A growing awareness of the health and safety problems arising from tattooing, body piercing and related activities across the EU has prompted the Commission to set up a project to look at the health risks in detail and to see if any legislative action is needed at EU level. The project, which is being co-ordinated by the EU's Joint Research Centre (JRC) in Ispra in Italy, has set up a working group of experts from the member states to produce a series of papers on the subject.

Health risks

In preparation for a workshop in Ispra in May this year on the technical, scientific and regulatory issues surrounding tattooing, body piercing and related practices, the JRC secretariat produced a paper, formally published in July, which reviews the risks and health effects from these activities. It considers both the infectious and non-infectious risks, as well as the risks arising from laser treatment of tattoos and the use of tattooing and piercing as markers of risk-taking behaviour.

It concludes from its review of the medical literature that a systematic observation and registration of health impacts is widely missing. One cause for concern is that the origin and chemical structure of colouring agents used for tattooing are hardly known, it says. The pigments used are mainly industrial organic pigments with a high microbiological and impurities load.

The main observed health effects from tattooing, body piercing and related practices are listed in the paper:

• viral infections such as hepatitis, AIDS, and cutaneaous infections;
• bacterial infections such as impetigo, toxic shock syndrome, tetanus, chancroid, tuberculosis and leprosy;
• fungal infections such as sporotrichosis and zygomycosis;
• allergic reactions such as cutaneous irritation and urticaria;
• granulomateus/lichenoid reactions;
• pseudo-lymphomas;
• lymphadenopathy;
• sarcoidosis;
• malignant lesions such as melanoma and skin cancer;
• behavioural changes; and
• other skin diseases such as psoriasis, photosensitisation, phototoxicity and photogenotoxicity.

The paper reports scant knowledge on the transport and metabolism of the colouring agents in the body both with respect to tattooing and removal of tattoos by laser treatment. Risk assessment studies for these substances are only just emerging. At present, existing knowledge is insufficient to quantify the administered dose of harmful substances, it concludes.

A number of measures to tackle the problems are suggested in the paper:

• an analysis and systematic health risk assessment of ingredients of substances used for tattoos;
• a raising of awareness among studios and their customers of the health impacts and regular training courses for tattooers and piercers in this area, along with the establishment of an accreditation bureau/laboratory for the education of tattooers and piercers and supervision of their studios;
• warnings to be given to clients informing them of the potential adverse health effects in vulnerable individuals due to the colours and materials used;
• the development of a "negative" list of substances and materials leading to adverse health effects with a subsequent prohibition on their application, along with the licensing of those colours and materials which are allowed and the proper labelling of the ingredients of those colours and materials;
• the use only of substances and materials on a "positive list", which are not harmful, do not dissolve in the blood stream, do not contain heavy metals and are compatible with the skin and blood vessels;
• the standardisation and regular control of hygienic conditions in studios with obligatory minimum hygiene rules;
• mandatory occupational disease surveillance of tattooers and piercers;
• the drawing up of epidemiological studies on the prevalence and causal association of tattoo and piercing-related adverse effects; and
• a clarification of the debate on epidemiological studies of tattoo- and piercing-related viral hepatitis.

Policy options

A second paper, produced under the Commission project looks at the controls currently exercised both in the EU member states and in other countries. It notes that currently, tattooing dyes and piercing materials represent a legal paradox; while they are used for cosmetic purposes, the route for their administration (injection/skin penetration) puts them outside the scope of the Cosmetics Directive (76/768/EEC). An informal consultation with the member states by the Commission revealed an emerging consensus that tattooing dyes should be considered as general consumer products and hence should be regulated under the General Product Safety Directive (92/59/EEC) and the directive relating to restrictions on the marketing and use of certain dangerous substances and preparations. The Commission is now considering this option.

As a result of its review of member states controls, the JRC project group is now considering the following areas for EU regulation:

• provisions on authorisation/registration of the activity;
• provisions on skills/education of the practitioners;
• provisions on the equipment/space;
• provisions on hygienic practices;
• provisions on sterility of products/equipment/practices;
• request for risk assessment;
• introduction of a negative list of substances; and
• introduction of a positive list of substances.

On the wider European level, some action has already been taken by the Council of Europe which is negotiating a draft resolution on tattoos and permanent make-up (PMU) following a number of worrying studies, including one in the Netherlands where 11 out of 63 tattoo products sampled in 2000 were microbiologically contaminated, seven of them seriously. The draft resolution applies to pre-marketing risk evaluation, composition and labelling of tattoo and PMU products, the conditions of application of tattoos, and PMU and obligatory information on specific health risks to the general public and the consumers. The Commission and the Council are seeking to work together in this area.

Risks and health effects from tattoos, body piercing and related practices, visit: http://europa.eu.int/comm/consumers/cons_safe/news/eis_tattoo_risk_052003_en.pdf

Working paper: regulatory review on the safety of tattoos, body piercing and of related practices, visit: http://europa.eu.int/comm/consumers/cons_safe/news/eis_tattoo_reg_052003_en.pdf

EU scientific opinion on West Nile virus

The recent news that some UK birds have developed antibodies to the potentially fatal West Nile virus (WNV) has brought home the need to make sure health authorities and others are prepared for any outbreak that may occur. To date, attention has focused mostly on the USA where the disease has claimed a large number of lives. However, there have been several incidences of the disease in Europe in recent years, notably in Romania and Italy in 1998 and in the south of France in 2000. Earlier this year the EU Scientific Committee on Veterinary Public Health (SCVPH) was asked by the Commission to review present knowledge on the epidemiological situation in Europe, including whether horses and/or other animals can be used as a sentinel or indicator for public health risk.

The resulting report is a useful summary of the current situation with regards to the WNV. It looks at its epidemiology, including its hosts and its transmission cycle, and the way in which humans are infected. It then looks at the various outbreaks that have occurred, both in Europe and elsewhere. There is a chapter on diagnostic tools and then a review of animals that may be used as sentinels. Finally, it considers current European surveillance systems.

The report concludes that the most useful sentinel animals are horses, dead wild birds, caged domestic fowl, and domestic poultry. Testing mosquitoes is not a practical method since the proportion of mosquito pools in wild populations that test positive is very low, says the Committee. As regards surveillance, the SCVPH does not believe that active surveillance programmes, such as those in the USA, are justifiable in the EU where there have been few human cases to date. They would be expensive and difficult to implement with a limited impact on public health. Instead, in all European countries, there should be a passive surveillance strategy based on the notification of clinically expressed encephalitis in humans and horses, followed by a documentation of the aetiological agent.

In European countries with reported WNV outbreaks, an active surveillance strategy should also be implemented in horses, limited to those areas where WNV outbreaks have occurred. In addition, a passive surveillance of wild and domestic bird mortality as well as surveillance based on sentinel domestic birds (chickens and ducks) could also be performed. These strategies should be implemented through the existing European transmissible disease surveillance networks, in cooperation with other networks involved in climate changes, flood, wetlands, bird repositories, all of which are risk factors linked to the vectors of WNV.

Opinion of the SCVPH on West Nile virus, visit: http://europa.eu.int/comm/food/fs/sc/scv/out67_en.pdf