Assessment of exposure to perfluorinated industrial substances and risk of immune suppression in Greenland and its global context: a mixed-methods study.

BACKGROUND: Perfluoroalkyl substances (PFASs) are ubiquitous global contaminants that do not readily biodegrade and are therefore routinely found worldwide in wildlife, humans, and the environment. There is a paucity of global assessments to understand regional and continental differences in exposure to PFASs and the associated health risks, including those for Indigenous Arctic communities who consume high trophic marine diets. We aimed to estimate the long-term exposure of dietary PFASs from consumption of polar bear and ringed seal meat and establish its association with blood serum concentrations of PFASs in Inuit in Ittoqoortoormiit (Scoresby Sound), East Greenland. We also aimed to assess the risk of immune suppression on the basis of European Food Safety Authority (EFSA) thresholds for weekly intake and blood serum concentrations of PFASs. Last, we conducted a worldwide risk assessment based on blood concentrations of PFASs emphasising Arctic exposure in a global context. METHODS: In this mixed-methods study, we conducted interviews to compare dietary exposure of PFASs in anonymous, non-pregnant, Inuit adults (aged ≥18 years) from full-time or part-time hunter families in Ittoqoortoormiit, East Greenland with ESFA toxic threshold values for tolerable weekly intake of the four most immunotoxic PFASs (∑4PFAS; perfluorooctanoic acid, perfluorononanoic acid, perfluorohexanesulfonic acid, and perfluorooctane sulfonate). Independent hospital staff from the local hospital randomly selected participants using simple randomisation using a telephone directory. Blood serum concentrations were then compared with EFSA risk categories: low (0·7-9·5 ng/mL), moderate (>9·5-17·5 ng/mL), high (>17·5-31·9 ng/mL), and severe (>31·9 ng/mL). We also reviewed the available scientific literature of ∑4PFAS concentrations in human blood to place the Inuit dataset in a broader global context. FINDINGS: Between Sept 21, and Oct 2, 2015, 22 participants were enrolled in the study, of which 12 were male and ten were female. Sex data were obtained from personal social security numbers and options were male or female. As a result of a subsistence diet high in marine mammal muscle, 322 (92%) of 350 people in the Ittoqoortoormiit cohort exceeded the established immunotoxic thresholds of ∑4PFASs set by EFSA's tolerable weekly intake of 4·4 ng/kg, and 301 (86%) were in the most severe risk category (>31·9 ng/mL) based on blood serum concentrations. This Inuit cohort had the highest non-occupational long-term exposure to PFASs worldwide despite their remote location relative to industrial sources. Using country-wide average values across global studies, we found that blood serum concentrations of PFASs in populations from European countries, North America, the Arctic, and Australia were generally higher than those in South America, Africa, and mainland Asia, with the highest concentrations found in people from USA, Canada, Greenland, Faroe Islands, Denmark, Iceland, Norway, Sweden, the UK, Spain, Poland, and Australia. These high exposure countries all fall within the EFSA moderate-risk and high-risk categories. INTERPRETATION: PFAS contamination of the environment and human populations occurs worldwide. This pollution not only poses substantial risks for immune system adverse events but also cardiovascular, cancerous, and reproductive endpoints. Data on such PFAS exposure is scarce in numerous countries. Therefore, it is important to also map out the exposure in these countries to enable a thorough global assessment of exposure and risks. FUNDING: Danish Cooperation for Environment in the Arctic.

A systematic review on risk and protective factors for suicide and suicidal behaviour among Greenland Inuit.

Since the 1970s, suicide has been a major public health issue in Greenland. The World Health Organization has emphasised the importance of the identification of both risk and protective factors in relation to suicide. The aim of this paper was to identify scientific literature on risk and protective factors for suicide and suicidal behaviour among Greenland Inuit. Searches in PubMed and PsycInfo resulted in 420 studies that were screened by three of the authors. After screening, the authors included 15 studies that were subject to quality assessment and data extraction. All 15 studies reported on risk factors, and only three mentioned protective factors. Most reported risk factors were on an individual level and were related to socioeconomic status, mental health, alcohol and substance use, and life stress. Risk factors related to the family mainly related to adverse childhood experiences, while the community level concerned access to education, work, and conflicts. The results indicate a large knowledge gap about protective factors for suicide and suicidal behaviour. The few protective factors reported were related to men having a family, high socioeconomic status, and being born between 1901 and 1950.

High burden of symptoms reported among patients diagnosed with chronic obstructive pulmonary disease (COPD) in Greenland after introducing the COPD Assessment Test in clinical practice.

The aim was to test the internal consistency of the Greenlandic version of the COPD Assessment Test (CAT) questionnaire and to estimate the symptom burden in patients with chronic obstructive pulmonary disease (COPD) in Greenland using the CAT questionnaire. A Greenlandic version of the CAT questionnaire was developed including forward translation, reconciliation, backwards translation, and pilot test. Afterwards, a cross-sectional study of patients with COPD was conducted. The internal consistency assessed by the Cronbach α coefficient was 0.823 for the Greenlandic version of the questionnaire (n = 103). The CAT was negatively correlated to spirometry values and current smoking. In the cross-sectional study (n = 250), 81.1% of the patients experienced a high symptom burden (≥10). The main CAT score was 17 (range 0-38). The CAT was used in 9 out of 17 towns in Greenland. The Greenlandic version of the CAT questionnaire demonstrated a good internal consistency. We observed a high burden of symptoms associated with reduced lung function and active smoking status among patient diagnosed with COPD in Greenland. The questionnaire can be used in clinical practice for assessment of symptom burden in patients with COPD in Greenland and may help to increase focus on symptom control and quality of care.

Indoor radon survey in Greenland and dose assessment.

Indoor radon and its decay products are the primary sources of the population's exposure to background ionizing radiation. Radon decay products are one of the leading causes of lung cancer, with a higher lung cancer risk for smokers due to the synergistic effects of radon decay products and cigarette smoking. A total of 459 year-long radon measurements in 257 detached and semi-detached residential homes in southwest and south Greenland were carried out, and a dose assessment for adults was performed. The annual arithmetic and geometric means of indoor radon concentrations was 10.5 ± 0.2 Bq m-3 and 8.0 ± 2.3 Bq m-3 in Nuuk, 139.0 ± 1.0 Bq m-3 and 97.3 ± 2.1 Bq m-3 in Narsaq, and 42.1 ± 0.7 Bq m-3 and 22.0 ± 3.1 Bq m-3 in Qaqortoq. Arithmetic and geometric mean radon concentration of 79.0 Bq m-3 and 50.3 Bq m-3 were estimated for adult, person-weighted living in south Greenland. The total number of detached and semi-detached residential homes where indoor radon is exceeding 100 Bq m-3, 200 Bq m-3, and 300 Bq m-3 is 37 homes (15.0%), 13 homes (5.2%), and 8 homes (3.2%), respectively. A positive correlation between indoor air radon concentrations and underlying geology was observed. The indoor radon contribution to the annual inhalation effective dose to an average adult was 0.5 mSv in Nuuk, 6.5 mSv in Narsaq, 2.0 mSv in Qaqortoq, and 4.0 mSv for south Greenland adult person weighted. The estimated annual average effective dose to adults in Narsaq is higher than the world's average annual effective dose of 1.3 mSv due to inhalation of indoor radon. Cost-efficient mitigation methods exist to reduce radon in existing buildings, and to prevent radon entry into new buildings.

Ancient DNA provides insights into 4,000 years of resource economy across Greenland.

The success and failure of past cultures across the Arctic was tightly coupled to the ability of past peoples to exploit the full range of resources available to them. There is substantial evidence for the hunting of birds, caribou and seals in prehistoric Greenland. However, the extent to which these communities relied on fish and cetaceans is understudied because of taphonomic processes that affect how these taxa are presented in the archaeological record. To address this, we analyse DNA from bulk bone samples from 12 archaeological middens across Greenland covering the Palaeo-Inuit, Norse and Neo-Inuit culture. We identify an assemblage of 42 species, including nine fish species and five whale species, of which the bowhead whale (Balaena mysticetus) was the most commonly detected. Furthermore, we identify a new haplotype in caribou (Rangifer tarandus), suggesting the presence of a distinct lineage of (now extinct) dwarfed caribou in Greenland 3,000 years ago.

Domestic water supply in rural Greenland - sufficiency, affordability and accessibility.

Global efforts are still under way to ensure sustainable development goal 6 of providing enough clean water to sustain public health in many regions, and especially in the Arctic where the remoteness of communities and the harsh climate make water provision especially challenging. This study aimed to examine the sufficiency, accessibility, and affordability of water supplies in rural Greenland. The state of the water supply was investigated using quantitative data on infrastructure and demographics. Qualitative data on water-related practices and perceptions were collected through fieldwork and interviews in a selection of settlements. Generally, the supply of drinking water was found to be sufficient and affordable for most. However, access was severely constrained by the lack of piping to rural homes (20% were piped). The daily water consumption of residents from un-piped households was between 13 and 23 L/d/cap, i.e. within the basic access level according to WHO, which is in theory not sufficient to sustain public health. Several health risks could be caused by the low daily consumption in un-piped homes, and water saving practices induced by it - i.e. the use of shared handwashing basins, and household water storage, which could lead to degradation of water quality at the point-of-use.

Prevalence of patients using antihypertensive medication in Greenland, and an assessment of the importance of diagnosis for the associated quality of care - a cross-sectional study.

This study aimed to estimate the age- and sex specific prevalence of patients using antihypertensive medication in Greenland, and compared the quality of care between patients with and without a diagnosis for hypertension. The study was a cross-sectional study comparing patients using antihypertensive medication in 2020 (6,629 patients) and 2021 (7,008 patients), respectively. For data from 2021, patients with a medical diagnosis code were identified. Data was obtained from the Greenlandic electronic medical record. The population of Greenland was used as background population. Quality of care was evaluated based on suggested indicators by international guidelines and goals from Steno Diabetes Centre Greenland. The prevalence of patients aged ≥20 years using antihypertensive medication had increased from 16.7% in 2020 to 17.5% in 2021. The prevalence increased by age and was higher among women compared to men. In 2021, the prevalence of patients aged ≥20 years with a medical diagnosis code for hypertension was 7.9%. The use of antihypertensive medication in Greenland is common. The associated quality of care was low. However, process indicators were significantly improved when patients had a medical diagnosis code. Future focus must be on initiating initiatives ensuring that more patients are registered with a medical diagnosis code.

An assessment of mercury and its dietary drivers in fur of Arctic wolves from Greenland and High Arctic Canada.

Mercury has become a ubiquitous hazardous element even ending up in pristine areas such as the Arctic, where it biomagnifies and leaves especially top predators vulnerable to potential health effects. Here we investigate total mercury (THg) concentrations and dietary proxies for trophic position and habitat foraging (δ15N and δ13C, respectively) in fur of 30 Arctic wolves collected during 1869-1998 in the Canadian High Arctic and Greenland. Fur THg concentrations (mean ± SD) of 1.46 ± 1.39 µg g -1 dry weight are within the range of earlier reported values for other Arctic terrestrial species. Based on putative thresholds for Hg-mediated toxic health effects, the studied Arctic wolves have most likely not been at compromised health. Dietary proxies show high dietary plasticity among Arctic wolves deriving nutrition from both marine and terrestrial food sources at various trophic positions. Variability in THg concentrations seem to be related to the wolves' trophic position rather than to different carbon sources or regional differences (East Greenland, the Foxe Basin and Baffin Bay area, respectively). Although the present study remains limited due to the scarce, yet unique historic study material and small sample size, it provides novel information on temporal and spatial variation in Hg pollution of remote Arctic species.

Background 210Po activity concentrations in Greenland marine biota and dose assessment.

Polonium-210 (210Po) is a radionuclide sentinel as it bioaccumulates in marine organisms, thereby being the main contributor to committed dietary doses in seafood consumers. Although seafood and marine mammals are an important part of the traditional Inuit diet, there is a general lack of information on the 210Po concentrations in the Greenlandic marine food chain leading to the human consumer. Here, we determine background 210Po concentrations in edible parts of different marine organisms from Greenland and provide a dose assessment. Blue mussels (Mytilus edulis), organs of ringed seal (Pusa hispida) and polar bear (Ursus maritimus) displayed significantly elevated 210Po concentrations in respect to all other studied organisms (p < 0.001). 210Po concentrations ranged from 0.02 Bq kg-1, w.w. in Greenland halibut (Reinhardtius hippoglossoides) muscle to 78 Bq kg-1, w.w. and 202 Bq kg-1, w.w. in ringed seal muscle and kidneys, respectively. 210Po concentration ratio for edible parts increases in the order bladderwrack (Fucus Vesiculosus), northern shrimp (Pandalus borealis), blue mussels, and from fish species to ringed seal and polar bear. 210Po distribution in fish, ringed seal, and polar bear follows a general pattern, the lowest concentrations were in muscle, and the highest concentrations were in the organs involved in metabolism. The derived 210Po annual absorbed dose in edible parts of studied marine organisms are several orders of magnitude lower than the recommended dose rate screening value of 10 µGy h-1. Effective doses from intake of 210Po to Greenland average children (1.4 mSv y-1), and high seafood and marine mammal consumers (2 mSv y-1 for adults and 3.6 mSv y-1 for children) are higher than the world average annual effective dose due to ingestion of naturally occurring radionuclides.

Association of food insecurity with dietary patterns and expenditure on food, alcohol and tobacco amongst indigenous Inuit in Greenland: results from a population health survey.

BACKGROUND: Amongst the indigenous Greenlandic Inuit, the experience of food insecurity has been attributed to a lack of money to buy enough food of sufficient quality to sustain a family, although a preference for alcohol and tobacco over food has also been cited. The purpose of the article was to compare dietary patterns and expenditure on food, alcoholic beverages and tobacco between survey participants who reported food insecurity and those who did not. METHODS: A countrywide cross-sectional health survey was carried out among 1886 adult Greenlandic Inuit in 2018. Diet was estimated by a food frequency questionnaire. Food insecurity status was based on the household hunger scale. Analyses were carried out by univariate general linear models adjusted for age, sex and social position. RESULTS: Nine percent of the participants reported food insecurity. Food insecurity was higher among younger participants, men and participants with low social position. Food insecure participants more often chose an unhealthy dietary pattern (43% vs. 32%) and they reported a higher energy intake. The food insecure spent the same amount of money on food as other participants but less on nutritious food and more on non-nutritious food. The cost per kilojoule (kJ) of the food of the food insecure was lower than that of the food secure (DKK 8.0 and 9.0 per 1000 kJ, respectively). The food insecure participants also spent considerably more on alcohol and tobacco. CONCLUSIONS: The results suggest that it is not only unemployment and lack of money that creates food insecurity and unhealthy dietary patterns in Greenland. Food insecure participants gave higher priority to buying non-nutritious food, alcohol and tobacco than did food secure participants. There seems to be at least two population subgroups in Greenland with poverty and substance use, respectively, as the immediate determinants for food insecurity. The results are important for the design of interventions against food insecurity and unhealthy dietary patterns.

Diagnosing dementia in the Arctic: translating tools and developing and validating an algorithm for assessment of impaired cognitive function in Greenland Inuit.

Background: The ageing Arctic populations raise the need for work-up of cognitive function that reflects language and cultural understandings.Aim: To translate and evaluate tools for work-up of cognitive impairment in Greenland.Methods: Step A: An expert panel was established to select tools suitable for the work-up of cognitive impairment at three different settings in Greenland. Step B: Tools were translated in a multiple-step process of independent translations with back-translation and adaptations by two independent translators and two Greenlandic physicians. Step C: a testing and validation process of the tools at three locations: the national hospital in the capital city; regional hospital in a town; health care centre in a small town.Results: Tools selected were Mini-Cog and RUDAS. Participants for testing of tools were 43 of 61 invited, of which six had dementia. RUDAS and Mini-Cog scores were associated (p < 0.001). The smoothed AUC was 0.87 (95%-CI, 0.65-0.95) for Mini-Cog and 0.90 (95%-CI, 0.76-0.97) for RUDAS. The sensitivity of Mini-Cog with a cut-off at ≤3 was 83.3%, and specificity was 62.2%. For RUDAS with a cut-off at ≤23, these were 100% and 75.7%, respectively.Conclusion: Requested tools have been translated for assessing cognitive function in the native Arctic setting. Small town residents with a Mini-Cog score of 3 or lower should be referred to a regional hospital for RUDAS, and a score of 23 or less should cause referral to the national hospital for a full work-up of cognitive function.

Social determinants of dietary patterns, food basket costs and expenditure on alcohol and tobacco amongst Greenland Inuit.

OBJECTIVE: Dietary transition, obesity and risky use of alcohol and tobacco are challenges to public health among indigenous peoples. The aim of the article was to explore the role of social position in dietary patterns and expenditures on food and other commodities. DESIGN: Countrywide population health survey. SETTING: Greenland. PARTICIPANTS: 2436 Inuit aged 15+ years. RESULTS: Less than half of the expenditures on commodities (43 %) were used to buy nutritious food, and the remaining to buy non-nutritious food (21 %), alcoholic beverages (18 %) and tobacco (18 %). Participants were classified according to five dietary patterns. The cost of a balanced diet and an unhealthy diet was similar, but the cost per 1000 kJ was higher and the energy consumption was lower for the balanced diet. Participants with low social position chose the unhealthy pattern more often than those with high social position (40 % v. 24 %; P < 0·0001), whereas those with high social position more often chose the balanced alternative. Participants with low social position spent less money on the total food basket than those with high social position but more on non-nutritious food, alcohol and tobacco. CONCLUSIONS: Cost seems to be less important than other mechanisms in the shaping of social dietary patterns and the use of alcohol and tobacco among the Inuit in Greenland. Rather than increasing the price of non-nutritious food or subsidising nutritious food, socially targeted interventions and public health promotion regarding food choice and prevention of excessive alcohol use and smoking are needed to change the purchase patterns.

Comparative toxicity assessment of in situ burn residues to initial and dispersed heavy fuel oil using zebrafish embryos as test organisms.

In situ burning (ISB) is discussed to be one of the most suitable response strategies to combat oil spills in extreme conditions. After burning, a highly viscous and sticky residue is left and may over time pose a risk of exposing aquatic biota to toxic oil compounds. Scientific information about the impact of burn residues on the environment is scarce. In this context, a comprehensive ISB field experiment with approx. 1000L IFO 180 was conducted in a fjord in Greenland. The present study investigated the toxicity of collected ISB residues to early life stages of zebrafish (Danio rerio) as a model for potentially exposed pelagic organisms. The toxicity of ISB residues on zebrafish embryos was compared with the toxicity of the initial (unweathered) IFO 180 and chemically dispersed IFO 180. Morphological malformations, hatching success, swimming behavior, and biomarkers for exposure (CYP1A activity, AChE inhibition) were evaluated in order to cover the toxic response on different biological organization levels. Across all endpoints, ISB residues did not induce greater toxicity in zebrafish embryos compared with the initial oil. The application of a chemical dispersant increased the acute toxicity most likely due to a higher bioavailability of dissolved and particulate oil components. The results provide insight into the adverse effects of ISB residues on sensitive life stages of fish in comparison with chemical dispersant application.

Alcohol in Greenland 1950-2018: consumption, drinking patterns, and consequences.

Alcohol is the single most important public health challenge in Greenland. We provide an overview of alcohol consumption, drinking patterns, and consequences of excessive use of alcohol in Greenland since 1950 through a synthesis of published results and analyses of population-based interview surveys. The import of alcohol fluctuated over the last 70 years with a peak in the 1980s at 22 litres 100% alcohol per person per year. In 1950 and 2015, the import of alcohol was similar at 8 litres. Several explanations have been put forward to explain the changes including restrictions, increased tax, demographic changes, treatment of alcohol disorders, and public health interventions. The proportion of abstainers increased from 1993 to 2018 while the proportion of participants with regular consumption decreased. About half of the population reported binge drinking at least monthly. Compared with Denmark, there were more abstainers and binge drinkers in Greenland, and fewer had a regular consumption. Although genetics may play a role for drinking patterns, social and cultural conditions are more important. Exposure to domestic alcohol problems and sexual abuse in childhood parallel the recorded import of alcohol and is a likely cause of transgenerational consequences such as youth suicides and alcohol problems.

Prevalence of problems with alcohol, marijuana and gambling among patients in a Regional Hospital in Northern Greenland: investigating the potential for brief interventions in a hospital setting.

Problems with alcohol, marijuana and gambling are major public health challenges in Greenland but their prevalence in a hospital setting has not been explored. Healthcare facilities play a significant role in Greenland. One important aspect is their provision of both primary and secondary healthcare services to a small and scattered population while their potential as settings for screening for problems with alcohol, substances and gambling is an unexplored area with large public health potential. This study explored the prevalences of problems with alcohol, marijuana and gambling in a hospital and the potential for the use of a hospital as a setting for screening for alcohol, substance and gambling problems. Patients from the Northern Ilulissat Hospital filled in a self-administered questionnaire regarding their behaviour related to alcohol, marijuana and gambling. Data were weighted and compared to the nationally representative 2018 Health Survey. In the Ilulissat Survey, a large proportion were abstainers but there were still problems related to alcohol, marijuana and gambling indicating a potential for screening in a hospital setting. The results based on data from 2,554 respondents showed that prevalences of problems with alcohol, marijuana and gambling are lower in the Ilulissat Survey compared to the 2018 Health Survey.

The effect of structural and functional social relations on smoking among adolescents - data from HBSC Greenland 2018.

The prevalence of adolescent smoking in Greenland is relatively high and remains an important topic to study. The present study reports the prevalence of smoking among Greenlandic adolescents in 2018 and the association between smoking and social relations. The study was based on HBSC Greenland 2018, using a theoretical framework proposed by Due and colleagues, which divides social relations into structural and functional relations. The study showed a statistically significant gender difference in smoking, as 11.4% of the girls reported to smoke compared to 7.9% of the boys. The smoking prevalence increased significantly with age, and differences were also found for a place of residence, as the smoking prevalence was higher in towns and settlements compared to Nuuk. The adolescent smoking prevalence was higher when living in a home with one adult or in a foster family, school home or orphanage, versus living in home with at least two adults. No significant associations were found between adolescent smoking and functional relations. The results are beneficial to consider when applying new interventions to prevent adolescent smoking initiation in Greenland.

210Po and 210Pb activity concentrations in Greenlandic seabirds and dose assessment.

Naturally occurring radionuclides, in particular, polonium-210 (210Po), have a greater contribution than anthropogenic radionuclides to the annual effective dose received by the general public due to consumption of seafood. Knowledge of potential trophic sources and transfer of 210Po to seabird species and subsequently to the Greenlandic people is, however, still poor. Here, we assess the transfer of 210Po and 210Pb to seabirds sampled during autumn and winter 2017 and 2018 in Greenland and provide a dose assessment. The activity concentrations of 210Po in muscle and liver, respectively, ranged from 0.2 ± 0.1 Bq kg-1 w.w. in glaucous gull (Larus hyperboreus) to 21.2 ± 22.6 Bq kg-1 w.w. in thick-billed murre (Uria lomvia) and from 32.0 ± 9.4 Bq kg-1 w.w. in common eider (Somateria mollissima) to 40.5 ± 49.0 Bq kg-1 w.w. in thick-billed murre. 210Po was non-uniformly distributed in the body of thick-billed murre. Kidneys and feathers showed higher 210Po activity concentrations than heart and bone. The 210Po/210Pb activity concentration ratios are higher than unity, indicating that 210Po is preferentially taken up by seabirds compared to its progenitor 210Pb. The derived annual absorbed dose from 210Po to the whole body of thick-billed murre was 6.4 × 102 ± 3.0 × 102 µGy. The annual effective dose to the average adult and representative person in Greenland due to ingestion of 210Po in seabirds was estimated to 13.0 µSv and 57.0 µSv, respectively. This derived dose is low and poses a slight risk, and risk communication is therefore deemed unnecessary.

Assessment of the quality of cause-of-death data in Greenland, 2006-2015.

Background: While the system of registration of mortality and cause of death (COD) in Greenland was established several decades ago, reporting procedures follow a complicated administrative process. Timely and reliable reporting on mortality and COD is of high importance for the usability of the collected data for research, health planning and decision making. Methods: COD data collected by the Chief Medical Office in Greenland from 2006 to 2015 (4490 registered deaths) were analysed with the software Analysis of National Causes of Death for Action (ANACONDA) v4.0. Unusable or insufficiently specified ICD codes are identified. The Vital Statistics Performance Index for Quality (VSPI(Q)) is estimated for the overall quality conclusions of the register's usability. Results: Sixty-eight per cent of the input data for Greenland was coded with a usable underlying COD, 24% with an unusable cause and 8% of deaths with an insufficiently specified cause. Almost 700 deaths were coded to an unusable code of 'very high impact'. The most prevalent unusable underlying causes were other ill-defined and unspecified causes, including no death certificate available, followed by senility, heart failure, sepsis and shock and cardiac arrest. The VSPI(Q) score was 66%, representing medium quality. Conclusions: In the 10 years' worth of data analysed, the true underlying COD in many cases was unknown. Several likely explanations for this include lack of systematic COD training for physicians, logistic and capacity challenges in Greenland that potentially could reduce the quality of the collected data and its usability in providing essential information about the true pattern of mortality in Greenland.