To the Editor—The therapeutic benefits of acupuncture have been confirmed by many studies.Reference Liu, Liu and Xu¹ Acupuncture has become an important component of complementary and alternative medicine throughout the world, and it has been recommended by guidelines.Reference Qaseem, Wilt, McLean and Forciea² Although the subsequent problem of healthcare-associated infection deserves our attention, few reports of these events are available in the Chinese literature, and these events may be drastically underreported.

Transmission of bloodborne diseases in subjects can occur due to inadequate disinfection and reuse of disposable needles. According to health authority regulations, reusable acupuncture needles should be sterilized by autoclaving. However, short-term disinfection by glutaraldehyde or alcohol soakings or wipes are not uncommon in the primary care organizations and small clinics in China.Reference Reynolds and McKee³ In view of China’s huge populations infected with hepatitis B (∼93 million) and hepatitis C (∼10 million) as of 2015,^{4, 5} as well as the estimated growth of HIV-infected patients (769,175) as of 2018,⁶ inadequate sterilization might lead to the spread of these diseases. More than 80 hepatitis B cases and several HIV cases have been associated with acupuncture in the other countriesReference Woo, Lin, Lau and Yuen⁷; however, it is strange that no confirmed cases have been reported in China, a country with the largest population of viral hepatitis and the greatest use of acupuncture.

Puncture site infections are not uncommon in China; 17 patients were reported to have been infected with nontuberculous Mycobacteria in a private clinic in Zhejiang province in 2012. Puncture site infections mainly result from the inadequate skin disinfection, the use of contaminated acupuncture needles, and the low compliance of hand hygiene among medical staff. The common pathogens of puncture site infections include Staphylococcus aureus, Mycobacteria, and Enterobacteriaceae.Reference Murray, Pearson and Coombs^8, Reference Jin, Zhou and Zhang⁹ More recently, with increasing antibiotic resistance, multidrug-resistant organisms have become important pathogens.Reference Woo, Lin, Lau and Yuen⁷

Occupational exposures might also lead to the transmission of bloodborne diseases to medical staff. Needlestick injuries can occur during the puncture process and withdrawal and discard of needles, in addition to needle cleaning, disinfection, and maintenance. Occupational exposures are very common in the Department of Acupuncture because practitioners of acupuncture are not very aware of standard precautions. During the process of acupuncture, puncture and withdrawal of needle without gloves, cleaning, and maintenance of needles without personal protective equipment are all too common. Nevertheless, epidemiological data regarding occupational exposures related to acupuncture in a national level in China are lacking.

Another issue of concern is that some organizations (eg, barbershops, beauty salons, massage parlors, clinics, and primary hospitals) and individuals perform acupuncture without qualification, and these illegal acts have not been eliminated effectively in China. Unqualified sterilization and nonstandard operating activities might occur more frequently under these conditions because of economic interests or the lack of knowledge of infection control. Outbreak of acupuncture-associated infection in China is possible, and infection control measures are urgently needed for the acupuncture process. The health authorities should apply lessons learned from the spread of human immunodeficiency virus (HIV) to 5 people at 1 hospital after a doctor reused dirty needles during treatment (reported on February 9, 2017).

The following measures might be of great help. First, detailed infection control rules during the acupuncture should be developed and strictly implemented nationwide. Second, reusable acupuncture needles should be replaced by disposable needles as soon as possible. Third, acupuncture staff should be educated about infection control. Lastly, acupuncture by unqualified persons should be forbidden.

Fortunately, the State Administration of Traditional Chinese Medicine is aware of this situation, and guidelines for the prevention and control of acupuncture-associated infections were issued on July 3, 2017.¹⁰ The guideline includes comprehensive and standardized the operation of acupuncture according to 10 aspects: (1) applicable range, (2) management requirements, (3) air ventilation, (4) environmental cleaning and disinfection of facilities especially procedure rooms, (5) cleaning and disinfection of fabrics, (6) provision of hand hygiene stations, (6) requirements for aseptic technique, (7) use and disposal of needles, (8) preprocessing of reusable needles, (9) prevention of occupational exposure, and (10) treatment of occupational exposure. Training courses for the guideline have been held throughout the country.