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Covid has surged, but there are hardly any ‘black fungus’ cases this time — doctors explain why

Experts said cases of mucormycosis peaked due to excessive misuse of steroids amid the 2nd wave. Unmonitored blood sugar levels and self-medication by many also contributed.

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New Delhi: Mucormycosis or black fungus, which led to more than 4,000 deaths in a mini-wave across India till July last year, seems to have disappeared altogether, with the number of cases coming down considerably across states.

Although medical experts haven’t been able to ascertain the exact cause of the surge in that brief period of four to six months last year — affecting large numbers of Covid-19 patients in a double whammy during the second wave — they’ve identified several reasons for the drop in mucormycosis cases and control of the epidemic.

These reasons include a “controlled and low dose of steroids”, “strict control and check of blood sugar level in admitted patients during treatment”, and following “strict quality of oxygen humidification protocols”.

According to doctors, people stopping self-medication, either for steroids or antibiotics, and stopping the use of “unhygienic oxygen cylinders at home” — which had become rampant during the second wave of Covid-19 last year — has also contributed to the dip in cases.

According to data with the central government, a total of 45,432 cases of mucormycosis were reported up to 15 July, which led to 4,252 deaths. However, the cases have now come down considerably — so much so that the Union Ministry of Health and Family Welfare is no longer collecting and maintaining data.

Maharashtra alone had reported more than 9,654 cases of mucormycosis till July 2021 — the highest in the country — but now has less than 40 cases across the state, government data accessed by ThePrint shows. 

Andhra Pradesh, too, reported 5,045 cases of mucormycosis till September 2021, but now has at only five cases across the state. Gujarat, which had reported 6,486 cases by July 2021, now has only a few hundred cases.

Tamil Nadu, which reported more than 4,075 cases till July 2021, also has very few cases now — the state health department could not furnish the current data. Punjab, which has reported 691 cases till now, does not have a single case of mucormycosis at present, data shows.

Mucormycosis is a rare but serious infection caused by a group of moulds called mucormycetes. These moulds live throughout the environment. It is an infection characterised by the death of tissues due to inadequate blood supply to the affected area, which can be fatal if not detected early and catches up with people with low immunity.

A study published in April last year found that 71 per cent of black fungus cases worldwide during the pandemic were reported from India. But mucormycosis wasn’t unheard of in India even before last year’s surge, with the country contributing the most cases across the world for the past three decades, Dr Monalisa Sahu, consultant, infectious diseases, at Hyderabad’s Yashoda Hospitals told ThePrint.

Also read: Steroid use, diabetes among 5 reasons why India has 71% of world’s black fungus cases: Study

Controlled use of steroids can avoid mucormycosis

According to research carried out by doctors at Lilavati and Fortis hospitals in Mumbai, steroids, if used under strict protocol and with tight control of blood sugar levels, can totally avoid the occurrence of mucormycosis. 

“The low-dose steroids were administered as per state government protocol for treating Covid-19, a nurse-driven strict glycemic control regime (blood glucose level was maintained through the admission in ICU) and it was concluded that a strict adherence to protocol of low-dose steroids coupled with strict glycemic control helped in eliminating the risk and incidence of mucormycosis in a tertiary care dedicated Covid-19 hospital,” says the study, published in the journal Diabetes and Metabolic Syndrome: Clinical Research and Reviews.

Speaking to ThePrint, Dr Shashank Joshi, senior endocrinologist in Mumbai, who was part of the research, said: “Such increase in cases of mucormycosis came as a mini-wave and disappeared as fast. The compelling factor in the rise of these cases, we found, was heavy use of steroids affecting mostly those with uncontrolled diabetes. Analysis of mucormycosis across the globe also shows that diabetes and steroid use are responsible for the condition.”

“These cases were most prominent in people with a poor immune response system, like the ones undergoing chemotherapy, or highly diabetic, or ones with kidney ailments,” he added.

Joshi further said that when the blood sugar level of the patients was monitored during treatment, along with a low dose of steroids, it helped in bringing the cases of mucormycosis down to negligible levels.

Dr Sahu also said mucormycosis cases rose due to the use of “high dose of steroids for Covid and indiscriminate use of higher antibiotics”. She cited “uncontrolled diabetes and coexisting complications of diabetes like diabetic ketoacidosis” as factors.

She further said new cases of black fungus are being reported now with the same frequency as during pre-Covid times, but are being managed with “combined administration of appropriate surgical and medical management”. 

“The number of cases is far less than that reported during the second wave, as there was a decrease in the risk factors that led to the huge surge of cases,” Sahu said. 

To avoid black fungus, she said, patients need to ensure that there is no self-use of steroids to treat Covid-19, and that there is good control of diabetes by anti-diabetic medication.

She also emphasised that proper mask hygiene must be followed, as our environment has ample black fungus spores, and they tend to germinate in moist conditions and then invade through the respiratory route.

Also read: This pharma firm in Gurugram first manufactured the drug that treats black fungus in India

‘Delta variant made people vulnerable to black fungus’

Dr Rahul Anil Pandit, director of critical care medicine and ICU at Fortis Hospital, Mulund, Mumbai, told ThePrint that mucormycosis was a result of the “Delta variant along with diabetes”.

“It was the severe Delta variant along with people with bad sugar levels that added up and caused the fungal infection. At that time, people who were not usually on steroids were also put on steroids. Steroids anyway cause a rise in sugar levels, and when they went unchecked in an already immunodeficient body, caused this fungal infection,” he said.

Dr Ameet Kishore, ENT specialist at New Delhi’s Apollo Hospital, also blamed the “overuse and misuse of steroids” and the Delta variant of the coronavirus for the surge in mucormycosis cases.

“In the last wave, the infection was severe because of the Delta variant, and it also saw an increased use of steroids. Steroids are immunosuppressive and their increased use seems to be a reason for a rise in patients with mucormycosis,” he said. 

“We see a few patients every now and then who are immunocompromised — that is, either heavy diabetes or a kidney issue — who develop this fungal infection. But during the second wave, many people with a Covid-19 history got it and, in most cases, there was a history of steroid use,” he said.

“Steroids were required for treatment of Covid-19 in the second wave, but they were overused in treatment and even misused by people who started taking self-medication out of fear of being hospitalised, which caused this condition,” he added.

Immunosuppressants are drugs used to keep one’s immune system in check. However, sometimes, with overuse of the medicine, the immune system mistakenly attacks healthy cells and tissues, making the body more vulnerable to infections — in this case, black fungus or mucormycosis.

Dr Kishore said that as the use of steroids became controlled, cases of mucormycosis were also reduced.

The chief Covid-19 nodal officer in Punjab, Dr Rajesh Bhaskar, also said that it was the severe Delta strain of the coronavirus that made people vulnerable to mucormycosis.

“There were cases of mucormycosis earlier too, but they rose with the rise in cases of the Delta variant. This fungal infection is in the air and catches people with low immunity,” he said.

“It is difficult to pinpoint if it was high use of steroids or self-medication by people that caused it. But we believe that it was the Delta variant that affected people’s immunity and in turn made them more vulnerable to this fungal infection,” he added. 

Also read: You can’t treat severe Covid, black fungus but can prevent risk factor in both — diabetes

Use of industrial oxygen may not be a factor

The second wave of the Covid-19 pandemic saw the use of industrial oxygen to address the lack of oxygen supply chains for medical use.

However, according to most doctors, the use of industrial oxygen may have played only a minimal role in the rise in mucormycosis cases. However, failing to follow strict quality of oxygen humidification protocols or using dirty, unsanitised cylinders may have played a role, experts said.

The difference between medical and industrial oxygen is in the level of purity, with the former being purer than the latter. Impurities can come from the containers of industrial oxygen, according to a statement by the Indian Medical Association.

While the statement said that industrial oxygen is not intended to be inhaled like medical oxygen, doctors said even industrial oxygen is pure and safe as it is used for pharmaceutical products. However, they added that its storage and transportation could have been a reason for the growth in cases of mucormycosis, if the cylinders weren’t properly sanitised. 

“It is not correct to say that use of industrial oxygen could have led to cases of fungal infection, as this is also pure oxygen, but its storage or how the oxygen was delivered could have been a problem,” Dr Pandit said.

Another doctor, who did not wish to be named, said people requiring oxygen support at home should ensure the use of clean distilled water in oxygen concentrators, else it could lead to fungal infection, and maybe that is what went wrong.

According to a letter by PGIMER Chandigarh researchers published in The BMJ, reusable oxygen humidifiers may also have played a major role in the transmission of pathogens via the generation of aerosol particles, as these reach deep into the lung immediately after inhalation.

“In the absence of disposable oxygen humidifiers that carry minimal risk of nosocomial infections, care should be taken for appropriate maintenance of reusable ones. Besides, clean distilled water should be used in humidifiers during oxygen therapy in Covid-19 patients,” the researchers wrote.

They added that proper handling and sanitisation of oxygen gas cylinders is important, and failure to ensure this may have played a role in the surge of mucormycosis cases. Moreover, the hospital environment — whether it is hygienic or not — is also a factor, the researchers said.  

Also read: How errors, inaction sent deadly Delta variant around the world in 2021

Personal hygiene, rampant use of antibiotics

According to doctors, in some cases of mucormycosis, the patients did not take any steroids, or have any comorbidity, but the infection was caused by issues of “personal hygiene”.

“Stringent personal hygiene is what is required, else it can lead to fungal infection. While this infection mostly affected people with comorbidities, there were young people, too, who were affected. In those cases, we took into consideration the issue of hygiene, which could have led to the growth of the fungal infection,” Dr Priti Kapadia, an ophthalmologist from Surat, Gujarat, told ThePrint.

“People were using steam inhalation with camphor, which could have caused dampness, giving a ground for fungal infection and easy penetration of the mucorales. Moreover, irrational use of antibiotics and even multivitamins including zinc was also a problem,” she said.

With inputs from Rishika Sadam.

(Edited by Rohan Manoj)

Also read: When should kids wear a mask: On school bus, in classroom, outdoors? Here’s what experts say


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