Operationalization of COVID-19 Rapid Diagnosis Using&nbsp;Xpert®&nbsp;Xpress SARS CoV-2 Assay in Resource-Limited Settings: Early Implementation Lessons From Uganda
Authors: Nsawotebba Andrew , Ibanda Ivan , Ssewanyana Isaac , Bagaya Bernard Ssentalo , Nyombi Abdunoor , Kagirita Atek , Mujuni Dennis , Tugumisirize Didas , Majwala Robert Kaos , Ocen Francis , Kabugo Joel , Adam Isa , Wekiya Enock , Munduku Benoni , Linda Lillian , Otita Morgan , Kalyesubula-Kibuuka Simon , Okiira Christopher , Kigozi Edgar , Ogwok Patrick , Joloba Moses Lutakoome , Nabadda Susan , Ssengooba Willy 
Published: January 2021

Abstract
Introduction: The novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) that causes COVID-19 disease is a global challenge. Several countries have adopted testing, isolation, and tracing strategy towards the control of the COVID-19 pandemic, but access to rapid and accurate testing is still a global challenge. The conventional PCR – based assay is the most commonly used test yet it has huge costs, infrastructural, and procurement logistical challenges. The Xpert® Xpress SARS-CoV-2 test is an automated in – vitro diagnostic test for the qualitative detection of nucleic acid from SARS-CoV-2 within a turnaround time of 60 minutes on the widely used GeneXpert Dx Instrument Systems. Here we document the best practices and challenges encountered with the operationalization of Xpert® Xpress SARS-CoV-2 testing in a resource-limited setting.Materials and Methods: The Xpert® Xpress SARS-CoV-2 implementation followed an operational work plan that included; Laboratory COVID-19 policy and planning, situational analysis of the Laboratory network, country Xpert® Xpress SARS-CoV-2 assay verification, and rollout at Mutukula Port Health Laboratory. The Laboratory strategy was based on a set of six objectives; conducting infrastructural modifications, building a strong COVID-19 testing capacity, developing robust Laboratory Quality and Information Management Systems, establishing a Bio-risk management and Bio-banking capacity.Results: The Xpert® Xpress SARS-CoV-2 testing implementation team that was appointed by the Ministry of Health (Uganda) successfully established the Xpert® Xpress SARS-CoV-2 testing Laboratory at Mutukula border in Uganda. As of 9th July 2020, this Laboratory had tested a total of 10,990 samples with a median turnaround time of 75 (IQR: 60 – 75) minutes for samples of persons entering through Mutukula Land Point of Entry as compared to the median TAT 1980 minutes before it was established. The laboratory had only one discordant result out of 20 panels in the inter-laboratory comparison retesting program.Conclusions: Implementation of Xpert® Xpress SARS-CoV-2 testing for rapid diagnosis of COVID-19 is feasible and significantly reduces the long TAT observed with conventional RT-PCR based testing. The operationalization of the Xpert® Xpress SARS-CoV-2 testing is largely dependent on the initial planning, adequacy of resources, and preparedness within the laboratory network. Challenges include; the difference in approaches to COVID-19 response, the attitude of truck-drivers/persons on Infection Prevention and Control measures, language barrier, and waste management issues.