Potential transmission of HBV, HCV and HIV infections in nail salons and barbershops

New analysis questions adequacy of disinfection regulations

The risk of hepatitis transmission through non-single use instruments -- such as nail files, nail brushes, finger bowls, foot basins, buffers, razors, clippers, and scissors -- during nail salon and barbershop visits cannot be excluded, according to the results of a new report unveiled today at the American College of Gastroenterology's (ACG) 76th Annual Scientific meeting in Washington, DC.

David A. Johnson, M.D., FACG of Eastern Virginia Medical School presented an abstract which analyzed a report developed by the Virginia Department of Health entitled, "Assessment of the Risk of Bloodborne Pathogen Transmission in Nail Salons and Barber Shops and Regulatory Requirements in Virginia." Dr. Johnson's assessment of the Virginia report indicated that there might be potential transmission of bloodborne pathogens (e.g., hepatitis B and C viruses) if non-single use instruments are not fully cleaned and disinfected according to the state regulations. The Virginia Department of Health found that the current Virginia regulations (dated September 1, 2011), which require intermediate-level disinfection for non-single use items in nail salons or barbershops, are sufficient in preventing bloodborne pathogens transmission, if there is full compliance.

"Whether there is sufficient compliance with disinfection requirements is an important variable in the safety of salon and barbershop services from a public health perspective," commented Dr. Johnson. "The risk of transmission of infectious disease, particularly hepatitis B and C, in personal care settings is significantly understudied in the United States."

Dr. Johnson explained that a report of a case of acute hepatitis C (HCV) that was "clearly related to a manicure/pedicure treatment" prompted this evaluation of the current patient risks associated with salon exposures.

A group coordinated by the Office of Epidemiology at the Virginia Department of Health conducted the aforementioned study. This Virginia Health Department study included a comprehensive literature search on Pubmed and Google using relevant key words such as nail salon, manicure, pedicure, barber, razor and hepatitis. Additionally, the group reviewed the safety regulations in Virginia and compared them with those in 13 other states and the District of Columbia.

The review of the published literature identified eighteen papers, including nine case-control studies, three case-series studies, and six population-based surveys, that assessed manicure, pedicure, or barbering as potential risk factors for HBV and/or HCV infection. Of the nine case-control studies, five evaluated HBV and/or HCV in nail salon settings and three of the five showed association with HBV and one of the five showed association with HCV. Eight of the nine case-control studies evaluated HBV and/or HCV in barbershop settings and five showed association with HBV and two showed association with HCV. The case-series studies and surveys are less indicative of an association for HBV and HCV in nail salon or barbershop settings. Caution is required in interpreting these findings because there are substantial heterogeneities in the population studied, sample size, case and control selection, analytic method, and control of confounding variables across studies. Furthermore, none of the nine case-control studies was conducted in the United States.

The federal Occupational Safety and Health Administration (OSHA) does not have specific guidelines for the prevention of HBV or HCV infection in nail salons and barbershops, according the Virginia Department of Health, and neither the current CDC case report form for HBV or HCV nor the National Electronic Disease Surveillance System captures barbering, manicures or pedicures as risk factors for transmission of hepatitis infection.

"The absence of infection control guidelines from federal health agencies (CDC and OSHA) for the prevention of hepatitis infections in nail salons and barbershops implies that barbering, manicure and pedicure have not emerged as significant risk factors for HBV and HCV infections in the United States," commented Dr. Johnson. "The true magnitude of this risk has yet to be defined and clearly needs further study."

In the meantime, Dr. Johnson urged nail salon and barbershop customers to be aware of the potential risks for hepatitis transmission, and to take precautions including asking questions to determine whether or not the nail salon or barbershop is properly cleaning and disinfecting tools and equipment. He also suggests customers bring their own equipment like clippers, razors and nail files (both men and women).

"No one should accept on blind trust that a business is taking the necessary steps to prevent transmission of bloodborne infections such as hepatitis," said Dr. Johnson. "Health care providers need to be aware of these risks -both for appropriate counseling of their patients, and when assessing possible causality in patients with hepatitis B or C."

Based on the Virginia Department of Health report there are several proposed recommendations to eliminate the potential transmission of HBV, HCV and HIV infections in nail salon and barbershop settings. These include: training for all nail salon and barbershop technicians, educating them about transmission of blood-borne infections and emphasizing principles of good hygiene, antisepsis and disinfection; as well as more stringent personal hygiene, storage, disinfection and inspection requirements.