PONE-D-22-03757The prevalence of molecular markers of resistance to sulfadoxine-pyrimethamine among pregnant women at first antenatal clinic attendance and delivery in the forest-savannah area of GhanaPLOS ONE

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

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Reviewer #1: The present study evaluates the prevalence of the marker mutations associated with antimalarial drugs (Sulphadoxine and pyrimethamine) resistance among pregnant Women at ANC and at the time of delivery in Ghana. The study has been designed well and appropriate statistical tools have been used to analyse the data. I congratulate the authors for providing scientific evidence for monitoring the emergence and spread of drug resistance in malaria endemic country of Ghana.

Major comments:

1. How did you calculate the sample size?

2. Further, why there is variation in total number of samples analysed for different mutations at ANC and at the time of delivery?

3. The average doses compliance was 2.9 doses. It is a known fact that poor doses compliance promotes drug resistance. Kindly discuss the situation of drug resistance in light of doses compliance in discussion section.

Minor comments:

1. Page no. 11, line no 207, the value of percentage should be 83% (157/189) in place of “81%.(157/189)”

2. Page no. 11, line no 213, the value of percentage should be 76.2% (138/181) in place of “72.6 % (138.181)”

3. Page no. 11, line no 215, the value of percentage should be 72% (18/25) in place of “76.2 % (18/25)”

Reviewer #2: The authors have analyzed the proportion of mutant alleles of two drug resistant genes namely Pfdhfr and Pfdhps among Plasmodium falciparum infected pregnant women from Ghana. They compared the allele frequencies prior to the commencement of intermitted treatment during pregnancy with sulfadoxine-pyrimethamine and at the time of delivery. Data generated is interesting and important for evaluating the effectiveness of the treatment and to make the informed policies.

However, it would be interesting if authors could mention any correlation between two sets of samples. The sampling details have been given in their two referred publications. However, whether the set of samples screened at the time of first visit and that the time of delivery are same or not is not mentioned. This information could generate a very interesting data like i) what was the status of infection at the time of delivery? Were most of the women uninfected at the time of delivery? If yes, that means the treatment is effective despite the presence of mutant alleles, ii) if the subjects screened at both times are common, what is the scenario of mutant alleles in them at two time points. Such type of comparison could generate more valuable information.

Authors may give more details of the time of sample collection and the set of participants in the methods section.

Reviewer #3: The author investigated the prevalence of SNPs in two groups of pregnant women with Plasmodium falciparum malaria at the time of enrolment and provided with IPTp-SP and at the time of delivery during 2017-19. Such a data for prevalence of SNPs in pfdhfr and pfdhps genes from various malaria endemic areas of Africa including Ghana is available for year 2010-2017. Data for prevalence of SNPs in pfdhfr and pfdhps genes during IPTp-SP scheme is also available from various part of Africa. However, regular surveillance data on prevalence of SNPs in pfdhfr and pfdhps genes is important for the effectiveness of IPTp-SP. It is here recommended the article for publication after some critical addition of facts in it. Critical revisions are mentioned below;

Major revision;

1. The author needs to change the nomenclature of mutants which is correct in Table-2 but written incorrectly everywhere in text and abstract too, e.g., N51I and C59R instead of C51I and N59R respectively in text and abstract.

2. It is not clear and convincing that why there is only two points of collection of DBS, before commencement and at the time of delivery. Is there no case of malaria around second dose or in-between the pregnancy? If no, then why not DBS collected in such point of time and investigated. Such cases where malaria occurred other than these two points of time of collection, should be included in the analysis and discussion.

3. Results of prevalence of SNPs in the group of n=31 where DBS collected at the time of delivery should be discussed with the respective data of prevalence of SNPs in each pregnant women which must have been collected before commencement of IPTp-SP. However, it is not mentioned that DBS for delivery group-n=31 was collected at commencement of IPTp-SP.

4. In discussion section line no-342 mention about increased selection due to IPTp-SP, which seems inappropriate as the prevalence of snps at the time of delivery or any point of time of collection may be a new infection and is random to get infected with any of the resistant genotype circulated in the studied area. It is suggested here that the explanation of any event of mentioned selection should be provided in discussion.

5. Discussion part should highlight the earlier studies providing the prevalence of these snp’s and genotypes in the studied area, to provide insight to the resistant genotypes in circulation.

6. The discussion should provide insight to the fact mentioned in line no-371 that the effectiveness of IPTp-SP is inferred with the smaller number of infections at the climax of pregnancy. This reduction in number should also compared with the in simultaneous number of malaria cases in the studied area in that particular time period to deduce the effectiveness of IPTp-SP. If an area has less resistant pfdhfr-pfdhps genotypes in circulation, that’s mean moderate prevalence of SP-sensitive phenotypes can straight way justify effectiveness of IPTp-SP, like the condition in this study, then why we need evaluation of effectiveness through such rigorous practice. It is understandable that the prevalence of SNPs will certainly affect the IPTp-Sp and how much needed to study the prevalence of SNP’s during IPTp-SP is to be discussed.

Best

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Reviewer #1: Yes: Dr. Anil Kumar Verma

Reviewer #2: No

Reviewer #3: Yes: PRASHANT MALLICK

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The prevalence of molecular markers of resistance to sulfadoxine-pyrimethamine among pregnant women at first antenatal clinic attendance and delivery in the forest-savannah area of Ghana

PONE-D-22-03757R1

Dear Dr. DOSOO,

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Kind regards,

Aparup Das, Ph. D.

Academic Editor

PLOS ONE

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