The assessment of eight nucleic acid amplification technologies for the molecular detection of infectious agents in low-resource settings

Nucleic acid amplification technologies (NAATs) are high-performance tools for rapidly and accurately detecting infectious agents. They are widely used in high-income countries to diagnose disease and improve patient care. The complexities associated with test methods, reagents, equipment, quality control and assurance require dedicated laboratories with trained staff, which can exclude their use in low-resource and decentralized healthcare settings. For certain diseases, fully integrated NAAT devices and assays are available for use in environmentally-controlled clinics or emergency rooms where relatively untrained staff can perform testing. However, decentralized settings in many low- and middle-income countries with large burdens of infectious disease are challenged by extreme environments, poor infrastructure, few trained staff and limited financial resources. Therefore, there is an urgent need for low-cost, integrated NAAT tools specifically designed for use in low-resource settings. Two essential components of integrated NAAT tools are: 1) efficient nucleic acid extraction technologies that can work with complex sample types; and 2) robust nucleic acid amplification & detection technologies. In prior work we reported the performance & workflow capacity for the first of these components - nucleic acid extraction technologies. This paper examines several novel nucleic acid amplification & detection technologies for their ability to meet specifications for resource-limited settings. We challenged seven developers of NAAT assays with blinded panels of RNA and/or DNA from several pathogens to evaluate their respective technologies for both diagnostic accuracy and suitability as an essential component for low-cost NAAT. In this exercise, we noted significant differences in performance among these technologies and identify those most promising for potential further development.