An outbreak of frightening sores among pedicure customers in a California salon has put the entire beauty industry on notice. Its lesson is simple: In the exploding marketplace of grooming services, your mantra should be “clean, clean, clean.” Make it a part of your daily routine, and you will protect yourself, your customers, and your business. Overlooking this rule can lead to ruin.
It Happened to Him
Tuan Ngo emigrated from his native Vietnam to the land of opportunity, the United States, where he learned English, earned his manicurist license from the state of California, and opened his own salon in the Central Coast farming town of Watsonville.
Within five years of opening Fancy Nails, Ngo’s shop was attracting clients who would drive as long as an hour for his quick service and walk-in policies. One of his most popular services was pedicures, and he offered 10 full-size chairs with whirlpool foot spas for his customers’ relaxation.
But that success all came crashing down last fall when a bacterial infection hit more than 100 of his clients with stubborn, ugly sores on their legs that lingered for months. High volume and apparent failure to follow the manufacturer’s cleaning instructions left built-up debris in his brand-new pedicure spas, creating a breeding ground for the usually harmless Mycobacterium fortuitum.
Santa Cruz County health officials shut Fancy Nails down, California’s Bureau of Barbering and Cosmetology moved against Ngo’s license and more than 50 women — and their lawyers — are waiting for the right moment to launch a massive lawsuit.
The tragedy of Ngo’s story is that this may have been avoidable.
“The majority of nail technicians are in this business because they want to make people feel better,” says Paula Malloy, executive vice president of marketing for Styling Technology Corp. (Scottsdale, Ariz.). “They just don’t realize that there’s bacteria everywhere, and when you don’t properly cleanse your implements and your workstations, those are areas where bacteria can grow and affect your clients’ well-being.”
Finding Pieces to the Puzzle
Ngo’s nemesis, M. fortuitum, belongs to a large family of bacteria. Distant cousins include the bacteria that cause tuberculosis and leprosy, while others cause no harm to humans at all. Scientists call it a “rapid-growth” bacterium because it grows relatively quickly compared to other mycobacteria in laboratory conditions.
We encounter all kinds of bacteria and viruses in the world every day, yet humans usually fight off infection. M. fortuitum in particular lives in municipal drinking water, in dirt, and on dust particles. It is found all over the world, yet it rarely causes problems except in unusual cases where it gets into surgical wounds.
California state and local health officials are partnering with the Centers for Disease Control in Atlanta to figure out why such a common organism has created so much havoc. Their concern, according to CDC epidemiologist Kevin Winthrop, is the potential for a larger outbreak of the sores, which take months of expensive antiobiotic treatment to heal.
Spurred on by what they still don’t know about M. fortuitum, county health officials in late December took samples from the foot spas of 31 nail salons in five populous counties across the state and sent them to the California Department of Health Services for testing.
State laboratory technicians tested the samples to find out how much M. fortuitum was lurking in the foot spas.
“The survey is to see just how prevalent this is in this setting, but it’s very preliminary. There are no results and no conclusions,” says CDC’s Winthrop, who is working with California’s Health Services on the investigation.
Perhaps the biggest unknown at this point is how much M. fortuitum is needed to cause an infection. “Infectivity is a big topic,” says Winthrop. “Why are some bugs infectious in some circumstances and not in others?” He explains: “It has to do with several things: the characteristics of the organism, the environment within which it lives, how prevalent it is, how much of it is there, how virulent it is. Then there are host factors, human factors: how strong is a person’s immune system, how strong is their skin?”
In the case of the Watsonville outbreak, many of the victims had shaved their legs recently before getting a pedicure at the salon. They had also received an oil massage on their legs afterward.
“Human skin is a barrier to infection,” explains Winthrop. “When there’s a breakdown in the skin layer — nicks, cuts, and scratches caused by normal shaving — that can increase bacteria’s ability to invade the skin.”
Oil seems to have sealed in the organism, according to Santa Cruz County Health Officer Betsy McCarty. But the sneaky microscopic animal can get past healthy skin, even crawling into a hair follicle. “There’s plenty of people who get this without shaving or having known nicks and abrasions of the skin,” says Winthrop. He and others involved in the investigation say they still don’t know why the outbreak happened when and where it did.
Even at one of America’s top spa manufacturers, Wisconsin-based European Touch Ltd., a division of Styling Technology, the outbreak took people by surprise. “We’ve been manufacturing these things for 15 years, and this is the first time anything like this has happened,” says Connie Meyer-Weissling, European Touch’s vice president of sales and administration.
“The foot spa survey is a piece of the puzzle,” says coordinator Candi Zizek of California’s Health Services. “The goal is to identify the risk and prevent these problems for other people.”
The information from the survey will be used to establish a baseline for future research and, perhaps, new state regulations. “We’re relying on the science to determine what we’re dealing with here,” says spokeswoman Tracy Weatherby of the California Department of Consumer Affairs, which oversees the state’s Bureau of Barbering and Cosmetology. “If findings determine that there is a need to make regulatory changes, we will certainly do that.”
One of the most important links will be establishing the threshold of infection — that is, how many bacteria must be present to cause disease? “We don’t know,” says Winthrop. “I’m sure it’s variable.”
Is Rapid Industry Growth to Blame?
Although researchers don’t know for sure yet, service volume may be one link in the chain of cause and effect. Fancy Nails did 200 pedicures a week in 10 full-size chairs, according to owner Ngo.
In conducting the spa survey, California Health Services’ Zizek is also questioning spa owners about how long they have used the machines, making this one of the first systematic attempts to gauge the growth of the pedicure industry.
Sales of pedicure spas have skyrocketed in the past two or three years. Start-up investment is relatively low, costing just $3,000 to $4,000 for a quality spa. Many states’ minimum licensing requirements are fairly easy to meet — a rallying cry for nail techs nationwide, many of whom would like to see more emphasis on continuing education from their state governing agencies. Yet profit margins are attractively high, making pedicures a popular new service for nail salons, hairstylists, day spas, and skin care providers.
At another large foot spa manufacturer, Amerispa LLC (Rancho Cordova, Calif.), the company shipped its first 300 units in 1998. It shipped more than 3,000 units in 2000, according to vice president Jim Casteel. “It’s an extremely high-growth industry,” says Casteel.
At European Touch, sales have soared from $250,000 a decade ago to $12 million in 1998 and $20 million in 2000, says Meyer-Weissling. That success has spawned many copycats who produce spa equipment at cheaper prices. If you are thinking about buying equipment, Meyer-Weissling says, look for brands that meet the standards of both Underwriters Laboratories and ANSI (American National Standards Institute).
“ANSI is the most important,” says Meyer-Weissling. “ANSI specifications are for the plumbing codes and this is all about the plumbing right now.”
Those standards call for whirlpool mechanisms to drain thoroughly, enough that only one tablespoon of water is left in jetted tubs. That way, there’s no reserve of water that has been sitting inside the plumbing — perhaps for hours or even days — that would mix with fresh water when the tub is filled for a new customer. For Linda Greene, director of education and operations for Gene Juarez Salons, large spas with porcelain sinks are good choices. She warns against models of any size with hoods over the basins.
“I think salons have to be careful when they’re choosing a spa,” says Greene. “When you have a hood or hidden areas, that’s when it’s hard to clean.”
For the Seattle-based chain, however, Greene has eliminated whirlpool spas altogether. The choice stemmed from a combination of concerns over ease of cleaning and desire for a type of service that doesn’t fit with pedicure chairs, she says. “There are just too many areas to clean. When you’re booked solid, you don’t have time,” she says.
So, time must be made for cleaning, says Ruth Windsor, a licensed manicurist at the Total Image salon in Garden City, Mich. “I make sure I don’t over-book,” she says. “You have to make sure you have that time to clean and prep between pedicures.”
Thorough Cleaning Is Key
The Watsonville outbreak has prompted California’s Bureau of Barbering and Cosmetology to develop recommended guidelines for cleaning pedicure foot spas (see sidebar). The procedures fill a regulatory gap concerning pedicure spas that currently refers licensees to manufacturers’ instructions only. But some manufacturers have instructions that are sketchy at best, the state health department’s Zizek found when she reviewed the materials. Good care, however, requires both cleaning the basin after each customer and flushing the entire system periodically — depending on the volume.
Both European Touch and Amerispa send specific guidelines with their spas that recommend regularly cleaning the basins with a non-abrasive cleaner such as Formula 409 or Simple Green, applied with a soft sponge. Be careful not to use anything that could scratch or gouge the surface, as those places can become breeding grounds for bacteria, says Amerispa’s Casteel.
Then, depending on how many pedicures you perform, flush out your spas on a regular basis using a low-foam dishwashing detergent such as Cascade or Calgonite, or one of the many professional products available. Let the whirlpool run for 10 to 15 minutes, then drain. European Touch recommends adding 2 to 3 ounces of household bleach to the mix, while Amerispa recommends putting the bleach in a second round and running the machine again.
After draining out the basin, dry it with a soft cloth, sopping up any puddles of water where bacteria could breed.
California’s Bureau of Barbering and Cosmetology is adding to the manufacturer guidelines, suggesting that spa owners first remove the screen over the whirlpool inlet and wash it with a chlorine solution. At Fancy Nails, county health investigators found debris had accumulated in that screen, giving M. fortuitum a perfect nest.
Spa owners should then flush the stations and leave the chlorine solution in the basin overnight, the state suggests.
(To make the chlorine solution, the state instructions suggest a 10 ppm solution, made with 1 tablespoon of bleach to 3 gallons of water. Amerispa’s Casteel suggests using half a cup of bleach.)
On top of that, jittery health officials in Santa Cruz County have advised local salons to add 1/4 teaspoon of bleach to the water used for each customer. In a 2.5 gallon foot spa, that much chlorine yields a 1 ppm solution, the minimum level required for public spas.
One sure no-no is using oil-based products in the spa or on clients’ feet or legs. “Oil gives the bacteria a breeding ground,” says Casteel. Oils contain protein, which the bacteria use for food, and it helps bacteria stick to everything inside the whirlpool mechanism. The impeller action to make the water move packs it in even more. With enough build-up, oil-based products can slow the water’s movement or completely clog the system.
If that happens, you may need to call in a local spa company to clean out your foot spa, raising the specter of expensive parts replacement, Casteel warns.
Worse, no one is sure how to kill M. fortuitum once the bacteria gets established inside the system’s plumbing. “That’s one of the things we’re looking at now,” says CDC’s Winthrop.
Raising the Bar
The outbreak may wind up pushing the industry to a new level of clean.
Styling Technology’s Malloy says she had already been working on new products with better disinfectant and scrubbing properties. “We’re working on something that will make it very, very easy for the technician to make sure that the chair is clean,” she says.
Zizek is trying to coordinate with industry leaders and their staff biologists and chemists, including ones from Styling Technology and Amerispa, to find out how to prevent any new outbreaks.
Meyer-Weissling is planning to update European Touch’s instructions to perform the flushing procedure after every 10 pedicures. She also has an instructional video in the works that will accompany each spa out the factory door. Part of the problem is communications. “When we write things like this, we assume people read them,” says Meyer-Weissling, acknowledging that nail techs probably don’t.
Amerispa now has instructions in Vietnamese, an acknowledgement that a growing proportion of salon owners are non-English-speaking immigrants.
But much will depend on the scientists, as they puzzle over M. fortuitum, why it caused the Watsonville outbreak and how it can be prevented from making people sick someplace else.
“It could have happened anywhere,” says CDC’s Winthrop. “It’s unpredictable. The key is prevention and the prevention can be obtained with adequate disinfection of the foot spas.”
Trina Kleist, a staff writer for the Santa Cruz Sentinel, is based in Watsonville, Calif.
California’s New Safety Recommendations for Foot Spas
The California Bureau of Barbering and Cosmetology recommends that salons using whirlpool pedicure foot spas follow these disinfection procedures to ensure proper cleaning and maintenance of the equipment and to prevent the spread of bacterial or parasitic disease:
Between Each Customer
• Wash the surfaces and walls of the footspas with detergent, rinse with clear water, and hand-dry.
• Add 1/4 teaspoon or 2 milliliters of household bleach before refilling the spa to provide a 1 parts per million (ppm) chlorine residual.
• Test for the proper chlorine residual with chlorine test strips for spas. These test strips are available at local pool supply stores.
At the End of Each Day
• Remove the screen and clean all debris trapped behind the screen for each spa.
• Wash the screen and inlet with a chlorine solution (1 tablespoonful or 15 milliliters of household bleach in 3 gallons of water would yield a 10 ppm solution).
• Circulate the 10 ppm solution through the spa system for five minutes and let it sit overnight.
• Drain and refill the foot spa the following morning.