Access to safe and clean bathrooms is important for several reasons, one of which is disease prevention. Lack of access to safe and clean bathrooms is a major reason the hepatitis A outbreak in California has been quick to spread and hard to halt.

Hepatitis A is a liver disease transmitted through ingestion of contaminated food and water or through direct contact with an infectious person, according to the WHO. The risk of hepatitis A is strongly associated with lack of safe water, and poor sanitation and hygiene.  Although California’s hepatitis A outbreak has been linked to the transient homeless population, according to the WHO the virus is also “one of the most frequent causes of foodborne infection.” So nothing is safe, as usual.

As of November 10, San Diego had reported 546 cases of the disease and 20 deaths. There are signs the outbreak is slowing and efforts to vaccinate the homeless population against hepatitis A are proving effective. According to The San Diego Tribune:

Last week…local health providers forwarded only eight possible hepatitis A cases to the health department for further investigation. There have been no new deaths, leaving the outbreak total at 20 for the second straight week.

It’s the lowest weekly new case total since the outbreak began, eventually launching a vast, multmilllion-dollar campaign to improve sanitation and housing conditions for the homeless.

What could still go wrong? The physician noted that the outbreak could still jump into another demographic population such as gay men who are considered at an elevated risk of hepatitis A infection. Because the virus’s incubation period can last up to 50 days, there is still a chance, he added, that an infected person could have exposed a large number of people who simply have not started to show symptoms yet.

In addition to the homeless and drug users, high-risk groups are those with compromised immune systems, existing liver disease and gay men. Public-facing job classifications also recommended for vaccination include food handlers, first responders and health care workers.

Another article in The San Diego Tribune notes that the city built a 2 million dollar restroom in 2014, “designed by an artist to invoke “Jonathan Livingston Seagull,” the popular 1970 novella about a seagull who wanted to be special.” While the restroom building looks pretty, many point out that the money could have been better spent on more restrooms to serve the city’s large homeless population, potentially avoiding such a massive outbreak. According to the article:

The city was warned repeatedly as far back as 2000 that human waste on city streets was a problem that threatened public health, and that there was a shortage of 24-hour public restrooms available to the city’s growing homeless population downtown.

In 2005, city officials shot down a grand jury recommendation calling for more toilets to address the shortage. City officials said the facilities could cost up to $250,000 each to buy and install, plus another $65,000 per year to maintain, and the city did not have “the resources to execute a project of this magnitude.”

Based on those cost estimates, the $2 million spent on the seagull-themed restroom could have paid for four such facilities and operated them for 16 years.