Hepatitis A outbreaks are spreading throughout Los Angeles, San Diego and Santa Cruz counties—mostly among the homeless populations in those places. So healthcare workers in Oakland—a city where the homeless population has grown 26 percent over the last two years, according to a recent Point in Time survey—are acting to prevent a similar outbreak.
Hepatitis A is a liver disease that typically spreads from person-to-person through food or water contaminated with the fecal matter of someone else who has the disease. It can also be spread through sexual or other close contact. Homeless people are at heightened risk for catching the virus because they lack access to clean toilets and to clean water for drinking and washing themselves and their food. Injection drug users are another at-risk population, according to the California Department of Public Health, because the disease can be spread through shared needles. And the Los Angeles County Department of Public Health is urging men who have sex with men to vaccinated.
The symptoms of the disease include fever, malaise, loss of appetite, diarrhea, nausea, abdominal discomfort, dark-colored urine and jaundice. But the incubation period is between 14 and 28 days, which means it can spread undetected in populations that live close together, like the homeless. “This can be really, really significant in your life and cause demise,” said Wanda Johnson, an Oakland-based nurse practitioner who works closely with the city’s homeless population. “It hasn’t happened [in Oakland], but in the wrong situation it could.”
According to the Alameda County Public Health Department’s website, which was last updated on October 30, the national hepatitis A outbreak is the largest in the country that’s spread person-to-person since a vaccine started being distributed in 1996. There have been over 600 cases of hepatitis A reported in California and 19 deaths from the disease in 2017, according to the California Department of Public Health.
Since the outbreak began, there have been nine cases in Los Angeles County; 74 cases in Santa Cruz, one of which resulted in death; and 536 cases in San Diego, 20 of which resulted in deaths. There have been 14 cases elsewhere in the state, according to the California Department of Public Health. According to the department’s website, the majority of those infected in this outbreak were homeless, used injection drugs, or both.
There have been 12 cases reported in Alameda County this year, according to the county health department, but none of those cases were related to the outbreak in other cities and none of those infected were homeless.
Still, the possibility of outbreak among the city’s homeless population has medical professionals concerned. “The illness could last for a couple of weeks up to a month,” Johnson said while standing in the back of a van fashioned to serve as a mobile health clinic to provide free services to the homeless. “Someone that is homeless that is already scraping to get by and have a place of shelter and have a place to rest and have good food, if you put them in a situation where they have a month-long illness, could be detrimental.”
Johnson was wearing an orange cardigan over a black blouse at the end of a Halloween shift. The van is owned by Alameda Health System, and is also staffed with workers from Alameda County Healthcare for the Homeless. On that day, it was parked in front on 7500 block of International Boulevard near the entrance of the East Oakland Community Project, a homeless shelter. Johnson keeps a black notebook, where she has been tracking news of the recent hepatitis A outbreak, and is the person who actually delivers the vaccine shot for clients who want one.
People would climb up steps onto the van, be checked in at a small vestibule by a registration clerk, then go into the back, where Johnson works. The vaccine is usually given in two doses that should be given at least six months apart. People who are allergic to the vaccine or are already moderately to severely ill with any disease are advised against taking it, according to the Center for Disease Control and Prevention (CDC). One dose of the vaccine is sufficient for short-term purposes, like outlasting an outbreak, and two doses of the vaccine will last at least 20 years, according to the CDC website. According to the California Public Health Department’s website, one dose of the vaccine is 95 percent effective in preventing transmission to a person doesn’t already have the disease, and two doses of the vaccine is nearly 100 percent effective.
Johnson said that sometimes she has to educate those unfamiliar with the disease about it in order to get them to accept a vaccine, but that 90 to 95 percent of people she offers it to accept it. It’s easier, she said, then getting people to take the flu shot.
Johnson said the vulnerability of the homeless to the disease—because they struggle to fulfill basic needs like shelter and food, commonly come into contact with unsanitary toilets and human waste, and have less access to sanitary tools like faucets and showers—drives healthcare workers like herself to get the vaccine out. “No access to water, nor to food, poor support systems, in a tent or on the street, with diarrhea—it [can be] just a bad situation all around,” she said.
The staff in the van offer more than just vaccines. One homeless man, for example, knocked on the door of the van and asked for condoms, which he received. They also offer urgent care, brief social work assessments and referrals to community health resources.
But Johnson said that many homeless people are not aware of free clinics like the mobile health van, or focus on more basic needs than preventative care. “Hepatitis A is not what’s on their minds,” she said. “That’s one reason why I love this little van: As we’re out there, it reminds people. It’s like a little coattail pull.”
Nationwide, hepatitis A vaccines are in short supply. A notice posted on the CDC website in October said that the two licensed manufacturers of the vaccines, Merck and GlaxoSmithKline, were experiencing increased demand for the vaccine outside of the country, limiting their ability to meet demands in the United States. It also said that Merck’s hepatitis A supply was unavailable for shipping.
And—despite receiving vaccine doses from outside of the state—there is a shortage in California. Sherri Willis, public information officer at the Alameda County Public Health Department, said said that after California Governor Jerry Brown declared a state of emergency due to the state’s outbreaks, the CDC sent additional vaccines to the state’s public health department. Willis said that the state received 50,000 more doses than expected, so the state’s health department has decided to distribute the additional doses to local health departments to immunize vulnerable populations, like homeless people, injection drug users and men who have sex with men, regardless of whether or not those counties have an outbreak. Alameda County received 300 additional vaccines.
As of press time, public health agencies in California are only recommending vulnerable populations get the vaccination. Depending on the number of cases in the counties where outbreaks have been declared, public health officials are recommending that people who are not at risk take different strategies to curb the spread of the disease. For example, Santa Cruz and Los Angeles County residents have received information about creating a solution of 10 parts water to one part bleach to clean anything that might have been contaminated by the virus.
Dr. Jeffrey Gunzenhowser, the interim health officer for Los Angeles County, said that the recommendation earlier this year that the Los Angeles County Public Health Department vaccinate all homeless people and those who use injection drugs “constituted a new area of work for us.”
“We had to do quite a bit to [try to] make that happen, because that’s not something we had done,” he said. “Here in L.A. County we have 58,000 homeless individuals, and so to create a process where we would be outreaching to them and providing vaccines was a new area of work for us. As a result of that, we had to form new partnerships, new relationships, we had to educate a lot of people. We had to better define where these folks are. But over the last few months we’ve put a great process in place … where we identify homeless individuals and provide them vaccines.”
Jeffrey Hoppin, communications manager for Santa Cruz County, said that although the county’s Health Services Agency has a small staff, they and members of the community “stepped up” to curb the outbreak. Still, he’s cautious about saying disease has been stymied in Santa Cruz. “We’ve been fairly successful in minimizing it, but I wouldn’t call it contained yet,” Hoppin said. “We’re still getting periodic cases and don’t want those to start growing again.”
Gunzenhauser recommended a two-step process for preventing an outbreak in other parts of California. He said that, first, counties should do everything to identify new cases of hepatitis A. Then, he said, counties should do outreach to all workers—like paramedics or sanitation workers—who interact with homeless people to teach them about the disease, how it’s spread and how to prevent it.
Gunzenhauser also noted that that hepatitis A is a disease that is preventable through “herd immunization,” which means that the more people get vaccinated, the less likely that one person transmitting the disease will lead to an outbreak.
“I think what we’re learning from San Diego County and San Diego is that once a hepatitis A outbreak gets established in a community, it can be extremely difficult to control,” Gunzenhauser said. “So, I think that every county in the state of California that has any substantial groupings of homeless individuals in their counties or cities is at risk.”