Daily Editorial Analysis for 26th May 2021

Slowing the pace of India’s mucormycosis threat

Why in News

• The alarming situation of mucormycosis in patients diagnosed and treated for COVID­19 has emerged as no surprise in the medical oncology community field.
• This outcome was the greatest fear as the administration of dexamethasone and other steroids began to become common.
• Some States, including Tamil Nadu, have declared mucormycosis as a notifiable disease under the Epidemic Diseases Act.
• Guidelines and protocols need to be adapted and modified rapidly to arrest this growing epidemic.
• According to the study published in Current Fungal Infection Reports, it estimated the burden of mucormycosis in India is 14 per 100,000 population which is almost 70 times higher than the other countries.
• In a multicenter study across several tertiary care hospitals in India, published in Clinical Microbiology and Infection, the rough estimate of proven mucormycosis was around 40 cases on an average over a 21-month period observed at each centre.

Focus on diabetes

• The mucormycosis does not transmitted from one individual to the other, the way COVID­19 is.
• The most common cause is uncontrolled diabetes mellitus (raised blood sugars). Other causes include the treatment of some cancers; steroids, chemotherapy or immunotherapy, and solid organ or stem cell transplantations.
• The common sites of presentation include rhino cerebral involvement (i.e., the fungus can damage the nose, paranasal sinuses, the eyes and the brain), and pulmonary involvement (i.e., the fungus can cause pneumonia).
• Raised blood sugars being a cause is of particular concern for multiple reasons.
• According to a study in The Lancet:
• The number of people with diabetes increased to 65 million in 2016 in India. The highest prevalence of diabetes was observed in Tamil Nadu, Kerala and Delhi.
• The crude prevalence of diabetes above 20 years of age has increased to 7.7% in 2016, from 5.5% in 1990.
• Further, there is an underlying higher genetic susceptibility to diabetes in Indians; some of these cases would get unearthed only after exposure to steroids.
• In a lab study published in Nature Metabolism, SARSCoV­2 can potentially multiply in pancreatic cells and contribute to increased blood sugar levels in COVID­19 patients.
• Steroids form a very important aspect of treatment for COVID­19 because they lower death rates by reducing the cytokine storm phase which can develop in some patients.
• However, steroids when used excessively or prematurely, and without medical supervision can be harmful. Besides causing reduced immunity levels, steroids can also increase blood sugar levels which can cause additional harm if left unchecked.
• Dexamethasone, methylprednisolone or prednisone are among the steroids used in the treatment of COVID­19.

Treatment approach

• Mucormycosis is associated with very high morbidity and mortality. Its treatment requires a multi-disciplinary team approach that includes microbiology, pathology, radiology, infectious diseases, surgery, pediatrics, hematology, intensive care, dermatology, and pharmacology.
• A multi­disciplinary approach is simply not feasible on a large scale, especially in areas with limited medical access.
• Surgery for mucormycosis can be debilitating requiring major resections and only limited antifungal drugs available for mucormycosis.
• The gold standard drug is liposomal amphotericin B, which is highly expensive.
• Amphotericin B deoxycholate (conventional) is cheaper, but is associated with an unfavourable toxicity profile including kidney problems, abnormalities in electrolyte levels; reduced sodium, potassium, calcium and magnesium levels can lead to other toxicities.
• Some other expensive treatment options include posaconazole and isavuconazole.
• All these medicines often have to be administered for prolonged durations, making treatment protocols difficult to sustain on a large scale, given the cost implications and difficulty in drug administration due to its side­effects.
• When a patient is recovering from COVID­19 infection, it is certainly going to be a challenge to perform debilitating surgeries and administer these antifungal drugs for a prolonged duration.

Monitoring is essential

• Steroid use at home for COVID­19 should be only under the supervision of a healthcare worker.
• The control of blood sugars during steroid intake is crucial to avoiding mucormycosis.
• When patients are medicating themselves at home, monitoring of capillary blood glucose is essential.
• If high blood sugars are encountered, a teleconsulting with a doctor is advisable.
• Going a step further, health authorities may consider arranging for blood glucose monitoring for patients at home on steroids, and also promoting awareness campaigns on the importance of controlled blood sugar levels.
• Patients on steroids for COVID­19 should report symptoms of mucormycosis at the earliest.
• Among other symptoms, they should look out for facial swelling on one side, protrusion of the eyeball, new onset visual disturbances, headache and vomiting, new onset swelling or ulcers with blackish discolouration, and prolonged fever.
• COVID­19 treatment experts and policy­makers may consider widespread training of health­care personnel including Accredited Social Health Activists (ASHAs) and nursing professionals to raise awareness on mucormycosis while educating people locally.

Conclusion

• The prolonged requirement for hospital admission linked to COVID­19 will also lead to a rise in other hospital acquired infections necessitating the use of multiple antibiotics.
• We are staring at the grim reality of managing large numbers of patients with other long­standing side­effects of steroids.
• Additionally, the concern is the alarming increase in multidrug resistant bacterial infections for which nation are grossly unprepared.

E-Courts: Supreme Court’s digitalisation vision will ease access to justice

Why in News

• The Covid-19 pandemic continues to necessitate relooking of traditional processes, and the preparation for increasing technology adaptation in service delivery.
• Citizen-centric services that have been disrupted or perhaps irreversibly altered have required a recalibration. Access to justice is a key citizen need that requires a futuristic approach to enhance efficiency, equity, and ease.

Digitalisation of Courts

• Technology will play a major part in ensuring the parameters of access to justice.
• Recently a draft vision document for Phase III by the Supreme Court of India’s e-Courts Committee (‘Vision’) has been released.
• This draft is a progressive and transformational roadmap for how technology and justice can be intertwined and optimised.
• The vision of intertwining technology and justice is a positive step in bringing to the forefront the need for technology and technology-augmented processes to enhance justice delivery for those who need it the most.
• It adopts a holistic approach, with checks and balances, principles and values, and, above all, a willingness to make technology a key driver to solve several of the issues before us today.
• It essentially provides a platform from which policy and implementation blueprints can emerge, involving 360-degree stakeholder participation.
• The nature of what ‘digital’ entails has been reimagined, i.e., the adoption of digital has been taken several notches above a mere replication of paper processes in the digital format. This allows innovation and downstream benefits of real-time big data to accrue to all who are involved with delivery of justice in India.
• It also helps optimally approach how the Vision can transform the delivery of justice to each and every individual touched by it.

Key aspects that enhance efficiency through technology

• Online Dispute Resolution (ODR): NITI Aayog reform.
• The NITI Aayog established a committee chaired by Retired Justice AK Sikri to formulate an action plan for ODR in India.
• Members of the committee include several secretaries of the government of India.
• The goal is to put in place a report and an action-plan that enables ODR in a sustainable framework now and adapts to become an option of first recourse for several categories of claims in a dynamic fashion.
• The report will be released shortly, and it has received the support of Justice Chandrachud as well as several other esteemed members of the judiciary, both current and former.
• The Vision looks to address include the simplifying of procedures to help eliminate or simplify repetitive and routine pre-digital era processes by adopting digital technology to improve efficiency.
• It also addressed the creation of a foundational digital infrastructure and capabilities to facilitate potentially infinite numbers of additional services/solutions. It looks towards putting in place a new institutional and governance framework including by the establishing of what will eventually become a National Judicial Technology Council in the longer term.
• Dispute mitigation, containment, and resolution:
• The Vision categorises dispute mitigation, containment, and resolution, and maps them to technology inputs.
• They together have been predicated on four key building blocks:
• A set of core values,
• A whole-of-system approach,
• A focus on adoption of technology by users, and
• A robust governance framework.
• Each of the above components will require technological integration with different institutions.
• The key goals and strategy prioritise the creation of a core digital infrastructure that can enable the development of services for dispute containment and resolution by the judiciary.
• Importance of guardrails and processes:
• The Vision lays emphasis on the importance of guardrails and processes.
• There is an extensive focus on principles, be they of integrity, accountability, transparency, procurement, or interoperability.
• These lay an extremely strong foundation for an effective governance framework.
• The ideas propagated in the Vision can be enhanced with stakeholder participation and ownership.
• Adoption benefits of the vision are manifold, and impact each stakeholder group.

Benefits of E-court

• Benefits for citizens include more optimal scheduling mechanisms, online digital filings, and different mediums of hearings, thereby increasing timely access to courts from anywhere.
• For lawyers, seamless filings, service of summons remotely, availability of identical digital case files as the court, better scheduling, digital hearings and e-filings are just some of the benefits.
• Judges could benefit from greater data, information and decision-making support that aids management of case-flow.
• A unified digital platform will allow courts to track the progress of cases, from the court of original jurisdiction through appellate courts, and greater access to information and research tools.
• For the judicial and legal system, benefits could include better data visibility on types and classes of cases that create most caseloads and how they proceed; this will enable more targeted intervention and resource allocation by the judiciary.

Conclusion

• Progressive and disruptive changes in justice delivery can alter the course of access to justice in an unprecedented way.
• The Vision has key components that can act as building blocks for ensuring ease of access to justice for the common man, augmented by efficiencies made possible by wide technology adoption.