Infection-Control Standards

Read how CDC guidelines for infection control should be applied to body piercing.

Adapted from the CDC infection control guidelines and modified for the Purpose of Body Piercing.

8/28/98

René Martin

 

Table of Contents

Article

I. INTRODUCTION

II. RISK OF TRANSMISSION OF HBV, HCV AND HIV IN BODY PIERCING

III. VACCINES FOR PIERCERS

IV. PROTECTIVE ATTIRE AND BARRIER TECHNIQUES

V. HANDWASHING AND CARE OF HANDS

VI. USE AND CARE OF NEEDLES

VII. STERILIZATION OR DISINFECTION OF EQUIPMENT

Indications for Sterilization or Disinfection of piercing equipment

Methods of Sterilization or Disinfection of piercing equipment

VIII. CLEANING AND DISINFECTION OF ENVIRONMENTAL SURFACES

IX. SINGLE-USE DISPOSABLE INSTRUMENTS

X. USE OF PREVIOUSLY WORN BODY JEWELRY

XI. DISPOSAL OF WASTE MATERIALS

XII. IMPLEMENTATION OF RECOMMENDED INFECTION-CONTROL PRACTICES FOR PIERCERS

XIII. ADDITIONAL NEEDS IN BODY PIERCING



Article

Summary

When implemented, these guidelines should reduce the risk of disease transmission in the piercing environment, from piercee to piercer, and from piercee to piercee. Based on principles of infection control, the document delineates specific guidelines related to protective attire and barrier techniques; handwashing and care of hands; the use and care of sharp instruments and needles; sterilization or disinfection of instruments; cleaning and disinfection of environmental surfaces; disinfection and the decontamination room; single-use disposable items; the handling of previously worn piercing jewelry; disposal of waste materials; and implementation of recommendations.

 

INTRODUCTION

This document offers guidance for reducing the risks of disease transmission among body piercers and their clients. The unique nature of most piercing procedures, instrumentation, and piercing studios may require specific strategies directed to the prevention of transmission of pathogens among piercers and their clients. These practices should be observed in addition to the practices and procedures for worker protection required by the Occupational Safety and Health Administration (OSHA) final rule on Occupational Exposure to Bloodborne Pathogens (29 CFR 1910.1030), which was published in the Federal Register on December 6, 1991.

Piercees and piercers may be exposed to a variety of microorganisms via blood or other bodily fluids. These microorganisms may include hepatitis B virus (HBV), hepatitis C virus (HCV), herpes simplex virus types 1 and 2, human immunodeficiency virus (HIV), Mycobacterium tuberculosis, staphylococci, streptococci, and other viruses and bacteria. Infections may be contracted in the piercing studio through several routes, including direct contact with blood, or other bodily fluids; indirect contact with contaminated instruments, equipment, or environmental surfaces; or contact with airborne contaminants present in either droplet spatter or aerosols of oral and respiratory fluids. Infection via any of these routes requires that all three of the following conditions be present (commonly referred to as "the chain of infection"): a susceptible host; a pathogen with sufficient infectivity and numbers to cause infection; and a portal through which the pathogen may enter the host. Effective infection-control strategies are intended to break one or more of these "links" in the chain, thereby preventing infection.

A set of infection-control strategies common to piercing studios should reduce the risk of transmission of infectious diseases caused by bloodborne pathogens such as HBV and HIV. Because all infected clients cannot be identified by medical history, physical examination, or laboratory tests, CDC recommends that blood and body fluid precautions be used consistently for all clients. This extension of blood and body fluid precautions, referred to as "standard precautions and body substance isolation," must be observed routinely in all piercing procedures.

 

II. RISK OF TRANSMISSION OF HBV, HCV AND HIV IN BODY PIERCING

Although the possibility of transmission of bloodborne infections from piercers to piercees is considered to be small, precise risks have not been quantified in the piercing studio setting by carefully designed epidemiologic studies. Reports published Reports of transmission this way have been documented in other countries. In the United States, studies have reported no association between HCV infection and body piercing exposures. However, the infection control practices among commercial and noncommercial establishments of this type can vary widely. Also, hepatitis B virus (HBV) has been transmitted through these types of exposures.

 

III. VACCINES FOR BODY PIERCERS

Although HBV infection is uncommon among adults in the United States (1%-2%), serologic surveys have indicated that 10%-30% of health-care or dental workers show evidence of past or present HBV infection. The OSHA bloodborne pathogens final rule requires that employers make hepatitis B vaccinations available without cost to their employees who may be exposed to blood or other infectious materials. In addition, CDC recommends that all workers, who might be exposed to blood or blood-contaminated substances in an occupational setting be vaccinated for HBV (6-8). Piercers also are at risk for exposure to and possible transmission of other vaccine-preventable diseases; accordingly, vaccination against influenza, measles, mumps, rubella, and tetanus may be appropriate for piercers.

The risk of infection with HCV following one needlestick exposure to blood from a client known to be infected with HCV is approximately 3-10%; for HIV, the risk is even lower at 0.3%. This rate of transmission is considerably lower than that for HBV, probably as a result of the significantly lower concentrations of virus in the blood of HIV-infected persons.

 

IV. PROTECTIVE ATTIRE AND BARRIER TECHNIQUES

For protection of personnel and clients in the studio, medical gloves (latex, nitrile or vinyl) always must be worn by piercers when there is potential for contacting blood, blood-contaminated saliva, or mucous membranes. Nonsterile gloves are appropriate for contact with intact skin; sterile gloves should be used for piercing procedures or for contact with unhealed piercings. Before each piercing is performed, piercers should wash their hands and put on new gloves; after each piercing or before leaving the piercing room, piercers should remove and discard gloves, then wash their hands. Piercers always should wash their hands and reglove between clients. Surgical or examination gloves should not be washed before use; nor should they be washed, disinfected, or sterilized for reuse. Washing of gloves may cause "wicking" (penetration of liquids through undetected holes in the gloves) and is not recommended. Deterioration of gloves may be caused by disinfecting agents, oils, certain oil-based lotions, and heat treatments, such as autoclaving. 

Three types of gloves are commonly available:

  1. Disposable examination gloves made of either vinyl, nitrile, or latex for procedures involving contact with unbroken skin.

  2. Sterile disposable gloves for use when sterility is necessary, such as during piercing procedures.

  3. General purpose utility gloves for use when cleaning instruments, equipment, and contaminated surfaces. Rubber household gloves are suitable, and can be decontaminated and reused.

As a barrier, there is no difference between an intact vinyl glove and an intact latex glove. However, any type of glove maybe defective. It would be prudent, therefore, to make sure your gloves are intact before using them.

As a public health measure, it is not necessary to double-glove, as long as the glove is intact. 

Masks should be worn during piercing procedures to reduce the amount of contamination from air droplet particles expelled through the mouth or nose. All parties within the piercing room should wear masks, including client and observers, unless the procedure prohibits such use (clients are unable to wear a mask during oral piercings).Chin-length plastic face shields or surgical masks and protective eyewear should be worn when splashing or spattering of blood or other body fluids is likely, as is common during manual decontamination of contaminated items. When a mask is used, it should be changed between clients or during piercing procedures if it becomes wet or moist. Used masks should never be redonned after removal. Face shields or protective eyewear should be washed with an appropriate cleaning agent and, when visibly soiled, disinfected between use. 

Protective clothing such as laboratory coats, or uniforms should be worn when clothing is likely to be soiled with blood or other body fluids. Reusable protective clothing should be washed, using a normal laundry cycle, according to the instructions of detergent and machine manufacturers. Protective clothing should be changed at least daily or as soon as it becomes visibly soiled. Protective garments and devices (including gloves, masks, and eye and face protection) should be removed before personnel exit areas of the piercing studio used for decontamination or piercing activities.

 

V. HANDWASHING AND CARE OF HANDS

Piercers should wash their hands before and after each piercing procedure (i.e., before glove placement and after glove removal) and after barehanded touching of inanimate objects likely to be contaminated by blood, saliva, or other bodily fluids. Hands should be washed after removal of gloves because gloves may become perforated during use, and piercers' hands may become contaminated through contact with client material. Soap and water will remove transient microorganisms acquired directly or indirectly from patient contact; therefore, for many routine piercing procedures, such as consultations , handwashing with plain soap is adequate. For piercing procedures, an antimicrobial surgical handscrub should be used.

When gloves are torn, cut, or punctured, they should be removed as soon as client safety permits. piercers then should wash their hands thoroughly and reglove to complete the piercing procedure. Piercers who have exudative lesions or weeping dermatitis, particularly on the hands, should refrain from piercing and decontamination procedures until the condition resolves. Guidelines addressing management of occupational exposures to blood and other fluids to which universal precautions apply have been published previously.

 

VI. USE AND CARE OF PIERCING NEEDLES

Needles contaminated with client blood, or other bodily fluids should be considered as potentially infective and handled with care to prevent injuries.

Used needles should be placed in appropriate puncture-resistant containers located as close as is practical to the area in which the items were used. Used needles should never be placed onto work surfaces such as mayo stands or setup trays. Needles used for piercing should not be reused, they should be treated as single-use items only.

 

VII. STERILIZATION OR DISINFECTION OF EQUIPMENT

Indications for Sterilization or Disinfection of Equipment

For the purposes of clarity, equipment used for piercing will be classified into three categories -- critical, semicritical, or noncritical -- depending on their risk of transmitting infection and the need to sterilize them between uses. Each piercing studio should classify all instruments as follows:

  • Critical. Piercing implements which are used during piercing procedures which may contact blood or other bodily fluids, or which come in direct contact with skin which is not intact are classified as critical and should be sterilized before each use and disposed of. These devices include needles, tapers, forceps, and receiving tubes.

  • Semicritical. Items such as calipers, gauge wheels, and marking implements which do not come in contact with broken skin but may contact mucous membranes and oral tissues are classified as semicritical. These devices should be disposable or sterilized after each use. If, however, sterilization is not feasible because the instrument will be damaged by heat, the instrument should receive, at a minimum, high-level disinfection.

  • Noncritical. Equipment such as client hand mirrors that come into contact only with intact skin are classified as noncritical. Because these noncritical surfaces have a relatively low risk of transmitting infection, they may be reprocessed between clients with intermediate-level or low-level disinfection or detergent and water washing, depending on the nature of the surface and the degree and nature of the contamination.

Methods of Sterilization or Disinfection of Equipment

Before sterilization or high-level disinfection, equipment should be cleaned thoroughly to remove debris. Persons involved in cleaning and reprocessing instruments should wear heavy-duty (reusable utility) gloves to lessen the risk of hand injuries. Placing instruments into a container of water or disinfectant/detergent as soon as possible after use will prevent drying of client material and make cleaning easier and more efficient. Cleaning may be accomplished by thorough scrubbing with soap and water or a detergent solution, or with a mechanical device (e.g., an ultrasonic cleaner). The use of covered ultrasonic cleaners, when possible, is recommended to increase efficiency of cleaning and to reduce handling of contaminated instruments.

All critical and semicritical equipment that is heat stable should be sterilized by steam under pressure (autoclaving), following the instructions of the manufacturers of the instruments and the sterilizers. Critical and semicritical instruments that will not be used immediately should be packaged before sterilization.

Proper functioning of sterilization cycles should be verified by the periodic use (at least monthly) of biologic indicators (i.e., spore tests). Heat-sensitive chemical indicators (e.g., those that change color after exposure to heat) alone do not ensure adequacy of a sterilization cycle but may be used on the outside of each pack to identify packs that have been processed through the heating cycle. A simple and inexpensive method to confirm heat penetration to all instruments during each cycle is the use of a chemical indicator inside and in the center of either a load of unwrapped instruments or in each multiple instrument pack. Instructions provided by the manufacturers of sterilization devices should be followed closely.

In all piercing settings, indications for the use of liquid chemical germicides to sterilize equipment (i.e., "cold sterilization") are limited. For heat-sensitive instruments, this procedure may require up to 10 hours of exposure to a liquid chemical agent registered with the U.S. Environmental Protection Agency (EPA) as a "sterilant/disinfectant." This sterilization process should be followed by aseptic rinsing with sterile water, drying, and, if the equipment is not used immediately, placement in a sterile container. 

EPA-registered "sterilant/disinfectant" chemicals are used to attain high-level disinfection of heat-sensitive semicritical instruments. The product manufacturers' directions regarding appropriate concentration and exposure time should be followed closely. The EPA classification of the liquid chemical agent (i.e., "sterilant/disinfectant") will be shown on the chemical label. Liquid chemical agents that are less potent than the "sterilant/disinfectant" category are not appropriate for reprocessing critical or semicritical instruments.

 

Chemical Germicides/ FDA and EPA Classifications

The Food and Drug Administration (FDA) and the Environmental Protection Agency (EPA) co-regulate liquid chemical

germicides.

Any chemical you use should have a label that shows the following:

  1. Either the FDA or EPA classification

  2. EPA registration and establishment numbers

  3. Directions for use and disposal

The FDA is the principal regulator for chemicals used as "sterilants/disinfectants." 

If "sterilant/disinfectant" and the word "sporicidal," (kills spores) are on the label, you can use the chemical for either sterilization or high-level disinfection. The same concentration of the chemical is used for both processes. Be sure to follow closely the instructions on the label regarding appropriate contact times, temperature, and concentration. Chemical germicides that are less potent than the "sterilant/disinfectant" category are not appropriate for processing.

The Environmental Protection Agency (EPA) is the principle regulator for chemicals used to disinfect contaminated environmental surfaces. These chemicals fall into two categories:

  1. For intermediate level disinfection, use EPA Classification: Hospital disinfectants with tuberculocidal activity label claims. Look for the terms "tuberculocidal" and "hospital disinfectant" on the label of any chemical you use for intermediate-level disinfection.

  2. For low-level disinfection, use EPA Classification: non-tuberculocidal hospital disinfectant.

 

If the label reads "hospital disinfectant", but does not indicate that it is tuberculocidal, then use this chemical for low-level disinfection.

 

VIII. CLEANING AND DISINFECTION OF ENVIRONMENTAL SURFACES

After each client procedure and at the completion and beginning of daily work activities, countertops and surfaces that may have become contaminated with client material should be cleaned with disposable toweling, using an appropriate cleaning agent. Surfaces then should be disinfected with a suitable chemical germicide.

A chemical germicide registered with the EPA as a "hospital disinfectant" and labeled for "tuberculocidal" (i.e., mycobactericidal) activity is recommended for disinfecting surfaces that have been soiled with client material. These intermediate-level disinfectants include phenolics, iodophors, and chlorine-containing compounds. Because mycobacteria are among the most resistant groups of microorganisms, germicides effective against mycobacteria should be effective against many other bacterial and viral pathogens.

Low-level disinfectants -- EPA-registered "hospital disinfectants" that are not labeled for "tuberculocidal" activity (e.g., quaternary ammonium compounds) -- are appropriate for general housekeeping purposes such as cleaning floors, walls, and other housekeeping surfaces. Intermediate- and low-level disinfectants are not recommended for processing critical or semicritical piercing equipment.

 

IX. SINGLE-USE DISPOSABLE INSTRUMENTS

All instruments, equipment and Single-use disposable items (e.g., gauze, dental bibs, disposable cups, and sundries) should be used for one client only and discarded appropriately. These items are neither designed nor intended to be cleaned, disinfected, or sterilized for reuse.

 

X. USE OF PREVIOUSLY WORN BODY JEWELRY

*For reuse by the original wearer only!*

Previously worn jewelry should be handled with the same precautions as contaminated equipment. Universal precautions should be adhered to whenever previously worn jewelry is handled.

Before previously worn jewelry is reused, the jewelry should be cleaned of adherent client material by scrubbing with detergent and water. Jewelry should then be autoclave sterilized prior to reuse on the original wearer only. 

Persons handling previously worn jewelry should wear gloves. Gloves should be disposed of properly and hands washed after completion of work activities. Additional personal protective equipment (e.g., face shield or surgical mask and protective eyewear) should be worn if contact with debris or spatter is anticipated when the jewelry is handled, cleaned, or manipulated. Work surfaces and equipment should be cleaned and decontaminated with an appropriate liquid chemical germicide after completion of work activities.

 

XI. DISPOSAL OF WASTE MATERIALS

Contaminated needles should be placed intact into puncture-resistant containers before disposal. Solid waste contaminated with blood or other body fluids should be placed in sealed, sturdy impervious bags to prevent leakage of the contained items. All contained solid waste should then be disposed of according to requirements established by local, state, or federal environmental regulatory agencies and published recommendations.

 

XII. IMPLEMENTATION OF RECOMMENDED INFECTION-CONTROL PRACTICES FOR PIERCERS

Emphasis should be placed on consistent adherence to these infection-control strategies, including the use of protective barriers and appropriate methods of sterilizing or disinfecting equipment and environmental surfaces. Each piercing studio should develop a written protocol for equipment reprocessing, piercing procedure cleanup, and management of injuries. Training of all piercers in proper infection-control practices should be supplemented with continuing education.

 

XIII. ADDITIONAL NEEDS IN BODY PIERCING 

Additional information is needed for accurate assessment of factors that may increase the risk for transmission of bloodborne pathogens and other infectious agents in a piercing studio. Studio documentation should address the nature, frequency, and circumstances of occupational exposures. Such information may lead to the development and evaluation of improved designs for piercing instruments, equipment, and personal protective devices. In addition, more efficient reprocessing techniques should be considered in the design of future piercing instruments and equipment. Efforts to protect both clients and piercers should include improved surveillance, risk assessment, evaluation of measures to prevent exposure, and studies of postexposure prophylaxis. Such efforts may lead to development of safer and more effective piercing devices, work practices, and personal protective equipment that are acceptable to piercers, are practical and economical, and do not adversely affect piercees.