Student nurses on overseas electives often choose destinations with high health and personal safety risks. Thorough risk assessment and minimisation are therefore vital
Health profession students are encouraged to take an elective during training and many do this overseas in tropical, low-income countries. Higher education institutions should offer advice and support on organising these placements but this varies and students may present for pre-travel health advice at their general practice or travel clinic. This article discusses how they should be advised.
Citation: Driver C (2013) Health risks for students on overseas placements. Nursing Times; 109: 21, 22-24.
Author: Carolyn Driver is an independent immunisation and travel health specialist nurse in Cheshire.
- This article has been double-blind peer reviewed
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There is a lack of literature on the health outcomes of student electives overseas, but the published research shows the following:
- Around 40% choose low-income tropical destinations;
- The potential for exposure to bloodborne viruses can be significant;
- Exposure to tropical infectious diseases is likely to be greater than for tourists;
- Students can experience psychological issues due to cultural differences, lack of resources and poor support in clinical situations where expectations of their abilities may be unrealistic;
- Personal safety can be compromised;
- The likelihood of being sexually assaulted is higher than in the UK (Hunter and Sulkin, 2012; Sharafeldin et al, 2010; Miranda et al, 2005; Goldsmid et al, 2003; Franklin et al, 2001).
Pre-travel risk assessment
A pre-travel risk assessment involves gaining full information about the traveller, journey, all planned destinations and the purpose of the trip. Many students will add time for tourist travel so it is important to consider the whole trip.
Assessments can be time-consuming; Chiodini et al (2012) suggest that 20 minutes is the minimum time that should be booked for the first pre-travel consultation and longer will be necessary for more complex travellers, such as student nurses. Consultations can be more efficient if travellers complete a questionnaire beforehand so all the necessary information is to hand. Many universities encourage elective students to fill in risk assessment forms and it is useful to bring a copy to the consultation as they may include information not found on typical pre-travel questionnaires.
The assessment involves identifying potential hazards, assessing the risk then managing the risks, prioritising those with the most significant consequences. Travel health advisers need access to good online resources, including national guidelines for vaccination and malaria prevention, and mapping resources (Box 1).
Box 1. Resources
During risk assessment, it can be easy to make assumptions such as thinking students have more knowledge than they do about the risks they face. Unless they have studied tropical disease or global health, they may be naive about many risks (Sweni et al, 2010; Moss and Beeching, 1999). A further complication is conflicting information, as students may have already received “advice” from the university, the organisation their elective has been booked through, their professional body, other students or family members. Nothing should be assumed or left out, however, and travel advisers need the knowledge and confidence to ensure they give the best advice, even if this differs from some that students have already received.
To manage the risks identified in the assessment, advisers need to give both verbal and written advice in addition to undertaking interventions such as administering vaccines or issuing prescriptions for prophylactic medication. Students may arrive at their appointment expecting to receive a couple of injections or to collect a prescription, and may be surprised to hear that vaccine-preventable infections account for only approximately 1.5% of what may happen to them on their trip (Boggild et al, 2010). While vaccines are important, they are only a small part of the whole risk management plan. Advice on lifestyle and the additional risks their placement may bring are also important but time constraints may mean advisers can only highlight areas for students to research for themselves.
These will vary from student to student and depend on factors such as:
- Destination - climate, prevailing health issues in the host country;
- Geographical situation - for example is the placement in a major city, a rural location or at a high altitude?
- Accommodation - will the student be sharing accommodation with local people or with other students and what is the standard of where they will be staying - for example concerning sanitation, screening of windows, air-conditioning and mosquito nets?
- Access to potable water;
- Isolation - will the student be travelling with friends or be one of the few visitors at the location?
- Transport - local transport, road conditions at the destination and risks even as a pedestrian;
- Personal safety /accident prevention - sexual harassment and assault have been reported by students (Sweni, 2010);
- Sexual health - Sharafeldin et al (2010) found that a small percentage of the cohort in their survey had sex with a new partner native to the country they were visiting.
These will vary from student to student and depend on factors such as:
- Bloodborne viruses - the risk of HIV infection may be significantly higher than at home. Some universities ban electives in surgical and obstetric specialties in countries with a high HIV infection risk, while others place no restrictions.
All students should be aware of standard procedures for risk reduction, but should not assume they will have easy access to gloves, goggles and protective clothing during their elective. Ideally they should try to avoid exposure-prone procedures but this may not be possible.
They should find out if post-exposure prophylaxis is likely to be available, or consider taking their own; this may or may not be supplied free by their university. They should know how and when to use it and have a plan for any follow-up action necessary. They should be advised to have a contact number for someone from their university or find out if their placement supervisor will be able to organise further treatment.
A comprehensive dental check-up before travel minimises the need for dental attention while away, which also reduces the risk of acquiring bloodborne viruses.
Students should also be aware of their professional responsibility to report possible exposure while abroad upon their return to the UK. Hunter and Sulkin (2012) raise concerns that this issue is poorly managed in general.
- Exposure to infectious diseases - students should be aware of current problems at their destination and the importance of food and water precautions, insect bite avoidance, schistosomiasis and rabies risk, and good general hand hygiene.
- Climate - students should be reminded of the importance of sun protection and hydration in hot climates.
- Psychological - students may face language barriers, cultural differences socially and at work, insufficient resources in the workplace and poor support in clinical situations where they are expected to carry out procedures they may not feel competent to do (Petrosoniak, 2010). These type of problems should be discussed with their UK supervisors before the trip so they can be advised on ways to manage these situations.
They should also research their destination thoroughly and try to prepare for what they may find; this could involve speaking to students who have done a similar placement.
First aid kit
Students should take their own comprehensive first aid kit, as it is not safe to assume they will have access to even basic medications and dressings at their placement. Suggestions for what this should contain can be found at fitfortravel.
Travel insurance and professional indemnity
A good comprehensive policy that covers students for their specific destination and all planned activities is essential.
This may involve checking with their usual professional indemnity provider that they are covered while abroad and, if not, taking out specific cover; these are offered by some professional organisations, while the Royal College of Nursing membership covers student electives.
Completing a risk assessment
Students should have considered much of the above if they have done their own risk assessments. However, universities vary considerably in ensuring students do this (Moss and Beeching, 1999) and, without much of this information, it can be difficult for travel health advisers to make accurate recommendations; it is therefore not unreasonable to request students complete this activity before returning for specific advice.
Healthcare students will generally be up to date with UK vaccinations but the adviser should not assume this to be the case.
Specific recommendations for travel vaccinations will depend on their destinations and vaccine history; students should, if possible, present their vaccination record. Country-specific information can be found on TRAVAX or NaTHNaC, and should be used in conjunction with information from the risk assessment.
Consideration should be given to students’ living conditions and any recreational travel plans they may have.
Advisers should research thoroughly the immunisations required, but should generally follow the guidance below:
- Those visiting the Indian subcontinent or any resource-poor country should be protected against hepatitis A and typhoid;
- They should be educated about the risk of rabies and understand the benefits of pre-exposure vaccination. Being on placement at a large hospital will not automatically guarantee that rabies immunoglobulin will be available. Even if it is, it may be equine derived, which carries increased risks of adverse effects. Once they have the full facts, students can make a choice but, whatever they decide, they should know what action to take if bitten or scratched by an animal;
- Those travelling to Sub-Saharan Africa or the Amazonian region of South America are likely to require yellow fever vaccination;
- Students visiting Sub-Saharan Africa should be advised to be protected against meningitis ACW135Y. They should have received the meningitis C vaccine as part of the UK schedule but meningitis A and W135 prevail in Africa;
- Cholera vaccine is usually recommended for those travelling to areas where the disease is endemic or there has been a recent outbreak if they will be unable to access potable water or observe sensible food precautions. It would be appropriate for students going to remote rural placements rather than to major cities;
- Japanese encephalitis vaccination is recommended for those planning to spend considerable time in rural farming communities in South-East Asia;
- Tick-borne encephalitis occurs in the more rural parts of Europe; it is a risk in eastern Europe, the Baltic states, Russia, Mongolia and northern China. It is more likely to be a hazard for students planning trekking holidays in those areas after their elective.
To establish the level of malaria risk, health advisers need specific information about the locations to be visited, so they can decide whether to recommend chemoprophylaxis or if bite avoidance alone will suffice.
Budget may sometimes influence students’ choice of drug but it is important they select a product they can commit to taking consistently. In a study of students on elective placements abroad, Sharafeldin et al (2010) found that a significant number of those taking mefloquine stopped because of side-effects and one of these went on to develop malaria. Adverse events usually manifest within the first couple of weeks, so trialling the drug for three weeks before departure can help to identify problems and allow time for an alternative to be prescribed. Some students in this study also stopped atovoquone and proguanil early; this was generally because of a shortage of tablets or simply forgetting to take them.
It is important to emphasise malaria risk during the consultation and to ensure students understand the importance of adherence to chemoprophylaxis regimens. They should seek prompt medical evaluation if they develop a fever during the trip or for a year afterwards as malaria occasionally occurs months after infection.
Bite avoidance is important for all travellers, regardless of malaria risk, as many other diseases can be transmitted via mosquitos or other insects. If air conditioning is not available or reliable, students travelling in tropical countries should sleep under a permethrin-treated bed net and use an insect repellent containing diethyl-N-toluamide (DEET) on all exposed skin. This should be applied day and night as different insects vary in biting times. Protective clothing will also reduce the chances of being bitten and cotton fabrics can be treated with permethrin to increase protection.
Existing health problems
Students with health problems such as asthma, diabetes and epilepsy need to be aware of how a change in climate and activity may affect their condition, and have an effective self-management plan.
They may also need to consider how to manage their medication while crossing time zones, and should carry a doctor’s letter confirming their need to carry any sharps or other equipment they may need while travelling.
They should be sure that their insurer is aware of their condition and that their insurance covers any problems it could cause.
Organisations such as Diabetes UK, Asthma UK and Epilepsy Action all have sections on their websites advising on overseas travel, and can often advise on insurers who offer reasonably priced policies.
While overseas electives can be valuable experiences for health students, they need to prepare carefully for their time abroad and not underestimate the physical and psychological challenges their placement may present.
While universities have a responsibility to advise students about planning this stage of their course, the reality is that support is variable and, if students seek advice from their general practice or travel clinic, a thorough risk assessment should be done to ensure all aspects of the trip have been considered.
- Around 40% of students undertaking elective placements abroad choose a low-income, tropical destination
- Elective students are at a greater risk from bloodborne viruses and tropical diseases than general tourists
- A pre-travel risk assessment should take at least 20 minutes
- Students should ensure they are insured for all planned activities
- Malaria prophylaxis can be started before departure, to assess if the drug selected is suitable
Boggild AK et al (2010) Vaccine preventable diseases in returned international travellers: results from the GeoSentinal Surveillance network. Vaccine; 28, 7389-7395.
Chiodini J et al (2012) Travel Health Nursing: Career and Competence Development. RCN Guidance. London: RCN.
Franklin GF et al (2001) Provison of drugs for post-exposure prophylaxis of HIV for medical students on overseas electives. Journal of Infection; 43, 191-194.
Goldsmid JM et al (2003) A preliminary study on travel health issues of medical students undertaking electives. Journal of Travel Medicine; 10, 160-163.
Hunter J, Sulkin T (2012) Potential exposure of medical students to blood borne viruses on medical elective and the use of HIV post exposure prophylaxis. Journal of Infection; 65: 2, 185-187.
Miranda JJ et al (2005) International health electives: four years of experience. Travel Medicine and Infectious Disease; 3, 133-141.
Moss PJ, Beeching N (1999) Provision of health advice for UK medical students planning to travel overseas for their elective study period: questionnaire survey. British Medical Journal; 318, 161-162.
Petrosoniak A (2010) International health electives: thematic results of student and professional interviews. Medical Education; 44, 683-689.
Sharafeldin E (2010) Health risks encountered by Dutch medical students during an elective in the tropics and the quality and comprehensiveness of pre and post-travel care. BMC Medical Education; 10, 89.
Sweni S (2010) Attitude and practice of medical students studying in Hungary and India toward health during overseas and domestic travel. Travel Medicine and Infectious Disease; 8, 51-55.