Management & Administration
The Need for Education in Molecular
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Immunohematology: A Survey of Specialists
in Blood Banking
Stephanie N. Kinney, MD,1 Jayanna Slayten, MS, MT(ASCP)SBBCM,2
Dan A. Waxman, MD2*
Laboratory Medicine 47:4:330-337
DOI: 10.1093/labmed/lmw042
ABSTRACT
Background: Within transfusion medicine, the education of molecular intentions of expanding the knowledge base in molecular topics. Most
technologies lacks standardization. IRLs (97%) think SBBT programs should continue to expand molecular
knowledge base. Most graduates (94%) believe more molecular topics
Objective: To address this problem, we surveyed specialist in blood should be included in the SBBT curriculum; however, only 50% believe
bank technology (SBBT) programs, immunohematology reference they currently apply their molecular knowledge in their post-graduate
laboratories, and SBBT graduates to define its current state. employment.
Methods: An anonymous online survey (SurveyMonkey) was emailed to
the 15 American Association of Blood Banks (AABB) SBBT programs, 59 Conclusion: We propose a more descriptive molecular diagnostics
AABB IRLs, and 82 SBBT graduates. curriculum for SBBT programs to help standardize the education of
molecular topics.
Results: In the didactic portion of the SBBT curriculum, all programs
incorporate knowledge base of blood groups, 13 incorporate molecular Keywords: molecular, immunohematology, specialist in blood banking,
techniques, and 5 include case studies. Thirteen programs have education, curriculum, transfusion medicine
Molecular techniques, including modifications of polymerase predict the phenotype of red cell, platelet, and neutrophil
chain reaction (PCR) and array technologies, are becoming antigens; 3) detect and identify red cell and platelet antibodies;
more integrated into the specialty of blood banking/transfusion 4) determine HLA type; and 5) perform relationship testing.”1
medicine. Zimring et al stated, “In transfusion medicine, these For example, much progress has been made in determining
techniques are used to 1) detect infectious pathogens; 2) the genetic background for blood group polymorphisms. The
commercialization of PCR makes the detection of such
polymorphisms rapid, so in a transfusion-dependent patient
who produces multiple alloantibodies, an extended antigen
Abbreviations
profile can provide guidance on additional antigens to which
AABB, American Association of Blood Banks; AMP, Association for
the patient may become sensitized.
Molecular Pathology; ASCP, American Society for Clinical Pathology; BB,
technologist in blood banking; BOC, Board of Certification; CLS, clinical
laboratory scientists; DMS, diagnostic molecular scientists; FISH, fluores-
cence in situ hybridization; HLA, human leukocyte antigen; HRM, high-
The didactic curriculum for medical laboratory scientists,
resolution melt-curve analysis; IRL, immunohematology reference labora-
tory; MLS, medical laboratory scientists; PCR, polymerase chain reaction; blood bank specialists, medical students, and residents
RBC, red blood cell; RFLP, restriction fragment length polymorphism; addressing molecular methods and technologies is not
SBBT, specialist in blood bank technology well defined and lacks standardization.2-9 The American
1
Department of Pathology and Laboratory Medicine, Indiana Society for Clinical Pathology (ASCP) Board of
University School of Medicine, Indianapolis, IN, 2Indiana Blood Center, Certification Examination Content Guideline for
Indianapolis, IN Technologist in Blood Banking (BB) and Specialist in
*To whom correspondence should be addressed. Blood Bank Technology (SBBT), lists “Molecular
dwaxman@indianablood.org techniques (eg, PCR, RFLP)” as a guideline for
330 C American Society for Clinical Pathology, 2016. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
V
Management & Administration
Pathology (AMP) Training and Education Committee
Table 1. SBBT Programs Responding to Survey
recommendations, we propose a more descriptive
Academic Center at OneBlood - St Petersburg, FL molecular diagnostics curriculum, which includes both
American Red Cross Blood Services - Pomona, CA
molecular techniques/technologies and the interpretation
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Walter Reed National Military Medical Center - Bethesda, MD
Blood Center of Wisconsin - Milwaukee, WI of results, for lab professionals to address the lack of
Blood Systems Laboratories - Tempe, AZ standardization.
Community Blood Center - Dayton, OH
Gulf Coast Regional Blood Center - Houston, TX
Hoxworth Blood Center/University of Cincinnati Academic Health Center -
Cincinnati, OH
Indiana Blood Center - Indianapolis, IN
Johns Hopkins Hospital - Baltimore, MD Materials and Methods
University Medical Center New Orleans - New Orleans, LA
National Institutes of Health Clinical Center - Bethesda, MD
An anonymous online survey (SurveyMonkey) was emailed to
Rush University - Chicago, IL
University Health System and Affiliates School of Blood Bank Technology - the 15 American Association of Blood Banks (AABB) SBBT
San Antonio, TX programs, 59 AABB IRLs, and SBBT programs to forward to
University of Texas Medical Branch - Galveston, TX their graduates (89). Each survey was tailored to the target
group and consisted of 7 to 8 questions focused around
molecular education and training. The questions mirrored the
students and programs. 10 This broad range SBBT Standard for didactic (knowledge base
of information makes developing and implementing a learning), psychomotor (clinical, technical and administrative
successful curriculum in molecular transfusion rotations), and affective (professional development) learning
medicine challenging. domains for the curriculum concerning use of molecular
techniques in transfusion medicine.
In order to assess the current state of the curriculum, and
application of these molecular topics and technologies The word “molecular” was left undefined in the survey. Our
within blood banking/transfusion medicine, we surveyed intention was for it to include a broad definition, to
SBBT programs, which prepare lab professionals to incorporate many technologies/techniques within blood
become transfusion medicine specialists, their graduates, banking and transfusion medicine, including but not limited
and immunohematology reference laboratories (IRLs). to DNA extraction, amplification, and detection techniques,
Utilizing this data, along with the Association for Molecular eg, PCR with added features like enzyme digestion
Figure 1
SBBT program responses to the question, “In the didactic curriculum of your SBBT program, how do you incorporate molecular? Indicate all
that apply to your program.”
www.labmedicine.com Lab Medicine 2016;47;330–337 331
DOI: 10.1093/labmed/lmw042
Management & Administration
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Figure 2
SBBT program responses to the question, “In the clinical, technical, or administrative rotations of your SBBT program, how do you incorporate
molecular? Indicate all that apply to your program.”
Figure 3
SBBT program responses to the question, “In the affective portion of your SBBT program, how do you incorporate molecular? Indicate all that
apply to your program.”
(restriction fragment length polymorphism [RFLP]; allele
specific primers (sequence specific primers or Results
oligonucleotides), detection by specific hybridization
(enzyme-linked immunosorbent assay-ELISA), and real-time All 15 SBBT programs (Table 1) responded to the survey. In the
PCR, genome sequencing, human leukocyte antigen (HLA) didactic portion of the SBBT curriculum, all programs
testing methods, and red blood cell (RBC) genotyping. incorporate knowledge base of blood groups, 13 programs
332 Lab Medicine 2016;47;330–337 www.labmedicine.com
332 DOI: 10.1093/labmed/lmw042
Management & Administration
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Figure 4
SBBT program responses to the question, “If yes, your program will expand the molecular training in your SBBT program—how will you add
this experience for your program?”
Figure 5
SBBT program responses to the question, “If no, your program will not expand the molecular training in your SBBT program—what are the
main limitations for expansion?”
incorporate molecular techniques, and 5 programs include case rotation (Figure 2). In the affective portion of SBBT
studies (Figure 1). In the clinical, technical, or administrative curriculum, most programs incorporate knowledge of
rotations, 7 programs provide either an observational or hands- molecular nature of blood groups (13 programs) and/or
on technical rotation in molecular techniques, 3 provide a application of molecular techniques (10 programs), with
clinical/administrative rotation involving molecular fewer programs offering case studies (4 programs),
techniques, while 5 programs do not require any molecular observation of molecular techniques (4 programs),
www.labmedicine.com Lab Medicine 2016;47;330–337 333
DOI: 10.1093/labmed/lmw042
Management & Administration
discussion with pathologist (2 programs), or no affective
Table 2. Immunohematology Reference Labs
Responding to Survey objective for molecular (2 programs) (Figure 3). Thirteen
programs (87%) have intentions of expanding the knowledge
American Red Cross - National Reference Laboratory for Blood Serology
base in molecular topics or techniques in the future and plan
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American Red Cross - Connecticut Region
American Red Cross - St. Paul, MN to do so with additional didactic information and problem
American Red Cross - Southern Region solving (Figure 4). Fewer plan to add a hands-on molecular
American Red Cross- Southeast Michigan Region rotation (4 programs) or problem solving molecular
American Red Cross - Greater Chesapeake and Potomac Region
American Red Cross - Southern California Region challenges (4 programs), and 3 programs have no plans to
The Blood Center - New Orleans, LA expand molecular training (Figure 4). Some of the limitations
Blood Centers of the Pacific - San Francisco, CA to expanding a molecular curriculum include lack of partners
BloodCenter of Wisconsin - Milwaukee, WI
that perform molecular testing to allow students to perform a
BloodSource - Mather, CA
Blood Systems Laboratories-IRL - Tempe, AZ hands-on technical rotation, lack of resources, cost, and lack
Central IL Community Blood Center - Springfield, IL of expertise in the molecular laboratories (Figure 5). Eleven
Centro Trasfusionale e di Immunoematologia - Milan, Italy (73%) SBBT programs believe that their graduates will apply
Community Blood Center - Dayton, OH
this knowledge in molecular topics in their post-graduate
Heartland Blood Centers - Aurora, IL
Hospital Israelita Albert Einstein - S~ao Paulo, Brazil employment.
Hoxworth Blood Center - Cincinnati, OH
Indiana Blood Center - Indianapolis, IN
Thirty IRL survey results (51% response rate) were received
Kuwait Central Immunohematology Reference Laboratories (KCIRL) -
Hawally, Kuwait and recorded; these included 3 international IRLs (Table 2).
Mayo Clinic - Rochester, MN The group indicated most IRL SBBTs obtained their SBBTs
University Medical Center of New Orleans - New Orleans, LA via experience Route 2. When asked to indicate the best
Memorial Blood Centers - St. Paul, MN
description of IRL molecular workload, most IRLs
Michigan Blood - Grand Rapids, MI
Miller-Keystone Blood Center - Bethlehem, PA determined when molecular testing is needed and partnered
National Institutes of Health (NIH) - Bethesda, MD with another lab for the testing (14 IRLs); IRLs perform the
Puget Sound Blood Center - Seattle, WA molecular testing (13 IRLs); few IRLs do not perform
University of Michigan - Ann Arbor, MI
molecular testing (3 IRLs) (Figure 6). When asked how the
University of Rochester, Strong Memorial Hospital - Rochester, NY
molecular aspects of transfusion medicine are incorporated
Figure 6
IRL responses to the question, “Indicate the best description of how your IRL incorporates molecular into IRL workload.”
334 Lab Medicine 2016;47;330–337 www.labmedicine.com
334 DOI: 10.1093/labmed/lmw042
Management & Administration
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Figure 7
IRL responses for the question, “In the training for IRL Specialists, how are molecular aspects of transfusion medicine incorporated? Indicate
all that apply to your IRL.”
in the training for IRL specialists, 3 used hands-on training genotyping is a molecular technology with many
for molecular techniques; 20 used a combination of blood advantages that is becoming increasingly utilized. It is used
group knowledge and case studies; 7 IRLs did not most heavily, even becoming standard of care, in predicting
incorporate molecular into the IRL training (Figure 7). antigen status in the alloimmunized and/or chronically
Nineteen (63%) IRLs believe that the SBBTs in their IRL use transfused patient (i.e. patients with sickle cell disease);11,12
their molecular knowledge consistently as part of IRL in resolving a serologic weak D phenotype or inconclusive
workload. Twenty-eight (93%) IRLs think SBBT programs RhD typing in the setting of obstetrics;13,14 and in predicting
should continue to expand the knowledge base and extended phenotype in patients with warm autoantibodies
technical skills in molecular methods. IRLs responded that or a positive direct antiglobulin test in which extended
molecular topics should be added to the curriculum of SBBT phenotype is difficult to obtain serologically.15 Educational
programs. programs must address knowledge base, technical
application, and problem solving for such technologies, but
SBBT graduates (82) responded to the survey representing the educational curriculum for the field is not well defined. A
13/15 SBBT programs. All programs incorporate literature search for molecular education and blood banking
knowledge base and technique review in the SBBT or transfusion medicine failed to reveal any articles. The
curriculum, but only 32 (39%) SBBT graduates had hands- ASCP Board of Certification (BOC) for BB and SBB
on molecular experience as part of the SBBT program. Examination Content Guideline, a useful tool for preparing
Seventy-seven (94%) program graduates be that more SBBT program curriculum, lists a few topics related to
molecular topics should be included in the SBBT molecular education, which include molecular knowledge of
curriculum; however, only 41 (50%) believe that they blood groups and applications of molecular techniques,
currently apply their molecular knowledge in their post- such as PCR and RFLP. Although this broad range of
graduate employment. information makes developing to implementing a successful
curriculum in molecular transfusion medicine difficult, the
fact of the matter is that molecular topics in blood banking/
transfusion medicine are not yet extensively included in the
Conclusions examination.
Molecular diagnostics are rapidly growing and constantly Through our survey about the education about molecular
changing. For example, within transfusion medicine, RBC topics and technology within blood banking, we found that
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DOI: 10.1093/labmed/lmw042
Management & Administration
Table 3. Proposed Technologist in Blood Banking (BB) and Specialist in Blood Bank Technology (SBB)
Molecular Education Curriculum Concepts Compared With ASCP BB, SBB Board of Certification
Examination Content Guidelinea
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Topic ASCP BB, SBB Board of Certification BB, SBB Level of Knowledge
Examination Content Guideline
General molecular biology
Nucleic acid chemistry Yes, II. A. 1 Conceptual understanding
Basic molecular theory Yes, II. A. 1
Genetics/inheritance Yes, II. A. 1
Molecular pathology
Molecular nature of blood groups Yes, II. A. 2 Deeper knowledge of molecular
Inheritance of blood groups Yes, II. A. 3 pathology
Applications of blood group genetics, including Yes, II. A. 4
interpretation of test results
Basic laboratory techniques
Basic laboratory mathematics Yes, IV. F Conceptual understanding and optional
Electrophoresis laboratory training
Molecular techniques
Nucleic acid isolation Conceptual understanding including
Traditional polymerase chain reaction (PCR) Yes, VI. C. 9 knowledge of use in transfusion
Reverse transcriptase (RT)-PCR medicine (i.e. RBC genotyping,
Real-time PCR determining HLA type, infectious
Restriction digest Yes, VI. C. 9 disease testing) and selected
Southern blot analysis laboratory training if available
Multiplex/nested PCR
Capillary electrophoresis
Sanger sequencing
High-resolution melt-curve analysis (HRM)
Fluorescent in situ hybridization (FISH)
Microarray
Complex sequencing (ie, pyrosequencing and
next-generation sequencing)
Quality assurance
Contamination control Conceptual understanding
Instrument maintenance Yes, IV. E. 1
Reagent storage Yes, VI. E. 2
Proficiency testing
Specimen collection/handling Yes, VI. E. 1
Test applications, analysis, and evaluation
Familiarity with concepts of assay validation and assay development Conceptual awareness
Demonstrable skills in literature search and technical writing
Laboratory management
Familiarity with concepts of regulatory requirements, productivity, Yes, IV. D Conceptual awareness
cost management, and personnel management
a
Table modified from Taylor et al.8
most of the 15 SBBT programs are similar when it comes to rotation. Most programs (13) plan to expand the knowledge
the didactic and affective portions of SBBT molecular base in molecular topics and techniques in the future, but
curriculum. However, we did not inquire about the details of note that limitations include lack of partners that perform
the didactics and therefore do not have a list of specific molecular testing to allow a hands-on technical rotation, lack
molecular curriculum topics within transfusion medicine. We of resources, cost, and lack of expertise in molecular
found greater variability among the clinical, technical, or laboratories. The SBBT programs appear to have identified
administrative molecular rotations offered by SBBT the need for improvement, and the SBB graduate and IRLs
programs, with 5 programs not requiring any molecular mirror this assessment.
336 Lab Medicine 2016;47;330–337 www.labmedicine.com
336 DOI: 10.1093/labmed/lmw042
Management & Administration
Almost all IRLs and SBBT graduates that responded think obscure, it is clear that this technology will only continue
SBBT programs should continue to expand the knowledge to develop, and our teaching of such methods needs to
base and technical skills in molecular methods. Most grow with it. LM
programs believe that their graduates will apply this
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knowledge in molecular topics to their post-graduate
employment; however, only 50% of graduates who
responded stated that they used molecular knowledge in References
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