An assessment of non-communicable disease mortality among adults in Eastern Uganda, 2010–2016

Davis Natukwatsa; Adaeze C. Wosu; Donald Bruce Ndyomugyenyi; Musa Waibi; Dan Kajungu

doi:10.1371/journal.pone.0248966

Peer Review History

Original SubmissionOctober 20, 2020
1 Dec 2020 Decision Letter - Amir Radfar, Editor PONE-D-20-31885 An analysis of non-communicable disease mortality among adults in Eastern Uganda, 2010-2016 PLOS ONE Dear Dr. NATUKWATSA, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’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 revise the manuscript and address all peer review comments (especially the quality of written English). Please submit your revised manuscript by Jan 15 2021 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 plosone@plos.org. 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Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: No Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes Reviewer #5: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: No Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes Reviewer #5: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes Reviewer #5: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: No Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes Reviewer #5: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: 1. The authors have included adults above 30 years in the study. Adults above 60 years are considered Elderly population. Elderly population usually have many NCDs. 2. Abstract : Keywords : NCD has been repeated. 3. Introduction : Sex may be replaced by Gender in the text and Tables. 4. References - Although relevant references have been cited but they are not uniform. 5. Ref.Nos.7, Name of the journal is missing. 6. Some references are quite old. If possible, cite recent ones. 7. The authors have cited references from Uganda and Nairobi. Is NCD not a problem of other countries ? Try to include relevant references from studies in other countries. Reviewer #2: Dear Authors, Thank you for Very interesting and important work on NCD mortality among the among adults in Eastern Uganda. Abstract, title and references Yes; the aim of the study is clear. It is very clear what the study found and how they did it.; Yes; the title of the study is relevant, self-explanatory and informative but I would like to suggest to omit an analysis of from the title and the title might be "Non-communicable disease mortality among adults in Eastern Uganda, 2010-2016". References are relevant and recent. Authors used the references very correctly and they included all the appropriate key studies. Introduction/background Introduction is explained nicely and justify the importance of the study. It is also explaining the topic in different dimension.; Yes; research question is outlined clearly and aligned with the research problem. Methods Yes; the process of subject selection is clear’.; Yes; this study can be replicated easily with the existing methodology written by the authors. Results Yes; data is presented in an appropriate way and tables are relevant and clearly presented but it will be better if the trends can be presented through 2 to 3 graphs. Titles, columns, and rows labelled correctly and clearly.; Yes; categories grouped appropriately in the tables.; Yes; the text in the results add to the data and is not repetitive and critically discussed in to the text.; Yes; I am clear about what is a statistically significant result.; Yes; I am also clear enough about what is a practically meaningful result. Discussion and Conclusions Yes; the results discussed from multiple angles and placed into context without being overinterpreted.; Yes; the conclusions answered the aims of the study.; Yes; the conclusions supported by results.; No; the limitations of the study are not fatal; and Yes; they are opportunities to inform future research Major Comments ----------------- 1. Yes, the study design appropriate to answer the aim 2. Yes, this study adds something new that is not known on this topic. 3. Yes, the article is consistent within itself Minor Comments ----------------- Need to trend analysis to understand the NCD mortality pattern. Now it is just distribution of NCDs deaths. Reviewer #3: PLOS REVIEW REPORT SUMMARY Use of verbal autopsy to assess premature NCD mortality in resource-poor settings such as rural Eastern Uganda appears appropriate in the absence of country wide civil registration and vital statistics.This study adds to the growing premature NCD mortality data in Africa, even in rural areas. MAJOR ISSUES Lack of comparison of these results with the INDEPTH Network data from multiple sites in Africa. Lack of comparison with epidemiology studies in rural and urban Uganda and and rest of the East Africa region Wide unexplained disparity and fluctuations in mortality rates in different years especially in CVD and diabetes as well as between males and females. Raises questions about the reliability and accuracy of the data. Lack of explanation with the unexpectedly high NCD mortality rates in a rural area in the presence of low NCD risk factors such as obesity rates (5.3%) and other risk factors. In other studies in sub-Saharan Africa, some of the sites reporting the highest rates of NCD mortality were also those with the greatest burden of HIV/AIDS-related mortality. It has been suggested that in such settings, around half of the mortality attributed to NCDs may well be associated with HIV. It is not clear how the authors dealt with this. MINOR ISSUES 1. The use of a probabilistic model to assign cause of death would have been preferable to the use of doctors. OTHER COMMENTS Very useful source of information in the absence of inadequate data in the rest of the country. Similar longitudinal studies would be useful in monitoring NCD mortality trends in other areas of the country to determine more reliable national trends. Despite the HIV, Ebola and the COVID-19 epidemics, for the present as well as the foreseeable future, NCDs will be responsible for the highest morbidity and mortality in sub-Saharan Africa.The findings of studies like this, should spur policy makers to take action to reduce premature adult mortality due to NCDs. Reviewer #4: Title: An analysis of non-communicable disease mortality among adults in Eastern Uganda, 2010-2016 1. Do the title and abstract accurately convey what has been found? Yes, title is ok, but I would use the word “assessment” instead of analysis – this is usually reserved for a novel way of analysis e.g., new statistical analysis method 2. Is the writing acceptable? Yes, writing is acceptable. 3. Are the data sound? Yes, steps followed look sound and well documented 4. Do the figures appear to be genuine, i.e., without evidence of manipulation? Yes, figures appear genuine 5. Does the manuscript adhere to the relevant standards for reporting and data deposition? Yes, standards are adhered to 6. Are the discussion and conclusions well balanced and adequately supported by the data? Yes, but discussion is quite light might need some beefing up. 7. Are limitations of the work clearly stated? Yes, study limitations are clearly stated. 8. Do the authors clearly acknowledge any work upon which they are building, both published and unpublished? Yes, this is done well in the discussion perhaps a little more in the introduction. 9. General Observation Overall, it is a well described and interesting paper that adds to the current body of evidence and speaks to the current NCD burden especially NCD mortality within sub-Saharan Africa generally and Uganda specifically. 10. Minor Essential Revisions • Classification of outcomes - indicate how multiple causes of death or multiple conditions present at time of death were handled and death classified in that case e.g., if at death someone had both Cancer and DM or had both DM and accidental death • Need to reformat the tables to highlight points of interest e.g., bolding or re-aligning or smaller font size for some figures e.g. Table 2 can be better displayed as below 2016 2015 2014 Men Women Overall Men Women Overall Men Women Overall 11.29 19.68 16.78 7.9 21.48 14.91 10.15 21.86 15.02 • Indicate the AAMR units e.g. is it deaths per 10,000 or per 100,000? • Built up the discussion nicely to indicate the burden and CV risk factor profile in Iganga-Mayuge - but do but not tie it up to show how this would lead to a high CVD mortality e.g. o What are the known mortality trends in the region if any e.g. Eastern Uganda, in Uganda or E. Africa? o How do these trends compare with what was found? o How do they compare with regional hospital mortality trends, any surprises there?? o What might account for the anomalies e.g., fewer deaths in females, fewer deaths to DM in 2016 etc.. o How might these data on mortality be useful going forward, perhaps operationally?? 11. Level of interest I think this is a worthwhile study and a timely addition of valuable information to the current body of evidence with regard to NCD mortality in sub-Saharan Africa. 12. Quality of written English Acceptable 13. Declaration of competing interests I declare that I have no competing interests Reviewer #5: The manuscript is technically sound as a verbal autopsy, a well-established method for such study, was utilized. The data also support the major conclusion of the manuscript that NCD is a major cause of death among the study population. However, the recommendation “…….a unified approach towards disease prevention and treatment that focuses on strengthening health systems” seems far fetching as the finding did not allude to any health system issues. ****** 6. 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: Yes: TAHZIBA HUSSAIN Reviewer #2: Yes: Palash Chandra Banik Reviewer #3: Yes: Prof. Peter Lamptey Reviewer #4: No Reviewer #5: Yes:** DR. FEKADU ADUGNA DADI, PUBLIC HEALTH SPECIALIST [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.] 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. Attachments Attachment Submitted filename: Review for PloS - Natukwatsa et al, 2020.docx https://doi.org/10.1371/journal.pone.0248966.r001
Revision 1
18 Feb 2021 Author Response Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: 1. The authors have included adults above 30 years in the study. Adults above 60 years are considered Elderly population. Elderly population usually have many NCDs. Thank you for this comment. Given our modest population, and observations that individuals in low- and middle-income country settings tend to develop and die from NCDs at an earlier age than individuals in high income country settings, we decided to examine NCD mortality in persons aged 30 years and above within our setting. Additionally, we performed age-adjustment to account for confounding by age. 2. Abstract: Keywords: NCD has been repeated. We have deleted the repeated word. 3. Introduction: Sex may be replaced by Gender in the text and Tables. The tables and text have been updated as suggested. 4. References - Although relevant references have been cited but they are not uniform. Thank you for this comment. We have adjusted the references so that they are uniform. 5. Ref.Nos.7, Name of the journal is missing. Name of journal has now been added to Reference No. 7. 6. Some references are quite old. If possible, cite recent ones. Thank you for this comment. We have included more recent citations where possible. For example: Kajungu D, Hirose A, Rutebemberwa E, Pariyo GW, et al. Cohort Profile: The Iganga-Mayuge Health and Demographic Surveillance Site, Uganda (IMHDSS, Uganda). International Journal of Epidemiology 2020 has been referenced in the materials and methods sections. Similarly, Nahimana MR, Nyandwi A, Muhimpundu MA, Olu O, et al. A population-based national estimate of the prevalence and risk factors associated with hypertension in Rwanda: implications for prevention and control. BMC Public Health 2018 has been cited under the discussion section. 7. The authors have cited references from Uganda and Nairobi. Is NCD not a problem of other countries? Try to include relevant references from studies in other countries. Thank you for this comment. More references from sub-Saharan Africa reporting findings from neighboring countries (Kenya, Rwanda, and Tanzania) have now been added to the discussion section. Reviewer #2: We thank the reviewer for recognizing the merits of our study. Below, we have provided point-by-point responses to the reviewer comments Major Comments ----------------- 1. Yes, the study design appropriate to answer the aim 2. Yes, this study adds something new that is not known on this topic. 3. Yes, the article is consistent within itself We thank the reviewer for recognizing the merits of our study Minor Comments ----------------- Need to trend analysis to understand the NCD mortality pattern. Now it is just distribution of NCDs deaths. We agree that a trend analysis would be helpful. However, due to few years of data under consideration (only seven years’ worth of data), the modest size of our population, and the few deaths observed in each year, we decided to focus on NCDs assessment with a possibility of doing trend analyses in subsequent publications when there is enough data. Reviewer #3: PLOS REVIEW REPORT SUMMARY Use of verbal autopsy to assess premature NCD mortality in resource-poor settings such as rural Eastern Uganda appears appropriate in the absence of country wide civil registration and vital statistics. This study adds to the growing premature NCD mortality data in Africa, even in rural areas. We thank the reviewer for recognizing the merits of our study MAJOR ISSUES Lack of comparison of these results with the INDEPTH Network data from multiple sites in Africa. We have now described findings from available peer-reviewed data from verbal autopsy validations and population-based NCD surveys in Africa within the discussion section. Lack of comparison with epidemiology studies in rural and urban Uganda and rest of the East Africa region We have now described findings from other epidemiological studies on the prevalence of NCD risk factors and morbidity within Uganda within the discussion section. Unfortunately, what is lacking are studies about NCD mortality, where much work still remains to be done. This is one of the gaps we aim to help bridge with the current study. Wide unexplained disparity and fluctuations in mortality rates in different years especially in CVD and diabetes as well as between males and females. Raises questions about the reliability and accuracy of the data. We agree with the reviewer that these disparities and fluctuations raise concerns. However, this is to be expected as our study was conducted in a very modest population over a relatively short period of time. Thus, even a few deaths can greatly influence the estimates in a given year. What we hope readers take away is that the findings show that NCDs contribute to a large proportion of deaths among adults, and there appear to be differences in some NCD mortality patterns between men and women. These differences warrant further exploration. In addition, interventions are needed to reduce NCD risk factors, morbidity, and mortality. Lack of explanation with the unexpectedly high NCD mortality rates in a rural area in the presence of low NCD risk factors such as obesity rates (5.3%) and other risk factors. Thank you for this comment. We note that other studies have shown substantial prevalence of various NCD risk factors in the Iganga and Mayuge communities. However, the mechanisms underlying the NCD mortality rates observed in our setting are not fully understood. We hope to study the potential social and metabolic mechanisms behind NCD mortality rates in this population in greater detail in future. In other studies in sub-Saharan Africa, some of the sites reporting the highest rates of NCD mortality were also those with the greatest burden of HIV/AIDS-related mortality. It has been suggested that in such settings, around half of the mortality attributed to NCDs may well be associated with HIV. It is not clear how the authors dealt with this. Thank you for this comment. However, we were unable to comprehensively examine the influence of HIV; this is a limitation of our study. MINOR ISSUES 1. The use of a probabilistic model to assign cause of death would have been preferable to the use of doctors. We would like to thank the reviewer for this comment. The use of physician review to assign cause of death is the method used by the Iganga-Mayuge Health and Demographic Surveillance Site, and thus what our analysis was based upon. OTHER COMMENTS Very useful source of information in the absence of inadequate data in the rest of the country. Similar longitudinal studies would be useful in monitoring NCD mortality trends in other areas of the country to determine more reliable national trends. Despite the HIV, Ebola and the COVID-19 epidemics, for the present as well as the foreseeable future, NCDs will be responsible for the highest morbidity and mortality in sub-Saharan Africa. The findings of studies like this, should spur policy makers to take action to reduce premature adult mortality due to NCDs. We thank the reviewer for recognizing the merits of our study. Reviewer #4: Title: An analysis of non-communicable disease mortality among adults in Eastern Uganda, 2010-2016 1. Do the title and abstract accurately convey what has been found? Yes, title is ok, but I would use the word “assessment” instead of analysis – this is usually reserved for a novel way of analysis e.g., new statistical analysis method Thank you for this comment. We have now modified the title and used the word assessment instead of analysis 2. Is the writing acceptable? Yes, writing is acceptable. 3. Are the data sound? Yes, steps followed look sound and well documented 4. Do the figures appear to be genuine, i.e., without evidence of manipulation? Yes, figures appear genuine 5. Does the manuscript adhere to the relevant standards for reporting and data deposition? Yes, standards are adhered to 6. Are the discussion and conclusions well balanced and adequately supported by the data? Yes, but discussion is quite light might need some beefing up. We have added additional information within the discussion. 7. Are limitations of the work clearly stated? Yes, study limitations are clearly stated. 8. Do the authors clearly acknowledge any work upon which they are building, both published and unpublished? Yes, this is done well in the discussion perhaps a little more in the introduction. Thank you for this comment and for acknowledging the work that has been put together. 9. General Observation Overall, it is a well described and interesting paper that adds to the current body of evidence and speaks to the current NCD burden especially NCD mortality within sub-Saharan Africa generally and Uganda specifically. 10. Minor Essential Revisions • Classification of outcomes - indicate how multiple causes of death or multiple conditions present at time of death were handled and death classified in that case e.g., if at death someone had both Cancer and DM or had both DM and accidental death This is a good point! In scenarios where there were multiple causes of deaths, we relied on information from physicians who would compare results and establish the most probable cause of death. We have noted the inability to account for multiple causes of death as a limitation in our discussion section. • Need to reformat the tables to highlight points of interest e.g., bolding or re-aligning or smaller font size for some figures e.g. Table 2 can be better displayed as below 2016 2015 2014 Men Women Overall Men Women Overall Men Women Overall 11.29 19.68 16.78 7.9 21.48 14.91 10.15 21.86 15.02 We appreciate the advice. After trying a number of different reformats, we made the decision to leave Table 2 as it was, in order to allow the reader easily have information to compare across the years and across genders. The table is to enable the reader to reference/confirm the results we report in the text, e.g., cardiovascular disease death rates are higher for women than for men. • Indicate the AAMR units e.g. is it deaths per 10,000 or per 100,000? We have indicated the units in the title for the table due to limited space within the table. We also included a note in the last row of the table to state that the age-adjusted mortality rates are expressed per 10,000 persons. • Built up the discussion nicely to indicate the burden and CV risk factor profile in Iganga-Mayuge - but do but not tie it up to show how this would lead to a high CVD mortality e.g. o What are the known mortality trends in the region if any e.g. Eastern Uganda, in Uganda or E. Africa? Thank you for the comment and advice. We have made amendments to the discussion section. Unfortunately, studies are still limited about NCD mortality in Uganda and neighboring countries, especially within population-based settings. This is one of the gaps we aim to help bridge with the current study. o How do these trends compare with what was found? The trends are congruent with findings of a substantial prevalence of NCD risk factors and disease burden in the region. Although there is a dearth of hospital or community-based studies on NCD mortality in the East Africa region, we identified a study reporting on disability adjusted life years (DALYs) due to NCDs in Kenya for the period of 1990-2016; this study found increasing DALYs over the time period. We have referenced the study within the discussion section. In addition, we have referenced the NCD mortality trends study we identified which was based on four-year retrospective data from Mulago Hospital. o How do they compare with regional hospital mortality trends, any surprises there?? Please see comment above o What might account for the anomalies e.g., fewer deaths in females, fewer deaths to DM in 2016 etc.. Fluctuations and anomalies may be partly explained by our small sample size. Thus, after stratification by year, even a few deaths can have great influence on estimated mortality rates. We are careful about our speculations about the observed anomalies, as they require further study to provide explanations. o How might these data on mortality be useful going forward, perhaps operationally?? Thank you for this comment. The findings provide a useful baseline from which to track future trends in NCD mortality and to add knowledge to the existing literature on NCD mortality in Uganda and sub-Saharan Africa more generally, where there is currently limited data on NCD mortality. 11. Level of interest I think this is a worthwhile study and a timely addition of valuable information to the current body of evidence with regard to NCD mortality in sub-Saharan Africa. 12. Quality of written English Acceptable 13. Declaration of competing interests I declare that I have no competing interests Reviewer #5: The manuscript is technically sound as a verbal autopsy, a well-established method for such study, was utilized. The data also support the major conclusion of the manuscript that NCD is a major cause of death among the study population. However, the recommendation “…….a unified approach towards disease prevention and treatment that focuses on strengthening health systems” seems far fetching as the finding did not allude to any health system issues. Thank you for this comment. The statement has been revised accordingly. Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0248966.r002
9 Mar 2021 Decision Letter - Amir Radfar, Editor An assessment of non-communicable disease mortality among adults in Eastern Uganda, 2010-2016 PONE-D-20-31885R1 Dear Dr. NATUKWATSA, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Amir Radfar, MD,MPH,MSc,DHSc Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed Reviewer #4: All comments have been addressed Reviewer #5: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes Reviewer #4: Yes Reviewer #5: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #4: Yes Reviewer #5: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes Reviewer #4: Yes Reviewer #5: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes Reviewer #4: Yes Reviewer #5: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: I have gone through the revised manuscript entitled, “An analysis of non-communicable disease mortality among adults in Eastern Uganda,2010-2016” carefully. The authors have incorporated the changes as suggested in the last review. With all good wishes, Reviewer #2: Now the manuscript is more improved and can be published in the journal in the present form. It is a very interesting and important study from Uganda. We know that we have very limited data from African region particularly in younger age group people. Best wishes. Reviewer #4: I am satisfied with the changes made and responses to my original review. With the exception of the table alignments (which they have justified somewhat). I think the authors have done good job at addressing the issues I raised. Reviewer #5: The manuscript is presented well and written in standard English. However, it needs proofreading (edits) as there are some grammatical errors. Eg. on page 12, fourth line from bottom, the phrase "........aged ≥ 18 years and over......." is redundant (the symbol is not required). ****** 7. 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: Yes: TAHZIBA HUSSAIN Reviewer #2: Yes:** Palash Chandra Banik Reviewer #4: No Reviewer #5: No https://doi.org/10.1371/journal.pone.0248966.r003
Formally Accepted
12 Mar 2021 Acceptance Letter - Amir Radfar, Editor PONE-D-20-31885R1 An assessment of non-communicable disease mortality among adults in Eastern Uganda, 2010-2016 Dear Dr. Natukwatsa: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Amir Radfar Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0248966.r004

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