PUBLIC HEALTH BRIEFS
Evaluation of the Syphia Chek Test for Syphilis In a High-Risk Population MORTON NELSON, MD, MPH, AND EDWARD PORTONI, MA This paper reports the results of a field trial to evaluate the slide test known as the Syphla Chek test for syphilis* in a high-risk population. In principle, the text is similar to the rapid plasma reagin (RPR) card test for syphilis developed by Brewer and Portnoy.1 The Syphla Chek antigen is a stabilized VDRL antigen2 affixed to a kaolin particle. The kaolin particle allows for macroscopic visualization of the serologic reaction.
Materials and Methods The serum specimens used in this study were collected from patients seen in Venereal Disease Clinics located at Central Health District and Highland Hospital, Oakland, California, from April through May 1975. Specimens were collected from 600 male and female patients and subsequently divided into two groups of 300 each-VDRL reactive and VDRL non-reactive. Clinical case records were initiated on all patients in the study and those clinically diagnosed as having syphilis were treated utilizing the current recommendations of the Center for Disease Control, United States Public Health Service, Atlanta, GA. Qualitative and quantitative VDRL slide tests3 were performed on all serum specimens, 24 to 48 hours after collection. After testing with the VDRL, the serum specimens were tested using the Syphla Chek card test.4 The VDRL antigen and buffer used in this study was purchased from Lederle Laboratories, American Cyanimid Corporation. The Syphla Chek test system was obtained from Hyland Laboratories. The qualitative Syphla Chek test uses 0.05 ml. of serum with 1/60 ml. of antigen. Rotation is at 180 RPM for six minutes. The slides are examined for agglutination against a black background using an indirect light source. An FTA-ABS3 was performed on all sera reactive or weakly reactive by the VDRL.
Results VDRL and Syphla Chek tests were performed on 600 test sera, 300 VDRL reactive and 300 VDRL non-reactive.
Address reprint requests to Dr. Morton Nelson, Associate Clinical Professor, Dept. of Family Medicine, University of California, College of Medicine, Irvine, CA 92717. Dr. Nelson is also Diretztor, Health Services, Orange County Public Health and Medical Services; Mr. Portoni is Chief, Public Health Laboratory Services, Alameda County Health Care Services Agency, Oakland, CA. This paper, submitted to the Journal January 3, 1977, was revised and accepted for publication May 9, 1977. *Developed by Hyland, a division of Travenol Laboratories, Inc., Costa Mesa, California. 970
Table 1 shows that the VDRL and the qualitative Syphla Chek slide test results were in exact agreement in 561 (93.5 per cent) of the sera tested. Considering reactive sera only, VDRL reactive sera were in exact agreement with Syphla Chek 90.3 per cent of the time, VDRL non-reactive sera 96.7 per cent of the time. The three sera reactive by the VDRL and non-reactive by Syphla Chek were two borderline and one was non-reactive by the FTA-ABS. Conversely, of the ten sera reactive by Syphla Chek and non-reactive by the VDRL, four were reactive, three borderline, and three nonreactive by the FTA-ABS. TABLE 1-Comparison of Qualitative VDRL and Syphia Chek Slide Tests SYPHLA CHEK SLIDE TEST VDRL Slide Test
Reactive
Weakly
Reactive
Reactive
230
10
1
16 0 246
41 10 61
2 290 293
Non-Reactive
Weakly
Reactive Non-Reactive TOTAL (600)
A comparison of the quantitative VDRL and Syphla Chek slide tests is shown in Table 2. On the quantitative tests, there is an exact agreement between the VDRL and Syphla Chek with 173 (57.7 per cent) of the sera tested. Considering a tolerance of + 1 dilution, the VDRL and Syphla Chek test results are comparable with 282 (94.0 per cent) of the sera. A set of blind samples (6 sera per set) was tested between every group of 30 pathologic test sera. This testing was designed to measure the reproducibility of the test systems throughout the study. The reproducibility of the qualitative test was 98.1 per cent with the VDRL, and with Syphla Chek, 96.3 per cent. Quantitatively, the VDRL reproducibility was 92.6 per cent and the Syphla Chek was 74.1 per cent. However, allowing a + dilution test tolerance, the reproducibility of the VDRL and the Syphla Chek became 100 per cent. The patients who were reactive by the VDRL test were divided into three groups: syphilitic untreated; syphilitic previously treated; and undiagnosed (these patients who were seen in the Venereal Disease Clinic but failed to return for follow-up and, therefore, there was no clinical confirmation to diagnoses). The data are shown in Table 3. In the pathologic population, one of the 241 sera reactive by the VDRL was non-reactive by Syphla Chek. This serum was borderline by the FTA-ABS. Ten of the 241 sera AJPH October, 1977, Vol. 67, No. 10
PUBLIC HEALTH BRIEFS TABLE 2-Comparison of Quantitative VDRL and Syphla Chek Slide Tests NUMBER VDRL OF SLIDE TEST SPECIMENS
SYPHLA CHEK SLIDE TEST
Titer
W 1:1 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 1:512 TOTAL
N 2
59 57 26 43 31 26 24 27 6 1 0 300
1
3
Titer W 1:1 1:2 1:4 1:8 1:16 1:32 1:64 41 16 9 37 9 2 2 14 9 1 1 5 7 15 12 2 2 4 16 8 1 2 13 9 2 4 12 7 19
51
60 32 30 31
reactive by the VDRL antigen were weakly reactive by the Syphla Chek antigen. Of these, two sera were reactive by the FTA-ABS, one serum was borderline by the FTA-ABS, and seven sera were non-reactive by the FTA-ABS. The remainTABLE 3-Qualitative Reactivity of Patients by Groups (syphilitic untreated, syphilitic previously treated, and undiagnosed population).
Reactivity Non-Reactive 1 Weakly Reactive 9 Reactive 117 TOTAL 127 Qualitative Reactivity in a Previously Treated Syphilitic Population Test Reactivity Syphla Chek Non-Reactive 0 Weakly Reactive 6 Reactive 43 TOTAL 49 Qualitative Reactivity in an Undiagnosed Population (Contacts and Drug Users)
VDRL 0 10 117 127
VDRL 0 8 41 49
Test
Reactivity Non-Reactive Weakly Reactive Reactive TOTAL
Syphia Chek 2 38 84 124
21
29
1:256 1:512
1 8 5
14
1 1
2
0
ing 230 sera reactive by the VDRL were reactive by the Syphla Chek test for a 96.3 per cent agreement among the 300 sera tested qualitatively by Syphla Chek and VDRL tests. If we consider the qualitative test results as either reactive or non-reactive, then the agreement between the VDRL and Syphla Chek with pathologic sera becomes 99.2 per cent.
Summary and Discussion
Qualitative Reactivity in a Known Syphilitic Population (Pretreatment) Test Syphla Chek
27
1:128
VDRL 0 44 80 124
The Syphla Chek slide test for syphilis is, in principle, similar to the rapid plasma reagin (RPR) card test for syphilis. The Syphla Chek test employes a stabilized VDRL antigen affixed to a kaolin particle for macroscopic visualization of the serologic reaction when mixed with serum. Of 600 specimens tested, it was found that the Syphla Chek test had a 90.3 per cent exact agreement with the VDRL test in reactive sera and a 96.7 per cent exact agreement with the VDRL in non-reactive sera by qualitative testing. Comparison of the Syphla Chek quantitative results indicate that 94 per cent of the sera tested were within plus or minus one dilution of the VDRL. The Syphla Chek slide test for syphilis has three major advantages: 1) no heat inactivation is required; 2) it can be read macroscopically; and 3) it can be run in a small laboratory or a physician's office with adequately trained personnel. It is suggested that the test be further studied in comparisons with the RPR and the VDRL. These studies should also include the comparison of quantitative titers in treated patients, since these are of critical importance to the physician when following the course of treatment in the syphilitic
patient. AJPH October, 1977, Vol. 67, No. 10
971
PUBLIC HEALTH BRIEFS
REFERENCES 1. Portnoy, J., Brewer, J., and Harris, A. Rapid plasma reagin card test for syphilis and other treponematoses. Public Health Reports, 77:645-652, 1962. 2. Borchardt, K.A. A macroscopic latex screening test for syphilis. American Journal of Clinical Pathology, 44:241-243, 1965.
3. Wood, R., Lennette, E., Spaulding, E., and Truant, J. Tests for Syphilis, In Manual of Clinical Microbiology. Second edition, DC: American Society for Microbiology, Washington, 1974. 4. Hyland Laboratories, Syphla Chek Evaluation Protocol, # 050023.
Costs of Mental Health Services in a Colombian Hospital ROBERT L. ROBERTSON, PHD, RICARDO PAB6N, MS,
Introduction Cost data can be useful in health planning and administration. Nevertheless, relatively few detailed cost studies have been conducted at the level of specific institutions, especially in the field of mental health, as judged from the literature of several countries.1-5 This report briefly describes a research project in the state of Valle del Cauca, Colombia, and presents the most important findings of that project's intensive study of the costs of services for a year at the principal mental health facility in Valle, San Isidro Hospital. The psychiatric hospital of San Isidro is located on the outskirts of Cali, a city of approximately one million inhabitants that serves as the center of a catchment area containing several million persons. San Isidro functions as a regional hospital in the national scheme of health institutions and also as a specialized university hospital. It has the usual range of services and staff members for a sophisticated hospital, as well as some innovative training and care activities and provides educational experiences to medical students.6 Inpatients have a total of 200 beds available, divided during the study period among: 46 "pensionado" beds for privately paying persons who receive special treatment and billing; 114 general beds for miscellaneous public patients of comparatively short durations; and 40 "chronic" beds for longterm public patients. Ambulatory services are classified into two broad groups: individual consultations in the outpatient department ("consulta externa"), staffed by physicians and allied health personnel; and "hospital diurno," which provides a set of services by a variety of personnel in half-day blocks.
Methods Although more detailed explanations of our cost finding methodology can be found in other sources,7 8 some highAddress reprint requests to Dr. Robert L. Robertson, Department of Economics, Mount Holyoke College, South Hadley, MA 01075. Prof. Pab6n and Prof. Barona are affiliated with the Departamento de Administraci6n, Universidad del Valle, Cali, Colombia. Submitted to the Journal September 8, 1976, this paper was revised and accepted for publication March 16, 1977. 972
AND
BERNARDO BARONA, MS
lights of it are described here. It had many conventional accounting components shared with other cost systems9 such as a three-part division of cost (responsibility) centerscalled by us "administrative," "auxiliary," and "final" centers. There were, however, a number of distinctive features to our methods, such as: verification of data quality by special monitors; time study through work sampling to distribute professionals' costs among education and other such outputs and the various service programs; and adaptation of the "simultaneous equations" method (requiring a computer) for allocating certain overhead costs to final products. Probably the most important element was the computation of costs with and without the inclusion of allowances for full resource use, whether or not paid for by the hospital-for example, students' time contributed to the service program and all capital items (buildings and equipment) utilized.
Results The findings on total costs are presented in Table 1. Their two data columns illustrate the capability of our system to separate the full value of all resources, paid for or not, (called the "total" approach) from the costs which would be found in a more conventional approach covering only the resources paid for by the hospital (called "partial"). Comparison of the totals of the two columns shows that the limited or partial approach yielded only about three-quarters of the full costs found when the allowances of the total method, especially for personnel and capital, were included. Although the specific case of San Isidro cannot be considered an exact indication of values elsewhere, it suggests to administrators of health institutions the importance of avoiding possible understatements of costs. Table 2 contains the average costs of final health services at the hospital, computed by dividing total costs by service utilization figures. It reveals some differences between two types of outpatient care and among the three inpatient categories. We shall limit our comments here to the findings for outpatients, but comparisons of inpatients' costs are available to interested readers. During the study period the unit cost of consulta externa was much higher than that of AJPH October, 1977, Vol. 67, No. 10
Evaluation of the Syphia Chek Test for Syphilis In a High-Risk Population MORTON NELSON, MD, MPH, AND EDWARD PORTONI, MA This paper reports the results of a field trial to evaluate the slide test known as the Syphla Chek test for syphilis* in a high-risk population. In principle, the text is similar to the rapid plasma reagin (RPR) card test for syphilis developed by Brewer and Portnoy.1 The Syphla Chek antigen is a stabilized VDRL antigen2 affixed to a kaolin particle. The kaolin particle allows for macroscopic visualization of the serologic reaction.
Materials and Methods The serum specimens used in this study were collected from patients seen in Venereal Disease Clinics located at Central Health District and Highland Hospital, Oakland, California, from April through May 1975. Specimens were collected from 600 male and female patients and subsequently divided into two groups of 300 each-VDRL reactive and VDRL non-reactive. Clinical case records were initiated on all patients in the study and those clinically diagnosed as having syphilis were treated utilizing the current recommendations of the Center for Disease Control, United States Public Health Service, Atlanta, GA. Qualitative and quantitative VDRL slide tests3 were performed on all serum specimens, 24 to 48 hours after collection. After testing with the VDRL, the serum specimens were tested using the Syphla Chek card test.4 The VDRL antigen and buffer used in this study was purchased from Lederle Laboratories, American Cyanimid Corporation. The Syphla Chek test system was obtained from Hyland Laboratories. The qualitative Syphla Chek test uses 0.05 ml. of serum with 1/60 ml. of antigen. Rotation is at 180 RPM for six minutes. The slides are examined for agglutination against a black background using an indirect light source. An FTA-ABS3 was performed on all sera reactive or weakly reactive by the VDRL.
Results VDRL and Syphla Chek tests were performed on 600 test sera, 300 VDRL reactive and 300 VDRL non-reactive.
Address reprint requests to Dr. Morton Nelson, Associate Clinical Professor, Dept. of Family Medicine, University of California, College of Medicine, Irvine, CA 92717. Dr. Nelson is also Diretztor, Health Services, Orange County Public Health and Medical Services; Mr. Portoni is Chief, Public Health Laboratory Services, Alameda County Health Care Services Agency, Oakland, CA. This paper, submitted to the Journal January 3, 1977, was revised and accepted for publication May 9, 1977. *Developed by Hyland, a division of Travenol Laboratories, Inc., Costa Mesa, California. 970
Table 1 shows that the VDRL and the qualitative Syphla Chek slide test results were in exact agreement in 561 (93.5 per cent) of the sera tested. Considering reactive sera only, VDRL reactive sera were in exact agreement with Syphla Chek 90.3 per cent of the time, VDRL non-reactive sera 96.7 per cent of the time. The three sera reactive by the VDRL and non-reactive by Syphla Chek were two borderline and one was non-reactive by the FTA-ABS. Conversely, of the ten sera reactive by Syphla Chek and non-reactive by the VDRL, four were reactive, three borderline, and three nonreactive by the FTA-ABS. TABLE 1-Comparison of Qualitative VDRL and Syphia Chek Slide Tests SYPHLA CHEK SLIDE TEST VDRL Slide Test
Reactive
Weakly
Reactive
Reactive
230
10
1
16 0 246
41 10 61
2 290 293
Non-Reactive
Weakly
Reactive Non-Reactive TOTAL (600)
A comparison of the quantitative VDRL and Syphla Chek slide tests is shown in Table 2. On the quantitative tests, there is an exact agreement between the VDRL and Syphla Chek with 173 (57.7 per cent) of the sera tested. Considering a tolerance of + 1 dilution, the VDRL and Syphla Chek test results are comparable with 282 (94.0 per cent) of the sera. A set of blind samples (6 sera per set) was tested between every group of 30 pathologic test sera. This testing was designed to measure the reproducibility of the test systems throughout the study. The reproducibility of the qualitative test was 98.1 per cent with the VDRL, and with Syphla Chek, 96.3 per cent. Quantitatively, the VDRL reproducibility was 92.6 per cent and the Syphla Chek was 74.1 per cent. However, allowing a + dilution test tolerance, the reproducibility of the VDRL and the Syphla Chek became 100 per cent. The patients who were reactive by the VDRL test were divided into three groups: syphilitic untreated; syphilitic previously treated; and undiagnosed (these patients who were seen in the Venereal Disease Clinic but failed to return for follow-up and, therefore, there was no clinical confirmation to diagnoses). The data are shown in Table 3. In the pathologic population, one of the 241 sera reactive by the VDRL was non-reactive by Syphla Chek. This serum was borderline by the FTA-ABS. Ten of the 241 sera AJPH October, 1977, Vol. 67, No. 10
PUBLIC HEALTH BRIEFS TABLE 2-Comparison of Quantitative VDRL and Syphla Chek Slide Tests NUMBER VDRL OF SLIDE TEST SPECIMENS
SYPHLA CHEK SLIDE TEST
Titer
W 1:1 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 1:512 TOTAL
N 2
59 57 26 43 31 26 24 27 6 1 0 300
1
3
Titer W 1:1 1:2 1:4 1:8 1:16 1:32 1:64 41 16 9 37 9 2 2 14 9 1 1 5 7 15 12 2 2 4 16 8 1 2 13 9 2 4 12 7 19
51
60 32 30 31
reactive by the VDRL antigen were weakly reactive by the Syphla Chek antigen. Of these, two sera were reactive by the FTA-ABS, one serum was borderline by the FTA-ABS, and seven sera were non-reactive by the FTA-ABS. The remainTABLE 3-Qualitative Reactivity of Patients by Groups (syphilitic untreated, syphilitic previously treated, and undiagnosed population).
Reactivity Non-Reactive 1 Weakly Reactive 9 Reactive 117 TOTAL 127 Qualitative Reactivity in a Previously Treated Syphilitic Population Test Reactivity Syphla Chek Non-Reactive 0 Weakly Reactive 6 Reactive 43 TOTAL 49 Qualitative Reactivity in an Undiagnosed Population (Contacts and Drug Users)
VDRL 0 10 117 127
VDRL 0 8 41 49
Test
Reactivity Non-Reactive Weakly Reactive Reactive TOTAL
Syphia Chek 2 38 84 124
21
29
1:256 1:512
1 8 5
14
1 1
2
0
ing 230 sera reactive by the VDRL were reactive by the Syphla Chek test for a 96.3 per cent agreement among the 300 sera tested qualitatively by Syphla Chek and VDRL tests. If we consider the qualitative test results as either reactive or non-reactive, then the agreement between the VDRL and Syphla Chek with pathologic sera becomes 99.2 per cent.
Summary and Discussion
Qualitative Reactivity in a Known Syphilitic Population (Pretreatment) Test Syphla Chek
27
1:128
VDRL 0 44 80 124
The Syphla Chek slide test for syphilis is, in principle, similar to the rapid plasma reagin (RPR) card test for syphilis. The Syphla Chek test employes a stabilized VDRL antigen affixed to a kaolin particle for macroscopic visualization of the serologic reaction when mixed with serum. Of 600 specimens tested, it was found that the Syphla Chek test had a 90.3 per cent exact agreement with the VDRL test in reactive sera and a 96.7 per cent exact agreement with the VDRL in non-reactive sera by qualitative testing. Comparison of the Syphla Chek quantitative results indicate that 94 per cent of the sera tested were within plus or minus one dilution of the VDRL. The Syphla Chek slide test for syphilis has three major advantages: 1) no heat inactivation is required; 2) it can be read macroscopically; and 3) it can be run in a small laboratory or a physician's office with adequately trained personnel. It is suggested that the test be further studied in comparisons with the RPR and the VDRL. These studies should also include the comparison of quantitative titers in treated patients, since these are of critical importance to the physician when following the course of treatment in the syphilitic
patient. AJPH October, 1977, Vol. 67, No. 10
971
PUBLIC HEALTH BRIEFS
REFERENCES 1. Portnoy, J., Brewer, J., and Harris, A. Rapid plasma reagin card test for syphilis and other treponematoses. Public Health Reports, 77:645-652, 1962. 2. Borchardt, K.A. A macroscopic latex screening test for syphilis. American Journal of Clinical Pathology, 44:241-243, 1965.
3. Wood, R., Lennette, E., Spaulding, E., and Truant, J. Tests for Syphilis, In Manual of Clinical Microbiology. Second edition, DC: American Society for Microbiology, Washington, 1974. 4. Hyland Laboratories, Syphla Chek Evaluation Protocol, # 050023.
Costs of Mental Health Services in a Colombian Hospital ROBERT L. ROBERTSON, PHD, RICARDO PAB6N, MS,
Introduction Cost data can be useful in health planning and administration. Nevertheless, relatively few detailed cost studies have been conducted at the level of specific institutions, especially in the field of mental health, as judged from the literature of several countries.1-5 This report briefly describes a research project in the state of Valle del Cauca, Colombia, and presents the most important findings of that project's intensive study of the costs of services for a year at the principal mental health facility in Valle, San Isidro Hospital. The psychiatric hospital of San Isidro is located on the outskirts of Cali, a city of approximately one million inhabitants that serves as the center of a catchment area containing several million persons. San Isidro functions as a regional hospital in the national scheme of health institutions and also as a specialized university hospital. It has the usual range of services and staff members for a sophisticated hospital, as well as some innovative training and care activities and provides educational experiences to medical students.6 Inpatients have a total of 200 beds available, divided during the study period among: 46 "pensionado" beds for privately paying persons who receive special treatment and billing; 114 general beds for miscellaneous public patients of comparatively short durations; and 40 "chronic" beds for longterm public patients. Ambulatory services are classified into two broad groups: individual consultations in the outpatient department ("consulta externa"), staffed by physicians and allied health personnel; and "hospital diurno," which provides a set of services by a variety of personnel in half-day blocks.
Methods Although more detailed explanations of our cost finding methodology can be found in other sources,7 8 some highAddress reprint requests to Dr. Robert L. Robertson, Department of Economics, Mount Holyoke College, South Hadley, MA 01075. Prof. Pab6n and Prof. Barona are affiliated with the Departamento de Administraci6n, Universidad del Valle, Cali, Colombia. Submitted to the Journal September 8, 1976, this paper was revised and accepted for publication March 16, 1977. 972
AND
BERNARDO BARONA, MS
lights of it are described here. It had many conventional accounting components shared with other cost systems9 such as a three-part division of cost (responsibility) centerscalled by us "administrative," "auxiliary," and "final" centers. There were, however, a number of distinctive features to our methods, such as: verification of data quality by special monitors; time study through work sampling to distribute professionals' costs among education and other such outputs and the various service programs; and adaptation of the "simultaneous equations" method (requiring a computer) for allocating certain overhead costs to final products. Probably the most important element was the computation of costs with and without the inclusion of allowances for full resource use, whether or not paid for by the hospital-for example, students' time contributed to the service program and all capital items (buildings and equipment) utilized.
Results The findings on total costs are presented in Table 1. Their two data columns illustrate the capability of our system to separate the full value of all resources, paid for or not, (called the "total" approach) from the costs which would be found in a more conventional approach covering only the resources paid for by the hospital (called "partial"). Comparison of the totals of the two columns shows that the limited or partial approach yielded only about three-quarters of the full costs found when the allowances of the total method, especially for personnel and capital, were included. Although the specific case of San Isidro cannot be considered an exact indication of values elsewhere, it suggests to administrators of health institutions the importance of avoiding possible understatements of costs. Table 2 contains the average costs of final health services at the hospital, computed by dividing total costs by service utilization figures. It reveals some differences between two types of outpatient care and among the three inpatient categories. We shall limit our comments here to the findings for outpatients, but comparisons of inpatients' costs are available to interested readers. During the study period the unit cost of consulta externa was much higher than that of AJPH October, 1977, Vol. 67, No. 10
