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:

[email protected].

Journal of Toxicology

CLINICAL TOXICOLOGY

Vol. 41, No. 1, pp. 23–28, 2003

MARCEL DEKKER, INC. • 270 MADISON AVENUE • NEW YORK, NY 10016

©2003 Marcel Dekker, Inc. All rights reserved. This material may not be used or reproduced in any form without the express written permission of Marcel Dekker, Inc.

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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



8 0 3.83 Apples

9 0.09 29.07 Apples

10 0.2 0.23 Mixed fruits



13 0.3 35.3 Apples, plums

14 0.7 49.7 Pplums

15 0.1 30.5 Pprunes, fruits


17 0.2 27.6 Prunes, fruits

18 8.6 40.5 Prunes, fruits


20 0.3 22.7 Plums, prunes


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


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



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

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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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Documents

Methanol Contamination of Romanian Home-Distilled Alcohol