Diarrhoea and Vomiting

What should we advise food handlers with diarrhoea and/or vomiting to do? When should they be excluded from work, for how long and by whom?

There are two categories of gastrointestinal infection to consider in relation to the risks posed by infected food handlers:

1. A vast majority of common causes which are usually self-limiting and require only temporary exclusion from work (Box A/A1).
2. A small group of more serious infections that require special considerations (Box B).

Other foodborne diseases like Clostridium botulinum and perfringens, Listeria monocytogenes, and Bacillus cereus are not associated with transmission by food handlers.

In general, household contacts with diarrhoea and/or vomiting would not be an indication to exclude food handlers from work. However, food handlers should report this to the management, particularly in respect of Hepatitis A and E. coli, and normal personal good hygiene should be reinforced.

Follow up stool testing is required in cases of enteric fever (typhoid caused by Salmonella typhi; paratyphoid fever caused by Salmonella paratyphi A,B, or C), Verocytotoxin-producing E. coli (VTEC).

Verocytotoxin-Producing E.coli (VTEC 0157)

The number of organisms needed to produce this infection may be very small and any infected food handler should be excluded from work until the bowel habit has been normal for 48 hours and two negative stool samples taken 48 hours apart have been obtained.

Symptomless household contact with a suspected or proven case does not require automatic exclusion from work, but reporting to management to step-up general hygiene is prudent and a stool sample should be taken.

Hepatitis A

Exclusion from work until seven days after the onset of symptoms, usually jaundice. Being a household contact does not require exclusion from work.

Enteric Fever

This is a serious infection and infected food handlers should be excluded from work immediately and the public health department informed.

Pre-employment testing of prospective food handlers or employees returning from abroad with a history suggestive of enteric fever is required. Six consecutive negative stools taken at two-week intervals are recommended to clear applicant.

Exclusion from work is indicated if:

• A positive stool sample is detected.
• An employee with acute infection.
• An employee who is a symptomless carrier.
• An employee who is household contact of acute case or carrier and who is found to be positive.
• An employee returning from abroad and found to be positive.
• An employee screened after contact with case or outbreak and found to be positive.

All above enteric fevers need effective antibiotics and advice on good hygiene to both employee and employer. Enteric fevers should be dealt with by the public health and environmental health departments but in general the following applies:

• Cases should be excluded from work until 6 consecutive negative stool samples, taken at 14 days interval, are obtained.
• Contacts should be excluded from food handling duties, although not necessarily from work, until three consecutive negative stools taken at weekly intervals starting three weeks after the last contact with an untreated case.