Author: Christy Pritchard, CAE and Paul Kohlmeier, BPE, RMT, R.Ac.
Cupping Canada Inc. gets a number of questions and inquiries from Cupping Therapy practitioners as to why we classify cups as being a Semi-Critical Medical Device which then requires a High-Level Disinfection process. To help clarify our position on this, we referenced a number of documents, including, but not limited to:
- Provincial Infectious Diseases Advisory Committee on Infection Prevention and Control (PIDAC-IPC): Best Practices for Cleaning, Disinfection and Sterilization of Medical Equipment/Devices In All Health Care Settings, 3rd Edition, May 2013 (https://www.publichealthontario.ca/-/media/documents/bp-cleaning-disinfection-sterilization-hcs.pdf?la=en)1
- Provincial Infectious Diseases Advisory Committee on Infection Prevention and Control (PIDAC-IPC): Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings, 3rd Edition, April 2018 (https://www.publichealthontario.ca/-/media/documents/bp-environmental-cleaning.pdf?la=en)2
- Canadian Standards Association: CSA Z314.3, CSA Z314.8 (https://webstore.ansi.org/Standards/CSA/CSAZ3142014-1510871)3
- Centres for Disease Control and Prevention: Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)(https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines.pdf)4
- Health Canada: Infection Control Guidelines – Hand Washing, Cleaning, Disinfection and Sterilization in Health Care.(http://publications.gc.ca/collections/collection_2016/aspc-phac/HP3-1-24-S8-eng.pdf)5
When looking at the above reference documents, it is easy to see how and why people become confused as cupping products have the potential to fall into one of two different classifications:
- Non-critical Medical Equipment/Devices are those that either touch only intact skin (but not mucous membranes) or do not directly touch the client/patient/resident.
- Semi-critical Medical Equipment/Devices are those that come into contact with mucous membranes or non-intact skin.
While it is recommended – and in some jurisdictions required! - that Cupping Therapy only be performed on intact skin, most everyone agrees that there may be a number of occasions when the skin would be considered as non-intact, such as:
- A bug bite
- A small cut from shaving or even a haircut
- A pimple that releases under the cup as a result of the suction
- A scratch
- A small scab
Most of these are not necessarily visible to the eye and ultimately result in the skin being considered as non-intact. Therefore, the classification as a Semi-critical Medical Device is considered as appropriate in consideration of the above and provides guidance in practicing safe infection control measures in healthcare.
Cupping Canada Inc. teaches across Canada and the USA as well as provides training to multiple health disciplines in both countries, and our goal is to ensure that we are teaching and promoting to the highest possible standards in relation to cleaning and disinfection. This ensures that regardless of the geographic jurisdiction being taught in, or the type of health professional attending our courses, that we are leaving no room for error!
Disinfection is the inactivation of disease-producing microorganisms. Cupping Canada Inc. promotes the use of a 7.5% Hydrogen Peroxide solution for the disinfection process as it is both environmentally friendly (you can pour it down the sink without cause for concern) and relatively inexpensive. There are some health professions in Canada that recommend a lower level of disinfection based on their determination that cupping products fall under the Non-critical classification, however as outlined above, Cupping Canada Inc. considers cupping products to be Semi-Critical.
According to the Centres for Disease Control and Prevention (CDC), the procedure of cupping could lead to contact with non-intact skin. If cupping tools are contaminated during cupping procedures, this poses a potential risk for infection with blood-borne pathogens and most contaminants are not necessarily visible to naked eye.
All of the governing authorities agree that Semi-critical devices must follow, at minimum, a high-level disinfection process using chemical disinfectants as follows:
Of all of the approved chemical disinfectants, Hydrogen Peroxide is regarded as the most environmentally friendly option. But disinfection is not the only step!! According to the Canadian Standards Association, all reusable medical equipment/devices are to be thoroughly cleaned before disinfection or sterilization.
High-level disinfection (HLD) is the recommended level of disinfection not only because of the potential that cups may come in contact with non-intact skin, but also because they eliminate vegetative bacteria, enveloped viruses, fungi, mycobacteria (e.g., Tuberculosis) and non-enveloped viruses.
In order to ensure that the highest possible standards are being followed when it comes to disinfection of your cupping products, Cupping Canada Inc. recommends and follows the guidelines as established by the CDC as they are the highest possible standards currently available.
Recommended cleaning and disinfection process:
- Sort and Soak: Unless they can be cleaned immediately, your cups should be sorted and then submerged in warm water and detergent to prevent the organic matter from drying on them. For vacuum cups, complete disassembly of each item is necessary to allow effective cleaning. Heavy or non-immersible items should be wrapped in, or covered with, a wet towel.
- Remove Organic Material: Use a detergent or enzymatic cleaner to ensure your cups are clean and all visible material on the cup has been removed. Detergent is used to reduce surface tension and suspend the soil in water. For best results, we recommend using Dawn dishwashing liquid.
- Rinse: A thorough rinsing is necessary to remove all the soil and cleaning agent from the items, to avoid spotting and to ensure thorough cleanliness. Depending upon the quality of the available water supply, the final rinse may require distilled or purified water. Cleaning agents (i.e., detergents) may also make surfaces slippery or leave residue that impairs equipment integrity and function. Ensure that residue of the cleaning agent are removed to prevent neutralization of the disinfectant.
- Drying: Ensure that the majority of excess water is allowed to drain off the cups. Drying prevents microbial growth so ensure that all of your cups and corresponding equipment are completely dry before disinfecting.
- High Level Disinfection: Soak your cups for a minimum of 30 minutes in the recommended 7.5% Hydrogen Peroxide solution. Soaking the cups for 6 hours will achieve sterilization levels.
- Rinse: Thoroughly rinse your cups again to remove any of the disinfectant.
- Drying: Allow your cups to dry before storing away or using on your next patient.
Please also note that Health Canada outlines that the following methods are not acceptable for achieving proper disinfection/sterilization:
- boiling / use in a dishwasher
- alcohol less than 90%
- ultraviolet light
- glass bead sterilization
- microwave ovens
- chemiclave sterilization