Abstract:
People living with HIV are at risk of many life-threatening opportunistic infections, the
majority of which are caused by exposure to unsafe drinking water and poor hygiene.
In South Africa, hospices were established in response to the growing HIV/AIDS
pandemic. Hospice is both a programme and a philosophy of care that is dedicated
to improving the quality of life for patients with life-threatening illnesses. At the core
of a hospice’s work is the concept of “palliative care”, which is defined by the World
Health Organization (WHO) as the active total care of patients whose disease is not
responsive to curative treatment, and whose goal is the achievement of the best
quality of life for patients and their families. The need for palliative care in South
Africa has increased with the escalation of HIV/AIDS. Moreover, resources to
provide optimum quality healthcare in hospices are very limited.
Food safety, synonymous with food hygiene, embraces all aspects of food
processing, preparation and handling to ensure the safety thereof for consumption
purposes. It has also been defined as the concept that food will not cause harm to
the consumer when it is prepared and/or eaten according to the intended use. The
meals prepared in a hospice have a remarkable associated safety risk, as they are
prepared for vulnerable people who are more susceptible to foodborne illness than
the rest of the population. During food preparation, micro-organisms can
contaminate foods and storage environments, surfaces, tools, equipment and
personnel engaged in handling and production activities (Clayton, Griffith, Price,
Peters 2002 and Legnani, Leoni, Berveglieri, Mirolo and Alvaro 2003). Foodhandling
practices in the domestic kitchen influence the risk of pathogen survival and
multiplication, as well as cross-contamination to other products. Microbiological risk
in the kitchen can be significantly reduced by preparing food properly. People, food
and domestic animals, including water and bioaerosols, introduce pathogens
continually into the home. these potential pathogens can enter the domestic kitchen via various
routes, for example, raw foods and respiratory droplets. Various bacterial species
can reside in the kitchen, food preparation rooms and storage facilities, and can be
direct sources of food contamination. This is a particularly worrying issue for a
hospice setting, where meals are prepared on a regular basis every day. Moreover,
this is of great concern for a hospice set-up that has limited isolation facilities. This
highlights the important role of food handlers in the transmission of foodborne
infections, as the hands are probably the single most important transmission route.
Consequently, the overall aim of the study was to assess food-related hygiene
awareness and practices amongst hospice food handlers, and the associated food
safety interventions. The study also identified the emerging food safety risks,
including the antimicrobial susceptibility profile of potential foodborne pathogens
isolated from the food preparation surfaces in the hospice kitchens and food
handlers. In order to achieve this, the following objectives were defined for the study:
to conduct an investigation into the hygiene awareness amongst staff of HIV/AIDS
hospices using KAP (knowledge, attitudes and practices) as an information collection
tool to characterise each hospice’s microbial profile; to compose and implement an
intervention programme in selected hospices to improve the food safety awareness
and practices; and, lastly, to evaluate the effectiveness of staff’s hygiene awareness
and practice interventions.
With regard to the KAP objective, it was found that the majority (68%) of the food
handlers did not receive food safety training, whilst only 32% of the respondents had
attended at least one formal training course on food hygiene. A descriptive survey of
the food handlers’ knowledge regarding food safety demonstrated the equivalent of
66.8% correct answers. However, a substantial lack of knowledge regarding the
correct temperature for a refrigerator, as well as hot, ready-to-eat food and cold,
ready-to-eat food emerged. This was demonstrated by the fact that respectively only
39% and 32% of the respondents were informed about the correct holding
temperature of hot and cold ready-to-eat food. Again, this shows that the food
handlers in this study had insufficient knowledge regarding time temperature
controls. Similar findings on the lack of adequate knowledge of food handlers regarding
temperature controls have also been reported (Panchal, Bonhote and Dworkin
2013). This particular knowledge gap could possibly be attributed to a lack of training
of food handlers in hospices on this important food-safety control measure. The
majority (64%) of the respondents agreed that preparation of food in advance may
contribute to the risk of food poisoning, whilst 68% of respondents were aware of the
risks related to reheating dishes prior to consumption.
To determine the antimicrobial susceptibility profile of the isolated foodborne
pathogens, the minimum inhibitory concentration (MIC) was determined using the
agar dilution method of the Clinical and Laboratory Standards Institute (CLSI). It was
noted with concern that the isolated microbial strains are becoming increasingly drug
resistant. For example, a 100% resistance of Acinetobacter baumannii strains to
cefoxitin was noted. Although gentamicin is one of the most important antibiotics
used in combination with other antibiotics worldwide for the treatment of S. aureus
infections, this antibiotic was predominantly inactive against S. aureus in this study,
since 75% of the organisms were resistant (MIC >16, range ≤0.25 ->16 mg.ml-1).
Oxacillin also proved to have poor activity against the isolated organisms (MIC50 and
MIC90, 8 and >16, range (0.25->16 mg.ml-1) respectively. Transmission of antibioticresistant
bacteria in hospices and other healthcare facilities could be due to
overcrowding and poor hygiene. The development and provision of food safety
training courses are important to achieve behavioural changes, coupled with an
improvement in skills and knowledge.
Focus groups were also conducted with hospice food handlers to explore their food
safety management systems, and to identify perceived barriers to implementing food
safety practices. The following barriers were identified: lack of management support,
inadequate resources, and inconvenient location of the pantry from the kitchen.
Suboptimal kitchen infrastructure was also identified as a hurdle to implement safe
food-handling practices. In response to the increasing need to educate food handlers about their
responsibilities for assuring the safety of food during preparation and handling, food
handler training, based on the WHO’s Five Keys to Safer Foods, was implemented
as an intervention programme. Before training, 32% of food handlers believed that
the same cutting board can be used for raw and cooked foods, provided that it looks
clean, whilst 73% of respondents, after receiving training, knew that this could
hamper food safety. A hazard categorization tool was developed in the course of the
study, and it comprises five focus areas: infrastructure, food preparation facilities,
sanitation, food handler training and hospice management.