Reusables and Disposables: Comparable Protection Against Hospital-Acquired Infections

Cardinal Health promotes its disposable isolation gowns as the “last line of defense” for minimizing the exposure risk to hospital-acquired infections (HAIs).” But the nation’s top public health protection agency, regulatory authorities, healthare industry standards organizations  and the evidence provided by some of the nation’s top subject matter experts contradict that claim.

Reusable isolation and surgical gowns comply with both Association for the Advancement of Medical Instrumentation (AAMI) and the Occupational Safety and Health Administration (OSHA) barrier standards.

Regardless of the material used to manufacture surgical gowns and drapes, these products must be resistant to liquid and microbial penetration, according Centers for Disease Control (CDC) guidelines, and surgical gowns and drapes must be registered with Food and Drug Administration to demonstrate their safety and effectiveness.

The CDC’s 2003 Guidelines for Environmental Infection Control in Health-Care Facilities, state “Reports of health-care associated diseases linked to contaminated fabrics are so few in number that the overall risk of disease transmission during the laundry process likely is negligible. When the incidence of such events are evaluated in the context of the volume of items laundered in health-care settings (estimated to be 5 billion pounds annually in the United States), existing control measures are effective in reducing the risk of disease transmission to patients and staff.”

Various published, peer-reviewed studies have proven that reusable healthcare textiles (HCTs) that are properly-laundered and handled are as safe as disposables. The research findings are borne out by facilities that have used reusable products for decades.

Lynne Sehulster, PhD., a health scientist in the CDC’s Division of Healthcare Quality Promotion (formerly the Hospital Infections Program) for 20 years, closely studied the issue. “There appears to be little to no evidence of patient-to-patient transmission of infection attributed to laundered textiles,” Sehulster wrote in 2015.

Her 2015 review, for the journal Infection Control & Hospital Epidemiology (ICHE), was based on findings and recommendations from peer-reviewed studies, as well as industry standards and guidelines. ICHE, the official publication of the Society for Healthcare Epidemiology of America, publishes scientifically authoritative, clinically applicable, peer-reviewed research on the control and evaluation of the transmission of pathogens in healthcare institutions.

Sehulster’s review found 12 confirmed outbreaks attributed to laundered healthcare textiles worldwide, that effected 350 people, over a period of 43 years from 1972 to 2015. The last incident was in Hong Kong.

Her root cause analysis of those 12 confirmed outbreaks identified inadvertent exposure of clean healthcare textiles to environmental contamination and mechanical problems with laundry equipment as the origins.

With regard to environmental contamination, she found that 33% of the cases resulted from exposure to dust in storage areas. Another 8% were caused by contamination during transit from the laundry facility to the hospital. The remainder resulted from process failures during laundering, such as improper wash cycles or water temperatures and issues regarding reused water. Four of the cases, accounting for 57%, resulted from towels contaminated with a common environmental, spore-forming microorganism that occurs in the late spring or summer.

“Innovations in the laundry industry have led to major advances in laundry equipment, laundry chemicals, fiber and fabric technology, and laundry facility design and engineering,” wrote Sehulster who retired from the CDC in 2017 and now consults through her company Environmental Infection Prevention, LLC.

“Four decades of experience using laundered, reusable HCTs strongly supports the notion that current industrial laundry processes are effective in interrupting potential patient-to-patient transmission of infectious diseases. The significance of this assessment increases when one notes the annual volume of laundered HCTs produced for U.S. hospitals,” wrote Sehulster.  “This volume of clean HCTs increases potentially by several billion pounds when the clean HCT demands of non-hospital venues are taken into account.”

Sehulster and Environmental Clarity researcher Michael Overcash, PhD., later updated the study to cover a 50-year period from 1970 to 2020 with a focus on the United States and he United Kingdom. They found that over a half century, 10 published events involving 69 patients with with HAIs had been attributed to reusable healthcare textiles, including patient gowns and other garments, bed linens (sheets, pillows and pillow cases, and blankets); towels and a mop pad.

The study, published in Infection Control & Hospital Epidemiology in July 2021, found that HAI rate as a percentage of population of the U.S. and the U.K. was similar, 0.5%–0.6%. 

In probability terms, the researchers said, the chance of a patient having an HAI linked to contact with a laundered, reusable textile is ∼1 in 14,900. “A person in the United States and the United Kingdom is more likely, based on the odds, to be struck by a meteor in any given year over a 78.5-year lifespan, which is 1 in 9,000,” the study concluded. 

“The annual cost savings from selecting reusable HCTs does not come with any measurable increased risk of HAI to patients and therefore represents a prudent healthcare facility decision.” 

In November 2020, a meta study conducted by Stanford University researchers assessing whether disposable textiles are more effective barriers than reusable isolation gowns, found “No existing literature shows non-woven (disposable) fabrics to be safer than impermeable woven fabrics, especially woven polyester.”

“The comparable safety provided by reusable gowns is especially important as the demand for gowns soars during and potentially after the global pandemic,” the Stanford researchers wrote in an article published in Frontiers in Public Health. 

The study stated that reusable isolation gowns are typically made of polyester, and some are composed of cotton or a blend of both fabrics. It noted that loosely woven cotton gowns, which were common historically, have since been pulled from the market due to high permeability.

“We advocate for reusable gowns as a means to lower healthcare costs, address climate change, and improve resilience while preserving the safety of healthcare workers,” wrote the researchers.