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Food Control 20 (2009) 807810

Contents lists available at ScienceDirect

Food Control
journal homepage: www.elsevier.com/locate/foodcont

Assessment of personal hygiene and practices of food handlers in municipal


public schools of Natal, Brazil q
Ana Karina Couto Campos a,1, ngela Maria Soares Cardonha b,1,2, Liana Bacurau Galvo Pinheiro b,1,
Neide Rocha Ferreira b,1,2, Paulo Roberto Medeiros de Azevedo c,3, Tnia Lcia Montenegro Stamford d,*
a
Center for Health Sciences, Federal University of Rio Grande do Norte, Av. Gal. Gustavo Cordeiro de Farias, s/n, Petrpolis, 59010-180 Natal, RN, Brazil
b
Department of Nutrition, Center for Health Sciences, Federal University of Rio Grande do Norte, Av. Gal. Gustavo Cordeiro de Farias, s/n, Petrpolis, 59010-180 Natal, RN, Brazil
c
Department of Statistics, Center for the Exact and Earth Sciences, Federal University of Rio Grande do Norte, University Campus, Lagoa Nova, CEP: 59078-970 Natal, RN, Brazil
d
Department of Nutrition, Center for Health Sciences, Federal University of Pernambuco. Av. Prof. Moraes Rego, 1235, Cidade Universitria, CEP: 50670-901 Recife, PE, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: The aim of this study was to assess the hygiene practices of food handlers in municipal schools of Natal,
Received 8 May 2008 Brazil, where 27 public schools were evaluated, using a checklist and microbiological analysis of hands. It
Received in revised form 3 October 2008 was found that 74.1% of the handlers did not receive periodic training, 51.9% did not undergo annual
Accepted 12 October 2008
health examinations and 100% did not practice proper hand hygiene, a situation that reected signi-
cantly (p < 0.05) in hand contamination, in which fecal coliforms were detected on 55.6% of the hands
analyzed. It was concluded that the schools studied did not have appropriate hygienic conditions, sug-
Keywords:
gesting the need for interventions that ensure the quality of school food served to the children.
School food
Personal hygiene
2008 Published by Elsevier Ltd.
Food hygiene

1. Introduction (intoxication) in sufcient amounts to develop pathology (Souza,


Silva, & Souza, 2004).
School food is dened as that consumed daily by students at Foodborne diseases account for a considerable degree of mor-
school. It must meet the nutritional needs resulting from their en- bidity and mortality and can have various origins such as chemical
ergy expenditure. These meals must provide the organism with all and parasitic; however, microbiological sources stand out for pos-
the necessary nutrients and be safe from the hygienic-sanitary ing a great risk to public health because of the severity of the clin-
point of view (Brasil, 2004a). ical symptoms and the large number of foods and microorganisms
Food elaborated with satisfactory hygienic standards is one of that can be involved (Silva, Germano, & Germano, 2000).
the essential conditions for promoting and preserving health, and Improper handling is responsible for most cases of foodborne
inadequate control is one of the factors responsible for the occur- disease, including the inappropriate use of temperature during
rence of foodborne disease outbreaks (Oliveira, Gonalves, Shino- food preparation and conservation, cross contamination, poor per-
hara, & Stamford, 2003). sonal hygiene and inadequate equipment (Gonalves, 1998).
Foodborne disease is caused mainly by the oral ingestion of via- When food handlers do not practice proper personal hygiene or
ble microorganisms (infection) or of the toxins they produce correct food preparation, they may become vehicles for microor-
ganisms, through their hands, cuts or sores, mouth, skin and hair,
among others (Silva, Germano, & Germano, 2003).
The presence of fecal coliforms in foods indicates post-sanitiza-
q
Article based on the results of the Masters Thesis of A.K.C.CAMPOS from the tion or post-process contamination, often caused by a lack of hand
Postgraduate Program in Health Sciences, Center for Health Sciences, Federal hygienization on the part of food handlers (Oliveira et al., 2003).
University of Rio Grande do Norte, Av. Gal. Gustavo Cordeiro de Farias, s/n,
Petrpolis, 59010-180, 84-32154220 Natal, RN, Brazil.
Coliforms are microorganisms of the family Enterobacteriaceae
* Corresponding author. Address: Rua: Jader de Andrade, 335, Casa Forte, 52061- that ferment lactose and produce gas at 37 C within 48 h. How-
060 Recife, PE, Brazil. Tel.: +55 81 21268470. ever, the fecal coliform subgroup is capable of fermenting lactose
E-mail addresses: akcouto@yahoo.com.br (A.K.C. Campos), acardonha@msn.com and producing gas at 44.5 C within 24 h. These coliforms contain
(ngela Maria Soares Cardonha), prma@ccet.ufrn.br (Paulo Roberto Medeiros de
a high number of Escherichia coli (E. coli), although their exact pro-
Azevedo), tlmstamford@yahoo.com.br (T.L.M. Stamford).
1
Tel.: +55 84 32154220.
portion is unknown (Souza et al., 2004).
2
Tel.: +55 84 32154329. Escherichia coli is a bacterium found in the intestinal tract of hu-
3
Tel.: +55 84 3215 4515. mans and only some lines are considered pathogenic to man. These

0956-7135/$ - see front matter 2008 Published by Elsevier Ltd.


doi:10.1016/j.foodcont.2008.10.010
808 A.K.C. Campos et al. / Food Control 20 (2009) 807810

are divided into ve categories based on virulence, clinical syn- 275/2002 of the National Agency of Sanitary Surveillance (ANVISA)
dromes and differences in epidemiology or in OH serotypes. One (Brasil, 2002). In total, 18 items were assessed, such as the use of a
of the categories is enter hemorrhagic E. coli, which produces tox- uniform and individual protective equipment (IPE), proper body hy-
ins that cause hemorrhagic colitis and in more serious cases hemo- giene and correct attitudes, appropriate handwashing, among oth-
lytic uremic syndrome (HUS), characterized by abdominal cramps, ers (Table 1). The checklist was lled out with information
aqueous and/or bleeding diarrhea and vomiting. The risks of this provided by the food preparers at each school, as well as direct
disease are greater in the elderly and in immunodepressed chil- observation by the interviewer of the handling practices used. The
dren under 5 years of age (Ormenese, Silveira, & Silva, 1999). results were compared with ANVISA Resolution RDC 216/2004 (Bra-
Considering that fecal coliform bacteria are not found in resident sil, 2004a, 2004b) and with Codex Alimentarius, 2003.
skin ora, their study in handlers is of extreme importance, given Data collection for microbiological analysis of the hands of food
that they may be found in transitory ora. Thus, the presence of fecal handlers was performed using a swab, previously moistened in
coliforms, when detected in handlers, characterizes a situation of sterile phosphate-buffered saline and applied to the entire surface
potential risk, owing to the interrelation of these bacteria and the of the hands and between the ngers (Chistovo, 1956). Three col-
possible occurrence of enteric pathogens (Hobbs & Roberts, 1998). lections were conducted at each school on different days to better
The important measures for preventing foodborne diseases represent the data, for a total of 81 samples.
caused by inappropriate handling include training and the aware- The most likely number (MLN) of coliforms was determined at
ness of handlers about proper techniques, correct personal hy- 45 C (AOAC/02986.33), according to the ofcial analytical method
giene, health assessment, implementation and carrying out of (AOAC, 2002). The parameter recommended by Silva Jr. (2005) was
good production practices, in addition to constant supervision. used, where a satisfactory result is the absence of fecal coliforms
Given that food handlers are the main food contamination vehi- on the hands of food handlers.
cles, the results obtained in the present study aim at contributing This study was approved by the Research Ethics Committee of
with proposals for improving the School Food Program and refor- the Federal University of Rio Grande do Norte and the data were
mulating government policies in light of the problems encoun- analyzed using Statistica 7.0 software (Statistica, 2004). Descrip-
tered. The goal is to protect and promote childrens health by tive statistics were used as well as the chi-square test to determine
providing safer foods and decreasing the cases of diarrhea caused whether there was a signicant difference between two categorical
by foodborne disease, which is one of the leading causes of child variables.
mortality in developing countries, including Brazil.
3. Results
2. Material and methods
The data obtained from the checklist applied to the food prepar-
The study was conducted with handlers responsible for the pro- ers are shown in Table 1, where it can be observed that most of the
duction of school food in 27 municipal schools in Natal, Brazil items do not meet current standards.
belonging to the north (11 schools), south (3 schools) east (3 Microbiological analyses of the handlers hands showed contam-
schools) and west (10 schools) administrative districts and corre- ination in a large number of samples. The highest percentage of
sponding to 38.6% of the total number of municipal schools (70 contamination was found in the western district, followed by the
schools). southern, northern and eastern districts, as illustrated in Table 2.
The schools were selected randomly, according to the propor-
tional stratied sampling technique (Scheaffer, Mendenhall, & Ott, 4. Discussion
1995). For data collection we used microbiological analysis of the
hands and a checklist to assess the hygienic conditions and practices Training and awareness of school food handlers is a fundamen-
used by the handlers. The checklist was based on SENACs Safe Food tal condition for avoiding contamination and ensuring the quality
Program (PAS) Table Checklist (SENAC, 2001) and Resolution RDC and safety of the food produced (Pistore & Gelinskib, 2006).

Table 1
Distribution of nonconforming practices and the hygiene conditions of food handlers in municipal public schools in Natal, Brazil.a

Observations Nonconformities
N %
Periodical training 20 74.1
Presence of proper body hygiene (covered hair, short, clean, unpolished nails, no jewelry, etc.) 22 81.5
Correct hand hygiene techniques 27 100
Presence of exclusive hand wash sink 20 74.1
Proper attitudes and gestures 24 88.9
Annual health examinations 14 51.9
Handlers with wounds or infections on their hands are temporarily removed from their function 14 51.9
Use of proper uniforms (light-colored pants and blouse/shirt, correct footwear and hair protection) 27 100
Use of individual protective equipment (IPE) 27 100
Use of disposable gloves for specic activities 20 74.1
Gloves are properly stored 0 0
Use of hair protection by visitors to the food production area 27 100
Employees work exclusively in the kitchen 6 22.2
Exclusive bathroom for the handlers 23 85.2
The bathrooms are isolated from the food production area 0 0
The bathrooms have antiseptic liquid soap and paper towels, the wastebaskets are lined with plastic bags, covered and have a foot pedal for minimal 23 85.2
contact when opening the lid
The bathrooms are kept clean 14 51.9
Personal effects of the employees are kept in lockers or other suitable areas outside the kitchen 22 81.5
a
According to Codex Alimentarius (2003) and Resolution RDC 216 of ANVISA (2004).
A.K.C. Campos et al. / Food Control 20 (2009) 807810 809

Table 2 require periodical health examinations; however, the System of


Distribution of fecal coliform contamination on the hands of food handlers in Sanitary Surveillance of Brazil, through Resolution 216/2004,
municipal public schools of Natal, Brazil, by administrative district.
establishes that food handlers, regardless of presenting with
Administrative districts Samples analyzed Samples contaminated apparent infectious or parasitic diseases or not, must undergo peri-
N % odical medical examinations and are not allowed to handle food if
North 33 15 39.40
they are diagnosed with any health problem that could compro-
South 9 5 55.60 mise the quality of the food produced.
East 9 3 33.30 According to the WHO (1987), in developing countries parasit-
West 30 22 73.30 oses affect 90% of the population and more than 60% of food-re-
Total 81 45 55.6 lated diseases are caused by microbiological agents, underscoring
that food preparers are the main vehicles of this transmission (Pan-
za & Sponholz, 2008).
The Codex Alimentarius (2003) states that all individuals com- The present study observed the absence of periodical health
ing into direct or indirect contact with food must be qualied and examinations in 51.9% of the handlers interviewed. Silva et al.
must recognize their role and responsibility in protecting food (2003) found even higher values (58.3%) in the municipal school
against contamination and deterioration. It further determines that food handlers of So Paulo, Brazil. It is important to point out that
every food producing area should provide a training program that certain health conditions can permanently disqualify individuals
is revised and updated whenever needed. from being food handlers. An example is typhoid fever (Salmonella
Training has to include measures to avoid food contamination, typhi), a condition from which the individual recovers, but be-
the development and growth of microorganisms, notions about comes an asymptomatic carrier capable of contaminating foods,
good handling practices and personal hygiene, proper hygieni- mainly as a result of improper hygiene practices (Silva et al.,
zation of food, utensils and the environment, among others, to en- 2003). Therefore, it is extremely important that handlers be in
sure that food handlers are kept informed of the required good health in order to decrease the risk of food contamination.
procedures for preserving the quality of the food produced. Idowu and Rowland (2007) assessed food sellers in Nigerian
Panza and Sponholz (2008) applied the checklist and found that schools and found the presence of fecal-oral transmission parasites
after employee training the percentage of items that conformed to in 92% of the handlers studied. The authors emphasize the impor-
sanitary legislation guidelines increased considerably, underscor- tance of periodical health examinations to detect and treat parasit-
ing once again the importance of training food handlers. oses, in order to diminish the risk of food contamination by these
The present study found that 74.1% of food handlers do not re- microorganisms.
ceive periodical training, which corroborates the results of Silva A food unit must have bathrooms located at a safe distance from
et al. (2003), who reported the absence of training in 66.7% of food the food production area and for the exclusive use of food handlers
handlers in the state schools of So Paulo. (Brasil, 2004b). The present study showed that only 11.1% of the
Although training is an important instrument for applying good schools had an exclusive bathroom for the food handlers and of
practices in food and nutrition units, the conduct of food handlers these, none had direct access to the kitchen, a positive point for
is essential for maintaining food safety. In the schools studied the reducing the risk of cross contamination.
following unhygienic practices were observed: meals were pre- It was found that some of the handlers (22.2%) did not work
pared too early and were kept under ambient temperature until exclusively in the kitchen, but were also responsible for bathroom
served, utensils were stored wet, favoring microbiological prolifer- hygiene. This activity poses a risk for cross contamination, in which
ation, dirty dishcloths were used to dry utensils, increasing the risk foods or utensils may be contaminated by microorganisms often
of cross contamination. These incorrect practices may lead to food found in these areas, such as fecal coliforms, mainly if there is im-
contamination, favor the growth and development of pathogens proper hand hygiene after completing this task. However, accord-
and cause foodborne disease. ing to the handlers, to minimize the risk, this activity was
It was also observed that 33.3% of food handlers used no hair performed after food preparation.
protection. Silva et al. (2003) assessed the hygienic-sanitary condi- Data on the incidence of foodborne disease in Brazil, released by
tions of state school kitchens in So Paulo and found that hair pro- the Regional Information System for Epidemiological Surveillance
tection was not used in 25% of the units studied. of Food Borne Diseases (SIRVETA), reveal that there was a gradual
Food handlers should tie back long hair and wear appropriate increase in the number of outbreaks in schools between 1999 and
hair covering (hairnets or toques), cut their nails short and not 2001, rising from 2.3% of schools in 1999 to 4.85% and 7.25% in
wear nail polish. During handling they should remove all jewelry 2000 and 2001, respectively (Souza, 2006).
and makeup (Brasil, 2004b; Codex Alimentarius, 2003). It is known that improper handling is one of the main causes of
A study conducted with restaurant food handlers in Natal, Brazil foodborne disease and that inappropriate hand hygiene is an
found that 41.7% of the handlers had long and dirty nails, 12.5% important risk factor for food contamination.
wore jewelry such as rings and watches and 58.3% had cuts on Handlers should always wash their hands when their level of
their hands, inamed cuticles or fungi (Miranda, Damasceno, & cleanliness may affect food quality; for example: just before food
Cardonha, 2002). handling, after any interruption, after touching contaminated
The present work found higher values than those mentioned material, after using the bathroom and whenever else needed.
above, in which 81.5% of the handlers had long nails and/or wore They should not smoke, sneeze, spit, cough, eat, handle money or
nail polish and jewelry and 51.9% reported performing routine engage in any act that could contaminate the food during the per-
activities with respiratory or skin infections, in violation of current formance of their activities (Codex Alimentarius, 2003).
sanitary legislation norms. In the present study, 74.1% of the schools do not have a sink exclu-
The Codex Alimentarius (2003) determines that persons, who sively for hand washing and 100% of the handlers do not practice cor-
are known or suspected of having any disease that might be trans- rect hand hygiene, mainly because most of the sinks (81.5%) do not
mitted by food, are forbidden to handle food items. It should also have antiseptic liquid soap or paper towels. Most have bar soap and
be pointed out that any such individual must immediately inform cloth towels, both important vehicles for food contamination.
management about the disease or symptoms in addition to under- Microbiological analyses (Table 2) of the handlers hands show
going a medical examination. The Codex and the WHO do not that they were contaminated by fecal coliforms in 55.6% of the
810 A.K.C. Campos et al. / Food Control 20 (2009) 807810

samples analyzed. This result showed an association with the ab- tional Diagnosis and Reformulation of Actions, which enabled this
sence of exclusive sinks and means for hand washing, at a signi- study to be conducted
cance level of p < 0.05. To the Department of Nutrition of the Federal University of Rio
Thus, we underscore the importance of correct hand hygiene, as Grande do Norte for support in carrying out this work.
shown by Shojou, Shoooshtaripoor, and Amiri (2006), where they
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