Public perception and the social and microbiological significance of uniforms in the prevention and control of healthcare-associated infections: an evidence review

Background: There is significant public concern in England about health carers wearing uniform in public places and that contaminated uniforms may contribute to the spread of healthcare-associated infections (HCAI). Evidence of a link between contaminated uniforms and HCAI, or that wearing uniforms in public spaces may contribute to the spread of infection from the healthcare environment to the wider community, has not previously been systematically assessed. Methods: A comprehensive review was conducted that focused on patient perceptions of the significance and infection risks of uniforms and microbiological and clinical evidence of the infection risks to patients from contaminated uniforms. Results: Uniforms play an important role in the public's perception of healthcare professionals. This is constructed from social and cultural images leading patients to judge the professionalism and trustworthiness of practitioners based on the clothes they wear. The colour and design of uniforms may reinforce socially constructed concepts of cleanliness that result in unachievable expectations. Evidence directly related to the laundering of uniforms is limited. Small scale studies show that uniforms and white coats become progressively contaminated during clinical care and most microbial contamination originates from the wearer of the uniform. Although some studies theorise that uniforms may transmit HCAI, no studies demonstrated this in practice. A small number of studies evaluated the phases of the wash cycle in hospital laundries for patient linen but not uniforms. They indicate that micro-organisms are removed and killed during laundering, and dilution during washing and rinsing is important. Significant reductions in micro-organisms occur at lower temperatures more commonly used in home laundering. A small number of studies show that home laundering provides effective decontamination. We found no recent studies that accounted for advances in domestic washing machine and detergent technology or that addressed the theoretical infection risk linked with wearing uniforms in public places. Conclusion: Despite the limited amount and quality of the evidence, the general public's perception is that uniforms pose an infection risk when worn inside and outside clinical settings. This is reinforced by media comment and a lack of clear, accessible information and may have a damaging effect on the relationship between professionals and patients and the public image of healthcare workers. There is no good evidence to suggest uniforms are a significant risk, that home laundering is inferior to commercial processing of uniforms or that it presents a hazard in terms of cross-contamination of other items in the wash-load with hospital pathogens. It is essential that the evidence is considered in a balanced way and not over-emphasised in the development of uniform policy and that the general principles of infection control are stressed.