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In countries with a low TB incidence (≤ 10 cases/100,000 population), active pulmonary tuberculosis (PTB) mostly affects vulnerable populations with limited access to healthcare. Thus, passive case-finding systems may not be successful in detecting and treating cases and preventing further transmission. Active and cost-effective search strategies can overcome this problem.


We aimed to review the evidence on the cost-effectiveness (C-E) of active PTB screening programmes among high-risk populations in low TB incidence countries.


We performed a systematic literature search covering 2008–2023 on PubMed, Embase, Center for Reviews and Dissemination, including Database of Abstracts of Reviews of Effects (DARE), National Health Services Economic Evaluation Database (NHS EED), Global Index Medicus and Cochrane Central Register of Controlled Trials (CENTRAL).


We retrieved 6,318 articles and included nine in this review. All included studies had an active case-finding approach and used chest X-ray, tuberculin skin test, interferon-gamma release assay and a symptoms questionnaire for screening. The results indicate that screening immigrants from countries with a TB incidence > 40 cases per 100,000 population and other vulnerable populations as individuals from isolated communities, people experiencing homelessness, those accessing drug treatment services and contacts, is cost-effective in low-incidence countries.


In low-incidence countries, targeting high-risk groups is C-E. However, due to the data heterogenicity, we were unable to compare C-E. Harmonisation of the methods for C-E analysis is needed and would facilitate comparisons. To outline comprehensive screening and its subsequent C-E analysis, researchers should consider multiple factors influencing screening methods and outcomes.


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  1. World Health Organization (WHO). Global tuberculosis report 2023. Geneva: WHO; 7 Nov 2023. Available from: https://www.who.int/publications/i/item/9789240083851
  2. World Health Organization (WHO). The end TB strategy. Geneva: WHO; 16 Aug 2015. Available from: https://www.who.int/publications/i/item/WHO-HTM-TB-2015.19
  3. World Health Organization (WHO). WHO consolidated guidelines on tuberculosis. module 2: screening: systematic screening for tuberculosis disease. Geneva: WHO; 22 Mar 2021. Available from: https://www.who.int/publications/i/item/9789240022676
  4. World Health Organization (WHO). WHO consolidated guidelines on tuberculosis: module 1: prevention: tuberculosis preventive treatment. Geneva: WHO; 25 Feb 2020. Available from: https://www.who.int/publications/i/item/9789240001503
  5. European Centre for Disease Prevention and Control (ECDC). Guidance on tuberculosis control in vulnerable and hard-to-reach populations. Stockholm: ECDC; Mar 2016. Available from: https://www.ecdc.europa.eu/sites/default/files/media/en/publications/Publications/TB-guidance-interventions-vulnerable-groups.pdf
  6. United Nations International Organization for Migration the Displacement Tracking Matrix (DTM). Migration flow to Europe – Arrivals. Le Grand-Saconnex: DTM. [Accessed: 15 Sep 2023]. Available from: https://dtm.iom.int/europe/arrivals
  7. Dalmau-Bueno A, García-Altés A, Vela E, Clèries M, Pérez CV, Argimon JM. Frequency of health-care service use and severity of illness in undocumented migrants in Catalonia, Spain: a population-based, cross-sectional study. Lancet Planet Health. 2021;5(5):e286-96.  https://doi.org/10.1016/S2542-5196(21)00036-X  PMID: 33964238 
  8. Santos JA, Leite A, Soares P, Duarte R, Nunes C. Delayed diagnosis of active pulmonary tuberculosis - potential risk factors for patient and healthcare delays in Portugal. BMC Public Health. 2021;21(1):2178.  https://doi.org/10.1186/s12889-021-12245-y  PMID: 34837969 
  9. Greenaway C, Pareek M, Abou Chakra CN, Walji M, Makarenko I, Alabdulkarim B, et al. The effectiveness and cost-effectiveness of screening for active tuberculosis among migrants in the EU/EEA: a systematic review. Euro Surveill. 2018;23(14):17-00542.  https://doi.org/10.2807/1560-7917.ES.2018.23.14.17-00542  PMID: 29637888 
  10. Alsdurf H, Empringham B, Miller C, Zwerling A. Tuberculosis screening costs and cost-effectiveness in high-risk groups: a systematic review. BMC Infect Dis. 2021;21(1):935.  https://doi.org/10.1186/s12879-021-06633-3  PMID: 34496804 
  11. How to clarify a clinical question | Learn EBM | Evidence-based medicine toolkit | British medical journal (BMJ) best practice. [Accessed: 18 Jan 2022]. Available from: https://bestpractice.bmj.com/info/toolkit/learn-ebm/how-to-clarify-a-clinical-question/
  12. Huang X, Lin J, Demner-Fushman D. Evaluation of PICO as a knowledge representation for clinical questions. AMIA Annu Symp Proc. 2006;2006:359-63. PMID: 17238363 
  13. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372(71):n71.  https://doi.org/10.1136/bmj.n71  PMID: 33782057 
  14. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919.  https://doi.org/10.1136/bmj.i4919  PMID: 27733354 
  15. Pareek M, Bond M, Shorey J, Seneviratne S, Guy M, White P, et al. Community-based evaluation of immigrant tuberculosis screening using interferon γ release assays and tuberculin skin testing: observational study and economic analysis. Thorax. 2013;68(3):230-9.  https://doi.org/10.1136/thoraxjnl-2011-201542  PMID: 22693179 
  16. Cavany SM, Vynnycky E, Anderson CS, Maguire H, Sandmann F, Thomas HL, et al. Should NICE reconsider the 2016 UK guidelines on TB contact tracing? A cost-effectiveness analysis of contact investigations in London. Thorax. 2019;74(2):185-93.  https://doi.org/10.1136/thoraxjnl-2018-211662  PMID: 30121574 
  17. Capocci SJ, Sewell J, Smith C, Cropley I, Bhagani S, Solamalai A, et al. Cost effectiveness of testing HIV infected individuals for TB in a low TB/HIV setting. J Infect. 2020;81(2):289-96.  https://doi.org/10.1016/j.jinf.2020.05.055  PMID: 32473234 
  18. Jit M, Stagg HR, Aldridge RW, White PJ, Abubakar I, Find and Treat Evaluation Team. Dedicated outreach service for hard to reach patients with tuberculosis in London: observational study and economic evaluation. BMJ. 2011;343(sep13 5):d5376.  https://doi.org/10.1136/bmj.d5376  PMID: 22067473 
  19. Verma G, Chuck AW, Jacobs P. Tuberculosis screening for long-term care: a cost-effectiveness analysis. Int J Tuberc Lung Dis. 2013;17(9):1170-7.  https://doi.org/10.5588/ijtld.12.0934  PMID: 23928166 
  20. Uppal A, Nsengiyumva NP, Signor C, Jean-Louis F, Rochette M, Snowball H, et al. Active screening for tuberculosis in high-incidence Inuit communities in Canada: a cost-effectiveness analysis. CMAJ. 2021;193(43):E1652-9.  https://doi.org/10.1503/cmaj.210447  PMID: 34725112 
  21. Smit GSA, Apers L, Arrazola de Onate W, Beutels P, Dorny P, Forier AM, et al. Cost-effectiveness of screening for active cases of tuberculosis in Flanders, Belgium. Bull World Health Organ. 2017;95(1):27-35.  https://doi.org/10.2471/BLT.16.169383  PMID: 28053362 
  22. Wahedi K, Biddle L, Bozorgmehr K. Cost-effectiveness of targeted screening for active pulmonary tuberculosis among asylum-seekers: A modelling study with screening data from a German federal state (2002-2015). PLoS One. 2020;15(11):e0241852.  https://doi.org/10.1371/journal.pone.0241852  PMID: 33151980 
  23. Goscé L, Girardi E, Allel K, Cirillo DM, Barcellini L, Stancanelli G, et al. Tackling TB in migrants arriving at Europe’s southern border. Int J Infect Dis. 2021;113(Suppl 1):S28-32.  https://doi.org/10.1016/j.ijid.2021.02.103  PMID: 33713814 
  24. McCabe C, Claxton K, Culyer AJ. The NICE cost-effectiveness threshold: what it is and what that means. PharmacoEconomics. 2008;26(9):733-44.  https://doi.org/10.2165/00019053-200826090-00004  PMID: 18767894 
  25. Oxlade O, Schwartzman K, Menzies D. Interferon-gamma release assays and TB screening in high-income countries: a cost-effectiveness analysis. Int J Tuberc Lung Dis. 2007;11(1):16-26. PMID: 17217125 
  26. Dasgupta K, Schwartzman K, Marchand R, Tennenbaum TN, Brassard P, Menzies D. Comparison of cost-effectiveness of tuberculosis screening of close contacts and foreign-born populations. Am J Respir Crit Care Med. 2000;162(6):2079-86.  https://doi.org/10.1164/ajrccm.162.6.2001111  PMID: 11112118 
  27. European Centre for Disease Prevention and Control and European Monitoring Centre for Drugs and Drug Addiction (ECDC and EMCDDA). Public health guidance on active case finding of communicable diseases in prison settings. Stockholm and Lisbon: ECDC and EMCDDA; May 2018. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/Active-case-finding-communicable-diseases-in-prisons.pdf

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