HSV-1 is common in adults and is the cause of cold sores. Many adults never have symptoms. However, the virus can make newborns very sick with high fever and seizures.
The centuries-old custom of direct oral suction during circumcision - done eight days after birth - is most commonly used in ultra-Orthodox communities. It has drawn heated debate because of its potential to spread the virus. In New York City, the Board of Health in 2012 required mohels, who perform the ritual circumcision or bris, to obtain written consent from families before using direct oral suction. Litigation ensued against the board. That year, the American Academy of Pediatrics also recommended against oral contact because of infection risk.
Leas, a research analyst at Penn's Center for Evidence-based Practice, said he and Umscheid, the center's director, did the first systematic review of medical literature on the subject. Leas said better studies are needed, but the review gives doctors objective information that could promote quick recognition and treatment of infection.
Leas became interested in the topic after a Penn doctor who treated many Orthodox patients asked about it.
There is no way of knowing how many babies are exposed to oral suction, he said, but the ritual step, known as metzitzah b'peh, is the dominant approach in some parts of New York and Israel.
It doesn't happen often in Philadelphia, Leas said, and would account for a "very, very small percentage of circumcisions" in the Jewish community anywhere.
During metzitzah b'peh, a mohel sips some wine, sucks a small amount of blood from the circumcision wound, and then spits the mixture into a cup, Leas said.
The historical origins of the practice are unclear, he said, but it may stem from early beliefs about saliva's value in healing. Some Jewish leaders approved alternatives after mohels in 19th-century Europe worried they might contract tuberculosis, syphilis, and other diseases from the babies.
Some mohels now place a sterile pipette between them and the baby. Others use gauze.
Leas said he and Umscheid did not take a stand on how to deal with the practice. Their goal was a "neutral, objective" paper. In it, though, they state, "Standard principles of infectious disease suggest that exposing a neonatal circumcision wound to human saliva, even briefly, creates a risk of HSV [herpes] transmission." When pressed, Leas said he'd like to see the Jewish community "self-regulate" to make sure mohels are healthy.
Conflict-of-interest disclosures on medical papers usually refer to financial interests. Leas said he and Umscheid agreed that other factors might be just as important as money when scientists analyze a topic or readers evaluate their positions. They wanted everyone to be working with facts.
"It's such a controversial topic in a very small corner of the world," he said.
So, they decided to mention their own circumcisions. Umscheid disclosed that he is a "nonpracticing Roman Catholic whose wife affiliates with secular Judaism." He and his son were circumcised by pediatricians in hospitals.
Leas and his wife are modern Orthodox Jews. He and his sons had Jewish circumcisions without direct oral suction.
Asked what the mohel used for his sons' circumcisions, Leas said he didn't know because he was not looking that closely. "Very often," he admitted, "the fathers do not watch."