Public health challenges are those that have solutions beyond the perimeters of narrow medical interventions. Regarding a potential public health menace as merely a medical challenge until numbers rise to hideous levels is bad practice. The mucormycosis (commonly and mistakenly called ‘black fungus’) epidemic superimposed on the second wave of the Covid-19 pandemic is a classic case in point. Within months, it has gone from a rare condition caused by ubiquitous and largely innocuous fungi to being declared an epidemic by a number of Indian states. Unfortunately, it continues to garner scarce recognition as a problem that warrants steadfast public health measures.
Silent disasters: A study conducted by the Indian Council of Medical Research (ICMR) between June and September 2020, with data from 17,534 Covid patients in 10 hospitals across eight cities, reported that nearly 3.6% (in the range of 1.7% to 28% between hospitals) of total patients developed a secondary infection, with around 78% having been reported two days after hospital admission and an average mortality of 56.7%. However, none of these infections were mucormycosis. Notwithstanding the possibility of missed mucormycosis cases during the first wave (one of the authors is personally aware of such a case), it raises the question as to why it has transformed into a veritable onslaught during the second wave. This, along with the high rate of secondary infection in many facilities and high mortality amongst Covid cases with secondary infection, should first and foremost have inspired a detailed epidemiological investigation months ago (irrespective of whether another wave would come or not) to identify and rein in the responsible factors, rather than making guesses, which we continue doing even today.
The incidence of mucormycosis has been increasing in the last couple of decades as indicated by some single- and multi-centre studies, possibly attributable among other factors to the rising prevalence of diabetes and suitable climatic conditions in India. A study across 16 institutions between September and December 2020 noted a 2.5 times increase in mucormycosis infections. Since December 2020, a palpable rise in cases can be made out from clinician testimonies. Technically, therefore, mucormycosis becoming an epidemic is not a recent phenomenon, but one that is many months old and is only bursting at the seams now.
The ICMR study also noted that nearly three-fourth of patients with secondary infections were given antibiotics from the ‘Watch’ and ‘Reserve’ lists of the WHO, which includes drugs having a greater propensity to bacterial resistance and must be reserved for certain special situations. Another study on Covid patients at the trauma centre of AIIMS, Delhi, noted multi-drug resistance in 60% of studied isolates with overall resistance up to 84%. One can expect the situation to have only worsened in the second wave. These forebode the horror of widespread antimicrobial resistance soon after the pandemic due to their indiscriminate use, which could be a much bigger and more enduring concern than mucormycosis.
The public health approach: On the one hand, overenthusiastic media reporting on mucormycosis has trivialised a public health crisis into a matter of frivolous colours (black, yellow, orange fungus and so on). The public health aspect of the situation has been sidelined and the voices of clinicians involved in treatment have been amplified, with a near absence of public health voices and perspectives in television discussions. On the other hand, our health system approach to mucormycosis fails to move beyond arranging doses of liposomal Amphotericin B and loosely pronounced advisories on rational use of drugs, with insufficient attention to epidemiology. A secondary epidemic superimposed on a pre-existing pandemic must not be accorded secondary priority. In fact, there is a range of distinctive reasons that make a public health response extremely crucial for combating the fungal threat: high fatality rate; high burden of comorbid risks like uncontrolled diabetes in the population; considerable toxicity profile of the drug used for the treatment; shortage of the drug and its prohibitive price; and so on.
The factors held responsible for mucormycosis have been widely discussed but not followed through adequately. The potential roles of industrial oxygen; impure water used in steam inhalers; unclean oxygen cylinders; early, excessive and indiscriminate steroid use; and so on have been customarily discussed but not fully explored. The crisis at hand merits an urgent and detailed epidemiological and scientific study, and must not merely be seen as an aggravated clinical condition. The findings of such studies should be made public and each state government should take corrective measures so that we could avoid a similar future situation, though the pathogenic agent may be different. Similarly, a passive attitude towards antibiotic misuse and not taking due public health cognisance and measures can prove very costly in the not-so-distant future.
The fact that a high proportion of these problems are hospital-acquired points towards strengthening infection prevention and control (IPC) in the hospitals. There is a need for robust conception and enforcement of standard treatment guidelines with overarching clinician participation. Robust ongoing surveillance and reporting; strong public campaigns to promote infection prevention, control practices and early treatment seeking; and disincentivising over-the-counter drug consumption are warranted. More needs to be done towards alleviating the disastrous financial impact of prohibitive conditions like mucormycosis than just subsidising them under public health insurance schemes since the latter see very limited effective utilisation. The cost of treating such secondary infections should be fully borne by the government, irrespective of the treatment facility being public or private.
Soon, cases of mucormycosis shall come down and the crisis will be forgotten as if it never happened. This has perennially been the tragic tale of the Indian public health response—the crucial lessons are hardly ever assimilated well enough to deter a future crisis. This has happened numerous times in the past with multiple crises, such as the deaths of children due to acute encephalitis syndrome (AES) or deaths related to hospital fires. Far too much extraneous noise and undue emphasis on medical interventions have diverted the attention from core issues. Why does a rare condition end up becoming an epidemic in India? It is one of the many questions we need to answer in order to prepare ourselves for future epidemics and pandemics.
Dr Soham D Bhaduri
Health policy expert and Chief Editor of ‘The Indian Practitioner’
Dr Chandrakant Lahariya
Epidemiologist, public policy and health systems expert, and co-author of ‘Till We Win: India’s Fight Against The COVID-19 Pandemic’