Reviewer ’s report  
 
Title:  Probiotics for V aginal Health in South Africa: What is on Retailers' Shelves?  
 
Version: 0 Date: 31 Oct 2016 
 
Reviewer:  Cindy  Arvidson  
 
Reviewer’s report:  
 
The manuscript entitled "Probiotics for Vaginal Health in South Africa: What is on Retailer's 
Shelves?" by Happel et al describes a study  in which commercial probiotic products available in 
two metropolitan areas of South Africa were examined for characteristics including microbial 
composition and recommended use. While probiotics for maintaining and improving 
gastrointestinal health predom inate the market, there is ample evidence in the literature to 
indicate that probiotics to maintain and improve vaginal health are also increasing. The 
manuscript itself is well -written and fairly detailed with respect to background, rationale for the 
study and the discussion of the results. The limitations are primarily the area of the study, which 
makes the actual results less relevant for the rest of the world. However, the discussion extends 
beyond the area of the study, so is of broader interest than S outh Africa.  
 
 
Specific comments are as follows:  
  
Introduction  
 
Pg. 3: The starting paragraph seems a bit awkward for a place to start. I would recommend 
switching the first two paragraphs to start off by emphasizing the protective role of the vaginal 
microbiota rather than starting off with what the composition is. That can come next, once the 
reader is "hooked".  
 
Line 23: the word "picture" seems awkward here. "Pattern" might be better.  
 
Line 35 and line 40: There are several other more current and more s pecific references for the 
association and mechanisms of protection of the vaginal tract from sexually -transmitted and 
urinary tract pathogens than are cited here. I would encourage the authors to seek out these 
papers and read them. It would make for a st ronger paper.   
 
Pg. 4: Line 29 -30: The definition of probiotics according to the FAO is:  "live microorganisms 
that, when administered in adequate amounts, confer a health benefit on the host".  
 
Line 35 (and several other places in the MS): The correct na me of the species is Bifidobacterium, 
not Bifidobacteria.  
 
Line 39: the fragment "and even yeast strains such as Saccharomyces cerevisiae." is awkward, 
consider re -wording.  
Line 39: add text to read "Probiotics have been used to treat…"  
 
Line 44: add the wo rd "for" to read "…maintain vaginal health, including for the treatment of 
BV."  
 
Starting on line 44: The last two sentences of this paragraph are very awkward. I think the point 
being made is that in order for vaginal probiotics to be effective they need t o colonize the vagina 
and produce all of the factors that contribute to their probiotic activity, but it isn't said very well. 
The word "however" is normally used to refer to a prior statement, but that is not the case here.  
 
Pg. 5: line 57: what is meant  by "covered"?  
 
Line 57: reword to read "…some of the largest medical companies…"  
 
 
Results  
 
Why are the figure legends embedded in the text? That is not a style I am familiar with and it 
makes for awkward reading.  
 
Pg. 9: line 23: what is meant by 9 x 1011 cfu - is that per dose? Per capsule? Per package? The 
units should be clarified for them to make any sense.  
 
Line 41: there is an apparent typo in the number: 6 x 109 cfu which should probably read 6 x 109 
cfu 
 
Pg. 10: line 37: the statement "…a determinant for the bacterial purine synthesis." doesn't make 
any sense. Folate/folic acid/vitamin B9 is probably added to some probiotics since it is a vitamin 
that is not synthesized by humans, who must get it from thei r diet. It is important for nucleotide 
synthesis in bacteria and humans. Some bacteria synthesize folate, including many 
Bifidobacterium sp. but only a few Lactobacillus sp. Ref. 37 is a paper on probiotics for 
dermatology, which is odd. A much better pape r that describes folate production by probiotic 
bacteria is Rossi et al. 2011. Nutrients 3:118 -134. Doi:10.3390/nu3010118.  
    
Pg. 11: line 38: change "Candida" to "candidiasis" since it is the disease (candidiasis) that the 
sentence is referring to, not t he organism that causes candidiasis.  
 
Line 45: change to read "…and reportedly reduces pathogenic bacteria…" since they are writing 
about what the product literature says it does, not what it actually does.  
 
Pg. 12: line 9: change the sentence to read "…l ocally to those that were imported, or probiotics 
stored on the shelf compared to those requiring refrigeration.  
 
 
Discussion  
 
Pg. 12; line 36: commensal "flora" should be changed to commensal "microbiota"  
Line 36: "host immunity" is confusing here. I under stand that there must be a synergy between 
the microbiota and the immune system, but it isn't clear how they are connecting that to 
protection from STI's.  
 
Line 47: add the word "within" to read "…~50% within 6 months"  
 
Pg. 13: line 9 -16: the point about H IV prevalence is awkward here  
 
Line 16: the sentence beginning "Factors contributing…" should begin a new paragraph since it 
is a change in topic.  
 
Line 33/36: what is the difference in GIT and gut? They should spell out what is meant by each 
term, since th ey are used by many people to mean different things.  
 
Line 45: reword to read: "…are frequently commensals of the healthy vaginal tract,"  
 
Line 45: consider adding L. iners to the list of lactobacilli commonly found in the vaginal tract of 
healthy women (se e Gregor Reid's work)  
 
Pg. 14: line 4: the word "potent" is awkward here  
 
Line 11: clarify what is meant by "these probiotic strains do not compete with each other"  
 
Line 18: it is not clear who "they" are. I assume Bifidobacterium spp., but grammatically i t is not 
clear.  
 
Line 21: the genus names are "Lactobacillus and Bifidobacterium"  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the  necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.   
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the  editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publica tion of this 
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3. Do you hold or are you currently applying for any patents relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
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