Microbial Quality and safety of cooked foods sold in Urban Schools in

Ghana: a review of food handling and health implications

Keywords:
Microbial Quality, Hazard Analysis Critical Control Point (HACCP), Quality
Improvement (QI), Vended foods, Food Hygiene
ABSTRACT:

Foodborne diseases are major causes of illness, human suffering and
economic losses. It is therefore imperative to study, monitor and supervise food
handlers to ensure that they observe personal hygiene to avoid food contamination.
This study reviews microbial quality of ready-to-eat foods with focus on food safety,
food storage, basic Hazard Analysis Critical Control Point (HACCP) public perception
of foodborne diseases, knowledge of food safety and personal hygiene, good
hygienic practices, and some foodborne diseases. Others include the vulnerable group
of foodborne diseases, bacterial food-borne diseases, causes of foodborne diseases
and causal organisms, parasitic food-borne diseases. The objective of this study is to
determine the microbial quality of vended foods in urban school canteens in Ghana
This study determines the microbial levels of vended foods sold in schools and to
explore food borne diseases of vended food in relation to hygienic practices for
recommendation of measures that can be implemented to ensure microbial food
safety in the canteens of the schools in urban areas. This is a descriptive study and a
review of facts from the literature and from the website and described.
063-072| JRPH | 2013 | Vol 2 | No 1
This article is governed by the Creative Commons Attribution License (http://creativecommons.org/
licenses/by/2.0), which gives permission for unrestricted use, non-commercial, distribution and
reproduction in all medium, provided the original work is properly cited.
www.jhealth.info
Journal of Research in
Public Health
An International Scientific
Research Journal
Authors:
Emmanuel Owusu
1
,
Reuben K. Esena
2*
,

Ted Annang
1
,
Margaret Ottah Atkpo
3
.

Institution:
1. University of Ghana ,
Institute of Environmental and
Sanitation Studies, Legon-Accra
Ghana.

2. University of Ghana, School
of Public Health, P. O. Box LG
13 Legon-Accra Ghana.

3. Food Microbiology Division,
CSIR- Food Research Institute,
Accra, Ghana.

Corresponding author:
Reuben K. Esena.



















Email:





Web Address:
http://www.jhealth.info/
documents/PH0016.pdf.

Dates:
Received: 22 Aug 2013 Accepted: 05 Sep 2013 Published: 28 Dec 2013
Article Citation:
Emmanuel Owusu, Reuben K. Esena,

Ted Annang and Margaret Ottah Atkpo.


Microbial Quality and safety of cooked foods sold in Urban Schools in Ghana: a review
of food handling and health implications
Journal of Research in Public Health (2013) 2(1): 063-072
An International Scientific Research Journal
Original Research
Journal of Research in Public Health
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INTRODUCTION
Food intake as a basic human requirement
exposes humans to the risk of foodborne pathogens.
Ready-to-eat-foods [or vended food are foods prepared
and sold by vendors in public places for consumption-
without-further-processing (WHO, 1996), including
fresh fruits and vegetables sold outside market areas
(WHO, 2006). This practice of food sale is on the
increase in West Africa as a result of socioeconomic
changes, characterized by massive urbanization in recent
times. This has made ready-to-eat foods important in the
informal sector of many-developing countries. Such
foods are inexpensive, convenient and often affordable
by urban and rural poor. This entrepreneurial activity
provides income for a vast number of persons, especially
women; and provides the avenue for self-employment in
business development skills to assist a wide variety of
people (Taylor et al., 2000).
In contrast to the benefits they provide, ready-to-
eat foods are however potential sources of disease.
Depending on the type of food, the method of
preparation and the manner in which it is held before
consumption, the risk of bacterial contamination may
occur (Muoz de Chvez et al., 2000).
High risk foods-such as meat, cooked rice, fish,
eggs, poultry, milk and similar foods must therefore be
handled hygienically to avoid the risk of being
contaminated with bacteria endotoxins and exotoxins.
The main type of pathogenic bacteria associated with
foodborne diseases include Salmonella spp, Clostridium
perfringens, Staphylococcus aureus, Listeria
monocytogenes, Campylobacter jejuni, Clostridium
botulinum, B. cereus, and Escherichia coli (Okolie et al.,
2012).
The link between reliance on street food
consumption and prevalence of gastrointestinal
infections has been established (Mensah, 2002). Street
food has also been implicated with environmental
contaminants such as chemicals, traces of pesticides and
heavy metals (Tomlin, 2002). Poor food handling
practices is known to result in up to 97 per cent of food
borne illnesses in establishments and the home (Howes
et al., 1996).
Food safety
Food safety has been defined as the conditions
and measures that are necessary during the production,
processing, storage, distribution and preparation of food
to ensure that it is safe, sound, wholesome and fit for
human consumption (WHO, 1984). Food safety is thus
the condition which ensures that food will not cause
harm to the consumer when prepared and/or eaten
according to their intended use. It is crucial to critically
handle, preparation, and storage of food to prevent food
borne illness. Ready-to-eat foods are a critical issue
because of the unhygienic conditions, under which some
are prepared and sold (Rheinlnder et al., 2008).
The Ghanaian community has experienced an
upsurge in the operation of ready-to-eat-foods and there
are an estimated 60,000 food vendors in the capital alone
(Afele, 2006; Ayeh-Kumi el al., 2009). It is therefore
imperative to ensure food safety at all times in all the
ready-to-eat food establishments. The aim is to protect
the huge number of consumers who may be infected with
foodborne pathogens at a time. Abdus-salam (1993) is of
the view that ready-to eat-foods could pose significant
public health problems because most food handlers lack
knowledge on safe food handling. This is compounded
by the difficulty in controlling and supervising them,
their large numbers and inadequate resources.
It is therefore important to ensure that food
handlers observe good personal hygiene to avoid
contamination or transmission of foodborne pathogens to
consumers who patronize their food unknowingly. In
line with this, WHO (1989) noted that a key vehicle for
micro-organisms transfer is from faeces, nose, skin and
other parts of the body into food. So hand washing is
important. A similar study by Pether and Gilbert (1971)
noted that bacteria such as Salmonella typhi and
Esena et al.,2013
064 Journal of Research in Public Health (2013) 2(1): 063-072
Escherichia coli can survive for varying periods on the
fingers and other parts of the body.
Food handlers must therefore be screened by the
appropriate regulatory body to ensure that they are
always in good health and hygienic conduct before they
sell to the public. In Ghana, one way to ensure food
safety of ready-to-eat food is by issuing periodic health
certificate to food vendors. This is confirmed by a study
by Musa and Akande (2002) who noted that in the
developing countries, the common approach to
regulating vended food is through medical examination
of food vendors.

METHODS
This is a descriptive review from a wide array
of literature from health records [Ministry of Health],
Ghana Health Service (GHS), Food and Drugs
Authority [Ghana] and from International Journals and
from the website. All these were analyzed and
described.
Ethical Principle
There was the need for Ethical approval. This
was obtained from Ethics Committee of the Ghana
Health Service, the University of Ghana School Of
Public Health and from the Municipal Director of Health
Services.
Food Handling
In Ghana, it is a requirement for food handlers to
go through medical screening for infectious diseases
before they are granted certificate of fitness to sell their
cooked foods. Further the Metropolitan, municipal and
district environmental health officers periodically
conduct screening exercises and vendors are expected
to carry out complete physical and medical examination
and obtain health certificates issued by the authorized
health centers. This practice is consistent with what
prevails in other developing countries. In some
developing countries, public health code requires food
handlers to undergo medical examination before they are
employed in food establishments. But these regulatory
measures are ineffective because it is an expensive
exercise for the impoverished food handlers and does not
prevent infection after the examination (WHO, 1996).
Despite this notion, Ngozi and Onyenekwe (2003) assert
that many developing nations place premium on food
handlers undergoing medical examination to ensure
detection, treatment and subsequent reduction in
transmission of foodborne pathogens.
According to WHO (2006), there are five
principles of food hygiene that can be implemented to
ensure food safety. These are prevention of
contaminated food from spreading, separation of raw and
cooked food to avoid cross-contamination, cooking food
thoroughly at the right temperature, storage of food at the
proper temperature and the usage of safe water and raw
material for food preparation. Failure to observe these
principles in food preparation exposes consumers to
pathogens and toxins that cause foodborne illnesses. One
of the means to ensure that ready-to-eat foods are
without pathogens and chemicals is the application of the
principles of Hazard Analysis Critical Control Point
(HACCP). The HACCP system seeks to identify
hazards associated with any stage of food processing and
determines the operations where control procedures are
necessary to guarantee food safety (http://
w h q l i b d o c . w h o . i n t /
publications/1992/9241544333_eng.pdf).
Bryan (1992) indicated that four factors should
be taken into account when choosing a place to conduct
HACPP. These include the food property, food
operation, volume of food prepared and susceptibility of
consumer. Food property factor relates to the process of
foods prepared and served in an establishment, the
characteristics of the food (such as pH, water activity)
and its ability to support the rapid growth of infectious
microorganisms. The food operations factor analyses the
process that the foods usually undergo that exposes them
to contamination. This process might not destroy
Esena et al.,2013
Journal of Research in Public Health (2013) 2(1): 063-072 065


contaminants and therefore contamination could
increase. The volume of food prepared risk factor
assesses the tendency of large volumes of the same food
prepared for people in advance that creates hazards when
not stored in conditions that prevents bacteria growth. In
that the risks increase with the time of holding. The
susceptibility of the consumer risk factor assesses those
people more prone to disease than the general population
such as the hospital patients, infants or the elderly
(Bryan, 1992).
HACCP as a measure of ensuring food safety has
many merits compared to the other traditional ways of
ensuring food safety. It is a proactive approach that
anticipates problems before they occur, provides rapid
control mechanisms, easy to monitor and can be used to
predict potential hazards (Bryan, 1992). It identifies
critical food safety risk factors that could serve as a basis
for training and education of street food vendors as well
as consumers. Furthermore, it emphasizes monitoring of
critical control points in food operation and serve as
inexpensive food safety assurance compared to chemical
and microbiological methods of analysis.
Some basic HACCP food safety approaches on food
handling
The principle of HACCP as food safety measure
is relevant right from the farm land to when the food is
on the table for consumption. To ensure food safety, raw
materials should be obtained from known and reliable
sources and not from clandestine dealers. Raw materials
are very relevant to the safety of street-vended foods
since they can introduce biological, chemical and
physical hazards that may persist through preparation
and processing of ready-to-eat foods. To protect against
food hazards, materials to be consumed in their raw state,
should be transported and stored separately from other
raw materials and non-food items. Raw foods (e.g., raw
meat and poultry) are often contaminated at source with
salmonellae, Campylobacter jejuni, Clostridium
perfringens, Yersinia enterocolitica, Listeria
monocytogenes, or Staphylococcus aureus (Bryan,
1992).
Water as a raw material is critical in ready-to-eat
foods preparations which when contaminated can
transmit foodborne illnesses when used for drinking,
washing of foods, incorporated in the food as an
ingredient and either used in the processing of the food
or for washing equipment, utensils and hands.
Angulo et al., (1997) intimated that water is a
well-known vehicle for enteropathogens such as E. coli,
Salmonella spp. and Campylobacter spp., amongst
others. In this connection, a study to determine the
bacteriological quality of the water used by some food
vendors in schools has shown frequent contamination
with Coliform and feacal Coliform (Chakravarty and
Canet, 1996). Dawson and Canet (1991) observed that
acute shortage of clean potable water compels many
vendors to re-use the water, especially for cleaning
utensils and used dishes.
Preparing and processing of ready- to-eat foods
Food preparation and processing are critical steps
prior to their sale and consumption and is important in
determining the safety of food. One key principle in
preparing and processing food is to avoid direct and
indirect contact between raw and cooked or prepared
foods which will be consumed without further heating
(WHO, 1996). Raw foods (e.g. salads and peeled or cut
fruit) should be prepared with special attention to
cleanliness. Grains (e.g. rice, pulses, and beans),
vegetables and some fruits (especially if they are to be
consumed raw) should be washed sufficiently with safe
water to reduce contamination to an acceptable level
(ht t p: / / www. who. i nt / foodsafet y/ publ i cat i ons/
fs_management/en/streetvend.pdf). Furthermore, the
preparation of food before its consumption, storage at
ambient temperature, inadequate cooling and reheating,
contaminated processed food, and undercooking are
identified as the key factors that contribute to food
poisoning outbreaks (WHO, 1989).
Esena et al.,2013
066 Journal of Research in Public Health (2013) 2(1): 063-072
Food storage
It is known that most foodborne diseases cases
are caused by the inappropriate handling in kitchens and
restaurants of contaminated food (including improper
storage, undercooking, or cross contamination) (Blaser,
2004). It has been reported that diarrhoeal cases can be
reduced by 39% via household water treatment and safe
storage (Fewtrell et al., 2005). Similarly, Mitakakis
et al., (2004) in a study identified food-handling and
storage practices in the home as major risk factors for
gastroenteritis. Longer holding time of certain high risk
foods create favorable conditions for the growth of
foodborne pathogens that causes foodborne diseases.
Foods vendors most often prepare ready -to eat foods in
bulk and store them for several hours after cooking
including overnight holding at ambient temperatures,
until sold, and thus can harbor high microbial
populations (El-Sherbeeny et al., 1985, Bryan et al.,
1992 and Lianghui et al., 1993). Bryan (1995) observed
that in such foods, the counts of pathogens including
Escherichia coli, Staphylococcus aureus, Bacillus
cereus and Clostridium perfringens are bound to be
unacceptably high.
Reheating
During reheating the time-temperature exposure
should be able to inactivate microorganisms and toxins
of concern. Omemu and Aderoju (2007) indicated in a
study that some food vendors often cook products ahead
of time, store them and then reheat them when requested
by customers. Their low knowledge of food hygiene
may require them to reheat food just to warm it and
improve on its palatability, rather than to destroy
pathogens. Bryan (1992) recommended that during
reheating the highest temperature attained at the
geometric centre of foods or the time-temperature
exposure of foods should be measured and recorded to
determine whether pathogens could survive the
temperature.

Knowledge of food handlers on food safety and
personal hygiene
The term food handler applies to persons who
prepare food and to those who sell it, if they are different
persons (WHO, 1996). Rheinlnder et al., (2008)
indicated that food safety is a major concern with ready-
to-eat foods as these foods are generally prepared and
sold under unhygienic conditions, with limited access to
safe water, sanitary services, or garbage disposal
facilities.
The importance of food handlers in the vending
of ready-to-eat foods cannot be overemphasized. They
have a prime role to play in food businesses, and thus
guarantee that meals served to their customers are
hygienic for consumption. It has been noted that the
examination of knowledge on food handling and health
problems on some food handlers proved that they did not
fully understand hazards, their risks and methods of
managing such hazards in the preparation and handling
of food (Amponsah et al., 2011).
WHO (1989) indicated that food handlers have
important role in ensuring food safety throughout the
chain of food production, processing, storage and
preparation. Any disregard and mishandling of hygienic
measures on the part of the food vendors may cause
pathogens to come into contact with food and multiply in
numbers of medical significance capable of causing
illness in the consumer. In Ghana, the use of a polythene
bag to package ready to- eat foods by food vendors is a
common phenomenon. In the course of packaging the
foods, food handlers blow air into the polythene bags to
open them and in the process a number of pathogens
could be passed on to the consumer. Mensah et al.,
(2002) are of the view that many food handlers introduce
biological and physical hazards through cross
contamination and mishandling of food.
Mensah et al., (2002) are of the view that the use
of bare hands to serve food increases the level of
contamination as entero-pathogens can survive on the
Esena et al.,2013
Journal of Research in Public Health (2013) 2(1): 063-072 067


hands for three hours or longer.
Pathogens can be harbored and transmitted on to
others by individuals who themselves are healthy. Such
carriers may have recently suffered an attack of food
poisoning and still be carriers of the organisms in their
body. In some in stances, carriers of food pathogens such
as Salmonella typhi and Bacillus cereus act as host over
a longer period of time having themselves acquired
immunity to organisms concerned. Such individuals
might end up transmitting organisms to other people
through food without being aware of it. It is thus
important that food handlers are educated on routes and
means through which pathogens invade the food they
prepare and sell to the public.
Addo et al., ( 2007) intimated that food vendors
who sell ready to eat meals on the streets are important
factors who contribute significantly to food borne
related diseases as they have very little or no educational
background and hence have low understanding of food
safety issues (Mensah et al., 2002). Most often food
handlers are unaware of their role as a reservoir of
infection (Nichol and Salek, 2007). Improper handling
and sanitation practices lead to person-to-person, person
to food and utensils to food cross contamination that
ultimately results in 27 % of reported outbreaks and
infection from food borne pathogens (WHO, 2002). The
transmission of pathogenic microorganisms by food
handlers is a problem in the food industry (Barza, 2004).
Food Hygiene Awareness among Food Handlers
There is no gainsaying that food handlers have a
major role in the prevention of food poisoning during
food preparation and distribution. Walker et al., (2003)
argued that food handlers usually cross-contaminate
processed food stuff and are likely to under-cook and
store foods properly. It is possible that in most cases,
they contaminate processed food stuffs without being
aware that they are doing so. Continuous training and
education thus become very important if food handlers
are to handle food in a hygienic and safe manner. Thus
the best preventive measure lies in educating the food
handler on good personal hygiene and food safety. Marth
(1985) however observed that the food handlers are
usually young, itinerant and inexperienced people who
hardly stay on the job for a year and hence it becomes
extremely difficult to find and educate them while
actively working. In relation to this Walker et al., (2003)
thus asserted that there is high probability that the
absence of continuous training and reinforcement is to be
blamed for lack of food hygiene knowledge concerning a
number of important aspects in safe food production. A
lot of studies have confirmed the rather low level of
knowledge of food handlers on hygienic and microbial
safety of ready-to-eat foods (Walker et al., 2003).
Inadequate hygienic knowledge and lack of
understanding of the basic principles of food hygiene is
thus a major bottleneck to the implementation of good
hygienic practices in the handling of ready-to-eat foods
in our schools and other public places. In this connection,
Ehiri and Morris, (1996) are of the view that there is the
need to conscientiously prevail upon and motivate food
handlers to put to practice their knowledge in food
hygiene.
In contrast to the assertion made by Walker
et al., (2003) and Bryan (1988), is the view that in
addition to ignorance, reluctance by food handlers to
apply the acquired knowledge also contributes in no
small measure to food poisoning by food handlers.
Connected to this, Angelillo et al., (2000), further
indicated that a study conducted in Italy depicted that
although food handlers had positive attitude towards
food safety, it has not supported their practices in food
handling. There seem therefore to be no correlation
between good knowledge in food handling and the actual
practice in food processing among food handlers. It is
abundantly clear therefore that apart from knowledge,
there might be other factors that bring about attitudinal
change in safe food handling practices. Taylor (2000)
identified these factors to include socio-economic status,
Esena et al.,2013
068 Journal of Research in Public Health (2013) 2(1): 063-072
educational level and literacy and itinerant nature of
most food handlers.
Appropriate hygienic aspects of vending
operations as a major source of concern may not be
readily available. Toilets and adequate washing facilities
are rarely available. Hand washing and washing of
utensils and dishes is often done in buckets or bowls.
Disinfection is not usually carried out, and insects and
rodents may be attracted to sites where there is no
organized sewerage disposal. It has also been observed
that food is not adequately protected from flies; and
refrigeration is not usually available (Mensah et al.,
2002).
Some Food borne diseases
Foodborne diseases are either infectious or toxic
in nature. The toxins usually enter the human body
through consumption of food. Foodborne illness on the
other hand is sickness that results from eating
contaminated food laden with pathogenic
microorganisms, chemical or physical agents. The
victims normally experience one or more symptoms such
as nausea, vomiting, diarrhea, dehydration, abdominal
pain, headache, and fever (McSwane et al., 2002).
Foodborne diseases are a serious health hazard and an
important cause of morbidity and mortality in developing
countries. It is an undisputable fact that most cases go
unreported and scientific investigations are rarely
conducted in most developing countries (Anuradha et al.,
1999). WHO (2002) observed that food and waterborne
diseases are the leading causes of illness and death in
under-developed countries, killing almost 1.8 million
people annually, most of whom are children.
Inappropriate handling practices by humans in
unhygienic behaviour could lead to food borne diseases
and poisoning (Adams and Moss, 2003); and foodborne
illness costs lives and money. The effect is that, millions
of people fall sick each year as thousands die after eating
con-taminated or mishandled foods. Children, the
elderly and people with weakened immune systems are
especially vulnerable to foodborne illness.

CONCLUSION AND RECOMMENDATION
Studies across Africa have shown the extent to
which health hazards are posed to children by foods sold
on streets; and it is known that such foods contribute
significantly to morbidity and even mortality among
children (Canet and NDiaye, 1996). For the fact that
food vendors operate in insanitary environments that
could cause transmission of pathogens into food and
subsequent outbreak of foodborne diseases, it is
important that monitoring of foods sold in the various
places are conducted by the regulatory authorities (e.g.
municipal environmental and sanitation directorate) as
quality checks. Furthermore, there should be policies to
regulate and ensure that school canteens are strategically
located and not close to filth such as dumping sites and
toilets.

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