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'Where was black fungus hiding before April?'

By VAIHAYASI PANDE DANIEL
June 18, 2021 10:16 IST
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'Where did this fungus suddenly come from and get all over the country?'

IMAGE: Dr B P Tyagi checks the eye of a patient infected with Black Fungus at a hospital in Ghaziabad, May 31, 2021. Photograph: Rahul Singh/ANI Photo
 

When we talk about COVID-19, there are two terms, and four words, that make our blood run cold.

Black mucor.

Third wave.

Its treatment is both difficult and extraordinarily expensive (recently a patient paid Rs 15 million**), especially given the shortage of reserved drugs to treat it.

If the mortality rate for COVID-19 is about 1 per cent in India*** and we are seeing such mayhem and destruction, mucor with its mortality rate of an astounding 54 per cent**** is to be feared much more.

Do we really know how the horrific black mucor, or, as it is more correctly termed, mucormycosis arose, as the second wave of COVID-19 reached its peak in India?

Mucor has always been floating in the air in our country.

Why did it take the advent of an even more renegade Indian mutant strain of COVID-19 to nightmarishly bring on a double epidemic of COVID-19 and mucor in our already beleaguered land?

The other question being hesitantly, fearfully whispered on everybody's lips (we don't really want to say it aloud, lest it come true) is: Will there be a third wave or if there is a third wave will it be as bad as our second wave?

Epidemiologist and internal medicine expert, Dr Shriprakash Kalantri has some valuable, judicious views and important doubts on both subjects.

A professor, researcher, teacher, rural disease expert, sensible medical advice tweeter, cycle enthusiast, and the head of the Mahatma Gandhi Institute of Medical Sciences, Sevagram, Dr Kalantri -- who recently remarked on Twitter, 'Perhaps no treatment, cancer chemotherapy, bypass surgery, kidney or liver transplant, costs as much as mucor does' -- in Part III of his interview to Vaihayasi Pande Daniel/Rediff.com, firmly declares that he believes much more research is required to actually discover how mucormycosis arose.

IMAGE: A patient waits to get treatment against black fungus at the Government ENT Hospital in Hyderabad, June 7, 2021. Photograph: PicStyle Photo Service/ANI Photo

In one of your tweets, you said, that maybe mucor is not necessarily caused by human body immunity being suppressed and blood sugar levels being high.
One of the side effects of COVID-19, all over the world, has been to bring on early diabetes. After getting COVID-19, people have had wildly high levels of blood sugar, which may not have been noticed on hospital admission.
Could one of the reasons why mucor found a footing in patients is because carers were not aware that they were potential diabetics? Or you feel that it may not be that at all?

I tweeted in the morning also, that every year, in rural teaching hospitals, where the people are not very conscious of their diabetic status, where they do not monitor their blood reports as frequently as is required, it's not uncommon for us to see people walking into the hospital, with sugars of 400, 500, or even 600.

We admit hundreds of such people every year.

Many of them are admitted with a very serious complication of diabetes called diabetic ketoacidosis (when the body produces very high levels of ketones or blood acids and complications result). But we never saw mucor.

So, there were people coming with sugars of 500, 600, 700, bad diabetes, ketoacidosis. But no mucor.

In the first wave we had patients with diabetes. No mucor.

People are blaming sugar and steroids today. My point is that this sugar and steroids (situation) also existed before April, when the first wave was there.

They are blaming lack of sanitation practices, humidifiers, the water being used in humidifiers, industrial oxygen and so on. But our hospitals were as dirty before as well. Our sanitation practices did not deteriorate almost overnight.

The sugar and steroids story makes a very compelling case, and also putting the blame on those oxygen and support systems, humidifers, etc.

But my point, again, is that even in my hospital, for example, in the first wave we had 2,718 patients. But no mucor.

And come April, around April 20 -- suddenly -- in the last month itself we saw some 37 patients of mucor.

In the first wave our practices did not change (and were not any different), the hospital environment did not change, sugar was there, steroids were there, the water in the humidifier was there. And there were no changes in the oxygen support systems.

Probably we are still not able to understand fully this epidemic of mucormycosis right now in India.

While it's very easy to blame the irrational use of steroids and high blood sugars and I do not deny that both (the indiscriminate use) steroids are bad and sugar is bad, but they alone do not explain the full story.

IMAGE: Dr Kavita Sachdeva treats a patient infected with black fungus at the NSCB Medical college and Hospital in Jabalpur, June 11, 2021. Photograph: Uma Shankar Mishra/ANI Photo

What is your gut feeling for why mucor arose only now?

My gut feeling is that probably it is the virus itself which is responsible.

Because if you see, there's a very clear cut-off point -- April 15 in our hospital.

Before April 15, no mucor.

After April 15, mucor.

April 15 more or less coincided with the advent of the second wave, when we had suddenly a lot of patients, more hypoxic patients.

Probably, my feeling is -- I could be completely wrong and it needs to be tested by good research -- in some way the virus could have contributed here. Its aggression or its virulence might have led to some changes.

And secondly, the external environment: the temperatures, the humidity levels,

Otherwise, this mucor is all over. We inhale this mucor with every breath.

It is sitting on my table, it is sitting on the wall, is sitting on the roof there. But our bodies, our body's immune system is competent enough to take care of this mucor.

If you have certain risk factors, for example, if you've got cancer, or you are undergoing chemotherapy or you have undergone an organ transplant, your body's immunity goes down. And if the body's immunity goes down, it loses its capacity to fight against fungus.

In the context of COVID-19, the COVID-19 itself decreases your body's immunity. And then you add high sugar, then you add steroids, your immunity further goes down.

And then the fungus might find its way into your sinuses and then would cause havoc in your body.

The point is, thinking completely in an unbiased manner, all of these things also existed before April 15.

Suddenly, after April 15, this fungus began to spread all over the country. So it's in Maharashtra, in Gujarat, one of the most affected states, but it is all over.

It is in rural hospitals and it is in urban hospitals. It is in small nursing homes, it is in big nursing homes. It is in a very expensive tertiary care hospitals, corporate hospitals, it is in public hospitals.

So where did this fungus suddenly come from and get all over the country?

This fungus was completely inconspicuous earlier.

Where was it hiding itself before April?

So there has to be more to the fungus than meets the eye probably.

In one of my tweets, I quoted that that we need a certain Dr John Snow of the 1854 Broadstreet Cholera Outbreak, London fame (who identified that a certain water system pump, polluted by sewage, on Broad Street and not 'foul air' was the cause of the outbreak).

(We need someone to investigate mucor), the way Dr Snow investigated cholera in London about 100 years ago.

We need good researchers to really figure out, in a very unbiased manner, what really explains this mini epidemic of fungus in our country.

Sugar is okay, steroid is okay. I do not deny their importance. They could have contributed, but they do not explain the story, not wholly, not substantially.

IMAGE: A doctor displays a piece of infected tissue after surgery to remove mucormycosis from a patient who recovered from COVID-19 at the Swaroop Rani hospital in Prayagraj, June 5, 2021. Photograph: Ritesh Shukla/Getty Images

Now there's evidence of all these different colours of fungus -- the white and the yellow etc. Are they all sisters and brothers of black mucor? Or is this something else?

(Laughs) The problem is purely from the semantics point of view, (calling it by its colour) is all wrong.

We should not call it a black fungus. It's not black.

IMAGE: A patient infected with white and black fungus after surgery at a hospital in Ghaziabad, May 31, 2021. Photograph: Rahul Singh/ANI Photo

The tissue goes black?

Yes. It creates those black spots or regions on the nose or cheeks, etc. Semantically it's wrong to say it is a black fungus.

Similarly, it's wrong to say a white fungus. It's called Candida albicans or Candida auris

In microbiology, it appears as white and sometimes it produces white patches over the tongue.

So, it's black and white and yellow, and I don't know how many colours they are ascribing to it (laughs).

The so-called 'white fungus' is equally as dangerous as the 'black fungus'.

What's happening is that in an ICU, when patients stay on ventilators for weeks together -- already antibiotic abuse is common -- these fungi find their way into the lungs.

There are two fungi - one is aspergillus (which causes pulmonary infections) and another is candida. These two they completely destroy the lungs.

The diagnostics are difficult. Radiologically or on CT scans, it is difficult to figure out whether it is COVID-19-associated lung damage or it's caused by fungus.

The treatments are extremely expensive, and almost unaffordable, and the mortality rates are very, very high.

So, while the so-called 'black fungus' is attacking the nose, cheeks and brain, the 'white fungus' is hitting the lungs also.

But this 'white fungus' is well known (unlike the new, more mysterious invasion of black mucor) because people who stay in the ICU for long or on a ventilator for long, or again those whose immunity is low -- cancer patients or diabetics or HIV patients -- they do get these infections.

The only thing is, because of more awareness, now, we are now probably recognising the so-called 'white fungus' more frequently than we used to in the past.

IMAGE: Healthcare workers administer COVID-19 vaccines at the Fazilpur Jharsa Village vaccination centre in Gurugram, June 10, 2021. Photograph: Yogendra Kumar/ANI Photo

A lot of mistakes have also caused this second wave in India, in addition to the rise of the variants.
Those mistakes haven't been acknowledged, especially by the leadership, or anybody. If mistakes are not acknowledged, then they are not rectified. We believe we were sort of cursed, and therefore we got a second wave. So, what's going to prevent a third wave? How can a third wave not happen?

Even the virus doesn't know how it's going to behave tomorrow and we are trying to predict.

We are trying to predict the unpredictable.

But some time back by both (WHO Chief Scientist) Dr Soumya Swaminathan and Dr Gagandeep Kang (public health specialist and microbiologist) had said, well, that this virus might persist for longer.

It might be associated with several waves, every year.

Some waves might be mild. Some waves might be serious.

These viruses might mutate.

And nobody knows exactly how the virus is going to behave over the next few months or over the next two years.

The idea is that we should be mentally prepared. And that more waves may come.

There is no point in indulging in hubris and exaggerated self confidence that we have won the battle now.

We should have the humility to say that: Well, the viruses might come back, they might become more unpredictable. Sometimes they might turn more virulent. Sometimes they might get more transmissible.

The time has come - now as the second wave is receding -- where we restore the dignity of the public health system.

And we make sure that our primary health centres, sub-centres, community health centers -- where 70 per cent of India lives -- are well equipped, they are adequately staffed, that their doctors and paramedics are properly trained.

There should be good coordination between primary, middle and tertiary care, so that the tertiary care hospitals are not overburdened. So that the people living in the villages are cared for in their own villages, in an atmosphere with which they are familiar.

By doing so, by strengthening the public health system, we can significantly reduce the cost of healthcare, as well as significantly reduce morbidity and mortality.

These problems have been ailing the public health system for almost seven decades now. Its dignity cannot be restored just within a few days or a few weeks.

But the time has come where we ensure that our primary emphasis is on primary care in villages.

Unless we do that, unless we focus on villages, small towns and tribal areas, and areas where marginalised populations and migrant workers live etc and don't only focus on large hospitals and ICUs, probably will not be able to handle the epidemic if it hits us again.

**Vidarbha's first black fungus patient spent Rs 1.5 crore (external link)

***Because of so many undocumented deaths in the second wave of the COVID-19 pandemic, the revised mortality rate for India is not known.
****According to CDC

Feature Presentation: Ashish Narsale/Rediff.com

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