The Indian government has already declared mucormycosis or black fungus an epidemic. The ENT doctors like me and doctors from other medical disciplines involved such as Opthalmology (Eye), Neurosurgery (Brain), Radiology (CT scan & MRI), Microbiology (KOH staining, Fungal culture) have never seen such a load of mucormycosis/ black fungus patients in our lives. The number of mucormycosis we have seen in the last one month is fifty times more than what we have seen in our careers. So, this disease, the causes, the treatment protocols are learned on the go. So, is our Jugaad of diverting industrial oxygen to fill the hole of medical oxygen supply deficit the main reason for this sudden spike in mucormycosis cases?
The well-established understanding is that the combination of COVID, Diabetes lowers our immunity and produces an iron-rich serum creating a suitable environment for the mucor to grow. Adding to this misery, the rampant use and misuse of steroids without proper blood sugar monitoring is lowering bodies defenses and at the same time spiking blood sugar levels. Mucormycetes is a fungus freely present in our environment in warm, damp climate in decaying organic waste, air conditioning units, construction sites, etc. Mucormycosis is an opportunistic infection that starts preying on humans when a suitable environment is provided for survival and growth such as seen in COVID patients having high sugar levels.
Let me make my case for why industrial oxygen use may be the actual culprit, although COVID, Diabetes, and Steroids are playing their supporting roles in this mucormycosis epidemic. Did you know that patients having many other autoimmune health conditions such as rheumatoid arthritis, systemic vasculitis, SLE (Systemic lupus erythematosus), and severe asthmatics receive steroids, sometimes in high doses (although for a short duration) as a treatment even before the COVID 19 pandemic. Why did we not see mucormycosis in them? Although given for a short duration, the high doses equal the time for which steroids are being given for COVID 19 patients. Sometimes, these doses are higher than what is being provided for COVID 19 patients. Yes, these patients may or may not have diabetes, and COVID 19 lowering their immunity. In the first wave of the pandemic in 2020, all these boxes were ticked i.e., COVID 19 infection, Diabetes, and Steroid usage, but we never saw such a magnitude of mucormycosis cases. So what changed this time?
What changed is the severe shortage of medical-grade oxygen supply due to a sudden spike in cases during the second wave. Medical oxygen differs from industrial oxygen in that the medical oxygen goes through multiple steps such as compression, filtration, and purification in oil-less or oil-free compressors. The cylinders into which the oxygen is loaded also undergo specific disinfection and cleanliness processes to maintain contamination-free delivery. Industrial oxygen used for welding, cutting, steel making, etc. does not go through these steps, and neither is such focus placed on maintaining cleanliness. The sudden diversion of such “unclean” probably mucor contaminated oxygen supply chain is leading to a spike in black fungus cases.
Adding to this, the high load of cases at hospitals and staff shortage, some of them positive for COVID 19 themselves, is leading to non-adherence to infection control protocols. The Government of Karnataka has already given directives to this end to contain the mucormycosis epidemic. Karnataka recorded 700 cases of black fungus last week. The orders include investigating and microbiologically sampling gaseous supply chains, OTs, ICUs, ERs., sterilization of all cylinders carrying medical supplies, masks, nasal cannulae, and gas delivery equipment, use of distilled water in humidifiers, etc. It has also advised concerned authorities to instruct gas providers, PPE, and mask manufacturing units to maintain strict SOPs and do random checks to monitor adherence.
In the coming days, more clarity will come about the role of industrial oxygen supply in causing mucormycosis. I hope and pray that this deadly disease comes to an end. It is emotionally draining to see patients losing their eyes and jaws; young patients, what a curse?
P.S: Jugaad is a colloquial word, which refers to a non-conventional, frugal innovation, often termed a “hack”. It could also refer to an innovative fix or a simple work-around, a solution that bends the rules, or a resource that can be used in such a way.