Hazard Analysis and Critical Control Point Evaluation of School Food Programs in Bahrain

Transcription

1 282 Journal of Food Protection, Vol. 59, No.3, Pages Copyright, International Association of Milk, Food and Environmental Sanitarians Hazard Analysis and Critical Control Point Evaluation of School Food Programs in Bahrain ABDULLA A. ALJI* and NICK J. SPENCER2 IPublic Health Program, College o.t"health Sciences, Manama, Bahrain; and 2School of Postgraduate Medical Education, University of Warwick, Coventry, UK CV4 7AL (MS#95-58: Received I March 1995/Accepted 11 September 1995) ABSTRACT Hazard analyses were conducted in six food preparation sites and 16 school canteens in the State of Bahrain. Sandwiches made with cheese, meat, eggs, liver, and beef burgers were prepared in small shops or a bakery outside schools. Foods were cooked between 4 and 5 A.M. Time-temperature exposure during cooking was adequate to kill vegetative microbes and their spores, but potential for recontamination existed from the hands of food workers, utensils, and cloths and sponges used for wiping. All foods were left at room temperature before they were transported in vans to schools where they were also kept at room temperature between 17 C and 41 C. Air temperature inside the canteens during this investigation was between 18.5 and 28 C with a relative humidity of 65 to 70%. Hazard analyses, which included observation of operations inside school canteens and sites of food preparation, measuring temperatures, and interviewing workers and consumers (teachers, students) were carried out. Hazards were primarily associated with preparation of foods long before they were consumed, physical touching of products, and holding foods at room temperature after preparation. Holding foods at room temperature would have allowed germination of bacterial spores and multiplication of microbes. Reheating of foods was not practiced. Health promoters must be aware of these hazards and need to educate food workers, administrators, and the public on the methods of prevention. develop- Key words: HACCP, school food safety, food poisoning, ing nations, Bahrain Foodborne illnesses are problems that threaten developing as well as developed countries (24). Although reports on foodborne diseases are often inadequate and outbreak incidents are usually underreported, many large outbreaks have been documented which resulted in great losses and suffering for victims, societies, and countries, In Bahrain, for example, several large outbreaks have occurred lately; many people have suffered ill health and one death was documented (1,2,20). * Author for correspondence: School of Postgraduate Medical Education, University of Warwick, Coventry, UK CV4 7AL. Tel: , ext. 3913; Fax: Although there are no adequate epidemiological data about the risk of foodborne illnesses in Bahrain, epidemiological investigations have shown that foods of animal origin such as meat, poultry, milk, eggs, and their products are often contaminated with pathogenic microorganisms and have frequently been identified as vehicles in outbreaks of food poisoning in developed countries (6, 10, 18). Cooking, holding cooked food at room temperature, cooling and reheating cooked foods are critical points especially if temperatures and time are not regulated (5, 8, 9, 13, 18). Hazard analyses and epidemiological studies (5, 8, 9, 16, 18, 21) have revealed that foods prepared in advance and kept at room temperatures for a long time (6 h or more) show a massive increase in bacterial counts, reaching a critical level (i.e., a dose that may cause foodborne illness; for example, as low as 10 3 for Salmonella spp.) (3, 4). Hence, these foods are considered high risk. This is especially true in countries such as Bahrain which has a climate in which summer temperatures reach 40 C and winter temperatures are as low as 11 C; relative humidity reaches 85% in the summer. A hazard analysis and critical control point (HACCP) program is a detailed and systematic investigation used in food production, preparation, and distribution sites (i) to control microbiological hazards associated with food, (ii) to ensure quality and wholesomeness of food, and (iii) to avoid many weaknesses associated with the traditional approach to inspection (9, 19, 21). Hazard analyses have successfully been implemented in many food preparation plants, restaurants, and street vending operations (7,9,12,13,14,15,17, 21). To assess microbiological hazards associated with foods eaten in Bahrain's schools, hazard analyses were conducted in school canteens and at the sites of food preparation. Initially the aim was (i) to determine possible sources of food contamination, modes of contamination, and survival and multiplication of microbes; (ii) to assess the food preparation procedures that affect contamination and survival and multiplication of microbes within school canteens; (iii) to identify critical control points; and (iv) to suggest appropriate preventive measures. However, having found that foods are prepared outside of the canteens by private contractors, the investigation was expanded to assess foods

2 HACCP ANALYSIS OF SCHOOL FOOD PROGRAMS IN BAHRAIN 283 at the sites of preparation. The study emphasized both the operation within each canteen and food preparation site and the physical structure of the canteens that might interfere with the safety of foods, with greater emphasis on operation and handling. MATERIALS AND METHODS Description of contractors Foods for the 16 schools were prepared by six private contractors. Places for food preparation were different with each contractor. Two contractors (A and B) prepared food in small shops. The kitchen in each shop was small (ca. 2.5 by 3 m), containing a deep freezer, refrigerator, and two gas stoves. The kitchen was used to store raw foods, to prepare and cook meat and other products, and to hold foods before transporting to schools. Two other contractors (C and D) prepared food in slightly bigger shops. They consisted of two rooms: one room for storing raw foods, preparation, cooking and storing part of the cooked foods, and the other for storage of cooked foods and displaying other foods for sale to the public. Another contractor (E) prepared foods in a bakery which consisted of three rooms. One room was used for preparing and cooking foods; a second room was used for wrapping and holding foods before transporting to schools; and the third room was used for displaying other cooked foods for sale to the public. Another contractor (F) prepared foods in a factory in which packaging was mechanical (i.e., there was no direct handling of food by workers). This one was not assessed in this study as special permission was not obtained to make the assessment. Contractors A, B, C, D, and E supplied foods to 5, 8, 13, 38 and 6 schools, respectively. Each school received from 180 to 690 cooked food items. Foods sold were similar in each school. They consisted of sandwiches that contained eggs, cheese, chicken, liver, minced beef, mutton balls (Kofteh), hamburgers, or beef kebabs. Lettuce and tomatoes were added to the sandwiches in eight schools by contractors A and D, whereas mayonnaise was used in two schools by contractor A. Contractor C prepared beef macaroni and donuts. All schools sold confectioneries, soft drinks and juice. The types of foods prepared by each contractor are listed in Table 1. School canteens Every school in Bahrain has a canteen or a cafeteria which is mainly constructed of cement and bricks. Only one school has a wooden canteen. Gas is used for cooking fuel. Tap water for cleaning and hand washing is available inside the canteens but toilets are not available as a part of the canteen environment except in one school. Workers use students' or teachers' toilets which in most cases do not contain warm water and soap. Cooking and hot TABLE 1. Types of food prepared and/or supplied by each contractor for schools in Bahrain Contractors A, B, C, D, E. B. A. C. A, D. All contractors. Types of foods Eggs, cheese, chicken, liver, minced beef (sandwiches) Mutton ball sandwiches Hamburger, beef kebab, mayonnaise (sandwiches) Macaroni, donuts Salads in sandwiches Confectioneries, drinks TABLE 2. Description of school canteens in Bahrain; n = 16 Availability of items (Comments) Yes (%) No (%) Cold water 14(87.5) 2 (12.5) Hot water 6 (37.5) 10 (62.5) Clean food contact surfaces 14(87.5) 2 (12.5) Clean floors 14(87.5) 2 (12.5) Cooking facilities 0 16 (100) Refrigerators (for drinks, ice 16 (100) 0 cream only) Hot holding facilities 0 16 (100) Food storage facilities 0 16 (100) Toilets 1 (6.35) 15 (93.8) Toilets were clean 6 (37.5) 10 (62.5) Toilets had hot water 8 (50) 8 (50) Toilets had cold water 16 (100) 0 Toilets with soap 6 (37.5) 10 (62.5) Insects present in canteens 4 (25) 12 (75) (flies were seen) Refuse containers available 6 (37.5) 10 (62.5) (all schools: outside canteen structure) holding facilities are not available in the canteens. Refrigerators are available but are used for cold drinks and ice creams only. A description of a typical canteen's structure is shown in Table 2. The average number of workers in each of the 16 canteens is three, comprising 32.3% Arabs, 25.8% Bengalis, 6.5% Sri Lankans, 25.4% Indians, and 10% Pakistanis. The workers from the Indian subcontinent were deficient in the Arabic and English languages. Hazard analyses Hazard analyses were conducted in 16 school canteens and six food-preparation sites which supply foods to the schools. School canteens and food preparation sites were evaluated in detail through observation of operations. Cooking temperatures were measured in one shop only (contractor A). As itis not the practice to eat raw foods or half-cooked foods of animal origin in Bahrain, deep frying and cooking of foods are universally used and one site could be taken as typical of all sites. Holding temperatures were measured for all foods in all canteens and food-preparation sites at different intervals (2, 4, 6, and 8 hours after cooking). Air temperatures were also recorded, using a digital thermometer with two separate sensor probes, one for the food and the other for air. During measurement of food temperature, the probe was placed in the center of the sandwiches and covered entirely (13). Students and faculty were interviewed regarding the quality of foods. Food workers were asked if they had any training in food hygiene. This study is a part of a wider research project to study food hygiene and food poisoning in Bahrain. It is one of few to study food safety in such detail in the Gulf region. RESULTS Preparation started between 9:00 P.M. and 12:00 A.M. for all contractors. Cooking started between 4:00 and 5:30 A.M. for contractors A, B, C, and D. For contractor E, cooking started at 2:30 A.M. Table 3 shows the times of preparation, cooking, arrival, and sales at six schools. Arrival and sales at the other schools were around the same times.

3 284 ALI AND SPENCER TABLE 3. Times of preparation, cooking, arrival at schools and sales in Bahrain by five contractors Arrived at Contractors Preparation Cooking schools Sold until A 11:00 P.M. 5:00 A.M. 9:00 A.M. 5:30 P.M. B 12:00 A.M. 5:30 A.M. 6:30 A.M. 10:40 A.M. e 11:30 P.M. 4:00 A.M. 7:00 A.M. 10:40 A.M. D 12:00 A.M. 4:30 A.M. 9:30 A.M. 10:20 A.M. E 9:00 P.M. 2:30 A.M. 9:45 A.M. 9:50 A.M. Foods were transported with no cooling system in vans or in the back of cars in cartons, plastic boxes, or plastic bags and arrived at the schools between 7:00 and 9:45 A.M. The distance over which food was transported is approximately 2 to 6 miles at a temperature of ca. 19 C. Sales started at 9:50 A.M. during the break. Fourteen schools sold food until 10:40 A.M., one school until 1:30 P.M., and the other until 5:00 P.M. The times of each part of the process are shown in Table 3. Deep frying was used to cook meat and liver in large frying pans. Meat was fried at 180 C and 205 C for 10 to 15 min. Liver was fried at the same temperatures but for 5 to 10 min. Hamburgers were fried on both sides on a hot plate at a temperature of 285 C for 5 min. Cooking temperatures were high enough to inactivate vegetative microbes and spores (18). At the site of preparation, cooking and holding were critical control points. Touching breads and buns and filling sandwiches with salads offered opportunities for contamination. The environment of the canteens and the places where foods were prepared were found to be critical to food safety in which opportunities for recontamination and multiplication of microbes existed due to (i) the size of these shops for the amount of foods prepared, according to the standards given by the Sports Council (23); (ii) handling and touching foods when filling sandwiches; and (iii) the presence of favorable temperatures (i.e., 17 C to 40 C). Holding foods at ambient temperatures was the most serious hazard noticed. The operation processes in the place of preparation and the environmental conditions are illustrated in Figure 1. This figure is a display of places, hazards, and critical control points. At schools, sandwiches and donuts were displayed in carton boxes, plastic containers, or plastic bags, and macaroni was put in small plastic containers in carton boxes. The minimum holding temperature measured for food was 17 C and the maximum was 41.5 C. The first holding temperature was measured ca. 2 h after cooking. Temperatures were also measured at ca. 4, 6, and 8 h after cooking. Four hours after cooking, food temperatures dropped to around room temperature. Table 4 shows the average temperatures of food and air inside the canteens at 2, 4, 6, and 8 h after cooking. Foods were found to be within such temperature ranges for several hours (2 to 10 h). Microbes tend to multiply rapidly in a temperature range of 20 C to 46 C and reach numbers ~ CC ~DD <f-~vrc RC C C)CC+M FIGURE 1. Flow diagram for preparation of sandwiches in schools and food preparation sites. CC, contamination is likely to be present; RC, recontamination is likely; D.D., microbial destruction is likely; M, microbes are likely to multiply; CCp, critical control point.

4 HACCP ANALYSIS OF SCHOOL FOOD PROGRAMS IN BAHRAIN 285 TABLE 4. Average holding temperatures of foods measured at different intervals after cooking as compared to air in preparation sites and in schools' canteens Food temperature after cooking (0C) 2h 4h 6h Air Preparation School School temperature Schools sites canteens canteens (0C) NMa NM NM NM NM NM Median temperature a NM, not measured. sufficiently high to cause foodborne illness in 4 to 6 h (15, 18). Foods were not reheated. Holding temperatures of foods at different intervals are illustrated in Fig. 2. Students in all schools except One were dissatisfied and complained about foods being cold, old, tough, and sometimes unhygienic, containing foreign contaminants such as hair, nails, sand, and glass. Three students attributed bouts of diarrhea to eating sandwiches in school. Teachers in three schools were totally dissatisfied with the quality of food. In other schools, however, teachers were more concerned about the nutritional value of foods and suggested alternative foods. Food workers stated that they did not receive any training in food safety before or during their work. Hours after cooking FIGURE 2. Cooking and holding temperatures of sandwiches and hamburgers in preparation sites and in school canteens. DISCUSSION Raw chicken, meat, eggs, and their products are often contaminated with pathogenic microbes and incriminated in foodborne disease outbreaks. Information from developed countries where surveillance data are available have shown the risk of such food items. In this study, although sampling was not done, the potential for pathogenic microbial contamination, germination, and multiplication exists because of high holding temperatures for long periods of time. Crosscontamination provides opportunities for microbial growth. Contamination might occur from (i) workers touching foods after cooking: although spoons were used to fill sandwiches, yet bread and buns were held by hands; and (ii) wiping cloths and sponges used in areas for both raw and cooked food. It is extremely difficult to completely eliminate contamination of foods, but it is easier to control further multiplication of pathogens and stop them from producing toxins in foods. Holding sandwiches which contain meat, chicken, eggs, and cheese for prolonged periods (i.e., several hours) after preparation and at temperatures of 17 to 40 C is a hazard and is unacceptable by most public health standards. Keeping potentially hazardous foods at room temperatures for several hours is the most frequent contributing factor to the occurrence of foodborne disease (5,8, 16,21,22). Sandwiches were touched by hands and wrapped manually and kept in boxes. Similar handling conditions were found to be the primary reason for significant bacterial contamination of foods in Japanese schools (11). Bryan (8) indicated that staphylococcal poisoning, shigellosis, and hepatitis A are often transmitted by infected persons touching cooked foods. Although wrapping sandwiches will decrease contamination by dust and microbes, it will maintain humidity inside the foods, thus creating a suitable environment for multiplication of microbes (15). Furthermore, wrapping foods will maintain the warmth and moisture for extended periods, thus allowing germination of spores and growth of vegetative cells. It will be extremely dangerous in summer when air temperatures rises to above 40 C and relative humidity to above 80%.. Bryan (10, 15), stated that the optimal growth temperature for food microbes varies from one microorganism to another. For example, the optimal growth temperature for Bacillus cereus is 30 C, for Clostridium perfringens is 46 C, and for Salmonella spp. ranges from 37 C to 43 C. The safety of foods sold in school canteens must focus on prevention of contamination and multiplication of microbes and of production of toxins. Workers performing manual packaging operations must exercise great care to prevent contamination of cooked foods. Food should not be prepared long in advance of consumption, and holding temperature should be maintained at over 54.5 C iffoods are to be held for over 4 h (14). A HACCP investigation serves no value if the findings are not implemented and used by the general public. Data gathered from this analysis can be used by health education officials and school administrators to promote appropriate

5 286 ALI AND SPENCER preventive measures, and the data should be used in training or educational programs for food workers in such geographical locations. The fact that workers have communication difficulties is a significant point to be taken into consideration when tailoring any health promotion activities or when hiring food workers. Preventive programs should encompass communication between health authorities, consumers, and politicians: collaboration, policy development, and enforcement. The public must be empowered by knowledge, health policies, and support to demand better services. HACCP programs can be used to ensure the safety of high-risk foods at all levels and the HACCP system must be introduced to food workers so that they can understand it and use it routinely. ACKNOWLEDGMENTS This study is done as a part of a Ph.D. thesis. Thanks are given to the Ministry of Education in the State of Bahrain for facilitating this study. Particular thanks are given to Dr. Frank L. Bryan, Food Safety and Consultation and Training, GA, USA, for revising this manuscript and for his comments. The authors also wish to thank Mr. Saeed Almas, senior school health education specialist, and Mr. Ahmad Khazal, health inspector, for their assistance. REFERENCES I. Akhbar Alkhaleege 1994, Issue 5837 (local newspaper). 2. Ali, A. A., T. Dudani, and I. Y. Abdulrahim Salmonellosis outbreak linked to improper handling of food in a hotel in Bahrain. Bahrain Med. J. 8: Blaser, M. J., and L. S. A. Newman Review of human salmonellosis: infective dose. Rev. Infect. Dis. 4: Bryan, F. L Status of foodborne diseases in the United States. J. Environ. Health 38: Bryan, F. L Factors that contribute to outbreaks of foodbome diseases. J. Food Prot. 41: Bryan, F. L Foodborne diseases in the United States associated with meat and poultry. J. Food Prot. 43: Bryan, F. L Hazard analysis of food service operations. Food Techno!. 35: Bryan, F. L Risks associated with practices, procedures and processes that lead to outbreaks of foodbome diseases. J. Food Prot. 51 : Bryan, F. L Hazard analysis critical control point evaluations. A guide to identifying risks associated with food preparation and storage. World Health Organization, Geneva. 10. Bryan, F. L., M. J. Fanelli, and H. Rieman Salmonella infections. In H. Riemann and F. L. Bryan (ed.), Foodborne infections and intoxications, 2nd ed. Academic Press, New York. II. Bryan, F. L., I. Fukunaga, S. Tsutsumi, L. Niyashiro, D. Kagawa, B. Sakai, H. Matsuura, and M. Oramura Hazard analysis of Japanese boxed lunches (bento). J. Environ. Health 54: Bryan, F. L., P. Teufel, S. Riaz, S. Roohi, F. Qadar, and Z. Malik Hazards and critical control points of street-vended chat, a regionally popular food in Pakistan. J. Food Prot. 55: Bryan, F. L., P. Teufel, S. Riaz, S. Roohi, F. Qadar, and Z. Malik Hazards and critical control points of street-vending operations in a mountain resort town in Pakistan. J. Food Prot. 55: Bryan, F. L., P. Teufel, S. Riaz, S. Roohi, F. Qadar, andz. Malik Hazards and critical control points of vending operations at a railway station and a bus station in Pakistan. J. Food Prot. 55: Bryan, F. L., P. Teufel, S. Roohi, F. Qadar, S. Riaz and Z. Malik Hazard and critical control points of food preparation and storage in homes in a village and a town in Pakistan. J. Food Prot. 55: Davey, G. R Food poisoning in New South Wales: Food Techno!. Aust. 37: Goff, H. D Hazard analysis and critical control point identification in ice cream plants. Dairy Food Sanit. 8: Hobbs, B. C., and D. Roberts Food poisoning and food hygiene, 6th ed. Edward Amold, London, UK. 19. International Commission on Microbiological Specifications for Foods Microorganisms in food 4. Application of the hazard analysis critical control point (HACCP) system to ensure microbiological safety and quality. Blackwell Scientific Publications, Ltd., London. 20. Ministry of Health. Bahrain Unpublished report. 21. Munce, B. A Hazard analysis critical control points and the food service industry. Food Techno!. Aust. 36: Roberts, D Factors contributing to outbreaks of food poisoning in England and Wales J. Hyg. 89: Sports Council, UK. January Safety in the kitchen and plant rooms. Part World Health Organization Report of the task force on integrated approaches to health education in food safety. Geneva, 3 to 7 December 1990.