Imported SARS-CoV-2 Variant P.1 in Traveler Returning from Brazil to Italy

We report an imported case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant P.1 detected in an asymptomatic traveler who arrived in Italy on an indirect flight from Brazil. This case shows the risk for introduction of SARS-CoV-2 variants from indirect flights and the need for continued SARS-CoV-2 surveillance.

with JSF (10). The patient showed no other skin eruptions besides the eschar at the site of the tick bite (Figure). It is highly possible that the eschar on this patient could have been caused by an inflammatory response induced by the local R. japonica infection. R. japonica did not induce systemic symptoms in this patient for 2 possible reasons. First, the incubation time for SFTS might be shorter than that of JSF. Second, the initiation of antimicrobial drugs in the early phase of disease might have ameliorated the clinical course of the diseases.
In conclusion, we describe a patient with a generalized SFTSV infection and a localized skin lesion caused by R. japonica at the site of a tick bite. This study suggests that SFTS patients with eschar at the site of a tick bite should be treated with appropriate antimicrobial drugs, such as doxycycline and minocycline.
The study was carried out partially with financial support from the Japan Agency for Medical Research and Development (AMED, 19fk0108081j and 20fk0108081j). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
T.F. and K.Y. contributed to clinical management and writing of the manuscript. M.S. contributed to writing of the manuscript. T.Y., T.K., and M.S. contributed to the virological diagnosis. All authors had full access to all data in the study and all take responsibility for the integrity of the data and the accuracy of the data analysis. https://virological.org/t/sars-cov-2-reinfection-bythe-new-variant-of-concern-voc-p-1-in-amazonasbrazil/596). Another lineage, P.2, was reported in Rio de Janeiro, Brazil, but has been associated with spike mutations only in E484K; >2 cases of reinfection have been documented several months after primary B.1.1.33 infections (P. Resende et al., unpub. data, https://virological.org/t/spike-e484kmutation-in-the-first-sars-cov-2-reinfection-case-confirmed-in-brazil-2020/584; C.K. Vasques Nonaka et al., unpub. data, https://doi.org/10.20944/pre-prints202101.0132.v1). Among the spike mutations, E484K is considered the main driver of immune evasion to mAbs and convalescent serum After visiting São Paulo, Brazil, during November 23, 2020-January 16, 2021, a family, including a 33-year-old man, his 38-year-old wife, and his 7-yearold daughter, flew back to their home in Italy. During their time in Brazil, the family did not travel outside of São Paulo, which is >2,000 miles from Amazonas. The family took an indirect return flight; they flew from São Paulo/Guarulhos International Airport in Brazil to Madrid, Spain, and from there flew to Milan Malpensa Airport in Italy. Molecular tests were performed on all 3 family members at the departure airport in Brazil, and all were SARS negative.

RESEARCH LETTERS
The family arrived in Milan on the afternoon of January 17 and took a train and a car to their home, 30 miles from Milan. Under current recommendations in Italy, all persons entering the country can decide to be screened for SARS-CoV-2. After consulting a general practitioner on January 21, the father went to the hospital for a screening nasopharyngeal swab sample. The sample was tested by using the Alinity platform (Abbott, https://www.abbott.com), which returned a positive result for SARS-CoV-2 RNA with a cycle threshold of 23. Reverse transcription PCR (RT-PCR) fragments corresponding to the receptor-binding domain (RBD) in the spike gene of SARS-CoV-2 were amplified from purified viral RNA by using a OneStep RT-PCR Kit (QIAGEN, https://www.qiagen.com). We used a reference sequence from GSAID (https:// www.gisaid.org; accession no. EPI_ISL_402124) and We report an imported case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant P.1 detected in an asymptomatic traveler who arrived in Italy on an indirect flight from Brazil. This case shows the risk for introduction of SARS-CoV-2 variants from indirect flights and the need for continued SARS-CoV-2 surveillance.
SARS-CoV-2 variant P.1 is characterized by K417N, but K417T also has been reported in several cases before our patient (1), suggesting ongoing evolution. On January 22, 2021, after we reported the sequencing results, the patient was admitted to the infectious and tropical diseases unit of ASST dei Sette Laghi-Ospedale di Circolo e Fondazione Macchi (Varese, Italy) for observation. The patient remained asymptomatic and was discharged on January 29. The patient's spouse also tested positive for SARS-CoV-2 RNA via a nasopharyngeal swab sample. Antibody tests conducted by using Liaison Analyzer (DiaSorin, https://www.diasorin.com) were negative for SARS-CoV-2 S1/S2 IgG in serum of both the man and his wife, suggesting a primary infection.
Direct flights from Brazil to Italy were canceled upon the unilateral decision of the government of Italy on January 16, 2021, but our findings confirm the risk for introducing SARS-CoV-2 variants from indirect