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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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.
