Background

• In autumn 2002, a local dermatologist reported 4 cases of Mycobacterium abscessus* skin infection to Toronto Public Health

• All 4 individuals received acupuncture at the same Toronto clinic and had skin lesions at the sites of needle insertion

• Control of this outbreak necessitated a review of the defi nition of a public health hazard and development of innovative public health approaches for a non-regulated profession

* This bacterium rarely causes infection in humans, outbreaks have been associated with injections1

Objectives

An investigation was initiated to:• Determine the extent of the outbreak• Identify infection control risks in an acupuncture setting • Initiate public health action to control this outbreak and prevent future outbreaks

Methods

• Active surveillance and laboratory confi rmation 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 methods for this setting were reviewed

Results

Epidemiological investigation• Of 147 clients visiting the acupuncture clinic between April and December 2002, 32 (21.8%) developed M. abscessus infection• Interviews with clients and the acupuncturist revealed:

• Use of reusable needles • Improper sterilization • Improper needle storage in a container of disinfectant solution prior to insertion

Public health legislation• Acupuncture is regulated in only 3 of 10 Canadian provinces (Figure 1)• Acupuncturists are not regulated health professionals in Ontario

• There are no specifi c training requirements to practice acupuncture in Ontario • There are no acupuncture regulatory guidelines or standards of practice

• Role of public health: • Limited to identifi cation of health hazards through routine inspections of personal

services settings (e.g., tattoo parlours, premises conducting piercings, and acupuncture centres)

• Inspections are recommended by the provincial Personal Services Settings Protocol (PSSP) under the authority of Ontario’s Health Protection and Promotion Act (HPPA)2

• Legal action can only be taken based on existing (observed) health hazards

Public health action• Initial inspection of the acupuncture clinic revealed no ongoing health hazard, no legal authority to close clinic• Legal action taken: • Based on subsequent identifi cation of inadequate infection control practices • HPPA Order to ensure the acupuncturist can only resume practice under proper and ongoing infection control procedures• Clients instructed by public health to visit physician for detection of M. abscessus

skin infection and testing for hepatitis B, C and HIV

Conclusions

• 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

• Lack of licensing requirements for acupuncturists in Ontario resulted in diffi culty identifying other clinics and monitoring their compliance with infection control

As a result of this outbreak:• Public health authorities have advocated for acupuncturists to be regulated health

professionals• Ontario guidelines are being revised to include an acupuncture section focusing on

appropriate infection control • Toronto Public Health is working with schools of traditional Chinese medicine to

improve training on infection control procedures

Recommendations

Toronto Public Health recommends:• Consumer awareness of qualifi cations of those providing acupuncture services and

safe infection control practices• Inclusion of a section in the Ontario’s PSSP detailing requirements for

acupuncture to prevent future outbreaks (Table 1)• Continued advocacy for regulation of acupuncture in Ontario and for

establishment of a supervisory board to ensure standards and oversee qualifi cations

Table 1: Selected recommendations for Ontario’s PSSP• Include specifi c acupuncture section• Disposable needles

• Should be single use, pre-packaged sterile, individually wrapped • Must be opened in front of client• Must be inserted immediately after opening• Should be discarded immediately after use into a sharps container

• 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• Maintain client records for one year

“Getting under your skin: An acupuncture-associated Mycobacterium abscessus outbreak, Canada”Monali Varia1,2 , C. Alterman2, M. Pritchard2, M. Finkelstein2,B. Yaffe2,4, C. Murray4,5, E. Phillips4,5, F. Jamieson3,4, B. Henry2,4

...produced by Instructional Media Centre, Laboratories Branch, 2004

Figure 1: Acupuncture regulations in Canada, 2004

Affi liations: 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

Acupuncture regulatedAcupuncture 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)

Acknowledgments

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.