More than a quarter of coronavirus-hit countries outside mainland China reported their first Covid-19 case in people who had recently travelled to Italy, research suggests.

Of the 99 countries identified by researchers as being affected in the 11 weeks before the global pandemic was declared, almost two thirds of the first cases were linked to travel to Italy (27%), China (22%), or Iran (11%), the study said.

The findings, published in The Lancet Infectious Diseases journal, suggest travel from a small number of countries with substantial transmission of the virus may have caused additional outbreaks around the world, one of the research leaders said.

The study, by researchers from the Centres for Disease Control (CDC) and Prevention in the US, identified Covid-19 cases reported between December 31 last year through to March 10 – the day before the World Health Organisation declared the pandemic.

Our findings suggest that travel from just a few countries ... may have seeded additional outbreaks around the world

The CDC used official websites, press releases, press conference transcripts, and social media feeds of national ministries of health or other government agencies to gather their data.

By March 10, they said 99 countries and locations outside mainland China had reported cases of Covid-19, and 75 of those identified their first reported case in an individual with history of travel to a country which had at least one case.

Dr Fatimah Dawood, from the CDC, said: “Our findings suggest that travel from just a few countries with substantial Sars-CoV-2 transmission may have seeded additional outbreaks around the world before the characterisation of Covid-19 as a pandemic on March 11, 2020.”

Researchers also looked at cluster frequencies and sizes by transmission settings, and found that while there were clusters of household transmission among early cases, those in occupational or community settings tended to be larger.

Co-author Dr Philip Ricks, from the CDC, said they highlighted a need to look at preventing outbreaks in faith-based settings, as well as continued work to mitigate spread in healthcare settings.

He said: “Four large clusters in our analysis, and large outbreaks reported elsewhere, have been linked with transmission in faith-based settings, highlighting the need to partner with faith-based organisations when designing and implementing community mitigation efforts.

“Six healthcare-associated clusters were also identified, underscoring the need for strict infection prevention and control practices and monitoring healthcare workers for signs of illness.”

The study authors said their work is the first of its kind to use publicly available worldwide case data to describe travel exposure and case cluster characteristics among early cases of the virus in different countries.

But they said they could not put together a complete picture of the virus in its early days because almost all the cases in their study were reported in middle-income and high-income countries from Asia and Europe.

Dr Dawood said: “The epidemiology of Covid-19 in low-income countries and in Africa could differ, as reported in previous influenza pandemics, and accurate data from these settings will be needed to assess the full global effect of the Covid-19 pandemic.”