Abstract
Background Rapid, cost-effective diagnosis of acute respiratory infections is now possible using multi-viral rapid-antigen point-of-care tests (MVRA-POCTs) with high sensitivity and specificity. These offer a realistic alternative to polymerase chain reaction tests in primary care. However, evidence of acceptability and clinical utility in this setting is limited.
Aim To pilot feasibility of integrating MVRA-POCTs into routine primary care, and investigate patient and clinician attitudes and behaviours.
Design & setting A prospective mixed-methods pilot study in seven New Zealand (NZ) primary care clinics during winter 2023.
Method Patients with acute respiratory symptoms received an MVRA-POCT (instead of COVID-19-only). Outcomes and acceptability were assessed via audits of electronic medical records, clinician and patient surveys, and interviews and focus groups with patients and clinic staff.
Results Swab results were recorded from a demographically diverse cohort of 1754 patients; 14% tested positive for any virus (n = 246/1754). All clinicians and most patients surveyed positively evaluated the test. All clinicians incorporated the MVRA-POCT into practice and found it useful. In total, 63% of prescribers (n = 26/41) reported results influenced antibiotic prescribing; 12% (n = 5/41) supported decisions about secondary care referrals for 12% (n = 5/41). All patient responders who tested positive (n = 39) and most testing negative (n = 172/180, 96%) would like the MVRA-POCT in future. Patients testing positive self-reported as more likely to follow non-pharmaceutical interventions to reduce transmission compared with those testing negative.
Conclusion MVRA-POCTs were well-accepted and readily incorporated into practice. Routine integration into primary care could potentially improve management of common respiratory illnesses and promote patient behaviour change to reduce transmission.
How this fits in
Evidence of acceptability and utility of multi-viral rapid-antigen point-of-care tests (MVRA-POCTs) in primary care settings is limited, but previous research shows that rapid point-of-care systems can be useful in guiding patient care decisions. We piloted use of MVRA-POCTs in seven New Zealand (NZ) primary care clinics during winter in 2023 to assess acceptability, feasibility, and impact on patient and clinician behaviour. Clinicians reported these tests fitted readily into routine practice, aided diagnosis, and decreased antibiotic prescriptions and further investigations, while patients valued the additional diagnostic information and reported increased implementation of non-pharmaceutical measures to reduce disease spread. We conclude that these tests could be a valuable addition to primary care in New Zealand.
Introduction
Rapid-antigen point-of-care tests (POCTs) for respiratory viruses have become an accurate alternative to polymerase chain reaction (PCR) tests1 and can be integrated alongside PCRs in primary care settings.2 Routine use of POCTs for COVID-19 diagnosis means they are familiar to community members and practitioners, and their rapid results and easy use enable timely implementation of non-pharmaceutical interventions (NPIs) such as isolation and mask-wearing.3 They are also routinely used in primary care before respiratory consultations.4,5
Hospital emergency departments in New Zealand (NZ) and elsewhere can currently use new, rapid, ‘tabletop’ PCR tests for influenza, COVID-19, and respiratory syncytial virus (RSV). Recent research suggests using rapid PCR systems in primary care may lead to behavioural change such as implementation of NPIs, timely and appropriate access to antivirals, and decreased prescription of inappropriate antibiotics.6–8 However, the cost and resources required limit their practicality in primary care.6,7 Newer multi-viral rapid-antigen point-of-care tests (MVRA-POCTs) report sensitivity and specificity at above 97% for four available viruses (RSV, COVID-19, influenza A and B),9 and offer rapid, cost-effective diagnosis of these significant acute respiratory presentations in the primary care setting. Population awareness of different respiratory viruses such as influenza and RSV has also recently increased: for example, it was widely reported in NZ that in 2020–2021 there was negligible circulating influenza,10 and that a peak of RSV occurred in 2021.11
Given the recent development and availability of accurate MVRA-POCTs for the most serious respiratory viruses, it is an appropriate time to explore targeted adoption and integration of such tests into primary care. This pilot study tested the acceptability and utility of MVRA-POCTs in routine primary care settings in NZ during the winter of 2023 (before they were publicly available for purchase) and explored whether these tests could potentially lead to changes in clinician and patient behaviours, enabling more rapid, accurate, and appropriate diagnosis and management of acute respiratory infections. If so, use of these tests could support a decrease in spread and severity of the more severe infections of COVID-19, influenza, and RSV.
Method
Study design and settings
We recruited three primary care practices representing seven clinics in Wellington, NZ, in winter 2023 for our mixed-methods pilot study: (a) a single general practice in a predominantly (85%) European suburb of relatively high socioeconomic status; (b) a central-city ‘walk-in’ urgent care centre staffed out-of-hours by a roster of local GPs; and (c) a multi-centre general practice with five clinics, including a youth clinic, located in an area of higher deprivation and with higher percentages of indigenous Māori (23%) and Pacific peoples (26%). The urgent care centre operated a separate respiratory clinic, while the GP sites varied between using a separate space or seeing patients with respiratory infections as usual with appropriate masking and ventilation.
The often acute nature of respiratory illnesses, and limited availability of same-day appointments with one’s own GP, meant the urgent care centre saw many more respiratory presentations (often >100 per day) than the GP clinics. The greater focus of the pilot on urgent care was intentional to take advantage of greater throughput of acute presentations within the available timeframe (that is, mid- to end of the flu season). The six GP clinics were included to identify potentially different feasibility and acceptability issues across a range of practice settings.
Figure 1 summarises the overall study design. Patients presenting with acute respiratory illnesses who met inclusion criteria were offered the MVRA-POCT via an anterior nares nasal swab (2 cm insertion, in line with manufacturer’s instructions).9 This was done at face-to-face triage in urgent care, and as part of the consultation in general practice (after telephone triage). The definition of acute respiratory illness was kept broad, and included both upper and lower respiratory tract illnesses, pharyngitis, sinus, and otitis media, at the swabbing clinician’s discretion. Basic clinical observations (heart rate, blood oxygen saturations, and temperature) and patient demographics for patients who received the MVRA-POCT were recorded in the patient management system (PMS). Usual care was followed.
The flowchart presents the study design for collecting patient, healthcare worker and patient management system data related to MVRA-POCT use in acute respiratory illness.The main patient pathway begins with patients and healthcare workers being informed of the study. Patients are then triaged as having acute respiratory illness (ARI), receive multi-viral rapid-antigen point-of-care testing (MVRA-POCT), and then receive standard clinical care. After this, patients consent for researchers to contact them.Several data-collection pathways then feed into a final results box: A survey is sent to patients. This pathway contributes directly to the final study outputs as survey results from patients and healthcare workers. Some patients who receive the survey then agree to interview, leading to a patient qualitative interview. This pathway contributes to the final study outputs as qualitative interviews with patients and healthcare workers. A survey is sent to healthcare workers (HCW). This also contributes directly to the final study outputs as survey results. Some healthcare workers proceed to an HCW qualitative interview, which contributes to the qualitative interview results. A separate process shows that a query is run on the patient management system (PMS). The resulting data are de-identified and then analysed, contributing to the final study outputs as disease characteristics from PMS data.The final output box lists three categories of study data: 1) Survey results from patients and healthcare workers. 2) Qualitative interviews with patients and healthcare workers. 3) Disease characteristics extracted from the patient management system.Overall, the diagram shows that the study combines clinical pathway information, patient and healthcare worker survey data, patient and healthcare worker interview data, and de-identified patient management system data to generate the final study results.
All swabbed patients who consented to being contacted by the study team were invited to participate in an anonymous online survey (Supplementary Box 1). A separate survey was sent to clinic staff at the conclusion of the study (Supplementary Box 2). Standard Likert scales were used, with optional free-text responses. A significant amount of rich qualitative comments entered into free-text fields was retrieved for separate thematic analysis.
The free-text survey data were supplemented by semi-structured follow-up interviews (phone and online) with a diverse mix of interested patient participants (see Table 1), recruited using a purposive iterative sampling approach. Sufficient information power was reached after talking to 15 individuals.
Interested staff and clinical leaders at each provider organisation attended a face-to-face group feedback session at the conclusion of the study, where they received a summary of study findings. Discussions were audio-recorded.
Patient participants
Inclusion criteria were acute in-person consultation-seeking patients with symptoms consistent with a respiratory illness. After feedback from clinicians and patients, the initial age restriction of ≥18 years was expanded (with ethical approval) to include all ages.
Point-of-care test
The MVRA-POCT is an immunochromatographic membrane assay with three independent pads containing detector antibodies conjugated to dye, for detection of nucleocapsid antigens. It is designed for self-testing, and has Therapeutic Goods Approval in NZ and Australia, and an advertised sensitivity and specificity of >97% for each of the four viruses.9 These tests were purchased by the research team; the supplier had no input into or financial contribution to this study.
Data analysis
Clinical data analysis
Anonymised data for all patients who received the MVRA-POCT were included in an audit-like activity using the PMS software at the end of the study to ascertain: patient demographics (age, sex, ethnic group); number of positive or negative tests; which viruses were diagnosed in which demographics; and basic clinical observations. Individual patient notes were not accessed. Data were tabulated and means and standard deviations calculated in Microsoft Excel.
Quantitative survey data analysis
Survey data were collected in Qualtrics, and analyses were performed using SPSS Statistics (version 29.0). Significance testing to investigate between group differences in survey responses was conducted using two-sample t-tests.
Qualitative data analysis
Two experienced qualitative researchers developed a simplified thematic coding framework based on the Theoretical Framework of Acceptability and the Theoretical Domains Framework.12 Semi-structured interview and survey free-text responses were incorporated into the framework using the qualitative software package, NVivo (version R14.23.3), with relevant points raised spontaneously by interviewees or survey responders subsequently added to the analysis as part of an iterative coding process. Any disagreements were discussed to achieve consensus. Because these data were complementary to the clinical and survey data, the thematic analysis has not been reported separately; representative quotes are included as relevant in the Results.
Results
Swab results and survey and interview participation
From mid-July 2023 to end-October 2023, a total of 1850 patients aged 0–87 years were swabbed with the MVRA-POCTs. Of the 1754 with a result recorded, 14% were positive (n = 246/1754). In n = 96/1850 cases, taking of a swab was recorded, but results were not entered, and therefore could not be included in analysis. Patient demographics are recorded in Table 2.
Of the 1850 patients tested, 295 initiated and 227 completed the survey (Table 1 shows characteristics). Sixty-eight patients began the survey but did not meet inclusion criteria or provided insufficient data for results to be included (see Supplementary Tables S1 and S2 for full results). Fifty-nine provided additional free-text comments. Fifteen patients participated in follow-up interviews.
Fifty-three clinic staff answered the survey (38 GPs, three urgent care physicians, 10 nurses, one nurse practitioner, and one receptionist). The majority (n = 42) were from the urgent care clinic; only staff working in the respiratory area of this clinic were eligible for this survey.
Feasibility, acceptability, and utility
When responding to survey questions, clinicians were asked to consider the majority of patients they saw who were eligible for this study. Responses showed that the MVRA-POCT integrated well into patient care in all pilot sites (Figure 2). All clinicians who responded (n = 52) reported that they incorporated MVRA-POCT results into some aspect of their clinical practice, that they were useful all or most of the time, and that the tests would be useful in the future. Consultation time was perceived to have sped up or not changed by n = 44/50 (88%) responders. Focus groups indicated that particularly in urgent care and youth clinics, swabbing in nurse triage provided opportunity for results to be immediately incorporated into patient education and management.
The horizontal bar chart presents clinician survey responses on the acceptability and clinical utility of MVRA-POCT. Responses are shown as percentages, with green bars representing positive change and pink bars representing no change.Most survey items show positive responses from clinicians. The highest positive responses were: Was accepted by “all” or “most” patients: 100% positive change. Would be useful in their medical centre: 100% positive change. Was used in advice given to patients: 94% positive change. Was useful for clinical practice “all” or “most” of the time: 84% positive change.For clinical decision-making, 66% of clinicians reported that MVRA-POCT influenced decisions around antibiotic prescribing.Two items showed both positive change and no change responses: Sped up the consult, or no change to consult time: 46% reported positive change and 42% reported no change. Might change their view about antivirals for influenza, yes or not sure: 41% reported positive change and 41% reported no change.The lowest positive response was for supported decision-making about referrals to secondary care, at 12%.Overall, the chart indicates that clinicians reported strong acceptability and perceived usefulness of MVRA-POCT, particularly for patient acceptability, patient advice and future use in medical centres. The reported effect was lower for referrals to secondary care.
Clinicians also reported (in survey responses and focus groups) that the MVRA-POCT was well-accepted by patients (Table 3):
‘People … like to know what they have.’ (Clinician feedback session C)
‘Winter … it was a nice way to … fast track … the quick swab.’ (Clinician feedback session C)
Reasons given by clinicians for patients declining the MVRA-POCTs included a recent self-swab (n = 7/10) and discomfort (n = 3/10). Some were initially reluctant but became willing when they realised the MVRA-POCT tested for other viruses besides COVID-19. ‘I think a lot of people were over COVID but as soon as you explained a bit more, they got really into it’ (Clinician feedback session B). Most patients surveyed felt it was important to know which virus they had. All patient responders who tested positive (n = 39) and most testing negative (n = 172/180, 96%) reported they were likely to have the MVRA-POCT done in the future if offered it (Table 3).
Clinicians did note that: ‘... swabbing children is slightly more invasive and tricky, so the acceptability might be a bit less’ (Clinician feedback session C). However, qualitative data indicated that patients thought disease identification in the young, who have frequent infections, was especially useful as it helped with decisions around school and day-care attendance:
‘If my kid had RSV, I would not send them to school or day-care having seen what it does to kids.’ (Patient interview; B151)
‘I am a primary school principal, and these tests would be very helpful to stop the spread of infection.’ (Patient survey; free-text response)
Patient survey responses rated the potential acceptability and utility of using MVRA-POCTs at home very highly, as also reflected in free-text comments and interviews:
‘There’s such pressure for people to work, so babies and young children end up at day-care, with snotty noses and unwell at times, and it would be really good to be able to swab them at home.’ (Patient interview; B107)
However, clinicians gave mixed responses to the idea of home testing, with some expressing concern that patients with severe disease may not seek review appropriately:
‘I wonder if there is a risk when people are testing at home if it comes up positive and they think well that’s fine it’s flu or whatever I don’t need to do anything, but do they know enough to know when they should seek help? …. So, there’s still some education needed.’ (Clinician feedback session A)
Others thought MVRA-POCTs might more appropriately support nurse-led respiratory clinics:
‘I’m a big proponent and very positive towards nurse-led care … for instance if someone comes up positive as the flu … if we can see them as a nurse and help them, I think that’s a really, really good idea and I think that we’re capable of making those decisions.’ (Clinician feedback session B)
Interviews also indicated increased recognition by both clinicians and patients of the severity of different viruses (and thus benefit of testing) for different age groups:
‘… quite surprised how many older people came in with RSV, quite sick with it, over 50s.’ (Clinician feedback session A)
‘Having a multiple virus test is great. Especially the RSV part — as a parent of a baby that ended up on breathing support from RSV, I think that people being aware they have it and what it can do to babies and old people should change behaviour. People are often like “I’m COVID-negative so I can go and spread my germs.”’ (Patient survey; free-text response)
Clinical characteristics of different illness presentations
The PMS audit highlighted other results with potential clinical utility (Supplementary Table 3). The notes showed that patients who tested positive for influenza had substantially higher temperatures than other positive presentations, and those with COVID-19 or RSV had higher temperatures than those who tested negative. Fever was present in 53% of those with influenza, 30% of those with RSV, 22% of those with COVID-19, and 18% of those who tested negative (temperature >37.4oC). These clinical observations were also reflected in qualitative interviews: ‘I was unwell, I had a really high fever, and I said to her in the car “I think I've got influenza”, and sure enough I did. So I wasn’t surprised’ (Patient interview; B107). There were no differences in heart rate or oxygen saturations between diseases.
Changing patient management
MVRA-POCT results affected advice given to patients for n = 47/50 responders (94%) (Figure 2). Of the 41 doctors, 26 (63%) reported that using the MVRA-POCT influenced their antibiotic prescribing decisions, while 15 (37%) were not influenced, with several reporting that they were more reliant on clinical judgement. Many indicated in survey comments that a positive viral result directly influenced their decision not to prescribe antibiotics:
‘Very useful to SHOW patients that they had a viral illness and therefore antibiotics not required.’ (Clinician survey; free-text response)
‘Positive tests for influenza/RSV/COVID made me confident it was viral not bacterial, so reduced antibiotic prescribing and I was able to offer a more accurate course of illness.’ (Clinician survey; free-text response)
Some patients also acknowledged the benefit of fewer unnecessary antibiotics: ‘... less likely to be using drugs unnecessarily eg, using antibiotics while waiting for the results of a throat swab’ (Patient survey; free-text response).
When asked about prescribing antivirals for influenza, 17 (41%) doctors felt that using the MVRA-POCTs might change their views, 17 (41%) were not sure, and 7 (17%) said it would not.
Results from the MVRA-POCT supported decision making around considering secondary care referral for five clinicians (12% of those able to refer), in particular for febrile children who may otherwise have been transferred to paediatrics for more investigations:
‘... it was useful for not having to send four kids up to ED in one night […] And it saved ambulance trips.’ (Clinician feedback session A)
‘Febrile babies under six months with a positive either flu or COVID [test] … babies can just have a fever and nothing else … and talking to paeds about it … they felt more comfortable not to have to do a full septic screen.’ (Clinician feedback session A)
Decreased referrals for chest X-ray were also mentioned: ‘like radiology with … febrile lower respiratory tract … if you’ve got flu, which you look quite unwell with often … you can kind of wait that 24 hours rather than going straight into investigations potentially … I think it does avoid some of those [chest X-rays]’ (Clinician feedback session C).
Changing patient behaviour
Patient participants rated the likelihood of the following practices while unwell with respiratory illness: staying at home; taking time off work; working from home; wearing a mask; washing their hands; and avoiding vulnerable people. Those who tested positive were more likely to report staying at home, taking time off work, wearing a mask, and avoiding older people compared with those who tested negative. Participants were also asked how likely they were to use these measures the last time they had a similar illness when the MVRA-POCT was not available. Of the 215 responding to this question, a larger proportion of those who tested positive reported a perception that they engaged in these practices more frequently than during a previous similar illness, compared with those who tested negative (Figure 3). Interviewees supported this behavioural change:
‘Having that clarity on what it is … if they didn’t have it [clarity] and they tested for COVID but that was negative, but they had the flu or RSV … they could still go pass that onto children.’ (Patient interview; C18)
A small minority of patients commented that the test result did not alter their behaviour, as they based their response on how unwell they felt, and/or on precautions, such as mask-wearing and staying home, which have been more normalised since the COVID-19 pandemic.
The bar chart compares the proportion of patients who reported being “more likely” to engage in six behaviours, compared with the last time they were sick with a similar virus when MVRA-POCT was not available. Each behaviour has two bars: one for patients with a positive MVRA-POCT result and one for patients with a negative MVRA-POCT result.Across all six behaviours, patients with a positive MVRA-POCT result reported higher “more likely” responses than patients with a negative result.The values are: Stay at home: 75% for positive MVRA-POCT result, compared with 15% for negative MVRA-POCT result. Take time off work: 71% for positive result, compared with 17% for negative result. Work from home: 53% for positive result, compared with 20% for negative result. Wear a mask: 65% for positive result, compared with 19% for negative result. Wash hands: 58% for positive result, compared with 29% for negative result. Avoid older people: 70% for positive result, compared with 31% for negative result.The largest difference between positive and negative MVRA-POCT result groups is for staying at home: 75% versus 15%, a 60 percentage-point difference. The smallest difference is for washing hands: 58% versus 29%, a 29 percentage-point difference. Overall, the chart indicates that a positive MVRA-POCT result is associated with greater stated likelihood of adopting behaviours that may reduce transmission or exposure.
Views on the use of MVRA-POCTs for sick leave provision differed, particularly between clinicians working in high versus low social deprivation settings. Those working in lower deprivation areas felt it might be a useful tool to access sick leave:
‘From an equity point of view, the tests would be helpful … if they have a positive test to show their employer without having to go to … see a GP and pay for a consultation to get a note … particularly in areas of low socioeconomic and also … problems … accessing doctors.’ (Clinician feedback session A)
However, clinicians working in areas of higher social deprivation acknowledged the potential dilemma of unpaid sick leave, which was more common in these areas:
‘I think time off work’s a big one for not wanting to swab … if you don’t have leave… which was a massive issue for a huge amount of our patients.’ (Clinician feedback session C)
Patients from this area, however, reported a positive result would make it easier to justify time off:
‘Knowing that it’s influenza or RSV or covid is a lot, like gives you more knowledge and ability to kind of say “hey, I can’t actually come in because of this reason.”’ (Patient interview; C18)
Discussion
Summary
This exploratory pilot study was undertaken in a pressured primary care operating environment during the winter of 2023, following the return of influenza and a significant COVID-19 peak in winter 2022 after NZ reopened its borders. It aimed to assess the feasibility and acceptability of using MVRA-POCTs in urgent care and general practice settings.
The tests integrated well into primary care in the pilot sites, with enthusiastic responses from both patients and clinicians, particularly in urgent care. Use of MVRA-POCTs positively influenced both self-reported patient behaviour (appropriate NPIs to reduce disease spread) and clinician management (decreased prescription of antibiotics for viral illnesses, decreased need for further investigations to diagnose illness). Clinicians reported that the test often shortened consultation times and was a useful addition to their practice. Almost all patients reported they would use the MVRA-POCTs again.
Strengths and limitations
The strengths of this study include the large number of patients swabbed (n = 1850; 259 with a positive test) and the inclusion of follow-up surveys of patients (n = 227) and clinicians (n = 52). Another strength was inclusion in the pilot of both urgent care and traditional general practice, and patients of different age groups, socioeconomic status, and ethnic groups, making the results potentially generalisable to other settings with similar healthcare infrastructure. We also investigated the potential impact on reported use of both pharmaceutical and non-pharmaceutical interventions. Although we were unable to record demographics of those who were offered and declined the swab (for reasons of practicality, in a busy clinic), all 23 clinicians responding to this question reported that ‘all’ or ‘most’ of those offered it accepted the swab; while patients were said to be ‘very keen’ (10 clinicians) or ‘somewhat keen’ (12 clinicians) to receive the swab. We can infer from this that most patients who were offered it accepted the swab.
Limitations include the non-randomised nature of the study design, the reliance on self-selection of patients to respond to survey or interview invitations, and that, owing to logistical constraints, the pilot ran only during half of the winter season. (In 2023, NZ had an early peak of influenza; this study did not begin until July; hence numbers of positive swabs declined over the course of this study, owing largely to decreases in influenza numbers.) Widespread availability of free COVID-19 POCTs at the time likely also led to many people with COVID-19 appropriately self-diagnosing at home and staying away from clinics.
To avoid adding to the workload of already busy clinics, we relied on clinicians recording information in the PMS to obtain data on swab results, patient demographics, and disease characteristics, and thus did not capture results from 96 of the 1850 patients swabbed. We may also not have captured all relevant data on disease characteristics owing to recording omissions. Additionally, to minimise selection bias, the test was offered to all patients triaged as presenting with a possible respiratory virus, the trade-off being that broad inclusion criteria were likely to contribute to lower positivity rates.
The influence of the MVRA-POCT on patient and clinician behaviours was self-reported and not supported by objective measures. A higher response rate to our patient survey would have been preferable, but the responders do adequately represent those swabbed, with a slight propensity to over-represent an older and more European population. We were pleased to have representative numbers of Māori responders but may have under-represented those who speak English as a second language.
Comparison with existing literature
PCR testing, the ‘gold standard’ for respiratory virus identification, can be useful in guiding patient care decisions;4,5 however, for primary care it is cost and time prohibitive. In a recent qualitative UK study using multi-viral POCT machines, clinicians felt their use aided prescribing and communication during uncertainty; use varied with clinician confidence and role, and costs and time demands limited routine use.13 MVRA-POCTs may therefore be a more viable option, despite lower sensitivity.
In our study, more than half of prescribers reported that MVRA-POCT results constructively influenced their decisions around antibiotic use. A study in the US estimated that around half the antibiotics prescribed in ambulatory care were inappropriate,14 and patients requesting antibiotics are more likely to be given them.15 Using POCTs to decrease prescribing of antibiotics for viral illnesses is highly desirable, given the increase in antimicrobial-resistant pathogens worldwide.16,17 Studies using POCTs report reduced use of antibiotics and increased use of antivirals in various settings, such as primary care,6 emergency departments,18 and student health clinics.19 This is particularly valuable if results are available in a timely manner.7 In our study, where MVRA-POCTs were done at triage, with results available at the start of the consultation, we noted particularly high clinician satisfaction, because the consult could be tailored around the diagnosis and there was no waiting time for the result. Additionally, around 40% of prescribers felt MVRA-POCTs may be helpful to make decisions about prescribing antiviral medications, which are currently hardly used in primary care in NZ; this could be beneficial in reducing disease severity in populations at high risk.20
Diagnosing influenza by POCTs can decrease rates of blood cultures and chest X-rays;19 in our study, some clinicians reported a reduction in chest X-ray requests and secondary care referrals. This was particularly notable in cases of febrile babies, avoiding septic screening in hospital.
Implications for research and practice
This study showed that MVRA-POCTs have good potential to integrate well into primary health care, particularly urgent care, in NZ, as a logical extension to the widespread and successful use of rapid-antigen POCTs during the COVID-19 pandemic. There is an urgent need for a well-conducted trial to evaluate the clinical effects of using these tests to assess whether there is a case for targeted use of MVRA-POCTs rather than COVID-19 POCTs, at least in the winter months. Similarly, we need a trial to evaluate effects on antibiotic prescribing, unnecessary investigations, repeat visits, and even hospitalisations. Wider benefits to society through behaviours leading to reduced viral spread are also possible, as well as potential healthcare cost savings. For example, an emergency department-based study reported a cost saving of approximately $US200 (approximately 150 GBP) per patient with influenza-like illness.4
Having experienced the benefits, the urgent care centre in this study now uses MVRA-POCTs for selected patients. However, the cost (currently $NZ15; approximately 6.50 GBP) is passed on, posing equity issues. Purchasing these tests is expensive for primary care, and unless MVRA-POCTs are funded by government agencies in the NZ setting, cost will remain a barrier. To rationalise their use, we suggest MVRA-POCTs could be used more frequently where the need for other further investigations is unclear; studies report that respiratory POCTs are more useful where diagnostic uncertainty is an issue.13
Equity issues also exist regarding sick leave and working from home. Patients reported that a positive test made it easier to justify absences and, if testing at home, may avoid the cost of a sick note. However, clinicians also reported that some patients prefer not to have a diagnosis that requires them to take unpaid sick leave.
Home use of MVRA-POCTs was widely favoured by patients. However, clinicians had concerns that unwell patients with comorbidities may delay review owing to already having the diagnosis — ‘just the flu’ — or conversely, that patients with negative tests may not seek appropriate care. Since conducting this study, MVRA-POCTs have become available for purchase in pharmacies for home use; although rare, patients sometimes present having already done a ‘quad swab’ at home. We suggest this indicates ongoing demand for and perceived utility of these tests by the public, especially in a context where multiple respiratory viruses (including influenza, RSV, and COVID-19) now circulate throughout each winter season. There is a need going forward to explore issues such as more targeted use, and potential downsides to inappropriate self-care test interpretation.
In conclusion, this pilot study has shown that using MVRA-POCTs in general practice and urgent care in the winter months is likely to be both feasible and acceptable for timely diagnosis of respiratory presentations, including influenza and RSV as well as COVID-19. Further studies (ideally randomised controlled trials; RCTs) are required before we can draw any firm conclusions on the clinical utility of using these tests more widely in primary care and other community settings such as aged residential care and in the home. If the findings do prove to translate to other settings, use of these tests may lead to benefits, such as reduced antimicrobial prescriptions and more streamlined care, and could be a tool for promoting patient behaviour change to reduce transmission.
Notes
Funding
We thank Flu Lab for funding the SHIVERS-V research team for the programme ‘Influenza in a post-COVID world’ of which this pilot was a part. This has allowed researchers in Aotearoa NZ to collect crucial data on influenza within a Southern Hemisphere ‘population laboratory’ and produce local innovations with international impact. Reference number: UAHPEC27013.
Ethical approval
Ethics approval was granted by the University of Otago Human Ethics Committee (Health) (Ref: H23/073).
Provenance
Freely submitted; externally peer reviewed.
Data
Publicatoon of the dataset relied on in this article is not possible due to regulatory requirements regarding confidentiality of patient information.
Acknowledgements
We wish to thank and acknowledge the following: the staff at all clinics involved in the study, in particular clinical leads who made this pilot possible; and the patients who were swabbed, answered the survey and were interviewed; Dr Richard Medlicott, at Island Bay Medical Centre for work developing and installing the patient management systems tool to record swab results and clinical details; and Lizzie Wesley-Smith, Clinical Nurse Advisor at the Immunisation Advisory Centre, NZ for copy-editing of the article draft.
Competing interests
The authors declare that no competing interests exist.
- Received June 3, 2025.
- Revision received August 12, 2025.
- Accepted October 1, 2025.
- Copyright © 2026, The Authors
This article is Open Access: CC BY license (https://creativecommons.org/licenses/by/4.0/)
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