Barbara L. Herwaldt, MD, MPH; Kathleen R. de Arroyave, BSN, RN; Jacquelin M. Roberts, MS; Dennis D. Juranek, DVM, MS
Herwaldt BL, de Arroyave KR, Roberts JM, Juranek DD. A Multiyear Prospective Study of the Risk Factors for and Incidence of Diarrheal Illness in a Cohort of Peace Corps Volunteers in Guatemala. Ann Intern Med. 2000;132:982-988. doi: 10.7326/0003-4819-132-12-200006200-00009
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Published: Ann Intern Med. 2000;132(12):982-988.
Diarrheal illness is the most common medical disorder among travelers from developed to developing countries and is common among expatriate residents in developing countries.
To assess the risk factors for and incidence of diarrheal illness among Americans living in a developing country.
Prospective longitudinal study.
Cohort of 36 Peace Corps volunteers.
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.
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.
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.
The data for each month represent the number of episodes divided by the number of person-days in the month, multiplied by 1000. The data for October 1991 began on 27 October. The onset dates for the participants' first diarrheal episode ranged from 29 October 1991 to 15 May 1992 (median, 4.4 weeks after arrival). The earliest, median, and latest onset dates of all 307 diarrheal episodes were 29 October 1991, 15 July 1992, and 24 January 1994. The one person who was still in the study from February through April 1994 did not have any diarrheal episodes during that period. Three of the four persons who had only one or two episodes were in the study for only 5 to 10 months.
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