The Billirud Mill Blastomycosis Outbreak: Comparison to Historical Controls.

A large outbreak of blastomycosis among paper mill workers in Escanaba, Michigan began with the first cases reported on February 28, 2023 and expanded to 120 cases. Analysis of baseline regional data and the data collected during this unprecedented outbreak provide insight on the outbreak's unique characteristics. The Michigan Disease Surveillance System provided descriptive and outcome data on blastomycosis cases in the Upper Peninsula from 2007 through 2022 and the 2023 outbreak. Baseline incidence for the region was estimated and outbreak cases were compared to historic controls using quantitative methods such as t-tests, chi-square, and Poisson and logistic regression. The Billirud blastomycosis outbreak has resulted in 28 confirmed and 92 probable cases. Blastomycosis incidence for the Upper Peninsula was 2.13 (95%CI: 1.75, 2.59) per 100,000 person-years with counties bordering Wisconsin having a higher incidence more than other counties (4.56, 95%CI: 3.48, 5.97; RR=3.46, 95%CI: 2.35, 5.11). Outbreak cases were significantly younger, more likely to be male, reported more respiratory symptoms, and had a shorter time from onset of illness to diagnosis. The Billirud paper mill blastomycosis outbreak is the largest reported to date, the first in an industrial facility, and the first to specifically involve Blastomyces gilchristii. Blastomyces species are endemic in regional forests, so other facilities handling forestry products may be at risk.

The characteristics of the cases from the largest outbreak of blastomycosis in North America are compared to sporadic cases from the same region over the previous 16 years. The outbreak cases were younger, more likely to be male, and reported more respiratory difficulties.

Male circumcision and prostate cancer: A geographical analysis, meta-analysis, and cost analysis.

INTRODUCTION: Attempts to find an association between male circumcision and prostate cancer risk have produced inconsistent results. METHODS: Age-standardized prostate cancer incidence, life-expectancy, geographical region, and circumcision prevalence from 188 countries were compared using linear regression analysis. Following a systematic literature review, a meta-analysis was performed on studies meeting inclusion criteria with evaluations of between-study heterogeneity and publication bias. A cost analysis (discounted at 3% and 5% per annum) was performed using the meta-analysis's summary effect and upper confidence interval. RESULTS: Univariate analysis revealed a trend for a positive association between country-level age-standardized prostate cancer incidence (per 100 000 person-years) and circumcision prevalence (ß=0.0887; 95% confidence interval [CI)]-0.0560, +0.233), while multivariate analysis found a significant positive association (ß=0.215; 95% CI 0.114, 0.316). Twelve studies were included in meta-analysis. The random-effects summary odds ratio of the risk of being genitally intact was 1.10 (95% CI 0.96, 1.26, between-study heterogeneity χ2 15=27.43; p=0.03; I2=82.8%). There was no evidence of publication bias. Cost analysis found infant circumcision was prohibitively costly, returning only between 1.6¢ and 13.8¢ for each dollar expended. CONCLUSIONS: Circumcision may be a positive risk factor on geographical analysis, but not in case-case-controlled studies. Circumcision is not economically feasible for preventing prostate cancer.

Circumcision registry promotes precise research and fosters informed parental decisions.

BACKGROUND: In 2017 Ploug and Holm argued that anonymizing individuals in the Danish circumcision registry was insufficient to protect these individuals from what they regard as the potential harms of being in the registry (overreaching social pressure, stigmatization, medicalization of a religious practice, discrimination and promoting polarized research). DISCUSSION: We argue that Ploug and Holm's fears in each of the areas are misguided, not supported by the evidence, and could interfere with the gathering of accurate data. The extent of the risks and harms associated with ritual circumcision is not well known. The anonymized personal health data supplemented with the circumcision registry will enable more precise research into the medical consequences of ritual circumcision, and allow parents to make more fully informed decisions about circumcision with minimal, if any, adverse consequences.

Response to Vogelstein: How the 2012 AAP Task Force on circumcision went wrong.

Vogelstein cautions medical organizations against jumping into the fray of controversial issues, yet proffers the 2012 American Academy of Pediatrics' Task Force policy position on infant male circumcision as 'an appropriate use of position-statements.' Only a scratch below the surface of this policy statement uncovers the Task Force's failure to consider Vogelstein's many caveats. The Task Force supported the cultural practice by putting undeserved emphasis on questionable scientific data, while ignoring or underplaying the importance of valid contrary scientific data. Without any effort to quantitatively assess the risk/benefit balance, the Task Force concluded the benefits of circumcision outweighed the risks, while acknowledging that the incidence of risks was unknown. This Task Force differed from other Academy policy-forming panels by ignoring the Academy's standard quality measures and by not appointing members with extensive research experience, extensive publications, or recognized expertise directly related to this topic. Despite nearly 100 publications available at the time addressing the substantial ethical issues associated with infant male circumcision, the Task Force chose to ignore the ethical controversy. They merely stated, with minimal justification, the opinion of one of the Task Force members that the practice of infant male circumcision is morally permissible. The release of the report has fostered an explosion of academic discussion on the ethics of infant male circumcision with a number of national medical organizations now decrying the practice as a human rights violation.

Circumcision Is Unethical and Unlawful.

The foreskin is a complex structure that protects and moisturizes the head of the penis, and, being the most densely innervated and sensitive portion of the penis, is essential to providing the complete sexual response. Circumcision-the removal of this structure-is non-therapeutic, painful, irreversible surgery that also risks serious physical injury, psychological sequelae, and death. Men rarely volunteer for it, and increasingly circumcised men are expressing their resentment about it.Circumcision is usually performed for religious, cultural and personal reasons. Early claims about its medical benefits have been proven false. The American Academy of Pediatrics and the Centers for Disease Prevention and Control have made many scientifically untenable claims promoting circumcision that run counter to the consensus of Western medical organizations.Circumcision violates the cardinal principles of medical ethics, to respect autonomy (self-determination), to do good, to do no harm, and to be just. Without a clear medical indication, circumcision must be deferred until the child can provide his own fully informed consent.In 2012, a German court held that circumcision constitutes criminal assault. Under existing United States law and international human rights declarations as well, circumcision already violates boys> absolute rights to equal protection, bodily integrity, autonomy, and freedom to choose their own religion. A physician has a legal duty to protect children from unnecessary interventions. Physicians who obtain parental permission through spurious claims or omissions, or rely on the American Academy of Pediatrics' position, also risk liability for misleading parents about circumcision.

Circumcision as a primary HIV preventive: extrapolating from the available data.

Billions of dollars to circumcise millions of African males as an HIV infection prevention have been sought, yet the effectiveness of circumcision has not been demonstrated. Data from 109 populations comparing HIV prevalence and incidence in men based on circumcision status were evaluated using meta-regression. The impact on the association between circumcision and HIV incidence/prevalence of the HIV risk profile of the population, the circumcision rates within the population and whether the population was in Africa were assessed. No significant difference in the risk of HIV infection based on the circumcision status was seen in general populations. Studies of high-risk populations and populations with a higher prevalence of male circumcision reported significantly greater odds ratios (odds of intact man having HIV) (p < .0001). When adjusted for the impact of a high-risk population and the circumcision rate of the population, the baseline odds ratio was 0.78 (95% CI = 0.56-1.09). No consistent association between presence of HIV infection and circumcision status of adult males in general populations was found. When adjusted for other factors, having a foreskin was not a significant risk factor. This undermines the justification for using circumcision as a primary preventive for HIV infection.

Infant circumcision: the last stand for the dead dogma of parental (sovereignal) rights.

J S Mill used the term 'dead dogma' to describe a belief that has gone unquestioned for so long and to such a degree that people have little idea why they accept it or why they continue to believe it. When wives and children were considered chattel, it made sense for the head of a household to have a 'sovereignal right' to do as he wished with his property. Now that women and children are considered to have the full complement of human rights and slavery has been abolished, it is no longer acceptable for someone to have a 'right' to completely control the life of another human being. Revealingly, parental rights tend to be invoked only when parents want to do something that is arguably not in their child's best interest. Infant male circumcision is a case in point. Instead of parental rights, I claim that parents have an obligation to protect their children's rights as well as to preserve the future options of those children so far as possible. In this essay, it is argued that the notion that parents have a right to make decisions concerning their children's bodies and minds-irrespective of the child's best interests-is a dead dogma. The ramifications of this argument for the circumcision debate are then spelled out and discussed.

Sexually transmitted infections and male circumcision: a systematic review and meta-analysis.

The claim that circumcision reduces the risk of sexually transmitted infections has been repeated so frequently that many believe it is true. A systematic review and meta-analyses were performed on studies of genital discharge syndrome versus genital ulcerative disease, genital discharge syndrome, nonspecific urethritis, gonorrhea, chlamydia, genital ulcerative disease, chancroid, syphilis, herpes simplex virus, human papillomavirus, and contracting a sexually transmitted infection of any type. Chlamydia, gonorrhea, genital herpes, and human papillomavirus are not significantly impacted by circumcision. Syphilis showed mixed results with studies of prevalence suggesting intact men were at great risk and studies of incidence suggesting the opposite. Intact men appear to be of greater risk for genital ulcerative disease while at lower risk for genital discharge syndrome, nonspecific urethritis, genital warts, and the overall risk of any sexually transmitted infection. In studies of general populations, there is no clear or consistent positive impact of circumcision on the risk of individual sexually transmitted infections. Consequently, the prevention of sexually transmitted infections cannot rationally be interpreted as a benefit of circumcision, and any policy of circumcision for the general population to prevent sexually transmitted infections is not supported by the evidence in the medical literature.

Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision.

The American Academy of Pediatrics recently released a policy statement and technical report on circumcision, in both of which the organisation suggests that the health benefits conferred by the surgical removal of the foreskin in infancy definitively outweigh the risks and complications associated with the procedure. While these new documents do not positively recommend neonatal circumcision, they do paradoxically conclude that its purported benefits 'justify access to this procedure for families who choose it,' claiming that whenever and for whatever reason it is performed, it should be covered by government health insurance. The policy statement and technical report suffer from several troubling deficiencies, ultimately undermining their credibility. These deficiencies include the exclusion of important topics and discussions, an incomplete and apparently partisan excursion through the medical literature, improper analysis of the available information, poorly documented and often inaccurate presentation of relevant findings, and conclusions that are not supported by the evidence given.

Not a surgical vaccine: there is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia.

OBJECTIVE: To conduct a critical review of recent proposals that widespread circumcision of male infants be introduced in Australia as a means of combating heterosexually transmitted HIV infection. APPROACH: These arguments are evaluated in terms of their logic, coherence and fidelity to the principles of evidence-based medicine; the extent to which they take account of the evidence for circumcision having a protective effect against HIV and the practicality of circumcision as an HIV control strategy; the extent of its applicability to the specifics of Australia's HIV epidemic; the benefits, harms and risks of circumcision; and the associated human rights, bioethical and legal issues. CONCLUSION: Our conclusion is that such proposals ignore doubts about the robustness of the evidence from the African random-controlled trials as to the protective effect of circumcision and the practical value of circumcision as a means of HIV control; misrepresent the nature of Australia's HIV epidemic and exaggerate the relevance of the African random-controlled trials findings to it; underestimate the risks and harm of circumcision; and ignore questions of medical ethics and human rights. The notion of circumcision as a 'surgical vaccine' is criticised as polemical and unscientific. IMPLICATIONS: Circumcision of infants or other minors has no place among HIV control measures in the Australian and New Zealand context; proposals such as these should be rejected.