A One Health Approach to Climate-Driven Infectious Diseases in Sub-Saharan Africa: Strengthening Cross-Sectoral Responses for Resilient Health Systems

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Monden and colleagues present a systematic review on the impact of climate change on infectious diseases in Sub-Saharan Africa from a One Health perspective. The topic is highly relevant, timely, and generally well addressed.

However, a more organic and structured presentation of the findings would greatly enhance the clarity of the paper and help distill key take-home messages that could be translated into research priorities and implementation policies.

• Introduction: The current introduction is quite broad. I suggest summarizing it and instead including some epidemiological background on the major infectious diseases discussed in the review.
• Section 3.2: The authors present infections in a fragmented way. I recommend discussing one infection or infection type per paragraph to improve readability and coherence. I also noticed limited attention to arboviral diseases, which deserve more emphasis.
• Table 2: The description of key findings is incomplete or unclear in some entries (e.g. 1 and 7). A more consistent and detailed summary would be helpful.
• Section 3.3: This section would benefit from a more detailed presentation of the types of One Health approaches implemented, including concrete examples.
• Section 3.4: There is some redundancy with Section 3.2, and at times it is unclear how the two sections differ in scope and content.
• Sections 4.1, 4.2, and 4.3: These sections seem to present results rather than discussion. I suggest limiting the discussion to a concise paragraph, possibly integrating the current Sections 4.4 and 4.5, which are more aligned with interpretative commentary.
• A summary figure could be of help

Author Response

Comment 1: Introduction: The current introduction is quite broad. I suggest summarising it and instead including some epidemiological background on the major infectious diseases discussed in the review.

Response 1:

Thank you for this comment. The introduction has been shortened, and some epidemiological background on malaria, schistosomiasis and diarrhoeal diseases, including related references, has been added.

 Comment 2: Section 3.2: The authors present infections in a fragmented way. I recommend discussing one infection or infection type per paragraph to improve readability and coherence. I also noticed limited attention to arboviral diseases, which deserve more emphasis.

Response 2:

Thank you for your comment. Section 3.2 has been restructured to present each infection type in separate, coherent paragraphs, improving readability and logical flow. We have also expanded the coverage of arboviral diseases to ensure a stronger emphasis.

 Comment 3: Table 2: The description of key findings is incomplete or unclear in some entries (e.g. 1 and 7). A more consistent and detailed summary would be helpful.

Response 3:

Thank you for your comment. The key findings in Table 2 have been revised for clarity and consistency.

 Comment 4: Section 3.3: This section would benefit from a more detailed presentation of the types of One Health approaches implemented, including concrete examples.

 Response 4:

Thank you for your comment. Section 3.3 has been expanded to include concrete examples of One Health implementation across sub-Saharan Africa, illustrating national, regional, and community-level initiatives.

 Comment 5: Section 3.4: There is some redundancy with Section 3.2, and at times it is unclear how the two sections differ in scope and content.

Response 5:

Thank you for your comment. Section 3.4 has been revised to improve clarity and remove redundancy, ensuring a clearer distinction between the two sections.

Comment 6: Sections 4.1, 4.2, and 4.3: These sections seem to present results rather than discussion. I suggest limiting the discussion to a concise paragraph, possibly integrating the current Sections 4.4 and 4.5, which are more aligned with interpretative commentary.

Response 6:

The Discussion section has been condensed and restructured to enhance interpretative clarity. The previous Sections 4.1–4.3 were merged and rewritten to avoid descriptive repetition, while the analytical content from 4.4 and 4.5 was integrated for coherence. The revised version now presents a concise synthesis that focuses on interpretation, implications, and key insights rather than results.

Comment 7: A summary figure could be of help

Response 7:

Thank you for your comment. A summary figure was added to the end of the results section, summarising the main findings, climate drivers, disease impacts, and One Health gaps. 

 

Reviewer 2 Report

Comments and Suggestions for Authors

I have detailed my comments and suggestions below:

1. Clarity of Objectives

Although the introduction effectively sets the context and importance of the One Health framework for climate-sensitive diseases in SSA, the specific objectives of this systematic review are not concisely summarized. The text states it "examines the role" and "explores how" climate change influences diseases, but these are broad aims. It is recommended that the authors conclude the abstract and the introduction with one or two clear, focused sentences that explicitly state the primary research questions this review seeks to answer. For example: "This systematic review aims to synthesize the evidence on (1) the specific pathways through which climate drivers are altering the epidemiology of malaria, schistosomiasis, and diarrheal diseases in SSA, and (2) the documented effectiveness and implementation challenges of One Health interventions in mitigating these climate-driven health risks."

 

2. Methodological Rigor

The review follows PRISMA guidelines, which is a strength. However, the methodology section could be more rigorous in several aspects. First, the exclusion of grey literature and non-English studies is a significant limitation that should be more critically discussed, as it may omit relevant local and ongoing initiatives from governments or NGOs. Second, the authors acknowledge that no formal risk-of-bias assessment was conducted due to study heterogeneity. While understandable, this should be justified further, and alternative strategies used to assess the reliability and consistency of the synthesized evidence (e.g., sensitivity analysis by study design) should be mentioned or considered. Finally, the process of data extraction and synthesis, particularly for qualitative findings on governance and policy, could be described in more detail to enhance reproducibility.

 

3. Novelty and Contribution

The manuscript synthesizes a valuable body of recent literature. However, the "Introduction" and "Discussion" sections would benefit from a more explicit articulation of how this review fills specific knowledge gaps. The authors should briefly compare their work to existing systematic reviews on similar topics (if any), clearly stating what new insights their review provides—for instance, its specific focus on the operationalization of One Health in the SSA climate context or its concurrent analysis of multiple disease groups. Furthermore, the practical and policy implications of the findings, while touched upon, could be more forcefully emphasized in a dedicated subsection to highlight the review's contribution to guiding national and regional action.

 

4. Figures and Visualizations

The review currently includes a PRISMA flow diagram and a mention of a heatmap (Figure 2). The heatmap is a good start, but the presentation of results could be significantly enhanced with additional visualizations. For example, a conceptual diagram illustrating the proposed Climate-Smart One Health (CS-OH) framework and its components would greatly improve reader comprehension. Additionally, a map showing the geographic distribution of the included studies or the identified disease hotspots across SSA would make the regional variations discussed in the text more tangible. The synthesis of key findings could also be summarized in a table format for clarity.

 

5. Language and Readability

The manuscript is generally well-written but contains numerous long and complex sentences, particularly in the introduction and discussion, which can hinder readability. I recommend a thorough language edit to break down lengthy sentences, streamline phrasing, and ensure consistent use of terminology. For instance, ensure consistent formatting of "One Health" (not "OH" in the main text) and disease names. Enhancing conciseness will improve the overall flow and impact of the narrative.

 

6. Some recent studies indicate that exposure to specific meteorological parameters, such as temperature and relative humidity, may be separately and jointly with air pollution, is associated with childhood infectious diseases (e.g., Helicobacter pylori infection, COVID-19). Some other new studies explain the potential mechanisms underlying the associations, such as ROS, airway inflammation, and TRP pathway . Please discuss your findings with (some of) these new evidence to further support your results and explain the potential mechanisms.

Author Response

 Comment 1: Clarity of Objectives

Although the introduction effectively sets the context and importance of the One Health framework for climate-sensitive diseases in SSA, the specific objectives of this systematic review are not concisely summarized. The text states it "examines the role" and "explores how" climate change influences diseases, but these are broad aims. It is recommended that the authors conclude the abstract and the introduction with one or two clear, focused sentences that explicitly state the primary research questions this review seeks to answer. For example: "This systematic review aims to synthesize the evidence on (1) the specific pathways through which climate drivers are altering the epidemiology of malaria, schistosomiasis, and diarrheal diseases in SSA, and (2) the documented effectiveness and implementation challenges of One Health interventions in mitigating these climate-driven health risks."

Response 1:

Thank you for this comment. Some epidemiological background on climate change and the three discussed diseases - malaria, schistosomiasis and diarrheal diseases - have been added to better elaborate the influence of climate change on these diseases. At the end,  focused sentences better clarify what this review seeks to answer.

Comment 2: Methodological Rigor

The review follows PRISMA guidelines, which is a strength. However, the methodology section could be more rigorous in several aspects. First, the exclusion of grey literature and non-English studies is a significant limitation that should be more critically discussed, as it may omit relevant local and ongoing initiatives from governments or NGOs. Second, the authors acknowledge that no formal risk-of-bias assessment was conducted due to study heterogeneity. While understandable, this should be justified further, and alternative strategies used to assess the reliability and consistency of the synthesized evidence (e.g., sensitivity analysis by study design) should be mentioned or considered. Finally, the process of data extraction and synthesis, particularly for qualitative findings on governance and policy, could be described in more detail to enhance reproducibility.

Response 2:

 Thank you for your feedback. We have expanded the Limitations section to explicitly state that excluding grey literature and non-English publications may omit relevant local initiatives; this decision was made to maintain consistency and comparability. In Section 2.3, we clarified that the diversity of study types prevented us from using a single risk-of-bias tool. We also specified that qualitative findings on governance and policy were thematically coded, independently extracted by two authors, and validated by two others to ensure reliability.

Comment 3: Novelty and Contribution

The manuscript synthesizes a valuable body of recent literature. However, the "Introduction" and "Discussion" sections would benefit from a more explicit articulation of how this review fills specific knowledge gaps. The authors should briefly compare their work to existing systematic reviews on similar topics (if any), clearly stating what new insights their review provides—for instance, its specific focus on the operationalization of One Health in the SSA climate context or its concurrent analysis of multiple disease groups. Furthermore, the practical and policy implications of the findings, while touched upon, could be more forcefully emphasized in a dedicated subsection to highlight the review's contribution to guiding national and regional action.

Response 3:

We have revised the discussion to clearly highlight what is new and relevant about this review. A new subsection now situates our work in relation to previous studies, showing how it adds value through its specific focus on the operationalization of One Health across multiple disease groups in Sub-Saharan Africa. We also expanded the section on policy and practice implications to include concrete recommendations and better demonstrate how the findings can support national and regional climate–health strategies.

 Comment 4: Figures and Visualizations

The review currently includes a PRISMA flow diagram and a mention of a heatmap (Figure 2). The heatmap is a good start, but the presentation of results could be significantly enhanced with additional visualizations. For example, a conceptual diagram illustrating the proposed Climate-Smart One Health (CS-OH) framework and its components would greatly improve reader comprehension. Additionally, a map showing the geographic distribution of the included studies or the identified disease hotspots across SSA would make the regional variations discussed in the text more tangible. The synthesis of key findings could also be summarized in a table format for clarity.

Response 4:

Thank you for your comment. We appreciate the suggestion to enhance the visualization of the key findings. In response, we have added a new figure ( Figure 3), which presents a conceptual diagram of the proposed Climate-Smart One Health (CS-OH) framework and its major components. Additionally, a concise Table 3 summarizing the principal disease groups, climate drivers, and representative CS-OH responses has been incorporated to synthesize the main results. These additions improve the clarity, visual appeal, and overall interpretability of the findings.

Comment 5: Language and Readability

The manuscript is generally well-written but contains numerous long and complex sentences, particularly in the introduction and discussion, which can hinder readability. I recommend a thorough language edit to break down lengthy sentences, streamline phrasing, and ensure consistent use of terminology. For instance, ensure consistent formatting of "One Health" (not "OH" in the main text) and disease names. Enhancing conciseness will improve the overall flow and impact of the narrative.

Response 5:

Thank you. We have revised the manuscript to improve readability by shortening long sentences and ensuring consistent use of terminology, including “One Health” and disease names.

 Comment 6: Some recent studies indicate that exposure to specific meteorological parameters, such as temperature and relative humidity, may be separately and jointly with air pollution, is associated with childhood infectious diseases (e.g., Helicobacter pylori infection, COVID-19). Some other new studies explain the potential mechanisms underlying the associations, such as ROS, airway inflammation, and TRP pathway . Please discuss your findings with (some of) these new evidence to further support your results and explain the potential mechanisms.

Response 6:

Thank you for your comment. We have expanded the Discussion section to incorporate recent evidence linking meteorological factors and air pollution to infectious disease risk in children, including Helicobacter pylori and COVID-19. 

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors, 
I have major concerns about this publication. I believe, if transformed and characterized as a scoping review this could work, if the search strategy is revised and the searches redone. 
Also, consider spending some more time on clearly defining the concept of "one health", as this may lead otherwise to arbitrary decisions in the eligibility assessment. 

p2/22 
Public health systems are increasingly challenged by emerging infectious diseases, i.e., novel or
resurgent diseases such as Cholera, Ebola, monkeypox, Zika, or COVID-19, and the region
has also observed a rise in zoonotic pathogen outbreaks recently due to monkeypox and
Ebola viruses [8]
=> why use monkeypox and not MPOX?

p1+2/22 Climate change is likely to affected SSA in different ways. This will increase as well decrease percipitation, shifting rain fall patterns.  (e.g. https://www.nature.com/articles/s41612-025-01123-8)
A key issue is also the different underlying scenarios and climate assumoptions. E.g., SSP2-4.5 vs. SSP5-8.5.
Furthermore, population growth, shifting in demograhic patterns, settlementlocation, economic activities, etc. will affect the level and extend of exposure and vulnerability of population. 
THis should be introduced in the introduction. 

p1+2/22: Furthermore, the authors should clarify why they believe that there will be an impact of Climate Change on the health disorders of interest. (i.e. briefly describe the assumed mechanism).

p1+2/22: Finally, the introduction should clarify why a "one health appraoch" would provide a relevant benefit. For example, what is the "one health" benefit for malaria or dengue fever? What is the added benefit you expect here? And what does it actually mean, to take this perspective?

Methods 3/22: Search strategy:
> The search strategy is not adequate for the task.
>>> No MeSh terms seemed to have been used?
>>> CC-Terms are insufficient: a study may look into the effects of extreme percipitation, shifting in rainfall patterns, or an increase in temperature and the impact on dengue from a one health perspective => this study would be missed. 
>>> the infectious disease terms are insufficient: the search strategy does not include relevant synonyms and other forms of spelling (e.g. zoonotic disease is not covered). A study on Cholera that does not use the term diarrheal disease is not covered.
>>> the ONE HEALTH filter is insufficinet. Potentially, as the concept of one health is a rather vague concept, that does not lead itself nicely to clear categorization. For example, terms arround interdisciplinarity is missing. But also terms surounding veterinary medicine or veterinarians cooperating with (human) physicians. => in the current form, relevant studies on One health would be missing.
>>> Furthermore, the SSA Filter is insufficient. For example, you would be missing studies conducted in Kongo or Kenya, if they do not use the relevant terms. 
==> overall, the search strategy is too narrow and insufficient. This is already a critical limitations of this review. This leads to the study being found being a more or less arbitrary selection of studies, rather than a systematic collection of studies. 

> THe authors used an arbitrary time filter, without justification 2019-2025. 
> The authors write: "The primary geographic focus was
SSA, but studies with a global or multi-regional focus were also included if they pro-vided data or insights relevant to the region" => this seems extremely arbitrary. An increase in percipitation and rainfall in the amazonas may be relevant for the Kongo basin. This eligibility crtieria would need to be clearly spelled out. 
> Similar to the introduction on One Health: what is the "cross-sectoral framework"? I feel, this would fit all or most public health research, e.g., where an economist and a medical specialist work together => this would fit a "cross-sectional framework"?

Results
> PRISMA-Flowchart: List seperately, how many publications you got from which database
> Exclusion criterion "Full-text not available" should be listed under reports not retrieved.
> The numbers provided in the PRISMA flowchart are two round to be believable: exactly 1200 studies, exactly 850 included in the Title abstract screening, exactly 100 in the assessed. These figures seem way to round to be believable. 
> Please provide a list of the individual records excluded studies included the specific reasons for exclusion 
> For it to be considered a systematic review, a form of quality appraisal would need to be conducted.  This is not the case here.

 

Author Response

Comment 1: p2/22 Public health systems are increasingly challenged by emerging infectious diseases, i.e., novel or resurgent diseases such as Cholera, Ebola, monkeypox, Zika, or COVID-19, and the region
has also observed a rise in zoonotic pathogen outbreaks recently due to monkeypox and
Ebola viruses [8]
=> why use monkeypox and not MPOX?

Response 1:

Thank you for your comment. The related sentence has been deleted due to shortening and reshaping the introductory section.

 Comment 2:  p1+2/22 Climate change is likely to affected SSA in different ways. This will increase as well decrease percipitation, shifting rain fall patterns.  (e.g. https://www.nature.com/articles/s41612-025-01123-8)A key issue is also the different underlying scenarios and climate assumoptions. E.g., SSP2-4.5 vs. SSP5-8.5.

Response 2:

 Thank you for this comment. A reference to temperature and rainfall regimes and remaining uncertainty has been added (IPCC AR6 and Takuela et al., 2025).

Comment 3: Furthermore, population growth, shifting in demograhic patterns, settlementlocation, economic activities, etc. will affect the level and extend of exposure and vulnerability of population.
THis should be introduced in the introduction. 

Response 3:

Thank you for this comment. The related paragraph has been moved closer to the beginning of the Introduction section (end of the first paragraph).

Comment 4:  p1+2/22: Furthermore, the authors should clarify why they believe that there will be an impact of Climate Change on the health disorders of interest. (i.e. briefly describe the assumed mechanism).

Response 4:

Thank you for your comment. This has been addressed in the amended details.

Comment 5:  p1+2/22: Finally, the introduction should clarify why a "one health appraoch" would provide a relevant benefit. For example, what is the "one health" benefit for malaria or dengue fever? What is the added benefit you expect here? And what does it actually mean, to take this perspective?

Response 5:

Thank you for your comment. The introduction section has been adjusted in the end to highlight the benefit of a more coordinated, integrated and cross-sectoral intervention aligned with the One Health framework.

Comment 6: Methods 3/22: Search strategy:
> The search strategy is not adequate for the task.
>>> No MeSh terms seemed to have been used?
>>> CC-Terms are insufficient: a study may look into the effects of extreme percipitation, shifting in rainfall patterns, or an increase in temperature and the impact on dengue from a one health perspective => this study would be missed. 

Response 6:

Thank you for your feedback. The search strategy has been revised to include both MeSH terms in PubMed, adapted terms for each database, and provided full search strings in supplementary materials. Database-specific yields are now reported before de-duplication, improving coverage and reproducibility.

Comment 7:  >>> the infectious disease terms are insufficient: the search strategy does not include relevant synonyms and other forms of spelling (e.g. zoonotic disease is not covered). A study on Cholera that does not use the term diarrheal disease is not covered.

Response 7:

Thank you for your comment. We have revised the infectious disease section to include synonyms and spelling variants. This ensures broader coverage and reduces the likelihood of missing relevant studies.

Comment 8: >>> the ONE HEALTH filter is insufficinet. Potentially, as the concept of one health is a rather vague concept, that does not lead itself nicely to clear categorization. For example, terms arround interdisciplinarity is missing. But also terms surounding veterinary medicine or veterinarians cooperating with (human) physicians. => in the current form, relevant studies on One health would be missing.

Response 8:

Thank you for your comment. The One Health block has been expanded to include additional related terms. 

Comment 9: >>> Furthermore, the SSA Filter is insufficient. For example, you would be missing studies conducted in Kongo or Kenya, if they do not use the relevant terms.
==> overall, the search strategy is too narrow and insufficient. This is already a critical limitations of this review. This leads to the study being found being a more or less arbitrary selection of studies, rather than a systematic collection of studies. 

Response 9:

Thank you for your comment. The SSA filter has been expanded to include regional terms, resulting in the addition of additional eligible studies that have now been incorporated into the synthesis.

Comment 10:  > THe authors used an arbitrary time filter, without justification 2019-2025.
> The authors write: "The primary geographic focus was SSA, but studies with a global or multi-regional focus were also included if they pro-vided data or insights relevant to the region" => this seems extremely arbitrary. An increase in percipitation and rainfall in the amazonas may be relevant for the Kongo basin. This eligibility crtieria would need to be clearly spelled out. 

Response 10:

Thank you for your comment. The Eligibility Criteria 2.2 has been revised to justify the 2019–2025 timeframe, aligning it with recent IPCC and WHO reporting cycles, and clarified that only global or multi-regional studies with explicit SSA data or stratified analyses were included. Indirectly relevant studies were excluded.

Comment 11: > Similar to the introduction on One Health: what is the "cross-sectoral framework"? I feel, this would fit all or most public health research, e.g., where an economist and a medical specialist work together => this would fit a "cross-sectional framework"?

Response 11:

Thank you for your comment. The definition of “cross-sectoral framework” has been clarified, aligning it with the Tripartite One Health definition, and studies with multidisciplinary collaboration but without explicit One Health integration were excluded to avoid arbitrary inclusion.

 Comment 12: Results
> PRISMA-Flowchart: List separately, how many publications you got from which database

Response 12:

Thank you for your comment. The PRISMA flowchart has been revised and now reports the number of records retrieved from each database separately in line with PRISMA 2020 recommendations.

Comment 13: > Exclusion criterion "Full-text not available" should be listed under reports not retrieved.

Response 13:

Thank you for the feedback. The study selection description and PRISMA flow have been revised to include a separate “reports not retrieved” category.

Comment 14: > The numbers provided in the PRISMA flowchart are two round to be believable: exactly 1200 studies, exactly 850 included in the Title abstract screening, exactly 100 in the assessed. These figures seem way to round to be believable

Response 14:

Thank you. The PRISMA flow has been revised to present database-specific yields and more precise counts.

 Comment 15: > Please provide a list of the individual records excluded, studies include the specific reasons for exclusion

Response 15:

Thank you for the comment. Section 2.3 has been revised to provide detailed reasons for full-text exclusions.

Comment 16: > For it to be considered a systematic review, a form of quality appraisal would need to be conducted.  This is not the case here. I believe, if transformed and characterized as a scoping review, this could work if the search strategy is revised and the searches redone. 

Response 16:

Thank you for the comment. The manuscript has been revised to clearly characterize it as a scoping review, and the methodology, PRISMA-ScR framework, and terminology have been updated accordingly. Section 2.3 explains the quality appraisal and uses the term “scoping review” instead of systematic review, throughout.

 

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Authors have addressed my concerns

Author Response

Comment 1: The Authors have addressed my concerns

Response 1

We thank the reviewer for the positive evaluation and for confirming that all concerns have been fully addressed. We appreciate the constructive feedback provided during the earlier round, which helped strengthen the manuscript.

Reviewer 2 Report

Comments and Suggestions for Authors

Many thanks for the authors’ careful explanations and revision. The authors have addressed all my comments. Now, I have no further comments.

Author Response

Comment 1: Many thanks for the authors’ careful explanations and revision. The authors have addressed all my comments. Now, I have no further comments.

Response 1

We sincerely thank the reviewer for the thoughtful feedback and for confirming that all comments have been addressed. We appreciate the reviewer’s contribution to improving the clarity and quality of the manuscript.

Reviewer 3 Report

Comments and Suggestions for Authors

In my previous review I pointed out several issues with the search strategy, which is a major limitation of the current manuscript.

Those seem to be addressed in Response 6 - 10.

Here, the authors wrote something on the line of "Thank you for your feedback. The search strategy has been revised", e.g. "to include synonyms and spelling variants".

However, the search strategy was not revised. It is still bad in the manuscript. And it does not match what was provided in the appendix. The search strategy in the appendix does not work, and does not produce the number of hits.
=> the authors seemed to have made, again, major mistakes or actively lied about what they did.

In my past review, I pointed out that the authors likely made the figures up, as too many numbers were too round. Now they changed the numbers slightly, without providing meaningful difference.

For example: 1206 records were identified in database searches (instead of 1200). But in both cases 850 were included in title and Abstract screening.

In the previous version 750 were included in the title abstract screening, in the new version, it is 729.

Suddenly, you have not been able to retrived 18 studies, which was previously 0.

Also, the reasons for exclusion seem to be conflicting between the two versions.

 

Furthermore, the authors write under search strategy (3/27): "A comprehensive search was conducted from 5 to 30 July 2025 across four databases: PubMed, Scopus, Web of Science, and the Cochrane Library" . Furthermore, you write that eligibility criteria "Studies were considered eligible if they were peer-reviewed articles published between January 2019 and July 2025"

In the appendix it states, that the search was conducted in July 2025.

I gave my feedback in October 2025.

==> How did did the manage to do your searches in July 2025 if I requested major revisions to the searches in October?

 

Also, the responses to my requests seemed to have been done be AI and not integrated into the manuscript.

Author Response

Comment 1: In my previous review I pointed out several issues with the search strategy, which is a major limitation of the current manuscript.Those seem to be addressed in Response 6 - 10. Here, the authors wrote something on the line of "Thank you for your feedback. The search strategy has been revised", e.g. "to include synonyms and spelling variants".However, the search strategy was not revised. It is still bad in the manuscript. And it does not match what was provided in the appendix. The search strategy in the appendix does not work, and does not produce the number of hits.
=> the authors seemed to have made, again, major mistakes or actively lied about what they did.

Response 1

We thank the reviewer for raising these concerns and for their careful attention to the search strategy, which is indeed a central component of this scoping review. We would like to clarify the changes made after the previous review round and how they are now reflected in the manuscript and Appendix.

Following the reviewer’s initial comments, we revised the search strategy, as described in Responses 6–10 of the previous round. This included the addition of further synonyms and spelling variants, clearer separation of climate, infectious disease, One Health, and Sub-Saharan Africa blocks, and closer alignment of controlled vocabulary (MeSH terms) with free-text keywords. These revisions were implemented at the time the searches were re-run in October 2025, and the PRISMA counts reported in the manuscript are based on those revised searches.We acknowledge, however, that in the earlier revised version, the documented example string in the Methods and the search strings in the Appendix contained formatting and syntactic inconsistencies (e.g. a missing OR operator, unbalanced parentheses, and typographical quotation marks). These presentation issues made the strategy difficult to read. They may have given the impression that the search had not been revised, even though the underlying logic and executed searches had in fact been updated.

To address this, we have now:

• Harmonized the search strategy between the Methods section and the Supplementary Materials so that the same Boolean structure is presented consistently in both.
• Integrated all synonyms and spelling variants described in the previous Response 6–10 directly into the documented search strings.
• Corrected minor syntactic issues (e.g. OR placement, parentheses, and quotation marks) so that the PubMed example and full Appendix strings are fully interpretable and executable.

Regarding the concern that the Appendix search “does not work and does not produce the number of hits”: we respectfully note that PubMed, Scopus and Web of Science are dynamic databases, whose indexing is updated continuously. As a result, contemporary attempts to reproduce the search (e.g. in October/November 2025) will not yield the same number of records as those obtained during the original search period (July 2025). For this reason, PRISMA-ScR guidelines emphasize reporting both the search strategy and the dates of execution; the PRISMA counts in our manuscript reflect the results at the documented July and October 2025 search dates and have not been changed in this revision.

We would like to reassure the reviewer and the editor that:

• no numerical, methodological, or conceptual changes have been made to the search results,
• the revisions in this round relate solely to clarifying and harmonizing the documentation of the strategy,
• there was no intention to mislead. Any perceived discrepancies arose from formatting issues in the previously documented strings and from the dynamic nature of database indexing, rather than from errors in how the search was originally conducted.

We hope this clarification and the now-harmonized search documentation adequately address the reviewer’s concerns.

 Comment 2: In my past review, I pointed out that the authors likely made the figures up, as too many numbers were too round. Now they changed the numbers slightly, without providing meaningful difference.For example: 1206 records were identified in database searches (instead of 1200). But in both cases 850 were included in title and Abstract screening.In the previous version 750 were included in the title abstract screening, in the new version, it is 729.Suddenly, you have not been able to retrived 18 studies, which was previously 0.Also, the reasons for exclusion seem to be conflicting between the two versions.

Response 2

We thank the reviewer for their attention to the PRISMA numbers and appreciate the opportunity to clarify how the differences between versions arose. As noted earlier, the search was updated in October 2025 following the reviewer’s feedback. Because this update produced a slightly different set of retrieved records, the downstream screening numbers changed accordingly. This explains the shift from 1,200 to 1,206 initial records. The change from 750 to 729 records screened at the title/abstract level is a result of the October rerun and deduplication. Such minor differences are expected during review updates and align with PRISMA-ScR guidance to report search dates, given that databases are continually updated.

Regarding the 18 studies that could not be retrieved in full, this reflects changes in access at the time of the October screening round. We have now clearly documented this step in the study selection process to ensure full transparency. The exclusion categories also differ slightly because the October screening included a slightly different set of full-text articles. We have reviewed this section carefully, ensured that all categories align with the eligibility criteria in Table 1, and confirmed that the totals are correct and internally consistent.

We would like to reassure the reviewer and the editor that all numbers reported in the PRISMA diagram correspond directly to the July and October search executions, and that none were altered outside the documented screening process. The differences between versions arise solely from the updated search requested during the previous review round and from normal database indexing changes.

We hope this clarification resolves the concerns raised and demonstrates that the numerical differences are transparent, methodologically grounded, and consistent with standard scoping review practice.

Comment 3: Furthermore, the authors write under search strategy (3/27): "A comprehensive search was conducted from 5 to 30 July 2025 across four databases: PubMed, Scopus, Web of Science, and the Cochrane Library" . Furthermore, you write that eligibility criteria "Studies were considered eligible if they were peer-reviewed articles published between January 2019 and July 2025" In the appendix it states, that the search was conducted in July 2025.I gave my feedback in October 2025. ==> How did did the manage to do your searches in July 2025 if I requested major revisions to the searches in October?

Response 3

We thank the reviewer for pointing out the need to clarify the timeline of the search. The manuscript originally described only the initial search period (5–30 July 2025), which may have caused confusion regarding the updates made after the first review round.

To clarify:

• The initial search was conducted from 5–30 July 2025, and the eligibility window remained January 2019–July 2025.
• Following the reviewer’s feedback, we updated the search in October 2025 using the same eligibility window.
  The purpose of this update was to identify studies published before July 2025 that had been newly indexed or updated in the databases between July and October.
• The October update did not introduce any studies published after July 2025, and therefore, the eligibility criteria and scope of the review remained unchanged.

The updated October search results are reflected in the PRISMA flow diagram and the revised study counts. To avoid any ambiguity, we have now explicitly stated in both the Methods section and the Appendix that the search was initially conducted in July 2025 and updated in October 2025 using the same eligibility window.

We hope this clarification resolves the reviewer’s concern regarding the sequence and timing of the searches.

Comment 4: Also, the responses to my requests seemed to have been done be AI and not integrated into the manuscript.

Response 4

We thank the reviewer for raising this point. We would like to clarify that all revisions requested during the previous round were fully integrated into the manuscript, including updates to the search strategy, refinement of terminology, clarification of eligibility criteria, and alignment of the PRISMA flow with the updated October 2025 search.

In this revision, we have carefully reviewed the entire manuscript to ensure that all previous responses are now clearly reflected in the text. This includes harmonizing the search strategy between the Methods and Supplementary Materials, clarifying the July and October search timeline, correcting formatting issues in the documented search strings, and ensuring consistent presentation of all PRISMA numbers and exclusion categories.

We appreciate the reviewer’s reminder to ensure full alignment between responses and manuscript text, and we have now verified that all revisions are fully incorporated.

We hope this clarification resolves the concern.

Comment 5:The introduction must be improved

Response 5

We thank the reviewer for this observation. In response, we have revised the Introduction to strengthen the conceptual framing and clarify the rationale for the review. Specifically, we:

• refined the description of climate-related drivers of infectious diseases;
• expanded the contextualization of vulnerability in Sub-Saharan Africa;
• clarified why malaria, schistosomiasis and diarrhoeal diseases were selected as representative climate-sensitive conditions;
• strengthened the explanation of the relevance of the One Health framework and the current gaps in its operationalisation; and
• added a clear statement on the purpose and contribution of the scoping review.

These revisions aim to improve clarity, flow and coherence while maintaining factual accuracy and alignment with the scope of the review. We hope that the revised Introduction satisfactorily addresses this comment.

Comment 6:Study design must be improved.

Response 6

We thank the reviewer for this observation. In response, we have clarified key elements of the study design to ensure greater transparency and alignment with PRISMA-ScR guidance. We added a concise explanation of the rationale for using a scoping review approach, clarified the role of the October 2025 search update (which re-ran the same eligibility window solely to confirm completeness), corrected the formatting of the example PubMed search string, and added a sentence describing the charting-based data extraction consistent with scoping review methodology. These editorial refinements improve clarity without altering the underlying methodology or results.