Health-related Challenges in United States Peace Corps Volunteers Serving for Two Years in Madagascar

Health-related Challenges in United States Peace Corps Volunteers Serving for Two Years in Madagascar Peter D. C. Leutscher and Sandra W. Bagley Background: The United States Peace Corps has nearly 8000 Volunteers (PCVs) working in more than 70 countries, predominantly in the developing part of the world. The volunteers are challenged by many new and unfamiliar health problems, as a result of change in living conditions during their service. The goal of this study was to assess the health problems of PCVs in Madagascar, and to use this information to evaluate the effectiveness of the current PCV health support program. Methods: PCVs, finalizing their 2 years of service, were enrolled in the study. Data were retrieved from individual Peace Corps service medical records, the close of service (COS) physical evaluation, and a PCV questionnaire, which elicited additional self-reported health problems and concerns. Results: Sixty-nine PCVs took part in the study. Median age at COS was 24 years (95% CI 23 26 years), and the male/female ratio was 1 : 3.6 (15 males and 54 females). Skin, gastrointestinal and respiratory infections constituted the three most common reported health problems. Among the registered parasitic infections were ova and parasites in the stool (42.0%), confirmed and presumptive malaria (15.9%) and schistosomiasis (11.6%). Female PCVs more frequently reported dermatologic manifestations than male PCVs: postadolescent acne (48.2% vs. 13.3%) and telogen hair loss (33.3% vs. 6.7%). Amenorrhea, as the most commonly reported menstrual alteration during service, was reported by 15 (27.7%) female PCVs. Conclusions: The PCVs in Madagascar encounter a broad range of health-related problems, most of which are preventable infectious diseases. Reinforcement of the preservice personal health-training curriculum later during service is needed. Reported dermatologic and menstrual disturbances in female subjects may be associated with stress-related estrogen imbalance. More studies are warranted to assess the stress impact of long-term travel on the female physiology. The United States Peace Corps was founded 40 years ago through an initiative by the late President John F. Kennedy. In 2003, the organization has almost 8,000 Peace Corps Volunteers (PCVs) who are currently working in more than 70 countries, which are predominantly located in the developing world. 1 Prevention of diseases is considered to be an essential component in PCV health support and services. Weekly sessions addressing personal health issues, such as Peter D. C. Leutscher, MD, PhD, DTMH: The United States Peace Corps, Medical Unit, BP 620, Antananarivo, Madagascar; Sandra W. Bagley, MSW, MS, PhD: The United States Embassy, Medical Unit, BP 620, Antananarivo, Madagascar. The authors had no financial or other conflicts of interest to disclose. Reprint requests: Peter D. C. Leutscher, MD, PhD, DTMH, The United States Peace Corps, Medical Unit, BP 620, Antananarivo, Madagascar. J Travel Med 2003; 10: 263 267. hygiene, malaria prophylaxis, infections, mental health and nutrition, are performed at arrival in-country and form part of the 3-month PCV preservice training program. The PCVs receive immunizations against measles, mumps and rubella (MMR), polio (IPV), yellow fever, viral hepatitis A, viral hepatitis B, typhoid fever (Vi), meningococcal meningitis A,C,Y,W-135 and rabies. Examples of health-supporting tools distributed to the PCVs include health handbooks, water filters, impregnated mosquito nets, and medical kits. The PCVs are of particular interest as travelers, because of their status as long-term overseas residents. They are exposed through their lifestyle over a 2-year period to a variety of different health problems with which they are not always familiar. They often live in remote rural areas where lack of infrastructure and a low level of hygiene are predominant characteristics. Little is known about the changes in health status of PCVs and long-term travelers, in general, in the developing countries. Only a few general studies have assessed travelassociated illness and other health-related conditions in long-term travelers. 2 7 Physiologic and psychological 263

264 Journal of Travel Medicine, Volume 10, Number 5 aspects of long-term travelers health status, in particular, are scantily addressed in the literature. This study provided a unique opportunity to obtain health status information in a well-defined study population of long-term travelers. The purposes of the study were twofold: (1) to monitor the overall pattern of health problems encountered by PCVs during 2 years of service in Madagascar; and (2) to improve the existing PCV preservice personal health-training curriculum using the collected data. Methods The study consisted of three groups of PCVs evaluated at close of service (COS) from April to December 2001. At COS, a physical examination was performed as part of the routine medical clearance procedure before the PCVs left Madagascar. The individual medical records were reviewed at the COS physical, and the documented health problems were recorded. A postservice screening protocol was followed, which included complete blood count, HIV testing, Mantoux TB skin test,urine dip analysis,a Pap smear,and ova and parasite examination of stool specimens collected from 3 consecutive days. 8 The PCVs were,like all PCVs serving in the African region, screened for schistosomiasis infection by use of an enzyme-linked immunotransfer blot (EITB). 9 An anonymous questionnaire was administered to the PCVs 3 months prior to the COS physical examination, to elicit additional self-reported health problems. The PCVs were informed that the questionnaire was used in a country-specific study of service-related health problems. Specific issues addressed in the questionnaire dealt with behavior aspects related to sexual practice, and compliance with malaria chemoprophylaxis. The PCVs were also questioned about hair loss, acne and alterations in the menstruation pattern. The questionnaire was edited and evaluated for clarity by a group of first-year PCVs prior to being administered to the study participants. The prevalence of health parameters in male and female subjects was compared using the chi-squared test. Results Study Group Of the 80 PCV candidates who arrived in Madagascar to participate in the 3-month preservice training course, 69 (86.3%) completed the 2 years of service in Madagascar. Of the 11 individuals who did not finish their service, none terminated their service due to medical reasons. Median age was 24 years (95% CI 23 26 years) at the time of COS, and the male/female ratio was 1 : 3.6 (15 males and 54 females). The PCV sites were located in different geographic zones in Madagascar and at different altitudes (range: sea level to 1200 1500 m). Overall Reported Health Problems and Medical Evacuation In total, 640 reported health problems were extracted from the 69 PCV medical records. Febrile illness, and skin, gastrointestinal and respiratory infections, constituted the majority of reported problems (Table 1). Ten (23.2%, 7.3 per 100 PCV-year) PCVs were medically evacuated from Madagascar to South Africa or the US for the following reasons: orthopedic (n 3), gynecology (n 2), dental (n 2), fever of unknown origin (n 2) and mental evaluation (n 1). There were no PCVs evacuated with a life-threatening condition, and all returned to continue service in Madagascar.One PCV in the study group was involved in an automobile accident, but suffered only minor injuries. Parasitic Infections Gastrointestinal parasitic infections were diagnosed in 29 (42.0%) PCVs (Table 2). Twenty-three (33.3%) PCVs were diagnosed with Ascaris lumbricoides and/or Trichuris trichiura,9 (13.0%) with Giardia lamblia, and 1 (1.4%) with Entamoeba histolytica.seven of the nine PCVs with giardiasis were asymptomatic when the diagnosis was made at the COS physical. Mefloquine is considered the first drug of choice for antimalarial chemoprophylaxis for PCVs upon entry to Madagascar. Fourteen (20.3%) of the 69 PCVs reported mild-to-moderate intolerance to mefloquine in the first 6 months of service. Alternative prophylaxis using doxycycline was prescribed to 11 PCVs, and chloroquine proguanil to three PCVs. At their request, 7 of the 14 subjects given alternative prophylaxis were put back on mefloquine. These PCVs reported that they felt more comfortable about a prophylactic regimen administered only once a week as opposed to a daily schedule in the Table 1 Distribution of Reported Health Problems in the Service Medical Records from 69 Peace Corps Volunteers (PCVs) in 2 years of Service in Madagascar Number of Reported Health Problems (%) Dermatology 144 (23.0) Gastroenterology 133 (21.3) Respiratory 95 (15.2) Urogenital 66 (10.6) Musculoskeletal 47 (7.5) Febrile illness 42 (6.7) Dental 23 (3.7) Mental health counseling 12 (1.9) Other 63 (10.1) Total 625 (100.0)

Leutscher and Bagley, Health-related Challenges in United States Peace Corps Volunteers Service 265 Table 2 Distribution of Registered Parasitic Infections during Peace Corps Service and at Close of Service (COS) physical During PC Service COS Physical Overall Incidence* n (%) n (%) n (%) Gastrointestinal parasitic infections 13 (18.8) 20 (29.0) 29 (42.0) 21.0 Helminths 10 (14.5) 15 (21.7) 23 (33.3) 16.7 Protozoa 3 (4.3) 7 (10.1) 10 (14.5) 7.3 Malaria 11 (15.9) 0 ( 11 (15.9) 8.0 Schistosomiasis * ( 8 (11.6) 8 (11.6) 5.8 Ectoparasites 8 (11.6) 0 ( 8 (11.6) 5.8 *Incidence: number of cases per 100 PCV-year. Ascaris lumbricoides (n 23). Trichuris trichiura (n 2). Giardia lamblia (n 9). Entamoeba histolytica (1). One confirmed case (Plasmodium malaria) and 10 presumptive cases. Schistosoma mansoni (n 6), S. haematobium (n 3). jigger flea (Tunga penetrans) (n 5), scabies (Sarcoptes scabiei) (n 2) and head lice (Pediculus capitis) (n 1). alternative regimens. Eleven (15.9%) PCVs (8.0 per 100 PCV-year) were reported with malaria: 1 with confirmed malaria (Plasmodium malaria infection) and 10 with presumptive malaria (Table 2). The 10 cases of febrile illness were interpreted as malaria and self-treated with Fansidar by the PCVs at the site. The diagnosis was not confirmed by laboratory work. Thirteen (18.8%) PCVs reported that they had not used chemoprophylaxis consistently during their service. Eight (11.6%) of the study group were positive for antischistosomal antibody by EITB: 5 were positive for Schistosoma mansoni,2 for S. haematobium, and 1 for both S. mansoni and S. haematobium. Ectoparasites, such as scabies, jigger flea (Tunga penetrans) and/or head lice, were observed in 8 (11.6 %) PCVs. None of 69 PCVs had hypereosinophilia (>1500/µL) at the COS physical. Other Infections Six (8.7%) preexposure immunized PCVs were given postexposure antirabies immunization following an event in which they were bitten by a suspected rabid animal. No cases of viral hepatitis, hemorrhagic fever, cholera or typhoid fever were observed in this group. Four (5.8%, 3.0 per 100 PCV-year) PCVs were detected with an increase in the Mantoux skin test of 5 mm at COS compared to the preservice test result. All four were prescribed a 6-month isoniazid course of TB prophylaxis. No cases of active tuberculosis (TB) were observed in the study group. Three (5.6%) female PCVs, and 2 (13.3%) male PCVs, were diagnosed with a sexually transmitted infection (STI) (overall, 6.9 per 100 PCV). A history of unprotected sex with a host national of unknown STI/HIV status was reported by 7 (46.7%) male PCVs and by 10 (18.5%) female PCVs. HIV testing, in addition to the routine preservice and COS physical testing, was requested by 5 (33.3%) males and by 6 (11.1%) female PCVs during service. All 11 PCVs tested negative at baseline and at follow-up. Physiologic Changes Dermatologic changes during service were more frequently reported by female PCVs than by males: postadolescent acne (48.2% vs. 13.3%, p <.05) and telogen hair loss (33.3% vs. 6.7%, p <.05). In total, 30 (55.6%) PCVs reported alterations of the normal menstruation pattern during service. Amenorrhea, defined as more than 3 months with absence of menstruation, was reported by 15 (27.7%) PCVs. This was a first-time event for 10 (66.7%) of the 15 volunteers. Vaginal yeast infection accounted for 45.3% of the urogenital problems reported by the female PCVs. Discussion This study presents health data obtained from a group of United States Peace Corps Volunteers living and working for 2 years in Madagascar. Although the study sample was small, the findings may still be representative for this population in general. The incidence of reported health problems was consistent with the incidence in other Peace Corps countries throughout Africa (Table 3). 1 Gastrointestinal and skin infections are some of the most frequent health problems reported by the PCVs. Gastrointestinal parasitic infections were diagnosed in half of the PCVs.The risk of infection is high in Madagascar, where nearly 100% of the children at 10 years of age have been diagnosed with intestinal nematodes. 10 The prevalence of giardiasis observed in the volunteers was comparable with previous observations in German travelers returning from the African countries. 11 Schistosomiasis infection is commonly diagnosed in expatriates and travelers returning from Africa. 12,13 Of the 8 PCVs with a positive serology test result, none presented symptoms of schistosomiasis infection. Schistosoma eggs were not detected in either stool or urine specimens. This is compelling evidence to support a policy of postservice or posttravel screening for schistosomiasis by serology

266 Journal of Travel Medicine, Volume 10, Number 5 Table 3 Incidence of Reported Health Problems in Peace Corps Volunteers (PCVs) in Madagascar and Overall for the African Region 1 Madagascar African region (118 PCV-years) (2358 PCV-years) Incidence* Incidence* (Range) Diarrhea 78.7 94.5 (27.9 221.0 Respiratory infections 60.1 41.8 (3.7 84.2) Skin infections 32.2 31.1 (2.2 89.4) Dental 30.5 20.4 (2.2 49.1) Medical evacuations 16.1 12.3 (3.7 23.5) Mental health 13.5 28.8 (2.5 99.3) Febrile illness 7.6 22.2 (3.4 77.3) Helminths 9.3 1.7 (0 15.7) Confirmed/presumptive malaria 6.8 10.4 (0 40.4) Schistosomiasis 5.9 1.6 (0 17.0) Sexually transmitted infections 5.1 3.5 (0 15.5) TB skin test positive 2.5 1.2 (0 7.7) Motor vehicle injuries 0 1.9 (0 8.2) Pregnancy 0 1.1 (0 14.9) Filariasis 0 0.2 (0 2.6) Cardiovascular 0 0.2 (0 1.9) Hepatitis 0 0.2 (0 2.8) *Incidence: number of cases per 100 PCV-year. Source: Peace Corp Office of Medical Services. 1 testing. Only one case of confirmed malaria (P. malaria) was diagnosed among the 69 PCVs, and 10 other cases were considered to be presumptive malaria. Without laboratory confirmation of malaria, an exact estimate of the incidence in Madagascar is not possible. The Peace Corps emphasizes the use of preventive measures against malaria in the PCV health care program, including impregnated mosquito nets and mandatory chemotherapeutic prophylaxis, in addition to provision of medication for self-treatment at the PCV site in case of prophylactic failure. The strategy for reducing the risk of malaria in PCVs has proven efficacious. Of the more than 20,000 PCVs who have served in sub-saharan Africa and other malaria-endemic areas in the past 12 years, only one has died of P. falciparum malaria. The use of a questionnaire in this study revealed that alterations in the normal menstruation pattern, hair loss and acne are frequently experienced by the female PCVs. A similar occurrence of menstrual disorders has been reported in studies among college students, military cadets and athletes. 14 16 Changes in diet,increased physical activity and stress have been associated with menstruation disturbances. One physiologic explanation for menstrual irregularity may be lifestyle stress stimuli. Stress causes a decrease in the gonadotropin-releasing hormone pulses from the hypothalamus, and this in turn decreases the secretion of luteinizing hormone and follicle-stimulating hormone from the pituitary gland. The depressed hypothalamus pituitary cascade fails to stimulate the ovary, leading to decreased production of estrogen, and consequently menstrual irregularities. 16,17 Hair loss and postadolescent acne were also commonly reported by the female PCVs. These androgenic alterations may develop in women when estrogen secretion decreases to a level at which it is inadequate to counter the existing testosterone production. 17 19 In fact, increased androgen production as a separate response to chronic stress may further aggravate the situation. Although these signs and symptoms are not life-threatening, they have a negative psychosocial impact and a quality-of-life effect. The median age of female PCVs is 24 years,and this age group may be more sensitive to unexpected body changes. It is therefore important to inform and to reassure the young women about these reversible conditions and about the therapeutic options from which they may benefit, such as estrogen replacement therapy using an oral contraceptive. 16,18,19 This study has also revealed a very worrying risk behavior profile among PCVs related to the consequences of unprotected sexual activity. This behavior may not be well thought through, due to the isolation experienced by the PCVs as a result of their living arrangements.they usually live great distances from fellow PCVs, they experience cultural and lingual constraints, and they find it difficult to establish a social network that can replace their normal peer support structure. Emotional support among PCVs during service is evidently an essential part of the overall risk-reducing strategy. Extensive training in the local language and culture is equally important to protect the PCVs and to reduce risk-taking behavior. Conclusion Peace Corps service overseas is acknowledged by most volunteers as a positive life-changing unique personal and professional experience. It is, at the same time, an extraordinary physical and emotional challenge for many of them. The main objective of the Peace Corps health care program is to assist the PCVs in dealing with these challenges and reducing their risk of suffering from adverse medical conditions. This study confirms how important it is to educate the PCVs in infectious disease preventive strategies during preservice training, such as safe water and food preparation, prevention of skin infections, malaria prophylaxis, and safe sexual practice. However, it is equally important to reemphasize the health recommendations during service. The occurrence of physiologic changes, particularly in female PCVs, during service is an important topic that should be addressed in the training curriculum. This study suggests that the new

Leutscher and Bagley, Health-related Challenges in United States Peace Corps Volunteers Service 267 findings related to the physiologic response in the longterm traveler warrant further studies. Acknowledgments Christine Rocuet, MD, and Diane Dessureault Roy, RN, at the Peace Corps Health Unit in Madagascar, are acknowledged for their assistance in collecting the data. Catherine Burke, Dr Ted Leon, Dr Richard MacKay and Dr Emil von Arx have provided constructive comments. References 1. Peace Corps Office of Medical Services. The 2000 Annual Report of Volunteer Health. Washington, DC: Peace Corps Office of Medical Services, 2000. 2. Cossar JH,Reid D,Fallon RJ,et al.a cumulative review study on travelers, their experience of illness and the implications of these findings. J Infect Dis 1990; 21:27 42. 3. Steffen R. Travel medicine prevention based on epidemiological data. Trans R Soc Trop Med Hyg 1991; 85:156 162. 4. Ahlm C,Lundberg S,Fesse K,et al.health problems and self medication among Swedish travelers. Scand J Infect Dis 1994; 26:711 717. 5. Sharp TW, DeFraites RF, Thornton SA, et al. Illness in journalists and relief workers involved in international humanitarian assistance efforts in Somalia. J Travel Med 1995; 2:70 76. 6. Hill DR. Health problems in a large cohort of Americans traveling to developing countries. J Travel Med 2000; 5:259 266. 7. Winer L, Alkan M. Incidence and precipitating factors of morbidity among Israeli travelers abroad. J Travel Med 2002, 5:227 232. 8. Peace Corps Office of Medical Services. Post-service health benefits and close of service or extension of service health evaluation. Peace Corps Technical Guidelines 320. Washington, DC: Peace Corps Office of Medical Services, 2001. 9. Tsang VCW, Wilkins PP. Immunodiagnosis of schistosomiasisscreen with FAST-ELISA and confirm with immunoblot. Clin Lab Med 1991; 11:1029 1039. 10. Kightlinger LK, Sees JR, Kithlinger MB. The epidemiology of Ascaris lumbricoides, Trichuris trichiura, and hookworm in children in the Ranomafana rainforest, Madagascar. J Parasitol 1995; 81(2):159 169. 11. Jelinek T, Löscher T. Epidemiology of giardiasis in German travelers. J Travel Med 2000; 7(2):70 73. 12. Harries AD, Fryatt R, Walker J, et al. Schistosomiasis in expatriates returning to Britain from the tropics: a controlled study. Lancet 1986; 341:86 88. 13. Cetron SM, Chitsulo L, Sullivan JJ, et al. Schistosomiais in Lake Malawi. Lancet 1996; 348:1274 1278. 14. Bachman GA, Kemmann E. Prevalence of oligomenorrhea and amenorrhea in a college population. Am J Obstet Gynecol 1982; 144:98 102. 15. Schneider MB, Fisher M, Friedman SB, et al. Menstrual and premenstrual issues in female military cadets: a unique population with significant concerns. J Pediatr Adolesc Gynecol 1999; 12:195 201. 16. Warren MP, Shantha S. The female athlete. Best practice & research. Clin Endocrinol Metab 2000; 14:37 53. 17. Kligman AM. Post-adolescent acne in women. Cutis 1991; 48:75 77. 18. Fitzpatrick TB, Johnson RA, Wolff K, Suurmond D. Color atlas & synopsis of clinical dermatology. Common and serious diseases, 4th edn. London: McGraw-Hill, 2001. 19. Redmond GP. Androgens and women s health. Int J Fertility Womens Med 1999; 44:83 95. Some drug stores really sell poisons, i.e. obselete drugs and no usher to lead you to a court where you can complain. RKES, Belize.