Health officials in California are struggling to contain fierce outbreaks of hepatitis A among homeless people and drug abusers in three counties, including San Diego, where at least 17 people have died.

Hundreds more have become ill and been hospitalized, mostly in the San Diego area, often not far from tourist destinations. The disease also has cropped up farther north in Los Angeles and Santa Cruz counties. Poor access to restrooms and sinks in homeless encampments is largely to blame.

Public health officials say the crisis has caught them off guard because it’s rare for the disease to spread so rampantly when it isn’t tied to a common source, such as a tainted food product. Meanwhile, as cases mount with no end in sight, critics fault authorities’ response as lethargic.

The California Department of Public Health says San Diego County’s is “the largest outbreak in the U.S. that is not related to a contaminated food product” since the U.S. first introduced a vaccine for hepatitis A in 1995.

“This is an unprecedented outbreak,” said Dr. Wilma Wooten, the county’s public health officer and director of Public Health Services for the  San Diego County Health & Human Services Agency. “This is new territory.”

Wooten, who earlier this month declared a public health emergency, said about 65 percent of the 461 people known to have contracted the liver-attacking virus in San Diego County since last November through Tuesday are homeless and/or illicit drug users.

Under the direction of the county health department, the city is now power-washing heavily soiled sections of downtown sidewalks and streets with a bleach solution.

Earlier this month, the county installed about 40 portable hand-washing stations throughout the downtown areas hardest hit by the virus. Also this month, city officials announced plans to add restrooms to downtown areas.

And Los Angeles County announced that 10 cases had been identified among homeless people either on the streets or in shelters. Half of those patients had been to the San Diego or Santa Cruz areas, but at least two cases were locally acquired. In Santa Cruz County on the Northern California coast, about 70 people, mostly homeless or drug users, have been diagnosed since last April.

Hepatitis A is a highly contagious but typically mild illness and often does not require treatment. It does not cause chronic liver disease, as do hepatitis B and C, and is rarely fatal. But among those with existing liver disease and other illnesses common among the homeless, it can cause an acute liver infection and death. The best way to prevent hepatitis A is to get vaccinated, according to the federal Centers for Disease Control and Prevention. 

Hepatitis A is usually spread when a person ingests fecal matter from an infected person — even in microscopic amounts, according to the CDC. That can happen when an infected person doesn’t wash his or her hands after defecating and then contaminates objects, food or water with which another person comes into contact.

Once the virus gains a foothold in a crowded homeless community lacking enough restrooms and sinks, it can spread easily. It can also spread through sexual contact, according to the CDC.

Leslie, 42, who asked that her last name not be used to protect her privacy, said she’s been camping out on San Diego’s streets for five years. She became ill with the virus last spring and was hospitalized.

“It was awful,” she said. “My skin was yellow, my pee — my urine — it looked like chocolate milk. And everything just hurt. I was achy all the time and tired. I couldn’t sleep enough.”

It took Leslie more than two months to fully recover but, she says, she’s grateful to have survived.

The California Department of Public Health said it has no protocol on how best to deal with large outbreaks of this kind. However, state officials  say they are consulting with the CDC and other states and working with county health authorities “to identify strategies that may be effective.”

In 2014, there were an estimated 2,500 cases of acute hepatitis A infections nationwide, according to the CDC.

Michigan is currently experiencing a large hepatitis A outbreak, as well, apparently spread in part through intravenous drug use and sexual contact. At least 14 people have died. Also escalating this year are hepatitis A infections among men who have sex with men in Colorado and New York City, and other cities worldwide, according to California health officials.

Slowing the spread among homeless people isn’t easy. Hepatitis A has a long incubation period before a person shows symptoms — between 15 to 50 days, in which a person can be infectious but not know it. What’s more, not everyone who becomes infected shows symptoms, such as fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, jaundice and joint pain.

The transience of the homeless population makes it challenging to educate and vaccinate people once an outbreak happens.

“This outbreak has really resulted in us needing to be creative and utilize strategies different from what we’ve utilized in the past,” said Wooten of San Diego County.

But critics say health officials have been too slow to act, especially to install toilets and sinks.

“This whole crisis is man-made,” Michael McConnell, a La Jolla, Calif., coin dealer and advocate for homeless residents, told the San Diego Union Tribune in a story published Monday. “The response is certainly much too late, based on when they knew they had a serious problem. Even today, all they’ve done is the most easy stuff. They have taken zero bold action.”

Some told the newspaper that the reaction is symptomatic of a lackluster response to the problems of  poor and homeless people in their midst.

The city and county of San Diego deny any unnecessary delays in handling the outbreak. Countywide, nearly 23,000 people have received vaccinations against the virus.

“We’ll continue to do whatever it takes to address this,” said San Diego spokeswoman Katie Keach.

Public health workers now are working with homeless outreach teams who have long-established ties to those living on the streets or in the wildlands of San Diego County.

“We go into the canyons, we go everywhere,” said Amy Gonyeau, chief operating officer for the Alpha Project, a nonprofit that provides homeless services. “We go out every day. We have our own vehicles and vans … we educate people on what’s going on.”

On a recent morning, an Alpha Project team delivered hygiene kits — soap, hand sanitizer and other toiletries packaged in clear plastic bags — to a crowded encampment in downtown San Diego’s East Village neighborhood. Tents and shopping carts line the sidewalks in this section of downtown that’s largely hidden from the city’s tourists.

“It looks like a war zone,” said Larissa Wimberly, an outreach supervisor for Alpha Project. “There’s people out here with HIV, people out here with cancer, there’s people out here with heart issues. There are people who are just old and feeble and they’re not eating right. It’s really sad.”

As Wimberly rides shotgun in a large, white Alpha Project van driven by her colleague Cain Mariscal, she points to the myriad tents and shopping carts. Behind and between them, she says, many residents relieve themselves.

“It’s everywhere,” she says of excrement. “It’s just really bad right now.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.