Quality of water for consumption and food processing activities is universally accepted as an essential component to ensure food safety at household (HH) level. Along with safe water, hand hygiene is also an important factor for reducing diarrheal illnesses. This was a cross-sectional study conducted in rural and urban HHs to detect hygiene indicators in drinking water samples at point of use (PoU) (n = 150) and their association with the hand hygiene of primary food preparers (n = 150). Overall, 24.7% and 9.3% of drinking water samples (PoU), 48% and 20% of hand rinse samples were contaminated by faecal coliforms and E. coli, respectively. Both drinking water (PoU) and hand rinse samples collected from rural HHs showed higher contamination, followed by those from urban slums and low income HHs. Significant association (p < 0.05) and probable risk with faecal coliforms (OR. 2.5; 95% CI: 1.1–5.4) and E. coli (OR. 14.5; 95% CI: 4.1–50.7) was found between hand rinses and drinking water samples that had bacteriological contamination. These results suggest that there was an extensive cross contamination at HH level. So, targeted education is essential on safe food/water handling practices in HHs to prevent food safety risks.

INTRODUCTION

Food safety is an area of public health action which aims to protect consumers from the risks of food poisoning and foodborne diseases, acute or chronic (WHO 2015). Food safety refers to all hazards which can make food injurious to health, including quality of drinking water. Diarrhoea is a common symptom of foodborne and waterborne diseases. Diarrhoeal diseases kill an estimated 2 million people annually and children constitute the majority, especially in developing countries (WHO 2015). In India, diarrhoea is responsible for about 13% of child deaths (UNICEF 2012). Several studies have demonstrated a high prevalence of bacterial contamination of water and foods within households (HHs) (Lanata 2003; Wright et al. 2004). This may cause a higher incidence of infections in susceptible individuals, particularly children. Therefore, the home setting is considered the first place in which foodborne diseases develop due to poor personal and/or environmental hygiene, with an increased risk of infection (Scott 2001; Kagan et al. 2002; Redmond & Griffith 2003). Many studies have shown that, even though consumers are aware of food safety measures, there exists a gap between food safety knowledge and practices which may result in foodborne illness (Medeiros et al. 2004; Patil et al. 2004). This is evident from the fact that people have started consuming bottled mineral water in view of safety and health (Beers, personal communication, July 2009). However, it requires safe practices not only in identifying the source of drinking water, but also in the collection, storage and drawing practices at HH level. It has been largely observed that the microbiological quality of water stored in vessels at home is poorer than the source, suggesting that contamination is widespread during collection, transport, storage and even while drawing water (Wright et al. 2004). These contamination points may negate the precautions taken to ensure water quality at the source.

The importance of drinking water quality is well established in India, but so far there is no study on the factors that determine the bacteriological quality of drinking water at the point of use (PoU) and also there are no studies to determine the quality of drinking water at source level or on handlers’ hand hygiene. The objectives of the study were to analyse the bacteriological quality of drinking water at PoU in the HHs of urban and rural areas and to determine the association between hand hygiene of the primary food preparers (who are involved in most of the food preparation, handling and serving activities of food to all family members) and the bacteriological quality of the drinking water (PoU).

MATERIALS AND METHODS

Research design

A cross-sectional design was applied to evaluate the faecal contamination of drinking water at PoU and also the hands of primary food preparers at home.

Sampling

A stratified random sampling method was used to study a total of 150 HHs including urban dwellers in three categories – high income group (HIG), middle income group (MIG), low income group (LIG), also slum dwellers in Hyderabad city and those living in rural areas of Ranga Reddy district, Telangana. Drinking water samples of 100 ml (n = 150) and hand rinse samples (n = 150) were also collected for microbiological analysis.

Ethics approval

The study protocol was approved by the Institutional Ethical Committee of the National Institute of Nutrition, Jamai-Osmania, Hyderabad, India. Vide protocol number 05/I/2014, August 24 2015.

Sample collection

From each of the five groups, 30 HHs were randomly selected. Drinking water (PoU) and hand rinse samples were collected in sterile containers from the primary food preparers in each HH and transported to the laboratory in an ice box which maintained <4 °C temperature. These samples were processed within two hours of collection. Hand rinse samples were collected from each HH by placing the persons’ right hand (which is used predominantly in all HH activities) above the opened sterile container and then rinsing with 60 ml of sterile distilled water for 40–50 seconds. This method was standardised in the laboratory before the collection of samples in the community. This same method was used successfully in a study conducted in South-East Nigeria (Chinakwe et al. 2012). Information was collected on the source of the drinking water as well as on the socioeconomic status of HHs along with sample collection.

Isolation and identification

Isolation and identification of hygiene indicators was performed according to USFDA–BAM (United States Food and Drug Administration–Bacteriological Analytical Manual). In this process, for isolation of hygiene indicators–faecal coliforms and E. coli–100 μl of each sample was used for inoculation. For this purpose, selective media (MacConkey Agar for E. coli and M-faecal coliform Agar for faecal coliforms) were obtained from Himedia Laboratories Ltd., Mumbai, India. All inoculated plates were incubated under aerobic conditions at 37 °C for 24 hours. After completion of the incubation period, inoculated plates were observed for the presence of the respective colony characteristics and were further confirmed by using appropriate biochemical tests.

Statistical analysis

Data were analysed using SPSS version 19.0 Software. Descriptive statistics was performed to evaluate contamination levels, analysis of variance (ANOVA) to establish the association between socio-economic status and contamination levels, chi squared test to identify the association between drinking water (PoU) and hand-rinse contamination and odds ratio (OR) to evaluate the probability of risk. P values less than 0.01 and 0.05 were considered as statistically significant.

RESULTS AND DISCUSSION

Sources of drinking water for HHs

Information was collected from HHs about the source of drinking water and other food preparation activities as shown in Table 1. About 54% of HHs obtained drinking water from municipality/panchayat taps, but none of them used further purification methods for drinking water. About 26.7% of HHs bought packaged drinking water from local sellers and 19.3% of them used bore well water after purification with aqua guard/purifier at home for drinking purposes.

Table 1

Sources of drinking water for HHs (n = 150)

Location/Income group Municipal/panchayat tap water Packaged drinking water Bore well water purified with Aqua guard/Purifier at home 
RURAL (n = 30) 14 (46.6%) 16 (53.3%) – 
URBAN (n = 120)   
HIG (30) 4 (13.3%) 3 (10%) 23 (76.6%) 
MIG (30) 14 (46.6%) 15 (50%) 1 (3.3%) 
LIG (30) 19 (63.3%) 6 (20%) 5 (16.6%) 
Slum (30) 30 (100%) – – 
Total Urban (n = 120) 67 (55.8%) 24 (20%) 29 (24.1%) 
Pooled (n = 150) 81 (54%) 40 (26.7%) 29 (19.3%) 
Location/Income group Municipal/panchayat tap water Packaged drinking water Bore well water purified with Aqua guard/Purifier at home 
RURAL (n = 30) 14 (46.6%) 16 (53.3%) – 
URBAN (n = 120)   
HIG (30) 4 (13.3%) 3 (10%) 23 (76.6%) 
MIG (30) 14 (46.6%) 15 (50%) 1 (3.3%) 
LIG (30) 19 (63.3%) 6 (20%) 5 (16.6%) 
Slum (30) 30 (100%) – – 
Total Urban (n = 120) 67 (55.8%) 24 (20%) 29 (24.1%) 
Pooled (n = 150) 81 (54%) 40 (26.7%) 29 (19.3%) 

Bacteriological quality of HH drinking water (PoU)

The results (Figure 1) demonstrated that irrespective of source, the drinking water samples (PoU) were contaminated with faecal coliforms (24.7%) and E. coli (9.3%). Based on the information obtained from the HHs regarding the sources of their drinking water, municipal/panchayat tap water showed high levels of contamination with 13.6% contaminated with E. coli and 24.7% with faecal coliforms at PoU. The packaged drinking water samples were also contaminated, 35% with faecal coliforms and 7.5% with E. coli at PoU. At HH level, in spite of using water purifiers for bore well water, faecal coliforms were detected in 10% of water samples at PoU.
Figure 1

Bacteriological quality of HH drinking water (PoU) from different sources.

Figure 1

Bacteriological quality of HH drinking water (PoU) from different sources.

Data on the bacteriological quality of water samples (PoU) collected from urban and rural HHs for drinking and food preparation activities are shown in Table 2. In this study, rural drinking water (PoU) samples were highly contaminated with faecal coliforms (46.6%) and E. coli (10%), whereas 19.1% of faecal coliforms and 9.1% of E. coli were detected in urban drinking water samples. Urban area samples collected from a slum were found to be highly contaminated with faecal coliforms (26.6%) and E. coli (23.3%). Drinking water (PoU) samples collected from LIG were also contaminated with faecal coliforms (20%) and E. coli (13.3%). In about 20% and 10% of water samples collected from MIG and HIG HHs, respectively, faecal coliforms were detected.

Table 2

Bacteriological quality of HH drinking water (PoU) in urban and rural areas (n = 150)

  Drinking water (PoU)
 
Location/Income group Faecal coliforms E. coli 
RURAL (n = 30) 14 (46.6%) 3 (10%) 
URBAN (n = 120)   
HIG (30) 3 (10%) ND 
MIG (30) 6 (20%) ND 
LIG (30) 6 (20%) 4 (13.3%) 
Slum (30) 8 (26.6%) 7 (23.3%) 
Total Urban (n = 120) 23 (19.1%) 11 (9.1%) 
Pooled (n = 150) 37 (24.7%) 14 (9.3%) 
  Drinking water (PoU)
 
Location/Income group Faecal coliforms E. coli 
RURAL (n = 30) 14 (46.6%) 3 (10%) 
URBAN (n = 120)   
HIG (30) 3 (10%) ND 
MIG (30) 6 (20%) ND 
LIG (30) 6 (20%) 4 (13.3%) 
Slum (30) 8 (26.6%) 7 (23.3%) 
Total Urban (n = 120) 23 (19.1%) 11 (9.1%) 
Pooled (n = 150) 37 (24.7%) 14 (9.3%) 

Note: ND – Not detected.

Contamination of hand rinse samples with hygiene indicators

In the present study, about 48% and 20% of the hand rinse samples were contaminated with faecal coliforms and E. coli, respectively (Table 3). Rural HH hand rinse samples were highly contaminated with faecal coliforms (83.3%) and E. coli (13.3%). About 39.1% and 21.6% of faecal coliforms and E. coli samples, respectively, were detected in urban hand rinse samples. The samples collected from slum HHs were highly contaminated compared to the other income groups.

Table 3

Hygiene indicators in hand rinse samples of primary food preparers from urban and rural areas (n = 150)

  Hand rinse samples
 
Location/Income group Faecal coliforms E. coli 
RURAL (n = 30) 25 (83.3%) 4 (13.3%) 
URBAN (n = 120)   
HIG (30) 11 (36.6%) 2 (6.6%) 
MIG (30) 7 (23.3%) 2 (6.6%) 
LIG (30) 14 (46.6%) 9 (30%) 
Slum (30) 15 (50%) 13 (43.3%) 
Total Urban (n = 120) 47 (39.1%) 26 (21.6%) 
Pooled (n = 150) 72 (48%) 30 (20%) 
  Hand rinse samples
 
Location/Income group Faecal coliforms E. coli 
RURAL (n = 30) 25 (83.3%) 4 (13.3%) 
URBAN (n = 120)   
HIG (30) 11 (36.6%) 2 (6.6%) 
MIG (30) 7 (23.3%) 2 (6.6%) 
LIG (30) 14 (46.6%) 9 (30%) 
Slum (30) 15 (50%) 13 (43.3%) 
Total Urban (n = 120) 47 (39.1%) 26 (21.6%) 
Pooled (n = 150) 72 (48%) 30 (20%) 

Association between the presence of hygiene indicator organisms in HH drinking water (PoU) and hand rinses of primary food preparers

The overall analysis of samples indicated a significant association (p < 0.05) between hand rinse samples and drinking water (PoU) samples which were contaminated with hygiene indicators. The same trend has been observed in the samples collected from rural and slum HHs (Table 4).

Table 4

Association between presence of hygiene indicator organisms in HH drinking water and hand rinse samples of primary food preparers (n = 150)

Hygiene indicators – Location of HHs Hand rinse samples Drinking water (PoU) χ2 P value 
E. coli (Rural) 8.205 0.004** 
E. coli (Slum) 6.679 0.01* 
E. coli (LIG) 0.879 0.348 
Faecal coliforms (LIG) 0.033 0.855 
Faecal coliforms (MIG) 2.981 0.084 
Faecal coliforms (HIG) 1.930 0.165 
Faecal coliforms (n = 150) 5.597 0.018* 
E. coli (n = 150) 25.525 0.000*** 
Hygiene indicators – Location of HHs Hand rinse samples Drinking water (PoU) χ2 P value 
E. coli (Rural) 8.205 0.004** 
E. coli (Slum) 6.679 0.01* 
E. coli (LIG) 0.879 0.348 
Faecal coliforms (LIG) 0.033 0.855 
Faecal coliforms (MIG) 2.981 0.084 
Faecal coliforms (HIG) 1.930 0.165 
Faecal coliforms (n = 150) 5.597 0.018* 
E. coli (n = 150) 25.525 0.000*** 

Notes: HH – Household; + Presence.

***p < 0.001.

**p < 0.01.

*p < 0.05.

Risk estimation

The presence of E. coli in drinking water (PoU) was 14.5 (OR. 14.5; 95% CI: 4.1–50.7) times more wherever the hands of primary food preparers were contaminated with E. coli. Similarly, the OR of drinking water (PoU) contamination with faecal coliforms at home was 2.5 times higher if hands were contaminated with faecal coliforms (OR. 2.5; 95% CI: 1.1–5.4).

Association between bacterial contamination of drinking water (PoU), hand rinse samples and urban HHs of different income groups

In urban areas, a significant (p < 0.05) mean difference was observed for the presence of hygiene indicator organisms (faecal coliforms and E. coli) in drinking water (PoU) and hand rinses of various income group HHs (HIG, LIG, MIG and slum) (Table 5). In both the cases, significant mean differences have been identified between HIG and slum, and MIG and slum.

Table 5

Association between bacterial contamination of drinking water (PoU) and hand rinse samples and HHs of different income groups in the urban area (n = 120)

Income group Mean ± SD P value 
E. coli in drinking water (PoU): 
 HIG 0.00 ± 0.00  
 Slum 0.71 ± 1.36 0.004* 
 MIG 0.00 ± 0.00  
 Slum 0.71 ± 1.36 0.004* 
Faecal coliforms in hand rinses: 
 MIG 0.61 ± 1.18  
 Slum 1.52 ± 1.65 0.07t 
E. coli in hand rinses: 
 HIG 0.27 ± 1.06  
 Slum 1.20 ± 1.46 0.031* 
 MIG 0.23 ± 0.91  
 Slum 1.20 ± 1.46 0.021* 
Income group Mean ± SD P value 
E. coli in drinking water (PoU): 
 HIG 0.00 ± 0.00  
 Slum 0.71 ± 1.36 0.004* 
 MIG 0.00 ± 0.00  
 Slum 0.71 ± 1.36 0.004* 
Faecal coliforms in hand rinses: 
 MIG 0.61 ± 1.18  
 Slum 1.52 ± 1.65 0.07t 
E. coli in hand rinses: 
 HIG 0.27 ± 1.06  
 Slum 1.20 ± 1.46 0.031* 
 MIG 0.23 ± 0.91  
 Slum 1.20 ± 1.46 0.021* 

Notes: * p < 0.05; t – trend.

In this study, the bacteriological quality of drinking water (PoU) and its association with the hand hygiene of primary food preparers was analysed. Microbiological contamination of water between source and point of use is widespread and often significant. Even with a clean source for drinking water, studies have shown a substantial amount of contamination at the HH level (Clasen & Bastable 2003). Increased faecal and total coliform counts in stored domestic water are especially found in areas with uncontaminated supplies (Jensen et al. 2004; Wright et al. 2004). In the present study, HHs acquired water for drinking and other food processing activities from three primary sources: municipality/panchayat taps operated and chlorinated by personnel in charge of the water supply, packaged drinking water from local sellers, and bore-well water. These results are comparable with a study conducted in South Africa which has similar economic and infrastructure conditions to India (Mellor et al. 2013).

According to Indian standards, in any water intended for drinking, E. coli/thermotolerant coliform bacteria (faecal coliforms) should not be detectable in 100 ml of any water sample (Bureau of Indian Standards 2012). But in the current study, 24.7% and 9.3% of the samples at PoU were contaminated with faecal coliforms and E. coli, respectively. This finding was also similar to a study conducted in Brazil, another country identified which resembles India in size, economic conditions and infrastructure. Here, 30.3% of drinking water samples at the consumption point were found to be contaminated with faecal indicator bacteria (Copeland et al. 2009). Contamination of municipal/panchayat water with 13.6% of E. coli and 24.7% of faecal coliforms was higher at PoU than other sources of water, which is quite different from the study conducted in South Africa (Mellor et al. 2013). This indicates that poor practices of HHs during collection, storage and drawing of water could be playing an important role in the quality of drinking water (PoU) even though the water has been treated with chlorine at the source and distribution levels.

The contamination of the untreated well water was not surprising, but mineral water (packaged drinking water), which is considered to be a cleaner alternative to tap water and purchased at a higher price, was also found to be contaminated. The study detected 35% of faecal coliforms and 7.5% of E. coli in packaged drinking water samples collected at HH level. This was comparable to a pilot study conducted in Brazil (B. Beers, personal communication, July 2009), which showed the vulnerability of water quality to problematic drinking water storage and hygiene practices. Even among the samples of water purified at HH level using home level purifiers, 10% of the samples had faecal coliforms. This indicates cross contamination while drawing water from the purifier.

The study results have shown that rural drinking water (PoU) samples were highly contaminated with faecal coliforms and E. coli followed by urban slum group, LIG, MIG and HIG. In another study conducted in Bangladesh rural areas, the faecal coliforms count was low in water at the supply point (tube-well water samples) but significantly higher in water samples stored at HH level (Hoque et al. 2006). This could be due to poor awareness and practices among HHs on food safety. Despite the provision of safe drinking water in urban municipal areas, there is contamination at PoU which was more in slum and LIG HHs and could be related to resource scarcity, poor personal hygiene and lack of awareness on safe methods of purification of water at home (Brick et al. 2004).

Along with sound HH water management, hand hygiene is the second important health behavior associated with diarrhoeal illness. Hand washing with soap has been shown to reduce the risk of diarrhoea by 47% (Curtis & Cairncross 2003). In the present study, about 48% and 20% of the hand rinse samples collected from primary food preparers were contaminated by faecal coliforms and E. coli, respectively. Rural HHs hand rinse samples have shown higher contamination than urban groups, ranging from 2–4.47 log CFU/ml. In a similar study in Peru, care takers’ hands were found to be contaminated with E. coli (23%) due to poor personal hygiene (Gil et al. 2014). In urban areas, a greater number of slum dwellers were found to be contaminated with faecal indicator organisms on their hands followed by those belonging to LIG, HIG and MIG. This increased number of persons with contaminated hands indicates poor personal hygiene and a relatively higher food safety risk in this community (Dharod et al. 2009). HIG HHs also showed higher contamination in hand rinse samples than MIG HHs. The results of the meta-analysis also indicated that there is less knowledge of hygiene and greater cross-contamination in high income individuals (Patil et al. 2005).

As we know, hands are an important infection transmission route and in support of this some researchers also suggest that water may be contaminated through hand contact (Roberts et al. 2001; Brown et al. 2008; Pickering et al. 2010; Mellor et al. 2013). The present study established a significant association between the presence of hygiene indicator organisms in drinking water (PoU) and hand rinse samples of primary food preparers. This finding is consistent with a study conducted in Tanzania identifying faecal contamination on hands as the strongest predictor of faecal contamination levels in stored drinking water at home (Mattioli et al. 2014). According to WHO, Hand hygiene (Key 1) and Use of safe water (Key 5) along with other concepts have been recognised as key practices to be followed during food preparation and handling to ensure food safety at HH level (WHO 2006). At home, the role of primary food preparers, usually mothers, in ensuring food safety is well accepted (Medeiros et al. 2004; Sudershan et al. 2008). In the current study, the prevalence of hygiene indicators in drinking water (PoU) from the treated source and on the hands of primary food preparers indicate that poor food safety practices still exist among HHs in spite of possessing knowledge about drinking water quality and its significance in ensuring good health.

CONCLUSIONS

The present study highlights that bacteriological quality of drinking water at PoU depends on the hand hygiene of the primary food preparers. Even though water was treated at source, other factors like income of the HH and storage practices have an influence on the quality of drinking water. The association between contamination of drinking water (PoU) and hand hygiene status suggest that extensive cross contamination was taking place within the house. These findings indicate that targeted food safety education on hand hygiene practices, safe HH storage and purification methods for drinking water are essential for various categories of HHs to prevent food and waterborne illness.

ACKNOWLEDGEMENTS

The authors acknowledge the encouragement given by the Director, National Institute of Nutrition (ICMR), Hyderabad, India, during the course of study and all respondents who participated in this study.

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