Uptake and feasibility of task-shifting of Xpert MTB/RIF Ultra testing from laboratory technicians to nurses to increase access and reduce time to results: a multi-country mixed method research
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Abstract
Introduction
Task-shifting of tuberculosis (TB) rapid molecular testing from laboratory technicians to nurses could help decentralizing TB diagnosis at Primary Health Centers (PHC) and allow in-ward testing to shorten treatment decision for very sick patients. We assessed the feasibility of XpertMTB/RIF Ultra (Ultra) testing on nasopharyngeal aspirate (NPA) by nurses in children with presumptive TB at PHCs and in hospitalized children with severe pneumonia within the TB-Speed project in seven countries.
Methods
Of 23 PHCs and 15 paediatric wards, 9 and 4 respectively had nurses trained to perform Ultra using the battery-operated GeneXpert Edge. Laboratory technicians performed the testing in the other sites. We compared proportion of samples tested, invalid or error results, TB detection yield, Turnaround Time (TAT) between sample reception and result at PHC, and between sample collection and result delivery to clinicians in paediatric wards between nurses and laboratory technicians. External Quality Assessment (EQA) and site support supervision assessed performances. Self-administered questionnaire and semi-structured individual interviews assessed nurses’ perceptions.
Results
Ultra was done in 253/254 (99.6%) and 258/258 (100%) samples for PHC and hospital nurses vs 895/897 (99.8%) and 874/874 (100%) for laboratory technicians, respectively. At PHC, the TAT was below 1h30 for 158/252 (62.7%) samples tested by nurses vs 677/893 (75.8%) by laboratory technicians, p<0.001. Ultra results were available to clinicians within 3h in 201/258 (77.9%) samples for nurses vs 464/874 (53.1%) for laboratory technicians in hospitals, p<0.001. EQA results <87.5% was more common for PHC nurses than PHC laboratory technicians or hospital nurses. Technical difficulties, lack of practice and workload were the main challenges, and training and supervision the main facilitators reported by nurses.
Conclusion
Task shifting of Ultra testing from laboratory technicians to nurses under close supervision could support decentralisation of TB diagnosis and shorten time to treatment decision for very sick patients.
Key Messages
What is already known on this topic
Centralisation of childhood tuberculosis cares in many high burden and low middle income countries (LMICs) contribute to the important gap of childhood tuberculosis diagnosis. In 2022, WHO recommended the decentralisation of childhood tuberculosis diagnosis to increase access. The rapid tuberculosis molecular XpertMTB/RIF Ultra test recommended by WHO can be deployed at primary health care level but there is still limited data on its use at this level of care and no data for settings without a laboratory. Another diagnostic challenge is the diagnostic delay, which can be fatal in very sick children. There is no data on in-ward Xpert Ultra testing to shorten diagnostic delays in very sick children.
What this study adds
As part of the TB-Speed operational research in 6 countries, we trained nurses from primary health centres without laboratory to perform Xpert Ultra tests on nasopharyngeal aspirate sample, using the GeneXpert Edge equipment. With close supervision and sufficient training, task-shifting of NPA Xpert Ultra testing from laboratory technicians to nurses was feasible and well accepted.
Similarly, in order to reduce diagnostic delays in very sick children, we trained hospital nurses to perform in-ward Xpert Ultra tests on nasopharyngeal aspirate in 6 countries. Nurses were able to achieve similar performance as laboratory technicians and the time to treatment decision was shorter when Xpert Ultra testing was done by nurses as compared to laboratory technician. To our knowledge this is the first study assessing Xpert Ultra testing by nurses in high tuberculosis burden and LMICs.
How this study might affect research, practice or policy
It is our hope that results from this study will foster the development of content and context specific approach of task-shifting to increase access and quality of healthcare services for TB diagnosis within the same labour force especially in LMICs.
Article activity feed
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This Zenodo record is a permanently preserved version of a PREreview. You can view the complete PREreview at https://prereview.org/reviews/15467372.
1. Summary and Overall Impression
This paper investigates if nurses, rather than laboratory personnel, can effectively conduct Xpert MTB/RIF Ultra tests to identify tuberculosis (TB) in children using nasopharyngeal aspirates. Part of the TB-Speed study, it was conducted in seven countries and examined hospitals as well as primary-health facilities. The aim was to find out whether task-shifting could increase access to TB diagnosis, particularly in locations with few laboratory personnel. The outcomes are encouraging. With comparable TB detection rates as technicians, nurses were able to finish almost all the tests. Tests performed by nurses in hospitals frequently got to doctors …
This Zenodo record is a permanently preserved version of a PREreview. You can view the complete PREreview at https://prereview.org/reviews/15467372.
1. Summary and Overall Impression
This paper investigates if nurses, rather than laboratory personnel, can effectively conduct Xpert MTB/RIF Ultra tests to identify tuberculosis (TB) in children using nasopharyngeal aspirates. Part of the TB-Speed study, it was conducted in seven countries and examined hospitals as well as primary-health facilities. The aim was to find out whether task-shifting could increase access to TB diagnosis, particularly in locations with few laboratory personnel. The outcomes are encouraging. With comparable TB detection rates as technicians, nurses were able to finish almost all the tests. Tests performed by nurses in hospitals frequently got to doctors faster, hence accelerating treatment choices. Though they also encountered difficulties such sporadic technical problems, less experience in certain environments, and more work, nurses said training and support helped them to feel more secure performing the exams. All things considered, this is a pertinent and timely research that provides significant proof to back decentralizing TB treatment. It indicates that in environments with constrained laboratory resources, task-shifting may be a feasible answer. How sites were selected is one area that might be bettered as the task wasn't random and other variables could have affected the outcomes. Furthermore, a little additional information on the analysis of the qualitative results would help to support the research.
2. Section-by-Section Review
Abstract
Major issues:
Not enough about the qualitative side: Since this is a mixed-methods study, it would be good to highlight at least one insight from the interviews or surveys with nurses. Right now, the abstract leans heavily on the numbers and gives very little attention to the nurses' perspectives.
Minor issues:
Inconsistent naming of the test: The test is called "Ultra" in some places and "Xpert Ultra" in others. It would be clearer to use "Xpert MTB/RIF Ultra" the first time and then stick to one version afterward.
Introduction
Major issues
The introduction does a good job explaining the background and rationale for decentralizing TB diagnosis, but it could more clearly state the research question or main objective of the study. Right now, the goal is implied but not directly spelled out in a single, clear sentence.
Minor issues
There's a sentence that says: "Another use for G1 and reason justifying training of nurses..." — it's a bit clunky. A smoother version could be: "Another reason to train nurses on the G1 is to make testing available on pediatric wards outside of lab hours."
Methods
Major Issue
The methods describe the data sources and study activities in good detail, but it's not entirely clear how sites were selected for nurse-led vs. technician-led testing. Since site selection can strongly influence outcomes, more information about this process—or a clearer statement that it was not randomized—would help readers assess potential bias.
Minor Issue
The description of the performance scoring system (site supervision indicators) is a bit hard to follow at first. It would help to briefly explain how the overall scores were calculated or interpreted before diving into individual indicators and Likert scale values.
Results
Major Issue
While the results are comprehensive, there's a lot of detail presented without clear summarizing takeaways. The section could benefit from a few short sentences highlighting the main comparisons—especially where nurse-led testing outperformed or underperformed technician-led testing—to help the reader quickly grasp what matters most.
Minor Issue
Some transitions between paragraphs or result categories (e.g., from test uptake to quality assurance to nurse perceptions) feel abrupt. Adding brief connecting phrases—like "In terms of quality control…" or "When looking at nurses' experiences…"—would improve the flow and help readers follow the structure more easily.
Discussion and Conclusion
Major Issue
The discussion highlights the study's positive outcomes and practical implications well, but it tends to downplay the limitations. While it briefly mentions site selection bias and support conditions, it doesn't fully explore how these may have impacted the findings or the generalizability to real-world settings without external support. A deeper reflection on these issues would strengthen the credibility of the conclusions.
Minor Issue
There are a few instances of repetitive phrases, like variations of "training and supervision are key" mentioned multiple times. Slightly streamlining or rephrasing these would make the discussion more concise and avoid redundancy.
Competing interests
The author declares that they have no competing interests.
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Hemant Shewade
Review 2: "Uptake and Feasibility of Task-Shifting of Xpert MTB/RIF Ultra Testing from Laboratory Technicians to Nurses to Increase Access and Reduce Time to Results: A Multi-Country Mixed Method Research"
Reviewers highlighted the study’s practical implications for improving TB diagnosis but noted limitations in qualitative analysis and low positivity rates.
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Stephanie Law
Review 1: "Uptake and Feasibility of Task-Shifting of Xpert MTB/RIF Ultra Testing from Laboratory Technicians to Nurses to Increase Access and Reduce Time to Results: A Multi-Country Mixed Method Research"
Reviewers highlighted the study’s practical implications for improving TB diagnosis but noted limitations in qualitative analysis and low positivity rates.
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Strength of evidence
Reviewer(s): S Law (McGill University) | 📗📗📗📗◻️
H Shewade (International Union Against Tuberculosis and Lung Disease) | 📒📒📒◻️◻️ -
