Oscar Alleyne
Rockland County Health Department, New York
March 17, 2015
From 2009 to 2014, seven cases of neonatal herpes emerged in Rockland County, New York. The cases occurred in the local Orthodox community and were suspected to result from the metzitzah b’peh practice during circumcision.
The metzitzah b’peh practice, involving a trained practitioner of the circumcision ritual (“mohel”), was the suspected source of infection with the potentially fatal herpes virus in the infants. After a fifth case was identified and with growing concern about the cases of neonatal herpes in Rockland County, the health department decided to pursue a new approach to identifying the source of the infection without assuming the mohel as the cause. Previously, the health department only had information about the mother and baby in the neonatal herpes cases and did not have the ability to conduct a comprehensive investigation. Negative stereotypes about the metzitzah b’peh practice had caused the Orthodox community to have a high degree of mistrust towards those outside of the community. However, Rockland County Health Department began to build relationships and establish trust with the Orthodox community to find a solution.
Representatives from the health department reached out to the Orthodox community’s religious leadership and defined a community liaison as the point of contact between the Orthodox community and the health department. Rockland County offered transparency by stating that their mission was to find an answer for the sake of public health surveillance and that no matter the outcome, they did not have the power to legislate a ban on the practice. Other health departments outside of Rockland County had tried to ban suspected mohalim from the metzitzah b’peh practice, but this only deepened the mistrust among the Orthodox community. Thus, trust was easier to establish in Rockland County since the health department worked without bias and did not suggest any definitive actions until the investigation was complete. The New York State Health Department had recommended a new DNA test to isolate, identify, and sequence possible causes for neonatal herpes. Rockland County then developed a protocol for testing which would include a DNA test on all high risk individuals—an average of seven individuals for each case—instead of directing the investigation primarily to the mohel.
In late 2013, when the fifth case emerged, the health department was able to develop and put its new protocol into practice. In the initial stages of the investigation, Rockland County collaborated with the Orthodox community throughout the process and made the community part of the investigation. Both the health department and the Orthodox community had agreed that during the investigation, the suspected mohel would not practice during the investigation period of approximately six months, and if the tests were conclusive, he would not practice for the rest of his life. Test results from this case were inconclusive so the mohel resumed conducting the practice. He however retired from conducting any further circumcisions. The transparency of the first case investigation helped to strengthen trust between Rockland County Health Department and the Orthodox community and helped to expedite testing when two additional cases emerged in 2014. Results from both of these tests showed that the mohel was not the source of infection.
The Rockland County Health Department’s relationship with the Orthodox community has changed rapidly in the last two years. This once insular community has now become a partner in public health with a shared goal of keeping babies safe. Rockland County Health Department has empowered the Orthodox community to know that they play a key role in helping mitigate illness and was especially pleased with how the Orthodox community has come to see them as a trusted partner. In the seventh case of neonatal herpes, the parents came forward to the health department first. Other parents within the Orthodox community are now coming forward to the health department for additional diseases such as measles. Rockland County has two important lessons learned for other health departments that are looking to develop trust with an insular community. First, it is critical to look at multiple sources during an investigation without bias, and second, relationships are best with the health department playing the role of partner rather than antagonist. NACCHO has designated the Rockland County Protocol as a Promising Practice for 2015.
From 2009 to 2014, seven cases of neonatal herpes emerged in Rockland County, New York. The cases occurred in the local Orthodox community and were suspected to result from the metzitzah b’peh practice during circumcision.
