 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. "The local emergency was declared to increase and heighten awareness of the seriousness of the outbreak," she said. “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. "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. “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. (CNN) An outbreak of hepatitis A has sickened 421 people and killed 16 in San Diego County between November and September, officials say. 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. 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. 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. 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. "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. 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. 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. “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. 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. 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. "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.
– San Diego is ramping up its battle against a deadly hepatitis A outbreak by opening up new public bathrooms around the clock and adding security cameras, per NBC7 and Newsweek. Officials announced about 20 permanent and portable bathrooms would be open citywide targeting the homeless population, Newsweek reports. They will be cleaned twice daily and monitored via security cameras. The city's homeless coordinator calls the additional bathrooms an "important step to stop the spread of hepatitis A," a liver infection transmitted when people don't wash their hands after using the bathroom. The city is also considering three new 100-bed shelters to help the homeless "transition off the street and into permanent housing," per Newsweek. About 65% of those infected have no permanent home, per CNN. The city declared a public health emergency on Sept. 1 after the epidemic sickened hundreds, with victims from ages 5 to 57, per the LA Times. So far, 16 people have died and 292 have been hospitalized. Since symptoms can take weeks to appear, the extent of the epidemic is not yet known. Workers have vaccinated 21,000 people, mostly the "at-risk population," added hand-washing stations, and began spraying streets with bleach. Mobile showers may come next, per CNN. Health authorities have identified no common sources, such as contaminated food, for the outbreak. But they issued a warning on Friday that anyone who ate at World Famous restaurant on certain days may have been exposed, per NBC. Symptoms include nausea, joint pain, fatigue, and dark urine. (Hepatitis C infections are on the rise nationwide.)