Disease Detectives: Linking the spread of Pseudomonas infection

This weblog is a component of Disease Detectives, a sequence which showcases PHE science.

How physique piercings and unsafe aftercare led to a nationwide outbreak of Pseudomonas Aeruginosa.

Everyday folks in the UK select to have physique piercings and hopefully most go easily and don’t lead to issues.

However when a quantity of folks from the East Midlands and the South East who had just lately had physique piercings turned in poor health with Pseudomonas aeruginosa which may go onto trigger sepsis and disfigurement of the ear lobe, we as epidemiological scientists wanted to undertake some detective work to find out if there was a hyperlink between them and to forestall others getting in poor health.

Identification of the outbreak

On 31 August 2016, the PHE centre in the East Midlands was alerted by the native Ear, Nose and Throat (ENT) hospital division that there was a cluster of six instances of ear abscesses following piercings at an East Midlands piercing studio. Four of the six abscesses examined constructive for P. aeruginosa, a bacterial infection which may have severe health implications.

The ENT crew had been involved that there could be an outbreak associated to piercings at the studio because it was uncommon to see so many abscesses like this. However it quickly turned obvious that the state of affairs was extra widespread when the PHE centre in the South East was additionally alerted to eight ear abscess instances (4 with confirmed P. aeruginosa infection) following piercings at an area studio.

Although the two outbreaks might have been coincidental, the similarities between them prompt there could be a typical concern inflicting the drawback. However we would have liked to do additional work to know in the event that they had been positively linked and in that case how given the studios had been greater than 100 miles aside.


Initial investigations

As epidemiologists, our function is to establish irregular patterns in health and sickness in the inhabitants; and to detect outbreaks of illness early to forestall extra folks from getting in poor health.

A multi-agency nationwide outbreak management group, involving the native authority, PHE, NHS England, the native Clinical Commissioning Group and the producer, was convened to research the outbreak.  Working with our environmental health and health safety colleagues we had been quickly in a position to establish nationally distributed aftercare resolution, produced by a single producer in the East Midlands, was frequent to each studios. From earlier expertise and the revealed scientific literature we thought that this aftercare resolution was more likely to be the possible supply.


As the aftercare resolution had been bought to piercing studios throughout the nation, motion was taken as quickly as doable to cease different folks from utilizing it till we had been clearer whether or not it was the supply or not. Below are some of the preliminary actions we undertook:

  1. We notified GP’s and Accident & Emergency departments of the incident and signposted a transparent pathway to them for reporting any suspected instances.
  2. Environmental Health Officers (EHOs) visited the two piercing studios in the East Midlands and the South East the place they reviewed piercing procedures and took microbiological samples of frequent merchandise in use together with cleansing merchandise, pores and skin puncture needles, jewelry, piercing gear and bottles (opened/unopened) of aftercare resolution.
  3. EHOs and Trading Standards visited the manufacturing web site of the aftercare resolution in the east Midlands to evaluation the manufacturing course of, pattern the gear and supplies utilized in its manufacture to examine for contamination and to find out the extent of the distribution chain and establish what high quality management was in place.
  4. Once the producer had recognized which piercing studios the aftercare resolution had been distributed to, we contacted them and requested they contact their purchasers to advise them to cease utilizing the resolution instantly. The producer additionally voluntarily recalled the product from sale.
  5. The producer of the aftercare resolution was issued with a prohibition discover to stop manufacture and provide of the product.
  6. Finally, the media had been requested to assist us warn and inform the public that this explicit aftercare resolution wasn’t protected to make use of.

The microbiological and epidemiological investigations

Our work nevertheless doesn’t cease at simply figuring out the trigger of the outbreak. In severe incidents like this, that are nationwide, we go additional into the element to provide the proof and statistics to clarify how an outbreak or incident occurred.

Alongside our microbiological sampling, we additionally undertook what known as a ‘retrospective cohort study’ for the two piercing studios. This concerned sending a web based questionnaire to purchasers who had been pierced at both of the studios between July and the starting of September 2016. The questionnaire aimed to collect as a lot data from every consumer as doable together with any medical historical past, piercing particulars and use of the aftercare resolution.

What did we discover?

There was sturdy environmental, microbiological and descriptive epidemiological proof that the outbreak was attributable to the use of the aftercare resolution which was distributed nationwide to a minimum of 38 piercing studios, 10 of which had instances. Confirmed and possible instances had been recognized throughout England however most had been from the East Midlands and South East.

The microbiological investigations had been notably essential to tying the components of this outbreak collectively. All the instances (other than one) from the East Midlands and the South East, examined constructive for the identical, uncommon, not beforehand seen sort of P. aeruginosa. In addition the identical micro organism was present in unopened and opened bottles of the aftercare resolution and on some of the gear and supplies used to fabricate the product.

From over 222 responses to the questionnaire we concluded that utilizing the aftercare resolution elevated the odds of growing a post-piercing infection by 4 instances.

Overall we recognized 162 outbreak instances, 29 of which had been confirmed. 1 in 8 of the instances required surgical procedure beneath normal anaesthetic.


This outbreak demonstrated some of the challenges round educating the public and the piercing trade about the voluntary codes for piercing aftercare and making certain they use them. Similarly the beauty manufacturing rules weren’t being adopted by the producer. Compliance with each of these might have prevented this outbreak.

This outbreak and the challenges in regulation, spotlight that steerage on piercing aftercare could have to be reviewed and recommend that there could also be a case for larger regulation of the high quality and security of merchandise used for wound cleaning in the piercing and tattoo trade.

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