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Background Between January 24, 2020 and February 15, 2020, an outbreak of COVID-19 occurred among 335 passengers on a flight from Singapore to Hangzhou in China. This study aimed to investigate the source of the outbreak and assess the risk of transmission of COVID-19 during the flight. Method Using a standardized questionnaire, we collected information on the travelers’ demographic characteristics and illness before, during, and after the flight. We also collected data on factors potentially associated with COVID-19 transmission during the flight. Results A total of 16 COVID-19 patients were diagnosed among all passengers; the overall attack rate was 4.8%. The attack rate among passengers who had departed from Wuhan was significantly higher than that among those who had departed from other places. One passenger without an epidemiological history of exposure before boarding developed COVID-19. During the flight, he was seated near four infected passengers from Wuhan for approximately an hour and did not wear his facemask correctly during the flight. Conclusions COVID-19 transmission may have occurred during the flight. However, the majority of the cases in the flight-associated outbreak could not be attributed to transmission on the flight but were associated with exposure to the virus in Wuhan or to infected members in a single tour group., Highlights • SARS-CoV-2 transmission, especially during flight, was of global concern. • An outbreak of COVID-19 among passengers on a flight was investigated. • There appears to have been limited transmission of COVID-19 to one person on board the flight based on the epidemiological findings.

www.thelancet.com/infection Vol 15 August 2015 879 Diseases with severe presentation are probably not captured by travel clinics. For example, most patients with travel-associated Legionnaires’ disease—a disorder with a substantial risk for European travellers—are directly admitted to hospitals. Travel-associated infections in migrants are complex for various reasons. Epidemiology can be affected by changing trends in the migrant’s country of origin, such as those with HIV originating from subSaharan countries. Destination of travel, exposure and risk behaviours while travelling, and health-seeking behaviour on return might differ between affluent tourists and migrants with low income visiting relatives. First, it is essential to determine the representativeness of migrants attending travel clinics compared with all migrants living in Europe. Second, specifi cities in terms of destination or diseases should be reported. Last, I would question the inclusion of patients whose only purpose of travel was to emigrate to Europe, since these migrants would have been out of reach of prevention strategies. The Comment by Eskild Petersen and Lin Hwei Chen published alongside the Article pointed out the lack of denominator data as the main limitation of the study. I would suggest to use available data on tourism patterns (eg, Eurostat or the UN World Tourism Organization) for further analyses.

Travelling abroad is increasingly popular among the 4.5 million Norwegians. In 2007, Norwegians made a total of 5.8 million holiday trips defined as stays away from all-year residences with a duration of at least four nights. In about half of these trips (3.4 million trips), the destination was outside Norway. The favourite destination in 2007 was Spain, which was chosen for more than 650,000 holiday trips, followed by Denmark, Sweden and Greece [1].