Use of Artificial Intelligence for Digital Breast Tomosynthesis Screening: A Preliminary Real-world Experience.

OBJECTIVE: The purpose of this study is to assess the "real-world" impact of an artificial intelligence (AI) tool designed to detect breast cancer in digital breast tomosynthesis (DBT) screening exams following 12 months of utilization in a subspecialized academic breast center. METHODS: Following IRB approval, mammography audit reports, as specified in the BI-RADS atlas, were retrospectively generated for five radiologists reading at three locations during a 12-month time frame. One location had the AI tool (iCAD ProFound AI v2.0), and the other two locations did not. The co-primary endpoints were cancer detection rate (CDR) and abnormal interpretation rate (AIR). Secondary endpoints included positive predictive values (PPVs) for cancer among screenings with abnormal interpretations (PPV1) and for biopsies performed (PPV3). Odds ratios (OR) with two-sided 95% confidence intervals (CIs) summarized the impact of AI across radiologists using generalized estimating equations. RESULTS: Nonsignificant differences were observed in CDR, AIR, and PPVs. The CDR was 7.3 with AI and 5.9 without AI (OR 1.3, 95% CI: 0.9-1.7). The AIR was 11.7% with AI and 11.8% without AI (OR 1.0, 95% CI: 0.8-1.3). The PPV1 was 6.2% with AI and 5.0% without AI (OR 1.3, 95% CI: 0.97-1.7). The PPV3 was 33.3% with AI and 32.0% without AI (OR 1.1, 95% CI: 0.8-1.5). CONCLUSION: Although we are unable to show statistically significant changes in CDR and AIR outcomes in the two groups, the results are consistent with prior reader studies. There is a nonsignificant trend toward improvement in CDR with AI, without significant increases in AIR.

Medical utilization surrounding initial opioid-related diagnoses by coding method.

OBJECTIVES: To identify methods for coding initial opioid-related disorder (ORD) diagnoses in administrative claims and determine whether coding methods correspond to acute medical utilization patterns. STUDY DESIGN: Retrospective analysis of Blue Health Intelligence commercial data. METHODS: We included members with 2 years of continuous coverage around the first appearance of an ORD diagnosis code (initial ORD) in medical or pharmacy claims with dates of service between October 2015 and March 2016. Initial ORD was identified by International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) F11 codes or buprenorphine for medication-assisted treatment (BUP-MAT) with a duration of 3 or more days. Descriptive analyses were evaluated prediagnosis, in the month of diagnosis, and post diagnosis and included mean cost per member per month (PMPM); mean monthly percentage of members with at least 1 opioid agonist prescription (OAP), inpatient visit, or emergency department (ED) visit; and percentage of members with at least 1 ICD-10-CM Z79.891 code (long-term [current] use of opiate analgesic). RESULTS: A total of 6426 initial ORD diagnoses were identified by F11.20 (65.2%), F11.x (28.7%), and BUP-MAT (6.1%). PMPM costs for BUP-MAT ($2054) were lower than for F11.20 ($5053) and F11.x ($6597) in the diagnosis month. Mean monthly percentage of members with at least 1 OAP declined from pre- to post initial ORD diagnosis (F11.20, 52.5% to 50.0%; F11.x, 44.1% to 37.9%; BUP-MAT, 34.0% to 12.7%). Members with initial ORD coded as F11.x had the highest mean percentage with at least 1 inpatient or ED visit in the diagnosis month (30.9% and 26.8%, respectively) versus F11.20 (19.3% and 10.8%) and BUP-MAT (5.1% and 3.5%). Percentage of members with at least 1 Z79.891 code was higher post diagnosis than in the month of diagnosis (F11.20, 34.6% vs 25.7%; F11.x, 16.5% vs 8.1%; BUP-MAT, 19.5% vs 8.1%). CONCLUSIONS: Medical utilization patterns of members with ORD differ by the coding method used to document their initial diagnosis in administrative claims.

Monitoring Pharmacy and Test Kit Stocks in Rural Mozambique: U.S. President's Emergency Plan for AIDS Relief Surveillance to Help Prevent Ministry of Health Shortages.

Support of human immunodeficiency virus (HIV) and tuberculosis (TB) testing and treatment supported by President's Emergency Plan for AIDS Relief (PEPFAR) in Africa requires immense quantities of tests and medications. We sought to use central pharmacy supply data of Mozambique's rural Zambézia Province (2017 population ≈5.11 million persons; ≈12.6% adult HIV prevalence in 2016) to examine shortages, stockouts, and trends in availability. Using stock surveillance for 60 weeks in 2014-2015, we assessed availability of 36 medications [4 classes: adult antiretroviral (ARV) medications, pediatric ARVs, anti-TB medications, and antibiotics] and diagnostic test kits (2 rapid tests for HIV; 1 each for malaria and syphilis). We contrasted these to 2018-2019 data. We modeled pharmacy data using ordinal logistic regression, characterizing weekly product availability in four categories: good, adequate, shortage, or complete stockout. We found 166 (7.7%) stockouts and 150 (6.9%) shortages among 2,160 weekly records. Earlier calendar time was associated with reduced medication supplies (p < .001). Certain medication/test kit classes were associated with reduced supply (p < .001). We found an interaction between time and medication class on the odds of reduced supply (p < .001). Pediatric ARVs had a 17.4 (95% confidence interval: 8.8-34.4) times higher odds of reduced medication supply compared with adult ARVs at study midpoint. Trends comparing the first and last weeks showed adult ARVs having 67% and pediatric having 71% lower odds of reduced supplies. Only adult ARV shortages improved amid growing demand. Data from 2018 to 2019 suggest continuing inventory management challenges. Monitoring of drug (especially pediatric) and test kit shortages is vital to ensure quality improvement to guarantee adequate supplies to enable patients and care providers to achieve sustained viral suppression. A central Mozambican drug repository in the nation's second largest Province continues to experience drug and rapid test kit stockouts.

Effect of Preoperative Opioid Use on Adverse Outcomes, Medical Spending, and Persistent Opioid Use Following Elective Total Joint Arthroplasty in the United States: A Large Retrospective Cohort Study of Administrative Claims Data.

OBJECTIVE: Between 17% and 40% of patients undergoing elective arthroplasty are preoperative opioid users. This US study analyzed patients in this population to illustrate the relationship between preoperative opioid use and adverse surgical outcomes. DESIGN: Retrospective study of administrative medical and pharmaceutical claims data. SUBJECTS: Adults (aged 18+) who received elective total knee, hip, or shoulder replacement in 2014-2015. METHODS: A patient was a preoperative opioid user if opioid prescription fills occurred in two periods: 1-30 and 31-90 days presurgery. Zero-truncated Poisson (incidence rate ratio [IRR]), logistic (odds ratio [OR]), Cox (hazard ratio [HR]), and quantile regressions modeled the effects of preoperative opioid use and opioid dose, adjusted for demographics, comorbidities, and utilization. RESULTS: Among 34,792 patients (38% hip, 58% knee, 4% shoulder), 6,043 (17.4%) were preoperative opioid users with a median morphine equivalent daily dose of 32 mg. Preoperative opioid users had increased length of stay (IRR = 1.03, 95% CI = 1.02 to 1.05), nonhome discharge (OR = 1.10, 95% CI = 1.00 to 1.21), and 30-day unplanned readmission (OR = 1.43, 95% CI = 1.17 to 1.74); experienced 35% higher surgical site infection (HR = 1.35, 95% CI = 1.14 to 1.59) and 44% higher surgical revision (HR = 1.44, 95% CI = 1.21 to 1.71); had a median $1,084 (95% CI = $833 to $1334) increase in medical spend during the 365 days after discharge; and had a 64% lower rate of opioid cessation (HR = 0.34, 95% CI = 0.33 to 0.35) compared with patients not filling two or more prescriptions across periods. CONCLUSIONS: Preoperative opioid users had longer length of stay, increased revision rates, higher spend, and persistent opioid use, which worsened with dose. Adverse outcomes after elective joint replacement may be reduced if preoperative opioid risk is managed through increased monitoring or opioid cessation.

Directly observed therapy and risk of unfavourable tuberculosis treatment outcomes among an international cohort of people living with HIV in low- and middle-income countries.

INTRODUCTION: Identification of persons living with human immunodeficiency virus (HIV)-associated tuberculosis (TB) at increased risk for unfavourable TB outcomes would inform efforts to improve such outcomes. We sought to identify factors associated with a decreased risk of unfavourable TB treatment outcomes among people living with HIV-infection (PLHIV) in low- and middle-income countries (LMIC), with a specific focus on directly observed therapy (DOT) compared with self-administered therapy (SAT) during the continuation phase of anti-TB therapy. METHODS: We conducted a retrospective cohort study among adults diagnosed with HIV-associated TB in Africa, Asia and the Americas from 2012 to 2013; data were collected from 2012 to 2016. Unfavourable TB treatment outcomes (death during TB treatment, and TB treatment failure or recurrence) were defined according to World Health Organization criteria. Receipt of DOT was obtained at the site level and defined as ≥5 days of DOT per week. The person administering DOT and treatment location varied by site. Lack of receipt of DOT was defined as SAT. Multivariable logistic regression estimated the adjusted odds of unfavourable TB treatment outcomes. RESULTS: Among 1862 adults with HIV-associated TB included, 252 (13.5%) had unfavourable TB outcomes (226 deaths, 26 recurrences/failures). Overall, 1825 (98%) received DOT in the intensive phase and 1617 (87%) received DOT in the continuation phase. DOT in the continuation phase was not significantly associated with unfavourable TB outcomes (aOR 1.43, 95% CI 0.86 to 2.38) compared to SAT. Body mass index (BMI) change during anti-TB treatment (per 2 units increase, aOR 0.74, 95% CI 0.68 to 0.82) and CD4+ count at TB diagnosis (200 vs. 50  cells/µL, aOR 0.54, 95% CI 0.39 to 0.73) were both independently associated with decreased odds of unfavourable TB treatment outcomes. CONCLUSIONS: In this large, international cohort of people living with HIV-associated TB in LMIC who received intensive phase DOT, DOT during the continuation phase of anti-TB therapy was not associated with a decreased odds of unfavourable TB treatment outcomes compared to SAT. Randomized trials evaluating the effect of continuation-phase DOT on TB outcomes among PLHIV are needed.

Hazardous alcohol use among female heads-of-household in rural Mozambique.

Hazardous drinking places individuals at risk for adverse health events, resulting in a major public health burden globally. Patterns of alcohol consumption among women in Africa remain poorly understood. We aimed to describe alcohol consumption in a representative sample of female heads-of-household in Mozambique. A 2014 population-based cross-sectional study of 3892 heads-of-household was conducted in Zambézia Province. Data on alcohol use were collected using the Alcohol Use Disorders Identification Test (AUDIT). Sociodemographic characteristics were summarized by alcohol use. A multivariable proportional odds model adjusted for age, education, Portuguese fluency, marital status, income, social support, depression, food insecurity, currently pregnant, and child mortality was used for the ordinal AUDIT scale as outcomes with robust covariance to account for clustering of respondents. The overall prevalence of current alcohol consumption among female heads-of-household was 15%. The mean PHQ-8 score was 2.7 (SD 4.7). The prevalence of women considered "hazardous drinkers" (score >4) was 8%. In bivariate analyses, depression, marital status, currently being pregnant, food insecurity, and death of a child were associated with higher risk of hazardous drinking. After adjusting for multiple characteristics, depression (aOR: 2.20 [1.28, 3.76] p = 0.004), death of a child (aOR: 2.44 [1.46, 4.07] p = 0.001), and being currently pregnant (aOR: 1.83 [0.99, 3.39] p = 0.002) were associated with hazardous drinking behavior. Being single (aOR: 0.48 [0.29, 0.80], p = 0.017) and food insecure (aOR: 0.96 [0.92, 1.00], p = 0.050) showed a protective effect on hazardous drinking behavior. The percentage of female heads-of-household in north-central Mozambique that regularly drink alcohol was lower than expected. This may be due to the unique characteristics of female heads-of-household and the extreme poverty pervasive in Zambézia.

Risk Prediction Score for HIV Infection: Development and Internal Validation with Cross-Sectional Data from Men Who Have Sex with Men in China.

Receptive anal intercourse, multiple partners, condomless sex, sexually transmitted infections (STIs), and drug/alcohol addiction are familiar factors that correlate with increased human immunodeficiency virus (HIV) risk among men who have sex with men (MSM). To improve estimation to HIV acquisition, we created a composite score using questions from routine survey of 3588 MSM in Beijing, China. The HIV prevalence was 13.4%. A risk scoring tool using penalized maximum likelihood multivariable logistic regression modeling was developed, deploying backward step-down variable selection to obtain a reduced-form model. The full penalized model included 19 sexual predictors, while the reduced-form model had 12 predictors. Both models calibrated well; bootstrap-corrected c-indices were 0.70 (full model) and 0.71 (reduced-form model). Non-Beijing residence, short-term living in Beijing, illegal drug use, multiple male sexual partners, receptive anal sex, inconsistent condom use, alcohol consumption before sex, and syphilis infection were the strongest predictors of HIV infection. Discriminating higher-risk MSM for targeted HIV prevention programming using a validated risk score could improve the efficiency of resource deployment for educational and risk reduction programs. A valid risk score can also identify higher risk persons into prevention and vaccine clinical trials, which would improve trial cost-efficiency.

Is substance use associated with HIV cascade outcomes in Latin America?

BACKGROUND: The HIV care cascade has improved in Latin America over the last decade. However, the influence of alcohol and noninjected drug use (NIDU) on cascade outcomes is mostly unknown. This study estimated the association of alcohol and NIDU with retention in care, loss to follow up (LTFU), and virologic failure (VF). METHODS: Individuals ≥18 years attending routine HIV clinic visits and completing the Rapid Screening Tool (RST; evaluating NIDU and ART adherence in 7-day recall period) during 2012-13 were followed up to 2015 in the Caribbean, Central and South America network for HIV epidemiology. Adjusted odds ratios (aOR) were calculated for the association of alcohol consumption and NIDU with retention in care by logistic regression; adjusted hazard ratios (aHR) were estimated for the associations with LTFU and VF by Cox regression. RESULTS: Among 3604 individuals, the proportions retained in care for one year were 84%, 79%, 72%, and 69% for patients reporting non-use, alcohol use, NIDU, and both alcohol and NIDU, respectively. For the same patient groups, the proportions LTFU over 18 months were 6%, 8%, 12%, and 13%, respectively. There were 1901 patients (53%) with HIV RNA results; VF proportions were similar between users and nonusers (ranging from 14-16%). After controlling for age, sex, study site, HIV transmission mode, time on ART, AIDS status, and CD4 count, neither alcohol use (aOR = 1.1, CI = 0.9-1.4; aHR = 1.0, CI = 0.8-1.3) nor NIDU (aOR = 1.3, CI = 0.9-1.8; aHR = 1.4, CI = 0.9-2.1) were significantly associated with retention or VF, respectively. However, both alcohol use (aHR = 1.2, CI = 1.02-1.4) and NIDU (aHR = 1.3, CI = 1.00-1.8) were associated with increased LTFU. CONCLUSION: Alcohol use and NIDU in a 7-day recall period increased the risk of being LTFU during the next 18 months, highlighting the need for routine screening and targeted interventions to keep these individuals in care and on ART.

Depression among female heads-of-household in rural Mozambique: A cross-sectional population-based survey.

BACKGROUND: An estimated 350 million people live with depression worldwide. In Mozambique, there are no national data quantifying the burden of mental illnesses. With the sixth highest suicide rate in the world, there is strong evidence of an unmet mental health need. We conducted a survey to measure the prevalence of depression among female heads of household and assess individual, social, and cultural risk factors associated with a positive depression screening. METHODS: This survey was conducted across 14 rural districts in central Mozambique in 2014. We gathered information from 3543 female heads of household (100% response rate) on > 500 variables, including a depression screening tool (PHQ-8). Weighted percentages of survey responses are reported. RESULTS: Among female heads of household, 14% screened positive for depression (PHQ-8 score ≥ 10). Our adjusted models show increased odds of depression per additional year of age (aOR: 1.02 [1.01, 1.04]; p = 0.002), additional year of education (aOR: 1.06 [1.02, 1.11]; p = 0.006), and additional kilometer from the nearest clinic (aOR: 1.05 [1.02, 1.07]; p = < 0.001). Experiencing food insecurity (aOR: 1.05 [1.02, 1.08]; p = 0.003) was associated with increased odds of depression. Being single (aOR: 0.42 [0.29, 0.60]) or divorced/widowed/separated (aOR: 0.57 [0.34, 0.98]; p < 0.001) vs. married was protective against depression, as was a perceived "sufficient" household income (aOR: 0.37 [0.19, 0.69]; p = 0.008). LIMITATIONS: Social desirability bias may have led women to underreport feelings of depression. CONCLUSIONS: The association of more education and marriage with increased odds of depression may reflect a frustration with limited opportunity for success experienced by some women in rural Mozambique.

A Pragmatic Approach for Reproducible Research With Sensitive Data.

Reproducible research is important for assessing the integrity of findings and disseminating methods, but it requires making original study data sets publicly available. This requirement is difficult to meet in settings with sensitive data, which can mean that resulting studies are not reproducible. For studies in which data cannot be shared, we propose a pragmatic approach to make research quasi-reproducible. On a publicly available website without restriction, researchers should post 1) analysis code used in the published study, 2) simulated data, and 3) results obtained by applying the analysis code used in the published study to the simulated data. Although it is not a perfect solution, such an approach makes analyses transparent for critical evaluation and dissemination and is therefore a significant improvement over current practice.

Determinants of full vaccination status in children aged 12-23 months in Gurùé and Milange districts, Mozambique: results of a population-based cross-sectional survey.

Background: In 2011, 64% of children in Mozambique, ages 12-23 months, were fully immunized. Large provincial differences in vaccine uptake exist. Methods: We conducted a survey of 1650 females with children aged 12-23 months in the districts of Gurùé and Milange. Implementation occurred from November to December 2014. Descriptive statistics and logistic regression using R-software 3.0.2 were used to examine factors associated with full vaccination status. ArcGIS version 10.3.1 (ESRI, Redlands, CA, USA) was used to map spatial patterns of vaccine uptake. Results: Full vaccination was roughly 48%. Identifying 'hospital' as a location to get vaccinated was associated with having a fully vaccinated child (OR=1.87, 95% CI=1.02, 3.41, p=0.043). Households where health decisions are made solely by the male or the female had 38% (95% CI=0.32, 1.21) and 55% (95% CI=0.29, 0.69) lower odds, respectively, of their child being fully immunized. For every 10 km increase from the nearest health facility there was a 36% lower odds of the child being fully immunized (OR=0.64, 95% CI=0.44, 0.93, p<0.001). Conclusion: Zambézia Province, as a whole and the districts of Gurùé and Milange specifically, is falling short of vaccination targets. Intensified efforts focused on the least educated, most distant and which take a more family-centered approach are needed to improve vaccine uptake.

Prevalence and determinants of malaria among children in Zambézia Province, Mozambique.

BACKGROUND: Malaria is the leading cause of death among children in Mozambique. Prevalence and factors associated with malaria are not well studied among children in rural Zambézia Province. Whether prevalence of malaria varies across diverse districts within the province is unknown. METHODS: A cross-sectional survey of female heads of household was conducted during April and May 2014, a period of peak malaria transmission. Data were collected on up to two randomly selected children aged 6-59 months per household. The outcome of interest was self-report of symptomatic malaria confirmed by diagnostic test in the past 30 days. Analyses accounted for the two-stage cluster sample design. Prevalence of symptomatic malaria was calculated for the province and three over-sampled focus districts-Alto Molócuè, Morrumbala, and Namacurra. Multivariable logistic regression of symptomatic malaria diagnosis included: district, age, sex, education, bed net use, urban setting, distance to health facility, income, roofing material, and pig farming. RESULTS: Data were collected on 2540 children. Fifty percent were female, and the median age was 24 months. Sixty percent of children slept under bed nets the night prior to the survey, but utilization varied between districts (range 49-89%; p < 0.001). Forty-three percent of children reported fever in the past 30 days, 91% of those sought care at a health facility, 67% of those had either a malaria rapid diagnostic test or blood smear, and 67% of those had a positive test result and therefore met our case definition of self-reported symptomatic malaria. There were significant differences in prevalence of fever (p < 0.001), health-seeking (p < 0.001), and diagnostic testing (p = 0.003) between focus districts. Province-wide prevalence of symptomatic malaria was 13% and among focus districts ranged from 14% in Morrumbala to 17% in Namacurra (p < 0.001). Higher female caregiver education (OR 1.88; 95% CI 1.31-2.70), having fewer young children in the household (OR 1.25; 95% CI 1.01-1.56), and higher income (OR 1.56; 95% CI 1.11-2.22) were independently associated with having a child with symptomatic malaria. CONCLUSIONS: Self-reported symptomatic malaria is highly prevalent among children in Zambézia Province, Mozambique and varies significantly between diverse districts. Factors facilitating access to health services are associated with symptomatic malaria diagnosis. These findings should inform resource allocation in the fight against malaria in Mozambique.

Tuberculosis Treatment Outcomes Among HIV/TB-Coinfected Children in the International Epidemiology Databases to Evaluate AIDS (IeDEA) Network.

INTRODUCTION: Management of tuberculosis (TB) is challenging in HIV/TB-coinfected children. The World Health Organization recommends nucleic acid amplification tests for TB diagnosis, a 4-drug regimen including ethambutol during intensive phase (IP) of treatment, and initiation of antiretroviral therapy (ART) within 8 weeks of TB diagnosis. We investigated TB treatment outcomes by diagnostic modality, IP regimen, and ART status. METHODS: We conducted a retrospective cohort study among HIV/TB-coinfected children enrolled at the International Epidemiology Databases to Evaluate AIDS treatment sites from 2012 to 2014. We modeled TB outcome using multivariable logistic regression including diagnostic modality, IP regimen, and ART status. RESULTS: Among the 386 HIV-infected children diagnosed with TB, 20% had microbiologic confirmation of TB, and 20% had unfavorable TB outcomes. During IP, 78% were treated with a 4-drug regimen. Thirty-one percent were receiving ART at the time of TB diagnosis, and 32% were started on ART within 8 weeks of TB diagnosis. Incidence of ART initiation within 8 weeks of TB diagnosis was higher for those with favorable TB outcomes (64%) compared with those with unfavorable outcomes (40%) (P = 0.04). Neither diagnostic modality (odds ratio 1.77; 95% confidence interval: 0.86 to 3.65) nor IP regimen (odds ratio 0.88; 95% confidence interval: 0.43 to 1.80) was associated with TB outcome. DISCUSSION: In this multinational study of HIV/TB-coinfected children, many were not managed as per World Health Organization guidelines. Children with favorable TB outcomes initiated ART sooner than children with unfavorable outcomes. These findings highlight the importance of early ART for children with HIV/TB coinfection, and reinforce the need for implementation research to improve pediatric TB management.

Prevalence and determinants of malaria among children in Zambézia Province, Mozambique

Background: Malaria is the leading cause of death among children in Mozambique. Prevalence and factors associated with malaria are not well studied among children in rural Zambézia Province. Whether prevalence of malaria varies across diverse districts within the province is unknown. Methods: A cross­sectional survey of female heads of household was conducted during April and May 2014, a period of peak malaria transmission. Data were collected on up to two randomly selected children aged 6­59 months per household. The outcome of interest was self­report of symptomatic malaria confirmed by diagnostic test in the past 30 days. Analyses accounted for the two­stage cluster sample design. Prevalence of symptomatic malaria was calculated for the province and three over­sampled focus districts­Alto Molócuè, Morrumbala, and Namacurra. Multivariable logistic regression of symptomatic malaria diagnosis included: district, age, sex, education, bed net use, urban setting, distance to health facility, income, roofing material, and pig farming. Results: Data were collected on 2540 children. Fifty percent were female, and the median age was 24 months. Sixty percent of children slept under bed nets the night prior to the survey, but utilization varied between districts (range 49­89%; p < 0.001). Forty­three percent of children reported fever in the past 30 days, 91% of those sought care at a health facility, 67% of those had either a malaria rapid diagnostic test or blood smear, and 67% of those had a positive test result and therefore met our case definition of self­reported symptomatic malaria. There were significant differences in prevalence of fever (p < 0.001), health­seeking (p < 0.001), and diagnostic testing (p = 0.003) between focus districts. Province­wide prevalence of symptomatic malaria was 13% and among focus districts ranged from 14% in Morrumbala to 17% in Namacurra (p < 0.001). Higher female caregiver education (OR 1.88; 95% CI 1.31­2.70), having fewer young children in the household (OR 1.25; 95% CI 1.01­1.56), and higher income (OR 1.56; 95% CI 1.11­2.22) were independently associated with having a child with symptomatic malaria. Conclusions: Self­reported symptomatic malaria is highly prevalent among children in Zambézia Province, Mozambique and varies significantly between diverse districts. Factors facilitating access to health services are associated with symptomatic malaria diagnosis. These findings should inform resource allocation in the fight against malaria in Mozambique.