{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,13]],"date-time":"2026-02-13T08:18:35Z","timestamp":1770970715946,"version":"3.50.1"},"reference-count":24,"publisher":"BMJ","issue":"2","license":[{"start":{"date-parts":[[2026,2,12]],"date-time":"2026-02-12T00:00:00Z","timestamp":1770854400000},"content-version":"unspecified","delay-in-days":11,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100032626","name":"UNITAID","doi-asserted-by":"crossref","award":["2022-50-START-4-ALL"],"award-info":[{"award-number":["2022-50-START-4-ALL"]}],"id":[{"id":"10.13039\/100032626","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,1,26]]},"published-print":{"date-parts":[[2026,2]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>High costs of screening and diagnostic tests remain a major barrier to timely tuberculosis (TB) identification in resource-limited settings. Evidence on the cost-effectiveness of scalable screening algorithms is limited. Start4All is a research project aimed at developing and evaluating algorithmic approaches to TB screening and diagnosis, with the goal of optimising technical and allocative efficiency when expanding diagnostic coverage to primary healthcare and community settings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and analysis<\/jats:title>\n                    <jats:p>Five screening and diagnostic tests will be evaluated: a capillary blood-based assay (C-reactive protein (CRP)), sputum-based rapid molecular tests (PCR; individual and pooled Xpert MTB\/RIF Ultra assay (Xpert Ultra, Cepheid\u00ae, California, USA)), a lateral-flow urine-based test for lipoarabinomannan (LF-LAM), and digital chest X-rays with artificial intelligence-based computer-aided detection (CXR-CAD). A microbiological reference standard of positive culture using the mycobacteria growth indicator tube will be used to confirm TB disease.<\/jats:p>\n                    <jats:p>We will compare the cost and effectiveness of concurrent and sequential positive serial combinations (screening algorithms) of CRP, CXR-CAD, LF-LAM, individual and pooled Xpert Ultra. Diagnostic performance will be estimated using sensitivity, specificity, predictive values and proportions of positive results, with Bayesian inference used to derive these estimates. The analysis will include adults (15 years and older) only and will be stratified by HIV status and level of care, including facility and community-based case finding. Effectiveness will be assessed based on the number of people with TB detected. Cost analysis will be conducted from the provider perspective, incorporating commodity and implementation costs. A decision tree model will be developed to assess the cost per number of persons with confirmed TB detected across all countries. Probabilistic sensitivity analysis will be conducted to account for uncertainty in model parameters, incorporating willingness-to-pay and willingness-to-accept thresholds.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Ethics and dissemination<\/jats:title>\n                    <jats:p>WHO ethical review committee approval ERC.0003921. Data will be available on reasonable request to the principal investigator of the consortium.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration number<\/jats:title>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"clintrialgov\" xlink:href=\"NCT05845112\">NCT05845112<\/jats:ext-link>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-111860","type":"journal-article","created":{"date-parts":[[2026,2,13]],"date-time":"2026-02-13T07:25:40Z","timestamp":1770967540000},"page":"e111860","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Start4All protocol for a Bayesian cost-effectiveness model of tuberculosis screening and diagnosis in seven high burden low-income and middle-income countries"],"prefix":"10.1136","volume":"16","clinical-trial-number":[{"clinical-trial-number":"nct05845112","registry":"10.18810\/clinical-trials-gov"}],"author":[{"ORCID":"https:\/\/orcid.org\/0009-0005-4934-751X","authenticated-orcid":false,"given":"Amanda","family":"McCoy","sequence":"first","affiliation":[{"name":"Liverpool School of Tropical Medicine, Department of Clinical Sciences, Global Health Economics and Financing Unit, Liverpool, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tushar","family":"Garg","sequence":"additional","affiliation":[{"name":"Stop TB Partnership, Grand-Saconnex, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1242-839X","authenticated-orcid":false,"given":"Marc","family":"Henrion","sequence":"additional","affiliation":[{"name":"Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi"},{"name":"Liverpool School of Tropical Medicine, Liverpool, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5937-6286","authenticated-orcid":false,"given":"Luan Nguyen Quang","family":"Vo","sequence":"additional","affiliation":[{"name":"Friends for International TB Relief, Hanoi, Vietnam"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tom","family":"Wingfield","sequence":"additional","affiliation":[{"name":"Centre for Tuberculosis Research, Liverpool School of Tropical Medicine, Liverpool, UK"},{"name":"Department of Global Public Health, Karolinska Institute, Stockholm, Sweden"},{"name":"Tropical and Infectious Diseases Unit, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Eve","family":"Worrall","sequence":"additional","affiliation":[{"name":"Liverpool School of Tropical Medicine, Department of Clinical Sciences, Global Health Economics and Financing Unit, Liverpool, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2026,2,12]]},"reference":[{"key":"2026021223252276000_16.2.e111860.1","unstructured":"WHO . Global tuberculosis report 2024. 2024."},{"key":"2026021223252276000_16.2.e111860.2","unstructured":"National surveys of costs faced by tuberculosis patients and their households 2015-2021. World Health Organization; 2022."},{"key":"2026021223252276000_16.2.e111860.3","unstructured":"World Health Organisation . WHO operational handbook on tuberculosis; module 2: screening; systematic screening for tuberculosis disease. 2021."},{"key":"2026021223252276000_16.2.e111860.4","doi-asserted-by":"crossref","DOI":"10.1136\/bmjph-2023-000276","article-title":"Cost-effectiveness of diagnostic tools and strategies for the screening and diagnosis of tuberculosis disease and infection: a scoping review","volume":"2","author":"Ockhuisen","year":"2024","journal-title":"BMJ Public Health"},{"key":"2026021223252276000_16.2.e111860.5","unstructured":"WHO . 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