The infections reported after acupuncture changed with the needles. The large outbreaks reported in the 1980s were of hepatitis B, a virus carried in blood, passed from patient to patient on needles that were reused. Regulators and professional bodies then required sterile needles used once and thrown away, and a 2013 review of case reports by Xu and colleagues found no case of hepatitis from 2000 to 2011. The outbreaks it did find were bacterial, and the investigators traced them to the skin and to equipment other than the needle. This page reports both periods, the rules written in response, and the one practice the guidance still disagrees about: whether to swab the skin before needling. The rare single infections that two large studies counted are on After a treatment.
Hepatitis B and reused needles
In 1984, 35 patients of one acupuncturist in Rhode Island were infected with hepatitis B. Investigators from the US Centers for Disease Control tested 316 of the 366 patients the acupuncturist had seen that year. Patients who received more needles were more likely to be infected: 9% of those given fewer than 150 needles over their course and 33% of those given 450 or more. The investigators watched the acupuncturist’s technique, noted several ways the needles could become contaminated, and concluded that the outbreak showed the risk of reusing needles. In Jerusalem in 1986 a physician’s acupuncture practice was linked to two clusters of hepatitis B of between 5 and 11 cases each, and the investigators, from Israel’s Ministry of Health, called for correct sterilisation to be enforced in every setting that pierces the skin.
Adrian White’s 2004 cumulative review of serious adverse events found 204 primary and 91 secondary reports of infection, and over 60% of them were hepatitis B. The next most common was infection of the outer ear after ear acupuncture, which Ear acupuncture covers. A 2003 review of 202 incidents reported in English from 1965 to 1999 by Lao and colleagues found that the infections came mainly from a few practitioners, saw fewer serious complications reported after 1988, and suggested that clean needle techniques and stricter training may explain the decline.
Single-use needles
In 1996 the US Food and Drug Administration moved acupuncture needles from class III, which requires approval before sale, into class II, devices sold under special controls. The controls require a needle to be sterile, made of a biocompatible material, and labelled for single use only and as a prescription device. Guidance elsewhere says the same:
- The WHO’s 1999 Guidelines on basic training and safety in acupuncture strongly recommend disposable sterile needles and guide tubes, each needle used once and once only and then discarded into a special container, and state that boiling needles or soaking them in alcohol does not sterilise them.
- The WHO’s 2020 benchmarks for the practice of acupuncture strongly recommend disposable single-use sterile needles and say they should not be reused.
- The British Acupuncture Council’s Code of Safe Practice (2016) requires members to use single-use pre-sterilised needles, a fresh needle for every point, and never to reinsert a needle once used.
- The Chinese Medicine Board of Australia’s infection prevention guidelines (2023) require needles to be single use, pre-sterilised and dropped straight after use into a rigid-walled sharps container.
The Xu review counted 94 cases of hepatitis in four outbreaks traced to reused needles in the authors’ earlier work, and wrote that hepatitis has rarely been reported since disposable needles were introduced.
Outbreaks since: mycobacteria
The Xu review found 239 infections reported from 2000 to 2011, and 191 of them came from five outbreaks of bacterial infection, which its authors attributed to skin contact with unsterilised equipment and dirty towels. Of the 239, 193 were caused by nontuberculous mycobacteria, relatives of the tuberculosis bacterium that infect the skin and the tissue under it.
| Outbreak | Cases | What the investigators found |
|---|---|---|
| Hong Kong, reported 2002 | 4 | The four strains survived longer in 75% alcohol than other skin bacteria |
| Seoul, 2001 | 40 | Disposable needles, not reused, and the skin usually rubbed with alcohol. Every environmental sample was negative, but the investigators suspected the towels and hot-pack covers; no further cases appeared after they were replaced and the boiling tank sterilised |
| Toronto, 2002 | 32 | Median time to symptoms one month; 23 of 24 followed up recovered, all with scarring or darkened skin |
| Korea, 2008 | 109 of 1,002 patients interviewed | The same strain in 31 patients’ wounds and in a diluted glutaraldehyde solution used to disinfect the clinic’s physical therapy devices; patients who also had interferential or low-frequency electrical therapy had 36 times the odds of infection |
Clean needle technique
In the United States the Council of Colleges of Acupuncture and Herbal Medicine has taught a Clean Needle Technique course since 1990, as a one-day class at first and now online, with a written and a one-to-one practical exam. Its manual is in its seventh edition (2015). Passing the course is one of the requirements for certification by the National Certification Board for Acupuncture and Herbal Medicine and a licensing requirement in most states. The WHO 1999 guidelines describe the same core practices: wash the hands before treating and again before needling, never touch the shaft of the needle with the fingers, press the site with sterile cotton wool on withdrawal, and discard anything soiled with blood into a special container. The British Acupuncture Council requires hands to be washed before and after every treatment and cleaned with alcohol gel before needles are removed.
Swabbing the skin
No study has compared swabbing the skin before acupuncture with not swabbing it. Peter Hoffman of the UK’s Central Public Health Laboratory made that point in 2001 and reasoned from injections instead: disinfection reaches bacteria on the surface of the skin but not those in its ducts, glands and follicles, and disinfecting clean skin before an injection is not generally considered necessary. The WHO’s 2010 best practices for injections list soap and water but not alcohol for injections into or just under the skin, and call the question unresolved for therapeutic injections into muscle. An undated position paper on skin preparation from the Council of Colleges, then the Council of Colleges of Acupuncture and Oriental Medicine, concludes that the skin should be clean before needling but that cleaning it with an antiseptic is not necessarily essential to prevent infection, while noting that its own manual’s sixth edition said to clean with alcohol.
The guidance documents divide accordingly:
| Body | Skin preparation |
|---|---|
| WHO, 1999 | Swab each point with 70% ethyl or isopropyl alcohol and let it dry |
| WHO, 2020 | Disinfect the point and the area around it before treatment |
| British Acupuncture Council, 2016 | Skin clean; swab with alcohol where moisture or exudate collects; wash dirty skin with soap and water; clean skin treated with creams or oils with 70% alcohol |
| Chinese Medicine Board of Australia, 2023 | No antiseptic needed on visibly clean skin. Antiseptic required on soiled or oiled skin, for a patient who may be immunocompromised, when needling into a joint space or bursa, and before a needle left in place, such as an ear stud or press needle |
Two of the outbreaks bear on the question. The Hong Kong strains survived in 75% alcohol longer than ordinary skin bacteria, and the Seoul patients were infected although the doctor usually rubbed their skin with alcohol before needling.
What the sources cannot tell you
Outbreaks are counted when public health investigators trace a cluster to one clinic; a single infection after acupuncture is reported only if a doctor writes it up, so the case-report reviews cannot give a rate. In the Seoul outbreak no environmental sample grew the organism, so its source remains the investigators’ judgement. The fall in hepatitis reports after disposable needles came in is a trend in published reports, not the result of a comparison. The guidance on swabbing rests on reasoning from injections. AcuiQ’s entries record what a study prescribed, not how its needles were handled or what happened to the people in it; What AcuiQ does not do sets out that limit.