Multi-disease groups – diarrhoeal diseases, kinetoplastids & helminths

A big fall in diarrhoeal disease funding left all three categories at or near record lows

Overall funding for diarrhoeal diseases was down in 2023, dropping to $144m (down $20m), more than offsetting last year's slight rebound and taking it to its lowest level ever – more than $100m below its 2009 peak. This significant decline raises concerns about the sustained commitment to combating diarrhoeal diseases globally. This year's reductions in funding fell most heavily on cryptosporidiosis and Shigella, while the long-term decline has been in funding for rotavirus (down more than $52m since 2009) and multiple diarrhoeal diseases (down $40m). Funding for cholera, on the other hand, rose by a further $3.2m (8%) leaving it close to its all-time high.

Shigella funding was down for the second year in a row after peaking in 2021. While the drop in 2022 was felt mostly by vaccines, most of the reduction in 2023 was due to a reversal of the big spike in diagnostics funding from both Gates and DOD in 2022. The apparent near-disappearance of industry’s vaccine funding is artefactual – reflecting a transfer of a candidate's development to non-participating pharmaceutical companies. This shift may affect transparency and tracking of progress in vaccine development efforts.

Cholera funding was up slightly again in 2023 ($3.2m, 8%) following a sharp increase in cholera fatalities which continued into 2024. All of this new funding has been invested in vaccine R&D, while basic research has been trending down. Even after years of decline, though, basic research remained the best funded of cholera’s product areas. An emerging shift towards vaccine R&D may signal a new emphasis on prevention and control of cholera outbreaks, drawing on prior basic research.

While rotavirus funding has remained largely unchanged at a little over $20m in each of the last three years, its long-term decline reflects previous reductions in vaccine funding from the Gates Foundation and from industry. This sustained decrease may impede the development of new vaccines and treatments, potentially affecting global efforts to reduce rotavirus-related child mortality.

Cryptosporidiosis funding saw the biggest drop in 2023, down $8.2m (-33%), following four years of relative stability. Cryptosporidiosis experienced reductions in funding from each of its three biggest funders, the NIH (down $1.6m, -14%), industry (down $3.8m, -40%) and Wellcome (down $2.7m, -84%) which together fell heavily on drug R&D, which dropped by $6m (-38%). These cuts to drug R&D were headlined by a sharp, and concerning, reduction in industry and Wellcome contributions to a Phase I drug trial. This decline is likely to threaten the development of new treatments for cryptosporidiosis, a significant cause of morbidity in vulnerable populations.

There was no funding for cryptosporidiosis vaccines in 2023 for the first time since 2007. While funding had been relatively low (averaging $0.2m in the first six years and increasing to over $1m in the years since 2014) this represents a worrying development, with dangerous implications in vulnerable infant populations as incidence is likely to increase alongside the increased frequency of heavy rainfall and flooding events brought on by climate change.

Funding targeting multiple diarrhoeal diseases was down by $5.4m (-36%) to $10m, following a brief rebound in 2022. It remains much lower than pre-2020 levels, when it averaged over $50m a year. The 2023 fall in multi- diarrhoeal disease funding, and much of the long-term decline, was driven by ongoing reductions in funding from the US DOD, which reduced its funding by $4.1m in 2023 – reflecting a large one-off drug grant in 2022 – and by more than $13m over the last decade, mostly due to declining vaccine investments. This, and a similar decline in Gates funding to PATH for multi-disease vaccines, may actually signal progress in the pipeline, as products become focused on specific target pathogens as they advance through the development process.

Funding for kinetoplastid R&D was almost entirely unchanged at its record low of $133m in 2023, though this stability partly reflected offsetting changes in underlying survey participation. It also masked some meaningful shifts at the individual disease level, with a big rise in Chagas' disease funding (up $5.7m, 13%, or more than $9m after adjusting for participation) and a sharp drop in multiple kinetoplastid R&D (down $3.8m, -18%, or almost $6m on a participation adjusted basis).

The near record funding for Chagas' disease was mostly thanks to big jump in industry drug funding, which rose by $5.6m (30%) to $25m. Industry has now committed almost $112m to Chagas' drug R&D over the past five years, compared to less than $60m, total, over the previous 12. The US NIH, the second largest funder of Chagas' R&D after industry in each of the last five years, also saw its funding rebound after two slightly down years, rising by $3.2m (25%) to $16m and offsetting a similarly sized drop in Unitaid's drug and diagnostic funding.

Research targeting multiple kinetoplastids, which is now down more than 70% from its 2017 peak to a new record low, fell due to reduced contributions from the UK FCDO and the German BMBF. The FCDO has been by far the largest funder of multi-kinetoplastid R&D, but reduced its funding by another $2.4m (-24%) leaving it more than $19m below its peak in 2017. In contrast to funding for multiple diarrhoeal diseases, there is no evidence of the FCDO, or other funders, shifting their efforts to pathogen-specific products as they advance through the pipeline. Declining funding for multi-disease approaches may undermine the eventual development of products targeting individuals diseases currently lacking in advanced candidates.

Overall funding for helminth infections fell $15m (-14%) to $94m in 2023, undoing the previous two years of growth and leaving it just above its 2016 decade low.

A large proportion of this drop was in funding for schistosomiasis (down $10m, -23%) – though it remained the highest funded disease – and lymphatic filariasis (down $7.4m, -34%), both of which had surged in 2022. These kinds of fluctuations often reflect the planned frontloading of grants, but, where they do not, they can undermine the forward planning of product developers.

Onchocerciasis funding was also down (-$3.3m, down 22%), while funding for multiple helminth infections was the only area to see a significant increase (up $6.7m, 42%). This round of shifts reverses many of the ones we saw in 2022, returning the distribution of funding to one quite similar to that of 2021. The main exception onchocerciasis, which has seen its funding decline each year since peaking in 2018 with the FDA approval of treatment with moxidectin.

The US NIH remained the largest single funder of helminth R&D, a total of $41m (down $1.7m, -4%) leaving it responsible for 44% of global funding. There were significant reductions in funding from the other major 2022 funders: the Gates Foundation and industry.

These same three funders – the NIH, Gates and industry – were also mostly responsible for the fall in schistosomiasis funding, along with the conclusion of a four-year funding programme from the US DOD. Over half of the drop in schistosomiasis funding was for vaccine R&D, with both the NIH and Gates decreasing their funding in this area by at least three-quarters.

Lymphatic filariasis funding was down a third in 2023 (down $7.4m, -34%), undoing a similarly sized spike in 2022. Both the 2022 spike and subsequent 2023 drop were due to changes in the German BMBF’s funding its TAKeOFF program, which aims to standardise clinical trial procedures for filariasis.

Hookworm funding declined by 20% ($1.0m). leaving it only a little higher than 2018’s record low.