Transmission dynamics of Neisseria gonorrhoeae in Greenland: A 55-year retrospective observational genomic study

Greenland has high gonorrhoea rates, yet the antimicrobial resistance (AMR) and especially genomic epidemiology and dynamics of gonococcal lineages remain unexplored. We characterized circulating gonococcal lineages in Greenland over 55 years, their AMR determinants and importation of AMR lineages.

We analyzed 463 gonococcal isolates collected from five municipalities in Greenland across 1960-1990 and 2012-2015. Antimicrobial susceptibility was determined using Etest, and whole-genome sequencing performed using Illumina NextSeq 550. Comparative genomic analysis included isolates from Denmark and other European and global datasets.

Tetracycline resistance was the most prevalent, while high-level resistance to benzylpenicillin, ciprofloxacin, azithromycin and ceftriaxone remained rare or absent. Genomic analysis revealed two major clades, with lineage-specific AMR determinants. Most lineages were unique to Greenland or shared exclusively with Denmark, but globally-circulating AMR high-risk clonal complexes have also been introduced in Greenland, e.g., NG-STAR CC20, ST20 and NG-STAR CC158, ST158; with decreased susceptibility to ceftriaxone, and resistance to ciprofloxacin and tetracycline.

The importation of the first AMR high-risk lineage (NG-STAR CC158, ST158) into Greenland threatened historical high antimicrobial susceptibility. Re-established gonococcal AMR surveillance, with genomic surveillance, improved clinical management of gonorrhoea, targeted public health interventions, and enhanced tailored sexual health education are imperative in Greenland.