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 dire, with 50–90% of infected mothers passing the disease to their unborn children, the results of which are catastrophic including stillbirth, preterm birth, neonatal death, and severe congenital infections.The situation becomes even more pressing when HIV co-infection is present, as the likelihood of transmission increases, adding further strain to maternal and child health.

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.

However, achieving this target is no easy feat. The diagnosis of CS is complicated by the absence of overt neonatal signs and symptoms, requiring a careful combination of maternal and neonatal serological and clinical information. This challenge, coupled with gaps in surveillance, diagnosis, and treatment availability, means that South Africa is still far from meeting these elimination goals.¹

The WHO’s 2007 plan calls for 95% of pregnant women to attend antenatal care, ideally before reaching 20 weeks of pregnancy, and for 95% of those women to be screened and tested for syphilis. It also requires that 95% of pregnant women who test positive for syphilis be treated with benzathine penicillin.  

Despite significant strides made in screening—syphilis testing has been part of South Africa's healthcare framework since the late 1990s—the country still struggles to meet these essential benchmarks. In fact, this recent report has highlighted how South Africa’s congenital syphilis rate continues to exceed the elimination target by a considerable margin.

In response, South Africa has introduced several measures to strengthen its approach. CS became a notifiable condition in 2017, with notifications recorded through the National Notifiable Medical Conditions (NMC) platform and supported by laboratory alerts for RPR-positive results. RPR testing is now standard practice, and children under two years who are suspected of CS are evaluated at clinicians' discretion. 

In 2023, the Department of Health updated its guidelines, mandating at least four syphilis tests during pregnancy, including dual HIV/syphilis testing, ensuring that women not previously diagnosed with HIV are screened comprehensively. This integration of services is a key step in improving maternal and child health outcomes.

An additional significant improvement in 2023 was the rollout of a combined case notification and investigation form aimed at streamlining data collection, case classification, and reporting. These efforts, leveraging both paper-based and electronic systems, are hoped to lead to more accurate reporting and better surveillance of CS cases.

We summarise the findings of the 2023 Congenital Syphilis Annual Surveillance Report released by the NICD which covers the period from January 1 to December 31, 2023, which reveals both progress and ongoing challenges in the fight against CS in South Africa.

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