Staying healthy on your elective

Ask your hosts to familiarise you with the area e.g. the transport system, the nearest telephone and bank, a street map, personal safety issues etc. In some developing countries it may be advisable to give your details to your embassy or consulate.

Diarrhoea

In developing countries the most common health problem is diarrhoea. As the well-known saying goes, 'travel broadens the mind and loosens the bowels'. The golden rules to avoid gastro-intestinal upsets are: BOIL IT, COOK IT, PEEL IT OR FORGET IT!

Also remember to:

• drink bottled or boiled water and use it for brushing teeth and cleaning dishes
• avoid ice and also fruit and vegetables that may have been washed in contaminated water
• purify water by boiling or use purifying tablets
• wash hands before preparing or eating food
• avoid swimming in non-chlorinated pools, or in stagnant or slowly flowing water (note also that in some countries fresh water swimming carries a risk of acquiring schistosomiasis).

Bottled water is widely available but always check the seal. If you're planning remote travel then take a method of purifying water such as iodine tablets or an ultrafiltration water bottle. Most cases of diarrhoea will resolve spontaneously within 48-72 hours. The most important measure during this time is to rehydrate with sachets of sugar and electrolytes. This is extremely important since severe dehydration can be life-threatening, even in a fit young person.

If you do not have any ready-made rehydration solutions, make up your own solution following this recipe:

• eight level teaspoons of sugar
• half a teaspoon of salt
• added to one litre of boiled water.

Do not travel or work if you have significant diarrhoea, but stay at your main base. Avoid alcohol as this will add to dehydration. If diarrhoea continues, loperamide might help. If you have a high fever, the diarrhoea does not settle, or contains blood, seek medical advice promptly.

Road traffic accidents and other hazards

Unfortunately, after diarrhoea, accidents are the next most common difficulty to befall travellers. Observe general road and pedestrian safety especially when traffic flow is the opposite of that in the UK. Use seat belts in cars and wear a helmet if on a bicycle or motorbike. Hire vehicles from a reputable company and be especially vigilant at night. If using public transport or taxis, make your own assessment of the driver's fitness to drive.

Heaters and boilers in your accommodation may not be properly maintained and carbon monoxide (CO) poisoning is a serious risk. Cheap CO detectors are now available in shops. Make sure that fires and the whole room are well ventilated; turn off any gas heaters or boilers in a room in which you're sleeping. Take special care with all electrical equipment.

Sunburn and sunstroke

Use a high factor (SPF 30-50) especially in snow or near water. Wear protective sunglasses and a hat. Stay in the shade during the heat of the day and keep well hydrated by keeping your fluid intake up.

Animal bites

Try to avoid close contact with animals and seek advice before you go about whether a rabies vaccination would be appropriate for the country you're visiting. If you're bitten, seek medical advice immediately regarding post-exposure prophylaxis; use a detergent such as washing-up liquid to cleanse the wound since rabies virus is killed by detergent. If you have not received rabies vaccine before travelling, you may need post-exposure prophylaxis with vaccination and immunoglobulin. Even if you have been immunised, if there is a risk of rabies from the bite you should seek two doses of post-exposure vaccine (which is widely available worldwide) but you will not need immunoglobulin.

Remember that monkeys may transmit the herpes B virus which can cause severe and often fatal encephalitis. Aciclovir can be taken as PEP.

Ticks may be infected with rickettsiae or other pathogens and you should check your body regularly while travelling and working in rural areas.

Arthropod-borne infections

Dengue

Dengue fever is the most widely distributed arthropod-borne infection worldwide. A new vaccine is available in some countries for semi-immune people, but it is not recommended for travellers. Travellers to dengue-endemic zones should take measures to reduce exposure. The mosquitoes which transmit dengue feed during the day. Therefore, wear suitable loose-fitting clothing to protect arms and legs and use repellent during the day as well as at night. Dengue typically causes a self-limiting illness with fever, rash, headache and arthralgia, although severe illness can occur.

Chikungunya

This is becoming more common and is similar to dengue. However there is often a more marked arthralgia and sometimes arthritis in addition to the fever and headache. Precautions are the same as for dengue.

Zika

A large outbreak in South America brought zika to the world’s attention in 2015. The epidemic has since waned but this infection, like dengue and chikungunya, remains a risk for travellers and the same measures to prevent mosquito bites should be used. 

Check current guidelines with respect to conceiving a child after visiting a zika-endemic region. In 2018 UK advice was to avoid conception whilst in the region, and for eight weeks afterwards for females, and for six months afterwards for males.

Malaria

Whilst you're away avoid mosquito bites by:

• using insect repellent with DEET e.g. 55%
• spraying your room and mosquito nets with pyrethrum insecticides, or use impregnated nets
• using a bed net and inspecting for and repairing holes
• checking inside the net before going to bed
• wearing long sleeve shirts and trousers in light colours (less attractive to mosquitoes).

Be aware of the following symptoms of malaria both whilst away and several months after your return:

• fever
• headache
• flu-like aches and pains
• rigors.

Seek medical advice immediately whilst away, and when back in the UK, if you become unwell. Mention that you have travelled to a malaria endemic area.

Needlestick injury and other exposure to blood and body fluids

If you sustain a needlestick injury it can be a very harrowing experience. Try and lessen the possibility of infection by being aware of the following guidelines.

On arrival, check local protocols for exposure to blood and body fluids, and establish the local procedures.

To prevent injury:

• wear gloves
• cover wounds
• use protective eye wear 
• dispose of sharps safely 
• do not re-sheath needles
• take particular care when performing exposure-prone procedures such as surgery, especially if you cannot clearly see your fingers when suturing, for example.

While on your elective, if you have a percutaneous or mucosal exposure to potentially HIV-infected blood or other high-risk body fluid, immediately do the following.

• Encourage the wound to bleed by holding it under running water, wash it using running water and plenty of soap. Do not scrub the wound while you're washing it.
• Don't suck the wound.
• Dry the wound and cover it with a waterproof plaster or dressing.
• Irrigate contaminated conjunctivae or mucous membranes with a lot of sterile saline or clean water for 10 minutes.
• Assess whether the patient may be HIV positive or suffering from AIDS. Where possible, arrange for the patient's blood to be tested for HIV (and HBV and HCV) with the informed consent of the patient. Someone else should arrange this for you e.g. the doctor in charge of the source patient, a staff/student Occupational Health Department, a HIV/infectious disease physician, a medical microbiologist or a virologist.
• Report the incident to an appropriate authority or medically qualified person locally, and keep a copy of the accident report.
• Try to contact someone at your school as soon as possible, to report the incident, get advice if necessary and/or confirm that it is being managed appropriately locally. Determine specifically whether HIV PEP is indicated. All such incidents are treated confidentially. If PEP is indicated you must have supervision from a physician.
• Report to the Occupational/Student Health Department on your return to the UK.
• If you have been at risk of acquiring HIV infection, you should use condoms and refrain from donating blood until a blood test confirms that you're uninfected.

Safe sex

Remember that alcohol and drugs can affect your judgement. Avoid casual sexual contacts and use safe sex precautions, including condoms.

Culture shock

If your only travelling experience has been on family holidays, arriving in a new continent on your own, or with only one friend, can be a shock. Add in a dose of jet lag, unfamiliar climate, unfamiliar language, and different food and you can feel overwhelmed. Expect this and be prepared to feel a little unsettled initially. Take your time and do not begin a punishing schedule immediately. Stay in one place for a few days and ensure you get adequate rest and meals. Discuss any concerns you have with fellow travellers.

Cultural differences

If you're visiting a country with a different religion from your own, you may wish to consult a senior member of staff at the host hospital about customs which you should be aware of, especially in relation to talking and dealing with patients. Make sure your clothing is appropriate to the local cultural norms. For example, usually you should dress as smartly for the wards as you would in a UK hospital, even if the climate is hot. Some cultures will expect men and women to wear closed shoes for smartness, and it may be common to have to remove shoes frequently, so bringing some smart, lightweight shoes that are easy to slip on and off is a good idea.

Research the local cultural norms around eating as you may be lucky enough to be invited for dinner with colleagues. For example, in some cultures declining a second helping suggests you didn't like their cooking, but leaving food on your plate is acceptable as it satisfies the host that they gave you enough food. Consider bringing some small lightweight gifts from the UK.

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