Snip, Snip

Another week, another post; this one on Jewish ritual circumcision…wait, what? How is this an infectious disease issue, you may ask? I’m not spoiling the ending…you’ll have to read to find out.

First, a meta-post: my apologies for the delay between my last post and this one. I have been struggling with how to best write this particular post, and when you read it, you’ll understand why. While I make no apologies for the views expressed on this blog, and I certainly do not shy away from controversial topics, even I had to acknowledge that this particular one is a bit dicey and had to be handled carefully; and it took me some time to figure out how best to do just that.

Those of you who know me In Real Life, know that I am Jewish. For those who are meeting me on this blog, well, shalom! However my views run toward the reform—the nonobservant—end of the spectrum. The particular subject of this blog is, in general, absolutely central to the Jewish experience. Circumcision (warning, some images NSFW) is, according to the Torah / the Old Testament, the primary covenant between God and the Jewish people. It is, arguably (and according to a more traditional viewpoint), the single most important practice that marks a male as Jewish. Separate from this, circumcision and one’s status as circumcised or not is also a highly personal and intimate thing, simply due to the details of the act itself [1]. So: a blog post about an extremely personal, intimate issue that is one of the central tenets of a major religion–where do I sign up? Here, apparently…

But as you’ll see, I am not writing about circumcision in general, nor do I wish to address any of the broader controversies surrounding it. No, here I am writing about one very specific practice, limited to a relatively smaller group of ultra-observant Jews, that has profound and personal (to my professional experience) infectious disease implications.

Now, where to begin…

The New York City Department of Health and Mental Hygiene (DOHMH for short) recently made headlines when they passed a regulation that will require consent from parents before an infant can have a particular form of Jewish ritual circumcision. The practice, known as metzitzah b’peh, is prevalent in parts of the ultra-Orthodox community and is distinguished by the circumciser (a mohel) using his mouth to remove blood from the incision. Its origins lie in a series of rabbinic injunctions regarding the practice of ritual circumcision and the need to let a small amount of blood out to, ironically, prevent infection. As its origins are hundreds of years old, the true medical necessity of this practice is doubtful to put it mildly. And while it should be obvious to any observer, it had apparently not occurred to the rabbinate that advocated for this practice that this itself could be a HUGE infectious risk.

Sure enough, over the years that this practice has been performed, a number of infants in Israel and scattered around the rest of the world have contracted disseminated Herpes Simplex Virus (HSV) infections from mohels who had an oral HSV infection at the time of the circumcision. In general, infants who are exposed to HSV through skin or mucous membrane contact are much less able to limit it to a simple skin infection. The virus invades and causes a disseminated infection, with organ damage, meningitis/encephalitis, or both. And the brain infection can lead to deafness, blindness, or permanent brain damage. Ultimately a severe disseminated HSV infection in an infant can be fatal; it frequently is, without treatment. And infants exposed to HSV via metzitzah b’peh are no different from infants exposed through other means.

This became an issue for the City of New York, and then in particular for me, when infants born in ultra-orthodox communities in Brooklyn began to contract HSV from mohels who practiced metitzah b’peh, starting in 2003–2005. To date, 11 infants have been identified who contracted an HSV infection in this way. I have taken care of one of them.

As a 4th-year medical student I took care of an infant who was in the throes of an acute HSV infection secondary to this practice. He had already suffered severe brain damage and was blind and possibly deaf. He was in the Intensive Care Unit. He was very, very sick. At the time, I was furious at his parents, who blocked investigation into the case at every turn. The family was hasidic, typical of these cases, and while the mother’s claims to be ignorant of the identity of the mohel and absent at the circumcision were believable given the gender separation present at orthodox religious ceremonies, the father’s professed ignorance was an obvious lie. In traditional circumcisions, the father holds the infant on a pillow on his lab while the mohel performs the act. That the father would not have seen the act itself, or met the mohel, was an impossibility. But they did not want the secular medical community invading their sacred world. They did not want the secular law enforcement community invading it either. And despite our pleas, and those from the city, that stopping this practice at that time would prevent needless future suffering and save lives, the hasidic community put up road blocks, insisting they would handle this internally through a Beit Din, or rabbinic court. Eventually, one of the mohels (who was responsible for 3 cases and 1 death) was identified and barred from practicing circumcision. However, since many of these religious procedures are performed without any civic oversight, it is unclear whether even this ban is being upheld.

It is in the context of this experience that I am ecstatic to see the city government finally taking some more substantive action through overall regulation. The DOHMH regulation requires informed consent from the parents before this practice of metzitzah b’peh can be done. That means being told of the risks of HSV infection–including blindness, brain damage, hospitalization for weeks, and death. I wholeheartedly agree with the idea of informed consent and regulation of this practice, but actually feel this does not go far enough. The regulation, despite how it might appear from the vigorous negative response from the orthodox community, lacks teeth. A mohel who performs this practice will only be investigated when a case of HSV is brought to the attention of the health department. And the punishment? A sternly-worded letter, a warning. No revoking of licenses, and certainly no arrests.

Not all physicians agree with the DOHMH decision, and feel it does too little:

Indeed, some panel members said they believed that requiring consent did not go far enough. “It’s crazy that we allow this to go on,” said Dr. Joel A. Forman, a professor of pediatrics at Mount Sinai School of Medicine.

I agree with Dr. Forman[2] and the many other physicians who recognize this procedure is exceedingly hazardous to an infant’s life. It should not be allowed to continue. Moreover, some orthodox rabbis also agree and go farther still:

“There is no requirement to make metzitzah b’peh. The Talmud says plainly it is not part of the ritual but belongs to the medical, post-surgical component,” said Rabbi Moshe Tendler, a medical ethicist and a dean of Yeshiva University’s rabbinical school, where he teaches fourth-year students about circumcision. Tendler, who has a doctorate in microbiology, said, “There is no doubt that insistence on metzitzah b’peh is wrong. I firmly believe that making metzitzah b’peh is a criminal act.”

With this last statement, I wholeheartedly agree. Based on my experience with my patient—seeing the devastating end result of this infection, seeing the way that the city was barred from investigating the cases, seeing the way the parents didn’t even seem to care that their obstruction was possibly affecting other infants—I believe that this practice needs to be outlawed. More specifically, as a clear and present danger to the children of the Jewish community, it should be illegal. Should an infant contract an infection due to a mohel’s performing this practice, that should be considered assault. An infant’s death from infection secondary to this practice should be considered manslaughter. The guilty party would be the mohel. And should the parents block investigation, as with any criminal investigation they could be considered liable—for charges of obstruction of justice, accomplice charges, I’m not sure of the correct legal terminology. But if this practice is handled as a criminal act, there could be legal consequences for them.

I am aware this is possibly trampling on religious freedom. I am aware this is a slippery slope, where if we can claim this practice is dangerous, what else can we claim? What other practices can we outlaw? But a practice that has devastated the lives of 11 infants and killed 2 just in New York City, let alone others around the world, cannot be allowed to continue. And an injunction or ban without legal consequences is useless. And along with punishing the mohels, legal consequences should have the potential to impact the families. Any law that does not do this, that does not cut off demand as well as supply, will likely not be effective.

Let me be clear—I am not in favor of a ban on circumcision. I am not even in favor of a ban on the practice of bloodletting during circumcision—this can be done using a sterile glass pipette in a way that is not a risk to the infant. It is only the specific practice of metzitzah b’peh, where the mohel puts his mouth on the infant’s genitals and in so doing exposes defenseless, innocent infants to the risk of death, that I feel should be outlawed.

As physicians, our obligation is to ‘first do no harm’. Not ‘first do no harm only when it is easy, convenient, and in keeping with religious and social norms’. The DOHMH regulation is a start, but only a start. The practice of metzitzah b’peh needs to be complete cut out… pun intended.

  1. Do I need to…ummm…spell it out…? The pictures in this link should be clear enough.  ↩

  2. A disclaimer: Dr. Forman was my program director during my pediatric residency at Mount Sinai, so I am a bit biased.  ↩

An Overreach on Overprescribing

A recent article by Jane Brody earlier this week in the New York Times discussed the overuse of an antibiotic group called fluoroquinolones. While she had the right idea, I think her approach and some of her data are at best flawed and at worst downright fear mongering. And while I certainly have a number of specific concerns about this article, they represent a more troubling broader tack being taken by popular press coverage of the phenomenon of antibiotic resistance and antibiotics in general.

Fluoroquinolones were originally created for use against hospital-acquired bacteria, especially antibiotic-resistant gram-negative bacteria. Their use, as Ms. Brody correctly points out, has now spread to more benign locations and situations. The group as a whole is one of the most popular antibiotics for use in community-acquired pneumonia, and it is also extremely popular as a treatment for sinusitis. For my part, as a practicing pediatric infectious disease physician, I use these agents only when a patient is allergic to, or their infection is resistant to, a penicillin-based antibiotic; I also use them when broadly effective oral treatment is required. Indeed, one of the advantages of fluoroquinolones, and why they are used so often in the outpatient setting, is that they are extremely well-absorbed when taken by mouth. They give blood levels nearly equivalent to those seen when administered by IV, which in certain infections can be very useful. All of that said, there is no reason to use them as any sort of routine outpatient or inpatient therapy and most guidelines agree that they are second-line drugs, in essentially all settings.

Ms. Brody recognizes all of this and argues for the decreased use of this class of antibiotics. But then she goes beyond that and attempts to argue that not only shouldn’t fluoroquinolones be used as they currently are, but she implies it is tantamount to malpractice to use them. Now, I grant that she does not use those words, but she points out numerous studies that she feels are strong evidence for problematic fluoroquinolone side effects and argues that physicians should know about these studies and not prescribe fluoroquinolones because of them. She also references the existing black box warning on the drug label (it causes tendinopathy) and says that doctors rarely discuss side effects and black box warnings with their patients.

And so, here is where I will now begin to pick apart and dismantle her article, starting with that near-final point of hers.

First, as a physician, I am offended by that offhand comment about warnings and side effects. I and nearly all of my current and former colleagues always inform patients of pertinent side effects or black box warnings on drugs we prescribe. Always. To offhandedly insinuate otherwise, especially while implying ignorance, is obnoxious and ignorant. Moreover, her handling of her so-called evidence, is shockingly unscientific and inaccurate.

Second, she presents a single patient with bizarre diffuse symptoms that are blamed on fluoroquinolones–as physicians we are (and even as a science journalist she too should have been) trained not to simply believe an isolated case–a study with an “n” of 1, as in only 1 patient participating in the study. This is simply not valid data and to include it is dishonest.

Third, she references one article that claims increased retinal detachments while on fluoroquinolones. The paper is solid and the data is good and is believable. However, the authors themselves state, while they had statistical significance, the clinical impact was very low because while the background rate of retinal detachments was 0.6%, even patients on fluoroquinolones had only a ~3% rate. tendinopathy or the neurologic issues now on the black box warning are both significantly more common. Why Ms. Brody spent time even discussing this eye issue and did not focus more on the things we know to bad about the drugs, is beyond me.

Fourth, the other major article she cites discusses the role of fluoroquinolones in inducing C diff diarrhea. She seems to claim that the article shows that fluoroquinolones are more likely to cause C diff than other antibiotics. This is false. A bit of a diversion on C diff: essentially, this is a secondary bacterial infection that is induced by antibiotics, causing overgrowth of a particular pathogenic bacteria. It is a real entity and is caused by a large number of antibiotics; and it is increasing in incidence. The major issue I take with the paper she cites is that during the time the authors were studying this connection, fluoroquinolone use was indeed rising but was the C diff due to this? Or were both rising for other reasons that could confound the results—an increase in hospitalized patients, for example. This effect by confounding is extremely likely in this case. And because the thrust of the article was that as fluoroquinolone use rose so did C diff, the point they argued was simply that this antibiotic too can cause C diff, so watch out. But there is no reason at the moment to suspect fluoroquinolones are any better or worse at inducing C diff than many, many other antibiotics. This work should not have been cited as it is not about a specific fluoroquinolone problem.

Finally, her tone throughout the article is one of alarm or emergency, as opposed to thoughtfulness, teaching, learning, or any combination thereof. The way to spread news to the NY Times readership is not through fear–it’s through news! I feel like Ms. Brody is peddling her wares differently and as a result ends up (hopefully unintentionally) masking the real truth. Because, the real reason not to use fluoroquinolones is not just that they are too broad but also they are not good , effective drugs! Bacteria can become resistant to almost any fluoroquinolone by a single mutation and this mutation does not seem to confer a survival disadvantage on the bacteria. They are also horrible drugs as a group for treatment of Staphylococcal infections, though many community practitioners do not seem to be aware of this and use them, with numerous clinical failures that we, the ID specialists, need to then fix.

My point is simple: I am not a pharmaceutical apologist and I recognize more than many that antibiotics are overprescribed—it’s my job to tell people when not to use antibiotics as much as it is to advise them on which to use. However there are many good reasons to not use the fluoroquinolones, some of which I have touched on here: tendinopathy, easy resistance, high rate of clinical failure against certain bacteria. For a journalist to cite bad studies or use anecdotal data to support her claim against an antibiotic not only undermines those claims, it undermines even the existing true data about the drug, as some physicians will begin to doubt all the data and may even prescribe the drug more.

But of course, for patients—the true audience for Ms. Brody’s piece—all they will read is the side effects and the personal tragedy and they will start to refuse fluoroquinolones at every turn, out of fear. They may trust their physician less because of her comments regarding proper warnings. They may begin to refuse all antibiotics, even when appropriate. None of these outcomes is a good one. Patients should be informed, but not at the expense of a productive therapeutic relationship with their physicians; not at the expense of appropriate treatment.

The hippocratic oath is often paraphrased as “first, do no harm.” Ms. Brody’s piece has, I fear, done a vast amount of harm; for her, for the reputation of her employer, and most important for the patients we physicians try, desperately, to serve, even in the face of unfortunately careless reporting.

Rounding up the Herd

As I have discussed in a previous post here, Pertussis, also known as whooping cough, is increasing in prevalence. There are outbreaks this year across the country, building on previous outbreaks last year and in 2010. In order to control these outbreaks, there are a number of strategies being suggested to increase immunization rates—from adding another adolescent dose of the vaccine, to increasing adult vaccination. However, one prominent population that has been a focal point in these outbreaks cannot currently be vaccinated: infants under 6 weeks of age, for whom the vaccine is not approved (pertussis vaccination starts with the routine shots at 2 months of age). How can we protect these infants?

A recent post on’s twitter feed linked to an article about the possible introduction of a newborn pertussis vaccine. This is a wonderful idea and could certainly help to address protection of infants from pertussis. However, either testing either the current DtaP vaccine or developing a newer version for use in this population are time-consuming propositions, both. On the order of years. And that will do nothing for people currently at risk from outbreaks currently in progress. There is another way to protect infants though, one that relies on the concept of herd immunity.

Herd immunity is the idea that by vaccinating a large enough number of individuals in a population–the “herd”–we will effectively halt transmission of the disease because there are not enough potential susceptible hosts. Thus the people who are unable to be vaccinated—infants in this case—will be protected by virtue of being surrounded by immune individuals. In the case of infants, this surround effect is rather evocatively called cocooning, with the idea of blanketing a baby with healthy, vaccinated people. This is accomplished in practice by vaccinating an infant’s mother, father, and caretakers. Previous efforts to accomplish this had relied on vaccinating the mother during pregnancy and encouraging others to be vaccinated during the same time period. But nearly every baby in the US is born in a hospital or similar facility and stays in the nursery for 2–4 days. Could the family be vaccinated then? The answer is a most emphatic yes!

Here in New York State, thanks to brilliant research and lobbying efforts of Shetal Shah, MD, a colleague of mine here at Stony Brook, this practice of cocooning— by encouraging vaccination of caretakers prior to the infant’s discharge home from the hospital—will now be law. Through work published in the journal Pediatrics in 2008, Dr Shah showed that the practice of vaccinating parers and caretakers prior to NICU discharge (Dr. Shah works in the neonatal intensive care unit) was well-tolerated, feasible, and effective. As the rather thorough press release explains, beginning January 2013, all parents and caregivers will be offered and encouraged to accept pertussis vaccination before taking their baby home from the hospital. The hope and aim is this will help to prevent pertussis cases in these infants in the event of an outbreak.

I for one am proud to live in a state so responsive to appropriate medical lobbying efforts, and so proactive in its vaccination practices. The next step is to broadly implement similar cocooning practices across the country and encourage similar laws in state legislatures elsewhere. Let’s get started!

A Pediatrician’s Labor Day: What Really Matters

It can be all too easy for those of us who work in the medical field to forget why it is we do what we do for a living. And when we do remember why, it can feel difficult to understand how we face what we face on a daily basis. But during those moments, acutely, when you are really facing what matters in the medical care of children, it is not we that are impressive for doing the work at all.

I have worked in or studied medicine in some capacity for 13 years–from a volunteer in a pediatric ER in college through to medical school, training, etc. At first none of it phased me because I didn’t really comprehend what I was seeing, how it affected people. I was probably too young–here’s a good reason for medical training to remain longer, but I digress. Then as I moved further along in my training, seeing the sick children–oncology patients with hair falling out, ICU patients on ventilators, the list goes on–became difficult to take. It was hard to talk to parents, to see the children every day. It became even harder when, as a resident, I began having children of my own. I could not dream of facing the parents of a child the age of my son (quite obviously, a moving target as he aged) without tearing up. Even when the child was healthy and it was just the concerns or anxiety of the parents that were troublesome, I was able to relate almost too much and their fears would make me fearful, would undermine my confidence and make me doubt my own medical knowledge.

But at some point during my fellowship training, despite eventually having a second child—a girl—thus making nearly all of a children’s hospital identifiable as “this could be my kid”, something changed. I could talk to the sobbing parents of the bone marrow transplant patient who was dying; I could take care of a 4 year old with bacterial sepsis who had the same lisp as my son. Hell, it was really hard but I could and still can do it. Somehow I got over that hump of functioning, of doing my job in the face of some of the worst suffering and sorrow that mankind can conjure up: that of a parent facing the idea of harm to, or even death of, their child.

And we all do this. I make no claims to being somehow unique or superhuman in this regard. Every pediatrician, every family doctor, every pediatric nurse, every child life specialist—anyone who cares for sick children in any capacity—does this. We make ourselves able to go to work every day through some combination of denial (this can never happen to my kid), defense mechanisms (it can be very easy to put up an emotional wall if you practice enough), and even just sensory acclimation (who knew you could tune out screams and cries). The human mind is an amazing thing

And yet, for us, it isn’t. For we go home at the end of the day. Our patients and their families do not.

Right now, my wife is caring for a little girl only a bit older than our daughter who will probably die of a brain tumor. I recently took care of an infant who died from bacterial meningitis, who went from awake with a fever to dead in hours. These are obviously extreme examples, but they are real. The lives of their parents will be forever irrevocably altered. Some families of patients like this are broken and never fixed—they cannot overcome the death of a child; others are changed, bent by the force of such an event and must slowly rebound and reshape into a new normal, whatever that may be. And for the family, the example of the meningitis patient may even be somehow easier to cope with, as sick as I realize that sounds. But that death was quick, with nothing to discuss. For the parents of the patient slowly dying of a brain tumor there are decisions to be made: more chemo? more surgery? Do-Not-Resuscitate? “Full court press” or let her go quietly and peacefully? These are questions about another person nobody should have to answer, let alone about their own children.

As a parent, when I start to think of this, start to imagine what I would do, how I would act, I can’t continue. It’s too much; I know too much. When my wife and I have tried to imagine whether we would allow a DNR or push for more treatment in our own children, it is a thought experiment that even in that setting is too painful to continue. We retreat from it, shuddering. And yet the parents of our patients like this cannot and for the most part do not do that. They come to visit, to sit with their child, to talk to the staff. They are there, in the case of some families, every hour of every day of every week until their child leaves the hospital–either by car or by hearse. There is no break from being a parent or a loved one.

Every day, I go to work in the morning, work my day, and go home in the evening. Most of the time the day feels uneventful—if I take care of a sick child, as I said, it doesn’t faze me as much anymore. And even if it’s a horrible day and a patient is truly very sick or even dies, and I feel that pain and that weight on my trip home, that hurt and burden fairly rapidly diminishes. I kiss my wife, and delight in my own children, and the memories of someone else’s pain fade away to be replaced by my own thoughts of happiness and even relief, and then often a bit of guilt at that relief. And the same story can be told by many, many, many other pediatric practitioners. That story is not impressive. We are the lucky ones. Even those of us who have no family to come home to, we still leave our patients at the hospital.

So on this Labor Day, when we are supposed to think on the achievements of ourselves as workers, and then also when many take advantage of the day off to spend time with family and loved ones, think instead about the ones we pediatricians work for. For many, their time, today on this three-day-weekend, is spent not around a barbecue or picnic table but in the hospital with their son, or their daughter, watching them anxiously as they either get better or do not. They are the ones truly laboring, carrying this horrible load, while we flit in and out and around.

To the parents of sick children everywhere: I cannot possibly pretend to feel your pain, but I thank you for bearing it so graciously and allowing those of us who care for your children to witness the strength of humanity that you show. If there were some way we could fully carry your load for you, trust that we would. In lieu of that: Thank You.

Happy Labor Day; let’s try and make it count.