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Chronic Diarrhea Associated with Drinking Untreated Water

Julie Parsonnet, MD; Susan C. Trock, DVM; Cheryl A. Bopp, MS; Cynthia J. Wood, BA; David G. Addiss, MD; Frank Alai, MPH; Leo Gorelkin, MD; Nancy Hargrett-Bean, PhD; Robert A. Gunn, MD, MPH; and Robert V. Tauxe, MD, MPH
[+] Article, Author, and Disclosure Information

Use of trade names is for identification only and does not imply endorsement by the Public Health Service or by the U.S. Department of Health and Human Services.

Requests for Reprints: Julie Parsonnet, MD, EDB/DBD/CID, Room 1-5428, Centers for Disease Control, Atlanta, GA 30333.

Current Author Addresses: Drs. Parsonnet, Addiss, Hargrett-Bean, and Tauxe, and Ms. Bopp: Enteric Diseases Branch, Division of Bacterial Diseases, Center for Infectious Diseases, Centers for Disease Control, Atlanta, GA 30333.

Drs. Trock and Gunn: Division of Field Services, Epidemiology Program Office, Centers for Disease Control, Atlanta, GA 30333.

Ms. Wood and Mr. Alai: Illinois Department of Public Health, 535 West Jefferson Street, Springfield, IL 62761.

Dr. Gorelkin: Division of Host Factors, Center for Infectious Diseases, Centers for Disease Control, Atlanta, GA 30333.

Ann Intern Med. 1989;110(12):985-991. doi:10.7326/0003-4819-110-12-985
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Purpose: To determine the cause of an outbreak of chronic diarrhea and to define the clinical profile of the illness.

Design: A case series of patients with chronic diarrhea and case-control and cohort studies to determine the vehicle and cause of the illness.

Setting: Rural Henderson County, Illinois.

Patients: Seventy-two patients who had onset of chronic diarrheal illness between May and August 1987. Controls were local residents and eating companions who did not have diarrheal illness. A cohort study included 80 truck drivers from a local firm.

Methods and Measurements: Nonbloody diarrhea was characterized by extreme frequency (median, 12 stools/d), marked urgency, fecal incontinence, and weight loss (mean, 4.5 kg). The median incubation period was 10 days. Nine patients were hospitalized; none died. Diarrhea persisted in 87% of patients after 6 months. Antimicrobial therapy produced no clinical improvement. No bacterial, mycobacterial, viral, or parasitic agents known to be enteropathogenic were detected in stools or implicated water. Three of five small-bowel biopsies showed mild inflammatory changes. Mild inflammation was also seen in two of nine colonic biopsies. Case-control studies implicated a local restaurant (P = 0.0001, odds ratio = 19) and subsequently the untreated well water served in the restaurant (P = 0.04, odds ratio = 9.3) as the vehicle of transmission.

Conclusions: This is the first outbreak of chronic diarrhea linked to drinking untreated water. The causative agent and pathophysiologic mechanism of the illness remain elusive.





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