{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T18:08:01Z","timestamp":1789150081453,"version":"build-2803163510"},"reference-count":27,"publisher":"Public Library of Science (PLoS)","issue":"9","license":[{"start":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T00:00:00Z","timestamp":1789084800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000060","name":"National Institute of Allergy and Infectious Diseases","doi-asserted-by":"publisher","award":["R01A1147321"],"award-info":[{"award-number":["R01A1147321"]}],"id":[{"id":"10.13039\/100000060","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosglobalpublichealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Glob Public Health"],"abstract":"<jats:p>The South African National Department of Health have set ambitious targets to scale up TB testing, focusing primarily on clinic attendees. In the context of declining funding for TB care and prevention, the most cost-effective approaches for targeting testing should be identified. We developed a mathematical model of TB in South Africa, explicitly incorporating clinic attendance by sex and HIV\/ART status. We simulated six screening approaches over 2026\u20132035 (individually and in combination): three clinic-based (symptom screening, intensified targeted universal TB testing [TUTT, symptom-agnostic sputum testing of clinic attendees in key risk groups], and intensified TUTT allowing saliva samples) and three targeted community-based (community radiographic screening, symptom screening, and universal Xpert Ultra testing), each implemented at a range of coverage levels. Model outputs were combined with a mechanistic cost function to estimate potential impact and cost-effectiveness from a societal perspective. The most cost-effective standalone approach was community radiographic screening at 10% annual population coverage, with an incremental cost-effectiveness ratio (ICER) of $421 per disability-adjusted life year (DALY) averted. 10\/11 scenarios along the expansion path included community radiographic screening at progressively higher coverage, combined with a clinic-based approach. Combining complementary approaches to reach both groups at increased risk of TB (e.g., clinic-based screening) and groups with lower screening coverage (e.g., community-based screening) may increase cost-effectiveness of TB screening, compared to standalone approaches. When designing TB screening strategies, both population risk and existing screening coverage should be considered.<\/jats:p>","DOI":"10.1371\/journal.pgph.0006738","type":"journal-article","created":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T17:26:27Z","timestamp":1789147587000},"page":"e0006738","update-policy":"https:\/\/doi.org\/10.1371\/journal.pgph.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Projected population level impact and cost-effectiveness of clinic and community-based tuberculosis screening approaches"],"prefix":"10.1371","volume":"6","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1409-8531","authenticated-orcid":true,"given":"Nicky","family":"McCreesh","sequence":"first","affiliation":[{"name":"TB Centre, London School of Hygiene and Tropical Medicine","place":["London, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Palwasha Y.","family":"Khan","sequence":"additional","affiliation":[{"name":"TB Centre, London School of Hygiene and Tropical Medicine","place":["London, United Kingdom"]},{"name":"Africa Health Research Institute","place":["Somkhele, South Africa"],"department":["Clinical Research Department"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ian","family":"Yoon","sequence":"additional","affiliation":[{"name":"TB Centre, London School of Hygiene and Tropical Medicine","place":["London, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Indira","family":"Govender","sequence":"additional","affiliation":[{"name":"TB Centre, London School of Hygiene and Tropical Medicine","place":["London, United Kingdom"]},{"name":"Africa Health Research Institute","place":["Somkhele, South Africa"],"department":["Clinical Research Department"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-4235-0152","authenticated-orcid":true,"given":"Mareca","family":"Sithole","sequence":"additional","affiliation":[{"name":"Africa Health Research Institute","place":["Somkhele, South Africa"],"department":["Clinical Research Department"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rein M. G. J.","family":"Houben","sequence":"additional","affiliation":[{"name":"TB Centre, London School of Hygiene and Tropical Medicine","place":["London, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4410-6635","authenticated-orcid":true,"given":"Richard G.","family":"White","sequence":"additional","affiliation":[{"name":"TB Centre, London School of Hygiene and Tropical Medicine","place":["London, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alison D.","family":"Grant","sequence":"additional","affiliation":[{"name":"TB Centre, London School of Hygiene and Tropical Medicine","place":["London, United Kingdom"]},{"name":"Africa Health Research Institute","place":["Somkhele, South Africa"],"department":["Clinical Research Department"]},{"name":"School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal","place":["Durban, South Africa"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4233-9080","authenticated-orcid":true,"given":"Sedona","family":"Sweeney","sequence":"additional","affiliation":[{"name":"TB Centre, London School of Hygiene and Tropical Medicine","place":["London, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,9,11]]},"reference":[{"key":"pgph.0006738.ref001","unstructured":"World Health Organization. Global tuberculosis report 2025. 2025."},{"key":"pgph.0006738.ref002","volume-title":"End TB campaign 2025\/26: operational plan","author":"N Ndjeka","year":"2025"},{"key":"pgph.0006738.ref003","volume-title":"TB screening and testing standard operating procedure","author":"L Mvusi","year":"2022"},{"key":"pgph.0006738.ref004","unstructured":"Ndjeka NLM, Jassat W, Mathema H. Update on TB Recovery Plan 3.0. National Department of Health."},{"issue":"4","key":"pgph.0006738.ref005","doi-asserted-by":"crossref","first-page":"241","DOI":"10.5588\/ijtldopen.25.0168","article-title":"Impact of US funding cuts and stop work orders on TB services and research in South Africa","volume":"2","author":"N Ndjeka","year":"2025","journal-title":"IJTLD Open"},{"key":"pgph.0006738.ref006","unstructured":"WHO. WHO consolidated guidelines on tuberculosis: module 2: screening: systematic screening for tuberculosis disease. 2021."},{"issue":"3","key":"pgph.0006738.ref007","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":"pgph.0006738.ref008","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":"pgph.0006738.ref009","doi-asserted-by":"crossref","first-page":"38","DOI":"10.5588\/ijtld.21.0257","article-title":"How much does TB screening cost? A systematic review of economic evaluations","volume":"26","author":"B Empringham","year":"2022","journal-title":"Int J Tuberc Lung Dis"},{"issue":"8","key":"pgph.0006738.ref010","doi-asserted-by":"crossref","first-page":"1172","DOI":"10.1016\/S1473-3099(22)00149-9","article-title":"Prevalence of bacteriologically confirmed pulmonary tuberculosis in South Africa, 2017\u201319: a multistage, cluster-based, cross-sectional survey","volume":"22","author":"S Moyo","year":"2022","journal-title":"Lancet Infect Dis"},{"key":"pgph.0006738.ref011","unstructured":"World Health Organization. Global tuberculosis report 2024. 2024."},{"issue":"10","key":"pgph.0006738.ref012","doi-asserted-by":"crossref","DOI":"10.18637\/jss.v109.i10","article-title":"Emulation and History Matching Using the hmer Package","volume":"109","author":"A Iskauskas","year":"2024","journal-title":"J Stat Soft"},{"key":"pgph.0006738.ref013","doi-asserted-by":"crossref","unstructured":"Yoon I, Govender I, Khan PY, Sithole M, McCreesh N, Grant AD. Estimating tuberculosis-related patient costs in KwaZulu-Natal, South Africa. 2026.","DOI":"10.64898\/2026.05.18.26353472"},{"issue":"10","key":"pgph.0006738.ref014","doi-asserted-by":"crossref","first-page":"2216","DOI":"10.1002\/hec.4722","article-title":"Estimating health care costs at scale in low- and middle-income countries: mathematical notations and frameworks for the application of cost functions","volume":"32","author":"M d\u2019Elb\u00e9e","year":"2023","journal-title":"Health Econ"},{"key":"pgph.0006738.ref015","first-page":"59","article-title":"Ward-based primary health care outreach teams in South Africa: developments, challenges and future directions","author":"H Schneider","year":"2018","journal-title":"South Afr Health Rev"},{"key":"pgph.0006738.ref016","doi-asserted-by":"crossref","DOI":"10.1093\/heapol\/czw183","article-title":"The patient costs of care for those with TB and HIV: a cross-sectional study from South Africa","volume":"32","author":"D Mudzengi","year":"2017","journal-title":"Health Policy Plan"},{"key":"pgph.0006738.ref017","unstructured":"National Department of Health. Health Technology Assessment Methods Guide 2022-2027. 2022. pp. 1\u201368."},{"issue":"5","key":"pgph.0006738.ref018","doi-asserted-by":"crossref","first-page":"546","DOI":"10.1093\/heapol\/czz152","article-title":"Estimating a cost-effectiveness threshold for health care decision-making in South Africa","volume":"35","author":"IP Edoka","year":"2020","journal-title":"Health Policy Plan"},{"issue":"10","key":"pgph.0006738.ref019","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0186496","article-title":"Revealed willingness-to-pay versus standard cost-effectiveness thresholds: evidence from the South African HIV Investment Case","volume":"12","author":"G Meyer-Rath","year":"2017","journal-title":"PLoS One"},{"issue":"1","key":"pgph.0006738.ref020","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1016\/j.jval.2021.11.1351","article-title":"Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) Statement: Updated Reporting Guidance for Health Economic Evaluations","volume":"25","author":"D Husereau","year":"2022","journal-title":"Value Health"},{"key":"pgph.0006738.ref021","unstructured":"Partnership ST. An early present for 2026: Innovative near-poc pulslife TB test available in GDF Catalogue for $3.60. 2025."},{"key":"pgph.0006738.ref022","doi-asserted-by":"crossref","first-page":"169","DOI":"10.12688\/wellcomeopenres.16702.2","article-title":"Can we find the missing men in clinics? Clinic attendance by sex and HIV status in rural South Africa","volume":"6","author":"S Randera-Rees","year":"2023","journal-title":"Wellcome Open Res"},{"issue":"1","key":"pgph.0006738.ref023","doi-asserted-by":"crossref","first-page":"19","DOI":"10.5588\/pha.15.0064","article-title":"Coverage of clinic-based TB screening in South Africa may be low in key risk groups","volume":"6","author":"N McCreesh","year":"2016","journal-title":"Public Health Action"},{"key":"pgph.0006738.ref024","unstructured":"National Department of Health. Health Technology Assessment Methods Guide. 2022."},{"key":"pgph.0006738.ref025","volume-title":"Xpert MTB\/RIF implementation manual: technical and operational \u2018how-to\u2019; practical considerations","author":"World Health Organization","year":"2014"},{"key":"pgph.0006738.ref026","first-page":"1","article-title":"The performance and yield of tuberculosis testing algorithms using microscopy, chest x-ray, and Xpert MTB\/RIF","volume":"14","author":"J Creswell","year":"2018","journal-title":"J Clin Tuberc Other Mycobact Dis"},{"key":"pgph.0006738.ref027","article-title":"Reported tuberculosis symptoms: an inadequate classifier of disease state","author":"N McCreesh","year":"2025","journal-title":"Clin Infect Dis"}],"container-title":["PLOS Global Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0006738","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T17:26:33Z","timestamp":1789147593000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0006738"}},"subtitle":[],"editor":[{"given":"Graeme","family":"Hoddinott","sequence":"first","affiliation":[{"name":"University of Sydney","place":["AUSTRALIA"]}],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,9,11]]},"references-count":27,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,9,11]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pgph.0006738","relation":{},"ISSN":["2767-3375"],"issn-type":[{"value":"2767-3375","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,11]]}}}