Hygienic Practices among Food Handlers
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Published: Wed, 14 Mar 2018
Hygienic Practices among Food Handlers in Mauritius
INTRODUCTION AND LITTERATURE REVIEW
Unsafe food causes many acute and life-long diseases, ranging from diarrhoeal diseases to various forms of cancer (WHO, 2010). According to the WHO about 2.2 million people are killed every year by food borne and water born diarrhoeal diseases among which 1.9 million of them are children. Food borne illnesses are defined as diseases, usually either infectious or toxic in nature, caused by agents that enter the body through the ingestion of food (WHO,2007).It has been reported that each year about 30% of the population of industrialized countries is affected by food borne diseases. The presence of wide range of food borne diseases and the high prevalence of diarrhoeal diseases in many developing countries suggests major underlying food safety problems.
During the past year we have witness different outbreaks related to food poisoning throughout the world. Studies carried out have shown that in 1988, an outbreak of hepatitis A, resulting from the consumption of contaminated clams, affected some 300,000 individuals in China (WHO, 2007). In 1994, outbreak of salmonellosis due to contaminated ice cream occurred in the USA, affecting an estimated 224,000 persons (WHO, 2007). In 1997, an outbreak of cholera related to water contamination occurred in Kenya and Mozambique, resulting in 130 and 14 deaths respectively (Afr Health, 1997). According to available statistics it is estimated that during the year 2009 there were 718 cases of food poisoning in Mauritius. (Ministry of health, 2010)
Various studies have been carried out and the presence of Salmonella, E. coli, L. monocytogenes, Staphylococcus spp., and histamine levels were noted. The comparison of the microbial quality of ground beef and ground beef patties from internet and local retail markets, it showed that the samples contained Salmonella, Listeria spp. and L. monocytogenes. (Pao S, Ettinger MR. 2009).Prevalence of E. coli and Salmonella spp, in street-vended food of open markets (tinguis) and general hygienic and trading practices in Mexico City, it showed that street-vended food pose a health risk as 43% of sample contained E.coli, 5% Salmonella and 80% of the stalls were Salmonella positive. (Epidemiol Infect. 2004). Another bacterium namely Staphylococcus was isolated from a sample in a relatively large proportion according to the study on bacteriological analysis of fresh produce in Norway, the result shows that the presence of pathogenic bacteria represents a risk to food born disease. (Int J Fod Microdiol. 2002). In another study carried out as the prevalence of food borne microorganisms in retail foods in Thailand, of the 200 samples tested 61% were Salmonella positive, 15.5 % Camphylobacter spp. Positive, 15 % C. jejuni positive, 21 % Arcobacter positive. (Foodborne Pathog Dis. 2007). In Alberta, Canada, a total of 36 markets were sample and the vegetables were analyzed for Salmonella, E. coli and Campylobacter. 8.2% of sample contained E. coli. (J Food Prot. 2009). A study was conducted to outline the prevalence of Salmonella species in various raw meat samples of a local market in Kathmandu and it revealed an unsatisfactory condition in the local meat market with 14.5% chicken sample, 13.5% buffalo sample and 3.3% goat sample to be contaminated with Salmonella and also that more than 805 were contaminated with coliform. (Ann N Y Acad Sci 2006)
Mauritius is a small tropical island situated in the southwest Indian Ocean. It has a population of 1,277,853 as at end 2009 (Ministry of Health 2009). The Ministry of Local Government and Rodrigues is the parent ministry of the five Municipalities, four District Councils and 124 Village Councils. Apart from their own revenue the local authorities benefits from grants from the parent ministry so as to provide adequate amenities and services to the residents. One of these includes the provision of market in villages and towns. Mahebourg village falls under the jurisdiction o f the Grand-port/Savanne District Council with a population of 15,753 inhabitants (Ministry of Health 2009).
To assess the level of hygienic practices among food handlers dealing with fleshy foods and vegetables in the Mahebourg market.
To assess the hygienic level of Mahebourg market.
To study the knowledge, aptitude and practice of hygiene among food handlers.
To study the opinion of consumers related to hygienic practices of food handlers.
Structure,layout and administration of Mahebourg market
Structure and layout plan of Mahebourg market
To get market plan layout from the GPSDC
Administration of the Mahebourg market (organigram):-
Principal health inspector, 01
Senior health inspector, 01
Health inspector and Assistant health inspectors, 02
Figure1 shows the hierarchy of the management of Mahebourg Market.
Hygiene control and inspection
Hygiene is a very important aspect in the management of any market. Provision are made in the market rules and regulations to allow the managing authority to remove any product that may be potentially harmful to the consumers and to declare null and void any contract in cases of recurrent violation of hygiene standards. Health Inspectors posters at Mahebourg Market are responsible to carry out daily inspections about hygiene as mentioned in some sections of the Market Regulations.
1.3. Hygienic facilities
The cleaning activity is being carried out by a cleaning company namely “Hyper Cleaning Ltd” and a checklist is being filled daily by Health Inspectors posted at Mahebourg Market.
1.3.2. Supply of water
There is an adequate supply of potable water in the market to be used by everyone, the Grand-port/Savanne District Council has installed an electric water pump so as to make provision for a continuous water supply and a plastic tank so as to prevent water contamination and act as a reservoir in case of water shortage. As per the food act of 1998, there are four concrete wash basin into the market and separate stainless wash basins for each occupier of each fleshy food section.
The ventilation system is vital in the regulation of humidity, where required, to ensure the safety and fitness of food. Ventilations systems should be designed and constructed ‘so that air does not flow from contaminated areas to clean areas and, where necessary, they can be adequately maintained and cleaned’ (Abdussalam & Kaferstein, 1994).
1.3.4. Waste collection and disposal
Waste collection and disposal is contract out to a private firm, collection and disposal is being made on every working days.
1.3.5. Control of flies, pests and rodent
As per the Food Act 19998 all the doors in fleshy food sections should be fitted with self closing devise so as to prevent dogs and other stay animals entering these sections, other openings must be fitted with fly proof so as to prevent entering of flies, insects.
According to Marriott (1997) sanitation ‘means creating and maintaining hygienic and healthful conditions’. It contribute in reducing contamination of food by microorganisms that cause food borne illness and food spoilage, it is therefore more than just cleanliness. Sanitary principles are devised by the manager or the government; for example, it applies to cleaning methods and waste disposal (Marriot, 1997).
1.4. Market Regulations – Local Government Act
The Local Government Act represents a guideline to the local authority for the management of respective markets through the market regulations.
1.5. Hygiene and food handlers
Hygiene is defined as healthy habits including bathing, keeping the mouth clean, frequent washing hands, keep fingernails clean and well trimmed, do not smoke, sneeze, cough, spit where food is being handle, do not attend duty when ill. It is thus one of the most effective ways we have to protect ourselves and others from illness (Victorian Government Department of Human Services, Melbourne, Victoria, Australia).
Food Hygiene is defined as ‘all the conditions and measures that are necessary during production, processing, storage, distribution and preparation of food to ensure that it is safe, sound and fit for human consumption (WHO).
The Food Safety Standards define a food handler as ‘anyone who works in a food production and who either handles food or surfaces that are likely to make contact with the food such as cutlery, plates and bowls.’ This may include preparing, cooking and serving, packing or displaying food.
1.5.3. Personal Hygiene for Food Handlers
Some microorganisms like E. coli and staphylococcus spp. Forms part of our natural flora and are present on our skin, hair, noses and in our mouths and bowels. Such microorganism can be harmless to the carrier by harmful to other host and are easily spread to food by direct contact with the food, therefore good personal hygiene is of high importance.
1.5.4. Training and Education
Frequent training courses on food hygiene are part of an on-going program structured by the Ministry of Health. It aimed at providing adequate advice and technical support to food handlers on proper food and personal hygiene practices.
1.5.5. Medical Check-up
Any food handler who suffered from or suffering from any of the following symptoms: sickness/diarrhea/changes to bowel habits; flu like symptoms; has knowingly been in contact with anyone suffering from typhoid; paratyphoid or cholera, must undergo medical check-up before starting to work.
1.6. Food safety
Food safety is the shielding food from the threat of contamination which may be caused by harmful bacteria, poisons and alien objects and also minimizing the risk of multiplication of harmful bacteria to such an extent that it may result in food poisoning or early spoilage.
1.6.1. Sources of Food Contamination
Food can get contaminated at various stages in its production. These contaminants can be physical, chemical or biological (Fraiser & Westhoff, 1978).
188.8.131.52. Physical hazards
Physical hazards are foreign particles, like glass or metal.
184.108.40.206. Chemical Hazards
Chemical hazards include substances such as cleaning solutions and sanitizers.
220.127.116.11. Microbial Hazards
Biological hazards include bacteria, viruses and parasites. Microorganism grows best in foods that are high in protein or carbohydrates such as meat, poultry, seafood, milk, rice and eggs. There exist different ways of microbiological food contamination, among which are faecal-oral route, normal bacteria flora ‘some organisms form part of our normal flora of the human being, for example, Staphylococcus aureus and can infect consumers'(Ward, 2000) and cross contamination.
18.104.22.168. Common food poisoning illnesses
Table 1. Shows the characteristics of some bacteria responsible for food-borne diseases, their incubation period, the symptoms and sources (Marriot 1997).
Poultry and meat products, especially stews, gravies and pies.
Abdominal pain, diarrhea and nausea.
Onset of Illness
8 to 12 hours, (usually 10 to 12 hours).
The microorganism is found in excreta of human, animals, soil.
It can grow in anaerobic conditions and can survives ordinary cooking.
Chicken, pigs and birds products.
High fever ( typhoid and paratyphoid fever), at times diarrhea and at times constipation
Onset of Illness
10 to 14 days
These are transmitted by oral-fecal route, food get contaminated by feaces of infected person/animal
The toxin produced by the species can survive ordinary cooking.
Meat, eggs and fish products.
Abdominal pain, severe vomiting, diarrhea, abdominal cramps.
Onset of Illness
1 to 6 hours (usually 2 to 4 hours).
Infected sores, nasal secretions and skin .The toxin that causes illness can survive ordinary cooking.
Contaminated meat and meat products, especially poultry.
Contaminated water, and raw milk.
Diarrhea, abdominal pain, fever, nausea, and vomiting.
Onset of Illness
1 to 10 days (usually 3 to 5 days).
Campylobacter bacteria are normally found in excreta of man and domestic animals such as poultry.
It may be contagious to other human beings.
Contaminated meat and meat products, water and raw milk.
Diarrhea, vomiting, abdominal cramps and fever
Onset of Illness
10 hours to 9 days ( usually 3 – 5 days)
These are transmitted by oral-fecal route, food get contaminated by feaces of infected person
Canned meat, fish and vegetables
Difficulty in movements, swallowing of food and respiration
Onset of Illness
If left untreated death may result in 72 hours
Main source is improperly canned food
Contaminated food e.g water
Profuse diarrhea and vomiting
Onset of Illness
The disease progresses from the first liquid stool to shock in 4-12 hours, with death following in 18 hours to several days if not treated.
A person may get cholera by drinking contaminated water or food, in brackish rivers and coastal waters.
1.7. Beef, Goat, Venison, Poultry and Fish
The Food Act 1998, food regulation state that meat offered for sale shall be the edible part of:-
‘a healthy slaughter animal slaughtered in an abattoir and includes the edible offal of the animal’.
‘a healthy animal shot or otherwise killed as game’.
Market regulations GN 9.. of 1997 :-
The section 29 of the market regulation GN .. of 1997 up to the section 46 of the same regulation (see appendix) cover different aspects such as slaughtering of animals, introduction into the market, exposed for sales, game meat, fish exposed for sales, carcasses with part of skin and tail, washing of hands and tripe, offal, gutting of fish and storage of unsold fleshy food items.
All living animals are brought to the Mauritius Meat Authority slaughterhouse, ‘where they are examined by the official veterinary and when an animal is declared healthy it can undergo the slaughter process’ (Catsberg & Kempen-Van Dommellen, 1990).
Before delivery a certificate is issued and it indicates:-
‘the name of the owner of the animal’
‘the market at which the meat is intended to be sold’
‘the number and weight of the carcasses or part of carcasses, the quantity of sausages, black pudding and other preparations intended to be introduced in the market’ (Market Regulations, 1997).
1.7.2. Exposure and display of fresh meat
According to the food regulations fresh meat on sale should be exposed in a chilling cabinet at a temperature of 1°C and 8°C. The chilling cabinet has to be maintained in a clean and hygienic condition. The butcher has to indicate that the meat on sale is chilled or frozen (Food Act 1998).
1.7.3. Quality characteristics of fresh meat
Meat and poultry are perishable foods and they are ideal food for microorganisms that cause discoloration, spoilage and food borne illness (Marriot, 1997).
The shelf-life of fresh meat depends upon preservation and adequate storage methods. Inappropriate storing of fresh meat ‘can lead to deterioration in quality and even spoilage’ (Catsberg & Kempen-Van Dommellen, 1990).
The poultry meat industry ‘has been and remains one of the most successful growth industries in agriculture in the world’ (Bremner & MacJohnson, 1996). In Mauritius it is mainly the flesh of chicken which is offered for sales as compared to other countries where poultry meat ‘can be turkeys, domestic ducks, tame geese, tame pigeon tame guinea fowl and tame quails’ (Catsberg & Kempen-Van Dommellen, 1990).
Poultry is a ‘significant reservoir of bacterial food-borne pathogens’ such as Salmonella, Campylobacter and has also been in many cases ‘the cause of human food poisoning outbreaks’. Inadequate storing of flesh poultry meat will cause ‘microbial spoilage and the shelf-life is also decreased’ (Bremner & MacJohnson, 1996).
1.7.5. Spoilage of poultry
Poultry meat is nutrient rich. The growth of certain types of bacteria renders spoilage of chicken inevitable. Psychotropic bacteria have the ability to grow under chilled conditions, grows faster when the temperature is raised to an optimum of 25°C (Bremner & MacJohnson, 1996).
The best way to check freshness is by the smell, color, appearance, taste, and the texture of cooked flesh. Sensory evaluation is smelling and visual check for quality. (Fox etal; 1995)
1.7.7. Spoilage of Fish
In fresh fish, there are 2 spoilage factors to consider, these are the enzymes and the bacteria.
Enzymes help to break down food particles into simpler forms and function even after death. Unfortunately, in terms of food quality once the fish die, anabolic and catabolic processes are not controlled. Enzymes activities increases when fish is kept at a temperature between -1.5°C and -5°C, compared to that at 0°C. This occurs because some cell membranes that separate enzymes and the substances are destroyed during the freezing process. (FAO, 1994)
Bacteria are another cause of fish spoilage that is more dangerous. They are present in high numbers in the gut of living fish, and also on the gills and skins. Bacteria are present on any living fish and feed on the substances of fish and continue to do so even after death. The waste products of bacteria are particularly foul smelling compounds such as ammonia and hydrogen sulfide. (FAO, 1994)
To study the hygienic practices at the Mahebourg Market, three different types of questionnaires were designed. They aim at:-
Assessing the hygienic level of Mahebourg Market.
Study the knowledge, aptitude and practices of the food handlers.
Assessment of hygienic level of food handlers from consumers.
It consists of two parts, the first on aimed at the general environment and structure of the building and the second part aimed at the personal hygiene of the food handlers. Personal observation was carried out on different days and time.
This questionnaire was designed so as to assess the knowledge, aptitude and practice of the food handlers. The survey was carried out on several days namely Monday, Thursday and Friday of each week for a whole month. These days were choosen regarding the activity of the markets, Monday and Friday are fair days and Thursday it’s the day of meat delivery from the Mauritius Meat Authority.
This questionnaire targeted the appreciation of the level of hygienic practices of the food handlers from the consumers. The questions were set in a way to facilitate answering from the consumer. As for the food handlers’ questionnaire survey this one also was carried out on the same day as the latter.
Method of Analysis
The analysis of results was carried out for each category of questionnaire as soon as the survey was done. Compilations of data were done Microsoft Office Excel 2003 and for simple compilation all answer was represented by a numerical value hence the setting up of a key on Microsoft Office Word as shown in Appendix … to Appendix …. Spss17.0 statistical package was used for all descriptive or interactive analysis.
3. RESULT ANALYSIS
3.1. Personal observation questionnaire.
The personal observation questionnaire was designed to gather information about different aspects such as the general environment of the market, facilities provided, personal and hygienic practices of food handlers. The markets management has taken care that no garbage is left over in the markets premises thus collection and disposal of refuse is done on same day. All the bins are made up of rusty irons sheets and are deprived of covers. On several occasions the presence of strays dogs, cats and birds were found roaming and flying inside the markets premises. According to the observation made 69.8% of the food handlers exposed fruits and vegetables for sales on aloe fibre placed on iron sheets with wooden cradle over the concretes tables, 2.3% exposed their fleshy food directly on the tables, 18.6 % on tiles and hooks and 9.3% uses both tiles and chilled cabinets.
Figure2 represents the mode of exposure of food items.
The flooring was not always kept clean, it was observed that 25.6% was cleaned, 16.3 % was muddy, 39.5% was slippery and 18.6 % was muddy and sliperry.
Figure3 represents the percentage of flooring being cleaned, muddy, slippery or both.
No cracks was observed in neither the vegetables section nor the fleshy food section
As per the Food Act four concrete wash basins were put at the disposition of the vegetables sellers for general usage and individual stainless steels wash basins for each occupier of the fleshy food section. 69.2% of the occupiers of the fleshy food section use wooden base for chopping and 30.8% use plastic chopping board for cutting purposes.
All the doors are equipped with self closing device but none of them are in working order. As per the Food Act all openings are fitted with flies proofing but 100% are partly damaged allowing entrance of flies.
In the vegetables section only 50% of the food handlers wears their apron and in the fleshy food section 76.9% of the food handlers having worn an apron were dirty and the remaining 23.1% does not wear any apron.
The hands and hair can be a source of contamination and may lead to food poisoning. In the vegetables section only 23.3% were using caps and 100% were not using gloves, in the fleshy food section 76.9% were not using their caps and 53.8% were not using gloves. Only 37.2% were well shaved and 39.5% were not well shaved, it is to be noted that this question does not apply to 23.3 % as they are of female sex.
Figure4 represents the percentage of food handlers being well shaved
During the survey it was noted that only 2.3% used to wash their hands prior to serving of consumers and 97.7 % does not wash their hands, 74.4 % and 25.6% used cold tap water and cold tap water with detergents/disinfectant respectively for cleaning of their utensils.
Figure5 represents the percentage of food handler using of cold tap water and clod tap water with detergents/disinfectants for cleaning purpose.
At the end of the survey the level of hygienic practices of the food handlers was evaluated and 14.0 % had a good hygienic practice, 39.5% were satisfactory and 46.5 % had poor hygienic practices.
Figure6 represents the level of hygienic practices.
3.2. Interview of food handlers questionnaire.
The interview of the food handler questionnaire was designed to assess the knowledge, aptitude and practice of the food handler and also to determine if they are operating accordingly to the Food Act regulations.The questionnaire was administrated to 45.5 % males and 54.5 % females with and age range from 26 to 60 years. 74.5 % sells fruits and vegetables whereas the remaining 9.1 %, 1.8%,9.1%, and 5.5% sells beef, fish, poultry and goat/venison/pigs respectively, among which 89.1% operate on a daily basis, 9.1 % works only once a week and 1.8 % three days a week.
Figure7 represents the percentage of different food items offered for sales.
100% of the interviewed food handlers states that they do poses a food handler certificate and that they are aware of good hygienic practices and also that they have followed a training session from the ministry of health in relation to personal and food hygiene. Even after having followed the said training, 16.4% sates that they usually smoke while being at work. 89.9% of the food handlers interview stated that they usually wash their hands after having smoked, eaten or gone to the toilet prior to handling of food stuffs, while the remaining 10.1% says that they does not follow the same principle. Concerning washing of their utensils 56.4% replied that they does it for at least twice a day, 41.8% says that the does it for more than two times and 1.8% stated that they wash it after each use.
Figure8 represents the frequency at which they wash their utensils.
When the food handlers were asked about their opinion on attending work while being injured or sick, 76.4% and 100% replied that they do not attend duty while suffering from any lesion or sickness respectively.85.5% of the food handlers import food everyday into the market so as to provide fresh food at all times during the week and 14.5% import food only once a week. According to the food handlers only 34.5% succeed in selling all their food and the remaining 65.5% cannot afford to sell all the food on the same day. 74.5% stated that the unsold food is kept covered with cloth or plastics after each working day whereas 25.5% stored the remaining in refrigerator, they, 100%, also added that the stored food is re-offer for sales on the next working day.
Figure9 represents the ways by which unsold food items are stored.
According to the Food Act Regulations, it is the sole responsibility of the food handler to keep the food the premises where food is being handle clean,76.4% says that they do not sue any insecticidal sprays/ sanitizer or any other chemical cleaning solution for killing insects or disinfection process while 23.6% agrees making use of such products.
Figure10 represents the use of chemicals for cleaning or disinfection purpose.
When they were asked if they knew what is food poisoning, 100% replied YES and they also agrees that unhygienic practices may lead to food contamination and food poisoning.
3.3. Feedback questionnaire from consumers.
The questionnaire for the consumer was designed in order to know the opinion of the consumer s visiting the market. Mahebourg market is the central market in the district of Grand-port which attracts people from all localities. The participants consisted of 45 % males and 55 % females and were mainly from Mahebourg/Beau Vallon 45.3% and the remaining 54.7% were from different localities as illustrated below. Most of the consumers, 63.7%, visit the market at least once a week.
Figure11 represents the percentage of visitors from different localities.
Among which 27.0% buys only vegetables, 5.0% buys only fleshy foods and 68.0% buys both fleshy food and vegetables. They were asked if they are satisfied with the food freshness and 66.3% states that they are satisfied, 29.0% were neither satisfied nor dissatisfied and 4.7% were not satisfied.
As per the Food Act all meat shall be exposed in chilled cabinets, only 4.0% confirmed that fleshy food is being exposed for sales in chilled cabinets. Food offered for sales in open air like on tables, hooks are liable to potential contamination from the surrounding environments.
Figure12 represents the mode of exposure of fleshy food
When they were asked if they have ever found any dogs, cats, birds or rodents inside the market premises, 100% says YES.
Not every person visiting a market has knowledge about good hygienic practices, only 87.3% of the participant had this knowledge. 100% replied that only a few food handlers do wear an apron or gloves while working. When they were told to evaluate the hygienic level of the food handlers 44.3% said 25% satisfied, 52.7% said 50% satisfied and 3.0% said 75% satisfied.
Figure13 represents the evaluation of the level of hygienic practices of food handlers by consumers.
As for good hygienic practices not all participants have an adequate knowledge about food poisoning, 87.7 % said Yes and 12.3% said NO. Among these 82.7% stated that they never suffered from any food poisoning whereas 1.3%, 8.3% and 7.7% suffered from vomiting, diarrhoea and all food poisoning symptoms respectively.
Figure14 represents the percentage of consumer having suffered from a symptom of food poisoning.
Concerning improving and maintaining hygienic practices in the market the consumer was ask to choose among the ministry of health (denoted as the sanitary authority), the local authority and the market management. 17.7% opted for the ministry of health, 5.3% the market management and 77.0% said that it is the responsibility of all of them and out of those interviewed 6.0% were neither satisfied nor dissatisfied with their work while 43.7% were not satisfied at all.
Figure15 represents the percentage satisfaction of performance of duty by different enforcing bodies.
Food Safety (Chapter 1, section 1.6) is a basic requirement of food quality which can be considered as a complex characteristic of food that determines its value or acceptability to consumers. However, food can transmit diseases from one person to another as well as serve as a growth medium for bacteria that can cause food poisoning. It is a common, yet distressing and sometimes life-threatening problem for people throughout the world depending on the type of infection one can have. Unhygienic practices among food handlers and poor hygienic conditions in which they trade are responsible for most cases of food borne diseases. Food handlers have been widely recognized as a source of infection during several food borne outbreaks.
In the study carried out at Mahebourg Market, most of the Food handlers were found to have a low literacy level and they therefore venture into food business, as it one of the best job option for an income generation .The majority of the food handlers were found to be females as serving is regarded to be females domain. According to them, they all possess a medical certificate but it is possible that they do not have one yet or their medical certificate have been expired and not renewed yet. It is also not surprising that many of the food handlers did not understand the importance of medical examination in terms of spread and prevention of food borne diseases. They were medically examined only because it is a legal requirement and pay no attention to its significance.
Consumers, regardless of their literacy level, frequented Mahebourg market at least once a week. They come from different localities as described in figure 11. There are two fair days Monday and Friday and people seize the opportunity to buy fresh vegetables at an affordable price as on these days there are competition of prices among the vegetable sellers.
In general the food handlers appeared to have a positive attitude towards hygienic practices (Chapter 3) .Although most of them were of opinion that Personal Hygiene and Food Hygiene were important to run their business, it was evident that these were not put into practice and the drive to generate an income was more important. It was obvious that despite having got a training session on hygiene, they still lack its principles and application.
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