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2013 ALERT # 1

New case of neonatal herpes infection following ritual Jewish circumcision; new regulations for providers and labs

Please Share this Alert with All Emergency Medicine, Pediatric, Pediatric Infectious Diseases, Infection Control, and Microbiology Laboratory Staff

  • New case of neonatal herpes following ritual Jewish circumcision reported, bringing total to 12 since 2000.
  • New regulation requires health care providers to collect vesicular swab specimens when evaluating an infant with suspected herpes infection, and send swabs to Wadsworth Center Laboratories.
  • New regulation requires clinical laboratories detecting herpes simplex virus in specimens from infants to send all specimens to Wadsworth Center Laboratories.

January 7, 2013

Direct oral suction during ritual Jewish circumcision (metzitzah b’peh) has been documented to transmit herpes simplex virus (HSV) type 1 to newborn males (1-4). In December 2012, the New York City Department of Health and Mental Hygiene (DOHMH) received a report of a new case of HSV-1 infection in a newborn male infant attributable to direct oral suction

In total, 12 laboratory-confirmed cases of HSV-infection attributable to direct oral suction have now been reported to DOHMH from 2000 – 2012. Two of these infants died, and two others suffered brain damage (4). In the most recent case, the location of herpes lesions (on the penis), viral type (HSV type 1, which is commonly found in the mouth of adults), and timing of infection (10 days after circumcision) are consistent with transmission during direct contact between the mouth of the ritual circumciser (mohel) and the newly circumcised infant penis. When evaluating an ill infant boy in the weeks following circumcision, providers should inquire whether direct oral suction was performed during circumcision and consider infection with HSV or other oral pathogens. Consult with a pediatric infectious disease specialist for guidance regarding the diagnosis and management of an infant with suspected herpes infection; also, see reference #5 under “References and resources” at the end of this alert.

New regulation affecting health care providers
In September 2012, the New York City Board of Health approved a new regulation that requires health care providers to collect a vesicular swab from any infant with suspected HSV infection. The swab(s) must be sent to the New York State Wadsworth Center Laboratories (Wadsworth

Center Laboratories) for diagnostic testing. The text of the regulation reads:

“At or before initiating treatment for a suspected case of herpes simplex virus infection occurring in a child aged 60 days or less, the health care provider ordering treatment shall collect specimens from one or more vesicles or from any skin lesions suggestive of herpetic disease. Unless otherwise directed by the Department, all such specimens shall be sent by the provider to the Wadsworth laboratories for diagnostic testing using molecular methods, and reports of positive and negative results shall be forwarded to the Department by the Wadsworth laboratories.”

The regulation above applies only to swabs of vesicles. Physicians are not required to collect other specimens for testing, but they are encouraged to follow good clinical practice and collect additional specimens to diagnose HSV or other causes of illness and to submit these to their local clinical laboratory. A complete diagnostic evaluation for suspected neonatal HSV includes collection of multiple specimen types for herpes testing, including cerebral spinal fluid, and liver function tests.

The complete text of Article 11 of the New York City Health Code can be viewed here:

New regulation affecting clinical laboratories
In September 2012, the New York City Board of Health approved a new regulation that applies to clinical laboratories. Laboratories that detect HSV in a specimen from an infant are now required to send the specimen(s) and all associated materials to Wadsworth Center Laboratories. The text of the regulation reads:

“When a clinical laboratory detects herpes simplex virus in a specimen collected from a child 60 days of age or less, the laboratory shall, unless otherwise directed by the Department, send the original specimen and any derived materials to the New York State Department of Health Wadsworth Center laboratories, or another laboratory determined by the Department for further testing as specified by the Department. If testing is conducted, positive and negative test results shall be forwarded to the Department.”

This regulation applies to any and all specimen types.

The complete text of Article 13 of the New York City Health Code can be viewed here: http://www.nyc.gov/html/doh/downloads/pdf/about/healthcode/health-code-article13.pdf

Collection of vesicular specimens
To collect a specimen from a vesicle, use a sterile flocked or dacron-tipped swab with a plastic shaft, unroof or open the vesicle with a sterile needle or scalpel, and vigorously rub or twist the swab on the exposed base of the lesion. Place the swab in liquid viral transport medium and send immediately to the laboratory. If transport to the laboratory cannot be done immediately, then the specimen should be refrigerated.

Shipping specimens to Wadsworth Center laboratories
Refrigerated fresh specimens should be shipped on cold pack by overnight service. If transport will be delayed more than two days, specimens should be frozen at -70ºC and shipped on dry ice using an overnight service. Never ship on a Friday or the day before a government holiday.

Laboratories submitting specimens should complete a Wadsworth Center virology requisition form, which can be found at http://www.wadsworth.org/divisions/infdis/DOH-4463_061109_fillable.pdf

When submitting specimens to Wadsworth Center Laboratories for HSV testing, page 1 of the requisition form should be completed. The name of the submitting laboratory should be included in the section of the form entitled “Submitter (test ordered by).” Check the box labeled “viral” in the section entitled “Laboratory examination requested,” write “HSV” in the space provided following “suspected organism/agent,” and check the box for “identification/confirmation.” When submitting vesicular swabs for diagnostic testing, circle the word “identification.” When submitting an HSV-positive specimen, circle the word “confirmation.”

Specimens should be shipped to the following address:

Virology Laboratory
Wadsworth Center, DAI
120 New Scotland Avenue
Albany, NY 12208

For questions about specimen handling or shipping, please contact Meghan Fuschino, Associate Director of the Virology Laboratory, at (518) 474-4177, or mef03@health.state.ny.us

Wadsworth Center Laboratories will test vesicular swabs submitted for diagnostic testing, and will report results to the submitting laboratory. If confirmatory testing is performed on a specimen in which HSV has already been detected, results will also be reported back to the submitting laboratory. Laboratories detecting HSV in specimens from infants should continue to report those results to the electronic clinical laboratory reporting system.

Health care providers are required to report all cases of neonatal herpes (clinically diagnosed and laboratory-confirmed) to the DOHMH (case report forms can be found at: http://www.nyc.gov/html/doh/html/hcp/hcp-urf2.shtml).


Julia A. Schillinger, MD
Director of Surveillance, Epidemiology, Research
Bureau of Sexually Transmitted Disease Control

Susan Blank, MD, MPH
Assistant Commissioner
Bureau of Sexually Transmitted Disease Control

Posted 02-07-2013 at 11:55AM

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