Progressive Mentorship

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Friday May 15, 2020

As studios begin to reopen, one hurdle that our industry will face is how to protect ourselves, our employees, and our clients from transmitting the COVID-19 virus to and from one another. Although our industry has the benefit of largely being aware of basic precautions and usage of personal protective equipment, we have generally only viewed these protections as a barrier between us and bloodborne pathogens and as a method of infection control within the wounds we create. 

Now, we must also take into consideration methods to reduce the risks of viral transmission in our studios as well. I will begin by saying that information is being released daily. The information here is based on studies that I was able to find, and they are listed below. For every study currently available, there seems to be another that refutes the same findings. This is only intended to provide some basic information that helps to aid in making the best choices for you and your studio. It is up to each of us to review new information as it becomes available, and use that to adapt to this new situation. 

*A quick note on filtration. Many of the masks and filters that are available or discussed in studies are tested at their ability to filter at 0.3 microns. This does not mean that they are unable to filter smaller particles. Rather, 0.3 microns is a standard of testing as it has been shown to be the most difficult size to filter, and therefore a weak point. Particles larger and smaller than this size have been shown to be easier for filtration. You can read and in depth study of that here:

https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/20170005166.pdf

or an easier to digest breakdown of that information here:

https://smartairfilters.com/en/blog/what-is-pm0-3-why-important/

The second is from a company which produces filters, and obviously biased toward selling a product. However, it is much easier to read through. 

In order to look at protection, we first have to decide what we are protecting ourselves from. How is COVID-19 transmitted?

The CDC, WHO, and other health agencies have stated that the COVID-19 virus is to be largely transmitted through droplets exiting the nose or mouth when sneezing, coughing, or speaking. These droplets, although incredibly small, tend to settle more quickly due to their size and gravity, which somewhat limits the range they will travel. 

However, there are several studies that are not only finding evidence of smaller aerosolized particles containing the COVID-19 virus, but also finding that those particles can be transported through moving air from room to room. These small particles are of a size which can remain suspended for an extended amount of time in the air. They also seem to be produced even in the absence of coughing or sneezing, such as from talking or breathing, and viral loads have been shown to have some of their highest counts just prior to and at the onset of symptoms. These particles have been shown to settle on personal items of the individuals infected, with one study testing the items within infected patients' rooms showing, “Overall, 76.5% of all personal items sampled were determined to be positive for SARS-CoV-2 by 25 PCR.” **PCR (polymerase chain reaction) refers to the method of testing. Positive results indicate viral genetic material of the Coronavirus (SARS-CoV-2) on material tested.

https://www.medrxiv.org/content/medrxiv/early/2020/03/26/2020.03.23.20039446.1.full.pdf

https://www.nejm.org/doi/full/10.1056/NEJMc2004973

Surfaces:

Understandably, our clients are not living within our piercing or tattoo room for the extended amount of time that these patients were. However, it is important to keep in mind that the items a client brings with them (purse, cell phone, jacket, etc) potentially could be carriers of the virus if the client is an asymptomatic carrier. It might be beneficial to have a designated wipeable area to place these items within your room or studio, and to ask clients not to place personal items on the counters or surfaces elsewhere throughout the studio. 

Likewise, limiting the access to shared seating such a waiting areas or disinfecting those areas between clients could prove useful to minimizing client to client transfer of the virus, should an asymptomatic client pass through your studio. 

Also worth considering with this study is that any of our personal items that are in an environment with clients in and out can potentially be contaminated. We should at very least keep the thought in the back of our minds that laptops, purses, keys, etc brought into the studio that return home with us could potentially transport the virus with us if not disinfected. 

Droplets and aerosolized particles

This area is the bigger piece of the puzzle. For the sake of looking at the most realistic approaches, I am going to assume that many of us do not have access to N95 masks due to supply shortages and the requests of the medical community that they be reserved for use within the medical field. With that, we are mostly limited to two options: basic medical masks or homemade cloth masks of various materials. The latter of which our clients are very likely to be wearing when they come to our studios. 

Many studies looking at the effectiveness of homemade and surgical masks test only the ability to protect the wearer, and only with a perfect seal on the testing device. In reality, outside of a fitted N95 mask, surgical and homemade masks tend to have small air gaps around the sides of the face and possibly at the sides of the nose when not made with an adjustable bridge. In one study, which was one of the few I found that attempted to replicate air gaps in masks (which is more realistic to most masks that are not a fitted N95), mask filtration for both surgical and homemade masks was shown to drop around 60% if there are gaps present. Although this isn't great news, it did find that surgical masks without gaps filtered around 75-99% of particles, and with gaps about 45-55% of particles depending on size. 

With homemade masks, material changes the efficacy of the mask greatly. Many studies seem to be showing that high thread count cotton is superior to lower count fabric choices, and combinations that 'sandwich' a layer of material with higher static electricity (such as silk, chiffon, or flannel) between layers of high thread count cotton performed the best. The results from a poorly fitting mask were similar. For example, a cotton/silk combination showed 94-98% filtration without gaps, but only 32-37% filtration with gaps. Many studies also seem to agree that lower thread count cotton and other loosely woven materials tend to be fairly ineffective at filtration of particles. Although much of our protocol and PPE usage might be difficult for us to share with our clients in an easy to understand manner, mask fit and material selection could be one area we can consider discussing with them that helps protect our studio, as well as offering a bit of information that could be useful outside of that as well. Along with that, client information that addresses not touching or adjusting your mask, especially while in the studio, could be beneficial as well. 

*The gap used is ∼1% of the active mask surface area, created by drilling holes in the testing tube around where the material was fitted to replicate gaps along the face. 

https://pubs.acs.org/doi/10.1021/acsnano.0c03252

Although the numbers vary greatly between studies, the information seems to agree with the recommendations that homemade masks should be a back up plan if surgical masks are unavailable. One interesting finding was that the addition of a nylon stocking over surgical or homemade masks showed, “The addition of a nylon stocking overlayer improved the removal efficiency for all loose-fitting masks, including commercial medical-type masks, by 15 to 50 percentage points and also decreased the time-based standard deviation (indicating more consistent particle removal)”. 

In surgical masks, this changed the filtration rate in their study from around 60% without the nylon stocking to around 85% with it. This change is likely due to the stocking creating a better seal over the mask, which could be an accessible addition for practitioners, with homemade or surgical masks. However, consideration of contamination will have to be taken when removing a stocking (as pictured below from this study) over the head for cleaning. Or, it could simply be cut away and disposed of each time. 

https://www.medrxiv.org/content/10.1101/2020.04.17.20069567v3.full.pdf

Our routines in mask changes will likely be adapted to this new environment as well. Where before, many likely changed masks between clients, in an environment where we are wearing masks throughout the entire studio rather than for only the potential of contamination directly during a procedure, now studios will need to address protocols on when mask changes happen and how. Wearing masks for longer amounts of time means taking into account that humid masks will have lower filtration capabilities, and mask changes will need to include a routine such as “handwashing – mask removal – handwashing – mask replacement”. 

An easy visual to see all of this through is the World Health Organizations “Chain of Transmission”.

Our goal is to look at this cycle of points of contraction and transmission and find where we can make a break in it. Any break in the cycle stops it. In an environment where there is no 100% break available, outside of isolation, we have to focus on where and how to bring the odds down as far as possible. 

No one mask, air filter, or other device on its own breaks the cycle. One agreement between virtually all studies is that hand hygiene, PPE selection, proper donning and removal of PPE, and a well planned protocol to bring everything together is key to more effective protection. 

Progressive Mentorship will continue to post information as this moves forward, but as always, we appreciate your input and feedback on news, developments, or questions. 

- Misty Forsberg