Staying healthy on your elective

Written by

Professor Jangu Banatvala
Emeritus Professor of Clinical Virology

Dr Anthea Tilzey
Clinical Senior Lecturer & Elective & SSC Lead

Dr John Philpott-Howard
Senior Lecturer & Consultant in Medical Microbiology

King's College London School of Medicine

Updated by

Professor Chris Conlon
Consultant in Infectious Diseases

Dr Lucinda Barrett
Specialist Trainee in Infectious Diseases

Oxford University Hospitals NHS Trust

The last thing you want on your elective is to be unwell. Therefore you must understand the risks involved with your plans and ensure that you do the following.

• Do all that you can in preparation before you leave e.g. organise immunisations and antimalarial prophylaxis as appropriate.
• Take precautions while you're away e.g. prevention of insect bites and exposure to bloodborne viruses.
• Know what to do and who to contact in the event of problems.

Your own dental school may have detailed information about health and safety on electives. Make sure that you read this carefully and follow the advice given.

Before you leave

Medical insurance

The amount of medical cover available to residents of the UK varies around the world. Eligible travellers from the UK should obtain a European Health Insurance Card (EHIC). The card entitles you to free or reduced medical treatment costs if you fall ill or have an accident whilst visiting a European Economic Area country.

Visit gov.uk for more information on EHICs and how to apply for one.

The UK also has a reciprocal agreement with other countries around the world. It is advisable to find out if the country you're going to is included. A list of all the countries that have a reciprocal agreement can be found on the NHS Choices website, healthcare abroad. 

Don't forget that even if you're travelling to a country which has an arrangement with the UK, this may not cover all the expenses you might incur, including returning to the UK for treatment. Therefore, travel insurance is strongly recommended.

Medical insurance will usually be a part of your travel insurance. You may be expected to pay for any treatment up front and then be reimbursed by the insurance company on your return, so keep all the receipts. With this in mind you may wish to consider taking a credit card for use in emergencies. Keep the telephone number of your travel insurance company's 24-hour medical advice line with you at all times.

Accessing health information

Check at least three months in advance of travelling whether you need immunisations for your destination. Don't forget to get information about all of the areas and countries you're travelling to, even if you're only planning to be there for a few days.

In order to obtain up-to-date advice on immunisations, prophylaxis and other measures to prevent illness, visit the National Travel Health Network and Centre (NaTHNaC).

Another useful site is run by the Centers for Disease Control and Prevention. 

The following may also be helpful:

• International Medical Volunteers Association (IMVA).
• WHO International Travel and Health.
• Fit For Travel.

Travel immunisations

Although the person responsible for student health may have seen you at the beginning of your clinical studies, it is important to be sure that you're immune to hepatitis B, polio, measles, mumps, rubella, varicella, diphtheria and tetanus. You will need specific advice for the countries to which you intend to travel. You may require travel immunisations as recommended by the authorities listed above e.g. hepatitis A, typhoid, rabies, Japanese encephalitis, and yellow fever. Be sure to keep a record of any immunisations you have had.

You may arrange your vaccinations through any of the following ways.

• Your dental school may offer a service via Occupational/Student Health.
• Your GP.
• Medical Advisory Service for Travellers Abroad (MASTA).
• Hospital for Tropical Diseases Travel Clinic.
• Trailfinders London Travel Clinic.

There are a number of other commercial companies besides the ones listed above who also offer immunisation services; your travel agent may have special deals with these groups. Vaccinations can be very expensive.

Those administering the vaccines will advise about reactions and contraindications, details of which are included in the Department of Health book Immunisation against infectious disease (the 'Green Book'). As well as vaccines, you may need advice about antimalarial prophylaxis. Remember that open-ended travel may take you into high risk malarial areas, and consider your holiday destinations as well as your elective travel.

Evidence of vaccination or immunity, or freedom from infection

You may be asked for evidence of immunity to certain infections, or you can be asked for evidence to show that you're not infected.

Yellow fever

This disease has a high mortality rate and is found in parts of Africa and South America (it has never been seen in Asia but travellers entering Asia after visiting these endemic areas must also show a vaccination certificate). Once immunised, you will receive a yellow fever certificate, which you can only get from a designated yellow fever vaccination centre. Keep it safe with your passport as you may need to show this to immigration officials.

Others

A number of host institutions ask students to provide evidence of immunity to, or freedom from, a range of infections: for example, antibody tests for anti-HBs (hepatitis B virus), measles, mumps, rubella and varicella. These blood tests and reports may be arranged through your Occupational Health service or at your local hospital. It may be necessary to have a booster dose of hepatitis B vaccine or a dose of the other vaccines if you're found to be nonimmune. Some countries are now asking that visiting students are immunised against pertussis.

You may also be asked to have tests for tuberculosis. These include the tuberculin test, evidence of a BCG scar, a chest radiograph or an interferon gamma release assay (IGRA) blood test. The provision of evidence that you're free from TB is particularly problematic since many students have received BCG and so may be tuberculin-test positive (some countries consider that a positive tuberculin test means you could have latent infection). You will need to enquire carefully about the requirements of the hospital(s) where you will be based for your elective, as these vary considerably. It can be difficult, and expensive, to arrange these tests. Ask your school about what might be available in your area.

If you have been asked to provide a chest radiograph, ask the receiving hospital if they would accept a negative IGRA result instead, so that you do not have unnecessary exposure to radiation.

Screening swabs for methicillin-resistant Staphylococcus aureus (MRSA)

In some countries, healthcare workers may be asked to provide evidence that they have been screened recently for MRSA. This usually means a nasal swab (some hospitals might request a perineal or groin swab in addition). This should be done several weeks before you leave, typically in the eight weeks before you arrive at the host institution - but check their exact requirements. An MRSA screen can usually be done in your own hospital and a report is available in about two to three days. You will need a report stating that you have been screened and are negative. If you're MRSA positive you can be decolonised using topical preparations, but it may take a week or two before you can be shown to be clear, so make sure you allow enough time after the screen and before travel.

Recently, some host institutions have asked students for evidence of training in the use of facial masks. They are referring to high-efficiency masks that are sometimes used for the care of patients with severe infections caused by new strains of viruses such as influenza or coronavirus. In Europe, the masks for such cases meet a standard known as FFP2 or FFP3, whereas in North America the standard is N95. Healthcare workers using these masks must be trained and 'fit tested' i.e. a check is made that the mask is secure and functions properly. If you're asked to provide evidence of 'fit testing' it may be possible to arrange it through your student health department, or you could arrange to have it done when you arrive at the host institution. That way you can be sure that the fit testing uses the type of mask available in the hospital/practice.

Obviously you will need to organise this evidence well in advance of your travel.

Malaria prophylaxis

The morbidity and mortality associated with falciparum malaria should not be underestimated and a number of travellers returning to the UK each year die from it. If you used to live in a malaria endemic area, you will have lost immunity fairly quickly after moving to the UK. You must get up-to-date advice concerning affected areas and current prevention and treatment. Ensure that you have sought advice about prophylaxis, that you take the tablets and that you take all precautions to avoid being bitten by mosquitoes. The NaTHNaC website provides options for different antimalarial tablets according to the countries visited.

Remember the ABCD of malaria:

Awareness of risk
Behaviour - appropriate clothing, use of repellents and bed nets
Chemoprophylaxis
Diagnosis - seek urgent help if you become unwell

If you're visiting more than one malaria endemic country and the prophylaxis recommendations differ, take the prophylaxis that covers the most resistant strains of plasmodium (e.g. some countries still only require chloroquine prophylaxis, but chloroquine resistance is common in many places). It may also be worth asking the hospital you're visiting. You must start taking the prophylaxis before you leave. Also, you must continue to take the drugs for a specified period after you leave the malaria endemic country.

Always remember to take your antimalarial tablets. Set the alarm on your phone or watch! Do not be persuaded by fellow travellers to stop taking them.

HIV and other blood-borne viruses

HIV may be significantly more prevalent in the country you're visiting than at home. For example, HIV is highly prevalent in some parts of sub-Saharan Africa. You can check the prevalence of HIV by country on the WHO website.

In addition, HIV prevalence among hospital in-patients can be higher still, especially in sub-Saharan Africa. Furthermore, infection control procedures may be poor in some countries. You should follow your school's advice on HIV; many schools recommend some restrictions on practice where the prevalence of HIV is high, standards of infection control are poor and when exposure prone procedures are likely to be performed - for example complex oral surgical procedures.

You should also consider:

• having a dental check-up before you go
• taking an adequate supply of gloves, masks and eye protection if appropriate
• taking a medical emergency travellers pack.

HIV post-exposure prophylaxis (HIV PEP)

The Department of Health has issued guidance about clinical staff, including dental students on elective, who are working abroad in countries with high HIV prevalence (HIV post-exposure prophylaxis: Guidance from the UK Chief Medical Officers' Expert Advisory Group on AIDS, Department of Health, 2008). Since this guidance was issued, HIV drugs have become much more widely available worldwide, particularly in high prevalence countries. Although some dental schools will suggest you take a 7 day "starter" pack of HIV PEP medicine with you, others may provide you with advice and support to obtain PEP locally.

Your school should provide you with advice about HIV PEP, how to use a PEP pack, and what to do if you have a needle stick injury, or other exposure to blood and body fluids.

Exposures regarded as significant are percutaneous injury (from needles, instruments, bone fragments, significant bites which break the skin etc.) exposure of broken skin (abrasions, cuts, eczema etc.) and exposure of mucous membranes, including the eye, and sexual exposure.

Report any exposure as soon as possible and seek advice immediately to establish the HIV status of the source patient. If the patient is subsequently shown to be HIV negative, the PEP can be discontinued.

If the exposure is to blood or body fluids/tissues from a patient shown to be strongly suspected of being HIV positive, and a negative test result is not confirmed, you should continue to take the anti-HIV drugs for four weeks, according to the prescription. Prolonged PEP can be quite unpleasant to take and healthy individuals often feel quite unwell during this time.

You should be followed-up by a local Occupational Health Department, HIV/infectious disease physician, medical microbiologist or virologist. The starter pack will give you time to arrange a follow up and, where necessary or appropriate, for further supplies to be obtained or couriered out.

Sexual transmission of HIV is of course the most common mode of spread of the virus. Ensure that any sexual encounters are safe.

Other blood-borne viruses

Other viruses which need to be considered following a significant blood or body fluid exposure include hepatitis B and hepatitis C viruses. You should be immune to hepatitis B. With regard to hepatitis C, follow-up blood tests will be required. It is essential that following any blood or body fluid exposure you report to Occupational/Student Health on your return to the UK.

Medical kits

Many students purchase a medical emergency traveller's pack. You may wish to seek advice from your elective co-ordinator at your school or GP about additional medicines to take. These could include the following.

For diarrhoea:

• oral rehydration solution
• loperamide (not to be used if there is a dysentery-like illness including bloody diarrhoea)
• metronidazole can be effective for amoebic dysentery and Giardiasis
• ciprofloxacin can be effective for severe salmonellosis, shigellosis or campylobacter infection (however, resistance to this agent is common in some countries)
• if you feel unwell it is best to seek medical attention.

You could also consider the following:

• antiseptic cream: it is very common for insect bites to become infected with staphylococcus aureus or streptococcus pyogenes, and such infections can be severe (if infection develops, seek medical attention)
• anti-histamine cream/tablets for bites
• motion sickness tablets
• painkillers/anti-inflammatory tablets
• any other regular medications and medicines to treat personal vulnerabilities e.g. ear infections.

Carry information on your person about medical conditions you may have, medications and allergies. If you have a significant chronic condition, you should carry contact details for the doctor who normally looks after you.

Health and safety checklist