The UK’s laundry/textile rental sector covers four separate markets: healthcare, hospitality, garment rental and specialist sectors such as cleanroom.
British Standards Institute and other national bodies developed EN14065 to allow healthcare laundries across Europe to work to a single standard for controlling, achieving and monitoring performance in terms of microbiological cleanliness.
It has been adopted widely and is relatively easy to read and simple to use. Even the appendices are widely read as they give a lot of advice on ways to achieve the standard’s aims.
The standard is not as prescriptive as the Department of Health’s publication CFPP01-04 which sets out detailed requirements for the organisations it monitors. However many organisations find that some of the methods in the DoH document are useful to achieve the aims of the European standard.
The big difference between EN14065 and the previous DoH guidelines HSG(95)18 is that the European standard does not insist on implied thermal disinfection. Launderers and rental operators may choose the disinfection technique provided they have a system that makes sure that adequate disinfection has been achieved.
It is no longer sufficient to assume that the correct wash temperature and time will kill all bugs (feed forward control). Now the laundry has to prove disinfection (feedback control).

Applications beyond healthcare
EN14065 can prove useful for other market sectors as well as healthcare. First, such organisations need to understand the terms.
Adequate disinfection: Implied thermal disinfection has never killed all types of bugs. Even a main wash that runs at over 71C and for longer than over three minutes plus mixing time cannot achieve a good enough kill on many spore forming bacteria including Clostridium difficile and Bacillus cereus in the spore form.
In these bacteria, the spore seems to surround itself with a "protective jacket" that resists the normal kill temperature, so a number of spores remain alive, open up, grow and multiply when conditions improve, as in the rinse zone or in the ward linen cupboard.
These species can be reduced to a safe level by adequate dilution and so many experienced hospital laundry managers will turn up the rinse flow in the event of an outbreak. This solution may be particularly useful in the summer months when Bacillus cereus tends to thrive much better.
It is also important to remove all nutrients from the cloth surface, to prevent any residual colonies of micro-organisms from multiplying in the linen cupboard where the excrement will give off unpleasant odours.
This is why contracts often specify whiteness as this is an easy way to assess whether clean textiles have attracted protein soiling. This usually happens when the detergent does not have enough suspending power or the detergent dose has been too small.
EN14065 usually requires a check on the microbiological contamination on finished goods leaving the laundry. This allows laundries to assess whether there is a risk of re-deposition occurring regularly and if so stop it before the risk becomes serious. Such checks are essential if whiteness starts to deteriorate.

Reduction level
Adequate disinfection does not equate to sterility. Most health authorities require a log5 reduction in the concentration of pathogens on the linen surface. This could mean reducing the surface concentration from 107 to 102.

Facing up to danger
We live in a dangerous world. Cities are connected by ships and airlines and as the number of travellers increases so too does the number and range of the bugs they bring.
In the last few years Africa has faced crippling outbreaks of Ebola (for which there is no satisfactory cure) and every country now lives under constant threat of bio-terrorism.

Don’t panic
Panicking will not solve such problems. Stop, assess the risk and be ready with a response that matches the dangers. One laundry managers’ training course regularly poses the following problem.
"You are the only manager on site when the police tell you that there is a slight risk that one of your vans may have collected linen from a hotel that has been contaminated with anthrax. What should you do?"
Answers usually vary from "give the linen a good wash" to a discussion on achieving implied thermal disinfection.
The correct answer is to quarantine the van and the driver until you get more information but accept that the linen will probably have to be incinerated.
Anthrax is a spore former that cannot be killed by implied thermal disinfection and opinions vary as to whether it can be destroyed by chemicals. The disease is frequently lethal so scrapping the van contents is a small price to pay for peace of mind.

Gaining a commercial edge
The commercial sector has recognised that improving infection control can give businesses an edge over competitors and it now leads the public sector in this.
Using the principles of EN14065, the private sector has now taken 80% of the healthcare laundering market. The investment in measures such as installing barrier walls has been relatively modest but at a time when the NHS has devoted its large
funding (quite correctly) to patient treatment, the private sector has been able to achieve great gains in a short time, with significant patient benefit and reassurance.

Other benefits
Such improvements have been accompanied by a significant reduction in water and energy consumption. In many cases the reductions have been assisted by replacing implied thermal disinfection with the thermo-chemical systems that have long been available in continental Europe.
The Robert Koch Institute in Germany has established an enviable reputation as the testing house to go to for certified trials in this area.
As a result of private sector involvement in such trials and of in-house developments by leading detergent suppliers, healthcare laundries are now achieving water consumption below below 6 litres/kg textiles, and energy use might soon dip below the critical 1.0kWh/kg.

Documentary evidence
Adopting a monitoring system based on EN14065, requires daily and weekly monitoring and record keeping.
To avoid the additional paperwork, the market leaders increasingly use computer based record systems.
The ability to produce recorded data reassures the customers if they have a query. At present there is little evidence of any imminent infection threat, either in the London hotel market or elsewhere.

Complaint numbers rise
The number of guest complaints about room linen is rising, and in particular the number of large claims relating to brown stains, which could conceivably be residual blood, on bath robes and guest towels.
The cost of defending such six or seven-figure claims can be very high and the defence needs to be robust.
The ability to produce immediate data on disinfection records is an effective first line response and
shows that the supplier is professional and competent.

Garment rental
Although the use of EN14065 to monitor and control bugs on rental garments is not yet established, food industry customers are increasingly aware of infection risks and are demanding feedback evidence that bug levels are being reduced to an acceptable standard.
The criterion used is generally the final bug count per 10 square cm on the area sampled and the industry seems to be looking for a maximum level of 102, with only a very occasional rise to 103 being accepted. This level is being widely achieved, even with sampling concentrated in the high soil areas (on the front waist, thighs and wrists).

Taking monitoring in-house
Monitoring bug levels can be carried out on site using dipslides as part of a EN14065 based system. This would allow more frequent monitoring and any "fails" would produce a much quicker response than would be possible with external monitoring.
The use of an EN14065- based system for garment rental, and for specialist garments for cleanroom use, would allow laundries to reassure the customer by producing documentary evidence that effective controls would be in place. Dipslides would be adequate for daily and weekly monitoring.These could be interspersed with swabbing garments at intervals of around three months, to provide numerical scores for key marker bugs.
The presence of E.coli would be flagged up by a dipslide, but with no separate numerical assessment.

Benefits of a disciplined approach
A disciplined approach to disinfection monitoring and control could bring benefits to all sectors of the laundry and rental market.
Implementing such an approach is relatively easy and monitoring could largely be done in-house and give market leaders an enviable edge over the competition.
An EN14065 system is one way of distinguishing true professional from the also-rans and of demonstrating the seriousness with which true cleanliness is being taken.

BUG COUNT: Dipslides can be used to check the level of bugs remaining on textiles after washing. The Total Viable Count (TVC) slide produces bright red colonies and the pattern can be compared with the manufacturer’s charts. This slide shows that the bug contamination is 104, which is unacceptable