In recent months, hepatitis A, Shigella bacteria, and typhus outbreaks have all been reported in cities across the country.
Yes, you read all of that correctly. Recent cases of these rare conditions have been cropping up in particularly vulnerable communities in large urban areas.
These diseases have especially been on the rise in homeless communities, where lack of medical care and unhygienic conditions have served as a breeding ground for so-called “medieval” diseases — diseases that typically don’t pose a threat to the general American population in the 21st century.
“We clearly are not in medieval times, but hepatitis A has reared its head, shigellosis [caused by Shigella] has appeared and, occasionally, even typhus, which is a disease that, let’s say, 98.3 percent of physicians in United States read about in medical school, then have completely forgotten because they’ve never seen it,” said Dr. William Schaffner, an infectious disease specialist at the Vanderbilt University School of Medicine.
Schaffner told Healthline that the rise of these usually rare conditions leave people who are homeless — or live in unhealthy conditions that are rife with flea-bearing rats, for instance — especially at risk.
Essentially, the appearance of these conditions highlights public health crises that stem from social inequities that leave certain communities more prone to disease.
“The homeless, for instance, is a population that has whole series of underlying illnesses that make them particularly susceptible. You have higher rates of substance abuse, drugs, and alcohol, often some kinds of mental disturbance, anxiety depression, et cetera, that are underlying illnesses from a previous hard life,” Schaffner explained. “So, all those things combined make this a susceptible population, especially putting them in close contact with human feces often in close proximity to each other, and occasionally around animals such as the rats.”
In October, the Los Angeles County Department of Public Health announced that it was investigating an outbreak of typhus in downtown Los Angeles.
Flea-borne typhus, which is what has been proliferating throughout the city, is caused by bacteria spread by fleas, and is usually found in tropical areas.
In the United States, the condition is rare, with most instances taking place in California, Texas, and Hawaii, averaging about 300 cases per year, according to the California Department of Public Health.
You can get the disease by coming in contact with infected fleas that initially contract the condition themselves by biting animals like rats.
“Although typhus normally occurs throughout LA County, we are observing several cases in the downtown Los Angeles area,” said Dr. Muntu Davis, MPH, Los Angeles County health officer, in the initial Los Angeles Department of Public Health release. “We encourage pet owners to practice safe flea control and encourage all cities in the county to ensure maintenance of their trash clean-up and rodent control activities.”
Since October, the problem has only continued to persist, with city officials considering ripping out flea-infested carpets in Los Angeles City Hall, according to ABC7.
So, is it a big deal?
The answer is a decided “yes.” Typhus can be severe. It causes fever and chills, body aches, and a rash, among other symptoms, but cases can be more severe as well.
If left untreated, it could lead to serious damage of the brain, heart, lungs, kidneys, and liver, according to the Centers for Disease Control and Prevention (CDC).
And it’s not the only old disease on the block.
Shigella bacteria, which causes diarrhea, fever, and stomach cramps, according to the CDC, has been sweeping through the homeless population in Seattle in recent years.
Last February, the Department of Public Health for Seattle and King County released a warning about outbreaks of the bacteria among the homeless population.
They announced that Shigella cases have been increasing in King County, Washington, since 2013, with a total of 164 cases in 2017 alone.
Compare that to the average of 89 per year over the previous five years, and you can see how stark the increase has been.
In Seattle and the surrounding county, men who have sex with men and men who are HIV-positive were reported to be at the highest risk, followed by international travelers.
Until recently, outbreaks in the homeless communities weren’t as common.
“The fact that we’re seeing multiple, different infections now increasing in the homeless population is an indicator of the sheer increase in the number of homeless people (in King County) and the fact that they’re in crowded conditions with poor hygiene and sanitation,” Dr. Jeff Duchin, health officer for the department, said in a statement reported by the Seattle Times.
Beyond this, the CDC said that it’s currently assisting 18 states in addressing hepatitis A outbreaks in people who experience homelessness as well as people who use injectable and non-injectable drugs.
Many of these conditions flourished in past centuries when cities had less stringent sanitation guidelines, where human feces, close quarters, and contaminated water and food made for the ideal conditions for these kinds of bacteria and infections to thrive.
Dr. Mark Mulligan, the director of the division of infectious diseases and immunology at NYU Langone Health, told Healthline that targeting the homeless community with necessary treatments, in particular, is key to combatting the spread of these conditions.
Mulligan said that the CDC recently recommended that all people who experience homelessness should be offered vaccination for hepatitis A.
He pointed out that such diseases “flourished in the pre-sanitation era, the pre-vaccination era when we didn’t have clean water.”
“For a wealthy country like ours to have these things happen is a symptom of people who aren’t able to share in the health benefits provided by society. It really touches on inequalities that come from mental illness, from addiction, from poverty,” he explained.
However, Mulligan said that distributing the necessary treatment to these populations is a challenge.
For one, many who experience homelessness are mobile — living in one place one night and elsewhere the next. This can create additional challenges to make sure someone who might be treated receives the proper follow-up care.
Mulligan said that health departments and nonprofits that engage with these communities are always trying to find new technologies and ways to best treat these diseases.
In his State of the State address in February, California Gov. Gavin Newsom highlighted the need to address these outbreaks, saying “our homeless crisis has increasingly become a public health crisis.”
Mulligan said he saw this kind of public acknowledgment as a positive step in the right direction.
“Just the fact that the governor of California is making a statement like he made, well, I think he was saying basically we have to do better. So if there is political will and resources behind that, then there must be ways we can do better,” he said.
Schaffner said there’s “no simple answer” for ways to quell hepatitis outbreaks in homeless communities, for instance.
In addition to the geographic difficulties posed by treating people who are on the move, Schaffner said oftentimes people’s “aversion to any kind of external supervision by any kind of governmental agency” can stand as a major challenge.
He said that in order to make greater strides in these outreach activities, many health departments have joined with partners like hospitals and social service organizations.
“One of the critical things is to get housing for the homeless. Housing that is safe, clean housing with water and soap and a bed is absolutely key to providing a whole array of social services as well as health services,” Schaffner said.
He cited his own city of Nashville as one that’s made efforts to provide better housing for homeless communities.
He said that New York City, unlike places like San Diego that experienced hepatitis A outbreaks, “does a better job than most” in providing shelters for people to spend the night.
“This gives access to some food, to a place to sleep, which stabilizes critical aspects of their lives and reduces death due to environmental exposure, particularly in the winter,” Schaffner added.
Mulligan said that right now he’s troubled by rhetoric that deemphasizes the benefit of vaccination, science, and proper medical care.
He pointed to the recent outbreaks of an easily preventable disease like the measles as a direct result of questioning science as an instrument to create a healthier society.
“We have more measles right now than we’ve had in 40 years in the U.S. for a different reason and in that case it’s because parents who are unsure about vaccinating their children and who are being fed myths about safety of vaccines,” Mulligan added.
For Mulligan, a society that doesn’t embrace all the tools available to it to stop the proliferation of disease epidemics is one that isn’t serving its citizens to the best of its ability.
While measles don’t necessarily fall under this category of ancient diseases, they represent what happens when those societal tools to spur public health improvements aren’t embraced.
Schaffner said that it’s about bringing people the dignity of proper shelter and safety.
“In a graphic way, giving shelter and protection to people who are in homeless communities, for instance, separates human beings from feces and trash,” Schaffner said. “Having access to something as simple as toilets that flush feces away and don’t expose you and others to fecal material, having the opportunity to wash hands and take an occasional shower — all those things help.”
He added, “We forget that access to something as simple as clean water reduces what in public health we call water-washed diseases, which involve a lot of skin infections, for example.”
Mulligan stressed that a lot of these rare diseases like typhus are seen around the world in places where people are “displaced, homeless, refugees” and are exposed to the lack of resources, shelter, food, and clothing.
He said that in a wealthy country like the United States, there’s really no excuse for these types of conditions to be so relatively common.
Mulligan said to best address this health crisis, we need to do a better job providing healthcare and services for the most vulnerable people in our society.