Saturday, February 7, 2015

NEW YORK: Metzitzah: Rockland adopts own protocol

Capital (New York)
Janauary 9, 2015

Rockland takes a new tack on risky circumcisions

While New York City remains stalled in its efforts to come up with a better way of regulating a controversial circumcision ritual practiced by some Orthodox Jewish sects, Rockland County health officials made a deal with a local community to create a protocol to assess and mitigate risks associated with the practice.

The ritual, called metzitzah b'peh, involves a mohel—the practitioner of the circumcision ritual—suctioning blood from a baby's wounded penis with his mouth. The practice of placing mouth to open wound has been linked by city health officials to the spread of Herpes Simplex Virus-1 to babies.

The protocol worked out in a nonbinding agreement between health officials and community leaders in Rockland County—home to one of the state's largest concentrations of ultraorthodox Jews—is as notable for what it doesn't attempt do to as what it does.

It doesn't alter the ritual, or require parents of boys undergoing it to sign a waiver acknowledging the dangers of the practice, as New York City currently requires. It also doesn't immediately eliminate the risk of babies contracting herpes from infected mohels.

But it does, by securing the cooperation of a deeply religious community that is sometimes hostile to regulation by secular authorities, allow for testing and data-gathering to identify and ban mohels who infect circumcised babies with herpes.

Per the agreement between the county health department and community leaders, if a mohel is found to be the direct source of a baby contracting HSV-1, then that mohel would be permanently banned from performing the ritual, according to Dr. Oscar Alleyne, the county's director of epidimiology.

The Rockland health department has so far tested eight babies who presented with herpes symptoms after circumcision, Alleyne said. Of those, three had the virus. In two cases, the Rockland health department concluded the mohel was not responsible. One case was inconclusive.

“From Rockland County's perspective, the individuals who did the metzitzah b'peh were not the ones who matched, and that tells us we have to look at the bigger picture,” Alleyne said.

It's a very small sample, but the effort attempts to address, however imperfectly, the health-based concerns about the practice.

Of the cooperation with the Orthodox community, Alleyne said, “That in and of itself was a major breakthrough."

Under the system set up in Rockland, if a state lab determines a circumcised baby has HSV-1, county officials work to identify all the potential point sources that come into contact with the infant. Those individuals are then swabbed and tested to see if they have HSV-1 and if their strain matches the infant's. Because the virus is not always detectable, the county conducts 60 swabs over a period of 30 to 60 days to try and ensure that nothing is missed.

The agreement also requires mohels not to perform the ritual on other babies while testing is taking place, and Rockland health officials are discussing additional measures that can make the practice more hygienic.

The community has agreed, according to Alleyne, that if a mohel is found to be the cause of infection then he will voluntarily stop performing anywhere in the world for the rest of his life.

The agreement between Rockland and the Orthodox communities there—the largest communities are in Monsey and New Square—is similar to one that was discussed with the New York City health department in 2006. That plan was rejected by the city, according to court documents.

By only testing mohels after the fact of an infection, the system can reduce but never actually eliminate the health risk. And it leaves in place a ritual that is unhygienic and, according to New York City health officials, among others, inherently dangerous.

But Alleyne says it is clearly the best option available to the county.

“We are a health department," he said. "We can't legislate the procedure. We don't have the ability to do so and there is the question of how efficacious it would be anyway. But there are ways for us to encourage practices to be safer.”

New York City's efforts to reckon with metzitzah b'peh would seem to bear him out, in terms of the difficulty of imposing a more aggressive system of regulation.

The issue has been a live controversy in New York City since the Bloomberg health department first sought to regulate the practice by requiring that parents sign a consent form acknowledging that the city health department does not believe the ritual is safe.

The regulation was challenged in court. Attorneys representing the Orthodox sects said the city's health department was overestimating the dangers, and that there was insufficient evidence to prove metzitzah b'peh is dangerous enough to warrant a public health intervention.

Mayor Bill de Blasio promised to address the consent-form arrangement—which the neither the city nor the Orthodox sects affected by it were happy with—on his first day in office. But he has yet to address the topic in any meaningful way.

Marti Adams, a spokeswoman for the mayor, told Capital the administration plans to unveil a policy "soon," but did not detail what that policy would be.

"The administration is working to develop a new, more effective policy that protects children and protects religious rights in a way that the community is comfortable with, and accepting of, and will participate in," Adams said. "We expect to announce this new policy soon.”

The city's efforts to regulate the ritual are complicated politically by the resolute opposition of the Orthodox sects who support unfettered metzitzah b'peh, but legally, by courts rulings that have made it clear that the practice can't simply be banned for being distasteful.

A federal appeals court ruled any city effort to infringe upon the practice must pass the “strict scrutiny” test, meaning the government must prove the law serves a compelling state interest and that it was written in the least burdensome way possible. The case was sent back to the lower court and has not yet been heard.

The city's health department has for years warned the practice can spread HSV-1, which is common in adults but can be dangerous for newborns.

City health officials have linked 17 cases of neonatal herpes to direct oral suction in the last 15 years. Of those, two have died and two more suffered brain damage.

The city maintains the timing and placement of the lesions is indicative of a virus that was caused by oral suction, and produced several expert witnesses who supported the claim.

Dr. Anna Wald, who assisted in drafting guidelines on the management of H.S.V. infection for the Centers for Disease Control and Prevention, said the evidence linking direct oral suction with neonatal infection is “strong, consistent, and more than biologically plausible.”

The health department argues that there are multiple lines of evidence supporting their assertion. Specifically, health officials say that no other explanation makes sense.

"Any hypothesis to explain these infections needs to explain why these infections are HSV-1, not HSV-2, occur on the genitalia, occur in newborn baby males but not females from Jewish families practicing direct orogenital suction, are clustered in a single Brooklyn zip code where there are no female infant herpes infections, have occurred in babies born to women who do not have HSV-1 infection, and occur within a time frame consistent with transmission during circumcision," said Jean Weinberg, a spokeswoman with the health department.

But without reaching an agreement with the mohels the way Rockland did, the city can't do the tests necessary to prove beyond a reasonable doubt that infected mohels cause the spread of the disease.
That's why city officials use phrases such as “the location … timing of signs and symptoms are consistent with” metzitzah b'peh.

Between 2006 and 2011, the city reported 84 cases of neonatal herpes. Among those, 30 boys had HSV-1 or untyped HSV infection, and five of these boys had confirmed or probable direct orogenital suction.‎ (The disease can also be passed on to babies by family members or other caregivers.)

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