Healthcare Infection Prevention

Art of the matter: Tattoos, body piercing, and HCV

Is CDC surveillance undermined by paradox’?

Personal statements and adornments made though tattoos and body piercing may have an insidious underside: Evidence continues to mount that they increase the risk of hepatitis C virus.

While public health officials remain unconvinced of a firm link in the United States, a recently published Australian study implicates both tattooing and body piercing in the spread of HCV.

Lending weight to the findings is the fact that they were published in the American Journal of Infection Control, the peer-reviewed publication of the Association for Professionals in Infection Control and Epidemiology (APIC).

"As tattooing and body piercing become increasingly fashionable worldwide, there is a growing need to improve infection control practices among nonmedical skin penetration operators," explained Jeanne Pfeiffer, RN, MPH, CIC, APIC president. "It’s imperative that commercial tattooists and body piercers adhere to sound infection control guidelines to protect themselves and their clients from transmission of hepatitis B and C infections."

Noting that that 70% of patients with HCV may develop chronic liver disease, she added, "The most frustrating aspect of the spread of these diseases is that they are so easily preventable."

As part of the study, researchers examined infection control practices among tattooists and body piercers in Sydney, Australia. A low proportion of owners/managers and staff at the tattoo and piercing sites gave the correct answer for the purpose of disinfection (52.8%/26.9%) and sterilization (50%/53.8%). About one-third of owners/managers (38.8%) and 56% of staff reported that their infection control compliance could be improved. Approximately one-fourth of owners/managers reported that the frequency of inspections was inadequate.

Even though the majority of demonstration and inspection items were complied with, deficiencies were observed concerning washing of hands, wearing of gloves, and sterilization procedures, the authors found.1

In the United States, Robert Haley, MD, professor in the department of internal medicine at the University of Texas Southwestern Medical Center in Dallas, has found historic data that traces HCV infection to tattooing.2

Haley assessed the relative importance of all risk factors for infection with HCV identified in a computer literature search. HCV seroprevalence and risk factors were measured in 626 consecutive workers from the southwestern United States visiting an orthopedic clinic for evaluation or treatment of back pain in 1991 and 1992. Of 626 workers, 43 (6.9%) were seropositive for HCV.

While injecting drug use, heavy alcohol consumption, and a history of ancillary work in health care all emerged as risk factors for HCV infection, the predominant risk factor was tattooing. "We did a multivariate analysis to try to determine how many cases were attributable to each risk factor," Haley says. "It wasn’t just that 30% of the cases had a tattoo; 30% of the cases were attributable to tattoos."

However, the Centers for Disease Control and Prevention (CDC) is not convinced that tattooing and body piercing are independent risk factors for HCV infection in the United States.

In information posted on the CDC infectious disease web site, the agency stated: "In other countries, HCV infection has been associated with folk medicine practices, tattooing, body piercing, and commercial barbering. However, in the United States, case-control studies have reported no association between HCV infection and these types of exposures. . . . Although any percutaneous exposure has the potential for transferring infectious blood and potentially transmitting bloodborne pathogens, no data exist in the United States indicating that persons with exposures to tattooing and body piercing alone are at increased risk of HCV infection."

The tattooing paradox

In a recent update of his prior study, Haley has found a "tattooing paradox" that suggests CDC surveillance is being confounded by subclinical HCV infection.3 The CDC hepatitis branch does not recommend routine regulation and inspection of tattoo parlors because surveillance of HCV-positive acute hepatitis cases rarely identifies tattooing in the incubation period. However, the majority of seroepidemiological studies agree that tattooing is a strong, independent risk factor for subclinical HCV seropositivity.

Haley hypothesized that this paradox could be explained if transmission of HCV by tattooing generally caused subclinical HCV seropositivity without the acute hepatitis syndrome.

He reanalyzed data from the aforementioned study of 626 consecutive patients who were unaware of their HCV serologic status and whose risk factors were ascertained by interview of an internist. A history of injection-drug use was strongly associated with both HCV seropositivity and a history of acute hepatitis. Having a commercially applied tattoo was strongly associated with HCV seropositivity, but not with a history of acute hepatitis.

"Intravenous injection of relatively large quantities of inocula of HCV may be more likely to result in the relatively rare acute HCV hepatitis syndrome, whereas intradermal exposure to small quantities of inocula may cause only subclinical HCV infections," Haley concluded. "If so, public policy on regulation and inspection of tattoo parlors should be determined by seroepidemiological studies rather than by the [CDC] Sentinel Counties Study of acute hepatitis cases."

For its part, the Alliance of Professional Tattooists (APT) on its web site clearly warned tattoo artists about the risk of transmitting and acquiring hepatitis: "The disease to consider when getting tattooed is hepatitis," the alliance stated. "Hepatitis, unlike HIV, is a very hardy virus that can survive long periods outside the human body and can be transmitted through little more than a scratch with an infected needle."

To prevent transmission of bloodborne pathogens, APT urged tattoo artists to autoclave their single service equipment, use individual portions of ink and lubricant, dispose of used sharps appropriately, use registered virucidals to clean their stations between clients, and use barrier protection.

"Basically, the artist must treat everyone [including themselves] as though they were infectious," the APT stated. "That way, everyone is protected and the potential for infection is reduced to next to nothing."

[Editor’s note: Canadian public health officials have developed comprehensive infection control guidelines for tattooing, piercing, and electrolysis.4 To obtain copies of the guidelines, contact the Canadian Medical Association at (613) 731-8610, ext. 2307 or (888) 855-2555. The publication can also be accessed via the Internet at]


  1. Oberdorfer A, Wiggers JH, Bowman J, et al. Infection control practices among tattooists and body piercers in Sydney, Australia. Am J Infect Control 2003 Dec; 31(8):447-56.
  2. Haley RW, Fischer RP. Commercially acquired tattoos and ancillary healthcare jobs as potentially important sources of hepatitis C infection. Abstract S-W2-05. Presented at the Centers for Disease Control and Prevention 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections. Atlanta; March 5-9, 2000.
  3. Haley RW, Fischer RP. The tattooing paradox: Are studies of acute hepatitis adequate to identify routes of transmission of subclinical hepatitis C infection? Arch Intern Med 2003 May 12;163(9):1,095-1,098.
  4. Laboratory Centre for Disease Control, Health Canada. Infection prevention and control practices for personal services: Tattooing, ear/body piercing, and electrolysis. Canada Communicable Disease Report 1999; 25S3:1-173.