Black Fungus Infection | India cannot allow another bug to dictate terms to us

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Mucormycosis is a fungal infection caused by a type of mold called mucormycetes. It is not a rare mold and exists all around us. It is present in the soil, water and even our households. It generally does not cause disease in healthy people, even if they are exposed to this mold all the time. But when the body’s defences are down due to some reason, this fungus can wreak havoc.

Misuse Of Medicines

Excessive use of steroids for COVID-19 treatment, irrational use of antibiotics, uncontrolled blood sugar levels and the use of immunosuppressant medications, are all situations where the body’s defence system is not functioning optimally. Many of these factors are connected to each other during this pandemic.

The use of steroids can increase the blood sugar levels in COVID-19 patients who are diabetic. In some places in India, antibiotics are prescribed without any specific indication to COVID-19 patients, thereby destroying the normal bacterial flora in the nose and air passages. This will allow invasive fungal species and pathogenic bacteria to grow in those parts of our body.

There is a reasonable degree of evidence to show that the excessive use of zinc supplements as an immunity booster in COVID-19 patients, may also increase the risk of mucormycosis. Some studies have also indicated that COVID-19 itself is a risk factor for this fungal infection.

The bottom-line is that, the disease’s aetiology is multifactorial by nature and we should not look for any specific causes in patients. But one thing everyone needs to understand is that mucormycosis is not transmitted from one person to other, and everyone is exposed to the spores of this mold all the time. That is the reason why many experts have discounted the causative role of dirty oxygen tubings, humidifiers and even contaminated nasal swabs.

Infection Spread

The most common infection is in the sinus cavities of our nose and the lungs. From the sinuses, it can spread to the eyes and brain, making it a potentially debilitating infection. The death rates can be as high as 50 percent, in patients who present with advanced disease.

Even in survivors, a significant proportion may lose an eye or some neuromuscular functions. Therefore, early identification and effective treatment becomes extremely important.

Typical clinical features, histopathological tests to identify the fungus from the affected tissues using microscopy and fungal culture, are the main diagnostic modalities used. The treatment is quite aggressive too. Urgent surgery to take out all the affected and dead tissues is extremely important to limit the spread of the disease. Prolonged administration of intravenous antifungal agents and reversal of the risk factors which resulted in the disease, are also of equal importance.

Medical Supplies

All of these are challenges, which need to be addressed at the highest levels of governance. In the short term, we need to get more Liposomal Amphotericin B and also improve the messaging strategies around the issue of mucormycosis. Since the local production capacity of Liposomal Amphotericin B is limited to a handful of companies, we need to take the import route to fill the gap between demand and supply. There should also be a mechanism to make sure that the drugs are distributed to states according to the case loads and that there is no hoarding/profiteering.

Besides, the medical professionals need to be sensitised about this issue, regarding its presentation and treatment. Since this used to be a very rare disease, not many healthcare professionals have an exposure to it. Most importantly, the public and the healthcare providers need to be aware about appropriate use of medicines.

Steroids and antibiotics were misused extensively in the COVID-19 second wave, either through self-medication or on the advice of professionals. In many instances, this misuse of medicines is a function of professional incompetence and lack of updated knowledge about the disease among the prescribers. Any available channel should be used to communicate evidence-based advisories to healthcare professionals in the frontline of our fight to contain COVID19. Rather than a punitive approach, some form of handholding should be the best way forward to ensure that medicines are used rationally and blood sugar levels are controlled more tightly.

Be Prepared

If we look at the immediate future, we need to establish well-equipped centres at the district or state level to manage cases of mucormycosis. These centres should have trained personnel to do the surgical intervention, support staff to aid the recovery process and supply of the required antifungals. Epidemiological studies are needed to improve our understanding of the causality and also ways to avoid it.

To avoid such situations in the future, we should be willing to upgrade the quality of medical education in India. Medical students should be taught about the appropriate use of medicines and the dangers associated with irrational prescriptions. The skill-sets of the healthcare providers, especially the general practitioners working in small towns and rural areas, should be enhanced through systematic training and capacity building.

Besides, the regulatory system for retail pharmacies should be tightened so that potent medicines such as steroids and antibiotics are not dispensed without a valid prescription. The overall accountability of the health system should go up, with a focus on quality of healthcare delivery. In a country where the access to healthcare indicators are already low, improving quality of care requires significant investment from the side of the government.

The collective conscience of the nation was hurt when we saw the misery of patients gasping outside hospitals, when they were waiting for a bed or an oxygen cylinder. At a time when things done with the best intentions also go wrong, we cannot afford to have another bug dictate terms to us.