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The cholera outbreak - getting back to the basics?

By Dzulkifli Abdul Razak
The Sun, June 15, 1996

FOOD-RELATED POISONING CAN BE described as a chain of events. It normally starts from a single source and tends to spread via the methods of food production, preparation, storage, distribution and lastly, consumption.

Perhaps the recent cholera panic is a case in point, coming allegedly from ice suppliers spreading eventually throughout the state of Penang, and finally the whole nation.

In every one of this situation, the challenge is to break out of the chain of events. This is easier said than done because the nature and incidence of poisoning can also be influenced by agricultural practices, food technology in industry and at home, as well as other ecological, environmental, socioeconomic and cultural practices.

If the outbreak of cholera cases is to be classified broadly under the category of food poisoning, then it must epitomise the ultimate in a series of food poisoning cases in the country in recent times.

While there have been a number of food poisoning cases reported last year, food poisoning seems to be a recurring theme, and its occurrences are quite prevalent with a number of cases involving more than 100 victims, namely schoolchildren.

In fact, according to the Ministry of Health, there has been an increase in food poisoning cases from 1,599 in 1993 to 2,283 in 1994.

According to the same source, there were more than 2,000 cases of food poisoning reported last year to the Health Ministry.

Looking at the latest statistics for 1996, the cholera cases alone already amount to more than 1,000 cases nationwide. At the last count, more than 1,240 cases were involved in practically all states. Although the situation is now well under control, there are still new cases being reported.

This is not just the question of statistics, which no doubt suffers from underreporting. It is more a question of awareness and about Malaysians of all walks of life taking control of the situation in tandem with the national aspiration of a healthy society as enshrined in Vision 2020.

The rather frequent cases of food-related poisoning, especially the likes of cholera, is most unfortunate. It is a "chain" that must be broken.

If we examine the literature, cases of cholera outbreakes are mainly reported in countries which are rather backward in terms of health status. Even then, not all of such countries are faced with this predicament.

By and large, it has been well under control, such that cholera vaccination is no longer a requirement in many countries. In this context, for Malaysia - noted for its rapid development and infrastructure - to experience such as outbreak is quite embarrassment.

It is perhaps not so much the physical infrastructure of the nation that is at fault but other factors. Worse still when the recent outbreak started in an urban centre such as Penang.

One would expect that most city dwellers by now should be knowledgeable enough about simple cases of food borne diseases and how to avoid them.

All that is required to stay free from food-borne (water-borne) illness such as cholera, is to a large extent, just plain common sense, most of which should be culturally advocated and practised. Very little in fact is new or need to be learned anew. The key issue therefore is not so much what we know, but rather what we do with what we know.

For example, most of us are familiar with some of the precautionary actions, which is really fundamental in preventing the chain of events that spread the disease in the first place. But are they being carried out diligently?

According to WHO, even in industrialised countries, outbreaks of food-borne disease have been linked with inadequate cooking or re-heating, the use of contaminated ingredients and unsafe water, the preparation of food too far in advance and its storage at room temperature, as well as cross-contamination between raw and prepared food.

As it stands today, cholera is one of the so-called re-emerging diseases, with some 384,403 cases reported worldwide in 1994, a 454% increase from 1990. The situation is such that WHO has created a new division to deal with "emerging diseases."

Precautions to avoid food borne poisoning include :

  • Drink boiled water.
  • Cover your food. Do not leave it exposed.
  • Eat freshly-cooked food.
  • Check if food is still fresh before eating it.
  • Throw away stale and contaminated food.
  • Watch out for unusual appearance, smell or taste.
  • Be selective in choosing the types of food.
  • Use clean water for preparing food and drinks.
  • Patronise only clean stalls.
  • Practise good sanitary habits.
  • Wash hands thoroughly before preparing, serving or eating food, especially after handling other things.

Apart from cholera-caused food poisoning, there are a number of other food poisoning cases documented as of this month alone.

Just when the incidents of cholera were peaking in mid-May, there was an equally disturbing report of "bad" chocolate-flavoured milk supplied to schools under the Education Ministry's school milk programme.

Ironically, in this case, the packets were reported to carry an expiry date of Oct 5, 1996 - some four months away. Something then must be amiss.

Taking just the schools and other educational institutions, there have been about 10 incidents involving food poisoning since the beginning of this year. One involved as many as 400 victims, a couple of cases involved more than 100 students, and in one school, the incidents of food poisoning happened twice within the span of three months.

If the number of cholera cases are taken into account, there must be almost 2,000 known food-related poisoning cases even before we progress into the middle of 1996. Coupled this with the many recent initiatives taken by the appropriate agencies to educate hawkers and food-sellers about food-safety in various states, including those in schools, we may still have a long way to go in combating food poisoning in our society.

Going by past records, the figures of food poisoning consistently show a worrying trend. Although the number is relatively low compared with that of 1989, the recent cholera outbreak does seem to indicate that the situation is rather fragile, and schools are indeed vulnerable.

The incidents involving schools are particularly of concern because the issue about cleanliness of food operators in school canteens is indeed a contentious one.

The Ministry of Eductaion in particular has drawn up regulations to tackle this problem and periodic checks are supposed to be carried out.

Despite all these, the situation remains precarious, not least because schools and educational institutions are where we should be "teaching" our children ( and indeed teachers-to-be) about good eating habits in a practical way.

In fact the recent cholera outbreak started off with trainees in a teacher's training college. According to the statement by the Minister of Health recently, of 3,508 school canteens inspected in 1994, only 21% were classified as "clean". The majority (72.3%) are "moderately clean".

This means that only a small proportion of our schoolchildren are relatively "well protected" from instances which might give rise to food poisoning. If this is so, there must be something more that needs to be considered in our effort to improve the situation. Perhaps it is time to get back to basics, to avoid further disasters.

The writer is a professor and director of Pusat Racun Negara, USM.

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