Lakewood babies face herpes risk; NJ lacks circumcision safety rules

Potentially thousands of male newborns in Lakewood may be exposed each year to a deadly form of herpes from an ultra-Orthodox circumcision ritual that mandates rabbis use their mouths to suck blood from the fresh cut.

But there is no safety protocol in place to assess and mitigate risks associated with the mouth-to-genital contact — despite four deaths statewide of infants between 1999 and 2015 where herpes simplex virus was found as an underlying cause, an Asbury Park Press investigation found.

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The ritual is prevalent among the township's booming Orthodox population. There were 4,464 births to township women in 2015 – a birth rate that is four times higher than the state rate.

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New York, where officials have linked metzitzah b'peh (sucking with the mouth) circumcisions to at least 24 cases of infant herpes since 2000, bans mohels from practicing, pending a herpes test, if they're believed to be responsible for passing the disease to infants. New Jersey doesn't have any similar rules.

A mohel, who is the rabbi performing the ritual, briefly places his mouth over the cut after removal of the foreskin of the penis and sucks out a small amount of blood, lustrating the area.

Medical experts say the procedure is risky because the oral contact puts babies at risk of getting harmful herpes simplex virus type 1 (HSV-1) viruses.

Many adults carry HSV-1 in their bodies. They may have no symptoms or only mild symptoms, such as cold sores. Unlike adults, babies are too young to fight the virus – they could suffer brain damage, develop a lifelong disability or in some cases die.

Faith and medicine

Despite the risk – discovering neonatal herpes in males who undergo the ritual is 3.4 times more frequent than for other male babies, according to a federal study – metzitzah b'peh is another case of conflict between faith and safe medical practices.

The issue has prompted state senator Robert Singer, a Republican who lives in Lakewood, to consider legislation to test rabbis for herpes.

But there is no medical oversight in New Jersey, and leaders of Lakewood’s Orthodox community say they would consider restrictions on the centuries-old ritual as an infringement on religious freedom.

Lakewood is home to Beth Medrash Govoha, the largest Orthodox Jewish college or seminary in the U.S. The growth of the yeshiva over the years spurred a boost in the population, which went from 45,000 in 1990 to more than 100,000 now, making it New Jersey's fifth-largest municipality.

Establishing a protocol governing oral suction circumcisions in Lakewood might be difficult if not impossible, said Dr. Paul Offit, a professor of vaccinology and pediatrics at the University of Pennsylvania School of Medicine, who said he's in favor of banning the ritual entirely.

"There's a tangled relationship between religion and America,'' said Offit, author of "Bad Faith: When Religious Belief Undermines Modern Medicine."

"In many states, it's legal for parents to deny their children care for religious reasons,'' Offit said. "There's a politically powerful Orthodox community in Lakewood that I'm sure would push back against anything that would impact their freedom to have the ritual circumcisions.''

The Centers for Disease Control and Prevention in a 2012 report said circumcisions should be performed under sterile conditions, and direct oral contact should be avoided as much as possible.

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Despite the four New Jersey infant HSV-related deaths, neonatal herpes is not among the diseases the state’s health and service providers are required to report to local health departments.

However, the Press found the four instances of New Jersey deaths of children under the age of 1 from HSV by examining CDC death records. Nationally, there were 284 such deaths of infants between 1999 and 2015.

New York's example

New York City officials say of the 24 cases since 2000 of infant herpes they've linked to metzitzah b'peh, two of those babies died and two more suffered brain damage. The city in March began barring mohels who test positive for herpes and who may have passed the virus to an infant.

In Rockland County, New York, where ultra-religious Jewish communities were established during the 1950s, health officials say they worked with Orthodox leaders to launch a protocol four years ago after seven cases of neonatal herpes emerged.

There's no need for New Jersey to follow suit, said Rabbi Avi Schnall, director of the Lakewood office of Agudath Israel of America, a nonprofit that advocates for civil and religious rights for Jews.

"There has never been any correlation between (the circumcisions) to herpes here,'' Schnaal said. "There are some in the community who would not consider metzitzah b'peh a required part of the ceremony, but there are others who believe it’s an integral part, and the religious right of those people should be defended.''

Community members who were shopping at Grebow Shopping Center, Howell, just north of the Lakewood border, said they feel that way, too.

“I don’t think it has anything to do with the Asbury Park Press,'' said Lakewood resident Abe Schwartz, 49. "I think it has to do with our religion. If someone outside wants to come here, we’ll circumcise you and make you Jewish. Otherwise, none of your business. This has been a tradition since the time of Isaac and Ishmael.’’

State officials wouldn't provide more information about the four infant deaths – such as locations, circumstances or genders – citing a law that limits public disclosure of vital records.

In Rockland, for any suspected herpes infection case after circumcision, county health officials use DNA testing to try to link a baby with the source of infection. Members of the Jewish community participate voluntarily in the process, said Dr. Oscar Alleyne, who was director of epidemiology there when the county established its safety procedure in 2013.

"We empowered the Orthodox community to know that they play a key role in helping mitigate illness and we were pleased with how the Orthodox community has come to see the Health Department as a trusted partner,'' said Alleyne, now the senior adviser for public health programs for National Association of County and City Health Officials, Washington, D.C.

State Sen. Singer said the Press investigation raises concerns about the dearth of reporting on neonatal herpes here and the lack of oversight of mohels.

“Even if it’s just one case (of neonatal herpes), we should know about it and where it’s coming from,’’ Singer said. “It should be a disease reportable to health departments.’’

Singer represents the 30th Legislative District, which includes Lakewood.

Singer, a member of the Ocean County Board of Health, said he's also interested in exploring whether it would be wise to have "mohels tested maybe once a year.''

"I don’t know, maybe there’s a cost factor to it, but other than that, why would that offend anybody?'' Singer said.

Schnall, from Agudath Israel of America, said testing mohels “risks encroaching the separation of church and state.''

So does having mohels provide a health department pamphlet to parents describing the risks of HSV as well as to obtain written consent acknowledging those risks, Schnaal said, referring to former rules in New York City under the Michael Bloomberg administration. The Bloomberg requirement was rolled back after Mayor Bill de Blasio took office in 2014.

“If the government wants to produce pamphlets or provide education on this, by all means. But to regulate the ritual and require of the parents or mohels that they need to do X, Y and Z, that’s different entirely,’’ Schnall said. “Such requirements would be an overreach of the government dictating how a religious practice should be performed.’’

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The demand among Lakewood residents for the oral suction circumcision for their babies is high, said Dr. Jeffrey Mazlin, an ­OB-GYN and part-time mohel based in New York.

“I know metzitzah b’peh is done by mohels a lot in Lakewood. My colleagues and I are reform mohels, so we don’t do this procedure,’’ Mazlin said. “My own thoughts are it’s potentially dangerous and the mohel has to make sure he doesn’t have any open sores if they’re performing it.’’

Several mohels who advertise their services in Lakewood declined to discuss how frequently they perform the ritual that’s said to be 4,000 years old.

“I don’t get involved with the press. Sorry,’’ one said when reached by telephone, before hanging up.

"My understanding is that it takes place with 90 percent of the babies in Lakewood,'' said Offit of the University of Pennsylvania School of Medicine.

Offit said state lawmakers should rally behind Singer to help improve tracking of neonatal herpes, which is also not a reportable disease nationally or in most states.

"I think it’s really important to change the reporting. Children are being put at risk unnecessarily,'' Offit said. "This is a time when it’s reasonable for the state to stand up and protect its children.''

Like Offit, Rabbi Moshe Tendler, a professor of medical ethics at Yeshiva University, New York, said the ritual should be abandoned.

"Oral suction of the incision is not required by halacha (the collective body of Jewish religious laws),’’ Tendler said from Israel in a telephone interview with the Press. "Yet it goes on.’’

‘’The medical facts are not in dispute, not by anyone who has an understanding of infection and contamination,'' he said. "Nowadays almost every mohel uses an ointment, a bacitracin, which most likely protects against most bacteria, but maybe some mohel don’t use it. In any case, it’s still unwise medically to do (the ritual).’’

The practice is performed each year on an estimated 3,000 New York City babies, health officials say. There’s no estimate for Lakewood but Tendler said, “I’m assuming that this is relatively universal. A mohel I recently spoke with, and to whom I advised against doing this, told me if he doesn’t make metzitzah, he will not be hired. He won’t be considered a kosher mohel.’’

Bob Jordan bjordan@gannettnj.com