Safe Tattooing

Safe Tattooing -


Contents:
- Disease questions and answers
- Needle stick effects and outlawed States
- Disinfection and sterilization
- Pigments, red reactions and other complications


Summary:

In spite of popular concern about AIDS, the most serious potential complication of tattooing is still Hepatitis B. The hepatitis B virus is extremely contagious and can be transmitted from the customer to the tattoo artist if the tattoo artist accidentally sticks himself with a contaminated needle, or from one customer to another if needles and tubes are not properly sterilized.

Tattoo artists should be vaccinated against hepatitis B. Sterilization of tubes and needles in an autoclave and use of disposable gloves will prevent the transmission of the hepatitis B virus from one customer to another. Sterilization cannot be effected by boiling or by immersion in chemical disinfectants.

Other reported complications of tattooing include allergic reactions to pigments, aggravation of existing skin disease, and keloid scarring.

A friend of mine who had worked successfully as a tattoo artist for over eight years recently quit tattooing because she was afraid of getting AIDS. She had tattooed a man who later died of AIDS. After hearing about his death she remembered that while tattooing him she had accidentally scratched herself with a contaminated needle. She went to her doctor for an AIDS test. The test was negative, but the doctor, who considered tattooing an abomination, did his best to frighten her by telling her how dirty and dangerous it is.

After talking to her I wondered whether there were any reports in the medical literature of AIDS being transmitted by tattooing. A few hours in the library turned up some interesting information on the transmission of infectious diseases among health care workers who accidentally stick themselves with contaminated needles. Most of this literature is also relevant to tattooing.

Almost all the published material is good news for tattoo artists. If tubes and needles are properly sterilized and the artist is reasonably careful, tattooing is almost 100% safe for both the customer and the artist. The risks are minimal. However, there are certain risks, and by being aware of them and taking appropriate precautions we can avoid them.

So here are some questions I asked the library, and some answers it gave me.

Suppose I'm working on a customer who has AIDS and I accidentally stick myself with a contaminated needle. Will I get AIDS?

Your chance of getting AIDS this way is about one in 200. Statistics collected worldwide show that of 1,852 health care workers who accidentally stuck themselves with AIDS contaminated needles, only 9 contracted the disease.(1, 2)

Why is the transmission rate so low? I heard that intravenous drug users get AIDS from contaminated needles.

In order for AIDS to be transmitted a small amount of blood (at least 0.1 ml = 2 drops) must be passed from one individual to another. Intravenous drug users commonly use their own blood to wash out any residue of the drug remaining in the syringe while the needle is still in the vein. This practice is called "flushing" or "booting." As a result, a small amount of blood can be transferred when needles are shared. In the case of an accidental needlestick injury the needle usually penetrates the skin superficially and is immediately withdrawn, with the result that little or no blood is transferred. (3)

What percentage of the population carries the AIDS virus?

About a million people in the US. are thought to be carriers of the virus. Most of these people do not have AIDS symptoms and do not know they have the virus. The total population of the US is about 250 million, so it is estimated that one person in 250 carries the virus. About 80,000 of these individuals have symptoms and have been diagnosed as having AIDS. (4, 5)

How many doctors and other health care workers have been infected with AIDS from accidental needlestick injuries?

Thirty-seven such cases were reported in North America and Europe between 1984 and 1991. This includes 5 doctors, 9 nurses, one dentist, and the rest lab technicians and other health care workers (1). A number of other cases of AIDS among health care workers are under investigation but have not been positively documented.(2)

So what are the odds that a tattoo artist will get AIDS from his customers?

Your chance of getting AIDS from a random needlestick is about one in 200 times 250, or one in 50,000. To put it another way, you'd have to tattoo 50,000 customers and stick yourself once for very customer before you could be reasonably sure of getting AIDS.

Is there any case on record of a tattoo artist who got AIDS as the result of sticking himself with a needle he used on a customer?

No. A computer search of the literature from 1981-1991 failed to reveal a single reported case of AIDS which had been transmitted by professional tattooing in North America. There are, however, two cases on record in which AIDS was apparently transmitted by tattooing in prison, where no attempt was made to sterilize the needles. (6)

Are there any other diseases you can get from accidentally sticking yourself with a contaminated needle?

Yes. A recent study has identified 22 diseases which have been transmitted by needlestick injuries. Among these are syphilis, malaria, tuberculosis, and a lot of other things you don't want to get. The disease which is most often transmitted this way is hepatitis B.(7)

Have doctors and other health care workers been infected with hepatitis B due to needlestick injuries or other exposure to contaminated blood?

Yes. Centers for Disease Control estimates that every year about 12,000 health care workers are infected with the hepatitis B virus due to accidents on the job. About 20% of health care workers show evidence of past or present infection with the hepatitis B virus. (2)

How dangerous is it?
Many individuals infected with the hepatitis B virus have no symptoms and do not know that they have been infected. About 25% of infected persons develop acute hepatitis. Some 10% of these will become chronic carriers of the virus. They can infect others and are at risk of developing chronic liver disease, including chronic active hepatitis, cirrhosis, and primary liver cancer. One or two per cent will die of the disease. (2)
Why is hepatitis B transmitted by needlestick injuries more often than AIDS?

There are two reasons.

1. The hepatitis B virus is harder to kill than the AIDS virus. The Hepatitis B virus forms spores which can survive indefinitely outside the body. These spores can only be killed by heating to 121 degrees centigrade for 30 minutes in an autoclave. (11) In contrast, the AIDS virus will not survive more than a few days outside the body. It can be killed by boiling water, immersion in alcohol, bleach, and many other disinfectants. (22)

2. The hepatitis B virus is highly infectious. Experiments on human volunteers have shown that infection can occur if as little as 0.00004 ml (0. 04 microlitres) of blood is transferred from one individual to another (as opposed to 0.1 ml for AIDS). If you stick yourself with a needle you've used on a customer who has hepatitis B, your chance of getting the disease is about one in five (compared with one in 200 for AIDS. (1)

What percentage of the general population carries the hepatitis B virus ?

In the general population of the US about 2 persons in a thousand are or have been infected. The incidence of infection is much higher (5 to 15%) among certain high risk groups such as homosexuals, persons with multiple sexual contacts, intravenous drug users, ex-prisoners, immigrants from Asia, and health care workers. (1)

Has hepatitis B ever been transmitted by tattooing?

Yes. A number of cases have been reported. The best known of these occurred in 1960 when New York City health officials blamed tattoo artists for 30 cases of hepatitis B and one death. The alleged cause of the problem was improper sterilization of instruments and the use of contaminated pigments. As a result, the New York City Board of Health outlawed tattooing in 1961. Two New York tattoo artists appealed the ruling and the case dragged on until 1966, when the Court of Appeals affirmed the decision of the lower court. (8)

Has tattooing been outlawed in other places in the US.?

Yes. These include Connecticut, Florida, Kansas, Massachusetts, , Oklahoma, South Carolina, Vermont, and Albuquerque, New Mexico. (9)

Are there any recent cases on record of a case of hepatitis B which was transmitted by tattooing?

There is no report in the literature of a case of hepatitis B which was transmitted by professional tattooing in North American during the last ten years.

What about places outside North America?

There are a number of reports of hepatitis B which was transmitted by tattooing in third world countries. The cause in every case was improperly sterilized needles.

Is there a vaccination for hepatitis B?

Yes. An effective vaccine has been available since 1982.

Who should get it?

It is recommended for all health care workers and others who might be exposed to human blood and other body fluids.

How much does it cost?

About $100.00

Will I be immune as soon as I get vaccinated?

No. The vaccination takes up to 6 months to become effective, and about 10% of those who are vaccinated will not become immune. In addition, there is another form of hepatitis, termed hepatitis C, against which there is no effective immunization. (1)

Has hepatitis C ever been transmitted by tattooing?

Yes. There is one case on record. (10)

How can I protect myself against needlestick injuries?

Studies of needlestick injuries among health care workers have identified three major risk factors: work pressure, fatigue, and lack of experience. Appropriate rest periods will help to minimize the danger of a needlestick. A study of needlestick injuries in hospitals revealed that over 80% of the injuries occurred not during use, but when instruments were being discarded or prepared for re-sterilization. (1) In tattooing, extra care should be taken when the tube and needle bar are being removed from the machine. Assuming the artist is right handed, a heavy general purpose utility glove worn on the left hand would help to minimize the danger of a needlestick injury.

Needlestick injuries have been sustained by hospital cleaning staff when handling garbage bags containing contaminated needles. Therefore contaminated needles should never be put in a wastebasket or a garbage bag. Never
leave contaminated needles lying around where someone could touch them.

How should contaminated needles be disposed of?

It is recommended that contaminated needles be placed in a puncture-proof plastic container. The container and its contents should be incinerated. (1) For the tattoo artist, a practical solution would be to put used needles in a plastic bottle of bleach. Bleach is a powerful disinfectant. When full, the bleach can be drained off and the bottle and needles can be disposed of in an incinerator.

How else should I protect myself?

Wear disposable latex or vinyl examination gloves. If you take a break to smoke or touch anything other than your machine and tube, remove the gloves and dispose of them. Put on new gloves when you start to work again. Anything which touches your gloves should be regarded as contaminated. Don't touch blood, used tissues, needles, tubes, or anything else which has touched blood with your bare hands. Dispose of used gloves and tissues in a double-duty garbage bag and send it to the incinerator.

What about sterilization?

All visible traces of blood and pigment must be removed from the instruments to be sterilized. The best way to do this is to scrub them with a brush and then clean them in an ultrasonic tank.

Many microorganisms form spores which can survive prolonged periods of boiling. They can also withstand immersion in Cidex (glutaraldehyde), Benzal (benzalconium chloride solution = zephiran), alcohol, or any other disinfectant. The hepatitis B virus is one of these microorganisms. The National Institute of Health recommends that instruments capable of transmitting the hepatitis B virus be sterilized in an autoclave at 121 degrees centigrade for thirty minutes.(11)

Can I use a pressure cooker instead of an autoclave?

Yes, but in order for sterilization to occur most of the air must be removed from the pressure cooker. Put the instruments to be sterilized and heat-sensitive autoclave tape into the pressure cooker and screw the lid on, but do not put the weighted cap on the vent. Let the water come to a boil and blow off steam for five minutes. During this time about one cup of water will boil off and much of the air will be expelled. Then place the weighted cap on the vent and cook for at least 30 minutes. Put the pressure cooker in a sink and run cold water over it. This causes the steam to condense. When you take the weighted cap off you will hear a sucking sound. This is the air rushing in to replace the air which was expelled. If the autoclave tape has turned black, you will know that sterilization has occurred.

Are there other methods of sterilization ?

Gas (ethylene oxide) and dry heat sterilizers are also effective, but are more expensive and time consuming than autoclaving.

Are there any reports of diseases other than AIDS and hepatitis B which have been transmitted by tattooing during the last ten years?

Four cases have been reported. All of them were outside North America, and all were due to the use of unsterilized needles. These include two cases of leprosy, one of tuberculosis, and one of blood poisoning. (13, 14, 15, 16)

Are there any other medical problems which can be caused by tattooing?

The most commonly reported problem is the red reaction. This consists of swelling, inflammation, and itching in the red part of a tattoo. It is often initiated and aggravated by exposure to sun light. Usually it is first noticed some years after the tattooing was done. The reported time lag varies from one to 16 years. In many individuals it is a minor and transient inconvenience, but in some it becomes so severe that it requires treatment by a dermatologist.

What percentage of my customers will have a severe red reaction?

In an attempt to determine the total number of red reactions in the tattooed population of Britain, Naval Surgeon R.W.B. Scutt sent questionnaires to 100 British dermatologists. They reported that during a nine year period (1960-1968) they had seen a total of 57 patients with red reactions. In other words, there were 5 or 6 cases per year in "a tattooed population of at least one million." (17). During the last ten years (1980-1991) seven papers on the red reaction have appeared in American and British medical journals. In all, 26 individual cases were reported. This works out to about four per year in a tattooed population of many millions.

What causes the red reaction?

At the time of Scutt's survey some tattoo artists were using red pigments which contained mercury. Scutt reported that of 57 patients with red reactions, 45 showed mercury sensitivity when tested. It was then believed that most red reactions were caused by mercury sensitivity. Since the publication of Scutt's paper a variety of other red pigments have been used in tattooing, including cadmium red (cadmium selenide), sienna/red ochre (ferric hydrate), and organic substances such as sandalwood and brazilwood. (18) But for reasons which are not fully understood, red reactions continue to be reported.

How can the red reaction be treated?

Mild cases respond to treatment with topical ointments. In more severe cases the removal of the tattoo by dermabrasion or other methods has been attempted. Recently the red reaction has responded to carbon dioxide laser treatment which "led to complete resolution of symptoms with an excellent cosmetic result and preservation of the tattoo design." (19)

Are there problems with other colors?

No reports of reactions to colors other than red have appeared since 1980. Before 1980 there were a number of reports of reactions to chromium in green tattoo pigment, cobalt in blue pigment, and cadmium in yellow pigment. (20)

What about other complications?

Certain cutaneous diseases may be aggravated by tattooing and develop locally within the tattooed area. There are a few reports of psoriasis in tattoos, and a few reports of keloid scars developing in tattoos. It might be wise to ask customers if they are subject to psoriasis or to keloid scarring.

Where can I find out more about tattoo complications?

There are three excellent reviews of the literature: Scutt (1972), Goldstein (1979) and Wilkes (1986) (17, 20, 21). These papers contain extensive bibliographies.

Where can I find out more about sterilization?

The standard work on sterilization is Principles and methods of sterilization in health sciences by John J. Perkins (11).

The British Medical Association publishes two pamphlets which contain much practical information: A code of practice for the safe use and disposal of sharps, (1) and A code of practice for sterilisation of instruments and control of cross infection (12). These pamphlets should be available in any medical library or they can be ordered from: The British Medical Association, Tavistock Square, London WC1H 9JP.

Centers for Disease Control publishes a periodical titled MMWR (Morbidity and Mortality Weekly Report) which is available in any medical library. A recent issue dealing with the prevention of AIDS and hepatitis is: Guidelines for prevention of transmission of Human Immunodeficiency Virus and hepatitis B Virus to health care and public safety workers. (2) Copies can be ordered from: U.S. Government Printing Office. Washington, D.C. 20402-9235