The Rockland County Department of Health developed an unique approach to investigating cases of neonatal herpes through the use of community collaboration, sound applied public health practices and an innovative laboratory methodology for Herpes Simplex 1 strain analysis
Rockland County Department of Health
In the Spirit of Collaboration: An Innovative Approach to Conducting NeoNatal Herpes Investigation
Rockland County is located approximately 30 miles north of New York City on the west side of the Hudson River. Geographically, the county of 115,000 acres contains more than 35,000 acres of preserved open space and parkland. Rockland continues to experience steady population growth in the past several years within its five towns and 19 villages, driven by the major forces of natural increase and net migration. The Rockland County population in 2010 was 311,687. The County population is approximately 72% White, 12.2% Black, 16.3% Hispanic, and 6.1% Asian (US Census, 2012). The County's foreign born population is 21%. Incidentally, 16.1% of the population over the age five speaks English less than “very well.” Among the primary languages spoken at home are Spanish (37,494), Yiddish (23,485) and French/French Creole (13,017).While herpes simplex in adults can cause the common cold sore, neonatal herpes simplex virus infection can cause severe perinatal infections. Neonatal HSV infections are often acquired during delivery, in utero and postnatal. Infections can be localized to skin, eyes, and mouth, involve the central nervous system or can cause disseminated infection involving multiple organs such as liver, lungs, adrenal glands, and brain. Disseminated infection is the most severe form of neonatal herpes, with a high mortality rate if untreated. Symptoms are usually observed when the infant is 5–9 days old and include seizures, irritability, respiratory distress, jaundice, bleeding, shock, and often vesicular rashes. Early treatment with high-dose antiviral medication like acyclovir reduces the mortality rate. Between 2000–2011, the New York City Department of Health and Mental Hygiene investigated cases of laboratory-confirmed HSV infection in 11 newborn males with two associated deaths. It was reported that these infections occurred in the weeks following out-of-hospital Jewish ritual circumcision. Of particular concern was that the ritual circumcision included an ultra-Orthodox Jewish practice known as metzitzah b’peh, in which the circumciser (mohel) places his mouth directly on the newly circumcised penis and sucks blood away from the circumcision wound (direct orogenital suction). Public health concern suggested that the neonatal HSV infection was introduced by this direct orogenital suction. The NYCDOHMH enacted a local law in 2012 which require mohels who perform oral suction in circumcisions to explain the risks to parents prior to the procedure, including the possible transmission of herpes simplex virus, and have parents sign a waiver. This law was contested by the ultra-Orthodox Jewish communities During 2009-2014, the Rockland County Department of Health similarly investigated 8 neonatal HSV cases. In 2013, after receiving a positive clinical lab report, the County health officials decided to employ a different approach after uncooperative responses from previous case investigations. The goals and objectives were to develop a collaborative approach to investigation of neonatal herpes infections within the Rockland ultra-Orthodox communities. This was implemented by making direct contact with the local Rabbinical leadership seeking cooperation. A liaison was selected by the community as a main point of contact to RCDOH for further discussion. When several concerns were cited, the consistent messaging from the RCDOH was that the primary public health concern was for the health of the infant, family and community. Additional multilevel discussions were held with the NYSDOH for the purposes of laboratory testing. The NYSDOH Wadsworth Center Laboratory currently uses a method of genetic “fingerprinting” HSV-1 viruses referred to as analysis of reiterative regions. The end result was the decision to develop a new protocol for HSV-1 investigation associated with ritual circumcision. The milestones included the express commitment by community for full cooperation with the RCDOH, a transparent investigation, the utilization of confidential testing of identified contacts with the RCDOH knowing the identity of all contacts being tested and signed Consent Forms and Affidavits. The protocol involved daily oral swabbing of contacts for HSV for a period to encompass 60 swabs. A baseline blood draw for the testing of HSV serology and a weekly blood draw for the testing of anti-viral metabolites for a period to coincide with the oral swabbing time frame was also required.The specific factors led to success were the direct communication, the transparency and the core public health principles for the protection of the population health and safety as paramount to the RCDOH's interest in this investigation. All of the objectives were met as the community compliance and the cooperation of local and state partners was successful. There is significant public health impact of this model practice: Better community relationships and trust of the local Health Department was developed. The genetic fingerprinting analysis has been shown to be more discriminating than previous RFLP techniques.
Rockland County has a very sizeable ultra-Orthodox population which includes the Hasidim ( Skver, Lubavitch (Chabad), Satmar, plus 30-40 other groups and the Non Hasidim which are also called Yeshivish which has a population size rivaling that of the Hasidim. These populations are thriving in New York, several other US states and international countries living in very tightly-knit and connected communities.
The public health issue was in determining how to investigate neonatal herpes investigations within a community that held high concern related to perceptions of religious persecution, attacks on their customs and traditions and a growing sentiment of unproven scientific evidence linking the practice of mbp to herpes infection in neonates.
In the past, HSV-1 investigations only ended at the immediate family level with the RCDOH only being able to obtain medical information on mother and infant. Historically, after initial cooperation, the community would close ranks and mohel identities were not disclosed in subsequent case investigations. There was significant distrust of the health department officials in their relationship to the NYCDOHMH, the NYSDOH and the CDC. A recent determination in a US Federal Appeals Court also found that the New York City's regulation must be reviewed under “strict scrutiny” to determine whether it infringes on Orthodox Jews’ freedom of religion.
This is a new practice in that the previous work done in developing a protocol in 2004-5 by the NYSDOH was no longer in practice or valid. This current practice was entirely locally driven and collaborative by design. It involved commitment by community for full cooperation with the RCDOH, a transparent investigation by the RCDOH, the utilization of confidential testing of identified contacts with the RCDOH knowing the identity of all contacts being tested and signed Consent Forms and Affidavits and laboratory analysis by the NYSDOH Wadsworth Center Labs Virology Department.
The RCDOH protocol involved daily oral swabbing of contacts for HSV for a period to encompass 60 swabs. A baseline blood draw for the testing of HSV serology and a weekly blood draw for the testing of anti-viral metabolites for a period to coincide with the oral swabbing time frame was also required.
The mohel or the person performing oral suctioning, if different, had to agree to not practice oral suctioning as part of performing metitzah b'peh ("mbp") while the testing is ongoing. If the testing period ends with no matches, the failure to retrieve herpes virus is not an indication that transmission from any of the individuals tested could not have occurred. In that instance however, the Rockland County Health Department will not be able to make a determination of the transmission source of the infant’s infection and will close the investigationIf the mohel was determined to be a match, both the mohel and community is in favor of an immediate ban of future performing of metitzah b'peh and practice of oral suctioning as part of performing metitzah b'peh. The Rockland County Health Department will complete its investigation and report findings through the required disease reporting system.
This was a staff intensive project due to the confidentiality and scheduling for testing in the homes of contacts however the creative and cooperative approach was instrumental to obtaining success. Of particular note, the RCDOH received 2 new case reports in the first quarter of 2014 of neonatal herpes. The first report was obtained through the standard electronic laboratory reporting mechanism in place, however the second which occurred 4 days apart was entirely self reported by the community to the RCDOH. That is a testimony of the level of trust and the spirit of collaboration that ensued as a result of this protocol.
It is the intent of the RCDOH that practice will become a standard for future evidenced based practices in mpb related HSV1 investigations.
The goals and objectives of this practice was to develop a collaborative approach to investigation of neonatal herpes infections within the Rockland ultra-Orthodox communities. This was implemented by making direct contact by the Director of Epidemiology and Public Health Planning, the Director of Communicable Disease Prevention and Control with the local Rabbinical leadership seeking cooperation. A liaison was selected by the community as a main point of contact to RCDOH for further discussion and collaboration. Additional multilevel discussions were held with the NYSDOH for the purposes of laboratory testing, and epidemiological review.
The protocol was developed with input from the Community and NYSDOH partners. Constant communication and clarification were essential to develop a relationship of trust and continued participation by all parties involved. Associated costs were for the shipping of specimens to the State Laboratory three times a week, the inkind costs of travel to the contacts homes for testing and in kind costs from the NYSDOH lab who provided the viral transport medium and performed the testing in their Virology lab.
The goal and objective of this practice was to develop a collaborative approach to investigation of neonatal herpes infections within the Rockland ultra-Orthodox communities. The implementation of this protocol was successful. Better community relationships and trust of the local Health Department was developed. There was significant progress in cooperation with other investigations. While the RCDOH was unable to determine link between infant and identified contacts in the 2013 case, there were 2 subsequent neonatal HSV1 cases in 2014 where the protocol was immediately employed and testing of contacts were underway within days of case notification.
The protocol has been implemented in 2013 for the initial case and in 2014 for 2 subsequent case reports. Data collected were the 388 Samples received on 7 different individuals collected between March 28, 2013 and August 15, 2013 for a period of 127 days. Results are still pending for the 2014 sample collection. There was a modification made in the protocol where all contacts were instructed to not use oral mouthwash prior to the oral swab collection as alcohol based oral mouthwash can deactivate viral activity and inhibit growth under culture. There practice is still in the process of evaluation however it is the outcome of the collaboration and ability to conduct a significant and enterprising public health investigation with full cooperation and a commitment by the community if evidence shows a genetic association with HSV1 in a neonate to contact mohel that the mohel will be banned internationally from performing mbp at any ritual circumcision.
The lessons learned from this practice are the benefits of engaging community stakeholders, sharing expertise, and working together on solving common problems in local communities. The partner collaboration was significant in the empowering of the local community to play an active role in the development of a protocol that focused on their health and safety, the RCDOH improved standing in relationship to fostering such collaboration and expertise and the State Health Dept in strengthening their Reiterative genetic fingerprinting analysis for HSV1
While there was no direct cost/benefit analysis performed, the RCDOH can say with great assurance that the ability to conduct 3 investigations of neonatal herpes to the extent within the time period presented have yielded far more valuable information than in previous investigations where the case data could not be collected past the infant and maternal health records.
There is sufficient stakeholder commitment to maintain the practice. The community aspire to have this replicated in other communities across the world where these communities exist and subsequent cases may be reported. In addition, the ability to enact recommendations for safer practices after ritual circumcision that does not involve direct oral suctioning are being discussed for adoption by the rabbinical leadership.
Conference|Model Practices brochure|E-Mail from NACCHO|NACCHO website|NACCHO Exchange|NACCHO Connect