India faces black fungus epidemic as cases climb

At least 7,250 people are confirmed to have mucormycosis in India but the actual spread may be much wider, and authorities in several states have now sounded the alarm on the rare life-threatening disease that is rapidly popping up across the country as a Covid-19 complication.

At least 219 deaths have been recorded due to mucormycosis, as per figures shared by officials in 13 states and Union territories with HT. The Indian government said on Thursday that states should declare the disease notifiable under the Epidemic Diseases Act, 1897, making it mandatory for all medical facilities to report infections to a central disease surveillance network. The Delhi government separately decided to set up special treatment facilities in three of its hospitals.

"We have asked states to add mucormycosis as a notifiable disease under the epidemic diseases act as in a communication to states yesterday (Wednesday). Doing so makes it mandatory for all hospitals to report cases so that we can consolidate data about it, and also ensures the screening, diagnosis and treatment is followed as per protocols of the Union government and Indian Council of Medical Research (ICMR)," said Lav Agarwal, joint secretary, Union health ministry, during a routine press briefing.

The Indian government told the Delhi high court on Thursday that as of May 19, there were 7,251 people with mucormycosis in India, of which 200 were in Delhi.

Mucormycosis is a fungal infection with a fatality rate of at least 50%. Typically a rare disease, experts and doctors say thousands have now contracted it because of an overuse of steroids or due to suppression of their immune system, which is often a fallout of attempts to stop the life-threatening immune overreaction due to Covid-19.

ICMR director-general Balram Bhargava said these infections are of fungal spores that typically exist in abundance in the environment. "If a person's immunity is suppressed, it will infect them. If the spores have access to high sugar, it will grow. We have seen this happen with Covid-19 patients with diabetes and uncontrolled sugar, or who are immuno-compromised or have been given immune-suppressants," he added.

Several states are scrambling to place orders for the life-saving drugs required for it, and a Union minister announced manufacturing was being stepped up. According to the Union government's lawyers at the Delhi high court, which asked the Centre to submit a report on steps taken to import drugs for it, the supplies of Amphotericin B, the only last line drug that can treat it, are being distributed on the basis of caseloads. The court was hearing a clutch of petitions for better Covid-19 management, and one of the petitioners mentioned the shortage of, and clamour for, Amphotericin B.

The Centre's counsels Kirtiman Singh and Amit Mahajan told the court that as per the case load, 3,150 vials have been released to the Capital in three tranches between May 11 and May 20. To this, the Delhi government's lawyer, senior advocate Rahul Mehra, said that the projected weekly demand was 15,000 vials.

"We are not questioning your allocation…you are doing good work… You need to import this to bridge the gap between your plan to enhance the capacity and completing manufacture before we lose more precious lives. So act fast on this…Float a global tender and ask internationally….Make a global enquiry," a bench of justices Vipin Sanghi and Jasmeet Singh told the Centre's lawyers.

Meanwhile, on Thursday, Mansukh Mandaviya, who is the Union minister of state for chemicals and fertilisers, said in a tweet: "Black Fungus (Mucormycosis) curing drug #AmphotericinB's shortage will be resolved soon! Within three days, 5 more Pharma companies have got New Drug Approval for producing it in India, in addition to the existing 6 pharma companies".

The shortage has been triggered by an unprecedented surge in cases, which often requires one patient to be treated with multiple vials of the antifungal drug. Experts at Delhi's All India Institute of Medical Sciences (AIIMS) said on Wednesday they would normally see 10-15 cases a year, but have now received over 100 cases this month itself.

"Cannot talk about disease incidence as such but in our clinical life we would see maximum five to seven such patients in the intensive care units. It was rare," said Dr Anjan Trikha, professor, department of anesthesia, critical care and pain medicine, AIIMS, Delhi on Thursday.

Delhi chief minister Arvind Kejriwal on Thursday said he has directed three government-run hospitals in Delhi to set up dedicated centres for mucormycosis cases, while promising to ensure adequate supply of medicines needed to treat the disease.

The facilities will be at Lok Nayak Hospital, Guru Teg Bahadur Hospital, and Rajiv Gandhi Super Speciality Hospital.

Delhi has in place a four-member technical committee to "streamline and systemise" the distribution of Amphotericin-B. Hospitals need to raise requests for supply with this committee. After an approval, the Directorate General of Health Services issues the drug to the representative of the facility.

Even though it has not been yet established whether the virus that causes Covid-19 is directly responsible for growing cases, clinicians say several factors found in Covid-19 patients could lead to the secondary infection.

"Mucormycosis needs a fertile soil to grow, and high blood glucose levels, lack of oxygen, acidosis and suppressed immunity all contributes towards the growth. In Covid-19 patients there is a high probability of having all these factors that perhaps is leading to increase in cases," said Dr Ambrish Mithal, chairman, department of endocrinology and diabetes, Max Healthcare.