Rare Jewish Circumcision Practice Linked to Neonatal Herpes

Yael Waknine

June 08, 2012

June 8, 2012 — A rare Jewish tradition performed during ritual circumcision carries a 3.4-fold increased risk for neonatal herpes simplex viral infection (HSV-1) relative to the general population, according to a Centers for Disease Control and Prevention (CDC) study published in the June 7 issue of the Morbidity and Mortality Weekly Report.

Ritual circumcision, known as brit milah or bris, is a common practice among Jews and is typically performed using sterile techniques, sterile gauze, and antimicrobial cream.

However, a small proportion of ultra-Orthodox Jewish rabbis and mohels (ritual circumcisers) use direct orogenital suction (metzitzah b'al peh [MbP]) to remove blood from the surgical site. The action allows transmission of HSV-1 to the infant, with potentially devastating results.

HSV-1 is typically responsible for cold sores and is carried orally in more than 50% of adults, who are often asymptomatic yet still capable of transmission. Newborns exposed to the virus can develop severe infection, which can result in death or permanent disability because their immune systems are not mature enough to fight off infection. Moreover, the child carries the virus for life and can transmit it to others.

Eleven cases of newborn HSV-1 infection were reported in New York City (NYC) between 2000 and 2011; all occurred after out-of-hospital brit milah, and 3 of the ceremonies were performed by a mohel who tested positive for the virus.

Six of the newborn cases were confirmed and the CDC deemed the rest probable, as the infants underwent MbP but their mothers and hospital personnel did not have the virus. Ten newborns required hospitalization; of these, 2 died and at least 2 others developed brain damage. Several infants developed skin, eye, and mouth lesions. The authors of the CDC study report that some parents were not aware that MbP would be performed as part of the brit milah.

Investigators sought to determine the relative risk for HSV-1 in newborns undergoing MbP relative to the general population using neonatal HSV case reports in the general population and NYC vital statistics for live male births from April 2006 through December 2011.

They found that 20,493 newborns could potentially have undergone MbP during that period, correlating with a risk for HSV-1 infection of 24.4 per 100,000 cases, a rate 3.4-fold higher than that found in the general population.

An Ancient Practice That Poses a Risk

Daniel Goodman, MD, a mohel in Atlanta, Georgia, is outraged that the practice of MbP continues in this day and age; he uses gauze and antiseptic ointment.

"[MbP] is a practice done only by the ultra-Orthodox communities. It is not the standard of the Jewish world," Dr. Goodman emphasized in an interview with Medscape Medical News. "With what we know about transmission of disease in 2012, it is disappointing that the rabbinic authorities in all these communities allow it to continue. It needs to stop because it puts children and [mohels] at risk, which is not the purpose of having a bris."

Rabbi Michael J. Broyde, MJB, professor of law at Emory University in Atlanta and Chaver (friend) of the Beth Din of America (rabbinical court), agrees.

"MbP was an ancient practice of the Jewish community and has now been shown to, in a very small number of cases, pose a risk to infants," explained Rabbi Broyde in an interview with Medscape Medical News.

"For decades already, nearly all [mohels] have ceased to do MbP at all or do so through a pipette or gauze, reducing the risk to zero, which is a wise policy that anticipates the current dangers well. In light of this, there is no reason to refrain from brit milah, with its Jewish ritual significance and many health benefits."

According to the CDC's Web site, male circumcision is medically beneficial in preventing the transmission of HIV/AIDS, herpes, and other viruses including human papillomavirus, which has been linked to cervical, vulvar, vaginal, penile, and anal cancers in men and their partners.

NYC Hospitals to Warn Parents

In a stepped-up effort to protect newborns, the NYC Department of Health and Mental Hygiene has asked all NYC-owned hospitals to distribute a "Before the Bris" pamphlet to warn parents against the practice and advise them to ask their mohel whether they perform MbP or use other methods such as a sterile pipette or gauze to draw blood from the wound.

As noted in the pamphlet, there is no proof that the mohel's use of alcohol-containing mouthwash or antiviral medications reduces the risk for transmission of HSV-1 or other infections.

According to a statement by NYC commissioner Thomas Farley, MD, MPH, all NYC-owned Health and Hospitals Corporation facilities and at least 8 prominent private hospitals have agreed to distribute the pamphlet.

Morb Mortal Wkly Rep. 2012;61:405-409. Full text

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