Herpetic infection after circumcision with direct suction

Herpetic infection after circumcision with direct suction

As it says on the section on the site dedicated to babies under 30 days, circumcision has 3 main parts which are: Milah (Circumcision), Periah (Uncovering), Metzizah (Suction). You can read more of the my medical insights of circumcision using this link.

However, the Metzizah (suction), can be done directly or indirectly. Doing it directly pose a risk for the neonates to get severe Herpetic infection.

So, read more and follow.

What is direct or indirect suction (Metzizah)?

The last part (suction) means drawing blood away from the cut by the mohel (the Rabbi or person performing the ceremony), which can prevent damage to the blood supply to the head of the penis after the incision.

Suction can be done directly (the Mohel’s mouth directly on the incision), or indirectly using a tube or a syringe (the Mohel’s mouth will touch the tube which will be on the incision).

There are many reports, from Israel and from around the world about neonatal herpetic infection after direct touch during the circumcision.

How does herpetic infection manifest in the newborn age?

Neonatal herpetic infection could manifest as skin infection, meningitis or fulminant disease involving many internal organs (brain, liver, bone marrow and more).
Even in the simplest cases, involving the skin only, the baby will need to be hospitalized for 2 weeks of IV treatment of anti-viral medication, and another 6 months of oral treatment with the same medication.
In cases of meningitis or fulminant disease, the baby could stay severely damaged. There are babies like that in Israel and all over the world.
So one must ask the question – why is there an option of performing the ceremony with direct touch, when it can be done indirectly?
I read an official document of the Chief rabbinate of Israel from June 2017, which summarizes information about the work of the Mohel. In this document you can see a few guidelines about direct suction: “before circumcision, in cases when the Mohel wants to perform the suction directly, he must present the parents with the options of preforming the ritual with direct or indirect suction, and act according to their choosing”.
Another commitment of the Mohel is this: “If I (the Mohel) would like to perform oral suction, then I must inform the parents about the different options of the ritual, and act according to their choosing”.
This tells me that there is an obligation to inform the parents about the different options and the consequences. I do hope this is the way things are happening.

But this is not enough. Since there are cases in which parents are choosing the direct method, I wonder if there should be a higher rank of religious leaders, considering the consequences and the cultural context of this ritual, and giving their opinion – is there a religious superiority to direct method over the indirect one?
If so, than they should step up and recognize the cost. In other words – how many babies must contract herpes and suffer from the consequences of the disease, in order to make life more important than the religious commandment.
If not, than they should ban the option of direct suction.

In different cases, I’ve heard parents explain that the Mohel said a few statements, including:
– “I do not have an active herpetic wound“. As you will see in another post (read here), the virus could be shed in the saliva even in cases when there are no active lesions visible. So this statement is not correct and borders with irresponsibility.
– “I take routine tests, and I do not have herpes“. A high percentage of the population had herpes in the past, whether they know it or not. Once you were infected in the past there is no test available which can be used as a routine survey to see if you are shedding the virus. You can take PCR in the saliva and see if the virus is shed each day. Obviously, this is not applicable.
– “I use disinfected mouthwash before the ceremony“. This is nice, and even mentioned in the guidelines to the Mohel. This method may lower the prevalence of herpes infection, but not preventing it entirely.
After this baby contracted the virus, the Mohel will say that there is no prove that the baby caught it from him. This is true, there was never a case when a saliva sample from the Mohel mouth was taken and compered to the specific strain that was isolated from the baby. This is because you cannot make the Mohel give a specimen from the saliva. But I can assure you, that the chronicity of the disease, the lesions and their location fully suggest direct suction as the source for the infection. And if someone disagrees, I would love to get a saliva sample and the approval of the mohel to check the virus strain.

So how many babies need to get hurt in order to for the chief rabbinate or any other religious authority to rise and speak loudly against direct suction?
When will there be a responsible Mohel that will say – It happened to me, or could happen to me, and I think that there is room to think and change our ways?
We’ll just have to wait and see.

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