Management & Administration

The Need for Education in Molecular

Immunohematology: A Survey of Specialists
in Blood Banking

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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
technologies lacks standardization.
Objective: To address this problem, we surveyed specialist in blood
bank technology (SBBT) programs, immunohematology reference
laboratories, and SBBT graduates to define its current state.
Methods: An anonymous online survey (SurveyMonkey) was emailed to
the 15 American Association of Blood Banks (AABB) SBBT programs, 59
AABB IRLs, and 82 SBBT graduates.
Results: In the didactic portion of the SBBT curriculum, all programs
incorporate knowledge base of blood groups, 13 incorporate molecular
techniques, and 5 include case studies. Thirteen programs have
intentions of expanding the knowledge base in molecular topics. Most
IRLs (97%) think SBBT programs should continue to expand molecular
knowledge base. Most graduates (94%) believe more molecular topics
should be included in the SBBT curriculum; however, only 50% believe
they currently apply their molecular knowledge in their post-graduate
employment.
Conclusion: We propose a more descriptive molecular diagnostics
curriculum for SBBT programs to help standardize the education of
molecular topics.
Keywords: molecular, immunohematology, specialist in blood banking,
education, curriculum, transfusion medicine

Molecular techniques, including modifications of polymerase
chain reaction (PCR) and array technologies, are becoming
more integrated into the specialty of blood banking/transfusion
medicine. Zimring et al stated, “In transfusion medicine, these
techniques are used to 1) detect infectious pathogens; 2)
Abbreviations
AABB, American Association of Blood Banks; AMP, Association for
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-
resolution melt-curve analysis; IRL, immunohematology reference labora-
tory; MLS, medical laboratory scientists; PCR, polymerase chain reaction;
RBC, red blood cell; RFLP, restriction fragment length polymorphism;
SBBT, specialist in blood bank technology
1
Department of Pathology and Laboratory Medicine, Indiana
University School of Medicine, Indianapolis, IN, 2Indiana Blood Center,
Indianapolis, IN
*To whom correspondence should be addressed.
dwaxman@indianablood.org
predict the phenotype of red cell, platelet, and neutrophil
antigens; 3) detect and identify red cell and platelet antibodies;
4) determine HLA type; and 5) perform relationship testing.”1
For example, much progress has been made in determining
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
profile can provide guidance on additional antigens to which
the patient may become sensitized.
The didactic curriculum for medical laboratory scientists,
blood bank specialists, medical students, and residents
addressing molecular methods and technologies is not
well defined and lacks standardization.2-9 The American
Society for Clinical Pathology (ASCP) Board of
Certification Examination Content Guideline for
Technologist in Blood Banking (BB) and Specialist in
Blood Bank Technology (SBBT), lists “Molecular
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

Table 1. SBBT Programs Responding to Survey
Academic Center at OneBlood - St Petersburg, FL
American Red Cross Blood Services - Pomona, CA
Walter Reed National Military Medical Center - Bethesda, MD
Blood Center of Wisconsin - Milwaukee, WI
Blood Systems Laboratories - Tempe, AZ
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
University Medical Center New Orleans - New Orleans, LA
National Institutes of Health Clinical Center - Bethesda, MD
Rush University - Chicago, IL
University Health System and Affiliates School of Blood Bank Technology -
San Antonio, TX
University of Texas Medical Branch - Galveston, TX
students and programs. 10 This broad range
of information makes developing and implementing a
successful curriculum in molecular transfusion
medicine challenging.
In order to assess the current state of the curriculum, and
application of these molecular topics and technologies
within blood banking/transfusion medicine, we surveyed
SBBT programs, which prepare lab professionals to
become transfusion medicine specialists, their graduates,
and immunohematology reference laboratories (IRLs).
Utilizing this data, along with the Association for Molecular
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.”
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Management & Administration
Pathology (AMP) Training and Education Committee
recommendations, we propose a more descriptive
molecular diagnostics curriculum, which includes both
molecular techniques/technologies and the interpretation
of results, for lab professionals to address the lack of
standardization.
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Materials and Methods
An anonymous online survey (SurveyMonkey) was emailed to
the 15 American Association of Blood Banks (AABB) SBBT
programs, 59 AABB IRLs, and SBBT programs to forward to
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
SBBT Standard for didactic (knowledge base
learning), psychomotor (clinical, technical and administrative
rotations), and affective (professional development) learning
domains for the curriculum concerning use of molecular
techniques in transfusion medicine.
The word “molecular” was left undefined in the survey. Our
intention was for it to include a broad definition, to
incorporate many technologies/techniques within blood
banking and transfusion medicine, including but not limited
to DNA extraction, amplification, and detection techniques,
eg, PCR with added features like enzyme digestion
Lab Medicine 2016;47;330–337 331
DOI: 10.1093/labmed/lmw042
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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
oligonucleotides), detection by specific hybridization
(enzyme-linked immunosorbent assay-ELISA), and real-time
PCR, genome sequencing, human leukocyte antigen (HLA)
testing methods, and red blood cell (RBC) genotyping.
Results
All 15 SBBT programs (Table 1) responded to the survey. In the
didactic portion of the SBBT curriculum, all programs
incorporate knowledge base of blood groups, 13 programs

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332 DOI: 10.1093/labmed/lmw042
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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
studies (Figure 1). In the clinical, technical, or administrative
rotations, 7 programs provide either an observational or hands-
on technical rotation in molecular techniques, 3 provide a
clinical/administrative rotation involving molecular
techniques, while 5 programs do not require any molecular
rotation (Figure 2). In the affective portion of SBBT
curriculum, most programs incorporate knowledge of
molecular nature of blood groups (13 programs) and/or
application of molecular techniques (10 programs), with
fewer programs offering case studies (4 programs),
observation of molecular techniques (4 programs),

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DOI: 10.1093/labmed/lmw042
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discussion with pathologist (2 programs), or no affective

Table 2. Immunohematology Reference Labs
Responding to Survey
American Red Cross - National Reference Laboratory for Blood Serology
American Red Cross - Connecticut Region
American Red Cross - St. Paul, MN
American Red Cross - Southern Region
American Red Cross- Southeast Michigan Region
American Red Cross - Greater Chesapeake and Potomac Region
objective for molecular (2 programs) (Figure 3). Thirteen
programs (87%) have intentions of expanding the knowledge
base in molecular topics or techniques in the future and plan
to do so with additional didactic information and problem
solving (Figure 4). Fewer plan to add a hands-on molecular
rotation (4 programs) or problem solving molecular
challenges (4 programs), and 3 programs have no plans to

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American Red Cross - Southern California Region
The Blood Center - New Orleans, LA
Blood Centers of the Pacific - San Francisco, CA
BloodCenter of Wisconsin - Milwaukee, WI
BloodSource - Mather, CA
Blood Systems Laboratories-IRL - Tempe, AZ
Central IL Community Blood Center - Springfield, IL
Centro Trasfusionale e di Immunoematologia - Milan, Italy
Community Blood Center - Dayton, OH
Heartland Blood Centers - Aurora, IL
Hospital Israelita Albert Einstein - S~ao Paulo, Brazil
Hoxworth Blood Center - Cincinnati, OH
Indiana Blood Center - Indianapolis, IN
Kuwait Central Immunohematology Reference Laboratories (KCIRL) -
Hawally, Kuwait
Mayo Clinic - Rochester, MN
University Medical Center of New Orleans - New Orleans, LA
Memorial Blood Centers - St. Paul, MN
Michigan Blood - Grand Rapids, MI
Miller-Keystone Blood Center - Bethlehem, PA
National Institutes of Health (NIH) - Bethesda, MD
Puget Sound Blood Center - Seattle, WA
University of Michigan - Ann Arbor, MI
University of Rochester, Strong Memorial Hospital - Rochester, NY
expand molecular training (Figure 4). Some of the limitations
to expanding a molecular curriculum include lack of partners
that perform molecular testing to allow students to perform a
hands-on technical rotation, lack of resources, cost, and lack
of expertise in the molecular laboratories (Figure 5). Eleven
(73%) SBBT programs believe that their graduates will apply
this knowledge in molecular topics in their post-graduate
employment.
Thirty IRL survey results (51% response rate) were received
and recorded; these included 3 international IRLs (Table 2).
The group indicated most IRL SBBTs obtained their SBBTs
via experience Route 2. When asked to indicate the best
description of IRL molecular workload, most IRLs
determined when molecular testing is needed and partnered
with another lab for the testing (14 IRLs); IRLs perform the
molecular testing (13 IRLs); few IRLs do not perform
molecular testing (3 IRLs) (Figure 6). When asked how the
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

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
for molecular techniques; 20 used a combination of blood
group knowledge and case studies; 7 IRLs did not
incorporate molecular into the IRL training (Figure 7).
Nineteen (63%) IRLs believe that the SBBTs in their IRL use
their molecular knowledge consistently as part of IRL
workload. Twenty-eight (93%) IRLs think SBBT programs
should continue to expand the knowledge base and
technical skills in molecular methods. IRLs responded that
molecular topics should be added to the curriculum of SBBT
programs.
SBBT graduates (82) responded to the survey representing
13/15 SBBT programs. All programs incorporate
knowledge base and technique review in the SBBT
curriculum, but only 32 (39%) SBBT graduates had hands-
on molecular experience as part of the SBBT program.
Seventy-seven (94%) program graduates be that more
molecular topics should be included in the SBBT
curriculum; however, only 41 (50%) believe that they
currently apply their molecular knowledge in their post-
graduate employment.
Conclusions
Molecular diagnostics are rapidly growing and constantly
changing. For example, within transfusion medicine, RBC
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genotyping is a molecular technology with many
advantages that is becoming increasingly utilized. It is used
most heavily, even becoming standard of care, in predicting
antigen status in the alloimmunized and/or chronically
transfused patient (i.e. patients with sickle cell disease);11,12
in resolving a serologic weak D phenotype or inconclusive
RhD typing in the setting of obstetrics;13,14 and in predicting
extended phenotype in patients with warm autoantibodies
or a positive direct antiglobulin test in which extended
phenotype is difficult to obtain serologically.15 Educational
programs must address knowledge base, technical
application, and problem solving for such technologies, but
the educational curriculum for the field is not well defined. A
literature search for molecular education and blood banking
or transfusion medicine failed to reveal any articles. The
ASCP Board of Certification (BOC) for BB and SBB
Examination Content Guideline, a useful tool for preparing
SBBT program curriculum, lists a few topics related to
molecular education, which include molecular knowledge of
blood groups and applications of molecular techniques,
such as PCR and RFLP. Although this broad range of
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
examination.
Through our survey about the education about molecular
topics and technology within blood banking, we found that
Lab Medicine 2016;47;330–337 335
DOI: 10.1093/labmed/lmw042
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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
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

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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
the didactic and affective portions of SBBT molecular
curriculum. However, we did not inquire about the details of
the didactics and therefore do not have a list of specific
molecular curriculum topics within transfusion medicine. We
found greater variability among the clinical, technical, or
administrative molecular rotations offered by SBBT
programs, with 5 programs not requiring any molecular
rotation. Most programs (13) plan to expand the knowledge
base in molecular topics and techniques in the future, but
note that limitations include lack of partners that perform
molecular testing to allow a hands-on technical rotation, lack
of resources, cost, and lack of expertise in molecular
laboratories. The SBBT programs appear to have identified
the need for improvement, and the SBB graduate and IRLs
mirror this assessment.

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336 DOI: 10.1093/labmed/lmw042

Almost all IRLs and SBBT graduates that responded think
SBBT programs should continue to expand the knowledge
base and technical skills in molecular methods. Most
programs believe that their graduates will apply this
knowledge in molecular topics to their post-graduate
employment; however, only 50% of graduates who
responded stated that they used molecular knowledge in
their current position. This is an interesting dichotomy and
probably multifactorial, perhaps related relates to the fact
that many IRLs currently partner with another laboratory that
performs the molecular testing. Also, perhaps IRLs that
perform molecular testing prefer to hire SBBTs with more
experience in such technologies.
The AMP Training and Education Committee has also noted
the lack of standardization of education in molecular
curriculum, specifically for medical laboratory scientists.8 In a
2014 article, it created recommendations for molecular
diagnostics curriculum for medical laboratory scientists (MLS)/
clinical laboratory scientists (CLS), and diagnostic molecular
scientists (DMS).8 Using the AMP recommendations and
modifying them to reflect applications in transfusion medicine,
we propose a more descriptive molecular diagnostics
curriculum for SBBT programs (Table 3). We have compared
these proposed topics to those listed on the ASCP BOC for
BB and SBB Examination Content Guideline. While many
topics overlap, we provide a more detailed list of specific
molecular techniques. Although a list of topics provides some
guidance, we believe that application of these topics is more
difficult to standardize. We plan to do this with didactics and
case studies using molecular techniques for resolution. Also,
we believe that the addition of a hands-on or observational
rotation(s) for SBBT students could address the expectations
of SBBT graduates and IRLs for greater emphasis on
molecular knowledge and techniques.
Much more work must be done before we can achieve
standardization of molecular education within blood
banking/transfusion medicine, including collaboration of
the ASCP BOC examination committee, SBBT programs,
and IRLs that offer molecular testing to assure the
graduates that they will be receiving the expected training
in molecular topics and techniques. Although the
education of molecular diagnostics still remains somewhat
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obscure, it is clear that this technology will only continue
to develop, and our teaching of such methods needs to
grow with it. LM
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