Tattooing and body piercing guidance Toolkit

Main contents DIG35.618

ISBN 978-1-906989-72-9 July 2013 Tattooing and body piercing guidance

FOREWORD 2 Appendix 02 42 – 43 Infection, its causes and spread, including ENDORSING ORGANISATIONS 3 a glossary of infection-related terms Toolkit INTRODUCTION 4 – 5 Appendix 03 44 Blood borne viruses USING THE GUIDANCE TOOLKIT 6 Appendix 04 45 ACKNOWLEDGEMENTS 7 Click on text to view Safe use and disposal of sharps PART A Appendix 05 46 Section 01 8 – 14 First Aid following a blood/body fluid exposure Legislative background on tattooing and skin Appendix 06 47 piercing activities Protocol for cleaning up blood or a blood Section 02a 15 stained body fluid spill Standard Principles of Infection Control Appendix 07 48 Section 02b 16 – 17 Principles for good waste handling Principles of Infection Control – Hand hygiene Appendix 08 49 Section 02c 18 – 20 Template protocol for environmental cleaning Principles of Infection Control – Personal of premises protective equipment Appendix 09 50 Section 02d 21 – 23 Tattooing/body piercing consent form Principles of Infection Control – Management Appendix 10 51 of sharps and exposure to blood and body fluids Aftercare follow-up record sheet Section 02e 24 – 25 Appendix 11 52 Principles of Infection Control – Safe handling, Decontamination requirements for equipment storage and disposal of waste materials used in tattooing and skin piercing Section 02f 26 Appendix 12 53 Principles of Infection Control – Cleaning and Equipment sterilization standard- self disinfection of the environment assessment and decision making tool for Section 02g 27 tattoo and body piercing practitioners References Appendix 13 54 Section 03 28 – 29 Equipment and body piercing jewellery Before and aftercare of a tattoo or body piercing sterilization standard for tattooists and body piercers Section 04 30 – 34 Decontamination Appendix 14 55 Autoclave daily record sheet Section 05 35 – 36 Product quality of tattoo ink PART C Section 06 37 Leaflets to download and print out Body piercing jewellery 01 Tattoo aftercare 56 02 Ear and face piercing aftercare 57 Section 07 38 – 39 Governance 03 Oral piercing aftercare 58 04 Body and surface piercing aftercare 59 Section 08 40 05 Genital piercing (female) aftercare 60 Management of infectious disease incidents relating to tattooing and body piercing 06 Genital piercing (male) aftercare 61 07 Microdermal implants aftercare 62 PART B Poster to download Appendix 01 41 How to handwash 63 Model Byelaws: Acupuncture, tattooing, semi- permanent skin-colouring, cosmetic piercing PART D and electrolysis Audit Tool to download 64 CONTENTS 1 PART E Literature review to download 65 Tattooing and body piercing guidance

FOREWORD Toolkit

Click on text to view FOREWORD GRAHAM JUKES DR PAUL COSFORD ENDORSING ORGANISATIONS Chief Executive, Chartered Institute of Director for Health Protection and INTRODUCTION Environmental Health Medical Director, Public Health England USING THE GUIDANCE Tattooing and body piercing have become This guidance toolkit has been developed as TOOLKIT increasingly popular and fashionable. Ensuring a collaborative piece of work between health ACKNOWLEDGEMENTS practitioners follow safe working practices is protection staff and partners for the tattoo and important for protection of both clients and body piercing industry. Its aim is to influence the practitioners themselves. It has been service provision, in particular by the promotion recognized for some time that there is a need of evidence based infection prevention and to promote safety and consistency across the control practice. This information has been range of tattooing and body piercing practices adapted into a comprehensive, practically based by basing requirements on best available governance framework as a resource to both scientific information whilst also taking support and guide practitioners in the field. account of practical experience. This guidance The need for and importance of this guidance toolkit encompasses expert advice as well as for the industry, has been recognised by many the opinions and experience of practitioners of health professionals and practitioners alike and what works at a practical level. I am delighted to support and endorse this toolkit guidance. ALAN BESWICK Principal Scientist, Health & Safety MARCUS HENDERSON Laboratory President, Tattoo and Piercing Industry Union A substantial amount of care and effort has gone in to producing this new guidance toolkit, The vast majority of members of the and its underlying strength lies in the evidence professional tattoo and body piercing based nature of its content; further supported community recognise the importance of by expert consensus where published the promotion and adoption of good practice in evidence may be lacking. The combination of order to safeguard both practitioners and public contributors to the toolkit confirms the desire alike. It is our hope that this document will of the authors to ‘get it right’ in terms of the provide an easy access reference guide to assist subject matter, presentation style and general those engaged in the industry in understanding accessibility of the information. Those who the necessity for examining their current have contributed include senior tattooing and practices and, where needed, making changes body piercing industry representatives, health to improve operational standards. care professionals, infection control scientists and health and safety specialists. The Health and Safety Laboratory is grateful to Public Health England and The Chartered Institute of Environmental Health for the opportunity to be involved in this guidance toolkit preparation, and is fully supportive of its content.

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ENDORSING ORGANISATIONS

Toolkit

Click on text to view FOREWORD CHARTERED INSTITUTE OF PUBLIC HEALTH ENGLAND (PHE) ENVIRONMENTAL HEALTH (CIEH) ENDORSING ORGANISATIONS From its establishment in April 2013, Public INTRODUCTION The CIEH is a registered charity and the Health England is the authoritative national USING THE GUIDANCE professional voice for environmental health. voice and expert service provider for public TOOLKIT It sets standards, accredits courses and health, established to protect and improve the ACKNOWLEDGEMENTS qualifications for the education of members nation’s health and wellbeing, and to reduce and other environmental health practitioners. inequalities. It provides information, evidence and policy advice to local and national government The three main business functions: and environmental and public health 1. Delivering services to national and local practitioners in the public and private sectors. government, the NHS and the public. As an awarding body, the CIEH provides qualifications, events, and support materials on 2. Leading for public health. topics relevant to health, wellbeing and safety 3. Supporting the development of the specialist to develop workplace skills and best practice. and wider public health workforce. HEALTH AND SAFETY LABORATORY PHE works with partners across the public health (HSL) system and in wider society to: The Health and Safety Laboratory (HSL) is an • Deliver, support and enable improvements Agency of Health and Safety Executive (HSE) in health and wellbeing in the areas set out and is the UK’s leading health and safety in the Public Health Outcomes Framework. research facility, employing over 350 scientific, • Lead on the design, delivery and maintenance medical and technical specialists. Its role is of systems to protect the population against to support the HSE Mission and directly help existing and future threats to health by organisations become healthier, safer and providing a comprehensive range of health therefore, more productive places in which protection services. to work. HSL capabilities encompass a wide range of topics including: occupational and TATTOOING AND PIERCING environmental health, human factors and INDUSTRY UNION (TPIU) risk assessment; safety engineering; work The TPIU has been working hard to become environment and specialist photographic and the recognised trade association representing technical services. This breadth of expertise individual TPI workers and their studios; underpins our particular strength in creating providing a collective voice for the industry; multi-disciplinary teams to solve health and helping to educate and inform our members safety problems.. on issues specific to our profession and to raise standards in the industry through sharing of information and discussion.

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INTRODUCTION Toolkit

Click on text to view FOREWORD This guidance toolkit has been prepared by a panel of health protection ENDORSING ORGANISATIONS and practitioner representatives. It comprises a consensus of expert advice INTRODUCTION which it is intended will provide an authoritative source of information. USING THE GUIDANCE Its contents are supported by extensive literature reviews (Part E). TOOLKIT ACKNOWLEDGEMENTS The purpose of the guidance toolkit is to support local authority and other regulatory officers in determining their requirements for effective control of risk in these activities and to promote a consistent approach. Similarly, it is intended to be of assistance to practitioners and businesses undertaking these activities to support them in adopting acceptable standards of practice. The use of this guidance toolkit will help to ensure the health and safety of both clients and operators and that tattooing and skin piercing practitioners will be operating in compliance with legal requirements.

BACKGROUND Over the years a variety of legislation has been introduced, mainly for local adoption, Tattooing and body piercing procedures have to encourage and support safe practice. become more popular and fashionable in the Model bylaws have been made available, United Kingdom (UK) as a whole, particularly but have not been accompanied by standard in the last decade. The range of tattooing and requirements for compliance. As a response body piercing procedures has also increased. to on-going concerns, a number of sets of There are no published data on the prevalence local/regional guidelines have been developed of tattoos in the general UK population. There by different agencies, often initiated by are also no comprehensive data for the UK on environmental health or health protection the prevalence of body piercing, but a small specialists (this guidance toolkit draws upon study has estimated that the prevalence of some of the previously published material). body piercing, other than of earlobes, in the However, there have been difficulties previously general adult population in England was 10% in engaging practitioners in the development (Bone A et al, 2008). of such guidelines and in securing adoption There are known and well reported health risks and wider implementation. which can be attributed to these procedures, It is also recognised that there are no nationally as well as associated legal issues. Improper recognised or accredited training courses, and unhygienic practice may result in localised standards for practice, agreed knowledge and skin infections at the site of the tattoo or skills frameworks or arrangements for monitoring piercing. There is also the risk of transmission and reporting of professional competence. of blood-borne viruses, for example Hepatitis The absence of accredited training and B, Hepatitis C, Hepatitis D or HIV, which can competencies for tattooing and body piercing is have more serious and long term health an area that needs to be addressed nationally consequences. It is therefore important that and is outside the scope of this guidance. The practitioners have safe working practices, working group has, however, been greatly and particularly that good infection control assisted in the preparation of this guidance by practices are followed at all times, so that both the Tattoo and Piercing Industry Union who are clients and practitioners are protected. recognised as a professional body for tattoo and body piercing practitioners in the UK. ➲ Main contents

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INTRODUCTION (continued) Toolkit

Click on text to view FOREWORD DEVELOPMENT OF THE GUIDANCE ENDORSING ORGANISATIONS This guidance was developed in response to INTRODUCTION concerns raised by tattoo and body piercing USING THE GUIDANCE practitioners, as well as health protection TOOLKIT and environmental health specialists. These ACKNOWLEDGEMENTS concerns were particularly in regard to the lack of robust and consistent guidance on standards of hygiene and safety. This has been leading to inconsistency in advice and variations in standards of practice.

A multi-agency steering group was set up comprising representatives from the Chartered Institute of Environmental Health, Health and Safety Laboratory, Public Health England (formerly Health Protection Agency), Tattoo and Piercing Industry Union and also individuals with practical experience of working in this area as expert advisors, practitioners or regulators.

The guidance is supported by extensive documentary evidence of scientific knowledge, reported research and published literature encompassing expert advice and the opinions and experience of practitioners of what works at a practical level.

References Bone A., Ncube F., Nichols T. & Noah ND. (2008) Body piercing in England: a survey of piercing at sites other than earlobe. BMJ; 336; 1426-1428.

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USING THE GUIDANCE TOOLKIT Toolkit

Click on text to view FOREWORD The guidance has been written as a key point of reference for use nationally ENDORSING ORGANISATIONS by tattoo and body piercing practitioners who work in regulated premises, INTRODUCTION local authority officers in their regulatory role and health protection staff USING THE GUIDANCE who are asked to provide expert advice. The guidance does not cover mobile TOOLKIT operators or non-registered practitioners, although the risks encountered THE AUDIT TOOL in relation to their activities will be of equal or greater concern. It does not PROVIDING FEEDBACK address the risks associated with procedures other than those commonly ACKNOWLEDGEMENTS accepted as necessary for tattooing and the insertion of body jewellery, although the procedures recommended for infection control are based upon sound principles of infection control and will have wider application.

The material is arranged so as to be readily No copyright is being claimed for the toolkit or accessible as a web-based toolkit, organised any of the material it contains and the authors in a manner that reflects the tattoo and encourage its wider distribution and use. body piercing setting, and with supportive documentation and literature that can be In offering and using the advice contained in downloaded and saved or printed in the this guidance it must be clearly understood that: manner that users prefer. • Legislation may change over time and the advice given is based on the It is intended that the adoption of the information available at the time this standards recommended in this guidance, toolkit was produced – it is not necessarily particularly those relating to infection control comprehensive and is subject to revision in and decontamination, will help to establish the light of further information. standards for good practice. Governance is promoted by the inclusion of template consent • Only the courts can interpret legislation forms, aftercare advice leaflets and a good with any authority, and practice infection control audit tool. • This advice is not intended to be definitive legal guidance nor is it a substitute for the THE AUDIT TOOL relevant law and independent legal advice should be sought where appropriate. This audit tool can be downloaded and used as individual sections or as a complete tool. PROVIDING FEEDBACK It is intended to be used by tattoo and body piercing practitioners, regulatory officers and The working group intend to reconvene to health protection practitioners to generate consider all feedback provided on the use evidence of the environment, practice and of this guidance toolkit after it has been in procedures in meeting standards and whether operation for 6 months after publication. practitioners are applying best practice and To that end feedback on your experience following guidance. The tool can be repeated is positively encouraged and will be to see if standards have been maintained or acknowledged and recorded for consideration. improved. Please send your feedback to Ian Gray, [email protected] Principal Policy Officer at the Chartered Institute of Environmental Health.

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ACKNOWLEDGEMENTS Toolkit

Click on text to view FOREWORD TATTOOING AND SKIN PIERCING OTHER GUIDANCE TAKEN INTO ENDORSING ORGANISATIONS WORKING PARTY MEMBERS ACCOUNT INTRODUCTION For the Chartered Institute of Calderdale Council: Advice and safe practice USING THE GUIDANCE Environmental Health for permanent tattooing and advice and safe TOOLKIT practice for body piercing (2008) David Kidney, Head of Policy (Chair of working ACKNOWLEDGEMENTS group) Dartford Borough Council: Code of practice for hygienic skin piercing (2009) Ian Gray, Principal Policy Officer, Tattooing and Body Piercing Infection Control For Public Health England (formerly Guidelines from Local Health Protection Teams the Health Protection Agency) (formerly Health Protection Agency Health Victor Aiyedun, Specialist Registrar in Public Protection Units) Health Medicine EDITORIAL GROUP Peter Hoffman, Consultant Clinical Scientist Alan Beswick

Susanne Howes, Health Protection Specialist Ian Gray, Convenor

Ann Lusmore, Health Protection Lead Nurse Marcus Henderson

Fortune Ncube, Consultant Epidemiologist Susanne Howes

Barry Walsh, Consultant in Communicable Ann Lusmore Disease Control SPECIAL ACKNOWLEDGEMENT For the Health and Safety Laboratory The working party would like to record its appreciation of the Chartered Institute of Dr. Alan Beswick, Principal Scientist, Environmental Health for undertaking the Microbiology design and publication of the guidance toolkit. For the Tattoo and Piercing Industry Union Marcus Henderson, President

Richard Stevens, Secretary

Representatives of Local Authority Environmental Health Services John Carlton, London Borough of Wandsworth

David Edwards, Medway Council

Michelle Garrigan, Sheffield City Council

Shona McQuade, Dartford Borough Council

Independent Advisor ➲ Main contents Norman Noah, London School of Hygiene and Tropical Medicine 7 Tattooing and body piercing guidance

PART A

Toolkit Legislative background on tattooing Section 01 and skin piercing activities Click on text to view SUMMARY SUMMARY Outside London Specific controls The use of legislation in this area of Generally, outside London there are provisions Outside London activity is primarily to ensure that infection to register both the premises (which can In London control arrangements are adequate and include a practitioner’s home) and the General controls effectively carried out wherever so-called practitioners themselves. The local authority Determining requirements ‘special treatments’ are carried out. ‘Special will also have powers to enact bylaws to LICENSING AND Treatments’ are usually defined as treatments regulate particular activities. However, as these REGISTRATION IN ENGLAND & for persons requiring massage, manicure, are adoptive powers, there may be some local WALES (EXCLUDING LONDON) acupuncture, tattooing, cosmetic piercing, authorities which do not have such registration LICENSING/REGISTRATION IN chiropody, light, electric or other special procedures in place and are relying on the LONDON treatment of a like kind or vapour, sauna or general legislation to control these activities. Exemptions within London other bath. In London HEALTH AND SAFETY AT WORK (ETC) ACT 1974 The primary means of enforcing infection Some local authorities in London operate a General duties control arrangements is by use of the licensing registration system similar to that outside Risk assessment or registration provisions. These are prescriptive London. However, in most of London, and Control of substances methods with offences and penalties for non- certain other Councils in England, there are hazardous to health compliance. The licensing and registration specific local powers with a system for licensing Management of contractors provisions are largely concerned with setting premises where skin piercing or other so- Enforcement requirements for good standards by requiring called ‘special treatments’ are provided which PUBLIC HEALTH CONTROLS the maintenance of established hygiene includes tattooing. AGE LIMITS AND CONSENT controls in respect of premises, equipment, Registration can be applied to a practitioner’s Tattooing procedures and practices. However, there home where regulated activities take place. The Other skin piercing activities are additional controls contained in primary registration is for fixed premises, however, the Acupuncture and electrolysis legislation that do contain provisions for the law allows local authorities to adopt a condition Ear and nose piercing immediate prohibition of activities or persons Consent of registration that permits the registered or for the closure of premises where risk of practitioner to work away from their fixed USE OF LOCAL ANAESTHETIC infection can be demonstrated. MEDICATION premises, although many do not permit this. Appendix 1 – Model Byelaws The legislation relating to tattooing and skin General controls piercing activities, as well as other so-called ‘special treatments’, can therefore be broadly The primary health and safety legislation applies split into two main areas: across the whole of England & Wales and is available for use by all local authorities without • Specific controls by registration or licensing the need for adoption. It can be used to impose of premises and people carrying out the and enforce infection control requirements in activities, and relation to all skin piercing activities, including • General controls of activities through primary peripatetic practitioners who visit a client’s home. legislation that is not specific to particular It allows for immediate prohibition of persons or activities but applies to all of them. premises that pose an imminent risk to health or safety. The use of health and safety legislation is Specific controls governed by substantial amounts of regulatory Arrangements for licensing and registration guidance and approved codes of practice. will differ depending on the particular However, none of this relates specifically to skin requirements of the local authority in whose piercing and therefore, regulatory officers need area the business is located or the activity is to use their skills of risk assessment within an being carried out. infection control setting. ➲ Main contents

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PART A

Toolkit Legislative background on tattooing Section 01 and skin piercing activities (continued) Click on text to view SUMMARY There is also public health legislation which b) The cleanliness of persons so registered provides local authorities with health and persons assisting persons so registered Specific controls Outside London protection powers to impose restrictions or in their practice and; In London requirements to protect public health where c) The cleansing and, so far as is appropriate, General controls voluntary cooperation to avert a health risk the sterilization of instruments, materials Determining requirements cannot be secured and where other methods and equipment used in connection with the LICENSING AND of control are ineffective, unsuitable or registered practices. REGISTRATION IN ENGLAND & disproportionate to the risk involved. Although WALES (EXCLUDING LONDON) these powers are very extensive, there are This is, therefore, specific legislation to ensure proper infection control measures. LICENSING/REGISTRATION IN stringent criteria for their use and safeguards LONDON for people who might be affected by them. The Secretary of State issued model bylaws, Exemptions within London (See below for public health controls) relating specifically to infection control, which HEALTH AND SAFETY AT local authorities could formally adopt. The Act WORK (ETC) ACT 1974 Determining requirements (LGA03) added further model bylaws in respect General duties It is intended that this national guidance will of cosmetic piercing and semi-permanent skin- Risk assessment provide an additional authoritative source colouring. The model bylaws have been reissued Control of substances of information to support local authorities in as a single document covering all activities that hazardous to health determining their requirements for effective are regulated under the LGMPA 82. Management of contractors control of risk in these activities and adopting Enforcement See Appendix 01 – Model Byelaws: a consistent approach in the application of the PUBLIC HEALTH CONTROLS Acupuncture, tattooing, semi-permanent skin- legislation. Similarly, it will be of assistance to colouring, cosmetic piercing and electrolysis AGE LIMITS AND CONSENT those businesses and practitioners undertaking Tattooing these activities to ensure that they are able The local authority can request reasonable Other skin piercing activities to operate safely and comply with legal information from applicants for registration. Acupuncture and electrolysis requirements. This cannot include details concerning persons Ear and nose piercing whom the applicant has given treatments to, Consent LICENSING AND REGISTRATION however, it could include evidence of training USE OF LOCAL ANAESTHETIC REQUIREMENTS IN ENGLAND & or competency for those being registered. MEDICATION WALES (EXCLUDING LONDON) Appendix 1 – Model Byelaws The registration is mandatory in that the There are provisions in Part VIII of the The local authority must issue a registration if Local Government (Miscellaneous Provisions) the application has been properly made. A Act 1982 (LGMPA82) for local authorities in registration can only be refused where a person England & Wales to require the registration has previously been convicted of an offence of persons carrying on the practices of under Section 16(1) or (2) of the Act (see below) acupuncture, tattooing, ear piercing or and the convicting magistrate cancelled the electrolysis. These powers are adoptive, and previous registration. A registration can only be local authorities are able to choose which cancelled by a magistrate upon conviction of of these practices would be required to be an offence, and this is in lieu of a fine. registered in their area. The Local Government Act 2003 (LGA03), Section 120, added semi- There are 3 possible offences – permanent skin-colouring and cosmetic • Carrying on the business of acupuncture, piercing to this list of activities for which tattooing, ear piercing or electrolysis without registration can be required. being registered, contrary to Section 16(1). The Act allows for local authorities to make • Contravening any bylaws made under the byelaws, for the purpose of securing: Act, contrary to Section 16(2). ➲ Main contents a) The cleanliness of premises and fittings in • Failing to display a copy of the registration such premises; and bylaws at the premises, contrary to 9 Section 16(9). Tattooing and body piercing guidance

PART A

Toolkit Legislative background on tattooing Section 01 and skin piercing activities (continued) Click on text to view SUMMARY The penalties for offences are fines on the there is no real limitation on what these may Standard Scale of Level 3 (currently £1000) for cover, but the Act does list nine specific areas, Specific controls Outside London offences against Section 16(1) and Section some of which are not related to infection In London 16(2), and Level 2 (currently £500) for an control. The London local authorities can General controls offence against Section 16(9). also make standard conditions that will be Determining requirements attached to all licences issued, however, there There are some exemptions from the are no standardised conditions across London LICENSING AND registration requirements. It does not apply to REGISTRATION IN ENGLAND & under the LLAA91. Therefore the requirements WALES (EXCLUDING LONDON) practices carried out by or under the supervision can vary between individual London local of a person who is registered as a medical LICENSING/REGISTRATION IN authorities, however, they all include infection LONDON practitioner (a Doctor registered with the control and other more general safety issues. General Medical Council) or for acupuncture by Exemptions within London a dentist, or their respective premises. Under the LLAA91 it is the premises that HEALTH AND SAFETY AT WORK (ETC) ACT 1974 are required to be licensed, not the persons Local authority officers can be authorised to carrying out the treatments. However, General duties enter any premises where they have reason to Risk assessment some London local authorities will name believe any of these three offences are being individual practitioners on the licence. Training Control of substances committed, but where entry is refused the hazardous to health requirements for practitioners may be authority of a warrant issued by a Justice of Management of contractors specified in conditions attached to the licence the Peace has to be obtained. Enforcement and some London local authorities operate free (but mandatory) registration schemes for PUBLIC HEALTH CONTROLS LICENSING AND REGISTRATION practitioners through conditions on the licence. AGE LIMITS AND CONSENT REQUIREMENTS IN LONDON Tattooing Exemptions within London Other skin piercing activities The Greater London (General Powers) Act 1981 Acupuncture and electrolysis (GLGPA81) provided London boroughs with The LLAA91 allows several exemptions from Ear and nose piercing a similar adoptive registration system as the the requirement for a licence: LGMPA82 which applied in the rest of England Consent a) Treatments carried out for no gain or and Wales, together with model bylaws and USE OF LOCAL ANAESTHETIC reward are exempt. MEDICATION similar offences relating to infection control. b) Doctors registered with the General Appendix 1 – Model Byelaws These legal provisions were mainly replaced in 1991 (see below), however some London Medical Council (GMC) are exempt for all boroughs are continuing to use the GLGPA81. treatments. c) Members of “bona fide bodies of health The London Local Authorities Act 1991 practitioners” can be exempted where (LLAA91), Part II provides a system of licensing they use their skills in curing or alleviating for premises offering ‘special treatment’, which of bodily diseases or ailments, but this is defined as treatment for persons requiring does not include a person whose skills are massage, manicure, acupuncture, tattooing, employed mainly for cosmetic alteration or cosmetic piercing, chiropody, light, electric or decorative purposes. other special treatment of a like kind or vapour, d) Dentists registered with the General Dental sauna or other baths. Although not mentioned Council (GDC) are exempt for acupuncture. in this list, semi-permanent skin-colouring is regulated as a treatment of a like kind to e) Various other exemptions are allowed but tattooing, and electrolysis is regulated as an they do not extend to skin piercing or skin electrical treatment. colouring activities. The licence for the premises is not mandatory The LLAA91 is adoptive. No model byelaws as it can be refused on 13 different grounds have been issued, however, the Act allows ➲ Main contents including, the suitability of the applicant; boroughs to issue a licence on “such terms structural stability of the premises; likely and conditions and subject to such restrictions 10 nuisance caused by the business; training as may be specified”. Effectively this means Tattooing and body piercing guidance

PART A

Toolkit Legislative background on tattooing Section 01 and skin piercing activities (continued) Click on text to view SUMMARY of staff; suitability of equipment and fire persons have a general duty of care to ensure precautions. When granted it is renewable their activities do not expose them or the Specific controls Outside London on an annual basis with the same grounds to general public to risks to their health or safety. refuse the renewal each year. If the licence is In London Within the framework of its overall strategy the not renewed then it ceases to exist. The licence General controls HSE has developed individual sector strategies, can be varied at any time, or transferred to Determining requirements with stakeholder involvement. Each sector another person, although this can be refused. LICENSING AND strategy sets out a series of aims grouped REGISTRATION IN ENGLAND & under the goals of the HSE Strategy which, if WALES (EXCLUDING LONDON) The local authority must notify the Police and the Fire Authority of each application, and met, will address ‘what’ needs to be done for LICENSING/REGISTRATION IN each sector to improve its health and safety LONDON these bodies can make comments that the local authority may consider, and act upon, if performance. The HSE Beauty Sector Strategy Exemptions within London they so wish. The consultation requirement is 2012-15 can be found at: HEALTH AND SAFETY AT for notification only and the consultees do not WORK etc. ACT 1974 http://www.hse.gov.uk/aboutus/ have to respond. General duties strategiesandplans/sector-strategies/beauty.htm Risk assessment Offences include operating a special Control of substances treatment premises without a licence, or not Risk assessment hazardous to health in accordance with the terms of the licence A risk assessment is the key step in protecting Management of contractors (a ‘breach of conditions’). The licence can be workers and the public, as well as complying Enforcement revoked by the local authority if the licensee is with the law. The risk assessment is a careful PUBLIC HEALTH CONTROLS convicted of a breach of conditions. Officers examination of what work activities could AGE LIMITS AND CONSENT authorised by the local authority have powers cause harm to people and this then guides Tattooing of entry where they believe an offence may decisions about precautions that need to Other skin piercing activities have been committed, and a warrant is not be taken, including infection prevention and Acupuncture and electrolysis required. Penalties on conviction for offences control measures. Ear and nose piercing are fines up to Level 4 on the Standard Scale Consent The HSE provides detailed advice on carrying (currently £2500) USE OF LOCAL ANAESTHETIC out risk assessments http://www.hse.gov.uk/ MEDICATION HEALTH AND SAFETY AT WORK risk/risk-assessment.htm including interactive Appendix 1 – Model Byelaws etc. ACT tools http://www.hse.gov.uk/risk/shop.htm The Health & Safety at Work etc. Act 1974 The Management of Health and Safety at (HASWA74) applies across the whole of Work Regulations 1999 requires all employers England & Wales and to all persons engaged and self employed persons to: in tattooing and skin piercing activities for gain • Undertake a risk assessment of their or reward. This includes peripatetic workers activities; who carry out treatments in the client’s home, • Remove, where possible, that risk or; although only the Health & Safety Executive have powers in relation to peripatetic workers. • Where residual risk is unavoidable, to provide control measures to reduce it as It provides means of securing effective far as possible, including as a last resort, infection control and the following areas are provision of personal protective equipment; particularly applicable. • Provide training to staff and persons they use to undertake their business activities General duties (contractors) to ensure they understand the Under Section 2 of the Act, all employers have risks and the control measures. a general duty of care to ensure the health, ➲ Main contents safety and welfare of their employees. Under One of the risks that must be considered here Section 3, both employers and self-employed is that of possible complications relating to 11 Tattooing and body piercing guidance

PART A

Toolkit Legislative background on tattooing Section 01 and skin piercing activities (continued) Click on text to view SUMMARY the procedure of skin piercing (for example: not employed by the person who owns and/ migration, scarring, teeth damage with oral or manages the premises where they work. In Specific controls Outside London piercing). Also, to be considered here will be these cases, they are usually self-employed and In London contra-indications for tattooing, cosmetic have some form of contract, formal or informal, General controls piercing and other activities, some for with the owner of the shop premises whereby Determining requirements obvious reasons, others not so obvious. The they pay the owner to allow them to work there. LICENSING AND practitioner therefore has to make sure that a In these circumstances the shop owner can be REGISTRATION IN ENGLAND & fully ‘informed consent’ procedure is adopted. said to be contracting out to the practitioner WALES (EXCLUDING LONDON) This means gathering information from the and in effect ‘endorsing’ their work’. LICENSING/REGISTRATION IN client about their health and suitability for LONDON the treatment, and giving the client enough These tattooists and piercers are therefore contractors undertaking the activities of Exemptions within London information about the possible complications the business owner for them. This means HEALTH AND SAFETY AT that could arise from the treatment for them to WORK etc. ACT 1974 make their own decision. that the premises owners cannot abdicate their own general duties under HASWA 74 General duties Risk assessment Control of substances hazardous to the individual practitioners. They have a Control of substances to health duty to ensure that persons working on their premises are competent and that they carry hazardous to health The Control of Substances Hazardous to out their work in a safe manner. The only way Management of contractors Health Regulations 2002 requires that a Enforcement they can do this satisfactorily is to assess the specific risk assessment is carried out by practitioners for themselves and monitor their PUBLIC HEALTH CONTROLS employers or self employed persons who activities to ensure they have carried out their AGE LIMITS AND CONSENT work with substances hazardous to health. own risk assessment, as they are required to Tattooing Substances which are hazardous to health do by law, and that they are following control Other skin piercing activities include biological agents. The hazards in this measures they have identified. The business Acupuncture and electrolysis context are the organisms which can cause owner has the ultimate power to remove the Ear and nose piercing communicable diseases could be transmitted risk, by stopping particular contractors working Consent from person to person by unhygienic practices. USE OF LOCAL ANAESTHETIC at their premises. MEDICATION Therefore a specific risk assessment in respect Appendix 1 – Model Byelaws of infection control is necessary for all persons Enforcement undertaking tattooing and skin piercing activities. The requirements of HASWA74 are enforceable through improvement and prohibition notices. Businesses employing less than 5 people do Improvement notices give a time limit for not have to record the findings of this risk compliance with requirements. Prohibition assessment, however they still have to satisfy notices can have the effect of immediately regulatory officers that their risk assessment is stopping the operations of a business or the suitable and sufficient. activities of a person where imminent risk The courts may accept that where a is apparent. All offences under HASWA74 practitioner can demonstrate that they are are punishable by unlimited fines and prison operating in accordance with these National sentences, so they provide a substantial Guidelines, then their assessment is sufficient. inducement for business to comply with requirements. Management of contractors The Management of Health and Safety at Work Regulations 1999 (Sections 10, 12 & 13) contains legal provisions which can be of ➲ Main contents particular importance to the many tattooists and cosmetic piercers who do not own the 12 premises which they operate from and are Tattooing and body piercing guidance

PART A

Toolkit Legislative background on tattooing Section 01 and skin piercing activities (continued) Click on text to view SUMMARY PUBLIC HEALTH CONTROLS permanent tattooing (except when carried out for medical reasons by a duly qualified medical Specific controls In March 2010 a set of new health protection practitioner or by a person working under their Outside London regulations were made under the amended direction). The practitioner has a defence if they In London Public Health (Control of Disease) Act 1984 can show that they had good reason to believe General controls to continue the process of modernising that the person was over 18 years of age. The Determining requirements health protection legislation in England. The consent of a client under 18 is not a defence. The LICENSING AND regulations, the Health Protection [Part 2A REGISTRATION IN ENGLAND & Police enforce this legislation and fines are up to Orders] Regulations 2010, provide updated WALES (EXCLUDING LONDON) Level 3 on the Standard Scale (currently £1000). local authority powers to protect public health LICENSING/REGISTRATION IN where voluntary cooperation to avert a health LONDON Other skin piercing activities risk cannot be secured and where other Exemptions within London There is no statutory minimum age for any other methods of control are ineffective, unsuitable HEALTH AND SAFETY AT form of skin piercing activity. Within London, the or disproportionate to the risk involved. WORK etc. ACT 1974 licensing framework makes it possible for local General duties Powers that impose restrictions or requirements authorities to state a minimum age for these Risk assessment are conditional on strict criteria being met. Before activities. However, this has not been consistently Control of substances making use of these powers, the local authority applied: some boroughs set no age restrictions; hazardous to health or Justice of the Peace must be satisfied that the some prohibit cosmetic piercing under 18 or 16, Management of contractors criteria relating to a particular threat to health and some allow it with parental consent; others Enforcement are met. The criteria cover evidence of infection allow ‘above the belt’ skin piercing above the PUBLIC HEALTH CONTROLS or contamination, assessment of the potential ages of 16 or18, and yet others ban all types of AGE LIMITS AND CONSENT for significant harm to human health, risk of genital and nipple piercing. Tattooing spread to others and necessity for action to be Acupuncture and electrolysis Other skin piercing activities taken in order to reduce or remove that risk. The When carried out properly these do not cause Acupuncture and electrolysis legislation also contains safeguards for people harm to the body, and leave no permanent Ear and nose piercing who might be subject to the legal measures. Consent markings. For this reason they are not likely to USE OF LOCAL ANAESTHETIC The measures are contained in the Public raise any concerns over common assault charges, MEDICATION Health (Control of Disease) Act 1984 (as although practitioners should be aware of possible Appendix 1 – Model Byelaws amended) together with the Health Protection indecent assault complications (see below). (Local Authority Powers) Regulations 2010 and Consent should still be obtained before treatment the associated provisions. takes place, and in the case of a minor this should be obtained from the parents or legal guardians. A web-based interactive toolkit has been developed to assist in the use of these health Ear and nose piercing protection powers. http://www.cieh.org/ Ear piercing, and in some cultures nose WorkArea/showcontent.aspx?id=37814 piercing, is generally considered acceptable when carried out on a minor, even below the AGE LIMITS AND CONSENT age of five, provided that a parent or legal guardian gives consent and is present whilst The need for limits on age, and requirements the procedure is carried out. for consent, can be a controversial area because in many circumstances specific Semi-permanent skin-colouring, cosmetic piercing, requirements have not been made in law. beading, branding, scarring, cutting and other Consent is a complex area of law, and one that extreme forms of body modification do cause is often misunderstood by the general public, actual harm and generally leave permanent marks and also some skin piercing practitioners. and can result in disfigurement. They can therefore ➲ Main contents be considered as assaults to the body, and so Tattooing potentially subject to the legislation concerning 13 The Tattooing of Minors Act 1969 imposes assault. This means that the question of age and a statutory minimum age of 18 years for the client’s informed consent are very important Tattooing and body piercing guidance

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Toolkit Legislative background on tattooing Section 01 and skin piercing activities (continued) Click on text to view SUMMARY Consent licensed for local anaesthesia prior to tattoo or body piercing.1 The client may wish to obtain a Specific controls In the legal proceedings of R v Brown (1994) topical local anaesthetic preparation prior to the Outside London 1 AC 212, the House of Lords ruled on appeal procedure; however responsibility for purchasing In London that consent could not be a defence against sections 20 and 47 of the Offences Against and application of the product should remain General controls with the client. The client should be advised Determining requirements the Person Act 1861 which deals with common assaults. However, the law also recognises that to read the Patient Information Leaflet which LICENSING AND certain activities that give rise to ‘harm’ are accompanies the product and should be aware REGISTRATION IN ENGLAND & of the following: WALES (EXCLUDING LONDON) lawful. This includes surgery, tattooing, ear piercing and violent sports. The courts have • Warnings, cautions and contraindications. LICENSING/REGISTRATION IN also held that the law allows children under the LONDON • Side effects. age of 18 to consent to cosmetic body piercing • That they are using the licensed product for Exemptions within London provided they are sufficiently mature to an un-licensed indication. HEALTH AND SAFETY AT understand the nature of the request. This kind WORK etc. ACT 1974 of assessment is clearly a subjective matter for • Recommendations regarding General duties the operator who will need to ensure that the administration and application. Risk assessment client is provided with sufficient information to Alternatively, a qualified practitioner, Control of substances allow them to proceed in an informed way and e.g. doctor, may prescribe a topical local hazardous to health without pressure. anaesthetic product to be self-administered Management of contractors by the client, or can prescribe and administer Under the Sexual Offences Act 1956, girls Enforcement a topical local anaesthetic product, in and boys under the age of 16 cannot legally PUBLIC HEALTH CONTROLS accordance with legal requirements of their give consent to intimate sexual contact under professional registration.2 AGE LIMITS AND CONSENT any circumstances, so piercing of nipples and Tattooing genitalia (for girls) or genitalia (for boys) can be Local anaesthetic injections are prescription-only Other skin piercing activities regarded as an assault offence. Evidence that medicines (POMs) therefore they can only be Acupuncture and electrolysis such contact was for sexual gratification would prescribed by a suitably qualified practitioner. Ear and nose piercing be required in order to constitute an indecent Local anaesthetic injections are not licensed for Consent assault. The Female Genital Mutilation Act local anaesthesia prior to tattoo or body piercing. USE OF LOCAL ANAESTHETIC 2003 states that certain procedures in respect In addition they should not be administered MEDICATION of female genitals is illegal unless carried out parenterally unless adequate resuscitation Appendix 1 – Model Byelaws for medical reasons. equipment is available.1 Information on the supply and administration of injectable medicines The signing of a declaration and providing proof outside their licensed medicinal uses is available of age should be a fundamental part of the from the Medicines and Healthcare Regulatory client consultation process and practitioners Agency (MHRA)2 and from the Nursing and should always require that the client signs Midwifery Council (NMC).3 a consent form prior to any work being commenced. However, the consent will only be References valid if the customer has been fully informed 1. British National Formulary (BNF) http://www. as to the nature of the process, the likely effect medicinescomplete.com/mc/bnf/current/PHP8663- local-anaesthesia.htm (accessed 22/4/2013) and potential problems involved. An example 2. MHRA; Frequently asked questions: Supply and of a consent form is provided in Appendix 9. administration of Botox®, Vistabel®, Dysport® and However, for practitioners own protection, it is other injectable medicines outside their licensed recommended that any consent forms they use medicinal uses such as in cosmetic procedures http:// are worded with the advice of a solicitor who is www.mhra.gov.uk/Howweregulate/Medicines/ familiar with this area of law. Availabilityprescribingsellingandsupplyingof medicines/Frequentlyraisedissues/BotoxVistabel Dysportandotherinjectablemedicines USE OF LOCAL ANAESTHETIC incosmeticprocedures/index.htm (accessed MEDICATION 22/4/2013) ➲ Main contents 3. NMC; Remote prescribing and injectable cosmetic There is a range of topical local anaesthetic medicinal products http://www.nmc-uk.org/Nurses- products for surface (skin) anaesthesia available and-midwives/Regulation-in-practice/Regulation-in- 14 from community pharmacies (Pharmacy only (P) Practice-Topics/Remote-prescribing-and-injectable- medicines), however none of these products are cosmetic-medicinal-products/ (accessed 22/4/2013) Tattooing and body piercing guidance

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Toolkit Section 02a Infection prevention and control Click on text to view SECTION 02A INTRODUCTION Responsibilities Under the Health and Safety at Work etc. INTRODUCTION Infection, its causes and spread Act (1974), all employers should ensure that Infection, its causes The causes and methods of spread of and spread all their employees are appropriately trained infections that are likely to arise in connection Factors in infection and proficient in the procedures necessary for with tattooing and skin piercing, are well control practice working safely. Employers and their employees Responsibilities understood. are also responsible to ensure that any person STANDARD PRINCIPLES OF See Appendix 02 – Infection, its causes on the premises is not placed at any avoidable INFECTION CONTROL and spread risk, as far as is reasonably practicable. They Appendix 02 – Infection, its also have a responsibility to protect voluntary causes and spread Unsafe or unhygienic practices by tattooing/ workers. Employers are also required by the SECTION 02B body piercing practitioners can lead to the Control of Substances Hazardous to Health PRINCIPLES OF INFECTION spread of infectious diseases that can affect Regulations 2002, known as COSHH, to review CONTROL – HAND HYGIENE the health of the client as well as jeopardise every procedure carried out by their employees SECTION 02C the health of the practitioner. Although some which involves contact with a substance bacterial or viral infections may be spread during hazardous to health, including pathogenic PRINCIPLES OF INFECTION CONTROL – PERSONAL procedures that do not involve skin penetration, micro-organisms. Specific guidance is available PROTECTIVE EQUIPMENT it is the occupational risk of transmission of from the Department of Health (Department SECTION 02D infections such as blood-borne viruses (BBVs), of Health, 1998). such as hepatitis B, hepatitis C, hepatitis D and PRINCIPLES OF INFECTION HIV, which can arise and which are of primary STANDARD PRINCIPLES OF CONTROL – MANAGEMENT OF SHARPS AND EXPOSURE TO concern. Precautions to minimise the possibility INFECTION CONTROL BLOOD AND BODY FLUIDS of exposure to blood from an infected client This guidance is based upon standard principles SECTION 02E or practitioner should be put in place by the which are the basic level of infection control adoption of safe practices and procedures. This PRINCIPLES OF INFECTION practice. Compliance with these standard CONTROL – SAFE HANDLING, should include immunisation against hepatitis B principles reduces the risk of transmission of STORAGE AND DISPOSAL OF (Department of Health, 2010a). blood-borne and other pathogens. WASTE MATERIALS SECTION 02F Factors in infection control practice Everyone providing treatments to clients PRINCIPLES OF INFECTION The risk of transmission of infection can be should know about and be able to carry CONTROL – CLEANING AND minimised by: out these standard principles for infection DISINFECTION OF THE prevention and control (National Institute for • Good cleanliness of the premises where the ENVIRONMENT Health and Care Excellence 2012). To that end tattooing and/or body piercing is taking Section 02g – References they should have received training in: place, and of the fixtures and fittings. • Good personal hygiene of the practitioners. • Hand hygiene and skin care. • Correct cleaning and sterilization or • The use of personal protective equipment disposal of instruments, materials and (PPE). equipment processes in place. • Sharps management and management of It is therefore important that the safe exposure to blood and body fluids. working practices described in this • Safe handling, storage and disposal of guidance are followed at all times in order waste materials. to protect both the client and practitioner. • Cleaning and disinfection of the environment.

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Toolkit Section 02b Infection prevention and control Click on text to view SECTION 02A PRINCIPLES OF INFECTION As a gold standard for infection control CONTROL – HAND HYGIENE purposes, NHS Estates (2002) recommend that INTRODUCTION hand wash basins should: STANDARD PRINCIPLES OF Hand hygiene is a major component of the INFECTION CONTROL standard principles and one of the most • Have elbow/foot-operated or non-touch mixer taps. SECTION 02B effective methods to prevent transmission of pathogens by reducing the number PRINCIPLES OF INFECTION • Have wall-mounted cartridge soap CONTROL – HAND HYGIENE of microorganisms that may be present. dispensers and paper towels available at The spread of infection from hands is well Hand washing facilities each hand wash basin. When to wash hands recognised and the importance of compliance • Not have a plug or overflow or be capable What to use to wash hands with hand hygiene practices is emphasised in of taking a sink plug. all national and international guidelines. How to carry out hand washing • Not have taps aligned to run directly into Use of hand rubs the drain aperture. Hand care Hand washing facilities Use of hand cream Hand washing facilities should be adequate • Have waterproof splashbacks. Care of broken skin and conveniently located in treatment areas • Have space allowed at the design stage for Poster – How to handwash (Department of Health, 2010a). Hand the placement of waste bins next to the SECTION 02C washing instructions should be clearly hand wash basin. displayed at the hand wash basin, such as in PRINCIPLES OF INFECTION When to wash hands CONTROL – PERSONAL the form of a poster. PROTECTIVE EQUIPMENT • Before and after an intervention with See Poster – How to handwash each client. SECTION 02D • After contact with any blood or body fluids. PRINCIPLES OF INFECTION Hand wash basins must be designated for that CONTROL – MANAGEMENT OF purpose only and have a constant supply of hot • Immediately after the removal of gloves. SHARPS AND EXPOSURE TO and cold running water, ideally delivered through • After using a tissue or handkerchief. BLOOD AND BODY FLUIDS a mixer tap. Under no circumstances should • After smoking. SECTION 02E equipment be washed in hand wash basins. • After visiting the toilet. PRINCIPLES OF INFECTION Liquid soap dispensers with single use CONTROL – SAFE HANDLING, • Before and after eating. liquid soap cartridges/bottles should be STORAGE AND DISPOSAL OF • Immediately after any other activity or WASTE MATERIALS used, ideally wall-mounted, although free contact with a client’s surroundings that standing dispensers would be considered SECTION 02F could potentially result in hands becoming suitable. Disposable liquid soap cartridges are PRINCIPLES OF INFECTION contaminated. CONTROL – CLEANING AND recommended because they do not permit a DISINFECTION OF THE topping-up process and this minimizes the risk What to use for hand washing ENVIRONMENT of contamination. For an ordinary hygienic hand wash, the Section 02g – References Wall-mounted disposable paper towels should use of liquid soap is sufficient. Preparations be next to the hand wash basins, and fully containing antiseptics that have a residual stocked at the start of each working day to effect on the skin surface are not required for minimise or reduce the need to fill up within use in tattoo and body piercing settings. hours during which the premises is operational (NHS Estates, 2002).

A foot-operated pedal bin, of an appropriate size, should be placed next to the hand wash basin for disposal of paper towels. ➲ Main contents

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Toolkit Section 02b Infection prevention and control Click on text to view SECTION 02A How to carry out hand washing Use of hand rubs

INTRODUCTION There are three distinct and essential stages Hand rubs containing alcohol based products to handwashing (National Institute for Health can enable practitioners to quickly and effectively STANDARD PRINCIPLES OF INFECTION CONTROL and Care Excellence, 2012) clean their hands before and after contact with clients. However, the use of a hand alcohol SECTION 02B 1. Preparation rub/gel is not a substitute for using soap and PRINCIPLES OF INFECTION Before washing hands, all wrist and hand water for hand washing e.g. when undertaking CONTROL – HAND HYGIENE jewellery should be removed. Cuts and tattooing and body piercing procedures (see Hand washing facilities abrasions must be covered with waterproof above), and should not be used when the hands When to wash hands dressings. Fingernails should be kept short, are visibly soiled or potentially contaminated What to use to wash hands clean and free from nail polish. Hands should with body fluids (National Institute for Health How to carry out hand washing be made wet by placing them under tepid and Care Excellence, 2012). Hand rubs should Use of hand rubs running water before applying liquid soap. Hand care conform to the standard BS EN 1500. The hand Use of hand cream rub solution must come into contact with all 2. Washing and rinsing Care of broken skin surfaces of the hand; the hands must be rubbed The hand wash solution must come into Poster – How to handwash together paying particular attention to the tips of contact with all of the surfaces of the the fingers, the thumbs and the areas between SECTION 02C hand. The hands must be rubbed together the fingers, until the solution has evaporated. PRINCIPLES OF INFECTION vigorously for a minimum of 10–15 CONTROL – PERSONAL seconds, paying particular attention to Hand care PROTECTIVE EQUIPMENT the tips of the fingers, the thumbs and the Use of hand cream SECTION 02D areas between the fingers. Hands should A hand cream can be applied regularly to PRINCIPLES OF INFECTION be rinsed thoroughly. CONTROL – MANAGEMENT OF protect skin from the drying effects of regular SHARPS AND EXPOSURE TO hand decontamination (National Institute 3. Drying BLOOD AND BODY FLUIDS for Health and Care Excellence, 2012). Each In a tattooing and body piercing setting, SECTION 02E practitioner should have their own supply and good quality disposable soft paper towels PRINCIPLES OF INFECTION a communal pot should not be used. would be considered the method of choice CONTROL – SAFE HANDLING, Care of broken skin STORAGE AND DISPOSAL OF because communal towels are a source of WASTE MATERIALS cross-contamination. Paper towels should Unbroken skin is the best defence because it SECTION 02F be stored in a wall-mounted dispenser provides the perfect barrier against infection. next to the washbasin and thrown away Small areas of broken or infected skin on PRINCIPLES OF INFECTION exposed parts of the practitioner’s body should CONTROL – CLEANING AND in a pedal operated waste bin. Hands DISINFECTION OF THE should not be used to lift the lid or they will be covered with a waterproof dressing that ENVIRONMENT become re-contaminated. completely covers the affected area. Section 02g – References

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Toolkit Section 02c Infection prevention and control Click on text to view SECTION 02A PRINCIPLES OF INFECTION Types of protective clothing CONTROL – PERSONAL Work clothing INTRODUCTION PROTECTIVE EQUIPMENT STANDARD PRINCIPLES OF Practitioner clothing should be clean at all INFECTION CONTROL Personal protective equipment (PPE) should be times, and professional in appearance. Work SECTION 02B available to all practitioners and staff who may clothing should be changed daily. Staff clothing be at risk whilst working in the premises. should not impede good hand washing, PRINCIPLES OF INFECTION CONTROL – HAND HYGIENE therefore the wearing of short sleeved tops is Assessment of risk advocated (Department of Health, 2010b). SECTION 02C Regulation 3 of the Management of Health PRINCIPLES OF INFECTION Gloves and Safety at Work Regulations 1999 (Health CONTROL – PERSONAL The Control of Substances Hazardous to and Safety Executive, 2008) requires every PROTECTIVE EQUIPMENT Health Regulations (Health and Safety employer to make a suitable and sufficient Assessment of risk Executive, 2002) require employers to assess assessment of: Types of protective clothing any substances hazardous to health, including Work clothing a) risks to the health and safety of their biohazards within blood and body fluids (such Gloves employees to which they are exposed as blood-borne viruses) and take steps to − Glove choice whilst they are at work; and reduce the risk of exposure. − Synthetic materials b) risks to health and safety of persons not in their − Latex gloves The use of gloves has two purposes: − Sterile gloves employment arising out of or in connection − Gloves used for cleaning with the conduct by them of their undertaking. 1. To protect the hands from becoming Aprons Therefore the selection of protective contaminated with dirt and microorganisms. Eye and face protection equipment must be based on an assessment 2. By changing gloves, to prevent transfer of SECTION 02D of the risk of transmission of infection between microbes from one client to another. PRINCIPLES OF INFECTION the practitioner and client and vice versa: CONTROL – MANAGEMENT OF Gloves must be worn when carrying out invasive SHARPS AND EXPOSURE TO Anticipated Wear Wear plastic Wear eye procedures, when in contact with sterile sites BLOOD AND BODY FLUIDS level of disposable or fluid and face and non-intact skin or mucous membranes, and SECTION 02E exposure gloves repellent protection during all activities that have been assessed apron PRINCIPLES OF INFECTION as carrying a risk of exposure to blood, body CONTROL – SAFE HANDLING, No fluids, secretions or excretions, or to sharp or STORAGE AND DISPOSAL OF exposure contaminated instruments (National Institute WASTE MATERIALS to blood/ body fluids for Health and Care Excellence, 2012). SECTION 02F anticipated X X X The correct method for wearing and removing PRINCIPLES OF INFECTION CONTROL – CLEANING AND gloves can be found on the WHO Save Lives DISINFECTION OF THE website: (http://www.who.int/gpsc/5may/ ENVIRONMENT Exposure Glove_Use_Information_Leaflet.pdf). Hands to blood/ Section 02g – References must be washed and dried thoroughly before body fluids anticipated putting on disposable gloves. but low risk Yes Yes X of splashing Gloves can tear or puncture visibly during use, or leakage may occur through microscopic holes. Hands may also become contaminated Exposure as gloves are removed. Gloves therefore must to blood/ not be seen as a substitute for good hand body fluids hygiene. Used gloves should be disposed of as anticipated with high Yes Yes Yes offensive waste (see waste section). ➲ Main contents risk of splashing 18 to the face Tattooing and body piercing guidance

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Toolkit Section 02c Infection prevention and control Click on text to view SECTION 02A Gloves are single-use items (National Institute • Is less elastic than latex but does shape to for Health and Care Excellence, 2012). This the wearer’s hand over time. INTRODUCTION means they must be put on immediately • Can be used for handling certain chemicals STANDARD PRINCIPLES OF before an episode of client contact or (Infection Control Nurses Association, 2002). INFECTION CONTROL procedure and removed as soon as the activity SECTION 02B is completed, or when leaving the client for However, nitrile contains the same types of chemicals as latex in the manufacturing process PRINCIPLES OF INFECTION any reason. Gloves must be changed between CONTROL – HAND HYGIENE different procedural activities for the same and allergic reactions have been reported. SECTION 02C client and between dealing with different Polyisoprene and Neoprene PRINCIPLES OF INFECTION clients, or removed if they become torn. • Offers effective protection against viral CONTROL – PERSONAL Glove choice penetration. PROTECTIVE EQUIPMENT • Has similar elasticity and physical Assessment of risk Gloves should be made available in a range of properties as latex. Types of protective clothing sizes for use by different practitioners (National Work clothing Institute of Clinical Excellence, 2012). • Is suitable for individuals sensitised to latex Gloves proteins. All gloves used for direct client care must − Glove choice conform to current EU legislation (CE marked • Can be used when a latex free environment − Synthetic materials as for single use) and should be appropriate is necessary (Infection Control Nurses − Latex gloves Association, 2002). − Sterile gloves for the task. Only PPE meeting the basic health Vinyl − Gloves used for cleaning and safety requirements of the EC Personal Aprons Protective Equipment Directive requirements is • Is suitable for use in areas where there is a Eye and face protection entitled to carry a CE mark and be sold for use low biohazard risk. SECTION 02D in the EC (Health and Safety Executive, 2012a). • Provides a good alternative for use when Practitioners should therefore look for the CE PRINCIPLES OF INFECTION staff or clients are sensitised to latex. mark information on glove packs plus EN 374- CONTROL – MANAGEMENT OF • In lab tests shows increased permeability 1:2003 or EN 374-2. These markings show the SHARPS AND EXPOSURE TO to blood borne viruses than latex. BLOOD AND BODY FLUIDS gloves are protective against chemicals and • Possesses lower tensile strength than latex SECTION 02E can resist microorganisms at a performance and breaks down more frequently. PRINCIPLES OF INFECTION level 2 test in penetration tests. Although CONTROL – SAFE HANDLING, this cannot infer protection against viruses, • Is prone to leaking. STORAGE AND DISPOSAL OF because they are not used in the performance • Is inelastic and can be baggy to wear. WASTE MATERIALS tests, in practice this is the highest level of • Is inexpensive in comparison to synthetic protection afforded against microorganisms SECTION 02F rubbers (Infection Control Nurses (Health and Safety Executive, 2012a). PRINCIPLES OF INFECTION Association, 2002). CONTROL – CLEANING AND Synthetic materials DISINFECTION OF THE Overall, vinyl gloves can be used to perform ENVIRONMENT Neoprene and nitrile gloves are synthetic gloves many tasks, but, depending on the quality Section 02g – References which have been shown to have comparable in- of the glove may not be appropriate when use barrier performance to natural rubber latex handling blood/blood-stained fluids (Royal gloves in laboratory and clinical studies. College of Nursing, 2012). Nitrile Polythene • Provides an excellent biological barrier, These gloves are not recommended for use resistant to punctures and tears. when undertaking activities involving blood/ • Comparable to latex in terms of barrier body fluids exposure and therefore should not performance. be used in the tattooing and body piercing setting. They are ill fitting, have heat sealed ➲ Main contents • Is a good alternative for latex sensitive individuals. seams that are predisposed to split and have a tendency to tear (Infection Control Nurses 19 • Can be used where a latex free Association, 2002). environment is necessary. Tattooing and body piercing guidance

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Toolkit Section 02c Infection prevention and control Click on text to view SECTION 02A Latex gloves (natural rubber latex) Gloves used for cleaning Latex gloves may be the preferred choice for For environmental cleaning purposes or for INTRODUCTION procedures in tattooing and body piercing manual pre-cleaning of equipment prior to STANDARD PRINCIPLES OF because of latex’s tactile sensitivity, barrier disinfection/sterilization, general-purpose INFECTION CONTROL property against viruses, good fit and optimal rubber gloves should be used. The gloves should SECTION 02B elasticity and user familiarity. However, latex be washed with general-purpose detergent PRINCIPLES OF INFECTION is a known skin and respiratory sensitiser and and warm water, and dried between uses. They CONTROL – HAND HYGIENE in a small number of people it can cause should be changed weekly, or more frequently SECTION 02C serious allergy (see below) (Health and Safety if the gloves become damaged (for example if PRINCIPLES OF INFECTION Executive, 2012a). There may also be issues there are signs of peeling, cracking and tears) CONTROL – PERSONAL when using latex gloves alongside petroleum- (National Patient Safety Agency, 2007). PROTECTIVE EQUIPMENT based lubricants which may affect the glove’s Aprons Assessment of risk integrity and therefore its protection ability. Types of protective clothing A disposable plastic apron must be worn when Work clothing Latex allergies are becoming common with there is a risk that clothing may be exposed Gloves prolonged use of latex gloves (Infection Control to blood, body fluids, secretions or excretions − Glove choice Nurses Association, 2002). The use of appropriate (with the exception of sweat or tears) (National − Synthetic materials synthetic gloves is therefore recommended to Institute for Health and Care Excellence, 2012). − Latex gloves avoid becoming sensitised. It is recognised, Plastic aprons should be used as single-use − Sterile gloves however, that within certain work environments, items and changed between clients. They − Gloves used for cleaning latex gloves are still used in large numbers due should be discarded and disposed of as Aprons to their efficacy and low cost. If latex gloves offensive waste after use. Eye and face protection are worn, then powder free, low protein content Eye and face protection SECTION 02D materials must be chosen to help prevent latex PRINCIPLES OF INFECTION allergy (Health and Safety Executive, 2012). Eye protection and face masks must be worn CONTROL – MANAGEMENT OF where there is a risk of blood, body fluids, SHARPS AND EXPOSURE TO Where latex gloves are in use, monitoring of secretions or excretions splashing into the eyes BLOOD AND BODY FLUIDS clients and staff should be undertaken. Any and face (National Institute for Health and SECTION 02E sensitivity shown to natural rubber latex in Care Excellence, 2012). A risk assessment of PRINCIPLES OF INFECTION either clients or staff should be documented the planned procedure should be undertaken CONTROL – SAFE HANDLING, and action must be taken to remove further to help inform decision making (e.g. when STORAGE AND DISPOSAL OF exposure risks. Alternatives to natural rubber manually cleaning equipment as part of WASTE MATERIALS latex gloves therefore must be made available decontamination processes). SECTION 02F (Health and Safety Executive, 2012). Further PRINCIPLES OF INFECTION information on latex allergy can be found If reusable goggles/protective glasses are CONTROL – CLEANING AND on-line at: http://www.hse.gov.uk/skin/employ/ used, they should be washed after each client DISINFECTION OF THE latex-gloves.htm and detailed information on or task using a general purpose detergent, ENVIRONMENT skin care and dermatitis in the work place can rinsed and stored dry. Eye protection should be Section 02g – References be found at: http://www.hse.gov.uk/skin/ compatible with any facemask used. Sterile gloves Face masks (such as surgical masks) should Sterile gloves are used for major surgical only be used if there is a risk of splashing of procedures and are not applicable to blood/body fluid droplets into the mouth tattooing/body piercing. or nose. If used, masks should be changed between clients and disposed of immediately after use. They must not be carried or worn around the neck. ➲ Main contents

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Toolkit Section 02d Infection prevention and control Click on text to view SECTION 02A PRINCIPLES OF INFECTION ‘Sharps/needlestick’injuries and INTRODUCTION CONTROL – MANAGEMENT OF exposure to blood and body fluids STANDARD PRINCIPLES OF SHARPS AND EXPOSURE TO BLOOD Types of injury/exposure INFECTION CONTROL AND BODY FLUIDS SECTION 02B A blood/body fluid injury/exposure incident PRINCIPLES OF INFECTION Introduction includes: CONTROL – HAND HYGIENE All body fluids should be regarded as potentially − Inoculation of blood by a needle or SECTION 02C infectious. Blood carries the highest risk of other ‘sharps’. PRINCIPLES OF INFECTION CONTROL – PERSONAL transmitting blood borne viruses such as hepatitis − Contamination of broken skin with PROTECTIVE EQUIPMENT B, C , D and human immunodeficiency virus (HIV). blood. SECTION 02D Blood borne viruses may also be transmitted by − Blood splashes to mucous membrane, PRINCIPLES OF INFECTION other body fluids, especially if contaminated by e.g. eyes or mouth. CONTROL – MANAGEMENT OF blood (Health Protection Agency, 2009). SHARPS AND EXPOSURE TO − Swallowing a person’s blood, e.g. after BLOOD AND BODY FLUIDS See appendix 03 – Blood borne viruses mouth-to-mouth resuscitation. Introduction Sharps and needles Sharps and needles − Contamination where the individual has Sterile needles an open wound, and clothes have been ‘Sharps/needlestick’ injuries The word ‘sharps’ is a generic term that and exposure to blood/ includes needles, scalpels, stitch cutters, glass soaked by blood. body fluid spills ampoules and sharp instruments that may − Bites (where the skin is broken). Types of injury/exposure become contaminated with blood or body Risks of transmission of blood- Risks of transmission of blood-borne borne viruses following a sharps fluid. In tattooing/body piercing premises, viruses following a significant injury/ injury/exposure sharps include equipment such as razors, Management of sharps/ exposure needlestick injuries and exposure needle bars with needles attached and to blood and body fluids cannulae (sometimes used for body piercing). Transmission of blood borne viruses (BBVs) Sharps/’needlestick’ injuries may result from contamination of mucous Blood/body fluid spills ‘Sharps’ contaminated with blood or other membranes of the eyes or the mouth, or Occupational health for blood borne virus prevention body fluids should be classified as hazardous of broken skin, with infected blood or other Risk assessment waste and handled accordingly. infectious material. There is no evidence Vaccination requirements that BBVs can be transmitted by blood See Section 02e Appendix 03 – Blood borne viruses contamination of intact skin, inhalation or by Appendix 04 – Safe use and All ‘sharps’ must be handled and disposed of faecal-oral contamination. disposal of sharps safely and with extreme care. After use they Appendix 05 – First Aid following should be placed immediately into yellow sharps The transmission risks after a mucocutaneous a sharps/ ’needlestick’ injury and exposure to blood/body fluid boxes/bins with orange lids, compliant with UN exposure (splash exposure) are lower than Appendix 06 – Protocol for 3291 and BS7320 standards. This is to reduce those after a percutaneous exposure (‘sharps’ cleaning up a blood or a blood the risk of exposure to blood-borne viruses, injury), estimated at 1 in a 1000 for HIV stained body fluid spill for example through an accidental ‘sharps’ (Health Protection Agency 2008). There is SECTION 02E or ‘needlestick’ injury (National Institute for currently no evidence on the risk of transmission PRINCIPLES OF INFECTION Health and Care Excellence, 2012). for hepatitis B virus (HBV) and hepatitis C virus CONTROL – SAFE HANDLING, (HCV) following mucocutaneous exposure STORAGE AND DISPOSAL OF See Appendix 04 – Safe use and disposal WASTE MATERIALS (Health Protection Agency, 2008). of sharps SECTION 02F PRINCIPLES OF INFECTION Sterile needles The risk of infection following a percutaneous CONTROL – CLEANING AND Only sterile single-use needles should be injury, especially deep penetrating injuries DISINFECTION OF THE ENVIRONMENT used for skin piercing or tattooing. Needles involving a hollow-bore needle or a device visibly Section 02g – References should be examined for imperfections prior contaminated with blood has been estimated at: to their use and discarded if any are found. • 1 in 3 when a source patient is infected ➲ Main contents Needles should either be used directly from the with HBV and is classed as being highly packaging or placed on a sterile surface/tray infectious at the time. 21 for immediate use. Tattooing and body piercing guidance

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Toolkit Section 02d Infection prevention and control Click on text to view SECTION 02A • 1 in 30 when the patient is infected with HCV. Occupational health for blood INTRODUCTION • 1 in 300 when the patient is infected with HIV borne virus prevention STANDARD PRINCIPLES OF (Health Protection Agency, 2008). Risk assessment INFECTION CONTROL Apart from the overall duty to carry out risk SECTION 02B Management of sharps/‘needlestick’ assessment of hazards in the workplace, the PRINCIPLES OF INFECTION injuries and exposure to blood and CONTROL – HAND HYGIENE Control of Substances Hazardous to Health body fluids SECTION 02C (COSHH). Regulations place a specific duty on PRINCIPLES OF INFECTION Injuries where a person’s broken skin or eyes, employers to assess the risks from exposure to CONTROL – PERSONAL mouth or other mucous membranes are hazardous substances, including pathogens PROTECTIVE EQUIPMENT exposed to another person’s blood or body (called biological agents in COSHH), and to SECTION 02D fluids, therefore, may carry a risk of infection bring into effect the measures necessary to PRINCIPLES OF INFECTION with blood borne viruses. CONTROL – MANAGEMENT OF protect workers and others from those risks as SHARPS AND EXPOSURE TO far as is reasonably practicable. BLOOD AND BODY FLUIDS Sharps/’needlestick’ injuries Introduction Prompt first aid and immediate risk assessment is In these circumstances the assessment of risks Sharps and needles needed in the event of such incidents to establish to health should include: Sterile needles the type of exposure sustained and to help Sharps/’needlestick’ injuries • How to prevent exposure to biological and exposure to blood/ determine what appropriate action is needed. body fluid spills agents. Types of injury/exposure See Appendix 05 – First Aid following a • Steps needed to achieve adequate control Risks of transmission of blood- blood/body fluid exposure borne viruses following a sharps of exposure. injury/exposure Blood/body fluid spills • Steps needed to avoid accidental ‘needle- Management of sharps/ needlestick injuries and exposure Blood and body fluid spills must be dealt with stick/sharps’ injury. to blood and body fluids quickly and effectively. Specialist body fluid Vaccination requirements ‘Sharps/needlestick’ injuries spill kits are available to purchase. These can Blood/body fluid spills Those at risk of blood/body fluid exposure Occupational health for blood be stored in a safe designated area in the borne virus prevention premises, enabling easy access and timely through sharps or splashes, therefore, should Risk assessment clear up. The expiry dates of products inside have a full course of hepatitis B vaccine. An Vaccination requirements kits should be regularly checked and out of accelerated course consisting of three doses at Appendix 03 – Blood borne viruses date items replaced as necessary. Posters and zero, one and two months (followed by a fourth Appendix 04 – Safe use and dose at twelve months after the first dose disposal of sharps simple training should be provided on the use for those at continued risk of exposure), and Appendix 05 – First Aid following of the body fluid spill kits. a sharps/ ’needlestick’ injury and antibody titres (blood levels) should be checked exposure to blood/body fluid The body fluid spill kit should contain: one to four months after the completion of the Appendix 06 – Protocol for primary course of vaccine. It is recommended • Disposable plastic aprons and synthetic cleaning up a blood or a blood that those at continued risk of infection stained body fluid spill (e.g. nitrile) gloves. should be offered a once only single booster, SECTION 02E • Disposable cloths. approximately five years after completion of the PRINCIPLES OF INFECTION CONTROL – SAFE HANDLING, • General purpose detergent. primary immunisation course (antibody levels STORAGE AND DISPOSAL OF • Chlorine granules. do not need to be checked before or after this WASTE MATERIALS booster dose). (Department of Health 2006). SECTION 02F See Appendix 06 – Protocol for cleaning up PRINCIPLES OF INFECTION blood or a blood stained body fluid spill Under the Health and Safety at Work etc CONTROL – CLEANING AND DISINFECTION OF THE Act 1974, employers must pay for protective ENVIRONMENT measures such as immunisation. This is usually Section 02g – References provided through the company occupational health provider. In the absence of an ➲ Main contents occupational health service, the employee could be asked to arrange immunisation 22 through their own GP, but the employer must Tattooing and body piercing guidance

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Toolkit Section 02d Infection prevention and control Click on text to view SECTION 02A make alternative arrangements if this cannot INTRODUCTION be done, and reimburse any charges made to STANDARD PRINCIPLES OF the employee for such arrangements. As with INFECTION CONTROL all control measures, immunisation needs to be SECTION 02B checked and reviewed and boosters provided, PRINCIPLES OF INFECTION where necessary. CONTROL – HAND HYGIENE SECTION 02C It would be considered good practice for PRINCIPLES OF INFECTION practitioners to keep copies of their vaccination CONTROL – PERSONAL PROTECTIVE EQUIPMENT history/antibody level results. If practitioners SECTION 02D refuse to have hepatitis B vaccination, it is advised the employer should consider asking PRINCIPLES OF INFECTION CONTROL – MANAGEMENT OF the employee to sign a disclaimer form. SHARPS AND EXPOSURE TO BLOOD AND BODY FLUIDS If the response to the hepatitis vaccine is Introduction not sufficient, the GP will need to investigate Sharps and needles Sterile needles whether there is a specific reason for non- Sharps/’needlestick’ injuries response to the vaccine. It is most important and exposure to blood/ for non-responders to know their status. They body fluid spills Types of injury/exposure may need to be protected by other measures Risks of transmission of blood- (e.g. immunoglobulin) following a ‘needlestick/ borne viruses following a sharps sharps’ injury. injury/exposure Management of sharps/ needlestick injuries and exposure There is no vaccine against hepatitis C and to blood and body fluids human immunodeficiency virus (HIV). Robust Sharps/’needlestick’ injuries infection control measures should be employed Blood/body fluid spills at all times to minimise the risk of exposure to Occupational health for blood borne virus prevention these viruses. Risk assessment Vaccination requirements If a practitioner is found to be positive for Appendix 03 – Blood borne viruses a blood borne virus disease, they should be Appendix 04 – Safe use and assessed and advised by their GP in relation to disposal of sharps working practices. Appendix 05 – First Aid following a sharps/ ’needlestick’ injury and exposure to blood/body fluid Appendix 06 – Protocol for cleaning up a blood or a blood stained body fluid spill SECTION 02E PRINCIPLES OF INFECTION CONTROL – SAFE HANDLING, STORAGE AND DISPOSAL OF WASTE MATERIALS SECTION 02F PRINCIPLES OF INFECTION CONTROL – CLEANING AND DISINFECTION OF THE ENVIRONMENT Section 02g – References

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Toolkit Section 02e Infection prevention and control Click on text to view SECTION 02A PRINCIPLES OF INFECTION There are a few municipal non-healthcare waste streams that are classed to be similar INTRODUCTION CONTROL – SAFE HANDLING, STORAGE AND DISPOSAL OF in nature to healthcare waste and are hence STANDARD PRINCIPLES OF included within the Department of Health’s INFECTION CONTROL WASTE MATERIALS waste guidance’s assessment framework. Good waste management is important to: SECTION 02B Waste such as ‘sharps’ and related wastes PRINCIPLES OF INFECTION • Reduce the health and safety risk to staff, from tattoo and body piercing practice CONTROL – HAND HYGIENE clients and visitors. is specifically included in this definition SECTION 02C • Protect the environment. (Department of Health 2012). PRINCIPLES OF INFECTION • Reduce waste disposal costs. CONTROL – PERSONAL Soft waste from body-piercing or tattooing PROTECTIVE EQUIPMENT Responsibility for waste materials practice can normally be assumed to present SECTION 02D no risk of infection, unless an indication to All organisations have a legal responsibility to the contrary is provided by a healthcare PRINCIPLES OF INFECTION dispose of waste safely, ensuring no harm is professional (Department of Health 2012). CONTROL – MANAGEMENT OF caused either to staff, members of the public SHARPS AND EXPOSURE TO However, as waste contaminated with non- BLOOD AND BODY FLUIDS or the environment. This responsibility begins infectious body fluids is capable of causing when waste is generated and ends with its SECTION 02E offence, it would be classed as ‘offensive’ final disposal. It is essential that persons waste (see below) and would require PRINCIPLES OF INFECTION handling waste fulfil their legal responsibilities CONTROL – SAFE HANDLING, appropriate packaging to indicate the bag by taking care to prevent injury or transmission STORAGE AND DISPOSAL OF contents (Department of Health 2012). Sharps WASTE MATERIALS of infection to themselves or others. waste would always be considered hazardous Responsibility for waste Premises should have a waste policy. The waste and should be disposed of accordingly materials practitioner is responsible for ensuring that (see below) (Department of Health 2012). National guidance on waste management contracts are in place for collection and safe Offensive waste Offensive waste disposal of offensive/hazardous waste from The guidance from the Department of Health Sharps the premises. It is essential to ensure with the (Department of Health 2012) states that “used All other waste waste management provider that appropriate gloves and aprons, swabs, small dressings, and Disposal of aerosol cans, glass, documentation is generated when necessary. cotton wool contaminated with body fluids bottles, broken crockery and dry The manager of the premises is also responsible arising from cosmetic piercing and other body cell batteries for monitoring the performance of staff and art plus other special treatment procedures Appendix 07 – Principles for waste contractors, as per agreed contract. good waste handling would be considered as offensive/hygiene waste where it is generated in quantity (one bag of 7 kg SECTION 02F National guidance on waste or more in any collection interval)”. Offensive management PRINCIPLES OF INFECTION waste should be placed into a yellow/black bag CONTROL – CLEANING AND In 2012 The Department of Health published (“tiger bag”) for disposal so that subsequent DISINFECTION OF THE the “Safe Management of Healthcare Waste” ENVIRONMENT holders of the waste can handle and dispose of to replace the 2006 version and to enable the material appropriately. Only where such Section 02g – References waste legislation in England to be in line with waste “is generated in small quantities (less Europe (Department of Health, 2012). The than 7 kg in one bag in any collection period) document is to be used as a best practice guide should it be disposed in the black-bag (general for the safe and effective handling of waste. waste) stream” (Department of Health 2012). The previous clinical waste classification system using groups A to E can no longer be used, ‘Sharps’ as the groups do not reflect the appropriate ‘Sharps’ should always be handled and disposed segregation for transport or disposal. of as hazardous waste (see Section 02d). In England and Wales, ‘sharps’ not ➲ Main contents See Appendix 07 – Principles for good contaminated with medicinal products (such as waste handling 24 those generated at a body piercing/tattooing premises), should be disposed of in a standards Tattooing and body piercing guidance

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Toolkit Section 02e Infection prevention and control Click on text to view SECTION 02A compliant yellow ‘sharps’ bin with an orange lid (Department of Health, 2012). INTRODUCTION STANDARD PRINCIPLES OF All other waste INFECTION CONTROL All other non-contaminated waste such as SECTION 02B paper should be placed in black bags, or bags PRINCIPLES OF INFECTION for recycling, within a foot operated pedal bin CONTROL – HAND HYGIENE and disposed of as normal household waste. SECTION 02C Aerosols, batteries and broken glass should not be placed in these bags. PRINCIPLES OF INFECTION CONTROL – PERSONAL Disposal of Aerosol Cans, Glass, Bottles, PROTECTIVE EQUIPMENT Broken Crockery and Dry Cell Batteries SECTION 02D These items should always be placed in a PRINCIPLES OF INFECTION designated cardboard box, lined with a plastic CONTROL – MANAGEMENT OF bag so that it is leak-proof. The box should be SHARPS AND EXPOSURE TO BLOOD AND BODY FLUIDS labelled to indicate its contents and method of disposal. SECTION 02E PRINCIPLES OF INFECTION CONTROL – SAFE HANDLING, STORAGE AND DISPOSAL OF WASTE MATERIALS Responsibility for waste materials National guidance on waste management Offensive waste Sharps All other waste Disposal of aerosol cans, glass, bottles, broken crockery and dry cell batteries Appendix 07 – Principles for good waste handling SECTION 02F PRINCIPLES OF INFECTION CONTROL – CLEANING AND DISINFECTION OF THE ENVIRONMENT Section 02g – References

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Toolkit Section 02f Infection prevention and control Click on text to view SECTION 02A PRINCIPLES OF INFECTION Colour-coding for cleaning INTRODUCTION CONTROL – CLEANING AND equipment DISINFECTION OF THE The aim of a colour-coding system for cleaning STANDARD PRINCIPLES OF ENVIRONMENT INFECTION CONTROL equipment is to prevent cross-contamination SECTION 02B Cleaning is the process that physically removes There is a national colour-coding system for PRINCIPLES OF INFECTION contamination with organic material such as the NHS (National Patient Safety Agency, CONTROL – HAND HYGIENE blood and body fluids, along with dirt and 2007b) (e.g. blue for general areas, red for SECTION 02C dust. Cleaning does not necessarily destroy toilet areas/wash hand basins),which could microorganisms from the item that is being be adapted for use in the tattooing and body PRINCIPLES OF INFECTION CONTROL – PERSONAL cleaned. However, providing and maintaining piercing setting. PROTECTIVE EQUIPMENT a clean and readily cleanable environment Use of chemicals SECTION 02D facilitates the prevention and control of infections. PRINCIPLES OF INFECTION Household detergent is adequate for most routine environmental cleaning. For high risk CONTROL – MANAGEMENT OF Equipment for cleaning SHARPS AND EXPOSURE TO environmental surfaces such as treatment BLOOD AND BODY FLUIDS Cleaning equipment that is regularly used surfaces, a hypochlorite solution of 1000 parts SECTION 02E should be fit for purpose, easy-to-use and well- per million (PPM) available chlorine should be PRINCIPLES OF INFECTION maintained (National Patient Safety Agency, used. This solution should be made up for use CONTROL – SAFE HANDLING, 2007a). A clutter-free environment and the on a daily basis, following the manufacturer’s STORAGE AND DISPOSAL OF adoption of local ‘clean as you go’ policies instructions, in a labelled container WASTE MATERIALS will provide the foundation for quality service provided by the commercial manufacturer SECTION 02F provision in a clean, safe place. Good cleaning (using, for example, one tablet of sodium PRINCIPLES OF INFECTION practice includes having: dichloisocyanurate (NaDCC) per litre format). CONTROL – CLEANING AND After twenty-four hours the solution must be • The provision and maintenance of a clean DISINFECTION OF THE discarded. The hypochlorite solution must ENVIRONMENT and appropriate environment by using not be transferred into a trigger spray bottle systems to manage the environment’s Equipment for cleaning but be used directly from the container onto Colour-coding for cleaning cleanliness with a documented cleaning a disposable cloth or paper towels. Surfaces equipment policy and rota plus a regular audit contaminated with blood should be cleaned in Use of chemicals programme. accordance with the guidance on dealing with Appendix 08 – Template • Equipment which is suitable for purpose, blood spillage as a higher concentration of protocol for environmental is able to be kept clean (i.e. impervious cleaning of premises hypochlorite will be required (see Appendix 06 surfaces) and maintained in good physical Section 02g – References – Protocol for cleaning up blood or a blood repair. stained body fluid spill). • Working from the cleanest area towards the dirtiest area to greatly reduce the risk of All chemicals should be handled and stored cross contamination. in accordance with the manufacturer’s instructions/COSHH guidance (Health and • A person in charge who has direct Safety Executive, 2002). Material safety data responsibility for ensuring that cleanliness sheets should be accessible to all staff. All standards are maintained. chemicals used on the premises should be • Single use cloths for cleaning tasks and used and stored in an identified cool, dry and cleaning equipment such as mops and well ventilated place (room/cabinet) that is buckets kept in good order (i.e. cleaned lockable, out of reach of visitors and members daily, renewed regularly and stored safely of the public and in the original containers. (cleaned, dried and stored inverted) in a Expiry dates should be routinely checked. ➲ Main contents designated area after use). See Appendix 08 – Template protocol for 26 environmental cleaning of premises Tattooing and body piercing guidance

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Toolkit Section 02g Infection prevention and control Click on text to view References Health and Safety Executive (2008). Health and SECTION 02A Calderdale Local Authority (2008). Advice and Safety Regulation – a short guide. (http://www.hse. INTRODUCTION safe practice for permanent tattooing plus advice gov.uk/pubns/hsc13.pdf) and safe practice for body piercing. (http://www. STANDARD PRINCIPLES OF Health and Safety Executive (2012a). The use of INFECTION CONTROL calderdale.gov.uk/business/licences/skinpiercing/ index.html) gloves. Blood Borne Viruses Guidance. (http://www. SECTION 02B hse.gov.uk/biosafety/blood-borne-viruses/use-of- Dartford Borough Council (2009). Code of practice gloves.htm) PRINCIPLES OF INFECTION for hygienic piercing. (www.dartford.gov.uk) CONTROL – HAND HYGIENE Health and Safety Executive (2012b). How to deal with an exposure incident. Blood Borne Viruses SECTION 02C Department of Health (1998). UK Health Departments Guidance for Clinical Health Care Guidance. (http://www.hse.gov.uk/biosafety/blood- PRINCIPLES OF INFECTION Workers: Protection Against Infection with borne-viruses/how-deal-exposure-incident.htm) CONTROL – PERSONAL Blood-borne Viruses Recommendations of the Health & Safety at Work etc Act (1974). PROTECTIVE EQUIPMENT Expert Advisory Group on AIDS and the Advisory Group on Hepatitis. HMSO (http://www.dh.gov. (http://www.legislation.gov.uk/ukpga/1974/37) SECTION 02D uk/en/Publicationsandstatistics/Publications/ Infection Control Nurses Association (ICNA) PRINCIPLES OF INFECTION PublicationsPolicyAndGuidance/DH_4002766) (now Infection Prevention Society (IPS)) (2002). A CONTROL – MANAGEMENT OF comprehensive glove choice. Fitwise, England. SHARPS AND EXPOSURE TO Department of Health (2006). Immunisation against Infectious Disease. (http://www.dh.gov. BLOOD AND BODY FLUIDS Management of Health and Safety at Work uk/en/Publicationsandstatistics/Publications/ Regulations. (www.opsi.gov.uk/si/si1999/19993242. SECTION 02E PublicationsPolicyAndGuidance/DH_079917) htm) PRINCIPLES OF INFECTION Department of Health (2010a). The Health CONTROL – SAFE HANDLING, NHS Estates (2002). Infection control in the built and Social Care Act 2008. Code of Practice environment. Design and planning (HBN 30 (2)). STORAGE AND DISPOSAL OF on the prevention and control of infections The Stationery Office. WASTE MATERIALS and related guidance. (http://www.dh.gov. uk/en/Publicationsandstatistics/Publications/ SECTION 02F National Institute for Health and Care Excellence PublicationsPolicyAndGuidance/DH_122604) (2012). Infection control: Prevention and control of PRINCIPLES OF INFECTION healthcare-associated infections in primary and CONTROL – CLEANING AND Department of Health (2010b). Uniforms and community care (CG139). (http://guidance.nice.org. DISINFECTION OF THE workwear: guidance on uniform and workwear uk/CG139) policies for NHS employers. (http://www.dh.gov. ENVIRONMENT uk/en/Publicationsandstatistics/Publications/ National Patient Safety Agency (NPSA) (2007a). Section 02g – References PublicationsPolicyAndGuidance/DH_114751) The national specifications for cleanliness in the NHS: a framework for setting and measuring Department of Health (2012). Safe management performance outcomes. (http://www.nrls.npsa.nhs. of healthcare waste V2.0. (http://www.dh.gov. uk/resources/?EntryId45=59818) uk/prod_consum_dh/groups/dh_digitalassets/ documents/digitalasset/dh_133874.pdf) National Patient Safety Agency (NPSA) (2007b). NHS colour coding hospital cleaning materials Health Protection Agency (2008). Eye of the and equipment 15. (http://www.nrls.npsa.nhs.uk/ Needle: UK surveillance of significant exposures to resources/?EntryId45=59810) BBV in healthcare workers. (www.hpa.org.uk/web/ HPAwebFile/HPAweb_C/1227688128096) National Patient Safety Agency (NPSA) (2009). The Revised Healthcare Cleaning Manual. (http://www. Health Protection Agency (2009). Inoculation nrls.npsa.nhs.uk/resources/?EntryId45=61830) Injuries and Children in Schools and similar settings: Risk Assessment Guidelines for Health Protection Royal College of Nursing (2012). Wipe it out- Units. (http://www.hpa.org.uk/webc/HPAwebFile/ Essential practice for infection prevention HPAweb_C/1259152291335) and control. Guidance for nursing staff. (http://www.rcn.org.uk/__data/assets/pdf_ Health and Safety Executive (2002). Guidance file/0008/427832/004166.pdf) on Control of Substances Hazardous to Health Regulations.(http://www.hse.gov.uk/coshh/)

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Toolkit Section 03 Before and aftercare of a tattoo or body piercing Click on text to view SKIN PREPARATION SKIN PREPARATION In the case of body piercing of minors, they must have a parent or other responsible adult NEED FOR AFTERCARE Where shaving is required, only single-use present when aftercare advice is given. Care of skin after tattooing razors are acceptable. Either a 70% alcohol- Care of skin after piercing impregnated single use swab (typically 70% Good practice is to include on the consent Aftercare leaflets isopropyl alcohol) or a 0.5% chlorhexidine in form a tick box or similar indicator to record WHAT TO DO IF A CLIENT 70% alcohol single use swabs (National Institute that aftercare advice has been explained and RETURNS WITH AN INFECTION for Health and Care Excellence, 2012) can be discussed at the time that the consent form Appendix 09 – Tattooing and used for skin disinfection. If the skin is visibly dirty was signed. body piercing consent form then the area should first be cleaned with soap See Appendix 09 – Tattooing/body piercing Appendix 10 – Aftercare and water and dried with a paper towel. follow-up record sheet consent form Where it is necessary to mark the skin, a single References Maintaining a good level of hygiene around use toothpick dipped into gentian violet or the treated area is essental during the healing other suitable dye could be used. The dye period. should be dispensed into a single-use pot for each client. Otherwise the entire bottle Care of skin after tattooing should be discarded after each client. As an Good practice is to cover the tattooed area alternative, or where large areas of skin need with sterile non-adhesive gauze which is then to be marked, then a single-use commonly secured with hypo-allergenic tape. Gauze available marker pen could be used, or a permits ventilation and aids healing. suitable single-use alternative. (Dartford Borough Council, 2009) A sterile, non-adhesive dressing may be appropriate for larger areas, at least during Where products such as petroleum jelly are the client’s journey home, but in many cases used for procedures, an appropriate amount of simply keeping the area clean and dry is likely material should be dispensed, using a single- to be the best approach. If plastic film wrap use implement (Calderdale Local Authority, is used for larger areas then it must be clean 2008), into a single-use pot for every client. (taken directly from the pack) and the client Practitioners should not use cream/lotion direct should be advised on when and how to replace from a jar/tube. Roll-on or stick applicators this covering. are not acceptable for use. The practitioner’s hands, even if gloved, should never come into Care of skin after piercing contact with the contents of these jars/tubes. The piercing site should be kept clean and dry NEED FOR AFTERCARE to promote healing. All piercings must be performed using good When checking the pierced site, hands should infection prevention technique and pre- be clean. It is not normally necessary to rotate sterilized equipment to reduce the chance or remove a piece of jewellery however, if the of infection occurring. The aftercare of body client has been advised to do this, it should be piercing sites and tattooed areas is also very handled as little as possible, with clean hands important in order to promote good healing and using a clean tissue and, if possible, to which lowers the risk of infection and reduces touch only the jewellery item. the risk of scarring. Clients should be advised about healing times Practitioners must explain to their clients the as these may be prolonged because of the time known potential complications associated with it takes for the jewellery “tunnel” to become dry the particular procedure they are being asked and then to heal after the initial piercing. ➲ Main contents to carry out. Upon completion of a treatment, 28 they must provide both verbal and written aftercare advice relevant to that treatment. Tattooing and body piercing guidance

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Toolkit Section 03 Before and aftercare of a tattoo or body piercing Click on text to view SKIN PREPARATION Aftercare leaflets WHAT TO DO IF A CLIENT NEED FOR AFTERCARE Lapses in aftercare are common causes of RETURNS WITH AN INFECTION Care of skin after tattooing infection following piercing and clients should be If any of the following signs or symptoms of Care of skin after piercing provided with an appropriate aftercare leaflet an infection develop, urgent medical attention Aftercare leaflets such as those available within this guidance. should be sought: WHAT TO DO IF A CLIENT Click on the aftercare leaflet thumbnail • Redness spreading around the site and RETURNS WITH AN INFECTION below to view the links for downloading extending away from it. Appendix 09 – Tattooing and body piercing consent form • Pus or green/yellow fluid oozing from the site. Appendix 10 – Aftercare Tattoo Ear and face • Bleeding that is not controlled by light follow-up record sheet 01 02piercing pressure. References • Pain (rather than discomfort). Tattoo Ear and face piercing Key Advice aftercare Key Advice Hand washing The aftercare of body piercing Hand washing The aftercare following a tattoo is important to promote good Hand washing is the single most important aftercare Hand washing is the single most is important to promote good Signs of infection healing and prevent the risk of method of reducing infection. Hands must Note: Cartilage piercings occasionally form important method of reducing infection. be washed prior to touching the affected lumps commonly known as granulomas. healing and prevent the risk of infection. Hands must be washed prior to touching If appropriate aftercare is not followed area, therefore reducing the risk of infection. This is just trapped fluid and can easily be the affected area, therefore reducing the resolved using the heat and pressure from a infection. infection may occur. The signs of Healing times for piercing will risk of infection. Wash your hands in warm water and liquid warm water compress once a day, replacing • Swelling. infection are: vary with the type and position soap, always dry your hands thoroughly one of your daily cleanings. For the first week or so it is with a clean towel or paper towel. This Wash your hands in warm water and • Swelling and redness that increases of the piercing and vary from liquid soap, always dry your hands should remove most germs and prevent Expect some swelling and soreness from normal for the area to be red around the wound. person to person. your new piercing. Any knock or bang can thoroughly with a clean towel or paper them being transferred to the affected area. and tender. cause swelling or soreness to flare up again towel. This should remove most germs • A severe burning and throbbing For the first few weeks it is A new piercing can be tender, itchy and throughout the healing phase. and prevent them being transferred to sensation round the site. normal for the area to be red, slightly red and can remain so for a As with all body art, infection is the affected area. Do not tender and swollen. few weeks. A pale, odourless fluid may use cotton wool to clean the a risk. To reduce these risks take • Increased tenderness and increasingly sometimes discharge from the piercing and piercing as the fibres in the cotton wool Tattoo aftercare painful to touch. form a crust. This should not be confused may get caught in the piercing. • Heat. advice from your practitioner Approximate healing times for the with pus, which would indicate infection. Do not pick at any discharge and do regarding aftercare. Good practice is to cover the tattooed • An unusual discharge (yellow or green) various piercings are: with an offensive smell. not move, twist or turn the piercing area with non-stick gauze which is then Ear piercing aftercare whilst dry. If any secreted discharge has secured with hypo-allergenic tape. Gauze Ear lobe piercing – 6 to 8 weeks The risk of infection can be Speak to your practitioner or seek medical Including Lobes/ Tragus/ Anti Tragus/ hardened then turning jewellery may permits ventilation and aids healing. attention immediately if you suffer from Ear cartilage piercing – 6 to 8 weeks Conch/ Helix/ Snug/ Diath/ Industrial/ Rook/ cause the discharge to tear the piercing, greatly reduced by good Cheek piercing – 2 to 3 months Translobal/ Transverse Lobe. allowing bacteria to enter the wound and A tattoo covering a large area may any of the above or have any concerns general hygiene including: prolonging the healing time. need to be covered with a sterile, non- regarding infection in your tattoo or if Eyebrow piercing – 2 to 4 months Facial piercing aftercare adhesive dressing, at least during your there are any signs of an allergic reaction Nose piercing – up to 6 months Including Eyebrow, Bridge, Jestum, Vertical Do not use sunbeds for the first two to any of the products used. • Immobility of, or reluctance to move, a • Hand washing before touching journey home. However, simply keeping Labret, Septum/ Nostril. weeks, or if you decide to then cover the the area clean and dry is likely to be the Remember these times are wound area with a breathable plaster the tattoo Soak the piercing for a few minutes by best approach. during tanning. approximate and will depend on submerging the area of skin containing the how healthy you are and whether piercing in a clean jug or bowl containing Do not swim for the first 24 hours • Keeping the tattooed A tattoo covering a large area may have following a piercing. plastic film wrap applied, this must be you look after the piercing a warm water solution (1/4 level teaspoon area covered with non-stick of preferably sea salt to an egg cup/shot clean (taken straight from the pack and properly until healed. Signs of infection glass of warm water). Alternatively wet a gauze which is secured with used immediately) and you should be If appropriate aftercare is not followed clean cloth or gauze in the solution and limb/digit/part of the body. infection may occur. The signs of advised when to replace this covering by As with all body art, infection is hypo-allergenic tape. apply as a warm compress. This will soften infection are: your practitioner. a risk. To reduce these risks take any discharge and allow you to clean the • Swelling and redness that increases advice from your practitioner entry and exit points of the piercing with Any cream that you apply must be used around the wound. regarding aftercare. a cotton bud or gauze. Once the discharge from an appropriate pot/tube at home is removed or softened then jewellery can • A severe burning and throbbing and you should wash your hands before The risk of infection can be be gently moved so as to work a little warm sensation round the site. application. Cream can be purchased greatly reduced by good general water through the piercing. When cleaning • Increased tenderness and increasingly from your practitioner or a pharmacist. always tighten the ball on any bars by painful to touch. hygiene including: screwing the ball to the right. Antibiotic creams should not be used • An unusual discharge (yellow or green) except if infection has occurred and under • Hand washing before touching Do this twice each day, preferably after with an offensive smell. Where the client informs the practitioner supervision of your Doctor. the piercing. washing or bathing. Speak to your practitioner or seek medical attention immediately if you suffer from • Keeping the piercing clean. You can also use mild antibacterial solutions any of the above or have any concerns and soaps to wash the wound site of an ear regarding infection in your piercing or if piercing. Ask your local pharmacist to advise there are any signs of an allergic reaction you and always follow the manufacturers’ to any of the products used. instructions. If irritation, redness or drying For further advice or information: occurs discontinue use. Antibacterial wash is For further advice or information: of a concern or problem, the practitioner is Contact your local Environmental Health NOT suitable for nostrils, septum or vertical Contact your local Environmental Health Department, or your local Public Health lips due to the tissue’s delicate nature. Department, or your local Public Health England Health Protection Team England Health Protection Team Dry the piercing using ONLY fresh disposable This Information is provided by: paper towel/kitchen roll. A communal This Information is provided by: Public Health England North West hand/bath towel should never be used. Public Health England North West Public Health England East Midlands Public Health England East Midlands Tattoo and Piercing Industry Union Tattoo and Piercing Industry Union advised to keep records of any action taken

Your practitioner is: Your practitioner is:

June 2013 June 2013 and advice given. See Appendix 10 – Aftercare follow-up Oral Body and record sheet 03piercing 04surface piercing References Oral piercing Body and surface piercing Key Advice aftercare Key Advice The aftercare of body piercing Hand washing The aftercare of body piercing Hand washing aftercare Hand washing is the single most important Hand washing is the single most important Calderdale Local Authority (2008). Advice and is important to promote good is important to promote good method of reducing infection. Hands Do not pick at any discharge and do Do not pick at any discharge and do healing and prevent the risk of healing and prevent the risk of method of reducing infection. Hands must must be washed prior to touching the not move, twist or turn the piercing be washed prior to touching the affected not move, twist or turn the piercing infection. affected area, therefore reducing the risk whilst dry. If any secreted discharge has infection. area, therefore reducing the risk of infection. whilst dry. If any secreted discharge has of infection. hardened then turning jewellery may hardened then turning jewellery may Healing times for piercing will cause the discharge to tear the piercing, Healing times for piercing will Wash your hands in warm water and liquid cause the discharge to tear the piercing, Wash your hands in warm water and allowing bacteria to enter the wound soap, always dry your hands thoroughly allowing bacteria to enter the wound and safe practice for permanent tattooing plus advice vary with the type and position liquid soap, always dry your hands vary with the type and position of the piercing and vary from and prolonging the healing time. with a clean towel or paper towel. This prolonging the healing time. thoroughly with a clean towel or paper of the piercing and vary from should remove most germs and prevent Do not use sunbeds for the first two Do not wear tight clothing following person to person. towel. This should remove most germs person to person. them being transferred to the affected area. and prevent them being transferred to weeks, or if you decide to then cover the nipple piercing For the first few weeks it is the affected area. wound area with a breathable plaster For the first few weeks it is A new piercing can be tender, itchy and during tanning. Do not wear tight clothing e.g. tights, and safe practice for body piercing. (http://www. normal for the area to be red, slightly red and can remain so for a belts or high waisted clothing after naval A new piercing can be tender, itchy and normal for the area to be red, tender and swollen. Do not swim for the first 24 hours few weeks. A pale, odourless fluid may piercing as this may irritate the wound slightly red and can remain so for a tender and swollen. following a piercing. sometimes discharge from the piercing and and delay healing. An approximate healing times few weeks. A pale, odourless fluid may form a crust. This should not be confused sometimes discharge from the piercing Special aftercare for tongue piercing Approximate healing times Do not use sunbeds for the first two for oral piercing are: with pus, which would indicate infection. and form a crust. This should not be For the first few days take care when for surface, navel and nipple weeks, or if you decide to then cover the calderdale.gov.uk/business/licences/skinpiercing/ wound area with a breathable plaster confused with pus, which would indicate eating and avoid spicy foods. piercing can be as long as Body and surface piercing aftercare Tongue piercing – 2 to 4 weeks. infection. during tanning. 6 months to 1 year. including Nape, Horizontal Navel, Niple, Lip – 3 to 6 weeks Cold products such as ice and ice cream Horizontal Eyebrow, Wrist, Anti-eyebrow, Oral piercing aftercare Do not swim for the first 24 hours Cheek – 2 to 3 months can help reduce swelling. Madison, Chin, Vertical Bridge, Pubic, For the internal healing of oral piercing Remember these times are following a piercing. Handweb and Prayer. Remember these times are including all piercing of the tongue , lip Refrain from oral sex of any description approximate and will depend Signs of infection index.html) and cheek until the piercing has fully healed. Soak the piercing for a few minutes by If appropriate aftercare is not followed approximate and will depend on how healthy you are and submerging the area of skin containing the infection may occur. The signs of on how healthy you are and Gargle after each meal with an alcohol-free Signs of infection whether you look after the piercing in a clean jug or bowl containing infection are: whether you look after the mouthwash or a warm salt water solution If appropriate aftercare is not followed piercing properly until healed. a warm water solution (1/4 level teaspoon (1/4 level teaspoon of preferably sea salt to infection may occur. The signs of piercing properly until healed. of preferably sea salt to an egg cup/shot • Swelling and redness that increases an egg cup/shot glass of warm water). infection are: As with all body art, infection glass of warm water). Alternatively wet a around the wound. clean cloth or gauze in the solution and As with all body art, infection is For the external healing of oral piercing: • Swelling and redness that increases is a risk. To reduce these • A severe burning and throbbing apply as a warm compress. This will soften Dartford Borough Council (2009). Code of practice including all piercings to the lip and cheek around the wound. sensation round the site. a risk. To reduce these risks take risks take advice from your any discharge and allow you to clean the • A severe burning and throbbing advice from your practitioner Wet a clean cloth or gauze in the warm practitioner regarding entry and exit points of the piercing with • Increased tenderness and increasingly sensation round the site. regarding aftercare. salt water solution and apply as a warm aftercare. The risk of infection a cotton bud or gauze. Once the discharge painful to touch. is removed or softened then jewellery can compress. This will soften any discharge • Increased tenderness and increasingly can be greatly reduced by good • The risk of infection can be be gently moved so as to work a little warm An unusual discharge (yellow or green) and allow you to clean the entry and exit painful to touch. general hygiene including: with an offensive smell. for hygienic piercing. (www.dartford.gov.uk) greatly reduced by good general points of the piercing with a cotton bud water through the piercing. When cleaning • An unusual discharge (yellow or green) or gauze dipped into the warm salt water always tighten the ball on any bars by Speak to your practitioner or seek medical hygiene including: with an offensive smell. solution. Once the discharge is removed • Hand washing before screwing the ball to the right. attention immediately if you suffer from any of the above or have any concerns • Hand washing before touching or softened then jewellery can be gently Speak to your practitioner or seek medical touching the piercing Do this twice each day, preferably after regarding infection in your piercing or if moved so as to work a little warm water attention immediately if you suffer from washing or bathing. the piercing there are any signs of an allergic reaction through the piercing. When cleaning any of the above or have any concerns • Keeping the piercing clean. You can also use mild antibacterial solutions to any of the products used. • Keeping the piercing clean. always tighten the ball on any bars by regarding infection in your piercing or if screwing the ball to the right. and soaps to wash the wound site. Ask your National Institute for Health and Care Excellence there are any signs of an allergic reaction local pharmacist to advise you and always to any of the products used. Do this twice each day, preferably after follow the manufacturers’ instructions. washing or bathing. If irritation, redness or drying occurs For further advice or information: discontinue use. For further advice or information: Dry the piercing using ONLY fresh Contact your local Environmental Health Contact your local Environmental Health disposable paper towel/kitchen roll. Dry the piercing using ONLY fresh disposable (2012). Infection control: Prevention and control of Department, or your local Public Health Department, or your local Public Health A communal hand/bath towel should paper towel/kitchen roll. A communal England Health Protection Team England Health Protection Team never be used. hand/bath towel should never be used. This Information is provided by: This Information is provided by: Do not use cotton wool to clean the Do not use cotton wool to clean the Public Health England North West Public Health England North West piercing as the fibres in the cotton wool may piercing as the fibres in the cotton wool Public Health England East Midlands Public Health England East Midlands get caught in the piercing. may get caught in the piercing. Tattoo and Piercing Industry Union Tattoo and Piercing Industry Union healthcare-associated infections in primary and Your practitioner is: Your practitioner is: community care (CG139). (http://guidance.nice.org. June 2013 June 2013 uk/CG139)

Genital piercing Genital Microdermal 05(female) 06piercing (male) 07implants

Genital piercing Genital piercing Microdermal implants Key Advice (female Key Advice (male Key Advice The aftercare of body piercing Hand washing ) aftercare The aftercare of body piercing Hand washing ) aftercare The aftercare of body piercing Hand washing aftercare is important to promote good Hand washing is the single most is important to promote good Hand washing is the single most important is important to promote good Hand washing is the single most important Do not swim for the first 24 hours method of reducing infection. Hands must Do not pick at any discharge and do healing and prevent the risk of important method of reducing infection. healing and prevent the risk of method of reducing infection. Hands Do not use antibacterial products as healing and prevent the risk of Hands must be washed prior to touching following a piercing. must be washed prior to touching the they can kill the good bacteria that are be washed prior to touching the affected not move, twist or turn the piercing infection. infection. area, therefore reducing the risk of infection. the affected area, therefore reducing the infection. affected area, therefore reducing the risk naturally present. whilst dry. If any secreted discharge has Do not pick at any discharge and do hardened then turning jewellery may risk of infection. of infection. Microdermal implants or dermal Wash your hands in warm water and liquid Healing times for piercing will not move, twist or turn the piercing Healing times for piercing will Do not swim for the first 24 hours cause the discharge to tear the piercing, anchors are small pieces of soap, always dry your hands thoroughly vary with the type and position Wash your hands in warm water and whilst dry. If any secreted discharge has vary with the type and position Wash your hands in warm water and liquid following a piercing. with a clean towel or paper towel. This allowing bacteria to enter the wound and of the piercing and vary from liquid soap, always dry your hands hardened then turning jewellery may soap, always dry your hands thoroughly jewellery made from titanium should remove most germs and prevent prolonging the healing time. of the piercing and vary from Do not pick at any discharge and do thoroughly with a clean towel or paper cause the discharge to tear the piercing, with a clean towel or paper towel. This inserted into the skin with the them being transferred to the affected area. Do not wear clothing that will rub against person to person. person to person. not towel. This should remove most germs allowing bacteria to enter the wound and should remove most germs and prevent move, twist or turn the piercing the piercing as this may irritate the whilst dry. If any secreted discharge has stem protruding above, onto A new piercing can be tender, itchy and and prevent them being transferred to prolonging the healing time. them being transferred to the affected area. wound and delay healing. For the first few weeks it is For the first few weeks it is hardened then turning jewellery may which an attachment of your slightly red and can remain so for a the affected area. normal for the area to be red, Refrain normal for the area to be red, A new piercing can be tender, itchy and cause the discharge to tear the piercing, choice is fitted. This attachment few weeks. A pale, odourless fluid may Do not use sunbeds for the first two from any type of sexual activity sometimes discharge from the piercing and tender and swollen. until the piercing has healed or is ‘dry’. slightly red and can remain so for a allowing bacteria to enter the wound and weeks, or if you decide to then cover the A new piercing can be tender, itchy and tender and swollen. should remain in place for at form a crust. This should not be confused wound area with a breathable plaster slightly red and can remain so for a few weeks. A pale, odourless fluid may prolonging the healing time. Always least three months or until the with pus, which would indicate infection. during tanning. The healing time for a few weeks. A pale, odourless fluid may use barrier protection such as The healing time for a sometimes discharge from the piercing and condoms, otherwise you are at increased Refrain piercing has fully healed. Once it genital piercing can be from sometimes discharge from the piercing genital piercing can be from form a crust. This should not be confused from any type of sexual activity Keeping the implant piercing clean Do not swim for the first 24 hours risk of acquiring a sexually transmitted until the piercing has healed or is ‘dry’. and form a crust. This should not be with pus, which would indicate infection. has fully healed other pieces of The implant needs to be cleaned twice following a piercing. 2 to12 weeks. infection. 2 to12 weeks. each day. Cleaning more frequently may confused with pus, which would indicate jewellery can be attached. Accidental damage or loss of disc Male Genital piercing aftercare Always use barrier protection such as damage the skin and slow down the Remember these times are infection. Signs of infection Remember these times are condoms, otherwise you are at increased Contact your practitioner if the implant including glans penis piercing such as Healing times for piercing will healing process. Your practitioner may also approximate and will depend approximate and will depend risk of acquiring a sexually transmitted advise you to soak the implant in warm salt gets caught in anything or the piercing Female Genital piercing aftercare If appropriate aftercare is not followed PA, Reverse PA, Apadravya, Ampallang, vary with the type and position on how healthy you are and infection may occur. The signs of on how healthy you are and infection. water twice a week. becomes damaged. including Clitoral Hood, Inner and Outer Dydoe and Frenum, as well as for other of the piercing and vary from whether you look after the infection are: whether you look after the piercings including Hafada, Scrotum, Make up a quantity of warm salt water In the unlikely event the disc breaks or Labia, Fourchette, Christina and Triangle. Signs of infection comes off, return to the practitioner and Foreskin and Guiche. person to person. solution (1/4 level teaspoon of preferably sea piercing properly until healed. • Swelling and redness that increases piercing properly until healed. If appropriate aftercare is not followed have a new disk fitted immediately. If the Soak the piercing for a few minutes by salt to an egg cup/shot glass of warm water). around the wound. infection may occur. The signs of For the first few weeks it is disc is not replaced the implant may get As with all body art, infection is submerging the area of skin containing As with all body art, infection is Soak the piercing for a few minutes by Use a clean cloth or gauze dipped in the submerging the area of skin containing infection are: normal for the area to be red, lost under the skin and will require removal. a risk. To reduce these risks take the piercing in a clean container, such as • A severe burning and throbbing solution and apply as a warm compress a risk. To reduce these risks take the piercing in a clean container, such as tender and swollen. Signs of infection a bowl containing a warm water solution sensation round the site. • Swelling and redness that increases and also to dab the area to make sure the advice from your practitioner (1/4 level teaspoon of preferably sea salt advice from your practitioner a bowl containing a warm water solution area under the disc is cleaned as this may If appropriate aftercare is not followed around the wound. As with all body art, infection is regarding aftercare. to an egg cup/shot glass of warm water). • Increased tenderness and increasingly regarding aftercare. (1/4 level teaspoon of preferably sea salt become encrusted. infection may occur. The signs of infection are: Alternatively wet a clean cloth or gauze painful to touch. to an egg cup/shot glass of warm water). • A severe burning and throbbing a risk. To reduce these risks take The risk of infection can be The risk of infection can be This will soften any discharge and allow in the solution and apply as a warm Alternatively wet a clean cloth or gauze sensation round the site. advice from your practitioner you to clean the piercing points with a • Swelling and redness that increases greatly reduced by good compress. This will soften any discharge • An unusual discharge (yellow or green) greatly reduced by good in the solution and apply as a warm regarding aftercare. cotton bud or gauze dipped into the warm around the wound. and allow you to clean the entry and exit with an offensive smell. compress. This will soften any discharge • Increased tenderness and increasingly general hygiene including: general hygiene including: salt water solution. • points of the piercing with a cotton bud and allow you to clean the entry and exit painful to touch. The risk of infection can be A severe burning and throbbing Speak to your practitioner or seek medical If the area around the implant becomes • or gauze. Once the discharge is removed • points of the piercing with a cotton bud sensation round the site. Hand washing before attention immediately if you suffer from Hand washing before greatly reduced by good general encrusted soak the piercing for a few or softened then jewellery can be gently or gauze. Once the discharge is removed • An unusual discharge (yellow or green) • Increased tenderness and increasingly touching the piercing any of the above or have any concerns touching the piercing or softened then jewellery can be gently with an offensive smell. hygiene including: minutes by submerging the area of skin moved so as to work a little warm water containing the piercing in a clean jug painful to touch. regarding infection in your piercing or if moved so as to work a little warm water • Keeping the piercing clean. through the piercing. When cleaning • Keeping the piercing clean. • Hand washing before touching or bowl containing the warm salt water • there are any signs of an allergic reaction through the piercing. When cleaning Speak to your practitioner or seek medical An unusual discharge (yellow or green) always tighten the ball on any bars by solution and loosen the discharge using a to any of the products used. always tighten the ball on any bars by attention immediately if you suffer from the implant. with an offensive smell. screwing the ball to the right. any of the above or have any concerns cotton bud or clean floss. screwing the ball to the right. • Keeping the implant clean. Speak to your practitioner or seek medical Do this twice each day, preferably after regarding infection in your piercing or if Always dry the area thoroughly after attention immediately if you suffer from washing or bathing. Do this twice each day, preferably after there are any signs of an allergic reaction cleaning your implant using ONLY fresh any of the above or have any concerns washing or bathing. to any of the products used. disposable paper towel/kitchen roll. regarding infection in your piercing or if Dry the piercing using ONLY fresh A communal hand/bath towel should there are any signs of an allergic reaction

disposable paper towel/kitchen roll. When cleaning always tighten the ball on never be used. to any of the products used.

A communal hand/bath towel should any bars by screwing the ball to the right. For further advice or information: For further advice or information: Do not over clean the site as this may For further advice or information: never be used. damage the skin around the implant Contact your local Environmental Health Dry the piercing using ONLY fresh Contact your local Environmental Health Contact your local Environmental Health Do not use antibacterial products as Department, or your local Public Health disposable paper towel/kitchen roll. Department, or your local Public Health Do not change the cap of the microdermal Department, or your local Public Health England Health Protection Team A communal hand/bath towel should England Health Protection Team implant until fully healed. If in any doubt take England Health Protection Team they can kill the good bacteria that are naturally present. This Information is provided by: never be used. This Information is provided by: advice from your operator This Information is provided by: ➲ Public Health England North West Public Health England North West Main contents Public Health England North West Do not use cotton wool to clean the Public Health England East Midlands Public Health England East Midlands piercing as the fibres in the cotton wool Public Health England East Midlands Tattoo and Piercing Industry Union Tattoo and Piercing Industry Union may get caught in the piercing. Tattoo and Piercing Industry Union

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29 June 2013 June 2013 June 2013 Tattooing and body piercing guidance

PART A

Toolkit Section 04 Decontamination Click on text to view PRINCIPLES OF PRINCIPLES OF Categorization of risks DECONTAMINATION DECONTAMINATION A general categorization of the risks that items Need for vigilance Decontamination is a combination of processes pose with regard to transmission of infection and Categorization of risks that render reusable items safe for reuse. the minimum decontamination standard that DECONTAMINATION PRACTICE should apply is set out in the following table: Layout of decontamination • For invasive items used in tattooing and area body piercing, these decontamination Risk Use of item Decontamination Decontamination of invasive processes will involve cleaning and (minimum items sterilization, after which environmental standard) Cleaning recontamination should be minimised and High Items Sterile or sterile Use of disinfectants recontamination with blood must be totally introduced single-use Sterilization eliminated. Pre-sterilized single-use items into normally Sterilizer operation, validation, are a good alternative. maintenance and record keeping sterile body • Using items once and then discarding them Care of items after sterilization areas or in Decontamination of blood and removes the need for decontaminating contact with body fluids in the working them. a break in skin or mucous environment items • Where an item is marked it is 2 membrane Appendix 11 – single-use and must not be reused even if Decontamination requirements decontaminated. Medium In contact Disinfect or single- for equipment used in • For items used in association with with intact use tattooing and skin piercing mucous invasive items, these decontamination Appendix 12 – Equipment membranes sterilization standard: self- processes should include both cleaning assessment and decision making and sterilization. Where this is not possible Low In contact Clean or clean tool for tattoo and body piercing (tattooing motors for example), their with intact and disinfect if practitioners contamination should be minimised skin contaminated with Appendix 13 – Equipment by the use of impervious covers which blood or body fluid and body piercing jewellery should be removed carefully after use Minimal Not normally No specific sterilization standard for so as not to contaminate the surface of in contact treatment tattooists and body piercers the item, and the item itself should be with skin (e.g. required, domestic. Appendix 14 – Autoclave daily chemically disinfected. Alternatively items floors and cleaning. Spills or record sheet can be single-use, such as with ink caps. walls) splashes of blood Further reading As with invasive items, environmental or body fluid recontamination should be minimised and should be safely cleared. recontamination with blood must be totally eliminated. DECONTAMINATION PRACTICE • For surfaces, contamination with blood should be made safe by careful application Layout of decontamination area of chemical disinfectants. The layout of a decontamination facility Need for vigilance is important, whether it is in a separate room or a dedicated part of the treatment It is vital that, once decontaminated, items are room, within body art premises. Items to be not directly or indirectly contaminated with decontaminated must flow along a defined blood or body fluid. This requires scrupulous process pathway from dirty (i.e. used and handling procedures and physical separation contaminated), through cleaning (which may from undecontaminated items and the have both a manual and an ultrasonic stage), ➲ Main contents surfaces they may have contaminated. through sterilization and into a phase of clean storage and return to use. 30 Tattooing and body piercing guidance

PART A

Toolkit Section 04 Decontamination Click on text to view PRINCIPLES OF At any stage, items must not be re-contaminated instruments: cleaning should be done under the DECONTAMINATION by direct or indirect contact with items at a lesser detergent solution surface to prevent splashing Need for vigilance stage of decontamination, e.g. items that have and care should be taken to avoid injury. Categorization of risks been cleaned must not be put on the same Any detergent should be safe for those who DECONTAMINATION PRACTICE surface or handled with the same utensils used for dirty items; items that have been sterilized use it, but thick washing-up gloves should Layout of decontamination nevertheless be used. If manual cleaning is area must not make contact with any surface that used, the detergent should be at or around Decontamination of invasive has been used for items before they have been items sterilized. In addition to this beware of using a neutral pH. It is common to use detergents Cleaning clean-looking item in the mistaken belief that it containing enzymes. However, it is thought Use of disinfectants has been fully decontaminated. that short exposures of dirt containing proteins Sterilization to these enzymes may give insufficient time for Sterilizer operation, validation, Only by having a progression through a effective action. There are also concerns that maintenance and record keeping defined layout, can the location of an item some of the enzyme mixtures (“subtilisins”) Care of items after sterilization correspond to its stage in the decontamination can give rise to allergic reactions in some who Decontamination of blood and process. This is always important, but come into contact with them. This should be body fluids in the working particularly so if more than one practitioner considered in risk assessments. Use of non- environment items uses the same facility, or if multiple copies of enzymatic detergents should be considered. Appendix 11 – identical equipment items are available for use, Decontamination requirements e.g. tattoo machine grips. Cleaning should be carried out in a sink for equipment used in dedicated to instrument cleaning and not one tattooing and skin piercing It is an advantage if the decontamination shared with other functions (handwashing, Appendix 12 – Equipment occurs in a dedicated room but if this is not eating utensil washing etc.). It can help to sterilization standard: self- possible, it should still occur in a dedicated area attain the correct dilution of a detergent if assessment and decision making tool for tattoo and body piercing in which a defined flow from dirty to clean can the sink is indelibly marked to a fill-line of practitioners be clearly established. known volume, allowing a measured addition Appendix 13 – Equipment of detergent to achieve the correct dilution. and body piercing jewellery Decontamination of invasive items Warm, but not hot, water should be used (hot sterilization standard for Any item that pierces the skin poses a high risk of water may coagulate proteins onto an item tattooists and body piercers transmission of infection. Only items intended and make then difficult to remove). Utensils Appendix 14 – Autoclave daily for reuse after cleaning and steam sterilization used for instrument cleaning should be record sheet should be reused. If any uncertainty exists dedicated solely for that purpose and should Further reading whether an item can be decontaminated by this be observably fit for purpose (e.g. bristles method then confirmation should be obtained on brushes in good order). Cleaning should from the supplier. take place under the surface of the detergent solution to minimise the potential of splashing See Appendix 11 – Decontamination the practitioner with the blood being removed. requirements for equipment used in tattooing and skin piercing Cleaning should be done as soon after an Cleaning item is used as possible as drying makes All items should be cleaned before sterilization. contamination less easily removed. It may If any blood or other proteinaceous material is make cleaning easier if items are stored left on an item that is to be steam sterilized it between use in clean fresh tap water or in a will become firmly fixed on the items and very high humidity atmosphere (such as a closed difficult to remove subsequently. vessel with a small amount of water).

Cleaning should use methods, detergents and Validation of cleaning should be by careful visual inspection of each item in good light. ➲ Main contents concentrations of those detergents compatible with items and specifically intended for Items with complex surfaces may require 31 instrument cleaning. The cleaning method should subsequent additional cleaning in an not put practitioners at risk from contaminants on ultrasonic waterbath (ultrasound creates Tattooing and body piercing guidance

PART A

Toolkit Section 04 Decontamination Click on text to view PRINCIPLES OF strong microcurrents in water by a process Sterilization DECONTAMINATION known as “cavitation” and is very effective Sterilization is the complete elimination of all Need for vigilance at removing soiling from otherwise hidden microbial life to a very high level of quality Categorization of risks crevices). Ultrasonic waterbaths should be assurance. It must be a robustly efficient DECONTAMINATION PRACTICE used, maintained and validated according to process guaranteed to work on every occasion. Layout of decontamination the manufacturer’s instructions. Whilst there are many theoretical ways in which area Use of disinfectants sterilization can be achieved, the only way that Decontamination of invasive body art practitioners can achieve it with the Chemical disinfection has far lower levels of items required quality is by steam sterilization. Cleaning quality assurance than steam sterilization and Use of disinfectants should not be used for invasive items. It should Other methods are either too complex or lack Sterilization only be used for decontamination of the equivalent quality assurance. Steam sterilizers Sterilizer operation, validation, environment and non-invasive items. Chemical are devices that can expose items to be maintenance and record keeping disinfectants are usually inactivated by organic sterilized to pure steam at above atmospheric Care of items after sterilization matter and should only be used after cleaning pressure in a chamber. The process must be Decontamination of blood and has removed the vast majority of organic automatic and steam sterilizers must monitor body fluids in the working matter. Disinfectants should be used in a environment items the process to ensure that all parameters controlled manner according to guidance and of sterilization have been met or, if any Appendix 11 – manufacturer’s instructions (e.g. the correct Decontamination requirements have failed, to clearly indicate a failed cycle. for equipment used in dilution, freshly prepared, applied as directed). (Pressure cookers do not have this inbuilt tattooing and skin piercing Do not mix disinfectants with other detergents quality assurance and are not suitable for Appendix 12 – Equipment or chemicals unless following manufacturer’s body art instrument sterilization. Devices sterilization standard: self- instructions. sold as baby bottle steam sterilizers use assessment and decision making lower temperatures and are not suitable for The disinfectant of choice for general tool for tattoo and body piercing body art instrument sterilization). The type practitioners disinfection of the environment should be a of steam sterilizer suitable for use by body hypochlorite solution containing 1,000 parts Appendix 13 – Equipment art practitioners is known variously as a small and body piercing jewellery per million available chlorine (ppm av Cl). steam sterilizer, a benchtop steam sterilizer or a sterilization standard for This is usually made by dilution of tablets of transportable steam sterilizer. These are small tattooists and body piercers sodium dichloisocyanurate (NaDCC), a form steam sterilizers that generate their own steam Appendix 14 – Autoclave daily of solid, stable hypochlorite, pre-measured to and are powered by a standard domestic record sheet give specific hypochlorite concentration when electrical supply and should conform to the Further reading dissolved in given volumes of water (always standard BS EN 13060. follow manufacturer’s instructions for attaining the correct concentration). Whilst solid NaDCC To effect the energy transfer necessary for is stable on dry storage, the hypochlorite sterilization, steam must be able to condense solutions it generates are unstable and should on all surfaces of an item, therefore hinged be made-up daily. Always use in accordance items should be opened and items should with the manufacturer’s materials safety data not overlap each other. If pockets of air are sheet. Hypochlorite solutions may bleach present, this blocks the ability of steam to fabrics and corrode metals other than good make contact with the surface in air. If porous quality stainless steel. They should never be (e.g. fabrics), hollow or wrapped items are mixed with strong acids (the production of placed in chambers that are then filled with highly toxic chlorine gas can result). They steam, this will not remove air from these loads should be used in well ventilated areas. but will only compress the air in them, leading to inadequate sterilization.

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Toolkit Section 04 Decontamination Click on text to view PRINCIPLES OF • Small steam sterilizers are produced in 3 A steam sterilizer should monitor each DECONTAMINATION different types: sterilization cycle and produce a record (e.g. Need for vigilance Type B steam sterilizers (also known as printout) of the cycle parameters, primarily Categorization of risks “vacuum” or “porous load” sterilizers): These the temperatures attained throughout the DECONTAMINATION PRACTICE have sterilization cycles that start by pulling sterilizing phase and the times of those Layout of decontamination a vacuum on the chamber to remove temperature readings. If the sterilizer cannot area most of the air in the chamber and within produce a record of cycle parameters, Decontamination of invasive porous, hollow or wrapped items; this is equivalent records should be produced by items followed by a series of pulses and removal observation of a cycle at the start of each Cleaning of steam to dilute any remaining air, day the sterilizer will be used. Steam sterilizers Use of disinfectants before the chamber is brought to sterilizing should be validated and maintained by Sterilization conditions. These sterilizers are suitable people specifically trained to do so according Sterilizer operation, validation, for porous, hollow or wrapped items. Any to a schedule provided by the sterilizer maintenance and record keeping wrapping must conform to the standard manufacturer. Records of validation and Care of items after sterilization maintenance should be retained as locally Decontamination of blood and BS EN 868, showing they are of a type that advised by the inspecting authority. body fluids in the working does not prevent the passage of steam and environment items will resist the passage of contamination See Appendix 14 – Autoclave daily record Appendix 11 – after sterilization has occurred. sheet Decontamination requirements for equipment used in Type S steam sterilizers: These are similar to There is a legal requirement to have a written tattooing and skin piercing type B, but have only been validated to process scheme of periodic examination of steam Appendix 12 – Equipment specific loads (and are normally produced to sterilizers under the Pressure Systems Safety sterilization standard: self- sterilize wrapped dental handpieces). These Regulations, 2000 by a “Competent Person assessment and decision making sterilizers are suitable for porous, hollow or (pressure vessels)” under these regulations. tool for tattoo and body piercing wrapped items only if validated for those A certificate of insurance is required for the practitioners specific items to be processed. sterilizer as a pressure vessel (Medical Devices Appendix 13 – Equipment Agency, 2002). and body piercing jewellery Type N steam sterilizers: These are steam sterilization standard for sterilizers with no assisted air removal. These Care of items after sterilization tattooists and body piercers sterilizers are suitable for non-porous, non- If items are wrapped, they will remain sterile as Appendix 14 – Autoclave daily hollow (solid) and unwrapped items only. long as the wrapping remains intact and dry. record sheet Further reading Type B and S sterilizers tend to be more If items are unwrapped, they can be placed expensive to buy and maintain and normally in a clean, lidded container. Great care should have longer cycle times than type N. be taken not to recontaminate them, with particular emphasis on recontamination from See Appendix 12 – Equipment sterilization undecontaminated instruments or surfaces standard: self-assessment and decision contaminated by blood or body fluid as they making tool for tattoo and body piercing are transferred into or out of the container, or as practitioners other items are removed from the container. This See Appendix 13 – Equipment and body is best achieved by having only those items in one piercing jewellery sterilization standard for container that will be used in a single procedure. tattooists and body piercers If a container does become contaminated, it should be washed and processed (open) in a Sterilizer operation, validation, steam sterilizer or discarded. maintenance and record keeping Sterilizers should only be used by those ➲ Main contents trained in their correct operation. Sterilizers should be operated according to the sterilizer 33 manufacturer’s instructions. Tattooing and body piercing guidance

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Toolkit Section 04 Decontamination Click on text to view Further reading PRINCIPLES OF Decontamination of blood DECONTAMINATION and body fluids in the working Medicines and Healthcare products Regulatory Authority (MHRA). Sterilization, Disinfection Need for vigilance environment and Cleaning of Medical Equipment: Guidance Categorization of risks Blood and other body fluids in the environment on Decontamination from the Microbiology DECONTAMINATION PRACTICE pose a risk of infection transmission: with blood Advisory Committee to Department of Health. Layout of decontamination the main hazards are of blood borne viruses; Part 1 – Principles (2010); part 2 – Protocols area with other body fluids a wider spectrum of (2005); Part 3 – Procedures (2006). http://www. Decontamination of invasive infectious micro-organisms are relevant. mhra.gov.uk/Publications/Safetyguidance/ items Environmental contamination with blood Otherdevicesafetyguidance/CON007438 Cleaning or other body fluids should be dealt with by Use of disinfectants Medical Devices Agency (2002). Benchtop Steam the removal of the contaminating material Sterilizers – Guidance on Purchase, Operation and Sterilization and disinfection as soon as possible after Maintenance. Sterilizer operation, validation, maintenance and record keeping the contamination occurs. The longer any (http://www.mhra.gov.uk/groups/dts-bi/documents/ Care of items after sterilization contamination remains on a surface, the more publication/con007327.pdf) it poses a direct risk to those who come in Decontamination of blood and Hoffman PN, Bradley CR, Ayliffe GAJ (2004). body fluids in the working contact with it, as well as the indirect risk of it Disinfection in Healthcare. 3rd Edn. Blackwell environment items being transferred to other surfaces from which Publishing. ISBN 1405126426 Appendix 11 – it may contaminate instruments that come Decontamination requirements into contact with clients. for equipment used in tattooing and skin piercing Remember: The person most at risk, is the Appendix 12 – Equipment person clearing the contamination. They sterilization standard: self- should have safe methods of working and use assessment and decision making appropriate personal protective equipment tool for tattoo and body piercing (PPE ) – which should always include single-use practitioners gloves, with additional PPE such as aprons if Appendix 13 – Equipment the contamination is extensive. and body piercing jewellery sterilization standard for Most environmental contamination is likely to tattooists and body piercers be minor. Such contamination can be removed Appendix 14 – Autoclave daily using single-use wipes and then, once clean, record sheet the area treated with a suitable disinfectant Further reading such as hypochlorite. (See cautions on hypochlorites above). If there is likely to be more extensive contamination, purpose-made disinfectant spill kits can be brought-in in readiness and used.

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34 Tattooing and body piercing guidance

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Toolkit Section 05 Product quality of tattoo ink Click on text to view BACKGROUND AND CONTEXT BACKGROUND AND CONTEXT MICROBIOLOGICAL AND CHEMICAL QUALITY CONCERNS MICROBIOLOGICAL AND Requirements already exist at both European CHEMICAL QUALITY and national level, whereby ink products The risks associated with tattooing treatments CONCERNS should be sterile and inert at first use. These have been acknowledged for many years, and RECOMMENDATIONS TO specified standards are not necessarily legally have been reported internationally (Lehman IMPROVE THE QUALITY OF binding, though bylaw requirements would et al., 2010). In addition to the standard safer INK PRODUCTS USED FOR TATTOOING become so if adopted by a local authority. At sharps controls to mitigate the risk of Blood the European level the quality requirements Borne Virus (BBV) transmission during tattooing, See Appendix 01 – Model Byelaws: Acupuncture, tattooing, for inks were initially laid down in 2003 by another potential hazard is that of infection semi-permanent skin-colouring, the Council of Europe, and further revised in via the ‘environmental’ route. This is typically cosmetic piercing and electrolysis 2008 (see at – https://wcd.coe.int/ViewDoc. associated with naturally occurring bacteria and References jsp?id=45869&Lang=en). fungi that have gained entry to the ink product at some stage during its manufacture or storage. In 2003 the UK Government published byelaws, This form of environmental contamination for use by local authority environmental health of inks, prior to their use on the client, is rarely officers (EHOs) to aid enforcement in this area. reported on. Despite the continually improving These have since been revised. standards in tattooing health and safety - much See Appendix 01 – Model Byelaws: of it related to eliminating the risk of BBV Acupuncture, tattooing, semi-permanent skin- transmission - the ‘environmental’ aspect of colouring, cosmetic piercing and electrolysis tattooing infection control remains beyond the control of most practitioners. The Welsh Assembly has also published its own byelaws to accommodate this area of Poor quality tattoo inks increase the potential enforcement and, like the UK model byelaws for localised bacterial skin infections as well as that preceded them, these stipulate that dermal allergies following tattooing treatments ‘..for the purposes of tattooing or semi- (Limentani et al., 1979; Jacob, 2002; Charnock, permanent skin-colouring, only sterile inert 2004; Suhair, 2007; Drage et al., 2010). Ink pigment, dispensed into single use pots or related problems might therefore be directly pre-packed in single use vials, is used.’ The related to the chemical and/or microbiological full documentation can be seen at: http:// quality of the ink or pigments used. Where wales.gov.uk/topics/health/protection/ this occurs, other efforts to maintain communicabledisease/acupuncture/?lang=en. tattooing hygiene standards could potentially be undermined if the inks themselves are A common requirement for all the above, contaminated at the point of use. where applied, is that the inks should be sterile at first use and should be inert (i.e. non- Tattoo ink products are typically purchased reactive with the body). For EHOs out in the from suppliers or directly from manufacturers field and for tattooists, there is an expectation and are delivered intra-dermally during that ink manufacturers will provide products treatment, so there is an increased potential that are fit for purpose. However, at present for the client’s body to be exposed to their there are few independent sources of data components, compared with, for example, a to confirm the quality of inks used in the UK, topically applied skin colorant. and no authoritative information to indicate whether this is universally achievable. Some Some inks are sold with little or no accompanying studies have shown that certain products may product data, and their composition may remain be contaminated with microorganisms and/or uncertain even at the point of use. metals, and the quality of inks used in the UK is ➲ Reports of metal sensitivity following Main contents likely to vary between manufacturers because tattooing have been published in the UK, of an absence of common standard quality 35 and dermatological responses have been requirements. Tattooing and body piercing guidance

PART A

Toolkit Section 05 Product quality of tattoo ink Click on text to view References BACKGROUND AND CONTEXT linked with particular ink colours, especially red products [some containing mercury] and Charnock C (2004). Tattooing dyes and pigments MICROBIOLOGICAL AND contaminated with bacteria. Tidsskr Nor CHEMICAL QUALITY greens/blue [chromate/cobalt] (Jacob, 2002; Laegeforen. 124(7):933-5. CONCERNS Mortimer et al., 2003; Gass & Todd, 2007). Drage LA, Ecker PM, Orenstein R, Phillips PK and RECOMMENDATIONS TO Edson RS (2010). An outbreak of Mycobacterium IMPROVE THE QUALITY OF RECOMMENDATIONS TO IMPROVE chelonae infections in tattoos. Journal of the INK PRODUCTS USED FOR THE QUALITY OF INK PRODUCTS American Academy of Dermatology. 62(3):501-6. TATTOOING USED FOR TATTOOING: Gass JK and Todd PM (2007). Multiple See Appendix 01 – Model • The presence of an accompanying manifestations of chromate contact allergy. Byelaws: Acupuncture, tattooing, product data sheet is a fundamental Contact Dermatitis. 56:290–291. semi-permanent skin-colouring, requirement to ensure that, as far as cosmetic piercing and electrolysis Jacob CI (2002). Tattoo-associated dermatoses: a possible, the appropriate quality tests have case report and review of the literature. Dermatol References been undertaken and passed for the ink. Surg. 28(10):962-5. Tattooists should therefore work wherever Lehman EJ, Huy J, Levy E, Viet SM, Mobley A and possible with inks that are accompanied McCleery TZ (2010). by the manufacturer’s product quality Bloodborne pathogen risk reduction activities in information, and should request this the body piercing and tattooing industry. American information from their supplier if it is not Journal of Infection. 38(2):130-8. provided; and, Limentani AE, Elliott LM, Noah ND, Lamborn JK • Practitioners should note the batch (1979). An outbreak of hepatitis B from tattooing. numbers of the products they purchase, Lancet. 2(8133):86-8. with delivery dates, as new inks are Mortimer NJ, Chave TA and Johnston GA (2003). purchased and received. Some suppliers Red tattoo reactions. Clinical and Experimental already provide a product listing and batch Dermatology. 28:508–510. numbers with their delivery note, and this Suhair OS, Miles HFJ, Simmons P, Stickley J and would equally serve as a dated record of ink De Giovanni JV (2007). Awareness of the risk products received. This record can then be of endocarditis associated with tattooing and body piercing among patients with congenital used in case of any subsequent concerns heart disease and paediatric cardiologists in the over ink quality. Wherever possible, and to United Kingdom. Archives of Disease in Childhood. strengthen the quality control link between 92:1013-1014 client and product(s) used, the colour of the inks used on each client should be noted at the time of treatment.

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36 Tattooing and body piercing guidance

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Toolkit Section 06 Body piercing jewellery Click on text to view GENERAL GENERAL NICKEL DIRECTIVE NICKEL DIRECTIVE The style of body piercing jewellery is distinct The Nickel Directive was a European Union References from traditional jewellery worn in the ear lobe Directive regulating the use of nickel in jewellery such as studs and butterfly designs. and other products that come into contact with the skin. The requirements also cover a Variations on the barbell and (captive) ring wide range of other items such as necklaces, design are those most commonly seen in body bracelets, wristwatch cases, zips and buttons. piercing because these substantial shapes minimise the risk of embedding, tearing and Since June 2009 it has been subsumed into migration. the EU REACH Regulation (Registration, Evaluation, Authorisation, legislation and High quality jewellery is made with smooth restriction of Chemicals). Nevertheless, the surfaces and joins in order to reduce the risk of term nickel directive is still used to refer to the irritation or of harbouring infection. restrictions on nickel usage and the prescribed Practitioners should ensure that all jewellery test for quantifying nickel release from used for skin piercings is sterile prior to its use. products. Jewellery can only be used if the Where jewellery is not purchased pre-sterilized nickel release rate from those parts of these but is sterilized within the premises, the products coming into direct and prolonged method by which sterilization has been carried contact with the skin is 0.5 micrograms per out will determine how sterile the jewellery square centimetre per week, or less. For body remains (see sterilization section). If jewellery piercing jewellery, post assemblies - the part is processed and stored properly, it may retain of the jewellery that is inserted into the wound its sterility indefinitely. However, practitioners caused by the piercing of the skin, including should be advised to discuss issues such as both the piece that goes through the wound shelf life with equipment (and packaging) and those parts of the jewellery intended manufacturers. to hold the piece in and against the wound (earring “back” or balls on the end of a piercing A number of materials are used in skin piercing bar or stud) - are prohibited unless their rate jewellery and acceptable materials include: of nickel release is 0.2 micrograms per square centimetre per week, or less. • Titanium. • Niobium. One problem with these requirements is that • Platinum. they do not apply to jewellery manufactured for export to countries outside the European • Gold – preferably solid gold 14 carat or Union. Where practitioners cannot prove that 18 carat (for ear piercing). The use of gold jewellery being used is in compliance with higher than 18 carat is not recommended these requirements, it is advised that use of in body piercing as it is too soft and the that jewellery stops until the practitioner can potential exists for scratching or pitting of obtain evidence from the manufacturer of its the metal which may increase the risk of compliance. infection at the piercing site. The use of gold lower than 14 carat is not recommended References in body piercing as it tends to be lower in The Regulation now incorporates the Nickel quality and has the potential to contain Directive (REACH), at item 27 of Annex XVII. metallic impurities, which may lead to Further information is available from: http://www. allergic response in the pierced individual. teg.co.uk/nickel/94-27-EC.htm

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37 Tattooing and body piercing guidance

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Toolkit Section 07 Governance Click on text to view TRAINING AND TRAINING AND COMPETENCIES • Needle stick injury (and basic first aid practice in relation to this). COMPETENCIES All tattooists and body piercers should PROCEDURE MANUALS/ undertake accredited training and be able • Safe sharps handling/disposal. POLICIES to demonstrate their competencies before • COSHH risk assessment/safe handling AUDIT AND QUALITY starting to practice. This guidance recognises, of chemicals. MONITORING however, that tattooists and body piercers • Training/education of staff. RECORD KEEPING in the UK do not have access to a nationally • Staff health including hepatitis B CONSENT AND AFTERCARE recognised and accredited course, nor is there vaccination status. DOCUMENTATION a nationally agreed set of competencies or See Appendix 09 – contains an ongoing objective monitoring of professional AUDIT AND QUALITY example of a consent form and competence by a recognised professional body. MONITORING there are a variety of written aftercare leaflets available Tattooists and body piercers currently Services, policies and practices should be See Appendix 10 – Aftercare undertake unaccredited courses, often run monitored on a regular basis by the premises follow-up record sheet by private companies, and/or undergo local manager/lead practitioner, not only to ensure References training and assessment against locally practice is up to date and evidence based, but determined competencies through self-funded for quality purposes as well. By having written, apprentice/mentorship schemes. These up-to-date policies and procedures, training methods vary in terms of quality, documentation of staff training and proof of duration and content. written, evidence based procedures/policies being followed, a premises can provide evidence of The absence of tattoo and body piercing quality standards being maintained. This is useful accredited training and competencies is an when premises are asked by other professionals, area that needs to be addressed nationally and clients, for proof of good practice procedures and is outside the scope of this guidance. and help demonstrate competence and quality in From an infection control viewpoint, any the event of a complaint. agreed national training and competencies for tattooists and body piercers should include the Undertaking audits is part of providing infection control areas listed in the procedure evidence of quality performance. The manuals/policies section (below). template infection control audit tool which is included with this guidance could be used PROCEDURE MANUALS/POLICIES for undertaking infection control audits at a tattooing /body piercing premises. It provides It is recommended that practitioners produce a spreadsheet which gives percentage scores a written procedure/policy manual for use by against good practice target scores in each staff. It should be based on evidence – based section and overall. guidance and be easily available and be easily understood by all groups of staff. Policies/ It is suggested that audits are initially procedures should be reviewed annually so undertaken every six months (or more that practice is up to date and should indicate frequently if scores are below standard targets) ownership (i.e. who is responsible for managing and an action plan developed to address any the policy) and authorship. gaps in audit findings. As a minimum an audit Policies/procedures should include: should be undertaken annually. It is important that there are named individuals designated • Hand washing procedure. against each action and that a deadline is • Cleaning policy and rota. given for each action so that progress can be • Decontamination procedures. identified against these by designated staff, as well allowing monitoring of progress to be ➲ Main contents • Management of waste. followed by the manager/owner. A repeat audit 38 • Management of blood spillages. allows the recording of changes made, as well • Use of personal protective equipment (PPE). as good practice to be monitored over time. Tattooing and body piercing guidance

PART A

Toolkit Section 07 Governance Click on text to view TRAINING AND RECORD KEEPING CONSENT AND AFTERCARE COMPETENCIES DOCUMENTATION Accurate records are invaluable if infection PROCEDURE MANUALS/ problems occur and may assist the practitioner Consent forms must be signed before any POLICIES when investigations are conducted – for procedure is commenced. Both written AUDIT AND QUALITY example, for verifying procedures performed and verbal aftercare information should be MONITORING and equipment check-tests carried out, when provided to the client as evidence of good and RECORD KEEPING they were performed and on whom/by whom. safe practice. CONSENT AND AFTERCARE It is important to keep accurate records of See Appendix 09 – contains an example of DOCUMENTATION every client including: a consent form and there are a variety of See Appendix 09 – contains an • Full name, address, telephone number, date written aftercare leaflets available example of a consent form and there are a variety of written of birth and proof of age if needed. AFTERCARE FOLLOW-UP RECORD SHEET aftercare leaflets available • Relevant medical history/ allergies. (ATTACH TO CONSENT FORM)

See Appendix 10 – Aftercare • Consent signature of client/ parent. NAME OF CLIENT: follow-up record sheet • Date and type of procedure conducted, ______

References site of procedure, type of jewellery (if Date & Description of any concern or problem Signature of time Action taken/advice given practitioner applicable).

• The name of the practitioner.

All records should be used safely and stored securely, maintaining client confidentiality (e.g. locked paper records, safe use of computers

to ensure clients details are not accessible by

the general public or others with no legitimate reason to access them. Records should be kept safely on the premises named in the licence

for a period of no less than 3 years (Dartford Borough Council 2009).

Staff training records should also be kept on site, as well as health and safety records such

as risk assessments, an accident/incident book, and a log book with details of regular equipment checks. See Appendix 10 – Aftercare follow-up record sheet

References Dartford Borough Council (2009). Code of practice for hygienic piercing. (www.dartford.gov.uk)

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39 Tattooing and body piercing guidance

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Toolkit Management of infectious disease incidents relating Section 08 to tattooing and skin piercing Click on text to view due consideration to the possibility of legal DEFINITION OF AN OUTBREAK DEFINITION OF AN OUTBREAK OR proceedings, and if required seek guidance OR INCIDENT INCIDENT regarding the chain of evidence for a potential An infectious disease related outbreak or OUTBREAK/INCIDENT INITIAL prosecution. RESPONSE incident can be defined as: In the case of a tattooing/body piercing setting, References • An incident in which two or more people experiencing a similar illness are linked in most incidents would be expected to relate to time/place. suspected blood borne virus transmission to another person (be that from a practitioner to • A greater than expected rate of infection a client or from a client to the practitioner). compared with the usual background rate The infection control practices in place within for the place and time where the outbreak the establishment would be reviewed as a key has occurred. part of any incident investigation.

OUTBREAK/INCIDENT INITIAL 1As of April 2013, the Health Protection Agency RESPONSE became Public Health England (PHE), although functions relating to these procedures remain In England, incidents/outbreaks are recognised largely unchanged. using surveillance methodology by the Public Health England (formerly the Health Protection References Agency)1, local authorities or microbiologists in Health Protection Agency (2011). London Infectious laboratories at a local or national level. At the Disease Outbreak Management Plan. local level is the Health Protection Team. As Health Protection Agency (2012). The soon as it becomes apparent that an incident/ Communicable Disease Outbreak Plan V1.3. outbreak may exist, immediate contact (Internal document). between these parties is essential.

A risk assessment is undertaken following receipt of initial information and a decision made as to whether an outbreak or incident exists. In order to inform all subsequent decisions and actions, key facts would be established by the duty (or on-call) Health Protection Team.

An outbreak/incident is usually declared by the Consultant in Communicable Disease Control (CCDC) or Consultant in Health Protection (CHP) after consultation with a consultant microbiologist and/or senior environmental health officer. The involvement and assistance of the tattoo/body piercing premises concerned would be a high priority.

Once an outbreak/incident is declared, a multi-agency outbreak/incident control team would be set up to fully investigate the incident, ensure control measures are in place and a report generated with lessons learned. ➲ Main contents All legal powers relating to the investigation of outbreaks lie with the local authority. An 40 outbreak/incident control team would give Tattooing and body piercing guidance

PART B – Appendix 01

Toolkit Model Byelaws: Acupuncture, tattooing, semi-permanent skin-colouring, cosmetic piercing and electrolysis

Click on text to view Click to download Appendix 01 – Model Byelaws: Acupuncture, tattooing, semi- permanent skin-colouring, cosmetic piercing and electrolysis Appendix 02 – Infection, its MODEL BYELAWS causes and spread, including a glossary of infection-related Acupuncture, tattooing, semi-permanent skin-colouring, terms cosmetic piercing and electrolysis Appendix 03 – Blood borne viruses Byelaws for the purposes of securing the cleanliness of premises registered under sections 14(2) or Appendix 04 – Safe use and 15(2) or both of the Local Government (Miscellaneous Provisions) Act 1982 and fittings in such premises and of persons registered under sections 14(1) or 15(1) or both of the Act and persons disposal of sharps assisting them and of securing the cleansing and, so far as appropriate, sterilization of instruments, materials and equipment used in connection with the practice of acupuncture or the business of Appendix 05 – First Aid tattooing, semi-permanent skin-colouring, cosmetic piercing or electrolysis, or any two or more of following a blood/body fluid such practice and businesses made by ………………… in pursuance of sections 14(7) or 15(7) or both of the Act. exposure Interpretation Appendix 06 – Protocol for 1.—(1) In these byelaws, unless the context otherwise requires— cleaning up a blood or a blood “The Act” means the Local Government (Miscellaneous Provisions) Act 1982; stained body fluid spill “client” means any person undergoing treatment; “hygienic piercing instrument” means an instrument such that any part of the instrument that Appendix 07 – Principles for touches a client is made for use in respect of a single client, is sterile, disposable and is fitted good waste handling with piercing jewellery supplied in packaging that indicates the part of the body for which it is intended, and that is designed to pierce either─ Appendix 08 – Template (a) the lobe or upper flat cartilage of the ear, or protocol for environmental (b) either side of the nose in the mid-crease area above the nostril; “operator” means any person giving treatment, including a proprietor; cleaning of premises “premises” means any premises registered under sections 14(2) or 15(2) of the Act; Appendix 09 – Tattooing/body “proprietor” means any person registered under sections 14(1) or 15(1) of the Act; “treatment” means any operation in effecting acupuncture, tattooing, semi-permanent skin- piercing consent form colouring, cosmetic piercing or electrolysis; Appendix 10 – Aftercare follow- “the treatment area” means any part of premises where treatment is given to clients. (2) The Interpretation Act 1978 shall apply for the interpretation of these byelaws as it applies up record sheet for the interpretation of an Act of Parliament. Appendix 11 – 2.—(1) For the purpose of securing the cleanliness of premises and fittings in such premises a proprietor shall ensure that— Decontamination requirements (a) any internal wall, door, window, partition, floor, floor covering or ceiling is kept clean for equipment used in tattooing and in such good repair as to enable it to be cleaned effectively; and skin piercing (b) any waste material, or other litter arising from treatment is handled and disposed of in accordance with relevant legislation and guidance as advised by the local authority; Appendix 12 – Equipment (c) any needle used in treatment is single-use and disposable, as far as is practicable, or otherwise is sterilized for each treatment, is suitably stored after treatment and is sterilization standard- self disposed of in accordance with relevant legislation and guidance as advised by the local assessment and decision authority; (d) any furniture or fitting in premises is kept clean and in such good repair as to enable it making tool for tattoo and body to be cleaned effectively; piercing practitioners Appendix 13 – Equipment and body piercing jewellery 1 sterilization standard for tattooists and body piercers Appendix 14 – Autoclave daily record sheet

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41 This PDF comprises of 6 pages Tattooing and body piercing guidance

PART B – Appendix 02 (continued)

Toolkit Infection, its causes and spread (including a glossary of infection-related terms)

Click on text to view THE CAUSES OF INFECTION Bacteria can replicate independently and some bacteria can form spores that survive Appendix 01 – Model Byelaws: Numerous microorganisms harmlessly colonise in the environment for long periods of time, Acupuncture, tattooing, semi- the skin and the mucosal surfaces to form the permanent skin-colouring, e.g. Mycobacterium tuberculosis, Group normal flora of the human body. The presence cosmetic piercing and A Streptococcus, Salmonella Enteritidis. of microorganisms does not constitute an electrolysis Antibiotics are used to treat bacterial infection. Colonising microorganisms cause Appendix 02 – Infection, its infections; bacteria can develop resistance no damage and often provide benefit to the causes and spread, including to antibiotics, e.g. MRSA (meticillin resistant person. It is when there is associated tissue a glossary of infection-related Staphylococcus aureus). terms damage that an infectious disease exists. Appendix 03 – Blood borne Potential pathogens can also act as colonisers Viruses are smaller than bacteria and cannot viruses such as Staphylococcus aureus replicate independently but grow inside the Appendix 04 – Safe use and host’s cells. Viruses cannot be treated with disposal of sharps GLOSSARY OF INFECTION- antibiotics; there are a few anti-viral drugs Appendix 05 – First Aid RELATED TERMS: available that are active against a limited following a blood/body fluid A pathogen is an organism capable of invading number of viruses such as influenza. Many exposure the body and causing disease. Such an organism common viral infections resolve without Appendix 06 – Protocol for is termed pathogenic (Bannister et al, 2006) treatment, e.g. measles, mumps, and rubella. cleaning up a blood or a blood stained body fluid spill An infectious disease is an illness caused Pathogenic Fungi can be either moulds or Appendix 07 – Principles for by a pathogen, which invades body tissues yeasts. Infections caused by moulds or yeasts good waste handling and causes damage. Not all infectious include ringworm caused by Trichophtyon Appendix 08 – Template diseases spread from person to person, e.g. rubrum and thrush, which is a common yeast protocol for environmental Legionnaires’ disease. infection caused by Candida albicans. cleaning of premises Appendix 09 – Tattooing/body A communicable disease is an infectious TRANSMISSION (SPREAD) OF piercing consent form disease that is capable of spreading from INFECTION Appendix 10 – Aftercare follow- person to person, e.g. measles, tuberculosis. How an infection is spread (transmitted) varies up record sheet according to the type of microorganism. Some Self infection (endogenous infection) Appendix 11 – microorganisms may be transmitted by more An infection that arises from the person’s own Decontamination requirements than one route: for equipment used in tattooing body flora e.g. bacteria that colonise the skin and skin piercing get into a break in the skin (wound) and cause • Direct or indirect contact, e.g. Herpes Appendix 12 – Equipment an infection such as an abscess caused by simplex virus, respiratory syncytial virus, sterilization standard- self Staphylococcus aureus. Staphylococcus aureus. assessment and decision • Respiratory droplets, e.g. influenza virus, making tool for tattoo and body Cross infection (exogenous infection) mumps, Bordetella pertussis (whooping piercing practitioners This is an infection that arises from an external cough). Appendix 13 – Equipment source e.g. from another person or via the and body piercing jewellery environment. • Airborne, e.g. pulmonary tuberculosis, sterilization standard for measles, chickenpox. tattooists and body piercers GROUPS OF ORGANISMS CAPABLE • Other infectious agents, such as blood- Appendix 14 – Autoclave daily OF CAUSING INFECTION. borne viruses, e.g. hepatitis B and C and record sheet Pathogens relevant to body art can be D viruses (HBV, HCV, HDV) and HIV are classified into: transmitted rarely in healthcare settings, via percutaneous (sharps/ needles) or mucous Bacteria are single celled organisms of membrane exposure (blood/ body fluid approximately one-thousandth to five- splashes to eyes/ mouth/ open wounds). ➲ Main contents thousandth of a millimetre in diameter.

42 Tattooing and body piercing guidance

PART B – Appendix 02

Toolkit Infection, its causes and spread (including a glossary of infection-related terms)

Click on text to view IN TATTOOING AND SKIN Indirect contact Appendix 01 – Model Byelaws: PIERCING PROCEDURES, Indirect spread of infection is said to occur when Acupuncture, tattooing, semi- INFECTION TRANSMISSION CAN an intermediate carrier is involved in the spread permanent skin-colouring, OCCUR BY DIRECT CONTACT AND of pathogens such as hands, fomites or vectors. cosmetic piercing and INDIRECT CONTACT. electrolysis • Hands – The hands of the practitioners Appendix 02 – Infection, its Direct contact (person to person) are probably the most important vehicles causes and spread, including Direct transmission occurs when of cross-infection within the tattooing a glossary of infection-related microorganisms are transferred from one and skin piercing environment. The hands terms infected person to another person without a of staff and clients can carry microbes Appendix 03 – Blood borne contaminated intermediate object or person. to other body sites, equipment and staff. viruses Examples of direct contact include: Therefore, promotion of hygienic practices Appendix 04 – Safe use and for everyone is the key to preventing and disposal of sharps • Blood or other body fluids (including blood controlling infections. stained) that enter the body through Appendix 05 – First Aid • A fomite is defined as an object that following a blood/body fluid contact with a mucous membrane or breaks becomes contaminated with infected exposure (i.e. piercings, cuts, abrasions) in the skin. organisms and which subsequently Appendix 06 – Protocol for transmits those organisms to another cleaning up a blood or a blood stained body fluid spill person. Examples of potential fomites are instruments or practically any inanimate Appendix 07 – Principles for good waste handling article e.g. contaminated needles/ tattooing equipment (blood-borne viruses). Appendix 08 – Template protocol for environmental References cleaning of premises Bannister B, Gillespie S and Jones J (2006). Infection Appendix 09 – Tattooing/body Microbiology and Management. 3rd edition. piercing consent form Blackwell Publishing. Appendix 10 – Aftercare follow- up record sheet Appendix 11 – Decontamination requirements for equipment used in tattooing and skin piercing Appendix 12 – Equipment sterilization standard- self assessment and decision making tool for tattoo and body piercing practitioners Appendix 13 – Equipment and body piercing jewellery sterilization standard for tattooists and body piercers Appendix 14 – Autoclave daily record sheet

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43 Tattooing and body piercing guidance

PART B – Appendix 03

Toolkit Blood borne viruses

Click on text to view Blood borne viruses (BBVs) are viral infections The infection is not passed on through everyday which are spread through infected blood activities such as coughing, sneezing, shaking Appendix 01 – Model Byelaws: Acupuncture, tattooing, semi- and body fluids, such as semen. The BBVs of hands or sharing food, crockery, baths or toilets. permanent skin-colouring, greatest concern in the tattoo and piercing cosmetic piercing and industry are hepatitis B virus (HBV), hepatitis C BBVs can cause serious, chronic diseases (e.g. electrolysis virus (HCV), hepatitis D virus (HDV) and human liver cirrhosis, cancer) or even death to the Appendix 02 – Infection, its immunodeficiency virus (HIV). Hepatitis B and individual affected. If an individual has an causes and spread, including C viruses infect and damage the liver. Hepatitis ongoing (chronic) infection, they will pose a a glossary of infection-related D (HDV) requires the presence of the hepatitis continuing risk of infection to others. terms B virus to survive in the body. This means that Sometimes an individual may be infected with Appendix 03 – Blood borne it is only possible to have hepatitis D if one also viruses a blood borne virus, but not be aware that they has hepatitis B. HIV stops a person’s body from have the infection and that they are therefore Appendix 04 – Safe use and fighting infections properly. disposal of sharps an infectious risk to others. Appendix 05 – First Aid BBVs can be passed on or ‘transmitted’ if an Infections from BBVs can be prevented or following a blood/body fluid infected person’s blood is able to enter another avoided in the tattoo and body piercing setting, exposure person’s bloodstream. This can happen in a if robust infection control practices (including Appendix 06 – Protocol for number of different ways: immunisation against hepatitis B) are used by cleaning up a blood or a blood stained body fluid spill • Sexual contact, both heterosexual and all practitioners at all times when dealing with anyone else’s blood and body fluids. Appendix 07 – Principles for homosexual. good waste handling • Infected blood passing from one person to Reference: Appendix 08 – Template another e.g. through cuts or damaged skin. British Liver Trust (http://www.britishlivertrust.org.uk) protocol for environmental • Sharing razors or toothbrushes. cleaning of premises • Sharing needles and syringes. Appendix 09 – Tattooing/body piercing consent form • Through ear piercing and other types of body piercing, tattooing and acupuncture if Appendix 10 – Aftercare follow- up record sheet equipment is not properly sterilized. Appendix 11 – • From mother to baby during or after Decontamination requirements pregnancy. for equipment used in tattooing • All blood donations are now screened for and skin piercing hepatitis B virus, but before this started it Appendix 12 – Equipment was possible to become infected through sterilization standard- self blood transfusions. assessment and decision making tool for tattoo and body piercing practitioners Appendix 13 – Equipment and body piercing jewellery sterilization standard for tattooists and body piercers Appendix 14 – Autoclave daily record sheet

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44 Tattooing and body piercing guidance

Click to download PART B – Appendix 04 PDF version

Toolkit Safe use and disposal of sharps

Click on text to view Before use: After use: Appendix 01 – Model Byelaws: • Ensure that sharps disposal box is correctly • Disposal of sharps is the responsibility of Acupuncture, tattooing, semi- assembled. the user. permanent skin-colouring, • Ensure that the label on the box is filled in • Dispose of sharps immediately after use. cosmetic piercing and electrolysis upon assembly. • Do not bend or break needles before disposal Appendix 02 – Infection, its • Ensure appropriate colour sharps box lid (e.g. a tattoo needle from a needle bar). causes and spread, including for use based on medicinal contamination • Do not leave full sharps boxes for disposal a glossary of infection-related and how the waste should be treated and by other staff. terms disposed of i.e. orange lid for sharps derived • Fill sharps boxes only to the ‘fill’ line and Appendix 03 – Blood borne from tattooing/body piercing procedures. viruses never overfill. • Sharps boxes are type approved for solids • Shut and lock box when full for disposal. Appendix 04 – Safe use and and should not be used for quantities of disposal of sharps liquid waste. • Never use tape to seal sharps boxes. Appendix 05 – First Aid • Sharps boxes must comply with UN 3291 • Label box with source such as name of following a blood/body fluid person/ premises and describe waste exposure and BS7320 standards. content. Appendix 06 – Protocol for • Boxes must be available in different sizes. • Dispose of sharps boxes as clinical waste cleaning up a blood or a blood Tamper-proof sharps containers are also stained body fluid spill available. for incineration only. Appendix 07 – Principles for • Boxes must be available at all locations • Never place sharps boxes in clinical/ good waste handling where sharps are used. offensive waste bags. Appendix 08 – Template • Boxes must never be placed on the floor. • Sharps containers must never be left protocol for environmental unsupervised. They must be locked in a • Boxes must be placed on a level surface or cleaning of premises cupboard/ operating/procedure room when wall-mounted below shoulder height and Appendix 09 – Tattooing/body not in use. piercing consent form be near to the area they are being used. • Never try and retrieve items from a sharps • Boxes must never be left in areas where Appendix 10 – Aftercare follow- container. up record sheet clients may have open access to them. • Place damaged sharps containers inside Appendix 11 – • Assess, in terms of risk, the most a larger container – lock and label prior to Decontamination requirements appropriate size of sharps container for for equipment used in tattooing disposal. Do not place inside a waste bag. the tattoo/body piercing setting. and skin piercing Reference Appendix 12 – Equipment During use: National Institute for Clinical Excellence (NICE) sterilization standard- self (2012). Infection control: Prevention and control • Practitioners must be competent in assessment and decision of healthcare-associated infections in primary and making tool for tattoo and body procedures using sharps. community care (CG139). piercing practitioners • The person using the sharp is responsible (http://guidance.nice.org.uk/CG139) Appendix 13 – Equipment for disposing of it. and body piercing jewellery • Never pass sharps from hand to hand. sterilization standard for tattooists and body piercers • Wear appropriate personal protective Appendix 14 – Autoclave daily equipment (gloves at a minimum). record sheet • Assemble devices with care. • Do not disassemble devices (e.g. needle bar and needle)—dispose of as a complete unit. • Do not re-sheath/recap used needles/razors. ➲ Main contents • Close sharps box opening (temporary closure device) between uses. 45 • Never move an open sharps box. • Use the handle to carry. Tattooing and body piercing guidance

Click to download PART B – Appendix 05 PDF version

Toolkit First Aid following a blood/body fluid exposure

Click on text to view Encourage bleeding where skin is punctured Appendix 01 – Model Byelaws: or broken. Acupuncture, tattooing, semi- 1 permanent skin-colouring, Do not suck the wound. cosmetic piercing and electrolysis  Appendix 02 – Infection, its Wash thoroughly with mild liquid soap causes and spread, including under running warm water. a glossary of infection-related 2 terms Do not use a scrubbing brush. Appendix 03 – Blood borne viruses  Appendix 04 – Safe use and If eyes are involved, wash immediately with disposal of sharps water for 5-10 minutes (use tap water, or Appendix 05 – First Aid 3 sterile water if available). following a blood/body fluid exposure If the mouth is contaminated, rinse with Appendix 06 – Protocol for plenty of water. cleaning up a blood or a blood  stained body fluid spill Any cuts/punctures should be covered with a Appendix 07 – Principles for 4 waterproof plaster. good waste handling Appendix 08 – Template  protocol for environmental Where there is considerable contamination cleaning of premises of unbroken skin, remove contaminated Appendix 09 – Tattooing/body 5 clothing and wash all affected areas with piercing consent form copious amounts of water. Appendix 10 – Aftercare follow-  up record sheet The priority Appendix 11 – Remember to seek medical advice at the is to seek Decontamination requirements local Emergency Department as prophylactic for equipment used in tattooing advice/ medical treatment (if required) ideally needs to be and skin piercing attention given ideally within one hour and no later Appendix 12 – Equipment immediately, than 72 hours. If relevant and if possible, it sterilization standard- self  at a local 6 is helpful if the details of the client whose assessment and decision Emergency making tool for tattoo and body needle was involved in the incident were Department, piercing practitioners brought to the Emergency Department in ideally within Appendix 13 – Equipment a sealed envelope to help enable the risk one hour of the and body piercing jewellery assessment process sterilization standard for injury occurring tattooists and body piercers  Appendix 14 – Autoclave daily Reference: record sheet Ensure that your manager or immediate Health and Safety senior is informed immediately of the Executive (2012) How to deal with an exposure incident. incident. Blood Borne 7 Viruses Guidance. The person who has received the injury (http://www.hse.gov. should complete an incident form as per uk/biosafety/blood- ➲ Main contents local guidelines. borne-viruses/how-deal- exposure-incident.htm) 46 Tattooing and body piercing guidance

Click to download PART B – Appendix 06 PDF version

Toolkit Protocol for cleaning up blood or a blood stained body fluid spill

Click on text to view CLEANING UP BLOOD OR A BLOOD BLOOD SPILLS ON CLOTHING STAINED BODY FLUID SPILL Appendix 01 – Model Byelaws: Change clothes (immediately if possible) and Acupuncture, tattooing, semi- • Prevent access to the area containing the place into a plastic bag. Wash clothes as soon permanent skin-colouring, spillage until it has been safely dealt with. as possible in a hot cycle. cosmetic piercing and electrolysis • Obtain chlorine based spill kit. CLEANING UP VOMIT OR URINE Appendix 02 – Infection, its • Put on apron and gloves SPILLS causes and spread, including • Apply disinfectant granules to the spill, this a glossary of infection-related Chlorine-based disinfectants will give off highly terms congeals the spill to enable easier cleaning of the area OR make up and use the disinfectant toxic gas if mixed with acidic substances. Appendix 03 – Blood borne Ideally chlorine-based products should not be viruses solution as per product instructions to a dilution of 10,000ppm available chlorine. used on vomit and urine due to the slight risk Appendix 04 – Safe use and of chlorine gas being released. To clean up disposal of sharps Leave in place for the designated exposure time (at least two minutes). Ensure the vomit or urine spills, follow the same process as Appendix 05 – First Aid surface can tolerate chlorine. above but replace chlorine-based disinfectant following a blood/body fluid granules with a non-chlorine based product, exposure DO NOT USE MOPS TO CLEAN UP BLOOD. or use paper towels to absorb as much of the Appendix 06 – Protocol for • Use the scoop and scraper (or disposable spillage as possible. Always clean areas with cleaning up a blood or a blood paper towels) to pick up the congealed detergent and warm water. A chlorine-based stained body fluid spill body fluid and place in the appropriate disinfectant can be used to disinfect the Appendix 07 – Principles for waste bag. area but only after the urine/vomit has been good waste handling • Using the disposable paper towels and cleaned up. Appendix 08 – Template protocol for environmental disinfectant solution clean area thoroughly cleaning of premises and dry afterwards. Detergent and warm IMPORTANT NOTE Appendix 09 – Tattooing/body water can also be used afterwards. Chlorine-based disinfectants/ piercing consent form • Ensure all equipment used is disposed of in absorbent granules such as sodium Appendix 10 – Aftercare follow- the appropriate waste bag and then finally dichloisocyanurate (NaDCC) should up record sheet remove gloves and apron and place in the not be used on urine or vomit spills. Appendix 11 – waste bag. NEVER mix chlorine-based disinfectants Decontamination requirements • Wash hands. with any other cleaning/disinfectants. for equipment used in tattooing Hypochlorite solutions may bleach • Ensure that the waste bag is placed in and skin piercing fabrics and other materials, as well the appropriate disposal bin/container Appendix 12 – Equipment as corrode metals, so care is needed immediately after use. sterilization standard- self regarding which surfaces they can be assessment and decision • Damp-mop the affected area. used upon. making tool for tattoo and body piercing practitioners MANAGING BLOOD SPOTS Appendix 13 – Equipment Apply chlorine based disinfectant solution to and body piercing jewellery Reference sterilization standard for a wet paper towel and clean spillage area. National Patient Safety Agency (2009). The Revised Healthcare Cleaning Manual. (http://www.nrls.npsa. tattooists and body piercers Discard waste as above. nhs.uk/resources/?EntryId45=61830) Appendix 14 – Autoclave daily record sheet IF BLOOD/BODY FLUID SPLASHES INTO THE EYES OR MOUTH Rinse freely with water. Seek immediate medical advice if the splash gets into the mucous membrane. ➲ Main contents

47 Tattooing and body piercing guidance

Click to download PART B – Appendix 07 PDF version

Toolkit Principles for good waste handling

Click on text to view GOOD WASTE HANDLING PRINCIPLES:

Appendix 01 – Model Byelaws: • Waste should be segregated at the point of origin. Acupuncture, tattooing, semi- permanent skin-colouring, • Bags/bins should only be filled to ¾ full. cosmetic piercing and electrolysis • Waste bags should be used in foot operated pedal bins. Appendix 02 – Infection, its • Waste bags should be sealed securely and marked with causes and spread, including ‘point of origin’ label prior to disposal. a glossary of infection-related terms • Waste should be collected on a regular basis by a licensed Appendix 03 – Blood borne waste management contractor. viruses • Personal protective clothing should be worn when Appendix 04 – Safe use and handling waste. disposal of sharps Appendix 05 – First Aid • Waste should be correctly bagged in appropriate colour- following a blood/body fluid coded bags which must be UN-approved and comply with exposure BS EN ISO 7765:2004 and BS EN ISO 6383:2004. Appendix 06 – Protocol for • Waste should be double bagged where the exterior of the cleaning up a blood or a blood bag is contaminated or the original bag is split, damaged stained body fluid spill or leaking. Appendix 07 – Principles for good waste handling • Waste should be kept in a rigid-sided, fire retardant holder Appendix 08 – Template or container with a foot operated lid, and, so far as is protocol for environmental reasonably practicable, out of the reach of children and cleaning of premises unauthorised personnel. Appendix 09 – Tattooing/body • Waste should be stored in a labelled, lockable/secure, piercing consent form vermin-proof storage space for collection, on a well- Appendix 10 – Aftercare follow- drained, impervious hard standing floor, which is provided up record sheet with wash-down facilities. Appendix 11 – Decontamination requirements • Bags should be securely sealed and labelled with coded for equipment used in tattooing tags at the point of use to identify their source. and skin piercing • Waste should not be decanted into other bags, regardless Appendix 12 – Equipment sterilization standard- self of volume; be contaminated on the outside or re-used. assessment and decision • ‘Sharps’ must be disposed of into approved sharps making tool for tattoo and body containers that meet BS 7320/UN 3291. piercing practitioners Appendix 13 – Equipment • ‘Sharps’ containers should NEVER be placed into any and body piercing jewellery waste bag. sterilization standard for tattooists and body piercers Appendix 14 – Autoclave daily record sheet

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48 Tattooing and body piercing guidance

Click to download PART B – Appendix 08 PDF version

Toolkit Template protocol for environmental cleaning of premises

Click on text to view ITEM FREQUENCY METHOD Appendix 01 – Model Byelaws: Acupuncture, tattooing, semi- High risk treatment After use Treatment area surfaces cleaned and dried permanent skin-colouring, surfaces between clients using detergent and then cosmetic piercing and disinfected using a bleach solution (1000 ppm) electrolysis Appendix 02 – Infection, its Use disposable cloths/paper towels causes and spread, including a glossary of infection-related Non high risk At least daily Use general-purpose detergent terms surfaces Dry thoroughly Appendix 03 – Blood borne viruses Use disposable cloths/paper towels Appendix 04 – Safe use and disposal of sharps Hand wash basins Daily Standard detergent and sinks Appendix 05 – First Aid following a blood/body fluid Floors Daily Mop with water and detergent exposure Appendix 06 – Protocol for Disinfectant is required only after cleaning up a blood or a blood contamination with blood spillages stained body fluid spill Appendix 07 – Principles for Bins As required Empty bins daily. good waste handling If contaminated, clean with water and Appendix 08 – Template detergent and then disinfect protocol for environmental cleaning of premises Couches Between clients Wipe with hot, soapy water and dry thoroughly Appendix 09 – Tattooing/body piercing consent form Clean with disinfectant against blood borne Appendix 10 – Aftercare follow- viruses if contaminated with blood up record sheet Walls/ceilings As required Routine cleaning not required Appendix 11 – Decontamination requirements Clean periodically with water and general for equipment used in tattooing purpose detergent and skin piercing Appendix 12 – Equipment Clean with disinfectant against blood borne sterilization standard- self viruses if contaminated with blood assessment and decision making tool for tattoo and body piercing practitioners Adapted from National Patient Safety Agency (2009). The Revised Healthcare Cleaning Manual. (http://www.nrls.npsa.nhs.uk/resources/?EntryId45=61830) Appendix 13 – Equipment and body piercing jewellery sterilization standard for tattooists and body piercers Appendix 14 – Autoclave daily record sheet

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49 Tattooing and body piercing guidance

PART B – Appendix 09

Toolkit Tattooing/body piercing consent form

Click on text to view Click to download Click to download Word document version PDF version Appendix 01 – Model Byelaws: Acupuncture, tattooing, semi- permanent skin-colouring, cosmetic piercing and Tattooing/Body Piercing Consent Form electrolysis Name of Premises: Appendix 02 – Infection, its Address & Tel No of Premises: causes and spread, including a glossary of infection-related terms Name of Practitioner (print): Appendix 03 – Blood borne Name of Client (print): viruses Address & Tel No of client: Appendix 04 – Safe use and disposal of sharps Age of Client and DOB: Appendix 05 – First Aid Age ID of Client Seen: Yes / No following a blood/body fluid Type of Procedure: Tattoo / Body Piercing exposure Description: Appendix 06 – Protocol for cleaning up a blood or a blood Site of Procedure and design if applicable): stained body fluid spill Type of Jewellery Used (as applicable): Appendix 07 – Principles for good waste handling Appendix 08 – Template protocol for environmental cleaning of premises Appendix 09 – Tattooing/body piercing consent form Appendix 10 – Aftercare follow- up record sheet Appendix 11 – Decontamination requirements for equipment used in tattooing and skin piercing Appendix 12 – Equipment sterilization standard- self assessment and decision making tool for tattoo and body piercing practitioners Appendix 13 – Equipment and body piercing jewellery sterilization standard for tattooists and body piercers Appendix 14 – Autoclave daily record sheet

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50 This document comprises of 3 pages Tattooing and body piercing guidance

PART B – Appendix 10

Toolkit Aftercare follow-up record sheet

Click on text to view Click to download Click to download Word document version PDF version Appendix 01 – Model Byelaws: Acupuncture, tattooing, semi- permanent skin-colouring, cosmetic piercing and electrolysis AFTERCARE FOLLOW-UP RECORD SHEET (ATTACH TO CONSENT FORM) Appendix 02 – Infection, its causes and spread, including NAME OF CLIENT: a glossary of infection-related terms ______Appendix 03 – Blood borne viruses Date & Description of any concern or problem Signature of Appendix 04 – Safe use and time Action taken/advice given practitioner disposal of sharps

Appendix 05 – First Aid following a blood/body fluid exposure

Appendix 06 – Protocol for cleaning up a blood or a blood stained body fluid spill

Appendix 07 – Principles for good waste handling Appendix 08 – Template protocol for environmental cleaning of premises

Appendix 09 – Tattooing/body piercing consent form

Appendix 10 – Aftercare follow- up record sheet

Appendix 11 – Decontamination requirements for equipment used in tattooing and skin piercing Appendix 12 – Equipment sterilization standard- self assessment and decision making tool for tattoo and body piercing practitioners Appendix 13 – Equipment and body piercing jewellery sterilization standard for tattooists and body piercers Appendix 14 – Autoclave daily record sheet

➲ Main contents

51 This document comprises of 1 page Tattooing and body piercing guidance

Click to download PART B – Appendix 11 PDF version

Toolkit Decontamination requirements for equipment used in tattooing and skin piercing

Click on text to view Equipment for Application of item Recommendations Appendix 01 – Model Byelaws: Tattooing: Acupuncture, tattooing, semi- Holders for needles i.e. tube, Hold needles that pierce skin Dismantle then clean and permanent skin-colouring, tip and grip sterilize, or single-use cosmetic piercing and electrolysis Needles and needle bars Pierce skin Single-use pre-sterilized Appendix 02 – Infection, its Ink caps Hold inks that will become Single-use causes and spread, including contaminated with blood a glossary of infection-related Ink cap trays Hold ink caps and will become Either single-use or clean and terms contaminated with blood sterilize Appendix 03 – Blood borne during use viruses Motors & clipcords Will become contaminated Reduce contamination by Appendix 04 – Safe use and with blood via the covering with impervious disposal of sharps practitioner’s hands barrier (e.g. plastic sleeving) Appendix 05 – First Aid following a blood/body fluid Remove impervious barrier exposure carefully after use minimising Appendix 06 – Protocol for transfer of contamination to cleaning up a blood or a blood the item stained body fluid spill Thoroughly remove any visible Appendix 07 – Principles for contamination with detergent, good waste handling then dry Appendix 08 – Template protocol for environmental Disinfect surface with 70% cleaning of premises alcohol Appendix 09 – Tattooing/body Elastic bands Will become contaminated Single-use piercing consent form with blood via the Appendix 10 – Aftercare follow- practitioner’s hands up record sheet Body piercing: Appendix 11 – Needles, cannulas Pierce skin Single use pre-sterilized Decontamination requirements for equipment used in tattooing Clamps used for skin folds, In close contact with pierced Clean and sterilize or single-use and skin piercing looped forceps, pliers and skin Appendix 12 – Equipment receiving tubes sterilization standard- self Jewellery Inserted into sterile body Sterilize or pre-sterilized assessment and decision tissues making tool for tattoo and body Spatulas, cotton/gauze pads Will become contaminated Single-use piercing practitioners and paper towels with blood Appendix 13 – Equipment and body piercing jewellery Vernier calipers Should only be used on clean, Clean between uses sterilization standard for unbroken skin Single use or autoclavable tattooists and body piercers alternative should be used for Appendix 14 – Autoclave daily oral and genital piercings record sheet Ear piercing guns These should only be of the Clean according to type that use single-use self- manufacturer’s instructions contained cartridge containing the stud and back, such that the gun itself makes no client ➲ Main contents contact Cartridges used with ear Single-use 52 piercing guns Tattooing and body piercing guidance

Click to download PART B – Appendix 12 PDF version Toolkit Equipment sterilization standard – self assessment and decision making tool for tattoo and body piercing practitioners

Click on text to view Appendix 01 – Model Byelaws: Dispose of safely Acupuncture, tattooing, semi- Is the equipment and appropriately Yes permanent skin-colouring, for single use? i.e. in offensive cosmetic piercing and waste bag or electrolysis sharps bin Appendix 02 – Infection, its causes and spread, including a glossary of infection-related terms Appendix 03 – Blood borne No viruses Appendix 04 – Safe use and disposal of sharps Appendix 05 – First Aid following a blood/body fluid The instrument The instrument exposure is hollow and/or is solid and Appendix 06 – Protocol for wrapped (including unwrapped cleaning up a blood or a blood solid items) stained body fluid spill Appendix 07 – Principles for good waste handling Appendix 08 – Template protocol for environmental Sterilize using cleaning of premises non-vacuum Appendix 09 – Tattooing/body autoclave with Sterilize using piercing consent form temperature and vacuum autoclave pressure indicator Appendix 10 – Aftercare follow- (type B or S) with up record sheet gauges (type N) or drying cycle Appendix 11 – vacuum autoclave Decontamination requirements (type B or S) with for equipment used in tattooing drying cycle and skin piercing Appendix 12 – Equipment sterilization standard- self assessment and decision making tool for tattoo and body piercing practitioners Appendix 13 – Equipment and body piercing jewellery sterilization standard for tattooists and body piercers Appendix 14 – Autoclave daily record sheet

➲ Main contents

53 Tattooing and body piercing guidance

Click to download PART B – Appendix 13 PDF version

Toolkit Equipment and body piercing jewellery sterilization standard for tattooists and body piercers

Click on text to view Appendix 01 – Model Byelaws: Option 1 Option 2 Option 3 Acupuncture, tattooing, semi- permanent skin-colouring, cosmetic piercing and electrolysis Using only: Using: Using only: Appendix 02 – Infection, its causes and spread, including solid unwrapped hollow instruments Single-use a glossary of infection-related instruments terms and/or hollow body piercing and Appendix 03 – Blood borne and jewellery pre-sterilized viruses solid unwrapped and/or using any instruments body piercing Appendix 04 – Safe use and disposal of sharps jewellery or body piercing jewellery which jewellery are wrapped Appendix 05 – First Aid following a blood/body fluid exposure Appendix 06 – Protocol for cleaning up a blood or a blood Your current Your current Your current stained body fluid spill autoclave is autoclave is autoclave is Appendix 07 – Principles for non-vacuum non-vacuum vacuum (type B good waste handling (type N) (type N) or S) with drying Appendix 08 – Template cycle protocol for environmental cleaning of premises Appendix 09 – Tattooing/body piercing consent form No change in If you are No change in No change in Appendix 10 – Aftercare follow- up record sheet your practice is unable to your practice is your practice is Appendix 11 – required switch to using required required Decontamination requirements a vacuum for equipment used in tattooing autoclave and skin piercing (type B or S) Appendix 12 – Equipment with drying sterilization standard- self assessment and decision cycle, then use making tool for tattoo and body single-use piercing practitioners instruments Appendix 13 – Equipment and and body piercing jewellery pre-sterilized sterilization standard for body piercing tattooists and body piercers jewellery Appendix 14 – Autoclave daily record sheet instead

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54 Tattooing and body piercing guidance

PART B – Appendix 14

Toolkit Autoclave daily record sheet

Click on text to view Click to download Click to download Word document version PDF version Appendix 01 – Model Byelaws: Acupuncture, tattooing, semi- permanent skin-colouring, cosmetic piercing and electrolysis AUTOCLAVE DAILY RECORD SHEET Appendix 02 – Infection, its Please keep these records in date order for inspection causes and spread, including Autoclave Type Serial Number a glossary of infection-related terms Week Commencing Location

Appendix 03 – Blood borne Type of Water used (ideally sterile water for irrigation) viruses

Appendix 04 – Safe use and Daily test Saturday Sunday Monday Tuesday Wednesday Thursday Friday disposal of sharps Cycle Counter Number Appendix 05 – First Aid Time to reach following a blood/body fluid holding temp exposure Temp during Appendix 06 – Protocol for holding period cleaning up a blood or a blood Pressure during holding period stained body fluid spill Total time at holding Appendix 07 – Principles for temp/pressure good waste handling Water drained at end of day where appropriate Appendix 08 – Template protocol for environmental Process check used cleaning of premises

Appendix 09 – Tattooing/body Printout attached piercing consent form Initials of authorised user Appendix 10 – Aftercare follow- up record sheet Weekly Safety Test Yes/No Comments Door seals secure Appendix 11 – Decontamination requirements Door safety devices for equipment used in tattooing functioning correctly Safety Valves operating correctly and skin piercing Yearly service by a competent Appendix 12 – Equipment engineer sterilization standard- self Comments assessment and decision making tool for tattoo and body Name Date Signature piercing practitioners

Appendix 13 – Equipment PLEASE KEEP THESE RECORDS IN A RING BINDER FOR SELF AUDIT/INSPECTION and body piercing jewellery sterilization standard for tattooists and body piercers Appendix 14 – Autoclave daily record sheet

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55 This document comprises of 1 page Tattooing and body piercing guidance

PART C – Leaflet 01

Toolkit Tattoo aftercare

Click on text to view Click to download PDF Leaflet 01 – Tattoo aftercare

Leaflet 02 – Ear and face piercing aftercare Tattoo aftercare Leaflet 03 – Oral piercing Key Advice Hand washing Signs of infection aftercare Hand washing is the single most If appropriate aftercare is not followed The aftercare following a tattoo important method of reducing infection. infection may occur. The signs of is important to promote good Hands must be washed prior to touching infection are: Leaflet 04 – Body and surface the affected area, therefore reducing the healing and prevent the risk of risk of infection. • Swelling and redness that increases piercing aftercare infection. around the wound. Wash your hands in warm water and liquid soap, always dry your hands • A severe burning and throbbing Leaflet 05 – Genital piercing For the first week or so it is thoroughly with a clean towel or paper sensation round the site. normal for the area to be red towel. This should remove most germs (female) aftercare • Increased tenderness and increasingly and tender. and prevent them being transferred to the affected area. painful to touch. Leaflet 06 – Genital piercing • An unusual discharge (yellow or green) As with all body art, infection is Tattoo aftercare with an offensive smell. a risk. To reduce these risks take (male) aftercare Good practice is to cover the tattooed Speak to your practitioner or seek medical advice from your practitioner area with non-stick gauze which is then attention immediately if you suffer from secured with hypo-allergenic tape. Gauze Leaflet 07 – Microdermal regarding aftercare. any of the above or have any concerns permits ventilation and aids healing. regarding infection in your tattoo or if implants aftercare The risk of infection can be A tattoo covering a large area may there are any signs of an allergic reaction greatly reduced by good need to be covered with a sterile, non- to any of the products used. Poster – How to handwash general hygiene including: adhesive dressing, at least during your journey home. However, simply keeping the area clean and dry is likely to be the • Hand washing before touching best approach. the tattoo A tattoo covering a large area may have plastic film wrap applied, this must be • Keeping the tattooed clean (taken straight from the pack and area covered with non-stick used immediately) and you should be advised when to replace this covering by gauze which is secured with your practitioner. hypo-allergenic tape. Any cream that you apply must be used from an appropriate pot/tube at home and you should wash your hands before application. Cream can be purchased from your practitioner or a pharmacist.

Antibiotic creams should not be used except if infection has occurred and under supervision of your Doctor.

For further advice or information: Contact your local Environmental Health Department, or your local Public Health England Health Protection Team This Information is provided by: Public Health England North West Public Health England East Midlands Tattoo and Piercing Industry Union

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June 2013

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56 This document comprises of 1 page Tattooing and body piercing guidance

PART C – Leaflet 02

Toolkit Ear and face piercing aftercare

Click on text to view Click to download PDF Leaflet 01 – Tattoo aftercare

Leaflet 02 – Ear and face piercing aftercare Ear and face piercing aftercare Leaflet 03 – Oral piercing Key Advice Hand washing Note: Cartilage piercings occasionally form Hand washing is the single most important lumps commonly known as granulomas. aftercare The aftercare of body piercing method of reducing infection. Hands must This is just trapped fluid and can easily be is important to promote good be washed prior to touching the affected resolved using the heat and pressure from a healing and prevent the risk of area, therefore reducing the risk of infection. warm water compress once a day, replacing Leaflet 04 – Body and surface one of your daily cleanings. infection. Wash your hands in warm water and liquid piercing aftercare soap, always dry your hands thoroughly Expect some swelling and soreness from Healing times for piercing will with a clean towel or paper towel. This your new piercing. Any knock or bang can vary with the type and position should remove most germs and prevent cause swelling or soreness to flare up again throughout the healing phase. Leaflet 05 – Genital piercing of the piercing and vary from them being transferred to the affected area. person to person. A new piercing can be tender, itchy and Do not use cotton wool to clean the (female) aftercare slightly red and can remain so for a piercing as the fibres in the cotton wool For the first few weeks it is few weeks. A pale, odourless fluid may may get caught in the piercing. Leaflet 06 – Genital piercing normal for the area to be red, sometimes discharge from the piercing and Do not pick at any discharge and do form a crust. This should not be confused tender and swollen. not move, twist or turn the piercing (male) aftercare with pus, which would indicate infection. whilst dry. If any secreted discharge has Approximate healing times for the hardened then turning jewellery may Ear piercing aftercare cause the discharge to tear the piercing, Leaflet 07 – Microdermal various piercings are: Including Lobes/ Tragus/ Anti Tragus/ allowing bacteria to enter the wound and Conch/ Helix/ Snug/ Diath/ Industrial/ Rook/ prolonging the healing time. implants aftercare Ear lobe piercing – 6 to 8 weeks Translobal/ Transverse Lobe. Ear cartilage piercing – 6 to 8 weeks Do not use sunbeds for the first two weeks, or if you decide to then cover the Cheek piercing – 2 to 3 months Facial piercing aftercare Poster – How to handwash Including Eyebrow, Bridge, Jestum, Vertical wound area with a breathable plaster Eyebrow piercing – 2 to 4 months Labret, Septum/ Nostril. during tanning. Nose piercing – up to 6 months Do not swim for the first 24 hours Soak the piercing for a few minutes by following a piercing. Remember these times are submerging the area of skin containing the piercing in a clean jug or bowl containing Signs of infection approximate and will depend on a warm water solution (1/4 level teaspoon If appropriate aftercare is not followed how healthy you are and whether of preferably sea salt to an egg cup/shot infection may occur. The signs of you look after the piercing glass of warm water). Alternatively wet a infection are: properly until healed. clean cloth or gauze in the solution and • Swelling and redness that increases apply as a warm compress. This will soften around the wound. As with all body art, infection is any discharge and allow you to clean the entry and exit points of the piercing with • A severe burning and throbbing a risk. To reduce these risks take a cotton bud or gauze. Once the discharge sensation round the site. advice from your practitioner is removed or softened then jewellery can • Increased tenderness and increasingly regarding aftercare. be gently moved so as to work a little warm painful to touch. water through the piercing. When cleaning • An unusual discharge (yellow or green) The risk of infection can be always tighten the ball on any bars by with an offensive smell. screwing the ball to the right. greatly reduced by good general Speak to your practitioner or seek medical hygiene including: Do this twice each day, preferably after attention immediately if you suffer from washing or bathing. any of the above or have any concerns • Hand washing before touching regarding infection in your piercing or if the piercing. You can also use mild antibacterial solutions there are any signs of an allergic reaction and soaps to wash the wound site of an ear to any of the products used. • Keeping the piercing clean. piercing. Ask your local pharmacist to advise you and always follow the manufacturers’ For further advice or information: instructions. If irritation, redness or drying Contact your local Environmental Health occurs discontinue use. Antibacterial wash is Department, or your local Public Health NOT suitable for nostrils, septum or vertical England Health Protection Team lips due to the tissue’s delicate nature. This Information is provided by: Dry the piercing using ONLY fresh disposable Public Health England North West paper towel/kitchen roll. A communal Public Health England East Midlands hand/bath towel should never be used. Tattoo and Piercing Industry Union

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June 2013

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57 This document comprises of 1 page Tattooing and body piercing guidance

PART C – Leaflet 03

Toolkit Oral piercing aftercare

Click on text to view Click to download PDF Leaflet 01 – Tattoo aftercare

Leaflet 02 – Ear and face piercing aftercare Oral piercing aftercare Leaflet 03 – Oral piercing Key Advice Hand washing Do not pick at any discharge and do aftercare Hand washing is the single most important not move, twist or turn the piercing The aftercare of body piercing method of reducing infection. Hands whilst dry. If any secreted discharge has is important to promote good must be washed prior to touching the hardened then turning jewellery may Leaflet 04 – Body and surface affected area, therefore reducing the risk cause the discharge to tear the piercing, healing and prevent the risk of of infection. allowing bacteria to enter the wound piercing aftercare infection. and prolonging the healing time. Wash your hands in warm water and Healing times for piercing will liquid soap, always dry your hands Do not use sunbeds for the first two Leaflet 05 – Genital piercing vary with the type and position thoroughly with a clean towel or paper weeks, or if you decide to then cover the wound area with a breathable plaster of the piercing and vary from towel. This should remove most germs (female) aftercare and prevent them being transferred to during tanning. person to person. the affected area. Do not swim for the first 24 hours following a piercing. Leaflet 06 – Genital piercing For the first few weeks it is A new piercing can be tender, itchy and normal for the area to be red, slightly red and can remain so for a Special aftercare for tongue piercing (male) aftercare tender and swollen. few weeks. A pale, odourless fluid may For the first few days take care when sometimes discharge from the piercing eating and avoid spicy foods. An approximate healing times and form a crust. This should not be Leaflet 07 – Microdermal confused with pus, which would indicate Cold products such as ice and ice cream for oral piercing are: infection. can help reduce swelling. implants aftercare Tongue piercing – 2 to 4 weeks. Oral piercing aftercare Refrain from oral sex of any description Lip – 3 to 6 weeks For the internal healing of oral piercing until the piercing has fully healed. Poster – How to handwash Cheek – 2 to 3 months including all piercing of the tongue , lip and cheek Signs of infection Remember these times are If appropriate aftercare is not followed Gargle after each meal with an alcohol-free infection may occur. The signs of approximate and will depend mouthwash or a warm salt water solution infection are: (1/4 level teaspoon of preferably sea salt to on how healthy you are and • Swelling and redness that increases an egg cup/shot glass of warm water). whether you look after the around the wound. piercing properly until healed. For the external healing of oral piercing: • A severe burning and throbbing including all piercings to the lip and cheek As with all body art, infection is sensation round the site. a risk. To reduce these risks take Wet a clean cloth or gauze in the warm • Increased tenderness and increasingly painful to touch. advice from your practitioner salt water solution and apply as a warm compress. This will soften any discharge • An unusual discharge (yellow or green) regarding aftercare. and allow you to clean the entry and exit with an offensive smell. points of the piercing with a cotton bud The risk of infection can be or gauze dipped into the warm salt water Speak to your practitioner or seek medical greatly reduced by good general solution. Once the discharge is removed attention immediately if you suffer from hygiene including: or softened then jewellery can be gently any of the above or have any concerns moved so as to work a little warm water regarding infection in your piercing or if • Hand washing before touching through the piercing. When cleaning there are any signs of an allergic reaction the piercing always tighten the ball on any bars by to any of the products used. screwing the ball to the right. • Keeping the piercing clean. Do this twice each day, preferably after For further advice or information: washing or bathing. Contact your local Environmental Health Department, or your local Public Health Dry the piercing using ONLY fresh England Health Protection Team disposable paper towel/kitchen roll. A communal hand/bath towel should This Information is provided by: never be used. Public Health England North West Public Health England East Midlands Do not use cotton wool to clean the Tattoo and Piercing Industry Union piercing as the fibres in the cotton wool may get caught in the piercing.

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June 2013

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58 This document comprises of 1 page Tattooing and body piercing guidance

PART C – Leaflet 04

Toolkit Body and surface piercing aftercare

Click on text to view Click to download PDF Leaflet 01 – Tattoo aftercare

Leaflet 02 – Ear and face piercing aftercare Body and surface piercing aftercare Leaflet 03 – Oral piercing Key Advice Hand washing Do not pick at any discharge and do aftercare Hand washing is the single most important not move, twist or turn the piercing The aftercare of body piercing method of reducing infection. Hands must whilst dry. If any secreted discharge has is important to promote good be washed prior to touching the affected hardened then turning jewellery may Leaflet 04 – Body and surface area, therefore reducing the risk of infection. cause the discharge to tear the piercing, healing and prevent the risk of allowing bacteria to enter the wound and piercing aftercare infection. Wash your hands in warm water and liquid prolonging the healing time. soap, always dry your hands thoroughly Do not wear tight clothing following Healing times for piercing will with a clean towel or paper towel. This nipple piercing Leaflet 05 – Genital piercing vary with the type and position should remove most germs and prevent of the piercing and vary from them being transferred to the affected area. Do not wear tight clothing e.g. tights, (female) aftercare belts or high waisted clothing after naval person to person. A new piercing can be tender, itchy and piercing as this may irritate the wound slightly red and can remain so for a and delay healing. Leaflet 06 – Genital piercing For the first few weeks it is few weeks. A pale, odourless fluid may Do not use sunbeds for the first two normal for the area to be red, sometimes discharge from the piercing and (male) aftercare form a crust. This should not be confused weeks, or if you decide to then cover the tender and swollen. with pus, which would indicate infection. wound area with a breathable plaster during tanning. Leaflet 07 – Microdermal Approximate healing times Body and surface piercing aftercare Do not swim for the first 24 hours for surface, navel and nipple including Nape, Horizontal Navel, Niple, following a piercing. implants aftercare piercing can be as long as Horizontal Eyebrow, Wrist, Anti-eyebrow, Signs of infection 6 months to 1 year. Madison, Chin, Vertical Bridge, Pubic, Poster – How to handwash Handweb and Prayer. If appropriate aftercare is not followed infection may occur. The signs of Remember these times are Soak the piercing for a few minutes by infection are: approximate and will depend submerging the area of skin containing the on how healthy you are and piercing in a clean jug or bowl containing • Swelling and redness that increases a warm water solution (1/4 level teaspoon around the wound. whether you look after the of preferably sea salt to an egg cup/shot • A severe burning and throbbing glass of warm water). Alternatively wet a piercing properly until healed. sensation round the site. clean cloth or gauze in the solution and As with all body art, infection apply as a warm compress. This will soften • Increased tenderness and increasingly is a risk. To reduce these any discharge and allow you to clean the painful to touch. entry and exit points of the piercing with • An unusual discharge (yellow or green) risks take advice from your a cotton bud or gauze. Once the discharge with an offensive smell. practitioner regarding is removed or softened then jewellery can aftercare. The risk of infection be gently moved so as to work a little warm Speak to your practitioner or seek medical can be greatly reduced by good water through the piercing. When cleaning attention immediately if you suffer from always tighten the ball on any bars by any of the above or have any concerns general hygiene including: screwing the ball to the right. regarding infection in your piercing or if there are any signs of an allergic reaction Do this twice each day, preferably after • Hand washing before to any of the products used. washing or bathing. touching the piercing You can also use mild antibacterial solutions • Keeping the piercing clean. and soaps to wash the wound site. Ask your local pharmacist to advise you and always follow the manufacturers’ instructions. For further advice or information: If irritation, redness or drying occurs Contact your local Environmental Health discontinue use. Department, or your local Public Health Dry the piercing using ONLY fresh disposable England Health Protection Team paper towel/kitchen roll. A communal This Information is provided by: hand/bath towel should never be used. Public Health England North West Public Health England East Midlands Do not use cotton wool to clean the Tattoo and Piercing Industry Union piercing as the fibres in the cotton wool may get caught in the piercing.

Your practitioner is:

June 2013

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59 This document comprises of 1 page Tattooing and body piercing guidance

PART C – Leaflet 05

Toolkit Genital piercing (female) aftercare

Click on text to view Click to download PDF Leaflet 01 – Tattoo aftercare

Leaflet 02 – Ear and face piercing aftercare Genital piercing (female) aftercare Leaflet 03 – Oral piercing Key Advice Hand washing Do not swim for the first 24 hours aftercare Hand washing is the single most following a piercing. The aftercare of body piercing important method of reducing infection. Do not pick at any discharge and do is important to promote good Hands must be washed prior to touching not move, twist or turn the piercing Leaflet 04 – Body and surface the affected area, therefore reducing the healing and prevent the risk of whilst dry. If any secreted discharge has risk of infection. piercing aftercare infection. hardened then turning jewellery may cause the discharge to tear the piercing, Healing times for piercing will Wash your hands in warm water and liquid soap, always dry your hands allowing bacteria to enter the wound and Leaflet 05 – Genital piercing vary with the type and position thoroughly with a clean towel or paper prolonging the healing time. of the piercing and vary from towel. This should remove most germs Refrain from any type of sexual activity (female) aftercare and prevent them being transferred to person to person. until the piercing has healed or is ‘dry’. the affected area. For the first few weeks it is Always use barrier protection such as Leaflet 06 – Genital piercing A new piercing can be tender, itchy and condoms, otherwise you are at increased normal for the area to be red, slightly red and can remain so for a risk of acquiring a sexually transmitted (male) aftercare tender and swollen. few weeks. A pale, odourless fluid may infection. sometimes discharge from the piercing The healing time for a and form a crust. This should not be Signs of infection Leaflet 07 – Microdermal genital piercing can be from confused with pus, which would indicate If appropriate aftercare is not followed infection. implants aftercare 2 to12 weeks. infection may occur. The signs of Remember these times are Female Genital piercing aftercare infection are: Poster – How to handwash approximate and will depend including Clitoral Hood, Inner and Outer • Swelling and redness that increases on how healthy you are and Labia, Fourchette, Christina and Triangle. around the wound. whether you look after the Soak the piercing for a few minutes by • A severe burning and throbbing piercing properly until healed. submerging the area of skin containing sensation round the site. the piercing in a clean container, such as As with all body art, infection is a bowl containing a warm water solution • Increased tenderness and increasingly a risk. To reduce these risks take (1/4 level teaspoon of preferably sea salt painful to touch. to an egg cup/shot glass of warm water). advice from your practitioner Alternatively wet a clean cloth or gauze • An unusual discharge (yellow or green) regarding aftercare. in the solution and apply as a warm with an offensive smell. compress. This will soften any discharge The risk of infection can be and allow you to clean the entry and exit Speak to your practitioner or seek medical greatly reduced by good points of the piercing with a cotton bud attention immediately if you suffer from any of the above or have any concerns general hygiene including: or gauze. Once the discharge is removed or softened then jewellery can be gently regarding infection in your piercing or if • Hand washing before moved so as to work a little warm water there are any signs of an allergic reaction to any of the products used. touching the piercing through the piercing. When cleaning always tighten the ball on any bars by • Keeping the piercing clean. screwing the ball to the right. Do this twice each day, preferably after washing or bathing.

Dry the piercing using ONLY fresh For further advice or information: disposable paper towel/kitchen roll. Contact your local Environmental Health A communal hand/bath towel should Department, or your local Public Health never be used. England Health Protection Team Do not use antibacterial products as This Information is provided by: they can kill the good bacteria that are Public Health England North West naturally present. Public Health England East Midlands Tattoo and Piercing Industry Union

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June 2013

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60 This document comprises of 1 page Tattooing and body piercing guidance

PART C – Leaflet 06

Toolkit Genital piercing (male) aftercare

Click on text to view Click to download PDF Leaflet 01 – Tattoo aftercare

Leaflet 02 – Ear and face piercing aftercare Genital piercing (male) aftercare Leaflet 03 – Oral piercing Key Advice Hand washing Do not use antibacterial products as Hand washing is the single most important they can kill the good bacteria that are aftercare The aftercare of body piercing method of reducing infection. Hands naturally present. is important to promote good must be washed prior to touching the Do not swim for the first 24 hours Leaflet 04 – Body and surface healing and prevent the risk of affected area, therefore reducing the risk of infection. following a piercing. piercing aftercare infection. Wash your hands in warm water and liquid Do not pick at any discharge and do Healing times for piercing will soap, always dry your hands thoroughly not move, twist or turn the piercing Leaflet 05 – Genital piercing vary with the type and position with a clean towel or paper towel. This whilst dry. If any secreted discharge has of the piercing and vary from should remove most germs and prevent hardened then turning jewellery may (female) aftercare them being transferred to the affected area. cause the discharge to tear the piercing, person to person. allowing bacteria to enter the wound and A new piercing can be tender, itchy and prolonging the healing time. For the first few weeks it is Leaflet 06 – Genital piercing slightly red and can remain so for a normal for the area to be red, few weeks. A pale, odourless fluid may Refrain from any type of sexual activity (male) aftercare tender and swollen. sometimes discharge from the piercing and until the piercing has healed or is ‘dry’. form a crust. This should not be confused Always use barrier protection such as The healing time for a with pus, which would indicate infection. condoms, otherwise you are at increased Leaflet 07 – Microdermal genital piercing can be from Male Genital piercing aftercare risk of acquiring a sexually transmitted 2 to12 weeks. infection. implants aftercare including glans penis piercing such as Remember these times are PA, Reverse PA, Apadravya, Ampallang, Signs of infection Dydoe and Frenum, as well as for other approximate and will depend If appropriate aftercare is not followed Poster – How to handwash piercings including Hafada, Scrotum, infection may occur. The signs of on how healthy you are and Foreskin and Guiche. whether you look after the infection are: Soak the piercing for a few minutes by piercing properly until healed. • Swelling and redness that increases submerging the area of skin containing around the wound. As with all body art, infection is the piercing in a clean container, such as a bowl containing a warm water solution a risk. To reduce these risks take • A severe burning and throbbing (1/4 level teaspoon of preferably sea salt sensation round the site. advice from your practitioner to an egg cup/shot glass of warm water). regarding aftercare. Alternatively wet a clean cloth or gauze • Increased tenderness and increasingly in the solution and apply as a warm painful to touch. The risk of infection can be compress. This will soften any discharge greatly reduced by good and allow you to clean the entry and exit • An unusual discharge (yellow or green) with an offensive smell. general hygiene including: points of the piercing with a cotton bud or gauze. Once the discharge is removed or softened then jewellery can be gently Speak to your practitioner or seek medical • Hand washing before attention immediately if you suffer from touching the piercing moved so as to work a little warm water through the piercing. When cleaning any of the above or have any concerns regarding infection in your piercing or if • Keeping the piercing clean. always tighten the ball on any bars by screwing the ball to the right. there are any signs of an allergic reaction to any of the products used. Do this twice each day, preferably after washing or bathing.

When cleaning always tighten the ball on For further advice or information: any bars by screwing the ball to the right. Contact your local Environmental Health Department, or your local Public Health Dry the piercing using ONLY fresh England Health Protection Team disposable paper towel/kitchen roll. This Information is provided by: A communal hand/bath towel should Public Health England North West never be used. Public Health England East Midlands Tattoo and Piercing Industry Union

Your practitioner is:

June 2013

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61 This document comprises of 1 page Tattooing and body piercing guidance

PART C – Leaflet 07

Toolkit Microdermal implants aftercare

Click on text to view Click to download PDF Leaflet 01 – Tattoo aftercare

Leaflet 02 – Ear and face piercing aftercare Microdermal implants aftercare Leaflet 03 – Oral piercing Key Advice Hand washing Do not pick at any discharge and do Hand washing is the single most important not move, twist or turn the piercing aftercare The aftercare of body piercing method of reducing infection. Hands must whilst dry. If any secreted discharge has is important to promote good be washed prior to touching the affected hardened then turning jewellery may Leaflet 04 – Body and surface healing and prevent the risk of area, therefore reducing the risk of infection. cause the discharge to tear the piercing, allowing bacteria to enter the wound and infection. Wash your hands in warm water and liquid piercing aftercare soap, always dry your hands thoroughly prolonging the healing time. Microdermal implants or dermal with a clean towel or paper towel. This Do not wear clothing that will rub against anchors are small pieces of should remove most germs and prevent the piercing as this may irritate the Leaflet 05 – Genital piercing them being transferred to the affected area. wound and delay healing. jewellery made from titanium A new piercing can be tender, itchy and Do not use sunbeds for the first two (female) aftercare inserted into the skin with the slightly red and can remain so for a weeks, or if you decide to then cover the stem protruding above, onto few weeks. A pale, odourless fluid may wound area with a breathable plaster Leaflet 06 – Genital piercing which an attachment of your sometimes discharge from the piercing and during tanning. form a crust. This should not be confused Do not swim for the first 24 hours choice is fitted. This attachment with pus, which would indicate infection. (male) aftercare should remain in place for at following a piercing. Keeping the implant piercing clean least three months or until the The implant needs to be cleaned twice Accidental damage or loss of disc Leaflet 07 – Microdermal piercing has fully healed. Once it each day. Cleaning more frequently may Contact your practitioner if the implant damage the skin and slow down the gets caught in anything or the piercing has fully healed other pieces of becomes damaged. implants aftercare jewellery can be attached. healing process. Your practitioner may also advise you to soak the implant in warm salt In the unlikely event the disc breaks or Healing times for piercing will water twice a week. comes off, return to the practitioner and Poster – How to handwash have a new disk fitted immediately. If the vary with the type and position Make up a quantity of warm salt water solution (1/4 level teaspoon of preferably sea disc is not replaced the implant may get of the piercing and vary from salt to an egg cup/shot glass of warm water). lost under the skin and will require removal. person to person. Use a clean cloth or gauze dipped in the Signs of infection If appropriate aftercare is not followed For the first few weeks it is solution and apply as a warm compress and also to dab the area to make sure the infection may occur. The signs of normal for the area to be red, area under the disc is cleaned as this may infection are: tender and swollen. become encrusted. • Swelling and redness that increases As with all body art, infection is This will soften any discharge and allow around the wound. a risk. To reduce these risks take you to clean the piercing points with a • A severe burning and throbbing cotton bud or gauze dipped into the warm sensation round the site. advice from your practitioner salt water solution. • Increased tenderness and increasingly regarding aftercare. If the area around the implant becomes painful to touch. The risk of infection can be encrusted soak the piercing for a few minutes by submerging the area of skin • An unusual discharge (yellow or green) greatly reduced by good general containing the piercing in a clean jug with an offensive smell. hygiene including: or bowl containing the warm salt water Speak to your practitioner or seek medical solution and loosen the discharge using a • Hand washing before touching attention immediately if you suffer from cotton bud or clean floss. any of the above or have any concerns the implant. Always dry the area thoroughly after regarding infection in your piercing or if cleaning your implant using ONLY fresh there are any signs of an allergic reaction • Keeping the implant clean. disposable paper towel/kitchen roll. to any of the products used. A communal hand/bath towel should For further advice or information: never be used. Contact your local Environmental Health Do not over clean the site as this may Department, or your local Public Health damage the skin around the implant England Health Protection Team Do not change the cap of the microdermal This Information is provided by: implant until fully healed. If in any doubt take Public Health England North West advice from your operator Public Health England East Midlands Do not use cotton wool to clean the Tattoo and Piercing Industry Union piercing as the fibres in the cotton wool may get caught in the piercing.

Your practitioner is:

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62 This document comprises of 1 page Tattooing and body piercing guidance

PART C – Poster

Toolkit How to handwash

Click on text to view Click to download PDF Leaflet 01 – Tattoo aftercare

Leaflet 02 – Ear and face piercing aftercare Leaflet 03 – Oral piercing How to Handwash? aftercare WASH HANDS WHEN VISIBLY SOILED! OTHERWISE, USE HANDRUB Leaflet 04 – Body and surface Duration of the entire procedure: 40-60 seconds piercing aftercare

Leaflet 05 – Genital piercing 0 1 2 (female) aftercare

Leaflet 06 – Genital piercing (male) aftercare Wet hands with water; Apply enough soap to cover Rub hands palm to palm; Leaflet 07 – Microdermal all hand surfaces; implants aftercare 3 4 5 Poster – How to handwash

Right palm over left dorsum with Palm to palm with fingers interlaced; Backs of fingers to opposing palms interlaced fingers and vice versa; with fingers interlocked;

6 7 8

Rotational rubbing of left thumb Rotational rubbing, backwards and Rinse hands with water; clasped in right palm and vice versa; forwards with clasped fingers of right hand in left palm and vice versa; 9 10 11

Dry hands thoroughly Use towel to turn off faucet; Your hands are now safe. with a single use towel;

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this document. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. WHO acknowledges the Hôpitaux Universitaires de Genève (HUG), in particular the members of the Infection Control Programme, for their active participation in developing this material.

May 2009

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63 This document comprises of 1 page Tattooing and body piercing guidance

PART D

Toolkit Audit tool

Click to download Excel document

INFECTION CONTROL AUDIT FOR TATTOO AND BODY PIERCING PREMISES* NAME AND ADDRESS OF PREMISES: TELEPHONE NUMBER: OWNER/ LICENCEE’S NAME: OPERATOR’S NAME: EMAIL CONTACT DETAILS

TYPE OF PREMISES (please tick as applicable) Tattooing Body Piercing Other (please state):

DATE OF AUDIT: NAME OF AUDITOR:

Indicators met: 0 Indicators not met: 0 Indicators not applicable: 0 Overall score: -­‐

This audit tool is to be used by practitioners, primarily, to enable good practice to be captured and documented. It can also identify best practice gaps which will need action to be taken using an action planning process. It can be used as a discussion point between practitioner and local authority officers, as to what practice gaps need to be prioritised.

Completion: Please allow approximately two hours to undertake the audit. In the "Met" column, record "Yes", "No" or "N/A" against all indicators.

To print all pages: Go to "print" and choose "entire workbook".

Calculating scores: Automatic - This tool will give you automated % scores for each standard, and an overall % score (above). However, this requires data to be entered electronically during or after audit.

Manual - Count up the number of 'Yes' answers and divide by the number of questions answered for that standard (excluding the "N/A"s), then multiply by 100 to get the percentage. To get the score for all the standards and for the audit overall, add the total number for each standard and divide by the number of questions and multiply by 100 to get the overall percentage.

*developed using Infection Prevention Society (IPS) audit tools for monitoring IC guidelines withing the community setting (2005); IPS self assessment audit for assessing implementation of HTM 01-05: decontamination in primary care dental practices and related infection prevention and control issues (2009); IPS audit tools for monitoring infection control standards (2004); International Scientific Forum on Home Hygiene (IFH) and IPS home hygiene -prevention of infection at home: a training resource for carers and their trainers (2003)

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64 This document comprises of 15 work sheets Tattooing and body piercing guidance

PART E

Toolkit Literature reviews

Click to download Word document

Literature review on the epidemiology of

tattooing and its complications

V0.7

Dr Victor Aiyedun

Specialist Registrar,

Public Health Medicine

Supervised by

Dr Fortune Ncube

Consultant Epidemiologist,

Health Protection Agency, Colindale

1

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65 This document comprises of 46 pages