PONE-D-23-33355Effects of gestational age on blood cortisol and prolactin levels during pregnancy in malaria endemic areaPLOS ONE

Dear Dr. Kiemde,

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 Mar 16 2024 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. 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,

Ibrahim Sebutu Bello, MBBS, MPH, MD, FMCGP

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. Note from Emily Chenette, Editor in Chief of PLOS ONE, and Iain Hrynaszkiewicz, Director of Open Research Solutions at PLOS: Did you know that depositing data in a repository is associated with up to a 25% citation advantage (https://doi.org/10.1371/journal.pone.0230416)? If you’ve not already done so, consider depositing your raw data in a repository to ensure your work is read, appreciated and cited by the largest possible audience. You’ll also earn an Accessible Data icon on your published paper if you deposit your data in any participating repository (https://plos.org/open-science/open-data/#accessible-data).

3. Thank you for stating the following financial disclosure: "International Society for Infectious Diseases (ISID), Small Grant 2014, “Determination of cytotoxicity of NK cells against erythrocytes infected by Plasmodium Falciparum during pregnancy”."

Please state what role the funders took in the study.  If the funders had no role, please state: ""The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."" 

If this statement is not correct you must amend it as needed. 

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

4. We note that your Data Availability Statement is currently as follows: All relevant data are within the paper.

Please confirm at this time whether or not your submission contains all raw data required to replicate the results of your study. Authors must share the “minimal data set” for their submission. PLOS defines the minimal data set to consist of the data required to replicate all study findings reported in the article, as well as related metadata and methods (https://journals.plos.org/plosone/s/data-availability#loc-minimal-data-set-definition).

For example, authors should submit the following data:

- The values behind the means, standard deviations and other measures reported;

- The values used to build graphs;

- The points extracted from images for analysis.

Authors do not need to submit their entire data set if only a portion of the data was used in the reported study.

If your submission does not contain these data, please either upload them as Supporting Information files or deposit them to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories.

If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) 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. If data are owned by a third party, please indicate how others may request data access.

5. We note that Figure 1 in your submission contain [map/satellite] images which may be copyrighted. All PLOS content is published under the Creative Commons Attribution License (CC BY 4.0), which means that the manuscript, images, and Supporting Information files will be freely available online, and any third party is permitted to access, download, copy, distribute, and use these materials in any way, even commercially, with proper attribution. For these reasons, we cannot publish previously copyrighted maps or satellite images created using proprietary data, such as Google software (Google Maps, Street View, and Earth). For more information, see our copyright guidelines: http://journals.plos.org/plosone/s/licenses-and-copyright.

We require you to either (1) present written permission from the copyright holder to publish these figures specifically under the CC BY 4.0 license, or (2) remove the figures from your submission:

a. You may seek permission from the original copyright holder of Figure 1 to publish the content specifically under the CC BY 4.0 license.  

We recommend that you contact the original copyright holder with the Content Permission Form (http://journals.plos.org/plosone/s/file?id=7c09/content-permission-form.pdf) and the following text:

“I request permission for the open-access journal PLOS ONE to publish XXX under the Creative Commons Attribution License (CCAL) CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/). Please be aware that this license allows unrestricted use and distribution, even commercially, by third parties. Please reply and provide explicit written permission to publish XXX under a CC BY license and complete the attached form.”

Please upload the completed Content Permission Form or other proof of granted permissions as an ""Other"" file with your submission.

In the figure caption of the copyrighted figure, please include the following text: “Reprinted from [ref] under a CC BY license, with permission from [name of publisher], original copyright [original copyright year].”

b. If you are unable to obtain permission from the original copyright holder to publish these figures under the CC BY 4.0 license or if the copyright holder’s requirements are incompatible with the CC BY 4.0 license, please either i) remove the figure or ii) supply a replacement figure that complies with the CC BY 4.0 license. Please check copyright information on all replacement figures and update the figure caption with source information. If applicable, please specify in the figure caption text when a figure is similar but not identical to the original image and is therefore for illustrative purposes only.

The following resources for replacing copyrighted map figures may be helpful:

USGS National Map Viewer (public domain): http://viewer.nationalmap.gov/viewer/

The Gateway to Astronaut Photography of Earth (public domain): http://eol.jsc.nasa.gov/sseop/clickmap/

Maps at the CIA (public domain): https://www.cia.gov/library/publications/the-world-factbook/index.html and https://www.cia.gov/library/publications/cia-maps-publications/index.html

NASA Earth Observatory (public domain): http://earthobservatory.nasa.gov/

Landsat: http://landsat.visibleearth.nasa.gov/

USGS EROS (Earth Resources Observatory and Science (EROS) Center) (public domain): http://eros.usgs.gov/#

Natural Earth (public domain): http://www.naturalearthdata.com/

6. We notice that your supplementary tables are included in the manuscript file. Please remove them and upload them with the file type 'Supporting Information'. Please ensure that each Supporting Information file has a legend listed in the manuscript after the references list.

[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: Partly

Reviewer #2: Partly

**********

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

Reviewer #1: No

Reviewer #2: I Don't Know

**********

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

**********

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: The manuscript investigates the effect of gestation on cortisol and prolactin levels in pregnant women, comparing primigravidae and multigravidae. The study design, methodology, and data analysis are well-described, and the results are presented clearly and concisely. The discussion adequately interprets the findings in the context of existing literature.

Major Comments:

1. Background:

o The introduction could be strengthened by providing a more focused review of the role of cortisol and prolactin in pregnant women, particularly in relation to immune function and stress response.

o The concept of "suppression of (some) immune responses" could be further elaborated upon, differentiating between specific types of immune responses and the nuances involved.

2. Methods:

o The inclusion and exclusion criteria for participants should be clearly stated, especially for the control groups.

o It would be helpful to explain the rationale behind the chosen time points for sample collection.

o The description of the laboratory procedures could be expanded to include details such as the manufacturers and specific kits used for the cortisol and prolactin assays.

3. Results:

o The tables and figures could be improved by adding more descriptive captions and legends.

o Consider including statistical tests and p-values in the figures directly.

o It would be helpful to present the results of the correlation analysis between cortisol and prolactin in a separate table.

4. Discussion:

o The discussion could be strengthened by addressing limitations of the study, such as the relatively small sample size and potential confounding factors.

o Consider including more references to support the claims made about the roles of cortisol and prolactin in pregnancy.

Minor Comments:

• Consider using a consistent formatting style for references throughout the manuscript.

• Ensure that all abbreviations are defined upon first use.

• Check for typos and grammatical errors.

Specific Points:

• Page 5: Define IPT (immunologic pregnancy test).

• Page 6: Explain how the detection limit of 100 ng/ml for prolactin was adjusted for higher concentrations.

• Page 7: Clarify what is meant by "non-response" in the sample size calculation.

• Page 7: Mention the statistical test used for comparing cortisol and prolactin concentrations between gravidity groups.

• Page 7: Specify the factors included in the LMER model for assessing the interplay between cortisol and prolactin.

Overall, the manuscript presents valuable data on the modulation of cortisol and prolactin levels during pregnancy. Addressing the major and minor comments will further strengthen the manuscript and improve its clarity and impact.

Reviewer #2: REVIEW COMMENTS

TITLE: Effects of gestational age on blood cortisol and prolactin levels during pregnancy in malaria endemic area

The study investigated a rather interesting and pertinent topic and the manuscript was generally well written. The specific issues that need to be addressed to improve the report are highlighted below. There are also some grammatical errors here and there that should be corrected eg. ”Primigravidae showed a higher increase of cortisol than multigravidae during pregnancy with statistically significant different(ce)”

Background

1. The first two paragraphs of the background do not appear to be relevant to the present manuscript but rather to the overall study. The background can start with the 3rd paragraph and then expanded a little bit.

Methods

2. The inclusion and exclusion criteria should be more explicit.

3. Were those with twin gestation excluded? Were women with malaria symptoms excluded, or there was no case of symptomatic malaria among those with positive tests? Only cases of asymptomatic malaria infection were mentioned in the result. This may need to be clarified. This information is more imperative considering that “Malaria, caused by Plasmodium falciparum, remains the first cause of medical consultation in pregnant women in this region…”

4. Were there any loss to follow-up or incomplete data??? If all the patients enrolled at baseline ended up completing the study. It is good to know what measures were made that ensured all respondents attended all follow-up visits, delivered at the facilities, and attended PNC.

5. Where and how were the controls recruited?

6. Sample size: the ideal way to adjust for 10% attrition is: Sample size / (1 – attrition rate)

7. Data analysis: a bit more detail would be in order. For example, which statistical test was used for the difference in quantitative variables between groups eg. hormone concentrations at delivery between babies and mothers (table 2), and between primigravidae and multigravidae (table 3), etc.

Results

8. Mode of delivery: was the mode of delivery the same (vaginal?) for all pregnant women? Did authors consider the possibility of the effect of the mode of delivery on the hormone concentration, especially cortisol, at V4-delivery?

9. Variation of cortisol during pregnancy: concerning the p-value of 0.024 in this sentence “Primigravidae showed a higher increase of cortisol than multigravidae during pregnancy with statistically significant different (p=0.024)” and also in figure 2, is it speaking to the difference in the increase between the two groups or the difference in the repeated measures across different visits for ALL pregnant respondents?

10. Variation of cortisol during pregnancy: “A gradual increase in cortisol concentrations from the enrolment to delivery was observed …with the highest concentrations measured at delivery…” This statement did not reflect the fact that there was no increase, but a decrease btw V2 and V3.

11. Variation of prolactin during pregnancy: Authors stated: “Nevertheless, the difference was not statistically significant during the follow-up (p=0.6).” Is this referring to the entire 6 visits? If that’s so, how does that juxtapose with the next statement starting with: “The (increase in??) concentration of prolactin was statistically significant from visit…”. If the latter was based on post-hoc analyses, it should be stated in the data analysis section, along with the specific statistical test used.

12. Figures 2&3: There is an indication that an ANOVA test was used for the analyses. Such information should be included in the data analysis section. However, considering the way the cortisol and prolactin concentrations were summarized and presented using the median, it suggests that they were NOT normally distributed (which can also be deduced from the box plots), hence a non-parametric alternative to repeated measure ANOVA may be more appropriate.

13. In all relevant tables, I suggest that Q1-Q3 be replaced with IQR, to synchronise with the way it was represented in the main text

14. Table 3: Some p-values are incorrectly written, have commas

15. Table 3: Kindly crosscheck the title, seems should be “Stratification….by gravidity….”

16. In all relevant tables, I suggest that Q1-Q3 be replaced with IQR, to synchronise with the way it was represented in the main text

17. Table 3: Some p-values are incorrectly written, have commas

18. Table 3: Kindly crosscheck the title, seems should be “Stratification….by gravidity….”

Discussion

19. In the study, while cortisol increased with GA, malaria positivity decreased. Hence, the following statement does not seem to be completely supported by the study findings: “The increase of prolactin and cortisol levels during pregnancy with the high impact of down regulation of cortisol on prolactin compared to prolactin on cortisol suggests that sustained increase of cortisol concentration can explain the increased susceptibility of pregnant women, particularly in primigravidae who live in malaria endemic areas”.

20. Conclusion: This needs to be revised for the following reasons:

a) The statement “…except for primigravidae pregnant women for whom this hormone decreases at delivery” is not true for cortisol”.

b) I have concerns about the conclusion of a ‘negative correlation’ based on the interpretation of the results. Negative correlation suggests that they were moving in the opposite direction i.e. while one was increasing, the other was decreasing. It seems to me that the interpretation should rather be that the rate or pattern of increase was different for both hormones i.e. the rate was higher for one than for the other, because to a large extent, both increased from baseline.

**********

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: Abhilasha Sharma

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.

Attachments

Attachment

Submitted filename: comments.docx

PONE-D-23-33355R1Effects of gestational age on blood cortisol and prolactin levels during pregnancy in malaria endemic areaPLOS ONE

Dear Dr. Kiemde,

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 Jul 08 2024 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. 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,

Ibrahim Sebutu Bello, MBBS, MPH, MD, FMCGP

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.

Additional Editor Comments:

Kindly provide a response to all the issues raised by the reviewer

[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: All comments have been addressed

Reviewer #3: 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: Partly

Reviewer #3: Yes

**********

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

Reviewer #2: N/A

Reviewer #3: 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

Reviewer #3: 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

Reviewer #3: 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: (No Response)

Reviewer #3: Dear authors

Many thanks for your research

Here are some comments on your original research.

1. In line 208 and 209 “The detection limit of prolactin with ichroma II is 100ng/ml. In case of concentration over 100ng/ml, ¼ and 1�8 dilution of the plasma was done with saline phosphate buffer as recommended” the detection limit is an incorrect phrase. In clinical laboratory, we describe the detection limit as: the lowest concentration that the procedure (laboratory kit) can detect. The highest concentration that the procedure or kit can detect and higher concentrations should be diluted is defined as the linearity range. Therefore, dear authors should correct this definition. Please, refer to kit inset sheet/instruction about the linearity and detection limit complementary descriptions.

2. In figures 1 and 2 (box plots), please, correct the p-values decimals. Please, remove extra decimals.

3. In discussion section, I think “the first year of live” is better to be replaced with “the first year of life”.

4. In discussion section, Lines 411 and 412 “This is an explorative study conducted in pregnant women. The study has been designed to determine the cytotoxicity of NK cells against erythrocytes infected by Plasmodium falciparum.” This phrase is related to which study? If it is related to the current study, I can not see any direct variable related to NK cells and immune system. If this is not related to the current study, please remove it from discussion and abstract and elsewhere in body text.

Many thanks with the best wishes

**********

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

Reviewer #3: Yes: Abdorrahim Absalan

**********

[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.

Effects of gestational age on blood cortisol and prolactin levels during pregnancy in malaria endemic area

PONE-D-23-33355R2

Dear Dr. Kiemde,

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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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,

Ibrahim Sebutu Bello, MBBS, MPH, MD, FMCGP

Academic Editor

PLOS ONE

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: (No Response)

**********

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

Reviewer #2: (No Response)

**********

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 Response)

**********

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: (No Response)

**********

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)

**********

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

**********