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Why India is facing a deadly ‘black fungus’ epidemic

AHMEDABAD, India – In the stuffy and crowded medical ward of the civilian hospital, the ear, nose and throat specialist quickly moved from bed to bed, pointing a flashlight in his mouth of one patient, examining the x-rays of another.

Specialist Dr Bela Prajapati is overseeing the treatment of nearly 400 patients with mucormycosis, a rare and often fatal fungal disease that has exploded across India in the wake of the coronavirus pandemic. Unprepared for the devastating second wave of Covid-19 this spring, many Indian hospitals have taken desperate measures to save lives – steps that may have opened the door for yet another deadly disease.

“The pandemic precipitated an epidemic,” said Dr Prajapati.

In three weeks, the number of cases of the disease – known by the improper term ‘black fungus’ because it is found on dead tissue – has climbed to more than 30,000 from negligible levels. States have recorded more than 2,100 deaths, according to reports. The Federal Ministry of Health in New Delhi, which tracks cases nationwide to allocate rare and expensive antifungal drugs, has not released figures on deaths.

The coronavirus pandemic has drawn sharp lines between rich countries and poor countries, and the mucormycosis epidemic in India is the latest manifestation of it. During the second wave, which hit India in April, its creaky and underfunded medical system ran out of beds, oxygen and other essentials as infections and deaths skyrocketed.

The mucormycosis epidemic adds even more urgency to the difficult task of protecting India’s 1.4 billion people. Only a small fraction have been vaccinated against the coronavirus, and they remain vulnerable to a third wave and the consequences that could ensue.

“Mucormycosis will subside and return to baseline as the cases of Covid subside,” said epidemiologist Dr Dileep Mavalankar. “But it could come back in wave three unless we find out why it’s happening.”

Many doctors in India think they know why. The bone and tissue-eating fungus can attack the gastrointestinal tract, lungs, skin, and sinuses, where it often spreads to the eye socket and brain if left untreated. Treatment for the disease involves complex, often disfiguring, surgery and a rare and expensive drug, contributing to a death rate of over 50 percent.

Mucormycosis is not passed from person to person. It develops from banal spores that sometimes accumulate in homes and hospitals. Doctors believe India’s overcrowded hospitals and their dire lack of medical oxygen have left an opening for the fungus.

Without enough oxygen for everyone, doctors in many places have injected patients with steroids, a standard treatment for doctors battling Covid around the world. They can reduce inflammation in the lungs and help Covid patients breathe easier.

Many doctors have prescribed steroids in amounts and for durations that far exceed World Health Organization recommendations, said Arunaloke Chakrabarti, a microbiologist and co-author of a study examining the causes of the epidemic of mucormycosis in India. These steroids may have compromised patients’ immune systems and made Covid-19 patients more susceptible to fungal spores.

The steroids may also have dangerously raised blood sugar levels, leaving people with diabetes vulnerable to mucormycosis. It could also increase the risk of blood clots, leading to tissue malnutrition, which the “fungus attacks”, said Dr Prajapati.

Desperate doctors may not have had a chance to ask patients if they have diabetes or other conditions before resorting to steroids.

“Doctors hardly had time to take care of patients,” said Dr Chakrabarti. “They were all looking to take care of the airways. “

According to the Ministry of Health, around four in five patients with mucormycosis have had Covid-19. More than half are diabetic.

Alok Kumar Chaudry, a 30-year-old engineer with surgical tape over his left eye and hooked up to an intravenous drip at the civilian hospital, is one of those with mucormycosis who first fell with Covid.

He was studying for the Indian Civil Service Exam in April in New Delhi when the second wave hit. After testing positive for coronavirus, and with scarce hospital beds, drugs and oxygen, he jumped on a train to his older brother’s home in rural Gujarat. There, his oxygen levels dropped to a life-threatening level of 54%.

After two weeks on oxygen and steroids at a local hospital, he recovered from Covid-19 but developed a sharp headache on the left side of his brain. Doctors believed that steroids may have caused it and it would go away.

“Suddenly the vision in my left eye went blank,” Chaudry said.

An MRI showed mucormycosis. Doctors said they should remove her eye.

He went to Ahmedabad Civil Hospital for a second opinion. Five specialists supervised a surgery that consisted of scraping dead tissue from his sinus tract. To clear the remaining infection, he received a 15-day course of amphotericin B, an antifungal drug.

Dr Chakrabarti said if Chaudry kept his eye he could still lose his life, as surgeons couldn’t remove the thin layer of infection behind his eye without removing the eye itself.

“I lost my sight in my left eye, my studies suffered,” said Chaudry. “I certainly want to know why the mucor formed. If it is faulty processing, someone is responsible. If it’s the wrath of God, what can I do?

The study co-authored by Dr Chakrabarti, published this month by the United States Centers for Disease Control and Prevention, said that heavy steroid use correlates with diabetes and unhealthy conditions in some hospitals had played a role.

Even before the pandemic, India had around 50 cases of mucormycosis per year, compared with, on average, just one case every two years in the United States and Western Europe. Environmental conditions play a role, as does the incidence of diabetes – India has more than twice as many people with the disease as the United States.

Usually in India, mucormycosis affects people with diabetes who are unaware of their condition or who do not take insulin properly. But in the current epidemic, many patients had no history of diabetes. The common thread was a Covid-19 infection treated with steroids, according to clinicians and researchers.

The government of Ahmedabad, Gujarat declared an epidemic of mucormycosis in May. Other states followed. Whether patients live or die often depends on how quickly they have debridement surgery that removes the fungus and then begins a two-week treatment with amphotericin B.

Prime Minister Narendra Modi, from Gujarat, described the fungal disease as a new “challenge” and said it was “important to create systems to deal with it”.

India provides small amounts of amphotericin B, which can be obtained free of charge from some public hospitals. But because supplies are limited, India imports it from the United States, where it costs around $ 300 per vial. Each patient needs 60 to 100 vials. Gilead Sciences, the American manufacturer, has donated approximately 200,000 vials.

Doctors use cheaper drugs that are also effective but more toxic, posing a risk of kidney damage.

“It’s a very painful choice,” said Dr Atul Patel, an infectious disease specialist at Sterling Private Hospital in Ahmedabad, which has treated dozens of patients with mucormycosis during the outbreak.

Dr Patel, another of the study’s authors, said that steroids, which in India are commonly prescribed for common ailments such as diarrhea or fever, were prescribed for Covid-19 patients with infections. benign who did not need it.

This was the case for one of Dr Patel’s patients, Ambaben Heerabhai Patel, 60, the matriarch of a farming family in rural Gujarat, who pays around $ 700 a day for antifungal treatment and others. services to Sterling.

It’s a steep cost, but Ms Patel had seen Dr Patel – no connection – for previous health issues related to her diabetes. After consecutive infections of Covid-19 and then mucormycosis, she did not want to take any risk.

Arriving at the hospital on May 17 with a severe headache and numbness to the face, Ms Patel said in early June from her private room at Sterling Hospital that she was feeling well for the first time in more than a year. month.

Of Dr. Patel, she said, “he’s like my god.”

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