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Practice of cupping (Hijama) and the risk of bloodborne infections

      To the Editor:
      Hijama is a type of wet cupping that is frequently practiced in many Muslim countries. This technique involves using a cup to pull the skin into traction, which results in a laceration of the skin with drawing of blood into the cup. Similar forms of cupping and bloodletting are also sometimes employed in traditional Chinese medicine and other systems of alternative medicine. However, very little evidence is available to justify the use of this technique as a method of treatment. A systematic review evaluating the efficacy of cupping as a method of treatment concluded that no high-quality evidence exists regarding the use of cupping as a method of treatment, except for treating pain.
      • Lee M.S.
      • Kim J.
      • Ernst E.
      Is cupping an effective treatment? An overview of systematic reviews.
      Even for the treatment of pain, most randomized trials conducted to date are of poor quality and possess severe methodologic flaws.
      • Kim J.
      • Lee M.S.
      • Lee D.
      • Boddy K.
      • Ernst E.
      Cupping for treating pain: a systematic review.
      At the other end of the spectrum, a growing body of evidence suggests that the practice of Hijama carries a significant risk of bloodborne infections, including HIV, hepatitis B, and hepatitis C infections. A meta-analysis of 357 clinical studies concluded that Hijama was a definitive risk factor for transmission of hepatitis C infection (pooled odds ratio, 1.5).
      • El-Ghitany E.M.
      • Wahab M.A.
      • Wahab E.W.A.
      • Hassouna S.
      • Farghaly A.G.
      A comprehensive hepatitis C virus risk factors meta-analysis (1989-2013); Do they differ in Egypt?.
      Another study based on 24,948 cases of hepatitis C infection reported in Saudi Arabia—a country where Hijama is routinely practiced—revealed that Hijama was the mode of transmission in a substantial proportion of patients.
      • Madani T.A.
      Hepatitis C virus infections reported in Saudi Arabia over 11 years of surveillance.
      A growing body of evidence has also implicated Hijama in the transmission of HIV and hepatitis B infections.
      Despite the lack of evidence supporting the efficacy of Hijama and the demonstrated risk of transmission of bloodborne pathogens, this technique continues to be practiced widely in several parts of the world.
      • Jan M.M.
      • Basamh M.S.
      • Bahassan O.M.
      • Jamal-Allail A.A.
      The use of complementary and alternative therapies in Western Saudi Arabia.
      Even worse is the fact that the risks posed by this technique have received virtually no attention by the general public or mass media. This may be attributable to complex religious, cultural, and social influences in regions where Hijama is routinely practiced. Health care professionals in such regions can play a key role in raising awareness regarding the risks posed by Hijama. At the same time, it is imperative for public health authorities to enforce regulations to ensure that people choosing Hijama as a method of treatment are fully aware of the health hazards posed by it.

      References

        • Lee M.S.
        • Kim J.
        • Ernst E.
        Is cupping an effective treatment? An overview of systematic reviews.
        J Acupunct Meridian Stud. 2011; 4: 1-4
        • Kim J.
        • Lee M.S.
        • Lee D.
        • Boddy K.
        • Ernst E.
        Cupping for treating pain: a systematic review.
        Evid Based Complement Alternat Med. 2011; 2011: 467014
        • El-Ghitany E.M.
        • Wahab M.A.
        • Wahab E.W.A.
        • Hassouna S.
        • Farghaly A.G.
        A comprehensive hepatitis C virus risk factors meta-analysis (1989-2013); Do they differ in Egypt?.
        Liver Int. 2014; (Article in Press)
        • Madani T.A.
        Hepatitis C virus infections reported in Saudi Arabia over 11 years of surveillance.
        Ann Saudi Med. 2007; 27: 191-194
        • Jan M.M.
        • Basamh M.S.
        • Bahassan O.M.
        • Jamal-Allail A.A.
        The use of complementary and alternative therapies in Western Saudi Arabia.
        Saudi Med J. 2009; 30: 682-686