A multiyear prospective study of the risk factors for and incidence of diarrheal illness in a cohort of peace corps volunteers in Guatemala

Background: Diarrheal illness is the most common medical disorder among tra velers from developed to developing countries and is common among expatriat e residents in developing countries. Objective: To assess the risk factors for and incidence of diarrheal illnes s 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 f actors for clinically defined episodes of diarrheal illness. Results: The 36 Peace Corps volunteers in this study had 307 diarrheal epis odes (median, 7 per person), which lasted a median of 4 days (range, 1 to 1 12) and a total of 10.1% of the 23 689 person-days in the study. The incide nce 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 in cluded drinking water whose source (for example, the tap) and, therefore, q uality, was unknown to the person; eating food prepared by a Guatemalan fri end or family; eating food at a small, working-class restaurant; eating fru it peeled by someone other than a Peace Corps volunteer; drinking an iced b everage; and eating ice cream, ice milk, or flavored ices. The relative ris ks comparing the presence of these exposures during the first 6-month perio d overseas with their absence during the second year of residence ranged fr om 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 oc cur 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 bever ages is beneficial.