South Africa’s Congenital Syphilis Cases Surge
This summary presents the key findings from the 2023 Congenital Syphilis Annual Surveillance Report released by the National Institute for Communicable Diseases (NICD), covering January 1 to December 31, 2023. It examines national, provincial, and district-level notification data and laboratory alerts, and highlights both progress and ongoing challenges in the elimination of congenital syphilis in South Africa.
Congenital syphilis (CS), primarily transmitted from mother to child during pregnancy or childbirth by the spirochaetal bacterium Treponema pallidum, continues to present a significant public health challenge in South Africa.
The consequences of untreated maternal syphilis are severe, with 50–90% of infected mothers passing the disease to their unborn children. Outcomes include stillbirth, preterm birth, neonatal death, and severe congenital infections. HIV co-infection further increases transmission risk, adding additional strain to maternal and child health services.
In 2007, the World Health Organization (WHO) set a global elimination target for congenital syphilis, aiming for fewer than 50 cases per 100,000 live births in countries with strong surveillance systems. Achieving this requires 95% of pregnant women to attend antenatal care before 20 weeks gestation, with 95% screened and 95% of those testing positive treated with benzathine penicillin.
Despite the inclusion of syphilis testing in South Africa’s healthcare framework since the late 1990s, the country continues to fall well short of these benchmarks. In response, a number of structural improvements have been implemented:
- CS became a notifiable condition in 2017, recorded through the National Notifiable Medical Conditions (NMC) platform
- RPR testing is now standard practice; children under 2 years suspected of CS are evaluated at clinicians’ discretion
- In 2023, the Department of Health mandated at least four syphilis tests during pregnancy, including dual HIV/syphilis testing
- A combined case notification and investigation form was rolled out in mid-2023 to streamline data collection and reporting
Congenital syphilis is a reportable condition under South Africa’s National Health Act. Case rates are tracked based on CS cases reported relative to live births, expressed per 100,000.
| Data Source | Description | Period Covered |
|---|---|---|
| DHIS Paediatric HIV DashboardsDistrict Health Information System | Provided facility-level data on infants and children under 2 meeting both a clinical case definition and an RPR-positive lab result. | January–December 2023 |
| NICD NMC PlatformNational Notifiable Medical Conditions | National extraction of clinical CS case notifications and laboratory RPR-positive alerts by quarter, province and district. | January–December 2023 |
Descriptive statistics were used to analyse quarterly trends in notifications and laboratory alerts at national, provincial, and district levels. A clinical CS case was defined as an infant or child under 2 years meeting both clinical case criteria and having an RPR-positive laboratory result.
Findings are presented across three levels: national notifications and laboratory alerts; provincial breakdowns; and district-level facility data.
1,739 CS cases — 198 per 100,000
South Africa recorded 1,739 clinical congenital syphilis notifications in 2023, representing a case rate of 198 per 100,000 live births. This is nearly four times the WHO global elimination target of 50 per 100,000.
5,160 RPR-positive alerts in under-2s
A total of 5,160 laboratory alerts for RPR-positive results were recorded in children under 2. While clinical notifications rose steadily, RPR alerts declined by 30% in Q3–Q4 — possibly reflecting improved clinical follow-through rather than an actual case reduction.
| Province | Share of National Notifications | Notable Trend | Case Rate |
|---|---|---|---|
| KwaZulu-Natal | 46% of all clinical notifications | Highest absolute notification volume nationally | — |
| Western Cape | Part of top-4 (89.9% combined) | Highest case rate nationally | 418 per 100,000 |
| Gauteng | Part of top-4 (89.9% combined) | RPR alerts declined 41–53% in Q3–Q4 | — |
| Eastern Cape | Part of top-4 (89.9% combined) | RPR alerts declined 41–53% in Q3–Q4 | — |
| Mpumalanga | Significant Q1–Q4 increase | Rose from 7 (Q1) to 32 (Q4) notifications | — |
| Limpopo | Lowest notification volume | Lowest case rate nationally | 14 per 100,000 |
165 facilities across 47 districts
Median of 3 notifications per facility (IQR 1–9; range 1–120). At district level, median was 11 notifications per district (IQR 4–47; range 1–313).
414 facilities across all 52 districts
Median of 2 RPR-positive results per facility (IQR 1–10; range 1–265). At district level, median was 54 results per district (IQR 26–97; range 1–963).
South Africa’s 2023 CS data reveal a country making measurable progress on surveillance infrastructure while remaining far from its elimination goals.
The case rate of 198 per 100,000 live births far exceeds the WHO elimination target of 50. While the increase in clinical notifications is partly attributable to improved case detection systems introduced in 2023, it also reflects the continued structural failure to achieve 95% antenatal coverage with effective syphilis screening and treatment.
The geographic concentration of cases — with Eastern Cape, Gauteng, KwaZulu-Natal and Western Cape collectively accounting for 90% of notifications — points to both higher burden and better detection in better-resourced provinces. The particularly high case rate in Western Cape (418/100,000) is likely a feature of more complete reporting rather than a unique exposure risk.
The discrepancy between rising clinical notifications and declining RPR laboratory alerts in Q3–Q4 requires careful interpretation. This could reflect improved clinical case follow-up, changes in health-seeking behaviour, or seasonality effects in ANC attendance. It does not necessarily indicate a real reduction in CS transmission during this period.
Data quality remains a significant constraint. Only one-third of previously reported cases contain the clinical detail required for full case classification. This compromises the accuracy of elimination progress assessments and the design of targeted interventions.
The 2023 report documents both tangible progress in maternal syphilis management and a set of priority recommendations required to close the gap between current performance and elimination targets.
Improved Syphilis Treatment Access
Full availability of benzathine penicillin as first-line treatment was restored by 2023 following critical shortages in 2018. All qualifying pregnant women can now access treatment.
Dual HIV/Syphilis Testing
Introduction of dual testing for pregnant women in 2023, alongside six routine antenatal tests, is a significant step toward early detection and treatment of maternal syphilis.
Streamlined Case Reporting
Mid-2023 adoption of the combined case notification/investigation form (CNF/CIF) aims to improve accuracy, data alignment, and efficient tracking of syphilis cases nationally.
Key Recommendations Moving Forward
Priority actions for healthcare providers, facilities, and the national Department of Health
- Ensure all pregnant women attending antenatal care are screened for syphilis at every contact, with a minimum of four tests per pregnancy including dual HIV/syphilis testing.
- Treat all syphilis-positive pregnant women with benzathine penicillin without delay, at the point of diagnosis, at every level of care.
- Train and re-train healthcare providers at all levels on CS clinical case definitions, notification requirements, and the correct use of the combined CNF/CIF reporting form.
- Conduct facility-level evaluations at selected hospitals to quantify under-reporting and estimate the true national CS burden.
- Expand surveillance to all 52 districts and improve completeness of clinical data submitted with notifications to allow accurate case classification and elimination tracking.
South Africa has made notable progress in maternal syphilis screening and treatment access, but challenges such as under-reporting and gaps in healthcare coverage persist.
Progress is real but insufficient
Restored benzathine penicillin availability, dual HIV/syphilis testing, and the new CNF/CIF reporting form represent genuine infrastructure improvements. But a case rate of 198 per 100,000 live births — nearly four times the elimination target — indicates that systemic change has not yet translated into measurable reductions in transmission. The full impact of 2023 interventions will be clearer in 2024 data.
Data quality is a clinical and programmatic constraint
With only one-third of cases containing sufficient clinical data for classification, South Africa cannot accurately assess its own elimination progress. Investment in data system completeness and healthcare worker training on notification procedures is a precondition for evidence-based policy response — not a secondary priority.
Geographic concentration demands targeted response
With KwaZulu-Natal, Gauteng, Western Cape and Eastern Cape accounting for 90% of notifications, a nationally uniform approach will not reach the highest-burden communities. District-level and facility-level evaluation is needed to identify where the system is failing and why — and to design interventions that match the local context of under-reporting, access barriers, and HIV co-prevalence.
Elimination is achievable but requires sustained political commitment
Congenital syphilis is a preventable condition. Every case represents a failure somewhere in the antenatal care pathway — at screening, at treatment, at follow-up, or at reporting. Meeting the WHO target will require sustained commitment to each of these steps at every level of the health system. The 2023 data provide the baseline; the choices made in 2024–2026 will determine whether elimination becomes achievable within a realistic planning horizon.
- Kufa, T., Thabane, E., Leshaba, D., Makhubele, M., & Puren, A. (2023). Congenital syphilis annual surveillance report, South Africa 2023. Public Health Bureau of South Africa. https://www.phbsa.ac.za/...
- Joseph Davey, D., de Voux, A., Hlatshwayo, L., et al. (2024). Prevention of congenital syphilis within antenatal PrEP services in South Africa: missed opportunities. The Lancet Infectious Diseases, 24(6), 571–572. https://doi.org/10.1016/S1473-3099(24)00259-7
