Crews from the company Clean Harbors began power-washing sidewalks and street areas with a bleach and chlorine solution in downtown San Diego on Monday as part of an effort to stop the spread of hepatitis A among homeless people. 
 
 The area cleaned Monday included sidewalks around 17th Street and Imperial Avenue, where hundreds of homeless congregate and live in tents and other shelters along city streets. The cleanings will continue in other downtown areas on Wednesday and Friday and repeat every other week. 
 
 A hepatitis A outbreak has left 15 homeless people dead and hospitalized nearly 300 others over the past 10 months. A lack of adequate access to restrooms, showers and hand-washing stations is believed to have contributed to the spread. 
 
 Besides starting the washing program Monday, the city announced it was extending the hours of 14 restrooms in Balboa Park, which will be open 24 hours a day starting Tuesday. 
 
 “By disinfecting our sidewalks and making additional public restrooms available 24/7, we’re following the direction of County health officials to address the unsanitary conditions that have helped fuel this outbreak,” said Craig Gustafson, senior director of communications for Mayor Kevin Faulconer. “We’re taking swift action to eradicate this virus from our streets and keep our most vulnerable residents safe.” 
 
 On Friday, Gustafson said Faulconer expected to announce this week a plan to set up multiple large tents to provide temporary, immediate shelter relief for hundreds of homeless people. Those tents will be equipped with restrooms, hand-washing stations and showers, he said. 
 
 The sidewalk washings and extended restroom hours this week were in response to a letter sent by county health official Aug. 31 asking the city to move forward with a list of specific sanitation actions to help control the spread of hepatitis A. 
 
 The county gave the city five business days to respond with the plan for remedying what it called a “fecally contaminated environment” downtown. 
 
 On Monday, county Communications Director Michael Workman said health officials still were evaluating the city’s response to the request. 
 
 The county also has taken steps to address the outbreak and plans to expand its efforts to other cities in the region soon. 
 
 County health officials already have provided hepatitis vaccinations to 19,000 people, including 7,300 considered to be at-risk of contracting the disease. The county also hired its own contractor to install 40 hand-washing stations in areas where the homeless often gather, and it has plans to install more this week. 
 
 The city has identified three downtown areas to be cleaned every other week. Monday’s areas included the sidewalks along Imperial Avenue below the Interstate 5 overpass, where the city had installed jagged rocks in an attempt to deter homeless people from camping in April 2016. Homeless people still used the site, prompting a need to wash the area. 
 
 The Monday cleaning area also includes streets north of National Avenue, south of F Street, west of 22nd Street and east of 10th Avenue. It also includes several blocks north of F Street and south of B Street between 10th Avenue and 17th Street. 
 
 On Wednesdays, crews will move west and clean streets north of Broadway, south of Fir Street, west of 10th Avenue and east of Pacific Highway. 
 
 On Fridays, crews will clean streets north of Harbor Drive, south of Broadway, west of 10th Avenue and east of Pacific Highway. ||||| San Diego health officials have implemented many measures to combat the city’s deadly hepatitis A outbreak, including power-washing the streets with a bleach solution and vaccinating more than 19,000 people. On Saturday they added yet another emergency measure: bathrooms with 24-hour security. 
 
 Four new portable restrooms and a handwashing stations were added to an area of the city that has a high population of homeless individuals, city officials announced in a statement. The facilities will be cleaned at least two times per day and will be watched over by full-time security. 
 
 “The installation of more public restrooms is important to stop the spread of hepatitis A,” Jonathan Herrera, the City’s Senior Advisor on Homelessness Coordination, said in a statement. “This is one of the many steps the City is taking to assist the County of San Diego in addressing this public health emergency.” 
 
 In addition to the four new restrooms, there’s also 16 more throughout the downtown area of the city, all of which are displayed on this map. Officials plan to install more public restrooms throughout the city. 
 
 The outbreak of the highly contagious virus has impacted hundreds of people. As of the latest count on September 12, there have been 421 cases reported of hepatitis A resulting in 292 hospitalizations and 16 deaths. The patients' ages range from 5 to 57, the Los Angeles Times reports. The majority of those who have been impacted are “homeless and/or illicit drug users,” according to the Health and Human Services Agency. 
 
 A plan to install three new homeless shelters in the coming months is also being discussed, Mayor Faulconer announced earlier in the week. 
 
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 “Each facility would have 100 or more beds, showers, meals and supportive services to help people transition off the street and into permanent housing,” the statement reads. 
 
 On Friday, officials warned that anyone who ate at World Famous, a popular restaurant on the Pacific Beach boardwalk, during these specific dates and times may have been exposed to the virus. 
 
 Hepatitis A is a liver infection typically contracted from contaminated food, water, or from close contact with someone else who has the virus. After being exposed, symptoms usually take a few weeks to appear and can include fatigue, nausea, dark urine, and joint pain. 
 
 Health officials are urging the public to get vaccinated for the virus, especially those who have been exposed and who have not been previously immunized for hepatitis A. 
 
 Free hepatitis A vaccinations are available at the San Diego Central Library on September 19 from 2 p.m. to 5 p.m. Vaccinations will also be administered at North Central Public Health Center, located at 5055 Ruffin Road in San Diego., on Saturday, September 16 from 10 a.m. to 2 p.m. ||||| Health officials in San Diego have scrambled for months to contain an outbreak of hepatitis A — vaccinating more than 19,000 people, putting up posters at bus stations and distributing hand sanitizer and cleansing wipes. 
 
 Despite those efforts, 16 people have died of the highly contagious virus in San Diego County and hundreds have become ill in what officials say is the nation’s second-largest outbreak of hepatitis A in decades. 
 
 Earlier this month, San Diego officials declared a public health emergency. 
 
 Though Los Angeles has so far escaped an outbreak, public health officials are hoping to head off a similar emergency. They say the virus could easily spread to Los Angeles because of its proximity to San Diego and the region’s large homeless population. 
 
 San Diego opens downtown restrooms amid hepatitis A crisis » 
 
 “We know it’s getting worse in San Diego, so we’re really ramping up,” said Cristin Mondy, the county’s area health officer for a region that includes downtown Los Angeles. 
 
 In their efforts to get their outbreak under control, San Diego health officials have adopted a technique from L.A. that they hope will stop cases from spreading locally: washing the streets with bleach. 
 
 “They didn’t have any outbreaks. We did. So we were like, ‘What’s going on there?’ ” said San Diego County public health officer Dr. Wilma Wooten. “That’s what we wanted to replicate here.” 
 
 Several hundred infected in San Diego 
 
 Hepatitis A is transmitted through feces, either through close contact, often sexual, with an infected person or by eating contaminated foods. The virus can cause liver damage or even death, especially for people who already have other liver diseases, such as hepatitis B or C. 
 
 San Diego health officials first identified an outbreak in March but traced the first case back to November. 
 
 Since November, 421 people in San Diego County have been infected with the virus, including the 16 who died, health officials said. Typically there are only two or three cases of hepatitis A per month in the county. The majority of those infected in the ongoing outbreak were either homeless or illicit-drug users, with cases concentrated in downtown San Diego and the cities of El Cajon, Santee and La Mesa, Wooten said. 
 
 A related outbreak began in Santa Cruz County as well this year, where 69 people have been infected by the same strain of hepatitis A so far, she said. Though hepatitis A is often contracted through contaminated food, the strain circulating in San Diego and Santa Cruz isn’t associated with food, but instead seems to be spreading from person to person, she said. 
 
 “We know that the numbers are going to increase, and they’ve been increasing since we first identified the outbreak,” Wooten said. 
 
 Since the spring, San Diego officials have put together a command center that meets once a week to map strategy. They investigate every case to find out who else might have been exposed and give them medicines. They sent out an alert Friday to try to locate anyone who might have caught the virus from an infected patient at a restaurant in Pacific Beach. 
 
 Workers have also visited homeless encampments and riverbeds to vaccinate thousands of people. Earlier this month they installed 40 hand-washing stations in areas of the city of San Diego with high homeless populations. 
 
 Unsanitary conditions make it more likely for hepatitis A to spread. A common way for the virus to be transmitted is when an infected person uses the bathroom and doesn’t wash their hands, experts say. 
 
 San Diego outbreak began in Nov. 2016 
 
 421 people infected 
 
 292 hospitalized 
 
 16 died 
 
 patients ages range from 5 to 87 
 
 65% of cases in homeless or illicit drug users, or both 
 
 68% of cases were men Sources: San Diego County Health and Human Services Department 
 
 Wooten said that over the summer she looked into ways that other health departments manage disease risk, especially those with big homeless populations. That’s when she learned that L.A. not only washes streets with water, but sanitizes them with bleach. 
 
 On Monday, San Diego crews began cleaning streets with a bleach solution, she said. 
 
 “We know that individuals here are ill, they’re on the streets, and there’s fecal material on the streets,” Wooten said. “Sanitation is going to help that.” 
 
 County health officials and city leaders will visit L.A. next week to see the practice firsthand, she said. 
 
 Gonzalo Barriga of the Los Angeles Department of Public Works said the protocol, known as Operation Healthy Streets, began after the city was cited in 2012 for multiple health hazards on skid row. 
 
 Now, city workers regularly clean sections of sidewalk in the neighborhood, with each street getting washed every two weeks, he said. Inspectors ask homeless people to remove their belongings from an area. Then they spray a bleach solution on any biohazards or waste on the street, such as feces or syringes, and dispose of them, said Barriga, who oversees the inspectors. 
 
 Then they wash the streets with water, followed by misting with a liquid that’s about 10% bleach, he said. 
 
 Los Angeles could be the next region hit 
 
 Cleaning the streets is especially important because health workers have been struggling to get people vaccinated against hepatitis A, Mondy said. Typically only children and people at high risk are vaccinated for hepatitis A, but the county is now recommending vaccines for all homeless people as well as illicit-drug users. 
 
 Cases of hepatitis in the United States have hit historic lows since a vaccine was introduced in 1995. Since then, there’s been only one outbreak bigger than San Diego’s, in which more than 900 people were infected after eating contaminated green onions served at a restaurant in Pennsylvania in 2003. 
 
 In Los Angeles County, 55 people have been diagnosed with hepatitis A since November, which is in line with the average case numbers for previous years, according to data from the health department. Five of the people infected lived in either San Diego or Santa Cruz counties when they were exposed, officials say. 
 
 Mondy said many people she approaches about getting a hepatitis shot don’t feel a sense of urgency because there’s no outbreak in L.A. So far county health officials have given out 1,000 vaccines, but they’re considering offering restaurant gift cards as an incentive to get more people to get inoculated. 
 
 Mondy said officials are targeting soup kitchens and clinics near Union Station and the downtown Greyhound bus station, because that’s where people are likely to arrive from San Diego. 
 
 “We’re trying our best to prevent this outbreak from happening,” she said. “We can see that there’s potential based on what’s going on in San Diego and Santa Cruz, so we’re making sure that our population is protected.” 
 
 A worker tapes signage telling people to get vaccinated to protect themselves against Hepatitis A in downtown San Diego. (Eduardo Contreras / AP) 
 
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 soumya.karlamangla@latimes.com 
 
 Twitter: @skarlamangla 
 
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– Declared a public health emergency on Sept. 1, a hepatitis A outbreak in California is only getting worse, the Los Angeles Times reports. There have been 421 confirmed cases of hepatitis A in San Diego County, and 292 people have been hospitalized. Sixteen people have died. The county has vaccinated 19,000 people, and on Monday workers started spraying sidewalks and and streets in downtown San Diego with bleach-infused water to kill the virus, according to the San Diego Union-Tribune. Hepatitis A can be spread when people don't wash their hands properly after going to the bathroom. The current outbreak has hit San Diego's homeless population hardest. The county is installing 40 hand-washing stations where homeless people congregate and is making some public restrooms available 24 hours a day. KGTV reports San Diego will be opening three temporary homeless shelters that, along with beds, will have restrooms and showers. Officials warn it could be months before these new measures show any positive effect on the outbreak.