title: Identification and quantification of diethylene glycol in pharmaceuticals implicated in poisoning epidemics: an historical laboratory perspective.
abstract: Over the last several decades, mass poisonings of diethylene glycol (DEG), usually ingested as an unintended component of pharmaceutical preparations, have occurred. In order to promptly halt the rise in deaths due to ingestion of these pharmaceuticals, laboratory analysis has often been employed to identify and quantify the etiologic agent after the medications have been tentatively implicated. Over the past 15 years, the Centers for Disease Control and Prevention has been involved in identifying DEG in implicated pharmaceutical products during three poisoning epidemics that occurred in Nigeria (1990), Haiti (1995), and, most recently, in Panama (2006). In each case, the timeliness of the identification was paramount in reducing the mortality involved in these mass poisonings. Using state-of-the-art analytical technology, we were able to provide initial identification of DEG within 24 h of receiving samples for each epidemic, allowing a timely public health response. However, over the past 15 years, the analytical instrumentation available and the laboratory responses undertaken have changed. In addition, the type of information and the degree of confirmation of results requested during each epidemic varied based upon the number of individuals involved and the political tenor involved with the outbreak. We describe our historical approach to identifying and quantifying DEG during each of these outbreaks. Furthermore, the reoccurrence of outbreaks has prompted us to establish standard technology to use in potential future outbreaks to allow an even more timely response. This methodology includes the development of biomarkers of DEG exposure, which would be extremely useful in instances where pharmaceuticals are not clearly implicated.
authors.affiliation: National Center of Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30341, USA. dbarr@cdc.gov
authors.forename: Dana B
authors.initials: DB
authors.lastname: Barr
authors.forename: John R
authors.initials: JR
authors.lastname: Barr
authors.forename: Gayanga
authors.initials: G
authors.lastname: Weerasekera
authors.forename: Jacob
authors.initials: J
authors.lastname: Wamsley
authors.forename: Suzanne R
authors.initials: SR
authors.lastname: Kalb
authors.forename: Andreas
authors.initials: A
authors.lastname: Sjödin
authors.forename: Joshua G
authors.initials: JG
authors.lastname: Schier
authors.forename: E Danielle
authors.initials: ED
authors.lastname: Rentz
authors.forename: Lauren
authors.initials: L
authors.lastname: Lewis
authors.forename: Carol
authors.initials: C
authors.lastname: Rubin
authors.forename: Larry L
authors.initials: LL
authors.lastname: Needham
authors.forename: Robert L
authors.initials: RL
authors.lastname: Jones
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Sampson
mesh_terms: D058186:Acute Kidney Injury / Q000139:chemically induced* / Q000453:epidemiology / Q000378:metabolism; D002851:Chromatography, High Pressure Liquid; D004196:Disease Outbreaks; D004340:Drug Contamination; D005026:Ethylene Glycols / Q000032:analysis* / Q000266:history / Q000506:poisoning; D006205:Haiti / Q000453:epidemiology; D049673:History, 20th Century; D049674:History, 21st Century; D006801:Humans; D009549:Nigeria / Q000453:epidemiology; D010176:Panama / Q000453:epidemiology; D004364:Pharmaceutical Preparations / Q000032:analysis*; D011041:Poisoning / Q000453:epidemiology* / Q000266:history / Q000378:metabolism; D012997:Solvents / Q000032:analysis* / Q000266:history / Q000506:poisoning; D021241:Spectrometry, Mass, Electrospray Ionization; D017550:Spectroscopy, Fourier Transform Infrared; D053719:Tandem Mass Spectrometry
chemical_list: D005026:Ethylene Glycols; D004364:Pharmaceutical Preparations; D012997:Solvents; C013484:diethylene glycol