Volume 46 Number 96
                    Produced: Mon Feb 14  6:49:47 EST 2005

Subjects Discussed In This Issue: 

Is Metzitzah Be-Peh hazardous? (3)
         [Nachum Klafter, MD, Bernard Raab, Eitan Fiorino]


From: Nachum Klafter, MD <doctorklafter@...>
Date: Sun, 13 Feb 2005 11:56:02 -0500
Subject: Is Metzitzah Be-Peh hazardous?

Ira Jacobson vigorously argues that there is insufficient evidence to
draw conclusions or recommend policy regarding the appropriateness of
metzitza be-peh based on a case series of 8 cases.  In addition to
feeling that the medical evidence is inadeaute, he is understandably
reluctant to concede that the morbidity and mortality associated with
these 8 cases is a result of a millenia old Jewish custom because this
would be a Hillul HaShem.  In his words: (v46n95):

> Now if the case studies, for example, represent four cases out of tens
> of millions, then the conclusion seems unwarranted.  Not to mention a
> likely hillul hashem.

I am quite troubled by Ira's remarks.  I would like to first address the
medical and statistical aspects of his argument, and then return to his
formulation of Hillul HaShem in this case.

As other mail-jewish contributors have correctly and eloquently replied
to Ira's arguments (e.g., Eitan Fiorino, Ben Katz).  However, he finds
their comments "laughable" (his word).  I would actually take this
further than Eitan and Ben did.  A case series of 8 cases is actually an
extremely significant data set from which any reasonable physician would
draw conclusions and make clinical recommendations.  We do this all the
time, with much smaller data sets.  Furthemore, in a few of the cases we
are dealing with, the infants' mothers were tested for HSV antiboties
and showed negative serology.  In the first few weeks of life, maternal
exposure and exposure at birth and breast feeding, and wound exposure
during the circumcision are the only two sources of potential infection
which would occur in normal situations.  Since all the mothers are
negative and all mohalim involved have tested positive for HSV, this is
a "slam dunk" from the point of view infectious disease and public
health.  A public health official who would not issue recommendations
based on this datat set would be seriously negligent.

Ira attempts to makes reference to statistics in order to buttress his
argument that the four mohalim who tested positive for Herpes is an
insufficient data set.  In his words:

> Now if the case studies, for example, represent four cases out of tens
> of millions, then the conclusion seems unwarranted.  Not to mention a
> likely hillul hashem.  First they say "carries a serious risk," and then
> they backtrack and say "may be hazardous."

This argument is seriously flawed.  In the first place, the denominator
he cites of "tens of millions" is way off base.  The denominator should
be the number of mohalim who are performing circumcisions in the
communities where these outbreaks occurred, which may be on the order of
only dozens or hundreds.  4 mohalim who are HSV positive is a very, very
serious finding.  One need not invoke statistics because these mohalim,
themselves are already positive, and they themselves pose a future
hazard if the go on to perform metzitzah be-peh in the future.

But more importantly, statistics are not applicable to cases like these.
Statistics are useful when trying to determine whether an apparent
correlation between phenomenon is peculiar enough that one should not
attribute this to randomness.  For example, when herpes was first
discovered, it would be appropriate to use statistics in order to
correlate antibody or antigen titers with the physical symptoms of
herpes.  This was one step in the process of gathering evidence for the
hypothesis that HSV causes herpetic lesions.  That was done decades ago
with thousands of samples.  It was repeated in multiple centers around
the world.  It is now long an accepted medical test with a known
sensitivity and specificity.  For our purposes, we know that 8 infants
were diagnosed with herpes.  Herpes has been established as the culprit
based on both symptom presentation and viral serology studies.  The
mother's are negative for herpes.  The mohalim involved postitive for
it.  There was oral-blood contact.  The symptoms appeared after the
circumcision within a time interval which is consistent with
transmission at the circumcision.  End of story.  There is no shayloh.

The main flaw in Ira's argument is as follows: Statistics simply don't
apply to cases like ours.  Lets say that 10 people are in a car wreck
and all sustain musculoskeletal injuries.  Do we need to invoke
statistics to determine that their injuries were caused by the car
wreck?  I doubt anyone will argue as follows: "Out of billions of people
on the world, you are going to conclude that a motor vehicle accident
cased these injuries based on just 10 cases?  That is laughable!"

There is one more test which could be done.  The viral strain which was
found in these infant boys could be compared with the serology of the
mohalim.  This could prove the very source of the viruses which were
found, but this test is unlikely to be done because it is expensive, and
might not be readily available where the infants were tested.  From a
public health perspective, this test is not necessary.  These infant
boys have herpes, we know how they contracted it, our management of
these patients will not change based on knowing the viral strain, and
our preventive measures are obvious [i.e., stopping these mohalim from
performing metzitza be-peh].

One report that I read seems to indicate that the mohalim did not know
that they had ever contracted HSV.  Therefore, there is every reason to
believe that more mohalim are out there with silent HSV.  No physician
or public health official in his right mind would want those mohalim to
be exposing the circumcision wound to their saliva.  And again, to
repeat myself from a previous post, this practice is not part of the
mitzvah.  It was an ancient and medieval medical practice, and in our
times with the advent of sterile technique it has no known health
benefit.  Exposing a wound to saliva conveys well known, well
understood, and well demonstrated heath risks.

In light of the above, a Rosh Yeshiva poskinned for me personally that I
may not perform metzitza be-peh under any circumstances, and when among
Jews who do not know the difference I should omit metzitza entirely.
When among observant Jews who will protest if metzitza is omitted, he
poskinned that I should perform metzitza through a sterile glass tube or
syringe in a manner which will prevent any saliva-blood contact.  (This
pesak has little relevance because I so infrequently perform brissin.)

Finally, regarding Hillul HaShem.  It is a Hillul HaShem to read about
mohalim defensively saying "G-d provides us with saliva because it
cleans wounds and is good for the baby.  We will not stop this
practice."  It is a Hillul HaShem for halakhically observant people to
cavalierly dismiss this very significant case series and invoke
"statistics" while the best medical experts issue cautions that more
cases would be expected if this practice continues.  On the other hand,
for rabbonim to consult with physicians and draw responsible conclusions
which are motivated to protect the Jewish public from tragedy is a
Kiddush HaShem and not a Hillul HaShem.  The above mentioned Rosh
Yeshiva was mekadesh shem shamayim when he poskinned for me.

Summary: A case study of 8 is a very powerful data set when dealing with
known disease entities and physicians draw conclusions from even smaller
data sets all the time.  To ignore a case series like this is wreckless
and negligent.

-nachum klafter, md
assistant professor of clinical psychiatry
University of Cincinnati

From: Bernard Raab <beraab@...>
Date: Mon, 14 Feb 2005 00:36:18 -0500
Subject: RE: Is Metzitzah Be-Peh hazardous?

>From: Avi Feldblum:
>I do not understand any position that advocates continuing this practice
>without the most stringent safeguards taken. I also do not understand why
>the Rabbinic leadership do not take a much more active stance to
>discourage or forbid metzitzah b'peh in favor of alternate halachically
>permissable options.

It is unrealistic to expect our rabbinic "leadership" to publicly take
any position which could open them up to attacks from the right. In my
view, that wing is totally unconstrained in their willingness to attack
and embarrass those who espouse "modern" positions, which they regard,
quite accurately in my view, as a threat to their control in matters of
orthodox halacha.

Although I understand this very well, it was still disturbing and
distressing to read of the position taken by one of our rabbinic
leaders, Rabbi Zvi Hersch Weinreb, executive vice president of the
Orthodox Union, who was quoted as saying, with regard to the infant who
died after contracting herpes almost certainly from his mohel: "We don't
know the facts of this case, and I am not sure that one isolated case,
however tragic, warrants a major change in the system." (NY Jewish Week,
2/11/05) I find this statement so shocking and insensitive, I would be
ready to believe that he was not accurately quoted.

Nevertheless, this illustrates why changes in orthodox practise will
frequently be spearheaded by the laity. Many changes have been achieved
in this way: The educated orthodox laity finds that a particular
practice or stringency is impractical, unsafe, or excessively difficult,
and an alternative practice becomes acceptable among them, usually with
the approval of one or two courageous LORs whose congregants then spread
the word.  Eventually, when it is clear that this has not led to mass
defections from other orthodox practices, the "rabbinic leadership" will
formalize the change with a halachic ruling.

In the present case, the process seems to be well underway: Many, or
maybe most, orthodox families and mohelim already practice alternative
forms of metzitzah based, it seems, on various "private" heterim. Formal
rabbinic approval will almost certainly follow....eventually.

b'shalom--Bernie R.

[Note: see a future issue with an excerpt from an article by Rabbi
Jachter; there have been clear public piskei halacha supporting not
doing metzitzah b'peh due to health risks. Mod.]

From: Eitan Fiorino <Fiorino@...>
Date: Mon, 14 Feb 2005 01:03:55 -0500
Subject: RE: Is Metzitzah Be-Peh hazardous?

> From: Ira L. Jacobson <laser@...> 
> Eitan Fiorino stated the following, first quoting my comment: 
>            My reaction is shock that a medical journal of 
>            any sort would report on "research" with such a 
>            tiny sample size and assign any degree of 
>            reliability to such a study. 
>      As someone immersed in the medical literature as a profession, I 
>      profess no "shock" whatsoever at the contents of this paper, which 
>      I have just finished reading.  It does not claim to be a 
>      randomized, controlled clinical trial - rather, it is essentially 
>      a case series.  Case reports and case series are very commonly 
>      reported in the medical literature. 
> Case reports at times discuss rare phenomena, and as such are just that. 
> The article under discussion, however, makes far-reaching conclusions, 
> to wit, "Conclusion.  Ritual Jewish circumcision that includes metzitzah 
> with direct oral/genital contact carries a serious risk for transmission 
> of HSV from mohels to neonates, which can be complicated by protracted 
> or severe infection.  Oral metzitzah after ritual circumcision may be 
> hazardous to the neonate." 
> Now if the case studies, for example, represent four cases out of tens 
> of millions, then the conclusion seems unwarranted.  Not to mention a 
> likely hillul hashem.  First they say "carries a serious risk," and then 
> they backtrack and say "may be hazardous." 

Now it seems to me that Ira's shock over a medical journal publishing
the results of such a small study has nothing to do with the study per
se, but rather he is unhappy the conclusions drawn by the authors.

I think the only element in the text quoted by Ira that is even worthy
of quibbling over is the word "serious."  I don't really know if this
study demonstrated a *serious* risk for HSV transmission - one would
want a lot more data before characterizing the actual risk of
transmission, although one could certainly claim that ANY risk for the
transmission of a serious, potentially lethal disease should be called a
"serious risk."  I detect no backtracking between the statement that
oral metzitza "carries a serious risk for transmission of HSV" and that
it also "may be hazardous" - because the procedure carries a risk of
disease transmission, the procedure may be hazardous.  I don't see any
backtracking at all.  This is, of course, entirely beside the point.
However one characterizes the risk of transmission - serious or not -
the critical issue is that there is a real risk of a potentially lethal

I agree there is a chillul hashem here.  The chillul hashem is that when
the idea of infant-mohel and mohel-infant disease transmission emerged
among the poskim, oral metzitza was not immediately and universally
banned and condemned.

> I think if the population consists of tens of millions of britot mila, a 
> sample of four or eight is laughable.  The conclusion to be drawn from 
> this study is that *those four* mohalim should take up another 
> profession.  That is a totally justifiable conclusion.  Perhaps regular 
> testing of all mohalim would be a justifiable recommendation. 

Laughable?  To whom?  To the parents of at least two children killed by
oral metzitza?  Laughable is a most unfortunate choice of words here.
There is nothing at all laughable about this situation because it is
extremely rare.

Millions of britot - yes - but how many britot by HSV-positive mohelim?
And how many of those resulted in infection of the neonate?  And exactly
how low a transmission rate should we, the community, view as acceptably
low for this procedure that is, once again, implemented solely for the
health of the infant? Given the alternatives, I can see absolutely no
justification for accepting any risk of transmission of disease to the
infant from the procedure of metzitza.

Should these mohels find other work?  In an ideal world they would - but
half of them refused to even be tested for the paper!!!  Do you really
think those guys found another line of work?  They are out there right
now, circumcising children, and one can only pray they have the chochmah
and decency to refuse to perform metzitza by mouth.  As for testing of
mohelim, how would that be implemented exactly?  There is no central
governing board.  Even if there were, test results can be wrong or
faked, a mohel could become infected between tests, etc.

I don't know, we can laugh all we want at how wildly improbable it is to
get herpes from a mohel, but the bottom line is we have a halachically
optional procedure that was thought to have a beneficial effect but
which we now know not only has no beneficial effect but is definitively
if rarely associated with potentially lethal infections.  And the best
thing the rabbis can think to ban is some guy's animal books???  G-d
help us all.



End of Volume 46 Issue 96