Dr. Shyam P Lohani

A vast majority of people in developing countries have still not received their first shot of COVID-19 vaccines. The percentages of people vaccinated in low-income countries are worrisomely low. This inequitable access to jabs has left millions of people still vulnerable to the virus. It has given a chance to the virus to mutate and spread back across the world. The new and more pathogenic variants are causing havoc among people in countries even with a large number of vaccinated people. They have been forced to re-impose strict preventive measures and travel restrictions.
The deadly second wave recently ravaged our country mainly due to a large number of susceptible populations as the mass vaccination campaign is not moving as intended. It was fueled by different factors such as people becoming careless about the preventive measures, attending weddings and social gatherings, political rallies, and religious assemblies. Vaccine hesitancy combined with the number of infections declining, fewer people were taking the vaccines which slowed down the vaccination drive.
In absence of measures to reduce contact between infected and non-infected or susceptible people, the higher the number of susceptible people faster would be the spread. With an increasing number of infected people, the number of susceptible people starts to decrease and after some time, the rate of spread also begins to slow down. In the beginning of the pandemic, the proportion of susceptible people was much higher than it is in the subsequent waves. In addition, there were a large number of people whose infection was never detected. The numbers of susceptible people were also reduced with the vaccination drive. And then the virus outsmarts humans due to its capacity to mutate. New strains with higher transmissibility emerged and spread exponentially.

More infectious strains
The second wave is mainly due to newer more transmissible variants and thus resulting in rapid spread. The pandemic of COVID-19 continues to rise in many countries due to new variants of coronavirus. There could be more variants of concern circulating among susceptible people. And, at our surprise shortness of breath is the most common clinical feature among symptomatic patients in the second wave who needed supplemental oxygen.
In the second wave, people who are infected with COVID-19 and recovered are being increasingly suffering from a rare infection known as mucormycosis or black fungus. It has been confirmed that severe COVID-19 could potentially weaken the immune system of our body. This could lead to increased vulnerability to other infections, especially to people who are immune-compromised.
Mucormycosis is not contagious, and majority of people coming in contact with the fungi do not develop an infection. However, people with severely weakened immune systems due to diabetes, cancer, HIV, skin injury, and surgery are at increased risk of mucormycosis. This is a rare type of fungal or opportunistic infection that occurs through exposure to fungi known as mucormycetes. They are commonly found in the environment, particularly in leaves, soil, compost, and animal dung. Mucormycetes can enter the body through the lungs, and exposed wounds in the skin.
The common types of mucormycosis include pulmonary (lung), rhinocerebral (sinus and brain), gastrointestinal, and cutaneous (skin) mucormycosis. Symptoms such as cough, fever, headache, chest pain, nasal or sinus congestion, and pain, shortness of breath are respiratory-related symptoms. Skin-related symptoms, which can spread to any part of the body, include blackened skin tissue, redness, swelling, tenderness, blisters, and ulcers.
The use of steroids is to reduce inflammation in the lungs for COVID-19 and thus help stop the damage that can occur when our immune system overwork to fight off coronavirus. At the same time, they also reduce immunity and increase blood sugar levels in both diabetics and non-diabetic COVID-19 patients. In addition, supplemental oxygen needed to people with severe COVID-19 can cause drying of the nasal cavity and further increase the risk of infection.
With an overall mortality rate of over 50 per cent, the fungal infection may have been exacerbated by the use of steroid, a life-saving drug for severe and critically ill COVID-19 patients. The fungal infection is usually treated by administering antifungal medication or performing surgery to remove the affected area. Mucormycosis can be fatal without treatment.
Initially affecting in the nose, the fungus can then spread into the brain, and can often only be treated by major surgery removing the eye or part of the skull and jaw. It has also been reported among COVID patients who were on ventilators in intensive care units owing to their airways being exposed to humidity and moisture.

Prevention
The dual risks of COVID-19 and mucormycosis raise challenging issues and require careful consideration of care and treatment. Therefore, the epidemic of opportunistic infection such as mucormycosis is yet another of the horrible surprises brought to us by the COVID pandemic.
Early identification of a case of mucormycosis is usually challenging as the patient arrives at heath care facilities late. Unlike some other fungal infections, diagnosis is difficult and yet requires specialty equipment and health care professionals.
It is not possible for us to envisage an end to the epidemic of black fungus. The greater awareness of most at-risk people may allow healthcare providers to recognise cases earlier. The most at-risk people, who are immune-compromised, should be protected. It is now upon us to act responsibly in order to break the chain of transmission. Preventive measures such as the use of masks, social distancing, and avoiding large gatherings should continuously be communicated. At the same time, it is vital to ensure vaccine equity across the world to protect healthcare systems and patients from COVID-19, as well as other deadly opportunistic infections such as Mucormycosis.

(Prof. Lohani is the founder and academic director at Nobel College. lohanis@gmail.com)