A Multiyear Prospective Study of the Risk Factors for and Incidence of Diarrheal Illness in a Cohort of Peace Corps Volunteers in Guatemala

20 June 2000 | Volume 132 Issue 12 | Pages 982-988

Background: Diarrheal illness is the most common medical disorder among travelers from developed to developing countries and is common among expatriate residents in developing countries.

Objective: To assess the risk factors for and incidence of diarrheal illness among Americans living in a developing country.

Design: Prospective longitudinal study.

Setting: Rural Guatemala.

Patients: Cohort of 36 Peace Corps volunteers.

Measurements: Collection of daily dietary and symptom data for more than 2 years; identification by multivariate Poisson regression analyses of risk factors for clinically defined episodes of diarrheal illness.

Results: The 36 Peace Corps volunteers in this study had 307 diarrheal episodes (median, 7 per person), which lasted a median of 4 days (range, 1 to 112) and a total of 10.1% of the 23 689 person-days in the study. The incidence density (episodes per person-year) was 4.7 for the study as a whole, 6.1 for the first 6-month period, 5.2 for the second 6-month period, and 3.6 thereafter. Statistically significant risk factors for diarrheal illness included drinking water whose source (for example, the tap) and, therefore, quality, was unknown to the person; eating food prepared by a Guatemalan friend or family; eating food at a small, working-class restaurant; eating fruit peeled by someone other than a Peace Corps volunteer; drinking an iced beverage; and eating ice cream, ice milk, or flavored ices. The relative risks comparing the presence of these exposures during the first 6-month period overseas with their absence during the second year of residence ranged from 1.90 to 2.67, and the summary attributable risk percentage (that is, the percentage of diarrheal episodes that could be ascribed to the exposures) was 75.4%. Exposures generally were riskier if they occurred during travel elsewhere in Guatemala rather than in the person's usual work area.

Conclusions: Diarrheal illness of mild-to-moderate severity continued to occur throughout Peace Corps service but decreased in incidence as length of stay increased. Various dietary behaviors increased the risk for diarrheal illness, which suggests that avoidance of potentially risky foods and beverages is beneficial.

Author and Article Information

From Centers for Disease Control and Prevention, Atlanta, Georgia, and Peace Corps Medical Office, Guatemala City, Guatemala.

Acknowledgments: We thank the Peace Corps volunteers for enthusiastically and faithfully participating in the study. We also thank Marlon Wolcott for helping design the log, Maddy M. Rice and Constance H. Vassaux for helping collect data, Jennifer W. Dickerson for entering data, Allen W. Hightower for providing statistical guidance, and Thomas R. Eng for facilitating the study.

Requests for Single Reprints: Barbara L. Herwaldt, MD, MPH, Centers for Disease Control and Prevention, Division of Parasitic Diseases, 4770 Buford Highway NE, Mailstop F22, Atlanta, GA 30341-3724; e-mail, bxh4{at}cdc.gov.

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Current Author Addresses: Drs. Herwaldt and Juranek and Ms. Roberts: Centers for Disease Control and Prevention, Division of Parasitic Diseases, 4770 Buford Highway NE, Mailstop F22, Atlanta, GA 30341-3724.

Ms. de Arroyave: Peace Corps Medical Office (Guatemala City), c/o US Embassy, Unit 3322, APO AA 34024.