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Lu J, Butler-Wu SM. Home and Clinical Laboratory Improvement Amendments-Waived Testing for Infectious Diseases-How Do These Fit in the Testing Landscape? Clin Lab Med 2024; 44:13-21. [PMID: 38280794 DOI: 10.1016/j.cll.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Though testing for infectious diseases has long been performed in traditional clincial laboratory settings, more widespread availability of waived testing is expanding accessibility of patients to rapid test results. This is being further expanded to home testing. Nevertheless, with this greater democratization and availability of clinical testing there are important limitations that need to be balanced. In this article, we review the current test landscape for infectious diseases waived testing and opportunities for assuring optimal quality testing.
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Affiliation(s)
- Jacky Lu
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA
| | - Susan M Butler-Wu
- Department of Pathology, Keck School of Medicine of the University of Southern California, HMR 211, 2011 Zonal Avenue, Los Angeles, CA 90033, USA.
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2
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Shirley JD, Bennett SA, Binnicker MJ. Current regulatory landscape for viral point-of-care testing in the United States. J Clin Virol 2023; 164:105492. [PMID: 37210882 DOI: 10.1016/j.jcv.2023.105492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/12/2023] [Accepted: 05/13/2023] [Indexed: 05/23/2023]
Abstract
Historically, the diagnosis of viral infections has been accomplished using a combination of laboratory-based methods, including culture, serology, antigen-based tests, and molecular (e.g., real-time PCR) assays. Although these methods provide an accurate way to detect viral pathogens, testing in a centralized laboratory may delay results, which could impact patient diagnosis and management. Point-of-care tests, including antigen- and molecular-based assays, have been developed to assist with the timely diagnosis of several viral infections, such as influenza, respiratory syncytial virus, and COVID-19. Despite the ability of point-of-care tests to provide rapid results (i.e., <30 min), there are issues to consider prior to their routine use, including test performance and specific regulatory requirements. This review will provide a summary of the regulatory landscape of point-of-care tests for viral infections in the United States, and address important considerations such as site certification, training and inspection readiness.
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Affiliation(s)
- Joshua D Shirley
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, United States
| | - Shannon A Bennett
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, United States
| | - Matthew J Binnicker
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, United States.
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3
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Morehouse ZP, Chance N, Ryan GL, Proctor CM, Nash RJ. A narrative review of nine commercial point of care influenza tests: an overview of methods, benefits, and drawbacks to rapid influenza diagnostic testing. J Osteopath Med 2023; 123:39-47. [PMID: 35977624 DOI: 10.1515/jom-2022-0065] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/15/2022] [Indexed: 12/27/2022]
Abstract
CONTEXT Rapid influenza diagnostic tests (RIDTs) are becoming increasingly accurate, available, and reliable as the first line of testing when suspecting influenza infections, although the global burden of influenza infections remains high. Rapid diagnosis of influenza infections has been shown to reduce improper or delayed treatment and to increase access to diagnostic measures in public health, primary care, and hospital-based settings. OBJECTIVES As the use of RIDTs continues to expand in all healthcare settings, there is a multitude of molecular techniques being employed by these various testing platforms. With this in mind, we compare the sensitivity, specificity, and time to diagnosis for nine highly utilized commercial RIDTs. METHODS Nine commercially available RIDTs were identified from the US Centers for Disease Control and Prevention (CDC) website, which were also referenced on PubMed by name within the title or abstract of peer-reviewed publications examining the sensitivity and specificity of each test against a minimum of three influenza A virus (IAV) strains as well as seasonal influenza B virus (IBV). Data from the peer-reviewed publications and manufacturers' websites were combined to discuss the sensitivity, specify, and time to diagnosis associated with each RIDT. RESULTS The sensitivity and specificity across the examined RIDTs were greater than 85.0% for both IAV and IBV across all platforms, with the reverse transcriptase-polymerase chain reaction (RT-PCR) assays maintaining sensitivity and specificity greater than 95.0% for all viruses tested. However, the RT-PCR platforms were the longest in time to diagnosis when compared to the other molecular methods utilized in the examined RIDTs. CONCLUSIONS Herein, we discussed the benefits and limitations of nine commercially available RIDTs and the molecular techniques upon which they are based, showing the relative accuracy and speed of each test for IAV and IBV detection as reported by the peer-reviewed literature and commercial manufacturers.
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Affiliation(s)
- Zachary P Morehouse
- Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA.,Omni International, Inc, A PerkinElmer Company, Kennesaw, GA, USA.,Jeevan Biosciences, Inc, Tucker, GA, USA
| | - Nathan Chance
- Kirksville College of Osteopathic Medicine, A.T. Still University, Kirksville, MO, USA
| | | | | | - Rodney J Nash
- Omni International, Inc, A PerkinElmer Company, Kennesaw, GA, USA.,Jeevan Biosciences, Inc, Tucker, GA, USA.,Department of Biology, Georgia State University, Atlanta, GA, USA
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Monocyte distribution width as a pragmatic screen for SARS-CoV-2 or influenza infection. Sci Rep 2022; 12:21528. [PMID: 36513693 PMCID: PMC9745720 DOI: 10.1038/s41598-022-24978-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 11/23/2022] [Indexed: 12/15/2022] Open
Abstract
Monocyte distribution width (MDW) is a novel marker of monocyte activation, which is known to occur in the immune response to viral pathogens. Our objective was to determine the performance of MDW and other leukocyte parameters as screening tests for SARS-CoV-2 and influenza infection. This was a prospective cohort analysis of adult patients who underwent complete blood count (CBC) and SARS-CoV-2 or influenza testing in an Emergency Department (ED) between January 2020 and July 2021. The primary outcome was SARS-CoV-2 or influenza infection. Secondary outcomes were measures of severity of illness including inpatient hospitalization, critical care admission, hospital lengths of stay and mortality. Descriptive statistics and test performance measures were evaluated for monocyte percentage, MDW, white blood cell (WBC) count, and neutrophil to lymphocyte ratio (NLR). 3,425 ED patient visits were included. SARS-CoV-2 testing was performed during 1,922 visits with a positivity rate of 5.4%; influenza testing was performed during 2,090 with a positivity rate of 2.3%. MDW was elevated in patients with SARS-Cov-2 (median 23.0U; IQR 20.5-25.1) or influenza (median 24.1U; IQR 22.0-26.9) infection, as compared to those without (18.9U; IQR 17.4-20.7 and 19.1U; 17.4-21, respectively, P < 0.001). Monocyte percentage, WBC and NLR values were within normal range in patients testing positive for either virus. MDW identified SARS-CoV-2 and influenza positive patients with an area under the curve (AUC) of 0.83 (95% CI 0.79-0.86) and 0.83 (95% CI 0.77-0.88), respectively. At the accepted cut-off value of 20U for MDW, sensitivities were 83.7% (95% CI 76.5-90.8%) for SARS-CoV-2 and 89.6% (95% CI 80.9-98.2%) for influenza, compared to sensitivities below 45% for monocyte percentage, WBC and NLR. MDW negative predictive values were 98.6% (95% CI 98.0-99.3%) and 99.6% (95% CI 99.3-100.0%) respectively for SARS-CoV-2 and influenza. Monocyte Distribution Width (MDW), available as part of a routine complete blood count (CBC) with differential, may be a useful indicator of SARS-CoV-2 or influenza infection.
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Shihabuddin BS, Faron ML, Relich RF, Van Heukelom P, Mayne D, Staat MA, Selvarangan R, Hueschen LA, Wolk DM, House S, Harnett G, McGann K, Steele MT, Romero JR, Arms J, Lander O, Loeffelholz M, Strouts F, Cohen D. Cepheid Xpert Xpress Flu/RSV evaluation performed by minimally trained non-laboratory operators in a CLIA-waived environment. Diagn Microbiol Infect Dis 2022; 104:115764. [PMID: 35917666 PMCID: PMC9271353 DOI: 10.1016/j.diagmicrobio.2022.115764] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/27/2022] [Accepted: 07/05/2022] [Indexed: 11/27/2022]
Abstract
The COVID-19 pandemic highlighted the significance of readily available and easily performed viral testing for surveillance during future infectious pandemics. The objectives of this study were: to assess the performance of the Xpert Xpress Flu and/or RSV test, a multiplex PCR assay for detecting influenza A and B virus and respiratory syncytial virus nucleic acids in respiratory tract specimens, relative to the Quidel Lyra Influenza A+B assay and the Prodesse ProFlu+ assay, and the system's ease of use by minimally trained operators. Overall, the Xpert Xpress Flu/RSV test demonstrated a high positive and negative percent agreement with the comparator assays, and was easy to use and interpret results, based on the operators’ feedback. We concluded that the Xpert Xpress Flu/RSV test is sensitive, specific, and easy to use for the diagnosis of influenza and RSV by minimally trained operators and can be a valuable tool in future infectious clusters or pandemics.
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Patel P, Laurich VM, Smith S, Sturm J. Point-of-Care Influenza Testing in the Pediatric Emergency Department. Pediatr Emerg Care 2020; 36:515-518. [PMID: 33065674 DOI: 10.1097/pec.0000000000002250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To see what the impact of introducing a rapid polymerase chain reaction-based influenza test has on length of stay (LOS) in emergency department, use of imaging, serum or urine testing, antibiotic use, and antiviral use. METHODS Audit of electronic medical health records was performed for all emergency department visits from 2014 to 2018 between November and March, which was defined as peak flu season. Patients were included if they were between 3 months and 18 years of age, presented during peak flu season, and were tested for influenza. The pre-point of care (POC) period was defined as November through March of 2014 to 2017 which was compared with the post-POC group which was defined as November through March of 2017 to 2018. RESULTS Patients tested for influenza in the pre-POC period were more likely to have complete blood count testing (44.7% vs 25.6% P < 0.01), more likely to have blood cultures performed (30% vs 16.3%, P < 0.01), more likely to have urine testing performed (21.5% vs 12.2%, P < 0.01), and more likely to have a chest radiograph completed (47.5% vs 34.4%, P < 0.01). There was no significant difference in rates of antibiotics used. There was increased rates of oseltamivir used in the post-POC period (21.2% vs 13.3%, P < 0.05. The median LOS decreased from 239 minutes in the pre-POC period to 232 minutes in the post-POC period (P < 0.05). CONCLUSIONS With the introduction of a polymerase chain reaction-based point-of-care influenza test, there were overall decreased rates of invasive blood work, urine studies, and imaging, and median LOS. There was also increased antiviral administration.
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Affiliation(s)
- Prina Patel
- From the Department of Pediatric Emergency Medicine, Connecticut Children's Medical Center, Hartford, CT
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Young S, Phillips J, Griego-Fullbright C, Wagner A, Jim P, Chaudhuri S, Tang S, Sickler J. Molecular point-of-care testing for influenza A/B and respiratory syncytial virus: comparison of workflow parameters for the ID Now and cobas Liat systems. J Clin Pathol 2019; 73:328-334. [PMID: 31826935 PMCID: PMC7279563 DOI: 10.1136/jclinpath-2019-206242] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 11/21/2022]
Abstract
Aims Point-of-care (POC) tests for influenza and respiratory syncytial virus (RSV) offer the potential to improve patient management and antimicrobial stewardship. Studies have focused on performance; however, no workflow assessments have been published comparing POC molecular tests. This study compared the Liat and ID Now systems workflow, to assist end-users in selecting an influenza and/or RSV POC test. Methods Staffing, walk-away and turnaround time (TAT) of the Liat and ID Now systems were determined using 40 nasopharyngeal samples, positive for influenza or RSV. The ID Now system requires separate tests for influenza and RSV, so parallel (two instruments) and sequential (one instrument) workflows were evaluated. Results The ID Now ranged 4.1–6.2 min for staffing, 1.9–10.9 min for walk-away and 6.4–15.8 min for TAT per result. The Liat ranged 1.1–1.8 min for staffing, 20.0–20.5 min for walk-away and 21.3–22.0 min for TAT. Mean walk-away time comprised 38.0% (influenza positive) and 68.1% (influenza negative) of TAT for ID Now and 93.7% (influenza/RSV) for Liat. The ID Now parallel workflow resulted in medians of 5.9 min for staffing, 9.7 min for walk-away and 15.6 min for TAT. Assuming prevalence of 20% influenza and 20% RSV, the ID Now sequential workflow resulted in medians of 9.4 min for staffing, 17.4 min for walk-away, and 27.1 min for TAT. Conclusions The ID Now and Liat systems offer different workflow characteristics. Key considerations for implementation include value of both influenza and RSV results, clinical setting, staffing capacity, and instrument(s) placement.
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Affiliation(s)
- Stephen Young
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA .,TriCore Reference Laboratories, Albuquerque, New Mexico, USA
| | | | | | - Aaron Wagner
- TriCore Reference Laboratories, Albuquerque, New Mexico, USA
| | - Patricia Jim
- TriCore Reference Laboratories, Albuquerque, New Mexico, USA
| | | | - Shaowu Tang
- Roche Molecular Systems Inc, Pleasanton, California, USA
| | - Joanna Sickler
- Roche Molecular Systems Inc, Pleasanton, California, USA
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Yoo SJ, Shim HS, Yoon S, Moon HW. Evaluation of high-throughput digital lateral flow immunoassays for the detection of influenza A/B viruses from clinical swab samples. J Med Virol 2019; 92:1040-1046. [PMID: 31696947 DOI: 10.1002/jmv.25626] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 11/05/2019] [Indexed: 12/24/2022]
Abstract
We evaluated the performance of new high-throughput digital lateral flow immunoassays (LFIAs) detecting influenza antigens and compared them with those of the widely used digital LFIA and the rapid nucleic acid amplification test (NAAT). We tested 199 clinical nasopharyngeal (nasal) swab samples using three LFIA tests (BD Veritor Plus, STANDARD F Influenza A/B FIA, and ichroma TRIAS) and the rapid NAAT (ID NOW Influenza A & B2). Agreements and clinical performances (sensitivity and specificity) were evaluated based on the results of reverse transcriptase-polymerase chain reaction (RT-PCR) and verification panel. The agreement of each test with RT-PCR was moderate to almost perfect. The sensitivity of ID NOW was significantly higher than that of LFIAs (P = .0005, .0044, and .0026 for influenza A and P = .0044, .0026, and .0044 for influenza B, respectively). The specificities were not significantly different between the four tests (P > .05). However, the reference panel suggests that ichroma TRIAS test is more sensitive than the other two LFIA tests. All three LFIA assays performed similarly with no false positives against influenza A. For influenza B, ichroma TRIAS had 2 of 166 false positives whereas there were no false positives for the other two LFIA tests. Influenza antigen digital LFIAs have advantages in terms of the workflow when simultaneous tests are required. Rapid NAAT has higher sensitivity, while new antigen LFIAs are efficient and high-throughput. It is recommended that users select appropriate methods and algorithms according to the number of specimens and laboratory conditions in each clinical laboratory.
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Affiliation(s)
- Soo J Yoo
- Department of Laboratory Medicine, Sanggye Paik Hospital, Inje University, Seoul, Korea
| | - Hee S Shim
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Sumi Yoon
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Hee-Won Moon
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea
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Abstract
The timely and accurate diagnosis of respiratory virus infections has the potential to optimize downstream (posttesting) use of limited health care resources, including antibiotics, antivirals, ancillary testing, and inpatient and emergency department beds. Cost-effective algorithms for respiratory virus testing must take into consideration numerous factors, including which patients should be tested, what testing should be performed (for example, antigen testing versus reverse transcription-PCR testing or influenza A/B testing versus testing with a comprehensive respiratory virus panel), and the turnaround time necessary to achieve the desired posttesting outcomes. Despite the clinical impact of respiratory virus infections, the cost-effectiveness of respiratory virus testing is incompletely understood. In this article, we review the literature pertaining to the cost-effectiveness of respiratory virus testing in pediatric and adult patient populations, in emergency department, outpatient, and inpatient clinical settings. Furthermore, we consider the cost-effectiveness of a variety of testing methods, including rapid antigen tests, direct fluorescent antibody assays, and nucleic acid amplification tests.
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