MATERIALS AND METHODS

Study design and setting: This research was carried out in two general hospitals in Mecca from May, 2014-November, 2014, which contributes in finding and determining the possible stage of production chain that causing microbial contaminations to hospitalized patients’ meal to improve the safety of such meals. The study had the ethical approval from both the Research Ethics Committees in Faculty of Applied Medical Sciences, University of Umm Al Qura and the Research Ethics Committees in Mecca Health Affairs Directorate. Sanitation and hygiene practices as well as microbial examinations of patients’ meals were evaluated along all stages of the production chain including: Receiving and storage ofingredients, preparation, cooking, collecting foods at the line and serving the meal to patients.

Methods: The GMP, sanitation and hygiene practices were assessed using a predesigned checklist included 80 items representing 11 parameters are as follows: Personal hygiene, food preparation, hot holding, cold holding, refrigerator and freezer, food storage, cleaning and sanitizing, utensils and equipment, garbage storage and disposal and pest control. Each item complying with hygienic requirements was given ten points. On the other hand, the microbial examinations were assessed from all production chain stages of patient meal. One hundred and eighty samples of patients’ meals from both hospitals were examined. A sample of about 100 g or 100 mL from each food item was aseptically collected in a sterile plastic container. The samples then were transported as soon as possible to the laboratory using an insulated ice box containing an ice pack. Ten-fold serial dilutions from each sample were prepared and subjected to the bacteriological examination including estimation total Aerobic Plate Count (APC), enumeration of mould and yeast count and detection for absence or presence of S. aureus, E. coli and Salmonella spp. according to the standard methods discussed by George et al.¹⁰ and Roberts and Greenwood¹¹.

Statistical analysis: Data were analyzed using SPSS, version 20 (IBM Corp., Armonk, New York, USA). Mann-Whitney test for non-parametric data was performed to determine the statistical differences of results between the two hospitals. p-value less than 0.05 was considered statistically significant. Data were expressed in form of Mean±SD.

RESULTS

Table 1 shows the GMP and sanitation procedures’ scores and percentages in the two hospitals. Results of the studied parameters displayed comparable values between both hospitals and no significant differences were observed in the total score between them (77.5 vs. 78.9%).

Table 2 demonstrates the comparison in colony forming unit per gram (CFU g^–1) of APC as well as moulds and yeasts counts in the selected foods during all stages of the production chain of patient meal in the two hospitals. No significant differences in the microbiological examinations were observed in the stages of receiving and storage of ingredients, preparation, cooking and collecting foods at the line between the two hospitals. Serving the meals to patients’ stage showed significantly (p = 0.036) higher APC value in hospital 1 than hospital 2. It was observed that APC as well as moulds and yeast counts were higher at the first two stages of the production chain for both hospitals, then decreased at the cooking stage.

Table 1:	Evaluation of GMP and sanitation procedures in the two hospitals

Table 2:	Comparison of APC as well as moulds and yeasts counts in foods during the production and serving stages of patient meals in the two hospitals

Table 3:	Detection of some food pathogens during the production and serving stages of patient meals in the two hospitals

Table 4:	Comparison of the APC and Salmonella spp. counts between the two hospitals for hot and cold served foods from the last stage of the production chain

The presence or absence of S. aureus, E. coli and Salmonella spp. bacteria during the production and delivery stages of patient meal in the two hospitals was shown in Table 3. Staphylococcus aureus and E. coli bacteria were detected at the first two stages of the production chain but neither of these bacteria were detected after cooking of foods. On the other hand, Salmonella spp. were detected at all stages of the production stage except the cooking stage.

Table 4 presents a comparison of the APC and Salmonella spp. counts between the two hospitals for hot and cold served foods from the last stage of the production chain. In hospital 1, cold served foods had significantly (p = 0.042) higher APC count than hot served foods and no Salmonella spp. were detected. However, hospital 2 showed higher APC counts for cold served foods than hot served foods but not statistically significant and Salmonella spp. count was significantly (p<0.05) higher in cold served foods than hot served foods. The cold served foods that showed the presence of Salmonella spp. were vegetable salad and coleslaw salad that contained mayonnaise.

DISCUSSION

This study aimed to determine the possible stages of the production chain that caused contamination to the patient meal and act as critical point at which control can be exercised to reduce, eliminate or prevent the possibility of a food safety hazard in two hospitals in Mecca region. The GMP and sanitation procedures between the two hospitals were implemented similarly. During the production chain of patient meal, cooking stage decreased the APC as well as moulds and yeast counts considerably but APC were detected during delivery of the meals to patients in one of the hospitals. At cooking and delivery stages, S. aureus and E. coli bacteria were not detected due to the cooking temperature. Although Salmonella spp. not detected in cooked and hot served foods, cold served foods showed presence of Salmonella spp. in vegetable salad and coleslaw salad that contained mayonnaise.

A possible contamination was detected during serving the meals to patients. Contaminations at this stage could happen by leaving prepared foods at an unsafe temperature for a long time at the pre-distribution stage, sick workers staying at work, food workers and handlers do not wash their hands carefully, foods contacted to contaminated surfaces, undercooked foods, using unclean trolleys, delaying the distribution of meals to hospital wards or unhygienic conditions at the hospital ward^12,13. Several measures could be adopted to prevent or minimize food contamination, those are: Cold consumed food should be eaten within 30 min of removal from the storage area, the temperature of hot and cold served foods to patients should be kept above 63°C and below 8°C, respectively, maintaining clean and hygienic utensils and equipments and training food workers for proper GMP implementation all the time^14,15. In addition, international standards recommend that the temperature throughout the cooked food should be held at 70°C for at least 2 min to destroy all pathogenic non-spore-forming bacteria¹⁵.

Many food borne outbreaks in hospitals and health care settings have been reported causing deaths to patients. However, immune-compromise individuals are to be the most affected and deaths in hospital food borne outbreak, which are preventable by implementing proper food safety measures¹⁶. E. coli bacteria caused outbreaks in healthcare settings in Scotland¹⁷, Canada¹⁸ and USA¹⁹ with 2 and 3 deaths in Canada and USA, respectively. Outbreaks from Salmonella spp. in hospitals also were noticed with 5 deaths in Netherlands²⁰ and 18 deaths in Australia²¹. The probable food carrier of these outbreaks from E. coli could be from undercooked foods, cross-contamination from raw to cooked foods, unpasteurized dairy products and fruit juices and raw vegetables and legumes²². While, the possible associated foods for Salmonella spp. outbreaks in hospitals were mainly from animal products as egg, poultry, meat, seafood as well as raw legumes, vegetables and fruits and unpasteurized juices²². The main carrier for S. aureus is the food handlers and contaminated utensils and equipments²³. Study results showed that cooking decreased APC, moulds and yeast, S. aureus, E. coli and Salmonella spp. bacteria in foods noticeably. Moreover, Salmonella spp. or other bacteria were not detected in the hot served foods. On the other hand, Salmonella spp. bacteria were found in vegetable salad and coleslaw salad that contained mayonnaise. These dishes were delivered cold or at room temperature, which could be suitable carriers for pathogenic non-spore-forming bacteria such as Salmonella. So, appropriate corrective actions should be applied to prevent possible outbreak from these foods, changing the supplier of mayonnaise or raw egg and raw vegetables to more trusted and reliable companies, having a certificate of conformity to international and local standard specifications and performing continuous monitoring for the safety of these products. Furthermore, the cooking step as a most important stage in microbial reduction, should be monitored thoroughly by a validated thermometer to prevent the growth of any pathogenic microbes from undercooked foods.

CONCLUSION

Traceability in the meal production chain of hospitalized patients in two hospitals in Mecca showed that the microbial load was high in receiving and storage of foods and during the preparation stages, then cooking step decreased the microbial count remarkably. During serving the meals to patient, Salmonella spp. were found in vegetable salad and coleslaw salad that contained mayonnaise. Hospital workers should be trained to implement GMP precisely and they have to know the most important foods that could be contaminated with pathogenic microbes to be handled carefully.

SIGNIFICANCE STATEMENTS

This study determined the possible stage of the patient meal production chain that caused contamination to food items in two hospitals in Mecca region. The results indicated that no significant differences in the microbiological examinations were observed in the stages of receiving and storage of ingredients, preparation, cooking and collecting foods at the line between the two hospitals. Serving the meals to patients’ stage showed remarkably higher APC values. Thus, this research could lead to a new theory on the importance of possible detection and the presence of higher microbial contamination during delivery the meals to patients and therefore, hygienic practices could be implemented to prevent any contamination at this stage.

ACKNOWLEDGMENTS

The researchers would like to thank the Institute of Scientific Research and Revival of Islamic Heritage at Umm Al-Qura University for financial support of the project No. 43309007.