Table 6. Summary of conclusions drawn from the current published literature and knowledge gaps relating to the role of textiles as fomites in the healthcare environment.

Subject area	Conclusion from current literature	Knowledge gaps
Contamination of Healthcare Textiles	Potential pathogens have been shown to contaminate the near-patient environment and healthcare worker attire. In vitro studies demonstrate that microorganisms can persist on textiles for several days. Textiles could therefore act as a reservoir for microorganisms, if they are able to transfer to other surfaces in sufficient numbers to cause disease.	In vitro studies may not adequately reflect in use conditions which might affect the observed survival. In particular, the load of microorganisms employed are often higher than natural levels of contamination, simulated soiling is used infrequently, and survival after dry transfer is not measured.
The Role of Healthcare Textiles in the Transmission of Infection	Microorganisms transfer between textiles and surfaces with less efficiency than non-porous surfaces. There is preliminary evidence for the transfer of microorganisms during simulated clinical activities, bedmaking and transportation of soiled linens. Outbreak case studies provide preliminary evidence of a link between HCAIs and textiles. The outbreak case studies indicate that minimising the contamination of textiles with microorganisms could reduce the risk of infections associated with healthcare textiles. Controls may include ensuring adequate decontamination of linen during laundering, monitoring for contamination of washing machines and rinse water and appropriate handling and storage of processed linen to prevent contamination.	There is a lack of direct evidence linking textile contamination and the transmission of HCAIs. High-quality controlled trials are required to provide evidence for the transmission of potential pathogens, or lack thereof, from healthcare textiles in the clinical environment. The small sample size and retrospective nature of outbreak case studies makes it difficult to conclude a direct link between the contaminated linen and outbreaks. Large epidemiological or intervention studies are required to provide more robust evidence of any direct link between contaminated textiles and HCAIs to conclude the scale of any potential transmission through this route.
Efficacy of Healthcare Laundry Processes	There is some evidence to suggest that potentially pathogenic microorganisms survive domestic laundering, particularly where conducted at low temperatures rather than those recommended by uniform policies. A disadvantage of domestic laundering is the lack of control and monitoring for decontamination compared to industrial laundering. Outbreak case studies have provided preliminary evidence for the transmission of infection by contaminated domestic washing machines, suggesting that contaminated healthcare worker uniforms could pose a risk of transmitting potential pathogens back into the clinical environment. Microorganisms, particularly thermotolerant species or spores, can survive industrial laundering processes.	Few published studies have investigated the survival of viruses during domestic laundering, which is of particular importance during the COVID-19 pandemic to prevent any risk of cross-contamination of SARS-CoV-2 from healthcare worker uniforms. There do not appear to be any published studies that have investigated the survival of coronaviruses during laundering. The significance of the contamination on industrially laundered textiles is not well understood, with only a small number of outbreak case studies investigating epidemiological links. There is a lack of standardised test methodology across the industrial laundering sector which would ensure the infection risk from processed laundry is low across the sector.