Article

Main Barriers in Reducing Microbial Load in Raw Vegetables

Served on Brazilian School Menus
Sueny Andrade Batista 1 , Emanuele Batistela dos Santos 2 , Gabriel Teles Câmara 1 , Ester Cardoso Paes Rose 1 ,
Pedro Tourinho Dantas 1 , Raquel Braz Assunção Botelho 1 and Verônica Cortez Ginani 1, *

1 Department of Nutrition, College of Health Sciences, University of Brasilia, Brasilia 70910-900, Brazil;
[email protected] (S.A.B.); [email protected] (G.T.C.); [email protected] (E.C.P.R.);
[email protected] (P.T.D.); [email protected] (R.B.A.B.)
2 Department of Food and Nutrition, Faculty of Nutrition, Federal University of Mato Grosso,
Cuiabá 78060-900, Brazil; [email protected]
* Correspondence: [email protected]

Abstract: This study assessed raw vegetable sanitizing in Brazilian schools and identified barriers
to standards. This experimental and quantitative study was conducted in 12 school food services
in the Federal District (Brazil) public primary education institutions. Microbiological analyses were
conducted with vegetable samples (before and after sanitizing) and water used in the sanitization
process, collected before the process. The Petrifilm® E. coli/Coliform Count Plates and COLIlert
methods were used to evaluate vegetables and water samples, and a checklist of good practices was
applied in each school food service to identify barriers to proper sanitization. Thirty-five samples
of raw vegetables were offered to students, 32 samples of water, and 17 hygiene processes were
evaluated. The results indicate that 76.5% (n = 13) of hygiene processes were considered unsatisfac-
tory, with an average increase of 5.8 log CFU g−1 (DV = 7.4) in the initial microbial load in 47.1%
(n = 8) of the evaluated processes; moreover, 33.3% (n = 6) of the samples exceeded the tolerable limit,
with an average value above 1.5 × 103 CFU/g. Attention to food handler training and necessary
organizational changes is essential to ensure safe food and promote healthy student eating habits,
highlighting the importance of strengthening basic hygiene practices and following the parameters
Citation: Batista, S.A.; dos Santos,
for sanitizing vegetables.
E.B.; Câmara, G.T.; Rose, E.C.P.;
Dantas, P.T.; Botelho, R.B.A.; Ginani,
Keywords: food hygiene; food safety; high-fiber foods; raw foods; school feeding
V.C. Main Barriers in Reducing
Microbial Load in Raw Vegetables
Served on Brazilian School Menus.
Hygiene 2024, 4, 527–539. https://
doi.org/10.3390/hygiene4040040 1. Introduction
The supply of high-fiber foods such as vegetables meets one of the goals established
Academic Editor: Fernando Perez
Rodriguez
in Brazil’s National School Feeding Program (NSFP). This program constitutes a relevant
dietary practice in Brazilian public schools [1]. It is guided by the human right to adequate
Received: 15 November 2024 food, the universality of free school meals, equity, sustainability, continuity, respect for
Revised: 6 December 2024 eating habits, and the sharing of responsibility to offer school meals [2].
Accepted: 13 December 2024 NSFP recommends that public school food menus be based on fresh foods. The supply
Published: 18 December 2024
of these foods varies from 280 g to 520 g per student during the week for those studying
part-time and full-time, respectively [3]. The benefits of this food group are numerous,
and its importance in preventing Non-Communicable Chronic Diseases (NCDs), such as
Copyright: © 2024 by the authors.
diabetes, cardiovascular diseases, hypertension, and obesity, is well documented [4].
Licensee MDPI, Basel, Switzerland. However, these foods have been increasingly associated with foodborne outbreaks,
This article is an open access article with a high occurrence related to Salmonella [5–7]. Outbreaks have been linked to the
distributed under the terms and consumption of vegetables worldwide, including in the European Union, China, Brazil,
conditions of the Creative Commons Korea, and the United States. Some of the vegetables involved have been melon [8],
Attribution (CC BY) license (https:// watermelon [9], apple, tomato, celery, lettuce, radish, and orange [10,11]. Another study
creativecommons.org/licenses/by/ points to the contamination of fresh and ready-to-eat leafy vegetables by pathogenic
4.0/). agents, with a higher prevalence of Staphylococcus aureus, Escherichia coli, and Clostridium

Hygiene 2024, 4, 527–539. https://doi.org/10.3390/hygiene4040040 https://www.mdpi.com/journal/hygiene

Hygiene 2024, 4 528

perfringens [12]. Elias, Decol, and Tondo [13] pointed to the presence of Foodborne Disease
(FBD) outbreaks associated with the consumption of contaminated vegetables in different
locations, such as in Latin America between 2000 and 2010 (4.4% of the total number of
outbreaks) and in the USA between 1998 and 2007 (33% of the total number of outbreaks
and 50% to portions of produce including salads). In New Zealand, in 2012, 716 food
poisoning outbreaks occurred, of which 13.3% were attributed to leafy vegetables, 10%
to tubers, 6.7% to fruits/nuts, and 3.3% to stem vegetables. Between 2014 and 2023, 2.6%
of food outbreaks in Brazil were caused by consuming vegetables and 1.8% by fruits and
similar [14].
Contamination and proliferation of pathogens that cause FBD can be associated with a
variety of situations, such as the use of untreated manure on agricultural land, runoff from
livestock operations, wildlife intrusion, contaminated groundwater, use of animal fertilizers
and pesticides, exposure to contaminated water (irrigation or flooding), ineffective pest
control, fecal contamination produced by wild and domestic animals, inefficient cold chain,
and worker and consumer hygiene [12,15,16].
Reiterating the link between good handling practices and the prevention of FBD, it is
essential to focus on the role of handlers in the final stages of the food supply chain. In the
case of vegetable contamination, surface contamination is a concern, and adequate hygiene
is paramount, given the possibility of disinfecting food inputs. When these practices are
not followed, it becomes a critical point, as it is the last barrier to avoiding FBD related to
the biological risks of raw vegetables. Brazilian public schools include the final stages of
the food supply chain and act as health-promoting environments, which aim to offer these
foods through the NSFP. When considering the characteristics (e.g., social vulnerability)
and number of students served in school food services (SFSs), Brazilian public schools
become a priority environment for public health policies.
In that regard, daycare centers and schools are potential locations for outbreaks
of water or food origin. Studies in China, Colombia, Finland, and Southeast/Central
Asia [17–20] corroborate this by pointing out the school environment as the location of
relevance, due to the vulnerability of the public (children, individuals in greater social
vulnerability) and the proportion that an outbreak can reach, due to the large number of
students who attend this environment. In China, between 2003 and 2017, school canteens
were responsible for 6.9% of reported outbreaks (n = 1353), 20,077 hospitalizations, and
eight deaths [21]. Lim et al. [22], when carrying out an epidemic investigation in elemen-
tary schools, identified an outbreak of diarrheal infection by enteropathogenic E. coli in
South Korea. In the Brazilian context, the school environment ranked fifth concerning
establishments with the highest incidence of outbreaks, responsible for 8.6% (n = 1075) of
notifications from 2000 to 2017 [23]. A new analysis that considered the period from 2014
to 2023 ranked third, representing 12.5% (n = 856) of reported outbreaks [14].
As for other aspects in the context of school feeding, the study by Da Cunha et al. [24]
evaluated the risk perception of FBD of handlers and directors in SFSs in public schools.
The participants perceived a medium risk; there was a negative correlation between age
and risk perception, an optimistic bias, non-recognition of the risk associated with the
binomial time versus temperature for cooking food, and a lower perceived risk of FBD after
eating raw vegetables.
A worrying reality is observed regarding the context presented, with urgent changes
needed to guarantee safe food for students. Failure to guarantee food safety (FS) in
the school environment violates the Human Right to Adequate and Healthy Food and
prevents the guarantee of Food and Nutrition Security. As a result, students will not be
able to achieve the school’s primary objective, which consists of human development in its
fullness, in conditions of freedom and dignity, and respecting and valuing differences, just
as what is recommended by the NSFP [1,2,25,26]. Given the above, this study evaluated the
effectiveness of raw vegetable sanitizing offered in Brazilian public schools and identified
the main barriers when the established sanitizing parameters were not achieved.
Hygiene 2024, 4 529

2. Materials and Methods

This experimental and quantitative study was conducted between November 2021
and June 2023 in 12 SFSs in the Federal District (Brazilian Federal Capital) public in-
stitutions serving primary education. The school sample was selected by convenience.
The participation of schools was conditional on adherence to the “Grow Healthy” and
“School Health Program” programs as part of the “Healthy Food and School Food Supply
Chain” project.
Microbiological analyses were carried out with vegetable samples (before and after
sanitization) and water samples before being used in the sanitization process. The proposal
was to evaluate the effectiveness of the vegetable hygiene processes. For this evaluation,
the Petrifilm total coliform and COLIlert methods were used for vegetable and water
samples, respectively. Samples were collected to carry out microbiological tests, according
to recommendations from the American Public Health Association (APHA) [27]. In addition
to microbiological analyses and data comparison, a good practices checklist for SFSs was
applied to identify barriers to possible failures associated with the hygiene process [28].
Each SFS was visited for three days, and the good practices checklist was applied.

2.1. Microbiological Analysis

For collecting vegetables, the use of SFSs utensils was prioritized. Each analyzed
vegetable had a sample collection of 100 g. However, only 25 g were used for analysis.
The samples were stored in sterile bags and transported at refrigeration temperature until
arriving in the laboratory. After collecting each food, serial dilution was prepared to
perform the analyses (10−1 , 10−2 , and 10−3 ).
Petrifilm® E. coli/Coliform Count Plates (No. 6404) were inoculated with 1.0 mL
aliquots of three dilutions of each food sample collected and prepared according to the
manufacturer’s instructions. After incubation at 35 ± 1 ◦ C for 48 ± 2 h, the blue colonies
with bubbles were considered E. coli, and the red colonies with bubbles were considered
total coliforms. The result was obtained by counting colonies and expressing in CFU/g.
According to the microbiological criteria recommended by the International Commission
on Microbiological Specification for Food [29], the acceptable standards for food samples
are counts below 102 per g/mL for coliforms at 35 ◦ C.
The water samples were analyzed using the COLIlert® method, a qualitative analysis
method that allows the simultaneous detection of total coliforms and Escherichia coli. On
each visit to the SFS, a 500 mL sample of water used in food production was collected.
Sodium thiosulfate was used to inactivate chlorine. All samples were transported at
refrigerated temperature to the laboratory. From the collected sample, 100 mL was removed
to carry out microbiological analyses, and the remaining amount was for further procedures.
The water samples (100 mL each) received the COLIlert® culture medium and were
incubated for 24 h at 35 ± 1 ◦ C. The color change of the sample detects the presence
of microorganisms. The yellow color indicates a positive result for total coliforms, and
positive fluorescence—with the aid of an ultraviolet lamp—indicates E. coli [30]. The
standards established by the Brazilian National Health Surveillance Agency for water
samples establish the absence of E. coli or thermotolerant coliforms and the absence of total
coliforms in 100 mL of the analyzed product.

Assessment of Hygiene Process

To evaluate the hygiene process for fresh raw food, it was considered that washing
followed by disinfection should eliminate ~1 log CFU g−1 [31,32].

2.2. Assessment of Food Safety Practices

This research stage consisted of applying a risk-based checklist approved by the
current Brazilian food safety legislation [33]. The National Education Development Fund
developed this tool to verify good practices in school food services [28]. Each school was
Hygiene 2024, 4 530

visited three times during the same week, and the results were organized as follows: if
non-compliance was detected only on one day, the item was considered non-conforming.

2.3. Statistical Analyses

Descriptive statistical analyses were conducted on the effectiveness of the vegetable’s
hygiene, water potability processes (percentage distribution), and the non-compliance
presented with the application of the checklist of good handling practices (mean, standard
deviation, and percentage distribution).

3. Results
Twelve schools were visited within 142 schools that met the project criteria. The SFSs
are in seven of the 35 administrative regions of the Federal District and represent around 8%
of the SFSs for primary education in the FD. Thirty-five food samples were collected, and
17 hygiene processes for raw fruits and vegetables were evaluated. In one of the schools
(School 9), the sample could not be collected before cleaning, as the inputs had already been
handled at the time of collection. However, the hygiene process was recorded according to
the handlers’ reports. Regarding water analysis, 32 samples were evaluated.
The results indicate that of the 17 hygiene processes, 76.5% (n = 13) were considered
unsatisfactory. There was an average increase of 5.8 log CFU g−1 (SD = 7.4) in the initial
microbial load in 47.1% (n = 8) of the food samples. It should be noted that, in School 9,
the food was offered only with the cleaning process, with no disinfection. However,
among the 18 hygiene processes (considering 17 samples post-sanitization and the only
sample collected in the school 9), 66.7% (n = 12) presented counts below 102 per CFU/g for
coliforms at 35 ◦ C, which is within the appropriate parameters for consumption. Of these,
8.3% (n = 1) are close to the tolerable limit. The samples that exceeded the tolerable limit,
33.3% (n = 6), presented an average value above the limit of 1.5 × 103 CFU/g (Table 1).

Table 1. Data on the effectiveness of vegetable cleaning processes with microbial loads before and
after cleaning, the process used, conclusion of findings expressed in colony-forming units, process
results according to ready-to-eat food, and water quality according to total coliforms in public schools.

Presence of Coliforms
Hygiene
Saniti- Increase or Meets the in Water
Schools Vegetables Zation Conclusion Reduction Standard
Before After
Process (CFU g−1 ) (<102 CFU/g) % n
(CFU/g) (CFU/g)
Ineffective/
S1 Apple 3 × 101 5.6 × 102 1 19.6 log No 100 3
increasing
Ineffective/ Unable to
S2 Apple <1 × 101 est 1 × 101 1 Yes 100 3
increasing calculate
Ineffective/ Unable to
S3 Pineapple <1 × 101 est 2 × 101 1 Yes 100 3
increasing calculate
Ineffective/
S3 Tangerine 2 × 101 5 × 101 1 1.7 log Yes 100 3
increasing
Ineffective/
S4 Pineapple 6.1 × 102 >2.5 × 103 1 3.4 log No 100 3
increasing
Unable to
S4 Tangerine <1 × 101 est <1 × 101 est 1 Effective Yes 100 3
calculate
Ineffective/
S5 Pineapple 1.8 × 102 >2.5 × 103 1 14.3 log No 100 3
increasing
Ineffective/
S6 Cucumber 5 × 102 2 × 102 1 0.7 log No 100 3
reduction
Hygiene 2024, 4 531

Table 1. Cont.

Presence of Coliforms
Hygiene
Saniti- Increase or Meets the in Water
Schools Vegetables Zation Conclusion Reduction Standard
Before After
Process (CFU g−1 ) (<102 CFU/g) % n
(CFU/g) (CFU/g)
Collard Unable to
S7 >2.5 × 103 >2.5 × 103 1 Ineffective No 66.7 2
greens calculate
Ineffective/
S7 Papaya 7.3 × 102 9.8 × 102 1 0.4 log No 66.7 2
increasing
Unable to No No
S8 Cabbage >2.5 × 103 >2.5 × 103 1 Ineffective No
calculate collection collection
Ineffective/ No No
S8 Pineapple 8.5 × 102 1.7 × 102 1 0.9 log No
reduction collection collection
Unable to No No
S8 Cabbage >2.5 × 103 >2.5 × 103 1 Ineffective No
calculate collection collection
Not Unable to
S9 * Melon - 4.7 × 102 2 No 100 2
evaluate calculate
Collard Effective/
S10 8.1 × 102 <1 × 101 est 1 1.1 log Yes 0 3
greens reduction
Effective/
S11 Melon 1.2 × 102 <1 × 101 est 1 1.1 log Yes 100 3
reduction
Effective/
S11 Pineapple 4 × 101 <1 × 101 est 1 1.1 log Yes 100 3
reduction
Ineffective/
S12 Apple 3.4 × 102 >2.5 × 103 1 7.1 log No 33 1
increasing
Notes = S: means school; Est: means estimated; CFU: colony-forming unit; Effective: when it eliminates at least
94.5% of the initial microbial load. * At School “nine”, only two water samples were collected. In the other schools,
three water samples were collected, except in School 8, where it was not possible to collect any samples due to
operational problems. In the sanitization process, 1 means “Water and hypochlorite”, and 2 means “Water”; %:
relative percentage of water samples positive for total coliforms; n: number of water samples collected.

As for the water samples, 81.3% (n = 26) were considered unsatisfactory, with to-
tal coliforms. Only one school (8.3%) presented all negative water samples for total
coliforms—the only one with total effectiveness in the hygiene process. As for the product
dilution parameters and action time, no process was followed correctly (Table 1).
The relevant results to the study regarding the application of the checklist of good
practices are presented in Table 2, and critical failures can be observed mainly in personal
hygiene, water tanks, vegetables consumed raw, utensils, and environmental hygiene, as
well as the presence of documents at operational and managerial levels.

Table 2. The main items related to the effective hygiene of raw vegetables obtained from the checklist
application for school food services.

Compliance Compliance
Checklist Items Checklist Items
% n % n
Water connected to the public network or
Washbasins equipped with
alternative network with its potability 100 12 41.7 5
running water
certified by reports
Medical exams are renewed periodically
Reservoir appropriately built 91.7 11 50 6
or at least once a year
Periodic and adequate cleaning of the Food handlers work without
8.3 1 83.3 10
water reservoir clinical illness
Adequate hand hygiene by food handlers 41.7 5 Handler’s hair is fully protected 33.3 4
Admission of the handler through
Proper hygiene of vegetables consumed raw 0 0 100 12
medical examinations
Hygiene 2024,
Hygiene 4,4FOR PEER REVIEW
2024, 6
532

Table 2. Cont.
Proper hygiene of vegetables consumed Admission of the handler through medical
0 0 100 12
raw examinations
Compliance Compliance
Presence of Good
Checklist Items Practice Manual with Checklist Items
%0 n0 All food handlers have formation in FS % 75n 9
access to food handlers
Presence of Good Practice Manual with
access to
0 0 Products used tohave
All food handlers clean and disinfect
formation in FS 75 9
Presence offood handlers about water
a document
16.7 2 utensils/equipment are registered with the 100 12
potability Products used to clean and disinfect
Presence of a document about water potability 16.7 2 Ministry of Healthare registered with
utensils/equipment 100 12
Presence of Standard Operating Procedures Utensils protected
the Ministry of Healthagainst dust, insects, and
8.3 1 25 3
with accessoftoStandard
Presence food handler
Operating Procedures rodents
Utensils protected against dust, insects,
8.3 1 25 3
with access to food handler and rodents
Benches and support tables sanitized after
Proper utensils chemical disinfection 25 3 33.3 4
returning
Benches andtosupport
work and/or changing shifts
tables sanitized
Proper utensils chemical disinfection 25 3 after returning to work and/or 33.3
Proper use of disposable cleaning cloths 0 0 Handlers with complete and clean shapes 33.34 4
changing shifts
Presence of a water reservoir 66.7 8 Absence of adornments 50 6
Proper use of disposable cleaning cloths 0 0 Handlers with complete and clean shapes 33.3 4
Proper use of non-disposable cleaning
Presence of a water reservoir 16.7
66.7 82 Absence
Absence ofofadornments
a beard 50 91.76 11
cloths
Proper use of non-disposable cleaning cloths
Washbasins for hand hygiene with suitable 16.7 2 Absence of a beard
Utensils and equipment dried naturally91.7
or 11
Washbasins for hand hygiene with 8 1 Utensils and equipment dried naturally 66.7 8
products 8 1 without using a cloth 66.7 8
suitable products or without using a cloth
Notes = %: relative percentage of schools that presented adequacy in the item; n: number of schools
Notes
that = %: relative
presented percentageinofthe
adequacy schools
item.that presented adequacy in the item; n: number of schools that presented
adequacy in the item.

Figure 1 demonstrates some situations in SFSs, where microbiological analysis

Figure 1 demonstrates some situations in SFSs, where microbiological analysis samples
samples were taken.
were taken.

Photos
Figure 1.1. Photos
Figure of of situations
situations found
found in in public
public school
school food
food services
services in in
thethe Federal
Federal District:
District: (1)—
Defrosting chicken
(1)—Defrosting nextnext
chicken to vegetables (papaya
to vegetables (papayaand
and cucumber) onthe
cucumber) on theday’s
day’s menu.
menu. (2)—Inadequate
(2)—Inadequate
storage of fruit with other food inputs. (3)—Inadequate storage of fruit with other food inputs. (4)—
Sliced fruit exposed to room temperature for more than 1 h in a basin containing water from the
production area (directly from the tap, without filtration). (5)—Papaya with cuts to force ripening.
(6)—Tangerines are used in cleaning, with units not submerged in the water and product solution.
Hygiene 2024, 4 533

storage of fruit with other food inputs. (3)—Inadequate storage of fruit with other food inputs.
(4)—Sliced fruit exposed to room temperature for more than 1 h in a basin containing water from the
production area (directly from the tap, without filtration). (5)—Papaya with cuts to force ripening.
(6)—Tangerines are used in cleaning, with units not submerged in the water and product solution.

4. Discussion
Most schools presented results indicating failures in the vegetable hygiene processes
(fruits and vegetables), with a small portion of the hygiene processes being fully effective
and meeting the microbiological standard of ready-to-eat food—the presence and levels of
total coliforms were highlighted. Total coliforms do not necessarily indicate the presence of
pathogenic microorganisms. Their presence, especially at increased levels, indicates the
need to change the practices adopted and the hygienic and sanitary quality of water and
food [34]. Therefore, the results demonstrate how the hygiene process is conducted, which
is the present study’s focus. The results could have generated outbreaks of foodborne
illness, as even though they were isolated inadequacies, they could have compromised
food safety and consequently affected student performance (school attendance, absence
from classes).
Relevant aspects were found when verifying the main nonconformities between the
SFSs that obtained effective sanitation processes and the SFSs that obtained a greater
increase in microbial load (School 1). It was observed in the mentioned school that the
handlers do not undergo periodic medical examinations and that not all of them received
food safety training. Therefore, the SFSs must regularly monitor both their health and their
practices. Documentary evidence on health status is essential for managers to monitor
the conditions of food handlers and prevent FBD outbreaks. In addition, managers must
provide continuous training and motivate adequate food handling practices [28,35], directly
involving the main link in FBD mitigation—the food handler. In the general context of
schools, it is observed that there were no adequate hand hygiene practices in all SFSs—
considered the simplest and most basic practice [36]. Even after the critical period of the
COVID-19 pandemic, when the importance of hygiene was well discussed, the practice
did not become an observed reality [37–39]. Notably, this practice is the most important for
preventing this group of diseases, and its relevance is supported by studies that show that
food handlers are involved in most reported cases of FBD [40,41]. The results of studies by
Hardstaff et al. [42], Lubis et al. [43], and Schumann et al. [44] reinforce the importance of
hand hygiene and the link between food handlers and foodborne outbreaks. These results
indicate poor hand hygiene, as sanitizers quickly inactivate total coliforms [27]. Given the
aspects mentioned, the importance of the handler in ensuring food safety (FS) is reinforced;
therefore, training in personal hygiene is essential.
Another inappropriate practice observed among food handlers included using orna-
ments (e.g., earrings)—a practice that potentially causes physical or biological contam-
ination of food. [45]. In this sense, Sultana and Nur [46] identified microorganisms in
food handlers’ ornaments and recommended prioritizing personal hygiene care to prevent
food contamination and cross-contamination [46]. Although microbiological analyses of
ornaments have not been carried out, their use is a potential cause of contamination.
The steps required to sanitize vegetables are another aspect. According to the cur-
rent Brazilian legislation, the procedures include cleaning, disinfection, and rinsing with
drinking water [33]. A study by Santillo and Mourad [47] points out that the appropriate
concentration of the sanitizer, the duration of action, and the exposure of the food to the
solution are often not used. Inadequate procedures combined with the possible presence
of microorganisms can threaten consumer health. Therefore, adapting procedures and
ensuring the quality of the water used is essential [48,49]. It should be noted that in all the
schools evaluated, no hygiene parameters were respected during the procedure.
Other items identified as non-compliant according to the Codex Alimentarius [50]
corroborate the microbiological analyses, such as (i) the defrosting of chicken close to
vegetables; (ii) inadequate storage of raw materials and sanitized foods; (iii) excessive
Hygiene 2024, 4 534

exposure of handled foods to room temperature; (iv) cuts on fruit surfaces to accelerate its
ripening—which can facilitate contamination; (v) and food not wholly submerged during
the hygiene process. Regarding exposure to room temperature, the handling process until
distribution did not exceed two hours, except in “School 1”. In this SFS, an increase in
microbial load was much higher than that of the other samples evaluated. This reinforces
the importance of not extrapolating binomial time versus temperature, which is the primary
causal factor of FBD [51].
Given the context of the SFSs, other factors are relevant, such as the lack of potability
of the water used in food production. All SFSs are supplied by water from the public
service, guaranteeing its potability up to the water meter or delivery point. After that point,
the responsibility becomes the customer’s [52]. Although all SFSs have a water reservoir,
no documents prove the buildings’ suitability. In only 41.7% (n = 5), the reservoir is cleaned
every six months by a specialized company, and only in 8.3% (n = 1) was there a document
proving the potability of the water. The results mentioned above are associated with the
presence of total coliforms in 88.6% (n = 39) of the water samples, and that only 8.3% (n = 1)
of the SFSs presented 100% samples free of the microorganisms investigated highlight the
urgency of changes to guarantee water potability and safe food production.
Studies have demonstrated the presence of the coliform group in school water sys-
tems [53–55]. In similar studies, authors concluded that water contamination by coliforms
may be associated with a lack of sanitary routine, disinfection of water reservoirs, and a lack
of maintenance on facilities, such as changing filters with adequate frequency, the possible
presence of contamination in the pipes, and the poor state of hygiene of the pipes [53,55].
The microbiological quality of water influences the hygienic-sanitary conditions of utensils,
equipment, and facilities and, consequently, the quality of prepared food [56]. The studies
above and the results found in the present study highlight the importance of sanitary
routines, inspection, and monitoring of the quality of water distributed in SFSs.
The failures in good practices observed in this study highlight the need for food
handlers training, as Brazilian legislation requires the assurance of FS in SFSs. It is essential
to clearly define the sanitation process, including the method, product, concentration,
and contact time of the chemical, and/or physical agents used. This information should
be included in standardized operating procedures and be easily accessible to handlers.
In addition, the good practices manual is essential for managing and operating food
services [33,35], and its use must be accompanied by adequate training. In this sense,
training and increasing the knowledge of food handlers does not necessarily result in
safe food handling procedures [57], highlighting a gap between discourse and adequate
hygiene practices [41,58]. This study shows that although 75% (n = 9) of SFSs offer training,
failures still occur, such as inadequate washing of hands, vegetables, and utensils (100%,
n = 12); inadequate use of non-disposable cloths (83.3%, n = 10); and utensils stored without
protection against dust, insects, and rodents (75%, n = 9). Zanin et al. [59] observed that
50% of the reviewed articles indicated that knowledge does not translate into appropriate
attitudes or practices. This reinforces the need to rethink training models to overcome
this gap.
Possible paths to be followed are suggested by the scientific literature in the area, such
as identifying factors of employee commitment, since food handlers with strong commit-
ment are more likely to implement safe food procedures; involve employees not only in
the work context but also in decision-making, encouraging them to present suggestions for
improvement during the training and learning processes [60]; and structure the knowledge
to be transmitted to the food handler to support the formation of risk perception [41,61].
Stedefeldt et al. [62] highlight the collaborative nature of the requirements for effective
training, including training leaders in people management and food safety (FS), estab-
lishing adequate workload, using language aligned with the handlers’ culture, offering
appropriate infrastructure, developing common values between handlers and the company,
and providing an adequate environment with the necessary resources. This approach
ensures that all stakeholders share responsibility for FS.
Hygiene 2024, 4 535

In addition, some points, independent of the handlers, must also be addressed, such
as the frequency and cleaning of the water tank, the preparation of documents such as good
practice manuals, and standardized operating procedures, ensuring the potability of the
water, the presence of an exclusive sink for hand hygiene, periodic examinations, ongoing
training, and the supervision of food handling [33,63]. The present study identified that
many SFSs do not adequately meet these requirements.
The flaws in good handling practices observed through microbiological analyses,
the checklist, and photographic records indicate the need for significant changes, even
more so when associated with the sociocultural context of public school students and their
possible vulnerability. Considering the extent of harmlessness, changes are necessary to
prevent FBD and contribute to a healthy diet. Thus, offering vegetables promotes health
through high-fiber foods [64]. These contribute to healthy growth and development, the
formation of adequate eating habits, and the prevention of another critical group of diseases,
NCDs [65,66].

Limitations
Given the sample size, the results should not be generalized. Instead, they serve as a
point of attention for developing training programs for food handlers. It is also noted that
the results may not necessarily reflect the routine conduct of the food service, as this is a
cross-sectional study. Therefore, the results should be used as guidance for improving food
safety conditions and not as a diagnosis.

5. Conclusions
This study showed a substantial increase in the initial microbial load of the coliform
group in vegetables after the cleaning process and that a considerable portion of the samples
is not within the tolerable parameter for consumption, thus highlighting critical flaws in
food handling. Added to this reality is the predominant presence of total coliforms in
water samples used in food production. Both findings point to the risk of FBD outbreaks,
compromising FS, and, consequently, the food security of students and mitigating the
benefits those high-fiber foods present. The greater vulnerability of the target audience of
these SFSs heightens the risk. Organizational, managerial, and operational changes are
urgent, and effective training processes must be understood and formulated so that the
adoption of appropriate practices can be implemented and executed.

Author Contributions: Conceptualization, S.A.B., E.C.P.R. and V.C.G.; Data Curation, S.A.B. and
G.T.C.; Formal analysis, S.A.B., G.T.C. and P.T.D.; Investigation, S.A.B. and G.T.C.; Methodology, S.A.B.
and V.C.G.; Resources, S.A.B.; Visualization; S.A.B.; Writing—Original Draft, S.A.B.; Supervision,
V.C.G.; Project administration, V.C.G.; Writing—Review and Editing, E.B.d.S., R.B.A.B. and V.C.G. All
authors have read and agreed to the published version of the manuscript.
Funding: This research was funded by FAPDF (No. 166/2020, notice No. 03/2018 Scientific,
technological research and innovation spontaneous demand) and DPG/UnB (notice No. /0010/2023).
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki and approved by the Ethics Committee of the College of Health Sciences of
the University of Brasilia—CEP FS/UnB (CAAE No. 02033218.0.0000.0030).
Informed Consent Statement: Informed consent was obtained from all subjects involved in
the study.
Data Availability Statement: Data is contained within the article.
Acknowledgments: The authors would like to thank PPGNH/UnB, CAPES, the State Department of
Education of the Federal District for their support, the students who participated in the study, and
members of the Research Project “Alimentação saudável e a cadeia produtiva da alimentação escolar”.
Conflicts of Interest: The authors declare no conflicts of interest.
Hygiene 2024, 4 536

References
1. Brazil, Education Ministry; National Education Development Fund, Deliberative Council. Resolução CD/FNDE nº 06, de 08 de
Maio de 2020: Dispõe Sobre o Atendimento da Alimentação Escolar aos Alunos da Educação Básica no Âmbito do Programa
Nacional de Alimentação Escolar—PNAE. 2020. Available online: https://www.gov.br/fnde/pt-br/acesso-a-informacao/
legislacao/resolucoes/2020/resolucao-no-6-de-08-de-maio-de-2020/view (accessed on 7 August 2024).
2. Brazil, Education Ministry; National Education Development Fund, Deliberative Council. Resolução/CD/FNFNDE 38DE nº
38, de 16 de Julho de 2009: Dispõe Sobre o Atendimento da Alimentação Escolar aos Alunos da Educação Básica no Programa
Nacional de Alimentação Escolar—PNAE. 2020. Available online: http://portal.mec.gov.br/component/content/article/195-
secretarias-112877938/seb-educacao-basica-2007048997/16691-programa-nacional-de-alimentacao-escolar-pnae (accessed on 7
August 2024).
3. Brazil, Education Ministry; National Education Development Fund. Planejamento de Cardápios para a Alimentação Escolar.
2022. Available online: https://www.gov.br/fnde/pt-br/acesso-a-informacao/acoes-e-programas/programas/pnae/manuais-
e-cartilhas/MANUAL_V8.pdf (accessed on 7 August 2024).
4. WHO (World Health Organization). Increasing Fruit and Vegetable Consumption to Reduce the Risk of Noncommunicable Diseases;
World Health Organization: Geneva, Switzerland, 2023. Available online: https://www.who.int/tools/elena/interventions/
fruit-vegetables-ncds (accessed on 7 August 2024).
5. Callejón, R.M.; Rodríguez-Naranjo, M.I.; Ubeda, C.; Hornedo-Ortega, R.; Garcia-Parrilla, M.C.; Troncoso, A.M. Reported
foodborne outbreaks due to fresh produce in the United States and European Union: Trends and causes. Foodborne Pathog. Dis.
2015, 12, 32–38. [CrossRef] [PubMed]
6. Painter, J.A.; Hoekstra, R.M.; Ayers, T.; Tauxe, R.V.; Braden, C.R.; Angulo, F.J.; Griffin, P.M. Attribution of foodborne illnesses,
hospitalizations, and deaths to food commodities by using outbreak data, United States, 1998–2008. Emerg. Infect. Dis. 2013, 19,
407–415. [CrossRef]
7. Yang, X.; Wu, Q.; Huang, J.; Wu, S.; Zhang, J.; Chen, L.; Wei, X.; Ye, Y.; Li, Y.; Wang, J.; et al. Prevalence and characterization of
Salmonella isolated from raw vegetables in China. Food Control 2020, 109, 106915. [CrossRef]
8. Hanning, I.B.; Nutt, J.; Ricke, S.C. Salmonellosis Outbreaks in the United States Due to Fresh Produce: Sources and Potential
Intervention Measures. Foodborne Pathog. Dis. 2009, 6, 635–648. [CrossRef]
9. Byrne, L.; Fisher, I.; Peters, T.; Mather, A.; Thomson, N.; Rosner, B.; Bernard, H.; McKeown, P.; Cormican, M.; Cowden, J.; et al. A
multi-country outbreak of Salmonella newport gastroenteritis in Europe associated with watermelon from Brazil, confirmed by
whole genome sequencing: October 2011 to January 2012. Eurosurveillance 2014, 19, 20866. [CrossRef] [PubMed]
10. Kwak, T.Y.; Kim, N.H.; Rhee, M.S. Response surface methodology-based optimization of decontamination conditions for
Escherichia coli O157:H7 and Salmonella Typhimurium on fresh-cut celery using thermoultrasound and calcium propionate. Int. J.
Food Microbiol. 2011, 150, 128–135. [CrossRef] [PubMed]
11. Mritunjay, S.K.; Kumar, V. Fresh farm produce as a source of pathogens: A review. Res. J. Environ. Toxicol. 2015, 9, 59–70.
[CrossRef]
12. Azimirad, M.; Nadalian, B.; Alavifard, H.; Panirani, S.N.; Bonab, S.M.V.; Azimirad, F.; Gholami, F.; Jabbari, P.; Yadegar, A.; Busani,
L.; et al. Microbiological survey and occurrence of bacterial foodborne pathogens in raw and ready-to-eat green leafy vegetables
marketed in Tehran, Iran. Int. J. Hyg. Environ. Health 2021, 237, 113824. [CrossRef] [PubMed]
13. Elias, S.d.O.; Decol, L.T.; Tondo, E.C. Foodborne outbreaks in Brazil associated with fruits and vegetables: 2008 through 2014.
Food Qual. Saf. 2018, 2, 173–181. [CrossRef]
14. Brazil, Health Ministry, Secretariat of Health and Environment Surveillance. Surtos de Doenças de Transmissão Hídrica e
Alimentar: Informe—2024. 2024. Available online: https://www.gov.br/saude/pt-br/assuntos/saude-de-a-a-z/d/dtha/
publicacoes/surtos-de-doencas-de-transmissao-hidrica-e-alimentar-no-brasil-informe-2024/view (accessed on 7 August 2024).
15. Alegbeleye, O.O.; Singleton, I.; Sant’ana, A.S. Sources and contamination routes of microbial pathogens to fresh produce during
field cultivation: A review. Food 2018, 73, 177–208. [CrossRef] [PubMed]
16. Ceylan, Z.; Meral, R.; Cetinkaya, T. Relevance of SARS-CoV-2 in food safety and food hygiene: Potential preventive measures,
suggestions and nanotechnological approaches. Virus Dis. 2020, 31, 154–160. [CrossRef]
17. Dewanti-Hariyadi, R.; Gitapratiwi, D. Prevalence of Foodborne Diseases in South East and Central Asia. Encycl. Food Saf. 2014, 1,
287–294. [CrossRef]
18. Ding, Z.; Zhai, Y.; Wu, C.; Wu, H.; Lu, Q.; Lin, J.; He, F. Infectious diarrheal disease caused by contaminated well water in Chinese
schools: A systematic review and meta-analysis. J. Epidemiol. 2017, 27, 274–281. [CrossRef] [PubMed]
19. Luna, J.C.; Zamora, A.; Hernández-Arango, N.; Muñoz-Sánchez, D.; Pinzón, M.I.; Cortés-Vecino, J.A.; Lora-Suarez, F.; Gómez-
Marín, J.E. Food safety assessment and risk for toxoplasmosis in school restaurants in Armenia, Colombia. Parasitol. Res. 2019,
118, 3449–3457. [CrossRef]
20. Maunula, L.; Rönnqvist, M.; Åberg, R.; Lunden, J.; Nevas, M. The Presence of Norovirus and Adenovirus on Environmental
Surfaces in Relation to the Hygienic Level in Food Service Operations Associated with a Suspected Gastroenteritis Outbreak.
Food Environ. Virol. 2017, 9, 334–341. [CrossRef]
Hygiene 2024, 4 537

21. Li, W.; Pires, S.M.; Liu, Z.; Ma, X.; Liang, J.; Jiang, Y.; Chen, J.; Liang, J.; Wang, S.; Wang, L.; et al. Surveillance of foodborne disease
outbreaks in China, 2003–2017. Food Control 2020, 118, 107359. [CrossRef]
22. Lim, M.-A.; Kim, J.-Y.; Acharya, D.; Bajgain, B.B.; Park, J.-H.; Yoo, S.-J.; Lee, K. A Diarrhoeagenic Enteropathogenic Escherichia
coli (EPEC) Infection Outbreak That Occurred among Elementary School Children in Gyeongsangbuk-Do Province of South
Korea Was Associated with Consumption of Water-Contaminated Food Items. Int. J. Environ. Res. Public Health 2020, 17, 3149.
[CrossRef]
23. Brazil, Health Ministry. Surtos de Doenças Transmitidas por Alimentos no Brasil. 2019. Available online: https://www.saude.
gov.br/svs (accessed on 7 August 2024).
24. Da Cunha, D.T.; Stedefeldt, E.; De Rosso, V.V. Perceived risk of foodborne disease by school food handlers and principals: The
influence of frequent training. J. Food Saf. 2012, 32, 219–225. [CrossRef]
25. Brazil, Civil House, Sub-Chief for Legal Matters. Lei Nº 11.346, de 15 de Setembro de 2006: Cria o Sistema Nacional de Segurança
Alimentar e Nutricional—SISAN com Vistas em Assegurar o Direito Humano à Alimentação Adequada e dá Outras Providências.
2006. Available online: https://www.planalto.gov.br/ccivil_03/_ato2004-2006/2006/lei/l11346.htm (accessed on 7 August 2024).
26. Martinez, P.; Gomes, M.d.L.S.; Marini, F.S. Public policies strengthen the relationship between family farming and food security
in Brazilian schools—A case study of Paraíba state. Heliyon 2023, 9, e20482. [CrossRef] [PubMed]
27. da Silva, N.; Junqueira, V.C.A.; Silveira, N.F.d.A.; Taniwaki, M.H.; Gomes, R.A.R.; Okazaki, M.M. Manual de Métodos de Análise
Microbiológica de Alimentos e Água, 5th ed.; Blücher: São Paulo, Brazil, 2018.
28. Brazil, Health Ministry, National Health Surveillance Agency. Guia de Instruções das Ferramentas para as Boas Práticas
na Alimentação Escolar. 2013; pp. 1–56. Available online: https://www.gov.br/fnde/pt-br/acesso-a-informacao/acoes-e-
programas/programas/pnae/manuais-e-cartilhas/ferramenta-de-boas-praticas-de-fabricacao-de-alimentos (accessed on 7
August 2024).
29. Legan, J.D.; Post, L.; Barnes, C.; Brookhouser-Sisney, A.; Chaney, W.E.; Corrigan, N.; Hunt, K.A.; Maus, R.D.; Pierre, S.; Rule,
P.; et al. Testing Methods in Food Microbiology. J. Food Prot. 2008, 2, 1–88. Available online: https://www.foodprotection.
org/members/fpt-archive-articles/2023-05-evaluating-microbiological-method-equivalence-a-decision-guide/ (accessed on 7
August 2024).
30. Pontelo, K.T.; de Aguiar, M.M.G. Validação de Método Alternativo para Pesquisa de Coliformes Totais e Escherichia coli na Água.
Pós em Revista. 2012, (6a). Available online: https://silo.tips/download/validaao-de-metodo-alternativo-para-pesquisa-de-
coliformes-totais-e-escherichia (accessed on 7 August 2024).
31. Arienzo, A.; Gallo, V.; Tomassetti, F.; Antonini, G. Implication of Sodium Hypochlorite as a Sanitizer in Ready-to-Eat Salad
Processing and Advantages of the Use of Alternative Rapid Bacterial Detection Methods. Foods 2023, 12, 3021. [CrossRef]
[PubMed]
32. Sun, S.H.; Kim, S.J.; Kwak, S.J.; Yoon, K.S. Efficacy of sodium hypochlorite and acidified sodium chlorite in preventing browning
and microbial growth on fresh-cut produce. Prev. Nutr. Food Sci. 2012, 17, 210–216. [CrossRef] [PubMed]
33. Brazil, Health Ministry. Resolução RDC n◦ 216, de 15 de Setembro de 2004: Dispõe sobre Regulamento Técnico de Boas Práticas
para Serviços de Alimentação 2004. pp. 1–14. Available online: https://bvsms.saude.gov.br/bvs/saudelegis/anvisa/2004/res0
216_15_09_2004.html (accessed on 7 August 2024).
34. FDA (Food and Drug Administration). BAM Chapter 4: Enumeration of Escherichia coli and the Coliform Bacteria. Bacteriological
Analytical Manual (BAM) Main Page. 2020. Available online: https://www.fda.gov/food/laboratory-methods-food (accessed
on 7 August 2024).
35. Brazil, Health Ministry. Instrução Normativa DIVISA/SVS no 16, de 23 de Maio de 2017: Aprova a Atualização do Anexo
da Instrução Normativa nº 4, de 15 de Dezembro de 2014, Que Aprovou o Regulamento Técnico Sobre Boas Práticas para
Estabelecimentos Comerciais de Alimentos e para Serviços de Alimentação. 2017; pp. 1–23. Available online: https://
www.sinj.df.gov.br/sinj/Norma/91e623e116984c1fb1dafa2c3c91d4eb/Instru_o_Normativa_16_23_05_2017.html (accessed on 7
August 2024).
36. Mathur, P. Hand hygiene: Back to the basics of infection control. Indian J. Med Res. 2011, 134, 611–620. [CrossRef]
37. Alwan, N.; Safwan, J.; Kerek, R.; Ghach, W. Hand hygiene during the spread of COVID-19: A cross-sectional study of awareness
and practices among academic institutions in Lebanon. Front. Public Health 2023, 11, 1256433. [CrossRef] [PubMed]
38. Alzyood, M.; Jackson, D.; Aveyard, H.; Brooke, J. COVID-19 reinforces the importance of handwashing. J. Clin. Nurs. 2020, 29,
2760–2761. [CrossRef]
39. WHO (World Health Organization). Handwashing an Effective Tool to Prevent COVID-19, Other Diseases. 2020. Avail-
able online: https://www.who.int/southeastasia/news/detail/15-10-2020-handwashing-an-effective-tool-to-prevent-covid-
19-other-diseases (accessed on 7 August 2024).
40. Baptista, R.C.; Rodrigues, H.; Sant’Ana, A.S. Consumption, knowledge, and food safety practices of Brazilian seafood consumers.
Food Res. Int. 2020, 132, 109084. [CrossRef]
41. de Andrade, M.L.; Rodrigues, R.R.; Antagiovanni, N.; da Cunha, D.T. Knowledge and risk perceptions of foodborne disease by
consumers and food handlers at restaurants with different food safety profiles. Food Res. Int. 2019, 121, 845–853. [CrossRef]
Hygiene 2024, 4 538

42. Hardstaff, J.L.; Clough, H.E.; Lutje, V.; McIntyre, K.M.; Harris, J.P.; Garner, P.; O’Brien, S.J. Foodborne and Food-Handler
Norovirus Outbreaks: A Systematic Review. Foodborne Pathog. Dis. 2018, 15, 589–597. [CrossRef]
43. Lubis, N.D.A.; Amelia, S.; Arrasyid, N.K.; Rozi, M.F. Modelling of Risk Factors Associated with Foodborne Disease among
School-Aged Children in Medan, Indonesia. Open Access Maced. J. Med Sci. 2019, 7, 3302. [CrossRef]
44. Schumann, A.C.; Ghisleni, C.P.; Spinelli, R.B.; Zyger, L.T.; Zeni, J. Avaliação Microbiológica de Mãos dos Manipuladores de
Alimentos e de Utensílios de Cozinha do Serviço de Nutrição de um Hospital do Norte do Estado do Rio Grande do Sul.
Perspect. Erechim. 2017, 41, 7–17. Available online: https://www.uricer.edu.br/site/pdfs/perspectiva/153_602.pdf (accessed on 7
August 2024).
45. FAO (Food and Agriculture Organization of the United Nations); WHO (World Health Organization). Prevention and Control of
Microbiological Hazards in Fresh Fruits and Vegetables—Part 3: Sprout. Meeting Report; Microbiological Risk Assessment Series; FAO:
Rome, Italy, 2023; No. 43. [CrossRef]
46. Sultana, T.; Nur, I.T. Ornaments of daily usage can be a source of microbial contamination and a causative agent of diseases.
Stamford J. Microbiol. 2020, 10, 5–8. [CrossRef]
47. Santillo, C.P.R.S.; Mourad, A.L. The environmental and microbiological efficiency of vegetable cleaning. Eng. Sanit. Ambient 2023,
28, e20220126. [CrossRef]
48. Melo, J.; Quintas, C. Minimally processed fruits as vehicles for foodborne pathogens. AIMS Microbiol. 2023, 9, 1–19.
[CrossRef]
49. Sethi, S.; Nayak, S.L.; Joshi, A.; Sharma, R.R. Chapter 5—Sanitizers for Fresh-Cut Fruits and Vegetables; Siddiqui, M.W., Ed.; Academic
Press: Cambridge, MA, USA, 2020; pp. 99–119, ISBN 9780128161845. [CrossRef]
50. FAO (Food and Agriculture Organization of the United Nations); WHO (World Health Organization). General Principles of food
Hygiene CXC 1-1969: Adopted in 1969. Amended in 1999. Revised in 1997, 2003, 2020, 2022. Editorial Corrections in 2011. 2023.
Available online: https://www.fao.org/fao-who-codexalimentarius (accessed on 7 August 2024).
51. Viera, F.D.; Stedefeldt, E.; Scheffer, P.A.; Machado, L.V.; Mucinhato, R.M.D.; De Castro, A.K.F.; de Souza Lima, T.A.; Da Cunha,
D.T.; de Freitas Saccol, A.L. Proposal of a new method for the risk scoring and categorization of Brazilian food services. Food Res.
Int. 2022, 156, 111127. [CrossRef] [PubMed]
52. Brasília, Environmental Sanitation Company of the Federal District. Decreto 20.658/99—Regulamenta a Lei No. 442, de 10 de
Maio de 1993: Dispõe Sobre a Classificação de Tarifas dos Serviços de Água e Esgotos do Distrito Federal e dá Outras Providências.
1999. Available online: https://www.caesb.df.gov.br (accessed on 7 August 2024).
53. Rochaa, E.S.; Rosicoa, F.S.; Silvaa, F.L.; da Luza, T.C.S.; Fortuna, J.L. Análise Microbiológica da Água de Cozinhas e/ou Cantinas
das Instituições de Ensino do Município de Teixeira de Freitas (BA). Rev. Baiana Saúde Pública 2010, 34, 694. Available online:
http://files.bvs.br/upload/S/0100-0233/2010/v34n3/a1871.pdf (accessed on 7 August 2024). [CrossRef]
54. Siqueira, L.P.d.; Shinohara, N.K.S.; de Lima, R.M.T.; de Paiva, J.d.E.; Filho, J.L.d.L.; de Carvalho, I.T. Avaliação microbiológica da
água de consumo empregada em unidades de alimentação. Ciência Saúde Coletiva 2010, 15, 63–66. [CrossRef]
55. de Moraes, M.S.; Moreira, D.A.d.S.; Santos, J.T.d.L.A.; de Oliveira, A.P.; Salgado, R.L. Microbiological evaluation of water
fountains of public and private schools from Santa Rita city (PB), Brazil. Eng. Sanit. E Ambient. 2018, 23, 431–435. [CrossRef]
56. Battaglini, A.P.P.; Fagnani, R.; Tamanini, R.; Beloti, V. Qualidade microbiológica do ambiente, alimentos e água, em restaurantes
da Ilha do Mel/PR. Semina:Ciencias Agrarias. Abril 2012, 33, 741–754. [CrossRef]
57. da Cunha, D.T.; Stedefeldt, E.; de Rosso, V.V. He is worse than I am: The positive outlook of food handlers about foodborne
disease. Food Qual. Prefer. 2014, 35, 95–97. [CrossRef]
58. da Cunha, D.T.; Stedefeldt, E.; de Rosso, V.V. The role of theoretical food safety training on Brazilian food handlers’ knowledge,
attitude and practice. Food Control 2014, 43, 167–174. [CrossRef]
59. Zanin, L.M.; da Cunha, D.T.; de Rosso, V.V.; Capriles, V.D.; Stedefeldt, E. Knowledge, attitudes and practices of food handlers in
food safety: An integrative review. Food Res. Int. 2017, 100, 53–62. [CrossRef]
60. Taha, S.; Osaili, T.M.; Saddal, N.K.; Al-Nabulsi, A.A.; Ayyash, M.M.; Obaid, R.S. Food safety knowledge among food handlers in
food service establishments in United Arab Emirates. Food Control 2020, 110, 106968. [CrossRef]
61. Frewer, L.J.; Shepherd, R.; Sparks, P. The Interrelationship Between Perceived Knowledge, Control and Risk Associated with a
Range of Food-Related Hazards Targeted At the Individual, Other People and Society. J. Food Saf. 1994, 14, 19–40. [CrossRef]
62. Stedefeldt, E.; Zanin, L.M.; Da Cunha, D.T.; De Rosso, V.V.; Capriles, V.D.; De Freitas Saccol, A.L. Chapter 18—The Role of Training
Strategies in Food Safety Performance: Knowledge, Behavior, and Management; Ricke, S.C., Donaldson, J.R., Phillips, C.A., Eds.;
Academic Press: Cambridge, MA, USA, 2015; pp. 365–394, ISBN 9780128002452. [CrossRef]
63. Brazil, Federal Council of Nutritionists. FCN Resolution No. 600, of February 25, 2018. Provides for the Definition of the
Areas of Activity of the Nutritionist and Their Attributions, Indicates Minimum Numerical Parameters of Reference, by Area
of Activity, for the Effectiveness of the Services Provided to Society and Provides Other Measures. 2018. Available online:
http://sisnormas.cfn.org.br:8081/viewPage.html?id=600 (accessed on 7 August 2024).
64. Brazil, Ministry of Education; National Education Development Fund. Caderno de Legislação 2023: Programa Nacional
de Alimentação Escolar. 2023. Available online: https://www.gov.br/fnde/pt-br/acesso-a-informacao/acoes-e-programas/
programas/pnae/manuais-e-cartilhas/copy_of_Cadernodelegislao_PNAE_2023.pdf (accessed on 7 August 2024).
Hygiene 2024, 4 539

65. Brazil, Ministry of Health; Secretariat of Health Surveillance; Department of Health Analysis and Surveillance of Noncommunica-
ble Diseases. Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas e Agravos não Transmissíveis no Brasil
2021–2030; Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Análise em Saúde e Vigilância de Doenças
Não Transmissíveis. 2021; p. 118, ISBN 978-65-5993-109. Available online: http://bvsms.saude.gov.br/bvs/publicacoes/plano_
enfrentamento_doencas_cronicas_agravos_2021_2030.pdf (accessed on 7 August 2024).
66. Gomes, F.S.; Reynolds, A.N. Effects of Fruits and Vegetables Intakes on Direct and Indirect Health Outcomes—Background Paper for the
FAO/WHO International Workshop on Fruits and Vegetables 2020; FAO and PAHO: Rome, Italy, 2021. [CrossRef]

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