Acupuncture transmitted infections
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1268 (Published 19 March 2010) Cite this as: BMJ 2010;340:c1268
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Acupuncture is a medical science based on a group of procedures which
involve stimulating anatomical points on the body often by penetration of
the skin with the help of thin metallic needles under manipulation by
either hands or by electrical stimulation (NCCAM).
During a study with the assistance of members of the British Acupuncture
Council undertaken by McPherson et al (2001), no serious adverse events
were observed after 34 407 acupuncture treatments. This study led the
investigators to term acupuncture as a ‘relatively safe form of
treatment’.
Acupuncture has clinically proven efficacy in several clinical conditions.
For example, it has been observed to have a definitive role in the
treatment of depressive neurosis (Xiong et al, 2010). Acupuncture has also
been tried in orthodontic patients having a gagging reflex and it has been
found to be effective in the treatment (Sari and Sari, 2010). Ear
acupuncture has been found to be useful in women for the management of
unilateral migraine pain (Allais et al, 2010). In a recent study,
electroacupuncture has been found to reduce neuroinflammatory responses in
symptomatic amyotrophic lateral sclerosis model (Yang et al, 2010).
In certain cases, acupuncture has been considered worthy of trials in the
management of certain diseases such as seasonal allergic rhinitis which is
a very common problem. A large randomized controlled clinical trial under
the name of Acupuncture in Seasonal Allergic Rhinitis (ACUSAR) has been
planned in Germany involving 400 seasonal allergic rhinitis patients and
41 physicians in 37 clinical OPDs (Brinkhaus et al, 2010). Acupuncture has
been labeled to have a ‘favorable safety profile’ and has been considered
to be a reasonable therapeutic option for managing chronic back pain,
osteoarthritis and headache (Sherman and Coeytaux, 2009).
In few cases, acupuncture procedures lack the large scale clinical
evidence. Role of acupuncture in the treatment of common woman health
problems (post-menopausal syndrome, polycystic ovarian syndrome and other
menstrual related symptoms) is under-studied. The little evidence of
utility of acupuncture in these conditions is based on single studies
(Smith and Carmady, 2010).
In some cases acupuncture has not been proven of much utility. One such
case is the study of effect of acupuncture on hot flashes in patients on
hormonal therapy for prostate cancer (Beer et al, 2010). Similarly, there
has been limited evidence for utility of acupuncture in the clinical
management of carpel tunnel syndrome (Carlson et al, 2010).
Recently, it has been claimed to have role in transmission of infections
(Woo et al, 2010). Acupuncture is part of Traditional Chinese medicine and
has been practiced in China and other Asian countries for thousands of
years. Acupuncture procedures; if not carried out by a qualified
practitioner; can pose serious adverse effects (NCCAM). Some of these
effects have been mentioned by Leavy (2002), Devitt (2001) and McPherson
et al (2001).
Acupuncture has relatively low adverse event rates. Some of the adverse
events can be attributed to the failure to observe statutory guidelines
regarding acupuncture devices (needles) and procedures. The U.S. Food and
Drug Administration (FDA) requires the usage of acupuncture needles by
licensed practitioners only subject to the condition that needles have to
be sterile, nontoxic, and for single use only. Many of the acupuncture
complications originate from use of inadequately sterilized needles; and
from improper delivery of acupuncture and related procedures (such as
failure to use a new set of disposable needles and swabbing treatment
sites with disinfectant prior to insertion of needles). Infections and
punctured organs may result from failure to comply with guidelines by
acupuncturists (NCCAM). These mishappenings on account of non-compliance
with statutory requirements can’t rob acupuncture of its proven tradition
and worth.
References:
1. Allais G, Romoli M, Rolando S, Castagnoli Gabellari I, Benedetto C. Ear
acupuncture in unilateral migraine pain. Neurol Sci. 2010; 31 (Suppl 1):
S185-7.
2. Beer TM, Benavides M, Emmons SL, Hayes M, Liu G, Garzotto M, Donovan D,
Katovic N, Reeder C, Eilers K. Acupuncture for Hot Flashes in Patients
With Prostate Cancer. Urology. 2010 May 20. [Epub ahead of print] PMID:
20494414.
3. Brinkhaus B, Witt CM, Ortiz M, Roll S, Reinhold T, Linde K, Pfab F,
Niggemann B, Hummelsberger J, Irnich D, Wegscheider K, Willich SN.
Acupuncture in seasonal allergic rhinitis (ACUSAR) - design and protocol
of a randomised controlled multi-centre trial. Forsch Komplementmed. 2010;
17(2):95-102.
4. Carlson H, Colbert A, Frydl J, Arnall E, Elliot M, Carlson N. Current
options for nonsurgical management of carpal tunnel syndrome. Int J Clin
Rheumtol. 2010; 5(1):129-142.
5. Devitt M. Surveys Confirm the Safety of Acupuncture. Report Suggests
MDs, Physiotherapists Less Competent than Licensed Acupuncturists.
Acupuncture Today 2001 2(11): Full text online (through webpage
http://acupuncturetoday.com/mpacms/at/issue.php?id=522 on May 29, 2010).
6. Leavy BR. Apparent Adverse Outcome of Acupuncture. JABFP 2002; 15 (3):
246-248.
7. MacPherson H, Thomas K, Walters S, Fitter M. The York acupuncture
safety study: prospective survey of 34 000 treatments by traditional
acupuncturists. BMJ 2001; 323 : 486-487.
8. NCCAM Webpage: http://nccam.nih.gov/health/acupuncture/ accessed on May
29, 2010.
9. Sari E, Sari T. The role of acupuncture in the treatment of orthodontic
patients with a gagging reflex: a pilot study. Br Dent J. 2010;
208(10):E19.
10. Sherman KJ, Coeytaux RR. Acupuncture for Improving Chronic Back Pain,
Osteoarthritis and Headache. J Clin Outcomes Manag. 2009; 16(5):224-230.
11. Smith CA, Carmady B. Acupuncture to treat common reproductive health
complaints: An overview of the evidence. Auton Neurosci. 2010 May 17.
[Epub ahead of print]. PMID: 20483671
12. Woo PC, Lin AW, Lau SK, Yuen KY. Acupuncture transmitted infections.
BMJ 2010; 340:c1268.
13. Xiong J, Du YH, Liu JL, Lin XM, Sun P, Xiao L, Gao X, Chen YW. Survey
clinical evidence of acupuncture therapy for depressive neurosis. Zhongguo
Zhen Jiu. 2010; 30(3):235-40.
14. Yang EJ, Jiang JH, Lee SM, Hwang HS, Lee MS, Choi SM.
Electroacupuncture reduces neuroinflammatory responses in symptomatic
amyotrophic lateral sclerosis model. J Neuroimmunol. 2010 May 9. [Epub
ahead of print] PMID: 20460191
Competing interests:
None declared
Competing interests: No competing interests
Only 50+/- in each study group, with no control group receiving no
intervention¹?
1. Manber, R et al. Acupuncture for Depression During Pregnancy: A
Randomized Controlled Trial.
Obstetrics & Gynecology. 115(3):511-520, March 2010.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
Professor Colquhoun must have missed Stanford University's recent
press release about the usefullness of acupuncture in treating depression
during pregnancy (1)- not to mention a raft of others which aparently
waft outside his peripheral vision.
Hilary Butler.
(1) http://med.stanford.edu/ism/2010/february/acupuncture.html
Competing interests:
None declared
Competing interests: No competing interests
Dear Dr Woo
In reference to your statement that you described the first case of
MRSA infection associated with acupuncture:
In 2008, my colleagues and I published on an outbreak of invasive
MRSA infection in 8 patients following acupuncture and joint injections
performed by a single practitioner in Perth, Western Australia in 2004.
All of these infections were serious enough to warrant
hospitalisation and parenteral antimicrobial therapy.
The most likely source of the outbreak was the practitioner, who was
shown to be colonised with the same MRSA clone (ST22-MRSA-IV) that caused
the patient's infections at two different timepoints during the outbreak.
Murray RJ, Pearson JC, Coombs GW, Flexman JP, Golledge CL, Speers DJ,
Dyer JR, McLellan DG, Reilly M, Bell JM, Bowen SF, Christiansen KJ.
Outbreak of invasive methicillin-resistant Staphylococcus aureus infection
associated with acupuncture and joint injection. Infect Control Hosp
Epidemiol. 2008 Sep;29(9):859-65.
http://www.ncbi.nlm.nih.gov/pubmed/18684094
Ronan J Murray
Competing interests:
None declared
Competing interests: No competing interests
The National Certification Commission for Acupuncture and Oriental
Medicine (NCCAOM) would like to respond to this editorial by Dr. Woo et
al, which claims that the number of reported acupuncture-related
infections worldwide was “the tip of an iceberg” and called for tighter
infection control measures. Unfortunately, the editorial failed to mention
that the largest and most highly trained segment of acupuncturists,
licensed acupuncturists (most of whom are NCCAOM certified practitioners)
have extensive training to include competency assessment in universal
precautions and clean needle technique (CNT) before obtaining their
national certification and licensure to practice acupuncture.
The article neglected to mention that the incident of infections is
drastically reduced when a consumer seeks a qualified practitioner who has
met the rigorous standards of the NCCAOM certification which includes
passing of the Council of Colleges of Acupuncture and Oriental Medicine
(CCAOM’s) clean needle technique course, a prerequisite to becoming an
NCCAOM certified practitioner. In addition, NCCAOM Diplomates must
complete 450 hours of education in biomedical clinical sciences and pass a
separate examination in biomedicine. These hours ensure that an
acupuncturist has the necessary skills to treat their patient in a safe
and efficacious manner as well as to know when to refer a patient to a
doctor or other healthcare practitioner for further diagnostic evaluation.
Since its inception in 1982, NCCAOM has issued more than 22,000
certificates in Acupuncture, Oriental Medicine, Chinese Herbology and
Asian Bodywork Therapy. The NCCAOM, a national non-profit organization is
constantly at work to build and strengthen safety and ethical standards in
the practice of acupuncture and Oriental medicine. The NCCAOM national
examinations are recognized in 43 of the 44 states that have laws for
licensing acupuncturists. This means that 98% of states that regulate the
practice of acupuncture and Oriental medicine require NCCAOM examinations
as a prerequisite for licensure.
According to this same editorial, “the best prevention from
infections transmitted by acupuncture is infection control measures such
as use of disposable needles, skin disinfection procedures and aseptic
techniques”. These exact knowledge and skills are all taught and assessed
through the CCAOM sponsored CNT course and examination that all NCCAOM
certified practitioners must complete before they can become certified and
licensed to practice acupuncture. In addition, certified NCCAOM Diplomates
must complete a rigorous testing process and must demonstrate completion
of more than 2,000 hours of education and clinical training provided by a
school accredited by ACAOM. In order to retain the Diplomate status, one
must recertify every four years.
Consumers should remember to always seek an acupuncture practitioner
who is licensed to practice acupuncture in their jurisdiction and who is
nationally certified. In the United States, they should be an NCCAOM
Certified Diplomate of Acupuncture or Oriental Medicine. One way to do
this is by searching the NCCAOM Certification Registry Search Engine on
the NCCAOM website. Consumers can be assured these practitioners have met
and continue to meet the highest level of competency to practice safety
and effectively.
"The mission of the NCCAOM is to establish, assess, and promote
recognized standards of competence and safety in acupuncture and Oriental
medicine for the protection and benefit of the public."
Competing interests:
Representative for National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM)
Competing interests: No competing interests
We read with interest the recent editorial by Woo (1), but we feel
that the message on acupuncture’s safety could be misleading because the
risk of infections due to acupuncture is a minor problem with respect
to other alarming safety issues related to Complementary and Alternative
Medicines (CAMs). As the same Authors state “in the 1970s and 1980s most
infections associated with acupuncture were sporadic cases involving
pyogenic bacteria and so far, more than 50 cases have been described
globally”, we believe not enough for the generation of an international
alert; and to define a new syndrome called “acupuncture mycobacteriosis”
may be excessive, the problem of mycobacteriosis involves all the types of
therapeutic needling.
Where hygienic standards are high and when sterile monouse needles are used,
the risk of infection is extremely low; although in scientific literature
are described severe infections, reported cases are very few respect to
millions of treatments every year and in all over the world (2).
Furthermore, with regard to the cases of infections cited by Woo (1), both
Mycobacterium abscess and hepatitis B outbreaks were referred to the same
two acupuncture clinics, and several other cases are absolutely
anecdotal or apparently due to malpractice of single acupuncturists. In
keeping with these observations, the most recent studies on acupuncture
safety conducted with a systematic approach, both retrospectively and
prospectively, showed a substantial safety of this practice, with 6
adverse events upon over a million needle applications in the
retrospective evaluation of 12 published clinical trials (3) , and 0.01%
of local infections (not systemic ones) in a prospective observational
study of 229,230 serial patients (4). The safety of acupuncture was
substantially confirmed also in children; according to a systematic
analysis of 22 clinical trials involving over 780 paediatric patients,
most commons events in children were sedation and needle pain, while no
case of infection was reported (5).
Natural health disciplines (including homoeopathy, ayurvedic medicine,
naturopathy and so on) are promoted to the public as safe, because
“natural”, and are often used and counselled as self medication also to
treat serious health conditions. In our opinion concerns about safety
and risk of CAMs are mostly due to the skip of medical consultation, when
the patient decide to trust incorrect diagnosis of non medical degree
practitioner based only on traditional or unscientific diagnostic systems,
practice self-medication especially with medicinal herbs or decide to
delay or interrupt well established treatments. Finally, physicians are
often unaware of the fact that their patients resort to CAMs (even in
delicate conditions like pregnancy (6)), with the risk that herbal
products and some homoeopathic remedies may interact with prescribed
conventional drugs.
To inform consumers on risks associated with use of natural health
products, and to underline the opportunity in consulting medical
professionals to treat health conditions an information campaign was
promoted by the Italian National Institute of Health (INIH).
A leaflet and a poster to inform consumers about CAMs and possible risks
associated with their use was issued by INIH, in collaboration with the
Natural Centre for Natural Medicine, S. Giuseppe Hospital in Empoli, the
Italian Society of Pharmacology and the Poison Control Centre, Niguarda Cà
Granda Hospital, Milan. The content was signed by more than 30 CAMs
national associations. It was send to all medical and paediatric
practitioners, and pharmacists working in Italy.
The main messages of the leaflet are: to search always advise from expert
medical doctors when using CAMs; to inform always the doctor or the
pharmacist about use of natural health products; not to leave effective
treatments in favour of not proved CAMs; to be careful when preparing teas
with medicinal plants, picked in the fields.
Besides there is the issue of the risk of potential malpractice liability
(7) for health care-givers both medical and not, with regard to this issue
we think should be considered primary lines the following points : 1) to
determine the real clinical risk level; 2) document the literature
supporting the therapeutic choice; 3) provide adequate informed consent;
4) continue to monitor the patient conventionally; 5) for referrals,
inquire about the competence of the complementary and alternative
medicine provider; 6) substitution of demonstrated efficacious therapies
with unconventional; 7) contemporary use of other therapies and possible
interferences; 8) the risks associated with long term effects of
experimental unconventional therapies; 9) the standard of care should be
the same for conventional treatments .
We believe to effectively and comprehensively document and understand
adverse events in CAMs, routine reporting according to CONSORT's harms
guidelines should become the norm in clinical trials (8).
References
1. Woo PC, Lin AW, Lau SK, et al.: Acupuncture transmitted
infections. BMJ. 2010 Mar 18;340:c1268.
2. Ernst E.: Cancer and Society: Acupuncture. Lancet Oncol 2010; 11:20.
3.White A. A cumulative review of the range and incidence of significant
adverse events associated with acupuncture. Acupunct Med. 2004
Sep;22(3):122-33.
4.Witt CM, Pach D, Brinkhaus B, et al.: Safety of acupuncture:
results of a prospective observational study with 229,230 patients and
introduction of a medical information and consent form. Forsch
Komplementmed 2009;16:91-97.
5.Jindal V, Ge A, Mansky PJ.: Safety and efficacy of acupuncture in
children: a review of the evidence. J Pediatr Hematol Oncol. 2008
Jun;30(6):431-42.
6.Lapi F, Vannacci A, Moschini M, et al.: Use, Attitudes and
Knowledge of Complementary and Alternative Drugs (CADs) Among Pregnant
Women: a Preliminary Survey in Tuscany. Evid Based Complement Alternat Med
2008;(May). doi: 10.1093/ecam/nen031.
7.Cohen MH, Eisenberg DM.: Potential Physician Malpractice Liability
Associated with Complementary and Integrative Medical Therapies. Ann
Intern Med. 2002;136:596-603
8. Capili B, Anastasi JK, Geiger JN.: Adverse event reporting in
acupuncture clinical trials focusing on pain. Clin J Pain 2010; 26: 43-8.
Competing interests:
acupuncture practitioner in a public hospital for 10 years
Competing interests: No competing interests
Prof Colquhoun states that the Cochrane Review on nausea and vomiting
is ‘the one’ positive one.
Acupuncture is most widely used for the following common, everyday
problems - chronic low back pain, osteoarthritis and headaches. The
Cochrane review results are as follows:
Chronic low back pain (1):
Against usual care: SMD -0.73 (95% CI -1.19 to -0.28)
Against placebo: WMD -10.21 (95% CI -14.99 to -5.44)
Osteoarthritis (2):
Against usual care: Standardised mean difference -0.96 (95% CI -1.19
to -0.72)
Against placebo: Standardised mean difference -0.28 (95% CI -0.45 to
-0.11)
Tension headache (3):
Against usual care: Responder rate ratio: 11.36 (95% CI 3.69 to
34.98)
Against placebo: Responder rate ratio: 1.24 (95% CI 1.02, 1.50)
These are all positive. Since acupuncture placebo is half-strength
treatment, these are truly amazing facts. One can (and, doubtless, will)
argue about the interpretation but these are the findings of what some
regard as the most rigorous reviews of current evidence.
Refs
1. Furlan AD, van Tulder MW, Cherkin DC, et al. Acupuncture and dry-
needling for low back pain. Cochrane Database SystRev 2005(1):CD001351.
2. Manheimer E, Cheng K, Linde K, et al. Acupuncture for peripheral joint
osteoarthritis. Cochrane Database Syst Rev 2010(1):CD001977.
3. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for tension-type
headache. Cochrane Database SystRev 2009(1):CD007587.
Competing interests:
The author is editor of Acupuncture in Medicine
Competing interests: No competing interests
It is, I suppose, not surprising that just about everyone who disagrees with my comment is an acupuncturist. If I were right about acupuncture being hocus-pocus and a theatrical placebo, they would be out of a job. That, I suppose, is a rather compelling vested interest.
In contrast, I have nothing to gain or lose. It would be very nice if you could cure all manner of conditions by sticking needles into people, just as it would be very nice if you could cure malaria by giving homeopathic sugar pills. Unfortunately, life is a bit more complicated than that.
Michael J Arnold (acupuncturist) selects the one Cochrane review that appears to give some support for effectiveness of acupuncture (in post-operative nausea and vomiting. Most Cochrane reviews have been far less positive. The vast majority of the many studies of acupuncture have shown no difference between 'real' acupuncture and sham, so there can be no real doubt that all the talk of meridians and chi are just pre-scientific gobbledygook. And even the advantage of acupuncture over no acupuncture in non-blind comparisons turns out to be too small to have much clinical significance.
Boris Dragin says "One gets an impression that a new wave of attacks on CAM, specifically Acupuncture is coming". What is coming is a new regard for evidence and a reduction in the willingness of people to acquiesce in the sort of political correctness that stopped them from saying "baloney" when that description was deserved.
Remember that the National Institutes of Health has spent over a billion dollare and has failed to come up with a single useful treatment. The fact of the matter is that the game is up for most forms of alternative medicine.
Competing interests:
None declared
Competing interests: No competing interests
To Whom It May Concern;
I was saddened to see your journal print the editorial on acupuncture
and infection risk. The article draws on examples dating from the 70s and
80s, as well as 2 new cases found in Hong Kong. It is unclear where the
cases came from and whether or not the industry standard, Clean Needle
Technique was followed. It seems this was a hospital in Hong Kong that
reuses needles which is not a legal practice in most countries.
In the U.S. acupuncturist are required to complete a clean needle
technique course and certification before licensure. This includes
detailed instruction on the theories, concepts and application of clean
needle technique, training and both a written and practical exam.
Acupuncturist are very well trained generally and especially in clean
needle technique. In the U.S., it is illegal to use anything other than
sterile, packaged, disposable needles that are carried away in the same
biohazard containers used by hospitals. There are very few reports of any
acupuncture related incidents and that is reflected in our low malpractice
insurance premiums and also in a survey reported by the BMJ (2001;323:486-
487) that looked at the adverse reactions of nearly 35,000 acupuncture
treatments. In this survey, there was an serious adverse event rate of
between 0 and 1.1 per 10 000 treatments.
By contrast, bloodstream infections, introduced through the large
intravenous catheters that deliver medication, nutrition, and fluids to
patients in intensive care, are a large cause of preventable death,
disability, and expense in our nations hospitals. While there are several
types of hospital acquired infections, independent research from Consumer
Reports recently focused on hospital acquired blood stream infections
because they cause at least 30 percent of the 99,000 annual hospital-
infection-related deaths in the U.S..
If the intention of this article was to inform the consumer of the
risks of acupuncture, it did a poor job. I worry that it will
unjustifiably dissuade people from receiving a treatment that could help
them. The Hippocratic oath tells us first, Do No Harm, and I believe this
editorial does harm.
Sincerely,
Sheri Krauss, Licensed Acupuncturist
on staff at Lourdes Hospital, Camden NJ.
Competing interests:
None declared
Competing interests: No competing interests
Food for thought
None of us in the present age would consent to having a non-
disposable needle stuck into our tissues!!!
Why is the practice acupuncture such a notable exception???
Competing interests:
None declared
Competing interests: No competing interests