Review for 10.1186/s12876-025-04073-w (2025)

Title: Evaluation of the risk level for celiac disease among adults in semi-rural and urban areas
(Moungo and Wouri) in Cameroon: a questionnaire based study
Version: 4 Date: 11 May 2025
Reviewer's report:
The authors have addressed most of the reviewers’ major and minor concerns in a thorough
and constructive manner. They provided detailed responses and implemented tangible revisions
in the revised manuscript. Nevertheless, several residual issues remain partially addressed
or insufficiently clarified, particularly concerning methodological transparency and statistical
interpretation.
Residual Issues and Gaps
1. Questionnaire-Based Risk vs. Diagnostic Accuracy
Partially Addressed:
The authors acknowledged the limitation that their findings reflect risk, not diagnosis, and added
clarifications in the discussion and conclusion. However, the abstract and results sections still
require stronger language to emphasize that no diagnostic confirmation (e.g., serology or biopsy)
was used. The phrase “a substantial portion of the population is considered at risk” might mislead
readers into interpreting this as prevalence data. Explicit qualifiers (e.g., “questionnaire-based
risk only”) should be reiterated in all main sections.
2. Sampling Bias and Generalizability
Partially Addressed:
The authors rationalize the use of hospital-based recruitment with explanations tied to healthcare
access in Cameroon. While this contextualizes the sampling frame, the defense still falls short
of clearly acknowledging the inherent selection bias. The explanation implies mitigation rather
than critical limitation. Furthermore, no adjustments or sensitivity analysis were performed to
address sample imbalance (350 vs. 150), which exaggerates urban–rural differences.
3. Regression and Statistical Interpretation
Adequately Addressed:
The authors dropped the unstable logistic regression models and substituted with Fisher’s exact
and chi-square tests, which is appropriate given the data structure and small cell sizes. They
also corrected language around odds ratios that previously misinterpreted OR < 1. However,
the rationale for score thresholds and categorizations (e.g., cutoffs for high vs. moderate risk)
remains weak and only described as “adapted from CDAQ” without citing validation in the local
context.
4. Terminology Consistency and Clarity
Addressed:
Inconsistent use of “semi-rural” vs. “rural” and “medium” vs. “moderate” was revised. The
authors clarified geographic definitions and standardized terminology throughout.
5. Risk Overestimation and Non-Celiac Etiologies
Partially Addressed:
The addition of tropical GI conditions (e.g., sprue, protozoal infections) as confounders is a
valuable enhancement. However, the discussion still leans heavily on dietary intake as a central
driver, with insufficient caution regarding the non-specificity of self-reported GI symptoms.
More emphasis should be placed on how regional endemic diseases and healthcare disparities
may inflate false-positive “risk” estimates.
6. Public Health Implications and Recommendations
Addressed:
The authors added appropriate commentary on the need for serological confirmation, physician
education, and awareness campaigns. This strengthens the manuscript’s translational relevance
and policy implications.
7. Language and Formatting Revisions
Addressed:
Grammar, sentence structure, typographical issues, and American vs. British spelling
inconsistencies were mostly corrected. Reviewer-suggested rewording was incorporated with
fidelity.
8. Statistical Formatting
Partially Addressed:
Scientific notation in tables was simplified in places, but some inconsistencies in decimal
precision and confidence interval formats remain. Table captions still lack clarity on sample size
and should be revised for full reader comprehension.
9. Recruitment and Inclusion Criteria Transparency
Partially Addressed:
Authors now state that participants were “recruited consecutively from hospital waiting areas,”
but inclusion/exclusion criteria remain underexplained. For example, it is unclear whether any
cases with preexisting GI disorders or dietary restrictions were excluded or controlled.
10. Mismatch Between Text and Tables
Resolved:
Discrepancies in symptom frequency reporting between text and tables (e.g., dermatitis
herpetiformis) have been corrected.