CIRCLIST - Circumcision news

The US National Institute of Allergy and Infectious Diseases has halted its HIV 'Network 505' vaccine trial, for the simple reason that it shows no prospect of beneficial effect. Conducted in the context of homosexual (MSM) rather than heterosexual relationships, this is not directly relevant to the issue of circumcision-v-vaccination as a form of protection against female-to-male transfer of the virus, but note the following quote:

One possible culprit in the failure is the adenovirus 5 booster used on the HVTN 505 trial.

Adenovirus 5 – dubbed ad5 for short – is a common virus used as a vector to carry antigens into the body. In the context of HIV, its use has now been shown in more than one vaccine trial to be potentially counterproductive. That, it seems, may be one useful lesson that can be learned from the latest failure.

Source: www.medpagetoday.com

It has long been realised that HIV acquired through heterosexual intercourse enters the male body by hijacking a normal function of the immune system and using it as a ‘Trojan Horse’. Put simply, the virus cloaks itself in a T4 cell produced by the prospective new host and then uses one of the same person’s Langerhans cells (commonplace in mucosal tissue such as inner foreskin) as a portal of entry. Uncloaked, the Langerhans cell would recognise the virus as a foreign body and would not admit it. Conventional wisdom suggests that circumcision disrupts the infection process by reducing the number of Langerhans cells available as portals of entry.

Researchers at the Translational Genomics Research Institute in Flagstaff, Arizona, have identified another possible explanation, which may be functioning in addition. Noting that the whole process needs both T4 cells and Langerhans cells, they have suggested that the improved penile hygiene resulting from male circumcision reduces the number of T4 cells produced by the potential host in response to other threats of infection. Hence fewer T4 cells available to act as the Trojan Horse.

Unfortunately, the research has already spawned a rather silly suggestion that circumcision might be rendered unnecessary as a means of HIV prophylaxis if the production of T4 cells were somehow to be switched off by other means. Ahem! Is it not the case that the T4 cells are needed to perform their normal function of countering other bacterial and viral threats beneath the foreskin of an uncircumcised male?

Full text of original paper: http://mbio.asm.org/content/4/2/e00076-13.full

The American Academy of Pediatrics (AAP) has seen fit to speak out against critics of its revised policy on infant circumcision, doing so in no uncertain terms:

However, the Task Force [in context, the The AAP Task Force on Circumcision 2012] feels strongly that this debate and the academic literature are demeaned when those with an ideological agenda disseminate inaccurate information, misapply scientific principles, make accusations that are unsupported, communicate in a vitriolic tone, and attempt to discredit and mischaracterise alternative views and those who hold them. Healthy debate and dialogue should be encouraged, but attempts to mislead and discredit have no place in the academic literature.

Will this silence the critics? Unlikely, given that the intactivist stance is founded on a belief system rather than fact. But it might make editors of scientific journals think twice before acting as mouthpiece for their views.

Sources: J Med Ethics doi:10.1136/medethics-2013-101456 and PMID: 23508207.

Notwithstanding that one brand of Plastibell look-alike emanates from the Kaesong Industrial Zone on the border between North and South Korea, you are invited to forget about current troubles in the Far East for a moment and concentrate instead on things nearer to home.

One of our opponents in the circumcision debate, the notorious Matthew Hess, has seen fit to publish in Comic Book format a set of cartoons decrying and ridiculing pre-pubertal circumcision in the Islamic context. Despite the fact that the storyline is set in the relatively secular society of Turkey, this seems pretty much guaranteed to upset Muslims worldwide. Remember the furore about the “Cartoons of the Prophet” published in Denmark back in September 2005?

Reports of Mr. Hess being sighted buying a bullet-proof vest may not be exaggerated.

Today’s ruling by the Supreme Court of India in the Novartis case raises an interesting question regarding patents in other branches of medicine, especially medical devices such as circumcision clamps.

In principle, the Court has struck down the long-established procedure of “evergreening” medical patents. That’s the process whereby patent validity has in the past been extended by applying to the original intellectual concept a new, time-extended protection arising from some novel incremental improvement.

The consequence of the judgement, as far as older designs of circumcision clamp are concerned, seems to be that cut-price parallel production can now be undertaken — in India, at least — without any obligation to pay royalties, even if the original developer has patented an incremental improvement. Expect some lawyers’ lights to be burning late this week whilst the full implications of the outcome of the Novartis case are digested.

We all know the truism that prevention is better than cure; it is a principle that underpins Circlist’s support for male circumcision on medical grounds. Infant male circumcision reduces the risk of urinary tract infection by 10-fold, making it as good as many vaccines and better than some. Infant urinary tract infections can and frequently do cause permanent kidney damage in babies who get them, and the strains of E.coli responsible for a high proportion of such urinary tract infections are amongst those showing increasing antimicrobial resistance.

A paper just published in Australia draws attention to the growing problem of antimicrobial resistance generally. Because of the emergence of super-bugs, the importance of prevention should gain increasing prominence in medical decision-making. But there is another implication too. Precautions to avoid infection during surgical procedures are also more important than ever.

See: Gram-negative resistance: can we combat the coming of a new “Red Plague”? David F M Looke, Thomas Gottlieb, Cheryl A Jones and David L Paterson. Med J Aust 2013; 198 (5): 243-244.

Two published papers have passed through the Circlist editorial office this week, both relevant to the choice of circumcision devices for scaling up medical provision of male circumcision in sub-Saharan Africa.

The Shang Ring, one-time front runner in the race for device accreditation, has been criticised from within the People’s Republic of China. In a trial involving 918 patients, the conclusion drawn is that “The timing of the ring removal is critical to avoiding complications. Surgeons’ knowledge in urology is also critical to the clinical outcome.” Hardly a recommendation when field use by ad hoc trained circumcision staff is in prospect. Details: PMID 23465168.

PrePex, on the other hand, has attracted favourable comment. “Circumcision performed by nurses using the PrePex device is safe, effective and easy to train. The procedure was minimally invasive and did not require injected anesthesia, sutures, or sterile settings. PrePex has the potential to help facilitate rapid, safe, non-physician male circumcision scale-up programs for HIV prevention, an imminent need in sub-Saharan Africa where physicians are limited.” Details: PMID 23466648.

In 2012, we reported legal proceedings in Cologne, Germany, against a mohel in respect of a traditional Bris Milah carried out to normal standards. Later in the year, the law throughout Germany was changed by the Bundestag, specifically making such ceremonial circumcisions legal. However, the change in federal law was not retrospective; it did not have the effect of quoshing the proceedings already in process.

We are pleased now to be able to report that the case has been dropped. Reporting restrictions are, in consequence, lifted and it can therefore be stated that the mohel involved was Rabbi David Goldberg from Hof, Bavaria, who has been active as a mohel since 1997.

Source: European Jewish Press

The Australian Medicare system has commenced a consultation exercise on the subject of reimbursement of the costs of male circumcision. The present government rebates are:

MBS Item Number 30653
CIRCUMCISION of a male UNDER 6 MONTHS of age
Fee: $45.65 Benefit: 75% = $34.25 85% = $38.85

MBS Item Number 30656
CIRCUMCISION of a male UNDER 10 YEARS of age but not less than 6 months of age
Fee: $106.15 Benefit: 75% = $79.65 85% = $90.25

MBS Item Number 30660
CIRCUMCISION of a male 10 YEARS OF AGE OR OVER
Fee: $182.15 Benefit: 75% = $136.65 85% = $154.85

Clearly these figures are unrealistically low; in context the "Fee" should equate to costs inclusive of both disbursements and normally-rebated oncosts. Following the current review, the Federal Government will be advised by the Health Department to de-list circumcision, to increase the rebate, or to do nothing.

In recent years, private practitioners have pitched their fees in the range $250 to $800, but it is necessary to appreciate that these prices are market-driven rather than being cost-plus. Elective circumcision, as opposed to theraputic circumcision, no longer takes place in public hospitals in Australia, so private clinics offering elective circumcision have something approaching a monopoly. Thus the fees currently charged privately should be seen as being somewhat on the high side of a fair government rebate.

The consultation exercise now under way is not intended to be a debate of the ethical rights and wrongs of circumcision. What’s being talked about is finance. Relevant input would be an updated cost appraisal or a new cost-benefit analysis quantifying all of the many prophylactic benefits of elective circumcision. Contributions need to reach the relevant authorities by 05 March. Readers of Circlist are invited to submit comments via the News Item link above, for consolidation and forwarding. Deadline for receipt at the Circlist Editorial Office: 12:00 UTC, Saturday 02.March.

Source: Professor Brian Morris, School of Medical Sciences, Sydney University, Australia. All the above figures are in Australian Dollars.

Since Saturday 2^nd February, there have been a number of unplanned interruptions to the availability of both www.circlist.com and www.circlist.info. These have been due to a fault on a server not under the control either of Circlist or our website host. On each occasion, the remedy has been to re-boot the defective server, but to date the underlying cause of the fault giving rise to the need to do this has not been found. Circlist is by no means the only organsiation affected; the total number of websites involved probably runs into many hundreds although few of them will have the visitor numbers enjoyed by circlist.com. The problem is being worked on and it is hoped that the usual reliability (normally better than 99.9%) will be restored before too long.

The conclusion this past week of the criminal legal case R-v-Adeleye enables us to comment freely on this sad matter without risk of prejudice to the proceedings. In short, back in April 2010 a one month old baby boy, a member of the Nigerian immigrant community in Oldham, England, died following a botched circumcision performed by a Nigerian nurse. The nurse was found guilty of manslaughter by gross negligence, having followed tribal routines rather than approved medical techniques for such surgery.

It is to be hoped that this tragedy will lead to the proper registration and supervision of circumcisers in the UK, so as to ensure that medically safe procedures are used in all home circumcisions.

Source: http://www.bbc.co.uk/news/

Here at Circlist, we had begun to think that the plethora of single-use instruments designed to assist with the anti-HIV campaign of adult male circumcision in sub-Saharan Africa was complete. Not so. Detail has yet to be released by the inventors, but stand by for another one. Not only does it take a different approach to that of Tara KLamp, Ali's Klamp, PrePex, Shang Ring and suchlike, but also it is of local (South African) origin. Watch this space!

[This does not refer to the XYZ Design clamp newly added to the Instruments & Techniques page of this website. That’s another one, specifically aimed at improving patient safety in Xhosa traditional initiation ceremonies]