Bloodborne Pathogens

Last month we discussed new and emerging pathogens and the importance of protecting yourself as a body art specialist. Although exposure to blood and body fluids by tattoo artists and piercers is relatively low, practicing universal safety precautions is extremely important in the body art industry. A single drop of blood could contain enough disease-causing organisms to cause significant illness. As a body art facility owner or employee, you have no idea what illnesses clients bring in through the front door. Although Hepatitis B is one the biggest viral concerns, other bacterial illnesses can be contracted during contact with small amounts of blood or body fluids during procedures. Depending on the bacterial or viral organism, the incubation period could be anywhere from 3 days to as long as 30 days or longer. That means when the organism is in your system, symptoms of the illness may not appear until days later. During this time, you’re shedding large amounts of the organism without showing symptoms. The Hepatitis B incubation period can be as long as 55 days so during this asymptomatic (no symptoms) period, large amounts of the HBV virus is active and available in your client’s blood during a tattoo procedure. There are more than 200,000 cases of HBV in the United states every year. According to the World Health Organization (WHO), an estimated 257 million people world-wide are living with a Hepatitis B virus infection. Because the Hepatitis virus can live outside the body for as long as seven days, conducting a procedure without using universal precautions can expose a tattoo artist to the virus and a serious illness can start the infection process very quickly.

Symptoms of bacterial and viral infections include nausea, vomiting, diarrhea and abdominal pain. Most of these illnesses go unreported and people do not visit an Urgent Care facility because symptoms usually go away with no need for treatment. If you do visit a medical facility, most doctors will assess the symptoms and decide to prescribe anti-biotics especially if the symptoms involve a fever. A prescription will most likely involve penicillin or a penicillin related drug. Let’s go back in history and take a quick look at the beginning stages of penicillin. Penicillin was considered a wonder drug and saved thousands of lives starting in the 1940’s. Prior to its discovery in 1928, there were no treatments for bacterial infections such as strep throat, tuberculosis and a wide variety of other bacterial infections. If you were lucky, your own immune system may have beaten the infection but that was tremendously rare, and most people died from bacterial infections. Simple cuts, scratches and abrasions almost always resulted in a slow, agonizing death.

Penicillin and its related drugs have been used for over 80 years and have triggered a very efficient defense mechanism in the bacteria they are used to treat. Production of the drug in the United States jumped from 21 billion units in 1943 to 1,663 billion units in 1944 to almost 7 trillion units in 1945. By March 1945 penicillin was distributed through the usual channels and was available to the consumer in his or her corner pharmacy. By 1949, the annual production of penicillin in the United States was 133,229 billion units and the price had dropped from $20 per 100,000 units in 1943 to less than ten cents.

Synthetic manufacture of Penicillin – photo credit: Wikimedia Commons

The cooperative efforts of American chemists, chemical engineers, micro-biologists, governmental agencies and chemical and pharmaceutical manufacturers placed penicillin on a fast track unlike any other drug at the time. As one scientist stated, “Too high a tribute cannot be paid to the enterprise and energy with which the American manufacturing firms tackled the large-scale production of the drug.” He added that had it not been for their efforts there would certainly not have been sufficient penicillin supplies by D-Day in Normandy in 1944 to treat the enormous casualties by both British and American soldiers during that invasion.

Although the discovery of penicillin was a true turning point in human history, even the sharpest and most creative scientists and micro-biologists did not anticipate the repercussions on a molecular level. Bacterial organisms have responded to our fight against them by mutating and protecting themselves against anti-biotics. The molecular fight has taken many years but it appears the tiny microbes are winning the battle and outsmarting our best medical efforts to control and kill them.

Next month, we will continue to discuss anti-biotic resistance due to the misuse of the drug once considered the wonder drug of all time.

New and Emerging Pathogens

Red blood cells inside a blood vessel – high magnification

Despite the advances in engineering, work practices, personal protective equipment and on-going pathogen research, the health risks posed by the handling of blood and Other Potentially Infectious Materials (OPIM), remain very high. Although exposure to blood by tattoo artists and body piercers is relatively low, they are not exempt from universal precautions to protect themselves. A single drop of blood could contain enough disease-causing organisms to cause significant illness. Most body art employees are required to take a bloodborne pathogen class as a condition of employment. The requirements of the OSHA Bloodborne Pathogens Standard continue to be essential in maintaining safe work environments for all employees engaged in handling blood and OPIM.

Employer implementation of the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard has been continually guided by OSHA’s interpretation of the Standard, OSHA’s citations for violations of the Standard and court rulings specific to the Standard. The Standard has motivated manufacturers to introduce new engineering controls (e.g, needleless systems) and develop and produce a wide variety of products that offer greater choice for worksite safety and personal protection.

Even with large federal agencies involved in breakthroughs in work place safety, new and emerging bloodborne pathogens continue to be a major global concern in the past 20 years. OSHA, the World Health Organization (WHO) the Food and Drug Administration (FDA) and the Centers for Disease Control (CDC) are constantly updating their bloodborne pathogen research and information. Pathogens are getting smarter than ever in their constant fight against the drugs used to kill them. Some scientists believe the pathogens are winning. When it comes to matching wits against the tiny organisms that cause a variety of disease from strep throat to whooping cough to tuberculosis and cholera, it’s easy to assume humans have the upper hand and clear advantage. Large brains, clever scientists, state of the art laboratories and powerful computers should easily outpace one-celled organisms. But a disturbing and unsettling number of bacteria are growing resistant to the health industry’s mainstay drugs. Misuse of anti-biotics is part of the problem, experts say.

The discovery of penicillin triggered the anti-biotic era. Before its introduction in 1928, there were no effective treatments for infections such as pneumonia, gonorrhea, rheumatic fever, strep throat and tuberculosis. Turn of the century hospitals were packed with patients with blood poisoning contracted from simple scratches and cuts and doctors were helpless and could do nothing for them but wait and hope. Anti-biotics are compounds produced by bacteria and fungi which are capable of killing or inhibiting microbial species. This phenomenon has long been known and may explain why the ancient Egyptians had the practice of applying a soft, moist mass of moldy bread to infected wounds.

In 1928, penicillin, the first true anti-biotic was discovered by Alexander Fleming, Professor of Bacteriology at St. Mary’s Hospital in London. Fleming began sorting through petri dishes containing colonies of staphylococcus, bacteria that cause boils, sore throats and abscesses. He noticed something unusual on one dish. It was dotted with colonies except one area where a blob of mold was growing. The zone immediately around the mold later identified as a rare strain of penicillin notatum, was clear. The mold had secreted something that inhibited bacterial growth. Fleming found that his mold “juice” was capable of killing a wide variety of harmful bacteria such as streptococcus, meningococcus and the diphtheria bacillus. Fleming wrote, “When I woke up just after dawn on September 28, 1928, I certainly didn’t plan to revolutionize all medicine by discovering the world’s first anti-biotic, or bacteria killer. But I guess that was exactly what I did.”

Fleming had neither the laboratory resources at St. Mary’s nor the chemistry background to take the next giant steps of isolating the active ingredient of the penicillium mold juice. Processing and purifying the mold juice proved to be very difficult. Fleming and his microbiologists tried everything in their power to purify the mold juice but failed consistently. In 1938, the task of purification was taken on by Dr. Howard Florey, a professor of pathology who was the director of the Sir William Dunn School of Pathology at Oxford University. He was a master at extracting research grants from tight-fisted bureaucrats and an absolute wizard at administering a large laboratory filled with talented scientists. In 1942, large pharmaceutical companies began to show interest in assisting Dr. Florey in his endeavors.

To illustrate the complexity and difficulty of purifying the mold juice, one scientist at one of the largest pharmaceutical companies at the time said, “The mold is temperamental as an opera singer, the yields are low, the isolation is difficult, the extraction is murder, the purification invites disaster and the quality control is unsatisfactory.” Even during the difficult, initial stages of the purification process of mass producing penicillin, the drug was ready to be used in 1944.

Next month we will continue to discuss the mass production of penicillin, it’s life saving properties and the eventual over-use of the drug causing massive bacterial resistance.


Last month we discussed government laws, regulations and ordinances that govern the day to day operations of a typical body art shop. We discussed the need for basic safety procedures that must exist in a body art shop to keep body art operators and customers safe. We also discussed how laws are enacted and the importance of government officials developing a working relationship with body art professionals in this law enactment process.

Twenty years ago, using body art professionals as consultants in law making was considered unacceptable and a direct insult to their intelligence. Government officials felt that body art shop owners were nowhere near qualified to assist in the law making process. Now, body art shop owners are actively involved in law making and work side by side with government officials to create a document that is easily understood, easily implemented and easily followed.

Even with body art professionals involved, ordinances can still get a bit vague and refer the reader to federal regulations, state regulations and other applicable laws without giving a specific answer. Let’s dissect some of these references and find out where to access other applicable laws. For instance, a typical government reference dealing with contaminated waste will state, “Red bags and sharps containers must then be disposed of by or delivered to an approved medical waste facility pursuant to but not limited to 29 CFR Part 1910.1030 and the state jurisdiction pertaining to solid waste management regulations promulgated by the particular state’s environment department or special waste regulating entity.”

An “approved medical waste facility” is defined as a facility that legally takes delivery of potentially infectious materials, hazardous waste, special waste and contaminated waste. Clients who use medical waste facilities typically include hospitals, nursing homes, doctor’s offices, dental offices, cremation facilities and any facility that uses syringes in the treatment of patients such as dialysis facilities and blood donation facilities. Body art facilities are now included as clients who occasionally must deliver certain types of waste to medical waste facilities.

Medical waste facilities are much different than residential trash collectors. Residential trash collectors pick up residential waste and deliver it to an approved landfill for proper burial. Medical waste facilities are equipped with special disposal equipment and highly specialized machinery approved by that particular state. Each state medical waste facility must adhere to federal government regulations and be inspected from the time they are built to the time they are in full operation. They typically have controlled flame combustion equipment and other incineration devices such as rotary kilns and liquid injection incinerators capable of thermally breaking down solid waste and rendering it harmless. The specialized combustion equipment typically reaches temperatures of over 3000-degrees Fahrenheit and permanently destroys toxic, organic compounds by breaking their bonds and reverting them to constituent elements (elements to live) thereby removing their toxicity. The leftover material, carbonized ash, is then delivered to a special waste landfill which receives only these types of special waste.

Ordinances around the country can also be vague on identifying the length of time contaminated waste such as sharps and red bags can be stored on site. For instance, the federal law that regulates on site storage of contaminated waste states, “Storage of contaminated waste on site shall not exceed the period specified by the state’s environment department or similar special waste regulating entity.” The reason this reference is vague and details are not included in the wording of an ordinance is because each state can vary on the length of time. Federal laws refer to discarding sharps and blood-soaked material “as soon as feasible” but state laws can determine a safe length of time based on scientific safety data regarding the potential risk of extended hazardous waste storage. Typically, 45 days is the upper limit on the shelf life of contaminated waste. In circumstances where a limited amount of procedures are conducted in a body art shop and only small amounts of sharps are sitting in sharps containers, the 45 day maximum shelf life clock does not start ticking until the sharps container is 2/3’s full. Once it is 2/3’s full, a typical body art shop has 45 days of on-site storage until the body art shop is required to arrange a special hazardous waste pick up from or delivery to an approved medical waste facility of your choice. Some medical waste facilities allow body art shops to deliver their hazardous waste in person to the facility. They will be very specific on how the hazardous waste can be delivered to the facility. Check with the particular special waste facility on the requirements on personal delivery to their site. Although most medical waste facilities allow personal delivery to their facilities, some do not.

Next month, we will discuss where to locate a very simple version of the Code of Federal Regulations for use when body art shop owners decide to start a business and simplify their ordinances.


In previous articles, we have discussed body art regulations, laws and ordinances and how they apply to the daily operations of body art establishments around the country and around the world. A vast majority of the time, government regulations are triggered by job related illness incidents involving injuries and even deaths. Other times, government regulations and laws are enacted because the nature of the business carries inherent risks. The bottom line is government regulations are implemented to minimize or prevent customer and employee health risks and keep business owners protected from potential high dollar law suits. Regulations will not always completely protect these businesses from being sued but will certainly help in court to show the business did their due diligence to demonstrate they made a valid attempt to comply with local laws. Regulations in the body art world are designed to provide artists and body art establishment owners a framework of safe procedures to keep clients and artists free of potential disease events.

Laws and ordinances can get very frustrating because law experts such as attorneys, local government city councils and county commissions write them based on their understanding of the laws that are applicable to a business where a specific health hazard is present such as blood and bodily fluids. In the body art world, government regulators and lawyers usually lack a full understanding of what body art specialists do and how they operate. In the past 15 years a trend toward involving actual body art establishment owners in the formulation of regulations has resulted in a collaboration resulting in a final document that contains common sense and logic on the body art side but also adds the required legal elements on the government side.

Ordinances, regulations and laws are famous for referring the reader to federal regulations, state regulations and other applicable laws without giving a specific answer. Body art business owners are left to attempt to make sense of these complicated ordinances and laws and continue to do business in the complex, vague and confusing world of laws that regulate their daily life. There’s a valid reason when ordinances refer to other applicable laws without providing a specific answer. Laws are updated, amended, changed, adjusted and must be flexible to adapt to new technology. By referring to other applicable codes, they maintain a reasonable level of accuracy and avoid including exhaustive technical references from other codes that could add hundreds of pages to the ordinance. Remember, once an ordinance is enacted and official, it could take years to change or amend it so by referring to other applicable laws, an ordinance will remain accurate for a very long time and not require constant changes based on other applicable laws that could change on a monthly basis.

Although the recent collaboration between body art business owners and government regulators has gone well in most cases, there are still areas in ordinances where government regulations can get vague and confusing. Most body art ordinances contain certain references to other applicable laws. It happens in almost all ordinances, laws and regulations around the country whether they regulate food safety, air quality, medical facilities, dental offices, tanning shops, nuclear power facilities or any area where an accident could result in great bodily harm or death. As a 25 year restaurant health inspector, the local food ordinance and federal food codes that regulate the food service industry are very specific in most cases. Areas like cold holding temperatures, hot holding temperatures and cooking temperatures require numeric values be reached and documented every time. In other areas of the ordinance, however, it’s not unusual to come across statements like, “installed and operated according to city code” or “sized and maintained according to law” or “must comply with city fire department standards.” In the plumbing section of the food ordinance, it refers to a completely separate plumbing code nine times in one paragraph.

Body art ordinances are no different. For instance, a typical government reference dealing with contaminated waste will state, “Red bags must then be disposed of by or delivered to an approved medical waste facility pursuant to but not limited to 29 CFR Part 1910.1030 and the state jurisdiction pertaining to solid waste management regulations promulgated by the particular state’s environment department or similar special waste regulating entity.” Another interesting reference appears regarding the disposal of contaminated waste, “Storage of contaminated waste on-site shall not exceed the period specified by the state’s environment department or similar special waste regulating entity.” You can start to see the potential frustration levels on the part of body art establishment owners after reading vague statements like that. I have worked with hundreds of body art establishment owners since 1998 and most genuinely want to follow the rules if they are explained and interpreted in clear, concise ways.

That’s where city, state and county health inspectors can help. Most health inspectors are trained to decipher, translate and make sense of government references like that. Next month, we will decipher some of the “other applicable laws” and where to locate those references.


When a law regulating body art gets started in any state, public health becomes the primary reason lawmakers make their first move. Although public health is the primary trigger, politics can factor into the decisions and affect the outcome. In the past, the body art industry had always been the unfortunate victim of unfair public perception and inexperienced, untrained and untalented tattooists causing injury and disease. It doesn’t take many confirmed disease incidents or careless tattoo procedures in back alleys or basements of private homes to get the immediate attention of lawmakers and public health officials.

In previous articles, we have discussed government regulations, ordinances and laws that surround any business, particularly body art businesses that carry a potential risk to customers and clients. Although some body art businesses are completely un-regulated, most body art businesses across the United States and throughout the world have some type of safety procedures in place to maintain a minimum level of client and artist safety. In other states, body art ordinances are exhaustive, complicated and almost impossible to decipher. In the body art industry, small amounts of blood and body fluids are inherent to the business. Although significant amounts of blood are generally not seen during a piercing procedure, tattoo procedures can generate enough blood to be a potential health risk if the procedures are not conducted safely and blood borne pathogens are not managed properly.

New pathogens are taking a strong hold and emerging at an alarming rate. Older pathogens such as Hepatitis B, HIV, Methicillin Resistant Staphylococcus Aureus (MRSA) and a variety of bacterial organisms such as e-coli, salmonella, shigella and typhoid fever are constantly evolving, mutating and manipulating themselves at the genetic level to become resistant to the medical industry’s best efforts to control them. Protecting public health has become a primary goal for the World Health Organization, the Centers for Disease Control and the Food & Drug Administration.

Many body art ordinances, laws and regulations in the United States and around the world use these organizations as a starting point to develop procedures for pathogen information and control because they base their information on proven scientific facts. In addition to using these national organizations, body art ordinance, law and regulation developers at the local level also rely heavily on body art industry experts to provide a real world application when they develop any government regulation concerning body art.

Government regulators now actively seek experts and qualified artists in the body art industry to formulate an ordinance covering tattooing and piercing procedures especially when it comes to the actual procedure itself. Body art experts are asked to work side by side with local and state regulators to come up with a plan that is satisfactory to both sides. An example of a collaborative effort that worked very well was in Albuquerque, New Mexico and several other states.

In 1997, a group of committed body art professionals approached the City of Albuquerque’s Environmental Health Department and insisted the industry be regulated. It was tremendously rare to have a group of any kind actually approach regulators with a request of that kind. Prior to the 1998 enactment of the Body Art Ordinance in Albuquerque, tattooing was technically banned in the entire State of New Mexico. The lack of an ordinance certainly didn’t stop tattoo artists from conducting procedures in states where an ordinance was not in force. Local police departments hesitated to get involved because it was alien territory for them. The main objective of this request to be regulated was to bring credibility and trust to an industry being tarnished by untrained and inexperienced tattooists. The new law required strict health and safety standards in all tattoo and piercing shops in the City of Albuquerque and enabled health inspectors to approach the illegal tattooists and cite them for unsafe and unsanitary conditions.

When local city and county government agencies and state regulators begin the process of enacting any new law regulating the body art industry, they sometimes fall a bit short in creating a workable and easy to understand document. They are usually not familiar with the industry and the daily operations of a body art establishment. Regulations and laws were seen as complicated, stifling and counter-productive to small tattoo and piercing shops wishing to start a business. Twenty years ago, using body art professionals as consultants in law making was considered unacceptable and an insult to their intelligence. That has changed.

Next month, we will dig deeper into the professional working relationships between government regulators and tattoo shop owners.



By Jay Cousins



According to the National Vaccine Information Center (NVIC) there is a difference between federal vaccine policies and state vaccine laws. Federal public health officials at the Centers for Disease Control (CDC) make national vaccine policy recommendations for children and adults. With the approval of state legislatures, public health officials in state health departments make and enforce vaccine mandates. That’s why vaccine laws and legal exemptions to vaccination vary from state to state. Although the NVIC is a public charity, anti-vaccination group, one of their primary messages remains to encourage well informed vaccine decision making by parents of small children.

Whether you support vaccinations or not, the chronic version of the hepatitis virus remains a disease whose risks are significantly higher due to complications from actually contracting the disease than the potential complications after receiving the hepatitis vaccine. Body art operators are not required to get the HBV vaccine but in most states, it is strongly recommended. Body art operators in most states can decline the HBV vaccination series but owners of body art establishments must then provide HBV brochures that explain the risks of contracting the disease.

According to the CDC, the number of chronic infections per year has declined from an average of 260,000 in the 1980’s to about 3000 as of 2014. The greatest decline in chronic HBV infections has occurred among children and adolescents The steady decline since the 80’s is largely due to vaccination strategies and an intense and unrelenting public awareness campaign designed to educate the public on the dangers and possibly life-threatening consequences of contracting the disease.

Recall for some people, HBV is an acute, or short term illness but for others such as infants and adolescents, it can become a long term, chronic infection. The chronic version of HBV can cause a chronic liver infection that can later develop into cirrhosis of the liver and liver cancer. The likelihood that an infection with the virus becomes chronic depends on the age at which a person becomes infected. Children less than 6 years old who become infected with the hepatitis virus are the most likely to develop chronic infections. According the the World Health Organization, (WHO) 80-90% if infants infected during the first year of life develop chronic infections and 30-50% of children infected before the age of 6 years old develop chronic infections.

The primary reason hepatitis vaccinations are strongly recommended is because of the dangerously long incubation period of the disease. The incubation period of the hepatitis virus can be as long as 120 days after initial exposure. During that time, most victims will typically not show symptoms but still be shedding millions of HBV particles in their stool, saliva, vaginal discharges and urine.

Laboratory diagnosis of HBV as well as HAV focuses on the detection of the hepatitis surface antigen HBsAG. If the antigen is present, there is a high likelihood that the virus is in the human bloodstream. Early detection of prostate cancer is done the same way. Blood is drawn and analyzed for prostate specific antigen (PSA). High numbers trigger additional testing in the same way the antigen for HBV is detected in the bloodstream. The World Health Organization recommends that all blood donations be tested for HBV to ensure blood safety and avoid accidental transmissions to people who receive blood products.

In 2015, WHO launched its first “Guidelines for the Prevention, Care and Treatment of Persons Living with Chronic Hepatitis Infection.” Their recommendations are to promote the use of simple, non-invasive diagnostic tests to assess the stage of liver disease and eligibility of treatment, to prioritize treatment for those with the most advanced liver disease and recommend the preferred use of nucleotide analogues with a high barrier to drug resistance in children between the ages of 2-11 years for first and second line treatment.

When babies become infected at birth or during infancy, only 10% clear the infection due to their immature immune systems. The remaining 90% develop chronic HBV. Most pregnant women do not know whether they are infected with HBV due to the lack of symptoms and extended incubation period and can unknowingly pass the virus to their newborns during child birth. Therefore, since the risk of newborns becoming chronically infected at birth is so high, both the WHO and CDC recommend that all infants receive their first dose of the HBV vaccine within 12-24 hours after birth.

By Jay Cousins