Dear Dr. Major,

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Willis, Kate Halsby, James Stark, Ana Gabriela Grajales, Holly Yu, Frederick J.  Angulo, Chloe McDonald are employees of Pfizer, and as part of their compensation, may hold Pfizer stock. -->-->Natalie Nightingale, Irene Wang, Calum Neish, Doneal Thomas, and Doneal Thomas are employees of IQVIA Solutions Canada Inc., which was a paid contractor to Pfizer in connection with the development of the study design and management. -->-->Saranya Nair was an employee of IQVIA Solutions Canada Inc. at the time of this study, which was a paid contractor to Pfizer in connection with the development of the study design and management. She is currently employed at Pfizer, Inc.-->-->Mark Loeb received compensation from Pfizer for his services as a member of the Lyme Disease Steering Committee. -->--> -->-->We note that one or more of the authors are employed by a commercial company. -->--> -->-->a. 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Reviewers' comments:

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Partly

Reviewer #2: Yes

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

Reviewer #1: N/A

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.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: No

Reviewer #2: No

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: This is a very worthwhile study, but in my view it needs some clarifications before publication. This is a very worthwhile study, but in my view it needs some clarifications before publication. This is a very worthwhile study, but in my view it needs some clarifications before publication. This is a very worthwhile study, but in my view it needs some clarifications before publication.

Main point:

The main issue is that a number of different data sets are used to identify patients with Lyme disease diagnosis. These include patients diagnosed with Lyme disease and treated in ER, patients who were hospitalised, patients treated at primary care clinics and patients with a positive laboratory test result at the provincial laboratory. There is a potential for patients to be double or triple counted. For example, a patient who went to ER, had a positive test result, then deteriorated and had to be hospitalised for treatment, could result in a single case being counted as three cases. There is mention of comparing amongst these data for the earliest likely onset data, but there is no specific mention of unique identifiers for the patients that would mean that multiple records for the same patient do not result in overinflated case numbers. Please include description of this.

Minor points:

Mention in the text that test results are positive two-tier test results using CDC criteria for interpretation of western blots.

Much of Table 2 is not visible as it is too wide for portrait view.

There is no mention of boreal forests being unsuitable for ticks in ref 23. To my knowledge there have been no studies to explore if boreal forest is intrinsically inhospitable for I. scapularis. It is likely that boreal forest is not suitable due to absence or low densities of white tailed deer, which are essential hosts for adult I. scapularis.

The ‘gold standard’ estimation of under-reporting in the US is by Kugeler et al. 2021 (Emerging Infectious Diseases 27(2)) but there is no mention of this.

The section regarding CDC’s definition of an endemic area and discussion of low incidence and high incidence provinces needs to be removed. In Canada more detailed definitions of an endemic area are used and these are not based on incidence. There is no distinction of low- and high-incidence provinces in Canada as Lyme disease is an emerging infectious disease in Canada, with associated spatiotemporal variations in incidence.

Reviewer #2: This manuscript provides a valuable description of administrative health data, highlighting the increasing trend of Lyme disease cases over time in Manitoba, Canada. The paper is clearly written, and the analyses are rigorous. I have just a few minor comments. This manuscript provides a valuable description of administrative health data, highlighting the increasing trend of Lyme disease cases over time in Manitoba, Canada. The paper is clearly written, and the analyses are rigorous. I have just a few minor comments. This manuscript provides a valuable description of administrative health data, highlighting the increasing trend of Lyme disease cases over time in Manitoba, Canada. The paper is clearly written, and the analyses are rigorous. I have just a few minor comments. This manuscript provides a valuable description of administrative health data, highlighting the increasing trend of Lyme disease cases over time in Manitoba, Canada. The paper is clearly written, and the analyses are rigorous. I have just a few minor comments.

There appear to be inconsistencies regarding the province targeted in this project. The manuscript clearly relies on administrative health data from Manitoba; however, Ontario is mentioned in several instances.

• Abstract (lines 45–46): The text currently states, “Our study aims to estimate medically-attended LD incidence in Manitoba, Ontario, using administrative health data.” This should be corrected to “…Manitoba, Canada.”

• Supplemental document: The authors included a Research and Ethics Board (REB) Certificate from the University of Waterloo. However, the title of that certificate is “An observational study of Lyme disease in Ontario, Canada: Incidence and Healthcare Resource Utilization,” which does not correspond to the topic of the current manuscript.

It is understandable that the first author, as a University of Waterloo graduate, may have included this certificate as part of her PhD work. Nonetheless, attaching an REB certificate that references a different subject and geographic scope introduces confusion and does not add value to the present manuscript.

Lines 137–140, page 7: The manuscript states: “If individuals met more than one algorithm definition on the same day, they were indexed on the algorithm per the following order of precedence: emergency room or inpatient algorithm, primary care algorithm, serology-based algorithm.”

Could the authors clarify the rationale for establishing this specific order of precedence? In the same paragraph, they note: “If individuals met more than one algorithm definition during the selection period, they were indexed on the earliest day they met any of the algorithm definitions.”

Based on this rationale, one would expect the primary care algorithm to take precedence, as most Lyme disease patients initially consult their family physician during the early phase of illness. Typically, it is only when primary care fails to recognize the disease that it may progress to later stages, potentially leading to emergency room visits or hospitalizations.

Line 144–146, page 7: The age categories presented in the Methods section (5-year groups) differ from those in Table 1 (10-year groups). I recommend using consistent age group categories throughout the manuscript.

Line 167–169, page 8: The sentence “Per reporting rules for administrative health data in Manitoba, all outputs with a count of less than 6 patients were suppressed, along with the second smallest group to prevent back-calculation (i.e., double suppression)” duplicates the statement already included in the Data Privacy and Ethics Statement (lines 160–162). It does not need to be repeated in the Data Analysis section. Please remove it.

Line 172–173: The manuscript states: “Where possible, analyses were stratified by age group, RHA, and sex.” However, incidence is not presented by age group in any of the tables. I recommend removing “age group” from this sentence for consistency.

Table 2:

The value of presenting analyses by RHA is unclear, as data in more than two-thirds of the cells are suppressed or not reported. If the authors wish to retain the RHA-level analysis, I recommend combining the last two RHAs (Interlake-Eastern RHA and Northern RHA) to improve data presentation and interpretability.

In addition, the abbreviation DS used in the table is not defined in the footnote and should be clarified.

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Reviewer #1: No

Reviewer #2: No

**********

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Dear Dr. Major,

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 Jan 21 2026 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.. 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.. 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.. 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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Kind regards,

Jorge Cervantes

Academic Editor

PLOS One

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #1: Partly

Reviewer #2: Yes

**********

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

Reviewer #1: N/A

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.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??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1:This manuscript is close to being ready for publication. My concerns regarding possible double counting of cases seems to have been mostly answered. However, some concerns about the inclusion of laboratory test data remain. Why would patients with positive test results not appear in the other databases, which identify clinical management? I cannot know – for this review by either the provincial laboratory director or a medical officer of Manitoba Health, Seniors & Long-term Care.This manuscript is close to being ready for publication. My concerns regarding possible double counting of cases seems to have been mostly answered. However, some concerns about the inclusion of laboratory test data remain. Why would patients with positive test results not appear in the other databases, which identify clinical management? I cannot know – for this review by either the provincial laboratory director or a medical officer of Manitoba Health, Seniors & Long-term Care.This manuscript is close to being ready for publication. My concerns regarding possible double counting of cases seems to have been mostly answered. However, some concerns about the inclusion of laboratory test data remain. Why would patients with positive test results not appear in the other databases, which identify clinical management? I cannot know – for this review by either the provincial laboratory director or a medical officer of Manitoba Health, Seniors & Long-term Care.This manuscript is close to being ready for publication. My concerns regarding possible double counting of cases seems to have been mostly answered. However, some concerns about the inclusion of laboratory test data remain. Why would patients with positive test results not appear in the other databases, which identify clinical management? I cannot know – for this review by either the provincial laboratory director or a medical officer of Manitoba Health, Seniors & Long-term Care.

Minor points:

In the introduction I would recommend using Borrelia burgdorferi sensu stricto rather than sensu lato. Early localised LD can appear as a rash, which can take the form of a bulls eye. I would maybe change ‘influenza type symptoms’ to something like non-specific malaise as there are no respiratory manifestations of Lyme disease.

In the methods it should be stated that the Discharge Abstract Database is a product of the Canadian Institute of Health Information (CIHI).

Reviewer #2:The authors have adequately addressed my comments raised in the first round of revision. I have no more comments.The authors have adequately addressed my comments raised in the first round of revision. I have no more comments.The authors have adequately addressed my comments raised in the first round of revision. I have no more comments.The authors have adequately addressed my comments raised in the first round of revision. I have no more comments.

**********

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Reviewer #1: No

Reviewer #2: No

**********

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Use of Administrative Data for Evaluating Trends in Medically-Attended Lyme disease, Manitoba, Canada, 2010-2021

PONE-D-25-22049R2

Dear Dr. Major,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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PLOS One

Additional Editor Comments (optional):

Some pending minor issues pointed out by one of the reviewers need to be addressed.

Reviewers' comments: