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Tattooing and
body piercing
guidance
Toolkit
Main contentsTattooing and body piercing guidance
t
o lki ACKNOWLEDGEMENTS
To
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FOREWORD
ENDORSING ORGANISATIONS
INTRODUCTION
USING THE GUIDANCE
TOOLKIT
ACKNOWLEDGEMENTS
Acknowledgements
These guidelines are extensively based on the Tattooing and Body Piercing Guidance: Toolkit
which was published by the Chartered Institute of Environmental Health (CIEH) London in 2013.
We acknowledge the contributions of the original authors and also those who contributed to the
production of this Northern Ireland version as set out below:
TATTOOING AND SKIN PIERCING WORKING GROUP MEMBERS
Chartered Institute of Environmental Health
Department of Health, Social Services and Public Safety (DHSSPS)
Public Health Agency
Health and Safety Liaison Group for Northern Ireland
Subgroup of the Chief Environmental Health Officers Group
(CEHOG)
January 2014
➲ Main contents
2Tattooing and body piercing guidance
t
FOREWORD 2 Appendix 03 42
lki
o ENDORSING ORGANISATIONS 3
Safe use and disposal of sharps
Appendix 04 43
To
INTRODUCTION 4–5 First Aid following a blood/body fluid exposure
USING THE GUIDANCE TOOLKIT 6 Appendix 05 44
Protocol for cleaning up blood or a blood
PART A stained body fluid spill
Section 01 7 – 12
CONTENTS Legislative background on tattooing and skin
piercing activities
Appendix 06
Principles for good waste handling
45
Section 02a 13 Appenendix 07 Template protocol for
environmental cleaning of premises
Standard Principles of Infection Control
Appendix 08 46
Section 02b 14 – 15
Tattooing/body piercing consent form
Principles of Infection Control – Hand hygiene
Appendix 09 48
Section 02c 16 – 18
Aftercare follow-up record sheet
Principles of Infection Control – Personal
protective equipment Appendix 10 49
Decontamination requirements for equipment
Section 02d 19 – 21
used in tattooing and skin piercing
Principles of Infection Control – Management
of sharps and exposure to blood and body fluids Appendix 11 50
Equipment sterilization standard- self
Section 02e 22 – 23
assessment and decision making tool for
Principles of Infection Control – Safe handling,
tattoo and body piercing practitioners
storage and disposal of waste materials
Appendix 12 51
Section 02f 24
Equipment and body piercing jewellery
Principles of Infection Control – Cleaning and
sterilization standard for tattooists and body
disinfection of the environment
piercers
Section 02g 25
Appendix 13 52
References
Autoclave daily record sheet
Section 03 26 – 27
Before and aftercare of a tattoo or body piercing PART C
Leaflets to download and print out
Section 04 28 – 32
01 Tattoo aftercare 53
Decontamination
02 Ear and face piercing aftercare 54
Section 05 33 – 34 03 Oral piercing aftercare 55
Product quality of tattoo ink
04 Body and surface piercing aftercare 56
Section 06 35 05 Genital piercing (female) aftercare 57
Body piercing jewellery 06 Genital piercing (male) aftercare 58
Section 07 36 – 37 07 Microdermal implants aftercare 59
Governance Poster to download
Section 08 38 How to handwash 60
Management of infectious disease incidents
relating to tattooing and body piercing PART D
Audit Tool to download 61
PART B
PART E
Appendix 01 40 – 41
Literature review to download 62
Infection, its causes and sprad, including
a glossary of infection-related terms
Appendix 02 41
Blood borne viruses
3Tattooing and body piercing guidance
t
o lki FOREWORD
To
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FOREWORD
ENDORSING ORGANISATIONS
INTRODUCTION
USING THE GUIDANCE
GARY MC FARLANE DR LORRAINE DOHERTY
TOOLKIT
Director, Chartered Institute of Assistant Director for Health Protection
Environmental Health Northern Ireland Public Health Agency
Tattooing and body piercing have become The tattooing and body piercing industry has
increasingly popular and fashionable. Ensuring seen a period of growth in Northern Ireland in
practitioners follow safe working practices is recent years.As such there is now an increased
important for protection of both clients and need to ensure that those who are working
the practitioners themselves. This toolkit has in this field are supported in delievering safe
been developed specifically for Northern parctice.As an interactive document, this toolkit
Ireland following the publication of a similar acts as a framework for good infection and
resource for England.In doing so we have control practice which enables the user to access
collaborated and worked with the relevant NI the sound evidence based guidance and to
agencies, notably the Department of Health appropriately manage infection risk. I would
Social services and Public Safety (DHSSPS), like to acknowledge the excellent collaborative
the Public Health Agency and the Health and working of health protection colleagues from
Safety Liaison Group (HSLG), a subgroup of PHA,PHE and CIEH and colleagues from the
the Chief Environmental Health Officers Group tattooing industry that has resulted in the
(CEHOG). We hope that the resources will prove publication of this invaluable tool. Its my
a practical tool for practitioners. pleasure to endorse this guidance toolkit as a
key resource for practitioners in the industry
PATRICIA ALLEN which can only lead to better health outcomes
Assistant Director of Northern Group for service users.
Systems Environmental Health
This guidance toolkit aims to influence
NIGEL MC MAHON
tattooing and body piercing practices Chief Environmental Health Officer
in Northern Ireland, in particular by the Department of Health, Social Services &
promotion of evidence based prevention and Public Safety
control measures. It provides easy access Infection prevention and control is a
to key guidance and best practice, giving paramount public health concern.The
practitioners and others a single authoritative promotion of safe working practices is
source of information.By doing so it is hoped important for practitioners, clients and public
that standards of safety and hygiene delivered health professionals including environmental
across the range of tattooing and body health staff. This reference guide attempts to
piercing practices will be consistently high for bring all of the relevant information together
Northern Ireland consumers. in one place for the benefit of those involved
in the industry, as well as for those that seek
to advise and regulate it. The guide has been
produced in partnership with a number of
organisations and individuals and I would offer
my thanks to all those involved. On behalf of
the working group, I would also like to record
our appreciation of the Chartered Institute
of Environmental Health for carrying out the
editing, web design and publication of the
toolkit online.
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4Tattooing and body piercing guidance
t
o lki ENDORSING ORGANISATIONS
To
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FOREWORD CHARTERED INSTITUTE OF PHA is a multi-disciplinary, multi-professional
ENDORSING ORGANISATIONS
ENVIRONMENTAL HEALTH (CIEH) body with a strong regional and local presence.
It has four key functions:
INTRODUCTION The CIEH is a registered charity and the
USING THE GUIDANCE professional voice for environmental health. • health and social wellbeing improvement;
TOOLKIT It sets standards, accredits courses and
qualifications for the education of members • health protection;
and other environmental health practitioners.
• public health support to commissioning
It provides information, evidence and policy
and policy development ;
advice to local and national government
and environmental and public health • HSC research and development
practitioners in the public and private sectors.
As an awarding body, the CIEH provides The PHA also work to create better inter-
qualifications, events, and support materials on sectoral working,including enchanced
topics relevant to health, wellbeing and safety partnership arrangements with local
to develop workplace skills and best practice. government, to tackle the underlying cause of
poor health and reduce health inequalities.
THE DEPARTMENT OF HEALTH,
SOCIAL SERVICES AND PUBLIC NORTHERN IRELAND CHIEF
SAFETY (DHSSPS) ENVIRONMENTAL HEALTH
OFFICERS GROUP
DHSSPS was established by the Departments
(NI) Order 1999. It is the Department’s mission The Northern Ireland Chief Environmental
to improve the health and social well-being of Officers Group (CEHOG) was formed as a
the people of Northern Ireland. liaison body to provide a forum to unite the
local government environmental health
The Department has three main business service in Northern Ireland and to establish
responsibilities: and maintain effective services partnerships
with bodies having an influence upon health
• Health and Social Care (HSC), which
in NI communties. The fundamental remit is
includes policy and legislation for
to aid the co-ordination and consistency of
hospitials, family practitioner services and
environmental health services, to assist the
community health and personal social
development of highly quality services and to
services:
provide a consultative body with links to other
• Public Health which covers policy, agencies and departments to facilitate the
legislation and administrative action to passage of advice on relevant policy matters.
promote and protect the health and well-
Membership of this liaison body includes all
being of the population; and
twenty six District Chief Environmental Health
• Public Safety, which covers policy and Officers, (or equivalent in title and function),
legislation for fire and rescue services. the four Group Chief Environmental Health
Officers and from outside local government,
THE PUBLIC HEALTH AGENCY the Chief Environmental Health Officer,
(PHA) DHSSPS and the NI Director of the Chartered
Institute of Environmental Health.
From its establishment in 2009, Public Health
Agency provides a renewed and enchanced
focus on public health and wellbeing by
bringing together a wide range of public health
➲ Main contents functions under one organisation.
5Tattooing and body piercing guidance
t
o lki INTRODUCTION
To
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FOREWORD This guidance toolkit has been prepared by a panel of health protection
ENDORSING ORGANISATIONS and practitioner representatives. It comprises a consensus of expert advice
INTRODUCTION which it is intended will provide an authoritative source of information.
USING THE GUIDANCE Its contents are supported by extensive literature reviews (Part E).
TOOLKIT
The purpose of the guidance toolkit is to support local authority and other
regulatory officers in determining their requirements for effective control
of risk in these activities and to promote a consistent approach. Similarly, it
is intended to be of assistance to practitioners and businesses undertaking
these activities to support them in adopting acceptable standards of
practice. The use of this guidance toolkit will help to ensure the health and
safety of both clients and operators and that tattooing and skin piercing
practitioners will be operating in compliance with legal requirements.
BACKGROUND Over the years a variety of legislation has
been introduced, mainly for local adoption,
Tattooing and body piercing procedures have
to encourage and support safe practice.
become more popular and fashionable in the
Model byelaws have been made available,
United Kingdom (UK) as a whole, particularly
but have not been accompanied by standard
in the last decade. The range of tattooing and
requirements for compliance. As a response
body piercing procedures has also increased.
to on-going concerns, a number of sets of
There are no published data on the prevalence
local/regional guidelines have been developed
of tattoos in the general UK population. There
by different agencies, often initiated by
are also no comprehensive data for the UK on
environmental health or health protection
the prevalence of body piercing, but a small
specialists (this guidance toolkit draws upon
study has estimated that the prevalence of
some of the previously published material).
body piercing, other than of earlobes, in the
However, there have been difficulties previously
general adult population in England was 10%
in engaging practitioners in the development
(Bone A et al, 2008).
of such guidelines and in securing adoption
There are known and well reported health risks and wider implementation.
which can be attributed to these procedures,
It is also recognised that there are no nationally
as well as associated legal issues. Improper
recognised or accredited training courses,
and unhygienic practice may result in localised
standards for practice, agreed knowledge and
skin infections at the site of the tattoo or
skills frameworks or arrangements for monitoring
piercing. There is also the risk of transmission
and reporting of professional competence.
of blood-borne viruses, for example Hepatitis
The absence of accredited training and
B, Hepatitis C, Hepatitis D or HIV, which can
competencies for tattooing and body piercing is
have more serious and long term health
an area that needs to be addressed nationally
consequences. It is therefore important that
and is outside the scope of this guidance. The
practitioners have safe working practices,
working group has, however, been greatly
and particularly that good infection control
assisted in the preparation of this guidance by
practices are followed at all times, so that both
the Tattoo and Piercing Industry Union who are
clients and practitioners are protected.
recognised as a professional body for tattoo and
body piercing practitioners in the UK.
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6Tattooing and body piercing guidance
t
o lki INTRODUCTION (continued)
To
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FOREWORD DEVELOPMENT OF THE GUIDANCE
ENDORSING ORGANISATIONS
FOR NORTHERN IRELAND
INTRODUCTION This guidance was developed in response to
USING THE GUIDANCE concerns raised by tattoo and body piercing
TOOLKIT practitioners, as well as health protection
and environmental health specialists. These
concerns were particularly in regard to the
lack of robust and consistent guidance on
standards of hygiene and safety. This has
been leading to inconsistency in advice and
variations in standards of practice.
A multi-agency steering group was set up
comprising representatives from the Chartered
Institute of Environmental Health,Department
of Health and Social Services and Public Safety
(DHSSPS), Public Health Agency (PHA) and the
Health and Safety Liaison Group for Northern
Ireland (a subgroup of the Chief Environmental
Health Officers Group) and also individuals with
practical experience of working in this area as
expert advisors, practitioners or regulators.
The guidance is supported by extensive
documentary evidence of scientific knowledge,
reported research and published literature
encompassing expert advice and the opinions
and experience of practitioners of what works
at a practical level.
References
Bone A., Ncube F., Nichols T. & Noah ND. (2008)
Body piercing in England: a survey of piercing at
sites other than earlobe. BMJ; 336; 1426-1428.
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7Tattooing and body piercing guidance
t
o lki USING THE GUIDANCE TOOLKIT
To
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FOREWORD The guidance has been written as a key point of reference for use nationally
ENDORSING ORGANISATIONS by tattoo and body piercing practitioners who work in regulated premises,
INTRODUCTION local authority officers in their regulatory role and health protection staff
USING THE GUIDANCE who are asked to provide expert advice. The guidance does not cover mobile
TOOLKIT
operators or non-registered practitioners, although the risks encountered
THE AUDIT TOOL
in relation to their activities will be of equal or greater concern. It does not
PROVIDING FEEDBACK
address the risks associated with procedures other than those commonly
accepted as necessary for tattooing and the insertion of body jewellery,
although the procedures recommended for infection control are based upon
sound principles of infection control and will have wider application.
The material is arranged so as to be readily No copyright is being claimed for the toolkit or
accessible as a web-based toolkit, organised any of the material it contains and the authors
in a manner that reflects the tattoo and encourage its wider distribution and use.
body piercing setting, and with supportive
documentation and literature that can be In offering and using the advice contained in
downloaded and saved or printed in the this guidance it must be clearly understood that:
manner that users prefer. • Legislation may change over time
and the advice given is based on the
It is intended that the adoption of the
information available at the time this
standards recommended in this guidance,
toolkit was produced – it is not necessarily
particularly those relating to infection control
comprehensive and is subject to revision in
and decontamination, will help to establish
the light of further information.
standards for good practice. Governance is
promoted by the inclusion of template consent • Only the courts can interpret legislation
forms, aftercare advice leaflets and a good with any authority, and
practice infection control audit tool. • This advice is not intended to be definitive
legal guidance nor is it a substitute for the
THE AUDIT TOOL relevant law and independent legal advice
should be sought where appropriate.
This audit tool can be downloaded and used
as individual sections or as a complete tool. PROVIDING FEEDBACK
It is intended to be used by tattoo and body
piercing practitioners, regulatory officers and We hope you find the guidance useful. It is
health protection practitioners to generate intended that the document wiil be revisited
evidence of the environment, practice and and updated periodically. To that end feedback
procedures in meeting standards and whether on your experience is positively encouraged.
practitioners are applying best practice and Feedback can be sent to Gary Mc Farlane,
following guidance. The tool can be repeated g.mcfarlane@cieh.org Director of The
to see if standards have been maintained or Chartered Institute of Environmental Health
improved. Northern Ireland.
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8Tattooing and body piercing guidance
t
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To
Legislative background on tattooing
Section 01 and skin piercing activities
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SUMMARY SUMMARY General controls
Specific controls The use of legislation in this area of activity The primary health and safety legislation in
General controls is primarily to ensure that infection control Northern Ireland (NI) is the Health and Safety
Determining requirements arrangements are adequate and effectively at Work (Northern Ireland) Order 1978 (HSWO).
REGISTRATION AND carried out wherever tattooing and skin It can be used to impose and enforce infection
BYELAW REQUIREMENTS IN control requirements in relation to all skin piercing
piercing are carried out.
NORTHERN IRELAND activities, including peripatetic practitioners who
HEALTH AND SAFETY AT The primary means of enforcing infection visit a client’s home. It allows for immediate
WORK (NI) ORDER 1978 control arrangements is by use of registration prohibition of persons or activities that pose an
General duties and the observance of provisions contained imminent risk to health or safety.
Risk assessment in byelaws.The registration and byelaw
Control of substances provisions are largely concerned with setting Determining requirements
hazardous to health
requirements for good standards by requiring It is intended that this guidance will provide an
Management of contractors
the maintenance of established hygiene additional authoritative source of information
Enforcement controls in respect of premises, equipment, to support local authorities in determining
AGE LIMITS AND CONSENT procedures and practices. However, there their requirements for effective control of risk
Tattooing are additional controls contained in primary in these activities and adopting a consistent
Other skin piercing activities legislation that do contain provisions for the approach in the application of the legislation.
Acupuncture and electrolysis immediate prohibition of activities or persons Similarly, it will be of assistance to those
Consent or for the closure of premises where risk of businesses and practitioners undertaking
USE OF LOCAL ANAESTHETIC infection can be demonstrated. these activities to ensure that they are able
MEDICATION
to operate safely and comply with legal
The legislation relating to tattooing and skin
requirements.
piercing activities,can therefore be broadly split
into two main areas:
• Specific controls by registration of premises
and people carrying out the activities, and
associated byelaws, and
• General controls of activities through primary
legislation that is not specific to particular
activities but applies to all of them.
Specific controls
Arrangements for registration will differ
depending on the particular requirements of
the local authority in whose area the business
is located or the activity is being carried out.
The majority of local authorities have adopted
byelaws in respect of the standards for the
maintenance of established hygiene controls
in respect of premises, equipment, procedures
and practices.
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9Tattooing and body piercing guidance
t
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To
Legislative background on tattooing
Section 01 and skin piercing activities (continued)
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SUMMARY REGISTRATION AND BYELAW Article 15 of the 1985 Order provides for
Specific controls REQUIREMENTS IN NORTHERN offences and for non-custodial penalties
General controls IRELAND (summary conviction and fine) for trading
Determining requirements without council and registration or breaching
There are provisions in Part V of the The
REGISTRATION AND council byelaws. The court may also order
Local Government (Miscellaneous Provisions)
BYELAW REQUIREMENTS IN suspension of, or cancellation of registration
Northern Ireland Order 1985 (LGMPO) for local
NORTHERN IRELAND (whether of a person or premises) on
authorities in NI to require the registration
HEALTH AND SAFETY AT conviction. When cancellation of registration
of persons carrying on the practices of
WORK (NI) ORDER 1978 happens, the court may order a fine, increased
acupuncture, tattooing, ear piercing or
General duties on a daily basis for late surrender of the
electrolysis. These powers are adoptive, and
Risk assessment cancelled registration certificate. There is also
local authorities are able to choose which
Control of substances an offence of not displaying a certificate of
hazardous to health of these practices would be required to be
registration or byelaws (in respect of which a
Management of contractors registered in their area The Local Government
person is liable on summary conviction to a
Enforcement (Northern Ireland) Order 2005 added semi-
fine).
permanent skin-colouring and cosmetic
AGE LIMITS AND CONSENT
piercing to this list of activities for which The penalties for offences are fines on the
Tattooing
registration can be required. Standard Scale of Level 3 (currently £1000) for
Other skin piercing activities
Acupuncture and electrolysis
offences under Article 15(1),Article 15(2), and
The Order allows for local authorities to
Consent Level 1 (currently £200) for an offence under
make byelaws, for the purpose of securing;
Article 15(9).
USE OF LOCAL ANAESTHETIC the cleanliness and hygiene of premises,
MEDICATION practitioners and equipment. These measures There are some exemptions from the
are intended to increase health protection and registration requirements. It does not apply to
reduce the risk of transmission of blood borne practices carried out by or under the supervision
virus infections. of a person who is registered as a medical
practitioner (a Doctor registered with the
The local authority can request reasonable
General Medical Council) or for acupuncture
information from applicants for registration.
by a dentist, or chartered physiotherapist, or
This cannot include details concerning persons
a state registered physiotherapist, or a state
whom the applicant has given treatments to,
registered chiropodist, or to premises under
however, it could include evidence of training
their supervision.
or competency for those being registered.
Local authority officers can be authorised to
The registration is mandatory in that the
enter any premises where they have reason
local authority must issue a registration if
to believe that an offence under Article 15
the application has been properly made. A
is being committed there, but where entry is
registration can only be refused where a person
refused the authority of a warrant issued by a
has previously been convicted of an offence
Justice of the Peace has to be obtained.
under Article 15 of the 1985 Order and the
convicting magistrate suspended or cancelled The Department of Health Social Services and
the previous registration. A registration can only Public Safety (DHSSPS) issued guidance on the
be cancelled by a magistrate upon conviction legal provisions relating to the regulation of
of an offence, and this is instead of or in cosmetic piercing and skin colouring businesses
addition to a fine. in 2005. The document also provides model
byelaws which local authorities could formally
adopt as well as guidance on the procedure for
the confirmation of byelaws by the DHSSPS.
➲ Main contents
http://www.dhsspsni.gov.uk/bodypiercing-
10 order.pdfTattooing and body piercing guidance
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To
Legislative background on tattooing
Section 01 and skin piercing activities (continued)
Click on text to view HEALTH AND SAFETY AT WORK The Management of Health and Safety at
SUMMARY
(NI) ORDER 1978 Work Regulations (Northern Ireland) 2000
requires all employers and self employed
Specific controls The Health & Safety at Work (Northern
persons to:
General controls Ireland) Order 1978 (HSWO) applies to all
Determining requirements persons engaged in tattooing and skin piercing • Undertake a risk assessment of their
REGISTRATION AND activities for gain or reward. This includes activities;
BYELAW REQUIREMENTS IN peripatetic workers who carry out treatments • Remove, where possible, that risk or;
NORTHERN IRELAND
in the client’s home, although only the Health • Where residual risk is unavoidable, to
HEALTH AND SAFETY AT & Safety Executive for Northern Ireland have
WORK (NI) ORDER 1978
provide control measures to reduce it as
powers in relation to peripatetic workers. far as possible, including as a last resort,
General duties
Risk assessment It provides means of securing effective provision of personal protective equipment;
Control of substances infection control and the following areas are • Provide training to staff and persons they
hazardous to health particularly applicable. use to undertake their business activities
Management of contractors (contractors) to ensure they understand the
Enforcement General duties risks and the control measures.
AGE LIMITS AND CONSENT Under Article 4 of the Order, all employers have One of the risks that must be considered is
Tattooing a general duty of care to ensure the health, that of possible complications relating to skin
Other skin piercing activities safety and welfare of their employees. Under piercing and tattooing. The practitioner must
Acupuncture and electrolysis Article 5, both employers and self-employed make sure that a fully ‘informed consent’
Consent persons have a general duty of care to ensure procedure is adopted. This means gathering
USE OF LOCAL ANAESTHETIC their activities do not expose them or the information from the client about their health
MEDICATION general public to risks to their health or safety. and suitability for the treatment, and giving
the client enough information about the
Risk assessment possible complications that could arise from the
A risk assessment is the key step in protecting treatment for them to make their own decision.
workers and the public, as well as complying
with the law. The risk assessment is a careful Control of substances hazardous
examination of what work activities could to health
cause harm to people and this then guides The Control of Substances Hazardous to
decisions about precautions that need to Health Regulations (Northern Ireland)
be taken, including infection prevention and 2003 (COSHH) requires that a specific risk
control measures. assessment is carried out by employers or self
employed persons who work with substances
The HSE provides detailed advice on carrying
hazardous to health. Substances which are
out risk assessments http://www.hse.gov.uk/
hazardous to health include biological agents.
risk/risk-assessment.htm, including interactive
The hazards in this context are the organisms
tools http://www.hse.gov.uk/risk/shop.htm and
which can cause communicable diseases
other pieces of guidance http://www.hseni.gov.
could be transmitted from person to person by
uk/..guidance/content-getting-started/content-
unhygienic practices.
risk-assessment.htm
Therefore a specific risk assessment in respect
of infection control is necessary for all persons
undertaking tattooing and skin piercing activities.
Businesses employing less than 5 people do
not have to record the findings of this risk
assessment, however they still have to satisfy
➲ Main contents regulatory officers that their risk assessment is
suitable and sufficient.
11Tattooing and body piercing guidance
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Legislative background on tattooing
Section 01 and skin piercing activities (continued)
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SUMMARY Management of contractors AGE LIMITS AND CONSENT
Specific controls The Management of Health and Safety at The need for limits on age, and requirements
General controls Work Regulations (Northern Ireland) 2000 for consent, can be a controversial area
Determining requirements (Regulations Sections 11, 12 & 13) because in many circumstances specific
REGISTRATION AND contains legal provisions which can be of requirements have not been made in law.
BYELAW REQUIREMENTS IN particular importance to the many tattooists Consent is a complex area of law, and one that
NORTHERN IRELAND and cosmetic piercers who do not own the is often misunderstood by the general public,
HEALTH AND SAFETY AT premises which they operate from and are and also by some skin piercing practitioners.
WORK (NI) ORDER 1978 not employed by the person who owns and/
General duties or manages the premises where they work. In Tattooing
Risk assessment these cases, they are usually self-employed and The Tattooing of Minors (Northern Ireland)
Control of substances have some form of contract, formal or informal,
hazardous to health Order 1979 imposes a statutory minimum age
with the owner of the shop premises whereby of 18 years for permanent tattooing (except
Management of contractors
they pay the owner to allow them to work there. when carried out for medical reasons by a duly
Enforcement
In these circumstances the shop owner can be qualified medical practitioner or by a person
AGE LIMITS AND CONSENT said to be contracting out to the practitioner working under their direction). The practitioner
Tattooing and in effect ‘endorsing’ their work’. has a defence if they can show that they had
Other skin piercing activities
These tattooists and piercers are therefore good reason to believe that the person was
Acupuncture and electrolysis
Consent contractors undertaking the activities of the over 18 years of age. The consent of a client
business owner for them. This means that under 18 is not a defence. The Police enforce this
USE OF LOCAL ANAESTHETIC
MEDICATION the premises owners cannot abdicate their legislation and fines are up to £500.
own general duties under the HSWO to the
Skin piercing activities
individual practitioners. They have a duty to
ensure that persons working on their premises There is no statutory age of consent for cosmetic
are competent and that they carry out their piercing (cosmetic body piercing and ear
work in a safe manner. The only way they piercing). Cosmetic piercing of a minor is lawful
can do this satisfactorily is to assess the provided a valid consent is given. Furthermore the
practitioners for themselves and monitor their courts have held that a parents right to decide
activities to ensure they have carried out their on behalf of his and her child yields to the child’s
own risk assessment, as they are required to competence to make a decision, for example if
do by law, and that they are following control he or she is capable of understanding the nature
measures they have identified. The business of the act to be done (see below). Body piercing
owner has the ultimate power to remove the for sexual gratification is unlawful. Children under
risk, by stopping particular contractors working the age of 17 are not able to consent lawfully to
at their premises. a piercing that would be regarded as indecent
assault. Genital or nipple piercing performed on
Enforcement someone under the age of 17 might be regarded
The requirements of HSWO are enforceable as an indecent assault under sexual offences
through improvement and prohibition notices. legislation depending on the facts of the case.
Improvement notices give a time limit for Ear piercing and in some cultures nose piercing is
compliance with requirements. Prohibition generally considered acceptable when carried out
notices can have the effect of immediately on a minor, even below the age of five, provided
stopping the operations of a business or the that a parent or legal guardian gives consent and
activities of a person where imminent risk is is present whilst the procedure is carried out
apparent. Failure to comply with HSWO may
➲ Main contents result in court action.
12Tattooing and body piercing guidance
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To
Legislative background on tattooing
Section 01 and skin piercing activities (continued)
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SUMMARY Acupuncture and electrolysis Genital Mutilation Act 2003 states that certain
procedures in respect of female genitals are
Specific controls When carried out properly these do not cause
illegal unless carried out for medical reasons.
General controls harm to the body, and leave no permanent
Determining requirements markings. For this reason they are not likely to The signing of a declaration and providing proof
REGISTRATION AND raise any concerns over common assault charges, of age should be a fundamental part of the
BYELAW REQUIREMENTS IN although practitioners should be aware of possible client consultation process and practitioners
NORTHERN IRELAND should always require that the client signs
indecent assault complications (see below).
HEALTH AND SAFETY AT Consent should still be obtained before treatment a consent form prior to any work being
WORK (NI) ORDER 1978 commenced. However, the consent will only be
takes place, and in the case of a minor this should
General duties valid if the customer has been fully informed
be obtained from the parents or legal guardians.
Risk assessment as to the nature of the process, the likely effect
Control of substances Other considerations and potential problems involved. An example
hazardous to health of a consent form is provided in Appendix 8.
Management of contractors Semi-permanent skin-colouring, cosmetic piercing, However, for practitioners own protection, it is
Enforcement beading, branding, scarring, cutting and other recommended that any consent forms they use
extreme forms of body modification do cause are worded with the advice of a solicitor who is
AGE LIMITS AND CONSENT
actual harm and generally leave permanent marks familiar with this area of law.
Tattooing
and can result in disfigurement. They can therefore
Other skin piercing activities
be considered as assaults to the body, and so
USE OF LOCAL ANAESTHETIC
Acupuncture and electrolysis
potentially subject to the legislation concerning
MEDICATION
Consent
assault. This means that the question of age and There is a range of topical local anaesthetic
USE OF LOCAL ANAESTHETIC
MEDICATION the client’s informed consent are very important products for surface (skin) anaesthesia available
from community pharmacies (Pharmacy only (P)
Consent medicines), however none of these products are
licensed for local anaesthesia prior to tattoo or
In the legal proceedings of R v Brown (1994)
body piercing.The client may wish to obtain a
1 AC 212, the House of Lords ruled on appeal
topical local anaesthetic preparation prior to the
that consent could not be a defence against
procedure; however responsibility for purchasing
sections 20 and 47 of the Offences Against
and application of the product should remain
the Person Act 1861 which deals with common
with the client. The client should be advised
assaults. However, the law also recognises that
to read the Patient Information Leaflet which
certain activities that give rise to ‘harm’ are
accompanies the product and should be aware
lawful. This includes surgery, tattooing, ear
of the following:
piercing and violent sports. The courts have
also held that the law allows children under the • Warnings, cautions and contraindications.
age of 18 to consent to cosmetic body piercing • Side effects.
provided they are sufficiently mature to • That they are using the licensed product for
understand the nature of the request. This kind an un-licensed indication.
of assessment is clearly a subjective matter for
• Recommendations regarding
the operator who will need to ensure that the
administration and application.
client is provided with sufficient information to
allow them to proceed in an informed way and Alternatively, a qualified practitioner,
without pressure. e.g. doctor, may prescribe a topical local
anaesthetic product to be self-administered
Under the Sexual Offences (Northern Ireland) by the client, or can prescribe and administer
Order 2008, girls and boys under the age of 16 a topical local anaesthetic product, in
cannot legally give consent to intimate sexual accordance with legal requirements of their
contact under any circumstances, so piercing professional registration.
of nipples and genitalia (for girls) or genitalia
(for boys) can be regarded as an assault Local anaesthetic injections are prescription-only
➲ Main contents offence. Evidence that such contact was for medicines (POMs) therefore they can only be
sexual gratification would be required in order prescribed by a suitably qualified practitioner.
13 to constitute an indecent assault. The Female Local anaesthetic injections are not licensed forTattooing and body piercing guidance
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Legislative background on tattooing
Section 01 and skin piercing activities (continued)
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SUMMARY local anaesthesia prior to tattoo or body piercing.
In addition they should not be administered
Specific controls
parenterally unless adequate resuscitation
General controls
equipment is available. Information on the
Determining requirements
supply and administration of injectable medicines
REGISTRATION AND outside their licensed medicinal uses is available
BYELAW REQUIREMENTS IN
from the Medicines and Healthcare Regulatory
NORTHERN IRELAND
Agency (MHRA)2 and from the Nursing and
HEALTH AND SAFETY AT Midwifery Council (NMC).
WORK (NI) ORDER 1978
General duties References
1. British National Formulary (BNF) http://www.
Risk assessment medicinescomplete.com/mc/bnf/current/PHP8663-
Control of substances local-anaesthesia.htm (accessed 22/4/2013)
hazardous to health 2. MHRA; Frequently asked questions: Supply and
Management of contractors administration of Botox®, Vistabel®, Dysport® and
Enforcement other injectable medicines outside their licensed
medicinal uses such as in cosmetic procedures http://
AGE LIMITS AND CONSENT www.mhra.gov.uk/Howweregulate/Medicines/
Tattooing Availabilityprescribingsellingandsupplyingof
medicines/Frequentlyraisedissues/BotoxVistabel
Other skin piercing activities
Dysportandotherinjectablemedicines
Acupuncture and electrolysis incosmeticprocedures/index.htm (accessed
Consent 22/4/2013)
USE OF LOCAL ANAESTHETIC 3. NMC; Remote prescribing and injectable cosmetic
MEDICATION medicinal products http://www.nmc-uk.org/Nurses-
and-midwives/Regulation-in-practice/Regulation-in-
Practice-Topics/Remote-prescribing-and-injectable-
cosmetic-medicinal-products/ (accessed 22/4/2013)
4.DHSSPSNI; Local Government (Northern Ireland)
Order 2005 Regulation of Cosmetic Piercing and
Skin-Colouring businesses Guidance on Artilce
31 and Schedule 2 http://www.dhsspsni.gov.uk/
bodypiercing-order.pdf
(accessed on 20/08/14)
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14Tattooing and body piercing guidance
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Section 02a Infection prevention and control
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SECTION 02A INTRODUCTION Responsibilities
Under the HSWO, all employers should ensure
INTRODUCTION Infection, its causes and spread
Infection, its causes
that all their employees are appropriately trained
The causes and methods of spread of and proficient in the procedures necessary for
and spread
infections that are likely to arise in connection working safely. Employers and their employees
Factors in infection
control practice
with tattooing and skin piercing, are well are also responsible to ensure that any person
Responsibilities understood. on the premises is not placed at any avoidable
STANDARD PRINCIPLES OF See Appendix 01– Infection, its causes risk, as far as is reasonably practicable. They
INFECTION CONTROL also have a responsibility to protect voluntary
and spread
Appendix 01 – Infection, its workers. Employers are also required by COSHH,
causes and spread Unsafe or unhygienic practices by tattooing/ to review every procedure carried out by
SECTION 02B body piercing practitioners can lead to the their employees which involves contact with
PRINCIPLES OF INFECTION spread of infectious diseases that can affect a substance hazardous to health, including
CONTROL – HAND HYGIENE the health of the client as well as jeopardise pathogenic micro-organisms. Specific guidance
SECTION 02C the health of the practitioner. Although some is available from the Department of Health
bacterial or viral infections may be spread during (Department of Health, 1998).
PRINCIPLES OF INFECTION
CONTROL – PERSONAL procedures that do not involve skin penetration,
PROTECTIVE EQUIPMENT it is the occupational risk of transmission of STANDARD PRINCIPLES OF
SECTION 02D
infections such as blood-borne viruses (BBVs), INFECTION CONTROL
such as hepatitis B, hepatitis C, hepatitis D and This guidance is based upon standard principles
PRINCIPLES OF INFECTION
CONTROL – MANAGEMENT OF
HIV, which can arise and which are of primary which are the basic level of infection control
SHARPS AND EXPOSURE TO concern. Precautions to minimise the possibility practice. Compliance with these standard
BLOOD AND BODY FLUIDS of exposure to blood from an infected client principles reduces the risk of transmission of
SECTION 02E or practitioner should be put in place by the blood-borne and other pathogens.
adoption of safe practices and procedures. This
PRINCIPLES OF INFECTION
CONTROL – SAFE HANDLING, should include immunisation against hepatitis B Everyone providing treatments to clients
STORAGE AND DISPOSAL OF (Department of Health, 2010a). should know about and be able to carry
WASTE MATERIALS out these standard principles for infection
SECTION 02F Factors in infection control practice prevention and control (National Institute for
PRINCIPLES OF INFECTION The risk of transmission of infection can be Health and Care Excellence 2012). To that end
CONTROL – CLEANING AND minimised by: they should have received training in:
DISINFECTION OF THE
ENVIRONMENT • Good cleanliness of the premises where the • Hand hygiene and skin care.
tattooing and/or body piercing is taking • The use of personal protective equipment
SECTION 02G – REFERENCES
place, and of the fixtures and fittings. (PPE).
• Good personal hygiene of the practitioners. • Sharps management and management of
• Correct cleaning and sterilization or exposure to blood and body fluids.
disposal of instruments, materials and • Safe handling, storage and disposal of
equipment processes in place. waste materials.
It is therefore important that the safe • Cleaning and disinfection of the
working practices described in this environment.
guidance are followed at all times in order
to protect both the client and practitioner.
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Section 02b Infection prevention and control
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SECTION 02A PRINCIPLES OF INFECTION As a gold standard for infection control
CONTROL – HAND HYGIENE purposes,it recommended that hand wash
INTRODUCTION
basins should:
STANDARD PRINCIPLES OF Hand hygiene is a major component of the
INFECTION CONTROL standard principles and one of the most • Have elbow/foot-operated or non-touch
effective methods to prevent transmission mixer taps.
SECTION 02B
of pathogens by reducing the number • Have wall-mounted cartridge soap
PRINCIPLES OF INFECTION
CONTROL – HAND HYGIENE of microorganisms that may be present. dispensers and paper towels available at
Hand washing facilities
The spread of infection from hands is well each hand wash basin.
When to wash hands recognised and the importance of compliance • Not have a plug or overflow or be capable
What to use to wash hands with hand hygiene practices is emphasised in of taking a sink plug.
How to carry out hand washing all national and international guidelines.
• Not have taps aligned to run directly into
Use of hand rubs
Hand washing facilities the drain aperture.
Hand care
Use of hand cream Hand washing facilities should be adequate • Have waterproof splashbacks.
Care of broken skin and conveniently located in treatment areas. • Have space allowed at the design stage for
Poster – How to handwash Hand washing instructions should be clearly the placement of waste bins next to the
SECTION 02C displayed at the hand wash basin, such as in hand wash basin.
the form of a poster.
PRINCIPLES OF INFECTION When to wash hands
CONTROL – PERSONAL
See Poster – How to handwash • Before and after an intervention with
PROTECTIVE EQUIPMENT
Hand wash basins must be designated for that each client.
SECTION 02D
purpose only and have a constant supply of hot • After contact with any blood or body fluids.
PRINCIPLES OF INFECTION
CONTROL – MANAGEMENT OF and cold running water, ideally delivered through • Immediately after the removal of gloves.
SHARPS AND EXPOSURE TO a mixer tap. Under no circumstances should • After using a tissue or handkerchief.
BLOOD AND BODY FLUIDS equipment be washed in hand wash basins.
• After smoking.
SECTION 02E
Liquid soap dispensers with single use • After visiting the toilet.
PRINCIPLES OF INFECTION
liquid soap cartridges/bottles should be • Before and after eating.
CONTROL – SAFE HANDLING,
STORAGE AND DISPOSAL OF used, ideally wall-mounted, although free
• Immediately after any other activity or
WASTE MATERIALS standing dispensers would be considered
contact with a client’s surroundings that
SECTION 02F suitable. Disposable liquid soap cartridges are
could potentially result in hands becoming
recommended because they do not permit a
PRINCIPLES OF INFECTION contaminated.
CONTROL – CLEANING AND topping-up process and this minimizes the risk
DISINFECTION OF THE of contamination. What to use for hand washing
ENVIRONMENT
Wall-mounted disposable paper towels should For an ordinary hygienic hand wash, the
SECTION 02G – REFERENCES use of liquid soap is sufficient. Preparations
be next to the hand wash basins, and fully
stocked at the start of each working day to containing antiseptics that have a residual
minimise or reduce the need to fill up within effect on the skin surface are not required for
hours during which the premises is operational. use in tattoo and body piercing settings.
A foot-operated pedal bin, of an appropriate
size, should be placed next to the hand wash
basin for disposal of paper towels.
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Section 02b Infection prevention and control
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SECTION 02A How to carry out hand washing Use of hand rubs
INTRODUCTION There are three distinct and essential stages Hand rubs containing alcohol based products
to handwashing (National Institute for Health can enable practitioners to quickly and effectively
STANDARD PRINCIPLES OF
INFECTION CONTROL and Care Excellence, 2012) clean their hands before and after contact with
clients. However, the use of a hand alcohol
SECTION 02B 1. Preparation rub/gel is not a substitute for using soap and
PRINCIPLES OF INFECTION Before washing hands, all wrist and hand water for hand washing e.g. when undertaking
CONTROL – HAND HYGIENE
jewellery should be removed. Cuts and tattooing and body piercing procedures (see
Hand washing facilities abrasions must be covered with waterproof above), and should not be used when the hands
When to wash hands
dressings. Fingernails should be kept short, are visibly soiled or potentially contaminated
What to use to wash hands
clean and free from nail polish. Hands should with body fluids (National Institute for Health
How to carry out hand washing
be made wet by placing them under tepid and Care Excellence, 2012). Hand rubs should
Use of hand rubs
running water before applying liquid soap. conform to the standard BS EN 1500. The hand
Hand care
Use of hand cream rub solution must come into contact with all
2. Washing and rinsing surfaces of the hand; the hands must be rubbed
Care of broken skin
Poster – How to handwash
The hand wash solution must come into together paying particular attention to the tips of
contact with all of the surfaces of the the fingers, the thumbs and the areas between
SECTION 02C
hand. The hands must be rubbed together the fingers, until the solution has evaporated.
PRINCIPLES OF INFECTION vigorously for a minimum of 10–15
CONTROL – PERSONAL
seconds, paying particular attention to Hand care
PROTECTIVE EQUIPMENT
the tips of the fingers, the thumbs and the Use of hand cream
SECTION 02D
areas between the fingers. Hands should A hand cream can be applied regularly to
PRINCIPLES OF INFECTION be rinsed thoroughly.
CONTROL – MANAGEMENT OF protect skin from the drying effects of regular
SHARPS AND EXPOSURE TO hand decontamination (National Institute
3. Drying
BLOOD AND BODY FLUIDS for Health and Care Excellence, 2012). Each
SECTION 02E
In a tattooing and body piercing setting, practitioner should have their own supply and
good quality disposable soft paper towels a communal pot should not be used.
PRINCIPLES OF INFECTION
would be considered the method of choice
CONTROL – SAFE HANDLING, Care of broken skin
STORAGE AND DISPOSAL OF because communal towels are a source of
WASTE MATERIALS cross-contamination. Paper towels should Unbroken skin is the best defence because it
SECTION 02F be stored in a wall-mounted dispenser provides the perfect barrier against infection.
next to the washbasin and thrown away Small areas of broken or infected skin on
PRINCIPLES OF INFECTION
CONTROL – CLEANING AND in a pedal operated waste bin. Hands exposed parts of the practitioner’s body should
DISINFECTION OF THE should not be used to lift the lid or they will be covered with a waterproof dressing that
ENVIRONMENT become re-contaminated. completely covers the affected area.
SECTION 02G – REFERENCES
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Section 02c Infection prevention and control
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SECTION 02A PRINCIPLES OF INFECTION Types of protective clothing
CONTROL – PERSONAL Work clothing
INTRODUCTION
PROTECTIVE EQUIPMENT Practitioner clothing should be clean at all
STANDARD PRINCIPLES OF
INFECTION CONTROL Personal protective equipment (PPE) should be times, and professional in appearance. Work
SECTION 02B available to all practitioners and staff who may clothing should be changed daily. Staff clothing
be at risk whilst working in the premises. should not impede good hand washing,
PRINCIPLES OF INFECTION
CONTROL – HAND HYGIENE therefore the wearing of short sleeved tops is
Assessment of risk advocated (Department of Health, 2010b).
SECTION 02C
Regulation 3 of the Management of Health Gloves
PRINCIPLES OF INFECTION
and Safety at Work Regulations (Northern
CONTROL – PERSONAL COSHH requires employers to assess any
PROTECTIVE EQUIPMENT Ireland) 2000 requires every employer to make
substances hazardous to health, including
Assessment of risk a suitable and sufficient assessment of:
biohazards within blood and body fluids (such
Types of protective clothing a) risks to the health and safety of their as blood-borne viruses) and take steps to
Work clothing employees to which they are exposed reduce the risk of exposure.
Gloves whilst they are at work; and
− Glove choice The use of gloves has two purposes:
b) risks to health and safety of persons not in their
− Synthetic materials
− Latex gloves
employment arising out of or in connection 1. To protect the hands from becoming
− Sterile gloves
with the conduct by them of their undertaking. contaminated with dirt and microorganisms.
− Gloves used for cleaning Therefore the selection of protective 2. By changing gloves, to prevent transfer of
Aprons equipment must be based on an assessment microbes from one client to another.
Eye and face protection of the risk of transmission of infection between
SECTION 02D the practitioner and client and vice versa: Gloves must be worn when carrying out invasive
PRINCIPLES OF INFECTION
procedures, when in contact with sterile sites
CONTROL – MANAGEMENT OF Anticipated Wear Wear plastic Wear eye and non-intact skin or mucous membranes, and
SHARPS AND EXPOSURE TO level of disposable or fluid and face during all activities that have been assessed
BLOOD AND BODY FLUIDS exposure gloves repellent protection as carrying a risk of exposure to blood, body
apron
SECTION 02E fluids, secretions or excretions, or to sharp or
PRINCIPLES OF INFECTION No contaminated instruments (National Institute
exposure for Health and Care Excellence, 2012).
CONTROL – SAFE HANDLING,
to blood/
STORAGE AND DISPOSAL OF
body fluids
WASTE MATERIALS X X X The correct method for wearing and removing
anticipated
SECTION 02F gloves can be found on the WHO Save Lives
website: (http://www.who.int/gpsc/5may/
PRINCIPLES OF INFECTION
CONTROL – CLEANING AND Glove_Use_Information_Leaflet.pdf). Hands
DISINFECTION OF THE Exposure must be washed and dried thoroughly before
ENVIRONMENT to blood/ putting on disposable gloves.
body fluids
SECTION 02G – REFERENCES anticipated
Yes Yes X Gloves can tear or puncture visibly during use,
but low risk
of splashing or leakage may occur through microscopic
holes. Hands may also become contaminated
as gloves are removed. Gloves therefore must
Exposure not be seen as a substitute for good hand
to blood/ hygiene. Used gloves should be disposed of as
body fluids
anticipated
offensive waste (see waste section).
with high Yes Yes Yes
risk of
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to the face
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Section 02c Infection prevention and control
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SECTION 02A Gloves are single-use items (National Institute Nitrile
for Health and Care Excellence, 2012). This • Provides an excellent biological barrier,
INTRODUCTION
means they must be put on immediately resistant to punctures and tears.
STANDARD PRINCIPLES OF before an episode of client contact or
INFECTION CONTROL • Comparable to latex in terms of barrier
procedure and removed as soon as the activity
performance.
SECTION 02B is completed, or when leaving the client for
PRINCIPLES OF INFECTION any reason. Gloves must be changed between • Is a good alternative for latex sensitive
CONTROL – HAND HYGIENE different procedural activities for the same individuals.
SECTION 02C client and between dealing with different • Can be used where a latex free
PRINCIPLES OF INFECTION clients, or removed if they become torn. environment is necessary.
CONTROL – PERSONAL
Glove choice • Is less elastic than latex but does shape to
PROTECTIVE EQUIPMENT the wearer’s hand over time.
Assessment of risk Gloves should be made available in a range of
sizes for use by different practitioners (National • Can be used for handling certain chemicals
Types of protective clothing
Institute of Clinical Excellence, 2012). (Infection Control Nurses Association, 2002).
Work clothing
Gloves However, nitrile contains the same types of
All gloves used for direct client care must
− Glove choice chemicals as latex in the manufacturing process
conform to current EU legislation (CE marked
− Synthetic materials and allergic reactions have been reported.
− Latex gloves
as for single use) and should be appropriate
for the task. Only PPE meeting the basic health Polyisoprene and Neoprene
− Sterile gloves
− Gloves used for cleaning and safety requirements of the EC Personal • Offers effective protection against viral
Aprons Protective Equipment Directive requirements is penetration.
Eye and face protection entitled to carry a CE mark and be sold for use • Has similar elasticity and physical
SECTION 02D in the EC (Health and Safety Executive, 2012a). properties as latex.
Practitioners should therefore look for the CE
PRINCIPLES OF INFECTION • Is suitable for individuals sensitised to latex
CONTROL – MANAGEMENT OF mark information on glove packs plus EN 374-
proteins.
SHARPS AND EXPOSURE TO 1:2003 or EN 374-2. These markings show the
BLOOD AND BODY FLUIDS gloves are protective against chemicals and • Can be used when a latex free environment
can resist microorganisms at a performance is necessary (Infection Control Nurses
SECTION 02E
level 2 test in penetration tests. Although Association, 2002).
PRINCIPLES OF INFECTION
CONTROL – SAFE HANDLING, this cannot infer protection against viruses, Vinyl
STORAGE AND DISPOSAL OF because they are not used in the performance • Is suitable for use in areas where there is a
WASTE MATERIALS tests, in practice this is the highest level of low biohazard risk.
SECTION 02F protection afforded against microorganisms
• Provides a good alternative for use when
PRINCIPLES OF INFECTION (Health and Safety Executive, 2012a).
staff or clients are sensitised to latex.
CONTROL – CLEANING AND
Synthetic materials • In lab tests shows increased permeability
DISINFECTION OF THE
ENVIRONMENT Neoprene and nitrile gloves are synthetic gloves to blood borne viruses than latex.
SECTION 02G – REFERENCES which have been shown to have comparable in- • Possesses lower tensile strength than latex
use barrier performance to natural rubber latex and breaks down more frequently.
gloves in laboratory and clinical studies.
• Is prone to leaking.
• Is inelastic and can be baggy to wear.
• Is inexpensive in comparison to synthetic
rubbers (Infection Control Nurses
Association, 2002).
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