As September rolled in, Mr Kamlesh Gadage visited the hospital for the 10th time in eight months.

The 36-year-old vegetable seller from Pune suffers from liver cirrhosis and had registered for a liver transplant last December. "I am fifth on the waiting list, but due to Covid-19, my wait is extending forever. I have a lot of pain and visit the hospital every 15 to 20 days," he said.

The Covid-19 pandemic and the nationwide lockdown have stopped nearly all organ donations in India.

Social distancing rules imposed on March 25, widespread fear of coronavirus infections, and a virtual suspension of non-Covid-19 treatments in speciality hospitals have left thousands of patients in need of liver, kidney, lung and heart transplants uncertain about their future.

Dr R. Kanthimathi, who heads the transplant authority in Tamil Nadu, the state with one of the largest numbers of organ donations in India, said: "Organ donations have fallen because of the reduced traffic accidents under the lockdown."

Hearts and lungs are harvested from dead donors - accident victims who become brain dead. Livers and kidneys come usually from live donors, often relatives.

Dr Aabha Nagral, Mr Gadage's physician and a trustee at Mumbai's Children's Liver Foundation, said: "Doctors and intensivists have been overworked and stressed for months with Covid-19 patients. Organ donations may not be their highest priority. There's a shortage of ventilators and intensive care units too."

Amid the pandemic, the number of organ donations has fallen globally. India sees 0.65 organ donation per million population, compared with 49 per million in Spain and 36 per million in the United States last year, and 6.6 per million in Singapore in 2017.

Covid-19 has further skewed that ratio. Tamil Nadu, for instance, had 15 heart, 17 lung, 34 liver and 69 kidney transplants from January to March. The state did not see any dead donors during its lockdown, with donors returning only when restrictions were eased in July.

Physicians have had to weigh the benefits of life-saving surgery with the risk of exposing their already-fragile patients with heart or lung failure to the coronavirus.

"There is a high chance of transmission of infection from the donor, doctors, ward boys, ambulance drivers to the immune-compromised recipient, so there are medico-legal issues," said Dr Sanjeev Jadhav, director of heart and lung transplants at Mumbai's Apollo Hospital.

As at Sept 8 in Tamil Nadu, there were 47 people waiting for a heart transplant, 27 for lung transplant, 474 for liver transplant and 5,789 for kidney transplant. In Maharashtra, as at Aug 29, there were 74 on the heart waiting list, 16 for lung transplant, 1,100 for liver transplant and 5,500 for kidney transplant.

Dr Vasanthi Ramesh, director of the National Organ and Tissue Transplant Organisation (Notto), which is building a national registry of organs, said: "Fortunately, after a near-total stop to organ donations during the lockdown, numbers have been going up to single digits per month since July, as India began to unlock its economy in phases."

To minimise the risk of infection, some state governments have now devised standard operating procedures. Tamil Nadu tests the donor, the recipient and also the recipient's close family members, for Covid-19. In Maharashtra, patients and healthcare workers are tested and monitored for a month before and after the transplant surgery.

Meanwhile, a new group has entered the waiting list for lung and heart transplants: Covid-19 survivors. On Aug 29, doctors in Chennai performed a lung transplant on a 48-year-old Covid-19 survivor, and on Sept 11, a hospital in Chandigarh transplanted lungs into a 32-year-old patient.

With India seeing over 5.2 million Covid-19 cases, Notto's Dr Ramesh is worried that there "may be a greater need for lungs and hearts in the future due to fibrosis in coronavirus-affected lungs. In that case, we should raise awareness about more organ donation now".

But Dr Paul Ramesh, a cardiothoracic, heart and lung transplant surgeon at Chennai's Apollo Hospital, was sceptical about transplantation as a solution for Covid-19 survivors. "The success of a lung transplant is measured initially at 30 days after surgery, then after one year. This is an unknown data point in Covid-19 patients anywhere in the world."