Tsunematsu Mikako, et al. Japanese Acupuncture and Moxibustion; 2023; Vol.17: 12–18

Original Article

The Influence of Different Hand Hygiene Operations on the Hygiene of
Acupuncture Needles - Including a Comparison of the Influence ofAcupuncturist's Eyesight
TSUNEMATSU Mikako1,2), IMAI Motoyuki3,4), IMAI Kenji1,2)
1) Department of Acupuncture and Moxibustion, Faculty of Health Care, Teikyo Heisei University
2) Institute of Oriental Medicine, Teikyo Heisei University3) Department of Electrical Engineering, Faculty of Engineering, Tokyo University of Science4) Department of Applied Chemistry, Graduate School of Science and Engineering, Hosei University

Abstract[Background] It is important to keep acupuncture needles clean to prevent infections, therefore keeping
acupuncturists' hands clean is also necessary. In Japan, the job of an acupuncturist is not only for sighted people
but also for visually impaired people. Whether visually impaired or not, acupuncture needles should be kept clean.
Objectives: This study aimed to evaluate the condition of pathogenic microorganisms adhering to acupunctureneedles for each hand hygiene condition including differences of acupuncturists' eyesight.
[Methods] The subjects were 10 visually impaired acupuncturists and 12 sighted acupuncturists. The acupuncturists
touched the acupuncture needles with their fingers under four conditions: bare hands before washing their hands,
bare hands after washing their hands and scrubbing, using nitrile gloves without disinfecting their hands and using
nitrile gloves and then swabbing with ethanol. After touching the needles, we incubated the needles using agar
plates and checked for bacterial colony appearance.
[Results] Before hand washing, bacterial colonies were detected on 11 of the 22 acupuncture needles after all
subjects touched them. After washing their hands and scrubbing, bacterial colonies were detected on 4 of the 22
acupuncture needles after all subjects had touched them. Using gloves without disinfecting their hands, bacterialcolonies were detected on only 2 of the 22 acupuncture needles after all subjects touched them. No bacteria weredetected on the acupuncture needles in any subjects when gloves were used and swabbed with ethanol.
Comparison between bare hands before washing their hands and after the three hand hygiene operations showeda difference in colony appearance (P=0.01). Bacterial colony detection patterns did not reveal differences between
visually impaired and sighted acupuncturists.
[Conclusions] Proper hand hygiene operations during acupuncture operations reduce bacterial contamination ofacupuncture needles regardless of the acupuncturists' eyesight.
Key words: hand hygiene operation, hands washing, gloves, disinfection, visually impaired people,
acupuncture needle

I. Introduction
Acupuncture is a treatment method that uses thinacupuncture needles that penetrate the skin and areinserted into the human body. It is important to keep
the medical instruments inserted into the body sterile
to prevent infections1) , and acupuncture needles arealso required. If the acupuncture needles arecontaminated by microorganisms, they may enter thehuman body and cause infections. In the review

papers involving adverse incidents, several infectious
adverse incidents related to acupuncture treatments
have been reported2-4) and they can also become
serious medical conditions.
Sterilized needles are used for acupuncture
treatments. In addition, currently it is common to use
sterile acupuncture needles for single use for
acupuncture treatment. However, there is a possibilityof touching the needles by acupuncturists during
treatments. If the acupuncturist's hands are not clean,

Corresponding author: Tsunematsu Mikako, Department of Acupuncture and Moxibustion, Faculty of Health Care, Teikyo
Heisei University, Higashi-Ikebukuro, Toshima-ku, Tokyo, 170-8445, Japan

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Tsunematsu Mikako, et al. Japanese Acupuncture and Moxibustion; 2023; Vol.17: 12–18

microorganisms may adhere to the needles and enter
the patient's body. Moreover, there is a possibility
that the microorganisms cause infection. Therefore,
keeping
acupuncturist's
hands
clean
duringacupuncture procedures is necessary to keep theacupuncture needles inserted into the patient's bodyclean.
This is because hand hygiene operations such as
washing hands using medical soap, hygienic handrubbing using alcohol-based solutions and using
medical gloves are recommended or mandated invarious guidelines involving acupuncture5-7). If we use
acupuncture needles with clean hands, the acupunctureneedles might be kept clean. Sugawara et al. has
observed Japanese acupuncturists' hand hygiene
behavior during their clinical situation8) . However, it
has not been investigated how the hand hygiene
operations affect the condition of the needles.
In Japan, the job of an acupuncturist is not only forsighted people but also one of the important jobs
historically for visually impaired people9) . For thevisually impaired, touching things with their hands is
an important sensory substitute for sight, and thisaction can sometimes cause their hands to become
dirty. However, even visually impaired acupuncturists
need to keep their fingers clean during theirtreatments. Thus, it is also necessary to confirm thatthe difference in vision status affects hand hygiene
conditions.
This study aimed to evaluate the condition ofpathogenic microorganisms adhering to acupunctureneedles for each hand hygiene condition including
differences of acupuncturists' eyesight.
II．Materials and Methods
The
subjects
were10
visually
impairedacupuncturists, including 7 low vision and 3 totally
blind acupuncturists, and 12 sighted acupuncturists.
The subjects of this study were recruited using two

universities' bulletin boards and mailing lists. The
characteristics of the subjects are described in Table
1. Before the experiment, the subjects were requested
not to wash or disinfect their hands.
The subjects touched the acupuncture needles with
their fingers under four conditions; bare hands before
washing their hands, bare hands after washing theirhands using medical soap and scrubbing with 70%
alcohol-based hand sanitizer, putting on gloves(Glacier zero, Moraine Co., Ltd, Tokyo, Japan)
without disinfecting their hands and putting on nitrile
gloves and then swabbing with 70% ethanol cotton
wipes to disinfect their hands. In hand washing parts,
the subjects wet their hands under running water,
applied soap thoroughly all over their hands, and thenrinsed the soap under running water. After washing,
the subjects dried their hands thoroughly with a single
use towel. In the hand alcohol disinfection parts, thesubjects used one pump of the nozzle of the handsanitizer and applied it thoroughly to their hands,
rubbed it in and until dry.
The subjects ran their fingers over sterilized
acupuncture needles made of stainless steel (0.22×48mm, Nissin Medical Instrument Co., Ltd, Osaka,
Japan) 5 times from the base to tip with their fingers
under the four conditions. Operations under the four
hands conditions were conducted consecutively on thesame day, as shown in Figure 1. The manipulations
were performed in the university acupuncture practiceroom or the university acupuncture office. Although
the subjects and the experimenter did not wear facemasks, they tried to prevent speaking wheneverpossible during the operations.
After touching the acupuncture needles, the subjects
put the needles on soybean casein digest agar plates(Nikken Biology Co., Kyoto, Japan). Those agar
plates were incubated for 24 hours at 37ﾟC. After the
incubation, we checked for the formation of bacterialcolonies on the plates as an indicator of the transfer
of contamination from the subject's hands to theTable 1. Characteristics of the Subjects
The categorical variables are expressed as n (%) and the continuous variables are expressed as mean (SD).

Tsunematsu Mikako, et al. Japanese Acupuncture and Moxibustion; 2023; Vol.17: 12–18

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Figure 1: Flow of The Experimentacupuncture needles. We compared the difference inbacterial colony appearance under the conditions ofbare hands before washing their hands and after three
hand hygiene operations: bare hands after washing
their hands and scrubbing with alcohol-based handsanitizer, putting on nitrile gloves without disinfecting
their hands and putting on nitrile gloves and thenswabbing with ethanol. Bacterial identification tests
were performed when colonies were detected.
Samples were analyzed by the SRL, Inc. using a
Microflex instrument (Bruker, USA) with a matrixassisted laser desorption/ionization time-of-flight mass
spectrometer. In two cases, identification tests could
not be carried out as they were later confirmed byphotographs. Also, we compared the difference ofbacterial colony appearance between visually impaired
and sighted subjects in each of the four hands
conditions.
Comparisons of two categorical variables wereanalyzed using Fisher's exact test. Statisticalsignificance level was set at P<0.05. Data wereanalyzed by using SPSS14.0.
This study was carried out with the approval of the
Ethics Committee of Teikyo Heisei University(Approval No. 29-116).
III. Results
Before washing their hands, bacterial colonies weredetected on 11 of the 22 acupuncture needles after all
subjects touched them. Out of those 10, 5 wereneedles from the 10 visually impaired acupuncturists
and 6 were from the 12 sighted acupuncturists (Table
2).
After washing their hands and scrubbing withalcohol-based hand sanitizer, bacterial colonies weredetected on 4 of the 22 acupuncture needles after all
subjects had touched them. Out of the 4, 2 were fromvisually impaired acupuncturists and 2 were from asighted acupuncturist (Table 2). All four subjects

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Tsunematsu Mikako, et al. Japanese Acupuncture and Moxibustion; 2023; Vol.17: 12–18(Table 1, subject ID: V6, V9, S11 and S12) also hadbacterial colonies detected at the "before handwashing" part of the experiment.
Putting on nitrile gloves without disinfecting theirhands, bacterial colonies were detected on only 2 ofthe 22 acupuncture needles after all subjects touched
them. The two subjects who had the bacteria detectedon their needles were both sighted acupuncturists(Table 2).
Comparison between bare hands before washing theirhands and after the three hand hygiene operations:bare hands after washing their hands and scrubbing
with alcohol-based hand sanitizer, putting on nitrile
gloves without disinfecting their hands and putting on
nitrile gloves and then swabbing with ethanol, showeda statistical difference in colony appearance (P=0.01)(Table 3).
Under the three conditions: before washing theirhands, after washing their hands and scrubbing withalcohol-based hand sanitizer and putting on nitrile
gloves without disinfecting their hands, bacterialcolony detection patterns did not reveal significant
differences between visually impaired and sighted
acupuncturists(P=0.67,
P=0.63
and
P=0.29,respectively) (Table 2).
No bacteria were detected on the acupunctureneedles in any subjects, neither visually impaired
acupuncturists nor sighted acupuncturists when putting
on gloves and then swabbing with ethanol (Table 2).
The isolated colonies from the needles after the
subjects touched the acupuncture needles with theirfingers before washing their hands were shown to be
Coagulase-negative staphylococci (CNS), Bacillus
cereus, Bacillus sp. (excluding Bacillus cereus),
Micrococcus sp. and Glucose non-fermenting gramnegative rod (NF-GNR) (Table 2).
IV. Discussion
Acupuncturist hand hygiene conditions may affectthe acupuncture needle hygiene conditions, thus we
examined the relation between acupuncturist's handhygieneoperations
andacupunctureneedlecontamination situations.
Before washing their hands, bacterial colonies weredetected on half of the acupuncture needles after the
subjects touched the acupuncture needles with theirfingers. This means that in the cases where
acupuncturists use acupuncture needles without proper
hand hygiene operations, bacteria would adhere tonearly half of acupuncture needles. Also, bacteria on
the needles may enter the patients' bodies and cause
infection in the patients.
On the other hand, after washing their hands andscrubbing with alcohol-based hand sanitizer, there
were four cases of bacterial adhesion to theacupuncture needles. Thus, bacterial adhesion fromtheir hands to the acupuncture needles was inhibitedcompared to before washing hands. The four subjects
whose acupuncture needles tested positive for bacteria
after washing their hands and scrubbing with alcoholbased hand sanitizer also tested positive for bacteriaon the needles before washing their hands. Whenlooking at different conditions of the hands, such as
healthy versus damaged, rough hands, it has beenreported that the total bacterial count on hands withdamaged skin was higher than that on healthy
hands10). Also, it has been reported that these states ofhands change the conditions of bacteria microbiota on
the hands10,11) . Although we did not check the handdamage of our subjects, they may have had somecharacteristics as mentioned above, allowing thebacteria to easily adhere to the acupuncture needles
even after washing their hands and scrubbing withalcohol-based hand sanitizer. In addition, there were
two cases of bacterial adhesion to the acupunctureneedle when putting on nitrile gloves without
disinfecting their hands and no cases of bacterial
adhesion to the acupuncture needles putting on nitrile
gloves and then swabbing with ethanol. Results ofcomparison between before washing their hands andafter the three hand hygiene operations showed astatistical difference in colony appearance, leading us
to the conclusion that some proper hand hygiene
operations may effectively inhibit bacterial adhesionto acupuncture needles.
For preventing acupuncture-related infections, someguidelines involving acupuncture recommend that
acupuncturists should wash their hands before
performing acupuncture, and also use gloves whenmore hygienic conditions are required5-7). In this study,
we confirmed that proper hand hygiene operations
inhibit bacterial adhesion to needles and may reduce
acupuncture-related infections.
Nitrile gloves are not completely sterile, thus we set
the condition that the surface of the nitrile glove bedisinfected by 70% ethanol in this experiment.
However, nitrile gloves are not usually disinfectedusing 70% ethanol on the surface. Also, disinfectants
that contain alcohol have been reported to reduce thebreaking load of nitrile gloves12) . Gloves should be
used a single time, and if a break is suspected, a new
glove should be used.
Especially, in needling with tube method, the needle
is pinched by an acupuncturist's fingers on the skin tostabilize, then inserted into the skin with the otherhand. The technique was invented by the Japaneseand made it possible to insert a thinner acupunctureneedle with safety and less pain regardless of vision
status9). However, needling with tube method is also
a technique that requires directly touching theacupuncture needle while inserting it into the bodyTsunematsu Mikako, et al. Japanese Acupuncture and Moxibustion; 2023; Vol.17: 12–18

Table 2. Each Hand Hygiene Conditions of the Subjects and Detection of Bacterial Colonies from the
Acupuncture Needles+: Bacterial colonies detected on acupuncture needles.
-: No bacterial colonies detected on acupuncture needles.
CNS: Coagulase-Negative Staphylococci
NF-GNR: Micrococcus and Glucose Non-Fermenting Gram-Negative Rod
The number of cases of bacterial colonies detected from the needles under each hands condition are given at
the bottom of the table.
The p value indicates the result of comparing the patterns of visually impaired and sighted acupuncturists.

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Tsunematsu Mikako, et al. Japanese Acupuncture and Moxibustion; 2023; Vol.17: 12–18

Table3. Comparison of the number of bacterial colonies from the needles between bare hands before washing theirhands and after the three hand hygiene operations

with the acupuncturist's fingers. Therefore, it ispossible that the condition of the acupuncturist's
hands is strongly related to the hygiene of theneedles. As far as our findings are concerned, if theacupuncturists wash their hands and scrubbing,
especially using gloves, the acupuncture needles canbe kept clean even with needling with tube method.
Although the bacteria isolated in this study weremainly weakly pathogenic and indigenous bacteria,some of the bacteria has a possibility of causing
infections, especially in immunocompromised patientsor elderly people13-16). Albeit not being detected in thisexperiment and causal relationships are not clear insome cases, several acupuncture-related infections
have been reported with Staphylococcus aureus17-21)
and Streptococcus anginosus22) , which can be
indigenous to the skin as well. Some of the patientsin these reports were elderly or immunocompromised17-19, 22) , but others had no underlying diseases20, 21) .
Moreover, these reports also included reports ofserious outcomes such as death17), infectious aortitis18)
and quadriplegia19) . Therefore, in order to provide
hygienicallysafeacupuncturetopatients,
acupuncturists must perform hygienic acupuncture
operations thoroughly.
Regarding the influence of vision status, there were
no differences in bacterial adhesion to the needles
between visually impaired and sighted subjects. Beingan acupuncturist is one the major jobs for visually
impaired people in Japan9). Within the method of thisexperiment, visual impairment did not affectacupuncture hygiene.
Although this experiment was conducted in alaboratory, the subjects almost only touched theacupuncture needles during the experiment. However,in clinical situations, acupuncturists may touch a lotof things other than acupuncture needles, for example

curtains for treatment booths, treatment instruments
like beds and wagons and patients' bodies. Especially,visually impaired acupuncturists may touch things to
confirm the situation around them instead of using
eyesight. Therefore, it is necessary to conduct future
experiments assuming clinical situations in whichpeople have contact with various objects before theneedling operation.
Also, we only checked acupuncture needle hygiene
conditions. We did not check subjects' hand hygiene
conditions, therefore we could not examine the impactof hand hygiene on acupuncture needles' hygiene. In
addition, since this experiment was conducted in theuniversity acupuncture practice room or the university
acupuncture office and subjects and experimenter did
not wear face masks, the possibility cannot be denied
that falling bacteria or bacteria derived from thesubject or experimenter's droplets may have adhered
to the medium. The experiments that take into
consideration
hand
hygieneconditions
andexperiments that are not be affected by external
environments should be conducted in the future.
V. Conclusions
Proper hand hygiene operations, washing hands andscrubbing and usage of clean gloves during
acupuncture treatments suggest to reduce bacteria
contamination of acupuncture needles regardless ofacupuncturists' vision status.
Acknowledgment
The authors would like to thank Yasuyo Yoshizawa
for engaging in useful discussions. We would also
like to thank Molly Sunamoto for carefully
proofreading the manuscript. This work was supported
by MEXT KAKENHI Grant Number JP 17K08927.

Tsunematsu Mikako, et al. Japanese Acupuncture and Moxibustion; 2023; Vol.17: 12–18

Conflict of interest
The authors declare no conflicts
associated with this manuscript.

ofinterest

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