GRASP report: data to August 2024
Updated 13 November 2024
Applies to England and Wales
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This report includes Second-Generation Surveillance System (SGSS) data to August 2024.
Main findings
Between 2022 and 2023 Neisseria gonorrhoeae isolates collected through Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) showed:
- no cases of ceftriaxone resistance (minimum inhibitory concentration (MIC) >0.125 milligrams per litre (mg/L))
- an increase in reduced susceptibility (MIC >0.03 mg/L ) to ceftriaxone, the current first-line therapy, from 0.21% (3 out of 1,460) in 2022 to 0.91% (16 out of 1,762) in 2023
- the modal MIC for ceftriaxone remained at 0.015 mg/L overall and across sexual orientation groups after the modal MIC for isolates from heterosexual men and women increased to equal that from gay, bisexual and other men who have sex with men (GBMSM) in 2022
- cefixime resistance (MIC >0.125 mg/L) is at 5.6% in 2023
- ciprofloxacin resistance (MIC >0.06 mg/L) remained unchanged at 58.6%
- tetracycline resistance (MIC >0.5 mg/L) remains high from 84.1% to 80.1%
- penicillin resistance (MIC >1.0 mg/L) remained stable from 13.6% to 14.3%
- as in previous years, no spectinomycin resistance was detected
- azithromycin MICs in 2023 have not been presented due to a laboratory technical issue
Whole genome sequencing of GRASP isolates showed:
- over three-quarters of the 2023 isolates belonged to only 13 multi-locus sequence types that also dominated in 2022
- resistance determinants associated with reduced susceptibility to cephalosporins and resistance to ciprofloxacin were mainly detected in isolates belonging to the 13 dominant multi-locus sequence types
- reduced susceptibility or resistance to cefixime (MIC 0.06 to 0.5 mg/L) and reduced susceptibility to ceftriaxone (MIC 0.015 to 0.06 mg/L) were associated with the expression of mosaic penA alleles, notably penA-34 and penA-93
- amino acid alterations in GyrA and ParC mediated resistance to ciprofloxacin were highly concordant with phenotypic testing
- high levels of resistance to tetracycline (MIC >8 mg/L) and penicillin (MIC >1 mg/L) were associated with the acquisition of the plasmid-mediated genes encoding Tet(M) and TEM b-lactamase, penicillinase, respectively
- only 1.6% of isolates had A2059G or C2611T mutations in the 23S ribosomal ribonucleic acid (rRNA ) gene, associated with higher azithromycin MICs (2 to 256 mg/L)
No cases of ceftriaxone resistance were detected in GRASP. However, outside of the sentinel surveillance system, 23 cases of ceftriaxone resistance have been detected since the start of 2022, totalling 32 cases detected in England since the first case, detected in 2015. Six of these recent cases were also extensively drug-resistant (XDR), with high levels of resistance to the second line treatment (azithromycin) as well as other antimicrobials.
Prescribing data demonstrated excellent adherence to the UK guideline for managing infection with N. gonorrhoeae, with 97.9% of individuals receiving the recommended first-line of ceftriaxone 1g intramuscular (IM) monotherapy in 2023.
The effectiveness of first-line treatment for gonorrhoea continues to be threatened by antimicrobial resistance. While ceftriaxone-resistant cases continue to have travel links with the Asia-Pacific region, some cases appear to have acquired infection in the UK and, as not all partners could be contacted, undetected transmission within England is possible.
To note, a laboratory technical issue has been identified with susceptibility testing for cefixime and azithromycin affecting data as early as 2018. Please see technical notes for further details on cefixime and azithromycin.
Recommendations
All primary diagnostic laboratories should test gonococcal isolates for susceptibility to ceftriaxone, the current first-line therapy for gonorrhoea (1g IM monotherapy) recommended in the UK.
Suspected ceftriaxone-resistant isolates (MIC >0.125 mg/L, European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoint) should be referred to the UKHSA STI Reference Laboratory (STIRL) for confirmatory testing and follow-up.
Possible cases of ceftriaxone treatment failure should be reported to the UK Health Security Agency (UKHSA) via the HIV and STI Data Exchange.
Where IM treatment is unsuitable, the oral alternative cefixime should be used with caution as the resistance rates now exceed 5%. The same applies for second-line treatment azithromycin. Azithromycin MICs are currently under review; however, there is no evidence to suggest that azithromycin should be considered as first-line treatment as the resistance is almost certainly >5%. Therefore treatment with cefixime and azithromycin should only be considered if antimicrobial susceptibility results are available prior to treatment, and a follow-up test-of-cure arranged.
Primary diagnostic laboratories are encouraged to report test results and antimicrobial resistance (AMR) data to the UKHSA SGSS to facilitate real-time monitoring of trends in N. gonorrhoeae diagnoses and AMR in England.
Healthcare practitioners should ensure that all individuals diagnosed with gonorrhoea are treated and managed according to national guidelines and should be alert to changes in recommended first-line therapies.
Introduction
Gonorrhoea, caused by the bacterium Neisseria gonorrhoeae, is the second-most-commonly diagnosed STI in England. If untreated, gonorrhoea can lead to complications, such as chronic pelvic pain, pelvic inflammatory disease, ectopic pregnancy and infertility.
Gonorrhoea diagnoses in England have more than doubled in the last decade (31,177 in 2013 to 85,223 in 2023). The number of gonorrhoea diagnoses increased by 7.5% between 2022 and 2023 and was the largest annual number reported since records began in 1918. Diagnosis rates of gonorrhoea remain highest among specific population groups: GBMSM, young people and people of Black Caribbean ethnicity.
Ceftriaxone is an extended-spectrum cephalosporin (ESC) that is currently recommended in the UK as the first-line therapy for gonorrhoea (1g IM monotherapy). ESCs are among few remaining antimicrobials that can be effectively used as first-line monotherapy for gonorrhoea.
Ongoing monitoring of AMR, comprising the culture of isolates, test-of-cure and the maintenance of comprehensive and enhanced surveillance is vital for the detection of emerging trends and to ensure that first-line treatments for gonorrhoea remain effective. Ineffective treatment facilitates onward transmission and the development of sequelae.
This report presents trends in gonococcal susceptibility to therapeutically relevant antimicrobials and explores the recent epidemiology of N. gonorrhoeae AMR in England and Wales. The GRASP includes a suite of surveillance systems to detect and monitor AMR in N. gonorrhoeae and to record potential treatment failures; these include the GRASP sentinel surveillance system, analysis of real-time laboratory data, and reports of suspected treatment failures.
The GRASP sentinel surveillance system
GRASP sentinel surveillance data is obtained annually from a network of sexual health services (SHSs) across England and Wales and their associated laboratories. In 2023, 25 SHSs (23 in England, 2 in Wales) and 20 laboratories participated in the programme. The geographical distribution of the 25 participating SHSs is shown in Figure 1.
Participating laboratories are requested to collect consecutive N. gonorrhoeae isolates over a 2 to 3 month period (that is July to August in 2023). All collected N. gonorrhoeae isolates are sent to STIRL for antimicrobial susceptibility testing. Antimicrobial susceptibility results are linked securely to the pseudonymised GUMCAD STI Surveillance System data to obtain demographic and clinical details. GUMCAD is a disaggregated, patient-level data set of all STI tests and diagnoses at SHSs in England. Supplementary demographic, clinical and behavioural data is submitted by participating SHSs to enhance GUMCAD data.
Two sample tests of proportion and Chi-square tests for trend are used to define recent and longitudinal antimicrobial susceptibility trends, respectively. Isolates are sequenced on the Illumina platforms and analysed to define the population structure and understand the molecular basis behind resistance to antibimicrobials (Appendix 2).
Full details on the data sets and methodology used for the GRASP sentinel surveillance system are available in the GRASP protocol.
Figure 1. Map showing 25 sentinel sexual health services participating in GRASP 2023 across England and Wales and London (shown at larger scale)
Source: Data from GRASP sentinel surveillance system.
Real-time laboratory data
Data from the GRASP sentinel surveillance system is supplemented year-round by real-time laboratory data, reported through the Second-Generation Surveillance System (SGSS) and by STIRL (Appendix 1).
Second-Generation Surveillance System (SGSS)
SGSS is an application that stores and manages laboratory data and notifications, capturing routine surveillance data on infectious diseases and AMR. Positive test results and AMR data is submitted on a voluntary basis from 157 laboratories that receive specimens from a range of healthcare providers, including SHSs, general practitioners and hospitals across England, Wales and Northern Ireland. Within GRASP, SGSS data is used to monitor real-time trends in N. gonorrhoeae diagnoses and AMR in England.
STI reference laboratory
Laboratories are asked to refer N. gonorrhoeae isolates with suspected ceftriaxone resistance (MIC >0.125 mg/L, EUCAST breakpoint) to STIRL for antimicrobial susceptibility testing and confirmation. For cases of suspected treatment failure, residual nucleic acid amplification tests (NAATs) can be referred to STIRL for molecular detection of the mutations within the penA allele most often associated with resistance to ceftriaxone. STIRL primarily acts as a reference and specialistic diagnostic service for laboratories in England, but also receives samples from Wales and Northern Ireland.
Treatment failures
Information on suspected ceftriaxone treatment failures in England is reported to UKHSA via the HIV and STI Data Exchange.
Sentinel surveillance sample
Sampling frame
The 2023 GRASP collection took place between 1 July to 31 August 2023. Figure 2 shows that during this period, 6,111 gonorrhoea diagnoses were reported to GUMCAD by the 23 English SHSs participating in GRASP. Over the same period, 2,700 N. gonorrhoeae isolates were sent to STIRL for antimicrobial susceptibility testing from these SHSs (2,846 isolates including Welsh clinics). Isolates were included in analyses if they could be both:
- case-matched to a GRASP participating SHS within the GUMCAD STI Surveillance System (n = 1,956)
- successfully tested for susceptibility to 8 therapeutically relevant antimicrobials by STIRL (n = 1,762).
Figure 2. Sentinel surveillance sampling frame flowchart in GRASP 2023
Source: Data from GRASP sentinel surveillance system
Where more than one isolate was collected from an individual, a hierarchy for testing was applied as shown in Table 1. Of note, the 2021 GRASP collection was the first time that pharyngeal isolates were prioritised ahead of all other sites due to concerns that resistance is most likely to emerge at this site. In 2020 and prior years, pharyngeal isolates were included within ‘any other site’ and were thus only tested if no specimens from other sites (rectal, urethral or cervical) were available. Among the 1,762 tested and case-matched isolates in 2023, the anatomical site of specimen collection was most commonly urethral (38.0%), followed by rectal (30.3%) and pharyngeal (20.9%). In comparison, pharyngeal isolates constituted only 7.7% of those included in the 2020 GRASP sample.
Table 1. Anatomical site of specimen collection hierarchy and percentage of all isolates within respective GRASP collections, 2019 to 2023
| Site of specimen collection | 2019 N=1,701 |
2020 N=1,534 |
2021 N=1,459 |
2022 N=1,460 |
2023 N=1,762 |
|---|---|---|---|---|---|
| Pharyngeal (highest priority) | 134 (7.9%) |
118 (7.7%) |
294 (20.2%) |
301 (20.6%) |
369 (20.9%) |
| Rectal | 484 (28.5%) |
415 (27.1%) |
354 (24.3%) |
379 (26.0%) |
534 (30.3%) |
| Urethral | 834 (49.0%) |
721 (47.0%) |
633 (43.4%) |
594 (40.7%) |
669 (38.0%) |
| Cervical | 215 (12.6%) |
216 (14.1%) |
141 (9.7%) |
150 (10.3%) |
152 (8.6%) |
| Any other site (lowest priority) | 34 (2.0%) |
64 (4.2%) |
37 (2.5%) |
36 (2.5%) |
38 (2.2%) |
Source: Data from GRASP sentinel surveillance system.
Sentinel surveillance sample
Among 1,762 individuals with a N. gonorrhoeae isolate included in the sentinel surveillance sample, 77.0% were male, of whom 77.6% (1,052 out of 1,356) were GBMSM (Table 2a). Most individuals in the sentinel surveillance sample were white (62.9%) followed by individuals of Black ethnicity (8.8%), and 6.6% of individuals were of Asian ethnicity. The modal age group was 25 to 34 years (42.2%), with ages ranging from 15 to 73 years. Just over half (50.9%) were resident in London. Among all individuals, 9.4% were living with HIV, and 93.2% (150 out of 161) of these were GBMSM.
Nearly half (47.8%) had been ever diagnosed with gonorrhoea previously and 19.0% were diagnosed with chlamydia at the time of their gonorrhoea diagnosis (Table 2b). Most individuals reported having either 0 to 1 (37.6%) or 2 to 5 (46.4%) sexual partners in the 3 months prior to their gonorrhoea diagnosis. A small proportion (4.0%) of individuals reported having a sexual partner abroad (outside of the UK) in the same time interval (Table 2c). Over half (63.6%) of individuals were reported to have received a test of cure, a similar proportion compared with 65.6% of individuals in 2022.
When the demographics of individuals included in the GRASP sentinel sample were compared with the demographics of those with a gonorrhoea diagnosis made at SHSs in the GUMCAD surveillance system over the same period (July to August 2023), women were under-represented in GRASP (16.7% versus 22.2%; probability (p) value <0.001), while GBMSM (59.7% versus 49.9%; p<0.001) were over-represented. London residents were also over-represented in the sentinel system relative to all diagnoses nationally (50.9% versus 42.7%; p<0.001).
Table 2a. Site of infection and symptom status of individuals in GRASP, by gender and sexual orientation, 2023 [note 1]
| Characteristics | GBMSM | Heterosexual men | Women | Not reported [note 2] | Total |
|---|---|---|---|---|---|
| Metric |
n (% of N) [note 3] |
n (% of N) [note 3] |
n (% of N) [note 3] |
n (% of N) [note 3] |
n (% of N) [note 3] |
| Number of individuals | 1052 | 304 | 294 | 112 | 1,762 |
| Site of infection: genital [note 4] | 383 (36.4%) |
279 (91.8%) |
238 (81.0%) |
59 (52.7%) |
959 (54.4%) |
| Site of infection: rectal [note 4] | 720 (68.4%) |
19 (6.3%) |
49 (16.7%) |
48 (42.9%) |
836 (47.4%) |
| Site of infection: pharyngeal [note 4] | 549 (52.2%) |
40 (13.2%) |
122 (41.5%) |
52 (46.4%) |
763 (43.3%) |
| Site of infection: other [note 4] | 0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
1 (0.9%) |
1 (0.1%) |
| Site of infection: multiple sites [note 4] |
483 (45.9%) |
33 (10.9%) |
92 (31.3%) |
43 (38.4%) |
651 (36.9%) |
| Symptoms: no | 646 (61.4%) |
50 (16.5%) |
167 (57.0%) |
73 (67.6%) |
936 (53.3%) |
| Symptoms: yes | 406 (38.6%) |
253 (83.5%) |
126 (43.0%) |
35 (32.4%) |
820 (46.7%) |
| Symptom: not reported [note 2] | 0 | 1 | 1 | 4 | 6 |
Source: Data from GRASP sentinel surveillance system
Note 1: Reporting errors cannot be excluded due to manual completion of GRASP data forms. Gender and sexual orientation are self-reported. Where gender and sexual orientation are ‘Not reported’, these include those who are gender diverse due to smaller numbers.
Note 2: ‘Not reported’ refers to instances where information was unknown or not stated.
Note 3: ‘N’ refers to all individuals in GRASP 2023 data set (by gender and sexual orientation) that have reported data for each characteristic and excludes all individuals where data was not reported.
Note 4: Numerator: individuals in GRASP 2023 data set infected at site specified (by gender and sexual orientation). Data reported are for individuals infected with N. gonorrhoeae at least at the specified site however, not exclusively this site.
Denominator: all individuals in GRASP 2023 data set (by gender and sexual orientation that have reported answers for each characteristic). Not all individuals are tested for gonorrhoea at each site.
Percentages do not add to 100% as individuals can be infected at more than one site. Also note that these numbers differ to isolates tested by specimen site as only one site is tested per individual.
Table 2b. Concurrent STI and previous gonorrhoea diagnosis status of individuals in GRASP, by gender and sexual orientation, 2023 [note 5]
| Characteristics | GBMSM | Heterosexual men | Women | Not reported [note 6] | Total |
|---|---|---|---|---|---|
| Metric |
n (% of N) [note 7] |
n (% of N) [note 7] |
n (% of N) [note 7] |
n (% of N) [note 7] |
n (% of N) [note 7] |
| Number of individuals | 1052 | 304 | 294 | 112 | 1,762 |
| Any concurrent STI: chlamydia [note 8] | 205 (19.5%) |
56 (18.4%) |
56 (19.0%) |
17 (15.2%) |
334 (19.0%) |
| Any concurrent STI: other STIs [note 8] | 34 (3.2%) |
3 (1.0%) |
5 (1.7%) |
4 (3.6%) |
46 (2.6%) |
| Previously diagnosed with gonorrhoea: no | 338 (36.3%) |
172 (73.8%) |
216 (88.9%) |
46 (63.0%) |
772 (52.2%) |
| Previously diagnosed with gonorrhoea: yes | 593 (63.7%) |
61 (26.2%) |
27 (11.1%) |
27 (37.0%) |
708 (47.8%) |
| Previously diagnosed with gonorrhoea: not reported [note 6] | 121 | 71 | 51 | 39 | 282 |
Source: Data from GRASP sentinel surveillance system.
Note 5: Reporting errors cannot be excluded due to manual completion of GRASP data forms. Gender and sexual orientation are self-reported. Where gender and sexual orientation are ‘Not reported’, these include those who are gender diverse due to smaller numbers.
Note 6: ‘Not reported’ refers to instances where information was unknown or not stated.
Note 7: ‘N’ refers to all individuals in GRASP 2023 data set (by gender and sexual orientation) that have reported data for each characteristic and excludes all individuals where data was not reported.
Note 8: Numerator: individuals in GRASP 2023 data set with any diagnosed concurrent STI (by gender and sexual orientation).
Denominator: all individuals in GRASP 2023 data set (by gender and sexual orientation that have reported answers for each characteristic). Not all individuals are tested for each STI.
Table 2c. Number of partners and reporting of sex abroad of individuals in GRASP, by gender and sexual orientation, 2023 [note 9]
| Characteristics | GBMSM | Heterosexual men | Women | Not reported [note 10] | Total |
|---|---|---|---|---|---|
| Metric |
n (% of N) [note 11] |
n (% of N) [note 11] |
n (% of N) [note 11] |
n (% of N) [note 11] |
n (% of N) [note 11] |
| Number of individuals | 1052 | 304 | 294 | 112 | 1,762 |
| Total sexual partners (past 3 months): 0 to 1 | 268 (28.4%) |
137 (47.9%) |
161 (59.9%) |
21 (33.3%) |
587 (37.6%) |
| Total sexual partners (past 3 months): 2 to 5 | 468 (49.5%) |
131 (45.8%) |
98 (36.4%) |
29 (46.0%) |
726 (46.4%) |
| Total sexual partners (past 3 months): 6 to 10 | 124 (13.1%) |
11 (3.8%) |
5 (1.9%) |
9 (14.3%) |
149 (9.5%) |
| Total sexual partners (past 3 months): 11 and over | 85 (9.0%) |
7 (2.4%) |
5 (1.9%) |
4 (6.3%) |
101 (6.5%) |
| Total sexual partners (past 3 months): not reported [note 10] | 107 | 18 | 25 | 49 | 199 |
| Sex abroad (past 3 months): no | 905 (95.8%) |
273 (95.5%) |
261 (97.0%) |
61 (96.8%) |
1500 (96.0%) |
| Sex abroad (past 3 months): yes | 40 (4.2%) |
13 (4.5%) |
8 (3.0%) |
2 (3.2%) |
63 (4.0%) |
| Sex abroad (past 3 months): not reported [note 10] | 107 | 18 | 25 | 49 | 199 |
Source: Data from GRASP sentinel surveillance system.
Note 9: Reporting errors cannot be excluded due to manual completion of GRASP data forms. Gender and sexual orientation are self-reported. Where gender and sexual orientation are ‘Not reported’, these include those who are gender diverse due to smaller numbers.
Note 10: ‘Not reported’ refers to instances where information was unknown or not stated.
Note 11: ‘N’ refers to all individuals in GRASP 2023 data set (by gender and sexual orientation) that have reported data for each characteristic and excludes all individuals where data was not reported.
Whole genome sequencing
Genotyping
To understand which N. gonorrhoeae strains are driving AMR, whole genome sequencing (WGS) was performed on all isolates. Those isolates with good quality sequencing data (1,714 out of 1,762; 97.3%) were included in further analysis. To identify sequence types (STs), the following methods were used:
- multilocus sequence typing (MLST) – detects variation between 7 housekeeping genes
- Neisseria gonorrhoeae multiantigen sequence typing (NG-MAST) – analyses differences in the porin B and transferrin-binding protein B genes
- Neisseria gonorrhoeae sequence typing for antimicrobial resistance (NG-STAR) – profiles alleles of 7 AMR associated loci
Sequence analysis identified 94 different MLST types, of which 13 types accounted for over three-quarters (1,304 out of 1,714, 76.1%) (Figure 3b), namely:
- ST1580 (n = 231)
- ST7822 (n = 196)
- ST9363 (n = 169)
- ST9362 (n = 161)
- ST10314 (n = 80)
- ST16676 (n = 73)
- ST7363 (n = 68)
- ST8134 (n = 66)
- ST11706 (n = 64)
- ST11422 (n = 56)
- ST1583 (n = 48)
- ST16885 (n = 48)
- ST1599 (n = 44)
Of note, these common STs also accounted for 72.3% of isolates sequenced in 2022, although in different proportions, suggesting little-changed population structure between these 2 years (Figure 3a). STs were further subdivided into 252 and 441 NG-STAR and NG-MAST types, respectively. The most common associations between MLST, NG-MAST and NG-STAR types are shown in Figure 3b.
Only ST16676 and ST16885 were not part of the top 13 STs in 2022 with 12 and 2 representatives, respectively. Nearly all ST16885 isolates in 2023 (95.8%, 46 out of 48) belonged to NG-STAR 4982 and NG-MAST 19002 and most ST16676 isolates (68.5%, 50 out of 73) belonged to NG-STAR 4668 and NG-MAST 20591, indicating that the increase of ST16676 and ST16885 is mainly due to clonal transmission.
Figure 3a. Distribution of major MLSTs in 2023 compared with 2022
Source: Data from GRASP sentinel surveillance system.
Figure 3b. Association between MLST, NG-STAR and NG-MAST among sequenced isolates in 2023 [note 12]
Source: Data from GRASP sentinel surveillance system.
Note 12: Segments are scaled according to the numbers of isolates belonging to each type. The inner circle represents the STs, the middle circle the NG-STAR types in relation to each ST and the outer circle the NG-MAST types in relation to each NG-STAR type.
Antimicrobial resistance
N. gonorrhoeae has developed resistance to all classes of antimicrobials recommended to treat gonorrhoea. Table 3 shows the AMR definitions used in GRASP. Antimicrobial susceptibility results were interpreted using current EUCAST breakpoints. Figure 4 and Table 4 show trends in the percentage of gonococcal isolates collected through the GRASP sentinel surveillance system resistant to selected antimicrobials since a change in the testing medium (2015 to 2023) then with a focus on more recent trends (2019 to 2023), respectively. Trends for tetracycline have not been presented as EUCAST has updated the resistance breakpoint for tetracycline against N. gonorrhoeae from 1.0 mg/L to 0.5 mg/L. Breakpoint plates at 0.5 mg/L were introduced in 2022; therefore, no data for this breakpoint are available prior to 2022. Full trend data from 2000 can be found in Appendix 5. Appendix 3 shows resistance to selected antimicrobials by individuals’ characteristics for GBMSM, heterosexual men, and women.
Table 3. Antimicrobial resistance definitions
| Antimicrobial | MIC breakpoint for resistance (mg/L) |
|---|---|
| Ceftriaxone | >0.125 |
| Azithromycin [note 13] | >0.5 |
| High-level azithromycin [note 14] | ≥256.0 |
| Cefixime | >0.125 |
| Ciprofloxacin | >0.06 |
| Penicillin | >1.0 and/or β-lactamase positive |
| Tetracycline [note 15] | >0.5 |
| Spectinomycin | >64.0 |
| Gentamicin [note 16] | Not applicable |
Source: Definitions from EUCAST.
Note 13: Until 2018, EUCAST had set a breakpoint of MIC 0.5 mg/L for N. gonorrhoeae azithromycin resistance. This has since been replaced with an ‘epidemiological cut-off’ (ECOFF) of 1.0 mg/L. For continuity with previous GRASP reports, the previous breakpoint of 0.5 mg/L is retained as a historic reference point.
Note 14: High-level azithromycin resistance is not defined by EUCAST, but the definition of ≥256 mg/L is internationally recognised.
Note 15: In 2023, EUCAST updated the tetracycline resistance breakpoint for N. gonorrhoeae from 1.0 mg/L to 0.5 mg/L.
Note 16: Gentamicin does not have a resistance breakpoint.
Figure 4. Percentage of N. gonorrhoeae isolates in GRASP that were resistant to selected antimicrobials, England and Wales, 2015 to 2023 [note 17]
Source: Data from GRASP sentinel surveillance system.
Note 17: The 5% threshold (≥5% of infections resistant to the first-line therapy) at which the World Health Organization (WHO) recommends that first-line monotherapy guidelines should be changed is indicated by the horizontal dashed red line. In 2021, pharyngeal isolates were prioritised ahead of all other sites for the first time, resulting in a substantial change in the distribution of specimen sites from 2021 onwards.
In 2023, EUCAST updated the resistance breakpoint for tetracycline against N. gonorrhoeae from 1.0 mg/L to 0.5 mg/L. Breakpoint plates at 0.5 mg/L were introduced in 2022; therefore, no data for this breakpoint is available prior to 2022 and trend data is not presented.
Please note cefixime MICs between 2019 to 2022 and azithromycin MICs between 2018 to 2022 are affected by a laboratory technical issue and should be interpreted alongside their respective technical notes. Azithromycin data for 2023 have not been presented due to these issues.
Table 4. Number and percentage of N. gonorrhoeae isolates in GRASP that were resistant to selected antimicrobials, England and Wales, 2019 to 2023
| Antimicrobial MIC resistance breakpoint (mg/L) | 2019 N=1,701 |
2020 N=1,534 |
2021 N=1,459 |
2022 N=1,460 |
2023 N=1,762 |
|---|---|---|---|---|---|
| Ceftriaxone (>0.125) [note 18] | 0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
| Azithromycin (>0.5) [note 19] [note 20] | 158 (9.3%) |
134 (8.7%) |
221 (15.2%) |
298 (20.4%) |
Not applicable |
| Azithromycin (>1.0) [note 19][note 20] | 52 (3.1%) |
64 (4.2%) |
74 (5.1%) |
99 (6.8%) |
Not applicable |
| Cefixime (>0.125) [note 19] | 14 (0.8%) |
9 (0.6%) |
4 (0.3%) |
11 (0.8%) |
99 (5.6%) |
| Ciprofloxacin (>0.06) | 727 (42.7%) |
679 (44.3%) |
683 (46.8%) |
855 (58.6%) |
1,033 (58.6%) |
| Penicillin (>1.0) or beta-lactamase positive | 305 (17.9%) |
147 (9.6%) |
207 (14.2%) |
198 (13.6%) |
251 (14.2%) |
| Tetracycline (>0.5) [note 21] | Not applicable | Not applicable | Not applicable | 1,228 (84.1%) |
1,424 (80.8%) |
| Spectinomycin (>64.0) | 0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
Source: Data from GRASP sentinel surveillance system.
Note 18: Although no ceftriaxone-resistant cases were detected in GRASP, cases have been confirmed through direct referrals to STIRL: 2 in 2019, 0 in 2020, 2 in 2021, 8 in 2022, 8 in 2023, 7 in 2024 (to end of August).
Note 19: Please note cefixime MICs between 2019 to 2022 and azithromycin MICs between 2018 to 2022 are affected by a laboratory technical issue and should be interpreted alongside their respective technical notes.
Note 20: Until 2018, EUCAST had a resistance breakpoint of 0.5 mg/L for azithromycin for N. gonorrhoeae. This has since been removed and replaced with an ‘epidemiological cut-off’ of 1.0 mg/L. For continuity with previous GRASP reports, the previous breakpoint of >0.5 mg/L is retained as a historic reference.
Note 21: In 2023, EUCAST updated the resistance breakpoint for tetracycline against N. gonorrhoeae from 1.0 mg/L to 0.5 mg/L. Breakpoint plates at 0.5 mg/L were introduced in 2022; therefore, no data for this breakpoint are available prior to 2022.
Ceftriaxone
Sentinel surveillance system sample
Among 1,762 isolates included in the sentinel surveillance sample in 2023, none were resistant to ceftriaxone (MIC >0.125 mg/L) (Table 4). The proportion of isolates with reduced susceptibility (defined here as an MIC >0.03 mg/L) to ceftriaxone increased to 0.91% (16 out of 1,762) in 2023 from 0.21% (3 out of 1,460) in 2022 (p = 0.01) (Figure 5).
Figure 5. Percentage of N. gonorrhoeae isolates in GRASP with reduced susceptibility to ceftriaxone (MIC >0.03 mg/L), England and Wales, 2015 to 2023 [note 22]
Source: Data from GRASP sentinel surveillance system.
Note 22: Reduced susceptibility to ceftriaxone is defined here as MICs >0.03 mg/L. Changes to the UK national guidance for the management of infection with N. gonorrhoeae are indicated by vertical dashed black lines with bold text. In 2021, pharyngeal isolates were prioritised ahead of all other sites for the first time, resulting in a substantial change in the distribution of specimen sites from 2021 onwards.
Despite a slight increase in isolates with a MIC >0.03 mg/L, there also was a shift towards more susceptible MICs of ≤0.004 and 0.008 mg/L, compared with 2022. The modal MIC remained at 0.015 mg/L overall (Figure 6) and across all gender and sexual orientation groups (Figure 7). However, the proportion of isolates with an MIC of 0.03 mg/L in heterosexual men (12.2%) and women (11.2%) increased to a similar percentage of that seen in GBMSM (12.3%). This is an increase compared with 2022, where GBMSM had a significantly higher proportion of isolates at MIC of 0.03 mg/L than heterosexual men and women.
Figure 6. Distribution of ceftriaxone MICs (mg/L) for N. gonorrhoeae isolates in GRASP, England and Wales, 2015 to 2023 [note 23]
Source: Data from GRASP sentinel surveillance system.
Note 23: In 2021, pharyngeal isolates were prioritised ahead of all other sites for the first time, resulting in a substantial change in the distribution of specimen sites from 2021 onwards.
Figure 7. Distribution of ceftriaxone MICs (mg/L) for N. gonorrhoeae isolates in GRASP, by gender and sexual orientation, England and Wales, 2023
Source: Data from GRASP sentinel surveillance system.
Real-time laboratory data
Since 2015, UKHSA has extracted N. gonorrhoeae AMR data from SGSS on a weekly basis for real-time follow-up of ceftriaxone-resistant N. gonorrhoeae. When a case of ceftriaxone-resistant N. gonorrhoeae is reported, the reporting laboratory is contacted and asked to refer the isolate to the STIRL for confirmatory testing if the isolate has not been referred already.
From January to August 2024, 16,505 N. gonorrhoeae isolates were reported to SGSS by laboratories across England, a 24.7% decrease relative to the same period in 2023 (21,928 isolates). The percentage of N. gonorrhoeae isolates tested for susceptibility to ceftriaxone (or cefuroxime as a proxy, see Appendix 1) in laboratories across England, as reported via SGSS, remained high at 98.9% (Table 5).
The percentage of isolates that were reported as resistant to ceftriaxone in SGSS remained stable from 0.2% in 2023 to 0.2% in 2024 (p = 0.83) (Table 5). Only 15.0% (6 out of 40) of isolates reported as resistant to ceftriaxone were referred to STIRL for confirmation in 2024, compared with 15.6% during the same period in 2023. This is an area for improvement, as all isolates with suspected ceftriaxone resistance should be referred in line with recommendations from national management guidelines for gonorrhoea.
Of 34 (out of 40) isolates reported as resistant but not referred to STIRL, 16 isolates had been misclassified by the reporting laboratory (for example due to transcription errors) and 2 isolates were ceftriaxone-resistant quality control isolates. These did not warrant further public health action. The remaining 16 isolates had been discarded prior to follow-up; however, most had implausible ceftriaxone MICs greatly exceeding the expected range for resistance (MIC 0.25 to 1 mg/L). This likely indicates contamination, an interpretation error or a reporting error. Nonetheless, it is possible that some of these discarded isolates would have been confirmed as ceftriaxone-resistant.
Figure 8 presents the total number of ceftriaxone-resistant N. gonorrhoeae cases per year, including cases that were directly referred to STIRL as per national recommendations. In the first 8 months of 2024, there were 7 confirmed cases of ceftriaxone-resistant N. gonorrhoeae in England. For most cases, there was a link to infection being acquired in the Asia-Pacific region. For comparison, there were 8 confirmed cases of ceftriaxone-resistant N. gonorrhoeae detected in England in 2023, 8 cases detected in 2022 and 2 cases detected in 2021.
Table 5. Ceftriaxone susceptibility testing and referral of N. gonorrhoeae isolates: data from primary diagnostic laboratories reported via SGSS and the UKHSA STIRL, 2020 to 2024
| N. gonorrhoeae isolates reported to | 2020 | 2021 | 2022 | 2023 | 2024 [note 24] |
|---|---|---|---|---|---|
| N. gonorrhoeae isolates reported to SGSS | 18,310 | 16,230 | 27,395 | 31,317 | 16,522 |
| N. gonorrhoeae isolates reported in SGSS that were tested for ceftriaxone susceptibility (%) | 18,195 (99.4%) |
16,110 (99.3%) |
27,056 (98.8%) |
30,868 (98.6%) |
16,332 (98.9%) |
| N. gonorrhoeae isolates reported as ceftriaxone-resistant in SGSS (% of N. gonorrhoeae isolates tested) | 42 (0.2%) |
23 (0.1%) |
51 (0.2%) |
71 (0.2%) |
40 (0.2%) |
| N. gonorrhoeae isolates reported as ceftriaxone-resistant in SGSS and referred to STIRL (% of total reported as ceftriaxone-resistant in SGSS) | 7 (16.7%) |
6 (26.1%) |
15 (29.4%) |
15 (21.1%) |
6 (15.0%) |
| Referred N. gonorrhoeae isolates confirmed as resistant by STIRL (% of total referred N. gonorrhoeae isolates) | 0 (0.0%) |
1 (16.7%) |
2 (13.3%) |
1 (6.7%) |
4 (66.7%) |
Sources: Data from SGSS (Appendix 1) and direct referral to STIRL.
Note 24: Data is a partial year from January to August 2024, while data for all other years is from January to December.
Figure 8. Number of confirmed cases of infection with ceftriaxone-resistant N. gonorrhoeae in England, 2015 to August 2024 [note 25]
Sources: Data from SGSS (Appendix 1) and direct referral to STIRL.
Note 25: Data is inclusive of all ceftriaxone-resistant N. gonorrhoeae cases detected in England (meaning both cases detected upon direct referral to STIRL and active follow-up of cases reported through SGSS).
Note 26: Extensively drug-resistant (XDR) infections are resistant to both first and second line treatment options and to other antibiotics.
Note 27: Data is a partial year from January to August 2024, while data for all other years are from January to December.
Cefixime
Cefixime resistance (MIC >0.125 mg/L) is estimated to be 5.6% in 2023 (Figure 4; Table 4). This appears to be a large increase from previous years; however, please refer to the technical note below, on cefixime MICs. In 2023, the modal cefixime MIC remained at 0.03 mg/L (Figure 9) and across gender and sexual orientation groups (Figure 10).
The proportion of isolates resistant to cefixime (MIC >0.125 mg/L) among GBMSM (6.0%) and heterosexual men (5.6%) was not found to be significantly different from that of women (3.7%) (p = 0.13 and p = 0.27, respectively).
Technical note on cefixime MICs
A laboratory technical issue has been identified with phenotypic susceptibility testing for cefixime. Since 2019, cefixime MIC data was impacted by one doubling-dilution for a proportion of isolates. Even though this impact is within the normal acceptable limits of MIC testing technical variation, the effect was systematic. Consequently, in these years, MICs were under-estimated by one doubling-dilution, thereby under-estimating the proportion with MICs above the resistance breakpoint. Specifically, some of the isolates with reported cefixime MICs of 0.125 mg/L (below the breakpoint) are likely to have had MICs of 0.25 mg/L (above the breakpoint). This is also consistent with the high prevalence of mosaic penA in 2022 (see Genotyping section below).
Figure 9. Distribution of cefixime MICs (mg/L) for N. gonorrhoeae isolates in GRASP, England and Wales, 2019 to 2023 [note 28]
Source: Data from GRASP sentinel surveillance system.
Note 28: In 2021, pharyngeal isolates were prioritised ahead of all other sites for the first time, resulting in a substantial change in the distribution of specimen sites from 2021 onwards.
Please note cefixime MICs between 2019 to 2022 are affected by a laboratory technical issue and should be interpreted alongside the technical note on cefixime MICs.
Figure 10. Distribution of cefixime MICs (mg/L) for N. gonorrhoeae isolates in GRASP, by gender and sexual orientation, England and Wales, 2023
Source: Data from GRASP sentinel surveillance system.
Genotyping
The penA gene encodes penicillin-binding protein 2 and is a key lethal target of β-lactam antibiotics in N. gonorrhoeae. Alterations in penA constitute a significant contributory mechanism for ceftriaxone and cefixime resistance, either by specific mutations in the penA or by mosaic patterns that have arisen from horizontal deoxyribonucleic acid (DNA) transfer, mainly from commensal Neisseria species. Mosaic alleles of penA typically have mutations encoding approximately 60 amino acid alterations from the penA of wild-type strains and semi-mosaic alleles usually have 20 to 30 amino acid alterations.
In total, 97 (5.7%) and 250 (14.6%) sequenced isolates (n = 1,714) harboured semi-mosaic or mosaic penA alleles, respectively. These isolates were largely associated with elevated cefixime (that is, 96.7% MIC ≥ 0.06 mg/L) and ceftriaxone MICs (that is, 95.1% MIC ≥ 0.015 mg/L). Mosaic penA comprised predominantly (94.8%, 237 out of 250) variants of the penA-34 allele and, to a much lesser extent, penA-10 (n = 5 out of 250), penA-38 (n = 1 out of 250) and penA-166 (n = 7 out of 250) whereas semi-mosaic penA included penA-93 (95.9%, 93 out of 97), penA-91 (n = 3) and penA-81 (n = 1).
Mosaic and semi-mosaic penA were mainly detected in isolates belonging to major STs (90.8%, 315 out of 347), including ST1580 (n = 214), ST7363 (n = 33), ST8123 (n = 26), ST9362 (n = 28) and ST16676 (n = 14) (Figure 11a). Overall, there was a slight decrease of isolates carrying mosaic (14.6% in 2023 versus 18% in 2022) and semi-mosaic (5.7% in 2023 versus 6.2% in 2022) penA in 2023 compared with 2022 (Figure 11b). To note, the identified technical issue with the media had resulted in 2022 isolates carrying mosaic penA, notably penA-34 (Figure 11c), predominantly exhibiting cefixime MICs 0.06 and 0.125 mg/L (just under the breakpoint), whereas a proportion of these were likely to have had cefixime MICs of 0.25 mg/L (above the breakpoint), thus giving a lower cefixime resistance rate in 2022.
Figure 11a. Distribution of mosaic penA variants among STs in 2023 [note 29]
Source: Data from GRASP sentinel surveillance system.
Note 29: Each circle represents a unique ST. The size of the circle reflects the number of isolates from each ST. The solid line connecting the circles shows single-locus variants.
Figure 11b. Distribution of penA types by year, 2022 to 2023
Source: Data from GRASP sentinel surveillance system.
Figure 11c. Distribution of penA alleles by year, 2022 to 2023
Source: Data from GRASP sentinel surveillance system.
Azithromycin
MIC data for azithromycin have not been presented for 2023 due to ongoing investigations, please see the technical note on azithromycin MICs below. However, high-level azithromycin resistance data is presented as follows. The proportion of isolates with azithromycin MICs ≥256 mg/L, an internationally recognised measure of high-level resistance, increased from 0.3% (4 isolates) in 2022 to 0.9% (16 isolates) in 2023 (p = 0.03). Isolates with high-level resistance were widely distributed geographically and were detected at 7 GRASP clinics in 2023.
Technical note on azithromycin MICs
A laboratory technical issue has been identified for azithromycin, which may impact MIC data from as early as 2018. The issue may, in part, be due to the culture media used for susceptibility testing as well as to a drug-dilution issue. For this reason, the full 2023 azithromycin dataset has not been published, pending review of susceptibility results. However, genomic data can reliably predict higher level azithromycin resistance (based on the presence of mutations in genes encoding 23S rRNA) which has been presented separately in the report. Overall, resistance is almost certainly >5%, and azithromycin remains unsuitable as empirical first-line treatment.
It is widely accepted that azithromycin susceptibility testing is vulnerable to laboratory variability, particularly changes in agar pH and, therefore, incubation atmosphere. Consequently, determining precise azithromycin MICs for N. gonorrhoeae strains can be more challenging than for some other antimicrobials. This is also supported by the withdrawal of the EUCAST breakpoint (>0.5 mg/L) for azithromycin, as defining a precise cut-off whereby treatment is likely to be unsuccessful for this antimicrobial, is problematic. The breakpoint was replaced with an ECOFF (>1 mg/L) when azithromycin is used together with another agent. A clinical resistance breakpoint for azithromycin monotherapy has not yet been determined.
Genotyping
Overall, mutations that are likely to result in increased expression of the multiple transferable resistance (Mtr)CDE efflux were detected in a high proportion of sequenced isolates. Among the present isolates, 29.1% (n = 499 out of 1714) harboured mosaic MtrR and MtrD, of which the majority (78%, 389 out of 499) belonged to ST7822 (n = 137), ST1580 (n = 87), ST8134 (n = 61), ST11422 (n = 56) and ST16885 (n = 48). Based on published data, isolates with mosaic Mtr efflux are expected to exhibit low levels of resistance to azithromycin (MIC 1.0 to 4.0mg/L). Where genome sequences are available, intermediate and high levels of azithromycin resistance were associated with the C2611T (n = 13) and A2059G (n = 14) mutations in all copies of the 23S rRNA gene, respectively.
Gentamicin
Antimicrobial susceptibility testing in GRASP has included gentamicin since 2019. Gentamicin had an MIC of 8.0 mg/L for only 1.5% of all isolates in 2023 (Figure 12), a decrease compared with 2.9% in 2022. The modal MIC for gentamicin decreased from 4.0 mg/L to 2.0 mg/L in 2023. The modal MIC of 2.0 mg/L was consistent across gender and sexual orientation groups, and all had similar proportions of isolates with an MIC of 2.0 mg/L (Figure 12). However the shift in gentamicin MICs are likely an artefact of testing due to a change in antibiotic supplier as opposed to a true shift, as the major MLSTs largely remain unchanged relative to 2022 (Figure 3a).
Figure 12. Distribution of gentamicin MICs (mg/L) for N. gonorrhoeae isolates in GRASP, by gender and sexual orientation, England and Wales, 2023
Source: Data from GRASP sentinel surveillance system.
Tetracycline, penicillin, ciprofloxacin and spectinomycin
The resistance breakpoint for tetracycline was updated by EUCAST in 2023, from 1.0 mg/L to 0.5 mg/L. Subsequently, a breakpoint plate at 0.5 mg/L was introduced in GRASP testing in 2022. Since full MICs have not been determined since 2017, no data for this breakpoint are available prior to 2022. There was a decrease in tetracycline resistance from 84.1% in 2022 to 80.1% in 2023 (p = 0.02) (Table 4).
High-level plasmid-mediated tetracycline resistance (MIC >8 mg/L) remained stable (18.3% in 2022 to 16.8% in 2023; p = 0.27). All sequenced isolates exhibiting high-level resistance to tetracycline carried the tet(M) resistance gene.
The proportion of isolates resistant to penicillin remained stable (13.4% in 2022 to 14.2% in 2023; p = 0.51) (Table 4). In 2023, 92.4% (232 out of 251) of penicillin-resistant isolates were penicillinase-producing N. gonorrhoeae (PPNG), which is plasmid-mediated resistance, a 5.1% decrease from 2022 (97.5% to 92.4%; p = 0.02).
Ciprofloxacin resistance has remained stable at 58.6% in 2023, but follows successive increases in resistance since 2016 when, resistance was 33.7% (Figure 4, Table 4). Ciprofloxacin resistance varied by gender and sexual orientation; 66.4% of isolates were resistant among GBMSM, compared with 48.0% among heterosexual men and 38.4% among women (Appendix 4).
Genomic analysis showed that alterations in gyrA and parC were highly concordant with phenotypic ciprofloxacin resistance (MIC >0.06 mg/L). Predicted amino acid alterations in -GgyrA at Ser-91 and Asp-95, alone or in combination with alterations in ParC at Asp-86, Ser-87, Ser-88 and Glu-91, were detected in 58% of sequenced isolates (n = 993 out of 1,714) and in 99.7% of those with phenotypic ciprofloxacin resistance. The alterations were detected in 62 different STs, however, eight of the most common STs, notably ST7822 (n = 195), ST9362 (n = 160), ST1508 (n = 132), ST10314 (n = 80), ST7363 (n = 68), ST11706 (n = 64), ST16885 (n = 48) and ST1583 (n = 45), accounted for more than three-quarters of these isolates (79.8%, 792 out of 993) (Figure 13).
No isolates were resistant to spectinomycin in 2023, as was the case between 2000 and 2022.
Figure 13. Resistance to ciprofloxacin among STs in 2023 [note 30]
Source: Data from GRASP sentinel surveillance system.
Note 30: Each circle represents a unique ST. The size of the circle reflects the number of samples from each ST. The solid line connecting the circles shows single-locus variants.
Prescribing practices
Antimicrobial prescribing data was reported for 1,956 individuals diagnosed with gonorrhoea at SHSs participating in GRASP in 2023, irrespective of whether a N. gonorrhoeae isolate was available for antimicrobial susceptibility testing.
Of these, 97.9% (1,914 out of 1,956) received ceftriaxone (1g IM), in accordance with BASHH first-line treatment recommendations; this proportion was similar for GBMSM (97.8%), heterosexual men (97.5%) and women (96.8%). Ciprofloxacin 500mg orally is recommended when antimicrobial susceptibility is known prior to treatment; however, only 2 individuals were prescribed ciprofloxacin.
The remaining 40 individuals were prescribed second-line treatments. Of these 17 (42.5%) received gentamicin and azithromycin, 16 (40.0%) received azithromycin 2g monotherapy, 4 (10.0%) received cefixime and azithromycin, and 3 (7.5%) received cefixime monotherapy.
Discussion
No cases of ceftriaxone resistance were observed among N. gonorrhoeae isolates collected in the GRASP sentinel surveillance system in 2023. Instead, reduced susceptibility to ceftriaxone (MIC >0.03 mg/L) is monitored, as we are likely to see an increase at this threshold before MICs cross the breakpoint for resistance. This figure for 2023 remained low at 0.91%. However, this represents a small but progressive increase since 2021 following successive decreases since 2018.
The MIC distribution of ceftriaxone shifted towards higher MICs in 2022, but has since returned to a distribution similar to 2021 and the few years prior. In 2022, the modal ceftriaxone MICs for isolates from heterosexual men and women had increased to meet that of GBMSM for the first time since 2017, and has remained the same in 2023.
Cefixime is an ESC recommended in the UK as an alternative regimen for gonorrhoea (together with azithromycin) if IM treatment is contraindicated or refused. Although rarely prescribed among clinics within the GRASP surveillance system, cefixime may be more commonly prescribed in other settings and by private providers.
The cefixime modal MIC remains at 0.03 mg/L across sexual orientations. However, cefixime resistance was estimated at 5.6% in 2023, which has implications for clinical use as resistance has now exceeded the 5% WHO threshold. Most resistant strains did however have MICs of 0.25 mg/L, just one dilution above the breakpoint (0.125 mg/L). In light of the 2023 cefixime resistance data, it is recommended that cefixime antimicrobial susceptibility results should be obtained before prescribing the drug, along with a follow-up test-of-cure.
Tetracycline resistance remains high at 80.1%, with 16.8% of tetracycline resistance attributable to plasmid-mediated high-level resistance.
Resistance to ciprofloxacin, penicillin and tetracycline continue to be more common among isolates from GBMSM compared with those from heterosexual men and women.
The majority of sequenced isolates in 2023 belonged to the same dominant STs as in 2022, suggesting little variation in the population structure between these 2 years. Common STs were major contributors to antibiotic resistance and many of their representatives carried determinants conferring resistance to multiple classes of antibiotics.
The acquisition of mosaic penA alleles was highly linked to reduced susceptibility to cephalosporins. The majority of isolates expressing mosaic penA alleles (96.8%, 242 out of 250) also carried the gyrA alterations conferring resistance to ciprofloxacin. There was a high concordance between ciprofloxacin resistance and the detection of alterations in gyrA and parC. In addition, the acquisition of plasmids harbouring the blaTEM or tet(M) genes was reliably associated with high levels of resistance to penicillin and tetracycline, respectively.
Prescribing data collected through the sentinel surveillance system demonstrates excellent compliance with the UK guidelines, with nearly all individuals receiving the recommended first-line therapy of ceftriaxone 1g IM monotherapy. There was one confirmed ceftriaxone-resistant pharyngeal treatment failure in early 2024, the first detected since 2018. The infection was cleared with a single dose of ertapenem (1g IV) after unsuccessful treatment with ceftriaxone (1g IM) followed by azithromycin (2g orally). Health practitioners are encouraged to continue reporting all possible cases of ceftriaxone treatment failure to UKHSA via the HIV and STI Data Exchange.
Outside of the GRASP sentinel surveillance system, 32 cases of ceftriaxone-resistant N. gonorrhoeae have been confirmed in England since 2015. Case numbers have increased in recent years, with 23 cases reported since the start of 2022 (8 in 2022, 8 in 2023, 7 in 2024 to end of August) versus 9 cases between 2015 and 2021. This is accompanied by an increasing frequency of extensively drug-resistant (XDR) cases, with 6 (out of 7 total) XDR cases detected since 2022.
Most cases continue to have travel links with the Asia-Pacific region, which has been shown to have the highest prevalence of ceftriaxone-resistant N. gonorrhoeae globally. However, as not all partners could be contacted, in addition to some cases having no travel links, local transmission within the UK is possible. Phenotypic and phylogenetic characteristics of these cases (n = 31) are available online. With only 6 out of the 23 recent cases were reported in SGSS by the primary diagnostic laboratories. Increasing reporting of test results and antimicrobial resistance data to SGSS could strengthen real-time monitoring of antimicrobial resistance among N. gonorrhoeae diagnoses in England.
Conclusions
The current recommended regimen of 1g ceftriaxone largely continues to clear both genital and extragenital infection. Nevertheless and despite the current low levels of reduced susceptibility, the effectiveness of ceftriaxone as the first-line treatment for gonorrhoea, continues to be threatened by the development and importation of AMR.
Where IM treatment is unsuitable, the oral alternative cefixime should be used with caution as the resistance rates now exceed 5%. The same applies for second-line treatment azithromycin. Azithromycin MICs are currently under review; however, there is no evidence to suggest that azithromycin should be considered as first-line treatment as the resistance is almost certainly >5%.Therefore treatment with cefixime and azithromycin should only be considered if antimicrobial susceptibility results are available prior to treatment, and a follow-up test-of-cure arranged.
Most isolates remain resistant to tetracycline (80.1%), which is likely to limit the effectiveness of doxycycline pre-exposure prophylaxis (doxyPEP) for preventing gonococcal infection.
The number of ceftriaxone-resistant cases reported via the real-time laboratory data schemes has increased since 2022 with more than double the total number reported in the 7 years since the first case detected in 2015.
A high level of vigilance is required to facilitate the timely detection of emerging trends in resistance and thus ensure the continued effectiveness of first-line treatments. Culture and antimicrobial susceptibility testing of N. gonorrhoeae isolates, test-of-cure, notification and management of sexual partners, remain vital.
Continued strong adherence to treatment guidelines and referral of isolates to STIRL for confirmatory antimicrobial susceptibility testing, where isolates are locally identified to be ceftriaxone-resistant, are also essential.
Appendices
Appendix 1. Real-time laboratory data
Data on N. gonorrhoeae isolates tested for antimicrobial susceptibility from January 2020 to August 2024 was retrieved from SGSS. SGSS is a centralised repository of communicable disease test results for every specimen tested by laboratories in England, Northern Ireland and Wales, including those of N. gonorrhoeae. There are 2 sub-repositories within SGSS that hold data on antimicrobial susceptibility: communicable disease reporting (CDR) and antimicrobial resistance (AMR). Data for England was extracted from both repositories and duplicate records were removed (where the same record was found in both the CDR and AMR repository).
Episodes of infection were defined and enumerated after removing reports for multiple specimens and specimen sites within a 6 week period per patient. If more than one isolate was collected from a patient, where resistance or antimicrobial susceptibility testing profiles differed, the resistant code was preferentially kept. Isolates with an ocular specimen site were removed prior to restricting isolates to one episode per 6 week period.
In primary diagnostic laboratories, ceftriaxone and cefixime susceptibility is occasionally inferred by testing cefuroxime as a proxy cephalosporin. If an isolate is found to be susceptible to cefuroxime it may reliably be reported susceptible to ceftriaxone or cefixime. If, conversely, the isolate is resistant to cefuroxime, resistance to ceftriaxone or cefixime cannot be inferred and laboratories should use a gradient strip method to determine the ceftriaxone and/or cefixime MICs.
Therefore, for SGSS, where the ceftriaxone or cefixime susceptibility results were missing and cefuroxime susceptibility was reported, susceptibility to ceftriaxone or cefixime result was recorded. Where the ceftriaxone or cefixime susceptibility results were missing and resistance to cefuroxime was reported, the ceftriaxone or cefixime result was recorded as missing since there was no way to verify whether ceftriaxone resistance was present.
Isolates reported to SGSS as ceftriaxone-resistant by laboratories across England were linked to STIRL’s Laboratory Information Management System based on available patient information. This was used to calculate the percentage of isolates successfully referred to and confirmed as resistant (or not) by STIRL.
Appendix 2. Methods for WGS
Genomic DNA was extracted and prepared for sequencing using the Nextera DNA library preparation kits. Sequencing was performed using the standard 2 × 101 base pairs (bp) protocol on Illumina sequencing instruments. The generated reads were quality filtered and had Illumina adapters removed using Trimmomatic. Good-quality reads were screened with Kraken to detect contaminations, and de novo assembled with SPADES using default parameters.
MLST, NG-MAST and NG-STAR types of sequenced isolates were determined with an in-house pipeline that uses a Blast-based approach to interrogate the assembled genomes with publicly available reference sequences on Public databases for molecular typing and microbial genome diversity (PubMLST) and NG-STAR. PenA alleles were determined according to the NG-STAR database. Known antimicrobial resistance determinants were searched against assembled genomes using Blastn and confirmed with a mapping-based approach.
Appendix 3. Antimicrobial resistance by individuals’ characteristics
Table 6a. Antimicrobial resistance by individuals’ characteristics for GBMSM in GRASP 2023 [note 30][note 31]
| Characteristics | Total GBMSM | Cefixime | Ciprofloxacin | Penicillin | Tetracycline |
|---|---|---|---|---|---|
| Resistant isolates | 1052 | 63 | 699 | 175 | 904 |
| Aged 15 to 19 | 17 | 1 (5.9%) |
12 (70.6%) |
3 (17.6%) |
15 (88.2%) |
| Aged 20 to 24 | 143 | 9 (6.3%) |
101 (70.6%) |
21 (14.7%) |
126 (88.1%) |
| Aged 25 to 34 | 470 | 22 (4.7%) |
310 (66.0%) |
66 (14.0%) |
401 (85.3%) |
| Aged 35 to 44 | 272 | 18 (6.6%) |
176 (64.7%) |
58 (21.3%) |
240 (88.2%) |
| Aged 45 and over | 150 | 13 (8.7%) |
100 (66.7%) |
27 (18.0%) |
122 (81.3%) |
| Ethnic group: white | 732 | 49 (6.7%) |
484 (66.1%) |
124 (16.9%) |
629 (85.9%) |
| Ethnic group: Black Caribbean | 27 | 1 (3.7%) |
15 (55.6%) |
5 (18.5%) |
21 (77.8%) |
| Ethnic group: Black African | 23 | 1 (4.3%) |
16 (69.6%) |
4 (17.4%) |
22 (95.7%) |
| Ethnic group: Black other | 9 | 0 (0.0%) |
8 (88.9%) |
3 (33.3%) |
6 (66.7%) |
| Ethnic group: Asian (including Chinese) | 81 | 5 (6.2%) |
53 (65.4%) |
16 (19.8%) |
66 (81.5%) |
| Ethnic group: other | 42 | 1 (2.4%) |
26 (61.9%) |
3 (7.1%) |
37 (88.1%) |
| Ethnic group: mixed | 66 | 3 (4.5%) |
46 (69.7%) |
10 (15.2%) |
59 (89.4%) |
| Ethnic group: not reported [note 32] | 72 | 3 (4.2%) |
51 (70.8%) |
10 (13.9%) |
64 (88.9%) |
| Residence: outside London | 396 | 18 (4.5%) |
254 (64.1%) |
68 (17.2%) |
359 (90.7%) |
| Residence: London | 656 | 45 (6.9%) |
445 (67.8%) |
107 (16.3%) |
545 (83.1%) |
| HIV status: negative | 900 | 53 (5.9%) |
600 (66.7%) |
147 (16.3%) |
779 (86.6%) |
| HIV status: positive | 150 | 10 (6.7%) |
97 (64.7%) |
27 (18.0%) |
123 (82.0%) |
| HIV status: not reported [note 32] | 2 | 0 (0.0%) |
2 (100.0%) |
1 (50.0%) |
2 (100.0%) |
Source: Data from GRASP sentinel surveillance system.
Note 30: No isolates were resistant to ceftriaxone or spectinomycin in the 2023 sentinel surveillance collection. The denominator for all percentages is the total GBMSM for each characteristic category (row total) however, as individuals can have isolates resistant to more than one antimicrobial, each row will not equal 100%. No azithromycin data is available for 2023 (please see the technical note on azithromycin MICs).
Note 31: Reporting errors cannot be excluded due to manual completion of GRASP data forms. Gender and sexual orientation are self-reported. Where gender and sexual orientation are ‘Not reported’, these include those who are gender diverse due to smaller numbers.
Note 32: ‘Not reported’ refers to instances where information was unknown or not stated.
Table 6b. Antimicrobial resistance by symptom status and previous gonorrhoea diagnosis for GBMSM in GRASP 2023 [note 33][note 34]
| Characteristics | Total GBMSM | Cefixime | Ciprofloxacin | Penicillin | Tetracycline |
|---|---|---|---|---|---|
| Resistant isolates | 1052 | 63 | 699 | 175 | 904 |
| Symptoms: no discharge and/or dysuria | 646 | 45 (7.0%) |
444 (68.7%) |
108 (16.7%) |
548 (84.8%) |
| Symptoms: yes (discharge and/or dysuria) | 406 | 18 (4.4%) |
255 (62.8%) |
67 (16.5%) |
356 (87.7%) |
| Previously diagnosed with gonorrhoea: no | 338 | 18 (5.3%) |
234 (69.2%) |
54 (16.0%) |
286 (84.6%) |
| Previously diagnosed with gonorrhoea: yes | 593 | 39 (6.6%) |
388 (65.4%) |
96 (16.2%) |
513 (86.5%) |
| Previously diagnosed with gonorrhoea: not reported [note 35] | 121 | 6 (5.0%) |
77 (63.6%) |
25 (20.7%) |
105 (86.8%) |
Source: Data from GRASP sentinel surveillance system.
Note 33: No isolates were resistant to ceftriaxone or spectinomycin in the 2023 sentinel surveillance collection. The denominator for all percentages is the total GBMSM for each characteristic category (row total) however, as individuals can have isolates resistant to more than one antimicrobial, each row will not equal 100%. No azithromycin data is available for 2023 (please see the technical note on azithromycin MICs).
Note 34: Reporting errors cannot be excluded due to manual completion of GRASP data forms. Gender and sexual orientation are self-reported. Where gender and sexual orientation are ‘Not reported’, these include those who are gender diverse due to smaller numbers.
Note 35: ‘Not reported’ refers to instances where information was unknown or not stated.
Table 6c. Antimicrobial resistance by number of partners and reporting of sex abroad for GBMSM in GRASP 2023 [note 36][note 37]
| Characteristics | Total GBMSM | Cefixime | Ciprofloxacin | Penicillin | Tetracycline |
|---|---|---|---|---|---|
| Resistant isolates | 1052 | 63 | 699 | 175 | 904 |
| Total sexual partners (past 3 months): 0 to 1 | 268 | 21 (7.8%) |
170 (63.4%) |
43 (16.0%) |
230 (85.8%) |
| Total sexual partners (past 3 months): 2 to 5 | 468 | 28 (6.0%) |
326 (69.7%) |
83 (17.7%) |
403 (86.1%) |
| Total sexual partners (past 3 months): 6 to 10 | 124 | 8 (6.5%) |
81 (65.3%) |
17 (13.7%) |
106 (85.5%) |
| Total sexual partners (past 3 months): 11 and over | 85 | 4 (4.7%) |
54 (63.5%) |
12 (14.1%) |
74 (87.1%) |
| Total sexual partners (past 3 months): not reported [note 38] | 107 | 2 (1.9%) |
68 (63.6%) |
20 (18.7%) |
91 (85.0%) |
| Sex abroad (past 3 months): no | 905 | 56 (6.2%) |
602 (66.5%) |
150 (16.6%) |
782 (86.4%) |
| Sex abroad (past 3 months): yes | 40 | 5 (12.5%) |
29 (72.5%) |
5 (12.5%) |
31 (77.5%) |
| Sex abroad (past 3 months): not reported [note 38] | 107 | 2 (1.9%) |
68 (63.6%) |
20 (18.7%) |
91 (85.0%) |
Source: Data from GRASP sentinel surveillance system.
Note 36: No isolates were resistant to ceftriaxone or spectinomycin in the 2023 sentinel surveillance collection. The denominator for all percentages is the total GBMSM for each characteristic category (row total) however, as individuals can have isolates resistant to more than one antimicrobial, each row will not equal 100%. No azithromycin data is available for 2023 (please see the technical note on azithromycin MICs).
Note 37: Reporting errors cannot be excluded due to manual completion of GRASP data forms. Gender and sexual orientation are self-reported. Where gender and sexual orientation are ‘Not reported’, these include those who are gender diverse due to smaller numbers.
Note 38: ‘Not reported’ refers to instances where information was unknown or not stated.
Table 7a. Antimicrobial resistance by individuals’ characteristics for heterosexual men in GRASP 2023 [note 39][note 40]
| Characteristics | Total heterosexual men | Cefixime | Ciprofloxacin | Penicillin | Tetracycline |
|---|---|---|---|---|---|
| Resistant isolates | 304 | 17 | 146 | 35 | 225 |
| Aged 15 to 19 | 29 | 1 (3.4%) |
9 (31.0%) |
2 (6.9%) |
20 (69.0%) |
| Aged 20 to 24 | 87 | 4 (4.6%) |
34 (39.1%) |
4 (4.6%) |
64 (73.6%) |
| Aged 25 to 34 | 113 | 6 (5.3%) |
58 (51.3%) |
18 (15.9%) |
79 (69.9%) |
| Aged 35 to 44 | 47 | 5 (10.6%) |
30 (63.8%) |
8 (17.0%) |
38 (80.9%) |
| Aged 45 and over | 28 | 1 (3.6%) |
15 (53.6%) |
3 (10.7%) |
24 (85.7%) |
| Ethnic group: white | 143 | 6 (4.2%) |
56 (39.2%) |
8 (5.6%) |
97 (67.8%) |
| Ethnic group: Black Caribbean | 29 | 2 (6.9%) |
15 (51.7%) |
5 (17.2%) |
23 (79.3%) |
| Ethnic group: Black African | 22 | 1 (4.5%) |
18 (81.8%) |
9 (40.9%) |
19 (86.4%) |
| Ethnic group: Black other | 2 | 0 (0.0%) |
1 (50.0%) |
0 (0.0%) |
2 (100.0%) |
| Ethnic group: Asian (including Chinese) | 14 | 2 (14.3%) |
9 (64.3%) |
3 (21.4%) |
11 (78.6%) |
| Ethnic group: other | 16 | 1 (6.3%) |
8 (50.0%) |
1 (6.3%) |
12 (75.0%) |
| Ethnic group: mixed | 24 | 0 (0.0%) |
11 (45.8%) |
5 (20.8%) |
17 (70.8%) |
| Ethnic group: not reported [note 41] | 54 | 5 (9.3%) |
28 (51.9%) |
4 (7.4%) |
44 (81.5%) |
| Residence: outside London | 223 | 15 (6.7%) |
98 (43.9%) |
29 (13.0%) |
158 (70.9%) |
| Residence: London | 81 | 2 (2.5%) |
48 (59.3%) |
6 (7.4%) |
67 (82.7%) |
| HIV status: negative | 273 | 11 (4.0%) |
127 (46.5%) |
33 (12.1%) |
198 (72.5%) |
| HIV status: positive | 6 | 1 (16.7%) |
6 (100.0%) |
1 (16.7%) |
5 (83.3%) |
| HIV status: not reported [note 41] |
25 | 5 (20.0%) |
13 (52.0%) |
1 (4.0%) |
22 (88.0%) |
Source: Data from GRASP sentinel surveillance system.
Note 39: No isolates were resistant to ceftriaxone or spectinomycin in the 2023 sentinel surveillance collection. The denominator for all percentages is the total heterosexual men for each characteristic category (row total) however, as individuals can have isolates resistant to more than one antimicrobial, each row will not equal 100%. No azithromycin data is available for 2023 (please see the technical note on azithromycin MICs).
Note 40: Reporting errors cannot be excluded due to manual completion of GRASP data forms. Gender and sexual orientation are self-reported. Where gender and sexual orientation are ‘Not reported’, these include those who are gender diverse due to smaller numbers.
Note 41: ‘Not reported’ refers to instances where information was unknown or not stated.
Table 7b. Antimicrobial resistance by symptom status and previous gonorrhoea diagnosis for heterosexual men in GRASP 2023 [note 42][note 43]
| Characteristics | Total heterosexual men | Cefixime | Ciprofloxacin | Penicillin | Tetracycline |
|---|---|---|---|---|---|
| Resistant isolates | 304 | 17 | 146 | 35 | 225 |
| Symptoms: no discharge and/or dysuria | 50 | 2 (4.0%) |
20 (40.0%) |
6 (12.0%) |
36 (72.0%) |
| Symptoms: yes (discharge and/or dysuria) | 253 | 15 (5.9%) |
125 (49.4%) |
29 (11.5%) |
188 (74.3%) |
| Symptoms: not reported [note 44] |
1 | 0 (0.0%) |
1 (100.0%) |
0 (0.0%) |
1 (100.0%) |
| Previously diagnosed with gonorrhoea: no | 172 | 11 (6.4%) |
77 (44.8%) |
19 (11.0%) |
120 (69.8%) |
| Previously diagnosed with gonorrhoea: yes | 61 | 5 (8.2%) |
29 (47.5%) |
6 (9.8%) |
52 (85.2%) |
| Previously diagnosed with gonorrhoea: not reported [note 44] |
71 | 1 (1.4%) |
40 (56.3%) |
10 (14.1%) |
53 (74.6%) |
Source: Data from GRASP sentinel surveillance system.
Note 42: No isolates were resistant to ceftriaxone or spectinomycin in the 2023 sentinel surveillance collection.The denominator for all percentages is the total heterosexual men for each characteristic category (row total) however, as individuals can have isolates resistant to more than one antimicrobial, each row will not equal 100%. No azithromycin data is available for 2023 (please see the technical note on azithromycin MICs).
Note 43: Reporting errors cannot be excluded due to manual completion of GRASP data forms. Gender and sexual orientation are self-reported. Where gender and sexual orientation are ‘Not reported’, these include those who are gender diverse due to smaller numbers.
Note 44: ‘Not reported’ refers to instances where information was unknown or not stated.
Table 7c. Antimicrobial resistance by number of partners and reporting of sex abroad for heterosexual men in GRASP 2023 [note 45][note 46]
| Characteristics | Total heterosexual men | Cefixime | Ciprofloxacin | Penicillin | Tetracycline |
|---|---|---|---|---|---|
| Resistant isolates | 304 | 17 | 146 | 35 | 225 |
| Total sexual partners (past 3 months): 0 to 1 | 137 | 7 (5.1%) |
64 (46.7%) |
17 (12.4%) |
106 (77.4%) |
| Total sexual partners (past 3 months): 2 to 5 | 131 | 7 (5.3%) |
59 (45.0%) |
14 (10.7%) |
91 (69.5%) |
| Total sexual partners (past 3 months): 6 to 10 | 11 | 2 (18.2%) |
8 (72.7%) |
1 (9.1%) |
8 (72.7%) |
| Total sexual partners (past 3 months): 11 and over | 7 | 0 (0.0%) |
5 (71.4%) |
0 (0.0%) |
6 (85.7%) |
| Total sexual partners (past 3 months): not reported [note 47] |
18 | 1 (5.6%) |
10 (55.6%) |
3 (16.7%) |
14 (77.8%) |
| Sex abroad (past 3 months): no | 273 | 15 (5.5%) |
125 (45.8%) |
27 (9.9%) |
198 (72.5%) |
| Sex abroad (past 3 months): yes | 13 | 1 (7.7%) |
11 (84.6%) |
5 (38.5%) |
13 (100.0%) |
| Sex abroad (past 3 months): not reported [note 47] |
18 | 1 (5.6%) |
10 (55.6%) |
3 (16.7%) |
14 (77.8%) |
Source: Data from GRASP sentinel surveillance system.
Note 45: No isolates were resistant to ceftriaxone or spectinomycin in the 2023 sentinel surveillance collection. The denominator for all percentages is the total heterosexual men for each characteristic category (row total) however, as individuals can have isolates resistant to more than one antimicrobial, each row will not equal 100%. No azithromycin data is available for 2023 (please see the technical note on azithromycin MICs).
Note 46: Reporting errors cannot be excluded due to manual completion of GRASP data forms. Gender and sexual orientation are self-reported. Where gender and sexual orientation are ‘Not reported’, these include those who are gender diverse due to smaller numbers.
Note 47: ‘Not reported’ refers to instances where information was unknown or not stated.
Table 8a. Antimicrobial resistance by individuals’ characteristics for women in GRASP 2023 [note 48][note 49]
| Characteristics | Total women | Cefixime | Ciprofloxacin | Penicillin | Tetracycline |
|---|---|---|---|---|---|
| Resistant isolates | 294 | 11 | 113 | 27 | 196 |
| Aged 15 to 19 | 40 | 1 (2.5%) |
8 (20.0%) |
3 (7.5%) |
21 (52.5%) |
| Aged 20 to 24 | 112 | 1 (0.9%) |
36 (32.1%) |
10 (8.9%) |
74 (66.1%) |
| Aged 25 to 34 | 104 | 7 (6.7%) |
50 (48.1%) |
10 (9.6%) |
74 (71.2%) |
| Aged 35 to 44 | 31 | 1 (3.2%) |
15 (48.4%) |
4 (12.9%) |
21 (67.7%) |
| Aged 45 and over | 7 | 1 (14.3%) |
4 (57.1%) |
0 (0.0%) |
6 (85.7%) |
| Ethnic group: white | 178 | 5 (2.8%) |
62 (34.8%) |
11 (6.2%) |
118 (66.3%) |
| Ethnic group: Black Caribbean | 15 | 1 (6.7%) |
8 (53.3%) |
3 (20.0%) |
12 (80.0%) |
| Ethnic group: Black African | 13 | 0 (0.0%) |
4 (30.8%) |
2 (15.4%) |
9 (69.2%) |
| Ethnic group: Black other | 1 | 0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
| Ethnic group: Asian (including Chinese) | 14 | 3 (21.4%) |
9 (64.3%) |
5 (35.7%) |
8 (57.1%) |
| Ethnic group: other | 9 | 2 (22.2%) |
8 (88.9%) |
0 (0.0%) |
8 (88.9%) |
| Ethnic group: mixed | 21 | 0 (0.0%) |
10 (47.6%) |
2 (9.5%) |
13 (61.9%) |
| Ethnic group: not reported [note 50] | 43 | 0 (0.0%) |
12 (27.9%) |
4 (9.3%) |
28 (65.1%) |
| Residence: outside London | 217 | 6 (2.8%) |
71 (32.7%) |
19 (8.8%) |
136 (62.7%) |
| Residence: London | 77 | 5 (6.5%) |
42 (54.5%) |
8 (10.4%) |
60 (77.9%) |
| HIV status: negative | 276 | 8 (2.9%) |
106 (38.4%) |
26 (9.4%) |
180 (65.2%) |
| HIV status: positive | 1 | 0 (0.0%) |
1 (100.0%) |
0 (0.0%) |
1 (100.0%) |
| HIV status: not reported [note 50] | 17 | 3 (17.6%) |
6 (35.3%) |
1 (5.9%) |
15 (88.2%) |
Source: Data from GRASP sentinel surveillance system.
Note 48: No isolates were resistant to ceftriaxone or spectinomycin in the 2023 sentinel surveillance collection. The denominator for all percentages is the total women for each characteristic category (row total) however, as individuals can have isolates resistant to more than one antimicrobial, each row will not equal 100%. No azithromycin data is available for 2023 (please see the technical note on azithromycin MICs).
Note 49: Reporting errors cannot be excluded due to manual completion of GRASP data forms. Gender and sexual orientation are self-reported. Where gender and sexual orientation are ‘Not reported’, these include those who are gender diverse due to smaller numbers.
Note 50: ‘Not reported’ refers to instances where information was unknown or not stated.
Table 8b. Antimicrobial resistance by symptom status and previous gonorrhoea diagnosis for women in GRASP 2023 [note 51][note 52]
| Characteristics | Total women | Cefixime | Ciprofloxacin | Penicillin | Tetracycline |
|---|---|---|---|---|---|
| Resistant isolates | 294 | 11 | 113 | 27 | 196 |
| Symptoms: no discharge and/or dysuria | 167 | 5 (3.0%) |
60 (35.9%) |
18 (10.8%) |
110 (65.9%) |
| Symptoms: yes (discharge and/or dysuria) | 126 | 6 (4.8%) |
53 (42.1%) |
9 (7.1%) |
85 (67.5%) |
| Symptoms: not reported [note 53] | 1 | 0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
1 (100.0%) |
| Previously diagnosed with gonorrhoea: no | 216 | 5 (2.3%) |
72 (33.3%) |
18 (8.3%) |
143 (66.2%) |
| Previously diagnosed with gonorrhoea: yes | 27 | 1 (3.7%) |
14 (51.9%) |
2 (7.4%) |
20 (74.1%) |
| Previously diagnosed with gonorrhoea: not reported [note 53] | 51 | 5 (9.8%) |
27 (52.9%) |
7 (13.7%) |
33 (64.7%) |
Source: Data from GRASP sentinel surveillance system.
Note 51: No isolates were resistant to ceftriaxone or spectinomycin in the 2023 sentinel surveillance collection. The denominator for all percentages is the total women for each characteristic category (row total) however, as individuals can have isolates resistant to more than one antimicrobial, each row will not equal 100%. No azithromycin data is available for 2023 (please see the technical note on azithromycin MICs).
Note 52: Reporting errors cannot be excluded due to manual completion of GRASP data forms. Gender and sexual orientation are self-reported. Where gender and sexual orientation are ‘Not reported’, these include those who are gender diverse due to smaller numbers.
Note 53: ‘Not reported’ refers to instances where information was unknown or not stated.
Table 8c. Antimicrobial resistance by number of partners and reporting of sex abroad for women in GRASP 2023 [note 54][note 55]
| Characteristics | Total women | Cefixime | Ciprofloxacin | Penicillin | Tetracycline |
|---|---|---|---|---|---|
| Resistant isolates | 294 | 11 | 113 | 27 | 196 |
| Total sexual partners (past 3 months): 0 to 1 | 161 | 8 (5.0%) |
58 (36.0%) |
10 (6.2%) |
108 (67.1%) |
| Total sexual partners (past 3 months): 2 to 5 | 98 | 0 (0.0%) |
37 (37.8%) |
10 (10.2%) |
65 (66.3%) |
| Total sexual partners (past 3 months): 6 to 10 | 5 | 0 (0.0%) |
2 (40.0%) |
1 (20.0%) |
1 (20.0%) |
| Total sexual partners (past 3 months): 11 and over | 5 | 1 (20.0%) |
2 (40.0%) |
1 (20.0%) |
3 (60.0%) |
| Total sexual partners (past 3 months): not reported [note 56] | 25 | 2 (8.0%) |
14 (56.0%) |
5 (20.0%) |
19 (76.0%) |
| Sex abroad (past 3 months): no | 261 | 8 (3.1%) |
95 (36.4%) |
21 (8.0%) |
172 (65.9%) |
| Sex abroad (past 3 months): yes | 8 | 1 (12.5%) |
4 (50.0%) |
1 (12.5%) |
5 (62.5%) |
| Sex abroad (past 3 months): not reported [note 56] | 25 | 2 (8.0%) |
14 (56.0%) |
5 (20.0%) |
19 (76.0%) |
Source: Data from GRASP sentinel surveillance system.
Note 54: No isolates were resistant to ceftriaxone or spectinomycin in the 2023 sentinel surveillance collection. The denominator for all percentages is the total women for each characteristic category (row total) however, as individuals can have isolates resistant to more than one antimicrobial, each row will not equal 100%. No azithromycin data is available for 2023 (please see the technical note on azithromycin MICs).
Note 55: Reporting errors cannot be excluded due to manual completion of GRASP data forms. Gender and sexual orientation are self-reported. Where gender and sexual orientation are ‘Not reported’, these include those who are gender diverse due to smaller numbers.
Note 56: ‘Not reported’ refers to instances where information was unknown or not stated.
Appendix 4. Characteristics of individuals in the GRASP sentinel surveillance system
Table 9a. Characteristics of individuals in GRASP, England and Wales, 2019 to 2023 [note 57]
| Characteristics | 2019 | 2020 | 2021 | 2022 | 2023 |
|---|---|---|---|---|---|
| Metric |
n (% of N) [note 58] |
n (% of N) [note 58] |
n (% of N) [note 58] |
n (% of N) [note 58] |
n (% of N) [note 58] |
| Number of individuals | 1,701 | 1,534 | 1,459 | 1,460 | 1,762 |
| Sexual orientation: GBMSM | 400 (24.1%) |
396 (27.1%) |
278 (20.1%) |
295 (21.1%) |
304 (18.4%) |
| Sexual orientation: heterosexual men | 971 (58.6%) |
785 (53.8%) |
904 (65.2%) |
852 (61.0%) |
1052 (63.8%) |
| Sexual orientation: women | 287 (17.3%) |
278 (19.1%) |
204 (14.7%) |
250 (17.9%) |
294 (17.8%) |
| Sexual orientation: not reported [note 59] |
43 | 75 | 73 | 63 | 112 |
| Aged 15 to 19 | 156 (9.2%) |
112 (7.3%) |
81 (5.6%) |
86 (5.9%) |
90 (5.1%) |
| Aged 20 to 24 | 355 (20.9%) |
340 (22.2%) |
257 (17.6%) |
358 (24.5%) |
365 (20.7%) |
| Aged 25 to 34 | 674 (39.6%) |
624 (40.7%) |
607 (41.6%) |
599 (41.0%) |
744 (42.2%) |
| Aged 35 to 44 | 315 (18.5%) |
298 (19.4%) |
316 (21.7%) |
270 (18.5%) |
373 (21.2%) |
| Aged 45 and over | 200 (11.8%) |
159 (10.4%) |
198 (13.6%) |
147 (10.1%) |
190 (10.8%) |
| Age: not reported [note 59] | 1 | 1 | 0 | 0 | 0 |
| Ethnic group: white | 1128 (66.3%) |
859 (56.0%) |
830 (56.9%) |
825 (56.5%) |
1109 (62.9%) |
| Ethnic group: Black Caribbean | 101 (5.9%) |
115 (7.5%) |
94 (6.4%) |
61 (4.2%) |
78 (4.4%) |
| Ethnic group: Black African | 67 (3.9%) |
69 (4.5%) |
63 (4.3%) |
69 (4.7%) |
66 (3.7%) |
| Ethnic group: Black other | 22 (1.3%) |
34 (2.2%) |
22 (1.5%) |
17 (1.2%) |
12 (0.7%) |
| Ethnic group: Asian (including Chinese) | 87 (5.1%) |
80 (5.2%) |
83 (5.7%) |
76 (5.2%) |
116 (6.6%) |
| Ethnic group: other | 62 (3.6%) |
51 (3.3%) |
41 (2.8%) |
50 (3.4%) |
74 (4.2%) |
| Ethnic group: mixed | 126 (7.4%) |
107 (7.0%) |
97 (6.6%) |
99 (6.8%) |
115 (6.5%) |
| Ethnic group: not known | 108 (6.3%) |
219 (14.3%) |
229 (15.7%) |
263 (18.0%) |
192 (10.9%) |
| Residence: outside London | 853 (51.9%) |
778 (51.3%) |
663 (45.4%) |
763 (52.3%) |
866 (49.1%) |
| Residence: London | 789 (48.1%) |
739 (48.7%) |
796 (54.6%) |
697 (47.7%) |
896 (50.9%) |
| Residence: not reported [note 59] | 59 | 17 | 0 | 0 | 0 |
| HIV status: negative | 1449 (87.9%) |
1270 (87.1%) |
1203 (87.3%) |
1276 (92.3%) |
1552 (90.6%) |
| HIV status: positive | 199 (12.1%) |
188 (12.9%) |
175 (12.7%) |
107 (7.7%) |
161 (9.4%) |
| HIV status: not reported [note 59] | 53 | 76 | 81 | 77 | 49 |
Source: Data from GRASP sentinel surveillance system.
Note 57: Reporting errors cannot be excluded due to manual completion of GRASP data forms. Gender and sexual orientation are self-reported. Where gender and sexual orientation are ‘Not reported’, these include those who are gender diverse due to smaller numbers.
Note 58: ‘N’ refers to all individuals in the GRASP data set (from 2019 to 2023) that have reported data for each characteristic and excludes all individuals where data was not reported.
Note 59: ‘Not reported’ refers to instances where information was unknown or not stated.
Table 9b. Site of infection, symptom status and sample origin of isolates of individuals in GRASP, England and Wales, 2019 to 2023 [note 60]
| Characteristics | 2019 | 2020 | 2021 | 2022 | 2023 |
|---|---|---|---|---|---|
| Metric |
n (% of N) [note 61] |
n (% of N) [note 61] |
n (% of N) [note 61] |
n (% of N) [note 61] |
n (% of N) [note 61] |
| Number of individuals | 1,701 | 1,534 | 1,459 | 1,460 | 1,762 |
| Site of infection: genital [note 62] | 1118 (65.7%) |
1018 (66.4%) |
873 (59.8%) |
855 (58.6%) |
959 (54.4%) |
| Site of infection: rectal [note 62] | 702 (41.3%) |
605 (39.4%) |
593 (40.6%) |
655 (44.9%) |
836 (47.4%) |
| Site of infection: pharyngeal [note 62] | 531 (31.2%) |
485 (31.6%) |
565 (38.7%) |
588 (40.3%) |
763 (43.3%) |
| Site of infection: other [note 62] | 100 (5.9%) |
52 (3.4%) |
23 (1.6%) |
38 (2.6%) |
1 (0.1%) |
| Site of infection: multiple sites [note 62] |
638 (37.5%) |
515 (33.6%) |
491 (33.7%) |
547 (37.5%) |
651 (36.9%) |
| Symptoms: no | 629 (42.6%) |
390 (28.7%) |
617 (42.3%) |
680 (46.7%) |
936 (53.3%) |
| Symptoms: yes | 847 (57.4%) |
969 (71.3%) |
840 (57.7%) |
776 (53.3%) |
820 (46.7%) |
| Symptom: not reported [note 63] | 225 | 175 | 2 | 4 | 6 |
| Sample origin: urethral | 834 (49.4%) |
721 (48.2%) |
633 (44.1%) |
594 (41.0%) |
669 (38.2%) |
| Sample origin: cervical | 215 (12.7%) |
216 (14.4%) |
141 (9.8%) |
150 (10.4%) |
152 (8.7%) |
| Sample origin: rectal | 484 (28.7%) |
415 (27.7%) |
354 (24.7%) |
379 (26.2%) |
534 (30.5%) |
| Sample origin: pharyngeal | 134 (7.9%) |
118 (7.9%) |
294 (20.5%) |
301 (20.8%) |
369 (21.1%) |
| Sample origin: high vaginal site | 18 (1.1%) |
16 (1.1%) |
9 (0.6%) |
22 (1.5%) |
19 (1.1%) |
| Sample origin: other | 3 (0.2%) |
11 (0.7%) |
5 (0.3%) |
2 (0.1%) |
8 (0.5%) |
| Sample origin: not reported [note 63] | 13 | 37 | 23 | 12 | 11 |
Source: Data from GRASP sentinel surveillance system.
Note 60: Reporting errors cannot be excluded due to manual completion of GRASP data forms. Gender and sexual orientation are self-reported. Where gender and sexual orientation are ‘Not reported’, these include those who are gender diverse due to smaller numbers.
Note 61: ‘N’ refers to all individuals in the GRASP data set (from 2019 to 2023) that have reported data for each characteristic and excludes all individuals where data was not reported.
Note 62: Numerator: individuals in the GRASP data set infected at site specified (from 2019 to 2023). Data reported are for individuals infected with N. gonorrhoeae at least at the specified site however, not exclusively this site.
Denominator: all individuals in the GRASP data set (from 2019 to 2023 that have reported answers for each characteristic). Not all individuals are tested for gonorrhoea at each site.
Percentages do not add to 100% as individuals can be infected at more than one site. Also note that these numbers differ to isolates tested by specimen site as only one site is tested per individual.
For individuals with multiple sites of infection, the isolate sample tested followed the hierarchy described above.
Note 63: ‘Not reported’ refers to instances where information was unknown or not stated.
Table 9c. Presence of concurrent STIs, previous gonorrhoea diagnosis and test of cure status of individuals in GRASP, England and Wales, 2019 to 2023 [note 64]
| Characteristics | 2019 | 2020 | 2021 | 2022 | 2023 |
|---|---|---|---|---|---|
| Metric |
n (% of N) [note 65] |
n (% of N) [note 65] |
n (% of N) [note 65] |
n (% of N) [note 65] |
n (% of N) [note 65] |
| Number of individuals | 1,701 | 1,534 | 1,459 | 1,460 | 1,762 |
| Any concurrent STI: chlamydia [note 66] | 388 (22.8%) |
312 (20.3%) |
309 (21.2%) |
313 (21.4%) |
334 (19.0%) |
| Any concurrent STI: other STIs [note 66] | 41 (2.4%) |
60 (3.9%) |
25 (1.7%) |
17 (1.2%) |
46 (2.6%) |
| Previously diagnosed with gonorrhoea: no | 1353 (82.1%) |
1123 (79.4%) |
527 (55.1%) |
619 (56.5%) |
772 (52.2%) |
| Previously diagnosed with gonorrhoea: yes | 295 (17.9%) |
291 (20.6%) |
430 (44.9%) |
476 (43.5%) |
708 (47.8%) |
| Previously diagnosed with gonorrhoea: not reported [note 67] | 53 | 120 | 502 | 365 | 282 |
| Test of cure: no | 407 (29.2%) |
459 (40.4%) |
463 (36.7%) |
436 (34.4%) |
532 (36.4%) |
| Test of cure: yes | 985 (70.8%) |
676 (59.6%) |
797 (63.3%) |
832 (65.6%) |
929 (63.6%) |
| Test of cure: not reported [note 67] | 309 | 399 | 199 | 192 | 301 |
Source: Data from GRASP sentinel surveillance system.
Note 64: Reporting errors cannot be excluded due to manual completion of GRASP data forms. Gender and sexual orientation are self-reported. Where gender and sexual orientation are ‘Not reported’, these include those who are gender diverse due to smaller numbers.
Note 65: ‘N’ refers to all individuals in the GRASP data set (from 2019 to 2023) that have reported data for each characteristic and excludes all individuals where data was not reported.
Note 66: Numerator: individuals in the GRASP data set with any diagnosed concurrent STI (from 2019 to 2023).
Denominator: all individuals in the GRASP data set (from 2019 to 2023 that have reported answers for each characteristic). Not all individuals are tested for each STI.
Note 67: ‘Not reported’ refers to instances where information was unknown or not stated.
Table 9d. Number of partners and reporting of sex abroad of individuals in GRASP, England and Wales, 2019 to 2023 [note 68]
| Characteristics | 2019 | 2020 | 2021 | 2022 | 2023 |
|---|---|---|---|---|---|
| Metric |
n (% of N) [note 69] |
n (% of N) [note 69] |
n (% of N) [note 69] |
n (% of N) [note 69] |
n (% of N) [note 69] |
| Number of individuals | 1,701 | 1,534 | 1,459 | 1,460 | 1,762 |
| Total sexual partners (past 3 months): 0 to 1 | 259 (36.6%) |
495 (48.3%) |
423 (42.9%) |
446 (44.2%) |
587 (37.6%) |
| Total sexual partners (past 3 months): 2 to 5 | 359 (50.8%) |
462 (45.1%) |
469 (47.6%) |
448 (44.4%) |
726 (46.4%) |
| Total sexual partners (past 3 months): 6 to 10 | 39 (5.5%) |
46 (4.5%) |
58 (5.9%) |
69 (6.8%) |
149 (9.5%) |
| Total sexual partners (past 3 months): 11 and over | 50 (7.1%) |
21 (2.1%) |
36 (3.7%) |
46 (4.6%) |
101 (6.5%) |
| Total sexual partners (past 3 months): not reported [note 70] | 994 | 510 | 473 | 451 | 199 |
| Sex abroad (past 3 months): no | 661 (93.5%) |
991 (96.8%) |
960 (97.4%) |
968 (95.9%) |
1500 (96.0%) |
| Sex abroad (past 3 months): yes | 46 (6.5%) |
33 (3.2%) |
26 (2.6%) |
41 (4.1%) |
63 (4.0%) |
| Sex abroad (past 3 months): not reported [note 70] | 994 | 510 | 473 | 451 | 199 |
Source: Data from GRASP sentinel surveillance system.
Note 68: Reporting errors cannot be excluded due to manual completion of GRASP data forms. Gender and sexual orientation are self-reported. Where gender and sexual orientation are ‘Not reported’, these include those who are gender diverse due to smaller numbers.
Note 69: ‘N’ refers to all individuals in the GRASP data set (from 2019 to 2023) that have reported data for each characteristic and excludes all individuals where data was not reported.
Note 70: ‘Not reported’ refers to instances where information was unknown or not stated.
Table 10. Sample origin of isolates included for individuals in GRASP, England and Wales, by gender and sexual orientation, 2023
| Characteristics | GBMSM | Heterosexual men | Women | Not reported [note 40] |
Total |
|---|---|---|---|---|---|
| Metric |
n (% of N) [note 71] |
n (% of N) [note 71] |
n (% of N) [note 71] |
n (% of N) [note 71] |
n (% of N) [note 71] |
| Number of individuals | 1052 | 304 | 294 | 112 | 1,762 |
| Sample origin: urethral | 325 (31.0%) |
273 (90.7%) |
12 (4.1%) |
59 (53.2%) |
669 (38.2%) |
| Sample origin: cervical | 1 (0.1%) |
0 (0.0%) |
150 (51.4%) |
1 (0.9%) |
152 (8.7%) |
| Sample origin: rectal | 482 (46.0%) |
9 (3.0%) |
16 (5.5%) |
27 (24.3%) |
534 (30.5%) |
| Sample origin: pharyngeal | 238 (22.7%) |
19 (6.3%) |
89 (30.5%) |
23 (20.7%) |
369 (21.1%) |
| Sample origin: high vaginal site | 0 (0.0%) |
0 (0.0%) |
19 (6.5%) |
0 (0.0%) |
19 (1.1%) |
| Sample origin: other | 1 (0.1%) |
0 (0.0%) |
6 (2.1%) |
1 (0.9%) |
8 (0.5%) |
| Sample origin: not reported [note 72] | 5 | 3 | 2 | 1 | 11 |
Source: Data from GRASP sentinel surveillance system.
Note 71: ‘N’ refers to all individuals in the GRASP data set (from 2019 to 2023) that have reported data for each characteristic and excludes all individuals where data was not reported.
Note 72: ‘Not reported’ refers to instances where information was unknown or not stated.
Appendix 5. Percentage of N. gonorrhoeae isolates resistant to selected antimicrobials from 2000 to 2023
Figure 14. Percentage of N. gonorrhoeae isolates in GRASP that were resistant to selected antimicrobials, England and Wales, 2000 to 2023 [note 73]
Source: Data from GRASP sentinel surveillance system.
Note 73: Due to changes in the diagnostic sensitivity medium used to test antimicrobial susceptibility of sentinel surveillance isolates, MICs for the 2015 to 2023 collections are not directly comparable with those from previous years. Trends from 2000 to 2014 compared with 2015 to 2023 must be interpreted with caution (point of change indicated by vertical dashed black line), particularly for azithromycin data.
The 5% threshold (≥5% of infections resistant to the first-line therapy) at which the WHO recommends that first-line monotherapy guidelines should be changed is indicated by the horizontal dashed red line. In 2021, pharyngeal isolates were prioritised ahead of all other sites for the first time, resulting in a substantial change in the distribution of specimen sites from 2021 onwards.
In 2023, EUCAST updated the resistance breakpoint for tetracycline against N. gonorrhoeae from 1.0 mg/L to 0.5 mg/L. Breakpoint plates at 0.5 mg/L were introduced in 2022; therefore, no data for this breakpoint is available prior to 2022 and trend data is not presented.
Please note cefixime MICs between 2019 to 2022 and azithromycin MICs between 2018 to 2022 are affected by a laboratory technical issue and should be interpreted alongside their respective technical notes. Azithromycin data for 2023 have not been presented due to these issues.
Appendix 6. Ethnic categories
The ethnic categories used in this report are as specified by the Office for National Statistics (ONS). Data is presented by disaggregated ethnic groups among people of Black ethnicity to highlight the variability in rates among the ethnic group experiencing the highest rates of the most commonly diagnosed STIs. People of Asian, mixed, other and white ethnicity are presented as aggregated ethnic groups for comparison. The ethnicities included in each of the aggregated ethnic groups are presented below.
List of ethnicities by ethnic category
White:
- British
- Irish
- any other white background
Mixed:
- White and Black Caribbean
- White and Black African
- White and Asian
- any other mixed background
Asian or Asian British:
- Indian
- Pakistani
- Bangladeshi
- Chinese
- any other Asian background
Black or Black British:
- Caribbean
- African
- any other Black background
Other ethnic groups:
- any other ethnic group
Acknowledgements
GRASP would like to thank the collaborating centres and the advisory group for their continued support, SHSs for the prompt submission of clinical data and laboratories for sending isolates to the national STI reference laboratory at the UKHSA, Colindale.
Advisory group (listed alphabetically)
R Browne, M Cole, H Donaldson, H Fifer, C Ison, E Jungmann, DM Livermore, H Mohammed, S Palanivel, R Pitt, M Rayment, J Ross, T Sadiq, J Shepherd, K Sibson, K Sinka, S Soni, K Templeton, D Weiand.
Collaborating centres
- Birmingham (H Ahmed, R Chaudhry, M Smith-Banks, M Hamad, J Phattey, S Brown, J Ross)
- Bristol (S Brazier, M Williams, J Gabb, A Wolujewicz)
- Brighton (B Cogger, K Parker, C Reynolds, G Jones, G Dean, S Soni)
- Cambridgeshire (C Krause, E Hodges, H Donson, M Grayson, S Ellam, R White, C Baker, R Smith)
- Cardiff (J Richards, L Davies, L Jones, R Drayton)
- Falcon Road (E Bird, C Wilson, L Birycki, L Aitken, P Wezka, K Stegmann, M Grayson, S Ellam, R White, C Baker, R Smith)
- Gloucester (J Lewis, A Read, M Phipps, J Boyes, A Godwin, A DeBurgh-Thomas)
- Homerton (P Horne, P Zachary, S Zetie, J Ofori-Boateng, F Abbs, A Keirs, D Martin, N Marshall, N North, D Ball, T Karadag)
- King’s (N Kaur, T Kamvumbi, R El Sheikh, C McDonald, M Brady, G MacMillan, M Brown)
- Leeds (S Birdi, F Windebank, M Uddin, A Evans, K Sibson, I Cocking)
- Liverpool (A Elmer, G McCarthy, B Harrison, E Clarke, H Carney, J Anson, C Brookfield)
- London Charing Cross, Chelsea and Westminster (S Goonesekera, S Shah, A Bari, H Donaldson, A Colcutt, B Cookhorn, K Bide, N Chapman, F Ahmed, I Mavropoulos, N Jeyapalan, J Greenham, I Clapp, S OConnor, R Pite, G Vonschweitzer, G Whitlock)
- Luton (K Zyla, S Mottershaw, G Keight, J Turner, D Karim, S Jaise, R Mulla)
- Manchester (H Heapy, S Flaherty, E Sandham, A Sukthankar, L Devine, Z Jeffrey, J Birtles, A Brooks, A Qamruddin)
- Newport (C Knapper, J Bendle, C Barret, Z Kempson, N Berry)
- Northampton (M Kelly, L Riddell, T Streeter, E Chiriseri, B Alounti)
- Nottingham (J Deery, C Okafor, M Pammi, J Dengate, J Bowskill)
- Sheffield (C Megson, A Carr, R Matcham, H Parsons, C Turnock, C Dewsnap)
- St Mary’s (O Dosekun, S Goonesekera, S Shah, A Bari, H Donaldson)
- Central and North West London (L Matthews, M Nur, M Mansoor, D Carta, D Harkness, R Browne, M Grayson, S Ellam, R White, C Baker, R Smith)
- Wolverhampton (S Lovegrove, J Hudson, D Dobie, K Whitehouse, R McCathie)
- Woolwich (D Ward, S Kegg, S Allen, P Merrett, M Dall’Antonia)
Authors: Suzy Sun, Prarthana Narayanan, Anna Vickers, Rachel Pitt, Michel X. Doumith, Sandra David, Sandhya Vivekanand, Zdravko Ivanov, Zeynab Yusuf, Fahima Rashid, James Johnson, Kirsty Bennet, Emma Callan, Michelle Cole, Hamish Mohammed, Katy Sinka, Sarah Alexander, Helen Fifer.
Suggested citation
Suzy Sun, Prarthana Narayanan, Anna Vickers, Rachel Pitt, Michel X. Doumith, Sandra David, Sandhya Vivekanand, Zdravko Ivanov, Zeynab Yusuf, Fahima Rashid, James Johnson, Kirsty Bennet, Emma Callan, Michelle Cole, Hamish Mohammed, Katy Sinka, Sarah Alexander, Helen Fifer. GRASP report: data to August 2024. November 2024, UK Health Security Agency, London