Time To Talk About Disinfection

With the Corona virus, COVID-19, being all over the news and affecting your practices, we see a perfect time to talk about disinfection in your practice. We are limiting this to cupping and IASTM tools, as personal hand washing and social spacing are reported everywhere. This post will cover how we recommend to clean and disinfect cups, and then we will go over the chemicals and processes that are common in the industry and give reasons as to why they should not be used.


Some of this info may challenge what you have learned previously. We base all of our content on the research that is available and sometimes that conflicts with what other instructors may have taught previously. This info comes straight from Health Canada, the CDC and the MSDS info from different products.


Cups generally fall under the category Semi-critical Medical Equipment/Device or Noncritical Medical Equipment/Device. Reprocessing then, should be for semi-critical medical equipment/devices as it is the higher of the two standards, and we are not testing them before putting them through a reprocessing process. The standard for semi-critical medical equipment/devices is High Level Disinfection (HLD).


While this sounds difficult, it is really easy as part of your reprocessing process. Reprocessing is the word used for using an item on a client and then processing it for safe use on another client. The process is wash, rinse, dry, disinfect, rinse and dry. Simple!


Wash – Washing cups and IASTM tools is the first step in reprocessing. Washing should be done in soap and water, with some sort of mechanical force. The aim is to remove all visible organic matter. This can be massage oil, sweat, hair, or whatever you can see on the cup.


Rinse – This just removes the soap off the cups/tool so that the disinfectant is not impeded in any way.


Dry – At this stage in our process, we just need to shake off the majority of the rinse water, so that the disinfectant is not diluted.


Disinfect – We recommend that you use 7.5% hydrogen peroxide (H2O2). This is the most environmentally friendly of the chemical disinfectants, though it is still harsh. Make sure that you are wearing gloves and if you tend to splash, eye protection. The cups and tools need to sit in the H2O2 for 30 minutes. This is called contact time, and if you are using another high level disinfectant, please refer to the label for the appropriate contact time.


Rinse – This is done to make sure the disinfectant is totally rinsed off the cup or tool. This is to protect your client’s skin (and your own!)


Dry – The cups or tools are left to air dry as part of the HLD process. Then they can be restocked to your room and cycled into your treatments.


A note about hydrogen peroxide. The bottle you get from the manufacturer will probably be at a much higher concentration that you need, likely 15-35%. You will need to dilute it down with distilled water. The math for this is quite easy. You need to know how much of the higher concentration H2O2 you need to make up a measured quantity of 7.5% peroxide. So, let’s show you the math with an example. Change the numbers to suit your situation.


You purchase some 34% H2O2 from the hydroponic or pool supply store. You need to end up with 7.5%. And, you want to end up with 4 litres of it (nearly a gallon). Four litres is 4000 millilitres (ml). So, how much 34% do you need? To get the answer, multiply 4000 x 7.5 and then divide the answer by 34. You should end up with 883 ml of the 34%. I have found, the easiest way to measure this is to use a 1000 millilitre measuring cup. Measure out the 883 ml of H2O2, then top the litre up with distilled water. Then add 3 more 1000 ml measuring cups full of distilled water. And you are done. Your total volume will be 4 L and and the concentration will be 7.5%. You want to use distilled water as most municipal water is treated with chlorine or fluoride and this does not mix well with hydrogen peroxide.


Even though cupping is done on intact skin there is still a chance blood or body fluids can come in contact with cups. It has happened to many health care practitioners (we ask in our courses!) Examples of this from my practice have been a patient with a bug bite that wasn't visible or mentioned that bled while cups were in place. Another patient had shaved that morning and had knicked her leg. There was no cut visible nor was this mentioned. Another patient had a hair cut in the morning and also had a razor knick that wasn't visible. A very small amount of blood was on the skin and touching the cups after the cupping treatment with each of these cases. The problem most people fail to see is that if the cup has not been disinfected from use on the patient before, there is a chance of cross contamination to this client. As well, in this case, after the treatment the cups need to be sterlized, a bump up the disinfection tree. There is always a chance this can happen which is why cups should always be treated to HLD. With hydrogen peroxide, sterilization can be achieved with a contact time of 6 hours.

So what about the other methods we have heard that are not recommended? Let's take a look. 

Alcohol - The FDA has not cleared any liquid chemical sterilant or high-level disinfectant with alcohol as the main active ingredient. Alcohols are not recommended for sterilizing medical and surgical materials principally because they lack sporicidal action and they cannot penetrate protein-rich materials. Two studies demonstrated the effectiveness of 70% isopropyl alcohol to disinfect reusable transducer heads in a controlled environment. In contrast, three bloodstream infection outbreaks have been described when alcohol was used to disinfect transducer heads in an intensive-care setting.  The documented shortcomings of alcohols on equipment are that they damage the shellac mountings of lensed instruments, tend to swell and harden rubber and certain plastic tubing after prolonged and repeated use, and bleach rubber and plastic tiles. 

Barbicide - is a quaternary ammonium product that Health Canada categorizes as a low-level disinfectant. Barbicides active ingredient is Benzalkonium chloride which is classed as a Category III antiseptic active ingredient by the United States Food and Drug Administration. Ingredients are categorised as Category III when "available data are insufficient to classify as safe and effective, and further testing is required” Health-care–associated infections have been reported from contaminated quaternary ammonium compounds used to disinfect patient-care supplies or equipment,

Cavicide - is an intermediate-level surface disinfectant. It is not appropriate for uses where skin is exposed to it. 

Bleach - sodium hypochlorite is not effective in the disinfection of bacterial spores and prions.

Seventh Generation - main ingredient Sodium lauryl sulfate (SLS) is a skin irritant. It can cause damage to the outer layer of skin by disrupting the function of skin proteins and causing itchy, cracked, and dry skin. Journal of the American College of Toxicology (1983, Vol. 2, No. 7) researchers noted, “The longer these ingredients stay in contact with the skin, the greater the likelihood of irritation, which may or may not be evident to the user.” The study authors go on to note that sodium lauryl sulfate causes “severe epidermal changes” to the area of the skin where it was applied. Since the primary side-effect of SLS, namely skin irritation, is dependent on the level and duration of exposure, consumer product formulators design products to avoid or minimize this effect during consumer use. 

If and ONLY if you are 100% certain no blood or body fluids have touched the cup can an intermediate disinfectant be used and ONLY if the cup is being use on the same patient. The cups must remain in contact with the disinfectant for a minimum of the time given on the product label (This is called contact time, and every disinfectant has one). However many of these chemicals have not been tested and used on all types of cups to see if they will damage cups. Many chemicals cause the cups to break down and cloud up. Why would you want to risk damaging your cups or more importantly spreading disease?

As newer disinfectants become available, persons or committees responsible for selecting disinfectants and sterilization processes should be guided by products cleared by the FDA and the EPA as well as information in the scientific literature.

Happy and Safe Cupping!



page 32 and Appendix B (p 71) and G (p 91)


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