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Infection Control Lapse

August 3, 2023

Infection control notification issued August 3, 2023 by local Health Unit

What is the risk?

Tools and piercing jewelry that are not properly cleaned and sterilized can cause skin infections from bacteria and may spread blood-borne infections such as hepatitis B, hepatitis C, and to a lesser extent, HIV. No infection or illness has been linked to this situation at this time.

Who is at risk?

Anyone who received piercing services from Melissa Charland (the operator) through Piercings by Melissa during the time period of February 25th until June 8th, whether at LUX Tattoo and Piercing or elsewhere.

Clients who received non-piercing services (e.g. tattoos) at LUX Tattoo and Piercings do not have any risk of exposure from this investigation.

What should I do?

If you are at risk of exposure, as described above, call 1-800-660-5853 ext 2222.

Below is the information package that has been sent to known clients at risk of exposure:

My piercing site didn’t have any infection or problems healing. Am I still at risk of exposure?

Piercing site infections and skin infections are primarily caused by bacteria. However, the risk of exposure that the Health Unit is concerned about are blood-borne infections from viruses: Hepatitis B, Hepatitis C, and to a lesser extent, HIV. These viruses do not cause skin infections. Because piercings go through the skin, there is a risk of transmission of blood-borne infections. In some instances, people who are infected with these viruses do not have symptoms until months or even years after infection. More information about these infections can be found on this webpage.

I saw my piercing tools were opened from sealed pouches. Am I still at risk of exposure?

You may have seen piercing tools that were in pouches used for sterilizing, including tape with heat-activated lines. Effective cleaning and sterilization is based on a number of factors beyond whether pouches were sealed or any single indicator such as heat-activated lines (for example, it also depends on whether adequate pressure was also reached, whether tools were packed properly into the sterilizer, etc.). These indicators of effective cleaning and sterilization are not obvious from looking at the reprocessed tool or its packaging. As a result, there is concern that all reusable tools may have led to a risk of exposure, even though they were processed using a sterilizer.

How did the Health Unit determine the time range of concern?

The Health Unit is using the date of February 25th, 2023 as the first date of potential exposure risk, because that is the date that the operator reports purchasing the sterilizer. Because the operator’s client records and cleaning and sterilization records are incomplete, we have not been able to further narrow the time range. It is possible that the second time that reusable tools were used (and therefore potentially exposed to a blood-borne pathogen) was after February 25th, but we have not been able to determine this date. Therefore, Health Unit has used a conservative date in assessing potential risk of exposure, out of an abundance of caution.

The Health Unit is using the date of June 8th, 2023 as the last date of potential exposure risk, because that is the date that we issued an order to Piercings by Melissa under Section 13 of the Health Protection and Promotion Act, which included a requirement to use only sterile single-use tools and pre-sterilized jewelry. The operator has not used reusable piercing tools since that time.

How did the Health Unit assess the risk?

The Health Unit’s assessment of the exposure was made with information from Piercings by Melissa, our inspection of the cleaning and sterilization processes used, and in consultation with Public Health Ontario. The following deficiencies in cleaning and sterilization were identified:

  • The process used to clean tools may have led to the formation of a biofilm, which can make subsequent cleaning and sterilization less effective
  • The cleaning solutions used were not disinfectants and could not be considered effective in inactivating pathogens
  • The Health Unit tested the ultrasonic cleaner, which was working properly. However, the ultrasonic cleaner was not used correctly by the operator, and not disinfected between uses. This may have led to cross-contamination of tools that were not reprocessed in the same batch.
  • Regarding the sterilizer:
    • The Health Unit was not able to obtain instructions for the operation of the sterilizer from the operator or from the manufacturer of the machine. It is not clear how to operate the machine correctly.
    • The user screen of the sterilizer was not functional, and the sterilizer printout had an unknown error code. Due to the lack of instructions for using the machine, it was not possible to know the significance of the error code.
    • The Health Unit tested the sterilizer, and found that it failed Chemical Indicators testing. This means the machine did not meet the minimums for successful sterilization, even if the operator were using the sterilizer correctly.
    • The operator did not use the sterilizer correctly, including not conducting all of the chemical and biological indicator tests to ensure that the machine was providing effective sterilization.
    • Tools were sterilized in the closed position, and too many tools were placed in the sterilizer at a time. This may have prevented all surfaces of the tools from being adequately sterilized.
  • As well, there was no documentation to show which tools were used on which clients (including whether disposable or reusable tools were used). As a result, the Health Unit was not able to determine if any clients could be ruled out from having been exposed.

After obtaining this information, the Health Unit consulted Public Health Ontario, who is the provincial organization that provides scientific and technical advice to health units across Ontario. They provided a review of the risk assessment in this situation, as well as a review of the literature regarding the risk of blood-borne infection transmission.

Based on all the information the Health Unit gathered, we determined that tools and piercing jewelry were not properly cleaned and sterilized, and that clients should be notified of a potential exposure to blood-borne infections.

Has the Health Unit been inspecting this premises?

The Health Unit inspects on a regular basis all personal service settings such as piercing salons, tattoo parlours, nail salons, and others. LUX Tattoo and Piercing was previously inspected in November of 2022, and piercing services were not being offered at that time. Operators of personal service settings are required to notify the Health Unit before they change the services they provide. We became aware of piercing services being offered by Piercings by Melissa at LUX Tattoo and Piercing in June of 2023, several months after these services had already begun. The Health Unit conducted an inspection at that time, and identified deficiencies in cleaning and sterilization.

What requirements has the Health Unit placed on Piercing by Melissa’s services?

The Health Unit’s investigation has only identified inspection violations having to do with reusable tools and piercing jewelry that was sterilized on site. We have made requirements for Piercings by Melissa, including her services through LUX Tattoos and Piercings, to ensure compliance with public health guidance under Section 13 of the Health Protection and Promotion Act (HPPA). These requirements include using sterile single-use tools and pre-sterilized jewelry, which do not need to be cleaned and sterilized. No other inspection violations have been identified at this time that would prevent the operator from providing piercing services that comply with public health requirements. We are working with Piercings by Melissa and with LUX Tattoos and Piercings to ensure compliance with guidance regarding cleaning and sterilization, including minimizing the risk of infection transmission if they choose to use reusable tools in the future.

Information about IPAC Lapses

  • Health units are mandated to inspect premises and follow-up on complaints related to infection prevention and control (IPAC) to assess the risk of transmission of infectious diseases, and to determine the appropriate public health response. Deviations in IPAC practices, called an IPAC lapse, can lead to the transmission of infectious diseases.
  • In some instances, particularly where there is an elevated risk of blood borne infections, clients at risk due to an IPAC lapse are contacted directly (by letter) by the Health Unit to inform them of the risk and action to take.
    • Note:  there is risk of infection for any lapse, but we do not send out letters out in all cases – usually only for lapses involving invasive procedures where risk of infection relates to blood-borne diseases.
  • The Health Unit is required to inform the public of all IPAC lapses by posting them on our website.
  • If you wish to submit a complaint about infection control practices a personal service setting, fill out the forms here: Infection Control Complaint Form – Leeds, Grenville and Lanark District Health Unit.
  • If you need more information about potential risk, contact 1-800-660-5853 ext 2222.

Resources about personal services procedures and blood-borne infections

Information about inspection of Personal Service Settings

  • Health units are required to inspect personal service settings (PSS) such as piercing parlours, tattoo parlours, nail salons, and others.
  • Always look for an establishment to have a certificate displayed from the Health Unit.
  • Health Unit inspection reports are publicly available and can be found on the Health Unit’s website in the section entitled INSIGHT.

Information about Beauty and Body Art Safety

The Health Unit has resources about beauty and body art safety to help you make informed decisions about services.