The Reply

Abstract

We thank Rehm and Lachenmeier for their insightful comments. The World Health Organization (WHO) definition of unrecorded alcohol does not solely encompass moonshine, but also includes other forms of alcohol, including smuggled alcohol and surrogate alcohol. Therefore, perhaps we should have defined moonshine in a broader sense, to encompass unrecorded alcohol that is either homemade or industrially produced. However, our intent in citing the WHO estimate was not to imply that the majority of unrecorded alcohol is contaminated with lead, but rather to suggest that a significant percentage of global alcohol consumption derives from illegally produced alcohol, which carries a higher risk for impurities. We agree that precise numbers for moonshine consumption globally are unavailable. However, it is likely that the current WHO approximation for prevalence of unrecorded alcohol (29%) is an underestimate, because consumer surveys assessing alcohol consumption significantly underestimate both recorded and unrecorded alcohol intake.1World Health Organization (WHO) Global Status Report on Alcohol and Health. Data from World Health Organization. WHO, Geneva, Switzerland2011Google Scholar, 2Lachenmeier D.W. Ganss S. Rychlak B. et al.Association between quality of cheap and unrecorded alcohol products and public health consequences in Poland.Alcohol Clin Exp Res. 2009; 33: 1757-1769Crossref PubMed Scopus (43) Google Scholar Moreover, most current surveys tend not to account for alcohol from populous areas such as Africa, where nearly half of all alcohol consumed is illegal.3African moonshine: kill me quick. The Economist Web Site. Available at: http://www.economist.com/ node/16018262. Accessed July 19, 2013.Google ScholarWhile Rehm and Lachenmeier suggest that the majority of unrecorded alcohol has not been associated with lead poisoning, few studies have measured lead levels in alcohol. A recent study4Lachenmeier D.W. Samokhvalov A.V. Leitz J. et al.The composition of unrecorded alcohol from eastern Ukraine: is there a toxicological concern beyond ethanol alone?.Food Chem Toxicol. 2010; 48: 2842-2847Crossref PubMed Scopus (29) Google Scholar analyzing recorded and unrecorded alcohol products from eastern Ukraine found that about 7% of moonshine samples made mostly for personal consumption contained excessive amounts of lead. These risks may, of course, be regional. We also draw attention to the article by Morgan et al,5Morgan B.W. Parramore C.S. Ethridge M. Lead contaminated moonshine: a report of Bureau of Alcohol, Tobacco and Firearms analyzed samples.Vet Hum Toxicol. 2004; 46: 89-90PubMed Google Scholar which suggests that moonshine contains significant amounts of lead.We agree with Rehm and Lachenmeier that saturnine gout is likely not a major public health problem at this time. However, we do not agree with the implication that the problem is trivial. We respectfully disagree with our colleagues' assertion that inquiries about moonshine consumption “may not be recommended.” Because alcohol (independent of lead contamination) is a risk factor for development of gout,6Choi H.K. Atkinson K. Karlson E.W. et al.Alcohol intake and risk of incident gout in men: a prospective study.Lancet. 2004; 363: 1277-1281Abstract Full Text Full Text PDF PubMed Scopus (537) Google Scholar it is necessary to inquire about consumption of alcohol (illegal or not) among gout patients. And because lead toxicity is a treatable illness, inquiry into the possibility of lead consumption among appropriate cohorts of gout patients provides an opportunity to intervene. We thank Rehm and Lachenmeier for their insightful comments. The World Health Organization (WHO) definition of unrecorded alcohol does not solely encompass moonshine, but also includes other forms of alcohol, including smuggled alcohol and surrogate alcohol. Therefore, perhaps we should have defined moonshine in a broader sense, to encompass unrecorded alcohol that is either homemade or industrially produced. However, our intent in citing the WHO estimate was not to imply that the majority of unrecorded alcohol is contaminated with lead, but rather to suggest that a significant percentage of global alcohol consumption derives from illegally produced alcohol, which carries a higher risk for impurities. We agree that precise numbers for moonshine consumption globally are unavailable. However, it is likely that the current WHO approximation for prevalence of unrecorded alcohol (29%) is an underestimate, because consumer surveys assessing alcohol consumption significantly underestimate both recorded and unrecorded alcohol intake.1World Health Organization (WHO) Global Status Report on Alcohol and Health. Data from World Health Organization. WHO, Geneva, Switzerland2011Google Scholar, 2Lachenmeier D.W. Ganss S. Rychlak B. et al.Association between quality of cheap and unrecorded alcohol products and public health consequences in Poland.Alcohol Clin Exp Res. 2009; 33: 1757-1769Crossref PubMed Scopus (43) Google Scholar Moreover, most current surveys tend not to account for alcohol from populous areas such as Africa, where nearly half of all alcohol consumed is illegal.3African moonshine: kill me quick. The Economist Web Site. Available at: http://www.economist.com/ node/16018262. Accessed July 19, 2013.Google Scholar While Rehm and Lachenmeier suggest that the majority of unrecorded alcohol has not been associated with lead poisoning, few studies have measured lead levels in alcohol. A recent study4Lachenmeier D.W. Samokhvalov A.V. Leitz J. et al.The composition of unrecorded alcohol from eastern Ukraine: is there a toxicological concern beyond ethanol alone?.Food Chem Toxicol. 2010; 48: 2842-2847Crossref PubMed Scopus (29) Google Scholar analyzing recorded and unrecorded alcohol products from eastern Ukraine found that about 7% of moonshine samples made mostly for personal consumption contained excessive amounts of lead. These risks may, of course, be regional. We also draw attention to the article by Morgan et al,5Morgan B.W. Parramore C.S. Ethridge M. Lead contaminated moonshine: a report of Bureau of Alcohol, Tobacco and Firearms analyzed samples.Vet Hum Toxicol. 2004; 46: 89-90PubMed Google Scholar which suggests that moonshine contains significant amounts of lead. We agree with Rehm and Lachenmeier that saturnine gout is likely not a major public health problem at this time. However, we do not agree with the implication that the problem is trivial. We respectfully disagree with our colleagues' assertion that inquiries about moonshine consumption “may not be recommended.” Because alcohol (independent of lead contamination) is a risk factor for development of gout,6Choi H.K. Atkinson K. Karlson E.W. et al.Alcohol intake and risk of incident gout in men: a prospective study.Lancet. 2004; 363: 1277-1281Abstract Full Text Full Text PDF PubMed Scopus (537) Google Scholar it is necessary to inquire about consumption of alcohol (illegal or not) among gout patients. And because lead toxicity is a treatable illness, inquiry into the possibility of lead consumption among appropriate cohorts of gout patients provides an opportunity to intervene. Unrecorded Alcohol and Lead PoisoningThe American Journal of MedicineVol. 126Issue 12PreviewWe have read with interest the article by Dalvi and Pillinger,1 who try to shed more light on the health consequences of unrecorded alcohol,2 focusing on its link to lead poisoning. Central to their argumentation is that close to one third of the global alcohol consumption is unrecorded, based on World Health Organization (WHO) data.3 While this estimate is indeed the best available, it is not an estimate for homemade or artisanal moonshine, as the authors suggest; WHO definition of unrecorded alcohol comprises other categories, such as cross-border shopping, surrogate alcohol (ie, alcohol not officially produced for human consumption), and illegally smuggled or industrially produced alcohol. Full-Text PDF