California is facing a public health emergency with one of the largest hepatitis A outbreaks in the state’s history. Over the last year, more than 500 confirmed hepatitis A cases broke out in San Diego alone, causing 19 deaths. This was followed by 10 cases in Los Angeles and 73 cases in Santa Cruz County, one of which resulted in death.
Affected counties confirmed linkage between the outbreaks by genetically testing the strains. The outbreak began in November 2016 in San Diego and the virus spread to Santa Cruz in April 2017 and LA this September.
Hepatitis A is a viral infection of the liver that causes flu-like symptoms in addition to nausea, vomiting and jaundice for many weeks. The California Department of Public Health found the majority of these infections impact houseless, substance dependent and incarcerated communities that are vulnerable to unsanitary environments.
“The really scary thing is that [you] can be infectious two weeks before [you] show symptoms,” said Dr. John Kaufmann, an infectious disease specialist at Dominican Hospital in Santa Cruz.
Insufficient sanitation facilities are a key reason for the outbreak, Kaufmann said.
Brent Adams, director of Homeless Outside in Santa Cruz and the Downtown Bathroom Task Force, documented the locations and cleanliness of the city’s port-a-potties. He reported seven port-a-potties in the downtown area — four in San Lorenzo Park, two on Cedar Street and one at the corner of Laurel and Front streets. Of these temporary facilities, which serve 200-300 people, only three are open 24 hours a day.
“There is no way that that is enough, that is barely enough for 50 people,” Adams said. “It is the situation statewide where you go to a port-a-potty and there is nowhere to wash your hands.”
Adams also said the port-a-potties are only cleaned five times a week and that it was not until the outbreak began that the public health department installed hand-washing stations at every port-a-potty. The Santa Cruz Public Health Department also combated the outbreak with public outreach and vaccinations.
Since April, Santa Cruz County has distributed over 1,500 vaccinations, about 1,000 of which were given to individuals from susceptible populations. The remaining vaccines were administered to people in frequent contact with these communities, such as public health and social workers.
The vaccine itself also presents a challenge in managing the outbreak. It is a two-part vaccination and, while already 95 percent effective after the first shot, the immunization is not immediate, Kaufmann said.
“You probably don’t develop the protection for at least a few weeks,” Kaufmann said. “There have been cases where people got vaccinated, but were unfortunately exposed during that in-between time and still came down with hepatitis A.”
The virus does not cause symptoms for 15-50 days after someone is infected, which makes hepatitis A hard to diagnose and highly contagious. Kaufmann said one of the difficulties in managing the outbreak is being able to effectively follow up with patients. The majority of hepatitis A cases do not require hospitalization and after a houseless patient is discharged from the emergency room it can be very challenging to get in contact with them.
According to Santa Cruz County public health official Dr. Arnold Leff, hepatitis A has about a 3 per 1000 mortality rate, but with proper care is not fatal. The deaths that occurred in San Diego and Santa Cruz counties were due to conjunctive health problems such as heart disease or secondary infection, which have higher frequencies in houseless and substance dependent communities.
Leff’s epidemiological data found 80 percent of the infected people in Santa Cruz reported being houseless, 73 percent reported substance dependency and 64 percent reported both houselessness and substance dependency
The county is prioritizing its resources for hand-washing stations, education and vaccinations. The Santa Cruz County Public Health Department took a financial toll because the outbreak required workers to turn attention away from their normal duties, Leff said.
“So far we are more than adequately managing this outbreak,” Leff said.
However, houseless residents like Kevin Paul feel the outbreak is in part due to the city’s unwillingness to prioritize issues that affect them, pointing to the construction of new paid bike storage facilities before the construction of hand-washing stations. That attitude, Paul said, overlooks the fact that hepatitis A affects more than just the houseless community.
“If I have hep[atitis] A and I go take a drink from a water fountain and put my lips on that thing […] and Johnny jumps up on there and gets a drink while the other kids are lifting him up, what do you think’s going to happen?” Paul said.
Members of nonprofit organizations such as the Downtown Bathroom Task Force and Food Not Bombs (FNB) give credit to the county for improving public sanitation, but do not think the city is doing enough. Keith McHenry, co-founder of FNB, said current facilities fail to account for all the needs of houseless individuals.
“They could have built […] permanent toilets, not just the portable toilets and the portable hand-washing stations, which would be accessible to people living on the streets,” McHenry said. “Right now, you’re not allowed to have your bike in the toilets, therefore all your belongings are outside and you have to come with a second person to watch your stuff. […] It’s ridiculous.”
In an effort to manage the disease, FNB frequently meets with county public health officials, hosts vaccination clinics and passes out educational packets on hepatitis A. Despite this, some city officials publicly blamed FNB for starting the epidemic.
Santa Cruz Police Chief Andrew Mills, for instance, wrote a letter to the editor to both the Good Times magazine and the Santa Cruz Sentinel. While Mills’ statement largely focused on alleviating houselessness, he also claimed the post office, where FNB regularly hands out meals to the houseless, was “ground zero for the hepatitis A outbreak.”
Since the letters were published, the county’s communications manager said the outbreak is not centralized and is strictly an issue of sanitation throughout Santa Cruz County.
“There is no epicenter. It’s not the post office, it’s not even really downtown,” said Santa Cruz County communications manager Jason Hoppin. “When you are doing epidemiology and getting into geographic locations, [it] is extremely difficult because people move around.”
Brent Adams said the city improved public sanitation with increased port-a-potties, frequency of sanitation of public restrooms and port-a-potties and the establishment of hand-washing stations. He does think there should be an increase in accessibility to showers and laundry services to properly address the daily sanitation needs of houseless people and prevent the transmission of hepatitis A.
“The stories we tell ourselves about homelessness are untrue and unhelpful,” Adams said. “It’s unfortunate that it takes something like this rather than compassion […] to lift the floor of experience for everybody into something that’s more clean, dignified and safe.”