Food Sanitation Dr Ragaa Shawky Assistant Professor Community

Food Sanitation Dr. Ragaa Shawky Assistant Professor Community Medicine Department

Definition & Objectives Food sanitation is a component of environmental sanitation, to provide the community with sound food. Sound food must be: n Safe n Retains its natural properties.

1) Safe Food is a pollution-free food, i. e. free of: § Radioactive contamination. § Poisonous metals as lead, arsenic, mercury. § Toxic chemicals as insecticides. § Natural poisons in some food as mushrooms. Infection: pathogenic organisms infective stages of parasites. § § Bacterial exotoxins. and

2) Retains its natural quality: normal physical and chemical properties, and not spoiled. Food borne diseases is caused by consuming contaminated food or beverages n

Principles of Food Sanitation 1) Food establishments: restaurants, canteens, food shops and stores and other public places for preparation, serving, selling or storing food are licensed after fulfilling sanitary requirements, and periodically inspected. 2) Food articles and utensils: used for processing, cooking, serving, storing and canning of food. They must be made of safe material, and kept clean and protected.

Principles of Food Sanitation 3) Food handlers: they are responsible for preparation, transport, selling or serving food to the public. Reservoirs of infection may contaminate food and so must be eliminated. 4) Consumers: a few simple precautions can reduce the risk of food borne diseases: COOK, SEPARATE, CHILL, CLEAN and REPORT

Principles of Food Sanitation COOK: meat, poultry and eggs to be sure that it is cooked sufficiently to kill bacteria, for example: § - Ground beef should be cooked to an internal temperature of 160° F. - Eggs should be cooked until the yolk is firm. SEPARATE: don't cross-contaminate one food with another By: washing hands, utensils, and cutting boards after they have been in contact with raw meat or poultry and before they touch another food. §

CHILL: Refrigerate leftovers well. Bacteria can grow quickly at room temperature, so refrigerate extra foods if they are not going to be eaten within 4 hours. § § CLEAN: Wash product. - Rinse fresh fruits and vegetables in running tap water to remove visible dirt and grime. - Remove and discard the outermost leaves of a head of lettuce or cabbage. - Because bacteria can grow well on the cut surface of fruit or vegetable, be careful not to contaminate these foods while slicing them up on the cutting board.

- Don't be a source of food borne illness yourself. - Wash your hands with soap and water before preparing food. - Avoid preparing food for others if yourself have a diarrheal illness. - Changing a baby's diaper while preparing food is a bad idea that can easily spread illness. REPORT: Report suspected food borne illnesses to your local department. §

Principles of Food Sanitation 5) Food stuff: Foods on the market must fulfill requirements of sanitary regulations (physical, chemical and biological), and regularly inspected and sampled for quality.

In 1998, an investigation was done for a gastroenteritis outbreak among employees of a company who complained of sever diarrhea, vomiting and raise in temperature. An association was found between the disease and eating sandwiches prepared by 6 food handlers. 1 - Enumerate the main causes of food-borne disease? 2 - What are the measures of food sanitation? 3 - What are the measures that should be done for food handlers?

Causes of Food-borne Disease A) Natural Toxins: e. g. Shellfish toxins, mushroom toxins, aflatoxins, potatoes. B) Microorganisms (Pathogens): 1 - Viral diseases: e. g. Poliomyelitis, Viral Hepatitis (A&E), Rota virus, Enterovirus, Adenovirus. 2 - Bacterial diseases: e. g. Enteric fevers, Brucella, Salmonella, Shigella, Botulism, Infectious food Poisoning, Cholera, E. coli. 3 - Parasitic diseases: e. g. Ascariasis, Entrobiasis, Taeniasis, Giardiasis, Ameobiasis, Cryptosporidium. 4 - Other pathogenic agents: e. g. Prions.

Measures that should be done for Food Handlers Pre-employment examination: those free of infection should be: n - TAB vaccinated (of limited preventive value) and Licensed (given certificate to work in food handling). - Health education: for personal cleanliness and good habits (especially clean hands). n

Measures that should be done for Food Handlers Supervision at work: to follow clean habits, and to screen suspected cases of disease. n Periodic examination and booster TAB vaccination: given license is valid for two years, and so must be renewed as long as the handler works in food handling. n

Examination of Food Handlers 1) Clinical Examination: To diagnose staphylococcal lesions of skin, and screen cases of suspected pulmonary tuberculosis. n To diagnose infective skin diseases, as scabies (not transmitted by food). n

Examination of Food Handlers 2) Laboratory Examination: n Urine: culture for typhoid-paratyphoid and sediment examined for schistosoma eggs, not transmitted by food). n Stool Examination: -Culture for Salmonellae (typhoidal and nontyphoidal), and Shigellae, but no examination for viruses. -Smear for Parasites eggs of: Enterobius, Hymenolepis nana and Taenia solium. Parasites cysts of intestinal protozoa: Entamoeba histolytica, Balantidium coli and Giardia lamblia.

N. B: eggs of Ascaris, Schistosoma, Ancylostoma, Taenia saginata and Heterophyes heterophyes, not transmitted through handlers. Swabbing of Throat and Nose: For Streptococcus haemolyticus, Staphylococcus aureus and Corynebacterium diphtheriae, with virulence testing of diphtheria-positives. n

Examination of Food Handlers 3) Hygienic practices of food handlers: n Personal cleanliness. n Sanitary protective clothing. n Tobacco, gums and food are not permitted during food handling. n Open cuts or wounds should be completely protected by a secure water proof covering before handle any food. n Through hand washing with soap after handling contaminated materials and after toilet.

Diarrheal Diseases (Gastro Enteritis)

Diarrheal Diseases (Gastro Enteritis) n n A clinical syndrome of different aetiology affecting GIT and associated with frequent loose or watery stools, vomiting & fever. Diarrhea is defined as passage of three or more loose or watery stools in 24 hours. Or a single loose or watery stool containing blood. In breastfed infants, who normally pass several soft or semi liquid stools each day, diarrhea as an increase in stool frequency or liquidity that is considered abnormal by mother.

Clinical Types of diarrhea 1. Acute watery diarrhea: Begins acutely, lasts <14 days and involves passage of frequent loose or watery stools without visible blood. 2. Chronic diarrhea: >14 days with remission & exacerbation. 3. Dysentery: Diarrhea with visible blood in the stools. 4. Persistent diarrhea: Begins acutely but lasts >14 days without remission & exacerbation. Laboratory investigations: stool culture to identify the cause

Case Assessment A. History: n n n n n Personal history : Name, age, sex & address. Diarrhea : Frequency, consistency, duration & bloody stool. Vomiting : Frequency, duration & colour. Urination : Last time urine passed. Thirst. Feeding & fluid intake : Time, amount taken & type. Other complaints : Cough, measles, ear problems & fever. Previous treatment during this episodes : ORS, drugs taken. Vaccination history.

B. Weigh: 1. To assess the degree of dehydration. 2. To estimate the amount of fluid required for initial rehydration. N. B. : Weight loss will be equal to the amount of loss of water by the body ( 1 gm weight loss = 1 ml water lost ). C. Temperature: - Fever may be due to: a) Infectious diarrhea. b) Associated infection as otitis media or pneumonia. c) Dehydration (disappears after rehydration). D. Examination: to detect * Presence & severity of dehydration. * Accompanying conditions Pneumonia, otitis media& undernutrition. * Complications e. g. ileal paralysis.

Signs A B C Fluid loss < 5 % of body weight 5 -9% ≥ 10 % Look at condition Well & alert Restless & irritable Lethargic or unconscious Eyes Normal Sunken Very sunken & dry Tears Present Absent Mouth & tongue Moist Dry Very Dry Thirst & drinking Not thirsty Thirsty , drinks eagerly Drinks poorly Skin pinch Goes back quickly Goes back slowly Goes back very slowly Pulse - As dehydration increases Radial & femoral pulses become more rapid. ( In severe dehydration weak & may be undetectable ). Breathing - Rapid deep breathing is a sign of acidosis. - In pneumonia, the breathing is rapid but not deep, cough is usually present & lower chest indrawing may be observed. Anterior fontanelle - Normal , depressed or very depressed. Limbs Skin becomes cool & moist. ( Nail beds may be cyanosed ). Decision making Patient has no signs of dehydration If patient has 2 or more signs If the patient has 2 or more signs Treatment: Use treatment plan A Use treatment plan B Use treatment plan C ( Arms & legs)

Treatment plans: 1. Treatment plan A : Management of diarrhea at home. 2. Treatment plan B : for patients with some dehydration. 3. Treatment plan C : for patients with severe dehydration.

Treatment plan A Aim To treat diarrhea at home. A. Food : - If the child is breast feeding Continue breast feeding. - If the child is not breast feeding Give usual milk. - If the child is > 6 months * Give starchy food mixed with vegetables, meat or fish ( if possible). * Add 1 -2 tea spoonful of vegetable oil to each serving. - K + Fresh fruit juice or mashed banana. - Offer food at least 6 times / day + Extra meal for 2 w after stoppage of diarrhea. B. Fluids : 1. ORS ( oral rehydration solution ) 75 ml / each loose stool 2. Rice water. 3. Soup. 4. Orange juice. 5. Yoghurt.

C. Follow up for the following symptoms : n Repeated vomiting. Persistence of fever. Persistence of diarrhea. Eating or drinking poorly. Marked thirst. n Blood in stool. n n

Treatment plan B Aim To treat dehydration within 4 hours. A. Food As plan A. B. Fluid As plan A except : ORS 75 ml / Kg then observation for any problem : * If the child vomits Wait 10 minutes & then continue ORS but at a slower rate ( a spoonful / 2 -3 min). * If the child's eye lids becomes puffy Stop ORS and give plain H 2 o or breast milk then when puffiness is gone give ORS as plain A.

C. Follow up for reassessment. - After 4 hours Reassess child using assessment charts : * If no signs of dehydration Shift to plan A. N. B When dehydration corrected, the child usually passes urine & may be tired & fall asleep ( = signs of improvement ). * If signs of dehydration are still present Repeat plan B, but start to offer food, milk & juice as described in plan A. * If signs indicating severe dehydration shift to plan C.

Advice given to mother during treatment plan B : 1. Show her how much ORS to give to finish the 4 hours treatment. 2. Give her enough ORS packets to complete rehydration therapy at home as plan A ( for 2 more days ). 3. Show her how to mix & give ORS : * A spoonful / 1 -2 min for children < 2 ys or sips from a cup for older children. * If vomiting A spoonful / 2 -3 min. * If diarrhea continues & ORS packets used up Give other home fluids. 4. Explain to mother 3 rules for treating diarrhea at home : * Food * Fluid * Follow up

Conditions in which we give children ORS at home : 1 - After treatment plan B or C. 2 - If they can't return to health worker with diarrhea gets worse. 3 - National policy to give ORS for all diarrhea children.

Treatment plan C Aim To treat severe dehydration quickly : * Children with severe dehydration should be treated urgently to avoid death from hypovolemic shock. * Treatment should be undertaken in hospital by experienced personnal. Steps : 1. Give ORS by mouth while I. V drip is set up. 2. Give 100 ml / Kg Ringers Lactant solution (if not available , normal saline ) 3. Reassess the patient every 1 -2 hours. 4. If dehydration is not improving give I. V. drip more rapidly. 5. Also give ORS ( 5 ml/kg/ hour ) as soon the patient can drink. 6. After 6 hours ( in infant ) or 3 hours ( in older patients ) evaluate patient using assessment charts then continue treatment according to the appropriate plan ( A, B or C ).

Indications of giving ORS by nasogastric tube ( 20 ml /Kg/ h for 6 hours ) 120 ml /kg 1234 - Repeated vomiting. Refusal of ORS or unable to drink. ↑ Stool output that exceeds ORS input. Exhausted mother. Indication of I. V. poly electrolyte sol. ( PES) or RINGER'S therapy. 1234 - Severe dehydration ( plan C ) Failure of oral rehydration. Paralytic illues. Unable to drink ( as in coma ).

n n Yacin is 9 months old. He weighs 5 kg. His temperature is 36. 8 C. He is at the clinic today because his mother and father are concerned about his diarrhoea. He has had diarrhoea for 5 days, the father said. They have not seen any blood in the stool. Yacin is not restless or irritable. He is not lethargic or unconscious. His eyes are not sunken. He is thirsty and eager to take the drink of water offered to him. His skin pinch goes back slowly. n n He does not have an ear problem. He does not have a fever.

1. Assess the condition of the child? 2. What plan of management should he have? 3. Calculate the amount of ORS required? 4. What should you do if the child has vomiting

Fatma is 18 months old. She weighs 11. 5 kg. Her temperature is 37. 5 °C. The health worker asked, “What are the child’s problems? ” The mother said “Fatma has diarrhea since 3 days. There was no blood in the stool. Fatma’s eyes looked sunken. The health worker asked, “Do you notice anything different about Fatma’s eyes? ” The mother said, “Yes. ” He gave the mother some clean water in a cup and asked her to offer it to Fatma. When offered the cup, Fatma would able to drink. When pinched, the skin of Fatma’s abdomen went back very slowly.

1. Assess the condition of the child? 2. What plan of management should he have? 3. What is the frequency of child assessment?

n n n Ali is 9 months old. He weighs 9. 5 kg. His temperature is 39. 5 C. His mother says he has had diarrhoea for 1 week. Ali does not have any general danger signs. The health worker assessed Ali for signs of diarrhoea. The mother said earlier that Ali has had diarrhoea for 1 week. Ali does not have blood in the stool. He is not restless or irritable; he is not lethargic or unconscious. He has sunken eyes. He is not thirsty and drinks normally when offered a drink. His skin pinch goes back quickly.

1. Assess the condition of the child? 2. What plan of management should he have? 3. Calculate the amount of ORS required?

National Control of Diarrhea Disease Program (NCDDP)

II. Implementation : Prevention: A. General Prevention: 1. Environmental sanitation. 2. Health education of the public: Sanitary preparation of artificial fed infant. Supplementary food to improve the nutritional status of children. Encourage breast feeding: exclusive 4 -6 month. Hand washing About mode of transmission of diseases & method of prevention. B. Specific Prevention: - Compulsory immunization against the main preventable diseases which may be complicated by 2 ry gastroenteritis

I. Case: n n n Control: Early case finding Notification to local health office Isolation with enteric precaution at home or in hospitals in severe cases. Disinfection: concurrent + terminal (of stool & soiled articles). Treatment: Oral rehydration therapy (ORT): Feeding of infants & children: Chemotherapy. n Release after cure. II. Contacts: n n Health education. Investigation of contacts & source of infection.

III. Evaluation of NCDDP: 1) ORS equipment. 2) Recording & reporting 3) Percentage cases referred for NGT or IV therapy: No of children referred X 100 monthly/ No of children with diarrhea

4) Service indicators : No of ORS packets dispensed/ No of diarrhea cases

5) Mortality impact indicators: n n MR Diarrhea – specific IMR Preschool child (1 -5 ys) DR Diarrhea specific DR 6) Community indicators: n * Mother's knowledge, attitude and skills.

Examples: An infant aged 4 months passes 6 motions of loose stool/ day. He is irritable, has dry mouth and skin pinch goes back slowly. 1 -What plan you will follow in his treatment? a- Plan A b- Plan B c- Plan C 2 -How much ORS you will give him? a- 50 ml/ each loose stool b- 75 ml/ each loose stool c- 75 ml/kg