Focus on Mainland Tanzania admitted to the St. Francis Designated District Hospital, serving the Ifakara DSS area, fell from approximately 70% (1999–2001) to between 18% and 32% (2006–2010) ( Figure B2). ••Mortality declines were also observed between 1998 and 2009. Under-five mortality declined from 141 deaths per 1000 live births in 1998 to 88 in 2009 (Figure B3). Likewise, infant mortality declined from 115 deaths per 1000 live births to 60 over the same period (Figure B3). Malaria transmission ••Malaria transmission intensity, as measured by the entomological inoculation rate (EIR) for unprotected persons, also declined during this period in the semi-urban town of Ifakara, located between the Kilombero and Ulanga villages. Between the early 1990s and 2008, there was an eighteen-fold reduction in the EIR, starting at 1481 in 1990–1994, dropping to 349 in 2001–2003, and dropping further to 81 in 2008. Rainfall ••Rainfall from 1998 to 2010 showed major year-to-year variability, but no systematic downward trend that could explain the change in malaria transmission. In summary, from 1998 through 2010 there were declines in malaria parasite prevalence, malaria slide positivity among inpatient admissions, malaria transmission, and infant and under-five mortality. During the same time, high net use was achieved first with any nets (treated and untreated), followed by an increase in ITN use. Declines in morbidity and mortality in the first half of the decade may be attributed to personal protection provided by high net use, urbanization, and other health interventions, including Vitamin A and integrated management of childhood illness (IMCI). Continued net use with the introduction of ITNs may have contributed to the sustained decline in morbidity and mortality