Risk for Hepatitis B and C Virus Transmission in Nail Salons and Barbershops and State Regulatory Requirements to Prevent Such Transmission in the United States Jun Yang, PhD, MS; Keri Hall, MD, MS; Azizeh Nuriddin, MPH; Diane Woolard, PhD, MPH rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Context: The potential for hepatitis B and C virus (HBV/HCV) transmission in nail salons and barbershops has been reported, but a systematic review has not been conducted. These businesses are regulated by state cosmetology or barbering boards, but adequacy of sanitary requirements has not been evaluated. Objectives: To conduct literature review to assess risk for HBV/HCV transmission in nail salons and barbershops and to evaluate sanitary requirements in HBV/HCV prevention in these businesses in 50 states and District of Columbia. Design: Several search engines were used for literature search. Studies that quantified risks associated with manicuring, pedicuring, or barbering were included. State requirements for disinfection and sterilization were reviewed and evaluated. Main Outcome Measure: For literature review, odds ratios, 95% confidence intervals, and confounding adjustment were extracted and evaluated. For regulation review, requirements for disinfection or sterilization for multiuse items in nail salons and barbershops were assessed according to the US federal guidelines. Results: Forty-six studies were identified and 36 were included in this study. Overall, the results were not consistent on risk for HBV/HCV transmission in nail salons and barbershops. For sanitary requirements, disinfection with an Environmental Protection Agency–registered disinfectant is required in 39 states for nail salons and in 26 states for barbershops. Sterilization was described in 15 states for nail salons and in 11 states for barbershops, but the majority of these states listed it as an optional approach. Sanitary requirements are consistent in states where 1 board regulates both businesses but are J Public Health Management Practice, 2014, 20(6), E20–E30 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
substantially discrepant in states with separate boards. Conclusions: Current literature cannot confirm or exclude the risk for HBV/HCV transmission in nail salons and barbershops. Existing sanitary requirements are adequate in the majority of states, but compliance is needed to prevent HBV/HCV transmission in these businesses. KEY WORDS: barbers, government regulation, hepatitis virus,
nails, prevention
Hepatitis B and C virus (HBV/HCV) infections constitute a substantial worldwide health problem. Approximately 350 million and 123 million persons globally suffer from HBV and HCV infections, respectively.1,2 In the United States, an estimated 800 000 to 1.4 million persons have chronic HBV
Author Affiliations: Division of Surveillance and Investigation, Office of Epidemiology, Virginia Department of Health, Richmond, Virginia (Drs Yang and Woolard); Martha Jefferson Hospital at Sentara Health System, Charlottesville, Virginia (Dr Hall); and Centers for Disease Control and Prevention, Atlanta, Georgia (Ms Nuriddin). The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention. The authors thank David Johnson, MD, Professor of Medicine at Eastern Virginia Medical School, for conceptual assistance, and Shuhui Wang, MPH, Marshall Vogt, MPH, and David Trump, MD, from the Virginia Department Health for assistance with map design, regulation review, and editorial suggestions, respectively. None of these people has received compensation for the contributions. The authors declare no conflicts of interest and no funding. Correspondence: Jun Yang, PhD, MS, Division of Surveillance and Investigation, Office of Epidemiology, Virginia Department of Health, 109 Governor St, Richmond, VA 23219 ([email protected]). DOI: 10.1097/PHH.0000000000000042
E20 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Risk for Hepatitis B and C Virus Transmission in Nail Salons and Barber Shops
infections, and 2.7 to 3.9 million persons have chronic HCV infections.3 Recognized risk factors for HBV infections include blood transfusions, intravenous drug use, body piercing and tattoos, unsafe sexual behaviors, and invasive health care procedures.4 For HCV infections, intravenous drug use is the primary risk factor in socioeconomically developed countries and unsafe medical injections and blood transfusions are the primary risk factors in lower-income countries.2,5 Transmission of HBV/HCV can occur in both health care and personal care settings if blood or serous fluid from an infected person has an opportunity to enter an opening in the skin of an uninfected person. In personal care settings (eg, nail salons and barbershops), transmission opportunities can be facilitated if multiuse items are contaminated with HBV/HCV from one person and are used on another person before being cleaned and disinfected.6 Examples of multiuse items include nail clippers, nail files, tweezers, brushes, drill bits, razors, and scissors. To facilitate infection control in health care settings, the Centers for Disease Control and Prevention (CDC) has developed the Guideline for Disinfection and Sterilization in Healthcare Facilities (CDC Guideline).7 Guidelines specifically addressing HBV and HCV prevention are unavailable for settings in which noncritical items are used on multiple clients routinely (eg, nail salons and barbershops). The CDC Guideline categorizes medical items as critical, semicritical, or noncritical.7 Critical items are those that confer a high risk for infection if they are contaminated with any microorganism (eg, objects that enter sterile tissue or the vascular system). Semicritical items confer a reduced risk because they only come into contact with mucous membranes or nonintact skin. Noncritical items are those that come in contact with intact skin but not mucous membranes and provide the least risk for transmitting infection.7 Examples of noncritical items for personal care services include razors, metal cuticle pushers and files, scissors, tweezers, and nail clippers. The CDC Guideline also addresses disinfection and sterilization strategies and approaches for preventing health care– associated infections, including HBV/HCV infections. Disinfection and sterilization are chemical or thermal processes designed to eliminate microorganisms. Sterilization is used primarily for critical items and certain semicritical items, and disinfection is used primarily for semicritical and noncritical items. Sterilization can eliminate bacterial spores but disinfection cannot.7 Given the theoretical risk for HBV/HCV transmission associated with manicuring, pedicuring, and barbering services, we conducted a literature review to assess this risk and a review of state
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regulations to evaluate the adequacy of sanitary requirements within the United States in preventing HBV/HCV transmission in nail salons and barbershops. To our knowledge, the literature review and the state regulation review for these settings as described in this study have not been previously reported.
● Methods Literature search and study selection A literature search was conducted through PubMed, PubMed Central, Medline, and reference cross-check in published articles. Key words that were used for the search were manicure, pedicure, nail salon, barber, razor, nail clipper, risk factor, and hepatitis. Epidemiologic studies published in English in the United States and other countries before May 31, 2013 were identified and reviewed. All studies were included for review except those that described only the percentages of risk factors among participants without a risk estimate (eg, calculation of odds ratios), and the published data were insufficient to generate a risk estimate. Information about publication year, study location, study population, study design, sample size, viruses studied, risk factors of interest and odds ratios, and confounding adjustment was extracted. Because the majority of studies that assessed manicuring, pedicuring, or barbering in the transmission of HBV/HCV also assessed sharing of personal items (eg, nail clippers and razors), we included all of these factors in the literature review to understand the risk for HBV/HCV transmission associated with nail care and barbering in both commercial and personal settings.
State regulations Active websites of state regulatory boards for nail salons and barbershops throughout the 50 states and the District of Columbia were explored or searched for regulations regarding sanitary requirements as of May 31, 2013. A website was regarded as active if a website was updated or modified within the last year with new information posted to reflect that the website contents were up-to-date. If the regulation could not be identified from the website or if further clarification was needed, the authors contacted the board by e-mail or telephone. For a regulation to be included for review, the regulation must be referred as a cosmetology regulation or a regulation covering nail salons or barbershops. Regulations were available online from 49 states and District of Columbia.
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E22 ❘ Journal of Public Health Management and Practice One state mailed the regulations to the investigators. Two investigators (JY and AN) independently conducted regulation reviews by focusing on descriptions of sanitary requirements, relevant products, and the required disinfection and sterilization methods. The CDC Guideline for Disinfection and Sterilization in Healthcare Facilities and the Food and Drug Administration’s guidance for industry on sterility information were used to interpret the terminology and disinfection and sterilization methods stipulated in each regulation.7,8 To understand the sanitary requirements within a state regulation, the reviewers first determined whether a definition section was available and if yes, whether sanitation, disinfection, and sterilization were defined consistently with the CDC Guideline. Second, the reviewers determined whether a general sanitary section was available and if yes, what general requirements were described, including methods or procedures, disinfectants, and implements to be disinfected. Third, the reviewers determined whether specific sanitary sections under nail services or barbering services were available and if yes, what requirements were described, including methods or procedures, disinfectants, and implements to be disinfected. Sanitary requirements specified for service areas other than manicuring, pedicuring, and barbering (eg, electrolysis and esthetics) were not regarded as requirements for nail salons and barbershops. Considering the substantial variations in disinfection and sterilization descriptions across regulations, an indication of US Environmental Protection Agency (EPA)–registered disinfectants was used to compare disinfection requirements throughout all 50 states and District of Columbia. Sterilization descriptions were interpreted on the basis of CDC and Food and Drug Administration guidance for the purpose of eradicating all microorganisms, including bacterial spores. A specific method of sterilization as recognized by CDC or Food and Drug Administration was needed for reviewers to determine whether a regulation described sterilization. Furthermore, the reviewers determined whether sterilization was required or optional if it was described. Geographic information system software, ArcGIS version 10 (ESRI, Redlands, California), was used to generate maps to display sanitary requirements on disinfection and sterilization in nail salons and barbershops in all 50 states and District of Columbia. The maps also displayed the number of regulatory boards for these 2 types of businesses to reflect the discrepancies of sanitary requirements by regulatory boards. For statistical purposes, District of Columbia was counted as a state.
● Results Literature review We identified a total of 46 studies through our literature search. After an initial review, 10 studies were excluded because risk estimates were not presented or the published data were insufficient for risk estimate calculation. The remaining 36 studies included 1 cohort study,9 8 population-based matched case-control studies,10-17 1 hospital and household-based matched case-control study,18 5 population-based unmatched case-control studies,19-23 6 facility or household-based unmatched case-control studies,24-29 8 cross-sectional studies among community populations,30-37 and 7 cross-sectional studies among prisoners or populations at high risk.38-44 The Table presents the publication year, study location, study design, study population, sample size, viruses studied, odds ratios, and confounding adjustment for the 36 studies that were included. Fifteen of the 36 studies assessed risk for HBV/HCV infection with manicuring, pedicuring, or sharing of personal nail clippers. Of these 15 studies, 6 assessed the risk for HBV infections in association with manicuring or pedicuring and 3 reported statistically significant associations. Two of these 3 studies were community-based studies in China (adjusted odds ratio [aOR], 2.0; 95% confidence interval [CI], 1.4-2.9)13 and Italy (aOR, 1.4; 95% CI, 1.0-2.1)20 ; the last was a household-based study in Italy (aOR, 1.3; 95% CI, 1.0-1.7).26 Assessing the risk for HBV infections in association with sharing of personal nail clippers accounted for 2 of the 15 studies, but only 1 reported a statistically significant association in the unadjusted analysis (OR, 2.8; 95% CI, 2.03.9; adjusted analysis was not performed).19 Seven of the 15 studies assessed the risk for HCV infections in association with manicuring or pedicuring, but only 2 reported statistically significant associations. These 2 studies were community-based studies conducted in France (aOR, 1.7; 95% CI, 1.2-2.6)11 and Brazil (aOR, 3.5; 95% CI, 1.9-6.3).22 Four of the 15 studies assessed the risk for HCV infections associated with sharing of personal nail clippers, but none reported a statistically significant association. Further review indicated that 32 of the 36 studies evaluated the risk for HBV/HCV infections associated with barbering services or sharing of personal razors. Of these 32 studies, 14 evaluated the risk for HBV infections in association with professional barbering services, and 6 reported statistically significant associations. Four of these 6 were community-based studies conducted in Thailand (unadjusted OR, 2.5; 95% CI, 1.7-3.2; adjusted analyses were not performed),19 Italy (aOR, 1.8; 95% CI, 1.5-2.2),20 Pakistan (aOR, 2.3; 95%
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Risk for Hepatitis B and C Virus Transmission in Nail Salons and Barber Shops
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TABLE ● Studies of Hepatitis B and C Virus (HBV/HCV) Transmission Associated With Manicuring, Pedicuring, Barbering, or Sharing of Personal Nail Clippers and Razors qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Year and Location Cohort study 2010b , Australia9
Participants 488 prisoners, 94 HCV patients
Population–based matched case-control study 196 patients, 400 control 2000b , Japan10 subjects 450 patients, 757 control 2006b , France11 subjects 64 patients, 227 control 2007b , France12 subjects 294 patients, 588 control 2008b , China13 subjects 2008b , Netherlands14 120 patients, 3948 control subjects 69 patients; 207 control 2009b , China15 subjects 327 HBV patients, 723 HCV 2009b , Pakistan16 patients, 723 control subjects 2011b , China17 305 patients, 610 control subjects
Virusa
Barbering OR (95% CI)
Sharing of Personal Nail Clippers OR (95% CI)
Not assessed
C− (OR not reported)c
C
Not assessed
C+; 4.9 (1.3-18.6)d Not assessed
C
C+; 1.7 (1.2-2.6) Not assessed
Not assessed
Not assessed
C
Not assessed
C−; 0.8 (0.4-1.4)
C−; 0.6 (0.3-1.1)
B
B+; 2.0 (1.4-2.9) B− (OR not reported) B− (OR not B− (OR not reported) reported) Not assessed Not assessed
Not assessed
C−; 1.2 (0.6-2.2)
B− (OR not reported) B− (OR not reported) Not assessed
B, C
Not assessed
B−, C− (OR not reported)
Not assessed
Not assessed
C
Not assessed
C+; 29.2 (13-66.0) Not assessed
Not assessed
C− (OR not reported)
C− (OR not reported)
C− (OR not reported)
C− (OR not reported)
B C
Not assessed
Not assessed
Sharing of Personal Razors OR (95% CI)
C
Hospital and household-based matched case-control study 94 patients, 188 control C 2009b , Egypt18 subjects Population-based unmatched case-control study 876 patients, 1750 control 1992e , Thailand19 subjects 2964 HBV patients, 598 HCV 2004b , Italy20 patients, 7221 control subjects 2005b , Pakistan21 64 patients, 260 control subjects 116 patients, 140 control 2010b , Brazil22 subjects 71 patients, 212 control 2010b , India23 subjects
Manicure or Pedicure OR (95% CI)
Not assessed
C− (OR not reported) Not assessed
B
B−; 0.8 (0.6-5.1) B+; 2.5 (1.7-3.2)
B+; 2.8 (2.0-3.9)
B+; 4.5 (3.8-5.3)
B, C
B+; 1.4 (1.0-2.1) B+; 1.8 (1.5-2.2) C−; 0.9 (0.4-1.9) C+; 1.4 (1.0-2.1)
Not assessed
Not assessed
B
Not assessed
B+; 2.3 (1.1-4.8)
Not assessed
Not assessed
C
C+; 3.5 (1.9-6.3) C+; 2.3 (1.3-4.3)
Not assessed
C+; 2.0 (1.1-3.7)
B
Not assessed
B+; 4.1 (2.1-8.0)
Not assessed
Not assessed
Not assessed
Not assessed
B+; 8.1 (2.8-28.3)
Not assessed
B+; 1.7 (1.1-2.5)
B− (OR not reported) Not assessed
B+; 1.3 (1.0-1.7) B+; 1.6 (1.4-1.9) C−; 1.0 (0.5-1.8) C−; 1.3 (0.9-2.0)
Not assessed
Not assessed
Not assessed
Not assessed
Not assessed
Hospital or household-based unmatched case-control study B 1985e , Singapore24 88 patients, 97 control subjects 2460 patients, 708 control B 1990b , Italy25 subjects 6395 HBV patients, 363 HCV B, C 1995b , Italy26 patients, 4789 control subjects 1997b , Italy27 162 patients, 788 control B subjects
B−; 2.5 (0.7-8.5)
Not assessed
(continues)
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E24 ❘ Journal of Public Health Management and Practice TABLE ● Studies of Hepatitis B and C Virus (HBV/HCV) Transmission Associated With Manicuring, Pedicuring, Barbering, or Sharing of Personal Nail Clippers and Razors (Continued) qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Year and Location 2006e , Pakistan28
2006b , Germany29
Participants 41 HBV patients, 63 HCV patients, 44 control subjects 17 patients, 26 control subjects
Cross-sectional study in community populations 6033 participants, 2002b , Egypt30 523 patients 2154 participants, 71 patients 2002b , Italy31 2005b , Turkey32 2006b , Pakistan33 2007b , Vietnam34 2008b , Pakistan35 2010b , Bangladesh36 2010b , Pakistan37
717 participants, 39 patients 3533 participants, 65 HBV patients, 55 HCV patients 837 participants, 8 patients 1131 participants, 46 patients 1997 participants, 582 HBV patients, 4 HCV patients 1997 participants, 476 patients
Virusa
Manicure or Pedicure OR (95% CI)
2011b , Brazil42 2011b , United States43 2011b , Nigeria44
Sharing of Personal Nail Clippers OR (95% CI)
Sharing of Personal Razors OR (95% CI)
B, C
Not assessed
B−; 0.04 (0.0-0.4) Not assessed C+; 2.8 (1.2-6.9)
Not assessed
B
B− (OR not reported)
B− (OR not reported)
Not assessed
Not assessed
C
Not assessed
C−; 0.9 (0.4-2.0)
Not assessed
C−; 1.0 (0.4-2.6)
C
Not assessed
Not assessed
Not assessed
B B, C
C− (OR not reported) Not assessed Not assessed
Not assessed Not assessed
B−; 1.8 (0.0-8.3) Not assessed
C C B, C
Not assessed Not assessed Not assessed
Not assessed Not assessed Not assessed
C−; 3.5 (0.8-14.7) Not assessed Not assessed
C
Not assessed
Not assessed B−; 0.6 (0.4-1.1) C−; 1.1 (0.5-2.1) Not assessed C+; 5.5 (2.6-11.7) B−, C− (OR not reported) C+; 5.0 (1.6-16.1)
Not assessed
Not assessed
Cross-sectional study in drug users, prisoners, or hospital patients 98 participants, 24 cases C Not assessed 1999e , Pakistan38 437 participants, 55 patients C Not assessed 2001b , Canada39 2005b , United States40 2010b , Pakistan41
Barbering OR (95% CI)
722 participants, 28 patients
C
Not assessed
357 participants, 21 HBV patients, 65 HCV patients 303 participants, 13 patients 782 female drug users, 162 HCV patients 360 hospital patients, 17 patients
B, C
Not assessed
C−; 2.3 (0.2-25.7) Not assessed Not assessed Not assessed Not assessed
C−; 0.4 (0.2-1.0)
C−; 3.6 (0.4-32.4) C− (OR not reported) C−; 1.8 (0.6-5.2)
Not assessed
Not assessed
C C
B−, C−; 0.5 (0.2-1.2)f C−; 0.3 (0.1-1.2) Not assessed Not assessed Not assessed
Not assessed Not assessed
C
Not assessed
Not assessed
Not assessed C− (OR not reported) C−; 1.0 (0.3-3.2)
Not assessed
Abbreviations: CI, confidence interval; HBV, hepatitis B virus; HCV, hepatitis C virus; OR, odds ratio. a B indicates that hepatitis B virus was studied; C indicates that hepatitis C virus was studied. b Results adjusted for other risk factors. c − indicates that a significantly increased risk was not identified. d + indicates that a significantly increased risk was identified (P < .05). e Results not adjusted for other risk factors.
CI, 1.1-4.8),21 and India (aOR, 4.1; 95% CI, 2.1-8.0)22 ; the last 2 were hospital-based studies conducted in Italy (aOR, 1.7; 95% CI, 1.1-2.5; aOR, 1.6; 95% CI, 1.41.9, respectively).25,26 One study in Pakistan indicated a negative association for HBV infection and barbering (unadjusted OR, 0.04; 95% CI, 0-0.4), which was likely the result of limited sample size.28 Five of the 32 studies evaluated the risk for HBV infections in association with sharing of personal razors, and 2 reported signifi-
cant associations in unadjusted analyses (OR, 4.5; 95% CI, 3.8-5.3; OR, 8.1; 95% CI, 2.8-28.3; adjusted analyses were not performed in these 2 studies).19,23 Of the 32 studies, 16 assessed the risk for HCV infection associated with professional barbering services, and 7 reported significant associations. These included 4 community-based case-control studies conducted in Japan (aOR, 4.9; 95% CI, 1.3-18.6),10 China (aOR, 29.2; 95% CI, 13.0-66.0),17 Italy (aOR, 1.4; 95% CI, 1.0-2.1),20
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Risk for Hepatitis B and C Virus Transmission in Nail Salons and Barber Shops
and Brazil (aOR, 2.3; 95% CI, 1.3-4.3)22 ; 1 hospital-based case-control study in Pakistan (unadjusted OR, 2.8; 95% CI, 1.2-6.9)28 ; and 2 community-based surveys in Pakistan (aOR, 5.5; 95% CI, 2.6-11.7; aOR, 5.0; 95% CI, 1.6-16.1).35,37 In addition, 10 of the 32 studies evaluated the risk for HCV infections in association with sharing of personal razors, but only 1 reported a statistically significant association (aOR, 2.0; 95% CI, 1.1-3.7).22 Only 2 studies conducted in the United States were identified through the literature search. One study, conducted among noninjection drug users, did not find a significant association with HCV for sharing of personal razors or clippers.40 Similarly, the other study was conducted among female drug users and did not find a significant association with HCV for sharing of personal razors.43 The risk for HBV transmission was not evaluated in these 2 studies.
Disinfection requirements Forty-six states require disinfection for multiuse items among clients in nail salons and specify the disinfectants to be used (Figure 1 ). Thirty-nine of these states require that an EPA-registered disinfectant be used. Seven of the 46 states have similar requirements for disinfection in nail salons but do not specify that products should be EPA-registered. Regulations from these 46 states include guidance on general sanitary requirements, disinfection procedures or methods, implements to be disinfected, and disinfectants that should be used. The described disinfection process usually includes thorough washing and cleaning of a soiled, multiuse implement and then immersing it completely in a disinfectant solution for 10 minutes or according to the manufacturer’s instructions on the disinfectant label. Five states do not specify methods of disinfection or disinfectants to be used in nail salons. For barbershops, 45 states require disinfection for multiuse implements among clients and specify the disinfectants to be used (Figure 1). Twenty-six of these 45 states stipulate that EPA-registered products be used for disinfection in barbershops. Nineteen of the 45 states describe or list products for disinfection but do not specify whether they should be EPA-registered. Six states do not specify methods of disinfection or disinfectants to be used in barbershops.
Sterilization requirements For nail salons, 15 states describe sterilization and list at least 1 method intended to eradicate bacterial spores. Thirteen of these 15 states list sterilization as an option but not a requirement for multiuse implements. Two states list sterilization as a requirement, but the requirement is only for selected multiuse implements
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(Figure 2 ). For barbershops, 11 states describe sterilization and list at least 1 method intended to eradicate bacterial spores. For all 11 states, sterilization is listed as an option but not a requirement for multiuse implements (Figure 2). Steaming, dry heat, autoclaving, boiling, and chemical sterilization were the primary sterilization methods described for both nail salons and barbershops.
Regulatory board and regulation discrepancy Twenty-three states have 1 combined board that regulates both nail salons and barbershops. In these states, disinfection requirements are consistent for nail salons and barbershops regarding disinfectant recommendations (Figure 1). Specifically, 19 states require use of EPA-registered disinfectants in both settings, and 4 states do not specify disinfectants for either setting. Sterilization requirements are also consistent for nail salons and barbershops in these states (Figure 2). Twenty-seven states have 2 separate boards that regulate nail salons and barbershops. Consistent disinfection requirements in both settings are available in only 13 states (Figure 1). Eight of the 27 states have different descriptions or recommendations for sterilization practices within nail salons and barbershops (Figure 2).
● Discussion Compared with the recognized risk factors for HBV/HCV transmission (eg, intravenous drug use, blood transfusion, and unsafe sexual activity), personal care services are relatively understudied and less documented, especially in the United States. The majority of the published studies were conducted in Asia, South America, and Europe, where the prevalence of HBV/HCV infections is relatively high.1,2,4 Only 2 studies have been reported in the literature among drug users in the United States, neither of which reported an association with personal care items.40,43 Findings from the published studies were inconsistent regarding the risk for HBV/HCV transmission associated with nail salon and barbershop services and with sharing of personal nail clippers or razors. Although certain studies demonstrated increased risks for HBV/HCV transmission for these potential risk factors, the majority of studies did not find an association. Caution is needed when interpreting and comparing the published data because of the heterogeneities across studies. Such heterogeneities include location, population sampled, sample size, case definition and selection of patients and control participants, instruments and approaches used for data collection, analytic methods,
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E26 ❘ Journal of Public Health Management and Practice FIGURE 1 ● State Disinfection Requirements in Nail Salons and Barber Shops—United Statesa
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
a Numbers on the map indicate regulation of nail salons and barber shops by 1 combined board or 2 separate boards. Alabama has only a State Board of Cosmetology that regulates nail salons; it does not have a State Board of Barber Examiners.
and adjustment of confounding factors. In addition, because certain studies were not designed primarily to investigate HBV/HCV transmission associated with these risk factors, they did not collect specific detailed data regarding these risk factors (eg, cuts or bruising obtained during services); therefore, we were unable to perform more precise analyses. Regarding regulations for nail salons and barbershops, the majority of states have adequate sanitary requirements to eliminate HBV/HCV from multiuse implements in these settings. Because implements used in nail salons and barbershops primarily come in contact with intact skin but not mucous membranes, they
belong to noncritical items on the basis of the CDC Guideline. Noncritical items usually require an exposure of 10 minutes in a low-level disinfectant, which is defined as a disinfectant capable of destroying all vegetative bacteria (except tubercle bacilli), lipid viruses, certain nonlipid viruses, and certain fungi, but not bacterial spores, for a practical period (eg, 10 minutes). Examples of low-level disinfectants include EPAregistered hospital disinfectants with an HBV/HIV label claim.7 If a state requires that a soiled implement be completely immersed in an EPA-registered disinfectant solution for 10 minutes or according to the disinfectant’s label instructions after thorough
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Risk for Hepatitis B and C Virus Transmission in Nail Salons and Barber Shops
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FIGURE 2 ● State Sterilization Requirements in Nail Salons and Barber Shops—United Statesa
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
a Numbers on the map indicate regulation of nail salons and barber shops by 1 combined board or 2 separate boards. Alabama has only a State Board of Cosmetology that regulates nail salons; it does not have a State Board of Barber Examiners.
washing and cleaning, HBV/HCV will be eradicated in this process. For states that do not specify EPAregistered disinfectants, if the listed disinfectants have germicidal capabilities, the disinfectants should eliminate HBV/HCV, if used correctly. However, these states might consider specifying EPA-registered disinfectants or specifying the required germicidal capabilities in the regulations to help nail salon and barbershop technicians better understand and implement the sanitary requirements. In addition to the germicidal capabilities of a disinfectant, certain factors can affect disinfection
effectiveness, including the physical nature and state of cleanliness of an item before disinfection, and compliance by nail or barber technicians with the sanitary requirements and the disinfectant’s label instructions. Thus, the prevention of HBV/HCV transmission relies on both adequate sanitary requirements and compliance. Because nail salons and barbershops usually have substantial employee turnover, providing continuing education for workers can reinforce the necessity of infection control and foster improved compliance with sanitation requirements. In addition, periodic inspection of a facility can help identify
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E28 ❘ Journal of Public Health Management and Practice and correct sanitary problems that might facilitate HBV/HCV transmission. Our study reveals that sterilization is not described in the majority of regulations. In the limited number of states where sterilization is described, it is listed primarily as an optional approach to removing microorganisms from multiuse items. In 2 states where sterilization is listed as a requirement for nail salons, it is intended to be used on selected rather than all multiuse items. Because sterilization is a higher-level process than disinfection for eliminating microorganisms, HBV/HCV can be eradicated by sterilization if used correctly. Considering the low resistance of HBV/HCV to disinfection, sterilization is not a necessary measure for HBV/HCV prevention when a standard disinfection process is implemented in nail salons and barbershops. However, sterilization might be needed if elimination of other microorganisms is within a regulation’s scope. The term sterilization is used sometimes to reference sanitation or disinfection and does not reference the eradication of bacterial spores within the regulation. This might cause a business operator to misinterpret the goal of sterilization on the basis of these guidelines; therefore, correct use of the term sterilization in these regulations is strongly recommended. Our study demonstrates that disinfection and sterilization requirements are consistent for nail salons and barbershops when both settings are regulated by the same board but are often discrepant when the businesses are regulated by separate boards. Because implements used in both settings require the same level of disinfection, improved communication and coordination are needed between the regulatory boards to provide consistent recommendations for nail salons and barbershops if they are not regulated by the same board. It is also noteworthy to point out that the regulatory boards should consider posting the regulations, especially the section of sanitary requirements, upfront on the website where visitors can easily find and download. There are several limitations in this study. For the literature review, one limitation is the lack of heterogeneity assessment for the published studies. Because these studies were conducted among different populations in different countries, there were variations in study design, sample size, definition and selection of cases and controls, data measurements and acquisition, analytic methods, and confounding control. These variations might be associated with the risk estimations across these studies. Another limitation is that these studies were reviewed only by 1 investigator (JY). Although the investigator reviewed these studies and the abstracted data multiple times, potential errors were still likely to occur. Another investigator’s independent review can usually prevent such potential
errors. For the regulation review, 1 major limitation is the lack of a standardized measurement for disinfection and sterilization in the regulations. For example, although we used “EPA-registered disinfectants” as a measurement to evaluate disinfection in the regulations, the quality and type of EPA-registered disinfectants allowed for use varied substantially from one regulation to another. Factors such as the dilution of a disinfectant and cleaning procedures employed also play a role in the effectiveness of disinfection. In addition, for disinfection to be effective, the duration of time that an item is exposed to disinfectants is also important. Because of the noted variations, we did not include these factors within our assessment. Similarly, we also noted variations for sterilization across the state regulations that mentioned this approach. Finally, we did not have access to information on regulation enforcement and compliance in the 50 states and District of Columbia. For the prevention of HBV/HCV in nail salons and barbershops, both adequate sanitary requirements and compliance are important.
● Conclusions Data from the literature cannot confirm or rule out the risk for HBV/HCV transmission associated with personal care services. Additional studies, which consider disinfection and sterilization quality and type along with compliance with state regulations, are needed that focus on the risk for HBV/HCV transmission through exposures in nail salons and barbershops. The sanitary requirements in the majority of states are sufficient for HBV/HCV prevention if workers comply with state requirements and adhere to disinfectants’ label instructions. However, efforts are needed in other states to improve and standardize regulations according to the CDC Guideline, especially if nail salons and barbershops are regulated by separate boards.
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Risk for Hepatitis B and C Virus Transmission in Nail Salons and Barber Shops
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20. Mariano A, Mele A, Tosti ME, et al. Role of beauty treatment in the spread of parenterally transmitted hepatitis viruses in Italy. J Med Virol. 2004;74(2):216-220. 21. Akhtar S, Younus M, Adil S, Hassan F, Jafri SH. Epidemiologic study of chronic hepatitis B virus infection in male volunteer blood donors in Karachi, Pakistan. BMC Gastroenterol. 2005;5:26. 22. Oliveira-Filho AB, Pimenta Ado S, Rojas Mde F, et al. Likely transmission of hepatitis C virus through sharing of cutting and perforating instruments in blood donors in the State of Para, Northern Brazil. Cad Saude Publica. 2010;26(4):837-844. 23. Jagannathan L, Chaturvedi M, Mudaliar S, Kamaladoss T, Rice M, Murphy EL. Risk factors for chronic hepatitis B virus infection among blood donors in Bangalore, India. Transfus Med. 2010;20(6):414-420. 24. Goh KT, Ding JL, Monteiro EH, Oon CJ. Hepatitis B infection in households of acute cases. J Epidemiol Community Health. 1985;39(2):123-128. 25. Mele A, Stazi MA, Gill ON, Pasquini P. Prevention of hepatitis B in Italy: lessons from surveillance of type–specific acute viral hepatitis. SEIEVA Collaborating Group. Epidemiol Infect. 1990;104(1):135-141. 26. Mele A, Corona R, Tosti ME, et al. Beauty treatments and risk of parenterally transmitted hepatitis: results from the hepatitis surveillance system in Italy. Scand J Infect Dis. 1995;27(5):441-444. 27. Sagliocca L, Stroffolini T, Amoroso P, et al. Risk factors for acute hepatitis B: a case–control study. J Viral Hepat. 1997;4(1): 63-66. 28. Shazi L, Abbas Z. Comparison of risk factors for hepatitis B and C in patients visiting a gastroenterology clinic. J Coll Physicians Surg Pak. 2006;16(2):104-107. 29. Dreesman JM, Baillot A, Hamschmidt L, Monazahian M, Wend UC, Gerlich WH. Outbreak of hepatitis B in a nursing home associated with capillary blood sampling. Epidemiol Infect. 2006;134(5):1102-1113. 30. Medhat A, Shehata M, Magder LS, et al. Hepatitis C in a community in Upper Egypt: risk factors for infection. Am J Trop Med Hyg. 2002;66(5):633-638. 31. Campello C, Poli A, Dal MG, Besozzi-Valentini F. Seroprevalence, viremia and genotype distribution of hepatitis C virus: a community–based population study in northern Italy. Infection. 2002;30(1):7-12. 32. Otkun M, Erdogan MS, Tatman-Otkun M, Akata F. Exposure time to hepatitis B virus and associated risk factors among children in Edirne, Turkey. Epidemiol Infect. 2005;133(3):509516. 33. Jafri W, Jafri N, Yakoob J, et al. Hepatitis B and C: prevalence and risk factors associated with seropositivity among children in Karachi, Pakistan. BMC Infect Dis. 2006;6:101. 34. Nguyen VT, McLaws ML, Dore GJ. Prevalence and risk factors for hepatitis C infection in rural north Vietnam. Hepatol Int. 2007;1(3):387-393. 35. Khattak MN, Akhtar S, Mahmud S, Roshan TM. Factors influencing Hepatitis C virus sero-prevalence among blood donors in north west Pakistan. J Public Health Policy. 2008;29(2):207-225. 36. Ashraf H, Alam NH, Rothermundt C, et al. Prevalence and risk factors of hepatitis B and C virus infections in an
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E30 ❘ Journal of Public Health Management and Practice
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Context: The potential for hepatitis B and C virus (HBV/HCV) transmission in nail salons and barbershops has been reported, but a systematic review has not been conducted. These businesses are regulated by state cosmetology or barbering boards, but adequacy of sanitary requirements has not been evaluated. Objectives: To conduct literature review to assess risk for HBV/HCV transmission in nail salons and barbershops and to evaluate sanitary requirements in HBV/HCV prevention in these businesses in 50 states and District of Columbia. Design: Several search engines were used for literature search. Studies that quantified risks associated with manicuring, pedicuring, or barbering were included. State requirements for disinfection and sterilization were reviewed and evaluated. Main Outcome Measure: For literature review, odds ratios, 95% confidence intervals, and confounding adjustment were extracted and evaluated. For regulation review, requirements for disinfection or sterilization for multiuse items in nail salons and barbershops were assessed according to the US federal guidelines. Results: Forty-six studies were identified and 36 were included in this study. Overall, the results were not consistent on risk for HBV/HCV transmission in nail salons and barbershops. For sanitary requirements, disinfection with an Environmental Protection Agency–registered disinfectant is required in 39 states for nail salons and in 26 states for barbershops. Sterilization was described in 15 states for nail salons and in 11 states for barbershops, but the majority of these states listed it as an optional approach. Sanitary requirements are consistent in states where 1 board regulates both businesses but are J Public Health Management Practice, 2014, 20(6), E20–E30 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
substantially discrepant in states with separate boards. Conclusions: Current literature cannot confirm or exclude the risk for HBV/HCV transmission in nail salons and barbershops. Existing sanitary requirements are adequate in the majority of states, but compliance is needed to prevent HBV/HCV transmission in these businesses. KEY WORDS: barbers, government regulation, hepatitis virus,
nails, prevention
Hepatitis B and C virus (HBV/HCV) infections constitute a substantial worldwide health problem. Approximately 350 million and 123 million persons globally suffer from HBV and HCV infections, respectively.1,2 In the United States, an estimated 800 000 to 1.4 million persons have chronic HBV
Author Affiliations: Division of Surveillance and Investigation, Office of Epidemiology, Virginia Department of Health, Richmond, Virginia (Drs Yang and Woolard); Martha Jefferson Hospital at Sentara Health System, Charlottesville, Virginia (Dr Hall); and Centers for Disease Control and Prevention, Atlanta, Georgia (Ms Nuriddin). The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention. The authors thank David Johnson, MD, Professor of Medicine at Eastern Virginia Medical School, for conceptual assistance, and Shuhui Wang, MPH, Marshall Vogt, MPH, and David Trump, MD, from the Virginia Department Health for assistance with map design, regulation review, and editorial suggestions, respectively. None of these people has received compensation for the contributions. The authors declare no conflicts of interest and no funding. Correspondence: Jun Yang, PhD, MS, Division of Surveillance and Investigation, Office of Epidemiology, Virginia Department of Health, 109 Governor St, Richmond, VA 23219 ([email protected]). DOI: 10.1097/PHH.0000000000000042
E20 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Risk for Hepatitis B and C Virus Transmission in Nail Salons and Barber Shops
infections, and 2.7 to 3.9 million persons have chronic HCV infections.3 Recognized risk factors for HBV infections include blood transfusions, intravenous drug use, body piercing and tattoos, unsafe sexual behaviors, and invasive health care procedures.4 For HCV infections, intravenous drug use is the primary risk factor in socioeconomically developed countries and unsafe medical injections and blood transfusions are the primary risk factors in lower-income countries.2,5 Transmission of HBV/HCV can occur in both health care and personal care settings if blood or serous fluid from an infected person has an opportunity to enter an opening in the skin of an uninfected person. In personal care settings (eg, nail salons and barbershops), transmission opportunities can be facilitated if multiuse items are contaminated with HBV/HCV from one person and are used on another person before being cleaned and disinfected.6 Examples of multiuse items include nail clippers, nail files, tweezers, brushes, drill bits, razors, and scissors. To facilitate infection control in health care settings, the Centers for Disease Control and Prevention (CDC) has developed the Guideline for Disinfection and Sterilization in Healthcare Facilities (CDC Guideline).7 Guidelines specifically addressing HBV and HCV prevention are unavailable for settings in which noncritical items are used on multiple clients routinely (eg, nail salons and barbershops). The CDC Guideline categorizes medical items as critical, semicritical, or noncritical.7 Critical items are those that confer a high risk for infection if they are contaminated with any microorganism (eg, objects that enter sterile tissue or the vascular system). Semicritical items confer a reduced risk because they only come into contact with mucous membranes or nonintact skin. Noncritical items are those that come in contact with intact skin but not mucous membranes and provide the least risk for transmitting infection.7 Examples of noncritical items for personal care services include razors, metal cuticle pushers and files, scissors, tweezers, and nail clippers. The CDC Guideline also addresses disinfection and sterilization strategies and approaches for preventing health care– associated infections, including HBV/HCV infections. Disinfection and sterilization are chemical or thermal processes designed to eliminate microorganisms. Sterilization is used primarily for critical items and certain semicritical items, and disinfection is used primarily for semicritical and noncritical items. Sterilization can eliminate bacterial spores but disinfection cannot.7 Given the theoretical risk for HBV/HCV transmission associated with manicuring, pedicuring, and barbering services, we conducted a literature review to assess this risk and a review of state
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regulations to evaluate the adequacy of sanitary requirements within the United States in preventing HBV/HCV transmission in nail salons and barbershops. To our knowledge, the literature review and the state regulation review for these settings as described in this study have not been previously reported.
● Methods Literature search and study selection A literature search was conducted through PubMed, PubMed Central, Medline, and reference cross-check in published articles. Key words that were used for the search were manicure, pedicure, nail salon, barber, razor, nail clipper, risk factor, and hepatitis. Epidemiologic studies published in English in the United States and other countries before May 31, 2013 were identified and reviewed. All studies were included for review except those that described only the percentages of risk factors among participants without a risk estimate (eg, calculation of odds ratios), and the published data were insufficient to generate a risk estimate. Information about publication year, study location, study population, study design, sample size, viruses studied, risk factors of interest and odds ratios, and confounding adjustment was extracted. Because the majority of studies that assessed manicuring, pedicuring, or barbering in the transmission of HBV/HCV also assessed sharing of personal items (eg, nail clippers and razors), we included all of these factors in the literature review to understand the risk for HBV/HCV transmission associated with nail care and barbering in both commercial and personal settings.
State regulations Active websites of state regulatory boards for nail salons and barbershops throughout the 50 states and the District of Columbia were explored or searched for regulations regarding sanitary requirements as of May 31, 2013. A website was regarded as active if a website was updated or modified within the last year with new information posted to reflect that the website contents were up-to-date. If the regulation could not be identified from the website or if further clarification was needed, the authors contacted the board by e-mail or telephone. For a regulation to be included for review, the regulation must be referred as a cosmetology regulation or a regulation covering nail salons or barbershops. Regulations were available online from 49 states and District of Columbia.
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E22 ❘ Journal of Public Health Management and Practice One state mailed the regulations to the investigators. Two investigators (JY and AN) independently conducted regulation reviews by focusing on descriptions of sanitary requirements, relevant products, and the required disinfection and sterilization methods. The CDC Guideline for Disinfection and Sterilization in Healthcare Facilities and the Food and Drug Administration’s guidance for industry on sterility information were used to interpret the terminology and disinfection and sterilization methods stipulated in each regulation.7,8 To understand the sanitary requirements within a state regulation, the reviewers first determined whether a definition section was available and if yes, whether sanitation, disinfection, and sterilization were defined consistently with the CDC Guideline. Second, the reviewers determined whether a general sanitary section was available and if yes, what general requirements were described, including methods or procedures, disinfectants, and implements to be disinfected. Third, the reviewers determined whether specific sanitary sections under nail services or barbering services were available and if yes, what requirements were described, including methods or procedures, disinfectants, and implements to be disinfected. Sanitary requirements specified for service areas other than manicuring, pedicuring, and barbering (eg, electrolysis and esthetics) were not regarded as requirements for nail salons and barbershops. Considering the substantial variations in disinfection and sterilization descriptions across regulations, an indication of US Environmental Protection Agency (EPA)–registered disinfectants was used to compare disinfection requirements throughout all 50 states and District of Columbia. Sterilization descriptions were interpreted on the basis of CDC and Food and Drug Administration guidance for the purpose of eradicating all microorganisms, including bacterial spores. A specific method of sterilization as recognized by CDC or Food and Drug Administration was needed for reviewers to determine whether a regulation described sterilization. Furthermore, the reviewers determined whether sterilization was required or optional if it was described. Geographic information system software, ArcGIS version 10 (ESRI, Redlands, California), was used to generate maps to display sanitary requirements on disinfection and sterilization in nail salons and barbershops in all 50 states and District of Columbia. The maps also displayed the number of regulatory boards for these 2 types of businesses to reflect the discrepancies of sanitary requirements by regulatory boards. For statistical purposes, District of Columbia was counted as a state.
● Results Literature review We identified a total of 46 studies through our literature search. After an initial review, 10 studies were excluded because risk estimates were not presented or the published data were insufficient for risk estimate calculation. The remaining 36 studies included 1 cohort study,9 8 population-based matched case-control studies,10-17 1 hospital and household-based matched case-control study,18 5 population-based unmatched case-control studies,19-23 6 facility or household-based unmatched case-control studies,24-29 8 cross-sectional studies among community populations,30-37 and 7 cross-sectional studies among prisoners or populations at high risk.38-44 The Table presents the publication year, study location, study design, study population, sample size, viruses studied, odds ratios, and confounding adjustment for the 36 studies that were included. Fifteen of the 36 studies assessed risk for HBV/HCV infection with manicuring, pedicuring, or sharing of personal nail clippers. Of these 15 studies, 6 assessed the risk for HBV infections in association with manicuring or pedicuring and 3 reported statistically significant associations. Two of these 3 studies were community-based studies in China (adjusted odds ratio [aOR], 2.0; 95% confidence interval [CI], 1.4-2.9)13 and Italy (aOR, 1.4; 95% CI, 1.0-2.1)20 ; the last was a household-based study in Italy (aOR, 1.3; 95% CI, 1.0-1.7).26 Assessing the risk for HBV infections in association with sharing of personal nail clippers accounted for 2 of the 15 studies, but only 1 reported a statistically significant association in the unadjusted analysis (OR, 2.8; 95% CI, 2.03.9; adjusted analysis was not performed).19 Seven of the 15 studies assessed the risk for HCV infections in association with manicuring or pedicuring, but only 2 reported statistically significant associations. These 2 studies were community-based studies conducted in France (aOR, 1.7; 95% CI, 1.2-2.6)11 and Brazil (aOR, 3.5; 95% CI, 1.9-6.3).22 Four of the 15 studies assessed the risk for HCV infections associated with sharing of personal nail clippers, but none reported a statistically significant association. Further review indicated that 32 of the 36 studies evaluated the risk for HBV/HCV infections associated with barbering services or sharing of personal razors. Of these 32 studies, 14 evaluated the risk for HBV infections in association with professional barbering services, and 6 reported statistically significant associations. Four of these 6 were community-based studies conducted in Thailand (unadjusted OR, 2.5; 95% CI, 1.7-3.2; adjusted analyses were not performed),19 Italy (aOR, 1.8; 95% CI, 1.5-2.2),20 Pakistan (aOR, 2.3; 95%
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Risk for Hepatitis B and C Virus Transmission in Nail Salons and Barber Shops
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TABLE ● Studies of Hepatitis B and C Virus (HBV/HCV) Transmission Associated With Manicuring, Pedicuring, Barbering, or Sharing of Personal Nail Clippers and Razors qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Year and Location Cohort study 2010b , Australia9
Participants 488 prisoners, 94 HCV patients
Population–based matched case-control study 196 patients, 400 control 2000b , Japan10 subjects 450 patients, 757 control 2006b , France11 subjects 64 patients, 227 control 2007b , France12 subjects 294 patients, 588 control 2008b , China13 subjects 2008b , Netherlands14 120 patients, 3948 control subjects 69 patients; 207 control 2009b , China15 subjects 327 HBV patients, 723 HCV 2009b , Pakistan16 patients, 723 control subjects 2011b , China17 305 patients, 610 control subjects
Virusa
Barbering OR (95% CI)
Sharing of Personal Nail Clippers OR (95% CI)
Not assessed
C− (OR not reported)c
C
Not assessed
C+; 4.9 (1.3-18.6)d Not assessed
C
C+; 1.7 (1.2-2.6) Not assessed
Not assessed
Not assessed
C
Not assessed
C−; 0.8 (0.4-1.4)
C−; 0.6 (0.3-1.1)
B
B+; 2.0 (1.4-2.9) B− (OR not reported) B− (OR not B− (OR not reported) reported) Not assessed Not assessed
Not assessed
C−; 1.2 (0.6-2.2)
B− (OR not reported) B− (OR not reported) Not assessed
B, C
Not assessed
B−, C− (OR not reported)
Not assessed
Not assessed
C
Not assessed
C+; 29.2 (13-66.0) Not assessed
Not assessed
C− (OR not reported)
C− (OR not reported)
C− (OR not reported)
C− (OR not reported)
B C
Not assessed
Not assessed
Sharing of Personal Razors OR (95% CI)
C
Hospital and household-based matched case-control study 94 patients, 188 control C 2009b , Egypt18 subjects Population-based unmatched case-control study 876 patients, 1750 control 1992e , Thailand19 subjects 2964 HBV patients, 598 HCV 2004b , Italy20 patients, 7221 control subjects 2005b , Pakistan21 64 patients, 260 control subjects 116 patients, 140 control 2010b , Brazil22 subjects 71 patients, 212 control 2010b , India23 subjects
Manicure or Pedicure OR (95% CI)
Not assessed
C− (OR not reported) Not assessed
B
B−; 0.8 (0.6-5.1) B+; 2.5 (1.7-3.2)
B+; 2.8 (2.0-3.9)
B+; 4.5 (3.8-5.3)
B, C
B+; 1.4 (1.0-2.1) B+; 1.8 (1.5-2.2) C−; 0.9 (0.4-1.9) C+; 1.4 (1.0-2.1)
Not assessed
Not assessed
B
Not assessed
B+; 2.3 (1.1-4.8)
Not assessed
Not assessed
C
C+; 3.5 (1.9-6.3) C+; 2.3 (1.3-4.3)
Not assessed
C+; 2.0 (1.1-3.7)
B
Not assessed
B+; 4.1 (2.1-8.0)
Not assessed
Not assessed
Not assessed
Not assessed
B+; 8.1 (2.8-28.3)
Not assessed
B+; 1.7 (1.1-2.5)
B− (OR not reported) Not assessed
B+; 1.3 (1.0-1.7) B+; 1.6 (1.4-1.9) C−; 1.0 (0.5-1.8) C−; 1.3 (0.9-2.0)
Not assessed
Not assessed
Not assessed
Not assessed
Not assessed
Hospital or household-based unmatched case-control study B 1985e , Singapore24 88 patients, 97 control subjects 2460 patients, 708 control B 1990b , Italy25 subjects 6395 HBV patients, 363 HCV B, C 1995b , Italy26 patients, 4789 control subjects 1997b , Italy27 162 patients, 788 control B subjects
B−; 2.5 (0.7-8.5)
Not assessed
(continues)
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E24 ❘ Journal of Public Health Management and Practice TABLE ● Studies of Hepatitis B and C Virus (HBV/HCV) Transmission Associated With Manicuring, Pedicuring, Barbering, or Sharing of Personal Nail Clippers and Razors (Continued) qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Year and Location 2006e , Pakistan28
2006b , Germany29
Participants 41 HBV patients, 63 HCV patients, 44 control subjects 17 patients, 26 control subjects
Cross-sectional study in community populations 6033 participants, 2002b , Egypt30 523 patients 2154 participants, 71 patients 2002b , Italy31 2005b , Turkey32 2006b , Pakistan33 2007b , Vietnam34 2008b , Pakistan35 2010b , Bangladesh36 2010b , Pakistan37
717 participants, 39 patients 3533 participants, 65 HBV patients, 55 HCV patients 837 participants, 8 patients 1131 participants, 46 patients 1997 participants, 582 HBV patients, 4 HCV patients 1997 participants, 476 patients
Virusa
Manicure or Pedicure OR (95% CI)
2011b , Brazil42 2011b , United States43 2011b , Nigeria44
Sharing of Personal Nail Clippers OR (95% CI)
Sharing of Personal Razors OR (95% CI)
B, C
Not assessed
B−; 0.04 (0.0-0.4) Not assessed C+; 2.8 (1.2-6.9)
Not assessed
B
B− (OR not reported)
B− (OR not reported)
Not assessed
Not assessed
C
Not assessed
C−; 0.9 (0.4-2.0)
Not assessed
C−; 1.0 (0.4-2.6)
C
Not assessed
Not assessed
Not assessed
B B, C
C− (OR not reported) Not assessed Not assessed
Not assessed Not assessed
B−; 1.8 (0.0-8.3) Not assessed
C C B, C
Not assessed Not assessed Not assessed
Not assessed Not assessed Not assessed
C−; 3.5 (0.8-14.7) Not assessed Not assessed
C
Not assessed
Not assessed B−; 0.6 (0.4-1.1) C−; 1.1 (0.5-2.1) Not assessed C+; 5.5 (2.6-11.7) B−, C− (OR not reported) C+; 5.0 (1.6-16.1)
Not assessed
Not assessed
Cross-sectional study in drug users, prisoners, or hospital patients 98 participants, 24 cases C Not assessed 1999e , Pakistan38 437 participants, 55 patients C Not assessed 2001b , Canada39 2005b , United States40 2010b , Pakistan41
Barbering OR (95% CI)
722 participants, 28 patients
C
Not assessed
357 participants, 21 HBV patients, 65 HCV patients 303 participants, 13 patients 782 female drug users, 162 HCV patients 360 hospital patients, 17 patients
B, C
Not assessed
C−; 2.3 (0.2-25.7) Not assessed Not assessed Not assessed Not assessed
C−; 0.4 (0.2-1.0)
C−; 3.6 (0.4-32.4) C− (OR not reported) C−; 1.8 (0.6-5.2)
Not assessed
Not assessed
C C
B−, C−; 0.5 (0.2-1.2)f C−; 0.3 (0.1-1.2) Not assessed Not assessed Not assessed
Not assessed Not assessed
C
Not assessed
Not assessed
Not assessed C− (OR not reported) C−; 1.0 (0.3-3.2)
Not assessed
Abbreviations: CI, confidence interval; HBV, hepatitis B virus; HCV, hepatitis C virus; OR, odds ratio. a B indicates that hepatitis B virus was studied; C indicates that hepatitis C virus was studied. b Results adjusted for other risk factors. c − indicates that a significantly increased risk was not identified. d + indicates that a significantly increased risk was identified (P < .05). e Results not adjusted for other risk factors.
CI, 1.1-4.8),21 and India (aOR, 4.1; 95% CI, 2.1-8.0)22 ; the last 2 were hospital-based studies conducted in Italy (aOR, 1.7; 95% CI, 1.1-2.5; aOR, 1.6; 95% CI, 1.41.9, respectively).25,26 One study in Pakistan indicated a negative association for HBV infection and barbering (unadjusted OR, 0.04; 95% CI, 0-0.4), which was likely the result of limited sample size.28 Five of the 32 studies evaluated the risk for HBV infections in association with sharing of personal razors, and 2 reported signifi-
cant associations in unadjusted analyses (OR, 4.5; 95% CI, 3.8-5.3; OR, 8.1; 95% CI, 2.8-28.3; adjusted analyses were not performed in these 2 studies).19,23 Of the 32 studies, 16 assessed the risk for HCV infection associated with professional barbering services, and 7 reported significant associations. These included 4 community-based case-control studies conducted in Japan (aOR, 4.9; 95% CI, 1.3-18.6),10 China (aOR, 29.2; 95% CI, 13.0-66.0),17 Italy (aOR, 1.4; 95% CI, 1.0-2.1),20
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Risk for Hepatitis B and C Virus Transmission in Nail Salons and Barber Shops
and Brazil (aOR, 2.3; 95% CI, 1.3-4.3)22 ; 1 hospital-based case-control study in Pakistan (unadjusted OR, 2.8; 95% CI, 1.2-6.9)28 ; and 2 community-based surveys in Pakistan (aOR, 5.5; 95% CI, 2.6-11.7; aOR, 5.0; 95% CI, 1.6-16.1).35,37 In addition, 10 of the 32 studies evaluated the risk for HCV infections in association with sharing of personal razors, but only 1 reported a statistically significant association (aOR, 2.0; 95% CI, 1.1-3.7).22 Only 2 studies conducted in the United States were identified through the literature search. One study, conducted among noninjection drug users, did not find a significant association with HCV for sharing of personal razors or clippers.40 Similarly, the other study was conducted among female drug users and did not find a significant association with HCV for sharing of personal razors.43 The risk for HBV transmission was not evaluated in these 2 studies.
Disinfection requirements Forty-six states require disinfection for multiuse items among clients in nail salons and specify the disinfectants to be used (Figure 1 ). Thirty-nine of these states require that an EPA-registered disinfectant be used. Seven of the 46 states have similar requirements for disinfection in nail salons but do not specify that products should be EPA-registered. Regulations from these 46 states include guidance on general sanitary requirements, disinfection procedures or methods, implements to be disinfected, and disinfectants that should be used. The described disinfection process usually includes thorough washing and cleaning of a soiled, multiuse implement and then immersing it completely in a disinfectant solution for 10 minutes or according to the manufacturer’s instructions on the disinfectant label. Five states do not specify methods of disinfection or disinfectants to be used in nail salons. For barbershops, 45 states require disinfection for multiuse implements among clients and specify the disinfectants to be used (Figure 1). Twenty-six of these 45 states stipulate that EPA-registered products be used for disinfection in barbershops. Nineteen of the 45 states describe or list products for disinfection but do not specify whether they should be EPA-registered. Six states do not specify methods of disinfection or disinfectants to be used in barbershops.
Sterilization requirements For nail salons, 15 states describe sterilization and list at least 1 method intended to eradicate bacterial spores. Thirteen of these 15 states list sterilization as an option but not a requirement for multiuse implements. Two states list sterilization as a requirement, but the requirement is only for selected multiuse implements
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(Figure 2 ). For barbershops, 11 states describe sterilization and list at least 1 method intended to eradicate bacterial spores. For all 11 states, sterilization is listed as an option but not a requirement for multiuse implements (Figure 2). Steaming, dry heat, autoclaving, boiling, and chemical sterilization were the primary sterilization methods described for both nail salons and barbershops.
Regulatory board and regulation discrepancy Twenty-three states have 1 combined board that regulates both nail salons and barbershops. In these states, disinfection requirements are consistent for nail salons and barbershops regarding disinfectant recommendations (Figure 1). Specifically, 19 states require use of EPA-registered disinfectants in both settings, and 4 states do not specify disinfectants for either setting. Sterilization requirements are also consistent for nail salons and barbershops in these states (Figure 2). Twenty-seven states have 2 separate boards that regulate nail salons and barbershops. Consistent disinfection requirements in both settings are available in only 13 states (Figure 1). Eight of the 27 states have different descriptions or recommendations for sterilization practices within nail salons and barbershops (Figure 2).
● Discussion Compared with the recognized risk factors for HBV/HCV transmission (eg, intravenous drug use, blood transfusion, and unsafe sexual activity), personal care services are relatively understudied and less documented, especially in the United States. The majority of the published studies were conducted in Asia, South America, and Europe, where the prevalence of HBV/HCV infections is relatively high.1,2,4 Only 2 studies have been reported in the literature among drug users in the United States, neither of which reported an association with personal care items.40,43 Findings from the published studies were inconsistent regarding the risk for HBV/HCV transmission associated with nail salon and barbershop services and with sharing of personal nail clippers or razors. Although certain studies demonstrated increased risks for HBV/HCV transmission for these potential risk factors, the majority of studies did not find an association. Caution is needed when interpreting and comparing the published data because of the heterogeneities across studies. Such heterogeneities include location, population sampled, sample size, case definition and selection of patients and control participants, instruments and approaches used for data collection, analytic methods,
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E26 ❘ Journal of Public Health Management and Practice FIGURE 1 ● State Disinfection Requirements in Nail Salons and Barber Shops—United Statesa
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a Numbers on the map indicate regulation of nail salons and barber shops by 1 combined board or 2 separate boards. Alabama has only a State Board of Cosmetology that regulates nail salons; it does not have a State Board of Barber Examiners.
and adjustment of confounding factors. In addition, because certain studies were not designed primarily to investigate HBV/HCV transmission associated with these risk factors, they did not collect specific detailed data regarding these risk factors (eg, cuts or bruising obtained during services); therefore, we were unable to perform more precise analyses. Regarding regulations for nail salons and barbershops, the majority of states have adequate sanitary requirements to eliminate HBV/HCV from multiuse implements in these settings. Because implements used in nail salons and barbershops primarily come in contact with intact skin but not mucous membranes, they
belong to noncritical items on the basis of the CDC Guideline. Noncritical items usually require an exposure of 10 minutes in a low-level disinfectant, which is defined as a disinfectant capable of destroying all vegetative bacteria (except tubercle bacilli), lipid viruses, certain nonlipid viruses, and certain fungi, but not bacterial spores, for a practical period (eg, 10 minutes). Examples of low-level disinfectants include EPAregistered hospital disinfectants with an HBV/HIV label claim.7 If a state requires that a soiled implement be completely immersed in an EPA-registered disinfectant solution for 10 minutes or according to the disinfectant’s label instructions after thorough
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Risk for Hepatitis B and C Virus Transmission in Nail Salons and Barber Shops
❘ E27
FIGURE 2 ● State Sterilization Requirements in Nail Salons and Barber Shops—United Statesa
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
a Numbers on the map indicate regulation of nail salons and barber shops by 1 combined board or 2 separate boards. Alabama has only a State Board of Cosmetology that regulates nail salons; it does not have a State Board of Barber Examiners.
washing and cleaning, HBV/HCV will be eradicated in this process. For states that do not specify EPAregistered disinfectants, if the listed disinfectants have germicidal capabilities, the disinfectants should eliminate HBV/HCV, if used correctly. However, these states might consider specifying EPA-registered disinfectants or specifying the required germicidal capabilities in the regulations to help nail salon and barbershop technicians better understand and implement the sanitary requirements. In addition to the germicidal capabilities of a disinfectant, certain factors can affect disinfection
effectiveness, including the physical nature and state of cleanliness of an item before disinfection, and compliance by nail or barber technicians with the sanitary requirements and the disinfectant’s label instructions. Thus, the prevention of HBV/HCV transmission relies on both adequate sanitary requirements and compliance. Because nail salons and barbershops usually have substantial employee turnover, providing continuing education for workers can reinforce the necessity of infection control and foster improved compliance with sanitation requirements. In addition, periodic inspection of a facility can help identify
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E28 ❘ Journal of Public Health Management and Practice and correct sanitary problems that might facilitate HBV/HCV transmission. Our study reveals that sterilization is not described in the majority of regulations. In the limited number of states where sterilization is described, it is listed primarily as an optional approach to removing microorganisms from multiuse items. In 2 states where sterilization is listed as a requirement for nail salons, it is intended to be used on selected rather than all multiuse items. Because sterilization is a higher-level process than disinfection for eliminating microorganisms, HBV/HCV can be eradicated by sterilization if used correctly. Considering the low resistance of HBV/HCV to disinfection, sterilization is not a necessary measure for HBV/HCV prevention when a standard disinfection process is implemented in nail salons and barbershops. However, sterilization might be needed if elimination of other microorganisms is within a regulation’s scope. The term sterilization is used sometimes to reference sanitation or disinfection and does not reference the eradication of bacterial spores within the regulation. This might cause a business operator to misinterpret the goal of sterilization on the basis of these guidelines; therefore, correct use of the term sterilization in these regulations is strongly recommended. Our study demonstrates that disinfection and sterilization requirements are consistent for nail salons and barbershops when both settings are regulated by the same board but are often discrepant when the businesses are regulated by separate boards. Because implements used in both settings require the same level of disinfection, improved communication and coordination are needed between the regulatory boards to provide consistent recommendations for nail salons and barbershops if they are not regulated by the same board. It is also noteworthy to point out that the regulatory boards should consider posting the regulations, especially the section of sanitary requirements, upfront on the website where visitors can easily find and download. There are several limitations in this study. For the literature review, one limitation is the lack of heterogeneity assessment for the published studies. Because these studies were conducted among different populations in different countries, there were variations in study design, sample size, definition and selection of cases and controls, data measurements and acquisition, analytic methods, and confounding control. These variations might be associated with the risk estimations across these studies. Another limitation is that these studies were reviewed only by 1 investigator (JY). Although the investigator reviewed these studies and the abstracted data multiple times, potential errors were still likely to occur. Another investigator’s independent review can usually prevent such potential
errors. For the regulation review, 1 major limitation is the lack of a standardized measurement for disinfection and sterilization in the regulations. For example, although we used “EPA-registered disinfectants” as a measurement to evaluate disinfection in the regulations, the quality and type of EPA-registered disinfectants allowed for use varied substantially from one regulation to another. Factors such as the dilution of a disinfectant and cleaning procedures employed also play a role in the effectiveness of disinfection. In addition, for disinfection to be effective, the duration of time that an item is exposed to disinfectants is also important. Because of the noted variations, we did not include these factors within our assessment. Similarly, we also noted variations for sterilization across the state regulations that mentioned this approach. Finally, we did not have access to information on regulation enforcement and compliance in the 50 states and District of Columbia. For the prevention of HBV/HCV in nail salons and barbershops, both adequate sanitary requirements and compliance are important.
● Conclusions Data from the literature cannot confirm or rule out the risk for HBV/HCV transmission associated with personal care services. Additional studies, which consider disinfection and sterilization quality and type along with compliance with state regulations, are needed that focus on the risk for HBV/HCV transmission through exposures in nail salons and barbershops. The sanitary requirements in the majority of states are sufficient for HBV/HCV prevention if workers comply with state requirements and adhere to disinfectants’ label instructions. However, efforts are needed in other states to improve and standardize regulations according to the CDC Guideline, especially if nail salons and barbershops are regulated by separate boards.
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Risk for Hepatitis B and C Virus Transmission in Nail Salons and Barber Shops
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