Controversial circumcision technique likely route of herpes transmission

New York -- Despite a move away from the practice in the mid-1800’s, some strictly Orthodox Jews still use their mouths to suck the site of circumcision during a bris. According to a new assessment, this practice was the likely cause of infant herpes in more than two dozen reported cases.

“There’s a lot of confounding things going on you can’t report for, but a lot of circumstantial factors in all or at least most of these cases point at sucking being the source of transmission,” said lead author Brian F. Leas of the Center for Evidence-Based Practice at the University of Pennsylvania Health System in Philadelphia.

The American Academy of Pediatrics recognizes that circumcision is generally very safe and has some health benefits, but specifically orogenital suction should not be done, Leas told Reuters Health by phone.

Many Jewish authorities have also spoken out against the practice.

But recently, a handful of male babies in the strictly Orthodox, or Charedi, Jewish community of New York City were diagnosed with herpes simplex type 1 (HSV-1) infections. More than half of U.S. adults carry this virus, which can manifest as cold sores. Since this is not genital herpes, which could be present in the birth canal, very few infants contract it.

According to the new report, past cases of this infection following circumcision with oral suction were likely due to this traditional technique.

In the report, the authors review six published case series or case reports documenting 30 cases of infant HSV-1 infection between 1988 and 2012 in New York, Israel and Canada.

The case reports differed in format, but all 30 male infants presented with genital lesions in the days following circumcision, which is consistent with viral transmission at that site, the authors write in the Journal of the Pediatric Infectious Disease Society.

In some cases, the men performing the circumcision, called mohels, underwent blood tests and in every case tested positive for HSV-1. In other cases, the mohels declined to be tested.

The infants’ symptoms ranged from mild to severe, and in two cases the infection was fatal.

There was never definitive proof that oral suction was the source of the infection, but it is the most likely answer in each case, Leas said.

It’s extremely hard to estimate how often these infections happen or how often this type of circumcision is done, even with the surveillance program currently in place in New York, he said.

In 2012, The Centers for Disease Control and Prevention recommended that doctors counsel parents considering out-of-hospital Jewish ritual circumcision about the risk of herpes infection, and that physicians take this possibility into account when treating an infant with genital lesions or fever who was recently circumcised.

“We knew from the beginning from a straightforward biological standpoint, a risk exists as soon as you do the procedure this way,” Leas said.

The Jewish community has repeatedly given mohels permission to skip the traditional “metzitzah b’peh,” or oral suction part of the ritual.

In 2005, the Chief Rabbinate of Israel and the Rabbinical Council of America reaffirmed the legitimacy of using instrumental suction instead of oral suction, and in 2012 the Israeli Association of Pediatrics published an official statement in which it strongly advised parents to refrain from using mohels who practice oral suction, and encouraged the Israeli Ministry of Health to disallow the practice.

Only a very small percentage of the Jewish community continues with the practice, said Dr. Ilan Youngster, who noted the above measures in an editorial accompanying the new report.

Youngster, of the Division of Infectious Diseases at Boston Children’s Hospital in Massachusetts, is originally from Israel and did his medical training there.

“The vast majority of circumcised kids are not subject to oral suction, not here and not in Israel,” he told Reuters Health by phone. ”But there is no registry so we have no idea how many kids really contract this kind of infection.”

Discussions in New York about requiring parental informed consent for circumcisions with oral suction have stalled, with some in the Charedi Jewish community viewing any regulation of ritual as religious persecution.

“The best way to go about this is together with the religious authorities, when you have people coming from this background who are also part of the medical community who can act as liaisons,” Youngster said.

Three new cases have been reported in New York City among the Charedi Jewish population in 2014, with two in July alone, according to The Jewish Week newspaper.

“What we hope is for an awareness that whether or not religious practice changes in New York or anywhere else, physicians who are in a position who work with these parents or families keep this in mind,” Leas said. “If a parent calls their pediatrician and a two week old boy has fever and rash in the genital area, 99 percent of the time it will be something else and the physician may never consider this as a possibility, may not test for this.”

“Treating very early with antivirals, most babies do recover and don’t have long lasting symptoms,” he said.