T R A N S F U S I O N C O M PL I C A T I 0 N S
Predictive value of past and current screening tests for
syphilis in blood donors: changing from a rapid plasma reagin
test to an automated specific treponemal test for screening
I. Aberle-Grasse, S.L. Orton, E. Notari IV, L.P. Layug, R.G. Cable,
S. Badon, M.A. Popovsky, A,]. Grindon, B.A Lenes, and A.E. Williams
BACKGROUND: This study evaluated the change from
a rapid plasma reagin (RPR) test to an automated spe-
cific treponemal test (PK-TP) in screening for syphilis in
blood donors.
STUDY DESIGN AND METHODS: A cross-sectional
seroprevalenceanalysis was performed on 4,878,215
allogeneic blood donations from 19 American Red Cross
Blood Services regions from May 1993 through Septem-
ber 1995. Positive predictive values relative to the confir-
matory fluorescent treponemal antibody absorption test
(FTA-ABS) were calculated.Differences in seroprevalence
were compared in RPR and PK-TPtests for 1) uncon-
firmed and confirmedtests, 2) first-time and repeat do-
nors, and 3) “recent” versus “past” infections. Donation
data from three additional Red Cross regions were evaiu-
ated for repeat donation patterns of blood donors who had
a donation that was positive in a serologic screening test
for syphilis.The value of RPR and PK-TPtests as surro-
gate markersfor HIV infectionwas compared.
RESULTS: Reactive rates were lower but the positive pre-
dictive values was higher for the PK-TP test than for the
RPR test. Initially, donors screened by PK-TP were more
likely to be confirmedas positivethan were donors
screened by RPR, but these rates became comparable.
It is estimated that a single HIV window-period donation
was removed by serologic testing for syphilis each year
of this study period.
CONCLUSIONS:The change to the PK-TP test resulted
in a lower repeatedly reactive rate, better prediction that
’ a confirmed-positive test for syphilis would occur in test-
ing in the FTA-ABS, fewer donations lost, and compa-
rable deferral rates. Because of the high rate of reactivity
to serologic testing for syphilis among donors previously
confirmed positive for syphilis, indefinite deferral after a
confirmed-positive index donation may be warranted.
Serologic testing for syphilis is ineffective as a marker of
HIV-infectiouswindow-period donations.
206 TRANSFUSION Volume 39, February 1999
S
erologic screening tests for syphilis have been per-
formed on the blood supply for 50 years.’ Until
recently, a reagin-based test (e.g.,rapid plasma
reagin [RPR]) had been used.The high rate of false-
positive reactionsin low-riskpopulations attributable to the
RPR test and the inefficiency and subjectivity of manual
screening led to the implementation of an automated spe-
cific treponemal test (PK-TT:Olympus Corp.,Lake Success,
NY) in most American Red Cross (ARC) blood centers over
the past 10 years. The change from the RPR to the PK-TP
was phased in between April 1990 and October 1995 in the
19 regions studied.
Blood components from donations with repeatedly re-
active results on serologic testingfor syphilis (STS) are rou-
tinely discarded without reference to the results of a rou-
tine fluorescent treponemal antibody absorption (FTA-ABS)
confirmatorytest. Currently,donors who do not have a con-
firmed-positivedonationmay donate again,and donors with
ABBREVIATIONS: ARC =American Red Cross;ARCBS = ARC
Blood Services;FTA-ABS = fluorescent treponemal antibody ab-
sorption (test);PK-TP = trade name for an automated specific
treponemal test for syphilis; PK-TPl = PK-TP test before
diluent modification; PK-TP2 = PK-TP test after diluent modi-
fication; PPV(s) = positive predictive value(s);RPR = rapid
plasma reagin (test);STS = serologic testing for syphilis.
From the Holland Laboratory, American Red Cross Blood Ser-
vices; and the American Red Cross National Reference Labo-
ratory for Infectious Diseases, Rockville, Maryland: and Ameri-
can Red Cross Services: the Connecticut Region, Hartford,
Connecticut; New England Region, Dedham, Massachusetts;
Atlanta Region, Atlanta, Georgia; and Miami Region, Miami,
Florida.
Supported in part by the American Red Cross Biomedical
ServicesARCNET Epidemiological Research and Surveillance
Program.
Received for publication April 21, 1998;revision received
June 18,1998,and accepted June25,1998.
TRANSFUSION 1999;39:206-211.

a confirmed-positive donation are deferred for 1 year after
completion of therapy but may then be re-entered into the
donor ~ 0 0 1 . ~
Onlytwo cases of transfusion-transmitted syphilishave
been reported in the literature in the past 30 years.3 How-
ever, a compelling reason for the continued used of STS,
according to a National Institutes of Health Consensus Con-
f e r e n ~ eis, ~that the extent to which STS contributes to the
current absence of posttransfusion syphilis is unknown. A
further reason given to continue STS is its potential utility as
a surrogate marker for other infections, such as HIY4
This study compared repeatedlyreactiveand confirmed-
positive rates in first-time and repeat donors, positive pre-
dictive values (PPVs)of the RPR and PK-TP tests relative to
FTA-ABS test, and differences in PK-TP testing before (PK-
TP1) and after (PK-TP2)diluent modification bythe manu-
facturer that was designed to reduce the rate of false-posi-
tive reactions. Also analyzed were sex and age group
differences in “recent” (RPR+)and “past”(RPR-1 infection
rates in donors with positive PK-TP tests confirmed by FTA-
ABS, serologic results and return donation patterns of blood
donors who are positive in both the RPR and the PK-TP and
confirmed in the FTA-ABS, and the value of RPR and PK-TP
as surrogate markers for HI\!
MATERIALS AND METHODS
Source population
Donation and laboratory test data were collected from
4,878,215allogeneic blood donations at 19ARC Blood Ser-
vices (ARCBS)regions from May 1993 through September
1995.The 19 study regions for which complete data from STS
were available were selected from the ARCNET data system.
These data represented about 43 percent of the total blood
collections in the ARCBS regions during this study period.
Data comparing first-time donors to repeat donors are eco-
logic; that is, comparisonsare made between different groups
during the same time period. Additional data on a subset of
651,087 allogeneic blood donations from three ARCBS re-
gions were used to evaluate serial donations. The following
demographic information was collected for all of the dona-
tions: the donor’sprevious donation date, the donation type
(allogeneicor autologous),first-timeor repeat donation, and
the donor’sself-exclusionstatus, as well as each donor’sdate
of birth, age, and sex. Laboratory screening and confirma-
tory data were also collected. Donors were classified as re-
peat if they had donated in the previous 3 years; otherwise,
theywere classified as first-time.
Laboratory testing
Nonspecific reagin tests for syphilis (VDRL [VeneralDisease
Reference Laboratory],RPR) involve testing for IgG and IgM
antibodies to cardiolipin (reagin)antigen that are generated
as a result of interaction between infected host tissues and
SEROLOGIC TESTING FOR SYPHILIS
Tkpowmupallidum itself.These antibodiesare also produced
in response to tissue damage from other nontreponemal dis-
ease. This type of test has been used historicallyas a screening
test in blood centers. Because a reactive test in infected indi-
viduals is a good indication of disease activity,it is also used
to follow patients’ responses to therapy.When used specifi-
cally to monitor for syphilis infection, this test becomes
nonreactive 6 to 12 months after successful treatment of
primary syphilis and up to 2 years after successfultreatment
of secondary syphilis. Specifictreponemal tests include the
FTA-ABS and the ?: pallidurn hemagglutination tests. The
FTA-ABS is a standard indirect immunofluorescence anti-
body test. False-positive results are known occur; the fre-
quency is greater in low-riskpopulations and the elderly.The
T pallidum hemagglutination test measures specifictrepone-
mal antibody by using passive agglutination of red cells sen-
sitized with a ~ ~ t i g e Specific
n . ~ . ~ antitreponemal tests provide
the earliest positive test results and are used for detecting
the likelihoodof any infection,past or recent.’a8 The PK-TP is
an automated hemagglutinationtest developed primarilyfor
blood banking.
Our laboratory test data included the results of STS by
the RPR, PK-TP1, and PK-TP2tests. The change from the RPR
to the PK-TP occurred at various times between April 1990
and September 1995 for individual centers. Donors tested
by the PK-TPl and PK-TP2 tests had significantlydifferent
confirmatory test results and therefore were analyzed sepa-
rately. All donations with reactive screeningtests underwent
confirmatory testing at the ARC National Reference Labo-
ratory for Infectious Diseases using a standard method of
FTA-ABS.5
A confirmed test result was defined as RPR+ or PK-TP+
and FTA-ABS+.A confirmed test result does not necessarily
mean true infection, as no gold standard for infectivitywas
used. Afalse-positivetest result was defined as RPR+or PK-
TP+ and FTA-ABS-. To assess recent infection, the RPR test
was performed on samples with positive results in the PK-
TP test that were confirmed with FTA-ABS. Recent infection
was defined as PK-TP+,FTA-ABS+,and RPR+ (PK-TP+/FTA-
ABS+IRPR+).Past infection was defined as PK-TP+, FTA-
ABS+, and RPR- (PK-TP+/FTA-ABS+/RPR-).
Statistical calculations
PPVs of the RPR and the PK-TP tests relative to the FTA-ABS
test were calculated (note: not true positive;see above). Fre-
quency distributions were calculated for RPR- and PK-TP-
unconfirmed and -confirmed seroprevalence. Differences
in screeningmethods were assessed by the Mantel-Haenszel
chi-square test usingsoftware (EpiInfo,Centers for Disease
Control and Prevention, Atlanta, GA) for sex and age group
strata (17-24,25-39,40-64,65and older). Because of mul-
tiple comparisons and large samples, a p value of 10.01was
considered significant?
Retum-donationpatterns and confirmation frequencies
were calculatedusing data from 651,087 serial donations in a
Volume 39,February 1999 TRANSFUSION 207
ABERLE-GRASSE ET AL.

three-region subset. In this subset, donors screenedwith PK-
TP1 and PK-TP2 are analyzed together because of the small
numbers.
The correlation between positive results in the RPR and
the PK-TP tests and HIVinfection was assessed by calcula-
tion of the odds ratio as an estimate of relative risk. To esti-
mate the number of window-period donations removed by
STS, the technique of Herrera et al.1° was applied by using
previously published risk estimates for window-period do-
nations and multiplying them by the proportion of donors
with confirmed HIVinfections in whom STS was also posi-
tive, but who were negative for other screeningtests and who
did not self-defer.This calculation assumes that infectious
window-period donations have the same ratio of positive
syphilisscreeningtest results and other test results as do con-
firmed HIV-positivedonations.The published risk estimate
used for HIV-1 window-period donations during the study
period was 1 in 450,000donations.' The estimate of the total
number of blood donations collected nationally in 1 year
during the study was 12 million donations.IOFor compari-
son purposes, the number of cases removed by STS in our
study was multiplied by the quotient of our study popula-
tion divided by 12 million.
and PK-TP2-positiveresults were more likely to be confirmed
by FTA-ABSthan were RPR-positiveresults, (6 and 7 times,
respectively).The highest PPV, relative to confirmatory test-
ing by FTA-ABS, was found by using PK-TP2 as the test of
record; it also indicated an increase in the specificityof the
PK-TP2 test. However, it can be seen in Table 2 that, when
stratified, this confirmed rate is lower in repeat donors pre-
viously screened by PK-TI?There was also a decrease from
PK-TPl to PK-TP2 in the rate of confirmed-positive results
for both first-time and repeat donors. Stratification by sex
and age can be seen in Fig. 1. Results of PK-TP2 testing were
significantlydifferent from those of PK-TP1 testing in all age
strata, regardless of sex, with the exception of the group aged
17- to 24-years old and women over 65 years of age.
Recent versus past infection
A comparison of recent (PK-TP+/FTA-ABS+/RPR+ ) and past
(PK-TP+/FTA-ABS+/RPR-)infection rates in donors tested
with PK-TP2 can be seen in Fig. 2. Estimates of recent infec-
tion rates are higher than past rates in 17- to 24-year-olds,
regardless of sex. These rates reverse themselves for the age
groups over 24.

RESULTS
Repeatedly reactive and TABLE 1. PPV of study population (4,878,215 allogeneic donations from 19
confirmatory rates and PPV ARCBS regions)between Mav 1993 and SeDtember 1995
For the study population of4,878,215, Number positive Number
in STS confirmed
the results of the screening and con- (% of total (% of total
firmatory testing and the PPVs are donations tested) donations tested) PPV(%)
shown inTable 1.Thechangefrom RPR RPR (n = 1,738,331) 4,591 (0.26) 391 (0.02) 8.5
to PK-TP2 apparently decreased the PK-TP1 (n = 1,338,379) 2,800 (0.21) 1,494 (0.11) 53.4
First-time donors (0.28)
number of reactive tests by more than Repeat donors (0.08)
half. The differences in the percentage PK-TP2 (n = 1,801,505) 2,151 (0.12) 1,274 (0.07)* 59.2t
of repeatedly reactive results for PK- First-time donors (0.22)
Repeat donors (0.04)
TP1 and PK-TP2 can be seen as a de- PK-TPl vs. PK-TP2 chi-square, 145.64; p value <0.00001.
crease of 43 percent. Both PK-TP1- t PK-TP1 vs. PK-TP2 chi-square,l6.54; p value = 0.00004.

TABLE 2. Seroprevalenceof first-time and repeat allogeneic donations when tested by RPR and PK-TP'
First-time donorst Repeat donors*
Number positive in STS Number confirmea Number positive in STS Number confirmed Percentage
(Yoof total (% of number (Yoof total Percentage of number of total
donations tested) positive in STS)§ donations tested) positive in STS)§ donations tested
RPR 993 (0.31) 160 (16.1) 3,598 (0.26) 230 6.4 0.02
PK-TP 1,825 (0.35) 1,278 (70.0) 2,924 (0.11) 0.08
Previous RPR 1,550 (0.24) 998 63.8 0.16
(n = 641,239)
Previous PK-TP 1,374 (0.08) 502 31.9 0.03
(n = 1.978.029)
Data comparing first-time donors to repeat donors are ecologic; that is, comparisons are made between different groups during the same
time period.
t RPR = 323,821; PK-TP = 518,505.
+ RPR = 1,410,000; PK-TP = 2,619,268.
5 PPV.

208 TRANSFUSION Volume 39, February 1999

 SEROLOGIC TESTING FOR SYPHILIS

0 18 positive and repeat donors previously

tested by PK-TPwho were confirmed
0 16
as positive.
In repeat donors, the rate of con-
-.-
0
0

4
014
firmed positives as a percentage of the
fn 012 total population tested with RPR was
-
0
0.02 percent. With the PK-TP test (do-
6 01
nors previously tested by RPR), this
-m
0

5 008 rate initiallyincreased to 0.16 percent.

h
L

a
2
0, 006
However, over time this rate de-
5P creased to 0.03percent which is almost
,f 004
as low as that with RPR.

0 02 RPR and PK-TP as a surrogate

markers for HIV infection
0
c a u m
i u)
u-) The correlation between positive re-
- N
sults in RPR and PK-TP tests and HIV
Age groups and sex infection was evaluated by calcula-
* p value ~0.01.
Fig. 1. PK-TP1 (m) versus PK-TP2 (0). tion of the odds ratio, defined as the
ratio of the probability of a confirmed
HIV-positive result given a con-
0 18 firmed-positive result in RPR and PK-
TP tests relative to the probability of a
0 16 confirmed HIV-positiveresult given a
0
m 0 14
negative or unconfirmed result in the
e
a
c RPR and the PK-TI? The odds ratios
6
I
012 were calculatedas 157(95%CI ,49-502)
for RPR and 149 (95%CI, 84-267)for
i-
-
m
e
01

008
P K - n which were not significantlydif-
ferent. The estimated number of po-
% tential infectious window-period do-
E 006 nations removed by RPR and PK-TP
0 screening nationally per year was ob-
004
tained by multiplying the window-pe-
0 02 riod risk" (1/450,000)by the percent-
age of HIV+ and RPR+ or PK-TP+
0
donations divided by all other tests
B (3.4% for RPR, 3.7%for PK-TP2) times
Age groups and sex
12 million donations. It was found to
Fig. 2. Recent (m) versus past (0)
infection in PK-TP2. be 0.9 donations for RPR and 1.0 do-
nations for PIC-TP2. These values are
not significantlydifferent.

First-time versus repeat donors, unconfirmed and
confirmed seroprevalence
InTable 2, the data comparing first-time donors tested with
RPR and those tested with PK-TP show similar, uncon-
firmed rates. While this rate decreased only slightly in re-
peat donors tested with RPR, with PK-TR the rate in repeat
donors decreased to 0.11 percent. The PK-TP-reactiverate
in repeat donors was higher in those who had previouslybeen
screened by RPR than in those who had previously been
screened by PK-TP Differencescan also be seen in the rate
of first-time donors tested by PK-TP who were confirmed as
Retention of donated components and deferral of
donors; return donation patterns
As a result of the increase in specificityof PK-TP compared
to RPR, over this studyperiod, 3140additional donationswere
availablein the study population. However,as seen in Table
1,the greater confirmation rate associated with PK-TP2 test-
ing than with RPR testing resulted in 9000 more donor de-
ferrals during this time period.
Results of tests of subsequent donations after a con-
firmed-positivedonation in the subset of 651,087are seen in
Table 3. Fewer donors were confirmed as positive on all sub-

Volume 39, February 1999 TRANSFUSION 209

ABERLE-GRASSE ET AL.
sequent donations when tested with RPR than with PK-TF?
Regardless of the screeningtest, few individualswho are con-
firmed as positive for syphilis on a donation return to do-
nate.
DISCUSSION
The low specificity of the nontreponemal RPR test in the
blood donor population is well documented. The observed
higher PPV of PK-TP for syphilis antibody (confirmed as
positive) is consistent with previously published data.3This
finding is not surprising, as the PK-TP and the FTA-ABS
have the same antigenic specificity. Because the same dis-
ease states that cause false-positive results in reagin-based
tests for syphilis are known to cause false-positive results
in the other test^,^-^ the value of STS as a predictor of infec-
tivity in the blood donor population is unknown.
According to the manufacturer, the diluent modifica-
tion from PK-TP1 to PK-TP2 resulted in higher specificity
and therefore a decrease in the false-positiverate. However,
our data indicate that there is a difference in the confirma-
tory rates for PK-TP1 and PK-TP2. Factors that maycontrib-
Ute to this difference in absolute rate include false-positive
repeatedly reactive donations that are confirmed positive
with PK-TP1,the prevalence of syphilis in each population
group, first-time:repeat donor ratio, sex or age mix, and a
decrease in sensitivity of the PK-TP2. It is not known
whether our data reflect a decrease in sensitivity.Initially,the
higher confirmatory rates found after testing by PK-TP than
after testing by RPR will be moderated by the proportion of
repeat donors in a given donor population and will deter-
mine any difference in the number of donors that will be
deferred. Over time, the confirmation rate after PK-TP test-
ing as a percentage of the total population tested appears to
approach that after RPR testing, although there is a net loss
of 0.01 percent of donors due to deferral. However, a sus-
tained higher level of donor deferrals should not be antici-
pated. Ifwe project the ARCNET data to the current nation-
wide collection estimate of 14 million donations," the
difference in the repeatedly reactive rate with RPR and PK-
TP2 translates to a net retention of approximately 25,000
more whole-blood units annually (although this is not sub-
stantiated by repeatedlyreactive rates for first-timedonors).
The major argument for the switch to PK-TP is the capability
TABLE 3. Subsequent donations after an STS confirmed-positivedonation
in the ARCNET group of 651.087 allogeneicdonations over a 3-year period
Number Number who
confirmed" returned to donate
Total screened (% of total) (Yoof number confirmed) (% of number-confirmed)
RPR (n = 228,524) 240 (0.10) 11 (4.6)
PK-TP In = 422.5631 215 (0.05) 10 (4.7)
PPV
210 TRANSFUSION Volume 39, February 1999
of automation and the elimination of the ambiguity associ-
ated with the manual reading of the RPR.
The higher prevalence of past infection relative to re-
cent infection in older groups is expected, because of cu-
mulative exposure and the higher incidence of syphilis in
the past. The greater number of recent infections seen in
the group aged 17 to 24 screened with PK-TP2 is expected,
because donors in this group have had less total lifetime ex-
posure and more recent exposure, which is most closely
associated with current syphilis infection. First-time donors
are more likely to screen repeatedly reactive and to be con-
firmed as positive than repeat donors tested with both RPR
and PK-TI! This is not surprising and is consistent with pre-
viously published studies that found that the rate of risk
behavior meriting deferral is higher in first-time blood do-
nors,12as is the incidence rate of infectious disease mark-
er~.'~
The higher rates in donors previously tested only with
the RPR than in those previously tested with the PK-TP may
be a result of the detection by PK-TP of treated andlor re-
covered infections that were not detected by RPR. From the
subset of 651,087,it can be seen that donors screened with
the PK-TP and confirmed positive by FTA-ABS are more
likely to remain positive on subsequent donations than
donors screened with RPR, although the return rate for con-
firmed-positive donors is low in both groups. The data seen
inTable2 support the current policy of allowingSTS-repeat-
edly reactive (unconfirmed) donors to return without de-
ferral. Conversely,the subset data suggest that it may be ef-
ficacious for PK-TP confirmed-positive donors to be
permanently deferred,as there is little evidenceof disappear-
ance of the antibody. This observation is related to the per-
manence of the serologic test result, and not infectivity.
As a surrogate marker, PK-TP is similar to RPR as a pre-
dictor of HIVinfection. Because of the low probability that a
donor would be in the window-period for both HIV and
syphilis when his or her blood was collected, it is dubious
whether any syphilis screening test is an effective surrogate
marker for HIVinfection.Because the ratio of donations that
were RPR+ or PK-TP+and HIV+ to donations that were RPR-
or PK-TP- and HIV+was much higher in our study than that
of the study by Herrera et a1.,I0we calculated that 1potential
case of HIVinfection (assuming 12 million donations annu-
ally)would be prevented nationallyin a year.While our study
calculated twice as many cases as the study by Herrera et al.
(0.2casesl4.5 million donations),our
results, whether for PK-TP or RPR, are
similar to the estimate of the National
Subsequent positive Institutes of Health Consensus Con-
confirmatory testing ferences of less than one HIVcase re-
moved annually by STS, and they sup-
3 (27.3)
port that group's conclusion that STS
9 (90.01 is not an effective surrogate marker
for HIV i n f e ~ t i o n . ~

Many of the evaluationsusing RPR, PK-TE!and FTA-ABS
results assume that confirmed-positiveresults represent true
infection, either past or recent. l’he rate of false-positivere-
sults is dependent upon the population screened and the test
used. False-positiveresults have been associated with hepa-
titis, mononucleosis,viral pneumonia, chicken pox, measles,
other viral infections, immunizations, pregnancy, and labo-
ratory error. False-positiveresults also have been associated
with connectivetissue diseases (systemiclupus erythemato-
sus) or diseases associated with hypergammaglobulinemia,
narcotic addiction,aging,leprosy, and malignancy?-8In popu-
lations that are unlikely to have syphilis, false-positive test
results have been shown to occur at a high rate (0.75%).14In
industrialized nations, a low prevalence in the population
equates to a high false-positive(noninfected) rate of 80 per-
cent or more in donor population^.'^ This high rate of false-
positive results may explain our calculated rate of 30 cases
per 100,000,as the estimated annual population incidence
rate of syphilis is 6.3 cases per 100,000population.I6If most
of these positive results are false, that observtion supports
the ineffectiveness of using this test as a screen for syphilis
infectivity in the United States blood donors.Consequently,
further epidemiologic and laboratory study of confirmed-
positive donors is needed to determine the relationship of
these positive test results to transmissible syphilis infection.
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AUTHORS
John Aberle-Grasse, MPH, Project Leader, Transmissible Dis-
eases Laboratory, Jerome H. Holland Laboratory, American Red
Cross, 15601 Crabbs Branch Way, Rockville, MD 20855.[Reprint
requests]
Sharyn L. Orton, MSPH, Project Leader. Transmissible
Diseases Laboratory, Jerome H. Holland Laboratory.
Edward Notari IV, MPH, Research Associate, Transmis-
sible Diseases Laboratory, Jerome H. Holland Laboratory.
Lynne P. Layug, MPH, Director Administrative and Client
Services, National Reference Laboratory for Infectious Dis-
eases, Rockville, MD.
Richard G. Cable, MD, Medical Director, American Red
Cross, Connecticut Region, Hartford, CO.
Stanley Badon, MD, Associate Medical Director, American
Red Cross, Connecticut Region.
Mark A. Popovsky, MD, Chief Executive Officer, American
Red Cross, New England Region, Dedham, MA.
Alfred J. Grindon, MD, Medical Director, American Red
Cross, Southern Region, Georgia Division, Atlanta, GA.
Bruce A. Lenes, MD, Medical Director, American Red
Cross Southern Region, South Florida Division, Miami, FL.
Alan E. Williams, PhD, Senior Research Scientist, Trans-
missible Diseases Laboratory, Jerome H. Holland Laboratory.
Volume 39, February 1999 TRANSFUSION 211