San Diego County is deploying a targeted, military-inspired response to a hepatitis A outbreak that has contributed to the deaths of 17 people, and spread to Los Angeles and Santa Cruz counties in California.
Most infections have occurred among the homeless or illicit drug users — often overlapping communities. “The population we’re trying to reach, they’re not going to see press releases, see the news to go to a clinic,” said Wilma Wooten, public health officer. “In many cases there’s an overlay of mental health issues, so that makes it harder to get them to trust you and trust you enough to take a vaccination for a disease they know nothing about.”
“Foot teams” of nurses, social service providers and law enforcement officers are going into the streets, riverbeds, canyons and encampments to find homeless people and start them on vaccinations that are their best defense against contracting the disease. The teams also distribute hygiene kits, and the county has set up additional public restrooms. The city of San Diego has been power-washing streets and bleaching areas frequented by the homeless. As of Sept. 23 more than 42,000 people have been vaccinated, including professionals who are at risk of coming in contact with the virus. Teams on foot, clinic vans and mass vaccination clinics have administered 15,662 vaccinations.
“It’s possible that people are deep in the river beds and ravines, that’s why we thought it was important to partner with our law enforcement and homeless outreach workers so we could go with them as they go into these various areas,” Wooten said. “We really had to go to where they are.”
By vaccinating a large enough population, Wooten said the county could create a herd immunity and protect people who were not vaccinated from exposure to the virus.
Supervisor Greg Cox, NACo’s first vice president, praised the city and county for working well together to eliminate blind spots in vaccination, sanitation and education.
“This is one of those health crises that every elected official worries about,” he said. “Clearly, we have a problem with homelessness, and the size of that community is making it spread faster.”
San Diego County had the fourth largest homeless population in the United States during its last point-in-time count, with 9,116 people identified living on the streets. Cox said various local, state and private funding sources were working to create more temporary housing, though the time frame for those projects was likely longer than this outbreak was likely to last.
“We have a horrendous housing affordability crisis, and a lot of situational homelessness because people are one paycheck away from the street,” he said.
The San Diego outbreak is concurrent with one in Mexico and another in southeast Michigan, which has killed 14 people, but they are different strains of the virus and not connected, Wooten said.
The same strain, however, has been showing up in Salt Lake County, where 25 cases of Heptatitis have been reported in 2017, with six coming in the first 16 days of September, according to Irene Risk, director of epidemiology for the Salt Lake County Health Department, via the Deseret News.
Before the outbreak, San Diego County typically saw three confirmed cases of hepatitis a month, mostly isolated cases among people who traveled. Then, epidemiologists noticed an uptick in reported cases in late February. The incubation period, which can be as long as 50 days, helped the public health department trace the start of contagion to November 2016.
The public health department identified the problem as an outbreak March 8, which started the county’s vaccination, sanitation and education battery. On Sept. 1, it declared a state of emergency.
As of Sept. 19, there were 461 open cases. Given the long incubation period, Wooten said San Diego was likely to surpass the 2003 Western Pennsylvania outbreak of hepatitis through contaminated scallions served at a Beaver County, Pa. restaurant, in which 660 people were infected and three died.
In comparison to the Pennsylvania outbreak, Wooten said the county is fighting the misconception that the virus is being spread primarily by food.
“This particular outbreak is not a food source, it’s person-to-person contact,” she said. “You have to consume a contaminated product, and you’ll get that if you come in contact with someone who is infected, touch them and then touch some food that you put in your mouth.”
Public health officials have not determined the source of the outbreak, but the virus is spread primarily through contact with contaminated fecal matter, even microscopic amounts or through sexual contact. Hepatitis is an inflammation of the liver that can cause mild to severe illness, but most patients recover with lifelong immunity, according to the World Health Organization.
“Generally if a person is healthy, death is a rare situation,” Wooten said. “All deaths (in San Diego County) have involved other underlying conditions.”
Incidents of hepatitis A nationwide have plummeted 95 percent since the introduction of the first vaccine in 1995.
An outbreak of a different hepatitis strain in southeastern Michigan has claimed 14 lives in Detroit and St. Clair, Macomb, Oakland, Wayne and Monroe counties.