• Vijaykrishna Dhanasekaran, Kimberly M Edwards, Ruopeng Xie, Haogao Gu, Dillon C Adam, Lydia D J Chang, Sammi S Y Cheuk, Shreya Gurung, Pavithra Krishnan, Daisy Y M Ng, Gigi Y Z Liu, Carrie K C Wan, Samuel S M Cheng, Dominic N C Tsang, Benjamin J Cowling, Malik Peiris, and PoonLeo L MLLMSchool of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China.HKU-Pasteur Research Pole, School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China.Centre for Immunology .
• School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China.
• J Travel Med. 2021 Dec 29; 28 (8).

BackgroundA large cluster of 59 cases were linked to a single flight with 146 passengers from New Delhi to Hong Kong in April 2021. This outbreak coincided with early reports of exponential pandemic growth in New Delhi, which reached a peak of > 400 000 newly confirmed cases on 7 May 2021.MethodsEpidemiological information including date of symptom onset, date of positive-sample detection and travel and contact history for individual cases from this flight were collected. Whole genome sequencing was performed, and sequences were classified based on the dynamic Pango nomenclature system. Maximum-likelihood phylogenetic analysis compared sequences from this flight alongside other cases imported from India to Hong Kong on 26 flights between June 2020 and April 2021, as well as sequences from India or associated with India-related travel from February to April 2021 and 1217 reference sequences.ResultsSequence analysis identified six lineages of SARS-CoV-2 belonging to two variants of concern (Alpha and Delta) and one variant of public health interest (Kappa) involved in this outbreak. Phylogenetic analysis confirmed at least three independent sub-lineages of Alpha with limited onward transmission, a superspreading event comprising 37 cases of Kappa and transmission of Delta to only one passenger. Additional analysis of another 26 flights from India to Hong Kong confirmed widespread circulation of all three variants in India since early March 2021.ConclusionsThe broad spectrum of disease severity and long incubation period of SARS-CoV-2 pose a challenge for surveillance and control. As illustrated by this particular outbreak, opportunistic infections of SARS-CoV-2 can occur irrespective of variant lineage, and requiring a nucleic acid test within 72 hours of departure may be insufficient to prevent importation or in-flight transmission.© The Author(s) 2021. Published by Oxford University Press on behalf of International Society of Travel Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

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