Micrococcus - Stoke-on

Good infection control and reliable tattoo ink quality; why
both are essential for a safe treatment outcome
Stoke on Trent Workshop – 25th November 2013
Dr. Alan Beswick,
The Health and Safety Laboratory,
Buxton, SK17 9JN
www.hsl.gov.uk
www.hsl.gov.uk
www.hsl.gov.uk
AnAn
Agency
of theof
Health
and Safety
Executive
Agency
the Health
and
Safety
Executive
About the Health & Safety Laboratory
(HSL – www.hsl.gov.uk)
 Located near Buxton, Peak District,
UK
 Britain's leading industrial health and
safety facility - an agency of HSE
 Established > 30 years
 ~400 people covering all main
science areas, e.g. microbiology,
immunology, chemistry, engineering,
ventilation, psychology, metallurgy &
materials,
minerals
&
fibres,
ergonomics,
computational
modelling, fire and explosives,
incident photography
 Offer services to public and private
sectors
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–
–
–
–
–
–
–
–
Research and development
Incident investigation for HSE
Write guidance for LA/HSE
Training
Specialist advice and consultancy
Environmental and biological monitoring
Validation and certification
Risk Assessment and control evaluation
Topics to cover
• Setting the scene - the origins of tattooing and body piercing;
• Body piercing - understanding the risks – providing the right advice
• Pigment / ink-based treatments - understanding the risks associated with
tattooing treatments;
• Recent research – what can it tell us?
and,
• Some related areas of interest
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To understand the subject fully it helps to
look at the origins of special treatments
Burmese tribal earrings –
the original ‘stretching’
Henna paste; a modern form of an
ancient Islamic custom
Many body adornment and modification styles have their origins in ancient
ethnic history
Images courtesy of Rufus C. Camphausen©;
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from Return of the Tribal, Park Street Press, 1997
There is evidence of permanent tattooing practices
over thousands of years and across all ethnic groups
Burma – 20th
Century
Egypt – 2000bc
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Polynesian –
17th Century
In modern society, body adornments derived from
early methods have been present for many years
Traditional ear piercing
In the UK tattoos
are now a fashion
accessory for
many people of
all ages
Permanent Tattooing
Images courtesy of Rufus C. Camphausen©; from Return of the
Tribal, Park Street Press, 1997
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Back in 2001/02…..
Health, safety and legal concerns associated with body piercing
were demanding attention
Ear migration
Navel migration & infection
Navel embedding
Standardised UK guidance did not exist, but was needed as a point of
reference for EHOs and others who needed information
Images courtesy of US Association of Professional Piercers
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Back in 2001…. few medical papers existed
on the complications of these treatments
E.g. Hanif, J. et al., BMJ, 422; 906 907 (April 2001)
Perichondritis of the pinna can be a
problem with high ear piercing
Pseudomonas aeruginosa and
Staphylococcus aureus – common
bacteria, but often the culprits
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HSL worked with many others – including operators - to
produce guidance on body piercing & tattooing
A Local Authority Circular (LAC) 76-2 was produced and contained info on:
• Record keeping - the benefits, incl. medical questionnaire
• After care advice
• Hygiene & infect. control
• Cleaning and disinfection - esp. steam sterilization issues
• COSHH - appropriate use and storage of disinfectants / biological agents
risk assessment
• Safe waste disposal - clinical waste
• Legal aspects – in plain English
• Useful information was received from 25 LAs – fed in to the early LACs
• Original LAC is no longer published on HSE’s web site but is available to
EHOs and via other web sites.
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More recent guidance followed –
discussions with operators has been central
Operator guidance produced in 2008 – accessible to everyone through the
Calderdale Council web site:
See pdf links at:
http://www.calderdale.gov.uk/bus
iness/licences/skinpiercing/index.
html
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More on guidance later……
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Micropigmentation
•
A multi-million pound per year industry in the UK
•
Caters for permanent make-up, smaller tattoos, and
medically related treatments such as scar camouflage
and skin pigment replacement
•
Clear emphasis on ‘beauty’ applications – so distinct
from traditional tattooing
Integral motor
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Traditional tattooing vs. micropigmentation
•
•
•
Detachable coil motor above
the grip and tip (handle and
needle regions)
Grip usually metal – durable &
can be autoclaved, easy to
clean - safe by design
‘One use only’ needles
standard practise
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•
Motor is usually integral in
the instrument
•
Hand piece sections can’t
always be autoclaved but are
hollow, so not easy to clean
•
‘One use only’ needles
standard practise
Potential problems identified with some
equipment more than 10 yrs ago
• Potential for tracking back of pigments inside machines – little or no
acknowledged of this by most manufacturers at the time
Residues present at motor interface; A
combination of heavy use and poor
cleaning
Contamination of needle,
needle bar and needle cover
with fluorescent marker dye
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Related laboratory research was undertaken –
HSE funded
• Six different, commonly used instruments were assessed by HSL to
establish whether heavy use / or misuse can result in tracking back etc.
• UV-excitable GloGerm pigment - used as ‘surrogate’ tattooing pigment –
assists in visualisation of contaminants
Sunshine – inner & outer
Medium-Tech sealed cassette
system
Key finding: Some machines track pigment back up to 4.5 cm in a session
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Route of contamination
Contamination when this machine was held at the horizontal
– not a recommended approach!
This machine has disposable parts and can be cleaned &
disinfected using a specified 5-step procedure
and so it can be re-used safely despite the mess!
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Some systems proved inherently safer –
by design
Sealed cartridge system now used on several machines:
- this physical barrier protects machine internal surfaces
- this type of system is safer by design than some other systems
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Summary points - micropigmentation
•
Research confirmed that some equipment is difficult to render
microbiologically safe between clients
•
With advice from independent experts, a 5-step cleaning procedure was
developed by HSE / HSL suited to clean most types of equipment in use
•
This method relies on ultra-sonication & chemical disinfection to remove
contaminating materials before reuse with another client
•
Use of ‘one use only’ parts such as needles, needle covers and other
instrument sections means that treatments are safe between clients
•
Some system designs – using cartridges – present a physical barrier that
prevents internal machine contamination
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Good planning & infection control
= safer treatment
•
Calderdale advice booklets contain information on all aspects of body
piercing, micropigmentation and tattooing
•
Infection control risk is explained – with links provided to other useful
information on risk assessment related to your business
•
Accessible legal advice is provided
•
By following this clear advice – and with additional support and advice
from EHOs – risks can be controlled
•
Take home message: Good practice = less infection risk = less
complication for operators and clients alike!
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What about the quality of inks &
pigments?
UK model byelaws (Dept. of Health Web site) require that:
“any dye used for tattooing or semi-permanent skin-colouring
is sterile and inert‘”:
The Council of Europe EU resolution ResAP (2008)1 to which UK MEPs
have signed up requires that inks and pigments ‘
“are sterile and supplied in a container which maintains
the sterility of the product until application”.
(This document also lists colorants & their known adverse health effects)
But what is the reality?
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Early evidence of microbiological
contamination a concern
•
Anonymised microbiological data for assorted pigments (all previously
unopened):
Test
Dye
a. Chocolate
brown
a. Black
a. Fuchsia
a. True red
a. Orange red
a. Rose beige
b. Maroon
claro
b. Negro
b. Rojo
c. Brown 10
c. Brown 11
Fungal
at 25C
Fungal
at 40C
0
0
0
0
Cfu/ml at
25C
Cfu/ml at
37C
Identification at
25C & 37C
2.67x105
2.8x105
Pseudomonas
0
0
0
30
0
3.3x105
0
650
0
0
0
0
0
0
0
0
2.4x105
0
5
5
20
0
n/a
Micrococcus and
Bacillus
Micrococcus
Bacillus
n/a
n/a
0
0
0
0
0
0
0
0
5
0
0
40
0
0
0
0
Micrococcus
n/a
n/a
Micrococcus
* Pre fixes a, b and c represent different manufacturers
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HSE study: Ink supply & quality (2008-2009)
A two stage project undertaken to allow us to:
• Determine the most commonly used products (inks & pigment) used by
tattooists & micropigmentation practitioners (England & Wales)
• Determine the manufacture & supply chain for each product
• Perform microbiological & toxic metals testing of a range of coloured
inks from at least ten companies supplying the UK trade
• Offer advice to HSE and/or affected manufacturers if the findings raised
concerns about UK ink product quality
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Where are inks and pigments being
obtained?
•
Of 143 ink products identified by HSL most were produced outside of the UK
•
About a 1/3rd purchased over the internet, a 1/3rd by regular mail order & the rest
from wholesalers or other more local suppliers
•
12 different products then examined for microbiological and chemical quality
Country of Origin of Ink Products Examined
15% (not stated)
4% (EU)
31% (UK)
10% (Asia)
40% (USA)
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What inks do people use?
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Ink study findings – anonymised microbiological
contamination – high cfu in yellow
Key message: no single
brand of ink was free
from some level of
bacterial contamination
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What about chemical hazards?
•
The inks were analysed to quantify levels of
toxic metals and this demonstrated:
•
Potential toxic metals detected in a range of
inks - but not at hazardous levels
•
Nickel, lead, cadmium & chromium (of
particular concern) not detected
•
Barium, Calcium, Copper, Iron & Zinc found
in some ink products - but these are
approved cosmetic & medicinal ingredients
•
Iron present at the highest levels, but is a
dietary requirement and of low toxicity
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In summary – ink / pigment quality
•
Investigations of pigments demonstrates the need to maintain vigilance
about microbiological contamination & the need for more information
about product components & quality
•
If end users demand better product quality information this will help to
raise production standards
•
Good suppliers will respond to end user pressures – choose products
carefully and ask whether product information is available, is reliable and
accurate
•
Using pigments in small volumes minimises risk of contamination and
eliminates need for storing previously opened containers
•
All of the above can help inform an effective risk assessment
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Recommendations from the research
We all need to have aspirations!! These would include:
• Clean room pigment / ink production of inks is rare but is appropriate
• Manufacturers should undertake routine microbiological tests on every
batch of ink for sale to:
 reassure purchasers of batch quality, and
 to provide enforcement officers with data that can be independently verified
• Better product information on accompanying data sheets is needed –
listing the basic composition of all inks
• Mono-dose packaging of inks (e.g., 0.5-1.0ml) to minimise likelihood of
undesirable long-term shelf storage or constant re-opening of same pot
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Recent developments - advice
• The Chartered Institute of Environmental Health and Public Health England (HPA
as was) released new guidance in August 2013 – consisted of:
• a guidance toolkit,
• audit tool, and
• review of all available literature
• Many contributors were involved and most of information is ‘evidence based’
• Available at: http://www.cieh.org/media/media3.aspx?id=47784
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A few words on henna….
NOT typically injected, but previous analysis on behalf of environmental health
officers in the several UK councils showed that:
• All imported henna products were microbiologically safe; but
• Some not henna at all!
• Between 23% and 94% paraphenylenediamine (PPD) was detected in some
products - used to darken the tattoo, but can cause severe allergic reactions at
levels of >6%
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Chemical tattoo removal
Image sequences
in each case
show successive
treatments;
from left to right
• Tattoo removal has traditionally been done by dermabrasion or laser – both
can be very uncomfortable
• Developments in laser technology have led to the use of the Ruby Laser different wavelengths of light used for removal of different coloured pigments
• Tattoo Eraze and Rejuvi - chemical systems claim to contain natural &
harmless chemicals that fade tattoos – technical information is generally scarce
• All same precautions required as for ink insertion - needle delivery is used
• This subject area deserves more research attention
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In summary
• Scientific findings allowed development of LAC guidance documents –
• tattooing, body piercing and micropigmentation
• More accessible guidance for operators more recently available in same three main
topic areas; these are open documents for anyone wishing to read them – Calderdale
web site
• Earlier scientific findings on pigment contamination have supported a much wider
study of UK tattoo inks – publication(s) will follow to raise awareness
• 2004 amendments to the Local Government (Miscellaneous Provisions) Act (1982) gave LAs greater ability to license body piercing, tattooing and micropigmentation
activities - using byelaws
……Several European countries currently discussing tattoo ink quality and its regulation,
so this area may develop..…watch this space!
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Thank you for listening
Acknowledgements
Catherine Makison – HSL
Micah Stocks-Greaves – HSL
Jane Green - HSL
Health & Safety Laboratory Buxton
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TPI