Journal of Travel Medicine, 2015, 23(1), 27

doi: 10.1093/jtm/tav005
Original article

Original article

Revisiting tuberculosis risk in Peace Corps Volunteers,

200613
Megan L. Brown, BS, Susan J. Henderson, MD, MPH*, Rennie W. Ferguson, MHS, and
Paul Jung, MD, MPH
US Peace Corps, Office of Health Services, Washington, DC, USA
*To whom correspondence should be addressed. Email: shenderson@peacecorps.gov

Abstract
Background. Risk of tuberculosis (TB) is generally considered to be low for long-term travellers, though risk varies
with travel destination, duration and purpose. Peace Corps Volunteers (PCVs) serve for 27 months as communitylevel development workers in various countries around the world and may be exposed to TB in the course of their
service. This study examines recent trends in TB in PCVs and compares rates with a previous analysis published by
Jung and Banks.
Methods. Tuberculosis case data submitted to the Peace Corps Epidemiologic Surveillance System by Peace Corps
Medical Officers and gathered from Federal Employees Compensation Act claims for latent TB infection (LTBI) and
active TB between 2006 and 2013 were aggregated and analysed for trends and significance.
Results. Overall, there were 689 cases of LTBI and 13 cases of active TB, for a rate of 0.95 cases of LTBI [95% confidence interval (CI) 0.881.02] and 0.02 cases of active TB (95% CI 0.010.03) per 1000 Volunteer-months. Both are significantly lower than rates presented in the initial study (P < 0.001). Per-country incidence rates for LTBI ranged from
0.00 to 4.52 cases per 1000 Volunteer-months. Per-country active TB rates ranged from 0.00 to 0.78 cases per 1000
Volunteer-months. Among the 13 cases of active TB, there was one successfully treated case of extensively drug-resistant TB.
Conclusions. Overall rates of both active and latent TB in PCVs were significantly lower compared with the previous
study period. PCVs continue to have statistically significantly higher rates of active TB compared with the general
US population but lower rates compared with other long-term travellers.
Key words: Tuberculosis, epidemiology, Peace Corps Volunteers

Introduction
Despite the progress that has been made in achieving the
Millennium Development Goals (MDGs) target of halting and
reversing tuberculosis (TB), the World Health Organization estimates that 1.5 million people died of TB and 9 million contracted the illness in 2013.1 In 2008, Jung and Banks2 published
an examination of TB risk in Peace Corps Volunteers (PCVs) between 1996 and 2005, concluding that PCVs have a higher risk
of contracting TB than the general US population but a lower
risk as compared with other non-US long-term travellers previously studied. The emergence and spread of multi-drug-resistant
(MDR) and extensively drug-resistant (XDR) TB has further
contributed to public concern.3,4 Worldwide, 5% of reported

Published by Oxford University Press International Society of Travel Medicine 2015.

This work is written by US Government employees and is in the public domain in the US.

TB cases are estimated to be MDR; of MDR cases, 9% are estimated to be XDR.5

Latent TB infection (LTBI) indicates exposure to TB and is
diagnosed when a previously non-reactive individual has a clinically significant immune reaction in response to exposure to either a tuberculin purified protein derivative skin test (PPD) or a
positive Interferon Gamma Release Assay (IGRA) blood test
with no symptoms or findings indicative of active TB and a normal chest radiograph.6 Five to 10% of those exposed to TB develop active disease.7
Risk of TB in travellers is generally accepted to be low, but
increases with endemicity in the country visited, engagement in
high-risk activities and length of time spent in-country.8,9

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Accepted 7 September 2015

Journal of Travel Medicine, 2015, Vol. 23, No. 1

Methods
Data analysed for this study were from the Peace Corps Office of
Health Services Epidemiologic Surveillance System (ESS). This system counts major health concerns experienced by currently serving
Volunteers. Data are submitted monthly by Medical Officers located in each Peace Corps country. ESS data provide only aggregate
data on the diagnosis and the country of service. It does not provide
demographic information such as age, sex, site placement, or sector
of work, nor does it provide details about the case.
ESS data only capture testing that is conducted during service.
For cases of tuberculin testing performed subsequent to a
Volunteers Close of Service (COS) date, data were drawn from the
Federal Employees Compensation Act (FECA) claims database.
FECA claims for LTBI and active TB were counted for the year in
which the Volunteer closed service and analysed with the ESS data.
For the purposes of this study, LTBI and active TB are defined in accordance with Peace Corps Medical Technical
Guidelines: a positive tuberculin skin test result 5 mm is considered positive (a conversion indicative of TB exposure) in
those individuals who are recent contacts of a TB case, have
known or suspected immunosuppressive disease, or have fibrotic changes on chest radiograph consistent with previous TB
infection. A result 10 mm is considered positive in those individuals who have recently returned from high-prevalence countries, residents and employees of high-risk congregate settings,
or persons with clinical conditions that make them high risk,
such as diabetes. A positive skin test 15 mm is considered

positive in individuals with no known risk factors. These guidelines are aligned with classification of tuberculin skin test (TST)
reactions from the US Centers for Disease Control and
Prevention. Peace Corps Medical Officers (PCMOs) are trained
to account for a Volunteers pre-service history of LTBI when
reading the skin test. Alternatively, some countries test for TB
with the IGRA. There are currently two IGRAs approved by the
FDA: the QuantiFERON-TB test, which was introduced in
V
2001, and the T-SPOT .TB test, which was introduced in
2008,1416 both of which are used by Peace Corps posts opting
to test for TB using IGRA. Although the previous Peace Corps
study used the term PPD Conversions to refer to positive tuberculin skin tests in previously negative individuals, this study refers to reactive exposure as LTBI. Determination of active TB
requires a chest radiograph and assessment of symptomology
and exposure; otherwise, the case is classified as LTBI.
As individuals may serve for different lengths of time, Volunteermonths were utilized as the denominator unit of measurement to
calculate the rates of conversion and active disease in each country.
This unit of measurement reflects the number of months that
Volunteers spent in their country of service and is the customary
person-time variable used in studies of long-term travellers.
Peace Corps groups its countries of service into three regions:
Africa; Europe, Mediterranean, and Asia; and Inter-America and
Pacific. For the purposes of this study, posts were divided further
into the following categories: Europe and Central Asia, East Asia
and South Asia, Africa, Central America, Caribbean, South
America and Pacific Islands. Volunteers serving in Dominica, Saint
Lucia, Saint Vincent and the Grenadines, and Grenada and
Carriacou are collectively grouped as the Eastern Caribbean post.
Significance was assessed using a two-tailed mid-P exact statistical test. P-values < 0.05 were considered significant.
Analysis was conducted using OpenEpi 3.0.1 (Atlanta, GA) and
Stata/IC 12.0 (College Station, TX).
R

Results
Data were queried from 1 January 2006 to 31 December 2013.
During the study period, 728 516 Volunteer-months were
served, compared with the 801 781 Volunteer-months served
during the initial study. Peace Corps Response Volunteers and
Global Health Service Partnership Volunteers accounted for
8238 (1%) of the total Volunteer-months. Of the Volunteer
population during the study period, female Volunteers accounted for 60% of the population. Seventeen percent selfidentified as minorities, and the mean age at the start of service
was 33 years (median 30 years, range 2190 years). There were
689 LTBIs and 13 cases of active TB, for a rate of 0.95 conversions [95% confidence interval (CI) 0.881.02] and 0.02 cases
of active TB (95% CI 0.010.03) per 1000 Volunteer-months.
Of these, 596 LTBIs and 10 cases of active TB were diagnosed
in-service or at close of service, and 93 LTBIs and 3 cases of active TB were diagnosed after service. In countries where Peace
Corps was active during the study period, per-country LTBI incidence rates ranged from 0.00 to 4.52 cases per 1000
Volunteer-months; per-country active TB rates ranged from
0.00 to 0.78 cases per 1000 Volunteer-months. Figure 1 depicts
the rates of LTBI and active TB per 1000 Peace Corps
Volunteer-months from 2006 to 2013.

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Reported rates of LTBI range from 1.4 to 4.26 cases per 1000
person-months.10,11
PCVs are similar to long-term travellers in that they spend
an extended period of time overseas and may have similar risk
profiles to other travellers. PCVs work around the world at the
request of host countries to pursue the organizations mission of
promoting world peace and friendship through sustainable
grassroots development.12 They serve approximately 27 months
in-country, with tours consisting of 10 weeks of training followed by 24 months of service. The average age of Volunteers is
28, though there is no upper age limit.13 Currently, 7% of
Volunteers are older than age 50.13 Volunteers work in the areas
of agriculture, community economic development, education,
environment, health, youth in development, or as part of the
Peace Corps Response program.13 Volunteers live embedded in
their communities, often staying with host families during their
service. A small fraction (<1.5%) serve shorter tours as Peace
Corps Response Volunteers (312 months) or Global Health
Service Partnership Volunteers (12 months) and serve under the
same conditions as traditional 27-month Volunteers.
Due to the nature of Peace Corps service and the countries in
which PCVs serve, many Volunteers are considered to be at risk
for exposure to TB during their service. All Peace Corps applicants are required to complete a tuberculin skin test prior to beginning their service to establish a baseline reaction
measurement as part of their pre-service health screening. All
Volunteers are screened with a tuberculin skin test again at the
completion of their service, and during service if clinically indicated. During service, Peace Corps provides safe housing and
quality medical care for Volunteers, which may reduce risk.

Journal of Travel Medicine, 2015, Vol. 23, No. 1

Figure 1. Rates of LTBI and active TB per 1000 Peace Corps Volunteermonths 200613

Figure 2. Rate of LTBI and active TB per 1000 Peace Corps Volunteermonths by region 200613

Table 1. Rate of LTBI and active TB per 1000 Peace Corps Volunteer-months by region, 200613
Total Volunteermonths,
200613

Total LTBIs,
200613

LTBI rate per 1000

Volunteer-months,
200613 (95% CI)

Total active
TB cases,
200613

Active TB rate per 1000

Volunteer-months, 200613
(95% CI)

Africa

306 172

273

Caribbean

35 424

33

Central America

99 473

122

East Asia and South Asia

45 891

13

Europe and Central Asia

146 374

200

Pacific Islands

25 991

19

South America

69 191

29

728 516

689

0.89a
(0.791.00)
0.93
(0.641.31)
1.23
(1.021.46)
0.28a
(0.150.48)
1.37
(1.181.57)
0.73
(0.441.14)
0.42a
(0.280.60)
0.95a

0.02a
(0.010.04)
0.03
(0.000.16)
0.01a
(0.000.06)
0.04
(0.010.16)
0.03
(0.010.07)
0.00
(0.000.14)b
0.00
(0.000.05)b
0.02a

Total
a

1
1
2
4
0
0
13

Significant (P < 0.05) decrease from the rate observed in the previous study.
One-sided, 97.5% CI.

Table 1 depicts the regions in which PCVs served during the

study period, with total Volunteer-months served; total cases of
LTBI and active TB reported for each region during the study
period; and rates of LTBI and active TB cases reported for each
region during the study period. Figure 2 compares the rates of
LTBI and active TB in each region.
The Europe and Central Asia region had the highest rate of
LTBI, with 1.37 conversions (95% CI 1.181.57) per 1000
Volunteer-months served. Central America had the next highest
rate, at 1.23 conversions (95% CI 1.021.46) per 1000
Volunteer-months served, followed by the Caribbean, Africa
and the Pacific Islands. South America and East Asia and South
Asia had the lowest regional rates.
The East Asia and South Asia region had the highest rate of
active TB, with 0.03 cases (95% CI 0.010.16) per 1000
Volunteer-months served, followed by Europe and Central Asia,
the Caribbean and Africa. Both the South America region and
the Pacific Islands region had a rate of 0.00 (no cases of active
TB). We observed a single case of XDR TB in Ukraine during
the study period, which was successfully treated.

The WHO identifies 22 countries as high burden countries

(HBCs), which collectively account for >80% of all worldwide
cases of TB (Figure 3); these countries were originally designated based on the absolute number of TB cases they experienced and have been prioritized by the WHO since 2000.1,17
Eleven HBCs had Peace Corps programmes between 2005 and
2013: Cambodia, China, Ethiopia, Indonesia, Kenya,
Mozambique, Philippines, South Africa, Tanzania, Thailand
and Uganda. Rates of LTBI in these countries ranged from
0.00 to 2.13 cases per 1000 Volunteer-months; rates of active
disease ranged from 0.00 to 0.14. Although these countries
were classified as HBCs, with the exception of the Philippines,
none of them accounted for the highest rates of LTBI or active
TB among Volunteers.
As shown in Table 2, Peace Corps posts with the highest
rates of LTBI were Guatemala (4.52 LTBI per 1000 Volunteermonths; total of 76 conversions), Mexico (3.79; 20), Fiji (2.80;
15), Moldova (2.31; 27), Sierra Leone (2.23; 7) and Ukraine
(2.23; 73). Thirty-two percent of all LTBI among PCVs occurred at these six posts. Accounting for the number of PCVs in

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Region

Journal of Travel Medicine, 2015, Vol. 23, No. 1

each country and their length of service, the rate of LTBI among
PCVs at these six posts combined was more than four times
greater than the rate of LTBI in all other Peace Corps countries;
this difference was significant (P < 0.001).
The posts with the highest rates of active TB (Table 3) were
Liberia (0.78 cases per 1000 Volunteer-months; 2 cases), Sierra
Leone (0.32; 1), Mexico (0.19; 1), Philippines (0.14; 2) and
Azerbaijan (0.10; 1). Fifty-four percent of all cases of active TB
among PCVs occurred in these five countries. The rate of active
TB among PCVs at these five posts combined was more than 23
times greater than the rate of active TB at all other Peace Corps
posts; this difference was significant (P < 0.001).

Discussion
Rates of both LTBI and active TB among PCVs were significantly less than the rates reported in the previous study period.
The rate of LTBI was 26% less in this study period (0.95 cases
per 1000 Volunteer-months) compared with the previous study
period (1.28 cases per 1000 Volunteer-months); the difference
was significant (P < 0.001).2 The rate of active TB was 67% less
in this study period (0.02 cases per 1000 Volunteer-months)
than the previous study period (0.06 cases per 1000 Volunteermonths) (P < 0.001).2

Figure 3. WHO-identified HBCs for TB

Table 2. Peace Corps countries 200613: highest LTBI rates

Peace Corps country

Years as a Peace
Corps country

Total Volunteer-months,
200613

Total LTBIs,
200613

LTBI rate per 1000

Volunteer-months,
200613(95% CI)

Guatemala

200613

16 802

76

Mexico

200613

5272

20

Fiji

200613

5354

15

Moldova

200613

11 694

27

Sierra Leoneb

200913

3137

Ukraine

200613

32 775

73

4.52a
(3.575.66)
3.79
(2.325.85)
2.80
(1.574.62)
2.31
(1.523.36)
2.23
(0.904.59)
2.23a
(1.752.80)

Significant (P < 0.05) increase from the rate observed in Jung and Banks.2
It was not open as a Peace Corps country during the study by Jung and Banks.2

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The rates of LTBI in the regions of East Asia and South Asia,
Africa and South America were lower than the regional rates reported in the earlier study (P < 0.05). The rates of active TB in
the regions of Africa and Central America were lower than the
regional rates in the previous study (P < 0.05). No region reported significantly higher rates of LTBI or active TB.
Peace Corps Volunteers continue to have significantly higher
rates of active TB compared with the general US population
(21.41 cases per 100 000 Volunteer-years in PCVs between
2006 and 2013 compared with 3.56 cases per 100 000 personyears among 25- to 64-year olds in the USA in 2013).18 This
rate is significantly less than the rate of 68.9 per 100 000
Volunteer-years between 1996 and 2005.2 Excluding the prior
study of Jung and Banks on PCVs, there are no other published
studies reporting active rates in US-based long-term travellers,
providing no other comparison data.
In the earlier study, the posts with the highest rates of PPD
conversion (LTBI) were Hungary (5.51 conversions per 1000
Volunteer-months; total of 6 conversions), Guinea-Bissau (5.31;
6), Ethiopia (3.38; 5), Cote dIvoire (3.16; 29) and Mali (3.11;
59). In this study, we found that the posts with highest LTBI rates
were Guatemala (4.52 LTBI per 1000 Volunteer-months; total of
76 conversions), Mexico (3.79; 20), Fiji (2.80; 15), Moldova
(2.31; 27), Sierra Leone (2.23; 7) and Ukraine (2.23; 73). Of the
Peace Corps countries observed in both studies, the countries
with the highest LTBI rates in the first study had generally lower
rates in the second study period: Cameroon (3.10 vs 0.76),
Albania (2.80 vs 0.66), China (2.79 vs 0.59), etc.
The posts with the highest rates of active TB in the previous
study were all located in the Africa region: Central African
Republic (2.13 cases of active TB per 1000 Volunteer-months; 1
case), Guinea-Bissau (0.89; 1), Ethiopia (0.68; 1), Cameroon
(0.38; 6) and Botswana (0.36; 1). The posts with the highest
rates of active TB in this study showed greater geographic diversity: Liberia (0.78 cases per 1000 Volunteer-months; 2 cases),
Sierra Leone (0.32; 1), Mexico (0.19; 1), Philippines (0.14; 2)
and Azerbaijan (0.10; 1).
The ratio of LTBI to active TB differed from post to post.
For example, the Philippines exhibited one case of LTBI for

Journal of Travel Medicine, 2015, Vol. 23, No. 1

Table 3. Peace Corps countries 200613: highest active TB rates

Peace Corps country

Years as a Peace
Corps country

Total Volunteer-months,
200613

Total active
TB cases, 200613

Active TB rate per 1000

Volunteer months,
200613

Liberia

200813

2549

Sierra Leonea

200913

3137

Mexico

200613

5272

Philippinesb

200613

14 506

Azerbaijan

200613

9539

0.78
(0.102.83)
0.32
(0.011.77)
0.19
(0.001.06)
0.14
(0.020.50)
0.10
(0.000.58)

It was not open as a Peace Corps country during the study by Jung and Banks.2

WHO-identified High-Burden Country for TB.

close of service or within 3 years of recognition that a health

condition is service-related. Active cases that developed after 3
years following close of service and were not reported to Peace
Corps may have been missed.
Given the limited information available regarding risk of
LTBI and active TB in long-term US travellers to other countries, this analysis may be useful for organizations and physicians supporting these travellers despite differences in the
populations.

Funding
This project was funded within the normal operating budget of the Peace
Corps Office of Health Services.
Conflict of interest: None declared.

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Journal of Travel Medicine, 2015, Vol. 23, No. 1

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