Accuracy and Incremental Yield of the Chest X-Ray in Screening for Tuberculosis in Uganda: A Cross-Sectional Study

Nalunjogi, Joanitah; Mugabe, Frank; Najjingo, Irene; Lusiba, Pastan; Olweny, Francis; Mubiru, Joseph; Kayongo, Edward; Sekibira, Rogers; Katamba, Achilles; Kirenga, Bruce

doi:10.1155/2021/6622809

Cited by 7 publications

(7 citation statements)

References 20 publications

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“…Like prior research, in this study, CXR screening increased TB case detection, reducing TB incidence and mortality [5,27]. However, CXR screening incurs high costs [11,27,30]. Total costs for CXR screening across the general population were more than 10 times higher than those for national TBSS screening in this study, aligning with findings in a study in Vietnam [31].…”

Section: Principal Findingssupporting

confidence: 85%

“…Like prior research, in this study, CXR screening increased TB case detection, reducing TB incidence and mortality [5,27]. However, CXR screening incurs high costs [11,27,30].…”

Section: Principal Findingssupporting

confidence: 64%

“…In the "End TB" strategy, the worldwide objectives for TB control by 2035 are to achieve a 90% decrease in TB incidence and a 95% reduction in TB deaths [27]. Globally, the most recommended tools for tuberculosis screening are TBSS and CXR.…”

Section: Principal Findingsmentioning

confidence: 99%

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Active Tuberculosis Screening via a Mobile Health App in Myanmar: Incremental Cost-Effectiveness Evaluation

Htet,

Phyu,

Zayar

et al. 2023

JMIR Form Res

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Background A mobile app that calculates a tuberculosis (TB) risk score based on individual social and pathological characteristics has been shown to be a better predictor of the risk of contracting TB than conventionally used TB signs and symptoms (TBSS) in Myanmar, where the TB burden is high. Its cost-effectiveness, however, has not yet been assessed. Objective This study aimed to determine the incremental costs of this mobile app and of chest x-rays (CXRs) in averting disability-adjusted life years (DALYs) among missed cases of active TB in the population being screened. Methods Elements of incremental costs and effectiveness of 3 initial TB screening strategies were examined, including TBSS followed by CXR, the mobile app followed by CXR, and universal CXR. The incremental cost-effectiveness ratio (ICER; ie, the additional cost for each additional DALY averted) was compared to TBSS screening. Based on the latest 2020 gross domestic product (GDP) per capita of Myanmar (US $1477.50), the ICER was compared to willingness-to-pay (WTP) thresholds of 1, 2, and 3 times the GDP per capita. Probabilistic sensitivity analysis was conducted with a Monte Carlo simulation to compute the levels of probability that the ICER for each strategy was below each WTP threshold. Results For each 100,000 population, the incremental cost compared to TBSS of active TB screening was US $345,942 for the mobile app and US $1,810,712 for universal CXR. The incremental effectiveness was 325 DALYs averted for the mobile app and 576 DALYs averted for universal CXR. For the mobile app, the estimated ICER was US $1064 (72% of GDP per capita) per 1 DALY averted. Furthermore, 100% of the simulated values were below an additional cost of 1 times the GDP per capita for 1 additional DALY averted. The universal CXR strategy has an estimated ICER of US $3143 (2.1 times the GDP per capita) per 1 DALY averted and an additional 77.2% DALYs averted compared to the app (ie, 576 – 325 / 325 DALYs); however, 0.5% of the simulated values were higher than an additional expenditure of 3 times the GDP per capita. Conclusions Based on the status of the economy in 2020, the mobile app strategy is affordable for Myanmar. The universal CXR strategy, although it could prevent an additional 77% of DALYs, is probably unaffordable. Compared to the TBSS strategy, the mobile app system based on social and pathological characteristics of TB has potential as a TB screening tool to identify missing TB cases and to reduce TB morbidity and mortality, thereby helping to achieve the global goal of “End TB” in resource-limited settings with a high TB burden.

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Section: Principal Findingssupporting

confidence: 85%

“…Like prior research, in this study, CXR screening increased TB case detection, reducing TB incidence and mortality [5,27]. However, CXR screening incurs high costs [11,27,30].…”

Section: Principal Findingssupporting

confidence: 64%

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Active Tuberculosis Screening via a Mobile Health App in Myanmar: Incremental Cost-Effectiveness Evaluation

Htet,

Phyu,

Zayar

et al. 2023

JMIR Form Res

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“… 35 The yield of TB diagnoses increased by 38% as a result of screening methodologies that include chest X-ray in addition to symptoms. 13 According to the EXIT-TB project done in East Africa, the use of chest X-ray services for TB increased TB case detection and reduced delays in TB care. 36 The Global Plan recommends that, at minimum, 95% of people developing TB each year need to be diagnosed and treated, and that no one should be left behind.…”

Section: Discussionmentioning

confidence: 99%

“… 12 A study done in Uganda reported chest X-ray screening for pulmonary TB had 93% sensitivity and 65% specificity, which were higher than the 76% and 31%, respectively, found in symptom screening. 13 The yield of TB diagnosis increased by 38% as a result of screening methodologies that included chest X-rays in addition to symptoms. In Ethiopia, people diagnosed with TB with mild or no symptoms of TB have a better outcome from screening based on chest radiography.…”

Section: Introductionmentioning

confidence: 99%

Facilitators and barriers to implementing chest radiography in tuberculosis systematic screening of clinically high-risk groups in Ethiopia: A qualitative study

Abraham,

Manyazewal,

Amdemariam

et al. 2024

SAGE Open Medicine

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Background: Chest X-ray has been included in national tuberculosis screening algorithms as a sensitive tuberculosis screening tool among high-risk groups. However, the implementation was influenced by multiple factors. We aimed to explore facilitators and barriers to implementing chest X-ray in systematic tuberculosis screening of clinically high-risk groups in Addis Ababa, Ethiopia. Methods: We conducted face-to-face, in-depth interviews with purposively selected participants at tertiary-level hospitals and a tuberculosis program coordinator at the Ethiopian Ministry of Health, who coordinates chest X-ray-guided systematic tuberculosis screening. A framework analysis was conducted using the consolidated framework for implementation research. Results: We identified 11 constructs that influenced the implementation of the chest X-ray intervention. Facilitators included the relative sensitivity of chest X-ray over symptom-based screening, its potential integration into existing systems, technological advancements in the area, policies and laws supporting the screening intervention, and the quality of the evidence of the screening intervention. Barriers included implementation complexity, high costs of the intervention, knowledge gaps among healthcare providers, training gaps, low priority for chest X-ray screening at the healthcare facility level, and a lack of external support from the Ministry of Health and stakeholders. Conclusion: This study identified contextual factors that influence the implementation of chest X-ray guided systematic tuberculosis screening among clinically high-risk groups that healthcare facilities and health ministries may use for decision-making. Addressing the barriers identified by the study would help to improve the implementation of chest X-rays for improved tuberculosis case detection and prompt treatment in clinically high-risk groups.

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Symptom- and chest-radiography screening for active pulmonary tuberculosis in HIV-negative adults and adults with unknown HIV status

Hoog¹,

Viney

Biermann

et al. 2022

Cochrane Database of Systematic Reviews

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Background Systematic screening in high‐burden settings is recommended as a strategy for early detection of pulmonary tuberculosis disease, reducing mortality, morbidity and transmission, and improving equity in access to care. Questioning for symptoms and chest radiography (CXR) have historically been the most widely available tools to screen for tuberculosis disease. Their accuracy is important for the design of tuberculosis screening programmes and determines, in combination with the accuracy of confirmatory diagnostic tests, the yield of a screening programme and the burden on individuals and the health service. Objectives To assess the sensitivity and specificity of questioning for the presence of one or more tuberculosis symptoms or symptom combinations, CXR, and combinations of these as screening tools for detecting bacteriologically confirmed pulmonary tuberculosis disease in HIV‐negative adults and adults with unknown HIV status who are considered eligible for systematic screening for tuberculosis disease. Second, to investigate sources of heterogeneity, especially in relation to regional, epidemiological, and demographic characteristics of the study populations. Search methods We searched the MEDLINE, Embase, LILACS, and HTA (Health Technology Assessment) databases using pre‐specified search terms and consulted experts for unpublished reports, for the period 1992 to 2018. The search date was 10 December 2018. This search was repeated on 2 July 2021. Selection criteria Studies were eligible if participants were screened for tuberculosis disease using symptom questions, or abnormalities on CXR, or both, and were offered confirmatory testing with a reference standard. We included studies if diagnostic two‐by‐two tables could be generated for one or more index tests, even if not all participants were subjected to a microbacteriological reference standard. We excluded studies evaluating self‐reporting of symptoms. Data collection and analysis We categorized symptom and CXR index tests according to commonly used definitions. We assessed the methodological quality of included studies using the QUADAS‐2 instrument. We examined the forest plots and receiver operating characteristic plots visually for heterogeneity. We estimated summary sensitivities and specificities (and 95% confidence intervals (CI)) for each index test using bivariate random‐effects methods. We analyzed potential sources of heterogeneity in a hierarchical mixed‐model. Main results The electronic database search identified 9473 titles and abstracts. Through expert consultation, we identified 31 reports on national tuberculosis prevalence surveys as eligible (of which eight were already captured in the search of the electronic databases), and we identified 957 potentially relevant articles through reference checking. After removal of duplicates, we assessed 10,415 ti...

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Accuracy and Incremental Yield of the Chest X-Ray in Screening for Tuberculosis in Uganda: A Cross-Sectional Study

Cited by 7 publications

References 20 publications

Active Tuberculosis Screening via a Mobile Health App in Myanmar: Incremental Cost-Effectiveness Evaluation

Active Tuberculosis Screening via a Mobile Health App in Myanmar: Incremental Cost-Effectiveness Evaluation

Facilitators and barriers to implementing chest radiography in tuberculosis systematic screening of clinically high-risk groups in Ethiopia: A qualitative study

Symptom- and chest-radiography screening for active pulmonary tuberculosis in HIV-negative adults and adults with unknown HIV status

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