1. BLOODBORNE PATHOGEN
EXPOSURES FOR TATTOOISTS AND
BODY PIERCERS:
CURRENT AND PROPOSED INTERVENTIONS
Colorado School of Public Health
EHOH 6614, April 2, 2014
Group 10:
Ryan Blair
Kathleen Harty
Shaina Kumar
Danielle Osowski
Laura Paulson
2. LEARNING OBJECTIVES
• Describe the risk
• Outline current regulations and regulatory agencies
• Use Hierarchy of Controls as a framework for risk
reduction
• Describe gaps in prevention solutions
• Suggest further prevention methods
3. WHO IS AT RISK?
Tattooing and body piercing is a growing industry.
• In 2012, an estimated 21% of American adults had at least one tattoo
(compared to 16% in 2003 and 15% in 2008)2.
• A 2004 survey of 500 adults between 18-50 found: 24% had a tattoo; 14%
had a piercing outside earlobes; 34% with earlobe piercings13.
• Estimated 21,000 tattoo parlors in US16.
• High demand increases possible exposure for body artists.
5. HIV
• More than 1.1 million people in the United States are living with HIV
infection5
• HIV does not survive long outside the human body (such as on surfaces),
and it cannot reproduce
• The risk of HIV infection from being stuck with a
needle used on an HIV-infected person is less
than 1%
• Currently there is not a vaccine or cure for HIV.
6. HEPATITIS B
• 1.4 million persons in the U.S. are estimated to be
infected with the virus, most of whom are unaware of their
infection status6
• Hepatitis B virus can survive outside the body at least 7
days
• The risk of Hepatitis B infection from being stuck with a
needle is 6%
• There is a vaccine for Hepatitis B, but no cure
7. HEPATITIS C
• 3.2 million persons in the United States have chronic
Hepatitis C virus infection7
• The Hepatitis C virus can survive outside the body at room temperature,
on environmental surfaces, for at least 16 hours but no longer than 4 days
• An exposure with an HCV-infected needle would have about a 1.8 percent
chance of becoming infected with the virus
• There is currently no vaccine for HCV, but there are new medications that
can cure the virus
8. CURRENT REGULATIONS:
FEDERAL
Some recommendations and resources but most regulation is at state
or local level
OSHA15
• Outlines bloodborne pathogen standards
• Requires each shop to develop an Exposure Control Plan
• Requires employers to provide Hep B vaccines at no cost
• Recommends each shop maintain a Sharps Incident Log
9. STATE REGULATION: COLORADO
• Colorado Board of Health adopted “Rules and Regulations for Body Art
Establishments” in 20019.
• Minimum requirements for body artists:
o “demonstrate and possess knowledge of Universal Precautions,
disinfection and sterilization techniques, procedures for infection and
exposure control...and the Infectious Waste Management Plan”
o Body artists must obtain Hepatitis B vaccine, or submit written
statement of refusal
• Other important points:
o Clients are not required to disclose infectious diseases
o LPHAs may have more stringent requirements
10. LOCAL REGULATION
EXAMPLE: BOULDER COUNTY1
Boulder County Public Health is an example of stricter requirements
• Artists are required to successfully complete a bloodborne
pathogen course
• Clients are asked to disclose communicable diseases
• Thorough inspections; public access to results online
13. ADMINISTRATIVE CONTROLS
• Develop exposure control and spill response programs.17
• Offer Hep B vaccinations to piercers at no cost.
• Provide PPE.
• Provide separate areas for piercings, cleaning
instruments, and sterilization.
• Provide adequate lighting.
• Provide adequate ventilation and filtered air to piercing
areas.
• Provide foot-operated sinks and waste receptacles.
• Provide easily accessible sharps containers.
14. BEHAVIORAL CONTROLS
• Get Hep B vaccination if not immune.17
• Report needlesticks and spills immediately.
• Immediately discard used needles in sharps containers.
• Limit the number of customers in piercing area.
• Avoid performing piercings and tattoos when fatigued.
• Wear PPE.
15. PERSONAL PROTECTIVE EQUIPMENT
• New, clean gloves required for each procedure (per
Colorado regulations )
• Hand-washing required before glove use, but some
evidence in health-care workers that hand hygiene
decreases when gloves are used12
• Face masks and eyewear: not required and risk in body
artists has not been studied. However, they could provide
some level of protection.
o a high incidence of blood splashes has been found
on protective eye and face wear of surgeons11;
everyday eyewear alone may not be effective8
• Footwear should also be sturdy enough to protect against
dropped sharps10
16. GAPS IN SOLUTIONS
• Compliance with infection
control standards, but not
with administrative controls14
• Variability in state and local
regulation
• Limited impact of state and
local regulations?
• Lack of data
17. RESOURCES FOR WORKERS
• Professional Organizations:
Association for Professional Piercers
Alliance of Professional Tattooists, Inc.
• Ways to report concerns?
• NIOSH: information about bloodborne
pathogens, selecting sharps containers,
developing exposure control plans, etc.
19. CONCLUSION
• Encourage increased PPE
• Include professional organizations as stakeholders
• Increase documentation and reporting of sharps incidents
• Increase compliance with exposure control plan
• More evaluation of whether bloodborne pathogen standards meet
needs of body artists
• And...
More research with body artists!
20. REFERENCES
1Boulder County Public Health (2010. Rules and regulations for body art establishments. Retrieved March 16, 2014 from
http://www.bouldercounty.org/doc/publichealth/032010bodyartregs.pdf
2Braverman, S. (2012). One in five US adults now has a tattoo. Retrieved from http://www.harrisinteractive.com/vault/Harris%20Poll%2022%20-
Tattoos_2.23.12.pdf
3Carlson, V., Lehman, E., & Armstrong, M. (2011). Tattooing regulations in U.S. Journal of Environmental Health, 75(3), 30-37.
4Centers for Disease Control and Prevention(2013). Workplace safety and health topics: Body art. Retrieved March 10, 2014 from
http://www.cdc.gov/niosh/topics/body_art/default.html
5Centers for Disease Control and Prevention (2013). HIV in the United States: At a glance. Retrieved from
http://www.cdc.gov/hiv/statistics/basics/ataglance.html
6Centers for Disease Control and Prevention (n.d.). Viral hepatitis headquarters. Retrieved March 16, 2014 from
http://www.cdcnpin.org/scripts/hepatitis/index.asp#overview
7Centers for Disease Control and Prevention (2014). Hepatitis C FAQs for the public. Retrieved March 16, 2014 from
http://www.cdc.gov/hepatitis/c/cfaq.htm
8Chong, S., Smith, C., Bialostocki, A., & McEwan, C. (2007). Do modern spectacles endanger surgeons. Annals of Surgery, 245(3), 495-501.
9Colorado Department of Public Health and Environment. (2001). Rules and Regulations for Body Art Establishments. Retrieved from
http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheadername1=Content-Disposition&blobheadername2=Content-
Type&blobheadervalue1=inline%3B+filename%3D%22Rules+and+Regulations+for+Body+Art+Establishments.pdf%22&blobheadervalue2=
application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251807406370&ssbinary=true
10Darby, D. & Darby, A. (2014). Personal protective equipment: Are you covered? Retrieved March 20, 2014 from
http://www.cosmetictattoo.org/article/personal-protective-equipment-are-you-covered.html#27
21. REFERENCES
11Davies, C., Khan, M., Ghauri, A., & Ranaboldo, C. (2007). Blood and body fluid splashes during surgery: The need for eye protection and face
masks. Annals of the Royal College of Surgeons of England, 89(8), 770-772.
12Fuller, C., Savage, J., Besser, S., Hayward, A., Cookson, B., Cooper, B., & Stone, S. (2011). The dirty hand in the latex glove: A study of hand
hygiene compliance when gloves are worn. Infection Control and Hospital Epidemiology, 32(12), 1194-1199.
13Laumann, A. & Derick, A. (2006). Tattoos and body piercings in the US: A national data set. Journal of the American Academy of
Dermatology, 55, 13-421.
14Lehman, E., Huy, J., Levy, E., Viet, S., Mobley, A., & McCleery, T. (2011). Bloodborne pathogen risk reduction activities in the body piercing
and tattooing industry. American Journal of Infection Control, 38(2), 130-138.
15Occupational Safety and Health Administration. (2012). Occupation safety and health standards: Bloodborne pathogens (standard number
1910.1030).
16Vanishing Tattoo. Tattoo facts and statistics. Retrieved March 28, 2014 from http://www.vanishingtattoo.com/tattoo_facts.htm
17Weber, M. (2001). Health hazard evaluation report 2000-0013-2830: Body piercing by Bink Tallahassee, Florida. Retrieved from
http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0265-2830.pdf
Hinweis der Redaktion
Introduction: Ryan
Ryan
cultural standards
Ryan
No estimate for number of body artists in US
Safety in body art industry often focuses on the consumer but artists are at risk as well
Danielle
Needlestick injuries are wounds caused by needles that accidentally puncture the skin
-Splashes are contact of mucous membrane or nonintact skin (e.g., exposed skin that is chapped, abraded, or with dermatitis) with blood, saliva, tissue, or other body fluids that are potentially infectious.
-Cross-contamination is the act of spreading bacteria and viruses from one surface to another.
When we talk about the risks of occupational exposure we always use the example of getting stuck with a known HIV-positive patient’s contaminated (bloody) needle. Not just anybody’s needle—an HIV-positive or Hep B or C patient’s needle. And not just any kind of needle—a used hypodermic (hollow-bored) syringe. (Tattoo needles found under bunks and behind dayroom benches are usually made from pieces of wire or staples filed to a point and therefore are far less of a risk than hypodermics.)
HIV: When we talk about the risks of occupational exposure we always use the example of getting stuck with a known HIV-positive patient’s contaminated (bloody) needle. Not just anybody’s needle—an HIV-positive patient’s needle. And not just any kind of needle—a used hypodermic (hollow-bored) syringe. (Tattoo needles found under bunks and behind dayroom benches are usually made from pieces of wire or staples filed to a point and therefore are far less of a risk than hypodermics.)
1-1 in 6 (15.8%) are unaware of their infection.
2-Many people have a hard time believing this, but the reason this number is so low is because HIV is a very fragile virus when it’s outside the body. It breaks down quickly when it’s exposed to air and on environmental surfaces. No virus reproduces outside a cell.
3-Tattooing or body piercing present a potential risk of HIV transmission, but no cases of HIV transmission from these activities have been documented. Be sure that only new needles, ink, and other supplies are used and that the person doing the procedure is properly licensed.
4- Current meds
“PrEP” stands for Pre-Exposure Prophylaxis. The word “prophylaxis” means to prevent or control the spread of an infection or disease. The goal of PrEP is to prevent HIV infection from taking hold if you are exposed to the virus. This is done by taking a pill that contains two HIV medications every day. These are the same medicines used to stop virus growing in people who are already infected.
There are currently five different "classes" of HIV drugs. Each class of drug attacks the virus at different points in its life cycle—so if you are taking HIV meds, you will generally take 3 different antiretroviral drugs from 2 different classes.
This regimen is standard for HIV care—and it’s important. That’s because no drug can cure HIV, and taking a single drug, by itself, won’t stop HIV from harming you. Taking 3 different HIV meds does the best job of controlling the amount of virus in your body and protecting your immune system.
1-Hepatitis B is a serious liver infection caused by hepatitis B virus (HBV). HBV infection can cause acute illness and lead to chronic or lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death. HBV is transmitted through percutaneous (puncture through the skin) or mucosal contact with infectious blood or body fluids. Hepatitis B vaccination is the most effective measure to prevent HBV infection and its consequences and is recommended for all infants and others at risk for HBV infection.
2-Hepatitis B virus can survive outside the body at least 7 days. During that time, the virus can still cause infection if it enters the body of a person who is not infected. That is why it is easier to spread through cross contamination**Any blood spills — including dried blood, which can still be infectious — should be cleaned using 1:10 dilution of one part household bleach to 10 parts of water for disinfecting the area. Gloves should be used when cleaning up any blood spills.
3-Due to the length of of time hep b can live outside the body it is much more infectious then any of the other viruses in this presentation.
4-Vaccine has been available since the 80’s
Hepatitis C is a liver disease caused by the hepatitis C virus (HCV) that sometimes results in an acute illness, but most often becomes a silent, chronic infection that can lead to cirrhosis (scarring), liver failure, liver cancer, and death. Chronic HCV infection develops in a majority of HCV-infected persons, most of whom do not know they are infected since they have no symptoms. HCV is spread by contact with the blood of an infected person. There is no vaccine for hepatitis C.
2- more infectious than HIV but less than Hep B.
3-
4- New Gilead medications can cure Hep C at a 90% cure rate. sofosbuvir is about 1,000. a pill but is being covered by some insurance providers including CO medicaid
Laura
an exposure control plan is written by establishment owner and describes the steps that will be taken to minimize employee exposure to blood, specific to their shop.
sharps log creates a record to let artists know how often and why injuries occur; can be used to reduce mistakes that lead to exposure
NIOSH provides info about state regulations, vaccines, bloodborne pathogen standards, etc.
Rules and Regulations: assembled by CDPHE, LPHAs, body artists, and Consumer Protection Division
formalized blood pathogen standard training is not required by state, may be by LPHAs
bloodborne pathogen training must be completed within 60 days of hire and renewed annually
Ryan
image: http://www.qualitysystems.com/support/pages/hierarchy-of-controls
Ryan
No real guidelines. CDC does not promote one product over another. it’s up to the employer to decide the controls used.
elimination- needleless kits. like a temp tattoo but permanent. more do it yourself than anything
Engineering controls are used to remove a hazard or place a barrier between the worker and the hazard. Well-designed engineering controls can be highly effective in protecting workers and will typically be independent of worker interactions to provide this high level of protection. The initial cost of engineering controls can be higher than the cost of administrative controls or personal protective equipment, but over the longer term, operating costs are frequently lower, and in some instances, can provide a cost savings in other areas of the process.
image: www.dhgate.com
Shaina
Administrative controls and personal protective equipment are frequently used with existing processes where hazards are not particularly well controlled. Administrative controls and personal protective equipment programs may be relatively inexpensive to establish but, over the long term, can be very costly to sustain. These methods for protecting workers have also proven to be less effective than other measures, requiring significant effort by the affected workers.
Shaina
Laura
[Personal protective equipment (PPE) includes gloves, respirators, hard hats, safety glasses, high-visibility clothing, and safety footwear. PPE is the least effective means of controlling hazards because of the high potential for damage to render PPE ineffective.[4] Additionally, some PPE, such as respirators, increase physiological effort to complete a task and, therefore, may require medical examinations to ensure workers can use the PPE without risking their health.]
(Katie)
-compliance with infection control standards, but not with administrative controls (Lehman, et al)
-less compliance with written exposure control plan, providing vaccinations to employees and record of who declined
-less compliance with record keeping means even less information about this occupational hazard, in an industry for which there are
already few reliable statistics to go on
-variability in state and local regulation
-the image here shows the level of tattoo regulation in different states… the authors’ opinion is that only 36 states have regulations that adequately address sanitation, 15 states have regulations that adequately address training 26 states have regulations that adequately address
infection control (Carlson et al)
-state and local regulations may not make a difference? -in the Lehman study, shops in areas with state or local regulations didn’t show difference in compliance
-researchers noted that many shop owners felt regulations were simply “paperwork excercise” an that enforcers didn’t understand the industry
-a few small study… there is a lack of data and a lack of research
-the Lehman study is too small to really draw conclusions, but there is not a lot of research out there
(Katie)
-in the Lehman study, membership in a professional organization was the most important factor associated with compliance with infection control standards
-Professional Organizations can be a useful resource, but are they putting out accurate information… it would be great if there was a partnership with public health/regulating agencies, to be on the same page (if they are not already)
-the NIOSH “blog” was intended to be a place where workers in this industry could bring up concerns, but it’s mostly concerned consumers commenting. But it would be great if there was more input from body art professionals in the regulatory process, and a straightfoward way to communicate concerns (peharps this would also be good place to involve professional organizations)
-The NIOSH page has a lot of good information (including breakdown of regulations by state) and resources (like informational postcards) and it’s easy to find
These postcards, aimed at body artists, promote knowledge about practices that can help artist protect themselves (and their customers)
including sharps containers, handling sharps as little as possible, reporting injuries, reducing cross-contamination, vaccinations and BBP training
Laura
Make sure pro organizations have most accurate information
Dissemination of sharps incidents will help establish prevalence and trends
More research is needed to accurately establish risk, and for targeting effective interventions.
Add any information you have (URLs, authors, titles, dates retrieved if it’s a site with no publication date) and Laura will format it in APA