Medical Mechanics of Tattooing

Originally written for Tattoodles.com  in 2005 these articles detail the history of the tattoo machine, tattoo history and methods and health issues associated with tattooing.

Permanent tattooing of any form carries inherent risks, including infection and disease.

I'm reminded of an Outer Limits or Twilight Zone movie scene, I don't recall which, where the antagonist is a "clean-freak", lives in a white, sealed apartment and wears gloves and a mask and is constantly cleaning, he sees a cockroach, tries to kill it, does so and then....thousands of roaches swarm into the sealed room through every drain, air vent and electrical outlet. Great scene; "but what does that have to do with tattooing?" I hear you ask. Well our lives are a bit like that, of course on a much, much smaller scale. They are all around, on surfaces and airborne, Consider the fact that one sneeze can project 100,000 droplets of mucus a distance of up to 10 meters at a speed of 99 miles per hour and if that sneeze contains any germs, (it does) they'll be spread too, let alone the amount of possible nastiness carried in our blood. At a microscopic level we are being swarmed by germs, the vast majority are harmless; however some may even be fatal.

As living organisms they do adapt and evolve with their environmental conditions, the continued use of low dose disinfectants may in fact increase their resistance to these chemicals and produce stronger strains so correct sanitation and infection prevention is vital to a safe(er) and healthy environment. The tattoo studio is no exception.

Tattooing saves the day, again...

The study of cross-contamination (the spread of germs from one place to another by human interaction) was first discovered through a survey of tattooing. Yes, one more invaluable contribution that the tattooing culture has passed on into global knowledge. 
In 1861 Ernest Berchon, a French Naval surgeon, published a paper on the medical complications of tattooing noting that the spread of syphilis was observed from one soldier to another, the later being a virgin and the tattooer was seen to spit into the drying pigment, several times, during the tattoo process. Berchon guessed that the organic matter contaminating the needles or pigment was responsible for the resulting infection and he wasn't far from the truth.

This was a revelation in medical circles because microorganisms were not known to cause infection at that time.

Surgeons did not wash hands or wear gloves and went from one patient to the other with contaminated clothing and skin spreading whatever disease was living in the fluids. Infection, as we know it, was considered a normal and healthy part of the healing process, pus and mucus secretions were seen as manifestations of the disease being expelled from the body. Excuse me while I pause to shudder........thank you.

As a result of these findings the medical field cleaned up its act, literally, and the cases of serious infections, blood poisoning, gangrene and death were reduced in hospitals and clinics across the world. The sheer number of

people tattooed under such conditions and the lack of reported infections lead me to believe that either infection was not common for those getting tattooed or that no one noticed or cared. The later is more feasible.

The CDC categorizes tattooists as "personal service workers" along with hairdressers, barbers, manicurists, acupuncturists, and massage therapists. Since the early 1980s, this category of workers has received intense scrutiny in ongoing CDC investigations of how the HIV virus that causes AIDS is spread. In its HIV/AIDS Surveillance Reports, the CDC has consistently noted that it has documented "no cases of HIV transmission through tattooing" anywhere in the USA since it began tracking such data in 1985.

No documental basis exists to support public perception that the process of contemporary commercial tattooing is unreasonably disease-prone rather it is the result of the demonizing of the tattoo culture by agenda driven political and religious groups that has kept this general idea alive for a few thousand years. Alright already I'll put the soap box away.
Infection from tattooing in a clean and modern tattoo studio is rare. 
Potential infections include everything from surface infections of the skin to Staphylococcus infections that can cause cardiological damage.

Universal Precautions, Standard Precaution and Clean vs. Sterile.

The Laboratory Centre for Disease Control, Health Canada and the U.S. Centers for Disease Control developed the strategy of "Universal Precautions" in 1983 to prevent occupational contact with patient blood and body fluids. "Standard Precautions", as defined by the Center for Disease Control in 1996, stress that all customers should be assumed to be infectious for blood-borne diseases such as AIDS and hepatitis B/C.

These strategies include:

Personal Protective Equipment (PPE) - PPE includes gloves, face masks etc.
Engineering Controls - Engineering controls refer to methods of isolating or removing hazards from the workplace. Examples of engineering controls include: sharps disposal containers, biohazard containers for wipes and disposable plastic barriers on power supply cords and water/spray bottles etc.
Work Practice Controls - Refers to practical techniques that reduce the likelihood of exposure by changing the way a task is performed. Examples of activities requiring specific attention to work practice controls include: training requirements, housekeeping, hand washing, careful handling of used needles and other sharps and frequent changing of gloves.
If your tattoo artist reaches for something that does not have a plastic barrier film specifically put on it for your session alone, he/she has contaminated that ink bottle/clip-cord/tattoo machine/telephone/door handle/dancing bear etc.

In order for an infection to occur four conditions must exist:

1.    The infectious agent must be present i.e. a virus.

2.    The entry site for infection must present i.e. a cut or needle stick.

3.    The mean of transmission must be present i.e. a contaminated object/surface contacting the entry site.

4.    The conditions for infection must be present i.e. sufficient infectious agent.

5.    Without all of the above, infection will not happen. Standard Precautions will stop one, two or all of these conditions.

The simple act of washing your hands, for at least twenty seconds under hot water with soap, will reduce the level of infectious agents by almost 95%.
PPE and barrier films (i.e. a plastic bag covering the tattoo machine) are considered clean, not sterile, that is to say they are new and fresh but have not been subjected to the processes needed to kill bacteria, fungi and viruses. This is where the Autoclave comes in.

The Vacuum Steam Autoclave is pretty much industry standard and mandated by law in most jurisdictions. It uses a combination of heat (250-270F) and several times atmospheric pressure (15-30 psi) to kill anything living on the instruments/equipment being sterilized: needles, tubes etc. It is possible for an instrument to be sterile but not clean. If proper pre-sterilization procedures have not been followed such as meticulous scrubbing, the casings and exoskeletons of organisms will remain, pigment particles from previous usage and residual fluids may be present. The autoclave process will kill anything living but does not remove these contaminate. In some cases a "bio-film" can build up overtime and actually protect organisms underneath it from the effects of an autoclave leaving them active and with the potential to infect.
Heat sterilization and chemical processes exist which also kill germs and remove contaminates but these methods come with additional dangers like chemical storage and fire hazard. Steam sterilization is used by hospitals and dentists and seems to be a very friendly, easy to monitor method for the tattoo studio. Autoclaves should be tested on a regular basis to determine the operational status of the machine.

Hard surface cleaners are also used to reduce the possibility of contamination and all surfaces should be cleaned between clients. Stencil application should not be done with a common surface such as a direct application of deodorant which could be exposed to shaving cuts from previous clients and can build up a colony of bacteria between tattooing sessions. 
So look for the "set up", drop-cloth, ink caps, needles, lubrication lotions and tubes etc. to come out of sterile packages, one time use only and disposed of after the tattoo. Personally, I set up my equipment in front of the client so they have the opportunity to see the process and ask any questions about what and why I'm doing what I do.

An open door or window to the outside world is not going increase your chance of infection. 
From the use of sterilization equipment to the use of plastic coverings on wash bottles, proper hand washing, frequent glove changing and clean working habits, aftercare sheets and proper covering for fresh tattoos, all go towards ensuring that the client has a safe and pleasant experience in the studio. We as tattooists should think of it as ensuring that we will be alive to continue tattooing for many more years to come. We value our health and that of our clients; they put a huge amount of trust into the artist to make them a piece that'll last them a lifetime and when they refer a friend in ten, twenty or thirty year's time we will be ready to receive them and give them the attention they deserve in a suitable environment. 
Respect is the bottom line; does the artist respect his/her own wellbeing and that of the customer? If the answer is yes then all possible precautions are taken and all will be well in the world, if the answer is no then walk away and find another place, another artist who does respect you and your tattoo.

Paul Roe
Washington DC
2005