Vaccines and antimicrobial resistance: opportunities for immunization programmes in the African Region

¹World Health Organization, Regional Office for Africa, Brazzaville, Congo, ²School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa, ³Centre for Vaccines and Immunology, National Institute for Communicable Diseases, Johannesburg, South Africa, ⁴Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa

^&Corresponding author
Chinwe Iwu-Jaja, World Health Organization, Regional Office for Africa, Brazzaville, Congo

Commentary    

Introduction

Antimicrobial resistance (AMR) poses an ever-increasing threat to health systems in the WHO African Region (AFR), where fragile infrastructure, limited access to second-line treatments along with misuse through misconceptions and cultural practices, amplify its impact. In 2019, drug-resistant bacterial infections caused approximately 250,000 deaths across the region [1]. Projections suggest that by 2050, AMR could result in nearly 2 million global deaths annually, with Africa bearing a disproportionate share of this burden [1]. Beyond its clinical implications, AMR is overwhelming the already stretched health services, eroding public trust in essential programmes, and reversing decades of progress in child survival and disease control.

Vaccines are not traditionally viewed as tools to combat AMR, yet growing evidence highlights their critical and underutilized role in this fight [2]. By preventing both primary infections and secondary bacterial infections that often follow viral illnesses, vaccines help reduce the need for antibiotics and alleviate the selective pressure that drives the emergence and spread of resistant pathogens [3]. Immunization programmes, therefore, are uniquely positioned to contribute to AMR mitigation while advancing their primary mission of disease prevention.

This commentary underscores the urgent imperative to integrate AMR considerations into immunization programmes and explains why such integration is both timely and essential. It highlights pragmatic indicators for monitoring vaccine-AMR linkages, offers strategies for leveraging existing systems without requiring additional infrastructure, and showcases actionable examples (“quick wins”) from African countries. Together, these insights present vaccines as a pivotal component in the broader fight against AMR and offer a roadmap for transforming this synergy into a powerful advocacy and implementation opportunity.

Why immunization programmes matter in Addressing AMR now?

For immunization programmes, the link to AMR is profound and pressing. Every infection averted by vaccination is one fewer course of antibiotics used, which helps slow the spread of resistance [3]. A recent modelling study estimated that scaling up vaccines could prevent up to 515,000 AMR-related deaths globally each year, with about a third of them in Africa [4] (Table 1). The 2016 United Nations High-Level Meeting on AMR urged countries to leverage all tools, including new vaccines to curb resistance. Likewise, Immunization Agenda 2030 (IA2030) explicitly highlights vaccination as crucial for combating AMR [4], and a WHO Action Framework on Vaccines and AMR calls for prioritizing certain vaccines (pneumococcal, Hib, typhoid, influenza) to reduce antibiotic use [4]. Furthermore, specialised goals such as defeating meningitis by 2030, also consider the place of vaccines in combating AMR. By making the case that “vaccines are not only our first line of defence against infections but also against drug-resistant infections,” immunization programmes can strengthen their role in national health strategies and garner broader support. Another reason the concept of vaccination and AMR matters now can be seen in the context of COVID-19 recovery. The pandemic disrupted routine immunization in many African countries and, paradoxically, spurred excessive antibiotic use. In Africa, up to 79% of mild/moderate COVID-19 patients received antibiotics despite little benefit [5], which further threatened to accelerate AMR. Further, as immunization programmes work to catch up on missed vaccinations, especially through initiatives like “The Big Catch-Up”, they also have a timely chance to promote the value of vaccines. High vaccine coverage will reduce secondary infections and inappropriate antibiotic prescriptions during future respiratory virus outbreaks.

Simple indicators to start monitoring the intersection of immunization and AMR

Evidence clearly shows that vaccines reduce the burden of antimicrobial resistance (AMR), yet such data remain scarce in the African Region [2]. Generating robust, country-specific evidence is essential to strengthen advocacy for vaccines as a tool in AMR control Monitoring this intersection need not be complex. Table 1 provides a practical framework for EPI managers to operationalize these indicators within existing systems, translating strategic recommendations into actionable monitoring steps. The following actionable indicators can be implemented using existing systems to progressively build evidence without creating new infrastructure:

Vaccine coverage for AMR-relevant vaccines

Tracking coverage rates for vaccines known to curb antibiotic demand, such as pneumococcal conjugate vaccines (PCV), Haemophilus influenzae type b, typhoid conjugate vaccine, and rotavirus vaccine provides a practical proxy for AMR mitigation. These vaccines prevent infections that often lead to antibiotic use, reducing opportunities for resistance to emerge. High coverage levels can signal potential reductions in antibiotic consumption. For example, rotavirus vaccination already prevents an estimated 13.6 million episodes of antibiotic-treated diarrhoea annually in under-two children, while PCV averts approximately 23.8 million antibiotic-treated respiratory infections in under-five children in low- and middle-income countries [6].

Resistance patterns in vaccine-preventable pathogens

Laboratory surveillance offers direct evidence of vaccines' impact on AMR by monitoring changes in resistance patterns among targeted pathogens. For instance, tracking the prevalence of penicillin-resistant Streptococcus pneumoniae or multidrug-resistant Salmonella Typhi before and after vaccine rollout can demonstrate impact. In South Africa, PCV introduction led to a 67-96% reduction in drug-resistant pneumococcal infections among children [7]. Even in settings with limited laboratory capacity, periodic sampling and testing of bacterial isolates at reference or sentinel sites can provide qualitative indicators of vaccine impact [8].

Disease-specific indicators

Reductions in the incidence of key vaccine-preventable diseases can indirectly reflect vaccines' role in lowering antibiotic demand. For example, tracking pneumonia hospitalizations in children under five following PCV introduction, or diarrhoea admissions after rotavirus vaccine rollout, provides actionable programme-level insights. National health surveys such as those conducted periodically by ministries of health and routine health management information systems, including facility-based reporting platforms, can supplement routine surveillance by capturing trends like the proportion of children with these disease symptoms who received antibiotics [8].

Antibiotic prescription trends

Monitoring trends in antibiotic prescriptions for vaccine-preventable diseases could be a direct measure of vaccines' contribution to curbing AMR. Programmes can collaborate with primary care or pharmacy services to monitor prescriptions for target infections. Even small-scale pilots in sentinel clinics can reveal meaningful trends. For example, in South Africa, modest influenza vaccine coverage (30% in children under five) was associated with the prevention of 24,000 antibiotic prescriptions annually by reducing flu illness and associated secondary bacterial complications that often lead to inappropriate antibiotic use [8]. Similarly, post-TCV introduction in Zimbabwe, antibiotic prescribing for typhoid showed a downward trend, although broader prescribing practices required further improvement [9].

Triangulation and secondary data analysis

In many settings, data for individual indicators may be incomplete or fragmented. Triangulating multiple sources such as immunization coverage data, hospital admission records, and antimicrobial use statistics can create a fuller picture of vaccine-AMR interactions [8]. Therefore, secondary analysis of existing datasets offers a cost-effective way to document trends without setting up new systems. Integration with existing systems (no new infrastructure needed) Addressing AMR through immunization does not require creating parallel infrastructures or stand-alone programmes. Instead, AMR considerations can be embedded into existing immunization and surveillance frameworks that highlight Monitoring and evaluation, allowing countries to leverage established systems for dual impact on vaccine-preventable diseases and resistance containment [8]. We elaborate on some of these considerations below.

Routine data systems: blatforms such as the District Health Information System 2 (DHIS2) and Integrated Disease Surveillance and Response (IDSR) already track immunization coverage and disease incidence in many African countries. Adding AMR-relevant metrics such as pneumonia admissions, antibiotic prescribing trends for vaccine-preventable illnesses, or resistance patterns in pathogens would allow programmes to monitor vaccines' indirect effects on AMR without additional reporting tools. As outlined in Table 2, these existing platforms can readily accommodate AMR-relevant metrics without requiring new infrastructure.

Programme reviews and evaluations: multi-year programme reviews, including reports targeted at funders, offer ideal platforms to integrate AMR considerations. Including AMR indicators in these routine evaluations provides a broader lens on immunization programme performance and reinforces the role of vaccines as tools for combating AMR [10]. Economic evaluations can quantify vaccines' broader AMR impact. For example, modelling in Ethiopia estimated that PCV introduction could prevent over 718,000 antibiotic treatment failures and save $32.7 million in healthcare costs [10]. Such analyses can strengthen investment cases and support long-term planning for vaccine introductions.

Cross-sector collaboration: collaboration with AMR surveillance teams and national One Health teams can facilitate data sharing and joint planning. Immunization programme managers can provide vaccine coverage data to AMR stakeholders while receiving updates on resistance trends relevant to vaccine-preventable pathogens. Such partnerships can enable efficient use of resources and align immunization with broader AMR strategies.

Capacity building and advocacy: incorporating AMR perspectives into EPI staff training and community advocacy can strengthen the narrative that vaccines are critical for preserving the effectiveness of antibiotics. Highlighting this connection during routine campaigns such as Vaccination Week can raise awareness and draw cross-sectoral support [3]. This messaging can also be integrated into vaccinology training programmes for public health professionals, healthcare workers, and immunization programme staff, ensuring they are equipped to advocate for vaccines as a key tool in the fight against AMR.

Some country examples and quick wins for immunization programmes

Immunization programmes in the African region are already showing how vaccines can serve as a frontline tool in tackling AMR, offering lessons and practical actions that can inform more activities across the region. Evidence from South Africa demonstrates PCV's impact on AMR through four key studies: a randomized controlled trial, a case-control study, a clinical surveillance study, and a genomic surveillance study revealing a 67-96% reduction in multidrug-resistant pneumococcal infections [7]. In addition, Ethiopia provides another compelling example where a dynamic modelling study estimated that PCV introduction would prevent approximately 718,100 antibiotic treatment failures and 9,520 AMR-related deaths, while saving $32.7 million in healthcare costs [10]. Partnering with universities or health economists to document these impacts can help immunization programmes strengthen their case for continued investment in immunization and sustained political support. During a drug-resistant typhoid outbreak in Zimbabwe in 2019, vaccination emerged as a critical response tool. The country deployed the Typhoid Conjugate Vaccine (TCV) in this large-scale campaign. Post-vaccination surveillance recorded no typhoid cases among vaccinated children, compared to 21% positivity in Salmonella Typhi tests before the campaign [9]. While clinical prescribing behaviours initially remained unchanged, this experience highlights the strategic role of vaccines in controlling resistant pathogen outbreaks and reducing population-level antibiotic use. Closing immunity gaps and targeting zero-dose children remains the most critical step, as increasing coverage for vaccines directly prevents infections and limits unnecessary antibiotic use. Another quick win can be seen from the angle of new vaccine introductions. Typhoid conjugate vaccines, malaria vaccines, and future TB and respiratory syncytial virus (RSV) vaccines all hold promise for reducing drug resistance. Advocacy efforts should also incorporate AMR messaging, positioning vaccines as essential tools in this regard.

Conclusion

Immunization programmes in the African Region have always embodied a larger mission, which involves protecting the health of communities and ensuring no one is left behind. As Africa celebrates five decades of immunization achievements and looks ahead to new vaccines and higher coverage, it is vital to recognize that drug-resistant infections threaten to undermine broader public health gains and strain health systems. Every vial of vaccine administered represents a step forward not only in protecting individuals from infectious diseases but also in curbing unnecessary antibiotic use and slowing AMR. Evidence from countries like South Africa, Ethiopia, and Zimbabwe confirms that integrating vaccines into AMR strategies is both feasible and impactful. For programme implementers, the task is to act on this insight: apply an AMR lens to data, collaborate across programmes, and make vaccines' role in fighting AMR part of routine advocacy. By embracing this two-way relationship, we can secure the future of both immunization and life-saving treatments in Africa.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All the authors have read and approved the final version of this manuscript.

Tables     

Table 1: quantified impact of vaccines on AMR in Africa

Table 2: key indicators for monitoring vaccine-AMR linkages within EPI programmes

References