Infection prevention in personal service settings
Volume 45-1, January 3, 2019: Challenges in infection control
Infection prevention in personal services settings: Evidence, gaps and the way forward
A Popalyar1, J Stafford2, T Ogunremi1, K Dunn1
1 Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, ON
2 Infection Prevention and Control Acute Care, Department of Health, Government of New Brunswick, Fredericton, NB
Popalyar A, Stafford J, Ogunremi T, Dunn K. Infection prevention guidance for personal services settings: Evidence, gaps and the way forward. Can Commun Dis Rep 2019;45(1):1-11. https://doi.org/10.14745/ccdr.v45i01a01
Keywords: personal services, infection, prevention, risk mitigation
Background: Personal services is a continuously evolving industry that encompasses a variety of aesthetic treatments and personal enhancement services. Personal services are an important public health concern because delivery of service may pose potential health risks for both clients and workers. To date, there is a lack of evidence on the specific infection risks involved with personal services and the magnitude of these risks. While guidance and regulation of personal services settings do exist, they appear in varying degrees and complexity across Canada.
Objectives: To summarize relevant literature on the risk of infections related to personal services; conduct an environmental scan of current provincial and territorial guidance and regulations; identify key risk mitigation measures; and summarize gaps and challenges.
Methods: A working group of national experts in the field was established for consultation on key issues. A narrative literature review was conducted to summarize findings from relevant articles. Key questions and a literature search strategy were developed and articles were screened and critically appraised for eligibility. An environmental scan of key guidelines was also conducted to identify relevant legislation and guidance. Findings from both the narrative review and environmental scan were summarized to inform guidance and identify gaps.
Findings: The review of the literature identified factors associated with increased risk of infection including inadequate training of personal services workers and non-compliance with established infection prevention principles. The environmental scan demonstrated that some guidelines have been developed by provincial/territorial ministries of health utilizing basic, generally accepted infection prevention principles. The established body of evidence that informs infection prevention and control recommendations is valid for health care settings; however there are factors to consider in extracting and applying such guidance to personal services settings. Major gaps and challenges remain in supporting both the advancement of infection prevention guidance and the development of enhanced regulatory frameworks, applicable to personal services settings in Canada.
Conclusion: This review involved a comprehensive examination of relevant literature and provides a summary of issues addressing the risk of infection in personal services settings. There is a paucity of high quality evidence to support guidance, and findings reveal the need for further investigation and enhanced awareness of public health risks associated with personal services. Nonetheless, these findings can inform future research and the development of infection prevention and control guidelines and recommendations for such settings.
Personal services is a continuously evolving industry that encompasses a variety of aesthetic treatments and personal enhancement services, from non-invasive (such as hair and nail services) to invasive procedures such as microneedling and other body modification procedures. Many of these services intentionally or accidentally penetrate the body’s defences, posing an infection risk to clients and personal services workers.
There is little information on the infection risks specifically associated with these services. In addition, there is no national surveillance system related to complications of the personal services industry in Canada. While guidance and regulation of personal services settings do exist, the degree and complexity varies across Canada. With a lack of evidence related to disease acquisition in personal services settings, general principles of infection prevention are applied; these may not be directly applicable to the industry.
The objectives of this article are to summarize the available relevant literature on the risk of infections related to personal services; conduct an environmental scan of current provincial/territorial ministry of health guidance and regulations; outline generally accepted infection prevention principles relevant to personal services settings; and summarize major gaps and challenges. This article is intended to bring greater awareness from a public health perspective and be a resource for those considering the development of guidelines or regulations in this area.
A review of practice guidelines, recommendations, position papers, etcetera, produced by personal services and/or public health professional associations or by educational programs is beyond the scope of this article.
Expert Working Group
In 2013, an expert working group was established to inform the Public Health Agency of Canada (PHAC) of issues associated with personal services and to provide infection prevention guidance for this setting. Expertise from the field included public health nurses and inspectors and infection prevention and control professionals from Nova Scotia, New Brunswick, Ontario, Manitoba and Alberta. The expert working group reviewed findings from the literature search and environmental scan.
A narrative literature review was conducted to determine and summarize findings from relevant studies on the risk of infections related to personal services and inform the development of guidance. Key questions addressed prevalence, infection risk factors and infection prevention strategies for the three categories of personal services: piercing; other invasive services; and non-invasive services. The Health Library (Health Canada) undertook a comprehensive literature search using PubMed, Embase, Global Health, Ovid MEDLINE, Ovid MEDLINE Daily and Ovid OLDMEDLINE databases for studies published from January 1999 to December 2016.
The search was limited to studies in English and French with no filters applied, which would limit retrieval by study design. The full texts of all retrieved studies were manually screened to identify studies that reported on the receipt of one or more of the following categories of services:
- Body modification (i.e., ear/body piercing, body/eyeball tattooing, micropigmentation, scarification, tongue splitting, beading, jewellery implants, ocular jewellery, branding)
- Injections (i.e., fillers)
- Cosmetology (i.e., aesthetics, hair dressing/barber services, shaving, microdermal abrasion, facials, artificial nails, manicures, pedicures, make-up, face painting, waxing, electrolysis); and/or
- Other personal services (i.e., health spa/skin clinic, mud/steam bath, laser service including hair removal/skin resurfacing, massage, tanning, aromatherapy, teeth whitening, colonic irrigation, flotation tanks/water therapy)
AND the development of one or more of the following:
- Skin/soft tissue infection
- Bloodborne infection (e.g., hepatitis B, hepatitis C, HIV, other); and/or
- Systemic infection (e.g., endocarditis, septicemia, other)
An environmental scan of ministry of health websites was conducted to identify provincial and territorial guidelines, standards and regulations to do with personal services.
Guiding principles for infection prevention and control, as applicable to personal service settings, were identified and summarized.
Summary of findings
Expert Working Group
Challenges and gaps identified by public health inspectors and infection prevention and control professionals highlighted the need for increased awareness as well as improved guidance and regulations.
Of the 729 papers identified for preliminary screening, 555 were reviews or abstracts and were therefore excluded. A further 92 papers did not meet the search criteria outlined in the scope. A critical appraisal of the remaining 82 studies was accomplished using the PHAC Infection Prevention and Control Guidelines Critical Appraisal Tool Kit Footnote 1, and a further 31 papers were eliminated due to flaws in methodology (n=16) or analysis of results (n=15). This resulted in a total of 51 papers on the risk of infections related to personal services.
Risk of infection and transmission
The risks identified in the literature were quite varied. Information relevant to infection risks and the magnitude of these risks specific to Canadian personal services settings were limited however, a number of studies identified factors associated with increased risk of infection in personal services settings in other countries:
- Inadequate training and skill level of personal services workers (resulting in poor infection prevention control practices) Footnote 2Footnote 3
- Poor or non-compliance with generally established infection prevention practices (resulting in individual cases or wider outbreaks of infection) Footnote 4Footnote 5Footnote 6Footnote 7
Specific findings related to breaches or non-compliance with recommended infection practices include:
- Improper glove use Footnote 8
- Improper cleaning of the environment Footnote 9Footnote 10
- Improper cleaning, disinfection and sterilization of tools or equipment Footnote 2Footnote 7Footnote 8Footnote 10Footnote 11Footnote 12Footnote 13Footnote 14Footnote 15Footnote 16Footnote 17Footnote 18Footnote 19Footnote 20
- Use of non-sterile instruments for invasive procedures Footnote 8Footnote 17Footnote 18Footnote 19Footnote 20
- Use of contaminated water, ink, supplies or equipment Footnote 6Footnote 7Footnote 21Footnote 22Footnote 23Footnote 24Footnote 25Footnote 26Footnote 27Footnote 28Footnote 29Footnote 30Footnote 31Footnote 32
- Pre-existing health status of the clients Footnote 33Footnote 34Footnote 35Footnote 36Footnote 37Footnote 38Footnote 39
- Failure to provide adequate after care instructions Footnote 40Footnote 41
- Deficiencies in the physical layout and inadequate infection prevention and control practices, including lack of hand washing facilities and/ or with no potable water Footnote 8
Studies showed that infections associated with personal services may be bacterial Footnote 38Footnote 42Footnote 43Footnote 44Footnote 45Footnote 46, viral Footnote 47Footnote 48Footnote 49Footnote 50Footnote 51Footnote 52 or fungal Footnote 53. The risk for transmission of bloodborne viruses within personal services settings is impacted by knowledge of and/or adherence to effective, established infection prevention practices Footnote 54Footnote 55Footnote 56Footnote 57Footnote 58. Specific risk factors associated with exposure to bloodborne infections during personal services procedures include:
- Potential contact with blood when sharps containers are not placed within reach, leading to unnecessary handling of contaminated sharps and injuries; improper disposal of sharps, by, for example, repackaging used sharps or discarding them in the regular garbage
- Cross-contamination of instruments and surfaces
- Re-use of disposable instruments and equipment such as razors and styptic pencils
- Inadequate disinfection and sterilization of equipment
- Inadequate management of cuts and abrasions on personal services workers
- Inconsistent hand hygiene and glove use
- Lack of knowledge about appropriate procedures and routes of transmission of bloodborne pathogens
- Lack of vaccine-induced protection (e.g., for hepatitis B)
The environmental scan was limited to provincial/territorial ministry of health websites to identify relevant legislation, regulations and approved guidelines, practices and standards. Guidance and regulations for personal services settings exist in varying degrees and complexity across Canada (Table 1). A review of practice guidelines, recommendations, position papers, etc. produced by personal services and/or public health professional associations or by educational programs was beyond the scope of the scan.
|Province/ territory||Guidelines, standards, protocols and/or other||Acts, regulations and/or bylaws|
|Newfoundland and Labrador||N/A||Personal Services Act, 2012 Footnote 59|
|Prince Edward Island||Guidelines for Tanning Salon Owners and Operators, 2011 Footnote 60Table 1 footnote a||PEI Public Health Act, 2018 Footnote 61|
|Nova Scotia||Salon and Spa Compliance Handbook, no date Footnote 62||Safe Body Art Act, 2011 Footnote 63
Health Protection Act, 2016 Footnote 64
Safe Body Art Regulations, 2018 Footnote 65
|New Brunswick||N/A||New Brunswick Bill 56 Public Health Act, 1998 Footnote 66|
|Quebec||Tattooers and Piercers: Protect Your Client and Yourself Against HIV and Hepatitis B and C, 1999 Footnote 67||N/A|
|Ontario||Infection Prevention and Control Best Practices for Personal Services Settings, 2009 Footnote 68
Infection Prevention and Control Disclosure Protocol, 2018 Footnote 69
Infection Prevention and Control Complaint Protocol, 2018 Footnote 70
Personal Service Settings Guideline, 2018 Footnote 71
The Ontario Public Health Standards: Requirements for Programs, Services, and Accountability, 2018 Footnote 72
|Health Promotion and Protection and Promotion Act, Ontario Regulation 136/18: Personal Service Settings, 2018 Footnote 73|
|Manitoba||Personal Services Facility Guideline, 2013 Footnote 74||N/A|
|Saskatchewan||Personal Service Facility Best Management Practices, 2014 Footnote 75||The Health Hazard Regulations, 2002 Footnote 76|
|Alberta||Health Standards and Guidelines for Tattooing, 2002 Footnote 77
Health Standards and Guidelines for Body and Ear Piercing, 2002 Footnote 78
Health Standards and Guidelines for Barbering and Hairstyling, 2002 Footnote 79
Health Standards and Guidelines for Esthetics, 2002 Footnote 80
Health Standards and Guidelines for Electrolysis, 2002 Footnote 81
|Public Health Personal Services Regulation, 2003 Footnote 82|
|British Columbia||Guidelines for Personal Services Establishments, 2017 Footnote 83
Guidelines For Body Modification, 2017 Footnote 84
Guideline for Personal Services Offered at Tradeshows, 2016 Footnote 85
Guidelines for Floatation Tanks, 2016 Footnote 86
Laser Hair Removal Devices: Safety Guidelines for Owners/Operators, 2005 Footnote 87
Microblading Services in Personal Service Establishments – Fact Sheet for Operators, 2017 Footnote 88
|Public Health Act, Regulated Activities Regulation, 2011 Footnote 89|
|Yukon||Personal Service Premises Inspection Model, 2013 Footnote 90||Public Health Act – Personal Service Establishment Regulations, 1984 Footnote 91|
|Northwest Territories||Standards for Personal Service Establishments, 2012 Footnote 92||Public Health Act – Personal Services Establishment Regulations, 2013 Footnote 93|
|Nunavut||N/A||Public Health Act, 2016 Footnote 94
Barber Shops and Beauty Salons Regulations, 1990 Footnote 95
General risk mitigation measures
The scope of personal services is very broad and different services and settings may require different infection prevention guidance. Generally accepted key measures that minimize infection risk are summarized in Table 2. Consistent application of infection prevention practices and precautions help prevent the acquisition and transmission of infections. The general infection prevention principles outlined in Table 2 are not comprehensive and are based on core infection prevention principles as identified in the PHAC guideline: Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings Footnote 96.
|Risk Mitigation Measure||Additional Context|
|Environmental cleaning and disinfection||
|Single-use devices and products||
|Reprocessing reusable devices||
Gaps and challenges
Following the review of findings from the narrative review and environmental scan as well as discussions with the expert working group, a number of gaps and challenges were identified. These are summarized in Table 3.
|Gap/Challenge related to:||Context|
|Related to infection prevention|
|Setting||Health care guidelines and standards for infection prevention are not directly applicable to personal services settings
|Limited and poor quality literature and data on risk of infection and the burden of illness associated with personal services settings
|Recommendations for cleaning and disinfection, including recommendations for products used to clean and disinfect, exist in varying degrees and complexities
|Infection prevention education and training||Education and training of workers on infection prevention is not feasible (or enforceable) in many personal services settings|
|Workplace and practice audits by personnel trained in infection prevention are often not available to personal services settings|
|Outside the scope of infection prevention|
|Legal infrastructure||A consistent definition of personal services across jurisdictions is difficult to achieve as this is a continuously evolving industry. Lists of procedures that can be offered in these settings exist; however they are quickly outdated and are inconsistent across jurisdictions|
|Jurisdictional guidance and/or regulation regarding acceptable procedures and standards may be limited for non-regulated workers. There are questions around the type of procedures acceptable for delivery by personal services workers versus delivery by health care professionals|
|Health care professionals are providing services in medical spa settings; this has created a grey area for public health inspectors. While the practice of the personal services worker falls under the jurisdiction of the professional regulatory body, the service delivery setting itself can require public health inspection if located outside the mandate of a health authority|
|Client safety||Chemicals and devices used in personal services settings can cause injuries such as those associated with the application of energy (e.g., lasers, fat freezing, cryotherapy chambers, plasma pens) and injections (e.g., mesotherapy). Health care organizations have protocols, procedures, and oversight in place to ensure devices and products are used safely and to address any injuries; many personal services settings do not have this type of infrastructure|
|Health Canada licences medical devices, products and chemicals that can be sold in Canada, but other substances that may not be licensed for use in Canada are available for purchase internationally via the internet|
|The public do not consistently have access to inspection reports that would assist them in their choice of personal services setting|
|Worker skill and knowledge||There is uncertainty regarding scope of practice, in particular for workers without a professional regulatory body|
|Many workers do not have formal standard education and training in the services they provide. They may be self-taught or learn from another worker|
|Most personal services settings require a license to operate, but not all workers have their practice regulated by a professional college/association|
There are concerns about infection prevention in the personal services industry. This article describes some of the concerns from a public health perspective, based on published studies and an environmental scan of guidelines and regulations available on provincial/territorial ministry of health websites. In addition, the gaps and challenges presented are a preliminary list of major issues as identified by the external expert working group, and do not encompass the full breadth or complexity of issues faced by public health in general.
There were notable limitations with the results of the literature review, in terms of comparability and applicability of available evidence to the Canadian context of personal services settings. This includes challenges with the quality of evidence, and limitations to extraction of data from case reports, self-reports, laboratory sampling, medical records and survey questionnaires. General principles and core elements for infection prevention are available from an established and recognized body of evidence that informs recommendations for practice in health care settings; however, there are challenges when applying measures from one setting to another. When extracting specific guidance for health care settings and adapting to personal services settings, some measures may not be relevant or directly apply.
This industry continues to evolve, with emergence of new procedures and services across a range of personal settings. The majority of publications and reports available focused on tattooing and piercing; however, a number of areas of personal services have no published information. Examples include body modification (tongue splitting, branding and scarification), nail salons and laser device uses for body enhancement. There is a need for further investigation to reflect the broad range of services and risks for exposure and transmission of infections in the Canadian context.
The feasibility of implementing infection prevention standards can be a challenge for alternate small business settings. The physical layout and design of these settings can contribute to infection prevention issues, there is limited evidence and data on the risk of infection in these settings, practices for cleaning and disinfection are inconsistent, and worker education and training on infection prevention are also limited depending on available resources.
In relation to the legal infrastructure, difficulties in defining personal services spill over into jurisdictional and regulatory issues and create grey areas in public health. Client safety is a major concern, particularly in the use of chemicals and devices in personal services settings. There is a need for standardized and consistent education and training of personal services workers.
While some organizations, such as the National Collaborating Centre on Environmental Health and the Canadian Institute of Public Health Inspectors, continue to examine and make efforts toward addressing issues related to personal services, further work is needed in this area. Canadian studies on infection prevention in personal services settings is recommended to provide information on the transmission pathways and risk of infections, and allow for assessment of burden of illness related to personal services settings in Canada. A continuously evolving industry also requires keeping an eye out for new services while working on legislation, regulation, guidelines, licensing and public education.
Personal services is a continuously evolving industry that encompasses a variety of aesthetic treatments and personal enhancement services, including procedures that range from non-invasive to more invasive, with associated risk of infection to clients and workers. This overview includes a summary of current regulations and guidelines across provincial and territorial jurisdictions. Findings were informed by the contribution of experts in the field, in addition to results from the narrative review and environmental scan.
Despite limitations to evidence on the specific infection risks associated with these services, reports and publications do indicate contributing factors and findings that can be used to inform risk mitigation strategies. At the current time, there is no established surveillance system for data related to complications associated with the personal services industry in Canada. This summary identifies gaps and challenges to bring greater awareness from a public health perspective, and opportunities to address public health concerns through policy, regulation and guidelines, in an effort to promote and monitor best practices for the health of Canadians.
AP – Data review, writing – original draft, review and editing
JS – Data collection, data analysis and interpretation, writing – review and editing
TO – Writing – review and editing
KD – Conceptualization, writing - review and editing, supervision and project administration
Conflict of interest
The authors would like to thank the following members of the expert working group for their subject matter expertise, contributions to the project that informed this article, and their input on former drafts of this article.
Jane Stafford (Chair), Department of Health, Government of New Brunswick, NB
Brenda Dyck, Winnipeg, MB
Carrie Fraser, Nova Scotia Department of Health and Wellness, Inverness, NS
Brenda Kwan, Durham Region Health Department, Whitby, ON
Christian Lapensée, Ottawa Public Health, Ottawa, ON
Jason MacDonald, Alberta Health & Alberta Health Services, Edmonton, AB
Amy Pavletic, Middlesex-London Health Unit, London, ON
Cathie Walker, Elgin St Thomas Health Unit, London, ON
The authors thank Laurie O’Neil and Christine Weir for their project leadership, expertise on infection prevention and control, and for conducting initial literature reviews in consultation with members of the expert working group. The authors would like to thank Heidi Pitfield for subject matter expertise, review and contribution to discussions on the manuscript.
This work was supported by the Public Health Agency of Canada.
This work is licensed under a Creative Commons Attribution 4.0 International License
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