Evaluating Food Safety and Hygiene in Sudanese Schools at Khartoum Bahri City: A Study on Contamination Risks and Health Impacts

Introduction: Food health and safety are important public health issues in both developing and developed countries due to the transmission of numerous microbial and chemical diseases through contaminated food, affecting millions of people worldwide.

Study Area: This study was conducted in elementary and secondary schools in the Sudanese city of Bahri between October 2022 and March 2023 to evaluate the level of food safety and hygiene services, as well as the health of food handlers.

Method: Data was collected using a questionnaire and hand swabs from food-handling workers. Correlations between the variables were examined using descriptive statistics and the chi-square test. Additionally, information was gathered from 136 swab samples.

Findings: According to the study’s findings, 19% of pupils had experienced food-borne illness in the past, and 57% of schools lacked permanent canteens for lunch service. The study also found a significant correlation between food contamination and the workplace (χ2 test, p < 0.001). Furthermore, several types of food-borne disease-causing bacteria were identified in the research. Conclusion: Lastly, the study’s findings indicate that food handlers’ working conditions are deteriorating, highlighting the need for continuous inspection and monitoring of food facilities.

Introduction

Food contamination has been linked to several causes, including inadequate sanitation and insufficient waste disposal facilities. Among street food vendors, many vending machines are located close to busy areas, such as schools, where customers congregate, and there are few essential services, like restrooms.

Food safety is a major public health issue in every country. Millions of people worldwide are at serious risk of food-borne illnesses caused by chemical pollutants, biotoxins, and microbiological infections in food [1]. Cafés and street vendors may serve unsafe meals to children. School officials have had to search for indigenous cures to protect pupils from illnesses originating from this source. Some potential measures include prohibiting food vendors from operating near schools, deterring children from buying from them, or encouraging and monitoring improvements in food hygiene among vendors [2].

The main causes of food poisoning outbreaks in schools include cross-contamination, leaving cooked food at room temperature before serving, and waiting too long between food preparation and serving [3]. Since street-vended foods and beverages are considered a global source of food-borne infections, they are defined as “foods and beverages prepared and/or sold by vendors in streets and other public places for immediate consumption or consumption at a later time without further processing or preparation” [4].

Prevalence of Selected Food-Borne Pathogens

One of the primary food-borne pathogens, S. aureus, is a gram-positive, facultatively anaerobic, non-spore-forming bacterium notorious for causing food-borne illness. Eating food tainted with a heat-stable toxin is a major cause of poisoning, and certain strains of S. aureus often produce this toxin when they infect food. Intoxication is often characterized by the abrupt and intense onset of symptoms, including acute nausea, cramps, vomiting, and prostration. There is also the potential for diarrhea. The most common disease caused by S. aureus is toxin-induced gastroenteritis. Food contamination primarily originates from and persists in humans [5].

Escherichia coli is a common bacterium found in both human and animal intestines. Even though the majority of bacterial strains are benign, some are known to cause food poisoning (O157:H7) through the consumption of contaminated food. The most frequent cause of E. coli food illness is eating undercooked meat. Unpasteurized milk is another prevalent source of food illness. Sandwiches or salads made with raw vegetables can also spread the bacteria via contaminated hands from one person to another.

Salmonella is a bacterium that can be found in a variety of foods, such as raw or undercooked meat, poultry, dairy products, shellfish, and eggs. It is possible for sick food workers to contaminate food, for inadequate hygiene to cause cross-contamination, and for the bacteria to spread from person to person. The consequences of Salmonella infection include rheumatoid syndrome, meningitis, reactive arthritis, septicemia, colitis, osteomyelitis, and pancreatitis [6]. For example, over 180 million symptomatic infections are caused by intestinal parasites, which rank 11th on the Food and Agriculture Organization/World Health Organization risk management list of intestinal parasites. Other studies have revealed that intestinal parasites are also frequently found in the feces of children who do not show any symptoms [7].

Shigellosis is a significant public health concern. Food and water tainted with feces are typically the mode of transmission. Person-to-person transmission via the fecal-oral pathway is another significant route. Food workers who practice poor personal hygiene have been shown to be crucial conduits for food contamination and transmission. Animals can contract Shigella, particularly poultry such as chickens and birds. Shigella infection has been linked to animal diseases that cause substantial morbidity and mortality [8].

Giardia lamblia is a tiny intestinal parasite that causes waterborne epidemics or occurs endemically. Children in developing nations and tourists visiting endemic areas are frequently infected with the parasite. It causes infections that range from mild to severe, leading to weight loss, diarrhea, and malabsorption [9].

Materials and Methods

In addition to taking swab samples from food handlers’ hands and conducting observations on the factors affecting the environment, data were gathered using previously tested questionnaires administered to some students in the targeted schools and food workers in various locations within or near the schools. The questionnaire consisted of four categories: students, food handlers, and location of employment. Swabs were collected from the hands of all 136 employees who participated in the questionnaire. These samples were then stored in sterile containers specifically designed for this purpose before being transported to microbiology laboratories for proper culturing. Following that, bacterial growth was detected and purified using conventional bacteriological techniques, as per Barrow and Feltham [10].

Sample Size

Our sample included 68 schools out of 239, in addition to 136 swabs taken from food workers inside or outside schools. The sample size for students was calculated using the following formula:

n=N(1+N(e2))

where:

n = the sample size,

N = the population of the study,

e = the margin error in the calculation.

When we applied the formula, we obtained a sample size of 398:

n=90,000(1+90,000(0.00252))=398

Inclusion and Exclusion Criteria

The study included all the schools that we were able to reach, ensuring representation from all administrative and educational sectors of the Bahri region. A questionnaire was conducted, and swabs were taken from food handlers who agreed to participate (n = 136). Food handlers who did not consent were excluded, as well as all children younger than 11 years and older than 16 years.

Study Site

Bahri City is situated between the Blue and White Niles, north of Khartoum. It has a total population of 752,281 and covers an area of approximately 45,597 km². Of this population, 76.2% live in urban areas, with the majority working in the public sector, while a small percentage are employed in private industries such as business and agriculture.

The three administrative units that make up this area are Baladiat Bahri, Bahri North, and Bahri Suburban. The seven educational sectors in Bahri City include Halfaya, Samrab, Bahri Al-Kubra, Al-Droshab, Al-Salit, and Al-Jili. There are 239 government schools in these areas, attended by 90,000 foreign students, with over half of them being female [11].

Results

Table I shows that most of the vendors included in the study operate from fixed kiosks (43%), while 28% have mobile selling places. It also indicates that 43% of the floors where food is sold are covered in dust, and about 54% lack sufficient or have non-existent facilities for handwashing. The results in Table I further reveal that while 46% of general hygiene conditions are rated as good, only 16% of vendors operate far from waste areas, and 40% have poor or insufficient implementation of food safety measures. Additionally, only 32% of vendors have access to a toilet that is suitable for use, while about 56% have facilities that are unsuitable or in poor condition.

Table I. The Environment in Which Vendors Work in the Targeted Schools (n = 68)

Variables			Frequency	Valid percent	Cumulate percent
1	Sale place structure	Kiosk	29	43%	43
		Mobile truck	20	29%	72
		Open trays	19	28%	100
Total			68	100%
2	The ground condition of the place of sale	Dusty	39	57%	57
		Smooth	29	43%	100
Total			68	100%
3	Existence of hand-washing facilities	Sufficient	31	46%	46
		Not sufficient	20	29%	75
		Not found	17	25%	100
Total			68	100%
4	The general cleanliness of the food places	Good	35	51%	51
		Moderate	21	31%	82
		Poor	12	18%	100
Total			68	100%
5	The presence of vendors near waste areas	Very close	16	24%	24
		Somewhat close	34	50%	74
		Far	18	26%	100
Total			68	100%
	Food safety application	Sufficient	18	26%	26
		Not sufficient	31	46%	72
		Poor	19	28%	100
Total			68	100%
6	Having a suitable bathroom	Suitable	28	42.2%	42.2
		Not suitable	40	58.8%	100
Total			68	100%
6	The presence of rodents and insects	Yes	15	22%	22
		No	29	43%	65
		Sometimes	22	32%	100
Total			68	100%
7	Method of waste disposal	Good	30	44%	44
		Decent	22	32%	76
		Poor	16	24%	100
Total			68	100%

Table II shows that most of the participants (51%) are between the ages of 11 and 17 years, with the majority being female (51%). Additionally, 52% of participants eat breakfast at school and 30% drink water from school refrigerators. Table II also indicates that 19% of the participants have experienced food poisoning before, while 56% have not, and 25% were unsure. Among those who had food poisoning, 14% received treatment in a hospital. The most common cause of poisoning was consuming salads, with participants reporting that this had occurred twice. Furthermore, 20% of participants reported noticing that the food was unclean, and 26% refused to eat it.

Table II. Students’ Questions about the Healthfulness of the Foods Served (n = 398)

No	Variables		Frequency	Valid percent t	Cumulative percent
1	Age group	11–13	201	51%	51
		14 < 17	197	49%	100
Total			398	100%
2	Gender	Male	194	49%	49
		Female	204	51%	100
Total			398	100%
3	Breakfast source	From school	207	52%
		From home	191	48%	100
Total			398	100%
4	Drinking water	From the tap	80	20.1%	20
		From the cooler	121	30.4%	50
		From pottery diapers	97	24.4%	74
		Bottles water	100	25.1%	100
Total			398	100%
5	Food poisoning occurs	Yes	75	19%	19
		No	223	56%	75
		Not sure	100	25%	100
Total			398	100%
6	If yes, where was the treatment done?	At home	21	5%	5
		In the hospital	54	14%	19
		No & not sure	323	81%	100
Total			398	100%
7	If yes, what type of food?	Snacks	3	1%	1
		Falafel	23	6%	7
		Salad	26	7%	14
		Egg	5	1%	15
		Sweets	10	2%	17
		Others	8	2%	19
		No & not sure	323	81%	100
Total			398	100%
8	How many times	Once	62	15%	15
		Twice	10	3%	18
		More than twice	3	1%	21
		No & not sure	323	81%	100
Total			398	100%
9	Meals cleaning	Yes	150	38%	38
		No	80	20%	58
		Not sure	168	42%	100
Total			398	100%
10	Refusing a meal due to uncleanliness	Yes	102	26%	26
		No	166	42%	192
		Not sure	130	33%	100
Total			398	100%

Table III shows that Staphylococcus aureus had the highest frequency at 35.7%, followed by Giardia lamblia at 28.6%, Salmonella typhi at 10.7%, Entamoeba histolytica/dispar at 10.7%, E. coli at 8.9%, and Shigella boydii at 5.4%.

Table III. Total Positive Samples of Swab Samples Taken from Food Handling Workers (n = 136)

Type of pathogen	Frequency	Percent
Staphylococcus aureus	20	14.7
E collie	5	4
Salmonella typhi	6	4
Entamoeba histolytica/disbar	6	4
Shigella boydii	3	2
Giardia lamblia	16	12
Total	56	56/136 (41.2%)

Table IV displays the results of positive samples in the workplace. Using a chi-square test (p < 0.001), Staphylococcus aureus had the highest frequency at 35.7%, followed by Giardia lamblia at 26.6%, Salmonella typhi and Entamoeba histolytica at 10.7% each, E. coli at 8.9%, and Shigella boydii at 5.4%.

Table IV. Types of Pathogens Frequency Associated with the Place of Work (n = 56)

Place of work	Types and frequency of pathogens						Total
	Staphylococcus aureus	E collie	Salmonella typhi	Entamoeba histolytica/dispar	Shigella boydii	Giardia lamblia
Kiosk	4 (4.14)	0 (0.0)	1 (1.8)	0 (0.0)	0 (0.0)	2 (3.6)	7 (12.5)
Mobile truck	10 (17.9)	2 (3.6)	2 (3.6)	3 (5.4)	1 (1.8)	6 (10.7)	24 (39.3)
Open trays	6 (10.7)	3 (5.4)	3 (5.4)	3 (5.4)	2 (3.6)	8 (14.3)	2 (49.2)
Total	20 (35.7)	5 (8.9)	6 (10.7)	6 (10.7)	3 (5.4)	16 (28.6)	56 (100)

Table V demonstrates the correlation between the workplace and positive sample results. The highest number of positive samples was found in open trays (18.8%), followed by mobile trucks (17.7%) and fixed kiosks (5.2%). Additionally, the table highlights the significant correlation between the positive samples obtained and the nature of the workplace (p < 0.001).

Table V. Results of the Positive Samples within Place of Work

Variables		Count and % within positive sample result		Total
		Positive	Negative
Place of work	Kiosk	7 (5.2%)	51 (37.5%)	58 (42.6%)
	Mobile truck	24 (17.7%)	16 (11.8%)	40 (29.4%)
	Open tray	25 (18.4%)	13 (9.6%)	38 (27.9%)
Total		56(41.2%)	80 (58.8%)	136 (100.0%)

Table VI illustrates the connection between morning food sources and past food poisoning incidents among students. Of the 18.8% of food poisoning cases that occurred at schools, the largest number (14.8%) was linked to school-provided meals, whereas only 0.4% of cases were associated with home-brought meals. The table demonstrates that this correlation was significant (p < 0.001).

Table VI. Breakfast Source within Food Poisoning Cases

Variables		Count & % within food poisoning cases		Total
		Poisoning cases	No poisoning
Training	From home	16 (4.0%)	175 (44%)	191 (48%)
	From school	59 (14.8%)	148 (37.2%)	207 (52%)
Total		75 (18.8%)	333 (81.2%)	398 (100.0%)

Discussion

Food-borne illnesses are a global public health concern, particularly in developing nations. Children are considered one of the groups most vulnerable to this. The results of this study showed that the percentage of those working in fixed places in the targeted schools was only 43%, while all the remaining vendors were either in non-fixed kiosks or displayed food on the road. Additionally, 57% of sales places were in dusty areas, and 37% had no or insufficient water for washing hands. In addition to the presence of waste near the places of sale and the poor method of disposing of it, all of this can cause food pollution.

Another part of the study results included a conversation with children to learn about the health of foods. It was found that 19% of them reported having suffered from food poisoning before, with most of the food items that caused this being salads and falafel. Additionally, 48% of the students ate breakfast from vendors inside schools.

The results of this study also indicate that 19% of food-handling workers do not have health cards and that 87% wear inappropriate clothing, which indicates non-compliance with health requirements. The study also showed that 41.2% of the swab samples taken from the workers’ hands were positive, as Staphylococcus aureus was isolated, along with E. coli, Salmonella typhi, Entamoeba histolytica/dispar, Shigella boydii, and Giardia lamblia, all of which contaminate food due to poor hygiene practices.

This finding is similar to other studies conducted in Khartoum, which indicated that 61.4% of food handlers in food establishments do not have medical examination cards. This may expose students to food-borne diseases if one of the workers is infected with a communicable disease. This violates the health specifications contained in the Food Control Law and Regulations of 1973 in Sudan, which stipulate that workers must have a health card to certify that they are free of communicable diseases [12].

There is also a review study conducted in several African schools, including Sudan, which indicated that most schools lack a kitchen or canteen. This explains why many students report receiving meals from home. The study also found that food vendors mostly sell unhealthy snacks and processed foods, often in an unhealthy environment [13].

The results also indicated that there is a relationship between the number of responding samples and the work environment, as well as between the food eaten in schools and cases of food poisoning. This highlights the need to pay attention to the importance of environmental health (p < 0.001).

Conclusion

The study concluded that the health status of the environment, food places, and food handlers is not suitable for adherence to specifications and standards due to the presence of many street vendors and temporary places for sale. This situation makes it difficult to consistently regulate food in schools, which has led to the emergence of some cases of food poisoning among students and the presence of certain microbes in the hands of food handlers.

Recommendations

• Given the importance of food for the growth of school children, it should be safe by staying away from sources of microbial contamination that cause it.
• The role of school administration in taking care of dining facilities should be increased.
• The critical control point of food for school children can be determined.
• Continuous inspection by health inspectors, obligating workers to conduct periodic inspections, and regulating sales within schools should be done.