{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T18:27:59Z","timestamp":1792693679455,"version":"4.5.0"},"reference-count":40,"publisher":"Public Library of Science (PLoS)","issue":"6","license":[{"start":{"date-parts":[[2025,6,11]],"date-time":"2025-06-11T00:00:00Z","timestamp":1749600000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100008627","name":"Global Affairs Canada","doi-asserted-by":"publisher","award":["CA-3-D000920001"],"award-info":[{"award-number":["CA-3-D000920001"]}],"id":[{"id":"10.13039\/501100008627","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosdigitalhealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Digit Health"],"abstract":"<jats:p>Availability of ultraportable chest x-ray (CXR) and advancements in artificial intelligence (AI)-enabled CXR interpretation are promising developments in tuberculosis (TB) active case finding (ACF) but costing and cost-effectiveness analyses are limited. We provide implementation cost and cost-effectiveness estimates of different screening algorithms using symptoms, CXR and AI in Nigeria. People 15 years and older were screened for TB symptoms and offered a CXR with AI-enabled interpretation using qXR v3 (Qure.ai) at lung health camps. Sputum samples were tested on Xpert MTB\/RIF for individuals reporting symptoms or with qXR abnormality scores \u22650.30. We conducted a retrospective costing using a combination of top-down and bottom-up approaches while utilizing itemized expense data from a health system perspective. We estimated costs in five screening scenarios: abnormality score \u22650.30 and \u22650.50; cough\u2009\u2265\u20092 weeks; any symptom; abnormality score \u22650.30 or any symptom. We calculated total implementation costs, cost per bacteriologically-confirmed case detected, and assessed cost-effectiveness using incremental cost-effectiveness ratio (ICER) as additional cost per additional case. Overall, 3205 people with presumptive TB were identified, 1021 were tested, and 85 people with bacteriologically-confirmed TB were detected. <jats:italic>Abnormality\u2009\u2265\u20090.30 or any symptom<\/jats:italic> (US$65704) had the highest costs while <jats:italic>cough\u2009\u2265\u20092 weeks<\/jats:italic> was the lowest (US$40740). The cost per case was US$1198 for <jats:italic>cough\u2009\u2265\u20092 weeks<\/jats:italic>, and lowest for <jats:italic>any symptom<\/jats:italic> (US$635). Compared to baseline strategy of cough\u2009\u2265\u20092 weeks, the ICER for <jats:italic>any symptom<\/jats:italic> was US$191 per additional case detected and US$ 2096 for <jats:italic>Abnormality \u22650.30 OR any symptom<\/jats:italic> algorithm. Using CXR and AI had lower cost per case detected than any symptom screening criteria when asymptomatic TB was higher than 30% of all bacteriologically-confirmed TB detected. Compared to traditional symptom screening, using CXR and AI in combination with symptoms detects more cases at lower cost per case detected and is cost-effective. TB programs should explore adoption of CXR and AI for screening in ACF.<\/jats:p>","DOI":"10.1371\/journal.pdig.0000894","type":"journal-article","created":{"date-parts":[[2025,6,11]],"date-time":"2025-06-11T17:49:07Z","timestamp":1749664147000},"page":"e0000894","update-policy":"https:\/\/doi.org\/10.1371\/journal.pdig.corrections_policy","source":"Crossref","is-referenced-by-count":11,"title":["Implementation costs and cost-effectiveness of ultraportable chest X-ray with artificial intelligence in active case finding for tuberculosis in Nigeria"],"prefix":"10.1371","volume":"4","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6781-8574","authenticated-orcid":true,"given":"Tushar","family":"Garg","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephen","family":"John","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Suraj","family":"Abdulkarim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adamu D.","family":"Ahmed","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Beatrice","family":"Kirubi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Md. Toufiq","family":"Rahman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emperor","family":"Ubochioma","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4885-940X","authenticated-orcid":true,"given":"Jacob","family":"Creswell","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,6,11]]},"reference":[{"issue":"9151","key":"pdig.0000894.ref001","doi-asserted-by":"crossref","first-page":"444","DOI":"10.1016\/S0140-6736(98)03406-0","article-title":"Transmission of Mycobacterium tuberculosis from patients smear-negative for acid-fast bacilli","volume":"353","author":"MA Behr","year":"1999","journal-title":"Lancet"},{"key":"pdig.0000894.ref002","volume-title":"WHO consolidated guidelines on tuberculosis: module 2: screening: systematic screening for tuberculosis disease","author":"World Health Organization","year":"2021"},{"issue":"9","key":"pdig.0000894.ref003","doi-asserted-by":"crossref","first-page":"1128","DOI":"10.1111\/tmi.12534","article-title":"National tuberculosis prevalence surveys in Asia, 1990-2012: an overview of results and lessons learned","volume":"20","author":"I Onozaki","year":"2015","journal-title":"Trop Med Int Health"},{"issue":"11","key":"pdig.0000894.ref004","doi-asserted-by":"crossref","first-page":"1308","DOI":"10.1111\/tmi.13485","article-title":"National tuberculosis prevalence surveys in Africa, 2008-2016: an overview of results and lessons learned","volume":"25","author":"I Law","year":"2020","journal-title":"Trop Med Int Health"},{"issue":"2","key":"pdig.0000894.ref005","doi-asserted-by":"crossref","first-page":"516","DOI":"10.1183\/13993003.00543-2016","article-title":"Development, roll-out and impact of Xpert MTB\/RIF for tuberculosis: what lessons have we learnt and how can we do better?","volume":"48","author":"H Albert","year":"2016","journal-title":"Eur Respir J"},{"key":"pdig.0000894.ref006","author":"Stop TB Partnership.","year":"2023"},{"issue":"10010","key":"pdig.0000894.ref007","doi-asserted-by":"crossref","first-page":"2334","DOI":"10.1016\/S0140-6736(15)00322-0","article-title":"Turning off the tap: stopping tuberculosis transmission through active case-finding and prompt effective treatment","volume":"386","author":"CM Yuen","year":"2015","journal-title":"Lancet"},{"issue":"5","key":"pdig.0000894.ref008","doi-asserted-by":"crossref","first-page":"543","DOI":"10.1164\/rccm.201207-1217OC","article-title":"Is passive diagnosis enough? The impact of subclinical disease on diagnostic strategies for tuberculosis","volume":"187","author":"DW Dowdy","year":"2013","journal-title":"Am J Respir Crit Care Med"},{"issue":"1","key":"pdig.0000894.ref009","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1038\/s41746-021-00471-y","article-title":"Computer-aided interpretation of chest radiography reveals the spectrum of tuberculosis in rural South Africa","volume":"4","author":"J Fehr","year":"2021","journal-title":"NPJ Digit Med"},{"issue":"1","key":"pdig.0000894.ref010","doi-asserted-by":"crossref","first-page":"1336","DOI":"10.1038\/s41598-023-28529-9","article-title":"A spatial analysis of TB cases and abnormal X-rays detected through active case-finding in Karachi, Pakistan","volume":"13","author":"SMA Zaidi","year":"2023","journal-title":"Sci Rep"},{"issue":"4","key":"pdig.0000894.ref011","doi-asserted-by":"crossref","first-page":"181","DOI":"10.3390\/tropicalmed5040181","article-title":"Optimizing active tuberculosis case finding: evaluating the impact of community referral for chest X-ray Screening and Xpert testing on case notifications in two cities in viet nam","volume":"5","author":"TH Mac","year":"2020","journal-title":"Trop Med Infect Dis"},{"issue":"9","key":"pdig.0000894.ref012","doi-asserted-by":"crossref","first-page":"447","DOI":"10.3390\/tropicalmed8090447","article-title":"Spectrum of TB disease and treatment outcomes in a mobile community based active case finding program in yogyakarta province, Indonesia","volume":"8","author":"NR Ananda","year":"2023","journal-title":"Trop Med Infect Dis"},{"issue":"5","key":"pdig.0000894.ref013","doi-asserted-by":"crossref","DOI":"10.1016\/S2468-2667(21)00033-5","article-title":"Community-based active case-finding interventions for tuberculosis: a systematic review","volume":"6","author":"RM Burke","year":"2021","journal-title":"Lancet Public Health"},{"issue":"11","key":"pdig.0000894.ref014","article-title":"Interventions to increase tuberculosis case detection at primary healthcare or community-level services","volume":"11","author":"FA Mhimbira","year":"2017","journal-title":"Cochrane Database Syst Rev"},{"issue":"2","key":"pdig.0000894.ref015","doi-asserted-by":"crossref","first-page":"58","DOI":"10.5588\/pha.18.0091","article-title":"Costs and operation management of community outreach program for tuberculosis in tribal populations in India","volume":"9","author":"H Sohn","year":"2019","journal-title":"Public Health Action"},{"issue":"3","key":"pdig.0000894.ref016","doi-asserted-by":"crossref","first-page":"171","DOI":"10.5588\/ijtld.20.0565","article-title":"Determining the value of TB active case-finding: current evidence and methodological considerations","volume":"25","author":"H Sohn","year":"2021","journal-title":"Int J Tuberc Lung Dis"},{"issue":"9","key":"pdig.0000894.ref017","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0270816","article-title":"Comparative assessment of the cost-effectiveness of Tuberculosis (TB) active case-finding interventions: A systematic analysis of TB REACH wave 5 projects","volume":"17","author":"I Gomes","year":"2022","journal-title":"PLoS One"},{"issue":"1","key":"pdig.0000894.ref018","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1186\/s40249-019-0603-z","article-title":"The role of active case finding in reducing patient incurred catastrophic costs for tuberculosis in Nepal","volume":"8","author":"SC Gurung","year":"2019","journal-title":"Infect Dis Poverty"},{"key":"pdig.0000894.ref019","doi-asserted-by":"crossref","first-page":"532","DOI":"10.1186\/1471-2334-14-532","article-title":"Choosing algorithms for TB screening: a modelling study to compare yield, predictive value and diagnostic burden","volume":"14","author":"AH Van\u2019t Hoog","year":"2014","journal-title":"BMC Infect Dis"},{"key":"pdig.0000894.ref020","volume-title":"Chest radiography in tuberculosis detection: summary of current WHO recommendations and guidance on programmatic approaches","author":"World Health Organization","year":"2016"},{"issue":"9","key":"pdig.0000894.ref021","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1003752","article-title":"Computer-aided X-ray screening for tuberculosis and HIV testing among adults with cough in Malawi (the PROSPECT study): A randomised trial and cost-effectiveness analysis","volume":"18","author":"P MacPherson","year":"2021","journal-title":"PLoS Med"},{"issue":"12","key":"pdig.0000894.ref022","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0277393","article-title":"Economic analysis of different throughput scenarios and implementation strategies of computer-aided detection software as a screening and triage test for pulmonary TB","volume":"17","author":"S Bashir","year":"2022","journal-title":"PLoS One"},{"issue":"9915","key":"pdig.0000894.ref023","doi-asserted-by":"crossref","first-page":"424","DOI":"10.1016\/S0140-6736(13)62073-5","article-title":"Feasibility, accuracy, and clinical effect of point-of-care Xpert MTB\/RIF testing for tuberculosis in primary-care settings in Africa: a multicentre, randomised, controlled trial","volume":"383","author":"G Theron","year":"2014","journal-title":"Lancet"},{"key":"pdig.0000894.ref024","doi-asserted-by":"crossref","first-page":"12215","DOI":"10.1038\/srep12215","article-title":"Automated chest-radiography as a triage for Xpert testing in resource-constrained settings: a prospective study of diagnostic accuracy and costs","volume":"5","author":"RHHM Philipsen","year":"2015","journal-title":"Sci Rep"},{"issue":"5","key":"pdig.0000894.ref025","doi-asserted-by":"crossref","first-page":"771","DOI":"10.1093\/cid\/ciaa135","article-title":"Yield, Efficiency, and Costs of Mass Screening Algorithms for Tuberculosis in Brazilian Prisons","volume":"72","author":"S Santos A da","year":"2021","journal-title":"Clin Infect Dis"},{"issue":"1","key":"pdig.0000894.ref026","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1186\/s44263-023-00017-2","article-title":"Comparing tuberculosis symptom screening to chest X-ray with artificial intelligence in an active case finding campaign in Northeast Nigeria","volume":"1","author":"S John","year":"2023","journal-title":"BMC Glob Public Health"},{"key":"pdig.0000894.ref027","author":"Global Drug Facility Stop TB Partnership","year":"2022"},{"key":"pdig.0000894.ref028","volume-title":"Global tuberculosis report 2023","author":"World Health Organization","year":"2023"},{"key":"pdig.0000894.ref029"},{"issue":"1","key":"pdig.0000894.ref030","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1186\/s44263-023-00033-2","article-title":"Early user perspectives on using computer-aided detection software for interpreting chest X-ray images to enhance access and quality of care for persons with tuberculosis","volume":"1","author":"J Creswell","year":"2023","journal-title":"BMC Glob Public Health"},{"key":"pdig.0000894.ref031","author":"Global Drug Facility Stop TB Partnership","year":"2025"},{"issue":"3","key":"pdig.0000894.ref032","doi-asserted-by":"crossref","first-page":"90","DOI":"10.5588\/pha.23.0028","article-title":"Improving TB control: efficiencies of case-finding interventions in Nigeria","volume":"13","author":"AP Babayi","year":"2023","journal-title":"Public Health Action"},{"key":"pdig.0000894.ref033","article-title":"An audit of registered radiology equipment resources in Uganda","author":"E Kiguli-Malwadde","year":"2020","journal-title":"Pan African Medical Journal"},{"issue":"3","key":"pdig.0000894.ref034","doi-asserted-by":"crossref","first-page":"1601877","DOI":"10.1183\/13993003.01877-2016","article-title":"Can tuberculosis patients in resource-constrained settings afford chest radiography?","volume":"49","author":"D Pedrazzoli","year":"2017","journal-title":"Eur Respir J"},{"issue":"10","key":"pdig.0000894.ref035","doi-asserted-by":"crossref","DOI":"10.1056\/AIoa2400018","article-title":"Prospective Multi-Site Validation of AI to Detect Tuberculosis and Chest X-Ray Abnormalities","volume":"1","author":"S Kazemzadeh","year":"2024","journal-title":"NEJM AI"},{"issue":"1","key":"pdig.0000894.ref036","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1186\/s44263-024-00081-2","article-title":"Expanding molecular diagnostic coverage for tuberculosis by combining computer-aided chest radiography and sputum specimen pooling: a modeling study from four high-burden countries","volume":"2","author":"AJ Codlin","year":"2024","journal-title":"BMC Glob Public Health"},{"key":"pdig.0000894.ref037","author":"Global Fund"},{"key":"pdig.0000894.ref038","doi-asserted-by":"crossref","first-page":"204","DOI":"10.4103\/ijmr.ijmr_845_22","article-title":"A comparison of the quality of images of chest X-ray between handheld portable digital X-ray & routinely used digital X-ray machine","volume":"157","author":"R Kamal","year":"2023","journal-title":"Indian J Med Res"},{"key":"pdig.0000894.ref039","author":"D Branigan","year":"2023"},{"key":"pdig.0000894.ref040","volume-title":"In: AI4HLTHInternet","author":"AI Products for Tuberculosis Healthcare"}],"container-title":["PLOS Digital Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pdig.0000894","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,6,11]],"date-time":"2025-06-11T17:49:25Z","timestamp":1749664165000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pdig.0000894"}},"subtitle":[],"editor":[{"given":"Simon","family":"Reif","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2025,6,11]]},"references-count":40,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2025,6,11]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pdig.0000894","relation":{},"ISSN":["2767-3170"],"issn-type":[{"value":"2767-3170","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,11]]}}}