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Tattoo Ordinance OptionsPrepared by: Crenna M. Brumwell, Esq. 300 Main Street Suite 330 Dubuque IA 52001 563 589-4381 ORDINANCE NO. 49 -08 AMENDING CITY OF DUBUQUE CODE OF ORDINANCES BY REPEALING SECTION 23-2 TATTOOING AND ADOPTING A NEW SECTION WHICH ADOPTS THE STATE OF IOWA TATTOOING CODE AND ADMINISTRATIVE RULES Section 1. City of Dubuque Code of Ordinances § 23-2 is repealed and the following new section is hereby adopted: Section 23-2. State Code Adopted: There is hereby adopted and incorporated by reference Iowa Code chapter 135.37 TATTOOING - PERMIT REQUIRED - PENALTY, as amended, and Iowa Administrative Code chapter 641-22, "Practice of Tattooing", adopted by the Iowa Department of Public Health revised January 15, 2003, which applies to sanitation and infection control, equipment, procedures, application for permit, the permit process, variances, adverse actions, the appeal process, and procedures for health departments to provide for the inspection and enforcement of such rules. Section 2. This Ordinance shall take effect on publication. Passed, approved and adopted the 7th day of July , 2008. Attest: ~~ i eanne F. Schneider, City Clerk /~~ Sri V` ~ ~(~Y`~ /:r ~! f Roy D. Buy ~l, Mayor THE CITY OF Dubuque A DUB E 1 - Masterpiece on the Mississippi 2007 TO: The Honorable Mayor and City Council Members FROM: Michael C. Van Milligen, City Manager SUBJECT: Tattoo Ordinance DATE: July 2, 2008 On April 21, 2008, the City Council referred the request from Jeff Davis of Mystic Tattoo, Inc. requesting a change in the City Ordinance regulating tattooing. In 1996, the City of Dubuque adopted the current ordinance, which, in addition to following the Iowa Administrative Code, requires, "The practice of tattooing shall be limited to physicians or osteopaths licensed in the State of Iowa, or to individuals directly under their supervision." Under the current 28E Agreement, the City would be the entity inspecting tattoo parlors for the Iowa Department of Public Health, if there were one in Dubuque County. Public Health Specialist Mary Rose Corrigan advises that since the current ordinance only allows for tattoos to be administered by someone under the direct supervision of a physician, the likelihood of tattoos being applied outside a health care facility is remote. The ordinance could be revised to allow tattooing "under the supervision of a physician" similar to the rule on how a physician assistant (PA) can practice. In this case, "Supervision would not require the personal presence of the supervising physician at the place where tattoo services are rendered." This language is modeled after the physician assistant (PA) rule language. The level of supervision provided would be at the discretion of the physician. However, since the level of supervision would vary, the public would not have knowledge of the physician's involvement with the tattoo parlor or artist. The City of Dubuque's Medical Advisor, Dr. John Viner, MD, outlines his concerns and summarizes the problems with tattoos in the attached letter. Dr. Viner states, "from a strictly public health point of view, there are good reasons for medical supervision." Public Health Specialist Mary Rose Corrigan advises that the City Council has three choices: 1. Maintain the Ordinance as it is without changes. 2. Modify the current Ordinance to not require "direct supervision by a licensed physician", but simply allow tattoos to be administered by someone under the supervision of a physician, whereas supervision would not require the personal presence of the supervising physician at the place where tattoo services are rendered. 3. Do not require any special ordinance and follow the "Practice of Tattooing" Iowa Administrative Code 641-22 and Chapter 135 of the Iowa Code, "Tattooing". C.~ ~ c~ Michael C. Van Milligen MCVM/jh Attachment cc: Barry Lindahl, City Attorney Cindy Steinhauser, Assistant City Manager Mary Rose Corrigan, RN, Public Health Specialist THE CITY OF Dubuque AI DUB E Masterpiece on the Mississippi 2007 TO: Michael an Milligen, City Manager FROM: Mary R Corrigan, RN, Public Health Specialist SUBJECT: Tattoo rdinance DATE: June 25, 2008 On April 21, 2008, the City Council referred the request from Jeff Davis, Mystic Tattoo, Inc., requesting a change to Code of Ordinance Section 23-2 "Tattooing". This memorandum provides suggested changes to the current Tattoo Ordinance. BACKGROUND In 1978, the City Code of Ordinances was amended to prohibit the operation of tattoo establishments or the practice of tattooing unless performed by a duly licensed veterinary or medical practitioner. In approximately 1993, the Iowa Department of Public Health adopted Chapter 22 of the Iowa Administrative Code regulating the practice of tattooing under the State Code. The Chapter sets guidelines for sanitation and infection control, equipment, procedures, application for tattooing permits and fees for those practitioners and establishments wishing to engage in the practice of tattooing (see attached). Establishments pay permits fees and the facilities are inspected annually. Iowa currently permits 166 tattoo establishments (see attached map). In 1996, the City of Dubuque adopted the current Ordinance which, in addition to following the Iowa Administrative Code, requires "the practice of tattooing shall be limited to physicians or osteopaths licensed in the State of Iowa, or to individuals directly under their supervision." Dubuque County also followed suit with adopting this same Ordinance. In 2004, a request was made to change the Tattoo Ordinance and the City Council did not act on that request. In addition to Dubuque County, other cities have similar ordinances as Dubuque, including East Dubuque, IL, Peachtree City, Atlanta, and others. Under the current 28E Agreement for Pool, Tattoo and Tanning Program Services, the City would be the entity inspecting tattoo parlors for the Iowa Department of Public Health if there was one in Dubuque County. The City Health Services Department has received approximately five inquiries over the past few years regarding establishing a tattoo parlor in the city of Dubuque. None of these have resulted in a permitted tattoo parlor. No inquiries or requests to change the Ordinance have been made by individuals wanting tattoos. No infectious disease outbreaks in the community have been linked to tattooing. DISCUSSION Other than a simple registry, the Iowa Department of Public Health does not require any special education, training or certification of a tattoo artist. Tattooing is an invasive procedure which would require special training and credentialing if it were done in a health care facility. Armstrong et al estimates bleeding occurring in 76% of clients after tattooing. No training or credentialing programs exist for tattoo artists. The National Environmental Health Association (NEHA) does reference requiring bloodborne pathogen training or American Red Cross courses in their model code. The State tattoo parlor license requirements do, however, address sanitation and infection control, equipment, procedures, etc. Since the current ordinance only allows for tattoos to be administered by someone under the direct supervision of a physician, the likelihood of tattoos being applied outside a health care facility is remote. The ordinance could be revised to allow tattooing "under the supervision of a physician" similar to the rule on how a physician assistant (PA) can practice. In this case, "Supervision would not require the personal presence of the supervising physician at the place where tattoo services are rendered." This language is modeled after the physician assistant (PA) rule language. The level of supervision provided would be at the discretion of the physician. However, since the level of supervision would vary, the public would not have knowledge of the physician's involvement with the tattoo parlor or artist. The City of Dubuque's Medical Advisor, Dr. John Viner, MD, outlines his concerns and summarizes the problems with tattoos in the attached letter. Dr. Viner states "from a strictly public health point of view, there are good reasons for medical supervision." If the City did require extra monitoring and inspections beyond the current Iowa Department of Public Health Code, it would have a Health Services Department staff and budget impact which could not be absorbed with the current tattoo parlor inspection fees of $200 per annual inspection as established by the State rules. A literature search revealed many research articles dealing with the adverse outcomes of tattooing. Findings of the research articles include: • Local infection is reported in about 5% of tattoos • Hepatitis C virus transmission is found in 3.5% of the people without tattoos and in 33% of the people with tattoos. People who have tattoos non-professionally applied or have multiple tattoos have a higher incidence than those with one tattoo. However, case control studies of acute Hepatitis C in the USA have failed to show a significant, direct association with tattoos. • The pigments used in tattoos are not regulated or approved by the Food and Drug Administration (FDA). They sometimes can cause pain and itching several weeks after the tattoo has been placed, and some cause allergic reactions. • Keloids and hypertrophic scars are other dermatologic complications of tattooing and occur in about 10%. • Many of the research articles also discussed piercing, which has a higher incidence of complications and adverse health effects such as up to a 30% infection rate. • Several of the research articles noted adverse outcomes of adolescents receiving tattoos and their general lack of knowledge on the risks associated with tattooing. Contributing to adverse outcomes in adolescents is if they receive their tattoos from an unregulated establishment. The State rules do not allow tattooing of anyone under 18 years of age. RECOMMENDATION I recommend the City Council choose one of the following options for the Tattoo Ordinance: 1. Maintain the Ordinance as it is without changes. 2. Modify the current Ordinance to not require "direct supervision by a licensed physician", but simply allow tattoos to be administered by someone under the supervision of a physician, whereas supervision would not require the personal presence of the supervising physician at the place where tattoo services are rendered. 3. Do not require any special ordinance and follow the "Practice of Tattooing" Iowa Administrative Code 641-22 and Chapter 135 of the Iowa Code, "Tattooing". COUNCIL ACTION Adopt one of the attached Ordinances. MRC/cj cc: Dr. John Viner, M.D. Prepared by: Crenna M. Brumwell, Esq. 300 Main Street Suite 330 Dubuque IA 52001 563 589-4381 ORDINANCE NO. -08 AMENDING CITY OF DUBUQUE CODE OF ORDINANCES BY REPEALING SECTION 23-2 TATTOOING AND ADOPTING A NEW SECTION 23-2 TO ALLOW TATTOOING UNDER THE SUPERVISION OF A MEDICAL DOCTOR (M.D.) OR OSTEOPATH (D.O.) Section 1. City of Dubuque Code of Ordinances § 23-2 is repealed and the following new section is hereby adopted: Section 23-2. Tattooing: (a) Definitions: For the purposes of this Section, the following words and phrases shall be construed as follows: (1) Physician: Medical Doctor (M.D.) or osteopath (D.O.) (2) Supervision: Does not require the physical presence of the supervising physician at the place tattooing is practiced except insofar as the physical presence of the supervising physician is expressly required by the Iowa Code or rules of the Iowa Department of Public Health. (3) Tattoo Artist: Any person engaged in the practice of tattooing. (4) Tattoo Establishment: Location where tattooing is practiced. (5) Tattooing: To puncture the skin of a person with a needle and insert indelible permanent colors through the puncture to leave permanent marks or designs. (b) Prohibition: The practice of tattooing shall be limited to physicians licensed in this state, or to individuals under the supervision of a physician licensed in this state. (c) Registration: Tattoo establishments and tattoo artists shall register annually with the City Manager and indicate the physician under whose supervision they are operating. Attest: Section 2. This Ordinance shall take effect on publication. Passed, approved and adopted the day of , 2008. Roy D. Buol, Mayor Jeanne F. Schneider, City -Clerk EFFECT OF AMENDMENT Section 23-2. Tattooing: (a) Definitions: For the purposes of this Section, the following words and phrases shall be construed as follows: (1) Physician: Medical Doctor (M.D.) or osteopath (D.O.) (2) Supervision: Does not require the physical presence of the supervising'- - - Formatted: Indent: Left: 0.5", Hanging: 0.5" physician at the place tattooing is practiced except insofar as the physical presence of the supervising physician is expressly required by the Iowa Code or rules of the Iowa Department of Public Health. (3~) Tattoo Artist: Any person engaged in the practice of tattooing. {~)(4) Tattoo Establishment: Location where tattooing is practiced. ~- - - Formatted: Buiiers and Numbering {~)(5) Tattooing: To puncture the skin of a person with a needle and insertF- - - Formatted: Bullets and Numbering indelible permanent colors through the puncture to leave permanent marks or designs. (b) Prohibition: The practice of tattooing shall be limited to physicians or esteepat#~s-licensed in this statee~ta#e, or to individuals direst4y-under their supervision of a physician licensed in this state. (c) Registration: Tattoo establishments and tattoo artists shall register annually with the City Manager Health SeFVises~~~~sie„-and indicate the physician er esteopatk>-under whose supervision they are operating. EFFECT OF AMENDMENT Sec. 23-2. State Code Adopted: There is hereby adopted and incorporated by reference Iowa Code chapter 135.37•- - _ Formatted: Indent: Left: 0^, First line: o" TATTOOING - PERMIT REQUIRED - PENALTY, as amended, and Iowa Administrative Code chapter 641-22, "Practice of Tattooing", adopted by the Iowa Department of Public Health revised January 15, 2003, which applies to sanitation and infection control, equipment, procedures, application for permit, the permit process, variances, adverse actions, the appeal process, and procedures for health departments to provide for the inspection and enforcement of such rules. ~,~-'~ Dubuque Internal Medicine - Doctors For Adults' April 30, 2008 Mary Rose Corrigan Dubuque Health Department 1300 Main Street Dubuque, Iowa 52001 Dear Ms. Corrigan: The issue of public health considerations in tattoo parlors was raised. I was asked to follow up with you about the public health aspects. We had explored these issues in 1996 and again in 2004. I have tried to gather some added information about what is happening in the community and the current policies from the Food and Drug Administration and the American Medical Association. There have been misunderstandings inthe community as represented in the newspaper. Medical tattoos are, indeed, currently being done by Dubuque physicians. The most common would be in plastic surgery and reconstructive work. Of course, this is done by licensed physicians. Another misconception that has been in the local news is that needle use in dentistry has a higher risk of HIV transmission than tattoos. This is incorrect. Twenty years ago, there was one incident of a dental transmission of HIV to multiple patients. I do not want to get into the explanation of this, but it was not routine dental practice. Hepatitis B virus, hepatitis C virus, and HIV are transmitted by needle. These are the principal blood-borne pathogens. This is why single use needles and blood precautions have been routinely instituted in health care. Currently, HN and HCV are at all time high prevalence in Dubuque and in Iowa. More Iowa jurisdictions followed our lead in recognizing the need for medical supervision of tattoos. I would also point out that our blood bank excludes blood donors for at least 12 months after receiving a tattoo in an unregulated state. I was interested in what was involved in establishing a commercial tattoo business. A cursory check of the Internet showed a complete mail order outfit for $179. An autoclave sterilizer was extra, but what actually is supposed to be re-sterilized? The claim is that needles are single use and disposed of in commercial tattooing, but I also see that special needle tips, which are not disposable, are also offered for sale. Dubuque Internal Medicine, P.C. 1515 Delhi Street, Suite 100 Dubuque, Iowa 52001-6389 563/557-911] Internal Medicine R. S. Bartsch, M.D. Z. Cao, M.D., Ph.D. J. M. Compton, M.D., F.A.C.P. A. D. Kelley, D.O. M. J. Kirkendall, M.D. C. J. Konz, M.D. P. J. Leeson, M.D., F.A.C.P. R. W. Lengeling, M.D. M. O. Liaboe, M.D. C. A. Longo, M.D. A. G. Meurer, M.D. B. D. Moran, M.D. G. M. Moran, M.D. D. K. Mozena, M.D. K. E. Nelson, M.D. G. V. Ridgley, Jr., M.D. H. A. Salas, M.D. R. W. Schope, M.D. J. P. Viner, M.D., F.A.C.P. Ambulatory Care L. Callaway, Jr., M.D. C. M. Kettmann, P.A.-C. Travel Medicine R. J. Fairley, M.D., M.P.H. Cardiology C. A. Longo, M.D. T. W. Martin, M.D., F.A.C.C. Dermatology J. M. Schope, M.D. Endocrinology R. A. Iverson, M.D., F.A.C.P. D. M. Putz, M.D. Gastroenterology K. V. Goirepati, M.D. I. M. Koontz, M.D. R. W. Lengeling, M.D. Infectious Diseases J. P. Viner, M.D., F.A.C.P. Medical Oncology iv1. E. Hermann, M.U. D. W. Zenk, M.D. Nephrology D. M. Ringold, M.D. J. E. Whalen, M.D. C. L. Kramer, A. R.N.P. J. A. Rambousek, A.R.N.P. Pulmonary Medicine R. W. Schope, M.D. Medical Director R. J. Fairley, M.D., M.P.H. Page 2 Mary Rose Corrigan Apri130, 2008 The issue of needle disposal is crucial, too. Needle disposal canisters can be obtained, but the disposal of these in health care settings must be through incineration by a licensed handler. This might be a deficiency of a commercial tattoo business. The use of inks and pigments in tattooing was also of interest. None of these are FDA approved. There is approval of these pigments for use in printing and for automobile use. Contrast the concern for heavy metals in toys coming from China with the lack of concern of unregulated pigments, many of which contain heavy metals which are actually injected into the body. Some of the more vivid pigments used in tattoos are made by micronized plastic. This is another threat for allergic problems. It brings to mind the pubic concerns that arose from silicone breast implants and immune reactions, some years ago. Particular concerns that should be raised regarding public health consequences of tattooing include infectious risk. I mentioned HIV and hepatitis C. You are familiar with the female actor who acquired HCV through a tattoo a few years ago. Hepatitis B needs to be highlighted, also. This is the most easily transmitted blood-borne pathogen. We are fortunate that we are a low prevalence part of the world and have an immunization that has been helpful against this virus. I have a current patient who has a different retrovirus, called HTLV which was acquired from tattooing. Informed consent for a tattoo must include several points. Dissatisfaction is a common problem. I am not classifying this with the public health concerns. Keloid development is another complication of tattooing and can be aggravated when the tattoo is attempted to be removed. Granulomas are also common reactions of the skin, as are allergies to pigments. MRI scanning can be a problem with metal-containing tattoos. The tattoo may become hazy under the magnetic field of this scan. MRI scanning can also provoke a burn in tattooed skin. Cosmetic tattooing has the added risk of eye injury because this is often performed around the eye. It does requires injection of local anesthetic which would not be in the realm of a tattoo business. I have not mentioned the MRSA outbreak related to commercial tattoo administration in Maryland in the recent past. Of course, we are in an MRSA epidemic and any disruption or injection into the skin of someone who happens to be colonized could obviously cause infection. Tattoos must never been given to minors. Page 3 Mary Rose Corrigan April 30, 2008 State regulation is recommended, but I am afraid that tattoo establishment in our city and county would also necessitate a higher duty of inspection. I have discussed the current State position for tattoo inspection with Talisa Miller. This involves autoclave inspection, monthly spore test record, and sanitary condition inspection, annually. Is this enough? Certainly, the half-dozen specific risks outlined above would need to be spelled out by informed consent. From a strictly public health point of view, there are good reasons for medical supervision. Sincerely, ,~. Jam. Tohn P. Viner, M.D. JPV/rs