COVID-19, India, and the “Black Fungus”
“Life in Delhi at the moment feels like you’re having an out-of-body experience. It’s hard to imagine this is actually real and happening . . . The worst part: There’s almost nothing you can do to help anyone immediately.” - Shweta Bahri, Delhi, Co-Founder, Earth Warriors Global
“Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.” - Martin Luther King, Jr.
In the U.S., we are getting closer and closer to reaching herd immunity and thereby nearing the end of our battle against COVID-19. We Americans have been fortunate—we have had a sufficient supply of vaccines against SARS-CoV-2 to lick the pandemic. (To date, ten states have already reached the 70% vaccination goal.) But other countries have been far less fortunate. A case in point is India where another wave of COVID-19 is overwhelming everything from healthcare delivery to cremation services. This Germ Gems post provides a summary of how the COVID-19 pandemic got so terribly out of hand in India, and it also describes a second epidemic that has emerged in India, namely, mucormycosis, a deadly disease caused by the so-called “black fungus.”
First wave of COVID-19 in India. The first wave of COVID-19 in India was relatively mild. The first cases were reported in January 2020 in the state of Kerala where three Indian medical students who had returned from Wuhan, China (the epicenter of the COVID-19 pandemic) were diagnosed. Lockdowns were announced in Kerala on March 23 and in the rest of the country on 25 March. By mid-May 2020, five cities (Mumbai, Delhi, Chennai, Ahmedabad, and Thane) accounted for around half of all reported cases in India. On June 10, India's recoveries exceeded active cases for the first time. Infection rates started to drop in September, and a premature euphoria over what was falsely perceived to be “herd immunity” influenced the country’s decision in October 2020 to reopen cinemas, schools, malls, bars and restaurants. By January 2021 daily cases dropped below 15,000.
As the cases of COVID-19 declined, the Indian government, led by Prime Minister Narenda Modi, ignored warnings that the pandemic wasn’t over. Behavioral changes, such as mask wearing and social distancing dissipated. Hindu festivals turned into superspreading events. (One such event in January, the Kumbh Mela religious festival in the northern city of Haridwar, attracted nearly 5 million largely unmasked Hindu pilgrims to the banks of the holy Ganges River). The healthcare system moved on to tackle other medical emergencies that were neglected earlier. And facilities that had been dedicated to COVID-19 were converted back to their previous functions.
In March 2021, a few weeks before a new surge of cases (the “second wave”), Indian health minister and physician Harsh Vardhan asserted that India was in the “endgame” of the COVID-19 pandemic. This notion supported the government’s decisions to export oxygen and to donate about 193 million doses of SARS-CoV-2 vaccines to other countries.
Second wave of COVID-19 in India. In mid-April 2021, the second wave of COVID-19 hit India like one of its proverbial monsoons. In an article on April 23, 2021 (the same day that India broke the world record for the most coronavirus cases in a single day, with more than 330,000 new cases) in Natural Geographic titled “How India’s second wave became the worst COVID-19 surge in the world,” Bynilanjana Bhowmick identifies the root causes of India’s second wave. In the article, Bhowmick quotes K. Srinath Reddy, president of the Public Health Foundation of India, who said: “We completely let down our guard and assumed in January that the pandemic was over.”
The second wave of the pandemic quickly overwhelmed India. The country experienced shortages of everything from doctors and nurses to hospital and intensive care unit beds as well as medical supplies of every kind. Economic hardship drove large numbers of newly unemployed laborers from cities to return on “labor trains” to their rural communities carrying SARS-CoV-2 with them.
By this time, SARS-CoV-2 variants had also emerged and appear to have played an important role in the second wave of COVID-19 in India. The first such variant, B.1.617, was first reported in India late last year. Ever since, it has been making its way around the world. As of May 24, 2021 researchers had identified three subtypes, the original B.1.617, and B.1.617.2 and B.1.617.3. While studies are currently underway to determine exactly what role these mutants played in India’s second wave, it appears they share an ability to spread more readily, that is, they are more contagious.
At present, India is officially reporting 26.9 million cases of COVID-19 and 1.6 million deaths. The true number of COVID-19 cases and deaths in India is, however, unknown, and most experts consider India’s official count to be grossly underestimated. (The U.S. continues to lead the world in COVID-19 cases.) People in India are expressing overwhelming fear, anxiety, and anger over their government’s botched preparedness and responses to the pandemic.
Enter the “black fungus”. India was challenged enough by fighting the COVID-19 pandemic. Then in December 2020, 44 cases of a rare and potentially life-threatening fungal infection called mucormycosis (or the “black fungus”) were reported in Ahmedabad, in the state of Gujarat, India. Cases increased rapidly in Gujarat and four other states, reaching 11,717 by mid-May. Recently, a range of states across India has declared the outbreak of this rare black fungus an official epidemic.
Mucormycosis is caused by a number of usually harmless molds that are found throughout the environment, including soil, air, and moldy fruit and bread. When fungal spores are inhaled or deposited in cuts in the skin or ingested, the fungus can grow and invade blood vessels. The symptoms and complications of mucormycosis are related to the site of fungal invasion, for example, headache and facial swelling in the case of the sinuses and brain (referred to as rhinocerebral mucormycosis), cough and shortness of breath when the lungs are involved, gastrointestinal symptoms associated with invasive infection of the stomach and intestines, and inflammation and ulcers in the skin when this is the primary site of fungal infection.
Ordinarily, if the immune system is intact, the “black fungus” doesn’t stand a chance at causing invasive disease. Cells of the immune system, such as neutrophils, macrophages, and B and T lymphocytes, and their mediators coordinate an attack that stops the fungus in its tracks.
So what is it about the COVID-19 pandemic in India that provided such fertile ground for the “black fungus”? While it isn’t entirely clear, it appears that two factors, both associated with impaired immunity, are involved. First, India has a very high incidence of diabetes mellitus—a disease known to lead to immunosuppression. Second, corticosteroids, which are therapeutic in cases of severe COVID-19, have been used indiscriminately in India to treat or prevent infection. Corticosteroids are potent immunosuppressors, and they also worsen the control of diabetes. While there is suspicion that SARS-CoV-2 itself can cause immunosuppression, much as is clearly seen with HIV/AIDS, there is little evidence to support this idea.
Treatment of mucormycosis is particularly challenging. There is only one antifungal drug that is effective, amphotericin B. But in India the supply of this agent is dwindling or already has dried up. In some cases, surgical excision of infected or dead tissue is essential.
Prognosis for COVID-19 control in India. One thing that is certain to influence the course of the pandemic in India is the mobilization of mass vaccination programs throughout the country. In his May 26th New York Times guest essay “Covid’s Deadliest Phase May Be Here Soon,” Dr. Zeynep Tufekci wrote, “Morally and practically, this emergency demands immediate action: widespread vaccination of those most vulnerable where the threat is greatest.” The threat in the Indian subcontinent is great; it is clearly time to marshal global strategies to quell the pandemic there, especially by fortifying COVID-19 vaccination programs.
In recent weeks, the case numbers of COVID-19 in India have been trending down. It’s too early to tell about the case numbers of mucormycois, but it appears that as the pandemic of SARS-CoV-2 infections wanes so too will cases of the “black fungus” epidemic. It may well be that vaccinating against COVID-19 in India could be a win-win situation--ending both the pandemic and the “black fungus” epidemic.