Nobuyoshi Matsuki et al Japanese Acupuncture and Moxibustion; 2024; Vol.18: 8–14

Original Research

An Internet-based survey of hepatitis B vaccination status among
acupuncturists in Japan
Nobuyoshi Matsuki, MPH, PhD1) Etsuji Suzuki, MD, PhD1,2)
Toshihide Tsuda, MD, PhD3) Hiroyuki Doi, MD, PhD1) Takashi Yorifuji, MD, PhD1)
1) Department of Epidemiology, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences,
Okayama University, Okayama, Japan
2) Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States3) Department of Human Ecology, Graduate School of Environmental and Life Science, Okayama University,
Okayama, Japan

Abstract[Introduction] A needle stick injury is one of the most serious concerns among healthcare professionals, including
doctors, nurses, laboratory technicians, and others. Acupuncturists are no exception. However, acupuncturists are
not included as a target occupation for hepatitis B vaccination in the "Vaccine Guidelines for Healthcare
Professionals" published by the Japanese Society for Infection Prevention and Control. Therefore, a questionnaire
survey was conducted to estimate the prevalence of acupuncturists who have received hepatitis B vaccination andwhether vaccination practices have changed since 1993, when it became a requirement for national examination.
[Methods] We conducted a cross-sectional study among 778 acupuncturists from the Facebook group Liaison
Council on Hospital and Acupuncture Clinic Cooperation (LCHACC). A questionnaire was used to survey the
subjects about the year they graduated from educational institutions and their hepatitis B vaccination experience.
Using categorical analysis, we estimated prevalence odds ratios (PORs) and their 95% confidence intervals (CIs).
Furthermore, to estimate Mantel-Haenszel PORs, we stratified the data by medical institution, work status, andeducational institution.
[Results] During the study period from August 1 to August 31, 2018, 128 acupuncturists were included in the
study from the 778 LCHACC study participants. The vaccination proportion for all participants was 31.8%. A
categorical analysis revealed that vaccination status was associated with a POR of 3.29 (95% CI: 0.69-31.31)
among individuals who graduated after 1993. Furthermore, when stratified by medical institution work status, theMantel-Haenszel POR was 3.18 (95% CI: 0.68-14.89). When stratified by educational institution, the MantelHaenszel POR was 3.52 (95% CI: 0.73-16.94).
[Discussion] The overall vaccination proportion of participants in this study was 31.8%, suggesting an urgent needfor vaccination recommendations for acupuncturists. Those who graduated after 1993 had a higher hepatitis B
vaccination POR of 3.29 than those who graduated before 1992. We observed no substantial change in thestratified analyses by medical work status or educational institution.
[Conclusions] It was suggested that there was a difference in vaccination proportion among graduates after 1993
compared with those who graduated before 1992.
Key words: acupuncture, hepatitis testing, hepatitis B vaccination, guideline, cross-sectional study

I. Introduction
Injury from a needle stick is one of the mostserious concerns among healthcare professionals,
including doctors, nurses, laboratory technicians,amongst others. Acupuncturists are not an exception.

Previous studies have reported instances of thehepatitis B virus adhering to acupuncture needles after
removal1,2), indicating a potential risk of infection forboth acupuncturists and patients. In fact, outbreaks ofhepatitis B linked to acupuncture were reported3-5) .

Corresponding author: Nobuyoshi Matsuki, Department of Epidemiology, Okayama University, 2-5-1 Shikata-cho Okayamacity 700-8558, JAPANReceived 20 Nov, 2023 Accepted 24 May, 2024

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Nobuyoshi Matsuki et al Japanese Acupuncture and Moxibustion; 2024; Vol.18: 8–14

Although some papers have recommended the regularvaccination of acupuncturists against blood-borne
diseases3, there is no survey on the vaccination ofacupuncturists; only surveys on vaccination are
conducted in acupuncture training schools in Japan6,7).
Unfortunately, acupuncturists are not included as atarget occupation for hepatitis B vaccination in the"Vaccine Guidelines for Healthcare Professionals"
published by the Japanese Society for Infection
Prevention and Control (Second Edition (2014) and
Third Edition (2020))8,9) , and adequate measures tovaccinate acupuncturists have not been implemented
in Japan. The recommendation for hepatitis B
vaccination among acupuncturists was only introduced
in 2020 with the revision of the "Safety GuidelinesforJapanese
Acupuncture
andMoxibustion
Practice"10).
Accordingly, we conducted an Internet-based survey
to promote the vaccination of acupuncturists against
hepatitis B. Our study has the following two aims:
First, to estimate the prevalence of acupuncturists
vaccinated against hepatitis B. Second, we surveyed
acupuncturists who graduated from educational
institutions before or after 1993, when theacupuncture license became a national examination.
The background for conducting such a survey is thatthe educational content of acupuncturists has changed
significantly since the national examinations began in
1993, with an increase in the number of modern
medicine courses and the introduction of mandatory
clinical practice11). In particular, the addition of publichealth courses would have had an impact on
vaccination education12) . Therefore, we hypothesizedthat the proportion of those who received hepatitis B
vaccination increased when this educational content
changed.
II. Methods
1. Participants
Our survey was conducted from August 1 to 31,
2018, using Google Forms, a free survey service
provided by Google, for 778 acupuncturists
participating in the Facebook group Liaison Council
on Hospital and Acupuncture Clinic Cooperation(LCHACC). This organization was founded in 2013
to promote cooperation among medical institutions
and acupuncturists, as well as to acquire knowledge
and skills for this purpose. The questionnaire included
a section to obtain consent for participation in thisstudy, and the responses to the questionnaire form
and the agreement to participate in the study on thequestionnaire form were deemed to constitute consent
to participate in the study.
The questions included sex, age, prefecture ofresidence, educational institution, year of graduation,
type of work, treatment location, other medical
qualifications, experience in receiving hepatitis tests,
possession of antibodies, history of hepatitis B
vaccinations, hepatitis B vaccination education
experience at an acupuncturist licensing educational
institution,
hepatitis
B
vaccination
education
experience at the place of employment, and if
educated at the place of employment, either ahospital, clinic, dental clinic, or acupuncture clinic.

Figure 1: Flow of selection and classification process of the study subjects

Nobuyoshi Matsuki et al Japanese Acupuncture and Moxibustion; 2024; Vol.18: 8–14

2. Variables
We defined exposure as graduation after 1993
because we wanted to know the changes in
educational content since the start of the national
examination in 1993. Regarding the outcome, we
defined those who responded to the questionnaire as
having received one series (three doses) of thehepatitis B vaccine as vaccinated.
Regarding the covariates, the survey asked whether
the respondents worked at a medical institution,
graduated from an educational institution, or
possessed other medical qualifications. Furthermore,
the educational institutions for obtaining acupuncturist
qualifications were universities, junior colleges,
professional training colleges, and schools for thevisually impaired. It has been reported that there is adifference in education on hygiene management
among universities, junior colleges, and schools forthe visually impaired under the jurisdiction of the
Ministry of Education, Culture, Sports, Science, andTechnology (MEXT) and professional training
colleges under the jurisdiction of the Ministry of
Health, Labour and Welfare (MHLW) in Japan13) .

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Therefore, we considered how graduation institutions
may affect vaccination status and used them as acovariate.
Hepatitis B vaccination education experience atacupuncture licensing educational institution, used in
the description to assess whether year of graduationinfluenced vaccination.
3. Statistical analysis
We estimated prevalence odds ratios (PORs) andtheir 95% confidence intervals (CIs) for hepatitis B
vaccination. Then, we also estimated Mantel-Haenszel
PORs stratified by whether the respondent works at a
medical institution or an educational institution (under
the jurisdiction of the MEXT or the MHLW). All
statistical analyses were performed using Stata version
15/IC (StataCorp LLC, College Station, TX, USA).
This study was approved by the Institutional
Review Board of Okayama University Graduate
School of Medicine, Dentistry, and Pharmaceutical
Sciences and the Okayama University Hospital Ethics
Committee [No. 1806-020].

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Nobuyoshi Matsuki et al Japanese Acupuncture and Moxibustion; 2024; Vol.18: 8–14

III. Results
Of the 778 participants in the targeted LCHACC,
132 responded to the survey. Four of theseparticipants were excluded because they refused toconsent, leaving 128 participants for this study(Figure 1). Fifteen participants graduated before 1992,
and 113 participants graduated after 1993.
Table 1 shows the characteristics of theparticipants. Of the study sample, all prefectures had
at least one participant, with the South Kanto region
having the largest number of participants at 70(55.1%). The most common type of school graduate
was a professional training college, accounting for
110 subjects (85.9%) of the total. Nine (7%) werecurrently working in a medical institution, and 62(48.4%) had never worked there, including in thepast. In total, 55 (45.8%) of the respondents withother medical qualifications were anma-massageshiatsu therapists, followed by 15 (12.5%) judo
therapists. Overall, 17 (24.6%) tested positive forhepatitis and had antibodies, and 40 respondents(31.3%) reported having been vaccinated. The
possession of other medical qualifications wasconsidered a possible confounding factor.
Figure 2 shows the evolution of vaccination statusover time. Of the 15 participants who graduatedbefore 1992, two (13.3%) received hepatitis B
vaccinations. Meanwhile, of the 113 participants who
graduated after 1993, 38 (33.6%) received thehepatitis B vaccination. The prevalence of vaccination
among those who graduated in 1993-1998, 1999-2003,
2004-2008, 2009-2013, and 2014-2018 was 36.4%,
33.3%, 34.5%, 43.5%, and 25.0%, respectively.
Table 2 shows the PORs and their 95% CIs for
vaccination status. Compared with those who
graduated before 1992, those who graduated after

1993 had a POR of 3.29 (95% CI: 0.69-31.31). When
we conducted stratified analyses by medical institution
work status or educational institution, MH-PORs were
3.18 (95% CI 0.68-14.89) and 3.52 (95% CI 0.7316.94), respectively.
The majority of the other medical qualification
holders in this study were anma-massage, shiatsu, andjudo therapists. Anma-massage-shiatsu and judo
therapists, whose educational systems are similar to
those of acupuncturists, were not analyzed.
IV. Discussion
The overall proportion of vaccination in all thesubjects in this study was low (31.8%), indicating anurgent need for vaccination recommendations for
acupuncturists. Acupuncturists were required toreceive their clinical training at on-campus facilities;
hence, no training was provided for them at medical
institutions14). Although this situation was improved byrevising the educational program in 201715) , themajority of acupuncturists who are currently qualified
have yet to experience clinical training at any medical
institution. In addition, acupuncturists are less likely
to be employed in medical institutions after
graduation (8.1%)16) , and medical institution workers
were similar to those in the previous study (7.0%).
Furthermore, vaccination education in a workplace
was similar for hospital (43.5%) and acupuncture
clinic (39.1%). However, "Vaccine Guidelines for
Healthcare Professionals" state that vaccination should
be given at the time of employment in hospitals8), so
it is possible that the vaccination is given directly
rather than through education. Therefore, it is possiblethat the vaccination education in hospital andacupuncture clinic is similar in prevalence, but interms of vaccination opportunities, hospital may have

Figure 2: Hepatitis B Vaccination Status Stratified by Year of Graduation

Nobuyoshi Matsuki et al Japanese Acupuncture and Moxibustion; 2024; Vol.18: 8–14

more vaccination opportunities than acupuncture clinic
because they are vaccinated in accordance with theguidelines. As a result, acupuncturists may have fewer
opportunities for vaccination than other medical
qualifications.
Those who graduated after 1993 had a higher
hepatitis B vaccination POR of 3.29 than those who
graduated before 1992. This finding supports the
hypothesis of this study that vaccination is altered byeducation after the start of the national examination.
We observed no substantial change in the stratified
analyses by medical work status or educational
institution. This may suggest that these are notconfounding factors in the hepatitis B vaccination,
indicatingthatvaccination
promotionforacupuncturists should be conducted for all
acupuncturists. Hepatitis B vaccination education at
acupuncturist-licensing educational institutions was
20.0% before 1992 and 41.6% after 1993, andvaccination education has been improving since 1993.
In the previous survey, 85.0% of the respondents
were male17) , and 66.7% of our study subjects weremale. In addition, 78.1% of the respondents in theprevious survey were practicing acupuncturists17), andthe corresponding figure was 65.6% in this study.
Because the distribution of regions of residence wassimilar to the previous survey17) , we think that
selection bias by region was negligible. Furthermore,regarding vaccination education, 33.1% of schools
educated students in the previous survey16) , and thecorresponding figure was 39.1% in this study. Basedon these results, we believe that our findings can begeneralized to the whole nation.
Anti-vaccination is a public health issue in somecountries, including Japan. For example, in Canada,
complementary and alternative medicine providers are
involved in the phenomenon of a growing populationthat is hesitant to be vaccinated17). Complementary andalternative medicine providers with limited experiencein vaccinations may be vaccine-averse. In this survey,
vaccination prevalence was low at 31.3%, and only
39.1% of acupuncturists received education on
hepatitis B vaccination at an acupuncturist-licensing
educational institution. This may hinder a proper
understanding of vaccines. Acupuncturists are

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nationally licensed complementary and alternative
medicine practitioners in Japan, and for better publichealth practices, they should be properly managed likeother medical qualifications.
There are several limitations to this study. First, thestudy had a large number of graduates after 1993 anda small number of graduates before 1992. This may
be due to the sampling on Facebook. This makes it
difficult for this study to accurately determine
vaccination trends before 1992. Furthermore, such
sampling resulted in a wider confidence interval for
estimates for graduates before 1992, which yielded
insignificant results. Second, the target group is likely
to have a higher level of vaccination awareness than
general acupuncturists. Of the 778 respondents, weneed to determine the demographics of the 646 who
did not respond to the survey. If most responses werefrom those interested in vaccination, the estimate of
the vaccination proportion may be overestimated.
Third, we adjusted for the graduation education
institutions under the jurisdiction of the MEXT and
those under the jurisdiction of the MHLW. However,
the educational content differs across graduate
schools. Therefore, the confounding bias of graduation
school could not be eliminated. Fourth, because thequestionnaire survey was conducted via the Internet,
we could not reach out to those who did not haveInternet access. This may cause selection bias.
Finally, recall bias is possible because a questionnaire
survey was used, and vaccinators may be more likely
to recall events in detail. This could lead to an
overestimation of the results. In addition, somevaccination-related questions may be difficult toanswer because of a lack of clear memory.
V. Conclusion
Among acupuncturists in Japan, there was a notabledifference in the proportion of hepatitis B
vaccinations based on graduation year. Specifically,
acupuncturists who graduated after 1993 wereapproximately three times more likely to havereceived the hepatitis B vaccination than those who
graduated before 1992. Given the low proportion ofhepatitis B vaccinations, there is an urgent need for13

Nobuyoshi Matsuki et al Japanese Acupuncture and Moxibustion; 2024; Vol.18: 8–14

vaccination recommendations among acupuncturists.
Further studies are warranted to investigate the factorsthat may contribute to varying attitudes towardvaccination among complementary and alternative
medicine practitioners in Japan, especially those who
graduated after 1993.
Acknowledgment
We are grateful to Naoya Hasegawa of the
LCHACC for the questionnaire. We thank Edanz(https://jp.edanz.com/ac) for editing a draft of thismanuscript.
Conflict of interest
No competing financial interests exist.
Funding statement
No funding.
The Japanese version of this manuscript is basedon NM's master's thesis completed at Okayama
University in 2019.
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