As India begins to recover from a devastating second wave of coronavirus infections, thousands of Covid-19 patients in the country developed the deadly "black fungus" infection.
India has had about 12,000 cases and more than 300 deaths from black fungus in the past few months, with several states affected.
Other countries have reportedly recorded many Covid-linked black fungus cases including Pakistan and Russia.
On May 25, Bangladesh reported its first death caused by black fungus.
A disease as unpleasant as it sounds, black fungus, or mucormycosis, is a fungal disorder that forces surgeons in some cases to remove patients’ eyes and jawbones to stem the infection.
It's a lot more common in developing countries. It's certainly more common in patients with diabetes and in organ transplant patients
Until this year, there had been only a few dozen published mucormycosis cases linked to Covid-19 worldwide, but in India alone recent case numbers run into the thousands.
A recent scientific paper said a combination of a severe Covid-19 outbreak and uncontrolled diabetes – a key risk factor – created “the perfect storm for mucormycosis”.
Here we outline what mucormycosis is and why so many people are being infected and even dying.
What is mucormycosis?
This group of infections is caused by spores of fungi known as mucormycetes. Common in soil and decaying organic matter, including leaves, fruit, vegetables and manure, they are usually harmless, but their airborne spores can cause illness in individuals with weak immune systems.
Symptoms include headache, fever, blocked nose, chest pain, breathing difficulties and, if the infection spreads to them, pain and pressure around the eyes and blurred or double vision.
Patients may cough up blood and develop a blackish discolouration over the bridge of the nose, with a process of tissue death or necrosis occurring. This occurs when too little blood flows to the tissue.
Figures from the US Centres for Disease Control and Prevention indicate that slightly more than half of people with the disease die.
Fortunately, the condition is not thought to spread from person to person.
How common is it?
The condition is rare in developed nations, with the CDC quoting a US study that found an annual rate of 1.7 cases per million people. But it occurs much more frequently in some developing nations.
“In my whole career, I’ve seen probably two or three cases,” said Dr Andrew Freedman, an infectious diseases specialist at Cardiff University in the UK.
“It’s exceedingly rare in the UK but it’s a lot more common in developing countries ... it’s certainly more common in patients with diabetes and in organ transplant patients.”
Figures published in March this year, before the worst of India's second Covid-19 wave, suggested that the country of 1.37 billion accounted for 71 per cent of cases worldwide.
Apart from India, Pakistan and Russia reported cases of the deadly disease.
Russia confirmed reports of black fungus among Covid-19 patients on May 17, but authorities said the situation was under control.
Why did numbers surge during India’s wave of Covid-19 cases?
People with Covid-19 are sometimes given steroids to reduce lung inflammation, but these drugs weaken the immune system and so increase the risk of mucormycete infection.
“Steroids ... are commonly used to treat severe Covid, and they predispose to rare infections, like fungal infections,” Dr Freedman said.
Particularly if steroids are used in excess, the fungus may be able to multiply and cause an infection.
That steroids can increase blood-sugar levels in some people with diabetes, which is common in India, is also thought to be a factor, with more than eight in 10 black fungus cases happening in diabetics. A frequent scenario is for the disease to develop in diabetics recovering from Covid-19 at home.
The disease is more common after a prolonged stay in intensive care, leading to concerns that contaminated oxygen cylinders, pipes and humidifiers in hospitals are causing infections.
Uncertainty persists, however, because there a5re reports from India that mucormycosis has been seen in individuals who have not been treated with steroids or given oxygen.
How is it treated?
Early treatment is important to stem the infection and prevent it from spreading. In advisory notes, the Indian Council of Medical Research and India’s Ministry of Health and Family Welfare tell clinicians to “not lose crucial time to initiate treatment”.
Black fungus is often treated by intravenous injections of anti-fungal medication for at least four weeks.
Surgery may be required to cut away dead tissue and prevent the infection spreading. Drastic measures are often called for, such as removing an eye to stop the fungus reaching the brain, or cutting out part of the jaw or the skull. Some patients now face a life where they will struggle to talk or eat normally because parts of their mouth were cut away.
Doctors are told to reduce and then discontinue steroid treatment in affected patients, and to stop giving other drugs that affect the immune system.
With India's coronavirus case numbers dropping by more than 20 per cent a week, doctors will be hoping that the prevalence of black fungus decreases too.
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Labour dispute
The insured employee may still file an ILOE claim even if a labour dispute is ongoing post termination, but the insurer may suspend or reject payment, until the courts resolve the dispute, especially if the reason for termination is contested. The outcome of the labour court proceedings can directly affect eligibility.
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Tearful appearance
Chancellor Rachel Reeves set markets on edge as she appeared visibly distraught in parliament on Wednesday.
Legislative setbacks for the government have blown a new hole in the budgetary calculations at a time when the deficit is stubbornly large and the economy is struggling to grow.
She appeared with Keir Starmer on Thursday and the pair embraced, but he had failed to give her his backing as she cried a day earlier.
A spokesman said her upset demeanour was due to a personal matter.
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Hydrogen has an estimated $11 trillion market potential, according to Bank of America Securities and is expected to generate $2.5tn in direct revenues and $11tn of indirect infrastructure by 2050 as its production increases six-fold.
"We believe we are reaching the point of harnessing the element that comprises 90 per cent of the universe, effectively and economically,” the bank said in a recent report.
Falling costs of renewable energy and electrolysers used in green hydrogen production is one of the main catalysts for the increasingly bullish sentiment over the element.
The cost of electrolysers used in green hydrogen production has halved over the last five years and will fall to 60 to 90 per cent by the end of the decade, acceding to Haim Israel, equity strategist at Merrill Lynch. A global focus on decarbonisation and sustainability is also a big driver in its development.
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- Olympic-size swimming pool with a split bulkhead for multi-use configurations, including water polo and 50m/25m training lanes
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Company profile
Company name: Suraasa
Started: 2018
Founders: Rishabh Khanna, Ankit Khanna and Sahil Makker
Based: India, UAE and the UK
Industry: EdTech
Initial investment: More than $200,000 in seed funding
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Libi has been involved in threatening and perpetuating acts of aggression and violence against Palestinians. His firm has provided logistical and financial support for the establishment of illegal outposts.
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Global state-owned investor ranking by size
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Cricketer of the Year – Shaheen Afridi (Pakistan)
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The Sinopharm vaccine was created using techniques that have been around for decades.
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"What is left is a skeleton of the virus so it looks like a virus, but it is not live."
This is then injected into the body.
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New central waste facility on site at expo Dubai South area to handle estimated 173 tonne of waste generated daily by millions of visitors
Recyclables such as plastic, paper, glass will be collected from bins on the expo site and taken to the new expo Central Waste Facility on site
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Of 173 tonnes of waste daily, an estimated 39 per cent will be recyclables, 48 per cent organic waste and 13 per cent general waste.
About 147 tonnes will be recycled and converted to new products at another existing facility in Ras Al Khor
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Aim is for 85 per cent of waste from the site to be diverted from landfill
