Date: Mon, 24 Feb 2020 at 16:19
Subject: NYC DOHMH Alert # 2 – Three New Cases of Neonatal Herpes Infection Following Ritual Jewish Circumcision
Dear Health Alert Network (HAN) Subscriber:
2020 ALERT # 2
Three New Cases of Neonatal Herpes Infection Following Ritual Jewish Circumcision
Please Share this Alert with All Obstetrics, Pediatrics, Pediatric Infectious Disease, Dermatology, Emergency Medicine, Infection Control, and Microbiology Laboratory Staff
• Three new cases of neonatal herpes following ritual Jewish circumcision have been reported to the NYC Health Department since December 1, 2019.
• Providers should consider herpes infection in male infants presenting with vesicles, pustules, or ulcers on the genitals or correlated dermatomes (e.g., foot, ankle, buttocks) following ritual circumcision.
• Infants suspected of having herpes simplex virus (HSV) infection should be hospitalized immediately and treated with intravenous acyclovir.
• There are measures mohelim may take to reduce, but not eliminate, the risk of neonatal herpes transmission during ritual Jewish circumcision. Mohelim performing direct orogenital suction (DOS) should rinse their mouth with alcohol-containing antiseptic mouthwash immediately before performing DOS.
• Providers are encouraged to distribute the Health Department’s brochure, “Have a Safe Bris for Your Baby” to expectant parents and/or new parents who visit your office or facility. This is also available in poster format.
February 24, 2020
Direct orogenital suction ((DOS), also called metzitzah b’peh) is a ritual Jewish circumcision practice during which a mohel (religious circumciser) uses his mouth to suck blood away from the penile circumcision wound. DOS can transmit herpes simplex virus (HSV) to newborn males, which can cause severe infection resulting in brain damage and death.
Since December 1, 2019, three male infants were diagnosed with neonatal herpes in New York City following ritual Jewish circumcision, with the most recent case reported in January 2020. In one of the three cases, hospitalization was delayed because health care providers did not recognize the signs and symptoms as indicative of herpes infection. Ultimately, all three babies were admitted to the hospital, received intravenous acyclovir, and are recovering.
Since April 2006, when neonatal herpes reporting became mandatory in NYC, there has been a total of 169 babies (male and female) with laboratory-confirmed neonatal herpes infection. Among these, 22 (13%) developed their infections following ritual Jewish circumcision.
Diagnosis, Reporting, and Specimen Collection
Clinicians should be alert to the signs and symptoms of neonatal herpes, especially in newborn males who have had ritual Jewish circumcision. Signs and symptoms may include a vesicular, pustular, or ulcerative rash, fever, poor feeding, irritability, and/or lethargy, in the weeks following DOS. Skin lesions typically appear on the genitals, groin, buttocks and ankle/foot [these areas represent related dermatomes] following DOS. However, fever and rash are not always present; thus, a history of DOS should raise suspicion for an atypical presentation of neonatal herpes. Babies suspected of having HSV infection should be immediately admitted to the hospital and treated presumptively with intravenous acyclovir. Do not use oral or topical forms of acyclovir to treat presumptive or confirmed herpes infection in a newborn.
In addition, clinicians diagnosing herpes infection in infants <60 days of age are required by law to report the infection to the NYC Health Department within 24 hours of diagnosis; specimens from one or more vesicles (if present) or from any skin lesions suggestive of herpetic disease must be collected and sent to the New York State Wadsworth Center Laboratories for molecular testing. For detailed guidance regarding diagnosis, reporting, specimen collection, and specimen shipping and handling, please refer to 2014 Health Alert #2 (January 28, 2014) at: https://www1.nyc.gov/assets/doh/downloads/pdf/han/alert/alert2-12814.pdf
Reducing the Risk of Neonatal Herpes Transmission During Ritual Jewish Circumcision
Parents who choose ritual Jewish circumcision for their son may not be aware that DOS will be performed or that it carries a risk for HSV transmission to their newborn. The NYC Health Department works to educate parents in communities where DOS may be practiced. In 2017, the Department distributed brochures entitled “Have a Safe Bris for Your Baby” and companion posters to NYC health care providers, including obstetrician/gynecologists and pediatricians. Hospitals where infants with DOS-related neonatal herpes have been born or admitted are asked to distribute the pamphlet to pregnant women admitted for labor and delivery and prominently display the poster in prenatal and labor and delivery areas. The Department has also performed outreach to providers serving communities where DOS may be practiced. Providers were reminded to remain vigilant for possible herpes infection following circumcision among their patients and to educate parents about the risk of DOS and the signs of possible herpes infection following circumcision. Hospitals and health care providers serving communities where DOS may be practiced should distribute “Have a Safe Bris for Your Baby” to expectant parents and new parents who visit their office or facility. This brochure (also available in poster format) is available at: nyc.gov/safebris.
Avoiding DOS during ritual Jewish circumcision is the only way to effectively eliminate the risk of herpes transmission during the bris. Parents and mohelim who plan on a circumcision that may include DOS should be informed of the following steps which may reduce, but not eliminate, the risk of disease transmission:
• Antiseptic mouthwash (specifically, Listerine™ Original Gold, with 26.9% alcohol) can reduce viable herpes virus in the saliva. Mohelim who perform DOS should rinse their mouths well with such mouthwash for at least 30 seconds in the 1-2 minutes immediately before performing DOS.
• In addition, all mohelim should: (1) use sterile instruments for the circumcision procedure; (2) wash their hands with a chlorhexidine-containing soap (e.g., hibiclens) for at least one minute using a brush to scrub under the fingernails; and (3) use an alcohol-based sanitizer (e.g. Purell) over the entirety of both hands and in and around the fingernails for at least 20 seconds before performing the bris.
Key Points for Providers:
1. When evaluating male infants with signs suggestive of neonatal herpes infection in the weeks following out-of-hospital circumcision, providers should inquire whether DOS (metzitzah b’peh) was performed and consider infection with HSV or other oral pathogens.
2. Neonates with herpes infection may not present with classic, grouped vesicular skin lesions and may be afebrile.
3. Babies suspected of HSV infection should be immediately admitted to the hospital and treated presumptively with intravenous acyclovir. Do not use oral or topical forms of acyclovir to treat presumptive or confirmed herpes infection in a newborn.
4. Health care providers diagnosing herpes infection in infants <60 days of age are required by law to report the infection to the NYC Health Department within 24 hours of diagnosis.
5. Providers evaluating infants <60 days of age with suspected HSV infection are required to collect specimens from one or more vesicles (if present) or from any skin lesions suggestive of herpetic disease and send the swabs to the New York State Wadsworth Center Laboratories.
6. Distribute the Health Department’s pamphlet “Have a Safe Bris for Your Baby” to expectant and new parents who visit your office or facility.
Inform parents and mohelim of the utility of using antiseptic mouthwash (specifically, Listerine™ Original Gold) products when planning a ritual Jewish circumcision where DOS may be performed.
Questions about diagnosis, reporting, and specimen collection may be directed to Dr. Julia Schillinger at (347) 396-7296. Questions about the pamphlet may be directed to Dr. Diana Sanchez at (347) 396-7311. Call 311 to order free copies of the pamphlet or poster in English and Yiddish. For electronic copies, please visit the Safe Bris webpage: nyc.gov/safebris.
Demetre C. Daskalakis, MD, MPH
Division of Disease Control
NYC Department of Health and Mental Hygiene
Julia A. Schillinger, MD, MSc
Director of Surveillance
Bureau of Sexually Transmitted Disease Control
Susan Blank, MD, MPH
Bureau of Sexually Transmitted Disease Control
Certain diseases and conditions are required by law to be reported to the NYC Health Department. For an updated list of reportable diseases and conditions and instructions on how to report, please visit: nyc.gov/health/diseasereporting.