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Tattoo-associated nontuberculous mycobacterial skin infections - multiple States, 2011-2012

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Tattoo-associated nontuberculous mycobacterial skin infections - multiple States, 2011-2012

Tattoo-Associated Nontuberculous
Mycobacterial Skin Infections — Multiple
States, 2011–2012
Weekly
August 24, 2012 / 61(33);653-656
On August 22, this report was posted as an MMWR Early Release on the MMWR website
(http://www.cdc.gov/mmwr).
Permanent tattoos have become increasingly common, with 21% of adults in the United States reporting having at
least one tattoo (1). On rare occasions, outbreaks of nontuberculous mycobacterial (NTM) skin infections have been
reported after tattooing (2,3). In January 2012, public health officials in New York received reports of Mycobacterium
chelonae skin infections in 14 New York residents who received tattoos during September–December 2011. All
infections were associated with use of the same nationally distributed, prediluted gray ink manufactured by company
A. CDC disseminated an Epi-X public health alert to identify additional tattoo-associated NTM skin infections;
previously identified cases were reported from three states (Washington, Iowa, and Colorado). Public health
investigations by CDC, state and local health departments, and the Food and Drug Administration (FDA) found NTM
contamination in tattoo inks used in two of five identified clusters. All infected persons were exposed to one of four
different brands of ink. NTM contamination of inks can occur during the manufacturing process as a result of using
contaminated ingredients or poor manufacturing practices, or when inks are diluted with nonsterile water by tattoo
artists. No specific FDA regulatory requirement explicitly provides that tattoo inks must be sterile. However, CDC
recommends that ink manufacturers ensure ink is sterile and that tattoo artists avoid contamination of ink through
dilution with nonsterile water. Consumers also should be aware of the health risks associated with getting an
intradermal tattoo.
On January 4, 2012, the Monroe County (New York) Department of Public Health began an outbreak investigation
after receiving a report of a person with a persistent papular rash beginning 1 week after being tattooed by an artist in
October 2011; M. chelonae was isolated from a skin biopsy. Since May 2011, the artist had been using company A
prediluted gray ink. Using a list of customers provided by the artist, a total of 19 infections were identified, including 14
confirmed with M. chelonae.
All infected persons had been tattooed with company A prediluted gray ink. The tattoo artist said he had not diluted
the ink before use, and a review of his practices did not reveal other potential sources of contamination. M.
chelonae was isolated from tissue specimens, and from one opened and one unopened bottle of company A
prediluted gray ink. Pulsed-field gel electrophoresis (PFGE) patterns of 11 available patient isolates and an unopened
bottle of company A prediluted gray ink were indistinguishable; the M. chelonae isolate from the opened ink bottle
showed 95% genetic relatedness to the other isolates. Water and environmental samples collected at the
manufacturing company and tattoo parlor were negative for M. chelonae.
Company A prediluted gray ink was a nationally distributed product. To identify additional tattoo-related NTM
infections not limited to exposure to any particular brand of ink, case finding was initiated February 15, 2012, through
Epi-X using the following case definitions: 1) a possible case was defined as persistent inflammatory reaction (i.e.,
redness, swelling, or nodules) localized within the margins of a new tattoo on a person between May 1, 2011, and
February 10, 2012; 2) a probable case was defined as a possible case with evidence of an NTM infection by
histopathology or clinical response to treatment; 3) a confirmed case was defined as a possible case with NTM
cultured from a wound or skin biopsy. The New York cluster included 14 confirmed and four probable cases, and one
possible case. An investigation by Public Health – Seattle & King County, Washington, identified five confirmed and
26 possible cases. Confirmed cases also were reported from Iowa (two) and Colorado (one) (Table). Among 22
confirmed cases, 63.6% involved men, and the median age of persons in the 22 cases was 33.5 years (range: 20–48
years).
Cases identified in Washington were associated with two clusters, and the initial two cases from patients with recent
tattoos were reported by clinicians to local public health authorities. The first, Washington cluster 1, had three
confirmed Mycobacterium abscessus cases and 24 possible cases in persons tattooed with black ink from company
B. Water and environmental samples collected from company B did not grow NTM, but the company reported
receiving complaints of unusually long-lasting skin reactions in clients tattooed with company B black ink from 35
customers in 19 states between August 2011 and March 2012. Customer identifiers were not available to CDC for
follow-up. Two M. abscessus clinical isolates from Washington cluster 1 were indistinguishable by PFGE, but NTM
was not recovered from samples of brand B ink. The second Washington cluster had two confirmed cases of M.
chelonae and two possible cases associated with company C gray ink. One clinical isolate from Washington cluster 2
was available for testing. A sample from an opened bottle of company C gray ink grew M. chelonae, which was
unrelated to the Washington cluster 2 clinical isolate and was unrelated to New York isolates, based on PFGE
patterns. Reviews of tattoo practices at the parlors associated with the clusters did not reveal other potential sources
of contamination.
The Iowa Department of Public Health reported two confirmed M. chelonae cases. Patients were tattooed with black
ink from company C. PFGE testing showed that two clinical isolates from Iowa and the clinical isolate from
Washington cluster 2 were indistinguishable from each other, but unrelated to New York isolates. Ink and
environmental samples were not available for testing.
The Colorado Department of Public Health and Environment reported one confirmed case of M. chelonae infection.
PFGE testing showed that this strain was unrelated to any of the clinical and ink isolates identified in other clusters.
Artists at the Colorado tattoo parlor reported using distilled or reverse osmosis water to dilute company D black ink.
Although used for tattooing, the ink was labeled as a drawing ink, and specified as not indicated for tattooing. The
artist rinsed needles with distilled or reverse osmosis water when switching colors of ink on the same client. An
unopened bottle of company D black drawing ink, reverse osmosis water samples, and environmental samples were
tested, but NTM were not recovered.
In March and April 2012, FDA conducted inspections of company A and company B ink manufacturing sites.
Ingredients used in the manufacture of tattoo inks at those sites included a wide range of pigments, carrier solutions,
and diluents, including distilled water in some formulations. Samples of unopened ink bottles, ink ingredients,
environmental samples, distilled water, and tap water were tested at CDC and did not yield NTM.
Reported by
Brenden Bedard, MPH, Byron Kennedy, MD, Monroe County Dept of Public Health; Vincent Escuyer, PhD, Kara
Mitchell, PhD, Wadsworth Center, Mycobacteriology Laboratory, New York State Dept of Health. Jeffrey S. Duchin,
MD, Public Health – Seattle & King County, Washington; Paul Pottinger, MD, Stanley Hurst, MD, Univ of Washington.
Ken Sharp, MPA, Timothy Wickham, MPH, Iowa Dept of Public Health. Sarah Jackson, MPH, Wendy Bamberg, MD,
Colorado Dept of Public Health and Environment. Pamela LeBlanc, MPH, Coordinated Outbreak Response and
Evaluation Network; Linda M. Katz, MD, Office of Cosmetics and Colors, Center for Food Safety and Applied
Nutrition, Food and Drug Administration. Taranisia MacCannell, PhD, Judith Noble-Wang, PhD, Heather O'Connell,
PhD, Alexander Kallen, MD, Bette Jensen, MMSc, Div of Healthcare Quality Promotion, National Center for Emerging
and Zoonotic Infectious Diseases; Duc B. Nguyen, MD, Michael H. Kinzer, MD, EIS officers, CDC. Corresponding
contributors: Duc B. Nguyen, vif8@cdc.gov, 404-639-0027; Michael H. Kinzer, michael.kinzer@kingcounty.gov, 206-
263-8169.
Editorial Note
This report describes cases of tattoo-associated NTM skin infections in four states. The use of ink contaminated
before distribution or just before tattooing likely led to infections in each of the reported clusters. In the New York
cluster, NTM isolates from clinical specimens, and unopened containers of company A prediluted gray ink were
indistinguishable. In Washington cluster 2 and the Iowa cluster, intrinsic contamination of company C gray ink was
indicated by indistinguishable M. chelonae clinical isolates from infected tattoo lesions, with no other common
exposure except the brand of ink used for tattooing. NTM isolates matching cases were not cultured from any other
brand of ink; however, whether the ink samples tested were from the same batches of inks used in the cases could
not be determined.
The frequency of NTM skin and soft tissue infections occurring subsequent to tattooing is not known, but these events
have been reported previously, and dilution of inks with nonsterile water during tattooing was implicated (3–6). Tattoo-
associated NTM infections can range from mild inflammation (e.g., rash, papules, or nodules) to severe abscesses
requiring extensive and multiple surgical debridements. NTM infections are difficult to treat and can require a
minimum of 4 months of treatment with a combination of two or more antibiotics. Physicians who encounter persistent
papular rashes or nodules localized to newly tattooed areas should consider the possibility of an NTM infection.
Contamination of tattoo inks can occur during the manufacturing process and might persist if steps are not taken to
eliminate harmful microbial contaminants in the finished product. A cross-sectional laboratory survey in 2010 of 58
unopened ink bottles from different manufacturers identified intrinsic contamination with a variety of organisms in 10%
of these inks (7), but did not test for the presence of NTMs.
Many NTM species (e.g., M. abscessus and M. chelonae) are found in water, so the addition of nonsterile water to ink
during its manufacture or at its point of use could lead to contamination with NTM (3–5), and potentially result in
infections. In addition, a common misconception is that distilled and reverse osmosis water are sterile (8), leading to
the mistaken assumption that these products are acceptable for diluting tattoo inks. Dilution of inks with nonsterile
water or other ingredients at the point of use might lead to product contamination. Dilution of ink also will dilute
preservatives, if present, and make them less effective.
Under the Federal Food, Drug, and Cosmetic Act, tattoo inks are considered to be cosmetics, and the pigments used
in the inks are color additives requiring premarket approval (9). No specific FDA regulatory requirement explicitly
provides that tattoo inks must be sterile. However, intradermal introduction of nonsterile substances, such as tattoo
ink, can pose a health risk and is a public health concern.
The practice of tattooing may be regulated by local jurisdictions (9). Such regulations generally have required blood-
borne pathogens training and the use of hygienic practice during tattooing. A few local jurisdictions, such as Los
Angeles County (10), have issued requirements that sterile water be used in tattoo ink dilution.
The findings in this report are subject to at least the following limitation. Because on-site investigations took place
months after cases were reported, potentially contaminated batches and ingredients, such as distilled water and
pigments, were not available for testing. Similarly, water sources used for the manufacture of inks or for ink dilution
when patients were tattooed were not available.
Because tattoo inks are injected intradermally, CDC recommends that ink manufacturers be held to higher product
safety standards, which should include production of sterile inks. In addition, tattoo artists should 1) avoid using
products not intended for use in tattooing; 2) avoid ink dilution before tattooing, and if dilution is needed, use only
sterile water; 3) avoid use of nonsterile water to rinse equipment (e.g., needles) during tattoo placement; and 4) follow
aseptic techniques during tattooing (e.g., hand hygiene and use of disposable gloves). To reduce their risk for
infection, consumers should 1) use tattoo parlors registered by local jurisdictions; 2) request inks that are
manufactured specifically for tattoos; 3) ensure that tattoo artists follow appropriate hygienic practices; 4) be aware of
the potential for infection following tattooing, and seek medical advice if persistent skin problems occur; and 5) notify
the tattoo artist and FDA's MedWatch program* if they experience an adverse event.
References
1. Braverman S. One in five U.S. adults now has a tattoo: yet over two in five without a tattoo say adults with
tattoos are less attractive. New York, NY: Harris Interactive; 2012. Available
at http://www.harrisinteractive.com/vault/harris%20poll%2022%20-tattoos_2.23.12.pdf . Accessed
February 23, 2012.
2. Drage LA, Ecker PM, Orenstein R, Phillips PK, Edson RS. An outbreak of Mycobacterium
chelonae infections in tattoos. J Am Acad Dermatol 2010;62:501–6.
3. Kluger N, Muller C, Gral N. Atypical mycobacteria infection following tattooing: review of an outbreak in 8
patients in a French tattoo parlor. Arch Dermatol 2008;144:941–2.
4. Lollis BD, Kent RS. Cluster of nontuberculous mycobacteria skin infections from tattoos. US Air Force School
of Aerospace Medicine: San Antonio, Texas; 2010. Available
at http://airforcemedicine.afms.mil/idc/groups/public/documents/afms/ctb_139146.pdf . Accessed August
16, 2012.
5. Binić, I, Janković A, Ljubenović M, Gligorijević J, Jančić S, Janković D. Mycobacterium chelonae infection
due to black tattoo ink dilution. Am J Clin Dermatol 2011;12:404–6.
6. Rodriguez-Blanco I, Fernández LC, Suárez-Peñaranda JM, Pérez del Molino ML, Esteban J, Almagro
M. Mycobacterium chelonae infection associated with tattoos. Acta Derm Venereol 2011;91:61–2.
7. Høgsberg T, Saunte DM, Frimodt-Møller N, Serup J. Microbial status and product labelling of 58 original
tattoo inks. J Eur Acad Dermatol Venereol 2011;doi:10.1111/j.1468-3083.2011.04359.x.
8. Wallace RJ Jr, Brown BA, Griffith DE. Nosocomial outbreaks/pseudo-outbreaks caused by nontuberculous
mycobacteria. Annu Rev Microbiol 1998;52:453–90.
9. Food and Drug Administration. Tattoos & permanent makeup. Silver Spring, MD: US Department of Health
and Human Services, Food and Drug Administration; 2010. Available
at http://www.fda.gov/cosmetics/productandingredientsafety/productinformation/ucm108530.htm . Accessed
August 7, 2012.
10. County of Los Angeles. Los Angeles County Code: department regulations—body art. Baldwin
Park, CA: County of Los Angeles, Department of Public Health; 1999. Available
at http://admin.publichealth.lacounty.gov/eh/docs/balacregulations.pdf . Accessed August 17, 2012.
* Additional information available at http://www.fda.gov/safety/medwatch/howtoreport/default.htm .
What is already known on this topic?
Outbreaks of tattoo-associated nontuberculous mycobacterial (NTM) skin infections are reported infrequently. Dilution
of tattoo inks with nonsterile water during tattooing has been implicated as a potential source of infection.
What is added by this report?
Investigations of 22 cases of tattoo-associated NTM skin infections in four states that occurred during 2011–2012
found contamination of ink with NTM before use. NTM contamination can occur during the manufacturing process as
a result of using contaminated ingredients or as a result of dilution with nonsterile water by the tattoo artist before use.
What are the implications for public health practice?
This report highlights the risk for tattoo-associated NTM skin infections resulting from use of contaminated inks or
nonsterile water for ink dilution. To prevent infection, CDC recommends that only sterile ink products and sterile water
should be used and appropriate hygienic practices should be followed when tattooing.
TABLE. Characteristics of nontuberculous mycobacteria (NTM) tattoo-associated skin
infection clusters — multiple states, 2011–2012
State No. of cases Mycobacterium spe
cies identified
Tattoo ink
supplier and type
Note
Confirme
d
Probabl
e
Possibl
e
Compan
y
Ink
New York 14 4 1 M. chelonae A Predilute
d gray
Clinical and
company A
ink isolates
indistinguisha
ble
Washingt
on
3 0 24 M. abscessus B Black No NTM
isolated from
company B
ink
Washingt
on
2 0 2 M. chelonae C Gray Clinical and
company C
ink isolates
unrelated
Iowa 2 0 0 M. chelonae C Black Available
clinical
isolates from
Iowa cluster
and
Washington
cluster 2 were
indistinguisha
ble
Colorado 1 0 0 M. chelonae D Black Clinical
isolate was
unrelated to
New York or
Washington
isolates, no
NTM isolated
from ink
... Among the 10 studies reporting microbiological complications, five were case reports and five were case series (table 1). [14][15][16][17][18][19][20][21][22][23] The quality was good in seven studies, poor in two and fair in one. ...
... Bedard et al reported cases of non-tuberculous mycobacteria skin infections related to the use of ink contaminated before distribution or just before tattooing. 14 Ramey et al in their case series found that warts were seven times more likely to be localised within black ink of tattoos when compared with coloured ink. 20 ...
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Background Tattoos were historically associated with deviant behaviours or religious and other social purposes, but in the last decades, they have gained increasing popularity and have become a mainstream. The aim of this systematic review is to assess the literature evidence about decorative tattoos complications, considering both infective and non-infective risks. Methods This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. We searched the following electronic bibliographic databases: PubMed, Scopus and Web of Science (science and social science citation index). Results The literature search resulted in 6473 studies. A total of 207 full articles were considered potentially relevant and were reviewed independently by researchers. After full-text evaluation, 152 of 207 articles were excluded, as they did not meet selection criteria. The remaining 55 studies were included in the systematic review and their quality assessment was performed. Ten studies reported microbiological complications, 37 reported non-microbiological effects and eight reported either microbiological and non-microbiological complications. Conclusions Several well-known and uncommon risks are associated with tattooing and tattoo after-care. Public health authorities could take into account health education programmes for tattooists and customers in order to prevent health complications in people with tattoos. PROSPERO registration number CRD42020177972.
... Cutaneous (dermal) exposure of NTM, resulting from skin abrasions and penetrating trauma (eg, injections, piercing, acupuncture, surgical treatment), can produce a rash illness, which often requires treatment with a combination of antibiotics for several months [2][3][4][5][6]. In recent years, a number of NTM outbreaks associated with tattoo studios have been reported in the literature [7]. These outbreaks have been associated with poor infection control practices at tattoo studios and contamination of graywash ink at the point of manufacture. ...
... Due to these concerns, the FDA and the manufacturer of ink A issued a national recall of the implicated lot number on 22 July 2015. Mycobacterium chelonae has been linked to tattoo-associated outbreaks in the literature [7,15]. However, to date, our investigation is the only one to have linked clinical and environmental isolates by WGS. ...
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... NTM infections can have incubation periods that exceed 5 years (2), often require prolonged treatment, and can lead to sepsis and death. Extrapulmonary NTM outbreaks have been reported in association with contaminated surgical gentian violet (3), nail salon pedicures (4), and tattoos received at tattoo parlors (5), although few surveillance data have been available for estimating the public health burden of NTM.* On January 1, 2014, the Oregon Health Authority designated extrapulmonary NTM disease a reportable condition. ...
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