Delivery Method: VIA UPS Product: Drugs

Recipient:

Recipient Name

Mr. Francisco Cervantes

Recipient Title

Chief Executive Officer

Noticias Mexico Hoy Grupo Multimedia, S.A. de C.V.

Privada Rio Atoyac No. 23
Colonia Rancho Colorado
72040 Puebla, Pue.
Mexico

Issuing Office: Center for Drug Evaluation and Research | CDER

United States


Warning Letter 320-22-19

June 27, 2022

Dear Mr. Cervantes:

Your firm was recently registered as a human drug manufacturer. The U.S. Food and Drug Administration (FDA) conducted testing of a drug product manufactured at your facility: Medical MARY CLEAN HAND Sanitizers, a consumer antiseptic rub (also referred to as consumer hand sanitizers) declared as manufactured by Noticias Mexico Hoy Grupo Multimedia SA de CV, FEI 3016821022, at Privada Rio Atoyac No. 23 Puebla, Mexico. Following an attempted import into the United States, Medical MARY CLEAN HAND Sanitizers was detained and refused admission at the border.

The results of FDA laboratory testing of a batch of this product detained at the border demonstrated that this drug product is adulterated within the meaning of section 501(d)(2) of the Federal Food, Drug, and Cosmetic Act (FD&C Act), 21 U.S.C. 351(d)(2), in that a substance was substituted wholly or in part therefor. In addition, the product is adulterated within the meaning of section 501(a)(2)(B) of the FD&C Act, 21 U.S.C. 351(a)(2)(B), in that the substitution demonstrates that the quality assurance within your facility is not functioning in accordance with Current Good Manufacturing Practice (CGMP) requirements.

In addition, Medical MARY CLEAN HAND Sanitizers is an unapproved new drug introduced or delivered for introduction into interstate commerce in violation of section 505(a) of the FD&C Act, 21 U.S.C. 355(a), and is misbranded under sections 502(j), (a), (e), (x), and (ee) of the FD&C Act, 21 U.S.C. 352(j), (a), (e), (x) and (ee). Introduction or delivery for introduction of this product into interstate commerce is prohibited under sections 301(d) and (a) of the FD&C Act, 21 U.S.C. 331(d) and (a). These violations are described in more detail below.

Adulteration Violations

Your drug product, Medical Mary Clean Hand Sanitizers is labeled to contain 75% volume/volume (v/v) of the active ingredient alcohol (ethanol). However, FDA laboratory testing of a batch of this product detained at the border found that your Medical Mary Clean Hand Sanitizers contained an average of 0.34% ethanol and 78% of methanol v/v. Therefore, this hand sanitizer drug product is adulterated under section 501(d)(2) of the FD&C Act in that the active ingredient of ethanol was substituted wholly or in part with methanol, a dangerous chemical when in contact with human skin or ingested.

Methanol is not an acceptable ingredient for hand sanitizers and should not be used due to its toxic effects. Skin exposure to methanol can cause dermatitis, as well as transdermal absorption with systemic toxicity. Substantial methanol exposure can result in nausea, vomiting, headache, blurred vision, permanent blindness, seizures, coma, permanent damage to the nervous system, or death. Although all persons using these products on their hands are at risk, young children who accidentally ingest these products and adolescents and adults who drink these products as an alcohol (ethanol) substitute are most at risk for methanol poisoning.

We were unable to contact your US Agent. On August 6, 2020, FDA notified the public of methanol contamination of your hand sanitizer at the following website: https://www.fda.gov/drugs/drug-safety-and-availability/fda-updates-hand-sanitizers-consumers-should-not-use.

FDA held a teleconference with Medical Mary LLC, a distributor of your products on August 10, 2020. We recommended they consider removing all of your firm’s hand sanitizer drug products currently in distribution to the U.S. market. Your distributor agreed to recall all Medical Mary hand sanitizer drug products. However, to date, neither your firm nor your distributor (Medical Mary LLC) have taken market action.

In response to this letter provide the following:

• A detailed investigation into how Medical Mary Clean Hand Sanitizers, declared as manufactured at your facility, and labeled as containing ethanol, were substituted in part or in whole with methanol.
• A list of all raw materials used to manufacture all of your hand sanitizer drug products, including the suppliers’ names, addresses, and contact information.
• A list of all batches of any hand sanitizer drug products shipped to the United States by your firm, and a full reconciliation of all material you distributed.
• Copies of the complete batch records for all batches distributed to the U.S.

The substitution and contamination with methanol in a hand sanitizer drug product declared to be manufactured in your facility demonstrates that the quality assurance within your facility does not appear to be functioning in accordance with CGMP requirements under section 501(a)(2)(B) of the Act.

Unapproved New Drug and Misbranding Violations

Medical MARY CLEAN HAND Sanitizers is a “drug” as defined by section 201(g)(1)(B) of the FD&C Act, 21 U.S.C. 321(g)(1)(B), because it is intended for the diagnosis, cure, mitigation, treatment, or prevention of disease and/or under section 201(g)(1)(C) of the FD&C Act, 21 U.S.C. 321(g)(1)(C), because it is intended to affect the structure or any function of the body. Specifically, this product is intended as a consumer antiseptic rub.

Examples of claims observed on the Medical MARY CLEAN HAND Sanitizers product label that provide evidence of the intended uses (as defined in 21 CFR 201.128) of the product include, but may not be limited to, the following:

“ANTI-BACTERIAL. . . Drug Facts . . . Use Hand Sanitizer to help reduce bacteria on the skin . . . Directions – Put enough product in your palm to cover hands and rub hands together briskly until dry.”

This topical antiseptic product is a “new drug” within the meaning of section 201(p) of the FD&C Act, 21 U.S.C. 321(p), because it is not generally recognized as safe and effective (GRASE) for use under the conditions prescribed, recommended, or suggested in its labeling. New drugs may not be introduced or delivered for introduction into interstate commerce without prior approval from FDA, as described in section 505(a) of the FD&C Act, 21 U.S.C. 355(a), unless they are lawfully marketed under section 505G of the FD&C Act (which is not the case for this product, as further described below) or under other exceptions not applicable here. No FDA-approved application pursuant to section 505 of the FD&C Act, 21 U.S.C. 355, is in effect for this drug product, nor are we aware of any adequate and well-controlled clinical studies in the published literature that support a determination that your Medical MARY CLEAN HAND Sanitizers drug product is GRASE for use under the conditions suggested, recommended, or prescribed in its labeling. Accordingly, this product is an unapproved new drug marketed in violation of sections 505(a) and 301(d) of the FD&C Act, 21 U.S.C 355(a) and 331(d).

We note that over-the-counter (OTC) topical antiseptic products had been the subject of rulemaking under the Agency’s OTC Drug Review. In particular, such products were addressed in a tentative final monograph (TFM) entitled “Topical Antimicrobial Drug Products for Over-the-Counter Human Use; Tentative Final Monograph for Health-Care Antiseptic Drug Products,” Proposed Rule, 59 FR 31402 (June 17, 1994) (1994 TFM), as further amended by the “Safety and Effectiveness of Consumer Antiseptics; Topical Antimicrobial Drug Products for Over-the-Counter Human Use; Proposed Amendment of the Tentative Final Monograph; Reopening of Administrative Record,” Proposed Rule, 81 FR 42912 (June 30, 2016) (Consumer Antiseptic Proposed Rule). Over the course of these rulemakings, three active ingredients (benzalkonium chloride, ethyl alcohol, and isopropyl alcohol) were classified as Category III for use as consumer antiseptic rub products, meaning that additional safety and effectiveness data are needed to support a determination that a drug product containing one of these active ingredients would be GRASE for use as a consumer antiseptic rub.

Section 505G of the FD&C Act addresses nonprescription drugs marketed without an approved application. Under 505G(a)(3) of the FD&C Act, drugs that were classified as Category III in a TFM that is the most recently applicable proposal or determination for such drug issued under 21 CFR Part 330 – and that were not classified in such a TFM as Category II for safety or effectiveness – are not required to have an approved application under section 505 in order to be marketed, as long as they are in conformity with the relevant conditions of use outlined in the applicable TFM, including the active ingredient, and comply with all other applicable requirements.

However, Medical MARY CLEAN HAND Sanitizers does not conform to the 1994 TFM, as further amended by the 2016 Consumer Antiseptic Rub Proposed Rule, nor any other TFM, proposed rule, or final rule, and does not meet the conditions under section 505G(a)(3) of the FD&C Act for marketing without an approved application under section 505.

According to the product label, Medical MARY CLEAN HAND Sanitizers purportedly contains the active ingredient ethyl alcohol 75% v/v. However, as previously discussed, FDA laboratory analysis revealed that a sample of Medical MARY CLEAN HAND Sanitizers contains a concentration of ethanol that is far less than the 75% v/v declared on the label. Such a product does not conform to the TFM or other applicable requirements.1

FDA laboratory analysis also revealed that a sample of Medical MARY CLEAN HAND Sanitizers contains a significant concentration of the undeclared ingredient methyl alcohol (methanol). Use of methanol as an active ingredient is not in conformance with the 1994. Furthermore, methanol is not acceptable as an inactive ingredient in hand sanitizers. As previously discussed, methanol has significant and sometimes fatal toxic effects and, therefore, does not meet the requirements under 21 CFR 330.1(e) that a product’s inactive ingredients be safe and suitable.2,3

Additionally, this methanol-containing drug product, Medical MARY CLEAN HAND Sanitizers, is misbranded under sections 502(j), (a), (e), (x), and (ee) of the FD&C Act, 21 U.S.C. 352(j), (a), (e), (x), and (ee). It is misbranded under section 502(j) of the FD&C Act, 21 U.S.C. 352(j), because it is dangerous to health when used according to its labeling as a hand sanitizer. As previously stated, skin exposure to methanol could lead to systemic absorption, and substantial methanol exposure can potentially result in, among other things, blindness, permanent nervous system damage, and even death.

This hand sanitizer is misbranded under section 502(a) of the FD&C Act, 21 U.S.C 352(a), because its labeling is false or misleading. As noted above, Medical MARY CLEAN HAND Sanitizers is labeled to contain ethyl alcohol 75% v/v. However, FDA laboratory analysis of a batch of this product demonstrates that the product contains a concentration of ethyl alcohol (ethanol) that is less than what is stated on the product label, and it contains a significant concentration of methyl alcohol (methanol), an ingredient that is not declared on the product label. Section 201(n) of the FD&C Act, 21 U.S.C. 321(n), provides that “in determining whether the labeling or advertising is misleading there shall be taken into account . . . not only representations made or suggested . . . but also the extent to which the labeling or advertising fails to reveal facts material in the light of such representations or material with respect to consequences which may result. . ..” Thus, the misleading representation of the concentration of the active ingredient ethyl alcohol (ethanol) and the failure of the product label to disclose the presence of methyl alcohol (methanol) in the product, causes this product to be misbranded under section 502(a) of the FD&C Act, 21 U.S.C. 352(a).

The failure of this product to list methyl alcohol (methanol) as an ingredient on its label also causes it to be misbranded under section 502(e)(1)(A) of the FD&C Act, 21 U.S.C. 352(e)(1)(A). Furthermore, this product is misbranded under section 502(x) of the FD&C Act, 21 U.S.C. 352(x), because the product label fails to disclose a domestic address or domestic telephone number through which the responsible person may receive a report of a serious adverse event with such drug.

Lastly, this product is misbranded under section 502(ee) of the FD&C Act, 21 U.S.C. 352(ee) because Medical MARY CLEAN HAND Sanitizers is a nonprescription drug subject to section 505G of the FD&C Act, 21 U.S.C. 355h, but does not comply with the requirements for marketing under that section and is not the subject of an application approved under section 505 of the FD&C Act, 21 U.S.C. 355.

The introduction or delivery for introduction of a misbranded drug into interstate commerce is prohibited under section 301(a) of the FD&C Act, 21 U.S.C. 331(a).

CGMP Consultant Recommended

Based upon the nature of the violations we identified at your firm, we strongly recommend engaging a consultant, qualified as set forth in 21 CFR 211.34, to evaluate your operations and to assist your firm in meeting CGMP requirements if your firm intends to resume manufacturing drugs for the U.S. market. We also recommend that the qualified consultant perform a comprehensive audit of your entire operation for CGMP compliance and that the consultant evaluates the completion and efficacy of your corrective actions and preventive actions before you pursue resolution of your firm’s compliance status with FDA. Your use of a consultant does not relieve your firm’s obligation to comply with CGMP. Your firm’s executive management remains responsible for resolving all deficiencies and systemic flaws to ensure ongoing CGMP compliance.

Conclusion

The violations cited in this letter are not intended to be an all-inclusive list of violations associated with your drug products. You are responsible for investigating and determining the causes of these violations and for preventing their recurrence or the occurrence of other violations.

Note that FDA placed all drugs and drug products manufactured by your firm on Import Alert 66-78 on August 21, 2020. Your drug products may be subject to detention without physical examination.

All drugs and drug products manufactured by your firm may remain listed on this import alert until there is evidence establishing that the conditions that gave rise to the appearance of the violation have been resolved, and the Agency has confidence that future entries will be in compliance with the Act. This may include an inspection prior to the agency considering the appearance of adulteration to be addressed.

If you decide you want to manufacture drugs for the United States in the future, request a Regulatory Meeting to discuss corrective actions.

This letter notifies you of our findings and provides you with an opportunity to address the above deficiencies. After you receive this letter, respond to this office in writing within 15 working days. Specify what you have done to address any violations and to prevent their recurrence. In response to this letter, you may provide additional information for our consideration as we continue to assess your activities and practices. If you cannot do so within 15 working days, state your reasons for delay and your schedule for completion.

Send your electronic reply to [email protected]

Identify your response with FEI 3016821022 and ATTN: Carla Norris.

Sincerely,
/S/

Francis Godwin
Director
Office of Manufacturing Quality
Office of Compliance
Center for Drug Evaluation and Research

CC:
Registered U.S. Agent
Cesar Lopez
3942 West 11th Place
Ingelwood, CA 90303

CC:
Consignee
Medical Mary LLC
3079 Baldwin Rd.
Lake Orion, MI 48359-1028

CC:
CAF Medical Solutions Inc.
4900 W Expressway 83 STE 240
Mcallen TX, 78501

____________________________

1 The 1994 TFM, which does not distinguish between antiseptic hand washes and rubs, proposed for antiseptic hand washes and healthcare personnel hand washes an alcohol concentration of 60 to 95% by volume in an aqueous solution: 59 FR 31442. Later amendments to the 1994 TFM distinguished between antiseptic hand washes and rubs, and between consumer and healthcare personnel antiseptics, but did not change the alcohol concentration originally proposed in 1994.

2 We note that “Medical MARY CLEAN HAND Sanitizers” also does not conform to any temporary policy FDA had implemented during the public health emergency. In March 2020, the Agency published three guidance documents to provide regulatory flexibility to certain firms to help meet the demand for alcohol-based hand sanitizer during the COVID-19 public health emergency (PHE). On December 31, 2021, these guidance’s were withdrawn, and firms must have ceased distribution, by March 31, 2022, of any remaining hand sanitizer products that were prepared under the temporary policies. See 86 FR 56960, October 13, 2021.

3 An inactive ingredient used in over-the-counter (OTC) monograph drugs must meet the requirements of 21 CFR 330.1(e), which requires, among other things, that inactive ingredients must be safe in the amount administered.