NEW DELHI (FINANCIAL TIMES) - A sharp rise in black fungus cases during India's catastrophic second Covid-19 wave has exposed the consequences of over-medication as stretched doctors flout prescription guidelines and panicked patients self-medicate.
The over-prescription of steroids, in particular, to treat Covid-19 patients has been blamed for an explosion of fatal black fungus infections and a shortage of the drug to treat it.
Doctors have reported a surge of patients suffering from black fungus or mucormycosis, an infection with a mortality rate of at least 50 per cent that starts in the nose and spreads quickly to the eyes and brain.
Experts have warned that administering too many steroids and other drugs could trigger secondary infections and antibiotic resistance in India.
"The number of cases I'm seeing is devastating. You usually see four to five cases in a lifetime, now we're seeing four to five cases a day," said Dr Atul Mittal, an ear, nose and throat surgeon at Fortis Memorial Research Institute, a hospital outside New Delhi.
"I feel they are all because of irrational use of steroids."
People with mucormycosis infections often require surgery to scrape out the dead tissue killed by the fungus. Many patients have recovered from coronavirus only to lose their eyes or upper jaw to save their lives.
Once the infection starts spreading, it can kill people within days, said Dr Mittal. "We can't let the disease grow, it will keep on invading like a termite."
Mucor mould is encountered everywhere in daily life: in soil, plants and decaying fruit. But mucormycosis cases are rare and only sometimes affect people with diabetes or with weakened immune systems, such as cancer patients.
However, doctors said that thousands of Covid-19 patients who took high doses of steroids for an extended period of time against medical guidelines are more susceptible to infection.
Steroids are prescribed to help ward off the "cytokine storm" - an excessive inflammatory response that hurts the body without stopping the infection - caused by the coronavirus.
But they also reduce immunity and raise sugar levels, creating fertile ground for the fungus to grow. India, home to the largest number of diabetics in the world after China, has thousands of patients at risk.
Across the country, hospitals are setting up ad hoc units to cope with increasing numbers of black fungus cases. And with many patients still undergoing steroid therapy for Covid-19, officials fear the numbers will only rise.
The health minister of Maharashtra, home to the country's commercial capital Mumbai, warned last week that there could be more than 2,000 cases in the state.
New drug shortages
But just as there were desperate pleas for oxygen and the antiviral drug remdesivir in India in recent weeks, now there are appeals from relatives of people suffering from mucormycosis to secure life-saving medicines, such as Liposomal amphotericin B.
Mr Harsh Gupta, a 28-year-old software engineer from Bhopal, Madhya Pradesh, said he had visited more than 50 pharmacies in the span of four days to find the injectable drug.
His diabetic father had just recovered from Covid-19 when he was diagnosed with mucormycosis and underwent surgery last Friday.
"There is a chance the infection may redevelop in the area again. In order to prevent that, this injection is very necessary," said Mr Gupta. "There is no chance surgery can happen twice."
Without the drug, his father is unlikely to survive. "It's not available anywhere," said
Mr Gupta. "We are helpless. We don't know what to do."
Gilead, which manufactures the drug, last week said it was "preparing several hundreds of thousands of additional stock of our anti-fungal medicine" with shipments starting soon.
Dr Lancelot Pinto, a pulmonologist at P. D. Hinduja Hospital in Mumbai, said the increase of mucormycosis cases reflected a wider trend of steroid misuse in India.
Laundry list of medications
The World Health Organisation (WHO) advises that coronavirus patients receive a daily dose of 6mg of dexamethasone, a corticosteroid, or its equivalent for seven to 10 days to reduce mortality in patients that are critically or severely ill.
"I've seen prescriptions of up to 500mg a day. It's not uncommon," said Dr Pinto, adding that often patients in India are prescribed steroids for as long as a month.
Taking steroids too early in the course of a Covid-19 infection can also affect the immune system and is suspected of leading to unnecessary hospitalisations of young adults who could otherwise fight off the disease, said Dr Pinto.
Under the intense pressure of the second wave, doctors have prescribed a laundry list of medications including steroids and antibiotics for people with mild symptoms.
Local governments in India have also sent out conflicting messages on which medications to take, sometimes going against global convention.
For example, several states are distributing the antiparasitic drug Ivermectin as a prophylactic treatment for Covid-19, despite warnings from the WHO against using it. Others have included antibiotics and steroids in home Covid-19 care packs.
Ms Leena Menghaney, a public health lawyer, said many people are self-medicating with antibiotics, raising the risk of antibiotic resistance.
"Every single family I know is hoarding or has used azithromycin," she said, referring to an antibiotic that Mr Donald Trump endorsed last year when he was president of the US. "We are burning a drug that is very important," she pointed out.