Knowledge, attitude, and practice towards Hepatitis B and vaccination status of pre-clinical medical students at Sylhet Women’s Medical College, Bangladesh

Ramesh Lamichhane; Pritha Adhikari; Bishnu Deep Pathak; Aashika Rai; Pratikshya Ojha; Kripa Maharjan; Hamida Sultana Ruche; Madhusudan Saha

doi:10.1371/journal.pone.0310443

Peer Review History

Original SubmissionMay 17, 2024
9 Jun 2024 Decision Letter - Dhan Bahadur Shrestha, Editor PONE-D-24-19904Knowledge, Attitude, and Practice towards Hepatitis B and Vaccination Status of Pre-clinical Medical Students at Sylhet Women’s Medical College, BangladeshPLOS ONE Dear Dr. Lamichhane, 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 24 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. 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Additional Editor Comments: I myself carefully read the manuscript and agreed to the comments by both reviewers, please revise the manuscript with needful considering those comments. [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: Yes Reviewer #2: No ****** 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: No ****** 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: In this study, the authors investigated the level of knowledge, attitude and practice regarding hepatitis B and vaccination among pre-clinical students in a medical college in Bangladesh in a descriptive cross-sectional study that included 189 participants. They conclude that only 1/3 of the participants was vaccinated and that lack of awareness of one's vaccination status was the most common reason. Only 1/4 of participants had good KAP related to hepatitis B. Vaccination status and previously received information was associated with high KAP score. There is limited literature regarding KAP about hepatitis B and vaccination in medical students in Bangladesh. The methods are good and findings from the study have real-world implications as high KAP scores were associated with vaccination status. Thus, information dissemination in this population is crucial as only 1/4 population had good KAP score. I would like to provide the following constructive feedback to the authors: 1. For questions- "vaccination against hepatitis B- yes or no" or "dose of HBV vaccine received- 1,2,3, 3 +booster?", was there an option indicating "i don't know" or an option to skip? This important as 43% of participants were "not aware of their hepatitis B vaccine status" so it is likely that 43% of the participants answered the 2 questions inaccurately. Recall bias is a big limitation of the study, which the authors do mention in the limitation section. They also mention that serological methods to confirm vaccination status would have been ideal to overcome this. However, I would recommend describing it more, including possible steps the authors took to minimize this bias in the study. 2. Was pre-testing/pilot testing performed? Some questions can possibly be interpreted in ways the authors did not indent/ not be clear (eg: Lack of accessibility for Hepatitis B vaccine, not aware of the Hepatitis B vaccine status). Also were any tests of validity of the questionnaire performed prior to the survey. 3. Authors did a good work with literature review in discussion but also describe the clinical/real-world implications of the results in the discussion. 4. Describe briefly the informed consent process- were participants told of what data collected and stored, who the investigators are, the purpose of study, etc. What personal information was collected? 5. Were any steps taken to prevent multiple entry of data from a single participant? How was it ensured that each entry of the survey was a unique participant? 6. Briefly mention what is the guideline for HBV vaccination in Bangladesh- childhood vaccination, healthcare workers? If it was part of childhood immunization program for more than 20 years, it is unlikely that 66% were not vaccinated (unless immunization coverage/ compliance is poor in the country) 7. I would add lack of generalizability/ ext validity in limitation- as study only included 1st and 2nd year medical students, and also 1 medical college in the country. Minor points - Line 280- sample size is not small as the entire population (1st and 2nd yr students at the medical college) was sampled. minor - line 82- this is not "non-probability convenient sampling method" as the whole population (all 1st and 2nd year students of the medical college) was used as sample. - Table 1. 5th row, 3rd column- should be 21 (20-21) - Table 5- present as n(%) I would like to commend the effort of all the authors who put together an excellent study. I would recommend acceptance of the manuscript after minor revisions. Reviewer #2: The authors have presented a work with findings from the perspective of their country. However, there are major points that should be corrected - Background needs to better demonstrate the novelty of this resource, and add more information on how is hepatitis B vaccine given in their nation (for free or charge). - Methods are unclear about recruitment and survey procedures. - The sampling technique and sample size are not clear yet. Explain how the study size was arrived at - Define all outcomes and give details of methods of assessment. In addition, the authors need to provide the cut-off level of good knowledge, attitude and practice, and references. For assessing KAP of the previous studies, knowledge, and practice variables are often classified as correct and incorrect, and attitude is assessed by using a five-point Likert scale and classified as positive and negative, the authors need to consider this. For KAP studies, the variable definition is not accurate, the results are less valid and reliable. - The questionnaire contained 5 for knowledge as described in the methods, the authors can explain how to calculate the knowledge sum of 54.01±7.57 (table 3) - The authors need to present the association between baseline characteristics and knowledge, attitude, and practice separately, not combining them (Table 5) ****** 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: Sajog Kansakar 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.0310443.r001
Revision 1
16 Jun 2024 Author Response RESPONSE TO ACADEMIC EDITOR: 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. � Thank you for this comment � We have edited as required in the manuscript. 2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). � Thank you for this comment � Informed written consent was taken from each participant. We have edited as required in the manuscript. 3. Please note that your Data Availability Statement is currently missing the DOI/accession number of each dataset or a direct link to access each database. If your manuscript is accepted for publication, you will be asked to provide these details on a very short timeline. We therefore suggest that you provide this information now, though we will not hold up the peer review process if you are unable. � Thank you for this suggestion � We have added DOI link of figshare data in the manuscript as required. 4. Please upload a copy of Supporting Information which you refer to in your text on page 26. � Thank you for this suggestion � We have uploaded the copy of supporting information as referred in the text (figshare doi link: https://doi.org/10.6084/m9.figshare.25845664.v1). RESPONSE TO REVIEWER-1: 1. For questions- "vaccination against hepatitis B- yes or no" or "dose of HBV vaccine received- 1,2,3, 3 +booster?", was there an option indicating "i don't know" or an option to skip? This important as 43% of participants were "not aware of their hepatitis B vaccine status" so it is likely that 43% of the participants answered the 2 questions inaccurately. Recall bias is a big limitation of the study, which the authors do mention in the limitation section. They also mention that serological methods to confirm vaccination status would have been ideal to overcome this. However, I would recommend describing it more, including possible steps the authors took to minimize this bias in the study. � Thank you for these comments. Actually, the question “reason for not being vaccinated against Hepatitis B” was applicable for those who responded ‘NO’ to vaccination. And, this was the most commonly reported cause of non-vaccination among the participants. � We have tried to explain more on methods that can be used to reduce recall bias in this type of study. We have edited this in the DISCUSSION section of the manuscript. 2. Was pre-testing/pilot testing performed? Some questions can possibly be interpreted in ways the authors did not indent/ not be clear (eg: Lack of accessibility for Hepatitis B vaccine, not aware of the Hepatitis B vaccine status). Also were any tests of validity of the questionnaire performed prior to the survey? � Thank you for this comment. These questionnaires were adapted from Shrestha DB et. al, 2020 with permission. This study was conducted in Nepal with pre-testing done in 5% of the study sample. So, considering the similar population characteristics in South Asian region, we did not perform pre-testing in our sample. � However, we did assess internal consistency of our questionnaires that showed a good internal consistency, with a Cronbach's alpha of 0.71. 3. Authors did a good work with literature review in discussion but also describe the clinical/real-world implications of the results in the discussion. � Thank you for your compliment and comment. We have edited in the DISCUSSION section of the manuscript, where we have tried to describe clinical implications of our results. 4. Describe briefly the informed consent process- were participants told of what data collected and stored, who the investigators are, the purpose of study, etc. What personal information was collected? � Thank you for this comment. We have explained this information in detail in methods section in the manuscript. 5. Were any steps taken to prevent multiple entry of data from a single participant? How was it ensured that each entry of the survey was a unique participant? � Thank you for this concern. We had sent the google forms to each participant in their social media platform (facebook, whatsapp, email, etc). Each form was designed to accept only one unique response, preventing resubmission once finished. So, there was no possibility of multiple entry of data from a single participant. 6. Briefly mention what is the guideline for HBV vaccination in Bangladesh- childhood vaccination, healthcare workers? If it was part of childhood immunization program for more than 20 years, it is unlikely that 66% were not vaccinated (unless immunization coverage/ compliance is poor in the country) � Thank you for this comment. We have added this information in DISCUSSION section of the manuscript. 7. I would add lack of generalizability/ ext validity in limitation- as study only included 1st and 2nd year medical students, and also 1 medical college in the country. � Thank you for this comment. We totally agree with you that there is lack of generalizability/external validity in our study due to inclusion of pre-clinical medical students of one medical college only. We have added this in our manuscript. 8. Minor points - Line 280- sample size is not small as the entire population (1st and 2nd yr students at the medical college) was sampled. - line 82- this is not "non-probability convenient sampling method" as the whole population (all 1st and 2nd year students of the medical college) was used as sample. - Table 1. 5th row, 3rd column- should be 21 (20-21) - Table 5- present as n(%) � Thank you for these valuable suggestions. We have edited accordingly in the manuscript. RESPONSE TO REVIEWER-2: 1. Background needs to better demonstrate the novelty of this resource, and add more information on how is hepatitis B vaccine given in their nation (for free or charge). � Thank you for this comment. � Studies of this nature are commonly conducted worldwide. However, given that Bangladesh is situated in an intermediate endemic zone with lower Hepatitis B vaccination rates compared to other Southeast Asian nations, this research holds significant clinical and administrative importance. While the topic may lack novelty, it remains practically important from a public health perspective, as medical students represent a vulnerable population with respect to Hepatitis B infection. � We have added the information related to Hepatitis B vaccination in Bangladesh in DISCUSSION section in the manuscript. 2. Methods are unclear about recruitment and survey procedures. � Thank you for this comment � We adopted whole sampling technique, i.e. included all the pre-clinical medical students of a medical college. A questionnaire was sent to individual participant in the form of Google forms via different social media (facebook, whatsapp, email), and their responses were recorded in Excel form. The first page of the Google form consists of background and objectives of the study, authors’information and consent options. Those who consented were forwarded to next pages which consist of actual questionnaires. All these responses were accurately recorded subsequently in Excel form which was later used for data analysis and interpretation. We have tried to explain this in the manuscript in more elaborative way. Please kindly consider it. 3. The sampling technique and sample size are not clear yet. Explain how the study size was arrived at � Thank you for this comment � We used whole sampling technique which included all the pre-clinical medical students (MBBS 1st and 2nd academic years), i.e. Sample size = Total population 4. Define all outcomes and give details of methods of assessment. In addition, the authors need to provide the cut-off level of good knowledge, attitude and practice, and references. For assessing KAP of the previous studies, knowledge, and practice variables are often classified as correct and incorrect, and attitude is assessed by using a five-point Likert scale and classified as positive and negative, the authors need to consider this. For KAP studies, the variable definition is not accurate, the results are less valid and reliable. � Thank you for this comment and suggestions. � These questionnaires were adapted from Shrestha DB et. al, 2020 with permission.1 Similar pattern of scoring was used in our study as well. We have edited an explanation about KAP scoring and different variables in the manuscript itself. 5. The questionnaire contained 5 for knowledge as described in the methods, the authors can explain how to calculate the knowledge sum of 54.01±7.57 (table 3) � Thank you for this suggestion. � We have explained this information in the manuscript. Actually, total score was calculated by adding individual score (based on Likert scale) on each item in knowledge, attitude and practice section. 6. The authors need to present the association between baseline characteristics and knowledge, attitude, and practice separately, not combining them (Table 5) � Thank you for this suggestion � Exploring association between baseline characteristics and knowledge, attitude and practice separately is a very good approach but it does not fall under our research objectives. Instead, we have studied the association between overall score (categorical) and baseline characteristics. It is because this association has been shown by a reference study by Shrestha DB et al,1 where association has been demonstrated between total KAP score category and baseline characteristics. REFERENCE 1. Shrestha DB, Khadka M, Khadka M, Subedi P, Pokharel S, Thapa BB. Hepatitis B vaccination status and knowledge, attitude, and practice regarding Hepatitis B among preclinical medical students of a medical college in Nepal. PLoS One [Internet]. 2020 Nov 1 [cited 2024 Mar 12];15(11):e0242658. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0242658 Attachments Attachment Submitted filename: Response to comments.docx https://doi.org/10.1371/journal.pone.0310443.r002
5 Aug 2024 Decision Letter - Dhan Bahadur Shrestha, Editor PONE-D-24-19904R1Knowledge, Attitude, and Practice towards Hepatitis B and Vaccination Status of Pre-clinical Medical Students at Sylhet Women’s Medical College, BangladeshPLOS ONE Dear Dr. Lamichhane, 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. As pointed out by reviewers, some methods and write up needs more clarity. Please submit your revised manuscript by Sep 19 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, Dhan Bahadur Shrestha, MBBS 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 #1: All comments have been addressed Reviewer #3: (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 #1: Yes Reviewer #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes 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 #1: 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 #1: 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 #1: (No Response) Reviewer #3: Minor: I recommend using the “pre-clinical medical student” throughout the manuscript to resolve the confusion associated with use of “pre-clinical medical student”, “medical student” or “health science students”. Need grammatical corrections throughout the manuscript to make it easily comprehendible for the reader. You may take help of English language expert. Abstract: In materials and methods: “An online, single-center, descriptive cross-sectional study”: Use web-based rather than on “online” In result: instead of only vaccine, mention the vaccine being Hepatitis B vaccine Manuscript Method: - Reason for the choosing pre-clinical medical students not clear and also the risk of exposure to hepatitis B among participants not mentioned, like whether they have exposure to clinical practice or not, if yes, how’s the risk of the hepatitis B as per hospital record on needle injury among targeted participant group - Reason for the selection of whole sampling method need to be explained - Need to acknowledge about the participants not giving consent, whether they were included or excluded Discussion: - “Moreover, pre-clinical medical students are less experienced and frequently sustain needle-stick injuries while performing different procedures with infected patients.” Need reference for this line and whether it applies to participants of this study or not. - Findings of study were compared to findings from other studies without mentioning whether they have similar cohort of participants or different. ****** 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 #1: No Reviewer #3: 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 https://doi.org/10.1371/journal.pone.0310443.r003
Revision 2
19 Aug 2024 Author Response RESPONSE TO REVIEWERS’COMMENTS: 1. I recommend using the “pre-clinical medical student” throughout the manuscript to resolve the confusion associated with use of “pre-clinical medical student”, “medical student” or “health science students”. � Thank you for the suggestion. We have edited in the manuscript as appropriate. 2. Need grammatical corrections throughout the manuscript to make it easily comprehendible for the reader. You may take help of English language expert. � Thank you for the valuable suggestion. We have tried our best to edit the manuscript accordingly. 3. In materials and methods: “An online, single-center, descriptive cross-sectional study”: Use web-based rather than on “online” � Thank you for the suggestion. We have edited accordingly. 4. In result: instead of only vaccine, mention the vaccine being Hepatitis B vaccine � Thank you for the suggestion. We have edited accordingly. 5. Reason for the choosing pre-clinical medical students not clear and also the risk of exposure to hepatitis B among participants not mentioned, like whether they have exposure to clinical practice or not, if yes, how’s the risk of the hepatitis B as per hospital record on needle injury among targeted participant group. � Thank you for this comment. Our study sample consists of pre-clinical medical students who are moving into their clinical phase in near future. The pre-clinical medical students have little experience and during their clinical posting, they are apparently exposed to infected patients. Moreover, they have to get involved in different types of invasive procedures putting them at a high risk of needle-stick injuries. So, this group of students is at high risk of acquiring Hepatitis B infection. We have described these things in detail with relevant references in our INTRODUCTION and DISCUSSION section. And, we have made a few edits in the manuscript as appropriate. Please kindly consider it. 6. Reason for the selection of whole sampling method need to be explained � Thank you for this comment. In our study, we have included all the medical students in their pre-clinical academic years (i.e. whole sampling method). This means, we have included the entire study population (i.e. pre-clinical medical students of a medical college) in this research. It helps to decrease selection bias, sampling error, and increase the accuracy of our findings. We have added this information in DISCUSSION section last paragraph. 7. Need to acknowledge about the participants not giving consent, whether they were included or excluded � Thank you for this valuable suggestion. We have edited this information in METHODS section of the manuscript. 8. “Moreover, pre-clinical medical students are less experienced and frequently sustain needle-stick injuries while performing different procedures with infected patients.” Need reference for this line and whether it applies to participants of this study or not. � Thank you for this comment. We have cited references 4, 5, 12, 13 for all these information in paragraph 1 of DISCUSSION. Since this is an integrated information, we thought referencing as a whole would suit better. Please consider it. 9. Findings of study were compared to findings from other studies without mentioning whether they have similar cohort of participants or different. � Thank you for this comment. We totally agree with your opinion regarding our study findings being compared with other studies without mentioning the cohort characteristics. Most of the time, we have tried to compare and contrast our results with the studies from South East Asia region where there are approximately similar socio-economic and educational characteristics. However, there were differences in sample size, sampling method, gender distribution, and other baseline characteristics. All those studies were observational studies (cross-sectional type), so we think that this difference should not matter much with our reporting in DISCUSSION section. Basically, we tried to compare our findings of vaccination rate and possible barriers to vaccination with other countries of the world (both developed and developing). Please kindly consider it. Attachments Attachment Submitted filename: RESPONSE TO REVIEWERS.docx https://doi.org/10.1371/journal.pone.0310443.r004
1 Sep 2024 Decision Letter - Dhan Bahadur Shrestha, Editor Knowledge, Attitude, and Practice towards Hepatitis B and Vaccination Status of Pre-clinical Medical Students at Sylhet Women’s Medical College, Bangladesh PONE-D-24-19904R2 Dear Dr. Lamichhane, 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, Dhan Bahadur Shrestha, MBBS Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0310443.r005
Formally Accepted
22 Sep 2024 Acceptance Letter - Dhan Bahadur Shrestha, Editor PONE-D-24-19904R2 PLOS ONE Dear Dr. Lamichhane, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, 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 customercare@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. Dhan Bahadur Shrestha Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0310443.r006

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