The objective of this study was to examine the factors which serve as barriers and enablers to accessing maternal and reproductive health services among women in rural Tanzania. A qualitative study, utilizing focus group discussions (FGDs), was conducted in three districts. An interview guide was developed that focused on individual or community-based factors affecting women's access to reproductive and maternal health services. Data was collected during December 2017 and May 2018, and analyzed using a thematic approach. The barriers included a lack of autonomy, lack of knowledge and education, travel and transportation barriers, lack of financial resources, lack of infrastructure, lack of confidentiality, lack of male involvement, cultural beliefs, and the use of traditional birth attendants. In contrast, the increased autonomy for women and the implementation of government policies were identified as enablers. Innovations need to be identified that address these barriers in order to increase access to maternal and reproductive health services in these districts.

The objective of this qualitative study was to understand community and health provider perspectives regarding pre-eclampsia and eclampsia in rural Tanzania. Key informant interviews and focus group discussions with health workers and community members were conducted in the Geita and Singida districts. An interview guide, focusing on individual or community-based factors affecting women's access to reproductive and maternal health services, was developed. Data was collected during December 2017 and May 2018 and analyzed using a thematic approach. Three themes emerged regarding perceptions about pre-eclampsia and eclampsia: 1) insufficient knowledge regarding signs, symptoms and risks, 2) misconceptions regarding the causes, due to beliefs and attitudes, and 3) variable patterns of health-seeking behavior among pregnant women who have signs and symptoms. While health providers had a good understanding about causes and management of pre-eclampsia and eclampsia, a much larger proportion of community members held misconceptions regarding the causes and recommended management. Community-based educational programs to improve community knowledge about the causes, risks and requirement of pre-eclampsia and eclampsia by trained health providers has the potential to improve maternal outcomesin rural Tanzania.

Dr. Godfrey Mbaruku, an obstetrician-gynecologist and one of Tanzania's most dedicated maternal health researchers, passed away in September 2018. His professional career spanned over four decades, with the last decade of his life dedicated to maternal health research, advocacy and policy in Africa. We undertook a review of the key global milestones in maternal health policy, funding and research that took place during Dr. Mbaruku's career until his untimely death in 2018. We then reflect on the progress of the maternal health agenda from 2018 to 2021 as lower middle income countries (LMICs) continue to strive to reach the sustainable development goals (SDGs) in the midst of a global pandemic. Dr. Godfrey Mbaruku's commitment to improving maternal health in Tanzania through his advocacy and research contributions over his professional life will forever serve as foundational pillars for the ongoing global effort to reduce maternal mortality.

Understanding the role of different species in the transmission of multi-host pathogens, such as rabies virus, is vital for effective control strategies. Across most of sub-Saharan Africa domestic dogs Canis familiaris are considered the reservoir for rabies, but the role of wildlife has been long debated. Here we explore the multi-host transmission dynamics of rabies across south-east Tanzania. Between January 2011 and July 2019, data on probable rabies cases were collected in the regions of Lindi and Mtwara. Hospital records of animal-bite patients presenting to healthcare facilities were used as sentinels for animal contact tracing. The timing, location and species of probable rabid animals were used to reconstruct transmission trees to infer who infected whom and the relative frequencies of within- and between-species transmission. During the study, 688 probable human rabies exposures were identified, resulting in 47 deaths. Of these exposures, 389 were from domestic dogs (56.5%) and 262 from jackals (38.1%). Over the same period, 549 probable animal rabies cases were traced: 303 in domestic dogs (55.2%) and 221 in jackals (40.3%), with the remainder in domestic cats and other wildlife species. Although dog-to-dog transmission was most commonly inferred (40.5% of transmission events), a third of inferred events involved wildlife-to-wildlife transmission (32.6%), and evidence suggested some sustained transmission chains within jackal populations. A steady decline in probable rabies cases in both humans and animals coincided with the implementation of widespread domestic dog vaccination during the first 6 years of the study. Following the lapse of this program, dog rabies cases began to increase in one of the northernmost districts. Synthesis and applications. In south-east Tanzania, despite a relatively high incidence of rabies in wildlife and evidence of wildlife-to-wildlife transmission, domestic dogs remain essential to the reservoir of infection. Continued dog vaccination alongside improved surveillance would allow a fuller understanding of the role of wildlife in maintaining transmission in this area. Nonetheless, dog vaccination clearly suppressed rabies in both domestic dog and wildlife populations, reducing both public health and conservation risks and, if sustained, has potential to eliminate rabies from this region.

Rabies is a neglected zoonotic disease that causes an estimated 59,000 human deaths worldwide annually, mostly in Africa and Asia. A target of zero human deaths from dog-mediated rabies has been set for 2030, and large-scale control programs are now advocated. However, in most low-income endemic countries surveillance to guide rabies control is weak and few cases of rabies are recorded. There is an urgent need to enhance surveillance to improve timely case detection and inform rabies control and prevention, by operationalizing a "One Health" approach. Here we present data from a study piloting Integrated Bite Case Management (IBCM) to support intersectoral collaboration between health and veterinary workers in Tanzania. We trained government staff to implement IBCM, comprising risk assessments of bite patients by health workers, investigations by livestock field officers to diagnose rabid animals, and use of a mobile phone application to support integration. IBCM was introduced across 20 districts in four regions of Tanzania and results reported after 1 year of implementation. Numbers of bite patient presentations to health facilities varied across regions, but following the introduction of IBCM reporting of bite patients at high-risk for rabies more than doubled in all regions. Over 800 high-risk investigations were carried out, with 49% assessed as probable dog rabies cases on the basis of clinical signs, animal outcome, and rapid diagnostic testing. The status of a further 20% of biting animals could not be determined but rabies could not be ruled out. Livestock field officers reported that use of rapid diagnostic tests (RDTs) were useful for confirming rabies occurrence. Overall, our study provides further evidence that IBCM is a practical approach that can improve rabies detection in endemic countries, and be used to monitor the impact of mass dog vaccinations, including potential to verify rabies freedom. However, the main challenges to implementation are limited training of health workers in rabies, perceived burden of real-time recording and limited resources for livestock field officers to undertake investigations. Nonetheless, IBCM dramatically improved case detection and communication between sectors and we recommend further implementation research to establish best practice and applicability to other settings.

Complications from unsafe abortion are among the major causes of preventable maternal morbidity and mortality, which may be compounded by delays and disparities in treatment. We conducted a secondary analysis of women with symptoms of hypovolemic shock secondary to severe obstetric hemorrhage in Tanzania. We compared receipt of three lifesaving interventions among women with abortions versus other maternal hemorrhage etiologies. Interventions included: non-pneumatic anti-shock garment (NASG) (N = 393), blood transfusion (N = 249), and referral to a higher-capacity facility (N = 131). After controlling for severity of disease and other confounders, women with abortion-related hemorrhage and shock had 78 percent decreased odds of receiving NASG (p < 0.001) and 77 percent decreased odds of receiving a blood transfusion (p < 0.001) compared to women with hemorrhage and shock from other etiologies. Our findings suggest that, in Tanzania, women with abortion-related hemorrhage received lower quality of care than women with other hemorrhage etiologies.

BackgroundObstetric hemorrhage (OH) remains one of the leading causes of maternal mortality, particularly in rural Africa. Tanzania has a high maternal mortality ratio, and approximately 80% of the population accesses health care lower level facilities, unable to provide Comprehensive Emergency Obstetric Care (CEmOC). The non-pneumatic anti-shock garment (NASG) has been demonstrated to reduce mortality as it buys time for women in shock to be transported to or to overcome delays at referral facilities.MethodsThis report describes one component of an ongoing maternal health improvement project, Empower, implemented in 280 facilities in four regions in rural Tanzania. The NASG along with a Closed User Group (CUG) mobile phone network were implemented within the overall EmOC project. Simulation trainings, repeated trainings, and close hands-on supportive supervision via site visits and via the CUG network were the training/learning methods. Data collection was conducted via the CUG network, with a limited data collection form, which also included free text options for project improvement. One-to-one interviews were also conducted. Outcome Indicators included appropriate use of NASG for women with hypovolemic shock We also compared baseline case fatality rates (CFR) from OH with endline CFRs.Data were analyzed using cohort study Risk Ratio (RR). Qualitative data analysis was conducted by content analysis.ResultsOf the 1713 women with OH, 419 (24.5%) met project hypovolemic shock criteria, the NASG was applied to 70.8% (n=297), indicating high acceptability and utilization. CFR at baseline (1.70) comparedto CFR at endline (0.76) showed a temporal association of a 67% reduced risk for women during the project period (RR: 0.33, 95% CI=.19, .60). Qualitative feedback was used to makecourse corrections during the project to enhance training and implementation.ConclusionsThis implementation project with 280 facilities and over 1000 providers supported via CUG demonstrated that NASG can have high uptake and appropriate use for hypovolemic shock secondary to OH. With the proper implementation strategies, NASG utilization can be high and should be associated with decreased mortality among mothers at risk of death from obstetric hemorrhage.

Estimates of dog population sizes are a prerequisite for delivering effective canine rabies control. However, dog population sizes are generally unknown in most rabies-endemic areas. Several approaches have been used to estimate dog populations but without rigorous evaluation. We compare post-vaccination transects, household surveys, and school-based surveys to determine which most precisely estimates dog population sizes. These methods were implemented across 28 districts in southeast Tanzania, in conjunction with mass dog vaccinations, covering a range of settings, livelihoods, and religious backgrounds. Transects were the most precise method, revealing highly variable patterns of dog ownership, with human/dog ratios ranging from 12.4:1 to 181.3:1 across districts. Both household and school-based surveys generated imprecise and, sometimes, inaccurate estimates, due to small sample sizes in relation to the heterogeneity in patterns of dog ownership. Transect data were subsequently used to develop a predictive model for estimating dog populations in districts lacking transect data. We predicted a dog population of 2,316,000 (95% CI 1,573,000–3,122,000) in Tanzania and an average human/dog ratio of 20.7:1. Our modelling approach has the potential to be applied to predicting dog population sizes in other areas where mass dog vaccinations are planned, given census and livelihood data. Furthermore, we recommend post-vaccination transects as a rapid and effective method to refine dog population estimates across large geographic areas and to guide dog vaccination programmes in settings with mostly free roaming dog populations.

Background: Rabies is preventable through prompt administration of post-exposure prophylaxis (PEP) to exposed persons, but PEP access is limited in many rabies-endemic countries. We investigated how access to PEP can be improved to better prevent human rabies. Methods: Using data from different settings in Tanzania, including contact tracing (2,367 probable rabies exposures identified) and large-scale mobile phone-based surveillance (24,999 patient records), we estimated the incidence of rabies exposures and bite-injuries, and examined health seeking and health outcomes in relation to PEP access. We used surveys and qualitative interviews with stakeholders within the health system to further characterise PEP supply and triangulate these findings. Results: Incidence of bite-injury patients was related to dog population sizes, with higher incidence in districts with lower human:dog ratios and urban centres. A substantial percentage (25%) of probable rabies exposures did not seek care due to costs and limited appreciation of risk. Upon seeking care a further 15% of probable rabies exposed persons did not obtain PEP due to shortages, cost barriers or misadvice. Of those that initiated PEP, 46% did not complete the course. If no PEP was administered, the risk of developing rabies following a probable rabies exposure was high (0.165), with bites to the head carrying most risk. Decentralized and free PEP increased the probability that patients received PEP and reduced delays in initiating PEP. No major difficulties were encountered by health workers whilst switching to dose-sparing ID administration of PEP. Health infrastructure also includes sufficient cold chain capacity to support improved PEP provision. However, high costs to governments and patients currently limits the supply chain and PEP access. The cost barrier was exacerbated by decentralization of budgets, with priority given to purchase of cheaper medicines for other conditions. Reactive procurement resulted in limited and unresponsive PEP supply, increasing costs and risks to bite victims. Conclusion: PEP access could be improved and rabies deaths reduced through ring-fenced procurement, switching to dose-sparing ID regimens and free provision of PEP. (C) 2018 Published by Elsevier Ltd.

Rabies can be eliminated by achieving comprehensive coverage of 70% of domestic dogs during annual mass vaccination campaigns. Estimates of vaccination coverage are, therefore, required to evaluate and manage mass dog vaccination programs; however, there is no specific guidance for the most accurate and efficient methods for estimating coverage in different settings. Here, we compare post-vaccination transects, school-based surveys, and household surveys across 28 districts in southeast Tanzania and Pemba island covering rural, urban, coastal and inland settings, and a range of different livelihoods and religious backgrounds. These approaches were explored in detail in a single district in northwest Tanzania (Serengeti), where their performance was compared with a complete dog population census that also recorded dog vaccination status. Post-vaccination transects involved counting marked (vaccinated) and unmarked (unvaccinated) dogs immediately after campaigns in 2,155 villages (24,721 dogs counted). School-based surveys were administered to 8,587 primary school pupils each representing a unique household, in 119 randomly selected schools approximately 2 months after campaigns. Household surveys were conducted in 160 randomly selected villages (4,488 households) in July/August 2011. Costs to implement these coverage assessments were $12.01, $66.12, and $155.70 per village for post-vaccination transects, school-based, and household surveys, respectively. Simulations were performed to assess the effect of sampling on the precision of coverage estimation. The sampling effort required to obtain reasonably precise estimates of coverage from household surveys is generally very high and probably prohibitively expensive for routine monitoring across large areas, particularly in communities with high human to dog ratios. School-based surveys partially overcame sampling constraints, however, were also costly to obtain reasonably precise estimates of coverage. Post-vaccination transects provided precise and timely estimates of community-level coverage that could be used to troubleshoot the performance of campaigns across large areas. However, transects typically overestimated coverage by around 10%, which therefore needs consideration when evaluating the impacts of campaigns. We discuss the advantages and disadvantages of these different methods and make recommendations for how vaccination campaigns can be better monitored and managed at different stages of rabies control and elimination programs.

A Rabies Elimination Demonstration Project was implemented in Tanzania from 2010 through to 2015, bringing together government ministries from the health and veterinary sectors, the World Health Organization, and national and international research institutions. Detailed data on mass dog vaccination campaigns, bite exposures, use of post-exposure prophylaxis (PEP), and human rabies deaths were collected throughout the project duration and project areas. Despite no previous experience in dog vaccination within the project areas, district veterinary officers were able to implement district-wide vaccination campaigns that, for most part, progressively increased the numbers of dogs vaccinated with each phase of the project. Bite exposures declined, particularly in the southernmost districts with the smallest dog populations, and health workers successfully transitioned from primarily intramuscular administration of PEP to intradermal administration, resulting in major cost savings. However, even with improved PEP provision, vaccine shortages still occurred in some districts. In laboratory diagnosis, there were several logistical challenges in sample handling and submission but compared to the situation before the project started, there was a moderate increase in the number of laboratory samples submitted and tested for rabies in the project areas with a decrease in the proportion of rabies-positive samples over time. The project had a major impact on public health policy and practice with the formation of a One Health Coordination Unit at the Prime Minister’s Office and development of the Tanzania National Rabies Control Strategy, which lays a roadmap for elimination of rabies in Tanzania by 2030 by following the Stepwise Approach towards Rabies Elimination (SARE). Overall, the project generated many important lessons relevant to rabies prevention and control in particular and disease surveillance in general. Lessons include the need for (1) a specific unit in the government for managing disease surveillance; (2) application of innovative data collection and management approaches such as the use of mobile phones; (3) close cooperation and effective communication among all key sectors and stakeholders; and (4) flexible and adaptive programs that can incorporate new information to improve their delivery, and overcome challenges of logistics and procurement.

ObjectiveUsing active surveillance approaches to investigate the transmissiondynamics of rabies on Pemba Island and across Southern Tanzania,whilst a large-scale dog vaccination program was underway1, to gaina greater understanding of the dynamics of infection as the disease isdriven towards elimination.IntroductionRabies is endemic in Tanzania and has circulated on Pemba Islandsince the late 1990s. In 2010, an elimination programme was initiatedin Southern Tanzania to demonstrate that human rabies deathscan be eliminated through mass dog vaccinations. We used activesurveillance approaches2to investigate the dynamics of rabies acrossthe area where this programme was implemented.MethodsGovernment census data and post-vaccination transects were usedto estimate the dog population and coverages achieved by vaccinationcampaigns. Routine surveillance of animal bite injuries using a mobilephone-based surveillance system3and active contact tracing wereused to identify animal rabies cases and human exposures. Epidemictrees were constructed using spatiotemporal distances between casesand used to estimate the effective reproduction number (Re). Weexamined factors affecting rabies incidence and transmission usinggeneralized linear mixed models.ResultsWe estimated a small dog population of 4095 and low dog:humanratio on Pemba (1:105). Overall island-wide vaccination coverageincreased from 16.8% in 2011 to 68.2% in 2014. We found a further48 human exposures (343%), who either were not reported or did notobtain post exposure prophylaxes (PEP). Routine surveillance wasfound to detect less than 10% (~8.75%). There was a rapid declinein cases detected on Pemba, from 42 before mass dog vaccinationswere implemented in 2011, to 2 cases in 2014 (Figures 1). Since May2014, no rabies cases have been detected. Similarly, Redeclined from1.02 to 0 and a significant relationship was found with rabies casesdecreasing with increasing vaccination coverage (p= 0.013, Figure 2).Across seven other districts on the Tanzanian mainland we alsoobserved major declines in rabies cases with very few cases of rabiesin dogs detected in 2016 (Figure 3).ConclusionsWe conclude that rabies has been eliminated from domestic dogpopulations on Pemba over the five years since vaccination campaignshave been implemented. Continued surveillance and investigationsof any bite incidents are therefore needed to ensure any subsequentincursions are controlled and freedom from rabies is maintained.On the Tanzanian mainland, it has taken longer to control rabies,however trajectories look promising with several districts close toeliminating the disease. However, detection of some wildlife casesin the last 12 months in these districts indicates the need to furtherinvestigate remaining foci and the role of wildlife in maintenance.

An estimated 59000 people die annually from rabies, keeping this zoonosis on the forefront of neglected diseases, especially in the developing world. Most deaths occur after being bitten by a rabid dog. Those exposed to a suspect rabid animal should receive appropriate post-exposure prophylaxis (PEP) or risk death. However, vaccination of dogs to control and eliminate canine rabies at the source has been implemented in many places around the world. Here, we analysed the vaccination and cost data for one such campaign in the area surrounding and including Dar es Salaam, Tanzania and estimated the cost per dog vaccinated. We also estimated the cost of human PEP. We found that the cost per dog vaccinated ranged from $2.50 to $22.49 across districts and phases, with the phase average ranging from $7.30 to $11.27. These figures were influenced by over purchase of vaccine in the early phases of the programme and the significant costs associated with purchasing equipment for a programme starting from scratch. The cost per human PEP course administered was approximately $24.41, with the average patient receiving 2.5 of the recommended four vaccine doses per suspect bite. This study provides valuable financial insights into programme managers and policymakers working towards rabies elimination.

Katie Hampson and colleagues describe their experience of developing and deploying a large-scale rabies surveillance system based on mobile phones in southern Tanzania.

Background: Standardized schemas, databases, and public data repositories are needed for the studies of malaria vectors that encompass a remarkably diverse array of designs and rapidly generate large data volumes, often in resource-limited tropical settings lacking specialized software or informatics support.Results: Data from the majority of mosquito studies conformed to a generic schema, with data collection forms recording the experimental design, sorting of collections, details of sample pooling or subdivision, and additional observations. Generically applicable forms with standardized attribute definitions enabled rigorous, consistent data and sample management with generic software and minimal expertise. Forms use now includes 20 experiments, 8 projects, and 15 users at 3 research and control institutes in 3 African countries, resulting in 11 peer-reviewed publications.Conclusion: We have designed generic data schema that can be used to develop paper or electronic based data collection forms depending on the availability of resources. We have developed paper-based data collection forms that can be used to collect data from majority of entomological studies across multiple study areas using standardized data formats. Data recorded on these forms with standardized formats can be entered and linked with any relational database software. These informatics tools are recommended because they ensure that medical entomologists save time, improve data quality, and data collected and shared across multiple studies is in standardized formats hence increasing research outputs.

In the Tanzanian city of Dar es Salaam, high coverage of long-lasting insecticidal nets (LLINs), larvicide application (LA) and mosquito-proofed housing, was complemented with improved access to artemisinin-based combination therapy and rapid diagnostic tests by the end of 2012.

Many of the pathogens perceived to pose the greatest risk to humans are viral zoonoses, responsible for a range of emerging and endemic infectious diseases. Phylogeography is a useful tool to understand the processes that give rise to spatial patterns and drive dynamics in virus populations. Increasingly, whole-genome information is being used to uncover these patterns, but the limits of phylogenetic resolution that can be achieved with this are unclear. Here, whole-genome variation was used to uncover fine-scale population structure in endemic canine rabies virus circulating in Tanzania. This is the first whole-genome population study of rabies virus and the first comprehensive phylogenetic analysis of rabies virus in East Africa, providing important insights into rabies transmission in an endemic system. In addition, sub-continental scale patterns of population structure were identified using partial gene data and used to determine population structure at larger spatial scales in Africa. While rabies virus has a defined spatial structure at large scales, increasingly frequent levels of admixture were observed at regional and local levels. Discrete phylogeographic analysis revealed long-distance dispersal within Tanzania, which could be attributed to human-mediated movement, and we found evidence of multiple persistent, co-circulating lineages at a very local scale in a single district, despite on-going mass dog vaccination campaigns. This may reflect the wider endemic circulation of these lineages over several decades alongside increased admixture due to human-mediated introductions. These data indicate that successful rabies control in Tanzania could be established at a national level, since most dispersal appears to be restricted within the confines of country borders but some coordination with neighbouring countries may be required to limit transboundary movements. Evidence of complex patterns of rabies circulation within Tanzania necessitates the use of whole-genome sequencing to delineate finer scale population structure that can that can guide interventions, such as the spatial scale and design of dog vaccination campaigns and dog movement controls to achieve and maintain freedom from disease.

Over the past 20 years, major progress has been made in our understanding of critical aspects of rabies epidemiology and control. This paper presents results of recent research, highlighting methodological advances that have been applied to burden of disease studies, rabies epidemiological modelling and rabies surveillance. These results contribute new insights and understanding with regard to the epidemiology of rabies and help to counteract misperceptions that currently hamper rabies control efforts in Africa. The conclusion of these analyses is that the elimination of canine rabies in Africa is feasible, even in wildlife-rich areas, through mass vaccination of domestic dogs and without the need for indiscriminate culling to reduce dog population density. Furthermore, the research provides valuable practical insights that support the operational planning and design of dog vaccination campaigns and rabies surveillance measures.

Infectious diseases are a major public health burden causing millions of deaths every year. Government authorities need to be able to monitor disease incidence and evaluate their interventions for disease control. Monitoring the status of infectious diseases is one of the most challenging problems facing the public health sector, and epidemiological surveillance systems for infectious diseases, particularly notifiable diseases are essential. Despite initiatives to encourage reporting of infectious diseases, underreporting and poor surveillance are on-going challenges for many developing countries. Most surveillance systems in these settings use traditional paper-based methods, which are both inefficient and impractical. There is a need for alternative tools to strengthen infectious disease surveillance systems in resource-limited settings. The remarkable progress made in mobile computing technology has the potential to improve infectious disease surveillance systems. However, user experience in digital technologies and infrastructure needs to be given greater attention. My study investigated the use of mobile phone devices as surveillance tools in health information systems. A mobile phone-based surveillance system was developed and applied in Tanzania as an alternative approach to traditional paper-based systems. Using this system different factors that affect the usability of mobile phone-based systems were investigated, by examining the quality of surveillance data in the context of completeness, timeliness and costs. After two years of operation in twenty-eight districts in southern Tanzania, numerous factors were identified that affect user accuracy and speed of use of the mobile phone-based surveillance. These include user experience in digital technology, particularly mobile device ownership; digital technology literacy, such as access and use of SMS and user’s age. The mobile phone-based surveillance system was more accurate compared to the traditional paper-based system with greater data reporting, more complete data and timelier reporting. Initially the mobile phone-based surveillance system required more capital investment, although the running costs of paper-based surveillance were greater. The utility of the mobile phone-based surveillance in monitoring and evaluating large-scale rabies control interventions was examined and the data produced was used to analyse the impacts of interventions on reducing disease incidence. Significant relationships were detected between the incidence of reported bite injuries in the focal district the previous month and in neighbouring districts that month, with more injuries detected in mainland Tanzania than on the island of Pemba. The relationship between bite injuries and vaccination coverage was complicated, with some evidence that vaccination reduced bite incidence. However, more data and a better model are needed to fully understand the impact of vaccination on bite incidence. The system provided timely information on the implementation of control measures and incidence of bite injuries, vital for improving control efforts. Use of automated short text messages (SMS) as part of the mobile phone-based surveillance was assessed to determine whether they could improve patient’s adherence to treatment regimens. Patients who received SMS reminders had significantly better compliance than those who did not, with attendance improved by at least 10%. Use of SMS reminders has the potential to improve patients’ compliance in other treatment regimens that require repeat clinic visits or administration of medicines. This thesis documented how the use of mobile phone devices can be used to improve surveillance in resource-limited settings. The use of effective integrated surveillance system could empower major stakeholders concerned with public health problems by providing them with appropriate real-time information on disease incidence and control interventions. In the final chapter the challenges encountered and insights gained in the application of mobile computing in strengthening infectious diseases surveillance are discussed. Despite infrastructural challenges such as unreliable power and Internet, mobile computing technologies can improve patient care and authorities can be prompted in a timely manner about infectious disease outbreaks and of supply shortages. In conclusion, innovative tools that can strengthen and integrate human and animal surveillance can improve the control and prevention of infectious diseases. Mobile phones have great potential for this, and can be used to strengthen health information systems.