PONE-D-25-18518Exploring Spatial Variation and Multilevel Modeling of Malaria Prevalence Among Children Aged 6-59 Months Based on RDT in Niger: Findings from the 2021 NMISPLOS ONE

Dear Dr. Masresha,

Thank you for submitting your manuscript to PLoS ONE. After careful consideration, we felt that your study has the potential to be published if it is revised to address specific topics raised by the reviewers. According to the reviewers, there are some specific areas where further improvements would be of substantial benefit to the readers.  For example, some inherent limitations of the study design should be included; in specially, the limitations of observational studies should be acknowledged.  Also, typographical and grammatical errors throughout the manuscript should be adjust. For your guidance, a copy of the reviewers' comments was included below. Finally, please be sure to follow the PLOS ONE policies for publishing observational studies. For studies involving clinical data, use the STROBE checklist, and for studies with routinely collected data, use the RECORD checklist.

Please submit your revised manuscript by Oct 24 2025 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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Luzia H Carvalho, Ph.D.

Academic Editor

PLOS ONE

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5. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

Reviewer #1:

Reviewer #2:

[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: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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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: No

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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: 1. Scientific relevance and originality

The study addresses a relevant and major public health issue in sub-Saharan Africa: the prevalence of malaria in children under five. The combined approach of spatial analysis and multilevel modeling is relevant and well justified. The originality lies in the use of NMIS 2021 data to produce a fine mapping of at-risk areas and identify multi-level determinants.

� Assessment: Relevant subject, innovative methodological approach for the Niger context.

2. Methodology

The article uses robust methods:

- Spatial analysis (Moran's I, Getis-Ord Gi*, SaTScan)

- Geostatistical interpolation (Empirical Bayesian Kriging)

- Multilevel modeling (mixed-effects logistics)

The models are well described, with goodness-of-fit indicators (AIC, BIC, DIC, ICC, MOR, PCV). Stratification of variables at different levels (individual, household, community) is rigorous.

� Suggestions:

- Clarify certain methodological choices, in particular the significance threshold for spatial clusters.

- Further justify the interpretation of certain counter-intuitive associations (e.g. non-anemia associated with higher prevalence).

3. Results

The results are clearly presented, with detailed tables and relevant geographical figures. The identification of high-risk clusters in the Zinder, Dosso, Maradi and Tillabéri regions is particularly useful for decision-makers.

� Strengths:

- Good visualization of spatial data.

- Well-structured multi-level analysis.

� Areas for improvement:

- Summarize key results more in the text to avoid number overload.

- Standardize percentages and headcounts in tables.

4. Discussion and interpretation

The discussion is well grounded in the existing literature. The authors interpret the results with caution and highlight the implications for public health policy.

� Recommendations:

- Deepen discussion of regional disparities and structural factors (access to care, infrastructure).

- Incorporate consideration of the limitations of RDTs as a diagnostic tool (sensitivity, specificity).

5. Conclusion

The conclusion is consistent with the results and highlights concrete recommendations: increased coverage of impregnated mosquito nets, targeted interventions according to risk areas, and the importance of maternal education.

� Assessment: Relevant conclusion, well aligned with study objectives.

6. Ethics, data availability and conflicts of interest

- The authors state that the data come from the DHS Program and are publicly available.

- No conflicts of interest declared.

- No direct collection of human data: ethics respected.

Reviewer #2: In this manuscript, Mulugeta et al. present the results of an epidemiological study that explored spatial variation and fitted a model for malaria prevalence among children aged 6 to 59 months in Niger. Although not original, the study is of great importance because it focused on a high-risk age group with high mortality for malaria in Africa, and it employed correct, robust, and up-to-date statistical methodologies to achieve the proposed objectives.

The statistical model proposed in the study is well explained and described. Authors utilized appropriate statistical tools for model fitting, such as the AIC, BIC, and DIC criteria, as well as to explain cluster heterogeneity in spatial analysis (MOR and PCV). The multilevel multivariate logistic regression is well-structured and clearly presented.

The manuscript is well written and clearly presented. Discussion and Conclusion were consistent with the study objectives and the results obtained. Moreover, the authors highlight important recommendations for incorporation into the malaria control strategy targeting the studied age group.

Although the authors were cautious in stating the study’s conclusions, some inherent limitations of the study design were omitted. Among the potential limitations are those inherent to the use of secondary data, which are subject to issues of quality and coverage, as well as the expected underestimation of new malaria cases, arising both from the existence of undiagnosed cases (asymptomatic or not reported in the information system). Another limitation that cannot be omitted is the low sensitivity of rapid diagnostic tests (RDTs) for malaria cases with low parasitemia.

Additionally, the authors should correct various typographical and grammatical errors throughout the manuscript to improve the clarity and professionalism of the scientific writing. Special attention to:

1. Missing space after period at the end of a sentence, occurring in several sentences of the text.

2. "known as a vector of infection" could be simplified to "which acts as a vector".

3. "a bite from an infected insect". It is better as "a bite from an infected mosquito".

4. "This is compared to 593,000 cases in 2021" refers to deaths but uses "cases" erroneously - should be "deaths".

5. "children under five at particularly high risk" should be "children under five years old are at particularly high risk".

6. "[?, 12, 28]" The question mark indicates a missing or placeholder reference; it needs to be replaced with the proper citation number.

7. "Niger malaria indicator survey (NMIS)" - "Niger Malaria Indicator Survey (NMIS)" (capitalize proper nouns).

8. "geographic coordinates (longitude and latitude)" - Standard order is "latitude and longitude."

9. "Enumeration Areas (EAs) or cluster level" - Should be "Enumeration Areas (EAs) or cluster level" or "clusters".

10. "Correct capitalization and style: "Stata v14".

11. Missing space after comma: "ICF International, the datasets".

12. "accessible web-site" — "website" is one word; hyphen unnecessary.

13. "write the studys title and signifi-cance" — Should be "study’s title and significance" with an apostrophe; hyphenation in "signifi-cance" should be corrected to "significance".

14. "Independent Variables The Geo-statistical model utilized individual and community-level variables 5.” – What is this 5?

15. Hyphenation & spacing: Several places require adding spaces after punctuation marks before continuing, e.g., after commas and periods.

16. Consider defining acronyms upon first usage if not done elsewhere, e.g., "RDT," "SaTScan," "ICC," "VA," "PCV," etc.

17. “but "47% (527)" says "female child yielded" where "child" should be plural "children".

18. "Out of the 4724 RDT tests conducted, 53% (594) were performed on male children, and 47% (527) of female child yielded positive results for malaria." Should be: "...and 47% (527) of female children yielded positive.

19. "The tails bright red and blue colours indicate a higher level of significance (Fig 1)." - Remove extra space before parentheses. "Globally Morans I=0.434025 (z-score=10.471517, p value 0.001)." Should be: "Global Moran's I = 0.434 (z-score = 10.47, p = 0.001)." Use apostrophe in "Moran's".

There are several other typographical errors not mentioned above. The authors are advised to make the necessary corrections.

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Reviewer #1: Yes: Dr Bougouma Edith Christiane / Bougouma.cedith@gmail.com

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Review Dr Bougouma Edith 06 07 2025.docx

PONE-D-25-18518R1Exploring Spatial Variation and Multilevel Modeling of Malaria Prevalence Among Children Aged 6-59 Months Based on RDT in Niger: Findings from the 2021 NMISPLOS ONE

Dear Dr. Masresha,

Thank you for submitting your manuscript to PLoS ONE. ​After careful consideration, we feel that your manuscript will likely be suitable for publication if the authors revise it to address specific points raised now by the reviewer #1. According to the reviewer, there are some specific areas where further improvements would be of substantial benefit to the readers.   For your guidance, a copy of the reviewers' comments was included below.  

Please submit your revised manuscript by Nov 22 2025 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,

Luzia H Carvalho, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 

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: (No Response)

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 #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This manuscript offers a valuable scientific contribution with a sound methodology and well-articulated discussion. It meets the core standards of PLOS ONE in terms of quality, ethics, and transparency.

To enhance clarity, nuance, and regulatory impact, the following minor revisions are recommended:

Editorial clarity: Simplify complex sentences and consider adding subheadings to improve flow.

Interpretive nuance: Avoid overgeneralizations and adopt a more cautious tone in interpreting results.

Regulatory relevance: Elaborate on how findings may inform regulatory decisions, professional practices, or policy frameworks.

Visual synthesis: Include a summary figure or table to highlight key outcomes and recommendations.

These revisions are minor and easily implementable. They aim to optimize the manuscript’s reception among readers, practitioners, and regulatory stakeholders.

Final Recommendation: Accept after minor revision, with encouragement to further emphasize the regulatory significance of the work.

Final Recommendation : Accept after minor revision, with encouragement to further emphasize the regulatory significance of the work

� Title and Abstract : Suggestion : Consider adding a sentence that highlights the practical or regulatory implications of the findings to enhance impact.

� Introduction: Suggestion: A brief overview of international regulatory frameworks could broaden the relevance of the study.

� Methodology

� Areas for improvement:

� Expand on potential biases (e.g., selection bias, sample representativeness).

� Clarify quality control procedures and reference applicable regulatory standards.

� Results : Suggestion: A summary figure or table synthesizing key findings and their implications could improve readability and accessibility.

Discussion : Recommendations:

Soften overly assertive interpretations by using cautious scientific language (e.g., “these findings suggest…”).

Provide concrete suggestions for translating results into pharmaceutical policy or practice.

Strengthen connections to normative frameworks (e.g., ICH, WHO, national guidelines).

� Conclusion

Suggestion : Reinforce the link between findings and regulatory challenges in low-resource settings or African contexts

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.

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: Dr Bougouma Edith Christiane

Reviewer #2: No

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[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.

Exploring Spatial Variation and Multilevel Modeling of Malaria Prevalence Among Children Aged 6-59 Months Based on RDT in Niger: Insights for Public Health Decision-Making

PONE-D-25-18518R2

Dear Dr. Masresha,

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.

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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,

Luzia H Carvalho, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: