Leading Edge 2022 Issue 2

2022 Issue 2 Alpha Laboratories Ltd. Diagnostics IN THIS ISSUE ... Welcome 2 Meet the Team Khanyile Dube, new Product Manager for FIT 10 Transitioning the BÜHLMANN fCAL® turbo for Calprotectin Testing from Siemens Advia 2400 to Atellica Analyser 2-3 Is Your Laboratory Ready for ISO 15189:2022? Considerations for Quality Management 11 A Game Changer for Faecal Elastase Testing fPELA turbo assay improves workflow and efficiency 4-5 Expert Reports from the Faecal Immunochemical Testing (FIT) User Group Meeting 12-13 Successful Routine use of Quantum Blue® Therapeutic Drug Monitoring Assays in an Italian Children’s Hospital 6-7 Judith Strachan is Presented with the 2022 ACB Foundation Award for her work on FIT 14-15 Novel Changes to the Flow CAST® Allergy Assay Improving Stability and Optimising Laboratory Workflow 8-10 Immediate Spin at Your Fingertips Rare Monoclonal Antisera 16 Solutions for Improved Workflows and Laboratory Efficiency

2 2022 ISSUE 2 LEADING EDGE - 2022-2 With constantly increasing pressures on staff and workloads in clinical laboratories, any support in improving workflow and efficiencies is always going to be welcome. In this issue of Leading Edge, we document case studies and product advances that demonstrate ways this can be achieved. The team in the Biochemistry Department at Addenbrookes Hospital has recently upgraded their Siemens instruments to the Atellica Analyser. Successful transition of their BÜHLMANN fCAL® turbo calprotectin has brought several benefits. Find out more on pages 2 and 3. At Spire Manchester Hospital, Kaleem Fayyaz describes the recent change, from ELISA to the BÜHLMANN fPELA assay for elastase as a game changer. Read the story on pages 4 and 5 to find out why. Our report from Italy, on pages 6 and 7, details how the flexibility of the rapid Quantum Blue® assay for therapeutic drug monitoring is supporting clinicians with decision making and helping patients. Plus, the introduction of the next generation Basophil Activation Flow CAST® assay, with enhanced stability of samples, optimises laboratory workflow for in vitro allergy testing. Read all about it on pages 8 to 10. You can also catch up on FIT updates from the experts, with reports from our FIT User Group and the ACB Foundation Award on pages 12-15. Switching things up... Transitioning the BÜHLMANN fCAL® turbo for Calprotectin Testing from the Siemens Advia 2400 to the Atellica Analyser. Georgette Glover, Senior Biomedical Scientist, Biochemistry Department, Addenbrookes Hospital Addenbrookes Hospital has been using the BÜHLMANN calprotectin assays for a number of years. They initially employed the fCAL® ELISA with the CALEX® sample extraction device, processed on a Dynex DS2 automated system. However, in December 2018 they switched technology to the BÜHLMANN fCAL turbo high throughput assay run on their Siemens Advia 2400 analyser. Addenbrookes currently test around 28,000 samples for calprotectin per annum. This has been gradually increasing for the last few years. Recently they have had new Atellica instruments installed by Siemens and Georgette Glover, a Senior Biomedical Scientist in the Biochemistry department at Addenbrookes talks about the transitioning the fCAL turbo assay to the new platform. The Atellica analysers were installed in January this year just before I returned from maternity leave. When I came back to work I began all the verification work on the new instruments in March as this was our priority project. Assay Set Up Setting up the calprotectin fCAL turbo assay was quite straightforward – Alpha Laboratories provided the protocol and the Atellica is really very user friendly, it sort of guides you through what you need to do. The only thing we changed was to use both the wells in the Siemens reagent pack with two fCAL turbo reagent packs. This provides us with improved efficiency and is better for the environment as it reduces the number of reagent packs used by half. Patient Sample Comparison We performed a 52 patient sample comparison running the CALEX on the Advia 2400 and the Atellica system. There was good agreement between the two methods. [Figure 1; right] We also conducted linearity, LLOQ and 5x5 precision assessments. On reviewing the resulting data the entire team was very happy with the results. Using the CALEX Sample Device Prior to the study, there was a concern as to whether we were going to be able to use the CALEX sample device because it was not an approved tube type on the Atellica software. Members of the Biochemistry Team at Addenbrookes Hospital

www.alphalabs.co.uk 3 However, when we started, we loaded the CALEX into special false bottom racks. This means we can specify the lower limit of liquid detection for the sample probe to avoid contact with the preparation stick within the CALEX tube. We just front load the racks onto the Atellica sample handler in a rack on rack off system – it really is very straight forward and there have been no issues. At the moment we don’t have the auto-dilute to report up to 8000µg/g switched on because we would need to keep the samples on the analyser for longer. We know the autodilute function works as we have tested it, but from a workflow perspective it is better that it is not activated. The use of an upper limit of 1500ug/g for reporting has not been raised as a concern by Clinicians. The verification took place over a period of one month. We didn’t plan to go live straight away so we continued the routine work on the Advia analysers until things were completely ready. Go Live We went live with the calprotectins on the Atellica at the end of June this year, once we had completed our validation work. We have now been running for 4 months, and everything has gone as smoothly as we could have hoped. Really it has been very quick and easy. We batch the samples and run them twice a week which is what we have always done, so the service provision is still the same. So far we have run over 10,000 samples and there have been absolutely no issues. EQA We have now returned results for 3 distributions, results from these have been acceptable and in keeping with our performance on the Advia 2400. Service Security Following our instrument upgrade by Siemens to the Atellica systems our calprotectin service has greater security. Our set-up involves 3 Atellica lines, each with two chemistry and one immunoassay analyser. The Atellica system provides a number of benefits over the Advia system, including real time reagent loading, higher throughput and having multiple chemistry analysers as back-up options if required - I am definitely a fan. Pancreatic Elastase We are currently working on other development projects in the laboratory. Once these are completed we hope to evaluate the BULHMANN fPELA assay for pancreatic assay. This is with the hope that an automated system can improve lab efficiencies in light of an ever growing workload. For more information, visit our website calprotectin.co.uk/fcalturbo Figure 1: 52 patient sample comparison of BÜHLMANN fCAL turbo assays run on the Advia 2400 and the Atellica analysers

4 LEADING EDGE - 2022-2 A Game Changer for Faecal Elastase Testing Switching to the new fPELA turbo assay for improved workflow and efficiency Kaleem Fayyaz, Blood Sciences Team Leader, Spire Manchester Hospital Spire Healthcare is a leading UK independent hospital group. It delivers high standards of care to insured, self-pay and NHS patients across 39 hospitals and 8 clinics. The laboratories at Spire Manchester Hospital provide the faecal testing services for the entire Spire group. The team there has recently switched its pancreatic elastase testing from an ELISA format to the new turbidimetric fPELA assay from BÜHLMANN. Kaleem Fayaaz, who is the blood sciences team leader at Spire Manchester, tells us about their assay transition: We test quite a large volume of samples for faecal elastase, receiving around 8-10 samples every day. These are mainly referred due to a ‘change of bowel habit’ in the clinical symptoms. The lab in Manchester performs all the testing for the entire Spire network, so all samples are referred to us. We also have a contract with an NHS Trust for all their elastase testing, so together this equates to around 3500 tests a year. However, this is increasing. Previously we were using the R-Biopharm (BioServ) ELISA method for pancreatic elastases on our Triturus analyser. This was run on Monday, Wednesday and Friday due to the requirement to batch samples for the ELISA plates and the fact that we could only get 50 samples on the carousel. Why Change? The main reason we looked to change the elastase assay format was the EQA performance. We had seen a a strong negative bias with the ELISA. We did lots of root cause analysis and had repeat samples from NEQAS, but the bias seemed to be with the method and since we were unable to resolve it this was obviously quite a concern. The second reason was the time - the ELISA method took about 3 hours depending on the number of samples within the batch. After 3 hours you didn’t know if the results would be okay because the calibrators and controls all ran at the same time. If something was wrong you would have to repeat the batch again. This was very difficult to resource and caused a delay in reporting. We did consider switching the elastase to an alternative ELISA method. However, simultaneously we were also investigating switching from the BÜHLMANN fCAL® ELISA to the BÜHLMANN fCAL turbo to be run on our Roche c501. With all the workflow benefits that would bring, it just made sense to do the same with the elastase and move straight to the BÜHLMANN fPELA turbo, when we needed to change anyway. Assay Verification The whole process of verifying the fPELA on the Roche platform was really good. All the supporting information that we needed was provided promptly and the relationship that we have with the Alpha Laboratories’ product and key account managers is really supportive. All our questions or issues were resolved quickly. Game Changer Overall, the transfer to the fPELA was really easy, simple and effective. The fact that you can get a result in 10 minutes is fantastic. This is interesting because initially we didn’t really think about this as a real benefit. But it is great in terms of the laboratory workflow and the service we are able to provide – it really is worlds apart from the ELISA method. For the staff that have been used to the ELISA method they really see the BUHLMANN fPELA as a game changer. Once we had completed the lab validation we sent out a communication to all our users, and everyone has been really pleased because the turn around time is now much quicker. The assay workflow is so much easier. It allows us to run the test daily, even over the weekend – that is how easy it is to run; it really is turbo! We went live with the fPELA in February 2022 and there really have been no issues – the calibrations and controls have always been spot on It really has been great. The extractions are done first thing in the morning by the MLAs and we run the QCs whilst everything is being prepared. The staff that do the extractions find the process much easier with the CALEX compared to the previous method, so they are delighted. When the samples are ready, the tests are loaded onto the analyser and you have results coming off within 10 minutes. So a batch of 30 samples is completed in about 20 minutes. They are authorised, and the results are out within 30 minutes. At the moment we probably only get about 5-10% of samples with requests for both calprotectin and elastase tests. However, this may be a communication issue whereby the clinical staff don’t realise that they can now request both tests from a single sample. „ The fact that you can get a result in 10 minutes is fantastic“

Turbo Charge Your Faecal Testing The BÜHLMANN fCAL® turbo and fPELA assays will revolutionise your faecal calprotectin and elastase testing, with a streamlined workflow. www.alphalabs.co.uk 5  Same CALEX® extraction for both assays: One extraction two tests  CALEX® can be given to patients for sample collection  Ambient, fridge and freezer stability for a flexible return to laboratory workflow  Wide assay range provides valuable clinical insight and keeps dilutions to a minimum - Calprotectin: 20 – 2000µg/g (autodilute to 8000µg/g) - Elastase: 10 - 500µg/g  Time to first result is 10 minutes, with further results every few seconds  Protocols available for most clinical chemistry analysers including Abbott, Beckman, Roche, Siemens as well as stand-alone options  Calibrators, controls and reagents are all in a stable, ready to use format and they don’t need to be lot matched For more details visit www.calprotectin.co.uk Improved EQA One of the primary reasons for switching was the EQA performance and this has improved immensely with no differences in interpretation from the group consensus since switching to the fPELA. For those hospitals currently using an ELISA method for their elastase I would say, trust me, change to the turbo method and it will change your life. It will save you time, it will save you effort, it will save you everything not just for yourself but for your MLA and BMS staff, the clinical team and the patients who are awaiting the results on the other side - it is literally a game changer. For more information, visit our website alphalabs.co.uk/elastase the team at Manchester Spire The Blood Sciences Team at Spire Manchester Hospital

6 LEADING EDGE - 2022-2 Successful Routine Use of Quantum Blue® Therapeutic Drug Monitoring (TDM) Assays in an Italian Children’s Hospital An interview with Dr. ssa Giuliana Cangemi This interview was conducted by BÜHLMANN with Dr ssa Giuliana Cangami - Head of the Chromatography and Mass Spectrometry Unit at the Central Laboratory of Analyses in Gaslini Intitute Pediatric Hospital in Genova, Italy. Can you introduce your organisation? In the Central Laboratory of Analyses in the Gaslini Institute Pediatric Hospital in Genova, one of the main tasks is to perform therapeutic drug monitoring (TDM). The laboratory specialises in the TDM of small molecules and for four years now, we have also been performing TDM for biologics. Most of the requests in the Central Laboratory of Analyses are coming from paediatricians. However, requests from external laboratories are also accepted and performed. It also happens that outsourced patients come to the Gaslini Institute with a prescription for the TDM tests. I would say that we had more requests from gastroenterologists when we initially started, but today rheumatologists are also keen to get TDM results for both, infliximab and adalimumab. „ The previously used ELISA method was time consuming but also not economically viable.“ Which technique do you use for TDM measurement and why did you choose this one? The first technique used for the TDM of the anti-TNFα such as infliximab and adalimumab was ELISA. This ELISA method was time consuming and also not economically viable when we had to perform a test including calibration and controls just for one or few patients. To avoid increasing the price of the assay, we had to wait to have enough samples to perform a batch. The price per patient was different depending on the number of patients tested per batch. This was also quite complicated to handle from an economical point of view. How did you introduce the BÜHLMANN Quantum Blue® TDM methods? Once we had been introduced to the rapid tests from BÜHLMANN Laboratories, we decided to perform a method comparison between the ELISA technique and both, Quantum Blue® Infliximab and Adalimumab rapid tests. The results were highly comparable for the trough levels between the Quantum Blue® assays and the ELISA technique, and the switch to the rapid assay was done quickly. At this time, only the rapid assays for trough levels were available and we decided to keep the ELISA method for the antibody measurement. This was not convenient, and we were ready to use the Quantum Blue® Anti-Infliximab and AntiAdalimumab as soon as they were available. As antibodies assays from the manufacturers are not standardised against each other, we did not perform a technical method comparison, but went straight for a clinical evaluation of the BÜHLMANN assays. The clinicians only require a qualitative measure of the antibodies as their need is to know whether immunisation is present or absent. Once they reviewed the good results of the evaluation, we directly switched from the ELISA to the Quantum Blue® assays and now we are using the full TDM portfolio from BÜHLMANN in our daily routine.

www.alphalabs.co.uk 7 Are there any other advantages of using the four BÜHLMANN TDM assays? Most of our patients are children, therefore the amount of blood needed to perform a test is important. The Quantum Blue® assays only request a few microlitres of blood, which is perfect for children. In addition, having the result within one hour from blood taking is an improvement in the rapid result reporting. At the beginning of the TDM measurement some time ago, we occasionally had primary non responders or secondary non responders due to treatment failure. In these cases, we had to try to quickly run a test, that was performed reactively. Today, we have screened all our patients from rheumatology and gastroenterology, and we are able to perform proactive monitoring thanks to the Quantum Blue® assays. Because of the quick turnaround time, we have also started to sometimes test patients just before they are discharged from the hospital and ready to go back home. However, in our daily organisation of normal routine, we have setup a specific day once a week for TDM measurements. This is really appreciated by the clinicians. They know exactly when they will get their results. Despite this test agenda, we sometimes get additional samples to be tested on another day of the week. Today, with Quantum Blue® flexibility, we have the possibility to do so, knowing exactly the costs of running only one sample per day. „ The results of the method comparison between the ELISA technique and Quantum Blue® TDM showed highly comparable trough levels.” Which measurement algorithm do you follow? We have decided to run both serum levels and antibodies in parallel as it helps us and the clinicians to get the complete picture of the patient situation. If the serum levels are within the therapeutic window, the results are optimal and there is no need to additionally test for antibodies. Conversely, when drug is undetectable, the fact that we can measure the antibodies at the same time helps physicians to take a decision on the action needed. „ TDM with Quantum Blue® is a very valuable tool for the clinicians to decide on dose increase or decrease as well as drug class switches.” Would you be interested in new developments on the Quantum Blue® Reader? Today we are performing the four BÜHLMANN assays in our daily routine: Quantum Blue® Infliximab, Quantum Blue® Adalimumab, Quantum Blue® Anti-Infliximab and Quantum Blue® Anti-Adalimumab. I would say that TDM with Quantum Blue® is part of our routine use now and a very valuable tool for the clinicians to decide on dose increase or decrease, but also to support the strategy of within or in between class switch of drugs. If I would have a wish for the future, I would think that a rapid assay for the measurement of tocilizumab might be interesting for juvenile arthritis patients. We have tested an ELISA technique already but would be more interested in a rapid test. In addition, vedolizumab serum levels would be interesting and an anti-TNFCalibri method from capillary blood. For children, this would be very attractive. For more information, visit our website alphalabs.co.uk/tdm

8 LEADING EDGE - 2022-2 Novel Changes to the Flow CAST® Allergy Assay Improving Stability and Optimising Laboratory Workflow Basophil Activation Tests (BAT) can be used to reliably diagnose allergies and are gaining increasing importance in this field. Basophil Activation assays, such as the Flow CAST® assay manufactured by BÜHLMANN, offer a very high specificity, and therefore a very good ability to distinguish those who are truly allergic from those who are not. Reduce the Use of Challenge Tests There is a growing body of evidence to suggest that Basophil Activation Tests can offer a higher degree of accuracy and clinical relevance compared to other allergy tests, and they have the potential to significantly reduce the number of challenge tests needing to be performed. In a study conducted by Santos et al. 20141, looking at peanut allergy in children, using BAT on its own as a single test led to a reduction in oral food challenges (OFC) by two thirds, and when using BAT as a second line test performed after equivocal skin prick tests (SPT) or Arah2 specific IgE (sIgE) tests, a 97% reduction in oral food challenges was observed. Basophil Activation Testing offers a safer alternative to a challenge test, which can help to reduce both the waiting time for a diagnosis, and the costs associated with performing challenge tests. BÜHLMANN has recently made changes to its Flow CAST Basophil Activation Test. The kit now includes a new version of the wash buffer which contains a stabiliser. The wash buffer is used to reconstitute the cell pellet immediately after red blood cell lysis. The stabiliser that is now included within the wash buffer allows for the cells to be fixed, with an additional thirty-minute incubation of the samples at room temperature. Extended Sample Stability - Improved Workflow Previously, the samples needed to be analysed using flow cytometry immediately following completion of the Flow CAST protocol. The added stabiliser now enables the samples to be analysed up to five days after completion of the protocol, if stored at 2-8C and protected from light. This change will significantly help to improve workflow in laboratories, allowing for samples to be reliably fixed, stored and then analysed on subsequent days, in case instrumentation is overwhelmed. This gives the laboratory additional time to analyse these samples, making it easier for them to plan instrumentation and staffing resources. Stability Studies BÜHLMANN performed stability studies using the anti-FcƐRI mAb stimulation control (included in the Flow CAST assay) on EDTA whole blood from four normal blood donors. This assessed the stability of the processed samples after cell stimulation and fixation with the new wash buffer, and determined the specimen stability of unprocessed EDTA whole blood samples before performing the Flow CAST assay. After completion of the Flow CAST protocol using the new wash buffer to fix the cells, the stability of the processed samples was assessed at 2-8C and 28C (whilst protected from light) and measured at several time points from 0 to 10 days. A decay over time of a maximum of 20% from the baseline according to results at time 0 were accepted to be 0. The results show that, for the short-term storage of stimulated and subsequently fixed cells, all test results remained above the 80% recovery criteria for the full study duration (10 days) when stored at 2-8C and protected from light (Figure A), and for 2 days when stored at 28C and protected from light (Figure B). Flow Cytometry Analysis In addition to this, during analysis by flow cytometry of the processed cells, similar analysis patterns can be observed between day 0 and day 5 (Figure C; opposite). Stability of Fixed Cells

www.alphalabs.co.uk 9 Stability of Unprocessed Samples Another stability study was conducted on unprocessed EDTA whole blood samples, to assess the stability of the samples at 2-8C and 28C for 0 to 4 days, before performing the Flow CAST assay. Again, a decay over time of a maximum 20% was accepted to be stable. The study revealed that EDTA whole blood samples stored at 2-8C were within the 80% recovery criteria for day 1 and day 2 (Figure D); and that EDTA whole blood samples stored at 28C leads to a drop below the 80% recovery criteria on day 2 (Figure E). Continued on next page...

10 LEADING EDGE - 2022-2 Continued... The results of these stability studies give rise to key recommendations for laboratories wishing to run the Flow CAST assay, as summarised in Table 1; below. • EDTA whole blood samples stored at 2-8C allows for a window of 48 hours until the assay needs to be performed • The changes to Flow CAST to include the stabiliser in the wash buffer prolongs the stability of activated and fixed basophils, up to 10 days at 2-8C (protected from light) and up to 2 days at room temperature (protected from light) Extended Blood Sample Logistics These recommendations allow for extended blood sample logistics, giving the laboratory time to process the samples once they are received, and further time to analyse the samples after completion of the protocol, in case instrumentation isn’t available. This allows for an improved workflow solution and enables the laboratory to optimise its time and resources. References; 1. Alexandra F. Santos, Abdel Douiri, Natalia Bécares, Shih-Ying Wu, Alick Stephens, Suzana Radulovic, Susan M.H. Chan, Adam T. Fox, George Du Toit, Victor Turcanu, Gideon Lack, 2. Basophil activation test discriminates between allergy and tolerance in peanutsensitized children, Journal of Allergy and Clinical Immunology, Volume 134, Issue 3, 2014, Pages 645-652, ISSN 0091-6749, https://doi.org/10.1016/j.jaci.2014.04.039. https://www.sciencedirect.com/science/ article/pii/S0091674914007283 3. Higher Basophil Activation Test Performance Flexibility by Prolonged Assay Read-Out of Fixed Cells, Dominik Vogt, Anna Melone, Martina Berchtold, Michele Romano, Collin Shaw, Nathanael Beck, Michael Schneider, Thomas Schuster, Christian-B. Gerhold and Michael Gerspach, BÜHLMANN Laboratories AG, Schönenbuch, Switzerland Stability Study Temperature Recommendation of max. storage time i) Storage of unprocessed EDTA whole blood 2-8°C 48 hours 28°C 24 hours ii) Storage of fixed cells after processing with standard protocol 2-8°C 5 days 28°C 48 hours Table 1: Recommended storage conditions for blood and processed cell stability For more information, visit our website alphalabs.co.uk/cast Meet The Team... Khanyile Dube Alpha Laboratories’ New Product Manager Khanyile Dube recently joined Alpha Laboratories as the new Faecal Immunochemical Testing (FIT) Product Manager. She is an adaptable research professional with over 5 years’ experience in the healthcare and pharmaceutical industry. She has demonstrated talent for strong multi-disciplinary relationships in support with key stakeholders and the delivery of unique scientific projects. After gaining my PhD in cancer research, I started a laboratory focused career in the Biotechnology industry, initially working in the development of animal vaccines and later the production of diagnostic testing kits and reagents. I thoroughly enjoyed the product development process and began to explore the possibility of expanding my skills further. An opportunity at Alpha Laboratories was very attractive as it allows me to exercise my leadership skills in managing the product throughout its life cycle, understanding customer requirements, defining the product vision, and engineering to deliver winning products. I am also very excited to work closely with our dedicated partners, Bowel Cancer Screening and Symptomatic hubs and to form relationships with various Key Opinion Leaders to ensure the FIT Testing service at Alpha Laboratories is always advancing to meet clinical needs. Recently I had the opportunity to travel to Minaris Medical Co., Ltd in Japan for hands on product training. I gained extensive knowledge on the HM-JACKarc system from installation, maintenance and at operational level. This was also a chance to discuss means of enhancing delivery of FIT products, particularly with a significant increase in demand. My visit enhanced understanding of the FIT product life cycle, observing various departments from Research and Development to Quality Control. I also shared Alpha Laboratories’ mission to supply more sustainable products, which was met with positive feedback. I look forward to more opportunities to further bridge the gap between our suppliers and FIT service users. When I am not working, I love cooking and experimenting on new recipes as I am an aspiring vegan! I absolutely love travelling and so, now and again I take a risk with solo travelling to countries I have never been before. I also enjoy working out at the gym and listening to deep house music on long drives. On a relaxing day, you might also find me at a Spa or reading a good non-fictional book. Contact Khanyile by email: kdube@alphalabs.co.uk

www.alphalabs.co.uk 11 Is Your Laboratory Ready for ISO 15189:2022? The ISO 15189:2022 standard will soon be published, necessitated by the required alignment with ISO 9001:2015, and ISO/IEC 17025:2017. As 10 years have passed since its original publication, the new standard will also consider the ever-changing demands of the medical laboratory community. The International Laboratory Accreditation Cooperation (ILAC), is in the process of reviewing the timelines for all organisations accredited to ISO 15189:2012 worldwide, to transition to accreditation to the new ISO 15189:2022 standard. Like many other accreditation standards, this will likely be a 3-year transition. A lot of technological advancements have taken place in clinical practice over the last 10 years. This is reflected in the new 2022 standard. For example, “request form” has been replaced with “examination request” which encompasses electronic formats now used by laboratories as well as the old paper-based systems. Risk Management Patient focus remains at the cornerstone of the new standard and accredited laboratories will need to demonstrate compliance with the updated ISO 15189, with a strong emphasis on risk management. Serious consideration will need to be made around areas of risk that can impact patient care and any decisions made in the laboratory will need to factor in calculated risk. Risk management will be applied to all aspects of the laboratory operations so that the risks associated with patient care are systematically identified, providing opportunities to improve. Decision making within organisations has been given more emphasis. Each organisation shall have more flexibility to implement elements of the standard as appropriate. However, each of the decisions taken should be substantiated with evidence. Point of Care The ISO 22870:2016 will be made redundant once the new ISO 15189 is published as the requirements for a Point of Care service are now incorporated in the new ISO 15189 standard. Additionally, there is an annex in the updated ISO 15189, to provide additional clarity and guidance on Point of care testing (POCT). Of note, there is no longer a specific requirement for a multidisciplinary POCT team although an accredited organisation can still have one where necessary. Should an organisation wish to continue with or introduce a POCT Service into its accreditation scope, a well-outlined service agreement should be the foundation of any service being offered into the laboratories. Traceability of Patient Samples There is no longer a strict requirement around sample labelling in laboratory settings. However, these still need to be managed under a fully traceable patient sample management chain. With the technological advancements since the last standard was issued many new ways of effectively managing the traceability of patient samples are now available including barcoding and RFID labels. Quality Control There has been an update to the quality control section of the standard. It is no longer a requirement for the laboratory to follow manufacturers’ minimum testing intervals, but to consider the stability of the assay and the associated risk to the patient of a Quality Control fail. For any laboratory working to ISO 15189 accreditation standards, there is a requirement to demonstrate that any testing service follows defined quality assurance levels, performing with competence and consistency. For example, there are many commercially available control, calibrator and reference materials that provide traceable thirdparty verification of a testing system. Those that follow the patient pathway provide greater confidence in test system results, over controls that use artificial materials, or that do not enumerate accurately over a number of parameters. Alongside regularly validated and calibrated equipment they help laboratories achieve and maintain accreditation. Accreditation to ISO 15189 underpins confidence in the quality of medical laboratories through a process that verifies their integrity, impartiality and competence. Assessments under UKAS accreditation ensure laboratories meet the relevant requirements including the operation of a quality management system and the ability to demonstrate that specific activities are performed within the criteria set out in the standard. Alpha Laboratories’ diverse range of multi-constituent controls provide verified third-party quality controls that can help support your laboratory’s compliance with the latest ISO 15189 quality management guidelines. Controls can be ordered direct or alternatively, added to your Managed Service Contract and are available for Clinical Chemistry, Haematology and Flow Cytometry. For more information, visit our website alphalabs.co.uk/iso15189

12 LEADING EDGE - 2022-2 Alpha Laboratories recently held a FIT user group meeting that was attended by some of the leading laboratories who utilise the HM-JACKarc technology for their faecal immunochemical testing service. Key speakers discussed their challenges and contributions towards standardisation and quality in FIT testing. Symptomatic FIT and the Role of the Laboratory: Overview, Lessons Learned and Future Development David Evans, Symptomatic FIT Co-Ordinator, Public Health Wales David presented a simplified patient referral pathway for both primary and secondary care in Public Health Wales (PHW). This comprises of an online interface that allows clinicians to submit electronic FIT referrals. These requests are downloaded from the online interface by the PHW laboratory and FIT-KITs are sent directly to the patients address for collecting their sample at home. The kits include the EXTEL HEMO AUTO MC Collection Picker, with complete instructions for collecting and returning the sample. Within a turnaround time of 9 days (from referral submission to result authorisation), samples are returned to the laboratory, faecal haemoglobin (f-Hb) is quantified and results are easily transferred to an online interface (LIMS) for access by GPs and referring consultants. PHW currently receives 4500-5000 referrals per month and reports an average return rate of 82%. David also shared a projected increase in demand for symptomatic referrals, particularly from primary care. Secondary care referrals remain consistent (See Figure 1). David further shared that with the use of the HM-JACKarc system, PHW are observing a 19% positivity rate across health boards using their service (% samples > 10µg/g of Hb), although a higher variation can be observed in health boards with a lower throughput. The major challenges faced by PHW are the number of non-responders, a lack of administrative support to track each patient and prompt non-responders and the lack of understanding between symptomatic FIT and bowel cancer screening FIT. Further developments will implement electronic requesting and focus on working closely with stakeolders to improve non-responder rate. FIT Quality Assurance Carolyn Piggot, FIBMS, Research Scientist, Bowel Cancer Screening Programme, Southern Hub, Guildford Carolyn Piggott presented on the factors that contribute towards the pre-analytical and laboratory challenges faced in FIT testing. The major contributors are the differences in faecal samples, inconsistent sampling by participants and haemoglobin (Hb) stability in faeces. In addition to sample variability, there is no FIT assay standardisation. Different reagents are used between each manufacturer and there is no primary reference materials of methodologies. The lack of standardisation or harmonisation of FIT means that variations are observed in f-Hb results generated on different systems. Carolyn mentioned a range of approaches to tackle these challenges. One is manufacturers‘ development of new buffers, focused on improved sample stability. Projects are also being undertaken at BCSP Guildford which include evaluation of the available EQA (Ref.1), third party internal QC (Ref.2) and the effect of Hb-variants (Ref.3). In addition, they are working in conjunction with the IFCC FIT Working Group established in 2017 to formally address the challenges (representatives from other manufacturers, clinical scientists, and representatives from EQA companies) according to the references below (Ref.4): Terms of Reference • To attempt to standardise analysis of haemoglobin in faecal samples by immunochemistry (FIT) • To identify all sources of pre-analytical variation and standardise if possible • To establish external quality assurance and third party internal quality control programmes • To determine impact of assay interference of Hb variants and other factors So far, work has been completed to establish the current status of 4 automated FIT systems (Ref.5): HM-JACKarc (Minaris Medical Co. Ltd, Japan): OC-Sensor PLEDIA (Eiken Chemical Co. Ltd, Japan); SENTiFIT 270 (Sentinel Diagnostics, Italy), NS-Prime (Alfresa Pharma, Japan); data show that all analysers met manufacturers’ claims. Additionally, EQA programmes investigated types and imprecision of EQAS available worldwide. 13 manufacturers of EQA were identified and 11 agreed to take part, to either provide: faecal-like material loaded by participants (UK NEQAS and HECTEF, Japan), faecal-like material loaded by EQA provider (WEQAS and CEQAL, Canada), or aqueous material loaded directly onto the analysers in cups (CRB, Italy, ESFEQA, Germany, Labquality, Finland, SEKK, Czech Republic, SEQC, Spain, SKML, Netherlands). Results showed that faecal-like matrices have larger coefficient of variant (CVs), and liquid materials have smaller CVs. Carolyn also reported on the evaluation of QC material from each FIT manufacturer, measured on the other three analysers, and the CVs were overall <9% and mostly <5%. Considering there were no third-party QCs available (in 2019), QC material available from the 4 FIT manufacturers could be used Working Towards Quality Standardisation for Faecal Immunochemical Testing (FIT)

www.alphalabs.co.uk 13 for independent QC if the companies are able to make it available to customers. Effects of Hb-variants were also investigated on four FIT assays. 11 of the 13 variants gave expected results while β thalassemia major (reduced β chain) gave 50% of the expected result, though as patients have regular transfusions normal Hb would likely be detected. Additionally cord blood/Hb-F is gradually replaced by adult Hb in the majority of people. The BCSP group also carried out a clinical study examining the comparability of faecal haemoglobin analysed by the 4 FIT systems (6), and the outcomes of colonoscopy. 233 patients collected a faecal sample using the 4 different sample collection bottles from the same stool before their colonoscopy, and 189 patients collected 2 samples using the Extel Hemo/HM-JACKarc system, as a comparison. At 100 µg Hb/g faeces the sensitivity for CRC and SBD was the same for all methods, though differences were seen at 10 µg/g. ‘Further work is required to understand the clinical impact of these differences to minimise them. Comparison of f-Hb results for real clinical samples and clinical outcomes is needed’. Overall, Carolyn’s conclusion was that the four analysers included in the evaluations are fit for purpose though the lack of standardisation and harmonisation of FIT testing means that differences are observed in f-Hb quantification. Current status and future plans for the UK NEQAS for Faecal Haemoglobin Finlay Mackenzie, Director of Birmingham Quality, an NHS Department within University Hospitals Birmingham Finlay defined External Quality Assessment as a retrospective assessment of quality – ‘EQA is an independent assessment of quality and is an essential component of an accredited laboratory’s governance system and assesses the performance of in-vitro diagnostic examination procedures.’ Part of the role of EQA is to assess the stability of diagnostic tests over time, this includes the Alpha Laboratories’ HM-JACKarc system, in comparison to other faecal haemoglobin (f-Hb) detection systems that are available. EQA aims to send representative patient samples to a network of national laboratories. Finlay shared his observations on the variations associated with differing f-Hb cut-offs between the National Screening Hubs and how critical it is to ensure homogeneity of a specimen for true representation. He shared his concerns about the large differences in numerical data between FIT testing methodologies, although this is not limited to f-Hb testing, as it also affects most other clinical chemistry tests, so it is a wider problem. Furthermore, the stability of samples may affect the uniformity of assessments as he expanded on the fact that biological samples may not respond in the same way all the time due to: • Tolerance limits • Manufacturing systems • Antibodies present Lastly, adapting to the clamour for ‘sanitisation’ by both patients and laboratories is also a challenge. Having a pre-filled cartridge assumes that the sample was taken correctly, and you have to take on trust that it was an accurate representative sample of the whole, real, stool. Overall, EQA aims to evaluate the entirety of the process and not just the relatively simple, well controlled parts, like the analysis itself. That said, all EQA providers aim to send easyto-use materials to laboratories in order to provide a sample type that is representative of what the laboratory routinely receives. Quantitative Faecal Hb EQA Programme Update Samantha Jones and Gareth Davies – WEQAS Samantha Jones initially shared the considerations undertaken by Weqas when setting up a new EQA programmes. A robust EQA programme should have elements of pre-analytics, analytics and post analytics where possible. Weqas also provide an educational aspect with all programmes, including case studies, educational questionnaires and sharing of best practices. Weqas provides organic material which closely mimics human faeces, spiked with human whole blood (0-800 µg Hb/g). Material at a range of Hb concentrations is prepared to cover the pathological and analytical range for FIT including samples at or near the clinical cut-off of 10 ug Hb /g used for symptomatic testing pathways and the higher cut offs used in asymptomatic population screening programmes. Weqas surveyed participants to ask what they would like to see within a Faecal Hb EQA Programme, taking these views into consideration during development. Samantha discussed NICE guidelines and recommendations for FIT testing, and the scope and purpose of the Weqas EQA programme. The programme aims, in the first instance, to assess analytical performance across all current platforms and ultimately to assess pre-analytical aspect of patient testing. The HM-JACKarc system is often used to evaluate spiked Hb volumes, stability and percentage recovery of samples. Weqas provides samples for all FIT testing systems including Alpha Laboratories’ HM-JACKarc system. Samantha briefly discussed the work of the IFCC Fecal Immunochemical Testing Working Group (WG-FIT), sharing updates and recommendations. These include looking at the performance of different matrices. Poor reproducibility for faecal like material has been observed due to variability in test pickers/people/material, although faecal like matrices assess both pre-analytical & analytical imprecision. Weqas material has been shown to have CVs between 10-20% at concentrations of 50 to 450 ug Hb / g, with good recovery vs spiked concentration. Weqas future developments include potentially issuing patient samples periodically, auditing practices against current guidelines and also assess pre-analytics e.g. under / overloading of samples For more information, visit our website faecal-immunochemical-test.co.uk Please see the full article with references at www.faecal-immunochemical-test.co.uk/ug2022

14 LEADING EDGE - 2022-2 A Fitting Tribute: Judith Strachan is Presented with the 2022 ACB Foundation Award Faecal Immunochemical Testing – Past, Present and Future At the ACB UKMedLab22 Scientific Meeting, held at the Royal College of Pathologists in London in November 2022, Judith Strachan was presented with the prestigious Foundation Award. This accolade recognises her services to Clinical Biochemistry and, in particular, her work with the Scottish Bowel Screening Programme (SBoSP). In her plenary speech, “FIT for the Future (Past and Present too!)”, Judith discussed the changing demands on the laboratory, based on her experience working at NHS Tayside. Judith Strachan is a consultant clinical scientist at NHS Tayside and is also honorary senior lecturer at the University of Dundee. She has worked in the laboratory at NHS Tayside since 1990, and in that time has been instrumental in developing the services offered, to ensure the laboratory meets the ever-changing demands of the NHS. First Steps of Faecal Testing Faecal tests for haemoglobin, calprotectin, and elastase are now commonplace, most of which have specific sample collection devices designed to maximise uptake of the test, minimise pre-analytical variation and facilitate easy processing in the laboratory. However, as recently as the late 2000s, faecal testing was still in its infancy. A UK pilot study was conducted in 2000 to understand the efficacy of guaiac faecal occult blood tests (gFOBT) in population-based bowel cancer screening. Following the success of the study, the Scottish Bowel Screening Programme (SBoSP) was launched in 2007. The gFOBT screening kit included: an invitation letter, the test card, and return envelope. The screening cohort invited people between the age of 50 and 74, with those over 75 able to opt-in. Individuals are sent a test every two years. Reminders are issued if no response is received within six weeks, to encourage maximum participation. Using gFOBT, the programme had an uptake of around 50-55%, and a positivity rate of 2%. This programme continued for nearly ten years, and in this time, faecal testing began to evolve further. Scotland continued to pave the way for the advancements in faecal testing. The faecal immunochemical test (FIT) became the technology of focus for Judith and her colleagues, as it was hypothesised that this test could serve not only population-based screening but the triaging of symptomatic patients, who meet the diagnostic criteria for suspected colorectal cancer referral. FIT & Population-Based Screening In 2017, the SBoSP transformed its screening service by replacing qualitative gFOBT with quantitative FIT. This was no small task: it involved a laboratory refit, installation and work-up of four new analysers, staff training, redesign of the return mailer, revamping of the communications, and a review of the screening algorithm. Then there were the clinical hurdles to overcome; the increase in participation (uptake) was noticeable almost immediately. Increased Uptake Individuals who had never participated in screening previously were more engaged with FIT, and uptake rose from around 53%, to 64% in less than 12-months [Figures 1-4]. Then, there is the positivity to consider: for gFOBT this was around 2%, but FIT saw this rise to over 3%, with some cohorts seeing positivity closer to 5%. The increased sensitivity with FIT means that more people are being sent for colonoscopy than would have been previously when gFOBT was used in the screening programme. That said, FIT has been shown to catch more precancerous growths, and other significant bowel disease, when compared to its predecessor. This now changes the landscape for cancer diagnostics and is where screening and symptomatic could collide if not carefully managed. FIT in the Symptomatic Cohort Colorectal cancer is the third most common cancer in the UK, with over 42,000 cases and 16,000 deaths annually. Around 10% of all GP consultations are the result of gastrointestinal symptoms (Jones et al., Br J Gen Pract 2009), but these symptoms are often vague, unquantifiable, and poor predictors of underlying pathology (Jellema et al., BMJ 2010). FIT offered a way to help guide referral from primary care, whilst providing important information to gastroenterologists about the possible severity of the pathology, therefore facilitating more appropriate triaging. It is largely thanks to Judith and her colleagues that as of 2022, almost all of health boards in Scotland use FIT as part of their referral pathway for patients with suspected colorectal cancer and other significant bowel disease. Samples are sent to one of five laboratories in Scotland, all using the HM-JACKarc, system for analysis and GPs usually receive the FIT results via electronic test reporting systems.

www.alphalabs.co.uk 15 The Legacy For over 10 years, Judith and her laboratory and clinical colleagues have worked tirelessly to advance faecal testing and she was instrumental in designing and rolling out one of the most well-coordinated FIT testing services in the world. This dedication has been duly recognised in the Foundation Award – and Judith joins three other NHS Tayside Foundation Award winners: Callum Fraser (1995), Brian Burchill (1997), and Bill Bartlett (2017), adding to NHS Tayside’s illustrious history for innovation and dedication to healthcare. Now to the Future The impact of the coronavirus pandemic on cancer pathways has been devastating. With reduced access to diagnostic tools, endoscopy services reduced to a mere fraction of what they once were, laboratories are working harder than ever to not only keep up with a general increase in demand, but to clear the backlog of patients whose diagnosis or treatment was delayed due to the pandemic. Patients are more aware of their health now than ever before. Familiarisation with lateral flow tests, at-home testing, and even a more detailed understanding of routine laboratory tests means they are better engaged with healthcare professionals. This makes them more likely to participate in screening, and to discuss health concerns quickly. Whilst these factors are hugely positive in the context of healthcare and population health management, the demand on the hospital and laboratory must not be underestimated. Judith made clear in her speech that FIT should continue to evolve and so too should other diagnostics. FIT is not a perfect test, and whilst it has been hugely beneficial in the triaging of patients, healthcare industry, laboratories, and clinical teams should not consider the work on FIT “complete”. There is always scope to improve services, and the pandemic served as a stark reminder that healthcare is not a static system, and there is a need to remain flexible, reactive, and cognisant of current limitations to ensure there is a drive for continuous improvement. We hope you join us in congratulating Judith, and in celebrating the work she has done these past thirty years. Alpha Laboratories is extremely grateful to her, her colleagues, and the wider team at NHS Tayside for their advice and guidance over the years. We look forward to continuing this valued partnership. With Thanks; Judith made a special note to thank the following people in her speech: Callum Fraser, Robert Steele, Craig Mowat, Blood Sciences Staff and Bowel Screening Staff at NHS Tayside, the Tayside Research Group, and National Services Division (NSD). Alpha Laboratories would also like to thank the following personnel for their help in ensuring the Screening Programme was launched, and still runs, as smoothly as possible; Mairi White, Alan Hankinson, and Matthew Davis. For more information, visit our website faecal-immunochemical-test.co.uk Figure 1: Comparison Graphs Bowel Cancer Screening Uptake in Scotland - Comparison of gFOBT and FIT Testing Methods Age range