DIRTY LAUNDRY.

Wendy L Bonifazi, RN, a contributing writer to Contemporary Long Term Care, is based in Fort Collins, Colorado.

DO YOU THINK YOUR BIGGEST laundry problem is what's missing?

Think again. According to experts, you should be concerned about what's there.

Even if your whites are white and your laundry is still warm from the dryer, chances are it's carrying live bacteria, viruses, and other pathogens. What's more, some of these organisms remain in the washer to contaminate subsequent loads.

According to research conducted by Charles Gerba, PhD, professor of microbiology at the University of Arizona, and Jean Rose, PhD, professor of water pollution microbiology at the University of South Florida in St. Petersburg, washing a typical load of clothing that includes underwear not only contaminates that load but leaves enough residual bacteria to contaminate a subsequent wash. Their study of the washing machines from 150 homes in Tampa and Tucson revealed that 60 percent had coliform bacteria and 10 percent contained E. coil. When the researchers washed sterile clothes in a non-bleach laundry cycle in these machines, 40 percent of the clothes became contaminated with fecal bacteria. Although E. coil was killed during drying on the permanent press cycle, salmonella, hepatitis A, Rotavirus, and some adenovirus survived, even on clothing that reached temperatures as high as 131 degrees Fahrenheit.

Risk factors

It only takes a few pathogens to cause infection, and contaminated laundry is teeming with them. "You can get 100 million E. coil in a washer load if one person is incontinent," says Gerba. "The underwear of a person who is not incontinent typically has 1/10th of a gram of feces, or the equivalent of four staples by weight--so small you can't really see it. That can contain a hundred million to 10 billion salmonella organisms, or ten million viruses. Rotavirus is 10 billion per gram of stool, which means a tenth of a gram of stool is a billion."

Gerba's research shows that washing probably eliminates 99.9 percent of the viruses. In the hypothetical case above, he points out, that would leave a million living rotaviruses. Drying would kill about another 90 percent-leaving 100,000.

Even people who feel fine can spread germs, explains Rose. "Even after they feel well, most people who have been infected with bacteria, viruses, and protozoa will excrete the organism for seven to ten days, and some protozoa for up to thirty days," she says. "And skin-infecting bacteria like staph survives washing and drying."

How much damage could these pesky particles do? Gerba thinks the problem is significant in long term care, where residents often have compromised immune systems, multiple illnesses, skin breakdowns, poor hygiene, or other vulnerabilities. "The risk may be low, but I'm worried that when it happens, the outcome for people in long term care can be very serious," he says. "For example, the risk of dying from Rotavirus is one in ten thousand in the general population, but one in a hundred for the long term care population."

For those exposed to salmonella, he adds, there is a 1-in-1,000 chance of death in the general population versus 1-in-25 in long term care. And adenovirus type 40 causes mild diarrhea in children, no illness in most adults, and death in 50 percent of immuno-suppressed cancer patients who contract it.

Also concerned is microbiologist J. William Costerton, PhD, director of the Center for Biofilm Engineering at the University of Montana, which has been awarded a National Science Foundation grant to study how biofilms (bacteria on surfaces) survive disinfection procedures. "If Staph. aureus or similar pathogens on cleaned laundry come in contact with a decubitus or other large break in the skin, there's almost a 100 percent likelihood of getting an infection," he says. "The worst thing is to breathe them in because you also lose a little bit of lung."

Hepatitis A and smallpox are among the infections linked to soiled linen, and others are possible. "There's the potential they occur and simply aren't recognized," says Steven Standaert, MD, formerly an intelligence service officer with the CDC. "Chances of transmission from dirty hands are higher, but almost impossible to separate from laundry. You can't say one is implicated and the other is not."

Rose and Gerba's research identifies another weak spot in infection control: the transfer of wet, still-contaminated laundry from washer to drier. "Employees handle all sorts of things that are worse. Laundry is not more risky, but it's a risk they don't think about, so they're needlessly exposed," says Rose. "It's a risk that can be readily controlled by wearing and discarding gloves, then washing hands before handling anything else."

Spreading organisms through "clean" laundry increases the frequency of a person's exposure to germs. "The more often you're exposed, the higher the risk," says Rose. "It doesn't matter whether the transmission route is chicken or laundry. Once you're exposed and the illness starts, the outcome depends on the host's immunity and the organism's virulence."

Guidelines and guesswork

So how can you minimize that risk?

Looking for guidance from official sources is like searching for a speck of lint in a laundry load. HCFA and the Joint Commission on Accreditation of Healthcare Organizations address laundry only briefly in their regulations. The Centers for Disease Control and Prevention's Hospital Infections Program Web site publishes just half a page on laundry, which advises: "Rather than rigid rules and regulations, common-sense hygienic practices for processing and storage of linen are recommended."

The CDC is currently revising those guidelines, but it considers the risk of spreading disease through laundry negligible, partly because it doesn't hear of outbreaks linked to laundry, according to program medical epidemiologist Elise Jochimsen, MD. But, she acknowledges, that doesn't mean such outbreaks don't occur. "The CDC doesn't really have data regarding long term care, and it needs more study," she says. "The source of nosocomial infections in long term care is often not identified."

Agencies often rely on data to determine policy recommendations, but the data just isn't there on infections and transmissions, particularly in long term care.

"There's not a lot of [research] interest in nursing homes. Long term care infections are seen as mundane problems that are not cutting edge," says Standaert, now of the division of infection control at Vanderbilt University in Nashville. "Most patients can't give reliable recent food histories, and they're exposed to other factors."

Facility managers share the blame, he says. Used to dealing with ongoing cases of infection, some overlook increases, allowing a few to turn into minor epidemics. "They still think of it as the norm, and don't realize the level warrants calling in an epidemiologist," says Standaert.

About five years ago, Standaert investigated an outbreak of salmonella gastroenteritis at a 250-bed nursing home in rural Tennessee. "It looked routine for a nursing home," he says. Over half the residents had diarrhea. Cultures of employees turned up a red flag. Although large numbers of nurses, who tested positive, were asymptomatic, several laundry workers who were ill had no contact with patients, nor did they eat in the facility dining room.

Standaert's team discovered that the laundry workers had contracted the illness--and may have spread it--through improper handling of feces-soiled linen. Their errors included poor hand-washing, lack of gowns, and inconsistent use of gloves. What's more, they ate lunch in the laundry room.

Coming clean

"There are hundreds of variables and choices in running laundry operations, and right and wrong ways for each," says Scott Clark, vice-president of Victor Kramer Company, a Rutherford, New Jersey-based laundry consulting and management company. He often sees long term care workers err by overloading equipment or cutting wash and dry times and temperatures to cut costs. In addition, staff often handle laundry unsafely, failing to' use gloves, gowns, or masks; bag improperly; or fail to separate loads by amount of soilage.

These errors can lead to contamination. "High temperature, high water volume, and detergent plus bleach or sanitizers are the most important factors in decreasing bacteria and other pathogens," says Rose. "A greater volume of wash water does a better job diluting and washing off material."

Clark advises managers to provide scales or piece-weight charts so employees don't exceed equipments' cleaning capacity. In addition, he says, make sure housekeeping staff use adequate bleach and disinfectants and hot enough water to get rid of most bacteria as well as stains (that means temperatures of about 170 degrees Fahrenheit, though the exact temperature varies depending on the length of the wash and dry cycles and the type of detergent used), and arrange microbial testing by an infection control specialist to see if microorganisms have been killed.

To kill pathogens remaining in washers, Gerba and Rose recommend running an empty hot-water wash with bleach.

All staff who handle laundry, including housekeepers, nurses, and aides, need to know how to strip beds and bag laundry to minimize risks to themselves and others. "You're taking a litigious risk if an employee becomes ill or dies," says Clark. "You need to protect operators from contamination."

According to OSHA, contaminated laundry should never be sorted or rinsed where it was used, but should be bagged immediately, with a minimum of agitation. (For a copy of OSHA's guidelines, call OSHA's training institute at 708-297-4810, or access the Web site at www:osha.org).

Employees who come in contact with soiled items should wear latex or equivalent gloves and clothing that won't spread contaminants. That means an apron or scrub suit to prevent liquid strike-throughs, a smock or cover-up to wear during meals, and uniforms for laundry and direct-care staff. It may also mean providing caps, masks, and face shields.

Many hospitals and some long term care providers provide and launder employees' uniforms and personal protective equipment, considering it part of their responsibility to protect employees from contracting or spreading infections. Some even believe the added cost may be offset by the reduction in infections--not to mention potential lawsuits. What's more, you risk being fined by OSHA if you don't provide at least some protective clothing. OSHA's Bloodborne Pathogens and Long-Term Care Workers guide (OSHA 3131, 1992), says employers must "provide, make accessible and require the use of personal protective equipment at no cost to the employee." Employers must also launder "contaminated articles, including employee lab coats and uniforms that are used to protect the employee from occupational exposure, with the help of either on-site equipment or a commercial service.

In fact, it may be good policy to wash all staff uniforms on-site. This can keep pathogens from infecting home laundries, which could in turn lead to family illnesses and employee absences. According to industry reports, Americans forgo bleach for 85 percent of their personal laundry loads, and as few as 5 percent use hot water. That means harmful pathogens are apt to survive and thrive after home laundering, particularly if employees are protecting their budgets by laundering infrequently, or their permanent-press polyester uniforms by keeping them Out of hot-water washes or high dryer settings.

Infection rates from salmonella, camphylobacter, E. coil, and other pathogens are skyrocketing, warns Gerba, and mishandled laundry is partly to blame. Nobody's saying that laundered linens are as hazardous as unwashed hands. But, says Rose, "Laundry is one potential route. It's not negligible, and it's something we can control."

                               Laundry list
        Pathogens and parasites that may be carried by contaminated
                        linen include the following.

SOURCE POSSIBLE PATHOGENS
Feces  Clostridium difficile
       Cryptosporidium
       Hepatitis A virus
       Pseudomonas eriginosis
       Rotavirus
       Salmonella
       Vancomycin-resistant
         enterococcus (VRE)
Urine  Adenoviruses
       Cytomegalovirus (CMV)
       Microsporidium
Blood  Hepatitis A (unusual)
       Hepatitis B
       Hepatitis C
       HIV
       Adult T-cell leukemia
       Arboviral infections
       Brucellosis
       Babesiosis
       Creutzfeldt-Jakob disease
       Lymphoma from HTLV-I and II
       Malaria
       Viral hemmoraghic fever
Skin   Fungi
       Lice
       Microbacterium fortuitum
       Scabies
       Staphylococcus
       Streptococcus
       Yeast