A surge in black mold cases during India’s catastrophic second Covid-19 wave has exposed the consequences of over-medication as stretched physicians ignore prescription guidelines and patients panic over self-medicating.
Over-prescription of steroids, particularly to treat Covid-19 patients, has been blamed on an explosion of fatal black fungus infections and a shortage of the drug to treat it.
Doctors have reported a wave of patients suffering from black fungus or mucormycosis, an infection with a death rate of at least 50 percent that starts in the nose and spreads rapidly to the eyes and brain.
Experts have warned that administering too many steroids and other drugs can cause secondary infections and antibiotic resistance in the country.
“The number of cases I see is devastating. Usually you see four to five cases in your life, now we see four to five cases a day,” says Dr. Atul Mittal, an ear, nose and throat surgeon at Fortis. Memorial Research Institute, a hospital outside New Delhi. “I feel they are all the result of irrational steroid use.”
People with mucormycosis infections often need surgery to scrape away the dead tissue killed by the fungus. Many patients have recovered from the coronavirus and have lost their eyes or upper jaw to save their lives.
Once the infection starts to spread, it can kill people within days, Mittal said. “We can’t grow the disease, it will keep invading like a termite,” he said.
Mucor fungus occurs everywhere in everyday life: in soil, plants and rotting fruit. But cases of mucormycosis are rare and only occasionally affect people with diabetes or weakened immune systems, such as cancer patients.
However, doctors said that thousands of Covid-19 patients who have taken high doses of steroids for an extended period of time, contrary to medical guidelines, are more susceptible to infections.
Steroids are prescribed to ward off the “cytokine rush” – an excessive inflammatory response that hurts the body without stopping the infection – caused by the coronavirus. But they also reduce immunity and raise sugar levels, creating fertile soil for the fungus to grow. Home to the largest number of diabetics in the world after China, India has thousands of at-risk patients.
Hospitals across the country are setting up ad hoc units to deal with the increasing number of black mold cases. With many patients in India still undergoing steroid treatment for Covid-19, officials fear the number will only rise. Maharashtra’s health minister, home to the commercial capital Mumbai, warned last week that there could be more than 2,000 cases in the state.
But just as there have been desperate requests in India in recent weeks for oxygen and anti-viral medication remdesivir, there are now also calls from relatives of people suffering from mucormycosis to obtain life-saving drugs, such as liposomal amphotericin B.
Harsh Gupta, a 28-year-old software engineer from Bhopal, Madhya Pradesh, said he has visited more than 50 pharmacies in the past four days to find the injectable drug.
His diabetic father had just recovered from Covid-19 when he was diagnosed with mucormycosis and underwent surgery on Friday.
“There is a chance that the infection could develop again in the area. To prevent that, this injection is very necessary ”, says Gupta. “There is no chance that surgery can be done twice.”
Without the drug, his father is unlikely to survive. “It’s not available anywhere,” said Gupta. ‘We are helpless. We don’t know what to do. ”
Gilead, which manufactures the drug, said it was “preparing several hundred thousand additional supplies of our anti-fungal drug, with shipments to begin this week.”
Lancelot Pinto, a pulmonologist at P D Hinduja Hospital in Mumbai, said the increase in mucormycosis cases reflects a broader trend of steroid abuse in India.
The World Health Organization recommends that coronavirus patients receive a daily dose of 6 mg dexamethasone, a corticosteroid, or its equivalent for seven to 10 days to reduce mortality in severely or critically ill patients.
“I’ve seen prescriptions of up to 500mg per day. It’s not uncommon,” said Pinto, adding that patients in India were often prescribed steroids for a month.
Taking steroids too early in the course of a Covid-19 infection can also compromise the immune system and is suspected of leading to unnecessary hospitalizations of young adults who might otherwise be fighting the disease, Pinto said.
Under the intense pressure of the second wave, doctors have prescribed a laundry list of medications, including steroids and antibiotics for those with mild symptoms.
Local governments in India have also sent conflicting messages about which drugs to take, sometimes in violation of global convention.
For example, several Indian states distribute anti-parasitic medication Ivermectin as a prophylactic treatment for Covid-19, despite WHO warnings not to use it. Others have included antibiotics and steroids in Covid-19 home care packages.
Leena Menghaney, a public health advocate, said many people self-medicate with antibiotics, which increases the risk of antibiotic resistance.
“Every family I know has been hoarding or taking azithromycin,” she said, referring to an antibiotic endorsed last year by Donald Trump, then US president. “We are burning a drug that is very important.”
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