Journal of Infection Prevention
© The Author(s) 2018
Article reuse guidelines:
Hand hygiene is universally accepted as the single most
important strategy for preventing and reducing healthcare-
associated infections (HCAIs), as well as being critical for
patient and practitioner safety. It is our hands that we use to
care, our hands to impart comfort and reassure our patients;
and yet the same hands can act as vehicles to transmit
microorganisms which can impact on patient safety, caus-
ing harm and even killing. Promotion of improved hand
hygiene is thus recognised as being a crucial measure in
public health and is considered to be an integral component
of the practice of infection prevention (Bloomfield et al,
2007). As such, the notion of the most effective method for
performing hand hygiene has been a particularly active area
The neglected element of hand hygiene
- significance of hand drying, efficiency
of different methods and clinical
implication: a review
John Gammon1 and Julian Hunt2
Hand hygiene is a fundamental strategy for controlling the spread of infection. Careful hand drying is integral to the
process of hand hygiene, which aims to optimise the removal of potentially pathogenic microorganisms. Ineffective hand
drying results in wet hands that are an infection risk increasing the potential for cross-infection, occupational contact
dermatitis for healthcare practitioners, harm to patients and environmental contamination.
Evidence indicates that there has been limited research regarding the significance of hand drying and the efficacy and
clinical impact of different drying methods. The purpose of this review paper was to scope and evaluate the existing
literature pertaining to hand drying; to examine the clinical consequences associated with wet hands for patients,
healthcare practitioners and the clinical environment; to assess the efficacy of different drying methods; to consider the
impact on patient safety; and to progress the research, debate and practice relating to hand drying. The methodological
framework applied in this review was that of Arksey and O’Malley (2007). Twenty-one papers identified from 112 abstracts
screened were included in the review. Analysis identified three primary themes emerging from the literature: (1) efficacy
of hand drying methods; (2) drying method and microbial translocation, dispersion and environmental contamination; and
(3) drying methods and environmental sustainability. This review highlights the equal importance of hand drying in the
process of hand hygiene and suggests that the efficacy of hand drying is a critical factor in the prevention of the transfer of
microorganisms to the environment, and from person to person following hand washing. In conclusion, this paper argues
that greater attention needs to be given to hand drying in terms of practice, policy and research and its importance in
clinical settings given greater focus.
Hand hygiene, hand drying, wet hands, translocation, review
Date received: 19 February 2018; accepted: 21 September 2018
1 Innovation, Engagement and Organisational Development, Swansea
University, Swansea, UK
2 College of Human and Health Sciences, Room 111, Swansea University,
Singleton Park, Swansea, UK
Julian Hunt, College of Human and Health Sciences, Room 111, Swansea
University, Singleton Park, Swansea SA2 8PP, UK.
815549BJI Journal of Infection PreventionGammon and Hunt
2 Journal of Infection Prevention 00(0)
of research (Magiorakos et al, 2010) and the importance of
thorough cleansing of the hands with soap and water or a
sanitiser to reduce the burden of HCAIs is well docu-
mented, having been heavily researched and publicised for
a number of years by campaigns and initiatives such as the
NHS CleanYourHandsCampaign (Gould et al, 2007; Stone
et al, 2012).
Hand drying is integral to effective hand hygiene pro-
cesses. Correct drying of hands after washing is vital for best
infection prevention and should be an essential component
of hand hygiene procedures and practices (Boyce and Pittet,
2002; Centres for Disease Control and Prevention, 2002;
National Health Service Professionals, 2013; World Health
Organization, 2009). The significance of hand drying encom-
passes not only the removal of moisture from the hands but
involves mechanical friction which further reduces the bac-
terial load and thus transfer of microorganisms (Taylor et al.,
2000; Yamamoto et al., 2005). Nonetheless hand drying is a
much-neglected aspect of hand hygiene, with limited evi-
dence relating to the options for hand drying, the efficacy of
different methods of hand drying in reducing contamination,
the amount of consequential microbial dispersion into the
clinical environment, the efficacy, frequency and compliance
of drying by healthcare practitioners and the consequences of
wet hands for the healthcare practitioner.
The purpose of this paper is to offer a critical review of
research examining the clinical importance of hand drying
and the implications of wet hands for patients, healthcare
practitioners and the clinical environment, to assess the
efficacy of different drying methods, to consider the impact
on patient safety, and to progress the research, debate and
practice relating to hand drying.
Methods of review
This review drew on the five-stage methodological frame-
work suggested by Arksey and O’Malley (2007). These five
stages are: identification of research questions; identifica-
tion of relevant studies; study selection; charting the data;
and collating, summarising and evaluating the results of the
scoping review. The research questions identified were:
What is the research supporting and evidencing con-
temporary hand drying practice and procedures?
To what extent does ineffective hand drying, and
consequently wet hands, impact on infection preven-
tion and control (IPC)?
What is the impact and efficacy of contemporary
hand drying methods?
Utilising Arksey and O’Malley’s (2007) framework ena-
bled an examination of the extent, range and nature of
research activity relating to hand drying, the identification
of gaps in the existing literature, and provided rigour and
transparency in terms of the methods adopted, allowing
replication and validity of the review findings. The credi-
bility and reflexive nature of this framework, together with
its wider recognition, were the reasons for its application.
The framework used to critically appraise the quality of
included studies was that of Greenhalgh (2010).
Electronic searches were undertaken of ASSIA, Medline
and PubMed databases for research that had collected data
about some aspect of hand drying. The review was limited
primarily to English language studies in the health arena
but not to any particular nation state. The search terms used
were hand drying, hand hygiene, wet hands, drying meth-
ods and environmental contamination. The abstracts of
potentially relevant citations were examined to determine
the relevance of the original research. Full texts of all rele-
vant articles were then obtained. In addition, bibliographies
and secondary references of obtained articles were exam-
ined for additional studies. Policy documentation and
reports were further searched for online.
Eligibility criteria for inclusion of articles in this review
were English language papers reporting empirical research
and published between 1985 and 2018, that related to
aspects of hand drying, most specifically papers that
focused on our identified research questions. We define an
empirical paper as one that contains evidence of data col-
lection and analysis, and included any studies that utilised
any method of empirical investigation: quantitative, quali-
tative or mixed methods. All relevant papers were included.
Papers published in languages other than English were
excluded. Of the 319 papers identified on screening, 279
did not meet the inclusion criteria and 40 full articles were
retrieved. Twenty-one original papers were identified as
addressing the identified research questions and are
included in this review.
Following the identification of the review research ques-
tions and relevant studies, the selected studies were charted,
analysed and synthesised, and emerging themes identified
and discussed. From this analysis, three primary themes
Efficacy of hand drying methods;
Drying method and microbial translocation, disper-
sion and environmental contamination;
Drying methods and environmental sustainability.
Further themes of note emerging from our review were:
Hand drying and occupational dermatitis;
Policy and practice;
However, these themes are not discussed at length in this
Gammon and Hunt 3
Theme 1: Efficacy of hand drying methods
Efficiency of different drying methods and their suitability
within clinical settings was one of the main themes in the
research evidence. Efficacy can be measured in terms of
extent of moisture removal and bacterial reduction.
However, there is limited evidence to inform clinical prac-
tice. Table 2 (see web appendices) summarises the existing
knowledge. Of the seven studies identified, the majority
Summary Table: Included Studies
For a more comprehensive overview of studies, see Table 1: Characteristics of included studies (see web appendices).
Publication details Theme
Ali Alharbi etal., 2016; Saudi Arabia. Theme 2: Drying method and microbial translocation, dispersion and environmental
Ansari etal., 1991; Canada. Theme 2: Drying method and microbial translocation, dispersion and environmental
Berkowitz, 2015; USA Theme 3: Drying methods and environmental sustainability
Best etal., 2014; UK Theme 2: Drying method and microbial translocation, dispersion and environmental
Best and Redway, 2015; UK Theme 2: Drying method and microbial translocation, dispersion and environmental
Budisulistiorini, 2007; Australia Theme 3: Drying methods and environmental sustainability
Gregory etal., 2013; USA Theme 3: Drying methods and environmental sustainability
Gustafson etal., 2000; USA Theme 1: Efficacy of hand drying methods
Theme 2: Drying method and microbial translocation, dispersion and environmental
Hanna etal., 1996; Australia Theme 2: Drying method and microbial translocation, dispersion and environmental
Huesca-Espitia etal., 2018; USA Theme 2: Drying method and microbial translocation, dispersion and environmental
Jensen etal., 2015; USA Theme 1: Efficacy of hand drying methods
Joseph etal., 2015; Canada Theme 3: Drying methods and environmental sustainability
Kimmitt and Redway, 2015; UK Theme 2: Drying method and microbial translocation, dispersion and environmental
Margas etal., 2013; UK Theme 2: Drying method and microbial translocation, dispersion and environmental
Matthews and Newsom, 1987; UK Theme 2: Drying method and microbial translocation, dispersion and environmental
Ngeow etal., 1989; Malaysia Theme 2: Drying method and microbial translocation, dispersion and environmental
Patrick etal., 1997; New Zealand Theme 1: Efficacy of hand drying methods
Redway and Fawdar, 2008; UK Theme 1: Efficacy of hand drying methods
Theme 2: Drying method and microbial translocation, dispersion and environmental
Snelling etal., 2010; UK Theme 1: Efficacy of hand drying methods
Taylor etal., 2000; UK Theme 2: Drying method and microbial translocation, dispersion and environmental
Yamamoto etal., 2005; Japan Theme 1: Efficacy of hand drying methods
4 Journal of Infection Prevention 00(0)
acknowledge paper towels to be the most effective means
of hand drying. This has been the consistent finding since
the early research of Redway and Knights (1998), who
argued that effective drying of hands reduces the number of
bacteria on hands and the risk of transfer, and that paper
towels, in terms of speed, drying efficiency, hygiene and
microbial environmental contamination, perform better
than warm air dryers or jet blade dryers.
For Patrick et al. (1997), residual water was most effi-
ciently removed from the hands by cloth towels, rather than
by warm air dryers. Their study found that it took around 45
s for an air dryer to achieve the equivalent results in 20 s
using a cloth. Given that many healthcare practitioners do
not use the devices for this length of time, they are not gain-
ing the hygiene benefit of completely dry hands.
Gustafson et al. (2000) examined the hygiene perfor-
mance of four hand drying methods: paper towel; cloth
towel; warm air dryers; and evaporation. Their study com-
pared the amounts of bacteria on the hands following dry-
ing by the four methods. All bacteria counts were determined
using a modified glove-juice sampling procedure.
Gustafson et al.’s (2000) study demonstrated no statisti-
cally significant differences in the efficiency of the four
hand drying methods for removing wetness or bacteria
from hands that had been washed.
Snelling et al. (2010) compared an ultra-rapid hand dryer
against warm air dryers and their effect on bacterial transfer
following drying, and the impact on bacterial numbers of
rubbing hands during dryer use. Snelling et al. quantified the
effects of hand drying by measuring the number of bacteria
on different parts of the hands before and after drying by the
different methods. The authors suggest that where hands are
dried for at least 30 s using conventional warm air dryers, it
is likely that hygiene benefits will be similar to that achieved
with 10 s of use of an ultra-rapid hand dryer. However, if the
drying time is significantly < 30 s, the ultra-rapid hand
dryer is hygienically superior for reducing transfer of
microbes to other surfaces. Their study further found that
rubbing the hands together while using warm air dryers
potentially counteracts the reduction in bacterial numbers
accrued during handwashing. In this, paper towels consist-
ently outperformed all other drying techniques, especially
with regard to bacteria left on the palms and fingertips. This,
the authors note, suggests that bacteria repopulating the sur-
face of the skin during the rubbing process were being phys-
ically removed by the paper towels along with the moisture.
In so doing, paper towels appear to remove bacteria in a way
in which conventional warm air dryers are incapable of rep-
licating. This is further confirmed in the work of Jensen
et al. (2015). Nonetheless, it should be noted that towels can
become contaminated (Jensen et al., 2015; Taylor et al.,
2000), which, in itself, could pose a hygiene hazard. In situ-
ations where demand for hand hygiene is high and stocks of
clean towels can become exhausted, washed hands remain
damp and the risk of bacterial transfer increases.
Redway and Fawdar’s (2008) study suggests that while
the drying efficiency of paper towels and jet air dryers are
equal, the hygiene performance of jet air dryers and warm
air dryers compared to paper towels is significantly worse
‘in all respects’ including drying efficiency, bacterial num-
bers on the hands, bacterial contamination of the air flow
and surfaces of the devices, and transmission of bacteria.
This may be as a result of friction. According to Redway
and Fawdar (2008), paper towels are more effective as bac-
teria are physically removed from the hands in a way that is
not possible with jet air dryers and warm air dryers. In
many ways, rubbing hands vigorously when using warm air
dryers increases bacteria numbers on the skin and airborne
dissemination (Yamamoto et al., 2005). It may be that rub-
bing hands causes the migration of bacteria from the hair
follicles to the skin surface (Snelling et al., 2010).
Theme 2: Drying method and microbial
translocation, dispersion and environmental
In deciding the most suitable method of hand drying for
healthcare settings, the extent of moisture removal needs to
be considered alongside the potential of microbial translo-
cation, dispersion and environmental contamination. This
review identified 13 studies assessing the capacity of dif-
ferent drying methods to translocate and disperse microor-
ganisms into the immediate environment and to other
persons. Nine studies identified note that jet dryers and
warm air dryers result in greater microbial dispersion com-
pared to paper towels. A number of studies noted greatest
microbial dispersal to be associated with the jet dryer while
other studies noted no significant difference.
Ngeow et al. (1989) investigated the potential risk of
warm air dryers contributing to airborne infection in a hos-
pital setting. Their study compared bacterial dispersal
caused by warm air dryers with that of paper towels. Ngeow
et al. (1989) demonstrated the dispersal of marker bacteria
within a radius of 3 ft from hot air dryers. Conversely, when
paper towels were used for hand drying, no bacteria were
found. The authors thus affirmed warm air dryers to be
unsuitable for use in critical care environments for risk of
contributing to cross-infection either via airborne dissemi-
nation or by way of contaminated personnel. Similarly,
Redway and Fawdar’s (2008) study suggests that paper
towels are likely to cause considerably less contamination
of other users and of the washroom environment than jet air
dryers, which were found to disperse artificial hand con-
tamination to a distance of at least 2 m. Paper towels and
warm air dryers produced more positive results than jet air
dryers regarding contamination of the washroom environ-
ment. Paper towels created less contamination at 0 m
(directly below the device) than warm air dryers, although
there was no significant difference at greater distances.
Hanna et al. (1996) further reported that warm air dryers
Gammon and Hunt 5
resulted in significant numbers of airborne bacteria in the
environment surrounding the user, while paper and cloth
towels produced negligible contamination of the vicinity.
Margas et al. (2013) compared the potential for cross-
contamination of the surrounding environment resulting
from paper towels and the use of a jet air dryer. Their
study showed that the two hand drying methods produced
different patterns of ballistic droplets and levels of micro-
bial contamination, under heavy use conditions: the jet
air dryer producing a greater number of droplets dis-
persed over a larger area and more microbial contamina-
tion of the immediate environment than paper towels.
Similarly, Best et al. (2014) used a paint and Lactobacillus
bacterial model to compare aerosolisation and dispersal
following hand drying with paper towels, a warm air or
jet air dryer. They demonstrated that paper towels pro-
duced less dispersal from the hands into the surrounding
environment than jet air dryers. Utilising an acid-indica-
tor model and artificial contamination of the hands with
yeast, research by Best and Redway (2015) showed that
the use of a jet air dryer to dry the hands dispersed liquid
and consequently, potential microbial contamination on
the hands, to greater distances (up to 1.5 m) than paper
towels, roller towels or warm air dryers (up to 0.75 m). In
Best and Redway’s (2015) study, jet air dryers were fur-
ther shown to disperse more liquid from the hands to a
range of different heights compared to the other hand
Ali Alharbi et al. (2016) sought to evaluate the perfor-
mance of warm air dryers in relation to microbial contamina-
tion of the washroom environment at an academic institution
in the Kingdom of Saudi Arabia. Their study found bacteria
to be numerous in the air flows. Bacterially contaminated air
was found to be emitted whenever the warm air dryer was
running, even at times when not being used for hand drying.
Their research asserts that that Staphylococcus haemolyticus,
Micriciccus luteus, Pseudomonas alcaligenes, Bacillus
cereus and Brevundimonad diminuta vesicularis were emit-
ted from all warm air dryers sampled, with 95% showing
evidence of the potential pathogen Staphylococcus. The
presence of these bacteria in the air flow of high numbers of
warm air dryers and increase in the numbers of these bacteria
on the hands of users suggests the potential for the spread of
food poisoning organisms following this method of hand
drying. Ali Alharbi et al. further isolated bacteria from the
contaminated air of the washroom, with Staphylococci and
Micrococci being blown out of 95% of the air; 56% showing
evidence of the potential pathogen S. aureus, thus substanti-
ating the findings of Yamamoto et al. (2005). Ali Alharbi
et al. (2016) conclude that warm air dryers produce more
ballistic droplets which are potentially carrying bacteria
across extensive areas spread further and have the potential
for depositing pathogenic bacteria onto the hands and body
of users. Bacteria can further be inhaled and distributed into
the wider environment at times when the dryer is running.
As noted previously, a number of studies identified in
this review noted no significant difference regarding micro-
bial translocation and dispersal, and method of hand dry-
ing. Matthews and Newsom (1987) compared the bacteria
aerosols released into the air when drying hands using
paper towels and warm air dryers. The authors conclude
that there was no significant difference between warm air
dryers and paper towels in terms of aerosol liberation and
that the former could be considered safe. Likewise, Taylor
et al. (2000) assessed whether warm air dryers alter the lev-
els of airborne microorganisms in the washroom environ-
ment. Their study determined that air emitted from the
dryer outlet contained fewer microorganisms than air enter-
ing the dryers and further, that levels of microorganisms on
the external surfaces of warm air dryers were not different
from those on other washroom surfaces. According to
Taylor et al., warm air dryers are appropriate for use in both
healthcare and food industry settings. The studies of
Matthews and Newsom (1987) and Taylor et al. (2000) are
further confirmed in the work of Ansari et al. (1991) and
Gustafson et al. (2000).
To date, there have been a few studies (Kimmitt and
Redway, 2015) evaluating the aerosolisation and dispersal
of virus particles during hand drying. Viral pathogens, such
as Norovirus, are thought to have a low infectious dose and
can be shed in large numbers of faeces (Gerhardts et al.,
2012). Kampf and Kramer (2004) note that viruses can sur-
vive on the hands for varying times: influenza and CMV
(10–15 min); HSV (up to 2 h); adenovirus (for a number of
hours); rhinovirus (seven days); and rotavirus and HAV (up
to 60 days). Thus, within the washroom environment, virus
dispersal has the potential to contaminate persons and sur-
faces, including surfaces of hand drying devices. Recent
research by Huesca-Espitia et al. (2018) determined that
sporeformers, including a laboratory strain of B. subtillis,
were found on plates exposed to hand dryer air or air moved
by small fans at multiple locations at the University of
Connecticut School of Medicine, including areas far away
from where these spores were produced. Their work indi-
cates that since spores in washroom air can be deposited on
surfaces from the air by hand dryers, this suggests a further
means of Clostridium difficile transmission and one that
may not be interrupted by either hand washing or tradi-
tional methods of surface decontamination methods.
Kimmitt and Redway (2015) used a MS2 bacteriophage
model to compare paper towels, warm air dryer and jet air
dryer, for their potential to disperse viruses and contaminate
the immediate environment during times of use. When the
three hand drying devices were compared in this study, there
were clear differences in the extent of virus dispersal from
the hands. The jet air dryer produced significantly greater
virus dispersal compared to the warm air dryer and paper
towel devices: > 60 times more viral plaques than the warm
air dryer and > 1300 times more than paper towels. The
authors suggest the differences in results between the three
6 Journal of Infection Prevention 00(0)
hand drying devices can largely be explained by their mode
of drying of hands: paper towels remove water by absorp-
tion; warm air dryers of the type tested in this study remove
water primarily by evaporation; and jet air dryers remove
water by shearing forces and dispersal in to the air.
Theme 3: Drying methods and
It is imperative to give consideration to the environmental
sustainability of different drying methods. Nevertheless,
rather surprisingly, this review found limited research
regarding the relative environmental impact of different
methods of hand drying. In total, six studies are included in
this review. While a number of descriptive articles noted
differing positions on this subject, they were not included
in this review as these papers very much presented the
opinions of individuals and/or commercial corporations.
The most widely used tool to assess the environmental
impact of products and services appears to be the Life
Cycle Analysis or Life Cycle Assessment (LCA)
(Budisulistiorini, 2007; Gregory et al., 2013; Joseph et al.,
2015; Montalbo et al., 2011). The LCA approach involves
the identification of all material demand, energy require-
ment and environmental emissions associated with the
manufacture, use, transport and disposal phases of a prod-
uct through its life cycle, thus ascertaining the life cycle
impacts that occur during the life cycle stages of the prod-
Budisulistiorini (2007) compared the environmental
performance of two methods of hand drying: paper towels
and electric hand dryer. According to Budisulistiorini
(2007), the electric hand dryer by means of hand drying
method surpasses paper towels towards environmental sus-
tainability performers. Paper towels emit relatively higher
greenhouse gases than the electric dryer method. Regarding
environmental sustainability, the electric dryer method sur-
passes paper towels with more positive scores for six indi-
cators (respiratory organics, respiratory inorganics, ozone
layer, ecotoxicity, acidification/eutrophication and fossil
fuels), with five indicators for paper towels (carcinogens,
climate change, radiation, land use and minerals).
In a more recent study, researchers at the Massachusetts
Institute of Technology conducted a LCA of the environ-
mental impact (with a particular focus on global warming
potential) of five hand drying systems (Gregory et al.,
2013)1. The authors conclude that high speed dryers have a
lower environmental impact and global warming potential
than paper towels and cotton roll towels. Gregory et al.
(2013) were unable to differentiate between the hands
under dryer, cotton roll towels and paper towels.
Drawing on the above studies, Joseph et al. (2015) carried
out a comparative LCA case study of two hand drying
methods at a university campus setting in Canada:
conventional hand dryer and roll paper towel. Their study
concluded that the use of a conventional hand dryer (rated at
1800 W and under a 30-s use intensity) has a lesser environ-
mental impact than the use of two paper towels (100% recy-
cled content, unbleached and weighing 4 g) issued from a
Jet air dryers are particularly noisy compared to all other
methods of hand drying, including warm air dryers. Redway
and Fawdar (2008) ascertain the mean decibel level of jet air
dryers at 0.5 m is 94.1 dB, which is in excess of that of a
passing heavy lorry 3 m away. The mean decibel levels at
1.0 m and 2.0 me are in excess of a typical busy street at
87.4 dB and 86.3 dB, respectively. When two jet air dryers
were used concurrently, the decibel level at a distance of 2 m
was 92dB. Thus, in environments with jet air dryers such as
public washrooms, the noise levels could constitute a poten-
tial risk to those people exposed to it for long periods.
Likewise, Berkowitz (2015) found that electric dryers pro-
duced more intense sound than predicted by manufacturers.
This review found there to be little agreement regarding the
most hygienic method of hand drying and the published evi-
dence regarding whether hand drying methods vary in their
efficacy or tendency to aerosolise and thus transmit microor-
ganisms is inconsistent. A number of studies affirm that paper
towels are the most efficient method of hand drying and that
warm air dryers (including jet air dryers) are associated with
amplified aerosolisation of microorganisms (Redway, 1994;
Redway and Fawdar, 2008; Redway and Knight, 1998) com-
pared to paper towels, while others suggest there is no differ-
ence (Ansari et al., 1991; Gustafson et al., 2000; Mathews and
Newsom, 1987; Taylor et al., 2000).
Methodological issues may explain these inconsisten-
cies, in part (Huang et al., 2012). Nevertheless, the degree
of wetness appears to be an important factor in determining
numbers of bacteria detected. Taylor et al. (2000) and
Mathews and Newsom (1987) investigated the residual
bacteria on the hands following drying with warm air dry-
ers and paper towels using contact plates. These studies
suggest little differentiation regarding the removal of bacte-
ria for the different drying methods. In their study, Taylor
et al. (2000) claim that the contact plate results appeared to
be a reflection of the degree of wetness following drying,
rather than the actual number of bacteria on the hands. In
other reviewed studies, a number of authors used longer
drying times of hot air dryers than others. Matthews and
Newsom (1987) used warm air dryers until the hands of
study participants were completely dry – ordinarily around
1 min. Redway and Fawdar (2008) sought to reproduce as
closely as possible the hand drying practices people use. In
their study, the mean hand drying times were 10 s for paper
towels and 20 s using warm air dryers. Thus, the signifi-
cantly poorer hygiene performance of warm air dryers may
be a reflection of their low efficiency and thus the greater
Gammon and Hunt 7
amount of water remaining on participants’ hands. Drying
times will consequently have practice implications and
impact on compliance.
Transmission of bacteria is most likely to occur from
hands that are wet than dry hands. There is a clear correla-
tion between the extent of wetness and the transfer of
organisms, which consequently will impact on infection
prevention within the healthcare settings (Merry et al.,
2001; Patrick et al., 1997) and thus consequently patient
safety. Bacterial numbers translocating on touch contact
decrease progressively as efficacy of drying removes resid-
ual moisture from the hands. Patrick et al. (1997) note the
single most important determinant of the number of micro-
organisms translocated from hands was the extent of resid-
ual moisture remaining on hands after washing. The work
of Merry et al. (2001) further confirms the role of residual
water on the hands in the level of touch- or contact-associ-
ated contamination. Therefore, careful hand drying is a
critical factor determining the level of touch- or contact-
associated bacterial transfer following hand washing; its
recognition consequently could make a significant contri-
bution towards improving hand hygiene care practices in
clinical and public healthcare sectors.
Bacterial dispersal and transmission can be encouraged
by the movement of air, thus increasing the likelihood of
cross-contamination. Redway and Fawdar’s (2008) research
suggests that air dryers in washrooms are often contami-
nated and emit bacteria in their airflow. Thus, there is a
potential risk of those persons standing at warm air or jet air
dryers acquiring pathogenic bacteria being potentially dis-
persed: either through inhalation; being deposited onto the
hands and body of users; and from being further distributed
into the wider environment (Ali Alharbi et al., 2016; Ngeow
et al., 1989; Taylor et al., 2000; Yamamoto et al., 2005).
The nature of clinical practice means that the hands of
healthcare practitioners are frequently exposed to wetness.
The literature refers to this as wet work. Healthcare practi-
tioners are at high risk for developing occupational hand
dermatitis as a consequence of frequent exposure to ‘wet
work’ (Behroozy and Keegel, 2014) due to the nature of
mandatory hygiene procedures, coupled to ineffective hand
drying and/or the use of hand gloves. Among healthcare
practitioners, nurses are particularly at high risk of hand
dermatitis. It is estimated that around one thousand nurses
develop work-related irritant contact dermatitis each year
in the UK (Behroozy and Keegel, 2014).
Hand hygiene and the efficacy of the hand drying method
involves not only the percentage of dryness of the hands but
also the removal of bacteria from washed hands and the pre-
vention of cross-contamination (Huang et al., 2012). In
healthcare settings, the appropriate cleansing of the hands of
staff or visitors before, or after, certain procedures and prac-
tices is of particular importance and a number of guidelines
on handwashing and hand cleansing have been issued by the
Centres for Disease Control and Prevention (CDC), the
National Health Service (NHS) and the World Health
Organization (WHO) (Boyce and Pittet, 2002; Centres for
Disease Control and Prevention, 2002; National Health
Service Professionals, 2013; World Health Organization,
2009). Warm air and jet air dryers are not recommended for
use in healthcare settings as a result of their hygiene and
environmental performance (Kimmitt and Redway, 2015;
Redway and Fawdar, 2008). Continuous cloth roller towels
are not recommended as they become common use towels at
the end of the roll and can be a source of pathogen transfer
to clean hands. Thus, disposable paper towels offer the most
hygienic method of hand drying in healthcare settings
(Kimmitt and Redway, 2015; Redway and Fawdar, 2008).
As part of our review, we studied national and local UK
government policy regarding hand drying. Contained within
wider NHS infection prevention and hand hygiene policy
and procedure, disposable paper towels are advocated in all
clinical settings as the ‘quickest and most effective’ means
of removing residual moisture that may facilitate transmis-
sion of microorganisms (Loveday et al., 2014). This review
found this directive adopted at localised levels by NHS
Trusts and NHS Health Boards throughout the UK.
The review found warm air dryers to have a lower envi-
ronmental impact (Budisulistiorini, 2007; Gregory et al.,
2013; Joseph et al., 2015) and to be less of an economic
burden (Budisulistiorini, 2007) than paper towels.
Nonetheless, Redway and Fawdar (2008) found the noise
levels of jet air dryers to constitute a potential risk and dis-
turbance for patients within the clinical environment, and to
those people exposed to it for extended periods in environ-
ments such as public washrooms. Paper towels are consid-
ered to be more of an economic burden than the use of
electric hand dryers (Budisulistiorini, 2007), in that it is nec-
essary to frequently replace paper towels, while following
initial instillation, electric air dryers require little mainte-
nance. These tensions between IPC objectives and environ-
mental impact beyond infection prevention, merits future
research that explores the interrelation between infection
prevention, environmental sustainability, and the design and
structure of hand drying machines and products.
Scoping reviews are most typically concerned with
reporting the results of collective studies. This review has
focused on the clinical importance of hand drying and the
implications of wet hands for patients, healthcare practi-
tioners and the clinical environment. Like all scoping
reviews, it is subject to a number of important limitations.
This review is limited by the phrases used for searching,
the databases accessed, the frame and method of searching
for literature and by time constraints. Searching additional
databases or using additional search phases may have iden-
tified more publications. The criteria that the article be
written or available in the English language may further
8 Journal of Infection Prevention 00(0)
have led to omissions of studies published in other lan-
guages, particularly since studies that were screened and
included were international.
Scoping reviews are one step removed from the primary
data, and therefore we rely on the authors’ reporting of
results. A number of studies included in our review did not
report sample sizes (Table 1; see web appendices). No
attempts were made to contact authors for this additional
information. In other studies, sample sizes were small
(Table 1; see web appendices). Nevertheless, this review
offers insight into efficacy of different hand drying meth-
ods and the consequences of different hand drying methods
in terms of microbial translocation and dispersal, occupa-
tional dermatitis and environmental sustainability.
This review did not identify research that specifically
measured the extent of drying (or residual moisture) by
healthcare practitioners irrespective of the methods used.
Research to measure wetness on the hands and hand drying
compliance by healthcare practitioners is an area of research
that needs to be considered.
Good hand hygiene is recognised as a critical factor in con-
trolling the spread of infectious diseases and delivering
effective IPC practice. Effective hand hygiene which
includes sound hand drying has the potential to control and
reduce the spread of HCAIs, prevent environmental con-
tamination, protect patients and minimise contact dermati-
tis for healthcare practitioners.
This scoping review suggests that greater attention needs
to be given to effective hand drying and its importance when
considering hand hygiene in the clinical context and that
patient safety is put at risk when healthcare practitioners fail
to dry their hands or inappropriate methods are used. More
high-quality studies regarding the significance of hand dry-
ing to hand hygiene and the hand hygiene debate are needed.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Peer review statement
Not commissioned; blind peer-reviewed.
Julian Hunt https://orcid.org/0000-0002-4549-6949
1 See also: Montalbo et al. (2011).
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