WHO South-East Asia Journal of Public Health
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 Table of Contents  
ORIGINAL RESEARCH
Year : 2012  |  Volume : 1  |  Issue : 1  |  Page : 20-27

Escherichia coli contamination of babies’ food-serving utensils in a district of West Sumatra, Indonesia


Faculty of Public Health, University of Indonesia, Depok, Indonesia

Date of Web Publication24-May-2017

Correspondence Address:
Dewi Susanna
Faculty of Public Health, University of Indonesia, Depok
Indonesia
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DOI: 10.4103/2224-3151.206910

PMID: 28612775

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  Abstract 


Background: Contamination of baby’s complementary food may occur with Escherichia coli from several sources including unclean utensils. We examined the relationship between socio-economic conditions, environmental factors, characteristics of food handlers and contamination of babies food-serving utensils with E. coli.
Methods: The study was conducted in 21 villages of the Community Health Centre (CHC) Selayo in Indonesia. A cross-sectional design was used. A sample of 142 households, which had a 6-12 month-old baby on complementary food, was chosen randomly using midwives’ registration books. Respondents were interviewed using a semi-structured questionnaire. Check-lists were used for observations. Standard laboratory methods were used for collection of specimen and confirmation of contamination with E. coli.
Results: More than half of the respondents (59.2%) used water that had high risk of contamination and 61.3% of the latrines did not meet the criteria of a healthy latrine. Waste management practices of nearly all respondents (97.9%) were below the standards set by the Ministry of Health. More than half of the respondents (68.3%) did not wash their hands with soap for 20 seconds and 52.1% did not use flowing water for washing hands. Majority of the respondents’ hands (57%, 81/142) and 72.2% (104/142) of the eating utensils were found to be contaminated by E. coli. Contaminated hands of food handlers were more likely to contaminate the babies food-serving utensils (OR: 3.7; 95%CI: 1.62-8.46, p 0.002).
Conclusion: Contamination of the hands of food handler was associated with contamination of babies food-serving utensils by E. coli. Hence, food handlers should be trained on proper hand washing methods.

Keywords: Infant, complementary food, utensil, Escherichia coli, sanitation, Indonesia


How to cite this article:
Kusuma A, Eryando T, Susanna D. Escherichia coli contamination of babies’ food-serving utensils in a district of West Sumatra, Indonesia. WHO South-East Asia J Public Health 2012;1:20-7

How to cite this URL:
Kusuma A, Eryando T, Susanna D. Escherichia coli contamination of babies’ food-serving utensils in a district of West Sumatra, Indonesia. WHO South-East Asia J Public Health [serial online] 2012 [cited 2019 Oct 18];1:20-7. Available from: http://www.who-seajph.org/text.asp?2012/1/1/20/206910




  Introduction Top


The contamination sources of a baby’s complementary food may include unclean utensils used during complementary food preparation, domestic animals, fresh water, waste water, irrigation water, animal products, infectious human and animal waste, food handlers (through unhygienic hands), flies, pests and environment (dirt or dust).[1],[2] The hygienic condition of a baby’s eating utensils, as one of the contamination sources of complementary food, may also be responsible for diarrhoea in babies.

A preliminary study in the operational area of the Community Health Centre (CHC) Selayo, had found good coverage with clean water and latrines (87.7% and 63% respectively) but 70% of the respondents were washing their baby’s eating utensils in the bathroom. In addition, none of the respondents washed their hands before preparing homemade complementary foods. This information indicated a possibility of contamination of utensils by the food handlers. Thus, we conducted a study on E. coli contamination of the complementary food serving utensils. The relationship of E. coli contamination of a babies food-serving eating utensils with the method of handling of babies food-serving utensils, sanitation condition of the environment, characteristics of the food handlers and socio-economic condition of the respondent were also examined.


  Methods Top


This study was conducted in the operational area of the Community Health Centre (CHC) Selayo, in Solok District, West Sumatra, Indonesia. Data were collected from December 2009 to February 2010. Ethical clearance was obtained from the Ethic Commission of the Public Health Faculty, University of Indonesia. Every respondent provided informed consent to the surveyor.

The households that had a baby aged 6-12 months were chosen randomly from the registry book of Jorong (village) midwives, i.e. babies with even registration numbers. The sample size for each Jorong was determined by the proportion of babies in the respective Jorong. A sample size of 97 was estimated based on the assumed contamination level of 50% for the eating utensils and precision of 10%.[3] After the addition of 10% to take care of refusals, the number of the samples required increased to 106. As the study had 14 variables, the ideal sample size estimated was 142.

Eighteen graduates of the Environmental Health Study Programme from the Padang Health Polytechnic collected the data. They had experience in food microbiology including E. coli examination, and had a general understanding about the interview methods and specimen taking technique. Prior to the data collection process, all surveyors were also trained by the Public Health Laboratory Officers from Padang on the technique of taking microbiology samples using aseptic methods and by the research team from the Faculty of Public Health, University of Indonesia for interview technique. The data collection instruments included questionnaires and check lists.

A total of 284 sample swabs were examined in the Health Ministry’s Provincial Health Laboratory (PHL) in Padang. These sample swabs consisted of 142 swabs from the eating utensils and 142 swabs from hands of the food handlers. The eating utensil swabs were collected from the plates and spoons used in serving complementary food. Ministry of Health procedures for microbiology of food utensils and hand swabs samples were used.[4],[5] The samples were immediately sent to the laboratory. Sample bottles were put inside a cold box equipped with cold packs in order to keep the temperature below 5°C until their arrival at the laboratory.[3] The method of taking swabs, transportation and processing of the samples in the laboratory was similar for the specimen taken from the hands of food handlers and from the feeding utensils.

The stages of E. coli confirmation in the laboratory were as follows:

Presumptive test

Test tubes and different media inside the tubes were sterilized. Bacterial seeding was conducted inside a test tube which consisted of 3 series tubes, each of the 3 tubes along with Durham tubes were inserted upside down in each test tube. Each test tube was filled with 10 cc lactose broth (LB) medium. The top layer of the clear liquid, which resulted from the milling or blending of the food samples, was added into each tube (10 cc, 1 cc and 0.1 cc) using aseptic method. The tube series were then incubated at 37°C for 24-48 hours. The existence of coliform bacteria was indicated by the shift of colour of LB medium from orange (purple) into yellow, which was accompanied by the production of gas, observable inside the Durham tube. The next step was to read the result of the estimated quantity of coliform bacteria based on the table of the Most Probable Number (MPN) from the combination of the positive result from the three incubation tube series.[4]

Confirmation test

The examination of faecal coliform and E. coli bacteria was conducted by putting one full loop of the identified coliform bacteria into the tube series containing sterilized Brilliant Green Lactose Bile (BGLB) 2% along with Durham tubes which were inserted upside down. The quantity of the tube series that were used in analyzing faecal coli and E. coli bacteria conformed to the quantity of the positive tube series during the examination of coliform bacteria (presumptive test). The tubes were then incubated at 44.5°C for 24-48 hours. They were labelled positive if there was fermentation of the medium indicated by the colour shift of the medium from dark green into light green or yellow and observation of gas inside the Durham tubes. The MPN number of faecal E. coli bacteria was read in the MPN table based on the number of positive tubes from the incubated BGLB tube series.[4]

To maintain the required temperature, surveyors placed every sample into a cold box and carried these in a car. After all samples were collected old cold packs were replaced with the new ones in CHC Selayo or in the Office of Health, Solok District. Later these were taken to PHL Padang. This way the temperature was kept under 5°C until all samples reached PHL Padang.[6],[7] Considering that the research location was prone to disaster and unexpected events such as electrical failure etc., two samples were taken. One of these samples was used as a back-up. Quality control included testing of 10% of the samples twice at the Primary Health Centre, Padang and Jakarta.


  Statistical analysis Top


The dependent variable used in this study was E. coli contamination on the utensils used for serving complementary food to babies in the age group of 6-12 months. The independent variables were: (i) Environmental factors - the contamination risk level of clean water facility, family latrine condition, condition of waste water drainage, trash disposal and animals inside the house; (ii) Food handlers’ characteristics included educational background, type of eating utensils used, knowledge on how to wash eating utensils, washing methods used for eating utensils and hygiene level of the hands (E. coli contamination); and (iii) Socioeconomic condition of the family including parents’ educational background, mothers’ profession, parents’ monthly income and mothers’ parity.

The data were entered into a database. After cleaning the data, univariate analysis was done to describe study variables. The frequency distribution of each variable for the nominal and ordinal scale and the mean and median value of the interval and ratio scale were examined. Bivariate analysis was carried out to observe whether there was a relationship between the dependent and independent variables. Chi-square test was used with the significance level of 0.05. Multivariate analysis was conducted to determine risk factors (several independent variables) that have a statistically significant relationship with the dependent variable using logistic regression analysis. All variables that were having a chi-square test p value of <0.25 in the bivariate analysis were included in the logistic regression model.


  Results Top


More than half of the parents (69%) were highly educated (high school or more), and 72.6% of the mothers were housewives, which is categorized as a low risk occupation. Family income exceeded Indonesian Rupiah 600 000 (approximately US$ 70.59) per month in 26.8% of the respondents. More than half of the mothers (59.9%) were in low risk category since they had delivered less than two children.

The observations of environmental factors revealed that more than half of the respondents (59.2%) used a clean water facility that had high contamination risk. The house latrine condition showed that more than half (61.3%) of the latrines had lower than the mean values of the standards required for a healthy latrine. Furthermore, waste management conditions of nearly all respondents (97.9%) did not meet the requirements set by the Ministry of Health.

More than half of baby food handlers (56.3%) were highly educated (high school or more). All food handlers (97.2%) used glass plates and stainless steel spoons for feeding the baby. More than half of them (70.4%) had good knowledge about how to wash eating utensils. Good knowledge meant that they scored more than the median value on 5 knowledge questions related to the washing of eating utensils. More than half of the food handlers (64.8%) washed eating utensils with a low risk method based on the median value of observation check list for 5 stages of hygienic washing method. However, only 35.2% had demonstrated correct washing methods. More than half (57%, 81/142) of the food handlers’ hands were found to be contaminated by E. coli.

Univariate analysis revealed that 72.2% (104/142) of the baby’s eating utensils were contaminated by E. coli. As shown in [Table 1], in bivariate analysis only food handlers’ hands hygiene was found to be statistically associated with E. coli contamination on the baby’s eating utensils (OR: 3.1; 95% CI: 1.4-6.7 p 0.006). In the multivariate analysis that included four variables having p value < 0.25 in bivariate analysis, hand hygiene was found to be associated with E. coli contamination on the baby’s eating utensils (OR: 3.7; 95% CI: 1.62-8.46 p 0.002) as shown in [Table 2]. There was no statistical interaction between the five variables included in the model such as education with hand hygiene, education with eating utensils method and parents’ education with eating utensils method.
Table 1: Association of socio-environmental variables with E. coli contamination on babies' food-serving utensils

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Table 2: Multivariate analysis of socio-environmental risk factors associated with E. coli contamination

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  Discussion Top


Food handler’s hand hygiene was significantly associated with E. coli contamination on the baby’s eating utensils. Contamination of hands with E. coli was 3.7 times more likely to lead to E. coli contamination on baby’s eating utensils compared to the uncontaminated hands of the food handlers. High risk basic sanitation facilities, low risk socioeconomic status, and low risk utensil washing method did not have an association with E. coli contamination of utensils. Bad hand hygiene has been reported in other studies. A study in Chandigarh, India, revealed that 79% of mothers’ fingers were contaminated by E. coli.[8] A research in Viet Nam also discovered that 69.9% of the respondents did not always wash their hands with soap before they prepared meals.[8] Another qualitative study by Usfar[9] in Tangerang found that 71% of the respondents did not wash their hands with soap after preparing foods such as meat, fish, and chicken. A study at Kampong Chnnang and Kampong Thom, Cambodia, also found that nine out of ten food handlers washed their hands with water only when they prepared a meal, and only a third of them washed their hands with soap, but one out of four food handlers did not wash his/her hands after having contact with raw food.[10] In Baroda, India half of the mothers of the observed households (50%) had poor hygiene level, based on the observation of an indicator of mother’s nail hygiene. About 30% of them had their nails contaminated by E. coli.[11] Food handlers’ hands hygiene is an important factor for minimizing baby’s contamination of eating utensils. Washing hands would not straight away minimize the risk because how they wash their hands is also an important factor. Even though food handlers may wash babies’ utensils in the right way, bad hand hygiene is a risk factor that must be controlled to minimize E. coli contamination of the utensils.

The main limitation of the study was that the utensils from where swab samples were taken had been washed before the surveyor came to the household. Food handlers may not have cleaned the utensils in the right way, but they did it better when the surveyor observed them. This is a limitation of cross-sectional design.[12] We did not examine water quality in this study using laboratory methods, but categorized contamination risk of water facilities by using sanitation inspection tools (Ministry of Health Sanitation Inspection check list). Most water facilities were found to be of low risk. In future studies, the researcher should include objective microbiological criteria for water quality.[13],[14],[15] We did not find an association of community socioeconomic conditions with the dependent variables. All respondents lived in almost the same culture, income and education category; their condition was almost the same in each household.[16] Another limitation was that the MPN test, meant for quantitative assay of Coliforms in drinking water, was used for a qualitative assay for the presence of E. coli on utensils and hand swabs. Many confounding variables, including the area swabbed, volume of diluent used and the quantitative criteria for safe and unsafe contamination can affect the results of the MPN test which is primarily standardized for drinking water.

High risk sanitation facilities could be the entry point of E. coli contamination. E. coli live as normal flora in the digestive tracts of mammals including humans. High risk excreta disposal facilities and waste water facilities could be the contamination sources of clean water. Contaminated clean water used for washing babies’ eating utensils and hands could be a contaminant too.[17] Low risk eating utensils washing methods could minimize the risk of E. coli contamination on eating utensils but contaminated hands could re-contaminate it. According to WHO, the eating utensils used for four to six month-old babies when they start to consume complementary food could potentially increase the risk of contamination, especially by E. coli, caused by the lack of hygienic management of the babies’ eating utensils in developing countries.[18] Hygienic management of babies’ eating utensils and hands hygiene must be improved together to reduce that risk of E. coli contamination of eating utensils.

To conclude, high risk sanitation facilities, low risk socioeconomic conditions, and low risk utensil washing method were not found to be associated with contamination of babies’ food-serving utensils. The most significant contributory factor was found to be food handlers’ hand hygiene. Food handlers’ hand hygiene should be improved to reduce the risk of E. coli contamination on the eating utensils of the baby.

Acknowledgements

We thank the Directorate of Research and Community Service of the University of Indonesia for Doctoral Research Grant contract No. 7550/DRPM-UI/B/N1.4/2009. We would also like to thank Professor Haryoto Kusnoputranto, DrH as Promoter, Professor Dr I Made Djaja as Co-promoter-1, Professor Dr Rizal Syarief as Co-promoter-2, and Professor Dr Sudarto Ronoatmodjo, Professor Dr Kusharisupeni, Dr Saptawati Bardosono, Dr Ririn Arminsih Wulandari, Dr Anies Irawati as examiners. Special thanks are also due to Mawarta Onida for her help in editing this manuscript.



 
  References Top

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Muoki MA. Tumuti DS and Rombo GO. Nutrition and public hygiene among children under five years of age in Mukuru slums of Makadara Division, Nairobi. East Afr Med J. 2008; 85(8): 386-97.  Back to cited text no. 15
    
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Szklo M, Nieto FL. Epidemiology beyond the basics. Aspen Publishers Inc., 2000.  Back to cited text no. 16
    
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