Hepatitis A, a highly infectious disease, is spreading through Portland’s homeless encampments and has infected more than a dozen people in the past few months.

As of Nov. 16, there have been 18 confirmed cases in Portland, officially qualifying as an outbreak according to the Maine Center for Disease Control and Prevention.

Most of those cases have been detected in the homeless community, advocates say. Though one case was diagnosed in an employee at the Green Elephant Bistro.

Alfredo Vergara, the public health director for the city of Portland. Ben McCanna/Staff Photographer

There is a smaller outbreak in Androscoggin County, which has reported three cases. This comes amid unusually high numbers of hepatitis A cases across the state, but the clusters of cases in Portland and Androscoggin County are the only two outbreaks, according to the CDC. It defines an outbreak as three or more cases of a disease that are linked.

It is an extremely contagious liver infection that is spread through unsanitary living conditions. Contaminated water, food and surfaces can all carry the disease, which originates in feces.

While homeless advocates say the outbreak stems from a lack of access to clean water for drinking and bathing, city officials say the unsanitary conditions are why they have cleared encampments and are focused on getting people into shelters.

“Hep A is a hygiene disease,” said Alfredo Vergara, Portland’s director of public health. “If you don’t have access to appropriate bathroom facilities or water and soap, then it’s going to just keep spreading.”

Vergara said that hepatitis A outbreaks have become more common nationwide and usually are found in places where people can’t maintain sanitary living conditions, like encampments. But this is the first one he is aware of in Portland.

According to data from the U.S. Centers for Disease Control and Prevention, more than 32,000 cases have been detected nationwide since 2016, primarily among people who use injection drugs or are homeless. This year, 46 cases have been identified across Maine.

ADDED CHALLENGES

Hepatitis A is easily prevented with a vaccine. Most people are vaccinated for the disease as children because they don’t know how to maintain basic hygiene practices and are more likely to get infected. Adults can become susceptible to infection if they don’t get another shot, but most people aren’t exposed to the disease after childhood.

For those who live in unsanitary conditions as adults, however, their chances of infection increase as that childhood vaccine becomes less effective over time.

“When you have a sick and unstable group of people who aren’t necessarily capable of taking care of themselves, then this is more likely to happen,” Vergara said.

Most people who get hepatitis A will have stomach pain, vomiting and diarrhea. But for people who are immunocompromised it can lead to hospitalization. Intravenous drug users, people infected with HIV and those with liver disease are at higher risk for serious illness.

“Having Hep A is awful no matter what, but being severely sick and still sleeping outside, you’re in circumstances where you aren’t able to take care of yourself and sleep in a bed or access a bathroom. There is so much added challenge,” said Andrew Volkers, a supervisor at the nonprofit Preble Street’s health services.

Portland’s outbreak dates to mid-September, shortly after the city dismantled the Fore River Parkway Trail homeless encampment.

The city had provided drinking water and a hose for showering at the Fore River site. When that encampment was shut down in September and many people moved to other areas of the city, including the state park-and-ride lot on Marginal Way and near Harbor View Park around Commercial Street, there was no longer running water available, outreach workers say.

Volkers said the lack of these resources is at the root of the outbreak and is contributing to its spread, and that the conditions for homeless people in the city are worse than they have been in the past.

“Unfortunately this (outbreak) adds a layer to the stigma that’s already so acutely felt. A lot of these people wish they could have showers and access to these things but they don’t,” Volkers said. “These are structural causes, but it’s framed as if it’s a personal issue rather than a systems issue.”

“We completely agree that sanitation is a big issue, which is why large encampments are not healthy or safe,” city spokesperson Jessica Grondin said on Friday, adding that the city looked in to providing water at the Marginal Way encampment but it was not possible because of where the fire hydrants are located.

“Over the winter, it would be even harder to provide water,” she said. “Which is another reason we are focused on getting people into shelter.”

Monday night, the City Council is expected to vote on a proposal that would allow camping through April. Some worry it will make the situation worse,  while others have said continuing to clear the camps only interrupts outreach work.

A ‘HORRIBLE REALITY’

The city has started handing out bottled water and soap, and health care workers are bringing vaccines directly to the encampments.

This is where they’ve had the most success, said Bridget Rauscher, manager of clinical services for the city’s public health department.

“People are pretty open to vaccines, especially when they’ve really built relationships with our staff who they trust,” Rauscher said. “They want to keep themselves safe as well.”

Anyone doing work in the encampments is encouraged to get vaccinated for hepatitis A.

The city also offers walk-in vaccine hours at its clinic on Forest Avenue and through the syringe services program. Rauscher says that while hepatitis A isn’t necessarily spread through needle-sharing, intravenous drug users often cut their drugs with water. If that water is contaminated, it can spread the disease.

Other community partners like Preble Street are trying to tell as many people as possible about the outbreak and encourage them to wash their hands and get vaccinated.

“This is another horrible reality right now,” Volkers said. “It’s just another thing that (homeless people) are facing on top of displacement, the elements and everything else.”

This story has been updated to reflect that the city provided drinking water at the Fore River encampment.