Why did the Mucormycosis outbreak Happen in India
During the second wave of Covid-19, patients being treated for covid-19 in India faced an extremely peculiar threat that was beyond that of the virus. Patients were faced with Mucormycosis, or as the general public and news outlets called it, ‘The Black Fungus’. Mucormycosis is caused by a fungus that infects the nose and eyes and if severe can attack the brain. This fungus can be extremely deadly to immunocompromised people such as those suffering from Cancer, Diabetes and HIV. The fungus attacked people being treated for severe covid in India, and in most cases those people would be suffering from an underlying health condition such as the ones mentioned above. Although this nickname for the fungus comes from its appearance and not to do with the black death of Europe caused by the plague, the death rate of the fungus is approximately 50% (Soutik Biswas, bbc.com), similar to the percentage of Europeans that died in the black death. However, it is still unclear why India’s Mucormycosis cases reached over 45000 cases with over 4300 deaths and thousands having body parts removed to prevent the fungus from entering the brain. This raises the question of why Indian Covid-19 patients were hit so much worse with this fungal infection during their recovery process than patients in any other country? In this paper, by referencing facts and studies as well as covid treatments in other countries I will argue that the prescriptions and treatments prescribed by doctors in India to those suffering from severe covid-19 due to them having underlying health issues was the reason for the Mucormycosis outbreak in India.
Mucormycosis is an extremely rare infection as it comes from the contraction of Mucor mould. This mould is found all around the environment humans are exposed to during their daily lives, however, is extremely rarely contracted as an infection as in most cases humans have a high enough immunity to protect them from this. Doctors in India blame the Mucormycosis outbreak on the high rate of underlying health conditions, especially diabetes, in India. The reason behind this is described by Dr. Nair from Mumbai in an interview with the BBC correspondent Soutik Biswas, “Diabetes lowers the body’s immune defences, coronavirus exacerbates it, and then steroids which help fight covid-19 act like fuel to the fire.” In this Dr. Nair says that Diabetes lowering the immune defence causes more extreme covid symptoms which results in the need for steroids to lower inflammation in the lungs of the patient: this in turn further reduces immunity making the patient extremely susceptible to Mucormycosis. Therefore, it may seem reasonable to say that a country with 77 million diabetics as of 2019 (Statista.com) would have many go through the process described above by Dr. Nair during the pandemic and therefore would result in an extremely high number of patients becoming susceptible to Mucormycosis. However, even for a country with a higher-than-normal rate of diabetes India reported a disproportionately high number of Mucormycosis (a non-contagious disease) cases during the pandemic with 140 cases per million population as compared to the rest of the countries that reported between 0.005 and 1.7 cases per million population (WHO). These statistics could suggest that the cause of the Mucormycosis outbreak in India is more to do with the treatments or another factor rather than the high rates of diabetes in India.
If the outbreak of Mucormycosis in India had a significant relationship to diabetes as many doctors suggested, this could be easily investigated. The US had 31 million diabetics in 2019 and china had a staggering 116 million diabetics (150% of the number of diabetics in India) in its population during the same year India measured 77 million diabetics (statista), however according to The World Health Organization both these countries fell in the 0.005 to 1.7 cases of Mucormycosis per million during the period in which India recorded 140 cases of Mucormycosis per million. These numbers above go to show that with a fairly similar number of diabetics to India in the US and China (+/-50%) the number of Mucormycosis patients in India are around 100 times greater than that in these two countries. Furthermore, although China’s reported cases of covid-19 are significantly lower with around 98,000 cases, the US reported a higher number of cases than India with 48 million as opposed to 35 million in India. Therefore, this would suggest that the number of Diabetics that suffered through covid in these two countries would be roughly similar. This raises the question that if the number of diabetics that suffered from covid did not directly influence the number of Mucormycosis what did?
One significant variation between China and the US as opposed to India is the treatment patients were given. In India, as mentioned above, patients with underlying health conditions or significant symptoms were treated using the use of steroids which further decreased the immunity of the patients making them susceptible to Mucormycosis. However, Linzi Fan’s study for current pharmacology reports shows that China stuck to a strict list of medicines that were prescribed to cases ranging all the way from mild to severe. The summary of the drugs in clinical use in Linzi Fan’s study are all described as antivirals without any mention of the use of steroids even for those cases that could be classified as severe. Therefore, the contrasting prescription of medication is fairly evident between China and India. In India doctors were prescribing patients steroids which resulted in the significant lowering of immunity whereas in China doctors were prescribing Antivirals that increase one’s immunity by forcing the body to produce a higher number of antibodies. Additionally, these antivirals such as Ribavirin and Lopinavir were completely tried and tested as they were developed medicines to combat viral illnesses such as HIV and Middle East Raspatory Syndrome and were therefore known to result in this positive effect on the body’s ability to combat viral infections such as Covid-19. Therefore, this study and contrasting medical prescriptions for Covid patients between India and china could suggest that the reason behind the Mucormycosis outbreak in India was the mis prescription of deimmunising steroids in India.
Furthermore, Patients in the US were treated in a similar manner to China. Patients in the US even with severe symptoms of covid-19 were treated with emphasis of the prescriptions being put on antiviral drugs. However, the US used even more advanced treatments which significantly reduce any risk of side effects due to its natural source. This is as in an article by Po-Lin Chen and her associates for Frontiers in Pharmacology they show that although the US used antiviral drugs as in China, a significant aspect of the covid treatment in the US was based on Convalescent Plasma transfusion. This is a treatment that neglects the need for any drugs that may result in side effects as this entails the patient suffering from covid having a transfusion into their blood of the plasma of a recovered covid patient that has antibodies in it. This was mainly used for people with severe symptoms as Po-Lin Chen says, “Patients with life threatening disease were more likely to improve from CP transfusion.” This treatment, although potentially being less effective towards its effect on Covid-19 recoveries as the role played by this treatment had a far less significant effect than the effect of the antivirals as mentioned by Po-Lin Chen, resulted in the increased immunity of patients as patients were able to have a higher number of antibodies in their blood. This contrasts to the treatment used in India of steroids for severely effected covid-19 patients that resulted in an overall reduction in immunity which then in turn resulted in a higher risk for patients as they became more likely to contract rare diseases such as the black fungus. This shows that the treatments used by the US increased the immunity of the patients as opposed to the patients in India that were prescribed with steroids which reduced their immunity. Therefore, this further suggests that the Mucormycosis outbreak in India could have been prevented if treatment was more similar to that of the US.
Furthermore, the severity of symptoms and the chance of death of Mucormycosis can be significantly reduced if handled correctly. In a study conducted by Brad Spellberg and Ashraf S. Ibrahim published in Springer, the researchers found that if treatment for Mucormycosis was started in five days or less after contraction the Polyene therapy would increase to 83%, however if treated after five days the chances of survival significantly drop to 49%. Therefore, if prescription of steroids was the only treatment within the means of doctors in India to give patients, it would be fairly obvious that keeping patients for observation through the steroid treatment would significantly reduce the number of deaths. This is as it was known by doctors that people with underlying health conditions going through steroid therapy were prone to contracting Mucormycosis. This observation would result in doctors noticing the contraction of Mucormycosis within the crucial five-day period and therefore would significantly reduce the number of deaths caused by this fungus in India. Therefore, if the steroid prescription was necessary in India the full steroid treatment given to patients could have been conducted with the observation period mentioned above to significantly reduce deaths and severe cases caused by Mucormycosis. Therefore, this further suggests that the treatment provided for sever cases in India was not the ideal environment for the avoidance of Mucormycosis.
In conclusion, it is important to acknowledge the fact that the use of steroids and treatment given to patients suffering from severe covid-19 symptoms through the prescription of steroids helped reduce the inflammation of the patients’ lungs which further helped in many patients recovering from covid-19. However, the prescription of steroids and treatment of patients during the process of taking steroids clearly shows to have had a significant impact on the number of cases of Mucormycosis. Additionally, if the treatment of extreme covid patients in India and those in other diabetic dense populations such as China and the US are compared, it becomes relatively clear that the options for the treatment of severe covid-19 cases were varied and therefore the risk of Mucormycosis for patients that were experiencing significant symptoms of Covid-19 was avoidable. This can be said as China and the US experienced around 1% of the Mucormycosis cases in India per million with the diabetic population being within 50% of India’s. The reason for this clearly points to the fact that China and the US predominantly treated severe patients with antiviral medication while India treated their severe patients with steroids. Therefore, a conclusion can be made that the solution to avoid high numbers of Mucormycosis cases in India is to treat severely affected covid-19 patients with antiviral medication instead of steroids.
Works cited
- Countries with the highest number of Diabetics Worldwide 2019. https://www.statista.com/statistics/281082/countries-with-highest-number-of-diabetics/ (Accessed Dec 1, 2021)
- Mucormycosis key Facts. https://www.who.int/india/emergencies/coronavirus-disease-(covid-19)/mucormycosis (Accessed Dec 2,2021)
- Coronavirus cases India. https://www.worldometers.info/coronavirus/country/india/ (Accessed Dec 2, 2021)
- Coronavirus Cases China. https://www.worldometers.info/coronavirus/country/china/ (Accessed dec 2, 2021)
- Coronavirus Cases USA. https://www.worldometers.info/coronavirus/country/us/ (Accessed Dec 2, 2021)
- Biswas, Soutik. “Mucormycosis: “The ‘Black Fungus’ maiming Covid patients in India.” BBC.com. 9 May 2021.
- Chen, Po-Lin., Lee, Nan-Yao., Cia, Cong-Tat., Ko,Wen-Chien., Hseuh, Po-Ren. “A review of Corornavirus Disease 2019 (Covid-19): Therapeutic repurposing and unment Clinical Needs.” Front. Farmcol. 17 November 2020.
- Spellberg, brad., Ibrahim, Ashraf S. “Recent Advances in the Treatment of Mucormycosis.” Springer Current Infectious disease report. 10 Aug 2010.
- Fan, L., Jiang S., Yang X. “Covid-19 Drug Treatment in China.” Curr Farmcol rep. 07 september 2020.
