Life-threatening cellulitis after traditional Samoan tattooing
Dr Margot McLean, Regional Public Health, Hutt Valley District Health Board, Private Bag 31–907, Lower Hutt, New Zealand; e-mail: email@example.com
Objective: Traditional Samoan tattooing is a significant and valued cultural practice. Any tattooing carries a risk of complications, including the potential for serious bacterial infection. We discuss the complex nature of the public health investigation into two cases of serious bacterial infection following traditional tattooing occurring in the same region in New Zealand within a six-week period.
Approach: Description of two cases of life-threatening cellulitis (one with necrotising fasciitis) related to traditional Samoan tattooing and presentation of findings from the public health investigation. Discussion of the complex legal and cultural issues that arose.
Conclusion: Our paper illustrates the potential for serious bacterial infection by tattooing when performed in a non-sterile manner. There are gaps in the regulatory framework available in New Zealand to address the public health risks of unsafe tattooing practices.
Implications: It is important to balance the fundamental right to perform the traditional cultural practice of tattooing with the need for meticulous infection control. Reducing the risk of infection will require working in partnership with the community to develop acceptable standards and guidelines and to improve the regulatory framework.
The traditional Samoan tattoo (known as pe'a, for men, or malu, for women) involves an ancient process carried out over several days or weeks by an artist (a ‘tufuga te tatau’). A pe'a is performed with piercing instruments made from boar tusk and covers the skin from waist to knee. Tufuga started working among the Samoan community in New Zealand in the early 1970s.1 Acquiring a pe'a is a significant expression of personal and cultural identity.
Any tattooing carries a risk of complications, including skin infection, allergy to dyes, and transmission of blood-borne viruses. This paper describes two cases of severe skin infection related to traditional Samoan tattooing. Both cases occurred in the same region within a six-week period. We aim to highlight the complex nature of the public health response in terms of disease severity, cultural and legal factors, and the need to maintain effective and culturally appropriate infection control practices in this setting.
A 23-year-old Samoan man presented to an emergency department 10 days after starting a pe'a tattoo. Localised skin infection developed three days into the procedure and he became systemically unwell from day seven with fever, rigors, and breathlessness. He had painful, red, oozing tattooed skin on the lower back and upper legs. His condition deteriorated and he collapsed at home.
On admission he was profoundly hypotensive with extensive cellulitis, purulent exudate and skin breakdown affecting most areas of the tattoo. Investigations demonstrated elevated serum creatinine (390 μmol/L), C-reactive protein (354 mg/L) and neutrophilia (white cell count 27×109/L). He was diagnosed with severe, extensive cellulitis, septic shock, and acute renal failure with tubular necrosis. He was aggressively treated with intravenous fluids and required a prolonged course of intravenous flucloxacillin and cephazolin. Culture of the infected tattoo identified Staphylococcus aureus and Group C Streptococcus. Recovery was complicated by ongoing renal failure that almost required dialysis and continuing severe pain. After four weeks the patient was transferred to the plastic surgery unit for management of chronic skin infection and necrosis. Two operations for surgical debridement and split skin grafting of the right thigh wound were successfully completed. He was discharged after six weeks and required ongoing outpatient wound management.
A 25-year-old Samoan man presented to an emergency department in a critical condition six days after starting a pe'a tattoo. He became unwell from day two, developing fever, chills, vomiting and increasing redness, pain and skin breakdown of tattooed skin on the abdomen, posterior trunk, buttocks and thighs. His condition deteriorated and he had not passed urine for over 30 hours.
On arrival he was critically unwell with severe septic shock and multi-organ failure. There was severe cellulitis and necrotising fasciitis of the tattooed area involving both thighs and circumferentially affecting the trunk, affecting 25% of the total body surface area. He had acute renal failure (creatinine 611 μmol/L), deranged liver function tests, a coagulopathy and an abnormal electrocardiogram. Following initial stabilisation with aggressive fluid resuscitation, inotropic support, blood products, sedation and analgesia, urgent debridement of extensive areas of necrotising fasciitis was performed, involving careful intraoperative management of significant blood loss (7 litres). Post-operatively he remained critically unwell for a substantial period and required ventilation, inotropic support, blood products, dialysis, and analgesia. Abdominal wound culture demonstrated Streptococcus pyogenes (Group A streptococcus, M-protein serotype emm89) and Pseudomonas aeruginosa. He required prolonged treatment with intravenous antibiotics (flucloxacillin, penicillin, ciprofloxacin and clindamycin). He returned to the operating theatre five times for wound debridement and split skin grafting. He had a long and complicated recovery requiring physiotherapy, nasogastric feeding and a high protein high-energy diet. On discharge six weeks later his skin grafts were healing satisfactorily, his renal function had normalised, and he was able to mobilise independently. Ongoing wound management, physiotherapy, occupational therapy and counselling were required.
Public health investigation
The plastic surgery unit alerted the regional public health unit of three cases of serious skin infection related to traditional Samoan tattooing. The third patient, an 18-year-old Samoan male, presented a few days prior to Case 2 and required two days of intravenous antibiotics for cellulitis of the right forearm. The third case was almost certainly linked but further investigation was not possible. Interviews ascertained that there was a common tattooist. The investigation then focused on investigation of this tattooist, case finding and microbiological investigation.
The tattooist was an experienced traditional Samoan practitioner who, with two assistants, worked from a garage or in clients’ homes. The garage had no running water and there were inadequate procedures for sterilisation and cleaning. Other infection control concerns included: no hand washing facilities, gloves apparently worn but never changed, reports of rags dropped to the floor subsequently used to wipe blood from skin, and ink stored in non-sterile containers. It appeared that the tattooist was not able to recognise when his clients were becoming seriously unwell and in need of urgent medical assessment.
A survey of regional general practitioners and emergency departments (in an area population of 420,000) investigated whether there were other cases of serious skin infection relating to traditional-style tattooing within the previous six months. In addition to the two cases of life-threatening cellulitis/ necrotising fasciitis, there had been eight other cases of cellulitis. Five of these were possibly or definitely performed by the same tattooist. Three required intravenous antibiotics and two required oral antibiotics. The three remaining cases identified were unrelated to this tattooist.
Microbiological testing was performed on items from the garage. Two used gloves found stored within a box of clean gloves cultured Group A streptococcus, M-protein type emm89. This serotype was also cultured from the abdominal wound of Case 2, and from one of the cases requiring oral antibiotics identified from the case-finding exercise, both cases being linked to the same tattooist. In New Zealand, the emm 89 serotype, identified since the 1980s, has been associated with skin and throat infections and a range of invasive infections. From 2004 to 2006, emm89 accounted for 5% of cases of Group A streptococcal infection (personal communication, Diana Martin, ESR April 2007). The identification of the same strain in itself does not confirm an association; however, isolating the same strain from the tattooist's gloves and two cases of tattoo infection is very suggestive of a connection.
Both cases were immune to Hepatitis B at the time of hospitalisation. We requested the clinicians to undertake follow-up serological testing for other blood-borne viruses. We cannot confirm that this has occurred.
There were few legal options to pursue. Only six of New Zealand's 74 local authorities have bylaws relating to tattooing and there was not one in this area. The Health Act 1956 does not have regulations covering skin piercing and there is no provision in the Act to stop or suspend skin piercing which poses a risk to public health. The Health and Safety in Employment Act 1992 has relevant general provisions, however the Department of Labour was reluctant to issue an infringement or prohibition notice due to an opinion that the tattooist's activity did not meet the criteria for work.
The tattooist voluntarily ceased practice until concerns around infection control could be addressed. Communication was challenging because of language barriers (requiring the use of interpreters) and because the tattooist did not have a home telephone and changed address twice during the investigation. An infectious disease specialist worked with the tattooist to ensure that basic infection control standards were understood and implemented. At the final session the tattooist performed a tattoo, demonstrating adequate infection control procedures.
Our paper highlights the potential for serious bacterial infection by tattooing when performed in a non-sterile manner, such as may occur with traditional tattooing techniques. The two patients described experienced life-threatening infective complications. It is difficult to accurately measure the burden of disease. Unfortunately we were unable to obtain information about the denominator as the tattooist did not keep any written records. We understand that this tattooist was the only tufuga working in the region at the time. Additional case finding in our region demonstrated a total of 10 people whose infected traditional-style tattoos required antibiotic treatment. Seven of these patients appeared to have been tattooed by the same practitioner.
We cannot fully explain the cause of this cluster of cases. There did not appear to have been any changes in the procedures used by the tattooist. It is possible a more virulent organism(s) may have entered the tattooing environment at this time, an environment already susceptible due to deficiencies in infection control.
Our investigation identified multiple problems in infection control, including a lack of running water, inadequate infection control knowledge, and no process for sterilisation of the instruments. The health risk is exacerbated when the tattooing procedure is not accompanied by guidance on when to seek medical advice prior to commencing a tattoo (for example, for those with chronic disease or impaired immunological function) or when complications arise.
There have been three published case reports on the infective complications of traditional tattooing. The first report describes a 36-year-old male who developed cutaneous sporotrichosis infection.2 Porter et al.3 reported two cases of necrotising fasciitis and cellulitis in New Zealand, with one case resulting in death. Korman et al.4 report a similar case from Victoria, Australia. There are strong similarities between these cases and those reported here.
In addition to the four New Zealand cases reported by Porter3 and this report, a chart review performed in 2008 of discharge notifications for necrotising fasciitis linked to traditional Samoan tattooing in New Zealand from 2000 to 2006 identified one further case.5
More information is available on the transmission of blood-borne viruses from tattooing.6 Receiving a tattoo by a professional tattooist appears to have a lower risk of blood-borne infection due the use of sterile needles and aseptic technique.7,8 The risk appears to increase with an increasing number of tattoos and with a larger area of skin involvement. It is possible that there is a greater potential for both bacterial infection and the transmission of blood-borne viruses with traditional tattooing techniques due to the non-sterile nature of the procedure and the large area of skin involved.
Meticulous infection control is necessary to reduce the risk of infection from traditional tattooing. Delicate bone instruments are unlikely to withstand heat sterilisation; compromise may be required. This may include careful cleaning of instruments followed by soaking in chemical sterilisation solutions. People seeking tattoo should be immune to Hepatitis B, and carriers of blood-borne viruses should be advised to have the procedure performed with tools that can be heat sterilised.
Our investigation identified gaps in the legal framework available in New Zealand to address the public health risks of unsafe tattooing practices. To date there has been no national regulation around skin piercing; the responsibility lies with individual local authorities. New Zealand has inconsistent local skin-piercing regulation. Only one area, Manukau City Council, which has a high Samoan population, specifically addresses traditional tattooing. The requirements detailed in the Manukau by-laws provide a useful framework for the development of nationally consistent guidelines or codes of practice.
Focus groups and key informant interviews with Pacific stakeholders identified a belief that responsibility for improving safety lies both with the practitioners and public authorities. There was strong support for a regulatory mechanism to be put into place in New Zealand.9
Reducing risk will require intersectoral collaboration and a community development approach, not only the development of standards and guidelines and the enforcement of regulations (which alone, could force some practitioners underground). Following this cluster, the Ministry of Health has developed, with the contribution of customary tattooists and their guild, the Lagi Malofie Society, as well as other Samoan community leaders and infectious disease experts, relevant guidelines for customary tattooing.10 The guidelines could form the basis of a Code of Practice which can be applied by the New Zealand Department of Labour through the Health and Safety in Employment Act. New legislation for public health is planned. This may allow for the subsequent development of national regulations which would provide greater safety and assurance around the process of traditional tattooing.
Traditional Samoan tattooing is a deeply significant and valued practice. Our paper illustrates the potential for harm should this technique be practised in an unhygienic manner and with insufficient knowledge of when to seek medical advice prior to, during and following the procedure. The issues discussed here are likely to be relevant for other countries where traditional tattooing occurs; including those nations periodically visited by travelling master tattooists. Balancing the fundamental right to perform a traditional cultural practice with the need for up-to-date infection control techniques and appropriate regard to health and safety requires care and is essential.
The authors thank Dr Charles Davis, Alexa Masina, Siloma Masina, Dr Diana Martin, and Dr Mark Jones for their comments on this paper.