Diarrhea causes significant morbidity and mortality in Indian children under 5 years of age. Flies carry enteric pathogens and may mediate foodborne infections. In this study, we characterized fly densities as a determinant of infectious diarrhea in a longitudinal cohort of 160 urban and 80 rural households with 1,274 individuals (27% under 5 years of age) in Vellore, India. Household questionnaires on living conditions were completed at enrollment. Fly abundance was measured during the wet and dry seasons using fly ribbons placed in kitchens. PCRs for enteric bacteria, viruses, and protozoa were performed on 60 fly samples. Forty-three (72%) fly samples were positive for the following pathogens: norovirus (50%), Salmonella spp. (46.7%), rotavirus (6.7%), and Escherichia coli (6.7%). Ninety-one episodes of diarrhea occurred (89% in children under 5 years of age). Stool pathogens isolated in 24 of 77 (31%) samples included E. coli, Shigella spp., Vibrio spp., Giardia, Cryptosporidium, and rotavirus. Multivariate log-linear models were used to explore the relationships between diarrhea and fly densities, controlling for demographics, hygiene, and human-animal interactions. Fly abundance was 6 times higher in rural than urban sites (P < 0.0001). Disposal of garbage close to homes and rural living were significant risk factors for high fly densities. The presence of latrines was protective against high fly densities and diarrhea. The adjusted relative risks of diarrheal episodes and duration of diarrhea, associated with fly density at the 75th percentile, were 1.18 (95% confidence interval [CI], 1.03 to 1.34) and 1.15 (95% CI, 1.02 to 1.29), respectively. Flies harbored enteric pathogens, including norovirus, a poorly documented pathogen on flies.
Diarrhea has been shown to be the cause of death of over 10% of Indian children under the age of 5 (1). Transmission of infectious diarrhea is fecal to oral, with zoonotic and/or anthroponotic cycles depending on the pathogen. Environmental factors that appear to be associated with the epidemiology of enteric pathogens include a wide range of events and processes. These include strong seasonal patterns, such as rain events, temperature extremes, soil and water ammonia levels, soil characteristics and vegetation cover, proximity of infective feces to water and food supplies ultimately used for human consumption, type of water disinfection used and the use of untreated or undertreated wastewater for agricultural irrigation, predation and sequestration of pathogens by invertebrates, pathogen reservoir characteristics, such as number and age of animals in direct and indirect contact with water and food supplies, and pathogen transport by flies and other flying insects (2).Flies are known to carry enteric pathogens, and it is thought that some foodborne transmission of enteric infections may be mediated by flies (3). Enteropathogens previously isolated from flies in field and laboratory experiments include Campylobacter