Trichophyton tonsurans infections after visiting a barbershop – findings from official hygiene monitoring

dgkh000507 10.3205/dgkh000507 urn:nbn:de:0183-dgkh0005078 Research Article Trichophyton tonsurans infections after visiting a barbershop – findings from official hygiene monitoring Trichophyton tonsurans-Infektionen nach dem Besuch eines Friseursalons – Ergebnisse der amtlichen Hygieneüberwachung Marcic Marcic Anne A Dr. med.

Public Health Department of the State Capital Kiel, Infection Protection Department, Kiel, Germany, Phone: +49 431 9012140Public Health Department of the State Capital Kiel, Infection Protection Department, Kiel, Germany

dr.anne.marcic@kiel.de author Freytag Freytag Stephen S

Public Health Department of the State Capital Kiel, Infection Protection Department, Kiel, Germany

author Langen Langen Katharina K

University Hospital Schleswig-Holstein, Campus Kiel, Clinic for Dermatology, Venereology and Allergology, Kiel, Germany

author German Medical Science GMS Publishing House

Düsseldorf

610 Trichophyton tonsurans barbershop disinfection measures reprocessing of work equipment official hygiene monitoring Trichophyton tonsurans Barbershop Desinfektionsmaßnahmen Geräteaufbereitung anlassbezogene infektionshygienische Überwachung 20241023 engl This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung). 2196-5226 19 GMS Hygiene and Infection Control GMS Hyg Infect Control 52 Hintergrund: Dem Amt für Gesundheit wurden Infektionen mit Trichophyton (T.) tonsurans bei neun Personen bekannt, die denselben Barbershop besucht hatten.Methode: Es fand eine anlassbezogene infektionshygienische Überwachung des Barbershops statt, bei der die Einhaltung der Anforderungen nach der „Landesverordnung zur Verhütung übertragbarer Krankheiten Schleswig-Holstein (HygieneVO)“ überprüft wurde. Zusätzlich wurden in Zusammenarbeit mit der Klinik für Dermatologie des Universitätsklinikums Schleswig-Holstein, Campus Kiel, hygienisch-mikrobiologische Umgebungsuntersuchungen von Materialien und Oberflächen durchgeführt.Ergebnisse: Es wurden deutliche Mängel im Hygienemanagement festgestellt. Die Anforderungen an die Hygiene, insbesondere an die Aufbereitung von Arbeitsgeräten und Flächen, waren nicht bekannt und wurden demzufolge nicht eingehalten. Die Umgebungsuntersuchung ergab den Nachweis von T. tonsurans in drei von zehn untersuchten Proben. Positiv waren Rasiergeräte und eine Schublade, die zur Lagerung von Rasiergeräten genutzt wurde.Schlussfolgerung: Von Barbershops kann eine relevante Infektionsgefahr nicht nur für Erreger blutübertragbarer Infektionen ausgehen. Bei Betreibern von Barbershops besteht ein Informations- und Schulungsbedarf im Hinblick auf die Einhaltung der Anforderungen an die Hygiene. Sie sollten in die Planung für die (stichprobenartige) infektionshygienische Überwachung von Einrichtungen nach § 36 Absatz 2 Infektionsschutzgesetz (IfSG) durch das Gesundheitsamt einbezogen werden. Die bisher etablierten Aufbereitungsfrequenzen sind für die Prävention von T. tonsurans-Infektionen nicht ausreichend und müssen angepasst werden. Background: The Public Health Department became aware of infections with Trichophyton (T.) tonsurans in a total of nine people who had visited the same barbershop.Method: Official hygiene monitoring of the barbershop was performed on an event-related basis, during which compliance with the requirements of the “Schleswig-Holstein State Ordinance on the Prevention of Communicable Diseases (Hygiene Ordinance)” was checked. In addition, hygienic-microbiological environmental examinations of materials and surfaces were performed in cooperation with the Department of Dermatology at the University Medical Center Schleswig-Holstein, Kiel Campus.Results: Significant deficiencies in hygiene management were identified. The hygiene requirements, especially for the reprocessing of work equipment and surfaces, were not known and were therefore not complied with. Environmental testing revealed the presence of Trichophyton tonsurans in three out of ten samples tested. Shaving equipment and a drawer used to store shaving equipment were positive.Conclusion: Barbershops can pose a relevant risk of infection, not only for pathogens that cause blood-borne infections. Barbershop operators need information and training regarding compliance with hygiene requirements. They should be included in the planning for the (random) infection hygiene monitoring of facilities by the public health department in accordance with Section 36 (2) of the Infection Protection Act (IfSG). The reprocessing frequencies established to date are not sufficient for the prevention of T. tonsurans infections and must be adapted. IntroductionIn July 2023, the Office of Public Health received a complaint from a citizen about a fungal infection on the back of his head after visiting a barbershop (Barbershop A).Barbershops carry out activities on humans in which pathogens, in particular blood-borne pathogens, can be transmitted to humans. They are therefore subject to the “Schleswig-Holstein State Ordinance on the Prevention of Communicable Diseases (Hygiene Ordinance)” and must draw up a hygiene plan in accordance with Section 2 (6) of the Hygiene Ordinance, in which all internal infection hygiene procedures are recorded in writing . They are among the facilities that can be monitored for infection hygiene in accordance with Section 36 (2) of the Infection Protection Act (IfSG) .During the investigations, further fungal infections were discovered in connection with visits to the same barbershop. Pathogen detection was not yet available at this time but was subsequently found in other patients who presented at the dermatology clinic at the university hospital.Initially, there was an event-related infection hygiene monitoring of Barbershop A, which was followed by further on-site visits to check hygiene management and the reprocessing of the materials used. In addition, hygienic-microbiological environmental examinations were performed. The situation gave rise to the monitoring of further barbershops and the derivation of consequences regarding information and training as well as monitoring planning. Materials and methodsAs part of an event-related inspection, the requirements of the Hygiene Ordinance for the prevention of communicable diseases were checked, including hand hygiene, reprocessing of work materials (razors, combs, scissors), surface cleaning and disinfection, reprocessing of textiles (towels and capes) and waste disposal. In the further course, a hygienic-microbiological environmental examination was performed at a follow-up appointment in cooperation with the Department of Dermatology at the University Hospital Schleswig-Holstein, Kiel Campus. Samples were taken from surfaces using brushes and imprints on dermatophyte-selective agar plates (with cycloheximide and gentamicin) (Figure 1 and Figure 2 ). Surfaces and devices were selected for examination that were possible sources of infection, including storage surface for razors, drawer for razors, four different razors (Figure 3 ) and the head washbasin. The selective agar plates were incubated at 27°C for 28 days. ResultsBarbershop A was not aware of the requirements of the Hygiene Ordinance, including the requirement to use VAH-listed disinfectants. No hygiene plan was available. Some of the work materials were reprocessed with an aldehyde-based instrument disinfectant in very high concentrations without completely wetting the materials to be reprocessed in a glass container commonly used in barbershops (Figure 4 ). The surfaces and some work materials were treated with commercially available drugstore products and additionally with special cleaning agents. Towels were washed at 40°C and machine dried.Hygienic microbiological sampling in Barbershop A revealed the presence of T. tonsurans in three out of ten samples tested. The detection was carried out on two razors, one of which showed pronounced growth (Figure 5 </PlainText></TextGroup><ImgLink imgNo="5" imgType="figure"/>), as well as in the drawer in which razors were stored (Figure 6 <ImgLink imgNo="6" imgType="figure"/>).</Pgraph><Pgraph>The elimination of the hygiene deficiencies was checked during further site inspections. Information materials on the requirements for hygiene measures in accordance with the Hygiene Ordinance and the creation of a hygiene plan were handed out and the conversion and establishment of proper reprocessing of work materials was accompanied (Figure 7 <ImgLink imgNo="7" imgType="figure"/>)</Pgraph><Pgraph>In our experience, barbershops generally do not receive sufficient information on which to establish the necessary hygiene measures when registering their business and commencing operations. For this reason, an information package was created that the trade supervisory authority can hand out when registering a business.</Pgraph><Pgraph>Routine sample hygiene plans for the hairdressing trade provide for the daily reprocessing of working materials and reprocessing after visible contamination with blood and secretions <TextLink reference="3"></TextLink>. This is not sufficient to prevent the transmission of <Mark2>T. tonsurans</Mark2>. As a consequence, a leaflet for addressees of the Hygiene Ordinance was created in which the routine disinfection of work materials was defined and supplemented by the addition “after contact with customers with suspected skin infection” <TextLink reference="4"></TextLink>.</Pgraph></TextBlock> <TextBlock linked="yes" name="Discussion"> <MainHeadline>Discussion</MainHeadline><Pgraph>Barbershops have been described as a source of <Mark2>T. tonsurans</Mark2> infections <TextLink reference="5"></TextLink>, <TextLink reference="6"></TextLink>. In Kiel, an accumulation of <Mark2>T. tonsurans</Mark2> infections occurred in July 2023, which initially came to the attention of the public health department through a citizen complaint. During the investigations and event-related inspections of the barbershop concerned, fundamental hygiene deficiencies were identified that were due to ignorance of the requirements. At the same time, the barbershop owner was willing to cooperate. The legal and professional requirements for businesses that carry out activities involving humans, in which pathogens can be transmitted to humans, were not known. Accordingly, gaps in hygiene management were identified which are associated with a risk of infection, particularly regarding reprocessing and surface disinfection.</Pgraph><Pgraph><Mark2>T. tonsurans</Mark2> is a dermatophyte with a worldwide distribution. Transmission between people can occur directly through infectious skin flakes. In the case described, indirect transmission through work materials and surfaces was investigated in connection with a visit to a barbershop. <Mark2>T. tonsurans</Mark2> was detected in three environmental samples from Barbershop A. The detection on shaving equipment and in a drawer for storing shaving equipment confirms the inadequate preparation of work materials and surfaces, and underlines the need for action. </Pgraph><Pgraph>Model hygiene plans <TextLink reference="3"></TextLink> include disinfection as a requirement for the reprocessing of work materials, generally only daily and in the event of visible contamination with blood or secretions. This requirement does not do justice to the risk of infection by <Mark2>T. tonsurans</Mark2>. To minimize the risk of transmission, the equipment used would also have to be disinfected after contact with a customer with a suspected skin infection.</Pgraph><Pgraph>The situation gave rise to the monitoring of additional barbershops for infection hygiene.</Pgraph><Pgraph>Neither the legal regulations on hygiene requirements nor the necessary measures were known in the monitored barbershops.</Pgraph><Pgraph>Overall, there was a willingness to cooperate on the part of the barbershop owners, and a fundamental interest in complying with the requirements and eliminating potential sources of infection.</Pgraph><Pgraph>The reprocessing frequency requirements must be increased in view of the risk of infection with <Mark2>T. tonsurans</Mark2>. Reprocessing after customers with suspected skin infection seems appropriate.</Pgraph></TextBlock> <TextBlock linked="yes" name="Conclusions"> <MainHeadline>Conclusions</MainHeadline><Pgraph>Barbershops can pose a relevant risk of infection, not only for pathogens that cause blood-borne infections. Barbershop operators require information and training regarding compliance with hygiene requirements. They should receive regular information on hygiene requirements and be included in the planning for the (random) infection hygiene monitoring of facilities by the public health department in accordance with Section 36(2) IfSG. Monitoring should focus on the reprocessing of work materials (shaving equipment) and the handling of these as well as the disinfection of relevant surfaces. The daily reprocessing frequencies established to date are not sufficient for the prevention of <Mark2>T. tonsurans</Mark2> infections and must be adapted so that reprocessing additionally takes place after serving clients who are suspected of having skin infections.</Pgraph></TextBlock> <TextBlock linked="yes" name="Notes"> <MainHeadline>Notes</MainHeadline><SubHeadline>Competing interests</SubHeadline><Pgraph>The authors declare that they have no competing interests.</Pgraph><SubHeadline>Author’s ORCID </SubHeadline><Pgraph><UnorderedList><ListItem level="1">Anne Marcic: <Hyperlink href="https://orcid.org/0009-0008-3660-040X">0009-0008-3660-040X</Hyperlink></ListItem></UnorderedList></Pgraph><SubHeadline>Supplementary note</SubHeadline><Pgraph>The original version of the article was published in Hygiene & Medizin: </Pgraph><Pgraph>Marcic A, Freytag S, Langen K. Trichophyton tonsurans-Infektionen nach Barbershop-Besuch – Erkenntnisse aus der infektionshygienischen Überwachung. HygMed. 2024;49(3):D6-D9. The original article has been minimally modified.</Pgraph><Pgraph>The topic was also presented at the 73<Superscript>rd</Superscript> scientific ÖGD congress of BVÖG, BZÖG, and DGÖG and at the 17<Superscript>th</Superscript> Congress for Hospital Hygiene of the German Society for General and Hospital Hygiene e.V.</Pgraph></TextBlock> <References linked="yes"> <Reference refNo="1"> <RefAuthor>Anonym</RefAuthor> <RefTitle></RefTitle> <RefYear>2007</RefYear> <RefBookTitle>Landesverordnung zur Verhütung übertragbarer Krankheiten (HygieneVO) vom 11. Oktober 2007</RefBookTitle> <RefPage></RefPage> <RefTotal>Landesverordnung zur Verhütung übertragbarer Krankheiten (HygieneVO) vom 11. Oktober 2007. 2007 Nov 11. Available from https://www.gesetze-rechtsprechung.sh.juris.de/bssh/document/jlr-SeuchVSH2007rahmen/part/X</RefTotal> <RefLink>https://www.gesetze-rechtsprechung.sh.juris.de/bssh/document/jlr-SeuchVSH2007rahmen/part/X</RefLink> </Reference> <Reference refNo="2"> <RefAuthor>Anonym</RefAuthor> <RefTitle></RefTitle> <RefYear></RefYear> <RefBookTitle>Gesetz zur Verhütung und Bekämpfung von Infektionskrankheiten beim Menschen (Infektionsschutzgesetz - IfSG) § 36 Infektionsschutz bei bestimmten Einrichtungen, Unternehmen und Personen; Verordnungsermächtigung</RefBookTitle> <RefPage></RefPage> <RefTotal>Gesetz zur Verhütung und Bekämpfung von Infektionskrankheiten beim Menschen (Infektionsschutzgesetz - IfSG) § 36 Infektionsschutz bei bestimmten Einrichtungen, Unternehmen und Personen; Verordnungsermächtigung. Available from: https://www.gesetze-im-internet.de/ifsg/__36.html</RefTotal> <RefLink>https://www.gesetze-im-internet.de/ifsg/__36.html</RefLink> </Reference> <Reference refNo="3"> <RefAuthor>Berufsgenossenschaft für Gesundheitspflege und Wolhfahrtpflege</RefAuthor> <RefTitle></RefTitle> <RefYear>2023</RefYear> <RefBookTitle>Hygiene im Friseursalon Reinigungs- und Desinfektionsplan Artikelnummer BGW 06-12-090</RefBookTitle> <RefPage></RefPage> <RefTotal>Berufsgenossenschaft für Gesundheitspflege und Wolhfahrtpflege. Hygiene im Friseursalon Reinigungs- und Desinfektionsplan Artikelnummer BGW 06-12-090. Hamburg: 2023 Mar 01. Available from: https://www.bgw-online.de/bgw-online-de/service/medien-arbeitshilfen/medien-center/reinigungs-und-desinfektionsplan-fuer-den-friseursalon-fuer-20260</RefTotal> <RefLink>https://www.bgw-online.de/bgw-online-de/service/medien-arbeitshilfen/medien-center/reinigungs-und-desinfektionsplan-fuer-den-friseursalon-fuer-20260</RefLink> </Reference> <Reference refNo="4"> <RefAuthor>Amt für Gesundheit der Landeshauptstadt Kiel</RefAuthor> <RefTitle></RefTitle> <RefYear>2023</RefYear> <RefBookTitle>Merkblatt für Tätigkeiten gemäß HygieneVO</RefBookTitle> <RefPage></RefPage> <RefTotal>Amt für Gesundheit der Landeshauptstadt Kiel. Merkblatt für Tätigkeiten gemäß HygieneVO. Kiel: Amt für Gesundheit; 2023. [last updated 2023 Nov 07]. Available from: https://www.kiel.de/de/gesundheit_soziales/gesundheit_vorsorgen_heilen/infektionsschutz/Merkblatt_Taetigkeiten_gemaess_HygieneVO.pdf</RefTotal> <RefLink>https://www.kiel.de/de/gesundheit_soziales/gesundheit_vorsorgen_heilen/infektionsschutz/Merkblatt_Taetigkeiten_gemaess_HygieneVO.pdf</RefLink> </Reference> <Reference refNo="5"> <RefAuthor>Müller VL</RefAuthor> <RefAuthor>Kappa-Markovi K</RefAuthor> <RefAuthor>Hyun J</RefAuthor> <RefAuthor>Georgas D</RefAuthor> <RefAuthor>Silberfarb G</RefAuthor> <RefAuthor>Paasch U</RefAuthor> <RefAuthor>Uhrlaß S</RefAuthor> <RefAuthor>Nenoff P</RefAuthor> <RefAuthor>Schaller J</RefAuthor> <RefTitle>Tinea capitis et barbae caused by Trichophyton tonsurans: A retrospective cohort study of an infection chain after shavings in barber shops</RefTitle> <RefYear>2021</RefYear> <RefJournal>Mycoses</RefJournal> <RefPage>428-36</RefPage> <RefTotal>Müller VL, Kappa-Markovi K, Hyun J, Georgas D, Silberfarb G, Paasch U, Uhrlaß S, Nenoff P, Schaller J. Tinea capitis et barbae caused by Trichophyton tonsurans: A retrospective cohort study of an infection chain after shavings in barber shops. Mycoses. 2021 Apr;64(4):428-436. DOI: 10.1111/myc.13231</RefTotal> <RefLink>https://doi.org/10.1111/myc.13231</RefLink> </Reference> <Reference refNo="6"> <RefAuthor>Bascón L</RefAuthor> <RefAuthor>Galvañ JI</RefAuthor> <RefAuthor>López-Riquelme I</RefAuthor> <RefAuthor>Navarro-Guillamón PJ</RefAuthor> <RefAuthor>Morón JM</RefAuthor> <RefAuthor>Llamas JA</RefAuthor> <RefAuthor>Ballesteros M</RefAuthor> <RefAuthor>Tejera-Vaquerizo A</RefAuthor> <RefAuthor>Angulo AG</RefAuthor> <RefAuthor>Guilabert A</RefAuthor> <RefAuthor>Romaní J</RefAuthor> <RefAuthor> en representación del grupo de estudio TCP (Tinea Capitis en Peluquería)</RefAuthor> <RefTitle>Brote de dermatofitosis en región de cabeza y cuello asociadas al rasurado en peluquerías: estudio descriptivo multicéntrico de una serie de casos</RefTitle> <RefYear>2023</RefYear> <RefJournal>Actas Dermosifiliogr</RefJournal> <RefPage>371-6</RefPage> <RefTotal>Bascón L, Galvañ JI, López-Riquelme I, Navarro-Guillamón PJ, Morón JM, Llamas JA, Ballesteros M, Tejera-Vaquerizo A, Angulo AG, Guilabert A, Romaní J; en representación del grupo de estudio TCP (Tinea Capitis en Peluquería). Brote de dermatofitosis en región de cabeza y cuello asociadas al rasurado en peluquerías: estudio descriptivo multicéntrico de una serie de casos [Outbreak of Dermatophyte Infections on the Head and Neck Related to Shave Haircuts: Description of a Multicenter Case Series]. Actas Dermosifiliogr. 2023 May;114(5):371-6. DOI: 10.1016/j.ad.2023.02.001</RefTotal> <RefLink>https://doi.org/10.1016/j.ad.2023.02.001</RefLink> </Reference> </References> <Media> <Tables> <NoOfTables>0</NoOfTables> </Tables> <Figures> <Figure format="png" height="249" width="367"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption><Pgraph><Mark1>Figure 1: Sampling using brushes</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="286" width="380"> <MediaNo>2</MediaNo> <MediaID>2</MediaID> <Caption><Pgraph><Mark1>Figure 2: Imprint on dermatophyte selective agar plates</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="339" width="456"> <MediaNo>3</MediaNo> <MediaID>3</MediaID> <Caption><Pgraph><Mark1>Figure 3: Razors for hygienic-microbiological examination</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="384" width="288"> <MediaNo>4</MediaNo> <MediaID>4</MediaID> <Caption><Pgraph><Mark1>Figure 4: Device reprocessing at the time of the first inspection</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="229" width="345"> <MediaNo>5</MediaNo> <MediaID>5</MediaID> <Caption><Pgraph><Mark1>Figure 5: Growth of </Mark1><Mark1><Mark2>T. tonsurans</Mark2></Mark1><Mark1>, imprint of a razor</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="237" width="354"> <MediaNo>6</MediaNo> <MediaID>6</MediaID> <Caption><Pgraph><Mark1>Figure 6: Growth of T. tonsurans, drawer</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="305" width="410"> <MediaNo>7</MediaNo> <MediaID>7</MediaID> <Caption><Pgraph><Mark1>Figure 7: Newly purchased instrument disinfection tray</Mark1></Pgraph></Caption> </Figure> <NoOfPictures>7</NoOfPictures> </Figures> <InlineFigures> <NoOfPictures>0</NoOfPictures> </InlineFigures> <Attachments> <NoOfAttachments>0</NoOfAttachments> </Attachments> </Media> </OrigData> </GmsArticle>