Post lockdown: Disinfection for both hospitality and healthcare28 September 2020
Disinfection has become the greatest worry for all sectors as we come haltingly out of the darkness and into the light. Richard Neale of LTC Worldwide warns that dealing with Covid-19 is not straightforward and will demand skills and knowledge that may challenge even the most experienced launderer.
As we come out of lockdown and businesses struggle to recover, we face a world economy which is very different from that of just a few months ago. Disinfection has gone from being a topic of interest to a few healthcare professionals, to something which now preoccupies almost everyone. Concerns are likely to be greatest in the developed nations of the first world, where Covid-19 appears to have caused the greatest number of early fatalities. Future concerns are likely to be even greater, because dealing with Covid-19 is not straightforward – it demands advanced professional skills and knowledge, which even many experienced industrial launderers could have difficulty grappling with. The problems for many onpremises laundries in care homes, cruise lines and hotels will probably be much greater. Some market-leading launderers have adopted the principles of the latest European standard EN14065:2016 and found that the simple principles in this work very well for them. This month we look in depth at the various challenges, because the sector will not have long to get properly to grips with them.
What is the problem?
Historically, it was the acute hospital sector which led the way with a universal and systematic method for controlling the recycling of pathogens from contaminated healthcare laundry onto otherwise clean hospital textiles. Britain and Europe largely followed the guidance developed by the International and Scientific Committee on Laundering (ISTCL), based on implied thermal disinfection. This specified use of either a wash process involving a stage which ran for at least three minutes (plus mixing time) at 71C (or 10 minutes at 65C) as a minimum2. This has spread worldwide and thermal disinfection is still widely used.
Initially, the spiralling costs and reducing availability of fossil fuels, and the risks associated with global warming, spurred the replacement of thermal disinfection with thermo-chemical disinfection at much reduced temperatures. As a result, leading suppliers of laundry chemicals developed a whole range of processes, which offered different time-temperature-chemical combinations to suit the users’ requirements. Many of these have been certified independently by the Robert Koch Institute in Germany and other reputable testing houses. This independent certification has provided justified assurance to healthcare customers and enabled the sector to achieve significant reductions in its carbon footprint. For example, the Textile Services Association in the UK has spearheaded a 25% overall reduction in energy consumption in the UK textile care sector since 20081.
With the advent of Covid-19 all this has changed. Implied thermal disinfection is fine for giving an adequate reduction in bacteria on healthcare linen2, but Covid-19 is a very virulent virus and the degree of reduction needed for assured safety in healthcare is unclear. Different researchers have advised different criteria but launderers who have successfully implemented low temperature washing are keen not to revert to the energy hungry processes of thermal disinfection. Leading suppliers of laundry chemicals have swiftly addressed this: independently certified processes are now available for dealing with Covid-19, again with a range of time-temperature-chemical combinations. Certified processes based on ozone disinfection were not known to LCN at the time of writing this article but could also be under development. Ozone has been shown to be a powerful disinfectant.
Is contaminated laundry a big risk?
The healthcare sector has found from experience that implied thermal disinfection is effective at controlling re-infections with those species for which it is known to work, which are generally thermally intolerant bacteria. If these can be reduced by correct laundering, then they cease to be much of a problem and the human body can deal with the tiny numbers surviving. Where implied thermal disinfection is much less effective is for contamination involving thermotolerant micro-organisms, such as Bacillus cereus3 and Clostridium difficile4. If these infections get into a ward containing vulnerable patients, they can be extremely difficult to eradicate. The presentoutbreaks of Covid-19 worldwide pose a further serious risk and launderers are justified in taking a cautious approach. Laundry which is potentially contaminated with Covid-19 should be laundered with processes which deal with this risk. It should not be ignored.
How can the industrial laundry answer the challenge?
There is an increasing argument that all laundry should be treated as potentially contaminated with Covid-19 and processes modified accordingly. This will affect all industrial launderers, including healthcare, hospitality, workwear and cruise line operators. There are three reasons for this being a strong recommendation:
- There are independently certified thermo-chemical processes to deal with Covid-19, already available from leading suppliers and further research is almost certainly continuing. This could eradicate the need to rely solely on implied thermal disinfection at high temperature.
- Some experts have predicted that this virus could form a permanent feature of the annual flu season, in which case it could be with us for a long time. A targeted vaccine and skilful laundering will both have a part to play.
- Covid-19 appears to be a difficult virus to destroy, so some processes may be required to feature the word ‘cumulative’ in their certification. That is to say that they rely on regular repeat laundering to keep the virus under control, rather than being useful just in the event of a local outbreak. Waiting for an outbreak before acting is ‘closing the stable door after the horse has bolted’, especially as Covid-19 has quite a long incubation period (during which onward transmission of the virus is quite possible5).
What should the small on premises laundry be doing?
Multi-ship cruise lines, large national and international hotel chains and the multisite care-home operators, will have access to the facilities and resources required to put revised and/or expanded procedures, training and supportive infrastructures in place very quickly. The adverse publicity for cruise lines of historical outbreaks of Norovirus and recent fatalities from Covid-19 bring back uncomfortable memories. As market leaders they will be using the specialist, cutting-edge knowledge now available from expert laundry technologists worldwide to update their laundry training, equipment profiles, detergent and washing technology and get this into their group procedures manuals (and health and safety manuals) in every ship, care-home and hotel across their organisation.
So where does this leave the care home laundry, which might have just two or three staff working a daily 4-hour shift? What about the small, on-site hotel laundry which uses any available member of staff to load and start machines as needed? The small cruise liner with just washer extractors might have very experienced operators, but will they have the skills and knowledge necessary to deal with Covid-19? Trying to answer these questions highlights the key problem facing these sectors. How can they quickly acquire the new skills and knowledge needed?
Immediate help for the small, single site or single ship operators could come initially from their chemicals’ suppliers, who should be able quickly to detail specific instructions on how to use their products to achieve linen which is disinfected to a level which is safe in this new climate. Users may find that it is they who have to demand this information and persist until they get it. Any user worldwide is welcome to address any queries on this to LCN and we will do our best to answer them. They might also find the next section of this article helpful.
European nations lead the way in management of disinfection in laundering
As long ago as 2002 the European Norme EN 14065 addressed the different problems in healthcare laundering and produced an excellent standard method to help managers to produce simple but watertight systems for assured disinfection. This standard was updated in 2016, to reflect the changes since then, for example in the rise of thermo-chemical disinfection and the decline in implied thermal methods.
EN 14065 does not specify any particular method of disinfection. It relies on the launderer and user together defining the quality of the final product in terms of the microbial and/or particulate contamination. The launderer then decides, with the help of its suppliers, how it is going to achieve this. This starts with identifying the laundering process itself and the procedures necessary to assure the user that this happens correctly every time. It will cover handling procedures from collection and bagging up in the healthcare facility itself through transport, processing, packing out and return to the user. Requirements involving machine selection, machine maintenance, training and routine monitoring quickly become apparent.
The beauty of the standard is that it is not prescriptive (it does not specify particular processes or tolerances)– it is a guide for effective management. It is designed to generate a watertight set of procedures, agreed between launderer and customer, and an acceptable level of assurance as to the quality of the final degree of decontamination. In some countries (such as the UK) this approach has replaced implied thermal disinfection (which was very prescriptive, with defined time/temperature controls, for example). The assurance that the agreed decontamination is being routinely achieved is based on simple monitoring, opening the way for a wide variety of different means of achieving this (including implied thermal disinfection for those who still prefer this).
Although the methodology of EN 14065 is very simple, the language of this type of standard might be confusing for a launderer, largely because of the terminology, which is similar to that used in the international quality standard ISO 9000. For this reason, launderers might prefer to build on the experiences of other launderers and seek help from one of the national laundry technology bodies who have converted the principles of EN 14065 into simple steps which the launderer can readily adopt.It will take about 12-months to get a fully-fledged EN 14065 system up and running and ready for the laundry to seek certification from a national standards body. This qualification has rapidly become a requirement for many healthcare contracts, especially those involving acute hospitals. The care-home sector is lagging behind, but this could and should change in the near future. Covid-19 has increased the discussion on the need for validated hygienic processing and this is unlikely to diminish. It therefore follows that EN 14065 could become an increasing requirement across both healthcare and hospitality sectors in the future and that is something that all those responsible for a laundry operation should now consider as a matter of some urgency.