No Conclusive Evidence on Circumcision Rite and Herpes

Letter to the Editor

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By Daniel Berman, Brenda Breuer and Awi Federgruen

Published March 09, 2014.
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In its editorial, compellingly titled “Protect the Children,” the Forward implores Mayor Bill DeBlasio to not “go wobbly,” urging him to “curtail” Metzitzah B’Peh (often referred to as simply MBP), a part of many ritual circumcisions, which has been asserted to cause Herpes Simplex (HSV1) infections.

The editorial is misguided in its medical and policy assertions.

Far from a fringe practice, MBP is performed on the majority of Jewish boys born in New York City. This is based on a 2012 UJA study, reporting that over 60% of New York’s Jewish children born are Orthodox and conservative estimates that over 80% of Orthodox circumcisions in New York involve MBP.

The procedure has never been proven to be related to, let alone a cause of HSV-1 in newborn infants. That was our conclusion as medical and statistical expert witnesses in six affidavits submitted in a federal lawsuit about the constitutionality of the 2012 NYC regulation of MBP. Our conclusions were echoed in affidavits by world renowned experts from NYU and the Hebrew University, as well as a 2012 Israeli government committee paper, stating, “according to those halachic authorities who hold that MBP is an essential part of the mitzvah of milah, there is no necessity to cease this procedure unless there will be clear-cut scientific evidence for endangering the baby by MBP in a statistically significant rate. This has yet to be proven.”

We belong to “modern Orthodox” communities where MBP is rarely performed, have no ideological commitment to the issue, and offered our expertise entirely pro bono.

A 2013 University of Pennsylvania study, moreover, analyzed the relevant evidence and all the prevailing literature and concluded that: ”This evidence base is significantly limited by a very small number of reported infections, most of which were not identified or documented systematically. Other important limitations include incomplete data about relevant elements of the cases, the presence of confounding factors, and indirect data sources.”

As to the single study claiming statistical evidence for an elevated risk among babies who had MBP, the report notes, “this finding is limited by methodological challenges in determining the total population at risk, limited information about some of the cases, and the small number of infected infants.”(UPenn has previously taken issue with our quoting this report and our characterization of its findings; according to the Forward, its project director wrote them: “I do not agree with the way they are portraying our report.” However, the quotes, above and below, are verbatim.)

The Forward claims that “ultra Orthodox leaders… continue to deny the scientific facts.” In fact, it is the city, not MBP’s defenders, that continues to deny these facts, ignoring the above objective evaluations.

The Forward seems unaware of a large body of literature demonstrating transmission of the HSV-1 to infants through family contacts and caretakers. (The only death from herpes in a boy circumcised with MBP, since 2006, when reporting of all neonatal herpes infections became mandatory, occurred after a sibling with active herpes on his lip spent two hours in intimate contact with the newborn, even sharing a pacifier with him.)

In fact, over the time period (April 2006-December 2011) that the city studied in their report, there were 79 other cases of neonatal herpes — cases where MBP had not been performed — resulting in 12 deaths. During the same time period, there were five cases among boys who may have had MBP (some, by the city’s own admission, are not certain) with one death. Obviously, the vast majority of cases of neonatal herpes have no association with MBP. Sharing the Forward’s objective to “protect the children,” is it really unreasonable to ask to explore other possible causes among boys who had MBP, and the City ‘s newborns at large?

The reason such investigations are not happening is not because the community is not cooperating. The Department Of Health and Mental Hygiene is at fault by not acknowledging the possibility of other causes of transmission of neonatal herpes in boys with MBP. Why should the possible causes exclude those responsible for the 79 cases mentioned above? In the most recent DOHMH health alert (2014 alert # 2), there is no consideration of any other source of transmission. The alert states “… location of… lesions” and “timing of infection” are consistent with transmission. They again ignore the UPenn review which addresses these two “proofs,” and states:

1) Location of lesions: “the dressing on the circumcision wound is usually changed at home at least once daily for several days after the procedure, while diapers are changed very frequently in infants, which could increase potential exposure to infection in the genital area in the days immediately following circumcision.”

2) Timing of infection: “the incubation period is also consistent with transmission in the hospital prior to discharge.”

It would appear that the DOHMH opened and closed its investigation of the case, by asking whether the child was a boy who had MBP. Since the answer was yes, the DOHMH closed the investigation, and concluded that the infection was transmitted through MBP. In the above 79 cases where the answer was no, the DOHMH had no further interest.

The Forward suggests: “the matter is easily investigated. Test the mother, test the mohel and see if either has the … virus.” As approximately 60% of American adults have been infected with HSV-1 (which in adults results in cold sores), this falls far short of what is scientifically necessary, and scientifically doable, to ascertain the source of the viral transmission. A proper investigation involves “DNA fingerprinting” of the virus, and from all people who potentially could have transmitted the virus to the infant. This procedure could either identify the source of the infection or eliminate suspected sources. Just recently, the feasibility of cooperation between a health department outside of New York City and its Orthodox community, under a proper testing protocol, was demonstrated.

The Orthodox community has declared its determination to cooperate in that type of unbiased, comprehensive, scientific investigation. With the advent of a new mayor, and a new health commissioner, we are hopeful that the city will do the same. We therefore echo the editors’ plea to the Mayor to “place yourself on the side of science,” collaborating in a properly conducted unbiased investigation.

Dr. Daniel Berman

Infectious Disease Specialist, Albert Einstein Hospital and Montefiore Medical Center

Brenda Breuer

Director of Epidemiologic Research, Mount Sinai Beth Israel

Awi Federgruen

Graduate School of Business, Columbia University


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