How Many Towels Should a Family of 4 Have
Mayo Clin Proc. 2012 Aug; 87(8): 791–798.
The Hygienic Efficacy of Different Hand-Drying Methods: A Review of the Evidence
Cunrui Huang
aSchoolhouse of Public Health and Plant of Health and Biomedical Innovation, Queensland Academy of Technology, Brisbane, Queensland, Australia
bCentre for Disease Control and Prevention of Guangdong Province and Guangdong Institute of Public Health, Guangzhou, Guangdong Province, Cathay
Wenjun Ma
bCenter for Disease Control and Prevention of Guangdong Province and Guangdong Institute of Public Health, Guangzhou, Guangdong Province, Red china
Susan Stack
cStack Masula Pty Ltd, Brisbane, Queensland, Australia
Abstract
The transmission of bacteria is more probable to occur from wet skin than from dry skin; therefore, the proper drying of hands after washing should be an integral role of the manus hygiene process in wellness care. This article systematically reviews the inquiry on the hygienic efficacy of unlike hand-drying methods. A literature search was conducted in April 2011 using the electronic databases PubMed, Scopus, and Web of Science. Search terms used were hand dryer and hand drying. The search was limited to articles published in English from January 1970 through March 2011. Twelve studies were included in the review. Hand-drying effectiveness includes the speed of drying, degree of dryness, effective removal of bacteria, and prevention of cross-contamination. This review found piffling understanding regarding the relative effectiveness of electrical air dryers. Yet, most studies suggest that paper towels can dry hands efficiently, remove bacteria effectively, and cause less contamination of the washroom environment. From a hygiene viewpoint, newspaper towels are superior to electric air dryers. Paper towels should be recommended in locations where hygiene is paramount, such as hospitals and clinics.
The 2009 human swine influenza A (H1N1) pandemic reminded health professionals and the community of the importance of hand hygiene to prevent the spread of diseases.1-eight The effectiveness of hand hygiene in infection command has been recognized since Semmelweis'due south observation in 1847 that the implementation of mitt washing reduced the number of deaths among women with puerperal fever.ix For centuries, hand washing has been considered the nigh important measure to reduce the burden of health care–associated infection.10-12
Mitt washing refers to washing hands with plain or antimicrobial soap and water.xiii In actual practise, it can vary considerably from a cursory rinse of the hands to extensive scrubbing. With adequate hand washing, significant reductions in the rates of infectious affliction have been reported in a variety of settings, such equally wellness intendance institutions,14,xv the nutrient industry,16,17 child twenty-four hours intendance centers,18 schools,19-21 and all customs and domestic situations.ane,22,23 Until now, however, a great number of studies have focused on topics such as paw-washing techniques,24 selection and handling of hand-washing agents,25-27 and how to improve manus hygiene adherence for wellness care workers.28-31 Less is known nearly the role of paw drying after washing and the relative efficacy of dissimilar hand-drying methods in reducing contamination.
The proper drying of hands should be an essential component of effective hand hygiene procedures.xi,thirteen Coates et al32 reported that washing hands with either lather and water or water alone combined with drying on paper towels can effectively remove bacteria from the hands. All the same, if hands are only shaken dry after washing, some bacteria are likely to remain. Patrick et al33 investigated the human relationship between the amount of residual h2o left on the hands and bacterial translocation levels. The transmission of bacteria was more likely to occur from wet hands than from dry easily. Merry et al34 also confirmed the important role of remainder water on the hands in the level of touch on- or contact-associated contamination.
Although studies take reported the importance of thorough hand drying after washing, the role of hand drying has not been widely promoted, and its relevance to manus hygiene and infection control seems to take been disregarded.35 Lack of attending to this aspect may negate the benefits of careful paw washing in health intendance. So far, lilliputian enquiry has been conducted to examine the contribution that proper hand drying makes to the overall effectiveness of mitt hygiene practices. The purposes of this article are to provide a systematic review of research examining the operation of different hand-drying methods and make recommendations for time to come research.
Methods
An extensive literature search was conducted in April 2011, using the electronic databases PubMed, Scopus, and Web of Scientific discipline. The search was express to articles published in English language from January 1970 through March 2011. The search terms used were hand dryer and hand drying.
Our goal was to analyze the hygienic efficacy of different hand-drying methods and and so recommend the best manus-drying option for health care professionals. Two inclusion criteria were used to select articles. First, studies had to compare the hygiene operation of at least 2 mitt-drying methods; studies solely focused on reporting the effectiveness of hand drying were excluded. 2nd, studies had to use an empirical research arroyo with quantitative outcomes; qualitative and review manufactures were excluded. Nosotros as well excluded conference abstracts to focus on more substantial results. 2 contained researchers (C.H. and Westward.M.) participated in all aspects of the review. They compared and discussed their findings with regard to inclusion and exclusion criteria. Disagreements were resolved by discussion with a third member of the team (Southward.S.).
Information extraction consisted of a v-stage process (Figure). Offset, duplicate articles were identified and removed before analysis. Second, the title and abstract of remaining articles were screened for eligibility against the inclusion criteria. Tertiary, total-text articles were retrieved and assessed co-ordinate to their study design and scientific approach. 4th, the references and citations of those articles identified were inspected to ensure that all relevant studies were included. Finally, a search of materials (gray literature) that fall exterior the mainstream of published journal and monograph literature, such equally government documents, conference proceedings, research reports, working papers, discussion papers, and newsletters, was conducted using the Google Scholar search engine.
Menstruum diagram of literature search strategy.
aRegime documents, conference proceedings, research reports, working papers, discussion papers, and newsletters.
All manufactures identified were critically reviewed by the authors and included as appropriate to provide an overview of the topic. The quality of this review was assessed using a critical appraisement framework. The authors used the Critical Appraisal Skills Programme checklist36 to ensure that the research question had been systematically identified, appraised, and summarized co-ordinate to predetermined criteria.
Results
A total of 12 articles were included in the review. Paper towels, fabric towels, and hot air dryers are commonly used to dry washed hands. Hands can also dry out by evaporation. Air dryers are electrical devices used to dry out hands, and they may operate either with a push button or automatically with an infared sensor.37 In recent years, a new version of air dryer (ie, jet air dryer) has been introduced. According to the manufacturer, a jet air dryer is unlike from other conventional hot air dryers because information technology uses a jet of unheated air and incorporates an air filter.38 The hygienic efficacy of mitt drying includes drying efficiency, the constructive removal of bacteria, and the prevention of cantankerous-contamination.39-41
Drying Efficiency
Patrick et al33 compared the drying efficiency of cloth towels and hot air dryers. The results indicated that residual water was more efficiently removed from the hands by cloth towels. After x seconds of drying with a single-serve material towel, the residual h2o on the hands was reduced to 4%. With fifteen seconds of drying, the remainder water was reduced to ane%. Even so, hot air dryers were much slower and took 45 seconds to reduce the residual water to 3%. Redway and Fawdar39 examined the drying efficiency of paper towels, hot air dryers, and jet air dryers. They found that paper towels and jet air dryers were almost equally efficient at drying hands. After ten seconds of drying, both achieved 90% dryness. Hot air dryers took considerably longer and needed a drying fourth dimension of forty seconds to accomplish a similar dryness.
In add-on, Patrick et al33 conducted an observation study in male and female person washrooms to determine the length of time that people spent drying their hands. Washrooms had either single-serve cloth towels or hot air dryer systems installed only not both. They found that male users spent an average of 3.five seconds on fabric towels and 17 seconds under hot air dryers. The same figures for women were 5.2 and 13.3 seconds. They found that using a drying fourth dimension of 5 seconds with material towels would accomplish 85% dryness of the hands, but using xx seconds of drying time under hot air dryers would reach less than 70% dryness. Knights et al42 also reported that hot air dryers in normal use can only reach 55% dryness of the hands for men and 68% dryness for women. In contrast, fabric towels and newspaper towels can generally achieve 90% or more dryness for both sexes.
Removal of Leaner
Although the degree of wetness encourages the survival and manual of leaner on the hands, other factors also influence the hygiene performance of a hand-drying method. Redway and Fawdar39 assessed changes in the number of leaner on the easily before and subsequently the use of paper towels, hot air dryer, or jet air dryer. Finger pads were sampled by contact plates, and the palms were sampled past swabbing and inoculation of agar plates. They constitute that paper towels reduced the numbers of all types of bacteria on the hands. However, the hot air dryer increased all types of leaner on the hands. The jet air dryer also increased most types of bacteria, but the increases were less than with the hot air dryer. In their written report, a new hot air dryer and a new jet air dryer were used; hence, the authors claimed that any increases in bacterial numbers subsequently the utilise of dryers must exist due to factors other than the contamination of the dryers themselves.39 Hanna et al43 and Blackmore44 compared the number of bacteria remaining on easily after drying with newspaper towels, cloth towels, or hot air dryers. Bacteria samples were taken from the hands onto contact plates. The authors also reported that hot air dryers were the least effective method of removing leaner from done easily.
In contrast, another study reported that hot air dryers are superior to paper and cloth towels. Ansari et al45 compared the effectiveness of paper towels, fabric towels, and hot air dryers in eliminating rotaviruses and Escherichia coli from the easily. For air drying, the done finger pads were held 10 cm from the nozzle of hot air dryers for ten seconds. For drying with newspaper towels or cloth towels, finger pads were placed onto the absorbent surface with uniform pressure for 10 seconds. The authors did non contain any friction in mitt drying because of the difficulties in standardizing and accurately representing field conditions. To evaluate the effects of dissimilar drying procedures, the microorganisms on the finger pad were eluted with balanced salt solution, and the eluates were then titrated. The report found that drying with hot air dryers produced the highest reduction and drying with cloth towels produced the lowest reduction in the number of both microorganisms. However, Ansari et al45 also mentioned that friction is frequently applied when hands are dried with newspaper or cloth towels. Whether friction can result in a further reduction of contamination during mitt drying remains to exist determined.
Some studies found no significant difference amidst mitt-drying methods for removing leaner from done easily. Gustafson et al46 examined the hygiene performance of newspaper towels, cloth towels, hot air dryers, and spontaneous evaporation. The written report compared the divergence between the amount of bacteria on the easily after drying by 4 methods. Bacteria were determined using a modified glove-juice sampling process, and the results revealed no difference amongst the 4 methods. Taylor et al47 and Matthews and Newsom48 investigated the residuum bacteria on the hands after drying with hot air dryers and paper towels using contact plates. They also found no divergence regarding removal of bacteria between the 2 methods.
Other studies have explored the differential results. Yamamoto et al49 used a contact plate method to evaluate the upshot of hot air dryers when hands were rubbed and when hands were held stationary. When hands were rubbed, leaner on the hands increased significantly afterwards fifteen seconds of apply. When hands were held stationary, leaner on the hands decreased. The authors further investigated the differences in bacterial numbers on hands betwixt drying with hot air dryers and paper towels. Newspaper towels were found to be more effective for removing bacteria from fingertips but non palms and fingers. This study finally concluded that hot air drying of stationary easily for 30 seconds with UV low-cal was more than effective for removing bacteria than paper towel drying. Drying with hot air dryers while rubbing hands was less constructive than using paper towels. Snelling et al35 compared a jet air dryer confronting 2 models of hot air dryers with regard to bacterial transfer after drying and the effect of rubbing hands during dryer utilize. For a drying fourth dimension of 10 seconds, both hot air dryers were associated with higher levels of bacteria transfer than when no dryer was used at all. However, the jet air dryer led to much less bacterial transfer than hot air dryers. When hot air dryers were used for 30 to 35 seconds, their functioning improved greatly only was still worse than that observed with the jet air dryer subsequently 10 seconds of use. Also, rubbing hands when using hot air dryers inhibited the overall reduction in bacterial numbers. To further compare with the paper towel method, the authors sampled leaner from palms, fingers, and fingertips using contact plates. They found that drying hands with paper towels was the best ways of removing bacteria from the easily, particularly from fingertips.
Effect on Cross-contamination
Washrooms and toilets are recognized as places at high risk of bacterial growth and transmission.50 Every time a toilet is flushed, a fine aerosol mist can be sprayed into the air, over an area of up to half dozen g2.51,52 This mist may comprise many types of fecal bacteria that tin cause diseases.53 Ngeow et al54 investigated the potential risk of hot air dryers contributing to airborne infection in a hospital setting. The study compared bacterial dispersal caused by hot air dryers with that caused by paper towels. The dispersal of bacteria by hot air dryers was constitute within a radius of approximately 3 ft from hot air dryers and to the investigator's laboratory coat. When paper towels were used for hand drying, no dispersal of bacteria was found. The authors therefore claimed that hot air dryers are unsuitable for use in critical care areas because they may contribute to cross-infection either via airborne broadcasting or via contaminated personnel. Hanna et al43 besides reported that hot air dryers resulted in a substantial number of airborne bacteria in the vicinity of the user, whereas paper and cloth towels produced negligible contamination of the surrounding environment. Redway and Fawdar39 evaluated the contamination of the washroom environs acquired by different hand-drying methods. Jet air dryers were found to disperse manus contamination to a altitude of at least 2 m. Newspaper towels and hot air dryers were much better than jet air dryers regarding contagion of the washroom surround. Paper towels were too better than hot air dryers for contagion directly below the device, merely there was no difference at greater distances.
Other studies have reported that drying easily with hot air dryers is not likely to generate airborne infection. Taylor et al47 evaluated whether hot air dryers change the levels of airborne microorganisms in the washroom environment. They found that air emitted from the dryer outlet independent fewer microorganisms than air inbound the dryers. They as well found that levels of microorganisms on the external surfaces of hot air dryers were not different from those on other washroom surfaces. Thus, the authors argued that hot air dryers were appropriate for use in both the health care and food industry. Similarly, Matthews and Newsom48 compared the leaner aerosols released into the air when drying hands by using iv different models of hot air dryers and past using paper towels. They establish no difference between aerosols liberated by paper towels and 2 models of hot air dryers, whereas the other 2 models of hot air dryers generated fewer aerosols than paper towels. They concluded that hot air dryers were safe from a bacteriologic viewpoint. However, it could exist argued that, in these studies, the air from the fans tin can dilute the aerosols, so the results are not strictly comparable.
Other Issues
User Preference
User preference is an of import determinant of hand hygiene adherence.40 A survey of 2000 citizens in Europe was conducted in 2008 to explore user perferences regarding different hand-drying methods.55 The survey revealed that 62% of users chose paper towels as their preferred hand-drying method, followed by hot air dryers (28%) and textile roller towels (10%). Another survey of 2516 Usa adults in 2009 notwithstanding establish that about people preferred to dry their easily with paper towels.56 If they had a choice, 55% of respondents selected paper towels, 25% selected jet air dryers, xvi% selected hot air dryers, 1% selected textile roller towels, and 3% were not sure. In Australia, a recent telephone survey institute that food manufacturers, facility managers, and commercial cleaners also rated paper towels as their most preferred method of hand drying.57 Hence, given the strong preference for using paper towels, hand hygiene adherence would perchance decrease if paper towels are non available in washrooms.
Skin Irritation
It is known that some antibacterial soaps, surgical manus preparations, and chlorine and iodine solutions can irritate the skin of hands.58,59 Use of air dryers may cause easily to become excessively dry, rough, and ruddy. Easily can go irritated with frequent washing and drying.sixty Affected persons often feel a feeling of dryness or burning; skin that feels rough; and erythema, scaling, or fissures. When the hands become irritated, health care workers may non launder their hands equally frequently or every bit well. Business concern regarding this effect of air dryers could go an important cause of poor credence of mitt hygiene practices.
Racket
Air dryers, specially jet air dryers, are plainly noisier than paper towels or cloth towels. According to Redway and Fawdar,39 the mean decibel level of using a jet air dryer at 0.5 thousand was 94 dB, which is in excess of that of a heavy truck passing 3 m away. When two jet air dryers were used at the same time, the decibel level at a altitude of 2 thousand was 92 dB. Therefore, in washrooms with jet air dryers, the dissonance level could constitute a potential risk to those exposed to it for long periods.
Environmental Effect
The use of paper towels may have adverse effects relating to waste product disposal and environment sustainability. Nonetheless, limited inquiry has been conducted to examine the environmental effect of different manus-drying methods. Budisulistiorini61 assessed the life bike of paper towel and hot air dryer methods for mitt drying. According to Budisulistiorini's study, the paper towel method emits relatively higher greenhouse gases than the hot air dryer method (1377 vs 1337 kg of carbon dioxide equivalent). In terms of surround sustainability, the hot air dryer method surpasses the paper towel method with better scores for vi indicators (respiratory organics, respiratory inorganics, ozone layer, ecotoxicity, acidification/eutrophication, and fossil fuels) compared with 5 indicators (carcinogens, climate alter, radiation, land utilise, and minerals) for newspaper towels.61
Cost
Using paper towels is more plush than using air dryers. Paper towels must be replaced oftentimes, whereas air dryers usually require little maintenance. Budisulistiorini61 argued that the paper towel method is labor intensive and also affected by users' behavior. However, air dryers can be costly to purchase and install. Therefore, those responsible for facility management should perform a careful cost analysis to determine whether they are cost-constructive in their building.
Discussion
Manus drying should exist an essential function of the mitt hygiene process in health intendance.11,13 Still, in that location appears to exist little understanding regarding the most hygienic method of mitt drying. The results of different studies accept also been conflicting.62 Some studies indicated that electrical air dryers are of inferior effectiveness when it comes to the outcome of hygiene,39,43,44 whereas others were of a firm opinion that they are a safety and effective ways of hand drying.47,48
The large discrepancy among studies may be partly explained by the differences in the experimental protocols used. The degree of wetness is an important cistron in determining the number of leaner detected. Taylor et al47 claimed that the contact plate results appeared to reflect the caste of wetness after drying rather than the bodily number of bacteria on the hands. Some investigators used a long drying fourth dimension of hot air dryers in their studies, whereas others used a short drying time. For example, Matthews and Newsom48 used hot air dryers until the study participants had completely dry easily, unremarkably for 1 infinitesimal. Notwithstanding, Redway and Fawdar39 attempted to reproduce people'south usual manus-drying practices as closely as possible. In their study, the mean manus-drying times were 10 seconds using paper towels and 20 seconds using hot air dryers. Then the significantly poorer hygiene performance of hot air dryers could be due to their depression drying efficiency and consequently the greater amount of water remaining on the hands.
Although jet air dryers had drying efficiency similar to paper towels, their hygiene operation was notwithstanding worse than paper towels.39 The differences in bacterial numbers after drying with air dryers and paper towels could be due to other factors rather than the percentage of dryness solitary. Friction can dislodge microorganisms from the pare surface during both hand washing and drying. Antimicrobial agents in soaps have too little contact time to take bactericidal furnishings during a single use or with sporadic washings, making friction the virtually important element in hand drying.xl It is likely that paper towels work better because they physically remove leaner from the hands, whereas hot air dryers and jet air dryers cannot.39 In many instances, however, rubbing hands with hot air dryers to hasten drying would just pb to greater bacterial numbers and airborne dissemination.49 It might exist that rubbing easily causes bacteria to migrate from the pilus follicles to the peel surface.35,44
Many studies have found friction to be a key component in mitt drying for removing contamination. For instance, Sprunt et al63 and Coates et al32 reported that bacteria were removed from washed hands by the mechanical annoying activeness of drying with paper towels. Taylor et al47 and Yamamoto et al49 conducted microbiological testing of the newspaper towels later use, which indicated that many bacteria were transferred from the hands to paper towels.
Air movement can encourage the dispersal and transmission of bacteria and increment the chance of cross-contamination. Surrounding air in the washroom is recirculated past air dryers. This recirculation may result in the dispersion of infective aerosols already in the atmosphere and those generated past easily being rubbed together for drying.45 Used air dryers in washrooms are oftentimes contaminated and can emit bacteria in their air flow.39 So, at that place is a potential risk of persons continuing in front of air dryers acquiring the bacteria beingness dispersed in the air current toward them. The bacteria can be inhaled or tin can be deposited on the person's body or clothes, thus making him/her a potential mobile source of infection.54
Overall, the hygienic efficacy of the hand-drying method is not only the percentage of dryness of the hands but also the removal of bacteria from washed hands and the prevention of cantankerous-contamination. Hot air dryers are by and large not recommended for use in health care settings because such dryers are relatively slow and noisy and their hygiene performance is questionable.44 Fabric roller towels are not recommended because they tin can become common-use towels at the end of the roll and tin be a source of pathogen transfer to clean hands. Recently, jet air dryers have undergone contained certification within the food safety arena in Australia, attesting to their increased hygiene benefits as opposed to the traditional hot air-drying method.64 However, the criteria and procedure of obtaining this type of certification remain questionable. The health and safety aspects of jet air dryers for use in locations where hygiene is paramount should still be carefully examined by the scientific community. Therefore, this makes paper towel drying, during which niggling air motility is generated, the most hygienic option of hand-drying methods in health intendance.39
The principles of hand hygiene are universal. They do not modify because of sex, pare color, or hand size.40 On the basis of our review, drying hands thoroughly with single-use, disposable newspaper towels is the preferred method of hand drying in terms of manus hygiene. This determination raises the question of what types of newspaper towel should be used for manus drying. Does the quality of paper towel have an event on paw hygiene adherence? When recycled paper is used for hand drying, what kinds of studies are appropriate to appraise the cost benefit of using recycled paper? Many questions remain unanswered. Unlike types of paper towel may take different absorption characteristics, which tin influence their capacity to remove bacteria from washed hands.45 The quality of newspaper towel is of import because poor-quality towels can damage skin past chafe and ineffective drying.41,65 Recycled paper would be more acceptable in the future because it tin can contribute to environment sustainability. Such research may take the potential to improve hand hygiene practice and sustainable development significantly.
The maintenance of a clean environment around paper towels is likewise important. Paper towels deposited in bins could act equally a bacteriologic reservoir if disposal is not managed properly.47 Regular sanitary cleaning of washrooms is the only way to reduce bacteria numbers and preclude cantankerous-contamination.51 Moreover, newspaper towels require delivery to users from dispensers. The risk of potential contamination among dispenser exits, paper towels, and hands should be considered in the pattern, structure, and use of paper towel dispensers.66 Architects working in the wellness care industry should also be aware of these issues when designing equipment for new facilities.67
Decision
Hand hygiene has the potential to prevent diseases and reduce wellness care–associated infections. The proper drying of hands after washing should be an essential component of constructive mitt hygiene procedures. Most studies have constitute that paper towels tin dry hands efficiently, remove bacteria effectively, and cause less contamination of the washroom surround. From a hygiene standpoint, paper towels are superior to air dryers; therefore, paper towels should be recommended for utilise in locations in which hygiene is paramount, such as hospitals and clinics. The provision of paper towels should also exist considered as a means of improving paw hygiene adherence amid wellness care workers. Our findings may have implications for health professionals and medical educators aiming to design constructive programs to promote paw hygiene practices.
Acknowledgments
We give thanks Shannon Rutherford, PhD, senior lecturer of the Griffith University, for her helpful comments in the preparation of the submitted manuscript.
Footnotes
Potential Competing Interests: Susan Stack has served as an occupational wellness and safe consultant for Kimberly-Clark, Sydney, Australia.
Supplemental Online Material
Video 1:
Author Interview Video
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