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The Laboratory Impact of Changing Syphilis Screening From the Rapid-Plasma Reagin to a Treponemal Enzyme Immunoassay: A Case-study From the Greater Toronto Area

Mishra, Sharmistha MD, MSc*†; Boily, Marie-Claude PHD†‡; Ng, Victoria PHD§; Gold, Wayne L. MD*; Okura, Tom BSc; Shaw, Marsha BSc; Mazzulli, Tony MD¶∥; Fisman, David N. MD, MPH***

Sexually Transmitted Diseases: March 2011 - Volume 38 - Issue 3 - p 190-196
doi: 10.1097/OLQ.0b013e3181f07e91
Original Study

Background: In 2005, syphilis screening in the Greater Toronto Area of Canada moved from the rapid plasma reagin (RPR) to a treponemal enzyme immunoassay (EIA). We sought to understand the consequences of this change on laboratory results and testing patterns with a population-based retrospective study of laboratory-based diagnoses of syphilis.

Methods: Samples positive under RPR (1998–2005) and EIA (2005–2008) screening were confirmed with an alternate treponemal test, and during the latter period underwent RPR testing. We compared monthly rates and the forecasting relationship between positives and future submissions with time-series methods, and assessed risk factors for EIA(+)/RPR(−) results using Poisson regression.

Results: A total of 3,092,938 submissions were included. Following EIA implementation, confirmed positive rates increased by 10.3 per 100,000 population (P < 0.001). 0.59% of EIA(+)/RPR(−) individuals converted to RPR(+) within 2 months. EIA(+)/RPR(−) patients were more likely to be male (incidence rate ratio [IRR]: 2.3, 95% confidence interval [CI]: 1.6–2.5), asymptomatic (IRR: 1.8, 95% CI: 1.3–2.8), and aged >50 years (IRR: 2.4, 95% CI: 1.6–3.5) than those with EIA(+)/RPR(+) results. We detected a significant positive feedback loop between positive tests and subsequent submissions. This relationship was only transiently evident for EIA(+)/RPR(−) results up to 1 year following the changeover.

Conclusions: EIA screening facilitates identification of probable latent syphilis and earlier serological detection of infectious syphilis, but may transiently cause increases in testing and indirectly suggests that physicians' interpretation of RPR(−) serology may lead to partner testing. In the absence of a true gold standard, implementation of EIA screening warrants careful communication regarding serological interpretation.

Implementation of a treponemal enzyme immunoassay for syphilis screening increased detection of rapid plasma reagin negative syphilis and was associated with a transient increase in future testing.

From the *Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada; †Department of Infectious Diseases Epidemiology, Imperial College London, London, United Kingdom; ‡Unite de recherche en Sante des Populations, Centre Hospitalier Affilié Universitaire de Québec, Quebec, Canada; §Centre for Public Health and Zoonosis, University of Guelph, Guelph, Ontario, Canada; ¶Public Health Laboratory-Toronto, Ontario Agency for Health Protection and Promotion, Ontario, Canada; ∥Department of Microbiology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; and **Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.

The authors thank Leo Chow (Public Health Laboratory-Toronto) for assistance in data retrieval and Steven Retchford for assistance in database management.

Supported by the Physicians' Services Incorporated Foundation grant number 06-31. Also supported by a Canadian Institutes for Health Research and Public Health Agency of Canada fellowship (to S.M.).

Correspondence: Sharmistha Mishra, MD, MSc, Division of Infectious Diseases, St. Michael's Hospital, 4–179 CC North, 30 Bond St, Toronto, ON M5B 1W8, Canada. E-mail:

Received for publication May 2, 2010, and accepted July 1, 2010.

© Copyright 2011 American Sexually Transmitted Diseases Association