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Date: Jul 22, 2014 11:16 AM
Subject: NYC DOHMH Alert # 16 - New cases of neonatal herpes infection following ritual Jewish circumcision
Dear Health Alert Network (HAN) Subscriber:
2014 ALERT # 16
New cases of neonatal herpes infection following ritual Jewish circumcision
Please Share this Alert with All Emergency Medicine, Pediatric, Pediatric Infectious Diseases, Infection Control, and Microbiology Laboratory Staff
• Two new cases of neonatal herpes following ritual Jewish circumcision with direct orogenital suction were reported in New York City in July 2014.
• Infants suspected of having herpes simplex virus infection should be hospitalized and treated with intravenous acyclovir.
• Health care providers are required to report diagnoses of neonatal herpes (with or without laboratory confirmation) to the New York City Department of Health and Mental Hygiene.
• Health care providers evaluating an infant <60 days of age for suspected neonatal herpes are required to collect a swab specimen from vesicles and submit the specimen to the New York State Wadsworth Center Laboratories.
July 22, 2014
Direct orogenital suction during ritual Jewish circumcision (also known as metzitzah b’peh) has been documented to transmit herpes simplex virus (HSV) to newborn males. In July 2014, the New York City Department of Health and Mental Hygiene received reports of two new cases of HSV infection in newborn male infants following direct orogenital suction. Since 2000, a total of 16 laboratory-confirmed cases of HSV-infection attributable to direct orogenital suction have been reported to the Health Department; three of these cases were reported in 2014 alone. Two of the 16 infants died, and at least two others suffered brain damage.
In both of the cases reported in July, the infant boys were born to mothers with full-term pregnancies, had normal vaginal deliveries, and underwent ritual Jewish circumcision including direct orogenital suction on day of life 8. In the first case, the baby was evaluated as an outpatient on day of life 16 for pustular lesions on the penis and genital area. HSV infection was suspected, and a genital specimen collected for viral culture. The baby was admitted to the hospital and treated with acyclovir and clindamycin. Additional specimens were collected at the hospital for HSV testing, including CSF, blood, and swabs of lesions; all were negative for HSV, and the baby was discharged on day of life 19. On day of life 22, the initial viral culture taken as an outpatient was positive for HSV (non-typable). The baby was re-admitted to the hospital for intravenous acyclovir treatment. In the second case, the baby developed lesions on his penis, left thigh, and left foot beginning on day of life 17. On day of life 19, the baby’s pediatrician collected specimens for bacterial culture, which came back negative. The next day, after the appearance of new vesicular lesions, the pediatrician suspected HSV, and the baby was admitted to the hospital. Two swabs of genital lesions and one swab of a foot lesion were positive for HSV-1 by PCR. In both cases, the location of lesions, timing of signs and symptoms, and laboratory identification of HSV are consistent with transmission of HSV during direct contact between the mouth of the ritual circumciser and the newly circumcised infant penis.
Diagnosis, Reporting, and Specimen Collection
For detailed guidance regarding diagnosis, reporting, specimen collection, and specimen shipping and handling, please refer to Health Alert #2 (January 28, 2014). The purpose of this Health Alert is to remind providers:
1. When evaluating an ill infant male in the weeks following circumcision, providers should inquire whether direct orogenital suction was performed during circumcision and consider infection with HSV or other oral pathogens.
2. Babies suspected of having HSV infection should be immediately admitted to a hospital and treated presumptively with intravenous acyclovir.
3. Health care providers diagnosing herpes infection in infants aged 60 days or younger are required by law to report the infection to the Health Department within 24 hours of diagnosis.
4. Providers evaluating infants 60 days or younger with suspected HSV infection are required by law to collect specimens from one or more vesicles (if present) or from any skin lesions suggestive of herpetic disease, and to send these swab(s) to the New York State Wadsworth Center Laboratories for diagnostic testing using molecular methods.
Jay K. Varma, MD
Division of Disease Control