Magnitude of Enteropathogens and Associated Factors Among Apparently Health Food Handlers at Wolkite University Student’s Cafeteria,

Abstract Objectives: The study aimed to assess enteropathogens carriage rate, and risk factors among apparently healthy food handlers at Wolkite University cafeteria, South Ethiopia. Results: Cross-sectional study was conducted among 170 food handlers to collect socio-demographic and related data by using structured questionnaires. Stool samples were collected and subjected to microscopic examination and cultured to determine intestinal parasites. Among the total study participants, 66% of them were found to be carriers of enteropathogens: bacteria (Salmonella typhi, Shigella species), and intestinal parasites (Ascaris lumbricoides,Taenia species, Giardia lamblia, Entameoba histolytica/dispar, Enterobius vermicularis, Hook worm and Trichuris trichiura. All Salmonella and Shigella isolates were sensitive to ceftriaxone, ciprofloxacin, and gentamicin. Age, job description, non medical checkup and hand washing practice before food preparation have a significant association with eneropathogens. Significant proportion of food handlers was found to be carriers of pathogens which require a periodic screening and antibiotic consumption monitoring.


Introduction
Human's health and well-being is indispensably relayed on safe delivery, sound and nutritious food [1]. However, sometimes, health intimidation can be fronted by consumption of contaminated foods result in food-borne disease. Moreover, diseases spread through food are common and persistent problems that result in appreciable morbidity and mortality across the globe especially to developing countries [2,3].
The World health organization (WHO) estimated that up to70% of the population suffer from diarrheal diseases in developing countries, with estimated 2 million deaths per year 3 [4,5].The diseases are caused mostly by foodborne microbial pathogens like Salmonella, Campylobacter, pathogenic Escherichia coli, Shigella, and other related intestinal parasites [6,7]. These organisms may exist on food handler's skin, from which they may be transmitted to cooked moist protein-rich foods, and become intoxication agents if these foods are then kept for several hours without refrigeration [10][11][12][13]. Fingernails compared to other parts of the hand, harbors many microorganisms and is difficult to clean [12].

1.
typhi is one of the major causes of food and water borne gastroenteritis in human [14,18,19] and remains an important health problem worldwide of which 16 million new cases and 600,000 deaths of typhoid fever annually [20] with antimicrobial resistance emergence as a current concern [21]. Evidences showed that different predisposing factors like food handler's personal hygiene, knowledge and practice of food hygiene are the major determinants for food contamination and outbreaks of food poisoning [15].
Food safety issues are common public heath burdens in our setups which are not well understood and have received little attention. Meals served at establishments in higher learning institution are prepared in large quantities pave a way to contamination, and there is a greater potential for the occurrence of food borne disease outbreaks if basic sanitary practices are not properly maintained [17]. Thus, this study is aimed at determining prevalence of intestinal pathogens and assessing the hygienic practices among food handlers at Wolkite University cafeteria, South Ethiopia.

Study Design
A cross sectional study was conducted at Wolkite University cafeteria, South Ethiopia from December to February 2017 from 170 food handlers. At present, the cafeteria has 340 food handling personnel serving for about 11,000 students. All food handlers from the University food handling establishment were included and then proportional allocation was considered to select 170 food handlers from each section. Food handlers who had taken anti-helminthics within the three weeks prior to the study and newly recruited were excluded.
Sample size was determined after a single size population proportion formula taking a proportion of 6.9% Salmonella species prevalence in Arbaminch University cafeteria(Mohammed), Z α/ 2=1.96, confidence level of 95%, and margin of error = 0.04.
The sample size became 156 and the final sample size after adding 10% non-response rate was 170.

Data collection and processing
Personal data, hygienic profile, knowledge and attitude assessments were handled by structured questionnaire adopted from similar survey and literatures.
Ova/parasite detection: A loop full of stool sample was collected from each food handler and examined following direct wet mount preparations in normal saline, iodine solution and formol-ether concentration sedimentation techniques as per the standards. The parasites identified in any one of the three techniques from a single specimen will be reported as positive [22].

Culturing of Salmonella and Shigella spp.
Stool specimens were pre-enriched with Selenite F broth and inoculated to Xylose Lysine

Socio-demographic characteristics
The study encompassed 170 food handlers, of which 149 (87.6%) were females. Food handlers were in the age range of 18 to 57 years. Out of the total study participants, 60.0% were married and 61.8% worked for 2-3 years. [Table 1]

Hand Washing Practices and knowledge
Of all food handlers, 112 (65.9%) had the habit of hand washing after toilet of which 37.5% washed with soap and water whereas majority, 62.5% used water only.
Nevertheless, 84 (49.4%) and 87 (51.2%) of them had a habit of hand washing after touching dirty objects and between handling and before eating food respectively. One hundred fifty two of the food handlers knew at least one type of food borne disease of which 55.3% answered that food contamination as a route. About 72.0% food handlers 6 replied unhygienic food preparation was cause of food borne diseases followed by germs, 60% while the least, 36 (21.1%) has responded chemicals as the source of food contaminants. [ Table S1].

Prevalence of intestinal Parasites
Thus, a total of 98 intestinal parasites and 14 bacterial strains were isolated of which 27.6%, 14.7%, and 7.1% were found to be positive for Ascaris lumbricoides, Taenia species and Giardia lamblia, respectively; and 5.9% of them were carriers of S. typhi while 32(32.6%) had miscellaneous parasitic infections. (Figure 1 and Figshare/ Figure 2)

Risk Factors for Enteropathogens
Age and job description of the food handlers have significant association with eneteropatgens (P=0.001). Enteropathogens species were more prevalent in those who were not checked medically (9:1) to (P=0.0229). However, there was a significant association between hand washing practice before food preparation and isolated pathogens [P=0.00; OR=4.8]. [Table S1]

Antimicrobial Susceptibility Pattern
All Salmonella and Shigella species showed 100% resistance to both ampicillin and amoxacillin. Neverthless, both isolates were found to be 100% sensitive to four of these drugs: ceftriaxone, ciprofloxacillin, norfloxacillin, and gentamicine. The overall multi-drug resistance rate of Salmonella and Shigella species was found to be 100% and 75% respectively. [Tabshare]

Discussion
This study revealed that about 112 (66%) of the food handlers were found to be carriers of one or more of the pathogenic organisms of which Ascaris lumbricoides, Taenia species and Giardia lamblia were the most common and represented 55.3% of the total infections.

Conclusions And Recommendations
Significant proportion of food handlers were affected by intestinal parasites and S. typhi carrier rate. Significant association was observed between hand washing practice before food preparation and isolated Salmonella. The overall multi-drug resistance rate of Salmonella and Shigella species was observed found to be 100% and 75% respectively.
Thus, concerned bodies should made prompt intervention to reduce further transmission of food borne diseases, including set up periodic medical check up, training on safe food handling and hand washing practice during critical times.

Limitation of the Study
As far as the limitation of this study concerned, Salmonella serotype and Taenia Species were not identified due to resource inavailability. Participants were informed about the purpose of the study and then written informed consent was obtained from each study participants and any information related to the participants was kept confidential and coded without mentioning their names. Laboratory results were sent to the responsible physician so that the participants would be benefited 9 from the study.

Consent for publication
Not applicable

Availability of data and material
Data is available on principal investigator and can be obtained with reasonable request.

Compiting Interests
We declare that there has been no competing interests among the authors.

Funding
The research was funded by Wolkite University.

Competing interests
The authors declare that they have no competing interests.
TA conceived the study, participated in the study design and data analysis, drafted and finalized the manuscript for publication.
AH participated in the data collection, data processing, and data analysis. Both authors contributed to the writing of the paper and approved the final paper.
EM also participated in the study design, data acquisition, and data analysis. Both authors contributed to the writing of the paper and approved the final paper.    Table S1.pdf