Healthcare Infection Protection-Tattooing may go more than skin deep if not practiced with the art of infection prevention

Hepatitis C due to tattooing emerges as major risk

Concerned that substandard asepsis in tattoo parlors has led to the spread of hepatitis C virus and other bloodborne pathogens, public health officials in Canada have developed comprehensive infection prevention guidelines for tattooing and other so-called personal services. The guidelines, which should be of particular interest to both infection control professionals and parents of budding adolescents, also assess the infectious risks of piercing and electrolysis.¹ (For information on how to obtain a copy of the guidelines, see editor's note at the end of this article.)

"The feeling was that because hepatitis B and C or HIV could be transmitted through personal services such as tattooing, piercing, or electrolysis if people were using dirty needles or poor practices, national guidelines and a national strategy should be developed for the prevention of spread of bloodborne pathogens," says Sharon Ono, RN, MS, project leader and nurse epidemiologist in the division of nosocomial and occupational infections in the Laboratory Centre for Disease Control in Ottawa, Ontario.

Infections and other complications have been linked to ear piercing, and there is concern these problems will be seen as well in body piercing as the practice increases in popularity. However, the primary risk involved with personal services appears to be hepatitis transmission via tattooing. (See tattoo infection control guidelines, pp. 2-3.)

There is a general consensus that asepsis in the industry has improved as tattoos have become a more mainstream style and infectious disease awareness has been heightened, but sources say there is still lack of regulation and enforcement throughout the booming industry in both the United States and Canada. "Of the shops that I visited, most of them are quite crowded, and some of them didn't have proper sterilizers, although they are moving in that area," Ono says. "Some provinces have regulation and some don't. Even if some have regulation, it hasn't always been enforced. Now I think they are paying greater attention to it."

Indeed, conditions have improved in many shops, as tattooists are more aware of their own risk and the potential loss of livelihood, says Garry Peak, a consultant on the guidelines and owner of the Pair-O-Dice tattoo parlor in Victoria, British Columbia. "I have been in the industry 20 years, and we have always tried to keep it really clean, because if we don't, we are going to put ourselves out of business," he says. "When it became really popular and all of these tattoo magazines were coming out, people could just send away and buy a tattoo machine, and the next thing you know, they are opening a shop. They had no idea of sterilization or even cleanliness. Some of the shops we went through — it would make you shake you head."

Peak emphasizes infection control training, use of autoclaves for reused equipment, and disposal of single-use needles used in tattooing. "It is not really that expensive," he says. "If they are reusing a needle, there is no excuse for it. They cost us about $35 a thousand, so you are talking pennies. I don't really want to infect anybody, No. 1. And I really watch cross contamination. If I have to touch anything, the gloves come off and on goes on a new pair."

A common motivator in improving asepsis is avoiding occupational infection, particularly as studies underscore a link between tattooing and hepatitis. While tattooists can be immunized for HBV, there is no vaccine for HCV. "You've got clients coming in that could have hepatitis C," Peak says. "You don't know that, so you have to treat every customer like they do."

Indeed, one of the more compelling epidemiologic links identified in the project — which included a comprehensive literature review — is tattooing and infection with hepatitis B and C. While HBV studies can be confounded by sexual risk factors, HCV is not thought to be efficiently transmitted by sexual activity. Tattooing was shown to be a significant risk factor for HCV infection in studies from all over the world, with researchers reporting that people were anywhere from three to 27 times more likely to have HCV if they have a tattoo.^2-5

Attributable infections

In the United States, veteran epidemiologist Robert Haley, MD, professor in the department of internal medicine at the University of Texas Southwestern Medical Center in Dallas, has found historical data that may shed light on the early spread of the HCV epidemic.⁶ 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 tells Healthcare Infection Prevention. "It wasn't just that 30% of the cases had a tattoo; 30% of the cases were attributable to tattoos. As far as I know, this is the first study that has actually done a multivariate analysis to actually determine attributable risk."

Interestingly, crude "jail-house" tattoos actually had a lower rate of attributable risk than more elaborate tattoos done in a commercial parlor. "The larger, the more colors, and the more artistic the design, the higher the risk of hepatitis C," Haley says. "Commercial tattoo parlors tend to tattoo one person after another in assembly-line fashion. Therefore, if you tattoo somebody right after you tattooed somebody with hepatitis C, then you are more likely to transmit the virus by unclean needles and equipment."

Though U.S. state and local health departments have infection control regulations in place for tattooing, the problem is enforcement, he says. "There are laws that regulate this, but the problem is they are not enforced," he says. "Up in Canada, I'm sure they are not enforced either. As soon as the 'enforcer' leaves, they are going to go back to what they were doing."

The Canadian guidelines are federal and non-binding, as individual provinces have the jurisdiction over health, Ono notes. "We're not saying that is the only way to do it, but it is one way to put the infection control practices into place," she says. "Even though it isn't regulatory, there is now a standard of practice."

[Editor's note: 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 www.hc-sc. gc.ca/hpb/lcdc.]

References

1. 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.

2. Kaldor JM, Archer GT, Buring ML, et al. Risk factors for hepatitis C virus infection in blood donors: A case-control study. Med J Aust 1992; 157:227-30.

3. Garcia-Bengoechea M, Emparanza JI, Sarriugarte A. Antibodies to hepatitis C virus: A cross-sectional study in patients attending a trauma unit or admitted to hospital for elective surgery. Eur J Gastroenterol Hepatol 1995; 7:237-241.

4. Ko Y-C, Ho M-S, Chiang T-A, et al. Tattooing as a risk of hepatitis C virus infection. J Med Virol 1992; 38:288-91.

5. Neal KR, Jones DA, Killey D, et al. Risk factors for hepatitis C virus infection: A case-control study of blood donors in the Trent region (UK). Epidemiol Infect 1994; 112:595-601.

6. 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.