Table 3.

TB screening algorithm costs among persons with clinical and structural risk factors

First author, Year	Country	Screening algorithm		Source of unit costs	Type of unit costs						Average cost1 of screening per person		Average cost1 of diagnosis per person
		Screening	Diagnostic tests		Staff	Equipment	Consumables	Overhead	Transport	TB Treatment
Persons with structural risk factors (N = 16)a
Migrants, refugees, internally displaced persons (IDPs)
Bogdanova 2019	Russia	Mass CXR screening	SSM	Reported	✓	✓	✓					$4 per migrant screened		$834 per TB case diagnosed
Smit 2017	Belgium	WHO 4SS, CXR	NR	Calculated		✓	✓					$18 per migrant screened		$506,025 per migrant diagnosed with TB
												NR		$6721 per asylum seeker diagnosed with TB
Homeless persons and intravenous drug users (IDUs)
Bogdanova 2019	Russia	Mass CXR screening	SSM	Reported	✓	✓	✓					$4-$13		$793 per TB case diagnosed
Jit 2011	United Kingdom	Mobile CXR screening for IDUs and homeless	NR	Reported	✓	✓	✓		✓	✓		NR		$9837 per QALY gained (UR: $6,302-$27,666)
Persons who live in urban slums
Sekandi 2015	Uganda	WHO 4SS for all HHC	SSM and CXR	Reported	✓	✓	✓		✓			NR		$1371 per additional TB case diagnosed
Shah 2017	Peru	Household visits for WHO 4SS for all HHC	Xpert MTB/RIF	Reported	✓	✓	✓	✓	✓	✓		$32 per person screened		$3244 per DALY averted
James 2017	Cambodia	Door-to-door WHO 4SS	SSM and Xpert	Reported	✓		✓		✓			NR		$268 per TB case diagnosed
Members of tribal or indigenous populations
Sohn 2019	India	Household visits for TB education and screening	SSM	Reported	✓			✓	✓			< $1 per person screened		$3–5 per TB case diagnosed
Persons residing in prisons
Machekera 2019	Zimbabwe	WHO 4SS, CXR	Xpert MTB/RIF	Calculated	✓		✓					$14 per person screened		$460 per TB case diagnosed
Smit 2017	Belgium	WHO 4SS, CXR	NR	Calculated		✓	✓					$18 per person screened		$14,034 per TB case diagnosed
Winetsky 2012	Former Soviet Union	WHO 4SS alone	NR	Reported	✓	✓	✓	✓				$3 per person screened		$538 per QALY gained
		MMR (CXR)	NR	Reported	✓	✓	✓	✓				$5 per person screened
		Xpert MTB/RIF	NR	Reported	✓	✓	✓	✓				$2 per person screened
Zishiri 2014	South Africa	WHO 4SS	Xpert MTB/RIF	Reported	✓	✓	✓	✓		✓		$33 per person screened		$1423 TB case diagnosed
Elderly (55 +)
Jo 2020	Cambodia (> 55)	Symptom screen	Xpert, SSM, CXR	Reported	✓	✓	✓	✓	✓			< $1 per person screened		$406 per TB case diagnosed
James 2017	Cambodia (> 55)	Symptom screen	Xpert, CXR	Calculated	✓	✓	✓	✓				< $2 per person screened		$340 per TB case diagnosed
Zhang 2017	China (> 65)	Door-to-door symptom screen or CXR	CXR, SSM, culture	Reported	✓	✓	✓	✓				NR		$74–$315 per TB case diagnosed
People living in areas with limited access to healthcare (remote, isolated, hard-to-reach areas)
Karki 2017	Papua New Guinea	Community-wide symptom screening	SSM	Reported	✓		✓		✓			NR		$158 per TB case diagnosed
Jo 2020	Cambodia	Symptom screen	Xpert, SSM, CXR	Reported	✓	✓	✓	✓	✓			< $1 per person screened		$406 per TB case diagnosed
Miners (i.e., workers with silica exposure)
Machekera 2019	Zimbabwe	WHO 4SS, CXR	Xpert MTB/RIF	Calculated	✓		✓					$14 per person screened		$404 per miner diagnosed
Persons with clinical risk factors (N = 3)b
Diabetes mellitus
Bogdonova 2019	Russia	CXR	SSM	Reported	✓		✓		✓			NR		$21,780 per TB case diagnosed
Ji 2020	China	CXR	SSM	Calculated	✓	✓	✓		✓			< $2 per person screened		$288 per DALY averted
Machekera 2019	Zimbabwe	CXR	Xpert	Reported	✓	✓	✓					NR		$2191 per TB case diagnosed
Respiratory disease
Bogdonova 2019	Russia	CXR	SSM	Reported	✓		✓		✓			NR		$32,746 per TB case diagnosed
Gastro-intestinal, genito-urinary, steroid use or fibrotic chest lesions
Bogdonova 2019	Russia	CXR	SSM	Reported	✓		✓		✓			NR		$11,648-$105,754 per TB case diagnosed

^aThere is limited evidence on screening among persons with structural risk factors, including migrants (n = 2), homeless persons and IDUs (n = 2), persons who live in urban slums (n = 3), members of tribal or indigenous populations (n = 1), persons residing in prisons (4), elderly (3), people living in remote areas (n = 2) and miners (1). The costs of screening among persons with structural risk factors ranged from $1–33 per person screened and $3–$506,025 per TB case diagnosed. Screening programs were found to be cost-effective in persons living in urban slums and homeless, with reported ICERs of $3244 per DALY averted and $9837 per QALY, respectively. Screening was not shown to be cost-effective in migrants with an of ICER $506,025 per migrant diagnosed. In the Former Soviet Union, screening persons residing in prisons was found to be cost-effective with an ICER of $538 per QALY gained. Door-to-door screening of the elderly in China was shown to be cost-effective with ICERs ranging from US$74 to $315 per additional TB patient diagnosed

^bThere is limited evidence on screening among persons with clinical risk factors, primarily from one study in Russia. One study in Russia demonstrated a cost ranging from $11,648 to $105,754 for systematic screening among persons with various clinical risk factors (i.e., gastro-intestinal, respiratory disease, genito-urinary, steroid use and fibrotic chest lesions). Two studies conducted in Russia and Zimbabwe reported the cost per person diagnosed with diabetes mellitus (DM) which ranged from $2191 to $21,780. A cost-effectiveness analysis of patients with DM in China found systematic screening using CXR was cost-effective with an ICER of $288 per DALY averted

ACF active case finding, HHC household contacts, SSM sputum smear microscopy, Xpert GeneXpert, WHO 4SS four symptom screen, mWRDs molecular WHO-approved rapid diagnostics, CXR chest x-ray, NR not reported

¹Costs in 2019 USD unless stated otherwise

‘✓’ indicates cost component was explicitly included in unit cost calculation