The familiar old virus that kills thousands of South Africans

Fear stalks global markets after widespread shutdowns in China and its connections to the outside world after the outbreak of a novel coronavirus not seen previously in humans, that produces flu-like symptoms and has caused over 28,000 infections and over 550 deaths – but plain old flu is ignored.

While international concern over this new virus is justified as its likely behaviour is largely unknown, it is worth knowing that influenza or flu, which is well-understood, causes 128,000 infections and 11,000 deaths annually in South Africa.

A 2019 study of South African data from 2013 to 2015 estimated the annual cost of treating influenza at R4-billion. The study estimated annual absenteeism and years of life lost (YLL) associated with influenza at 13.2 million days and 305,000 years respectively.

“The economic burden was high from both a government and a societal perspective,” said Stefano Tempia of the National Institute for Communicable Diseases (NICD) and the United States Centre for Disease Control (CDC), the lead author of the study, the Health and economic burden of influenza-associated illness in South Africa, 2013-2015.

“In South Africa, a middle‐income country of 54.8 million people in 2015, over 10 million mild, 128,000 severe‐non‐fatal and 11,000 fatal influenza‐associated illness episodes are estimated to occur annually with a heavy burden among young and old individuals and persons with chronic medical conditions, including HIV and tuberculosis infection,” Tempia wrote.

Since the news of the coronavirus outbreak in Wuhan, China in December, 28,276 people (20,471 in China) have been infected and 564 died as of 6 February, according to the World Health Organisation (WHO). Infections have been reported in 24 other countries, with one death in China’s special administrative region of Hong Kong and one in the in the Philippines of a Wuhan man.

There is yet to be a case recorded on the African continent.

Deaths from the Wuhan coronavirus are mostly of people over 60 who have existing illnesses, a similar demographic for flu.

Coronavirus symptoms are typically of the lower respiratory tract rather than upper as is the case with flu, meaning the infection is more severe than flu, with more hospitalisations. But while the coronavirus and flu have similar symptoms, the former has a much higher mortality rate at about 2% to 3% of cases. The equivalent rate for flu is 0.1%.

Annual influenza epidemics result in an estimated three to five million cases of severe illness, and between 290,000 and 650,000 deaths globally, says a June 2019 publication by the NICD.

“The burden of influenza in sub-Saharan Africa (and specifically in South Africa) is substantial, with some studies suggesting elevated influenza-associated mortality rates compared to other regions,” according to a June 2019 publication of the NICD with Lucille Blumberg as lead author.

“During the influenza season (usually between May and September) in South African hospitals, approximately 14% of inpatients with lower respiratory tract infection and 25% of patients with influenza-like illness will test positive for influenza,” the NICD publication says.

“In South Africa, it is estimated that approximately 11,800 seasonal influenza-associated deaths occur annually. In addition, an estimated 47,000 episodes of influenza-associated severe acute respiratory illness occur annually, of which 22,481 result in hospitalisation.”

The considerable coverage of the flu-like coronavirus while millions of people die annually from flu has been highlighted by website Global Research which reported that there are five million cases of flu worldwide and 650,000 deaths annually, making seasonal flu a “serious concern”, yet the Wuhan coronavirus dominates the headlines.

Likewise, CNBC reported that the flu has already killed 10,000 people across the US as the world frets over coronavirus, saying the flu remains a higher threat to the US public health than the new coronavirus.

Compared to the dozen cases of coronavirus, CNBC reported, “at least 19 million people have come down with the flu in the United States with 180,000 ending up in the hospital, according to the Centers for Disease Control and Prevention. The flu season, which started in September and can run until May, is currently at its peak and poses a greater health threat to the US than the new coronavirus, physicians say.”

USAToday reported on January 29 that when we think about the relative danger of this new coronavirus and influenza, “there’s just no comparison,” said William Schaffner, a professor of preventive medicine and health policy at Vanderbilt University Medical Center. “Coronavirus will be a blip on the horizon in comparison. The risk is trivial.”

If Americans aren’t afraid of the flu, perhaps that’s because they are inured to yearly warnings, USAToday reported. “For them, the flu is old news. Yet viruses named after foreign places – such as Ebola, Zika and Wuhan – inspire terror.”

“Familiarity breeds indifference,” Schaffner said. “Because it’s new, it’s mysterious and comes from an exotic place, the coronavirus creates anxiety.”

Some doctors joke that the flu needs to be rebranded, USAToday said. “We should rename influenza; call it XZ-47 virus, or something scarier,” said Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia.

The Tempia study found that pregnant women in South Africa constitute an important risk group for influenza-associated mortality. Among an estimated 646 to 1,428 seasonal influenza-associated deaths in women of child-bearing age in South Africa in recent years, the majority occurred in HIV-infected individuals and the influenza-associated mortality was threefold higher in pregnant compared with non-pregnant women.

Approximately 5% of these deaths are in children younger than five, the Tempia study found. “Among individuals aged five years and above, an estimated 50% of influenza-associated deaths are in the elderly and approximately 30% are in HIV-infected individuals.”

It estimated the economic impact at a negative 0.08% of gross domestic product.

Tempia said that approximately one million doses of influenza vaccine are available in the private sector annually, and about the same number of doses in the public sector since 2010. Vaccination guidelines are revised annually, and influenza vaccination is recommended for groups at increased risk of influenza‐associated severe illness, with the highest priority given in recent years to pregnant women and HIV‐infected individuals.

“Nonetheless, the number of doses of influenza vaccine remains insufficient to cover the recommended risk groups, estimated to be over 20 million individuals,” he said.

“However, despite the substantial disease and economic burden of influenza‐associated illness in South Africa, given the competing health priorities in the country, it is unlikely that the South African government will introduce universal influenza immunisation in the near future,” Tempia said.

An alternative strategy to risk-group-based vaccination is to target the community transmitters of infection, such as school‐aged children, thereby potentially reducing overall community disease burden and associated cost.

Health Minister Zweli Mkhize, a medical doctor, has been proactive on the Wuhan coronavirus, holding two press conferences last week, one before the WHO declared it to be a PHEIC (Public Health Emergency of International Concern) and another immediately the day after.

But given the fallout which flu annually brings in illness, loss of productivity and death, Mkhize could do well to show similar leadership when the flu season arrives in May this year. MC