Jewish Circumcision Ritual Baby Deaths May be Preventable with Prophylactic Treatment
Recent news reports tell us that the Jewish circumcision ritual called “metzitzah b’peh”—or oral suction—in which a mohel places his mouth directly on a newborn’s circumcised penis to suck away blood during the religious rite/procedure has led to multiple instances of herpes virus infection and in some cases—death of newborn infants.
Herpes simplex virus (HSV) is a common cause of cold sores (HSV-1) and genital herpes (HSV-1 and HSV-2). The problem with herpes simplex virus is that the cold sore type is present without symptoms in the mouths of a large portion of adult society and is considered to be ubiquitous. While for many, this type of infection results in little more than an occasional open sore on the mouth, for infants it can mean permanent disability or death.
The report of infections and deaths of infants from the circumcision practice was made public recently in the CDC’s Morbidity and Mortality Weekly Report, which revealed that a study has found that between November 2000 and December 2011, eleven newborn males in New York were diagnosed with an HSV infection that resulted in 10 hospitalizations and 2 deaths.
The cause of the HSV infections was attributed to the aforementioned ultra-Orthodox Jewish circumcision ritual metzitzah b’peh. In the study, researchers determined that the risk of an infant contracting an HSV infection in New York is 3.4 times greater with oral contact from the circumcision ritual than without.
The researchers point out that any oral contact with a newborn’s circumcised penis increases the risk of not just HSV, but numerous other pathogens as well and therefore that circumcision should be considered to be a surgical procedure requiring aseptic conditions. Health-care professionals are advising Jewish parents that the oral-genital suction part of the ritual should be avoided.
However, recommendations of avoiding the oral-genital part of the ritual is problematic in that they are essentially asking ultra-Orthodox Jews to change a religious rite that has been in practice for many years and has special significance that cannot be easily dismissed. Where does freedom of religion and its practices fit in with the protecting the health and safety of a newborn?
This may be an unsolvable problem, but for now science may offer an acceptable compromise that can save lives—prophylactic treatment with an antiviral medication such as acyclovir.
In an article published last November in the journal Pediatrics, researchers found that delayed initiation of acyclovir therapy in neonates with herpes simplex virus (HSV) infection is associated with in-hospital mortality, while earlier treatment decreases mortality.
In the study, researchers from the Children's Hospital of Philadelphia assessed the correlation between delayed treatment with acyclovir and death in 1,086 infants with HSV infection who were on average 10 days old. Early treatment was defined as administration of acyclovir within one day of hospital admission, whereas delayed treatment was defined as between 1 and 7 days following admission.
Of the 1,086 infants 24.1 percent received delayed acyclovir administration, of which 86.2 percent of these cases the acyclovir was given on the second or third day of hospitalization. The mortality rate of the infants who were delayed in receiving antibiotic treatment was 9.5 percent, while the mortality rate of infants receiving acyclovir within the 1st day of hospitalization was 6.6 percent.
The authors of the study determined that early treatment with acyclovir saves lives and wrote that, "Delayed initiation of acyclovir therapy was associated with in-hospital death among neonates with HSV infection. Our data support the use of empiric acyclovir therapy for neonates undergoing testing for HSV infection."
According to a recent article in The Hospitalist, the decision to use empiric acyclovir therapy is typically delayed because “…symptoms upon presentation may be nonspecific and testing may take several days, clinicians must often decide whether to initiate empiric therapy with acyclovir.”
However, if as in the case of the Jewish circumcision ritual metzitzah b’peh, where there is a known risk of a newborn infant contracting an HSV infection from the mohel, would not prophylactic treatment with acyclovir be a sensible compromise until this religious/health issue is resolved? Or at the very least, a strong mohel mouthwash or some other means to make conditions as aseptic as possible?
Clearly, a Jewish circumcision ritual that places babies at an increased health risk is going to raise a significant amount of controversy. But before we jump on a bandwagon that says that this is an unsavory practice that needs to be stopped immediately, we would do better to try to understand the practice and find solutions or compromises that are both respectful and helpful.
Image Source: Courtesy of Wikipedia
“Delayed Acyclovir Therapy and Death Among Neonates With Herpes Simplex Virus Infection” Pediatrics Vol. 128 No. 6 December 1, 2011 pp. 1153 -1160; Samir S. Shah, MD et al.
The Hospitalist June 2012: “Empiric Acyclovir Recommended for Potential Neonatal Herpes Simplex Virus Infection” by Mark Shen, MD.