Dear Dr. Hasker:

Thank you very much for submitting your manuscript "Post kala azar dermal leishmaniasis and leprosy prevalence and distribution in the Muzaffarpur health and demographic surveillance site" (PNTD-D-19-01032) for review by PLOS Neglected Tropical Diseases. Your manuscript was fully evaluated at the editorial level and by independent peer reviewers. The reviewers appreciated the attention to an important topic but identified some aspects of the manuscript that should be improved.

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Sincerely,

Fabiano Oliveira

Guest Editor

PLOS Neglected Tropical Diseases

Jesus Valenzuela

Deputy Editor

PLOS Neglected Tropical Diseases

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Reviewer's Responses to Questions

Key Review Criteria Required for Acceptance?

As you describe the new analyses required for acceptance, please consider the following:

Methods

-Are the objectives of the study clearly articulated with a clear testable hypothesis stated?

-Is the study design appropriate to address the stated objectives?

-Is the population clearly described and appropriate for the hypothesis being tested?

-Is the sample size sufficient to ensure adequate power to address the hypothesis being tested?

-Were correct statistical analysis used to support conclusions?

-Are there concerns about ethical or regulatory requirements being met?

Reviewer #1: Study objectives, methods, and ethics are clearly described. No comments.

Reviewer #2: Line 78 -79 is repeated in line 93-94

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Results

-Does the analysis presented match the analysis plan?

-Are the results clearly and completely presented?

-Are the figures (Tables, Images) of sufficient quality for clarity?

Reviewer #1: Study results are clearly presented, and matching the analysis plan. No comments.

Reviewer #2: Line 201: Only 4 PKDL suspects – this is quite a low number traditionally from ACD programmes that target PKDL, but may reflect the expertise of the physician and/or the lack of misdiagnosis with leprosy.

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Conclusions

-Are the conclusions supported by the data presented?

-Are the limitations of analysis clearly described?

-Do the authors discuss how these data can be helpful to advance our understanding of the topic under study?

-Is public health relevance addressed?

Reviewer #1: Authors fail to discuss the possible biases in the prevalence estimates, due to sub-optimal performance of the diagnostic confirmation tests used, or to the significant underreporting of adult males in the survey. This may have resulted in an underestimation of the prevalence estimates.

Reviewer #2: (No Response)

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Editorial and Data Presentation Modifications?

Use this section for editorial suggestions as well as relatively minor modifications of existing data that would enhance clarity. If the only modifications needed are minor and/or editorial, you may wish to recommend “Minor Revision” or “Accept”.

Reviewer #1: (No Response)

Reviewer #2: Out of interest were the 276 cases of previous VL found during the survey?

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Summary and General Comments

Use this section to provide overall comments, discuss strengths/weaknesses of the study, novelty, significance, general execution and scholarship. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. If requesting major revision, please articulate the new experiments that are needed.

Reviewer #1: I would like to congratulate the authors with this excellent study. This community survey elucidates the current prevalence of two important skin diseases, which are subject to elimination, and based on a spatial analysis suggests options for case finding strategies to support elimination.

Although I fully agree with the conclusion that a more in-depth cost-effectiveness study from the health system perspective is needed, the discussion on possible case finding strategies remain a bit thin.

Authors suggest skin camps as an efficient and effective case finding strategy, however, only less than 2% of the people attending the skin camps were diagnosed with either leprosy or PKDL. Skin camps are a very resource intensive investment, which would have to be organised with a regular frequency in order to pick up the relatively low number of PKDL and leprosy cases. Should this be a priority in resource allocation for public health in a state, which is suffering from dire poverty and more important public health problems. Moreover, individuals with mild (macular) PKDL lesions may chose not to attend the skin camps, and may decline the treatment, which is long and with significant side effects.

Authors suggest using the ASHAs network in case finding, but do not discuss what role these community health workers could play in active case finding strategies and to what extent they can make clinical (suspect) diagnoses, or how an additional task for skin diseases would compete with other priority tasks in the workload of the ASHAs.

In view of the clear case clustering for leprosy, a strategy of door-to-door screening in the immediate neighbourhood of identified cases could be cost-effective, considering the relatively high prevalence of the disease. However, for PKDL I would like to challenge authors to conclude that there may not be a cost-effective and sustainable case finding strategy, and that this has implications for sustainable VL elimination.

Reviewer #2: Very clear and concisely written paper. Its true that the main limitation of this is validity in other settings that are not so well controlled, but at the same time the incidence and pathophysiological evolution of PKDL should not be much different to elsewhere.

Well done!

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Reviewer #1: No

Reviewer #2: No

Dear Dr. Hasker,

We are pleased to inform you that your manuscript, "Post kala azar dermal leishmaniasis and leprosy prevalence and distribution in the Muzaffarpur health and demographic surveillance site", has been editorially accepted for publication at PLOS Neglected Tropical Diseases.

Before your manuscript can be formally accepted and sent to production you will need to complete our formatting changes, which you will receive in a follow up email. Please note: your manuscript will not be scheduled for publication until you have made the required changes.

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Thank you again for supporting open-access publishing; we are looking forward to publishing your work in PLOS Neglected Tropical Diseases.

Best regards,

Fabiano Oliveira

Guest Editor

PLOS Neglected Tropical Diseases

Jesus Valenzuela

Deputy Editor

PLOS Neglected Tropical Diseases

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