A cross-sectional online study was conducted at 98 hospitals of various levels (primary, secondary, and tertiary) across 21 cities in southwest China, covering a diverse range of acupuncture practitioners, from April to May 2024. A convenience sampling method was adopted to recruit all eligible participants who met the following criteria: (1) age ≥ 18, (2) having practiced acupuncture therapy for at least six months, (3) able to complete the questionnaire survey with normal mental and cognitive function, and (4) voluntary participation in this study. Participants with NSI that occurred beyond the study period (over three years prior to data collection) were excluded from the study.

The sample size was determined using a single population proportion formula: n = u a / 2 2 π 1 − π δ 2 , which is commonly used in cross-sectional studies to calculate sample sizes (4). Here, a was 0.05, u was 1.96, π was 50%, and δ was 0.05, leading to a minimal sample size requirement of 384. Considering potential participant rejection and invalid questionnaires, we further expanded our sample size to a larger number. A total of 601 participants completed questionnaires, among whom 23 provided invalid questionnaires and thus were removed from the analysis, leading to a final sample of 578 (effective response rate: 96.17%). The study is reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Ethical approval was obtained from the Institutional Review Board of Zigong First People’s Hospital (No. 2024093). Data were collected through Sojump, one of the largest and most popular online survey platforms in China (26). Prior to the survey, study flyers were sent to the directors of the Infection Prevention and Control Departments from 98 hospitals via WeChat, the most commonly used social media platform in China. The directors then arranged for the eligible acupuncture practitioners to complete the survey. Those who were interested in this study could scan the QR code on WeChat to complete the survey after providing electronic informed consent. Participants were informed that no personal identification information was collected and that they could withdraw at any time. To ensure data completeness, the survey could only be submitted after it was fully completed. To avoid duplicate questionnaires, each smartphone or computer ID could only be used to submit the survey once.

A researcher-designed questionnaire based on the literature, policies, and guidelines related to occupational exposure was used as the primary survey instrument in this study (27, 28). The final version of the questionnaire was determined based on feedback from experts in this field. The questionnaire comprises four parts. The first part includes participants’ general information, such as gender, age, education level, working years, profession, professional title, and hospital level. It also incorporates questions related to hepatitis B vaccine and serological status. The second part consists of 16 questions on knowledge and behaviors related to occupational protection. This section starts with occupational protection training, including whether participants have received training, the last time of training, and the way of knowledge acquisition. Additionally, it includes questions regarding the definitions of occupational exposure and standard prophylaxis, transmission routes of bloodborne pathogens, and preventive measures.

The third section focuses on the risk assessment of occupational exposure, comprising four questions that examine participants’ perceptions of the probability, severity, and coping ability associated with such exposure. Finally, participants who have experienced NSI were also required to complete the fourth section, which comprises ten questions related to the epidemiological characteristics of these injuries. These include the frequency of the injury, the type of acupuncture needle causing the injury, the place of the injury, the procedure/task during which the injury occurred, etc.

All data were analyzed using IBM SPSS Statistics 24. Frequencies and percentages were used to describe categorical variables. Pearson chi-square tests were utilized to examine differences among various groups. A multivariate logistic regression analysis was performed to investigate the associations between sample characteristics and NSI and identify independent factors associated with NSI. The model was selected based on its ability to assess multiple independent variables simultaneously and to identify factors that may not be apparent in bivariate analysis. To enhance the model’s accuracy, the following steps were taken: (1) potential confounding variables were identified and included in the model, (2) a backward elimination procedure was employed to ensure that only significant predictors were included, and (3) multicollinearity was checked using variance inflation factors (VIFs) to ensure that predictors were not highly correlated. A 2-sided p value of less than 0.05 indicated statistical significance.

The basic characteristics of the participants are presented in Table 1. Among the 578 participants included in the study, most were female (60.7%), aged between 25and 40 (66.4%), had undergraduate education or below (92.6%), and were formal employees (88.2%). About half of the participants were physicians (51.7%) and worked in tertiary hospitals (52.2%). Most participants had received the HBV vaccine (81.0%) and obtained occupational protection knowledge mainly from the hospital (61.4%). Half of them (53.5%) had been tested for HBV, HCV, TP, and HIV during the last year.

A total of 198 participants (34.3%) reported experiencing NSI at least once in the past three years. However, a significant proportion of 46.0% (195 out of 424) failed to report NSI to the hospital’s Infection Control Committee. Table 2 shows the detailed characteristics of the NSI cases. NSI most frequently occurred once (46.5%) or twice (23.7%) in the treatment room (41.3%) or the physiotherapy room (38.7%). NSI was mainly attributed to filiform needles (84.7%), with unknown pathogen sources (59.1%). Additionally, most participants did not wear gloves when the NSI occurred (75%), and 41.3% had NSI during needle removal. After the NSI, most participants received treatment according to the standard process (78.8). In addition, 32.4% had antibody tests, 20.3% had liver function tests, 29.0% reported experiencing anxiety, and 5.7% expressed significant fear.

We first compared the differences in all sample characteristics between participants with and without NSI using Pearson chi-square tests. The two groups showed statistically significant differences in various sample characteristics, such as gender, education level, profession, employment type, and training experience, which are listed in Table 3. These significant factors were further included in the multivariate logistic regression analysis, and the remaining significant factors are shown in Table 4. Factors associated with an increased risk of NSIs included postgraduate education or higher (OR = 2.174, 95% CI: 1.020, 4.634), high probability of occupational exposure (OR = 2.940, 95% CI: 1.826, 4.735), moderate perception of exposure severity (OR = 9.149, 95% CI: 1.948, 42.97), and high perception of exposure severity (OR = 7.025, 95% CI: 1.497, 32.969). In contrast, factors associated with a reduced risk of NSIs included: females (OR = 0.576, 95% CI: 0.379, 0.876), nurses (OR = 0.396, 95% CI: 0.210, 0.746), working in other professions (OR = 0.362, 95% CI: 0.151, 0.868), adherence to standard preventive measures (OR = 0.396, 95% CI: 0.210, 0.746), and consistent adherence to post-exposure procedures (OR = 0.092, 95% CI: 0.021, 0.398).

Our results indicate that acupuncture practitioners are at a significantly high risk for NSI, with an incidence rate of 34.3%, similar to the reported 32.86% in a previous national survey of HCWs in China (29). However, this rate was higher than the 10.35% reported in a study conducted at a single tertiary Traditional Chinese Medicine hospital (10). Additionally, 12.1% of acupuncture practitioners in our study reported more than five NSIs over the past three years, compared to 10.35% reported in a previous study (10). This difference is likely due to our study’s retrospective review of NSIs over the past three years and a broader research scope involving multiple centers and hospitals at varying levels. Our study also revealed a high under-reporting rate for NSI at 46.0%, consistent with previous studies reporting rates of 35–50% (7–9). Several studies have identified common reasons for not reporting, including the prolonged reporting process, concerns over losing a job, and underestimating the hazards of NSI (7, 29, 30). The consistently high under-reporting rates across various studies underscore the urgent need to establish standard and comprehensive reporting systems, both in China and globally. Such systems are crucial for ensuring accurate data collection and improving the safety of HCWs worldwide.

In this study, we found that filiform needles accounted for most NSI exposure cases. This is likely due to the widespread use of filiform needles in acupuncture treatment and the handling difficulties due to small size. Our study also found that most injuries occurred in treatment and physiotherapy rooms during the process of withdrawing acupuncture needles, which was consistent with previous findings (10). Therefore, enhancing protective measures in these high-risk areas and developing specialized sharp containers for filiform needles could be crucial preventive measures (31, 32). NSI has been shown to transmit over 20 bloodborne pathogens, including HBV, HCV, HIV, and syphilis, contributing to most occupational infections (33). In our study, 40.9% of participants were exposed to these pathogens, with HBV being the primary source (13.3%), which was congruent with previous findings (5, 23, 34). Additionally, we found that 10.5% of the needles linked to NSI were contaminated with HIV, a rate significantly higher than the 3–6% reported in earlier studies (23, 34). Notably, our study revealed that a considerable proportion of acupuncture practitioners experienced anxiety (29.0%) and fear (5.7%) following NSI, similar to the anxiety rates of 25–30% reported in previous studies (4, 23). For example, a study by Li et al. showed that 12.6% of HCWs who experienced NSI considered quitting, 3.5% wanted to change jobs, and 1.8% reported that the stress affected their families (23). Thus, NSI not only poses a risk to acupuncture practitioners’ physical health but also causes significant psychological stress.

Based on our findings, several factors were associated with an increased risk of NSIs, including holding a postgraduate or higher degree, being a physician, having a high probability of occupational exposure, and having a moderate to high perception of occupational exposure severity. Practitioners with postgraduate or higher degrees were found to have a significantly higher risk of NSIs, consistent with previous research (7). This increased risk may be due to challenges in translating extensive theoretical knowledge into practical acupuncture skills. Although highly educated practitioners possess strong theoretical understanding, they may lack sufficient hands-on experience, leading to less precise needle handling and higher risk of injury. Moreover, the current medical education system often prioritizes theoretical knowledge and advanced techniques over practical training in safety protocols and needle stick injury (NSI) prevention. As a result, even highly educated practitioners may not receive sufficient training on the practical aspects of NSI prevention, leaving them vulnerable to occupational risks. However, evidence supports that education and training focused on NSI prevention and infection control are effective measures (4, 29, 35). Furthermore, the risk of NSI was higher among doctors than nurses and other medical staff, likely due to doctors’ more frequent use of acupuncture needles (10). Similarly, a higher probability of occupation exposure risk indicates higher chances of contacting dangerous objects, leading to a higher risk of NSI. Additionally, moderate and high perceptions of occupational exposure severity were associated with a higher risk of NSI. It is noteworthy that an excessively high perception of occupational exposure severity may represent an over-exaggeration and anxiety of the occupation hazards, which may paradoxically impede occupational protective practices, thereby augmenting the risk of exposure. Conversely, risk perception of occupational exposure at a low level may represent a normal level of awareness of potential hazards and psychological response, which can keep individuals vigilant while not over-anxious, thereby reducing the risk of NSI (36, 37).

Our findings shown that female acupuncture practitioners were associated with a reduced risk of NSI. This may be due to factors such as greater adherence to safety protocols, more cautious handling of needles, and higher awareness of occupational risks, which collectively contribute to a reduced likelihood of injury. Additionally, our study demonstrated that adherence to standard prevention strategies in the workplace was linked to a reduced risk of NSI, consistent with previous research findings (8, 9). Standard precautions are widely recognized as the most effective approach for preventing and controlling nosocomial infections, protecting HCWs and patients, and ensuring public safety (38). Previous studies have shown that using double gloves can significantly reduce exposure to bloodborne pathogens on sharp instruments (8, 35, 39). However, while these findings are promising, additional research is needed to evaluate the long-term effectiveness and practicality of these preventive strategies in real-world settings. Additionally, our study further found that adhering to standard procedures after exposure was associated with a lower risk of NSI. Therefore, it is imperative that we not only focus on pre-exposure prevention measures but also emphasize the importance of standardized post-exposure management.