Washington State Department of Health officials announced hepatitis A outbreaks in four Washington counties Tuesday, with 13 confirmed cases among the homeless population and people who use drugs in King, Snohomish, Spokane and Pend Oreille counties.

“It’s a moderate problem and I am concerned it’s the warning of a larger outbreak to come,” said Dr. Scott Lindquist, the Washington state epidemiologist for communicable diseases.

These case numbers are still relatively small — in King County there were 14 cases of hepatitis A last year, none of them among the homeless population — but they have public health officials focused on prevention.

Yesterday, Lindquist put out an alert to every county public health department in Washington, encouraging them to push for testing in treatment centers and syringe exchanges, and making sure people handling food at shelters are vaccinated and not touching food with their bare hands, among other things. Nine of the cases were in Spokane County; two in King; and one each in Snohomish and Pend Oreille, in the state’s northeastern corner.

While hepatitis A is rare, people who are homeless and people who use illicit drugs are at greater risk of infection, which can cause severe liver damage. The viral disease spreads through person-to-person contact or consuming tainted food or water, but can be prevented by vaccination. 

Nationally, a yearslong surge of hepatitis A has killed 221 people as of July 26, according to the CDC, and hospitalized over 13,000. Phoenix and Boise have both seen hepatitis outbreaks in recent months as well.

The first case of a homeless person with hepatitis A was announced in April, in King County. On Tuesday, Public Health — Seattle & King County announced a new case discovered last week that matches the same strain of hepatitis A as the April case. King County responded to the April case with a broad effort to get its homeless population vaccinated, with 1500 vaccinations so far.

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Cities with large homeless populations are the most at risk for outbreaks. In San Diego, a 2017 outbreak among the homeless population claimed 20 lives. Local governments spent an estimated $12 million, putting up temporary shelters capable of housing hundreds of people at a time, power-washing streets, and installing portable toilets and hand-washing stations.

Washington has been vaccinating children against hepatitis A since 2006, but there is still a large population of adults who aren’t vaccinated. The state department of health is investigating the new cases to see where they originated.

“It just takes one person, from an exposure, say, in San Diego, to come up to the homeless environment up here and spread,” Lindquist said.

People looking to get vaccinated against hepatitis A can find information on King County’s website at kingcounty.gov/HepA. If you’re living homeless and looking for a place to get the vaccine for free, King County has a map of locations.