By Dean L. Winslow, MD, FACP, FIDSA

Professor of Medicine, Division of General Medical Disciplines, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine

Dr. Winslow reports no financial relationships relevant to this field of study.

SYNOPSIS: During 2017, a large outbreak of hepatitis A was identified in California. The majority of patients were homeless. Addressing the problem of homelessness should be a priority for our country.

SOURCE: Kushel M. Hepatitis A outbreak in California — addressing the root cause. N Engl J Med 2017 Dec. 6. doi: 10.1056/NEJMp1714134. [Epub ahead of print.]

In 2017, at least 649 people in California were infected with hepatitis A, 417 were hospitalized, and 21 died. This is the largest outbreak of hepatitis A in the United States in the past 20 years.1 The vast majority of those affected have been homeless. Almost all of these patients were unsheltered.


This large outbreak of hepatitis A mainly is focused in homeless patients in San Diego and highlights the physical threats associated with homelessness, which sadly affects a growing proportion of Americans. The cited article discusses the problems of crowding, lack of sanitation, and lack of a safe food supply associated with individuals living in homeless encampments and shelters. These factors facilitate the initiation and perpetuation of infectious diseases such as hepatitis A.

While we commonly think of antimicrobial agents as being responsible for much of the success we have achieved in the battle against infectious diseases during the 20th and 21st centuries, the fact is that much of our progress occurred many decades before these therapies were available. In Europe, the British Isles, and North America, it was well-recognized by the middle of the 19th century that crowded living conditions, lack of access to clean food and water, poor hygiene, and lack of shelter contributed greatly to infectious disease transmission and prevalence. Accordingly, as deliberate improvements in public health came about, the prevalence of these diseases fell dramatically.

I had the good fortune of spending this past fall quarter teaching in Oxford, England. While I did see a few homeless people in the United Kingdom, homelessness does not exist there on the magnitude that it does in the United States. I honestly believe that the reason we have such a problem of homelessness in the United States is because of both a lack of will and lack of compassion on the part of both our politicians and much of our country.

Data do not support the misconception that homeless people are lazy. It is ironic that the President was criticized roundly recently for his comments about immigrants from Africa, Haiti, and El Salvador while he welcomed immigrants from Norway. In actuality, countries like those in Scandinavia and the Netherlands have largely solved the problem of homelessness by providing housing, universal healthcare (including mental healthcare), and free education to their population. In addition, these countries have no gun violence. Somehow, I don’t believe the United States will be inundated anytime soon by immigrants from Norway. We really can and should do better in the United States to care for our most vulnerable.


  1. California Department of Public Health. Hepatitis A outbreak in California: CDPH Weekly Update as of Nov. 10, 2017. Available at: Accessed Jan. 15, 2017.