SKIN PENETRATION: ACUPUNCTURE, TATTOOING AND EAR PIERCING

In prison tattooing and piercing are usually done with needles and other sharp objects that are often used by someone else before. Small blood particles may remain on the equipment. The infection risks with tattooing and piercing can easily be prevented by using bleach disinfection procedures for sterilizing the needles, or by providing facilities for boiling the syringes (see chapter 6.1 in this chapter). Some basic advice is given here in order to avoid getting infected via skin penetration.

7.1 What is a skin penetration procedure?
Source: www.health.nsw. gov.au/public-health/ ehb/publications
The following recommendations for safer skin penetration are based on the Australian New South Wales Code of Best Practice *12. These skin penetration procedures are adopted to the prison setting and include commonly applied techniques for:

Acupuncture

Tattooing and

Ear piercing

Even if not all recommendations can be followed in the prison, due to a lack of access to cleaning or sterilisation equipments or because of time pressure as tattooing and ear piercing are generally not allowed in most prisons, the recommendations might help to reduce the transmission of blood borne and other infectious diseases to inmates.

The background
Skin that is intact, without cuts, abrasions or lesions, is a natural protective barrier against infection. Penetrating the skin can introduce infective micro-organisms into the body. Infection can occur if equipment that pierces, punctures or penetrates the skin is contaminated, or from direct person to person contact with blood or other body substances. The use of infection control techniques for skin penetration procedures eliminates the introduction of infective micro-organisms into the body.
Unhygienic practices and procedures may affect the health of both prison staff and inmate. Where procedures involving skin penetration are not managed correctly, they have the potential to transmit bacterial and fungal infections, as well as viral infections such as HIV, hepatitis B and hepatitis C.
Skin infections can also occur without breaking the skin. For this reason all equipment must be cleaned between each inmate to eliminate the potential to spread infection. Equipment used in a procedure that does not penetrate the skin, but comes in contact with the skin can spread staphylococcal, streptococcal and pseudomonal infections, all of which are bacterial infections. Other types of skin infections can include herpes (a viral infection), ringworm or tinea (fungal infections), scabies (a form of mite infection). Head lice can also be transferred through contact with contaminated hair.
Micro-organisms are everywhere; they live on skin, in food and dirt. They are easily spread between inmates and operators and are easily transferred by contact with unwashed hands, soiled equipment, or contact with blood and body substances.
Micro-organisms can be present even after cleaning has removed all visible soil and stains. Cleaning can reduce the numbers of micro-organisms, however an invisible trace of blood on equipment that penetrates the skin can spread diseases such as HIV, hepatitis B and hepatitis C.
Inmates must be aware that all blood and other body substances are potential sources of infection. To prevent the transfer of microorganisms, operators must perform procedures in a safe and hygienic manner that include the use of tongs, disposable single use gloves, maintaining clean premises, clean equipment and safe methods of work.

7.2 General
To achieve the highest standard of safety the following advice should be kept in mind:

Hand Washing
Hand washing and hand care are the first steps in any infection control program to prevent the transfer of micro-organisms. Cuts and abrasions on exposed skin should be covered by a waterproof dressing which should be changed as necessary and when soiled. The surface of hands and nails must be cleaned immediately before and after skin penetration.
All surfaces can contain micro-organisms. When surfaces are touched, the micro-organisms can be transferred to the hands.
The more surfaces or items touched the greater the microbial he hands.

¨ Hands should be washed immediately before and after skin penetration procedures!

To protect both the operating inmate and inmate from microorganisms, hands must be cleaned:
Before and after treatment
After contact with any blood or body substance
Immediately prior to putting on a new pair of gloves u Immediately after removing gloves
After touching the nose or mouth
Before and after smoking, eating and drinking
After going to the toilet
Before and after treating wounds or handling soiled wound dressings

The following is the recommended method to clean hands:

Wet hands
Use soap with warm running water
Rub hands vigorously
Wash hands all over, including backs of hands, wrists, thumbs and between fingers for 15-20 seconds
Rinse hands well
Thoroughly dry hands with a single use paper towel

! Do not use nailbrushes for scrubbing hands as they may damage the skin!

Single use equipment
Pre-sterilised single use items are recommended for use in skin penetration procedures. Using pre-sterilised single use equipment with the correct infection control techniques will ensure microorganisms are not being transferred from person to person.
Items that are identified as single use, are not necessarily sterilised.

! It is recommended that single use items are used on each inmate

Gloves for skin penetration procedures
Gloves are worn as a physical barrier to protect the wearer’s hands from contamination and to prevent the transmission of micro-organisms. Single use gloves must be worn at all times during a skin penetration procedure to protect both. This will be problematic to follow in the prison setting, if not possible careful hand washing procedures should be done at least.

! All persons carrying out skin penetration must wear single use gloves during the procedure and dispose of them when finished.

Gloves for cleaning
General purpose utility gloves, e.g. rubber gloves, should be used for:
Equipment cleaning
Decontamination procedures
Handling chemicals
General purpose utility gloves should be washed in detergent, rinsed and left inverted to dry after each use. Gloves should be inspected before each use and discarded if damaged or in a state not able to provide protection. Hands should be washed after using general purpose gloves.

Best practices
The following best practices are recommendations for skin penetration procedures:

Equipment set up:
Unopened bags of sterilised equipment should be set up just prior to the procedure to ensure the skin penetration procedures can be undertaken without interruption. Interruptions increase the chance of transferring microorganisms.
When sterilised equipment is set up for use on an inmate, it should not be removed from its sterile packaging until the procedure is ready to occur.
All equipment set up for use on an inmate is assumed to be soiled after the procedure even if the equipment is not used. All equipment must be disposed, or cleaned and sterilised (if required) before re-use.

Liquids, creams and gels:
Any liquids or gels (eg. lotions, creams, oils and pigments) should be measured and decanted into single use containers for each inmate. Excess or unused liquids and gels must be discarded after completion of treatment.
If liquids or gels can not be decanted separately for each inmate, then single use applicators or spatulas are to be used, and they are not to be re-dipped.
If re-useable containers are used they must be cleaned and sterilised (if required) after each use.
Use collapsible squeeze tubes/bottles or pump packs to dispense liquids and gels.
Liquids and gels should be removed with a clean unused spatula or spoon each time, even when it is for the same inmate.
Never return decanted stock to original containers.
It is recommended that a skin penetration procedure is not performed if the operating inmate has a cut or wound that is not able to be covered sufficiently, and there is the likelihood of the area being exposed to blood or other body substance from the procedure.

7.3 Skin preparation
Before commencing a skin penetration procedure, skin should be wiped with a suitable antiseptic and allowed to air dry. Suitable antiseptic solutions include ethyl or isopropyl alcohol (70-80%) or aqueous or alcoholic formulations of povidine iodine (1 % W/V available iodine).

7.4 Cleaning
Cleaning is the physical removal of dirt from equipment surfaces by washing in detergent and warm water to reduce the number of micro-organisms.
All equipment must be cleaned before it is reused. Cleaning greatly reduces the microbial load on the dirty item. It is essential to clean before disinfection or sterilisation to remove all visible organic matter and other residue. Accumulation of organic matter, detergents or other material on the equipment can inhibit the disinfection or sterilisation process.
All surfaces must be cleaned and rinsed thoroughly and regularly. Surfaces should be cleaned immediately after soiling or spills occur. Effective cleaning ensures that equipment and surfaces are clean to the naked eye and free from any residues.

Cleaning the Equipment
Cleaning involves the use of water, detergent or cleaning agent, and physical or mechanical action. The manufacturer’s instructions should be checked before cleaning.

A good cleaning process includes:
Moving equipment directly to an area set aside and designed for cleaning
Pulling equipment apart and disposing of all non re-useable pieces
Immersing the equipment in warm water and detergent to remove visible soil
Holding the equipment under the surface of the water and scrubbing carefully with a clean brush
Rinsing the equipment with warm to hot water
Allowing the equipment to air dry or using a clean lint free cloth
Storing equipment in sealed containers or in a location that ensures it remains clean, dry and dust free

Care of cleaning equipment
Brushes, utility gloves and other items used to clean equipment must be maintained in a clean and serviceable condition. All cleaning items should be stored clean and dry. Damaged cleaning equipment does not clean effectively and can transfer micro-organisms to the equipment being cleaned, and to other surfaces.
Cleaning items should themselves be cleaned regularly and stored clean and dry.

7.5 Disinfection
Disinfection is the killing of disease-causing micro-organisms except bacterial spores.
All equipment must be cleaned. Cleaning is a critical step in the control of micro-organisms because dirt protects micro-organisms from disinfection. After thoroughly cleaning the equipment will be thermally or chemically disinfected (for the different procedures please look at 6.1 in this chapter).
Disinfection will reduce the microbial load on equipment and surfaces even further but it will not remove all of them. For that reason, all equipment that penetrates the skin must be sterilised and not just disinfected.
Disinfection can be used as an optional best practice technique to help remove micro-organisms. Disinfection will not be effective unless the equipment has been thoroughly cleaned to remove dirt. If equipment that is not designed to penetrate the skin becomes contaminated, it must be thoroughly cleaned prior to being re-used as a best practice method. After the process of disinfection equipment should be left to air dry after the disinfection process. It should be stored in a clean, dry, dust free environment.

! Disinfection is not a substitute for cleaning or sterilisation

The next best solutions to disinfect needles, colour containers and other relevant materials is to use iodine or alcohol solutions. (The procedure is described under 6.1 in this chapter)

7.6 Sterilisation in “emergency cases”
Tattoo needles can be sterilised in emergency cases by cleaning, disinfecting and afterwards putting into an oven (best placed in a home made box of aluminium). The temperature is 200 C for 20-30 minutes. This only works when there are no plastic parts to the needle, because they would melt.

7.7 Questions left and alternatives
Beware that the following problems may arise:
Where to dispose the needles?
How to take care of the new tattoo?
How to avoid medical problems such as contact dermatitis, infections of the wounds?
How to solve problems with regard to piercings in special parts of the body (breast, tongue, earlobe)?
Alternatively, different forms of tattoos may be supported. In Italy (Venice) a group of external HIV/AIDS drug services tries to promote henna as an alternative to traditional tattooing. Of course this is a different culture; tattoos don’t last as long on the body (months rather than permanent), but it does seem to be worth trying (see Emilian/Kampwerth 1998)