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PLoS One
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PLOS ONE
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10.1371/journal.pone.0302698
PONE-D-23-32936
Research Article
Medicine and Health Sciences
Medical Conditions
Tropical Diseases
Neglected Tropical Diseases
Snakebite
Biology and Life Sciences
Organisms
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Vertebrates
Amniotes
Reptiles
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Health Care Facilities
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Signs and Symptoms
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Medicine and Health Sciences
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Toxicology
Toxic Agents
Toxins
Knowledge and perceptions of snakes, snakebites and their management among health care workers in Sudan
Snakes, snakebites and their management in Sudan
https://orcid.org/0000-0003-3524-4825
Saeed Ali Awadallah Conceptualization Methodology Validation Writing – original draft 1 2 *
https://orcid.org/0000-0003-3280-8293
Gibreel Omer A. Formal analysis Methodology Validation 3
B. Mousa Ayman Data curation Writing – original draft Writing – review & editing 1
Omer Saeed M. Conceptualization Data curation Writing – review & editing 4
Omer Abdallateif Alkhair Data curation Writing – original draft Writing – review & editing 5
A. M. A. Elalawy Intisar Conceptualization Writing – review & editing 6
Hassan Fahal Ahmed Conceptualization Methodology Supervision Validation Writing – original draft Writing – review & editing 2
1 Department of Pharmacology and Therapeutics, Faculty of Clinical and Industrial Pharmacy, National University-Sudan, Khartoum, Sudan
2 Mycetoma Research Center, University of Khartoum, Khartoum, Sudan
3 Accounting & Management Information Systems Department, College of Business Administration, Gulf University for Science & Technology, Mubarak Al-Abdullah, Kuwait
4 Faculty of Medicine and Health Sciences, Gadarif University, Al Qadarif, Sudan
5 Faculty of Medicine, Omdurman Islamic University, Omdurman, Sudan
6 Alrayan College of Health Sciences and Nursing, Pharmacy Program, Almadina, Saudi Arabia
Omara Timothy Editor
BOKU: Universitat fur Bodenkultur Wien, AUSTRIA
Competing Interests: The authors have declared that no competing interests exist.

* E-mail: aliawadsaeed@nu.edu.sd
20 9 2024
2024
19 9 e030269819 10 2023
5 4 2024
© 2024 Saeed et al
2024
Saeed et al
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Background

Snakebite statistics in Sudan are lacking despite the high estimated burden of the problem. One study in Sudan reported the presence of 17 medically significant snakes belonging to three major families: Burrowing asps, Elapidae, and Viperidae. These snakes usually become abundant during and after the rainy season, and most snakebite victims are farm workers. This study was set out based on the observed snakebite management, poor outcomes and lack of information on the healthcare provider’s knowledge of this serious, deadly medical and health condition in snakebite-endemic regions of Sudan.

Materials and methods

In August 2022, a descriptive cross-sectional survey was conducted involving 394 medical and healthcare providers in snakebite-endemic regions of Sudan (Gaddarif, Sinnar, Khartoum, and Kassala). A validated questionnaire was used. It consisted of seven sections addressing the study population demographic characteristics, knowledge of snakes, snakebites, and their management. Data analysis used various statistical tests using Microsoft Excel and the Statistical Package for Social Sciences (SPSS) version 20 (IBM SPSS Inc., Chicago, IL) was done.

Results

Among the 394 participants (44.7% males, 53.3% females), 58.1% demonstrated adequate knowledge of snakes, and 45.3% exhibited adequate knowledge of snakebites. A mere 25.9% received training in snakebite management, with 60.4% possessing adequate knowledge in this domain. Only 14% expressed high confidence in managing snakebites, and 40.9% reported having protocols for snakebite management at their health facilities.

Conclusion

The study highlighted the inadequacy of healthcare providers’ knowledge in snakebite-endemic areas in Sudan regarding snakes, snakebites and snakebites management. Urgent interventions, such as intensive continuing professional education and training, are essential to address this neglected medical and health problem.

The author(s) received no specific funding for this work. Data AvailabilityThis article presents all the raw data utilized in this study.
Data Availability

This article presents all the raw data utilized in this study.
==== Body
pmcIntroduction

Snakebite is considered one of the world’s most serious medical problems. Snakebite was a neglected disease in the past, the World Health Organiztion (WHO) declared snakebite envenomation a neglected tropical disease On June 9th, 2017 [1]. It called for new strategies to combat it and resources to implement them [2]. There are 5.4 million venomous snake bites globally, with 1.8 to 2.7 million cases of envenomings. [3]. Around 81,410 to 137,880 people die each year because of snake bites, and around three times as many amputations and other permanent disabilities are caused by snakebites annually. [1]. WHO reported that 81–95% of snake bites occur in the tropical regions of South Asia, Southeast Asia, Sub-Saharan Africa and Latin America [4]. In sub-Saharan Africa, the number of persons treated in health centers for snakebite envenomation is estimated at 315,000 cases per year, with more than 9,000 amputations and 7,000 deaths. Since many victims do not seek medical care, they are invisible to official reports; thus, the number of snake envenomation remains underestimated [5].

In some parts of the African continent, the snakebites’ burden is higher than that of trypanosomiasis, leishmaniasis, and onchocerciasis, and its mortality can be higher than malaria [6]. The snakebites’ high mortality in Africa is multifactorial, including lack of effective antitoxins, inadequate health care system, and scarcity of rapid access to medical centers [7]. Furthermore, many inhabitants of rural areas believe in traditional healers and do not seek treatment due to low socioeconomic and health education levels, many victims die shortly after the snakebite accident, and that is not reported in the hospital records [8]. In rural regions, where most snakebites occur, the general population’s awareness of appropriate behaviour in response to snakebites is poor [9]. A study in Nigeria showed that most patients had attempted at least one potentially deleterious first-aid measure prior to presentation to hospitals [10]. In Ghana, an intervention to improve snakebite medical care ability and adherence to protocols significantly improved care and decreased snakebite mortality [11].

Snakebite statistics in Sudan are lacking despite the high estimated burden of the problem [12]. During the last 70 years, only a few data have been reported on Sudanese venomous snakes, and the Natural History Museum, University of Khartoum, reported some [13, 14]. Based on previous study which reported the presence of 17 medically significant snakes belonging to three major families: Burrowing asps, Elapidae, and Viperidae [15, 16]. These snakes usually become abundant during and after the rainy season, and most snakebite victims are farm workers [17].

This study was set out based on the observed snakebite management, poor outcomes and lack of information on the healthcare provider’s knowledge of this serious, deadly medical and health condition in snakebite-endemic regions of Sudan (Gaddarif, Sinnar, Khartoum, and Kassala) [14].

Material and methods

This descriptive cross-sectional survey was conducted in 15 August 2022 to 20 September 2022 using snowball sampling. The study participants were from snakebites envenomation endemic regions of Sudan. It included 394 medical and healthcare providers. After a review of the literature [5, 8], the standardized questionnaire prepared in English, and the draft questionnaire validated by authors for review and comments in order to ensure applicability, suitability, and consistency in environment of Sudan, furthermore a pilot test was conducted to further support the face and content validity.

The Sudan Snakebite Research Network developed this questionnaire. The questionnaire was widely distributed online, and all participants gave written informed consent. The questionnaire comprised seven sections covering demographic characteristics, knowledge of snakes (eight questions), knowledge of snakebites (nine questions), practice in dealing with snakebites (five questions), attitude toward affected patients (two questions), and snakebite management (ten questions).

Data analysis

The data underwent entry and management using Microsoft Excel and the Statistical Package for Social Sciences (SPSS) version 20 (IBM SPSS Inc., Chicago, IL). Frequency and percentage were computed for qualitative variables, while quantitative variables were characterised by median and interquartile range (IQR). A comprehensive score encompassing knowledge, attitude, and practice was determined and subsequently categorised as adequate or inadequate based on the average score. Percentages were employed to articulate attitudes towards dealing with snakebites. The analysis of questions involved scoring each correct answer as 1, with "don’t know" and incorrect responses receiving 0 points. The result is expressed as percentages. The results were rated adequate and inadequate based on the median.

Ethical considerations

Ethical clearance for the study was obtained from the National University Institutional Review Board numbered NU-REC/11-018/12, and all participants gave written informed consent.

Results

The study included 394 medical and healthcare providers, with 176 (44.7%) males and 218 (53.3%) females. Among the participants, 142 (36%) were under 40, while 252 (64%) were 40 or older with average age (29.3 ± 8). The distribution of participants included pharmacists (31%), medical officers (23.9%), registrars (20%), house officers (11.7%), nurses (6.8%), and consultants (6.6%), Table 1.

10.1371/journal.pone.0302698.t001 Table 1 Socio-demographic characteristics of the study participants (n = 394).

Variables	Variable	No. (%)	
Sex	Male	176 (44.7)	
Female	218 (53.3)	
Age	21–30	55 (14)	
31–40	87 (22.1)	
41–50	139 (35.3)	
Above 50	113 (28.6)	
Occupation	Medical officer	94 (23.9)	
House officer	46 (11.7)	
Registrar	79 (20)	
Consultant	26 (6.6)	
Pharmacist	122 (31)	
Nurse	27 (6.8)	
Working Sector	Governmental	229 (58.1)	
Private	165 (41.9)	
Years of practice	< 5 years	255 (64.7)	
5–10 years	89 (22.3)	
>10 years	50 (13)	
Attended training on snakebite management	Yes	102 (25.9)	
No	292 (74.1)	
Skills in snake bite management	Self-education (internet or textbooks)	109 (28.5)	
Learning from senior colleagues	142 (37)	
Knowledge and skills gained during training	39 (10.2)	
Don’t Know	94 (24.3)	

Analysis revealed that 255 participants (64.7%) had less than five years of experience in medical and health practice, 89 (22.3%) had experience ranging from five to ten years, and 50 (13%) possessed more than ten years of experience. Regarding training in snakebite management, only 102 participants (25.9%) had received such training. Among them, 37% acquired it from senior colleagues, 28.5% were self-educated, and 10% obtained it through training courses, Table 1.

There were eight questions on snake knowledge, and the results showed that 321 (81.5%) knew the fact that not all snakes are poisonous, 129 (32.7%) stated all snakes are carnivorous, 255 (64.7%) knew not all snakes are venomous, 113 (28.7%) recognised all snakes have fangs in front of their mouth, 213 (54.1%) thought snakes pick sounds using their ears, 213 (54.1%) believed snakes are important for farmers, and 255 (64.7%) believed deforestation and urbanisation have increased human-snake interaction, Table 2). The study showed that 322 participants (81.7%) knew snakes are reptiles, Table 3. Moreover, 229 participants (58.1%) answered snake knowledge questions correctly, while 165 (41.9%) had incorrect answers.

10.1371/journal.pone.0302698.t002 Table 2 The study participants knowledge of snakes and snakebites (n = 394).

	Yes (%)	No (%)	I don’t know (%)	
Snake Knowledge	
All snakes are venomous	36 (9.1)	321 (81.5)	37 (9.4)	
All snakes are carnivorous	129 (32.7)	156 (39.6)	109 (27.7)	
All snakes are venomous	94 (23.9)	255 (64.7)	45 (11.4)	
All snakes have fangs in front of their mouth	113 (28.7)	164 (41.6)	117 (29.7)	
Snakes pick sounds using their ears	71 (18)	173 (43.9)	150 (38.1)	
Snakes are important for farmers	213 (54.1)	89 (22.6)	92 (23.3)	
Deforestation and urbanisation have increased human-snake interaction	255 (64.7)	57 (14.5)	82 (20.8)	
Snakebites Knowledge	
Handling a dead snake’s head is safe	209 (53)	85 (21.6)	100 (25.4)	
Marks can always be seen on the victim after every snake bite?	161 (40.9)	195 (49.5)	38 (9.6)	
Can a person report at the hospital with symptoms of snake bite without actually being bitten by a snake?	219 (55.6)	95 (24.1)	80 (20.3)	
Sleeping under mosquito nets can prevent snakebites	122 (31)	223 (56.6)	49 (12.4)	
A venomous snake bite always injects venom into the victim	172 (53.7)	151 (38.3)	71 (18)	
Signs and symptoms of snake bites are determined by the type of snake responsible for the bite.	316 (80.2)	32 (8.1)	46 (11.7)	
The signs and symptoms of a snakebite depend on the amount of venom injected by the snake.	279 (70.8)	60 (15.2)	55 (14)	

10.1371/journal.pone.0302698.t003 Table 3 The study participants knowledge of snakes and snakebites (n = 394).

Variable	Categories	Frequency (%)	
Snakebite Knowledge	
How to identify a snake bite	Type of snake	78 (19.8)	
Signs and symptoms	209 (53)	
Victim presenting complaints	55 (14)	
I don’t know	52 (13.2)	
Time of bite	During the day	31 (7.9)	
During the night	274 (69.5)	
Not sure	65 (22.6)	

There were nine questions concerning snakebite knowledge, and 85 participants (21.6%) responded correctly to the statement that handling a dead snake’s head is not safe enough. Additionally, 195 (49.5%) recognised the fact that marks can always be seen or found on the victim after every snakebite, and 219 (55.6%) believed that a person reported at the hospital with symptoms of snakebite could be given an antitoxin injection without actually being bitten by a snake. Moreover, 122 (31%) believed sleeping under mosquito nets can prevent snakebites. A total of 151 (38.3%) did not think the statement that a venomous ("poisonous") snake always injects venom (poison) into the victim. Furthermore, 316 (80.2%) recognised that the snake type determines the symptoms and signs of snakebites, and 279 (70.8%) thought that the symptoms and signs of the snakebite depend on the amount of venom injected by the snake, Table 2. The obtained data showed that 209 participants (53%) believed the symptoms and signs could determine the snake and venom injected, and 31 (7.9%) felt the snakebite commonly occurs during the day, Table 3. For snakebite knowledge, 179 participants (45.3%) answered the questions correctly, while 215 (54.7%) responded incorrectly.

The study showed that 247 participants (26.7%) believed that a tourniquet prevents the spread of poison in the remaining part of the body, and 320 (81.2%) stated reassurance of the victim should be practiced as the first protocol for prevention. Regarding the belief that an incision at the bite site helps remove the poison, 186 participants (47.2%) held this belief, and 282 (71.6%) thought if the leg is the bite site, its elevation will not reduce poison spread. Moreover, 297 participants (75.4%) believed bringing the snake to the treating physician increases the chances of survival by correctly identifying the snake, Table 4. In this study, 238 participants (60.4%) answered snakebite practice questions correctly, while 156 (39.6%) did not.

10.1371/journal.pone.0302698.t004 Table 4 The study participants’ practice regarding snakebites (n = 394).

Variable		
Yes (%)	No. (%)	
A tourniquet prevents the spread of venom in the remaining part of the body	247 (26.7)	147 (73.3)	
Reassurance of the victim should be practiced as the 1st protocol for prevention	320 (81.2)	74 (18.8)	
Incision at the site of bite helps removing venom	186 (47.2)	208 (52.8)	
If the bite site is leg, elevating it will reduce the spread of venom	112 (28.4)	282 (71.6)	
Bringing snake to treating physician increases chances of survival by correct identification	297 (75.4)	97 (24.6)	

Concerning attitudes toward snakebites, residing in cities as a protective factor against snakebites was stated by 297 participants (75.4%), and 106 (26.9%) believed that snakebites result from revenge inspired by past incidents, Table 5.

10.1371/journal.pone.0302698.t005 Table 5 The study participants attitude regarding snakebites (n = 394).

Variable		
Yes (%)	No (%)	
Residing in cities is a protective factor from snake bite	297 (75.4)	97 (24.6)	
Snakebite is an outcome of revenge inspired by past incidents	106 (26.9)	288 (73.1)	

The study showed that only 55 participants (14%) rated themselves as very confident in managing snakebites, and 203 participants (51.5%) had previously managed a snakebite patient. Regarding management and help provided by participants in snakebite management in 2021, only 20 participants (5.1%) managed more than 100 patients, and 56 (14.2%) managed between 10 and 50 patients. Concerning the availability of snakebite management protocol, 161 (40.9%) stated they have that at their health facilities. Only 179 participants (45.4%) said their health facility has what it takes to manage snakebites effectively, Table 6.

10.1371/journal.pone.0302698.t006 Table 6 Management of snakebites (n = 394).

Variable	Response	No. (%)	
Management of snake bites	Very confident	55 (14)	
Confident	106 (26.9)	
Fairly confident	132 (33.5)	
Not confident	101 (25.6)	
Have you ever managed, supervised or nursed a snakebite patient before?	Yes	203 (51.5)	
No	191 (48.5)	
Prevalence of snakebites seen by HCWs	One person every day	08 (2)	
1 to 5 persons a week	76 (19.3)	
More than five persons a week	22 (5.6)	
1 to 5 persons every month	46 (11.7)	
More than five persons every month	06 (1.5)	
One person every three months	11 (2.8)	
More than five persons every three months	07 (1.8)	
1 to 5 persons in the year	28 (7.1)	
More than five persons in the year	05 (1.3)	
Not Sure	185 (46.9)	
The health facility has a protocol for the management of snakebites	Yes	161 (40.9)	
No	144 (36.5)	
I don’t know	89 (22.6)	
The health facility has what it takes to effectively manage snake bites	Yes	179 (45.4)	
No	215 (54.6)	

Regarding the management of snakebites, 265 participants (67.3%) considered it an emergency. Additionally, 178 (45.2%) usually admit snakebite patients to hospitals, while 26 participants (6.6%) usually refer patients immediately to other centers. (Table 7)

10.1371/journal.pone.0302698.t007 Table 7 The study participants knowledge of snakebites management (n = 394).

Statement	Response	No. (%)	
How do you triage (prioritise) someone with a snakebite in your facility?	Emergency	265 (67.3)	
Urgent	102 (25.9)	
Not urgent	07 (1.8)	
I don’t know	20 (5)	
What do you do when people report to your health facility with snakebite?	Refer immediately	26 (6.6)	
Give first aid treatments and refer	166 (42.1)	
Admit and treat	178 (45.2)	
Call for assistance from another health facility	24 (6.1)	
Which of the following tests will you first recommend when someone reports snakebite to determine there was actually an injection of venom into the person (envenoming)?	Full blood count	182 (46.2)	
Grouping and cross matching	65 (16.5)	
20 minutes whole blood count test	61 (15.5)	
Urinalysis for myoglobinuria	86 (21.8)	
Antivenoms are the only antidotes in managing snake bites by venomous snakes.	Yes	267 (75.4)	
No	58 (7.1)	
I don’t know	69 (17.5)	
Antivenoms made anywhere in the world is good for the management of snake bite victims	Yes	199 (50.5)	
No	83 (21.1)	
I don’t know	112 (28.4)	
Should antivenoms be given to all patients bitten by snakes?	Yes	191 (48.4)	
No	161 (40.9)	
I don’t know	42 (10.7)	
When an anti-snake venom is injected into the muscle (intramuscular), it is as effective as when injected into the veins (intravenous)	Yes	57 (14.5)	
No	205 (52)	
I don’t know	132 (33.5)	
Anti-snake venoms remain useful for months or even years after stated expiry dates	Yes	45 (11.4)	
No	152 (38.6)	
I don’t know	197 (50)	
In using anti-snake venoms, it is better to give low doses repeated over several days than high initial doses.	Yes	132 (33.6)	
No	118 (29.9)	
I don’t know	144 (36.5)	

Sixty-one participants (15.5%) correctly said a 20-minute whole blood count test is the most appropriate test for snakebite management. The statement that antivenoms are the only antidotes in managing snakebites by venomous snakes was agreed upon by 267 participants (75.4%). (Table 7)

Moreover, 199 participants (50.5%) stated antivenoms made anywhere in the world are suitable for managing snakebite victims, and 191 (48.4%) thought that antivenoms should be given to all patients bitten by snakes. Fifty-seven participants (14.5%) believed that the intramuscular injection of an anti-snake venom is as effective as an intravenous one. Furthermore, 197 participants (50%) did not know how long the anti-snake venoms could remain useful after the expiry date. Regarding anti-snake venoms, 132 participants (33.6%) believed it is better to give low doses repeated over several days than high initial doses. (Table 7)

Discussion

Snakebites represent a substantial global medical and health challenge, with the potential for fatal consequences, especially prominent in specific regions [12]. The repercussions extend beyond immediate health concerns, encompassing a significant economic impact on individuals and communities [18].Those affected by snakebites may encounter enduring disabilities, leading to the loss of livelihoods and heightened poverty, thereby sustaining a cycle of disadvantage [19]. In Sudan, most of the basic information on snakebites is lacking; likewise, the medical and healthcare workers knowledge of this fatal disease, so this study was set out. [14]

In this study, most participants (64.7%) possessed less than five years of practical experience. Only a quarter (25.9%) underwent snakebite management training, which was informal in 90% of them. These findings are serious as the study participants practicing in snakebites endemic regions. These findings align with a report from Kenya Uganda, and Zambia, which showed only 12% of the healthcare workers received formal snakebite management training [20]. These findings necessitate designing objectives and continuing professional development training and education for healthcare providers, particularly those working in snakebite-endemic regions of Sudan (Gaddarif, Sinnar, Khartoum, and Kassala) [14].

Based on previous studies, managing snakebites affected patients can be challenging, particularly in regions where venomous snakes are prevalent, and healthcare resources may be limited [21]. The difficulties and constraints associated with snakebite management include the limited access to healthcare, lack of antivenom availability, variability in snake venom, difficulty in snake identification, inadequate training of healthcare personnel, financial constraints, cultural beliefs and practices, lack of public awareness, insufficient research and data and climate and environmental factors [22]. These challenges require a comprehensive approach involving improved healthcare infrastructure, better access to antivenom, education and training for healthcare professionals and communities, and increased research to enhance our understanding of snakebite dynamics [21]. All these should be addressed in managing these patients, designing continuing professional development activities and prevention programmes. International collaboration and support are also crucial to developing effective strategies for snakebite management in diverse regions [23].

As stated in table [7] in this study, the participants’ knowledge of antivenom was inadequate to lack of knowledge in answering antivenom questions. In Sudan, numerous endemic areas lack access to antivenom, resulting in severe consequences. Multiple factors contribute to the constrained availability of quality antivenom in regions affected by snakebites [24]. The antivenom high production cost renders it unaffordable for many patients. Additionally, numerous distribution challenges stemming from limited infrastructure, poor transportation networks, and inadequate storage facilities further impede antivenom’s efficient and timely dissemination to affected areas. [10] Complicating matters is the diverse array of snake species and the variability in venom composition, necessitating the production of different antivenoms tailored to specific snakebites, which is impossible in the country [25]. Medical and healthcare providers should be aware of these issues.

Based on previous study, in many parts of the country, cultural values and traditional healing procedures may guide the decision-making process for snakebite victims and families. Some individuals may prefer traditional remedies over modern medical care, resulting in delayed treatment. Hence, healthcare providers need to organise objective health education sessions and events to reduce the burden of late presentation with massive disease and complications [26].

It is clear from this study that healthcare providers lack snakebite-effective management, and this is in line with many reports from the African continent. [27, 28]. Thus, structured and objective training and educational programmes should provided within the medical and health undergraduate and postgraduate curricula. The data revealed that only 40.9% of our participants have snakebite management protocols in their health facilities, which is low in accordance with report from Ghana (73.7%) [29], which is one of challenges in Uganda (lack of up-to-date robust clinical guidelines) [17]. Snakebite management guidelines are crucial tools that improve healthcare interventions’ consistency, quality, and effectiveness. These guidelines significantly reduce the morbidity and mortality associated with snakebites by providing a structured framework for assessment, treatment, and prevention.

Overall, the participants in the study exhibit insufficient knowledge regarding snakes and the management of snakebites, and there is a notable absence of reports on these matters. This underscores the need to conduct surveillance studies to understand their epidemiology better. Such studies are essential for formulating targeted control and prevention measures based on objective insights [9].

As with other neglected tropical diseases, [30] training healthcare providers on snakebite management using digital facilities is important in improving patient outcomes. It not only addresses accessibility and cost considerations but also promotes interactive, consistent, and up-to-date learning. Such training strategies enhance the preparedness and effectiveness of healthcare professionals in managing snakebite cases.

The primary strength of the present study lies in its substantial sample size, comprising healthcare providers operating in endemic regions. This sample offers valuable insights into the knowledge base of practitioners involved in treating patients affected by snakebites. Nonetheless, conducting more comprehensive investigations is essential to discern details about local health facilities, management guidelines and protocols, patients presentations, and treatment outcomes. Such in-depth studies are crucial for sharing experiences and understanding the intricacies associated with snakebite management in specific localities.

Supporting information

S1 File (DOCX)

10.1371/journal.pone.0302698.r001
Decision Letter 0
Omara Timothy Academic Editor
© 2024 Timothy Omara
2024
Timothy Omara
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version0
10 Nov 2023

PONE-D-23-32936Knowledge, Attitude, and Practices of Snakes, Snakebites and their Management among Health Workers in Sudan: Need for Internet-mediated Knowledge Management System for Continuing Professional Development.PLOS ONE

Dear Dr. Saeed,

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.

ACADEMIC EDITOR:The title could be revised to precisely read: Knowledge and perceptions of snakes, snakebites and their management among health workers in Sudan

Please indicate how the sample size was arrived at.

Provide the questionnaire used in the survey (possibly as a supplementary file)

Avoid starting sentences with numbers.

References need to be captured correctly using the same style.

There are several studies with Africa which gives the perceptions about snakes and snakebites from both traditional healers and health workers. These could help the authors discuss their results meaningfully.  See for example;

https://doi.org/10.1371/journal.pone.0291032

https://doi.org/10.1016/j.toxcx.2021.100078

https://doi.org/10.4269%2Fajtmh.20-1078

https://doi.org/10.1186/s41182-019-0187-0

https://doi.org/10.1093/inthealth/ihac043

https://www.medrxiv.org/content/medrxiv/early/2023/02/23/2023.02.16.23286015.full.pdf

This submission could also benefit from English language proofreading by a proficient speaker.

The rest of the suggestions are in the attached manuscript file.

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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,

Timothy Omara, PhD

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at 

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2. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.  

Whilst you may use any professional scientific editing service of your choice, PLOS has partnered with both American Journal Experts (AJE) and Editage to provide discounted services to PLOS authors. Both organizations have experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. To take advantage of our partnership with AJE, visit the AJE website (http://learn.aje.com/plos/) for a 15% discount off AJE services. To take advantage of our partnership with Editage, visit the Editage website (www.editage.com) and enter referral code PLOSEDIT for a 15% discount off Editage services.  If the PLOS editorial team finds any language issues in text that either AJE or Editage has edited, the service provider will re-edit the text for free.

Upon resubmission, please provide the following: 

● The name of the colleague or the details of the professional service that edited your manuscript

● A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a *supporting information* file)

● A clean copy of the edited manuscript (uploaded as the new *manuscript* file)

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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: No

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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: No

**********

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: No

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: A well-conducted survey showed the need to train health professionals to deal with patients bitten by venomous snakes.

Observe the correct use of the terms poisonous, venomous, venom and venom.

Poison is a toxin that gets into the body by inhaling, swallowing, or absorption through the skin (Poisonous animals = toads and pupper fish). Venomous animals (some snakes and scorpions): it's when the toxin is injected into you.

See attached the manuscript with a few corrections.

Reviewer #2: Terming snakes as venomous rather than calling it poisonous would be correct.

Title is not clear. I could not understand "Practices of Snakes", as there is no information of snake's practice in the manuscript. The conclusion is divorced from the result.

As manuscript contains rare and amazing information about the poor farmers problem and knowledge of health workers in this regard please connect conclusion to the findings. Manuscript is not quite in flow with Title-Result-Discussion and Recommendation.

Yes, recommendation seem fitting at abstract and manuscript but it would be misleading in the title itself.

Provide the data availability statement.

Repetition of result in discussion section and regular citation of same literature multiple times makes the discussion section of manuscript quite dull. Addition of multiple references from different part of the world with inference of the result would help in making better manuscript.

**********

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: Paulo Sérgio Bernarde

Reviewer #2: Yes: Sunil Sapkota

**********

[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.

Attachment Submitted filename: PONE-D-23-32936_reviewer.pdf

Attachment Submitted filename: R1 Manuscript KAP snakes (1).docx

10.1371/journal.pone.0302698.r002
Author response to Decision Letter 0
Submission Version1
21 Nov 2023

1. The title was changed following your recommendation

2. We explain how the sample size was arrived at.

3. The survey will be provided.

4. Numbers were avoided in the starting of sentences.

5. The references were formatted correctly using the same style.

6. Four studies from other African countries were added.

7. The submission benefit from English language proofreading by a proficient speaker.

8. The suggestions were in the attached manuscript file were included.

Attachment Submitted filename: Rebuttal letter.docx

10.1371/journal.pone.0302698.r003
Decision Letter 1
Omara Timothy Academic Editor
© 2024 Timothy Omara
2024
Timothy Omara
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version1
22 Jan 2024

PONE-D-23-32936R1Knowledge and perceptions of snakes, snakebites and their management among health workers in Sudan.PLOS ONE

Dear Dr. Saeed,

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 Mar 07 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,

Timothy Omara, PhD

Academic Editor

PLOS ONE

[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 #2: 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 #2: Partly

Reviewer #3: No

**********

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

Reviewer #2: No

Reviewer #3: No

**********

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 #2: No

Reviewer #3: No

**********

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 #2: Yes

Reviewer #3: No

**********

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 #2: Please be specific about which group of health workers lack knowledge on snake bite management. Mention the location of study area, mention in which health institution the study was conducted. Mention ratio of health workers to the ratio of health workers participated in the study.

Reviewer #3: Title: "Assessment of Knowledge and Practices among Medical and Healthcare Providers in Snakebite-Endemic Regions of Sudan"

The paper by Saeed et al is a report on the Knowledge and Practices among medical and healthcare providers i nsnakebite-endemic regions of Sudan'. Please see below my comments for your consideration. Further comments are provided i nthe attached document.

Abstract:

The manuscript under consideration purports to assess the knowledge and practices of medical and healthcare providers regarding snakebites in Sudan, a region grappling with the significant burden of this neglected tropical disease. While the topic is undoubtedly pertinent, the manuscript exhibits several critical flaws in methodology, analysis, and overall scientific rigor, casting serious doubts on its validity and contribution to the scientific literature.

Major Concerns:

1. Methodological Shortcomings:

- The manuscript's methodology lacks clarity, particularly in its description of the sampling technique. The use of snowball sampling raises questions about the representativeness of the study population. Additionally, the reliance on a self-administered web-based questionnaire introduces a selection bias, excluding individuals with limited access to the internet or those who may be less inclined to participate in online surveys.

- The questionnaire's validation process is inadequately reported, leaving the reader uncertain about the tool's reliability and validity. The lack of information regarding the pilot study's outcomes or adjustments made to the questionnaire undermines the study's scientific rigor.

2. Data Analysis and Reporting Issues:

- The data analysis section is notably deficient in critical details. The statistical tests employed are vaguely described, and the specific analyses performed using Microsoft Excel and SPSS lack transparency. A more detailed explanation of statistical methods is imperative for readers to assess the validity of the study's findings.

- The presentation of results lacks clarity and coherence. Essential information, such as confidence intervals and measures of variability, is conspicuously absent, hampering the reader's ability to interpret the significance and reliability of the reported results.

3. Incomplete Background and Literature Review:

- The introduction fails to provide a comprehensive background on the existing knowledge and research gaps in the field of snakebite management in Sudan.

4. Generalization and External Validity:

- The study claims to draw conclusions about the knowledge and practices of healthcare providers in snakebite-endemic regions of Sudan. However, the absence of a clear geographic delineation of the study areas and the use of a convenience sampling method limit the generalizability of the findings to the broader target population.

5. Ethical Considerations and Informed Consent:

- The manuscript lacks transparency regarding ethical considerations. While it mentions obtaining ethical clearance, critical details such as the reference number, and participant confidentiality measures are missing. This omission raises ethical concerns and undermines the manuscript's scientific integrity.

Conclusion:

In light of the aforementioned critical concerns regarding methodology, data analysis, literature review, generalization, and ethical considerations, it is my firm recommendation that this manuscript be rejected for publication. The scientific community deserves robust and rigorously conducted research, and this manuscript falls significantly short of meeting those standards. Addressing the outlined deficiencies is imperative for any future resubmission to be considered for publication.

**********

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 #2: Yes: Sunil Sapkota

Reviewer #3: Yes: Mitchel Okumu

**********

[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.

Attachment Submitted filename: R4 Manuscript KAP snakes 2024_1_6.docx

Attachment Submitted filename: R4 Manuscript KAP snakes (1).docx

10.1371/journal.pone.0302698.r004
Author response to Decision Letter 1
Submission Version2
7 Mar 2024

Comments to reviewer:

Reviewer #3: Title: "Assessment of Knowledge and Practices among Medical and Healthcare Providers in Snakebite-Endemic Regions of Sudan"

The paper by Saeed et al is a report on the Knowledge and Practices among medical and healthcare providers in snakebite-endemic regions of Sudan'. Please see below my comments for your consideration. Further comments are provided in the attached document.

1. Methodological Shortcomings:

- The manuscript's methodology lacks clarity, particularly in its description of the sampling technique. The use of snowball sampling raises questions about the representativeness of the study population. Additionally, the reliance on a self-administered web-based questionnaire introduces a selection bias, excluding individuals with limited access to the internet or those who may be less inclined to participate in online surveys.

Author comment:

The used of snowball sampling has been extensively used in studies where hard to reach population problem was present, in our case we tried our best to collect samples of our respondents from 4 areas in Sudan known for the high rate of snake bite. We used the method stated by Raifman et al to sample hard to reach population.

In RDS and time-location sampling (TLS), factors that influence inclusion can be estimated and accounted for in an effort to generate representative samples. RDS is particularly equipped to reach the most hidden members of hard-to-reach populations.

(Raifman, S., DeVost, M.A., Digitale, J.C. et al. Respondent-Driven Sampling: a Sampling Method for Hard-to-Reach Populations and Beyond. Curr Epidemiol Rep 9, 38–47 (2022). https://doi.org/10.1007/s40471-022-00287-8)

- The questionnaire's validation process is inadequately reported, leaving the reader uncertain about the tool's reliability and validity. The lack of information regarding the pilot study's outcomes or adjustments made to the questionnaire undermines the study's scientific rigor.

Author Comment:

After a review of the literature (8, 31), the standardized questionnaire prepared in English, and the draft questionnaire validated by authors for review and comments in order to ensure applicability, suitability, and consistency in our environment, as well as to define the face and content validity.

2. Data Analysis and Reporting Issues:

- The data analysis section is notably deficient in critical details. The statistical tests employed are vaguely described, and the specific analyses performed using Microsoft Excel and SPSS lack transparency. A more detailed explanation of statistical methods is imperative for readers to assess the validity of the study's findings.

- The presentation of results lacks clarity and coherence. Essential information, such as confidence intervals and measures of variability, is conspicuously absent, hampering the reader's ability to interpret the significance and reliability of the reported results.

Author comment:

Due to the nature of the study as descriptive exploratory study, none of the inferential statistical method was employed. This is line with numerous similar papers that publish such types of exploratory studies in area of snakes, snakebites and snakebite management.

3. Incomplete Background and Literature Review:

- The introduction fails to provide a comprehensive background on the existing knowledge and research gaps in the field of snakebite management in Sudan.

Author comment:

In Sudan, snakebite statistics are lacking despite the high estimated burden of the problem [12]. During the last 70 years, only a few data have been reported on Sudanese venomous snakes, and the Natural History Museum, University of Khartoum, reported some [13,14]. One study reported the presence of 17 medically significant snakes belonging to three major families: Burrowing asps, Elapidae, and Viperidae [15]. These snakes usually become abundant during and after the rainy season, and most snakebite victims are farm workers [16].

4. Generalization and External Validity:

- The study claims to draw conclusions about the knowledge and practices of healthcare providers in snakebite-endemic regions of Sudan. However, the absence of a clear geographic delineation of the study areas and the use of a convenience sampling method limit the generalizability of the findings to the broader target population

Author Comment:

The study participants were from snakebites envenomation endemic regions of Sudan (Gaddarif, Sinnar, Khartoum, and Kassala) (figure 1)

5. Ethical Considerations and Informed Consent:

- The manuscript lacks transparency regarding ethical considerations. While it mentions obtaining ethical clearance, critical details such as the reference number and participant confidentiality measures are missing. This omission raises ethical concerns and undermines the manuscript's scientific integrity.

Author comment:

• Reference number: NU-REC/11-018/12

• Our study observed all the rights of the participants and conscious of the confidentiality of the information obtained and kept the anonymity of the participants during and after the scheduled period of the study.

Reviewer #2: Please be specific about which group of health workers lack knowledge on snake bite management. Mention the location of study area, mention in which health institution the study was conducted. Mention ratio of health workers to the ratio of health workers participated in the study.

Author comment:

In table 1 the healthcare workers participated in the study were there.

Ali Awadallah Saeed

Corresponding author

Attachment Submitted filename: Responses to reviewers.docx

10.1371/journal.pone.0302698.r005
Decision Letter 2
Omara Timothy Academic Editor
© 2024 Timothy Omara
2024
Timothy Omara
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version2
24 Mar 2024

PONE-D-23-32936R2Knowledge and perceptions of snakes, snakebites and their management among health workers in Sudan.PLOS ONE

Dear Dr. Saeed,

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 May 08 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,

Timothy Omara, PhD

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.

Additional Editor Comments:

Dear authors,

In addition to the reviewer comments, please revise your manuscript taking into considering some minor concerns I identified with the current draft:

-In Table 1, the average age (29.3 ± 8) should be deleted, it should only be indicated in the main text. Please also provide the ages in some meaningful ranges. The current groups (< 40 and ≥ 40) does not give a good picture of the participants in this study.

-Table 3, the first aspect (Type of snakes) is not necessary, please remove it.

[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 #2: (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 #2: Partly

**********

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

Reviewer #2: N/A

**********

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 #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 #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 #2: There are some typo error in manuscript, specially in abstract section, please make proper edits. There are copy paste repetition of some lines from discussions in the abstract. Please be consistent with use of fonts and citation rules of the journal.

**********

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 #2: Yes: Sunil Sapkota

**********

[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.

Attachment Submitted filename: PONE-D-23-32936R2 -2nd-round.docx

10.1371/journal.pone.0302698.r006
Author response to Decision Letter 2
Submission Version3
4 Apr 2024

Dear Academic Editor of Plos One Journal

Thank you very much for your informative comments in our manuscript entitled:

Knowledge and perceptions of snakes, snakebites and their management among health workers in Sudan.

Hereby the responses for your comments:

1. The references were formatted correctly using the same style.

2. Four studies from other African countries were added.

3. The suggestions were in the attached manuscript file were included.

4. In Table 1, the average age (29.3 ± 8) deleted, and indicated in the main text.

5. The ages represented in some meaningful ranges.

6. In table 3, the first aspect (Type of snakes) removed.

Corresponding author

Ali Awadallah Saeed

Attachment Submitted filename: Rebuttal letter 3.4.2024.docx

10.1371/journal.pone.0302698.r007
Decision Letter 3
Omara Timothy Academic Editor
© 2024 Timothy Omara
2024
Timothy Omara
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version3
8 Apr 2024

Knowledge and perceptions of snakes, snakebites and their management among health workers in Sudan.

PONE-D-23-32936R3

Dear Dr. Saeed,

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,

Timothy Omara, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

10.1371/journal.pone.0302698.r008
Acceptance letter
Omara Timothy Academic Editor
© 2024 Timothy Omara
2024
Timothy Omara
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
25 Jul 2024

PONE-D-23-32936R3

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