Cause for concern

In an interview with BBC, Dr. Pandey of the 1,100-bed State-run Maharaja Yeshwantrao Hospital of Indore has stated that the ‘black fungus’ infection is a bigger challenge than Covid -19 and if patients are not treated in time, the mortality rate can go up to 94%. He also pointed out that the cost of treatment is very high and the drugs are in short supply.

Is the disease scary? can be gauged by the statements of an ENT surgeon, Dr.Bhumkar (Published in the Times of India.), who says, “Mucor surgery is like cancer surgery. We have to remove every part necrotised by the fungus and perhaps even some extra margin to ensure that nothing is left behind. Only after we reduce the fungal load can medicines like liposomal amphotericin B or conventional medicines work”. The difficult part is, if surgery is required, then whether there is availability of surgeons at all Covid Centers/Hospitals?

Nosocomial Infection

Classical medical textbooks and research articles define mucormycosis as a nosocomial infection also termed as a hospital-acquired infection which are infectious diseases acquired in a hospital/health care facility. To be considered nosocomial, the infection is to be absent at admission and must develop at least 48 hours after admission. These infections can lead to serious problems like sepsis and even death.

(Black fungus may require surgery for removal of dead/infected tissue.)

Predisposing Factors

‘Black fungus’ or mucormycosis is an opportunistic infection caused by members of the fungus of the genera Rhizopus, Mucor, and other fungi (singular – fungus). Among the predisposing conditions responsible for acquiring this infection are the presence of diabetes (diabetic ketoacidosis resulting in high blood sugar and low blood pH) and treatment with corticosteroids. High glucose levels and low blood pH are ideal conditions for this fungus to cause the infection.

Along with treatment with amphotericin B and other drugs, control of diabetes and other underlying conditions along with surgical removal of necrotic tissue are essential lines of treatment in managing mucormycosis. Even with early diagnosis and immediate intervention, the infection may result in loss of vision in at least one eye.

Sources of Infection

These fungi are not part of the normal human flora. Nosocomial mucormycosis is known to be a hospital-acquired fungal infection. The fungal spores are carried from the hospital environment to susceptible patients through air (airborne) or contact transmission. The infection is rare and is not a usual occurrence. The fungi causing this disease are found in soil, dust, bread, fruits, etc. It is almost ubiquitous i.e., found almost everywhere.

There may be multiple sources of infection and a thorough investigation can lead to the discovery of potential sources. Mucormycosis or ‘black fungus’ in hospitals is generally associated with insufficient or absence of any air filtration systems in health care facilities, non-sterile medical supplies (particularly oxygenation systems and their peripherals), and deficient device sanitation/disinfection poor ventilation, high humidity, and dust but the potential source can be confirmed only after research and analysis. Probable causes could also be the linen, catheters and tubes, air filtration systems insufficient to trap spores, non-sterile bandages, patches, tape, and adhesives, or even food. Infections are known to occur due to multiple exposures. It is to be noted that the disease is very rare in developed countries.

The Silver Lining – Treatment available, not contagious

The only silver lining is that mucormycosis is treatable with antifungal antibiotics like amphoterin B and others. However, the question is do we have enough available stocks of this antibiotic? Some states have already declared it an epidemic and Maharashtra Health Minister has publicly declared that there is a shortage of these antibiotics. Surgery is required to remove necrotic (dead)/infected tissue. The fact that mucormycosis is not contagious and does not spread from person to person gives us some relief.

‘Judicious’ use of steroids?

Immunocompromised diabetic patients are the most vulnerable to this infection. The concern is whether the recent guidelines given by the ICMR are being followed by the physicians? The guidelines recommend judicious use of steroids leaving the interpretation of ‘judicious’ to the physicians who are managing Covid cases. The guidelines, however, do not resolve the issue. 

The fact that needs serious consideration that nowhere else in the world has this deadly infection raised its head during the Covid pandemic, not even in other third-world countries. The fact that this infection is related to unhygienic or improper way of handling patients, patient environment, and equipment cannot be denied. Due to the acute oxygen shortage, the patient’s relatives were seen administering oxygen to the patient at almost any available place outside the health care centres and in the worst of conditions. Patients were seen to be treated outside the hospital environment where it is impossible to control the quality of air and prevent infection.

The confusion caused by oxygen shortage and the hapless relatives of the patients managing to get oxygen cylinders and other related equipment from all possible sources may be one of the probable reasons for giving way to this dangerous infection whose fatality rate is much higher and also capable of leaving permanent disabilities. 

Data about the available sources of the oxygen cylinders? Whether they were/are usable for medical purposes? Whether the masks, cannulae, etc. used were of desirable quality? Whether they were used in the prescribed manner? Would be of great value in treating this epidemic. The reasons for this emerging fungal infection also need to be ascertained to avoid future occurrences in places where it has not yet occurred.

Ample caution is required regarding the air quality of temporary structures or non – hospital buildings and structures to be used as Covid treatment facilities. Air quality management for patients being treated with immunosuppressive drugs is of utmost importance. It is for the same reason that the ICUs in the hospitals are supposed to have special air filtering mechanisms to prevent any such occurrences of secondary infections and infections like mucormycosis.

Mucormycosis is a rare infection and most physicians may not even have come across in their career and therefore diagnosis and prognosis will require supervision by experts. The infection spreads rapidly and the rhinocerebral infection seen may also require surgical interventions. 

Prevention better than cure

With a mortality rate of 50 percent, the best way to deal with this infection only seems to be able to prevent it. Infection control measures can prevent future outbreaks. Regions where this outbreak is not found, need to be extra careful regarding hospital hygiene and restrict the probable source of the fungal spores and their exposure. Efforts to maintain environmental hygiene in the treatment facility/hospital are crucial for prevention and also for the fact that early diagnosis is not easy and by the time symptoms appear it is already too late for recovery without any irreversible bodily harm like loss of vision.

Steroid treatment needs monitoring

In such chaotic times when the health infrastructure in India is more than challenged, emphasizing prevention seems to be the only practical strategy to deal with this dangerous infection. What is required is real-time guidance from a central or decentralized helpline available also at the state or district level for those physicians operating in remote areas or smaller towns. This guidance and can prove to be extremely critical; especially in response to patient management with steroids.

Whether it could have been avoided?

Proper oxygen availability for Covid patients and its proper administration by trained personnel probably could have prevented this disaster. The oxygen crisis seems to be the most probable cause for this infection. The infection has already been declared as an epidemic in certain States. It only reminds us that we are still a developing country with a health infrastructure that itself is sick and in the ICU. 

Currently, what seems to be of crucial importance is the manner of use of steroids in diabetic and other patients and how the physicians respond to this challenge because controlling other factors seem to be impossible during these chaotic times. ‘Black fungus’ epidemic has shown our ailing health system the mirror. Hope we learn our lessons, this time.