Foodborne Diseases in Malaysia a Review

Food Control 22 (2011) 823 e830

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Review

Foodborne diseases in Malaysia: A review  J.M. Soon a b , H. Singh c 1, R. Baines a 2 ,

,

*

,

,

a

School of Agriculture, Royal Agricultural College, Cirencester, Gloucestershire GL7 6JS, UK  Department of Agro Industry, Faculty of Agro Industry and Natural Resources, Universiti Malaysia Kelantan, 1600 Pengkalan Chepa, Kelantan, Malaysia c World Health Organization (WHO) Representative Of  fice  fice for Brunei Darussalam, Malaysia and Singapore, 1st Floor, Wisma UN, Block C, Kompleks Pejabat Damansara, 50490 Kuala Lumpur, Malaysia b

a r t i c l e

i n f o

 Article history: Received 27 May 2010 Received in revised form 30 November 2010 Accepted 7 December 2010 Keywords: Foodborne disease Food service Malaysia Surveillance

a b s t r a c t

This paper reviews foodborne diseases occurring in Malaysia and the strategies taken by the Malaysian government. Half of the foodborne related diseases from the early 1990s until today were associated with outbreaks in institutions and schools, mostly due to unhygienic food handling procedures. Outbreak surveillance surveillance and monitoring, monitoring, training and Hazard Analysis Analysis Critical Critical Control Control Point (HACCP) implementaimplementation at food service establishments all play a vital role to prevent and/or reduce foodborne diseases. Some of the key agencies agencies from the Malaysian Ministry Ministry of Health, academia, academia, industries industries and research institutions institutions continue to strengthen strengthen their collaboration collaboration and networking networking in order to coordinate coordinate the prevention and control of foodborne diseases and thus improve public health. Developments to date have shown improvement in surveillance and monitoring. In Malaysia, the main contributing factor to foodborne diseases was identified as insanitary food handling procedures which accounted for more than 50% of the poisoning episodes. episodes. Food handlers play a major role in the prevention prevention of food poisoning poisoning during food preparation; hence, food handler training is seen as one of the main strategies to increase food safety practices. There are 125 accredited food handlers training institutes as of September 2010. The application of knowledge and skills from training into the workplace is important and reasons for limitations limitations of training training initiatives initiatives are discussed. discussed. 2010 0 Elsevier Elsevier Ltd. All rights rights reserved. reserved. Ó 201 ’

Contents 1. 2.

3.

4.

Introd Introduct uction ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 823 Foodbo Foodborne rne disea diseases ses in Malay Malaysia sia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 824 2.1 2.1. Foodbo Foodborne rne disea diseases ses repor reportin ting g in Malays Malaysia ia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 824 824 2.2. Foodborne Foodborne disease disease outbrea outbreaks ks in education education institutions institutions in Malaysia Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 825 Interv Intervent ention ion strat strategi egies es . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 826 3.1 3.1. Outbre Outbreak ak survei surveilla llance nce and and monitor monitoring ing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827 827 3.2. 3.2. Traini Training ng and educ educati ation on as preve preventi ntive ve contr control ol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827 827 3.3. Hazard Hazard Analysis Analysis Critical Critical Control Control Point Point (HACCP) (HACCP) in food service service establi establishmen shments ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 828 Conclu Conclusio sion n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 829 Ackno Acknowle wledgm dgment ent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 829 Refer Referenc ences es . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 829

1. Introduction * Corresponding author. School of Agriculture, Royal Agricultural College, Cirencester, Gloucestershire GL7 6JS, UK. Tel.: þ44 7500 233538; fax: þ44 1285 650219. 650219. E-mail addresses: [email protected] (J.M. Soon), [email protected] (H. Singh), [email protected] (R. Baines). 1 Tel.: þ603 2093 9908; fax: þ603 2093 7446. 2 Tel.: þ44 01285 652531x2255.

0956-7135/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.foodcont.2010.12.011 doi:10.1016/j.foodcont.2010.12.011

Foodborne disease outbreaks are de fined as the occurrence of  two two or more more cases cases of a simila similarr illn illness ess result resultin ing g from from the inges ingestio tion n of  a commo common n food food (Olse Olsen, n, Mck Mckinn innon, on, Goul Gouldin ding, g, Bean Bean,, & Slut Slutsker sker,, 2000). 2000 ). Food Foodbo born rne e illn illnes esse sess are are comm common on alth althou ough gh the the vast vast major majority ity of cases cases are are undia undiagno gnosed sed or go unrepo unreporte rted d becaus because e

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 J.M. Soon et al. / Food Control 22 (2011) 823e830

a complex chainof events must occur before a foodborneinfectionis of ficially logged. A breakat any point inthe chainwill resultin a case not being reported (CDC, 2000). For example, during 1990 e2008, a total of 17,094 outbreaksof foodborne disease were reportedin the United States. These outbreakscaused a reported370,266personsto become ill (CDC, 2009a). However, it is estimated that foodborne diseases may result in 76 million illnesses, 325,000 hospitalizations and 5000deaths eachyear inthe U.S. (Mead et al., 1999). In England and Wales, foodborne diseases resulted in an estimated of 1.3 million cases, 21,000 hospitalizations and 500 deaths annually (Adak, Long, & O Brien, 2002). Meanwhile, in Australia, about 5.4 million cases,15,000 hospitalizations and 120 deaths were reported annually (AGDHA, 2005). These examples showed that a large number of foodborne diseases usually go unreported due to the complex chain of reporting and monitoring procedures. Diarrheal diseases alone, a considerable proportion of which is foodborne, kills 1.8 million children every year worldwide ( WHO, 2007). In Malaysia, the reported food and waterborne diseases in 2009, e.g. cholera, dysentery, typhoid and Hepatitis A were low, ranging from 0.14 to 1.07 cases per 100,000 population. In contrast, food poisoning cases is on the rise as evident by the incidence rate of  62.47 cases per 100,000 population in 2008 and 36.17 in 2009 (MOH, 2009, 2010a). Critics of foodborne disease reporting systems argue that their value is limited because data is published much too late after the events have occurred. While these are valid criticisms, it should be understood why there is limited data and why it takes so long to report. First, it should be stressed that complete data from large federated countries with a number of levels of government are dif ficult to obtain; e.g. local/regional/county or state/provincial/ federal. Furthermore, resources to conduct full traceback investigation are limited (Todd, 1990). This is further compounded by many implicated food items having a shorter shelf-life and they may be consumed or thrown away during the epidemiology and environmental traceback. There may be substantial under-reporting in mild and common illnesses as most individuals regard diarrhea as a transient inconvenience rather than a symptom of  disease, and hence may not consult the doctor. In addition, for the system to function, the general practitioner must order a stool culture, the laboratory must identify the etiologic agent and report the positive results to the local or state public health institution (Rocourt, Moy, Vierk, & Schlundt, 2003 ). Given these limitations on reporting, the actual number of cases that occur is likely to be substantially greater than the number of cases that are reported (Fig. 1). For example, it has been estimated that 38 cases of  salmonellosis occur for every case that is reported ( Cooke, 1991; Voetsch et al., 2004). Another limitation is the dif ficulty in attributing a specific caseto a specific source as various pathogens can be transmitted by a variety of different food and non-food exposures. Once a food is implicated as a common source of outbreak, a detailed review of its production process may reveal the points where the contamination was likely to have originated. This information is of particular interest to risk assessors as it allows them to identify the hazards and thus develop mitigation strategies. However, such information is only gathered in a minority of foodborne outbreak investigations and requires a multi-disciplinary approach ( Braden & Tauxe, 2006). ’

2. Foodborne diseases in Malaysia  2.1. Foodborne diseases reporting in Malaysia

In Malaysia, the current foodborne disease surveillance data is collected mainly through physician-based surveillance and outbreak investigations. Through this system, noti fication is

Fig. 1. Surveillance pyramid. The number of illnesses reported to public health department is a small fraction of the total number of illnesses (adapted from: Braden & Tauxe, 2006; Cooke, 1991; Voetsch et al., 2004 ).

received from government health facilities consisting of health centers, outpatient departments and hospitals and also from private hospitals and general medical practitioners. Noti fications and monitoring are received by the Communicable Diseases Surveillance Section, Diseases Control Division, Ministry of Health, Malaysia (Fig. 2), via an electronic reporting system known as the Communicable Diseases Control Information System (CDCIS) (MOH, 2007a). There are five food and waterborne diseases on the list of communicable diseases which are required to be noti fied under the Prevention and Control of Infectious Diseases Act 1988 (Act 342). These are cholera, typhoid/paratyphoid fevers, viral hepatitis A, food poisoning and dysentery ( MOH, 2007a). A decade ago, the of ficial reported figures for foodborne infections may represent only the tip of the iceberg. The true incidence of foodborne infections in Malaysia was unknown and there has been little attempt to ascertain the magnitude of the problem (Lim, 2002). Beuchat (1998) agreed and noted that due to the lack of  foodborne disease investigation and surveillance in most developing countries, most outbreaks often go undetected. However, it is interesting to note that in 2006, a total of 6938 cases of food poisoning were reported with an incidence rate of 26.04% ( MOH, 2006), followed by a 100% rise of food poisoning cases in 2007

 J.M. Soon et al. / Food Control 22 (2011) 823e830

Laboratory surveillance

Microbiology laboratories

Institute of  Medical Research, Public Health Laboratories

Mandatory Notification

Public – Health centres and hospitals; Private clinics, hospitals

Clinical based (sentinel/national syndromic cases)

Sentinel - selected clinics, national hospitals

825

Community based surveillance

Other agencies

Community / Media and international sources

District Health Offices Veterinary Department (zoonoses)

State Health Department

National: Disease Control Division, Ministry of Health

Fig. 2. Communicable diseases surveillance system in Malaysia (Thong, 2006).

(incidence rate of 53.19%) (MOH, 2007a). The drastic increase in 2007 may not be showing a true increase in food poisoning cases, but the increase may be due to the improvement of the reporting and registration system, through the establishment of the Crisis Preparedness and Response Center (CPRC) in May 2007 (Commonwealth Health Ministers Update, 2009; MOH 2009). The Ministry of Health has also produced a manual on syndromic approach to infectious disease noti fications where noti fication is based on a syndrome (e.g. acute gastroenteritis) rather than a specific disease (FAO, 2004). Syndromic notification is advantageous since it facilitates timely notification and enables rapid response to a disease outbreak without being delayed by laboratory confirmation (Disease Control Division, 2004). This is a part of the National Communicable Diseases Surveillance System which complements the mandatory noti fiable disease surveillance (pers. comm., 30 October 2010). Meanwhile, the National Laboratory Surveillance Programme is a laboratory base surveillance system which entails the reporting of certain microorganisms isolated in all public or private laboratories in Malaysia to the Ministry of Health. The following bacteria are monitored by the National Laboratory Surveillance System: Salmonella typhi and Salmonella  paratyphi, Salmonella spp., Vibrio cholera along with Haemophilus in fluenzae and Neisseria meningitidis (MOH, 2007a). The food section (food laboratory) provides laboratory testing for food, water and environmental analysis for the purpose of  outbreak investigation, surveillance and enforcement of the Food Act 1983. These tests are done to support programmes under the Disease Control Division and the Food Safety and Quality Division to reduce the exposure of the community to unsafe food. The Food Section of Food Laboratory also provides training, development of  protocols and quality system harmonization for all food laboratories under the Ministry of Health ( MOH, 2007a). The Vaccine Preventable Disease, Food and Waterborne Disease Sector have always been vigilant in their activities related to prevention and control of food and waterborne diseases. This sector had strengthened its network with other parties within the Ministry of  Health Malaysia, namely Food Safety and Quality Division, Engineering Services Division and Enforcement Unit from the Department of Public Health. Through this network, all public health activities related to food and waterborne diseases were overseen together from the head quarters level ( MOH, 2006). ’

 2.2. Foodborne disease outbreaks in education institutions in Malaysia

Accepting the limitations in surveillance and reporting in the early 2000s, the number of food poisoning cases reported in the country had fallen from 8640 cases in year 1999 to 4641 cases in 2005 (Fig. 3). This could be due to the result of the food handlers training programme launched since 1996 and the inspections carried out at food premises. Until January 2010, 473,306 personnel had been trained under the Food Handlers Training Programme (pers. comm., 13 April 2010). It is noted that most of the foodborne related diseases were associated with outbreaks in institutions ( Disease Control Division, 2005, 2006, 2007, 2008a), with 62% of the episodes in schools, followed by academic institutions (17%) while community gatherings accounted for 8% (MOH, 2007a). This is in agreement with Grif fith (2000) who indicated that up to 70% of the foodborne illnesses in the USA, the UK and the Netherlands were associated with catering or food service establishments. Most of the cases were due to unhygienic handling of food and lack of cleanliness in food preparation establishments. Tirado and Schmidt (2000) also concluded that these substantial proportions of foodborne diseases can be attributed to food preparation practices in the domestic environment. Some of the main risk factors are inappropriate storage (32%), inadequate heat treatment (26%) and cross contamination from raw to cooked foods (25%) ( Smerdon, Adak, O Brien, Gillespie, & Reacher, 2001 ). In Malaysia, the main contributing factor was identified as insanitary food handling procedures which accounted for more than 50% of the poisoning episodes ( MOH, 2007a). For example, in  January 2008 alone, thirty incidents of food poisoning and one food chemical intoxication were reported (Table 1). As previously stated, most of the implicated food settings occurred in schools and academic institutions food preparation premises and inappropriate food handling practices, meals prepared tooearly and kept at ambient temperature until served and unhygienic practices were the causes of food poisoning cases. A total of 997 cases were reported throughout the country for this period. This is in agreement with Olsen et al. (2000) who demonstrated that foods consumed in institutions and other food services are considered the leading locations for foodborne outbreaks. ’

’

’

’

’

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Fig. 3. Number of noti fiable foodborne diseases in Malaysia from 1990 to 2009. Source: MOH (2007b, 2009, 2010a) and Zulkifle (2007).

According to McCabe-Sellers and Beattie (2004), the reasons for this include: epidemiological selection (outbreaks involving several people are more likely to be traced back to the source than are individual cases), lack of quality assurance in food services and failure of employees to followgood hygienic practices. The ultimate goal for food service operations is to produce safe and wholesome food. The occurrence of foodborne outbreaks shows the need of  improving food safety in food service area, which is the last part of  the food production system before consumption ( Morrison, Caf fin, & Wallace, 1998). In view of this, a joint committee incorporating Ministry of Health and Ministry of Education was formed to

specifically address and manage the issue of food poisoning in schools. Among the activities conducted were media campaigns, food contractor seminars at schools nationwide and road shows on food safety in selected schools (MOH, 2007a). 3. Intervention strategies

Strategies for intervention to reduce foodborne diseases include surveillance and monitoring, appropriate training for preventative control and the adoption of food safety management systems and risk models. These interventions are discussed below.

 Table 1 Food poisoning outbreaks in Malaysia from 1 January to 2 February 2008.

No.

Location/implicated food setting

Cases (Hospitalizations)

Implicated food vehicle

Cause of contamination

References

1 2

College s cafeteria School s canteen

14 21

Inappropriate storage Inappropriate storage

Disease Control Division (2008a) Disease Control Division (2008a)

3

Academy s cafeteria

75

Chicken Nasilemak (steamed coconut rice) Fish

Disease Control Division (2008b)

4 5 6 7 8

School canteen Library s cafeteria College s cafeteria School canteen School canteen

10 58 46 8 124

Beef broth Nasilemak Chicken paprika Chicken rice Fried rice and beef broth

9 10 11 12

Home School canteen School canteen Boarding school canteen School canteen School canteen School canteen Food stall

5 38 59 14

Chicken Soto (soup) Crackers Chicken korma

20 46 24 7 (5)

Various institutional settings (school canteens, hostels and nurses training college)

15 incidents; 428 cases

Chicken Fried noodles Fish Putumayam (vermicelli-like noodles made from rice flour and coconut milk) Various foods

Unhygienic food preparation area; unhygienic personnel; inappropriate food handling practices Inappropriate food handling practices Inappropriate storage Inadequate heating before consumption Inappropriate storage Inappropriate storage of raw materials and cross contamination Cross contamination Not reported. Not reported Unhygienic practices of both workers and premise Inadequate cooking Contaminated raw materials Unhygienic practices Blood samples tested positive for Premethrin. Source of contamination unknown Inappropriate food handling and inadequate food sanitary measures

13 14 15 16

17

’

’

’

’

’

’

Disease Control Division (2008b) Disease Control Division (2008b) Disease Control Division (2008b) Disease Control Division (2008b) Disease Control Division (2008b) Disease Control Division (2008b) Disease Control Division (2008b) Disease Control Division (2008b) Disease Control Division (2008b) Disease Control Division (2008b) Disease Control Division (2008b) Disease Control Division (2008b) Disease Control Division (2008c)

Disease Control Division (2008c)

 J.M. Soon et al. / Food Control 22 (2011) 823e830

 3.1. Outbreak surveillance and monitoring 

Early detection of emerging risks is bene ficial to prevent diseases from spreading widely. International organizations, national and regional authorities have put various mechanisms in place in order to carry out monitoring and surveillance of adverse events following consumption. Various systems exist to date that measure the occurrence of foodborne disease. International surveillance is pursued by World Health Organization (WHO) which hosts the International Food Safety Authorities Network (INFOSAN). INFOSAN is intended to be an information network for the dissemination of important information about global food safety issues. Through INFOSAN, authorities in member states can exchange information on routine as well as emerging foodborne diseases. Rapid alert or outbreak situations that are of relevance to international public health should be reported in real time through INFOSAN s computerized Global Outbreak Alert and Response Network (GOARN). The alerts are then handled and coordinated by WHO which can offer technical assistance to member nations experiencing the outbreaks ( WHO, 2006). In the United States, the Foodborne Diseases Active Surveillance Network (FoodNet) is the principal foodborne disease component of the Centers for Disease Control and Prevention s (CDC) Emerging Infections Programme which actively collects data on cases of  foodborne diseases from laboratories and health professionals in 10 sites covering 13% of the American population ( Braden & Tauxe, 2006; CDC, 2009b). While in Europe, the Rapid Alert System for Food and Feed (RASFF) is an important tool to exchange information on food safety and control measures between member states. RASFF also informs countries outside the EU of noti fications concerning products exported by the countries ( Johannessen & Cudjoe, 2009). Similarly, the Malaysian Foodborne Diseases Network (MyFoodNet) was established to monitor and coordinate the surveillance system of foodborne diseases in the country ( FAO, 2004). Furthermore, a Food Safety Information System of  Malaysia (FoSIM) was launched in 2003. FoSIM is an intelligent web-based information system linking 34 entry points in the country with 14 food quality control laboratories, 13 state health departments and the Food Safety and Quality Division. FoSIM assists the management of food safety surveillance to ensure imported foods sold in Malaysia are safe for human consumption (Food Safety and Quality Division, 2010). Food premises inspection and closures were carried out intensively and the number of  inspections increased from 70,747 in 2002 to 88,969 inspections in 2007. The percentage of non-compliant companies and food businesses closed also increase from 3.32% to 5.60% (Fig. 4) (MOH, 2006, 2007a). These figures show that the Ministry of Health indeed is committed toward ensuring food safety for the public. “

”

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While large outbreaks like cholera epidemics and food poisoning in schools are easily detected, diffuse outbreaks often go unreported. There is a need to establish a system of active surveillance in sentinel populations. With improved surveillance and more accurate data, the magnitude of the problem from both the health and economic aspects can then be calculated ( Lim, 2002). CDC also launched several approaches to foodborne disease surveillance, including FoodNet, PulseNet and the National Antimicrobial Resistance Monitoring System f or Enteric Bacteria (NARMS) in the U.S. (Tauxe, 2006) while the OzFoodNet system is the active surveillance in Australia ( Ashbolt et al., 2002).  3.2. Training and education as preventive control

Food handlers have a major role in the prevention of food poisoning during food preparation since they may cross contaminate raw and cooked foodstuffs as well as inadequately cooked and stored foods (Walker, Pritchard, & Forsythe, 2003). Hence, food handler training is seen as one of the main strategies to increase food safety practices (Smith, 1994). The Ministry of Health in Malaysia launched the Food Handlers Training Programme in 1996 to ensure hygienic practices during handling, preparation and sale of food ( Jinap, Mad Nasir, & Mohd Salim, 2003). There are 125 accredited food handlers training institutes as of September 2010 (Fig. 5) (MOH, 2010b). From 1996 till January 2010, 473,306 personnel had been trained under the Food Handlers Training Programme (pers. comm., 13 April 2010). A survey carried out by Toh and Birchenough (2000) in Malaysia revealed a positive impact between education and the hawkers knowledge and attitude scores. Education increased the hawkers knowledge and hence, improved their attitudes toward food safety and hygiene, foodborne illnesses and their prevention. The Epidemic IntelligenceProgramme (EIP) was also initiated in 2002 to train public health practitioners in epidemiology investigation and disease surveillance. EIP was adapted from the Epidemic Intelligence Service of Centre for Disease Prevention and Control, US. (Harpal, 2009). It is interesting tonote that the numberof notifiable foodborne diseases went up between the year 1996 and 1999. This may be partly explained as follows: a study by Acikel et al. (2008) has shown that educating food handlers and repeating the training periodically decreases food-related infection. However, knowledge alone may not lead to changes in food handling practices, as suggested by Angelillo, Viggiani, Rizzo, and Bianco (2000) . Angelillo et al. (2000) interviewed 411 food handlers in Italy and observed that even though the interviewed food handlers had a positive attitude towards food safety during interviews; the positive attitude was not observed during real-time food handling. In other words, a food safety culture was not established in the workplace. There aremany reasons for thelack of impact of training initiatives and the implementation of safe food handling practices within the food service industry. The problems identi fiedby Grif fith (2000) were: (i) high turnover of staff; (ii) low pay staff; (iii) low status of staff; (iv) large number of part-time workers; (v) staff  language problems and/or low educational levels; (vi) often little attention to qualityassurance; (vii) large number of complex meals; (viii) majority of food often served/prepared to meet short periods of high demand at mealtimes; (ix) current fashion for visually artistic dishes requiring increased handling; (x) provision of food to large numbers of vulnerable consumers; (xi) poor access to food safety information, (xii) facilities and equipment oftencramped and inadequate and (xiii) shift rotation ( Capunzo et al., 2005). Food safety education is most effective when messages are targeted toward changing behaviors most likely to result in foodborne illness. The five major control factors for pathogens are personal hygiene, adequate cooking, avoiding cross contamination, keeping ’

’

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’

“

Fig. 4. Number of food premises inspections and closures from 2002 to 2007. Source: MOH (2006, 2007a). ’

827

”

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Fig. 5. Number of food handlers training institutes (total ’

¼

125; as of September 2010) in various states of Malaysia ( MOH, 2010b).

food at safe temperatures, and avoiding foods from unsafe sources (Medeiros, Hillers, Kendall, & Mason, 2001 ). One of the important elements in the effectiveness of food hygiene training is the support given by managers to encourage safe food handling practices among food handlers during real work time (Seaman& Eves, 2010). Previous research by Egan et al. (2007), Seaman and Eves (2006), and Seyler, Holton, Bates, Burnett, and Carvalho, 1998 also concluded that support from the management and peers play a vital role in motivating staff to enact safe food hygiene practices. The use of food safety trainers with a range of language skills too could improve safe food handling practices (Rudder, 2006). We would argue that a review of the effectiveness of the training carried out in Malaysia would bene fit from considering the above factors to see whether they contributed to the limited development of a food safety culture in the food service sector. However, the key to training will always be centred on developing appropriate risk analysis and management, in addition to the adoption of Hazard Analysis Critical Control Point (HACCP) for key stages within a food business and along food supply chains.  3.3. Hazard Analysis Critical Control Point (HACCP) in food service establishments

Baines, Davies, and Batt (2005) suggested that the key to food safety breakdown challenges is prevention, which can be built into Purchase

Delivery

Receipt (Raw materials)

Storage Thawing Initial Preparation

Cooking

CCP 2a?

CCP 1?

Hot holding

Chilled storage

CCP 2b?

Service

Reheating

CCP 3?

Service

Fig. 6. Generic flow diagram for catering operations with possible (?) Critical Control Points (CCPs) listed (Grif fith, 2000).

industry practices by identifying where potential risk factors may occur in the chain. The preferred strategy for this is the adoption of  Hazard Analysis Critical Control Point (HACCP) as opposed to the traditional end product testing approach to food safety assurance (FAO/WHO, 1983; Woteki, Glavin, & Kineman, 2004). The implementation of HACCP in food regulation as a requirement has been considered to have a positive in fluence on food safety (Cormier, Mallet, Chiasson, Magnússon, & Valdimarsson, 2007 ) and governments have mandated the use of HACCP system (Unnevehr &  Jensen, 1999). MOH also promotes food safety through the certi fication of the MalaysianCertificationScheme for HACCP (FAO/WHO, 2004). In 2008, HACCP was introduced to hospitals food service establishments in Malaysia (State Health Department of Selangor, 2009). HACCP systems were initially designed and applied to the food manufacturing industries (Panisello & Quantick, 2001). However, HACCP system in manufacturing plants differs from the HACCP system in the food service areas due to the fact that food service contains more hazards mainly due to the time and procedures involved in preparation of a range of foods to serving of meals. The handling and assembling, holding time and temperature, reheating procedure, and hygiene of personnel are factors that make food service operations distinct from food manufacturing (Sun & Ockerman, 2005). According to Mortlock, Peters, and Grif fith (1999), food manufacturers were five times more likely than retailers andfour times more likely than caterersto be using HACCP. It should also be noted that it is harder to monitor and control the food safety in the food service sector due to the complexity of foods and the preparations involved in food service ( Sun & Ockerman, 2005). A generic flow diagram for catering operations was illustrated by Grif fith (2000) along with possible Critical Control Points (CCPs) in the process ( Fig. 6). Furthermore, in order to reduce foodborne illnesses, the following procedures should be strictly adhered to: (i) pre-employment health screening; (ii) health monitoring; (iii) staff hygiene rules; and (iv) hand hygiene ( Kang, 2000) (Fig. 6). We should also consider the size and value of the food service businesses; as Route (2001) indicated that lack of  financial and human resources in small food businesses are the main barriers to HACCP implementation. Meta-analysis carried out by Jev snik, Hlebec, and Raspor (2006) shows that training, human resources, planning, knowledge and competence, documentation, resources and management commitment are the main barriers in HACCP implementation. However, with suf ficient guidance and support, ’

 J.M. Soon et al. / Food Control 22 (2011) 823e830

HACCP is also considered achievable for small food businesses (Bertolini, Rizzi, & Bevilacqua, 2007; Taylor & Kane, 2005 ). Moreover, HACCP should be part of a continuous and ongoing company training and management programme in order to embed food safety culture within the workplace. 4. Conclusion

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The global burden of foodborne diseases and its impact on development and trade is a cause for concern. Reliable epidemiological data are urgently needed to enable policy-makers as well as other stakeholders to monitor and evaluate food safety measures (WHO, 2010). Similarly, foodborne diseases in Malaysia may just be a tip on the iceberg and require intensive monitoring and surveillance from the public, academia, industries and research institutions to reduce the impact of foodborne diseases. Some of the key agenciesin Malaysia, such as the Food andWaterborne Disease Unit (Communicable Disease Section) and the Surveillance Section (Diseases Control Division) which coordinate the prevention and control of food and waterborne diseases, Food Safety and Quality Division which carries out surveillance of food and food-premises hygiene and nationwide laboratories which provide laboratory and epidemiological support in outbreak investigations and surveillance can continue to strengthen their collaboration and networking between units and departments to improve public health. Developments to date have shown the improvement in surveillance. Although training hasbeen carried out it appears to be less effective when correlated to reported food outbreaks over the same period. Wehave arguedthat the limited benefits derived from training are probably linked to the lack of cascading of knowledge and skills allied to the lack of effective follow up on monitoring and mentoring when trainees return to the workplace.  Acknowledgment

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