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Letter From Thomas Frieden to Antonia Novello on Metzitzah

I’ve obtained a letter dated June 9, 2006 from New York City Health Commissioner Thomas Frieden to New York State Health Commissioner Antonia Novello in response to her deal with ultra-Orthodox leaders that indicated a differentiated approach among city and state on the issue of metzitah b’feh.
It lists four “fundamental concerns” with the state’s protocol:
1) Use of betadine/povidone on the circumcision wound, as opposed to simply an antibiotic ointment.
2) The protocol only allows for the state to investigate infections “and does not mention any role for local health officers,” and that the city intends to exercise its jurisdiction. As well, there’s a close reading of the following part of the protocol:

So long as each local health department in whose jurisdiction such public health investigation is proceeding agrees to be bound by, without addition to or modification of, any and all provisions of this Circumcision Protocol, community Rabbis are expected to lend their support and cooperation in the event of any such public health investigation.

Frieden responds that “your
language implies that a community can stipulate how to conduct an investigation and may be justified in not cooperating.”
3) “The protocol’s approach to culture and molecular analysis has many fundamental
problems,” including:
*The requirement of mohels linked to — but not proven to be the source of — infections to take antiviral medication has been shown only to reduce, but not eliminate, the risk of genital herpes transmission, and there is “no data to show that oral antivirals
eliminate transmission of HSV-1 from the mouth”;
* “Related to this concern is the implicit assumption in your protocol that lack of a positive
culture from the mohel may be associated with a lower risk of infectiousness,” something I don’t gather from the state’s protocol, but the concluding sentence of this paragraph is much clearer, “Given the infrequency with which virus may be isolated in culture, or even detected by PCR, it should be expected that for many case investigations it will not be possible to obtain virus from both baby and mohel for RFLP comparison.”
* “Your protocol also assumes that virus will always be available from the infant,” when that’s not necessarily true and “even if an isolate is obtained from the infant, there are occasions where isolates are lost or do not remain viable in storage.”
* “Furthermore, identifying a caretaker with a viral isolate which is an RFLP match with the
infant’s isolate cannot be used to rule out the mohel as the source of infection (Section IV D3). As you know, any laboratory result must be interpreted as part of an epidemiologic investigation; it is possible, for example, that a family member’s HSV infection resulted from contact with the infected infant.”
4) “Our fourth fundamental concern is that the children of parents for whom metzitzah b’peh
is not considered religiously necessary may undergo this procedure without the knowledge
and/or request of both parents, and this is not addressed by your protocol. Every effort should be made, in conjunction with practicing mohelim, to ensure that metzitzah b’peh is only performed when parents clearly are aware that it will be performed and wish it to be performed.”
The letter goes on to list in an attachment eight “less fundamental concerns,” primarily relating to the specifics of achieving a worthwhile investigation and who should be involved in maintaining the protocol.
Frieden concludes with a surprisingly optimistic paragraph:

Overall, we think it might be most practical to simply propose that every metzitzah b’peh is preceded by mouthwash with Listerine or similar product, is followed by application of povidone/iodine, that it not occur if there is an active oral lesion, and that it only occur for children for whom the parents feel it is religiously necessary. Such an approach would merely reflect the taking of minimal precautions, which should be taken as an ethical matter regardless of the existence or not of a protocol relating to investigations, and none of which encroach in any way on any religious freedoms. We would all hope that these measures might be universally adopted, and might result in the disappearance, or virtually disappearance, of HSV-1 infections following metzitzah b’peh in the future.

Presumably, Frieden wouldn’t express that “hope” if he didn’t think it realistic.
If you want to read the letter in full, I’ve posted the PDF here (please link to this post and not the file).

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