In California, a housing crisis turned into a health crisis as hep A cases spread

Twenty-one people have died and more than 500 have been infected by an outbreak of hepatitis A in California since November 2016. Hepatitis A is an infectious disease — in the U.S. it’s most often acquired by coming into contact with fecal matter from someone else who is infected or through contaminated food or water. At least those are the most immediate causes. But the outbreak in California, the largest since the U.S. started tracking hepatitis A, lays bare that homelessness can be as much a cause of disease as the virus itself.

The state’s southernmost county, San Diego, has been the hardest hit by the outbreak. So far, 582 cases and 20 deaths have been reported there. Further north, in Santa Cruz, there have been 76 confirmed cases and one death. Symptoms can include fever, nausea, jaundice, and joint or abdominal pain. Both counties, like many in California, have seen an uptick in the homeless population in recent years, according to the unsheltered homeless counts conducted every two years in the state’s counties.

The vast majority of the California cases have been among people without a home. Being without a bathroom or a place to bathe, or being forced to sleep or spend time in unsanitary conditions has a way of encouraging the spread of disease.

Once hepatitis A begins to spread, it can be hard to stop. Thousands of doses of vaccine were handed out in the affected counties in California last fall, but even with a successful vaccination program, it can take months for the spread of disease to come to an end — Santa Cruz only recently declared an end to its outbreak. The incubation period — the time between infection and when symptoms show — is 15 to 50 days, according to the Centers for Disease Control and Prevention. People frequently don’t develop symptoms, and therefore don’t know they are infected, until after they have already passed it on. But among people who are homeless, it can be tough just to distribute the vaccines, as public officials must first gain the trust of individuals who can be wary of their motives. 

In San Diego County, 62 percent of people who are homeless live in their cars, on the street, or in encampments. In Santa Cruz, it’s 80 percent. California, which is experiencing a major housing shortage, doesn’t have enough spaces at shelters to house all of its homeless.

Both Santa Cruz and San Diego have made recent efforts to designate spaces where people can sleep at night with safe access to bathrooms. In Santa Cruz, officials placed portable toilets and washing stations in a park nestled between the city’s downtown and the county government offices. The park was already frequented by the city’s growing population of people without homes. It has been a contentious issue in the community. Some people worry about safety along a pedestrian and bike pathway that runs along the park. Others worry about the health of people camping there. Many are concerned about both.

In an effort to curb the outbreak, law enforcement recently adopted a new policing strategy in Santa Cruz, announcing that they would no longer hand out camping citations between 9 p.m. and 6 a.m. to people unless there was a complaint from a private property owner, or another crime was reported. The hope was that by encouraging people to sleep in a safe, clean area, the outbreak could be stopped. It seems to have worked. The city recently voted to work towards building a permanent shelter.

In San Diego, the city also temporarily designated a public area equipped with showers, washing stations and bathrooms for people to sleep. But with the state experiencing an unprecedented housing shortage, long-term solutions will not come easily.

The vaccine is one way to prevent the virus that causes Hepatitis A from spreading. But a safe, clean living space is just as important, not only for stopping this outbreak, but for preventing the spread of other infectious diseases as well. As with any disease, finding the cause can depend on the magnification of the microscope. Viruses cause infections, but it’s often the conditions we live in that determine whether or not we are susceptible to them.

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