Table 4 Recommendations for travel doctors undertaking occupational risk management for medical electives

General

Advise students that occupational risks are accentuated by various factors, including greater demands and opportunities to perform invasive procedures, poorly resourced work areas, lack of personal protective equipment, fatigue from activities, and often greater caseloads compared with prior experiences in home institutions.

[90]

Tuberculosis

Inform students that tuberculosis (TB) is common in lower income countries, particularly in sub-Saharan Africa, Papua New Guinea, and the poorer regions of Asia and South America. Multidrug-resistant tuberculosis is a notable emerging threat. Medical students are commonly exposed to TB while on their medical electives.

[36, 91,92,93,94]

Educate students on modes of transmission of TB and minimisation of exposure risk, particularly through the wearing of high-filtration masks. Enlighten students about potential obstacles to risk avoidance, including lack of adequately ventilated rooms, delays in suspected case identification, limited diagnostic facilities, reluctance to wear masks, limited resources for directly observed therapy, and reliance on passive case finding.

[36, 95, 96]

Undertake baseline testing for latent TB infection prior to departure (interferon gamma release assay or tuberculin skin testing).

[97]

Consider BCG vaccination in students not previously vaccinated, especially if working in TB wards in countries with high rates of multidrug or extended-drug-resistant TB.

[98]

Recommend follow-up testing for TB infection 8–12 weeks after return. The object of testing is to identify and treat students who have been recently infected and who are thus at significant risk of progression to clinical disease.

[36]

Blood-Borne Viruses

Ensure that students are aware that blood-borne viruses are common in many elective destinations and that occupational exposures occur in elective students. Students should be aware of their own HIV, HBV and HCV serological status (including proven immunity to hepatitis B) and should know the principles of risk management when performing invasive procedures.

[99,100,101,102]

Expect all sharps injuries to be managed according to guidelines, including cleansing of the wound, incident reporting and documenting, baseline testing of source patients and exposed persons, consideration of post-exposure prophylaxis (PEP) and follow-up serological testing.

[103]

Ensure that PEP for HIV infection is available to students where the risk of occupational exposure is significant. Students must be prepared to make quick decisions regarding empiric commencement of PEP – ideally within two hours of any incident. Consider PrEP for higher risk situations.

[101, 104, 105]

Ensure that students have been vaccinated against hepatitis B unless naturally immune or already chronically infected. Students who are uncertain about their hepatitis B serostatus should be tested.

[106, 107]

Personal violence

Ensure that students are aware of the risk of personal violence in clinical settings. Advise students to remain vigilant at all times for the warning signs of patient distress and aggressive behaviour. Inform students that they must withdraw from potentially violent situations and seek immediate advice and support from colleagues and supervisors.

[28, 108]

Other Diseases

Given the typically short duration and high stakes nature of electives, encourage a high degree of vigilance to minimize the risk of food and water-borne diseases.

[109]

Recommend vaccination against hepatitis A unless vaccinated or proven to be immune from natural infection.

[107]

Consider vaccination against typhoid fever, the actual risk of infection varying somewhat from region to region.

[107]

Consider cholera vaccination if travelling to areas affected by humanitarian crises or notable high-risk regions. The vaccine may also afford cross-protection against traveller’s diarrhoea due to enterotoxigenic Escherichia coli.

[107]

Ensure up-to-date vaccination against influenza, varicella, diphtheria, tetanus, pertussis, measles, mumps, rubella and poliomyelitis.

[110,111,112]

Consider vaccination against meningococcal disease, owing to potential exposure to clinical cases and likely exposure to new serotypes in the general community. Essential for students travelling to the ‘meningitis belt’ of equatorial Africa.

[112, 113]

Ensure guidelines for prevention of other exotic diseases are followed, including those for arboviral and other mosquito-borne (particularly yellow fever, Ebola, dengue, Zika and malaria) and rabies.

[107]

Emotional wellbeing

Recognize risk factors for emotional distress include travelling alone, prior mental illness, low levels of resilience, insufficient pre-departure training and perceived or actual lack of support during the elective. Adequate preparation, in-country support and post-return debriefing are likely to reduce emotional distress arising from situations experienced on an elective.

[47, 58]