Prevalenceof Intestinal Parasites and Associated Factors Among Food Handlers Working in Food and Drink Establishments at Mizan-aman Town, Southwest Ethiopia, 2018, Community Based Study

Background: Food borne diseases has remained a major global public health issue with substantial morbidity and mortality associated with the consumption of contaminated food staffs. Parasitic infection is among the major disease especially in developing countries and sub-Saharan countries. Objective:-This study was to determine the prevalence of intestinal parasites and associated factors among food handlers working in food and drink establishments at Mizan Aman town southwest Ethiopia. Method:- A community based cross sectional study was conducted in Mizan Aman town. A total of 418 food handlers from randomly selected 209 foods and drink establishments were interviewed and nally stool samples were taken. Parasitological assessment was performed by qualied laboratory technologists using the physiological saline for wet mount and zinc sulphate and formol ether concentration techniques were used. Data were analyzed using statistical SPSS version 21. P ≤ 0.05 was taken as statistically signicant Result: The overall prevalence of intestinal parasites in Mizan Aman town was 26.1% .work experience >10 years (AOR=0.52,95% CI ;2.430,5.012),the food handlers who did not trimmed their nger,(AOR =1.89,95% CI :1.01,3.960) and using common knife for cutting raw meat and other foods (AOR=0.57, 95% CI : 3.61,5.54) were factors associated with parasitic infections. Conclusion: The magnitude of intestinal parasite in mizan aman town is high and work experience, nger trimming status, and using common knife for cutting raw meat and other foods were factors associated with the parasitic infections

stunted growth, anemia and cognitive impairment (17). Food-handlers working in restaurants, and cafeteria harbor and excrete intestinal parasites that may contaminate food and serve as source of food-borne infections [10].
To prevent, food borne illnesses, all food handlers are required to practice food hygiene and safety activities. Food hygiene is the set of basic principles employed in the systematic control of the environmental conditions during production, packaging, delivery/transportation, storage, processing, and preparation, selling and serving of food in such a manner as to ensure that food is safe to consume. However, inappropriate and inconsistent food hygiene and safety activities can cause a health threat in developing countries due to di culties in securing optimal hygienic food handling practices [15], [16].
Globally 819 million people were infected with Ascaris lumbricoides (A. lumbricoides), 464.6 million people were infected with Trichuris trichiura ,438.9 million people were infected with hookworm,500 million people were infected with Entamoeba histolytica (E. histolytica) and 2.8 million people were infected with Giardia lamblia [12].
Parasitic diseases which are one of major diseases in the world especially in developing countries [5]. Many studies discovered that parasitic infections cause so many diseases [9].They cause mental retardation, abdominal cramp, nausea, bloating, anorexia, anemia, stunt growth, malnutrion and diminished work capacity (17). As WHO report, about one third population in developed countries were infected by intestinal parasites whereas report for developing country indicates ve times higher than developed countries [17]. In developing countries, up to 70% of cases of diarrheal disease are associated with the consumption of contaminated food. On the other hand, the growth of urbanization and transportation increased the number of peoples who use hotels and cafeterias for feeding and drinking services [16].
Because of food prepared in large quantities is more likely to be contaminated, there is a greater potential for the occurrence of food borne disease outbreaks if basic sanitary practices are not maintained [16].Ethiopia is one of developing countries whose majority of population is affected by intestinal parasites [2], [18].
Food handlers play a great role in communication of parasitic infection [17]. In developing countries as Ethiopia food handlers are hired without any screening for intestinal infections [19].
Asymptomatic patients with parasitic infections were considered to be hazardous to the society because such food handlers routinely exercise their jobs without giving due attention for the transmission of infections. As a result, intestinal parasites can be transmitted to consumers directly or indirectly through food, water, and ngers from food handlers [17].
Studies showed that, the prevalence of parasitic infection was found to be from 2% to 61% [20], [17].The parasitic infection and transmission was found to be associated with age ,job position, year of service, educational status, hand washing practice after toilet, hand washing before and after serving, trimming nger nails, wearing cup , gown, training and medical checkup [10]. Therefore this study was aimed to assess the prevalence of intestinal parasites and associated factors among food handlers working in food and drink establishments at mizan-aman town. The study will help in initiation of raising the quality service provision to the food and drink establishments' owners. In addition, it will also play a great role for achievement of national growth and transformation plan, by helping in reducing morbidity and mortality in relation to unsafe food and drink services provision. Moreover, this study will also be a baseline for researchers, and other concerned bodies whether governmental or nongovernmental bodies

Study area and period
The study was conducted in Bench Maji zone at Mizan Aman town in SNNP Regional State which is located 561 km from Addis Ababa in south west direction, the town has total population of 57,537, of these 30,379 were males and 27, 158 females (CSA, 2007).There were 135 and 189 food and drink establishments within the town. Totally 324 food and drink establishments were registered by Mizan Aman town Trade and Industry O ce in 2018.

Study design
A community based cross-sectional study was conducted in mizan aman town .

Source Population
All food handlers working in food and drink establishments in Mizan Aman town Study population All randomly selected food handlers working in each selected food and drink establishments in Mizan Aman town Sample size Sample size was calculated by using a single population proportion formula assuming 95% con dence interval, 5% margin of error and prevalence of intestinal parasites 44.1 % among food handlers' at Jimma zone Yebu town was taken as proportion [12]. Therefore, Where P=0.44% Z=95% d =5%) and 10 % non-response rate.

Data collection tools and procedures
Data and stool collection tools Data collection materials were adapted from other related researches and translated to Amharic and back to English by experts.pre test was done on 5% of calculated sample size in Tepi town and questionnaires were modi ed accordingly.

Data and stool collection procedures
All participants were informed about the purpose of the study and after getting their willingness, interview was made, about a paean size of the stool samples were collected from each selected food handlers after interview. Collected stool specimens were transported by cold box to Mizan Aman Health Science College laboratory and Parasitological assessment was performed by quali ed laboratory technologists using both the physiological saline and iodine wet mount and Formol ether concentration techniques as described on the standard. Dispensing the saline preferably from a small dropper bottle which can be closed when not in use to avoid contaminating the reagent was done [12]. The direct saline wet mount was employed not to miss trophozoites of E. histolytica and G. lamblia. All of the parasites detected by direct saline wet mount were also detected by Formol ether concentration technique.
Data and stool sample collectors Ten laboratory technicians were recruited for the data and stool sample collection after two days training .Five supervisors were also assigned to check data completeness on daily bases.

Inclusion and exclusion criteria
Inclusion criteria All food handlers who were engaged in food preparation, serving and cleaning utensils during the study period were included.

Exclusion criteria
Food handlers with con rmed intestinal parasite infection and on treatment were excluded from this study Data analysis Data were coded and entered, in epi data version 3.1 and transported to SPSS version 21.0 for analysis purpose. Percentage and frequency distribution was performed. Bivariate analysis was done to check association between dependent and each independent variable. Variables having p-value < 0.25 in the bivariate analysis were taken for multivariate logistic regression. Variables whose p-value <0.05 were considered as statistically signi cant Data quality management Supervisors and data collectors were trained focusing on the way of communication with participants and specimen handling.
Before the actual data collection pre test was done on 5% of sample size in Tepi town. data were checked for completeness, coded and entered into Epi-data 3. The nding of this study was presented to Mizan Aman Health Science College. The copies of the nding were given to Trade and Industry O ce.Moreover, attempts will be made to publish reputable international journals.

Socio demographic characteristics
A total of 418 food handlers participated in the study, but 19 of them refuse to participate, so the response rate was 95.4 %. Among 399 participants 203 (50.9%) were female and 194(49.1%) were male. Regarding the age of participants, majorities (48.6 %) were less than 20 years old and only 1% were 65 years and above. Majority (54.4%) of the respondent's educational status was primary education (from grade 1-8) whereas only 4% of the study participants attended their education to university level. Two hundred thirty seven (59.4%) sample's speci c job in the establishment was waiter, but only 52 (13%) sample's job was cleaner. Almost half (49.4%) of the respondents work experience in the food and drinking establishment was below 1 year, and only 1% of the study participants have above 10 year work experience. Only 6.8% of the study samples have training on food preparation and hygiene. 13.7%of them were infected by intestinal parasites which were the highest proportion from total prevalence of parasites. Only 27(6.8%) food handlers had training in food safety and about 48(12%) of them had medical check-up (see Table 1

Infection status
Regarding infection status, 26.1% of the participants were found to be infected with intestinal parasites. The most prevalent species was Ascaris lumbricoid (7.3%)followed by tricuriasis (4%)whereas the least prevalent species was hook worm (see gure 2 below)

Multivariate analysis
The odd of infection is 48% less likely in the participants who served for more than 10 years compared to that of participants who served for less than 1year.The risk of infection among the study participants who wash their hands after food preparation is 1.37 times more likely to be infected compared to respondents who wash their hands routinely.
Respondents who did not trim their ngers nails were 1.89 times more likely to be infected than that of the respondents who trimmed their nger nails. The risk of infection in Study participants who does not use common knife to cut raw meat and other foods were 43% times lower than those who use common knife.see table 3 below   Discussion Several studies across the world have determined the prevalence of intestinal parasites among food handlers. HundaolGirma et al, revealed that ; the prevalence rates of the intestinal parasites infections among food-handlers in different part of the world range from 28.7% to 52.2% [12]. The prevalence of intestinal parasites among food handlers working in food and drink establishments at mizan-aman town was 26.1%. This is nearly similar with the nding of (25%) in Gonder University Ethiopia [6]. However it is higher than what was reported in northern Iran, the prevalence of intestinal parasites was 3.73% [4]and in Axum, Ethiopia which was 14.5% [5].
On the other hand, the result of this study was lower than a cross sectional study report in Bahir Dar town, in which 158 (41.1%) of food handlers were found to be infected with intestinal parasites. [7]. Another similar study in Arbaminch University revealed that 36% of the study participants found to be infected with intestinal parasites [8] and a study conducted in Jimma Zone, Yebu town reported highest rate of intestinal parasite 44.1% [9].The differences might be due to differences in climate, geographical location, socio-demographic features of the populations.
According to our research nding, the odd of infection is 48% less likely in the participants who served for more than 10 years compared to that of participants who served for less than 1year. But, according to the research done in southern part of Ethiopia, there was no association between year of service and prevalence of parasitic infection (8). The risk of infection among the study participants who wash their hands only after food preparation is 1.37 times more likely to be infected compared to respondents who wash their hands routinely. The habit of hand washing practice was similarly associated with infection rate according to research conducted in Arbamich (8). Respondents who did not trim their ngers were 1.89 times more likely to be infected than that of the respondents who trimmed their ngers. This nding was similar with that of Arbaminch according to the report; parasitic infection rate was 2 times higher among the participants who didn't trim their nger nails. The risk of infection in Study participants who does not use common knife to cut raw meat and other foods were 43% times lower than those who use common knife. This study nding was in contrary with that of Arbaminch town, according to the report, the odds of infection in the participants who use common knife to cut raw meat and other foods was 72% times lower compared to that of not use common knife. (8)

Conclusion
The prevalence of intestinal parasite in Mizan Aman city food and drinking establishment is 26.1 %.and work experience, nger trimming status, and using common knife for cutting raw meat and other foods were factors associated with the parasitic infections.

Consent for publication
The nding of this study was presented to Mizan Aman Health Science College. The copies of the nding were given to Trade and Industry O ce.Moreover, attempts will be made to publish reputable international journals.

Availability of data and materials
The data that support the ndings of this study is available at the hands of Mr. AM, the corresponding author and it can be delivered to the journal based on request at any time.

Competing interests
The authors declare that they have no competing interests.