Reviewer #1: This manuscript addresses a highly relevant public health issue. Overall the manuscript is well-structured and presents important findings however, a few refinements could enhance clarity. Specifically, the discussion could be strengthened by drawing clearer implications for policy and scalability,how lessons from high-fidelity can be adapted to low fidelity settings. Adding explanatory footnotes to some of the tables and ensuring that figures and tables, supporting materials are properly referenced intext .

Reviewer #2: This manuscript addresses an important and understudied implementation science topic: implementation fidelity of tuberculosis (TB) screening among diabetes mellitus (DM) patients in routine care settings in Tanzania. The topic is relevant to TB–DM collaborative activities and aligns well with global priorities. However, several substantive issues need to be addressed before the findings can be interpreted with confidence.

Sampling strategy There is a lack of clarity and internal consistency between the sampling strategy described in the Methods and the way provider numbers are reported in the Results. The Methods indicate that 2–4 healthcare providers were selected per facility using proportional allocation and simple random sampling, yet Table 1 reports aggregate numbers by facility type (e.g., dispensary, health centre, hospital) without indicating how many providers were recruited from each of the 20 facilities. This makes it difficult to assess representativeness and raises concerns about clustering (e.g., whether multiple providers came from the same facility). The authors should clearly report the number of participants recruited per facility, ideally in a supplementary table, and explain how the stated sampling strategy was operationalised.

Outcome definition and interpretation The primary outcome is provider-level implementation fidelity, measured through self-reported adherence to TB screening guideline components. However, the Results and Discussion repeatedly imply patient-level screening coverage (e.g., statements suggesting that a certain proportion of DM patients were screened for TB). No patient-level numerator or denominator is presented, and the Methods do not describe record review or observation. The authors should consistently frame the outcome as provider-level fidelity, revise language that implies patient screening coverage, and explicitly acknowledge the absence of patient-level screening data as a limitation if such data were not collected.

Unsupported causal explanations The Discussion attributes low implementation fidelity (17%) to factors such as lack of integrated TB–DM training and provider role allocation, yet these explanations are not adequately supported by the study data. Training does not appear to remain significant in adjusted analyses, and several explanatory statements are not referenced. In addition, the Discussion suggests that degree-holding providers may focus on administrative duties, while the Methods state that staff in administrative roles were excluded from the study. These contradictions should be resolved, and causal language should be softened or removed where not directly supported by evidence.

Discussion focus The Discussion begins by restating the study’s aim and strengths rather than clearly summarising the key findings. Several paragraphs repeat results or focus heavily on comparisons with other studies, with limited interpretation of what the findings mean for the Ubungo or Tanzanian primary care context. The Discussion would be strengthened by focusing on (i) the most poorly implemented screening components, (ii) why dispensaries showed lower fidelity, and (iii) the implications for TB–DM integration, supervision, and training in similar settings.

Statistical reporting The analytical approach (modified Poisson regression) is appropriate for the outcome, but there appear to be potential reporting errors (e.g., confidence intervals in Table 4 where bounds appear inconsistent). These should be carefully checked. In addition, typographical errors (e.g., “modified poison regression”) should be corrected.

Limitations section The limitations are acknowledged; however, they could be more clearly framed from an implementation science perspective, including reliance on self-reported practices, absence of observational or record-based verification, and the cross-sectional design limiting causal inference.

Reviewer #1: PLOS Global Public Health ECONOMIC AND HEALTH IMPACTS OF BOVINE TUBERCULOSIS ON RURAL ZAMBIAN COMMUNITIES

General Assessment This manuscript addresses a relevant and timely topic, exploring the economic and health impacts of bovine tuberculosis (bTB) on rural communities in Zambia through a mixed-methods approach. The work is valuable and provides important insights into the socioeconomic vulnerabilities associated with bTB. However, several areas require clarification and strengthening to enhance the scientific robustness and public health relevance of the study.

Major Comments 1. Missing epidemiological context on zoonotic TB in humans The manuscript discusses the public health implications of bTB but does not provide available data on M. bovis infection prevalence in humans at: • national level, • district level (Lundazi and Monze), • or from comparable regions in sub-Saharan Africa. To address this gap, please consider integrating key global references on zoonotic TB, such as: • WHO (2017). Roadmap for Zoonotic tuberculosis https://www.who.int/publications/i/item/9789241513043 • Olea-Popelka, F., & Fujiwara, P. I. (2018). Building a Multi-Institutional and Interdisciplinary Team to Develop a Zoonotic Tuberculosis Roadmap. Frontiers in Public Health, 6, 167. https://www.frontiersin.org/articles/10.3389/fpubh.2018.00167/full Including these references will help contextualize the burden of zoonotic TB and strengthen the public health discussion and better support conclusions.

1. Public health implications are underdeveloped While the economic impact of bTB is well described, the public health dimension is comparatively limited. The manuscript would benefit from: • more explicit discussion of zoonotic risks for different demographic groups, • potential barriers to diagnosis and reporting of M. bovis in rural healthcare settings, • implications for One Health surveillance. This would provide a more balanced interpretation aligned with the study objectives.

2. Limited comparison with existing literature The discussion currently focuses mainly on East and Southern Africa. It would be helpful to cite global and regional reviews addressing the wildlife–livestock–human interface, which is central to bTB epidemiology in Zambia. Please consider adding: De GARINE-WICHATITSKY M, CARON A, KOCK R, et al. 2013 (Cambridge): A review of bovine tuberculosis at the wildlife–livestock–human interface in sub-Saharan Africa https://www.cambridge.org/core/journals/epidemiology-and-infection/article/review-of-bovine-tuberculosis-at-the-wildlifelivestockhuman-interface-in-subsaharan-africa/19D207B4D88531AB03A96FEF7BF6F95E Munyeme et al. (2011). A Review of Bovine Tuberculosis in the Kafue Basin Ecosystem https://pmc.ncbi.nlm.nih.gov/articles/PMC3087610/ These references are particularly relevant given the role of Kafue lechwe as a reservoir species and the importance of studying disease dynamics at the domestic–wildlife–human interface.

3. Interpretation of increased vulnerability in elderly respondents The interpretation that elderly individuals are more affected because of reduced immunity and lower awareness requires careful qualification. While it is plausible that older adults may be more likely to progress to clinical disease due to immunosenescence, the study did not include any diagnostic testing for M. bovis infection in humans. Without diagnostic data, such as tuberculin skin testing (e.g., the Mantoux test), interferon-gamma release assays, or microbiological confirmation, the study cannot infer the true prevalence of mycobacteria infection across age groups. It is important to acknowledge that younger individuals may have similar or even higher infection rates but remain asymptomatic due to a more effective immune response. Thus, the distinction between: • infection prevalence (which requires diagnostic testing), and • clinical disease expression (more common in immunosuppressed or elderly individuals) should be clearly stated to avoid overinterpretation of the findings.

4. Methodological clarifications required Several methodological details require further explanation: • Clarify whether “strong cough” and “diseased animals” were self-reported or confirmed by veterinary staff. • Consider discussing potential confounders affecting milk/meat yield (other diseases, nutrition, seasonality). • Income calculations assume fixed milk prices; please comment on possible seasonal or regional/geographic price variability. Addressing these points will improve methodological transparency.

Minor Comments 1. Some sections require language editing to improve clarity and flow. 2. Figures and tables would benefit from clearer captions and more detailed descriptions. 3. A brief description of cattle management systems in Lundazi and Monze would provide useful context for interpreting transmission risks. 4. The Discussion could better highlight the value added by the mixed-methods approach. 5. You may consider revising the reference list, as several entries appear duplicated. Specifically, the following references are listed more than once:  Demetriou 2020 (Refs. 23 and 26)  Oloya et al. (Refs. 29 and 37)  Ameni et al. (Refs. 30, 38, and 45)  Kansiime et al. (Refs. 28 and 36)  Kazwala et al. (Refs. 32 and 39)  Mfinanga et al. (Refs. 33 and 40)  Duguma et al. (Refs. 34 and 41)  Kassa et al. (Refs. 35 and 42) Additionally, two reviews by Tschopp (Refs. 18 and 24) appear very similar and may need verification to confirm they are distinct publications. A careful review of the reference list is recommended to avoid redundancy and improve clarity.

Overall Recommendation The manuscript provides useful insights but requires substantial revisions. Strengthening the epidemiological context, integrating key references, and refining the public health discussion will significantly improve the impact and clarity of the work and enhance its contribution to PLOS Global Public Health.

After careful editorial assessment, I regret to inform you that we are unable to proceed with this manuscript for publication. The decision is rejection, based on fundamental concerns related to scientific novelty, conceptual framing, methodological validity, and public health relevance, which collectively preclude suitability for this journal.

1. Limited novelty and incremental contribution The central research question whether caregiver “hot-to-touch” assessment accurately detects fever compared with thermometer measurement is well established in the literature. Multiple systematic reviews and primary studies over the past two decades have already demonstrated that tactile assessment has moderate sensitivity and poor specificity, often overestimating fever. The present manuscript largely reconfirms known findings without offering a novel conceptual framework, methodological advance, or actionable insight that substantially extends current knowledge. While the multi-country dataset is large, scale alone does not compensate for the lack of conceptual or analytical innovation expected for a general global public health journal.

2. Conceptual and clinical misalignment The study population is restricted to children with medically attended diarrhea enrolled in a Shigella surveillance platform, yet the research question is framed broadly around caregiver fever detection. This creates a conceptual mismatch: fever in diarrheal illness is neither the dominant nor the most clinically decisive symptom driving triage, referral, or mortality risk in such settings. As a result, the findings have limited relevance for broader fever detection strategies, integrated community case management (iCCM), or child survival policies. The manuscript does not convincingly justify why this specific clinical subgroup provides a valid or generalizable test case for caregiver fever assessment.

3. Methodological concerns affecting validity Several methodological choices substantially weaken interpretability: The dichotomization of caregiver accuracy using a ≥50% threshold is arbitrary, not clinically meaningful, and insufficiently justified. This approach risks misclassification and dilutes interpretive clarity. Clinical covariates (e.g., respiratory rate, heart rate, chest indrawing) are measured only at enrollment, yet are used to explain caregiver accuracy across a 14-day follow-up period, violating temporal plausibility. The analysis does not adequately address within-child correlation arising from repeated daily measurements, raising concerns about model specification and variance estimation. Extremely small sample size in Peru, combined with its inclusion in pooled analyses, further complicates cross-site inference. These issues are not minor and would require substantial redesign of the analytical framework, rather than revision.

4. Overinterpretation and limited policy relevance The conclusions and discussion extend beyond what the data can reasonably support. While the manuscript reiterates the importance of thermometers and caregiver education, these recommendations are already well accepted and are not meaningfully advanced by the study’s findings. The manuscript stops short of providing concrete, evidence-based guidance on how caregiver assessment might be integrated, improved, or safely relied upon in real-world decision-making. Consequently, the policy and practice implications are weak and largely generic, limiting the manuscript’s impact for a global public health audience.

Comments to the Author

1. Does this manuscript meet PLOS Global Public Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Partly

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

Reviewer #1: N/A

1. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. 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

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

PLOS Global Public Health 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

1. Review Comments to the Author

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

Reviewer #1: Thank you for the opportunity to review this manuscript. Overall, it makes an important contribution to understanding climate and health policy in Argentina, but several issues should be addressed before it is suitable for publication:

The manuscript addresses an important and timely topic, analyzing climate and health policy in Argentina through stakeholder perspectives.

The qualitative design (interviews, document analysis, stakeholder workshop) is appropriate for the research question.

Valuable insights are provided on governance, financing, technical networks, federalism, and awareness gaps, with lessons for Latin America more broadly.

Inconsistencies in sample reporting: text mentions both 31 interviews and 26 interviews with 31 participants. This must be clarified and reconciled with Table 1.

The analysis section requires more detail on how coding disagreements were resolved and how workshop data were integrated.

The rationale for merging WHO framework dimensions should be better explained to ensure analytical nuance is not lost.

The Data Availability Statement does not comply with PLOS requirements. Data are not publicly available and no concrete mechanism for controlled access is provided. At minimum, de-identified excerpts or a codebook should be shared.

Ethics approvals are described but approval identifiers/protocol numbers should be included for transparency.

The manuscript is intelligible and written in standard English but contains issues that should be corrected:

Abstract is too long and must be shortened to ~250–300 words.

“Intersectionality” should be corrected to “intersectorality.”

“Precarized personnel” should be rephrased as “temporary personnel with insecure contracts.”

“Professionals and non-professionals” should be replaced with clearer wording (e.g., “clinical and support staff”).

Redundancy around “technical teams” and “federalism” should be reduced.

References require major correction:

Multiple broken Zotero placeholders are present.

Several entries are incomplete or missing DOIs/URLs.

Reference formatting must be standardized to PLOS style.

Discussion section:

Some statements overgeneralize from interviewee quotes (e.g., physicians not sensitized); these should be framed more cautiously.

Financing section should explore in more depth why mitigation dominates international funding.

References to political events (2024–2025) should be time-stamped as “at the time of data collection” to avoid rapid obsolescence.

Overall, the study is methodologically appropriate and conclusions are mostly supported by the data.

Revisions are necessary to ensure methodological clarity, compliance with data availability policy, correction of references, and refinement of language before publication.

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Reviewer #1: No

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