Food Safety Practices as Determinants of Self-Reported Foodborne Illness Among Seafood Consumers

Food Safety Practices as Determinants of Self-Reported Foodborne Illness Among Seafood Consumers | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Food Safety Practices as Determinants of Self-Reported Foodborne Illness Among Seafood Consumers Arundhathi V, MINI SEKHARAN N This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6813639/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Improper food handling practices in the supply chain significantly contribute to foodborne illnesses. As global concerns about food safety intensify, understanding domestic food handling practices and raising consumer awareness is essential. This study examines the association between self-reported foodborne illness and seafood handling practices among consumers across Kerala, India. A cross-sectional survey was conducted using an online questionnaire from March to December 2023, involving 2,079 seafood consumers. Of the respondents, 8.5% (n = 177) reported experiencing a seafood-related foodborne illness. Consumers who reported illness (case group) demonstrated significantly lower adherence to safe seafood handling practices compared to those who did not (control group). Multivariate logistic regression identified several demographic and behavioural predictors of illness. Key demographic factors significantly associated with increased illness risk included younger age, occupation, income, and area of residence. Unsafe practices—such as improper seafood purchasing and storage, inadequate kitchen hygiene, cross-contamination, and insufficient temperature control—were linked to higher illness risk. In contrast, protective behaviours, including checking freshness, thorough cooking, reheating, and prompt refrigeration, significantly reduced risk. Although raw data showed a higher proportion of illness among older adults, regression analysis revealed that increasing age was associated with a reduced likelihood of reporting illness, highlighting the importance of accounting for confounding variables in food safety research. These findings emphasize the need for targeted consumer education that addresses kitchen hygiene, cross-contamination prevention, and safe storage practices. Demographic-specific public health initiatives, consistent supply chain monitoring, and effective regulatory oversight are essential to mitigating seafood-related illness risks. Food Safety Foodborne Illness Handling Practice Seafood Consumption India 1. INTRODUCTION Foodborne illness is a significant global health concern, frequently resulting in acute or subacute diseases following the consumption of contaminated food or water (Almaary, 2023 ). The World Health Organization (WHO) highlights the impact of these illnesses, particularly in developing nations, where foodborne illness contributes notably to both morbidity and mortality. Each year, more than 600 million people worldwide suffer from foodborne illness, with children under five years old accounting for 30% of the fatalities (WHO, 2015). Seafood, in particular, poses considerable health risks due to its highly perishable nature and susceptibility to contamination by pathogens and toxins throughout the supply chain. In the United States alone, seafood was linked to 4,815 illness outbreaks between 1998 and 2015, resulting in 359 hospitalisations and four deaths (Barret et al., 2017). Similarly, the Caribbean, Japan, Korea, and the Pacific have reported multiple seafood-related food poisoning outbreaks (Chinain et al., 2021 ; Fleming et al., 2018 ). Common pathogens associated with seafood borne illnesses, include Vibrio spp., Salmonella spp., Shigella spp., Escherichia coli., and Listeria monocytogenes (Almaary, 2023 ; Ayyappan & Joseph, 2021 ). These pathogens can cause a range of symptoms from mild gastrointestinal disturbances such as nausea, diarrhoea, stomach pain to more severe systemic illnesses including fever, headache, and tachycardia. These health risks underscore the importance of understanding seafood handling practises to reduce contamination, mitigate associated risks and protect consumer health. In the United States, 52% of seafood-related outbreaks are linked to restaurant meals, and 33% to seafood prepared at home (Barret et al., 2017). This underscored the importance of maintaining food safety across the entire supply chain from production to the consumer's table. Adopting effective food safety practices, such as thorough cleaning, appropriate cooking, adequate chilling and freezing, proper storage and preventing cross-contamination, plays a vital role in mitigating these risks (FDA, 2024b; WHO, 2015). Consumers food handling practices at home are equally critical in minimising foodborne illnesses. Raising awareness about potential hazards including biological, chemical and physical risks in seafood, including toxins and pathogens, and the adoption of proper storage, preparation and preservation techniques are essential for inhibiting spoilage, minimising risks and maintaining seafood quality and safety (Choudhury et al., 2022 ; Lupo & Angot, 2020 ). Therefore, maintaining good handling practices throughout the supply chain and at the consumer level are essential to ensure seafood remains safe for consumption. In India, despite regulatory efforts by agencies such as the Food Safety and Standards Authority of India (FSSAI) and the Integrated Disease Surveillance Program (IDSP), substantial research gaps persist, particularly concerning household seafood handling practices and their impact on the incidence of foodborne illness. This study addresses these gaps by examining the relationship between self-reported foodborne illness and seafood handling practices among seafood consumers in Kerala, India. The research will compare handling practices between those who have experienced seafood related illnesses and those who have not. By addressing this research gap, the study aims to inform targeted public health initiatives and enhance regulatory oversight to reduce illness risks and improve consumer awareness of safe food handling. While this study specifically investigates seafood-related foodborne illnesses due to its regional dietary significance, it does not eliminate the possibility of other food sources contributing to reported symptoms. The study’s focus reflects the high prevalence of seafood in local diets and its potential association with foodborne illnesses as reported and seafood handling practices followed by participants. 2. MATERIALS AND METHODS 2.1. Participants Kerala is a coastal state in India with high rate of seafood consumption and distinct dietary preferences. This study surveyed seafood consumers from 14 districts of Kerala between March and December 2023. Participants were recruited using a convenience sampling method. Online survey forms (Microsoft Forms and Google Forms) were distributed via social media platforms, ensuring accessibility for individuals with internet access while capturing diverse demographics. A total of 3000 respondents were invited to participate in the survey, and 2484 participants completed the survey. Eligibility criteria for participation included: (1) seafood consumers being 18 years or older, (2) consuming seafood at least once per week and (3) residing in Kerala. To enhance data quality, responses were screened for completeness and consistency. After excluding incomplete and duplicate entries, a total of 2079 valid responses were included in the final analysis. 2.2. Research Design The study followed a cross-sectional survey design, using a semi-structured, self-administered questionnaire. The questionnaire was developed by integrating established literature (Baptista et al., 2020 ; Langiano et al., 2011 ; Mol et al., 2018 ), and insights from field interactions, and expert consultation to ensure that it was both comprehensive and relevant to seafood consumers in Kerala. To ensure seafood’s contribution to reported illnesses, the questionnaire included targeted questions addressing specific symptoms reported after seafood consumption. Participants were also asked to differentiate between seafood-related illnesses and other potential health conditions. Questions such as "Are you currently having any disease or systemic illness other than food poisoning or seafood-borne illness?" were included to isolate seafood-related symptoms. The questionnaire was divided into three sections: (i) Demographic characteristics: Six questions covered participants age, gender, education, occupation, family monthly income, and area of residence; (ii) Seafood consumption habits and illness experiences: Four questions assessed the participant’s role in purchasing and preparing seafood, their frequency of seafood consumption, and self-reported seafood-borne illnesses experienced in the past year with reason for illness occurrence. (iii) Seafood handling practices: Twenty statements were aligned with the Five Keys to Safer Food guidelines from the World Health Organization (WHO, 2006), focusing on key food safety practices such as keeping clean, separating raw and cooked foods, cooking thoroughly, storing food at safe temperatures and using safe water and raw materials. Responses were rated on a 5-point scale ranging from "Never" to "Always" (Table 2). For standardisation the survey responses were categorized and transformed based on their risk implications. Practices that inherently increased the risk of seafood-borne illness were reverse-coded so that higher scores corresponded to higher risk. For other practices higher scores directly represented safer practices. final scores were further classified into three categories based on their mean scores: unsafe practices (0.00–2.00), moderately safe practices (2.05–3.5), and safe practices (3.55–5.00). The questionnaire was translated into the regional language of Kerala state, i.e. Malayalam, and validated using a back-translation method to ensure accuracy and comprehension. Informed consent was obtained from all participants, and data confidentiality was strictly maintained with no incentives were provided to participants. The reliability of the questionnaire was confirmed through Cronbach’s alpha values ranging from 0.788 to 0.817, indicating good internal consistency across the questionnaire sections. Validity of the questionnaire was ensured through expert review and pilot test conducted among 52 seafood consumers with feedback used to refine the questionnaire for clarity and relevance. 2.3. Statistical Analysis Descriptive statistics were used to summarise qualitative data such as, demographic characteristics, illness incidence and seafood handling practices. Independent sample t-test was used to compare seafood handling practices (mean scores 20 statements measured on a 5-point scale ranging from 0 (Never) to 5 (Always)) between participants who experienced seafood-related illnesses and those who did not. Mann-Whitney U test was applied as a non-parametric alternative for variables that did not meet normality assumptions (McKnight & Najab, 2010) ( Table 3 ). Multivariable logistic regression was conducted to assess the correlation between self-reported foodborne illness (dependent variable) and demographic characteristics and seafood handling practices (independent variables). Collinearity among independent variables was evaluated using linear regression with tolerance values ( 10). Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated for each independent significant variable (Table 4). Statistical significance was set at P < 0.05 and data were analysed using the Statistical Package for the Social Sciences (SPSS Inc. Version 26.0). 3. RESULTS 3.1. Demographic and behavioural characteristics of respondents The age distribution of respondents showed that ( Table 1 ) the largest groups were aged 27–42 years (33.0%) and 18–26 years (32.9%), with the smallest proportion (12.1%) belonging to the 59–77 age group. Females made up the majority (53.7%) of the sample, followed by males (46.3%). Education levels indicated that 33.1% held a degree, while 26.0% had a masters and 24.4% had a PhD or equivalent professional degree qualification. Students constituted the largest occupational category (37.4%), followed by private employees (20.3%) and government servants (20.1%). Monthly family income ranged primarily between 40,001–60,000 INR for 27.8% of respondents. In terms of residence, 42.5% lived in suburban areas, 33.6% in urban areas, and 23.9% in rural areas. Over half of the respondents (54.7%) identified as the principal seafood purchasers for their households, and 43.9% were responsible for seafood preparation. Seafood purchase frequency varied, with 42.8% buying seafood on alternate days and 22.8% buying it daily. 3.2. Incidence and distribution of seafood borne illness Of the 2079 respondents, 8.5% (n = 177) reported experiencing seafood-related illnesses. The incidence of illness varied significantly across age groups (p < 0.001), with the highest rate among older adults aged 59–77 years (18.7%). In contrast, illness rates were 7.2% among 18–26 years, 6.7% among 27–42 years, and 7.6% among 43–58 years ( Table 1 ). Males reported marginally higher illness rates than females (9.7% vs. 7.5%, p = 0.080). Education level was significantly associated with illness (p < 0.009), with the highest incidence among respondents with PhD or equivalent degrees (11.6%) and the lowest among those with a degree (6.1%). Unemployed individuals reported the highest illness rates (25.7%), while business and self-employed respondents reported the lowest (5.8%) (p < 0.001). Respondents with a monthly family income of 20,001–40,000 INR reported the highest incidence (12.4%), while those earning 40,001–60,000 INR reported the lowest (5.9%) (p < 0.002). Urban residents exhibited significantly higher illness rates than rural residents (10.9% vs. 6.6%, p < 0.018). Behavioural factors also influenced illness rates: principal seafood purchasers (11.6%) and principal seafood preparers (10.2%) reported higher rates (p < 0.001 and p < 0.015, respectively). Weekly purchasers (10.8%) reported higher illness rates compared to daily (8.6%) or alternate-day purchasers (6.6%) (p < 0.013). <> 3.3. Self-reported health concerns associated with seafood consumption Among the 8.5% (n = 177) of respondents who reported health-related issues after seafood consumption, the most common symptoms were vomiting (n = 63, 35.6%), diarrhea (n = 36, 20.3%), allergy (n = 42, 23.7%), stomach pain (n = 22, 12.4%), and headache (n = 14, 7.9%). The primary causes of these illnesses were classified into two categories: (i) Handling-related illnesses (47.4%, n = 84): Attributed to spoiled or contaminated seafood (28.8%, n = 51), improperly cleaned shellfish (7.9%, n = 14), and consumption from street vendors or restaurants (10.2%, n = 18), (ii) Non-handling-related illnesses (40.6%, n = 72): From allergic reactions (29.9%, n = 53) and histamine poisoning from oily fish (10.7%, n = 19), and (iii) Other unidentified health-related factors (12.4%, n = 22). 3.4. Food handling practices among seafood consumers of Kerala Among the 2079 respondents, 8.5% (n = 177) reported experiencing seafood-related illnesses, forming the 'Case group,' while the remaining 91.5% (n = 1902) who did not report such illnesses comprised the 'Control group. The analysis revealed variations in food handling practices, with differences observed across illness groups. The average score for the food handling practices among respondents was 2.7 ± 0.6. <> Case group reported lower adherence to hygiene practices, such as washing hands with soap before handling raw seafood, with a mean score of 2.14 compared to the Control group’s mean score of 2.53. Additionally, a larger proportion of the Case group failed to sanitize utensils and countertops after contact with raw seafood, with 74.0% of respondents in the Case group not performing this critical step, compared to 64.3% in the Control group. Similarly, unsafe thawing practices were more common in the Case group, where 63.3% thawed frozen seafood at room temperature, compared to just 27.2% in the Control group. The higher frequency of unsafe thawing practices in the Case group was significant (p < 0.001), contributing to an increased risk of foodborne illness. Both groups exhibited moderate scores in practices like storing raw seafood separately from cooked foods, with the Case group scoring 3.21 and the Control group scoring 4.25 on the scale. Additionally, the Case group reported moderate adherence to practices like ensuring raw seafood fluids did not drip onto other foods (mean = 2.69) and refreezing thawed fish (mean = 2.93). The Case group demonstrated higher adherence to safe practices like checking seafood freshness by smell, texture, and appearance, with a mean score of 4.71. Similarly, 77.4% of the Case group reported cooking seafood thoroughly until it was opaque and flaked easily, although this was still significantly lower than the Control group, where 94.7% followed this practice (p < 0.001). The Case group reported reheating leftover seafood more frequently, with 93.2% engaging in this practice compared to 86.1% in the Control group (p = 0.012). Despite these safe practices, the Control group consistently exhibited higher safety scores overall. Table 2 presents a comprehensive comparison of the seafood handling practices followed by the Case group and the Control group. 3.5. Comparison of food handling practices among case group and control group of seafood consumers The analysis revealed significant differences between the two groups, with the Case group exhibiting riskier food handling behaviours than the Control group (Mann-Whitney U test, p < 0.05). Unsafe practices, including inadequate seafood storage, cross-contamination, and improper thawing, were more prevalent among those who reported foodborne illnesses. Significant differences were observed in checking seafood freshness, using separate cutting boards for different type of foods, storing raw seafood separately, and thawing seafood at room temperature ( p < 0.001). However, certain practices, such as washing hands before handling seafood and using clean plates for cooked seafood, did not show statistically significant differences between the groups. These are summarized in Table 3 . <> 3.6. Multivariate logistic regression analysis The multivariate logistic regression analysis identified significant relationships between specific food handling practices, demographic factors, and self-reported foodborne illness. Age, occupation, income, and area of residence were significant predictors of self-reported foodborne illness (p < 0.05). Several unsafe food handling practices increased the likelihood of illness, including failure to sanitize utensils and countertops after raw seafood contact, not using separate cutting boards for fish, meat, and vegetables, and improper storage of raw seafood in shopping bags or containers. Additionally, keeping fish and other foods on the same refrigerator shelf, inadequate cooking, and thawing frozen seafood at room temperature were significantly associated with a higher risk. Other contributing factors included leaving fish on the counter before cooking, reheating leftovers until only warm, and delaying refrigeration beyond two hours (p < 0.05). No significant collinearity issues were detected among the independent variables, as confirmed through preliminary linear regression analysis (Table 4 ) <> 4. DISCUSSION 4.1. Incidence and distribution of seafood-borne illnesses Seafood is a staple part of the diet in the state of Kerala in India, and previous studies have reported foodborne pathogens, toxins and contamination risks associated with seafood consumption in the region. For instance, Silvester et al. ( 2022 ) reported the presence of multidrug-resistant Vibrio parahaemolyticus in shellfish from Cochin, a major seafood export hub of Kerala, underscoring the critical need for regular monitoring and intervention to prevent such pathogens from reaching consumers. Similarly, Sunitha et al. ( 2017 ) identified Listeria monocytogenes and Salmonella spp. in raw seafood sourced from Wayanad, a district of Kerala known for its rich natural resources, thus highlighting the potential health risks associated to seafood consumption in the region. However, Menon et al. (2020) emphasized that adherence to good hygiene practices at fish catchment and processing areas could significantly reduce the risks associated with Listeria contamination. The study reported that the incidence of self-reported foodborne illness related to seafood consumption was 8.5%, which is lower than the outbreak-based reported by Barrett et al. ( 2017 ) in the United States and inconsistent with the pathogen-specific prevalence rates reported by Tanveer et al. ( 2024 ) in Asia, likely due to differences in regional variations in seafood safety practices. This inconsistency could be attributable to exposure to pathogenic factors, study populations, survey administration schedules, research methodologies, and survey techniques. Nevertheless, these findings require further validation through additional research to verify these patterns and elucidate the underlying reasons. 4.2. Consumer seafood handling practices at home Improper food handling practices in both domestic kitchen and commercial settings have the potential to significantly increase the risk of foodborne illnesses. This study surveyed seafood consumers in Kerala, India to explore unsafe food handling practices, which may explain the association between seafood handling practices at home and foodborne illness. Poor food-handling practices were common among seafood consumers who have encountered food borne illness with several food handling practices categorised as unsafe among seafood consumers (mean scores ranging from 0.00 to 2.00; Table 2 ). These critical practices require immediate attention to mitigate the risk of seafood-borne illnesses. Mol et al. ( 2018 ) reported that 57% of participants from Turkey preferred asking retailers to clean and eviscerate fish at the time of purchase and nearly 40% always prefer to clean surfaces only at the end of day. Ozilgen. (2010) reported that more than 85% Turkish university students wash their hands with soap and water before preparing foods. Baptista et al. ( 2020 ) reported that 91.68% of Brazilian respondents of different age groups sanitize utensils used for raw seafood handling. In the survey, a significant percentage of case group (72.9%) reported avoiding the purchase of fish just before they left the market and 71.8% of the case group consumers in the study had not clean kitchen surfaces immediately. Both findings are consistent with results reported in Turkey (Mol et al., 2018 ), where 52.8% consumers always bought fish just before leaving the market and they mostly prefer to clean surfaces only at the end of the day. Four fifths of seafood consumers (80.2%) reported that they had not separated raw seafood from other food in their shopping bags. For instance, Godwin & Coppings. (2005) reported that 7% of US consumers used coolers to protect cold foods during transport, and many refrigerators were above recommended temperatures. Hicks ( 2016 ) reported that effective temperature management of seafood during transport minimises bacterial growth and spoilage by maintaining quality. Over four fifths of seafood consumers (92.1%) never used separate cutting boards for fish, vegetables, or meat, which aligns with reports from Koppel et al. ( 2014 )’s study indicating the increased risk of cross contamination during food preparation. Furthermore, 83.7% of control group did not refrigerate or freeze seafood within two hours of purchase, and 61.9% refroze thawed fish. These findings are consistent with observations in Brazil (Baptista et al., 2020 ) and Asian countries (Koppel et al., 2014 ). Moreover, 76.8% of seafood consumers did not marinate raw seafood in the refrigerator, contrary to FDA guidelines (FDA, 2024a) that recommend marinating seafood in sealed containers at 5°C, further underscoring the need for improved food safety education on proper food marinating techniques in mainland (Gong et al., 2011 ). The study found that nearly 63.3% of consumers thawed seafood at room temperature. This risky behaviour could be mitigated by adopting a “direct-from-frozen” approach (Neff et al., 2021 ). This involves cooking seafood without defrosting, which could reduce waste, enhance food safety, and increase convenience. Additionally, only 7.3% of participants in this study reported labelling fish with the date when freezing, underscoring the importance of accurate labelling for tracking the age of frozen seafood to ensure it is consumed safely within the safe period (Hicks, 2016 ). The findings of this study suggest that there are several key areas for improvement in food handling practices of seafood consumers in Kerala, particularly in purchasing, handwashing, surface cleaning and sanitation, marination, and storage behaviours. The literature indicates that consumer knowledge often does not align with their self-reported or observed behaviours (Marasteanu et al., 2018 ; Redmond & Griffith, 2003 ), emphasizing the need for more observational research to assess food safety practices. Addressing these knowledge gaps in knowledge and behaviour through targeted education and awareness campaigns is critical for improving food safety behaviours. Consumers must be informed about the significance of adhering to proper food handling practices at home to reduce the incidence of foodborne illnesses and promote continual improvement in their food safety practices. 4.3. Demographic factors, food handling practices and seafood-borne illness The study found that demographic factors and food handling practices significantly influenced the incidence of seafood-related foodborne illness. Descriptive statistics in Table 1 indicated that older adults (59–77 years) reported the highest proportion of seafood-related illness (18.7%), while younger adults aged 27–42 years reported the lowest proportion (6.7%). However, multivariable logistic regression analysis ( Table 4 ) revealed that after adjusting for food handling practices and other demographic variables, increasing age was associated with a significantly reduced likelihood of reporting foodborne illness (OR = 0.735; 95% CI: 0.597–0.905; p = 0.004). This contradiction between proportions and adjusted risk suggests that other confounding factors such as unsafe food handling behaviours and other socioeconomic factors may influence illness rates independently of age. Although older adults reported higher absolute rates of illness, their adjusted odds of illness were lower once these behavioural and demographic factors were accounted for. This finding may reflect the influence of safer food handling behaviours among older adults, as suggested by their higher behavioural scores in areas like hand hygiene and seafood storage. However, the data do not allow us to draw definitive conclusions about causality, and additional qualitative or longitudinal research would be needed to confirm these mechanisms. One possible explanation is that older adults, despite being biologically more vulnerable to foodborne pathogens due to diminished immune function, may compensate through more cautious and consistent food safety practices developed over a lifetime (Anderson et al., 2011 ; Buzby, 2002 ). On the other hand, younger adults, while biologically more resilient, may engage more frequently in unsafe food handling behaviours, which increases their risk despite their lower absolute reported illness rates (Byrd-Bredbenner et al., 2007 , 2008 ). These observations reinforce the importance of multivariable analysis in epidemiological research, as simple descriptive comparisons may vague underlying risk patterns. From a public health perspective, these results emphasize the need for targeted food safety education initiatives that particularly address unsafe food handling practices among younger populations to reduce seafood-borne illness risk. Furthermore, occupation significantly (p < 0.001) impacts foodborne illness incidence, with specific job sectors exhibiting greater risks. Occupations involving long hours or limited access to food safety education may lead to riskier food handling practices, contributing to increased illness rates. In the study, respondents with a higher monthly family income and those residing in urban areas face a 1.2- and 1.5- times increased risk of seafood-borne illness, respectively. Higher income levels are often associated with less time spent on food preparation, leading to greater reliance on quick, convenient cooking methods that may not always prioritise food safety. Socioeconomic status (SES) and changing demographic patterns, such as increased number of women in the workforce, often result in younger individuals preparing their own meals, which can increase the risk of foodborne illnesses. However, higher incomes generally improve access to quality food and food safety education, they also contribute to lifestyle changes that may not always support safe food handling. In many low- and middle-income countries, food safety concerns often limit the consumption of nutrient-rich foods due to hygiene concerns, even though issues of affordability and access persist (Conway et al., 2023 ; Liguori et al., 2022 ). Urban setting, pose additional food safety challenges due to high population density and complex food handling environments. Research from China has shown that, foodborne illnesses linked to Vibrio parahaemolyticus is more frequent in urban areas, where inadequate temperature control and poor hygiene practices further worsen the risks (Bian et al., 2022 ; Piglowski, 2023). According to the World Health Organization’s "Five Keys to Safer Food" program, critical food safety practices such as cleaning, separating, cooking, chilling, and use of safe water or raw materials (WHO, 2006) are essential in reducing the risk of foodborne illnesses. In the study consumers who evaluated seafood freshness based on sensory characteristics, such as appearance, texture, and odour, were less likely to report foodborne illnesses. The Codex Alimentarius guidelines for effective sensory evaluation recommended that fresh seafood should have clear bright eyes, firm flesh, bright red or pink gills and shiny scales, and no or an ocean odour. While discolouration of the flesh, dullness of the appearance, a foul odour or brown or faded gills indicate a loss of freshness. Hence, consumer who enhance their ability in assessing seafood freshness can significantly contribute to improved public health outcomes (Viana et al., 2022 ). On the other hand, consumers who purchase fish just before leaving the market face a 1.5 times increased risk of illness, showing the importance of effective temperature management during transport. Promptly refrigerating or freezing seafood within two hours of purchase is crucial for preventing pathogen growth (p < 0.001), demonstrating a protective effect against foodborne illness. In contrast, not leaving the fish on kitchen counter with a plan to cook later decrease the illness risk as well (p < 0.001), indicating a protective effect against seafood borne illness. Improper temperature control practices, such as thawing seafood at room temperature, increase the risk of affecting foodborne illness by 1.4 times. Temperature abuse during purchasing and handling of seafood, such as prolonged exposure to ambient temperatures and poor purchase timings accelerates bacterial growth. However, the use of proper thawing methods, such as thawing seafood in a refrigerator or with cold water, significantly reduces the risk of seafood-borne illness compared with thawing at room temperature, which is associated with increased pathogen growth. The U.S. FDA (2024b) recommends thawing seafood in a refrigerator or using cold water to prevent rapid bacterial spread. Additionally, refreezing thawed seafood unless it has been cooked should be avoided, as it can compromise both safety and quality. Cross-contamination during seafood handling is a critical concern for preventing foodborne illnesses and often occurs when pathogens from raw seafood, such as Vibrio spp., Salmonella spp., and Listeria monocytogenes, are transferred to other foods through direct contact or contaminated utensils, cutting boards, and surfaces. Not sanitising utensils and countertops after handling raw seafood significantly increases the risk of seafood borne illness by 1.2 times. Public health guidelines emphasise sanitizing utensils and countertops with hot, soapy water or a dishwasher to thoroughly clean cutting boards, knives, and other tools after contact with raw seafood (FDA, 2022). Additionally, the improper use of separate cutting boards for seafood, vegetables, poultry, and meat elevates the risk by 1.4 times, which aligns with previous research identifying inadequately cleaned kitchen tools are major contributors to foodborne illnesses (De Jong et al., 2008 ). Inadequate cleaning and sanitizing practices contribute contamination cycles, increasing the risk of food borne illness. Adherence to recommended practices, including proper hygiene, cleaning, and sanitation, is essential for reducing foodborne illnesses associated with seafood (CDC, 2024; WHO, 2006). Consumers who fail to keep raw seafood separate in shopping bag (1.2 times) and fail to store it in separate containers (1.4 times) are more likely to experience foodborne illness. Similarly, keeping raw seafood on the same shelf with other foods in the refrigerator increases the risk by 1.2 times. Placing raw fish on the lower shelf of the refrigerator can prevent potential contamination by preventing seafood juices from dripping onto ready-to-eat or cooked foods. In many households this risk is significant when various foods are stored together. Hence, proper storage practices and regular cleaning of high-contact areas in the refrigerator, such as the door handle and bottom shelf, is crucial for preventing contamination reducing the growth and spread of harmful pathogens. Neglecting these high contact areas can increase the risk of contamination and compromise food safety (Agi et al., 2021 ; Cunningham et al., 2022 ). The study noted that not cooking seafood thoroughly until it is opaque and flakes easily with a knife or other utensils increases the risk by 1.7 times. Cooking seafood to an internal temperature above 74°C and reheating leftovers thoroughly is effective in eliminating pathogens. Research indicates that Vibrio species are eliminated at 55°C, Salmonella species at 75°C, and Listeria species at 85°C, emphasising the need for appropriate cooking temperatures tailored to different seafood species (Chintagari, 2022 ). Proper cooking methods, such as preheating the pan or using controlled cooking temperatures are key approaches to ensure food safety. Additionally, perishable seafood should be consumed within 24 hours if it is stored for more than two hours after cooking. Leftover seafood must be promptly refrigerated and maintained at temperatures below 5°C to ensure safety. In Kerala, while consumers have a strong perception of the nutritional benefits of fish but exhibit lower awareness of specific health benefits and express concerns about fish quality, particularly in relation to transportation and the lack of freshness certification systems (Rejula et al., 2021 ; Sajeev & Joshy, 2024 ). Although most consumers have a moderate perception of fish safety, significant differences in safety issue perceptions highlight the need for targeted government interventions in supply chain management and quality assurance to address both real and perceived risks. Limitations This study has several limitations. First, it relies on self-reported data, which may be subject to recall bias and reporting inaccuracies. Second, the analysis focuses on seafood-borne illnesses without differentiating between specific seafood types (e.g., finfish, shellfish, mollusks, crustaceans) or conducting pathogen-specific analysis (e.g., Salmonella , Vibrio , norovirus), limiting the granularity of risk assessment. Third, as the study was conducted in Kerala, a coastal state in India, its findings may not be generalizable to inland regions or other states with different seafood consumption patterns. Fourth, the cross-sectional study design prevents establishing causal relationships between seafood handling practices and illness, and the absence of microbiological testing restricts validation of contamination sources. Fifth, small sample sizes in certain demographic subgroups may reduce the robustness and statistical power of subgroup-specific findings. Additionally, while the study focuses on handling-related causes of seafood-borne illness, it also acknowledges other non-microbial causes such as allergic reactions and histamine poisoning—particularly from oily fish consumption. These cases were not integrated into the core analysis but are recognized as important areas for future investigation. Greater differentiation between microbial contamination and biological responses would enhance risk communication and public health education. Future research should address these gaps by including pathogen detection, seafood-type differentiation, larger and more diverse samples, and longitudinal or experimental designs to strengthen causal inferences and broaden generalizability. CONCLUSION Improper seafood handling practices related to temperature control, kitchen hygiene, cross-contamination, and storage significantly elevate the risk of seafood-borne illness. Additionally, unsafe purchasing behaviours were important contributors to self-reported illness. Conversely, protective practices such as checking freshness, thorough cooking, prompt refrigeration, and reheating leftovers until hot were associated with reduced risk. Demographic factors, including age, occupation, income, and residence, also influenced illness risk, highlighting the need for tailored interventions. Although older adults reported higher illness proportions in raw data, regression analysis showed they were less likely to report illness when accounting for other variables—underscoring the importance of multivariate approaches in public health research. The findings highlight the need for targeted consumer education on safe seafood handling, hygiene, and cross-contamination prevention. To ensure seafood safety and reduce illness, public health initiatives must be demographic-specific, supported by regulatory oversight, clear food safety communication, and robust supply chain monitoring to reduce seafood-related health risks in Kerala. Declarations Acknowledgements The authors express their gratitude to School of Industrial Fisheries, Cochin University of Science and Technology (CUSAT), and to all participants who contributed to the study in Kerala. Author Contributions A.V. (Corresponding Author) led the conceptualization, methodology, data collection, data analysis, writing, review & editing. M.S.N. contributed to conceptualization, methodology, supervision, data analysis, review & editing. All authors reviewed and approved the final manuscript. Data Availability The authors confirm that all data generated or analysed during this study are available upon request from the corresponding author. The data are not publicly available due to confidentiality concerns. Ethics Approval and Consent to Participate Ethical review and approval were waived by the Ethics Committee of the School of Industrial Fisheries, Cochin University of Science and Technology (CUSAT), as the study maintained the anonymity of respondents and did not involve sensitive data. All data collection procedures followed ethical guidelines in accordance with CUSAT’s ethical standards, particularly those promoted by the Centre for Integrity in Research and Ethics (ICREP), which provides insights into the ethical rules and norms guiding academic research. Informed consent was obtained from all participants, who were informed that their responses would remain anonymous and that participation was entirely voluntary. Competing Interests The authors declare no competing interests. Funding Declaration No funding was received for this research. Consent to Publish Declaration All authors consent to publish. Clinical trial number Not applicable References Agi, V. N., Aleru, C. P., & Uweh, E. J. (2021). Bacterial contamination of some domestic and laboratory refrigerators in Port Harcourt Metropolis. European Journal of Health Sciences, 6(1), 16–34. https://doi.org/10.47672/ejhs.662 Almaary, K. S. (2023). Food-Borne Diseases and their Impact on Health. 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Accessed 15.07.24 Tables Table 1 Demographic characteristics and unadjusted incidence of self-reported seafood-related illness among respondents (N = 2,079) Demographic characteristics Total respondents (N) Proportion of ill in category (n = 177) p Age (segments) < 0.001 18–26 683 7.2 27–42 687 6.7 43–58 458 7.6 59–77 251 18.7 Gender < 0.080 Female 1117 7.5 Male 962 9.7 Education < 0.009 Secondary school 342 9.1 Degree 688 6.1 Masters 541 8.3 PhD/ equivalent 508 11.6 Occupation < 0.001 Government servant 418 6.9 Private employee 422 7.6 Business/ self employed 208 5.8 Student 778 5.0 Unemployed 253 25.7 Monthly family income < 0.002 <20000 327 9.2 20001–40000 498 12.4 40001–60000 578 5.9 60001–80000 474 6.8 80001< 202 9.4 Area of residence < 0.018 Urban 698 10.9 Suburban 884 7.7 Rural 497 6.6 Principal seafood purchaser < 0.001 Yes 1138 11.6 No 941 4.8 Principal seafood preparer < 0.015 Yes 912 10.2 No 1167 7.2 Purchase frequency < 0.013 Daily 474 8.6 Alternately 889 6.6 Weekly 716 10.8 Proportions represent the percentage of respondents within each demographic category who reported experiencing seafood−related illness. These are unadjusted rates. See Table 4 for adjusted associations . Table 2 Food handling practices among seafood consumers of Kerala based on self-reported incidence of seafood-borne illness. Food handling practices Respondents Never Rarely Some times Often Always Mean ± SD p Use Safe Water and Raw Materials I check seafood freshness by examining smell, texture, and appearance when purchasing. Case group 4.5 1.7 0.0 6.2 87.6 4.71 ± 0.925 < 0.001** Control group 1.4 0.6 2.8 38.7 56.5 4.48 ± 0.717 I ask the retailer to clean/eviscerate the fish when buying Case group 44.1 32.8 0.0 0.6 22.6 2.25 ± 1.565 < 0.001** Control group 66.7 19.1 2.0 4.3 7.8 1.68 ± 1.208 Keep Clean I wash my hands with soap before handling raw seafood Case group 58.2 15.8 0.0 5.6 20.3 2.14 ± 1.623 0.428 Control group 57.6 18.6 2.0 13.1 8.6 1.97 ± 1.378 I clean kitchen surfaces immediately, not just at the end of the day Case group 71.8 5.1 6.2 6.2 10.7 1.79 ± 1.401 < 0.001** Control group 87.4 5.6 0.8 1.9 4.3 1.30 ± 0.924 I don’t sanitize utensils and counter tops with hot, soapy water after contact with raw seafood Case group 74.0 5.1 0.6 1.7 18.6 1.86 ± 1.577 0.009* Control group 64.3 6.6 0.4 2.2 26.5 2.20 ± 1.757 Separate Raw and Cooked I don’t use separate cutting boards for fish, meat, and vegetables Case group 92.1 0.0 0.0 2.3 5.6 1.29 ± 1.013 < 0.001** Control group 76.9 14.0 0.9 3.6 4.6 1.45 ± 1.015 I use clean plates and utensils for cooked seafood, not the same ones used for raw seafood Case group 11.3 0.0 0.0 6.2 82.5 4.49 ± 1.271 0.913 Control group 7.0 0.2 0.0 10.8 82.0 4.61 ± 1.043 I don’t keep raw seafood separate from other foods in my shopping bag Case group 80.2 4.0 0.0 1.1 14.7 1.66 ± 1.437 < 0.001** Control group 57.4 10.0 0.4 5.0 27.2 2.35 ± 1.764 I don’t store raw seafood in separate containers or zip-lock bags from cooked or ready-to-eat foods Case group 41.8 0.6 0.0 10.2 47.5 3.21 ± 1.912 < 0.001** Control group 9.2 3.2 2.0 24.5 61.1 4.25 ± 1.234 I ensure raw seafood fluids do not drip onto other foods in the shopping bag and refrigerator Case group 54.2 0.0 5.1 4.0 36.7 2.69 ± 1.898 0.006* Control group 43.5 1.3 0.7 8.8 45.8 3.12 ± 1.913 I keep fish and other foods on the same shelf in the fridge or freezer Case group 52.5 0.0 0.0 4.0 43.5 2.86 ± 1.971 < 0.001** Control group 25.3 2.5 2.4 3.7 66.1 3.89 ± 1.742 Cook Thoroughly I don’t cook seafood thoroughly until it is opaque and flakes easily. Case group 4.0 1.7 4.0 13.0 77.4 4.58 ± 0.951 < 0.001** Control group 1.0 0.1 1.4 2.8 94.7 4.90 ± 0.490 I reheat leftover seafood until it is warm or hot before eating. Case group 3.4 1.1 0.0 2.3 93.2 4.81 ± 0.796 0.012* Control group 2.1 0.6 1.4 9.8 86.1 4.77 ± 0.701 Keep Food at Safe Temperatures I buy fish just before leaving the market. Case group 72.9 6.8 2.8 11.9 5.6 1.71 ± 1.290 < 0.001** Control group 56.8 21.0 2.6 10.9 8.7 1.94 ± 1.344 I promptly refrigerate or freeze seafood within two hours of purchase Case group 79.1 6.8 1.7 2.3 10.2 1.58 ± 1.282 0.052 Control group 83.7 10.1 0.9 2.1 3.2 1.31 ± 0.861 I thaw frozen seafood at room temperature; not using cold running water. Case group 63.3 5.1 1.1 11.3 19.2 2.18 ± 1.676 < 0.001** Control group 27.2 6.7 1.8 16.8 47.5 3.51 ± 1.723 I refreeze thawed fish unless it has been cooked Case group 50.3 0.6 0.0 4.0 45.2 2.93 ± 1.970 < 0.001** Control group 26.4 1.1 1.7 7.3 63.5 3.80 ± 1.742 I don’t leave fish on the counter if I plan to cook it later the same day Case group 68.9 15.3 1.7 2.8 11.3 1.72 ± 1.330 < 0.001** Control group 80.8 14.2 1.0 1.6 2.4 1.31 ± 0.784 I marinate seafood in the refrigerator, not at room temperature Case group 76.8 9.0 2.3 4.0 7.9 1.57 ± 1.219 0.255 Control group 70.3 21.9 1.8 2.3 3.8 1.48 ± 0.939 I label the fish with the date when I put it in the freezer Case group 79.7 7.9 1.7 3.4 7.3 1.51 ± 1.173 0.389 Control group 82.0 8.2 1.4 3.3 5.1 1.41 ± 1.040 Mean score categorization: Unsafe handling (0.00–2.00), moderate handling practice (2.05–3.5 cm) and safe handling (3.55-5.00 cm) p: p value determined using Mann-Whitney U test. Table 3 Comparison of seafood handling practices between case and control groups Food handling practice Mean rank Mann-Whitney u Z p Case group Control group I check the freshness of seafood by examining its smell, texture, and appearance during purchasing. 1314.10 1014.49 119812.0 -7.348 < 0.001 When i buy fish from market or stalls, i ask the retailer to eviscerate it. 1266.20 1018.95 128290.0 -6.179 < 0.001 I buy fish just before leaving the market 908.90 1052.20 145122.5 -3.411 0.001 I wash my hands with soap before handling raw seafood. 1070.57 1037.16 162916.0 -0.792 0.428 I clean kitchen surfaces only at the end of day 1194.73 1025.60 140940.0 -5.955 < 0.001 I clean and sanitize utensils and counter tops with hot, soapy water they come into contact with raw seafood. 945.44 1048.80 151589.0 -2.607 0.009 I keep raw seafood separate from other foods in my shopping bag. 830.42 1059.50 131232.0 -5.527 < 0.001 I use separate cutting board for fish, meat and vegetables cutting 907.89 1052.29 144943.5 -4.248 < 0.001 I store raw seafood in separate containers or zip-top bags from cooked or ready-to-eat foods. 804.88 1061.88 126710.0 -6.209 < 0.001 I ensure raw seafood juices do not drip onto other foods in the shopping bag and refrigerator. 932.89 1049.97 149368.5 -2.740 0.006 I use clean plates and utensils for cooked seafood, not the same ones used for raw seafood. 1036.86 1040.29 167771.0 -0.109 0.913 I cook seafood thoroughly until it is opaque and flakes easily with a knife or other utensil 875.82 1055.28 139267.0 -8.729 < 0.001 I reheat leftover seafood until it is warm or hot before eating 110.63 1034.08 157064.0 -2.503 0.012 I leave fish on the counter if i plan to cook it later that same day. 1168.93 1028.00 145506.0 -4.273 < 0.001 I marinate seafood in the refrigerator and not at room temperature. 1000.85 1043.64 161397.5 -1.137 0.255 I refrigerate or freeze seafood within two hours of purchase. 1094.49 1034.93 158682.0 -1.944 0.052 I don’t keep fish and other foods on the same shelf in the fridge or freezer 793.50 1062.94 124696.0 -6.756 < 0.001 I mark the date on the fish that I put in the freezer. 1064.99 1037.67 163904.5 -0.861 0.389 I thaw frozen seafood in the refrigerator or under cold running water, not at room temperature 663.46 1075.04 101679.0 -9.322 < 0.001 If thawed fish is not used completely, i refreeze it. 829.47 1059.59 131063.0 -5.675 < 0.001 Case group (n = 177) Control group (n = 1902) P < 0.05, < 0.01 Table 4 Multivariable logistic regression analysis of factors associated with self-reported seafood-related illness Demographic factors and seafood handling practice p a Odds ratio (95% CI) b 1. Age 0.004* 0.735 (0.597–0.905) 2. Occupation < 0.001** 0.734 (0.640–0.841) 3. Monthly income (family) 0.001** 1.283 (1.103–1.492) 4. Area of residence 0.002** 1.505 (1.165–1.945) 5. Check freshness by sensory evaluation < 0.001** 0.616 (0.475-0.800) 6. Don’t sanitize utensils and countertops after raw seafood contact 0.015* 1.210 (1.037–1.411) 7. Don’t use separate cutting boards for fish, meat, and vegetables 0.035* 1.487 (1.029–2.150) 8. Don’t Keep raw seafood separate in shopping bag 0.042* 1.200 (1.007–1.429) 9. Don’t store raw seafood in separate containers < 0.001** 1.480 (1.281–1.709) 10. Keep fish and other foods on the same shelf in fridge 0.006* 1.294 (1.078–1.553) 11. Don’t cook seafood thoroughly 0.003* 1.729 (1.206–2.477) 12. Reheat leftovers until warm or hot 0.023* 0.662 (0.464–0.945) 13. Buy fish just before leaving market < 0.001** 1.576 (1.312–1.893) 14. Promptly refrigerate or freeze seafood within two hours < 0.001** 0.555 (0.448–0.688) 15. Thaw frozen seafood at room temperature < 0.001** 1.413 (1.200-1.664) 16. Don’t leave Fish on Counter (Plan to Cook Later) < 0.001** 0.424 (0.330–0.545) a P−values from multivariable logistic regression model . b Odds Ratios (OR) with 95% Confidence Intervals (CI) reflect the likelihood of reporting seafood−related illness based on demographic characteristics and food handling practices. An OR > 1 indicates higher risk; OR < 1 indicates protective factors . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6813639","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":477449781,"identity":"60ba2677-22c4-4243-aa65-fde68a68088f","order_by":0,"name":"Arundhathi V","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIiWNgGAWjYLAC3gYGBgNmEMuAQQ4hzIxfiwRMizFY5ABRWqDsxAa4FhyAf/YZswdvd9jVmbPzmD34UXAvvX9G+sPPHxjs5BnYebHqlDiXY24490yyhGUzj7lhj0Fx7owbOcYSBxiSDRuY+RKwWnOGx0yat41ZwuAwW5oEj0FC7gaJHAagFuYEBmYeA2w65CFa6sFaJP8YJKQbSKQ//nGAoR6nFgOIlsNALczHpIG2JBhIJJgBbTmMU4vhGbYyybltxyU3gLTIGCQYzjjzxszijMFxwzYcWuTOMG+TeNtWzW9w/mCb5Js/CfL87emPb1RUVMvz85/BqgUXACpmI0X9KBgFo2AUjAIUAADdEVMlxvPEmgAAAABJRU5ErkJggg==","orcid":"","institution":"Cochin University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Arundhathi","middleName":"","lastName":"V","suffix":""},{"id":477449782,"identity":"2c759c8e-72c3-4d32-8691-082ab6eba2a6","order_by":1,"name":"MINI SEKHARAN N","email":"","orcid":"","institution":"Cochin University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"MINI","middleName":"SEKHARAN","lastName":"N","suffix":""}],"badges":[],"createdAt":"2025-06-03 17:23:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6813639/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6813639/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91620917,"identity":"2a3b0b6b-23f9-485c-b591-254de4b63ca7","added_by":"auto","created_at":"2025-09-18 11:24:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1593611,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6813639/v1/7df2fac8-9b95-490a-8b63-0b609ef8c70e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eFood Safety Practices as Determinants of Self-Reported Foodborne Illness Among Seafood Consumers\u003c/p\u003e","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eFoodborne illness is a significant global health concern, frequently resulting in acute or subacute diseases following the consumption of contaminated food or water (Almaary, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The World Health Organization (WHO) highlights the impact of these illnesses, particularly in developing nations, where foodborne illness contributes notably to both morbidity and mortality. Each year, more than 600\u0026nbsp;million people worldwide suffer from foodborne illness, with children under five years old accounting for 30% of the fatalities (WHO, 2015). Seafood, in particular, poses considerable health risks due to its highly perishable nature and susceptibility to contamination by pathogens and toxins throughout the supply chain. In the United States alone, seafood was linked to 4,815 illness outbreaks between 1998 and 2015, resulting in 359 hospitalisations and four deaths (Barret et al., 2017). Similarly, the Caribbean, Japan, Korea, and the Pacific have reported multiple seafood-related food poisoning outbreaks (Chinain et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Fleming et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Common pathogens associated with seafood borne illnesses, include Vibrio spp., Salmonella spp., Shigella spp., Escherichia coli., and Listeria monocytogenes (Almaary, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Ayyappan \u0026amp; Joseph, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). These pathogens can cause a range of symptoms from mild gastrointestinal disturbances such as nausea, diarrhoea, stomach pain to more severe systemic illnesses including fever, headache, and tachycardia. These health risks underscore the importance of understanding seafood handling practises to reduce contamination, mitigate associated risks and protect consumer health.\u003c/p\u003e \u003cp\u003eIn the United States, 52% of seafood-related outbreaks are linked to restaurant meals, and 33% to seafood prepared at home (Barret et al., 2017). This underscored the importance of maintaining food safety across the entire supply chain from production to the consumer's table. Adopting effective food safety practices, such as thorough cleaning, appropriate cooking, adequate chilling and freezing, proper storage and preventing cross-contamination, plays a vital role in mitigating these risks (FDA, 2024b; WHO, 2015). Consumers food handling practices at home are equally critical in minimising foodborne illnesses. Raising awareness about potential hazards including biological, chemical and physical risks in seafood, including toxins and pathogens, and the adoption of proper storage, preparation and preservation techniques are essential for inhibiting spoilage, minimising risks and maintaining seafood quality and safety (Choudhury et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Lupo \u0026amp; Angot, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Therefore, maintaining good handling practices throughout the supply chain and at the consumer level are essential to ensure seafood remains safe for consumption.\u003c/p\u003e \u003cp\u003eIn India, despite regulatory efforts by agencies such as the Food Safety and Standards Authority of India (FSSAI) and the Integrated Disease Surveillance Program (IDSP), substantial research gaps persist, particularly concerning household seafood handling practices and their impact on the incidence of foodborne illness. This study addresses these gaps by examining the relationship between self-reported foodborne illness and seafood handling practices among seafood consumers in Kerala, India. The research will compare handling practices between those who have experienced seafood related illnesses and those who have not. By addressing this research gap, the study aims to inform targeted public health initiatives and enhance regulatory oversight to reduce illness risks and improve consumer awareness of safe food handling. While this study specifically investigates seafood-related foodborne illnesses due to its regional dietary significance, it does not eliminate the possibility of other food sources contributing to reported symptoms. The study\u0026rsquo;s focus reflects the high prevalence of seafood in local diets and its potential association with foodborne illnesses as reported and seafood handling practices followed by participants.\u003c/p\u003e"},{"header":"2. MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003e2.1. Participants\u003c/h2\u003e\n \u003cp\u003eKerala is a coastal state in India with high rate of seafood consumption and distinct dietary preferences. This study surveyed seafood consumers from 14 districts of Kerala between March and December 2023. Participants were recruited using a convenience sampling method. Online survey forms (Microsoft Forms and Google Forms) were distributed via social media platforms, ensuring accessibility for individuals with internet access while capturing diverse demographics. A total of 3000 respondents were invited to participate in the survey, and 2484 participants completed the survey. Eligibility criteria for participation included: (1) seafood consumers being 18 years or older, (2) consuming seafood at least once per week and (3) residing in Kerala. To enhance data quality, responses were screened for completeness and consistency. After excluding incomplete and duplicate entries, a total of 2079 valid responses were included in the final analysis.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003e2.2. Research Design\u003c/h2\u003e\n \u003cp\u003eThe study followed a cross-sectional survey design, using a semi-structured, self-administered questionnaire. The questionnaire was developed by integrating established literature (Baptista et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e; Langiano et al., \u003cspan class=\"CitationRef\"\u003e2011\u003c/span\u003e; Mol et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e), and insights from field interactions, and expert consultation to ensure that it was both comprehensive and relevant to seafood consumers in Kerala. To ensure seafood\u0026rsquo;s contribution to reported illnesses, the questionnaire included targeted questions addressing specific symptoms reported after seafood consumption. Participants were also asked to differentiate between seafood-related illnesses and other potential health conditions. Questions such as \u0026quot;Are you currently having any disease or systemic illness other than food poisoning or seafood-borne illness?\u0026quot; were included to isolate seafood-related symptoms.\u003c/p\u003e\n \u003cp\u003eThe questionnaire was divided into three sections:\u003c/p\u003e\n \u003cp\u003e(i) Demographic characteristics: Six questions covered participants age, gender, education, occupation, family monthly income, and area of residence;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(ii)\u0026nbsp; Seafood consumption habits and illness experiences: Four questions assessed the participant\u0026rsquo;s role in purchasing and preparing seafood, their frequency of seafood consumption, and self-reported seafood-borne illnesses experienced in the past year with reason for illness occurrence.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(iii) Seafood handling practices: Twenty statements were aligned with the Five Keys to Safer Food guidelines from the World Health Organization (WHO, 2006), focusing on key food safety practices such as keeping clean, separating raw and cooked foods, cooking thoroughly, storing food at safe temperatures and using safe water and raw materials. Responses were rated on a 5-point scale ranging from \u0026quot;Never\u0026quot; to \u0026quot;Always\u0026quot; (Table 2).\u0026nbsp;\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003eFor standardisation the survey responses were categorized and transformed based on their risk implications. Practices that inherently increased the risk of seafood-borne illness were reverse-coded so that higher scores corresponded to higher risk. For other practices higher scores directly represented safer practices. final scores were further classified into three categories based on their mean scores: unsafe practices (0.00\u0026ndash;2.00), moderately safe practices (2.05\u0026ndash;3.5), and safe practices (3.55\u0026ndash;5.00). The questionnaire was translated into the regional language of Kerala state, i.e. Malayalam, and validated using a back-translation method to ensure accuracy and comprehension. Informed consent was obtained from all participants, and data confidentiality was strictly maintained with no incentives were provided to participants. The reliability of the questionnaire was confirmed through Cronbach\u0026rsquo;s alpha values ranging from 0.788 to 0.817, indicating good internal consistency across the questionnaire sections. Validity of the questionnaire was ensured through expert review and pilot test conducted among 52 seafood consumers with feedback used to refine the questionnaire for clarity and relevance.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv\u003e\n \u003ch2\u003e2.3. Statistical Analysis\u003c/h2\u003e\n \u003cp\u003eDescriptive statistics were used to summarise qualitative data such as, demographic characteristics, illness incidence and seafood handling practices. Independent sample t-test was used to compare seafood handling practices (mean scores 20 statements measured on a 5-point scale ranging from 0 (Never) to 5 (Always)) between participants who experienced seafood-related illnesses and those who did not. Mann-Whitney U test was applied as a non-parametric alternative for variables that did not meet normality assumptions (McKnight \u0026amp; Najab, 2010) \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;3\u003cem\u003e).\u003c/em\u003e Multivariable logistic regression was conducted to assess the correlation between self-reported foodborne illness (dependent variable) and demographic characteristics and seafood handling practices (independent variables). Collinearity among independent variables was evaluated using linear regression with tolerance values (\u0026lt;\u0026thinsp;0.1) and the variance inflation factors (VIF\u0026thinsp;\u0026gt;\u0026thinsp;10). Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated for each independent significant variable (Table\u0026nbsp;4). Statistical significance was set at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 and data were analysed using the Statistical Package for the Social Sciences (SPSS Inc. Version 26.0).\u003c/p\u003e"},{"header":"3. RESULTS","content":"\u003ch2\u003e3.1. Demographic and behavioural characteristics of respondents\u003c/h2\u003e\n \u003cp\u003eThe age distribution of respondents showed that \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;1\u003cem\u003e)\u003c/em\u003e the largest groups were aged 27\u0026ndash;42 years (33.0%) and 18\u0026ndash;26 years (32.9%), with the smallest proportion (12.1%) belonging to the 59\u0026ndash;77 age group. Females made up the majority (53.7%) of the sample, followed by males (46.3%). Education levels indicated that 33.1% held a degree, while 26.0% had a masters and 24.4% had a PhD or equivalent professional degree qualification. Students constituted the largest occupational category (37.4%), followed by private employees (20.3%) and government servants (20.1%). Monthly family income ranged primarily between 40,001\u0026ndash;60,000 INR for 27.8% of respondents. In terms of residence, 42.5% lived in suburban areas, 33.6% in urban areas, and 23.9% in rural areas. Over half of the respondents (54.7%) identified as the principal seafood purchasers for their households, and 43.9% were responsible for seafood preparation. Seafood purchase frequency varied, with 42.8% buying seafood on alternate days and 22.8% buying it daily.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2. Incidence and distribution of seafood borne illness\u003c/h2\u003e\n \u003cp\u003eOf the 2079 respondents, 8.5% (n\u0026thinsp;=\u0026thinsp;177) reported experiencing seafood-related illnesses. The incidence of illness varied significantly across age groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with the highest rate among older adults aged 59\u0026ndash;77 years (18.7%). In contrast, illness rates were 7.2% among 18\u0026ndash;26 years, 6.7% among 27\u0026ndash;42 years, and 7.6% among 43\u0026ndash;58 years \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cem\u003e).\u003c/em\u003e Males reported marginally higher illness rates than females (9.7% vs. 7.5%, p\u0026thinsp;=\u0026thinsp;0.080). Education level was significantly associated with illness (p\u0026thinsp;\u0026lt;\u0026thinsp;0.009), with the highest incidence among respondents with PhD or equivalent degrees (11.6%) and the lowest among those with a degree (6.1%). Unemployed individuals reported the highest illness rates (25.7%), while business and self-employed respondents reported the lowest (5.8%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Respondents with a monthly family income of 20,001\u0026ndash;40,000 INR reported the highest incidence (12.4%), while those earning 40,001\u0026ndash;60,000 INR reported the lowest (5.9%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.002). Urban residents exhibited significantly higher illness rates than rural residents (10.9% vs. 6.6%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.018). Behavioural factors also influenced illness rates: principal seafood purchasers (11.6%) and principal seafood preparers (10.2%) reported higher rates (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and p\u0026thinsp;\u0026lt;\u0026thinsp;0.015, respectively). Weekly purchasers (10.8%) reported higher illness rates compared to daily (8.6%) or alternate-day purchasers (6.6%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.013).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026lt;\u003c/strong\u003e Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cstrong\u003e\u0026gt;\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3. Self-reported health concerns associated with seafood consumption\u003c/h2\u003e\n \u003cp\u003eAmong the 8.5% (n\u0026thinsp;=\u0026thinsp;177) of respondents who reported health-related issues after seafood consumption, the most common symptoms were vomiting (n\u0026thinsp;=\u0026thinsp;63, 35.6%), diarrhea (n\u0026thinsp;=\u0026thinsp;36, 20.3%), allergy (n\u0026thinsp;=\u0026thinsp;42, 23.7%), stomach pain (n\u0026thinsp;=\u0026thinsp;22, 12.4%), and headache (n\u0026thinsp;=\u0026thinsp;14, 7.9%). The primary causes of these illnesses were classified into two categories: (i) Handling-related illnesses (47.4%, n\u0026thinsp;=\u0026thinsp;84): Attributed to spoiled or contaminated seafood (28.8%, n\u0026thinsp;=\u0026thinsp;51), improperly cleaned shellfish (7.9%, n\u0026thinsp;=\u0026thinsp;14), and consumption from street vendors or restaurants (10.2%, n\u0026thinsp;=\u0026thinsp;18), (ii) Non-handling-related illnesses (40.6%, n\u0026thinsp;=\u0026thinsp;72): From allergic reactions (29.9%, n\u0026thinsp;=\u0026thinsp;53) and histamine poisoning from oily fish (10.7%, n\u0026thinsp;=\u0026thinsp;19), and (iii) Other unidentified health-related factors (12.4%, n\u0026thinsp;=\u0026thinsp;22).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003e3.4. Food handling practices among seafood consumers of Kerala\u003c/h2\u003e\n \u003cp\u003eAmong the 2079 respondents, 8.5% (n\u0026thinsp;=\u0026thinsp;177) reported experiencing seafood-related illnesses, forming the \u0026apos;Case group,\u0026apos; while the remaining 91.5% (n\u0026thinsp;=\u0026thinsp;1902) who did not report such illnesses comprised the \u0026apos;Control group. The analysis revealed variations in food handling practices, with differences observed across illness groups. The average score for the food handling practices among respondents was 2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026lt;\u003c/strong\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cstrong\u003e\u0026gt;\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eCase group reported lower adherence to hygiene practices, such as washing hands with soap before handling raw seafood, with a mean score of 2.14 compared to the Control group\u0026rsquo;s mean score of 2.53. Additionally, a larger proportion of the Case group failed to sanitize utensils and countertops after contact with raw seafood, with 74.0% of respondents in the Case group not performing this critical step, compared to 64.3% in the Control group. Similarly, unsafe thawing practices were more common in the Case group, where 63.3% thawed frozen seafood at room temperature, compared to just 27.2% in the Control group. The higher frequency of unsafe thawing practices in the Case group was significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), contributing to an increased risk of foodborne illness. Both groups exhibited moderate scores in practices like storing raw seafood separately from cooked foods, with the Case group scoring 3.21 and the Control group scoring 4.25 on the scale. Additionally, the Case group reported moderate adherence to practices like ensuring raw seafood fluids did not drip onto other foods (mean\u0026thinsp;=\u0026thinsp;2.69) and refreezing thawed fish (mean\u0026thinsp;=\u0026thinsp;2.93). The Case group demonstrated higher adherence to safe practices like checking seafood freshness by smell, texture, and appearance, with a mean score of 4.71. Similarly, 77.4% of the Case group reported cooking seafood thoroughly until it was opaque and flaked easily, although this was still significantly lower than the Control group, where 94.7% followed this practice (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The Case group reported reheating leftover seafood more frequently, with 93.2% engaging in this practice compared to 86.1% in the Control group (p\u0026thinsp;=\u0026thinsp;0.012). Despite these safe practices, the Control group consistently exhibited higher safety scores overall. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e presents a comprehensive comparison of the seafood handling practices followed by the Case group and the Control group.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003e3.5. Comparison of food handling practices among case group and control group of seafood consumers\u003c/h2\u003e\n \u003cp\u003eThe analysis revealed significant differences between the two groups, with the Case group exhibiting riskier food handling behaviours than the Control group (Mann-Whitney U test, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Unsafe practices, including inadequate seafood storage, cross-contamination, and improper thawing, were more prevalent among those who reported foodborne illnesses. Significant differences were observed in checking seafood freshness, using separate cutting boards for different type of foods, storing raw seafood separately, and thawing seafood at room temperature (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, certain practices, such as washing hands before handling seafood and using clean plates for cooked seafood, did not show statistically significant differences between the groups. These are summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026lt;\u003c/strong\u003e Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cstrong\u003e\u0026gt;\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003e3.6. Multivariate logistic regression analysis\u003c/h2\u003e\n \u003cp\u003eThe multivariate logistic regression analysis identified significant relationships between specific food handling practices, demographic factors, and self-reported foodborne illness. Age, occupation, income, and area of residence were significant predictors of self-reported foodborne illness (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Several unsafe food handling practices increased the likelihood of illness, including failure to sanitize utensils and countertops after raw seafood contact, not using separate cutting boards for fish, meat, and vegetables, and improper storage of raw seafood in shopping bags or containers. Additionally, keeping fish and other foods on the same refrigerator shelf, inadequate cooking, and thawing frozen seafood at room temperature were significantly associated with a higher risk. Other contributing factors included leaving fish on the counter before cooking, reheating leftovers until only warm, and delaying refrigeration beyond two hours (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No significant collinearity issues were detected among the independent variables, as confirmed through preliminary linear regression analysis (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026lt;\u003c/strong\u003e Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cstrong\u003e\u0026gt;\u0026gt;\u003c/strong\u003e\u003c/p\u003e"},{"header":"4. DISCUSSION","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Incidence and distribution of seafood-borne illnesses\u003c/h2\u003e \u003cp\u003eSeafood is a staple part of the diet in the state of Kerala in India, and previous studies have reported foodborne pathogens, toxins and contamination risks associated with seafood consumption in the region. For instance, Silvester et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) reported the presence of multidrug-resistant Vibrio parahaemolyticus in shellfish from Cochin, a major seafood export hub of Kerala, underscoring the critical need for regular monitoring and intervention to prevent such pathogens from reaching consumers. Similarly, Sunitha et al. (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) identified Listeria monocytogenes and Salmonella spp. in raw seafood sourced from Wayanad, a district of Kerala known for its rich natural resources, thus highlighting the potential health risks associated to seafood consumption in the region. However, Menon et al. (2020) emphasized that adherence to good hygiene practices at fish catchment and processing areas could significantly reduce the risks associated with Listeria contamination. The study reported that the incidence of self-reported foodborne illness related to seafood consumption was 8.5%, which is lower than the outbreak-based reported by Barrett et al. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) in the United States and inconsistent with the pathogen-specific prevalence rates reported by Tanveer et al. (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) in Asia, likely due to differences in regional variations in seafood safety practices. This inconsistency could be attributable to exposure to pathogenic factors, study populations, survey administration schedules, research methodologies, and survey techniques. Nevertheless, these findings require further validation through additional research to verify these patterns and elucidate the underlying reasons.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.2. Consumer seafood handling practices at home\u003c/h2\u003e \u003cp\u003eImproper food handling practices in both domestic kitchen and commercial settings have the potential to significantly increase the risk of foodborne illnesses. This study surveyed seafood consumers in Kerala, India to explore unsafe food handling practices, which may explain the association between seafood handling practices at home and foodborne illness. Poor food-handling practices were common among seafood consumers who have encountered food borne illness with several food handling practices categorised as unsafe among seafood consumers (mean scores ranging from 0.00 to 2.00; Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These critical practices require immediate attention to mitigate the risk of seafood-borne illnesses. Mol et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) reported that 57% of participants from Turkey preferred asking retailers to clean and eviscerate fish at the time of purchase and nearly 40% always prefer to clean surfaces only at the end of day. Ozilgen. (2010) reported that more than 85% Turkish university students wash their hands with soap and water before preparing foods. Baptista et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) reported that 91.68% of Brazilian respondents of different age groups sanitize utensils used for raw seafood handling.\u003c/p\u003e \u003cp\u003eIn the survey, a significant percentage of case group (72.9%) reported avoiding the purchase of fish just before they left the market and 71.8% of the case group consumers in the study had not clean kitchen surfaces immediately. Both findings are consistent with results reported in Turkey (Mol et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), where 52.8% consumers always bought fish just before leaving the market and they mostly prefer to clean surfaces only at the end of the day. Four fifths of seafood consumers (80.2%) reported that they had not separated raw seafood from other food in their shopping bags. For instance, Godwin \u0026amp; Coppings. (2005) reported that 7% of US consumers used coolers to protect cold foods during transport, and many refrigerators were above recommended temperatures. Hicks (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) reported that effective temperature management of seafood during transport minimises bacterial growth and spoilage by maintaining quality. Over four fifths of seafood consumers (92.1%) never used separate cutting boards for fish, vegetables, or meat, which aligns with reports from Koppel et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2014\u003c/span\u003e)\u0026rsquo;s study indicating the increased risk of cross contamination during food preparation.\u003c/p\u003e \u003cp\u003eFurthermore, 83.7% of control group did not refrigerate or freeze seafood within two hours of purchase, and 61.9% refroze thawed fish. These findings are consistent with observations in Brazil (Baptista et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and Asian countries (Koppel et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Moreover, 76.8% of seafood consumers did not marinate raw seafood in the refrigerator, contrary to FDA guidelines (FDA, 2024a) that recommend marinating seafood in sealed containers at 5\u0026deg;C, further underscoring the need for improved food safety education on proper food marinating techniques in mainland (Gong et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). The study found that nearly 63.3% of consumers thawed seafood at room temperature. This risky behaviour could be mitigated by adopting a \u0026ldquo;direct-from-frozen\u0026rdquo; approach (Neff et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This involves cooking seafood without defrosting, which could reduce waste, enhance food safety, and increase convenience. Additionally, only 7.3% of participants in this study reported labelling fish with the date when freezing, underscoring the importance of accurate labelling for tracking the age of frozen seafood to ensure it is consumed safely within the safe period (Hicks, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). The findings of this study suggest that there are several key areas for improvement in food handling practices of seafood consumers in Kerala, particularly in purchasing, handwashing, surface cleaning and sanitation, marination, and storage behaviours. The literature indicates that consumer knowledge often does not align with their self-reported or observed behaviours (Marasteanu et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Redmond \u0026amp; Griffith, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2003\u003c/span\u003e), emphasizing the need for more observational research to assess food safety practices. Addressing these knowledge gaps in knowledge and behaviour through targeted education and awareness campaigns is critical for improving food safety behaviours. Consumers must be informed about the significance of adhering to proper food handling practices at home to reduce the incidence of foodborne illnesses and promote continual improvement in their food safety practices.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.3. Demographic factors, food handling practices and seafood-borne illness\u003c/h2\u003e \u003cp\u003eThe study found that demographic factors and food handling practices significantly influenced the incidence of seafood-related foodborne illness. Descriptive statistics in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e1\u003c/span\u003e indicated that older adults (59\u0026ndash;77 years) reported the highest proportion of seafood-related illness (18.7%), while younger adults aged 27\u0026ndash;42 years reported the lowest proportion (6.7%). However, multivariable logistic regression analysis \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e revealed that after adjusting for food handling practices and other demographic variables, increasing age was associated with a significantly reduced likelihood of reporting foodborne illness (OR\u0026thinsp;=\u0026thinsp;0.735; 95% CI: 0.597\u0026ndash;0.905; p\u0026thinsp;=\u0026thinsp;0.004).\u003c/p\u003e \u003cp\u003eThis contradiction between proportions and adjusted risk suggests that other confounding factors such as unsafe food handling behaviours and other socioeconomic factors may influence illness rates independently of age. Although older adults reported higher absolute rates of illness, their adjusted odds of illness were lower once these behavioural and demographic factors were accounted for. This finding may reflect the influence of safer food handling behaviours among older adults, as suggested by their higher behavioural scores in areas like hand hygiene and seafood storage. However, the data do not allow us to draw definitive conclusions about causality, and additional qualitative or longitudinal research would be needed to confirm these mechanisms. One possible explanation is that older adults, despite being biologically more vulnerable to foodborne pathogens due to diminished immune function, may compensate through more cautious and consistent food safety practices developed over a lifetime (Anderson et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Buzby, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). On the other hand, younger adults, while biologically more resilient, may engage more frequently in unsafe food handling behaviours, which increases their risk despite their lower absolute reported illness rates (Byrd-Bredbenner et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2007\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). These observations reinforce the importance of multivariable analysis in epidemiological research, as simple descriptive comparisons may vague underlying risk patterns. From a public health perspective, these results emphasize the need for targeted food safety education initiatives that particularly address unsafe food handling practices among younger populations to reduce seafood-borne illness risk.\u003c/p\u003e \u003cp\u003eFurthermore, occupation significantly (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) impacts foodborne illness incidence, with specific job sectors exhibiting greater risks. Occupations involving long hours or limited access to food safety education may lead to riskier food handling practices, contributing to increased illness rates. In the study, respondents with a higher monthly family income and those residing in urban areas face a 1.2- and 1.5- times increased risk of seafood-borne illness, respectively. Higher income levels are often associated with less time spent on food preparation, leading to greater reliance on quick, convenient cooking methods that may not always prioritise food safety. Socioeconomic status (SES) and changing demographic patterns, such as increased number of women in the workforce, often result in younger individuals preparing their own meals, which can increase the risk of foodborne illnesses. However, higher incomes generally improve access to quality food and food safety education, they also contribute to lifestyle changes that may not always support safe food handling. In many low- and middle-income countries, food safety concerns often limit the consumption of nutrient-rich foods due to hygiene concerns, even though issues of affordability and access persist (Conway et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Liguori et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Urban setting, pose additional food safety challenges due to high population density and complex food handling environments. Research from China has shown that, foodborne illnesses linked to Vibrio parahaemolyticus is more frequent in urban areas, where inadequate temperature control and poor hygiene practices further worsen the risks (Bian et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Piglowski, 2023).\u003c/p\u003e \u003cp\u003eAccording to the World Health Organization\u0026rsquo;s \"Five Keys to Safer Food\" program, critical food safety practices such as cleaning, separating, cooking, chilling, and use of safe water or raw materials (WHO, 2006) are essential in reducing the risk of foodborne illnesses. In the study consumers who evaluated seafood freshness based on sensory characteristics, such as appearance, texture, and odour, were less likely to report foodborne illnesses. The Codex Alimentarius guidelines for effective sensory evaluation recommended that fresh seafood should have clear bright eyes, firm flesh, bright red or pink gills and shiny scales, and no or an ocean odour. While discolouration of the flesh, dullness of the appearance, a foul odour or brown or faded gills indicate a loss of freshness. Hence, consumer who enhance their ability in assessing seafood freshness can significantly contribute to improved public health outcomes (Viana et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOn the other hand, consumers who purchase fish just before leaving the market face a 1.5 times increased risk of illness, showing the importance of effective temperature management during transport. Promptly refrigerating or freezing seafood within two hours of purchase is crucial for preventing pathogen growth (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), demonstrating a protective effect against foodborne illness. In contrast, not leaving the fish on kitchen counter with a plan to cook later decrease the illness risk as well (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating a protective effect against seafood borne illness. Improper temperature control practices, such as thawing seafood at room temperature, increase the risk of affecting foodborne illness by 1.4 times. Temperature abuse during purchasing and handling of seafood, such as prolonged exposure to ambient temperatures and poor purchase timings accelerates bacterial growth. However, the use of proper thawing methods, such as thawing seafood in a refrigerator or with cold water, significantly reduces the risk of seafood-borne illness compared with thawing at room temperature, which is associated with increased pathogen growth. The U.S. FDA (2024b) recommends thawing seafood in a refrigerator or using cold water to prevent rapid bacterial spread. Additionally, refreezing thawed seafood unless it has been cooked should be avoided, as it can compromise both safety and quality.\u003c/p\u003e \u003cp\u003eCross-contamination during seafood handling is a critical concern for preventing foodborne illnesses and often occurs when pathogens from raw seafood, such as Vibrio spp., Salmonella spp., and Listeria monocytogenes, are transferred to other foods through direct contact or contaminated utensils, cutting boards, and surfaces. Not sanitising utensils and countertops after handling raw seafood significantly increases the risk of seafood borne illness by 1.2 times. Public health guidelines emphasise sanitizing utensils and countertops with hot, soapy water or a dishwasher to thoroughly clean cutting boards, knives, and other tools after contact with raw seafood (FDA, 2022). Additionally, the improper use of separate cutting boards for seafood, vegetables, poultry, and meat elevates the risk by 1.4 times, which aligns with previous research identifying inadequately cleaned kitchen tools are major contributors to foodborne illnesses (De Jong et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Inadequate cleaning and sanitizing practices contribute contamination cycles, increasing the risk of food borne illness. Adherence to recommended practices, including proper hygiene, cleaning, and sanitation, is essential for reducing foodborne illnesses associated with seafood (CDC, 2024; WHO, 2006). Consumers who fail to keep raw seafood separate in shopping bag (1.2 times) and fail to store it in separate containers (1.4 times) are more likely to experience foodborne illness. Similarly, keeping raw seafood on the same shelf with other foods in the refrigerator increases the risk by 1.2 times. Placing raw fish on the lower shelf of the refrigerator can prevent potential contamination by preventing seafood juices from dripping onto ready-to-eat or cooked foods. In many households this risk is significant when various foods are stored together. Hence, proper storage practices and regular cleaning of high-contact areas in the refrigerator, such as the door handle and bottom shelf, is crucial for preventing contamination reducing the growth and spread of harmful pathogens. Neglecting these high contact areas can increase the risk of contamination and compromise food safety (Agi et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Cunningham et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study noted that not cooking seafood thoroughly until it is opaque and flakes easily with a knife or other utensils increases the risk by 1.7 times. Cooking seafood to an internal temperature above 74\u0026deg;C and reheating leftovers thoroughly is effective in eliminating pathogens. Research indicates that Vibrio species are eliminated at 55\u0026deg;C, Salmonella species at 75\u0026deg;C, and Listeria species at 85\u0026deg;C, emphasising the need for appropriate cooking temperatures tailored to different seafood species (Chintagari, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Proper cooking methods, such as preheating the pan or using controlled cooking temperatures are key approaches to ensure food safety. Additionally, perishable seafood should be consumed within 24 hours if it is stored for more than two hours after cooking. Leftover seafood must be promptly refrigerated and maintained at temperatures below 5\u0026deg;C to ensure safety. In Kerala, while consumers have a strong perception of the nutritional benefits of fish but exhibit lower awareness of specific health benefits and express concerns about fish quality, particularly in relation to transportation and the lack of freshness certification systems (Rejula et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Sajeev \u0026amp; Joshy, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Although most consumers have a moderate perception of fish safety, significant differences in safety issue perceptions highlight the need for targeted government interventions in supply chain management and quality assurance to address both real and perceived risks.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study has several limitations. First, it relies on self-reported data, which may be subject to recall bias and reporting inaccuracies. Second, the analysis focuses on seafood-borne illnesses without differentiating between specific seafood types (e.g., finfish, shellfish, mollusks, crustaceans) or conducting pathogen-specific analysis (e.g., \u003cem\u003eSalmonella\u003c/em\u003e, \u003cem\u003eVibrio\u003c/em\u003e, norovirus), limiting the granularity of risk assessment. Third, as the study was conducted in Kerala, a coastal state in India, its findings may not be generalizable to inland regions or other states with different seafood consumption patterns. Fourth, the cross-sectional study design prevents establishing causal relationships between seafood handling practices and illness, and the absence of microbiological testing restricts validation of contamination sources. Fifth, small sample sizes in certain demographic subgroups may reduce the robustness and statistical power of subgroup-specific findings. Additionally, while the study focuses on handling-related causes of seafood-borne illness, it also acknowledges other non-microbial causes such as allergic reactions and histamine poisoning\u0026mdash;particularly from oily fish consumption. These cases were not integrated into the core analysis but are recognized as important areas for future investigation. Greater differentiation between microbial contamination and biological responses would enhance risk communication and public health education. Future research should address these gaps by including pathogen detection, seafood-type differentiation, larger and more diverse samples, and longitudinal or experimental designs to strengthen causal inferences and broaden generalizability.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCONCLUSION\u003c/b\u003e \u003c/p\u003e \u003cp\u003eImproper seafood handling practices related to temperature control, kitchen hygiene, cross-contamination, and storage significantly elevate the risk of seafood-borne illness. Additionally, unsafe purchasing behaviours were important contributors to self-reported illness. Conversely, protective practices such as checking freshness, thorough cooking, prompt refrigeration, and reheating leftovers until hot were associated with reduced risk. Demographic factors, including age, occupation, income, and residence, also influenced illness risk, highlighting the need for tailored interventions. Although older adults reported higher illness proportions in raw data, regression analysis showed they were less likely to report illness when accounting for other variables\u0026mdash;underscoring the importance of multivariate approaches in public health research. The findings highlight the need for targeted consumer education on safe seafood handling, hygiene, and cross-contamination prevention. To ensure seafood safety and reduce illness, public health initiatives must be demographic-specific, supported by regulatory oversight, clear food safety communication, and robust supply chain monitoring to reduce seafood-related health risks in Kerala.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors express their gratitude to School of Industrial Fisheries, Cochin University of Science and Technology (CUSAT), and to all participants who contributed to the study in Kerala.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA.V. (Corresponding Author) led the conceptualization, methodology, data collection, data analysis, writing, review \u0026amp; editing. M.S.N. contributed to conceptualization, methodology, supervision, data analysis, review \u0026amp; editing. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that all data generated or analysed during this study are available upon request from the corresponding author. The data are not publicly available due to confidentiality concerns.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics Approval and Consent to Participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical review and approval were waived by the Ethics Committee of the School of Industrial Fisheries, Cochin University of Science and Technology (CUSAT), as the study maintained the anonymity of respondents and did not involve sensitive data. All data collection procedures followed ethical guidelines in accordance with CUSAT\u0026rsquo;s ethical standards, particularly those promoted by the Centre for Integrity in Research and Ethics (ICREP), which provides insights into the ethical rules and norms guiding academic research. Informed consent was obtained from all participants, who were informed that their responses would remain anonymous and that participation was entirely voluntary.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors consent to publish.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAgi, V. N., Aleru, C. P., \u0026amp; Uweh, E. J. (2021). 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Risky Eating Behaviors of Young Adults\u0026mdash;Implications for Food Safety Education. \u003cem\u003eJournal of the American Dietetic Association\u003c/em\u003e, \u003cem\u003e108\u003c/em\u003e(3), 549\u0026ndash;552. https://doi.org/10.1016/j.jada.2007.12.013\u003c/li\u003e\n\u003cli\u003eCenters for Disease Control and Prevention (CDC). (2024). About Four Steps to Food Safety. Food Safety. Available at: https://www.cdc.gov/food-safety/prevention/index.html#:~:text=Use%20one%20cutting%20board%20or,need%20to%20be%20washed%20first . Accessed 15.07.24.\u003c/li\u003e\n\u003cli\u003eChinain, M., Gatti, C., Darius, H., Quod, J., \u0026amp; Tester, P. (2021). Ciguatera poisonings: A global review of occurrences and trends. Harmful Algae, 102, 101873. https://doi.org/10.1016/j.hal.2020.101873 \u003c/li\u003e\n\u003cli\u003eChintagari, S. (2022). Determination of minimum safe cooking temperatures for shrimp to destroy foodborne pathogens. https://doi.org/10.31390/gradschool_theses.2035 \u003c/li\u003e\n\u003cli\u003eChoudhury, S., Medina-Lara, A., Daniel, N., \u0026amp; Smith, R. (2022). Seafood safety: A need for greater awareness. Journal of public health research, 11(3), 22799036221124058. https://doi.org/10.1177/22799036221124058\u003c/li\u003e\n\u003cli\u003eConway, A., Ehuwa, O., Manning, M., Maye, A., Moran, F., Jaiswal, A. K., \u0026amp; Jaiswal, S. (2023). Evaluation of irish consumers\u0026apos; knowledge of salmonellosis and food-handling practices. Journal fur Verbraucherschutz und Lebensmittelsicherheit = Journal of consumer protection and food safety, 18(1), 43\u0026ndash;55. https://doi.org/10.1007/s00003-022-01405-w \u003c/li\u003e\n\u003cli\u003eCunningham, B., O\u0026rsquo;Neill, V., Devereux, M., McGann, D., \u0026amp; O\u0026rsquo;Hora, J. (2022). Use of a door handle disinfection system to reduce the risks associated with microbial loads on fomites in a healthcare setting. Journal of Hospital Infection, 130, 104\u0026ndash;107. https://doi.org/10.1016/j.jhin.2022.09.003 \u003c/li\u003e\n\u003cli\u003eDe Jong, A., Verhoeff-Bakkenes, L., Nauta, M., \u0026amp; De Jonge, R. (2008). Cross-contamination in the kitchen: effect of hygiene measures. Journal of Applied Microbiology, 105(2), 615\u0026ndash;624. https://doi.org/10.1111/j.1365-2672.2008.03778.x \u003c/li\u003e\n\u003cli\u003eFleming, L. E., Katz, D., Bean, J. A., \u0026amp; Hammond, R. (2018). Epidemiology of Seafood Poisoning. 287\u0026ndash;310. https://doi.org/10.1201/9781351072113-9 \u003c/li\u003e\n\u003cli\u003eGodwin, S. L., \u0026amp; Coppings, R. (2005). Analysis of Consumer Food-Handling Practices from Grocer to Home Including Transport and Storage of Selected Foods. 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Food safety at home: knowledge and practices of consumers. Zeitschrift F\u0026uuml;r Gesundheitswissenschaften/Journal of Public Health, 20(1), 47\u0026ndash;57. https://doi.org/10.1007/s10389-011-0437-z \u003c/li\u003e\n\u003cli\u003eLiguori, J., Tr\u0026uuml;bswasser, U., Pradeilles, R., Port, A. L., Landais, E., Talsma, E., Lundy, M., B\u0026eacute;n\u0026eacute;, C., Bricas, N., Laar, A., Amiot, M., Brouwer, I., \u0026amp; Holdsworth, M. (2022). How do food safety concerns affect consumer behaviours and diets in low- and middle-income countries? A systematic review. Global Food Security, 32, 100606. https://doi.org/10.1016/j.gfs.2021.100606 \u003c/li\u003e\n\u003cli\u003eLupo, C., \u0026amp; Angot, J. (2020). Probl\u0026egrave;mes de sant\u0026eacute; publique li\u0026eacute;s \u0026agrave; la consommation de fruits de mer. Bulletin De L Acad\u0026eacute;mie Nationale De M\u0026eacute;decine, 204(9), 1017\u0026ndash;1033. https://doi.org/10.1016/j.banm.2020.10.001 \u003c/li\u003e\n\u003cli\u003eMarasteanu, I., Liggans, G., Otto, J., \u0026amp; Lasher, A. (2018). Advancing retail food policy debates: Estimating the risk of contaminated servings of food attributed to employee food handling practices in retail food establishments. Journal of Food Protection, 81(12), 2034\u0026ndash;2039. https://doi.org/10.4315/0362-028x.jfp-18-251 \u003c/li\u003e\n\u003cli\u003eMcKnight, P. E., \u0026amp; Najab, J. (2010). Mann‐Whitney U test. The Corsini Encyclopedia of Psychology, 1. https://doi.org/10.1002/9780470479216.corpsy0524 \u003c/li\u003e\n\u003cli\u003eMenon, K. V., Sunil, B., \u0026amp; Latha, C. (2021). Prevalence and antibiotic resistance profile of Listeria spp. associated with seafoods from fish catchment areas in Kerala, India. Veterinary World/Veterinary World, 14(3), 777\u0026ndash;783. https://doi.org/10.14202/vetworld.2021.777-783 \u003c/li\u003e\n\u003cli\u003eMol, S., Akay, K. U., \u0026amp; Guney, G. \u0026Ccedil;. (2018). Seafood safety at home: Knowledge and practices. International Journal of Gastronomy and Food Science, 13, 95\u0026ndash;100. https://doi.org/10.1016/j.ijgfs.2018.07.003 \u003c/li\u003e\n\u003cli\u003eNeff, R. A., Love, D. C., Overbey, K., Biehl, E., Deutsch, J., Gorski-Steiner, I., Pearson, P., Vigil, T., Turvey, C., \u0026amp; Fry, J. P. (2021). Consumer seafood waste and the potential of a \u0026lsquo;Direct-from-Frozen\u0026rsquo; approach to prevention. Foods, 10(11), 2524. https://doi.org/10.3390/foods10112524 \u003c/li\u003e\n\u003cli\u003eOzilgen, S. (2010). Food safety education makes the difference: food safety perceptions, knowledge, attitudes and practices among Turkish university students. Journal F\u0026uuml;r Verbraucherschutz Und Lebensmittelsicherheit, 6(1), 25\u0026ndash;34. https://doi.org/10.1007/s00003-010-0593-z \u003c/li\u003e\n\u003cli\u003ePigłowski, M. (2023). Hazards in seafood notified in the Rapid Alert System for Food and Feed (RASFF) in 1996\u0026ndash;2020. Water, 15(3), 548. https://doi.org/10.3390/w15030548 \u003c/li\u003e\n\u003cli\u003eRedmond, E. C., \u0026amp; Griffith, C. J. (2003). Consumer Food Handling in the Home: A Review of Food Safety studies. Journal of Food Protection, 66(1), 130\u0026ndash;161. https://doi.org/10.4315/0362-028x-66.1.130 \u003c/li\u003e\n\u003cli\u003eRejula, K., Sajeev, M.V., Mohanty, A.K (2021). Health Benefits, quality and Safety of fish in Kerala: Consumer perception and implications for extension system. Indian Journal of Extension Education, 57(03). https://doi.org/10.48165/ijee.2021.57301 \u003c/li\u003e\n\u003cli\u003eSajeev, M. V., \u0026amp; Joshy, C. G. (2024). Exploring perceptions and health awareness in fish consumption across coastal and inland Kerala. Indian Journal of Extension Education, 60(1), 100\u0026ndash;104. https://doi.org/10.48165/ijee.2024.60119 \u003c/li\u003e\n\u003cli\u003eSilvester, R., Saji, A., Divakaran, A. R., Dilshana, P., Nair, R., Hatha, M., \u0026amp; Harikrishnan, M. (2022). Increased incidence and antimicrobial resistance among Vibrio parahaemolyticus in shellfishes from major fish markets in Cochin, South India: Seafood risk assessment. Annals of Animal Science, 22(3), 1105\u0026ndash;1114. https://doi.org/10.2478/aoas-2021-0077 \u003c/li\u003e\n\u003cli\u003eSunitha, R., Prejit, N., Vinod, V., Suni, B., Ash, K., Vergis, J., \u0026amp; Mathews, E. B. (2017). Occurrence of Listeria monocytogenes and Salmonella spp. in Seafood Collected from Wayanad, Kerala. Journal of Immunology and Immunopathology/Journal of Immunology and Immunopathology, 19(2), 97. https://doi.org/10.5958/0973-9149.2017.00014.4 \u003c/li\u003e\n\u003cli\u003eTanveer, M., Ntakiyisumba, E., \u0026amp; Won, G. (2024). Prevalence and risk factors for seafood-borne Vibrio vulnificus in Asia: a systematic review with meta-analysis and meta-regression. Frontiers in Microbiology, 15. https://doi.org/10.3389/fmicb.2024.1363560 \u003c/li\u003e\n\u003cli\u003eU.S. Food and Drug Administration. (2022). Food Safety Education Month: Preventing Cross-Contamination | Food Safety and Inspection Service. Available at: https://www.fsis.usda.gov/news-events/events-meetings/food-safety-education-month-preventing-cross-contamination. Accessed 15.07.24.\u003c/li\u003e\n\u003cli\u003eU.S. Food and Drug Administration. (2024a). Refrigerator Thermometers - Cold Facts about Food Safety. Available at: https://www.fda.gov/food/buy-store-serve-safe-food/refrigerator-thermometers-cold-facts-about-food-safety#:~:text=Marinated%20Foods%3A%20Always%20keep%20food,to%20a%20rapid%20boil%20first. Accessed 15.07.24.\u003c/li\u003e\n\u003cli\u003eU.S. Food and Drug Administration. (2024b). Safe Food Handling. Available at: https://www.fda.gov/food/buy-store-serve-safe-food/safe-food-handling. Accessed 15.07.24\u003c/li\u003e\n\u003cli\u003eViana, F. M., Monteiro, M. L. G., Ferrari, R. G., Mutz, Y. S., Martins, I. B. A., Salim, A. P. a. A., De Alcantara, M., Deliza, R., Mano, S. B., \u0026amp; Conte-Junior, C. A. (2022). Multivariate nature of fish freshness evaluation by consumers. Foods, 11(14), 2144. https://doi.org/10.3390/foods11142144 \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. (2006). Five keys to safer food manual. World Health Organization.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. (2015). WHO\u0026rsquo;s first ever global estimates of foodborne diseases find children under 5 account for almost one third of deaths. Available at: https://www.who.int/news/item/03-12-2015-who-s-first-ever-global-estimates-of-foodborne-diseases-find-children-under-5-account-for-almost-one-third-of-deaths. Accessed 15.07.24\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cem\u003eDemographic characteristics and unadjusted incidence of self-reported seafood-related illness among respondents (N\u0026thinsp;=\u0026thinsp;2,079)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eDemographic characteristics\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eTotal respondents (N)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eProportion of ill in category\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e(n\u0026thinsp;=\u0026thinsp;177)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (segments)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u0026ndash;26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e683\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27\u0026ndash;42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e687\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43\u0026ndash;58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e458\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59\u0026ndash;77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e251\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e18.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.080\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e962\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e9.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e342\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDegree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e688\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMasters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e541\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhD/ equivalent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e508\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e11.6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOccupation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGovernment servant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate employee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBusiness/ self employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e778\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e253\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e25.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMonthly family income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;20000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e327\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20001\u0026ndash;40000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e498\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e12.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40001\u0026ndash;60000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e578\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60001\u0026ndash;80000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e474\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80001\u0026lt;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e202\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArea of residence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e698\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e10.9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuburban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e884\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e497\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrincipal seafood purchaser\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e11.6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e941\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrincipal seafood preparer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e912\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e10.2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1167\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePurchase frequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e474\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlternately\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e889\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeekly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e716\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e10.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003eProportions represent the percentage of respondents within each demographic category who reported experiencing seafood\u0026minus;related illness. These are unadjusted rates. See Table 4 for adjusted associations\u003c/sup\u003e.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFood handling practices among seafood consumers of Kerala based on self-reported incidence of seafood-borne illness.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eFood handling practices\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eRespondents\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eNever\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eRarely\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eSome\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003etimes\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eOften\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eAlways\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"9\"\u003e\n \u003cp\u003e\u003cem\u003eUse Safe Water and Raw Materials\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI check seafood freshness by examining smell, texture, and appearance when purchasing.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.925\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.717\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI ask the retailer to clean/eviscerate the fish when buying\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.565\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.208\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"9\"\u003e\n \u003cp\u003e\u003cstrong\u003eKeep Clean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI wash my hands with soap before handling raw seafood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.623\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.428\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.97\u0026thinsp;\u0026plusmn;\u0026thinsp;1.378\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI clean kitchen surfaces immediately, not just at the end of the day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.79\u0026thinsp;\u0026plusmn;\u0026thinsp;1.401\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.924\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI don\u0026rsquo;t sanitize utensils and counter tops with hot, soapy water after contact with raw seafood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.577\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.009*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e64.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1.757\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"9\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeparate Raw and Cooked\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI don\u0026rsquo;t use separate cutting boards for fish, meat, and vegetables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.29\u0026thinsp;\u0026plusmn;\u0026thinsp;1.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.45\u0026thinsp;\u0026plusmn;\u0026thinsp;1.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI use clean plates and utensils for cooked seafood, not the same ones used for raw seafood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.49\u0026thinsp;\u0026plusmn;\u0026thinsp;1.271\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.913\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.61\u0026thinsp;\u0026plusmn;\u0026thinsp;1.043\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI don\u0026rsquo;t keep raw seafood separate from other foods in my shopping bag\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.66\u0026thinsp;\u0026plusmn;\u0026thinsp;1.437\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.764\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI don\u0026rsquo;t store raw seafood in separate containers or zip-lock bags from cooked or ready-to-eat foods\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.21\u0026thinsp;\u0026plusmn;\u0026thinsp;1.912\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.234\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI ensure raw seafood fluids do not drip onto other foods in the shopping bag and refrigerator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.898\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.006*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.913\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI keep fish and other foods on the same shelf in the fridge or freezer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.971\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.89\u0026thinsp;\u0026plusmn;\u0026thinsp;1.742\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"9\"\u003e\n \u003cp\u003e\u003cstrong\u003eCook Thoroughly\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI don\u0026rsquo;t cook seafood thoroughly until it is opaque and flakes easily.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.58\u0026thinsp;\u0026plusmn;\u0026thinsp;0.951\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.90\u0026thinsp;\u0026plusmn;\u0026thinsp;0.490\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI reheat leftover seafood until it is warm or hot before eating.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.796\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.012*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.701\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"9\"\u003e\n \u003cp\u003e\u003cstrong\u003eKeep Food at Safe Temperatures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI buy fish just before leaving the market.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.71\u0026thinsp;\u0026plusmn;\u0026thinsp;1.290\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.94\u0026thinsp;\u0026plusmn;\u0026thinsp;1.344\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI promptly refrigerate or freeze seafood within two hours of purchase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.282\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.861\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI thaw frozen seafood at room temperature; not using cold running water.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.18\u0026thinsp;\u0026plusmn;\u0026thinsp;1.676\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.723\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI refreeze thawed fish unless it has been cooked\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.970\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1.742\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI don\u0026rsquo;t leave fish on the counter if I plan to cook it later the same day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1.330\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.784\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI marinate seafood in the refrigerator, not at room temperature\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.57\u0026thinsp;\u0026plusmn;\u0026thinsp;1.219\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.255\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.939\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eI label the fish with the date when I put it in the freezer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.173\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.389\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u0026thinsp;\u0026plusmn;\u0026thinsp;1.040\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003eMean score categorization: Unsafe handling (0.00\u0026ndash;2.00), moderate handling practice (2.05\u0026ndash;3.5 cm) and safe handling (3.55-5.00 cm)\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003ep: p value determined using Mann-Whitney U test.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of seafood handling practices between case and control groups\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eFood handling practice\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eMean rank\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eMann-Whitney u\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eCase group\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eControl group\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI check the freshness of seafood by examining its smell, texture, and appearance during purchasing.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1314.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1014.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e119812.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-7.348\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhen i buy fish from market or stalls, i ask the retailer to eviscerate it.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1266.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1018.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e128290.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-6.179\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI buy fish just before leaving the market\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e908.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1052.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e145122.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-3.411\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI wash my hands with soap before handling raw seafood.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1070.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1037.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e162916.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.792\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.428\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI clean kitchen surfaces only at the end of day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1194.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1025.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e140940.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-5.955\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI clean and sanitize utensils and counter tops with hot, soapy water they come into contact with raw seafood.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e945.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1048.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e151589.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-2.607\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI keep raw seafood separate from other foods in my shopping bag.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e830.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1059.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e131232.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-5.527\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI use separate cutting board for fish, meat and vegetables cutting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e907.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1052.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e144943.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-4.248\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI store raw seafood in separate containers or zip-top bags from cooked or ready-to-eat foods.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e804.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1061.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e126710.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-6.209\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI ensure raw seafood juices do not drip onto other foods in the shopping bag and refrigerator.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e932.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1049.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e149368.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-2.740\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI use clean plates and utensils for cooked seafood, not the same ones used for raw seafood.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1036.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1040.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e167771.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.913\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI cook seafood thoroughly until it is opaque and flakes easily with a knife or other utensil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e875.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1055.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e139267.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-8.729\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI reheat leftover seafood until it is warm or hot before eating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e110.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1034.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e157064.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-2.503\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI leave fish on the counter if i plan to cook it later that same day.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1168.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1028.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e145506.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-4.273\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI marinate seafood in the refrigerator and not at room temperature.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1000.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1043.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e161397.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.255\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI refrigerate or freeze seafood within two hours of purchase.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1094.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1034.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e158682.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.944\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI don\u0026rsquo;t keep fish and other foods on the same shelf in the fridge or freezer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e793.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1062.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e124696.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-6.756\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI mark the date on the fish that I put in the freezer.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1064.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1037.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e163904.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.861\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.389\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI thaw frozen seafood in the refrigerator or under cold running water, not at room temperature\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e663.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1075.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e101679.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-9.322\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIf thawed fish is not used completely, i refreeze it.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e829.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1059.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e131063.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-5.675\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eCase group (n\u0026thinsp;=\u0026thinsp;177)\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eControl group (n\u0026thinsp;=\u0026thinsp;1902)\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u0026lt;\u0026thinsp;0.01\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003ctable id=\"Tab3\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMultivariable logistic regression analysis of factors associated with self-reported seafood-related illness\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDemographic factors and seafood handling practice\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOdds ratio (95% CI) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1. Age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.004*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.735 (0.597\u0026ndash;0.905)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2. Occupation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.734 (0.640\u0026ndash;0.841)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3. Monthly income (family)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.283 (1.103\u0026ndash;1.492)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4. Area of residence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.002**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.505 (1.165\u0026ndash;1.945)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5. Check freshness by sensory evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.616 (0.475-0.800)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6. Don\u0026rsquo;t sanitize utensils and countertops after raw seafood contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.015*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.210 (1.037\u0026ndash;1.411)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7. Don\u0026rsquo;t use separate cutting boards for fish, meat, and vegetables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.035*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.487 (1.029\u0026ndash;2.150)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8. Don\u0026rsquo;t Keep raw seafood separate in shopping bag\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.042*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.200 (1.007\u0026ndash;1.429)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9. Don\u0026rsquo;t store raw seafood in separate containers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.480 (1.281\u0026ndash;1.709)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10. Keep fish and other foods on the same shelf in fridge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.006*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.294 (1.078\u0026ndash;1.553)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11. Don\u0026rsquo;t cook seafood thoroughly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.003*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.729 (1.206\u0026ndash;2.477)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12. Reheat leftovers until warm or hot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.023*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.662 (0.464\u0026ndash;0.945)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13. Buy fish just before leaving market\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.576 (1.312\u0026ndash;1.893)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14. Promptly refrigerate or freeze seafood within two hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.555 (0.448\u0026ndash;0.688)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15. Thaw frozen seafood at room temperature\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.413 (1.200-1.664)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16. Don\u0026rsquo;t leave Fish on Counter (Plan to Cook Later)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.424 (0.330\u0026ndash;0.545)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\u003csup\u003ea\u003c/sup\u003e \u003csub\u003eP\u0026minus;values from multivariable logistic regression model\u003c/sub\u003e.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\u003csup\u003eb\u003c/sup\u003e \u003csub\u003eOdds Ratios (OR) with 95% Confidence Intervals (CI) reflect the likelihood of reporting seafood\u0026minus;related illness based on demographic characteristics and food handling practices. An OR \u0026gt; 1 indicates higher risk; OR \u0026lt; 1 indicates protective factors\u003c/sub\u003e.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Food Safety, Foodborne Illness, Handling Practice, Seafood Consumption, India","lastPublishedDoi":"10.21203/rs.3.rs-6813639/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6813639/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eImproper food handling practices in the supply chain significantly contribute to foodborne illnesses. As global concerns about food safety intensify, understanding domestic food handling practices and raising consumer awareness is essential. This study examines the association between self-reported foodborne illness and seafood handling practices among consumers across Kerala, India. A cross-sectional survey was conducted using an online questionnaire from March to December 2023, involving 2,079 seafood consumers. Of the respondents, 8.5% (n\u0026thinsp;=\u0026thinsp;177) reported experiencing a seafood-related foodborne illness. Consumers who reported illness (case group) demonstrated significantly lower adherence to safe seafood handling practices compared to those who did not (control group). Multivariate logistic regression identified several demographic and behavioural predictors of illness. Key demographic factors significantly associated with increased illness risk included younger age, occupation, income, and area of residence. Unsafe practices\u0026mdash;such as improper seafood purchasing and storage, inadequate kitchen hygiene, cross-contamination, and insufficient temperature control\u0026mdash;were linked to higher illness risk. In contrast, protective behaviours, including checking freshness, thorough cooking, reheating, and prompt refrigeration, significantly reduced risk. Although raw data showed a higher proportion of illness among older adults, regression analysis revealed that increasing age was associated with a reduced likelihood of reporting illness, highlighting the importance of accounting for confounding variables in food safety research. These findings emphasize the need for targeted consumer education that addresses kitchen hygiene, cross-contamination prevention, and safe storage practices. Demographic-specific public health initiatives, consistent supply chain monitoring, and effective regulatory oversight are essential to mitigating seafood-related illness risks.\u003c/p\u003e","manuscriptTitle":"Food Safety Practices as Determinants of Self-Reported Foodborne Illness Among Seafood Consumers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-01 16:14:37","doi":"10.21203/rs.3.rs-6813639/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a1264d5e-df45-4626-bae6-0ea5a0574071","owner":[],"postedDate":"July 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-18T11:24:22+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-01 16:14:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6813639","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6813639","identity":"rs-6813639","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}