When Religion Puts you at Risk for Infectious Diseases

There’s a letter to the editor in the June 15th, 2012 edition of Clinical Infectious Disease that speculates on a link between ritual cleansing and brain-eating amoebae fatal infections. It comes to us from Pakistan, where in 2010, a single small private hospital recorded the deaths of 20 devout Muslim men due to Naegleria fowleri infection.

N. fowleri, also known as “brain-eating amoebae” causes one of those rare, and devastatingly fatal, infections.  Just a couple infections occur in the US annually. Last summer, it was trending in the news because three young people died. Primary amoebic meningoencephalitis (PAM), the illness N.fowleri causes, occurs within a week of infection. The stereotypical patient is one who has gone swimming in fresh water bodies such as a pond, river, or lake during the warm summer months. The other stereotypical patient is one who has used tap water with their Neti pot to irrigate their sinuses.

In both scenarios the amoebae, if present in the water, is forcibly introduced into the nose and once stuck there starts looking for food. It travels along nerve roots through the floor of the skull and into the brain where it causes hemorrhage and necrosis. Within a week, the victim suffers signs of meningitis including headache, fever, stiff neck or seizures and then death in a few days.

Rite of Ablution

Which brings us back to the letter to the editor above which I find quite fascinating. The rite of ablution, where impurities are washed away in preparation for prayer, is performed by many devout Muslims around the world. To think that such a simple act may put one at risk for a deadly infection, however rare it may be, is quite frightening. I am reminded of the first tenet of the Hippocratic Oath – first do no harm. While, I realize religion is not medicine why wouldn’t religious practices hold this tenet to be true too?

Circumcision

The other major religious ritual that comes to mind as carrying with it a potentially fatal infection is the Jewish circumcision. In ultra-Orthodox circles, the ceremony involves orogenital suction (metzitzah b’peh) where the mohel puts his mouth directly on the newborn’s freshly circumcised penis to suck away the blood. The CDC recently reported that in New York City alone, 11 baby boys in the past decade or so have acquired herpes (HSV) as a result. 2 died, at least 2 developed brain damage, and all but one required hospitalization. This is serious.  I remember first reading about the practice and the risk of neonatal herpes back in 2004 in Pediatrics, the official journal of the American Academy of Pediatrics. It was a report of 8 cases of neonatal genital HSV-1 after circumcision in Israel. In Israel, in 2004. I guess what’s most alarming to me is that we have known for a while how hazardous this practice can be yet just this past year we lost the life of yet another innocent otherwise healthy baby boy in New York City.

It begs the question, at what point does public health win over religious tradition? At what point do religious liberties go too far. When an adult Jehovah’s Witness refuses blood transfusion on religious grounds, I can stand back and hope all goes well for their sake. When they refuse a blood transfusion for their child on the same basis, it’s not as easy to stand aside. Luckily for me, I decided in medical school that I wanted to be an internist, a physician for adults, thereby limiting my exposure to people making wrong decisions for children. But it doesn’t really make it any easier to watch people make decisions that put them at risk for bad health outcomes.