COVID-19 PANDEMIC AND MUCORMYCOSIS
Centres for Disease Control and Prevention (CDC), defines mucormycosis as a rare fungal infection caused by molds called mucormycetes. These molds exist in environments all around us and are be found in soil, rotting food, bird and animal excretions, water and air around construction sites, and moist environments. We breathe them in via fungal spores in the air and the infection often starts in the nose before spreading to the eyes and brain. This is a rare, non-contagious disease – but it can be debilitating or fatal if not treated quickly.
The signs and symptoms of mucormycosis depend on where in the body the fungus is growing– rhinocerebral, pulmonary, gastrointestinal or cutaneous. When Mucor attacks the sinuses, it spreads to the lungs, the brain and the central nervous system. Common symptoms of the resulting mucormycosis include fever, headache, rashes, reddish and swollen skin near the nose or eyes (that turns black–so the name Black fungus), facial pain, cough producing bloody or dark fluids, and shortness of breath. Disseminated mucormycosis typically occurs in people who are already sick from other medical conditions. Patients with disseminated infection in the brain can develop mental status changes or coma.
Many people may come into contact with mucormycetes but only a rare few develop mucormycosis. When a patient whose immune system has been compromised inhales Mucor spores, they may develop mucormycosis. As per a report, the frequency of mucormycosis infections has increased in the last decade, principally because of the greater number of organ transplants. People who have received transplanted organs depend on immunosuppressant drugs to keep their bodies from rejecting the new organs, but in this state they are also predisposed to infection.
People suffering from COVID-19, HIV/AIDS and other viral diseases, congenital bone marrow disease, severe burns, cancers and untreated or irregularly treated diabetes have reduced immunity and are prone to developing mucormycosis. COVID-19 patients who have received steroids are particularly at risk because steroids suppress the immune system. That is why judicious use of these drugs is crucial.
While mucormycosis cannot spread from person to person, according to Centres for Disease Control and Prevention(CDC), healthcare-associated outbreaks have been linked to adhesive bandages, wooden tongue depressors, hospital linens, negative pressure rooms, water leaks, poor air filtration, non-sterile medical devices, and building construction.
Even before the pandemic, cases of mucormycosis in India were increasing faster than the global average, according to a 2019 meta-analysis. It affects an estimated 14 in every 100,000 people in India compared to 0.06 per 100,000 in Australia, for example. But the situation has become more worse in India amid COVID-19 pandemic and the problem got exacerbated.
Globally, outbreaks of mucormycosis have been mostly seen occurred due to contaminated products such as hospital linens, medications and packaged foods. And there have been very few mucormycosis infections associated with Covid-19 in countries other than India. The widespread nature of the reports of mucormycosis currently in India suggests it is not coming from a single contaminated source. A recent summary of Covid-19-associated mucormycosis showed 94% of patients had diabetes. World Health Organization considers diabetes as a growing challenge in India with estimated 8.7% diabetic population in the age group of 20 to 70 years. The condition has skyrocketed in India during recent years. A recent study found that 72.96 million Indian adults live with diabetes — a dramatic increase over the 26 million estimated in 1990.
People with diabetes and obesity tend to develop more severe Covid-19 infections. This means they are more likely to receive corticosteroids, which are frequently used to treat Covid-19. But the corticosteroids – along with diabetes – increase the risk of mucormycosis.
While some experts assume the increase might have something to do with India’s intense second wave of COVID-19, UK- based expert pulmonologist, Dr Tasaduk Sultan Khan arguments that the Indian experts should take into consideration the excessive domestic use and improper storage of animal dung in India as a strong possible factor. He argues that we cannot just blame steroid use and diabetes alone in the genesis of this disease and certainly the reasons are many but real propensity reason will be far and few. He advises that it is of crucial importance that medical fraternity coupled with occupational health care workersshall come together tostudy the demographic data of all the Black fungus infested patients to zoom on the real aetiology of this dreaded disease.
Moreover, the virus that causes Covid-19 can damage airway tissue and blood vessels, which could also increase susceptibility to fungal infection. So damage to tissue and blood vessels from Covid-19 infection, treatment with corticosteroids, high background rates of diabetes in the population most severely affected by the coronavirus and importantly, more widespread exposure to the fungus in the environment are all likely to be playing a part in the situation we are seeing with mucormycosis in India currently.
With regard to its management, ensuring the judicious use of steroids in patients and a proper glycaemic control shall serve a purpose. However, the best way to limit your risk of mucormycosis is to get vaccinated as soon as possible so that your immune system is not taxed by COVID-19 should you come into contact with it. These kinds of fungal infections are rare, but there are so many other complications that COVID-19 can cause.
The two drugs most effective at treating mucormycosis are liposomal form of amphotericin B and posaconazole — as recommended by Centers for Disease Control and Prevention(CDC), provided the infection is found early. Moreover, there are a few simple steps we can follow to lower our risk of contracting mucormycosis. The first step is to educate society about the disease. Second–we must periodically sample the air in hospitals, especially in the critical care wards, to check for the presence of spores. Third–we must ensure that the humidifiers used during oxygen therapy are sterile. Fourth– recovering patients should be advised to remain indoors until they regain their natural strength and immunity. Fifth–patients engaged in farming or gardening should be advised to lay off from work until the storm has settled.
Protecting yourself from the environmental component—Wearing face masks, shoes, long pants, and a long-sleeved shirt when doing outdoor activities such as gardening, yard work, or visiting wooded areas or while handling materials such as soil, dust, moss, or manure. Besides to reduce the chances of developing a skin infection, cleaning skin injuries well with soap and water, especially if they have been exposed to soil or dust — will go a long way in preventing us from contracting mucormycosis.
The writer is Kashmir-based physician, renowned Educator and a Columnist. He is the Founder & Director of ‘Jammu and Kashmir Innovative Foundation for Transforming Society (JKIFTS) and also Founder & CEO ‘Dr Tasaduk’s Medical Foundation’. [email protected]