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I am pleased to inform you that, after reviewing your detailed responses to the reviewers' comments and the revised manuscript, I am accepting your manuscript for publication.
Having assessed the revision myself, I confirm that you have addressed all of the reviewers' comments comprehensively. Each of the concerns raised by the reviewers has been adequately resolved, particularly the clarification of the sampling method, updates to the vaccination data, and adjustments in the discussion and attitude sections. These revisions have significantly improved the clarity and quality of the manuscript.
Congratulations, and thank you for your valuable contribution.
Thank you for submitting your manuscript. Your study on HBV education and awareness among healthcare professionals in northern Sudan is highly valuable, particularly given the scarcity of data from African settings. The manuscript is generally clear, and the data are well-presented. However, several areas require significant revisions to enhance the manuscript's quality and impact.
The manuscript is well-written overall. However, careful checking for technical corrections, typos, and referencing errors is needed. Please refer to the comprehensive list of corrections provided by reviewer 3. The metadata file format is problematic. For final publication, please provide it in a more standard file type.
The recent WHO report and guidelines for HBV (published in 2024) should be included to provide updated context. These reports highlight the global response to HBV, particularly in the WHO African region, and offer approaches for diagnosis, treatment, and prevention.
Regarding the experimental design, the study design is sound, including participant calculation and ethical approval. However, please specify the language(s) in which the study was conducted (e.g., English, Arabic).
Provide more detail on recruitment and data collection. Specifically, clarify how data were collected and stored in an anonymized format using Facebook and WhatsApp.
For Tables 2, 3, 4, and 5, explain how the good vs. poor knowledge scores, attitude scores, and practice scores were calculated.
As for the validity of the findings, as raised by the reviewers some questions about HBV knowledge are ambiguous. For example, question 9 in Table 2 regarding treatment for hepatitis B could be misleading. Please interpret these results with caution and address the ambiguity in the discussion.
Special care should be taken to this specific points to address:
Line 79: Explain why the HBV prevalence estimate differs from other studies.
Participation Rate: Clarify the 100% participation rate and its plausibility.
Age Distribution: Correct the statement about the majority of students being under 21 years old.
Last Three Years of Medical Studies: Justify why this period is specifically reported.
Attitudes Section: Reconsider the categorization of material in this section. Suggest further exploration of attitudes in the discussion.
Lines 187-189: Clarify the proportions of correct vs. incorrect practices and address any ambiguities.
In the Discussion section please check these points:
Line 225: Revise the concept of "lower attitude levels" and clarify the relationship between sample size and attitudes.
Vaccination Barriers: Discuss potential barriers to vaccination and strategies to increase coverage. Consider how students can promote vaccine uptake.
Mandatory Testing and Vaccination: Explore alternative strategies before recommending mandatory testing and vaccination, considering potential challenges and incentives.
Conclusions: Update the conclusion to emphasize the need for accessible and affordable HBV testing and vaccination, rather than solely recommending qualitative research.
Additional Comments:
Minor edits and typos as noted should be corrected.
Clarify ambiguities in tables and ensure they are self-explanatory.
Ensure all table titles are complete and informative.
Further concerns and detailed feedback are provided in the PDF from the first reviewer. Please carefully review these comments and address all issues highlighted.
Additionally, please provide a detailed response to each of the reviewers' concerns when you resubmit your manuscript. This will help us understand how you have addressed each point raised.
Please make these revisions and resubmit the manuscript for further review. Addressing these concerns will significantly enhance the quality of your work.
Thank you for your attention to these details
This is a reasonable study of a segment of those training to become health care workers in northern Sudan. regarding HBV knowledge and testing and vaccination. The language is clear. I have comments in the PDF regarding some ways to improve the precision of the writing
Good description of research methods. I asked for more information regarding the random selection of respondents.
The validity is good for the populations surveyed.
See PDF
no comment
For Tables 2, 3, 4, and 5, the author may need to provide some explanation on how they calculated the good vs. poor knowledge scores, attitude scores, and practice scores.
The authors made a few comparisons to other countries in terms of knowledge, attitude, and practice towards HBV. Besides sample size, could there be other factors contributing to the differences? The authors might consider making assumptions or suggestions on what North Sudan can learn from other countries to increase vaccination coverage.
I commend the authors for having undertaken this study which tackles an important but neglected topic of HBV education and awareness among healthcare professionals. There is a particular scarcity of data representing African settings, despite the high burden of HBV in many African populations, so new data that can inform practical interventions are a welcome addition to the field. Overall, the article is clear and well written. Data are clearly presented in summary tables.
The manuscript would benefit from careful checking for technical corrections, typos and referencing (I have provided a list of these at the end of the review).
I am unable to open the metadata file due to the format - for the final publication this should be provided as a more standard file type.
Referencing is generally good, but it would be helpful to include the recent WHO report and guidelines for HBV (both published in 2024), which state that the global response is off track, highlight the majority of new HBV infections are within the WHO African region, and set out approaches for diagnosis, treatment and prevention. This adds to the background context for this work.
The study design is sound, including a calculation to determine the number of participants required to provide confidence in outputs. Methods are described in sufficient detail to allow replication, and the study was conducted with ethical approval.
It would be useful if the authors could add to say in what language(s) the study was conducted (English / Arabic / others?)
I would also like more detail of recruitment and data collection, which is described as being by facebook and whatsapp, but how were data actually collected and stored (in appropriate anonymised format)?
Some of the questions about knowledge of HBV are ambiguous. For example, question 9 listed in Table 2 – ‘there is treatment for hepatitis B’ – this is very ambiguous and I am not surprised it split the field. It is correct that there is treatment for hepatitis B (safe, cheap, effective antiviral therapy in the form of tenofovir or entecavir to suppress the virus), so half the cohort reasonably answered yes. However, if the question is intended to probe whether there is *curative* treatment then it would indeed (largely) be correct to say no, although interferon based treatments can lead to HBsAg seroconversion. While the question cannot be changed now that the study is completed, the results of this question should be interpreted with caution (line 155), and the potential ambiguity should be addressed in the discussion.
Specific questions:
• Line 79 - a study reporting a HBV prevalence of 15.5% - is this a different population or territory compared to other studies? Are there reasons why prevalence estimate is so different from the other studies?
• 100% participation rate is very high and out of keeping with most other studies – does this mean all of those originally invited to take part in the study accepted and completed? This seems somewhat implausible.
• ‘The majority of the students were under 21 years old (35.2%)’ – this does not follow, as only about 1/3 were under 21 (not the majority!).
• ‘half of them were from the last three years of their medical studies’ – is there a reason for specifically reporting on the last three years of medical studies? (eg is this the most clinically hands-on period? It could be contextualised by stating how long medical training is overall).
• ‘Attitudes’ section – much of the material presented here seems like it would fit better in the categories of either knowledge or practice – I would expect ‘attitudes’ to be around perceptions, experiences, stigma and discrimination, religious or personal beliefs etc, which are actually not explored in this study. Again there is no way to change the questions now, but I suggest this point could be picked up in discussion to say there is room for further exploration of attitudes.
• Lines 187-189 – this sentence about incorrect practices is ambiguous; it’s not clear whether the proportions of respondents presented are those answering correctly or incorrectly, and some of these answers are highly nuanced, eg ‘receiving anti-HBV serum’ (presumably refering to immunoglobulin) would depend on the nature of the exposure, the vaccine status of the recipient, and the availability of immunoglobulin (generally very hard to access).
Points arising from the Discussion section:
• Line 225 – ‘lower attitude levels’ is not a meaningful concept – an attitude can be different but not ‘lower’ (as per comment on the results section, this appears to be confusing attitudes with knowledge). I am not sure how the authors can conclude that the sample size of a study affects attitudes – suggest rewrite this.
• Low rates of vaccination were identified – did the researchers consider what factors presented barriers to a complete vaccine course? (lack of awareness, poor accessibility of vaccine doses, out-of-pocket costs, time away from other responsibilities, other challenges?). What strategies could be recommended to increase vaccine coverage in this susceptible group who are at high risk of exposure? How could students be actively engaged in promoting vaccine uptake in their own peer group and more widely?
• Line 250 – recommending mandatory testing and vaccination is not universally agreed as a policy and there are no data in the study to suggest that students’ views towards this approach were collected. It would be worth exploring contrasting views - while in some settings mandating action may be appropriate or accepted, this can also be controversial, divisive and have unintended spin-offs (in places where Covid vaccines were mandated, this was frequently not a success). Would the researchers consider that before mandating testing and vaccination there are other ways to incentivise this behaviour (better information, improved pathways to access vaccines, lower costs etc).
• Conclusions – ‘Future researchers should investigate real qualitative methods of assessing the actual KAP levels.’ – while I agree that qualitative studies could certainly be of value, this does not seem appropriate as the final conclusion for this study – it would be better to conclude with a statement to say that there is a pressing need for healthcare workers to be willing and able to access affordable and acceptable HBV testing and vaccination in order to protect them as individuals, but also as part of wider societal progress towards international elimination goals.
Minor edits and typos for correction:
• Line 69 – replication of the word ‘viral’ – it would be better to start by saying ‘Hepatitis B virus’ and then introduce the acronym HBV and use this consistently throughout.
• Line 72 – citation is not in the correct format.
• Lines 72-74 describes primary modes of transmission; this is no longer correct as the commonest route for new infections worldwide is mother to child (vertical) transmission. This point is included in the WHO factsheet which is cited as reference 9 in this study.
• Ljne 79 – is there some text missing at the start of this line?
• Line 81 – ‘the incidence rate of needle stick injuries among healthcare workers was found to be 43%’ – this needs some clarification with a unit of time – does this mean each month? Each year? over a lifetime of working? Is this figure globally representative?
• Line 89 – ‘low practice’ is ambiguous – what does this mean? Low access to testing? Low uptake of vaccination? Something else?
• Line 96 – it would be better to use the word ‘infection’ rather than ‘disease’ (not all HBV infection is associated with liver disease).
• Line 99 – the acronym KAP needs to be spelt out in full at first use.
• Line 176 – missing full-stop at end of sentence.
• Line 250 – ‘cos’ should be ‘cost’
• Table 3, 4 and 5 – all have either extra brackets or missing brackets in the data columns.
• Table 5 includes a question about cutting and styling beards, which appears to have been answered by all 426 participants, although it seems reasonable to assume this question should not apply to females – please clarify.
• Table 8 – HBV status is classified as only positive or negative – presumably the numbers here are small because the majority do not know their HBV status? – suggest add a row to report the number with ‘status unknown’. Likewise for ‘received booster dose’ should there be a row for ‘unknown’?
• Table titles should ideally be modified for completeness so that the table can be interpreted as a ‘stand alone’ item, e.g. title of table 1 ‘ Socio-Demographics of the participating students, 2023’ should be modified for completeness to say ‘ Socio-Demographics of 426 medical students participating in a study about knowledge, attitudes and practices towards HBV infection in Sudan, 2023’
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