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Officials Fumbled With Permits, Pilot Project As Deadly Hepatitis Outbreak Surged

Mindy Coughlin, left, and Heidi Unruh, center, both San Diego County Health and Human Services Agency Public Health Nurses and an outreach worker from Friend to Friend talk to a homeless person about getting the hepatitis A vaccination in downtown San Diego in this undated photo.
County of San Diego
Mindy Coughlin, left, and Heidi Unruh, center, both San Diego County Health and Human Services Agency Public Health Nurses and an outreach worker from Friend to Friend talk to a homeless person about getting the hepatitis A vaccination in downtown San Diego in this undated photo.
Officials Fumbled With Permits, Pilot Project As Deadly Hepatitis Outbreak Surged
Officials Fumbled With Permits, Pilot Project As Deadly Hepatitis Outbreak Surged GUEST: Lisa Halverstadt, reporter, Voice of San Diego

The hepatitis A outbreak primarily affecting San Diego's homeless population has become more deadly. 15 people have died from the infectious disease, that is an increase of 11 deaths in the past two months. 264 people have been hospitalized out of more than 350 cases reported. Despite the spread of the disease, city and county efforts to provide handwashing stations or any form of public washroom have been slow and small scaled. That is according to Lisa Halberstam, whose report on the outbreak appears in voice of San Diego. Lisa, welcome to the program.Thank you for having me, Maureen.The latest news is that the county has just moved one of the two handwashing stations closer to downtown. It is now outside the family resource Center, what did you find? What have been the obstacles to setting up these public facilities?There have been a number of permitting processes and other processes that the county has said that it needs to follow before further deploying these stations one thing to say at the top, one thing helping to spread the fuel they spread the virus is that a lot of homeless individuals have the same access to restrooms that most of us have. Therefore, they do not have the access to wash their hands, this virus person-to-person. In most hepatitis A outbreaks it has been an issue of a food related outbreak, the system the county said that they would consider would be starting a pilot to put some handwashing stations out to put them in areas where homeless people congregate so they would have greater access, but we have seen about two months later is that there are two handwashing stations and there placed her on July 13 outside of a health facility in Midway. That is miles away from the heart of that outbreak really is, yesterday, as he said, one of them was moved downtown to the family resource Center at 10th and C Street, that is just north of East Village which is the hub of San Diego community center it is also a major ground zero for the outbreak.Is there anything the city is doing to make this harder for the county to do?There is a need according to the city and County to have a permit, to place these handwashing stations, what I have seen, just in the course of my reporting was that the county was saying that there had been some roadblocks to try and install these handwashing stations downtown. We -- a week later when I spoke with the County, the city and the county were saying that they were going to allow one of the stations to be moved into the city in front of the County building without a permit but for additional ones there would need to be a permit. That is still in the works at this point.Has a been any declaration that this hepatitis outbreak is a public health emergency in San Diego?A lot of advocates and others I have a voice to that. When it comes to government officials or even news coverage, this isn't something that a lot of people have been aware of. I would say even just the county's response to this kind of falls more of a process that is standard, even though that the county has stepped up and they have done lots of vaccinations, they haven't vaccinated more than 7100 people that are considered at risk and more than 18,000 total. -- 70,000 people that are considered to be at risk of more than 18,000 total. Last time was --Last time we spoke with someone, the focus was on vaccinations instead of handwashing stations. What they said was that vaccinations are the key to stopping this outbreak. Is that what you are fining?Yes, the health officials have emphasized that vaccines are the number one way to combat this, one of the challenges, though, is that you are dealing with a population that does not have the same access to handwashing. Also, it may be harder to potentially access, in terms of getting those vaccines out. The county has really stepped up what they are calling foot teams where nurses are going out and giving vaccines and hygiene kits to individuals living in homeless and countenance. A lot of these folks don't have the same access to the doctor's office that most of your listeners have. Also, just as in the general population, a lot of homeless people are reluctant to get the vaccines.Is there to vaccination protocol?Yes, you get one shot and then six months later there is a second shot. Now, what I am hearing from health experts is that that first shot is pretty effective, however, in order to really seal the deal you do need to get a second shot.Last week the public health officer expanded the vaccination recommendations that people who handle food in San Diego should also be vaccinated against hepatitis A. What is your findings on how this is spreading?What I have found is that the county is not certain of the cause of this outbreak at this point. As I said before, in many of these cases, where they have made national headlines, it has been a foodborne virus. In this case, they believe that it is being spread person to person. There is not a lot known about the actual source. County officials assure me that this is something that they are working overtime to try and figure out. There are still a lot of questions.I've been speaking with Lisa Halberstam whose report on the outbreak appears in voice of San Diego. Accu.Thank you for having me. [ music ]

In June, county officials went public with a plan to respond to the deadliest hepatitis A outbreak in decades. Two months later, they have little to show for it – and people are continuing to die.

Health experts believe poor hygiene is fueling the spread of the virus, which has disproportionately pummeled the city’s homeless population, so they decided to deploy temporary hand-washing stations in places where the homeless settle.

But so far, the county’s managed to set up just two hand-washing stations – and until Wednesday both were miles away from the downtown streets that are essentially ground zero of the outbreak.


As officials have sputtered, the crisis has surged. Fifteen people have died and more than 260 have been hospitalized. The number of reported cases has more than doubled since the June announcement alone.

County officials have typical gripes about bureaucratic red tape, an issue with a vendor and an inability to swiftly coordinate with city officials. They also insist that the plan to put out hand-washing stations must first exist as a pilot program before it can be rolled out on a larger scale.

“It’s not just as easy as just putting a unit out there,” said Dr. Wilma Wooten, the county public health officer directing the regional response to the hepatitis A outbreak.

More than two months after the idea hatched and as the crisis has continued to claim lives, Wooten and city of San Diego officials say they are finalizing a permit that would allow the county to place hand-washing stations in areas where regional data has revealed the outbreak is most concentrated. On Wednesday, more than a month later, the county moved one of the stations to its downtown Family Resource Center at 10th Avenue and C Street. County bureaucrats say they hope to hash out separate permitting agreements with El Cajon and Escondido as well as nonprofits that serve the homeless.

County officials said the hand-washing stations are just a small piece of a more comprehensive response. They have sent county workers to homeless encampments to hand out hygiene kits and give vaccines, the approach experts agree is the most effective tool to prevent spread of the virus. They have inoculated more than 7,100 people considered particularly at risk, along with thousands more considered less so. They have partnered with government and nonprofit agencies across the region to spread the word and suggest sanitation changes.


Things have moved more slowly on the hand-washing stations. Hand-washing is considered the second most crucial step to fight the outbreak behind vaccinations, and many homeless people have been wary of getting vaccinated.

Dr. Rohit Loomba, director of hepatology at UC San Diego, said that while vaccines are the most potent weapon against the outbreak, increased hand-washing opportunities in areas like downtown where lots of homeless people congregate could help a particularly vulnerable population – and stem future outbreaks.

“Hand-washing is important, and we should think about not just hepatitis A, but there are other (gastrointestinal) infections also happening,” Loomba said. “They’re also preventable and cause a lot of morbidity.”

County officials say they wanted to make sure homeless people would use the wash stations and to understand maintenance needs before installing them across the county. They said they had to follow government protocols. They could not just place a hand-washing station on non-county property without proper approvals. They also said the initial vendor they counted on for the hand-washing stations ultimately could not deliver, forcing the county to ink a new contract with another vendor on July 6.

So the county started with a pilot, a sluggish process that seems more befitting a plan to increase annual flu shots than to combat a fast-growing outbreak that’s left 11 dead just since the county announced its plan.

That meant just two hand-washing stations on the county’s own property – one in the corner of a quiet county health facility parking lot that some homeless people frequent and another just paces away from an indoor restroom at the same health complex – went up on July 13. Both were more than five miles away from the downtown homeless encampments where hundreds have settled and the outbreak has spread most.

“We’re talking to everyone, trying to just deploy as many as possible,” Wooten said.

The county is also working with city of San Diego officials on a permit to add more hand-washing stations in the city and starting discussions with officials elsewhere.

Stacey LoMedico, the city’s assistant chief operating officer, said the city stands ready to allow a stations at other locations as soon as county officials finish their work on the permit.

That could happen within a few days, LoMedico said late last week.

Just a week ago, Wooten told Voice of San Diego that “politics” had interfered with efforts to install hand-washing stations downtown and forced the county to look at its own properties first.

“We don’t control those areas so the best we can do is have conversations,” Wooten said.

Emails provided by Metropolitan Transit System show the agency was reluctant earlier this month when the county suggested placing two hand-washing stations at the 12th and Imperial Transit Center in East Village.

Karen Landers, MTS’s general counsel, raised flags about the transit agency’s past experiences with portable toilets once placed on MTS property in East Village. She expressed concern that hand-washing stations would create further “quality of life” challenges in area already crowded with homeless people.

MTS security director Manuel Guaderrama brought up more specific concerns.

“My only thoughts are that this would probably become a magnet for homeless people to come onto our property just to use the sink (take a bath, brush their teeth, wash their dishes, etc.), especially during non-revenue hours,” wrote in an Aug. 15 email. “Perhaps the health department can set up locations with just the sanitizer.”

Public health officials have cautioned that hand sanitizers and wipes are not as effective as hand-washing in preventing the spread of the virus.

Wooten said last week the county was continuing to talk with MTS but has since discussed installing hand-washing stations at nearby Father Joe’s Villages and outside the Neil Good Day Center just a couple blocks away.

Update: This story has been updated to reflect that the county moved one of its two hand-washing stations to a downtown location on Wednesday, after this story first published.

Corrected: May 27, 2024 at 9:38 AM PDT
Lisa writes about San Diego city and county governments. She welcomes story tips and questions. Contact her directly at or 619.325.0528.