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STRONGERTOGETHER critical values | volume 8 | Issue 2

GlobalHEALTH

April 2015

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Global Health Issues are Domestic Health Issues

Growing ePathology Locally to Expand it Globally

Ensuring the Safety of Blood Donors and Recipients Worldwide

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critical values | volume 8 | issue 2

Senior Editor Molly V. Strzelecki

Contributing EditorSusan Montgomery, MBA

Art Direction and Design Martin Tyminski, MFA Copy Editor Janet Franz

ASCP Staff Advisers E. Blair Holladay, PhD, SCT(ASCP)CM

Chief Executive Officer Steven F. Ciaccio, CPA, CAEChief Operating Officer

STRONGERTOGETHER critical values | volume 8 | Issue 2

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©2015 Copyright by the American Society for Clinical Pathology (ASCP). Critical Values is published quarterly by the American Society for Clinical Pathology, a nonprofit professional society with more than 100,000 members working as pathologists and laboratory professionals. Free to members of ASCP, Critical Values presents news and feature stories about issues of compelling interest to all members of the laboratory team. Publication of an article, column, or other item does not constitute an endorsement by ASCP of the thoughts expressed or the techniques, organizations, or products described therein.

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STRONGERTOGETHER

Global Health When ASCP took its first step into the global healthcare arena, the Society had a very direct and unyielding goal: to improve health and patient care around the world. While that is still our ultimate objective, over the past 10 years we have expanded and diversified our reach, working in more than 90 countries. In doing so, ASCP has demonstrated that global health concerns and connects us all, and improving patient care through advancement, knowledge, and collaboration strengthens us.

ASCP has partnered with discerning organizations such as the Clinton Global Health Initiative, the Centers for Disease Control and Prevention, and the International Society of Gynecological Pathologists, helping provide better care for patients in many developing nations. We have played a major role in improving care for those with HIV/AIDS, serving as expert consultants through the President’s Emergency Plan for AIDS Relief. In December 2014, ASCP hosted its first Middle East Conference in Abu Dhabi, United Arab Emirates, bringing educational workshops to more than 300 laboratory professionals from the surrounding regions. We have a wealth of resources that can help raise healthcare standards around the world, and as a global leader in pathology and laboratory medicine we have a responsibility to contribute to the common good. Global health is local health, and sharing our knowledge benefits us all.

In this issue of Critical Values, our authors look at the issues in global health that are having an impact at home and abroad. In sub-Saharan Africa, patients are living longer with HIV/AIDS, and now healthcare workers face the new challenge of treating non-communicable diseases in these same patients. Drs. Guarner, Roberts, Nelson, and Wilson’s article, “Increasing Access to Diagnostic Capacity Needed for Cancer Care in Underdeveloped Regions,” explores the deficiencies in the current system. The authors note that, “Logistical and infrastructure barriers to cancer care are common. In many instances this may be due to lack of instrumentation or lack of reagents. In other cases it is due to a lack of technical expertise to both perform and interpret test results.” Despite these difficulties, there are solutions, the authors conclude, to provide better access to cancer care.

Last year, the Ebola epidemic swept across West Africa, and thousands of healthcare workers from around the globe traveled to cities and towns ravaged by the disease to aid in containing and stopping the deadly virus. Those providers risked their own health, and compelled health systems in the United States to re-examine their capacity for handling highly infectious and deadly diseases. In her article, “Global Health in the Clinical Laboratory,” Emily Lu Ryan, PhD, gives a firsthand account of preparing for and treating returning healthcare

workers who became infected themselves as they were treating others. Dr. Ryan and the team at Emory Healthcare underwent stringent protocols to protect themselves and the patients and to prevent the virus from spreading further.

In his article, “Growing ePathology Locally to Expand it Globally,” Thomas Bauer, MD, of the Cleveland Clinic shows how digital pathology and whole slide imaging can be used to help make diagnoses in countries where there is a severe shortage of pathologists. Dr. Bauer and his colleagues first developed an ePathology department at the Cleveland Clinic, and they are now exploring ways to implement this for remote consultations.

And finally, Susan Montgomery, communications writer, explores the work that Kevin Land, MD, and colleagues are doing to develop the U.S. Biovigilance Network and increase hemovigilance. Tracking information about adverse blood events to improve patient care in the United States has lagged in the past, but new strides in the effort have caught the attention of global organizations such as the World Health Organization and the International Society of Blood Transfusion.

By being proactive in our global healthcare efforts we strengthen our commitment to the pathology and laboratory community worldwide. We are not just Stronger Together here in North America, we are Stronger Together when we sync our efforts around the world.

Thank you for your continued support of ASCP. Please send me your comments and suggestions at [email protected]. My very best to each of you.

E. Blair Holladay, PhD, SCT(ASCP)CM

Critical Values

about

Like ASCP on Facebook Follow me on Twitter at @Blair_Holladay

Dr. Holladay is CEO of ASCP.



ASCP Staff Advisers E. Blair Holladay, PhD, SCT(ASCP)CM

Chief Executive Officer Steven F. Ciaccio, CPA, CAEChief Operating Officer


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4 critical values | April 2015

About Critical Values E. Blair Holladay

Leadership Messages Global Health Issues are Domestic Health Issues William G. Finn

Rising to the Challenge and Leading on Patient-Centric Global Priorities Diana Kremitske Tapping into Global Health OpportunitiesMaria Hintzke

Departments

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Increasing Access to Diagnostic Capacity Needed for Cancer Care in Underdeveloped RegionsJeannette Guarner, Drucilla Roberts, Ann Nelson, and Michael L. Wilson

Global Health in the Clinical Laboratory Emily Lu Ryan

Ensuring the Safety of Blood Donors and Recipients WorldwideSusan Montgomery

Growing ePathology Locally to Expand it Globally Thomas Bauer ASCP News

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By William G. Finn, MD, FASCP

Dr. Finn

Message from the PresidentLeadership Messages


On September 30, 2014, the Centers for Disease Control and Prevention (CDC) confirmed the first case of Ebola virus infection diagnosed in the United States.1 A man who had recently traveled to Liberia had presented the previous week to Texas Presbyterian Hospital of Dallas with symptoms compatible with Ebola, and laboratory testing in Texas and at the CDC subsequently confirmed the infection. Approximately eight days later the patient died as a result of the disease, and two days after that a nurse who had cared for him also tested positive for Ebola.1 She was subsequently transferred to the National Institutes of Health Clinical Center in Bethesda, Md., and survived the illness.

The first documentation of the emergence of Ebola in North America acted as a stark reminder of how small the world has become. Global health issues are de facto domestic health issues when the spread of infection is just a plane ride away. Last September at the Global Health Security Summit, referring to the Ebola outbreak in West Africa, President Barack Obama remarked that, “This epidemic underscores—vividly and tragically—what we already knew, which is, in a world as interconnected as ours, outbreaks anywhere, even in the most remote villages and the remote corners of the world, have the potential to impact everybody, every nation.”2 Over the past five years, keynote speakers at ASCP Annual



Meetings—including former President Bill Clinton, former first lady Laura Bush, her daughter Barbara Pierce Bush, former Secretary of State Hillary Clinton, and renowned global health advocate Dr. Paul Farmer—have reminded us that engagement in the global sphere of health care is good for the health of our people here at home.

ASCP’s challenge is to assure real-time response to rapidly emerging global health priorities for the benefit of our mem-bers and our patients. This responsibility hit home to the pa-thology and laboratory medicine community when there was word last October that a laboratory professional (who had handled laboratory samples from the Texas Ebola patient) had been quarantined on a cruise ship in the Caribbean.3 At

that point ASCP was out in front of Ebola education for our members, with rapid response to member questions and needs. ASCP quickly produced podcasts on this issue, includ-ing a session—available free of charge through the ONELab site—addressing the top 10 questions received from the membership. The questions are answered and discussed by two leading experts in the field of medical virology and epi-demiology: Dr. Nancy Cornish, a medical officer with the CDC Division of Laboratory Science and Standards, and Dr. Lance Peterson, director of microbiology and infectious diseases re-search at NorthShore University HealthSystem in Evanston, Ill.4 ASCP had previously published the firsthand account of the team from Emory University about managing laboratory support for a patient transferred from West Africa to Atlanta



Message from the PresidentLeadership Messages

for Ebola treatment,5 and quickly made available additional publications on the role of the laboratory in managing the Ebola outbreak.6,7

ASCP’s leadership has been established by years of engagement in the global health community, which puts us in a unique position to respond rapidly to the needs of members in an ever-shrinking world. We remain the principal pathology organization managing the training of laboratory professionals and the development of diagnostic infrastructure for AIDS relief in sub-Saharan Africa and other developing regions through the President’s Emergency Plan for AIDS Relief, with the full support and partnership of the CDC and the World Health Organization. We continue to work on global health priorities in concert with other non-governmental organizations such as the Clinton Global Initiative and the Bush Institute’s Pink Ribbon Red Ribbon campaign. The ASCP Board of Certification—for decades the marquis brand of excellence in certification of laboratory professionals—is active worldwide via the ASCPi credentialing process. We recently held our inaugural meeting of the newly formed ASCP International Commission as part of our first international educational conference in Abu Dhabi, United Arab Emirates, in December 2014.

Over the years, ASCP’s engagement efforts also have evolved to recognize the increasing importance of non-communicable diseases (NCDs) in the arena of global health.8 It may be more difficult to see the immediate local impact of global outreach efforts for diseases such as cancer, cardiovascular disease, or diabetes (not the kind of diseases that are a plane ride away). However, a recently published task force report from the Council on Foreign Relations (CFR) warns that “the United States has strong interests in not only increasing its engagement on the rising NCD epidemic in developing countries, but in doing so now.”9 The CFR report highlights projections from the World Economic Forum that the impact from NCDs will cost the economies of developing nations more than $21 trillion in the course of the coming decade—a total, the report points out, that is nearly equal to the annual economic output of these nations as of 2013, and that could have an impact on foreign support for U.S. strategic interests worldwide.

One year ago, ASCP Immediate Past President Dr. Steven Kroft wrote a piece in this space, titled “Making the Case for Global Health,” amid concerns by some that efforts to reach out to the developing world might not jibe with efforts to serve our members here at home.8 The events of the last year have highlighted the fact that this is no longer an “either/or” calculation. If we are to be prepared fully to face the emerging health challenges that affect us locally, it is imperative that we think and act in global terms. It is no longer an issue of “making the case.” It is instead an issue of appropriate pre-paredness for maintaining and protecting public health for our members and our patients—a responsibility that, in the 21st century, simply cannot be pursued solely within our borders.

References

1. Chevalier MS, Chung W, Smith J, Weil LM, Hughes SM, Joyner SN, et al: Ebola virus disease cluster in the Unit-ed States–Dallas County, Texas, 2014. MMWR Morbid-ity and mortality weekly report 2014;63(46):1087-8.

2. The White House Office of the Press Secretary: Remarks by the President at Global Health Security Summit. Available from: http://www.whitehouse.gov/the-press-office/2014/09/26/remarks-president-global-health-security-agenda-summit.

3. Healy J: Ebola is ruled out after cruise ship carrying hospital worker returns to Texas. New York Times. 2014 October 20, 2014.

4. OneLab: Ebola in the Laboratory: The Ques-tions That Keep You Up at Night. Available from: http://labculture.ascp.org/community/forums#plckforumid=Cat%3A83da8937-f5af-4186-b84b-7dac724f003dForum%3A59422721-7a61-4d1e-bb11-a1364565a7fb&plckforumpage=ForumDiscussion&plckdiscussiononpage=1&plckforumpostshowfi-rstunread=&plckfindpostkey=&plckdiscussionid=Cat%3A83da8937-f5af-4186-b84b-7dac724f003dForum%3A59422721-7a61-4d1e-bb11-a1364565a7fbDiscussion%3A06979afa-c541-4a09-8f0e-cc6215966120&plckforumpostonpage=1&plckpostid=.

5. Hill CE, Burd EM, Kraft CS, Ryan EL, Duncan A, Win-kler AM, et al: Laboratory test support for ebola patients within a high-containment facility. Lab Med 2014;45(3):e109-11.

6. Iwen PC, Garrett JL, Gibbs SG, Lowe JJ, Herrera VL, Sambol AR, et al: An integrated approach to laboratory testing for patients with ebola virus disease. Lab Med 2014;45(4):e146-51.

7. Iwen PC, Smith PW, Hewlett AL, Kratochvil CJ, Lisco SJ, Sullivan JN, et al: Safety considerations in the laboratory testing of specimens suspected or known to contain Ebola virus. Am J Clin Pathol 2015;143(1):4-5.

8. Kroft SH: The case for global health. Critical Values 2014;7(2):6-8.

9. Daniels Jr ME, Donilon TE, Bollyky TJ: Independent task force report no. 72: The emerging global health crisis: noncommunicable diseases in low and middle-income countries. New York: Council on Foreign Relations, 2014.

Dr. Finn is Medical Director of Warde Medical Laboratory and a partner at IHA Pathology and Laboratory Manage-ment in Ann Arbor, Mich.



Around ASCP Journals

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what’s the Correct Diagnosis? IgG4? Lupus lymphadenitis? Lymphoplasmacytic lymphoma? Angioimmunoblastic lymphoma? Castleman’s Disease?

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STRONGERTOGETHER

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The American Society for Clinical Pathology offers information and education that can aid your practice as pathologists or laboratory professionals. Whether you read the printed journals or get your information online, the American Journal of Clinical Pathology (AJCP) and Lab Medicine provide the latest research, reports, and studies. Here are some highlights from recent issues.

AJCPThe February issue of AJCP features a study by Drs. Geoffrey Wool and Anne Deucher on bone marrow necrosis, in which they performed a 10-year review of bone marrow biopsy specimens. The March issue has a commentary by members of the African Strategies for Advancing Pathology group on how diagnostic services are intricately linked to improved global health outcomes. In the same issue, Dr. Jeannette Guarner and colleagues describe their experience presenting a four-day laboratory medicine course to clinicians in Ethiopia. The April issue contains an article by Linda Andiric and Charles Massambu describing the implementation and improvement in the first groups of medical laboratories in Tanzania selected to participate in the training program on Strengthening Laboratory Management Towards Accreditation. These articles and others can be accessed at www.ajcp.com as part of your ASCP membership.

Lab MedicineThe Winter 2015 issue of Lab Medicine features a case study by Dr. Melkon DomBourian and colleagues that discusses a five-hour-old male neonate with cyanosis. Dr. Leon Su and co-authors focus on collaboration in their article, “Decreas-ing Preoperative Autologous Blood Donation: Collaboration Between a Hospital and a Blood Center to Prompt Change in Physician Ordering Behavior.”

Lablogatory has several bloggers writing about global top-ics that affect everyone. Dr. Joe Chaffin of “Blood Bank Guy” fame shares his knowledge about viruses such as Chikun-gunya and Dengue and the implications on the blood supply. Marie Levy writes about the fight against malaria and Bev-erly Sumwalt discusses the importance of personal protec-tive equipment. You can read these and more great posts by our expert bloggers at www.labmedicineblog.com.

If you’re interested in becoming a blogger, contact [email protected].



Ms. Kremitske

Global health initiatives encompass a variety of activities to support infrastructure development, education, accredita-tion, new or improved diagnostic capability, access to medical treatments, and also equitable healthcare delivery. They re-quire a multitude of coordinated actions by teams of individ-uals to provide support to resource-limited countries where severe health problems affect human survival.

Numerous examples of how laboratory medicine is needed in the context of global health can easily be found. For example, the U.S. Global Health Program website describes initiatives on eradicating AIDS, improving child and maternal health, and reducing infectious diseases.1 Another example is the emergence of Ebola and the infection prevention and control measures that must occur for handling suspected or con-firmed cases. Additionally, ASCP's Center for Global Health is demonstrating the Society’s commitment to address world health priorities through improving the quality of laboratory

medicine in severely impoverished countries. These are just a few of many examples of how the laboratory plays a vital role in global health solutions, and is rising to the challenge.

Promoting Awareness and Taking Action

ASCP’s goals include advancing patient-centric public priorities, and global health is aligned with this goal. The society is engaged in strengthening knowledge of laboratory practices and training workers in underserved parts of the world as part of its workforce development efforts. These efforts, supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) and initiated in conjunction with the Centers for Disease Control and Prevention, have enabled an outstanding level of commitment in countries that have a dire need for resources. Through ASCP’s Center for Global Health, members provide expert resources in the form of consultants and technical assistants for 17 countries, most

Message from the Chair of the Council of Laboratory Professionals

Leadership Messages

By Diana Kremitske, MHA, MS, MT(ASCP)

Rising to the Challenge and Leading on Patient-Centric Global Priorities




Leadership Messages

of them in sub-Saharan Africa, the Caribbean, and Southeast and Central Asia.2

ASCP continues to bring awareness to global health needs through its educational offerings. Distinguished speakers at ASCP Annual Meetings who are leaders of global health programs serve to heighten the awareness of specific global health concerns and demonstrate the alignment of ASCP’s patient-centric values on this imperative. Last year, at the 2014 Annual Meeting, I listened with interest as Barbara Pierce Bush described the work of Global Health Corps, and how individuals with different skill mixes outside of health professions are engaged and support each other to carry out this important work. Also, at the 2012 Annual Meeting, Dr. Doyin Oluwole explained the Red Ribbon Pink Ribbon campaign, focusing on women’s health needs—specifically breast and cervical cancer—in various African countries. It was truly inspiring to learn about their approaches to addressing serious health problems and how dedicated they are to these vitally important missions. They showed clearly how attention to global health demands strong leadership and collaboration. These were moments to reflect on how laboratory medicine contributes firsthand to the bigger picture of world health and makes laboratory practices better around the world.

Going into the Field

How are individual laboratory professionals expanding their reach in this arena? ASCP members are engaged in volunteering their time as consultants in global health outreach programs, traveling to underserved locations, and improving the host country’s laboratory quality and capabilities through education. I can only imagine the personal reward they feel when they share their expertise for such honorable causes. In these engagements, consultants are resourceful and overcome a variety of challenges. They are providing laboratory education where standards are quite different from those in the U.S. and where communication between the instructor and students may be challenged by language barriers. David Gingrich, PBT (ASCP)CM, member of the ASCP Commission on Science, Technology, and Public Policy, shared his experience as an ASCP outreach consultant, training members of the workforce in Dunshanbe, Tajikistan, on phlebotomy procedures and principles. It was a welcomed opportunity for 41 individuals who were trained over seven days with the help of interpreters. Differences in laboratory practices and laboratory personnel roles were apparent. Trainees in the sessions held the title of laboratory assistant or nurse and had a much broader role compared to the traditional role of a phlebotomist. Equipment that is common to well-equipped laboratories was all new to the Tajikistan trainees, including safety devices, wing sets, and multi-sample collection devices. Blood collection procedures were more commonly performed with a syringe and needle.3

Besides carrying out technical training programs, volunteers also address major infrastructure needs, such as lack of a laboratory information system (LIS). Just imagine a laboratory operation without the benefit of an LIS and the interfaced orders, results, electronic reporting, and quality

assurance tools that go with it. Or implementing an LIS where laboratory personnel have no experience with one. Raymond Aller, MD, FASCP, director of Informatics and clinical professor of Pathology at the University of Southern California, in a presentation at the 2014 Annual Meeting, described the following challenges and considerations. In limited-resource settings, an LIS in lab operations may not exist at all, may be inadequate, or be perceived as not needed due to non-automated testing methods, although laboratory information systems are useful in entirely manual laboratories. Economic resources to acquire a lab information system are not available. Practical designs, quality software, and systems that can withstand unforeseen external events such as power failures are important considerations. Internet access may not be reliable, so remote support would be challenging. Limited familiarity with an LIS by end users makes understanding of essential workflows difficult.4 You reset your thinking about what are the best LIS attributes and what is an effective implementation strategy under the conditions. The quality of the laboratory operation is improved by understanding these infrastructure needs and implementing an LIS that is best suited to them.

Would You Like to Rise to the Challenge?

If the prospect of getting more involved in global health interests you, one way to start is to become more informed about this topic. Get to know how our society is involved in global health initiatives by browsing the ASCP website at www.ascp.org and visiting the ASCP Institute for Science, Technology, and Policy, Center for Global Health section. Additionally, ONELab offers an interactive platform where laboratory professionals can share information and opinions on global health topics through blogs and participation in the online global health forum. There is much to learn about global health needs, and laboratory professionals who desire a career or volunteer opportunity in this field should feel confident that they are uniquely prepared by scientific and analytical training to be solid contributors.

References

1. US Global Health Programs. Retrieved from www.ghi.gov/index.html Accessed January 2015.

2. American Society for Clinical Pathology Institute for Sci-ence, Technology, and Policy Center for global health consultant opportunities. Retrieved from www.ascp.org/ISTP/Global-Outreach/Global-Outreach-Opportu-nities Accessed January 2015.

3. D. Gingrich, PBT (ASCP)CM, personal communication, January 16, 2015.

4. Aller, R., Kidane, S., Robinson, C. Majige, D., 2014. Pro-ceedings from 2014 ASCP Annual Meeting: Informat-ics for the Global Laboratory: Quality Lab Medicine in Resource-Limited Countries. Tampa, FL.

Ms. Kremitske is Vice President, Lab Operations, for Geisinger Health System in Danville, Penn.

ASCP takes that accolade very seriously which is why we invest so much time and effort into developing the best educational resources available. The activities below are just a sample of the many varied and comprehensive live education events and online courses that ASCP offers.

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Dr. Hintzke

By Maria Hintzke, MD

Leadership Messages

Message from the Chair of the Resident Council

is evidenced by the many roadblocks experienced in Sudan, including not having enough formalin or other transport media for surgical specimens, which often must travel countless miles across the country to be processed.

While each of these presentations provides an approximately 30-minute peek into the world of pathology, should our in-terest and attention really stop at the last PowerPoint slide as we return to the day’s cases? The easy answer, though perhaps not the correct one (especially since there’s still so

Each year during Global Health Week, residents and observers in my program give the department brief presentations about health care, and more specifically pathology, in their countries of origin. In past years, I’ve had the opportunity to get a glimpse of what medical systems are like in Peru, Ecuador, Egypt, Sudan, and Belarus, to name just a few countries. These presentations highlight not only many of the areas in which the United States is still lagging behind, such as a comparatively high infant mortality rate when juxtaposed to that in Belarus, but also demonstrate the great disparities that exist in the different healthcare systems. This

Tapping into Global Health Opportunities





much of this article left), would be yes. However, things are not that easy. If we try to ignore the world around us, we are bound to fail. Examples can be taken from this past year’s headlines in health care. Viruses such as Chikungunya and Ebola may have initially seemed like distant concerns in other countries, but quickly became major domestic concerns as well. As our world seems to get smaller and smaller, we real-ize just how interconnected we all are.

So, you may be wondering now, since we’re clearly not going

to settle with the easy answer, what can we as residents do beyond skimming the headlines in the Daily Diagnosis email from ASCP while walking to get a much-needed but not nec-essarily palatable cup of coffee from the hospital cafeteria? As I’ve always associated global health outreach as more com-mon for specialties such as surgery, internal medicine, and family medicine than with pathology, I was somewhat sur-prised to find when researching the topic that there are nu-merous opportunities for laboratory professionals, residents, and practicing pathologists to get involved in patient care on

Local laboratory professionals participated in ASCP’s Training of Trainers advanced hematology workshop in Gisenyi, Rwanda.


an international level. Several training programs including those at Massachu-setts General Hospital in Boston and Weill Cornell Medical College in New York City offer rotations during residen-cy in which residents have opportunities to work internationally. These rotations offer residents a venue to participate in laboratory quality-improvement proj-ects, research, and anatomic pathology service work including surgical pathol-ogy, cytopathology, and fine needle aspiration and autopsy performance in resource-limited countries like Uganda, Tanzania, Kenya, and Vietnam.

The benefits of such rotations are many. As the Mayo International Health Pro-gram outlines, the goals of these rotations include the fol-lowing: “(1) provide valuable care to underserved patients, (2) promote increased cultural awareness, (3) provide exposure to the diagnosis and treatment of diseases not usually seen in modern Western medicine, (4) increase awareness of cost-effective care in a setting of limited resources, (5) promote improvement of history and physical examination skills, [and] (6) provide opportunities for research.”1 The residents who participate in these rotations, regardless of specialty, attain many of these goals and more.

Are you interested in an international rotation but don’t know where to start? The American Medical Association (AMA) offers a guide to programs and organizations that offer international electives or other global volunteer opportunities as well as information regarding setting up international rotations for residency programs, which you can find here: http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/resident-fellow-section/rfs-resources/international-residency-opportunities.page? Is the cost of participating in a global outreach effort hindering you? ASCP recognizes the importance of these global opportunities. Through the ASCP Resident Council Subspecialty Grant, several residents have received funds to offset the costs of international experiences in both anatomic and clinical pathology.2

There are also numerous opportunities outside of residency-based rotations to make an impact on a global level. Many in-stitutions, such as Brigham and Women’s Hospital in Boston, provide telepathology services to countries such as Rwanda. This form of outreach helps improve patient care in countries in which clinical care and treatment often proceeds without the help of pathology, as is often the case in Rwanda and other resource-limited countries in which there may be just one or two pathology labs for more than 10 million people.3

Additionally, the Professionals Analyzing Pap Smears, Inc. (PAPS Team International), a California-based nonprofit or-ganization founded in 1999, sends volunteer healthcare teams composed of cytotechnologists, physicians, and nurs-es to Kenya to screen for cervical and breast cancer. These

Leadership Messages

teams not only screen for cancer and treat patients during their on-site visits, but they also ensure that this crucial patient care continues in the form of permanent, self-sustaining, accessible, and affordable clinics once the PAPS team leaves by pro-viding the necessary equipment, supplies, and training for healthcare professionals in the developing country.4 To date, three permanent clinics have been established and more than 10,000 patients have been screened.5

ASCP also recognizes the international significance of cervical cancer, which is currently the leading cause of cancer-related death in women in sub-Saharan Africa, and is working towards building

sustainable solutions in Botswana through alliances with the Botswana Ministry of Health, the University of Botswana, and the Bush Institute. “When ASCP announced it was seeking 10 cytologists to send to Botswana in May [2013] to allevi-ate a backlog of 7,500 Pap slides, 225 members volunteered within 24 hours. Altogether, more than 300 members have now offered to make the trip,” noted an ASCP press release.6

These types of global efforts could not happen without members like you. As you have made it this far reading this article, I’m glad that you didn’t settle on the easy answer and I hope that as an ASCP member you can contribute to making an impact globally. If you would like to share your own inter-national experience or know of any additional opportunities, please email me at [email protected].

References

1. Sawatsky A et al. “Eight Years of the Mayo International Health Program: What an International Elective Adds to Resident Education.” Mayo Clinical Proceedings August 2010; 85(8): 734-741.

2. Bruner E. “Pathology Residents Contend with Fewer Resources, More Patients in Need Overseas.” Critical Values April 2013; 6(2): 15-16.

3. Brigham and Women’s Hospital. “Fewer Specimens in Suitcases: BWH Telepathology Brings Rapid Diagnosis to Rwanda.” BWH Health Hub. http://bwhclinicalandre-searchnews.org/2013/08/27/fewer-specimens-in-suitcases-bwh-telepathology-brings-rapid-diagnosis-to-rwanda/ Accessed January 2015.

4. Titus, Mark. “In Focus: PAPS Team International.” Critical Values April 2008; 1(2): 18.

5. The PAPS Team International. http://www.the-paps-team.org. Accessed February 2015.

6. ASCP. “Cytologists’ Response to Botswana’s Appeal for Help ‘Astounding.’ http://www.ascp.org/Newsroom/Cy-tologists-Response-to-Botswanas-Appeal-for-Help-Astounding.html. Accessed January 2015.

Dr. Hintzke is a fourth-year pathology resident at the Medical College of Wisconsin in Milwaukee, Wis.

Cathy Robinson (center), international technical manager for the ASCP Institute for Science, Technology, and Policy, Center for Global Health, oversees participants practicing blood draws at a Namibian phlebotomy workshop.

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By Jeannette Guarner, MD, Drucilla Roberts, MD, Ann Nelson, MD, and Michael L. Wilson, MD

Global Health

Increasing Access to Diagnostic Capacity Needed for Cancer Care in Underdeveloped Regions

Dr. Guarner Dr. Roberts Dr. Nelson Dr. Wilson



As many developing countries experience growing economies, an expanding middle class, increases in residents’ longevity, and more urbanization, the need for access to health care to treat non-communicable diseases will rapidly increase.1 Of the non-communicable diseases, none poses a greater challenge than cancer. Not only are there many types of cancer, affecting all of the organs and tissues in the body, but the diagnosis of cancer requires a multiplicity of tests, treatments differ substantially among types of cancer, and the healthcare infrastructure needed to support both diagnosis and treatment differ from that needed to manage patients with most other chronic diseases.

Beyond treatment of individual patients, in countries with a cancer registry the diagnosis is entered into a database that allows the country to track the relative frequencies of cancers, along with other demographic information about cancer patients. As treatments are based on tissue diagnosis of cancer, these registries use the information from pathology

reports. In the U.S., registries draw data from information present in synoptic pathology reports.2 Thus it is obvious that cancer registries cannot exist without adequate pathology services. Moreover, as they mature, cancer registries provide important information to public health officials and administrators; they allow a country to define priorities in prevention and treatment guidelines, allocate resources, and develop long-term plans for teaching and training the future workforce. But in the absence of effective registries, none of this is possible.

As one example, many developing countries emphasize the diagnosis and treatment of cancers that are common in Western countries, even though emerging information suggests that other cancers may be more common in those places. Examples include squamous cell carcinomas of the conjunctiva, gestational trophoblastic disease, carcinoma of the esophagus, and cancers of the liver.3,4 In Africa, the AIDS malignancy consortium has taken an important step





in establishing databases for HIV-positive patients, but databases for malignancies not related to HIV infection do not exist or are very limited in most developing countries.

The Details Behind Diagnosis

The diagnosis of cancer typically begins with either devel-opment of signs and symptoms worrisome for cancer (e.g., unexplained weight loss) or with the discovery of a mass. Be-cause many diseases can give rise to a mass, the differential diagnosis is typically between infectious causes versus ma-lignant or benign tumors.

In countries where the incidence of infectious diseases is low, most masses are thought to be due to cancer. However, there are many inflammatory and infectious conditions that manifest as masses. Prime examples include solitary coin lesions in the lung presumed to be malignant but when resected are found to be infectious granulomas.

The opposite happens in countries where the incidence of infectious disease is high; in that instance the coin lesion may be assumed to be tuberculosis and the patient treated for infection. But if the patient has cancer that was never diagnosed, the tuberculosis treatment will fail and the

resources will be wasted. Moreover, the patient’s disease will be classified as an infection, resulting in misclassification of disease and misallocation of future resources due to inaccurate information. Unfortunately, the second scenario is the reality in many countries in Africa where there are no local pathologists—or where a resected specimen sits in formalin for months before a diagnosis is rendered.5

Once a cancer diagnosis is made, what is expected in developed countries is very different from what occurs in other parts of the world. In addition to not always having the same array of treatments offered in developed countries, support services for patients receiving chemotherapy and radiotherapy may not exist.

In developing countries, several examples from the laboratory perspective are illustrative. If a patient develops pancytopenia and fever, microbiology laboratory services may be inadequate to pinpoint a source of infection. Even where microbiology services are available, the use of manual versus automated systems can result in delays in diagnosis. Both scenarios result in the use of broad-spectrum antibiotics, contributing to the spread of bacteria resistant to multiple antibiotics. Pancytopenic patients may also need platelet transfusions for severe thrombocytopenia or packed red blood cells for





anemia. But not only are blood banks uncommon in many areas, even when present they often provide only whole blood, which constitutes 80 percent or more of the blood products available in many developing countries. For patients with anemia, giving whole blood helps (at the expense of some degree of volume overload), but the platelets available in refrigerated whole blood are not functional and cannot be used to treat thrombocytopenia. In addition, replacement of clotting factors is not possible in developing countries that do not fractionate blood products.

Improving Access to Care

Logistical and infrastructure barriers to cancer care are com-mon. Tumor markers that may be useful for screening, diag-nosis, staging, or to monitor presence of recurrences may not be available. In many instances this may be due to lack of in-strumentation or lack of reagents. In other cases it is due to a lack of technical expertise to both perform and interpret test results. Inconsistency in the supply of reagents may impact not only tumor marker measurement, but also performance of more basic laboratory work such as complete blood cell counts and chemistry tests.

Up to this point, much of the funding for improving access to cancer care in Africa has been project oriented.6 Although these projects have provided some degree of infrastructure, which could be leveraged to diagnose and treat malignancies not included in specific projects, this is not always possible. Although reasons differ, many projects are restricted to specific issues due to the way funding streams are structured, or limitations due to the need to collect data on only a specific cancer or group of cancers. Most important, the majority of projects are limited to a specific area, often to a specific hospital and for a limited time period. Patients outside that system typically do not have access to resources within the project.

Another issue with pathology services in Africa is the disparity between public and private institutions. Although private laboratories are common in sub-Saharan Africa, with histologic and immunohistochemical capabilities, most people in poor countries where the pathology infrastructure is less well -developed depend upon public hospitals for care. Improving public institutions’ anatomic pathology services should be a priority and is a necessity for improved cancer care.

Making Changes, Enhancing Care

Access to tissue diagnoses for patient care and to create cancer registries is also vital, but in many parts of Africa there is little access to the pathology services needed. In one study in Kampala, Uganda, from 1994 to 1996, tissue diagnoses were available for 68.9 percent of cancer registry patients; a study in the same city a few years later showed a decrease to 58.6 percent for patients in that registry.7,8 This is not limited to Africa: in other areas of the world even baseline data regarding the relative prevalence of benign versus malignant conditions is lacking.9

Advocacy should come from patients demanding improved and increased access to cancer care, from providers demand-ing the ability to provide that care, and from administrators demanding the ability to offer the resources to their provid-ers. Epidemiologists should demand that good registries be developed and that data from these registries be used to drive treatments and support services needed for cancer care. At the highest level, advocacy should come from public officials, who need to demand increased allocation of resources and development of cancer treatment programs on a larger scale.

References

1. World Health Organization. 2008-2013 action plan for the global strategy for the prevention and control of non-communicable diseases. Geneva: World Health Or-ganization.

2. Hassell L, Aldinger W, Moody C, Winters S, Gerlach K, Schwenn M, et al. Electronic capture and communica-tion of synoptic cancer data elements from pathology reports: results of the Reporting Pathology Protocols 2 (RPP2) project. J Registry Manag 2009;36:117-24.

3. Masanganise R, Rusakaniko S, Makunike R, Hove M, Chokunonga E, Borok M, et al. A historical perspective of registered cases of malignant ocular tumors in Zim-babwe (1990 to 1999). Is HIV infection a factor? Cent Afr J Med 2008;54:28-32.

4. Yakasai I, Ugwa E, Otubu J. Gynecological malignancies in Aminu Kano Teaching Hospital Kano: a 3 year review. Niger J Clin Pract 2013;16:63-6.

5. Mpunga T, Tapela N, Hedt-Gauthier B, Milner D, Nshi-miyimana I, Muvugabigwi G, et al. Diagnosis of cancer in rural Rwanda: early outcomes of a phased approach to implement anatomical pathology services in resource-limited settings. Am J Clin Pathol 2014;142(4):541-5

6. Adewole I, Martin D, Williams M, Adebamowo C, Bha-tia K, Berling C, et al. Building capacity for sustainable research programmes for cancer in Africa. Nat Rev Clin Oncol 2014;11:251-9.

7. Parkin DM, Wabinga H, Nambooze S. Completeness in an African Cancer Registry. Cancer Causes & Control 2001;12:147-152.

8. Wabinga H, Parkin DM, Nambooze S. Kampala Cancer Registry Report for the Period 2007-2009. Kampala, Uganda: Kampala Cancer Registry, 2012.

9. Roberts DJ, Wilson ML. Improving diagnostic pathology capacity for global cancer care: where to start. Am J Clin Pathol 2014;141:150-151.

Dr. Guarner is in the Department of Pathology at Emory University School of Medicine in Atlanta, Ga. Dr. Roberts is in the Department of Pathology at Massachusetts General Hospital in Boston, Mass. Dr. Nelson is at the Joint Pathol-ogy Center in Silver Spring, Md. Dr. Wilson is in the De-partment of Pathology and Laboratory Services at Denver Health in Denver, Colo., and Editor in Chief of the American Journal of Clinical Pathology.

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By Emily Lu Ryan, PhD

Global Health in the Clinical Laboratory

Global Health

Dr. Ryan

How Emory prepared for and treated U.S. healthcare workers with the Ebola virus





Clinical laboratory testing is the lifeblood of medical practice in the United States. Nonspecific testing, like a complete blood count (CBC) and differential, is performed on almost everyone who seeks emergency medical care. Testing has become so ubiquitous that point-of-care glucose meters are standard of care in most hospital settings. Can you imagine a medical setting without testing? How would you monitor electrolytes and fluids? What would happen if you removed the glucometers from your hospital?

As difficult as it is for us to imagine, this situation is not un-common in many other parts of the world. As recently as May 2013 in West Africa, the region currently dealing with an Eb-

ola epidemic, there was only one clinical laboratory, located in Mali.1 In many countries, in fact, it is not unusual for treat-ment to be administered without clinical testing. That’s one of the reasons American healthcare workers infected with Ebola were flown back to the United States for treatment.

On Thursday, July 31, 2014, the Emory Serious Communi-cable Diseases Unit (SCDU) at Emory Healthcare in Atlanta was called upon to receive and treat the first of these Ebola patients. Preparations began immediately and we had only 48 hours to ready the facility. We verified calibrations, col-lected sufficient reagents and materials, revised protocols, and reviewed the test menu with the clinicians. The SCDU

had specific point-of-care instruments reserved for laborato-ry testing for patients admitted to the unit,2 and while these instruments had been maintained with proficiency testing and comparison testing every six months, they otherwise had rarely been used. Laboratory professionals brushed up on safety and personal protective equipment (PPE) training and procedures. The original SCDU group had been preparing for years, with drills every six months.

There was a possibility that a second patient could arrive (the unit had previously treated only one patient at a time), and a group of us were introduced to these activities for the first time. Saturday morning we learned how to properly put on and remove all the required PPE; training included learning to take off paint-covered gloves under black light without splashing paint anywhere. Because of the complicated PPE, every laboratory professional was assigned a safety buddy to help with donning and doffing the PPE as well as supervising testing. As always, the first tools in a laboratory’s arsenal are excellent technicians, but even the best can sometimes forget and put things on the grate in front of the biosafety cabinet instead of all the way inside; this tiny disruption in airflow renders that protective engineering control ineffective. It was therefore the safety buddy’s job to make sure such simple actions were properly performed to maximize the safety of all involved. The mantra of “safety first” was applied at every step of the process.

Our testing menu has always been minimal but sufficient for our infectious disease physicians. It historically consisted of a blood gas analyzer with electrolyte measurements via ion-selective electrodes, a Piccolo chemistry analyzer, a standard dipstick urinalysis reader, and a hematology analyzer. Early in

our preparation for the Ebola patients we discovered our orig-inal hematology analyzer had developed a leak and stopped working. Through a series of discussions with the care team and tech support, we decided the physicians would work with the hemoglobin and hematocrit from the blood gas analyzer and the international normalized ratio (INR) value from the CoaguChek until we could get a new hematology analyzer for the rest of the CBC. Our infectious disease physicians were thankful for every test we could offer these healthcare work-ers, and let us know what was needed as first, second, and third priorities once the patients arrived.

Patient in Residence

Things went well—even better than we could have dreamed —two days later when the first patient arrived. Our hematology analyzer arrived a few days later and began operation after we made sure it functioned within parameters, performing a short validation study and review of instrument comparison data. An added benefit of the new analyzer was that it was a completely closed system; it could sit on the counter and free up precious space inside the 4-foot-wide biosafety cabinet. Once it was up and running, a CBC was added to the daily laboratory workup.

Our initial procedure dictated that laboratory professionals would run the INR analyzer, a requirement that became problematic. If a physician ordered an INR to check the patient’s clotting time, the unit’s nurse coordinator had to call the laboratory professional on duty, who then had to call his or her safety buddy, and they both had to get to the unit (one or both may not have been on-site), gown up, enter the lab, and perform the test. This process could take more

Santibhavank P / Shutterstock.com



26 critical values |

than two hours, severely delaying patient care. To resolve this problem, we trained and fully assessed competency of the SCDU nursing staff, who agreed to run the point-of-care INR (which they do at other locations in Emory Hospital) for the rest of the patients’ visits. Situations such as this required flexibility, creative problem solving, and a clear understanding of regulations, all essential skills in laboratory management.

A few days into treatment, there were discrepant potassium results between the blood venous ion-selective electrode (ISE) value and the enzymatically derived chemistry value on the Piccolo. The on-call physician asked me which measure-ment he should use for treatment. Given the slight hemolysis (2+) and my familiarity with ISE methods, I determined the blood gas value was more reliable. This exchange made me wonder how these questions are answered in field hospitals in Africa that may not have running water, let alone sufficient air conditioning to keep instruments within specifications. There they can treat only the symptoms they can see, such as vomiting and diarrhea, and do not always have the capacity to test for issues such as organ failure or DIC.

Staff at each U.S. institution that treated Ebola patients made different decisions about which tests to offer, how often to test, and which instruments to use. These decisions were driven by the availability of instrumentation, the physical setup of the hospital and laboratory, the clinical history of the patient, and the acuity of illness. What all these sites had in common was the availability of laboratory testing to inform and support the clinicians treating these patients. This illus-trates a stark difference between Ebola treatment here and in West Africa. It is amazing that people survive this devastating disease with the minimal testing and intervention available in most field hospitals. There is ongoing conversation in popu-

lar media and medical literature about health disparities and how this current Ebola epidemic is a global issue (as of Janu-ary 10, 2015, 8,000 lives have been lost to Ebola). As a clini-cal laboratory professional in the U.S., what can we contrib-ute to the fight against Ebola? Shipping off instruments and reagents to help would be useless; these instruments require stable electricity and are too sensitive to dirt, dust, and heat.

But it’s important to educate people about the trials we faced and the resources we used to treat individuals with Ebola here, and ask people to consider the great difficulties and challenges healthcare workers encounter when treating Ebola elsewhere. Technology is always improving, and one day there may be laboratory instruments robust enough to work in the sort of environment these workers face. But, until then, we can rely only on the knowledge gained through this process of treating patients with a devastating disease like Ebola, and share our insight with others.

References

1. Schroeder LF, Amukele T. Medical laboratories in sub-Saharan Africa that meet international quality standards. Am J Clin Pathol June 2014;141:791-795

2. Hill C, Burd E, Kraft C, Ryan E, Duncan A, Winkler A, Cardella J, Ritchie J, Parslow T. Laboratory test sup-port for ebola patients within a high-containment facility. Lab Med 2014 45:e109-e111.

Dr. Ryan is a Clinical Chemistry Fellow in the Department of Pathology at Emory University School of Medicine in Atlanta.

A schematic of the isolation unit at Emory Healthcare. Photo courtesy of Emory Healthcare.



Global Health





Ensuring the Safety of Blood Donors and Recipients Worldwide By Susan Montgomery

Blood transfusions and blood-related products are admin-istered to millions of people around the world each year, with approximately 108 million donations of blood collected worldwide annually.1

The medical laboratory plays a critical role in ensuring the safe-ty of blood donors and patients who receive blood transfusions and blood products through effective safety protocols. While blood donor and recipient safety efforts are still in their infancy in the United States, they are expanding in part because of a new database to store and analyze this information.

“Until recently, the United States had no systematic and stan-dardized way to capture adverse event data for blood dona-tions and transfusions, which limits the ability to improve outcomes and develop best-practice policies,” says Kevin Land, MD, FASCP, senior medical director of Field Operations at Blood Systems, Inc., in Scottsdale, Ariz., and chair of the AABB’s Donor Hemovigilance Working Group.

“The United States has needed to track standard and more complete information about blood, tissue, and cell therapy-related adverse events to investigate their causes and out-comes, and to improve the quality of patient care,” says Dr. Land, who is also a member of AABB’s overarching Hemov-igilance Steering Committee and the International Society of Blood Transfusion (ISBT) Donor Vigilance Committee. “While vigilance efforts were occurring within several individual United States blood collection facilities, the processes were essentially manual and institution-specific.”

Hemovigilance is the blood-specific aspect of biovigilance. Hemovigilance systems emerged when epidemics such as AIDS threatened the blood supply, leading to the deaths of thousands of individuals who had received tainted blood-related products. The first hemovigilance systems were de-veloped in Europe in the early 1990s. In 1998, the European Haemovigilance Network was established; its goal was to create uniform standards and definitions. Recently renamed the International Haemovigilance Network (IHN), the group has expanded to include countries outside of Europe.2

Global Health



More than five years ago, the U.S. Food and Drug Adminis-tration (FDA) determined that the United States was lagging behind other countries, especially Western Europe, in the he-movigilance of donors and recipients. Specifically, there was no single centralized system to monitor blood safety. This is derived from a report, “Biovigilance in the United States, Efforts to Bridge a Critical Gap in Patient Safety and Donor Health,” which was drafted in response to the 2006 FDA Ad-visory Committee on Blood Safety and Availability recom-mendations (and concurrence by the Assistant Secretary of Health) and stated: 3

• that the Department of Health and Human Services (DHHS) coordinate Federal actions and programs to support and facilitate biovigilance in partnership with private sector initiatives, and

• that DHHS form a task group to perform a gap analy-sis of current systems and make recommendations for public-private partnerships in biovigilance (blood, cell, tissue, and organ therapies).

The report noted the absence of a cohesive national hemo-vigilance program. It specifically pointed out the absence of:

• Long-term stability• National scope • Multicenter design• Common definitions• Broad data access and sharing• Real-time data availability• Active use to document practice improvement

The FDA issued a call to systematically address the situation. The DHHS and the AABB partnered to develop the U.S. Bio-vigilance Network to collect and analyze nationwide data to reduce adverse events associated with a broad range of bio-logic therapies. Dr. Land now chairs the Donor Hemovigilance arm of the network, comprising representatives from Amer-ica’s Blood Centers, the American Red Cross, hospital-based blood collectors, the U.S. Armed Forces, the Plasma Protein Therapeutics Association, Canadian Blood Services, ISBT, and IHN. An outside vendor, KBSI, developed the software.

Since the inception of the Donor Hemovigilance Working Group in 2007, 22 blood collection facilities across the United States have implemented, or are in varying stages of imple-menting, the donor hemovigilance system. Meanwhile, the U.S. Centers for Disease Control and Prevention (CDC) is now coordinating hemovigilance efforts to capture adverse event data for patients who have received blood transfusions or blood-related products. Adoption for both efforts has been slowed by competing priorities within institution information technology systems, although the importance of these ef-forts is understood.

“Last year, the donor hemovigilance committee published our first annual report using 2012 data,” says Dr. Land. “We are in the process of writing the 2013 report now.”

Adverse reactions from 1,171,906 individual donations were represented from the five blood collection facilities that had contributed sufficient denominator data (univariate) to be included in the report.4 All but 1 percent of these donations were allogeneic. The data demonstrated that of the 148 potential donation-related data points, many are not cur-rently captured or easily extracted from current blood es-tablishment computer systems (BECS). Data elements such as simple donor demographics are easily available, but even data elements such as donor weight and blood pressure are not always recorded electronically. Device-related variables (manufacturer, model, software version, kit type, etc.) are dif-ficult to obtain electronically at this time.

The annual report is mainly seen as a baseline report to which future reports can be compared. Interesting results include the demonstration that while 11 percent of donors are high school age, 61 percent are at least 40 years old and 21 per-cent are at least 60 years old. Younger donors are more likely to donate during the traditional American school year rather than during the summer, while donors 30 and older show a relative increase in donations during the summer. First-time donors are most likely to have an adverse reaction, regard-less of their age, and younger donors with low body mass are particularly susceptible to vasovagal reactions. Hematoma/

International Reporting Community Grows Rapidly

The World Health Organization (WHO) established an International Reporting and Learning Systems (RLS) Community of Practice in 2008 at a confer-ence at Johns Hopkins University, Baltimore. Since then, the RLS Community has expanded to include a global community of patient safety and adverse event experts who share knowledge, innovations, and best practices. The RLS community strives to validate interventions and broaden awareness of reporting and learning systems issues globally.1

The WHO jointly launched a global consultant on hemovigilance program with the United Arab Emir-ates, the International Haemovigilance Network, and the International Society of Blood Transfusion in November 2012 in Dubai, UAE.2 The United States was represented by the Centers for Disease Control and Prevention and the AABB. Among the pro-gram's recommendations was a proposal to estab-lish formal adverse reaction reporting mechanisms for both donor and patient safety.

References1. http://www.who.int/patientsafety/imple-

mentation/reporting_and_learning/en/ 2. http://www.who.int/bloodsafety/haemo-

vigilance/global_consultation/en/



bruise reactions occur at a small but steadily increasing rate as donors age.5

The most encouraging aspect of the data, according to Dr. Land, is that blood collection facilities are finding ways to use the data to drive improvements. Innovative uses for the data include assessing post-implementation effectiveness of risk reduction strategies such as pre-hydration stations and salt replacement initiatives, restriction of blood donations based on new total blood volume calculations, and the impact of tension training on donor adverse events. Facilities have also used the data to identify statistical sampling sizes needed for auditors, simplify managerial review of donor adverse events (standard reports are included in the software), and improve donor recruitment. “Current BECS are not designed to allow easy access and analysis of the data they store,” says Dr. Land. “Our system frees data and allows centers to easily answer their questions using their data, almost in real time. The donor hemovigilance database is demonstrating that great data can be used for a variety of reasons, not just for surveillance.”

Additional blood centers and hospitals that have blood col-lection facilities—in the U.S., Europe, and the Americas—are also interested in joining this initiative. The challenge is how the initiative will be funded moving forward. The DHHS pro-vided the funding for the initial buildout phase. “We are very grateful for all of the support we have received from DHHS,” Dr. Land says.

Going Global

A promising new development is the merging of the U.S. Do-nor Hemovigilance initiative’s data set with that of the ISBT Donor Hemovigilance Data Set. “We now have a combined worldwide ontology, or standardized vocabulary,” Dr. Land says. “At the onset of our program, we used ISBT’s existing definition set. We changed and expanded those definitions based on recent developments in literature, research, and publications, while including the international community in the discussions. We didn’t want a U.S.-only solution.

“The definition set was near completion when ISBT estab-lished a working group to update their donor hemovigilance definitions," Dr. Land continues. "That group graciously re-viewed the U.S. Donor Hemovigilance definition set and determined that except for six items, ISBT agreed with the changes we had made. The ISBT and AABB committees got together and found acceptable compromises for all six items, and the final definition set was approved by both organiza-tions late last year. A joint publication to announce the final definition set is underway. It is very exciting.”

The World Health Organization (WHO) is interested in the Do-nor Hemovigilance group’s work on the definition set. WHO does not have a formal definition set at this point, but is ac-tive in overall donor hemovigilance, especially in framing the structure that countries should use to develop their own mon-itoring system. “When international blood organizations are interested in the work you are involved in, it does validate that the topic you are working on is important and that the group’s

efforts have reached a certain stage of maturity,” says Dr. Land, who was named the 2012 Modern Healthcare Top Clinical In-formaticist for his work on this project and on patient safety.6

The next steps are for the Hemovigilance Steering Committee in the U.S., which includes the Donor Hemovigilance Commit-tee, the CDC’s (Patient) Recipient Hemovigilance Committee, and other aspects of hemovigilance to come together to work with the international organizations.

Obtaining the funding sources to expand the project inter-nationally will take time. Yet, from a global standpoint, the benefits will be invaluable. This initiative will: 1) improve blood donor and patient safety in developing and developed countries, and help establish national policies on safety; 2) ensure a continuous process of data collection and analysis is maintained; 3) utilize standardized policies and definitions that will allow vendors to more readily provide solutions to automate the collection and analysis of critical data; and 4) require facilities to demonstrate use and interoperability of their IT solutions to improve patient care, as meaningful use progresses from Stage 1 and ultimately to Stage 3. Standard-ized definitions and numerator and denominator data greatly simplify the effort to generate meaningful metrics.

References

1. Blood Safety and Availability Fact Sheet No. 279, updated June 2014, World Health Organization, www.who.int/mediacentre/factsheets/fs279/en/, Accessed January 2015.

2. Biovigilance in the United States: Efforts to Bridge a Critical Gap in Patient Safety and Donor Health, 3.0 Global Models of Comprehensive Hemovigilance, De-partment of Health and Human Services, pg. 16. https://wayback.archive-it.org/3922/20140403203201/ http://www.hhs.gov/ash/bloodsafety/biovigilance/ash_to_acbsa_oct_2009.pdf, Accessed January 2015.

3. Biovigilance in the United States: Efforts to Bridge a Critical Gap in Patient Safety and Donor Health, 4.4 A New Initiative: A Public-Private Partnership in Hemov-igilance Surveillance Reporting, Department of Health and Human Services, pg. 39. https://wayback.archive-it.org/3922/20140403203201/http://www.hhs.gov/ash/bloodsafety/biovigilance/ash_to_acbsa_oct_2009.pdf, Accessed January 2015.

4. 2012 AABB Donor Hemovigilance Report, Donor Infor-mation, pg. 5

5. www.aabb.org/research/hemovigilance/Pages/donor-hemovigilance.aspx. Accessed January 2015.

6. 2012 AABB Donor Hemovigilance Report, Donor Demographics, pg. 5 www.aabb.org/research/hemo-vigilance/Pages/donor-hemovigilance.aspx. Accessed January 2015.

7. Top 25 Clinical Informaticists, Modern Healthcare, Nov. 3, 2012, http://www.modernhealthcare.com/ar-ticle/20121103/MAGAZINE/311039952/top-25-clini-cal-informaticists-text-list. Accessed January 2015.

Ms. Montgomery is a Communications Writer for the American Society for Clinical Pathology.


Global Health

Growing ePathology Locally to Expand it Globally The recent development of high-resolution scanners capable of creating high-quality digital images of microscope slides has created the opportunity for pathologists to apply digital imaging and electronic workflow to education, research, ar-chiving, quality assurance, image analysis, and diagnosis. At the same time, the development of Internet-based image-sharing applications allows consultant pathologists to have secure access to the digital images along with the associated clinical information needed to provide a diagnosis to a client at a remote location.

Approximately 85 percent of the world’s subspecialist pa-thologists are located in the United States, while some parts of the world have a severe shortage. For example, there is one pathologist for approximately every 17,000 people in the U.S., whereas China has one for every 74,000 people. We at the Cleveland Clinic, like those at several other institu-tions, think digital technology can provide patients and cli-ent pathologists around the world with access to consultant pathologists, enabling consistent care across the globe and creating new revenue streams for anatomic pathology labo-ratories. Similar resources can be used to provide centralized subspecialty interpretation of frozen sections from regional hospitals and outpatient surgery centers.1

However, implementing whole slide imaging (WSI) in a large academic pathology department is a complicated process (see sidebar on page 34). Several years ago, anticipating an important role for digital imaging in the future, we estab-lished a section within our Department of Anatomic Pathol-

ogy designated “ePathology” that is composed of several scanning technicians, an IT specialist, an administrative di-rector, and a part-time medical director. We evaluated mul-tiple systems from different vendors, analyzed workflow for several intended uses, then gradually built experience and support among the large group of pathologists who we an-ticipated would use the system.

We started by promoting digital imaging for research and ed-ucation, then developed a comprehensive digital education li-brary that we made freely available to all staff and residents. We converted almost all education conferences to digital, and established a Web portal that allows our pathologists to share digital cases with selected participants in courses or lectures worldwide. Focusing first on education provided valuable resources and also gave the staff pathologists in our department, now numbering nearly 100, experience navigat-ing WSI. The pathologists also gradually developed confi-dence in their ability to make diagnoses from digital images.

Developing Innovation

As of early 2015, WSI has not yet been cleared by the Food and Drug Administration for primary diagnosis in the U.S. But regardless of the ultimate regulatory pathway, the adoption of WSI for diagnosis, like any new test adopted by a labo-ratory, needs to be internally validated. A working group of the College of American Pathologists has published rec-ommended guidelines for validating WSI for diagnosis.2

By Thomas Bauer, MD, PhD Dr. Bauer

April 2015 | critical values 33




Parallel to the development of those guidelines, we did our own intra-observer concordance study intended to validate the interpretation of WSI for primary diagnosis for routine cases of the type seen in both the subspecialty practice model we have at our main campus and in a more community-oriented practice of our affiliated regional hospitals.3 More specifically, we hypothesized that whole slide imaging review would be non-inferior to microscope slide review, and that it would be considered non-inferior if it showed 4 percent or fewer major discrepancies compared to microscope slide review.

Before starting the study we consulted with a statistician who calculated that a review of 464 cases might be need-ed to establish non-inferiority. Two pathologists ultimately reviewed a total of 607 cases comprising more than 1,000 individual diagnoses. There were nine major discrepancies (3 percent), but in four of those nine cases, the diagnosis made from the digital image was actually better than the original diagnosis made more than one year prior from microscope slides, yielding an adjusted major discrepancy rate of only 1.65 percent. The cases with major and minor discrepancies were of the types commonly encountered in surgical pathol-ogy, and some of them had been “shown around” to develop a consensus diagnosis at the time of original interpretation. We interpreted our results to support the use of WSI for primary diagnosis of routine surgical pathology cases.

Limitations of that study included participation of only two pathologists and use of consecutive, routine cases, many of which were relatively easy to interpret. Therefore, we did a second intra-observer concordance study using more dif-ficult cases that had been submitted to the Cleveland Clinic for consultation.4 That study involved 26 pathologists from 11 subspecialty groups who interpreted 217 consultation cases (301 total diagnoses) using both microscope slides and WSI with a mean “wash-out interval” of 44 days. The results showed only 1 percent major discrepancies, and those dis-crepancies again involved difficult cases for which different

interpretations among pathologists are recognized to be rela-tively common.

Putting ePathology into Practice

We interpreted these results to support the use of WSI for diagnosing consultation cases, and we have since established and launched formal agreements with two institutions in China and are evaluating additional relationships with other hospitals and reference labs both in the United States and around the world. Improvements are still needed to optimize ePathology. For example, additional development is neces-sary with respect to interfaces between imaging hardware, viewing applications, and our laboratory information system. Our workflow for generating final reports and submitting those reports to remote clients also currently lacks efficiency, and prompt communication between clients and consultants is important when microscope slides need to be rescanned or when special stains are required. But, in general, our experi-ence with these consultation cases has been very encourag-ing so far.

Another potential application of WSI is for the remote inter-pretation of frozen sections. As part of an effort to consolidate anatomic pathology services within a complex multi-hospital system, and at the same time offer subspecialty interpreta-tion of frozen sections to our surgical colleagues, we are in the process of deploying scanners and network support to 13 af-filiated regional hospitals and outpatient surgery centers. We are encouraged by the experience of Dr. Andrew Evans and coworkers1 and anticipate launching this service throughout our system in the second quarter of 2015.

References

1. Evans AJ, Chetty R, Clarke BA, Croul S, Ghazarian DM, Kiehl TR, Perez Ordonez B, Ilaalagan S, Asa SL. Primary frozen section diagnosis by robotic microscopy and virtual slide telepathology: the University Health Network experience. Hum Pathol. 2009;40:1070-1081.

2. Pantanowitz L, Sinard JH, Henricks WH, Fatheree LA, Carter AB, Contis L, Beckwith BA, Evans AJ, Lal A, Parwani AV. Validating whole slide imaging for diagnostic purposes in pathology: guideline from the College of American Pathologists pathology and laboratory quality center. Arch Pathol Lab Med. 2013;137:1710-1722.

3. Bauer TW, Schoenfield L, Slaw RJ, Yerian L, Sun Z, Henricks WH. Validation of whole slide imaging for primary diagnosis in surgical pathology. Arch Pathol Lab Med. 2013;137:518-524.

4. Bauer TW, Slaw RJ. Validating whole-slide imaging for consultation diagnoses in surgical pathology. Arch Pathol Lab Med. 2014;138:1459-1465.

Dr. Bauer is Medical Director for ePathology and Medical Director of the Cleveland Clinic Central Biorepository in Cleveland.

Implementing Whole Slide Imaging for Diagnosis

• Establish a digital pathology core center• Evaluate and select WSI system/vendor• Detailed workflow analysis• Build support among pathologists

who will use the system• Validate the WSI system for

the intended use• Build or buy Internet-based image-

sharing/reporting application• User training (technicians and

pathologists)• Launch WSI service• Quality assurance



Creating Sustainable Healthcare Systems Around the Globe

Over the past decade, ASCP has expanded its footprint to provide education, certification, and advocacy on behalf of patients, pathologists, and laboratory professionals in more than 90 countries around the world. This is critical in an in-creasingly connected world, where diseases move more freely than ever before and populations are often unprepared to address them. Changes in the development, implementa-tion, interpretation, and communication of medical laboratory tests are constantly evolving and in perpetual motion. The molecular and genetic basis of disease continues to revolu-tionize pathology and laboratory medicine.

As the premier organization representing all professionals in pathology and laboratory medicine, ASCP is committed to helping strengthen the medical laboratory infrastructure in local communities and across the globe. The field of diag-nostic medicine will substantially change in the coming years, and ASCP members are playing a significant role in shaping this evolution.

“For the past decade, ASCP has been helping to build sustainable laborato-ry infrastructures in countries world-wide,” says ASCP President William G. Finn, MD, FASCP. “Targeting work-force development and accreditation, ASCP has helped design curricula, de-velop faculty, and improve the knowl-edge and skills necessary to support public health.”

To underscore this commitment, ASCP hosted its first in-ternational conference last December in Abu Dhabi, United Arab Emirates. Approximately 300 pathologists and medi-

cal laboratory professionals gathered for two days to share their knowledge and experiences at ASCP Middle East 2014. The scientific and educational meeting, attended by ASCP CEO E. Blair Holladay, PhD, SCT(ASCP)CM, and Jennifer Young, CT(ASCP)CM, ASCP director of International Operations, is part of the Society’s initiative to position pathologists and labo-ratory professionals as leaders in health care worldwide by developing the global laboratory medicine community. By expanding to provide greater access to live education and networking opportunities, ASCP hopes to improve laboratory practices and patient care across the globe.

Improving Laboratory Practices Worldwide

The meeting was hosted with the support of the ASCP UAE Advisory Board, whose volunteer members help promote the ASCP Board of Certification’s (BOC) international certification of laboratory professionals. Attendees at this inaugural con-ference filled the meeting’s sessions, which included topics such as “Implementing Laboratory Management in Interna-tional Settings.” Beyond laboratory management, the meet-ing also featured cutting-edge scientific content on topics ranging from microbiology to blood banking.

Dr. Finn

In December, 300 pathologists and laboratory professionals attended ASCP Middle East 2014



“It was a wonderful experience that offered one-to-one discussions with the ASCP team, eminent speakers, and a fantastic ambiance,” commented Mati Ur Rehman Khan, as-sistant laboratory manager at Al Garhoud Private Hospital in Dubai, United Arab Emirates.

Fall 2014 was a busy season elsewhere on the global front as well. In November, Patricia Tanabe, MPA, MLS(ASCP)CM, ex-ecutive director of the ASCP Board of Certification (BOC), vis-ited China as part of an expanded partnership with KingMed, the largest medical laboratory in China. ASCP is bringing edu-cational programs and certification to the more than 6,000 laboratory professionals in that country. The Society is fulfill-ing its mission to protect patients worldwide by collaborating with KingMed to prepare China’s laboratory professionals to meet international standards.

“KingMed Diagnostics is committed to becoming a reliable partner of physicians and the No. 1 clinical laboratory and pathology solutions provider in China, with a focus on the improvements of competence in comprehensive services including products, technologies, management, and human resources,” says Liang Yaoming, dean of Guangzhou Medical University KingMed College of Laboratory Medicine and pres-ident and CEO of KingMed Diagnostics. “KingMed Diagnostics is also committed to corporate social responsibilities by pro-moting the standardization of medical laboratory protocols.”

Expanding ASCP’s Mission

Additionally, the BOC has seen tremendous success in ex-panding the vision of certification and a trained laboratory workforce beyond the United States to the world. Beginning in October 2014, the ASCP BOC expanded the number of cer-tification exam categories that will be available to medical laboratory professionals outside of the United States. “This is a major initiative, as it opens up many of our exams to an international audience,” Ms. Tanabe said.

As it seeks to elevate the level of healthcare practice in other countries, ASCP is also strengthening its International Com-mission to help guide the Society’s international strategy. The Commission is composed primarily of pathologists and labo-ratory professionals who work in different regions around the world and provide a perspective on the needs of their regional colleagues, offering insights that guide ASCP on how to best advance the practice of laboratory medicine.

“In many ways the International Commission overlays the other ASCP commissions and advises, from an international perspective, ASCP on education, membership, cer-tification, and public policy,” says Lee H. Hilborne, MD, MPH, DLM(ASCP)CM, FASCP, chair of ASCP’s International Commission. “The International Com-mission expands ASCP’s mission of excellence in education and advocacy on behalf of patients, pathologists, and laboratory professionals to an interna-tional audience.”

In the year ahead, the Commission will focus on India, China, and Brazil, where there are strong opportunities to form new collaborative relationships with healthcare organizations within these countries. It will also continue to focus on other areas, including the Middle East, Europe, Australia, and other parts of Asia and South America, according to Dr. Hilborne.

On the Front Lines with the Center for Global Health

ASCP members are often on the front lines of providing edu-cation and mentoring to laboratory professionals in resource-limited countries around the world. Nowhere is this more evident than in sub-Saharan Africa, where ASCP members dedicate their personal time to serve as expert consultants through the President’s Emergency Plan for AIDS Relief (PEP-FAR) program to improve the quality of laboratory medicine and delivery of patient care. ASCP consultants play a vital role in providing training through the Strengthening Laboratory Management Towards Accreditation (SLMTA) program that improves the skills of laboratory professionals in PEPFAR countries, guiding them through improvement projects. ASCP played an integral role in conceptualizing the SLMTA program, which has grown exponentially. Last year alone, ASCP con-sultants took part in 70 training activities in 17 countries and provided educational training to 908 participants in PEPFAR countries. A few examples of the Center for Global Health ac-tivities include:

A new program, launched in 2014, provides pre-service SLM-TA training for educators, bridging the gap between tradition-al university education and practical skills used in the work-place. It provides a common language that students will use

and allows them to develop prac-tical skills for the laboratory. This program is now in place in Tanzania and Lesotho to support instructors and universities as they incorporate SLMTA concepts into their curricu-lums.

ASCP Senior Vice President of Sci-ence, Technology, and Policy Jeff Ja-cobs traveled to Cape Town, South Africa, in December 2014 to pres-

Dr. Hilborne Mr. Jacobs

ASCP piloted a new program in Lesotho and Tanzania to provide pre-SLMTA training for educators.



ent an educational session at the 2nd biennial meeting of the African Society for Laboratory Medicine (ASLM). A pan-Afri-can organization of laboratory professionals, ASLM has been working collaboratively with government and healthcare organizations, including ASCP, to build a sustainable medical laboratory infrastructure that will improve access to quality care. ASCP volunteers have been bringing their expertise in training and certification to assist ASLM in its mission. One of ASLM’s goals is to have 30,000 trained and certified labora-tory professionals by 2020.

During the conference, the Center for Global Health’s technical manager, Cathy Robinson MSA, MLS(ASCP)CM, presented her findings on the effectiveness of SLMTA. This oral presenta-tion showed that SLMTA helps move laboratories toward the International Organization for Standardization I5189/17025 accreditation, measured through large increases in the SLIP-TA checklist.

The ASLM conference in Cape Town also provided a forum for laboratory professionals, policy and health delivery experts, government and non-governmental organizations, public and private sector groups, and the diagnostics industry to inter-sect, learn, and strengthen networks.

In February, ASCP consultants traveled to Nigeria to teach educators from 10 universities to use digital microscopes that can project images to a screen that accommodates larg-er class sizes. This workforce initiative presents a solution to traditional multi-observation teaching microscopes that can accommodate only a few individuals at a time.

As its seeks to broaden its global reach, ASCP has collabo-rated with the United States and Canadian Academy of Pa-thology to present “Africa Calls,” an exchange of scientific in-formation and continuing medical education via a bi-monthly teleconference to pathologists and medical laboratory pro-fessionals at 25 “hubs” in 12 countries in sub-Saharan Africa.

PEPFAR Activities Flourish

Due to the substantial accomplishments in these countries in Africa, ASCP’s PEPFAR Initiative has expanded to South-east Asia and Eastern Europe to address similar disparities in those underserved regions of the world. Rex Famitangco, MS, MLS(ASCP)CM, is serving as an expert consultant on one

of ASCP’s new PEPFAR activities to provide support for bio-safety workshops in 15 laboratories in Ukraine. Mr. Fami-tangco, along with another ASCP consultant, Linda Andiric, MT(ASCP), joined staff from ASCP’s Center for Global Health to present the bio-safety workshops.

“Before the workshops, we were invited by the Centers for Disease Control–Ukraine to visit one of the country’s HIV laboratories that is seeking accreditation with the Interna-tional Organization for Standardization Quality Management System,” he says. “We reviewed their workflow processes and provided recommendations to help them move forward. The laboratory director and director of the HIV Center are truly committed to making improvements.”

Mr. Famitangco also served as an ASCP expert consultant during two trips to Guyana last year and will participate in an upcoming visit to Nigeria. As a native of the Philippines, he reflected, “Coming from a different country and migrating to the United States, I am grateful to ASCP for giving me the op-portunity to serve fellow laboratory professionals across the globe to impart knowledge that we have here in the United States to ensure patient safety. In order for us to eradicate emerging diseases and infections, proper education and training is very important. Those of us in the United States have an obligation to assist our colleagues around the globe in achieving this goal.”

Join Our Global Community

Encouraging interaction among the global laboratory com-munity helps facilitate knowledge exchange and advance the laboratory profession around the world. ASCP is keeping pathologists and laboratory professionals connected through the online communities ONELab and Labs Are Vital, a global community for laboratory professionals supported by ASCP and several partner organizations.

Last fall, ASCP joined pathology organizations around the world to raise awareness of the vital role of pathology and laboratory medicine with the first annual International Pa-thology Day on Nov. 5. Along with the other Labs Are Vital partners, ASCP hosted the 2014 Labs4Life Photo Contest, which invited pathologists and laboratory professionals around the world to take a photo with a “Labs4Life” sign at a local or national landmark. More than 40 photos were sub-mitted, and nearly 11,000 votes were cast to determine the winner.

Take action! Check out Labs Are Vital at www.labsarevital.com and ONELab at labculture.ascp.org to connect with your international colleagues and join the conversation today!

Rex Famitangco, MS, MLS(ASCP)CM, demonstrates hand washing techniques using Glo GermTM at a bio-safety workshop in Ukraine.



Far left image: ASCP 2014 Best Scientific Poster Winner Dr. Kun Jiang (right), was subsequently awarded a $50,000 grant from Moffitt Cancer Center, Tampa, FL, to expand his research on esophageal cancer.

LAST CALL:

Register & Submit Abstracts : ascp.org/ascp2015

What do you most want to see from ASCP

2015? This year’s meeting is all about YOU,

and ASCP is listening. Share your thoughts

and opinions, interact with peers, and hear

directly from 2015 speakers and faculty. It’s

all happening online now on ASCP OneLab:

Learn more & Register Online: ascp.org/ascp2015

Make it YOUR meeting.

Registration is Now Open!

Submit your abstracts by April 30!

Don’t miss your chance to shine in front of an internationally renowned audience, and to launch your research to the next level.

Save up to $350 when you register by April 30

Showcase your work.

Join in at: ascp.org/my2015

An unlimited supply of sunny beaches, an eclectic arts

and shopping district, exciting nightlife, and even family

fun are all within close proximity. Experience the beauty

and relaxed atmosphere of Southern California, in the

second largest city in the Greater Los Angeles area.

Education tracks are now even better – Follow your area of interest session-by-session throughout the meeting. High-interest areas include:

• CMP Certification Track

• Laboratory Management

• Resident Review Series

• Hematopathology

• GYN Cytopathology

• Gastrointestinal Pathology

Master your specialty.

... and much more!

Kick back in beautiful Long Beach.

Image Credit: Long Beach Convention & Visitors Bureau

CV_2015-Annual-meeting_March-spread_vPrnt.indd 2-3 3/4/15 2:13 PM



Far left image: ASCP 2014 Best Scientific Poster Winner Dr. Kun Jiang (right), was subsequently awarded a $50,000 grant from Moffitt Cancer Center, Tampa, FL, to expand his research on esophageal cancer.

LAST CALL:

Register & Submit Abstracts : ascp.org/ascp2015

What do you most want to see from ASCP

2015? This year’s meeting is all about YOU,

and ASCP is listening. Share your thoughts

and opinions, interact with peers, and hear

directly from 2015 speakers and faculty. It’s

all happening online now on ASCP OneLab:

Learn more & Register Online: ascp.org/ascp2015

Make it YOUR meeting.

Registration is Now Open!

Submit your abstracts by April 30!

Don’t miss your chance to shine in front of an internationally renowned audience, and to launch your research to the next level.

Save up to $350 when you register by April 30

Showcase your work.

Join in at: ascp.org/my2015

An unlimited supply of sunny beaches, an eclectic arts

and shopping district, exciting nightlife, and even family

fun are all within close proximity. Experience the beauty

and relaxed atmosphere of Southern California, in the

second largest city in the Greater Los Angeles area.

Education tracks are now even better – Follow your area of interest session-by-session throughout the meeting. High-interest areas include:

• CMP Certification Track

• Laboratory Management

• Resident Review Series

• Hematopathology

• GYN Cytopathology

• Gastrointestinal Pathology

Master your specialty.

... and much more!

Kick back in beautiful Long Beach.


CV_2015-Annual-meeting_March-spread_vPrnt.indd 2-3 3/4/15 2:13 PM

Register Online: ascp.org/ascp2015

when you register

Save up to $350by April 30

Registration Early

is Now Open!


Join us for three incredible meetings all in one location.

2015 Workshop of SH/EAHP

October 29-31

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