The government’s effort to purchase 10,000 vials of Liposomal Amphotericin B, the main drug used to treat mucormycosis, a rare fungal infection commonly known as ‘black fungus’, has faced a roadblock after an Indian company emerged as the lowest bidder amid an export ban on the drug by India.

Officials at the Department of Health Services said that three foreign companies—an Indian, a Chinese, and a Bangladeshi—have submitted bids to supply the medicine for the disease, which is life-threatening and painful for patients.

More than a month and a half since the bid was opened, the department has been unable to award the contract to the Indian bidder even though the tender was issued on June 15 to procure the medicine under the exceptional circumstances procedures as specified in Public Procurement Act and Regulations.

Officials didn’t reveal the names of the companies participating in the tender bid. Still, two officials involved in the procurement process told the Post that the Indian company had quoted the price at around Rs11,000 per vial. In contrast, the prices quoted by the Chinese and Bangladeshi companies exceed Rs22,000 per vial.

“The Chinese company has quoted the second-lowest price,” an official at the department said.

Officials said that despite participating in the bid, the Indian company could not assure the supply of the medicine citing the ban on the export of the medicine by the Indian government.

“The Indian company says that it will supply the medicine as soon as India lifts the ban. But how long should we wait for the Indian government to lift the ban?” asked the official.

In a notification dated June 1, the Directorate General of Foreign Trade under India's Commerce Ministry categorised Amphotericin B under the restricted category for export with immediate effect. The black fugus has so far killed over 4,300 people while over 45,000 people suffered from this rare disease in India, according to a report on CNN in late July.

Amid rising cases of mucormycosis along with a surge in Covid-19 infections, the government on June 15 had invited bids by giving just a seven-day deadline to the interested companies. The bids were supposed to be opened on June 22.

After the opening of the bids, it has been confirmed that there are three bidders to supply the vital medicine for mucormycosis but no decision has been taken as officials feared to award a contract to the second-lowest bidder whose quoted price is nearly double the lowest bidder’s.

Dr Bhim Sing Tinkari, director at the management division under the Department of Health Services, admitted that the prices quoted by the companies have created a dilemma for us.

“As per the law, we have to award the contract to the lowest bidder,” said Tinkari. “So we will ask the Indian company if it can supply the medicine within a few days. If it cannot supply the medicine as per our requirement, we may scrap the current bids and issue a fresh tender.”

Since the second-lowest bidder, a Chinese firm, has quoted around double the price of the lowest bidder, Tinkari said he was not in favour of awarding the contract to the Chinese company. “I will not take the risk of awarding the contract to the second lowest bidder because it has quoted almost double the price than the lowest bidder,” he said. “Instead, I will scrap the bid and ask hospitals to procure the drugs themselves.”

Since June-end, the country has faced a shortage of Liposomal Amphotericin B after 1,000 vials of the drug provided by the World Health Organisation to the government were used up by the end of June.

Doctors used Deoxycholate and Posaconazole to treat the patients of mucormycosis. But, doctors said that Deoxycholate has many side effects such as problems in the kidneys and can cause hypersensitive reactions while Posaconazole is the maintenance dose that is usually given to recovering patients.

Doctors say that it is a dangerous disease and mostly found among diabetic Covid-19 patients. It affects the brain, sinuses, and lungs and can be life-threatening to diabetic or severely immunocompromised individuals like cancer and HIV/AIDS patients. It causes blackening or discolouration over the nose, blurred or double vision, chest pain, breathing difficulties, and blood in the cough.

Indiscriminate use of steroids for some Covid-19 patients could be linked to mucormycosis or other fungal infections, doctors say.

Despite the seriousness of the case, neither the government currently has any significant stock of Liposomal Amphotericin B nor is it available in the domestic market ever since India banned its export.

Amid a shortage of the drug, the Department of Health Services on July 15 issued a tender for the supply of Liposomal Amphotericin B. The government is struggling to procure the medicine at a time when Covid-19 cases are on the rise in recent days, with hospitals reporting an increased flow of patients. Doctors and officials say that along with the rise in Covid-19 cases, there is the risk that new cases of black fungus could emerge.

The Tribhuvan University Teaching Hospital, which had not reported new patients of mucormycosis for around a month, received its new patient earlier this week. “We conducted a surgery on the new patient—a 41-year man from Chitwan—on Tuesday,” said Dr Rabindra Pradhananga, coordinator of the Mucormycosis Management Committee at the hospital.

Now the hospital is treating four patients of Mucormycosis. It has so far treated 19 such patients, a majority of whom were admitted to the hospital in May and June.

But, the good news is that the hospital got Liposomal Amphotericin B from the government to treat two patients. “We are treating two patients, including the new one, with the medicine after the government made the drug available to us,” said Dr Pradhananga.

According to him, a patient needs six vials of Liposomal Amphotericin B a day, and the hospital has received the drugs for four days, with a commitment to more supplies.

Krishna Prasad Paudel, spokesperson for the Ministry of Health and Population, said that the government recently received some Liposomal Amphotericin B doses, which were distributed to government-run hospitals.

However, there are concerns about whether the government would be able to purchase this vital drug which is also used to treat the patients of Kala-azar. Dr Pradhananga said that even though Mucormycosis cases have gone down over the last month, a fresh surge in Covid-19 cases is concerning.

“We cannot rule out a rise in Mucormycosis cases one again,” he said. On Thursday, the Health Ministry reported 3,007 new coronavirus cases in the last 24 hours, taking the nationwide infection tally to 708,079. The country’s death toll has now reached 9,994.

According to the ministry, around two dozen cases of Mucormycosis have been identified so far in the country after they started to appear in May.