Infection-Control
Practice Standards for 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. 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 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
routinely between uses 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
followclosely 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
reprocessing.
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 reprocessing
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 or by using an
ultrasonic cleaner. 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.
Research
and design for this site by: Xipe
Project
last update 11.15.03
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