Following India's Covid Crisis, a Black Fungus Epidemic Emerges.
Across the country, the deadly disease has sickened former coronavirus patients. Doctors believe that hospitals, in their desperation to keep Covid patients alive, made decisions that exposed them.
The ear, nose, and throat specialist moved swiftly from one bed to the next in the stifling, densely packed medical ward at Civil Hospital, shining a flashlight into one patient's mouth and examining another's X-rays.
Dr. Bela Prajapati is a specialist who oversees treatment for nearly 400 patients with mucormycosis, a rare and frequently fatal fungal infection that has swept across India on the back of the coronavirus pandemic. Unprepared for this spring's devastating Covid-19 second wave, many of India's hospitals took desperate measures to save lives — measures that may have paved the way for the spread of yet another lethal disease.
“The pandemic has accelerated the spread of an epidemic,” Dr. Prajapati explained.
In three weeks, the disease — dubbed "black fungus" because it is found on dead tissue — exploded to more than 30,000 cases from negligible levels. According to news reports, states have recorded more than 2,100 deaths. The federal health ministry in New Delhi, which is monitoring nationwide cases in order to allocate scarce and expensive antifungal medication, has not released a death toll.
The coronavirus pandemic drew stark distinctions between wealthy and impoverished nations, and the mucormycosis epidemic in India is the most recent manifestation. During the second wave, which struck India in April, the country's creaky, underfunded medical system was unable to provide beds, oxygen, and other basic necessities, resulting in an increase in infections and deaths.
The mucormycosis epidemic heightens the urgency of protecting India's 1.4 billion people. Only a small percentage of the population has been vaccinated against the coronavirus, leaving them vulnerable to a third wave and the associated consequences.
“As Covid cases decline, mucormycosis will decline and return to baseline levels,” said epidemiologist Dr. Dileep Mavalankar. “However, it may reappear in the third wave unless we can determine why it is occurring.”
Numerous doctors in India believe they understand why. The fungus that feeds on bone and tissue can infect the gastrointestinal tract, lungs, skin, and sinuses, where it frequently spreads to the eye socket and brain if left untreated. Treatment for the disease entails complex, frequently disfiguring surgery and an uncommon and expensive drug, all of which contribute to the disease's high mortality rate of more than 50%.
Mucormycosis is not contagious. It is caused by common spores that can accumulate in homes and hospitals. Doctors believe that India's overcrowded hospitals and severe lack of medical oxygen created an opening for the fungus.
Due to a lack of oxygen, doctors in many locations injected patients with steroids, a standard treatment for doctors combating Covid worldwide. They may help reduce pulmonary inflammation and make it easier for Covid patients to breathe.
Numerous doctors prescribed steroids in doses and durations far exceeding those recommended by the World Health Organization, according to Arunaloke Chakrabarti, a microbiologist and co-author of a study examining the causes of India's mucormycosis outbreak. These steroids may have weakened patients' immune systems and increased their susceptibility to fungal spores.
Additionally, the steroids may have dangerously increased blood sugar levels, leaving diabetic patients susceptible to mucormycosis. Additionally, it may increase the risk of blood clots, resulting in malnourished tissue that the "fungus attacks," Dr. Prajapati explained.
Before resorting to steroids, desperate doctors may not have had the opportunity to inquire about patients' diabetes or other conditions.
“Doctors hardly had time to manage patients,” Dr. Chakrabarti explained. “They were all examining ways to care for the respiratory system.”
According to the health ministry, approximately four out of five patients with mucormycosis have Covid-19. More than half of the population is diabetic.
Alok Kumar Chaudry, a 30-year-old engineer who is wearing surgical tape over his left eye and is connected to an I.V. drip at Civil Hospital, is one of the mucormycosis patients who contracted Covid initially.
In April, he was in New Delhi studying for India's civil service exam. He jumped onto a train to his older brother's rural Gujarat home after testing positive for the coronavirus and finding hospital beds, drugs, and oxygen in short supply. His oxygen levels plummeted to a potentially lethal 54 percent while he was there.
He recovered from Covid-19 after two weeks on oxygen support and steroids at a local hospital, but developed an acute headache on the left side of his brain. Doctors suspected that it was caused by steroids and that it would resolve on its own.
“Suddenly, my left eye's vision went blank,” Mr. Chaudry explained.
A magnetic resonance imaging (MRI) revealed mucormycosis. The doctors informed him that they would have to amputate his eye.
He sought a second opinion at Ahmedabad's Civil Hospital. Five specialists oversaw a procedure in which dead tissue in his sinus tract was scraped away. He received a 15-day course of amphotericin B, an antifungal medication, to eradicate any remaining infection.
Dr. Chakrabarti stated that even if Mr. Chaudry retained his eye, he risked losing it, as surgeons could not remove the thin layer of infection behind his eye without also removing the eye.
“I've lost vision in my left eye, which has impacted my studies,” Mr. Chaudry explained. “Without a doubt, I'm curious as to why mucor formed. If it is due to improper treatment, then someone is accountable. What can I do if it is God's wrath?”
Dr. Chakrabarti's co-authored study, which was published this month by the United States Centers for Disease Control and Prevention, concluded that excessive steroid use, the association with diabetes, and unsanitary conditions in some hospitals all played a role.
Even prior to the pandemic, India recorded approximately 50 cases of mucormycosis per year, compared to a single case every two years on average in the United States and Western Europe. Environmental factors, as well as the prevalence of diabetes, play a role — India has more than twice the number of diabetics as the United States.
Mucormycosis is typically found in India and affects people with diabetes who are either unaware of their condition or are not taking insulin properly. However, many patients in the current outbreak had no history of diabetes. The common denominator, clinicians and researchers say, was a Covid-19 infection treated with steroids.
In May, the Ahmedabad government declared mucormycosis an epidemic. Additional states have followed suit. Patients' survival is frequently contingent on their ability to undergo debridement surgery to remove the fungus and then begin a two-week course of amphotericin B.
Prime Minister Narendra Modi, a Gujarat native, described the fungal disease as a new "challenge" and emphasized the importance of "establishing systems to combat it."
India manufactures small quantities of amphotericin B, which is available for free at some public hospitals. However, due to limited supplies, India imports it from the United States, where it costs approximately $300 per vial. Each patient requires between 60 and 100 vials. Gilead Sciences, the manufacturer in the United States, has donated approximately 200,000 vials.
Physicians are prescribing less expensive medications that are equally effective but more toxic, posing a risk of kidney damage.
“That is a very difficult choice,” Dr. Atul Patel, an infectious diseases specialist at Ahmedabad's private Sterling Hospital who has treated dozens of mucormycosis patients during the outbreak, said.
Dr. Patel, another of the study's authors, stated that steroids, which are commonly prescribed in India for routine ailments such as diarrhea or fever, had been prescribed to Covid-19 patients who did not require them for mild infections.
That is the case for one of Dr. Patel's patients, Ambaben Heerabhai Patel, 60, the matriarch of a rural Gujarat farming family who pays approximately $700 per day for antifungal treatment and other services at Sterling.
It's a high price, but Ms. Patel had previously seen Dr. Patel — no relation — for diabetes-related health issues. She did not want to take any chances following back-to-back infections with Covid-19 and then mucormycosis.
Ms. Patel, who arrived at Sterling Hospital on May 17 with a severe headache and facial numbness, said in early June from her private room that she felt well for the first time in more than a month.
“He's like my god,” she said of Dr. Patel.