Jumping Genes Cross Plant Species Boundaries

Background: Food hygiene in hospital poses peculiar problems, particularly given the presence of patients who could be more vulnerable than healthy subjects to microbiological and nutritional risks. Moreover, in nosocomial outbreaks of infectious intestinal disease, the mortality risk has been proved to be significantly higher than the community outbreaks and highest for foodborne outbreaks. On the other hand, the common involvement in the role of food handlers of nurses or domestic staff, not specifically trained about food hygiene and HACCP, may represent a further cause of concern. The purpose of this study was to evaluate knowledge, attitudes, and practices concerning food safety of the nursing staff of two hospitals in Palermo, Italy. Association with some demographic and work-related determinants was also investigated. Methods: The survey was conducted, by using a semi-structured questionnaire, in March-November 2005 in an acute general hospital and a paediatric hospital, where nursing staff is routinely involved in food service functions. Results: Overall, 401 nurses (279, 37.1%, of the General Hospital and 122, 53.5%, of the Paediatric Hospital, respectively) answered. Among the respondents there was a generalized lack of knowledge about etiologic agents and food vehicles associated to foodborne diseases and proper temperatures of storage of hot and cold ready to eat foods. A general positive attitude towards temperature control and using clothing and gloves, when handling food, was shared by the respondents nurses, but questions about cross-contamination, refreezing and handling unwrapped food with cuts or abrasions on hands were frequently answered incorrectly. The practice section performed better, though sharing of utensils for raw and uncooked foods and thawing of frozen foods at room temperatures proved to be widely frequent among the respondents. Age, gender, educational level and length of service were inconsistently associated with the answer pattern. More than 80% of the respondent nurses did not attend any educational course on food hygiene. Those who attended at least one training course fared significantly better about some knowledge issues, but no difference was detected in both the attitude and practice sections. Conclusion: Results strongly emphasize the need for a safer management of catering in the hospitals, where non professional food handlers, like nursing or domestic staff, are involved in food service functions. Published: 3 April 2007 BMC Health Services Research 2007, 7:45 doi:10.1186/1472-6963-7-45 Received: 5 January 2007 Accepted: 3 April 2007 This article is available from: http://www.biomedcentral. com/1472-6963/7/45 © 2007 Buccheri et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Page 1 of 11 (page number not for citation purposes) BMC Health Services Research 2007, 7:45 http://www.biomedcentral. com/1472-6963/7/45 Background In the last decades, the epidemiology of foodborne diseases is changing with new or unexpected pathogens often emerging on a countrywide or worldwide scale, new foods expanding the range of potential vehicles of pathogens, wider social contexts being involved and new classes of individual being at higher risk [1,2]. These changes may be attributable to several socio-economic and demographic factors, including dramatic quali-quantitative changes in primary production, processing, distribution and handling of food and the increasing exposure of individuals, like elderly, patients with impaired immunity and many hospitalized subject [3-6]. Epidemiological and surveillance data suggest that faulty practices in food processing plants, food service establishments and home play a crucial role in the causal chain of foodborne diseases. This issue has also proved to be critical in some nosocomial foodborne outbreaks [7-11]. Hence, a major goal of the hospital is to provide safe food to patients who frequently are at higher risk of acquiring infections and their complications [12,13]. In Italy, like in other European countries, great efforts are being put in place to promote food safety at all levels of the food chain, and the European legislation has mandated that all food businesses adhere to the Hazard Analysis and Critical Control Points (HACCP) system [14]. The importance of food hygiene training is also experiencing a growing acknowledgement by both food workers and the official control systems in Europe. Both the European Directive 93/43 and the more recent Regulation 852/2004 require food hygiene training for every food handler [15]. Food hygiene in the hospital can acquire peculiar features: indeed, many patients could be more vulnerable than healthy subjects to microbiological and nutritional risks; large numbers of persons can be exposed to infections and possible complications; gastroenteritis can impair digestion and absorption of nutrients and the perception or fear about poor food hygiene practices might result in patients rejecting the meals supplied by the hospital catering [12,13]. In nosocomial outbreaks of infectious intestinal disease, the mortality risk has been proved to be significantly higher than the community outbreaks and highest for foodborne outbreaks [16]. On the other hand, further peculiar concern arises from the common involvement in the role of food handlers of nurses or domestic staff, who are not specifically trained about food hygiene and HACCP, but can be engaged in receipt, distribution and serving of ready made foods and supervision of these services. The aim of this study was to evaluate knowledge, attitudes and practices of the nurses routinely involved in food service functions in two hospitals of Palermo, Italy. Association with some demographic and work-related variables was also investigated. Methods Setting For the purpose of the study, we selected two hospitals included into the Azienda di Rilievo Nazionale ed Alta Specializzazione (ARNAS) in Palermo, Italy: a) the acute general hospital "Civico and M. Ascoli" with 43 wards and 900 beds; b) the paediatric hospital "G. Di Cristina" with 13 wards and 220 beds. The two hospitals are contracted out to an external caterer under the regulations in force in Italy and the additional conditions specified by the hospital board. The catering service is provided by a single premise, where an HACCP plan is in place since 2000 and a quality assurance program is running in accordance with the UNI EN ISO 9002 standards. The meals are plated individually according to patient needs and wants, stored and transported in either a heated or cooled state and delivered to wards for immediate distribution. On arrival at the ward level, a random checking to ensure that food is served at the correct temperature is performed by the nursing staff. This is charged also with the function of monitoring the intervals of time between reception and distribution of meals and the hygienic practices of the domestic staff through the entire food handling procedure the until disposal of wastes. To ensure that correct qualitative standards are being adhered to, a monitoring program is in place by the medical direction of the two hospitals to assess the quality of food, hygiene, production standards, specifications and service. Survey instrument From March to November 2005, knowledge, attitudes and practices about food hygiene of the nursing staff of the two hospitals under study were investigated by means of a questionnaire survey. The medical directors of the hospitals were sent a letter explaining the purpose and the investigation procedure. Because the survey data did not influence patient management and the issue being investigated is a matter of public record, ethical approval for the study was not required. After obtaining approval, the questionnaire was addressed to all nurses potentially involved in food related functions in the acute general hospital "Civico and M. Ascoli" and the paediatric hospital "G. Di Cristina" (751 and 228, respectively). To overcome the difficulties arising from the habitual 8-hours shifts of the health care workers and minimize the nonrespondent prevalence, the questionnaire was self-administered. Confidentiality of the answers was also warranted. Page 2 of 11 (page number not for citation purposes) BMC Health Services Research 2007, 7:45 http://www.biomedcentral. com/1472-6963/7/45 A questionnaire (see the additional file 1), containing mainly multiple-choices questions, was prepared based upon questionnaires previously used in studies done in Italy and in other countries [17-20]. It included five sections: a) demographic characteristics, employment status and hospital/ward where the nurse worked; b) knowledge about food hygiene; c) attitudes towards prevention of foodborne diseases; d) measures to be used in prevention of foodborne diseases; e) sources of information about food hygiene. The questions concerning knowledge about foodborne disease agents and foods epidemiologically linked to transmission of pathogens listed some microrganisms, and respondents were asked to choose from among three options – yes, no, don't know – about their association with foodborne disease and to couple at least one food vehicle to each pathogen. A question on a nonfoodborne agent of special interest for healthcare workers, hepatitis B virus (HBV), was added. Answers were classified as correct when they contained exclusively food items whit a well recognized role as a vehicle for the pathogen under analysis. The answers in the section of practices were simplified, including only three choices (always, often, occasionally). Statistical procedures Food safety knowledge, attitude and practice scores for the respondents were, respectiv