Dear Dr. Nualnoi,

Thank you very much for submitting your manuscript "Accuracy of rapid lateral flow immunoassays for human leptospirosis diagnosis: a systematic review and meta-analysis" 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. The reviewers appreciated the attention to an important topic. Based on the reviews, we are likely to accept this manuscript for publication, providing that you modify the manuscript according to the review recommendations.

Both have suggested minor revisions to be made. Both reviewers have noted that there is significant heterogeneity among the tests results. The authors should address these points in their revisions accordingly.

Please prepare and submit your revised manuscript within 30 days. If you anticipate any delay, please let us know the expected resubmission date by replying to this email.

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

[1] A letter containing a detailed list of your responses to all 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).

Important additional instructions are given below your reviewer comments.

Thank you again for your submission to our journal. 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,

Manisha Biswal

Academic Editor

PLOS Neglected Tropical Diseases

Ana LTO Nascimento

Section Editor

PLOS Neglected Tropical Diseases

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Both have suggested minor revisions to be made. Both reviewers have noted that there is significant heterogeneity among the tests results. The authors should address these points in their revisions accordingly.

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 objectives of the study are clearly stated, and the study design is appropriate. Databases searched were described, but I miss the "keywords" and specific dates of the search. Selection criteria are there and correct statistical analyses were used to draw conclusions.

Reviewer #2: The objective is clear, and the study design is appropriate, authors were strict in adhering to guidelines and in the review of the selected studies. However, not including articles in Spanish and Portuguese (among other languages) might limit the results as regions that speak these languages produce a lot of research on leptospirosis.

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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: Results are clearly described and match with the methods. Results of the quality assessment are assessed and presented in good quality and understable way.

Reviewer #2: The results are clear and adequate for the type of study, figures, and tables are sufficient and clear, and well complimented with the supplements. However, in your Forest Plot analysis, you show an I2 value of 95.76 for sensitivity and 96.35 for specificity which suggests that the studies included might have been too heterogeneous for a metanalysis.

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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: Conclusions are supported by the data presented. It is not easy to draw conclusions on the sensitivity and specificity of leptospirosis diagnostic LFIs, when there is so much heterogeneity among the tests. This has been explained very well, together with limitations and considerations. Final conclusion in the last paragraph could be a bit more strong.

Reviewer #2: There is no conclusion section, some conclusions are presented in the discussion but a section with the author's main conclusions presented in a clear and summarized way is needed.

Public health relevance of the study results is not well addressed, the authors could take a stand on whether they believe current evidence supports the use of LFIs in clinical practice (exp: useful, not useful, or not enough evidence to determine their usefulness).

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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 editorial comments.

Reviewer #2: I suggest it be accepted after minor modifications.

Line 1: The name registered in PROPERO for the register of the systematic review is different from the name used in this paper (In PROSPERO the authors use the word “Performance”, here they use the word “Accuracy”)

Line 63: Clarify your idea, transmission occurs through direct contact with fluids from infected animals, not the animal itself.

Lines 65-64: Fever might be the most common symptom among patients who seek medical care, but most patients present asymptomatic of interspecific symptoms.

Line 73: Replace “in the genus of” by belonging to the genus

Line 108: IFA is not considered a reference test for the diagnosis of leptospirosis, only MAT, culture, or PCR. However, it can be taken into account because this test generates a quantitative result of 1:400 or a fourfold increase in the control sample. The authors made reference to the reason they included studies that used IFA as a reference test in the discussion (lines 304-306), however, they might consider making this clear in the methodology.

Line 159: Review the grammar of that sentence. (remove “for reasons”)

Line 173: Review the grammar of that sentence. (remove the s from “numbers”, remove the “were”, and remove the “per study” (the variation in sample sizes was among the different studies not within each study))

Lines 184-192: At the start of the paragraph when you cite the number of studies you include the percentage they represent in your sample (lines 184 and 185) however after that you just cite the number of studies without providing the percentage they represent (lines 185, 187, 188, and 192). Use one or the other but try to keep the same format.

Line 379: 20 represents the number of LFIs used by the different studies included in your findings. However, can you state this corresponds to the number of developed and marketed LFIs (remember that you only included studies in English)?

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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: Significant, well-written study, that tries to fill a clinical gap about the accuracy of rapid diagnostic tests for human leptospirosis. Although the heterogenicity of the tests limits the authors to give some clinical relevant directions and novelty, the authors were able to formulate the answers on their objectives.

Reviewer #2: The study was clear and well done, the subject is important because once again. The findings point to the fact that rapid tests (LFIs) do not have an adequate performance for the diagnosis of leptospirosis and the reference tests (MAT, PCR, and culture) are difficult to implement and apply in areas where the disease prevails, which leads to underdiagnosis, under-registration and inadequate treatment.

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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:

Please note that, as a condition of publication, PLOS' data policy requires that you make available all data used to draw the conclusions outlined in your manuscript. Data must be deposited in an appropriate repository, included within the body of the manuscript, or uploaded as supporting information. This includes all numerical values that were used to generate graphs, histograms etc.. For an example see here: http://www.plosbiology.org/article/info%3Adoi%2F10.1371%2Fjournal.pbio.1001908#s5.

Reproducibility:

To enhance the reproducibility of your results, we recommend that you deposit your 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. Additionally, PLOS ONE offers an option to publish peer-reviewed clinical study protocols. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols

References

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article's retracted status in the References list and also include a citation and full reference for the retraction notice.

Attachments

Attachment

Submitted filename: Corrections LFI 02032024.docx

Dear Dr. Nualnoi,

Thank you very much for submitting your manuscript "Accuracy of rapid lateral flow immunoassays for human leptospirosis diagnosis: a systematic review and meta-analysis" 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. The reviewers appreciated the attention to an important topic. Based on the reviews, we are likely to accept this manuscript for publication, providing that you modify the manuscript according to the review recommendations.

Dear Authors,

The revised version was sent to two reviewers who feel it that some minor changes are still required. Please go through their comments and revise as appropriate.

Please prepare and submit your revised manuscript within 30 days. If you anticipate any delay, please let us know the expected resubmission date by replying to this email.

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

[1] A letter containing a detailed list of your responses to all 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).

Important additional instructions are given below your reviewer comments.

Thank you again for your submission to our journal. 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,

Manisha Biswal

Academic Editor

PLOS Neglected Tropical Diseases

Ana LTO Nascimento

Section Editor

PLOS Neglected Tropical Diseases

***********************

Dear Authors,

The revised version was sent to two reviewers who feel it that some minor modifications are required. Please go through their comments and revise as appropriate.

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:

Please note that, as a condition of publication, PLOS' data policy requires that you make available all data used to draw the conclusions outlined in your manuscript. Data must be deposited in an appropriate repository, included within the body of the manuscript, or uploaded as supporting information. This includes all numerical values that were used to generate graphs, histograms etc.. For an example see here: http://www.plosbiology.org/article/info%3Adoi%2F10.1371%2Fjournal.pbio.1001908#s5.

Reproducibility:

To enhance the reproducibility of your results, we recommend that you deposit your 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. Additionally, PLOS ONE offers an option to publish peer-reviewed clinical study protocols. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols

References

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article's retracted status in the References list and also include a citation and full reference for the retraction notice.

Dear Dr. Nualnoi,

We are pleased to inform you that your manuscript 'Accuracy of rapid lateral flow immunoassays for human leptospirosis diagnosis: a systematic review and meta-analysis' 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,

Manisha Biswal

Academic Editor

PLOS Neglected Tropical Diseases

Ana LTO Nascimento

Section Editor

PLOS Neglected Tropical Diseases

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