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.

4. ROUTES OF EXPOSURE: Needlestick Injuries Splashes Cross-contamination

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

11. RISK REDUCTION

12. POSSIBLE CONTROLS Elimination? Substitution o Plastic Needle Tips Engineering o Retractable needles o Sharps containers

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.

18. 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!

19. 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&blobheade rvalue2=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

20. 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