Unseen but Present: Asymptomatic COVID-19 Cases and Air Travel to Hong Kong

The global spread of infectious diseases was influenced by human movement dynamics, particularly for highly transmissible diseases like COVID-19. Asymptomatic COVID-19 cases lacked symptoms before diagnosis, posing a challenge for containment. Their contribution to air travel remains understudied. This retrospective cross-sectional study investigated the role of asymptomatic COVID-19 cases in air travel and their impact on the global spread of the virus. Through our analysis of 11,775 COVID-19 cases in Hong Kong (January 2020-April 2021), log-binomial regression models assessed the association between asymptomatic status and air travel behavior 14 days before diagnosis. The Wilcoxon rank-sum test compared median flight durations between asymptomatic and symptomatic cases. Results revealed two-thirds of cases with air travel history were asymptomatic, with asymptomatic airport or flight crew ten times more likely to travel than symptomatic counterparts (adjusted PRR=10, 95% CI: 4.00-25.00). For non-crew individuals, the adjusted PRR was 1.14 (95% CI: 1.12-1.16). Median flight duration for asymptomatic cases was 4.6 person-hours shorter than symptomatic ones (p<0.01). These findings highlight the significant contribution of asymptomatic cases to air travel and suggest under-detection during initial travel restrictions. Our study emphasizes proactive public health measures early in pandemics involving airborne infections, irrespective of symptom presentation.