The results of a protocol successfully put into place by the Rockland County Health Department with the close cooperation of the local Orthodox community became public, and has sparked mounting calls on the NYC Health Department to revise its policy on metzitzah b’peh (MBP).
As described in last week’s weekly Hamodia, the Rockland protocol uses cutting-edge DNA testing to determine the source of herpes infection in infants. While the vast majority of neonatal herpes cases in the City are either females, or are males who did not have MBP, the NYC Health Department has repeatedly asserted that HSV-1 herpes infections found in infant boys who underwent a bris that included MBP was caused by the mohel.
Over the two-year period that the protocol has been in effect, eight cases were presented to the Rockland County Health Department. Five were conclusively determined not to be HSV-1. Of the remaining three, the mohalim were tested under the terms of protocol. One led to an inconclusive result, as not enough virus was detected in the mohel to warrant DNA testing. In the other two cases, it was conclusively determined that the mohalim were not a DNA match to the respective infants.
In response to an inquiry by Hamodia, Dr. Oscar Alleyne, director of Epidemiology and Public Health Planning for the Rockland County Health Department, declined to discuss specific cases, but he did agree to discuss the protocol in general.
“We have seen cases where the cause of the HSV in infants was not the person performing MBP. This is why a comprehensive investigation looking at all potential point sources of infection is necessary from the Rockland County DOH’s perspective,” Dr. Alleyne said.
In the Rockland County’s protocol, individuals deemed to possibly be sources of the infection submit to genetic testing for HSV. During the testing period, if a mohel is one of the individuals being tested, he refrains from performing MBP until the testing is concluded and the results come back from the lab. If a DNA match is found linking an individual to the baby, the Health Department will recommend that strict infection control practices be put in place to reduce the potential for further or future exposure to babies. If a mohel is linked to the baby, the protocol — which was entered into with the guidance and under the approval of Rabbanim in both Rockland County and New York City — calls for the mohel to no longer perform MBP for the rest of his life anywhere, locally or internationally.
“For 10 years, New York City has refused the community’s offer to do DNA testing,” said Yerachmiel Simins, an attorney who has served as legal consultant to interrogated parents and mohalim, and as community liaison in the Rockland initiative to set up DNA testing. “They said the presence and timing of lesions, and maybe even a generic HSV test result, is all the proof they needed that MBP ‘caused’ HSV-1, justifying their knee-jerk ban on any mohel they could find that was merely ‘associated’ with a case. The two definitive non-matches that occurred in Rockland could not be a clearer refutation of the City’s hypothesis.”
Simins argued that the City’s approach actually put the infants’ lives at risk.
“The City’s tunnel-visioned approach overlooked other possible sources of transmission, a fact we also implored them about all this time, allowing these other transmitters to continue unabated. If the City were truly interested in public health, they would have abandoned their benighted approach long ago. It’s high time they admit their mistake, take off their blinders, and embrace a more objective and scientific methodology.”
In a conversation with Hamodia, a relative of an infant who was diagnosed with HSV-1 in New York City says that City officials focused exclusively on the mohel.
“After the test came back positive, the authorities informed us that ‘It has to be the mohel,’” the relative, who asked not to be identified, related. “They didn’t even want to consider any other possibility.”
According to Simins, the Rockland County protocol also proves that the community — and the mohalim — are more than willing to cooperate with an unbiased health department.
“Rockland County Department of Health had 100 percent cooperation of all mohalim in the three confirmed cases to be tested under the protocol. In one case, the mohel had to travel numerous times — at his own expense; he wouldn’t take money for the mitzvah — from Montreal to Monsey for his testing.”
The Rockland County Health Department readily confirmed the cooperation of the community.
“Since we developed our local protocol, we have had significant cooperation and full access to the community as we have been conducting these investigations, with clear and open lines of communications,” Dr. Alleyne said. “In fact, in a number of instances, the community self-reported suspected cases so they can be evaluated and we can ensure that proper treatment is in place, if it turned out to be a confirmed case.”
Simins had a message for New York City: “The community never wanted to go into lockdown, but they had no choice. Stop the attack on MBP and let’s work together to address the real causes of neonatal herpes,” the attorney pleaded.
Hamodia inquired as to whether the Rockland results called into question New York City’s assumptions about past cases, but the NYC Health Department didn’t respond directly as to whether it will now rethink its approach regarding DNA testing.
Instead, employing medical jargon, the City argued that, among other reasons, the specific type of herpes, the timing of the infection, the clustering of cases and an absence of alternative hypothesis support their position.
“Any ‘hypothesis’ is just that — a hypothesis,” says Simins. “It is merely a theory, which may or may not be borne out by evidence obtained through observation. Here, we have clear, unequivocal results that provide the best evidence possible: In these cases, at least, the theory simply is not true. And, of course, that has tremendous, and negative, implications for the theory as a whole.”
In a conversation with Hamodia, Dr. Daniel S. Berman, an Infectious Diseases attending physician at Montefiore Medical Center, cited an example of a medical hypothesis presented in the literature that turned out to be wrong.
“There was a theory put forth by prominent virologists in the mid-1980s that chronic Epstein-Barr virus (EBV) infection was associated with a state of chronic fatigue and malaise,” Dr. Berman recalled.
“I have personal recollection of listening to a presentation, when I was a medical resident at the New York University Medical Center, on the subject presented by the leading author of one of the articles, Dr. Straus, a prominent virologist, working for the NIH at the time. I remember the excitement of this finding that there was an explanation for primarily young adults with chronic fatigue.”
Yet this theory has since been discredited, Dr. Berman says. According to the seventh edition of Principles and Practice of Infectious Diseases, which is, according to Berman, “probably the most prestigious textbook of infectious diseases,” the initial suggestion that persistent Epstein-Barr infection is a frequent cause of fatigue and malaise “has become untenable on the basis of serologic and epidemiologic observations.”
Simins says that the Rockland county DNA results are in themselves sufficient reason that NYC should change its approach.
“Let’s be clear: This is not to say that it is impossible for HSV-1 to be transmitted via MBP that is not performed properly; i.e., with all the safety precautions that conscientious mohalim use, such as disinfecting prior to circumcision. But these results are definitive proof that the City’s approach is categorically wrong — and dangerous, for it not only ascribes exclusive transmission to a practice that has now been proven not to be the route in these cases, but it overlooks the routes that were,” Simins added.
“If the City were truly interested in public health, and not just in an anti-MBP agenda, they would embrace these results, abandon their approach and acknowledge the benefits of collaboration instead of confrontation,” Simins concluded.
A version of this story appeared in Tuesday’s daily edition.