Gujarat declared Mucormycosis an epidemic and made it a notifiable disease on May 20, a day after Centre’s notification directing the states on the same. Noticeably, out of an 18-member team of ICMR that issued guidelines on the issue on May 9, ten experts were from Gujarat. However, by May 12, the state had crossed the highest number of cases in India when a national level video meeting was held to discuss the issue in the states.
Noticeably, multiple states like Rajasthan, Telengana, Haryana with lesser cases than Gujarat had deemed Mucormycosis as epidemic before the directive from the Central government.
As of May 25, there are 2425 active cases of Mucormycosis in just six major government hospitals in districts. Rajkot Civil hospital has 600 active cases, Civil hospital Ahmedabad has 470, New Civil hospital in Surat has 120, SSG hospital in Vadodara has 154, Shri Takhtsinghji General hospital in Bhavnagar has 116 and Guru Govindsingh government hospital has 114 active cases of Mucormycosis or black fungus, a post COVID-19 complication.
There is no publicly available data on the number of cases of Mucormycosis released by the Gujarat government yet. After the disease was deemed as an epidemic, a statement released from the office of Chief Minister of Gujarat stated, “The core committee under CM Vijay Rupani decided to deem Mucormycosis an epidemic under the Epidemic Diseases Act, 1857. All diagnosis and treatment will be undertaken as per ICMR guidelines. All suspect and confirmed cases will now have to be regularly reported to the GoI.”
“Mucormycosis, a fungal infection can happen to any immuno-compromised patient. Covid-19 is a disease that diminishes the immunity of a patient drastically that gets worse it the patient is comorbid conditions like diabetes. In fact, 80 to 85 percent of the 600 patients of Mucormycosis we have here in Rajkot Civil hospital have diabetes and had been treated with high doses of steroid. There is, however, no age group observed as such for the fungal infection. Usually, in the second wave of COVID-19 we have had patients between 40 to 60 years who are also getting Mucormycosis but there also has been young patients of less than 20 years and paediatric cases,” Doctor RS Trivedi, Medicial Superintendent of Rajkot Civil Hospital told the Newsclick.
“We had cases of Mucormycosis before the pandemic too and had primarily seen it in people diagnosed with Acquired Immune Deficiency Syndrome (AIDS). Even now, there is one tuberculosis patient who also has been diagnosed with Mucormycosis. So, it is safe to say that those with low immunity are susceptible to the fungal infection. This apart there is always chance of a fungal infection in humid environment. It could also happen to a patient who has been on long oxygen support and the apparatus has not been kept clean or cleaned but not with sterile (clean) water. However, these are just hypothesis and not been conclusively proven yet,” he added.
“There are multiple theories but none have been proven to conclusively say as to why Gujarat has such high number of cases of Mucormycosis. One theory is
lack of hospital hygiene. If that is to be considered, one has to analyse if more cases are being registered in government hospitals or private hospitals while keeping in mind that private hospitals should get more cases of diabetes as it is more prevalent in urban and affluent crowd. Another theory is that the fungus is generating from decaying vegetable, but so far no cases have been heard from garbage pickers,” Doctor Dileep Mavalankar, Director of Indian Institute of Public Health, told Newsclick.
“Though the infection is not unheard of and has been in cancer patient and children with diabetes pre pandemic, the number of cases has gone drastically high and so far, data from the state hasn’t been sampled or analysed,” he added.
Noticeably, an Indian Council of Medical Research (ICMR) cross-sectional door-to-door study published in 2017, reveals that that the prevalence of prediabetes (border-level or slightly higher level of glucose levels than normal and are at the risk of developing diabetes) in Gujarat is 10.7 percent.
It further found that the highest number of cases of pre-diabetes was in age group of 25 to 34 in both urban and rural men while cases in age group 20 to 24 were higher in rural men than urban men.
For women, the incidence of prediabetes was higher in rural women in the age group of 20 to 24 while in all the other age groups it was more or less similar for both rural and urban women. The study found that overall, the prevalence of diabetes was 10.3% in urban areas, 5.1% in rural areas and 7.1% across the state.
Shortage of Amphotericin B, drug used to treat Mucormycosis
On May 8 this year, CM Vijay Rupani announced that the state had ordered 5000 vials of Amphotericin B, drug used in treatment of Mucormycosis for “more than 100 patients in the state.”
However, on the same day, Rajkot Civil hospital, that has recorded highest number of cases in the state owing to being the biggest government hospital in the Saurashtra region, placed an indent of 12000 vials of Amphotericin B, drug use in treatment of Mucormycosis. This would be the hospital’s second batch of procurement of the medicine through Gujarat Medical Services Corporation Limited (GMSCL) after already spending Rs 1.5 crore earlier.
Notice outside a hospital in Ahemdabad that they have run out of Amphotericin B, a drug used to treat Mucormycosis.
Noticeably, on May 19, the Central government formulated a policy for “equitable distribution” of Liposomal Amphotericin B injections and a “distribution system” was established. The private hospitals can procure the medicine from the seven government hospitals – Ahmedabad, Gandhinagar, Bhavnagar, Surat, Rajkot, Jamnagar and Baroda and the government hospitals have to place indents through GMSCL only.
The Central government has limited the quota to 150 patients only
which is barely 10 percent of the total requirement of the state where each patient requires at least 100 injections and Gujarat has recorded 2425 active cases in just six major hospitals so far. On May 22, three major hospitals in Ahmedabad – Civil hospital, LG Hospital and SVP hospital ran out of the medicine and hung boards on their gate informing the families of the patients. Following which, multiple private hospitals had to discharge patients as they ran out of medicine and had no means to procure.
“We treat mucor with anti-fungal medicine and Amphotericin B is the drug of choice. We go for conventional or systemic when patient is stable or Liposomal when patient immune compromised as we don’t want renal failure. So preferably we would want to treat with Liposomal B but there are more cases and not adequate medicine,” said Doctor RS Trivedi.
“In worst case scenarios, when internal organs are affected, we go for surgery. ear, nose and throat are the first and prime spot for Mucormycosis and patients with sinusitis are a soft target. If aggressive, it can spread to facial areas when we call dental or even plastic surgeons and patients require long treatment and hospitalization,” he added.