A recent and worrying dimension of COVID-19 in India is mucormycosis and other opportunistic invasive fungal infections, more than 41,000 through 12 July. Mucormycosis is normally a very rare but lethal infection. Misuse of steroids, antibiotics and uncontrolled diabetes emerged as key explanations for why the black fungus has hit India and key to understanding why antimicrobial resistance is crucial to creating a safer and more equal world in the future.
Mucormycosis is caused by exposure to mucor mould, a mould that is normally found in decaying fruits and vegetables as well as in soil and manure. The mould is therefore all over the place – all the time, and is often present in the nose and mucus of healthy people, but that is usually not a problem.
But when the COVID-19 Delta variant hit India, it became a major problem, since the fungus can affect the brain and the lungs of severely immunocompromised people and be life-threatening. Mucormycosis has an overall mortality rate of 50%.
It may have been triggered by the use of steroids as part of the life-saving treatment for severe and critically ill people with COVID-19, but this is only part of the story, since the black fungus has not hit other places to the same extent.
Why did a COVID-19 pandemic cause more than 41,000 people to suffer from this otherwise rare disease in India? And how can the case help the world in the future?
Beyond the clinical paradigm
A recent article reporting data from the Indian Council of Medical Research and its network of tertiary care medical institutions promoting antimicrobial stewardship has brought forth some significant facts on inappropriate antibiotic usage that also accounts for high levels of antimicrobial resistance in India.
Although the clinical treatment protocols of the Ministry of Health and Family Welfare had cautioned against routinely using broad-spectrum antibiotics, three of the 10 network hospitals administered more than three antibiotics to the people hospitalized with COVID-19.
Ten per cent also received antifungal agents without any evidence of fungal infection; the paper acknowledged “indiscriminate use of antimicrobials, including antifungals”. The authors also observed that these hospitals prescribed antibiotics that the World Health Organization (WHO) has said should be used sparingly, and another 9% received antibiotics that were not recommended.
Driven by human behaviour and perceptions, antimicrobial resistance is mediated by social and economic factors leading to inappropriate use of antibiotics. Pharmaceutical industries have an important role to play too, with little regulation for treating antibiotics in the effluent from the pharmaceutical industry.
The One Health approach – with collaborative efforts of multiple disciplines working locally, nationally and globally – provides an integrated road map across the human, animal and environmental sectors. This entails gaining in-depth understanding of local contexts of community organisation and the social, cultural and behavioural drivers of inappropriate use of antibiotics.
Community level: the missing piece
No specific agencies or structure can provide guidance at the community level regarding safe and appropriate use of antimicrobials. The obvious first stops are primary health centres for human health–related issues and veterinary hospitals for livestock.
The accessibility, availability, responsiveness and quality of care at these institutions are often inadequate, leading to widespread self-medication or over-the-counter use of antimicrobials. An agency closer to the community is needed that can sensitise on appropriate antimicrobial usage, both for humans and livestock.
Demystification of technical terms
A fairly common inappropriate use of antimicrobials is in treating people with infectious diseases such as malaria and tuberculosis, in which people often stop using the drug once they are relieved of symptoms. At the local level, community members and patients are generally unable to relate to the technical terms and guidelines. Demystifying the technical aspects of antimicrobial resistance in the local language can enable users to understand the problem and use antimicrobials as prescribed and judiciously.
Local examples of good and ill effects of antibiotics can be shared with the community. On the other hand, the prescriber often interprets and practices this process purely from an economic viewpoint, to resolve the infections fast. There is generally pressure on veterinary and para-veterinary practitioners for quick-fix solutions to make the livestock animals healthy and productive. They often concede to the community’s demands and prescribe antimicrobials that may not be necessary or do not explain the correct usage of prescribed drugs.
Simplifying the data is also key to effective community engagement. Translating critical scientific data into local languages can improve understanding of technical issues, leading to behaviour change.
Examples can be drawn from other health programmes in India, such as the Integrated Child Development Services, where anthropometric data are simplified and communicated through Road to Health cards to signal the progress of growth milestones to the mothers and caregivers.
Coordination at local level is key
The One Health concept constitutes the discourse at more informed levels, with a lack of coordination among human, animal and environment health experts and practitioners at the local level. No common database is available in India that can be referred to in case of a disease outbreak.
Data on antimicrobial resistance are available only from a limited number of tertiary care hospitals. There is a lack of involvement of district or subdistrict hospitals in generating data. Involvement of health centres at all levels will enable data to be generated in a time-bound fashion. The Integrated Disease Surveillance Programme lacks data from the veterinary department.
A common platform is needed in which data from the human, environment and veterinary departments can be collated. The antimicrobial resistance surveillance of the Government of India, Indian Council of Medical Research and National Centre for Disease Control can also be used for disease surveillance.
However, presently these bodies are working with the tertiary care hospitals only and need to enlarge the network to secondary and primary levels too.
Intersectoral convergence
Two recent significant developments are potential game changers.
Integrated public health laboratories are seeking to integrate collection, transport and testing of human, veterinary, wildlife and environmental samples. The Integrated Health Information Portal shall integrate data from national health programmes as well as those from Department of Animal Husbandry Dairying and Fisheries, National Animal Disease Reporting System and the Ministry of Environment, Forest and Climate Change.
The need for One Health committees at the state and district levels has been articulated recently, with representation from district administration, public health including clinical medicine, veterinary and wildlife institutions as well as environmental health and private (including corporate) stakeholders.
The implementation and governance of One Health committees in India requires strategies based on stakeholder communication, willingness to cooperate for collective action, collaboration and coordination between various stakeholders (human, animal, environment and allied sectors), continual reporting and surveillance of public health exigencies, critical reviewing and crisis management.
Fostering community engagement
The role of the corporate and private sectors in enhancing community engagement can be vital. Corporations, particularly the pharmaceutical industry, can invest the (government-mandated) corporate social responsibility funds towards promoting awareness and informing the community about antimicrobial resistance. These funds can also contribute to antimicrobial resistance research. Data can be generated at the grassroots by the NGOs and community-based organisations to feed into antimicrobial resistance–related studies.
The role of local formal and informal veterinary care providers is significant, since they influence the use of antibiotics in animal husbandry. The state pollution control boards need to make antimicrobial resistance an agenda and shall be able to provide relevant environmental data. Sustained stakeholder consultations can help identify barriers to intersectoral coordination.
The World Bank’s health assembly concept involves people from the community to engage in a dialogue; in India, the village health, sanitation and nutrition committees (under the National Health Mission) can help bridge the gap between people and government and engage in the antimicrobial resistance discourse.
The future of fighting antimicrobial resistance
So can we use the current black fungus tragedy in India to learn something about how we can fight antimicrobial resistance in the world in the future? The answer is of course yes.
First and foremost, surveillance networks need to enlarge to include human, veterinary, wildlife and environmental samples.
Second, intersectoral mechanisms such as One Health committees can forge local-level partnerships and operationalise integrated models.
Third, communication strategies based on surveillance data can foster community engagement to build this agenda from the bottom up.
