Ethics approval for analysis of data relating to mass dog vaccination was obtained from University of Edinburgh’s Veterinary Ethics Research Committee (64/5: Investigation of rabies vaccination approaches). All data were collected as part of rabies control public health campaigns, with permission from the relevant local authorities in the areas of work. All data were stored on secure cloud-based servers with restricted access to authorised project management staff.

Vaccination campaigns were implemented by the international Non-Governmental Organisation (NGO) Mission Rabies in partnership with local municipalities, governments and NGOs in Blantyre/Chiradzulu/Zomba Districts (Malawi), Goa State (India) and Ranchi City (India). In these core project sites, the Mission Rabies App was used throughout the year to support mass dog vaccination, school education and emergency community response to reported rabies cases. Additional proof-of-concept mass dog vaccination campaigns, vaccinating approximately 5,000 dogs, were conducted for two week periods annually in Negombo (Sri Lanka), Meru (Tanzania) and Koch-Goma (Uganda) from 2015 without education or rabies response components. In 2017, the system was adopted in Haiti through partnership with Poxvirus and Rabies Branch of Centre for Disease Control and Prevention (CDC), and Ministere de L’Agriculture des ressources Naturelles et du Developpement Rural (MARNDR) for coordination of the national dog vaccination campaign. Independent partner organisations also used the Mission Rabies App for purposes of coordinating dog sterilization work, dog enumeration studies and mass dog vaccination in Goa (India), Kabul (Afghanistan), Kragujevac (Serbia), Sarajevo (Bosnia and Herzegovina), Baku (Azerbaijan), Yerevan (Armenia), Praia de Faro (Portugal). In a number of project sites partner organisations complement rabies control through interventions to improve dog population management. Dogs undergoing surgery routinely received rabies vaccine at the same time in all projects entering data in the Mission Rabies App.

The structure of mass dog vaccination campaigns varied depending on local dog demographics and ownership practices; in Malawi, Uganda and Tanzania a combination of central point (CP) and door-to-door (DD) vaccination was used, whilst in India and Sri Lanka teams moved through the streets vaccinating dogs using DD and catch-vaccinate-release (CVR) to access dogs [19,20]. Vaccination team size varied depending on approach with CP/DD teams generally consisting of two to three people, whilst CVR teams were usually seven people. Dogs were parenterally vaccinated with Nobivac Rabies (MSD Animal Health) and temporarily marked with non-toxic paint on the forehead to enable assessment of coverage. Direct dog sight surveys and household questionnaires were conducted in the days following vaccination of a region to assess vaccination coverage [19,20].

Education work in core project sites involved trained education officers delivering rabies education classes in schools throughout the regions of work. Education teams consisted of one or two people following a set schedule to visit regions before the arrival of vaccination teams, increasing awareness of the upcoming vaccination activities. Classes were delivered in the local language and lasted 15–30 minutes covering topics of bite avoidance, wound washing and post exposure prophylaxis as well as aspects of responsible dog ownership and dog population management relevant to the local setting.

Emergency rabies response services were established in core project sites to respond to suspected canine rabies cases reported by the community. These serve to prevent ongoing transmission of rabies virus to humans and other animals by removing the suspected animal, as well as monitoring the impact of vaccination efforts and improving animal welfare through humane management of rabid animals. Emergency canine rabies response teams comprised of at least two dog catchers, a driver and a veterinarian.

Development of the Mission Rabies App began in April 2014 and was launched on field projects in November 2014. Improvements and expansion in functionality and design have taken place in response to field experience and user feedback to meet local project needs. Access to the basic functionalities of the system were made available free-of-charge from October 2017. Projects for external users were created upon application and available for download in android or iOS versions from the google Play Store and Apple App Store respectively.

Since launch, data were collected using a wide variety of smartphone devices, including Samsung Galaxy J1 and Samsung Galaxy J2, running the Android 4.4.4 (KitKat) operating system and above on 4.3 inch screen displays. Portable power banks were used to charge phones where necessary in the field. The backend database was managed using Microsoft SQL Server and the interface was written in C# and hosted on asp.net webform. The Android application was written in JAVA and the iOS application was written in Objective C.

Data entered on secure smartphones were stored offline locally to the handset before being uploaded through SSL certificate secured connections to a cloud based server, which were accessed through a password protected website. Partition of data by project enabled restriction of access by individual users only to data that is relevant to their field of work. Fig 1 shows an illustration of the structure of data access within existing projects in India, however the same model was applied in other countries with flow of data and restriction of access at the user, district, region and country levels.

The Mission Rabies App was used by staff to record information about operational outputs in each area of work; 1) mass dog vaccination 2) dog population surveys 3) education in schools and 4) emergency canine rabies response. The app was used by trained local staff in all project sites, with varied previous experience using smartphones and educational level, however the majority of users were educated to high-school level. Each project site had a project manager who was responsible for monitoring operational output and coordinating geographic direction of vaccination, survey and education teams. For the most part, these staff were non-native to the country of work, however local project managers successfully implemented the system in India. Project managers had prior abilities in basic use of computers, Microsoft Office tools and online systems and received approximately one hour of initial training in use of the web platform, followed by additional remote training through streamed online videos about updates to the system.

Training varied by project location and role, however training in data entry using the app generally took place over half a day, including interactive assessment and data review. Refresher training was conducted annually and when new staff were recruited, with debrief feedback sessions at the end of mass campaigns. Periodic checks through co-supervision by management staff in the field during mass vaccination campaigns were used to correct any variation from standard operating procedures. Further information about the training protocol for education officers and retention of rabies understanding was described by Bailey et al (2018) [21].

The initial purpose of the app system was to gather data from the field for central collation and review by project management staff in near real-time, before functionalities were expanded to enable geographic team direction.

Data were entered on customised forms, which were created on the web-interface and assigned to individual projects. Forms were grouped by category according to the type of data being entered; vaccination, survey, education, rabies response (S1 Table). Dynamic question logic formats with branching and dependent question logic enabled more complex form structures and compulsory fields ensured completeness of data. Questions were displayed in groups on scrolling screens to facilitate rapid data entry and, where necessary, division of long surveys into workable chunks (Fig 2).

During initial pilot campaigns, more comprehensive data about each dog were collected to fulfil grant requirements and to generate an understanding of population size, structure and ownership for the benefit of planning future work. In most cases an additional staff member was employed in each vaccination team to record data about the dogs being vaccinated, however for implementation in the Haiti National campaign, efficiency was improved beyond the initial pilot vaccination phase by only recording basic information about each dog (date, time, GPS location) which could be captured with a single button in the app, without entry of dog-specific data, therefore negating the need for additional staff.

The app periodically connected to the server to check for changes to forms and map boundaries, after which app functionalities could be used offline in the field. Users uploaded (synchronised) form data from phones when data connection was available, typically at the end of each day, usually via a Wi-Fi connection at the campaign office, or via 3G when returning to regions with good connection. Connection was generally poor in rural areas, however vaccine distribution points were often located in urban centres where connection is more available, allowing for data upload at least once a day. The data were automatically compiled into a web-based database for access by the project manager.

In addition to transfer of data from the field to the project manager, the system also enabled the team manager to effectively communicate the geographical boundaries within which the team was required to operate. Regions were manually created in GIS software using existing administrative boundaries, land type and dog population data to divide a region of work into contiguous zones of an appropriate size for a team to work in for approximately one day. The size of regions depended on the amount of data available for each project site; for example in Goa, regions containing approximately 100 dogs or of a size of 1km² was applied. These contiguous zones were converted into KML format for uploading into the web platform where the project manager assigned each team regions using different colours, which appeared as boundaries on Google Maps within the smartphone forms (Fig 3). Teams then navigated with the help of their current location and a line showing the path of where they walked during that vaccination session (Path Tracker), with the aim of visiting all populated parts of the region and avoiding repeating areas that have already been completed. Toggling between Google Satellite and Google Road maps is of particular use in rural areas, enabling the user to visit all households during door-to-door work, even where defined roads do not exist.

A set of regions were generally allocated to each team for them to work through over several days, with the project manager reviewing progress on a daily basis on backend maps (Fig 3) and allocating additional regions as and when required. The exact number of regions and frequency of redirection varied by location, with the system having the flexibility for project managers to use an approach that suited their local project structure.

In total, 1,547,501 form entries were made on the app between 01/11/2014 to 22/04/2018 under categories of vaccination, surgery, survey and education (Table 1, Figs 5 and 6). The rate of data entry increased from 6,080 entries per month in 2014 to 60,195 per month in 2017 (S1 Fig).

In total, 1,005,292 dog vaccinations were recorded on the system, including 905,383 dogs vaccinated during field mass vaccination campaigns (90% of Vaccination Form entries) and a further 99,909 undergoing surgery (Table 1, S2 Fig). In many project sites, information about dogs found to already be vaccinated and other species vaccinated during the campaign were also recorded in Vaccination Forms, enabling campaign data to also provide wider insights into dog ownership and overall vaccine usage. The total number of children recorded in the app as being taught in school about rabies in project sites in India and Malawi during the study period was 1.3 million at 4,018 schools (Table 1).

Working zones were used on Mission Rabies project sites to direct vaccination teams in 12 areas across six countries (Table 2). The working zones were of a size that could approximately be covered by a vaccination team over a period of 1–3 days, making them a suitable unit to direct teams by, moving every few days. Furthermore these areas could generally be surveyed by two wheeler moped within a day, enabling the same regions to be used to direct surveyors conducting post vaccination assessments.

The app was used to support the coordination of vaccination and education departments in Goa through direction to specific map regions. Fig 7 illustrates a period of work in Goa from March to June 2017, where regions are targeted by education teams in the period before vaccination begins. During this period, rabies education teams delivered classes to 24,927 children, representing 89% of students at the schools visited. Vaccination teams followed to vaccinate 10,131 dogs through the same regions.

During the period of study, the app was improved and refined, with addition of new functionalities in response to user feedback. These were released to users through updates which needed to be installed periodically. In November 2016 the system was updated to facilitate the creation of multiple projects, grouped under a single organisation. This enhanced data security and scalability of the system to multiple independent organisations. In March 2017 the addition of a simple “counter” functionality was created for the Haiti setting, enabling the rapid capture of the date, time and GPS for each dog vaccinated through the click of a button. Enhancement of the backend mapping functions and region allocation of individual users has been an ongoing area of development to improve the usability and data review for project managers.

The progressive increase in usage of the system has coincided with expansion of the Goa campaign from a focal pilot project in 2014 to a systematic campaign covering the entire State of Goa (Fig 8). In 2017 the Centres for Disease Control and Prevention used the app to support the national mass dog vaccination campaign in Haiti, implemented by the Ministry of Agriculture (MARNDR). Feedback on the app from the Chief Veterinary Officer of Haiti included “The Mission Rabies [App] maps that show the day’s vaccination record are very helpful to me as the CVO when I want to update… the Minister of Agriculture of Haiti on the progress of our rabies vaccination campaign.” (M Millien, personal communication March 2018).