  
by Steve Gilbert
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.
Q. Suppose
I'm working on a customer who has AIDS and I accidentally stick myself with a contaminated needle. Will
I get AIDS?
A. Your chance of getting
AIDS this way is about 1 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)
Q. Why
is the transmission rate so low? I heard that intravenous drug users get AIDS from contaminated needles.
A. 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 needle-stick injury the needle
usually penetrates the skin superficially and is immediately withdrawn, with the result that little or no blood is transferred.
(3)
Q. What percentage of the population carries the AIDS virus?
A. 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)
Q. How many doctors and other health
care workers have been infected with AIDS from accidental needle-stick injuries?
A.
37 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)
Q. So
what are the odds that a tattoo artist will get AIDS from his customers?
A.
Your chance of getting AIDS from a random needle-stick 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.
Q. 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?
A. 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)
Q. Are there any other diseases you can get from accidentally
sticking yourself with a contaminated needle?
A. 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)
Q. Have doctors and other health care workers been infected with hepatitis
B due to needle-stick injuries or other exposure to contaminated blood?
A. 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)
Q. How dangerous is it?
A. 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)
Q. Why is hepatitis B transmitted by needle-stick injuries more often than AIDS?
A. There are 2 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)
Q. What percentage of the general population carries the hepatitis
B virus ?
A. 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)
Q. Has hepatitis B ever been transmitted
by tattooing?
A. 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)
Q. Has tattooing been outlawed in other places in the US.?
A.
Yes. These include Connecticut, Florida, Kansas, Massachusetts, Oklahoma, South
Carolina, Vermont, and Albuquerque, New Mexico. (9)
Q. Are there any recent cases on record
of a case of hepatitis B which was transmitted by tattooing?
A. 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.
Q. What about places outside North America?
A. 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.
Q. Is
there a vaccination for hepatitis B?
A. Yes.
An effective vaccine has been available since 1982.
Q. Who should get it?
A. It is recommended for all health care workers and others
who might be exposed to human blood and other body fluids.
Q. How much does it cost?
A. About $100.00
Q. Will I
be immune as soon as I get vaccinated?
A. 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)
Q. Has
hepatitis C ever been transmitted by tattooing?
A. Yes.
There is one case on record. (10)
Q. How can I protect myself against needle-stick injuries?
A. Studies of needle-stick 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 needle-stick. A study of needle-stick 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 needle-stick injury.
Needle-stick 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.
Q. How should contaminated needles be disposed of?
A. 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.
Q. How else should I protect myself?
A. 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.
Q. What about sterilization?
A. 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)
Q. Can I use a pressure cooker instead of an autoclave?
A. 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.
Q. Are there other methods of sterilization ?
A. Gas (ethylene oxide)
and dry heat sterilizers are also effective, but are more expensive and time consuming than autoclaving.
Q. Are
there any reports of diseases other than AIDS and hepatitis B which have been transmitted by tattooing during
the last ten years?
A. 4 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)
Q. Are there any other medical problems
which can be caused by tattooing?
A. 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.
Q. What percentage
of my customers will have a severe red reaction?
A. 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.
Q. What causes the red reaction?
A. 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.
Q. How can the red reaction be treated?
A. 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)
Q. Are there problems with other colors?
A. 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)
Q. What about other complications?
A. 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.
Q. Where
can I find out more about tattoo complications?
A. There
are 3 excellent reviews of the literature: Scutt (1972), Goldstein (1979) and Wilkes (1986) (17, 20, 21). These
papers contain extensive bibliographies.
Q. Where can I find out more about
sterilization?
A. 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
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Hepatitis B: Are your patients at risk?
Do you have:
- adolescent patients?
- patients who are sexually active with multiple partners?
- patients living with people who are chronic carriers of hepatitis
B virus?
- patients whose jobs potentially expose them to human blood
or body fluids?
- patients who use illicit drugs?
- patients who travel internationally to endemic areas?
- patients who were born in Asia, Africa, the Amazon Basin in
South America, the Pacific Islands, Eastern Europe, or the Middle East?
- patients who are Native Americans or Alaskan Natives?
- patients who have hemophilia?
- patients who are receiving hemodialysis treatment?
- patients who are monogamous but whose partners are at risk
for hepatitis B virus infection?
If you responded yes to any one
of these questions, you have patients who are at risk of infection with the Hepatitis B virus.
What is Hepatitis B?
The hepatitis B virus infects
the liver in all age groups and can lead to:
- cirrhosis
- liver cancer
- death
in many of those afflicted.
The virus is found in the blood and
body fluids of infected individuals and can be spread through:
- sexual contact
- sharing needles or razors
- from mother to child during birth
- by living in a household with an infected carrier
The hepatitis B virus is a
hardy virus that can live outside the body for several weeks.
What is America doing about Hepatitis B?
The Centers for Disease Control and Prevention and many public and private health organizations
are committed to the control and eventual eradication of hepatitis B in the United States.
How can I protect my patients?
A safe, highly effective vaccine for the prevention of hepatitis
B has been available for over a decade. A three-shot series will protect your patients and contribute to the elimination of
this silent, highly infectious killer from every community in America. Please review your adolescent and adult patient's medical
records and ask about risk factors. Encourage your patients to start their hepatitis B vaccine series as soon as possible
Facts Every Health Care Provider Should Know About Hepatitis B
- Hepatitis B can be fatal.
- Hepatitis B, once caught,
has no cure. There is, however, safe & proven prevention in the form of the hepatitis B vaccine.
- Hepatitis B virus infects
over 200,000 people in the US every year & there are currently 1.5 million chronic carriers in America alone.
- Hepatitis B kills over 5,000
Americans each year. It's a leading cause of chronic cirrhosis & a known cause of hepatocellular carcinoma. Death is usually
delayed 10 to 20 years from the time of original infection.
- The hepatitis B virus is
found in blood & body fluids such as semen, vaginal secretions & breast milk. It can be spread through sexual contact;
by sharing needles or razors & by tattooing or body piercing with unsterile equipment.
However, 40% of those infected don't know how they contracted the disease & acknowledge no risk factors when asked.
- Pregnant women with hepatitis
B will infect more than 50% of their infants. 90% of the 6,000 infants infected perinatally in the US each year will become
chronic hepatitis B carriers & 25% will eventually die of cirrhosis or liver cancer.
- Up to 30% of all pediatric
infections occur through contact with adult chronic carriers of hepatitis B living in the same household.
- 77% of those infected
with the hepatitis B virus every year are between the ages of 15-39. Fewer than 5% of adolescents & young adults have
received the hepatitis B vaccine.
- Hepatitis B vaccine is the
only product that will prevent a sexually transmitted disease (STD), as
well as cancer.
- Many patients infected with
hepatitis B have no symptoms. When symptoms do appear, they include loss of appetite, extreme tiredness, vomiting, stomach
pain & jaundice.
- Safe, effective hepatitis B vaccines have been available since 1982. Please protect your patients; give them the vaccine.
link to this information provided by click here
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