From the outbreak of the new crown pneumonia epidemic in April, India has become the "epicenter" of the global epidemic, with the average number of new infections exceeding 400,000 per day, and now the cumulative number of confirmed cases has exceeded 31 million, and the cumulative number of deaths has exceeded 420,000.
The daily growth of confirmed cases and deaths is accompanied by a gradual chaos of social order and an extreme shortage of medical resources.
However, wave after wave of unevenness has risen again.
According to the Ministry of Health, as of July 20, India has reported more than 45,000 cases of mucormycete infection and more than 4,300 deaths.
As of 28 June, more than 40,000 cases of mucormycosis infections in India, resulting in more than 3,000 deaths; as of 22 May, there were 8,848 cases of mucormycosis infection in India, with 212 deaths; and as of early May, only about 300 people were infected with mucormycosis in India.
What is Mucormycosis?
Mucormycosis, also known as mucormycosis, refers to a systemic fungal infectious disease caused by mucorales fungi present in the natural environment.
A person infected with mucormycosis receives treatment at a local hospital in the city of Ajmer in the northwestern Indian state of Rajasthan on June 7, 2021
It can invade the sinuses, brain and lungs, and symptoms are headaches, nosebleeds, coughing up blood, facial numbness and swelling, blurred vision, difficulty breathing, and in severe cases, damage to the maxilla or even blindness. It can also invade the body's arterial vessels, inducing thrombosis and necrosis.
Mucormycosis is characterized by rapid onset, rapid progression and high mortality. In severe cases, the fatality rate can exceed 50%. Because the affected area becomes black or discolored, it is also called "Black Fungus".
Mucormycosis is mainly infected by inhalation of airborne spores, and spores are also common routes of infection ingested into moldy foods and trauma contamination by spores.
The disease is rarely transmitted from person to person. Even on a global scale, mucormycosis is rare. In fact, we inhale many fungal spores every day, but the immune system and healthy lungs are usually highly resistant to fungal infections. Pathogenicity, i.e. dangerous fungal infections occur only when the immune system is weakened.
Although mucormycosis is a rare disease, mucormycosis is very common and is widely present in nature, soil, air, feces, food and all moldy organic matter. Especially in high temperature, high humidity and poor ventilation conditions to grow well. Mucormycetes are everywhere, but most people are not infected.
Mucormyces is not a single mold.
In this extended family, not all members cause mucormycosis. Only the genus Rhizomepus, Mucoryces, and Ploughmyces in the family Mucormycetes are the most common pathogens that cause mucormycosis. On the contrary, some members have made outstanding contributions to our food industry.
Wutong bridge mucorella, lactobacillus, mullus total, elegant radial mucormycetes, etc. are the most commonly used mucormycete species in the production of curd milk and edamame tofu, and they produce a variety of proteases that can help us decompose raw materials such as soybean protein, can enhance the color and fragrance of curd milk, and can form a skin film to maintain the shape of curd milk.
At present, Mucormyces is the largest and most widely used production strain in China's curd production, accounting for about 90%-95% of the saprophyll bacteria.
Why India?
So why has India become a hotbed of fungal infections this time?
The great outbreak of mucormycosis in India is no accident:
First, the incidence of mucormycosis in India is inherently widespread.
According to reports of Mucormycosis in India, the presence of mucormycosis in soil, decaying food, construction sites and even humid environments is well beyond the contamination of products such as hospital sheets, medicines and packaged foods worldwide.
On June 5, 2021, an otolaryngologist performed surgery on a patient with mucormycosis at a hospital in Abbad, Allahah, India
Obviously, India's sanitary environment is a "hotbed" for the growth of mucormycetes. This, combined with the hot and humid monsoon climate, makes the incidence of mucormycosis in India much higher than the global level. Therefore, due to natural and geographical factors, fungal infections may be more common in Southeast Asian countries.
A march 2021 study by Indian microbiologists published in the journal Microbiology, as well as a study by the Australian Broadcasting Corporation citing the International Molecular Diversity Conservation Organization in a May 10 report, showed that even before the outbreak of COVID-100,000, the global median incidence of mucormycosis per 100,000 people was only 0.2 cases, while the incidence rate in India reached 14, which is 70 times the global average.
Second, the surge in mucormycosis infections in India may be related to the use of steroids to treat COVID-19.
According to the recommendations of the World Health Organization (WHO), patients with severe illness can be relieved with "systemic corticosteroid therapy". Steroids such as "dexamethasone" have been shown to be effective in reducing the mortality rate of new crown pneumonia, which can reduce the mortality rate from 40% to 20%, which is not only effective, but also particularly cheap.
Originally, the lungs of patients with new coronary pneumonia often have different degrees of damage and are susceptible to infection. Due to the extensive use of corticosteroids and other drugs in treatment, the immune system of patients with new crown pneumonia has been suppressed and their immune function has been impaired. When our lungs are damaged or our immune system is suppressed, these spores can grow in our respiratory tract or sinuses and invade body tissues, leading to symptoms of infection.
Indian think tank NITIAayog held a press conference on May 22, with medical expert Dr. Paul A. Vinod Kumar Paul said the surge in mucormycosis cases can be attributed to the disproportionate use of steroids when treating COVID-19 patients.
Third, mucormycetes prefer to grow in a mild, acidic environment. Diabetic patients are more susceptible to mucormycete infections because of their high blood sugar and acidic tissue environment.
Long before the COVID-19 pandemic, diabetes was identified worldwide as a risk factor for mucormycosis. Of all cases of mucormycosis published in global scientific journals between 2000 and 2017, 40% of patients had diabetes.
According to India's Ministry of Health, the prevalence of diabetes among adults in the country is 12% to 18%.
Adding fuel to the fire is that steroid drugs to treat COVID-19 not only lower human immunity, but also raise blood sugar levels, which increases the likelihood of contracting mucormycosis.
The BBC report also cited two other studies conducted by Indian doctors: one of which looked at more than 100 patients with mucormycosis, of whom 79 were men and 83 had diabetes; the other studied 45 patients with mucormycosis, all of whom had diabetes. "None of the blood sugars in patients with mucormycosis are normal." Indian ophthalmologist Akshay Nayar told the BBC.
India's health minister, Vardan, also said that in the cases of infection, 64% of patients had diabetes and 53% had been taking steroid medications.
If immunity is reduced, mucormycosis is prone to occur
Fourth, it is related to the medical and health conditions in India.
Experts suspect that the spread of mucormycosis is related to possible contamination at all stages of oxygen use.
Professor K. Srinath Reddy, president of the Indian Public Health Foundation, has said that the recent surge in the number of patients with mucormycosis in India may be due to inhalation of contaminated water. "This time, more patients need oxygen," he said. Many patients use oxygen concentrators at home, and if the water is slightly contaminated, there is a risk of contracting the fungus, especially those with poor immunity. ”
In addition, Mafat, director of the Department of Otolaryngology at a public hospital in Mumbai, also reminded that mucormycetes are present on damp surfaces, so "patients should ensure that the humidifier does not leak water (to prevent fungal growth) when receiving oxygen support".
Sampath Chandra Prasad Rao, a surgeon in Bangalore, believes that the quality of oxygen cylinders and oxygen tubes used in hospital intensive care units is problematic, incomplete disinfection during the conversion of industrial oxygen into medical oxygen, or the use of contaminated tap water instead of sterile water in ventilator humidified water can cause pollution.
At the same time, India's Ministry of Health said that many patients with new crown pneumonia have humidifiers in the intensive care unit, and fungi are more likely to invade the human body in humid environments.
Other health experts believe that the use of contaminated cotton swabs during nucleic acid testing and sampling may also be the cause of the spread of mucormycosis.
There is something even more terrible
According to data released by India's health minister at the press conference on June 28, the fatality rate of mucormycete infection cases has far exceeded that of new crown pneumonia.
Doctors examine patients suspected of having mucormycosis on May 25, 2021, Mumbai, India
At the same time, India's already full medical resources are on the verge of collapse and cannot bear more pressure. The patient is worse off than dead, and it is unbearable to see.
First, patients face diagnostic difficulties in the first place.
Nasal and cerebral infections caused by Mucormyces can be roughly divided into early, mid-to-late stages.
After the mucorcus breaks through the nasal mucosa, it will spread through the blood vessels and infect the tissues around the nose, mouth and eyes locally, at which time most of the necrotic tissues need to be removed through small surgery, and then combined with antifungal drugs can be cured.
However, due to the rapid influx of mucormycetes, the optimal treatment period is generally only the first few days. To make matters worse, early symptoms are often the most difficult to detect.
Chandru from Chennai City, whose family first sought medical attention to an inflammation of the mouth caused by mucormycetes, but the doctor only treated it as a common inflammation and did tooth extraction. Even after her face and eyes started to swell and become inflamed, doctors thought it was just a normal reaction caused by tooth extraction.
After 4 days, her symptoms developed into protruding eyes, vision loss, and even blindness— often symptoms of further inward invasion of the mucormycetes affecting the optic nerve and a mid-stage infection. They went to a special mucormycete infection center for diagnosis, and finally were diagnosed with mucormycosis infection, at which point they had to remove the entire eyeball.
Another patient, Jijabai Thakare, only consulted a doctor in the small village when he was already blind (in the middle of the infection). The unprofessional village doctor only gave her completely unrelated antibiotics, and after only 3 days, her left half of her body was completely paralyzed — a symptom of a later infection of mucormycetes invading the brain.
"The patients who have reached this stage are incurable, and we can only put them in God's hands." Doctor Kothalkar said. A few days later, Jigabai was unable to treat him and unfortunately died.
Second, even if patients are diagnosed in time and survive, many have to remove eyeballs or other infected organs to avoid further spread to the brain.
In late May, Mumbai ophthalmologist Akshay Nair received a 25-year-old woman infected with the disease. She had just recovered from COVID-19, but didn't know why she was feeling more and more uncomfortable. She first had a headache, a fever, a black snot with blood, and her eyes were in terrible pain, her vision became blurred, and she was almost blind.
Dr. Nair gave her an eye exam and was shocked to find dense black fungus growing in her eye sockets. And her nose, the whole of which became their petri dish. To avoid further spread of the mold, Dr. Nair removed the patient's eye.
"I can only save her life by removing her eyes, otherwise, the fungus cannot be eliminated, it will invade her brain, and her life will be in danger."
Since April, Dr. Nair has treated 40 patients infected with mucormycetes, 11 of whom had to have one eye removed.
From December last year to February this year, six of his colleagues in major cities, including Mumbai, Bangalore and Delhi, also reported 58 cases of mucormycetes, most of whom were infected within 12 to 15 days of recovering from COVID-19.
At Sion Hospital in Mumbai, Renuka Bradoo, head of the Department of Otolaryngology, said that in the past two months, their department has received 24 patients with mucormycosis, up from 6 in the past year. Of those 24, some lost an eye and 6 died, the vast majority of whom were recovered from COVID-19. "We now see two or three of these patients a week. It's been a nightmare during the pandemic. ”
Raghuraj Hegde, an ophthalmologist in Bangalore, said he had treated 19 mucormycete patients, mostly young people, in the past two weeks. "Some people are so sick that we can't even operate on them."
Third, other fungal infections have also been found.
"Melanomycosis" has made people shudder. However, something even more frightening came, and india has also diagnosed several cases of "leukomycosis".
What's more, at the end of May, Indian medical staff found three types of fungi in the body of a 45-year-old patient at the same time: black fungus, white fungus and yellow fungus!
Leukomycosis is an extremely rare case of the fungus and is more dangerous than melanomycosis. Moreover, xanthomycosis is more rare: The yellow fungus has never infected humans, and has only been infected with reptiles in history.
It's really not the most terrifying, only more terrifying.
On June 16, local time, India's Economic Times reported that a man in India suffered from "green fungal disease" after recovering from new crown pneumonia. He developed symptoms such as high fever and nosebleeds, and on examination it was found that the fungus had infected 90% of his sinuses, blood and lungs.
Even more frightening is the Indian Shry? A representative of the Arobindo Institute of Medical Sciences (SAIMS) said: "This is the first case of green fungalism found in Madhya Pradesh, but I am not sure if it is the first in the country. ”
What should I do if there is a shortage of medicines?
In response to the increasing number of cases of mucormycosis, Indian Prime Minister Narendra Modi has called it a "new challenge". In his recent speech, he said that it is very important to systematically solve the problem of mucormycosis.
On 20 May, the Ministry of Health of India asked states to declare mucormycosis a notifiable epidemic under the Epidemics Act to find more effective ways to respond. The Delhi High Court also recommended that the federal government increase imports of related medicines.
However, the specific drug "amphotericin B" for the treatment of mucormycosis is in low production and expensive. A dose costs between 6,000 and 8,000 rupees (about 530 to 700 yuan), while a patient with mucormycosis requires a dose of up to 90 to 120 doses. Patients are required to inject the drug daily for up to 6 to 8 weeks during treatment. Many families cannot afford treatment.
Samiya Mushtaq, 29, was diagnosed with mucormycosis and the family had spent about 400,000 rupees (about 35,000 yuan) to buy him medicine, unable to afford the next cost. His mother said her son already had kidney disease. Since being infected with the new crown virus, he has been diagnosed with mucormycosis, "now all the money has been used up." ”
The production of medicines to treat mucormycosis is hampered by the shortage of APIs, and it is difficult for families who can afford treatment to obtain adequate medicines.
Wadewa, a 64-year-old mucormycosis patient, has undergone two surgeries, but the infection has spread to his nose and is spreading to his eyes. After Wadiva fell ill, doctors prescribed 100 vials of the drug. However, hospital pharmacies cannot purchase drugs, and patients need to buy them themselves. The family traveled around, buying medicine at a high price, and only bought 30 bottles.
In response to the shortage of drugs in many regions, the Indian government has distributed 29,250 bottles of amphotericin B to the states, but it is still a drop in the bucket.
In Malahashtra, the worst state of COVID-19, more than 1,500 people have been diagnosed with mucormycosis. The state's monthly demand for amphotericin B has increased 100-fold from 3,000 to 300,000 doses before the outbreak, but the current capacity of the pharmaceutical plant is far from meeting the demand.
However, by the end of May, the state had only bought 8,500 doses, plus a quota of 16,500 doses received from India's central government, for a total of 25,000 doses. Like remdesivir, an antiviral drug used to treat COVID-19, Malahastra has put in place amphotericin B controls to prevent the black market from hoarding and trading the drug. However, the US media "Forbes" magazine said that the black market price of the drug has reached 5 to 10 times the usual.
In addition, the Indian government has provisionally decided to issue 5 licenses, which will increase the number of companies producing amphotericin B to 10, and announced that it will import 600,000 doses of such drugs to meet domestic demand. But the five pharmaceutical companies won't be able to start production until July, and they can only supply a total of 110,000 bottles, and India will still rely on imports.
Amphotericin B is in short supply, and manufacturers are looking for more avenues to buy APIs. The shortage of active pharmaceutical ingredients (APIs) for amphotericin B is the main difficulty in increasing the production of this drug in the short term.
To this end, some Indian companies are seeking help from Chinese companies. According to the Indian Express, some people recently contacted China's North China Pharmaceutical Group. "We'll get 40kg-50kg of API by the end of June. We also communicated with the General Drug Administration of India to contact another Chinese company to supply the drug. Indian supplier BDR Pharmaceuticals chairman and general manager said.
Indian pharmaceutical companies said that if the supply of APIs can be guaranteed, the production of amphotericin B is expected to reach 500,000 to 800,000 doses per month. Another capacity bottleneck, however, is that another essential ingredient for the drug, purified synthetic lipids, still needs to be supplied by a Swiss company that has only recently issued orders for December in order to prioritize covid-19 vaccine production in Europe and reduce its supply to India. India's current local production is only 21kg.
Similarly, filters used in the production process need to be imported from the United States and also face shortages.
And industry insiders revealed that the production cycle of amphotericin B is about 25 days, even if all manufacturers immediately invest in the maximum production capacity, it will not be as soon as mid-July to alleviate the tight supply situation.
From the strong counterattack of the epidemic in April to the present, from showing off the fastest vaccination speed to the highest daily increase in the number of infections exceeding 400,000, from the so-called global pharmaceutical power to the shortage of mucormycosis special drugs, in just over three months, the sky is underground. I wonder if India has learned a lesson? Or what lessons have been learned?
Source: Central Committee of the Communist Youth League