Proper hand hygiene is a fundamental component of infection prevention and control. Consequently, both WHO and ECDC have issued guidance on optimal hand washing to minimise the spread of bacteria. In hospital settings, where toilets are often frequented by visitors, staff and patients – whose immune systems may already be vulnerable – hand hygiene and the prevention of cross infection is of critical importance.
While there is guidance on hand washing, there is less advice on the role of hand drying. Professor Mark Wilcox of Leeds University and Leeds Teaching Hospitals, and Keith Redway, Emeritus Professor formerly of the University of Westminster, have undertaken a range of studies examining the impacts of different hand drying methods on the spread of microbes. They have analysed the performance of tissue paper towels, roller towels, warm air dryers and jet air dryers. Studies show that electric dryers contaminate both the air and surfaces in toilets with higher levels of bacteria and viruses than other options. [i],[ii],[iii],[iv].
Professor Wilcox’s latest research, a multisite hospital study across three countries – France, Italy and UK – found higher levels of antibiotic-resistant bacteria in toilets equipped with jet air dryers – including MRSA and ESBL-producing enterobacteria and enterococci. The authors conclude that paper towels offer the most hygienic way to dry hands and minimise the spread of bacteria following a visit to the toilets.
The study design
The study was designed in Leeds and then executed independently by respected research scientists at two further hospitals – Professor Frédéric Barbut of the Infection Control Unit, Hospital Saint-Antoine AP-HP, Paris, France; and Professor Silvio Brusaferro, Department of Medicine, Udine University Hospital, Italy.
Each hospital compared two toilets frequented by patients, visitors and staff. Both were equipped with paper towel dispensers and jet air dryers but offered only one option at any given time. The independently designed and executed study was undertaken in 2017 and supported by a grant from ETS.
Key findings across the three markets
In general, bacterial contamination in toilets using paper towels (PT) was lower than in those using jet air dryers (JAD), and total bacterial recovery was significantly greater from JAD outer surfaces versus PT dispensers.
In UK toilets - recovery of MSSA was 3 times more common and 6-fold higher from JAD versus PT surfaces. MRSA was recovered 3 times more often from the JAD surface or the floor beneath compared with PT sites. Significantly more ESBL-producing bacteria were recovered from washroom floors during JAD vs PT use.
In France – higher numbers of bacteria were recovered from the floors and drier surfaces in the JAD setting than when using PT. ESBL-bacteria were recovered from dust twice as commonly during JAD use than during PT use.
In Italy – dispersion of microorganisms was over 25 times greater with JAD than with PT.
Findings have significant implications for hand drying guidance in healthcare settings
The findings have important implications for minimising the risk of cross-infection in hospital toilets. They highlight the need for proper consultation between Infection control Teams (doctors and nurses working in infection prevention and control) and facilities managers when taking decisions about which type of hand drying method to offer.
Health authorities across Europe should evaluate whether to issue specific guidance on optimal hand drying. German hospitals already recommend paper towels in toilets as do NHS Scotland, and both the French Hospital Hygiene Board, SF2H, guidance and that of NHS Scotland recommend jet air dryers are not used in healthcare settings because of the higher levels of bacteria dispersal and propagation.
In healthcare settings, selecting paper towels as the method of hand drying could prove crucial in upholding better hygiene and health.