Report to/rapport au : Ottawa Board of Health Conseil de santé d Ottawa. October 21, octobre 2013

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1 Report to/rapport au : Ottawa Board of Health Conseil de santé d Ottawa October 21, octobre 2013 Submitted by/soumis par : Dr./Dr Isra Levy, Medical Officer of Health/Médecin chef en santé publique Contact Person / Personne ressource: Siobhan Kearns, Manager/Gestionnaire Environment & Health Protection Branch / Direction de l'environnement et de la protection de la santé Ottawa Public Health/Santé publique Ottawa , ext./poste 23483, siobhan.kearns@ottawa.ca and Dr. Carolyn Pim, Associate Medical Officer of Health/ Médecin adjointe en santé publique Ottawa Public Health/Santé publique Ottawa , ext./poste 23684, carolyn.pim@ottawa.ca CITY WIDE / À L ÉCHELLE DE LA VILLE Ref N : ACS2013-OPH-EHP-0004 SUBJECT: OBJET : INFECTION PREVENTION AND CONTROL IN PERSONAL SERVICE SETTINGS PRÉVENTION ET CONTRÔLE DES INFECTIONS DANS LES ÉTABLISSEMENTS DE SERVICES PERSONNELS REPORT RECOMMENDATIONS That the Board of Health for the City of Ottawa Health Unit: 1. Approve the Infection Prevention and Control Plan for Personal Service Settings (PSS) as outlined in this report; and 2. Direct Ottawa Public Health staff to report back to the Board of Health upon receipt of any updates from the Ministry of Health and Long-Term Care (MOHLTC) regarding the PSS Risk Assessment Tool and Public Health Accountability Agreement performance indicators that relate to PSS.

2 RECOMMANDATIONS DU RAPPORT Que le Conseil de santé de la circonscription sanitaire de la ville d Ottawa : 1. Approuve le Plan de prévention et de contrôle des infections pour les établissements de services personnels (ÉSS), tel qu énoncé dans le présent rapport; 2. Demande au personnel de Santé publique Ottawa de faire rapport au Conseil de santé dès la réception de toute mise à jour émanant du ministère de la Santé et des Soins de longue durée portant sur l outil d évaluation des risques des établissements de services personnels (ÉSS) ou sur les indicateurs de rendement de l entente sur la responsabilisation en santé publique. EXECUTIVE SUMMARY Personal service settings (PSS), such as hairdressers, barber shops, tattoo and body piercing studios as well as facilities that provide electrolysis, acupuncture and various other aesthetic services in Ottawa, are inspected by Public Health Inspectors at OPH. Over the past several years there has been an increase in the variety of services offered, which include more invasive body modification procedures such as tongue splitting and branding. These procedures are associated with risk of blood-borne infection, including Hepatitis B (HBV), Hepatitis C (HCV), and Human Immunodeficiency Virus (HIV), as well as skin infections. In response to this trend, in 2012, the Ottawa Board of Health reinvested $200,000 to increase inspections to improve infection prevention and control in personal service settings. From 2011 to 2012, mandatory routine inspections of high-risk PSS premises increased from 40% to 68% of all known premises. Currently, OPH is on track to inspect 100% of known high-risk PSS in Challenges exist with identifying, regulating and inspecting PSS premises, including: surveillance of blood-borne illnesses as they relate to PSS premises, enforcing regulations as they apply to PSS premises and potential new provincial inspection requirements. OPH aims to improve infection prevention and control in PSS and enhance public safety through a multi-year, five-pronged PSS Infection Prevention and Control Plan. OPH will work towards ensuring PSS are inspected in accordance with provincial requirements, provide inspection results online for residents, increase operator training, increase public awareness of infection prevention and control measures at PSS premises and advance a quality assurance program for PSS inspections. RÉSUMÉ Les inspecteurs en santé publique mènent des inspections dans les établissements de services personnels tels que les boutiques de coiffeur, les salons de coiffure, les studios de tatouage et de perçage corporel ainsi que les établissements proposant des services d électrolyse, d acupuncture et plusieurs autres services esthétiques à Ottawa. Au cours des dernières années, on a observé un élargissement de la gamme de services offerts,

3 laquelle comprend désormais des procédures de modification du corps plus invasives comme fourcher ou marquer la langue. Ces procédures sont associées à des risques d infection transmises par le sang, y compris l hépatite B (VHB), l hépatite C (VHC), et le virus de l immunodéficience humaine (VIH), ainsi que les infections cutanées. Face à cette tendance, en 2012, le Conseil de santé d Ottawa a réinvesti $ pour augmenter le nombre d inspections dans les établissements de services personnels et ainsi y renforcer la prévention et le contrôle des infections. De 2011 à 2012, les inspections obligatoires périodiques menées dans les installations des établissements de services personnels à haut risque sont passées de 40 % à 68 % de toutes les installations connues. Actuellement, la SPO s apprête à inspecter 100 % de tous les établissements de services personnels à haut risque connus en L identification, la réglementation et l inspection des établissements de services personnels posent des défis, notamment sur le plan de la surveillance des maladies transmises par le sang, qui sont liées aux installations des établissements de services personnels, de l exécution des règlements qui s appliquent aux installations des établissements de services personnels et de l instauration toujours possible de nouvelles dispositions provinciales en matière d inspections. SPO entend renforcer la prévention et le contrôle des infections dans les établissements de services personnels ainsi que la sécurité du public en soumettant ces derniers à un Plan de prévention et de contrôle des infections en cinq volets. SPO veillera à faire inspecter les établissements de services personnels conformément à la réglementation provinciale, mettre en ligne les résultats des inspections à l intention des résidents, à améliorer la formation des exploitants, à sensibiliser le public aux mesures de prévention et de contrôle des infections prises dans ces installations, et à faire avancer le programme d assurance de la qualité visant les inspections menées dans ces établissements. BACKGROUND Ottawa Public Health (OPH) inspects personal service settings (PSS), 1 such as hairdressers, barber shops, tattoo and body piercing studios as well as facilities that provide electrolysis, acupuncture and various other aesthetic services. As the popularity of PSS has grown over the years, so too has the variety of services being offered at these establishments. In addition to the more traditional services, such as manicure, pedicure, and tattoo, some PSS are performing extreme body modification procedures, such as branding and tongue splitting. The growing popularity and variety of personal services being offered has led to health concerns and increased public interest in PSS. Of particular concern is the inherent risk of transmission of blood borne infection to both personal service clients and operators. Penetration of skin or mucous 1 As defined in the Infection Prevention and Control in Personal Services Settings Protocol, This protocol which serves as a guidance document to Boards of Health on how to operationalize specific requirements within the Ontario Public Health Standards defines personal services settings as: settings in which aesthetic services are delivered, such as but not limited to: hairdressing and barber shops; tattoo and body piercing studios; electrolysis; acupuncture; and various other aesthetic services.

4 membranes (e.g. the inside of the mouth) can lead to viral and bacterial infections, including Hepatitis B (HBV), Hepatitis C (HCV), and Human Immunodeficiency Virus (HIV), as well as skin infections. The Ontario Public Health Standards (OPHS), through the Infection Prevention and Control in Personal Services Settings Protocol, 2008, targets that health units perform routine inspections for all premises at least once per year, as well as respond to any public complaints. The Ministry of Health and Long-Term Care (MOHLTC) has also described best practices for the inspection of PSS that focus on infection prevention and control precautions at every premises. 2 Those tasked with inspecting these service settings Public Health Inspectors survey, identify and educate operators about best practices for infection prevention and control. Recent Local Developments In 2012, in response to the increased variety and invasiveness of procedures offered in Ottawa PSS premises, the Board of Health reinvested budget efficiencies of $200,000 toward increasing inspections of PSS. In the absence of provincial definitions for high and low risk facilities, OPH developed criteria for classification of facilities according to risk. OPH identifies high-risk personal service settings as establishments offering services that break the skin such as body piercing, tattooing, micropigmentation, ear lobe piercing, body modification, electrolysis, and/or acupuncture. Multi-service spas (spas that offer more than one service) are also included. 3 Hairdressers and nail and pedicure salons are considered low-risk personal services settings, as there is a risk, albeit modest, that a tool or object could break the skin. Currently, there are 938 known PSS establishments (205 high-risk and 733 low-risk) in Ottawa. 4 Following the Board s 2012 budget investment in PSS, OPH was able to increase the frequency of high-risk PSS inspections. As outlined in Document 1, OPH is now on target to inspect 100% of high-risk PSS premises by the end of OPH also began exploring different approaches to infection prevention and control in PSS establishments. An environmental scan of nine other health units with demographic profiles similar to Ottawa was conducted in As well, OPH surveyed Ottawa residents and PSS operators to get their feedback on infection prevention control and PSS. For more detail pertaining to OPH s consultation, Document 2. 2 Infection Prevention and Control Best Practices for Personal Service Settings, Infection Prevention and Control Unit, Public Health Division, Ministry of Health and Long Term Care, January Medical spas where all the staff are registered health professionals are NOT inspected. Sometimes not all staff are registered and then we would inspect only that service. Medical spas may offer face-lifts or botox, but are supervised by a medical professional. 4 In 2012, OPH inspected 208 high risk and 121 low risk establishments. Of those inspected, 58 high risk and 20 low risk locations required re-inspection to ensure identified deficiencies in infection control practices had been addressed. In addition, in complaints were received regarding alleged issues at PSS establishments.

5 In March 2013, the Board carried a motion to direct staff to explore strategies to improve infection prevention and control practices in PSS. Recent Provincial Developments The MOHLTC has recently developed and piloted a new PSS Risk Assessment Tool to address the variation between Ontario health units regarding inspection, identification and regulation of PSS. The intention is to deploy this tool to all health units in OPH participated in the piloting phase of this Risk Assessment Tool and provided feedback to the MOHLTC. This tool is intended to assess a premises risk category with a combination of a) inherent risk due to the type of procedures provided and b) inspection performance history of the premises. As part of the roll-out of this tool, the MOHLTC could require one annual risk assessment for each PSS. In addition, the Public Health Accountability Agreement performance measurement target for PSS, which was introduced in 2011, is still in development and may change following the implementation of The Provincial PSS Risk Assessment Tool. Challenges with the Inspection of Personal Service Settings Despite local and provincial developments, there are a number of challenges with identifying, regulating and inspecting PSS premises, including surveillance of bloodborne illnesses as they relate to PSS premises, enforcing regulations of PSS premises and working to meet provincial requirements. Conducting surveillance of blood-borne illnesses, and identifying a PSS as a potential cause of a blood-borne infection is difficult. Diseases transmitted through blood-borne pathogens often have longer incubation periods with individuals not experiencing symptoms in the earlier stages of their infection. Also, it may be difficult to link bloodborne infections in individuals to PSS exposure, as there may be other contributing factors, such as sexual behaviour or drug use. Another challenge is the maintenance of an accurate registry of all PSS establishments in Ottawa, as PSS are not required to obtain a municipal license to operate. As such, OPH may only become aware of the existence of PSS after a complaint has been lodged or health hazard has been identified. 5 Further, the proposed provincial Risk Assessment Tool categorizes a premises risk on the number and severity of deficiencies found during inspection. As such, the risk category of a particular premises may change. This will mean that the number of highrisk PSS could vary from year to year, especially during the initial adoption of the tool, 5 Due to limited enforcement and an assessment that the health of the public would not be affected, a licensing Bylaw was repealed in 2003 that had required a municipal license for hair dressing services. A 2012 OPH survey indicated that 77% of respondents were unaware that PSS did not require a municipal license. OPH s environmental scan demonstrated that a number of other health units in Ontario require full (Halton, Middlesex-London and Toronto) or partial (Peel, Durham, York, Eastern) licensing for PSS.

6 which may increase the number of inspections and re-inspections required to ensure all infection prevention and control requirements are met. Finally, because there are no set fines relating to PSS, Provincial Offences Notices cannot be issued for deficiencies noted during a PSS inspection. All deficiencies that cannot be addressed through education and voluntary compliance must rely on the Health Protection and Promotion Act and the issuance of a Medical Officer of Health or Public Health Inspector health hazard order under section 13 of the Act. 6 Enforcing a health hazard order usually requires liaising with the judicial system and can result in significant staff time and resources. As a result of the above challenges, there continue to be large disparities between Ontario public health units with respect to how they identify, regulate and inspect PSS. Inspections & Resources OPH s overall PSS inspection strategy is predicated on ensuring that surveillance efforts focus on premises that pose the greatest risk to the public. Public Health Inspectors use inspection as an opportunity to educate owners/operators on public health best practices. Though OPH strives to inspect all premises at the highest frequency interval possible, resource and budgetary considerations require management to prioritize inspections to ensure those premises that pose the greatest risk to the public are inspected for compliance with all applicable legislation and best practice guidelines. As a priority, OPH has dedicated resources to ensure high-risk PSS premises are inspected at least once per year. OPH deploys 40 Public Health Inspectors to meet the various inspection thresholds across multiple environmental public health programs laid out by the MOHLTC, including PSS. 7 In 2012, Public Health Inspectors conducted 1,030 infection control inspections including over 400 PSS inspections, more than 12,050 food safety inspections, approximately 1,000 recreational water inspections, over 1,000 environmental complaint investigations, 1,350 environmental inquiry responses and certified nearly 2,000 food handlers. Given other performance targets, the growing number and diverse nature of PSS premises do not permit Public Health Inspectors to reach all establishments at their prescribed, risk-based inspection interval. While OPH endeavours to inspect all PSS 6 Order by M.O.H. or public health inspector re health hazard 13. (1) A medical officer of health or a public health inspector, in the circumstances mentioned in subsection (2), by a written order may require a person to take or to refrain from taking any action that is specified in the order in respect of a health hazard. R.S.O. 1990, c. H.7, s. 13 (1). 7 OPH performs inspections in a number of different programs, including personal service settings, not limited to: food premises; long term care facilities, retirement homes and nursing homes; institutional outbreaks; small drinking water systems; health hazard investigations; rabies cases; day cares; public pools; as well as respond to any complaints

7 premises once per year regardless of risk categorization, all targets in this regard have not been met under the current resource framework. DISCUSSION Personal Services Setting Infection Prevention and Control Plan Based on a full review of best practises, the findings from the operator and public surveys, and in the context of the challenges noted above, OPH has developed a fivepronged PSS Infection Prevention and Control Plan. This plan includes: Inspection, Disclosure, Training, Health Promotion and Quality Assurance. While a comprehensive PSS Infection Prevention and Control Plan would also include a licensing component to help identify establishments and assist with enforcement protocols, OPH intends to optimize this plan prior to seeking regulatory licensing interventions (Document 2). As a proactive measure to build capacity, OPH will deploy a targeted PSS team that will be tasked with implementing the plan. This team will work to ensure inspections are completed, disclosure systems are developed, operator training is provided, public education and awareness of the health risks associated with PSS is enhanced, and quality assurance to the process is provided. The dedicated team will also be responsible for implementing the necessary actions to incorporate any new PSSdirectives from the MOHLTC, including the Risk Assessment Tool and Public Health Accountability Agreement targets. Inspection Plan One hundred per cent of known PSS premises currently categorized as high-risk by OPH will be inspected by year end This will represent a 32% increase in high-risk inspections from Moving forward, OPH is committed to increasing its capacity to inspect all high- and low-risk PSS, as well as any required re-inspections, and respond to complaints. In addition, OPH will ensure any new provincial guidelines are adhered to, including completing the MOHLTC s risk assessment tool, as required. OPH will continue communication with the MOHLTC regarding the Public Health Accountability Agreement performance indicator relating to PSS. Once the final performance indicators have been determined, any necessary adjustments to the inspection plan will be made. Disclosure PSS premises are provided with a certificate of inspection. Operators are encouraged to post these certificates in a visible location at their premises. In the PSS operator survey (Document 2), almost half (48%) of respondents indicated that they post their inspection certificates in a visible location. Over the next several years, OPH would like to begin posting inspection results on the City s web site. OPH will work with the City s Information Technology Services Department (IT) to bring this initiative forward through the 2015 Corporate IT planning

8 process. Armed with this disclosure information, Ottawa residents will have the ability to make informed decisions regarding PSS patronage. OPH will promote the disclosure website in an effort to raise community awareness of this resource. Operator Training When inspecting a PSS premises, Public Health Inspectors will continue to educate owners/operators in regards to key infection prevention and control practices to limit risk to themselves, their clients, and the general public. Educational interventions seek to inform the premises policies and procedures to ensure that they are in compliance with all applicable public health legislation and following best practices. To develop training for operators and owners, OPH will engage PSS operators, and tap into the York Regional Health Unit s existing course materials, to develop a comprehensive PSS Infection Prevention and Control training course for local operators in Ottawa. 8 The OPH survey (Document 2) indicated PSS operators would be receptive and interested in receiving supplementary education and information regarding Infection Prevention and Control best practices. 9 While it is anticipated that OPH may face some challenges in the initiation of such a training program, other similar programs (e.g. food handler training) are offered in Ottawa with good results. Health Promotion through Public Education Over the next year, OPH will also implement a social awareness and media campaign regarding PSS. OPH has liaised with other Ontario health units that have indicated that ongoing operator engagement is critical to the success of training and public education initiatives in the PSS arena. As such, OPH will build upon the operatorengagement initiatives to raise awareness of infection control risks associated with PSS use, OPH s role in inspecting PSS facilities. OPH will continue to develop and provide web resources and disclosure mechanism to assist the general public in choosing inspected and appropriate PSS for their needs. In 2014, OPH will continue its practice of providing at least one infection prevention and control training session to each of the six aesthetic colleges in Ottawa York Regional Health Unit is a leader in PSS resource development. Recently, they published Name of York Magazine which provides readers with a visually impressive periodical detailing IPAC and PSS best practices. 9 In OPH s PSS Operator Survey, respondents indicated that they would like to receive more IPAC resources (fact sheets, flow charts, quick tips, etc.); indicated that they would find e-newsletters with IPAC tips, updates from OPH or the MOHLTC very useful; would like information for the public that they could provide to their clients; would like a quick reference booklet or kit with OPH infection prevention and control resources; as well as other resources. Notwithstanding, operators also indicated that they were not interested in receiving training for services they do not offer. 10 Versailles Academy, West End Academy, Algonquin College, La Cite Collegiale, Ottawa Academy, The Beauty Academy

9 Quality Assurance As part of the ongoing quality assurance and evaluation components of the PSS program, and in conjunction with on-going communication with the MOHLTC regarding the implementation of the Provincial PSS Risk Assessment Tool and Accountability Agreement(s), OPH will continue to work to identify an appropriate inspection interval for high and low risk PSS premises. Proactive processes will be implemented to track inspections on a quarterly basis and identify repeat offenders. OPH will also monitor communications from the MOHLTC regarding new PSS inspection protocols, and adapt the quality assurance program as necessary. As a discernible strength of OPH s plan, supervisors and Public Health Inspectors will make use of dynamic and innovative performance management measures with the goal of addressing those issues associated with premises found to exhibit patterns of noncompliance. By taking a distinctly Ottawa approach to quality assurance, OPH s objective continues to be the promotion of an environment that prioritizes public safety through an effective, transparent, and consistent approach to PSS inspection. In addition, OPH will continue to work with By-law and Regulatory Services and the City Clerk and Solicitor s Department to further explore options for licensing PSS premises. NEXT STEPS As OPH awaits a decision from the MOHLTC regarding required inspection frequency of PSS establishments, the risk assessment tool and Accountability Agreement indicator(s), OPH will update the Board of Health. Public Health Inspectors will continue to ensure all PSS premises currently identified as high-risk are inspected at least once prior to the end of OPH also will collaborate with internal and external partners to develop the training, disclosure, and quality assurance pieces of the PSS inspection program. Finally, OPH will work with other city departments, as needed, to explore options for licensing PSS premises. CONSULTATION In 2013, to further enhance inspection, regulation and identification of PSS, the Board of Health directed OPH staff to explore strategies to improve infection prevention and control practices in PSS. OPH initiated dialogues with the City Clerk and Solicitor s Department and the By-law and Regulatory Services Branch regarding the feasibility, implications and efficacy of introducing a new licensing category specific to personal service settings. While are no legal impediments to implementing a new licensing category, there are a number of logistical impediments, including resource and enforcement challenges, that limit implementation at this time. OPH will however continue to communicate with the City Clerk and Solicitor s Department and By-law and Regulatory Services to collect and weigh all the relevant information for potential regulatory changes at the municipal level, as necessary.

10 LEGAL IMPLICATIONS There are no legal impediments to the implementation of the recommendations in this report. FINANCIAL IMPLICATIONS There are no financial implications associated with this report. TECHNOLOGY IMPLICATIONS The City s Information Technology Services Department will work with Ottawa Public Health to bring this initiative through the 2015 Corporate IT Planning process. BOARD OF HEALTH STRATEGIC PRIORITIES The recommendations in this report support the Board of Health strategic priority to reduce health risks related to preventable infectious and non-infectious diseases. TERM OF COUNCIL PRIORITIES The recommendations in this report support the Term of Council Priorities under Healthy & Caring Communities. SUPPORTING DOCUMENTATION Document 1 High-Risk and Low-Risk Personal Service Setting Inspections Document 2 Personal Service Setting Environmental Scan and Community Consultations DISPOSITION Ottawa Public Health Staff will implement the Infection and Control Plan as outlined in this report and report back to the Board on any updates to the PSS risk assessment tool and related performance indicators under the Public Health Accountability Agreement.