Hiding in Plain Sight: The Unaddressed Risk of Self-Harm With Alcohol-Based Hand Sanitizers

Dear sir,

The COVID-19 pandemic has brought with it a multitude of concerns that otherwise would have remained woefully neglected due to their lack of public health impact. Among them, one especially important concern for mental health professionals (MHP) is the rampant promotion of alcohol-based hand sanitizers (ABHS). In this letter, we shed some light on the potential negative impact of this on the community and recommend some ways forward.

ABHS had been in use for hand hygiene even before the pandemic. However, after the COVID-19 pandemic struck, the importance of personal hand hygiene measures gained widespread promotion and recognition. The masses readily accepted ABHS as a rapid, portable, and hassle-free alternative to repeated handwashing with soap and water. The availability and sale of ABHS went through the roof. They have since become ubiquitous in hospitals and other places such as houses, public places, modes of transit, and so on.

The usual contents of ABHS include isopropyl alcohol and ethanol, with the amount of alcohol ranging from 60% to 95%. ¹ Their ingestion is potentially hazardous to human health and can result in clinical manifestations of acute alcohol intoxication. Various manifestations include behavioral, cardiac, gastrointestinal, pulmonary, neurological, and metabolic effects that can even lead to death. ² Intentional ingestion of ABHS with goals of intoxication or suicide is more common than accidental ingestion in healthcare settings. Furthermore, such intentional ingestion is more likely to result in significant untoward events like mortality. ³

Consumption of poisonous substances is reportedly the second most common modality for suicide in the Indian population, comprising about 28% of the total cases. ⁴ There is currently a dearth of Indian literature on the prevalence of ABHS as a tool for self-harm. However, several reports of self-harm by ABHS ingestion are available in the global literature, predominantly in the younger population.^1,3

Mental illnesses, along with various psychosocial factors such as poverty, poor social support, and marginalization, have close associations with the risk of suicide, and the current pandemic is likely to inflate these problems further. ⁵ In our clinical experience, patients with several psychiatric diagnoses, including psychosis, severe depression, or emotionally unstable personality disorder, have verbally expressed wishes to harm themselves with ABHS. A few of the verbatims are mentioned here.

• #1: “When I feel extremely distressed and do not find a way out, I often end up thinking, what will happen if I drink this?”

• #2: “If I wanted to do something in the ward, I could easily drink the sanitizer, and nobody would even know.”

• #3: “When I was angry, this was the only thing in sight, so I couldn’t help thinking about taking it.”

Though no systematic study has been done about the use of ABHS in particular as a mode of self-harm, a likely cause found from the verbatims was the easy accessibility. Appropriate precautions had to be exercised, in discussion with the caregivers and hospital staff, to alleviate the possibility.

Thus, it is imperative to take immediate steps to prevent potentially catastrophic outcomes in those with risk of self-harm or suicide, more so in people with mental illness.

The first and foremost strategy to prevent self-harm is to limit access to ABHS from the vicinity of persons with a high risk of self-harm. ³ MHP need to be made aware of the potential risks associated with ABHS, especially in persons at risk of harm to themselves or others.

Suggested modifications of hand hygiene measures for the at-risk population are as follows:

Alternatives to ensure hand hygiene may include relying on soap and water for persons at risk.

Single-use small sachets containing small quantities can be availed, instead of the 500ml bottles usually available in hospital settings.

Gel-based alternatives to the usual liquid preparations can be used.

Use of spray nozzles that are non-detachable from the bottle’s body can serve the purpose.

Exposure to ABHS is associated with more serious adverse effects than non-ABHS like chlorhexidine, ¹ although this option is tainted by the doubtful disinfectant efficacy of the non-ABHS and thus needs further exploration. ⁶

Newer techniques can be devised with appropriate pharmacokinetic and feasibility testing. An idea is to add emetic agents into the ABHS to deter persons at risk from oral consumption. However, this needs to be studied for feasibility and efficacy before consideration.

The pandemic is far from over. ABHS is likely to continue as a double-edged sword, life-saving yet potentially lethal. MHP need to be a step ahead in preparation for an upsurge of deliberate or accidental poisoning by ABHS, as the best strategy for managing self-harm is prevention. The prevention strategies mentioned above are difficult to generalize. Thus, we emphasize their implementation in the psychiatric set-ups wherein self-harm or suicide is more common than in the general population. Methodologically sound large-scale studies, including qualitative analysis of patients’ verbatim, can be conducted to identify the correlates and potential target areas for interventions.