Enteric and Diarrheal Diseases

Our goal

To eliminate enteric and diarrheal disease deaths in children.

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Mothers and infants at the Germana Gale Health Post in Silte, Ethiopia.

At a glance

  • Each year, enteric (gastrointestinal) and diarrheal infections kill about 500,000 children under age 5, primarily in the developing world.
  • Gut pathogens are also associated with stunting and impaired cognitive development as well as other long-term health problems.
  • We focus on vaccines as a cost- effective way to protect children from infection by specific microbes.
  • We support the goals of the integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD), an effort led by the World Health Organization (WHO) and UNICEF to accelerate disease prevention and control.
OUR STRATEGY

Our strategy

Our team's primary focus is to advance the development of safe, affordable, and effective vaccines for the leading causes of diarrheal and enteric diseases in low- and lower-middle-income countries. Our work in vaccines is complemented and enhanced by interventions that target the underlying biological vulnerability of babies and children, work led by the Maternal, Newborn & Child Health Discovery & Tools team. To inform decisions on when and how to deploy new interventions and expand the use of existing ones, we fund research on the global and regional burden of these diseases.

A mother administers a rotavirus vaccine to her son at the Kiambu Level 5 Hospital in the County of Kiambu, Kenya on May 14, 2019.
A mother administers a rotavirus vaccine to her son at a hospital in Kiambu County, which is north of Nairobi, Kenya. Domique Cattan
AREAS OF FOCUS

Areas of focus

Our grantmaking focuses heavily on vaccines because we want to prevent children from suffering from enteric and diarrheal diseases. Our efforts include investments in vaccines for rotavirus and the leading bacterial causes of diarrheal and enteric disease: Shigella, cholera, and typhoid.

Rotavirus. Rotavirus is the most common cause of diarrheal hospitalizations and deaths in children under age 5 in the developing world. Existing rotavirus vaccines have been shown to dramatically reduce the number of hospitalizations and deaths. WHO recommends their use in all countries, particularly in places where diarrhea is a major cause of child mortality.

We work closely with Gavi, the Vaccine Alliance, and national governments to support the introduction and sustainable delivery of rotavirus vaccines where they are most needed and to ensure adequate supply and appropriate formulations, packaging, and labeling.

We also work with PATH and vaccine manufacturers in emerging economies such as India and Indonesia to invest in new rotavirus vaccines that will diversify the market, increase vaccine supply, and decrease costs.

Cholera. Cholera kills as many as 130,000 people each year and occurs in both epidemic and endemic settings. At least 51 countries in sub-Saharan Africa and Asia have endemic cholera. Several recent outbreaks in Guinea, Haiti, Sierra Leone, Zimbabwe, and elsewhere have severely strained these countries’ under-resourced health systems.

With our support and the support of other international partners, WHO established a global oral cholera vaccine stockpile in 2013—a key milestone for cholera prevention and control. Millions of doses have been shipped to more than 20 countries for use during outbreaks and humanitarian crises and in endemic areas.

Stable vaccine demand should expand supply, lead to more competitive pricing, and spur additional demand in countries with a high burden of cholera. We also support the development of evidence-based policy guidelines for oral cholera vaccine use in outbreak settings, as well as better data collection to build a case for the use of cholera vaccines in endemic areas.

Shigella. Shigella is a ubiquitous bacterial pathogen in most regions of the developing world, where it is a major cause of moderate to severe diarrhea in children under age 5.

No vaccine is yet available for Shigella, but we are investing in vaccine candidates and in tools that could accelerate the development process.

Typhoid. Typhoid kills about 160,000 people each year, with the highest known burden in South Asia. The burden of typhoid in Africa is also substantial, and several outbreaks have recently occurred. An effective and affordable vaccine is the best short-term solution for controlling typhoid fever in countries with poor access to clean water, sanitation, and hygiene, as well as high rates of antibiotic resistance.

We are working with the International Vaccine Institute and vaccine manufacturers to develop a conjugate vaccine that can be used in children under age 2 and that will have a longer duration of protection than the current polysaccharide vaccine. In 2015, Bharat Biotech licensed Typbar TCV®, a new typhoid conjugate vaccine for India, and in January 2018 the vaccine was prequalified by WHO. Several hundred thousand doses have since been used, including to help control an outbreak of a super-resistant typhoid strain in Pakistan. A second typhoid conjugate vaccine, TYPHIBEV®, was prequalified by WHO in December 2020. We are also exploring more broadly protective vaccines that, for example, target both typhoid and paratyphoid. Important additional areas of work include understanding transmission dynamics and improving surveillance systems, including for environmental surveillance, to accurately measure disease burden.

We work to generate evidence that can help enhance our understanding of burden, evaluate the impact of interventions, and plan future investment strategies. These efforts include studies to define the burden of diarrheal and enteric disease pathogens and assess the effects of vaccine introductions.

We are supporting several surveillance networks, including global pediatric diarrheal disease surveillance through WHO, typhoid surveillance in South Asia and Africa, and a larger network of foundation-funded sites through the Child Health and Mortality Prevention Surveillance (CHAMPS) network.

We work to ensure that child health is a priority nationally and globally, with sufficient funding and political will to increase the delivery of vaccines, preventive interventions, and treatments for enteric and diarrheal diseases. Our efforts include supporting the goals of the integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD).

WHY FOCUS ON ENTERIC AND DIARRHEAL DISEASES?

Why focus on enteric and diarrheal diseases?

A major cause of death for children in the developing world, enteric and diarrheal diseases kill about 500,000 children under age each year. Children who survive face repeated infections by gut pathogens in the early years of life, which can lead to serious, lifelong health problems. Evidence suggests an association between repeated gut infections and gut dysfunction, which may lead to poor nutrient absorption, weaker immune response to oral vaccines, stunted growth, and impaired cognitive development.

Typhoid fever and its cousin, paratyphoid A fever, are the main causes of bacterial blood infections in children in Southeast Asia; children in many parts of sub-Saharan Africa also suffer from typhoid. Typhoid stands out as a neglected disease: Children living in poor, densely populated urban areas with inadequate water and sanitation infrastructure suffer the highest rates of typhoid and paratyphoid fever. Typhoid fever is becoming an even more dangerous public health problem due to rapid and unregulated urbanization in developing countries, combined with the emergence of multidrug-resistant typhoid.

The impact of these diseases has gone largely unnoticed. Research, funding, and political commitment to address these diseases are lacking, which results in a lack of critical information about the pathogens (including viruses, bacteria, and parasites) that cause these diseases as well as the environmental factors that increase their occurrence.

Effective and affordable tools for prevention and treatment exist, but most do not reach the poorest communities and regions.

The past 20 years have seen a significant decline in the number of children under age 5 who have died from diarrhea, in part due to socioeconomic development and better access to treatment. However, too many children still die from infections that are entirely preventable or treatable. Prevention efforts that focus on vaccines in the short term and improvements in water, sanitation, and hygiene in the long term can significantly reduce both suffering and death from these diseases.

Safe and effective vaccines exist for rotavirus, cholera, and typhoid. WHO has recommended that all national immunization plans include rotavirus vaccine, and Gavi has supported the introduction of a vaccine for low-income countries since 2009. In 2016, ROTAVAC®, a new rotavirus vaccine manufactured by Bharat Biotech, was introduced in India, where the burden of rotavirus is highest, and in 2018 the vaccine was prequalified by WHO. Other new vaccines in development should increase supplies and improve access over the next several years.

The cholera vaccine Shanchol™, manufactured by Shantha, was licensed in India and approved by WHO in 2011. WHO approved EuBiologics’ oral cholera vaccine, Euvichol®, in 2015. Two new typhoid conjugate vaccines have become available in the past few years: Bharat Biotech’s Typbar TCV was approved by WHO in 2018 and TYPHIBEV, manufactured by Biological E. Ltd., received approval in 2020. Also under development are vaccine candidates for Shigella and additional typhoid conjugate vaccines.

Affordable treatments such as oral rehydration solution, zinc supplements, and antibiotics for children with dysentery are available for children suffering from diarrhea. In addition, exclusive breastfeeding in the first six months of life, improved personal and household hygiene, and access to safe water and better sanitation can help prevent children from getting the infection in the first place.

STRATEGY LEADERSHIP

Strategy leadership

OUR PARTNERS

Our partners

The following are some of our partners. This list excludes specific vaccine manufacturers, with whom we engage most often through product development partners.
Sabin Vaccine Institute

The Sabin Vaccine Institute is committed to extending the full benefits of vaccines to all people, regardless of who they are or where they live. Sabin has built an ecosystem of funders, innovators, implementers, practitioners, policymakers and public stakeholders to work toward a future free from preventable diseases.

Coalition Against Typhoid (CaT)

CaT works to prevent typhoid and other invasive salmonelloses through research, education, and advocacy. With more than 800 members, CaT coordinates partnerships, convenes decision-makers, and advocates for sustainable solutions, including access to next-generation vaccines and clean water.

Clinton Health Access Initiative (CHAI)

CHAI is a global health organization committed to saving lives and reducing the burden of disease in low-and middle-income countries. More than 80 countries have access to CHAI-negotiated deals on medications, diagnostics, vaccines, and other health tools.

Gavi, the Vaccine Alliance

Gavi is an international organization created in 2000 to improve access to new and underused vaccines for children living in the world's poorest countries. Gavi has helped vaccinate more than 822 million children in the world’s poorest countries, preventing more than 14 million deaths.

International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)

Based in Dhaka, Bangladesh, icddr,b is committed to solving public health problems facing low- and middle-income countries through innovative scientific research, including laboratory-based, clinical, epidemiological, and health systems research.

International Vaccine Institute (IVI)

IVI focuses on vaccines against infectious diseases affecting the world’s most impoverished people and aims to make vaccines available and accessible to vulnerable populations in developing countries.

International Vaccine Access Center (IVAC)

Located in the Johns Hopkins Bloomberg School of Public Health, IVAC builds knowledge and support for the value of vaccines to help increase access around the world.

PATH

PATH is a global organization that works to accelerate health equity by bringing together public institutions, businesses, social enterprises, and investors to solve the world’s most pressing health challenges.

UNICEF

The world’s largest provider of vaccines, UNICEF supports child health and nutrition, safe water and sanitation, quality education and skill building, HIV prevention and treatment for mothers and babies, and the protection of children and adolescents from violence and exploitation.

World Health Organization (WHO)

WHO directs and coordinates international health within the United Nations system. Its main areas of work are health systems; health through the life-course; noncommunicable and communicable diseases; preparedness, surveillance, and response; and corporate services.