However, I have come across an extreme amount of ignorance when it comes to understanding exactly what the medical concerns are regarding the transmission of HSV (Herpes simplex virus) and circumcisions. The ignorance in the Orthodox Jewish world seems to reflect the ignorance of the general population about this virus, which I encounter on a regular basis in my medical practice. As such I feel like I need to counsel everyone regarding how this virus works, and then you can understand what the issues really are.
For starters, HSV is a virus. That means that it cannot be treated with antibiotics. This particular virus has the nasty habit of being incurable, which means that once you become exposed to it, it will be in your system forever. It has figured out a way to hide deep inside your nerve roots ("ganglia") and hang out there for the rest of your life. Every once in a while it may decide to leave its hiding place, travel up the nerves to your skin, and cause a lesion to pop out on your skin and annoy you.
When this happens, the sore is likely to shed more virus, so if someone else becomes exposed to it, he/she can catch it from you. However, the virus is even sneakier than that. Sometimes it travels out to your skin and sheds virus, but doesn't show any sores at all. This is called asymptomatic shedding. This means that you can be shedding and transmitting the virus and have no idea at all that it is going on. While an active lesion is much more likely to shed virus than when there are no symptoms, it is well known that asymptomatic shedding can and does occur.
So that's the bad news, what is the good news? The most important good news is that HSV is generally not a very dangerous virus at all, in the overwhelming majority of cases. The vast majority of people with this virus will go about their innocent lives and have virtually no consequences, except maybe an annoying sore every once in a while. Most people don't even know that those annoying sores are HSV, they just think it is a pimple that came and went after a few days. They usually don't even know that they have HSV, and they certainly don't know that they can transmit it to someone else!
But that good news can also be bad news. Why is that? Because if you don't know that you can transmit it, and it can be transmitted even if you have no symptoms at all, how are you supposed to prevent the transmission of HSV throughout the general population? Well, guess what! You now understand why close to 90% of the adult population of the US has been exposed to HSV 1 at some point in their lives.
When two moist surfaces of the body, such as the oral region, and/or the genital region come into contact, and one surface is shedding HSV, this is the most effective way to transmit the virus. If one person has a cold sore (which is caused by HSV), or is shedding asymptomatically, and people share a cup, a kiss, share a food utensil, wipe their mouth or cough and then pass the kugel, or any other moist contact, the virus can be transmitted. Of course the chances are very small each time this type of contact occurs, but if it happens over and over again, it only takes once ...
The vast majority of people will have been exposed to HSV in this manner. By now you should understand that a person with HSV 1 is usually not infected because he/she is guilty of some type of sexual contact. Most of the time it was completely innocent, and most of the time the person him/herself is never even aware of having been exposed.
You probably noticed that I mentioned HSV 1, which means that there is another type called HSV 2. This is a very closely related virus that tends to hang out more in the genital region. This type is usually transmitted through genital or oral/genital contact. However, there is much crossover between the two types, as HSV 1 is often found in the genitals, and HSV 2 is often found orally as well.
HSV 1 outbreaks are generally more mild than HSV 2 outbreaks, and especially with HSV 2 in the genitalia, the first outbreak can be quite severe. But both types of the HSV virus have a very similar clinical course, and they are transmitted in basically the same way. The reported cases of HSV transmission through MBP in New York were HSV 1 cases, not HSV 2. This is important because HSV 1 is much more common, and is still more associated with Oral infection than with genital infection.
So what's the big deal? If it is true that HSV is only a nuisance and rarely causes health problems, why is it such a concern? What is all the hoopla regarding MBP?
The big deal is that in certain very rare cases, if HSV gets into certain body fluids it can cause very serious problems. Those two places are the blood, where it can cause viremia (a viral blood infection) or in the brain where it can cause encephalitis or meningitis. Viral infections such as these can be extremely dangerous, and are notoriously difficult to treat, especially because antibiotics do not work against viruses. Furthermore, as you recall, there are no cures for HSV.
When would someone be at highest risk for such a horrible infection of the blood or the brain with this virus? For starters, if it is introduced directly into the blood. That would be really bad. Now if you take a person who does not have a very strong and mature immune system, that would be worse. Then if it enters the brain of someone who is still developing neurologically, that would be tragic beyond words.
Now let's make it scarier. Let us find a well meaning person. This person seems perfectly healthy. He himself has no idea that he has any infections of any type. Everyone around him knows that he is "very clean" and scrubs his hands really well. He has lived a virtuous lifestyle and has never exposed himself to any situation which would make one concerned that he may have gotten any transmittable diseases. Maybe when he was a child in cheder he shared a cup of juice and got a little cold sore, which went away after a few days because his Mom shmeared on some Vaseline. He was a little "tzaddik'l" and went on to become a popular Mohel. But he has this HSV 1 virus for life. In his mouth.
Let us go further. This mohel never sees any lesions that he thinks could represent a major health risk, except occasionally he may get a cold sore which he thinks is just chapped lips. The mohel is such a tzaddik and so well loved and well respected that he does a Bris Milah just about every day in his community. Asymptomatic shedding is very rare, so it only happens a few days a year, but he does a bris milah every day ....
And one fine day, a happy young couple brings their beautiful little child to shul for his bris milah. The well meaning, wonderful Mohel performs the ceremony. He does MBP. This young child, with an immature immune system, and a developing nervous system, now has an open wound, giving the virus direct access to his bloodstream, and to his newly forming brain. The Mohel happens to be shedding virus that day, and has no symptoms whatsoever. And the virus gets into the baby's bloodstream, and it replicates, and may God save us, a horrible, totally preventable, unspeakable tragedy occurs.
This is the problem. Like I said before, the cases reported in New York were HSV 1, simple Oral HSV that 90% of the adult population has. The only way to prevent it from happening is by avoiding the exposure in the first place and protecting our children from tragedy. May common sense prevail.
In this post, I have tried to dispel the following extremely prevalent and extremely dangerous notions (I have heard ALL of these in murmurings at shul kiddushes, Shabbos tables, during leyning - bein gavra l'gavra only of course etc...)
- If the Mohel is a genuine tzaddik and ben Torah there is no risk of herpes transmission
- the Modern Orthodox are just trying to find ways to show that the Chareidim have Herpes infested Mohelim and they are all hypocrites
- If the Mohel has no history of disease and has no herpes sores there can't be a risk
- This Mohel has done thousands of Bris Milah ceremonies and "no one" has ever had a problem (this would be extremely difficult to prove, and even if it was true, it still doesn't protect you)