‫הוועדה הבינמשרדית להסמכה ולפיקוח על המוהלים‬

‫בס"ד‬
20 Tmuz 5782
19 June 2022

Halakhic-Medical Position Paper1

Metzitzah Be’Peh in traditional Jewish ritual circumcision

Synopsis and Recommendations

According to current medical and halachik information available to us, we are of the opinion that there is no
need to ban Metzitzah Be’Peh (MBP) for those halakhic authorities (poskim) that consider this action a vital
integral part of the traditional observance of ritual Jewish circumcision, for the following reasons:

 Even if there is an indication that there is a small chance that neonatal herpes infection (NNH) may
be contracted after MBP, this is based only on circumstantial evidence and not clear scientific proof.
 The incidence of NNH after MBP is significantly lower than other infections related to circumcision,
and certainly much lower than the other general complications related to circumcision (such as
bleeding etc.). So, just as we do not ban milah in general because of these complications, similarly
we need not ban MBP for those poskim who opine that this is a vital integral part of the traditional
circumcision.
 In general, there are situations in daily life, involving adults and children alike, that involve far
greater risks than the assumed risks of MBP. Examples of these are: parents allow cosmetic surgery
for their children even when there is no real medical indication; parents allow their children to
participate in dangerous competitive sports, parents allow children to cross busy streets, etc. In such
instances there is no demand to eliminate these activities even though they have associated risks
which are far greater than those associated with MBP.
 Making halakhic decisions as to when risks are great enough to forbid an action is a
complicated process and depends on the frequency of the risk, its severity, on the
importance of the action, on the general acceptance of the populace to do that action and
other considerations. Any decision to restrict a religious practice on the basis of the
medical risk can only be made by an accepted halakhic authority after he has been
presented with all the scientific data and proofs and been given the specific details of the
case(s) involved. Therefore, without a general or specific halakhic decision by one of the
great contemporary halakhic authorities on this issue, MBP should not be stopped.

1
Written by Prof. Rabbi Avraham Steinberg, MD and Dr. Moshe Westreich, MD; reviewed by Dr. Rabbi
Mordechai Halperin, MD and Dr. Uriel Levinger, MD.

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However, because there are indications that NNH may possibly be contracted after MBP, there is an
obligation to make every effort to lessen the possible risk, even if this is as yet unproven, and recommend that
mohalim adopt the following practices whenever MBP is contemplated as part of the milah2:

 In appropriate circumstances the mohel should offer the parents the choice between MBP and suction
by tube (pipette), and if the family prefers MBP the mohel should inform the family of the small risk
of infection, including neonatal herpes, and obtain their informed consent.

 A mohel should not perform MBP if he has any oral lesion (sores), or any infectious disease that can
be transmitted via saliva, until the oral lesion has healed or his infection has passed.

 If there have been two or more cases of neonatal herpes in infants circumcised by a particular mohel
using MBP, he should cease performing MBP until proven non infective. (See attached protocol)

 Before performing the milah the mohel should use either an antimicrobial soap or an alcohol-based
hand scrub, to scrub his hands for the length of time recommended by the manufacturer (usually 2-6
minutes). If he is using a non-alcohol-based hand scrub, the Mohel should wash his hands with the
non-alcohol soap and dry his hands completely, then use an alcohol-based product to rinse the hands,
as recommended. Again allow hands to dry thoroughly before performing the circumcision. (See
attached protocol)

 The Committee requires every mohel 5 minutes prior to performing MBP to rinse his mouth well
with Listerine or Peridex for 1 minute at least.

 In all cases of neonatal Herpes infection after circumcision, virological and immunological data
should be collected from the Mohel, baby and all the immediate care givers of the child.

2
The effectiveness of some of the actions suggested has not been scientifically proven, but were
recommended by experts in the field of virology as a means of lessening the viral load and/or possibly
decreasing virus viability.

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 ‫הוועדה הבינמשרדית להסמכה ולפיקוח על המוהלים‬

POSITION PAPER:
METZITZAH B'PEH - MEDICAL ASPECTS

The Interministerial Oversight Committee of Mohalim of the Israeli Chief Rabbinate and the Ministry of
Health informs hereby the rabbinic authorities, medical practitioners, mohalim and the general public its
position with regard to the issue of metzizah b'peh (MBP), and the practical implications of its performance.

1. General background

The mitzvah of milah (ritual circumcision) is one of the most ancient commandments of the Torah, dating
back to Abraham, the forefather of our nation. From time immemorial the mitzvah has been performed in all
Jewish communities as a Biblical commandment and not because of any medical advantage it may impart3.
This mitzvah has had the unique merit of its being performed by the great majority of the Jewish people in all
countries right through the modern era. This almost unanimity of performance even among non-observant
Jews is remarkable considering that Jewish communities never had any legal means to encourage its
performance. This phenomenon is explained in the Talmud:

"We have learned - Rabbi Shimon the son of Gamliel says: those commandments which
the Jews accepted with joy, such as milah, as stated by the Psalmist 'I rejoice at Thy word
as one that finds great spoil', they continue to perform them with joy"; It is also taught -
Rabbi Shimon the son of Elazar says: Every mitzvah for whose performance the Jews were
willing to sacrifice their lives under gentile decrees, like idol worship and milah, is still
performed faithfully" 4.

Indeed, over the generations there were periods of forced conversion when enemies of Israel forbade the
performance of milah in particular, Jews performed the mitzvah at the risk of danger to their lives5. This has
occurred even in our own era, under the Nazi Regime in Germany, in the former Soviet Union under Stalin
and other countries.

2. Metzitzah as part of milah

The Talmud6 discusses Metzizah and relates to it a medical benefit to prevent a danger to the baby7. There
have always been those that have voiced opinion against milah in general and even more so with respect to

3
It is well known that there is health benefit from circumcision. See summary on the subject in the
Encyclopedia Hilchatit Refuit, new edition 5766, volume 4, Milah, pp. 457-463. The subject has been proven
without doubt especially in the era of the AIDS epidemic. But nevertheless we are commanded to do the
mitzvah irrespective of the added benefits.
4
Tractate Shabbat 130a.
5
See in detail the history of decrees against milah: Chashmonayim 1:1:48 and 2:6; Tractate Gerim 1:1;
Tractates Shabbat 19a, Rosh Hashana 19a, Taanit 18a, Meila 17a. See further Zichron Berit Larishonim part 3
#3; Encyclopedia Ivrit vol 23, Mila, pp. 19-23.
6
Tractate Shabbat 133b.
7
There is a halakhic dispute whether metzitzah is merely a medical measure to prevent danger or whether it
is an integral part of milah. See the discussion on the differences of opinion among halakhic authorities in

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Metzizah as part of the Mitzvah8. In the beginning of the 19th century opposition to Metzizah in general and
MBP particularly was based on three main contentions: lack of a medical indication to Metzizah; a fear of
endangering the infant because of transfer of infection when performing MBP 9; and a fear that it might
increase bleeding at the wound site. Because of this, factions arose in some of the Jewish communities that
were opposed to MBP, and three approaches to Metzitzah developed:

 One group wanted to eliminate all forms of metzitzah, arguing that conditions had changed from the
time of the Talmud, and modern (i.e. 19th Century) medicine showed that eliminating Metzitzah will
not endanger the baby’s health and in fact its performance is dangerous. This position has been
rejected by all halakhic authorities because clearly established religious principles of the ancient
Rabbis cannot be over-ruled without concrete proof that such change is required and those who
encourage such changes are indeed suspect of heresy10.
 A second group opposed any change in the classic custom of MBP and insisted on its performance as
it has been done over the generations11.
 A third group insisted on continuation of metzitzah in all cases, since this is a halakhic requirement
of milah and it may not be over-ruled. However, Metzitzah may be done in a different manner, that
avoids direct contact with the mouth of the mohel, and different methods have been developed (such
as the pipette, etc.)12. Those Rabbis that accept such alternate methods have deliberated over the
relative benefits of each method and have made recommendations accordingly.

Hence, the arguments and discussions concerning MBP are certainly not new, they are only renewed
periodically.

3. Neonatal herpes and Milah

Most recently the question of MBP has arisen anew because of publication of a few articles dealing with cases
of infants infected with herpes after MBP. However, an analysis of these reports raises questions as to the
scientific validity connecting MBP and the spread of Herpes and if such spread does occur it is certainly a
relatively rare occurrence.

Encyclopedia Hilchatit Refuit, loc. sit.(n. 2) pp. 484-5. This is beyond the scope of the position paper. We are
also not discussing the issue of danger prevention by the process and its medical utility. See Encyclopedia
there, as well the article: M. Halperin, The tradition of metzitzah: restoring a forgotten medical indication. In
JME Book Vol. III, (Pub.: The Schlesinger Institute, Jerusalem, 2011), pp.179-201. This again is beyond the
scope of this position paper.
8
See Otzar Ha'brit, vol. 4 appendix A, on the history of metziza. See also Sedei Chemed, kunteres
hametzitzah, who spends tens of pages justifying MBP and brings a statement of protest by over 250 rabbis
from Austria-Hungry in 1900 against any changes in the traditional procedure. At the end of the publication
he brings a great warning that was published in Jerusalem in 1901, signed by the most distinguished Rabbis of
the period, who forbid metzitzah by an instrument and he insisted on MBP.
9
In the 20th century infections with syphilis and tuberculosis were attributed to MBP, but it is clear today that
no such transmission occurs without active TB of the mohel.
10
See Responsa Daat Cohen #141-2.
11
See a list of a great number of Poskim in the Encyclopedia Hilchatit Refuit loc. sit. p. 488.
12
See at length there pp. 489-496.

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13
The two main articles that investigated this problem were Gesundheit, et al and Blank, et al 14, and will be
discussed below:

These are the relevant data from the paper by Gesundheit, et al:
 Seven cases are reported from Israel and one from Canada of newborns affected by herpes in the
period soon after a circumcision which included MBP.
 These 8 cases are from a period of 8 years -1994 to 2002.
 All of the cases had herpetic lesions on the abdomen or near the genital area, and they do not cite any
other cases of neonatal herpes (NNH) with similar lesions in which MBP was not done.
 Importantly, in one case in which the mohel was found to be serologically positive for herpes the
mother tested positive as well.

This paper lacks certain vital information:

 In 4 out of the 8 cases the mohalim were not tested at all for herpes antibodies.
 No epidemiological information was provided about the herpes status of the parents, immediate
families or other caregivers for most of the infected infants.
 No DNA tests were done to match the herpes virus in the infants to those of the mohalim15. This
would have been the most reliable technique to prove the connection 16.

These are the relevant data from the paper by Blank, et al:
 Eleven cases are reported from the New York City area affected by herpes in the period soon after a
circumcision which included MBP.
 These 11 cases are from a period of 11 years – 2000 - 2011.
 All of the cases had herpetic lesions on the abdomen or near the genital area, and they do not cite any
other cases of neonatal herpes (NNH) with similar lesions in which MBP was not done.
 According to the authors there was corroboration that MBP was performed in six of the cases while
in the other five the parents refused to make this corroboration and the authors make the assumption
that it was performed.
 Serological status for HSV was reported for one mohel and two of the mothers. In the one case
where the mohel tested positive for herpes the mother tested positive as well. There is not
information regarding serological status for any of the other parents, immediate family members or
other caregivers.
 The authors infer that the family and care givers were not the source of infection based on the
assumption that none had evidence of herpetic disease during the two years prior to the infection of
the infants.

13
Gesundheit, B, et al, Pediatrics, 114:259, 2004. See also Gesundheit, B., et al, Harefuah, 144:126, 2005.
14
MMWR, June 8, 2012/ 61(22):405-409.
15
This is the recommendation of the New York State Department of Health (Revised 06/2006):
Circumcision Protocol Regarding the Prevention of Neonatal Herpes Transmission, section IV(C),
published in: Jewish Medical Ethics (eds: M. halperin et al), Vol. VIII, No. 1, December 2011, pp. 36-
39.
16
Thus suspected HIV infections were tested by DNA - CDC's Investigation of HIV transmission by a
dentist, Sep 1992, as were the cases concerning Hepatitis B - Harpaz R, et al, NEJM 334:549-560, 1996.

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 The authors estimated the incidence of herpes infection after MBP as 24.4 per 100,000 (that undergo
MBP) which makes it a 3.4 times greater risk for such infants to contract herpes compared to infants
that did not undergo MBP. These statistics are derived from an analysis of the number of children in
Jewish kindergartens and the relative distribution of population into separate religious affiliations
within the Jewish community17. The authors assume that all children in Chassidic kindergartens
(100%) would have had MBP performed and that only half (50%) of the Yeshivote kindergartens
would have had MBP. They further assumed that no other Jewish kindergarten children would have
had MBP.

17
Schick, M., A census of Jewish day schools in the United States, 2008-2009. New York, NY: The Avi
Chai Foundation; 2009. Available at http://avichai.org/wp-content/uploads/2010/06/Census-of-JDS-in-the-
US-2008-09-Final.pdf

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This paper lacks certain vital information:

1 - In 45% of the cases (5/11) we do not really know if MBP was actually performed.

2 - The authors' assumption regarding the number of MBP performed appears to be incorrect,
because, based on decisions of contemporary Jewish halakhic authorities in the Yeshiva world,
it can be assumed that the percentage of families that now perform MBP is not 50% as surmised
by the authors, but is most likely 100%. In addition the authors failed to count the families of
Chabad and Central Orthodox as part of those thatperform MBP. Therefore, it is safe to
conclude that the percent of families that would perform MBP is not 58% as assumed by the
authors but is closer to 84%. Also, the number of MBP performed is not 20,493 but is almost
30,000. This is almost a 50% increase and will certainly impact in the determination of relative
probability of incidence and risk of herpes infection after MBP.

3 – Whatever the source of the infection it remains a relatively rare complication, with an
incidence of one case per year.

In most reported cases of NNH the baby becomes infected at the time of birth 18 without any connection with
MBP. It is reported that 85% of the infants with NNH became infected during their passage through the birth
canal; 5% had congenital herpes; and 10% got NNH post-natally from caregivers19. In some cases the mother
did not know that she harbored the herpes virus, and in several cases the mothers tested negative to herpes
antibodies soon after birth even though they were infected 20. These articles on NNH indicate that the most
common source of NNH is the mother followed by caregivers and not MBP.

Even if there is a connection between MBP and neonatal herpes it represents a small risk as indicated by the
data from the report of Gesundheit and Blank. This can be seen even when one looks at the data of risk and
incidence published by Blank, et al. One must remember that their numbers are based on their assumed
number of MBP performed compared to the number of cases with NNH after MBP. However, as stated
above, their assumed number of MBP and the number of cases could be way off the mark. We have pointed
out that the number of MBP could be 50% greater and the number of proven cases with NNH after MBP
could be 45% (or more) fewer. Thus statistical analysis of these new numbers would substantially change the
incidence and risk and make them even lower. As stated by the New York State Department of Health21,
“There is a theory in some medical literature that, although extremely rare, the practice of MBP could be a
route of transmission for HSV-1".

18
Whitley, RJ, In: Kundsin RB, Falk L (eds), Impact on the fetus of parental sexually transmitted disease, Part
III - Viruses, New York Academy of Sciences, 103-17, 1988; Brown ZA, et al, NEJM 324:1247-52, 1991;
Jones CL, Neonatal Netw 15:11-5, 1996.
19
Brown ZA, et al. Effect of serologic status and cesarean delivery on transmission rates of herpes simplex
virus from mother to infant. JAMA 289:203–9, 2003.
20
Whitley, RJ, ibid; Brown ZA, et al, ibid; Jones CL, ibid; Thanhauser D, NEJM 325:965, 1991.
21
New York State Department of Health (Revised 06/2006): Circumcision Protocol Regarding the
Prevention of Neonatal Herpes Transmission, section I(4), published in: Jewish Medical Ethics (eds: M.
Halperin et al), Vol. VIII, No. 1, December 2011, pp. 36-39.

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In addition we recently received information from Dr. Daniel S. Berman 22, an infectious disease expert from
the New York City area, who personally investigated some of the cases in the report by Blank, et al, that
indicates problems with the MMWR paper. Dr. Berman explains that the eleven year study period reported in
Blank, et al was divided in to two parts: The first five and half years was prior to a state requirement of
reporting all cases of NNH and the second was a subsequent five and a half years in which this requirement
was in force. In the first period there were six cases of NNH after MBP, however in two of the cases the
authors acknowledge that there was no “confirmation” that MBP was actually performed. In addition,
Berman contends that one of the “confirmed” cases may not be definite and brings evidence that in fact MBP
was not performed. During the second period there were 5 cases of NNH after MBP but only two were
“confirmed”, but in one of these “confirmed” cases there is no laboratory evidence that the child had HSV1
infection. Thus, of the eleven cases there are only four cases of truly “confirmed” HSV1 infection after MBP
(only one of these during the period of required reporting). Berman also brings new evidence that the number
of MBP performed during the study period was actually much higher than that assumed by the Blank, et al.,
but he does not offer his own estimate. In the work by Blank, et al they cite, based on their numbers, the
incidence of NNH in general to be 7.1 per 100,000 births, therefore if there were 20,493 MBP performed and
there were five cases, then there is a 3.4 times greater chance of developing NNH in those that had MBP
compared to those that did not. Berman points out, correctly, that the number of cases is so small that a
change of 1-2 cases would change all calculations dramatically. For instance, Berman points out that during
the surveillance period it is reasonable to assume that the number of cases is actually one and not five as
assumed by Blank, et al. In addition, if one assumes that the number of MBP performed during this same
period is closer to 30,000 (see above), then the incidence of contracting HSV after MBP is 0.46 times as great,
rather than 3.4 times – a 50% decrease in the risk of contracting HSV compared to those that did not undergo
MBP. Berman also points out that Blank’s paper is faulty because no appropriate laboratory tests were done
on most the mohalim and mothers, and none were done on the other family members or caregivers. They also
relied on reports that none involved had recent signs of herpetic disease to determine that they were not the
source of infection. The problem with this is that there is a reasonable possibility that these people could have
been the source of infection and without such testing they should not have been ruled out as the source.

In actual fact there is no scientific proof in the cited publications regarding the etiologic connection between
MBP and neonatal herpes23 for the following reasons:

 In half of the reported cases reported by Gesundheit there is no proof that the mohel had ever been
carrier of herpes since no tests for herpes exposure were done on them. In addition, in one case it
may have been the mother that was the source of the infection rather than the mohel. In 82% of the
reported cases by Blank there is no proof that the mohel had ever been carrier of herpes since no tests
for Herpes exposure were done on the mohalim. In addition, in two cases it may have been the
mothers that was the source of the infection rather than the mohel.

22
Personal communication (2012) of Berman, Daniel S., M.D., F.A.C.P., Infectious Disease, Westchester
Square and Montefiore Medical Centers, New York, NY.
23
This was also the conclusion of S. Glick and A. Eidelman in their article in JME Book Vol. III, (Pub.: The
Schlesinger Institute, Jerusalem), 2011, pp.208-211.

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 No appropriate epidemiologic testing was done on family members (other than some of the mothers)
or other caregivers in most of the cases, so that it is not possible to rule out that they may have been
the source of infection.
 In no case was DNA mapping (as is now recommended by the New York State Department of
Health) performed to show the virus identity in the infant and mohel.
According to the information supplied by Berman, there may be marked discrepancies between the
assumed numbers and actual numbers regarding the number of cases of NNH after MBP and the number
of MBP performed; therefore, it is impossible to make a statistical correlation between the two to deduce
the source of the infection or the risks of contracting NNH after MBP.

In addition, halakhah in general, including the rules of Pikuach Nefesh (life threatening situations) does not
require us to totally eliminate every possible risk in performing mitzvot or other activities in our daily lives.
Automobile travel with children in the vehicle in Israel involves a much greater risk to the child than the
danger of neonatal herpes after MBP, but there is no obligation to refrain from automobile travel. Many daily
occupations involve different degrees of possible risk to life, and yet we are permitted to take these risks. As
the Scripture says "and his life depends on it"24, and the Rabbis permit a minuscule risk of life for the purpose
of earning one's livelihood25. Moreover, society does not ban dangerous sports for children, such as karate,
soccer, scuba diving climbing and the like. In the medical sphere, cosmetic surgery for children is permitted
even though it has no clear medical indications yet incurs dangers and complications which are by far more
common than after MBP. For similar reasons, for those poskim who rule that it is a required part of milah by
a clear halakhic mandate, there is no reason to ban MBP even if there is a small chance of contracting herpes.

4. Conclusions

 We feel that there is a small chance that neonatal herpes infection may be contracted after MBP, but
this is based only on circumstantial evidence, not clear scientific proof.
 The incidence of neonatal herpes after MBP is significantly lower than other infections related to
circumcision, and certainly much lower than the other complications related to circumcision (such as
bleeding etc.)26.
 In general, there are situations in daily life, involving adults and children alike that involve far
greater risks than the assumed risks of MBP. Examples of these are: parents allow cosmetic surgery
for their children even when there is no real medical indication; parents allow their children to
participate in dangerous competitive sports, parents allow children to cross busy streets, etc. In such
instances there is no demand to eliminate these activities even though they have associated risks
which are far greater than those associated with MBP.
 Making halakhic decisions as to when risks are great enough to forbid an action is a complicated
process and depends on the frequency of the risk, its severity, on the importance of the action, on the
general acceptance of the populace to do that action and other considerations 27.

24
Deuteronomy 24:15.
25
Tractate Baba Metzia 112a.
26
An incidence of 0.34% was reported a few years for ritual circumcisions performed in Israel, with no
difference in incidence rate between circumcisions performed by a physician or a traditional circumcisor. See
- Ben Chaim J, et al, IMAJ 7:368, 2005
27
Tractate Shabbat 129b.

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Therefore, based on the published facts and the analysis of the information they contain, in which there are no
definite scientific proofs, we cannot reject the performance of MBP, similar to the manner that we do not
reject the very performance of milah, based on claims of medical risks in the various other stages of the milah.
Any decision to restrict a religious practice on the basis of the medical risk can only be made by an accepted
halakhic authority after he has been presented with all the scientific data and proofs and been given the
specific details of the case(s) involved28.

It is our assessment that the topic of NNH after MBP should be dealt with in the following manner:

 We should evaluate the statistics of NNH in general, including cases that develop after circumcision
in the same way the scientific community evaluates the risk of infection in any medical procedure:
The greater the indication for the procedure, the greater is the tolerance for an incidence of infection
and vice versa. In other words, if there is little medical indication for a particular procedure then we
are less tolerant of infections.
 Nevertheless, if a medical procedure is indicated in the presence of a certain risk for infection, we
must take every precaution to reduce the risk so that it is as low as possible, but it does not mean that
because some risk does exist we must now stop performing that procedure entirely.
 Therefore, according to those halakhic authorities who hold that MBP is an essential part of the
mitzvah of milah, there is no necessity to cease this procedure unless there will be clear cut scientific
evidence for endangering the baby by MBP in a statistically significant rate from the halakhic and
scientific points of view. This has yet to be proven.
 Just as the small incidence of infections after circumcisions performed by mohalim (who perform the
procedure under less than ideal sterile conditions) is not considered sufficient reason to change the
traditional manner of performing the circumcision, so too according to the statistical /
epidemiological data available concerning the low risk of NNH after MBP, there is no need to
consider stopping the performance of MBP, which has been an accepted part in the performance of
the traditional circumcision for generations.
 In spite of the relatively small risk of infection from the herpes virus or other infectious agents when
performing milah, we are obligated to take all possible steps to further reduce the chance of infection
when performing milah, including MBP.

5. Recommendations

We, therefore, recommend that the mohel follow the following steps when MBP is contemplated as part of the
milah, although some of them have not been scientifically proven to be fully effective;

 In appropriate circumstances the mohel should offer the parents the choice between MBP and suction
by tube (pipette).
 A mohel should not perform MBP if he has any oral lesion (sores), or any infectious disease that can
be transmitted via saliva, until the oral lesion has healed or his infection has passed.

28
See article by Shabtai and Sultan in ASSIA – Jewish Medical Ethics, Vol. VI, No. 1, December 2007,
pp. 26-48; JME Book Vol. III, (Pub.: The Schlesinger Institute, Jerusalem, 2011), pp.138 -173.

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 If there have been two or more cases of neonatal herpes in infants circumcised by a particular mohel
using MBP, he should cease performing MBP until proven non infective. (See attached protocol)
 Before performing the milah the mohel should use either an antimicrobial soap or an alcohol-based
hand scrub, to scrub his hands for the length of time recommended by the manufacturer (usually 2-6
minutes). If he is using a non-alcohol-based hand scrub, the Mohel should wash his hands with the
non-alcohol soap and dry his hands completely, then use an alcohol-based product to rinse the hands,
as recommended. Again allow hands to dry thoroughly before performing the circumcision 29. (See
attached protocol)
 The Committee requires every mohel 5 minutes prior to performing MBP to rinse his mouth well
with Listerine or Peridex for 1 minute at least.
 In all cases of neonatal Herpes infection after circumcision, virological and immunological data
should be collected from the Mohel, baby and all the immediate care givers of the child.



The Committee members visited Rabbi Shmuel Wasner on 25 Shevat 5765 (February 4 th 2005) for him to rule
on the matter and he responded:

"After we heard about single cases where the milah was performed in accordance with halakhah
and tradition and after performing the circumcision and the metzizah be'peh herpes infection was
found in the baby, and it was suspected the MBP was the cause of the baby's disease, and hence
several physicians came to discuss whether the traditional MBP should be abolished and instead
metzizah should be performed with an instrument.
In order to clarify the matter senior mohalim together with expert physicians came to us to discuss
and listen to the Torah view for future acts.
After we listened carefully to the arguments by the mohalim and physicians and after looking into
the Torah view we hereby explain the following:

a.After most experienced physicians followed thousands of britot for many years which were
performed with MBP and they found only isolated cases of neonatal herpes, and even in
those cases it was not proven that the mohel was the cause of the disease, therefore there is
no halakhic reason to change the accepted tradition of MBP.
b. Mohalim are not obligated to undergo blood tests in order to verify that they are not carriers
of herpes, since it has been proven that such cases are very rare; only if it is known that an
individual is actually sick with herpes (not merely a carrier) he should refrain from this great
mitzvah.
Shemuel Halevi Wasner"

In the light of these facts Rav Elyashiv published his ruling (psak halakhah) on 15 Adar A 5765 (February
24th 2005):

29
Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings. MMWR
2002/51 (RR16); 32-33.

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"After it has been determined by specialist physicians in the USA and Israel that there is no
concern that MBP, as practiced for generations, will G-d forbid cause damage to the newborn
being circumcised, and thank G-d tens of thousands of our Jewish brethren perform this mitzvah
with joy without problems, it is clear that all the talk of eliminating MBP is nonsense talk; G-d
forbid that we introduce any change whatever in MBP. However, if the mohel has a lesion in his
mouth the MBP should be performed by another person."

In addition, Rabbi Y. Efrati wrote to Rabbi Prof. A. Steinberg on 29 Tishri 5768 (October 11 2007) the
following letter:

"Concerning your suggestion that the Supervisory Committee of Mohalim should issue an
instruction that "a mohel who is suspected of transmitting herpes infection to more than one
baby should not perform metziza bepeh himself but rather appoint someone else to do so" – I am
hereby to inform you that in the opinion of Rabbi Eliashiv they can issue such an instruction".



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Addendum:

Protocol for Investigation of Cases of

Neonatal herpes After Circumcision30
The Ministry of Health will conduct an investigation of all infants with neonatal herpes (NNH) after
circumcision without prejudging the cause. Such an investigation would include, but not be limited to
reviewing medical records, interviewing, and testing the mohel in question and all pertinent caregivers. The
mohel in question must stop MBP for 45 days or until the investigation is completed (whichever is longer,
unless it has been determined that the mohel is not the source).
The investigation will include the following laboratory testing:
The lesion(s) on the baby will be swabbed and tested for HSV by conventional virus culture.

A. If the culture result on the baby is positive, the virus will be typed to determine whether it is type HSV-1 or
HSV-2.

B. The primary caregivers (PCG) (up to four) and the mohel will be serologically tested (Western Blot) for
evidence of herpes virus infection. If found to be positive, further serologic testing will be done to identify the
virus type: HSV-1 or HSV-2.
1. If the serologic test (Western Blot) on the mohel or PCG is negative or is a different type (HSV-1 or
HSV-2) from the type found in the newborn, the mohel or PCG will be ruled out as the source of herpes
infection in the newborn. The mohel may resume practice of MBP.

2. If, on the contrary, the virus type matches the virus type of the newborn (
HSV-1 or HSV-2), then the mohel, and any other caregivers whose virus type also matches the
newborn's virus type will undergo viral culturing to attempt to recover the virus. The sample for viral
culture will be obtained by daily mouth swabs (other than on the Sabbath). Since viral shedding can
occur between 9 and 15 days per month, recovery of the virus may take as long as a month of swabbing.
If HSV is isolated, it should undergo further testing by restriction fragment length polymorphism
(RFLP). RFLP will be arranged by the Ministry of Health and the sample will be sent to an appropriate
laboratory capable of state-of-the-art RFLP testing and analysis, satisfactory to the Ministry of Health.
RFLP testing will take an additional time period of up to two weeks.

3. All RFLP testing will be conducted in a blinded fashion so that the testing laboratory does not know
the identity of the subjects who submitted the specimens.

C. The following actions will be taken, based on the RFLP results:

1. If the herpes viral DNA of the newborn and the mohel are identical, as determined by RFLP then the
mohel is implicated as the source of herpes infection in the infant and this mohel will therefore be
banned for life from performing MBP.

30
Adapted from Guidelines published by the State of New York, USA – 28.4.2006.

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2. After RFLP:
a. If the mohel and newborn have a different HSV viral DNA subtype, then the mohel is
determined not to be the source of the infant's infection. He may resume performing MBP.
b. In the event, however, that it is a relative or a caregiver who has an identical HSV viral DNA
subtype as the newborn then they are implicated as the source of herpes infection in the infant
and the mohel may resume performing MBP.

3. In the event that the mohel cannot be ruled out as the source of infection in the newborn because 1) herpes
virus has not yet been recovered for RFLP sub-typing and 2) no other caregiver is shown to have herpes virus
identical to the newborn's virus, then, under these circumstances if the mohel wishes to continue the practice
of MBP, he has to take one of the following options (the choice of which one shall be at his discretion):
a. Continue abstaining from practicing MBP until such time, if any, as the virus is recovered
from the mohel or any other person, through additional swabbing and results are obtained after
testing by RFLP. If such results are obtained, then the appropriate actions will be taken as set
forth as stated above; or
b. When the mohel will participate frequently in circumcision with MBP, take one 500 mg
valacyclovir tablet orally every day of his life; or
c. When the mohel will participate only occasionally in circumcision with MBP, take one 500
mg valacyclovir tablet orally every day for three days before circumcision.

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