{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T17:41:36Z","timestamp":1777052496037,"version":"3.51.4"},"reference-count":51,"publisher":"BMJ","issue":"4","license":[{"start":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T00:00:00Z","timestamp":1776988800000},"content-version":"unspecified","delay-in-days":23,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,3,26]]},"published-print":{"date-parts":[[2026,4]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To describe the epidemiology, ecological determinants and public-health response to a yellow-fever (YF) outbreak in Wa East District (WED), Ghana, and to identify operational gaps to strengthen surveillance and immunisation in high-risk rural settings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>A cross-sectional descriptive outbreak investigation integrating epidemiological, entomological, vaccination-coverage and community knowledge assessments, conducted under Ghana\u2019s Integrated Disease Surveillance and Response framework.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>WED, located in the Upper West Region of Ghana, is an agrarian, forest-fringe area bordering the Mole National Park, characterised by limited access to health services and seasonal nomadic movements.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>All suspected YF cases (N=57) reported between epidemiological weeks 41\u201346 of 2021; 50 community respondents interviewed for knowledge and awareness and 52 households inspected for entomological indices.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Main outcome measures<\/jats:title>\n                    <jats:p>\n                      Demographic and clinical characteristics of cases, spatial\u2013temporal distribution, vaccination coverage,\n                      <jats:italic>Aedes<\/jats:italic>\n                      vector indices, community knowledge and awareness levels and response interventions.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      A total of 57 suspected cases (33 males 24 females) were identified, of which 12 (21.1%) were laboratory-confirmed. The case-fatality ratio among confirmed cases was 33.3% (95% CI 9.7% to 65.1%). Most cases occurred in individuals aged 6\u201330 years and were clustered in the Ducie community. The epidemic curve, based on confirmed cases, showed a single focal wave between epidemiological weeks 41 and 46 of 2021, peaking in week 45 and declining thereafter following intensified outbreak response activities, particularly surveillance and risk communication. Routine YF vaccination coverage was 25% before the outbreak, increasing to 95% after the mass campaign. The district\u2019s composite risk score was 83%, indicating very high transmission risk. Entomological indices (House Index=48.5%, CI=36.1%, Breteau Index=159.6) exceeded WHO thresholds, confirming intense\n                      <jats:italic>Aedes<\/jats:italic>\n                      proliferation. Community awareness was low, with only 22% recognising the viral cause, 16% identifying mosquitoes as vectors and 10% knowing that vaccination prevents YF.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>\n                      The outbreak reflected the convergence of ecological vulnerability, low baseline immunity and poor community awareness. Sustained high routine immunisation, structured\n                      <jats:italic>Aedes<\/jats:italic>\n                      surveillance and continuous risk communication are essential to prevent recurrence and advance Ghana\u2019s commitment to the WHO Eliminate Yellow Fever Epidemics strategy.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-112217","type":"journal-article","created":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T17:05:39Z","timestamp":1777050339000},"page":"e112217","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Epidemiological, entomological and community determinants of the 2021 yellow fever outbreak in Wa East District, Ghana: cross-sectional descriptive outbreak 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Navrongo, Upper East Region, Ghana"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Justine","family":"Bangniyel","sequence":"additional","affiliation":[{"name":"Public Health Department, Upper West Regional Health Directorate, Ghana Health Service, Wa, Upper West Region, Ghana"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ishmael Kunateh","family":"Alhassan","sequence":"additional","affiliation":[{"name":"Applied Epidemiology and Disease Control, University of Ghana, Accra, Ghana"},{"name":"Laboratory Department, Upper West Region, Wa Municipal Hospital, Wa Municipal, Upper West Region, Ghana"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Collins Boateng","family":"Danquah","sequence":"additional","affiliation":[{"name":"Public Health Department, Upper West Regional Health Directorate, Ghana Health Service, Wa, Upper West Region, 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Molecular Characterization of Circulating Yellow Fever Viruses from Outbreak in Ghana, 2021\u20132022. Emerg Infect Dis 2023;29. doi:10.3201\/eid2909.221671","DOI":"10.3201\/eid2909.221671"},{"key":"2026042410051588000_16.4.e112217.33","doi-asserted-by":"crossref","first-page":"232","DOI":"10.3201\/eid2813.221044","article-title":"Leveraging Lessons Learned from Yellow Fever and Polio Immunization Campaigns during COVID-19 Pandemic, Ghana, 2021","volume":"28","author":"Amponsa-Achiano","year":"2022","journal-title":"Emerg Infect Dis"},{"key":"2026042410051588000_16.4.e112217.34","unstructured":"World Health Organization . Yellow fever: vaccine preventable diseases surveillance standards. 2020."},{"key":"2026042410051588000_16.4.e112217.35","unstructured":"World Health Organization . Technical guidelines for integrated disease surveillance and response (IDSR) in the African Region. 3rd edn. 2019."},{"key":"2026042410051588000_16.4.e112217.36","unstructured":"World Health Organization . Yellow fever strategic response plan. 2016."},{"key":"2026042410051588000_16.4.e112217.37","unstructured":"World Health Organization . Laboratory manual for yellow fever. 2023."},{"key":"2026042410051588000_16.4.e112217.38","unstructured":"World Health Organization . Operational guidance on the use of yellow fever assays in the context of surveillance. 2023."},{"key":"2026042410051588000_16.4.e112217.39","unstructured":"Government of Ghana MoH, National Surveillance Unit . Integrated disease surveillance and response in Ghana. 2015. Available: https:\/\/www.moh.gov.gh\/wp-content\/uploads\/2016\/02\/Integrated-Disease-Surveillance-and-Response-Ghana-Guidelines.pdf"},{"key":"2026042410051588000_16.4.e112217.40","unstructured":"World Health Organization . Risk assessment on yellow fever virus circulation in endemic countries. 2014."},{"key":"2026042410051588000_16.4.e112217.41","unstructured":"Organization WH . Pictorial identification key of important disease vectors in the WHO South-East Asia Region. 2020."},{"key":"2026042410051588000_16.4.e112217.42","unstructured":"Joint F . Guidelines for colonization of aedes mosquito species. Version 1. Joint FAO\/IAEA Division of Nuclear Techniques in Food and Agriculture; 2018."},{"key":"2026042410051588000_16.4.e112217.43","unstructured":"Organization WH . Toolkit for integrated vector management in Sub-Saharan Africa. World Health Organization; 2016."},{"key":"2026042410051588000_16.4.e112217.44","unstructured":"The Pacific Community and World Health Organization . Manual for surveillance and control of aedes vectors in the Pacific. 2020."},{"key":"2026042410051588000_16.4.e112217.45","doi-asserted-by":"crossref","unstructured":"Rueda LM . Pictorial keys for the identification of mosquitoes (Diptera: Culicidae) associated with Dengue Virus Transmission. 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