Context

Mucormycosis or, “black fungus”, is being detected relatively frequently among Covid-19 patients in various states. The disease often manifests in the skin and also affects the lungs and the brain.

The rising trend of the infection has compelled the Government to ask the states to make it notifiable under Epidemic Diseases Act 1897and making it mandatory for states to report both suspected and confirmed cases to the Integrated Disease Surveillance Programme (IDSP).

Background

• A notifiable disease is any disease that is required by law to be reported to government authorities which allows the authorities to monitor the disease, and provides early warning of possible outbreaks. The World Health Organization’s International Health Regulations, 1969 require disease reporting to the WHO in order to help with its global surveillance and advisory role.
• Making a disease legally notifiable by doctors and health professionals allows for intervention to control the spread of highly infectious diseases. Registered medical practitioners need to notify such diseases in a proper form within three days, or notify verbally via phone within 24 hours depending on the urgency of the situation.
• This means every government hospital, private hospital, laboratories, and clinics will have to report cases of the disease to the government.
• The process helps the government keep track and formulate a plan for elimination and control. In less infectious conditions, it improves information about the burden and distribution of disease.
• The Centre has notified several diseases such as cholera, diphtheria, encephalitis, leprosy, meningitis, pertussis (whooping cough), plague, tuberculosis, AIDS, hepatitis, measles, yellow fever, malaria dengue, etc.
• The onus of notifying any disease and the implementation lies with the state government.
• Any failure to report a notifiable disease is a criminal offence and the state government can take necessary actions against defaulters.

Analysis

What is Mucormycosis?

• Mucormycosis (previously called zygomycosis) is a serious but rare fungal infection caused by a group of molds called mucormycetes.
• These fungi live throughout the environment, particularly in soil and in decaying organic matter, such as leaves, compost piles, or rotten wood.
• People get mucormycosis by coming in contact with the fungal spores in the environment. For example, the lung or sinus forms of the infection can occur after someone breathes in spores. Mucormycosis can also develop on the skin after the fungus enters the skin through a cut, scrape, burn, or other type of skin trauma.
• It mainly affects people with low immunity due to other diseases such as people who have health problems or take medicines that lower the body’s ability to fight germs and sickness including those with cancer, diabetes, organ transplant, and hospitalized or recovering Covid-19 patients.
• Mucormycosis can’t spread between people or between people and animals.

Types of fungi that cause mucormycosis

• Several different types of fungi can cause mucormycosis. These fungi are called mucormycetes and belong to the scientific order Mucorales. The most common types that cause mucormycosis are Rhizopus species and Mucor
• Other examples include Rhizomucor species, Syncephalastrum species, Cunninghamellabertholletiae, Apophysomyces, Lichtheimia (formerly Absidia), Saksenaea, andRhizomucor.

Types of mucormycosis

• Rhinocerebral (sinus and brain) mucormycosis is an infection in the sinuses that can spread to the brain. This form of mucormycosis is most common in people with uncontrolled diabetes and in people who have had a kidney transplant.
• Pulmonary (lung) mucormycosis is the most common type of mucormycosis in people with cancer and in people who have had an organ transplant or a stem cell transplant.
• Gastrointestinal mucormycosis is more common among young children than adults, especially premature and low birth weight infants less than 1 month of age, who have had antibiotics, surgery, or medications that lower the body’s ability to fight germs and sickness.
• Cutaneous (skin) mucormycosis occurs after the fungi enter the body through a break in the skin (for example, after surgery, a burn, or other type of skin trauma). This is the most common form of mucormycosis among people who do not have weakened immune systems.
• Disseminated mucormycosis occurs when the infection spreads through the bloodstream to affect another part of the body. The infection most commonly affects the brain, but also can affect other organs such as the spleen, heart, and skin.

Symptoms of Mucormycosis

• The symptoms of mucormycosis depend on where in the body the fungus is growing.
• Symptoms of rhinocerebral (sinus and brain) mucormycosis include:
  • One-sided facial swelling
  • Headache
  • Nasal or sinus congestion
  • Black lesions on nasal bridge or upper inside of mouth that quickly become more severe
  • Fever
• Symptoms of pulmonary (lung) mucormycosis include:
  • Fever
  • Cough
  • Chest pain
  • Shortness of breath
• Cutaneous (skin) mucormycosis can look like blisters or ulcers, and the infected area may turn black.Other symptoms include pain, warmth, excessive redness, or swelling around a wound.
• Symptoms of gastrointestinal mucormycosis include:
• Abdominal pain
• Nausea and vomiting
• Gastrointestinal bleeding
• Patients with disseminated infection in the brain can develop mental status changes or coma.

How is mucormycosis diagnosed?

• A sample of fluid from the respiratory system (lungs or sinuses) is collected.
• A tissue biopsy may be performed under a microscope or in a fungal culture.
• CT scan of lungs, sinuses, or other parts of body, depending on the location of the suspected infection may also be performed.

Treatment for Mucormycosis

• Mucormycosis is a serious infection and needs to be treated with prescription antifungal medicine, usually amphotericin B, posaconazole, or isavuconazole.
• These medicines are given through a vein (amphotericin B, posaconazole, isavuconazole) or by mouth (posaconazole, isavuconazole).
• Other medicines, including fluconazole, voriconazole, and echinocandins, do not work against fungi that cause mucormycosis. Often, mucormycosis requires surgery to cut away the infected tissue.

Conclusion

Many hospitals in the countries are now reporting a significant increase in cases of ‘Covid-19-associated mucormycosis (CAM)due to severe diabetesand the indiscriminate use of steroids in the treatment for Covid-19 as it suppresses the immune system.This is why steroids should not be used unless absolutely necessary.

The rare, non-contagious diseasecan be debilitating or fatal if not treated quickly. If its progression is not checked early, 50-80% of patients could die.

Declaring Mucormycosis as a notifiable disease would help the governments to formulate a plan for elimination & control and providing the antifungal medicines in the hospital and retail markets. This is why, many states have already made CAM as the notifiable disease and others are following this.

There are a few simple steps we can follow to lower our risk of contracting mucormycosis such as to educate society about the disease; periodically sample the air in hospitals, especially in the critical care wards, to check for the presence of spores; to ensure that the humidifiers used during oxygen therapy are sterile; to advise recovering patients to remain indoors until they regain their natural strength and immunity; etc.