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Is Controversial Circumcision Ritual Dangerous?

To many, it’s a disgusting ritual. But is it dangerous?

For years, New York City health officials have cited scientific evidence that metzitzah b’peh, in which a mohel uses his mouth to suction blood from the circumcision wound, infects babies with the potentially fatal herpes virus. Now, the ultra-Orthodox community claims to have scientific evidence that mohels are not always the source of infection.

Their proof resides with E. Oscar Alleyne, director of public health planning in Rockland County, New York. Over the past two years, Alleyne has conducted DNA tests on three mohels who used what’s known as MBP when they circumcised babies that later tested positive for herpes.

The results of Alleyne’s first investigation were inconclusive. The results of the next two investigations showed that the two mohels who circumcised the boys were not the source of the disease.

Yerachmiel Simins, an attorney who liaises between the large ultra-Orthodox community in Rockland County and health officials, told the ultra-Orthodox newspaper Hamodia on January 12, “The two definitive non-matches that occurred in Rockland could not be a clearer refutation of [New York] City’s hypothesis.” But medical experts say it is not possible to draw conclusions from just two results. They also note that although Alleyne ruled out the mohels as the source of the two infections, Alleyne has failed so far to discover who did infect the babies.

Jonathan Zenilman, chief of the infectious diseases division at Johns Hopkins University, said, “The [ultra-Orthodox] community will say it’s conclusive, but I don’t know any expert who will say it’s conclusive at all.” One thing that can be said conclusively: Two health departments, 40 miles apart, have had vastly different experiences trying to deal with herpes infection in ultra-Orthodox infants.

New York City’s health department has been at loggerheads with the ultra-Orthodox community for years over MBP. The two sides are locked in a legal battle over a consent form that the city introduced in 2012, which forces mohels to inform parents that MBP exposes their baby to the risk of herpes, “which may result in brain damage or death.” When ultra-Orthodox babies are infected with herpes in New York City, parents often refuse to divulge the name of their mohel or to submit to testing themselves.

An hour’s car ride north, in suburban Rockland County, Alleyne has secured the cooperation of one of the largest ultra-Orthodox communities in America.

About 91,000 Jews, mainly ultra-Orthodox, live in the area.

Since Alleyne began working with the community two years ago, parents have come forward voluntarily to report eight suspected cases of neonatal herpes. In the three confirmed cases of the disease, mohels, parents and other caregivers have submitted to weeks of oral swabs, which are then sent to a laboratory for testing.

A Rockland County community member who has been involved in the issue in New York City and in Rockland County for many years said the ultra-Orthodox community has requested DNA testing in New York City for a long time, but the city refused.

“We are on the same side of the issue,” said the community member, who did not wish to be named. “We want to know where infections are coming from.”

The community member said that when Alleyne contacted the ultra-Orthodox community in 2013, offering to work together to isolate the source of the disease, the community was willing to cooperate. During the course of discussions, both sides agreed to oral swabs and DNA testing to isolate the source of the disease.

Jay Varma, New York City’s deputy commissioner for disease control declined an interview request.

A health department spokeswoman said, in a written statement, that the city has “considered a variety of potential sources of infection.” But the spokeswoman added that the evidence supports the conclusion that babies are being infected during MBP. Such evidence includes the timing of onset of lesions shortly after circumcision with MBP, the location of lesions on the infants’ genitalia, and the fact that all of the babies in New York City were infected with HSV-1, which is most commonly found in the mouth.

The spokeswoman added that three mohels have been associated with multiple cases of neonatal herpes and that the link between MBP and herpes has been documented in the U.S., Canada and Israel.

She said: “Any hypothesis to explain these infections needs to explain why these infections are HSV-1 (not HSV-2), occur on the genitalia, occur in newborn baby males but not females from Jewish families practicing [MBP], are clustered in a single Brooklyn zip code where there are no female infant herpes infections, have occurred in babies born to women who do not have HSV-1 infection, and occur within a time frame consistent with transmission during circumcision.”

Ben Kruskal, chief of infectious disease at Harvard Vanguard Medical Associates, a large practice in Boston, said some of the cases being ascribed to mohels may well turn out to have been caused by another source.

But given the number of neonatal herpes cases in the ultra-Orthodox community and the fact that the virus predominantly affects boys, Kruskal said, “I am loath to dismiss MBP as a cause entirely.”

Alleyne’s results come at a crucial time in the public health battle against neonatal herpes in the ultra-Orthodox community.

New York City’s health department believes that 17 infants have been infected with herpes because of MBP since 2000. Two of those babies died. and two suffered brain damage.

Ultra-Orthodox mohels have largely ignored the city’s consent form regulation because they do not believe that MBP is a health risk. Since the form was mandated, the city believes that five ultra-Orthodox babies have been infected with herpes following MBP.

Because of a lack of cooperation between the city and the ultra-Orthodox community, health officials were able to identify mohels involved in only two of those cases. Both mohels were banned from performing MBP, though the city has no way of enforcing its ban.

The city will not release the names of the banned mohels, so parents have no way of knowing which mohels to avoid. While Bill de Blasio was running for the of New York City mayor’s office, he said that he would find a better way of balancing the religious needs of the ultra-Orthodox community with the health and safety needs of infants.

This January, at the beginning of de Blasio’s second year in office, the mayor’s deputy director of intergovernmental affairs, Avi Fink, told The New York Times that the city was considering a new approach.

Fink, an Orthodox Jew, did not go into specific details. But it seems that the city will drop the consent form in favor of a campaign to educate parents about the risks of MBP and herpes.

“You can have something on paper that seems robust, and maybe even seems invasive and strong,” Fink told the Times, referring to the consent forms. “But part of how the mayor is going to ensure success in this is how many people are we actually touching and communicating with, and how much awareness and education can we actually accomplish.”

The question is, if the ultra-Orthodox community does not believe that babies are being infected with herpes during MBP, then what effect will an education campaign have?

The Forward tried to ask Fink this question, but he declined a request for an interview.

Alleyne does not claim that his results say anything definitive about a link — or a lack of a link — between MBP and neonatal herpes. He is just happy that he has won the trust and cooperation of the ultra-Orthodox community. Between 2009 and 2014, the county had seven confirmed cases of neonatal herpes. Two of those infections were in girls from the non-Jewish community. The other five infants were ultra-Orthodox boys.

All seven infants had HSV-1 infection, a type of herpes that is commonly found in the mouth and usually manifests itself as cold sores. Although HSV-1 is harmless to adults, it can be devastating to an infant’s developing immune system.

About 90% of neonatal herpes cases are caused by a mother transmitting the disease to her infant during childbirth.

The other 10% of cases are usually transmitted after birth by adult caregivers.

The Herpes virus Image by ThinkStock

Although HSV-1 is known as oral herpes, a mother can carry the disease in her genitals following mouth-to-genital contact with an infected person.

Robyn Neblett Fanfair, from the Division of STD Prevention at the Centers for Disease Control and Prevention, said that although neonatal herpes infection has remained stable in recent decades, a shift toward more HSV-1 infections has been reported.

About 70% of adults in Rockland County are believed to carry the HSV-1 virus, Alleyne said. But they are contagious only at times when the virus is said to be “shedding.”

Alleyne said that before 2013, ultra-Orthodox parents with infants who exhibited herpes symptoms would not reveal the name of the mohel who performed MBP on their child, nor would they submit themselves to testing. In 2013 he contacted ultra-Orthodox leaders to ask for their help in an investigation into a case of neonatal herpes in the community.

Alleyne said that the negotiations were conducted through the lawyer, Simins. Alleyne could not specify how many ultra-Orthodox communities he was negotiating with, but he said that all sides came to an agreement. Now, whenever his department has a confirmed case of an ultra-Orthodox infant with HSV-1 infection, the mohel, parents and any other caregivers suspected of being the source of the virus submit to an investigation.

A health worker collects swabs from the mouths of the suspected carriers twice a day until the department has 60 samples from each individual. Those samples are sent to New York’s state public health laboratory, in Albany, for testing. If anyone tests positive for HSV-1, the laboratory runs an analysis of the strain in his or her mouth to see if it matches the strain in the infected infant.

Kelly Wroblewski, director of infectious disease programs at the Association of Public Health Laboratories, said the method is similar to that used to trace related cases in investigations for other infectious diseases, such as tuberculosis or hospital-acquired infections. “It is a powerful and informative way to uniquely identify the virus and help determine the source,” Wroblewski said.

Alleyne said that ultra-Orthodox communal leaders agreed that as long as an investigation is active, the suspected mohel will not perform MBP.

If the mohel’s virus matches the infant’s virus, Alleyne said, the community has agreed to ban that mohel from performing MBP anywhere in the world for the rest of his life.

Alleyne said that he has no way of making sure that the community complies. But he added that his health department has made a “good-faith effort” to work with the community and that adopting “a position of mistrust defeats my whole goal in public health.”

If the mohel tests positive for herpes but the virus does not match the infant’s infection, Alleyne said, he recommends that the mohel stop performing MBP or use a sterile pipette to simulate oral suction, because the risk of exposing the infant to herpes “is high.”

Alleyne would not say whether the two mohels in the 2014 cases tested positive for the herpes virus. But the Rockland community member who has been involved with the issue said the two mohels did test positive for the virus. They both continue to perform MBP.

“They are continuing to practice and use whatever safety practices they were using before, which is why they have never been sources of infection in the past,” the community member said, referring to the mohels disinfecting their mouths before performing MBP.

The first neonatal herpes investigation Alleyne led under the new protocol was in 2013. He declined to go into the specifics of the case. But he did say that although some individuals tested positive for herpes, the laboratory was unable to grow enough genetic material from the swab samples to run a DNA test. The results of that investigation were inconclusive.

Of the two 2014 cases, Alleyne said investigations to determine the source of the infections are ongoing. Among New York City’s Jews, an estimated 3,500 boys undergo MBP each year. Of those boys, the city reports an average of one or two cases of neonatal herpes each year.

The Centers for Disease Control estimates that boys who undergo MBP have a 1 in 4,000 chance of contracting the disease, more than three times higher than boys who do not undergo MBP.

Zenilman said that the results of the program in Rockland County raise the question, “Where did these infections come from?”

Rockland County’s health department will not divulge specifics about the cases, such as time of onset of herpes symptoms and location of lesions. But Zenilman said: “There is no biological reason why newborn boys are more susceptible than newborn girls. It doesn’t make sense.” It makes perfect sense for defenders of MBP.

They don’t discount the possibility that MBP might occasionally infect a baby with herpes. Simins told Hamodia that MBP, performed without “the safety precautions conscientious mohalim use, such as disinfecting [the mouth] prior to circumcision,” may be a source for the virus.

But Simins added that the results from Rockland County “are definitive proof that New York City’s approach is categorically wrong.”

“If the city were truly interested in public health and not just an anti-MBP agenda,” Simins said, “they would embrace these results, abandon their approach and acknowledge the benefits of collaboration instead of confrontation.”

Contact Paul Berger at [email protected] or on Twitter, @pdberger

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