makassar,Indonesia
5
3
JakartaGlobe(2010)
Teheran,Iran
?
BBCNews(2010)
ProMED-mail(2010)
2010
KampongChamprovince,Cambodia
42
6
2011
KurilArchipelago,Russia
19
4
Mysouth.su(2011)
2006
Jordan
?
17
AbdallatIMetal(2009)
2011
Khartoum,Sudan
>137
71
AbdulRahimandAlShiekh(2012)
2007
Karachi,Pakistan
55
40
Foxnews.com(2007)
2011
LosRios,Ecuador
>770
51
TheEconomist(2011)
20
Indianexpress.com(2007)
2011
170
ProMED-mail(2012a);BBCNews(2011)
2006
?
17
PhnomPenhPost(2010)
WestBengal,India
>370
2008
UlanBator,Mongolia
>25
14
Wikipedia(2008)
2011
FondBaptiste,Haiti
40
2008
Karnataka&TamilNadu,India
285
150
BBCNews(2008)
2011
Bodrum,Turkey
22
5
Wikipedia(2011)
2011
CentralProvince,Kenya
?
29
Allafrica.com(2011)
2011
CentralHighlands,Vietnam
8
5
ProMed(2011)
2011
Pursat,Cambodia
79
7
Phnompenhpost.com
2007
Multan,Pakistan
?
2008
Sindhupalchock&Sindhuli,Nepal
>17
10
RajbhandariRetal(2008)
2008
Hormuzgan,Iran
92
12
Rte.ie(2008)
2017– Metanolinitiativet– FredagsmøtetAHUS
Year
Location
2012
AndhraPradesh,India
2012
Blitar,Indonesia
7
5
Orissa,India
100
31
2012
Tasikmalaya,WestJava,Indonesia
5
Cambodia
367
2012
Affected
37
Methanolpoisonings2014
Fatalities
Notes
19
ProMED-mail(2012),zeenews.india.com(2012)
BBCNews(2012)
4
49
ProMED-mail(2012)
2012
Pakistan
71
68
2012
Tegucigalpa,Honduras
48
24
NewstrackIndia(2012)
2012
Tripoli,Libya
>60
?
Personalcommunication
2012
KabupatenBogor,WestJava,Indonesia
5
1
2012
2012
2012
Gurdaspur,Punjab,India
18
Punjabnewsexpress.com
VinnytsiaCity,Ukraine
?
3
Nathnac.org
CzechRepublic
130
50
ZakharovSetal.Inpress(2014)
2012
Denpasar,Bali,Indonesia
3
3
2012
TangerangSelatan,Banten,Indonesia
4
3
2012
Poland
2012
Bihar,India
2012
Gaya+Bhojpur,India
7
11
Euronews.com(2012)
6
zeenews.india.com(2012)
32
zeenews.india.com(2012)
2013
Tripoli,Libya
1066
101
Personalcommunication,LibyaHerald.com
2013
Selangor,Malaysia
31
20
Personalcommunication
8
Hassanian-Moghaddam.JPublicHealth(2014)
2013
Rafsanjan,Iran
2013
Bandung,Indonesia
2013
Faisalabad,Pakistan
694
2
2
>40
26
2013
Havana,Cuba
88
11
2013
Karachi,Pakistan
>25
18
8
zeenews.india.com(2013)
23
8
zeenews.india.com(2013)
12
TheJakartaglobe.com(2013)
17
14
2013
Amethi,India
2013
Kolkata,India
2013
Surabaya,Indonesia
2013
CentralJakarta,Indonesia
2013
Indramayu,WestJava,Indonesia
2013
KabupatenBandung,Indonesia
4
2
10
10
UCAnews.com(2013)
Theguardian.com(2014)
UCAnews.com(2013)
2013
Jelgava,Latvia
11
8
UPI.com
2013
UttarPradesh,India
>80
42
independent.co.uk
2013
Karachi,Pakistan
7
3
tribune.com.pk
2013
SouthJakarta,Indonesia
6
6
2013
Surabaya,EastJava,Indonesia
5
2
2013
Tulungagung,EastJava,Indonesia
6
1
2013
Sleman,Yogyakarta,Indonesia
3
WestBengal,India
>18
2013
PAHO(2011)
2017– Metanolinitiativet– FredagsmøtetAHUS
Methanolpoisonings2012-2013
2012
20
Year
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
Location
Surabaya,EastJava,Indonesia
Surabaya,Indonesia
Bali,Indonesia
Moravia,CzechRepuplic
Cirebon,Indonesia
Krasnokamensk,Russia
BukitLawang,NorthSumatera,Indonesia
AndraPradesh,India
Embu,Muranga,Kitui&Kiambu,Kenya
Indramayu,WestJava,Indonesia
Eldoret&Kapsabet,Kenya
Punjab,Pakistan
Bekasi,WestJava,Indonesia
KebonJeruk,JakartaBarat,Indonesia
Hyderabad,Pakistan
Karachi,Pakistan
Magelang,CentralJava
Magelang,CentralJava,Indonesia
Indramayu,WestJava,Indonesia
Garut,WestJava,Indonesia
Sumedang,WestJava,Indonesia
Bantul,Indonesia
Bekasi,WestJava,Indonesia
Affected Fatalities
6
3
32
19
34
3
2
6
4
48
14
1
1
32
5
>330
94
15
3
126
29
10
8
5
4
2
2
20
45
32
12
12
14
12
4
4
17
115
10
4
2
4
3
Notes
jakartaglobe.com
thejakartapost.com
RadioPrahaogpraguepost.com
washingtonpost.com,Rapidcityjournal.com
thehindu.com
Rostrupetal2015.
Rostrupetal2015.
tribune.com.pk
jakartaglobe.com
tribune.com.pk
tribune.com.pk
Jakartapost.com
thejakartaglobe.beritasatu.com(2014)
thejakartaglobe.beritasatu.com(2014)
thejakartaglobe.beritasatu.com (2014)
1
6
2013
Riau,Indonesia
6
2
2013
Bandung,Indonesia
8
7
2017– Metanolinitiativet– FredagsmøtetAHUS
zeenews.india.com(2013)
2017– Metanolinitiativet– FredagsmøtetAHUS
2
Methanolpoisonings2015
Year
2015
Location
Affected
Fatalities
Notes
WesternMozambique
252
75
theforbes.com
2015
Lucknow(UttarPradesh),India
200
41
personalcommunication,bbc.com,abcnews.com
2015
Prabumulih,SouthSumatera,Indonesia
7
5
2015
Ondo,Nigeria
2015
Palembang,SouthSumatera,Indonesia
38
2015
Bandung,WestJava,Indonesia
2015
14
9
6
3
Mumbai,India
>145
35
97
timesofindia
Biratnagar,Nepal
5
ekantipur.com
2015
WojiandGokana,Nigeria
80
70
EMETNET.ORG
2015
Blitar,Indonesia
4
3
2015
UttarPradesh,India
18
2015
Garut,WestJava,Indonesia
2015
Bekasi,WestJava,Indonesia
5
2
WestBengal,India
>200
126
12
3
2015
Sukabumi,Indonesia
Garut,WestJava,Indonesia
2015
Surabaya,EastJava,Indonesia
10
hindustantimes.com
1
mmegi.bw
2
4
89
28
focus-fen.net+EMETNET.ORG
Port-au-Prince,Haiti
EMETNET.ORG
Malang,EastJava,Indonesia
?
4
5
2015
4
12
Siberia,Russia
63
Kratie,Cambodia
46
2
CAMBODIADAILY
2015
Izmir,Turkey
10
3
hurriyetdailynews.com
2015
2015
Garut,WestJava,Indonesia
2
2
2015
2015
Hyderabad,India
2015
Kratieprovince,Cambodia
Tennessee,USA
Fatalities
?
2
12
6
2
Yogyakarta,Java,Indonesia
49
26
2016
Boyolali,CentralJava,Indonesia
2016
Yogyakarta,Java,Indonesia
4
jakartapost.com
1
2
2
2016
Port-au-Prince,Haiti
32
21
miamiherald.com
2016
Vietnam
2016
Aydin,Turkey
>1000?
2
1
hurriyetdailynews.com
2016
Majalengka,Indonesia
1
1
2016
Cirebon,Indonesia
6
1
Vietnamnews.vn
2016
Karachi,Pakistan
2016
KabupatenBandung,Indonesia
5
1
2016
OganIlir,Indonesia
10
3
Jember,Indonesia
3
3
2016
Cimahi,Indonesia
2016
45
5
1
1
13
10
WestJava,Indonesia
4
1
2016
CentralKalimantan,Indonesia
3
3
Lucknow,India
2016
Yogyakarta,Java,Indonesia
>40
6
33
2016
2016
KabupatenBandungBarat,Indonesia
6
1
2016
Bali,Indonesia
1
0
18
6
hindustantimes.com
2016
Bihar,India
18
16
>200
23
khmertimes.com
2016
EastNusaTenggara,Indonesia
1
1
Karachi,Pakistan
?
4
tribune.com.pk
2016
Mojokerto,Indonesia
3
1
Sanghar,Pakistan
4?
9
3
dawn.com
2016
Bantul,Indonesia
5
2
Yakoruda,Bulgaria
5
focus-fen.net
2016
7
Jakartapost.com
6
Sumadang,Indonesia
Samburu,Kenya
KabupatenBandung,Indonesia
?
4
2016
2015
2
2016
Karawang,WestJava,Indonesia
7
1
2015
Depok,Indonesia
6
6
2016
Surat,India
31
21
2017– Metanolinitiativet– FredagsmøtetAHUS
financialexpress.com
6
2015
8
jamaicaobserver.com
1
2015
Halmahera,Indonesia
Wallstreetjournal.com
3
Riau,Indonesia
Bantul,Indonesia
2016
2015
2015
Notes
indiatoday.com
2
Semarang,Indonesia
2016
2016
EMETNET.ORG
Affected
2016
2016
10
Istanbul,Tyrkia
2015
2015
Location
Lahore,Pakistan
2016
2
Cianjur,WestJava,Indonesia
2015
2015
Year
2016
naij.com
1
2015
2015
Methanolpoisonings2016(I)
1
citizentv.co.ke
nyoooz.com
2017– Metanolinitiativet– FredagsmøtetAHUS
Methanolpoisonings2016(II)-2017
Year
Location
2016
2016
2016
2016
2016
2016
2016
2016
2016
2016
2016
2016
2016
2016
2016
2016
2016
2016
2016
2016
2016
2016
2017
2017
2017
2017
2017
2017
2017
2017
Kharkiv,Ukraine
Jehlum,Pakistan
Yogyakarta,Java,Indonesia
Kediri,EastJava,Indonesia
Lahore,Pakistan
Cilacap,Indonesia
Prabumulih,SouthSumatera,Indonesia
Rajshahi,Bangladesh
Mindourou&AbongBang,Cameroon
Cakung,Jakarta,Indonesia
Russia
Garut,WestJava,Indonesia
Purworejo,CentralJava,Indonesia
Palembang,Indonesia
Kendal,CentralJava,Indonesia
Tasikmalaya,WestJava,Indonesia
KampongChhnangprovince,Cambodia
Surabaya,EastJava,Indonesia
Sandaotong,China
KabupatenBandung,Indonesia
Irkutsk,Siberia,Russia
TobaTekSinghPakistan
Gujranwala,Pakistan
Peshawar,Pakistan
Burdwan,WestBengal,India
Karawang,WestJava,Indonesia
Bandung,WestJava,Indonesia
Murang´a,Kenya
Samundri,Faisalbad,Pakistan
Surat,India
Affected Fatalities
72
4
3
3
7
16
43
14
4
1
9
2
4
78
4
15
4
123
150
6
6
36
5
20?
4
36
11
2
3
1
1
15
5
21
10
1200
3
1
4
2
3
15
3
3
3
76
42
4
5
6
2
6
4
4
6
Notes
all.true-news
dailymail.com
tribune.com.pk
?
newsbangladesh.com
heraldlive.zo.za
tempo.com
Tass.com:Estimatedfatality/year
cambodiadaily.com
mirror.com
tass.no
thesun.co.uk
thenews.pk.com
tribune.com.pk
huffingtonpost.in
jakartaglobe.id
jakartapost.com
standardmedia.co.ke
dailypakistan.com
indianexpress.com
2017– Metanolinitiativet– FredagsmøtetAHUS
2017– Metanolinitiativet– FredagsmøtetAHUS
Metanologmetabolisme
Diagnostikk
Ethanol
• Anamnese/sykehistorie
Methanol
Fomepizole/
ethanol
Ethylene glycol
-
• Kliniskefunn- uspesifikke
Alcohol
dehydrogenase
Formaldehyde
Aldehyd
dehydrogenase
Glycol aldehyde
Aldehyde
dehydrogenase
Acetaldehyde
Formate
Folinic acid
+
10-formyl
tetrahydrofolate
synthetase
Glycolate
oxidase
Glycolic acid
Oxalic acid
CO2 + H2O
2017– Metanolinitiativet– FredagsmøtetAHUS
Calcium oxalate
• Analytiskefunn;
–
–
–
–
Arteriellblodgass – enkelt,mensierINGENTINGomårsaken
Osmolaltgap(OG)/Aniongap(AG)– uspesifikkogoftestutilgjengelig
Metanolanalyser– sværtsjeldenttilgjengelig
Maursyreanalyser1,2
1
2
HovdaKEetal. JAnalToxicol 2005;29(6):586-588
HovdaKEetal..Scand JClin LabInvest2015;75(7):610-4
2017– Metanolinitiativet– FredagsmøtetAHUS
3
2017– Metanolinitiativet– StabsmøtetRH
2017– Metanolinitiativet– FredagsmøtetAHUS
Principles&basicstructure
Detectablefewhoursafter
methanolmetabolism
(>6hoursbeforesymptoms
appears)
Neg test
www.orphandiagnostics.com
0-1mM
2017– Metanolinitiativet– FredagsmøtetAHUS
Postest
1-3mM
3-10mM
TheMethanolPoisoningInitiative(MPi)
Methanolpoisoningataglance
-withnomeansofanalyticalequipmentavailable
Point-of-care
diagnostikk
methanol'
Ethanol+/+
fomepizole+
8+
ADH$enzyme$
formaldehyde+
formic'acid'
Forenklede
behandlingsprotokoller
Folinic+acid+
++
CO2+++H2O+
Diagnosis:
-
Methanolisnottoxicitself,butitismetabolizedtothehighly
toxicformicacid/formate(seefig):Thetreatmentisfocusedon
blockingtheenzyme(ADH)witheitherethanolorfomepizole,
bufferthemetabolicacidosiswithbicarbonate,andifpossible
usedialysistoremovemethanol,formateandcorrectthe
metabolicacidosis.
Folinicacidmayalsobegiventoenhancetheendogenous
metabolismofformate.
Alloftheaboveshouldbeinitiatedasearlyaspossible,but
anyofthesetreatmentsareimportant–
Usewhatyouhaveavailable!
History:Intakeofillegal/bootlegalcohol,othersintheenvironmentwithconfirmedorsuspect
methanolpoisoning(seriouslyill,fatalities,blindnessetc.)
Symptoms:hyperventilation(respiration(RF)>20-25/min)/dyspnoea,visualdisturbances(all
kindsof),GI-symptoms,chestpain,“hangover”.
Treatment:
-
TaskForce
>10mM
2017– Metanolinitiativet– FredagsmøtetAHUS
MSFFieldMissionTraining/
FirstResponderTraining
-
Giveantidote(ethanolorallyorintravenously–dosing:Seeoppositeside)withoutdelay
Givebicarbonate(NaHCO3)assoonaspossibleintravenously.
o 500mmol/L:Give250-500mLormorewithin1-2hoursuntilhyperventilationis
corrected(RF<20/min).
o 167mmol/L: Give 1000-1500mL or more within 1-2 hoursuntilhyperventilationis
corrected(RF<20/min).
Ifonlyoraltreatmentisavailable:Tabletsof500mgbicarbonate(=6mmol),6-10tabletsevery
houruntilhyperventilationiscorrected(RF<20/min).
Folinicacid(orfolicacid)50mgiv.ororally(e.g.10tabletsof5mg)every6hoursfor24-48hrs.
Ifintubationisnecessary:Thepatientmustbehyperventilated(RF>25/min)(untiltransferred
toaunitwithICU
Whentocallforassistance:
Iftherearepatientswithastrongsuspicionofmethanolpoisoning,callthelocalreferralhospital
orofficeofMedecinssansFrontieres(MSF/DoctorswithoutBorders-0728602590or
0728970614)foradviceandtodiscusspossibilitiesforintervention.
Oneofthemostimportantreasonsforthisisthepossibilitytoidentifytoxicalcoholinthe
environment,startearlytreatmentANDbeabletowarnthepublicaboutthepossibledanger.
Wherethereisonethereisusuallymany
Suggesteddosingregimenforethanol(beawareofindividualdifferencesandfrequent
under-dosing):
Loadingdose
2017– Metanolinitiativet– FredagsmøtetAHUS
Dokumentasjon/
forskning
Internasjonalt
samarbeid
10%ethanol
20%ethanol
40%ethanol
15mL/kg
7.5mL/kg
4mL/kg
2mL/kg
2mL/kg/hr
1mL/kg/hr
0.5mL/kg/hr
0.25mL/kg/hr
Drinkingdose/hour
(regulardrinker)
4mL/kg/hr
2mL/kg/hr
1mL/kg/hr
0.5mL/kg/hr
Ruleofthumb:Beercontains5%,wine12-14%andspirits40-45%ethanol.
Criterionfortreatmentwhenmethanolpoisoningissuspected(clinicalfindingsonly):
Lokale
helsemyndigheter/MOH
5%ethanol
Drinkingdose/hour
(notregulardrinker)
A. Asymptomatic patients: Observe.
B. Hyperventilation, no visual disturbances. Adequate blood pressure/pulse: Give ethanol and
bicarbonate. Observe minimum 24 hours
C. Hyperventilation, visual disturbances, conscious: Give ethanol, bicarbonate, consider transport to
dialysis facilities, folinic acid
D. Hyperventilating, unconscious: Give ethanol, bicarbonate, transport to dialysis facilities, folinic acid
E. Normoventilating/slow breath, unconscious: Likely poor prognosis if methanol poisoning. Be careful
with ethanol in case this is a ethanol intoxication instead unless confident of methanol poisoning.
Give bicarbonate, folinic acid, and consider transport to referral hospital if possible
Transferforadvancedtreatmentsuchasdialysisand/orventilatorsupportisoftenrelevant
Prognosticaspects
Comaonadmissionandlackofhyperventilationindicatespoorprognosisifthepatientissufferingfrom
methanolpoisoning,butpureethanolintoxicationoracombinationofthosemaybeadifferential
diagnosis
2017– Metanolinitiativet– FredagsmøtetAHUS
4
TheMethanolPoisoningInitiative(MPi)
Point-of-care
diagnostikk
Forenklede
behandlingsprotokoller
TaskForce
MSFFieldMissionTraining/
FirstResponderTraining
Lokale
helsemyndigheter/MOH
Dokumentasjon/
forskning
Internasjonalt
samarbeid
2017– Metanolinitiativet– FredagsmøtetAHUS
TheMethanolPoisoningInitiative(MPi)
2017– Metanolinitiativet– FredagsmøtetAHUS
Point-of-care
diagnostikk
Forenklede
behandlingsprotokoller
TaskForce
MSFFieldMissionTraining/
FirstResponderTraining
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helsemyndigheter/MOH
Dokumentasjon/
forskning
Internasjonalt
samarbeid
2017– Metanolinitiativet– FredagsmøtetAHUS
2017– Metanolinitiativet– FredagsmøtetAHUS
2017– Metanolinitiativet– FredagsmøtetAHUS
2017– Metanolinitiativet– FredagsmøtetAHUS
5
08:00 – 16:00
08:00 – 16:00
2017– Metanolinitiativet– FredagsmøtetAHUS
08:00 – 16:00
6