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Spread of Infection while Handling Food in Hospitals

Discuss about the Food Handling Guidelines in Hospital Based Care.

Responsible for making sure that the food they are serving, meets all the levels of safety. From the levels of production, processing, storage as well as preparation, food handlers are responsible for every steps of the process (Lopez et al., 2013). When a person falls sick in a hospital due to the food consumed over there, the cardinal principle of hospital care stands challenged, after all hospitals are supposed to ensure that no harm befalls on the patient. Hospital Associated Infections (HAI) has been the main reason why most of the times people fall sick during their stay in the hospital (Porsbol, Jensen & Norung, 2013). Along with invasive procedures, immuno compromised states, patients on ventilators or catheters; the food, which is being consumed at the hospitals, is also responsible for patients in contracting HAI.  

In this essay, evidence based research has been carried out where the topic, food handling guidelines in hospitals, has been explored. The spread of the infection through the pathogens in the hospital context has been focused by carrying out evidence-based research. The quality control and safety of the patients and staff has been considered and a comparative study has been carried out. The comparison has been drawn between the food handling guidelines modeled in New Zealand against the rest of the world.

The main organisms causing foodborne diseases especially in a hospital are Salmonella, Campylobacter, Escherichia coli, Listeria monocytogenes, Yersinia, Campylobacter, Toxoplasma gondii, STEC (Shiga- toxin producing E. coli), Giardia intestinalis, Norovirus, Cryptosporidium (Kadariya, Smith & Thapaliya, 2014). The evidence-based studies which has explanation of the spread of the infection has been given below. Most of the studies are within the evidence levels III-VII. Since they are not very high on the list of level of evidence therefore it can be assumed that there is little information available on this particular aspect. Mostly, the outbreaks are hardly ever reported and recorded by the hospital authorities.

Belliot et al., (2014) had carried a study on the food borne pathogen Norovirus causing gastroenteritis. The study was a Level IV evidence based research where the results were obtained from a cohort study sample. This particular paper has been chosen because the study deals with norovirus and its role in causing gastroenteritis among patients in the hospital. Being a causative organism for HAI, this evidence was chosen. In this study prevalence of the disease in a health care system was analyzed which showed that unhygienic conditions while serving food has been the reason for immune compromised patients at the hospitals to have contracted the disease. Patients who have undergone transplantation procedures in organs such as intestine, heart, kidney, liver, pancreas, are susceptible in contracting the infection by the Norovirus. The virus not only contaminates food, but if the food handlers are not careful, the virus can contaminate even water. From the aspect of New Zealand, the government for patients infected with Norovirus has spent a hefty sum of $3 million. The pathogen affects the staff as well as the patients and can only be curbed by practicing hygienic standards while handling food. Bitler et al. (2013)(Level III) and Trivedi et al. (2012)(Level III) have made similar reports.

Quality and Safety of the Patients and Staff: Recommendations

Pinto et al. (2015) had carried a study of a hospital food in Brazil and had found out with the help of the microbiological assay that the food samples were contaminated with traces of Pseudomonas sp. The study was a Level VI evidence based study where evidences were collected from a qualitative study. The food samples were tested for Staphylococcus, Salmonella and Listeria too. The patients who are the participants of Enteral Nutrition Therapy (ENT) were susceptible to microbial contamination of food. The food is mostly rich in macro and micronutrients for the patients who are deficient in nutrition and this allows the microorganisms to thrive and increases the risk of HAI. The study revealed that it is not possible to test the presence of the microbial contamination before consumption because the food ha to be consumed soon.  

Stewardson et al. (2014) had carried a study where he had assessed the contamination of hospital food by Extended-spectrum β-lactamase (ESBL) producing Enterobacteriaceae (ESBL-PE). The study was a Level VI evidence based study where evidences were collected from a qualitative study. Catering services, that provide their services to the hospitals in Geneva, has been found to use poultry, which has been contaminated with ESBL-PE along with β-lactamase residue. The staff who had consumed the same food was found to be affected by it. It was later determined that the administration of antibiotics to the poultry has resulted into such a situation.

Lee & Greig (2013) had carried out a study where they had reviewed the Salmonella outbreaks from the nosocomial aspects in the hospital. Contaminated food was identified to one of the several reasons responsible for causing the outbreak. The study was a Level V evidence based study as the data that were collected were of systematic reviews, which had carried out a qualitative analysis. The study found out that the pathogen was infecting the patients through food. The source was identified as raw and uncooked foods such as eggs and other animal products. The food borne Salmonella outbreaks can only be stopped by practicing safe and hygienic cooking at the kitchen in the hospitals.  

MMWR (CDC Morbidity and Mortality Weekly Report) (2012) presented a report where a State Psychiatric Hospital in Lousiana had faced an outbreak of food borne infection by the pathogen Clostridium perfringens. The report can be classified as Level VII evidence based study where an expert committee, such as CDC (Center for Disease Control and Prevention), has presented the report. The food served to the patients was found to be the main reason of infection. It was noted that the meat that was served to the patient was not properly cooked and was served as ingredient for cold chicken sandwich and salad. The hospital appeared to have violated the sanitary code of the Lousiana state.

Quality and safety of the patients and staff can be ensured by practicing safety measures to curb the spread of the food borne diseases at the hospitals. The following steps can be followed in order to ensure quality control and safety, were given by the Australian Food Safety Information Council (2014), such as,

training the hospital staff to maintain a clean and safe environment, promote awareness in regard to HAI, staff health should be monitored; waste disposal at the hospital should be also monitored, sterility should be on top of the priority list in every aspect of hospital care to prevent food borne outbreak at the hospital (Mullan et al., 2016). Care should also be taken that the foods are being cooked properly in order to reduce the chances of cross-contamination. The food should also be maintained at a proper temperature in order to prevent microbial growth.

In respect to evidence based study, Abdul-Mutalib et al. (2012)(Level IV) carried out a study, which pointed out the importance of maintaining personal hygiene in respect to the food handlers. Along with the patients, they are also exposed to the food borne pathogens. Most of the times, the food handlers are the vectors for the pathogens and therefore, practices like wearing clean and sterile gloves while handling food items, wearing clean clothes, not wearing accessories and using clean utensils,  are important in order to prevent the micro organisms from multiplying and causing infection.

Fox & Friefeld (2012)(Level VI) have carried out a review on neutropenic diet as a novel move towards reducing chances on HAI. Neutropenic diet refers to a diet especially designed for the cancer patient where there is a limitation is levied on the content of the diet. The measure was imposed to reduce the chances of the cancer patients from contracting gastro intestinal tract related pathogens. For cancer patients who are already undergoing chemotherapy, has their immunity challenged. Due to this, they are fall prey to the disease causing pathogens easily giving them a bout of HAI. Therefore, they are given a neutropenic diet, which is also known as ‘sterile diet’ or ‘low bacteria diet’ or ‘low microbial diet’.

Oludare et al. (2016)(Level III) has pointed the necessity for maintain food safety at the hospitals and went onto stating the guidelines the food handlers should take into accord so the patient do not develop a bout of HAI. They have stated that while cooking the raw and the fresh food should be prepared separately. Once defrosted, the food item should never be frozen back. The food handlers should wear masks and gloves while preparing or serving food. In short, the HACCP (Hazard Analysis and Critical Control Points) guidelines should be maintained in order to meet the standards of food safety. Castle et al. (2014)(Level III) and Jevsnik et al. (2013)(Level IV) have carried out similar studies.  

Lee & Greig (2013)(Level V) have stated in their work how food and safety hygiene can be maintained in the hospitals to prevent the patients from developing an infection by consuming contaminated food. They have stressed on how the food handlers should maintain personal hygiene while preparing or packing the food. They should not smoke in the kitchen or the serving area. The food handlers should be completely a different set of people hired by the hospital officials. The lesser contact they have with the patient the better. In this way, the safety of the food handlers also remains intact. There equipments should be clean at all times in which the food is prepared or served. Care should be taken that sink where the utensils and containers are being washed is clean too. It is necessary that the food handlers should always the monitor the temperature of the food that they are cooking and follow the HACCP guidelines at all times.

Kadariya, Tara & Thapaliya (2014) (Level VI), has highlighted the potential risk the enterotoxins of the pathogens causing food borne diseases poses. Lack of proper storage conditions of certain food items leads to the production of the toxins in the food. These foods can also lead to life threatening conditions if not taken proper care. Both the patients as well as the food handler are at risk from it. Martins, Hogg & Otero (2012)(Level IV) have worked on food handling by a catering company that is responsible for delivering food to the hospitals in Portugal. They have outlined the issues related to the food handlers, which results into contamination of the food. Verhoef et al. (2013)(Level V) had carried out a similar study and found out the reasons of contamination of food with Norovirus.

The Food Safety Standards 3.2.2, which is part of the Food Standards Australia New Zealand (FSANZ), outlines the safety-based practices and general requirements while handling food. It has a lot of similarity with the food handling guidelines as stated by WHO (World Health Organization). Both the standards concentrate on the design and construction of the premises which is responsible for the preparation of the food as well as for storage of food. Both the standards agree that the food service facilities as well as the food handlers should be trained and equipped with information related to food hygiene and the transmission of pathogens through food. The standards also aim at carrying out surveys on based on random trials to determine how far the handlers are following the guidelines. The standards also outline that the foods should be properly refrigerated and cooked properly and then stored in clean vessels in order to prevent microbial contamination.


As a concluding remark, it has been noted from the evidence-based study that food borne diseases is quite nagging and it is affecting a large number of people. However, most of the times, these outbreaks at the hospitals are not recorded. Worse, the reason for the outbreak is never analyzed. It has to be curbed and it can only take place when the hospital staffs are strictly following the food handling guidelines that has been outlined by the Ministry of Health, New Zealand. The expense of treating patients at the hospitals due to HAI is huge and it has been shooting ever since. This is affecting the economy of the nation as a whole. To save those revenues that are lost only to treat patients affected by HAI, the hospital officials are becoming stringent in their ways of providing treatment and care to the patients. Awareness is being raised among the staffs that are directly responsible in preparing and handling of the food in the hospitals. Not just in New Zealand alone, but also on a global scale, standards need to be improved in food handling in hospitals. The mortality rate along with the morbidity rate has to be managed by safeguarding the patients from contracting food borne diseases.


Abdul-Mutalib, N. A., Abdul-Rashid, M. F., Mustafa, S., Amin-Nordin, S., Hamat, R. A., & Osman, M. (2012). Knowledge, attitude and practices regarding food hygiene and sanitation of food handlers in Kuala Pilah, Malaysia. Food Control, 27(2), 289-293.

Australian Food Safety Information Council. (2014). Retrieved on 11th November, 2016.

Belliot, G., Lopman, B. A., Ambert?Balay, K., & Pothier, P. (2014). The burden of norovirus gastroenteritis: an important foodborne and healthcare?related infection. Clinical Microbiology and Infection, 20(8), 724-730.

Bitler, E. J., Matthews, J. E., Dickey, B. W., Eisenberg, J. N. S., & Leon, J. S. (2013). Norovirus outbreaks: a systematic review of commonly implicated transmission routes and vehicles. Epidemiology and infection, 141(08), 1563-1571.

Castle, N., Wagner, L., Ferguson, J., & Handler, S. (2014). Hand hygiene deficiency citations in nursing homes. Journal of Applied Gerontology, 33(1), 24-50.

Centers for Disease Control and Prevention (CDC), (2012). Fatal foodborne Clostridium perfringens illness at a state psychiatric hospital--Louisiana, 2010. MMWR. Morbidity and mortality weekly report, 61(32), p.605.

Fox, N.R. D., LMNT, C., & Freifeld, A. G. (2012). The neutropenic diet reviewed: Moving toward a safe food handling approach. Oncology, 26(6), 572.

Jevšnik, M., Ovca, A., Bauer, M., Fink, R., Oder, M., & Sevšek, F. (2013). Food safety knowledge and practices among elderly in Slovenia. Food control, 31(2), 284-290.

Kadariya, J., Smith, T. C., & Thapaliya, D. (2014). Staphylococcus aureus and staphylococcal food-borne disease: an ongoing challenge in public health. BioMed research international, 2014.

Lee, M. B., & Greig, J. D. (2013). A review of nosocomial Salmonella outbreaks: infection control interventions found effective. Public health, 127(3), 199-206.

Lopez, L., Carey-Smith, G., Lim, E., Cressey, P., & Pirie, R. (2013). Annual Report Concerning Foodborne Disease in New Zealand.

Management of Food Safety in Hospital and Health Service Facilities. Department of Health. Retrieved on 11th November.                   

Martins, R. B., Hogg, T., & Otero, J. G. (2012). Food handlers’ knowledge on food hygiene: The case of a catering company in Portugal. Food Control, 23(1), 184-190.

Mullan, B., Allom, V., Sainsbury, K., & Monds, L. A. (2015). Examining the predictive utility of an extended theory of planned behaviour model in the context of specific individual safe food-handling. Appetite, 90, 91-98.

Oludare, A. O., Ogundipe, A., Odunjo, A., Komolafe, J., & Olatunji, I. (2016). Knowledge and Food Handling Practices of Nurses in a Tertiary Health Care Hospital in Nigeria. Journal of environmental health, 78(6), 32.

Pinto, R. O. M., Correia, E. F., Pereira, K. C., Sobrinho, C., de Souza, P., & Silva, D. F. D. (2015). Microbiological quality and safe handling of enteral diets in a hospital in Minas Gerais, Brazil. Brazilian Journal of Microbiology, 46(2), 583-589.

Porsbol, L. J., Jensen, T., & Norrung, B. (2013). Occurrence and control of viruses in food handling environments and in ready-to-eat foods. Food Borne Viruses and Prions and Their Significance for Public Health, 181.

Safe Food Handling. World Health Organization. Retrieved on 11th November, 2016.

Stewardson, A. J., Renzi, G., Maury, N., Vaudaux, C., Brassier, C., Fritsch, E., ... & van de Laar, T. (2014). Extended-Spectrum β-Lactamase–Producing Enterobacteriaceae in Hospital Food: A Risk Assessment. Infection Control & Hospital Epidemiology, 35(04), 375-383.

Trivedi, T. K., DeSalvo, T., Lee, L., Palumbo, A., Moll, M., Curns, A., ... & Lopman, B. A. (2012). Hospitalizations and mortality associated with norovirus outbreaks in nursing homes, 2009-2010. Jama, 308(16), 1668-1675.

Verhoef, L., Gutierrez, G. J., Koopmans, M., & Boxman, I. L. (2013). Reported behavior, knowledge and awareness toward the potential for norovirus transmission by food handlers in Dutch catering companies and institutional settings in relation to the prevalence of norovirus. Food control, 34(2), 420-427.

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