The hepatitis A fight is starting to ramp up outside the city of San Diego.
From Chula Vista to Oceanside, municipalities have been holding vaccination clinics, working with mobile vaccination teams and trying to get the word out about hand washing, the key activity that can stop the virus that has caused 16 deaths and 444 cases throughout the region since November.
San Diego has a significant head start on sanitation. Crews started installing 40 hand-washing stations in areas with high concentrations of homeless residents on Sept. 1 but, 20 days later, similar equipment is not yet in place in smaller cities.
That should change very soon, said Dr. Wilma Wooten, the county’s public health officer. She said a contractor hired by the county will add 20 more of the stations at locations in the city of San Diego by the end of the day Friday before installing more in neighboring areas on Monday.
“We have 55 waiting to be placed above and beyond what has been placed in the city of San Diego,” Wooten said.
Though she said during a presentation to the county board of supervisors on Sept. 6 that the health department would “continue working with other municipalities to implement sanitation efforts and expand education,” it has taken some time, Wooten said, for cities to determine where they want these resources installed.
She said the fact that it has taken more than 20 days to expand the program beyond the confines of the county’s largest city does not mean anyone was dragging their feet. Cities, she said, have a fair amount of sovereignty within their boundaries.
“There was no issue with delay. It’s process. We have to meet with them. We can’t just go and put out hand-washing stations anywhere we want,” Wooten said.
El Cajon, with 37 cases as of Sept. 11, has the largest concentration of outbreak-related illness outside San Diego.
Bill Wells, the east county city’s mayor, said that pressure washing some city streets with bleach water began Thursday, and vaccination teams have been active for longer than that. He said he was not miffed that the county is just now getting around to bringing in hand-washing stations. El Cajon, he said, has about 38 sinks available in areas such as Wells Park and the county library where homeless congregate.
“I think it was about as fast as it could have been considering this is the first time I can remember responding to a disease process like this. We’ve never, as a city, had to get involved with these kinds of things before,” Wells said.
Chula Vista said in a short statement thursday night that it has had 17 hepatitis A cases so far and expects to have temporary hand-washing stations installed next week in 13 different locations including five city parks — lauderbach, Harborside, Bay Blvd., Memorial and Orange.
Oceanside, which has had seven cases of hepatitis A among its homeless population, is also awaiting hand-washing stations as are National City and Escondido. Wooten said the county has not yet had placement conversations with Santee and La Mesa which have also seen six or more outbreak cases. specific case counts for those cities were not available Thursday.
Meanwhile, the sheer size and character of the outbreak is continuing to turn heads among experts nationwide.
Dr. Lee-Ann Jaykus, a distinguished professor of food science at north carolina state university, said Thursday that, not only is an outbreak with more than 400 cases unheard of since the hepatitis A vaccine arrived in the late 1990s, but the fact that testing has shown that infections are coming from the pathogen’s “1B” strain is particularly surprising. The CDC states that the 1B strain generally circulates in North Africa and the Middle East.
“Generally, genotype 1A is dominant in the Americas, and so it’s just really strange and surprising to see 1B popping up in this manner,” Jaykus said.
She chuckled at the sometimes-expressed notion that this outbreak came from Mexico, and was perhaps picked up from dirty water exiting the tijuana river estuary and washing up on south county beaches.
“No way. We know that 1A is just as dominant in Mexico as it is in America,” Jaykus said.
She was also struck, she said, by the fact that 24 percent of those infected were not homeless or intravenous drug users. It would be interesting to know, she added, whether these folks are getting infected in the same areas of the city that have seen large numbers of homeless infections.
“I would really want to know if there was a geographic association between these two populations,” Jaykus said, adding that such a correlation could suggest some common source other than drugs or poor sanitation.
Wooten said that county investigators have found some associations among this 24 percent.
“We have found that half of those individuals have some relationship with homelessness or illegal drug use,” she said.
She added that research teams are studying the interrelationship of these cases, but so far, the county has not released data to the public that shows cases stratified by their types.
Meanwhile, long lines at free vaccination events were reported in many locations since city and county leaders held a news conference on the outbreak Tuesday. Wooten said data was not available on how many additional vaccinations those events have generated this week but added that a new figure will be released on Tuesday.
In the months leading up to the news conference, nearly 23,000 vaccinations have been in response to the outbreak.
If there was one message that the public health officer wanted to hammer home thursday evening it was this: The outbreak is not being transmitted by contaminated food but rather by person-to-person contact. This bug is moving, she riterated, through the “fecal-oral route” which means that a person literally has to accidentally consume a bit of stool left by another person in order to become infected.
“We want to help people understand that you can’t absorb this infection, you can’t get it through the air by breathing it in,” Wooten said.