When a hepatitis A outbreak struck San Diego’s homeless population more than two years ago, experts and advocates worried it was only a matter of time before it traveled up the Interstate 5 corridor and landed in Seattle.

A local outbreak over the last several months has showed their concerns were justified. More than 100 people have been sickened by hepatitis A in King County since the beginning of January, compared with annual totals of five to 16 cases over the last decade, according to Public Health — Seattle & King County. Nearly 50% have been among people experiencing homelessness.

Of 30 local cases in March, 14 were from people who were homeless in the Ballard area, according to Public Health director Patty Hayes.

Officials are now confronting two outbreaks at once: A novel coronavirus pandemic that has proven deadly, as well as hepatitis A, a highly infectious liver disease transmitted through fecal matter that disproportionately harms people who are homeless. And advocates say the city has not done enough to prevent either in its unsheltered homeless communities.

The Seattle Times’ Project Homeless is funded by BECU, The Bernier McCaw Foundation, The Bill & Melinda Gates Foundation, Campion Foundation, the Paul G. Allen Family Foundation, Raikes Foundation, Schultz Family Foundation, Seattle Foundation, Starbucks and the University of Washington. The Seattle Times maintains editorial control over Project Homeless content.

In a tense committee meeting on homelessness at the Seattle City Council on Wednesday, nonprofit leaders called on the city to reopen bathrooms in public buildings, such as libraries, and staff them with help from the National Guard to prevent the hepatitis A outbreak from spreading.

What we are seeing unfold in our city is a truly shocking experience,” Alison Eisinger, executive director of the Seattle/King County Coalition on Homelessness, told council members. 

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Lack of access to running water and bathrooms — a long-running criticism of Seattle from advocates and the city auditor’s office alike — make the disease ripe for spreading among people living outside. With businesses closing and day centers reducing hours due to COVID-19, the disease caused by the novel coronavirus, the advocates say the risk has risen exponentially.

Warning signs

There had been ample warning this was coming.

In July 2019, the Washington Department of Health declared a hepatitis A outbreak after identifying 13 cases in people from King County, Spokane, Pend Oreille and Snohomish County. In August, the state sent letters to homeless service providers warning that people who were homeless or used drugs were at particular risk. By December, a homeless King County man had died after being hospitalized for an acute hepatitis A infection.

Since the San Diego outbreak, Public Health — Seattle & King County and outreach workers had already been providing vaccines with the hope of stopping a potential outbreak in its tracks. But those efforts don’t reach people who aren’t willing to be vaccinated, said Michael Ninburg, executive director of the Hepatitis Education Project.

“Frankly, it wasn’t a surprise,” Ninburg said. “We had been fearful that something like this would happen ever since the outbreak in San Diego.”

After the Ballard cases were reported, the city shut down Ballard Commons last week for cleaning, and the city’s Navigation Team, a group of police and outreach workers, distributed hygiene kits and information on hepatitis A and COVID-19. The team also encouraged people to get vaccinations provided across the street by the Hepatitis Education Project.

But homeless service providers say the city could be doing far more. At Wednesday’s meeting, outreach workers painted a stark picture of the lack of resources for their clients during the coronavirus pandemic.

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Dawn Whitson, with city-contracted outreach group REACH, told the council when she’s out doing her job in the streets, there are so few public bathrooms that she herself has resorted to going to the bathroom in alleyways. Whitson added that when she has shared these concerns with the city and asked for more resources, the city had few answers.

“I was pretty much stonewalled,” Whitson said. “Told that there was no one I could speak to.”

Seattle has lagged behind some other cities with large unsheltered populations when it comes to setting up hand-washing stations and portable toilets during the crisis.

Dozens of new hygiene stations have been installed in Alameda County, home to Oakland and Berkeley. Los Angeles has set up 370 hand-washing stations and 170 portable toilets. Seattle made available just 14 portable toilets and six hand-washing stations four weeks after the first local COVID-19 death.

Councilmember Lisa Herbold criticized the city’s response.

“From what I can see, our failure to address the greatest needs of those with the least should indict us all for really putting our city at risk,” Herbold said.

Deputy Mayor Casey Sixkiller told the council the city has faced difficulties in operating new hygiene resources that have been made available during the COVID-19 pandemic. Some have been vandalized, he said, and staffing has been hard to coordinate. The cost of additional mobile bathrooms and hand-washing stations was also a factor, Sixkiller said, as demand for them from other municipalities has increased.

Mayor Jenny Durkan has made “repeated requests” for federal and state resources such as staffing help, including in letters to FEMA and Vice President Mike Pence, her office said.

“Staffing challenges are not just a City problem, it’s impacting our service providers as well, which is why some City employees have been reassigned to help staff shelters,” Kamaria Hightower, spokeswoman for Durkan, wrote in an email. “The Mayor is in full agreement that we need more funding, staff and resources to supplement the work of service providers and City employees who remain on the job.”

The biggest thing the city can do now to prevent hepatitis A from spreading is to provide ample access to hygiene services for people living outside, Ninburg said, though he acknowledged doing so is “admittedly a tough proposition when you’ve got encampments dispersed all over the region.”

Seattle has long resisted providing hand-washing stations and portable toilets to people in encampments, with officials having argued it condones illegal camping. Still, last December the city approved $1.3 million to be spent on five mobile “pit stops,” which would be staffed and include toilets, sinks, sharps containers and dog-waste receptacles. Last month, the Centers for Disease Control and Prevention rolled out guidelines that encouraged local governments to provide access to such resources during the COVID-19 pandemic.

“There are solutions out there, so we just have to make it a priority,” Ninburg said.

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