Misdiagnosis Raises New Doubt on NYC Approach to Milah

The NYC Health Department has come under increasing scrutiny for its ongoing campaign against metzitzah b’peh (MBP) after a recent diagnosis at a New York City hospital of neonatal herpes following a bris milah was discredited upon further testing by a New York State laboratory.

The latest twist in the years-long saga, which includes an ongoing court battle over an unprecedented regulation of bris milah,occurred when the case was transferred to the Rockland County Health Department, where a model program using DNA testing to determine the source of herpes infection has been put into place with the close cooperation of the local Orthodox community.

In the recent case, an infant with a respiratory infection was brought to a New York City hospital by his parents. The infant tested positive for herpes simplex virus type 1 (HSV-1) on a rapid-detection test known as H&V, and the New York City Department of Health and Mental Hygiene was immediately notified. According to NYC protocol regarding religious Jewish families, the parents were questioned about their son’s circumcision, whether or not the circumcision included MBP, and the identity of the mohel.

“That’s been the city’s long-standing practice,” said an attorney who has been involved with numerous such cases during the past 10 years. “When an Orthodox couple brings their infant to a city hospital after a circumcision to be treated for anything, even a respiratory infection, the standing order is to suspect HSV-1, try to identify the mohel, and ban him.”

When it became known that the family residence was not in New York City but upstate, however, the case was transferred to the Rockland County Department of Health for investigation.

That jurisdiction has in place a collaborative protocol with its Orthodox Jewish population, under the direction of its Department of Health, which conducts DNA testing in all cases of neonatal HSV-1 after MBP.

According to New York State Department of Health guidelines for investigating reportable communicable diseases, an initial positive test for HSV has to be followed up by a confirmatory state lab result. During the investigation period, the child is medically treated with anti-viral medications. If the confirmatory state lab comes back negative for HSV, then the case is dismissed and the physicians may end the antiviral treatment.

When Rockland County attempted to confirm that the state lab had the virus from the infant to compare against, the state responded that it could not produce any virus from the specimens sent from the city, and all tests of the specimens by the state lab were negative, causing the reclassification of the original H&V result.

“Lab officials said the H&V test is liable to misinterpretation and produces false positives, which is what happened here,” said a community liaison closely involved in the case. “Our willingness to work together brought the truth to light, though unfortunately, not before weeks of needless hospitalization and medication.”

“Without the involvement of Rockland County,” said the attorney, “this case would have ended with the positive H&V, and we would have seen another NYC Health Alert. Despite the city’s objections, this case moved to Rockland and was dealt with completely differently — focusing on identifying the source of infection rather than promoting an incremental ban on MBP.”

In response to an inquiry by Hamodia, a spokesperson for the NYC Health Department replied that “we do not have the results of case investigations conducted by Rockland County.”

When asked about the accuracy of the H&V test, the NYC spokesperson acknowledged that “all laboratory tests are subject to error. Laboratory tests need to be interpreted in the context of the patient’s physical examination, symptoms, current medications, the timing of specimen collection, and the manner of specimen handling; laboratory tests alone do not guide medical decision-making.”

The initiative for the Rockland County program, now two years running, began when Dr. Oscar Alleyne, director of Epidemiology and Public Health Planning for the Rockland County Health Department, reached out to the community. Community members who had long sought a venue for objective testing readily agreed, and a medically-based protocol was quickly worked out. All testing is done at the state’s Wadsworth Laboratory in Albany.

In an interview with Hamodia, Dr. Alleyne related that in the department’s view, the investigation of suspected neonatal herpes cases will be more successful when approached from “a culturally competent, scientifically based and collaborative stand point.

“Since we developed our local protocol, we have had significant cooperation and full access to the community as we have been conducting these investigations, with clear and open lines of communications,” Dr. Alleyne said. “In fact, in a number of instances, the community self reported suspected cases so they can be evaluated and we can ensure that proper treatment is in place, if it turned out to be a confirmed case.”

“While we cannot make an absolute determination on a particular practice, our focus is on our essential role of local public health, which includes empowering, educating, and engaging our community to ensure safer and better health protective procedures.”

He described the protocol that the Rockland County Health Department has put in place: “When we investigate a suspected case of infection, we identify a comprehensive list of all the individuals who may have been the point of exposure to the baby. This could be family household contacts, friends, medical personnel, mohel, caregivers, and others. We apply our epidemiological expertise to examine the entire sequence of events that may be a potential source of infection and exposure.

“What is important to know is that not all skin infections that are evaluated are going to turn out to be HSV,” he added.

In the Rockland County’s protocol, those individuals deemed to possibly be a source of the infection submit to genetic testing for HSV. This consists of the Health Department taking a swab — using something that looks like a sterile Q-tip —on the inside cheek of the individual. Sixty such swabs are taken of each identified individual during the testing period. If any of the results come back positive for HSV, they are analyzed and, using DNA testing, compared to that of the infected baby’s.

During the testing period, if a mohel is one of the individuals being tested, he refrains from performing MBP until the testing is concluded and the results come back from the lab. If a DNA match is found linking an individual to the baby, the Health Department will recommend that strict infection control practices be put in place to reduce the potential for further or future exposure to babies. If a mohel is linked to the baby, the protocol — which was entered into with the guidance and under the approval of Rabbanim in both Rockland County and New York City — calls for the mohel to no longer perform MBP for the rest of his life anywhere, locally or internationally.

The misdiagnosis in this recent case calls into question other HSV-1 cases handled by the city that were assumed, but not confirmed, to be linked to MBP.

The 2014 Health Alert #16, which was sent out by the NYC Health Department, discusses an infant who tested positive for HSV as an outpatient at a pediatrician’s office, but the test was inconclusive as to whether it was HSV-1 or another type of HSV that would not be attributable to MBP. The infant was admitted to the hospital for additional testing, “including CSF, blood, and swabs of lesions; all were negative for HSV,” according to the Health Alert itself.

When asked why it still categorized this case as a HSV-1 virus “attributable” to MBP, the city health department replied that the infant “had a laboratory test that was positive for herpes simplex virus infection” following a bris milah with MBP.

“It’s pretty outrageous,” said the attorney. “HSV-1 wasn’t confirmed by any test in that case, and every single hospital test was negative for all types of HSV.”

“Do you realize that according to the city, the vast majority of neonatal HSV-1 cases in the city are females and non-MBP males? This is a health-care policy based on an agenda,” said the Jewish liaison.

“If New York City were truly interested in good health-care outcomes, they would have conducted reliable DNA testing like Rockland County,” he added.

When asked by Hamodia why it has not implemented a protocol similar to the one in place in Rockland County, the health department replied, “We are in an ongoing discussion with community stakeholders on this policy, and will share more information as it becomes available.”

An askan closely involved in the matter was more pessimistic. “They have consistently and flatly refused to adopt the Rockland County protocol. If only they would have a change heart.”

This article appeared in print on page 1 of today’s edition of Hamodia.