Nurses using Xpert Ultra speed tuberculosis diagnosis in children

Childhood tuberculosis care is often centralized in higher-level hospitals, which limits access and delays diagnosis for many children. Eden Ngu and colleagues set out to test a practical alternative: moving rapid molecular testing out of central labs and into primary health centres (PHCs) and hospital wards by training nurses to run the test at the bedside. This was done as part of the TB-Speed project across seven countries. The team focused on the World Health Organization–recommended XpertMTB/RIF Ultra test (referred to as Ultra) performed on nasopharyngeal aspirate (NPA) samples. They explored two settings where decentralizing testing could matter most: PHCs without laboratories, where nurses might provide testing instead of travelling samples to distant labs, and pediatric wards where very sick children with severe pneumonia need fast treatment decisions. The study asked whether nurses could reliably run Ultra using the battery-operated GeneXpert Edge platform, whether results were returned faster, and what nurses thought about taking on this task. The goal was to assess feasibility, performance, and whether in-ward testing could shorten critical diagnostic delays for very sick children.

The researchers worked at 23 PHCs and 15 paediatric wards; nurses were trained to perform Ultra at 9 PHCs and 4 wards while laboratory technicians did testing at the remaining sites. They compared the proportion of samples tested, instances of invalid or error results, TB detection yield, and Turnaround Time (TAT) between sample reception and result at PHC, and between sample collection and result delivery to clinicians in paediatric wards. External Quality Assessment (EQA) and site supervision monitored laboratory quality, and nurses completed a self-administered questionnaire and semi-structured interviews about their experience. Ultra testing was completed in 253/254 (99.6%) and 258/258 (100%) samples for PHC and hospital nurses respectively, versus 895/897 (99.8%) and 874/874 (100%) for laboratory technicians. At PHC, TAT was below 1h30 for 158/252 (62.7%) samples tested by nurses compared with 677/893 (75.8%) by laboratory technicians (p<0.001). In hospitals, Ultra results were available to clinicians within 3h in 201/258 (77.9%) samples when nurses tested, versus 464/874 (53.1%) when laboratory technicians tested (p<0.001). EQA scores below 87.5% were more common for PHC nurses than for PHC laboratory technicians or hospital nurses. Nurses reported technical difficulties, lack of practice and workload as main challenges, and highlighted training and supervision as key facilitators.

The findings show that with focused training and close supervision, nurses can run XpertMTB/RIF Ultra on nasopharyngeal aspirate using GeneXpert Edge and achieve testing coverage comparable to laboratory technicians. Importantly, bringing testing to the point of care reduced the time clinicians had to wait for results in hospital wards, a setting where faster diagnosis can change treatment decisions for very sick children. The study suggests that task-shifting—moving specific laboratory tasks to nurses—can support decentralisation of TB diagnosis, especially in primary health centers without labs, and can provide in-ward testing to shorten delays for severe cases. The research team notes that quality assurance remains essential, since EQA scores under 87.5% were more frequent among PHC nurses, pointing to the need for ongoing support, practice opportunities and supervision. As the first study to assess Xpert Ultra testing by nurses in high tuberculosis burden and low- and middle-income country settings within the TB-Speed project, the results aim to inform context-specific policies and training approaches that could expand timely, reliable TB diagnosis in children.