CINXE.COM

<!DOCTYPE html> <html xmlns="http://www.w3.org/1999/xhtml" lang="en" xml:lang="en" itemscope itemtype="http://schema.org/Article" class="no-js"> <head prefix="og: http://ogp.me/ns#"> <link rel="stylesheet" href="/resource/css/site-content.css?79f248ebefa43b7800a14562e5049ab4"/>   <link rel="stylesheet" type="text/css" href="https://fonts.googleapis.com/css?family=Open+Sans:400,400i,600"> <link media="print" rel="stylesheet" type="text/css" href="/resource/css/print.css"/> <script type="text/javascript"> var siteUrlPrefix = "/plosmedicine/"; </script> <script src="/resource/js/vendor/modernizr-v2.7.1.js" type="text/javascript"></script> <script src="/resource/js/vendor/detectizr.min.js" type="text/javascript"></script> <link rel="shortcut icon" href="/resource/img/favicon.ico" type="image/x-icon"/> <meta http-equiv="Content-Type" content="text/html; charset=utf-8"/>  <script type='text/javascript'> var googletag = googletag || {}; googletag.cmd = googletag.cmd || []; (function() { var gads = document.createElement('script'); gads.async = true; gads.type = 'text/javascript'; var useSSL = 'https:' == document.location.protocol; gads.src = (useSSL ? 'https:' : 'http:') + '//www.googletagservices.com/tag/js/gpt.js'; var node = document.getElementsByTagName('script')[0]; node.parentNode.insertBefore(gads, node); })(); </script>  <script id="doubleClickSetupScript" type='text/javascript'> googletag.cmd.push(function() { googletag.defineSlot('/75507958/PMED_728x90_ATF', [728, 90], 'div-gpt-ad-1458247671871-0').addService(googletag.pubads()); googletag.defineSlot('/75507958/PMED_160x600_BTF', [160, 600], 'div-gpt-ad-1458247671871-1').addService(googletag.pubads()); var personalizedAds = window.plosCookieConsent && window.plosCookieConsent.hasConsented('advertising'); googletag.pubads().setRequestNonPersonalizedAds(personalizedAds ? 0 : 1); googletag.pubads().enableSingleRequest(); googletag.enableServices(); }); </script> <script type="text/javascript"> var WombatConfig = WombatConfig || {}; WombatConfig.journalKey = "PLoSMedicine"; WombatConfig.journalName = "PLOS Medicine"; WombatConfig.figurePath = "/plosmedicine/article/figure/image"; WombatConfig.figShareInstitutionString = "plos"; WombatConfig.doiResolverPrefix = "https://dx.plos.org/"; </script> <script type="text/javascript"> var WombatConfig = WombatConfig || {}; WombatConfig.metrics = WombatConfig.metrics || {}; WombatConfig.metrics.referenceUrl = "http://lagotto.io/plos"; WombatConfig.metrics.googleScholarUrl = "https://scholar.google.com/scholar"; WombatConfig.metrics.googleScholarCitationUrl = WombatConfig.metrics.googleScholarUrl + "?hl=en&lr=&q="; WombatConfig.metrics.crossrefUrl = "https://www.crossref.org"; </script> <script defer="defer" src="/resource/js/defer.js?13928eb59791c3cc61cf"></script><script src="/resource/js/sync.js?13928eb59791c3cc61cf"></script> <script src="/resource/js/vendor/jquery.min.js" type="text/javascript"></script> <script src="/resource/js/vendor/fastclick/lib/fastclick.js" type="text/javascript"></script> <script src="/resource/js/vendor/foundation/foundation.js" type="text/javascript"></script> <script src="/resource/js/vendor/underscore-min.js" type="text/javascript"></script> <script src="/resource/js/vendor/underscore.string.min.js" type="text/javascript"></script> <script src="/resource/js/vendor/moment.js" type="text/javascript"></script> <script src="/resource/js/vendor/jquery-ui-effects.min.js" type="text/javascript"></script> <script src="/resource/js/vendor/foundation/foundation.tooltip.js" type="text/javascript"></script> <script src="/resource/js/vendor/foundation/foundation.dropdown.js" type="text/javascript"></script> <script src="/resource/js/vendor/foundation/foundation.tab.js" type="text/javascript"></script> <script src="/resource/js/vendor/foundation/foundation.reveal.js" type="text/javascript"></script> <script src="/resource/js/vendor/foundation/foundation.slider.js" type="text/javascript"></script> <script src="/resource/js/util/utils.js" type="text/javascript"></script> <script src="/resource/js/components/toggle.js" type="text/javascript"></script> <script src="/resource/js/components/truncate_elem.js" type="text/javascript"></script> <script src="/resource/js/components/tooltip_hover.js" type="text/javascript"></script> <script src="/resource/js/vendor/jquery.dotdotdot.js" type="text/javascript"></script>  <script> dataLayer = [{ 'mobileSite': 'false', 'desktopSite': 'true' }]; </script> <title>PLOS Medicine</title>  <script> $(document).ready(()=> { let lemurTitle = $('article > h1').text(); if (lemurTitle && lemurTitle != '') { $('title').text(lemurTitle + ' | ' + 'PLOS Medicine'); } }); </script> </head> <body class="static plosmedicine">  <noscript><iframe src="//www.googletagmanager.com/ns.html?id=GTM-TP26BH" height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript> <script> (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start': new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0], j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src= '//www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f); })(window,document,'script','dataLayer','GTM-TP26BH'); </script> <noscript><iframe src="//www.googletagmanager.com/ns.html?id=GTM-MQQMGF" height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript> <script>(function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start': new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0], j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src= '//www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f); })(window,document,'script','dataLayer','GTM-MQQMGF');</script>   <script type="text/javascript"> ;window.NREUM||(NREUM={});NREUM.init={distributed_tracing:{enabled:true},privacy:{cookies_enabled:true},ajax:{deny_list:["bam.nr-data.net"]}}; window.NREUM||(NREUM={}),__nr_require=function(t,e,n){function r(n){if(!e[n]){var o=e[n]={exports:{}};t[n][0].call(o.exports,function(e){var o=t[n][1][e];return r(o||e)},o,o.exports)}return e[n].exports}if("function"==typeof __nr_require)return __nr_require;for(var o=0;o<n.length;o++)r(n[o]);return r}({1:[function(t,e,n){function r(t){try{s.console&&console.log(t)}catch(e){}}var o,i=t("ee"),a=t(32),s={};try{o=localStorage.getItem("__nr_flags").split(","),console&&"function"==typeof console.log&&(s.console=!0,o.indexOf("dev")!==-1&&(s.dev=!0),o.indexOf("nr_dev")!==-1&&(s.nrDev=!0))}catch(c){}s.nrDev&&i.on("internal-error",function(t){r(t.stack)}),s.dev&&i.on("fn-err",function(t,e,n){r(n.stack)}),s.dev&&(r("NR AGENT IN DEVELOPMENT MODE"),r("flags: "+a(s,function(t,e){return t}).join(", ")))},{}],2:[function(t,e,n){function r(t,e,n,r,s){try{l?l-=1:o(s||new UncaughtException(t,e,n),!0)}catch(f){try{i("ierr",[f,c.now(),!0])}catch(d){}}return"function"==typeof u&&u.apply(this,a(arguments))}function UncaughtException(t,e,n){this.message=t||"Uncaught error with no additional information",this.sourceURL=e,this.line=n}function o(t,e){var n=e?null:c.now();i("err",[t,n])}var i=t("handle"),a=t(33),s=t("ee"),c=t("loader"),f=t("gos"),u=window.onerror,d=!1,p="nr@seenError";if(!c.disabled){var l=0;c.features.err=!0,t(1),window.onerror=r;try{throw new Error}catch(h){"stack"in h&&(t(14),t(13),"addEventListener"in window&&t(7),c.xhrWrappable&&t(15),d=!0)}s.on("fn-start",function(t,e,n){d&&(l+=1)}),s.on("fn-err",function(t,e,n){d&&!n[p]&&(f(n,p,function(){return!0}),this.thrown=!0,o(n))}),s.on("fn-end",function(){d&&!this.thrown&&l>0&&(l-=1)}),s.on("internal-error",function(t){i("ierr",[t,c.now(),!0])})}},{}],3:[function(t,e,n){var r=t("loader");r.disabled||(r.features.ins=!0)},{}],4:[function(t,e,n){function r(){U++,L=g.hash,this[u]=y.now()}function o(){U--,g.hash!==L&&i(0,!0);var t=y.now();this[h]=~~this[h]+t-this[u],this[d]=t}function i(t,e){E.emit("newURL",[""+g,e])}function a(t,e){t.on(e,function(){this[e]=y.now()})}var s="-start",c="-end",f="-body",u="fn"+s,d="fn"+c,p="cb"+s,l="cb"+c,h="jsTime",m="fetch",v="addEventListener",w=window,g=w.location,y=t("loader");if(w[v]&&y.xhrWrappable&&!y.disabled){var x=t(11),b=t(12),E=t(9),R=t(7),O=t(14),T=t(8),P=t(15),S=t(10),M=t("ee"),N=M.get("tracer"),C=t(23);t(17),y.features.spa=!0;var L,U=0;M.on(u,r),b.on(p,r),S.on(p,r),M.on(d,o),b.on(l,o),S.on(l,o),M.buffer([u,d,"xhr-resolved"]),R.buffer([u]),O.buffer(["setTimeout"+c,"clearTimeout"+s,u]),P.buffer([u,"new-xhr","send-xhr"+s]),T.buffer([m+s,m+"-done",m+f+s,m+f+c]),E.buffer(["newURL"]),x.buffer([u]),b.buffer(["propagate",p,l,"executor-err","resolve"+s]),N.buffer([u,"no-"+u]),S.buffer(["new-jsonp","cb-start","jsonp-error","jsonp-end"]),a(T,m+s),a(T,m+"-done"),a(S,"new-jsonp"),a(S,"jsonp-end"),a(S,"cb-start"),E.on("pushState-end",i),E.on("replaceState-end",i),w[v]("hashchange",i,C(!0)),w[v]("load",i,C(!0)),w[v]("popstate",function(){i(0,U>1)},C(!0))}},{}],5:[function(t,e,n){function r(){var t=new PerformanceObserver(function(t,e){var n=t.getEntries();s(v,[n])});try{t.observe({entryTypes:["resource"]})}catch(e){}}function o(t){if(s(v,[window.performance.getEntriesByType(w)]),window.performance["c"+p])try{window.performance[h](m,o,!1)}catch(t){}else try{window.performance[h]("webkit"+m,o,!1)}catch(t){}}function i(t){}if(window.performance&&window.performance.timing&&window.performance.getEntriesByType){var a=t("ee"),s=t("handle"),c=t(14),f=t(13),u=t(6),d=t(23),p="learResourceTimings",l="addEventListener",h="removeEventListener",m="resourcetimingbufferfull",v="bstResource",w="resource",g="-start",y="-end",x="fn"+g,b="fn"+y,E="bstTimer",R="pushState",O=t("loader");if(!O.disabled){O.features.stn=!0,t(9),"addEventListener"in window&&t(7);var T=NREUM.o.EV;a.on(x,function(t,e){var n=t[0];n instanceof T&&(this.bstStart=O.now())}),a.on(b,function(t,e){var n=t[0];n instanceof T&&s("bst",[n,e,this.bstStart,O.now()])}),c.on(x,function(t,e,n){this.bstStart=O.now(),this.bstType=n}),c.on(b,function(t,e){s(E,[e,this.bstStart,O.now(),this.bstType])}),f.on(x,function(){this.bstStart=O.now()}),f.on(b,function(t,e){s(E,[e,this.bstStart,O.now(),"requestAnimationFrame"])}),a.on(R+g,function(t){this.time=O.now(),this.startPath=location.pathname+location.hash}),a.on(R+y,function(t){s("bstHist",[location.pathname+location.hash,this.startPath,this.time])}),u()?(s(v,[window.performance.getEntriesByType("resource")]),r()):l in window.performance&&(window.performance["c"+p]?window.performance[l](m,o,d(!1)):window.performance[l]("webkit"+m,o,d(!1))),document[l]("scroll",i,d(!1)),document[l]("keypress",i,d(!1)),document[l]("click",i,d(!1))}}},{}],6:[function(t,e,n){e.exports=function(){return"PerformanceObserver"in window&&"function"==typeof window.PerformanceObserver}},{}],7:[function(t,e,n){function r(t){for(var e=t;e&&!e.hasOwnProperty(u);)e=Object.getPrototypeOf(e);e&&o(e)}function o(t){s.inPlace(t,[u,d],"-",i)}function i(t,e){return t[1]}var a=t("ee").get("events"),s=t("wrap-function")(a,!0),c=t("gos"),f=XMLHttpRequest,u="addEventListener",d="removeEventListener";e.exports=a,"getPrototypeOf"in Object?(r(document),r(window),r(f.prototype)):f.prototype.hasOwnProperty(u)&&(o(window),o(f.prototype)),a.on(u+"-start",function(t,e){var n=t[1];if(null!==n&&("function"==typeof n||"object"==typeof n)){var r=c(n,"nr@wrapped",function(){function t(){if("function"==typeof n.handleEvent)return n.handleEvent.apply(n,arguments)}var e={object:t,"function":n}[typeof n];return e?s(e,"fn-",null,e.name||"anonymous"):n});this.wrapped=t[1]=r}}),a.on(d+"-start",function(t){t[1]=this.wrapped||t[1]})},{}],8:[function(t,e,n){function r(t,e,n){var r=t[e];"function"==typeof r&&(t[e]=function(){var t=i(arguments),e={};o.emit(n+"before-start",[t],e);var a;e[m]&&e[m].dt&&(a=e[m].dt);var s=r.apply(this,t);return o.emit(n+"start",[t,a],s),s.then(function(t){return o.emit(n+"end",[null,t],s),t},function(t){throw o.emit(n+"end",[t],s),t})})}var o=t("ee").get("fetch"),i=t(33),a=t(32);e.exports=o;var s=window,c="fetch-",f=c+"body-",u=["arrayBuffer","blob","json","text","formData"],d=s.Request,p=s.Response,l=s.fetch,h="prototype",m="nr@context";d&&p&&l&&(a(u,function(t,e){r(d[h],e,f),r(p[h],e,f)}),r(s,"fetch",c),o.on(c+"end",function(t,e){var n=this;if(e){var r=e.headers.get("content-length");null!==r&&(n.rxSize=r),o.emit(c+"done",[null,e],n)}else o.emit(c+"done",[t],n)}))},{}],9:[function(t,e,n){var r=t("ee").get("history"),o=t("wrap-function")(r);e.exports=r;var i=window.history&&window.history.constructor&&window.history.constructor.prototype,a=window.history;i&&i.pushState&&i.replaceState&&(a=i),o.inPlace(a,["pushState","replaceState"],"-")},{}],10:[function(t,e,n){function r(t){function e(){f.emit("jsonp-end",[],l),t.removeEventListener("load",e,c(!1)),t.removeEventListener("error",n,c(!1))}function n(){f.emit("jsonp-error",[],l),f.emit("jsonp-end",[],l),t.removeEventListener("load",e,c(!1)),t.removeEventListener("error",n,c(!1))}var r=t&&"string"==typeof t.nodeName&&"script"===t.nodeName.toLowerCase();if(r){var o="function"==typeof t.addEventListener;if(o){var a=i(t.src);if(a){var d=s(a),p="function"==typeof d.parent[d.key];if(p){var l={};u.inPlace(d.parent,[d.key],"cb-",l),t.addEventListener("load",e,c(!1)),t.addEventListener("error",n,c(!1)),f.emit("new-jsonp",[t.src],l)}}}}}function o(){return"addEventListener"in window}function i(t){var e=t.match(d);return e?e[1]:null}function a(t,e){var n=t.match(l),r=n[1],o=n[3];return o?a(o,e[r]):e[r]}function s(t){var e=t.match(p);return e&&e.length>=3?{key:e[2],parent:a(e[1],window)}:{key:t,parent:window}}var c=t(23),f=t("ee").get("jsonp"),u=t("wrap-function")(f);if(e.exports=f,o()){var d=/[?&](?:callback|cb)=([^&#]+)/,p=/(.*)\.([^.]+)/,l=/^(\w+)(\.|$)(.*)$/,h=["appendChild","insertBefore","replaceChild"];Node&&Node.prototype&&Node.prototype.appendChild?u.inPlace(Node.prototype,h,"dom-"):(u.inPlace(HTMLElement.prototype,h,"dom-"),u.inPlace(HTMLHeadElement.prototype,h,"dom-"),u.inPlace(HTMLBodyElement.prototype,h,"dom-")),f.on("dom-start",function(t){r(t[0])})}},{}],11:[function(t,e,n){var r=t("ee").get("mutation"),o=t("wrap-function")(r),i=NREUM.o.MO;e.exports=r,i&&(window.MutationObserver=function(t){return this instanceof i?new i(o(t,"fn-")):i.apply(this,arguments)},MutationObserver.prototype=i.prototype)},{}],12:[function(t,e,n){function r(t){var e=i.context(),n=s(t,"executor-",e,null,!1),r=new f(n);return i.context(r).getCtx=function(){return e},r}var o=t("wrap-function"),i=t("ee").get("promise"),a=t("ee").getOrSetContext,s=o(i),c=t(32),f=NREUM.o.PR;e.exports=i,f&&(window.Promise=r,["all","race"].forEach(function(t){var e=f[t];f[t]=function(n){function r(t){return function(){i.emit("propagate",[null,!o],a,!1,!1),o=o||!t}}var o=!1;c(n,function(e,n){Promise.resolve(n).then(r("all"===t),r(!1))});var a=e.apply(f,arguments),s=f.resolve(a);return s}}),["resolve","reject"].forEach(function(t){var e=f[t];f[t]=function(t){var n=e.apply(f,arguments);return t!==n&&i.emit("propagate",[t,!0],n,!1,!1),n}}),f.prototype["catch"]=function(t){return this.then(null,t)},f.prototype=Object.create(f.prototype,{constructor:{value:r}}),c(Object.getOwnPropertyNames(f),function(t,e){try{r[e]=f[e]}catch(n){}}),o.wrapInPlace(f.prototype,"then",function(t){return function(){var e=this,n=o.argsToArray.apply(this,arguments),r=a(e);r.promise=e,n[0]=s(n[0],"cb-",r,null,!1),n[1]=s(n[1],"cb-",r,null,!1);var c=t.apply(this,n);return r.nextPromise=c,i.emit("propagate",[e,!0],c,!1,!1),c}}),i.on("executor-start",function(t){t[0]=s(t[0],"resolve-",this,null,!1),t[1]=s(t[1],"resolve-",this,null,!1)}),i.on("executor-err",function(t,e,n){t[1](n)}),i.on("cb-end",function(t,e,n){i.emit("propagate",[n,!0],this.nextPromise,!1,!1)}),i.on("propagate",function(t,e,n){this.getCtx&&!e||(this.getCtx=function(){if(t instanceof Promise)var e=i.context(t);return e&&e.getCtx?e.getCtx():this})}),r.toString=function(){return""+f})},{}],13:[function(t,e,n){var r=t("ee").get("raf"),o=t("wrap-function")(r),i="equestAnimationFrame";e.exports=r,o.inPlace(window,["r"+i,"mozR"+i,"webkitR"+i,"msR"+i],"raf-"),r.on("raf-start",function(t){t[0]=o(t[0],"fn-")})},{}],14:[function(t,e,n){function r(t,e,n){t[0]=a(t[0],"fn-",null,n)}function o(t,e,n){this.method=n,this.timerDuration=isNaN(t[1])?0:+t[1],t[0]=a(t[0],"fn-",this,n)}var i=t("ee").get("timer"),a=t("wrap-function")(i),s="setTimeout",c="setInterval",f="clearTimeout",u="-start",d="-";e.exports=i,a.inPlace(window,[s,"setImmediate"],s+d),a.inPlace(window,[c],c+d),a.inPlace(window,[f,"clearImmediate"],f+d),i.on(c+u,r),i.on(s+u,o)},{}],15:[function(t,e,n){function r(t,e){d.inPlace(e,["onreadystatechange"],"fn-",s)}function o(){var t=this,e=u.context(t);t.readyState>3&&!e.resolved&&(e.resolved=!0,u.emit("xhr-resolved",[],t)),d.inPlace(t,y,"fn-",s)}function i(t){x.push(t),m&&(E?E.then(a):w?w(a):(R=-R,O.data=R))}function a(){for(var t=0;t<x.length;t++)r([],x[t]);x.length&&(x=[])}function s(t,e){return e}function c(t,e){for(var n in t)e[n]=t[n];return e}t(7);var f=t("ee"),u=f.get("xhr"),d=t("wrap-function")(u),p=t(23),l=NREUM.o,h=l.XHR,m=l.MO,v=l.PR,w=l.SI,g="readystatechange",y=["onload","onerror","onabort","onloadstart","onloadend","onprogress","ontimeout"],x=[];e.exports=u;var b=window.XMLHttpRequest=function(t){var e=new h(t);try{u.emit("new-xhr",[e],e),e.addEventListener(g,o,p(!1))}catch(n){try{u.emit("internal-error",[n])}catch(r){}}return e};if(c(h,b),b.prototype=h.prototype,d.inPlace(b.prototype,["open","send"],"-xhr-",s),u.on("send-xhr-start",function(t,e){r(t,e),i(e)}),u.on("open-xhr-start",r),m){var E=v&&v.resolve();if(!w&&!v){var R=1,O=document.createTextNode(R);new m(a).observe(O,{characterData:!0})}}else f.on("fn-end",function(t){t[0]&&t[0].type===g||a()})},{}],16:[function(t,e,n){function r(t){if(!s(t))return null;var e=window.NREUM;if(!e.loader_config)return null;var n=(e.loader_config.accountID||"").toString()||null,r=(e.loader_config.agentID||"").toString()||null,f=(e.loader_config.trustKey||"").toString()||null;if(!n||!r)return null;var h=l.generateSpanId(),m=l.generateTraceId(),v=Date.now(),w={spanId:h,traceId:m,timestamp:v};return(t.sameOrigin||c(t)&&p())&&(w.traceContextParentHeader=o(h,m),w.traceContextStateHeader=i(h,v,n,r,f)),(t.sameOrigin&&!u()||!t.sameOrigin&&c(t)&&d())&&(w.newrelicHeader=a(h,m,v,n,r,f)),w}function o(t,e){return"00-"+e+"-"+t+"-01"}function i(t,e,n,r,o){var i=0,a="",s=1,c="",f="";return o+"@nr="+i+"-"+s+"-"+n+"-"+r+"-"+t+"-"+a+"-"+c+"-"+f+"-"+e}function a(t,e,n,r,o,i){var a="btoa"in window&&"function"==typeof window.btoa;if(!a)return null;var s={v:[0,1],d:{ty:"Browser",ac:r,ap:o,id:t,tr:e,ti:n}};return i&&r!==i&&(s.d.tk=i),btoa(JSON.stringify(s))}function s(t){return f()&&c(t)}function c(t){var e=!1,n={};if("init"in NREUM&&"distributed_tracing"in NREUM.init&&(n=NREUM.init.distributed_tracing),t.sameOrigin)e=!0;else if(n.allowed_origins instanceof Array)for(var r=0;r<n.allowed_origins.length;r++){var o=h(n.allowed_origins[r]);if(t.hostname===o.hostname&&t.protocol===o.protocol&&t.port===o.port){e=!0;break}}return e}function f(){return"init"in NREUM&&"distributed_tracing"in NREUM.init&&!!NREUM.init.distributed_tracing.enabled}function u(){return"init"in NREUM&&"distributed_tracing"in NREUM.init&&!!NREUM.init.distributed_tracing.exclude_newrelic_header}function d(){return"init"in NREUM&&"distributed_tracing"in NREUM.init&&NREUM.init.distributed_tracing.cors_use_newrelic_header!==!1}function p(){return"init"in NREUM&&"distributed_tracing"in NREUM.init&&!!NREUM.init.distributed_tracing.cors_use_tracecontext_headers}var l=t(29),h=t(18);e.exports={generateTracePayload:r,shouldGenerateTrace:s}},{}],17:[function(t,e,n){function r(t){var e=this.params,n=this.metrics;if(!this.ended){this.ended=!0;for(var r=0;r<p;r++)t.removeEventListener(d[r],this.listener,!1);e.aborted||(n.duration=a.now()-this.startTime,this.loadCaptureCalled||4!==t.readyState?null==e.status&&(e.status=0):i(this,t),n.cbTime=this.cbTime,s("xhr",[e,n,this.startTime,this.endTime,"xhr"],this))}}function o(t,e){var n=c(e),r=t.params;r.hostname=n.hostname,r.port=n.port,r.protocol=n.protocol,r.host=n.hostname+":"+n.port,r.pathname=n.pathname,t.parsedOrigin=n,t.sameOrigin=n.sameOrigin}function i(t,e){t.params.status=e.status;var n=v(e,t.lastSize);if(n&&(t.metrics.rxSize=n),t.sameOrigin){var r=e.getResponseHeader("X-NewRelic-App-Data");r&&(t.params.cat=r.split(", ").pop())}t.loadCaptureCalled=!0}var a=t("loader");if(a.xhrWrappable&&!a.disabled){var s=t("handle"),c=t(18),f=t(16).generateTracePayload,u=t("ee"),d=["load","error","abort","timeout"],p=d.length,l=t("id"),h=t(24),m=t(22),v=t(19),w=t(23),g=NREUM.o.REQ,y=window.XMLHttpRequest;a.features.xhr=!0,t(15),t(8),u.on("new-xhr",function(t){var e=this;e.totalCbs=0,e.called=0,e.cbTime=0,e.end=r,e.ended=!1,e.xhrGuids={},e.lastSize=null,e.loadCaptureCalled=!1,e.params=this.params||{},e.metrics=this.metrics||{},t.addEventListener("load",function(n){i(e,t)},w(!1)),h&&(h>34||h<10)||t.addEventListener("progress",function(t){e.lastSize=t.loaded},w(!1))}),u.on("open-xhr-start",function(t){this.params={method:t[0]},o(this,t[1]),this.metrics={}}),u.on("open-xhr-end",function(t,e){"loader_config"in NREUM&&"xpid"in NREUM.loader_config&&this.sameOrigin&&e.setRequestHeader("X-NewRelic-ID",NREUM.loader_config.xpid);var n=f(this.parsedOrigin);if(n){var r=!1;n.newrelicHeader&&(e.setRequestHeader("newrelic",n.newrelicHeader),r=!0),n.traceContextParentHeader&&(e.setRequestHeader("traceparent",n.traceContextParentHeader),n.traceContextStateHeader&&e.setRequestHeader("tracestate",n.traceContextStateHeader),r=!0),r&&(this.dt=n)}}),u.on("send-xhr-start",function(t,e){var n=this.metrics,r=t[0],o=this;if(n&&r){var i=m(r);i&&(n.txSize=i)}this.startTime=a.now(),this.listener=function(t){try{"abort"!==t.type||o.loadCaptureCalled||(o.params.aborted=!0),("load"!==t.type||o.called===o.totalCbs&&(o.onloadCalled||"function"!=typeof e.onload))&&o.end(e)}catch(n){try{u.emit("internal-error",[n])}catch(r){}}};for(var s=0;s<p;s++)e.addEventListener(d[s],this.listener,w(!1))}),u.on("xhr-cb-time",function(t,e,n){this.cbTime+=t,e?this.onloadCalled=!0:this.called+=1,this.called!==this.totalCbs||!this.onloadCalled&&"function"==typeof n.onload||this.end(n)}),u.on("xhr-load-added",function(t,e){var n=""+l(t)+!!e;this.xhrGuids&&!this.xhrGuids[n]&&(this.xhrGuids[n]=!0,this.totalCbs+=1)}),u.on("xhr-load-removed",function(t,e){var n=""+l(t)+!!e;this.xhrGuids&&this.xhrGuids[n]&&(delete this.xhrGuids[n],this.totalCbs-=1)}),u.on("xhr-resolved",function(){this.endTime=a.now()}),u.on("addEventListener-end",function(t,e){e instanceof y&&"load"===t[0]&&u.emit("xhr-load-added",[t[1],t[2]],e)}),u.on("removeEventListener-end",function(t,e){e instanceof y&&"load"===t[0]&&u.emit("xhr-load-removed",[t[1],t[2]],e)}),u.on("fn-start",function(t,e,n){e instanceof y&&("onload"===n&&(this.onload=!0),("load"===(t[0]&&t[0].type)||this.onload)&&(this.xhrCbStart=a.now()))}),u.on("fn-end",function(t,e){this.xhrCbStart&&u.emit("xhr-cb-time",[a.now()-this.xhrCbStart,this.onload,e],e)}),u.on("fetch-before-start",function(t){function e(t,e){var n=!1;return e.newrelicHeader&&(t.set("newrelic",e.newrelicHeader),n=!0),e.traceContextParentHeader&&(t.set("traceparent",e.traceContextParentHeader),e.traceContextStateHeader&&t.set("tracestate",e.traceContextStateHeader),n=!0),n}var n,r=t[1]||{};"string"==typeof t[0]?n=t[0]:t[0]&&t[0].url?n=t[0].url:window.URL&&t[0]&&t[0]instanceof URL&&(n=t[0].href),n&&(this.parsedOrigin=c(n),this.sameOrigin=this.parsedOrigin.sameOrigin);var o=f(this.parsedOrigin);if(o&&(o.newrelicHeader||o.traceContextParentHeader))if("string"==typeof t[0]||window.URL&&t[0]&&t[0]instanceof URL){var i={};for(var a in r)i[a]=r[a];i.headers=new Headers(r.headers||{}),e(i.headers,o)&&(this.dt=o),t.length>1?t[1]=i:t.push(i)}else t[0]&&t[0].headers&&e(t[0].headers,o)&&(this.dt=o)}),u.on("fetch-start",function(t,e){this.params={},this.metrics={},this.startTime=a.now(),this.dt=e,t.length>=1&&(this.target=t[0]),t.length>=2&&(this.opts=t[1]);var n,r=this.opts||{},i=this.target;"string"==typeof i?n=i:"object"==typeof i&&i instanceof g?n=i.url:window.URL&&"object"==typeof i&&i instanceof URL&&(n=i.href),o(this,n);var s=(""+(i&&i instanceof g&&i.method||r.method||"GET")).toUpperCase();this.params.method=s,this.txSize=m(r.body)||0}),u.on("fetch-done",function(t,e){this.endTime=a.now(),this.params||(this.params={}),this.params.status=e?e.status:0;var n;"string"==typeof this.rxSize&&this.rxSize.length>0&&(n=+this.rxSize);var r={txSize:this.txSize,rxSize:n,duration:a.now()-this.startTime};s("xhr",[this.params,r,this.startTime,this.endTime,"fetch"],this)})}},{}],18:[function(t,e,n){var r={};e.exports=function(t){if(t in r)return r[t];var e=document.createElement("a"),n=window.location,o={};e.href=t,o.port=e.port;var i=e.href.split("://");!o.port&&i[1]&&(o.port=i[1].split("/")[0].split("@").pop().split(":")[1]),o.port&&"0"!==o.port||(o.port="https"===i[0]?"443":"80"),o.hostname=e.hostname||n.hostname,o.pathname=e.pathname,o.protocol=i[0],"/"!==o.pathname.charAt(0)&&(o.pathname="/"+o.pathname);var a=!e.protocol||":"===e.protocol||e.protocol===n.protocol,s=e.hostname===document.domain&&e.port===n.port;return o.sameOrigin=a&&(!e.hostname||s),"/"===o.pathname&&(r[t]=o),o}},{}],19:[function(t,e,n){function r(t,e){var n=t.responseType;return"json"===n&&null!==e?e:"arraybuffer"===n||"blob"===n||"json"===n?o(t.response):"text"===n||""===n||void 0===n?o(t.responseText):void 0}var o=t(22);e.exports=r},{}],20:[function(t,e,n){function r(){}function o(t,e,n,r){return function(){return u.recordSupportability("API/"+e+"/called"),i(t+e,[f.now()].concat(s(arguments)),n?null:this,r),n?void 0:this}}var i=t("handle"),a=t(32),s=t(33),c=t("ee").get("tracer"),f=t("loader"),u=t(25),d=NREUM;"undefined"==typeof window.newrelic&&(newrelic=d);var p=["setPageViewName","setCustomAttribute","setErrorHandler","finished","addToTrace","inlineHit","addRelease"],l="api-",h=l+"ixn-";a(p,function(t,e){d[e]=o(l,e,!0,"api")}),d.addPageAction=o(l,"addPageAction",!0),d.setCurrentRouteName=o(l,"routeName",!0),e.exports=newrelic,d.interaction=function(){return(new r).get()};var m=r.prototype={createTracer:function(t,e){var n={},r=this,o="function"==typeof e;return i(h+"tracer",[f.now(),t,n],r),function(){if(c.emit((o?"":"no-")+"fn-start",[f.now(),r,o],n),o)try{return e.apply(this,arguments)}catch(t){throw c.emit("fn-err",[arguments,this,t],n),t}finally{c.emit("fn-end",[f.now()],n)}}}};a("actionText,setName,setAttribute,save,ignore,onEnd,getContext,end,get".split(","),function(t,e){m[e]=o(h,e)}),newrelic.noticeError=function(t,e){"string"==typeof t&&(t=new Error(t)),u.recordSupportability("API/noticeError/called"),i("err",[t,f.now(),!1,e])}},{}],21:[function(t,e,n){function r(t){if(NREUM.init){for(var e=NREUM.init,n=t.split("."),r=0;r<n.length-1;r++)if(e=e[n[r]],"object"!=typeof e)return;return e=e[n[n.length-1]]}}e.exports={getConfiguration:r}},{}],22:[function(t,e,n){e.exports=function(t){if("string"==typeof t&&t.length)return t.length;if("object"==typeof t){if("undefined"!=typeof ArrayBuffer&&t instanceof ArrayBuffer&&t.byteLength)return t.byteLength;if("undefined"!=typeof Blob&&t instanceof Blob&&t.size)return t.size;if(!("undefined"!=typeof FormData&&t instanceof FormData))try{return JSON.stringify(t).length}catch(e){return}}}},{}],23:[function(t,e,n){var r=!1;try{var o=Object.defineProperty({},"passive",{get:function(){r=!0}});window.addEventListener("testPassive",null,o),window.removeEventListener("testPassive",null,o)}catch(i){}e.exports=function(t){return r?{passive:!0,capture:!!t}:!!t}},{}],24:[function(t,e,n){var r=0,o=navigator.userAgent.match(/Firefox[\/\s](\d+\.\d+)/);o&&(r=+o[1]),e.exports=r},{}],25:[function(t,e,n){function r(t,e){var n=[a,t,{name:t},e];return i("storeMetric",n,null,"api"),n}function o(t,e){var n=[s,t,{name:t},e];return i("storeEventMetrics",n,null,"api"),n}var i=t("handle"),a="sm",s="cm";e.exports={constants:{SUPPORTABILITY_METRIC:a,CUSTOM_METRIC:s},recordSupportability:r,recordCustom:o}},{}],26:[function(t,e,n){function r(){return s.exists&&performance.now?Math.round(performance.now()):(i=Math.max((new Date).getTime(),i))-a}function o(){return i}var i=(new Date).getTime(),a=i,s=t(34);e.exports=r,e.exports.offset=a,e.exports.getLastTimestamp=o},{}],27:[function(t,e,n){function r(t){return!(!t||!t.protocol||"file:"===t.protocol)}e.exports=r},{}],28:[function(t,e,n){function r(t,e){var n=t.getEntries();n.forEach(function(t){"first-paint"===t.name?p("timing",["fp",Math.floor(t.startTime)]):"first-contentful-paint"===t.name&&p("timing",["fcp",Math.floor(t.startTime)])})}function o(t,e){var n=t.getEntries();if(n.length>0){var r=n[n.length-1];if(c&&c<r.startTime)return;p("lcp",[r])}}function i(t){t.getEntries().forEach(function(t){t.hadRecentInput||p("cls",[t])})}function a(t){if(t instanceof v&&!g){var e=Math.round(t.timeStamp),n={type:t.type};e<=l.now()?n.fid=l.now()-e:e>l.offset&&e<=Date.now()?(e-=l.offset,n.fid=l.now()-e):e=l.now(),g=!0,p("timing",["fi",e,n])}}function s(t){"hidden"===t&&(c=l.now(),p("pageHide",[c]))}if(!("init"in NREUM&&"page_view_timing"in NREUM.init&&"enabled"in NREUM.init.page_view_timing&&NREUM.init.page_view_timing.enabled===!1)){var c,f,u,d,p=t("handle"),l=t("loader"),h=t(31),m=t(23),v=NREUM.o.EV;if("PerformanceObserver"in window&&"function"==typeof window.PerformanceObserver){f=new PerformanceObserver(r);try{f.observe({entryTypes:["paint"]})}catch(w){}u=new PerformanceObserver(o);try{u.observe({entryTypes:["largest-contentful-paint"]})}catch(w){}d=new PerformanceObserver(i);try{d.observe({type:"layout-shift",buffered:!0})}catch(w){}}if("addEventListener"in document){var g=!1,y=["click","keydown","mousedown","pointerdown","touchstart"];y.forEach(function(t){document.addEventListener(t,a,m(!1))})}h(s)}},{}],29:[function(t,e,n){function r(){function t(){return e?15&e[n++]:16*Math.random()|0}var e=null,n=0,r=window.crypto||window.msCrypto;r&&r.getRandomValues&&(e=r.getRandomValues(new Uint8Array(31)));for(var o,i="xxxxxxxx-xxxx-4xxx-yxxx-xxxxxxxxxxxx",a="",s=0;s<i.length;s++)o=i[s],"x"===o?a+=t().toString(16):"y"===o?(o=3&t()|8,a+=o.toString(16)):a+=o;return a}function o(){return a(16)}function i(){return a(32)}function a(t){function e(){return n?15&n[r++]:16*Math.random()|0}var n=null,r=0,o=window.crypto||window.msCrypto;o&&o.getRandomValues&&Uint8Array&&(n=o.getRandomValues(new Uint8Array(31)));for(var i=[],a=0;a<t;a++)i.push(e().toString(16));return i.join("")}e.exports={generateUuid:r,generateSpanId:o,generateTraceId:i}},{}],30:[function(t,e,n){function r(t,e){if(!o)return!1;if(t!==o)return!1;if(!e)return!0;if(!i)return!1;for(var n=i.split("."),r=e.split("."),a=0;a<r.length;a++)if(r[a]!==n[a])return!1;return!0}var o=null,i=null,a=/Version\/(\S+)\s+Safari/;if(navigator.userAgent){var s=navigator.userAgent,c=s.match(a);c&&s.indexOf("Chrome")===-1&&s.indexOf("Chromium")===-1&&(o="Safari",i=c[1])}e.exports={agent:o,version:i,match:r}},{}],31:[function(t,e,n){function r(t){function e(){t(s&&document[s]?document[s]:document[i]?"hidden":"visible")}"addEventListener"in document&&a&&document.addEventListener(a,e,o(!1))}var o=t(23);e.exports=r;var i,a,s;"undefined"!=typeof document.hidden?(i="hidden",a="visibilitychange",s="visibilityState"):"undefined"!=typeof document.msHidden?(i="msHidden",a="msvisibilitychange"):"undefined"!=typeof document.webkitHidden&&(i="webkitHidden",a="webkitvisibilitychange",s="webkitVisibilityState")},{}],32:[function(t,e,n){function r(t,e){var n=[],r="",i=0;for(r in t)o.call(t,r)&&(n[i]=e(r,t[r]),i+=1);return n}var o=Object.prototype.hasOwnProperty;e.exports=r},{}],33:[function(t,e,n){function r(t,e,n){e||(e=0),"undefined"==typeof n&&(n=t?t.length:0);for(var r=-1,o=n-e||0,i=Array(o<0?0:o);++r<o;)i[r]=t[e+r];return i}e.exports=r},{}],34:[function(t,e,n){e.exports={exists:"undefined"!=typeof window.performance&&window.performance.timing&&"undefined"!=typeof window.performance.timing.navigationStart}},{}],ee:[function(t,e,n){function r(){}function o(t){function e(t){return t&&t instanceof r?t:t?f(t,c,a):a()}function n(n,r,o,i,a){if(a!==!1&&(a=!0),!l.aborted||i){t&&a&&t(n,r,o);for(var s=e(o),c=m(n),f=c.length,u=0;u<f;u++)c[u].apply(s,r);var p=d[y[n]];return p&&p.push([x,n,r,s]),s}}function i(t,e){g[t]=m(t).concat(e)}function h(t,e){var n=g[t];if(n)for(var r=0;r<n.length;r++)n[r]===e&&n.splice(r,1)}function m(t){return g[t]||[]}function v(t){return p[t]=p[t]||o(n)}function w(t,e){l.aborted||u(t,function(t,n){e=e||"feature",y[n]=e,e in d||(d[e]=[])})}var g={},y={},x={on:i,addEventListener:i,removeEventListener:h,emit:n,get:v,listeners:m,context:e,buffer:w,abort:s,aborted:!1};return x}function i(t){return f(t,c,a)}function a(){return new r}function s(){(d.api||d.feature)&&(l.aborted=!0,d=l.backlog={})}var c="nr@context",f=t("gos"),u=t(32),d={},p={},l=e.exports=o();e.exports.getOrSetContext=i,l.backlog=d},{}],gos:[function(t,e,n){function r(t,e,n){if(o.call(t,e))return t[e];var r=n();if(Object.defineProperty&&Object.keys)try{return Object.defineProperty(t,e,{value:r,writable:!0,enumerable:!1}),r}catch(i){}return t[e]=r,r}var o=Object.prototype.hasOwnProperty;e.exports=r},{}],handle:[function(t,e,n){function r(t,e,n,r){o.buffer([t],r),o.emit(t,e,n)}var o=t("ee").get("handle");e.exports=r,r.ee=o},{}],id:[function(t,e,n){function r(t){var e=typeof t;return!t||"object"!==e&&"function"!==e?-1:t===window?0:a(t,i,function(){return o++})}var o=1,i="nr@id",a=t("gos");e.exports=r},{}],loader:[function(t,e,n){function r(){if(!P++){var t=T.info=NREUM.info,e=v.getElementsByTagName("script")[0];if(setTimeout(f.abort,3e4),!(t&&t.licenseKey&&t.applicationID&&e))return f.abort();c(R,function(e,n){t[e]||(t[e]=n)});var n=a();s("mark",["onload",n+T.offset],null,"api"),s("timing",["load",n]);var r=v.createElement("script");0===t.agent.indexOf("http://")||0===t.agent.indexOf("https://")?r.src=t.agent:r.src=h+"://"+t.agent,e.parentNode.insertBefore(r,e)}}function o(){"complete"===v.readyState&&i()}function i(){s("mark",["domContent",a()+T.offset],null,"api")}var a=t(26),s=t("handle"),c=t(32),f=t("ee"),u=t(30),d=t(27),p=t(21),l=t(23),h=p.getConfiguration("ssl")===!1?"http":"https",m=window,v=m.document,w="addEventListener",g="attachEvent",y=m.XMLHttpRequest,x=y&&y.prototype,b=!d(m.location);NREUM.o={ST:setTimeout,SI:m.setImmediate,CT:clearTimeout,XHR:y,REQ:m.Request,EV:m.Event,PR:m.Promise,MO:m.MutationObserver};var E=""+location,R={beacon:"bam.nr-data.net",errorBeacon:"bam.nr-data.net",agent:"js-agent.newrelic.com/nr-spa-1212.min.js"},O=y&&x&&x[w]&&!/CriOS/.test(navigator.userAgent),T=e.exports={offset:a.getLastTimestamp(),now:a,origin:E,features:{},xhrWrappable:O,userAgent:u,disabled:b};if(!b){t(20),t(28),v[w]?(v[w]("DOMContentLoaded",i,l(!1)),m[w]("load",r,l(!1))):(v[g]("onreadystatechange",o),m[g]("onload",r)),s("mark",["firstbyte",a.getLastTimestamp()],null,"api");var P=0}},{}],"wrap-function":[function(t,e,n){function r(t,e){function n(e,n,r,c,f){function nrWrapper(){var i,a,u,p;try{a=this,i=d(arguments),u="function"==typeof r?r(i,a):r||{}}catch(l){o([l,"",[i,a,c],u],t)}s(n+"start",[i,a,c],u,f);try{return p=e.apply(a,i)}catch(h){throw s(n+"err",[i,a,h],u,f),h}finally{s(n+"end",[i,a,p],u,f)}}return a(e)?e:(n||(n=""),nrWrapper[p]=e,i(e,nrWrapper,t),nrWrapper)}function r(t,e,r,o,i){r||(r="");var s,c,f,u="-"===r.charAt(0);for(f=0;f<e.length;f++)c=e[f],s=t[c],a(s)||(t[c]=n(s,u?c+r:r,o,c,i))}function s(n,r,i,a){if(!h||e){var s=h;h=!0;try{t.emit(n,r,i,e,a)}catch(c){o([c,n,r,i],t)}h=s}}return t||(t=u),n.inPlace=r,n.flag=p,n}function o(t,e){e||(e=u);try{e.emit("internal-error",t)}catch(n){}}function i(t,e,n){if(Object.defineProperty&&Object.keys)try{var r=Object.keys(t);return r.forEach(function(n){Object.defineProperty(e,n,{get:function(){return t[n]},set:function(e){return t[n]=e,e}})}),e}catch(i){o([i],n)}for(var a in t)l.call(t,a)&&(e[a]=t[a]);return e}function a(t){return!(t&&t instanceof Function&&t.apply&&!t[p])}function s(t,e){var n=e(t);return n[p]=t,i(t,n,u),n}function c(t,e,n){var r=t[e];t[e]=s(r,n)}function f(){for(var t=arguments.length,e=new Array(t),n=0;n<t;++n)e[n]=arguments[n];return e}var u=t("ee"),d=t(33),p="nr@original",l=Object.prototype.hasOwnProperty,h=!1;e.exports=r,e.exports.wrapFunction=s,e.exports.wrapInPlace=c,e.exports.argsToArray=f},{}]},{},["loader",2,17,5,3,4]); ;NREUM.loader_config={accountID:"804283",trustKey:"804283",agentID:"402703674",licenseKey:"cf99e8d2a3",applicationID:"402703674"} ;NREUM.info={beacon:"bam.nr-data.net",errorBeacon:"bam.nr-data.net",licenseKey:"cf99e8d2a3", // Modified this value from the generated script, to pass prod vs dev applicationID: window.location.hostname.includes('journals.plos.org') ? "402703674" : "402694889", sa:1} </script>  <header> <div id="topslot" class="head-top"> <a id="skip-to-content" tabindex="0" class="button" href="#main-content"> Skip to main content </a> <div class="center"> <div class="title">Advertisement</div>  <div class='advertisement' id='div-gpt-ad-1458247671871-0' style='width:728px; height:90px;'> <script type='text/javascript'> googletag.cmd.push(function() { googletag.display('div-gpt-ad-1458247671871-0'); }); </script> </div> </div> </div> <div id="user" class="nav" data-user-management-url="https://community.plos.org"> </div> <div id="pagehdr"> <nav class="nav-main"> <h1 class="logo"> <a href="/plosmedicine/.">PLOS Medicine</a> </h1> <section class="top-bar-section"> <ul class="nav-elements"> <li class="menu-section-header has-dropdown " id="browse"> <span class="menu-section-header-title"> Browse </span> <ul class="menu-section dropdown " id="browse-dropdown-list"> <li> <a href="/plosmedicine/issue" >Current Issue</a> </li> <li> <a href="/plosmedicine/volume" >Journal Archive</a> </li> <li> <a href="https://collections.plos.org/s/plos-medicine-special-issues" >Special Issues</a> </li> <li> <a href="/plosmedicine/s/collections" >Collections</a> </li> <li> <a href="/plosmedicine/s/find-and-read-articles" >Find and Read Articles</a> </li> </ul> </li> <li class="multi-col-parent menu-section-header has-dropdown" id="publish"> Publish <div class="dropdown mega "> <ul class="multi-col" id="publish-dropdown-list"> <li class="menu-section-header " id="submissions"> <span class="menu-section-header-title"> Submissions </span> <ul class="menu-section " id="submissions-dropdown-list"> <li> <a href="/plosmedicine/s/getting-started" >Getting Started</a> </li> <li> <a href="/plosmedicine/s/submission-guidelines" >Submission Guidelines</a> </li> <li> <a href="/plosmedicine/s/figures" >Figures</a> </li> <li> <a href="/plosmedicine/s/tables" >Tables</a> </li> <li> <a href="/plosmedicine/s/supporting-information" >Supporting Information</a> </li> <li> <a href="/plosmedicine/s/latex" >LaTeX</a> </li> <li> <a href="/plosmedicine/s/other-article-types" >Other Article Types</a> </li> <li> <a href="/plosmedicine/s/preprints" >Preprints</a> </li> <li> <a href="/plosmedicine/s/revising-your-manuscript" >Revising Your Manuscript</a> </li> <li> <a href="/plosmedicine/s/submit-now" >Submit Now</a> </li> </ul> </li> <li class="menu-section-header " id="policies"> <span class="menu-section-header-title"> Policies </span> <ul class="menu-section " id="policies-dropdown-list"> <li> <a href="/plosmedicine/s/best-practices-in-research-reporting" >Best Practices in Research Reporting</a> </li> <li> <a href="/plosmedicine/s/human-subjects-research" >Human Subjects Research</a> </li> <li> <a href="/plosmedicine/s/animal-research" >Animal Research</a> </li> <li> <a href="/plosmedicine/s/competing-interests" >Competing Interests</a> </li> <li> <a href="/plosmedicine/s/disclosure-of-funding-sources" >Disclosure of Funding Sources</a> </li> <li> <a href="/plosmedicine/s/licenses-and-copyright" >Licenses and Copyright</a> </li> <li> <a href="/plosmedicine/s/data-availability" >Data Availability</a> </li> <li> <a href="/plosmedicine/s/complementary-research" >Complementary Research</a> </li> <li> <a href="/plosmedicine/s/materials-software-and-code-sharing" >Materials, Software and Code Sharing</a> </li> <li> <a href="/plosmedicine/s/ethical-publishing-practice" >Ethical Publishing Practice</a> </li> <li> <a href="/plosmedicine/s/authorship" >Authorship</a> </li> <li> <a href="/plosmedicine/s/corrections-expressions-of-concern-and-retractions" >Corrections, Expressions of Concern, and Retractions</a> </li> </ul> </li> <li class="menu-section-header " id="manuscript-review-and-publication"> <span class="menu-section-header-title"> Manuscript Review and Publication </span> <ul class="menu-section " id="manuscript-review-and-publication-dropdown-list"> <li> <a href="/plosmedicine/s/editorial-and-peer-review-process" >Editorial and Peer Review Process</a> </li> <li> <a href="/plosmedicine/s/reviewer-guidelines" >Guidelines for Reviewers</a> </li> <li> <a href="/plosmedicine/s/accepted-manuscripts" >Accepted Manuscripts</a> </li> <li> <a href="/plosmedicine/s/comments" >Comments</a> </li> </ul> </li> </ul> <div class="calloutcontainer"> <h3 class="callout-headline">Submit Your Manuscript</h3> <div class="action-contain"> <p class="callout-content"> <em>PLOS Medicine</em> publishes research and commentary of general interest with clear implications for patient care, public policy or clinical research agendas. </p> <p class="button-contain"> <a class="button button-default" href="/plosmedicine/s/submit-now"> Get Started </a> </p> </div>  </div> </div> </li> <li class="menu-section-header has-dropdown " id="about"> <span class="menu-section-header-title"> About </span> <ul class="menu-section dropdown " id="about-dropdown-list"> <li> <a href="/plosmedicine/s/journal-information" >Journal Information</a> </li> <li> <a href="/plosmedicine/s/staff-editors" >Staff Editors</a> </li> <li> <a href="/plosmedicine/s/editorial-board" >Editorial Board</a> </li> <li> <a href="/plosmedicine/s/publishing-information" >Publishing Information</a> </li> <li> <a href="https://plos.org/publication-fees" >Publication Fees</a> </li> <li> <a href="https://plos.org/press-and-media" >Press and Media</a> </li> <li> <a href="/plosmedicine/s/resources" >Resources</a> </li> <li> <a href="/plosmedicine/s/contact" >Contact</a> </li> </ul> </li> <script src="/resource/js/vendor/jquery.hoverIntent.js" type="text/javascript"></script> <script src="/resource/js/components/menu_drop.js" type="text/javascript"></script> <script src="/resource/js/components/hover_delay.js" type="text/javascript"></script> <li id="navsearch" class="head-search"> <form name="searchForm" action="/plosmedicine/search" method="get"> <fieldset> <legend>Search</legend> <label for="search">Search</label> <div class="search-contain"> <input id="search" type="text" name="q" placeholder="SEARCH" required/> <button id="headerSearchButton" type="submit" aria-label="Submit search"> <i title="Submit search" class="search-icon"></i> </button> </div> </fieldset> <input type="hidden" name="filterJournals" value="PLoSMedicine"/> </form> <a id="advSearch" href="/plosmedicine/search"> advanced search </a> <script src="/resource/js/components/placeholder_style.js" type="text/javascript"></script> </li> </ul> </section> </nav> </div> </header> <main id="main-content"> <div class="lemur-content two-column"> <nav class="site-content-nav"> <ul class="nav-page"> <li data-anchor="loc-about-the-journal" name="loc-about-the-journal"><a href="#loc-about-the-journal"> About the Journal </a></li> <li data-anchor="loc-easy-submission" name="loc-easy-submission"><a href="#loc-easy-submission"> Easy Submission </a></li> <li data-anchor="loc-preparing-a-full-submission" name="loc-preparing-a-full-submission"><a href="#loc-preparing-a-full-submission"> Preparing a Full Submission </a></li> <li data-anchor="loc-author-resources" name="loc-author-resources"><a href="#loc-author-resources"> Author Resources </a></li> </ul> </nav> <article> <h1>Submit Now</h1> <div data-section-id="2549"> <h2><a data-anchor-id="8209" id="loc-about-the-journal" name="loc-about-the-journal"></a>About the Journal</h2> <p style="line-height: 1.62; margin-top: 0pt; margin-bottom: 0pt; padding: 0pt 0pt 14pt;"><i>PLOS Medicine</i> publishes articles of general interest on biomedical, environmental, social and political determinants of health. The journal emphasizes work that advances clinical practice, health policy or pathophysiological understanding to benefit health in a variety of settings.</p> <p style="line-height: 1.62; margin-top: 0pt; margin-bottom: 14pt;"><em><i>PLOS Medicine</i></em> also seeks to publish articles in the area of translational medicine that provide substantial, novel mechanistic insights into disease processes, with potential implications for clinical care.</p> <div>   </div> </div> <div data-section-id="2550"> <h2><a data-anchor-id="8210" id="loc-easy-submission" name="loc-easy-submission"></a>Easy Submission</h2> <p style="font-family: arial;">We use an easy, format-free submission process for all research articles to help save you time and effort.</p> <ol style="font-family: arial;"> <li><strong>Initial submission.</strong> Upload your manuscript and cover letter. Choose to submit either a single PDF, or separate manuscript and figure files. There are no formatting requirements, and our mini initial submission form takes just 10 minutes to complete.</li> <li><strong>Editorial evaluation.</strong> We’ll evaluate your submission within about a week.* If the editors select your manuscript for external peer review, we’ll invite you to provide additional information.</li> <li><strong>Full submission.</strong> Complete the full submission form. In preparation for external peer review, we’ll ask you to give more details, like the full author list and a competing interest statement. No journal-specific formatting is required until a manuscript is close to acceptance.<img alt="" class="img-default" src="/plosmedicine/indirect/f30f893094bede36f9a88435eeec6bf83bec43a3308af039525545293c090a2a">*91% of research submissions receive an initial decision within 5 days, 94% within a week</li> </ol> <div class="block-more-information"> Submitting a magazine article? <br> Non-research articles are submitted as full submissions. <a href="https://journals.plos.org/plosmedicine/s/other-article-types">Read the complete guidelines</a>. </div> </div> <div data-section-id="2552"> <h2><a data-anchor-id="8078" id="loc-preparing-an-initial-submission" name="loc-preparing-an-initial-submission"></a>Preparing an Initial Submission</h2> <p style="font-family: arial;">All research articles are eligible for our easy, three-part submission process.</p> <p style="font-family: arial;">Your initial submission will consist of:</p> <ol style="font-family: arial;"> <li>Manuscript, with a<a href="https://journals.plos.org/plosmedicine/s/submission-guidelines#loc-title-page"> </a><a href="https://journals.plos.org/plosmedicine/s/submission-guidelines#loc-title-page">title page</a> listing all the authors</li> <li>A <a href="https://journals.plos.org/plosmedicine/s/submission-guidelines#loc-cover-letter">cover letter</a></li> <li><a href="https://journals.plos.org/plosmedicine/s/supporting-information">Supporting information</a> files, if relevant</li> </ol> <p style="font-family: arial;">You can choose to format your initial submission as either:</p> <ul style="font-family: arial;"> <li>A single PDF containing the manuscript, figures, and supporting information, or</li> <li>A PDF or Word document manuscript, with figures and supporting information uploaded individually</li> </ul> <p style="font-family: arial;">In either case, upload your cover letter as a separate file.</p> <p style="font-family: arial;"> </p> <div style="text-align: center;"> Get started now. </div> <div style="text-align: center;">   </div> <div style="width: 746.667px; text-align: center;"> <h4 style="display: inline-block;"><a href="https://www.editorialmanager.com/pmedicine/" style="color: rgb(255, 255, 255); display: block; width: 250px; background: rgb(20, 52, 199); border: 1px solid rgb(67, 97, 144); padding: 17px; border-radius: 5px; margin: 0px;">Editorial Manager</a></h4> </div> </div> <div data-section-id="2457"> <h2><a data-anchor-id="8079" id="loc-preparing-a-full-submission" name="loc-preparing-a-full-submission"></a>Preparing a Full Submission</h2> <p>If the editors decide to send your manuscript for peer review, we’ll invite you to make a full submission. At this stage, you’ll need to provide:</p> <ul> <li><a href="/plosmedicine/s/supporting-information">Full author list and details</a></li> <li><a data-parent-id="34" href="/plosmedicine/s/submission-guidelines#loc-competing-interests">Competing interest statement</a></li> <li><a data-parent-id="34" href="/plosmedicine/s/submission-guidelines#loc-financial-disclosure-statement">Funding disclosure statement</a></li> <li><a data-parent-id="undefined" href="/plosmedicine/s/data-availability">Data availability statement</a></li> <li><a data-parent-id="34" href="/plosmedicine/s/submission-guidelines#loc-human-and-animal-research">Human</a> and <a data-parent-id="34" href="/plosmedicine/s/submission-guidelines#loc-animal-studies">Animal </a>ethics statements, if relevant</li> </ul> <p>For research articles, you can also choose to have PLOS forward your manuscript to medRxiv for consideration for posting as a preprint.</p> </div> <div data-section-id="2436"> <h2 style="text-align: left;"><a data-anchor-id="8224" id="loc-author-resources" name="loc-author-resources"></a>Author Resources</h2> <p style="text-align: left;">Consult these resources to make sure that your manuscript is ready for submission, and find out what to expect later on in the editorial assessment and peer review process.</p> <table class="table-basic"> <tbody> <tr> <td style="width: 20%; text-align: left; vertical-align: top;"><a href="/plosmedicine/s/submission-guidelines">Submission guidelines</a></td> <td style="width: 80%; text-align: left; vertical-align: top;">Information about the article types available for primary research and guidelines for manuscript style and formatting</td> </tr> <tr> <td style="text-align: left; vertical-align: top;"><a href="/plosmedicine/s/editorial-and-publishing-policies">Editorial and publishing policies</a></td> <td style="text-align: left; vertical-align: top;">Information about the requirements that apply to our submissions, including policies on data availability, competing interests, disclosure of funding sources, authorship, and reporting standards.</td> </tr> <tr> <td style="text-align: left; vertical-align: top;"><a href="/plosmedicine/s/other-article-types">Other article types</a></td> <td style="text-align: left; vertical-align: top;">Information about preparing submissions to the <em><i>PLOS Medicine</i></em> magazine.</td> </tr> <tr> <td style="text-align: left; vertical-align: top;"><a href="/plosmedicine/s/revising-your-manuscript">Revision guidelines</a></td> <td style="text-align: left; vertical-align: top;">Information about preparing a revised submission.</td> </tr> <tr> <td style="text-align: left; vertical-align: top;"><a href="https://plos.org/publish/fees/">Publication fees</a> and <a href="https://plos.org/publish/publishing-faqs/#publication-fees-and-fee-assistance">fee assistance</a></td> <td style="text-align: left; vertical-align: top;">Information about publication fees and fee assistance options. Publication fees will be billed upon acceptance. Authors seeking fee assistance must apply at submission, using the form in the submission system. An author’s ability to pay publication fees is never a consideration in the publication decision process.</td> </tr> </tbody> </table> </div> </article> </div><script defer src="/resource/js/components/scroll.js" type="text/javascript"></script> <script defer src="/resource/js/components/floating_nav.js" type="text/javascript"></script> <script defer src="/resource/js/pages/site_content.js" type="text/javascript"></script> </main> <footer id="pageftr"> <div class="row"> <div class="block x-small"> <ul class="nav nav-secondary"> <li class="ftr-header"><a href="https://plos.org/publications/journals/">Publications</a></li> <li><a href="/plosbiology/" id="ftr-bio">PLOS Biology</a></li> <li><a href="/climate/" id="ftr-climate">PLOS Climate</a></li> <li><a href="/complexsystems/" id="ftr-complex-systems">PLOS Complex Systems</a></li> <li><a href="/ploscompbiol/" id="ftr-compbio">PLOS Computational Biology</a></li> <li><a href="/digitalhealth/" id="ftr-digitalhealth">PLOS Digital Health</a></li> <li><a href="/plosgenetics/" id="ftr-gen">PLOS Genetics</a></li> <li><a href="/globalpublichealth/" id="ftr-globalpublichealth">PLOS Global Public Health</a></li> </ul> </div> <div class="block x-small"> <ul class="nav nav-secondary"> <li class="ftr-header"> </li> <li><a href="/plosmedicine/" id="ftr-med">PLOS Medicine</a></li> <li><a href="/mentalhealth/" id="ftr-mental-health">PLOS Mental Health</a></li> <li><a href="/plosntds/" id="ftr-ntds">PLOS Neglected Tropical Diseases</a></li> <li><a href="/plosone/" id="ftr-one">PLOS ONE</a></li> <li><a href="/plospathogens/" id="ftr-path">PLOS Pathogens</a></li> <li><a href="/sustainabilitytransformation/" id="ftr-sustainabilitytransformation">PLOS Sustainability and Transformation</a></li> <li><a href="/water/" id="ftr-water">PLOS Water</a></li> </ul> </div> <div class="block xx-small"> <ul class="nav nav-tertiary"> <li> <a href="https://plos.org" id="ftr-home">Home</a> </li> <li> <a href="https://blogs.plos.org" id="ftr-blog">Blogs</a> </li> <li> <a href="https://collections.plos.org/" id="ftr-collections">Collections</a> </li> <li> <a href="mailto:webmaster@plos.org" id="ftr-feedback">Give feedback</a> </li> <li> <a href="/plosmedicine/lockss-manifest" id="ftr-lockss">LOCKSS</a> </li> </ul> </div> <div class="block xx-small"> <ul class="nav nav-primary"> <li><a href="https://plos.org/privacy-policy" id="ftr-privacy">Privacy Policy</a></li> <li><a href="https://plos.org/terms-of-use" id="ftr-terms">Terms of Use</a></li> <li><a href="https://plos.org/advertise/" id="ftr-advertise">Advertise</a></li> <li><a href="https://plos.org/media-inquiries" id="ftr-media">Media Inquiries</a></li> <li><a href="https://plos.org/contact" id="ftr-contact">Contact</a></li> </ul> </div> </div> <div class="row"> <p> <img src="/resource/img/logo-plos-footer.png" alt="PLOS" class="logo-footer"/> <span class="footer-non-profit-statement">PLOS is a nonprofit 501(c)(3) corporation, #C2354500, based in San Francisco, California, US</span> </p> <div class="block"> </div> </div> <script src="/resource/js/global.js" type="text/javascript"></script> </footer> </body> </html>