Two public health workers, armed with a satchel full of syringes, found their first patient just steps outside the Stout Street Health Clinic’s front door.

Matt Wilmes explained their mission to David Mai: The city has seen the first signs of an outbreak of hepatitis A and is offering free vaccinations against the virus. Mai nodded his agreement, and, after his records were checked on a tablet, he rolled up his shirt so public health nurse Maggie McClean could prick his exposed flesh.

“It doesn’t hurt, and I don’t want to get sick,” said Mai, 66.

It’s part of a massive campaign in Denver that has vaccinated about 3,500 people over the last 18 months in preparation for a long-feared outbreak of hepatitis A. It’s a virus that spreads through squalor, a disease that has left homeless people frightened and struggling to protect their hygiene.

Hepatitis A, an infection of the liver, has swept through homeless shelters and street encampments in other U.S. cities since 2017, sickening about 22,000 people and killing 216 — especially people who are vulnerable because of substance abuse and poor health care. Outbreaks have appeared across the West, including a cluster in Colorado’s El Paso County this year.

Now, there are strong signs that the outbreak has reached Denver, home to some of the state’s largest shelters and camps. With five cases reported now, local health authorities are ramping up a vaccination effort like Denver has never seen before. The massive response may forestall the kind of crisis that racked San Diego and other cities — but it’s a troubling new side effect of Denver’s housing crisis.

And it raises questions, some advocates say, about the lack of public restrooms and basic sanitation for many people living on the streets.

“We should be doing everything we can to make their lives survivable, making sure that they have services, so that they’re not forced to go days without proper sanitation or days without access to proper restrooms,” said Cathy Alderman, vice president of communications with Colorado Coalition for the Homeless.

How the disease works

Hepatitis A is not an exotic disease, and medical experts say there’s no need for panic. Occasional cases are linked to contaminated food and travel abroad. It is preventable by vaccine, and most children have been vaccinated since the early 2000s.

Most adults, however, are not protected, and people experiencing homelessness are especially vulnerable. Denver’s health authorities, seeing the disease spread through other cities, began offering vaccines at small sessions in the fall of 2017.

When a case was diagnosed here last month, followed by a cluster of three in mid-July, Denver Public Health and its partners sharply accelerated the effort. Now, they’re aiming to give out 700 vaccines per month, including by offering them to jail inmates.

Modern U.S. cities have rarely seen public health campaigns on this scale, said Dr. Seth Foldy, director of epidemiology, informatics and preparedness at Denver Public Health.

“I think the last time we worked on this scale in most American cities would have been measles outbreaks that occurred in the mid- to late 1980s,” he said. And the massive effort in San Diego, he said, is “probably unprecedented.”

El Paso County has been the heart of Colorado’s outbreak, with 80 reported cases out of a statewide total of 101. Ninety percent of the cases there were associated with drug use and 70 percent with homelessness, according to Kimberly Pattison, program manager for communicable disease at El Paso County Public Health.

“It’s an acute illness. It doesn’t become chronic — but it can still cause a long period of hospitalization, and your length of illness can be anywhere from several weeks to several months,” Pattison said. “For people who already have liver damage, you have a higher risk of damaging the liver.”

In metro Denver, there are likely more than 5,000 people living without steady housing. The vaccination campaign is largely focused on people experiencing homelessness and people with drug addictions. The hope is that giving enough vaccinations — Foldy wouldn’t give an exact number — will create “herd immunity,” limiting the disease’s spread.

A single vaccination is 95 percent effective and may grant immunity for several years. People who receive a second shot, usually six months later, typically become immune for life.

“We hope that our past vaccination efforts have been enough to put a wet blanket on the community, so every new case doesn’t immediately generate other cases. But we believe we still have much vaccination ahead,” Foldy said.

The bigger problem

Even so, the vaccines will only close the door to one disease. The larger problem is just how difficult it is for people living outside and in shelters to maintain their hygiene.

“I use those wipes on my hands all the time now — I don’t know how good they are, but I want to wipe my hands down,” said Robert Hucal, 64, who first became homeless two years ago. His retirement savings from a custodian career fell short, and he’s unable to continue his physical labor, he said.

“It seems like lately, everyone’s been sick. They’ll get a cough. They seem like they’ll be sneezing,” he said.

When he uses the restroom at the Crossroads shelter, he will find feces on the toilet — a sign of the constant struggle to keep a busy facility clean. The shelter’s crews sanitize its mats, floors, showers, bathrooms and more each day, and it’s hosting hepatitis vaccination clinics.

People living outside are especially vulnerable, because they often are cooking and eating near where they use the bathroom. The problem, Hucal said, is both that people don’t have the supplies they need to stay clean and that many are struggling with mental illness.

To some advocates, it’s a clear sign that the city needs more public restrooms and hand-washing stations.

Denver, a city of 700,000 people, counts only seven permanent public restrooms, three of which are behind security checkpoints in public buildings. The city also has two mobile restrooms that have circulated the city since 2016. Denver has spent $1.1 million to operate them, in part because they are staffed.

Alderman, of CCH, said the city needs to move quickly to get more, better shelters opened — not just mats on floors — while also opening restrooms and hand-washing stations, as the city of San Diego has done. Soap-and-water hand washing also can contain the disease’s spread more so than alcohol-based cleansing gels.

“It’s degrading,” said Joshua Rampp, 42, just after getting his second-round vaccination. “It somewhat feels like you’re less of a human being. You want to get a job, be a productive human being, and you can’t even wash your hands.”

City shelters have restrooms and hand-washing facilities but the city will look to add more, Ann Cecchine-Williams, deputy executive director of the Denver Department of Public Health & Environment, wrote in an email. The immediate priority, she said, is the vaccine campaign, which also is focused on people who travel abroad and men who have sex with men.

On the streets of Denver this week, the vaccination effort had mixed success. Some people lined up eagerly, but others — especially younger people — were far more skeptical.

Dustin Fitzpatrick, 28, refused the vaccine. “I’m a naturalist. I don’t like any kind of chemicals in my body,” he said, sitting in his tent alongside 21st Street.

Along the South Platte River, Robert Hucal said he originally didn’t want the shot. But after hearing warnings and seeing signs at the Crossroads shelter, he was ready.

“Where are they tomorrow?” he asked. “I’ll go.”

About hepatitis A

Hepatitis A is a contagious infection that affects the liver’s ability to function. Symptoms can include fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, clay-colored bowel movements, joint pain and yellow skin and/or eyes, according to Denver Public Health. Some people, especially young children, have no symptoms. A list of upcoming free vaccination clinics can be found on the department’s website, www.denverpublichealth.org.