Symonne Pereira Tappes1; Débora Cavalheiro Chaves Folly1; Gisele da Silva Santos1; Camila de Aquino Feijó1,2; Marcelo Pustiglione2
One of the causes of foodborne diseases is contamination during food preparation; food handlers carrying pathogens might be involved in the origin of this condition. This problem is more serious in health care facilities, since consumers of contaminated food are already ill. Therefore, operational procedures should be formulated to prevent incidents. We performed a review of scientific studies, legislation and regulations on this subject. The results indicate that the main causes of food contamination involving food handlers to be considered in strategies to reduce, or even eliminate foodborne diseases include: flaws in hand hygiene, intestinal parasites, lack of knowledge of good manufacturing practices (GMP) and of the etiologic agents of foodborne diseases, and lack of GMP monitoring. We conclude that standardized operational procedures should be developed, including clear and objective flowcharts (suggested here) to be managed by the safety and occupational medicine staff, in addition to providing training to food handlers on GMP and correct use of personal protective equipment and work clothes.
Doenças transmitidas por alimentos (DTA) têm como uma de suas causas a contaminação no processo de produção do alimento. Logo, trabalhadores portadores de doenças infectocontagiosas que manipulam alimentos podem representar a origem dessas patologias. No caso de manipulação de alimentos em serviços de saúde, essa ocorrência é ainda mais grave por causa das características do consumidor: o doente. Portanto, faz-se necessário elaborar procedimentos operacionais para prevenção desse evento. O objetivo deste trabalho foi estabelecer subsídios técnicos e legais para fundamentar a elaboração de procedimentos operacionais padrão e fluxogramas para as ações de vigilância da higiene e saúde dos manipuladores de alimentos dos serviços de alimentação de um hospital universitário de grande porte do município de São Paulo. Foi realizada revisão bibliográfica por meio de pesquisa de artigos científicos, pareceres, resoluções e normas regulamentadoras sobre o tema. As principais causas observadas na contaminação de alimentos que devem ser consideradas para subsidiar as propostas para reduzir, ou até eliminar, a possibilidade de DTA são, em relação aos manipuladores: falhas na higienização das mãos, presença de enteroparasitoses, desconhecimento das boas práticas de fabricação (BPF) e dos agentes causadores de DTA; falta de fiscalização das BPF. Concluiu-se que existe a necessidade de elaboração de procedimentos operacionais padrão com fluxogramas claros e objetivos (propostos no texto), gerenciados pela equipe de segurança e medicina do trabalho, além de capacitação e treinamento dos manipuladores acerca das BPF e da utilização correta de equipamentos de proteção individual e uniformes.
Palavras-chave: doenças transmitidas por alimentos; produção de alimentos; manipulação de alimentos; saúde do trabalhador; doenças parasitárias.
In the state of São Paulo, Brazil, the Health Surveillance Center, State Secretariat of Health, is responsible for the control of the quality of food1. Within this context, one particular focus of concern for this agency — which mission is to preserve and promote the health of the population — is the prevention of foodborne diseases, i.e. those which result from the intake of contaminated foodstuffs and/or water. There are more than 250 types of foodborne diseases, most of them caused by bacteria or their toxins, viruses and parasites2.
The World Health Organization rates foodborne diseases a serious global public health problem, which accounts for illness in 1 in 10 people and 33 million years of life lost. The Centers for Disease Control and Prevention reported that foodborne diseases affect 1 in 6 people in the United States (48 million people) resulting in 128,000 admissions to hospital and 3,000 deaths3.
According to the Brazilian Ministry of Health, several factors contribute to the occurrence of foodborne diseases, including: poor sanitation, poor quality drinking water, inadequate personal hygiene, and intake of contaminated foodstuffs3.
In Brazil, the Collegiate Board Resolution no. 216, from 15 September 20044, defines as food handlers all the individuals who work in a food business and are in direct or indirect contact with food. For this reason, this population of workers should receive special attention from health surveillance agencies. Indeed, food handlers carrying pathogens may contaminate the products or foodstuffs they handle, and thus put the health of consumers at risk5.
In the case of health care facilities this problem should receive utmost attention, since eventually contaminated food may be served to individuals with an already impaired state of health. Therefore, besides the tests indicated in the Occupational Health Medical Control Program (OHMCP) in compliance with the Ministry of Labor Regulatory Standard 76, additional tests should be performed to investigate cases of infectious or parasitic diseases among food handlers, be they symptomatic or not.
To provide technical and legal grounds for standard operational procedures (SOP) and flowcharts to monitor the state of hygiene and health of food handlers at the food services department of a large university hospital in São Paulo, Brazil.
MATERIALS AND METHODS
We performed a review of the Brazilian and international literature to establish the state of the art in the subject of interest, and analyze and synthesize the available information.
The literature search was conducted in databases Scientific Electronic Library Online (SciELO), Latin American and Caribbean Center of Information on Life Sciences (Regional Library of Medicine-BIREME) and Virtual Health Library (VHL) among others. We also looked for rulings (Google database), resolutions and regulatory standards (legislation databases). The time frame was set to the period from 1995 to 2017, and the keywords used were food safety, food contamination and food handling, in Portuguese and English, found in Health Sciences Descriptors (DeCS).
We selected 18 studies published in Portuguese, English or Spanish, and four pieces of legislation.
The results are presented in Charts 1 and 2. The software Excel was used to plot graphics and flowcharts to systematize the data considered relevant.
RESULTS AND DISCUSION
According to the Health Surveillance Center Regulatory Standard 57, from 9 April, 2013, food handling comprises all the procedures used to transform raw materials into foodstuffs along the following steps: processing, fractioning, packaging, storage, transport, distribution, and retail display.
Food handlers are all the individuals who work in a food business and handle ingredients and raw materials, equipment and tools used in preparation and packaging, or are involved in the fractioning, distribution and transport of foodstuffs7.
The topics most frequently addressed in the selected studies were: pathogens among food handlers, training, and relevance of hand hygiene (Graphic 1). We also analyzed the frequency of the words used in abstracts (Graphic 2).
Some of the analyzed studies investigated intestinal parasites to call the attention to the transmission of foodborne diseases by food handlers. The parasites most frequently reported were Entamoeba coli, Endolimax nana and other commensals. Also pathogenic parasites were described, mainly Entamoeba histolytica/Entamoeba dispar, Giardia lamblia, Ancylostomidae and Strongyloides stercoralis, which represent a more serious situation as concerns contamination8-10.
In the study by Capuano et al.8, most individuals infected with parasites were asymptomatic at the time of medical visits, while only 14.7% reported complaints. Workers carrying commensals were not allowed any contact with food for the duration of treatment.
Yeasts were found during investigation of onychomycosis, sometimes associated with nail infection by Staphylococcus10. In a study11, 33 of 88 of nasal mucosa samples tested positive for Staphylococcus aureus, being 13 potentially enterotoxigenic. These findings point to the role of food handlers in the transmission of foodborne diseases, since the odds of transmitting Staphylococcus are high for workers with respiratory symptoms.
Several authors stressed the relevance of familiarity with good manufacturing practices (GMP) and within this context, of training courses as the main means for food handlers to acquire such knowledge. The Brazilian Health Regulatory Agency (ANVISA) Collegiate Board Resolution no. 216 categorizes as "good practices" all the procedures which should be implemented in food services to ensure the hygiene of food as per the sanitary legislation. While knowledge of GMP was found to be poor among food handlers, it improved after they received training12-14, from 71 (minimum sufficient) to 89% (sufficient) in the study by González-Munõz and Palomino-Camaro13. Also other authors emphasized the relevance of training15-18 and periodic refresher8 courses, with assessment of their efficiency19. Some of the factors found to enhance the success of training programs are management support, equipment and tool availability, and motivation19.
Inspection by authorized agencies or food service managers was also mentioned as crucial to promote GMP. One single study20 analyzed foodstuffs, and found that their condition complied with the hygiene and sanitary requirements in vigor. Yet the authors observed that some procedures were irregular, and attributed this fact to the lack of technical managers at the analyzed institutions (schools)20.
Some authors developed an instrument for internal monitoring — Analysis of Hazards and Critical Points for Control (Análise de Perigos e Pontos Críticos de Controle — APPCC) to be administered by owners or managers of foods services8.
Devides et al.12 found that 23 of 192 participants in their study had taken some training course on food handling, however 47% of them only to comply with health surveillance agency requirements.
Some studies subjected samples taken from the hands of food handlers to microbiological analysis, and all were found to be contaminated, mainly by anaerobic mesophilic bacteria, Clostridium, Staphylococcusaureus, coliforms and Escherichia coli15,21-24; Candida spp. predominated among fungi25. Pathogens were also found on personal protective equipment (PPE) which situation further contributes to contaminate food22.
The findings reported in the analyzed studies were mainly due to lack of knowledge about hand hygiene and foodborne diseases among workers15,23. In one single study the participants reported to wash their hands and tools, but with water alone15.
In some facilities the environmental conditions were not favorable to adequate hand washing, e.g. insufficient number of washbasins and lack of disposable paper hand towels or other means to dry the hands21,22.
Pathogens were found on the hands of workers even when they had received adequate technical training. This finding points to the need to insist on stressing the relevance of personal and food hygiene24.
Chart 3 describes the main reasons for food contamination pointed out in the analyzed studies and possible solutions.
The unfavorable findings reported in the analyzed studies occur against the good practice legislation for the food industry and services in the state of São Paulo. According to such legislation, food handlers cannot be carriers of any evident or non-evident infectious or parasitic disease, and their state of health should be duly documented in medical and laboratory reports as per the regulations in force6,7.
Workers with lesions or diseases involving the skin, mucous membranes or nails, wounds or cuts on the hands or arms, or acute or chronic eye, lung, pharyngeal or gastrointestinal infection cannot be allowed to handle foodstuffs. Workers with any of these conditions should be referred for medical examination and treatment and not permitted to handle foodstuffs as long as these conditions persist7.
The State Secretariat of Health Administrative Ruling no. 2,61926, from 2011, items 15.34.1 and 15.34.2, establishes that in addition to the tests described in the OHMCP, food handlers and all those involved in the distribution and serving of meals should be subjected to stool culture and the ova and parasite (O&P) exam at the time of hiring and on 6-month medical examinations; those who exclusively handle packaged foods should be tested once a year.
ANVISA established additional regulations for food handlers, further reinforced in later administrative rulings. Such regulations stress the need for adequate personal hygiene, wearing clothes appropriate for the job, in good state, clean and changed at least once daily. They further call the attention to the relevance of hand hygiene since the time of arriving in the workplace, after handling foodstuffs, and after any interruption of tasks. These rulings also state that employers/technical managers must mandatorily place posters in visible places providing orientation on appropriate hand washing and antisepsis, and other hygiene habits4.
Additional hygiene rules for food handlers include: not smoking, not singing, not whistling, not sneezing, not coughing, not eating, not spitting, not handling money, and avoid talking unnecessarily while handling food. In regard to personal hygiene: wearing hairnets or caps, keeping the nails short and without enamel, avoiding wearing jewelry and makeup, and beards in the case of men4.
Many of these requirements should be included in local SOPs for food handlers' hygiene and health, including the need for training programs and records of the employees who effectively attend sessions to be presented when requested by inspectors27.
None of these documents attribute food contamination and possible transmission of foodborne diseases to food handlers alone, but address in general terms structural aspects and work processes in food services facilities.
The results of the present study evidence the relevance of formulating SOPs for food handlers' hygiene and health, including personal hygiene and hand washing. Instructions should be given on appropriate hand washing, step by step, and describing the necessary products.
Employers should ensure adequate conditions for appropriate hand washing (number and distribution of washbasins, soap, paper towels, etc.) and place posters illustrating the procedure and its relevance.
SOPs should clearly describe the procedures to be implemented whenever food handlers exhibit respiratory or gastrointestinal symptoms, lesions on the skin, or any other health condition that might threaten the safety of food. The medical staff should formulate standardized measures, for instance, whether asymptomatic workers infected with commensals should or not receive treatment.
Training has paramount importance (including duration, content and frequency) and attendance should be mandatorily recorded as per the legislation in force. Also appropriate PPE and daily changes of clothes are highly significant aspects.
OHMCP should indicate what tests will be required from food handlers and their periodicity, since the legislation affords some flexibility to the physicians in charge and as function of the geographical location of organizations. To conclude, we developed two flowcharts with measures to monitor the state of health of food handlers (Flowcharts 1 and 2, Chart 4).
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19 de Setembro de 2018.
Aceito em 13 de Julho de 2019.
Fonte de financiamento: nenhuma