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Black, Yellow and White Fungus: the damage misinformation causes in COVID-19 crisis

By Akshat Jain 

India is seeing the second wave with COVID-19 crossing all metrics by leaps and bounds. As if COVID related pulmonary infection and “Long Covid” wasn’t enough in making lives of common folk miserable, the resurgence of “Black Fungus” and now the “White Fungus” is sending people for cover and hoarding of antifungal medications is causing their critical shortage for patients who actually need that.  

Black Fungus

Mucormycosis or wrongly touted “Black Fungus” named after the color of the ulcer base when this infection spreads to the skin, is a very rare condition, and only usually seen in patients who are the sickest, most ill and immunocompromised. As of this week, about 9,000 cases of Mucormycosis have been reported all over India. As a cancer specialist I come across this infection once or twice a year (and that is a bad year) but given the death rate of over 50%, this is particularly dangerous infection to have. Caused by a fungus that is very difficult to eradicate from the body once it homes itself in the skin and tissues of the face (nose, sinuses, mucosal surfaces etc.) the treatment is usually a painful surgery where everything in the path of the fungus that spreads like a root of the tree, needs to be scooped out.

Alerting signs of the infection

1.     Facial pain, swelling

2.     Loss of sensation to parts of skin

3.     Low grade fever along with swelling of skin

4.     Black spots that turn into bleeding ulcers on any part of the body

In patients who are immunocompromised due to severe COVID infection or patients who have received a lot of steroid medication (dexamethasone, prednisolone, methylprednisolone) for COVID infection are particularly at high risk.

Prevention

·        Water in oxygen supply routes in COVID patients should be cleaned daily – ventilators, humidifiers, cylinders, oxygen concentrators

·        Clean water source needed for practices like “steam” therapy, Jal Neti

·        Judicious use of steroids – not all COVID 19 patient needs steroids

·        Avoid “cocktail” therapy and judicious use of only proven therapies: remdesivir, monoclonal antibodies, steroids for moderate-severe infection patients, IVIG for children with COVID.

But misinformation about this infection has made people run and stock up on amphotericin B, the lifesaving intravenous antifungal treatment medications, causing widespread shortage, just like the oxygen crisis.

Misinformation and false sense of security

Having taken part in video conferencing with health ministers of various Indian states, medical leadership and power brokers over the past month, one thing is very clear to me. This pandemic has left no household big or small untouched.  Everyone is doing their level best to ease access to care.

Remarkably while the “Bhilwara Model” in Rajasthan failed miserably when it really mattered, decentralized approach in empowering area rural health centers (RHCs) and Primary Health Centers (PHCs) to supply them with pulse oximeters, oxygen cylinders, and oxygen concentrators being practiced now, will give long lasting dividends. Especially keeping sick rural patients in the comfort of their villages and establishing a supply chain once the “Vaccine apartheid” ends ,will make roll-out smooth and accountable – something that most state governments need to optimize at the regional levels.

Correct information about vaccine availability, side effects, safety features and most importantly the lifesaving protection that one gets from this first line of defense needs to be hammered in great detail. Earlier in the year this misinformation on the vaccines spread by politically motivated folks led to vaccine wastage and again misinformation spread by certain actors led to poor vaccination acceptance rates, which certainly did not help in prevention of the second wave.

The author is Hematologist Oncologist and Stem Cell Transplant Specialist based in Los Angeles, CA

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India Latest News

Evidence: The bedrock of Covid management

By Gagandeep Kang

Twitter in India is a desperate place. Pleas for beds, sources of oxygen, remdesivir and plasma overwhelm, even as volunteers amplify messages and scramble to help. Tongue twisters — tocilizumab, itolizumab — appear in discussion as people call, message and sink into despair and guilt at being unable to procure what they are told is needed to care for their family or friend.

We are struggling with a health care system that is inequitable in access and quality at the best of times. There is limited surge capacity for seasonal illnesses in hospitals, few trained and competent staff, especially in infectious diseases and critical care, and a fragmented health care system. At any time, and especially now, evidence-based medicine, or “the right care at the right time to the right patient” is essential.

As the Indian medical community and health policymakers, we have not done well in this pandemic. We have promoted, as “cures”, poorly evaluated treatments from our traditional systems of medicine. This is a disservice to the accrued knowledge over millennia of the science of life in Indian systems of medicine.

Evidence-based medicine requires lifelong learning, and the continued education of medical communities and patients. For a new infectious disease where we have little knowledge of how damage is caused and how to manage or reverse it, it is important to focus on the generation of evidence by testing old and new drugs and medical management measures.

To know what drugs are needed when, it is important to understand how the disease is caused and develops. In the early phase, the disease is primarily driven by replication of Sars-CoV-2. Later, and especially when the infection is not controlled and symptoms start to become severe, the disease appears to be driven by an uncontrolled immune and inflammatory response to Sars-CoV-2 that leads to tissue damage. Based on this understanding, in general, any antiviral treatment would have the greatest effect early in the course of the disease, while immunosuppressive/anti-inflammatory therapies would be needed in the later stages of Covid-19.

For remdesivir, the Solidarity trial showed no effect on severe disease or death, but the ACTT-1 trial showed that for patients who were at the stage of requiring supplemental oxygen, but not yet needing high-flow oxygen or non-invasive ventilation, remdesivir provided some benefit in shortening duration and preventing death. This highlights that the drug is not for every patient, but for a small subset at a specific stage of treatment.

Similarly, for tocilizumab, evidence-based recommendations are narrow, for a subset of patients with rapid progression who need either high-flow oxygen or non-invasive ventilation, and in combination with other therapy including steroids. For plasma therapy, there is no evidence that any plasma from any group of donors is helpful as shown in the Indian Council of Medical Research-supported Placid trial, and is not currently recommended.

As people desperately seek drugs that may not be needed, we have an ethical and moral responsibility to ensure that all healthcare providers use evidence to inform treatment. Professional organisations, clinical research communities, the regulator and policymakers must play a role in ensuring that treatments are used according to need and not to create false hope.

(Gagandeep Kang is professor, Christian Medical College, Vellore. The article appeared in The Hindustan Times)

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India Latest News

Deadly 2nd wave spreads from cities to small towns

Intro: More states announce lockdowns as an unabated second Covid wave cripples India amid acute oxygen and drug shortage

New Delhi: India’s deadly Covid-19 second wave has devastated big cities like Delhi, Mumbai, Lucknow and Pune. Hospitals and crematoriums have run out of space, and funerals are taking place in car parks. But the pandemic has now firmly gripped many smaller cities, towns and villages where the devastation is largely under-reported.

Kota in Rajasthan has reported more than 6,000 cases in the past week, and 264 deaths since the pandemic began – but 35% of those happened in April alone, reports the BBC.

There is an acute shortage of oxygen and drugs like remdesivir and tocilizumab. The district is home to many coaching centres for students from all over the country taking exams to get into prestigious medical and engineering colleges.

Allahabad in Uttar Pradesh recorded 54,339 cases up to April 20, but it has registered a 21% increase since then, adding 11,318 cases in the past week.

About 32% of the reported 614 deaths in the city happened in April alone. 

“Yogi Adityanath, the state’s chief minister, recently said there was no shortage of drugs, hospital beds or oxygen, but experts say the reality on the ground is vastly different,” the report mentioned.

Kabirdham in Chhattisgarh did not have any active cases of Covid-19 on 1 March. But it has added almost 3,000 cases in the past seven days.

Local journalists say that the district is not able to handle really sick patients as it did not prepare to manage the sharp uptick in cases. Several people have died without getting proper treatment in the district.

Bhagalpur and Aurangabad districts in Bihar are also badly hit.

Nainital, Uttarakhand is struggling to cope with the rising number of cases. At least 131 out of its 142 ICU beds were occupied on 27 April and only 10 out of its 771 oxygen beds were free. It has reported more than 4,000 cases and 82 deaths in the past week.

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International Latest News

India gets global help to tackle its worsening Covid crisis

New Delhi: As India’s tally of covid-19 infections crossed three lakh for the sixth consecutive day on April 28, more countries pledged to support the world’s hardest-hit hotspot with supplies of medical equipment and oxygen required to treat thousands of critically ill patients who are desperately looking for treatment.

The US, France, Germany, Kuwait, Saudi Arabia and Russia have pledged support to India as it battles a ferocious second wave of covid-19 infections that has brought the country’s health infrastructure on the verge of collapse.

India has received 318 Oxygen Concentrators from the US, and 500 BiPAPs, 250 oxygen concentrators and other medical supplies from Singapore, that landed in the covid-battered country on an Air India flight.

Key US business groups such as the US-India Business Council and the US Chamber of Commerce, besides chief executive officers of more than 40 companies, announced the formation of a “Global Task Force on Pandemic Response: Mobilizing for India.”

Some major companies like Apple Inc., Google Inc, Microsoft Corp. and Deloitte have already announced aid for India.

Shortages of key drugs, lack of oxygen and hospital beds are among the challenges confronting health care workers.

France is sending eight oxygen generators, five containers of liquid oxygen and 28 ventilators in the first tranche of aid.

The country’s foreign ministry said that each oxygen generator can fulfill the needs of 15 critically ill patients.

“As many countries are doing, what Australia will do is we will provide an initial package…of support and to deliver this as soon as possible,” Australian Prime Minister Scott Morrison said in Canberra.

The 27-member European Union said, “Urgently needed oxygen, medicine and equipment will be delivered over the coming days by EU member states to India, following the country’s request for support through the EU Civil Protection Mechanism.”

As part of this effort, Ireland was to dispatch 700 oxygen concentrators, an oxygen generator, 365 ventilators; Belgium was to send 9,000 doses of antiviral drug remdesivir; Romania to help with 80 oxygen concentrators and 75 oxygen cylinders; Luxembourg to send 58 ventilators; Portugal to dispatch 5,503 vials of remdesivir and 20,000 litres of oxygen; while Sweden was to channel 120 ventilators.

Saudi Arabia’s aid of 80 MT of liquid oxygen is enroute via the sea route, Hong Kong is sending 800 oxygen concentrators. India will also get six Cryogenic oxygen containers from the UAE.

Sources said that Germany is sending a mobile oxygen production unit which will be made available for three months along with 120 ventilators and 80 million KN95 masks.

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India assures ramp up in supply of oxygen, Remdesivir to states

New Delhi: Union Finance Minister Nirmala Sitharaman praised the Indian industry for its extreme forbearance, patience and perseverance, using Japanese word ‘Gamanzuyoi’.

Addressing more than 150 senior industry captains in a virtual interaction organised by the Confederation of Indian Industry (CII), she emphasised on the need for adopting micro-containment strategy in dealing with the second surge of the pandemic and acknowledged that the deliberations with CII had helped shaped this strategy.

Explaining the rationale, the Finance Minister said that unlike last time, the government now has important tools such as vaccines and medicines to deal with the pandemic.

On meeting the phenomenal increase in demand for medical oxygen, a critical treatment tool for Covid-19, she assured seamless supply to states. Measures that the government is taking include importing medical oxygen, round the clock working of oxygen filling stations and allowing containers used for nitrogen and argon to be used for oxygen, she added.

Sitharaman also gave details of government initiatives to help ramp up capacity of Remdesivir from 36 lakh vials per month to 78 lakh vials per month. Some of these measures include rapid clearances for new capacities, stopping exports, stopping the exports of APIs and formulations used in the manufacture of this life saving drug, and allowing EoUs and manufacturers located in SEZs to also sell in the domestic market, she said.

During the interaction, CII members manufacturing Remdesivir apprised the Finance Minister that they were in fact working towards exceeding the committed target of 78 lakh vials per month and aiming to reach a production of 1 crore vials per month.

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Latest News USA

USFDA approves Remdesivir for Covid-19 treatment

The US Food and Drug Administration (USFDA) on October 22 gave its final nod to Gilead’s antiviral drug Remdesivir for treating hospitalized Covid-19 patients. Remdesivir is the first approved Covid-19 treatment in the United States.

“The FDA is committed to expediting the development and availability of Covid-19 treatments during this unprecedented public health emergency,” said FDA Commissioner Stephen Hahn, in a statement.

“Today’s approval is supported by data from multiple clinical trials that the agency has rigorously assessed and represents an important scientific milestone in the Covid-19 pandemic,” he added.

The agency concluded that Remdesivir demonstrated efficacy in treating hospitalized patients with Covid-19.

On May 1, 2020, the USFDA issued an Emergency Use Authorization (EUA) for Remdesivir sold under brand name Veklury for the treatment of laboratory confirmed Covid-19 in adult and pediatric patients hospitalized with severe disease.

The approval of Remdesivir was supported by the agency’s analysis of data from three randomized, controlled clinical trials that included patients hospitalized with mild-to-severe COVID-19.

The USFDA does have certain limitations on the drug. Remdesivir is not yet approved for children under 12 years old. The USFDA noted in its review that there still wasn’t good data on how the drug would affect children, people who are pregnant, or anyone with kidney or liver issues, and it also mentions that there isn’t good data on interactions between drugs.

USFDA identified hepatotoxicity as major safety issue with the drug.

Remdesivir works by blocking viruses from making copies of themselves. It was first developed by Gilead to treat Ebola and research over the past few years showed that it could block the coronaviruses SARS and MERS from replicating inside cells.

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Latest News USA

Indian Americans chant mantras, pray for Trump outside military hospital

A prayer vigil was held on Sunday evening for President Donald Trump and First Lady Melania Trump by the Indian American community to wish them a speedy recovery. His supporters not only gathered outside the hospital but also showed support virtually from cities across the United States.

“I would like to thank the people of our community who are there at the Walter Reed hospital, praying for our President Trump and the First Lady. Despite being diagnosed with COVID-19, our President and his supporters have done more than what Biden has done in 47 years,” said Nisha Sharma, Congressional candidate from California District 11.

The community members chanted mantras and echoed the sound of the conch shell or Shankha for the speedy recovery of President Trump and the First Lady.

Sentinels of Dharma, a Hindu American organization hosted the event. During the prayer meeting, Indian Americans also endorsed President Trump in his re-election bid and reached out to other community members all over the country to campaign in his favor.

President Trump could be released from the Walter Reed National Military Medical Center as soon as Monday, his medical team said in an update on Sunday to members of the White House press pool, as the president continues his treatment on dexamethasone and Remdesivir to fight coronavirus.

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coronavirus Health International

Mr Fauci expects FDA to issue emergency authorization for Remdesivir to treat Covid-19

Washington: Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, said he expects the Food and Drug Administration to issue an emergency-use authorization for remdesivir soon to treat Covid-19. 

Fauci said that while the FDA has not made a final decision yet, he projects “it’s going to be really quickly.

Speaking during an appearance on the Today show, Fauci said he believes Gilead Sciences, the maker of remdesivir, is committed to make the treatment available “as much as they can, as quickly as they can.”

“I’m pretty confident that that will be the case because I believe they’re committed to trying to get this out as quickly as possible,” Fauci told NBC’s Savannah Guthrie.

A trial of the experimental drug remdesivir showed it might help patients recover more quickly from the infection. 

Fauci was optimistic about the results, saying “The data shows that remdesivir has a clear-cut, significant, positive effect in diminishing the time to recovery.”

The government-funded study found that patients who took remdesivir recovered faster than patients who did not. It’s not a home run, but federal officials are keen to provide any hope they can in a pandemic that has infected more than 1 million Americans and killed close to 60,000 of them.

Results from the preliminary trial show remdesivir improved recovery time for coronavirus patients from 15 to 11 days. That’s similar to the effect that the influenza drug Tamiflu has on flu. Tamiflu also doesn’t cure patients quickly, but can reduce how long they are sick.

“Although a 31% improvement doesn’t seem like a knockout 100%, it is very important proof of concept,” Fauci said of remdesivir. “What it has proven is that a drug can block this virus.”

However the WHO said it’s too early to comment on the remdesivir trial results released Wednesday.

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