CONTEXT

• Recently there has been an alarming rise in India in the incidence of mucormycosis, in patients who have been diagnosed and treated for COVID-19.
• As a result, some States, including Tamil Nadu, have declared mucormycosis as a notifiable disease under the Epidemic Diseases Act.

MUCORMYCOSIS

• It is a serious but rare fungal infection caused by a group of molds called mucormycetes, which is abundant in the environment.
• It mainly affects people who have health problems or take medicines that lower the body’s ability to fight germs and sickness.
• The infection is associated with very high morbidity and mortality.

RISK OF MUCORMYCOSIS IN INDIA 

• The risk of mucormycosis  is overwhelming, as the estimated burden of mucormycosis in India is 14 per 100,000 in a study published in Current Fungal Infection Reports.
• This is almost 70 times higher than what is reported in other countries.

COMMON CAUSES OF INFECTION 

• Mucormycosis is not transmitted from one individual to the other, the way COVID-19 is.
• The most common cause is uncontrolled diabetes mellitus (raised blood sugars).
• Other causes include the treatment of some cancers; steroids, chemotherapy or immunotherapy, and solid organ or stem-cell transplantations.
• The common sites of presentation include rhino-cerebral involvement (i.e., the fungus can damage the nose, paranasal sinuses, the eyes and the brain), and pulmonary involvement (i.e., the fungus can cause pneumonia).

RAISED BLOOD SUGAR CAUSES CONCERN FOR MULTIPLE REASONS

• According to a study in The Lancet, the number of people with diabetes increased to 65 million in 2016 in India.
• The crude prevalence of diabetes above 20 years of age has increased to 7.7% in 2016, from 5.5% in 1990.
• Further, there is an underlying higher genetic susceptibility to diabetes in Indians; some of these cases could get unearthed only after exposure to steroids.

COVID-19 HAS WORSEN THE SITUATION

• According to a lab study, SARS-CoV-2 can potentially multiply in pancreatic cells and contribute to increased blood sugar levels in COVID-19 patients.
• The treatment of COVID-19 is only worsening this situation. Steroids form a very important aspect of treatment for COVID-19 because they lower death rates by reducing the cytokine storm phase which can develop in some patients.
• However, steroids when used excessively or prematurely, and without medical supervision can be harmful.
• Besides causing reduced immunity levels, steroids can also increase blood sugar levels which can cause additional harm if left unchecked.
• Dexamethasone, methylprednisolone or prednisone are among the steroids used in the treatment of COVID-19.

TREATMENT APPROACH AND RELATED LIMITATIONS

• Its treatment requires a multidisciplinary team approach that includes microbiology, pathology, radiology, infectious diseases, surgery, pediatrics, hematology, intensive care, dermatology, and pharmacology.
• But, a multi-disciplinary approach is simply not feasible on a large scale, especially in areas with limited medical access.
• Also, surgery for mucormycosis can be exhausting requiring major resections.
• Additionally, there are limited antifungal drugs available for mucormycosis.
• The gold standard drug is liposomal amphotericin B, which is priced out of reach for many, while other drugs are either very expensive too or have several side effects.
• All the medicines used for treatment, often have to be administered for prolonged durations, making treatment protocols difficult to sustain on a large scale, given the cost implications and difficulty in drug administration due to its side-effects.
• Further, when a patient is recovering from COVID-19 infection, it is certainly going to be a challenge to perform debilitating surgeries and administer these antifungal drugs for a prolonged duration.
• While the treatment for mucormycosis requires prolonged hospital admissions, the health care institutions are already facing the limitations to accommodate the COVID infected masses.

WAY FORWARD

• Steroid use at home for COVID-19 should be only under the supervision of a health-care worker.
• The control of blood sugars during steroid intake is crucial to avoiding mucormycosis.
• When patients are medicating themselves at home, monitoring of capillary blood glucose is essential.
• If high blood sugars are encountered, a tele-consult with a doctor is advisable.
• Going a step further, health authorities may consider arranging for blood glucose monitoring for patients at home on steroids.
• There is a need to promote awareness campaigns on the importance of controlled blood sugar levels.
• Patients on steroids for COVID-19 should report symptoms of mucormycosis at the earliest.
• COVID-19 treatment experts and policy-makers should consider widespread training of health-care personnel including Accredited Social Health Activists (ASHAs) and nursing professionals to raise awareness on mucormycosis while educating people locally.

CONCLUSION 

• The prolonged requirement for hospital admission linked to COVID-19 will also lead to a rise in other hospital-acquired infections necessitating the use of multiple antibiotics. 
• Hence, the concern is the alarming increase in multi-drug resistant bacterial infections for which we are grossly unprepared.

Reference:

1. https://www.thehindu.com/opinion/lead/slowing-the-pace-of-indias-mucormycosis-threat/article34644652.ece