PONE-D-23-42213Drug-resistant tuberculosis care and treatment outcomes over the last 15 years in EthiopiaPLOS ONE

Dear Dr. Tesema,

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.

Progress of the TB program in Ethiopia as discussed in this article provides a guide to programs in other countries. The guidance can be strengthened by discussing the results in light of the changing scenario over the period of assessment. Further analysis of data is warranted for this. Additionally, specific comments need to be individually addressed satisfactorily.  

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Yatin N. Dholakia, MD

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PLOS ONE

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

Our sincere and deepest gratitude goes to the USAID-supported Eliminate TB Project for its comprehensive and uninterrupted support of the TB program in Ethiopia, including funding support.

We would like to thank all staff from the project and from federal and regional hospitals who were involved in the data collection and compilation.

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Additional Editor Comments:

Progress of the TB program in Ethiopia as discussed in this article provides a guide to programs in other countries. The guidance can be strengthened by discussing the results in light of the changing scenario over the period of assessment. Further analysis of data is warranted for this.

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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: N/A

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: Yes

Reviewer #2: Yes

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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: Thank you for the opportunity to review the manuscript Tesema et al. Drug-resistant tuberculosis care and treatment outcomes over the last 15 years in Ethiopia.

This paper is a timely contribution to an important topic. A couple of suggestions to strengthen the paper are noted below:

Overall

I think a very valuable piece of evidence but could be strengthened in a couple of key places to help readers who may be less familiar with the health service context of Ethiopia. Have made a couple of suggested.

Title

• Consider adding the study design to the title of the paper

Abstract

• Would benefit from more structure to the abstract. A couple of sentences on the background to the study would be beneficial.

• Could you say more about how many routine surveillance records was included in this analysis.

Main

• Does this study need permission from an ethics committee? My understanding is that the data are predominantly from published data sources or internal reports. None have been declared, though I commend the authors on seeking permission from one of the provincial health bureaus.

• Please clarify whether the routinely collected data used were patient-level data or aggregated summary data used for program management. Please clarify though which potential identifiers were removed to ensure anonymity – and who’s anonymity. Otherwise hard to assess.

• Pg3 ln 57 – please review this sentence as unclear

• Pg 3 ln 64 – suggest stating the burden of tuberculosis and DR-TB specifically in Ethiopia.

• Pg 4 ln 76 – would be good to know what the denominators are of these percentages.

• Were data used only from Oromia province. How generalisability are these findings to other provinces in Ethiopia?

• Pg 7, ln 131 – what does DRS stand for?

• Would suggest a paragraph summarising the context of DR TB care in Ethiopia, before launcing into the details. As currently names of hospitals are mentioned but may not be clear to the reader how they fit into wider service delivery

• Need more information on the statistical analysis done to produce estimates reported on page 10, ln 207.

• Can you explain a bit more why linked to the introduction of XPert MTB/RIF?

• Would be interesting to see data from Oromia versus other regions of Ethiopia – how are they different or similar?

• Pg 12, ln 235 – why were the utilisation of vans not as expected?

• Pg 12, ln 243 – what is HMIS

• These challenges mentioned focused on pastoralists/ people living in more rural regions – were there any important challenges to mention for the urban areas?

• Pg 13, ln 250 How was treatment access defined and assessed? Could improve this by saying … treatment access defined as XXX and assessed through our analysis of YYY data

• Pg 13 ln 251 – 1 what to 67 what?

• Pg 13 ln 261 – how was treatment success defined here?

• Pg 13, ln 267 what is TSR? Try to explain appreviations in each section of the paper before use and if used only once, rather spell it out

• Think that you could strengthen the paper by adding a paragraph describing Ethiopia’s economic situation ex. GDP per capita, proportion of budget spent on health and proportion of health spending from donor funding. Then discuss key health indicators – first overall then tuberculosis specific. Would then follow this with a descriptive paragraph on how the health system is generally organised and then how tuberculosis care and dr-TB care more generally fits into the health service.

Reviewer #2: The authors deserve appreciation for the commendable work in providing a snapshot of progress of TB programme in Ethiopia, specifically with DR-TB services. High treatment success rate among DR-TB patients would be exemplary for several other countries. However, it would be important to make the article more compact and focused by further analysis of the available data. Overall some major changes are required.

1. As of now the challenges and successes of the programme appear to be based on the assumptions of the authors and not coming out of analysis of the available data. While Table 1 presents the timelines of transition and, corresponding enrollment and treatment success rates, it does not demonstrate any link between them.

2. Other issues with Table 1 are - a) It is not easy to make out the annual enrollment while TSR is provided on annual basis, and b) It is not possible to figure out whether TSR is for the year or earlier cohort. This is specifically important to understand any changes to TSR with introduction of a different regimen.

3. It is also known that new tools, technologies and regimen have a gradual, phased introduction. This aspect is not clearly reflected in the manuscript -specifically proportion of population having access to these new developments.

4. As per the introduction, the aim of the manuscript is "assess Ethiopia’s experience in scaling up an ambulatory, decentralized model of care with a good treatment success rate (TSR) while managing multiple regimen transition processes and external shocks." However, the results do not come out very well answering this question, except some generic statements.

5. There are some challenges mentioned under "Challenges encountered during program implementation". However there is no further discussions on how these were specifically addressed or need to be addressed, such as low utilization of mobile vans, postal services, data quality.

6. Similar to #5 above, under the section "Data entry and analysis, one of the themes is "Resource limitation and lack of locally evidenced solutions". There is not much discussion on this aspect later in the manuscript.

7. Overall, it will also be good to include some specific leadership decisions, effective policy implementation process and planning methodology that led to success of the programme.

8. Minor comment - There is a lot of global information provided at the beginning that may not be relevant to the these of the manuscript. You could consider shortening it

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Reviewer #1: No

Reviewer #2: Yes: Vineet Bhatia

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Drug-resistant tuberculosis care and treatment outcomes over the last 15 years in Ethiopia: results from a mixed-method review of trends

PONE-D-23-42213R1

Dear Dr. Emawayish Tesema

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.

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Kind regards,

Yatin N. Dholakia, MD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Progress of the TB program in Ethiopia as discussed in this article provides a guide to programs in other countries.

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

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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

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

Reviewer #2: Yes

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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

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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

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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: (No Response)

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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.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: Yes: Vineet Bhatia

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