Many public health specialists in Nepal have been heaving a sigh of relief that the infection graph for the second wave is starting to flatten, but with reports of black fungus, third wave and new variants there is no respite.
Everything that India has suffered since March has repeated itself in Nepal on a smaller scale. The black fungus outbreak could be a microcosm of the post-second wave world, of ‘epidemics within a pandemic’ as opportunistic infections and new Covid-19 waves prey on collapsed health systems.
In theory, Nepal should not have a strong flare-up like India because we have fewer risk characteristics, says epidemiologist Lhamo Yangchen Sherpa.
“Covid is communicable so it spreads regardless of demographic factors, but black fungus is rarely contagious and selective.” she says. “India’s population has a higher proportion of elderly, diabetics and immunocompromised people than us, and these are the groups most vulnerable to black fungus,” she says.
Indeed, there were reports in India of black fungus even pre-Covid, with 140 cases per million, which was the highest in the world. It currently has 12,000 cases and 300 deaths from the fungus that mostly affects Covid patients on ventilators and survivors on long-term steroid treatment.
But for all we know, the infection may already spreading in Nepal, starting from the Tarai and moving up just like the Covid second wave. The ‘black fungus’ mucormycosis is found abundantly in the soil, and thrives on steroid overuse, especially on Covid patients with diabetes and other ailments.
Cleared out easily by a healthy body, mucormycosis latches on to patients whose immune systems are compromised.
“Covid treatment is a double-edged sword, it suppresses the virus-induced hyperimmune response but also raises blood sugar levels and weakens infection-fighting ability, making conditions perfect for mucormycosis,” explains Sherpa.
The Health Ministry announced in its daily briefing on Thursday that there were 6,825 new confirmed Covid-19 cases– up from Wednesday’s tally of 5,316–with 5,904 recovering. This brings the total number of active cases to 576,936, with 101,839 in isolation . Of the 1,444 in hospital ICUs, 398 are on ventilator support.
Those in ICUs and ventilators face a double whammy as hospitals treat them with steroids and desperately reuse uncleaned humidifiers and discarded oxygen cylinders. According to the Health Ministry, 10 to 12 patients with black fungus have been detected so far, but there may be more.
Covid survivors who needed critical ICU treatment and are continuing with steroids are left more susceptible to black fungus infection anytime. Nepal’s first recorded fatality from black fungus was a 60-year-old patient in Lumbini Provincial Hospital recently recovered from Covid.
“Black fungus infection has been spotted even in those recovered from Covid for the past six weeks or more,” say Khemraj Bhusal a consultant physician at Greencity Hospital. But as stable survivors are sent home they become potential blind spots in black fungus tallies.
Hospitals in the frontlines can ill-afford to meet new shadow caseloads. Diagnosing mucormycosis infection early requires biopsies, sample examinations and even follow-up CT scans, requiring specialised personnel and advanced equipment that most district hospitals in Nepal do not have.