Fish pedicures unlikely to cause HIV infection

The Daily Mail and the Sun are alarming their readers today with articles alleging that “fish foot spa pedicures could spread HIV and hepatitis C” and that there is a "fish foot spa virus bombshell".  The story has been picked up other media outlets, including Fox News, the Times of India and the Daily Telegraph.  However, the stories mostly twist and distort the source they are based on: a set of recommendations from the Health Protection Agency (HPA) on the management of fish pedicures and fish spas. Indeed, the HPA titled its press release: “Fish pedicures unlikely to cause infection.”

There are no known cases of HIV infection due to the use of fish spas, or indeed from any other water-borne route.

An increasing number of salons and beauty therapists offer ‘fish pedicures’ in the UK. They involve immersing the feet in a tank of water containing Garra rufa fish (a small toothless species of freshwater carp) that nibble off dead and thickened skin. The use of Garra rufa fish is long established in Turkey, India and the Far East where it has a history as a treatment for a variety of skin conditions and, more recently, as a cosmetic treatment for the removal of dead and hardened skin from the feet.

While there is little evidence in scientific literature of the potential public health risk to users, some are concerned about the presence of bacteria in the fish tank water. Moreover, while the fish are only meant to nibble dead skin, some clients may occasionally bleed into the water, raising anxieties about the transmission of blood-borne viruses.

There are restrictions on the practice in Germany and 18 states of the USA. Four Canadian provinces have banned the procedure on the grounds that fish used as ‘instruments’ for pedicures cannot be disinfected or sterilised between clients.

The HPA’s report examines the available evidence and scientific plausibility for the transmission of blood-borne viruses from person to person, via the water in the fish tank. Hepatitis B and C survive outside the body for longer than HIV and the only suspected blood-borne virus transmission cases via water relate to hepatitis B.

 An infected client would need to bleed from an open cut, abrasion or wound into the water, and then another client would need to also have an open cut, abrasion or wound for the infected blood to enter his or her bloodstream. Importantly, the concentration of virus would be substantially reduced by the diluting effect of the water.

If virus contaminated a fish’s mouth, it would be unlikely to remain on the mouth and thus to effect a transmission to the next client. Moreover, a fish cannot itself be infected with the human immunodeficiency virus (and there is no 'fish equivalent' of HIV).

Overall, the HPA describes the risk of blood-borne virus infection as “extremely low”, although it cannot be completely excluded.

It does make a number of hygiene recommendations for operators of fish spas (e.g. refreshing the water supply). To reduce the risk of infections being passed on or picked up, clients who have broken skin, athlete’s foot, a verruca, psoriasis or eczema affecting the feet or lower legs should not have fish pedicures.

Similarly, the HPA advises that people with HIV (and hepatitis B or C) should not have fish pedicures. However, it is not clear what scientific evidence this recommendation is based on or whether it is a proportional response to this theoretical transmission risk.

Lisa Power of the Terrence Higgins Trust dismissed the media’s concern about the issue: "The reality is, in this country, too many people are contracting HIV because they aren't using condoms, not because they're going for fish pedicures."