Dear Dr Alshalah,

Thank you very much for submitting your manuscript "From fangs to antidotes: a scoping review on snakebite burden, species, and antivenoms in the Eastern Mediterranean Region" 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.

Both reviewers identified the need of this manuscript due to the neglect of research on envenoming in this region. Both reviewers have suggested substantial, mostly editorial, comments to improve the flow and interpretation of the manuscript for a potential reader. I recommend you apply these suggestions in re-draft for resubmission.

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).

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,

Stuart Robert Ainsworth

Academic Editor

PLOS Neglected Tropical Diseases

José María Gutiérrez

Section 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: See report

Reviewer #2: The objectives of this study are clearly defined and the method design appropriate. Limitations to the methodology are also acknowledged in the discussion.

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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: See report

Reviewer #2: Results are clearly presented. It would be nice to have another figure or two displaying results, but this is understandable as this is not an experimental study but a literature review.

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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: See report

Reviewer #2: Conclusions are supported by the data and its relevance to public health is addressed.

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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: See report

Reviewer #2: This manuscript is well written and provides a good summary of snakebite in the Mediterranean region, which has received considerably less attention than other areas of the world in regard to snakebite. I recommend this manuscript for publication after minor revision.

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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 following points should be addressed:

• Define Eastern Mediterranean countries; this can be in the form of a map.

• In the Supplement IV: Offending Species by country, the authors did not include Atractaspis, there are cases attributed to this snake in Jordan and Saudi Arabia. Also cases caused by Pseudocerastes fieldi were recorded from Jordan

• Citations of some references should be checked such as:

Amr ZS, Abu Baker MA, Warrell DA. Terrestrial venomous snakes and snakebites in the 582 Arab countries of the Middle East. Toxicon Off J Int Soc Toxinology. 2020 Apr 15;177:1–15.

• Some important references on Jordan and Qatar are missing:

Saadeh, A.M., 2001. Case report: acute myocardial infarction complicating a viper bite. Am. J. Trop. Med. Hyg. 64, 280–282. https://doi.org/10.4269/ajtmh.2001.64.280 -for Jordan

Elmoheen, A., Salem, W. A., Haddad, M., Bashir, K., Thomas, S. H. 2020. Experience of Snakebite Envenomation by a Desert Viper in Qatar. Journal of Toxicology. https://doi.org/10.1155/2020/8810741

• In the Supplement IV: it lists 15 species of snakes, while the authors stated that 30 species were Identified indigenous snakes.

• The time specified between 200-2023 caused some discrepancy in the other species that are considered venomous such as Naja sp. in both the Middle East and North Africa. At least these species should be mentioned.

Conclusion

First, I thank the authors for their efforts to outline this review, it is very important for all health officials of countries in the study area. However, the presentation of the results should be improved to facilitate the reader to better understand a sequential, ordered and graphical results.

Graphs, maps and tables that can be extracted from the supplementary data should be incorporated to enhance the final format.

The manuscript should be revised as suggested.

Reviewer #2: The manuscript "From fangs to antidotes: a scoping review on snakebite burden, species, and antivenoms in the Eastern Mediterranean Region is well written and reports on a region that has been neglected in regard to reports on snakebite. My main recommendation are as follows:

1. At least one other figure should be added to help readers visualise the results, as there are few figures in this manuscript. A figure depicting the region studied on a map (all countries evaluated) would add to the manuscript, or could even be an additional panel in Figure 2.

2. Additionally, maybe incorporation of information from venomous snake field guides in this region, it would be good to know what is being reported in the scientific literature vs information from herpetology guidebooks.

3. Lastly, this manuscript might be better considered a systematic review and not a primarily research article?

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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.

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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

Dear Dr Alshalah,

We are pleased to inform you that your manuscript 'From fangs to antidotes: a scoping review on snakebite burden, species, and antivenoms in the Eastern Mediterranean Region' 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,

Stuart Robert Ainsworth

Academic Editor

PLOS Neglected Tropical Diseases

José María Gutiérrez

Section Editor

PLOS Neglected Tropical Diseases

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