ROCHESTER, Minn. — With the Minnesota Department of Health having declared an outbreak of Hepatitis A in the state among the homeless, the vulnerabilities for public health of a volunteer-driven care model have come into view.

Nationally, an outbreak of hepatitis A has been identified in the U.S. since 2016, with 23,000 cases and 233 deaths so far. The state formerly added 23 Minnesota cases to that list this week, having identified persons with the illness in nine counties, 13 requiring hospitalization.

A transient illness, Hepatitis A is distinct from Hepatitis C, which is chronic. But the illness can nonetheless live on surfaces, has no drug treatment and can cause severe liver damage in some cases. It is spread by close contact that results in trace amounts of fecal matter coming in contact with a person’s mouth.

Transmission is reduced by hand washing and standard hygiene practices not readily available for persons without access to clean bathrooms, laundry and bathing. Exposure is reduced with the use of gloves and bleach to clean spills and bathrooms, and a vaccination can prevent sickness in those who come into contact with the illness. With the illness now affecting homeless populations, it’s unclear if the volunteers who work on the front lines of the communicable illness are systematically protected.

“I’m not aware of what training or policies are in place [with volunteers who work for the homeless]” says Kristin Sweet PhD, MPH of the Minnesota Department of Health. “As far as mandated or recommended vaccinations, there aren’t recommendations that people working with these populations get the vaccine ... I believe that’s largely because this is a new situation we’re seeing.”

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“While hepatitis A is very contagious, and people can even spread the virus before they feel sick, the risk to staff or volunteers work in environments that serve or are working directly with these individuals is low – especially if they have been vaccinated and use good hygiene practices,” said Kari Etrheim of Olmsted County Public Health in an email.

She concurred that the recommendation for vaccination is informal within Rochester.

“There are no rules or laws governing vaccination of volunteers related to hepatitis A. However all businesses/organizations that have occupational exposure to blood or other potentially infectious materials (OPIMs) observe Universal Precautions to prevent contact with blood or OPIMs ... Training is provided by the establishment with support from Public Health."

Etrheim says the health department has advised area homeless shelters on best practices.

“I do know our disease prevention specialist met with the Dorothy Day House recently to talk about some of these issues. I know that she’s been making the rounds and talking with people about this in particular as regards safety and prevention.”

Celia Wight, a longtime volunteer at the shelter says that the organization may issue an advisory soon.

“I think it’s a great idea to send a note to all of our volunteers to be aware that it might be a good thing to do. I think we've always promoted with our volunteers good health practices, like, with any spillage or body fluids we have a procedure for that. We use bleach as well in all the laundry. A lot of what we do is routine preventive measures.”

It’s unclear how the illness spread along the narrow geography of counties identified, one that stands in stark contrast to the image of homelessness as an urban phenomenon. Except for a single case in in west-central Minnesota, the affected counties in the Minnesota hepatitis A outbreak adhere to a narrow band of exurban and rural counties running from the southeast Twin Cities, due north along the eastern boundary of the state, extending to Saint Louis County on the north shore of Lake Superior.

Sweet believes the proximity of these cases to one another reflects in-state outbreak as well as travelers bringing it into Minnesota from elsewhere.

“That’s just about where people move,” says Sweet. “They might live somewhere, and they go stay with someone else for a while. If people are unstably housed they may be living within a family member's house, then go to a friend’s house, then to some other situation. We’ve also seen a number of people with hepatitis A over the last nine months who have traveled to other places where outbreaks are happening ... There’s not a single source of this outbreak.”

Nor is it clear, health authorities says, if the outbreak is a signal of rising homelessness.

“It’s very hard to say. I’ve heard many people say many different things about what's going on here, and why this is happening right now. I can’t say that I can give you the answer. I think it’s something many people are trying to figure out, but I don't have a good answer to the question.”