Potential Contamination
of Healthcare Workers’
Attire During a
Pandemic
By Peter Graves, BSN, RN, CNOR; and Maureen Spencer, M.Ed.,
BSN, RN. CIC, FAPIC
T
oday more than ever, transmission of pathogens is on
everyone’s mind. For good reason. SARS CoV-2, the virus
that causes COVID-19 infection, is highly transmissible and
contagious causing world-wide disease and overwhelming
the healthcare system. On the front lines of the battle
against the COVID-19 are physicians, nurses, and countless
dedicated healthcare workers. These healthcare workers
are wearing available personal protective equipment (PPE),
sometimes new, and in some facilities, they are re-using their
PPE. In either situation, it can be reasonably anticipated that
contamination of the healthcare workers clothing (uniform,
scrubs) worn under the PPE can become contaminated during
their workday. This raises a concern for transmission and
cross-contamination.
Healthcare Personnel Attire (HPA)
It is important to recognize and define the modern
healthcare personnel’s attire (HPA) in the era of COVID-19.
It is well recognized in the literature, prior to the COVID-19
pandemic, that there is a paucity of studies that allowed
professional organizations to make evidenced based
recommendations on HPA. 1 Traditional HPA has been viewed
as portraying a professional appearance. Today however,
scrubs are typically worn throughout the healthcare facility,
clinics, and even in public. Historically, scrubs were worn
only in the operating room where they were facility provided
and laundered in a commercial facility. Today, scrubs are
often worn for comfort or may be required based upon
the clinical setting as defined by the organization. Prior to
the COVID-19 outbreak these were typically laundered at
home. Across the globe, healthcare settings are diverse and
healthcare workers and support staff often wear uniforms,
dresses, suits, trousers, blouses, white coats, fleece, sweaters
and other clothing made from various textiles. This creates
a conundrum for making standardized recommendations
to protect the entire healthcare team, their families, and
the community.
Compounding the challenges for healthcare workers
and healthcare organizations, SARS-CoV-2 is also rapidly
spreading in the community. 2 The Centers for Disease
Control and Prevention (CDC) acknowledges that the
virus can spread person-to-person, through contact with
contaminated surfaces, and from one’s hands when touching
mucous membranes and the face. 2 Today, concerns for HPA
contamination arises from both community exposures and
from within the healthcare settings. Healthcare worker
uniforms/scrubs are often worn from work to home which
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raises concerns for potential community spread. In 2014,
Bearman and colleagues recognized that studies “have
demonstrated contamination of healthcare personnel apparel
with potential pathogens.” 1 While the risk for transmission
of SARS-CoV-2 from contaminated uniforms/scrubs to the
community and into homes has yet to be established, it
does raise concerns nonetheless.
In some clinical settings (e.g., operating rooms, invasive
procedural areas), staff are required to change into facility
provided surgical attire. It is also commonplace today to
see healthcare workers wearing their uniforms/scrubs in
public, not just in proximity to the healthcare facility, but
in coffee shops, grocery stores, and other public spaces. In
a 2010 study by Nordstrom and colleagues discovered a
significantly higher bacteria counts from home-laundered
scrubs and unwashed scrubs. In the home-laundered scrubs
44 percent (18/41) were positive for coliform bacteria, but
no isolates were Escherichia. 3 Therefore, it is not at all a
stretch to consider the possibility that SARS-CoV-2 could
reside for a period of time on HPA.
Presently, healthcare workers frequently wash or sanitize
their hands and don and doff personal PPE. Since some PPE
may not completely cover HPA, and they touch and adjust
their clothing throughout the workday, contamination could
occur. Healthcare workers are also mobile, often moving
from area to area, encountering various environmental
surfaces, patients, and co-workers. They typically change
their uniforms/scrubs once a day, unless they become visibly
soiled or contaminated.
Contamination of Uniforms
There are many studies published on the contamination
of HPA in various clinical settings. From scrubs to neck ties,
lab coats to head coverings, HPA worn during the care
of patients can become contaminated, sometimes with
pathogenic organisms. 4-10 Today, we are experiencing a
pandemic where SARS-CoV-2 has been demonstrated to
survive on various surfaces from a few hours to days. 11
In a study by Bloomfield evaluating the surfaces of nurse’s
uniforms at the end of their shift, both Clostridium diifficile
(C. diff) and methicillin-resistant Staphylococcus aureus
(MRSA) were detected. 12 In a study by Treakle evaluating the
contamination of lab coats, 23 percent were contaminated
with MSSA and 18 percent with MRSA. 13 In a 2011 study
published by Wiener-Well, 60 percent of hospital staff
uniforms were contaminated with multidrug-resistant
organisms (MDRO). 6
With the recent finding that SARS-CoV-2 can survive
for days on common healthcare surfaces, 11 one needs
to be concerned with the potential transmission to the
healthcare workers uniform which is worn into and out
of the healthcare setting. In a 2012 observational study
conducted in six intensive care units, it was reported that
21 percent of patient and healthcare worker interactions
contaminated the gloves and gown of the care provider. 14
Reuse of PPE due to severe shortages are happening
today across the United States. Therefore, there is concern
that HPA could be potentially contaminated with pathogenic
may 2020 • www.healthcarehygienemagazine.com