A second crisis is killing the survivors of the worst wave of covid-19 in India

(CNN) – Srinivas S. lies on a gurney in an operating room at St John’s Hospital in Bengaluru as surgeons carefully remove pieces of blackened tissue and rotten bones from his face.

The 41-year-old driver is one of more than 45,000 citizens infected with black fungus, or mucormycosis, since the start of the country’s second wave of COVID-19 in late March.

Like Srinivas, the vast majority of the patients, about 85%, were COVID-19 patients, according to the Indian Ministry of Health. By July, more than 4,300 people had died from the fungal infection.

Srinivas’s sister, Shyamala V., sits by his bedside and considers what life would be like for his brother’s wife and their two young children, ages two and four, if he became one of them.

“I am very afraid for him; he has two small children. Who will take care of them?” She said.

Black fungus is the second covid-19 crisis in India. Before this year, the infection was rare in India, although it was about 80 times more common there than in developed countries.

It is caused by mucormycetes, a type of fungus that people are exposed to every day, but when their immune system has been hit by COVID-19, they become more vulnerable to infection. Unless treated quickly, black fungus can cause permanent facial damage, vision loss, and death; it has a mortality rate of more than 50%.

Cases have increased in India and a small number of cases have been detected elsewhere: in Nepal, Afghanistan, Egypt and Oman, according to their respective ministries of health.

The number of black fungus cases in India are much higher now than after the country’s first wave of coronavirus last September. That may be due to the rapid spread of the Delta or B.1.617.2 variant of the virus.

Diabetes causes elevated blood sugar levels, perfect conditions for a fungus that feeds on sugar. In India, at least 77 million people had diabetes in 2019, second only to China, which had 116 million (the United States had 31 million) according to the International Diabetes Federation, which partly explains why black fungus cases in India are comparatively high.

The World Health Organization says that the prevalence of diabetes is increasing faster in low- and middle-income countries than in high-income countries. Along with an increase in COVID-19 cases, doctors predict that the black fungus will become more common around the world.

Unbearable pain

Srinivas, who only uses one name, thought he had overcome the worst of the covid-19, but his left eye soon began to swell so much that he could barely open it. The pain was excruciating.

He had never heard of the black fungus, but was concerned when his eye and nose started bleeding in May. “There was a lot of blood coming out, so I thought, what’s going on?” Srinivas told CNN from his hospital bed before his third operation to remove the infected tissue.

Srinivas says he went to four hospitals before doctors diagnosed him with black fungus and referred him to a fifth hospital where he finally received treatment.

Before the pandemic, India had between 3,000 and 4,000 cases of mucormycosis each year, according to figures provided to the Indian Parliament by Health Minister Mansukh Mandaviya.

Back then, the disease was not notifiable, meaning that states were not required to report cases to the central government. That changed in May as the number of cases increased. By the end of June, more than 40,845 cases had been reported across the country.

Two weeks later, that number had increased by about 9% to 45,374. Of those patients, about half are still receiving treatment, the Health Ministry said Tuesday.

Medicines shortage

There is no quick fix for mucormycosis. Patients undergo surgery to remove the infected tissue through a procedure known as debridement. They are then treated with the liposomal amphotericin B antifungal drug to prevent the infection from coming back.

As the number of cases increased in May, several states reported shortages of the medicine and India’s Ministry of Chemicals and Fertilizers stepped in to regulate supplies. Five more companies were approved to produce the drug in India and new import orders were placed.

In early June, doctors at St John’s Hospital said they were still forced to ration doses due to irregular supplies. “It becomes a big challenge because am I underdosing 11 patients by giving them a [dosis] to each when am I supposed to give three to each patient? Do I select patients who receive this amphotericin B? It has been extremely difficult, “said Dr. Sanjiv. Lewin, chief of medical services at the hospital.

Later that month, Lewin said supplies of the drug improved slightly but remained unpredictable. At the time, Srinivas’ sister said that she had not received her dose of liposomal amphotericin B for three days.

“We have gone all over Bangalore looking for the injection, but even private hospitals have to order the drug from government hospitals. It is just not available anywhere,” Shyamala said.

The drug, which costs about $ 95 a dose, is not available outside of hospitals. Srinivas’s family has relied on the help of their employers and low-interest loans to pay for the medicine and private hospital fees.

Three doses a day are needed for at least 28 days, doctors say, meaning the cost of treatment could be as high as $ 8,000, something out of the reach of many.

Mandaviya, India’s health minister, noted that when reports of mucormycosis emerged in May, the country produced around 150,000 vials of amphotericin B. “The world helped us at that time … wherever in the world there was amphotericin, They sent it to us and we imported 1,300,000 vials of the drug, “Mandaviya said Tuesday.

“I admit that some people may not have obtained the drug, but the government did everything it could,” he added.

What Causes Black Fungus?

Several factors are behind the rise of black fungus in patients after the second wave of covid-19 in India, according to doctors, including the drugs used to treat them.

Senior health officials from India’s covid-19 task force and the Indian Institute of Medical Sciences said that excessive use of steroids to treat COVID-19 had suppressed patients’ immune systems and made them more susceptible to black fungus.

Under India’s covid-19 administration protocols, steroids can be prescribed in moderate and severe cases of covid-19, although the latest guidelines issued in May recommend “prudent use” to prevent and manage conditions such as mucormycosis.

Some doctors also suspect that a shortage of medical-grade oxygen may have played a role, arguing that prolonged low oxygen levels can make patients more vulnerable to infection.

Some doctors believe there may be a link between increased black fungal infection and the delta variant, a more transmissible strain of COVID-19 that was first detected in India in December.

Since then, the delta variant has spread to 96 countries and the World Health Organization hopes that it will soon become the most dominant strain in the world.

While several studies have confirmed that COVID-19 patients are more vulnerable to the black fungus, researchers have not determined whether the delta variant creates greater risk factors than other strains.

Spread all over the world

India’s second wave of covid-19 has passed, but there are fears of a third wave and what it could mean for black fungus outbreaks in India. The infection is not contagious between people, but clearly the environment is suitable for its spread.

So far, no other country has reported a sharp increase in cases, even as the delta variant spreads across the globe. For example, as of mid-June, the delta variant accounted for 99% of COVID-19 cases in the UK, but no cases of mucormycosis had been reported.

Srinivas is a covid-19 survivor, but it will be some time before he can return to work. She was unable to speak for weeks after surgery to remove traces of black fungus, initially due to pain and swelling, then later because a feeding tube had been inserted due to the loss of part of her jaw.

“I can see … I feel fine, I will try to get back to work as soon as possible. I have two young children. I have been in the hospital for a long time and I haven’t even seen them,” Srinivas commented in early July.

Srinivas was discharged last Saturday after two months in the hospital, although his left eye remains closed due to swelling and he must visit the hospital every week to monitor his progress.

“I don’t think I can go back to work for a year,” said her sister Shyamala, “but it will be difficult to make her stay home.”