الفهرس 
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Abstract
Multiple outbreaks of foodborne diseases among tourists of various nationalities while vacationing in Egypt have been attributed to the consumption of food within the country. To address this issue, there is a pressing need for comprehensive studies to identify the risk factors contributing to food safety concerns within tourist hotels. By pinpointing these risk factors, appropriate measures and programs can be developed to minimize their occurrence, ultimately ensuring safer food experiences for tourists.
While global research has shed light on the primary risk factors associated with foodborne disease outbreaks in different countries, it is noteworthy that the Government of Egypt has not yet published any formal reports assessing the risk factors specifically related to food safety in various food establishments.
This particular study was executed with the purpose of aiding NFSA in a scientifically grounded assessment of food establishment performance and the identification of major risk factors influencing food safety in establishments serving tourists. By doing so, the study seeks to propose effective interventions that can prevent the recurrence of foodborne illnesses. Additionally, the study aims to guide official audits and inspections toward these areas of concern for targeted improvements.
The study’s scope encompassed three-, four-, and five-star hotels in Greater Cairo. However, due to the COVID-19 lockdown, not all of these hotels were operational during the data collection period, which spanned from February 20, 2022, to April 20, 2022. As a result, data was gathered from a subset of hotels, including 16 three-star hotels, 17 four-star hotels, and 29 five-star hotels.
To achieve its objectives, the study employed a variety of tools and methodologies. A comprehensive checklist was designed to capture essential information about each food establishment inside the hotels. This checklist included sections dedicated to a) evaluating the construction, facilities, and equipment, b) assessing handwashing and personal hygiene practices, c) monitoring temperature and time control measures, d) examining practices to prevent cross-contamination, and e) tracing sources of raw materials.
Temperature measurements were taken at various stages of food preparation, as well as within hot and cold food storage facilities. Additionally, water temperatures during the heat sanitization of utensils were recorded. The study also conducted interviews with food managers and chefs to gauge their understanding of fundamental food safety concepts and practices.
In order to bolster the scientific validity of the study, samples of food and surface swabs were meticulously collected and subsequently analyzed in a laboratory that holds international accreditation. This rigorous approach was taken to ensure the accuracy and reliability of the study’s findings.
In summary, this study serves as a vital step towards enhancing food safety in tourist-oriented food establishments. By identifying critical risk factors and proposing effective interventions, it contributes to safeguarding the health and well-being of tourists and the broader community.
All of the surveyed hotels were connected to the municipal drinking water and sewage networks, with the majority situated in Cairo Governorate. In nearly all of these hotels, at least one dedicated handwashing sink was available within food preparation areas, the only exception being one three-star hotel. The majority of these sinks (about two-thirds) were solely designated for handwashing purposes, without any other use. Accessibility to handwashing sinks was reported in over (85%) of the surveyed hotels, and in around half of the three-star hotels and over three-quarters of the four- and five-star hotels, the number of sinks was deemed adequate.
However, the provisioning of essential supplies for handwashing sinks—such as soap, warm water, and paper towels—was not consistently adequate, particularly in three-star hotels. Furthermore, alongside handwashing facilities, hand sanitizers were present in over three-quarters of the surveyed hotels within food preparation areas. In terms of waste disposal, receptacles for discarding paper towels were available near handwashing sinks in less than two-thirds of the hotels. Although these receptacles were required to be without covers to prevent hand contamination after washing, the majority of them were equipped with foot-operated covers.
Similar conditions extended to the restrooms used by food handlers, where handwashing sinks often lacked sufficient supplies of soap, warm water, and paper towels, particularly in three-star hotels. Waste receptacles for paper towel disposal were more adequately placed, available in over (90%) of the surveyed hotels.
The study revealed that proper handwashing practices were closely linked to the availability of sufficient soap and paper towels, emphasizing the need to maintain these supplies consistently. The frequency of handwashing was positively associated with the presence of an appropriate number of handwashing sinks. However, no statistically significant correlation was observed between food handler training and the adherence to proper or frequent handwashing.
In addition to hand hygiene, assessments of other aspects of personal hygiene indicated varying compliance rates, including wearing clean outer clothing (65%), trimming fingernails (70%), using hair restraints (65%), and refraining from wearing jewelry (70%).
Maintaining the temperature of Time/Temperature Control for Safety (TCS) foods outside the Temperature Danger Zone (TDZ) is crucial to mitigating the risk of foodborne illnesses at different stages of food handling and preparation within the hotel industry. Probe thermometers, employed to measure the core temperature of food, were available in almost three-quarters of the observed hotels (81.4%), while non-contact thermometers, utilized for surface temperature assessment, were present in half of the establishments (49.2%). Notably, a lack of thermometers of both types was noted in one-quarter of three-star hotels and just over one-tenth of four-star hotels. The calibration of thermometers was observed in only one-third of three-star hotels (33.3%), but in nearly three-quarters of four-star hotels (71.4%) and in the majority of five-star hotels (88.5%), with a statistically significant difference observed.
The study highlighted that a quarter of the hotels received TCS food in transportation lacking refrigeration or freezing capabilities, thereby exposing the food to the Temperature Danger Zone. While the surveyed hotels generally adhered to the four recommended FDA methods for thawing TCS food, non-approved methods like submerging frozen TCS food in containers of still water or leaving it at room temperature were observed in almost a third of three-star hotels, though not in any of the five-star hotels, with a statistically significant difference between the hotel tiers.
During the cooking process, approximately half of the surveyed hotels (56.1%) ensured food temperatures would reach the required minimum cooking temperatures. The percentages varied across hotel tiers, with five-star hotels exhibiting the highest compliance (70%) and three-star hotels lagging behind (25%). Statistically significant differences were observed between these hotel categories. Proper reheating practices were followed in fewer than one-third of three-star hotels (28.6%), while approximately two-thirds of four-star hotels (63.6%) and almost all five-star hotels (95.5%) demonstrated correct reheating methods. Statistically significant differences were again identified among hotel tiers.
Concerning cooling practices, around one-third of three-star hotels (38.5%) employed correct cooling methods. This percentage nearly doubled to (68.8%) in four-star hotels and rose further to over (82.8%) in five-star hotels. The presence of blast chillers, vital tools for effective food cooling, was limited to only (6.3%) of three-star hotels, rising to (41.2%) in four-star hotels and (86.2%) in five-star hotels. Statistically significant differences were found between the three types of hotels.
Adequate facilities for hot holding of Time/Temperature Control for Safety (TCS) food were available in most four- and five-star hotels, as well as two-thirds of three-star hotels. Facilities for cold holding of TCS food were present in over three-quarters (81.8%) of all surveyed hotels, with no statistically significant differences between hotel tiers. However, not all of these facilities were in proper working condition during the visits, with nearly one-fifth requiring maintenance.
Cross contamination prevention measures, including manual and mechanical ware washing, were assessed. Three-compartment sinks were present in over (80%) of four- and five-star hotels, but only in one-third of three-star hotels. In cases where three-compartment sinks were absent, alternative means were used in just (10%) of three-star hotels and one-third of four- and five-star hotels. Adequate supplies like hot water and detergent for manual ware washing were available in over (90%) of the hotels. The sanitization stage was conducted in approximately (75.6%) of hotels with appropriate sinks or alternatives. Test kits/devices for sanitizer concentration were lacking in three-star hotels, present in only (37.5%) of four-star hotels, and (74.1%) of five-star hotels. Statistically significant differences were detected.
Regarding ware washing machines, all five-star hotels (96.6%) had at least one single-compartment machine, compared to only half (50.0%) of three-star hotels. All five-star hotels had multiple compartment machines, as did two-thirds (64.7%) of four-star hotels, and only one three-star hotel (6.3%). The water temperature for sanitization in these machines was insufficient in all machines in three-star hotels and around one-third of four- and five-star hotels. Accurate temperature measuring devices were present in only about one-third (31.9%) of checked machines in the surveyed hotels. Accuracy was absent in the temperature readings of machines from three-star hotels.
Significant differences between hotel tiers were evident in the availability of sanitization chemicals (25.0%, 66.7%, and 96.3% for three-, four-, and five-star hotels, respectively) and the presence of sanitizer test kits (0.0% in three-star, 74.1% in five-star hotels).
Storage facilities for utensils were considered adequate in approximately three-quarters (74.2%) of all surveyed hotels. The maintenance and condition of these facilities were good in (87.1%) of the hotels. Broken utensils unfit for use were discovered in nearly one-third of hotels, regardless of star rating.
Assessment of tools also included the presence of scoops for ice makers, found in less than half (44.1%) of surveyed hotels. Availability of single-use gloves varied, with almost (80%) in four- and five-star hotels, and slightly less in three-star hotels, showing a statistically significant difference.
Distinctly colored cutting boards were present in all five- and four-star hotels, and in (85.7%) of three-star hotels, displaying a statistically significant difference. Knowledge among food handlers about the color coding of cutting boards for various food types was less prevalent in three-star hotels (63.6%) compared to over (85%) in four- and five-star hotels, with a statistically significant difference. Over half (54.2%) of the hotels had cutting boards in suboptimal condition due to cracks, impeding effective cleaning.
During inspections, improper practices were observed, including inappropriate glove use (41.4%), incorrect use of cutting boards (30.5%), and improper use of wiping cloths (16.7%). Significant differences were found between hotel tiers in terms of proper storage of pesticides, appropriate labeling of toxic materials, storing pesticides in food preparation areas, and storing cleaning materials separately. Suitable storage places or facilities for tools used for cleaning were available in about one-third (35.5%) of hotels, with separate facilities for cleaning these tools found in around (40.0%) of assessed hotels.
Buffet setups present a high-risk situation if not managed effectively, as customers might introduce contamination. Open buffet monitoring to prevent improper practices was observed in all three- and four-star hotels and (90.0%) of five-star hotels. Food guards were less common in three-star hotels (18.2%) compared to four- and five-star hotels (96.7% and 75.0%, respectively). The practice of covering food to safeguard against customer contamination was seen in over three-quarters (77.8%) of three-star hotels, with less frequent use in four- and five-star hotels (41.7% and 57.7%, respectively).
Other practices to prevent cross-contamination, such as removing soiled tableware, providing clean tableware for refills, using protected or individual condiment servings rather than bulk containers, supplying utensils for each container, and replacing empty containers instead of refilling them directly, were followed in over (90%) of hotels. Nevertheless, practices like handling tableware without avoiding food contact surfaces, wrapping tableware, and wearing gloves when serving ready-to-eat (RTE) foods were only observed in three-quarters of the hotels, leaving a quarter at risk.
Though all four- and five-star hotels, along with the majority of three-star hotels (83.3%), reported using temperature control of Time/Temperature Control for Safety (TCS) food in open buffets as a public health measure, temperature monitoring during display was observed in less than two-thirds of three-star hotels and approximately three-quarters of four- and five-star hotels. The use of time as a public health control measure was reported by about two-thirds of the hotels. The majority of hotels (98% for lunch and 96.2% for dinner) adhered to the four-hour limit for open buffet duration. However, this limit was exceeded in almost a third of hotels during breakfast service.
Construction and physical facility issues were identified across all types of hotels, including five-star establishments. These problems encompassed the use of materials that are not easily cleanable, durable, and smooth for constructing floors, walls, and ceilings. Holes or cracks in these surfaces were also noted, along with the absence of coving and sealing at the junctures of floors and walls. Additionally, drainage lines were found to be inadequately covered.
On the positive side, over (90%) of hotels had appropriately designed floors that sloped toward drains for efficient water flushing and had concrete or asphalt surfaces in exterior areas. However, concerns were raised in about one-third of the hotels regarding the proper maintenance of physical facilities, cleanliness, and appropriate disposal of wastewater to drainage lines without accumulation on floors during visits. Plumbing system maintenance and the installation of necessary air breaks/air gaps or backflow prevention devices were also noted as issues. These issues are anticipated to decrease following the issuance of NFSA BOD 12/2020, which outlines concrete requirements for construction and physical facilities compliance to obtain a food handling license from the National Food Safety Authority (NFSA).
Storage facilities were assessed, revealing that three-star hotels encountered more problems with adequacy, ventilation, light intensity, shelving, and appropriate materials compared to four- and five-star hotels.
Storage practices were also evaluated, including food temperature upon receipt, adherence to First In First Out (FIFO) practices, checking expiry dates, identifying foul odors or mold, signs of infestation, proper sealing, labeling, cleanliness, separation of different types of food, and procurement from approved sources with documented invoices. These practices were better implemented in four- and five-star hotels than in three-star hotels.
Food safety training for handlers has been mandatory since Prime Minister Decree 412/2019. Compliance with this requirement was assessed at two levels: providing training to all food handlers and providing training to food managers/chefs who guide handlers in their roles. The study found that not all hotels met this legal requirement, with the highest non-compliance rate observed in three-star hotels. In over (85%) of three-star hotels, food handlers had not received the mandated training. Moreover, more than half of three-star hotels lacked trained food managers/chefs, limiting their guidance. Compliance rates were better in four-star hotels and highest in five-star hotels for both levels of training.
Food managers/chefs’ responses to knowledge questions about food safety concepts and practices were least satisfactory in three-star hotels and best in five-star hotels. This trend was observed in six questions, including managing food handlers with foodborne illnesses, upper and lower limits of temperature danger zone (TDZ), hamburger cooking temperature, cross-contamination prevention during storage and cleaning. The statistically significant relationship between training and knowledge was observed for only the first four questions. However, responses in three-star hotels were best for two knowledge questions: appropriate glove use and the concentration of free residual chlorine for dish sanitization. In one question about restricting access to food preparation areas to only authorized personnel, the best response was seen in four-star hotels.
Clinics were present in all five-star hotels, almost three-quarters of four-star hotels, and in less than one-fifth of three-star hotels. Full-time physicians were absent in clinics in three- and four-star hotels, as well as in three-quarters of five-star hotels. Written policies for excluding or restricting food handlers showing symptoms of foodborne illnesses were available in around one-third (37.5%) of the surveyed hotels.
Logbooks for recording illnesses among food handlers were less common, found in less than one-third of three-star hotels (30%), about half of four-star hotels (45.5%), and three-quarters of five-star hotels (75.0%), with statistically significant differences between the hotel tiers. Sick leave wages were provided by nearly three-quarters of the hotels, while logbooks for recording illnesses among guests were present in less than one-third (34.6%) of all surveyed hotels, with lower percentages in three-star (7.7%) and four- (46.2%) and five-star (42.3%) hotels.
Recording cases of diarrhea, vomiting, or both among food handlers or guests was exclusive to five-star hotels, with no cases noted in the logbooks of three- and four-star hotels. No significant associations were found between registering such cases in the logbooks and the presence of clinics, physicians (full- or part-time), written exclusion policies, or sick leave wages.
Microbiological analysis of various food samples indicated the following:
• All fruit salad samples (46/46) were negative for contamination with Escherichia Coli, Listeria Monocytogenes, Salmonella, and Coagulase Positive Staphylococcus aureus.
• All cold cuts samples (47/47) were negative for Listeria Monocytogenes.
• Almost all juice samples (46/47) were negative for contamination with Escherichia Coli, Salmonella, and Coagulase Positive Staphylococcus aureus. Only one juice sample from a five-star hotel was contaminated with Escherichia Coli.
• Most green salad samples (54/56) were negative for Bacillus Cereus, Clostridium Perfringens, Escherichia Coli, Listeria Monocytogenes, Salmonella, and Coagulase Positive Staphylococcus aureus. Only two samples tested positive for either Clostridium Perfringens or Escherichia Coli.
• Nearly all cumin samples (47/48) were contaminated with pesticides beyond the limits set in the Egyptian National Food Safety Authority’s Decision No. 6/2021.
A significant percentage of pepper (74%) and chili (35%) samples violated the national legal Maximum Residue Limits (MRLs).