136 850 THS. {MPLICATEGNS OF MECRQBEOLOGY 70 THE FOOD SERVICE INDUSYRY A promem §ov “19 Degree of M. S. MICEEGAN STATE UNIVERSITY Florecito S. L320 1966 LIBRARY Michigan State University 1 NW E11811 1‘ 1X“ 31 A} E t'UF ' 313N0\\'\\C‘S H '1) 1:1: .- ‘.3\'1\C,"{'\\Q A“ ~Nvflfi”fl1 NV” ' r “MAN ECOLOGY M1CH. 48823 . L“ 1770 '1 13"".1. 1.531" 13111.: .1. 17.111 :3"; .. 1 3 1 1.1mm! “iii-‘11 '11. .T1.1.I_)1"1.‘.'i-I~‘ (1.11 H :1. (1: r" (.11 1:?) .11. (.11 .1. 1.1.1 1::1 y} 14 ~ 35 .. .1. ’5F3r:_.'.fr; 1-11-11? 1 k k 1.... (3:1 '21 1;.) , I377 .1. (LI 1‘ 152' 1:1: .1. 111:.) $333 .. 11'1'13’11-1C6I111.11.1115; 1:: '1". Mi (:1: 1" 1:11:11. 0.11. (:1sz 11.13 1:11 M * (’ - .1. ‘5' (inf. ”N [:13 1 1 1 1 1 1.119133%; STATE UNNERSHY ’ ROLLEGE OF HUMAN ECOLOGY 1 REFERENCE LIBRARY 1 MICHIGAN STATE UNIVERSITY COLLEGE OF HOME ECONOMICS EAST LANSING, MICHIGAN PLACE IN RETURN Box to remove this checkout from your record. TO AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE 6/01 c:lCIRC/DateDuo.p65-p.15 IMPLICATIONS OF MICROBIOLOGY TO THE FOOD SERVICE INDUSTRY By Florecito S. Lazo A PROBLEM Submitted to the Dean of the College of Home Economics Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE Department of Institution Administration 1966 ACKNOWLEDGMENTS The author wishes to express her sincerest gratitude to Professor Katherine Hart, Chairman of the Institution Administration Department, for her helpful guidance and assistance in the preparation of this manuscript. She extends her deep appreciation to Miss Jean McFadden, Instructor of the Institution Administration Department, for her encouragement, and to Doctor Frank Peabody, Professor of Microbiology and Public Health, for his valuable suggestions. She also wishes to thank her family for the inspira- tion they have given her during her period of study. ii TABLE OF CONTENTS INTRODUCTION PRINCIPLES OF MICROBIOLOGY Microorganisms - The Bacteria Shape and Size Growth and Reproduction Occurrence Microbial Activities — Food Poisoning Food Intoxication Clostridium botulinum Staphylococcus aureus Clostridium perinngens Food Infection Salmonella Streptococcus Parasitic Infection Protozoa Helminth Parasites FOOD SANITATION PRACTICES AND PROCEDURES Role of Management Planning Organizing Coordinating Motivating Controlling Role of Food Service Personnel Basic Considerations Rules for Food Handlers Health and Disease Control Personal Hygiene General Observations BIBLIOGRAPHY iii Page 28 29 3O 3O 31 32 33 36 36 38 42 44 INTRODUCTION Progressive industrial development and socio-eco— nomic changes have provided employment for many people in many countries of the world. This has created the need for additional food service facilities in the form of industrial cafeterias, restaurants and lunch counters for employees in the labor force. In the United States, increase of work demands and distance from job to home make it inconvenient for the employees to eat all of their meals at home. This situation is also true have brought has become a present time to the Philippines. Due to these changes that peOple to eat outside the home, food sanitation great concern. The Philippines has at the a major problem dealing with sanitation of restaurants and other quantity food operations. Vicente C. Buencamino, Sanitary Engineering Adviser of the Bureau of Health Services in Manila, stated that: there are more health hazards in the capital, in chartered cities and municipal cen~ ters (called poblacions) than any other barrios of a municipality, especially with regard to food sanitation. . . . It is in these places where people concentrate to live and find opportunities in life that complex problems are created, not only concerning food, but also related to other factors of environment. It is in these places where most public eating and food processing and manufacturing establish- ments operate. Furthermore, Jose Tena, Manila Sanitary Inspector, writes about the public establishments in Manila: The restaurants in Manila are dirtyl They pose a grave peril to public health. Day in and day out the people are exposed to food-borne diseases such as dysentery, cholera, diarrhea- enteritidis, and tuberculosis. The restaurants sell contaminated food swarming with microbes. Restaurant operators violate health and sanitary regulations with impunity. The United Nations Information Center in Manila reported that ”. . . bacteria . . . thrive in the hot and humid conditions of the Philippine climate.”3 The presence of pathogenic bacteria in food is due to the contamination of the food from an infected animal from which food is prepared, or from an infected person who has contact with food during preparation and/or service. 1Vicente F. Buencamino, ”Status of Food Sanitation in the Philippines,“ World Health Organization Western Pacific Region Seminar on Food Sanitation (Manila, Philip— pines, October 12, 1962), p. 1. 2Jose Tena, "Restaurants are Filthy,” Weekly Graphic, Manila, Philippines, May 19, 1965, p. 87. 3United Nations' Food Technology Work in the Philippines (Manila, Philippines: United Nations Informa— tion Center), p. l. The following diseases may be spread by contaminated 4 food: Amebiasis Scarlet fever Diptheria Streptococcus sore throat Diptheria, bacillary Tuberculosis Paratyphoid fever Typhoid fever Poliomyelitis These and many other diseases, including those listed below, may also spread indirectly or directly from food handlers to customers:5 Chicken pox Pneumonia, broncho Conjunctivitis, infectious Pneumonia, lobar Encephalitis, epidemic Smallpox Influenza Syphilis (rarely) Measles Common cold Meningococcus meningitis Vincent's angina Mumps Whooping cough In the control of disease there are three different methods of accomplishing results: sanitation, development of individual resistance and medical treatment. Medical treatment has been practiced since the days of Hippocrates, and although it is far from the superstitions of the healers of early times to the therapy of today, medical treatment has always had the same objective—-the cure of disease. 4K. Marden et al., ”Administrative Control of Food Handlers and Place Dispensing Food and Drink,” American Journal of Public Health, XXVIII (November, 1938), p. 1278. 51bid. Today it is now realized that if prevention of disease is to be thorough it must go beyond the individual and must deal with the very habits of society. Concomitantly, food administrators and food handlers are instrumental in pre- venting disease through awareness of health hazards that are food oriented and sanitation education in the food service industry. The writer‘s intent has been to review the princi- ples of microbiology, to investigate the sanitation prac- tices and procedures in the United States related to food handlers, and to summarize this information for use by food supervisors in the Philippines. PRINCIPLES OF MICROBIOLOGY Every year hundreds of diseases caused by food-borne microorganisms occur in the United States. Some of them are reported; many are not. According to the 1951—1960 reports (37) made to the United States Public Health Service, 7,000 to 12,000 people suffered annually from these diseases, and the total number of cases is estimated to be ten to twenty times as great as those recognized and reported (15). Despite precautions taken to protect food served to the public, prevalence of food-borne disease still presents a major problem. Such occurrences need not happen, and yet, they do. Why do they happen and how do we prevent these from happen— ing? Basic principles of microbiology can explain many causes of illness due to improper handling of food and also expand the knowledge of what occurs under given conditions. Microorganisms — The Bacteria Fossil records indicate that disease—producing organisms have plagued man since his first appearance on earth. Roman and Arabic writers speculated on the existence of non—visible forms of life. Some early philosophers even suggested that "germ” contagion passes from one person to another causing disease. Needless to say, these theories remained mere speculations until man devised instruments for the observations of sub—visible organisms (50). In 1590, Zacharias Janssen produced a compound micro- scope, but his lenses were too imperfect and his persever— ance insufficient to permit him to see the microbes. Antonj van Leevenhoek of Holland is credited with the first recorded observation of the world of sub-visible life. During his 'leisure hours, this successful Dutch merchant produced a 'simple microscope consisting of home-ground convex lenses mounted in brass and silver. His lenses were so perfect that when Leeuvenhoek coupled them with keen eyesight and extreme patience he was able to observe the larger micro- organisms in 1676 (6). Almost two hundred years later, in 1865, a trained scientist, Louis Pasteur worked in France on fermentations which led to an investigation of the ”sick” wines of France. Pasteur showed that putrefaction was due to the presence of flavor-destroying bacteria (17). Another great figure, contemporary to Pasteur, was the German physician, Robert Koch who developed a liquefi- able, solid culture medium for isolating pure strains of disease—producing microbes free from contamination by ordinary organisms of the dust and air. He was the first to prove the cause and effect relationship of bacteria to disease (38). Shape and Size Bacteria or their products, undoubtedly, are respon- sible for the majority of the outbreaks of food-borne dis- eases (2, 11, 35). These living organisms too small to be seen by the naked eye, are in three shapes: spheres, straight rods, or bent rods. A spherical or ellipsoidal bacteria is usually termed a coccus. Considerable variation in shape is found among the cocci, although the cells are typically globular when two cocci lie side by side. The approximated side may be flattened, sometimes even concave. The cells of many bacteria are rod—shaped and rela- tively straight. Such a rod-shaped organism may be called a bacillus. The rod may be long or short; it may have rounded ends, or it may be truncate, or even concave. Some bacteria have the shape of a bent end; if the amount of bending is slight, the cell has the appearance of a short arc of a circle. The cell may be in the form of a spiral, in which case an organism is called a spirillum. The spirillum may show several or numerous complete turns of the spiral, or it may appear merely as a slightly bent rod. Bacterial size is usually expressed in terms of a micron which is one-millionth of a meter or one-thousandth of a millimeter which is approximately 1/25,000 of an inch (6, 16). Such figures indicate how small these bacteria really are. Because of their smallness, management is faced with not only a problem of contending with ”invisible crea- tures," but also with convincing employees of the actual existence of these organisms and of dealing with them as a constant threat to public health. Growth and Reproduction A11 bacteria grow and reproduce very quickly, given favorable conditions (16). The significant growth factors are temperature, moisture, oxygen and hydrogen ion concen- tration. For each microorganism the one temperature for the most rapid growth is called the optimum growth temperature. On the basis of optimum growth temperature bacteria can be grouped into three classes: psychrOphiles, mesophiles, thermophiles. The psychrophiles or cold-loving microbes grow slowly at 320F, and thrive at refrigerator temperatures below 680F. The mesophiles, which have an optimum range between 680 and 104OF, are the largest bacterial group and include all animal pathogens. The thermophiles grow best at temperatures above’llBOF and are of economic importance in the food processing industries since they survive the processing temperatures and grow rapidly during the period of cooling (50). Microorganisms require a certain level of moisture for growth. The keeping quality of a foodstuff is therefore closely associated with its water content. Dehydration as means of food preservation is based on reducing the water content of the food below the level necessary for the growth of microorganisms. Oxygen is a prime requisite for all bacterial growth. Depending on how they acquire oxygen, bacteria are either aerobic or anerobic. Aerobic bacteria obtain their oxygen from air just as animals do, and their growth is limited by the amount of oxygen available. Growing in liquid such as milk or broth, they depend on dissolved air. On the other hand, anerobic bacteria are unable to live in the presence of air; they obtain oxygen from compounds which are oxygen rich, such as sugar. The acidity or basicity of the medium in which micro- organisms grow is determined by the concentration of hydrogen ions. The pH scale, by which this property is measured, runs from 0 to 14; the low values indicating acid and the high values, alkaline. Most organisms have an optimum pH growth at or near neutrality pH 7.0. With few exceptions, the range for bacterial growth falls between pH 4 and pH 10. If the food is high in acid, pH 4.5 or less, virtually all bacteria will be inhibited since few can tolerate acid (50). 10 Multiplication of bacteria ordinarily takes place by the process of transverse binary fission. This is the sim— plest method of reproduction as it merely requires one cell to lengthen and then divide transversely into two individ- uals. In this respect bacteria are much like protozoa and the simplest algae (16). A certain group of bacteria, the bacilli, produce spores. When bacteria produce spores, each individual bears but one spore and gives up its own existence in order to produce the spore. Such spores do not serve the purpose of multiplication, but enable the species to resist unfavorable environmental conditions. Bacterial spores can remain alive for long periods of time and can resist extremes of temper- ature, light, and chemical agents without being killed. This factor is particularly important in calculating time- temperature charts for the food processing industry (5). Occurrence Bacteria are ubiquitous wherever the temperature is not so high as to destroy life, or chemicals or other agen- cies do not interfere. Bacterial organisms are abundant in soil and air, in the depths of lakes and oceans, in certain foods, decaying organic matter of all kinds, on the skin, and within the intestines of man and animals (50). Bacte- ria will be found growing practically wherever there is assimilable food, and where suitable environment has enabled ll them to produce spores, cells or cysts relatively resistant to drying, low temperature, and similar unfavorable condi- tions. Bacteria are Spread from two main sources; from man himself or from the animals with which he comes in close contact. Bacteria gain access to the body through the res- piratory tract, the digestive tract or the skin. The mode of bacterial transmission comes under three main headings: direct transmission, indirect transmission and intermediate transmission (6). Direct contact transmission may come from bacteria per se or from a carrier of bacteria. Contact may be actual such as a touching of the skin as in handshake, or by drop- let transmission such as occurs in sneezing or coughing. Droplet infection is the usual mode of transmission of disease such as measles, common colds and whooping cough. Through the consumption of tainted food or polluted water, bacteria are spread indirectly. In most cases of indirect infection, the bacteria are taken into the system through the mouth and discharged from the body through the feces. Infections that are spread by intermediate hosts are the trichinosis from hogs and salmonella from rodents. Insects such as flies and roaches are also intermediate 12 hosts. These insects, besides being intermediate hosts themselves, also spread bacteria by purely mechanical trans— fer from one man to another (13). Microbial Activities — Food Poisoning Microorganisms may be grouped under the heading of useful, innocuous, and harmful. Certain microorganisms dur- ing food processing can cause undesirable changes in the food that might be dangerous to the health of the individ- ual (6). Microorganisms may affect the acceptability of food in several ways. Bacteria causing infectious disease may be present; toxin and poisonous products may develop by the growth of organisms; or changes affecting the palatability or nutritive value of the food may occur. The most prevalent disease in the world next to the common colds and measles is food poisoning. Each year approximately three million Americans contract this disease (46). The term ”food poisoning” as commonly understood in- cludes any illness brought about by some injurious agent ingested in food which may be microbial or non—microbial in origin. Microbial poisoning may be due to the action of ingested toxins (food intoxication) or multiplication of ingested bacteria (food infection). 13 Smith (38) has classified food poisoning causes in four categories: 0 Individual idiosyncrasies a Chemical Food that is naturally poisonous (toadstool, etc.) Poison accidentally or purposely added (plant sprayed, etc.) o Microbial Food intoxication Food infection 0 Parasite infection (trichinosis, etc.) The cases arising from individual idiosyncrasies and chem- ical poisoning have been excluded from this discussion as this paper is only concerned with microbial and parasite infection. Food products responsible for the bacterial types of food poisoning either have become toxic because of bacte— ria growing in them before consumption or the food acts as a carrier of infection. Before the true relationship of bacte- ria to food poisoning was recognized, illness resulting from unwholesome food was attributed to basic nitrogenous products of protein breakdown known as ptomaines (40). Causes of food illness are now well documented, and the term ”ptomaine poi- soning” is recognized as a misnomer. Nevertheless, these compounds have achieved a bad reputation and to the popular l4 mind almost any form of digestive disturbance is automati- cally thought to be due to ptomaine poisoning. Food Intoxication Many pathogenic microorganisms produce a poisonous substance called toxin and hold this toxin within the cell until the cell wall is destroyed or until after death of the organism. Such toxin is known as intracellular toxin or endotoxin. Other bacterial products or toxins which are thrown from the cell into the surrounding environment are called extracellular toxins or exotoxins. Intracellular toxins are most frequently encountered in food-borne diseases (6). Three microbial toxins are known to cause food intoxication: Clostridium botulinum toxin is the most fatal; Staphylococcus aureus toxin is the most common; and Clostridium perfringens toxin is the mildest. Clostridium botulinum.--The disease botulism is caused by the toxin produced by the rod—shaped organisms called Clostridium botulinum and is usually fatal. This organism is widely distributed in the soils, and the spores may be found on the roots, leaves, and fruits of plants. Botulism organisms do not grow in acid foods, but they can poison non-acid foods. On this account, all canned foods of low acidity must be processed at 2120F for at least six 15 hours to destroy the maximum number of spores of this orga- nism likely to be present in a canned product and having maximum resistance to heat (8). Contaminated home—prepared foodstuffs which contributed to the 47 botulism cases reported in 1963 included chili peppers, green beans, corn, mushrooms, figs, beets, and home smoked fish; commercial products reported as sources of contamination in 1963 in- cluded liver paste, tuna fish, smoked white fish, and smoked white fish chubs (28). The growth of Clostridium botulinum in canned food produces a very characteristic penetrating butyric odor, similar to that of rancid butter. This odor is very pro— nounced in meats and peas and least noticeable in canned string beans and fruits. Cases are on record, however, in which the spoiled product (home—canned string beans) did not have a very objectionable odor (8). Fortunately, the poisonous toxin produced by the botulinum organism can be destroyed by heating at 1800F or the boiling point for 10 to 15 minutes. If there is any doubt as to whether processed food is spoiled, the food should never be tasted until after it has been boiled for 10 minutes or longer (49). First evidence of botulism is great muscular weak— ness, fatigue and dizziness. There is no fever. Nausea and vomiting may occur but are not pronounced nor lasting. Con- stipation and urine retention, not diarrhea, appear. One of the most characteristic symptoms is visual disturbance. 16 The eyes do not adjust to variations or degree of light intensity. The throat may have excessive salivation. There may be aphonia, a complete loss or partial loss of voice. There is no damage to the brain and the mind remains clear. If death occurs, it is from 4 to 8 days, as a rule, and is due to respiratory failure (6, ll). Staphylococcus aureus.-—Staphylococcus food poison- ing is the most common type of food poisoning in the United States. The staphylococcus organism is found in the throats of individuals, on the skin as a causative agent of pimples, boils and carbuncles, and in great abundance in the post— nasal drip of patients recovering from colds. The organisms are, therefore, transmitted to food by food service workers who pick pimples, boils or other body infection, or who cough or sneeze into food. The illness is manifested chiefly by nausea, vomit— ing, diarrhea and a moderate rise in temperature. The onset is sudden, the symptoms appearing a few hours after the ingestion of contaminated food and subsiding in a day or two. This type of food poisoning is seldom, if ever, severe enough to cause death. The foods most commonly associated with staphylococ— ,cus food poisoning are cream-filled pastries, chocolate eclairs, cream puffs, cakes with cream fillings, salads, and, less commonly, meats (49). If staphylococcus are present in 17 food, they multiply at a tremendous rate and produce a toxic substance. The toxin produced is resistant to both heat and cold. However, the toxin can be made less toxic by heating to 3750F for 30 minutes. This is the basis for recommending the re-baking of cream—filled pastries (32). The control of staphylococcus food poisoning depends upon proper care in preparation of and refrigeration of foods. Clostridium perfringens.-—The role of Clostridium perfringens (welchii) in food poisoning in the United States is just now being rediscovered. This type of food poisoning is relatively common in Great Britain and other European countries where home refrigeration ordinarily is lacking. Such illness results from growth of the anerobe in cooked meats which have been held at room temperatures overnight or longer. The symptoms which appear some 10 to 18 hours after eating are those of an abdominal upset characterized by nausea, marked cramps and diarrhea, usually without fever or vomiting. Fatalities are rarely encountered and no immunity seems to result (12). 18 Food Infection Infections caused by certain Species of Salmonella and Streptococcus are frequently called food poisoning. Salmonella.—-Food poisoning of the infectious type is primarily due to organisms belonging to one of the fifty known types of Salmonella of which the three most common are Salmonella enteritidis (Gaetner's bacillus), Salmonella aertryche (typhimurium), and Salmonella suifestifer (Cholera suis) (6, 47). Salmonella enteritidis was first isolated by Gaetner from the meat of diseased cow that had been responsible for a number of cases of food poisoning. Salmonella enteritidis is pathogenic for cattle and produces a dysentery in calves. Most outbreaks occur as a result of eating the meat of infected cattle. Salmonella suifestifer or Cholera suis was thought to be the cause of hog cholera at one time and is often associated with the disease although it is not the cause. It is widespread in hogs and associated with food poisoning following the consumption of pork. Salmonella aertryche or typhimurium is a natural parasite of rodents and is also pathogenic for cattle. It is usually associated with meats that have been contaminated by droppings of rodents. Salmonella infections are usually associated with meats that have been processed, that is, made into patties 19 and meatballs. The extra handling increases the possibility of contamination. Improper refrigeration allows for rapid multiplication of the organism. The infections are most common in the summer months when warm weather increases the chance of bacterial growth in inadequately refrigerated food. Salmonella food poisoning produces abdominal pains, diarrhea, fever, nausea and vomiting. Symptoms may appear from 6 to 48 hours after eating contaminated food and they originally persist from 24 to 72 hours. During this time and possibly for weeks later, a person is a carrier of the bacteria and can pass infection to others or contaminate food by handling unless strict personal sanitation is observed. Salmonella organisms do not form spores and are destroyed by boiling. There is no practical method for detecting the presence of this organism in pork by inspec- tion, so the only safeguard is to treat all pork as if it were infected and process it at 140°F for an hour in order to destroy the organisms (46). The rising incidence of Salmonella food poisoning in the home, at public functions, and in hospitals and institutions is of much concern among public health author- ities. The cases reported annually increased from 504 in 1942 to 15,390 in 1963 (49). The Communicable Disease Center of the United States Public Health Service reported 20 an 11 per cent increase occurred in 1964 over the previous year. To safeguard the consumer, the government has estab— lished an inspection service which, although not perfect, goes a long way toward insuring the safety and high quality of the food reaching the customer (46). Streptococcus.--These infections resemble those caused by Salmonella organisms in many ways. Streptococcus faecalis has been blamed, although another enterococcus, Streptococcus faecalis var. liquefaciens was held responsible for one outbreak (15). Symptoms are nausea, somatic vomiting, colic—like pain and diarrhea. Mostly meat products have been involved thus far in Streptococcus faecalis infections like roast and barbecued beef, beef croquettes, Vienna sausage, ham, bologna, and turkey dressing. Other foods include cheese, cream pies, chocolate pudding, and canned evaporated milk. Frazier (15) has listed the principles involved in the prevention of outbreaks of food-borne Streptococcus faecalis infections: (1) avoidance of contamination of the food with this organism, (2) prevention of growth of the organisms by adequate refrigeration, and (3) thorough cook- ing of the food. Eliminating infections from Streptococcus faecalis is difficult, for it is found commonly in milk and milk products, has been noted in dried eggs, and is present in fecal matter. 21 Parasitic Infection In addition to the bacterial food—borne infection, there are a number of animal parasites that may attack man. This type of infection is usually discussed in conjunction with bacterial food poisoning and infection because all have similar symptoms and all are food-borne. While these infec— tions are more properly considered in parasitology, a few of the more important will be reviewed in this section of the manuscript. Any parasite which is embedded in food contents as well as adhering to surface of hands and utensils used in preparation of food may enter the human body. In some instances parasites inhabiting the intestinal tract of man or other animals may be simply transferred by contamination of food or water or by direct contamination of the hands to the alimentary tract of a new individual (16). A certain stage of the parasite is passed in the body of one species of animal; but in order to attain complete development and rounding out of the life cycle, transfer to another host must take place. In some cases, man functions as the inter- mediate host, but most commonly as final host of the para— site. For example, the larval stage of the pork tapeworm occurs in hogs; the adult stage in man. The parasites of man that cause food—borne infections are practically limited to two groups, the protozoa and the helminths (15). 22 Protozoa.-—Protozoa sometimes found in the human intestine include the parasite of amoebic dysentery, Endamaoeba histolytica, which is a tissue feeding parasite and makes its primary invasion into the wall of the large intestines. This invasion results in a more or less exten— sive ulceration; and although the majority of persons in- fected do not exhibit marked symptoms, others show every gradation of intestinal upset from slight diarrhea to a debilitating and often fatal dysentery. Furthermore, in infected persons the amoeba are carried to the liver and in a small percentage of cases give rise to serious hepatitis abscesses. From this site they may also break over into the lungs or be carried to other organs such as the brain and spleen, where they produce abscesses similar to those in the liver. The parasites complete their life history only in carriers who are not suffering from marked symptoms. In the individual, certain amoeba secrete thin wall producing cysts. The cysts pass out of the body with the feces and find their way back to man always by means of various types of fecal contamination. Human beings are infected by Endamaoeba histolytica from swallowing cysts of the parasite derived from carriers passing these in their feces. The contamination of food and drink is mainly brought about by the presence of infected food handlers, by the use of night soil as fertilizer for 23 garden vegetables, and by allowing flies free access to infected feces and food (22). Helminth Parasites.——The helminth parasite or worms which produce disease in man are divided into two large groups, the flat worm and the round worm. The flat worm comprises the flukes and the tapeworm. The flukes are trematode worms, mostly flattened leaf—like form, which live in such localities as the intestines, bile, ducts, lungs, and portal veins, and produce diseases char— acteristic of these specific localizations. The tapeworms in their adult stage form long tapelike ribbons which are essentially colony form, instead of occurring as single individuals. The eggs of the tapeworm, which are laid in the intestine, pass out of the body with the feces. Fish repre- sent a potential source of infection to man or animals. In the majority of cases intestinal infection with the adult worm produce no clinical symptoms. In a certain number of cases, however, a pronounced anemia resembling pernicious anemia develops of which the symptoms readily disappear with the removal of the infective parasite (21). For both of these worms, insufficiently cooked food is the principal means of human infection. The round worm parasite that infects man shows a wide diversity in life cycles. Likewise, the method of transmission also varies. Some complete their entire life 24 cycle in a single host, and others an alternate of hosts. Some are transferred from man to man by various blood—suck- ing insects. In others, the infectious forms pass out of the body with the feces and infect human beings by contam- ination of food and drink. Still others live in the muscles of certain animals and are transmitted by eating the flesh of these animals (6). The most dreaded of these parasites is Trichinella spiralis which causes the infection trichinosis. The usual hosts for the parasite are hogs and rats, but man is highly susceptible and can be infected by eating insufficiently cooked pork. Trichinosis is a disease characterized by fever, muscular pain, or an enormous increase in the number of eosinophil corpuscles. As a disease trichinosis wears many disguises and is frequently diagnosed as a number of other diseases and disorders, as an upper respiratory infec- tion, acute nephritis or rheumatic fever. Trichinosis may present a complicated clinical picture, and an accurate diag- nosis on the basis of symptoms is not easy. Evidence that food containing pork such as pork sausage and ham loaf has been consumed may be a valuable clue to diagnosis. Trich— inosis can be prevented by thorough cooking at not lower than 1370F so as to destroy the trichinae larvae (22). Generally, the prevention against any parasitic in- fection consists largely of general hygiene measures--per— sonal cleanliness and treatment of infected individuals (15). FOOD SANITATION PRACTICES AND PROCEDURES The basic principles of food establishment sanitary regulations require that the customer‘s health be protected against contaminated food and communicable disease organisms (6). In order to understand what measures might be taken to protect the customer's health, it is important to examine the "chain of disease transmission” or the ”infectious process." For any disease to occur, six conditions must be met and all of them must occur in a set and logical sequence. These six steps or links in the chain of transmission are (39): o Etiologic agent, that is, the causative organisms, pathogen, or infective agent or material 0 Reservoir of infection or habitat that permits the survival of the etiologic agent 0 Escape of the etiologic agent from the reservoir to the next prospective host 0 Transmission from the reservoir to the next prospec- tive host 0 Entry into the prospective host a Susceptible host. 25 26 To protect the customer, a means of eliminating or modifying one of the links in the chain of transmission must be devised. This will disrupt the infectious process and prevent disease from occurring. Prevention of disease or sanitation measures will be augmented by the assumption that all food is contaminated and, therefore, precautions must be taken. The aim is to eliminate or modify one of the links in the chain of transmission. How well the patrons of public food and drink estab- lishments of all types are protected depends upon how well an establishment, whatever its size, conforms to the sani- tary points enumerated below: a Safety of the food and drink served 0 Personal hygiene and food handling practice of the food workers 0 Safety of the water supply 0 Sanitary disposal of sewage and water—carried wastes 0 Protection of food from contamination during process- ing, display and storage 0 Washing, sanitizing and storing of utensils and equipment 0 Sanitary maintenance of the premises including general arrangements and upkeep, refrigeration, light, ventilation, toilet and hand washing facil- ities, housekeeping practices and the disposal of garbage and refuse. 27 Mallman (24) has stated that food service personnel make up 99.99 per cent of the problem of food care and sani- tation. Although it has been pointed out that the source of contamination may be in the food supply, more commonly it originates with food service personnel. The workers are, in most outbreaks of food poisoning and food—borne diseases, the source of disease either directly or indirectly. This section of the manuscript will deal with per- sonal hygiene and food handling practices of food workers and point out ways of lessening the possible passage of microbial disease organisms from the worker to the food. Role of Management Any business or profession carries with it certain obligations and responsibilities; food service operators have a personal responsibility not only to keep restaurants clean but to prevent food-borne illness and to maintain the highest possible standards of customer protection. Every person working where food and drink are prepared should be responsible for the safe service of good food. His own health as well as that of his customers is at stake; his practices and habits have a direct influence upon public health. Food sanitation begins at the top (9). This is a responsibility which must be shared by top administrators 28 and housekeeping, engineering, purchasing, and food service. These are the members of the team that must function to- gether if food—borne disease is to be prevented. Local health department officials should be invited to assist in planning new food services, remodeling old ones, or to make a periodic inspection of the day-by-day operation from a sanitary viewpoint. State health departments should also be consulted as they are always ready to help in specialized problems. All these groups work for the best in food ser- vice sanitation and are thus ”guardians" of the public health. Food sanitation is a team problem and should be solved by a team approach (39). The National Industrial Conference Board listed five major areas where this team could work together. They are planning, organizing, coordi- nating, motivating, and controlling (18). Let us look at these five areas of management and see how they relate to the achievement of food service sanitation. Planning Plan what to do and how to do it, realizing that planning is necessary to good sanitation. Every person involved "in the doing" must also be able to participate "in the planning." Food service managers, restaurant oper- ators, and dietitians must cooperate with the sanitarians 29 and sanitary industry in planning the ”what” and the ”how.” Sanitarians must be regarded not as policemen but allies in planning good sanitation. Employees at all possible levels must know not only the objective but also understand how they are going to carry out the program to meet the objective and the reasons why they are doing it. Employee's involvement may be in the form of film showing and follow—up discussions, demonstra- tions, and other aids which are readily available through governmental and industrial organizations (39). Organizing This area embraces definition of functions, arrang- ing of facilities, division of tasks and assigning tasks to individuals or groups. Organizing will vary greatly accord- ing to the type and size of operation. Here, the element of supervision becomes apparent. If the organization is small, the manager's supervision extends to detailed operation. As complexity and diversity of an operation require division of work, the manager relies more and more on supervisors whom he expects to understand "how” they are going to meet the objective, the reason ”why” they are doing it, and to have the ability to interpret the objectives to the lowest level worker (48). Most important of all, good organizing implies the delegation of responsibility for sanitation standards. This 3O responsibility includes continuous interpretation to people actually doing the job. Responsibility must be accompanied by authority to deal with those who cannot be motivated to do the job properly. Coordinating Coordination implies good communication. Here again, good supervision is imperative. Communicated information on what is to be done and how it is to be done is essential, but failure can never be detected without adequate super— vision. Communication is often accomplished well verbally, but written procedures are essential as a beginning point. Without initial interpretation, understanding and constant follow—up, they are soon forgotten. Motivating This term means getting a person to do something because he wants to do it. The food service Operator must be properly motivated himself so as to motivate employees to do the job properly. The motivation of the manager, while much the same as that of employees——namely, the satisfaction of basic needs--is often stimulated by the profit element (30). The employee in food service is faced with a rela— tively repetitious job, somewhat lacking in stimulation. In many cases, he or she is not nearly as interested in a 31 fastidious job of serving food and personal cleanliness as is the proprietor, sanitarian or patron. Material rewards alone do not satisfy human needs. The average person will do what is right if he knows it is best for him and for other persons. He will do it much more willingly if he gains recognition as a worthwhile person and for work well done. Many studies in industry have shown that recognition for work well done, a feeling of belonging to the organiza- tion, and a sense of being appreciated rate well above wage levels and fringe benefits as reasons for why people work (33). Controlling This means working with facts, the detection of strengths and weaknesses, and the instigation of steps to make use of strength and correct weakness. Control is accomplished primarily through personal supervision and reports. In the case of food service sanitation, personal cleanliness is extremely important. Man with his eyes alone cannot analyze the results of sanitizing process or detect the presence or spread of dangerous bacteria. Scientific testing is essential. We see in all these five areas that management is responsible legally and morally for establishing a quality sanitation program within an institution (36, 40). A practi— cal and comprehensive sanitation program entails informed 32 supervision, trained employees, clearly outlined methods and follow—up inspection. However, the foremost considera— tion in a training program for employees requires that man- agement must be made aware of the role of public health practices in a food processing and/or serving program. Technological advances, up-to-date equipment and better training are too often counterbalanced by careless- ness and indifference. Progress in food hygiene has been most evident where the management has been cooperative and where regular inspection and close supervision have been possible (9). Management must provide the facilities which enable the employee to do his task easily and properly. Proper facilities should be provided near working areas to provide adequate cleaning and washing of hands and utensils. Adequate handwashing lavatories should also be provided in the vicinity of the kitchen. If management has done its part by providing these facilities, it is in a much better position to require high standards of cleanliness from its employees. Role of Food Service Personnel Restaurant sanitation rests directly upon every individual working in the establishment. Because personnel form a vital link in the chain of sanitary food service, the personal habits of food handlers have been stressed. In spite of the wide application of ordinances and codes and 33 the employment of many sanitary and food inspectors, the increase of food poisoning and food-borne diseases continues undiminished (24). Basic Considerations The employer has to be reminded that before employ- ing new staff he should be satisfied that they know and understand the basic principles of food hygiene and that their medical history is satisfactory. At one time health authorities felt secure in manda- tory physical examination for employees, but these have proved to be of relatively little value in reducing inci- dence of food-borne diseases. These examinations are often not sufficient to detect a typhoid carrier and frequently fail to restrict respiratory disease patients from employ- ment (39). The cost of these examinations is not commensu- rate with public health benefits obtained. This has been demonstrated in recent years by many health departments replacing physical examinations with educational programs. The day—to—day health of employees is the most important consideration in protecting the public. Exclusion of sick persons or persons suffering from infected wounds from all food handling operation is the best control method. An initial medical examination upon employment is advantageous if it includes a morbidity history of the patient (35). When examination discloses a history of 34 typhoid fever, diptheria, acute tuberculosis, or any illness initiating infection that can be transmitted through food or drink, freedom from pathogenic infection should be confirmed by laboratory test before the person is employed. Persons with discharging infected wounds or lesions should not be permitted to handle food, utensils, or equipment. Infec- tions from these sources are often the cause of the staph- ylococci type of food poisoning (42). The protection of the food from contamination by workers is possible only by good personal hygiene. The principles of food personnel hygiene are well established and there is little controversy about their application to food sanitation; but there still remains the problem of getting food handlers to practice them conscientiously. At least three factors operate against careful handling of food: first, just as those familiar with food sanitation can attest, there are certain individuals who are by nature or temperament unfit to handle food; second, there is a rapid turnover in personnel causing unstable employment and insuf- ficient training; and third, the food handler is under stress particularly at meal time in his attempt to give quick service. This situation often contributes to care— lessness. Although these conditions must be faced realis- tically, they are not insuperable. The food handlers must be counseled to plan ahead and taught good food handling methods. 35 The following approach to the problem will be help— ful (10): 0 Be sure that the employees really understand the danger of noncompliance by telling them actual cases where carelessness caused disaster. 0 Give them a feeling of responsibility by explaining how the health-—perhaps even the lives of customers and fellow employees-~depends on them. 0 Appeal to their personal pride in appearance and good manners. This entire phase of food sanitation must be approached with a sympathetic attitude. Many persons handling food have meager educational backgrounds, and long technical explana- tions will be of little value to them. A common sense approach on the basis of decency and practical application will generally obtain results more effectively than a long dissertation on the etiology of microorganic diseases. In order to make a health sanitation program work- able, food handlers must be enlightened and urged to cooper- ate. Control on this administrative level can by far bring the best results. Rigid application of rules must be stressed. 36 Rules for Food Handlers The primary objective of sanitary supervision is to prepare and serve food to the public and to prevent illness or death from spoiled or contaminated food (39). Most states, cities, and towns have laws governing the sanitation of eating and drinking establishments. Regulating control may be based on grading, system, permit revocation or other measures. For the guidance and assistance of those respon- sible for sanitation of eating places, the United States Public Health Service has developed recommended standards of sanitation practices which are now the basis of most state and local codes (40). Those parts of the Food Hygiene Regu- lation which relate to personnel are clearly of great impor‘ tance in food service establishments. Health and Disease Control.-—Section C, number 1 of the 1962 Ordinance and Code Regulating Eating and Drinking Establishments prepared by the United States Public Health Service states: No person while affected with any disease in communicable form or while a carrier of such dis— ease, or while afflicted with boils, infected wounds or sores, or an acute respiratory infec- tion shall work in any area of a food-service establishment in any capacity in which there is likelihood of such a person contaminating food or food-contact surfaces with pathogenic organisms, or transmitting disease to other individuals; and 37 no person known or suspected of being affected with any such disease or condition shall be employed in such an area or capacity.6 This regulation definitely spells out that persons with colds, sore throats, nausea, vomiting, abdominal pain, and diarrhea should not work around food. Also, persons with skin eruptions such as boils or infected cuts should not work with food; however, if this measure is too drastic, the policy should be flexible enough so that the worker can at least be transferred to some duty not involving direct handling, provided that sores are properly bandaged and com— pletely protected from contact with food or utensils (10). Employees should never pick noses or pimples, boils or black— heads. If this should be done inadvertently, they should immediately wash their hands with soap and water before re— suming work. Any skin eruption containing even minute quan- tities of pus can subject foods, particularly custard, baked hams and cold pressed meats, to infection. An acute cold with attendant coughing and sneezing can expose food to droplet and hand contamination; sneezes must be caught in a handkerchief or better yet a disposable tissue, or directed away from food. Observance of good manners will be 6Ordinance and Code Regulating Eating and Drinking Establishments, Public Health Service Publication No. 37 (Washington, D. C.: U. S. Government Printing Office, 1962), p. 47. 38 appreciated by fellow employees who will in turn show the same considerations. Close observation of food handlers is recommended. Any person with even suspected symptoms of disease should be questioned and temporarily suspended from work, at least until he has been given a ”clean bill of health" by the health officer or by a physician designated by him when such legal authority can be applied. Personal Hygiene.-—Section C, number 2 of the same ordinance states: All employees shall wear clean outer garments, maintain a high degree of personal cleanliness, and conform to hygiene practices while on duty. They shall wash their hands thoroughly in an approved hand-washing facility before starting work, and as often as may be necessary to remove soil and contamination. No employee shall resume work after visitin the toilet room without first washing his hands. Personal cleanliness is one of the fundamental prin- ciples of food handling. The food handler must be taught to keep his hands clean. Proper washing of the hands before coming to or returning from work with food, after using the toilet, whenever soiled, and after contamination from cough— ing or sneezing is of utmost importance. This is essential to avoid contamination of food. Hands contaminated with discharges of the mouth, nose, throat, and the gastro-intes- tinal tract can be a menace to the public health. The 71bid., p. 48. 39 fingernails must be kept neatly trimmed and free from dirt at all times. Staphylococcus germs have frequently been found in cultures taken from under fingernails. Clean fin- gernails are indispensable to good appearance. Nail polish, if used, should be colorless or natural in shade. The nails and cuticles should receive frequent care to avoid hangnails. To wash hands thoroughly, hot running water, soap, a nail brush and individual towels are necessary, and the manage- ment must be able to provide these. Handwashing signs should be conspicuously displayed in toilet rooms and in work rooms (1). Daily bathing is advisable. It stimulates circula- tion, helps the skin eliminate body wastes, massages the muscles, rids that tense tired feeling, and altogether gives pep. To be of real benefit, the body should be cleaned with warm water, a suitable soap and scrubbing. Use a deoderant to combat body odors. Frequent shampoos are also advisable. Dirty hair in a food establishment is as offensive as an unclean body (31). Brushing the teeth must be often and thorough. Brushing the teeth not only removes food particles, thus warding off decay, but discourages film from accumulating and stimulates circulation of blood through the gums. Be- cause restaurant workers are in fairly close contact with each other and their customers, they need to avoid unpleasant 40 body odors and bad breath. It also ensures that the indi- vidual worker is personable and attractive at all times. Clean, washable, light-colored outer garments should be worn by food workers. All workers, including dishwashers, bus boys, and kitchen help should wear a clean apron, coat, frock, or uniform. Street clothing is unsuitable because it may serve as a source of contamination to food, dishes, and utensils; besides, it often can not easily be laundered. If uniforms are not clean, all other possible means of preven- tion are diminished or complicated since hands and sometimes food are in contact with outer garments. Clean uniforms should be easily accessible to food handlers at all times (10). Underclothing must be fresh and clean daily. Perspi- ration and food odors penetrate underclothes and can be instantly detected. Hair is another source of contamination (15). It should be covered so that there is IN) temptation to brush the hair from the face with the hands. Hair nets, caps, or bands designed to keep hair in place should be worn by food handlers. This is, of course, primarily a guard against falling hair. It also improves the personal appearance of the employees. Posture is not directly involved in food-borne dis- eases. Nevertheless, the more tired an employee is, the more 41 he is apt to relax defenses on sanitation procedures. Posture improves appearance and is less tiring. Whether standing or walking, one should keep shoulders erect, chest up, abdomen flat, and hips drawn back. The feet should be placed close together and pointed straight ahead. Body should be balanced on both feet. Do not slouch against the counter or lean against the wall. To save both strength and disposition, restaurant workers need to stand correctly; that requires sensible shoes. They give more mileage with less complaint (2). Smoking should not be permitted in a room where food is being prepared. Ashes tend to get in the food; smoking constitutes a fire hazard; it is unpleasant for fellow employees who are non—smokers. Moreover, it is almost impossible to smoke without fingering the lips. If disease organisms are present in the mouth or throat, they are sure to be mixed with the saliva that gets on the fin— ger. Smoking may also promote spitting, affording transmis- sion of disease organisms present in the saliva to food or food contact surfaces (29). Locker rooms should be kept neat, emptied and cleaned frequently with all waste materials deposited in a covered receptacle provided. Old, soiled or unused clothing should not be permitted to accumulate in lockers. Street clothing when not in use should be kept in lockers, not 42 laying around. Food should not be brought into the locker rooms. Meals should be eaten in the dining rooms provided. The accumulation of unused material in lockers forms an excellent harborage for roaches. They also make locker facilities unsightly and unpleasant for an individual's comfort and his fellow employees (10). Food serving practices involve a large variety of common and improper handling methods, several of which may be cited here: handling food with fingers rather than with appropriate utensils——butter patties without a butter fork, chipped ice or cubes without a scoop, pastries without tongs; holding glasses by the rim instead of the bottom or side; holding knives by the sharpened end; holding clean containers with fingers inserted inside; wiping cutting knives on a soiled apron; licking fingers and then handling food; using a side towel to wipe away perspiration (32). General Observations High standards of hygiene in restaurants cannot be achieved without cost and, indeed, these costs are obvious. 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