Protection from HIV on electives: questionnaire survey of UK medical schools

Elective studies are an important part of the medical curriculum. Sixty to seventy per cent of British medical students (2400-3000 a year) spend their electives in developing countries. In 1999 the BMJ published our survey at one teaching hospital of students returning from electives, focusing on risks from bloodborne virus infections.¹ In the same edition a survey of all United Kingdom medical schools showed similar concerns and recommended a national policy on protecting medical students,² and an accompanying editorial described students on electives as “unprepared, ill advised, and at risk.” The United Kingdom health departments now recommend that healthcare workers, including medical and dental students, intending to work overseas in areas of high HIV prevalence should consider carrying starter packs of HIV postexposure prophylaxis. They also recommend that information on bloodborne virus infection control should be included in the medical curriculum.³

Methods and results

To determine whether these reports¹,² and recommendations³ had produced improvement, we designed a questionnaire for medical schools (available on bmj.com), approved by the Council of Heads of Medical Schools. It was sent in November 2000, via deans, to those providing advice on electives in all 23 British medical schools. Forms were returned by March 2001.

All but three schools had changed their elective policies with regard to bloodborne viruses as a result of our paper or the health department's advice (table). No school forbade electives in areas of high HIV prevalence. Some advised restrictions on clinical practice in areas of high HIV endemicity (13) or poor standards of supervision or infection control (15). Five schools did not recommend HIV postexposure prophylaxis starter packs, although two of these advised students against any invasive procedures, including venepuncture, in the absence of local needlestick injury protocols offering postexposure prophylaxis. Some schools did not provide written advice on vaccinations or antimalarial prophylaxis, some did not provide an immunisation service, and one provided neither. General health hazards reported during the previous three years were (in order of frequency): assault, malaria, dysentery, road traffic injuries, and schistosomiasis. Three students died, one while diving, one in a road crash, and one through carbon monoxide poisoning from a faulty gas water heater.

Comment

Although some medical schools still do not recommend HIV postexposure prophylaxis for students on electives, we think that it should be provided when indicated. Students are vaccinated against hepatitis B, and education about the risks and prevention of bloodborne viruses and the follow up of needlestick injuries, whether at home or abroad, is important throughout the curriculum. Although students on electives are more likely to be injured through trauma and violence or infected with malaria, we concentrated on the risks from HIV, since these have again been highlighted by two recent studies. One showed that in parts of sub-Saharan Africa half of adult male inpatients are HIV positive and 56% of interns had experienced penetrating injuries, 18% from HIV positive patients.⁴ One UK medical school reported that 38 out of 103 students had had significant exposure to potentially infected blood on their electives.⁵ Although we respect the views of schools who do not advise postexposure prophylaxis because self prescribing of potentially toxic drugs without supervision is too risky, a seven day course is unlikely to cause serious side effects and starter packs give students time to seek expert advice and follow up.

Schools should balance the educational advantages of electives with the health risks involved. At the very least they should provide updated advice on bloodborne virus infections, travel vaccinations, and general hazards such as unprotected sexual intercourse, assault, and political instability. Advice could be centrally provided.

Table.

Responses of the 23 medical schools returning the questionnaire on the advice they give to students on electives

Question	No of respondents answering yes	Comments
(1) Do you provide written advice on bloodborne viral infections (BBVs)?	23	Produced by mixed groups, eg virologists, microbiologists, infectious disease consultants, occupational health physicians, elective advisers
(2) Did you read our paper in the 1999 BMJ?	23
(3) Did you change your elective policy with regard to bloodborne viral infections as a result?	15	Only three schools did not change their policy as a result of either (3) or (4)
(4) Did you change your elective policy with regard to bloodborne viral infections following publication of the DoH guidelines in July 2000?	15
(5) Do you advise restrictions on clinical attachments in areas with a relatively high prevalence of HIV?	13	Restrictions included trauma, obstetrics, and surgery, particularly deep pelvic and abdominal, thoracic, and orthopaedic
(6) Do you advise restrictions on clinical attachments in areas with poor standards of infection control or supervision?	15	Two schools advised against any invasive procedures, including venepuncture, in the absence of a needlestick protocol offering HIV postexposure prophylaxis
(7) Do you advise students to take starter packs of HIV postexposure prophylaxis if appropriate?	18	Zidovudine and lamivudine (10), triple therapy (4), zidovudine (2), unspecified (2); student's pay (13)
(8) Do you provide written advice on vaccinations or antimalarials?	18	Only one school provided neither of (8) or (9)
(9) Do you provide a vaccination service?	18