Dear Dr Marquiony Marques dos Santos

Thank you very much for submitting your manuscript "Weaknesses in primary health care favor the growth of acquired syphilis" for consideration at PLOS Neglected Tropical Diseases. As with all papers reviewed by the journal, your manuscript was reviewed by members of the editorial board and by several independent reviewers. In light of the reviews (below this email), we would like to invite the resubmission of a significantly-revised version that takes into account the reviewers' comments.

We cannot make any decision about publication until we have seen the revised manuscript and your response to the reviewers' comments. Your revised manuscript is also likely to be sent to reviewers for further evaluation.

When you are ready to resubmit, please upload the following:

[1] A letter containing a detailed list of your responses to the review comments and a description of the changes you have made in the manuscript. Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

[2] Two versions of the revised manuscript: one with either highlights or tracked changes denoting where the text has been changed; the other a clean version (uploaded as the manuscript file).

Editors' comments:

- Please present descriptive data in the abstract (number of cases, most important findings from descriptive analysis)

- The presentation of the formula for calculation of AAPC is not necessary - a citation of a reference will be sufficient.

Important additional instructions are given below your reviewer comments.

Please prepare and submit your revised manuscript within 60 days. If you anticipate any delay, please let us know the expected resubmission date by replying to this email. Please note that revised manuscripts received after the 60-day due date may require evaluation and peer review similar to newly submitted manuscripts.

Thank you again for your submission. We hope that our editorial process has been constructive so far, and we welcome your feedback at any time. Please don't hesitate to contact us if you have any questions or comments.

Sincerely,

Jorg Heukelbach

Guest Editor

PLOS Neglected Tropical Diseases

Olivier Chosidow

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: The methods used for the study were acceptable.

Reviewer #2: The objectives of the study are clearly articulated with a clear and testable hypothesis. The study design, as well as the sample (criteria and size) and its time frame are sufficient to meet the stated objectives and for the tested hypothesis.

The analyzes used support the considerations in the present work. The study used secondary, non-collectible ethical data involved.

Although not mandatory, a suggestion that can add even more value to the present study is based on the fact that these data are part of a national project for Rapid Response to Syphilis in Primary Health Care Networks, this project started in Brazil, approximately in 2018, and one of the objectives is to strengthen the fight against syphilis in priority municipalities in Brazil in primary health care, therefore, I suggest that the analyzes include data from 2019, since these actions of supporters in PHC teams can , or not, impact the findings presented until 2018.

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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: The results are clearly presented; however Table 1, 2 and 3 need to be modified with shading or lines to separate the data presented for each variable. The current presentation makes it difficult for a readers eye to follow the row across.

Reviewer #2: The results are clear and consistent, despite the large number of variables and municipalities involved, the tables and charts are clear and are necessary for understanding the study.

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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: The authors concludes are well described ans supported by the data analyzed.

The authors did a nice job describing how the data illuminate the public health crisis in Brazil and areas which could be improved to help reduce the number of acquired syphilis cases.

Reviewer #2: The conclusions presented are extremely important for coping with Syphilis Acquired in Brazil.

One of the limitations that the authors do not present is to consider the continental dimension of Brazil, which comprises many sociodemographic differences and inequality in health care coverage in the country, the latter being an important factor in discussing these results.

This study type of study is very important for Public Health, as it relates the service at PHC and the trend of acquired syphilis cases, since in Brazil, it is these teams in primary health care that are at the forefront of coping to that epidemic.

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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: A few minor revisions are required:

1. The author needs to define HDI when it first appear in the document.

2. The Tables need to be reformatted to allow for easier interpretation by the readers. Addition of shading or lines should improve this issue.

3. If the data are available, it's recommenced that the authors include a table with specifics about the cohort reviewed (e.g. sex, mean age, sexual preference, stage of diagnosed syphilis, etc)

3. On lines 75-77, the authors need to clarify what "group" is they are considering neglected.

Reviewer #2: The suggestion would be to review the data including the 2019 data in the analyzes, as already indicated in the comments on the method.

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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: The manuscript by Marques dos Santos, et al. supports the idea that modification to Brazil's primary health care systems could help reduces the number of acquire syphilis cases. In general the manuscript is well written and with the minor revisions, this manuscript will help other regions globally to investigate similar factors such as primary health care and sociodemographic structures, and with attention could significantly influence a reduction in syphilis cases.

Reviewer #2: The article discusses an acquired syphilis that has its rates increasing worldwide. This article presents the perspective of the tendency of Syphilis Acquired with Primary Health Care, this look will contribute a lot to the understanding of the increase of an easily treatable and dysagnotic disease, but despite that, its rates continue to increase.

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Reviewer #1: No

Reviewer #2: No

Figure Files:

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org.

Data Requirements:

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Reproducibility:

To enhance the reproducibility of your results, PLOS recommends that you deposit laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see https://journals.plos.org/plosntds/s/submission-guidelines#loc-methods

Dear Colleague

To:Marquiony Marques dos Santos

We are pleased to inform you that your manuscript 'Weaknesses in primary health care favor the growth of acquired syphilis' has been provisionally accepted for publication in PLOS Neglected Tropical Diseases.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests.

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

Should you, your institution's press office or the journal office choose to press release your paper, you will automatically be opted out of early publication. We ask that you notify us now if you or your institution is planning to press release the article. All press must be co-ordinated with PLOS.

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

Best regards,

Olivier Chosidow

Deputy Editor

PLOS Neglected Tropical Diseases

Olivier Chosidow

Deputy Editor

PLOS Neglected Tropical Diseases

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