Food Food SanitationSanitationDr. Ragaa ShawkyDr. Ragaa Shawky

Assistant ProfessorAssistant Professor

Community Medicine Community Medicine DepartmentDepartment

Definition &Definition & ObjectivesObjectives

Food sanitationFood sanitation is a component of is a component of environmental sanitation, to environmental sanitation, to provide the community with sound provide the community with sound food.food.

Sound food must be: Sound food must be: Safe Safe

Retains its natural properties.Retains its natural properties.

1) 1) Safe FoodSafe Food is a pollution-free is a pollution-free food, i.e. free of:food, i.e. free of:

Radioactive contamination. Radioactive contamination.

Poisonous metals as lead, arsenic, Poisonous metals as lead, arsenic, mercury. mercury.

Toxic chemicals as insecticides.Toxic chemicals as insecticides. Natural poisons in some food as Natural poisons in some food as mushrooms. mushrooms.

Infection: pathogenic organisms and Infection: pathogenic organisms and infective stages of parasites. infective stages of parasites. Bacterial exotoxins. Bacterial exotoxins.

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

Principles of Food Principles of Food SanitationSanitation

1)1) Food establishmentsFood establishments: : restaurants, restaurants, canteens, food shops and stores and other canteens, food shops and stores and other public places for preparation, serving, selling public places for preparation, serving, selling or storing food are licensed after fulfilling or storing food are licensed after fulfilling sanitary requirements, and periodically sanitary requirements, and periodically inspected. inspected.

2)2) Food articles and utensilsFood articles and utensils:: used for used for processing, cooking, serving, storing and processing, cooking, serving, storing and canning of food. They must be made of safe canning of food. They must be made of safe material, and kept clean and protected. material, and kept clean and protected.

Principles of Food Principles of Food SanitationSanitation

3)3) Food handlers:Food handlers: they are responsible for they are responsible for preparation, transport, selling or serving preparation, transport, selling or serving food to the public. Reservoirs of infection food to the public. Reservoirs of infection may contaminate food and so must be may contaminate food and so must be eliminated. eliminated.

4)4) Consumers:Consumers: a few simple precautions a few simple precautions can reduce the risk of food borne diseases:can reduce the risk of food borne diseases:

COOK, SEPARATE, CHILL, CLEAN and COOK, SEPARATE, CHILL, CLEAN and REPORT REPORT

Principles of Food Principles of Food SanitationSanitation

COOK:COOK: meat, poultry and eggs to be sure that meat, poultry and eggs to be sure that it is cooked sufficiently to kill bacteria, it is cooked sufficiently to kill bacteria, for for example: example:

- Ground beef - Ground beef should be cooked to an internal should be cooked to an internal temperature of 160° F. temperature of 160° F.

- Eggs - Eggs should be cooked until the yolk is firm.should be cooked until the yolk is firm.

SEPARATE:SEPARATE: don't cross-contaminate one food don't cross-contaminate one food with another with another By:By: washing hands, utensils, and cutting boards washing hands, utensils, and cutting boards after they have been in contact with raw meat after they have been in contact with raw meat or poultry and before they touch another food. or poultry and before they touch another food.

CHILL:CHILL: Refrigerate leftovers well. Refrigerate leftovers well.Bacteria can grow quickly at room temperature, Bacteria can grow quickly at room temperature,

so refrigerate extra foods if they are not going so refrigerate extra foods if they are not going to be eaten within 4 hours.to be eaten within 4 hours.

CLEAN:CLEAN: Wash product. Wash product.

- Rinse fresh fruits and vegetables in running tap - Rinse fresh fruits and vegetables in running tap water to remove visible dirt and grime. water to remove visible dirt and grime.

- Remove and discard the outermost leaves of a - Remove and discard the outermost leaves of a head of lettuce or cabbage. head of lettuce or cabbage.

- Because bacteria can grow well on the cut surface - Because bacteria can grow well on the cut surface of fruit or vegetable, be careful not to of fruit or vegetable, be careful not to contaminate these foods while slicing them up on contaminate these foods while slicing them up on the cutting board . the cutting board .

- Don't be a source of food borne illness yourself.- Don't be a source of food borne illness yourself.

- Wash your hands with soap and water before - Wash your hands with soap and water before preparing food.preparing food.

- Avoid preparing food for others if you yourself - Avoid preparing food for others if you yourself have a diarrheal illness.have a diarrheal illness.

- Changing a baby's diaper while preparing food - Changing a baby's diaper while preparing food is a bad idea that can easily spread illness. is a bad idea that can easily spread illness.

REPORT:REPORT: Report suspected food borne Report suspected food borne illnesses to your local department. illnesses to your local department.

Principles of Food Principles of Food SanitationSanitation

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

In 1998, an investigation was done for aIn 1998, an investigation was done for a gastro-enteritis outbreak among gastro-enteritis outbreak among employees of a company who complained employees of a company who complained of sever diarrhea, vomiting and raise in of sever diarrhea, vomiting and raise in temperature. An association was found temperature. An association was found between the disease and eating between the disease and eating sandwiches prepared by 6 food handlers.sandwiches prepared by 6 food handlers.

1- Enumerate the main causes of food-borne 1- Enumerate the main causes of food-borne disease?disease?

2- What are the measures of food sanitation?2- What are the measures of food sanitation?

3- What are the measures that should be done 3- What are the measures that should be done for food handlers?for food handlers?

Causes of Food-borne Causes of Food-borne DiseaseDiseaseA) A) Natural Toxins:Natural Toxins: e.g. Shellfish toxins, e.g. Shellfish toxins, mushroom toxins, aflatoxins, potatoes. mushroom toxins, aflatoxins, potatoes.

B) B) Microorganisms (Pathogens):Microorganisms (Pathogens):

1- Viral diseases: 1- Viral diseases: e.g. Poliomyelitis, Viral Hepatitis e.g. Poliomyelitis, Viral Hepatitis (A&E), Rota virus, Enterovirus, Adenovirus. (A&E), Rota virus, Enterovirus, Adenovirus.

2- Bacterial diseases: 2- Bacterial diseases: e.g. Enteric fevers, Brucella, e.g. Enteric fevers, Brucella, Salmonella, Shigella, Botulism, Infectious food Salmonella, Shigella, Botulism, Infectious food Poisoning, Cholera, E. coli. Poisoning, Cholera, E. coli.

3- Parasitic diseases: 3- Parasitic diseases: e.g. Ascariasis, Entrobiasis, e.g. Ascariasis, Entrobiasis, Taeniasis, Giardiasis, Ameobiasis, Cryptosporidium. Taeniasis, Giardiasis, Ameobiasis, Cryptosporidium.

4- Other pathogenic agents: 4- Other pathogenic agents: e.g. Prions. e.g. Prions.

Measures that should be done Measures that should be done for for Food HandlersFood Handlers

Pre-employment examination:Pre-employment examination: those those free of infection should be:free of infection should be:- TAB vaccinated (of limited preventive TAB vaccinated (of limited preventive value) andvalue) and

- Licensed (given certificate to work in food Licensed (given certificate to work in food handling). handling).

Health education: Health education: for personal for personal cleanliness and good habits (especially clean cleanliness and good habits (especially clean hands). hands).

Measures that should be done Measures that should be done for for Food HandlersFood Handlers

Supervision at work: Supervision at work: to follow clean to follow clean habits, and to screen suspected cases of habits, and to screen suspected cases of disease. disease.

Periodic examination and booster TAB Periodic examination and booster TAB vaccination: vaccination: given license is valid for two given license is valid for two years, and so must be renewed as long as years, and so must be renewed as long as the handler works in food handling. the handler works in food handling.

Examination of Food Examination of Food HandlersHandlers

1) Clinical Examination:1) Clinical Examination: To diagnose staphylococcal lesions of skin, To diagnose staphylococcal lesions of skin, and screen cases of suspected pulmonary and screen cases of suspected pulmonary tuberculosis. tuberculosis.

To diagnose infective skin diseases, as To diagnose infective skin diseases, as scabies (not transmitted by food). scabies (not transmitted by food).

Examination of Food HandlersExamination of Food Handlers

2) Laboratory Examination:2) Laboratory Examination: UrineUrine:: culture for typhoid-paratyphoid and culture for typhoid-paratyphoid and

sediment examined for schistosoma eggs, not sediment examined for schistosoma eggs, not transmitted by food).transmitted by food).

Stool ExaminationStool Examination: : --CultureCulture for Salmonellae (typhoidal and nontyphoidal), for Salmonellae (typhoidal and nontyphoidal),

and Shigellae, but no examination for viruses.and Shigellae, but no examination for viruses.

--SmearSmear forfor Parasites eggs of: Parasites eggs of: Enterobius, Hymenolepis nana Enterobius, Hymenolepis nana

and Taenia solium.and Taenia solium.

Parasites cysts of intestinal protozoa: Parasites cysts of intestinal protozoa: Entamoeba Entamoeba histolytica, Balantidium coli and Giardia lamblia. histolytica, Balantidium coli and Giardia lamblia.

..

N.B: N.B: eggs of eggs of Ascaris, Schistosoma, Ascaris, Schistosoma,

Ancylostoma, Taenia saginata and Ancylostoma, Taenia saginata and

Heterophyes heterophyes, Heterophyes heterophyes, not transmitted not transmitted

through handlers.through handlers.

Swabbing of Throat and Nose:Swabbing of Throat and Nose:

ForFor Streptococcus haemolyticus, Streptococcus haemolyticus,

Staphylococcus aureus and Corynebacterium Staphylococcus aureus and Corynebacterium

diphtheriae, with virulence testing of diphtheriae, with virulence testing of

diphtheria-positives. diphtheria-positives.

Examination of Food Examination of Food HandlersHandlers

3) Hygienic practices of food 3) Hygienic practices of food handlers:handlers: Personal cleanliness.Personal cleanliness.

Sanitary protective clothing.Sanitary protective clothing.

TobaccoTobacco, , gums and food gums and food are not permitted are not permitted during food handling.during food handling.

Open cuts or wounds Open cuts or wounds should be completely should be completely protected by a secure water proof covering protected by a secure water proof covering before handle any food. before handle any food.

Through hand washing with soap Through hand washing with soap after after handling contaminated materials and after toilet. handling contaminated materials and after toilet.

Diarrheal Diarrheal Diseases Diseases (Gastro

Enteritis)

Diarrheal Diseases (Gastro Enteritis)

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 diarrhea1. 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 Case AssessmentAssessment

A. HistoryA. History:: Personal history : Name, age, sex & address.Personal history : Name, age, sex & address.

Diarrhea : Frequency, consistency, duration & bloody stool.Diarrhea : Frequency, consistency, duration & bloody stool. Vomiting : Frequency, duration & colour .Vomiting : Frequency, duration & colour . Urination : Last time urine passed .Urination : Last time urine passed . Thirst. Thirst. FeedingFeeding & & fluid intakefluid intake : Time, amount taken & type. : Time, amount taken & type. Other complaints : Cough, measles, ear problems & fever.Other complaints : Cough, measles, ear problems & fever.

Previous treatmentPrevious treatment during this episodes : ORS, drugs taken. during this episodes : ORS, drugs taken. Vaccination history.Vaccination history.

B. B. Weigh: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. C. Temperature:Temperature: - Fever may be due to: a) Infectious diarrhea. b) Associated infection as otitis media or pneumonia. c) Dehydration (disappears after rehydration).

D.D. Examination:Examination: to detect * Presence & severity of dehydration. * Accompanying conditions Pneumonia, otitis media& undernutrition . * Complications e.g. ileal paralysis.

SignsA BCFluid loss >5 % of body weight5-9% ≥10%

Look at condition

Well & alertRestless & irritableLethargic or unconscious

EyesNormalSunkenVery sunken & dry

TearsPresentAbsentAbsent

Mouth & tongue

MoistDryVery Dry

Thirst & drinking

Not thirstyThirsty , drinks eagerlyDrinks poorly

Skin pinchGoes back quickly Goes back slowlyGoes 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( Arms & legs)

Skin becomes cool & moist. ( Nail beds may be cyanosed ).

Decisionmaking

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 AUse treatment plan B Use treatment plan C

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 2w 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 :

Repeated vomiting . Persistence of fever . Persistence of diarrhea . Eating or drinking poorly . Marked thirst.

Blood in stool.

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 H2o 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 < 2ys 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 ( 5ml/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

1- Repeated vomiting . 2- Refusal of ORS or unable to drink . 3- ↑ Stool output that exceeds ORS input . 4- Exhausted mother . Indication of I.V. poly electrolyte sol . ( PES)

or RINGER'S therapy . 1- Severe dehydration ( plan C ) 2- Failure of oral rehydration . 3- Paralytic illues . 4- Unable to drink ( as in coma ).

Yacin is 9 months old. He weighs 5 kg. His Yacin is 9 months old. He weighs 5 kg. His temperature is 36.8temperature is 36.8C. He is at the clinic today C. He is at the clinic today because his mother and father are concerned because his mother and father are concerned about his diarrhoea.about his diarrhoea.

He has had diarrhoea for 5 days, the father He has had diarrhoea for 5 days, the father said. They have not seen any blood in the said. They have not seen any blood in the stool. Yacin is not restless or irritable. He is stool. Yacin is not restless or irritable. He is not lethargic or unconscious. His eyes are not not lethargic or unconscious. His eyes are not sunken. He is thirsty and eager to take the sunken. He is thirsty and eager to take the drink of water offered to him. His skin pinch drink of water offered to him. His skin pinch goes back slowly. goes back slowly.

   He does not have an ear problem. He does not He does not have an ear problem. He does not

have a fever. have a fever.

1.1. Assess the condition of the child?Assess the condition of the child?

2.2. What plan of management should he What plan of management should he

have?have?

3.3. Calculate the amount of ORS required?Calculate the amount of ORS required?

4.4. What should you do if the child has What should you do if the child has

vomitingvomiting

Fatma is 18 months old. She weighs 11.5 kg. Fatma is 18 months old. She weighs 11.5 kg. Her temperature is 37.5 °C. The health Her temperature is 37.5 °C. The health worker asked, “What are the child’s worker asked, “What are the child’s problems?” The mother said “Fatma has problems?” The mother said “Fatma has diarrhea since 3days.diarrhea since 3days.

There was no blood in the stool. Fatma’s eyes There was no blood in the stool. Fatma’s eyes looked sunken. The health worker asked, looked sunken. The health worker asked, “Do you notice anything different about “Do you notice anything different about Fatma’s eyes?” The mother said, “Yes.” He Fatma’s eyes?” The mother said, “Yes.” He gave the mother some clean water in a gave the mother some clean water in a cup and asked her to offer it to Fatma. cup and asked her to offer it to Fatma. When offered the cup, Fatma would able to When offered the cup, Fatma would able to drink. When pinched, the skin of Fatma’s drink. When pinched, the skin of Fatma’s abdomen went back very slowly.abdomen went back very slowly.

1.1. Assess the condition of the child?Assess the condition of the child?

2.2. What plan of management should he What plan of management should he

have?have?

3.3. What is the frequency of child What is the frequency of child

assessment?assessment?

Ali is 9 months old. He weighs 9.5 kg. His Ali is 9 months old. He weighs 9.5 kg. His temperature is 39.5temperature is 39.5C. His mother says he has C. His mother says he has had diarrhoea for 1 week. had diarrhoea for 1 week.

Ali does not have any general danger signs. Ali does not have any general danger signs.

   The health worker assessed Ali for signs of The health worker assessed Ali for signs of

diarrhoea. The mother said earlier that Ali has diarrhoea. The mother said earlier that Ali has had diarrhoea for 1 week. Ali does not have had diarrhoea for 1 week. Ali does not have blood in the stool. He is not restless or blood in the stool. He is not restless or irritable; he is not lethargic or unconscious. He irritable; he is not lethargic or unconscious. He has sunken eyes. He is not thirsty and drinks has sunken eyes. He is not thirsty and drinks normally when offered a drink. His skin pinch normally when offered a drink. His skin pinch goes back quickly.goes back quickly.

1.1. Assess the condition of the child?Assess the condition of the child?

2.2. What plan of management should he What plan of management should he

have?have?

3.3. Calculate the amount of ORS required?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 2ry gastroenteritis

Control:I. Case: 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. Release after cure.

II. Contacts: 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:

MR Diarrhea – specific IMR Preschool child (1-5ys) DR Diarrhea specific DR

6) Community indicators: * 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 stoolb- 75 ml/ each loose stool c- 75 ml/kg