In the middle of the COVID-19 pandemic, two cases of a different virus might seem like a blip on the radar of a public health official.

But Spokane Health Officer Dr. Bob Lutz is concerned by the new cases of hepatitis A among the region’s homeless. The viral liver disease that can cause severe symptoms and sometimes death.

Hepatitis A has been a major focus of public health officials since the number of cases began to rise last year. There have now been 90 confirmed cases in Spokane County, and the disease remains stubbornly resistant to the efforts to stamp it out.

The Spokane Regional Health District’s hepatitis A outreach efforts, and its response to the spread of the disease, have had to shift as it pours resources into its battle with the coronavirus.

One man is currently hospitalized with hepatitis A and a woman was released from isolation this week, according to Lutz, who has warned that the virus can spread rapidly through the homeless community.

“Neither of them had been vaccinated, which for us is the big red flag,” Lutz said.

The health district has worked diligently to provide more than 1,000 vaccinations for hepatitis A to homeless people, who represent the overwhelming majority of diagnosed cases locally, and to others.

The efforts have helped stem the spread of the disease. Since peaking at 20 identified cases last October, there were five in February, two in March and two so far this month.

But outreach efforts have been hampered by COVID-19.

“We’ve not been able to do any street outreach, any kind of work with the shelters,” Lutz said. “Our concern is that with all the focus on COVID, we’re going to have people at risk.”

While homelessness is not in and of itself a risk factor, it “amplifies the likelihood” of transmission, Lutz said. The health district’s primary response has been to provide vaccinations and to stress the importance – and availability of – sanitation at local shelters.

The virus is spread when a person ingests it through fecal matter present on a surface, according to the Centers for Disease Control and Prevention. That’s a concern for people who are homeless and often do not have easy access to basic sanitation.

For the unsheltered, the COVID-19 pandemic has made access to sanitation even more difficult, Lutz noted. Park bathrooms are not open, and many businesses have shut down.

King County has seen a recent uptick in hepatitis A cases, leading some local leaders to call for the reopening of public restrooms, the Seattle Times reported last week.

Jewels Helping Hands operates the city’s warming center on Cannon Street and a temporary shelter inside the downtown Spokane Public Library. People regularly using the shelter have been vaccinated, according to Jewels founder Julie Garcia.

The nonprofit is now focusing on outreach three nights a week with Spokane Neighborhood Action Partners, in an effort to connect the unsheltered homeless population with vaccines for hepatitis A or a test for COVID-19 if they are symptomatic.

“We have people who don’t ever access health care and don’t know this (coronavirus) spreads as fast as it does,” Garcia said.

Shelters like Jewels Helping Hands have strengthened their cleaning protocols and implemented stricter safety measures in response to the COVID-19 pandemic, but there are many people who are unsheltered. It was not immediately clear if the two people diagnosed with hepatitis A in Spokane this month were unsheltered or staying in an emergency shelter, Lutz said.

Based on the incubation period of the disease, Lutz is concerned that it has already been spreading through the community. Many may experience only mild symptoms and chalk it up to the stomach flu.

“This has just sort of been under the ground and behind the scenes,” he said. “This outbreak is not over, and we have to be on top of it.”