1. “Getting under your skin: An acupuncture-associated
Mycobacterium abscessus outbreak, Canada”
Monali Varia , C. Alterman , M. Pritchard , M. Finkelstein , 1,2 2 2 2
B. Yaffe , C. Murray , E. Phillips , F. Jamieson , B. Henry
2,4 4,5 4,5 3,4 2,4
Affiliations: 1. Canadian Field Epidemiology Program, Health Canada, Ottawa, Canada 2. Toronto Public Health, Toronto, Canada 3. Central Public Health Laboratory, Toronto, Canada 4. University of Toronto, Toronto, Canada 5. Sunnybrook and Women’s College Health Sciences Centre, Toronto, Canada
Background
• In autumn 2002, a local dermatologist reported 4 cases of Mycobacterium abscessus * Public health action
skin infection to Toronto Public Health • Initial inspection of the acupuncture clinic revealed no ongoing health hazard,
• All 4 individuals received acupuncture at the same no legal authority to close clinic
Toronto clinic and had skin lesions at the sites of needle • Legal action taken:
insertion • Based on subsequent identification of inadequate infection control practices
• Control of this outbreak necessitated a review of the • HPPA Order to ensure the acupuncturist can only resume practice under proper
definition of a public health hazard and development of and ongoing infection control procedures
innovative public health approaches for a non-regulated • Clients instructed by public health to visit physician for detection of M. abscessus
profession skin infection and testing for hepatitis B, C and HIV
*
This bacterium rarely causes infection in humans,
outbreaks have been associated with injections1 Table 1: Selected recommendations for Ontario’s PSSP
• Include specific acupuncture section
• Disposable needles
• Should be single use, pre-packaged sterile, individually wrapped
Objectives
• Must be opened in front of client
An investigation was initiated to: • Must be inserted immediately after opening
• Determine the extent of the outbreak
• Should be discarded immediately after use into a sharps container
• Identify infection control risks in an acupuncture setting
• Initiate public health action to control this outbreak and prevent future outbreaks • Cannot be re-used, either on same client or another client
• Wash hands before and after glove use
• Wear new disposable gloves for each client
Methods • Maintain client records for one year
• Active surveillance and laboratory confirmation of symptomatic cases was conducted
for clients who attended the clinic between April to December 2002
• Public health legislation on the regulation of acupuncture and optimal infection control Conclusions
methods for this setting were reviewed
• This outbreak was detected due to a cluster of cases of an unusual organism,
other infections caused by more common organisms such as S. aureus may go
undetected
Results
• Lack of licensing requirements for acupuncturists in Ontario resulted in difficulty
identifying other clinics and monitoring their compliance with infection control
Epidemiological investigation
• Of 147 clients visiting the acupuncture clinic between April and December 2002, As a result of this outbreak:
32 (21.8%) developed M. abscessus infection • Public health authorities have advocated for acupuncturists to be regulated health
• Interviews with clients and the acupuncturist revealed: professionals
• Use of reusable needles • Ontario guidelines are being revised to include an acupuncture section focusing on
• Improper sterilization appropriate infection control
• Improper needle storage in a container of disinfectant solution prior to insertion • Toronto Public Health is working with schools of traditional Chinese medicine to
improve training on infection control procedures
Public health legislation
• Acupuncture is regulated in only 3 of 10 Canadian provinces (Figure 1)
• Acupuncturists are not regulated health professionals in Ontario Recommendations
• There are no specific training requirements to practice acupuncture in Ontario
Toronto Public Health recommends:
• There are no acupuncture regulatory guidelines or standards of practice
• Consumer awareness of qualifications of those providing acupuncture services and
• Role of public health:
safe infection control practices
• Limited to identification of health hazards through routine inspections of personal
• Inclusion of a section in the Ontario’s PSSP detailing requirements for
services settings (e.g., tattoo parlours, premises conducting piercings, and
acupuncture to prevent future outbreaks (Table 1)
acupuncture centres)
• Continued advocacy for regulation of acupuncture in Ontario and for
• Inspections are recommended by the provincial Personal Services Settings Protocol
establishment of a supervisory board to ensure standards and oversee
(PSSP) under the authority of Ontario’s Health Protection and Promotion Act
qualifications
(HPPA)2
• Legal action can only be taken based on existing (observed) health hazards
Acknowledgments
Figure 1: Acupuncture regulations in Canada, 2004 We thank the Public Health Branch, Ontario Ministry of Health and Long-Term Care
and all health units involved in the outbreak investigation, H. Rowe for assistance
with the database and L. Panaro, CFEP Program Director.
Acupuncture regulated
Acupuncture not regulated
References
1. Trupiano J.K., Sebek B.A., Goldfarb J., Levy L.R.,
Hall G.S., Procop G.W.
Mastitis due to Mycobacterium abscessus after body piercing
Clinical Infectious Diseases 2001; 33:131-4.
2. Health Protection and Promotion Act, R.S.O. 1990, c.H.7
(revised July 24, 1998)
...produced by Instructional Media Centre, Laboratories Branch, 2004