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April 20, 2014 / 20 Nisan, 5774
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Metzitzah B’Peh – Where We Are And Where We Need To Go

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As a vascular surgeon for over 20 years I care for wounds daily. As an occasional mohel for 30 years I am familiar with all aspects of milah. I thus feel obligated to share my perspective on this most important topic. If I don’t, who will? In order to decide halachic matters, rabbis need accurate and representative medical input. This is my only goal.

From a medical perspective, the controversy over metzitzah b’peh (MBP) has focused on whether indeed there is any serious risk of transmission of the herpes type-1 virus from the mohel to an infant. Why is this a concern? It is well established that over 50 percent of adults show serological evidence of previous infection with oral herpes and some of these people will shed herpes from their mouth even without open sores. A 1999 study found that 70 percent of adults shed virus at least once a month even without oral lesions. This data suggests a theoretical risk of herpes infection transmission when a mohel has direct oral contact with the bris wound. An infant is immunocompromised, and an infection that is relatively mild in an adult can be deadly in an infant.

Is this just a concern, or does such infection transmission actually happen? There are a number of cases with a high index of suspicion that link MBP to herpes infection of an infant’s genital area. There were three such cases in the 1990′s (one of whose care I was involved in); eight cases reviewed in a paper in the medical journal Pediatrics in 2004; three cases between 2004 and 2006 in New York City, including an infant death and another who survived but with significant neurological damage; an additional four recently published cases in New York City from 2006-2010, and a death in 2011 in New York City attributed to MBP. These total 19 cases. It is almost certain that there are others, since not all cases are reported. Mandatory reporting was instituted in New York State in 2006. In New Jersey, no such requirement exists today.

It is the opinion of many infectious disease specialists and public health authorities that the association between MBP and herpes is adequately established by these cases, considering the location of the herpes in the infant’s genital area, the timing of infection soon after the bris, the clusters of association with a given mohel and other epidemiological parameters. Furthermore, basic medical theory eschews oral contact with a wound, especially since our current medical knowledge does not attribute any benefit to MBP. The risk/benefit ratio is thus infinite. As such, these specialists recommend modifying MBP by either using a gauze or glass tube instead of direct oral contact. This was the solution approved by the Chasam Sofer and other rabbanim, and adopted by many Jewish communities, when faced with the same issue more than 150 years ago.

A dissenting, minority opinion is presented by Dr. Daniel S. Berman, an adult infectious diseases specialist who has published in the lay press on this topic. He has reviewed the above data, critiqued the authors of previous medical articles, and has questioned the validity and motivations of their medical opinions. He suggests anti-religious bias as a significant factor in their conclusions and in the actions of the New York City department of health. He doubts that MBP is the cause of infection and posits that herpes is more likely contracted from other sources, such as caretakers of the infant. He also argues that no absolute confirmation of a causal relationship in any of these cases has ever been proven. To prove causality would require DNA evidence linking the specific herpes strains and this has never been done. It must be noted, however, that to perform DNA analysis, community and mohel cooperation would, of course, be necessary and this has not been forthcoming.

I am unaware of other physicians who share the essence of Dr. Berman’s point of view. Nevertheless, my observation is that Dr. Berman’s opinion has been accepted by the overwhelming majority of the chassidish and yeshivish communities. “Nothing has been proven and MBP is absolutely safe” has become the mantra in this discussion. Furthermore, there has been no halachic call to modify MBP at this point except from the Rabbinical Council of America.

I have described the status quo, but now come the real issues. Is it appropriate to accept a minority view in matters of fact and pikuach nefesh? How should halachic authorities decide in a case where medical facts and their interpretations are of such prime importance and where those facts are the subject of debate?

Furthermore, I shudder to think of the almost unrecoverable stain and loss of confidence on the integrity of the halachic process that would result, should MBP be ultimately proven (via DNA or other means) to be a source of herpes transmission. Many will appropriately ask, “How could we have permitted such significant halachic decisions to be made based on the unconventional and minority opinion of Dr. Berman, when most other specialists felt that an association between MBP and herpes had been amply established? What type of system permits this to happen? Why didn’t we seek a wider consensus?”

Some have said that the Chasam Sofer’s p’sak has no relevance today, since they claim that it was only a hora’at sha’ah; a ruling under unusual circumstances that is applicable only for a given time and place. Even if so, perhaps we qualify for a hora’at sha’ah p’sak today, considering that infection with herpes type-1 virus today is at epidemic levels in adults and the consequences to an infant who contracts it is so great. Let those who claim that MBP is absolutely safe prove its safety and we can then reverse this temporary modification.

What do I recommend? I believe that the time has come to establish a formal medical committee that will consider the input and opinions of multiple national experts on pediatric infectious disease, virology and public health. There are plenty of such experts who can weigh in on this debate. This committee will issue a report and make a best-determination of probable fact, considering what is known today. It will also highlight legitimate differences of opinion where they exist. This report can be updated as further data emerges. Poskim can then use these finding of fact to make a determination of halacha.

I know there are many halachic issues. Amongst them: Is MBP a minhag or part of the actual bris? Is it only a medical recommendation by the Talmud that can be modified or discarded as medical knowledge changes? Does metzitzah need to be b’peh or is any other suction source or method of drawing away blood equivalent? Since I am not a rabbi, I am not qualified to rule. I merely seek a way to have fair representation of medical facts and judgment for those ruling on halachic matters.

I believe an organized approach will increase medical factual accuracy, and also result in increased confidence in the halachic process. Our children deserve nothing less than both of these outcomes.

Gary A. Gelbfish MD, FACS, is a vascular surgeon in private practice. He is a mohel certified by the Rabbinate of the State of Israel.

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About the Author: Gary A. Gelbfish MD, FACS, is a vascular surgeon in private practice. He is a mohel certified by the Rabbinate of the State of Israel.


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5 Responses to “Metzitzah B’Peh – Where We Are And Where We Need To Go”

  1. This article makes to much sense. The crazies who run things today will never allow its sensable suggestions to see the light of day.

  2. William Kohn says:

    The bottom line — the chassidish kehillas will not bow to scientific proof and will exercise their political muscle to keep the civil authorities at bay. As such, the leaders of the various chassidish communities owe it to their members to review the strong circumstantial evidence that links one or more mohellim to the spread of the virus and to prevent those mohellim from continuing to perform bris milah. Until that happens, if ever, the leaders of the chassidish communities bear direct responsibility for the deaths and illness caused by MBP. These leaders can use their political muscle to intimidate the civil authorities, but there is a higher authority that cannot be bullied. He will ultimately pass judgment on their recklessness and disregard for their followers' health. As for the Yeshivish world, the past weeks have seen their cowardice as they hide behind Rabbi Shafran's double speak and Dr. Berman's article, which has been critically debunked by other scientists. Additionally, we have also all been witness to the spectacle of Rav Kamenestky's initial statement and his hasty retreat or "clarification".

  3. I actually read the four medical articles AND THEIR references and there is not one shred of correlation between the sources and statements made by Tendler and company. My favorite of Tendler's lies in his Aug 2004 Pediatrics paper is that the Ignacz Semmelweiss discovered disease transmission (May 1847) after a baby got Tuberculosis from an infected Mohel (First case in the literature- Lindemann, Deutsche Mediicinische Wochenschrift 1883. p442. [the 2 cases were in 1873, 8 years after Semmelweis died.]) As a result, Rabbi Moshe Schreiber, the Chasam Sofer, who died in 1839 permitted the Tube which was invented in by Max von Pettenkofer in 1887. Instead on describing the profile of maternally transmitted HSV-1, then expllaining why these cases differ and then claiming the mohel must therefore be the source, Tendler and company list five factors of textbook maternally transmitted HSV-1, ignore their own citations and then claim the mohel is the source. Specfically 1) The mother is immediately disqualified because she is asymptomatic in a disease that is 60% to 98% asymptomatic. 2) She is disqualified because she is seronegative. A seronegative mother with a primary infection has the highest risk of infection (50%). No follow up serology is done to confirm the mother remained seronegative and is not the source. 3) Neonatal HSV-1 infections have been on the rise in all industrialized nations due to declining adolescent HSV-1 seroprevalance and already exceed 50% in many countries. Yet, the authors imediately discount the mother on the basis of an HSV-1 infection. 4) The location of lesions is on a trauma site due to trauma of a maternally infected baby not due to metzitzah. 4) the onset is usually the exact timing stated in the AAP gudelines for maternally transmitted HSV as well as in several articles by Nahmias, Prober, Kimberlin, Whitley, including several papers cited by Lorry Rubin in his March 2000 PIDJ paper and ignored.

    The biggest idiots are the useless bureacrats in the NYC Dept of health, that are spoon fed all the facts, figures, numbers and statistics and have no clue what they mean. Susan Blank is a co-author of a 1998 CDC STD guidelines stating that an asymptomatic, seronegative mother with recently acquired HSV is at the highest risk to transmit to her baby (30%-50%) Julia Schillinger is the co-author of half a dozen papers on the demographics of HSV seroprevalance going back to at least 2000 (MMWR5106) that identify young white seronegative women as being at increased risk for having a baby with NHSV-1. She's the co-author of two paper that state multiple partners are an HSV-2 risk factor and not an HSV-1 risk factor, yet she's oblivious to the fact that Lorry Rubin exclude the mothers in his two cases of HSV-1 infection because "It's highly unlikely that either mother had multiple partners a risk factor for genital herpes" i.e., because she didn't engage in HSV-2 risk factors. Schillinger, after writing five or more papers on the demographics of HSV infection is oblivious to the fact that the authors use 1980 United States statistics to evaluate the likelihood of infection in their Israeli and Canadian cases. (Compare to Kropp RY, Pediatrics.2006. 117(6):1955, 62.5% cases are HSV-1, 98% are due to asyptomatic vertical transmission) In their 2007 ISSTDR presentation the NYC DoH reeled out their first year of mandatory NHSV statistics revealing that 39% of cases were HSV-1 (nearly two out of five) 66% of fatalities were HSV-1 and 66% of fataltites were girls. Yet despite their own data that Neonatal HSV-1 is on the rise due to factors other than metzitzah, NYC DoHMH prefers to follow the guidelined set by 22 authors that have never written a ppaer on herpes, 17 of whom have never witten a ppaer mentioning the word HSV or herpes (pubmed search with authors name) and every Jewish male baby is therefore immediately due to metzitzah instead of the normal 40 year old protocol for excluding the parents first, including first DNA testing of the PARENTS, the source in 90% of cases. Read the literature on NHSV, not Tendler's fabrications.
    And I'm not Danny Berman. I did a lot more research than he did.

  4. The Rambam believed it was dangerous to do a brit without MBP. He also believed the sun revolved around the earth. If we can prove that non-halachic circumcision is no more dangerous than milah with MBP (that shouldn't be too hard), would that convince anyone?

  5. Hey Mark did you ever meet him when you worked at Maimonides? I remember him. He is one of Jerry's wife's cousins (She is a Gelbfish).

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More Articles from Dr. Gary A. Gelbfish
Gelbfish-041312

As a vascular surgeon for over 20 years I care for wounds daily. As an occasional mohel for 30 years I am familiar with all aspects of milah. I thus feel obligated to share my perspective on this most important topic. If I don’t, who will? In order to decide halachic matters, rabbis need accurate and representative medical input. This is my only goal.

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