Prevalence and factors associated with intestinal parasitic infections among food handlers of Southern Ethiopia: cross sectional study

Food borne diseases are public health problems worldwide. It was estimated that about 30 % of the population living in the developed world suffers from diarrheal diseases, mostly caused by food borne microbial pathogens. About 2 million deaths occur annually due to food borne diseases in developing countries [1, 2].

Globally about one third of the total population is estimated to be infected with intestinal parasites, the majority being people living in tropical and sub-tropical parts of the world [3]. About 819 million people are infected with Ascaris lumbricoides (A. lumbricoides), 464.6 million people with Trichuris trichiura (T. trichuira), 438.9 million people with hookworm infection [4], 500 million people with Entamoeba histolytica (E. histolytica), and 2.8 million people are infected with Giardia lamblia (G. lamblia) [5].

As in many developing countries, cases of intestinal parasitosis are also highly abundant in Ethiopia. It is estimated that one third of Ethiopians are infected with A. lumbricoides, one quarter is infected with T. trichiura and one in eight lives with hookworm. As a result, Ethiopia has the second highest burden of ascariasis, the third highest burden of hookworm, and the fourth highest burden of trichuriasis in Sub-Saharan Africa [6].

As a result of this, the Federal Ministry of Health (FMoH) of Ethiopia has prioritized intestinal parasitic infection as one of the Neglected Tropical Diseases (NTDs) in the National Master Plan of NTDs, to address the public health problems due to NTDs [7].

High prevalence of intestinal parasitic infections and poly parasitism affect the health status of individuals mainly affecting physical and mental developments causing malnutrition, anaemia, stunting, cognitive impairment, lowered educational achievement and interfering with productivity [8, 9]. It was estimated and indicated by different researchers; high prevalence of intestinal parasites is largely due to lack of personal and environmental sanitation, lack of safe water supply, human behavior, poverty, ignorance of health promotion practices and impoverished health services [10–12].

Transmission of intestinal parasites is effected directly or indirectly through faeces contaminated objects such as food, water, soil and finger. Although various modes of transmission of intestinal parasites are known to exist, several studies have shown the higher magnitude of hand to mouth transmission as potential sources of exposure to parasitic infections [13, 14]. Accordingly, food handlers with poor personal hygiene working in food serving establishments could be potential sources of infections by many of the intestinal helminths and protozoa. Therefore, food handlers with poor personal hygiene working in food service establishments could be potential sources of infections [15, 16].

Various studies have been conducted to assess how prevalent intestinal parasitic infections among food handlers in different parts of the world including Ethiopia. In Ethiopia, the rate of infection with intestinal parasites among food handlers ranged from 29 to 72 % with different reports on the predominant species of parasites and hygiene practices [1, 10, 13, 14]. The importance of food handlers as threats in the transmissions of parasitic diseases has been stressed by several authors [9, 17, 18] and therefore, the aim of this study was to determine intestinal prevalence and associated risk factors among food handlers working in Arba Minch University Students’ Cafeteria.

Food handlers may be carrying a wide range of intestinal parasites and have been implicated in the transmission of many infections to the public in the community and to students in University. The spread of disease via food handlers is a common and persistent problem worldwide [13, 20]. Therefore, this study was undertaken to assess prevalence of intestinal parasites, among food handlers of Arba Minch University Student’s Cafeteria, Arba Minch, South Ethiopia.

In this study, most of food handlers working in students’ cafeteria of Arba Minch University were females, young adults and had low educational levels; which is in line with studies from different parts of Ethiopia like Bahir Dar, Gondar town and Addis Ababa [13, 14, 21]. The overall proportion of infected female food handlers (22.6 %) with intestinal parasites was higher than the proportion of infected male food handlers (12 %). This can be due to the fact that women are much more involved in kitchen work than men. Most of the males participate in the delivery of the already prepared food, while women are those who go bare footed during the preparation of the food, as well as those who do the washing of vegetables and fruits mainly in the kitchen.

Concerning the relation of age group and parasitic infection, the study revealed relatively a higher infection rate in the age group younger than 20 years. No significant difference was found in the distribution of parasitic infection among all age groups which shows that there is equal exposure to the infection and suggests an effect of environmental conditions on infection.

It is expected that all food handlers at University, military, hospitals etc. cafeterias to have a periodic medical checkup for food borne pathogens. Despite this fact, the interview result of our study showed that none of food handlers had a medical checkup for intestinal infection which agrees with study done in Bahir Dar town, Ethiopia [14].

In this study about 36 % of the food handlers were carriers of one or more of the pathogenic intestinal parasites. This is comparable with the finding of 38.1 % done in Nigeria [22], 32 % in Makka, Saudi Arabia [23] and 41.1 % in Bahir dar, Northwest Ethiopia [14]. However, it is higher than study of 1.3 to 7 % in India [16], 6.9 % in Omdurman, Sudan [24], 8.8 % in Turkey [25], 15.5 % in Sari, Northern Iran [11], 24.3 % in Gaza Strip, Palestine [26] and 29.1 % in Gondar, Northwest Ethiopia [21]. It was lower than the prevalence of 44.1 % from Jimma [1], 45.3 % from Addis Ababa [13], 49.4 % from Mekelle [10], 58.4 % from Jimma [9] and 71.8 % from Addis Ababa, Ethiopia [27]. The differences in reported prevalence in various studies may be due to socioeconomic status, climatic conditions, poverty, and personal and community hygiene.

In the present study, multiple intestinal parasitic infections were found with A. lumbricoides being the predominant parasite from helminthes followed by Taenia species, and E. histolytica/dispar was the most predominant from protozoan parasites followed by G. lamblia. High prevalence of ascariasis is a good indicator of improper fecal disposal, while that of entameobiasis reflects use of poor water quality among the study participants. This was consistent with the finding of a similar study conducted in Enugu State, Nigeria [28], and in different parts of Ethiopia [9, 10, 13, 14].

In this study encouraging results were obtained regarding practices of hand washing after toilet and before food preparation. Food handlers’ hand washing practices after toilet (100 %) was in parallel with the previous studies done in Ethiopia like, 90.6 % in Bahir dar [14]. However, hand washing practices of food handlers was low especially after touching body parts and after blowing nose which increase the likely hood of microorganisms cross contamination. These reflected that food handlers lack awareness about food contamination with poor hygienic practices.

Poor personal hygiene, including inadequate hand washing among food handlers is a common practice that contributes to food born diseases [10]. Parasite eggs in the soil can contaminate vegetables, then hands and hence directly enter into the mouth, or ingested by eating raw vegetables [11, 29].

This study identified high protozoan and helminthic infection that can easily be transmitted via feco-oral route, either directly from person to person or indirectly by eating or drinking fecally contaminated food and water. Hence, in this study multivariate logistic regression model indicated that untrimmed finger nail, hand washing practice after toilet, hand washing before food handling, preparing food when suffering from diseases like diarrhea and using common knife for cutting raw flesh food and other food were identified as determinant factors for food handlers being infected by intestinal parasites. The present study was subjected to the following limitations. The study was non-blinded. Due to lack of antigen tests, Entamoeba histolytica and Entamoeba dispar were not separated. This study did not attempt to assess the parasite carriage of the finger nail contents and parasite intensity due to logistic reasons. Specific methods such as the adhesive scotch tape for E. vermicularis, Harada Moori’s filter Paper for S. stercoralis and for hookworm infections was not done.

This study revealed a high prevalence of intestinal parasites among food handlers. Since most of the intestinal parasites are transmitted by the feco-oral route, food handlers could be an important source of infection to the general population. Therefore, constant epidemiological surveillance through biannual routine parasitological tests and treatment of the infected cases along with the improvement of personal hygiene and environmental sanitation are recommended to control the parasitic infection in food handlers.