Thread and new story: We were all shocked at the sudden rise of mucormycosis cases in India this year. Yesterday, the government said we had touched a whopping 45,000 cases by July 15 (possibly starting May 19, but starting date unknown) (1)…
How did this fungal disease pop out of seemingly nowhere? Of course, mucormycosis existed before: a rare disease, seen predominantly in people with uncontrolled diabetes. Why did the Covid pandemic make its numbers jump through the roof? (2)
The primary hypothesis today is that the use of steroids for Covid was so unprecedented (they were used in both irrationally high doses+very widely), that they made patients vulnerable to mucormycosis. Steroids were also a mucormycosis risk-factor earlier, along with diabetes (3)
But this doesn't explain everything. Steroids have been used in high doses (even irrationally) for other respiratory illnesses, like influenza. Yet, we don't often see mucormycosis spikes coincidental with influenza season (4)
Most experts I spoke to believe that there is something about Covid that is making patients biologically vulnerable to mucormycosis (5)
Some of the mechanisms suggested (not an exhaustive list): (a) SCOV2 damages pancreatic islets (b) Certain cytokines released during Covid trigger insulin resistance (c) Covid suppresses neutrophils and macrophages, both key protection against mucormycosis (6)
(d) Covid increases free iron in the blood, creating favourable conditions for Mucorales. A. Chakrabarti's group is currently doing a case control study comparing levels of inflammatory markers and immune cells between Covid associated Mucor cases and non Mucor Covid cases (7)
Perhaps we will eventually have answers. But A Chakrabarti and other mycologists want to take this opportunity to warn us about the threat of fungal pathogens to public health (8)
Not just Mucorales, but also Candida, Aspergillus, Cryptococcus, Histoplasma and many more fungi are highly neglected causes of illness in India. Diagnostic capacity for these is extremely poor. (9)
For a variety of reasons (including global warming, as always), the prevalence of fungal infections, including life threatening invasive ones, has been growing over the last few decades (10)
Until the Covid pandemic came along, making the symptoms of mucormycosis common knowledge, many cases remained undiagnosed. Lack of diagnosis and treatment for this disease often means death. In fact, before amphotericin B came into use in 1958, no one survived mucormycosis (11)
Improving diagnostic capacity for fungal pathogens means more training for clinicians/microbiologists, but also a network of referral labs like India's Virus Research and Diagnostic Laboratories (12)
But even though India has 105 VRDLs, as on today, it has 3 functioning government-run fungal referral labs. This creates a big gap in diagnostic capacity, because not everyone can do the sophisticated tests needed for fungi (13)
If there is one thing we take away from the mucormycosis outbreak, it is that we must invest in fungal pathogen surveillance and diagnostic capacity. Because surprising outbreaks like mucormycosis will happen again. And we don't want to be blindsided like we were this time (14)
For more, READ MY STORY! :)… (15/15)
PS: About the oxygen-mucor link, atleast 4 hospitals tried to isolate Mucorales from their oxygen pipelines and cylinders (A Chakrabarti really doesn't believe that is a source of Mucorales, because oxygen is not a favourable environment for these fungi), but didn't find it.
PS 2: Thanks to a whole lot of people who gave me important perspective for this story, but I couldn't quote eventually. @drshafikuchay, Satyajit Rath, @spkalantri

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More from @PriyankaPulla

5 Jun
Okay, having read a translation of the report on Anvisa's website about Covaxin and @hildabast's useful thread, here is my quick take. This is not a reversal of the previous decision of Brazil to import 20 mn doses…
The translated report contains the phrase "partial authorisation", and talks about only 4 million doses, not 20 million, as earlier. And there are several caveats.
Based on the corrective actions Bharat Biotech agreed to take, and also accounting for "information gaps", Brazil will import the vaccine, as long as 1) BB implements the GMP changes promised 2) presents a certificate of potency (thanks @hildabast for the translation)
Read 10 tweets
4 Jun
Important story that throws light on the confused mess of a trial that led to the approval of 2DG. It is such criminality to push these drugs on people.
More importantly - isn't there a single person in this country whom the Dr Reddy's, Biocons or Glenmarks of the world can hire to design a decent trial for them?
Is it so bloody hard to design ONE trial that can properly test a hypothesis, carry it out cleanly & transparently, and report the results asap? Seems like it is truly impossible in this country.
Read 4 tweets
2 Jun
Agree. I don't think the indemnity itself is the problem, as is Pfizer's demand for indemnity against compensation for *negligence* (that's different from indemnity against compensation for AEFI)
Indemnity against negligence potentially includes manufacturing negligence, storage negligence. That's a whole different world, and I don't get why a manufacturer should have no liabilities on that front.
As far as indemnity against compensation for AEFI goes, if it gets people like SII to acknowledge there are AEFIs, and helps recipients get paid for AEFIs (like thrombosis) that have actually been linked to the vaccine, I don't see why every manufacturer shouldn't get it.
Read 4 tweets
25 May
I find this article really problematic…
It frames the early approvals of the Russian and Chinese vaccines, without phase 3 trials, as some sort of a vague perception problem, and not of real consequence.
Simultaneously, makes some vague jabs at "problems" with the western vaccines.
Read 6 tweets
18 May
Dear doctors who are telling everyone that Covaxin is as good as any other vaccine, please also raise your voice about these horrendous violations in the clinical trial that was used to develop the vaccine are promoting. This is your job too.
The investigators in the trial of the vaccine you are promoting are refusing to give an informed consent form to the family of a deceased participant. You have a responsibility to protest this.
"the vaccine you are promoting", I meant.
Read 4 tweets
18 May
Many people are finding out the hard way that when vaccine manufacturers claim 100% efficacy against severe disease in a clinical trial, this doesn't translate to deal life. Vaccine efficacy against severe disease is probably very high, but not 100%.
And effectiveness - in real life - where people who have been excluded from clinical trials (the immunocompromised, for instance), is probably even lower. That's why we needed effectiveness studies for this country.
That's why we *saw* effectiveness studies done for vaccines like AZ and Pfizer. It matters. It's not just some fun academic exercise.
Read 4 tweets

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