1. Health Risk Factors during Tattooing
1.1Infections
1.2Allergic reactions
1.3Necessities of Hygienic Guidelines
Guidelines
2. Tattoo Artist and Customer
2.1 Qualification of Personnel
2.1.1Education
2.1.2Personal Hygiene
2.1.3Immunization
2.1.4.1 Post-Treatment
2.1.4.2 First-Aid
2.1.4.3 Injuries with used needles
2.2 Pre-Qualifications for Customer
2.2.1Physical Requirements
2.2.2Information and Permissions
3. Location
3.1Cleaning of work area
3.2Sterilizations and Autoclaves
3.3Ultrasonic Cleaner
3.4Needle Disposal Container
3.5Waste Disposal
3.6Instrumentation Box
4. Equipment
4.1Instruments
4.1.1Tattoo machines
4.1.2Grip pieces
4.1.3Needles and needle poles
4.2Colors
4.3Spread able topical ointments, razors, tongue depressors, color caps and linens
5. Disinfection Procedures
5.1Hands
5.2Skin
5.3Work surface
5.4Instruments
6. The Tattoo Process
6.1Customer Protection
6.2Self-protection
6.3Post-Treatment
7. Compliances
7.1Autoclaves and hot-air-sterilizers
7.2Studio-surveillance
Prologue:
Tattooing is a conscious responsible activity whereby specific guidelines need to be followed to protect the customer and one self
1. Health Risk Factors during tattooing
During the process of tattooing you sustain a superficial wound, similar to a scratch/scab wound. With careless use the possibility of transmitting a bacteria/viral carrier into the organism and causing infections is therefore great. In addition there is the possibility of an allergic reaction to the colors and tints that are being used. This can cause the tattoo to become distorted and the color could be absorbed and can even disappear into the skin. There is also the risk of an allergic reaction due to the use of Latex gloves. Since the tattooing qualifies as a cosmetic procedure, a-septic conditions are not a requirement but the following Hygiene guidelines should be followed:
1.1.Infections
Besides different bacterial infections there is also the possibility of an infection caused by a virus (HCV, HIV, HBV, CMV and others). Some of these Infections can be treated with medication, against Hepatitis B you can get immunized. We recommend this immunization for any Tattoo Artist.
Viruses that get transmitted solely through the blood stream (mainly HIV and Hepatitis C) are an especially great risk. There are few situations when these illnesses can get transmitted, and with application of strict Hygiene Guidelines the art of tattooing could be considered on of these few.
1.1 Allergic Reactions
Different types of tints and pigments can cause allergic reactions. It can cause reddening and little blisters in and around the tattoo. A thick scab can also indicate that the skin is trying to reject the color. In most cases the Tattoo Artist, through experience, is aware which colors are more tolerable. Despite that, one should pay special intentions to ingredients. Also to be considered are new techniques to determine the tolerance of certain colors. During the Interview with the customer it should be asked whether or not there are pre-existing known allergies or skin problems/sensitivities (i.e. Neurodermitis)
1.1Necessities of Hygienic Guidelines
The process of tattooing should not jeopardize the Health of the Customer or the Artist; therefore it is necessary to eliminate as much as possible the Opportunity for an infection. The following Guidelines are used for a precaution during the process of tattooing to ensure the safety for the customer and the Artist.
Guidelines
2.Tattoo Artist and Customer
2.1Qualification of Personnel
2.1.1 Education
Since the art of tattooing does not need the usual Education Requirements it is harder to determine who is capable of doing a clean/safe tattoo job. It is known that some artists got very good just through “hands on” experience it is recommended for any aspiring tattoo artist to get an apprenticeship with an accredited Tattoo Studio. This will prevent bad experiences and supports cleaner work. In addition the future artist will learn about hygienic procedures. It is also suggested that any aspiring tattoo artist should inquire about the rules and regulations to work with the greatest safety for their customers and themselves. The participation at specific Hygiene Schooling is a requirement for all of the Tattoo Studio Staff. Courses are already being offered by D.O.T.e.V.
2.1.2Personal Hygiene
A Tattoo Artist should wear clean clothes every day. These should be protected from contamination by wearing an apron or sheets. Soiled clothing should be washed at least at 60 degree C to kill eventual pathogenic germs. Soiled clothing should only be transported in sealed plastic bags.
2.1.3Immunization
It is possible to get immunized for Hepatitis A and B viruses. A onetime series of shots will eliminate the possibility of either transmitting or receiving the viruses. These Immunizations are highly recommended for the Tattoo Artist..
2.1.4.1Post-Treatment
As previously mentioned tattooing can cause allergic reactions. In addition the following causes can slow down the healing process: neglecting personal care, heavy sun exposure, pressure or irritation. Any artist should be able to determine whether the use of Ointments (with the Ingredient Dexpanthenol) or a follow/up doctor visit is to be advised. It is recommended for any artist to sign up for continued education programs (availability for such programs is in development).
2.1.4.2First-Aid
During the tattooing there is the possibility of problems with your blood circulation or blood pressure. This can also cause very severe allergic reactions (i.e. breathing problems). That’s why it is highly recommended that any Tattoo Artist should be certified in First Aid. Tattoo specific courses are in the making.
2.1.4.3Injuries with used needle
In case of an injury with a used needle which could transmit possible infectious carriers the wound needs to be completely blooded out and cleaned with a specific alcohol based disinfectant and after this has been done, a doctor needs to be consulted right away. Due to the circumstances of the injury the physician will very possibly do tests for Hepatitis A/B/C and HIV (if the patient has not been previously immunized). If there is a good chance for a possible infection he will administer preventative medication.
2.2Pre-Qualifications for Customer
2.2.1Physical Requirements
Anybody who wants to get a Tattoo has to be of legal age (18 years) and past the growth spurt. For under-aged persons we need a permission slip from the legal guardian. Persons suspected under the influence of alcohol or drugs should not be tattooed. In the same instance a person who has consumed considerate amounts of alcohol/or painkillers the day prior should not be tattooed, since these qualify as blood thinners and therefore hinder the tattoo process.
A woman that is pregnant should not be tattooed.
Any patches of skin that show signs of Neurodermitis, sunburn or similar pigmentations, should not be tattooed. Moles and blemishes should not be tattooed. Whether or not scar tissue can be tattooed, should be evaluated case by case.
2.2.1.1.Information and Permissions
Any person that would like to get a Tattoo should be properly advised; either in written or verbal form, what kind of risks is involved with such a procedure.
3Location
3.1:Work Area (Cleaning of Work Area
The work area does not necessarily have to be divided from the receptionist area by actual closed in walls, but a functional divider is required (i.e. Screens). No food or drink is allowed in work area. Smoking and bringing pets is also prohibited. The work area should have plenty of lighting, good air circulation and be easily cleaned. The floors and work counters have to be even and water-repellent or at least easy to clean (i.e. Tiles, PVC, Linoleum etc). Required is a washbasin with running cold and warm water. Since the washbasin and faucets are only used before or after tattooing, a cross-contamination can be excluded by following hygienic regulations. Therefore a no-touch faucet is not required. In every work area practical Soap/Disinfectant/Paper towel dispensers should be available. The area for the instruments needs to be easily cleaned and smooth. This specific area should be covered with one-way cover-ups, for instance foils/paper towels and a new one needs to be provided for each customer. In addition there has to be a procedure chair and/or gurney available that have to be covered by water repellent fabric. This also applies for the Artist’s chair. Since the work area has to easily cleaned only the instruments used for tattooing are allowed. Any materials that are necessary should be placed within reach of your work area. Do not unwrap until ready to use. Sterilized instruments should not come in touch with other surfaces besides their wrapping
3.2Sterilizations and Autoclaves
In any Tattoo studio all instruments that are used for sterilization have to be standard Inventory to do an on-site sterilization.
The sterilization is twice as effective, if the goods are pre-cleaned and the contamination level is at a minimum. Through pre-disinfections and thorough cleaning the amount of germs should be drastically reduced.
The suggested concentrations, in the actual usage of this Process, and the disinfection/sterilization time are calculated so that the usual present contamination degree is such, that in effect the goods to be sterilized cannot get infected and that all re-producing microorganisms are inactivated or destroyed. If a Tattoo Studio uses their own soldered needles such will have to be sterilized in the appropriate sterilization container before use. For the sterilization of the grippers and needle pole it is sufficient to sterilize for 45 minutes with the hot-air sterilization container (see attached test results).
3.3Ultrasonic Cleaner
On any work surface there has to be an ultrasonic cleaner available. It removes hardened particles (like blood or colors) that have attached themselves to the needle. For every customer the use of a one-time plastic cup with the appropriate cleaning solution is a must. This cup needs to be discarded right away after the treatment and emptied into the basin and placed into the appropriate waste container. Only the usage of one-time cups enables the quick and reliable cleaning in the ultrasound container without cross-contamination.
3.4Needle Disposal Container
Used needles, which have been in contact with blood, are heavily soiled and for that specific reason they have to be disposed differently after the disinfection/sterilization process. For the proper disposal of the needle, trade approved needle disposal containers have to be used. These needle disposal containers remain closed and will be disposed of when they are full.
3.5Waste Disposal
A wastebasket for the discarded paper towels (trash bags required) has to be placed beside the washbasin. Paper towels, color caps, tongue depressors, Any refuse that gets generated during the tattoo process needs to be placed immediately into the appropriate waste container. The work area has to be clean and void of any refuse. For this purpose you should have a re-closable waste container, which can be opened by foot pedal, or an open waste container that needs to be emptied after every customer. If you are using a closed waste container, cleaning it once a day is sufficient. Of course it cannot be overflowing. It is very important not to touch the container during tattooing since cross contamination could happen easily. Trash bags are a must.
3.6 Instrumentation Box
For the storage of un-sterile instruments it is required to keep them in an instrument box until the time of sterilization. This has to be an appropriate container that is filled with a disinfectant solution. This box has to be closed at any time and has to be stored in a accident-safe location. The amount of instruments the box should hold is determined by making sure they all are covered generously by the disinfectant. This box needs to be purged one time per week and the disinfectant needs to be renewed. The date of the new refill of the disinfectant should be noted on the lid.
4Equipment
The Equipment should be highly functional as well as guaranteeing the safety of the artist and customer by following simple cleaning rules and using only the best quality.
4.1 Instruments
4.1.1 Tattoo machines
Tattoo machines and clip cords, if they don’t have to be disinfected, should be bagged fresh for every customer. Freezer bags and Saran wrap are acceptable. After completion of the Tattoo the bags have to be removed, the machines cleaned and disinfected with the appropriate solution. For this process the machines should be disconnected from the power source.
4.1.2Grip pieces
Suggested is the use of one-time grip pieces. Re-usable pieces are also acceptable, but have to be thoroughly cleaned with a brush and cleaning solution under running water. Please use disposable gloves. Before sterilization these instruments have to be placed in the instrumentation box and need to be disinfected with the disinfectant solution. For the process of sterilizing an autoclave or hot-air sterilization equipment is needed (Proof of Affectivity using hot-air sterilization equipment is enclosed).
The grip pieces have to be either packed into sterilization foil (sealed) before sterilization, or have to be used immediately after sterilization. If you are using sterile-foils, the date of the sterilization has to be noted on the bag. Only bags with identification labels that change colors during sterilization, to rule out a mix up of sterile and non-sterile pieces, should be used. The duration time for the grip pieces is six months if they are protected from UV-light and dust. Otherwise the duration time is reduced to one month.
4.1.3Needles and needle poles
Suggested is the use of one-way steel needles. Soldered needles with needle poles are liable to be sterilized before use. It is possible for used needles, after a thorough cleaning, to get disinfected in the ultrasonic bath and can be autoclaved again. If the needles have been treated in this fashion, they have to be stored where they are protected from UV-light and dust and have to be used before the expiration date. The durability of these needles is maximally six months. The needles have to be used immediately after sterilization or have to be sealed in autoclave-foil. If they are vacuum-sealed, the time of sterilization has to be noted on the foil. The duration time for these needles is three month if they are protected from UV-light and dust. Otherwise the duration time is reduced to one month. Always wear gloves while handling used needles.
4.2 Colors
Colors can cause an allergic reaction. It is recommended in the initial interview with a potential customer to ask if they have a tendency for allergic reactions or any skin problems. Should this be the case it would be advised to do an allergy test or consult a dermatologist. The colors that are being used need to be certified by the Manufacturer and the Ingredients of the color should be denoted. In addition the colors should be germ free and should not contain pathogenic germs as well as heavy metals or Azo-pigments. If squeeze bottles or twist-off bottles are used new color caps have to be issued for each new customer. While re-filling contact of the bottle neck with the cap has to be avoided.
4.3 Spread able topical ointments, razors, tongue depressors, color caps and linens
Spread able topical ointments, razors, tongue depressors and color caps should be stored away from the work area in closed containers. Razors, color caps and tongue depressors will be removed from their containers by using clean gloves and get disposed in the garbage after a one-time use. The spread able topical ointment can only be applied with a clean tongue depressor. After removal the container has to be closed immediately. Pure Vaseline in not useable, since Latex gloves are not resistant after repeated use. Recommended is the use of Eutra Tetina (Comp: mineral oil, petrolatum, paraffin, tocophenol). It is a lot more tolerable for hands and gloves. Only powder free gloves should be used. Linens that are used during tattooing need to be bagged and be kept away from the work area. There should only be as many linens in the work area as actually needed for this particular customer. The used linens get disposed in the readily available waste bin right away during tattooing. Color bottles should be wrapped in one-way bags, which should be changed with every new customer. The bottles have to have tops that don’t need to be changed for refilling (squeeze bottles with twist-off caps). The bottle tops should only be opened with clean gloves or one-way papers to refill clean one-way caps. It is not allowed to refill already used caps. If necessary, use a new cap. The color bottles have to closed at any time and protected from dust to avoid the penetration through microorganisms.
5. Disinfection Procedures
To ensure Customer and Self-Protection all disinfection procedures need to be executed effectively. How any procedure step needs to be executed is described in detail here. The used dsinifection materials need to be approved according to DGHM/DVV guidelines for their affectivity and have to be listed according to DGHM.
5.1Hands
Infectious germs very often get transmitted during contact with hands. For this reason the actual hand contact with a customer should be kept to a minimum. The hygienic disinfections of the hands should eliminate the germs that get transmitted through contact with micro bacterial contaminated objects and attach themselves to the surface of the skin.
The disinfections of hands are one of the most important criteria for preventing and fighting off infections. The washing of hands should be kept to a minimum. It is just a means for cleaning.
Attention: Repeated cleaning of hands is the cause for more skin irritations than the actual hand disinfections causes.
In the case of acute infectious and contaminating danger, especially handling of human body excretions from customers or handling of goods that are contaminated with excretions or blood, your hands need to be protected with on-way gloves to prevent direct exposure to these substances. Contaminated hands can only be cleaned with water and soap after they have been disinfected. Examples for requiring hygienic hand disinfection are:
After contact with blood, excretions or bodily fluids.
Before contact with customers or contact with the entrance area of the tattoo needle.
After contact with contaminated surfaces or goods.
After disposing of protective gloves.
Techniques for hygienic hand disinfections:
Dispensing of enough alcoholic disinfectant from pump or arm handle disposal containers with the use of elbow.
YOUR HOLLOW HAND HAS TO BE COMPLETELY FILLED
Rubbing together of both hands with focus on covering the problem areas. In case of contamination it is advised to cover the underarms as well.
DURATION OF SATURATION SHOULD BE AT LEAST 30 SECONDS.
5.2Skin
Goal: Significant reduction of germs in the specific skin area before beginning the procedure of tattooing. The customers skin needs to be generously shaved and should get saturated with a skin disinfectant spray (padding of the area is not required) with a duration of at least 15 seconds. De-activation of spores or viruses cannot be expected at this duration period, but is really not necessary at this point. Please touch the spray bottle with fresh gloves. The contents/ingredients of the bottle as well as the fill date need to be denoted. Only original bindings can be used, do not transfer.
5.3 Work surface
Floors, work surface, treatment gurney, chairs and washbasin have to be cleaned after every workday. In addition, any surface that could have been in direct or indirect contact with a customer’s blood needs to be disinfected with the appropriate solution. Recommended are surface disinfectants with HBV effectiveness. Please observe the Manufacturers directions regarding duration of saturation. The area to be disinfected needs to be scrubbed with light pressure, using a sponge or cleaning cloth that is lightly saturated with the thinned down disinfectant solution. The purpose for this is to remove any soiled areas that have hardened on the surface. It is not enough to just spray the solution onto the surface. A thin film needs to be visible on the treated surface. It is not permissible to clean the treated surface right away. The suggested duration time for the solution needs to be complied with. It is recommended to use appropriate safety items for the disinfection and to protect the hands from contact with the disinfectant. Any sponges, linens or similar items need to be disinfected and dried after use. Do not store wet. For the disinfection of large soiled areas the scrubbing disinfection method will not be enough. Large soiled areas need to be removed from the surface first and then disinfected. Gloves are mandatory for this procedure.
5.4 Instruments
Instruments should be disinfected and cleaned immediately after use. Hardened soiled areas will complicate the process of disinfecting and cleaning considerably. The use of moist air and chemical disinfectants can be used for disinfecting the instruments. Instruments need to be placed into the disinfecting solution that all surfaces are completely covered and no air bubbles are allowed. Obvious visible contaminated areas need to be scrubbed with the disinfectant immediately. Hollow bodied instruments need to be flushed with the disinfectant solution and need to be filled that there are no air bubbles present.
6. The Tattoo Process
6.1 Customer Protection
To guarantee maximum protection for the customer the work area and instruments need to follow hygienic guideline when it comes to cleanliness. It is very important that the skin of the customer is only touched with fresh new gloves. Latex gloves should have a CE-Identification and should have been tested according to EN455/AQL 1,5 requirements. If the artist touches anything besides the disinfected skin area (own clothing, phone…etc.) the hands need to be disinfected again and put on new gloves. In addition look for signs whether some of the customers blood got in contact with surface. After the fresh tattoo is completed it should be smeared with a topical ointment (Mel fat/ Vaseline) and covered with either the appropriate bandage or foil. These should be removed approximately 2 – 6 hours later.
6.2 Self-Protection
To protect themselves during tattooing and while handling instruments any artist should wear gloves to eliminate the possibility to come into contact with the blood or skin of a customer.
6.3 Post-Treatment
Every customer needs to be, verbally or in writing, informed what he needs to do for post-treatment. Explain to the customer that the purpose of the foil/bandage is to protect the tattoo from getting soiled. The foil should be removed after 2 – 6 hours and the tattoo should be carefully wiped with a clean cloth and possibly using a mild soap. After cleaning the tattoo it should be thinly covered with an ointment containing Dexpanthenol. This procedure should be repeated 2 – 3 times a day until the tattoo is completely healed. To ensure a speedy healing the tattoo should not be exposed to any sunlight for at least 2 weeks. Also avoid any pressure or irritation. The use of solariums, pools or tight closing should be avoided. The Tattoo needs to be protected from getting soiled. Any signs of reddening, swelling or the appearance of blisters should be checked by a physician.
7. Compliances
7.1 Autoclaves and hot-air-sterilizers
All autoclaves and hot-air-sterilizers need to be tested for their ability to function by an accredited institution on an annual basis. For this process bio-indicators are used. Bacterial spores of specific resistance tolerances that are measured against the process are applied to a carrier and the appropriate spore filled dirt is wrapped into foil paper and is inserted into the center of the sterilisator according to the pre-determined conditions, for the duration of the sterilization. The testing should be performed und circumstances according to the way that the sterilizer is usually operated. Hereby the indicators are organized where you would expect the longest Equalization points. Afterwards the bio-indicators are incubated for seven days in fertilizing Boullion and are not allowed to show no germ growth according to the sterilization process. Bio indicators used should comply to DIN 58946, DIN 58947 or DIN 58948 standards, depending on Process. Notifications of this testing should be presentable if requested.
7.2:Studio Surveillance
Every Tattoo studio should have a surveillance visit every 2-3 years by an un-objective institute. Purpose of this surveillance is the control of compliance according to the given Hygiene Guidelines as outlined by the Tattoo and Piercing Studio Checklist (see Enclosure). The Goal is the guarantee to comply with the highest quality standards.
This is already happening within the studios that are belonging to the D.O.T.e.V.