To the Editor.—When the pandemic started in 2020, an article titled “Geospatial Spread of Antimicrobial Resistance, Bacterial and Fungal Threats to Coronavirus Infectious Disease 2019 (COVID-19) Survival, and Point-of-Care Solutions” by Kost1  in Archives of Pathology & Laboratory Medicine warned of the threat of fungal epidemics. The threat became a reality in India, where an outbreak of black fungus infection or mucormycosis recently killed more than 2100 COVID-19 patients.2  Molds called mucormycetes in the order Mucorales triggered the outbreak that damages the eyes, muscles, nerves, lungs, and brains of patients, with a mortality rate of 50%. India has recorded 29.7 million cases of COVID-19 infections and 382 000 deaths as of June 17, 2021. Major hospitals are facing chronic shortages of intensive care unit beds and oxygen. In this gloomy health crunch, the black fungus has infected more than 31 000 COVID-19 patients.2  The fungal outbreak has further amplified pressure on the already burdened health care system. In Bangalore, hospitals can no longer accommodate patients. The Delhi state government has ordered hospitals to set up emergency mucormycosis centers. Maharashtra state has recorded 7057 cases and 609 deaths, which is the highest in the country, followed by Gujarat with 5418 cases and 323 deaths.2  Unhygienic behavior can cause a flare-up of fungal infections, such as people in Gujarat state who cover their bodies with cow dung to evade COVID-19 infections, which should prompt a ban on superstitious endeavors regarding contagions.3  The lead scientific advisor to the government of India has recently warned about the upcoming third wave of COVID-19, so the health community must be well prepared to also tackle the black fungus recurrence.4 

Mucormycosis is an emerging infectious disease in India and thus epidemiologic data are limited. A quick search of “mucormycosis India” in Web of Science from 1994 to 2021 resulted in only 79 hits with mere case studies and reviews. Long-term epidemiologic monitoring is therefore imperative. Hospitals are facing severe shortages of antifungal drugs and the treatment is expensive. A single antifungal intravenous shot costs about US $50, and a patient requires US $2800 for 8 weeks of therapy. But the poor cannot afford it, so subsidized treatment is required. What is worse is that India spends only 1.3% of its gross domestic product for health, which is one of the lowest percentages in the world. A 5-fold increase in health spending forthwith is essential, and only then can the crisis of COVID-19 allied black fungus be resourcefully tackled before it is too late.

Geospatial spread of antimicrobial resistance, bacterial and fungal threats to coronavirus infectious disease 2019 (COVID-19) survival, and point-of-care solutions
Arch Pathol Lab Med. 2021;
Black fungus killed over 2, 100 in last 3 weeks, cases grew 150% to 31,000
News 18 website.
People in India are smearing cow dung over their bodies to ward off COVID-19 as second wave crisis worsens
Business Insider
May 15, 2021.
As COVID-19 rages in India, scientist warns further waves “inevitable.” Reuters

The author has no relevant financial interest in the products or companies described in this article.