Tongue swab Xpert MTB/RIF Ultra testing for TB using a revised consensus protocol

Tongue swabs are a promising specimen type for TB diagnosis. In a previous study, using a consensus protocol, tongue swabs tested with Xpert MTB/RIF Ultra outperformed sputum smear microscopy, but a substantial proportion (6.1%) of results were non-actionable (e.g., invalid/error). We evaluated a revised protocol for tongue swab Xpert Ultra testing in four high-burden countries.Participants aged ≥12 years with presumptive TB were enrolled from outpatient clinics in the Philippines, South Africa, Nigeria, and Zambia. Tongue swabs were processed using Sample Reagent (SR, Cepheid, USA) diluted 2:1 with phosphate buffer or phosphate-buffered saline and tested with Xpert Ultra. Diagnostic performance was assessed against culture-based microbiological reference standard and compared to sputum tests.From March to November 2024, 1,168 participants were enrolled (median age 37 [IQR: 28-48] years; 46.7% female; 21.8% living with HIV; 18.5% culture-confirmed TB). The proportion of non-actionable tongue swab results was 5.6% overall, but <4% in all countries except South Africa (15.4%). Tongue swab sensitivity was 66.0% (95% CI: 59.0-72.5); specificity was 99.6% (95% CI: 98.9-99.9).The revised protocol yielded low error rates at most sites and moderate sensitivity, supporting tongue swabs as an alternative specimen for Xpert Ultra testing when sputum is unavailable..