Tackling the silent killers of children

As the first rays of sunlight signal the beginning of a new workday for the bustling fishing villages outside of Karachi, Pakistan, community health workers also ready themselves to treat children suffering from killer diseases that go virtually unnoticed in the media — enteric and diarrheal illnesses.

For children across South Asia, enteric and diarrheal diseases continue to be a major cause of mortality and illness in children under the age of 5. At the Bill & Melinda Gates Foundation — where I work — we talk a lot about these intestinal or enteric diseases. It is how I both start and end my workday. It is the image of sick children and their distressed mothers that keep me focused on preventing illness, and death, from these diseases.

Enteric and diarrheal diseases are associated with a variety of illnesses: severe watery diarrhea; inflammation of the intestinal lining that can lead to dysentery, or leakiness of the gut lining; and a bacterial invasion from the gut that causes typhoid fever.

Many enteric infections remain silent killers because the tools to diagnose them are not widely available in poor environments, leading to lack of recognition of global burden. Salmonella typhi, the bacteria responsible for typhoid fever is one of these silent and neglected infections, and affects millions of people every year. Only through concerted investment in improving water and sanitation and developing new vaccines, as well as ensuring that the poorest and most marginalized have access to the current prevention and treatment tools, can we significantly reduce enteric and diarrheal disease.

Over a hundred years ago, typhoid was a major cause of illness and death in Europe and North America. Famous personalities such as Prince Albert, the husband of Queen Victoria, and one of the Wright brothers, Wilbur died from typhoid. Stanford University was founded in the memory of Leland Stanford Jr. who died from typhoid fever in 1884. However, massive improvements in water and sanitation have led the disease to all but disappear from the Western countries — yet typhoid continues to remain a part of life and death in much of the rest of the world.

Today, typhoid fever, and its related 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; large outbreaks have been reported in Malawi, Uganda, and Zimbabwe recently. Global estimates of cases from typhoid are between 11 million and 27 million, and deaths of 130,000-270,000, every year.

Typhoid stands out as a neglected disease due to its large unaddressed global burden, and lack of any serious control effort or funding. It occurs mostly in children living in densely populated poor urban areas with inadequate water and sanitation infrastructure. Rapid and unregulated urbanization in developing countries and the emergence of multidrug-resistant typhoid are making typhoid fever a dangerous public health problem without any easy solutions.

The adoption of the Sustainable Development Goals presents the international community with an opportunity to recognize typhoid fever as an urgent public health threat, and drive a typhoid control strategy which incorporates both improvements in urban water and sanitation infrastructure and childhood vaccines for prevention. In addition, working together to establish a global impact goal could support alignment and concerted action.

Based on our understanding of the global burden of typhoid and the public health threat, the foundation has made a recent decision to expand investments in typhoid, as part of our strategy to reduce the impact of enteric infections on the most impoverished. We will focus on the development of typhoid conjugate vaccines, given that TCVs have potential to overcome programmatic barriers faced by older typhoid vaccines, which are not targeted for eliciting immunity in young children.

Additional key areas of work will include improving surveillance systems to accurately measure disease burden, and developing a multi-sectoral intervention toolkit that incorporates both vaccine and WASH interventions against typhoid.

Our typhoid work will be informed by successes we’ve had in the development and introduction of other important vaccines for neglected infectious diseases affecting sub-Saharan Africa and South Asia, such as MenAfriVac for meningococcal meningitis in Africa, Japanese B encephalitis vaccine in India, two cholera vaccines (Shanchol and Euvichol) for use in the global stockpile for preventing and responding to cholera outbreaks, and most recently Rotavac, an indigenously produced vaccine against rotavirus diarrhea in Indian children.

For the moms in Karachi, ensuring that their children get a healthy start in life is the number one priority. That’s why we’re increasing our investment in order to dramatically reduce the incidence and impact of these silent killers.

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