Comprehensive occupational health services for healthcare workers in Zimbabwe during the SARS-CoV-2 pandemic

Fungai Kavenga; Hannah M. Rickman; Rudo Chingono; Tinotenda Taruvinga; Takudzwa Marembo; Justen Manasa; Edson Marambire; Grace McHugh; Celia L. Gregson; Tsitsi Bandason; Nicol Redzo; Aspect Maunganidze; Tsitsi Magure; Chiratidzo Ndhlovu; Hilda Mujuru; Simbarashe Rusakaniko; Portia Manangazira; Rashida A. Ferrand; Katharina Kranzer

doi:10.1371/journal.pone.0260261

Peer Review History

Original SubmissionFebruary 1, 2021
29 Mar 2021 Decision Letter - Claudia Marotta, Editor Transfer Alert This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present. PONE-D-21-03459 Comprehensive occupational health services for front-line healthcare workers in Zimbabwe during the SARS-CoV-2 pandemic PLOS ONE Dear Dr. Hannah Rickman, 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 submit your revised manuscript by 21 April. 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: 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, Claudia Marotta Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide 3. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information please specify how verbal/oral consent was recorded. If your study included minors, please state whether you obtained consent from parents or guardians in these cases. If the need for consent was waived by the ethics committee, please include this information. Futhermore, please include a copy of the baseline questionnaire used as a part of the study as Supporting File. 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. Additional Editor Comments (if provided): dear authors follow reviewer suggestions to improve your paper [Note: HTML markup is below. Please do not edit.] 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: Yes Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: 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: No Reviewer #2: 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: Yes Reviewer #2: 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: It looks good sound as first National study, you already mentioned your limitations, be sure about reviewing the language and pilgiarism. Also you can add to your recommendations part related to National policy for health care workers. Reviewer #2: Critical review of the manuscript titled ”Comprehensive occupational health services for front-line healthcare workers in Zimbabwe during the SARS-CoV-2 pandemic” submitted to Archives of Environmental & Occupational Health The authors have set up an occupational health screening service for healthcare workers (HCWs) in Harare, Zimbabwe, in the summer of 2020 at the peak of the first wave of COVID-19 pandemic in the country. The service was voluntarily visited by HCWs from Harare healthcare facilities, where they received a complex screening including symptoms and testing of a series of communicable (SARS-CoV-2, HIV, TB) and non-communicable (obesity, hypertension, diabetes, mental disorders) diseases. The effort is appreciable and the findings in the 27th July and 30th October period are well analysed and presented. The manuscript is written in perfect scientific style and format. I have only a few major and minor comments related to limitations and possible additional analysis of study findings. Major comments 1) The authors mention that the voluntary participation in the screening could introduce selection bias, which certainly exist. To that an important additional information is the size of the source/target population, which is not reported. How big is the source population, i.e. healthcare staff in Harare and at the Parirenyatwa Group of Hospitals? 2) How was the occupational screening service advised? Did the advertisement reach the target population evenly? 3) The title names front-line HCWs as the study population; however, the screening was offered free-of-charge for any HCWs, if I understand correctly. How was the participation of front-line HCWs assured? 4) “All clients were asked about symptoms of COVID-19 including fever, cough, coryzal symptoms, joint pain, headache and loss of smell or taste.” (page6, lines 19-20). How was the set of symptoms determined? E.g. fatigue and chest tightness are also typical symptoms of COVID-19 disease, but not on the list. 5) Who stayed out of SARS-CoV-2 testing? Were they different in any characteristics from those, who accepted testing? 6) “A further 23 clients without symptoms were also tested, of whom 20 (87%) reported contact with someone with COVID-19.” (page10, lines 18-19). It would be interesting to see how the proportion of positive PCR test results varied between groups of different indications for testing. 7) On Figure 1, the proportion of positive results from those tested would give a more valid picture since the absolute number of attendances to the screening service changed with time. 8) Similarly to the tested non-communicable disease, the potential risk factors of COVID-19 positivity could also be analysed (i.e. availability and use of preventive measures, knowledge and attitude), even though there were only a limited number of cases. 9) Was there a question on the possible occupational exposure to COVID-19 patents in a healthcare setting? The authors speculate that most of the SARS-CoV-2 infections are probably community transmissions. It would be interesting to estimate it from available data. 10) “All infections were non-severe, and many were pauci- or asymptomatic.” (page 17, lines 22-23). The study provides only a snapshot about the status of the positively tested participants. Is there follow-up information about the pauci- and asymptomatic cases? Some of them may have developed more severe symptoms later or became long-COVID cases. Minor comments 1) “While the clients waited for screening, a trained researcher administered a baseline questionnaire, which included questions on past medical history, knowledge about COVID-19 prevention and management, attitudes and behaviours related to COVID-19 and availability of PPE and other resources in their workplace.” (page 8, lines 2-5). What about the SSQ questionnaire? Was it not administered with the baseline questionnaire? 2) “Overall 7% (69/951) of clients reported at least one TB symptom but most were unable to produce a sputum sample.” (page 13, lines 16-17). What does “unable to produce a sputum sample” mean? 3) “Secondly, recruitment coincided…” (page 17, line 9). It is actually the third limitation. 4) “We observed significant levels of SARS-CoV-2 infection amongst Zimbabwean healthcare workers,…” (page 17, lines 21-22). The significance of the prevalence of infection depends on the base for comparison. The rate is not high compared to many other places and times. Summary The manuscript discusses the observations of a very important occupational health service for HCWs during the COVID-19 pandemic. The data are correctly analysed and interpreted, and the manuscript is well-written. However, there is room for some clarification and extension of analysis as suggested in the comments. ****** 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: 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.] 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. https://doi.org/10.1371/journal.pone.0260261.r001
Revision 1
1 Jun 2021 Author Response Dear Editor, Thank you for considering our manuscript for publication and for sending comments from peer reviewers. Please find below a detailed response to the editorial comments and reviewers’ comments. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf We have double checked the requirements and have made the necessary changes. 2. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide We are committed to providing open access data, within the confines of producing a de-identified minimal dataset. All participants in the study are healthcare workers within a clearly identifiable (and named) healthcare facility, and there is a substantial risk that individuals could be identified because of a combination of demographic characteristics (e.g. sex and occupation). The principal investigator and collaborators felt that there was an unacceptable risk to participant confidentiality, particularly as these data include sensitive health information (including about HIV status and other chronic illnesses). We have therefore produced a deidentified dataset in which information on occupation and sex has been removed, and ages replaced with age categories, permitting the reproduction of almost all analyses without compromising confidentiality. This follows the guidelines at http://www.bmj.com/content/340/bmj.c181.long as suggested. This dataset has been submitted as part of the re-submission. 3. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information please specify how verbal/oral consent was recorded. If your study included minors, please state whether you obtained consent from parents or guardians in these cases. If the need for consent was waived by the ethics committee, please include this information. Furthermore, please include a copy of the baseline questionnaire used as a part of the study as Supporting File. Thank you. All participants were adults aged over 18; this has been added to the methods. Verbal consent was recorded electronically as part of the clinical questionnaire, with the ethics committees waiving a requirement for written consent; this is documented in the methods section. Questionnaire included as a supporting file. REVIEWER COMMENTS Major comments 1) The authors mention that the voluntary participation in the screening could introduce selection bias, which certainly exist. To that an important additional information is the size of the source/target population, which is not reported. How big is the source population, i.e. healthcare staff in Harare and at the Parirenyatwa Group of Hospitals? Parirenyatwa Group of Hospitals employs an excess of 2000 staff. However, most of the domestic workers and security staff are employed by private companies. In addition, students including those studying nursing, medicine and laboratory sciences, who had access to the screening service are not included in the staff estimates. Furthermore, while Parirenyatwa Group of Hospitals employs more than 2000 staff, the staff contingent actually working during the study period was much smaller. As outlined in the manuscript “As a result of the national lockdown, the facility moved to “emergency operations”, with outpatient services closed from the end of March 2020. Provision of other health services was limited by the industrial action by doctors and nurses.” Given the limitations regarding the size of the catchment population we are unable to provide an estimate about the proportion reached with this service. We have added a line to the methods to explain this. 2) How was the occupational screening service advised? Did the advertisement reach the target population evenly? We have added a line in the methods to explain how the service was advertised. All care was taken to ensure that news of the service reached all work groups, but this was a pragmatic study and data were not collected on how advertisement reached different groups. 3) The title names front-line HCWs as the study population; however, the screening was offered free-of-charge for any HCWs, if I understand correctly. How was the participation of front-line HCWs assured? We appreciate that the distinction of a “front-line” healthcare worker may be misleading, so have removed this descriptor from the title and conclusion. The service was set up to be inclusive from the start, i.e. we encouraged domestics, security staff and also people working as part of the estates (for example those working in the laundry and operating the incinerator) to access the services. These staff members may not be considered “front-line” health care workers, but may have a considerable risk of being exposed to SARS-CoV-2. 4) “All clients were asked about symptoms of COVID-19 including fever, cough, coryzal symptoms, joint pain, headache and loss of smell or taste.” (page6, lines 19-20). How was the set of symptoms determined? E.g. fatigue and chest tightness are also typical symptoms of COVID-19 disease, but not on the list. Thank you – a fuller list of symptoms was also included but is not listed in full in the manuscript – please see questionnaire in Supplementary Materials for more information. At the time of recruitment there was not an internationally-accepted list of symptoms suggestive of possible COVID, so this list was derived from available guidance and consensus medical opinion. 5) Who stayed out of SARS-CoV-2 testing? Were they different in any characteristics from those, who accepted testing? Few participants declined SARS-CoV-2 testing when offered (particularly as there was very limited availability of SARS-CoV-2 testing in Zimbabwe at the time), but data on this were not specifically collected. Of the 66 clients with COVID-19 symptoms, six were not tested. We have included the descriptive characteristics of those not tested for SARS-CoV-2, those testing negative, and those testing positive, as a supplementary table (Supplementary Table 1). 6) “A further 23 clients without symptoms were also tested, of whom 20 (87%) reported contact with someone with COVID-19.” (page10, lines 18-19). It would be interesting to see how the proportion of positive PCR test results varied between groups of different indications for testing. We have included the descriptive characteristics (including contact history) of those not tested for SARS-CoV-2, those testing negative, and those testing positive, as a supplementary table. 7) On Figure 1, the proportion of positive results from those tested would give a more valid picture since the absolute number of attendances to the screening service changed with time. Thank you for the suggestion. We wanted also to demonstrate the finding that, during the first weeks of the service, symptomatic clients predominated leading to a high proportion being tested, and that the balance of service users changed over time as well as the proportion testing positive, and therefore chose to present the data as in Figure 1. 8) Similarly to the tested non-communicable disease, the potential risk factors of COVID-19 positivity could also be analysed (i.e. availability and use of preventive measures, knowledge and attitude), even though there were only a limited number of cases. We considered this, but the low number of cases precluded any meaningful statistical analysis and we therefore did not include this within the main body of the analysis. As the occupational health service continues to operate and to identify additional cases, this may be possible in future analyses. We have included the descriptive characteristics of those not tested for SARS-CoV-2, those testing negative, and those testing positive, as a supplementary table. 9) Was there a question on the possible occupational exposure to COVID-19 patents in a healthcare setting? The authors speculate that most of the SARS-CoV-2 infections are probably community transmissions. It would be interesting to estimate it from available data. We agree that this is an interesting question. Our questionnaire only asked about contact to those with COVID-19, and did not differentiate between occupational and non-occupational exposure. This may be changed for future iterations. 10) “All infections were non-severe, and many were pauci- or asymptomatic.” (page 17, lines 22-23). The study provides only a snapshot about the status of the positively tested participants. Is there follow-up information about the pauci- and asymptomatic cases? Some of them may have developed more severe symptoms later or became long-COVID cases. All participants were followed up until symptoms had fully resolved, and until 14 days from their positive test. We have expanded in the results. Of course it is possible that some participants may have subsequently developed post-COVID syndromes, but at the time follow-up ended all participants were well. Minor comments 1) “While the clients waited for screening, a trained researcher administered a baseline questionnaire, which included questions on past medical history, knowledge about COVID-19 prevention and management, attitudes and behaviours related to COVID-19 and availability of PPE and other resources in their workplace.” (page 8, lines 2-5). What about the SSQ questionnaire? Was it not administered with the baseline questionnaire? Thank you – we have clarified in the methods section. Clients were asked to fill the SSQ questionnaire while they were waiting. The questionnaire was self-administered to ensure that clients had enough time to consider the questions and minimise social-desirability bias. The SSQ questionnaire includes questions which some people may not feel comfortable to answer truthfully when asked by another person, for examples questions on self-harm and crying. The client submitted to questionnaire to the nurse – who checked the score and looked for any answers which would raise red flags. 2) “Overall 7% (69/951) of clients reported at least one TB symptom but most were unable to produce a sputum sample.” (page 13, lines 16-17). What does “unable to produce a sputum sample” mean? Even amongst symptomatic, hospitalised or immunosuppressed cohorts with presumptive TB, a high proportion are unable to spontaneously expectorate a sputum sample. One might expect this proportion to be even higher amongst minimally-symptomatic clients identified in untargeted screening. For infection prevention and control purposes a decision was taken not to perform sputum induction. 3) “Secondly, recruitment coincided…” (page 17, line 9). It is actually the third limitation. Thank you; amended. 4) “We observed significant levels of SARS-CoV-2 infection amongst Zimbabwean healthcare workers,…” (page 17, lines 21-22). The significance of the prevalence of infection depends on the base for comparison. The rate is not high compared to many other places and times. We have edited this to “important” to avoid the suggestion of a statistical comparison. Attachments Attachment Submitted filename: ICAROZ_Response to reviewers.docx https://doi.org/10.1371/journal.pone.0260261.r002
15 Jul 2021 Decision Letter - Muhammad Adrish, Editor PONE-D-21-03459R1 Comprehensive occupational health services for healthcare workers in Zimbabwe during the SARS-CoV-2 pandemic PLOS ONE Dear Dr. Rickman, 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. ============================== ACADEMIC EDITOR: Please review comments made by the reviewer and provide your response in the revised manuscript. ============================== Please submit your revised manuscript by August 14th, 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: 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, Muhammad Adrish, MD, MBA, FCCP, FCCM 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: HTML markup is below. Please do not edit.] 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 #2: (No Response) ******** 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 #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: 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 #2: No ****** 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 #2: 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 #2: Critical review of the revised manuscript titled ”Comprehensive occupational health services for healthcare workers in Zimbabwe during the SARS-CoV-2 pandemic” submitted to PLOS ONE The authors have responded to all the major and minor comments in an acceptable way. Nevertheless, the place of the modifications made in the manuscript are not specified in the responses (line numbers), neither highlighted in the text of the manuscript (track changes or coloured background). Without this, nowadays routinely provided, guiding information I am not able to follow the amendments of the manuscript. I could also find access to the supplementary materials, too, that have also been modified during the revision. I would like to request this additional information from the authors to be able to make a final judgement on the manuscript. ****** 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 #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.] 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. https://doi.org/10.1371/journal.pone.0260261.r003
Revision 2
6 Oct 2021 Author Response Dear Editor, Thank you for considering our manuscript for publication and apologies for the delayed response to comments. Please see below an amended version of the initial response to reviewers, which now includes line references for all changes. As requested by PLOS One, we had uploaded both a tracked changes and a clean, unmarked version of the manuscript, which were both included in the previous submission. The line references refer to the tracked changes version (included second in the submission PDF). We hope this will make the response easier to follow, but please do contact us if there are any additional concerns. We are sorry to hear there were problems with the supplementary materials – these had been uploaded with the previous submission, but we have contacted the journal to make sure these are all accessible and there are no other issues. Kind regards, Dr Hannah Rickman Attachments Attachment Submitted filename: ICAROZ_Response to reviewers_2.docx https://doi.org/10.1371/journal.pone.0260261.r004
8 Nov 2021 Decision Letter - Akihiro Nishi, Editor Comprehensive occupational health services for healthcare workers in Zimbabwe during the SARS-CoV-2 pandemic PONE-D-21-03459R2 Dear Dr. Rickman, 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, Akihiro Nishi, M.D., Dr.P.H. Academic Editor PLOS ONE Additional Editor Comments (optional): The two reviewers upon the original and second submissions are satisfied. I am happy to suggest Accept at this moment. 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 #2: 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 #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: 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 #2: 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 #2: 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 #2: Critical review of the revised manuscript titled ”Comprehensive occupational health services for healthcare workers in Zimbabwe during the SARS-CoV-2 pandemic” submitted to PLOS ONE The authors have provided responses to all the major and minor comments and amended the manuscript at appropriate places. The manuscript is acceptable in the present form. Nevertheless, the authors might consider two further recommendations when finalizing the publication. • The “Contact of TB case” option is duplicated in Q13 of the questionnaire. • The answer given to major comment 7) about Figure 1 could be included in the text for clarification. ****** 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 #2: No https://doi.org/10.1371/journal.pone.0260261.r005
Formally Accepted
15 Nov 2021 Acceptance Letter - Akihiro Nishi, Editor PONE-D-21-03459R2 Comprehensive occupational health services for healthcare workers in Zimbabwe during the SARS-CoV-2 pandemic Dear Dr. Rickman: 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. Akihiro Nishi Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0260261.r006

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .