Sent: Wednesday, March 08, 2017 9:42 AM
Subject: NYC DOHMH Alert #4: New Case of Neonatal Herpes Infection Reported Following Ritual Jewish Circumcision
Dear Health Alert Network (HAN) Subscriber:
2017 ALERT # 4
New Case of Neonatal Herpes Infection Reported Following Ritual Jewish Circumcision
First Case Reported in New York City in 2017
Please Share this Alert with All Emergency Medicine, Pediatric, Pediatric Infectious
Disease, Dermatology, Obstetric, Infection Control, and Microbiology Laboratory Staff
• A new case of neonatal herpes following ritual Jewish circumcision has been reported to the New York City Health Department.
• When evaluating male infants with suggestive symptoms in the weeks following out-of-hospital circumcision, providers should inquire whether direct orogenital suction (metzitzah b’peh) was performed during circumcision and consider infection with herpes simplex virus (HSV) or other oral pathogens.
• Infants suspected of having HSV infection should be hospitalized and treated with intravenous acyclovir.
• Please distribute the Health Department’s pamphlet “Make a Safe Bris for Your Baby” to expectant parents and/or new parents who visit your office or facility. This is also available in poster format.
March 8, 2017
Direct orogenital suction (DOS) during ritual Jewish circumcision (also known as metzitzah b’peh) is a practice during which a mohel (religious circumciser) uses his mouth to suck blood away from the circumcision wound on the infant penis. DOS can transmit herpes simplex virus (HSV) to newborn males.
This is the first case of neonatal herpes following ritual Jewish circumcision, reported in New York City in 2017. The infant was the full-term product of an unremarkable gestation and delivery.
He was circumcised by a mohel on the 8th day of life. On day 15 of life he developed a rash on the genitals, buttocks, inner thigh, and ankle, which became vesicular by day 17 of life. Vesicular culture grew HSV-1. The infant was admitted to hospi tal for a full 14 day course of intravenous acyclovir. His serum was negative for IgG antibody to herpes simplex virus types 1 and 2, and cerebrospinal fluid was HSV PCR negative. The location of the lesions, timing of signs and symptoms (following ritual Jewish circumcision and within one incubation period for HSV-1), and laboratory identification of HSV-1 are consistent with transmission during DOS.
Most cases of neonatal herpes are acquired during delivery, when a neonate passes through the birth canal of a woman with genital herpes infection. HSV infection after delivery is uncommon.
However, in NYC, a substantial proportion of male neonatal herpes cases are related to DOS, an entirely preventable cause of infection.
Since 2006, when neonatal herpes reporting became mandatory in NYC, there has been a total of 144 laboratory-confirmed neonatal herpes cases, including 10 in 2015, 17 in 2016, and 4 to date in 2017. Of the 82 m ale neonatal herpes cases since 2006 (HSV-1, HSV- 2, or untyped HSV), 18 (22%) followed ritual Jewish circumcision; when only HSV-1 cases are considered, 38% (16/42 male HSV-1 cases) followed ritual Jewish circumcision.
This alert describes the first laboratory-confirmed case of neonatal herpes infection following ritual Jewish circumcision reported in New York City in 2017. In 2016 there were 2 such cases, and in 2015 there were 3 cases. Since 2000, there has been a total of 24 laboratory-confirmed cases of HSV infection following ritual Jewish circumcision reported to the Health Department. Two of the 24 infants died, and at least two others suffered brain damage.
The NYC Health Department is working to educate parents about the risks of DOS. Parents who choose ritual Jewish circumcision for their son may not be aware that DOS will be performed or may not be aware of its potential risks. In 2015, the Department distributed pamphlet s entitled “Make a Safe Bris for Your Baby” and companion posters to NYC health care providers, including obstetrician/gynecologists and pediatricians. Hospitals where infants with DOS-related neonatal herpes have been born or admitted were also asked to distribute the pamphlet to pregnant women admitted for labor and delivery, and to display the poster prominently in prenatal, and labor & delivery areas. Despite these efforts, parents of case-patients infected have not reported seeing the pamphlet or poster.
Obtaining copies of “Make a Safe Bris for Your Baby” pamphlet or poster Hospitals and healthcare providers should distribute “Make a Safe Bris for Your Baby” to expectant parents and/or new parents who visit your office or facility. To obtain hard copies of the pamphlet in English or Yiddish, or for copies of the companion poster, call 311. For electronic copies, please visit the Safe Bris webpage:http://www1.nyc.gov/site/doh/health/health-topics/safe-bris.page
Diagnosis, Reporting, and Specimen Collection
For detailed guidance regarding diagnosis, reporting, specimen collection, and specimen shipping and handling, please refer to Health Alert #2 (January 28, 2014) at:
Key Points for Providers:
1. When evaluating male infants with suggestive symptoms in the weeks following out-of-hospital circumcision, providers should inquire whether direct orogenital suction (metzitzah b’peh) was performed and consider infection with HSV or other oral pathogens.
2. Herpes-infected neonates may not present with the classic finding of grouped vesicular skin lesions and may be afebrile.
3. Babies suspected of having HSV infection should be immediately admitted to the hospital and treated presumptively with intravenous acyclovir.
4. Distribute the Health Department’s pamphlet “Make a Safe Bris for Your Baby,” to expectant parents and/or new parents who visit your office or facility.
4. Health care providers diagnosing herpes infection in infants <60 days of age days are mandated to report the infection to the NYC Health Department within 24 hours of diagnosis.
5. Providers evaluating infants <60 days of age with suspected HSV infection are required by law to collect specimens from one or more vesicles (if present) or from any skin lesions suggestive ofherpetic disease, and to send these swab(s) to the New York State Wadsworth Center Laboratories for diagnostic testing using molecular methods.
Questions about the pamphlet may be directed to Dr. Diana Sanchez at (347) 396-7311
. Questions about diagnosis, reporting, and specimen collection may be directed to Dr. Julia Schillinger at (347) 396-7296
Julia A. Schillinger, MD, MSc
Director of Surveillance
Bureau of Sexually Transmitted Disease Control
Susan Blank, MD, MPH
Bureau of Sexually Transmitted Disease Control
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