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Infectious Diseases

Updated 02 June 2020

How the 2009 H1N1 pandemic can give us more insight into Covid-19 in SA, according to scientists

South Africa’s struggle with Covid-19 can’t be compared to other countries, as our winter season is still coming, and co-morbidities such as HIV and TB could be devastating factors.

  • While the Covid-19 virus is new, there are similarities to H1N1
  • SA is in a unique position and our Covid-19 deaths are not the same as other countries
  • Experts look at some of our factors that could impact Covid-19 in SA


Even though the novel coronavirus, also known as SARS-CoV-2, is a completely new pathogen, with the first South African case announced on 5 March 2020, there are a couple of key similarities to the H1N1 pandemic of 2009.

An editorial, published in The South African Medical Journal, looks at how the trajectory of Covid-19 could potentially follow that of H1N1.

How these pandemics landed in South Africa (and where)

Both Covid-19 and the H1N1 strain of influenza came to South Africa from other countries through travel, where it then spread to less affluent socioeconomic areas of the country. The editorial points out that, just like Covid-19, the highest number of cases of H1N1 influenza also occurred in Gauteng, Western Cape and KwaZulu Natal.

Both H1N1 and Covid-19 first occurred in more affluent areas, but then filtered through to lower socioeconomic areas, where the impact of a pandemic is often devastating due to several factors. These can include a lack of basic hygiene products, potable water and poor sanitation. People usually live in overcrowded situations, which makes physical distancing nearly impossible.

According to the authors, these socioeconomic factors threaten vulnerable communities and can have severe implications for the potential impact of Covid-19.

H1N1 death rates in South Africa compared to Covid-19

In South Africa, the H1N1 virus of 2009 resulted in 12 331 confirmed cases and 91 deaths from the period of 14 July to 12 October 2009. This was surprisingly low compared to other parts of the world, especially in the Northern Hemisphere.

According to the authors, the preliminary Covid-19 incidence and mortality rate in South Africa also still appears to be lower than other parts of the world, even though winter is almost upon us.

Our specific co-morbidities and Covid-19

Dr Glenda Gray, along with other authors, looked at various factors unique to South Africa, such as our high prevalence of HIV and tuberculosis and the possible effect that may have on our Covid-19 situation.

Even though the exact effect of HIV and TB on Covid-19 isn’t exactly clear from the existing data, Covid-19 could be impacted by the high prevalence of these two diseases. What could also have a significant impact, is the disruption of normal public health services and prevention programmes due to Covid-19 for those already suffering from HIV and TB.

Not only are HIV and TB patients in danger, but other health risks such as vaccination, cancer screenings and other non-communicable diseases are also affected. Other short-, medium- and long-term health implications should therefore not be sidelined during the Covid-19 pandemic.

Could winter make Covid-19 worse?

As seen with H1N1 in 2009, the rate of transmission seemed to decline significantly during the transition period from winter to spring.

Previous research has shown that respiratory disease such as influenza are more prevalent during winter for several reasons and the inhalation of cold air can have negative effects on the lungs for people with respiratory conditions, specifically those with asthma.

Other factors are environmental triggers such as cigarette smoke, urban pollution and the inhalation of pollutants and irritants in the work and home environments.

Not only are pollutants a factor in some work environments such as manufacturing, but poor air quality can also occur in the home because of open fires, especially in low-income houses in South Africa.  

As South Africa is now entering its influenza season, it’s important for strategies to look at the shared risks for both Covid-19 and seasonal influenza. Secondary infections caused by seasonal influenza could potentially increase one’s risk for severe Covid-19 or even death.

Understanding South Africa to help win the battle

Being aware of South Africa’s unique position and looking back at the H1N1 pandemic’s pattern in 2009 could help explain why the morbidity and mortality rate in South Africa may differ from in those of other parts of the world. It might also help to set up public health service interventions and resources.

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