Review Reports

3. Point-by-point response to Comments and Suggestions for Authors

Comments 1: This study presents an interesting ecological study using spatial analysis of the four clinical forms of leishmaniasis in Honduras—ulcerative cutaneous leishmaniosis (UCL), mucosal leishmaniasis (ML), non-ulcerated cutaneous leishmaniasis (NUCL), and visceral leishmaniasis (VL)—utilizing epidemiological data from 2009 to 2016. Although the topic is of significant epidemiological relevance, the study requires revision before it can be considered for publication.

Response 1: Thank you for your comments. We have made the requested revisions so that our article can be considered for publication.

Comments 2: Title: ​​Considering that the analyses performed in this study focus exclusively on the geographic distribution of leishmaniasis cases across municipalities in Honduras, employing methods such as Global Moran's I and Hot Spot Analysis (Getis-Ord Gi*) that do not incorporate the temporal dimension of epidemiological data, we suggest adjusting the article's title to more accurately reflect the research scope. We recommend emphasizing the exclusively spatial nature of the analysis (not spatiotemporal), thereby ensuring greater precision in communicating the methodological approach and findings to readers.
Suggested title: Spatial Analysis of Different Clinical Forms of Leishmaniasis in Honduras from 2009 to 2016

Response 2: Thank you for your comment. We have reviewed the manuscript and agree with your opinion. The title has been changed to the suggested one.

Comments 3: Methods: Leishmaniasis Morbidity Analysis/Risk mapping - describe why the thematic maps in Figure 4 illustrate the spatial distribution of the incidence rate of the four clinical forms of leishmaniasis only in the years 2009, 2012, and 2016, calculated per 10,000 inhabitants. Also for local hot spots of four clinical forms of leishmaniasis identified using the Getis-Ord Gi* Statistic.

Response 3: Thank you for your comment. The main reason we only used the years 2009, 2012, and 2016 for the analyses was that only in those years was there detectable spatial variation.

Comments 4: Results: Please specify the distribution of the 15,345 confirmed cases by clinical form (UCL, ML, NUCL, and VL) between 2009 and 2016. 

Response 4: Thank you for your comment. Table 1 has been included in the manuscript, which specifies the distribution of leishmaniasis cases during the study period, as well as the distribution of cases by clinical form.

Comments 5: Case distribution: UCL (n=?), ML (n=?), NUCL (n=?), and VL (n=?) out of the total 15,345 cases.

Response 5: Thank you very much for your comment. The data on the distribution of clinical forms was reviewed and corrected in the text.

Comments 6: Provide a table with cases of leishmaniasis according to age groups during the period in Honduras.

Response 6: The table was added to the manuscript with the title: Table 3. Cases and incidence rate of leishmaniasis by age group during the period 2013–2016 in Honduras. The incidence data were included because another reviewer suggested it, and we felt it was appropriate to create a table with cases and incidence.

Comments 7: Please provide a table quantifying the hot spots identified by the Getis-Ord Gi* statistic, specifying the regions for each clinical form, rather than relying solely on visual representation in maps

Response 7: The table was added to the manuscript with the tittle: Table 5. High-Value Clusters (Hot Spots) Identified by the Getis-Ord Gi* Statistic.

Comments 8: Please include limitations of the study

Response 8: The limitations of our study have been included in the manuscript.

3. Point-by-point response to Comments and Suggestions for Authors

Comments 1: It would be useful to have data from more recent years, as we are approaching the end of 2025. However, if this is not possible, it is compensated by including data from a broad range of years (8 years), which offer reliable results.

Response 1:Thank you for your comment. We also believe it is necessary to use a closer data range. Unfortunately, recent, curated information is not available. This data was collected and curated by our group from the official website of the National Chagas and Leishmaniasis Program in Honduras, which is now decommissioned, and the program was restructured more than five years ago. Despite this limitation, we believe our manuscript is important for understanding the ecology of leishmaniasis in Honduras through spatial analysis.

Comments 2: Since this article focuses on the clinical forms of human leishmaniasis in Honduras, it would be helpful to include a typology of the four forms considered, as well as photographs

Response 2: Figure 2 has been included in the manuscript, describing each of the clinical forms with its respective photograph.

Response 2-2: We must clarify that Figure 2, entitled "Figure 2. Representative images showing different clinical forms of leishmaniasis in Honduras", has been removed because the images are from the academic repository of one of the manuscript's co-authors. We were unable to obtain signed consent from the patients involved for their use.

Comments 3: Update the reference 1 (more recent ones from the Weekly epidemiological record and Report of leishmaniasis in the Americas by PAHO.

Response 3: The reference has been updated and the text has been modified.

Comments 4: It is confusing the mention of Leishmania (L.) infantum chagasi  associated with both VL and NUCL due to the mention in lines 53-55 that a variant of CL has recently been renamed Leishmania (Leishmania) poncei n. sp. Then, 4 Leishmania species are present in Honduras. Clarify in this part of the text, as in the rest of the document, the identity of the species causing NUCL in Honduras. There is considered that both L. infantum and L. poncei could be responsible for NUCL?

Response 4: Thank you for your comment. We have reviewed the text and decided to remove the mention of the species Leishmania poncei n. sp. Further research on this species is still needed to clarify its role in the transmission cycle of non-ulcerative cutaneous leishmaniasis in Honduras and other Central American countries. We apologize for the confusion.

Comments 5: Population data for Honduras dates back to 2002. Is there more recent data on this topic?

Response 5: Unfortunately, the last official census of Honduras was conducted in 2001 and published in 2002. For our analysis, we used the annual population projections from that census.

Comments 6: Suggested to include inthe document the supplementary tableF and to reduce the text text as follows "The department with the highest number of cases was Olancho, with 4,064 cases (26.5%), with an incidence rate of 75.2, whilst Copan was the department with the lowest number of cases (7 cases, 0.04%, incidence rate 0.7, as Lempira (Table 1)".

Response 6: Thank you very much for your comment. We have added Supplementary Table F to the manuscript, which has been renamed Table 1.

Comments 7:  Age and Gender: Include results regarding the incidence of clinical forms acoording to age groups.

Response 7: The table was added to the manuscript with the title: Table 3. Cases and incidence rate of leishmaniasis by age group during the period 2013–2016 in Honduras.