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Outbreak of Tattoo-Associated Nontuberculous Mycobacterial Skin Infections—Miami, Florida, 2015

Posted By Isabel Griffin, Edhelene Rico, Juan Suarez, Emily Moore, Emily Davenport, Danielle Fernandez, et al., Friday, June 3, 2016
Updated: Tuesday, May 31, 2016

As tattoos have become increasingly popular over recent years in the United States, outbreaks of tattoo-associated infections occasionally occur. On April 29, 2015, the Florida Department of Health in Miami-Dade County, Epidemiology, Disease Control, and Immunization Services (EDC-IS) was notified by a local dermatologist reporting three patients with suspect nontuberculous mycobacterial (NTM) infection after receiving new tattoos at a local tattoo studio. EDC-IS identified multiple tattoo-associated infection cases through an investigation in conjunction with the U.S. Food and Drug Administration (FDA).

On April 30, an interview with the tattoo studio owner revealed that one of the tattoo artists had purchased open bottles of greywash ink, which were reportedly used on symptomatic clients. EDC-IS contacted clients who received tattoos from December 1, 2014 to April 30, 2015, in order to identify clients who may have been exposed. FDA collected environmental samples, including the studio’s tap water and the open bottle of implicated greywash ink. In addition, FDA collected five unopened bottles of greywash ink from local tattoo studios which reported using greywash from the same implicated lot number. Case definitions were created according to interviews with initial cases. A suspect case was a person who received a tattoo and developed a rash which lasted longer than two weeks; a probable case was defined as a suspect case with histopathological or stain evidence of an infectious organism; a confirmed case was someone who met the suspect case definition with a culture identifying an infectious agent or positive immunohistochemical (IHC) stain or polymerase chain reaction (PCR).

Thirty-eight clients of 246 interviewed met the case definition: 7 confirmed, 1 probable, and 30 suspect. Twenty-seven (71%) were male, and the median age was 28 years (range: 19-54 years). Laboratory test results from clinical and environmental specimens revealed Mycobacterium abscessus in clinical samples, the tap water, and the opened bottle of greywash ink. M. chelonae was detected in five unopened bottles of greywash ink collected from the local tattoo studios. Multivariate logistic regression showed that tattoo-associated infection associated with a specific artist was not statistically significant; however, clients who reported receiving grey ink were 8.24 times as likely to have a rash than those who did not report receiving grey ink (OR: 8.24, 95% CI: 3.069—22.127) (Figure 1).

Sources of this outbreak may have included contaminated greywash, tap water tested from the tattoo studio, or a combination of both. Peaks in cases apparent from the epidemic curve, coupled with the positive NTM tap water results may indicate the presence of a biofilm in the water pipe (Figure 2). Characteristic properties of biofilms include a process of attachment, growth, and breaking off which may periodically increase levels of NTM typically found in tap water sources (1). Following M. chelonae-positive results from the unopened bottles of ink, FDA and the greywash manufacturer issued a national recall of the implicated lot number on July 22, 2015.

  1. Hall-Stoodley, Luanne, and Paul Stoodley. "Biofilm Formation and Dispersal and the Transmission of Human Pathogens." Trends in Microbiology 13.1 (2005): 7-10. Web. Sept. 2015.

Pictured from left to right: Reynald Jean, MD, Emily Moore, MPH, Edhelene Rico, MPH, Debbie Summers, Anne Barrera, MPH, Isabel Griffin, MPH, Alvaro Mejia-Echeverry, MD

Not pictured: Juan Suarez, Anthoni Llau, PhD, Christine Oliver, Samir Elmir, Guoyan Zhang, MD, MPH, Emily Davenport, Lakisha Thomas, Pedro Noya-Chaveco, MD, MPH, Marie Etienne, RN, Juan Jose Estrada, Enrique Uribarri, Yuray Martinez,Michael Ragheb, Erin Hansman, Amanda Muana, Laura Vallejo, Danielle Fernandez, MPH, Ann Schmitz, DVM, AM

Authors: Isabel Griffin, MPH, Edhelene Rico, MPH, Juan Suarez, Emily Moore, MPH, Emily Davenport, Danielle Fernandez, MPH, Anthoni Llau, PhD, Alvaro Mejia-Echeverry, MD, Guoyan Zhang, MD, Reynald Jean, MD

Acknowledgements: Christine Oliver, Samir Elmir, Michael Ragheb, Erin Hansman, Amanda Muana, Laura Vallejo, Lakisha Thomas, Anne Barrera, Pedro Noya-Chaveco, Florida Department of Health in Miami-Dade County; Florida Department of Health, Bureau of Public Health Laboratories

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