Clothing, household linens, laundry and home hygiene

This fact sheet has been put together to provide background information and
practical advice on what to do about the risk of spread of infection via clothing and
household linens. This fact sheet has been produced for healthcare professionals,
community workers and the media, and others who are looking for background
understanding about infection risks associated with domestic laundry and/or are
responsible for providing guidance to the public on how to launder clothing and
household linens

Clothing, household linens and items such as cleaning cloths, like the any other
surface in the home, can become contaminated with potentially harmful microbes
(bacteria, viruses and fungi) during normal daily wear or use.1 Although infection risks
for clothing and household linens may be less than those associated with hands or
other common hand touch surfaces, nevertheless these risks need to be
appropriately managed in accordance with the level of risk. As well as making
clothing etc visibly clean, home laundering should also be able to both:
 Reduce the risk of transmission of infectious illnesses amongst family
members
 Reduce the “silent” spread of antibiotic resistant strains such as MRSA
(resident skin carriers), or multidrug resistant Gram negative species (e.g.
NDM-1, ESBL-producing strains which may be carried e.g within the bowel
flora) amongst healthy family members

Activities or situations where clothing and household linens can spread microbes
such that family members may become colonised or infected include:
 During wear, or use of items such as underwear. socks, bedlinens, towels etc
which are contaminated with potentially harmful or antibiotic resistant strains
 When infected family members share items such as towels with other family
members during normal daily activities.
 When members of sports teams share items such as towels
 Where contaminated and non-contaminated items are included in the same
laundry cycle, contamination can pass from contaminated to uncontaminated
items
 When contaminated clothing is handled before laundering or when inadequately
laundered items are transferred/handled from the washer
 If there is a build up of microbes in the washing machine (e.g build up of biofilms)
these may be deposited on the clothing etc during laundering
 If the laundry process fails to fully remove contamination and laundry remains
damp for a period, there is the chance for growth of residual micro-organisms.
Reducing spread of germs between family members

In the home, the major sources of microbes which need to be controlled through
good hygiene practices are infected or colonised family members, domestic pets and
food (mainly raw food).

Infectious agents that have the potential to spread via clothing and other fabric items,
including cleaning cloths, include enteric bacteria such as Salmonella, Shigella,
Campylobacter, E. coli (including E. coli O157 and O104) and C. difficile, and enteric
viral strains such as norovirus, rotavirus, adenovirus and astrovirus. It also includes
respiratory (cold and flu) viruses such as rhinovirus and respiratory syncytial virus.
Risks from skin pathogens are mainly associated with Staphylococcus aureus
(including meticillin resistant S. aureus, MRSA), yeasts (such as Candida albicans)
together with dermatophyte fungal strains such as Trichophyton rubrum (responsible
for athletes foot), and viral strains such as herpes. In developed countries T. rubrum
accounts for 70% of all dermatophytoses (including athlete’s foot) in humans and can
be transmitted via socks.

Clothing and household linens such as towels, sheets etc that are most likely to
become contaminated with pathogens from family members are those which come
into direct contact with the body e.g. underwear, personal towels, bedlinen,
facecloths, nappies. “Outer” clothing i.e. clothing not in direct contact with the body, is
less likely to be a risk unless it becomes contaminated by e.g. vomit or faeces. Micro-
organisms can be transferred from one family member to another, where family
members share towels, for example.

Other “fabric items” which can spread germs around the home are cleaning cloths,
dishcloths and tea towels. These, together with hands, and hand and food contact
surfaces are considered by IFH to be the “high risk” routes for transmission of
microbes in the home.2 Cloths which are used during food preparation, or are used to
clean the toilet or areas around the toilet are a particular risk as are cloths used to
clean up material such as faeces or vomit, or surfaces associated with domestic
animals. These items should ideally be decontaminated after each session of use,
either by laundering or by other suitable means. For more information consult the
IFH information and hygiene advice sheet “Look after the cleaning cloths in your
home – and they will look after you”.

How big is the risk for clothing and household linens?

From an analysis of the microbiological and epidemiological data, IFH has concluded
that clothing and household linens etc are a risk factor for transmission of infection in
home and everyday life settings during normal daily activities, although the lack of
quantitative data directly linking contaminated clothing to infection in the domestic
setting makes it difficult to assess the extent of the risk.1

Although the microbiological data indicates that the “normal daily life” risks from
clothing and household linens are somewhat less than those associated with hands,
hand contact and food contact surfaces, and cleaning cloths which are seen as the
key routes of transmission in the home, nevertheless it is concluded that these risks
needs to be appropriately managed through effective laundering practices.

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These conclusions are drawn from an IFH review 1 of data showing how pathogens
(or strains which may spread antibiotic resistance determinants) are transferred to
clothing etc from a variety of sources during normal daily life, and the extent to which
they can survive and spread from contaminated fabrics to hands and surfaces, such
that we can become exposed to potentially infectious doses. The review also
identified some 18 observational studies of cases, outbreaks of infection and self-
reported infections in which clothing, etc was identified as a likely source of infection
transmission. The most direct evidence of a link between inadequate domestic and
community laundering and infection comes from a study of New York households
which showed that, out of a wide range of hygiene practices studied, 2 specific
“targeted” laundry practices, using a communal laundry and not using bleach in
communal laundering, were associated with increased infection risk, whereas for all
other cleaning practices which were assessed there was no evidence of association
with infection risk.3 A further study showed that using hot water and using bleach for
laundering was protective against infection.

It is important to recognise that infection risks associated with contaminated clothing

etc are not constant, and can increase significantly under certain conditions. e.g. in
healthcare situations. Risks of transmission via clothing etc are likely to increase in
situations where a family member has diarrhoea or vomiting, or a skin or wound
infection. It also increases in circumstances where a family member has reduced
immunity to infection. People with reduced immunity now make up an increasing
proportion of the population, currently up to 20%. 4 The largest proportion is the
elderly, many of whom have chronic ill health with associated with increased
vulnerability to infection. In situations of increased risk the approach to hygiene is
the same as for “normal” family members, the difference being that, if effective
procedures are not used and/or these procedures are not rigorously applied there is
higher infection risk.

In view of the current level of public health concern about infection risks associated
with home and everyday life settings, particularly in relation to increasing healthcare
now delivered at home to people who are infected or to vulnerable groups, there is
growing awareness of the need to promote safe laundering of clothing and household
linens as part of a multibarrier approach to home hygiene which also includes hand,
food, respiratory and other hygiene practices in the home. This is also important as a
strategy to reduce the spread of antibiotic resistant strains and reduce the need for
antibiotic prescribing.

Reducing the “silent” spread of antibiotic resistant strains

Tackling antibiotic resistance is a global priority, and, in the last few years, there has
been increasing awareness that hygiene measures are an important part of reducing
spread of resistant strains.5 Currently, the focus is on resistant superbugs in
hospitals, but it is now recognised that this is just as much a home and community
problem. In the community, otherwise healthy people can become persistent skin
carriers of MRSA, or faecal carriers of enterobacteria strains which can carry multi-
antibiotic resistance factors (e.g NDM-1 or ESBL-producing strains). Because these
people are perfectly healthy, the risks are not apparent until, for example, they are
admitted to hospital, when they can become “self infected” with their own resistant
organisms following a surgical procedure, and then spread it to other patients. It is
thought that the major source of healthcare-associated infection is the patient’s own
endogenous body flora. Sometimes these infections occur in the community, as
happened in 2005 when a young soldier acquired what should have been an easily
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treatable skin infection from a PVL-producing strain of MRSA, but subsequently died.
As persistent nasal, skin or bowel carriage in the healthy population spreads “silently”
across the world, the risks from resistant strains in both hospitals and the community
increases. In the last few years a significant amount of new data has been published
showing the extent to which “healthy” people in the community can carry resistant
strains, and how person to person transmission can occur within the home.6

Transmission of Staphylococcus aureus and Methicillin resistant

Staphylococcus aureus (MRSA) via clothing and linens

Staphylococcus aureus is an organism which is carried harmlessly in the nostrils,

throat, and on the skin (particularly in areas such as the armpits and groin). About
one third of the population constantly carry S. aureus, and one third carry it on a
transient/short term basis. Usually the individual is unharmed by colonisation, but
where the skin becomes damaged e.g. superficial wounds or abrasions or ulcers, or
develops conditions such as psoriasis and eczema, the organism can cause
infections such as boils. Occasionally a serious infection such as bacteraemia can
result. S. aureus carriers constantly shed the organism from the skin’s surface, most
usually associated with skin scales. These organisms can become attached to
clothing or household linens where they can survive for long periods of time, even in
dry clothing, and can be transmitted to other family members.

Of particular concern are the new “community” strains of MRSA (CA-MRSA).

Experience in the USA suggests that these strains are transmissible within families,
but also in community settings such as prisons, schools and sport teams. Skin-to-
skin contact (including intact unabraided skin) and indirect contact with contaminated
objects such as towels, sheets and sports equipment seem to represent the mode of
transmission. This means that care of sports clothing and equipment is important to
prevent the spread of this organism. Sports clothing and equipment such as towels
should be laundered after each use.

A review of the evidence indicates that clothing and household linens are a risk factor
for spread of S. aureus (including MRSA and PVL-producing MRSA strains), and that
effectiveness of laundry processes may be an important factor in defining the rate of
community spread of these strains.1

For more information about S. aureus and MRSA consult the IFH fact/hygiene advice
sheet “Methicillin Resistant Staphylococcus aureus (MRSA) and the home”.

What about Clostridium difficile?

Whether, or to what extent, underclothing might be a vehicle for spread of C. difficile

in the community is not known. A UK study suggests that only about 1 in 5 of
C.difficile infections are spread between patients in hospital. 7 There is growing
awareness that community-acquired C. difficile is important and there are data
indicating transmission to humans from animals.   Studies suggest carriage rates for
C. difficile in the healthy adult community of up to 3% with higher colonisation rates in
the over 65 age group.8,9

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How does laundering reduce germ levels on clothing?

During laundering, temperature, together with the action of water and detergent work
together to reduce microbial contamination levels on fabrics:

Physical removal.
During the main cycle, dirt and microbes are detached from the fabric and suspended
into the wash water. These are then “washed away” during the rinse and spin cycles.
This mechanism is often referred to as dilution.

Thermal inactivation.
In addition to physical removal, micro-organisms can be killed by heat. Thermal
inactivation increases as the temperature is increased.

Chemical inactivation.
During laundering, some chemical inactivation of microbes by the surfactants and
activated oxygen-based bleach used in detergents contributes to the hygiene
effectiveness of laundering (see more details below). Adding hypochlorite bleach in
the washing process also achieves inactivation of microbes.

A number of other components can also contribute including:

 Where laundry is dried, added microbicidal effect can be achieved particularly

from exposure to sunlight.
 Drying in a tumble drier can further reduce microbial load.
 Where clothes and linens are ironed, particularly where they are ironed damp,
heat and steam penetrating the fabric causes reductions of microbial load.
 Microbial contamination is further reduced if clothes are stored dry.

Data on the hygiene effectiveness of laundering is given in a 2013 IFH review.10

Formulation of laundry detergents

Laundry detergents contain a mix of ingredients including surfactants, builders,

optical brighteners, perfume etc. In common usage, "detergent" refers to mixtures of
chemical compounds including alkylbenzenesulfonates, which are similar to soap but
are less affected by hard water. The cleaning action of laundry detergents arises
primarily from the action of the surfactants and other ingredients, which are designed
to maximise release and suspension of dirt and microbes into the wash liquid,
together with enzymes and/or an activated oxygen-based bleach which digest and
remove stains. These are then rinsed away during the rinse and spin cycles.

Although activated oxygen bleach is included in many powder detergents to digest

and remove stains, it also produces some chemical inactivation of bacteria, fungi and
viruses. Surfactants also exert some chemical inactivation action against certain
species although the extent of their action is not known. The extent of inactivation will
depend on the concentration, wash temperature, pH, level of soiling etc.

Examples of the most common activated oxygen bleaches used in laundry

detergents are persalts (now commonly percarbonate) plus activators such as
tetraacetylethylenediamine (TAED) which generate peracetic acid in situ. The rate
and extent of release of active oxygen and thus the microbiocidal action decreases
as the wash temperature decreases, but bleach activator manufacturers claim that
effective action can be delivered even at temperatures down to 20°C.
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The principal components of all cleaning products must be listed on the pack by law
and not all laundry detergents contain activated oxygen bleach components. If a
laundry product contains a bleach system, “oxygen-based bleaching agent” will be
listed as one of the ingredients on the pack. If it is not listed, it means that the product
does not contain an activated oxygen bleach. As a rule of thumb, powders and
tablets normally contain an activated oxygen bleach, but liquids, and products used
for “coloureds” do not:

Powder / Tablets Liquids

Bio Non-bio Colour Bio Non-bio Colour
‘bleach’ + + + + - - - - - -
Enzymes + + - - +/- + + - - +/-
For more information go to:
http://uk.cleanright.eu/index.php?
option=com_content&task=view&id=112&Itemid=143&Itemid_fourth=130

Low temperature laundering

Whilst laundry hygiene is important, equally it is important to consider sustainability

issues i.e the environmental impact of higher temperature laundering, use of
detergents and other chemicals, and the need to conserve water. In recent years the
household soap and detergents industry has made a significant investment in
developing laundry products that perform (i.e deliver clean clothing) at low
temperatures. The energy consumption required to heat the water in a washing
machine contributes by far the largest proportion of the environmental impact of
laundering. In order to save energy, increasingly over the past few years, home
laundering has been carried out at lower temperatures (30-40°C).

The desire to wear and use clothing etc which is clean, is deeply rooted part of our
culture in terms of nurturing our families, feeling good about ourselves and so on.
From a public health perspective however, it is important that the process of
laundering is also effective in managing risks associated with potentially harmful
microbes, bearing in mind that visibly clean and hygienically clean are not
necessarily the same thing. Although laundry processes should be able to deliver
clean fabrics with the minimum use of water, power and chemicals, it is equally
important that laundered clothing and household linens do not represent a risk in
terms of transmitting potentially harmful microorganisms.

The guidance given in this document is based on the principle that, if we are to
minimise energy consumption associated with household laundering whilst at the
same time managing infection risks, the items that make up the weekly wash need to
be segregated into categories, with relatively more stringent laundering requirements
specified for higher risk categories.

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Standardising laundry temperatures and other laundering conditions

In 2013 IFH carried out a review of the data on the hygiene effectiveness of
laundering at various temperatures, under varying conditions.10 A key finding was the
lack of standardisation and control within studies, and the variability in test conditions
(wash cycle time, number of rinses etc) between studies. The consequent variability
in the data (i.e the reduction in contamination on fabrics) obtained, in turn makes it
extremely difficult to propose guidelines for laundering with any confidence, based on
currently available data. As a result there is significant variability in the
recommendations for hygienic laundering of clothing etc in healthcare and domestic
situations given by different agencies.11-16

A particular concern is recent data 17,18 suggesting that, although guidance can be
given about preferred laundering temperatures, in reality modern washing machines
do not reach the temperature specified on the machine controls. The data also
showed the differing extents to which temperature declines during the wash cycle.
These data suggest that, for programmes set at 60°C, the maximum temperature
reached ranged from around 46-53°C, whilst for programmes set at 40°C, the
maximum temperature was around 35-39°C. For programmes set at 30°C, the
maximum temperature was about 28-29°C. A 2013 WHICH report showed that
around two thirds of UK domestic washing machines set to 60°C did not actually
reach the prescribed temperature.19

Uniforms of healthcare workers

In the UK, US and elsewhere, healthcare workers frequently launder their uniforms at
home. Microbiological evidence shows the extent to which their clothing can become
contaminated by contact with infected patients indicating the importance of effective
laundry hygiene at home.1 A UK questionnaire study of nurses working in 3 hospitals
indicated that 31% of nurses did not use the hospital laundry whilst a US survey of
nursing staff indicated that 26% home-laundered their scrubs.

Uniforms of healthcare workers should be laundered separately from other laundry

items. They should be handled and washed or laundered using a process which
eliminates the risk of spread of infection in the home.

Guidance on machine laundering of clothing and household linens

The following guidance is primarily intended for reference use by hygiene

professionals/infection control practitioners, community workers, the professional and
consumer media etc who need to give advice to their patients, or to the public in
general. Because of the need to launder different categories of clothing at different
temperatures according to level of risk, and the need to take account of the heat and
bleach sensitivities of different fabrics, these guidelines are somewhat complex. For
communication with consumers/patients, the information needs to be interpreted and
simplified to meet the specific needs of the individual patient or public group, and
transmitted through leaflets and/or one to one communication etc.

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As a rule of thumb:

For higher risk Launder at 60°C or more with an

items active oxygen bleach-containing
detergent
For lower risk For items which come into Launder at 30-40°C with an
items close and persistent contact active oxygen bleach-containing
with the body detergent
For items not in close and Laundering at 30°C with all/any
persistent contact with the formulated detergent should be
body sufficient

As discussed in more detail above, the lack of consistent data on the hygiene
effectiveness of laundering at various temperatures, under varying conditions makes
it extremely difficult to propose guidelines for home laundering for consumers with
confidence, based on currently available data. A particular concern is data
suggesting that in reality modern washing machines do not reach the temperature
specified on the machine controls.

Although it could be argued that there is no clear epidemiological data showing to

what extent clothing etc contributes to transmission of potentially harmful organisms,
or that lowering of laundry temperatures constitutes a health risk to consumers, there
is extensive microbiological and epidemiological data demonstrating some level of
health hazard.1 In view of all these considerations, IFH has concluded that that
laundry guidance should follow a precautionary approach, which incorporates a
margin of safety against the current lack of standardisation and control which means
that typically some household cycles deliver significantly lower hygiene effectiveness
than others.

The follwing guidance has been formulated to give consumers the best and most
appropriate guidance based on current knowledge, taking account of both
environmental issues and the need to protect consumer health. If we could
understand more about the infection risks, the factors which contribute to the hygiene
effectiveness of laundering, and how to better control domestic machine laundering
parameters such as temperature in order to deliver hygiene effectiveness, hopefully,
in the longer term, it should be possible to recommend a less precautionary (i.e less
stringent) level of guidance, thereby further increasing the sustainability of the
laundry process.

Categorization of laundry items according to level of risk

The following guidance is based on the principle that, in order to minimise overall
energy consumption associated with household laundering whilst at the same time
managing infection risks, the items that make up the weekly wash need to be
segregated into categories according to level of risk, and relatively more stringent
laundering requirements specified for higher risk categories. It is recommended that
clothing, household linens etc. should be divided into the following categories:

Category A. Higher risk items

Category A1
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Specific items of clothing, household linens etc. where there is considered to be a
higher risk that they may have become contaminated with pathogens or antibiotic
resistant strains during normal daily use or wear including:
 Uniforms of healthcare workers and clothing of other workers who are likely to
come into contact with pathogens, which are laundered at home e.g.
restaurant, laboratory and sewage workers, veterinarians, farmers, etc.
 Clothing of family members giving care to infected family members
 Clothing etc. which is heavily soiled e.g. with faeces or vomit, or body fluids
(including re-usable babies’ nappies)
 Sports clothing, particularly high-contact sports such as rugby football,
American football, martial arts, etc.
 Cloths, towels etc used in the kitchen during food preparation, in the nursery
and in the toilet area.
 Clothing of patients in hospitals, which is taken home by the family for
laundering
 Clothes of patients with chronic wounds (up to 1 - 2 % of every old people will
have chronic wounds which can be heavily contaminated with
Staphylococcus aureus and Pseudomonas aeruginosa).
 Clothing of family members with skin diseases such as dermatitis, who may
be heavy shedders of e.g. S. aureus
 Fabric items associated with domestic pets e.g. pet blankets

Category A2
All items of clothing, household linens etc. used or worn in situations where there is
higher infection risk:
 because someone in the home is infected - e.g. shedding bacterial pathogens
in faeces, or fungal pathogens, such as in athletes foot, from their skin, or
Candida from mucous membranes
 because there is someone in the home who is particularly vulnerable to
infection e.g. undergoing cancer chemotherapy, HIV/AIDS etc.

Category B. Lower risk items

Category B1
Those items of normal daily wear which come into direct, significant and persistent
contact with body surfaces during normal daily wear (see endnote i) This includes:
 underclothing (including socks, vests, bras, pants), sweat shirts. towels, bed
linens, face cloths and other personal items

Category B2
Those items of normal daily wear outer clothing which do not have extensive and
persistent contact with body surfaces. This is considered to apply to items such as:
 jackets, sweaters, skirts, trousers, soft furnishings, table linens etc.

Where category B items are being used or worn in “risk” situations as described for
Category A2 above (i.e where a family member is infected, or at increased risk of
infection) they should be considered as category A and laundered as per instructions
for laundering of Category A.

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Guidance for laundering of Category A and Category B items

The following conditions for laundering are recommended:

Before wash
Never put wet items in the laundry basket
Separate laundry so you don't "mix germs":
o Do not mix potentially soiled (towels, linens, underclothing) with low risk
clothing (shirts, trousers, socks)
o Do not mix "food with other" i.e. do not mix tea towels and dishcloths with
other items

Laundering of Category A items.

It is recommended that these items should always be machine laundered at 60°C or

more, using an active oxygen bleach-based laundry product (see endnotes ii and iii).
The hygienic effectiveness of laundering under these conditions depends on
ensuring that:
 the machine is not overloaded i.e. is loaded according to instructions
 the correct dosage of detergent is added according to pack instructions,
 the machine, load and wash water is heated to, and reaches 60°C, prior to
commencement of the cycle (see endnote iv).
 a standard wash cycle is used (i.e avoid a “quick wash”, “water saving” or
other “eco” cycles)
 the load is subjected to at least 2, preferably 3 rinse and spin cycles

Notes:
1. Laundering at 60°C should be possible for most Category A1 items because of the
types of fabrics which are used.
- For some items, particularly in Category A2 (delicates, coloureds or woollens), it
may not be possible to wash at these temperatures and/or to use a bleach-based
detergent. For these items the following is recommended:
 Carry out a prewash by soaking clothes in cold water with non oxygen bleach-
based detergent. Drain off as much wash liquid as possible and if possible
wring out. Then wash at 30-40°C according to instructions on the care label.
 The hygiene effectiveness of the process may be increased by using an
antimicrobial prewash product or hygienic rinse aid according to
manufacturer’s instructions and claims guidance on efficacy (i.e its efficacy
against bacteria and/or viruses and/or fungi etc.)
- For items which are not sensitive to bleach, chlorine bleach (1 cup of household
bleach diluted to 2 pints water) may be added to the final rinse cycle to give an
additional level of hygiene assurance
- In some cases it may be advisable to use a professional laundering service in
order to achieve adequate hygiene.

2. Segregation of laundry
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Although the evidence suggests that laundering of items at 60°C with an activated
oxygen bleach-based detergent is sufficient to prevent transmission of any
pathogens between different items within the same wash load, because of the “risk
status” of these items it is advised that Category A items are segregated into
separate loads e.g.
 Launder items used around food, e.g. tea towels and dishcloths, separately
from other items.
 Launder items from a known infected person, or items visibly/heavily soiled
with blood, faeces or potentially infected body fluids separately from items for
other family members
 Uniforms of healthcare and other designated workers should be laundered
separately from other laundry items.

3. Hygienic quality assurance of these items can be further increased (i.e. the margin
of safety) by:
 Drying in sunlight
 Tumble drying at 40°C or more, for 20 minutes or more (see endnote v).
 Ironing – particularly steam ironing

4. Where a family member is known to be infected with Clostridium difficile,

laundering of soiled items at 60°C with an activated oxygen bleach-based detergent
is not sufficient. Local infection control teams should be consulted to determine the
most suitable means to ensure decontamination.

5. Heavily soiled items. As stated above, it is advised that items soiled with blood,
vomit, etc. should be laundered at 60°C with an activated oxygen bleach-based
detergent. By contrast items heavily soiled with food material (unless it is uncooked
raw foods such as raw meat or chicken), mud etc. may appear very dirty but are not
necessarily contaminated with high levels of pathogens. However it may be
necessary to launder these items at 60°C with an activated oxygen bleach-based
detergent in order to achieve the desired level of visible cleanliness

6. Additional guidance:
 Wear disposable latex gloves when handling laundry if it is visibly soiled.
 Remove residual solid material with a tissue and placing it in the toilet before
laundering or washing.
 Sluicing (hand-washing dirty linen before putting it in the washing machine) is
not recommended as this can create aerosols that may contain pathogens.
 Wash hands after handling soiled laundry.
 Dry laundry as soon as possible after washing.

7. House dust mites. House dust mites which can cause allergies can build up in all
types of household textiles. Laundering at 60°C with an activated oxygen bleach-
based detergent is recommended to reduce the risk.

Laundering of Category B items

Category B1 items

It is recommended that these items should be machine laundered at 30-40°C, using

an activated oxygen bleach-based laundry product (see endnotes ii and iii). The
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hygienic effectiveness of laundering under these conditions depends on ensuring
that:
 the machine is not overloaded i.e. is loaded according to instructions
 the correct dosage of detergent is added according to pack instructions,
 the machine, load and wash water is heated to, and reaches 30 or 40°C, prior
to commencement of the cycle (see endnote iv)
 a standard wash cycle is used (i.e avoid a “quick wash”, “water saving” or
other “eco” cycles)
 the load is subjected to at least 2, preferably 3 rinse and spin cycles

Category B2 items

For category B2 items, which are considered as “lower risk” (i.e. excluding in
situations where family members are infected, or at increased risk of infection),
although laundering at 30°C with a non activated oxygen bleach-based detergent is
considered to deliver limited decontamination, this is considered satisfactory for
these items.

Notes:
1. Although laundering at 30-40°C with an oxygen bleach-based detergent may be
possible for many/most Category B1 items, for some items, particularly delicates or
coloreds, it may not be possible to wash at these temperatures and/or to use a
bleach-based detergent. For these items the following is recommended:
 Carry out a prewash by soaking clothes in cold water with non oxygen bleach-
based detergent. Drain off as much wash liquid as possible and if possible
wring out. If it is not feasible to launder at the specified temperature/
detergent, items should be washed according to instructions on the care
label.
 The hygiene effectiveness of the process may be increased by use an
antimicrobial prewash product or hygienic rinse aid according to
manufacturer’s instructions and claims guidance (i.e. on efficacy against
bacteria and/or viruses and/or fungi etc.)

2. Segregation of laundry - Evidence suggests that laundering of items at 30-40°C

may be insufficient to prevent transmission of any pathogens between different items
within the same wash load. It is thus advised that Category B1 and B2 items are
segregated into separate loads and laundered separately.

3. Hygienic quality assurance of these items is further increased by:

 Drying in sunlight
 Tumble drying at 40°C or more, for 20 mins or more (see endnote v)
 Ironing – particularly steam ironing

Further Guidelines for all laundry

 Wash hands after handling soiled laundry.

 Dry laundry as soon as possible after washing. Don’t leave it damp for long
periods, e.g. in the washing machine overnight, because any remaining
microbes may multiply quite rapidly. In particular, although these are not
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 harmful, this particularly includes microbe which impart unpleasant odours to
the textiles
 In large houses or apartment buildings, laundry facilities are shared by all
residents/householders thereby increasing the risk of transfer considerably. If
using shared laundry facilities, e.g. a launderette, always use a bleach-based
product and launder at 40-60°C.

Care of the washing machine

Particularly for washing machines which are only run at 30-40°C with a non AOB
detergent, bacterial and fungal biofilms will build up in the machine. Although, as yet
there is no evidence that these species are harmful to health in the domestic setting
(although a 2013 infection outbreak in low birth neonates associated with this source
has been reported in a hospital), these microbes can be transferred in large numbers
to the clothes etc. They can also impart strong and unpleasant odours to the textiles.
The washing machine should be cared for as follows:
 Keep your washing machine clean - including rubber lining which should
preferably be cleaned with a weak bleach solution (1 cup of household bleach to
2 pints water)
 Rinse and scrub detergent box weekly - if need be use boiling water
 Open the door and the detergent box when the washing machine not in use to
enable inner surfaces of the washing machine to dry.
 Once a week or every fifth cycle, use a high temperature wash, or alternatively a
chemical disinfectant on an empty cycle, to clean the interior of the machine the
machine and prevent the development of odours which are not necessarily
harmful, but unacceptable. In order to reduce this build up, the machine should
be run with the program with not only the highest wash temperature as specified
in the documentation; but also the highest detergent level and the longest
washing time. This is because research has shown that at a normal low suds
level the ‘hot’ water will not heat and clean the inner of the machine sufficiently.

Endnotes

i. It is not possible to compile an exhaustive/definitive list of which items fall in this

category and which fall in category B1. It is left to health worker/consumer
interpretation, bearing in mind that, in some cases it could lead to some small
increase in risk
ii. During laundering, chemical inactivation of microbes on fabrics can be achieved
using various bleach components. Normally oxygen bleaches (persalts) with a low
temperature activator are used or, as is common in some countries, chlorine-based
bleaching agents are added to the wash load. If a laundry detergent contains
activated oxygen bleach this should be stated in the ingredients on back of pack. For
more details consult the section above on formulation of laundry detergents.
iii. An alternative process may be used provided it can be demonstrated through
scientifically valid in vivo method, that it delivers an equivalent level of effectiveness
against bacteria fungi and viruses.
iv. It should be noted that, in some countries e.g. USA water at the given temperature
is added to the machine prior to adding the clothing. This means that the temperature
of the load during the wash cycle is likely to be well below this initial temperature
throughout the wash cycle
v. Tumble drying is not recommended as a measure to achieve hygiene due to its
poor sustainability

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References/Evidence base
1. Bloomfield SF. Exner M, Signorelli C, Nath KJ, Scott EA.The infection risks
associated with clothing and household linens in home and everyday life
settings, and the role of laundry (2011) International Scientific Forum on Home
Hygiene. http://www.ifh-homehygiene.org/best-practice-review/infection-risks-
associated-clothing-and-household-linens-home-and-everyday-life
2. Bloomfield SF. Exner M, Signorelli C, Nath KJ, Scott EA. (2012) The chain of
infection transmission in the home and everyday life settings, and the role of
hygiene in reducing the risk of infection. International Scientific Forum on Home
Hygiene. http://www.ifh-homehygiene.com/best-practice-review/chain-infection-
transmission-home-and-everyday-life-settings-and-role-hygiene
3. Larson EL, Lin SX, Gomez Pichardo C. Predictors of infectious disease
symptoms in inner city households. Nursing Research 2004; 53:190-7.
4. Bloomfield SF, Exner M, Fara GM, Nath KJ, Scott, EA; Van der Voorden C. The
global burden of hygiene-related diseases in relation to the home and
community. (2009) International Scientific Forum on Home Hygiene.
http://www.ifh-homehygiene.org/review/global-burden-hygiene-related-diseases-
relation-home-and-community
5. Recommendations for future collaboration between the U.S. and EU.
Transatlantic Taskforce on Antimicrobial Resistance 2011. Available at:
http://ecdc.europa.eu/en/activities/diseaseprogrammes/TATFAR/Documents/210
911_TATFAR_Report.pdf.
6. Bloomfield SF. Risks associated with spread of antibiotic resistant strains in the
“healthy” community and in the home – a review of the published data. 2012
International Scientific Forum on Home Hygiene. http://www.ifh-
homehygiene.org/review/spread-antibiotic-resistant-strains-home-and-
community-review-preparation
7. Eyre DW, Cule ML, Wilson DJ, Griffiths D, Vaughan A, O'Connor L, Camilla
L.C., Golubchik T, Batty EM, Finney JM, . Wyllie DH, Didelot X, Piazza P,
Bowden R, Dingle KE, Harding RM, Crook DW, Wilcox MH, Peto TEA, Walker
AS. Diverse Sources of C. difficile Infection Identified on Whole-Genome
Sequencing N Engl J Med 2013; 369:1195-1205.DOI: 10.1056/NEJMoa1216064
8. Miyajima F, Roberts P, Swale A, Price V, Jones M, et al. (2011) Characterisation
and Carriage Ratio of Clostridium difficile Strains Isolated from a Community-
Dwelling Elderly Population in the United Kingdom. PLoS ONE 6(8): e22804.
doi:10.1371/journal.pone.0022804.
9. Bloomfield SF, Cookson BD, Falkiner FR, Griffith C, Cleary V. 2006. Methicillin
resistant Staphylococcus aureus (MRSA), Clostridium difficile and ESBL-
producing Escherichia coli in the home and community: assessing the problem,
controlling the spread (2006). International Scientific Forum on Home Hygiene,
http://www.ifh-homehygiene.org/best-practice-review/methicillin-resistant-
staphylococcus-aureus-mrsa-clostridium-difficile-and-esbl.
10. Bloomfield SF, Exner M, Signorelli C, Scott EA, Effectiveness of laundering
processes used in domestic (home) settings (2013) International Scientific
Forum on Home Hygiene. http://www.ifh-homehygiene.org/review/effectiveness-
laundering-processes-used-domestic-home-settings-2013
11. Laundry: washing infected materials. CDC.
http://www.cdc.gov/HAI/prevent/laundry.html
12. Recommendations ---Laundry and Bedding. In: Guidelines for Environmental
Infection Control in Health-Care Facilities. Recommendations of CDC and the
Healthcare Infection Control Practices Advisory Committee (HICPAC).
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm

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13. Guidelines for laundering in healthcare facilities.
http://www.docstoc.com/docs/144204091/CDC-Guidelines-for-laundry-
operationsdoc---NISH-Laundry-Services
14. Choice Framework for local policies and procedures 01-04: decontamination of
linen for health and social care 2012 consultation draft. UK Department of Health
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/14
8538/CFPP_01-04_Social_care_Final.pdf
15. Uniform and workwear: Guidance on uniform and workwear policies for NHS
employers. 2010 UK Department of Health. http://www.ncuh.nhs.uk/about-
us/freedom-of-information/disclosure-log/requests/infection-control/000771-
09.pdf
16. Laundry treatment at high and low temperatures. UK health and Safety
Executive 2013. http://www.hse.gov.uk/biosafety/blood-borne-viruses/laundry-
treatments.htm
17. Vossebein L. Wäschehygiene im Haushalt / Linen Hygiene in Households
SOFW-Journal, 139, 3-2013, 51-58.
18. Lucassen R, Bockmuhl DP. Antimicrobial efficacy of hygiene rinses under
consumer-related conditions. Tenside Surf Det 2013; 50:259-262.
19. So you think you’re washing at 60°C. Which? September 2013, 62-63.

IFH home hygiene Guidelines and Training Resources

1. Guidelines for prevention of infection and cross infection the domestic
environment. International Scientific Forum on Home Hygiene. Available from:
http://www.ifh-homehygiene.com/best-practice-care-guideline/guidelines-
prevention-infection-and-cross-infection-domestic
2. Guidelines for prevention of infection and cross infection the domestic
environment: focus on issues in developing countries. International Scientific
Forum on Home Hygiene. Available from: http://www.ifh-
homehygiene.org/best-practice-care-guideline/guidelines-prevention-
infection-and-cross-infection-domestic-0
3. Home hygiene - prevention of infection at home: a training resource for carers and
their trainers. International Scientific Forum on Home Hygiene. Available from:
http://www.ifh-homehygiene.com/best-practice-training/home-hygiene-
%E2%80%93-prevention-infection-home-training-resource-carers-and-their
4. Home Hygiene in Developing Countries: Prevention of Infection in the Home and
Peridomestic Setting. A training resource for teachers and community health
professionals in developing countries. International Scientific Forum on Home
Hygiene. Available from: www.ifh-homehygiene.org/best-practice-
training/home-hygiene-developing-countries-prevention-infection-home-
and-peri-domestic

This fact/advice sheet was last updated by IFH in October 2013.

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