PONE-D-21-03031

Trends in non-pharmaceutical intervention (NPI) related community practice for the prevention of COVID-19 in Addis Ababa, Ethiopia

PLOS ONE

Dear Dr. Abera Kumie

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.

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As the Academic Editor, I agree with the reviewers that the topic is an important one and the large number of evaluations  in the setting you describe help to capture the overall poor compliance with the NPIs under study and represents real world observations. I also agree with the reviewers that significant work is required to make this manuscript suitable for publication.

Please address all the reviewer comments with the exception of  Reviewer 2's comments about sample size given this is a descriptive epidemiologic study. You can look at significance of differences between groups and provide some mean and median values where appropriate . Both reviewers commented about the details surrounding the NPIs and would agree more details are required other than a general WHO reference and the respiratory hygiene which is presumably referring to masks wearing needs to be defined more precisely. The references to large amounts of transmission from asymptomatic cases needs  updating  (see  Koh WC, Naing L, Chaw L, Rosledzana MA, Alikhan MF, Jamaludin SA, Amin F, Omar A, Shazli A, Griffith M, Pastore R, Wong J. What do we know about SARS-CoV-2 transmission? A systematic review and meta-analysis of the secondary attack rate and associated risk factors. PLoS One. 2020 Oct 8;15(10):e0240205). You also need to refine what part of the WHO document to which you are referring in reference 14 and the Jefferson review listed as reference 23 has been updated to a recent new date from Nov 2020. The Discussion is too long and unfocused in areas and needs to be tightenmded and agree with the comments of Reviewer 1 in this context. The references are not in the standard format for the Journal and case, formatting, access dates and full urls must be provided.

You are strongly recommended to have someone whose native language is English review since there are many grammatical and syntax errors and it impacts negatively on the readability.

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Please submit your revised manuscript  within 45 calendar days of the receipt of this letter.  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. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

John Conly, MD

Academic Editor

PLOS ONE

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3. Thank you for stating the following in the Acknowledgments Section of your manuscript:

"The data collection was funded by the School of Public Health of Addis

Ababa University. The Authors have contributed professionally in view of supporting the

Ministry of Health in enhancing proactive informed decisions."

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

"The author(s) received no specific funding for this work."

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

4. Please amend the manuscript submission data (via Edit Submission) to include author Abera Kumie.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. 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: Partly

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: No

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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

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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: No

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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: Overall, this is an important area of study given the ongoing COVID-19 pandemic. Public participation with non-pharmaceutical interventions (NPIs) including hand hygiene, respiratory hygiene and physical distancing are crucial to successful containment and prevention of ongoing transmission in the community. Observational studies such as this do help identify areas for improvement.

However, I feel this paper requires significant work before it should be considered for publication. My main concerns are; 1) the lack of statistical analysis with respect to the descriptive data presented and 2) need for language editing and clarity, particularly in the discussion.

ABSTSTRACT

Overall, well written. However, I find the number of observations described in the methods section somewhat confusing and misleading compared to how this is described in the methods section of the paper itself. I would suggest simplifying this description. The statistics presented in the results lack significance analysis (i.e. p-values). I do not think the conclusion in the abstract necessarily match the results described.

INTRODUCTION

Paragraph 1 – “Pre-asymptomatic cases facilitate most of the transmission” Do you mean pre-SYMPTOMATIC here?

Paragraph 2 – I think the first two sentences are not necessary for your background argument.

Paragraph 4 – I think the end of the introduction would benefit from a clearer study objective statement as a separate small paragraph.

METHODS

Paragraph 1 – This paragraph may work better as part of the introduction.

Paragraph 3 – I would clearly state that all age groups (including children) were included in the study population.

Paragraph 4 – It would be helpful to expand on which types of sites (and how many) were included for observation. I would also include more detail about how you observed drivers and public transportation as this was specifically mentioned in the results section.

Paragraph 5 – I would include a copy of the two check lists used in the study.

Paragraph 6 – A minimum of 30 minutes of observation time is suggested but was a maximum time period defined? Why was a standard observation time not used?

Paragraph 7 – With respect to the age variable, I am concerned about the accuracy and reproducibility of estimated age categories used in this study. What is the rationale for why these particular age groupings were used? I would also suggest clearly stating how you defined proper and improper respiratory hygiene, hand hygiene and physical distancing for the purpose of this study, rather than referencing WHO. It would also be important to clarify if both soap/water and hand sanitizers were considered adequate hand hygiene as there is some discussion about this later in the paper.

Paragraph 8 – Descriptive statistics do not appear to be used for analysis. This needs to be defined further in this section, the applied to the data and presented in the results/table section.

Paragraph 9 – With respect to consent, was the public or any of the places of business used as observation sites made aware of this study?

RESULTS, FIGURES AND TABLES

Paragraph 1/Table 1 – Week one appears to be an outlier with respect to number of observations made on a weekday vs weekend compared to the other weeks is there is reason for this? I don’t believe it was addressed in the discussion, either.

Table 2 is not necessary as this data is easily described in the text of paragraph 2.

Paragraph 3/Table 3 – No statistical analysis performed therefore unable to know if differences described are significant based on the number of observations made. Why was transportation presented separately in this table? Why not a breakdown by facility type as well (see my comments regarding figure 3)?

Paragraph 4/Figure 3 – This is interesting data regarding facility type but not particularly clear when presented in this format. I would suggest a breakdown and analysis similar to Table 3.

Paragraph 5 – I think it is important to show the compliance data with all three NPI measurements at the same time as it demonstrates how challenging it can be for the general public to adhere to multiple recommendations at the same time. However, I do not feel the discussion of the various other 2 out of 3 NPI combinations is particularly useful.

Table 4 – The idea of “risk” categories was not defined in the methods or mentioned in the results section. These categories are arbitrary and I do not feel this particular table/analysis should be included.

DISCUSSION AND CONCLUSION

The discussion and conclusions requires a significant amount of editing for clarity. There should also be separate paragraphs specifically addressing limitations of the study as well as specific future interventions or research.

In paragraph 1, use of face masks was considered satisfactory but what is your definition of this? There is no discussion around types of masks, observed donning/doffing procedures, re-using old/soiled masks. These issues may be beyond the scope of this particular study but should be mentioned in the limitations section.

Paragraph 2 suggests that declining compliance with NPIs in other communities is common over time but it would be helpful to have a discussion around why this occurs.

Paragraph 3 addresses how the declaration of a state of emergency and other measures, such as limiting people’s movements in the community, are also important interventions. This paragraph requires some editing to clarify this point and what the impact was specifically in Ethiopia.

Paragraph 4 – There are two competing ideas in this paragraph that need to be separated and explored further. The issue of available soap/water stations versus hand sanitizer is important. It is unclear if hand sanitizer was readily available or if it was included an appropriate method of sanitization in the methods of this study. The second issue is around public education campaigns, specifically around hand hygiene. I public education campaigns should be described and explored further with respect to their effect on this study’s results and include the other NPIs as well.

Paragraph 5 – The last sentence of this paragraph is not necessary and I would suggest removing it. Otherwise, this paragraph is very important. Are there any studies that have attempted to look at physical distancing strategies that could be useful in busy, open air market settings from other countries?

Paragraph 6 –Were religious and cultural leaders involved in promoting NPIs or encouraging celebrating religious days in smaller groups or at home?

Paragraph 7 – This paragraph seems out of place and many sentences are redundant with ideas addressed in other paragraphs.

Reviewer #2: Dear Authors:

Thank you for your effort in putting together this manuscript, covering a very important topic.

Unfortunately, I have several concerns, which will need to be adequately addressed prior to my endorsement of your paper for publication in PLOS ONE. I will outline them as follows:

1. PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, grammatically correct, and unambiguous. Given the number of grammatical errors and confusingly worded statements in your paper, I would strongly suggest that you seek independent editorial assistance prior to submitting a revision. Very importantly, please make it clear that by the term respiratory hygiene, you are referring to masking (as the term respiratory hygiene is also used to describe adherence to cough etiquette).

2. Your data in the results section is simply a description of the percentage of different groups of people that you observed adhering to your there non-pharmaceutical interventions. From what I can tell, there is no described sample size nor is there any testing for statistical significance (with a standard alpha = 0.05 and power typically designated at 80%). Without an inclusion of any hypothesis testing and p-values, one could conceivably state that all of the differences you observed between (and within) different groups over time was due to chance alone. If necessary, you may want to avail of a statistician.

3. It would be helpful if you could describe in more detail the nature of the observations and the observers. Do you believe that there was an element of observer bias over time, and that people changed their behavior because they knew they were being watched in these different settings? Clearly, it appears that adherence to masking increased to a high degree in the context of security force related enforcement. However, why was similar enforcement not seen with physical distancing? (This may have been due to the challenges of enforcing distancing in large crowded areas). It also seems fairly clear that handwashing rates did not increase due, in large part, to a lack of available soap and water as you mention. However, you mention that hand sanitizer use, which is more common amongst youth, was not included in your results. Why is this the case?

4. With respect to your age demographic info (i.e < 18 yo, 18-50 yo and >50 yo), you mention that it was easy to categorize people into these groups based on appearance alone. Although it may be easy to tell a 35 year old apart from a 75 year old, it may have been difficult to tell a 17 year old apart from a 19 year old. Ultimately, these discrete categories seem a bit arbitrary, given that they are "guesstimates" at best.

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: PONE-D-21-03031_reviewer.pdf

PONE-D-21-03031R1

Trends in non-pharmaceutical intervention (NPI) related community practice for the prevention of COVID-19 in Addis Ababa, Ethiopia

PLOS ONE

Dear Dr. 

Thank you for submitting your revised 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 re-revised version of the manuscript that addresses the points raised during the review process.

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You have addressed the majority of the peer reviewer and Academci Editor comments so thank you for your efforts in this regard. The study fulfills a key gap in evaluating "real world" COVID-19 mitigtation measures by the  general public in a large African city and hence are very meaningful. The contents are sound with respect to the study and its results. However the following points  must  be addressed.

1. The  Engish grammar and syntax are not at a standard which would be acceptable. I have taken the liberty of addressing the English grammatical errors throughout the manuscroipt and have placed the corrections in a series of strikethroughs and sticky notes. Please review carefully.and make the changes in the Word version and ensure no scientific content has been altered .

2. The references are in major need of "cleaning" to ensure they are in the appropriate format for the Journal with respect to abbreviations of the journal names, italics for Latin terms, case, punctuation,  etc and must be completely correct.

3. The supplemental files have spelling errors, syntax errors and English grammatical errors and need to be carefully reviewed and approriate corrections made. 

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Please submit your revised manuscript within 30 calendar days of receipt of this letter . 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. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

John Conly, MD

Academic Editor

PLOS ONE

Journal Requirements:

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.

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Attachments

Attachment

Submitted filename: PONE-D-21-03031_R1 Edits by Academic Editor.pdf

PONE-D-21-03031R2

Trends in non-pharmaceutical intervention (NPI) related community practice for the prevention of COVID-19 in Addis Ababa, Ethiopia

PLOS ONE

Dear Dr. Tefera,

Thank you for submitting your revised manuscript to PLOS ONE. There remain several required revisions, mainly in the English grammar, font shifts and cleaning of  references .  Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please see the attached pdf with the suggested changes. 

Please submit your revised manuscript by Oct 15 2021. 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. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ 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 academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• 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, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

John Conly, MD

Academic Editor

PLOS ONE

Journal Requirements:

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.

[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: PONE-D-21-03031_R2 Ehtiopia editor edits.pdf

Trends in non-pharmaceutical intervention (NPI) related community practice for the prevention of COVID-19 in Addis Ababa, Ethiopia

PONE-D-21-03031R3

Dear Dr. Tefera,

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.

There remain some minor typographical errors eg " Despite the p public enforcement," and double periods in places  and the references have case issues and the journal name abbreviations are not all in the correct format. Please work with the publisher to make the necessary corrections. 

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.

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Kind regards,

John Conly, MD

Academic Editor

PLOS ONE