Final Research Plan

Screening for Syphilis Infection in Nonpregnant Adolescents and Adults

The final Research Plan is used to guide a systematic review of the evidence by researchers at an Evidence-based Practice Center. The resulting Evidence Review will form the basis of the USPSTF Recommendation Statement on this topic.

The draft Research Plan was available for comment from June 26 to July 23, 2014, at 5:00 p.m., ET. To view the draft Research Plan, click here.

I. Analytic Framework

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II. Key Questions to Be Systematically Reviewed

What is the effectiveness of screening for syphilis in reducing complications of the disease and transmission or acquisition of other sexually transmitted infections in asymptomatic, nonpregnant, sexually active adults and adolescents? What is the effectiveness of specific screening intervals and screening among population subgroups?
What is the effectiveness of risk assessment instruments or other risk stratification methods for identifying persons who are at increased risk for syphilis?
What is the accuracy of currently used screening tests and strategies (e.g., sequence of tests) for detecting syphilis infection?
What are the harms of screening (e.g., labeling and false-positive or false-negative results)?

III. Contextual Questions

Contextual questions will not be systematically reviewed and are not shown in the Analytic Framework.

Which population subgroups, including men who have sex with men, are at highest risk for incident syphilis infection?
Which population subgroups are at highest risk for syphilis-related morbidity and mortality?

IV. Research Approach

The Research Approach identifies the study characteristics and criteria that the Evidence-based Practice Center will use to search for publications and to determine whether identified studies should be included or excluded from the Evidence Review. Criteria are overarching as well as specific to each of the key questions (KQs).

	Include	Exclude
Disease definition	Positive result for syphilis on any test modality
Populations	Asymptomatic, nonpregnant adolescents and adults, including patients coinfected with other STIs, including HIV	Symptomatic patients; neonates, infants, and children; pregnant women; contacts of cases; studies of HIV patients, for whom syphilis testing is disease management rather than a screening intervention
Interventions	KQs 1, 4: Screening effectiveness, including effectiveness of different screening intervals KQ 2: Risk assessment instruments and other risk stratification methods that identify persons who are at increased risk for syphilis infection; definitions of “increased risk” and true disease status will be determined by the available studies KQ 3: FDA-approved tests available in the United States that detect syphilis in biological specimens, including varying testing strategies (e.g., traditional, reverse sequence)
Comparators	KQ 1, 4: No screening or alternate screening strategy or methods KQ 2: True disease status KQ 3: Study-specific comparator or “gold standard,” as determined by the study itself (e.g., an enzyme-linked immunosorbent assay technique could be evaluated by comparing its sensitivity and specificity with that of MHA-TP and FTA-ABS tests)	No comparison
Outcomes	KQ 1: Reduction in complications of syphilis (e.g., neurosyphilis, symptomatic neurosyphilis, tertiary syphilis, congenital syphilis); disease transmission, including HIV transmission; other relevant clinical outcomes; rates of infection and other similar measures of infection KQ 2: Detection of infection KQ 3: Diagnostic accuracy (i.e., measures of the test's sensitivity, specificity, positive and negative predictive values, and other related measures) KQ 4: Harms from screening (e.g., labeling, false-negative or false-positive results and related harms, including psychosocial harms)	KQ 1: Outcomes that are not directly related to health outcomes (e.g., laboratory studies) KQ 4: Harms related to true-positive and true-negative tests, including psychosocial harms
Settings	Primary care and primary care–referable settings (e.g., correctional facilities and community care, such as schools, family planning clinics, obstetrics and gynecology clinics, emergency departments, and STI clinics)
Study designs	All KQs: Good-quality systematic reviews Benefits: Randomized, controlled trials; observational studies with comparison groups, including ecological studies Harms: Randomized, controlled trials; observational studies, including cross-sectional and ecological studies	Benefits: Observational studies without comparison groups; case reports Harms: Case studies

Abbreviations: FDA = U.S. Food and Drug Administration; FTA-ABS = fluorescent treponemal antibody absorption; MHA-TP = microhemagglutination assay for Treponema pallidum antibodies; STI = sexually transmitted infection.

V. Response to Public Comment

A draft version of the research plan was posted for public comment on the USPSTF Web site from June 26 to July 23, 2014. Four individuals or organizations provided comments. A few comments requested that the review include serologic followup of persons with a syphilis diagnosis. While the USPSTF understands that serologic followup may play an important role in preventing complications and ongoing transmission of syphilis, the USPSTF considers this clinical management rather than primary prevention, and it is therefore outside the scope of this review. Comments about the key questions primarily concerned the inclusion and exclusion criteria, which have been clarified in the research plan. These clarifications include further defining persons who are eligible for screening (i.e., asymptomatic persons), that the definitions of increased risk and true disease status will be determined by the available studies, that gold standards will be defined by the studies themselves, and the research literature on harms will be summarized and the magnitude of effect will be determined if possible. Harms of treatment with penicillin will be included in the background section rather than in a key question because its harms are well-established. The contextual questions will be addressed by studies reporting rates and trends of syphilis rather than those evaluating screening effectiveness. The inclusion criteria were expanded to add more extensive descriptions of the populations and settings for screening and health outcomes and to clarify that study designs low on the evidence hierarchy may be used if no other studies are available.

AHRQ Publication No. 14-05213-EF-5
Current as of September 2014

Internet Citation:

U.S. Preventive Services Task Force. Screening for Syphilis Infection in Nonpregnant Adolescents and Adults: Final Research Plan. AHRQ Publication No. 14-05213-EF-5. http://www.uspreventiveservicestaskforce.org/uspstf14/syphilis/syphfinalresplan.htm

Final Research Plan: Screening for Syphilis Infection in Nonpregnant Adolescents and Adults