What is important is not the practice itself,but safe clinical settings related to the practice

Whether needling practices like acupuncture are potential risk factors for transfusion-transmissible infections (TTIs) is an important issue for blood transfusion healthcare policy. Controversial results of research in this area might add confusion and misunderstanding about the safety of these interventions. Amid this ambiguity, a recently published retrospective observational study on the risk of TTI after tattooing, body piercing, or acupuncture among Dutch blood donor supports the safety of these needling practices using a large amount of contemporary data. ¹ Between 2006 and 2015, 287 donors were confirmed to have developed TTIs following 9,266,036 donation attempts, and only 29 of 287 TTI-positive donors were reported to have had needle-related events (NREs), which corresponds to an odds ratio (OR) of 1.04 for repeat donors and 1.40 for new donors. In addition, plausible risk factors among TTI-positive donors with recent NRE included high-risk occupations, contact with blood, residing in a highly endemic area, and high-risk sexual contact, rather than only needling practice. The meaning of this result seems to be clear: people who have recently undergone needling practices such as acupuncture do not have a particularly high risk of TTI, so deferral policy for donors based on recent needling experiences should arguably be ended, at least in the Netherlands. ¹

However, contradictory results have recently been published. Van Remoortel et al. conducted a systematic reviews of 21 observational studies to investigate the association between needling practice and TTIs among blood donors, and they suggested an increased risk of hepatitis C (HCV) infection after tattooing (OR = 5.28, 95% confidence interval (CI) = 4.33–6.44), acupuncture (OR = 1.56, 95% CI = 1.17–2.08), and piercing (OR = 3.25, 95% CI = 1.68–6.30). Based on the results of this meta-analysis, the authors insisted that receiving percutaneous needle treatments needed to be considered an important risk factor for TTI, so measures for preventive deferral such as a donor health questionnaires should be justified. ² What are the reasons for these contradictory results? We think that there is a profound limitation in the meta-analysis of these studies that introduces a distortion of reality. Blood-borne infection (BBI) during needling practice is closely related to the contamination of equipment by infected blood, or infected practitioners failing to use appropriate preventive measures. ³ If the settings for needling practice are well controlled by strict regulations pertaining to the aspects of personal hygiene and sterilization, it is unlikely that BBI would occur even after these needling procedures. ¹ In the case of acupuncture, a study suggested that reports of hepatitis reduced significantly between 2000 and 2011, which might reflect the widespread usage of disposable acupuncture needles. ⁴ From this perspective, there could be geographical or temporal differences among the primary studies included in the meta-analyses: if some countries have strong regulations regarding these needling practices while others do not, if some countries did establish regulation when the studies were conducted and some didn’t but have since changed, then the studies included in the meta-analysis might have high clinical heterogeneity. ² Sensitivity analyses needed to be conducted based on factors such as the presence or absence of strong regulation and differences over time in order to ensure robustness of results of the meta-analysis; without these we may be left with a case of “garbage in, garbage out,” which is sometimes said of flawed systematic reviews. ⁵

The message we wish to convey here is that needling practices are safe “where these can be considered safe.” ¹ Accordingly, the risk of TTIs following acupuncture should not be unreasonably overemphasized based on insufficient evidence.