Food Safety & Control

Food Safety In Hospitals

Dr. Adel Omara
HP

2020

High Institue Of Public Health

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Introduction
Food safety is an essential public health issue for all countries. In recent years a number of
extremely outbreaks of foodborne diseases have occurred. Many of these outbreaks have
involved more than one country, and some more than one continent. Policy-makers and
consumers in many countries are re-evaluating their strategy for food safety and the international
aspects of public health within that strategy. In every part of the world people wage a constant
battle against food contamination, foodborne diseases, and food wastage. Efforts to reduce these
survival- threatening, devastating consequences of food contamination certainly started in
prehistoric times. Cooking, smoking and simple sun drying were probably the first method used.
Other more sophisticated technologies came along like fermentation and canning. More recently,
advanced technologies in food preservation and packaging have been developed to make our
food safer. However, despite these advanced in food science and technology, the safety of our
food supply is at the beginning of the third millennium, still a cause of concern (1).

Definition of food safety:

The term “safe food” represents different ideals to different audiences. Consumers, special
interest groups, regulators, industry, and academia will have their unique descriptions based on
their perspectives. Much of the information the general public receives about food safety comes
through the media. For this reason, media perspectives on the safety of the food supply can
influence those of the general public (2).
On the other hand the terms food safety and food quality can sometimes be confusing. Food
safety refers to all those hazards, whether chronic or acute, that may make food injurious to the
health of the consumer. It is not negotiable. Quality includes all other attributes that influence a
product’s value to the consumer. This includes negative attributes such as spoilage,
contamination with filth, discoloration, off-odors and positive attributes such as the origin, color,
flavor, texture and processing method of the food. This distinction between safety and quality
has implications for public policy and influences the nature and content of the food control
system most suited to meet predetermined national objectives(3).
Food safety is used as a scientific discipline describing handling, preparation, and storage of food
in ways that prevent food-borne illness (4). It also referred to the conditions and practices that
preserve the quality of food to prevent contamination and food-borne illness (5). While FAO
defined the food safety is about handling, storing, and preparing food to prevent infection and to
help make sure that our food keeps enough nutrients for us to have healthy diet(6).

Why food safety is important to public health: According to WHO (Oct., 2016),
1. More than 200 diseases are spread through foods: 1 of 10 people fall ill every year from
eating contaminated food, and 240,000 people die each year as a result. Children under 5
years of age are at particularly high risk, with some 125,000 young children dying from
food-borne disease every year.
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2. Contaminated food can cause long-term health problems: the most common symptoms of
food-borne diseases are stomach pains, vomiting and diarrhea. Food contaminated with
heavy metals or with naturally occurring toxins can also cause long-term health problems
including cancer and neurological disorders.
3. Foodborne diseases affect vulnerable people harder than other groups: infections caused
by contaminated food have a much higher impact on populations with poor or fragile health
status and can easily lead to serious illness and deaths. For infants, pregnant women, the
sick and the elderly, the consequences of food borne disease are usually more severe and
may be fatal.
4. There are many opportunities for food contamination to take place: today`s food supply is
a complex and involves a range of different stages including on- farm production,
slaughtering or harvesting, processing, storage, transport and distribution before the food
reaches the consumers.
5. Globalization make food safety more complex and essential: globalization of food
production and trade in making the food chain longer and complicates food borne disease
outbreak investigation and product recall in case of emergency.
6. Food safety is multisectoral and multidisciplinary: to improve food safety, multitude of
different professionals is working together, making use of the best a available science and
technologies. Different governmental departments and agencies, encompassing public
health, agriculture, education and trade, need to collaborate and communicate with each
other and engage with the civil society including consumer groups.
7. Food contamination also affect the economy and society as a whole: food contamination
has far reaching effects beyond direct public health consequences- it undermines food
exports ,tourism, livelihood of food handlers and economic development, both in
developed and developing countries.
8. Some harmful bacteria are becoming resistant to drug treatments: antimicrobial resistance
is a growing global health concern. Overuse and misuse of antimicrobials in agriculture and
animal husbandry, in addition to human clinical uses, is one of the factors leading to the
emergence and spread of antimicrobial resistance. Antimicrobial-resistant bacteria in
animals may be transmitted to human via foods.
9. Everybody has a role to play in keeping food safe: food safety sharing responsibilities
between governments, industry, producers, academia, and consumers. Everyone has a role
to play. Achieving food safety is a multi-sectoral efforts requiring expertise from a range of
different disciplines- toxicological, microbiology, parasitology, nutrition, health
economics. and human and veterinary medicine, local communities, women`s groups and
school education also play an important role.
10. Consumers must be well informed on food safety practices: people should make informed
and wise food choices and adapt adequate behaviors. They should know common food
hazards and how to handle food safety, using the information provided in food labeling.(7)
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How did food become unsafe?

Food can become contaminated at any point during production ,distribution,and prepration.
Everyone along the production chain, from producer to consumer , has arole to play to ensure the
food we eat does not cause diseases.(7)

No one likes experiencing nausea, vomiting, diarrhea, or abdominal pain, but according to the
Center for Disease Control (CDC) and Prevention*, an estimated 48 million people in the US get
sick from a foodborne illness every year. This results in 128,000 hospitalizations and 3,000
deaths. Since children under 5 have less-developed immune systems and lower body weights,
they experience high rates of food-borne illnesses. People can become ill from foodborne
illnesses in a number of ways.

1. Biological contaminants, which include bacteria, viruses, parasites, toxins, and fungi, can
grow in foods that are not kept at proper temperatures. Some of these bacteria are familiar to you
from the news – Salmonella, E Coli, Listeria. Food left out at room temperature allows bacteria
to grow to levels that can cause illness. Avoid the ‘Danger Zone” (temperatures between 40°F to
140°F) where bacteria multiply and grow faster.

2. Chemical and physical contaminants can also cause foodborne illnesses. Chemical elements
include cleaning products and pesticides that may contain harmful ingredients. Physical
contaminants include glass, wood, hair, and metal, among others. If you drop a jar of jelly on the
floor and it cracks or breaks, don’t try to save any of the jelly as there may be tiny pieces of glass
in it.

3. Cross-contamination is the unintentional transfer of contaminants to a food, a food preparation

surface, or an object such as a knife. Cross-contamination also occurs when one food gets
contaminated with traces of other foods in processing plants. For example, if someone cooked
fish sticks in oil using a deep fryer they should not cook French fries in that same oil. The fries
will get contaminated with traces of seafood left in the oil and this might cause an allergic
reaction to someone allergic to seafood.

Often, contaminated food does not look bad or spoiled and does not taste different. This makes it
more difficult to identify when food has been contaminated and may make us or others sick(8).

Food safety basic principles:

Every food Establishment uses, processes, and sells food in different ways. However, the general issues
and key principles of food safety remain the same, whatever the style of the operation. All food safety
training programs should contain the “big three” factors that could cause food to become unsafe.
Food must be kept out of harm’s way from human errors, but if you don’t train food workers
what they are, they won’t know why these factors are so important to your operation. The basics
can make us or break us in one or maybe two food handling mistakes. Those basic three
principles that we must train all managers and food workers about are:
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• Personal Hygiene for Food Professionals

• Time & Temperature Control

• Cross-contamination Prevention

Professional Personal Hygiene: It’s not all common sense to everyone. Food workers must
observe the highest possible standards of personal hygiene to make certain that food does not
become contaminated by pathogenic microorganisms, physical or chemical hazards. High
standards of personal hygiene also play an important part in creating a good public image, as
well as protecting food. Hand washing, fingernails, food worker illness policy (including
exclusion of ill workers, cuts, burns, bandages, etc.), hair, uniforms, glove use, jewelry, personal
cleanliness, or unsanitary habits such as eating, drinking, smoking, or spitting are all parts of
defining personal hygiene standards. Poor hand washing is one of the leading causes of
foodborne illness. “Active Hand Hygiene” is a concept that really helps. There is a benefit to
writing down standard operating procedures for the correct hand washing method / safe hands
procedure to follow when each crewmember is trained about this crucial expectation in your
facility (i.e., 20 second hand wash, when to wash, if using a nailbrush, type of soap, hand
sanitizer, which glove or utensil for which ready-to-eat food task, etc.).

Time & Temperature Control of Foods: We can reduce bacterial growth in potentially
hazardous foods by limiting the time food is in the danger zone (140° F to 41° F) during any
steps of the food flow from receiving through service. The FDA Food Code recommendation no
more than a cumulative 4 hours in the danger zone. Use a calibrated thermometer to chart time
and temperature based upon your menu for: cold holding (41° F), hot holding (140° F), cooking
(based on the food), reheating (165° F), and cooling. Rapid cooling of hot foods (leftovers) or
foods cooked several hours advance of service is a special challenge, which allows a six hour
two stage cooling method (140° F to 70° F in 2 hours and 70° F to 41° F in 4 hours).

Cross-contamination Prevention: This is simply the transfer of harmful microorganisms or

substances to food and covers a multitude of potential food handling errors in all stages of food
flow. Cross contamination can occur at any time. The three routes: 1) food to food, 2) hands to
food, or 3) equipment to food. Ready-to-eat foods must receive the most care to prevent
contamination. (9)

Food safety in hospitals:

The importance of safe food for hospitalized patients and the detrimental effect that
contaminated food could have on their recovery has been emphasized (10). Patients receiving
foods from a single kitchen with poor food handling practices could suffer a foodborne infection
which could result in an outbreak involving the whole hospital (11). Outbreaks of foodborne
infection in hospitals are associated with high attack rates and disruption of services (12). In
2002, hospitals in The Netherlands were implicated in 9% of 281 gastroenteritis outbreaks (13).
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In Poland, the annual outbreaks of food poisoning and foodborne infections in hospitals and
sanatoria from 1985 to 1999 constituted from 1.5% to 6.3% of the total number of such
outbreaks in the country (14). A foodborne outbreak of salmonella infection at a private hospital
in London in 1994 had an attack rate estimated to be 5% among the approximately 200 patients
and staff at risk (12).
Outbreaks of foodborne infections in hospitals are preventable but are facilitated by several
factors; these include staff carriers, poor hygiene conditions in the kitchens, carelessness, and
lack of training of food handlers. The particular danger of contaminated food in hospitals is that
such food is given to consumers in poor health (15). In Bavaria, Salmonella enteritis’s outbreak
in hospitals and nursing homes resulted in 6 deaths (16), and in Australia (17), outbreaks in
hospitals and facilities caring for the aged were responsible for 35% of deaths from foodborne
infections. Hence there is a great need for education and increased awareness among food
services staff in hospitals regarding safe food handling practices (18).

The factors affected the food safety in hospitals:

1. Knowledge, attitudes and practice of food handlers
1.1 Education
1.2 Socioeconomic factor.
1.3 Gender
1.4 Years of employment
1.5 Training course
1.6 Routine medical checkup.
1.7 Food handling (reception of food ,its storage ,preparation ,cooking ,serving
2. Building and facilities (infrastructure)
2.1 Location of kitchen and its surrounding
2.2 The design and construction
2.3 Cleaning
2.4 Waste disposal
2.5 Pest control
2.6 Toilet facilities
3. equipment and utensils
3.1 Material of equipment
3.2 Condition of food equipment
3.3 Method of cleaning.

According to the WHO, foodborne disease(FBDs)in developing nations are serious because of
bad hygienic food handling methods , bad understanding and absence of infrastructure (19). This
is due to prevailing poor food handling and sanitation practices, inadequate food safety laws,
weak regulatory systems, lack of financial resources,…etc. (20). Knowledge, attitude and
practice of food handlers are important for identifying how efficient training in food safety is
allowing prioritize actions in planning training. The evaluation of KAP is the first step to
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understand the food handler’s point of view. After this evaluation other diagnostic strategy
becomes necessary to enhance this understanding (21)

Establishment of kitchen building and other facilities including: location of the kitchen and its
surroundings, the design and construction, cleaning, waste disposal, pest control , toilet facilities
,ventilation and lightening. All that details in establishment of the hospital kitchen is required to
improve the food safety system and prevent the risk of prevalence of food borne illness.
Kitchen is very important part of the foodservice facility. Kitchen floor plan, selected cooking
equipment as well as indoor climate affects a lot to productivity of the whole foodservice facility.
The problems related to kitchen layout, equipment selections, ventilation and lighting conditions
require the expertise of many specialists. Especially ventilation design is a very challenging task.
High cooling loads and air flow rates demand accurate design. In commercial kitchens it is useful
to keep heat gains as low level as possible, because heat gains have an immediate effect on air
flow rates, ventilation system requirements, thermal conditions and energy economy.

Related Studies:
One study conducted by Azanwa.J, Gebrehiwot . M, Dagna. H. Factors associated with food
safety practices among food handlers : facility- based cross sectional study to assess factors
associated with food safety practices among food handlers in Gondar city food and drinking
establishments. The facility- based cross sectional study was undertaken from March 3 to May
28,2018, in Gonder city. Gives the result of one hundred and eighty-eight (49%) had good food
handling practice out of three hundred and eighty-four food handlers. Marital status (AOR : 0.36
%, 95%CI .0.05, 0.85), safety training (AOR:4.01,95%CI.2.17,9.77), supervision by health
professional (AOR:4.10,95%CI.17.1,9.77), routine medical checkup(AOR: 8.80
,95%CI.5.04,15.36)and mean knowledge (AOR:2.92,95%CI.1.38,4.12)

Another study conducted by : Mohammed.D, El Gerges.N, Abou Jaoude.M.Food safety

knowledge , attitude and practices of food handlers in Lebanese hospitals: A cross sectional
study .this study aim to assess the food safety knowledge, attitudes and practices among food
handlers working in Lebanese hospitals and to explore the association between the obtained
scores, handler socio-demographic and working characteristics. An observational cross-sectional
study was carried out, using a semi-administered, semi-structured questionnaire interviewing 254
food handlers working in 13 different hospitals located in Beirut (n=7) and Mount Lebanon
(n=6). The mean age of the 254 recruited food handlers was 37.6 ± 10.3 years, 63.8% were
males, 60.1% had primary level education and the majority (90%) had previously received a
course on food safety in hospitals. The most incorrect practice was thawing food at room
temperature (72.8%). On average, food handlers scored 59.2%, 83.7% and 83.2% on the
knowledge, attitudes and practices questions, respectively and 75.4% on the overall knowledge,
attitude, and practice (KAP) score. Knowledge scores were significantly higher among food
handlers who attended a training course (60.8%, p=0.001), working in government and hospitals
not affiliated to university (71.3%, p=0.013 and 60.5%, p=0.013, respectively). Respondents who
served for more than 21 years in university-affiliated hospitals were significantly (p < 0.001)
more likely to have positive attitudes. The reported practices and overall KAP scores were
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significantly higher among those who had been working for more than 21 years, in government
hospitals. Men scored better than women for practices scores (85.2%, 79.6%, p=0.001).

One study is conducted by H. El Derea,1 E. Salem,1 M. Fawzi 1 and M. Abdel Azeem in

Alexandria –Egypt Safety of patient meals in 2 hospitals in Alexandria, Egypt before and after
training of food handlers,2008. The researchers assessed the food safety knowledge and food
handling practices of 23 food handlers in 2 hospitals in Alexandria, Egypt [Gamal Abdel Nasser
(GAN) and Medical Research Institute (MRI)] before and after a food safety training
programme, and also the bacteriological quality of patient meals and kitchen equipment. There
was a significant improvement in all knowledge-associated parameters except for personal
hygiene in GAN. There was an improvement in the food safety practices in both hospitals. The
bacteriological quality of most patient meals and food preparation surfaces and utensils improved
after training. The bacteriological quality of patients’ meals served in GAN was generally better
than that in MRI.

One study conducted by Yasmeen Mohamed Elsersy, Asmaa Abdel-Raheem Omar, Nehal Salah
EL- Deen Shehab El-Deen, Gamalat Mohamed Ali El-Saleet : Assessment of Food Safety in
Hospital Kitchens in Tanta City Gharbia governorate-Egypt. Its aim to assess food safety in
hospital kitchens (university and other governmental hospital kitchens) in Tanta city, Gharbia
Governorate, Egypt. Methods: A cross sectional study was conducted in 9 hospital kitchens (3
university kitchens and 6 governmental kitchens) and all food handlers in these kitchens (175)
were included in the study. Two tools were modified by the researcher to collect the needed data.
A Modified kitchen observational checklist and Food handlers' observational checklist were
used. Results: All university kitchens had insufficient application of food safety measures in both
morning and evening shifts. Regarding governmental kitchens food safety requirements; 40%
were insufficient and 60% were somewhat sufficient in morning shift, but in the evening shift
60% of kitchens were insufficient and 40% of them were somewhat sufficient. The majority of
both university and governmental food handlers had insufficient practice regarding application of
food safety measures (94.9% and 84.2%) respectively.

Study conducted by Cecilia Buccheri1, Alessandra Casuccio2, Santo Giammanco1,

Marco Giammanco1, Maurizio La Guardia1 and Caterina Mammina: Food safety in hospital:
knowledge, attitudes and practices of nursing staff of two hospitals in Sicily, Italy, the study aims
to evaluate knowledge, attitudes, and practices concerning food safety of the nursing staff of two
hospitals in Palermo, Italy. Association with some demographic and work-related determinants
was also investigated. Overall, 401 nurses (279, 37.1%, of the General Hospital and 122, 53.5%,
of the Pediatric Hospital, respectively) answered. Among the respondents there was a
generalized lack of knowledge about etiologic agents and food vehicles associated to foodborne
diseases and proper temperatures of storage of hot and cold ready to eat foods. A general positive
attitude towards temperature control and using clothing and gloves, when handling food, was
shared by the respondent’s nurses, but questions about cross-contamination, refreezing and
handling unwrapped food with cuts or abrasions on hands were frequently answered incorrectly.
The practice section performed better, though sharing of utensils for raw and uncooked foods
and thawing of frozen foods at room temperatures proved to be widely frequent among the
respondents. More than 80% of the respondent nurses did not attend any educational course on
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food hygiene. Those who attended at least one training course fared significantly better about
some knowledge issues, but no difference was detected in both the attitude and practice sections.

On the other hand, one study undertaken by Mervyn Wilson Anna E. Murray Margaret A. Black
and David A. McDowell: The implementation of hazard analysis and critical control points in
hospital catering. This paper attempts to consider the role of HACCP within hospital catering.
The necessity of eliminating the risk of hazards by the establishment of critical control points is
the prerequisite of good food hygiene practice. The above findings and suggestions for
improvement are by no means exhaustive, as each catering unit is likely to have its own
particular problems. Further analysis of the implementation of HACCP to other catering units is
required in order to paint a fuller picture of the HACCP process in action.

Also study conducted by Ahmed Fathy Hamed and Nesreen A. Mohammed: Food safety
knowledge, attitude and self-reported practices among food handlers in Sohag Governorate,
Egypt. This study aimed to determine food safety knowledge, attitude and self-reported practices
of food handlers in Sohag Governorate, Egypt, and factors affecting their knowledge, attitude
and practices. A cross-sectional study was done from May 2016 to March 2017 on 994
participants working in four randomly selected districts in Sohag Governorate. A questionnaire
was designed to obtain data about socio-demographic variables, food safety knowledge, attitude,
and practices of the participants. Results: More than 39% of the participants had good
knowledge, 61.2% had positive attitudes and 56.3% reported good food safety practices. On
univariate logistic regression, most of the variables significantly influenced participants'
knowledge. Only residence and education were significantly associated with positive attitudes.
However, none of the studied variables impacted participants’ practices. A stepwise logistic
regression identified that age, sex, residence, education, and occupation are strong predictor
variables of good knowledge. Residence and education significantly influenced positive
attitudes.

Application of Food Safety Program:

In European countries, great efforts have been expended to improve food safety at all levels of
the food chain, and new European legislation has mandated that all food operators adhere to the
Hazard Analysis and Critical Control Points (HACCP) system. HACCP is a structured and
rational approach to the analysis and prevention of potential hazard points at every stage of food
operation. It requires operators to enumerate and identify all steps in their activities that are
critical to achieving food safety and to identify and evaluate safety measures. Especially in
hospitals, food hygiene requires attention to detail in relation to all preventive measures to
minimize the hazards of food poisoning, particularly given the presence of “consumers”
(hospitalized patients at risk) who often are more vulnerable than healthy subjects. (22)

The Codex Alimentarius is a collection of internationally-adopted food standards presented

in a uniform manner. The Codex Alimentarius includes standards for all principal foods whether
processed, semiprocessed or raw for distribution to the consumer. The Codex Alimentarius
includes provisions in respect of food hygiene, food additives, pesticide residues, contaminants,
labeling and presentation, methods of analysis and sampling. Codex standards contain
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requirements for food aimed at ensuring for the consumer a sound, wholesome food product free
from adulteration, correctly labeled and presented".
In practice, this means that Codex currently produces:
 Food safety standards relating to maximum levels of pesticide residues, additives,
contaminants (including microbiological contaminants) that can be present in foods;
 Standards in the form of guidelines on processes and procedures (e.g. codes of practice,
 HACCP);
 Labeling standards that may be health-related (e.g. allergens, nutritional labeling), for
consumer fraud protection (e.g. weights and measures, date marking), or for consumer
information (e.g. halal, organic labeling);
 Commodity/product standards that define what a commodity is (e.g. species of sardines) or
how it is made and what it may contain (e.g. cheddar cheese, corned beef); and
 Quality descriptors as part of commodity standards which are often grading characteristics
(e.g. color of different types of asparagus). (23)

Food Safety Challenges:

The globalization of the food supply could potentially mean that new food safety risks can be
introduced into countries, previously controlled risks can be re-introduced into countries, and
contaminated food can be spread across greater geographical areas. However, there is no
evidence that food imported into the United States is riskier, per se, than domestically produced
food. There are many well-established food safety challenges, as well as issues perceived to be
food safety concerns, such as:

 microbial pathogens (that is, illness-causing bacteria, viruses, parasites, fungi, and their toxins),
 pesticide residues,
 food additives,
 environmental toxins, such as heavy metals (for example, lead and mercury),
 persistent organic pollutants (for example, dioxin),
 unconventional agents, such as prions associated with 'mad cow disease' in cattle,
 zoonotic diseases that can be transmitted through food from animals to humans (for example,
tuberculosis), and
 foods produced with certain practices, such as irradiation, or animal products produced with
growth hormones or antibiotics.

Seven Food Safety Regulatory Trends Commonly Found in Industrialized Nations

1. Forming one agency to focus on food safety,
2. Using risk analysis to design regulation,
3. Recognizing that a farm-to-table approach is often desirable for addressing food safety
hazards,
4. Adopting the HACCP system as a basis for new regulation of microbial pathogens in food,
5. Adopting more stringent standards for many food safety hazards,
6. Adding new and more extensive regulation to handle newly identified hazards, and,
7. Improving market performance in food safety through provision of information. (24)
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sons,2003 .P 13-855

3. FAO Food And Nutrition(2003) :Assuring Food Safety And Quality: Guidelines for
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4. Food Safety, Retrieved from: https://en.wikipedia.org/wiki/Food_safety

5. (World Health Organization[WHO],2014)Frequently Asked Questions in Food

safety .
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6. Food & Nutrition: A Handbook for Namibian Volunteer Leaders. Republic of

Namibia, Published by: Ministry of Higher Education, Training and Employment
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7. (World Health Organization[WHO],2016)10 Facts in Food Safety

Retrieved from: https://www.who.int/features/factfiles/food_safety/en/

8. (3 Types of Food Contamination and 3 Ways to Prevent Them) By: Dr. Jennifer
Rodriquez-Bosque on January 29, 2018
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3-ways-to-prevent-them/

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Courtesy from: http://www.foodservice.org/

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12. Maguire H et al. Hospital outbreak of Salmonella virchow possibly associated

with a food handler. Journal of hospital infection, 2000, 44(4):261–6.
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13. Van Duynhoven YT et al. A one-year intensified study of outbreaks of

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14. Przybylska A. [Outbreak of foodborne and waterborne infections and

intoxications in hospitals and sanatoria in Poland in 1985–1999]. Przeglad
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15. Custovic A, Ibrahimagic O. [Prevention of food poisoning in hospitals.] Medicinski

arhiv, 2005, 9(5):303–5 (abstract) [In Bosnian].

16. Heissenhuber A et al. Gehauftes Auftre-ten von Erkrankungen mit Salmonella

Enteritidis in Krankenhäusern und Altenheimen im Landkreis Oberallgau
(Bayern) im Juli 2004 [Accumulated occurrence of illnesses with Salmonella
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July 2004]. Gesundheitswesen, 2005, 67(12):845–52 (abstract).

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of catering establishments and food safety knowledge and practices of food
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23. The Procedural Manual of the Codex Alimentarius Commission states (p 28

English version)
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