Response to ReviewersRevised Manuscript with Track ChangesManuscript

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:Journal Requirements:

1) Please ensure that the CRediT author contributions listed for every co-author are completed accurately and in full.

At this stage, the following Authors/Authors require contributions: Oscar Herrera, Stefan Witek-McManus, James Simwanza, Lyson Samikwa, Stella Kepha, Rejoice Msiska, Sean Galagan, Elliott Rogers, Peter Makaula, J. Russell Stothard, Judd Walson, Lazarus Juziwelo, Rachel Pullan, Khumbo Kalua, and Robin Bailey. Please ensure that the full contributions of each author are acknowledged in the "Add/Edit/Remove Authors" section of our submission form.

The list of CRediT author contributions may be found here: https://journals.plos.org/plosntds/s/authorship#loc-author-contributions

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- ® on page: 10.

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7) Please ensure that the funders and grant numbers match between the Financial Disclosure field and the Funding Information tab in your submission form. Note that the funders must be provided in the same order in both places as well. State the initials, alongside each funding source, of each author to receive each grant. For example: "This work was supported by the National Institutes of Health (####### to AM; ###### to CJ) and the National Science Foundation (###### to AM).".

If you did not receive any funding for this study, please simply state: u201cThe authors received no specific funding for this work.u201d

Reviewers' comments:

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: •Robust parasitological methods: Kato-Katz and urine filtration are appropriate and well-established diagnostics for S. mansoni and S. haematobium, respectively.

•Integration of malacological data: This strengthens the ecological relevance of the findings and provides context for ongoing transmission dynamics.

•Clear data association: Clear association between self-reported symptoms (e.g., red urine) and infection supports the reliability of symptom-based surveillance in resource-constrained settings.

Reviewer #2: (No Response)

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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 study revealed a surprisingly high prevalence of S. haematobium (47.7%) and a notable burden of heavy-intensity infections (37.9%), suggesting ongoing transmission despite repeated MDA rounds.

Reviewer #2: (No Response)

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: Using a community-based cross-sectional design nested within the DeWorm3 endline survey, the authors assessed parasitological burden through Kato-Katz and urine filtration, and evaluated behavioral risk factors via questionnaire. A parallel malacological survey at key water contact sites was also conducted. The study revealed a surprisingly high prevalence of S. haematobium (47.7%) and a notable burden of heavy-intensity infections (37.9%), suggesting ongoing transmission despite repeated MDA rounds.

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: 1. Observed weaknesses/Limitations of the study

•Limited age/sex scope: The study focuses solely on male participants aged 10–15, excluding girls and other age groups who may also bear significant burden.

•Low coverage of stool and urine sampling: Only 243 out of 306 participants provided urine samples, and a slightly smaller number completed the risk factor questionnaire, potentially introducing bias or missingness in the risk analysis.

•No serological or antigen-based diagnostics (e.g., POC-CCA or UCP-LF CAA) were included, which limits sensitivity for light infections and hampers comparability with other community-based mapping studies.

•Cross-sectional design limits inference on causality or seasonality, especially as the survey was conducted over just two months (July–August).

•Limited discussion of potential reasons for high S. haematobium despite MDA, such as water contact behaviour patterns, sanitation access, or treatment adherence.

2.Gaps and Suggestions for Manuscript Improvement

•Expand discussion on MDA limitations: The manuscript should further explore why MDA has not reduced heavy infections, discussing factors like coverage accuracy, treatment efficacy, reinfection rates, or drug delivery strategy.

•Broaden risk-factor analysis: Include multivariable regression results (even if not significant) to show which behaviors or exposures were most associated with infection.

•Clarify malacological survey: More detail is needed on snail infection status, cercarial shedding, or snail density trends—critical to linking human and environmental transmission.

•Consider including females in future work: Gendered differences in water contact and school attendance could influence transmission risk. There are no communities with only males only exclusion of the other gender in any study is already bias driven.

•Strengthen conclusions with policy relevance: Offer concrete recommendations, such as inclusion of non-lakeshore areas in control programs, WASH interventions, or entomological surveillance expansion.

Reviewer #2: (No Response)

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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: This study investigates the prevalence and risk factors of schistosomiasis among adolescent boys aged 10–15 years in non-lakeshore, upland communities of Namwera, Mangochi District, Malawi a setting often considered to be at lower risk. Using a community-based cross-sectional design nested within the DeWorm3 endline survey, the authors assessed parasitological burden through Kato-Katz and urine filtration, and evaluated behavioral risk factors via questionnaire. A parallel malacological survey at key water contact sites was also conducted. The study revealed a surprisingly high prevalence of S. haematobium (47.7%) and a notable burden of heavy-intensity infections (37.9%), suggesting ongoing transmission despite repeated MDA rounds.

Reviewer #2: (No Response)

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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

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Attachments

Attachment

Submitted filename: Reviewer Comments.pdf

Dear Dr Herrera,

We are pleased to inform you that your manuscript 'Schistosomiasis amongst adolescent boys in non-lakeshore southern Malawi: Investigating local risk-factors within a nested community-based cross-sectional survey' 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,

Brianna R Beechler, Ph.D., DVM

Academic Editor

PLOS Neglected Tropical Diseases

Francesca Tamarozzi

Section Editor

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

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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 #2: (No Response)

**********

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 #2: (No Response)

**********

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 #2: (No Response)

**********

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 #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 #2: (No Response)

**********

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 #2: Yes:  Jean-Baptiste K. Sékré