City health officials said yesterday that they had identified two new cases in which infants were infected with herpes this year during a circumcision ritual practiced by some Orthodox Jews. During the circumcision, the practitioner, or mohel, sucks the blood from the circumcision wound to clean it. Since 1988, health officials have identified at least five infants believed to have been infected during such procedures by Type 1 herpes, commonly carried by adults. One baby died and another may have suffered brain damage, health officials said. Dr. Thomas R. Frieden, the commissioner of health and mental hygiene, disclosed the new cases yesterday in an open letter to Orthodox Jews in which he called upon parents to consider other religiously viable options, including using a tube or sponge. But he did not ban the practice.
Of course, he cannot ban the practice – Mayor Bloomberg, suspiciously close to the mayoral election this Fall, promised Satmar and Agudath Israel in an apparent pre-election quid-pro-quo that he would not do so, and turned the 'investigation' into the mohel (ritual circumciser) that started it all, Rabbi Yitzchok Fischer, over to a Satmar beit din (religious court). The beit din has not managed to deal with the case so far. (Its schedule must be very full dealing with their community's 'special needs.')
One thing is clear– haredim are willingly sacrificing children to preserve a part of the circumcision rite that is not biblically mandated, and was only made part of that rite based on 1500-year-old Talmudic science to protect the health of the infant. In the ultimate irony, rabbis now fight to needlessly endanger the lives of infants, not protect them.
The City has set up a special website to deal with the problem. The problem is that most of the communities still doing metzitza b'peh have banned the internet. At any rate, the City notes that:
In metzitzah b'peh, the mohel places his mouth on the freshly circumcised penis to draw blood away from the cut. If the mohel is infected with oral herpes (as most adults are), metzitzah b'peh can expose the infant to the herpes virus. While severe illness associated with this practice may be rare , there is a definite risk of infection.
Oral herpes spreads easily through saliva, especially when saliva touches a cut or break in the skin, such as during metzitzah b'peh.Most people with oral herpes don't know they are infected and don't have symptoms. Even without symptoms, however, people can spread the infection.
Because the immune system of newborns is not developed enough to fight serious infection, herpes infections pose grave risks to infants.
There is no proven way to reduce the risk of metzitzah b'peh
Although a mohel may use oral rinses or sip wine before metzitzah b'peh, there is no evidence that these actions reduce the spread of herpes. [This is Rabbi J.David Bleich's 'solution' to the problem – have the mohel rinse his mouth first. He said this to 'refute' Rabbi Moshe Tendler's call to ban metzitza b'peh.] A mohel who takes antiviral medication may reduce the risk of spreading herpes virus during metzitzah b'peh, but there is no evidence that taking medication eliminates this risk.
Zachary Scholem Berger reports on a Dear Colleague letter sent yesterday by the NYC Health Department to physicians:
You may have heard about the Health Department’s recent investigation of several cases of herpes simplex type 1 infection in male infants following circumcision which included metzitzah b’peh.
Metzitzah b’peh is a practice performed by some mohelim (religious circumcisers) as part of the circumcision. After removing the foreskin, the mohel places his mouth on the baby’s freshly circumcised penis to draw away the blood. In 1998, the Health Department investigated two cases of neonatal herpes due to herpes simplex virus type 1 (HSV-1) – one of these infections occurred in 1988, the other in 1998. Both were associated with one mohel (Mohel A) who performed metzitzah b’peh during circumcision. Mohel A agreed to stop practicing metzitzah b’peh.
In November 2004, the Health Department was notified of 3 male infants with HSV-1. All were circumcised by one mohel (Mohel B), who performed metzitzah b’peh. The infants developed herpes infection in the genital area 8-10 days after circumcision and were hospitalized for several weeks. One baby died from the infection. Two cases were reported by physicians in 2005 and both are also consistent with infection from metzitzah b’peh. Every case occurred in the time frame consistent with transmission from metzitzah b’peh.
Our investigation found Mohel B to be the source of the 2004 cases, and metzitzah b’peh to be the means of infection for these and other cases, for the following reasons:
• The medical circumstances are inconsistent with infection acquired at delivery, in the newborn nursery, or from caretakers.
• Infection is consistent with acquisition of herpes at circumcision. For example, two infants who were circumcised several weeks after birth showed signs of infection in the time frame that would be expected were the infection acquired during circumcision.
• Several mothers tested negative for HSV-1, making it impossible for them to have been the source of infection.
• All infants tested culture-positive for HSV-1, which is found in the mouths of most adults.
• The location of herpes sores (on infant genitals and buttocks) is very unusual and strongly suggests that infection was introduced at the genitals.
With an estimated average of fewer than 30 cases of all forms of infant herpes infections occurring per year in New York City, the odds of one mohel being associated with 3 cases of neonatal herpes are infinitesimally small (about 6.9 million to 1). In the interest of allowing religious communities to address these health concerns first, the Health Department agreed to let rabbinical authorities ensure that the mohel stopped performing the practice at least until the authorities conclude an investigation. In addition, the connection between metzitzah b’peh and neonatal herpes has been documented in the medical literature. Three investigations published within the past 5 years (from New York City , Israel [2, 3] and Canada) describe 11 cases of males with HSV-1 infections on their genitals following metzitzah b’peh. Among the 11 cases, there are 4 pairs of cases (including the 1988/1998 cases from New York City).
In the United States, approximately 70% of persons age 40 and older are infected with herpes simplex virus type 1. The mouth is the most common site of HSV-1 infection; HSV-1 spreads easily through infected saliva, especially when saliva comes in contact with a cut or break in the skin, such as occurs during metzitzah b’peh. Most adults with oral herpes do not know they are infected and do not have symptoms. Even without symptoms, however, people with oral herpes can spread the infection to others. If herpes lesions are present, they tend to occur (and recur) on the skin or mucous membranes at the site at which infection was introduced or in related dermatomes. HSV-1 infection is lifelong; antibody is evidence of infection.…
Susan Blank, MD, MPH Julia Schillinger, MD, MSc
Assistant Commissioner Director of Surveillance, Epidemiology, and Research
Bureau of Sexually Transmitted Disease Control
New York City Department of Health and Mental Hygiene
But, there is more. The Health Commissioner's letter (Download std-bris-commishletter.pdf) implies that the reason the City has not banned metzitza b'peh is that the haredi community would ignore the ban and further endanger infants by the added secrecy that would be involved:
The Department has reviewed all of the evidence and there exists no reasonable doubt that metzitzah b’peh can and has caused neonatal herpes infection. We have always maintained that it is our preference for the religious community to address these issues itself as long as the public's health is protected. While some medical professionals and others in the Jewish community have called on the Department to completely ban metzitzah b'peh at this time, it is our opinion that educating the community through public health information and warnings is a more realistic approach.
Every death caused by metzitza b'peh is on the heads of those rabbis and community leaders who demand it. Shame on them.
UPDATE: I asked Sandra Mullin of the New York City Department of Health and Hygine the following questions.
1. Is Rabbi Fisher involved in these new cases? Is he the mohel?
"We know he wasn't involved with one case; we do not know who was involved with the other.
2. Has the Williamsburg-based Jewish court (beit din) reached any decision regarding Rabbi Fisher?
"Not to our knowledge."
In other words, the haredi community is covering for the mohel in case #2. This explains in part why the city has not outlawed metzitza b'peh – doing it underground will only make the problem worse. So, again, babies die and are maimed as rabbis fiddle and prevaricate.