Acupuncture-Related Needlestick Injuries Among Healthcare Workers in China: A Multicenter Cross-Sectional Study

Abstract

Background

Needlestick injuries (NSIs) are a major occupational hazard for healthcare workers, but evidence on acupuncture-related NSIs remains limited.

Methods

A multicenter cross-sectional survey was conducted among acupuncture physicians, students, and nurses across 10 provinces in China from February to July 2025. Past-year and lifetime NSI prevalence, severe NSI prevalence, and blood-exposure NSI prevalence were estimated. Incidence density was calculated as the number of injuries per 1000 person-years. Multivariable logistic regression was used to identify factors associated with past-year NSI occurrence and non-reporting.

Results

A total of 2147 participants were included. Past-year and lifetime NSI prevalence were 40.71% and 55.43%. Physicians had the highest past-year prevalence (49.22%), followed by students (43.19%) and nurses (17.42%). The overall incidence density was 998.14 per 1000 person-years. Acupuncture needles were the most frequently implicated device (85.38%), and needle removal was the most common injury scenario (71.34%). Only 24.12% of participants always reported NSIs, while 34.96% never reported any NSI. Training was associated with reduced NSI risk and reduced non-reporting behavior. Hepatitis B vaccination coverage remained suboptimal, particularly among students.

Conclusion

Acupuncture-related NSIs are frequent and substantially underreported in China. Occupation-specific training, strengthened controls for high-risk workflows, higher vaccination coverage, and improved reporting systems are needed.

Introduction

Needlestick injuries (NSIs) occur when healthcare workers accidentally pierce their skin with sharps and serve as a primary route for blood-borne infections.¹ Healthcare workers (HCWs) face inherent vulnerability due to frequent exposure to sharp objects.^2,3 NSIs have accounted for 39%, 37%, and 4.4% of hepatitis C, hepatitis B, and HIV infections among HCWs.⁴ Epidemiological data indicate that, after a percutaneous exposure to infected blood, the average risk of infection is about 3% for hepatitis C, 30% for hepatitis B in susceptible persons, and 0.3% for HIV.⁵ Beyond physiological risks, these injuries cause psychological distress, including post-traumatic stress disorder,⁶ reduce job satisfaction⁷ and impose a substantial health-economic burden.⁸

Systematic review reports an exposure risk between 46.4% and 59.1% for nurses, physicians, and dentists.⁹ Common risk factors include inadequate training, excessive workloads, and poor safety awareness, with injuries typically occurring during instrument preparation or needle recapping.^6,10 NSI prevalence can be reduced through institutional programs addressing behavioral and device-related causes,¹¹ while adherence to standard infection prevention and control (IPC) precautions prevents 70% of associated healthcare-acquired infections.¹²

Acupuncture is a widely used non-pharmacological therapy used across diverse clinical domains,¹³ including pain management,^14,15 mental health,¹⁶ endocrine and metabolic,^17,18 and cardiovascular disorders.¹⁹ The 2019 WHO Global Report indicates its use in 183 countries,²⁰ with nearly one million licensed practitioners in China alone.²¹ The repetitive nature of acupuncture insertion with minimal safety-engineered design features may increase occupational injury risk beyond that of standard drug delivery. To date, only one survey with limited sample size revealed that 34.3% of acupuncture physicians, technicians, and nurses experienced needlestick injuries over the past three years, yet 46.0% of these incidents went unreported.²² Large-scale multicenter evidence across diverse occupational groups and healthcare settings remains lacking, particularly regarding NSI burden, injury details, and post-exposure management. Further evidence is needed to inform the development of targeted prevention strategies for acupuncture-related HCWs.

This cross-sectional study aimed to assess the prevalence, injury circumstances, and post-exposure management of acupuncture-related NSIs among physicians, students, and nurses in China, and to identify factors associated with NSI occurrence and reporting behavior.

Methods

Study Design and Participants

A multicenter, cross-sectional survey was conducted from February to July 2025 across 10 provinces in China, encompassing 9 Traditional Chinese Medicine universities, 13 hospitals, and 15 primary healthcare institutions. Data were collected via Wenjuanxing (Questionnaire Star), a widely used online survey platform in China. To ensure data quality, the questionnaire was distributed by trained investigators at each center via a standardized QR code. Each participant was allowed to submit the questionnaire only once.

Eligibility criteria included licensed acupuncture physicians, nursing staff working within acupuncture departments, and acupuncture students enrolled in government-accredited training programs. Individuals who had only received short-term, informal acupuncture training were excluded.

The study adhered to the Declaration of Helsinki and was approved by the Ethics Committee of the Affiliated Hospital of Shandong University of Traditional Chinese Medicine (Approval No. 2025-Lunshen-001-QT). Written informed consent was obtained from all participants. Findings are reported in alignment with the Checklist for Reporting of Survey Studies (CROSS).²³

Sample Size Calculation

We employed purposive sampling to recruit participants. The required sample size was determined using the standard formula for cross-sectional studies:

Based on a significance level α = 0.05 (u = 1.96), an allowable error δ = 0.05, and the expected acupuncture NSI prevalence π = 34.3% based on a published literature in China,²² the calculated requirement was 347 participants. To ensure adequate statistical power for subgroup comparisons, this threshold was applied to each of the three cohorts (physicians, students, and nurses), yielding a total target sample size of at least 1041.

Survey Instrument

The study instrument was developed based on existing NSI survey domains identified in previous studies concerning physicians, nurses, and dentists,^24–26 as well as established occupational safety guidelines.^27,28 The items and responses were adjusted to reflect acupuncture clinical practice. A group including acupuncture doctors, students, and nurses, reviewed the draft for validity and feasibility. The questionnaire consists of five domains: socio-demographics; lifetime and past 12-month NSI prevalence, including types of sharps and injury scenarios; contributing risk factors; post-exposure management; and training and vaccination status.

Past-year NSI was defined as experiencing at least one acupuncture-related needlestick injury during the preceding 12 months, and injury frequency was also recorded. Lifetime NSI was defined as having experienced at least one acupuncture-related needlestick injury at any time during the participant’s clinical practice or training. For lifetime events, severe NSI was defined as a deep puncture or cut with profuse bleeding, and blood-exposure NSI was defined as an injury involving a contaminated sharp, based on the EPINet Report for Needlestick and Sharp Object Injuries criteria.²⁹

Statistical Analysis

Statistical analysis was performed using R version 4.3.2. Continuous variables were expressed as means and standard deviations, while categorical data were presented as frequencies and percentages. Group differences were compared using chi-square tests. Incidence density was estimated as the number of injuries per 1000 person-years, with exact Poisson confidence intervals, and between-group differences were assessed using negative binomial regression with likelihood ratio tests. Multivariable logistic regression was conducted to identify factors associated with needlestick injuries. Two-sided P-values < 0.05 were considered statistically significant.

Results

Demographic Characteristics

A total of 2147 participants were included, with a mean age of 30.18 ± 8.61 years, of whom 1442 (67.16%) were female. The sample comprised 638 physicians (29.72%), 1153 students (53.70%), and 356 nurses (16.58%). Physicians were mainly residents (301, 47.18%) and attending physicians (230, 36.05%). Most students were master’s students (635, 55.07%). Among nurses, nurses-in-charge accounted for the largest proportion (127, 35.67%). Physicians and nurses were primarily from tertiary hospitals (584, 58.75%), followed by primary (234, 23.54%) and secondary hospitals (176, 17.71%) (Table 1).

Table 1.

Baseline Characteristics of Study Participants

Characteristic	N = 2147
Age	30.18 (8.61)
Gender
Male	705 (32.84%)
Female	1442 (67.16%)
Occupation
Students	1153 (53.70%)
Physicians	638 (29.72%)
Nurses	356 (16.58%)
Students Educational Level
Undergraduate	411 (35.65%)
Master’s	635 (55.07%)
PhD	107 (9.28%)
Physician Title
Resident	301 (47.18%)
Attending	230 (36.05%)
Associate Chief Physician	86 (13.48%)
Chief Physician	21 (3.29%)
Nurse Title
Nurse	106 (29.78%)
Senior Nurse	93 (26.12%)
Nurse-in-Charge	127 (35.67%)
Associate Chief Nurse	27 (7.58%)
Chief Nurse	3 (0.84%)
Hospital Level
Primary Hospital	234 (23.54%)
Secondary Hospital	176 (17.71%)
Tertiary Hospital	584 (58.75%)

Notes: Hospital level data are reported for physicians and nurses only (n = 994); students were not affiliated with a specific hospital.

Prevalence of Acupuncture-Related NSIs

Overall, 40.71% of participants (874/2147) reported a past-year NSI, with 43.55% in males and 39.32% in females. Past-year NSI prevalence differed significantly across occupational groups (P < 0.001): physicians 49.22% (314/638), students 43.19% (498/1,153), and nurses 17.42% (62/356). Among students, past-year NSI prevalence was highest among master’s students (337/635, 53.07%), followed by PhD candidates (39/107, 36.45%) and undergraduates (122/411, 29.68%; P < 0.001). Prevalence did not vary by professional title among physicians (P = 0.517) or nurses (P = 0.604) but was highest in secondary hospitals (48.30%; P = 0.007) (Table 2 and Figure 1).

Table 2.

Incidence of Lifetime, Past-year, Severe, and Blood-Borne Needlestick Injuries by Participant Characteristics

Characteristic	Past-Year NSI	P	Lifetime NSI	P	Lifetime Severe NSI	P	Lifetime Bloodborne NSI	P
Overall	874 (40.71%)		1190 (55.43%)		21 (0.98%)	-	764 (35.58%)
By Gender		0.068		0.022		0.454		0.320
Male	307 (43.55%)		416 (59.01%)		9 (1.28%)		240 (34.04%)
Female	567 (39.32%)		774 (53.68%)		12 (0.83%)		524 (36.34%)
By Occupation		<0.001		<0.001		0.542		<0.001
Students	498 (43.19%)		609 (52.82%)		9 (0.78%)		375 (32.52%)
Physicians	314 (49.22%)		440 (68.97%)		7 (1.10%)		297 (46.55%)
Nurses	62 (17.42%)		141 (39.61%)		5 (1.40%)		92 (25.84%)
By Students Educational Level		<0.001		<0.001		0.119		<0.001
Undergraduate	122 (29.68%)		137 (33.33%)		6 (1.46%)		85 (20.68%)
Master’s	337 (53.07%)		404 (63.62%)		2 (0.31%)		253 (39.84%)
PhD	39 (36.45%)		68 (63.55%)		1 (0.93%)		37 (34.58%)
By Physician Title		0.517		0.092		0.182		0.446
Resident	148 (49.17%)		194 (64.45%)		5 (1.66%)		131 (43.52%)
Attending	116 (50.43%)		166 (72.17%)		0 (0.00%)		116 (50.43%)
Associate Chief Physician	43 (50.00%)		66 (76.74%)		2 (2.33%)		41 (47.67%)
Chief Physician	7 (33.33%)		14 (66.67%)		0 (0.00%)		9 (42.86%)
By Nurse Title		0.604		<0.001		0.743		0.059
Nurse	20 (18.87%)		28 (26.42%)		1 (0.94%)		20 (18.87%)
Senior Nurse	19 (20.43%)		39 (41.94%)		2 (2.15%)		27 (29.03%)
Nurse-in-Charge	17 (13.39%)		54 (42.52%)		1 (0.79%)		33 (25.98%)
Associate Chief Nurse	5 (18.52%)		19 (70.37%)		1 (3.70%)		12 (44.44%)
Chief Nurse	1 (33.33%)		1 (33.33%)		0 (0.00%)		0 (0.00%)
By Hospital Level		0.007		<0.001		0.354		<0.001
Primary Hospital	82 (35.04%)		113 (48.29%)		2 (0.85%)		67 (28.63%)
Secondary Hospital	85 (48.30%)		115 (65.34%)		4 (2.27%)		80 (45.45%)
Tertiary Hospital	209 (35.79%)		353 (60.45%)		6 (1.03%)		242 (41.44%)

Figure 1.

Prevalence of lifetime, past-year, severe, and blood-exposure acupuncture-related NSIs across occupational groups.

Regarding lifetime exposure, 55.43% of participants (1190/2147) reported having experienced at least one NSI, 21 (0.98%) reported severe NSIs, and 764 (35.58%) reported blood-exposure NSIs. Lifetime NSI prevalence was highest among physicians (440/638, 68.97%), followed by students (609/1153, 52.82%) and nurses (141/356, 39.61%). Severe NSIs were most frequently reported by nurses (5/356, 1.40%), followed by physicians (7/638, 1.10%) and students (9/1153, 0.78%). Lifetime blood-exposure NSIs were reported by 297 physicians (46.55%), 375 students (32.52%), and 92 nurses (25.84%) (Table 2 and Figure 1).

Incidence Density of Acupuncture-Related NSIs

The incidence density of acupuncture-related NSIs was 998.14 per 1000 person-years (95% CI: 956.32–1041.31). Significant differences were observed across occupational groups (P < 0.001), with the highest incidence density among physicians (1235.11 per 1000 person-years), followed by students (1085.00 per 1000 person-years) and nurses (292.13 per 1000 person-years) (Supplementary Table 1 and Figure 2).

Figure 2.

Incidence density of acupuncture-related NSIs across occupational groups.

Factors Associated with Acupuncture-Related NSIs

In the overall multivariable logistic regression model, compared with students, nurses showed a significantly lower risk of NSIs (OR = 0.26, 95% CI: 0.18–0.37; P < 0.001). Training status was significantly associated with a lower risk of NSIs (OR = 0.75, 95% CI: 0.62–0.91; P = 0.003) (Figure 3).

Figure 3.

Multivariable logistic regression analysis of factors associated with past-year acupuncture-related NSIs and unreported incidents.

Notes: Dashes indicate that the odds ratio (OR) could not be calculated due to zero events or insufficient sample size in the specific cell.

Abbreviations: OR, odds ratio; CI, confidence interval.

In subgroup analyses, among students, older age was associated with increased NSI risk (OR = 1.11, 95% CI: 1.05–1.18; P < 0.001), and master’s-level students showed higher risk than undergraduates (OR = 1.85, 95% CI: 1.34–2.55; P < 0.001). Among physicians, training was associated with reduced risk (OR = 0.51, 95% CI: 0.35–0.73; P < 0.001). Among nurses, working in secondary hospitals was associated with higher risk than tertiary hospitals (OR = 3.45, 95% CI: 1.47–7.94; P = 0.004) (Figure 3).

Acupuncture-Related NSIs Details

Acupuncture-related NSIs details were collected from 1190 participants with lifetime NSIs (Supplementary Table 2). Acupuncture needles were the most frequently implicated devices (1016/1190, 85.38%), followed by hypodermic needles (283/1190, 23.78%), lancets (218/1190, 18.32%), and broken cupping jars (67/1190, 5.63%). Acupuncture needles predominated among physicians (92.73%) and students (92.61%), while hypodermic needles (66.67%) and lancets (41.13%) were more frequent among nurses. In terms of injury scenarios, needle removal was the most commonly reported circumstance (849/1190, 71.34%), followed by disposal into a sharps container (301/1190, 25.29%), returning needles to the package (281/1190, 23.61%), and passing needles (280/1190, 23.53%).

Among contributing factors, distraction due to other tasks (544/1190, 45.71%), time pressure (469/1190, 39.41%), and uncomfortable working posture (418/1190, 35.13%) were most frequently reported, followed by insufficient workspace (266/1190, 22.35%) and a cluttered working environment (231/1190, 19.41%).

Post-Exposure Management and Reporting Behaviors

Post-exposure measures and reporting behaviors, assessed using a 5-point Likert scale (never to always), are demonstrated in Supplementary Table 3. Most participants reported that they always performed immediate wound cleaning and bleeding promotion (968/1190, 81.34%) and applied wound disinfectants (906/1190, 76.13%). Adherence to professional medical consultation (509/1190, 42.77%) and testing for blood-borne pathogens (458/1190, 38.49%) remained relatively low across all groups. Additionally, 12.61% (150/1190) reported always taking no post-exposure action.

Injury reporting frequency differed significantly across occupational groups (P < 0.001). Overall, only 24.12% (287/1190) always reported their NSIs, while 34.96% (416/1190) never did, with the highest never-reporting rate among students (38.42%, 234/609). Training was the only factor consistently associated with reduced never-reporting (Overall: OR 0.32, 95% CI 0.25–0.42; Students: OR 0.32, 95% CI 0.23–0.45; Physicians: OR 0.34, 95% CI 0.22–0.52; all P < 0.001), though no significant association was identified among nurses (Figure 3).

The most frequently cited factor for not reporting was considering the injury minor (392/1190, 32.94%). Other major barriers included being certain the patient had no infectious disease (271/1190, 22.77%), not knowing how to report (217/1190, 18.24%), and being too busy at the time of injury (207/1190, 17.39%). The reporting process being too cumbersome or time-consuming (196/1190, 16.47%) also contributed to underreporting.

Occupational Protection

Overall, 67.82% (1456/2147) of participants reported having received occupational protection training, being highest among nurses (333/356, 93.54%), followed by physicians (465/638, 72.88%) and students (658/1153, 57.07%). Among the training components, theoretical knowledge of NSI risks was the most frequently covered (1408/1456, 96.70%), followed by practical needle handling guidance (1303/1456, 89.49%) and post-injury emergency protocols (1292/1456, 88.74%), while training on reporting procedures and legal requirements was less commonly provided (917/1456, 62.98%) (Table 3).

Table 3.

Occupational Protection Status of Acupuncture-Related HCWs

Category	Subcategory	Total (N=2147)	Students (N=1153)	Physicians (N=638)	Nurses (N=356)	P Value
Received Training	Yes	1456 (67.82)	658 (57.07)	465 (72.88)	333 (93.54)	<0.001
	No	691 (32.18)	495 (42.93)	173 (27.12)	23 (6.46)
Training Content	Theoretical knowledge of NSI risks	1408 (96.70)	629 (95.59)	453 (97.42)	326 (97.90)	0.091
	Practical needle handling guidance	1303 (89.49)	553 (84.04)	434 (93.33)	316 (94.89)	<0.001
	Post-injury emergency protocols	1292 (88.74)	535 (81.31)	438 (94.19)	319 (95.80)	<0.001
	Reporting procedures and legal requirements	917 (62.98)	294 (44.68)	338 (72.69)	285 (85.59)	<0.001
Hepatitis B Vaccination	Fully vaccinated	1659 (77.27)	836 (72.51)	521 (81.66)	302 (84.83)	<0.001
	Partially vaccinated	200 (9.32)	115 (9.97)	61 (9.56)	24 (6.74)
	Not vaccinated	288 (13.41)	202 (17.52)	56 (8.78)	30 (8.43)

As for hepatitis B vaccination, 77.27% (1659/2147) of participants were fully vaccinated, while 9.32% (200/2147) were partially vaccinated and 13.41% (288/2147) remained unvaccinated. Students had the lowest full vaccination rate (836/1153, 72.51%) (Table 3).

Discussion

This large multicenter study provides epidemiological evidence on NSIs among acupuncture-related HCWs in China, a population underrepresented in occupational health research. Acupuncture-related NSIs were frequent, with 40.71% reporting at least one event in the past year and 55.43% reporting lifetime exposure.

Our observed past-year NSI prevalence among acupuncture physicians (49.22%) exceeded that reported in prior acupuncture-specific research (34.3%)²² and in general physician populations from Chinese hospital-based studies (31.05%), and was also higher than estimates reported for surgical-department healthcare workers (43.22%),³⁰ a group typically considered at high occupational risk for NSIs. For acupuncture students, the past-year NSI prevalence was 43.19% overall and 53.07% among master’s students, which were higher than the pooled prevalence reported for nursing students overall (35%) and for Asian nursing students (39.7%).³¹ The corresponding past-year prevalence among acupuncture nurses was 17.42%, lower than the pooled 1‑year NSI prevalence of 40.97% reported for nurses worldwide.³² A meta-analysis of worldwide occupational needle-stick exposure estimated a 1‑year pooled NSI prevalence of 32.4% across all healthcare workers³³ and a 1‑year prevalence of approximately 35.7% in developing countries.³⁴ Taken together, acupuncture physicians and students demonstrated a higher past-year NSI prevalence than typically reported for physicians in general clinical settings, while acupuncture nurses exhibited a notably lower prevalence than the worldwide average for nurses.

In line with the prevalence findings, the overall incidence density of acupuncture-related NSIs in our cohort was 998.14 per 1000 person-years (1235.11 per 1000 person-years among physicians), higher than the pooled self-reported sharps-injury incidence of 88.2 per 100 person-years reported for surgical units.³⁵ The NSI burden among acupuncture physicians and students likely reflects specialty-specific workflow in which acupuncture needles are the primary treatment tool, and each session involves repeated insertion and removal, resulting in frequent sharps exposure. Importantly, the design of acupuncture needles makes safety-engineered modifications less feasible in routine practice, a key measure for reducing NSI risk in other clinical sharps.³⁶ By contrast, nurses in acupuncture settings more often assist with needle removal and routine care than perform most needling procedures, unlike ward nurses who frequently administer injections. This difference was reflected in the injury profile, with nurse injuries more often involving hypodermic needles (66.67%) and lancets (41.13%) and less often involving acupuncture needles (31.21%), whereas injuries among physicians and students more often involved acupuncture needles (92.73% and 92.61%, respectively). Needle removal was the most common injury circumstance across all groups, but its proportion was lower among nurses. This finding is consistent with routine acupuncture practice, particularly among physicians and students, in whom needle removal is repeated multiple times for each patient and often performed in rapid succession, increasing opportunities for handling errors. Similar task‑ and device‑dependent patterns have been reported in other settings.³⁷ Occupation-specific prevention strategies and training priorities should be implemented across professional groups.

Reporting NSIs is a critical prerequisite for occupational protection, because source testing and post-exposure prophylaxis are typically initiated only after an exposure is reported. In our cohort, 34.96% of respondents reported never reporting any NSI, which was lower than the pooled non-reporting proportion of 63% among nursing students in a meta-analysis³¹ but higher than that in another large multicenter survey in China (28.53%).³⁰ The most frequently cited reason for non-reporting was the perception that the injury was minor, consistent with previous reports that perceived low severity is a major reason for underreporting.³⁸ Current occupational exposure guidelines consider any percutaneous injury involving blood or other potentially infectious body fluids to be clinically relevant and to require standard post-exposure management, regardless of apparent wound severity.³⁹ Accordingly, even seemingly minor needlestick injuries should not be treated as negligible events. In line with previous studies,^38,40 lack of reporting knowledge and the perception that reporting is too time‑consuming also emerged as important barriers in our cohort.

Although most participants reported consistently performing immediate wound cleansing and disinfection after NSIs, fewer than half “always” sought professional medical consultation or underwent testing for blood-borne pathogens, with 12.61% of participants reporting that they always took no post-exposure action. These findings fall short of current US Public Health Service and WHO recommendations,^39,41 which state that any percutaneous exposure to blood or other potentially infectious body fluids in healthcare personnel should trigger formal occupational health evaluation, consideration of post-exposure prophylaxis, and baseline and follow-up serologic testing, in addition to local wound care.

Underreporting and suboptimal post-exposure management highlight the need for occupational safety training. The Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard emphasizes that occupational training for healthcare workers with potential blood exposure should at least explain how bloodborne pathogens are transmitted, how to recognize exposure‑prone tasks, and what steps to take after an exposure, including prompt reporting and seeking evaluation.⁴² Training was linked to lower NSI risk overall and among physicians, and to less non-reporting overall and among physicians and students, as shown in our analyses, although these findings should be interpreted cautiously given the cross-sectional design and potential self-reporting bias. Recent knowledge–attitude–practice (KAP) evidence among acupuncture physicians and medical students similarly suggests that training is critical for translating awareness into safer occupational practices.⁴³ Both observational and intervention studies have shown that nurses who receive structured training on NSI prevention and post-exposure management have lower NSI rates and better reporting practices.^2,44 In acupuncture-related HCWs, reporting procedures and legal requirements were the least covered training components, and these areas should be strengthened further.

Hepatitis B remains a major occupational hazard for healthcare personnel,⁴⁵ as HBV is the most efficiently transmitted blood-borne pathogen after occupational exposure, and hepatitis B vaccination is recommended for all healthcare workers as pre-exposure prophylaxis.⁴⁶ In our study, 77.27% of participants were fully vaccinated; coverage was lowest among students (72.51%), who also had the highest unvaccinated proportion (17.52%). A national survey of Chinese healthcare workers reported complete hepatitis B vaccination in 60% of staff,⁴⁷ and a recent global meta-analysis estimated that 44.8% of nurses worldwide had completed the full hepatitis B vaccine series.⁴⁸ Overall, vaccination coverage in acupuncture-related HCWs appears relatively high, but improvement is still needed, particularly among students.

Additionally, several subgroup findings are notable. Among students, master’s level and older age were both associated with higher NSI risk, partly reflecting collinearity between age and education level. Notably, master’s students had a higher past-year NSI prevalence than physicians, indicating increased clinical workload during master’s training combined with limited early-stage procedural experience. Among nurses, the higher risk observed in secondary hospitals may be related to heavier workload and occupational stress in some settings. Prior evidence from China suggests that nurses in certain secondary hospitals, particularly 2A institutions, can experience work-pressure levels comparable to those in tertiary hospitals, potentially increasing procedural error risk.⁴⁹ However, given the relatively lower NSI burden in nurses, this finding should be interpreted cautiously and confirmed in further studies. Importantly, blood-exposure NSIs among acupuncture physicians represent a priority occupational safety concern, given their direct blood-borne transmission risk and the high lifetime prevalence in our cohort (46.55%), particularly in outpatient settings where pre-visit pathogen status is often unknown.

In summary, our multicenter findings show a high NSI burden in acupuncture practice, particularly among physicians and students, substantial underreporting, and untargeted post-exposure management. Accordingly, we recommend the following: (1) implement occupation-specific training, with separate modules for physicians, students, and nurses, and mandatory content on reporting procedures and post-exposure management; (2) strengthen high-risk workflow controls, including standardized needle-removal procedures, appropriate sharps handling, and point-of-use sharps containers for safe disposal; (3) improve hepatitis B vaccination coverage, particularly among students; and (4) simplify and reinforce reporting systems so that every acupuncture‑related NSI reliably triggers structured evaluation and, when indicated, post‑exposure prophylaxis. We also recommend conducting similar surveys in other countries as soon as feasible to generate comparative evidence and inform occupational protection strategies for acupuncture-related HCWs globally.

Several limitations should be acknowledged. First, the cross-sectional design precludes causal inference. Second, self-reported data may be affected by recall bias, particularly for lifetime NSI estimates. Third, because occupational groups were recruited using purposive sampling rather than in proportion to their true workforce distribution, pooled prevalence estimates are not population-weighted and should be interpreted cautiously.⁵⁰ Therefore, within-group estimates are more informative for interpretation. Finally, social desirability bias may have led to overreporting of post-exposure practices and underreporting of injuries,⁵¹ and the true burden of NSIs may accordingly be higher than our estimates suggest. Although these findings can help inform occupational safety practice, they should be considered exploratory. Prospective multicenter studies with real-time injury recording are needed to further validate the current evidence.

Conclusion

Acupuncture-related NSIs were common, with the highest burden observed among physicians and students. Underreporting was substantial, and post-exposure management was often incomplete. Training was associated with lower NSI risk and better reporting behavior. Occupation-specific safety training, strengthened high-risk workflow controls, improved hepatitis B vaccination coverage, and more consistent reporting and post-exposure evaluation are needed. Further prospective evidence is needed to provide a more precise and comprehensive characterization of acupuncture-related NSIs.

Funding Statement

This work was supported by the Taishan Scholar Program (Grant No. tsqn202312376).

Data Sharing Statement

The datasets generated during and/or analyzed during the current study are available from the corresponding authors, Jing Han and Huafeng Cui, upon reasonable request.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

Dr Jing Han reports Support for the manuscript from Taishan Scholar Program, during the conduct of the study. The authors have no competing interests to declare.