Discordant Results from Reverse Sequence Syphilis Screening --- Five Laboratories, United States, 2006--2010

Discordant Results from Reverse Sequence Syphilis Screening --- Five Laboratories, United States, 2006--2010
Weekly
February 11, 2011 / 60(05);133-137

CDC recommends syphilis serologic screening with a nontreponemal test, such as the rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) test, to identify persons with possible untreated infection; this screening is followed by confirmation using one of several treponemal tests. Recently, the availability of automatable treponemal enzyme and chemiluminescence immunoassays (EIA/CIA) has led some laboratories to adopt a reverse sequence of screening in which a treponemal EIA/CIA is performed first, followed by testing of reactive sera with a nontreponemal test. To better understand the performance of reverse sequence screening for syphilis, CDC analyzed data from five laboratories that used reverse sequence screening during 2006--2010. This report describes the results of that analysis, which indicated that among sera reactive on initial screening with a treponemal EIA/CIA, 56.7% had a nonreactive RPR test. Among these discordant sera, 31.6% also were nonreactive by treponemal testing using Treponema pallidum particle agglutination (TP-PA) or fluorescent treponemal antibody absorbed (FTA-ABS) tests. Among discordant sera, the rate of nonreactive confirmatory treponemal tests was 2.9 times higher in a population with low prevalence of syphilis, suggesting that the low-prevalence population had a higher percentage of false-positive test results. Although CDC continues to recommend the traditional algorithm with reactive nontreponemal tests confirmed by treponemal testing, in this report CDC offers additional recommendations if reverse sequence syphilis screening is used.

Treponema pallidum, the bacterium that causes syphilis, cannot be cultured. As a result, serologic testing is the method most often used to diagnose syphilis in patients with suspected disease. Because syphilis can be asymptomatic, serologic screening is recommended for 1) persons at high risk, to detect latent infections; 2) pregnant women, to prevent congenital syphilis; and 3) blood donors, to prevent transmission through transfusion. Serodiagnosis of syphilis involves the detection of two distinct types of antibodies: 1) nontreponemal antibodies directed against lipoidal antigens released from damaged host cells and possibly from the treponemes themselves and 2) treponemal antibodies directed against T. pallidum proteins. Nontreponemal antibody tests can be nonreactive early in the course of infection and in late stages of disease, and often become nonreactive (serorevert) after treatment of early infection (1). Treponemal antibodies appear earlier than nontreponemal antibodies and usually remain detectable for life, even after successful treatment.

To reduce the time and labor required for syphilis screening, some laboratories have adopted reverse sequence screening in which sera are tested first by a treponemal EIA/CIA that permits automation for high throughput testing, followed by nontreponemal testing of reactive specimens. This reverse sequence can result in identification of discordant sera that are reactive with a treponemal test but nonreactive with a nontreponemal test. This result does not occur with the traditional algorithm because only nontreponemal-reactive sera are tested with a treponemal test. Discordant testing results could be caused by 1) previous syphilis infection, treated or untreated, with persistence of treponemal antibodies but seroreversion of nontreponemal antibodies, 2) a false-positive treponemal test result, or 3) early primary syphilis in a person who has yet to develop nontreponemal antibodies.

In 2008, a CDC report found that among 6,548 sera that were reactive with a screening EIA, 3,664 (56.0%) were nonreactive by reflex nontreponemal testing (2). Among the 3,664 discordant sera, 2,512 were tested with a TP-PA or FTA-ABS, of which 433 (17.2%) were nonreactive, suggesting false-positive EIA treponemal test results. In that analysis, results from four different laboratories using two different commercial EIAs and different testing protocols were combined without subanalyses. The report recommended a confirmatory treponemal test for discordant sera (using a test other than EIA or CIA) to identify persons who might require treatment (2).

Since the 2008 CDC report, confusion has persisted among clinicians, laboratorians, and public health practitioners regarding testing and treatment decisions and partner notification when using the reverse sequence for syphilis screening (3). Management decisions for patients with discordant sera and nonreactive confirmatory treponemal tests are especially difficult. To evaluate reverse sequence screening in populations with high and low syphilis prevalence and to evaluate the use of TP-PA and FTA-ABS tests for identifying false-positive EIA/CIA screening tests, CDC analyzed syphilis screening data from five clinical laboratories. Three sites served patient populations with low prevalence of syphilis (large managed-care organizations), and two sites served patient populations with high prevalence (including men who have sex with men and patients with human immunodeficiency virus infection).

A total of 140,176 sera screened with a treponemal EIA/CIA were included in the analyses (4--7; SM Novak-Weekley, Southern California Permanente Group Regional Reference Laboratories, personal communication, 2010). Data from sera with equivocal test results were not included as reactive tests. For each site and overall, the following percentages were calculated: 1) reactive EIA/CIAs among all sera, 2) discordant sera among those with reactive EIA/CIAs (i.e., those with negative nontreponemal test results), and 3) nonreactive confirmatory TP-PA or FTA-ABS tests among discordant sera. The same calculations were performed for the populations with low prevalence and high prevalence of syphilis.

Among the 140,176 specimens screened with an EIA/CIA, 4,834 (3.4%) had a reactive test result (Table). Among these 4,834 EIA/CIA-reactive sera, 2,743 (56.7%) were RPR-nonreactive, of which 866 (31.6%) were nonreactive by TP-PA or FTA-ABS testing, suggesting that the initial EIA/CIA result was a false-positive. The percentage of reactive EIA/CIAs was 6.3 times higher (14.5%) in the population with high prevalence of syphilis than the population with low prevalence (2.3%). The percentage with discordant results was higher in the low-prevalence population than in the high-prevalence population (60.6% versus 50.6%), but among the discordant sera, the percentage with nonreactive TP-PA or FTA-ABS tests was 2.9 times greater in the low-prevalence population than the high-prevalence population (40.8% versus 14.1%).

Reported by
JD Radolf, MD, Univ of Connecticut Health Center. G Bolan, MD, IU Park, MD, JM Chow, DrPH, California Dept of Public Health. JA Schillinger, MD, P Pathela, DrPH, S Blank, MD, New York City Dept of Health and Mental Hygiene, New York. SN Zanto, MPH, Montana Dept of Public Health and Human Svcs Laboratory Svcs Bureau. KW Hoover, MD, KA Workowski, MD, DL Cox, PhD, RC Ballard, PhD, Div of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.

full-text:
Discordant Results from Reverse Sequence Syphilis Screening --- Five Laboratories, United States, 2006--2010