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  • 2. UPDATED AFTERCARE BROCHURES Newly reformatted with additions reflecting new trends and frequently asked questions from Piercers and Piercees alike. NEW AFTERCARE: • Clear concise instructions on cleaning • "Less is more" message • More information on jewelry issues • Facial piercings now covered in Oral Aftercare instructions NEW FORMAT/DESIGNS: • Cohesive appearance of all APP brochures • Eye-catching and aesthetically pleasing • Professional image to support APP standards The new brochures are available for sale on the APP web site ( for $20 per 100, postage paid. Subjects include: • Aftercare Guidelines for Facial and Body Piercing* • Aftercare Guidelines for Oral Piercing* • Picking Your Piercer* • Troubleshooting for You and Your Healthcare Professional (with jewelry removal tips and hints) • Oral Piercing Risks and Safety Measures *Available in Spanish FREE SAMPLES AVAILABLE UPON REQUEST Order by fax or phone (888) 888-1APP or visit our website: MARK YOUR CALENDARS! The annual APP Conference and Exposition takes place every year in beautiful Las Vegas, Nevada. There are classes offered in everything from piercing technique to marketing, current industry legislation to accounting, studio set- up to aftercare. There is something for everyone, from the first time attendee to the long term shop owner, with classes geared specifically for health care professionals. The exposition includes venders from all segments of the body piercing industry from the United States and abroad. Thousands of items are available at the year’s largest gathering of manufactur- ers and distributors directly targeting the body piercing market. For updates about the conference please visit: or call (505) 242-2144 or (888) 888-1APP A PIERCEE'S BILL OF RIGHTS EVERY PERSON BEING PIERCED HAS THE RIGHT: 1. To be pierced in a hygienic environment by a clean, conscientious, sober piercer wearing a fresh pair of dis- posable medical examination gloves. 2. To be pierced with a brand new, completely sterilized single-use needle that is immediately disposed of in a medical Sharps container after use on one piercing. 3. To be touched only with freshly sterilized and appropriate implements,properly used and disposed of or re-ster- ilized (where appropriate) in an autoclave prior to use on anyone else. 4. To know that piercing guns are NEVER appropriate, and are often dangerous when used on anything -- including earlobes. 5. To the peace of mind that comes from knowing that their piercer knows and practices the very highest stan- dards of sterilization and hygiene. 6. To a have a knowledgeable piercer evaluate and discuss appropriate piercings and jewelry for her/his individ- ual anatomy and lifestyle. 7. To be fully informed of all risks and possible complications involved in his/her piercing choice before making any decisions. 8. To seek and receive a second opinion either from another piercer within the studio or from another studio. 9. To have initial piercings fitted with jewelry of appropriate size, material, design, and construction to best pro- mote healing. Gold-plated, gold-filled or sterling silver jewelry is never appropriate for any new or unhealed piercing. 10. To see pictures, be given a tour of the piercing studio, and to have all questions fully and politely answered before making or following through on any decision. 11. To be fully informed about proper aftercare, both verbally and in writing, and to have continuing access to the piercer for assistance throughout the healing process. 12. To be treated with respect, sensitivity and knowledge regardless of gender, sexual orientation, race, religion, ethnicity, ability, health status or piercing choice. 13. To change her/his mind, halt the procedure and leave at any point if the situation seems uncomfortable or improper.
  • 3. THE ASSOCIATION OF PROFESSIONAL PIERCERS MANUAL U.S. EDITION CONTENTS WHAT IS THE APP? ............................................................................................................................. 1 INTRO TO MICROBIOLOGY FOR THE PIERCER............................................................................... 5 INFECTION CONTROL......................................................................................................................... 9 STERILE CHART ................................................................................................................................ 14 CLEANING, DISINFECTION AND STERILIZATION .......................................................................... 15 EQUIPMENT ....................................................................................................................................... 19 ENVIRONMENT.................................................................................................................................. 25 SKIN PREPARATION ......................................................................................................................... 29 AFTERCARE........................................................................................................................................31 PIERCING HEALING TIMES .............................................................................................................. 35 JEWELRY............................................................................................................................................ 37 ETHICS AND LEGALITIES ................................................................................................................. 43 COMPLIANCE AND TRAINING ..........................................................................................................49 EMERGENCIES.................................................................................................................................. 53 AFTERWARD...................................................................................................................................... 58 GLOSSARY......................................................................................................................................... 59 UNDERSTANDING MSDS.................................................................................................................. 63 APPENDIX A - FULL TEXT OF BLOODBORNE PATHOGENS STANDARD 1910.1030.................. 65 APPENDIX B - HEPATITIS B VACCINE DECLINATION (MANDATORY) ......................................... 77 APPENDIX C - APPLICATIONS FOR MEMBERSHIP........................................................................ 79 This manual was first published in 1998 and was revised in 2002 and 2005. Previous edition credits are extended to: Gahdi Elias, Allen Falkner, Tracy Faraka, Kent Fazekas, Michaela Gray, Drew Lewis, Cheyenne Morrisson, David Vidra, Dr. Jack Ward [Original Edition]; and to: Elayne Angel, Scott Brewer, Steve Joyner, Lisa Lystad, M.D., Patrick McCarthy, Sky Renfro, Bethra Szumski, April Williams-Warner, Dr. Jack Ward [2002 Edition]. Contributors to the 2005 edition include: Elayne Angel, Alicia Cardenas, Luis Garcia, Phish Goldblatt, Schane Gross, April Johnson, Jason King, Paul King, Megg Mass, Christina Shull, Crystal Sims, Bethra Szumski, James Weber, and the intrepid Caitlin McDiarmid. Some cover photos courtesy of Evolution Body Piercing, Inc. Cover design by Paul Romano, Copyright © 1998, 2002, 2005. All rights reserved. The goal of the Association of Professional Piercers is to circulate vital health, safety and educational information to the piercing industry, health care workers and the general public. This manual is copyrighted under Federal Law. Any reproduction of its contents is prohibited without prior written permission. For specific reprint permissions, please contact us directly.
  • 4. 1 WHAT IS THE APP? The Association of Professional Piercers (APP) is an international health and safety organization dedicated to the dissemination of information about body piercing. We are a fully voluntary and nonprofit alliance of indi- viduals and corporations concerned about the safety and standards of the body piercing industry. Governed by an elected Board of Directors, the APP unites piercing professionals who freely share resources to help fellow members, piercers, healthcare professionals, health inspectors, and the public access the most current and accurate information about our art form and its procedures. THE ORIGINS OF THE APP In 1994, representatives from several piercing studios organized a political action group in response to prob- lematic legislation in California (Proposition AB101). The organization quickly grew to accommodate mem- bers nationwide and around the world, becoming the world’s largest body piercing education facilitator and providing invaluable organization and representation for the piercing profession. WHAT IS THE PURPOSE OF THIS MANUAL? This manual is intended as a reference and study aid for all people who care about the promotion and practice of responsible body piercing -- including piercers, health officials, legislators, medical and insurance profes- sionals, and members of the general public. Those in countries other than the US are invited to use this manual as a guide, keeping in mind that regulations, available products and industry standard techniques may vary by location. Please consult with professional piercing associations in your own country. WHAT ARE THE LIMITATIONS OF THIS MANUAL? The following manual is not a training course or a for- mula to make one an instant piercer. This manual is intended to provide a basic overview of the health and safety concerns faced by all body piercers and to offer guidelines that minimize expected risks. This manual is not a substitute for formal training and education. Although this manual is updated periodically, informa- tion in this edition may not be current or appropriate for your individual practice. It is imperative that each piercer seek out and evaluate new health and safety techniques and products with reference to his/her own practice and local circumstances. For recent updates to this information, please see our website. While this manual and its information, suggestions and guidelines are offered for use throughout the world, this version is specifically designated as the “USA Edi- tion.” We recognize that laws vary and not all products, chemical formulas, tools and jewelry types are readily available or desirable everywhere. As a result, we offer the USA Edition as a general foundation and encourage APP members in other areas of the world to update, clarify and edit this version (with permission) to be appropriate to their region. THE APP: • Provides a professional association and peer support for piercers. • Publishes a quarterly newsletter dedicated to pierc- ing-related news, research and information to keep geographically dispersed individuals current in the industry. • Standardizes and publicizes industry procedures and protocols regarding hygiene, quality and education, and assists piercers in meeting and/or exceeding these standards. • Provides support and assistance in implementation of appropriate legislation for the industry. • Provides piercing, business, health and safety educa- tion through annual conferences for piercers, health inspectors, and others related to the industry. • Promotes consumer education and public under- standing of body piercing practices through educa- tional lectures, publications, staffed phone and email lines, a comprehensive website and media relations. (See the inside front cover of this manual for more information.)
  • 5. 2 • Promotes alliance between the piercing and health- care industries through cross-attendance at health- related conferences and lectures, joint publica- tions and research, resource sharing and ongoing dialogue. • Does not police the piercing industry or piercers. The APP will, however, respond to and resolve complaints against its members and claims of membership which are invalid. • Does not license or certify piercers. Members do receive a certificate of membership which must be renewed annually. Attendees of APP classes receive a certificate of seminar participation. • Does not teach people “how to pierce” or perform piercings at its functions. The APP provides supple- mental education to piercers and has Corporate Members who provide basic piercing education. • Does not dictate the piercing technique(s) or products its members use, what aftercare they suggest, or what specific piercings they may choose to perform, provided they respect local laws and regulations. • Addresses only the practice of body piercing. The APP does not have a position on tattooing, branding, scarification, dermal punching, scalpeling, implants, or other types of body modification where they are allowed by law. MEMBERSHIP The APP has five types of memberships: • Professional Business Member • Professional Business Member-at-Large • Associate Member • Corporate Member • Patron Member Professional Business Members and Pro- fessional Business Members at Large: • Are body piercers; • Uphold a set of safety and hygiene standards that are equal to, or more stringent than those established by state or local governments; • Have at least one year of professional piercing experi- ence; • Have knowledge of appropriate sterilization and cross-contamination prevention through Bloodborne Pathogens Training, required annually for member- ship; • Work in a studio that meets current environmental criteria for hygiene, safety, and ethical practice; • Undergo training and certification in CPR, Blood- borne Pathogens, and First Aid, renewed according to membership requirements; • Must provide monthly spore test results for their studio’s autoclave(s) (sterilizer) • Must sign the APP Health and Safety Agreement and answer an extensive questionnaire to prove knowl- edge of and adherence to current best practice. Associate Members: • Are either piercers with less than one year of profes- sional experience, or non-piercing employees in a piercing studio (owners, counter people); • If beginning piercers, must meet the same standards as our Business Members; • If non-piercers, must work in a studio that meets studio requirements; • Must work in a studio which has at least one APP Business member on current staff. Corporate Members: • Are companies that provide support services to the piercing industry; Some examples of Corporate Members are health and technical educators, medical supply companies, jewelry wholesalers and insur- ance companies; • Must provide a letter of intent; • Must provide documentation regarding their busi- ness, including jewelry samples if applicable. Patron Members: • Are individuals who work outside the piercing industry and who support the APP and its goals. HOW DO I BECOME A MEMBER? A full list of membership requirements, including personal and environmental criteria, is included in the Appendix. This includes the Application for APP Membership, Health and Safety Agreement and Ques-
  • 6. 3 tionnaire. For questions please contact us directly at APP PUBLICATIONS, PROD- UCTS AND EDUCATIONAL SERVICES: • Brochures for piercers, educators, consumers, and healthcare personnel (Available titles listed inside front cover) • Health and Safety Procedure Manual • The Point quarterly newsletterThe Point quarterly newsletterThe Point • Public Service Announcements for Radio and Print (available on cd and in written format) • APP T-shirts - New designs every year • APP Annual Conference and Exposition ° Piercing-related, industry-specific classes offered in Techniques, Equipment, Management, Aftercare, Studio Set-Up, Business Documentation, Blood- borne Pathogens, CPR, First Aid and more ° Week-long conference with roundtable discus- sions, social events, and networking ° Largest body jewelry and piercing-related product exposition in the US ° Package and individual class prices available • Website: ° Contact information for current members ° Getting Pierced: Everything you need to know, including how to find a good piercer and Aftercare information ° FAQ’s: Piercing and Minors, Pregnancy, Pierc- ing Guns, Genital Piercings, Oral Piercings, and more... ° Job Board: free listing of jobs available and those seeking positions
  • 7. 4
  • 8. 5 Although body piercing has historically been considered a ritual art form, in modern times the practice cannot be separated from our knowledge of biological science. In order to be fully educated in the field, piercers should have a working knowledge of the science behind the art. In particular piercers should understand the ba- sics of Microbiology, Bacteriology, Immunology, and Virology. Scientific facts will provide the professional piercer with the necessary knowledge to carry out appropriate hygiene and safety practices in the work environment and to make informed decisions under changing conditions. DEFINITIONS Cross-contamination is the act of spreading pathogenic (disease-causing) organisms from one item or surface to another. It is the responsibility of the professional piercer to operate at all times with a high regard for the health and safety of their customers, their co-workers, and themselves. Employing appropriate protocols will minimize the risk of cross-contamination with harmful microorganisms such as bacteria and viruses. Microbiology is the study of microscopic organisms. Some microorganisms are beneficial or resident to the individual, but others are detrimental, potentially causing illness or even death. By understanding how microorganisms live and reproduce, the piercer will be able to minimize disease transmission risks. Bacteriology is the study of bacteria.Bacteriology is the study of bacteria.Bacteriology Many varieties of bacteria exist in our environment, some good, some bad. Some bacteria normally live on our bodies (resident) and help protect us from foreign strains (transient), or otherwise work with the body chemistry to optimize health. The type of bacteria in yogurt may aid the digestive tract, while bacteria on teeth can cause tooth decay. Bacteria are of immense importance because of their capacity for rapid growth and reproduction. Bacteria are capable of surviving without a host. Immunology is the study of the ability to resistImmunology is the study of the ability to resistImmunology infection. The immune system treads a fine line between successful defense of the organism and its complete destruction. An underreaction may allow pathogens to gain a foothold and overpower the individual. However, an overreaction can also lead to dire consequences for the individual. Virology is the study of viruses, which are submicro- scopic organisms. Viruses differ from other microorganisms in that they depend on the cells they invade for growth and repro- duction. Some viruses do not kill cells but cause illness, and then seem to disappear. They can remain latent and later cause another, sometimes much more severe form of disease. Viruses cause measles, mumps, polio, herpes, influenza, and the common cold. Some viral infections can be treated with drugs, some cannot. Bacteria are single-celled microorganisms so small that they cannot be seen without the assistance of pow- erful magnification. They have characteristics of both plants and animals. There are hundreds of different types of bacteria, sub- divided into families with common properties. Two very important and relevant classifications of bacteria exist. They are either nonpathogenic (harmless), or they are pathogenic (harmful, with the ability to cause disease). Nonpathogenic bacteria are the most plentiful. Some are actually beneficial and perform important func- tions in our bodies, such as assisting in digestion or protecting the skin from overcolonization by invading organisms. Millions of microscopic organisms inhabit the spaces in which we live and work. Particles of organic matter including bacteria, viruses, fungi, and spores are pres- ent despite the most dedicated efforts to keep things clean. Fortunately, the majority of these organisms are harmless or can be dealt with successfully by the immune system. However, if there is an opening into the body, some of these organisms can enter and cause illness, particu- larly when the body’s own defenses are compromised AN INTRODUCTION TO MICROBIOLOGY FOR THE PROFESSIONAL PIERCER
  • 9. 6 through illness, inadequate nutrition, and other risk factors. While some organisms cause only temporary minor discomfort, others can result in serious or even fatal diseases. Since microorganisms are omnipres- ent, it is important to understand how to prevent them from gaining access into the body through piercings both during a procedure and afterward. It is also important to help clients understand how hygiene, nutrition, and lifestyle can facilitate or devastate their healing process. The most common forms of bacteria of concern for piercers are Coccus, Bacillus and Spirillum. Coccus (plural Cocci) Cocci are spherical or ovoid in form. One of the most commonly occurring bacteria of concern to piercers is Staphylococcus. This bacterium is present in boils, ab- scesses, and most surface infections. It can enter the body during the piercing or any time during the healing stages while the piercing is an open wound. This risk makes client education and post-piercing care critical in prevention. Some Staph is becoming resistant to antibiotic treatment, making prevention even more es- sential to the health of our clients. Other common types of Cocci are Diplococci (which causes Pneumonia) and Streptococci. Other diseases caused by this family of bacteria are Scarlet Fever and Meningitis. Bacillus (plural Bacilli) This bacteria belongs to the family Bacillaceae. All species are rod-shaped and sometimes occur in chains. Bacillus is the organism that causes dysentery, cholera, and diphtheria. Spirillum (plural Spirilla) This is a genus of spiral-shaped microorganisms belonging to the family Pseudomonadacea. When in flexible form they are called spirochetes. Syphilis is in this group. Pathogenic organisms that cause diseases such as tetanus, tuberculosis and diphtheria are generally beyond our concern when Standard Precautions are observed. To minimize exposure risk: • Focus • Utilize clean technique • Understand appropriate sterilization, and • Practice it at all times. MICROORGANISMS OF THE SKIN There are two types of skin microorganisms: Resident: Those that survive and multiply on theResident: Those that survive and multiply on theResident: skin. Resident flora can be removed with antimicrobial soaps. Some of the normal resident bacteria of the skin include diptheroids (found in outer ear, armpits, and groin/genital areas), micrococci, (Staphylococci epi- dermis found on skin surfaces) and a variety of canes (Propionibacterium canes, Corynebacterium canes found on the face and other skin surfaces). Transient: Those that were acquired through recentTransient: Those that were acquired through recentTransient: exposure. These can survive for a limited amount of time, generally less than 24 hours. Most often they are acquired from others who are infected. Soap is effective for the removal of most transient microorgan- isms. If conditions are conducive, overgrowth of some transient bacteria can occur. Staphylococcus aureus colonization is found in boils, folliculitis and carbuncles. Streptococcus infections can take the form of cellulitis, impetigo and pneumonia. FACTORS THAT INFLUENCE THE SURVIVAL AND GROWTH OF MICROORGANISMS There are three main considerations determining whether or not a microorganism is potentially a problem for you or your clients: 1. Stability of an organism in its physical environ- ment; 2. Availability of the correct transmission medium needed by the organism to spread; 3. Quantity of organisms expelled from the host into the transmission medium. Pathogenicity: The potential of an organism toPathogenicity: The potential of an organism toPathogenicity: cause disease. The factors that influence the patho- genicity of an organism are: 1. Host susceptibility; 2. Organism strength and number; 3. Portal of entry: The organism must have a way into the host. Transmission: The method by which an infectiousTransmission: The method by which an infectiousTransmission: agent is passed. The transmission of an organism is
  • 10. 7 dictated by the availability of an appropriate Agent, Host and Environment. Eliminating the route of transmission to the portal of entry (a fresh piercing) interrupts this process and is well within the piercer’s control. Routes of transmission are: Direct contact: Person-to-person spread; requires actual physical contact between the existing host and a new portal of entry (e.g. the piercer and a client). A needle stick is a direct contact route of transmission. Indirect contact: Exposure to microorganisms de- posited first on inanimate objects and then transferred to the client. Objects in the environment that are not adequately disinfected or sterilized between clients can result in indirect contact exposure. This is generally referred to as cross-contamination. Using tools first at the counter and then for a piercing procedure without sterilizing would be an example. Touching non-sterile items with gloved hands during a procedure, and then continuing to work on the client without changing gloves would also be considered cross-contamination. Airborne: Pathogenic organisms can also be acquired by inhaling infected droplets that become airborne when an infected person coughs or sneezes. Termed “droplet transmission,” this can easily be avoided with simple precautions, such as covering the mouth and nose when coughing or sneezing (and then wash hands!) Vector-borne: The transmission of organisms by an animal or insect bite, or through exposure to animal blood or other infectious bodily fluids. Zoonosis: Zoonotic diseases are diseases of animals that may be transmitted to humans under natural con- ditions. Once infected, humans can transmit some of these diseases to one another. While no reasonable piercer should be working on animals, it is possible for these diseases to enter the piercing environment by allowing pets or other animals, their droppings or accessories, into the piercing studio. Proper hygiene as well as many local regulations dic- tate that animals never belong in the piercing studio or in any space contiguous with a piercing studio (e.g. an adjoining office). Clean and enclosed fish aquaria may be permissible, however dogs, cats, rodents, reptiles and birds present a potential threat to client and staff safety and should never be admitted. One possible exception would be a guide dog or assistance animal. In this case reasonable alternatives and precautions should be sought to avoid the contamination of the piercing environment while considering the needs of the client. BREAKING THE CHAIN OF INFECTION It is essential that the professional piercer understand how infection occurs, and more importantly, how to prevent this from happening in the work environment. The “Chain of Infection” requires that these elements be present: 1. An Infectious Agent, such as bacteria or virus 2. A Reservoir (existing host) 3. A Portal of Exit from the reservoir (the path out of the existing host) 4. A Vehicle of Transmission for the agent (the path between hosts) 5. A Portal of Entry (the path into a new host) 6. A New Host The single most important thing piercers can do to break this chain is WASH THEIR HANDS. This very simple and basic step has been proven to reduce or eliminate most pathogenic bacteria from the hands. This is the first line of defense in the prevention of disease transmission.
  • 11. 8
  • 12. 9 HANDWASHING Frequent and conscientious handwashing is the most important action a piercer can take to reduce the pres- ence and transmission of pathogenic microorganisms. Correct handwashing procedures are easy to follow and are extremely effective when used throughout the day. A studio’s handwashing sink should be used only for hand washing (never tool cleaning) and should have hands-free operation. Hands should not come into contact with faucets or handles. If the sink does not have a foot pedal or motion sensor operated system, an elbow or dry disposable paper towel can be used to operate the water flow. The use of quality liquid soap in a pump or automatic dispenser is strongly encouraged. Bar soaps collect bacteria and other dangerous contaminants from han- dling. Liquid antimicrobial or antibacterial soap has been proven most effective in the inhibiting of bacterial growth and is preferred. Choose a gentle, dye- and fragrance-free anti-micro- bial or antibacterial soap made for healthcare workers and others who wash frequently. Most commercial soaps are not intended for those who wash their hands frequently. They can leave hands chaffed, chapped and irritated and may kill beneficial resident flora. This can actually increase the potential risk of pathogen transmission to the piercer. See the APP website for suggested products ( Single-use paper towels should be dispensed from a stationary, fully covered paper towel dispenser that dispenses only one paper towel at a time. Paper towel rolls run the risk of contamination of the entire roll from handling. Air dryers cut down on paper waste but may blow pathogenic matter around the area. HOW TO WASH HANDS PROPERLY: 1. Wet hands thoroughly with tepid water. 2. Dispense a dime-sized amount of liquid soap into palm and lather. 3. Vigorously scrub all surfaces of both hands up to mid-forearm. 4. Pay special attention to nails, nail beds, between fingers and wrists. 5. Continue for a minimum of thirty seconds. 6. Pat hands dry with a single-use paper towel. A moisturizing lotion can be used to prevent overdry- ing and cracking. Maintaining the health of the hands, skin, nails and nail beds is crucial in the first line of defense against transmission of disease. Several brands of lotion that also seal and protect skin (“invis- ible gloves”) are available through healthcare product suppliers. Lotion must be allowed to dry before don- ning gloves to maintain glove integrity and minimize exposure to glove chemicals. HAND SANITIZERS Waterless hand sanitizer gels have become staples in many piercing shops because they are easy to use and do not require a trip to the sink. Some piercers use them in between glove changes, or keep them at the counter for clients entering the shop. However, careful consideration should be given as to when their use is appropriate. While some studies show these products to be as effective as hand washing in certain situations, other research indicates that they do not significantly reduce overall amounts of bacteria on the hands, and in some cases may even increase it. Most tests proving sanitizers’ germ-killing capacities at up to 99.9% effective were done on inanimate objects, not on living skin. Physiological conditions on human skin may yield far different results. Alcohol-based hand sanitizers work by stripping the outer layer of oil from the skin, thereby killing transient bacteria and delaying regrowth and surfacing of resi- dent bacteria. To use, a dime-sized drop of sanitizer should be pumped onto the skin and rubbed over all surfaces until dry. If hands are dry within 20 seconds, not enough gel was used. Hand sanitizers are not cleaning agents. They do not remove surface dirt or visible soil. Dirt, food, lubricant and other things on your hands will make them less effective. Therefore, in order for hand sanitizers to work properly, hands must first be washed with soap and water before applying. INFECTION CONTROL
  • 13. 10 HAND SANITIZERS VERSUS ANTIMICROBIAL SOAPS In 2002, the Centers for Disease Control released guidelines “recommending alcohol-based gel as a suitable alternative to hand washing for health-care personnel in health-care settings” (CDC, 2002) when moving between patients. The Food and Drug Admin- istration, on the other hand, says that hand sanitizers may be used as a supplement, but not as a substitute for hand washing. In an FDA comparison study, plain soaps antimicrobial hand soaps, E2-rated hand soaps (a USDA Classifica- tion requiring equivalency to 50 parts per million chlo- rine), and instant hand sanitizers were tested to gauge their relative effectiveness in reducing bacteria on hands. With a 20-second wash procedure, all three types of soap effectively reduced bacteria. E2 soaps were signifi- cantly more effective than the other two soaps. Instant hand sanitizers, on the other hand, showed a significant increase in bacterial numbers on hands. According to most publications, while hand sanitiz- ers are acceptable for use in addition to a thorough handwashing, and are certainly better than no cleaning at all, they are not a substitute for scrubbing with soap and water. Additionally, they are generally advised for healthcare workers, but not for food handlers or the gen- eral public. Since piercers fall squarely into none of these groups, each must come to his/her own conclusion. A final word of caution: While often advertised as being less irritating to hands than regular washing, alcohol-based hand sanitizers can be overdrying, caus- ing cracked skin, contact dermatitis, and accelerating potential latex sensitivities. If you opt to use these products for your staff and/or clientele, choose a brand carefully, consider non-alcohol varieties, and have an alternative available for clients who cannot or will not use these products. GLOVES Gloves are practically, legally and ethically imperative for professional piercers. Finding appropriate gloves and learning how to don them properly will protect the piercer from potential contaminants and reduce the risk of disease transmission between client, piercer and co-workers. It is important to follow the basic rules of glove use: 1. Wash hands prior to donning gloves and immedi- ately afterwards. 2. Keep fingernails trim and smooth, and remove jewelry and watches to prevent accidental tears (per OSHA regulations). 3. Use only disposable gloves. 4. Store gloves properly, away from light, heat and moisture. When should gloves be worn? • During all set-up and cleaning. This prevents cross- contamination and protects hands from exposure to harsh chemical disinfectants. • During sweeping, mopping and trash removal. Any object on the piercing studio floor should be consid- ered contaminated and only touched with gloved hands. • During all disinfection or sterilization procedures. • When working in Biohazard Areas or dealing with contaminated tools or containers. Many piercers double-glove when processing contaminated in- struments. (Check with your glove manufacturer to ensure this will not compromise glove integrity.) • When transporting sterilized implements from the autoclave to designated storage space. Clean gloves should be available in all areas where transport may be initiated. • During contact with a client. A professional piercer should never touch the area of a client’s piercing with ungloved hands. This protects against possible transmission of a client’s resident and transient flora. It also provides a level of professionalism and comfort between the client and piercer. • During a period of contact only, not continuously. When should gloves be changed? • If glove integrity is compromised (gloves become weakened or contaminated). • If a visible weak spot, pinhole or tear is detected or suspected. • When gloves turn yellow or brown. Changes in glove color can take place after prolonged wear. This is normal and occurs from a reaction between traces of copper on sweaty skin and dithiocarbamate, a curing chemical found on the surface of some gloves. Since this reaction can accelerate the breakdown of rubber, gloves should be changed frequently enough to prevent it. Four minutes is the maximum amount of time suggested for using each pair of latex gloves.
  • 14. 11 • When moving from “field” to “field” (from non-sterile to sterile tools, or between segments of a procedure). To prevent cross- contamination gloves should be changed when moving from a more contaminated area to less contaminated area (see Sterile Chart on page 14). • During a procedure. Many studios develop a written plan concerning glove changes during a procedure. For example, a studio may require at least five pairs of gloves per procedure for: 1. Initial set up of tray and instruments 2. Opening autoclave packages 3. Initial skin prep and marking 4. Piercing procedure 5. Post-procedure clean up Although the number of gloves used in a procedure will vary, setting a minimum number of gloves used can help reduce the likelihood of cross-contamination. The important point is that every piercer understand the concept of cross-contamination, and change gloves as necessary to avoid compromising fields. Many piercers use hand sanitizers and lotions as an additional cleanser or barrier, and to minimize potential contamination through dry, cracked skin. If using latex gloves, be aware that petroleum- or oil-based products must be avoided. Chemicals in petroleum products can penetrate the latex, compromising its barrier integrity. Water-based lotions should be chosen, applied after glove use and washing (post-piercing) and allowed to fully dry before donning new gloves. Anti-inflamma- tory, conditioning and chemical barrier lotions are also available for the healthcare industry and may minimize skin irritation from constant washing and chemical exposure. If a glove becomes hard, brittle or too soft, or loses its elasticity, shape or usual color, it may be degraded and should not be used. As requested by the FDA, glove manufacturers may print expiration dates on glove boxes. Gloves should be used before this date. If the date is unknown, be sure to use glove shipments in the order they were received, and to store all gloves in clean, cool, dry and well-ventilated conditions in their original packaging. Gloves should never be washed, disinfected or autoclaved unless specifically recommended by the manufacturer. As explained by OSHA, “Washing with disinfecting agents may cause deterioration of the glove material and may encourage “wicking” or enhanced penetration of liquids into the glove via undetected pores thereby transporting potentially infectious ma- terials into contact with the hand.” (OSHA instruction CPL 2-2.44C) Whenever you have doubt about the integrity of your gloves, remove the gloves, wash hands and don fresh gloves. Piercers should be aware that sensitization to latex (latex allergies) are becoming increasingly common among both piercers and clients. To protect the health of their staff and clients, many studios are choosing alternative synthetic gloves and eliminating latex from their practices. STERILE GLOVES Some piercers choose to use sterile gloves during piercing procedures; some are required to do so by state law. There are arguments for and against the use of sterile gloves. Where the issue is not dictated by law, a studio should make a research-based deci- sion about whether or not to use sterile gloves in its practice. Sterile gloves are not required by APP standards, though piercers who choose to go beyond the estab- lished minimum guidelines may do so. Donning Sterile Gloves Piercers should use the “open donning” method. The (right-handed) technique is as follows: 1. Pick up the cuff of the right glove with left hand. Slide right hand into the glove until you have a snug fit over the thumb joint and knuckles. Your bare left hand should only touch the folded cuff - the rest of the glove is sterile. Do not use bare hand to adjust fit. 2. Slide right fingertips into the folded cuff of the left glove. Pull out the glove and fit right hand into it. 3. Unfold the cuffs down over wrists. Make sure gloved fingertips do not touch bare forearms or wrists. Donning Clean Gloves 1. With freshly washed hands, remove one glove from the clean glove box by grasping it at the bot- tom edge. Be careful to reach into box as little as possible, and not to touch the fingers of any glove with bare hands. (Discard individual gloves that accidentally contact hands, or that present “fingers first” and cannot be removed by the cuff.) 2. Grasp rolled cuff and slide your hand as far into the glove as possible. DO NOT use your bare hand to adjust fit from the outside.
  • 15. 12 3. With your now gloved hand, reach into the clean glove box and remove a second glove. 4. Without touching bare skin to the outside of ei- ther glove, slide your other hand into the second glove. 5. Now adjust both gloves for fit. Remember that any portion of glove touched by bare hands should not then be touched with gloved hands. CHOOSING THE RIGHT GLOVE Latex Latex is a polymeric membrane of natural rubber de- rived from the sap of the rubber tree (Hevea Brasilien- sis). It is made heat-stable, resilient, strong and elastic through vulcanization (heating with sulphur) and the addition of accelerators and antioxidants. Non-sterile medical grade latex gloves are used by many piercers for everyday duties within the studio. Latex gloves vary in thickness and texture and should be chosen for durability, comfort and tactile sensitivity. Latex gloves are sometimes powdered to ease don- ning. These powders are usually cornstarch or talc- based and are placed in the glove after manufacturing. Research has shown that glove powder can lead to granulomas in open tissue, and may increase potential for airborne latex proteins and latex sensitivities. Con- sider using non-powdered gloves for all procedures. Many manufacturers are now processing gloves with a polymer coating such as silicone for easy donning without powder. Latex gloves contain protein antigens and curing agents (such as accelerators and antioxidants) that may cause an allergic dermatitis or systematic anaphylaxis (discussed further below). Even those gloves labeled “hypoallergenic” will not always prevent reactions in a highly sensitive person. Those with severe sensitivi- ties may be unable to enter a shop with airborne latex proteins or powders. Latex gloves should never be used on a client who informs you of an allergy to latex, and many shops have chosen to become latex-free for the safety of all clients and staff. If latex is the pri- mary type of glove used in a studio, latex-free gloves should be stocked for clients with latex allergies and a comprehensive latex allergy procedure should be developed. NON-LATEX ALTERNATIVES Many piercers opt for latex-free synthetic alternatives such as Nitrile. While all the options listed below are latex-free, not all synthetic materials are appropriate for all uses. Synthetics also vary widely in price. When bought in bulk from well-chosen manufacturers, many of the best synthetic glove products can be found at reasonable prices. Vinyl Vinyl (PVC) gloves are an easily available alternative to latex. However, they are not as strong as latex and are more easily punctured. They fit loosely, are non-elastic, and may slip, exposing the piercer’s skin or interfering with skilled procedures. Vinyl gloves are the most porous of exam glove op- tions, and may allow penetration by even large mole- cules of blood and fluids over long exposure. The failure rate of stressed vinyl gloves is reported at about 51.3% (compared with 3% for latex and 0% for Nitrile).* Additionally, vinyl gloves do not necessarily eliminate the potential for contact dermatitis because many of the same chemicals used in processing latex gloves are also used in vinyl gloves. Those reacting to additives in latex gloves may need to avoid vinyl as well. For these reasons, vinyl gloves are less than ideal for most procedural applications in the studio. Nitrile Nitrile gloves are a protein-free, low-chemical, synthetic alternative made from nitrile polymer. They are three times more resistant to chemicals and punctures than latex of the same thickness and have a reported stress failure rate of 0%.* While nitrile’s thickness and lack of elasticity require getting used to after thin latex, many piercers find these gloves to be more secure and to allow full dexterity. They are available with textured fingertips for increased grip, and can be had in a range of colors to increase client awareness of glove use. Although slightly more expensive than latex, nitrile gloves are reasonable when bought in bulk and offer an excellent synthetic alternative for those desiring high quality protection and minimal risk of chemical- or allergen-exposure. Test several manufacturers’ products to find an optimum product for your individual needs and budget. Polyurethane and Styrene Co-polymers Other high quality synthetic alternatives such as Tac- tylite and Allergard are available. Some have very little allergy potential and provide a good barrier. Fit, feel and cost vary by material, brand and design. In general these gloves are more expensive than others,
  • 16. 13 but may well be worth it depending upon a piercer’s preferences and circumstances. Contact individual suppliers for samples. *Adenna, Inc. ©1997-2004. LATEX SENSITIVITIES Since the implementation and recommendation of Uni- versal Precautions by the Centers for Disease Control and Prevention (CDC) and Occupational Safety and Health Administration (OSHA) , latex sensitivities have been on the rise. Estimates suggest 2 - 6% of the gen- eral population is latex sensitive. Among healthcare workers this percentage rises to 8 - 12%. Due to the extensive exposure many people in the healthcare, emergency service, body art and other industries have to latex gloves and protective gear, allergic reactions among these groups are increasingly common and if unchecked can interfere with continued employment. Reactions can range from minor rash to life-threaten- ing respiratory distress. Because latex allergies are actually sensitization reactions from overexposure to latex, and because latex is so pervasive in our home and work environments, prevention through limiting exposure is crucial. Those who come into frequent contact with latex through the skin or inhalation be- come sensitized, and may go on to develop full allergic reactions. These reactions often occur gradually, but can also come on quite suddenly. Those who use gloves at work, have had multiple surgeries, or who have multiple allergic sensitivities or spina bifida are especially at risk. In the piercing studio, many items besides gloves contain latex. Adhesive tape, rubber bands, some autoclave wrap, CPR masks, and even the handles of some tools and covering on ballpoint pens may contain traces of latex. All of these can trigger reac- tions. Piercers should understand the types of latex reaction and how to deal with latex-sensitive clients and coworkers. The three types of latex hypersensitivity reactions that occur are classified in order of severity as Irritant Contact Dermatitis, Type IV Reaction and Type I Reaction. Irritant Contact Dermatitis This type of reaction is actually not an allergy, but rather a surface irritation caused by excessive handwashing, harsh soaps, chemicals, hand sanitizers and/or glove powder. It can appear as overly dry, cracked, sore or flaky skin and rash. To avoid or relieve contact derma- titis, switch to milder products, avoid powdered gloves, and use a soothing hand sealant after washing. Avoid hand sanitizer or products that increase irritation and be aware that cracked skin is open to latex, chemical and pathogenic penetration. Although contact dermatitis is not serious in itself, it can lead to further problems if not cared for. Type IV Reaction: Chemical Protein Hypersensitivity Type IV is a delayed reaction to an allergen that usually appears 48 to 96 hours after contact. Most people with Type IV hypersensitivity experience some form of der- matitis, such as rash, scales, inflammation, or eczema. Reactions may also include conjunctivitis, runny nose or asthma-like symptoms from airborne detritus. It is generally believed that this type of response is due to the chemicals used in manufacturing the rubber and not due to the latex itself. Type I Reaction: Latex Protein Sensitivity This is an immediate and systemic response to latex proteins. People with this type of reaction may have intense burning and irritation at the contact site, hives within 5 to 60 minutes, itchy eyes, swelling of lips and tongue, abdominal pain, asthma, nausea, and in severe cases death from anaphylactic shock. What To Do For their own health and that of their clients, it is im- perative that professional piercers take these health concerns seriously. If you suspect you have a latex sensitivity, consult a doctor or allergist. Because se- vere reactions can develop suddenly and continued exposure increases this risk, cease all contact with latex products. This will often mean making the entire studio latex-free. The use of low-chemical, low-protein, low-endotoxin powder free synthetic gloves (such as nitrile) is recommended in suspected cases of all three types of hypersensitivity. Question all clients regarding latex sensitivity prior to piercing and use only non-latex materials on clients with a history of sensitivity. Hand sealants, non-latex gloves and avoidance of chemical triggers may ease dermatitis and Type IV Reactions. Medications and allergy therapies are available to mini- mize some symptoms of Type I Reactions, but there is no clinically recognized treatment or cure. For more information NIOSH has issued an Alert, Preventing Allergic Reac- tions to Natural Rubber Latex in the Workplace (DHHS [NIOSH] Publication No. 97-135). Free copies are available from the NIOSH Publications Office: 1-800- 35-NIOSH (1-800-356-4674).
  • 17. 14 From STERILE to CLEAN to CONTAMINATED Every piercer should thoroughly grasp how their environment and the tools they use pass through stages from sterile to clean to contaminated. The chart below should help your understanding. Visualize sterile as white and contaminated as dark red with several shades in between. Always remember that when a lighter colored item comes in contact with a darker one it becomes that color, and can pass it on, until it is disinfected or sterilized. Nothing darker than pale pink should ever come in contact with a piercing, directly or indirectly. Bare hands should avoid red items. If red items are touched, hands should be immediately washed. Dark red items should never be touched with bare hands. WHITE Sterile. No living matter. Autoclaved implements, jewelry, needles, etc. in un- opened, sterile bags, untouched. PALEST PINK Very clean. Only very small quantities of airborne matter. Sterile implements just removed from their bags. Disinfected imple- ments only touched with freshly gloved hands, trays or surfaces immediately after disinfection/ bleaching. Bagged “sterile” implements after several weeks in storage. PALE PINK Clean. Only small quantities of airborne matter. Presterilized corks, rubber bands, non- sterile latex gloves, tissues, cotton swabs, etc. stored in protective containers and only touched with freshly gloved hands. Surface of “sterile” field, only touched with freshly gloved hands. Needles, forceps, sterilized jewelry, etc. after several minutes in open air, unused. Surface of skin imme- diately after aseptic skin prep. Hands immediately after correct hand washing procedure. PINK Not clean. Normal levels of airborne matter. Needles, forceps, corks, rubber bands, etc.., after extended exposure to open air or frequent handling. Clothing, surfaces, implements, neither contaminated with bloodborne organ- isms, nor recently disinfected. Unused jewelry prior to sterilization/disin- fection. Piercing room furniture, etc. RED Dirty. High levels of airborne matter and possible presence of bloodborne matter. Floors, countertops, sinks, doorknobs, light switches, and other areas that may have been exposed to bloodborne contaminants, either directly or indirectly. Unbroken, uncleaned skin. Frequently handled display jewelry. Phones Money DARK RED Contaminated. High levels of airborne/bloodborne matter. Bodily fluids, new or old. Piercings, new or healed. Broken skin of any kind. Used piercing implements, used disposable piercing needles. Previously worn jewelry. STERILE CHART
  • 18. 15 Cleaning, disinfection and sterilization are all part of the same process, but they differ significantly in the number and types of microorganisms killed. Under- standing the differences enables the piercer to choose the correct way to make contaminated items safe to use. It also determines proper disposal methods for items that cannot be decontaminated and are unsafe for use in the studio. CLEANING Cleaning is the process that physically removes debris and reduces many of the microorganisms present on an object. Cleaning is the first step in the decontamination pro- cess. It is important to clean items prior to disinfecting and/or sterilizing them. There are some items that will not require disinfecting or sterilizing prior to use, and for which only thorough cleaning with an antibacterial or antimicrobial soap is necessary. Washing hands before and after performing pierc- ings, and several times during the day is such a decontamination process. Of course, even the most stringent handwashing does not take the place of wearing gloves. Tools used in piercing procedures must be thoroughly cleaned before sterilization in order to remove gross matter such as body fluids and lubricants. Otherwise the presence of these can keep steam from effectively reaching all surfaces during a sterilization cycle. In order to do this thoroughly without the risks of manual scrubbing, studios should use an ultrasonic cleaner. Ultrasonic Cleaners are a quick and safe way to execute the critical step of removing matter from in- struments and jewelry prior to sterilizing. Ultrasonics do NOT sterilize. Ultrasonics work by using ultrasound energy (wave motion above the level of audible sound). This energy is transmitted to the cleaning solution within the machine where it creates tiny bubbles of vaporized liquid that explode when they reach a high pressure. An extremely thorough cleaning of all surfaces, even inside of tubes and hinges, occurs as shock waves dislodge debris from the contaminated articles placed in the bath. For optimal results the technician must carefully fol- low the manufacturer’s guidelines for use of solution, additives, temperature, baskets, lids and timers. For example, even Stainless Steel forceps may appear cor- roded if the solution is not properly Ph-balanced. With bench-top models, soils removed from components will be suspended in the solution. If all items are not rinsed immediately after the cycle, the soils in the solu- tion will redeposit themselves on tools during drying. All forceps and hinged tools must be run with the jaws open to expose all contaminated surfaces. There is some controversy regarding the risk of aerosolized (airborne) contaminants during the running cycle of an ultrasonic. To be safe, the APP strongly encourages the use of lids during running cycles. Some piercers even enclose the ultrasonic unit or add second- ary barriers to minimize potential risks from airborne aerosolized pathogens. A HEPA filter in the cleaning room is an excellent additional precaution. DISINFECTION Disinfection is the process that kills some but not all disease-causing microorganisms. Some nonpathogenic microorganisms can remain on any item that you have disinfected. What kind and how many of those you might kill depends on what level of disinfection you use. Bacterial spores and the Mycobacterium Tuberculosis var. bovis are difficult-to- kill, laboratory test microorganisms used to classify the strength of a chemical disinfectant as follows. Three Levels of Disinfection 1. Low-Level Disinfection is the least effective pro- cess and is what most of us think of when we talk about “clean.” It does not kill bacterial spores or M.tuberculosis var. bovis. 2. Intermediate-Level Disinfection is a process that kills the tough tuberculosis microorganism. This is important because a process that kills M.tuberculosis var. bovis is also effective against a host of other organisms that are much easier to kill, such those that cause HIV. 3. High-Level Disinfection is a process that will destroy some, but not all bacterial spores, as well CLEANING, DISINFECTION & STERILIZATION
  • 19. 16 as bacteria, fungi, and viruses (like the one caus- ing Hepatitis B), in addition to the microorganisms killed at the Intermediate Level. According to the CDC, High- Level Disinfection can only be achieved with a chemical solution that can sterilize given appropriate conditions. However, although High- Level Disinfection kills the same types of organ- isms as sterilization, only full autoclave sterilization renders items that have been contaminated with Bloodborne Pathogens safe for reuse. STERILIZATION Sterilization is the process that kills all microbial life. In addition to all bacteria, viruses and fungi, steriliza- tion will also kill bacterial spores, which are resilient and are the most difficult microorganisms to kill. A process able to eliminate bacterial spores will kill other types of microorganisms such as fungi and viruses. Steriliza- tion eliminates the organisms that cause Tuberculosis, Hepatitis B, Hepatitis C and HIV, as well as all other infectious agents. When you have sterilized properly, there will be no microorganisms alive. Any item or product in your shop that may have been exposed to bloodborne pathogen contamination must be sterilized prior to use. This includes reusable items such as tools, forceps and setup trays. If a contami- nated reusable item cannot be sterilized appropriately, it must be discarded. Single-use, disposable items such as piercing needles must also be sterilized prior to use. However, once used disposables must never be sterilized and reused. Many piercing studio operators do not yet under- stand the need to sterilize all jewelry before use in new piercings. Logically, there is no point of using a sterile needle just to follow it with non-sterile jewelry. We can only know how jewelry is handled within our own shops, and must therefore ensure that no poten- tial contaminants from the manufacturers or shipping contact our clients. Regardless of the source of their jewelry, a reputable piercing shop should insert only high quality body piercing jewelry that is sterilized on the premises prior to insertion. It is not a manufacturer’s responsibility to sell only sterilized jewelry. At the same time, manufacturers also must not misrepresent what is being sold by falsely labelling jewelry as “sterile” or “ready for insertion,” or by making other misleading claims. Best practice for any shop is to run new jewelry shipments through an ultrasonic cycle (preferably in a clean ultrasonic reserved for clean jewelry), and to then autoclave all pieces prior to use. Sterilization Procedure Options • Steam under Pressure (Saturated steam/steam autoclave): 220-270 kip pressure at 140 degrees Celsius (284 degrees Fahrenheit) for 15-40 minutes depending on cycle. • Dry Heat (Dry-Clave): Processing at 177 C (350 F) for 1 hour. This is appropriate only for items that cannot withstand steam exposure. • Gas Plasma (ETO gas/chemical autoclave): Re- quires specific site construction for venting of poten- tially toxic fumes and is not practical for piercers. • Gamma Radiation (exposure to specific radioac- tive waves): Highly regulated and costly, requiring specific site construction and disposal criteria. Im- practical for piercers. • Liquid Chemical (cold sterilization): Immersion in an EPA (Environmental Protection Agency) approved and FDA (Food and Drug Administration) controlled chemical agent per manufacturers’ guidelines (com- monly 10-12 hours). Maintaining the sterility of items once removed from the solution is difficult. Problems with disposal and exposure to toxic chemicals make this method impractical for piercers. Sterilization in the Studio Pressurized steam is the only practical and cost-effec- tive method of sterilization in the piercing studio. For our purposes, sterilization requires an autoclave, a piece of medical equipment that employs the steam under pres- sure method of sterilization. Autoclaves can be obtained from a medical supplier and range between $600 and several thousand dollars, depending on size, type and features. Items that have already been cleaned and pro- cessed in an ultrasonic are placed in specially-designed sealable autoclave bags that allow penetration by steam during the sterilization cycle, but protect sterile items from contamination after processing. Until these bags are opened during a piercing procedure, their contents remain sterile unless bag integrity is compromised by puncture, moisture or age. Having a clave on premises is not helpful if it is not in working order. Manufacturer guidelines for main- tenance should be stringently followed. Medical sup- pliers also provide easy in-house methods for studios to check the viability of the sterilization process. Most autoclave bags have indicator strips that change color when exposed to steam, making it easy to distinguish bags that have been processed from those that have not. However, the color change of indicator strips on the autoclave packaging is not a reliable method of determining if an autoclave is working properly. It tests only exposure to steam, not whether the heat, pressure
  • 20. 17 and duration of that exposure was sufficient to achieve sterilization. Integrator strips are another method for checking clave reliability in house. Integrators are strips or de- vices used in pouches and/or autoclave chambers that prove the conditions for sterilization were met. They are similar to indicators, except that they change color when they have been exposed to the ideal combination of steam, pressure, heat and timing. They should ideally be run and logged daily. Spore tests are the most thorough way of testing autoclave function. They are periodically run through an autoclave cycle, and then sent to an external testing facility for analysis. The testing facility checks to see that there is no subsequent growth of bacterial spores on the medium. Since spores are extremely difficult to kill, the lack of spores on the test medium after autoclaving indicates that more fragile organisms have also been destroyed and the autoclave is functioning properly. Spore tests are absolutely necessary to ensure that items are indeed being sterilized. Failed spore tests require an immediate halt in piercing operations until tools and other items can be reliably resterilized. For this reason some shops keep more than one autoclave on premises. Your studio should have a written policy outlining the procedure that must be followed immedi- ately following notification of a failed spore test. Studios should develop and follow a written steriliza- tion program that includes how and when indicator, integrator and spore tests will be run, recorded and filed. Batch numbers can be included in the log so that a given set of tools can be quickly traced to a particular cycle and double-checked in case a concern regarding a particular piercing or client arise. Some new auto- claves come conveniently equipped with a printer that will provide a sheet documenting the sterilization cycle of each load. This printout is simply a written record and does not take the place of an indicator, integrator or spore test. Logs proving autoclave use and integrity are essential to the conscientious running of a studio, and will be invaluable should post documentation be required for regulatory or legal purposes (e.g. in the event of a lawsuit). Statim Some piercing studios use steam-flushing pressure- pulse autoclaves (such as Statim autoclaves) for sterilization. The sterilization process in this type of autoclave facilitates air removal and steam penetra- tion, and has an extremely short processing time. The steam-flush pressure-pulse autoclave is acceptable for sterilization in the piercing studio as long as certain guidelines are followed: • Due to the high number of cycles run each day, these autoclaves must be spore tested weekly. • Daily, weekly and monthly maintenance of steam, pressure-pulse autoclaves is required. This type of autoclave requires a more rigorous maintenance schedule than traditional autoclaves and a written log of all maintenance should be kept. The Statim has three sterilization cycles, each de- signed to sterilize a specific type of instrument. • Unwrapped cycle - 275 F for 3.5 minutes • Wrapped cycle - 275 F for 10 minutes • Rubber and plastic cycle - 250 F for 15 minutes The following can be sterilized in the Statim 2000: Nylon, polycarbonate (Lexan), polypropylene, PFTE (Teflon), acetal (Delrin) polysulfone (Udel), poly- etherimide (Ultem) silicone rubber, and polyester. The following cannot be sterilized in the Statim 2000 on any cycle: Polyethylene, ABS, styrene, cellulosics, PVC, acrylic (Plexiglas), PPO (Noryl) latex, neoprene, and similar materials. If you are not sure, do not load items until you have checked with the manufacturer. Processing of these ma- terials may lead to instrument or equipment damage. Do not mix instrument types (i.e. plastics and un- wrapped tools) in the same Statim load. DISINFECTING SOLUTIONS What can I use as a disinfecting agent in my shop? What disinfectants you use will depend on the applica- tion and product availability. Appropriate products are marketed under many names and in several categories. All require exposure times of at least 10 minutes in order to effectively disinfect, with the exception of surfaces already considered “clean” (See Sterility Chart on page 14 for explanation). Everything in the immediate piercing environment should be decontaminated with no less than an Inter- mediate Level of disinfection. Note that disinfectants are used only on inanimate surfaces (objects) and antiseptics are used only on animate (living) surfaces. Disinfecting solutions are grouped into families ac- cording to similar characteristics and properties. Choose products proven to be nontoxic, broad spectrum, hospi- tal grade disinfectants, with a narrow efficacy time and
  • 21. 18 a long, stable shelf life. Labelling should specifically state that the product is bactericidal, virucidal, fungicidal and tuberculocidal. Some may also be described as germicidal or sporicidal as well. Glutaraldehyde - 2% Solutions These are non-biodegradable biohazards and have been classified by the FDA as toxic. These solutions are commonly found in two varieties, the acidic and the al- kaline. The alkaline type will require an activating agent to bring them to the proper Ph levels, thereby making them usable. They generally require a long exposure time in order to be effective. Most, if not all of these that are currently available require special ventilation and vapor monitoring equipment and must be disposed of according to specific local and federal regulations. Once activated, these products have a limited shelf life and are rendered ineffective fairly quickly. Some common products in the alkaline solutions family are Cidex Plus, Procide, and Omnicide. Com- mon acidic Glutaraldehyde products are Sterall and Banicide. The acidic formulations do not require activa- tion, but are only tuberculocidal after about 30 minutes of exposure time. All Glutaraldehyde solutions destroy unlike metals. Using any of these products with mixed metals such as stainless steel tools, brass jaw pliers, and plated pliers will lead to rapid corrosion. Phenolics - 10% Solutions Phenols are surface disinfectants and are not broad spectrum enough to make them useful for most surfaces in the piercing studio. These are sold under such names as Birex, Procide, and Lysol. Iodophores These are iodine-based disinfectants that will stain surfaces and discolor metals. This makes them a poor choice for soaking jewelry or tools. Additionally these disinfectants have been shown to potentially contain high levels of an organism called Pseudomonas, which grows in the solutions when stored for an extended pe- riod of time. Furthermore, many individuals are iodine sensitive or allergic to these products. Biocide, Micro- dyne, and Iodofive are common product names. Chlorine Compounds Sodium hypochlorite, more commonly known as bleach, acts as a protein disintegrator. Most pathogens are protein-based, making this an effective surface disinfec- tant. A solution of 10% bleach to 90% water will destroy most pathogens in less than 10 minutes. For bleach to be effective, the surface area must be aggressively scrubbed first, and the solution allowed to remain on the surface for a full 10 minutes. The diluted mixture has a shelf life of less than 48 hours so it should not be mixed and stored for later use. Many people are highly sensitive to this chemical and some may experience severe allergic reactions to va- pors in a recently cleaned room. Using other chemicals (particularly ammonia-based cleaners) in the same area may produce a toxic reaction and poisonous gas. A bleach solution is incompatible with stainless steel tools or surfaces. Its use in ultrasonic cleaners or au- toclaves will not only void warranties, but will destroy these costly pieces of equipment. Jewelry should never be soaked in even a weak bleach solution. Quaternary Ammonium Compounds Known as “Super-Quats,” these products are sometimes mixed with other chemicals such as alcohol. Although towelette wipes impregnated with Super-Quat solutions are excellent surface cleaners, not all disinfectants in this group will kill Tuberculosis, which is a particularly hardy pathogen. These products should also not be used for soaking jewelry. Common product names are Saniklens, Aseptic-seryl, and Bafix. Synergistic Formulas A synergistic action involves two or more agents co- operating with each other to result in an effect greater than the additive effect of each agent operating by itself. These solutions are non-toxic, biodegradable, broad-spectrum disinfectants that are also non-cor- rosive and nonstaining. Once opened, the stability of these solutions ranges from 6 to 10 months maintain- ing full potency. They do not require special disposal handling. Synergistic solutions are available in spray bottles, liquid pour bottles, foams, and impregnated towelettes. They can be used as hard surface disinfectants and for jewelry soaking. (Note that autoclave sterilization remains the only appropriate way to prepare jewelry for use in a fresh piercing.) Two of the most common products used by professional piercers are the syner- gistic formulas Madacide and Discide. Isopropyl Alcohol Alcohol can be used as a low-level disinfectant only. It is not recommended as a soak or for disinfecting con- taminated environments because it is not a sufficiently effective cleaner.
  • 22. 19 DISPOSABLE SUPPLIES To minimize the risk of cross-contamination and to ensure that the piercing procedure is as clean as possible, many components of a piercing set-up are disposable. Unless supplies will be sterilized in a Statim autoclave immediately prior to the procedure, all disposables must be individually packaged in autoclave bags, sterilized, and remain in their pouches stored in enclosed, nonporous containers until use. Disposable materials that can and should be autoclaved include piercing needles, corks, rubber bands, cotton swabs, toothpicks, and gauze. When setting up for a piercing or jewelry insertion, the piercer should first select and assemble all materi- als and tools that might be needed for that procedure. In avoiding cross-contamination, it is entirely unac- ceptable to reach into the piercing cabinet or drawers with gloves that have touched a client. Therefore, the piercer should anticipate possible needs and required items before the procedure begins. If additional sup- plies are required, the piercer must don fresh gloves before accessing any items in the piercing cabinet/ drawers, and must change gloves before touching the client or sterile tools. Use of Various Disposables Presterilized Rubber Bands: Because the jaws of forceps should never be locked onto a client during piercing, these are wound around forceps handles to achieve desired tension. Presterilized Cotton Swabs: Excellent for clean- ing and drying in tight spots, and for erasing stray marks. They come in several different lengths and thicknesses. Presterilized Toothpicks: Used with gentian violet for marking placement. Presterilized Wire Snips: Can be used to connect internally threaded jewelry and piercing needles to maintain needle-jewelry connections for smooth jewelry transfers. PIERCING NEEDLES Acceptable piercing needles are hollow and extremely sharp, with a smoothly sloping cutting edge and no scratches or surface flaws that could damage the tis- sue. Most piercing needles are sold as “super sharp,” or double- or triple-bevelled and come in several lengths. Piercers should inspect each needle immediately be- fore use to be sure there are no burrs or irregularities. Should the piercer choose to bend or shorten a needle, great care should be taken to avoid creating such flaws. Some companies are now manufacturing needles in different lengths and bent options. Of course, the true test of needle sharpness and quality will be in use. Since needle quality will affect both the comfort and healing of clients, as well as the smoothness and speed of the piercer’s technique, the use of only high quality needles is encouraged. Piercing needles are available in sizes corresponding to the gauges of jewelry for fresh piercings. Needles are commonly used in 18, 16, 14, 12 and 10 gauge. Most professional piercers agree that needles thinner than 18 gauge or thicker than 8 gauge are inappropri- ate for fresh piercings. Thicker needles may damage tissue, and the excessive weight of metal jewelry thicker than 8 gauge may result in tissue damage or delayed healing. Needle Handling, Storage, and Disposal Piercing needles have an extremely sharp, precision- ground blade, making them both hazardous to ship and handle, and easily damaged. Bulk, unsterilized needles should arrive at the piercing studio in a clearly marked, thick plastic, padded roll tube. Under no cir- cumstances should needles be mailed in a plastic bag, taped to a cardboard square, or rolling around loose in a cardboard box. These methods create the risk of a needlestick, and are certain to dull the fine points of the needles. Most piercing studios perform in-house sterilization of piercing needles. This gives certainty that proper handling has occurred at every stage of the process. Unless needles are autoclaved immediately prior to a piercing procedure in a Statim autoclave, shipments of needles should be immediately packaged and labeled with gauge and date of sterilization. Sterile needles in autoclave packets must be kept in clean, dry enclosed containers until use. Some local regulations and shop policies set expiration dates on sterilized needles and tools, after which the items are no longer considered sterile. Unused sterilized needles stored past their EQUIPMENT
  • 23. 20 expiration date should be repackaged and autoclaved, and marked with a new expiration date. After a single use, needles must be immediately disposed of into an approved Sharps container. They should never be resterilized after use nor used more than once. Sharps Disposal Untreated, used Sharps disposal containers may not be included with ordinary trash. Sharps containers and waste in red Biohazard liners must be picked up by a Biohazard waste management company or disposed of in a manner that does not violate regulated waste laws. All containers in a studio bearing the Biohazard label must have the contents disposed of according to regulated waste laws. REUSABLE EQUIPMENT Most professionals will use a wide range of tools to speed the procedure and maximize the comfort of the client. Piercing tools come in many styles, qualities and price levels. Piercers are cautioned that while inexpensive tools are abundant, the quality of tools is usually exhibited in their performance and durability. Tools that work well enhance your individual technique, rather than complicate it. High quality piercing tools are made of long-life stainless steel and are designed with piercing applications in mind. Much like surgical imple- ments, initially they will be costly, but they are intended and engineered for repeated use over many years. Following each use, the contaminated tool should be: 1. Cleaned in an ultrasonic. (See ultrasonic manu- facturers’ instructions for optimal solution and cycle length.) 2. Rinsed 3. Dried 4. Bagged and labeled with date (as well as batch number and operator initials if required). To pro- long life of instruments with movable parts, many professionals apply surgical instrument lubrication (and allow it to dry) prior to bagging. 5. Sterilized in an autoclave *Note: Steps 1-4 should be performed only in an area designated as contaminated, and by prop- erly trained personnel wearing personal protective equipment. TYPES OF TOOLS Forceps Forceps come in a variety of shapes and sizes and are used to align and secure tissue, increasing accuracy and speed of the piercing. Properly applied, forceps gently compress the piercing site while causing the piercee minimal discomfort and no additional tissue damage. Some forceps are designed for specific body parts, such as the septum and navel. Others are available modified to an individual pierc- er’s preference, for instance with a slotted, smooth or ser- rated head. Hemostats (“Multipurpose Tools”) These are useful for holding jewelry, beads and needles during procedures. They are available with smooth or serrated jaws, and some are customized with grooves for opening and closing rings as well. The smooth-jawed are less likely to scratch the delicate finish on jewelry. However, either finish of jaw should be wrapped in sterile protective padding, such as plastic surgical tape or a cloth band-aid, for optimum protection. Needle Holders Needle holders are used in surgery for suturing. Their strong jaws with a central groove make them ideal for opening and closing small gauge and small diameter rings. Needle Receiving Tubes (“NRTs”) NRTs are used to support and protect the tissue around piercings when forceps may not be preferred. They are often used for nostrils, septums, Prince Al- berts, vertical clitoral hoods, and some ear cartilage piercings. NRTs come in vari-
  • 24. 21 ous lengths, sizes and modifications. They are usu- ally hollow stainless steel tubes with perfectly smooth openings, often with one flared or angled end. Some piercers prefer a shatter-resistant, autoclavable, clear Borosilicate glass NRT, which allows full needle vis- ibility during the procedure. Pliers Many kinds of pliers are used in piercing procedures, and are described below. Optimally pliers should be made of stainless steel to withstand repeated autoclav- ing. The obvious exception is smooth brass-jaw pliers, which have the unique advantage of being unlikely to scratch the surface of jewelry due to their brass-coated jaws. Many pliers can be nickel- or chrome-plated to resist rusting, but will eventually break down and become unusable. The corroding metal can damage the delicate components of the autoclave. These tools must be replaced at the first sign of rust. Ring Closing Pliers: Used to narrow the gap on captive rings to create proper tension for holding the bead. Ring Opening (or Expanding) Pliers: Used to remove and insert captive beads and occasionally to widen the gap on captive rings for insertion and removal. Bending Pliers: Used for custom bending nostril screws, fishtail labrets and needles. These are usually jewelers’ pliers and are available with a number of differ- ent head shapes. The most com- monly used are called “double rounds.” Connecting Snips Small pieces of wire used to stabilize the jewelry transfer during the initial piercing when using internally threaded jewelry. Even experienced piercers find the wire connection between the jewelry and needle help- ful in maintaining alignment. When nicely finished and made of titanium or niobium wire in contrasting colors, connecting snips are easily distinguished on the pierc- ing tray and are safe for re-sterilizing. Calipers These instruments are used for measuring the jewelry gauge and diameter, or the distance be- tween markings for piercing place- ment. They are available in both standard inch and metric calibrations, and some offer both units of mea- surement. Though calipers are available in both plastic and metal, few styles can be autoclaved. Usually the fancier and more accurate models cannot be sterilized, so great care should be taken not to contaminate them. There are a few simple styles available in autoclavable stainless steel. Though less accurate and somewhat harder to read, they have an obvious advantage in the piercing studio. Gauge Wheels Most American body jewelry manufacturers have stan- dardized measurement of the thickness of their jewelry wire with the Browne and Sharp/American Standard wire gauge system. In other industries this system has been historically used for measuring gold wire. There are some variances between wholesale companies, so it is always wise to double-check jewelry gauge to the wheel and to the needle before the piercing procedure. Outside the US, manufacturers use metric millimeters for measuring gauge. Insertion Tapers These are tapered pieces of 18g and larger stainless steel or titanium, used to gradually expand an existing piercing channel. Tapers are most often used to stretch a piercing up to the next gauge, to locate/stretch a healed piercing that has shrunk, and to quickly locate the piercing channel if a jewelry transfer is lost during the initial piercing. Reusable tapers are made of auto- clavable materials and are available in many lengths, slopes and styles. In particular, concave tapers are used with non-threaded or larger initial jewelry, and pin-coupling tapers are available for inserting smaller gauge internal jewelry. When using tapers, understand
  • 25. 22 that longer, gently sloping tapers (3 inches and up) are best for stretching, while shorter tapers are used for jewelry transfers. The longer and more gradual the taper, the more gentle the stretch. Piercing Trays Piercing trays are the basic foundation upon which the piercing set-up and aseptic field is laid. All procedures should be worked from an autoclaved tray set-up or autoclaved tray liner, rather than a countertop or other surface. Trays should be made of autoclavable plastic or stainless steel, and covered with a plastic-backed dental bib or another impenetrable tray liner. Bagged equipment can be laid out upon the liner just prior to a procedure. The actual procedure surface is called an “aseptic field,” and is a sterilized surface that becomes exposed to air contact only at the beginning of the piercing procedure. The aseptic field used by most piercers is the inside surface of a freshly opened sterile forceps pack, or a sterile 3x3 or 4x4 gauze. Once a forceps or gauze pack is opened, sterile tools, needles, jewelry and disposables can be dropped onto the flattened inside surface for use. Needles, jewelry and tools should never be placed on a non-sterile tray or tray liner surface. “Clean” is not sufficient enough for a procedure surface. Procedure surfaces must be sterile. Optimally, piercing trays should fit into the autoclave and should be sterilized at least daily, or immediately if cross-contamination is suspected. Sundry Jars These autoclavable tempered glass and/or stainless steel jars are useful for storing individually packaged sterile items. There are also a few grades of autoclav- able plastic available. Sundry jars should not be used to store bulk sterilized unpackaged items because they are periodically open to air contact, and because bulk sterilized items are only sterile until removed from autoclave packaging. (Again, “clean” items are not clean enough for a piercing procedure.) Sundry jars need to be disinfected daily and sterilized weekly, or immediately if cross-contamination is suspected. THE PIERCING GUN APP members make a commitment to using the best piercing techniques for hygiene, healing and client comfort. These require: piercing instruments that are sterile and/or disposable; jewelry that is sterile, implant grade and anatomy-appropriate; and methods that minimize tissue trauma and scarring. Although pierc- ing gun companies continue to respond innovatively to some of the risks listed below, at the time of this printing the use of an ear stud gun cannot be accepted in the practice of APP members. While piercing guns may seem to be a quick, easy and convenient way of creating holes, they can have major drawbacks in terms of sterility, tissue damage and inappropriate jewelry design. These concerns, which have been documented in the medical literature, are addressed below. Reusable ear piercing guns can put clients in direct contact with the blood and body fluids of previous clients. During a piercing, microspray of body fluid from one client can aerosolize and contaminate the inside of a gun. Even if sterile jewelry packs are used, the next client’s tissue and jewelry may contact contaminated surfaces, potentially transmitting bloodborne pathogens through the reusable ear piercing gun. Although guns may be exposed to bloodborne pathogens dozens of times a day, few, if any, gun piercing establishments possess the expensive equipment (steam autoclave or chemclave) necessary to sterilize them. Considering the dozens of clients who may have di- rect contact with a single gun in one day, pathogens like hepatitis, pseudomonas and common staph constitute a serious public health threat if they are introduced into even one reusable piercing gun. Young children and those with immature or compromised immune systems may be at higher risk. Piercing guns can cause significant tissue damage. Piercing guns use pressure to force a dull metal shaft through the skin. The procedure can cause similar tis- sue damage to a blunt force trauma, such as significant pain, swelling, scarring, and an increased potential for complications. The more serious complications associated with gun piercing increase when stud guns are used on structural tissue such as cartilage. Cartilage has less blood flow
  • 26. 23 than lobe tissue and a correspondingly longer healing time. Therefore infections in this area are more com- mon and can be much more destructive. The use of non-sterile piercing equipment and insufficient after- care has been associated with increased incidence of auricular chondritis, a severe and disfiguring infection in cartilage tissue. This can result in deformity and col- lapse of structural ear tissue, requiring antibiotic therapy and extensive reconstructive surgery to correct. The length, design and material of traditional gun studs are inappropriate for initial piercings. Traditional ear piercing studs are too short for some earlobes, most cartilage and other body parts. Once they are locked on by the gun mechanism’s pressure, compressed tissue remains constricted and can be- come irritated. Diminished air and blood circulation can lead to prolonged healing, scarring, swelling and possibly impaction. Both piercers and medical per- sonnel have seen stud gun jewelry embedded in ear lobes and cartilage (as well as navels, nostrils and lips), sometimes requiring surgical removal. Jewelry that fits too closely also increases the risk of infection because it does not allow for thorough clean- ing. Body fluids normally discharged during healing can become trapped around the hole by inappropriately designed jewelry. Unless this discharge is thoroughly and frequently removed, it can attract bacteria and becomes an invitation to secondary infection Ear piercing studs made of materials that are not FDA-approved or ASTM-certified as safe for long term implant in the human body should not be used. Even when coated in non-toxic gold plating, materials from underlying alloys can leach into human tissue through corrosion, scratches and surface defects, causing cy- totoxicity and allergic reaction. Since manufacturing a durable corrosion- and defect-free coating for such studs is extremely difficult, medical literature recom- mends only implant grade (ASTM F-138) steel and titanium for piercing stud composition. Studs made of any other materials, including non-implant grade steel (steel not batch-certified as ASTM F-138), should not be used, regardless of the presence of surface plating. Misuse of ear piercing guns is extremely common. Even though many manufacturers’ instructions and local regulations prohibit it, many gun piercers do not stop at piercing only the lobes, and may pierce ear cartilage, nostrils, navels, eyebrows, tongues and other body parts with the ear stud guns. This is absolutely inappropriate and very dangerous. Considering that a large proportion of gun piercers’ clientele are minors or young adults, it is not surpris- ing that few gun piercing complications are reported to medical personnel. Many of the clients may have been pierced without the consent of parents or guardians who provide healthcare access. Therefore, many cases of infection, scarring and minor complications may go unreported and untreated. Because of the ease of acquiring a gun piercing and the lack of awareness of risk, many consumers fail to associate negative experi- ences with the stud gun itself. They believe that, since it is quicker and easier to acquire a gun piercing than a manicure, gun piercing must be inherently risk-free. Legislation has begun to prohibit the use of guns on ear cartilage and non-lobe locations, and New Hampshire has made all non-sterile equipment illegal, but these changes are not yet nationwide. As profes- sional piercers and public health advocates, we have an obligation to provide consumers and legislators with accurate and adequate information to understand the risks and benefits of gun piercing. FURTHER REFERENCES ON EAR PIERCING GUNS 1. Journal of the American Medical Association. 2004 February 25; 291(8): 981. Outbreak of Pseudomonas aeruginosa Infections Caused by Commercial Piercing of Upper Ear Cartilage William E. Keene, PhD, MPH Amy C. Markum, RN, BSN Mansour Samadpour, PhD 2. Pediatric Emergency Care. 1999 Jun15 (3): 189-92. Ear-piercing techniques as a cause of auricular chon- dritis. More DR, Seidel JS, Bryan PA. Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, California, USA. 3. Journal of Laryngology and Otology. 2001 Jul; 115(7): 519-21. Ear deformity in children following high ear-piercing: current practice, consent issues and legislation. Jervis PN, Clifton NJ, Woolford TJ. Department of Otolaryngology, Royal Hallamshire Hospital, Sheffield, UK.
  • 27. 24 4. International Journal of Pediatric Otorhinolaryngology. 1990 Mar; 19(1): 73-6. Embedded earrings: a complication of the ear-piercing gun. Muntz HR, Pa-C DJ, Asher BF. Department of Pediatric Otolaryngology, St. Louis Children's Hospital, Washington University Medical Center, MO 63110. 5. Plastic and Reconstructive Surgery. 2003 Feb; 111(2): 891-7; discussion 898. Ear reconstruction after auricular chondritis secondary to ear piercing. Margulis A, Bauer BS, Alizadeh K. Northwestern University Medical School, The Chil- dren's Memorial Medical Center, Chicago, Ill 60614, USA. 6. Contact Dermatitis. 1984 Jan; 10(1): 39-41. Nickel release from ear piercing kits and earrings. Fischer T, Fregert S, Gruvberger B, Rystedt I. 7. British Journal of Plastic Surgery. 2002 April; 55(3): 194-7. Piercing the upper ear: a simple infection, a difficult reconstruction. Cicchetti S, Skillman J, Gault DT. Department of Plastic and Reconstructive Surgery, Mount Vernon Hospital, Northwood, UK. 8. American Journal of Infection Control. 2001 Aug; 29(4): 271-4. Body piercing as a risk factor for viral hepatitis: an integrative research review. Hayes MO, Harkness GA. University of New Hampshire, School of Health and Human Services, Durham, USA. 9. Cutis. 1994 Feb; 53(2): 82. Embedded earrings. Cohen HA, Nussinovitch M, Straussberg R. Pediatric Community Clinic, Petach Tikvah, Israel. 10. Scandinavian Journal of Rheumatology. 2001; 30(5): 311. Does mechanical insult to cartilage trigger relapsing polychondritis? Alissa H, Kadanoff R, Adams E. 11. Toxicology In Vitro. 2000 Dec; 14(6): 497-504. Cytotoxicity due to corrosion of ear piercing studs. Rogero SO, Higa OZ, Saiki M, Correa OV, Costa I. Instituto de Pesquisas Energeticas e Nucleares, IPEN, PO Box 11049, CEP 05422-970, SP, Sao Paulo, Brazil. 12. Journal of the American Medical Association. 1974 Mar 11; 227(10): 1165. Ear piercing and hepatitis: Nonsterile instruments for ear piercing and the subsequent onset of viral hepatitis. Johnson CJ, Anderson H, Spearman J, Madson J. 13. Journal of the American Medical Association. 1969 Mar 24; 207(12): 2285. Hepatitis from ear piercing. Van Sciver AE. 14. The Lancet: Infectious Diseases. 2002 December 1; 2(12): 715. Piercing the cartilage and not the lobes leads to ear infections Pam Das
  • 28. 25 RECEPTION AND SALES ROOM Counter The counter surface should be a nonporous surface such as glass or metal that can be easily disinfected as needed throughout the day. An FDA-approved hard surface disinfectant should be used according to the manufacturer’s instructions for this purpose. Glass cleaner should be used to minimize streaking. Keep disposable relish cups, sealable plastic baggies, dental bibs and tissues at the counter to minimize cross-contamination by customers. Have clients place previously worn jewelry into relish cups or baggies, never on the counter. Even new, unworn jewelry brought in by a client must be handled as if it is contaminated. It very well might have been “just tried on for a second,” which is reason enough to treat it as contaminated. Throw away contaminated disposable items once they have contained a client’s own jewelry, whether they report it was previously worn or not. It is extremely common for customers to touch their jewelry and piercings when they are at the counter, even when they are asked to refrain from such activity. Keep a close watch on your customers and politely but firmly insist that they not handle their own jewelry and/or piercings on the premises. Fully explain your concern for their safety and the reasons behind the rule, and do not tolerate this potential for cross-contamination in the studio. If a client does touch their own jewelry or piercing (whether new or healed), immediately require them to wash their hands or provide germicidal hand wipes for their use to prevent cross-contamination of the studio. Be consistent with requiring hand sanitizing after each and every such contact. A posted sign at the front counter can explain: “For your health and that of others, please do not remove, insert, or handle your jewelry in the store. We will do it for you.” With the possible exception of a welcoming hand- shake, touch pierced clients only with freshly gloved hands. Many piercers feel that wearing gloves for contact of even non-pierced areas establishes a level of professional detachment between the piercer and the client. Dial calipers, gauge wheels, ring expanding pliers, and other tools that are used at the counter should be used for new, unworn jewelry only. Disinfect or sterilize the front counter tools as neces- sary. Should contamination occur, items that cannot be autoclaved must be disposed of. Display Display jewelry should be protected from potential con- tamination. Customers should not be allowed to touch display jewelry to any part of their skin, piercing, or own jewelry. When in doubt, handled items should be autoclaved before being returned to the display case. Sterile jewelry used for initial piercings should not be kept in the display case. If jewelry from the display case is to be used for an initial piercing, the item must meet all criteria for initial piercing jewelry and must be sterilized before use. If display or stock jewelry can- not be autoclaved, contact the manufacturer for proper handling, care and maintenance. Whenever possible, handle display jewelry with gloved hands. THE PIERCING ROOM The piercing room must be a completely separate enclosed room with walls and door(s) made of non- porous material (tile, semigloss paint, sealed brick, vinyl). Unsealed brick, cement, wood and other uneven or porous wall surfaces can trap and harbor disease- causing pathogens. Flooring in the piercing room should be made of linoleum, tile (ceramic, vinyl), sealed wood, or other nonporous material, and should have approximately 4-6 inches of splash guard around the perimeter to protect walls. Floors should be mopped daily with a disinfectant specific to the type of flooring. Lighting in the piercing room must be bright and adjustable. Depending on lighting needs, fixed light- ing can be combined with adjustable lamps. Lamps that are touched or adjusted during procedures must be disinfected at least daily and throughout the day as needed when the potential for cross-contamination ex- ists. Piercers who touch light fixtures during procedures must change gloves before resuming the procedure. To prevent client contact with Biohazard and clean areas of the piercing room, a specific area should be provided and visibly marked for client’s belongings. The Sharps container and contaminated tools should not be located close to sterilized piercing implements ENVIRONMENT
  • 29. 26 and supplies. Many piercers use a Biohazard-labeled shelf above their trash can for contaminated tools. This establishes a single contamination area in the room. Used piercing implements should be kept in an enclosed, nonporous tray or container marked “Biohaz- ard.” The Sharps container should be secured to avoid accidental spillage, and should be at a height easily accessible to all piercers employed in the studio. Packaged equipment and other supplies used during procedures should be stored in a cabinet, credenza, or other enclosed, nonporous storage area. These supplies should be handled only with clean, freshly gloved hands. A HEPA filter or other air purification device should be located in each piercing room and throughout the studio in other necessary locations. Purifiers are selected according to square footage specifications and should be maintained according to manufacturer’s instructions. Replacing filters as recommended is essential to the proper functioning of these air cleaning devices. Signs visibly convey important information to dis- tracted clients and minimize the need to repeatedly announce some information. Some examples of useful signs for the studio: Over the piercing setup area: “Do not touch or put anything on this table.” In areas where contaminated items are located: “Biohazard: Do not Touch.” On non-Biohazard trash cans: “Contaminated Waste” Furniture Storage units and medical supply cabinets should be of a nonporous, easily disinfected surface material, and have several drawers for storing air- and light- sensitive supplies. Furnishings should be disinfected no less than once daily and whenever cross-contamination occurs. Mayo stands are portable tray holding devices. These stainless steel rolling carts must be disinfected before and after each use. Any stand or surface used as a procedure surface must also be disinfected. Client seating is available in a wide variety of styles. The most commonly used types are dentist’s chairs, massage tables, and gynecological exam tables. Choose your furniture for comfort, adjustability, and ease of disinfection. Seating covers should be of a nonporous material such as vinyl or sealed leather. Disposable table paper is a suggested additional covering (mandatory where required by law). Client seating must be disinfected before and after each use even if no contamination is apparent. Scabies, parasites, and other transmissible organisms may be transferred from the hair or clothing of a client to the table or chair. Trash cans must be heavy-grade plastic or metal, lidded, foot-pedal operated, and clearly labeled. Cans should be fitted with plastic liners and placed where they will be accessible to piercers yet out of the reach of clients. According to usual medical standards, most piercing studios do not produce enough blood- soaked trash to necessitate regulated biohazard waste management. However, it is appropriate to voluntarily use a biohazard waste container that is collected by a biohazard waste service weekly or monthly. Red biohazard trash can liners should be used in these containers and should never be disposed with regular trash. Be certain to check local regulations on handling regulated waste. Reasonable access to a sink used exclusively for handwashing is mandatory. In-room prep sinks are ideal. This sink should be used only for pre- and post- piercing handwashing, and optimally should operate via a hands-free method (foot pedals, motion sensors). Air conditioners, fans, and heaters should be used with caution in the piercing room because they can blow contaminants into the designated clean areas of the room. If used, turn these devices toward the door and away from the piercing supply cabinet, trays, and seat- ing. Airflow should always be “from clean to dirty”. BIOHAZARD AND STERILIZA- TION ROOM(S) Two Room Set-Up An ideal studio design would include two rooms for sterilization procedures: one contaminated; one “clean.” The first room would contain the biohazard sink, presoak container, ultrasonic cleaning unit, and autoclave packaging materials. Here shop staff would decontaminate and package used forceps, tapers, pliers and other tools. The second room, or “clean room,” would contain a handwashing sink, autoclave(s), and an additional (uncontaminated) ultrasonic unit for processing new jewelry. While it is not commonly seen in the piercing indus- try, there are some studios that have eliminated the
  • 30. 27 need for a biohazard processing area in their studio by using only disposable tools and equipment. This may not be a viable option for most studios due to the increased cost. One Room Set-Up Many studios have limited space and must place ster- ilization and biohazard processing in one room. This can be done effectively provided the two areas are clearly separated. The ultrasonic unit and “dirty” sink should be posi- tioned as far away from the autoclave(s) and “clean” area as possible to reduce the risk of contaminating the outside of the autoclave and/or items being removed from the autoclave. (See Sterility Chart on page 14.) Nonporous barriers such as Plexiglas can be erected to create boundaries between clean and dirty zones. All contaminated surfaces and objects should be clearly labeled “Biohazard.” General Guidelines The sterilization room(s) should be as far from client traffic as possible and should be labeled to keep clients from entering the room: “Warning: Biohazard! Employees Only” Remember that once an item is used in the biohaz- ard area, it cannot be used for any other purpose or in any other room unless it can be autoclaved. This includes tissue and glove boxes, paper towel rolls, pencils, tape, etc. Piercers working in facilities that share space with other body art practitioners such as tattooists must have an ultrasonic unit dedicated for their own use. Ultrasonic cleaners used for contaminated processing require a solid tight-fitting lid to reduce the quantity of airborne contaminants. Everything in the proximity of the ultrasonic unit is considered contaminated and should be handled only with protective gloves. The autoclave area has tremendous potential for cross-contamination. Operating procedures must be carefully outlined and consistently followed. 1. Gloves should be changed when moving from the contaminated area to the autoclave area and any other time when moving to a surface cleaner than what was just touched. 2. Don clean gloves to open the autoclave before loading tools into it. Place contaminated items into the open autoclave, without touching any clean surfaces with dirty gloves. 3. Dispose of gloves and wash hands before return- ing to the autoclave. A new set of gloves should be donned before shutting the autoclave door and starting the cycle. 4. Once an autoclave cycle is complete and the con- tents are dry, promptly remove sterile items from the autoclave and place them in safe storage. This will minimize the potential for cross-contaminating the recently sterilized objects. Extra care must be taken to avoid contaminating the sterile packages as they are removed from the autoclave with freshly gloved hands. OSHA guidelines, printed sterilization procedures, and any other signage required in the area should be framed or laminated to allow for proper cleaning. THE RESTROOM Restroom sinks should have hot and cold water, a paper towel dispenser, and liquid antibacterial soap in a pump dispenser. A trash can with liner must be provided. The toilet, sink, doorknobs, lights witches, and other frequently-handled surfaces must be thor- oughly cleaned daily, and disinfected throughout the day as needed. It is also appropriate to include signage such as: “For your own health and that of others, please do not remove, insert, or handle your jewelry in our bathroom. We will do it for you.”
  • 31. 28
  • 32. 29 The Purpose of Skin Preparation The purpose of skin preparation (“skin prep”) before a piercing is to render the surface of the area to be pierced as free as possible from oil, perspiration, dirt, and transient and resident bacteria. STAGES OF SKIN PREP Antiseptic Solutions Chemical agents selected for skin prep should have the following properties: • A broad-spectrum antimicrobial action • Rapid activation and prolonged effectiveness • Minimal irritation/sensitization potential • Quick and convenient application The chart below compares some of the frequently- and historically-used products in this industry. COMPARISON OF SKIN PREP PRODUCTS Hibiclens Betadine Linear Alcohol Techni-Care Scrub Time (Minutes) 8 3.5 11 .5 Dermatitis Potential 30% 30% High <1% Amount Needed 10 ml 10 ml N/A 2.5 ml PH Measurement 5.86 4.0 6.8 7.2 Tissue Contraindications Yes Yes Yes None Toxicity Chemical Burns Eyes, Ears Skin Eyes Non-Toxic Genitals Transdermal Penetration No Unknown No Yes Occular Irritation Yes Yes Yes Minimal Any skin prep product selected must be used accord- ing to manufacturer’s guidelines. Applicator options include presoaked swabs, towelettes, and products such as Techni-Care dispensed from a pump apparatus onto sterile gauze or swabs. Aseptic Cleaning for Skin Surfaces Effective skin asepsis is achieved through both me- chanical and chemical means. Using a suitable skin prep, begin at the center of the site to be pierced. While applying enough pressure to create friction, scrub in a circular motion, widening gradually outward. If necessary, sterile gauze can be used to dry the area, again using a circular motion, moving from the center outward. This minimizes the chance of pulling contaminants from unclean skin back onto the area already cleaned. Note: Betadine has a 3.5 minute scrub time, and scrubbing must be repeated three times with separate sterile gauze pads or swabs. Preparation Procedure for Oral Piercing The client should be given a small amount of antimicro- bial mouthwash in a disposable cup. He/She should rinse thoroughly with the mouthwash for a minimum of thirty seconds and should not rinse with water or touch the lips or mouth surfaces thereafter. Note: For Oral/ Facial piercing such as the lip, both types of prep must be implemented. Marking the Skin Marking should be done after aseptic skin cleaning or oral prep. All products and implements coming in contact with the client should be single-use and sterile or antimicrobial, including the marking implement. Gentian Violet (available at most pharmacies) applied with a sterilized toothpick meets these requirements. Any other marking implement must be single use. Client Cooperation Once the skin is prepped, the client must be directed to keep unwashed, ungloved hands away from the area. If the client touches on or near the prepped skin, the procedure for aseptic cleaning must be repeated. ANESTHETICS A skilled, experienced piercer should work quickly and gently so that anesthesia is unnecessary. Whatever sensations a piercee encounters should be momentary and are part of an honest piercing experience. There is no doubt that the worst part of a piercing for most piercees is the mental aspect of worrying, imagining, and fearing the unknown. The physical reality of it should be easy by comparison. Anesthetics effective for prevention of all sensation during a piercing would require a prescription and/or need to be administered or applied by a licensed medical professional. The majority of piercers are not licensed medical practitioners and therefore cannot legally provide these medications. Medical profession- als who are also trained and experienced piercers are generally not piercing within the scope of their medical practice. They should advise against anesthetics for SKIN PREPARATION
  • 33. 30 the reasons explained below. Injectable Anesthetics These are illegal unless administered by a licensed medical practitioner. Using an injectable product such as Lidocaine or Xylocaine is ill-advised and inappropri- ate. The injection would be more uncomfortable and take longer to administer than the piercing itself. Fluid injected into tissue also distorts the area and causes additional trauma. This can hamper accurate piercing placement and is likely to result in additional discomfort as the anesthesia dissipates. Serious complications such as an allergic reaction may be caused by the anesthetic as well. All else aside, there is little sense in sticking a client with a needle and injecting their body with a foreign substance in order to perform a piercing. Topical Anesthetics The use of over-the-counter topical anesthetics such as creams is not necessary for body piercings. These products are ineffective for minimizing sensation to the area that will be pierced. An effective topical anesthetic only numbs the upper layers of tissue and, as with injectable agents, the potential for allergic reactions exists. A prescription-strength topical anesthetic is illegal unless prescribed by a licensed medical professional. These may induce tissue edema (swelling), alter skin texture and affect accurate jewelry placement. These effects make the piercing procedure itself more chal- lenging for the piercer to perform. It is difficult to be sure of the ultimate appearance of the piercing when tissue is distorted. The tissue will only resume normal shape gradually as the effects of the product on the tissue are diminished. Ethyl Chloride is a prescription-only freeze spray. When sprayed on tissue, it can result in frostbite dam- age and can complicate and delay healing. It is quite painful to have applied, and takes much longer to administer than a simple piercing. Every effort should be made to discourage clients who have access to anesthetics from using them prior to piercing. While the client may have legal access to these medications and take full responsibility for their own actions, you are responsible for the quality and safety of the work you perform. Some piercers refuse to pierce clients who have used anesthetics until after the chemicals have dissipated from the site. Ice is another method of superficial freezing. Like ethyl chloride, it may result in tissue damage. All of the complications related to ethyl chloride apply to ice. Additionally, ice is not sterile. The only appropriate use of ice during a piercing would be for the client to hold an ice cube in his/her hand. This works as sensory confusion much like a doctor or nurse pinching one hip while injecting the other. This ice cube technique can be helpful for highly anxious piercees. Drugs and Alcohol Purposely self-medicating with prescription or recre- ational drugs or alcohol prior to a piercing is unwise and is an inappropriate behavior. An ethical piercer who becomes aware that a client is in an altered state will refuse to perform the piercing. In addition to the obvi- ous ethical breach, such a situation involves dangers for both parties. Only individuals in full possession of their faculties should be pierced.
  • 34. 31 Client education and continued care are essential services every piercer should provide. Clients need to understand the importance of maintaining a clean environment, and be given full written instructions for appropriate piercing care during healing. A well-placed piercing fitted with high quality jewelry performed under hygienic conditions can still go awry if proper aftercare procedures are not observed. Many misconceptions still exist about what products and methods are most effective for piercing care. The APP has established an industry standard of sugges- tions for piercing care. While we recognize the fact that each human body is unique, we have found that the following guidelines are optimal for uneventful, timely healing for the vast majority of piercees. Even clients with prior experience healing piercings should receive complete instructions every time, as is now required by many local laws. Many suggestions have changed over time, and it is important to impart the most recent care guidelines available. The following care instructions should be provided to each piercee both verbally and in a written format to take home with them. Preprinted tri-fold pamphlets containing these written care guidelines are available from the APP. See the in- side cover of this manual or website for more details. AFTERCARE GUIDELINES FOR BODY PIERCINGS Cleaning Solutions Use either one or both of the following solutions for body piercing: • Packaged sterile saline solution with no additives (read the label) or non-iodized sea salt mixture. Dissolve 1/8-1/4 teaspoon of non-iodized (iodine free) sea salt into one cup (8 oz) of warm distilled or bottled water. A stronger mixture is not better! Saline solution that is too strong can irritate the piercing. • Liquid anti-microbial or germicidal soap. Cleaning Instructions for Body Piercings 1. WASH hands thoroughly prior to cleaning, or touch- ing on or near piercing for any reason. 2. SALINE: Soak for several minutes at least two to three times daily. Simply invert a cup of warm solution over the area and press it against the skin to form a vacuum. The longer the soaks, the better. For certain placements it may be easier to apply fresh gauze or a cotton ball saturated with saline solution. Follow soaks with a brief rinse to remove any residue. 3. SOAP: To be used no more than once or twice a day. While showering, lather up a pearl size drop of the soap to clean the jewelry and the piercing. Leave the cleanser on the piercing no more than thirty seconds, then rinse thoroughly to remove all traces of soap from the piercing. 4. DRY with disposable paper products such as gauze or tissues. Re used cloth towels can harbor bacte- ria and catch on new piercings causing injury. Pat gently to avoid trauma. What Is Normal? • Initially: Some bleeding, localized swelling, tender- ness, or bruising. • During Healing: Some discoloration, itching, se- cretion of whitish-yellow fluid (not pus) that forms crust on jewelry when dried. The tissue may tighten around jewelry as it heals. • Once Healed: Jewelry may not move freely in the piercing. That is okay. DO NOT force it. If you fail to clean the piercing as part of your daily hygiene routine, smelly (but normal) secretions may accu- mulate. Continue cleaning piercing in the shower after healing. A piercing may seem healed before healing is com- plete. Piercings heal from the outside in and, although it feels healed, the tissue on the inside remains fragile longer. BE PATIENT and keep cleaning throughout the entire healing period. Even healed piercings can shrink or close in minutes after having been there for years! This varies from person to person. If you like your piercing, leave the jewelry in place. What To Do • Wash hands prior to touching the piercing. Leave it alone except when cleaning. It is not necessary to rotate the jewelry while healing except possibly during cleaning. AFTERCARE
  • 35. 32 • Stay healthy. Get enough sleep and eat a nutritious diet. The healthier your lifestyle, the easier it is for your piercing to heal. Exercise during healing is fine, just “listen” to your body. • Keep the bed clean. Make sure bedding is clean and changed regularly. Wear clean, breathable clothing that protects your piercing while sleeping. • Showering is preferable to taking a bath because bathtubs tend to harbor bacteria. If you would like to take a bath, clean the tub well before each use. What To Avoid • Avoid Undue Trauma such as friction from clothing, excessive motion of the area, playing with jewelry and vigorous cleaning. These activities can lead to un- sightly and painful scar tissue, migration, prolonged healing, and other complications. • Avoid Chemicals such as alcohol, hydrogen perox- ide, Betadine, Hibiclens or ointments. • Avoid Over Cleaning. This can delay healing and irritate the piercing. • Avoid All Contact. Oral contact, rough play, and contact with others’ bodily fluids on or near your piercing during healing can irritate your piercing and expose you to infection. • Avoid Stress and Recreational Drug Use including excessive caffeine, nicotine, and alcohol. • Avoid Submerging Piercing in bodies of water such as lakes, pools and jacuzzis. You could also protect the piercing with waterproof bandages such as Tegaderm, available at drugstores. • Avoid Cosmetics. Keep all beauty and personal care products away from the area on or around the piercing -- including cosmetics, lotions, and sprays. • Avoid Accessories. Do not hang charms or other ob- jects from jewelry until the piercing is fully healed. HINTS AND TIPS Jewelry • Leave Jewelry In During Healing. Unless there is a problem with the size, style or material of the initial jewelry, leave it in place for the entire healing period. A qualified piercer should perform any necessary jew- elry changes during healing. See the APP website for “Picking your Piercer” brochure. • If Temporary Removal Is Necessary. Contact your piercer if a medical procedure or other event requires removal. There are non-metallic jewelry alternatives to keep the hole open. • Leave Jewelry In At All Times. Even old, well- healed piercings can shrink or close in minutes after having been there for years! Reinsertion can be difficult or impossible. • Check Balls. With clean hands or a paper product, regularly check threaded ends on jewelry for tight- ness. (“Righty-tighty, lefty-loosey”.) • Carry A Spare: In case of loss or breakage, keep a clean spare ball with you. • Ready To Remove? If you decide you no longer want the piercing, seek professional help to remove jewelry and continue cleaning piercing until the hole closes. In most cases only a small indentation will remain. • Never remove jewelry during infection! If the sur- face seals over, the infection can be trapped inside, complicating treatment. FOR PARTICULAR AREAS Navel A hard, vented eye patch (sold at pharmacies) can protect the area from restrictive clothing (such as stockings), excess irritation, and impact during physical activities such as contact sports. It can be applied with surgical tape under tight clothing, or secured using a length of ace bandage around the body (to avoid irrita- tion from the adhesive). Ear/Ear Cartilage and Facial Use the t-shirt trick: Dress your pillow in a large, clean t-shirt and turn it over or inside-out nightly, one clean t-shirt provides four clean surfaces for sleeping. Maintain cleanliness of telephones, headphones, eyeglasses, helmets, hats and anything that contacts the pierced area. Use caution when styling your hair and advise your stylist of a new or healing piercing. Nipple The support of a tight cotton tank top or sports bra provides protection and be comfortable, especially for sleeping. Genital Wash hands before touching on or near the piercing. Prince Albert and Apadravya piercings can bleed freely for the first few days. Keep wrapped in sterile gauze as needed. Sex or blood thinners may exacer- bate or renew bleeding.
  • 36. 33 If using soap to clean, urinate after cleaning any piercing that is near the urethra. In most cases gentle, fluid-safegentle, fluid-safe sexual activity is fine as soon as you feel ready. Comfort and hygiene are vital. To increase comfort and decrease trauma, soak in warm saline solution or plain water to remove any crusty matter prior to sexual activity. Use barriers such as condoms, dental dams, and Tegaderm* to avoid contact with a partner’s bodily fluids, even in long-term relationships. Use a new container of water based lubricant.* Do not use your own or others’ saliva as a lubricant. After sex, an additional saline soak or clean water rinse is suggested. *Consult your piercer or the APP website, or call (888) 888-1APP for current suggested products. This will allow for us to keep current as advances are made in the field. AFTERCARE GUIDELINES FOR ORAL PIERCINGS Cleaning Solutions Use either one or both of the following cleaning solu- tions for inside the mouth: • Antimicrobial or antibacterial alcohol-free mouth rinse * • Packaged sterile saline solution* with no additives (read label) or Non-iodized Sea Salt Mixture: Dissolve 1/8 to 1/4 teaspoon of Non-iodized (iodine- free) Sea Salt into one cup (8 oz) of warm distilled or bottled water. Astronger mixture is not better! Saline solution that is too strong can irritate the piercing. Note: Those with high blood pressure or a heart condition should check with a doctor before using a saline product inside the mouth as the primary clean- ing solution. Cleaning Instructions for Inside the Mouth Rinse mouth 4-5 times daily with cleansing solution for 30-60 seconds after meals and at bedtimes during the entire healing period. Overcleaning may cause discoloration or irritation of the tongue. Cleaning Instructions for the Exterior of Labret (cheek and lip) Piercings Soak in saline solution and/or wash with liquid antimi- crobial or germicidal soap* as described below: 1. WASH hands thoroughly prior to cleaning or touch- ing on or near your piercing for any reason. 2. SALINE: Soak at least two to three times daily. Simply soak directly in a cup of warm saline solution for a few minutes. The longer you soak, the better. For certain placements it may be easier to apply fresh gauze or a cotton ball saturated with saline solution. A brief rinse will remove any residue. 3. SOAP: Use no more than once or twice a day. While showering, lather up a pearl-size drop of soap to clean the jewelry and the piercing. Leave the cleanser on the piercing no more than thirty seconds, then rinse thoroughly to remove all traces of soap from the piercing. 4. DRY with disposable paper products such as gauze or tissues. Cloth towels can harbor bacteria and catch on new piercings causing injury. Pat gently to avoid trauma. What Is Normal? For The First Three To Five Days: Significant swell- ing, light bleeding, bruising, and/or tenderness. After That: Some swelling, light secretion of a whit- ish-yellow fluid (not pus). A piercing may seem healed before healing is com- plete. Piercings heal from the outside in, and although it may feel healed, the tissue remains fragile on the inside. BE PATIENT, and keep cleaning throughout the entire healing period. Even healed piercings can shrink or close in minutes after having been there for years. This varies from person to person. If you like your piercing, leave the jewelry in place. What To Do • Help Reduce Swelling: Dissolve small pieces of ice in the mouth. Take an over the counter, nonsteroidal anti-inflam- matory such as Ibuprofin or Naproxyn Sodium* ac- cording to package instructions. Sleep with your head elevated above your heart for the first few nights. • Maintain Good Oral Hygiene: Use a new soft- bristled toothbrush and keep it clean (put it through the dishwasher). Brush teeth, and use your chosen rinse (saline or mouthwash) after every meal. During healing, floss daily and gently brush teeth, tongue and jewelry.
  • 37. 34 Once healed, brush jewelry more thoroughly to avoid plaque build up. • Stay Healthy: The healthier your lifestyle, the easier it will be for a piercing to heal. Get enough sleep and eat a nutritious diet. What To Avoid • DO NOT PLAY WITH THE JEWELRY. Long-term effects of playing with and clicking the jewelry against the teeth can result in permanent damage to teeth and other oral structures. See the APP’s Brochure: “Oral Piercing Risks and Safety Measures” for more information. • Avoid undue trauma. Excessive talking or playing with the jewelry during healing can lead to unsightly and uncomfortable scar tissue, migration, and other complications. • Avoid Alcohol. Mouthwash containing alcohol can irritate the area and delay healing. • Avoid Oral Sexual Contact including French (wet) kissing or oral sex during healing, even with a long term partner. • Avoid Chewing gum, tobacco, fingernails, pencils, sunglasses, etc. • Avoid Sharing plates, cups, and eating utensils. • Avoid smoking! It increases risks and lengthens healing time. • Avoid Stress and All Recreational Drug Use. • Avoid Bloodthinners including any aspirin or alco- hol, or large amounts of caffeine. • Avoid Submerging in bodies of water such as lakes and pools. *Consult your piercer or the APP website, or call (888) 888-1APP for current suggested products. This will allow you to keep current as advances are made in the field. HINTS AND TIPS Jewelry • Replace Jewelry. Once the swelling has subsided, it is vital to replace the original longer jewelry with a shorter post. Consult your piercer for his/her down- size policy. Because this necessary jewelry change may occur during healing, it should be done by a qualified piercer. • Check Balls. With clean hands or paper product, be sure to regularly check threaded ends on your jewelry for tightness (“Righty-tighty, lefty-loosey”). • Carry A Spare: In case of loss or breakage, keep a clean spare ball with you. • Ready To Remove? If you decide you no longer want the piercing, seek professional help to remove jewelry and continue cleaning piercing until the hole closes. In most cases only a small indentation will remain. • Never remove jewelry during infection! If the sur- face seals over, the infection can be trapped inside, complicating treatment. Eating • Eat small bites of food, placed directly onto the molars. • Chew Slowly. • Avoid spicy, salty, acidic or hot temperature foods or beverages for a few days. • Cold foods and beverage are soothing and help reduce swelling. • For tongue piercings: Try to keep your tongue level in your mouth as you chew and swallow. • For labret (cheek and lip) piercings: Be cautious about opening your mouth too wide as this can result in the backing of the jewelry catching on the teeth. Each body is unique and healing times may vary considerably. If you have any questions, please contact your piercer. DISCLAIMER These guidelines are based on a combination of vast professional experience, common sense, research and extensive clinical practice. This is not to be considered a substitute for medical advice from a doctor. If you sus- pect an infection, seek medical attention. Keep in mind that the removal of jewelry can lead to further complica- tions. Be aware that many doctors have not received specific training regarding piercing. Your local piercer may be able to refer you to a piercing friendly medical professional. See the APP Brochure “Troubleshooting For You And Your Healthcare Professional”.
  • 38. 35 PIERCING HEALING TIMES Labia (outer) 3-4 Months or longer Labret 6-8 Weeks or longer Lip (side) 6-8 Weeks or longer Lorum 3-4 Months or longer Navel 6-9 Months or longer Nipple (female) 6-9 Months or longer Nipple (male) 3-4 Months or longer Prince Albert 6-8 Weeks or longer Pubic 3-4 Months or longer Rook 6-9 Months or longer Scrotum 3-4 Months or longer Septum 6-8 Weeks or longer Surface 6-9 Months or longer Tongue 6-8 Weeks or longer Tragus 6-9 Months or longer Triangle 3-4 Months or longer 6-8 Weeks: Clitoral Hood, Clitoris, Earlobe, Eyebrow, Foreskin, Fourchette, Inner Labia, Labret, Lip, Prince Albert, Septum, Tongue 3-4 Months: Earl, Frenum, Guiche, Outer Labia, Lorum, Male Nipple, Pubic, Scrotum, Triangle 6-9 Months: Ampallang, Apadravya, Cheek, Conch, Daith, Dydoe, Ear Cartilage, Navel, Female Nipple, Rook, Surface Piercings, Tragus Ampallang 6-9 Months or longer Apadravya 6-9 Months or longer Cheek 6-9 Months or longer Clitoral Hood 6-8 Weeks or longer Clitoris 6-8 Weeks or longer Conch 6-9 Months or longer Daith 6-9 Months or longer Dydoe 6-9 Months or longer Ear Cartilage (all variations) 6-9 Months or longer Earl (Bridge) 3-4 Months or longer Earlobe 6-8 Weeks or longer Eyebrow 6-8 Weeks or longer Foreskin 6-8 Weeks or longer Fourchette 6-8 Weeks or longer Frenum 3-4 Months or longer Guiche 3-4 Months or longer Labia (inner) 6-8 Weeks or longer Below is a list of average healing times for various piercings. Because these differ from many cli- ents’ expectations, details of healing times and suggested aftercare should be provided to clients before they consent to be pierced. Inform piercees that since human bodies differ, healing times vary and cannot be guaranteed. When in doubt they should continue aftercare for at least the maximum time listed below.
  • 39. 36
  • 40. 37 STANDARDS AND CERTIFICATIONS Of the countless metals and alloys available, few have been proven safe and effective for initial wear in body piercings. To find the most acceptable materials for internal wear, our industry utilizes material guidelines used for medical implants, as defined by the ISO and ASTM. ISO The International Organization for Standardization (ISO) is a worldwide non-governmental federation of national standard bodies from over 140 countries. The mission of ISO is to promote the development and distribution of international standardization for scientific and technological practices, including medical, metal, and chemical activity. ASTM The American Standard for Testing Materials (ASTM) is a not-for-profit organization that provides a global fo- rum for the development and distribution of consensus standards for materials and testing. Despite its name, ASTM standards are accepted and used internation- ally in scientific and medical research, development and testing. Use of ISO and ASTM standards are voluntary and only become legally binding when a governmental body makes them so, or when they are cited in a contract. Manufacturers in a variety of industries will sometimes state a product has been tested according to ASTM or ISO standard by citing the applicable code number on the product label or packaging. In the case of metals this will appear on the mill sheet. Mill Sheet Also referred to as a mill certificate or material certifi- cate, this is a document created by a metal foundry, provided to the wire mill, and then to the manufacturer. It guarantees the specifications of the alloy and is your proof of content quality. On request, any manufacturer producing body jewelry should produce the mill certificates obtained from the wire mill where their raw material was purchased. If a jewelry manufacturer is unwilling or unable to produce this certification, their steel and titanium jewelry can- not be considered to meet ASTM or ISO standards and should not be used. Some area laws now require that shops provide mill sheets proving the ASTM/ISO compliance (and therefore the biocompatibility) of their jewelry. CERTIFIED MATERIALS FOR NEW PIERCINGS ASTM Compliant Stainless Steel Low carbon stainless steels, such as 316L and 316LVM are used in the body jewelry industry because of their proven biocompatibility. For many years 316LVM was the preferred steel standard for a fresh piercing. While this is a good start, it is important to know that not all 316L or 316LVM stainless will meet ASTM certification, and may vary in biocompatibility. Therefore shops must have mill certificates from jewelry manufacturers show- ing that the steel being used is F-138 compliant. Stainless steel contains nickel, which is a well-docu- mented irritant. One significant benefit of implant-certi- fied materials is a passive layer of chromium oxide that allows virtually no nickel to contact the customer. Implant Certified Titanium Implant Certified Titanium (ASTM F-136) is an ex- tremely inert and lightweight alloy. Additionally, titanium can be anodized to create jewelry of different colors. The colors are created by producing an oxide layer of varying thicknesses and do not affect the biocom- patibility. They may fade with time and certain types of chemical exposure, but again this does not affect biocompatibility. OTHER APPROPRIATE MATERIALS FOR NEW PIERCINGS There are other materials considered acceptable for fresh piercings, but which do not have ISO and ASTM standards. The following are considered acceptable because they either have a long history of successful use, or have favorable biocompatibility ratings. Niobium Niobium is very similar to titanium but does not have a set ASTM standard. It is used extensively in the medical industry for implant components and has been the subject of thorough biocompatibility testing. JEWELRY
  • 41. 38 Like titanium it can be anodized to produce different colors. Unlike titanium, it can also be colored black in either a glossy or matte finish. Matte finish black niobium has a rough finish and is NOT acceptable for fresh piercings. Solid 14K or 18K White or Yellow Gold Medical documentation relating to gold biocompatibility is scarce. However, gold has been used successfully for piercing jewelry for thousands of years and is consid- ered by both our industry and the medical industry to be biocompatible for most people when it is pure enough. All gold jewelry contains a mixture of gold and other metals called an alloy. Every jeweler uses different alloy mixtures and often guards the recipes as trade secrets. Since the specific percentage of each metal are different to obtain, it is impossible to set specific standards and metal requirements for gold alloys. However, we can say the following: The purest form of gold, 24k, contains no other materi- als but is too soft for use in body jewelry. Jewelry that is too soft is easily scratched, nicked or burred, and is difficult to thread without stripping. Jewelry less than 14k is less than 57% gold and can contain large amounts of other metals that may react to the body. Therefore, it should not be used. 18k is an optimum standard for body jewelry, and 14k may also be used. Only solid white or yellow gold is appropriate for inser- tion into the body. Colored golds, such as rose or green gold, are alloys with variations in the amount of copper, silver or other metals. These alloys are more likely to cause adverse reactions in the body and should only be used for beads and decorative attachments. In the making of white gold alloys, metals such as nickel, platinum or palladium are used to make the gold white in appearance. Because of the risk of nickel reac- tions, most manufacturers offer nickel-free white gold, which is strongly recommended for use in body jewelry and is required by some area regulations. Platinum This very heavy and expensive precious metal is ex- tremely inert and is therefore ideal for body jewelry. It is a brilliant white color and is harder to work than other precious metals. Styles may be limited as a result of both its high cost and greater difficulty in manufacturing. PTFE This inert plastic comes as a solid rod and uses tapped balls. When a ball is twisted onto the end of the rod, the existing pattern inside the ball effectively “threads” the post, keeping the ball in place. PTFE is quite use- ful in medical situations where metal jewelry cannot be worn. Tygon This micro-bore tubing is used in many medical ap- plications because it is USP Class 6-compliant. Male balls can be threaded into the hollow center, creating barbell-style jewelry that can be cut to custom size. Because of changes in the material over use time, Tygon should be changed every two months. Addi- tionally, the manufacturer does not recommend it for long-term use. JEWELRY MATERIALS FOR HEALED PIERCINGS When used and cared for responsibly, the following ma- terials are generally appropriate for healed piercings. Because all bodies are different, be aware that some individuals may experience sensitivity or reactions to one or more of these. Tempered Glass (Pyrex) Lead-free glass plugs are usually safe and comfortable in piercings, especially in stretched ear lobes. Boro- silicate glass is autoclaveable but can be susceptible to breakage in thinner pieces. High-Density, Low-Porosity Non-Toxic Hardwoods Hardwood plugs are a popular and comfortable choice for many clients. Because some woods are toxic or have been treated with various chemicals, it is important to purchase plugs from a knowledgeable and reputable manufacturer. Wood cannot be autoclaved or disin- fected so each wood piece should be worn by only one piercee. Accepting returns or exchanges of wood pieces is never appropriate. A non-chemical soap is suggested for cleaning wood jewelry. Periodic conditioning of wood plugs with cosmetic-grade natural oils can improve du- rability, appearance and long-term comfort. Other Organic Materials Several types of organic jewelry are acceptable for use in healed piercings. These include (but are not limited to) stone, horn, bone, coconut wood, bamboo, and petrified ivory. These materials are most often used in ear lobes. In some areas, such as lips, moisture may cause porous jewelry to swell, making removal more difficult. Care should be taken in both choosing and conditioning organic jewelry.
  • 42. 39 High-Density, Low-Porosity Nontoxic Plastics There is some controversy surrounding the long-term wear of acrylic jewelry. While a clean piece of FDA approved acrylic is an acceptable choice for a healed piercing for some clients, its chemical components are less biocompatible than many other materials. Some grades are more likely to cause reactions than others and should be chosen with caution. Acrylic cannot be autoclaved or disinfected and should therefore be con- sidered appropriate for single person use only. Acrylic can crack, shatter or cloud when coming in contact with alcohol or alcohol-based disinfectants, hair products and mouthwashes. Petroleum-based lubricants can cause plastics to break down, potentially releasing chemical irritants into the skin. Acute sensitivities to acrylic can develop suddenly even in those who have worn it comfortably in the past. Therefore care should be taken when choosing and using acrylic jewelry. JEWELRY TO AVOID Conventional Jewelry Jewelry designed specifically for earlobe piercing or purchased at a conventional jewelry store is never ap- propriate for use in body piercings. The materials and workmanship are seldom of implant quality, and the styles may involve sharp edges and/or details that may trap bacteria. Earring wires and posts are also much too thin, which can cause discomfort and potentially cut into a piercing. Ear studs with butterfly closures trap excreted body fluids and bacteria. Gold-filled, Rolled, or Plated Jewelry This type of jewelry is always unacceptable for body piercings. These products are made by placing a very thin layer of gold over either inferior metal jewelry (e.g. nickel or aluminum), or over a steel piece first covered by an underplating of nickel or copper (to help the gold adhere to the steel). The thin gold outer layer can wear off, leaving sharp edges and exposing the poor quality metals underneath. Furthermore, the plating process is often achieved by means of a cyanide bath or mercury amalgam. This process creates the potential for these two highly toxic chemicals to contact the body and leach into the bloodstream. Silver Silver is an unstable alloy that oxidizes (tarnishes) eas- ily and is not biocompatible. Many piercees find that even if they wear silver comfortably in ear piercings, other areas of the body are more sensitive and are quickly irritated by it. Even sterling silver is not ap- propriate for use in body piercings. Many piercees will have reactions to silver beads or charms that contact sensitive skin near piercings or rest against piercing holes (especially on navels). Other Grades of Stainless Steel High carbon steel and steel of the 302, 306, and 400 series are inappropriate for piercing jewelry. Many of these grades of steel break down or corrode when in continued contact with body fluids. Always request mill certificates directly from the manufacturers. They are required by law to provide these documents detailing the composition of the metal. Aluminum Aluminum resembles niobium in appearance and is similar to titanium in weight. However, it is never appropriate for body jewelry. Long-term aluminum exposure has been connected to neurological damage, Alzheimer’s Disease and metal sensitivities. THINGS TO LOOK FOR IN QUALITY JEWELRY Jewelry Quality Because the jewelry industry is overly saturated with substandard jewelry, it is common for piercers and cli- ents alike to forget that quality jewelry, not cost, should be the deciding factor in the purchasing of jewelry. Keep in mind that this jewelry will be worn inside the body in continuous contact with internal tissue. It should be of the best materials, design and workmanship avail- able. Furthermore, the unique individual, anatomy and location should be considered in determining the most appropriate jewelry in each case. Polish High quality piercing jewelry must be polished to a mirror finish. Jewelry that is not highly polished will be more porous, potentially causing discomfort and delayed healing. Poorly polished jewelry may also have compromised biocompatibility. Piercing jewelry must be free of all polishing com- pounds. These may appear as deposits near a fixed bead or in the threading. All jewelry must also be free of nicks, scratches and burrs.
  • 43. 40 Annealing Annealing is a heat treatment that tempers metal, making it more pliable and easier to open and close. Annealed jewelry does not need to be opened forcefully with pliers, reducing the risk that it will be scratched dur- ing procedures. Jewelry that is well annealed should be able to be opened with only finger pressure in sizes such as 14 gauge 1/2” diameter and 12 gauge 5/8” diameter. There will still be more than enough tensile strength to hold in a captive bead. Curved jewelry such as captive rings or fixed bead rings is made from wire that is wrapped in the manu- facturing process. This wrapping can change the mo- lecular structure of the metal. It should be annealed to restore it to its pre-wrapping grade. Threading The United States APP membership elected to require internally threaded jewelry for initial piercings. External threads may tear new tissue, trap bacteria and release polishing materials into the initial piercing. Balls for tapped/threaded jewelry thicker than 16 gauge should be countersunk so that the bead fits onto the end of the jewelry more closely, thus minimizing accumulation of excreted matter. Non-Threading Threadless (press-fit) barbells and balls are a new jewelry option in the industry. Well made jewelry of this type is an acceptable alternative to traditional threaded jewelry. Machining Many people currently manufacturing body piercing jewelry are amateurs who do not have the knowledge or skill to produce well-machined jewelry. Piercers must therefore carefully check all pieces prior to use. • Beads and posts should be drilled to match, and should not be off-center. • Check for gaps between the ball and post that could retain bacteria and signify poor drilling. • Ends of rings and posts should not be blunt or sharp, but smoothly rounded for painless insertion. Jewelry Size, Gauge, Diameter Each piece of jewelry is measured using two propor- tions: Gauge and Diameter. Gauge refers to the thick- ness of the wire. Most American piercers use the Brown and Sharpe/American wire gauging system. Most other countries measure gauge in metric millimeters. The diameter of a ring is its width measured across the inside of the ring. The diameter or length of a barbell is the length of the shaft measured between the balls. Inexperienced and uncaring piercers frequently insert inappropriately sized jewelry into new piercings. A skilled piercer knows that each body is unique and will individually select pieces of appropriate gauge, size, and style for each client. Initial jewelry should be se- lected for its suitability during healing. Remember that the piercing is permanent but the jewelry can always be changed after healing. JEWELRY STYLES Captive Bead Ring This ring is the most commonly used type of body jewelry. It consists of a gapped ring with a bead held captive in the gap by the tension of the ring. The ring is opened by removing and replacing the bead (“popping” the bead in and out). This style may not be appropriate for jewelry of very thin sizes, particularly in softer gold, when there is not enough pressure/tension to keep the bead from falling out. Fixed Bead Ring This has a bead perma- nently soldered or fixed onto one end of the ring, and is opened and closed by bending the ring side- ways (as if tearing a coin). This style is most suitable for piercings in which the jewelry is not changed frequently. Since thicker or harder rings can be difficult to open or close, fixed bead rings are most often made in smaller gauges and in gold. Barbell This piece of jewelry is a straight post with one threaded ball on each end. It is most commonly seen in tongue pierc- ings, but can be used in many other piercings in which a ring is not suitable, or when jewelry needs to lie close to the body with a minimal profile.
  • 44. 41 Curved Barbell These are similar to bar- bells with two threaded balls, but have a shaft that curves in a uniform arc like a crescent moon. They are most commonly associated with navel piercings, but are also appropriate in other areas where friction from protruding jewelry is problem- atic, but a straight barbell is unsuitably shaped. J Barbell The J Barbell is a curved barbell whose shaft is shaped like a “J”. These are used in navels for which the J curve more closely mimics the piercee’s anatomy than does the crescent curved barbell. Circular Barbell This is similar in shape to a ring, but with more versatility of a barbell’s screw-on balls. The threaded balls allow it to be easily removed and reinserted. A circular barbell is especially suitable when the look of a large gauge ring is desired without the difficulty of opening and closing a ring of such thickness. Surface Barbell This “staple shaped” barbell was developed specifically for use in surface pierc- ings. The theory is that the staple shape helps coax the body into healing by minimizing upward pressure on the tissue over the piercing and allowing blood to flow freely in the local tissue, thereby minimizing the chances of migration. Nostril Screw Nostril screws are based on an old East Indian design. The screw allows the stud to hug the inside of the nostril without injuring the septum or falling out easily. It does not require a backing (which can trap bacteria) as a regular stud earring does. This is more attractive, safer, and superior for comfort. There are left-bend and a right-bend nostril screws, depending on whether the jewelry is worn in the right or left nostril. The tail end of the screw should point up and away, concealed inside the nostril. Also, nostrils can vary considerably in thickness, and dimensions must be taken into account when selecting or custom bending the nostril screw for each client. Labret Stud A labret stud is essentially a mini- barbell with a small, flat disc on one end. These are most commonly used for labret piercings and in places where a flat back fits most comfortably with anatomical struc- tures on one side of the piercing (e.g. against teeth, some inner ear cartilage). They often come with both ends threaded so that ball and disc sizes and shapes can be customized to the client’s individual anatomy and preferences. Fishtail Labret The fishtail is an alterna- tive to the labret stud for lip piercing. Its shape re- sembles a nostril screw, but it is longer and often thicker to suit the thick and soft lip tissue. After allowing sufficient length to wear through the lip, the post is bent at a right angle, and the “tail” is worn resting along the bottom of the gumline inside the lip on one side. These are most comfortable when fit and custom bent to the client’s mouth. Threadless Barbell This has the same shapes and uses as the barbell, curved barbell or labret post, except that instead of the usual screw-on ball(s), a “snap together” ball is pressed into the post. Septum Retainer Retainers are specialized pieces of jewelry, used only in septum pierc- ings and often shaped like a staple or U. They are useful for clients
  • 45. 42 who want to keep jewelry in their septum piercings, yet need to make the piercing inconspicuous. The center of the piece is worn through the piercing and the “legs” are flipped up and forward inside the nostrils to remain unseen. Plugs and/or Eyelets These styles can be worn in healed stretched or enlarged piercings, most often in ear lobes. They can be made of a variety of materials, including stainless steel, glass, wood, stone, horn, bone, amber, and gold. They are often flared at one or both ends to keep the jewelry in place. Plugs that are not flared are often kept in place with small o-rings of high-grade silicon or latex. O-rings should be worn slightly away from the skin to allow air to contact the piercing, let moisture escape, and minimize potential reactions. Silicon is best for those with latex sensitivities.
  • 46. 43 It is widely accepted that the following ethical standards should be adhered to in every piercing establishment. In some cases local or state laws will exceed these standards. The APP suggests that every piercer consult with an attorney in his/her state to determine whether state and/or local regulations affect the ap- plication of these standards. PERSONAL BOUNDARIES APP literature outlines a client’s rights with regard to piercing services. The piercer also has the right to ex- pect appropriate behavior from his/her clients. These boundaries are to protect both piercer and client from potentially dangerous or inappropriate situations. The following are reasons a piercer may decline to perform a particular piercing, reschedule or abort a piercing, or dismiss a client from the studio permanently: • The client appears intoxicated, behaves erratically, or is not in full possession of his or her mental or physi- cal facilities. Note: In cases attributable to medical or psychiatric conditions, the piercer may tactfully request a signed letter from or a conversation with the client’s doctor, psychiatrist or other caregiver verifying the client’s ability to make responsible choices. • The client maintains poor personal hygiene that could compromise the well-being of the piercing and/or that significantly affects the ability of the piercer to perform the procedure. • The client makes comments or gestures of a sexual or otherwise inappropriate/offensive nature. • The piercer may wish to consider not only his/her own personal boundaries, but also his/her obligation to ensure a studio atmosphere that is respectful of all clients and staff. Many shops refuse to serve clients who repeatedly make racist, sexual, homophobic, or otherwise offensive comments, or who behave rudely towards other clients or shop personnel. Posting a statement to this effect may help minimize your liability for discrimination, as well as advertise your intentions to those waiting. (For example: “We reserve the right to refuse service to anyone who is drunk, disorderly, or disrespectful.”) Clients who are aggressive or unruly in the waiting room often get worse as they become more nervous, and may need to return at a later date when they are better able to control themselves. • It is also important to remember that the shop staff must set and maintain behavior standards for the studio. The content and style of staff interaction, apparel and personal habits, studio design, decora- tion, website, music, and shop policies all reflect your level of professionalism. Clients use this information to judge both what to expect of you and what you expect of them. • In localities where shop personnel are extremely vis- ible or well-known, these expectations may extend into off-work hours outside the studio. You may want to consider how you want to be perceived by clients who meet or observe you when you are not at work. PIERCERS ARE NOT PERFECT No piercer, however experienced or skilled, is perfect. Unfortunately, in every career some piercings will be poorly placed, jewelry transfers will be missed, and items will be dropped. Piercers should always handle these situations with professionalism, honesty, and tact. Blaming the client (“It’s your fault -- you moved.”) is never appropriate and contributes to a sense of panic and regret in the room. Piercing is a service profession. As a professional piercer, it is part of your job descrip- tion to expect and allow for client reactions. A piercer should take responsibility for the error and correct it to suit the client’s needs and preferences. If the client is displeased with the results or you de- termine the piercing may not heal successfully due to an inaccuracy in placement, it should be removed and re-pierced, either immediately or at a later date. If you have made a mistake, it is appropriate to offer additional services free of charge. If the client has experienced undue discomfort it may be reasonable to offer an ad- ditional discount, free piercing, or jewelry. DETERMINING APPROPRIATE- NESS OF A PIERCING Sometimes it is inappropriate to perform even the most standard piercing. A piercer should politely refuse to perform a piercing that could be dangerous, ill suited, unsuccessful, or for which they are not trained. It is helpful to have an educated and piercing friendly phy- ETHICS AND LEGALITIES
  • 47. 44 sician to contact when clients do not have a physician that they are comfortable consulting. The following examples for which a second and/or medical opinion may be needed before proceeding: • There is an obvious skin or tissue abnormality that may include but is not limited to rashes, lumps, bumps, scars, lesions, swellings, fluid, tenderness, moles, freckles, and/or abrasions; • The client is or has impending plans to become pregnant and wishes to get a nipple, navel, or other piercing. (It is advisable to refrain from piercing during pregnancy to allow the body to focus on the important, complex, and demanding task that it is handling already. Additionally, if the client was to faint it could result in serious consequences to the unborn child.); • The client wants to pierce irregular or surgically-al- tered anatomy; • The client is unsuited due to occupational, recre- ational, or environmental factors; • The client requests piercings that are frequently unsuccessful (commonly rejected by the body), particularly when the client is uneducated about or unwilling to accept responsibility for the risks of such piercings; • The client has a heart murmur, diabetes, hemophilia, autoimmune disorder, or other medical condition(s) that may negatively influence the piercing procedure or healing process; • The client has a heart condition such as Mitral Valve Prolapse that requires prophylactic antibiotic treat- ment before dental and other procedures. In these cases the client must consult a physician prior to any procedure. Medication may be required to avoid life- threatening complications. APPROPRIATE PLACEMENT For thousands of years, tribal people around the world have made similar choices in piercing placements. This is not because of a lack of creativity, but because of long-term experience with the superior stability of certain anatomy. As piercing has resurfaced in the globalized community, new information on anatomy, jewelry, and asepsis have made possible some piercing placements not previously considered. TECHNIQUES Techniques vary considerably from piercer to piercer. Some will utilize tools such as forceps and needle receiving tubes, others use special hand positioning that allows for freehand piercing. Most will combine knowledge of various techniques, use of tools, and hand placements in the way that works best for them in each individual piercing situation. The most fundamental aspects for the evolution of a piercer’s personal style are proper training, continued education, and an open mind. While it is important to continue observing other piercers and learning through- out your career, new procedures and techniques should not be undertaken merely for the sake of innovation or emulation. To ensure client and piercer safety, pierc- ers should be thoroughly trained and well skilled in the basic procedures before attempting more difficult methods. When trying new techniques or experimenting with new styles, it is essential to research all aspects of the procedures. Elicit multiple opinions about differences in piercee comfort, sterility, efficiency, ease of healing, jewelry type, placement, risks and benefits, etc. Talk to piercers who use alternate techniques as well as those who choose not to, and find out why. Also ask clients what they prefer and why, and take their responses seriously. We do what we do for them. After obtaining as much information as possible, you can make an informed decision. You may also find you change back after time, or that you begin to alternate between techniques depending on individual circumstances. All piercing placements, old or new, should be decid- ed by anatomical suitability and overall safety. Piercing placements that are ‘new’ should not be invented for the sake of personal aggrandizement or novelty. Of course, no field progresses without cautious ex- perimentation. Any trials should be a matter of personal consideration and not involve the general public. It is neither safe nor professional to use paying customers to test techniques or placement theories. Experimental piercings should not be introduced to the paying public or the press until they have proven to be successful and safe for a sufficient percentage of individuals over a reasonable amount of time. Piercing liability insurance providers may refuse to cover experimental piercing placements and local regulations may prohibit certain variations. For more information, contact your insurance provider and/or health department directly. OFF-SITE PIERCING Piercing at music festivals, nightclubs, conventions and street fairs may seem like a creative way to build
  • 48. 45 clientele. Guest piercing at other studios may seem like fun. However, these situations may create pitfalls for a piercer seeking to maintain appropriate hygiene standards, ethics, and reputation. When piercing in a public space, club or festival, the most obvious concern is control of one’s space. How will you maintain a sanitary environment in a smoky club filled with sweating bodies and alcohol? It can be difficult to distinguish between inebriated and sober clientele and false identification is common. Condi- tions are often conductive neither to hygienic piercing practices nor to the safety and cleanliness of a fresh piercing. How will you keep new piercees from imbib- ing afterwards and heading to the packed dance floor? Can they avoid smoking and drinking after a tongue piercing? In such places, piercing can take on a freak-show element that is distasteful to most professional piercers. Additionally, peer pressure, lack of private consulta- tion, and the thrill of the show may push some clients to make decisions they would not otherwise make and may regret. While this is not technically your problem, you are the one creating the opportunity, and are charged with running a professional and ethical busi- ness. Many piercers avoid public piercing altogether and this is a valid option. Wherever you decide to work, the setup needs to be no less hygienic than your business studio. This means nonporous flooring, a fully enclosed piercing room, stainless steel trays, an autoclave, Sharps containers, and observance of all hygienic practices required in a studio. If you are unable or unwilling to make the investments of time, money, and research to assemble and move a full piercing studio, it is inap- propriate for you to be piercing off-site. Additionally, many cities now have regulations limiting or prohibiting mobile piercing studios, or requiring temporary licenses and inspections. Check with local health departments before you set up shop. COMPETITIVENESS The rapid rise of popularity in piercing has led to an increased competitiveness between piercers. In some cities, two or more piercing studios operate on one block. Competing studios often have different levels of health and safety awareness and may be inclined to share these details with clientele. It is easy to be- come frustrated and engage in negative interactions with competitors, especially if you feel that you are the more informed, conscientious piercer, or when they are bad-mouthing you. Good piercers should strive to maintain a genuinely professional demeanor with all other piercers, includ- ing competitors. This can facilitate the exchange of information and enhance progress for the industry and all parties involved. Although it takes some careful wording, try to find ways to educate clientele and the public about health concerns without making accusa- tions against another shop. Even when another shop insists on behaving badly, maintaining a professional public attitude speaks well of your experience and confidence, and will earn your clients’ respect. It is very important to remember that anything you say about a competitor can be held against you in the event of a libel or slander lawsuit -- even if it is true. You could instead show concern for your clients’ health and safety by giving out a checklist of things to look for at any piercing studio, including your own. You can educate the wider community by putting this in a print ad. A brochure with such a checklist is available from the APP. It is entitled Picking Your Piercer and can be ordered directly from the APP website at: www. The Piercee’s Bill of Rights poster, also available on the site, further advises clients on how to choose and interact with a piercer. PAPERWORK & BUSINESS DOCUMENTATION Professional piercers should obtain and keep on file a release/consent form for every service performed within the studio, including piercings, stretchings, and insertions. This should be done regardless of whether it is required by legislation and/or your insurance. The consent form should state that the client re- quested the piercing (i.e. you did not pierce him/her without consent) and you informed the client about how to properly care for the piercing. While release forms do not prevent legal action, they do provide evidence that you have made an effort to educate your client and to operate a legitimate business. The release form should also contain records of the following information from the client: • Valid photo identification number and type (state is- sued driver’s license or ID card); • Passport or Military identification. Many shops pho- tocopy this onto the release form; • Date of birth; • Allergies, particularly to latex, iodine (if used) or any prod- ucts routinely used in your studio during a piercing;
  • 49. 46 “To induce _________ (company or piercer’s name) to pierce my __________ (name of piercing/ana- tomical region of piercing) and in consideration of doing so, I hereby release _________ (company or piercer’s name) from all manner of liabilities, claims, actions, and demands, in law or in equity, which I or my heirs might have now or hereafter by reason of complying with my request to be pierced. I have provided accurate information on any medical conditions I may have that could affect the outcome of this procedure. These include, but are not limited to, allergies (such as iodine, latex and metals), diabetes, anemia, hemophilia, high/low blood pressure, heart disease (including any condition that may require prophylactic antibiotics), swelling, rash, lumps or discoloration of the area to be pierced, and any immunosuppressive disorder. I have provided information on any medications I am currently taking, and on any piercings, tattoos, surgeries or serious illnesses or injuries I have experienced in the past 90 days. I certify that I am not pregnant or nursing. To ensure proper healing of my piercing, I agree to follow the written aftercare guidelines until healing is complete. I understand that this type of piercing usually takes _______ (healing time) or longer to heal. I recognize that the suggestions and aftercare given to me by _________ employees or agents are based upon their experience in this field and current industry standards. Employees of __________ are not doctors, and their suggestions, whether written or verbal, stated or implied, are not meant to be taken as medical advice. In the event of a serious medical concern I should see my physician. I have signed this release on ________ (date). I declare under penalty of perjury that the above is correct. ________________ (Signature of Client) • That client has not consumed alcoholic beverages or other intoxicants within the last 24 hours; • Information on recent intake of any medications such as blood thinners, aspirin, ibuprofin, or other NSAIDs (see Glossary for details); • Disclosure of whether the client is under the care of a physician for any condition that might affect the procedure or healing process; • Acknowledgment of having eaten within the last 2 hours. Note: Clients should eat a healthy meal before being pierced to minimize dizziness, nausea or fainting. Refined sugar such as soda or sweets can increase the risk of these low blood sugar/vasovagal reac- tions; • Diabetes, hemophilia, or other medical condition(s) Sample release form: The signature of the client must be at the end of this statement, not prior to it.
  • 50. 47 that may affect the piercing procedure or healing (if inquiry is allowed by law); • Any other information required by state or local au- thorities or insurance provider. The wording above is only a generally applicable suggestion. In certain states it is not legal to ask about some aspects of a client’s medical history on a release form (e.g. Hepatitis, STDs, or HIV status); in other states it is a requirement. Check your local laws for compliance. Piercing-specific liability insurance providers may re- quire you to use one of their release forms with slightly different wording. Legally suitable wording will also vary by state and even by country, so it is advisable to consult an attorney when drafting release forms. Check and uphold your local laws. The APP finds it prudent to store all client paperwork indefinitely, and many area regulations have specific minimum requirements for retaining release forms (e.g. three years). Again, check your local laws for specifics in your area. Additional details should be added to release forms for the following circumstances: • Piercings of minors • Piercings done off-site (at clinics, conventions, etc.) • Insertion of a client’s own jewelry. (Note: Some local laws prohibit the insertion of used and/or non-sterile jewelry. Please see sections on Sterilization, Disinfec- tion and Appropriate Jewelry for more information.) MINORS Laws regarding the piercing of minors vary by location. In the United States, the legal age of consent or legal responsibility is usually 18 years of age. Until then a minor’s body is the legal responsibility of his or her parent or legal guardian. Additionally, any contract (such as a release form) signed by a minor is not legally binding unless it is also signed by the person legally responsible for her/him. For these reasons, significant caution is required when piercing minors, even on the earlobes. A child who cannot comprehend the procedure and consequences cannot consent and should not be pierced under any circumstances. Particularly with infants and toddlers, the body and immune system are still developing (this includes ear lobes), and a baby is obviously unable to care for a piercing. Some piercers agree to pierce babies or children, thinking to save them from the ear-piercing gun. It is important to remember that as professionals we are responsible for our own actions and cannot try to compensate for how people choose to treat or raise their children, or how other piercers work. The best course of action is to provide parents with all pertinent information about health and safety, including the risks of the procedures, the best possible aftercare and jewelry, and how to find a hygienic practitioner if they must pierce their child. While we cannot change others’ actions, or change our own to accommodate theirs, we can help them make educated decisions. With consent and release from a parent or legal guardian, minors of an appropriate age may be eligible for piercing, depending on circumstances, studio policy and local laws. The APP suggests that only the following piercings be considered for minors: • Ear lobe or Cartilage • Navel • Oral/Facial • Nostril • Eyebrow Other piercings are either potentially dangerous, unethical to perform, or problematic to heal on minors whose bodies are still growing and changing. Under no circumstances is it acceptable, nor is it ever appropriate, for a piercer to perform a piercing on the nipples or genitals of an individual under 18 years of age. This is ethically unconscionable and may even be deemed sexual assault in a court of law. Parents or legal guardians who consent to this type of piercing for a minor in their care may also be charged with sexual misconduct by some courts. For any piercing of a minor, a parent or legal guardian must be present to sign a consent form. State-issued photo identification is required from the legal guardian, and a bona fide form of identification from the minor (driver’s license or state photo ID; birth certificate plus school yearbook). In the event the parent has a differ- ent last name and/or address from the child, documen- tation is needed to prove the relationship (for example: divorce or remarriage certificate; custodial or adoption papers; birth certificate). A unique single exception would be an emancipated and/or married minor who presents positive proof of their legal emancipation and/or marriage. In certain states such minors are considered adults for legal and practical purposes. Check local legislation regarding emancipated/married minors. A valid business practice is to simply refuse to pierce anyone under the age of 18. Many studios follow this
  • 51. 48 policy. It is wise to check with an attorney in your state to clarify the letter of the law when deciding your studio’s policy on this matter. Once you have devel- oped a policy that is comfortable and works well, be consistent. Photos displaying genital piercings may be consid- ered pornographic in the hands of a minor. If minors are allowed in the studio, having two separate, well- labeled portfolios available for display is advisable. In this case you may also need to remove any explicit pictures from the walls. Explicit conversations (verbal or online) about genital piercings are also inadvisable. If your shop has a website or responds to email, be aware that photos and some information may be viewed by minors or by clients in areas where such material is illegal. Posting a warning and self-selecting statement of age may minimize your liability. For example: “By clicking here I verify that I am over 18 and take full responsibility for viewing this site and its contents.” Again, check with your lawyer for locally appropriate wording and laws. The piercing room must be under your control at all times. You are responsible for the health and safety of everyone in your studio and must set personal and shop policy accordingly. While it is often helpful for a client to have a friend in the piercing room for moral support, many piercers limit the number of observers to one or two, and verbally explain to observers where to stand and how to act. Many piercers do not allow small children or others who cannot/will not behave appropriately in the piercing room. In forming your own policy, keep in mind that piercing is both a technical, hygienic procedure and a personally meaningful experience. Try to find a way to work that respects both the integrity of your technique and the emotional needs of your client. If you do allow guests in the piercing room, be aware that they may become light-headed during the piercing. A low, stable fold- ing chair can keep them out of your set-up area and minimize fainting mishaps. DRUGS AND ALCOHOL Being under the influence of drugs and/or alcohol is never appropriate for either party involved in a piercing procedure. A piercer must be focused, in control, and able to deal with unforeseen complications. Further- more, he/she is responsible for the safety and health of everyone in the piercing studio. Any piercer who feels it is acceptable to work under the influence of drugs or alcohol is reprehensible, unprofessional, and a menace to him/herself and his/her clients. Even if he/she does not appear inebriated at work, a piercer who is addicted to alcohol or drug is a serious potential hazard. A counterperson who is under the influence likewise represents both a liability and an extremely poor consumer relations statement. Piercers should agree to pierce only sober, consent- ing clients who appear to be in full possession of their mental and physical facilities. Piercing a client who is not in a sober and sane condition raises serious ethical questions. First, an inebriated or medicated individual is not legally able to give informed consent. Any con- sent obtained under such conditions is not a binding contract and may put the piercer at risk. Further, once sober the client may regret the decision made under altered consciousness. Even for a skilled and focused piercer, it is dangerous to work on a client who is under the influence of drugs or alcohol because: • She/he may bleed more heavily, faint and/or vomit; • She/he may not be able to communicate vital infor- mation to the piercer or follow important instructions from the piercer; • She/he may move suddenly, endangering the piercer and her/himself; • She/he may become belligerent, physically or ver- bally inappropriate, emotional, dishonest or unman- ageable; • She/he may later have inaccurate recollections of the piercing encounter, thus putting the piercer’s reputa- tion and legal integrity at risk. While it may be tempting to take the money of those who have had a drink to get up their courage, it is ultimately a bad decision for you and for your client. Furthermore, accepting clientele who are under the influence contributes to public perception of the pierc- ing industry as immoral, unsafe, and irresponsible. Few passersby will believe your studio practices high standards of hygiene if they see drunk and/or disorderly people in or around the shop. Allowing clients to get pierced after drinking or tak- ing drugs also validates the idea that piercing pain is beyond normal tolerance and denies clients the op- portunity to fully engage in their piercing experience. Getting and healing a piercing requires being aware of and responsible for one’s body. Therefore, a piercee who is not ready to get a piercing done while sober is not ready to get a piercing.
  • 52. 49 OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION (OSHA) COMPLIANCE OSHA is a federal agency that monitors and regulates worker safety for all businesses with one or more em- ployees. Whether or not piercing-specific legislation has passed in your area, OSHA has explicit require- ments that directly relate to piercing. They apply even if you have only one employee. Since federal and state regulations may apply, it is important to inquire about the most relevant informa- tion for your area. To comply with OSHA requirements, piercing studios with one or more employees must meet these standards: Listing of standard operating procedures, detailing: • Exposure Control ° Exposure Control Plan ° Exposure Determination • Methods of Compliance ° Observation of Universal Precautions for Bloodborne Pathogens ° Engineering and Work Practice Controls ° Personal Protective Equipment ° Housekeeping ° Regulated biohazard waste disposal • Communication of hazards to employees, written and verbal (Hazard Communication Plan) • Employer-provided Hepatitis B vaccine or declination (on file) • Record keeping/documentation ° Accurate reporting of all exposure incidents ° Appropriate information and training OSHA requires that any employee who has the risk of occupational exposure to blood or other potentially infectious materials receive training at the time of initial assignment, and at least annually thereafter. Training must cover the following topics: 1. An accessible copy of the regulatory text (see ap- pendix) and an explanation of its contents 2. A general explanation of the epidemiology and symptoms of bloodborne disease 3. An explanation of the modes of transmission of bloodborne diseases 4. An explanation of the employer’s Exposure Control Plan and the means by which the employee can obtain a copy of the written plan 5. An explanation of the appropriate methods for rec- ognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials 6. An explanation of the use and limitations of meth- ods that will prevent or reduce exposure including appropriate engineering controls, work practices, and personal protective equipment 7. Information on the types, proper use location, re- moval, handling, decontamination, and disposal of personal protective equipment 8. An explanation of the basis for selection of personal protective equipment 9. Information on the Hepatitis B vaccine, including information on its efficacy, safety, method of ad- ministration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge to employees covered by the standard 10. Information on the appropriate actions to take and the persons to contact in an emergency involving blood or other potentially infectious materials 11. An explanation of the procedure to follow and ac- tions to take if an exposure incident occurs includ- ing the method of reporting the incident and the medical follow-up that will be made available 12. Information on the post-exposure evaluation ad follow-up that the employer is required to provide for the employee following an exposure incident 13. An explanation of the signs, labels, and/or color- coding required 14. An opportunity for interactive questions and an- swers with the person conducting the training session during and after training session. PIERCER TRAINING The APP does not have any official requirements in this particular area, since there are many different ways to develop proficiency in piercing. Some piercers learn to pierce by trial and error, by observation of a video, studying a magazine, and/or by attending a seminar or training class. However, this approach alone is limited COMPLIANCE AND TRAINING
  • 53. 50 in that each of these methods provides incomplete or inadequate training. It is widely agreed that an apprenticeship under a qualified professional piercer is the best way to most thoroughly and scrupulously learn the art of piercing. Even the most reputable training seminars including lectures on anatomy, safety, hygiene, technique, and hands-on piercing experience will not fully train you to be a piercer. A seminar that lasts only a few days or even several weeks cannot possibly provide enough exposure to the variety of anatomy or piercing or practice for you to be a qualified piercer without additional training. Regardless of any certificates they may provide, you will not be a skilled piercer ready to work independently in the field from a piercing seminar alone. However, seminars can be a wonderful foundation or addition to a formal apprenticeship. What is an Apprenticeship? An apprenticeship is defined as a specific period of guided progress through the basic, intermediate, and advanced levels of piercer training. Before undertaking an apprenticeship, you should consider the following: What is your motivation for wanting to become a piercer? If you are hoping for quick money, a hip and easy job, or stable, guaranteed, lifelong employment, think again. As should be obvious from reading this manual, pursuing a professional piercing career is a long-term, labor intensive and costly endeavor. In the past few years, a proliferation of studios and piercers combined with a slowdown in the economy has resulted in a shrinking job market. Even if you undertake a high quality apprenticeship, there is no guarantee of future or continuous employment. During an apprenticeship, the novice piercer should do the following: • Locate a suitable apprenticeship in a reputable studio under a well-respected, highly skilled, and experi- enced professional. • Attend an industry specific bloodborne pathogens training class, such as that given by OSHA, the Red Cross, or National Safety Council. • Attend a First Aid/CPR class, such as that given by the Red Cross or YMCA. • Learn customer service, appropriate jewelry quality and selection, bedside manner, aftercare procedures, and troubleshooting. • Spend a minimum of three months as a full-time trainee, learning sterilization, disinfection, cross-con- tamination avoidance, and other health and safety issues before piercing. • Train in performing insertions and stretching exist- ing piercings before beginning to pierce. This is a valuable opportunity to practice smooth aseptic tech- nique, skin prep, tool/jewelry handling and bedside manner with little risk. • Spend a minimum of six months to a year in full-time supervised training as an apprentice before achieving the title of piercer. The location, client volume, and standards of the training studio will help to determine the necessary duration of an apprenticeship. • Observe all procedures before attempting them, and attempt a new procedure only with close supervision by a senior/training piercer. • Acquire an understanding of human anatomy as it relates to performing and handling piercing. This is crucial. Formal classroom training in anatomy is extremely helpful for comprehending the internal anatomy. Variations in external anatomy can only be learned through time and experience with hundreds of clients. Some states have drafted legislation requiring courses in anatomy and/or physiology be taken in order to be licensed for piercing. • Perform new piercings in order of relative difficulty, depending on client availability, mutual comfort level, and individual anatomical considerations. The ap- prentice should start with simpler procedures and progress to more advanced piercings over time. After sufficient experience is achieved and proficiency is demonstrated, the apprentice may begin to per- form the more difficult or advanced piercings at the supervisor’s discretion. Apprentice Training Before taking an apprentice, please consider the following: • Do you possess the necessary qualifications, skill and experience, patience, communication skills, ethics, organization, commitment, time and teaching ability? • What is your motivation for taking an apprentice? Is it for profit? To train your own staff for long-term employment? Ego gratification? • What will happen to the apprentice after training? Will he/she be hired on in your own studio? Will he/she open a studio down the block from you or work for your competitors?
  • 54. 51 • Will he/she be able to find employment in the already saturated piercing field at all? • If your motivation is to fill a job vacancy, job boards and the APP conference are less expensive and faster means of locating qualified piercers who are already trained. If you plan to train an apprentice, note the following: • An apprentice will probably interpret your methodol- ogy and techniques as the “right” way to pierce. If you are producing the next generation of professionals, be sure to pass on current and correct information. • Choose your apprentices carefully because your reputation will continue to be affected by their actions as they practice piercing for years to come. The APP does not specifically monitor the way piercers train their apprentices. However, the following criteria are suggested for piercers offering apprenticeships: • Compliance with appropriate state and local regula- tions, including business and piercing-specific licens- ing; • A senior or training piercer with at least four years of full-time piercing experience • Liability insurance coverage for the studio, and for the senior/training piercer and/or apprentice • Apprentices should not charge the public full price for a supervised piercing. A small materials fee or a half price fee is more appropriate and professional • If an apprentice is an employee, he or she should receive wages in accordance with federal and state requirements TITLES Establishing standard job titles related to levels of pierc- ing expertise is difficult because misunderstanding and abuse of titles is widespread. The definitions commonly used in the piercing industry are as follows: Apprentice During the first year of training, all individuals are considered to be apprentices. During this time, the individual is learning basic concepts and skills that set a firm foundation for the future. Piercer A Piercer is an individual who has pierced full time for a minimum of one year and can confidently and accurately perform most common piercings. Having immediate access to a supervisor and/or a network of experienced piercers who can answer questions and offer assistance as need arises is appropriate during this phase. A Piercer should still have a trainer or peer observe and assess his/her piercings from time to time. Senior or Training Piercer A Senior Piercer has been piecing full time for four or more years and behaves in a manner befitting a role model at all times. S/he is modest but in possession of a vast body of experience and information. A Senior Piercer continues to actively seek out new information, constructive criticism, and ideas from others. A Senior Piercer is an educator, willing to share knowledge by networking, writing, or training. Master Piercer This is an honorary title and should never be self-ap- pointed. Unfortunately, over the past few years it has been abused to the extent of near meaninglessness. A Master Piercer is an individual with more than five years of full time piercing experience, who has been acknowledged by the piercing community for a sub- stantial contribution to the field of piercing. S/he is comfortable enough with his/her abilities that s/he has no need to rely on the title, and so ironically, rarely claims it. The proficiency that makes one a Master Piercer requires constant diligence and a relentless pursuit of excellence. CONTINUING EDUCATION Piercing is not a static skill. To maintain one’s abilities it is crucial to acquire continuing education throughout one’s career. Piercing seminars and conferences are not just for novices. A true professional will seek out training, not only for new information, but also for the much-needed review of old facts, principles, and practices. Industry recognized advanced piercing seminars will offer inten- sive hands-on, supervised training featuring the most current information and techniques. Established National and International Conferences present classes on current techniques, aftercare, jew- elry materials and other technical and theoretical details of piercing. These are unparalleled events for skills training, networking, job opportunities, and sharing of knowledge amongst piercers. OSHA requires that employees with an occupational risk of exposure to bloodborne pathogens receive an-
  • 55. 52 nual training regarding risk management. There are a number of educating agencies from which to choose, but few actually relate this course work information to the piercing environment. Choose a class that will provide relevant application of this knowledge and that offers information such as prevention of disease transmission, infection control, and sterilization training in the piercing studio. First Aid, CPR, and any advanced emergency training should be kept current. Massage schools are another available resource for piercers to learn about grounding, touch, and bedside manner. Community colleges are a good place to find inex- pensive college-level anatomy and physiology courses. There are many fine anatomy texts, CD-ROMS, and videos on the subject of the human body, particularly in medical and university bookstores. Numerous websites also contain relevant information and resources.
  • 56. 53 BEING PREPARED IN THE STUDIO All piercing shops should have at least one first aid kit that is well stocked, familiar and available to all staff, and that is used for emergencies only. At a minimum, the kit should contain; • Antiseptic ointment • Gloves • Plastic Bags • Triangular Bandage • Blanket (emergency type) • Candy, glucose tablets • Scissors and Tweezers • Hand Cleaner • Small Flashlight with extra batteries • Band Aids (assorted sizes) • CPR mask • Cold Packs • Adhesive Tape • Gauze pads (2x2 & 4x4 ) • Roller Bandage • Roller Gauze (1 and 2 are good sizes) Each of the piercing stations or rooms should also be emergency equipped. These kits should contain at least the following; • Small flashlight /extra batteries • Band Aids • CPR mask • Cold pack • Hard sugar candy and/or packed orange juice, or glucose tablets Some emergencies in the piercing studio can be avoided by being prepared. The piercing release form can provide relevant information about the health of the customer that can alert the piercer to potential problems. Knowing how to respond appropriately is important if a customer faints or a diabetic suffers an insulin reaction (see Special Circumstances section). Knowing beforehand that a particular client may be prone to such occurrences can help you plan ahead. While the release form cannot be used to gather information about the health status of a customer if the question is a violation of the person’s right to pri- vacy, questions such as, “Are you prone to fainting?” or, “Are you diabetic?” can provide information that is important to know. Asking a person, “Are you HIV positive?” is a violation of the right to privacy and in most states is prohibited by law. In a professionally run shop, OSHA safety standards will be observed and Standard Precautions employed. Therefore, information gained by the answer would have absolutely no bearing on the procedure provided to that customer. NEEDLESTICK ACCIDENTS One of the risks faced by professional piercers is the possibility of an accidental exposure to blood or other potentially infectious materials (OPIM). This could happen by a needlestick with a contaminated piercing needle or exposure through splashing, spraying, or other contact with contaminated materials, objects, or surfaces. Every action in a piercing procedure should be de- liberate and intended to minimize the risk of a needle accident. A professional piercer who remains focused, alert and in control of the environment will greatly mini- mize the possibility of this event. To reduce the likelihood of a needlestick incident: • Dispose of used needles in Sharps containers im- mediately • Know the location of all needles at all times. Once removed from the sterile package and used, never set down or lose sight of the needle. • Don’t clutter your tray. Dispose of any necessary gauze, paper products, and packaging before pierc- ing • Don’t rush when using, handling, or disposing of needles. Focus on your actions. • Be consistent with your tray set up. If you are using needles and insertion tapers in the same procedure, keep them separate and know where everything is at all times. • Remain in control and do not pierce clients who are overly nervous or not prepared for the piercing. • Do not pierce if you are ill, tired or if you have not eaten for a prolonged period of time. Be at your best, awake, and aware; your clients deserve nothing less. EMERGENCIES
  • 57. 54 • Examine all other equipment such as tools, corks, gloves, and rubber bands. Flaws and failure of these to perform as intended can lead to needle sticks. • If there is any possibility that an unused needle has become contaminated, it must be immediately dis- posed of into the Sharps container. • If the used needle is corked, do not remove the cork before disposal unless it is necessary. If re-corking is necessary, federal regulations require the use of mechanical implements such as hemostats or for- ceps. • Always replace Sharps containers when they have been filled to the full line. • Never remove anything from a Sharps container. To reduce the likelihood of other exposure incidents: • Do not reach into contaminated instrument trays. Items should be removed mechanically or by the procedure outlined in your studio’s exposure control plan. • Use caution when handling contaminated sharps such as scissors or insertion tapers. • When tools are scrubbed manually, they should be completely submerged under water to prevent un- necessary splashing and spraying. • If contaminated tools are presoaked in a disinfecting solution, this must be done in the biohazard/steril- ization room (as opposed to the piercing room) to prevent spills and splashes that could occur when transporting the soaking container from one room to another. • If the ultrasonic unit that you are using does not have a built-in draining system, this must be dumped slowly and steadily to avoid spills and splashes. By observing the precautions listed above and having a clearly written Exposure Control Plan that is specific to your studio, much can be done to minimize the fear and uncertainty that often follows an exposure incident. If, despite all cautions being observed, a needlestick occurs: • Secure the needle to prevent additional sticks. If necessary, call a co-worker to finish the procedure. • Wash the area for several minutes with antimicrobial or antibacterial liquid soap. • Rinse and bandage the wound. • Remain calm. Take some time to calm down before returning to the procedure room if you have a co- worker standing in for you. You may or may not feel that it is appropriate to ask about a client’s health status, particularly regarding Hepatitis and HIV. Depending on the laws in your area, you may be treading on very dangerous legal ground by asking someone to disclose, in whatever manner, their status regarding HIV and other communicable diseases. In some states, it is illegal to ask. Immediately file your OSHA’s Occupational Post- Exposure report and follow your studio’s Exposure Control Plan. These are established with your health and safety in mind. You must seek immediate medical attention, es- pecially if your client has disclosed that they are HIV positive or if you have good reason to suspect that they may be. It is important to know that there is an HIV pro- phylaxis available that could prevent HIV infection, but this must be done within the first 24-48 hours. While this treatment has severe negative side effects (said to be comparable to chemotherapy), it is an important option for those who have been exposed to HIV or the blood of somebody who is at high risk for HIV infection. If you are not already vaccinated, you may sign up for a ten day series of Hepatitis B shots that may help protect you from the disease. A medical professional can help you determine if this is an appropriate treat- ment for you. Blood testing done shortly after the needlestick injury occurred is also suggested. Although immediate testing will not indicate if disease was transmitted through the needlestick injury, it will provide a baseline to compare future testing to. If the employee is unsure if they would like to have their blood immediately tested, it is also im- portant to know that their blood can be drawn and saved for later testing, if they become inclined to do so. Mentally review the accident. Think about the events leading up to the exposure and what could be done different. Learn from your mistake and take additional precautions when in a similar situation in the future. BLEEDING Most piercings do not bleed much, if at all, but the possibility always exists. It is good practice to remind clients that any break in the skin can bleed, and that piercings are no exception. If the client is made aware in advance that the possibility of bleeding exists, they are much less likely to be concerned or anxious if it should happen. The client who has recently ingested alcohol, aspirin, caffeine or certain prescription drugs is more likely to
  • 58. 55 bleed, sometimes profusely. Inform clients to avoid these blood-thinning agents if at all possible. Piercers should prepare themselves and their client for the pos- sibility of additional bleeding when a piercee has these agents in his/her system. Some piercings such as Prince Alberts and eyebrows are located in more vascular areas so they are more apt to bleed. Using a needle of a gauge larger than the jewelry may result in excess bleeding. To minimize bleeding and client discomfort, use a larger needle only when necessary. Removing jewelry from a fresh piercing may produce copious bleeding. In an emergency, it may be best not to remove the jewelry; let the emergency room handle the situation. When you anticipate bleeding, have sterile gauze pads ready. To stop bleeding, apply firm pressure for two minutes. Dispose of all used gauze pads contain- ing blood in biohazard waste. A small disposable ice pack can be applied to help minimize swelling and bleeding. Apply ice to stop bleeding in an oral piercing. For a tongue piercing, have the client gently suck on small cubes, chipped ice, or shaved ice. The amount of blood may seem greater when mixed with saliva. Cautery (styptic) pencils and similar products are not appropriate for use on puncture wounds such as pierc- ings. Additionally, they can be very painful. It is unprofessional to release a client with an actively bleeding piercing. Be sure that bleeding has essentially ceased and that the area is reasonably clean before the client leaves. It is illegal for a piercer to stitch or attach tissue. If a client is bleeding profusely and you cannot stop it with pressure, the client must be taken to the hospital. Emergency Bleeding Piercers are not to treat bleeding emergencies, so the client should be brought to the emergency room immediately. Examples of emergency bleeding are: • Profuse bleeding that does not stop after several minutes of pressure, particularly from oral, surface- to surface or genital piercings, excluding the normal bleeding of a Prince Albert or apadravya • Significant bleeding that persists several days after the piercing excluding the normal bleeding of a Prince Albert or apadravya. FAINTING It can happen occasionally that a customer will pass out or faint before, during, or after a piercing. For some people, even the filling out paperwork at the counter and picking out jewelry results in their feeling faint. Answers to a question on the release form regarding whether a client has a history of fainting can be very helpful to the piercer in preparing for that possibility. It is important to understand why some people lose consciousness (pass out). A common misconception is that low blood-sugar levels are the only cause of this reaction. Fainting is frequently caused by a loss of blood flow to the brain. Most often this is a response triggered by the Pneumogastric or vagus nerve, called a vasovagal response. The occurrence of fainting is more likely if the client has consumed excessive caffeine, or certain prescription drugs. Also, if the client has not eaten a meal within 4 hours and the stomach is empty; if the weather is very hot and/or humid, if the client stands up too soon after being pierced, the client has not slept well, has a high anxiety level, or any combination of the above. A client may faint or become light headed at any time. It could happen while browsing at the front counter, be- ing marked for the piercing, during the actual piercing or several minutes after the piercing. Beware that a client’s companion may also faint! Keep watch on all people who come into your busi- ness and maintain control of the environment so that a fainting person will not surprise you. Observant employees and piercers can often spot a person who is having trouble. Symptoms that are frequently seen are: • Pale complexion • Headache or blurred vision • White or blue lips • Crying • Nausea • Trembling • Inability to concentrate, irritability or confusion • Excessive perspiration • Drowsiness, dizziness, or lack of coordination Whether it is the client or an onlooker experiencing the difficulty, the course of action should be the same. If the person is not in a supine (feet elevated above the heart) position, place them in such a posture.
  • 59. 56 Or, if they are seated, bend them forward, so the head is between the knees. Continue to talk to them, reassure them, and offer cool water, candy, juice, and/ or glucose tablets. A cold compress on the forehead, wrists and/or back of the neck may help. An actual loss of consciousness can often be prevented with these measures. If the client does “pass out” do not give them any sort of inhalants such as ammonia. These are considered a last resort. That is, they are only to be used if the per- son remains unconscious for more than two minutes, which is rare. DO NOT attempt to put anything in their mouth. Move away any object that may cause injury to the person. Some shaking or twitching is not unusual with fainting. Most often the person will “come to” within a few seconds. However, a few seconds can seem extraor- dinarily long, so it is important that you remain calm and aware. It is possible that they can still hear you, although they may be unable to respond. Attempt to achieve communication by saying their name calmly, and not too loudly. People are often very confused when regaining con- sciousness and may not know who you are or where they are, or what has taken place. Let them know where they are and what has happened. Do not let them jump up and leave the building. Although this is a very com- mon reaction, it is ill advised. People are sometimes ashamed that they have fainted and therefore want to leave immediately Turn off or dim bright lights in the room. The applica- tion of an ice pack to the forehead or back of the neck and/or a cool drink of water can be helpful in reducing the sense of being too warm. Have the person lie quietly for a few minutes. As they begin to feel better, first have them sit up for a few minutes. Several minutes later you may al- low them to stand up. If at any point they begin to feel unstable or unwell, have them lie down again. Stay with the person as long as necessary, and call for assistance from a co-worker if needed. If this should happen during a piercing, first, secure the needle. It may be acceptable to attend to the pier- cee and finish the jewelry insertion later. If the presence of the needle may endanger you or the client, as with a tongue or lip piercing, immediately remove the needle and deal with the situation at hand. It may not be wise to proceed with the piercing even when the customer is fully recovered. Discuss these concerns with the customer and if necessary, suggest they make the appointment for another day. Emotional disturbances or panic attacks can often take on the appearance of a serious physical condition. It is important in these instances not to draw undue attention to the situation. Such episodes are often humiliating for the client. A quiet place to sit, a drink of cool water, and a self-administered dose of what- ever medication has been prescribed for the condition (where applicable) is generally all that is necessary to resolve the situation. LOSS OF CONSCIOUSNESS Special Circumstances The types of client reactions most often handled in a piercing studio are in no way life-threatening. There are, however, certain circumstances in which the symptoms discussed above including a loss of consciousness may be the result of a more serious physical condition. The knowledge gained through the required First Aid/CPR courses will increase the piercers awareness of appropriate steps to take in an emergency, and thereby increase the confidence level of the individual should an emergency occur. The following are a few potentially more serious conditions about which all piercers should be aware: Diabetes is not an infectious disease. It is a condi- tion that has to do with the body’s inability to effectively produce insulin in response to blood sugar. Some diabetics can control their diabetes by diet and others require medication. Insulin reactions occur when the blood sugar level is too low. This could be caused by nervous or emo- tional tension, strenuous exercise, too little food or a delayed meal. Consumption of food will raise blood sugar levels. Customers should be asked to record on the release form whether they have eaten within the previous 4 hours. Should the symptoms (listed under the Faint- ing section above) appear, it is critical that the diabetic receive immediate assistance. If no treatment is given, this becomes a life-threatening event. Most diabetics are aware of their blood sugar levels and will ask for assistance when needed. Provide the customer with some form of sugar. This can be fruit juice, several pieces of candy, sugar, or soda pop (not diet). Improvement should be seen within about 10 minutes. If the condition does not improve, call Emergency Medical Services (EMS).
  • 60. 57 Heart disease afflicts an estimated 70 million Ameri- cans. Of the nearly one million deaths annually attrib- uted to cardiovascular disease, more than half result from heart attacks. A person is just as likely to suffer a heart attack in your studio as anywhere else. CPR training courses outline the proper procedures for a person suspected of suffering from a heart attack. Seizures involve convulsions and intense shaking of the body with aggressive, jerky outward movements. This is much more serious than simply passing out and you should call 911. The affected party may also uri- nate, defecate, or vomit. This is uncommon, but natural. Maintain professionalism and try not to make the client feel embarrassed about such an occurrence. Seizures may be caused by an acute or chronic condition. One chronic condition is known as epilepsy. Epilepsy is usu- ally controlled with medication. Still, some people with epilepsy may have seizures from time to time. Just as with someone who has merely fainted, make the area safe for the client, removing any nearby objects that may cause injury. Place a thin protective cushion or article of clothing under the head and try to turn them onto their side. DO NOT attempt to hold or restrain the person or place anything in his/her mouth. Again, CPR /First Aid courses will outline in detail the proper steps to take if this occurs.
  • 61. 58 AFTERWARD Merely reading this manual has not in any way endowed you or anyone else with the ability to pierce or provided the knowledge to do so safely. If you plan to offer piercing services, it is your professional and ethical responsibility to seek out a highly skilled, experienced professional piercer and undertake an apprenticeship. Only after exten- sive hands-on training and expert supervision will you be able to provide high quality professional services. This manual has attempted to provide details of acceptable safety and hygiene standards, and appropriate piercing practices. Reputable piercers will work diligently to meet all relevant documented procedures and to uphold the standards described within this manual. There are equivalent methods, products and equipment that may be acceptable, if they meet the criteria of minimal customer discomfort, maximum safety and zero risk of cross-contamination. Meeting all of these standards is not quick and easy; it takes a great deal of time, effort and money to cre- ate a safe working environment with all required equipment and supplies, training and preparation. A piercer who upholds all of the standards described herein should feel very proud to be a reputable, respectable and responsible piercer. If you can honestly say you do everything appropriately as described in this manual, you should pat yourself on the back and congratulate yourself! Keep up the good work and also keep up with new information as it becomes available. There is always more to learn. The industry is continuing to develop and mature. The APP is always acquiring new information, so it is likely that no matter how often we update this manual, some of the information contained within has already become obsolete. Whether you are a professional piercer, a serious piercing enthusiast, a piercing-friendly medical professional, a public health official or a concerned legislator, it is your responsibility to keep up with the latest techniques, products and other piercing information. Readers are encouraged to contact the APP by email at or visit our website at with any suggestions, comments, criticism or contributions.
  • 62. 59 Acute: Short term or temporary; often severe but quickly resolved. AIDS: Acquired Immunodeficiency Syndrome, a disease that may result from HIV infection causing breakdown of the immune system. Airborne: Capable of being transmitted by air par- ticles. Anaphylaxis: A hypersensitive (allergenic reaction) state of the body to a foreign protein or drug. Latex, iodine and other chemicals commonly found in the piercing studio can cause this reaction. Reactions are sudden in onset and can include increased irri- tability, cyanosis, convulsions, unconsciousness and even death. Death generally occurs due to spasms of the bronchioles in the lungs. Anesthetic: A drug or other agent used to produce insensibility to pain or touch. Most anesthetics are available by prescription only and are not legal for piercers to use on clients. Many can cause complica- tions in the piercing procedure. Anesthetic, Injectable: A drug or other agent applied subdermally by use of a syringe or other injection device. Only trained, licensed medical profession- als are legally qualified to administer this class of prescription-only anesthetics. Anesthetic, Topical: A drug or other agent applied to the surface of the skin with the intent of providing relief from pain. Topical anesthetics include ice, ethyl chloride (spray freeze), EMLA and the xylocaine family of topical creams and ointments. Most topical anesthetics are available only by prescription and most are not intended for use in or near puncture wounds. These can irritate skin and complicate piercing procedures and should not be used. Antibacterial: Destroying or suppressing the growth or reproduction of bacteria. Antibiotic: A chemical substance produced by a liv- ing organism that has the capacity to destroy and/or suppress the growth of other microorganisms. Antibodies: Infection-fighting proteins released by white blood cells. Antigen: A substance that causes antibody forma- tion. Antimicrobial: Capable of killing or suppressing the growth of microorganisms. Asepsis: A condition free from germs. Autoclave: A strong steel vessel used for sterilization of equipment and materials at high temperature and under pressure. Bacillus: (Plural Bacilli); A genus of bacteria belonging to the family Bacillaceae, and including the organisms that cause dysentery, cholera and conjunctivitis. Bacteria: Minute unicellular microorganisms with both plant and animal characteristics. Also known as germs or microbes. The primary types are cocci, spirilla and ba- cilli. Bacterial diseases include pneumonia, staph infec- tions, tetanus, tuberculosis, syphilis, and diphtheria. Bacteriocidal/Bactericidal: Capable of destroying bacteria. Bloodborne Pathogen: A pathogenic microorganism that is present in human blood and can cause disease in humans. Body Substance Isolation: An infection control strat- egy that considers all body substances as potentially infectious. Broad Spectrum: A wide range of microorganisms. Cartilage: A type of dense connective tissue consisting of cells embedded in a substance or matrix. Cartilage has no nerve or blood supply of its own. There are several types of cartilage: Articular: Hyaline cartilage covering the articular sur- faces of the bones. Costal: Cartilage connecting the true ribs and ster- num. Hyaline: Flexible and slightly elastic; fine connective tissue found in the septum and nostrils, larynx and trachea. Elastic: A rigid network of yellow fibers that give strength and shape to the external ear and the audi- tory tube. Chemical Sterilization: See Sterilization, Chemical. Chronic: Long-term, protracted, ever-present or return- ing. Often indicates an incurable medical condition or illness. Coccus: (Plural: Cocci). A type of bacteria that is spherical or ovoid in form. Many are pathogenic, causing diseases such as scarlet fever, pneumonia and meningitis. GLOSSARY OF TERMS
  • 63. 60 Cold Sterilization: See Sterilization, Cold. Contamination: The presence or the reasonable anticipated presence of blood or other potentially infectious materials on an item or surface. Contaminated Sharps: Any contaminated object that can penetrate the skin, including but not limited to needles, snip wires and broken glass. Cross-Contamination: The act of spreading patho- genic organisms from one item or surface to an- other. Cyanosis: A disordered condition of the circulatory system from inadequate oxygen in the blood, result- ing in a bluish color to the skin. Disease Transmission: The passage of a disease to a person. Disinfect: To free from pathogenic organisms, or to prevent pathogens from reproducing. Decontamination: The use of physical or chemical means to remove, inactivate or destroy bloodborne pathogens on a surface or item to the extent that they are no longer capable of transmitting pathogens. The item is thus rendered safe for handling, use or disposal. Direct-Contact Transmission: The transmission of a disease by touching an infected person’s body fluids. Disease: Disturbed or abnormal structure or physiologi- cal action in the living organism as a whole, or in any of its parts. Literally, the lack of ease. Edema: A swelling caused by excess fluid in the inter- cellular spaces. Edema can be caused by a chemi- cal reaction, an infection, stress to the area, (as in improper piercing technique) or other causes. Engineering Controls: Physical controls such as sharps disposal containers that isolate or remove the bloodborne pathogen from the workplace. Epithelial Tissue: A membranous tissue consisting of one or more layers of compactly joined cells of various types and sizes Exposure Control Plan: A systematized protocol created by an employer to protect employees from infection by identifying jobs that require employee training, protective equipment, and immunizations. Exposure Determination: The identification and docu- mentation of job classifications in which occupational exposure to blood can occur. Exposure Incident: A specific mucous, non-intact skin or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties. Fascia: A fibrous membrane covering, supporting and separating muscles. Fascia also unites the skin with underlying tissue. Fungal: Any inflammatory condition caused by a fungus. Fungicidal: That which is capable of killing fungi. Gamma Radiation Sterilization: See Sterilization, Gamma Ray. Germicidal: That which is capable of killing germs. Handwashing Facility: An area dedicated to hand- washing that provides an adequate supply of running potable water, soap and single-use towels. HBV: Hepatitis B Virus. HBV is one of the viruses that cause illness directly affecting the liver and is a bloodborne pathogen. HCV: Hepatitis C Virus. HCV is one strain of the Hepatitis Virus formerly referred to as non-A-non-B Hepatitis. HEPA: High Efficiency Particulate Air (filter) used to improve air quality and reduce the quantity of airborne contaminants. Hepatitis: A disease that causes swelling, soreness, and loss of normal function of the liver. Symptoms include weakness, fatigue, anorexia, nausea, ab- dominal pain, fever, jaundice and headache. HIV: Human Immunodeficiency Virus is a virus that infects immune system blood cells in humans and renders them less effective in preventing disease. Immune: Resistant to infectious disease. Immune System: The body’s group of natural re- sponses for fighting disease. Immunization: A process or procedure by which re- sistance to infection is produced in people. Indirect-Contact Transmission: The transmission of a disease from one host to another through a contaminated object. Inert: Devoid of active properties. Indicator: Indicators are paper or tape strips impreg- nated with a chemical that changes color when ex- posed to heat and steam in an autoclave. They are often found on autoclave tape, autoclave pouches, and strips, but are not limited to these items. Acti- vated indicator marks are useful for identifying pack- ages and articles which have been exposed to the
  • 64. 61 physical conditions of an autoclave cycle, but they not prove sterilization. Integrator: Integrators are strips or devices used in pouches and/or autoclave chambers that prove the conditions for sterilization were met. They are similar to indicators, except that they change color when they have been exposed to the ideal combination of steam, pressure, heat and timing. Jaundice: A yellow discoloration of the skin, mucous membranes, and/or whites of the eyes, character- istic of the later stages of Hepatitis or other liver disease. Microorganism: A bacteria, virus, or other microscopic organism that may enter the body. Microorganisms that cause infection or disease are called germs. Mucous Membrane: Any one of the four types of thin sheets of tissue that cover various parts of the body, such as the lining of the mouth or nose. Mucus: The clear secretion of the mucous mem- branes. Non-Intact skin: Skin that has a break in the surface. It includes but is not limited to abrasions, cuts, hang- nails, paper cuts and burns. NSAIDs: Nonsteroidal anti-inflammatory medications such as ibuprofen. Occupational Exposure: Reasonable anticipated exposure to potentially infectious material that may result from the performance of an employee’s du- ties. Occupational Safety & Health Administration (OSHA): The federal agency responsible for the development, administration and enforcement of employment-related health and safety regulations. Opportunistic Infection: An infection that strikes a person with a weakened immune system. Pre-Cleaning: The act of soaking or otherwise disin- fecting a contaminated tool prior to actual sterilization. Pre-cleaning is not a substitute for cleaning tools in an ultrasonic machine. Spore Test: A biological monitoring process in which a third party laboratory culturing service is engaged to monitor spore growth on media processed in a studio’s autoclave. The service provides documen- tation that serves as a tangible record and legal document proving a studio’s ability to achieve proper sterilization. Sporicidal: Kills mold and other spores. Spores, espe- cially TB, are generally very hard to kill, so sporicidal agents are powerful enough to kill a broad range of organisms. Steam Sterilization: See Sterilization, Steam. Sterilization: The complete elimination of all microbial life. If an object is sterile, nothing lives on its surfaces. As the air around us is teeming with organisms, noth- ing that has been in contact with air is considered sterile. Sterilization, Cold: Killing organisms by long-term immersion in a liquid sterilant solution (usually 24 - 72 hours). Sterilization, Chemical: Sterilization by exposure to Ethylene Oxide (EO) gas. Sterilization, Gamma Ray: An effective, very rapid method of sterilization by means of exposure to gamma radiation. Sterilization, Steam: Sterilization by means of ex- posure to high pressure, superheated steam. The most common, efficient sterilization method for most piercers. This is also known as “hospital” or autoclave sterilization. Sterilization, Liquid: See Sterilization, Cold. Thermal Death Time: The amount of time required to kill a given organism at a given temperature, mea- sured in minutes. Generally, the higher the tempera- ture, the shorter the thermal death time. Minimum TDT for most autoclaves and a majority of organisms is 15 minutes at 270 F. Tuberculocidal: A very strong agent capable of de- stroying hardy TB spores. Virucidal: Capable of killing viruses. Virus: An ultra-microscopic microorganism that is parasitic within living cells. Many viruses can cause disease in humans. A virus cannot grow or reproduce apart from a living cell. It invades living cells and uses their chemical machinery to keep itself alive and to replicate itself. It may reproduce with fidelity or with errors (mutations). This ability to mutate is responsible for the ability of some viruses to change slightly in each infected person, making treatment more difficult.
  • 65. 62
  • 66. 63 According to OSHA standards, MSDS must be kept on file for all chemicals used within the studio. This includes everything from window/glass cleaner and hard surface disinfectants to skin prep prod- ucts and soaps used for hand washing and more. Copies of MSDSs for all potentially hazardous chemi- cals to which employees may be exposed must be read- ily available to all employees during each work shift. CHEMICAL PRODUCT INFORMATION This section provides the name, address, and telephone number of the company that produced the product, the MSDS’s date of issue, and the name of the material. The name of the material on the MSDS must be spelled exactly as it is on the container you received. In addi- tion, you will find the following information: • Product Name • Commercial or marketing name • Synonym • Approved chemical name and/or synonyms • Chemical Family • Group of chemicals with related physical and chemi- cal properties • Formula: Chemical formula, if applicable; i.e., the conventional scientific definition for a material • CAS Number • Number assigned to chemicals or materials by the Chemical Abstracts Service (CAS) • Composition of Ingredients This section lists the product’s individual hazard- ous chemicals and their relative percentages. The material’s corresponding CAS Number must also be listed. All ingredients that meet the OSHA Hazard Com- munication standard criteria of a hazardous ingredient must be identified here. Manufacturers may also choose to list active ingre- dients, significant ingredients regulated under other Federal, state, or local regulations, or a complete ingre- dient disclosure, including nonhazardous components. Complex mixtures recognized as single substances may be listed as single components. If any of the hazardous components is a trade secret, this will be indicated in lieu of identifying the component. Suppli- ers of such products must still provide health hazard data on the MSDS and additional information to safety professionals who have a verifiable need to know. HAZARDOUS IDENTIFICATION INFORMATION This section is divided into two parts. The first part describes the material’s appearance and gives an overview of the most significant immediate concerns for emergency personnel. The second part provides information on the potential adverse health effects and symptoms associated with exposure to the material, its components, or known by products. In addition, this section lists all of the routes of entry pertinent to this material. Acute (short-term) and chronic (long-term) health effects, symptoms of exposure, and medical conditions aggravated by ex- posure must be stated. If the material is carcinogenic, that fact must be stated. First Aid Measures This section describes medical and first aid treatments for accidental exposure by route of exposure (i.e. in- halation, skin, eye, ingestion). Any known antidotes that may be administered by a layperson or specially trained personnel will be indicated here. Fire Fighting Measures This section provides basic fire fighting guidance for trained fire fighters, emergency responders, employ- ees, and occupational health and safety professionals. It describes the flammable and explosive properties of the material, the proper extinguishing materials, and the precautions and procedures to safely and effectively fight the fire. Accidental Release Measures This section provides spill, and leak procedures, and response procedures for emergency responders and environmental professionals. It describes evacuation procedures, and other emergency advice to protect the health and safety of the responders and the en- vironment. UNDERSTANDING MATERIAL SAFETY DATA SHEETS (MSDS)
  • 67. 64 Handling and Storage Information This section provides safe handling and storage information for employees, occupational health and safety professionals, and employers. General handling precautions and practices are described to prevent release of hazardous substances to the environment and overexposure during contact with the material, and also to minimize continued contact after handling. In addition, this section explains necessary storage conditions to avoid damage to containers, contact with incompatible materials and subsequent dangerous reactions, evaporation or decomposition of the stored material, or flammable and explosive atmospheres in the storage area. Exposure Controls/Personal Protection This section discusses methods intended for occupa- tional health and safety professionals and employers for reducing worker exposure to hazardous materials. Exposure controls include engineering controls such as ventilation and special process conditions (e.g. isolation, enclosure), or administrative controls (e.g. training, labeling, warning devices). This section also provides guidance on personal pro- tective equipment (PPE) including respirators, safety glasses, goggles, gloves, aprons, and boots. Physical and Chemical Properties This section lists physical data, including a material’s boiling point, solubility in water, viscosity, specific grav- ity, melting point, evaporation rate, molecular weight, appearance and odor. These properties can help in predicting how the material will act and react so that you can determine safe handling procedures and select appropriate personal protective equipment. Stability and Reactivity Information This section lists materials and circumstances that could be hazardous when combined with the material covered by the MSDS. This section provides informa- tion on chemical incompatibilities, conditions to avoid, decomposition products, and the material’s stability. Toxicology Information This section provides information on toxicity testing of the material and/or its components. The information in this section is intended for medical professionals, occupational health and safety professionals, and toxicologists. Ecological Information This section assists you in evaluating the effect a chemical may have if it’s released into the environment. It may also be useful in evaluating waste treatment practices. Disposal Considerations This section provides proper disposal information for environmental professionals or individuals responsible for waste management activities. Information may include special disposal methods or limitations per Fed- eral, state, or local regulations, and waste management options, such as recycling or reclamation. It may also include RCRA waste classifications and EPA waste identification numbers and descriptions. Transport Information This section provides shipping classification information for the employer, distributor, emergency responders, and transport/shipping departments. If regulated, shipping information includes U.S. Department of Transportation (DOT) hazardous materials description/ proper shipping name, hazard class, and identification numbers (UN or NA numbers). Regulatory Information This section provides regulatory information for employ- ers and regulatory compliance personnel. U.S. Federal regulations such as OSHA, TSCA, SARA, CERCLA, and CWA are addressed. Reportable quantities (RQ) for spills or discharges and threshold planning quanti- ties (TPQ) for hazardous materials stored at facilities are listed. Other Information This section provides a location for additional infor- mation, such as a list of references, keys/legends, or preparation and revision indicators. Hazard ratings defining the acute health, flammability, and reactivity hazards of a material may also be included.
  • 68. 65 FULL TEXT OF BLOODBORNE PATHOGENS STANDARD 1910.1030 (a) Scope and Application. This section applies to all occupational exposure to blood or other poten- tially infectious materials as defined by paragraph (b) of this section. (b) Definitions. For purposes of this section, the following shall apply: Assistant Secretary means the Assistant Secretary of Labor for Occupational Safety and Health, or des- ignated representative. Blood means human blood, human blood components, and products made from human blood. Bloodborne Pathogens means pathogenic microor- ganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to hepatitis B virus (HBV) and hu- man immunodeficiency virus (HIV). Clinical Laboratory means a workplace where diag- nostic or other screening procedures are performed on blood or other potentially infectious materials. Contaminated means the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface. Contaminated Laundry means laundry which has been soiled with blood or other potentially infectious materials or may contain sharps. Contaminated Sharps means any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires. Decontamination means the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmit- ting infectious particles and the surface or item is rendered safe for handling, use, or disposal. Director means the Director of the National Institute for Occupational Safety and Health, U.S. Department of Health and Human Services, or des- ignated representative. Engineering Controls means controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace. Exposure Incident means a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties. Handwashing Facilities means a facility providing an adequate supply of running potable water, soap and single use towels or hot air drying machines. Licensed Healthcare Professional is a person whose legally permitted scope of practice allows him or her to independently perform the activities required by paragraph (f) Hepatitis B Vaccination and Post-ex- posure Evaluation and Follow-up. HBV means hepatitis B virus. HIV means human immunodeficiency virus, experimen- tal animals infected with HIV or HBV. Needleless Systems means a device that does not use needles for (1) the collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established; (2) the administration of medication or fluids; or (3) any other procedure involving the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps. Occupational Exposure means reasonably antici- pated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties. Other Potentially Infectious Materials means (1) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to dif- ferentiate between body fluids; (2) Any unfixed tis- sue or organ (other than intact skin) from a human APPENDIX A
  • 69. 66 (living or dead); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV. Parenteral means piercing mucous membranes or the skin barrier through such events as needlesticks, human bites, cuts, and abrasions. Personal Protective Equipment is specialized cloth- ing or equipment worn by an employee for protec- tion against a hazard. General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not con- sidered to be personal protective equipment. Production Facility means a facility engaged in in- dustrial-scale, large-volume or high concentration production of HIV or HBV. Regulated Waste means liquid or semiliquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semiliquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are ca- pable of releasing these materials during handling; contaminated sharps; and pathological and microbio- logical wastes containing blood or other potentially infectious materials. Research Laboratory means a laboratory producing or using research-laboratory-scale amounts of HIV or HBV. Research laboratories may produce high concentrations of HIV or HBV but not in the volume found in production facilities. Sharps with Engineered Sharps Injury Protections means a non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or ar- tery, or administering medications or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident. Source Individual means any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee. Examples include, but are not limited to, hospital and clinic patients; clients in institutions for the developmentally disabled; trauma victims; clients of drug and alcohol treatment facilities; residents of hospices and nursing homes; human remains; and individuals who donate or sell blood or blood components. Sterilize means the use of a physical or chemical pro- cedure to destroy all microbial life including highly resistant bacterial endospores. Universal Precautions is an approach to infection control. According to the concept of Universal Pre- cautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens. Work Practice Controls means controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique). (c) Exposure Control (c)(1) Exposure Control Plan. (c)(1)(i) Each employer having an employee(s) with occupational exposure as defined by paragraph (b) of this section shall establish a written Exposure Control Plan designed to eliminate or minimize employee exposure. (c)(1)(ii) The Exposure Control Plan shall contain at least the following elements: (c)(1)(ii)(A) The exposure determination required by paragraph (c)(2), (c)(1)(ii)(B) The schedule and method of implemen- tation for paragraphs (d) Methods of Compliance, (e) HIV and HBV Research Laboratories and Production Facilities, (f) Hepatitis B Vaccination and Post-Expo- sure Evaluation and Follow-up, (g) Communication of Hazards to Employees, and (h) Recordkeeping, of this standard, and (c)(1)(ii)(C) The procedure for the evaluation of circumstances surrounding exposure incidents as re- quired by paragraph (f)(3)(i) of this standard. (c)(1)(iii) Each employer shall ensure that a copy of the Exposure Control Plan is accessible to employees in accordance with 29 CFR 1910.1020(e). (c)(1)(iv) The Exposure Control Plan shall be re- viewed and updated at least annually and whenever necessary to reflect new or modified tasks and proce- dures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure. The review and update of such plans shall also: (c)(1)(iv)(A) reflect changes in technology that eliminate or reduce exposure to bloodborne patho- gens; and (c)(1)(iv)(B) document annually consideration and implementation of appropriate commercially available and effective safer medical devices designed to elimi-
  • 70. 67 nate or minimize occupational exposure. (c)(1)(v) An employer, who is required to establish an Exposure Control Plan shall solicit input from non- managerial employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps in the identification, evaluation, and selection of effective engineering and work prac- tice controls and shall document the solicitation in the Exposure Control Plan. (c)(1)(vi) The Exposure Control Plan shall be made available to the Assistant Secretary and the Director upon request for examination and copying. (c)(2) Exposure Determination. (c)(2)(i) Each employer who has an employee(s) with occupational exposure as defined by paragraph (b) of this section shall prepare an exposure determi- nation. This exposure determination shall contain the following: (c)(2)(i)(A) A list of all job classifications in which all employees in those job classifications have occupa- tional exposure; (c)(2)(i)(B) A list of job classifications in which some employees have occupational exposure, and(c)(2)(i)(C) A list of all tasks and procedures or groups of closely related task and procedures in which occupational ex- posure occurs and that are performed by employees in job classifications listed in accordance with the provi- sions of paragraph (c)(2)(i)(B) of this standard. (c)(2)(ii) This exposure determination shall be made without regard to the use of personal protective equip- ment. (d) Methods of Compliance (d)(1) General. Universal precautions shall be ob- served to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered poten- tially infectious materials. (d)(2) Engineering and Work Practice Controls. (d)(2)(i) Engineering and work practice controls shall be used to eliminate or minimize employee exposure. Where occupational exposure remains after institution of these controls, personal protective equipment shall also be used. (d)(2)(ii) Engineering controls shall be examined and maintained or replaced on a regular schedule to ensure their effectiveness. (d)(2)(iii) Employers shall provide handwashing facili- ties which are readily accessible to employees. (d)(2)(iv) When provision of handwashing facilities is not feasible, the employer shall provide either an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes. When antiseptic hand cleansers or towelettes are used, hands shall be washed with soap and running water as soon as feasible. (d)(2)(v) Employers shall ensure that employees wash their hands immediately or as soon as feasible after removal of gloves or other personal protective equipment. (d)(2)(vi) Employers shall ensure that employees wash hands and any other skin with soap and water, or flush mucous membranes with water immediately or as soon as feasible following contact of such body areas with blood or other potentially infectious materials. (d)(2)(vii) Contaminated needles and other contami- nated sharps shall not be bent, recapped, or removed except as noted in paragraphs (d)(2)(vii)(A) and (d)(2)(vii)(B) below. Shearing or breaking of contami- nated needles is prohibited. (d)(2)(vii)(A) Contaminated needles and other contaminated sharps shall not be bent, recapped or removed unless the employer can demonstrate that no alternative is feasible or that such action is required by a specific medical or dental procedure. (d)(2)(vii)(B) Such bending, recapping or needle removal must be accomplished through the use of a mechanical device or a one-handed technique. (d)(2)(viii) Immediately or as soon as possible after use, contaminated reusable sharps shall be placed in appropriate containers until properly reprocessed. These containers shall be: (d)(2)(viii)(A) puncture resistant; (d)(2)(viii)(B) labeled or color-coded in accordance with this standard; (d)(2)(viii)(C) leakproof on the sides and bottom; and (d)(2)(viii)(D) in accordance with the requirements set forth in paragraph (d)(4)(ii)(E) for reusable sharps (d)(2)(ix) Eating, drinking, smoking, applying cos- metics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure. (d)(2)(x) Food and drink shall not be kept in refrigera- tors, freezers, shelves, cabinets or on countertops or
  • 71. 68 benchtops where blood or other potentially infectious materials are present. (d)(2)(xi) All procedures involving blood or other po- tentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spatter- ing, and generation of droplets of these substances. (d)(2)(xii) Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited. (d)(2)(xiii) Specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage during collection, handling, process- ing, storage, transport, or shipping. (d)(2)(xiii)(A) The container for storage, transport, or shipping shall be labeled or color-coded according to paragraph (g)(1)(i) and closed prior to being stored, transported, or shipped. When a facility utilizes Univer- sal Precautions in the handling of all specimens, the labeling/color-coding of specimens is not necessary provided containers are recognizable as containing specimens. This exemption only applies while such specimens/containers remain within the facility. La- beling or color-coding in accordance with paragraph (g)(1)(i) is required when such specimens/containers leave the facility. (d)(2)(xiii)(B) If outside contamination of the primary container occurs, the primary container shall be placed within a second container which prevents leakage dur- ing handling, processing, storage, transport, or shipping and is labeled or color-coded according to the require- ments of this standard. (d)(2)(xiii)(C) If the specimen could puncture the pri- mary container, the primary container shall be placed within a secondary container which is puncture-resis- tant in addition to the above characteristics. (d)(2)(xiv) Equipment which may become contami- nated with blood or other potentially infectious materi- als shall be examined prior to servicing or shipping and shall be decontaminated as necessary, unless the employer can demonstrate that decontamination of such equipment or portions of such equipment is not feasible. (d)(2)(xiv)(A) A readily observable label in accor- dance with paragraph (g)(1)(i)(H) shall be attached to the equipment stating which portions remain con- taminated. (d)(2)(xiv)(B) The employer shall ensure that this information is conveyed to all affected employees, the servicing representative, and/or the manufacturer, as appropriate, prior to handling, servicing, or shipping so that appropriate precautions will be taken. (d)(3) Personal Protective Equipment - (d)(3)(i) Provision. When there is occupational ex- posure, the employer shall provide, at no cost to the employee, appropriate personal protective equipment such as, but not limited to, gloves, gowns, laboratory coats, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. Personal protective equip- ment will be considered “appropriate” only if it does not permit blood or other potentially infectious materials to pass through to or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used.(d)(3)(ii) Use. The employer shall ensure that the employee uses appropriate per- sonal protective equipment unless the employer shows that the employee temporarily and briefly declined to use personal protective equipment when, under rare and extraordinary circumstances, it was the employee’s professional judgment that in the specific instance its use would have prevented the delivery of health care or public safety services or would have posed an increased hazard to the safety of the worker or co- worker. When the employee makes this judgement, the circumstances shall be investigated and documented in order to determine whether changes can be instituted to prevent such occurrences in the future. (d)(3)(iii) Accessibility. The employer shall ensure that appropriate personal protective equipment in the appropriate sizes is readily accessible at the worksite or is issued to employees. Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided. (d)(3)(iv) Cleaning, Laundering, and Disposal. The employer shall clean, launder, and dispose of personal protective equipment required by paragraphs (d) and (e) of this standard, at no cost to the employee. (d)(3)(v) Repair and Replacement. The employer shall repair or replace personal protective equipment as needed to maintain its effectiveness, at no cost to the employee. (d)(3)(vi) If a garment(s) is penetrated by blood or other potentially infectious materials, the garment(s) shall be removed immediately or as soon as feasible. (d)(3)(vii) All personal protective equipment shall be removed prior to leaving the work area. (d)(3)(viii) When personal protective equipment is re- moved it shall be placed in an appropriately designated
  • 72. 69 area or container for storage, washing, decontamina- tion or disposal. (d)(3)(ix) Gloves. Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, and non-intact skin; when performing vascular access procedures except as specified in paragraph (d)(3)(ix)(D); and when handling or touching contaminated items or surfaces. (d)(3)(ix)(A) Disposable (single use) gloves such as surgical or examination gloves, shall be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised. (d)(3)(ix)(B) Disposable (single use) gloves shall not be washed or decontaminated for re-use. (d)(3)(ix)(C) Utility gloves may be decontaminated for re-use if the integrity of the glove is not compromised. However, they must be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of de- terioration or when their ability to function as a barrier is compromised. (d)(3)(ix)(D) If an employer in a volunteer blood dona- tion center judges that routine gloving for all phleboto- mies is not necessary then the employer shall: (d)(3)(ix)(D)(1) Periodically reevaluate this policy; (d)(3)(ix)(D)(2) Make gloves available to all employ- ees who wish to use them for phlebotomy; (d)(3)(ix)(D)(3) Not discourage the use of gloves for phlebotomy; and (d)(3)(ix)(D)(4) Require that gloves be used for phle- botomy in the following circumstances: (d)(3)(ix)(D)(4)(i) When the employee has cuts, scratches, or other breaks in his or her skin; (d)(3)(ix)(D)(4)(ii) When the employee judges that hand contamination with blood may occur, for example, when performing phlebotomy on an uncooperative source individual; and (d)(3)(ix)(D)(4)(iii) When the employee is receiving training in phlebotomy. (d)(3)(ix)(D)(4)(ii) When the employee judges that hand contamination with blood may occur, for example, when performing phlebotomy on an uncooperative source individual; and (d)(3)(ix)(D)(4)(iii) When the employee is receiving training in phlebotomy. (d)(3)(x) Masks, Eye Protection, and Face Shields. Masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated. (d)(3)(xi) Gowns, Aprons, and Other Protective Body Clothing. Appropriate protective clothing such as, but not limited to, gowns, aprons, lab coats, clinic jackets, or similar outer garments shall be worn in occupational exposure situations. The type and characteristics will depend upon the task and degree of exposure antici- pated. (d)(3)(xii) Surgical caps or hoods and/or shoe cov- ers or boots shall be worn in instances when gross contamination can reasonably be anticipated (e.g., autopsies, orthopaedic surgery). (d)(4) Housekeeping - (d)(4)(i) General. Employers shall ensure that the worksite is maintained in a clean and sanitary condi- tion. The employer shall determine and implement an appropriate written schedule for cleaning and method of decontamination based upon the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed in the area. (d)(4)(ii) All equipment and environmental and work- ing surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials. (d)(4)(ii)(A) Contaminated work surfaces shall be decontaminated with an appropriate disinfectant after completion of procedures; immediately or as soon as feasible when surfaces are overtly contaminated or after any spill of blood or other potentially infectious materials; and at the end of the work shift if the sur- face may have become contaminated since the last cleaning. (d)(4)(ii)(B) Protective coverings, such as plastic wrap, aluminum foil, or imperviously-backed absorbent paper used to cover equipment and environmental surfaces, shall be removed and replaced as soon as feasible when they become overtly contaminated or at the end of the workshift if they may have become contaminated during the shift. (d)(4)(ii)(C) All bins, pails, cans, and similar recep- tacles intended for reuse which have a reasonable likelihood for becoming contaminated with blood or other potentially infectious materials shall be inspected
  • 73. 70 and decontaminated on a regularly scheduled basis and cleaned and decontaminated immediately or as soon as feasible upon visible contamination. (d)(4)(ii)(D) Broken glassware which may be contami- nated shall not be picked up directly with the hands. It shall be cleaned up using mechanical means, such as a brush and dust pan, tongs, or forceps.(d)(4)(ii)(E) Reusable sharps that are contaminated with blood or other potentially infectious materials shall not be stored or processed in a manner that requires employees to reach by hand into the containers where these sharps have been placed. (d)(4)(iii) Regulated Waste— (d)(4)(iii)(A) Contaminated Sharps Discarding and Containment. (d)(4)(iii)(A)(1) Contaminated sharps shall be dis- carded immediately or as soon as feasible in contain- ers that are: (d)(4)(iii)(A)(1)(i) Closable; (d)(4)(iii)(A)(1)(ii) Puncture resistant; (d)(4)(iii)(A)(1)(iii) Leakproof on sides and bottom; and (d)(4)(iii)(A)(1)(iv) Labeled or color-coded in accor- dance with paragraph (g)(1)(i) of this standard. (d)(4)(iii)(A)(2) During use, containers for contami- nated sharps shall be: (d)(4)(iii)(A)(2)(i) Easily accessible to personnel and located as close as is feasible to the immediate area where sharps are used or can be reasonably antici- pated to be found (e.g., laundries); (d)(4)(iii)(A)(2)(ii) Maintained upright throughout use; and (d)(4)(iii)(A)(2)(iii) Replaced routinely and not be al- lowed to overfill. (d)(4)(iii)(A)(3) When moving containers of con- taminated sharps from the area of use, the containers shall be: (d)(4)(iii)(A)(3)(i) Closed immediately prior to removal or replacement to prevent spillage or protrusion of con- tents during handling, storage, transport, or shipping; (d)(4)(iii)(A)(3)(ii) Placed in a secondary container if leakage is possible. The second container shall be: (d)(4)(iii)(A)(3)(ii)(A) Closable; (d)(4)(iii)(A)(3)(ii)(B) Constructed to contain all con- tents and prevent leakage during handling, storage, transport, or shipping; and (d)(4)(iii)(A)(3)(ii)(C) Labeled or color-coded accord- ing to paragraph (g)(1)(i) of this standard. (d)(4)(iii)(A)(4) Reusable containers shall not be opened, emptied, or cleaned manually or in any other manner which would expose employees to the risk of percutaneous injury. (d)(4)(iii)(B) Other Regulated Waste Containment - (d)(4)(iii)(B)(1) Regulated waste shall be placed in containers which are: (d)(4)(iii)(B)(1)(i) Closable; (d)(4)(iii)(B)(1)(ii) Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping; (d)(4)(iii)(B)(1)(iii) Labeled or color-coded in accor- dance with paragraph (g)(1)(i) this standard; and (d)(4)(iii)(B)(1)(iv) Closed prior to removal to prevent spillage or protrusion of contents during handling, stor- age, transport, or shipping.(d)(4)(iii)(B)(2) If outside contamination of the regulated waste container occurs, it shall be placed in a second container. The second container shall be: (d)(4)(iii)(B)(2)(i) Closable; (d)(4)(iii)(B)(2)(ii) Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping; (d)(4)(iii)(B)(2)(iii) Labeled or color-coded in accor- dance with paragraph (g)(1)(i) of this standard; and (d)(4)(iii)(B)(2)(iv) Closed prior to removal to prevent spillage or protrusion of contents during handling, stor- age, transport, or shipping. (d)(4)(iii)(C) Disposal of all regulated waste shall be in accordance with applicable regulations of the United States, States and Territories, and political subdivisions of States and Territories. (d)(4)(iv) Laundry. (d)(4)(iv)(A) Contaminated laundry shall be handled as little as possible with a minimum of agitation. (d)(4)(iv)(A)(1) Contaminated laundry shall be bagged or containerized at the location where it was used and shall not be sorted or rinsed in the location of use. (d)(4)(iv)(A)(2) Contaminated laundry shall be placed and transported in bags or containers labeled or color- coded in accordance with paragraph (g)(1)(i) of this standard. When a facility utilizes Universal Precautions in the handling of all soiled laundry, alternative labeling or color-coding is sufficient if it permits all employees to recognize the containers as requiring compliance
  • 74. 71 with Universal Precautions. (d)(4)(iv)(A)(3) Whenever contaminated laundry is wet and presents a reasonable likelihood of soak- through of or leakage from the bag or container, the laundry shall be placed and transported in bags or containers which prevent soak-through and/or leakage of fluids to the exterior. (d)(4)(iv)(B) The employer shall ensure that em- ployees who have contact with contaminated laundry wear protective gloves and other appropriate personal protective equipment. (d)(4)(iv)(C) When a facility ships contaminated laun- dry off-site to a second facility which does not utilize Universal Precautions in the handling of all laundry, the facility generating the contaminated laundry must place such laundry in bags or containers which are labeled or color-coded in accordance with paragraph (g)(1)(i). (e) HIV and HBV Research Laboratories and Production Facilities. (e)(1) This paragraph applies to research laboratories and production facilities engaged in the culture, produc- tion, concentration, experimentation, and manipulation of HIV and HBV. It does not apply to clinical or diag- nostic laboratories engaged solely in the analysis of blood, tissues, or organs. These requirements apply in addition to the other requirements of the standard. (e)(2) Research laboratories and production facilities shall meet the following criteria: (e)(2)(i) Standard Microbiological Practices. All regulated waste shall either be incinerated or decon- taminated by a method such as autoclaving known to effectively destroy bloodborne pathogens. (e)(2)(ii) Special Practices. (e)(2)(ii)(A) Laboratory doors shall be kept closed when work involving HIV or HBV is in progress. (e)(2)(ii)(B) Contaminated materials that are to be decontaminated at a site away from the work area shall be placed in a durable, leakproof, labeled or color- coded container that is closed before being removed from the work area. (e)(2)(ii)(C) Access to the work area shall be limited to authorized persons. Written policies and procedures shall be established whereby only persons who have been advised of the potential biohazard, who meet any specific entry requirements, and who comply with all entry and exit procedures shall be allowed to enter the work areas and animal rooms. (e)(2)(ii)(D) When other potentially infectious materi- als or infected animals are present in the work area or containment module, a hazard warning sign incorporat- ing the universal biohazard symbol shall be posted on all access doors. The hazard warning sign shall comply with paragraph (g)(1)(ii) of this standard. (e)(2)(ii)(E) All activities involving other potentially infectious materials shall be conducted in biological safety cabinets or other physical-containment devices within the containment module. No work with these other potentially infectious materials shall be conducted on the open bench. (e)(2)(ii)(F) Laboratory coats, gowns, smocks, uni- forms, or other appropriate protective clothing shall be used in the work area and animal rooms. Protective clothing shall not be worn outside of the work area and shall be decontaminated before being laundered. (e)(2)(ii)(G) Special care shall be taken to avoid skin contact with other potentially infectious materials. Gloves shall be worn when handling infected animals and when making hand contact with other potentially infectious materials is unavoidable. (e)(2)(ii)(H) Before disposal all waste from work ar- eas and from animal rooms shall either be incinerated or decontaminated by a method such as autoclaving known to effectively destroy bloodborne pathogens. (e)(2)(ii)(I) Vacuum lines shall be protected with liquid disinfectant traps and high-efficiency particulate air (HEPA) filters or filters of equivalent or superior effi- ciency and which are checked routinely and maintained or replaced as necessary. (e)(2)(ii)(J) Hypodermic needles and syringes shall be used only for parenteral injection and aspiration of fluids from laboratory animals and diaphragm bottles. Only needle-locking syringes or disposable syringe-needle units (i.e., the needle is integral to the syringe) shall be used for the injection or aspiration of other potentially infectious materials. Extreme caution shall be used when handling needles and syringes. A needle shall not be bent, sheared, replaced in the sheath or guard, or removed from the syringe following use. The needle and syringe shall be promptly placed in a puncture- resistant container and autoclaved or decontaminated before reuse or disposal. (e)(2)(ii)(K) All spills shall be immediately contained and cleaned up by appropriate professional staff or others properly trained and equipped to work with po- tentially concentrated infectious materials. (e)(2)(ii)(L) A spill or accident that results in an expo- sure incident shall be immediately reported to the labo-
  • 75. 72 ratory director or other responsible person.(e)(2)(ii)(M) A biosafety manual shall be prepared or adopted and periodically reviewed and updated at least annually or more often if necessary. Personnel shall be advised of potential hazards, shall be required to read instructions on practices and procedures, and shall be required to follow them. (e)(2)(iii) Containment Equipment. (e)(2)(iii)(A) Certified biological safety cabinets (Class I, II, or III) or other appropriate combinations of personal protection or physical containment devices, such as special protective clothing, respirators, centrifuge safety cups, sealed centrifuge rotors, and containment caging for animals, shall be used for all activities with other potentially infectious materials that pose a threat of exposure to droplets, splashes, spills, or aerosols. (e)(2)(iii)(B) Biological safety cabinets shall be certi- fied when installed, whenever they are moved and at least annually. (e)(3) HIV and HBV research laboratories shall meet the following criteria: (e)(3)(i) Each laboratory shall contain a facility for hand washing and an eye wash facility which is readily available within the work area. (e)(3)(ii) An autoclave for decontamination of regu- lated waste shall be available. (e)(4) HIV and HBV production facilities shall meet the following criteria: (e)(4)(i) The work areas shall be separated from ar- eas that are open to unrestricted traffic flow within the building. Passage through two sets of doors shall be the basic requirement for entry into the work area from access corridors or other contiguous areas. Physical separation of the high-containment work area from access corridors or other areas or activities may also be provided by a double-doored clothes-change room (showers may be included), airlock, or other access facility that requires passing through two sets of doors before entering the work area. (e)(4)(ii) The surfaces of doors, walls, floors and ceilings in the work area shall be water resistant so that they can be easily cleaned. Penetrations in these surfaces shall be sealed or capable of being sealed to facilitate decontamination. (e)(4)(iii) Each work area shall contain a sink for washing hands and a readily available eye wash fa- cility. The sink shall be foot, elbow, or automatically operated and shall be located near the exit door of the work area. (e)(4)(iv) Access doors to the work area or contain- ment module shall be self-closing. (e)(4)(v) An autoclave for decontamination of regu- lated waste shall be available within or as near as possible to the work area. (e)(4)(vi) A ducted exhaust-air ventilation system shall be provided. This system shall create directional airflow that draws air into the work area through the entry area. The exhaust air shall not be recirculated to any other area of the building, shall be discharged to the outside, and shall be dispersed away from occupied areas and air intakes. The proper direction of the airflow shall be verified (i.e., into the work area). (e)(5) Training Requirements. Additional training requirements for employees in HIV and HBV research laboratories and HIV and HBV production facilities are specified in paragraph (g)(2)(ix). (f) Hepatitis B Vaccination and Post-expo- sure Evaluation and Follow-up (f)(1) General.(f)(1)(i) The employer shall make avail- able the hepatitis B vaccine and vaccination series to all employees who have occupational exposure, and post-exposure evaluation and follow-up to all employ- ees who have had an exposure incident. (f)(1)(ii) The employer shall ensure that all medical evaluations and procedures including the hepatitis B vaccine and vaccination series and post-exposure evaluation and follow-up, including prophylaxis, are: (f)(1)(ii)(A) Made available at no cost to the em- ployee; (f)(1)(ii)(B) Made available to the employee at a reasonable time and place; (f)(1)(ii)(C) Performed by or under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional; and (f)(1)(ii)(D) Provided according to recommendations of the U.S. Public Health Service current at the time these evaluations and procedures take place, except as specified by this paragraph (f). (f)(1)(iii) The employer shall ensure that all laboratory tests are conducted by an accredited laboratory at no cost to the employee. (f)(2) Hepatitis B Vaccination. (f)(2)(i) Hepatitis B vaccination shall be made avail- able after the employee has received the training required
  • 76. 73 in paragraph (g)(2)(vii)(I) and within 10 working days of initial assignment to all employees who have occu- pational exposure unless the employee has previously received the complete hepatitis B vaccination series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons. (f)(2)(ii) The employer shall not make participation in a prescreening program a prerequisite for receiving hepatitis B vaccination. (f)(2)(iii) If the employee initially declines hepatitis B vaccination but at a later date while still covered under the standard decides to accept the vaccination, the employer shall make available hepatitis B vaccination at that time. (f)(2)(iv) The employer shall assure that employees who decline to accept hepatitis B vaccination offered by the employer sign the statement in Appendix A. (f)(2)(v) If a routine booster dose(s) of hepatitis B vac- cine is recommended by the U.S. Public Health Service at a future date, such booster dose(s) shall be made available in accordance with section (f)(1)(ii). (f)(3) Post-exposure Evaluation and Follow-up. Fol- lowing a report of an exposure incident, the employer shall make immediately available to the exposed em- ployee a confidential medical evaluation and follow-up, including at least the following elements: (f)(3)(i) Documentation of the route(s) of exposure, and the circumstances under which the exposure in- cident occurred; (f)(3)(ii) Identification and documentation of the source individual, unless the employer can establish that identification is infeasible or prohibited by state or local law; (f)(3)(ii)(A) The source individual’s blood shall be tested as soon as feasible and after consent is obtained in order to determine HBV and HIV infectivity. If consent is not obtained, the employer shall establish that legally required consent cannot be obtained. When the source individual’s consent is not required by law, the source individual’s blood, if available, shall be tested and the results documented. (f)(3)(ii)(B) When the source individual is already known to be infected with HBV or HIV, testing for the source individual’s known HBV or HIV status need not be repeated.(f)(3)(ii)(C) Results of the source individual’s testing shall be made available to the ex- posed employee, and the employee shall be informed of applicable laws and regulations concerning disclo- sure of the identity and infectious status of the source individual. (f)(3)(iii) Collection and testing of blood for HBV and HIV serological status; (f)(3)(iii)(A) The exposed employee’s blood shall be collected as soon as feasible and tested after consent is obtained. (f)(3)(iii)(B) If the employee consents to baseline blood collection, but does not give consent at that time for HIV serologic testing, the sample shall be preserved for at least 90 days. If, within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing shall be done as soon as feasible. (f)(3)(iv) Post-exposure prophylaxis, when medically indicated, as recommended by the U.S. Public Health Service; (f)(3)(v) Counseling; and (f)(3)(vi) Evaluation of reported illnesses. (f)(4) Information Provided to the Healthcare Profes- sional. (f)(4)(i) The employer shall ensure that the healthcare professional responsible for the employee’s Hepatitis B vaccination is provided a copy of this regulation. (f)(4)(ii) The employer shall ensure that the healthcare professional evaluating an employee after an exposure incident is provided the following information: (f)(4)(ii)(A) A copy of this regulation; (f)(4)(ii)(B) A description of the exposed employee’s duties as they relate to the exposure incident; (f)(4)(ii)(C) Documentation of the route(s) of exposure and circumstances under which exposure occurred; (f)(4)(ii)(D) Results of the source individual’s blood testing, if available; and (f)(4)(ii)(E) All medical records relevant to the ap- propriate treatment of the employee including vac- cination status which are the employer’s responsibility to maintain. (f)(5) Healthcare Professional’s Written Opinion. The employer shall obtain and provide the employee with a copy of the evaluating healthcare professional’s written opinion within 15 days of the completion of the evaluation. (f)(5)(i) The healthcare professional’s written opinion for Hepatitis B vaccination shall be limited to whether Hepatitis B vaccination is indicated for an employee, and if the employee has received such vaccination.
  • 77. 74 (f)(5)(ii) The healthcare professional’s written opinion for post-exposure evaluation and follow-up shall be limited to the following information: (f)(5)(ii)(A) That the employee has been informed of the results of the evaluation; and (f)(5)(ii)(B) That the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment. (f)(5)(iii) All other findings or diagnoses shall remain confidential and shall not be included in the written report. (f)(6) Medical Recordkeeping. Medical records required by this standard shall be maintained in ac- cordance with paragraph (h)(1) of this section. (g) Communication of Hazards to Employees (g)(1) Labels and Signs -(g)(1)(i) Labels. (g)(1)(i)(A) Warning labels shall be affixed to con- tainers of regulated waste, refrigerators and freezers containing blood or other potentially infectious material; and other containers used to store, transport or ship blood or other potentially infectious materials, except as provided in paragraph (g)(1)(i)(E), (F) and (G). (g)(1)(i)(B) Labels required by this section shall in- clude the following legend: (g)(1)(i)(C) These labels shall be fluorescent orange or orange-red or predominantly so, with lettering and symbols in a contrasting color. (g)(1)(i)(D) Labels shall be affixed as close as feasible to the container by string, wire, adhesive, or other method that prevents their loss or unintentional removal. (g)(1)(i)(E) Red bags or red containers may be sub- stituted for labels. (g)(1)(i)(F) Containers of blood, blood components, or blood products that are labeled as to their contents and have been released for transfusion or other clini- cal use are exempted from the labeling requirements of paragraph (g). (g)(1)(i)(G) Individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage, transport, shipment or disposal are exempted from the labeling require- ment. (g)(1)(i)(H) Labels required for contaminated equip- ment shall be in accordance with this paragraph and shall also state which portions of the equipment remain contaminated. (g)(1)(i)(I) Regulated waste that has been decontami- nated need not be labeled or color-coded. (g)(1)(ii) Signs. (g)(1)(ii)(A) The employer shall post signs at the entrance to work areas specified in paragraph (e), HIV and HBV Research Laboratory and Production Facili- ties, which shall bear the following legend: (Name of the Infectious Agent) (Special requirements for entering the area) (name, telephone number of the laboratory director or other responsible person.) (g)(1)(ii)(B) These signs shall be fluorescent orange- red or predominantly so, with lettering and symbols in a contrasting color. (g)(2) Information and Training. (g)(2)(i) Employers shall ensure that all employees with occupational exposure participate in a training program which must be provided at no cost to the employee and during working hours. (g)(2)(ii) Training shall be provided as follows: (g)(2)(ii)(A) At the time of initial assignment to tasks where occupational exposure may take place; (g)(2)(ii)(B) Within 90 days after the effective date of the standard; and (g)(2)(ii)(C) At least annually thereafter. (g)(2)(iii) For employees who have received training on bloodborne pathogens in the year preceding the ef- fective date of the standard, only training with respect to the provisions of the standard which were not included need be provided. (g)(2)(iv) Annual training for all employees shall be provided within one year of their previous training. (g)(2)(v) Employers shall provide additional train- ing when changes such as modification of tasks or procedures or institution of new tasks or procedures affect the employee’s occupational exposure. The ad- ditional training may be limited to addressing the new exposures created. (g)(2)(vi) Material appropriate in content and vo- cabulary to educational level, literacy, and language of employees shall be used. (g)(2)(vii) The training program shall contain at a minimum the following elements: (g)(2)(vii)(A) An accessible copy of the regulatory text of this standard and an explanation of its contents;
  • 78. 75 (g)(2)(vii)(B) A general explanation of the epidemiol- ogy and symptoms of bloodborne diseases; (g)(2)(vii)(C) An explanation of the modes of trans- mission of bloodborne pathogens; (g)(2)(vii)(D) An explanation of the employer’s expo- sure control plan and the means by which the employee can obtain a copy of the written plan; (g)(2)(vii)(E) An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials; (g)(2)(vii)(F) An explanation of the use and limitations of methods that will prevent or reduce exposure includ- ing appropriate engineering controls, work practices, and personal protective equipment; (g)(2)(vii)(G) Information on the types, proper use, location, removal, handling, decontamination and dis- posal of personal protective equipment; (g)(2)(vii)(H) An explanation of the basis for selection of personal protective equipment; (g)(2)(vii)(I) Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge; (g)(2)(vii)(J) Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials; (g)(2)(vii)(K) An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available; (g)(2)(vii)(L) Information on the post-exposure evalu- ation and follow-up that the employer is required to pro- vide for the employee following an exposure incident; (g)(2)(vii)(M) An explanation of the signs and labels and/or color coding required by paragraph (g)(1); and (g)(2)(vii)(N) An opportunity for interactive questions and answers with the person conducting the training session. (g)(2)(viii) The person conducting the training shall be knowledgeable in the subject matter covered by the elements contained in the training program as it relates to the workplace that the training will address. (g)(2)(ix) Additional Initial Training for Employees in HIV and HBV Laboratories and Production Facilities. Employees in HIV or HBV research laboratories and HIV or HBV production facilities shall receive the fol- lowing initial training in addition to the above training requirements.(g)(2)(ix)(A) The employer shall assure that employees demonstrate proficiency in standard microbiological practices and techniques and in the practices and operations specific to the facility before being allowed to work with HIV or HBV. (g)(2)(ix)(B) The employer shall assure that employ- ees have prior experience in the handling of human pathogens or tissue cultures before working with HIV or HBV. (g)(2)(ix)(C) The employer shall provide a training program to employees who have no prior experience in handling human pathogens. Initial work activities shall not include the handling of infectious agents. A progression of work activities shall be assigned as techniques are learned and proficiency is developed. The employer shall assure that employees participate in work activities involving infectious agents only after proficiency has been demonstrated. (h) Recordkeeping (h)(1) Medical Records. (h)(1)(i) The employer shall establish and maintain an accurate record for each employee with occupational exposure, in accordance with 29 CFR 1910.1020. (h)(1)(ii) This record shall include: (h)(1)(ii)(A) The name and social security number of the employee; (h)(1)(ii)(B) A copy of the employee’s hepatitis B vac- cination status including the dates of all the hepatitis B vaccinations and any medical records relative to the employee’s ability to receive vaccination as required by paragraph (f)(2); (h)(1)(ii)(C) A copy of all results of examinations, medical testing, and follow-up procedures as required by paragraph (f)(3); (h)(1)(ii)(D) The employer’s copy of the healthcare professional’s written opinion as required by paragraph (f)(5); and (h)(1)(ii)(E) A copy of the information provided to the healthcare professional as required by paragraphs (f)(4)(ii)(B)(C) and (D). (h)(1)(iii) Confidentiality. The employer shall ensure that employee medical records required by paragraph (h)(1) are: (h)(1)(iii)(A) Kept confidential; and (h)(1)(iii)(B) Not disclosed or reported without the
  • 79. 76 employee’s express written consent to any person within or outside the workplace except as required by this section or as may be required by law. (h)(1)(iv) The employer shall maintain the records required by paragraph (h) for at least the duration of employment plus 30 years in accordance with 29 CFR 1910.1020. (h)(2) Training Records. (h)(2)(i) Training records shall include the following information: (h)(2)(i)(A) The dates of the training sessions; (h)(2)(i)(B) The contents or a summary of the train- ing sessions; (h)(2)(i)(C) The names and qualifications of persons conducting the training; and (h)(2)(i)(D) The names and job titles of all persons attending the training sessions. (h)(2)(ii) Training records shall be maintained for 3 years from the date on which the training occurred. (h)(3) Availability.(h)(3)(i) The employer shall en- sure that all records required to be maintained by this section shall be made available upon request to the Assistant Secretary and the Director for examination and copying. (h)(3)(ii) Employee training records required by this paragraph shall be provided upon request for examination and copying to employees, to employee representatives, to the Director, and to the Assistant Secretary. (h)(3)(iii) Employee medical records required by this paragraph shall be provided upon request for examina- tion and copying to the subject employee, to anyone having written consent of the subject employee, to the Director, and to the Assistant Secretary in accordance with 29 CFR 1910.1020. (h)(4) Transfer of Records. (h)(4)(i) The employer shall comply with the require- ments involving transfer of records set forth in 29 CFR 1910.1020(h). (h)(4)(ii) If the employer ceases to do business and there is no successor employer to receive and retain the records for the prescribed period, the employer shall notify the Director, at least three months prior to their disposal and transmit them to the Director, if required by the Director to do so, within that three month period. (h)(5) Sharps Injury Log. (h)(5)(i) The employer shall establish and maintain a sharps injury log for the recording of percutaneous injuries from contaminated sharps. The information in the sharps injury log shall be recorded and maintained in such manner as to protect the confidentiality of the injured employee. The sharps injury log shall contain, at a minimum: (h)(5)(i)(A) the type and brand of device involved in the incident, (h)(5)(i)(B) the department or work area where the exposure incident occurred, and (h)(5)(i)(C) an explanation of how the incident oc- curred. (h)(5)(ii) The requirement to establish and maintain a sharps injury log shall apply to any employer who is required to maintain a log of occupational injuries and illnesses under 29 CFR 1904. (h)(5)(iii) The sharps injury log shall be maintained for the period required by 29 CFR 1904.6. (i) Dates (i)(1) Effective Date. The standard shall become effec- tive on March 6, 1992. (i)(2) The Exposure Control Plan required by para- graph (c) of this section shall be completed on or before May 5, 1992. (i)(3) Paragraph (g)(2) Information and Training and (h) Recordkeeping shall take effect on or before June 4, 1992. (i)(4) paragraphs (d)(2) Engineering and Work Prac- tice Controls, (d)(3) Personal Protective Equipment, (d)(4) Housekeeping, (e) HIV and HBV Research Laboratories and Production Facilities, (f) Hepatitis B Vaccination and Post-Exposure Evaluation and Fol- low-up, and (g)(1) Labels and Signs, shall take effect July 6, 1992.
  • 80. 77 I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B Virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline the Hepatitis B vaccination at this time. I under- stand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me. Employee Signature __________________________________ Date ______________________________________________ Employer Signature __________________________________ Date ______________________________________________ APPENDIX B HEPATITIS B VACCINE DECLINATION (MANDATORY)
  • 81. 78
  • 82. 79 APPLICATIONS FOR MEMBERSHIP MEMBERSHIP TYPES AND ELIGIBILITY CRITERIA: Professional Business Member* Works full time as a piercer and has more than one year of professional experience. Must meet both personal and environmental membership criteria. Professional Member at Large*Professional Member at Large* Pierces part time or periodically at more than one studio and has been a professional business member for more than three years. Must meet personal and environmental membership criteria at all studios. Associate Member* Has less than one year of professional experience, or is a non-piercer working in a pierc- ing establishment. If working as a piercer, personal and environmental criteria must be met. If working as a non-piercer, environmental criteria must be met. Associate membership will be valid only in a studio currently employing at least one professional business member. Corporate Associate MemberCorporate Associate Member An entity or individual working in a field or providing a service that is associated with the application of body piercing. Examples of Corporate Associate Members are jewelry manufacturers, medical suppliers, insurers, educators, etc. Applicants must contact the current Secretary for a list of criteria. Patron Member An individual who supports the APP and its goals but is not actively involved in the body pierc- ing industry. This membership may not be used for the promotion of any form of piercing services, jewelry sales or web services. Dues are the only requirement for this membership. *International Member A subdivision of memberships for piercers or non-piercers working in the piercing in- dustry outside of the United States of America. International personal criteria differs slightly from the standard to accommodate for classes and training available, among other continental differences. MEMBERSHIP DUES: Professional Business Member & Professional Member At Large $150.00 ($50.00 annual renewal) Associate Member $100.00 ($50.00 annual renewal) Corporate Associate Member $200.00 ($200.00 annual renewal) Patron $50.00 ($50.00 annual renewal) Dues are billed upon acceptance. DO NOT SEND them with your application; DO SEND a non-refundable $25.00 processing fee per video. One video is required per studio. The Association of Professional Piercers Attn: Secretary 2132 A Central Ave SE #285 Albuquerque, NM 87106 If you have any questions about your application, the current Secretary can be reached at, or call 1-888-888-1APP or 1-505-242-2144. PLEASE ALLOW 6-8 WEEKS FOR PROCESSING 03/05 APPENDIX C
  • 83. 80 APPLICATION FOR PATRON MEMBERSHIP A patron member is someone not actively involved in the body piercing industry, but supports the APP and it’s goals. This membership may not be used for the promotion of any form of piercing services, jewelry or web services. Dues are the only requirement for this type of membership. Patron membership dues are $50 ($50 annual renewal). Please submit completed application to: The Association of Professional Piercers Attn: Secretary 2132 A Central Ave SE #285 Albuquerque, NM 87106 If you have any questions about your application, the current Secretary can be reached at, or call 1-888-888-1APP or 1-505-242-2144. Name _________________________________________________________________________________ Name of Business (if applicable)____________________________________________________________ Address_______________________________________________________________________________ City, State, Zip__________________________________________________________________________ Phone________________________________________ Fax_____________________________________ Email_________________________________________________________________________________ Signature of Applicant ______________________________________________ Date ________________ By my signature above I certify that I have read and I agree to the terms of this application. PLEASE ALLOW 6-8 WEEKS FOR PROCESSING 04/05
  • 84. 81 CORPORATE ASSOCIATE MEMBERSHIP APPLICATION Corporate Associate Member Is an entity or individual working in a field or providing a service that is associated with the application of body piercing. Examples of Corporate Associate Members are jewelry manufacturers, medical suppliers, insurers, educators, etc. Corporate Associate Membership dues are $200.00 ($200.00 annual renewal). Dues are billed upon acceptance. DO NOT SEND them with your application. Please submit completed application to: The Association of Professional Piercers Attn: Secretary 2132 A Central Ave SE #285 Albuquerque, NM 87106 If you have any questions about your application, the current Secretary can be reached at, or call 1-888-888-1APP or 1-505-242-2144. Name of Company______________________________________________________________________ Name of Contact ________________________________________________________________________ Company Address_______________________________________________________________________ City, State, Zip__________________________________________________________________________ Phone________________________________________ Fax_____________________________________ Website _______________________________________________________________________________ Email__________________________________________________________________________________ Would you like your email address on our website? qYes qNo Please include the following documentation: q A completed copy of this application form. q Letter of intent, requesting membership and outlining in what way your company is relevant to body piercing. q Business documentation: business license or other items verifying the company or group as an entity. q Signed logo usage agreement. (The term ‘license’ in this agreement refers only to the use of the logo, your company may not claim to be ‘APP licensed’). continued…
  • 85. 82 CORPORATE ASSOCIATE MEMBERSHIP APPLICATION CONT. THE FOLLOWING CRITERIA MUST BE INCLUDED FOR WHOLESALE JEWELRY DISTRIBUTORS: q Catalog or brochure. q Mill specs for all gauges of steel and Titanium wire, balls, and bar. q MSDS sheets for Gold and Niobium. q Samples, disassembled, of the following: • 3 14 gauge 1/2” steel captive bead rings w/steel balls • 3 14 gauge 1/2” titanium captive bead rings w/titanium balls • 3 12 gauge steel barbells • 3 12 gauge titanium barbells Independent metal testing may be conducted by the APP at any time to verify provided documentation. This will be at your expense, approximate cost is $300- $500. THE FOLLOWING CRITERIA MUST BE INCLUDED FOR AFTERCARE PRODUCT DISTRIBUTORS: q MSDS sheets for all aftercare products being distributed. Results of extensive clinical studies performed by one or more independent laboratory or other documentation may be requested. THE FOLLOWING CRITERIA MUST BE INCLUDED FOR EDUCATORS: q Qualifications of the class instructor(s). q A copy of the class curriculum. q Copies of all handouts, workbooks or materials given to class participants. q A voided copy of any certificates or awards given upon course completion*. *Certificates distributed for piercer training must state the number of hours or days the course took to complete, and that completion of the course does not claim that the participant is certified or licensed to pierce. OTHER INDUSTRY SPECIFIC CRITERIA MAY BE REQUESTED ON AN INDIVIDUAL BASIS. Signature of Applicant ______________________________________________ Date ________________ By my signature above I certify that I have read and I agree to the terms of this application. 04/05
  • 86. 83 PROFESSIONAL BUSINESS/ASSOCIATE MEMBERSHIP APPLICATION Type of APP Membership desired (please check one): q Professional Business Member q Professional Business Member at Large q Associate Member – Piercer q Associate Member- Non Piercer Name of Applicant________________________________________________________________________ Studio & Address_________________________________________________________________________ City__________________________________________ Country __________________________________ Studio Phone___________________________________ Fax _____________________________________ Home Address___________________________________________________________________________ Phone_________________________________________ Website _________________________________ qYes qNo Would you like your email address on our website? Email_______________________________ THE FOLLOWING PERSONAL CRITERIA MUST BE INCLUDED FOR EACH PIERCER APPLYING: q A completed copy of this application form. q A completed questionnaire, preferably typewritten. q A copy of current CPR certification or equivalent training. q A copy of current First Aid certification or equivalent training. q A copy of current Bloodborne Pathogen Training Certificate or equivalent training (to be renewed annually regardless of expiration date). q Signed Health and Safety Agreement. q Signed Logo Usage Agreement q Proof of how long piercer has been piercing professionally. A notarized statement,* dated business document, or news- paper article are examples of appropriate proof. *If a notarized statement is submitted as proof, it must come from a party other than the applicant. THE FOLLOWING ENVIRONMENTAL CRITERIA MUST BE INCLUDED UNLESS ENVIRONMENTAL CRITERIA HAS BEEN SUBMITTED WITHIN THE LAST YEAR**: q A walk through 360 degree video of applicant’s entire studio including store front, foyer, piercing room(s), biohazard area, sterilization area, restroom, inside all drawers, closets, and all other spaces. Narration is appreciated. q $25 processing fee per video. One video is required per studio. VHS or DVD (region 1) are the preferred video formats. Other video formats may require additional time to process and any fees incurred for video transferring will be charged to applicants. Please contact the current Secretary for more information. q Photograph of all applicant’s autoclaves with make, model and serial number printed on the back of photo Autoclaves should be medical grade with a dry cycle. q Copy of two most recent spore test results from all autoclaves in use. q Copies of all release forms in use at applicant’s studio. q Copies of all aftercare information distributed at applicant’s studio. q Copy of studio’s business license. q Business card. q One or more samples of applicant’s advertising. **Any and all materials should be updated voluntarily by the member if significant changes are made in the environment, advertising, equipment, aftercare etc. These updates to the member’s file should be done at the time any changes are made. As an Applicant to the Association of Professional Piercers (APP), I understand that my video tape (and other materials) becomes the property of the APP. I hereby release the APP and/or its legal representatives and assigns, the irrevocable and unrestricted right to use these materials for education, training, and for any other purpose and in any manner and medium. I hereby release the APP and its legal representatives and assigns from all claims and liability relating to said tapes and materials. Signature of Applicant ______________________________________________ Date ________________ By my signature above I certify that I have read and I agree to the terms of this application.
  • 87. 84 “WALK THROUGH 360° VIDEO” CRITERIA Revised 03/2005 The purpose of submitting a walk through 360° video with your membership application is to help us determine the level of health and safety awareness in your studio. We look for the criteria on this list, and also note anything that may be a potential hazard to clients or staff. Items that are required for membership have been labeled as such. Other items are strong suggestions that are not required for membership of themselves, however the studio that lacks several of these may not be operating at the level that is desired of APP members. FRONT COUNTER/DISPLAY AREA q REQUIRED FOR MEMBERSHIP: The counter surface should be glass, metal, or other non-porous surface that can be disinfected several times each day. q Gloves and disposable products to prevent cross-contamination should be kept at the front counter area. BIOHAZARD/STERILIZATION ROOM(S) q REQUIRED FOR MEMBERSHIP: A completely separate and enclosed biohazard room for processing used implements, jewelry and supplies is crucial to your health and safety and that of your clients. q REQUIRED FOR MEMBERSHIP: All flooring in the piercing room/s and biohazard room must be non-porous and easily disinfected. q REQUIRED FOR MEMBERSHIP: There must be clear delineation between clean and dirty areas. Biohazard areas should be labeled as such. The ultrasonic unit and the sink used for rinsing contaminated tools should be positioned as far away from sterilizer as possible to reduce the risk of contaminating freshly autoclaved items. If space is a problem, one solution would be to install a Plexiglas barrier to divide clean and dirty areas. q There should be at a minimum one ultrasonic cleaner to process contaminated items. Failure to remove debris from instruments or jewelry prior to sterilization can negatively affect the efficacy of the autoclave. The Center for Disease Control considers manual scrubbing of instruments to be an act that will actually increase the likelihood of exposure, due to pathogens on the equipment becoming airborne. Many studios have a second ultrasonic cleaning unit used only to process new jewelry. q An air purifier or separate ventilation for this space is strongly suggested. q Hand washing should never take place at the contaminated sink. PUBLIC/EMPLOYEE RESTROOM q REQUIRED FOR MEMBERSHIP: No sterilization equipment may be housed in the public restroom. q The restroom used by employees should have liquid soap in a pump or wall-mounted dispenser and a paper towel dispenser with easy, one-handed access. PIERCING ROOM q REQUIRED FOR MEMBERSHIP: A completely separate enclosed piercing room with walls and door(s) is a required. No other services such as tattooing, hair styling, or retail sales should take place within this room. q REQUIRED FOR MEMBERSHIP: All flooring in the piercing room/s must be non-porous and easily disinfected. q REQUIRED FOR MEMBERSHIP: All surfaces in the piercing room that could potentially be contaminated during a procedure must be non-porous to allow for proper cleaning. This includes piercing table, mat and base, shelving, and counters. q REQUIRED FOR MEMBERSHIP: Pre-sterilized piercing implements should be kept in enclosed and non- porous con- tainers, drawers or cabinets. q It is strongly suggested that there be clearly visible delineation between clean and dirty areas. The Sharps container and contaminated-tools tray should not be close to sterilized piercing implements and supplies. One solution would be to install a labeled biohazard shelf above the trashcan for the contaminated materials, thereby establishing a single contamination area in the room. q Used piercing implements should be kept in a lidded, non-porous tray or container that is marked “Biohazard”.
  • 88. 85 q The Sharps container should be secure to avoid accidental spillage. In the United States, NIOSH suggests that the Sharps container be mounted with the opening 56” from the floor and OSHA requires that operators have reasonable access to it. Additionally, the Sharps container should be located such that it can be easily utilized by the piercer in all phases of a procedure without putting clients or observers at risk. q All biohazardous waste containers should be marked as Biohazard, be lidded and have foot operation. It is appropriate to label your other lidded trashcans “Do Not Touch”. These should be placed in low or no traffic areas to avoid accidental exposure. q A HEPA air filter or other air purification system located in the piercing room is extremely beneficial, especially if other services are offered within the studio. q As many surfaces as possible in the piercing room should be non-porous. All pictures, posters, and wall hangings should be framed. q As many products as possible should be sterile and single use. This includes the marking implement. q All packaged equipment, sundry jars, or other materials and equipment used during a piercing should be handled only with clean freshly gloved hands. EMPLOYEE HAND-WASHING AREA q REQUIRED FOR MEMBERSHIP: Reasonable access to a sink used for hand-washing is mandatory. In-room prep sinks are preferable. q Optimally, the sink used for pre and post-piercing hand-washing should operate via a hands-free method. q Wall-mounted or pump liquid soap dispensers and paper towel dispensers should have easy, one-handed access. This will greatly reduce the likelihood of cross-contamination.
  • 89. 86 HEALTH AND SAFETY AGREEMENT The APP requires a signed agreement on record from each individual member. Violation of these basic, critical health and safety requirements is grounds for immediate revocation of membership. Please initial each numbered line as indicated to show that you have read and fully understand each point. 1.____ I agree not to use ear-piercing guns in my studio due to the impossibility of properly sterilizing the equip- ment and the inappropriateness of ear piercing gun jewelry. 2.____ I agree that all needles will be pre-sterilized, used on one person only in one sitting, and will be imme- diately disposed of in a medical sharps container. 3.____ I agree that all forceps, tubes, etc. will be pre-sterilized. If they are not used immediately, they will be stored in sterile bags and used on only one person in one sitting. After one such use, instruments will be ap- propriately decontaminated and then sterilized in an autoclave. 4.____ I agree that as many supplies as possible including corks, rubber bands, toothpicks etc., should be indi- vidually packaged and pre-sterilized in an autoclave and disposed of immediately after a single use. Skin prep products will be properly dispensed if acceptable based on the product or individually packaged and disposed of immediately after use. 5.____ I agree that a new pair of medical-grade (sterile and/or non-sterile) will be donned appropriately and worn for every procedure and that gloves will be changed frequently, and whenever there is the slightest chance for cross-contamination. 6.____ I agree that the room used for piercings will be an enclosed room and used exclusively for piercing and jewelry insertion. This room must also be kept separate from the sterilization area. Piercing room, biohazard room, bathrooms and other common areas, will be kept scrupulously clean and shall be disinfected frequently. All surfaces shall be non-porous, allowing them to be cleaned with an FDA-approved disinfectant solution throughout the day and whenever cross- contamination might occur. 7.____ I agree that all jewelry for initial piercings will be autoclaved prior to insertion. 8.____ I will use only appropriate jewelry in initial piercings. Appropriate jewelry is made of implant certified stainless steel that is ASTM F-138 compliant or ISO 5832-1 compliant, implant certified titanium (Ti6Al4V ELI) that is ASTM F-136 compliant or ISO 5832-3 compliant, solid 14 karat or higher white or yellow gold, Niobium (Nb), solid platinum, or a dense low-porosity plastic such as Tygon or PTFE. Threaded jewelry for initial pierc- ings must have internal tapping (no threads on posts) starting from 16 gauge. Jewelry must be free of nicks, scratches, burrs, and polishing compounds. Ring ends should be rounded. 9.____ I agree that it is important to be open, available and not under the influence of legal or illegal substances which might compromise my abilities. I agree to maintain my certification in First Aid/ CPR, and Bloodborne Pathogen training. I agree to meet or exceed all health, safety and legal standards as required by my state and local authorities. I understand that it is important not to misrepresent myself, my abilities, or my standards in any way. I agree to consider all new health and safety suggestions, as they become known to me and to make appropriate changes in my technique as applicable. I agree that it is the moral, ethical, and professional respon- sibility of all piercers to continue to seek out, absorb and share health and safety information relevant to the craft throughout my career. I also agree to adhere to the APP logo specification and guidelines. Name (please print): __________________________________________ Studio Name: _______________________________________________ Signature_____________________________________________ Date _____________________ Witness______________________________________________ Date _____________________
  • 90. UPDATED AFTERCARE BROCHURES Newly reformatted with additions reflecting new trends and frequently asked questions from Piercers and Piercees alike. NEW AFTERCARE: • Clear concise instructions on cleaning • "Less is more" message • More information on jewelry issues • Facial piercings now covered in Oral Aftercare instructions NEW FORMAT/DESIGNS: • Cohesive appearance of all APP brochures • Eye-catching and aesthetically pleasing • Professional image to support APP standards The new brochures are available for sale on the APP web site ( for $20 per 100, postage paid. Subjects include: • Aftercare Guidelines for Facial and Body Piercing* • Aftercare Guidelines for Oral Piercing* • Picking Your Piercer* • Troubleshooting for You and Your Healthcare Professional (with jewelry removal tips and hints) • Oral Piercing Risks and Safety Measures *Available in Spanish FREE SAMPLES AVAILABLE UPON REQUEST Order by fax or phone (888) 888-1APP or visit our website: MARK YOUR CALENDARS! The annual APP Conference and Exposition takes place every year in beautiful Las Vegas, Nevada. There are classes offered in everything from piercing technique to marketing, current industry legislation to accounting, studio set- up to aftercare. There is something for everyone, from the first time attendee to the long term shop owner, with classes geared specifically for health care professionals. The exposition includes venders from all segments of the body piercing industry from the United States and abroad. Thousands of items are available at the year’s largest gathering of manufactur- ers and distributors directly targeting the body piercing market. For updates about the conference please visit: or call (505) 242-2144 or (888) 888-1APP A PIERCEE'S BILL OF RIGHTS EVERY PERSON BEING PIERCED HAS THE RIGHT: 1. To be pierced in a hygienic environment by a clean, conscientious, sober piercer wearing a fresh pair of dis- posable medical examination gloves. 2. To be pierced with a brand new, completely sterilized single-use needle that is immediately disposed of in a medical Sharps container after use on one piercing. 3. To be touched only with freshly sterilized and appropriate implements,properly used and disposed of or re-ster- ilized (where appropriate) in an autoclave prior to use on anyone else. 4. To know that piercing guns are NEVER appropriate, and are often dangerous when used on anything -- including earlobes. 5. To the peace of mind that comes from knowing that their piercer knows and practices the very highest stan- dards of sterilization and hygiene. 6. To a have a knowledgeable piercer evaluate and discuss appropriate piercings and jewelry for her/his individ- ual anatomy and lifestyle. 7. To be fully informed of all risks and possible complications involved in his/her piercing choice before making any decisions. 8. To seek and receive a second opinion either from another piercer within the studio or from another studio. 9. To have initial piercings fitted with jewelry of appropriate size, material, design, and construction to best pro- mote healing. Gold-plated, gold-filled or sterling silver jewelry is never appropriate for any new or unhealed piercing. 10. To see pictures, be given a tour of the piercing studio, and to have all questions fully and politely answered before making or following through on any decision. 11. To be fully informed about proper aftercare, both verbally and in writing, and to have continuing access to the piercer for assistance throughout the healing process. 12. To be treated with respect, sensitivity and knowledge regardless of gender, sexual orientation, race, religion, ethnicity, ability, health status or piercing choice. 13. To change her/his mind, halt the procedure and leave at any point if the situation seems uncomfortable or improper.