San Diego Fighting a Deadly Hepatitis Outbreak Linked to Homeless Encampments

An outbreak of hepatitis A in San Diego County that has killed 16 people and sickened hundreds of others since November continues unabated, as health officials rush to deploy containment strategies.

“This is an unprecedented outbreak,” said Dr. Wilma Wooten, the public health officer for San Diego County. “This is new territory.”

Of the 444 people in San Diego County known to have contracted the liver‐attacking virus since November, about 65 percent are homeless or use illicit drugs, according to Wooten. She declared a public health emergency on Sept. 1.

Hepatitis A is an acute illness of the liver, but it does not cause chronic liver disease (as is the case with hepatitis B and C.) Hepatitis A isn't normally fatal, but it can be if the patient has other infections, including hepatitis B or C.

The California Department of Public Health says the spread of the virus in San Diego County is the largest outbreak in the U.S. that is unrelated to a contaminated food product since 1995 (when a vaccine for hepatitis A was introduced in the United States).

Other California communities are grappling with outbreaks of hepatitis A as well. The disease has sickened 69 people in Santa Cruz County since last April. Many affected there are homeless or use illicit drugs, according to the Santa Cruz County Health Services Agency.  On Sept. 19, the County of Los Angeles announced a local outbreak after 10 cases were identified among its homeless population.

Health officials linked four of the L.A. cases to the San Diego outbreak and one to the Santa Cruz County outbreak.

“Hepatitis A is usually spread when a person ingests fecal matter -- even in microscopic amounts -- from contact with objects, food or drinks contaminated by feces or stool from an infected person,” according to the Centers for Disease Control and Prevention (CDC).

Known as the “fecal‐oral” route of spread, this typically occurs when an infected person doesn’t wash their hands after going to the bathroom and then touches objects or food. In crowded homeless communities -- many of which lack public restrooms and sinks -- the virus is often spread through such person‐to‐person contact.

It can also spread through sexual contact with an infected person, according to the CDC.

For the California counties now grappling with outbreaks, slowing the spread isn’t easy. The long incubation period of the virus -- between 15 to 50 days -- and the transient nature of the homeless population make it challenging for public health agencies to find, educate and vaccinate people after an outbreak begins.

What’s more, the California Department of Public Health said it has no protocol to guide cities and counties on how best to deal with outbreaks associated with poor or limited sanitation, because those routes of transmission are “very rare” in the United States.

But the state said it it's working on gathering information from the  CDC, and is working with the San Diego public health authorities to identify effective strategies.

Wooten said San Diego is using a variety of approaches to stem the spread.

“This outbreak has really resulted in us needing to be creative,” she said.

One approach: pairing public health workers with homeless outreach teams who have long‐established ties to those living on the streets, in the canyons and in the wildlands of San Diego County.

“We go into the canyons, we go everywhere,” said Amy Gonyeau, chief operating officer for the Alpha Project, a nonprofit that provides homeless services. “We go out every day. We have our own vehicles and vans … we educate people on what’s going on.”

On a recent morning, an Alpha Project team delivered hygiene kits -- consisting of soap, hand sanitizer and other toiletries packaged in a large plastic bag -- to a crowded encampment in downtown San Diego’s East Village.

“It looks like a war zone,” said Alpha Project's outreach supervisor, Larissa Wimberly.  “There’s people out here with HIV, people out here with cancer, there’s people out here with heart issues. There are people who are just old and feeble and they’re not eating right. It’s really sad.”

Tents and shopping carts crowded the sidewalks in this section of downtown, one largely hidden from the city’s tourists and residents.

Wimberly explained that many who live here relieve themselves among the tents and carts.

“It’s everywhere,” she said of the human excrement. “It’s just really bad right now.”

So bad that the city -- under the direction of the county health department -- has begun power-washing heavily soiled sections of downtown sidewalks and streets with a bleach solution.

That follows the installation, earlier this month, of about 40 portable hand‐washing stations throughout the downtown areas hardest hit by the virus.

In addition, the county’s public health workers have been coming to the encampments to offer the hepatitis A vaccinations to the homeless.

Leslie, a 42‐year‐old homeless woman, was among the victims of the virus. She asked that her last name not be used.

Leslie said she's been camping out on San Diego’s streets for five years and became ill last spring.

“It was awful,” she said. “My skin was yellow, my pee -- my urine -- it looked like chocolate milk. And everything just hurt. I was achy all the time and tired. I couldn’t sleep enough.”

Leslie was hospitalized and it took more than two months for her to fully recover, but she said she’s grateful to have escaped with her life.

Some have criticized the more than two-month delay between the county announcing plans for hand-washing stations in downtown areas where the homeless live, and their eventual installation earlier this month.

“Since that announcement, 11 people are dead and the number of hepatitis A cases has more than doubled,” the San Diego Union-Tribune editorial board wrote on Sept. 1.

“Well you know, we can’t just roll them out because we don’t have jurisdiction over city property,” Wooten said of the sinks installed in downtown. “So we had to work through that process.”  

Wooten said the county made a decision to first test a few sinks in a small pilot program, and that was necessary.  “We wanted to see if people would use them,” she said.

San Diego, too, denied any unnecessary delays in handling the outbreak and is now working to expand the number of available public restrooms downtown, said Katie Keach, spokeswoman for the city.

Countywide, nearly 23,000 people have received vaccinations against the virus, including about a third who are homeless or use illegal drugs.  Vaccination is considered the key line of defense against hepatitis A  --  normally a mild illness that can become severe in those who are already suffering from other health problems, Wooten said.

The Centers for Disease Control and Prevention recommends all children receive the two-part hepatitis A vaccine at 1 year of age. But California and most other states do not include it in the required vaccinations for children entering kindergarten.