Abstract
Congenital syphilis (CS), caused by vertical transmission of Treponema pallidum subsp. pallidum, remains a major but preventable cause of fetal 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 literature, national surveillance reports, and international policy documents relating to congenital syphilis in South Africa, covering microbiology and pathogenesis, epidemiology, clinical burden, diagnostics, health system drivers, and elimination strategy. Persistent congenital syphilis transmission in South Africa is driven by an interacting set of factors including delayed antenatal booking, missed screening opportunities, incomplete treatment or delays, inadequate partner management, human immunodeficiency virus (HIV) co-infection, poverty, and health system inefficiencies including recurrent benzathine penicillin shortages. Congenital syphilis remains associated with adverse pregnancy outcomes including miscarriage, stillbirth, prematurity, neonatal mortality, and long-term disability. 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. A coordinated health systems approach, aligned with WHO triple-elimination validation criteria, is required to achieve the country’s stated 2028 elimination target.