A descriptive survey on microbiological risk in beauty salons

Accepted Manuscript A descriptive survey on microbiological risk in beauty salons

Laura Mancini, Mario Figliomeni, Camilla Puccinelli, Cristina Romanelli, Fabrizio Volpi, Anna Maria D'Angelo, Silvana Caciolli, Emilio D'Ugo, Elisabetta Volpi, Roberto Giuseppetti, Stefania Marcheggiani PII: DOI: Reference:

S0026-265X(17)30165-0 doi: 10.1016/j.microc.2017.02.021 MICROC 2707

To appear in:

Microchemical Journal

Received date: Revised date: Accepted date:

9 September 2016 10 February 2017 17 February 2017

Please cite this article as: Laura Mancini, Mario Figliomeni, Camilla Puccinelli, Cristina Romanelli, Fabrizio Volpi, Anna Maria D'Angelo, Silvana Caciolli, Emilio D'Ugo, Elisabetta Volpi, Roberto Giuseppetti, Stefania Marcheggiani , A descriptive survey on microbiological risk in beauty salons. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Microc(2017), doi: 10.1016/j.microc.2017.02.021

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ACCEPTED MANUSCRIPT A descriptive survey on microbiological risk in beauty salons Laura Mancini1, Mario Figliomeni1, Camilla Puccinelli1, Cristina Romanelli2, Fabrizio Volpi1, Anna Maria D'Angelo1, Silvana Caciolli1, Emilio D'Ugo1, Elisabetta Volpi1, Roberto Giuseppetti1, Stefania Marcheggiani1

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Department of Environment and Health, Istituto Superiore di Sanità, Viale Regina Elena, 299 00161 Rome, Italy. 2 Notified Body 0373, Istituto Superiore di Sanità, Viale Regina Elena, 299 00161 Rome, Italy

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Corresponding author: [email protected]

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Keywords: microbiological risk, beauty salons, descriptive survey

ACCEPTED MANUSCRIPT Abstract

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Beauty salons are an employment sector with potential exposure to biological agents. The beauty industry (beauty salons, health farms etc.) has grown considerably in the past decade. This, however, led to a proportional increase in the number of people who could become infected in case of accidental contact with infected material. Indeed, such activities may pose health risks to both workers and clients if the appropriate precautions are not followed. The study investigated microbiological risk and infection-control practices in 120 beauty salons in Rome. Information was gathered using a questionnaire that covered occupational safety measures, for an evaluation of microbiological risk. Infection among clients was identified by the staff of 67.5% of centers. Of these, 30.8% reported either fungal infections or dermatitis. Most (89.2%) of the centers that encountered mycosis also found dermatitis, while 10.8% reported only mycosis. Of the beauty centers 31.7% took microbiological risk management measures. This study showed the importance of the relationship between microbiological risk and health, highlighting the need for training/information for beauty salon staff as well as clients.

ACCEPTED MANUSCRIPT Introduction

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Beauty salons are an employment sector with potential exposure to biological agents, given the nature of the treatments, that are carried out directly on the body of individuals who can host pathogens and opportunistic microorganisms [1]. Diseases can be spread through direct contact with bodily fluids from: coughing, sneezing, contaminated blood, pus, sores, cuts or grazes. Many bacteria, viruses, fungi and yeasts are associated with this kind of activity. The bacteria commonly identified in manicure, for instance, are Streptococcus spp., Enterococcus spp., Micrococcus spp., Bacillus spp., Enterobacter spp., Klebsiella spp., Acinetobacter spp., Citrobacter spp., Escherichia coli [1; 2], Mycobacterium fortuitum [3; 4; 5], while the yeasts are Candida spp. and Rhotorula spp. [1]. Similarly, in pedicure, bacteria, viruses and fungi have been identified. Bacteria like Mycobacterium chelonae [6] and Mycobacterium mageritense [3; 7; 8; 9] viruses like HBV and HCV [10, 11], and fungi such as Rhizopus spp. [2]. Notably, the risk of transmission in the event of accidental contact with infected material is high in the case of bloodborne pathogens, due to the high viral loads typically present in the blood [12].

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The beauty industry has grown considerably in the past decade, leading to a proportional increase in the number of exposed subjects who could potentially become infected through accidental contact with contaminated material or cross-infection.

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In Italy, the industry currently serves 40 million customers a year in more than 30.000 beauty salons employing over 70.000 individuals [13]. The microbiological risk in a beauty center varies depending on the activity and, crucially, on the level of implementation of hygiene procedures, such as the use personal protective equipment (PPE), and the sanitization, sterilization and disinfection of instruments and medical devices. Particularly significant is the risk of cross-infection. Due to the nature of a beauty therapist’s work, daily physical contact with clients is very common, often in the context of invasive procedures. Microbiological risk in the beauty centers is rarely addressed and remains an important problem [14]. Hands dermatitis, for example, is a well-recognized condition and frequently observed in professional beauty salons, hairdressers and barbers [15, 16]. The environment of beauty salons, due to the frequent exposure to invasive procedures, for environmental contamination, linked to the production of potentially contaminated aerosols, represents an area at risk. An outbreak of community-associated USA300 methicillin-resistant Staphylococcus aureus was reported to have occurred in the Netherlands, involving 11 cases, among them a beautician, two of her customers, and eight indirect contacts [17].

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Environmental contamination linked to the production of potentially infectious aerosols, the use of sharp instruments which, if not accurately sanitized, can cause bloodborne infections such as hepatitis B, hepatitis C and HIV, and inadequate sanitation of premises, furniture and linens are some areas of possible intervention. Equipment used in professional beauty salons must comply with state laws: in Italy, Decree, n.110/2011 [18] regulates electromedical equipment used by beauticians. It includes provisions for the safe operation of many devices and of equipment used in professional beauty salons, and requires that such instruments be checked regularly and used only by experienced, properly trained, staff. The aim of this study was to investigate the activities of beauty salons in the context of microbiological risk. It is a survey on the knowledge and practice of beauty salon staff in the province of Rome, regarding microbiological risk and its management.

ACCEPTED MANUSCRIPT An observational, descriptive survey was carried out to assess beauticians knowledge on the transmission of infections, on infection control procedures, sterilization and disinfection equipment (disposables, barrier measures, protective clothing), the protection of beauty salon staff (management of risk from sharp instruments), and risk management in the case of infection among clients.

Methods

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The study was conducted from April to July of 2014. Two hundred beauty salons were randomly selected throughout Rome (at least one for each postal code). A questionnaire was administered to the managers, or in some cases a senior beautician. The Interviews, one per beauty center, were performed "in situ" by our researchers. ID codes were used to protect the privacy of the centers and interviewees.

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The interview consisted of 9, multiple choice or open-ended questions (Table 1). The first 3 questions addressed the type of beauty salon (small, family run business or franchise), the staff's level of education and professional training and the number and gender of habitual and occasional clients. Question 4 pertained to the equipment and instruments available to the staff, to the frequency of maintenance, and to the use of PPE in this context. Question 5 touched upon the methods used to sterilize materials and/or instruments. Waste management (waste sorting, including infectious waste) was addressed in question 6. A question ascertaining whether workers had encountered cases of mycosis, dermatitis or other infectious conditions among the clients, and how the microbiological risk was managed in such cases, was also present (question 7). Question 8 addressed the protocols followed during the treatment of clients, with particular regard to health and hygiene. Question 9 evaluated the use of medical devices in beauty salon (as defined in EU Directive 93/42/EEC [19] and subsequent amendments).

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Statistical analysis

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A correspondence analysis (CA) was performed on data relating to PPE, sterilization and disinfection of instruments, protocols of beauty treatment applied. Subsequently, correlations between the two main axes of the CA and data on type of beauty salon and the staff's level of training were investigated. Analyses were performed using the PAST software v 3.12 (2016) [20].

ACCEPTED MANUSCRIPT Results One-hundred and twenty of the 200 salons approached, agreed to participate in the survey. Summary results of each question have been reported in table (Table 1). Most of beauty salon, 95 %, investigated were small or family run business companies. As for the beautician’s level of education, all have operators with beautician degree and only in one center was the staff specialized. Customers were either habitual or occasional, generally of both sexes, with a slightly higher proportion of women.

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Personal protective equipment was used by therapists in 99 % of beauty salons. Most interviewees (68%) did not specify the kind of PPE employed; 13 % reported the use of gloves, and 10% mentioned gloves and masks. In 95% of the participating beauty salons, clients were also given PPE. The PPE used was disposable; only one salon reported that they sterilize plates for electrical stimulation after use.

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In response to the question on sterilization methods, more than 95% of the centers use more than one method of decontamination. Almost all beauty salons used immersion disinfectants (98.3%), followed by autoclave (64.7%). Quartz sterilization was used by about 32% of centers, and UV by 9.2% . Regarding the waste managements, all beauty salon performed waste management according to regulations.

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The responses to the question on microbiological risk revealed that, in 30.8 % of the salons surveyed, cases of either fungal infection or dermatitis among the clients had been identified by the staff. Eighty-nine point two percent of beauty salons having encountered mycosis also had cases of dermatitis, while 10.8% reported having seen only mycosis among their clients. None of the salons saw dermatitis cases alone. Risk management was applied in 31.7% of surveyed salons: in the salons which infections were identified, in the 67.5 % of salons, clients were advised to contact a physician or a dermatologist.

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As far as the decontamination of bowls following pedicure/manicure, 62.5% of salons employed all three methods - rinsing, disinfection and sterilization, some (1.7%) only sterilize, while others (1.7%) only disinfect. Some (4.2%) beauty salons reported alternative methods as well, such as the use of disposables (towels, sheets etc.). The remainder of the salons (29.9%) employed a combination of methods. For reusable materials, over 86% of the surveyed salons use either sterilization or disinfection methods. For the use of medical devices, 87% of the centers do not use such devices, while 13% use disposable and reusable ones. Who employ reusable devices as well, sterilizing and disinfecting them after use. The medical devices used belong to the non-sterile class, or the lowest risk category. The CA (Figure 1) performed on PPE, decontamination methods and microbiological risk management yielded no significant assemblages in terms of sterilization and disinfection techniques. Furthermore, microbiological risk management was not a discriminating factor in this analysis. The only beauty salon (ID 31) graphically isolated was the only one that did not employ sterilizing systems, such as autoclave, but only performed disinfection using quartz.

ACCEPTED MANUSCRIPT The correlation analysis (Table 2) found no associations between either the type of beauty salon (small or franchising) or the therapist's level of education on the one hand, and infection-control measures (decontamination techniques, microbiological risk management, use of PPE). Discussion

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The questionnaire was designed as a tool for evaluation studies of health policy in population surveys. It was intended to be applicable to a wide range of types and severity of conditions. In this case, the survey resulted in a first descriptive account of hygienic conditions and microbiological risk management practices in beauty salons in Rome.

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Conclusions

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The vast majority of beauty therapists reported using PPE (98%), providing clients with the equipment (95%) and using either sterilization or disinfection (95%). Sanitization is the most basic level of microbiological decontamination and should be carried out before disinfection (the second level) and sterilization (the third). A beauty salon should sterilize all metal tools, metal implements and plastic tools. The use of chemicals is the most popular and effective way of sterilizing beauty tools and implements. The absence of a correlation between beauty therapists’ level of education and training or type of beauty salon, and sterilization techniques, or PPE use, suggests a good level of care in Rome's beauty salons. The need to regulate the activities of beauty salons with health standards and guidelines arises from the consideration that such activities, if not conducted in accordance with best practice, could pose a risk to public health. Microbiological risk in beauty salons varies depending on the activity. Particularly relevant in esthetic centers is the risk of crossinfection [15, 16]. From a microbiological point of view, the most frequent risks to be considered are those that result from: inadequate hygiene procedures, such as failure to use PPE, and inadequate sanitization, sterilization and disinfection of the instruments and medical devices used. The category of these materials includes small tools, sharp instruments, removable parts of equipment that come into direct contact with the client, but also non-disposable gowns and drapes. The beauty centers that participated in the present study often used a combination of sterilization and disinfection methods depending on the type of activities performed by the center and its needs. In some cases, sterilization is required - performed with validated methods and preceded by rinsing to lower the initial bioburden. In other cases, disinfection is sufficient.

We investigated microbiological risk and infection-control measures in beauty salons in Rome. Overall, the survey conducted outlines an encouraging situation which, clearly, may also be improved, in light of the following findings: a limited ability to recognize infection in a patient; little use of microbiological tests to ascertain the quality of sterilization; low levels of knowledge on medical devices among members of the staff. With a view to protect public health, beyond conforming to the standards of hygiene and safety conditions in the working environment, special attention should be paid to the enforcement of infection-control measures and procedures during activities that may pose a risk to customers and professionals. Such procedures should be followed with the utmost care, so as to ensure aseptic conditions.

ACCEPTED MANUSCRIPT To conclude, activities such as those performed in beauty salons may pose a risk to the health of workers, clients. An easy-reference summary of both national and regional regulations covering infection control and microbiological risk assessment for the beauty industry is likely to prove an important contribution to public health. Author Contributions

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Laura Mancini, Stefania Marcheggiani and Cristina Romanelli conceived, designed and supervised the project. Mario Figliomeni, Anna Maria D'Angelo, Silvana Caciolli, Emilio D'Ugo, Roberto Giuseppetti, Elisabetta Volpi performed the field sampling. Camilla Puccinelli and Fabrizio Volpi analyzed the data. Laura Mancini, Stefania Marcheggiani and Mario Figliomeni co-authored the paper. All authors revised and approved the manuscript and agree with its submission to Microchemical Journal Acknowledgements

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This study was funded by the Italian Ministry of Health. We would like to thank all National Trade Associations involved and all the beauty salons that opened their doors to the research team and supported it during field work. Our gratitude also goes to Cinzia Grasso and Massimiliano Bugarini for their technical support.

Conflict of interest

References

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The authors declare no conflict of interest.

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1. Hedderwick SA, McNeil SA, Lyons MJ, Kauffman CA. Pathogenic organisms associated with artificial fingernails worn by healthcare workers. Infect Control Hosp Epidemiol. 2000 Aug;21(8):505-9. 2. Sekula SA, Havel J, Otillar LJ. Nail salons can be risky business. Arch Dermatol. 2002 Mar;138(3):414-5. 3. Winthrop KL, Albridge K, South D, et al. The clinical management and outcome of nail salon-acquired Mycobacterium fortuitum skin infection. Clin Infect Dis 2004; 38:38–44. 4. Vugia DJ, Jang Y, Zizek C, Ely J, Winthrop KL, Desmond E. Mycobacteria in nail salon whirlpool footbaths, California. Emerg Infect Dis. 2005 April. 5. Herrero JB, Borbujo C, Román MT, Serrano O, de Lucas R, Borbujo J. 1996. Cutaneous infection caused by Mycobacterium chelonae. Presentation of 3 cases with multiple lesions. Rev. Clin. Esp. 196(9):606-9.

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6. Redbord KP, Shearer DA, Gloster H, Younger B, Connelly BL, Kindel SE, et al. Atypical Mycobacterium furunculosis occurring after Pedicures. J Am Acad Dermatol. 2006 Mar;54(3):520-4. 7. Stout JE, Gadkowski LB, Rath S, Alspaugh JA, Miller MB, Cox GM. pedicure- associated rapidly growing mycobacterial infection: an endemic disease. Clin Infect Dis 2011 Oct; 53(8):787-792. 8. Enemuor SC, Ojih MI, Isah S., Oguntibeju OO. Evaluation of bacterial and fungal contamination in hairdressing and beauty salons. AJMR Vol. 7(14), pp. 1222-1225, 2 April, 2013 9. Gira AK, Relsenauer AH, Hammock L, et al. Furunculosis due to Mycobacterlum mageritense associated with footbaths at a nail salon. J Clin Microbio 2004: 42: 1813–1817 10. 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; 74:216–20 11. SEIEVA. Epidemiology of hepatitis B and C. Rapporti ISTISAN [serial online] 2006; 06/12: 11-27. Available from: URL http://www.iss.it/binary/publ/cont/06-12.1149070762.pdf 12. ISTAT 2011. Ripartizione dei Centri Estetici in Italia per Regione (Elaborazione AICEB su dati ISTAT e Registro Imprese 2011 13. Confesercenti, 2016:http://www.catconfesercenti.it/Iniziative/OLTRE30000IMPRESEDELBENESSEREI NATTESADIUN.aspx) 14. Frusteri L, De Grandis D, Scarlini F, Pontuale G. Manuale per la valutazione del rischio biologico – Ambienti di lavoro indoor e outdoor. EPC Editore, 2011 15. Naz S., Iqtedar M., ul Ain Q., Aftab K. Incidence of Human Skin Pathogens from Cosmetic Tools used in Beauty Saloons from Different Areas of Lahore, Pakistan. J. Sci. Res. 4 (2), 523-527 (2012). 16. Amodio E, Benedetto MA, Gennaro L, Maida CM, Romano N (2010). Knowledge, attitudes and risk of HIV, HBV and HCV infections in hairdressings of Palermo City (South Italy). Eur. J. Public Health 20:433-437. 17. Huijsdens XW, Janssen M, Renders NH, Leenders A, van Wijk P, van Santen Verheuvel MG, van Driel JK, Morroy G. Methicillin-resistant Staphylococcus aureus in a beauty salon, the Netherlands. Emerg Infect Dis. 2008 Nov;14(11):1797-9 18. Italian Ministerial Decree of May 12, 2011 n. 110 published in the “Gazzetta Ufficiale” no. 163 of July 15. Regolamento di attuazione dell’articolo 10, comma 1, della legge 4 gennaio 1990, n. 1, relativo agli apparecchi elettromeccanici utilizzati per l’attivita’ di estetista. (2011) 19. European Council Directive of 14 June 1993 concerning medical devices 93/42/EEC 20. Hammer, Ø., Harper, D.A.T., Ryan, P.D., 2001. PAST: Paleontological Statistics Software Package for Education and Data Analysis. Palaeontologia Electronica 4 (1), 9

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Table 1. Survey description and summary results Number

Question

Question’s Structure

Summary Results

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Type of beauty salon

1 multiple-choice question (4 possible answers)

95 % of beauty salon investigated are small or family run business

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Beauty therapists' level of education

1 open-ended question

All therapists have at least beautician degree

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Gender and type of clients

2 multiple-choice questions (2 possible answers each)

Clients are generally of both sexes, also habitual and occasional.

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Infection-control measures for workers and customers

4 open-ended questions

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Sterilization methods

1 multiple-choice question (3 possible answers) and 1 open-ended question

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Waste management

1 multiple-choice question (3 possible answers) and 1 open-ended question

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Microbiological risk

2 open-ended questions

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Infection-control procedures during treatments

5 multiple-choice questions (2 possible answers each), 2 open-ended questions

62.5 % of beauty salon employed Rinsing, disinfection and sterilization

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Use of medical devices

3 multiple-choice questions (2 possible answers each), 1 open-ended question

87% of the centers do not use medical devices

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In 99 % of beauty salon therapists used PPE In 95% of beauty salon clients are given PPE

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95% of the centers use more than one method of decontamination: immersion disinfectants and autoclave are respectively the most used. All beauty salon performed waste management according to Regulations. 30.8% of beauty salon recognized microbiological risk intended as mycosis and dermatitis 31.7 % of beauty salon performed risk management

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Table 2. Correlation between CA results and type of beauty salon, and beauty therapists' level of education and training

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Axis 1 Axis 2

Correlation factor r Beauticians' level of Type of beauty salon education and training -0.020 0.154 0.024 -0.090

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Figure 1. Correspondence Analysis performed on PPE, decontamination methods and microbiological risk management data (Axis 1= total of variance 48.6 %; Axis 2= total of variance 20. 5% ).

ACCEPTED MANUSCRIPT Highlights

The potential exposure for human health to biological agents in beauty salons The activities of beauty salons in relation to the microbiological risk. Mainly identified risk factors found are fungal infections or dermatitis in users.

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Highlight the need for training/information for operators and beauty salon goers.