Enteric and Diarrheal Diseases

Our goal
To eliminate diarrheal disease deaths in young children and to effectively control enteric fever as a public health problem.
Mothers and infants at the Germana Gale Health Post in Silte, Ethiopia.
Mothers and infants at the Germana Gale Health Post in Silte, Ethiopia.

At a glance

  • Diarrheal infections kill more than 500,000 children under age 5 each year, primarily in lower-income countries.
  • In addition, enteric fever causes about 25,000 deaths in young children in countries with poor access to clean water and safe sanitation.
  • Enteric and diarrheal diseases are 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 pathogens that cause these diseases.
  • We support the goals of the integrated Global Action Plan for Pneumonia and Diarrhea, an effort led by the World Health Organization and UNICEF.
Our strategy

Our strategy

We focus on advancing the development and delivery of safe, affordable, and effective vaccines for the leading causes of enteric and diarrheal diseases in low- and lower-middle-income countries. We also support research on the global and regional burden of disease and the development of tools to model and assess disease transmission. This research helps inform decisions on when and how to deploy new interventions and expand the use of existing ones.

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 rotavirus vaccine to her son at a hospital in Kiambu County north of Nairobi, Kenya. (Photo © Domique Cattan)
Areas of focus

Areas of focus

We work with global partners to invest in new and improved vaccines that protect children against the major enteric and diarrheal disease pathogens and are safe and affordable. We work with the international community to support deployment of these vaccines in communities at risk of these diseases. 

Diarrheal diseases are common in young children, leading to about 500,000 deaths worldwide every year.

Diarrheal diseases are common in young children, leading to about 500,000 deaths worldwide every year.

We focus on advancing the development and delivery of vaccines to combat these diseases, which disproportionately affect children in lower-income settings. Our efforts include investments in vaccines for rotavirus, the most common pathogen that causes moderate to severe diarrhea, and the leading bacterial causes of diarrheal diseases, Shigella and cholera. We also focus on typhoid, a disease affecting populations with less access to safe sanitation, clean water, and medical services.

Rotavirus. Rotavirus is the most common cause of diarrheal hospitalizations and deaths in children under age 5 in lower-income countries. Existing rotavirus vaccines have been shown to dramatically reduce the number of hospitalizations and deaths. The World Health Organization (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 in all infants globally and to ensure adequate supply and appropriate formulations, packaging, and labeling.

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

Despite the success of current rotavirus vaccines, their effectiveness is often lower in low-resource settings than in middle- and high-income countries. The reasons include a condition called gut enteropathy that is associated with multiple other enteric infections, inflammation and malnutrition, high maternal antibody levels, and the microbiome. We are working with several partners to develop next-generation rotavirus vaccines that are more effective and can help increase vaccine access in low-income settings.

Cholera. Cholera kills as many as 120,000 people each year. At least 47 countries in sub-Saharan Africa and Asia have endemic cholera, which means the disease is consistently present. Several recent outbreaks in Nigeria, Yemen, South Sudan, Zimbabwe, Cameroon, and elsewhere have severely strained these countries’ under-resourced health systems. For example, in 2021–2022, Nigeria experienced a surge in cholera cases, with thousands of cases and many deaths, highlighting the largest peak in disease in over a decade and showing the potential impact of outbreaks in endemic settings. A cholera outbreak in the Democratic Republic of the Congo between 2013 and 2017 resulted in more than 3,300 deaths. Simultaneous outbreaks of measles and Ebola overwhelmed the country’s health system, demonstrating the importance of strong health systems that reach communities quickly with lifesaving tools such as oral cholera vaccines.

With support from our foundation and other international partners, WHO established a global oral cholera vaccine stockpile in 2013, which is managed by Gavi—a key milestone for cholera prevention and control. The Global Task Force on Cholera Control has facilitated the shipment of more than 100 million doses of cholera vaccine to more than 26 countries for use during outbreaks and humanitarian crises and in endemic areas. The cholera vaccine supply remains insufficient, however, so we support additional vaccine manufacturers in emerging economies in producing more. Stable vaccine supply should lead to more competitive pricing and spur additional demand from countries with a high burden of cholera. Several countries have implemented successful cholera vaccination campaigns and expanded their requests for additional doses in subsequent years.

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 targeted use of cholera vaccines in endemic or “hot spot” areas.

Typhoid. Every year, typhoid infections kill nearly 100,000 people, primarily children in lower-income countries. In recent years, cases of antibiotic-resistant typhoid have increased, making the disease even more dangerous.

Typhoid conjugate vaccines (TCVs) offer a solution. First developed in 2015 with our support, these vaccines are a game-changer for preventing the spread of typhoid. They are the first typhoid vaccines to be approved for use in children under age 2—one of the groups most vulnerable to typhoid. They also provide long-lasting immunity and reduce the need for antibiotics, which helps prevent drug-resistant strains of typhoid from emerging and spreading. TCVs were developed and are now manufactured in South Asia and Southeast Asia, where the burden of typhoid is greatest.

More than 36 million children have already received a dose of TCV, and the results have been promising and remarkably consistent: Studies have shown that TCVs can prevent 80% or more of typhoid cases. The vaccine has been included in routine childhood immunization programs in countries including Pakistan, Liberia, and Zimbabwe, and more countries are planning to introduce the vaccine soon. TCVs are helping us get closer to a world where no child dies from a vaccine-preventable disease.

Shigella. Shigella is a common bacterial pathogen in most low-income regions, with more than 93,000 deaths in children under age 5 in 2019. Shigella infection is also associated with significantly reduced growth. Due to its growing resistance to multiple drugs, therapeutic options are limited, which makes developing a vaccine a high priority.

No vaccine is currently available for Shigella, but we are working with public health partners, biotechnology companies, and in-country vaccine manufacturers to accelerate the development process, including investing in early-stage candidates and analytical tools.

We work to generate evidence that can help us understand enteric and diarrheal disease burden, evaluate the impact of interventions (including assessing the effects of vaccine introductions), and plan future investment priorities.

We work to generate evidence that can help us understand enteric and diarrheal disease burden, evaluate the impact of interventions (including assessing the effects of vaccine introductions), and plan future investment priorities.

We support several surveillance networks, including for global pediatric diarrheal disease surveillance through WHO and its regional offices, typhoid surveillance in South Asia and Africa, and the Child Health and Mortality Prevention Surveillance (CHAMPS) network, a global network of foundation-funded study sites.

We also invest in the development of affordable tools to assess disease burden, such as environmental surveillance, and we work with partners to model data to ensure their translation into rapid public health action. For example, we work with researchers at Imperial College London and partners at the Christian Medical College in Vellore, India; Malawi Liverpool Wellcome Trust in Blantyre, Malawi; and Kwame Nkrumah University of Science and Technology in Kumasi, Ghana, to validate environmental surveillance tools for typhoid alongside clinical surveillance. More recently, building on these efforts, our partners have implemented SARS-CoV-2 surveillance and environmental surveillance of multiple respiratory and enteric pathogens using a promising low-cost platform for enhancing outbreak and pandemic preparedness.

We work to ensure that child health is a priority at the national and global levels, with sufficient funding and political will to increase the delivery of vaccines, preventive interventions, and treatments for enteric and diarrheal diseases.

We work to ensure that child health is a priority at the national and global levels, 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 Diarrhea and the Immunization Agenda 2030. Our core partners in this work include Gavi, UNICEF, WHO, PATH, the International Federation of the Red Cross, and Save the Children.

Why focus on enteric and diarrheal diseases?

Why focus on enteric and diarrheal diseases?

Enteric and diarrheal diseases are the second leading infectious causes of death for young children in lower-income countries, killing more than 500,000 children under age 5 each year. Children who survive often face repeated diarrheal infections in the early years of life, which can lead to serious, lifelong health problems. Evidence suggests an association between repeated infections and poor nutrient absorption, weaker immune response to oral vaccines, stunted growth, and impaired cognitive development.

Typhoid fever and its cousin, paratyphoid fever, are significant public health problems in South Asia, Southeast Asia, and many parts of sub-Saharan Africa. Typhoid stands out as a neglected disease: Children living in poor, densely populated urban areas without clean 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.

Research, funding, and political commitment to address these diseases are lacking in many places, which results in a dearth of critical information about the pathogens and 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 dying from diarrheal diseases, in part due to socioeconomic development, improved water and sanitation systems, and better access to vaccines, diagnostics, and treatments. However, too many children still perish 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 longer term can significantly reduce both suffering and death from these diseases.

yoti, aged 27 months, after her vaccination as part of the TyVAC Nepal Study in Wolku ward in Lalitpur, Nepal on November 21, 2017.
Strategy leadership

Strategy leadership

Our partners

Our partners

The following is an illustrative list of our grantees. It excludes specific vaccine manufacturers, with whom we engage most often through product development partners.

PATH serves as our product development partner for rotavirus and other vaccines and is a key partner in our country-level policy work and vaccine introductions, including for rotavirus and typhoid.

International Vaccine Institute (IVI)

IVI works with us to generate epidemiological evidence on cholera and typhoid and to support the development of vaccines against these diseases.

Bill & Melinda Gates Medical Research Institute (Gates MRI)

Gates MRI, an affiliate of the foundation, works with us to support the development of Shigella vaccines in the pre-clinical and early clinical stages.

Typhoid Vaccine Acceleration Consortium (TyVAC)

TyVAC, a partnership between the University of Maryland, Oxford University, and PATH, aims to accelerate the introduction of new typhoid conjugate vaccines as part of an integrated approach to reducing the burden of typhoid in countries eligible for support from Gavi.

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.

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

Based in Dhaka, Bangladesh, icddr,b is an important foundation partner in generating data on cholera, rotavirus, and typhoid for global dissemination.

World Health Organization (WHO)

We work with WHO on all of our priority disease areas, including cholera, hepatitis E, rotavirus, Shigella, and typhoid fever. WHO’s Department of Immunization, Vaccines and Biologicals is a key foundation partner in generating evidence and data for policy decisions and vaccine implementation.

Global Task Force for Cholera Control (GTFCC)

We work with the GTFCC to support cholera control efforts.

Johns Hopkins Bloomberg School of Public Health

The Bloomberg School’s departments of epidemiology and of international health aim to improve the understanding of cholera by testing surveillance tools, modeling transmission, generating disease burden estimates, and supporting genomic surveillance efforts.

Related programs

Related programs

A child receives a pneumococcal conjugate vaccine (PCV) from an Auxiliary Nurse Midwife (ANM) Worker in Madhya Pradesh, India. 

The team working to prevent and reduce pneumonia, the leading cause of death for kids under 5

Users with membership cards at a community toilet for women in an urban slum in Pune, India.
Water, Sanitation & Hygiene

The team supporting the widespread use of safe and sustainable sanitation