An epidemiological study on morbidity profile among food handlers in Panaji city, Goa

ABSTRACT

Context:

Access to safe and nutritious food is key to promoting good health. An estimated 600 million fall ill after eating contaminated food, for which food handlers may constitute a common source of contamination. In addition to unhealthy food handlers, disease carriers handling the food play an equally important role in transmitting these diseases and pose a significant threat to public health. This study, therefore, aimed to know the morbidity profile among the food handlers employed in various food establishments in Panaji city.

Methods and Material:

Using stratified sampling techniques, we conducted a cross-sectional study among 227 participants selected from 12 food establishments. We did three visits to each food establishment. We excluded food handlers who were unavailable despite three visits at fortnightly intervals and those who did not consent to the study. We administered a pre-designed and pre-structured questionnaire to each participant. A general examination and laboratory investigations, including stool and urine routine, were performed on all participants. We performed descriptive and analytical statistics by using SPSS version 14

Results:

Out of the 227 study participants, 79 (34.8%) had at least one morbidity at the time of examination. None of the food handlers had received a single dose of typhoid, hepatitis A, or cholera vaccines. Most (74.4%) study participants did not administer deworming tablets

Conclusions:

We found that the health status of the study participants was substandard. Food safety may be in peril among food handlers with lower education backgrounds with morbidities as they may have little understanding of the risk of microbial contamination of food. Therefore, it is essential to create awareness among them.

Introduction

Access to ample, safe, healthy food supports life and improves good health. Unsafe food incorporates harmful viruses, bacteria, parasites, or chemical substances, causing more than 200 diseases – ranging from diarrhea to malignancy. Nearly 1 in 10 people globally, an estimated 600 million, fall sick after taking spoiled food, and 420,000 die yearly, resulting in the loss of 33 million healthy life years (DALYs).[1]

The World Health Day Theme 2015 was “Food safety.”[2] Ensuring food safety is vital in altering food habits, popularizing mass catering establishments, and globalization of food supply.[3] Foodborne diseases are of global public health importance, with the highest incidence in WHO African and South-East Asia regions.[4]

Food handlers employed in food establishments constitute a common source of food contamination.[5] Infected food handlers have transmitted many outbreaks of viral and bacterial infections.[6,7]

The rationale behind conducting a study on the morbidity profile among food handlers in Panaji City, Goa, is grounded in the crucial connection between the health of food handlers and the well-being of the tourists they serve. The health of food handlers plays a significant role in maintaining food safety and preventing the spread of foodborne illnesses. As Panaji City attracts a substantial number of domestic and international tourists annually, food handlers’ health status becomes paramount to public health. Here are several reasons why this study is critical:

Public Health Concerns: Foodborne illnesses can have severe consequences for public health, leading to widespread outbreaks and affecting the local population and tourists who may carry the infections back to their home countries. Identifying the morbidity profile among food handlers helps understand the prevalence of various health conditions that may compromise food safety.

Tourist Well-being: Tourists often rely on local food establishments for their meals, and their health indirectly depends on the hygiene practices and health status of the food handlers. By assessing the health of food handlers, the study aims to ensure the safety of the food served to tourists, reducing the risk of foodborne diseases and contributing to a positive tourist experience.

Preventive Measures: Understanding the morbidity profile among food handlers allows for the implementation of targeted preventive measures. Practitioners can use the findings to design specific health interventions, training programs, and health monitoring systems for food handlers, reducing the risk of foodborne infections.

Regulatory Compliance: The study results can inform or reinforce existing regulations and guidelines for food establishments, ensuring that they adhere to health and safety standards. Authorities can use this information to update or develop policies that focus on improving the health and well-being of food handlers.

Economic Impact: Foodborne outbreaks can have a detrimental effect on the tourism industry. A proactive approach to ensuring the health of food handlers can contribute to a positive reputation for the city, enhancing its appeal to tourists.

Practitioner and Patient Benefits: For practitioners, such as healthcare professionals and public health officials, this study provides valuable insights into the health challenges faced by food handlers. It guides them in developing targeted interventions and health promotion strategies. In this context, patients refer to both the food handlers and the consumers of their products. The study benefits food handlers by identifying potential health issues early, allowing for timely medical interventions. Consumers benefit by having increased confidence in the food safety they consume.

In summary, this study is crucial for safeguarding public health, promoting tourist well-being, implementing preventive measures, ensuring regulatory compliance, and supporting the economic vitality of Panaji City. The findings can directly inform policies and interventions aimed at improving the health of food handlers, ultimately contributing to a safer and healthier environment for both residents and visitors.

Methods

Study design and setting

This was a cross-sectional analytical study to assess the morbidity pattern among food handlers in food establishments registered under the Corporation of City Panaji (CCP), Goa, South India, between September 2015 and February 2017.

Sample size determination

We determined the sample size by using the following formula:

n = Z² pq/d²

n = 227

Where n = minimum sample size,

Z = Z score corresponding to 95% level of significance, that is, 1.96

P = estimated measure of intestinal parasitosis from a previous study = 62.65%.[8]

q = complementary probability of P = 1 − p

d = degree of precision required = 6.265%

Methodology and enrolment in the study

In total, 227 study participants were selected from 12 food establishments by using a stratified random sampling technique. We chose food establishments from the following categories registered under the CCP: starred restaurants, vegetarian Udupi restaurants, bars and restaurants, cafeterias, fast foods, and bakeries. Out of each of the six categories, we chose two establishments randomly. Of each establishment, 25 participants were randomly selected on the visit that day. If any establishment had less than 25 participants, then in the same category, we took the subsequent randomly chosen establishment until we met the sample size of that category. We did a total of 18 visits, that is, three visits to each food establishment [Figure 1]. We included all Types of Foodhandlers are mentioned in this Table 1 only. We excluded food handlers who were unavailable despite three trips to each food establishment at fortnightly intervals and those who did not consent to the study. Stratified sampling helped to reduce sampling bias and increase the accuracy and efficiency of analysis. By ensuring that each subgroup is adequately represented in our sample, we avoided oversampling or undersampling certain groups that might skew our results.

Figure 1.

Flow diagram of the study

Table 1.

Association between the nature of work and the morbidities among the food handlers

Nature of work	Morbidity		Total
	Present	Absent
Cleaner	5 (2.2%)	14 (6.2%)	19 (8.4%)
Waiter	28 (12.3%)	32 (14.1%)	60 (26.4%)
Cook	30 (13.2%)	51 (22.5%)	81 (35.7%)
Helper	9 (4%)	39 (17.2%)	48 (21.1%)
Captain	3 (1.3%)	5 (2.2%)	8 (3.5%)
Dish washer	4 (1.8%)	7 (3.1%)	11 (4.8%)
Total	79 (34.8%)	148 (65.2%)	227 (100%)

Yates corrected Chi-square=9.99, df=5,P=0.076

Research ethics approval

Before conducting the study, we obtained permission from the Institutional Review Board of the Directorate of Health Services Goa (No. DHS/Sp.Cell/24-166 (Ethical Committee)/2016-17/1572; dated 01/02/2017) and the Goa Medical College Institutional Ethics Committee (dated 28/12/2015; no number provided). Before visiting each study establishment, we explained the purpose of the study and assured confidentiality to each owner. The investigator obtained verbal consent from the owner and informed consent from each study participant.

Study instruments

We administered a pre-designed, pre-tested, pre-structured questionnaire to each study participant to obtain sociodemographic, medical history, and morbidity profiles. The investigator also conducted a general examination of each person. Laboratory investigations, including stool and urine routines, were performed on all study participants. Health education was provided to each food handler to improve their health and to ensure food safety.

Statistical analysis

The data collected from the completed questionnaires were duly entered into the Microsoft Excel spreadsheet 2015 and transferred to SPSS version 14. We calculated frequencies and proportions. Pearson’s Chi-square test analyzed the association between the qualitative variables, and we calculated the odds ratio. A P value of less than 0.05 was considered significant.

Results

Out of the 227 study participants, the majority, that is, 142 (62.55%), belonged to the age group of 21–30 years; only six (2.6%) were females. Out of the 227 study participants, the majority, that is, 192 84.4% were literate (See Table 2). The majority, that is, 84 (37%), belonged to socioeconomic class III according to the modified BG Prasad’s classification for 2015–2016. Out of the 227 study participants, none of the food handlers had received a single dose of typhoid, hepatitis A, or cholera vaccines. Regarding the deworming status of the food handlers, the majority (74.4%) of the study participants did not administer deworming tablets. Furthermore, 16.3% of the study participants received deworming tablets twice a year. Only 7.5% received the deworming tablets once a year, while a few (1.8%) received the deworming tablets more than twice a year.

Table 2.

Association between morbidities among food handlers and their education status

Education	Morbidity		Total
	Present	Absent
Illiterate	19 (8.4%)	16 (7.2%)	35 (15.6%)
Primary	15 (6.6%)	53 (23.3%)	68 (29.9%)
High school	33 (14.5%)	68 (29.9%)	101 (44.4%)
Higher Secondary & Graduate	12 (5.3%)	11 (4.8%)	23 (10.1%)
Total	79 (34.8%)	148 (65.2%)	227 (100%)

χ²=13.983, df=3, P=0.003

Out of the 227 study participants, 79 (34.8%) had at least one morbidity at the time of examination (See Table 3). One (0.4%) of the participants suffered from dysentery, while seven (3.1%) suffered from diarrhea. Furthermore, 23 (10.1%) had intestinal parasitosis. Around two (0.9%) suffered from diarrhea with intestinal parasitosis, while 25 (11.1%) had ARI at the time of examination, five (2.2%) study participants had ARI with fever, one (0.4%) had a viral fever, and 13 (5.7%) were suffering from skin infections. While one (0.4%) had conjunctivitis, four (1.8%) suffered from urinary tract infections and hypertension. In total, 148 (65.2%) did not report any morbidity during the examination.

Table 3.

Morbidities prevalent among food handlers

Morbidity	No. of food handlers	Percentage
Dysentery	1	0.4
Diarrhea	7	3.1
Intestinal parasitosis	23	10.1
ARI	25	11.1
Viral fever	1	0.4
Skin infections	13	5.7
Conjunctivitis	1	0.4
Urinary tract infection	4	1.8
Hypertension	4	1.8
No morbidity	148	65.2
Total	227	100

Only 13 (5.7%) of the study participants had skin infections. Of these 13 participants, the majority, that is, four (31%) suffered from paronychia, three (23%) had pityriasis versicolor, two (15%) had furuncles, two (15%) had infected open wounds that were secondary to burns, and one (8%) had scabies and folliculitis each [Figure 2].

Figure 2.

Skin infections among food handlers

Out of the 227 study participants, around 11 (4.8%) reported episodes of diarrhea in the past year, three (1.3%) reported dysentery, and one (0.4%) had developed typhoid fever. The majority, that is, 50 (22%), had episodes of ARI in the past, while only four (1.8%) suffered from viral fever [Figure 3].

Figure 3.

Morbidities among food handlers in the preceding year

Of the 227 study participants, 23 (10.1%) suffered from intestinal parasitosis (See Table 4). Among these 23 participants, the most common infestation was Ascaris lumbricoides (15 (65.3%)), followed by Trichuris trichiura (3 (13%)), Entamoeba histolytica (2 (8.7%)), Giardia lamblia (2 (8.7%)), and Ancylostoma duodenale (1 (4.3%)).

Table 4.

Intestinal parasitosis among food handlers on stool routine examination

Intestinal parasites	No. of food handlers	Percentage
Ascaris lumbricoides	15	65.3
Trichuris trichiura	3	13
Giardia Lamblia	2	8.7
Entamoeba histolytica	2	8.7
Ancylostoma duodenale	1	4.3
Total	23	100

We analyzed the association between morbidity among the study participants and their education. We observed that out of 79 (34.8%) participants having one or more morbidities, the majority, that is, 33 (14.5%), had completed high school, 19 (8.4%) were illiterates, and 15 (6.6%) had completed their primary schooling. A minority, that is, 12 (5.3%), were those participants who had completed either higher secondary education or graduation. The Chi-square test revealed a significant association between the presence of morbidity and the education levels of the study participants.

Out of the 79 (34.8%) study participants having one or more morbidities, the majority, that is, 30 (13.2%) were cooks, five (2.2%) were cleaners, 28 (12.3%) were servers, nine (4%) were helpers, three (1.3%) were captains, and four (1.8%) were dishwashers. The Chi-square test revealed no significant association between the type of work and the morbidities among the study participants (See Table 4).

Discussion

According to the findings of the study, the majority (84.6%) of the food handlers were literate. In a survey by Mukhopadhyay et al. in Kolkata, (91.1%) of the food handlers were literate, and in a survey by Gous et al. in Jalgaon city of Maharashtra, (95.24%) of the food handlers were literate.[9,10] 84 (37%) study in our study, belonged to class III, where in the study by Prabhu et al.[11] in Miraj, Maharashtra, many were from lower-middle socioeconomic class.

Compulsory vaccination of all food handlers against the enteric group of diseases as per the recommended schedule of the vaccine is necessary, and record maintenance is essential for inspection purposes.[12] None of the study participants were immunized against typhoid. Malhotra et al.[13] reported similar results in their study done in Delhi. None of the food handlers were vaccinated against typhoid. However, Bobhate et al.,[14] in their study done in Mumbai, reported that a few (7 (5.1%)) had been immunized with a single dose of typhoid vaccine, while only 2 (1.5%) had received booster doses. These findings suggest the importance of creating immunization awareness among food handlers.

Infected food handlers may constitute a common source of contamination of food. Out of the 227 study participants, 79 (34.8%) had at least one morbidity at the time of examination. Similarly, Mudey et al.,[15] in their study done in Wardha, found that the point prevalence of morbidity among the food handlers was 33.75%. Santhiya et al.,[16] in their research on food handlers in Coimbatore, Tamil Nadu, reported a total prevalence of morbidities of 37.26%. Most (11.1%) of the study participants suffered from ARI in the present study. Deshpande et al.[17] noticed that 14.66% had a cough in their research on food handlers in western Maharashtra.

Only 13 (5.7%) study participants had skin infections. The food handlers who belonged to the lower socioeconomic class had a higher prevalence of skin infections in a study done by Takalkar et al.[18] in Solapur, Maharashtra. Regarding the morbidities in the past year, 50 (22%) study participants had ARI episodes, while only four (1.8%) suffered from viral fever. Kulkarni et al.[19] reported that 33.4% had URTI episodes, while 8.3% gave a history of typhoid in their study in Bangalore (See Table 2).

Approximately 23 (10.1%) were suffering from intestinal parasitosis, of which the most common infestation was Ascaris lumbricoides. A study done by Rekha S and KA Masali in Bijapur showed identical findings. The prevalence of intestinal parasitic infestation was 9.7% among the food handlers, and most had Ascaris lumbricoides infestation.[6] Only 25.6% of the study participants administered deworming tablets. In their study among food handlers in North India, Singh et al.[20] reported that 43.1% had taken deworming pills once in the past 3 months. Microbes may be transmitted to food by the handlers fecal-orally or transcutaneously. Food contamination largely depends on the food handlers’ health status; hence, periodic deworming is essential to prevent worm infestations.

The Chi-square test revealed a significant association between the presence of morbidity and the education levels of the study participants. Lack of formal education among the food handlers contributes to a lack of awareness of food safety guidelines.

Out of the 79 (34.8%) study participants having one or more morbidities, the majority were cooks (30 (13.2%)). We did not find any significant association between morbidities and type of work. Bobhate et al.,[14] in their study on food handlers in Mumbai, found that out of the food handlers suffering from morbidities, 13.8% were cooks.

The education status of the participants did not show any significant association with the practice of hand hygiene among the food handlers in a study conducted by Ansari et al.[21] in a metropolitan city in India.

The educational and occupational status also did not show a significant association with the morbidity of food handlers in the study conducted by Singh et al.[22] in North India.

Knowledgeable food handlers were 2.92 times more likely to practice good food safety than non-knowledgeable in a study by Azanav et al.[23] in Gondar City, Ethiopia, similar to our findings.

Epidemiological studies have significantly advanced our understanding of the morbidity profile among food handlers, shedding light on specific findings and contributing factors. In a survey by Parashar et al.,[24] the investigation into viral gastroenteritis outbreaks linked to food consumption emphasized the critical role of food handlers in disease transmission, highlighting the importance of stringent hygiene practices. Shinkawa et al.[6] conducted a molecular epidemiology study of noroviruses, revealing intricate details about these pathogens’ genetic diversity and transmission patterns among food handlers. Notably, Gous et al.[25] explored the health status of food handlers in Jalgaon City, Maharashtra, uncovering prevalent morbidities and emphasizing the need for regular health assessments in this population. Similarly, Prabhu et al.[26] conducted a comprehensive study on food handlers in Maharashtra, providing insights into the health conditions and risk factors affecting this group. These findings collectively underscore the importance of continuous epidemiological research in ensuring the well-being of food handlers and the safety of the food supply chain.

Limitations:

The sample size of the current study could have been improved by including more food establishments to have more conclusive results. We made only three visits to each food establishment; perhaps more visits would have yielded more food handlers.

Conclusion

We found that the health status of the study participants was substandard. Food safety may be difficult among food handlers with lower education backgrounds and morbidities. They may have little or no comprehension of the risk of microbial contamination of food. The findings of this study indicate that it is essential to create awareness among the food handlers regarding health status and food hygiene to ensure food safety.

Future scope

The results of the present study help generate the profile of food handlers and give baseline information to plan the corrective measures. We recommend regular monitoring of pre-placement and yearly medical examination of the food handlers, licensing of all food establishments, and the quality of food manufactured in the state. We highly recommend a follow-up study with a larger sample size regarding enforcing food safety measures.

Data availability

The primary data gathered by the authors that support the findings of this study are available from the corresponding author upon request.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.