PNTD-D-24-01513

Clinical characteristics and serotype association of dengue and dengue like illness in Pakistan

PLOS Neglected Tropical Diseases

Dear Dr. Iqbal,

Thank you for submitting your manuscript to PLOS Neglected Tropical Diseases. After careful consideration, we feel that it has merit but does not fully meet PLOS Neglected Tropical Diseases's publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript within 60 days Mar 16 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosntds@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pntd/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

* A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. This file does not need to include responses to any formatting updates and technical items listed in the 'Journal Requirements' section below.

* A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

* An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, competing interests statement, or data availability statement, please make these updates within the submission form at the time of resubmission. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Edda Sciutto

Academic Editor

PLOS Neglected Tropical Diseases

Paul Brindley

Editor-in-Chief

PLOS Neglected Tropical Diseases

Shaden Kamhawi

co-Editor-in-Chief

PLOS Neglected Tropical Diseases

orcid.org/0000-0003-4304-636XX

Paul Brindley

co-Editor-in-Chief

PLOS Neglected Tropical Diseases

orcid.org/0000-0003-1765-0002

Additional Editor Comments (if provided):

After reviewed the article entitled "Clinical characteristics and association of dengue serotypes and dengue-like diseases in

Pakistan", we found that the study is well conducted and presents the situation of dengue in patients treated in a tertiary care center in Pakistan.

Although we consider these findings potentially publishable in Plos of Neglected Diseases, the authors must first address the recommendations particularly made by the second reviewer.

Please submit the article including these recommendations, answering reviewer #2's comments one by one to be reviewed.

Journal Requirements:

[Note: HTML markup is below. Please do not edit.]

Reviewers' Comments:

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 clearly articulated with a clear testable hypothesis, and the study design appropriate to address the stated objectives. the sample size sufficient to ensure adequate power to address the hypothesis

Reviewer #2: A minimum sample size should be defined using statistical methods, this was ommitted.

Statistical methods to assess sensitivity and sensibility were not included, which was the gold standard? A detail statistical methodology must be included, and a valid scientific argument of using the selected gold standard according to the nature of the diagnosis of dengue.

**********

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 and completely presented

Reviewer #2: The title 3.2 sensitivity of serological pattern has no relationship with the presented results, as in the results described the sensitivity of clinical diagnosis compared to PCR.

3.5 Clinical Diagnosis of Dengue Mixed Serotypes: Is it possible to present this results in a table, for a better understanding of the data

Figures are not of sufficient quality

**********

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 current study conducted in a large tertiary care center in Pakistan, highlights the profound

impact of Dengue worsened by flooding and poor sanitation, posing considerable challenges to public

health. The high prevalence of Dengue cases emphasizes the urgent need to address the importance of robust infrastructure and sanitation. Immediate measures by authorities are

crucial to control vector populations and protect public health. The main limitation of this study includes

lower number of dengue severe cases and the unavailability of the resources to perform dengue

sequencing for mixed infections.

Reviewer #2: Do the authors discuss how these data can be helpful to advance our understanding of the topic under study? The results and the data obtained, were no use correctly to discuss it

-Is public health relevance addressed? It should be expanded and improved in the discussion

**********

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: Accept

Reviewer #2: (No Response)

**********

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 current study aims to explore the clinical presentations and features of dengue fever in a tertiary care hospital.

Collected data on cases including clinical symptoms and laboratory results including qRT-PCR and serotype characterization. The majority of subjects enrolled (75%) had mild disease without warning signs. The sensitivity

of clinical diagnosis was found to be 87.25% and the specificity of 68.35%. qRT-PCR detected 43.5% of cases

with viral fever initially screened negative. Screening with rapid tests requires further confirmation by molecular assay in cases with dengue and dengue-like illness.

Reviewer #2: A major revision is needed. The main concern is how the sensitivity and specificity results are presented, a rationale for the use of the gold standard is not detailed, and the methodology is not detailed. The discussion is brief, the data was used very little.The discussion should be expanded; nothing is discussed about the clinical findings and the serotypes found.

**********

PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

Figure resubmission:

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. Registration is free. 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 PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. If there are other versions of figure files still present in your submission file inventory at resubmission, please replace them with the PACE-processed versions.

Reproducibility:

To enhance the reproducibility of your results, we recommend that authors of applicable studies 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. 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 Iqbal,

We are pleased to inform you that your manuscript 'Clinical characteristics and serotype association of dengue and dengue like illness in Pakistan' 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,

Edda Sciutto

Academic Editor

PLOS Neglected Tropical Diseases

Paul Brindley

Editor-in-Chief

PLOS Neglected Tropical Diseases

Shaden Kamhawi

co-Editor-in-Chief

PLOS Neglected Tropical Diseases

orcid.org/0000-0003-4304-636XX

Paul Brindley

co-Editor-in-Chief

PLOS Neglected Tropical Diseases

orcid.org/0000-0003-1765-0002

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

In this new version, the authors have addressed and included the clarifications and modifications requested by the reviewers. The article is now acceptable for publication.