Congenital Syphilis in South Africa: A Narrative Review of Epidemiology, Health System Drivers, Prevention, and the Path to Elimination

Congenital syphilis (CS), caused by vertical transmission of Treponema pallidum subsp. pallidum, remains a major but preventable cause of foetal and neonatal morbidity and mortality globally. Despite established antenatal screening programmes and the availability of effective treatment with benzathine penicillin G (BPG), South Africa continues to experience a substantial burden of maternal and congenital syphilis, with a 2023 national case rate approximately four times the World Health Organization (WHO) elimination target. This narrative review synthesises evidence from peer-reviewed publications, national surveillance reports, and policy documents identified through systematic searches conducted up to September 2026 [searched through August 2026] on congenital syphilis in South Africa. It addresses the microbiology and pathogenesis, epidemiology, clinical burden, diagnostic approaches, health system determinants, and strategies for elimination. Persistent transmission is associated with documented gaps in antenatal booking, repeat screening, treatment completion and partner management, and with recurrent benzathine penicillin shortages; HIV co-infection, poverty and other social and structural factors are likely contributors, but direct evidence for them is more limited. Congenital syphilis remains associated with adverse pregnancy outcomes including miscarriage, stillbirth, prematurity, neonatal mortality, and long-term disability. The elimination of congenital syphilis in South Africa requires strengthening antenatal care coverage, universal and repeat syphilis screening, prompt and complete maternal treatment, partner services, enhanced surveillance systems, and closer integration with HIV programmes. Progress towards the country’s 2028 elimination target will depend on a coordinated health systems approach aligned with WHO triple-elimination validation criteria.