ASCLS Today Volume 35, Number 1

Sara Oswald, ASCLS Developing Professionals Forum Vice Chair

A few months ago, one of my work colleagues was visibly upset when she got off the phone with a provider. The chemistry results for this patient were all out of whack, and when she called to report the issue to the provider, she was informed this patient was transgender and on hormone therapy. “These people are so annoying!” she vented. “Why can’t they just put down what they are?”

I found myself in the unusual position of both fully understanding her frustration with confusing test results, but also having close friends in the transgender community and understanding the many challenges they face with their healthcare. I was able to explain some of this to my coworker, while also trying not to preach. Because, I get it. It is frustrating when we aren’t given the information we need to do our jobs. But I also get that transgender people are dealing with a lot of frustrations in this process, too.

“Those of us who are cisgender think nothing of marking M or F on [healthcare] forms, but transgender people know that what they mark may impact how others perceive them, what pronouns are used when people talk to them and about them, and even the quality of healthcare they may receive.”

First, to address my coworker’s question, “Why can’t they just write down what they are?” That’s actually quite a conundrum. Currently most healthcare forms are set up to accept either male or female. There is no transgender man or transgender woman, or even a separate question asking what sex they were at birth. Do they select the sex listed on their birth certificate or the one on their driver’s license? Do they select what matches their chromosomes, or what matches the current phenotype of their body?

Those of us who are cisgender think nothing of marking M or F on these forms, but transgender people know that what they mark may impact how others perceive them, what pronouns are used when people talk to them and about them, and even the quality of healthcare they may receive.

But the real issue with wanting transgender people to mark the sex they were assigned at birth on the intake form is that it doesn’t resolve the problems we have in the lab. Multiple studies have reported significant changes in basic chemistry, endocrine, and hematologic parameters in transgender patients receiving hormone therapy. These changes put them outside the normal ranges for either sex.¹

There are several studies currently taking place working toward establishing reference ranges for these individuals, but due to the diversity of the population (i.e., those who pursue gender reassignment surgery vs. those who remain on hormone therapy vs. some combination of the two), these reference ranges will be slow to materialize, if they come at all.²

In the meantime, unless a transgender individual is lucky enough to live near a specialty clinic, they may be the only transgender patient their doctor sees. The physician may not understand what tests to order to monitor the patient’s hormone therapy, or the long-term health effects that can occur if the hormone therapy is not properly monitored, such as venous thromboembolism, fractures, cardiovascular disease, stroke, and various hormone-dependent cancers.³

So, what can we do? How can we in the lab advocate for these patients? First, we can honor their humanity. These people are not “other,” they are sisters, brothers, daughters, and sons. They are our friends and colleagues. We can speak of these patients respectfully and use their preferred pronouns even when they are not in the room. Secondly, we can push for more gender-inclusive healthcare intake forms and clinical software. And finally, we can advocate for legislation and research that will provide us with the reference ranges we need to provide transgender people with the care they need to live long and healthy lives.

References

1. Goldstein, Zil et al. “When Gender Identity Doesn’t Equal Sex Recorded at Birth: The Role of the Laboratory in Providing Effective Healthcare to the Transgender Community.” Clinical Chemistry vol. 63,8. August 1, 2017.
2. Krasowski, Matthew and Humble, Robert. “The Clinical Laboratory and Informatics Challenges of Transgender Patient Care.” AACC Academy Scientific Shorts. June 17, 2019.
3. Delgado-Ruiz, Rafael et al. “Systematic Review of the Long-Term Effects of Transgender Hormone Therapy on Bone Markers and Bone Mineral Density and Their Potential Effects in Implant Therapy.” Journal of Clinical Medicine vol. 8,6 784. June 1, 2019.

Sara Oswald is in the MLT Program at Colorado Mesa University in Grand Junction, Colorado.

Susan J. Leclair, PhD

As with many working couples, my husband and I had an average relationship with our town. We paid our taxes and complained but did little more. After retirement, we started to become more active and thus began to interact with the people who worked in the town offices. The new town clerk arrived in September, having essentially one month to learn about the town’s policies and procedures while getting ready for the 2020 Election Day.

Photo credit: Tiffany Tertipes, Unsplash Author Susan Leclair volunteered to count early ballots in her town for the 2020 election. She found many similarities to working in the lab.

On October 22, we showed up at 9 am to volunteer to help get the voting machines certified and ready to work. Together with the chairpersons of the town’s two political committees and a few others, we sat down to mark-up test ballots. Each person created 50 test ballots and tallied each vote by hand. Thus, for example, there were votes for each of the four candidates for president, one vote for U.S. senator, and so on down to the state-wide ballot initiates.

Our town has nine precincts of about 3,000 registered voters, and each machine has one main counter memory chip and a back-up, so each set of ballots was then counted for a total of 18 times. Each run had to numerically match the totals of each set of test ballots. A tech rep from the manufacturer of the voting machines stayed for the entire day to correct any mechanical or electronic issues that might arise. It seemed to us that we were back in the laboratory running calibration, reference range construction, and quality control routines. We left around 4 pm that day. And, as many of you would do and have done when you are busy, we had skipped lunch to get this done.

The secretary of state allowed cities and towns to count early in-person, absentee, and mail-in ballots. We decided to help out, for as the famous last words adage says, “After all, how hard could this be?”

On the night before our arrival, the town clerk’s team had taken all of that day’s in-person, absentee, and mail in ballots and opened the outer envelope and removed the inner envelope. They then determined that the ballot envelope was completed correctly or not. Those valid envelopes were then reported by name, address, and precinct number to the Secretary of State’s Office. That office then entered them into the state application, which allowed voters to track the status of their ballots. The local officials then sorted all ballots by precinct, then by street and number. Finally, they alphabetized all the ballot envelopes by name. This took approximately six hours each night with the town officials rarely going home before 2 am. These boxes of precinct-sorted inner envelopes faced us each morning.

“It seemed to us that we were back in the laboratory running calibration, reference range construction, and quality control routines.”

At 9 am, we were set up as pairs. Pair One had one person read the information on the envelope as the other person checked the official voter registration list. That meant making sure that Smith, John J., Sr., was recorded and not Smith, John J., Jr., or Smith, John T. Any ballots not completely matching the register were held for additional screening. For example, an envelope marked Smith, John J. (no Sr. or Jr.), was held until Election Day when it would be determined if another Smith, John J., had voted and which one. If there was no other Smith, John J., the town clerk would contact Smith, John J., and ask who voted and would that person come in and, as it was said in other states, “cure” the ballot. In like manner, ballots with names not corresponding to the voter registration list and ballots with incomplete or illegible information were followed up.

Pair Two, or Pair One if there were not enough people for a real assembly line, then opened each envelope and removed the ballot, taking care not to damage the ballot in any way. Any damage, no matter how trivial, meant that the ballot would be hand tallied. No automated envelope openers. The second person then unfolded each ballot, checked to make sure that the voter’s choices could be counted by machine, and made sure that all folds were made as smoothly as possible, since folds cause the counting machines to jam.

Did people follow directions? Of course … not. There were ballots in red ink, in pencil, or using check marks or Xs. Some people wrote down their choice in the write-in space, even though the person’s name was on the printed ballot. Some folded the ballots perpendicular to the original folds. At least in this situation, we didn’t need to contact a person for a specimen redraw. We simply put them aside for a manual count. If the town officials could ascertain the voter’s intent, it was counted by hand.

Finally, the ballots made their way to the counter. The machine was identified for Precinct 1 and each readable ballot was entered. The machine is set up for voting day, so there is a 10-second lag between each ballot. Each precinct has about 3,000 voters, and it appeared that the early in-person and the mail-in/absentee ballots accounted for approximately 1,800 ballots. If all went well, six ballots per minute would have a potential of five hours for a complete count of each one of nine precincts, or 45 hours of perfect coordination between ballot counter and instrumentation.

Jams slowed things down. Putting in the next ballot early results in a jam. Putting the ballot in at an angle results in a jam. A ballot with significant folds results in a jam. And then there were the, “I have no clue why this one is not being accepted” jams. All rejected ballots, regardless of cause, were put aside for a manual count.

Manual counts were performed by two election officials with each maintaining their own tally. After a batch was counted, the two tallies had to agree, or they had to start again. For our state, that meant tallies for 11 individual races. Other states had larger ballots.

We worked every day from 9 am to 5 pm for six days. When we went home, we heard citizens say we were inept and stupid. As we begun, so we ended—in the clinical laboratory.

Susan J. Leclair is Chancellor Professor Emerita at the University of Massachusetts Dartmouth.

THE EMERGING ROLE OF LABORATORY PROFESSIONALS IN THE COVID-19 RESPONSE

Shawn Luby, MS, MLS(ASCP)^CM

Photo credit: Lisa Ferdinando, U.S. Department of Defense

So, what can you tell me about these T-cells I keep hearing about?”

This was a question I honestly never imagined I would be answering during a weekly video call with my family amidst an ongoing global pandemic. Luckily for my family members, I was knee deep in virtually teaching our MLS students about the intersection between the innate and adaptive immune response, and I felt confident that I could give adequate justice to the mighty T-cell in 30 seconds or less.

In my mind I eloquently responded to my family (full of musicians) with something along the lines of, “T cells are like a musical bridge, helping to connect the different parts of our immune response.” In reality, I panicked a bit, tried explaining Cd4+ vs Cd8+ T cells, stumbled through MHC class I and II (why did I bring this up?), and unceremoniously ended with, “You are all more than welcome to check out my video lectures if you’d like,” to which my family chuckled and politely declined.

ASCLS recently joined the COVID-19 Vaccine Education and Equity Project. Find resources to advocate for the vaccine at covidvaccineproject.org/resources.

In reality, the experience of laboratory professionals serving informally as health educators is nothing new, as my inbox full of lab results sent along from friends, family members, and family member’s pets can attest. What is new, of course, is the urgency in the general public’s desire for a broader understanding of molecular testing, virology, and the immune response.

Navigating this sudden interest in our daily professional lives has been interesting to say the least, however, the educational service and public health advocacy that we as laboratory scientists will provide during the COVID-19 pandemic is just beginning.

As the conversation shifts from testing to vaccination, we will once again be called upon to support and guide our communities—this time through a global vaccination campaign. Certainly, the development of multiple effective vaccines is something to celebrate.¹ Importantly however, if we look at previous vaccination strategies, it is clear that the public’s “buy-in” or demand for a vaccine is a most crucial element in any successful vaccination program.²

As such, implementation will require clear communications, and as valued members of the medical community, we should prepare now to engage in these efforts. To put it simply, the time for the medical laboratory community to collectively embrace and harness our strength as public health advocates has arrived, so let’s get ready.

Addressing Vaccine Hesitancy

Established in 2012, the international SAGE Working Group on Vaccine Hesitancy identifies three factors—known as the 3Cs—that impact an individual’s hesitancy in seeking vaccination: confidence, complacency, and convenience.³

Further, they denote specific categories that influence the 3Cs: contextual influence (geographical, political), individual/group influences (perception and social influence), and vaccine/vaccination-specific influences (cost, ease of access).³ Importantly they noted, while communication was not a specific categorical factor like the 3Cs, the lack of adequate communication from any vaccination program negatively influences the community’s “buy-in,” and contributes to overall hesitancy. The working group notes that when hesitancy is identified, it must be addressed, with the goal being to clearly highlight the value of the vaccine to the community through education.³

Globally, there are already widespread reports of apprehension and hesitancy with regard to COVID-19 vaccination.⁴ There are questions from the public about the unprecedented speed of development that will need to be addressed.⁵ There are also clear concerns about the continued underrepresentation of people of color in COVID-19 vaccine clinical trials, a likely consequence of a system still struggling to acknowledge and ameliorate the deep seeded and omni-present influences of racism in our medical instituions.^6,7

Finally, there will be questions regarding vaccine technologies, transportation and storage, and the availability and administration of the vaccine itself. The challenge to all of us will be to respond with understanding, patience, and a good amount of clear and accessible scientific information.

How to Be a Vaccine Advocate

The first step is to stay updated on the science behind the vaccine. The New England Journal of Medicine has made all publications related to COVID-19 available to the public for free at www.nejm.org/coronavirus. The World Health Organization is posting regular updates monitoring the progression of COVID-19 vaccine candidates, along with an impressive Q&A section addressing vaccine development, safety, and administration.⁸ Additionally, your workplace or local health departments may develop COVID-19 vaccine educational materials, which can be shared with members of your community.

The next step in the process is to get involved. Consider proactively reaching out to family and friends to see if they have any questions about COVID-19 vaccination. Research suggests that a simple conversation with a trusted health provider has a strong influence on vaccine compliancy, and certainly your conversations will provide opportunities for your community members to gain confidence in their understanding of the vaccine.²

If that goes well, consider preparing a short presentation covering vaccine topics like mRNA, spike proteins and IgM vs IgG, and then invite your family and friends to join you online for a COVID-19 education session. On an institutional level, approach (and encourage) laboratory administrators to support the development of lab-led public health messaging regarding COVID-19 testing, vaccination strategies, and immune responses.

Finally, be prepared to continue these conversations for many months to come. Some estimates suggest that it will take until 2023 to achieve global coverage, and while we wait for vaccine production and delivery, we will certainly continue to see an avalanche of COVID-19 information and misinformation on social media.⁹ In this environment, we will be looked to for our expertise, and it will be needed for the duration.

Importantly, take the time to celebrate your successes and share your strategies. After all, while the stakes have never been so high, our visibility as medical laboratory professionals has never been higher, and it will take all of us, working together, to succeed.

References

1. Covid vaccine update: Tracking progress against coronavirus - Washington Post [Internet]. [cited 2020 Nov 23]; Available from: https://www.washingtonpost.com/graphics/2020/health/covid-vaccine-update-coronavirus/
2. Weintraub RL, Subramanian L, Karlage A, Ahmad I, Rosenberg J. COVID-19 Vaccine To Vaccination: Why Leaders Must Invest In Delivery Strategies Now. Health Aff 2020;10.1377/ hlthaff.
3. MacDonald NE, SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: Definition, scope and determinants. Vaccine 2015;33(34):4161–4164.
4. We’re running out of time to tackle COVID-19 vaccine hesitancy. Pharm J 2020.
5. Heaton PM. The Covid-19 Vaccine-Development Multiverse. N Engl J Med 2020;383(20):1986–1988.
6. Vaccine trials need Black volunteers - The Washington Post [Internet]. [cited 2020 Nov 23]; Available from: https://www.washingtonpost.com/business/2020/10/27/covid-vaccine-trials-need-blacks/
7. Mensah GA. Black and minority health 2019: more progress is needed. J Am Coll Cardiol 2019;74(9):1264–1268.
8. The push for a COVID-19 vaccine [Internet]. [cited 2020 Nov 30]; Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines
9. COVID-19 Vaccine Predictions: Using Mathematical Modelling and Expert Opinions to Estimate Timelines and Probabilities of Success of COVID-19 Vaccines | Center For Global Development [Internet]. [cited 2020 Nov 24]; Available from: https://www.cgdev.org/publication/covid-19-vaccine-predictions

Shawn Luby is Assistant Professor in the Division of Clinical Laboratory Sciences at the University of North Carolina-Chapel Hill.

HOW ASCLS-HAWAII MOBILIZED TO SAVE IT

Sheri Gon, MPH, MLS(ASCP)^CM; Claire Muranaka, MLT(ASCP), ASCLS-Hawaii President; and Kristen Croom, MLS(ASCP)^CMMB(ASCP), ASCLS Region X Director

The University of Hawaii at Manoa Budget Committee initially recommended eliminating the Medical Technology Program to save money during the COVID-19 induced recession.

A distinguishing feature of ASCLS is that it serves as a grassroots professional organization. ASCLS provides a network of professionals across the nation to advocate for the medical laboratory profession. When an educational program was threatened with closure, the Hawaii ASCLS constituent society acted quickly to address the situation.

Timeline

COVID-19 was declared an outbreak by the World Health Organization (WHO) on January 30, 2020. By March 11, WHO called it a pandemic. On March 24, Hawaii Governor David Ige issued a statewide lockdown to minimize the spread of SARS-CoV-2, the virus that causes COVID-19.

The University of Hawaii System planned lockdown of all campuses at this time. All instruction moved to an online format beginning the week after spring break. No in-person instruction was allowed. This proved difficult for courses that require hands-on instruction.

A Budget Committee was formed at University of Hawaii at Manoa (UHM) and was tasked with review of all academic programs. Small programs, like Medical Technology that graduate 10-15 students per year, would be reviewed and possibly cut by the Budget Committee for the purpose of making UHM financially sound during the COVID-19 induced recession. This process of review by the Budget Committee was announced across all UHM programs.

By August, the Budget Committee submitted its initial recommendations to Provost Michael Bruno. Small programs would cost less to the university if merged into larger departments, restructured to increase enrollment, or eliminated. At the time of the initial report, the Budget Committee’s recommendation was to eliminate the UHM Medical Technology Program on the assumption that the Kapiolani Community College (KCC) MLT program could provide adequate numbers of personnel for the local medical laboratories. This assumption by the Budget Committee needed correction before any actions were to take place.

“We were able to mobilize the team and the letter writing campaign in a matter of days to ensure that our voices and concerns were heard.”

Fast-Acting Advocacy

A letter writing campaign was suggested by the ASCLS-HI leadership. The provost and Budget Committee needed to learn more about the different credentials (MLT and MLS) before they could make their recommendations final.

They also needed to learn how much the local medical laboratory industry relied on the UHM Medical Technology Program for staffing. Because of a national workforce shortage of medical laboratory personnel, hiring from the Continental United States is exceedingly difficult.

Once discussion of the threat to UHM Medical Technology was shared with the ASCLS-HI leadership, this news was forwarded to the national ASCLS office, CLMA Aloha Chapter, DOH Division of Laboratory Licensing, local laboratories (DLS, CLH), and alumni of the UHM Medical Technology Program. A letter from the ASCLS-HI leadership was addressed to the Budget Committee and Provost Bruno in time for the Board of Regents meeting on October 1. Letters from employers and alumni were sent to Provost Bruno in support of the Medical Technology Program.

The Board of Regents scheduled meetings with deans to get justification to continue their programs. This was planned for October 1. Dr. Jerris Hedges is the current dean of the medical school. Faculty of the UHM Medical Technology Program provided him information and statistics to share about the program when it was his turn to meet with the Board of Regents and Provost Bruno. It was important to distinguish the difference between MLT and MLS credentials and the amount of education required to achieve the BS-MLS certification.

There are overlaps in these two credentials, but expectations for decision making is much higher with the MLS certified professional. In addition, bachelor’s degrees are not awarded in community colleges. To maintain a steady source of MLSs would require an accredited program that results in BS-MLS graduates. There is no going around the fact that national standards dictate MLT and MLS education and certification.

Outcome

On October 13, the Budget Committee revised its recommendation to read, “Collaborate with KCC to increase numbers of students who enter the KCC program as well as the number who transfer to UHM to complete the 2+2 program.”

The ASCLS-HI leadership was thankful to have educators on the team to let us know this was occurring. We were able to mobilize the team and the letter writing campaign in a matter of days to ensure that our voices and concerns were heard. We were also thankful that we had lab leaders and bench techs on the team to provide real examples of shortages and how this will affect our ability to care for the patients. We are truly thankful for all our members that voiced their concerns to save the program.

Sheri Gon is an Instructor in the University of Hawaii at Manoa Department of Medical Technology in Honolulu, Hawaii.

Claire Muranaka is Senior Medical Lab Tech at Diagnostic Laboratory Services in Aiea, Hawaii.

Kristen Croom is Director of Laboratories, Pathology and Molecular Services, at the Queen’s Medical Center in Honolulu, Hawaii.