Editorial 1 : How dangerous is methanol poisoning?
Context
Atleast 38 people had died after consuming spurious liquor in the Kallakurichi district of Tamil Nadu while as many as 82 others were receiving treatment in hospitals.
What is the alcohol in liquor?
- Liquor is differentiated by its alcohol content — from the 5% or so of beer to the 12% or so of wine to the 40% or so of distilled spirits (all by volume).
- In the beverages consumed for recreational purposes, the alcohol in question is almost always ethanol.
- In this context, ethanol is technically a psychoactive drug that, in low doses, reduces the level of neurotransmission in the body, leading to its typical intoxicating effects.
- Contrary to popular belief, the World Health Organisation has found that no level of [its] consumption is safe for our health.
- Long-term use leads to dependence, heightens the risk of some cancers and heart disease, and may eventually cause death.
What is Ethanol
- Ethanol (C2H5OH) is one carbon atom bonded to three hydrogen atoms and one more carbon atom; the second carbon atom is also bonded to two hydrogen atoms and the hydroxyl group, also known as the ion OH–.
- Inside the body, ethanol is metabolised in the liver and the stomach by alcohol dehydrogenase (ADH) enzymes to acetaldehyde.
- Then, acetaldehyde is transformed into acetate by aldehyde dehydrogenase (ALDH) enzymes.
- The adverse effects of alcohol consumption, from the hangover to a cancer, are due to acetaldehyde.
What is spurious liquor?
- Spurious liquor is characterised by the liquid mixture containing methanol as well.
- The police were able to determine last year that the spurious liquor incidents arose from the same source, and that arrack sellers had purchased methanol from factories and sold it to the victims. Arrack is distilled from the fermented sap of the palm tree.
- In many older cases, spurious liquor has typically been a homemade liquor to which methanol was added to strengthen the intoxicating effects and/or to increase its bulk volume.
- The Food Safety and Standards (Alcoholic Beverages) Regulations 2018 stipulate the maximum permissible quantity of methanol in different liquors.
- These values span a wide range, including “absent” in coconut fenny, 50 grams per 100 litres of country liquor, and 300 grams per 100 litres of pot-distilled spirits.
What is methanol?
- The methanol molecule (CH3OH) consists of one carbon atom bonded with three hydrogen atoms and one hydroxyl group.
- Schedule I of the Manufacture, Storage and Import of Hazardous Chemical Rules, 1989 includes methanol.
- The Indian Standard IS 517 applies to how the quality of methanol is to be ascertained.
- The most common way to produce methanol is to combine carbon monoxide and hydrogen in the presence of copper and zinc oxides as catalysts at 50-100 atm of pressure and 250° C.
- In the pre-industrial era, going back to ancient Egypt, people made methanol by heating wood to a very high temperature.
- Methanol has several industrial applications, including as a precursor to acetic acid, formaldehyde, and aromatic hydrocarbons. It is also used as a solvent and as antifreeze.
How does spurious liquor kill?
- The deadliness of spurious liquor arises from methanol.
- The human body contains infinitesimal quantities of methanol (4.5 ppm in the breath of healthy individuals, per a 2006 study) as a result of eating some fruits.
- But even for an adult, more than 0.1 ml of pure methanol per kilogram of body-weight can be devastating.
- Once ingested, ADH enzymes metabolise methanol in the liver to form formaldehyde (H-CHO).
- Then ALDH enzymes convert formaldehyde to formic acid (HCOOH). The accumulation of formic acid over time leads to a condition called metabolic acidosis, which can lead to acidaemia: when the blood’s pH drops below its normal value of 7.35, becoming increasingly acidic.
- The blood’s pH is normally maintained by a balance between an acid, like carbon dioxide (CO2), and a base, like the bicarbonate ion (HCO3–).
- The ‘metabolic’ in ‘metabolic acidosis’ means the concentration of the bicarbonate ion is dropping, leading to the acid gaining the upper hand.
- Formic acid also interferes with an enzyme called cytochrome oxidase, disrupting cells’ ability to use oxygen and leading to the build-up of lactic acid and contributing to acidosis.
- According to a paper, consuming methanol also leads to “methanol-induced optic neuropathy …, a serious condition that may result in long-term or irreversible visual impairment or even blindness [due to] damage and loss of function of the optic nerve and retina.
- Methanol-poisoning can also cause cerebral edema, haemorrhage, and death.
Treatment
- Once methanol is ingested, the body takes some time to completely eliminate it.
- One estimate suggests as much as 33% is still left behind after 48 hours. It is completely absorbed via the gastrointestinal tract. And blood methanol level can reach its maximum value within 90 minutes.
- There are two immediate ways to treat methanol poisoning. One is to administer pharmaceutical-grade ethanol.
- This may sound counter-intuitive but ethanol competes very well with methanol for the ADH enzymes, which metabolise ethanol around 10x faster. As a result, the methanol is kept from being metabolised to formaldehyde.
- The other option is to administer an antidote called fomepizole, which has a similar mechanism: it slows the action of the ADH enzymes, causing the body to produce formaldehyde at a rate the body can quickly excrete, preventing the deadlier effects from kicking in.
- Both courses of action are limited by availability: fomepizole is expensive whereas pharmaceutical-grade ethanol needs to be administered under expert supervision.
- Healthcare workers may also have the individual undergo a dialysis to remove methanol and formic acid salts from the blood, and mitigate damage to the kidneys and the retina.
- They may also administer folinic acid, which encourages the formic acid to break up into carbon dioxide and water. Both fomepizole and folinic acid are in the WHO’s list of essential medicines.
Conclusion
Governments can combat spurious alcohol by enforcing strict regulations, conducting regular inspections, raising public awareness, strengthening law enforcement, collaborating with industry, using technology for monitoring, and fostering international cooperation.
Editorial 2 : Sickle cell patients need urgent access to modern medication
Context
Sickle Cell Disease (SCD) remains a formidable challenge in the landscape of global health, particularly in places like India, where its burden is significant, particularly among tribal populations.
What is SCD?
- Sickle cell disease, a chronic condition, encompasses a group of inherited disorders affecting haemoglobin, the protein responsible for oxygen transport in the body.
- Typically, red blood cells possess a disc-like shape and are flexible, facilitating smooth movement through blood vessels. However, in SCD, a genetic mutation causes these red blood cells to adopt a crescent or “sickle” shape.
- These sickle-shaped RBCs lead to disruption of blood flow in small vessels and result in numerous complications.
Understanding the burden
- SCD affects 20 million people worldwide. India grapples with a formidable challenge posed by SCD, with millions affected.
- The high prevalence of this genetic disorder underscores the urgent need for targeted interventions and robust healthcare infrastructure to mitigate its impact.
- According to an article by Forbes, India has the second-highest global prevalence of the disease, with one in 86 births positive for SCD.
- Newborn screening programmes aimed at early detection of SCD have been instituted in many parts of the world.
- This has led to the early institution of essential preventive care elements such as, key immunisations, penicillin prophylaxis, and consistent health screening for common complications, resulting in improved survival rates in paediatrics.
- It underscores the importance of universal newborn screening and early diagnosis.
- Patients with SCD suffer a broad spectrum of complications that contributes to their increased morbidity and mortality.
- From end-organ damage and increased infection susceptibility, to stroke and pulmonary complications, the challenges presented by SCD are diverse.
- The geographic and socioeconomic disparities exacerbate the challenges faced by individuals living with SCD, necessitating tailored approaches to ensure equitable access to care.
Treatment and access
- Recently though, the landscape of SCD treatment has witnessed remarkable advancements.
- After multiple decades where Hydroxyurea was the only disease modifying therapy for SCD, there are now multiple medications that are approved and available.
- Spearheaded by breakthroughs in gene therapy, we can now discuss transformative, curative therapies.
- Universal access to proven medications like hydroxyurea is crucial, emphasising the need for scalable solutions to ensure widespread availability.
- Collaborative efforts between healthcare stakeholders, government agencies, and pharmaceutical entities are imperative to streamline the distribution channels and bridge existing gaps in accessibility.
Advocating for collaboration
- Collaboration lies at the heart of advancing SCD research and treatment paradigms.
- Collaborative initiatives focused on screening programmes, drug accessibility, and gene therapy research can catalyse progress and foster innovation in SCD management.
- Empowering tribal communities holds the key to addressing the endemicity of SCD in India.
- Community engagement, culturally sensitive interventions, and capacity-building initiatives are essential to effect meaningful change.
- Through interactive workshops, educational campaigns, and storytelling sessions, the initiative succeeded in dispelling myths surrounding SCD and promoting early screening and intervention.
- This grassroots approach exemplifies the transformative potential of community empowerment in combating SCD and fostering health equity.
Research and collaboration
- Sustained investment in translational research and clinical trials is needed to realise the promise of gene therapy and other emerging treatments.
- Telemedicine, wearable devices, and remote monitoring solutions can enhance patient care, particularly in underserved regions.
- Advances in artificial intelligence and machine learning hold promise in predicting disease complications, optimising treatment regimens, and personalising therapeutic approaches based on individual patient profiles.
- Global collaboration is essential in addressing the multifaceted challenges posed by SCD.
At the Government level
- The Indian government initiated the National Sickle Cell Anaemia Elimination Mission in 2023, aiming to eradicate SCD by 2047.
- This initiative entails enhancing awareness, conducting universal screening of approximately seven crore individuals aged 0-40 in affected tribal regions, and providing counselling through collaborative endeavours between central ministries and State governments.
Conclusion
Everything considered, the journey towards combating SCD in India is multifaceted, requiring a holistic approach that encompasses early diagnosis, scientific innovation, healthcare infrastructure strengthening, and community empowerment.
