|No.47

Freshen up!

A newsletter from ICD/SEAMEO Cooperative Program Industry Council for Development and SEAMEO Regional Center for Food and Nutrition August-October 2012

FOOD SAFETY IN COMPLEMENTARY FEEDING : MORE EDUCATION TO GRASS ROOT IS NEEDED

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May 2012, in Lemah Ireng hamlet, Village of Kaliabu, Mejayan sub-district, District of Madiun, East Java Province, Indonesia, there was a food poisoning incident in young children linked to mung bean porridge and quail egg which was served as complementary food program in Posyandu (Integrated Health Post). Around 50 children under five were hospitalized, 6 of them were in critical condition and one of them went into a coma. The porridge was prepared by the wife of the head of the subvillage (hamlet). She claimed that she cooked the porridge as usual. Last year, in May 2011, food poisoning cases during complementary food program in Posyandu also occurred in Muhara hamlet, Mekarsari village, Maleber sub-distrct, Kuningan District, West Java Province, Indonesia. Around 10 children under five were vomiting after eating ricechicken porridge. In the same month, in another Province (Passo village, Baguala sub-district, Ambon Municipality, Maluku Province), food poisoning caused the death of two children aged 2 and 3-years old. Five children under five were also hospitalized after eating chicken ginger stew with green papaya (tinolang manok) and home-made bagoong (fish paste) in two barangays in Piddig, Ilocos Norte, the Philippines on 19th January 2012. The incidents above were only a few reported cases while many others remain unknown as foodborne incidents, resulting in under-reporting. These incidencts reflect the current condition or practices of food handlers who prepared complementary food for young children.

Contact Address SEAMEO RECFON Jalan Salemba Raya 6, Jakarta INDONESIA Phone: +62-21-31930205; 3914017 Fax: +62-21-3913933 E-mail: [email protected] Website : http://www.seameo-recfon.org

While many food safety education interventions have been conducted for food handlers, there is a need to explore the effectiveness of those educational activities for improving food safety knowledge, attitudes, and practices of those food handlers. Recent study titled “Meta-Analysis of Food Safety Training on Hand Hygiene Knowledge and Attitudes among Food Handlers” was published in the Journal of Food Protection in April 2012. The objective of the study was to assess the extent to which food safety training or intervention strategies increased knowledge of and improve attitudes toward hand hygiene. The result of the study showed that even though the trainings were effective for improving the knowledge of food handlers on hand hygiene, they were less effective for motivating food handlers to practice good hand hygiene. The study recommended refresher training and long-term reinforcement of good food handling behaviors to be conducted for sustaining good hand washing practices. In conclusion, more effective and continuous food safety education interventions should be conducted especially for food handlers at the household level who prepare food for high risk people or vulnerable group such as young children. (/LR)

Editorial Board Judhiastuty Februhartanty P. McClure SEAMEO-RECFON, Indonesia Unilever Plc, United Kingdom Marina Pergiwati Scott Boxshall PT. Unilever Indonesia Nestle Indonesia

Editors Evi Ermayani Lina Rospita Design & Lay Out Putri Tunjung Sari

Freshen Up! — Food Safety Matters PATHOGENIC Escherichia coli : CONTAMINATION IN COMPLEMENTARY FOOD FOR YOUNG CHILDREN Sources

and transmission Escherichia coli are normal inhabitants of the intestinal tract of humans and other warm-blooded animals. The presence of Escherichia coli in food indicates sewage or animal waste contamination, poor hygienic conditions in handling and improper storage, and inadequate heat treatment. Some Escherichia coli are pathogenic. The bacteria can spread from person to person. Escherichia coli is transmitted to humans through consumption of raw or undercooked food, fecal contamination of food and water, and also cross-contamination during food preparation (e.g. contaminated surfaces or kitchen utensils with meat). Raw food materials likely to be contaminated by pathogenic Escherichia coli are meat, fish, vegetables, milk, and polluted water. Symptoms. Pathogenic Escherichia coli are infectious food borne bacteria. The main symptoms are severe cramps and abdominal pain, watery diarrhea, and even bloody diarrhea. The incubation period can range from three to eight days. A rare but serious complication case of Hemolytic Uremic Syndrome (HUS) occurs when toxins get into the bloodstream and causing kidney injury or failure or pancreas damage and central nervous system impairment. The symptoms of pathogenic E. coli contamination are worse in children, especially those that are suffering from other illnesses. Prevention. Pathogenic Escherichia coli are heat-sensitive, in preparing food at home, be sure to follow safe preparation and

handling of food for young children, such as:  Use safe water and raw materials  Read expiry date / observe broken package before food preparation  Consume cooked food and boiled water  Use clean utensils  Cook food thoroughly  Separate raw and cooked food Pathogenic E. Coli  Use separate utensils for meat and non meat  Store meat in refrigerator/freezer  Store cooked food in clean place at safe temperature  Reheat cooked food after storage before consumption  Wash fruit and vegetables before consumption  Wash hands with soap and run water before touching child’s food  Wash hands after handling waste or animals  Do not prepare or handle food when having illness  Consume cooked food as soon as it is served Treatment A child who suffers from bloody diarrhea or severe abdominal cramps should be sent for medical treatment, kept hydrated and received adequate nutrition. It is not recommended to use antibiotics as Escherichia coli treatment because the bacteria create a toxin in its cell and if you kill the cell with antibiotics the toxin gets released into the bloodstream which may possibly increase the risk of HUS. HUS should be treated by hospitalization. (from various sources) (/LR)

LESSON LEARNT FROM WHITE REVOLUTION IN INDIA In the year 2012, milk consumption in Indonesia is 11.7 l/cap/yr. This figure is lower compare to other Asian countries such as Vietnam 14.1 l/cap/y, 2011; Philippines 13.1 l/cap/y, 2011; Thailand 31.7 l/cap/y, 2010; China 20.8 l/cap/y, 2010. With the low consumption, national milk production of Indonesia only contributes 30% of total milk consumed by the Indonesian people. This situation is not satisfactory since based on annual milk consumption data, trend of milk consumption in Indonesia is increasing. This situation was similar to India in the early 1950 where there was a big gap between supply and demand for milk and milk products. In India, dairy production is important for employment, income levels, and the nutritional quality of diets. Milk production in India is dominated by smallholder farmers including landless agricultural workers. For example, 80 percent of milk comes from farms with only two to five cows.

A well-known smallholder dairy production initiative, Operation Flood, laid the foundation for a dairy cooperative movement that presently ensures returns on dairy investments to 13 million members. Operation Flood also advanced infrastructural improvements to enable the procurement, processing, marketing, and production of milk and to link India’s major metropolitan cities with dairy cooperatives nationwide. This intervention transformed the policy environment, brought significant technological improvement into the rural milk sector, established many village cooperatives, and oriented the dairy industry toward markets. Following the success of the operations, the initiative was then named White Revolution. Since then on, milk pro-duction in India has risen from less than 30 million tons in 1980 to around 87 million tons in 2003 and has been estimated to keep increasing. Currently, in 2011, milk consumption in India reached 70 l/cap/y. (/EE)

News from Alumni On July 4, 2012 two of our Burmese trainers shared their research work in front of nutritionists, medical and public health professionals hosted by University of Public Health (UPH), at the Ministry of Health, Yangon, Myanmar. Khaing Mar Zhaw shared about “Exploration of Myanmar Rural Caregivers’ concepts on childhood diarrheal disease (6-24 mo) and its management related to ORS use and feeding practice” and Min Kyaw Htet on “Role of sub-clinical inflammation on micronutrient status of Myanmar adolescent girls during micronutrient supplementation”. Prior to the sharing, both were involved in the discussion of proposal development for Food Safety regional training for Mekong countries to be held in 2013 in Yangon in collaboration with SEAMEO RECFON and UPH Yangon. Dwi Nastiti Iswarawanti who is currently pursuing her doctoral degree will confer her public defense for the study titled “The effectiveness of training on cadres’ competencies in communicating safe complementary feeding to caregivers” on August 28, 2012.(/JF) Page 2

Freshen Up! — Food Safety Matters INCIDENT SUMMARY Product Sauced rice noodles soup (sinantak) sold at a school canteen for morning snack. Area Larion Bajo Elementary School, Larion Bajo village, Tuguegarao City, Cagayan province, the Philippines (June 14, 2012). Nature of incident Oxalic acid poisoning, an organic compound with the formula H2C2O4 usually used in waste water treatment to remove calcium and in commercial cleaning solutions to remove rust and hard water stains on metal, plumbing, counter tops and even ceramic tiles, and also used as wood preservatives. Illness/symptoms The victims started vomiting shortly after eating the noodles, complained of headache and weakness, difficulty of breathing and cyanosis (bluish nails), felt dizzy from diarrhea. People affected There were 41 students between 5-7 years old and 3 teachers hospitalized, 2 of 41 students died. Cause/background of the case The food poisoning was apparently an accident brought by some mixed-up of the condiments during the preparation of the noodles with soup. The health education teacher prepared/cooked the food for the subject of Home Economics and Livelihood Education at 8.00 am at the Home Economics kitchen of the school canteen. The noodles were sprinkled with three spoons of white crystalline oxalic powder placed in a plastic jar container which the teacher mistakenly believed to be iodized salt. The noodles then served at 9.00-9.30 am during recess time. The first case was detected at 9.45 am. Other cases occurred thereafter until 2.00 pm. Actions taken The victims were separately rushed to different hospitals. Two children died while being taken to a hospital in the city. The other victims have been in "stable condition" and rescoring. The police brought the sample of the white crystal substance to

the Philippine National Police Regional Office 2 Crime Laboratory for further investigation. The investigation was witnessed by co-teachers of the home education teacher who prepared the noodles. The sample turned out to be oxalic acid, a substance in bleaching solutions. The Tuguegarao City Health officer sent blood and urine samples of the victims and samples of spoiled noodles to the Department of Health central office in Manila for another examination to ensure the result and found the same result with previous investigation. The consequences of the incident The City Mayor assisted in the hospitalization expenses of the victims. The parents have vowed to file criminal and administrative charges against the school officials. Department of Education promised to give financial support to the families, and formed a committee to investigate the case. The Police investigated the teacher who allegedly put the poisonous substance in the cooked food. The teacher suspected has been relieved pending results of the investigation. She has been temporarily relieved from her post and is under police’s custody for possible filing of charges. She apologized to all concerned over the food poisoning incident. Bodies involved Tuguegarao City People General Hospital, Cagayan Valley Medical Center, Holy Infant Clinic, Clinica de Leon, Saint Paul Hospital; The Philippine National Police Regional Office 2 Crime Laboratory; National Disaster Risk Reduction and Management Council (NDRRMC) of the Philippine; Tuguegarao City Mayor; Cagayan 3rd District Representative; Department of Education Region of Cagayan Valley; Education Secretary of Department of Education; Department of Health of the Philippine Lessons learned - Chemicals for cleaning the equipments should be labeled properly and not stored in the food preparation area. - More food safety education is still needed nowadays, even for teachers. Source The Philippine National Disaster Risk Reduction and Management Council (NDRRMC); Philippine Daily Inquirer; Luzon News bits; GMA NEWS. (/LR)

Publication WHO Guidelines for the safe preparation, storage and handling of powdered infant formula, 2011 The purpose of this guideline is to provide guidance and support for governments, in general. Each country should adjust to the climatic and socioeconomic condition within the country. Training is required for parents, caregivers, and staff in hospitals and day-care centers. This guideline consists of guideline on how to prepare powdered infant formula in care settings including its poster, and also guideline on how to prepare formula for bottle-feeding and for cup-feeding at home. This guideline was developed based on recommendation from FAO and WHO expert meetings held in 2004 and 2006 on Enterobacter sakazakii and other microorganisms in Powder Infant Formula (PIF).

WHO news corner Food Safety News, No 44 - 8 Feb 2012 IN THIS ISSUE:  FOSCOLLAB: New tool for data and information exchange  Launch of a new web-interface to collect GEMS/Food data  FERG Strategic planning meeting and kick-off event of the pilot country studies  Health Risks at the Human-Animal-Ecosystems interface  Antimicrobial resistance at the 30th World Veterinary Congress  Codex Trust Fund - 2012 support levels for eligible countries  Call for experts - Campylobacterosis  New publications available on the web Link: http://www.who.int/foodsafety/publications/newsletter/44/ en/index.html

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Freshen Up! — Food Safety Matters FACT SHEET: The need to empower cadres on safe complementary feeding Child underweight contributes most significantly to the world global hunger index (GHI). Under nutrition has been responsible for 60% of 10.9 million deaths of young children annually (1). Diarrhea as the main symptom of foodborne illness has been associated with malnutrition and is considered the most common cause of death in young children especially in developing countries. Diarrhea contributes to children underweight in about 61% of cases (2). The incidence of diarrhea was highest among children aged between 6 and 12 months – the age range which coincides with the usual weaning period. Diarrhea, especially persistent diarrhea, often causes deterioration of nutritional status, and poor nutritional status has been shown to prolong the duration of illness. Moreover, poor appetite during illness results in low food intake among children. Hence, it leads to serious consequences for the growth and immune system of infants and children (3). A study on Hazard Analysis Critical Control Point (HACCP) found that caregivers had improper perceived behaviour on complementary foods preparation (4), resulting in Escherichia coli contamination in the critical points, such as caregiver’s hands (58%), feeding utensils (75%) as well as in the complementary foods (72.5%) (5). Poor nutritional status among young children is immediately caused by sub-optimal breastfeeding in the first six months of life and the poor quality of complementary foods. Caregiver’s practices will affect nutrient intake, health and the cognitive and psychosocial development of the child. Health providers such as hospital and community health centers can play a critical role in providing support and motivation, through influencing decisions about feeding practices among caregivers. In Indonesia, the health centre makes use of the existing social network in the community to help increase coverage of health services. In this regard, the role of posyandu becomes imperative. Posyandu or Pos Pelayanan Terpadu (Integrated Service Post) is a health activity aimed at empowering the community and providing them with access to primary health care in order to reduce mother and infant mortality rate (6). Community health workers can help mobilize community resources, act as advocates for the community and build local capacity (7). One of cadre’s tasks is to provide nutrition advice as response to growth status of weighed children in monthly posyandu activity as well as home visits for children with growth failure. The cadres were expected to be able to advise caregivers on safe food intake to ensure optimal physical and mental development of children. There is a contradictory dilemma. Cadres were inquired to perform their task properly, however the pre-requisite on clear expected competencies are not available. Insufficient conditions may lead to insufficient performance of posyandu cadres of their tasks. A study in Riau

Province found that most cadres never received any training (53%). Generally, educational materials were not available in posyandu (71%). The skill of most cadres on growth curve interpretation was also poor (8) and most cadres (59.3%) do not understand the function of growth cards in related to nutrition counseling. Considering the importance of their roles, it is necessary, therefore, to improve their capacities in safe complementary feeding including the communication tehnique to caregiver. Hence, this may strengthen and motivate caregivers so that they are capable to make correct decisions with respect to complementary feeding of children. It is necessary to develop a training model which aims to improve the competency of cadres in safe complementary feeding as well as to communicate this issue to the caregivers. Empowering the cadres in safe complementary feeding would be a useful means for human resource development of health staff in non-study and other areas. The training delivery can be adjusted to the particular situation and resources. The implementation of the training should consider the learner’s characteristics, socio-economic, culture, norms and values in the area. Indonesia is one of the countries responding to the global call for 1000 days of golden opportunity to alleviate children’s malnutrition, as reflected in Short and Long Term Planning of Indonesia (Rencana Jangka Panjang dan Menengah Nasional) 2009-2014 by reduction of the national infant mortality rate from 34 to 24 by the year 2014. Promoting sound breastfeeding and safe complementary feeding of children under two is one of the crucial interventions needed to achieve the vision. (/DNI) References : 1. World Health Organization. WHO working Group on the growth Reference Protocol and the WHO Task Force on methods for the Natural regulation of fertility. Growth of healthy infants and the timing, type, and frequency of complementary foods. Am. J. Clin. Nutr. 2002; 76:620-627. 2. Black RE, Moris SS, Bryce J. Where and why are 10 million children dying every year? The Lancet. 2003; 361:2226-34 3. Motarjemi Y. Contaminated weaning food: a major risk factor for diarrhea and associated malnutrition. Bull World Health Org 1993;71(1):79-92. 4. Rospita L. Hazard analysis critical control point study of foods for 6-24 months old children and food handlers’ practices in Bekasi, West Java. Unpublished. Thesis. Faculty of medicine University of Indonesia. Study program in Nutrition. Jakarta. 2009. 5. Kusuma A. Kontaminasi Escherichia coli pada penyajian makanan pendamping bayi usia 6-12 bulan menggunakan metode analisa bahaya titik titik kendali kritis. Unpublished. Dissertation. Fakultas Kesehatan Masyarakat. Program Doktor Ilmu Kesehatan Masyarakat. 2011. 6. Departemen Dalam Negeri. Pedoman pengintegrasian layanan sosial dasar di pos pelayanan terpadu. Peraturan Menteri Dalam Negeri no 19 tahun 2011. Jakarta. 2011. 7. Bhattacharyya K, Winch P, Le Ban K, and Tien M. Community health worker incentives and disincentives: How they affect motivation, retention, and sustainability. Basic Support for Institutionalizing Child Survival Project (BASICS II) for the United States Agency for International Development. Arlington, Virginia. 2001. 8. Mudjianto TT, Hidayat TS, Hermina, Luciasari E, Afriansyah N, Fuada N. Faktorfaktor positif untuk meningkatkan potensi kader posyandu dalam upaya mencapai keluarga sadar gizi. Penelitian Gizi dan Makanan. 2003;26 (2): 27-34.

Upcoming events ISO 22000 Training, at SEAFAST Baranangsiang, Bogor, Indonesia. Food Review Indonesia

Sept 25-27, 2012

International Training Programme in Food Safety, Quality Assurance and Risk Analysis, at Universiteit Gent, Belgium 3rd Oman International Food safety conference 2012 at Muscat, Oman. http://www.omanfoodsafety.com/2012/ 6th Asian Conference on Food and Nutrition Safety, Singapore with theme “Minimizing Risk, Maximizing Benefit”. http://ilsiacfns2012.com/

Sept 10 – Dec 23, 2012

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Oct 29-31, 2012 Nov 26-28, 2012