Food hygiene risks and related practices in central South African HIV/AIDS hospices : a qualitative assessment

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.