A controlled study on intinction: a safer alternative method for receiving Holy Communion.
IntroductionThe sacrament of Holy Communion has been practiced by Christians of all denominations for 2,000 years. This sacred and unifying ritual is modeled after the Last Supper at which Jesus Christ presided. Since popular belief holds that Christ and His disciples shared a common cup of wine, most Christian denominations use a common communion cup during the Holy Eucharist. However, variations on the practice of administering the consecrated wine have developed as Christianity has evolved.
The potential hazards that present themselves when one sips from a common communion cup in church have long been the subject of religious debate and scientific investigation. All of the scientific studies that have been performed over the last 100 years have drawn the same conclusion: there is a possible risk involved to an individual who sips from a common cup, as some microorganisms survive significantly longer than the time that normally elapses between one parishioner's sip and the next.
Fears about the potential for spread of disease during this religious sacrament arose in the last century as knowledge of infectious disease processes began to develop. As early as 1887, Terry of Utica, New York, was publicly advocating a move away from the use of the common communion cup, based on general uncleanliness (1). In 1893, Stebbins and Ely discussed the risks involved with the common communion cup at a meeting of the Rochester, New York, Pathologic Society (2).
Actual laboratory testing of the communion wine before, during, and after the administration of the Lord's Supper was performed in 1894 by Forbes, through which he discovered that unused communion wine was "practically sterile" whereas the wine remaining in the chalice at the end of the church service contained, among other things, bacteria, mucus, and epithelial cells (3). Forbes also discussed an epidemic of diphtheria in Rochester, New York, that affected 24 individuals who had shared a common drinking (not communion) cup.
Anders was widely published in the late 1800s and the early part of this century, pleading with the Christian community to avoid the common cup (4,5,6). Citing all the diseases that could be spread from mouth to mouth by saliva on a common cup, Anders went on to advise dentists regarding infection control. Anders and Furbush performed laboratory investigations in which tubercle bacilli as well as Staphylococci, white blood cells, and epithelial cells were found in the dregs of a common communion cup (5).
Even religious publications of the time advocated a move away from the common cup, in order not to dissuade parishioners from attending church services (7). The Philadelphia County Medical Society in 1894 suggested the use of individual communion cups by the churches (8).
An investigation performed by Page in 1925 included testing the rim of the communion chalice and the purificator used to clean it (7). Some laboratory animals that were injected with broth cultures from the rim of the test chalice and purificator died, but the evidence was not conclusive enough to definitely implicate the communion chalice.
A brief mention in the Queries and Minor Notes section of JAMA in 1939 indicated the possibility that the custom of diluting communion wine with water during the consecration portion of the church service might actually decrease the number of microbes, due to the chlorine content of the water (9). This suggestion was not backed by any research. A report by Twinam and Pope in 1942 indicated a possible spread of tuberculosis via a common communion cup, but this was not confirmed as the individuals in question had also had close contact in the church choir and at social functions (10). In 1943 Burrows and Hemmens conducted an extensive study of the antimicrobial effects of a silver communion cup (11). It was already known that extremely small quantities of ionized silver have a bacteriocidal effect (12), but this study investigated whether an actual silver communion chalice containing communion wine could maintain the life of particular oral microorganisms. Burrows and Hemmens concluded that the silver communion cup is not an important vector of infectious diseases, even though some microorganisms survived.
Stokes, Beermon, and Ingraham observed in 1945 that the sharing of moist cups, an activity similar to sharing a communion cup, could transmit Treponema pallidum from a person with an oral lesion to an uninfected individual (13).
In 1967 Gregory, Carpenter, and Bending disputed the 1943 findings of Burrows and Hemmens, concluding that the common communion cup poses a definite risk to participants (14). Their study revealed that such species as Mycobacterium avium, Bacillus, Micrococcus, Neisseria, Staphylococcus, and Streptococcus could survive on a silver chalice as well as in the consecrated wine. That same year, an extensive investigation by Hobbs, Knowlden, and White led to the conclusion that the risk of contracting infectious diseases via the common cup was small, in part because 90% of their test microorganisms were removed by a cloth purificator (15). They acknowledged, however, that "the common communion cup may serve as a means of transmitting infection." They observed that a human body should be able to deal effectively with the small numbers of pathogens remaining in the shared communion cup; obviously their work predated the Acquired Immunodeficiency Syndrome (AIDS) epidemic that has rendered so many victims defenseless against even small numbers of opportunistic organisms.
A 1993 investigation by two parishioners at an Episcopal church in Lexington, Kentucky, indicated that bacteria can survive in communion wine (16). They tested the wine remaining in the chalice 10 minutes after the completion of the Holy Communion service, but did not determine what microorganisms, if any, had died during that time or had survived the few seconds in between parishioners' sips.
Immunization programs and antibiotics have reduced the threat of many diseases that concerned early investigators. Other diseases, however, remain just as threatening to the general population, and can be life-threatening to individuals who are immunosuppressed or immunocompromised due to AIDS, chemotherapy, radiation therapy, or congenital disorders. Even the "average, healthy individual" is more susceptible at some times than others, due to factors such as temporarily immunocompromising infections or stress.
AIDS, in particular, has caused the issue of the common cup to resurface with great intensity. Religious publications have been inundated with articles arguing the cases for and against this practice (17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33). Most of these attempt to address the unreasonable AIDS-transmission phobia. Although the Human Immunodeficiency Virus (HIV) has been found in saliva, no case of transmission has been attributed to the communion cup. However, as Leonard of the Centers for Disease Control points out, lack of evidence "should not imply that there is no risk" (20). In 1988 Gill published an extensive analysis of the likelihood for transmission of HIV, Hepatitis B Virus (HBV), and other pathogens via saliva that is in or on a common communion cup (34). He concluded that transmission of pathogenic microorganisms via this route was unlikely, but suggested that the situation should be monitored as knowledge of AIDS increases. The American Dental Association has concerned itself with the prevention of the spread of HIV as well as HBV and other saliva-borne and bloodborne diseases. The association's studies and published guidelines regarding surface sterilization of nondisposable instruments can be related to the passing of a common communion cup from one mouth to the next (35,36,37,38,39,40).
Leaders in both the religious and scientific communities have proposed alternatives to the common cup practice that would satisfy those concerned with infection control while maintaining the essential elements of the sacrament. These include individual cups for each parishioner, individual spoons, bypassing the wine altogether, dipping the purificator cloth in vodka before use, and intinction (5,6,8,20,31,33,38,41,42).
This study compared the already-established risks involved with sipping from the common cup with the as-yet-unestablished risks involved with intinction. Intinction is the act of steeping the bread or wafer in the wine, thus enabling the communicant to receive the two elements conjointly. The term "intinction" derives from the Latin for "dipping in." Intinction is an increasingly popular practice among certain Christian denominations, most notably Episcopal and Lutheran. Many adamantly oppose the practice, claiming that it diminishes the communal feeling of sipping from a common cup, that it does not reenact the Last Supper accurately, that the consecrated wine could drip from the dipped wafer onto the floor or onto an individual's clothing, and that the process actually increases the risk for infection spread because fingertips (which could dip into the wine during the procedure) may be more contaminated than saliva and are more likely to harbor fecal pathogens. Others argue that this is a reasonable alternative to the common cup, providing parishioners with a means of receiving both elements without the discomfort associated with sharing a cup with many people. Hobbs, Knowlden, and White actually state that intinction would completely abolish any risk of infection; this statement was made without any supportive data (15).
Methods
Culture Media and Supplies
Trypticase Soy Broth (BBL) with 5% Fildes Enrichment (TSB-F) was used to cultivate organisms directly from the wafers. BBL Sheep Blood Agar-Chocolate Agar biplates (SBA-CHOC) were used for the wine samples and the fingertip samples.
Sterile inoculating loops (0.01 ml), Fisher Scientific, were used for sampling the wine and for subculturing the broth cultures.
Wine
The wine used was Guasti Altar Wine, California Tokay, alcohol 19% by volume, J. Filippi Vintage Company, Mira Loma, California. At the start of each study, 0.01 ml of the wine was transferred to each half of an SBA-CHOC as a sterility check.
Chalice
The chalice was a sterling silver communion chalice (International Sterling E844). Silver is most commonly used in churches of all denominations, due to its known antimicrobial properties, to its lasting beauty, and to the generally accepted belief that pottery and glass vessels are more likely to support bacterial growth (3,11,12,15).
Communion Wafers
The wafers were standard, white bread communion wafers provided by the Parish of Christ the Redeemer in Pelham Manor, New York. Ten wafers that had not been dipped in wine were placed in TSB-Fs as a baseline check for any microorganisms that might be present on the bread. The wafers are not sterilized and come in cellophane-wrapped packages of 100. Neither the wine nor the wafers was ever consecrated.
Human Subjects
The 43 volunteer "parishioners" (hereinafter referred to as parishioners) were solicited via posters and fliers from the faculty, staff, administration, and student body of Felician College. There is no uniform definition of a "typical" parish congregation; therefore, anyone who chose to participate in the study was welcomed, keeping the population size and demographics as random as possible. Volunteers represented a heterogeneous mix of age, sex, ethnic background, and health. Parishes that were polled reported having as few as four and as many as 140 individuals receive Holy Communion at a Eucharistic service, depending on the day of the week, the time of year, and the size of the congregation; 43 falls within the range of a "typical" congregation size.
The parishioners were apprised that their participation in the study would pose no greater risk to them than that of participating in a Eucharistic service. All participants signed "Informed Consent" documents, indicating their familiarity with the study in which they were to take part. The intinction process was explained to the parishioners, but they were not allowed to practice nor were they given detailed instructions, as such activities would not take place in an actual Eucharistic service. Randomly there may be any number of first-time intincters at a Eucharistic service.
The parishioners and the two volunteer "ministers" (hereinafter referred to as ministers) were instructed not to wash their hands just prior to the start of each series of tests. Typically, these people would have been sitting in a Eucharistic service for at least 30 minutes before the administration of the sacraments. During this time, fingertips might touch many potentially-contaminating surfaces. In addition, most Eucharistic services include the "Exchange of the Peace," during which individuals shake or grasp the hands of their friends and other parishioners in nearby pews. As this is a potential means of exchanging microbial flora, and since it takes place prior to the administration of the sacraments, the ministers and parishioners in this study were instructed to shake the hands of between two and 10 people just prior to the start of the testing.
Both series of tests were carried out in a room with a table set up to simulate an altar rail. A minister distributed the wafers and handled the chalice. Forty-three parishioners stood in line and received and dipped their wafers as they would in a Eucharistic service. In the first series, the parishioner intincted his/her own wafer. In the second series, the minister intincted the wafer and then placed it directly into the parishioner's mouth.
In both series, before the testing began, the ministers applied the fingertips of their right hands to the two surfaces of an SBA-CHOC. This was done to determine the flora present on the skin of the hands that would be touching all of the wafers. Immediately prior to participating in the intinction process, each parishioner applied his or her fingertips to an SBA-CHOC in the same way. This was done to determine the flora on each individual's hand and to help identify the source of any unusual microbes that might turn up after subculture and incubation.
In both series, 0.01 ml samples of the chalice wine were inoculated onto SBA-CHOC after each intinction, and the intincted wafers were placed into TSB-F.
Informal polling of several ministers revealed that anywhere from 25% to 75% of parishioners manage to touch the wine with their fingertips during intinction. Since this is a random phenomenon, the volunteers were not instructed as to any precautions regarding fingertip contact with the wine. The number of times that fingertips touched the wine was noted. When the wafers were intincted by the minister and placed directly into the parishioners' mouths, the number of times the minister's fingers touched the wine or the mouth of the parishioner was noted.
At the end of both series, the ministers applied their fingertips to the surfaces of an SBA-CHOC in order to determine any change in the microbial population of their skin.
Ministers commonly consume the remaining wine at the end of Holy Communion, so the entire remains of the sample was decanted into TSB-F immediately following both "ceremonies." The volume of the remaining wine was not measured as this is also an extremely variable quantity.
The agar plates containing the wine inocula and the TSB-Fs containing the wafers were incubated, and identification of microbial growth was carried out as needed.
Intinction Combined with Sipping
In some parishes, one chalice is used, and each parishioner has the choice of either sipping from the cup or intinction. It would be difficult to measure the risk of acquiring an infectious disease when one either sips from or intincts into a single chalice which is being used for both processes. The risk would probably fall somewhere between that involved with using a chalice strictly for sipping and using one strictly for intinction. No attempt was made to replicate this process because of this variability.
Results and Discussion
Skin Flora
Using a random population that represented as "typical" a church congregation as anyone could describe, it was revealed that the hands of all the parishioners (100%) contained normal skin flora, including, primarily, S. epidermidis, diphtheroids, and Bacillus species. A few individuals also had a small amount of S. saprophyticus, C. albicans, alpha Streptococcus, and S. aureus, all of which could be considered normal flora on the fingertips, especially in the very small quantities in which they were found. One parishioner (2.3%) had a large quantity of E. coli on his hands, and one (2.3%) had a small amount of P. mirabilis.
Wine Samples
Of the 86 wine samples taken after individuals had intincted, 81 (94.2%) yielded no growth. The only microorganism that was recovered from the wine was S. epidermidis, one colony of which grew from five (5.8%) of the 86 samples. This is an insignificant microorganism in a dismissible quantity. None of the potentially pathogenic fecal microbes found on the fingertips was recovered from the wine. Seven individuals (16.3%) dipped their fingertips into the wine during the intinction process. In every case (100%), the following wine samples yielded no growth. When the wafer was intincted by the minister, 6.9% of the wine samples showed some bacterial growth as opposed to 4.7% when the parishioner dipped his/her own. However, the growth was only one colony of S. epidermidis in each case, considered insignificant. The minister touched her fingertips to the wine four (9.3%) times, and in 11 (25.6%) instances the parishioners' lips or tongue touched the minister's fingertips.
The cultures of the entire amount of wine remaining in the chalice at the end of the samplings yielded no growth at all. These results differ from those of studies in which the wine was sipped from the common cup (3,5,16).
Wafer Samples
One (10%) out of 10 of the unintincted wafers taken from the cellophane packs yielded growth, a very small amount of Bacillus species. More than one-half of the parishioner population (25 out of 43, 58.1%) and both ministers carried this organism as part of their normal fingertip flora anyway. Overall, the intincted wafer cultures yielded the same flora as the parishioners contained on their hands in most instances, indicating no greater risk to an individual than placing one's fingertips in one's mouth. Bacillus species was recovered from the cultures of 39 (45.3%) out of 86 of the intincted wafers.
When a parishioner intincted hi s/her own wafer, 21% of the wafers yielded no growth at all, in spite of the parishioners' and ministers' hands containing appreciable amounts of normal flora. In 29 (67.4%) out of 43 cases, the bacteria which grew from the wafer were the same as those found on the individual's fingertips. Of those cases in which a different microorganism grew on the wafer than was on the individual's fingertips, it was usually Bacillus species. In two (4.7%) instances, a potential pathogen was found on the wafer of a person whose fingertips did not contain it (S. aureus). In one instance it might have been passed from the previous parishioner who was a carrier; in the other there had been seven individuals without S. aureus immediately prior.
All (100%) of the wafer cultures that were intincted by the minister yielded some growth, as opposed to 79.1% of those that the parishioner dipped for himself or herself. In two (4.7%) consecutive instances, a potential pathogen appeared on the wafers (Enterobacter cloacae), and in both cases the minister as well as the parishioner had touched their fingertips to the wine, and the minister had touched the lips of both individuals.
Conclusion
Although intinction does not abolish all risk of infection to a parishioner, it does seem to reduce the risk over that of sipping from a common communion cup. Fingertips may contain fecal pathogens, but these do not always get transferred into the wine and thus to subsequent parishioners. Intinction by the minister appears to be slightly more risky. The cleanliness of the minister's hands seems to be a factor, as the intinction-by-minister cultures yielded more growth overall.
References
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Acknowledgements
This research was funded by Felician College. Appreciation is expressed to the volunteers who participated in the data collection, and to Lester LaGrange for his guidance.
Note from the Author
Anyone who would like to read the complete laboratory study may request a copy from the author at the following address:
Anne LaGrange Loving, M.S., M.(A.S.C.P.) Professor of Microbiology Felician College 262 South Main Street Lodi, NJ 07644 U.S.A.
Anne LaGrange Loving, M.S., M. (A.S.C.P.), Asst. Professor of Microbiology, Felician College, 262 South Main St., Lodi, NJ07644.
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| Author: | Loving, Anne LaGrange |
|---|---|
| Publication: | Journal of Environmental Health |
| Date: | Jul 1, 1995 |
| Words: | 4087 |
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