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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 Knocking on doors, climbing through fences: How L.A. County's health investigators are out trying to stop syphilis ||||| 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. ||||| (CNN) An outbreak of hepatitis A has sickened 421 people and killed 16 in San Diego County between November and September, officials say. Additionally, 292 of the 421 have been hospitalized as a result of the viral infection, which causes inflammation of the liver. 
 
 Over the previous five years, the county recorded just 28 infections per year on average. 
 
 "This is an outbreak of unprecedented proportion, and we have not seen an outbreak of this nature as relates to hepatitis A before," said Dr. Wilma Wooten, public health officer and director of public health services for the county's Health and Human Services Agency. 
 
 Most of the infections, 65%, are occurring among people who are homeless, who use illicit drugs or who experience a combination of those two factors. 
 
 The remaining cases include 23% in people associated with the homeless population, such as friends, and 12% in people who are lacking records and are most likely homeless, according to Wooten. 
 
 Hepatitis A is typically spread when people eat contaminated food or water; more rarely, the virus is transmitted person-to-person through the "fecal-oral route," she explained. 
 
 "Basically, if an individual is infected with hepatitis A and they use the bathroom and don't wash their hands, and then they can spread or contaminate the environment: door handles, ATMs or whatever they touch," Wooten said. Other people who touch the same objects and fail to wash their hands before eating, smoking or touching their faces can become infected as well. 
 
 Symptoms of hepatitis A , which include fever, fatigue, nausea and abdominal pain, usually last less than two months, although some people can be ill for as long as six months, according to the Centers for Disease Control and Prevention. Although there are no special treatments, doctors recommend rest, adequate nutrition and fluids. Most people recover completely and do not have any lasting liver damage. 
 
 Wooten declared a state of emergency for the county, home to about 3.3 million people, on September 1. 
 
 "The local emergency was declared to increase and heighten awareness of the seriousness of the outbreak," she said. 
 
 Vaccinations, bleach and more 
 
 To combat the outbreak, public health officials have adopted a three-part strategy: vaccination; sanitation, which includes hygiene; and education. 
 
 Since June, the San Diego Police Department has been offering free hepatitis A shots through its homeless outreach and other programs. 
 
 "We've vaccinated over 21,000 individuals," Wooten said. "The majority of those are the at-risk population or individuals who have association with the at-risk population." 
 
 The San Diego Central Library will host free vaccination clinics on the third Tuesday of each month beginning September 19. 
 
 The city of San Diego -- one of 18 incorporated municipalities and one unincorporated municipality that make up the county -- has "the largest number of homeless individuals downtown," Wooten said, "so we deployed or put out hand-washing stations" about two weeks ago. 
 
 "The homeless community was very thankful and appreciative. We're looking at other locations where they can be deployed." 
 
 "We're also encouraging municipalities to look at other things they can do, like increasing access to public bathrooms," Wooten said, adding that bleach is needed to kill the virus when cleaning restrooms. 
 
 "The city of San Diego is also looking at mobile showers and also strategies to help people wash their clothes," she said. "All of those things have been considered to help with personal hygiene as well as sanitation of the streets." 
 
 Craig Gustafson, senior director of communications for the city of San Diego, wrote in an email that "the City hired a vendor to begin using a bleach cleaning solution on public right-of-ways on Monday. The cleanings will occur three times a week (Mondays, Wednesdays and Fridays) every other week in the downtown area." 
 
 The education outreach includes flyers posted and pamphlets available in public places, including municipal buildings and libraries. 
 
 The state of emergency "could lead to additional state and federal funding to reimburse for costs related the outbreak," Gustafson said. 
 
 Cases elsewhere in California 
 
 Separately, Santa Cruz County "has reported 69 cases in 2017," Jorge De La Cruz, a spokesman for the California Department of Public Health, wrote in an email. State public health officials consider this an additional outbreak. 
 
 many infected people have been difficult to contact due to homelessness or illicit drug use. Two challenges involved in the investigation of the Santa Cruz outbreak, according to the county health department website , are the fact that hepatitis A has a long incubation period -- 15 to 50 days -- and thatmany infected people have been difficult to contact due to homelessness or illicit drug use. 
 
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 "To date, no common source of food, beverage, or other cause has been identified; as a result, the source of the outbreak remains undetermined," the website says. 
 
 "Outside of San Diego and Santa Cruz counties, 126 cases of hepatitis A have been reported to date (in California) in 2017," De La Cruz wrote, adding that the total number of cases in the state as of Thursday was 631. 
 
 On Tuesday, the Los Angeles County Department of Public Health said it has confirmed 10 cases of hepatitis A among homeless people. 
 
 Dr. Jeffrey Gunzenhauser, the county's interim health officer, said in a statement, "our outreach teams and clinics are offering free vaccine to persons who are homeless, active drug users, and those who provide services and support to those individuals." The most recent cases in Los Angeles appear to be locally acquired, according to the department. 
 
 Wooten said that "underlying medical conditions like hepatitis B or hepatitis C or both, or other chronic liver disease" may be contributing to the high hospitalization and death rates among the homeless in San Diego. 
 
 "Going forward, we are doing everything we can do and working with all of our partners, and I can't predict how long this will last. We will be working on this anywhere from another six to 12 months, potentially," she said. "If we get our arms around it sooner, we welcome that."
– 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.