Monday, April 24, 2017

MbP and Herpes - Alive and Well

Circumcision - tools of the trade (JTA)
Jewish newborns are still at risk for an entirely preventable health problem in the form of MbP (Metzitza B’Peh or Metzitza b’Feh if you prefer the more grammatically correct term). Little has changed. The Herpes Simplex Virus Type 1 (the common cold sore) is alive and well and still available to seriously affect the health of your child.

In case anyone has forgotten, Metzitza B’Peh is the ritual performed immediately after a newborn male baby is circumcised – usually 8 days after his birth. The purpose for this procedure - which involves drawing blood out of the circumcision wound - is explained in the Gemara as a Halachicly required health procedure. The method used to do that has for centuries been via direct mouth to wound oral suction by a Mohel.

The problem with the herpes virus is that a Mohel can be infected without being symptomatic in the early stages. So that unaware he places his herpes infected  mouth directly on a baby’s open circumcision wound easily leaving it open to infection.

As I’ve noted in the past many times, the Gemarah does not mention how to draw out the blood (Metziza). It just tells us to do so. Doing it B’Peh (by mouth) developed post Gemarah. And for centuries was considered the most efficient way to fulfill the Metzitza requirement. Until the discovery of micro organisms that can negatively affect the baby’s health.

Mohalim that do MbP are aware of the problem and still do it, claiming that they rinse out their mouth with antiseptic and the transfer of herpes to a baby via MbP is extremely rare and unproven in any case.

Unproven and rare though it may be, many Poskim – even as early as the 19th century have ruled that one may fulfill the Gemarah’s Metzitza requirement by using a sterile pipette that avoids direct contact, or a piece of gauze.

The problem is that most Chasidim believe that one MUST use the mouth. And as the Chumra chaisng world turns these days many non Chasidim prefer it be done that way, too. Most Mohalim will accommodate the parents. Some Mohalim will not do it any other way!

So what’s the problem? Well, disinfectants do not do the job. A herpes virus can withstand those disinfectants and cause the baby serious health problems and even death.

This came to a head a few years ago when there were a couple infant deaths via herpes contracted around the time of the circumcision.  Although there was never any direct proof that MbP was the cause - the circumstantial evidence was pretty strong.

In an attempt to protect the health of infants that undergo circumcision, New York City’s health department – backed by then Mayor Michael Bloomberg mandated a consent requirement. Parents that wanted a Mohel to do MbP had to sign a form stating that they understood the dangers of their newborn being infected and still wanted to do.  

A battle royal ensued. Chasidim felt they were being denied their religious freedom. They were backed by Agudah who joined them in fighting this new rule.

I supported consent requirement. I did not feel it violated the religious rights since it did not ban the procedure itself. Knowledge is power.

There were those that felt this requirement did not go far enough since the risk of a herpes infection still existed.

I understand that. But as long as a parent is informed and the risk is relatively low I felt that informed consent was the best compromise. The Chasidic community and Agudah didn’t like it, though. They felt it was an undue infringement of their religious rights. Adding that a consent form unfairly stigmatized MbP - and opened up a slippery slope to banning circumcision altoghter.

Shortly after that New York elected a new mayor, Bill de Blasio. He had  promised Chasidic voters he would revisit this issue if he was elected. He kept his promise. In a deal reached with Chasidic leaders and Agudah, de Blasio canceled the consent requirement. Instead it was agreed by all parties that the public be made aware of the problems with MbP and that Mohalim would be carefully monitored. If found to have infected a baby with herpes by doing it, they would be banned for life.

I am not happy with that compromise. But I guess it’s better than nothing. I am not happy because despite the claims made by supporters of MbP that there is no direct DNA type biomedical proof that any Mohel ever infected a baby with herpes via MbP - there is plenty of circumstantial evidence that they did. 

The argument that there is no direct biomedical connection yet established sounds like the old argument made about cigarette smoking and lung cancer. The evidence was only statistical. In fact I believe the direct cause is still not known. Is there anyone that would make the same argument about smoking they are making about MbP?!

It isn’t only about a baby dying - a distinct but rare possibility. It is about causing permanent damage to a baby that survives the infection. Here is how Rav Hershel Shachter feels about it (From a 2013 Forward article): 
In a public lecture last February in London, Schachter, who is a rosh yeshiva, or senior chief rabbinic authority, at Y.U.’s Rabbi Isaac Elchanan Theological Seminary, claimed that his daughter’s hospital treated three cases per year of Hasidic babies infected with herpes. The infections were “obviously because of metzitzah b’peh,” Schachter told his audience. 
4 babies per year seen in just one hospital in one city! If I were a parent with a newborn baby boy, I would demand that MbP NOT be used. Sure, the chances are low. But not low enough for me. Especially when we can have a 100% guarantee that a Mohel will not affect a baby by MbP by not doing it at all – instead using one of the sterile methods described above.

He added that his daughter said these cases are under reported by her hospital because their Chasidic clients would not return if they were made public!

The reality is that babies are still contracting herpes from infected Mohalim that do MbP. The people that prefer it for religious reasons are unmoved by any warning issued by their community or their Mohel – even assuming they get one. They want the ‘Frummest’ circumcision they can get.  And that means that MbP is a foregone conclusion and not negotiable. Besides - they’ve seen it used so often without consequence that it simply does not enter their minds that there is any danger.

But what if it does happen? Is the Mohel going to be banned as agreed upon by Chasidic leaders and Agudah? Not so much, I guess. From a JTA article
The New York City Health Department said it cannot complete an investigation into who infected four infants with herpes through a circumcision rite because the boys’ fervently Orthodox families will not identify the mohels. 
“Unfortunately, some in the community are resistant to sharing the name of the mohels,” Health Department spokesman Christopher Miller told DNA info New York on Tuesday. “This is a very insular community.” 
According to DNAinfo, six families in Williamsburg, Brooklyn, have seen children contract herpes since 2015 from metzitzah b’peh, which involves the ritual circumciser, or mohel, cleaning the circumcision wound by oral suction. Among the six families, only two have provided the names of their mohels, Miller said. 
In March, the city ordered those two mohels to stop performing metzitzah b’peh. 
How sad that babies in any number are subject to such preventable risks. How sad for their parents who now suffer the consequences of having been needlessly convinced that MbP is the best way to fulfill Halacha. Because I am convinced that it is a terrible way to fulfill the Mitzvah of Pikuach Nefesh.