The Occupational Safety and Health Administration (OSHA)1 requires that anyone who can potentially be exposed to bloodborne pathogens in a workplace must receive training to stay protected. In addition, each employer must have a site-specific exposure control plan (see template) that deals with bloodborne pathogens in the workplace. This course meets the OSHA requirements for education in the workplace when used in conjunction with an orientation on your site-specific exposure control plan.

Bloodborne pathogens

What are bloodborne pathogens? They are disease-causing microorganisms that are carried through infected blood. There are many known examples, but the most notorious are the hepatitis B virus (HBV), the hepatitis C virus (HCV), and the human immunodeficiency virus (HIV).³ Moreover, there is always the possibility of discovering a new bloodborne pathogen that causes a disease with which we are not yet familiar.³

Both hepatitis B and hepatitis C affect the liver. For this reason, it is important to understand what this organ does for the body. Why is your liver so important? Your liver is located in the right upper quadrant of your abdomen below the diaphragm and is essential for many bodily functions. It is so important that you cannot live without it. Let’s take a look at some of the chief roles of the liver.

First and foremost, it acts as a filter. Deoxygenated blood carrying nutrients, toxic substances, and medications are delivered to the liver via the hepatic portal vein. This blood then flows through the liver tissue to specialized capillaries known as sinusoids. Within the sinusoids, blood is filtered through the hepatic cells (hepatocytes) to process or store nutrients and to remove waste materials and by-products from the bloodstream before they affect the rest of the body. The liver also assists with the removal or release of sugar within the blood depending upon its level. Using chemical enzymes that are stored there, it converts sugar into glycogen which is utilized by the body to create energy. When the body’s blood glucose level is too low, the liver breaks down glycogen and releases sugar into the bloodstream for use by the body.

The liver also stores minerals, proteins, and vitamins until they are needed by the body at which time they are released back into the bloodstream. These include vitamins A, D, and B-complex. One of the most important vitamins stored in the liver is B12 which is used to make red blood cells. Hemoglobin—the complex protein that carries oxygen and causes blood to be red—is also stored in the liver.

Last, but not least, the liver can manufacture blood proteins such as fibrinogen. Fibrinogen is necessary for the body to form blood clots. Without fibrinogen, a person could bleed to death from a minute injury. The liver also manufactures albumin. Albumin is a protein that contributes to the body’s ability to maintain fluid balance. A small amount of disease-resisting globulin is also manufactured here.

Hepatitis and other diseases that attack the liver can prevent the liver from performing any or all of the above functions. The seriousness of the disease process depends on the amount of damage done and how much of the liver’s function is prevented or decreased.

Join the discussion: What treatment options are available for hepatitis B and C? Does hepatitis B always need treatment, why or why not? Please share your experience. Discuss on Med Talk.

Bodily fluids

Many bodily fluids present a risk for the transmission of infectious diseases, but blood is the most common. Blood is responsible for most transmissions of disease within the healthcare setting.

Other potentially infectious materials (OPIM) include the following body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids. Note that urine is not explicitly included in this list — this is because urine does not present a risk for the transmission of bloodborne pathogens unless it contains blood.5

Universal precautions were developed by the Center for Disease Control (CDC) in the late 1980s in response to the HIV outbreak. The effective guideline defines that all bodily fluid is treated as if they were known to be infectious. Even though every patient is treated as if they carry an infectious disease, communication of an infectious disease remains imperative amongst healthcare providers.

Universal precautions protect against the pathogens that we don’t know about. For example, if we had practiced universal precautions before the HIV or hepatitis outbreaks, the impact of outbreaks would have been much smaller. The Healthcare Infection Control Practices Advisory Committee (HICPAC) updated universal precautions to standard precautions and defined in greater detail the guidelines. The entire position paper is available here: https://www.cdc.gov/infection-control/hcp/isolation-precautions/

Standard Precaution recommendations from the CDC contain the following ten subdivisions of recommendations:

1. Hand hygiene
2. Personal protective equipment (PPE)
3. Respiratory hygiene/cough etiquette
4. Patient placement
5. Patient care equipment and instruments/devices
6. Care of the environment
7. Textiles and laundry
8. Safe injection practices
9. Infection control practices for special lumbar puncture procedures
10. Worker safety

All recommendations are based on the premise that each patient or piece of equipment is considered contaminated and treated as such.

Hepatitis B

The virus that causes hepatitis B is HBV (hepatitis B virus). It is most commonly transmitted through blood, semen, or OPIM. Anyone who is at risk of exposure should be vaccinated against hepatitis B. The vaccination is available through your primary care physician and most local health department offices. It is a three-shot series—the second injection is received about a month after the initial dose is given, and the third injection is received six months after the initial dose. Once the vaccination series is completed, it is effective in preventing hepatitis B in 95% of exposures.

In the United States, there are approximately 2 million people who have chronic hepatitis B. The majority of them are unaware of their infection. However, they remain infectious to others, making this a dangerous situation.

There are 257 million who are infected worldwide. Appropriate screening and education regarding hepatitis B are imperative to stopping the spread of this virus. The US Preventive Services Task Force (USPSTF) and CDC recommend that all patients be screened for hepatitis B using a surface antigen blood test.

When someone is first diagnosed with hepatitis it is considered an acute infection. After the patient has it for 6 months or longer it is deemed to be chronic. Even though most patients are unaware of their infection they continue to infect others and may already have severe liver damage before they are aware of their symptoms. It can cause inflammation of the liver, fibrosis (scarring), cirrhosis (severe scarring that decreases function), and can cause liver cancer.

The only way to contract the virus is through contact with infected blood or bodily fluid. It is not transmissible by touching, kissing, or casual contact. The most common infection occurs when it is transmitted from an infected mother to the child during birth. Infected blood after an injury or scratch or exchanging bodily fluid during sex can also transmit the disease. Sharing unsterile needles have become a particularly large problem given the current opioid addiction problem in the United States. Additional behaviors that place a person at high risk of hepatitis B include:

• Traveling to countries with moderate to high risk.
• Occupational exposure to blood or blood products.
• Having a sexually transmitted disease.
• Having sex with an infected partner.
• Having multiple sexual partners.
• Living with a person that has chronic hepatitis B.
• Men with sexual contact with other men.
• Being a hemodialysis patient.
• Injecting drugs or sharing needles with others.

Most symptoms appear approximately three months following exposure but can appear as early as six weeks and as late as six months. The symptoms usually last for several weeks but can last for six months. Most adults fully recover. Some people remain with the HBV virus (chronic hepatitis B). Most people remain symptom-free for 20–30 years. Although symptom-free, once diagnosed, you must have your liver enzymes checked regularly to monitor for liver damage from chronic infection.

Symptoms of hepatitis B include:

• Loss of appetite.
• Fatigue.
• Loss of appetite; nausea and vomiting.
• Aches and pains beyond normal fatigue.
• Abdominal pain over the location of the liver.
• Yellow skin and eyes (jaundice).
• Dark urine.
• Joint pain.
• Pale-colored stools.

Hepatitis C

Hepatitis C is caused by the hepatitis C virus (HCV). It is spread when blood from a person infected with the virus touches the blood of someone who is not infected. It does not spread by casual contact, such as drinking glasses, food, or toilet seats. There are certain groups of people that are at a higher than average risk for contracting hepatitis C. They include:

• Anyone who received tattoos or body piercings with non-sterile instruments.
• Current or past use of shared needles.
• Healthcare workers who have been accidentally stuck with a contaminated needle.
• Anyone who received a blood transfusion, blood product, or donor organ before the screening that began in 1992 in the US.
• Anyone who is on any form of renal (kidney) dialysis.
• People who are already infected with HIV.
• Babies born to infected mothers.
• Anyone who has spent time in prison.
• Anyone who received a blood product to prevent blood clotting before 1987.

The CDC recommends that all baby boomers (born 1945–1967) be tested for hepatitis C. They were infected in the 70s and 80s when infection control standards were not as effective as today. The virus was not discovered until 1989. Donated blood was not screened until 1992. Many of these patients have had chronic hepatitis C that did not cause symptoms for decades and are only now starting to show signs of liver damage from the disease. Hepatitis is curable and new treatments are being tested every day.

Symptoms of the disease can range from acute and very bothersome to somewhat vague and hard to recognize. These include:

• Loss of appetite – a loss of appetite is when you have less desire than normal to eat. This can be caused by several medical conditions. It can be the result of a bacterial or viral (as in hepatitis C) infection in any location of the body.
• Weight loss – any weight loss when not dieting is usually a symptom of an underlying medical condition. In the case of hepatitis, it is associated with the loss of appetite that frequently occurs with the infection.
• Fatigue – although not directly caused by HPC, if liver damage has occurred, scarring (cirrhosis) develops making the liver unable to function optimally, which leads to fatigue and general health changes.
• Red palms – are caused by a variety of medical problems. This is caused by hepatitis C because of abnormally high estrogen levels in the body.
• Raised liver enzymes – this is the easiest way to detect liver damage. This can be caused by certain medications, but in the case of hepatitis C it is caused by damage already done or being done to liver tissue.
• Difficulty clotting blood – the liver creates proteins that assist with the clotting of blood. As it becomes damaged, the ability to make those proteins is diminished, thus causing a person to bruise easily and bleed longer than normal from an injury.
• Spider-like veins on the skin (spider nevus) – is a sign of liver disease when located in more than one area. It is the result of too much estrogen in the system and occurs with hepatitis C.
• Inability to concentrate on tasks – the liver removes toxins from the body; therefore, when damage to the liver occurs, these build up causing short-term memory loss as well as the ability to concentrate. Often people describe this as “brain fog.”
• Abdominal pain – the virus can cause pain in the area of the abdomen where the liver is located (right upper quadrant). The liver itself does not have nerve endings; consequently, it cannot induce pain. However, the inflammation of the sac around the liver or other close organs can and does cause pain.
• Tar colored stools – are signs of blood in the digestive system, particularly the small intestine, stomach, or esophagus. Liver damage causes the liver not to make proteins that help the blood to clot and this may result in bleeding.
• Fluid in the abdomen (ascites) – occurs when the pressure in the veins of the liver causes fluid to leak into the abdomen. It may lead to life-threatening infections and requires aggressive treatment.

Hepatitis A

Hepatitis A is not a bloodborne pathogen, but nonetheless is an infectious disease that needs to be discussed in the environment of Tattoo Parlors and medical facilities as well. Hepatitis A is also a disease causing inflammation of the liver, but is transmitted via a different method than hepatitis B and C. This virus is transmitted from person to person via fecal material. This can occur with direct contact with feces, or more commonly with contact with contaminated water (sewage contaminated water) or food contaminated with fecal material. This occurs most commonly with produce that has been contaminated with the feces of animals from the farm on which it is grown. It is then consumed without proper cleansing and the virus is spread to people. This can also occur by person to person contaminated food. An individual’s hands are contaminated with fecal material from failure to wash after using a bathroom. That same individual then prepares food that is then contaminated with the virus and consumed by another individual who then becomes hepatitis A positive.

Hepatitis A, unlike B or C does not result in a chronic liver infection. It is however a serious and long-lasting disease. Symptoms can last up to two months and include

• Stomach pain
• Nausea and vomiting
• Fatigue
• Jaundice

It is unusual, if not impossible to be infected with hepatitis A more than once in a lifetime because the antibodies that respond to the infection last a lifetime and prevent the patient from acquiring the disease a second time. There is a vaccination for hepatitis A but can be expensive. For this reason it is normally reserved for those at high risk, such as people working in 3rd world countries, workers exposed to high risk environments such as sewage facilities and other people who would be expected to come in contact with the virus on a regular basis.

Staph infections – methicillin resistant Staphylococcus aureus (MRSA)

Staph is a bacteria that is present on skin in many people. Healthy people carry on their skin or in their noses but are not infected by it and unless tested do not know of its existence. It is not a problem unless it enters your body, usually through an opening in your skin, such as an injury or commonly when obtaining a tattoo. Another variety of staph infection is methicillin resistant Staphylococcus aureus. This is an infection that can attack any area of your body but most commonly causes skin infections. It is difficult to treat because it is resistant to the most common antibiotics used to treat staph infections. Usually the person gets no more than a rash, irritations that look like blisters or other skin presentations. It is usually self-limiting. MRSA can be introduced into more systemic areas such as lungs, the urinary tract and other internal organs. This most commonly occurs at the site of a surgical wound. For this reason tattoo parlors are a high risk area for MRSA.

MRSA or other staph infections can also be transmitted by touching surfaces or people that have the bacteria on them. Regular handwashing and careful cleaning of surfaces in areas that may be contaminated are the best ways to prevent the transmission of all staph infections.

Staph infections, because they are bacterial, respond to antibiotic treatment. MRSA requires the use of much stronger antibiotics. As its name implies, it is resistant to the most common antibiotics used to treat staph infections.

IMPETIGO is caused by staph infections as well. It is usually an issue for small children from age 2–5 but is not unheard of in older children and adults. It presents much the same way with rash. The rash of impetigo usually shows up on the face, arms and legs. It is almost always self-limiting but in bad cases can require antibiotics. The best prevention is general cleanliness including hand washing, limiting touching of the face, eyes and mouth and keeping surfaces cleaned and disinfected.

Tuberculous (TB)

TB is a serious infection that affects the respiratory system (lungs). It was extremely rare until its resurgence in the mid to late 1980’s when the HIV virus made its debut. TB is most common in people who have depressed immune systems. TB is present in many situations but for the most part, individuals’ immune systems are able to fight it off and they do not contract the virus. However, for people who may have a depressed immune system including the elderly, the ill, people with chronic infections or those taking immunosuppressive medications such as chemotherapy, TB can be a major issue.

TB is transmitted through droplets such as those that are spewed through the air with sneezing and/or coughing. Droplets can be spread within 6 feet of those coughing or sneezing. Covering coughs or sneezes with the arm or a tissue is the best way to avoid contamination. Washing hands frequently and avoiding touching the face and eyes is helpful. Symptoms of TB infection are sometimes overlooked because they mimic the signs and symptoms of other much more common diseases. They include:

• Coughing that lasts a long time (usually more than three weeks)
• Blood that appears on the tissue with coughing
• Fatigue
• Fever
• Night sweats
• Pain in the chest area with coughing or breathing
• Chills
• Loss of appetite.

TB that goes untreated or is resistant to treatment can affect other organs in the body such as kidneys or even the brain. It is important to recognize the signs and symptoms of TB and begin treatment. Although there are some vaccines available in third world countries where TB is much more common, they are not recommended or used in the United States.

There are no specific preventions recommended in the tattoo environment because it is impossible to identify those who are TB positive. Good hygiene practices including regular washing of hands and disinfecting of surfaces within the parlor are the best preventative measures available.

Scabies

Scabies is not an infection, but rather an infestation. It is however contagious. The most common people to contract scabies are those living among large numbers of people such as prisons, institutions and even children who are in child care facilities. It is literally mites called sarcoptes scabiei that live and reproduce in the outer layers of the skin. They can be present for months before they cause symptoms. They will present with:

• Intense itching
• Rash with small pimples
• Scales or blisters
• Skin sores can open from itching
• Track like burrows just under the skin.

Although they can live anywhere dark, moist areas are best suited to them. So folds of the skin, between fingers, at the waistline or in the navel are common. Scabies are spread with skin to skin contact. Literally the mites climb from one person to another so casual contact is not enough time for this to happen. Scabies can cause other bacterial infections such as impetigo because of damage to the skin surface.

Scabies is NOT self-limiting. They must be killed with prescription creams that kill the mites. Leaving scabies to “see if they go away” will just give the infestation time to increase. Early treatment is essential in controlling scabies. In addition to the treatment of the “ground zero” patient, people in close contact such as spouses or cellmates should be treated as well to kill the mites before infestation can take hold.

Ringworm

Ringworm is not a worm. It is a fungal infection of the skin. It is most common in the scalp, feet, nails, groin. It will appear as red patchy rash. It is the cause of what is commonly known as “jock itch” and “athlete’s foot.” Depending upon the severity of the presentation, it can be treated with over the counter creams and/or prescription strength creams or in extreme cases oral prescription medications. Because it is fungal, it likes warm, wet areas. Prevention is aimed at not providing those areas. Drying completely following bathing, wearing loose clothing, washing bedding and clothing regularly during outbreaks are just a few ways of containing spread.

Molluscum contagiosum

It is a viral infection of the skin that presents with flesh colored, dome shaped lesions that almost always have a small dimple in the middle. They are caused by the poxvirus. It is spread by direct contact or sharing of objects such as towels. It can also be spread during sexual intercourse. It is considered highly contagious. Prevention is the same as most contagious diseases; frequent hand and surface washing and disinfecting.

Herpes zoster

Herpes zoster is a reactivation of the chickenpox virus that has laid dormant for a period of time. It usually begins with pain along a nerve route with the eruption of a red rash within 2–3 days. There is a vaccination available for its prevention. Older patients are at particular risk of this infection. It is treated with anti-viral prescription medications like acyclovir, famciclovir and valacyclovir.

Sometimes wet compresses can help the pain, but most often it is severe enough to require system pain control. The only time that herpes zoster is contagious is when there are active blisters on the person. In the environment of a tattoo parlor, clients with active blisters should be refused.

Herpes simplex

There are two types of herpes simplex presentations. Both are caused by viruses, (either type 1 or type 2). Type 1 causes sores around the mouth (cold sores) and type 2 causes sores and blistering around the genitals. Type one is usually spread by oral secretions such as during kissing or sharing toothbrushes. It can be spread with oral sexual contact and result in type 1 virus being present as genital sores. Type 2 is spread during sexual contact or during childbirth. Both forms of Herpes can remain dormant for long periods of time and then resurface from time to time. They are only contagious when there are active sores present. There is no cure, but treatment is aimed at reducing the amount of time of an outbreak or lengthening the time between outbreaks. Because it can be spread with contact, those with visible active sores should not receive tattoos during active periods.

General reduction of transmission

You probably noticed that the prevention of many of the above bacterial and viral diseases are similar. Good hygiene is essential, especially in an establishment such as a tattoo parlor where skin integrity is interrupted for the procedure. Handwashing is the single largest defense against the spread of any disease. In addition, cleaning and disinfection of surfaces within the environment is extremely important. Policies should be in place for the routine disinfection of all surfaces that come in contact with clients and or artists.

In addition, policies should be in place to refuse service to anyone with active sores of any kind on the skin and/or active respiratory illnesses. Common sense precautions like these go a long way in preventing the spread of infectious diseases.

The Skin

The skin is the largest organ in the human body. The skin of the average adult has an area of 20 square feet. It has several functions. It protects the underlying organs and systems from infection and injury. It houses many sensory nerves that provide communication to and from the brain. The deeper the layer of skin, the more vascular (blood vessels) it is. Dermatology is the study and treatment of the skin and the disorders that occur there. Before we can understand what can go wrong, we need to take a look at the skin and how it is supposed to work.

The skin is composed of three main layers. Picture two pieces of Saran wrap, moist laying on top of each other. The upper level is the one we see and deal with daily. It is called the EPIDERMIS. It is the outermost layer and is composed of four or five layers of epithelial cells. The epidermis provides a waterproof barrier and is responsible for our skin tone. Skin is classified as “thick” or “thin” skin. This depends upon the number of layers present. Most of the skin is classified as thin. Thick skin is found only on the palms of the hands and the soles of the feet. The epidermis does not contain blood vessels or other structures such as lymph vessels or sweat glands. The color of the skin is created by melanocytes that produce pigment. They are located in this layer as well.

The DERMIS is the main layer of skin and contains blood and lymph vessels. Also contained in the dermis are the hair follicles and sweat glands. It is made of tough connective tissue. Its job is to be a cushion against stress. It is the part of the skin that provides the sense of touch and heat by housing the nerve endings that experience those sensations. It is responsible for the elasticity of the skin.

The HYPODERMIS is the layer just beneath the dermis. It is composed of fat and connective tissue. It is a well-vascularized (many blood vessels) layer that also contains connective tissue and fat. It is the place in the skin that stores fat to work as insulation. It is the hypodermis that stores the fat that everyone tries to lose while dieting.

Disease and conditions of the skin

While there are thousands of diseases that affect the skin, we have tried to touch on the most common. It is important to the tattoo artist that he/she recognizes that disorders of the skin do exist and that they can have serious consequences. Before placing a tattoo on what appears to be damaged or diseased skin, one should ensure that the client has been seen by their physician and have been cleared to have the tattoo performed.

In addition to diseases and conditions of the skin, there are complications resulting from tattoos that may occur. The tattoo must be aware of them and educate their client to be alert to watch for them. We will touch on the most common ones here.

INFECTION is by far the most common. It can also be the most dangerous because if left untreated can become systemic and cause major health issues to the client. It can occur immediately after getting a tattoo or can be delayed by days or even months. Most infections begin as a redness that becomes darker and spreads instead of the normal irritation of tattooing that diminishes and disappears. It can be itchy and painful. The client may develop a fever or chills. The client should be directed to seek attention from their physician if any of the above occurs.

RASH BECAUSE OF ALLERGY Some clients may exhibit signs of an allergic reaction to the ink used in tattooing. They can be immediate or even delayed by years. Some clients may exhibit no signs of an allergy and then following another medical procedure, like a joint replacement or the start of treatment for certain diseases, experience an allergic reaction to the ink. Normally it presents with redness and swelling around the area of the tattoo. The skin can crust and flake, or watery fluid may leak from the site. You may observe small pimply bumps on the skin around the tattoo.

Serious reactions may occur (most often immediately after or during tattooing). They include racing heart, trouble breathing, difficulty swallowing, chest tightness, dizziness, serious pain, flushing or hives. If any of these occur, this is a true medical emergency. 9-1-1 should be called immediately.

A mild reaction will present with a noticeable change within the skin that has been inked. It can be thickened or red, itchy, or painful. If this lasts more than 1–2 weeks the client should be directed to see their physician or dermatologist.

Works cited

1. Prevention of Hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1996;45(No.R.R.15)1-30.
2. Robertson BH, Averhoff F, Cromeans TL, et al. Genetic relatedness of hepatitis A virus isolates during a community wide outbreak. J Med Virol 2000;62:144-150
3. Feinstone SM. Hepatitis A: epidemiology and prevention. Eur J Gastroenterol Hepatol 1996; 8:300-305.
4. Hawn TR, Day TA, Scriba TJ, et al. (December 2014) Tuberculosis vaccines and prevention of infection Microbiology and Molecular Biology Reviews 78 (4): 650-71.
5. Basic TB Facts. Centers for Disease Control and Prevention (CDC.gov). March 13, 2012, accessed March 3, 2020.
6. Grimm L, Payette, MJ, Herpesviruses: Test your Knowledge. medscape.com Accessed March 3, 2020
7. James, William D, Berger, Timothy G. Andrews’ Diseases of the skin; Clinical Dermatology. Saunders Elsevier, ISBN 978-0-72162921-6.

HIV and AIDS

HIV (human immunodeficiency virus) is a virus that is present within the same bodily fluids as those discussed with hepatitis. It attacks the body’s immune system, specifically white blood cells called T cells. After a while, the virus can destroy the T cells to the point that the body has a difficult time fighting off infections. These are referred to as opportunistic infections. They are the most common cause of death in patients with HIV. Certain cancers can also occur because of the impacted immune system. When an HIV patient acquires an opportunistic infection or cancer they are said to have AIDS (acquired immunodeficiency syndrome). This is the final stage of infection with HIV. Not everyone with HIV develops AIDS.⁴

Treatment for HIV has moved ahead leaps and bounds and is now very successful. We will discuss treatment options later in this section. Before the introduction of ART (a common treatment for HIV positive patients), that occurred in the 1990s, people who were HIV positive would rapidly progress to AIDS with an extremely high mortality rate.

HIV is only transmitted via HIV positive blood or OPIM. It is not transmitted by casual contact such as kissing, sweating, or tears. You cannot contract HIV from pets or sharing toilets or food sources. HIV is most commonly transmitted through sexual behaviors or the sharing of needles. HIV can be spread by the following:

• Having sex with an infected partner. This includes anal, vaginal, heterosexual, or homosexual relationships.
• Sharing needles, rinse water, or other equipment that is used to prepare drugs for injection with an infected person. HIV can remain active on a used needle for up to 42 days depending on how it is stored.
• HIV can be given to a child during birth or breastfeeding.
• Although rare, healthcare workers, tattoo artists, or others working with needles and sharps can contract HIV by being stuck with a needle or sharp object that has been used on an HIV positive person.

There is no vaccine available for HIV and there is no cure. There are, however, many treatments available for HIV positive people that can substantially prolong life.

It can take weeks to months after exposure for a person to test positive for HIV. It can take even longer for symptoms to occur. Symptoms of HIV can include any or all of the following:

• Unexplained weight loss
• Fever and chills
• Repetitive infections that are difficult to get rid of despite treatment
• Rashes that remain for long periods
• Fatigue that has no cause
• Night sweats
• Mouth ulcers
• Muscle aches
• Swollen lymph nodes

Join the discussion: What type of HIV tests are available, and how do they work? How soon after exposure can a test detect HIV? Please share your experience. Discuss on Med Talk.

How should my company protect me?

Title 29 of the Code of Federal Regulations: https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030

Bloodborne pathogens can be scary! People who do not understand the risks and how to protect themselves can be very anxious about blood and OPIM. The possibility of exposure in the work environment can be a considerable stressor.

This regulation is the standard requirement for bloodborne pathogen programs and safety in all workplaces that have employees who may be directly exposed to blood. Tattoo artists, healthcare providers, dentists, and hygienists are a small example of those at risk.

States may have standards that go beyond those set forth by the Federal Government under Title 29. The standard for each state is accessible by accessing the website for their Department of Health Regulations and then searching for “Bloodborne Pathogens Standard.”

Although unusual, some local jurisdictions have elected to enact regulations in addition to those provided at the federal and state level. The most common of these are written to regulate tattoo artists who are functioning within their jurisdiction.

https://www.osha.gov/etools/hospitals is a comprehensive review of the Bloodborne Pathogens Standard with potential hazards and possible solutions to each section. This is an excellent reference if you are writing your company’s bloodborne pathogen policies and procedures.

How does exposure occur?

To protect ourselves from exposure, we have to first understand how it happens. Although we are dealing with bloodborne pathogens, you need to keep in mind that other body fluids may be infectious as well. Saliva, vomit, or even droplets from sneezing may contain blood, so all of these fluids are treated as if they are contaminated.

The following is a list of bodily fluids that may carry bloodborne pathogens.

• Breast milk
• Saliva (because it may contain blood, especially in dental procedures or where an injury to the mouth has occurred)
• Semen and vaginal secretions
• Amniotic fluid
• Cerebrospinal fluid (the fluid around the brain and spine) — this is only a danger in the healthcare environment
• Pleural fluid (fluid found between the membranes that surround the lungs) — this is only a danger in the healthcare environment
• Vomit and urine are usually not a danger. However, if they contain any amount of blood, they become potential fluids for transmission.

The microorganisms that cause diseases such as HBV, HCV and HIV are present in the blood of patients who are already infected. Exposure occurs when these pathogens gain entry into your bloodstream in amounts significant enough to cause disease. The amount needed to contract the disease differs depending upon the type of pathogen involved and how well your body can fight it off.⁶

Being exposed to contaminated blood does not necessarily mean that you will become infected. Whether or not you contract the disease will depend on the concentration of germs/viruses in the contaminated blood, the amount of blood that enters your body, and how effective your body is at fighting off diseases (your immune system). Vaccinations play a significant role in preventing the development of diseases that we may be exposed to in many different environments.

The best way to deal with exposure is to prevent it in the first place!

Several factors need to be present for a successful exposure to occur.

• An infection must be present. For example, a new needle that is used for a tattoo or equipment that has been properly cleaned and sterilized contains no infectious materials, so the transmission cannot occur. However, if blood is present from a previous client that is infected with a microorganism such as hepatitis C, and the same equipment is used on another client without being cleaned, the possibility of exposure is high.
• There are a number of ways that exposure can occur.
  • Airborne – the client may inhale droplets in the air.
  • Vector – the client may come in contact with a secondary method of transport such as an insect bite.
• A person can be directly or indirectly exposed to infectious microorganisms.
  • Direct transmission occurs when a person comes into direct contact with blood or OPIM that originated from an infected person. This would include exposure to a client’s blood while performing a tattoo without the use of gloves. Direct transmission can also occur when a healthcare provider or tattoo artist experiences a needle stick while working with an infected person.
  • Indirect transmission occurs when a person is exposed to an infectious agent on an object or in the air. This includes infections that are caused by insect bites. For example, a piece of equipment used on a client that has not been properly cleaned. The previous client was infected with a contagious disease, and their equipment was not cleaned. The contaminated equipment is then used on a second client. The potential for transmission exists from exposure to the infectious agent on the equipment.

Prevention of exposure

There are two ways to prevent exposure. First, to minimize the chances of accidental exposure in the workplace, make sure that proper practices are in place. This can be achieved by educating workers on the safe handling of blood and body fluids. The second is to protect individuals from exposure by providing them with personal protective equipment (PPE).

The guidelines that are followed to minimize exposure to bloodborne pathogens are called universal precautions.⁸ Universal precautions not only protect against diseases that we are aware of such as hepatitis or AIDS but even against those that may not have been discovered yet. Universal precautions assume that all blood and body fluids are contaminated. Universal precautions require that all blood and OPIM be treated as if they are infectious. This means that you should be as careful with EVERY client/patient as you would be with a client/patient whom you know carries an infectious disease.

Sanitation

The work environment must be maintained, clean, and sanitized at all times. Surfaces that do not require sterilization will be decontaminated after each use using a hospital-grade disinfectant solution. The solution can be an EPA-registered tuberculocidal disinfectant or sodium hypochlorite 0.5% concentration, by volume (household bleach is 10% concentration in water). The sodium hypochlorite solution, once correctly mixed, should be dated—do not use if it is more than 24 hours old.

All work surfaces must:

• Be nonabsorbent.
• Be smooth.
• Have no:
  • Open seams.
  • Pits.
  • Breaks.

All surfaces in the work environment will be cleaned and sanitized between patients and clients and after any contamination or exposure to blood or OPIM.

Liquid waste, such as sanitizer, towels, and liquid used for cleaning will be placed in bags and containers that are

• Impervious to moisture.
• Sufficiently strong and thick enough to prevent expulsion.
• Labeled with the biohazard symbol.

Biohazard containers and bags should be stored in a locked area that is not open to the public. The room should have a biohazard symbol prominently displayed on the door.

There must be two separate sinks—one for cleaning equipment and one for handwashing. The handwashing sink must have single-use soap and disposable towels or a hand dryer readily available. No reusable towels are permitted.

Choices of Disinfectants

• SaniZide Plus® Spray – can be purchased in 2 oz spray bottles to disinfect surfaces.
• Microcide SQ® Disinfectant – is an acceptable option. It can be purchased in a concentrate or a spray bottle.

Both of the above disinfectants meet the requirements for use when disinfecting surfaces within a tattoo facility.

Disinfectants for Instruments

• Sklar and Wavicide-01 are both acceptable germicide disinfectant solutions for use on instruments in a tattoo facility.

Remember that Safety Data Sheets (SDS—formerly known as Material Safety Data Sheets, or MSDS) must be placed in an area that provides the employees with easy access. Each chemical that is present in the facility must have an SDS sheet available at all times.

Works cited

1. Occupational Safety & Health Administration. https://www.osha.gov/laws-regs
2. Twitchell KT. Bloodborne pathogens. What you need to know–Part I. AAOHN J. 2003;51:38-47.
3. Twitchell KT. Bloodborne pathogens. What you need to know–Part II. AAOHN J. 2003;51:89-99.
4. OSHA’s bloodborne pathogens standard: analysis and recommendations. Health Devices. 1993;22:35-92.
5. Weinbaum CM, Mast EE, Ward JW. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. Hepatology. 2009;49(5suppl)S35-S44.
6. Beltrami EM, Williams IT, Shapiro CN, et al. Risk and management of blood-borne infections in health care workers. Clin Microbiol Rev. 2000;13:385-407.
7. Wilburn SQ. Needlestick and sharps injury prevention. Online J Issues Nurs. 2004;9:5.
8. Bloodborne pathogens. 1910.1030-OSHA. https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030