Just a quick post before Shabbat begins. I noticed an article in the Jerusalem Post that may have an effect on the way the Chareidi community views becoming an organ donor. Apparently, doctors in Israel were successful in transplanting a kidney from a donor that had been without a heartbeat for several hours.
This is an exceptional accomplishment, because it opens the possibility for those who believe in Cardiac death to donate their organs after what they consider to be halachic death. (See my extensive posts from October 2010 for more on this topic). Whether or not it actually changes the practice of the Chareidi world remains to be seen of course.
Just FYI, there still is a long way to go before it can become regular practice to harvest donor organs after cardiac death. The new techniques will need to be tested and attempted on other organs as well as the kidneys. Furthermore, harvesting the organ prior to cardiac death is still much more likely to be successful. However, maybe it can open the path for a Chareidi living will that explicitly states that the individual is willing to donate his/her organs if cardiac death is established first.
This may turn out to be a real opportunity for the Chareidi world, once organs can be donated even after cardiac death, they can join the ranks of the potential organ donors! I certainly hope we see that happen!
Friday, August 29, 2014
Monday, August 25, 2014
MBP - Does a rinse with Schnapps help?
I must admit that I was somewhat caught by surprise by the overwhelming responses to my previous post about MBP. In addition to the comments that are published, I received many emails as well, and tried my best to respond to all of them. Sitting up late at night in the hospital can sometimes be a useful time for emails! I used to use that time for Nach Yomi, and catching up on medical articles, but now it seems to be email and blog time! BTW, Nach Yomi is an OU program that has changed my life, and I highly recommend it to the many Nach deficient people out there. If even one of you takes up Nach Yomi as a result of my encouragement, then this blog may turn out to be something useful after all! But let's get back to MBP.
If at all possible, I beg you to comment publicly on the blog rather than send me an email. I want everyone to benefit from your thoughts, whether you agree with me, or not. If you want to remain anonymous, I have no problem with that at all. The discussions generated by the comments can be very interesting and beneficial for everyone, and it allows me to respond publicly. I will still read and respond to emails, but please let everyone benefit from your ideas, not just me.
One of the issues that has come up over and over again is the question of whether or not rinsing the mouth with wine or whiskey helps mitigate the risk of transmission of the HSV virus. One person even wrote to me in an email, that apparently in Yemen, the custom was to perform the MBP with a mouthful of Arak, and even to rinse several times. His source was Rav Kapach's Sefer Halichot Teiman. Since there has been so much interest in this topic, I am dedicating this post to the question of alcohol rinses and HSV transmission.
There are many reasons why the alcohol rinse does not mitigate the concern for HSV transmission. For starters, alcohol as a disinfectant loses most of its potency when it is less than 60-90% concentration. Even the strongest whiskey's are rarely more than 40-45% alcohol. See the CDC here for details on the concentration of alcohol necessary for it to have any useful potency for germicidal use. Furthermore, bear in mind, that the alcohol is further diluted as soon as it is placed in the mouth by natural saliva. So the alcohol used is simply not strong enough to kill bacteria or viruses.
In addition, even if one were to use pure ethyl alcohol to rinse the mouth, it would still be impossible to kill all the viruses and bacteria present in the mouth. The mouth is full of areas to which the alcohol will never reach, such as the gums, between the teeth, all the folds between the cheeks and lips and the teeth and so on. It is well known that it is impossible to actually disinfect the mouth. So even if you could reduce the amount of virus present in the mouth, there is no way anyone can eliminate the possibility of transmission. To make matters worse, the skin on the outside of the lips can transmit virus as well, and this area is never rinsed.
We also need to bear in mind, that the germicidal activity of alcohol, even when it is potent enough to kill bacteria, is measured when it is used on smooth surfaces, together with scrubbing the surface. In order to effectively replicate this, one would have to scrub every surface within and around the mouth (which is absolutely impossible like I described before) with alcohol with at least a 70% concentration!
The bottom line is that the alcohol in wine and schnapps is simply too weak to be effective, and even if it were an adequately strong germicide, the mouth cannot be disinfected.
I think it is worthwhile to bring another example that will hopefully drive home the point that the only way to eliminate the risk of HSV transmission is to eliminate the direct contact between the one who has the virus and the baby.
We all know that surgeons sterilize their hands and arms, or "scrub", before performing surgery and coming into contact with open wounds. However, would anyone ever even think of allowing surgeons to operate bare-handed just because they washed their hands really well and scrubbed them with germicidal solutions? Of course not! We mandate gloves and gowns and etc. because it is common sense to eliminate contact between the surface of the surgeon's hands and the open wounds. That is the only way to guarantee that germs do not get passed back and forth.
In the same way it makes no sense to allow contact between someone's open mouth and the open circumcision wound, no matter how much schnapps one may rinse his mouth with.
If at all possible, I beg you to comment publicly on the blog rather than send me an email. I want everyone to benefit from your thoughts, whether you agree with me, or not. If you want to remain anonymous, I have no problem with that at all. The discussions generated by the comments can be very interesting and beneficial for everyone, and it allows me to respond publicly. I will still read and respond to emails, but please let everyone benefit from your ideas, not just me.
One of the issues that has come up over and over again is the question of whether or not rinsing the mouth with wine or whiskey helps mitigate the risk of transmission of the HSV virus. One person even wrote to me in an email, that apparently in Yemen, the custom was to perform the MBP with a mouthful of Arak, and even to rinse several times. His source was Rav Kapach's Sefer Halichot Teiman. Since there has been so much interest in this topic, I am dedicating this post to the question of alcohol rinses and HSV transmission.
There are many reasons why the alcohol rinse does not mitigate the concern for HSV transmission. For starters, alcohol as a disinfectant loses most of its potency when it is less than 60-90% concentration. Even the strongest whiskey's are rarely more than 40-45% alcohol. See the CDC here for details on the concentration of alcohol necessary for it to have any useful potency for germicidal use. Furthermore, bear in mind, that the alcohol is further diluted as soon as it is placed in the mouth by natural saliva. So the alcohol used is simply not strong enough to kill bacteria or viruses.
In addition, even if one were to use pure ethyl alcohol to rinse the mouth, it would still be impossible to kill all the viruses and bacteria present in the mouth. The mouth is full of areas to which the alcohol will never reach, such as the gums, between the teeth, all the folds between the cheeks and lips and the teeth and so on. It is well known that it is impossible to actually disinfect the mouth. So even if you could reduce the amount of virus present in the mouth, there is no way anyone can eliminate the possibility of transmission. To make matters worse, the skin on the outside of the lips can transmit virus as well, and this area is never rinsed.
We also need to bear in mind, that the germicidal activity of alcohol, even when it is potent enough to kill bacteria, is measured when it is used on smooth surfaces, together with scrubbing the surface. In order to effectively replicate this, one would have to scrub every surface within and around the mouth (which is absolutely impossible like I described before) with alcohol with at least a 70% concentration!
The bottom line is that the alcohol in wine and schnapps is simply too weak to be effective, and even if it were an adequately strong germicide, the mouth cannot be disinfected.
I think it is worthwhile to bring another example that will hopefully drive home the point that the only way to eliminate the risk of HSV transmission is to eliminate the direct contact between the one who has the virus and the baby.
We all know that surgeons sterilize their hands and arms, or "scrub", before performing surgery and coming into contact with open wounds. However, would anyone ever even think of allowing surgeons to operate bare-handed just because they washed their hands really well and scrubbed them with germicidal solutions? Of course not! We mandate gloves and gowns and etc. because it is common sense to eliminate contact between the surface of the surgeon's hands and the open wounds. That is the only way to guarantee that germs do not get passed back and forth.
In the same way it makes no sense to allow contact between someone's open mouth and the open circumcision wound, no matter how much schnapps one may rinse his mouth with.
Thursday, August 21, 2014
MBP - Dispelling Some Common Misconceptions
The mere sight of the term MBP (Metzitza B'Peh - direct oral/genital suction of the circumcision wound) may set off fireworks in the minds of many of the medical halachic rationalist readers of this blog. Some of you might have been waiting for me to say something about this subject. MBP has been in the news lately due to some high profile court rulings in New York, so it is once again a hot topic. However, I must disappoint you by admitting that I don't have that much to add that hasn't already been said. In fact, a close friend of mine, Shlomo Sprecher, has already written what I consider to be the most definitive rationalist medical halachic (even if he didn't use the term "RMH" to describe it!) article on this topic, and you can read it here. I highly recommend that you read it if you haven't already done so.
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.
Postscript:
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...)
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.
Postscript:
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)
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