Genomic sequencing of a national emm66 group A streptococci (GAS) outbreak among people who inject drugs and the homeless community in England and Wales, January 2016-May 2017.

An outbreak of an uncommon emm type (emm66.0) of group A streptococcus (GAS) occurred in England and Wales between January 2016 and May 2017, involving 52 individuals who were homeless or injecting drugs users. In order to investigate the outbreak, epidemiological and network analysis were performed; moreover 55 isolates (32 outbreak, 5 non-outbreak and 13 historical - 2005-2015) were tested with whole genome sequencing (WGS), antimicrobial resistance determination, Bayesian evolutionary analysis (BEAST). Forty one isolates (including 32 outbreak strains) belonged to a single emm66.0 clade (average SNP difference 6.6; range 0-16 SNPs) separate from the other isolates and two strains previously considered part of the outbreak (SNP average: 5876; range 93-8417 SNPs). Antibiotic resistance was not detected in the outbreak clone. No common source of infection was identified. WGS confirmed expansion of an emm66.0 clone in a hard-to-reach population and enabled refinement of the initial case definition.