From less than 100 cases a year, India has reported about 10,000 cases of the deadly mucormycosis or 'black fungus' in just a few months amid the massive second wave of the COVID pandemic.
Doctors and health experts are on a hunt to find out what could be driving the unprecedented surge in black fungus cases.
From steroid theory, iron theory, to mask and zinc theory, the medical fraternity is exploring all the factors that could have triggered the infections, not just in COVID patients, but also in those who have recovered from the disease.
Is there a correlation between the quality of the industrial oxygen used and the spike in the otherwise rare infection? We speak with experts.
Is There a Missing Link?
Diabetes, indiscriminate use of steroids and immunosuppression due to the COVID virus, still continue to be the major factors which the doctors agree upon. But is there a missing link that would explain the unusual rise the country is witnessing?
Dr Sampath Chandra Prasad Rao, a skull surgeon at Manipal Hospital in Bengaluru says, we need to look at it from an epidemic point of view. Dr Rao is one of the leading members of a team of medical experts, examining the source of contamination and providing SOPs to the Karnataka government.
There has been a delay in declaring this an epidemic and making it a notifiable disease, Mr Rao said.
Mucormycosis was declared an epidemic on May 20.
When an epidemic is declared, one of the first things that is done is to trace the possible source of contamination.
When there is a source, which is bearing in on an immunocompromised population like in India, with COVID, with everything that the scientific community has agreed upon, then we have a huge crisis like we’re having now. That is when 10,000 cases can be seen.Dr Sampath Chandra Prasad Rao, skull surgeon, Manipal Hospital, Bengaluru
Mr Rao said there are multiple factors like steam inhalation, in-house contamination, waste disposal, among others that could be influencing the fungal colonization at home.
What about the use of industrial units to supply medical grade oxygen?
"If you look at the timeline, the huge surge in cases happened just about the time after the industrial units were put into oxygen production," Dr Rao said, adding that there is a big reason to believe that this could be a contributing factor.
Quality of Medical Oxygen, Cylinders and Pipelines
As demand overshot supply of oxygen, the centre directed industrial units to divert liquid oxygen for medical use. While the move helped bridge the oxygen gap, there is no guarantee the SOPs were followed to maintain the hygiene of the medical grade oxygen, Dr Rao said.
"Unknowingly, perhaps, have we let an alien into the medical system?"
“There is a long process with multiple steps between production of liquid oxygen to the delivery of liquid oxygen cylinders to hospitals. So, in this process, are SOPs being followed?” he asked.
The oxygen cylinders are also a huge source of contamination when sterilization techniques are not followed. Most of them are available on a rental basis and are made of steel or aluminium, which are prone to rust. Pipelines may also be a source of microbial contamination.
The country was also facing a shortage of tankers suitable to transport and store oxygen, especially liquid oxygen. As a result, Liquid Nitrogen Gas Tankers were converted to Liquid Oxygen Tankers. Such conversion carries a significant risk of contamination with microbes including bacteria and fungi if extreme precaution is not taken.
Another factor, Dr Rao pointed out, is the contamination of medical gas, which is the result of compression of 8 cubic feet of atmospheric air into 1 cubic foot of compressed air. All contaminants in atmospheric air, including water and carbon monoxide, are, therefore, concentrated eightfold in compressed air.
"Thus, you're sending in compressed eightfold contaminated air into the patient's major pathways...It becomes very important for us to check the oxygen gas supplies and other gases supplies, especially due to the change in status quo," Dr Rao said.
Dr Ajay Swaroop, ENT Chairman at Sir Ganga Ram Hospital in Delhi thinks it’s not a question of oxygen itself, but of storage, the cylinders, the pipes through which the gas is being fed out and the outlets which might be the source of fungus.
"If it is industrial oxygen, the cylinders are not being treated as medical stores. They are not that clean, they are not sterilized. They may be rusted. They may be lying somewhere in a shed and they may have fungus growing over it. Then the tubes which are used, they may be contaminated,” Dr Swaroop said.
Meanwhile, speaking at the Union Health Ministry press conference, AIIMS Director Dr Randeep Guleria, said there is “no definite link between oxygen therapy and catching the infection”.
“Many patients taking treatment at home, who were not on oxygen therapy, have also been found to get infected with mucormycosis," Dr Guleria said.
Are There Other Sources of Infection?
While the use of industrial oxygen is a major cause of concern, Dr Rao said the mucor wave could also be due to other community factors.
"I’m not going to say that one particular factor is responsible. There are plenty of factors that can increase the spore count in the air because we're seeing a wide spectrum of patients," Dr Rao said, adding that it is important to identify all the sources because it not “either-or, it is one upon the other.”
- Steam inhalation
- AC vents
- Waste segregation
- Oxygen concentrators
Steam inhalation introduces water droplets into the air and thus into the nasal passages. These water droplets are capable of carrying fungi.
"I think anything that is done indiscriminately can be harmful for the body," Dr Rao said.
The habit of switching off A/C units is a very common practice to save electricity. This may lead to condensation of water and rise in relative humidity and temperature, favouring fungal growth.
Decomposition of organic waste due to waste segregation may also act as a source of fungal spores inside the house.
While using oxygen concentrators, it's important to use distilled (sterile) water, so that most of the bacteria and viruses are killed. Distilled water does not produce water droplets.
Dr Rao also stressed on the need to use hygienic masks to prevent the growth of fungi.
How Can We Tackle the Outbreak?
At the executive level, it is important for the government to lay down SOPs for the supply chain, along with regular checkups to make sure that sanitization protocols are followed, especially in gaseous supply chains, Dr Rao said.
Postulating and investigating possible sources of mucor at oxygen manufacturing units, hospitals and at PPE and mask-manufacturing units are also necessary.
Dr Swaroop thinks the problem cannot be tackled by trying to enforce with some rule of law.
“When is comes from within…when people who are in the business of producing oxygen are sort of aware that this can happen…only then the problem will be solved.”Dr Ajay Swaroop, ENT Chairman, Sir Ganga Ram Hospital, Delhi
At the hospital level, the hospitals should up their protocols and be equipped to identify and deal with all sources of contamination, he said.
At the community level, it is necessary the people are aware of their responsibilities and how the fungus could be caused at home and in the workplace.
Mr Rao said identifying the source is of utmost importance right now because it is not just one factor causing the epidemic.
"COVID may come and go, but mucor may remain for long period of time...A slow, gradual, higher baseline of mucor cases."