Cost to perform door-to-door universal sputum screening for TB in a high-burden community

Abstract

BACKGROUND: Population-based active case-finding (ACF) identifies people with TB in communities but can be costly.METHODS: We conducted an empiric costing study within a door-to-door household ACF campaign in an urban community in Uganda, where all adults, regardless of symptoms, were screened by sputum Xpert Ultra testing. We used a combination of direct observation and self-reported logs to estimate staffing requirements. Study budgets were reviewed to collect costs of overheads, equipment, and consumables. Our primary outcome was the cost per person diagnosed with TB.RESULTS: Over a 28-week period, three teams of two people collected sputum from 11,341 adults, of whom 48 (0.4%) tested positive for TB. Screening 1,000 adults required 258 person-hours of effort at a cost of US$402,000, 70% of which was for GeneXpert cartridges. The estimated cost per person screened was $36 (95% uncertainty range [95% UR] 34–38), and the cost per person diagnosed with Xpert-positive TB was $8,400 (95% UR 8,000–8,900). The prevalence of TB in the underlying community was the primary modifiable determinant of the cost per person diagnosed.CONCLUSION: Door-to-door screening can be feasibly performed at scale, but will require effective triage and identification of high-prevalence populations to be affordable and cost-effective.

Community-based active-case finding for tuberculosis: navigating a complex minefield

“…Screening algorithms can include an initial symptom screen (with different symptom combinations providing trade-offs in terms of sensitivity and specificity for microbiologicallyconfirmed pulmonary TB) [26,58], followed by a confirmatory test: sputum smear is relatively cheap, and in well-functioning systems can achieve moderate sensitivity [59], whereas molecular testing with NAAT provides gains in sensitivity-particularly for people living with HIV [60]-at substantially greater cost. Strategies such as the universal offer of sputum nucleic acid amplification (NAAT) testing regardless of symptoms (as in the ACT3 Study [30]) are likely to be more effective but with substantially greater programmatic costs [61].…”

Expanding molecular diagnostic coverage for tuberculosis by combining computer-aided chest radiography and sputum specimen pooling: a modeling study from four high burden countries

“…[7,8] Despite recent price reductions of consumables and reagents [9], ensuring universal mWRD coverage may cost over $1 billion per year. [10,11] To mitigate high mWRD costs, a screening step can be used to rule out people with a low probability of TB disease. [12] Among various options, chest X-ray (CXR) has become the screening tool of choice in many settings due to the ability to identify the large cohort of asymptomatic people with TB.…”