With several parts of the country reporting a surge in the supplementary fungal infection mucormycosis in Covid-19 patients, the Health Ministry on Thursday made the infection notifiable, making it mandatory for states to report both suspected and confirmed cases to the Integrated Disease Surveillance Programme (IDSP).
Mucormycosis is a fungal infection in which sinuses or lungs are affected after fungal spores in the air are inhaled. The incidence of this infection has traditionally been low — it was reported mainly in patients with uncontrolled diabetes. However, many hospitals in the countries are now reporting a significant increase in cases of ‘Covid-19-associated mucormycosis (CAM)’.
This is due to broadly two reasons: in Covid-19 patients who have severe diabetes, the risk of fungal infection is high; and due to the indiscriminate use of steroids in the treatment for Covid-19.
ICMR has begun tracking CAM through its national registry since May 15; the exact case burden is, however, not known yet. With Thursday’s directive, every suspected and confirmed case of CAM has to be reported through the district-level chief medical officer to the IDSP in order to effectively track the burden and address issues related to the infection.
“You are requested to make mucormycosis a notifiable disease under Epidemic Diseases Act, 1897, wherein all Government and Private Health facilities, Medical Colleges, will follow guidelines for screening, diagnosis, management of mucormycosis, issued by MoHFW and ICMR and make it mandatory for all these facilities to report all suspected and confirmed cases to Health Department through district-level chief medical officer and subsequently to IDSP surveillance system,” Lav Agarwal, Joint Secretary, Ministry of Health & Family Welfare wrote to the states.
ICMR Director General Dr Balram Bhargava on Thursday flagged that CAM was also being reported in patients who had been newly diagnosed with diabetes, because the Covid-19 virus was entering the pancreas and raising blood sugar levels.
“In people whose immunity is suppressed, the fungus will grow; if the fungus receives sugar it will grow. Therefore, we are seeing this (mucormycosis) in those Covid-19 patients, who have diabetes, or whose sugar is not under control, or who are receiving immunosuppressant drugs. We are also seeing it in patients who are newly diagnosed with diabetes; because Covid-19 virus can also enter the pancreas and increase the sugar levels. Therefore, we have to ensure that sugar levels are under control; and physicians have to prescribe the right dose of cortisone,” Dr Bhargava said.
In its communication to states, the Health Ministry said the treatment of mucormycosis requires a “multidisciplinary” approach involving eye surgeons, ENT specialists, general surgeons, and neurosurgeons.
“In recent times a new challenge in the form of a fungal infection namely mucormycosis has emerged and is reported from many states amongst Covid-19 patients especially those on steroid therapy and deranged sugar control. This fungal infection is leading to prolonged morbidity and mortality amongst Covid-19 patients,” Agarwal wrote.
Earlier, AIIMS chief Dr Randeep Guleria had said that physicians should not prescribe steroids to patients who do not need oxygen therapy. “To stop the fungal infection, we have to ensure there is no misuse of steroids. Those with mild disease and (who) don’t need oxygen, should not been prescribed steroids; second, we should ensure that people who have diabetes should keep monitoring their sugar levels. Third, we have to wear two masks, because it can be found in air, especially places like construction sites,” Dr Guleria had said.
Minister of State for Chemicals and Fertilisers Mansukh Mandaviya on Thursday said the shortage of amphotericin-B, used to treat mucormycosis, will be addressed soon. Five more pharma companies have got new drug approval to produce it in India, in addition to the six existing pharma companies who have started to ramp up production, he said.
Also on Thursday, the Delhi High Court said that the Centre must immediately import amphotericin-B from wherever it is available in the world, and directed it to place on record the steps being taken to import the medicine.
A Division Bench of Justices Vipin Sanghi and Jasmeet Singh said the domestic production of the medicine was “far less” than the current requirement across the country.
“This issue is time. What is at a premium here? The premium here is time and human life, so therefore 5 per cent allocation does not meet the desired result. It is neither here nor there. It does not serve the purpose. It has to be the complete supply. You need to import to bridge this gap between the plan to produce more and the actual production coming about, otherwise we will lose more precious lives. We want you to act today,” the court said.
It directed the Centre to disclose the present production capacity; details of producers who have been licensed to produce the medicine, their present capacity and their enhanced capacity; and by when the enhanced capacity would become available. The court also sought data regarding the present caseload and the projected caseload for the next two weeks.
List of states that have reported cases of mucormycosis:
The Gujarat government on Thursday declared mucormycosis (black fungus infection) reported among Covid-19 patients as an “epidemic” and made it a notifiable disease under the Epidemic Diseases Act. The decision by the Gujarat government was taken at a core committee meeting chaired by chief minister Vijay Rupani.
As of Thursday, across four government hospitals in three cities, a total of 980 mucormycosis patients were undergoing treatment.
With the fungal infection so far claiming 90 lives in the state, Health Minister Rajesh Tope Thursday told Prime Minister Narendra Modi that mucormycosis is a matter of prime concern for the state at present, and that the Maharashtra government needs more supply of the medicine used in its treatment. Tope made the statement at a meeting held by Modi, during which the latter interacted with 17 district collectors of Maharashtra.
On Wednesday, the state health minister had urged the Union government to swiftly allocate to the state Amphotericin B injections, used to treat the infection. Maharashtra has at least 1,500 Covid-19 patients suffering from the black fungus. Among them, 850 are in hospital.
A total of nine people have been diagnosed with mucormycosis, or black fungus, in Tamil Nadu, said Health Secretary J Radhakrishnan on Thursday. However, no person has died because of mucormycosis in the state so far.
Addressing reporters in Chennai, Radhakrishnan said the state has constituted a 10-member mucormycosis committee comprising deans, the Director of Public Health and Preventive Medicine (DPH) and doctors from various departments, including ENT, diabetology, microbiology and medicine.
Around 100 patients recovering from Covid-19 have been reported to be infected with mucormycosis in the state, following which the fungal infection was declared an epidemic in Rajasthan on Wednesday.
Mucormycosis has been notified as an epidemic and a notifiable disease in the state under the Rajasthan Epidemic Act 2020, according to a notification issued by the state’s Principal Health Secretary Akhil Arora.
The Telangana government has declared black fungus (mucormycosis) as a notifiable disease under the Epidemic Diseases Act 1897 after 80 cases were reported in both government and private hospitals.
All government and private health facilities have been ordered to follow guidelines for screening, diagnosis and management of black fungus by the union health ministry and Indian Council of Medical Research. It is also made mandatory for all government and private health facilities to report all suspected and confirmed cases to the Health Department.
Amid rising cases of black fungus among both active and recovered Covid patients, the Punjab government also declared it a notified disease under the Epidemic Diseases Act. It is now mandatory for all government and private healthcare facilities across the state to report every suspected/confirmed case of the disease.
As per the notification issued by Punjab government’s Department of Health and Family Welfare, “….the state of Punjab is threatened with the outbreaks of dangerous epidemic disease namely Mucormycosis among Covid-19 patients being treated with steroids and that ordinary provisions of law for the time being in force are insufficient for the purpose. Now therefore in exercise of the powers conferred under Section 2, 3 & 4 of the Epidemic Diseases Act, 1897…The Governor of Punjab is pleased to make the regulation namely ‘The Punjab Epidemic Diseases Mucormycosis among Covid-19 Patients Regulations, 2021..”
The Manohar Lal Khattar government has also declared mucormycosis a notified disease in the state. Eight people have died of black fungus in Haryana as the state has so far reported 316 cases of the deadly infection. Of the total cases, the maximum 114 have been recorded in Gurgaon, followed by 45 in Sirsa, 42 in Faridabad, 31 in Hisar and 20 in Rohtak. Forty-eight fresh cases of black fungus were reported in Haryana on Thursday, the officials said.
With cases of black fungus in the state on the rise, a meeting regarding management of the disease was held under the chairmanship of Health Minister Anil Vij on Thursday.
Amid cases of mucormycosis being reported in the national capital, Chief Minister Arvind Kejriwal on Thursday said dedicated centres will be set up for the treatment of black fungus cases at three city government-run hospitals.
The centres will be set up at Lok Nayak Jai Prakash Narayan Hospital, Guru Tegh Bahadur Hospital and Rajiv Gandhi Super Speciality Hospital for treatment of black fungus, Kejriwal tweeted.
He made the announcement after discussing the rise in black fungus cases with officials and specialists at a meeting.
The state has so far reported 90 cases of Mucormycosis among people who have recovered or are still recovering from Covid-19, PTI reported an official as saying on Wednesday. One of these patients died in Durg district. Of the total Mucormycosis patients under treatment, 61 are admitted in the All India Institute of Medical Sciences (AIIMS), Raipur.
The Andhra Pradesh government has placed orders for purchasing 15,000 vials of Liposomal Amphotericin-B injection to treat persons infected with black fungus. Till May 17, as many as nine cases of the infection were reported in different districts of the state but there were no related fatalities.
Principal Secretary (Health) Anil Kumar Singhal had on Monday said that the fungal infection would also be declared a ‘notified disease’, making it mandatory for private hospitals to share details of the cases, if any, they were treating.
In view of a rise in cases of black fungus among active and recovered Covid-19 patients, the Madhya Pradesh government has decided to launch the “nasal endoscopy” campaign, said state Medical Education Minister Vishvas Kailash Sarang on Wednesday. The campaign is aimed at the early detection and treatment of mucormycosis.
Meanwhile, Madhya Pradesh Chief Minister Shivraj Singh Chouhan has directed to set up a dedicated task force comprising the health minister, medical education minister, ENT experts, and additional chief secretaries/principal secretaries of the departments concerned for making arrangements for the treatment of black fungus.
The CM also directed the task force to start functioning immediately, the official added.
With PTI inputs
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