Infection Control Guidelines for Personal Services (PDF)

ISSN 1188-4169 Date of Publication: July 1999 Volume 25S3 Supplement infection control guidelines Infection Prevention and Control Practices for Personal Services: Tattooing, Ear/Body Piercing,...

ISSN 1188-4169 Date of Publication: July 1999 Volume 25S3 Supplement infection control guidelines Infection Prevention and Control Practices for Personal Services: Tattooing, Ear/Body Piercing, and Electrolysis Our mission is to help the people of Canada maintain and improve their health. Health Canada This publication was produced by the Document Dissemination Division at the Laboratory Centre for Disease Control, Health Canada. To obtain additional copies or subscribe to the Canada Communicable Disease Report, please contact the Member Service Centre, Canadian Medical Association, 1867 Alta Vista Drive, Ottawa ON, Canada K1G 3Y6. Tel.: (613) 731-8610, ext. 2307; 888-855-2555 (toll free in Canada and U.S.) or by FAX: (613) 236-8864. This publication can also be accessed electronically via Internet using a Web browser at http://www.hc-sc.gc.ca/hpb/lcdc  Infection Prevention and Control Practices for Personal Services: Tattooing, Ear/Body Piercing, and Electrolysis Health Canada Laboratory Centre for Disease Control Bureau of Infectious Diseases Division of Nosocomial and Occupational Infections  Working Group Members Sharon Onno (Project Leader) Agnes Honish (Coordinator) Nurse Epidemiologist, Occupational Infections Infection Control Consultant Division of Nosocomial and Occupational Infections 14008-120 Street Bureau of Infectious Diseases, Health Canada Edmonton, Alberta T5X 4X8 Laboratory Centre for Disease Control, PL 0603E1 Tel: (403) 457-2200 Fax: (403) 476-5992 Tunney’s Pasture, Ottawa, Ontario K1A 0L2 E mail: [email protected] Tel: (613) 954-4869 Fax: (613) 998-6413 E mail: [email protected] Joann Braithwaite Dre Michèle Dupont Environmental Health Officer Médecin-conseil Toronto Department of Public Health Santé au Travail et Environnementale Infection Control Division Régie régionale de la Santé et des Services sociaux de 277 Victoria Street, 4th Floor Montréal-Centre Toronto, Ontario M5B 1W1 Direction de la Santé publique Tel: (416) 392-7420 Fax: (416) 392-0667 1301 Sherbrooke Est E mail: [email protected] Montréal, Québec H2L 1M3 Tel: (514) 528-2400 ext. 3228 Fax: (514) 528-2459 Dr. Margaret Fast Thecla Fenton Medical Officer of Health Chrysalis Professional Electrolysis City of Winnipeg Community Services 9534-95 Avenue Main Floor, 33 Wamoch Street Edmonton, Alberta T6C 2A4 Winnipeg, Manitoba R3B 3L6 Tel: (780) 448-0953 Fax: (780) 448-0449 Tel: (204) 986-3440 Fax: (204) 986-3706 Member of the Canadian Association of Professional Electrologists (COPE) Karolyn Jeffries Mary LeBlanc Smiling Buddha Tattoo Infection Prevention and Control Coordinator 2409 - 33rd Ave. SW Carewest Calgary, Alberta T2T 2A2 Fanning Centre Tel: (403) 242-5922 Fax: (403) 240-2120 722-16 Ave. NE Member of the Alliance of Professional Tattooists Calgary, Alberta T2E 6V7 Member of the Alliance of Professional Body Piercers Tel: (403) 230-6975 Fax: (403) 230-6969 E mail: mary.leblanc@ chra-health.ab.ca Elizabeth Meharg Garry Peak Director, Meharg International Pair-O-Dice School of Electrolysis 418 Craigflower Road 188 Birk Dale Road Victoria, BC V9A TV8 Scarborough, Ontario M1P 3S1 Tel: (250) 386-3423 Tel: (416) 750-9001 Fax: (416) 288-9708 Member of the Canadian Association of Professional E mail: [email protected] Tattooists (CAPT) Member of the Federation of Canadian Electrolysis Associations (FCEA) Denise Robinson Needle Exchange, Editor CEO Ambient Inc, 1646 Ridge Road Vankleek Hill, Ontario K0B 1R0 Tel: (613) 678-3880 E mail: [email protected] iii  Observers to the working group Paula Alphonse Lindsay Blaney Cosmetic Project Officer Senior Policy Advisor Health Canada, Product Safety Bureau HPB Transition, Legislative Renewal Secretariat Statistics Canada Health Canada Main Building, Wing 1000 HPB Bldg., Room 0126, PL 0700A Tunney’s Pasture, PL 0301B2 Ottawa, Ontario K1A 0L2 Ottawa, Ontario K1A 0K9 Tel: (613) 957-3842 Fax: (613) 954-0716 Tel: (613) 954-3904 Fax: (613) 952-1994 E mail: [email protected] E mail: [email protected] Health Canada would like to thank the following provincial and local organizations that sent us copies of their documents related to personal service workers. Their contribution assisted in the development of the manual. Health Standards and Guidelines for Personal Services Health Standards and Guidelines for Tattooing Health Standards and Guidelines for Piercing Health Standards and Guidelines for Electrolysis Alberta Health Guidelines for Personal Service Establishments (PSEs) Guidelines for Tattooing BC Ministry of Health and Ministry Responsible for Seniors British Columbia Ministry of Health Guideline for the Operation of Tattoo Studios Manitoba Health Personal Services Settings Protocol - Infection Control Program Mandatory Health Programs and Services Guidelines Ministry of Health of Ontario, Public Health Branch Tatouage et prévention des infections transmises par le sang Direction de la Santé publique Québec Guideline for Personal Service Facilities Community Health - Prevention Services Branch Saskatchewan Health Le sida et l’hépatite B au travail - Mission prévention possible Cité de la Santé de Laval Département de Santé Communautaire Safe Electrolysis - Infection Control Guidelines East York, City of Toronto AIDS Committee of Toronto, Metro Council OTHER COUNTRIES Infection Control Standards for the Practice of Electrology American Electrology Association, United States Standards of Practice for Ear Piercing Standards of Practice for Beauty Treatment and Electrolysis Standards of Practice for Tattooing and Body Piercing Infectious Diseases Unit, Public Health Division Victorian Government Department of Human Services AUSTRALIA Guidelines for Body Piercing Guide to Hygienic Skin Piercing King’s College School of Medicine & Dentistry Department of Public Health & Epidemiology London, ENGLAND iv  Special thanks for input from the following people who have contributed information about the industry: Tattooing Tom Coles Darren Jolly Canadian Association of Professional Tattooists (CAPT) Canadian Association of Professional Tattooists (CAPT) Dave Long Gary Chynne Skinetics Studio Studio One Tattoo Supplies Pat Shibley-Gauthier The Canadian Micro-Pigmentation Centre, Inc. Ear/Body Piercing Fred Safford Ear Piercing Manufacturers of the U. S., Inc. Sterilization, Sanitation, and Safety Standards for Tattooing, Permanent Cosmetics and Body Piercing, 1998. California Conference of Local Health Officers NEHA Body Art Model Code and Guidelines Electrolysis Hazel Glusman Margaret Delaney Canadian Organization of Professional Electrologists Canadian Organization of Professional Electrologists (COPE) National (COPE) National Corrine Bonfond Judith Finn L’Association des électrolystes du Québec Inc. Electrolysis College of Canada, Inc Carol Town Kathleen Barker Town Electrolysis Society of Ontario Electrologists Dr. Robert Richards Electrolysis: Observations from 13 years and 140,000 hours of experience Provincial Government Representatives Graydon Gibson Dr. Erika Abraham British Columbia, Ministry of Health Ministry of Health, Ontario We apologize to anyone who assisted us but was not mentioned by name. v  Table of Contents Background..................................... xi Part 1: Umbrella Document for Overall Infection Prevention and Control Practices........................... 1 I. Introduction................................... 1 II. Why Develop Infection Prevention and Control Practices or Guidelines?................................... 1 III. Steps to Assess Infection Risk For Tattooing, Ear/Body Piercing and Electrolysis................................. 2 1. What is the Potential Infection Risk from Skin Piercing Procedures?................................. 2 a. Source of Pathogens Causing Infections................. 2 b. Infections by Contaminated Objects................... 3 2. What is the Documented Risk of Infection Following Skin Piercing Procedures?............................ 4 3. How Many People in the Canadian Population Have Had Skin Piercing Procedures?.......................... 5 a. The Frequency of Skin Piercing Procedures in Certain Populations................................ 5 b. The Increasing Number of Tattoo, Body Piercing and Electrolysis Shops............................. 5 4. How Many Clients Have Been Infected Prior to Skin Piercing Procedures?................................. 6 IV. Infection Control for a Safe Business...................... 6 1. The Shop................................... 6 a. Premises................................. 6 b. Choice and Use of Instruments and Equipment............. 7 2. Cleaning, Disinfection, and Sterilization................... 8 a. Cleaning Instruments and Equipment.................. 8 b. Cleaning the Environment........................ 9 c. Disinfection................................ 10 d. Sterilization................................ 13 vii  3. Infection Prevention Practices for the Practitioner................ 17 a. Asepsis.................................... 17 b. Hand Washing................................ 17 c. Barriers.................................... 18 4. Skin Care Before and After Piercing....................... 18 a. Skin Inspection................................ 18 b. Skin Preparation............................... 19 c. Skin Care Following Piercing........................ 19 5. Waste Disposal.................................. 19 a. Regular Waste................................ 19 b. Contaminated Waste............................. 19 c. Sharps.................................... 19 6. Client Records.................................. 20 7. Practitioner Health and Safety.......................... 20 a. Bloodborne Pathogen Precautions...................... 20 b. Immunization................................. 20 c. Chemical Hazards.............................. 20 d. Hand Care.................................. 21 e. Sharps Injuries................................ 21 f. Practitioner Education for Infection Control................. 22 Part 2: Specific Implications of Infection Prevention and Control in Tattooing, Ear/Body Piercing and Electrolysis............ 23 Guidelines for Infection Prevention and Control in Tattooing.............. 24 I. Introduction................................... 24 II. What is Tattooing?................................ 24 III. Infection Prevention in Tattooing........................ 25 1. Equipment and Supplies........................... 26 2. Preparing the Work Station and the Client for Tattooing........... 27 3. Detailed Infection Prevention and Control Procedures for Tattooing................................... 27 Guidelines for Infection Prevention and Control in Ear/Body Piercing......... 34 I. Introduction................................... 34 II. What is Ear/Body Piercing?........................... 34 1. Needle Technique.............................. 34 2. Ear Piercing Gun Technique........................ 35 III. Infection Prevention during Ear/Body Piercing................. 35 1. The Ear Piercing Gun............................ 35 2. Skin Piercing Needles............................ 36 3. Jewelry.................................... 36 4. Healing of Pierced Area........................... 36 5. Equipment and Supplies........................... 36 6. Preparing the Work Area and the Client for Ear/Body Piercing....... 37 7. Detailed Infection Prevention and Control Procedures for Ear/Body Piercing.............................. 38 viii Guidelines for Infection Prevention and Control in Electrolysis............. 46 I. Introduction................................... 46 II. What Is Electrolysis?............................... 46 1. Galvanic Method............................... 47 2. Thermolysis Method............................. 47 3. Blend Method................................ 48 III. Laser Hair Removal............................... 48 IV. Infection Prevention for Electrolysis....................... 48 1. Equipment and Supplies........................... 49 2. Preparing the Work Area and the Client for Electrolysis........... 49 3. Detailed Infection Prevention Procedures for Electrolysis.......... 50 Part 3: Literature Review............................. 57 I. Introduction................................... 57 II. Summary of the Literature on Tattooing..................... 58 1. Frequency in the Population......................... 58 2. Infectious Risks................................ 58 a. Case Reports............................... 58 b. Epidemiologic Studies.......................... 58 c. Literature Review............................. 59 3. Non-infectious Risks............................. 59 a. Case Reports............................... 59 b. Literature Review............................. 60 III. Summary of the Literature on Ear/Body Piercing................ 60 1. Introduction................................. 60 2. Ear Piercing................................. 60 a. Frequency in the Population....................... 60 b. Infectious Risk.............................. 60 c. Non-infectious Risk............................ 61 3. Body Piercing................................ 61 a. Frequency in the Population....................... 61 b. Infectious Risk.............................. 61 c. Non-infectious Risk............................ 62 IV. Summary of the Literature on Electrolysis.................... 62 1. Introduction................................. 62 2. Infectious Risk................................ 62 3. Non-infectious Risk.............................. 62 References..................................... 63 Appendix A: Glossary of Terms.......................... 71 ix  Background During the fall of 1997, the Division of Nosocomial and Occupational Infections, Laboratory Centre for Disease Control (LCDC), Health Canada, announced a plan to develop infection prevention and control practices or guidelines for three personal services: tattooing, ear/body piercing and electrolysis. The process for development of the guidelines included the selection of a geographically dispersed Working Group with representatives from industry, infection control, environmental health, public health, and LCDC. Some commonly asked questions and answers about the guidelines follow. 1. What is the purpose of the guidelines? The purpose of the guidelines is to describe infection prevention and control practices for personal services, including tattooing, ear/body piercing, and elec- trolysis. The guidelines are based on an assessment of potential or documented evidence of infection risk posed by skin piercing procedures and the principles of infection control to manage the risk. The framework of the Harm Reduction Model is used which, if followed, will reduce infection control risks. 2. For whom are the guidelines written? The guidelines are written for practitioners who perform tattooing, ear/body piercing, and electrolysis. The recommendations for infection prevention and control practices in the personal service guidelines have incorporated practical suggestions from industry representatives. Environmental health officers and infection control practitioners may also find the document helpful. 3. How is the document organized? The document is composed of three parts: Part l: Umbrella Document for Overall Infection Prevention and Control Practices xi  Part 2: Specific Implications of Infection Control in Tattooing, Ear/Body Piercing, and Electrolysis Part 3: Literature review 4. Will the standards in the guidelines be regulated or enforced? The guidelines reflect standards of practice for the prevention of infection for tattooing, ear/body piercing and electrolysis. Any regulatory process that governs personal services remains a provincial public health responsibility. 5. How can I obtain further information about the guidelines? Please contact: Division of Nosocomial and Occupational Infections Bureau of Infectious Diseases Laboratory Centre for Disease Control Health Canada, PL 0603E1 Ottawa, Ontario K1A 0L2 Tel: (613) 952-9875 Fax: (613) 998-6413 For additional information, please call your provincial or local public health department or municipality, or the professional associations for tattooing, ear/body piercing, and electrolysis. This publication can be accessed electronically via Internet using Web browser at http://www.hc-sc.gc.ca/hpb/lcdc/dpg_e.html#infection. xii  Part l Umbrella Document for Overall Infection Prevention and Control Practices I Introduction Part I, the Umbrella Document, contains a description of why infection prevention and control practices or guidelines are needed (Section II), an assessment of infec- tion risk posed by tattooing, ear/body piecing and electrolysis (Section III) and general information relevant to the operation of a safe business (Section IV). The Umbrella Document describes the principles of infection prevention and control relevant to these three skin piercing procedures. The Umbrella Document prefaces Part 2, which describes the equipment, instruments, and procedures used in tattooing, ear/body piercing and electrolysis. Part 3 contains a literature review that describes, in more detail, the infection risk associated with these skin piercing procedures. A reference list and glossary com- plete the document. II Why Develop Infection Prevention and Control Practices or Guidelines? The national guidelines were developed to reduce the spread of infections, includ- ing infections from bloodborne pathogens (BBPs),a in Canadians. Transmission of BBPs, e.g. hepatitis B virus (HBV), hepatitis C virus (HCV), or human immunode- ficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), can occur from exposure to infected blood/body fluids(1). a See Appendix 1, Glossary of Terms, at the end of the document. 1  In the skin piercing industry, the documented and theoretical spread of BBPs by needles that are not sterile underlies the need for infection prevention and control guidelines. Documented infections after skin piercing procedures are noted in Part 3: Literature Review and have occurred primarily following tattooing and ear piercing. Evidence of infections following non-ear piercing procedures is more limited. BBP infections have not been reported after electrolysis, as the intent is to enter the natural hair follicle. The recommendations contained in the guidelines are based on an assessment of infection risk in the Canadian population supported by current knowledge of infectious disease transmission, infection prevention and control practices, and epidemiology. The client’s risk of exposure to a BBP infection varies. The more clients there are who have been infected with a BBP before they undergo skin piercing procedures, the more likely that someone else can be exposed during tattooing, ear/body piercing, and electrolysis unless the needles and instruments are sterile. Clients are not required to tell the practitioner if they are infected with a BBP. Because surveillance studies that look specifically at infections related to skin piercing procedures do not exist, the infection risk cannot be defined with accu- racy. However, the risk, if the client is exposed to a BBP, may parallel that of a health care worker who is accidentally injured with a needle from a person in- fected with HBV, HCV, or HIV/AIDS. If the standards of practice for infection prevention and control in this document are followed they will assist practitioners who pierce skin to protect the health of both their clients and themselves. III Steps to Assess Infection Risk for Tattooing, Ear/Body Piercing, and Electrolysis The four components of an assessment of infection risk include the potential risk of spreading infection by skin piercing procedures, the documented infection risk in the literature, the frequency of skin piercing procedures in the population and the proportion of clients who are infected prior to the skin piercing procedure. 1. What is the Potential Infection Risk from Skin Piercing Procedures? a. Source of Pathogens Causing Infections To understand why it is important to follow the guidelines to prevent infection in skin piercing procedures, it is necessary to understand potential sources of infection or where these pathogens live. Humans are protected from many infections by the skin or mucous mem- branes. When the skin or mucous membrane is pierced, pathogens have a 2  chance to enter the body. This may result in infection. The pathogens that en- ter the client’s body may come from another person via contaminated objects or from the client’s own skin or mucous membrane. Most people have microor- ganisms on their own skin or mucous membranes that do not cause a problem unless the skin or membrane is pierced or broken. i. Transfer of Pathogens from Another Person If the skin piercing object is contaminated, pathogens have a way to enter the body. The skin piercing object becomes contaminated by the methods that follow: The skin piercing object is contaminated by the infected blood/body fluids from the client or the practitioner. Pathogens that could be introduced are HBV, HCV, or HIV. The skin piercing object is contaminated by pathogens from an unclean work surface in the environment. Invisible pathogens could be contained in very small amounts of blood/body fluids. The skin piercing object is touched by the contaminated pathogens on the worker’s hands, allowing pathogens to enter the client’s body, for example, via the needle. ii. Transfer of Pathogens from the Clients Themselves Often, pathogens that are present on the client’s skin are harmless until the skin is pierced and they have a way to enter the body. Pathogens on the skin enter the body when the skin is pierced with needles, e.g. a wart virus (papillomavirus) on the skin spreads warts on the upper lip(2). A mucous membrane is pierced, which permits pathogens to enter the pierced area, e.g. streptococcal bacteria cause a serious infection of tissue from a barbell in the tongue(3). b. Infections by Contaminated Objects To help define the chance of infection when a personal services client or prac- titioner is injured with a contaminated needle, some examples from the health care field are described, since they involve similar situations and the risks are well documented. i. Accidental Needlestick Injuries Of 100 health care workers injured with a sharp instrument, e.g. a needle that contains blood infected with HBV, 19 to 30 will become infected with hepatitis B. This risk is reduced to nearly zero if the health care worker has 3  been immunized and has developed antibodies against HBV. If the health care worker is exposed to HCV, three to 10 people in 100 will become infected; and, if the exposure is to HIV/AIDS, fewer than one person in 300 will develop HIV(1). ii. Devices That Hold Sharps In at least three separate situations, patients developed hepatitis B from pathogens on a lancet holder(4,5). This spring-loaded device holds a lan- cet, used to pierce a finger so the blood sugar level can be tested. Even though a new sterile lancet was used for each person, it is believed the lancet holder was splattered with blood containing HBV, and the virus was then spread to other patients who later developed the disease. This example emphasizes the importance of cleaning and disinfecting or steril- izing any items that hold sterile sharp objects that pierce the skin. Blood does not have to be visible on a device to transmit infection. Simi- larly, it is possible that blood from an infected client that has contaminated a tattoo machine, ear piercing gun, or holder for the electrolysis needle(6) exposes other clients to a risk of infection unless it has been appropriately cleaned and disinfected. iii. Outbreak of Hepatitis B from Contaminated Electroencephalogram (EEG) Needles In Ontario between 1992 and1996, 75 people were infected with hepatitis B when they had an EEG, which involves placing needles in the scalp. It was reported that the most likely reason for the outbreak was poor infec- tion control practices, which resulted in contaminated needles that spread hepatitis B(7). The method of doing EEGs in Ontario has since changed to a non-invasive one. 2. What is the Documented Risk of Infection Following Skin Piercing Procedures? To determine whether infections have been transmitted to the client or the practi- tioner performing any of the three skin piercing procedures, a literature search was conducted and the results are reported in Part 3. Other sources of information on the risk and how to manage it are included in resource documents from profes- sional associations, guidelines from most Canadian provinces, and a smaller num- ber of documents from health jurisdictions in other countries. There are documented cases in the literature of infections acquired during each of these three skin piercing procedures. The infections reported most frequently occur after tattooing, a smaller number after ear or body piercing, and very few after electrolysis. Infections that have been transmitted by skin piercing procedures include hepatitis B, hepatitis C, warts, herpes, and a variety of bacterial skin infec- tions. 4  The literature contains many other reported non-infectious health risks (not the focus of this document) caused by skin piercing procedures. Complications follow- ing skin piercing procedures include sensitivity to tattoo pigments, reactions to metals from body Jewelry, and scar tissue formation. A type of cancer, malignant melanoma, has been detected in tattooed skin. Only a relatively small number of infections have been reported overall in relation to the apparently high number of people who have had skin piercing procedures carried out. This may mean either that the infection risk is low, that infections hap- pen but are sometimes unnoticed, or that infections are noticed but not always reported. 3. How Many People in the Canadian Population Have Had Skin Piercing Procedures? A number of factors might increase the infection risk to Canadians as a result of tattooing, ear/body piercing or electrolysis. The more people there are who have any one of these skin piercing procedures carried out, the more likely the proce- dures are the source of BBP infections unless the needles and instruments are sterile. Although no one has studied how many people in Canada have undergone tattooing, ear/body piercing or electrolysis, there are some indicators of the frequency of these procedures. a. The Frequency of Skin Piercing Procedures in Certain Populations i. Two U.S. surveys reported that 73%(8) and 83%(9) of women had had their ears pierced. ii. In a Canadian prison, 47% of males and 53% of females had tattoos(10). iii. In the United States, between 1960 and 1980 the number of women tattooed quadrupled; 50,000 to 100,000 were tattooed annually, nearly half of all tattooing in the nation(11). b. The Increasing Number Of Tattoo, Body Piercing And Electrolysis Shops In Canada i. The Capital Region, Edmonton, with a population of approximately 750,000, has 16 tattoo shops that employ 23 tattooists and nine body piercers (Dennis Chu: personal communication, 1998). A 1991 telephone survey of 210 establishments performing personal services found that there were 779 electrolysis treatments weekly in 23 shops and 532 ear piercings in 122 shops (Agnes Honish: personal communication, 1998). Of the 532 weekly ear piercings, 90/122 (40%) were performed in beauty salons. ii. The Calgary Region, with a population of approximately 800,000, has 12 tattooists, six practitioners who perform both tattooing and skin piercing, 5  and two who perform skin piercing only (Karolyn Jeffries: personal commu- nication, 1998). iii. Three voluntary associations for Canadian electrologistsb have a combined membership of 1,250. 4. How Many Clients Have Been Infected Prior to Skin Piercing Procedures? Some clients who request skin piercing procedures may already be infected with one or more viruses or bacteria. If a significant fraction of Canadians are infected with BBPs, it follows that the risk during any of the three skin piercing procedures may be increased unless the needles and instruments are sterile. However, it is possible that people who undergo skin piercing procedures may have lower or higher rates of infection in comparison to the Canadian population as a whole. The number of Canadians, per thousand population, infected with BBPs has been estimated: for hepatitis B it is 5 in 1,000, for hepatitis C it is 10 in 1,000, and for HIV it is 1.5 in 1,000(1). It is important to note that some groups in the Canadian population have much higher rates of infection. For example, it was reported that in a prison population in British Columbia 28 of 100 inmates were positive for HCV(12), and another prison in Ontario reported that 69 of 100 were infected with hepatitis C(13). The number of Canadians who are infected with other pathogens, e.g. on the skin or in tissue, before undergoing a skin piercing procedure is not known. IV Infection Control for a Safe Business 1. The Shop The design of the physical space for skin piercing procedures should be simple, organized, and clean. When practitioners are designing a shop, renovating, or moving into an existing space, they should contact the local health department or municipality for shop requirements and any regulations or standards. a. Premises i. Shop zones should be organized to prevent cross contamination of clean, disinfected or sterile equipment with dirty equipment; two separate zones are best. clean zone: the customer treatment area should be used for tattooing, ear/body piercing, or electrolysis procedures. All sterilized packages, disinfected and clean equipment should be stored in this area. b Canadian Organization of Professional Electrologists, Federation of Canadian Electrolysis Associations, and Association des électrolystes du Québec Inc. 6  dirty zone: a contaminated area, with a washing sink and holding basins, should be available for used items that need to be cleaned and disinfected or sterilized at the end of the day. ii. General requirements that should be present: all surfaces should be constructed of materials that are smooth, non-porous, and easily cleaned; good lighting and ventilation; hot and cold running water — two sinks are recommended: a hand washing basin in the clean zone and a utility sink in the dirty zone. If only one sink is available, care should be taken to avoid contamination of the faucet or equipment that has been cleaned. cabinets or storage space (preferably enclosed) are protected from dust and moisture; public washroom access. b. Choice and Use of Instruments and Equipment i. Instruments re-usable instruments should be smooth, non corrosive, and constructed of materials that are able to withstand heat during sterilization, e.g. surgical stainless steel. ii. Machines controls for machines should preferably be foot operated; an ultrasonic cleaning device, with a lid, may be used to clean instruments; it does not sterilize or disinfect but provides excellent cleaning and may prevent injuries to the workers; steam (preferably) or dry heat sterilizer, with operator’s manual, should be used for sterilization. Dry heat sterilization may be damaging to some products, e.g. the solder used for attaching needles to the needle bar in tattooing may melt in the dry heat oven. The method chosen will depend on the item to be sterilized. it is preferable not to touch office equipment, e.g. the telephone, treatment table, or magnifying glass arm, during treatment procedures. If they are used during the procedure, they should be covered with a plastic sheath or cleaned after each client service. Gloves should be changed if the office equipment is used by the practitioner during a procedure. 7  iii. Necessary Equipment packages of sterile instruments and sterile needles; metal tray for holding sterile sets of instruments or clean equipment prior to the skin piercing service; storage containers, with lids, to store clean items such as cotton balls or small sterile packages, e.g. forceps; single-use plastic sheaths or bags to cover items that cannot be easily cleaned, e.g. the tattoo machine, the cord, the plastic spray bottle used to clean and disinfect the skin during tattooing; metal basin or other suitable container for dirty equipment. iv. Necessary Supplies medical gloves, e.g. latex, nitrile, neoprene, or vinyl; single-use wooden tongue depressors or cotton-wrapped sticks for removing creams, gels, or ointments from a bulk container into smaller, single-use packages; clean linen or disposable towels for patient protection or cover for a working surface; wrapping materials or suitable containers to contain instruments for sterilization; chemical time/temperature and/or humidity sensitive tape, strips or pellets for monitoring each sterilization cycle; spore strips or vials for testing the sterilization process monthly; liquid hand washing soap contained in a pump style container or cartridge for a wall mounted unit; detergent for cleaning; commercial sharps containers (puncture-resistant) for sharp waste; hospital grade disinfectant(s). 2. Cleaning, Disinfection and Sterilization a. Cleaning Instruments and Equipment Contaminated instruments should be cleaned in the dirty zone, preferably in a utility sink. Cleaning removes soil and body materials, e.g. blood, from instru- ments, equipment, and environmental surfaces. Cleaning must occur as a first 8  step before the disinfection or sterilization process, or the disinfection or steril- ization will be ineffective. A step-by-step cleaning guide follows. Table 1 Steps to Clean Instruments Cleaning Process Comments 1. Soak items that cannot be immediately Used instruments should be soaked to pre- cleaned in basin of cool water with or with- vent blood and other organic matter from out detergent. drying on the item. Do not soak dirty items in hot water or a disinfectant before clean- ing, because it causes the soil and matter to stick to the surface of the object. 2. Put on utility gloves (non-medical gloves). Utility gloves are suitable for cleaning and have a wider bib at the wrist to help pre- vent water from entering the inside of the glove. They are also reusable and there- fore economical. Some items may require a more delicate glove. 3. Take instruments apart and rinse in luke- Hot water makes body proteins stick to warm running water. objects. 4. Prepare cleaning sink by adding warm wa- Ensure that objects are visible by using a ter and detergent. low sudsing detergent. 5. Clean instrument surfaces by using friction Scrub below the water surface to prevent (washing and scrubbing motions). Use a splashing into the eyes or on the clothing. small brush to clean any crevices or seams An ultrasonic cleaning device, with a lid, in instruments, e.g. hinges. may be used for cleaning. 6. Drain dirty water. Rinse cleaned instru- Rinsing removes residual detergent and ments in clean, warm water. soil that may impair the function of the instrument or interfere with the action of disinfectants. 7. Either air dry or dry with a lint free towel. If wet items are not dried a film may be left on the surface (biofilm), which contains mi- croorganisms. 8. Store cleaned instruments in a covered Uncovered, clean instruments may become container until disinfected or sterilized, if contaminated by dust or moisture. required. 9 Remove utility gloves; wash, rinse and Cleaned utility gloves may be used again hang to dry. as long as the rubber is not torn or punc- tured. 10. Wash hands. Hands should be washed after glove re- moval to avoid contamination. b. Cleaning the Environment It is important to keep the shop clean, as this reduces the chance of cross con- tamination during skin piercing procedures. Pay special attention to work sur- 9  faces that may become contaminated by used instruments or equipment, or surfaces touched by the practitioner’s unclean hands. The following categories of cleaning are advised: i. Routine Cleaning Use a solution of detergent and water to clean dust and soil from all sur- faces in the shop. Equipment or surfaces that have been touched and are potentially contaminated during procedures require special care. ii. Special Cleaning of Contaminated Surfaces After each client, use gloved hands to clean and disinfect equipment or surfaces that may have become contaminated. A low level disinfectant (see Table 2), mixed according to manufacturers’ directions and the spec- ified contact time, should be used to disinfect contaminated surfaces. Alternatively, an intermediate level disinfectant, e.g. a solution of house- hold bleach, 1 part bleach and 9 parts water mixed fresh daily (1:10), may be used(1). iii. Blood Spills When a blood spill occurs, the practitioner should wear gloves and blot up the blood with disposable towels before applying a disinfectant to the surface area. The towels should be discarded into a plastic-lined waste receptacle. After the spill area has been cleaned, an intermediate level hospital grade disinfectant should be applied to the area for the length of time recommended by the manufacturer. As an alternative, a solution of household bleach and water (as described above) should be left on the surface for 10 minutes(1). c. Disinfection In Canada, all disinfectants are registered and given a drug identification number (DIN). This means the manufacturer has to support the claims about which microorganisms the disinfectant kills and its safety for use. When you buy a disinfectant, ask the manufacturer to give you a material safety data sheet (MSDS)c, which gives information about use of the product and worker safety. i. Classification of Items for Disinfection How the item is used determines the classification. Equipment and instru- ments are classified as noncritical, semicritical, or critical. Table 2 de- scribes the classification of items, the type of disinfectant for each c Canadian Centre for Occupational Health and Safety, Hamilton, Ontario. Internet address: http://www.ccohs.ca 10  category, and the method of disinfection(1,14), to help you decide the best method. Items must be cleaned before they can be disinfected. Table 2 Classification of Items for Disinfection Classification Disinfectant Method NONCRITICAL items that may Low level disinfectants are come into contact with in- good for noncritical items. tact skin and /or are used for routine housekeeping Items that are rarely contami- Detergent is adequate. Clean to remove dust or soil nated with blood/body fluid, from items/equipment and e.g. client chair and table, surfaces with a solution of sponge holder, electrolysis detergent and warm water. machine arm holding the electrolysis magnifying glass Items that are often contami- Low level disinfectants, Clean and follow with low nated with blood/body fluid, e.g. quaternary ammonium level disinfection for reusable e.g. lamp handles, clip cord, compounds or “Quats”, or a items and environmental sur- dirty instrument tray, tattoo combination of a low level dis- faces that may be contami- motor frame, tattoo chuck or infectant-detergent; 3% nated. Wet or spray a paper clamp, pump packs, spray hydrogen peroxide com- towel to wipe the clean item/ bottle, electrolysis magnifying pounds surface with the disinfectant glass prepared and used according to the manufacturer’s direc- tions, i.e. allow sufficient sur- face contact time with the disinfectant. SEMICRITICAL items come Intermediate and high level into contact with mucous disinfectants are good for membrane or non-intact items that come into contact skin, or they hold a sterile with mucous membranes or item non-intact skin, or that hold a sterile item. Items that cannot be soaked Intermediate level disinfec- Clean item is wet wiped with and hold a sterile item that tants, e.g. 70% isopropyl alco- an intermediate level disinfec- may have been splattered with hol or 1 part 5.25% household tant and air dried after each blood/body fluids, bleach and 9 parts water. client. e.g. pin device that holds Bleach may be corrosive to electrolysis needle metals. Items capable of being High level disinfectants, Clean item is soaked for a soaked and hold a sterile e.g. 2% gluteraldehyde or number of minutes, as speci- item that may have been splat- 6% hydrogen peroxide. fied by the manufacturer, tered with blood/body fluids, to achieve a high level of e.g. plastic needle pusher disinfection. 11  Classification Disinfectant Method CRITICAL items enter deep in Sterile items must be used to the skin, e.g. tattoo or enter the skin. ear/body piercing needles, hypodermic needle used during electrolysis, Jewelry Metal items to pierce the skin Pre-sterilized, single use, should be purchased sterile or packaged needles or ear ring packaged and sterilized by a studs should be used. Items steam or dry heat method. that are not pre-packaged as sterile must be sterilized. Sterile electrolysis needles should never be saved and re- used on the same client. Chemicals that sterilize are not recommended for critical items as it is difficult to monitor and confirm that sterilization has been achieved and the packaging of items to maintain sterility is not possible. ii. Disinfectant Types Disinfectants are grouped into three broad categories (low, intermediate, high) depending on their action, i.e. the ability to kill certain organisms(14) (Table 3). 12  Table 3 Disinfectant Type and Action Disinfectant Action Comments LOW LEVEL Effective for non-critical items. DO NOT use to disinfect The most common are quater- Kills some bacteria and instruments. nary ammonium compounds viruses e.g. staphylococcus, Always add to water accord- or “Quats”. Some phenols and herpes, HBV, HCV, and HIV. ing to the manufacturer`s 3% hydrogen peroxide are in- Does not kill Mycobacterium directions. cluded in this group. tuberculosis, fungi, or spores. Generally, not irritating to the practitioner. INTERMEDIATE LEVEL Effective for some semicritical Mostly non-toxic, but some 70% isopropyl alcohol, 5.25% items. iodophors and bleach burn household bleach, and Kills the microorganisms for skin and stain fabrics. Bleach iodophors, e.g. iodine solu- low level disinfectants plus mixture: 1 part bleach and tions are included in this fungi but does not kill Myco- 9 parts water should be pre- group. bacterium tuberculosis, or pared every 24 hours. spores. Household bleach is not a good choice for disinfection of metal instruments or equipment as corrosion is a problem. HIGH LEVEL Used for semicritical items Gluteraldehyde is non- Common examples are and for critical items that corrosive but is irritating to the 2% gluteraldehyde and cannot withstand heat steril- skin, and vapours are toxic. 6% hydrogen peroxide (stron- ization. NEVER use gluteraldehyde ger than the 3% hydrogen Kills all viruses, bacteria as a spray. Good ventilation peroxide found in the drug (including Mycobacterium is required when using this store). tuberculosis) but does not kill product. spores. These products are 6% hydrogen peroxide can be able to sterilize objects with corrosive to some metals, e.g. longer soaks according to aluminum. times suggested by the manufacturer. d. Sterilization (Table 4) All items that pierce the skin must be sterile. Single-use needles purchased as sterile must be used before the expiry date and should not be reused or resterilized. Skin piercing objects, Jewelry, and direct instrument attachments, e.g. needle bar for tattooing, forceps and tweezers for electrolysis, must be sterilized by the practitioner. Any sterile instruments that are accidently touched or are contaminated in any other way, either before or during treatment, should be replaced by another sterile instrument or needle. All items for sterilization must be pre-cleaned and appropriately packaged prior to sterilization. Wiping instruments with disinfectants does not sterilize 13  them. Successful steam/heat sterilization depends on time, temperature, pressure (in the autoclave), and full contact with the item to be sterilized. i. Packaging and Loading of Instruments(15) Instruments are packaged in paper, plastic, or paper/plastic peel-down pouches/bags to protect the instrument when it is sterile and permit removal without it becoming contaminated. Paper/plastic peel-down packages offer good visibility but have limited strength. Plastic/paper packaging must not be reused. Instruments for one client may be grouped into one bag or in sets on a tray or metal container. Packaged items are loaded into the sterilizer to allow all items to be in contact with steam. Chemically treated paper bags or tape are available that change colour when the load has been exposed to the required combination of time, temperature, and steam; chemical indicators do not provide proof of sterilization. Biological spore test is the accepted standard for proof of sterilization. Packages for sterilization should be dated to ensure rotation of supplies. ii. Type of Sterilizer One of two methods of sterilization should be used for skin piercing equip- ment: steam autoclave (steam under pressure) or dry heat sterilizer. - STEAM AUTOCLAVE The autoclave sterilizes more rapidly than the dry heat method and is the recommended method of sterilization for skin piercing items. It may also be used to sterilize liquids. The common steam sterilizer temperature is 121° C (250° F ) with pressures that are preset by the manufacturer(15). The length of time required for sterilization depends on whether the instru- ment is packaged or not. Packaged items at a temperature of 121° C nor- mally require a sterilization time of 30 minutes or a temperature of 133° C for 15 minutes, although unpackaged items may require less time. Always follow autoclave operator manual instructions for sterilization. Some autoclaves do not have a drying cycle and the door must be left slightly open to allow the packages to dry. If the packages are removed when wet, contamination may occur. 14  - DRY HEAT STERILIZER The dry heat sterilizer relies on heat only and requires longer exposure times than when steam and pressure are used. The door must remain closed throughout the process. Examples of temperatures required for sterilization are(14): 171° C for 60 minutes 160° C for 120 minutes 149° C for 150 minutes 141° C for 180 minutes 121° C for 12 hours The advantages of dry heat sterilization include minimal rusting and corrosion of instruments. This method can also be used for glass and powders, and may be useful for instruments that cannot be taken apart. A disadvantage of the process is that paper packages may burn. Because of limited options for packaging materials and longer heat exposure times, the dry heat sterilization method is seldom used in the skin piercing indus- try. Always follow operator manual instructions for sterilization. NOTE: Sterilization cannot be achieved by using a glass bead steril- izer, microwave oven, domestic oven, pressure cooker, boiling pot or ultraviolet sterilizer. iii. How to Monitor Sterilization Chemically treated paper bags or tape that changes colour must be used to confirm that the items in each load to be sterilized have been exposed to the required combination of time, temperature, and steam. Chemical indicators do not provide proof of sterilization. The only sure method to show that sterilization has been achieved is to use the spore test. To monitor steam sterilization, the spore (Bacillus stearothermophilus) strips or vials should be placed into the centre of the load during a regular cycle in the sterilizer. To monitor dry heat steriliza- tion the spores of Bacillus subtilis should be used. The spore test should be then sent to a laboratory where it is tested for spore kill. The test should be performed before the equipment is first used for procedures and once a month or more frequently, depending on use. If a positive spore test occurs, the use of the autoclave should be suspended until the autoclave function is checked. Consult a laboratory or health inspector in your area to obtain test strips and for advice regarding a positive test. Regular maintenance of the sterilizer should be scheduled as per manufacturers’ instructions or more frequently if necessary. Service records should be logged and kept for information. All staff involved in the sterilization of instruments/equipment should be trained to operate the sterilizer. 15  iv. Storage of Sterilized Instruments/Equipment sterilized items must be kept sealed in the original package/set until just before use; sterilized items must be stored in a clean, protected, dry area where dust, moisture, and vermin cannot disturb the equipment; single instruments from a package of multiple sterile instruments must be removed with forceps (which have been sterilized and packaged as a single item). The package must be sterilized again. packages that are torn, punctured or wet should not be used as sterile; frequent handling of sterile packages should be avoided. Table 4 Steps for Sterilization Steps Comments Clean instruments as per Table 1: Steps to Instruments that are not clean cannot be Clean Instruments. effectively sterilized. Wash hands. Unclean hands will put debris on clean objects, and sterilization may not be accom- plished. Package cleaned instrument. Paper/plastic peel-down pouches or sets on trays or in metal containers should be used. Place chemically treated tape or thermal Heat indicator tape or bags should be used indicator on bags that change colour. on each load to monitor exposure to steam or heat. Load the sterilizer evenly and do not overload Overloading will prevent the sterilizer from the chamber. Packs should rest on edge in doing the job. Tight packing of instruments loose contact with each other. Packs should and trays should be avoided. not be oversized. Set appropriate dials to start the sterilization Monitor the sterilizer to verify it is achieving process. sterilization by including the spore test at least once month. Place the spore test in the auto- clave as per manufacturer’s instructions. Remove items when dry. Leave the autoclave door ajar to permit drying of packages. Store sterilized items in a clean, dry, place Handling increases the chance of punctures that is protected from dust, dirt, moisture and of sterilized bags. DO NOT use damaged vermin. packages. 16 3. Infection Prevention Practices for the Practitioner Once items are cleaned, disinfected and sterilized, the practitioner should keep equipment and instruments free of contamination. Clean and aseptic procedures are dependent on the practices of the practitioners. The next section describes how to keep items clean and/or sterile. a. Asepsis The skin piercing object must be sterile at the outset of the procedure and should not become contaminated with another client’s blood or the blood of the practitioner during the procedure. The skin piercing object should be protected from contamination by the following practices: Wash hands before and after wearing gloves. Keep items used during a procedure within easy reach to avoid accidental contamination. The equipment used during the procedure should be positioned above waist level and clearly visible to the practitioner. Do not touch contaminated areas with a sterile object. Keep environmental objects clean, e.g. cord that you touch during the procedure. Concentrate on the activity, and change the skin piercing object if it becomes contaminated. b. Hand Washing Hand washing is the single most important practice to prevent cross- infection in the client and the practitioner. i. When should hands be washed? before and after touching the client before handling and opening sterile supplies after handling contaminated items before and after removing gloves before eating after using the toilet or blowing one’s nose when in doubt about the need to wash your hands. 17  ii. How should hands be washed? rinse hands under warm water; lather with soap and use friction to clean the hands and fingers for 10 seconds; rinse hands under warm running water; dry hands thoroughly with a single-use towel; use the towel to turn off the tap or use elbow/foot operated taps. c. Barriers i. Medical gloves should be worn for all procedures that might involve skin or mucous membrane contact with blood or fluid capable of transmitting BBPs as an added barrier to protect the practitioner’s hands from becom- ing contaminated. Gloves also afford the practioner some protection from sharps injuries. Hands should always be washed before gloves are put on and after they are taken off. Latex allergies are a growing concern to both clients and practitioners. Common symptoms include skin rash, runny nose and/or eyes, asthma and, less commonly, more severe breathing problems. Individuals with latex allergies should be referred to a dermatologist or allergist for advice. Non-powdered, low-protein latex gloves may solve the problem or, in some cases, latex may have to be avoided completely(14). ii. Masks are not routinely necessary unless the practitioner or client has a respiratory tract infection, e.g. a cold. iii. Smocks, aprons, uniforms, lap pads and other outerwear may be used to protect clothing. If worn, these items should be laundered regularly and when soiled. 4. Skin Care Before and After the Piercing Skin preparation before skin piercing procedures should involve a skin inspection and cleaning with an antiseptic. a. Skin Inspection The skin should be inspected to ensure that there is no abnormality or sign of infection. Skin should not be pierced if there are signs of infection such as warts, pimples, crusts or open skin areas. 18  b. Skin Preparation The skin piercing site should be disinfected using a skin antiseptic, which is applied with a clean cotton ball or gauze. The clean cotton ball or gauze may be moistened with the antiseptic that flows in a stream from the pump con- tainer. When the pump is empty, the container should be washed and dried before it is refilled. Alternatively, disposable pre-packaged antiseptic swabs may be used. c. Skin Care Following the Piercing New gloves should be worn when antibacterial lotions or ointments are ap- plied to freshly pierced areas. If the lotion or ointment is removed from a bulk container, a single-use spatula, e.g. tongue depressor, should be used to avoid contamination of the bulk container. In some skin piercing procedures, a dry sterile dressing is applied. Oral and written instructions for care at home should be provided to the client. The signs and symptoms of possible complications should be discussed. Ad- vise the client how to deal with slight redness, pain and swelling. The client should be advised to seek medical advice if infection develops. Do not remove Jewelry from an infected piercing but seek medical advice. 5. Waste Disposal The waste generated in a skin piercing shop should be segregated and disposed of according to municipal/provincial regulations. Some general guidelines follow: a. Regular Waste Regular office waste such as office paper or single-use paper hand washing towels may be discarded in regular waste paper bins. b. Contaminated Waste Blood-contaminated waste should be disposed of in plastic bags and tied before being put in regular waste pick-up. It is preferable to avoid having waste receptacles with a swinging lid in the skin piercing area as they are touched, and therefore are contaminated. c. Sharps Sharps such as needles or razor blades should be placed in puncture-resistant sharps containers that are handy to where the practitioner is working. Sharps should not be sterilized or disinfected before disposal because decontamina- tion may not be certain and handling of sharps may pose an unnecessary risk 19  of injury to the practitioner. Some pharmacies may exchange full sharps con- tainers for empty ones. Contact your local public health unit or municipality for instructions regarding disposal of sharps containers in your area. 6. Client Records A record of each skin piercing procedure should be kept, including the client’s name, date of birth, address, phone number, date of procedure; practitioner’s name; and site of procedure. Information contained in records may be useful if any infection occurs. Records should be kept in accordance with local requirements and, if not stated, for a minimum period of one year. 7. Practitioner Health and Safety a. Bloodborne Pathogen Precautions Bloodborne pathogen (BBP) precautions were previously called Universal Precautions. In 1987, Health Canada published guidelines to prevent HIV/AIDS transmis- sion to practitioners who come into contact with blood. The principles of BBP precautions are contained in an updated document published in 1997, Preventing the Transmission of Bloodborne Pathogens in Health Care and Public Service Settings(1). Any effective approach to the prevention of the transmission of BBPs is based on the assumption that all blood and certain body fluids are potentially infectious. Precautions applied to all patients for all procedures that might involve skin or mucous membrane contact with blood or fluid capable of transmitting BBPs may reduce the exposure of personal service workers to blood. The basic components of BBP precautions include immunization, hand washing, protective attire, e.g. medical gloves, prevention of needlestick injuries, and cleaning of blood spills. b. Immunization All staff who perform skin piercing procedures should have up-to-date immuni- zations as recommended for adults in Canada, including diphtheria and teta- nus every 10 years(16). Because of potential exposure to blood, practitioners are advised to receive three doses of hepatitis B vaccine, which offers 95% protection against hepatitis B infection. There is no vaccine for hepatitis C or HIV/AIDS. c. Chemical Hazards A Material Safety Data Sheet (MSDS) for each chemical, e.g. disinfectant, should be kept on the premises. The MSDS provides information on the toxic effects to humans, e.g. skin contact or inhalation; instructions for safe handling; 20  and emergency procedures if accidental splashes or swallowing of the chemi- cal occur. d. Hand Care Healthy skin with no cracks is an excellent barrier to pathogens that cause infection. Use hand cream frequently on washed hands throughout the day and after work. Practitioners with skin lesions or breaks in the skin should wash well and cover the area with waterproof dressing before putting on gloves. If this cannot be done, the practitioner should refrain from working with clients until the skin condition has healed. e. Sharps Injuries Contaminated sharps should be disposed of in puncture proof containers im- mediately after use to avoid accidental sharps injuries. The more blood there is in the hollow bore of a needle, the deeper has been the insertion of the needle, and the higher the level of viral activity in the blood from active disease; the more likely that a person who is injured will be exposed to the infection, and that there will be transmission of disease(17). i. A sharps injury to a worker is defined as: a poke or scratch with a contaminated needle; a cut on contaminated equipment; a blood splash onto practitioner’s skin that is cracked or otherwise broken; a splash of blood or contaminated fluid on a practitioner’s mucous membranes, e.g. mouth or eyes. ii. After an accidental exposure to blood the following is recommended: Allow the punctured area to bleed freely. Wash the punctured area with soap and running water. If the eye or mouth is involved, flush it well with water. Apply a skin antiseptic and cover with a dry dressing. Obtain the name, address and phone number of the client and tell him/her that blood tests may be required. 21  Immediately call the doctor or local public health department for advice, as preventive treatment may be advised. Document the injury. f. Practitioner Education for Infection Control All practitioners and shop employees should receive instruction about infection prevention and control to ensure a safe environment for workers and clients. Call your local public health unit or municipal health service for assistance with infection control. Practitioners should understand written procedures and be able to apply them practically. Practitioners should not eat, smoke or drink beverages while working with the client. 22  Part 2 Specific Implications of Infection Prevention and Control in Tattooing, Ear/Body Piercing and Electrolysis 23  Guidelines for Infection Prevention and Control in Tattooing I Introduction Tattooing has been reported as the source of many types of infection as well as of numerous skin reactions produced by pigment in the skin (See Part 3: Literature Review). The potential for the spread of pathogens exists because blood comes to the skin surface during tattooing. Tattoo needles are the most likely way to intro- duce pathogens into the body. Therefore the needles and the devices that hold them must be sterile at the outset of the procedure. All remaining tattooing infec- tion prevention and control practices, including safer handling of instruments and equipment, are intended to reduce the chance of pathogen transmission from one person to another during tattooing. Unsafe infection prevention practices place the practitioner and the client at risk of infection. Avoiding sharps injuries and other exposures to the client’s blood will reduce the chance of infection in the practitioner. II What is Tattooing? The practice of tattooing dates back to prehistoric times as a form of permanent body adornment for individual expression, identity, rites of passage and, more recently, as a form of permanent cosmetic make-up for women. Tattooing permanently deposits pigments into the skin to a depth of 1-2 mm, which creates an imprint of a design. The design is either drawn free hand by the artist or more commonly follows a stencilled design that has been copied onto the skin prior to tattooing. Cosmetic tattooing may be used for eyelids and nipples. The contemporary electric powered tattoo machine vibrates a cluster of fine needles several hundred times a minute creating a series of skin punctures. The solid nee- dles impregnate pigment into the skin. Other facts about the tattooing procedure follow: Tattoo needles are soldered onto a long, moveable shaft called the needle bar, which is placed into a stainless steel tube that serves as the “grip”. During tattooing, the needle bar (with mounted needles) protrudes from the end of the tube, driven by the needle bar post (see Figure 1). The number of needles on the needle bar varies depending on the effect desired: a single needle for fine outlining, three to four needles for thicker lines, and up to 14 needles for shading or dense deposits. The protruding needles are dipped into tattoo pigment that is poured into individual caps or cups for each client. 24  Figure 1 The Tattoo Machine* * Adapted with permission: Spaulding, H Tattooing A to Z (A Guide to Successful Tattooing) Spaulding & Rogers Mfg. Inc.1998; 31. Pigments used during tattooing may be purchased in liquid form, or the practitioner may prepare the product using chemically pure, non-toxic and non-sensitizing pigment powder and other ingredients according to the manufacturer’s instructions. Dyes and pigments containing mercury, e.g. cinnabar/vermilion/red mercuric oxide, are not permitted to be used in Canada(18). Pigments should be prepared in a hygienic manner. The needles penetrate the outermost layer of skin (the epidermis) and reach the next layer (the dermis). During tattooing, excess pigment and blood is wiped away with tissue or paper towels. Tattooed skin heals in about two weeks. Immediately after tattooing, the skin swells slightly and a small amount of bloody to colourless body fluid comes to the surface. The swelling lasts for a few hours, and then the skin is inflamed much like a sunburn. Tattoos are permanent, although over many years colours fade and borders become less distinct. Tattoos may only be removed by special medical procedures, e.g. lasers, which are expensive and not always effective. III Infection Prevention in Tattooing The most critical item for infection risk during tattooing is the set of needles mounted in the needlebar. Needles must not be cleaned in the ultrasonic cleaner and reused with a new colour, as the needles are not sterile. Needles cannot be sterilized for reuse because their very close placement to each other when sol- dered onto the needlebar means that they cannot be adequately cleaned (even if the ultrasonic cleaning device is used). Because the needles have contact with 25  the client’s bloodstream in tissue under the skin, the sterile needles must be used only for one tattooing session, on only one client. Used needles should be carefully removed from the needlebar to reduce the risk of needlestick injury to the practitioner and placed in the sharps container. Careful handling of the tattoo needles during the procedure reduces infection risk. The following sections 1 through 3 list tattooing instruments and equipment, their use during tattooing, and procedures for infection prevention and control. Part I: Umbrella Document provides the details necessary for full implementation of this guideline. CAUTION: Some individuals may have an allergic reaction to even the most pure and non-toxic pigments. If the client shows any type of allergic reaction during the tattooing process, e.g. paleness, shortness of breath, difficulty breathing, undue swelling, or puffiness around the eyes, the tattooing process should be stopped and immediate emergency medical attention should be obtained(18). 1. Equipment and Supplies The practitioner will need the following equipment to carry out safe tattooing procedures. Special equipment and supplies are available in Canada or the United States. Additional supplies are readily available locally from medical and dental supply outlets. Ultrasonic cleaning device Spray bottle (with soap and water) Sterilizer (autoclave) Razor Instrument packaging (for sterilization) Pigment (ink) Bacterial spore test (strip or vial) Caps/cups for pigment Tattoo machine with clamp or chuck Tray to hold caps/cups Clipcord Towels (paper) Grip and tube assembly Tray Needles Skin antiseptic Needle bar Lubricating gel Elastic bands Hand washing soap in pump container Stencil transfers (disposable) or Plastic Lap pad or protective clothing stencils (reusable) Forceps Dressing/gauze Metal container for used instruments Ointment (single use or bulk) Metal container with lid for sterile items Wooden tongue depressor(s) Pump pack (for antiseptic) Disinfectant(s) Image transferring solution Disposable paper cup (tap water) Heat indicator strips for sterilizing Cloth/paper protector (for furniture) Solder gun/solder Plastic sheath or bags Brush (for cleaning) Medical gloves Sharps disposal container 26 2. Preparing the Work Station and the Client for Tattooing a. Position the client comfortably. b. The skin/tissue should be assessed prior to tattooing. If any skin/tissue abnormality exists, the tattooing procedure should not be performed. c. Ensure that the work area is large enough to arrange all equipment that is needed. d. Furniture that will have direct contact with the client’s skin should be covered with paper or clean cloth. e. Disposable paper towels should cover work surfaces and metal trays where tattooing equipment or supplies will be placed. f. The tattoo machine, clipcord, and spray bottle(s) should be covered with plastic. Any other surfaces that are touched with contaminated gloved hands should be covered with plastic, e.g. lamp handles. The plastic should be replaced after the treatment of one client and before the next one. g. The sharps container should be placed in a convenient location in the workstation to permit immediate disposal of sharps after use. h. A metal container with water should be placed on a counter in the work area for holding dirty instruments until they can be cleaned. i. All items used for the tattooing procedure should be positioned within easy reach of the practitioner to prevent accidental contamination of instruments. j. A plastic-lined waste bin should be placed within reach of the practitioner for the disposal of non-sharp items contaminated with blood. k. The sterile needles, needlebar, grip and tube assembly should be assem- bled with gloved hands in a manner that avoids contamination of needles. It is good practice to open packages containing sterile needles in front of the client. l. When the treatment is complete, dispose of needles in the sharps con- tainer in front of the client. 3. Detailed Infection Prevention and Control Procedures for Tattooing Table 5 provides a list of tattooing equipment and supplies, their use during tattooing, and a practical method of applying infection control principles, which should be followed, unless the manufacturer provides written instruc- tions stating otherwise. 27  Table 5 Detailed Infection Prevention and Control Procedures for Tattooing Equipment/ Use During Procedures for Supplies Tattooing Infection Prevention 1. Skin preparation: spray bottle with a The skin area to be The spray bottle should be covered with solution of soap shaved is sprayed with a single-use plastic sheath, e.g. plastic and water the solution for lubri- bag. This plastic should be discarded cation purposes. after each client service. At the end of each day, or when soiled, the spray bot- tle should be cleaned and disinfected with a low level disinfectant. single use dispos- The skin is shaved Razors should be discarded in the able razor prior to tattoo sharps container after use on each placement. client. skin antiseptic, Antiseptic is used to The skin antiseptic should be applied e.g. 70% isopropyl clean and disinfect the with a cotton ball/gauze or swab using alcohol skin prior to tattooing. a circular motion. If alcohol is used, it should be stored in a pump pack that is used to moisten the cotton balls. Alter- natively, the cotton balls/gauze may be moistened by pouring the antiseptic from the original container into a disposable paper cup. The disposable cup should be discarded in the waste bin after use. Skin antiseptics should not be applied to the skin with a spray pump. For cosmetic tattooing of areas around the eye, e.g. eyeliner, water should be used and an antiseptic should be avoided. 2. Stencil and image transferring solution: lotion or spray Lotion or other solu- Lotion should be applied in the same bottle with solution tion moistens the skin way as skin antiseptics OR with spray as above, skin anti- prior to application of bottle. Deodorant sticks are not recom- septic, e.g. 70% the stencil. mended instead of lotion. isopropyl alcohol single use stencil Stencils are used to Single-use stencils should be discarded transfers or plastic outline the design of after use. reusable stencils the tattoo on the skin If plastic stencils are used, they should be cleaned and disinfected with deter- gent after use on each client. If the skin was broken, 70% alcohol should be used to wipe the stencil. 28  Equipment/ Use During Procedures for Supplies Tattooing Infection Prevention 3. Lubricating product, The lubricating prod- The lubricating product should be re- e.g. gel or petroleum uct is placed on the moved from bulk container with a single- jelly skin with a single-use use wooden spatula or dispensed from a spatula or a piece of pump container onto a single-use appli- clean gauze prior to cator, e.g. clean gauze. Any remaining tattooing. product must be discarded and never used on another client. Alternatively, a single-use preparation may be used. 4. Tattoo dyes: pigments/ink Sterile needles, which Currently, commercially prepared have been dipped into pigments are not sterile and attempts pigments, pierce the by practitioners to sterilize the dyes tissue below the skin to have not been successful. Contamination create the permanent of pigment bulk containers should be tattoo. avoided by placing pigment in smaller containers, e.g. plastic squeeze bottles. caps/cups Each unique pigment The pigments used for one client should is placed in an indi- be poured into clean, single use plastic vidual cap/cup into caps or disposable cups. The caps/cups which the tattoo nee- and any leftover pigments should be dles are dipped. discarded after use with each client. pigment cap hold- Trays are sometimes The pigment cap trays should be ing tray used to hold the cleaned and disinfected with a low or pigment caps. intermediate level disinfectant after use with each client. disposable cup with Tap water is used to Water should be poured into the dirty tap water rinse pigment from the zone sink at the completion of the proce- needles prior to using dure. Discard disposable single-use another colour. cups into a plastic lined waste bin. 5. Cleaning the skin during tattooing: spray bottle con- The skin is cleaned to Care should be taken to avoid contami- taining a solution of enable the practitioner nation of the soap solution when it is soap and water as to see it clearly and to being prepared and during use. The in #1. avoid the mixing of spray bottle should be covered and colours. cleaned/disinfected as in #1. The solution should not be “topped up” with more solution. The inside of the bottle should be washed and dried prior to adding new solution. disposable paper Paper towels are used All towels should be discarded into a towels to wipe the sprayed plastic lined waste bin. area during tattooing. 29  Equipment/ Use During Procedures for Supplies Tattooing Infection Prevention 6. Tattoo machine: motor frame The motor frame is The clipcord and the motor frame should clipcord connected to an elec- be covered with a disposable plastic trical source by the sheath. The plastic sheath should be clipcord. The clipcord discarded after each client service. The may be touched multi- clipcord and motor frame should be ple times if one or sprayed and cleaned with an intermedi- more machines are ate level disinfectant after each use, used during tattooing e.g. 70% alcohol. on one client. chuck or clamp The chuck/clamp After each client service the clamp attaches the needle should be cleaned and wiped with a low bar/tube to the motor level disinfectant. frame. elastic bands The elastic bands The elastic bands are discarded into the apply pressure on the waste bin. needlebar so that the needles that rest in the bottom of the tube tip. 7. Instruments: needles, e.g. stain- Needles are soldered Any flux residue produced by soldering less steel onto needle bars. The should be removed with a solution of needle bars needles place pig- baking soda and water prior to clea