Download A Review of the Role of Clothing and Household Linens

A Review of the Role of Clothing and Household Linens in the Spread of Community-based S. aureus (including MRSA) Infections
E.Scott, Simmons College, Boston MA & International Forum on Home Hygiene
S.F. Bloomfield, London School of Hygiene and Tropical Medicine, UK & International Forum on Home Hygiene
Abstract
A review of the literature1 indicates that clothing and household linens
play a significant role in the spread of infectious diseases in the home
and everyday settings during normal activities. Sources of evidence
included field studies assessing microbial contamination on clothing,
survival studies, cross-contamination during laundering and outbreak
studies. The data suggest that the greatest risks occur immediately after
contact with, or shedding from an infected source. Although the risks
decrease as numbers of viable units steadily declines, indications are that
pathogens can persist on the surfaces of fabrics from hours (viruses or
Gram negative bacteria), to days or weeks for desiccation-resistant
strains such as S. aureus, C. difficile or fungal spores. Transmission via
clothing and household linen may play a role in the spread of S. aureus
(including MRSA) infections. Effective laundering is important is
preventing the spread of S. aureus and MRSA in household/community
settings. The findings of this review suggest that clothing and household
linens which come into direct contact with the body, together with
uniforms of healthcare workers should be routinely laundered in a
manner which renders them not only visibly but also hygienically clean.
This information should be used to inform household laundry practice.
Evidence for Transmission via
Clothing and Household Linens
HANDS
 19 published studies were identified where transmission via clothing and linens
was identified as a likely cause, or was identified as a significant risk factor.
These involved viral, bacterial and fungal infections, and included gastrointestinal
and respiratory tract, together with skin and wound infections.
HAND CONTACT
SURFACES
FOOD CONTACT
SURFACES
CLOTHING AND HOUSEHOLD LINENS
CLEANING
CLOTHS & OTHER
CLEANING
UTENSILS
Figure 2: Routes of Transmission of Infection Involving
Clothing and Household Linens
SKIN
Introduction
Evidence suggest that although the risks associated with clothing and
household fabrics is less than that associated with hands and high
frequency contact surfaces, it is still significant.
Clothing and household linens
(sheets, pillows and towels
etc) have the potential to act
as vehicles for infection
spread in home and everyday
settings. The potential routes
of spread are shown in Fig 2.
Additional points where
clothing etc can spread
infection are:
1. Where contaminated items
are handled before and
during laundering.
2. If the laundry process fails
to eliminate contamination,
there can be cross
contamination to other
items in the laundry load.
CLOTHING &
HOUSEHOLD
LINENS
PEOPLE
DOMESTIC
ANIMALS
SURFACES
HANDS
Case and carrier
control study of
communityassociated MRSA
skin and soft tissue
infection (SSTI)
outbreak in a college
football team.
Sharing bars of soap and having pre-existing cuts
Nguyen
or abrasions were associated with infection. A
et al 20053
carrier-control study found that having a locker near
a teammate with an SSTI, sharing towels, and living
on campus were associated with nasal carriage.
Case control study of
55 cases of MRSA in
a US prison
Risk for MRSA infection increased with lower
Turabelidze
frequency of hand washing per day and showers
et al 20064
per week. Patients were also less likely than
controls to wash personal items (80.0% vs. 88.8%)
or bed linens (26.7% vs. 52.5%) themselves instead
of using the prison laundry.
MOUTH
FOOD
CLOTHING
ETC. DURING
LAUNDERING
 Laundry processes should be able to deliver hygienically clean fabrics with
minimum use of water, power and chemicals.
 To achieve this, laundry equipment and products should be clearly labeled so
that consumers can understand whether, and under what laundering conditions,
the laundry process can be expected to produce fabrics which are “hygienically”
as well as visibly clean
Table 1: Recent Studies Indicating Transmission of
S. aureus/MRSA Involving Clothing and Linens in the Community
TOILETS, BATHS, SINKS,
WASH BASINS, ETC.
HANDS
 Hygiene measures must themselves be sustainable9.
 Examples of recent reports involving S. aureus/MRSA are shown in Table 1.
FLOORS, WALLS, FURNITURE, ETC.
FOOD
Within the home, the control points of infection transmission include the
hands, cleaning utensils, hand contact surfaces , clothing and household
fabrics (Fig 1).
Sustainability
Figure 1: Ranking of Sites and Surfaces in the Home Based
on Risk of Transmission of Infections
EYES & NOSE
S. aureus and CA-MRSA on Clothing and Other Fabrics
 Evidence suggests that S. aureus and CA-MRSA are transmissible in
households2 as well as in settings such as prisons, schools and sport teams3-5.
Skin-to-skin contact and indirect contact with contaminated objects including
fabrics such as towels, sheets and sports equipment seem to represent the
mode of transmission.
Recommended Household Laundry Guidelines
for Higher Risk Situations10
Wash at 60°C or higher, using an oxygen bleach-based laundry product and
following manufacturer’s instructions when:
 There is a community-based infection/shedding or immuno-compromised
individual in the home
 Uniforms/scrubs of healthcare workers are laundered at home
 Clothing is heavily soiled e.g. with feces or vomit (including cotton diapers)
 Washing sports clothing, particularly for high-contact sports such as football, judo,
wrestling, etc.
 Washing cloths and towels used in the kitchen during food preparation.
References
Intervention study to
manage outbreak of
MRSA skin infections
in a US county jail.
64 total cases and 19
MRSA cases
Intervention involved antibacterial soap dispensers,
2x daily showering, sharing of personal hygiene
items such as towels discouraged, showers
cleaned 2x weekly, tables cleaned with bleach after
meals, staff received personal hygiene education,
inmates with skin infections were cohorted, faulty
thermostats and other aspects of laundry process
corrected. Laundry was the first area where
changes were implemented. This resulted in a
prompt decline of skin infections even before other
measures could be implemented.
Elias
et al 20105
Survival of Transfer of S. aureus on
Clothing and Household Linens
Laundering Healthcare Scrubs at Home

1. The infection risks associated with clothing and household linens in home and everyday life settings, and the role of
laundry. IFH 2011. http://www.ifhhomehygiene.org/IntegratedCRD.nsf/f5236e2da2822fef8025750b000dc985/
d0e3b0f361079f1780257865003d43b1?OpenDocument&Highlight=0,laundry

2. Kundsin RB. Staphylococcal disease in the home. Clinical Medicine 1966;3:27-9

3. Nguyen et al. Recurring methicillin-resistant Staphylococcus aureus infections in a football team.Emerging Infectious
Diseases 2005;11:526-32.

4. Turabelidze et al. Personal hygiene and methicillin-resistant Staphylococcus aureus infection. Emerging Infectious
Diseases 2006;12:422-7.

5. Elias et al. Community-based intervention to manage an outbreak of MRSA skin infections in a county jail. J
Correctional Health Care. 2010 ; 16(3):205-15.

6. Marples et al. A laboratory model for the investigation of contact transfer of micro-organisms. Journal of Hygiene
1979;82:237–48

7. Mackintosh et al. An extended model for transfer of micro-organisms via the hands: differences between organisms
and the effect of alcohol disinfection. Journal of Hygiene 1984;92:345–55.

8. Sattar et al. Transfer of bacteria from fabrics to hands: development and application of a quantitative method using
Staphylococcus aureus as a model. Journal of Applied Microbiology 2001;90:962-70

9. Preventing the spread of infectious diseases in the European Union - targeted hygiene as a framework for sustainable
hygiene. IFH 2010. http://www.ifh-homehygiene.org/IntegratedCRD.nsf/f5236e2da2822fef8025750b000dc985/
62812e8ac19247fe802576c60054693f?OpenDocument&Highlight=0,sustainability
 Numbers of viable units decline at a more or less rapid rate on dry clothing etc,
depending on the species and other factors such as RH but Gram positive spp.
such as S. aureus, C. difficile and fungal spp. can survive long periods (several
days to months) on fabrics.
 UK study: 31% of nurses did not use the hospital laundry10
 US survey of nursing staff indicated that 26% home-laundered their scrubs10

10. Clothing, household linens, laundry and home hygiene. IFH 2012. http://www.ifh-homehygiene.org/IntegratedCRD.nsf/
f5236e2da2822fef8025750b000dc985/5af36a2c5698f561802575240056f120?OpenDocument&Highlight=0,laundry
 Transfer rates from moist fabrics are of the order of 1-10%, but in some cases
transfer was as little as 0.1% or less, or as high as 50%. A key factor which
affects transfer is whether the contaminated fabric is moist or dry; laboratory
models6-8 indicate that the number of organisms transferred is significantly less
(up to 10 fold decrease) if donor fabric or hands are dry.
 Domestic low temperature (<60C) quick wash cycles (<10mins) & lack of
detergent can result in failure to eliminate MRSA and Acinetobacter baumannii
from clothing and may also result in cross-contamination/colonization in the
washing machine11

11. Lakdawala et al 2011. Effectiveness of Low-Temperature Domestic Laundry on the Decontamination of Healthcare
Workers’ Uniforms. Infection Control and Hospital Epidemiology. 2011; 32(11):1103-1108. Published by: The University of
Chicago Press