In the JournalsPerspective

Tattoo ink causes outbreak of nontuberculous mycobacteria

An outbreak of nontuberculous mycobacterial skin infections in Florida was traced to contaminated tattoo ink and tap water, according to findings published in Clinical Infectious Diseases.

Officials launched an investigation after a dermatologist in Miami-Dade County reported three patients with skin infections to the state health department.

“In recent years, a number of nontuberculous mycobacterial outbreaks associated with tattoo studios have been reported in the literature,” Isabel Griffin, MPH, epidemiologist and biological scientist at the Florida Department of Health (DOH) in Miami-Dade County, and colleagues wrote. “These outbreaks have been associated with poor infection control practices at tattoo studios and contamination of graywash ink at the point of manufacture.”

Interviews with the first three patients revealed they all received a tattoo from the same studio and artist in February and March of 2015. The source of the infections was determined to be a bottle of graywash ink — a diluted ink used to create a greater range of gray colors within a tattoo — which had been opened when purchased, Griffin and colleagues reported.

someone getting a tattoo 
An outbreak of nontuberculous mycobacteria was linked to tattoo ink and tap water used for ink dilution.
Source: Adobe Stock

Investigators interviewed a total of 226 clients and identified 38 as outbreak-associated cases. According to Griffin and colleagues, individuals whose tattoos had gray tattoo ink were 8.2 times more likely to report a rash (95% CI, 3.07-22.13). Genetic analysis of environmental samples and skin biopsies uncovered two Mycobacterium fortuitum isolates in the graywash ink and one skin biopsy and 11 M. abscessus isolates, five from the bottle of graywash ink, two from tap water and four from skin biopsies. Griffin and colleagues observed that these isolates were indistinguishable, leading to a national recall of the implicated ink. Investigators also discovered that five unopened bottles of graywash ink obtained from two other Miami-Dade tattoo studios contained M. chelonae isolates.

According to the authors, CDC and FDA sterilization recommendations for tattoo ink manufacturers vary. The CDC advises manufactures to ensure sterilization of tattoo ink and recommends against dilution with nonsterile water, such as tap water.

“Tattoo patrons should be made aware of the infection risks associated with tattooing, not only those that result from bloodborne pathogens, but also bacteria in contaminated inks and nonsterile water,” Griffin and colleagues wrote. “The community would benefit from additional safeguards regarding tattoo ink manufacturing, guidelines for the dilution of tattoo ink, improved consumer information, and education on reporting adverse reactions and tattoo-related outbreaks to FDA and DOH.” – by Marley Ghizzone

Disclosures: The authors report no relevant financials disclosures.

An outbreak of nontuberculous mycobacterial skin infections in Florida was traced to contaminated tattoo ink and tap water, according to findings published in Clinical Infectious Diseases.

Officials launched an investigation after a dermatologist in Miami-Dade County reported three patients with skin infections to the state health department.

“In recent years, a number of nontuberculous mycobacterial outbreaks associated with tattoo studios have been reported in the literature,” Isabel Griffin, MPH, epidemiologist and biological scientist at the Florida Department of Health (DOH) in Miami-Dade County, and colleagues wrote. “These outbreaks have been associated with poor infection control practices at tattoo studios and contamination of graywash ink at the point of manufacture.”

Interviews with the first three patients revealed they all received a tattoo from the same studio and artist in February and March of 2015. The source of the infections was determined to be a bottle of graywash ink — a diluted ink used to create a greater range of gray colors within a tattoo — which had been opened when purchased, Griffin and colleagues reported.

someone getting a tattoo 
An outbreak of nontuberculous mycobacteria was linked to tattoo ink and tap water used for ink dilution.
Source: Adobe Stock

Investigators interviewed a total of 226 clients and identified 38 as outbreak-associated cases. According to Griffin and colleagues, individuals whose tattoos had gray tattoo ink were 8.2 times more likely to report a rash (95% CI, 3.07-22.13). Genetic analysis of environmental samples and skin biopsies uncovered two Mycobacterium fortuitum isolates in the graywash ink and one skin biopsy and 11 M. abscessus isolates, five from the bottle of graywash ink, two from tap water and four from skin biopsies. Griffin and colleagues observed that these isolates were indistinguishable, leading to a national recall of the implicated ink. Investigators also discovered that five unopened bottles of graywash ink obtained from two other Miami-Dade tattoo studios contained M. chelonae isolates.

According to the authors, CDC and FDA sterilization recommendations for tattoo ink manufacturers vary. The CDC advises manufactures to ensure sterilization of tattoo ink and recommends against dilution with nonsterile water, such as tap water.

“Tattoo patrons should be made aware of the infection risks associated with tattooing, not only those that result from bloodborne pathogens, but also bacteria in contaminated inks and nonsterile water,” Griffin and colleagues wrote. “The community would benefit from additional safeguards regarding tattoo ink manufacturing, guidelines for the dilution of tattoo ink, improved consumer information, and education on reporting adverse reactions and tattoo-related outbreaks to FDA and DOH.” – by Marley Ghizzone

Disclosures: The authors report no relevant financials disclosures.

    Perspective

    Tattooing is a form of artistic self-expression and, importantly, it is not without risks. In this study in Florida, an infectious outbreak after tattooing was reported and through significant support from the local public health department, a source of the organism was discovered.


    An amazing and concerted effort was made using resources from many different venues: medical, public health, tattoo artists and their clients. Through self-disclosure and review and open, honest communication, an important discovery was reaffirmed: tattoo ink should only be diluted with sterile water.

    The classic stereotypes that people may hold about tattoo artists are that they are in the back alley, and there is a lot of secrecy, but that was not the case here. There was a collaboration between the tattoo parlor, the tattoo artist and public health. Ten years ago, something like this would have gone quietly away, and a number of people would have said, “This is what happens when you get tattoos,” versus, “We need to dive into this and figure out how this happened and we need to recall this and promote safety for our constituents and our people because it could have been so much worse.”

    Most people in the field of tattooing follow the rules by using standard techniques with sterile water and proper usage of gloves. They also adhere to the guidelines of making sure that clients have obtained legal age of consent, are not intoxicated, have been vaccinated against tetanus and do not have a medical issue that would affect the immune system and ultimate healing.

    Health care providers may not know about the tattoo process. This is why we wrote a tattoo policy statement to help inform health care providers. Tattoo artists do know what they are doing. It is important for health care providers to support their patients when they have questions about tattoos and guide them to a place that is clean, safe and reputable with correct protocols in place for safe practice.

    • Cora C. Breuner, MD, MPH
    • Division of adolescent medicine and department of sports medicine
      Seattle Children’s Hospital
      Professor of pediatrics
      Adjunct professor of orthopedics and sports medicine
      University of Washington School of Medicine

    Disclosures: Breuner reports no relevant financial disclosures.