Principles of Infection Control for the Tattoo Industry

In the beginning of 2017, I was commissioned to author a book covering the topic of infection control for the tattoo industry. Over the next several months, I researched and worked on this book and it was definitely an arduous task to complete this. The book was published in the fall of 2017 and as a result, I have been asked to present over this topic at educational events and industry conventions. I have also been asked to write articles for international platforms and online magazines. Please enjoy my latest article.

Safety and Sanitation in the Cosmetic Tattoo Industry.

Shanan Zickefoose, BSN, RN, CPCP

In the last decade, the cosmetic tattoo industry has birthed a new generation of short-term training programs, and as a result, safety and sanitation is often overlooked by trainers due to the time restraints in this style of training. Both trainers and new technicians must understand the of risk of exposure to bloodborne pathogens, and it is vital for the cosmetic tattoo industry and body art professionals to execute protocols to protect both the artists and the clientele. Protocols should include best practice for: aseptic technique, hand hygiene, personal protection equipment, decontamination methods, and recognizing signs and symptoms of infection. Our goal in this article is to provide fundamental information to assist the industry in best infection control practices.

Rationale of Standard Precautions

In 1985, as a result of the human immunodeficiency virus (HIV) epidemic, blood and body fluid protection precautions were implemented on all clients which were commonly known as Universal Precautions. Revisions were made over the years and in 1994, a two-tier system of precautions was implemented by the United States Centers for Disease Control and Prevention (CDC). The two-tier system is based on Standard Precautions and Transmission Precautions.

The CDC recommends Standard Precautions protocols is recognized as the safest way to provide infection controls when Other Potential Infectious Material (OPIM) and can cause exposure. OPIM is defined as both visible and nonvisible blood, or matter from mucous membranes and non-intact skin.

Best Practice for Safety and Sanitation

In the cosmetic tattoo industry, it is important to implement best practice protocols which include correct hand hygiene, the proper use of Personal Protective Equipment (PPE), and approved cleaning and disinfection of our workstations. Hand hygiene is the most important part of infection control. According to the CDC, a single hand has over 10 million bacteria. Imagine you and your client touching your hands together and you can share over 40 million bacteria.

One hand > 10 million bacteria
Two hands > 20 million bacteria
You + your client’s hands > 40 million bacteria

To prevent the spread of infection, it is important to perform hand hygiene often and according to guidelines such as the CDC. We will discuss hand washing and alcohol-based disinfectants and the best practice for use.

Hand Washing is the first line of defense to remove contaminants and involves using warm water and antiseptic soap. Hands should be washed with soap and warm water for 20 seconds. Warm water is best for washing hands as hot water can damage the skin and cold water does not provide adequate cleaning. It is important to avoid antibacterial soap, as it can cause bacterial mutations, therefore, regular antiseptic soap is best. After hand washing, it is acceptable to support hand hygiene with the use of alcohol-based hand sanitizers. Alcohol based disinfectants are germicidal and help reduce transmission of pathogens. When purchasing, it is important to look for minimal alcohol percentages of at least 60% ethanol or 70% isopropanol. Alcohol hand sanitizers do not substitute for hand hygiene when hands are visibly soiled.

CDC Recommends When to Perform Hand Hygiene:

By hand washing before and after having direct contact with a client’s intact skin
After contact with non-intact skin, body fluids or excretions, blood, plasma, mucous membranes, or wound dressings
After contact with inanimate objects (including tattoo equipment) in the immediate vicinity of the client
If hands will be moving away from a contaminated-body site during client care
Before and after leaving the client tattoo procedure for any reason
After glove removal
After using a restroom
Before and after eating
At the end of the day

Note:

Avoid the use of long fingernails, bracelets, watches, and long sleeves because 40% test positive for both Gram (-) and Gram (+) bacteria. Some contaminants that have been found on these objects:

Gram (-)

E. coli
Klebsiella
Acinetobacter (pneumonia and meningitis)
Pseudomonas

Gram (+)

Methicillin resistant staphylococcus aureus (MRSA)
Streptococcus

Detailed Protocols for hand hygiene, personal protective measures, and cleaning and disinfection are detailed in section 5 of Principles of Infection Control for the Tattoo Industry.

Personal Protective Measures

After performing hand hygiene, it is time to put on your Personal Protective Equipment (PPE).

• Gloves

• Mask and protective eye goggles, or face shield. In the United States, if you are an employer or an employee, you must abide by OSHA rules. If the technician chooses to wear a mask or eye protection, you must wear both at the same time. You may not use one while avoiding the other but must don both.

• Disposable gowns or poly aprons

• Disposable arm covers

For those in other countries, please check your local regulations for more information.

Note:

Gloves are the single most important barrier of protection, and it is best practice is glove use during ALL instances of touching skin. We are working around mucous membranes when touching the face, it is always best practice to use gloves around these areas. You should never be touching the clients’ faces without gloves. Remember one single hand harbors up to 10 million bacteria. In the United States, the National Environmental Health Association (NEHA) recently released the Body Art Model Code (BAMC) and according to section 2.8 When coming into contact with the client, the body artist must wear gloves at all times. The gloves must be immediately discarded, and the body artist’s hands must be washed—at a minimum—after the completion of each procedure, and/or when gloves are torn, punctured, or otherwise compromised, or at any other time when necessary to prevent cross contamination.

Decontamination Methods

Preparation and breakdown of the procedure area involves a two-step process, which begins by environmental cleaning, followed by disinfection. This is often misunderstood as a single step. Cleaning and disinfection are defined as follows:

1) Environmental Cleaning – removes all visible soil, debris, and foreign matter from work surfaces and equipment.

2) Disinfection – eliminates bloodborne pathogens and microorganisms from surfaces, equipment, and the environment.

Cleaning begins by manually wiping, brushing and/or scrubbing and the goals of cleaning are to reduce the number of contaminants on surfaces, reduce and the multiplication of bacteria, and prevent contaminants from diluting disinfecting agents. Disinfection is achieved by using chemical agents. In the United States, it is best practice to use an EPA-registered tuberculocidal disinfectant that is labeled effective against HBV and HIV. Many disinfecting agents can be used for both cleaning and disinfecting.

• Read manufacturers’ labels to determine:

• Compatibility for the surface.

• Required direct contact time to produce effectiveness.

• Disinfecting: If you are going to use a wipe product, clean first, then allow the surface to dry completely. Then, get a new wipe to disinfect.

• Contact times will vary based on the product you are using. That means the product must stay wet during the entire contact time. If it dries before the contact time, you are not effectively killing the bacteria.

Sterilization involves the complete elimination of all pathogens including bacteria, viruses, parasites, and bacterial spores. Sterilization is the only method of providing complete coverage against infection control. When purchasing manual hand tools, disposable single use devices, and needles, it is necessary to buy and use sterilized instruments only. These tools are sterilized by gamma rays and ethylene-oxide gas. Sterile package labeling must include:

Description of package contents
Lot number control
Date of sterilization
Sterilization identifier to recognize complete sterilization was achieved

Ask your supplier for a copy of their proof of sterilization document.

Wound Healing

The cosmetic tattoo wound will initiate a normal inflammatory response and will undergo a normal healing process that provides a natural defense against infection. The initial healing response will last approximately 3-5 days and during this time the risk of infection is at the highest. During this time post procedure, there will be initial swelling, redness, heat, and pain.

Within a few days of the procedure, it is important to teach clients to watch for signs & symptoms of infection:

• Prolonged pain

• Severe redness

• Heat

• Excessive swelling

• Excessive wound discharge that is thick or creamy (white, yellow, or green)

If your client shows signs of infection, please encourage them to see their physician for appropriate treatment. Physicians have the authority to culture and prescribe appropriate treatment if a client shows signs of infection. It is important to avoid the use of antibiotic ointments in your aftercare protocol. They can cause allergic dermatitis, but more importantly, they can provide opportunity for bacterial mutations in your clients.

As technicians, it is vital to implement protocols and create a plan to prevent infection for your clients. As discussed earlier, the best methods of infection control include the following: aseptic technique, proper hand hygiene, best practice use of PPE, cleaning, disinfection, and sterilization. For more details protocols that are specific to our industry, please refer to my book:

Principles of Infection Control for the Tattoo Industry