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Persons using assistive technology might not be able to fully access information in this file. Herpes simplex virus (HSV) infection commonly causes "cold sores" (HSV type 1 [HSV-1]) and genital herpes (HSV-1 or HSV type 2 [HSV-2]); HSV infection in newborns can result in death or permanent disability.
In November 2004, DOHMH was notified of twin male infants who developed disseminated HSV-1 infection following ritual circumcision (Table 1, cases 3 and 4); one died. Investigation of 14 hospital staff members who cared for the infants after birth found no clinical evidence of current HSV infection and no history of HSV infection in the preceding 2 years. During the investigation, DOHMH learned of a 2003 case of neonatal HSV-1 infection following Jewish ritual circumcision that included direct orogenital suction by mohel A (Table 1, case 2).
In 2005, DOHMH learned of three additional cases of neonatal herpes infection following Jewish ritual circumcision with confirmed or probable direct orogenital suction. In April 2006, DOHMH established population-based surveillance for neonatal herpes by modifying the New York City Health Code to mandate that laboratories report any laboratory test result indicating the presence of HSV in specimens from infants aged ?60 days and that health-care providers report any infant aged ?60 days receiving a diagnosis of herpes infection, even if laboratory confirmation is lacking.
Cases of laboratory-confirmed HSV-1 or untyped HSV infection in male infants were investigated to determine date of illness onset and whether ritual circumcision had been performed and had included direct orogenital suction. To estimate the relative risk for neonatal herpes following Jewish ritual circumcision with confirmed or probable direct orogenital suction, neonatal HSV cases reported from April 2006 through December 2011 were used to construct incidence rate numerators, and New York City vital statistics for live male births were used for incidence denominators. To estimate the number of males potentially exposed to direct orogenital suction each year, first the number of males entering full-day or half-day kindergarten in Jewish day schools in New York City in 2010 was obtained (6,197) (1).
Efforts made by DOHMH to prevent neonatal herpes included meetings with ultra-Orthodox Jewish community leaders to urge mohel A to stop practicing direct orogenital suction during circumcision and issuing an alert to health-care providers and an open letter to the Jewish community warning that the practice poses a health risk. Previous reports have described neonatal HSV-1 infection following Jewish ritual circumcision that included direct orogenital suction (3,4), including two additional cases in New York City occurring 10 years apart (5) that are not included in this report. For the 11 cases described in this report, transmission from the mother or health-care workers was largely excluded, and the preponderance of evidence pointed to acquisition during orogenital suction. Preventing the practice of direct orogenital suction is difficult, because ritual circumcision is a religious practice that usually occurs outside of health-care facilities. Physicians should counsel parents considering out-of-hospital Jewish ritual circumcision about the risks associated with direct orogenital suction and, when evaluating a recently circumcised male infant with herpes infection, inquire about direct orogenital suction. Cases of neonatal herpes simplex type 1 (HSV-1) infection following Jewish ritual circumcision with direct orogenital suctioning of the circumcision site have been reported in the United States, Canada, and Israel. This report describes the largest series of cases (11) of neonatal herpes associated with Jewish ritual circumcision with direct orogenital suction, and is the first to estimate relative risk.
Circumcision is a surgical procedure that can transmit infection if not performed under sterile conditions. Alternate text: The figure above consists of 11 timelines, showing the number of days between Jewish ritual circumcision and appearance of herpes lesions, among 11 male infants with neonatal herpes following Jewish ritual circumcision with confirmed or probable orogenital suction in New York City, during 2000-2011.
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An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. During November 2000–December 2011, a total of 11 newborn males had laboratory-confirmed HSV infection in the weeks following out-of-hospital Jewish ritual circumcision, investigators from the New York City Department of Health and Mental Hygiene (DOHMH) learned.
The twins were born by cesarean delivery with surgical rupture of membranes and discharged at 4 days of life with normal physical examinations. Investigation of hospital records found infection control policies sufficient to prevent HSV transmission from staff to neonates and no evidence of nosocomial HSV transmission to any neonates during the previous 2 years.
This infant developed vesicles on the penis, perineum, buttocks, back, and foot, beginning 10 days after circumcision.

One case was an untyped HSV infection from 2000 (Table 1, case 1) and two cases were HSV-1 infections from 2005 (Table 1, cases 5 and 6). During April 2006–December 2011, a total of 84 laboratory-confirmed cases of neonatal herpes were reported.
The incidence of laboratory-confirmed neonatal herpes (HSV-1 or untyped HSV) among males who had ritual circumcision with confirmed or probable direct orogenital suction was compared with the incidence of laboratory-confirmed HSV-1 or untyped HSV infection among males unlikely to have had direct orogenital suction. Two sets of parents said they were unaware beforehand that direct orogenital suction would be performed.
In addition, a legally binding directive was issued by the New York City Commissioner of Health directing mohel A to cease and desist from direct orogenital suction. The findings of this investigation and the previously published reports are consistent with a cause-and-effect relationship between Jewish ritual circumcision with direct orogenital suction and neonatal HSV-1 infection.
First, in the cluster of three cases associated with mohel A, the twins were born by cesarean delivery, and the mother of the other HSV-infected neonate was HSV seronegative. Although this report is the first to quantify the risk associated with the practice of direct orogenital suction during Jewish ritual circumcision, the relative risk depends, in part, on assumptions used to estimate the number of male infants who undergo circumcision with direct orogenital suction, and those assumptions might not be valid. Oral suction of an open wound poses an inherent risk for transmission of HSV-1 and other pathogens to a newborn infant and is not safe.
Continued efforts are needed to work with mohelim to adopt safe practices and educate parents regarding the risks for direct orogenital suction. Because approximately 20% of neonatal herpes patients do not have skin lesions (9), physicians should consider herpes infection when evaluating a newborn infant with fever following Jewish ritual circumcision.
Neonatal genital herpes simplex virus type 1 infection after Jewish ritual circumcision: modern medicine and religious tradition. Effect of serologic status and cesarean delivery on transmission rates of herpes simplex virus from mother to infant. Oral contact with an open wound in a neonate risks transmission of HSV and other pathogens.
Jewish law has various rules for scheduling circumcision; for example, circumcision might be delayed if an infant is ill. The number of days from circumcision to lesions rangs from 5 to 20, with a median of 8 days.
Even when there is no signs of blisters, the area can “shed” the virus.  Discuss with your doctor, and your partner ways of not spreading the disease. Their mother had no history of oral or genital herpes and no genital lesions at or after delivery.
Histologic examination of the diamniotic-dichorionic placenta showed no evidence of HSV infection. In five cases, the identity of the mohel could not be determined; beginning in 2005, parents interviewed by DOHMH for the purposes of case investigation refused to explicitly state whether direct orogenital suction had been performed.
The previous reports and these 11 additional cases strongly suggest HSV-1 can be transmitted to a neonate when circumcision involves direct orogenital suction of the penile incision. In mothers with genital herpes lesions at term, risk for perinatal transmission can be reduced by cesarean delivery (6). Second, neonatal HSV-1 infection in males is uncommon, with a median of three cases each year in New York City, making it improbable that a single mohel would be associated with more than one case of male HSV-1 neonatal herpes in 2 years by chance alone. For example, because not all of the cases were in ultra-Orthodox Jewish families, estimates of the exposed population might be underestimated.
Circumcision is a surgical procedure that involves cutting intact skin; sterile technique should be used to minimize infection risk. Before circumcision, mohelim should inform both parents whether they perform direct orogenital suction and explain the risk of herpes transmission, so that parents can choose not to have their newborn exposed.

Even where neonatal HSV reporting is not mandated, physicians should notify local health departments about cases potentially associated with direct orogenital suction to prevent further cases.
Professionals advising parents and parents choosing Jewish ritual circumcision should be aware of this risk, and direct orogenital suction should be avoided. In six of the 11 cases, health-care providers confirmed parental reports that the ritual circumcision included an ultra-Orthodox Jewish practice known as metzitzah b'peh, in which the circumciser (mohel, plural: mohelim) places his mouth directly on the newly circumcised penis and sucks blood away from the circumcision wound (direct orogenital suction).
At 8 days of life, the twins were circumcised by mohel A, who performed direct orogenital suction. Hospital staff members who cared for the infant had no clinical evidence of herpes infection, and no evidence was found of nosocomial HSV transmission to neonates 2 years before and after the infant's birth. One of those patients died (Table 1, case 11); the other patient (Table 1, case 10) was the brother of a 2008 case (Table 1, case 8). Because mohel X could have been mohel A, the number of mohelim involved in the 11 cases could not be determined with certainty but was at least three and not more than eight. Hadler, MD, Thomas A Farley, MD, New York City Dept of Health and Mental Hygiene, New York, New York. Although mohel A had no evidence of shedding HSV when tested, oral HSV shedding is intermittent and difficult to detect without repeated sampling (7). However, if the exposed population was overestimated, the risk associated with the practice of direct orogenital suction might be greater than described in this report.
In 2004, the prevalence of HSV-1 infection was 73% in New York City adults aged ?20 years (8). Local health departments should then notify the mohel who performed the procedure, so that he can voluntarily cease putting infants at risk. In the remaining cases, other evidence suggested that genital infection was introduced by direct orogenital suction (probable direct orogenital suction). At 16 days of life, both twins were evaluated for fever and lesions on their abdomen, buttocks, and perineum, including the genitals. Specimens collected from mohel A 97 days after the twins' circumcisions were positive for antibody to HSV-1 (blood) and negative by culture and polymerase chain reaction (mouth swabs). The brothers were both circumcised by the same mohel (mohel X), whom their parents declined to identify. Third, the timing of symptom onset in all cases was consistent with acquisition during circumcision.
Given the high prevalence of HSV-1 infection in the general population and risk for asymptomatic shedding, mohelim should assume they are infected and at risk for transmitting HSV. To protect infants' health, public health departments might need to take legal measures to ensure mohelim associated with cases of neonatal herpes cease the practice of direct orogenital suction.
Fourth, the location of herpes lesions on the neonates' genitals and related dermatomes is unusual and suggests infection was introduced at the genitals. No other neonatal herpes cases were reported from that zip code area during April 2006–December 2011. Health-care professionals advising parents and parents choosing Jewish ritual circumcision should inquire in advance whether direct orogenital suction will be performed, and orogenital suction should be avoided.

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