Tuberculosis incidence among children under five years of age in Mozambique: Spatial distribution and predictors in a nationwide Bayesian disease mapping study

• Mozambique carries a substantial burden of tuberculosis (TB). • TB incidence among children under five years old shows marked geographic variation. • Higher incidence rates are concentrated in the southern and central regions. • Thirty-nine out of 154 districts were identified as high-risk (hotspot) areas. • Social determinants of health significantly predict childhood TB incidence. Tuberculosis (TB) remains a leading cause of infectious disease-related morbidity and mortality worldwide, disproportionately affecting children in high-burden settings. Mozambique is among the 30 countries with the highest TB burden. However, the spatial distribution and predictors of pediatric TB at the subnational level remain poorly characterized. This study aimed to analyze the geographic distribution and determinants of TB incidence among children under five in Mozambique and to identify high-risk districts. We conducted an ecological study using data from all 154 districts in Mozambique. The study included all newly diagnosed cases of TB in children under five years old between 2016 and 2020. Data were obtained from the Mozambique Ministry of Health (MISAU) and other public datasets. To account for spatial dependence and improve estimates in districts with low case counts, we applied hierarchical Bayesian Poisson regression models. From 2016 to 2020, a total of 29,002 TB cases were reported among children under five. TB incidence varied geographically across the country, with higher rates concentrated in the southern and central regions. Thirty-nine districts (25.3%) were identified as hotspots. A 10% increase in the illiteracy rate was associated with a 37% rise in TB incidence (RR: 1.37; 95% CrI: 1.15 1.60). Higher healthcare facility density was also linked to increased incidence (RR: 1.16; 95% CrI: 1.00 1.34). In contrast, districts with average annual temperatures above the national median had 20% lower TB incidence (RR: 0.80; 95% CrI: 0.65 0.96). Similarly, higher level of bank account ownership was associated with a 26% reduction in incidence (RR: 0.74; 95% CrI: 0.57 0.96). Childhood TB incidence in Mozambique is spatially heterogeneous and strongly influenced by social determinants of health. Identifying high-burden districts can guide geographically targeted interventions, including improved health literacy, equitable resources allocation, and the strengthening of social support programs to reduce TB risk. To effectively mitigate the burden of childhood TB, efforts in hotspot districts should prioritize enhanced surveillance, expanded healthcare access, and the integration of context-specific social and educational strategies that address the underlying drivers of vulnerability.