It’s not just a shigellosis outbreak. 

Alongside a highly contagious gastrointestinal infection that began rapidly spreading among homeless people in King County last fall, public health officials say other diarrheal illnesses targeting the same population are also on the rise — fueled by a lack of hygiene options accessible during the pandemic.

In previous years, shigellosis mostly affected people who were housed — and in an average December, typically two or three cases a week. This past December, at least 37 people were sickened by shigellosis, 31 of them homeless or recently homeless. 

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Since the end of October, more than 100 people living homeless and largely outdoors have contracted the infection. 

And more than 60% of all shigellosis cases saw people hospitalized, often with severe symptoms like bloody diarrhea and dehydration.  

But shigellosis is not the only gastrointestinal disease targeting homeless people. In that same time frame, public-health officials have also seen an uptick in E. coli and less common cryptosporidiosis infections in King County’s homeless population.  

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All three are spread through fecal-oral transmission and have similar symptoms. 

People who are homeless are at much greater risk for these illnesses because of lack of access to hand-washing and sanitation resources, officials said. Many of the restaurants and library branches where people could once use bathrooms or get clean drinking water before the pandemic have closed those facilities to the public for more than a year.  

“I think that that’s definitely contributing to an outbreak, particularly of this size,” said Elysia Gonzales, medical epidemiologist with Public Health — Seattle & King County. “It may not have been the original reason, but it is likely exacerbating it.” 

Officials typically see a 20% to 30% hospitalization rate for shigellosis, Gonzales said. The current higher hospitalization rate is likely due to a number of factors, she said, including higher rates of underlying malnutrition and compromised immune systems. Homeless people who are sick are also less likely to have access to or seek out medical care for milder symptoms. 

Few new sanitation and hygiene resources have been made available relative to the more than 5,500 people living outdoors, in vehicles or in abandoned buildings in King County since the start of the pandemic.

While Seattle has reopened some library bathrooms, added two shower trailers and installed 14 portable toilets and 15 hand-washing stations, lawmakers last week questioned city government on why funding earmarked for a potential 63 new “street sinks” last fall has not yet been spent. 

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People living in encampments have requested more toilets and hand-washing facilities, said Hepatitis Education Project executive director Michael Ninburg, whose nonprofit works to provide health care, hygiene and sanitation resources in Seattle encampments.

“These folks, they know that they are more than inconvenienced,” Ninburg said. “They know that they’re at risk for these waterborne enteric bacteria and we haven’t seen the washing stations have a great effect.”

TJ Cosgrove, community health services division director at Public Health, said the agency is working with the city of Seattle on strategies to combat the outbreak, including reopening downtown drinking water fountains that had remained shuttered because of COVID-19. 

“In the context of diminishing (COVID-19) case counts, in the context of vaccines rolling out and wanting to prevent additional spread of these illnesses and making sure people have access to clean drinking water, it’s an appropriate thing to bring back,” Cosgrove said. 

Public-health officials have not yet identified the source of the initial outbreak. Tracking the infections among people who live outside is difficult — officials have not been able to follow up with more than half of the people who have fallen ill.  

But officials are hopeful that the shigellosis outbreak could be on its way out. Counts of new illnesses have decreased since March.  

“It’s really too early to say for sure,” Gonzales said. “We may have another bump.” 

Correction: The original version of this story misspelled the last name of Elysia Gonzales.