The Board of Supervisors today unanimously ratified a declaration of a public health emergency in San Diego County related to an outbreak of hepatitis A that has sickened nearly 400 people, 15 fatally.

The emergency was declared by the county's public health officer, Dr. Wilma Wooten, on Friday to gain further public awareness of the problem.

In a presentation to the supervisors, Wooten said about two-thirds of the cases have been among people who were homeless and/or illicit drug users. Laboratory testing traced the first cases to last November, and county health officials recognized the outbreak in March, she said.

Since then, around 19,000 hepatitis A vaccinations have been given, including more than 7,300 provided to people considered to be at-risk of contracting the disease, which attacks the liver, according to Wooten.

Vaccinations for hepatitis A are a two-shot regimen, separated by six months, so it will be a challenge to locate members of the at-risk groups to give them their second inoculations, she said.

Supervisor Greg Cox said the outbreak is just a symptom of the much larger issue of homelessness, which has worsened considerably in San Diego County in the last few years.

``By taking this action today, we will hopefully be in a position to work with the city of San Diego and other 17 cities to make sure that they're taking the steps that they need to take, that we will be taking the steps we need to take in the unincorporated area, to try to make sure that we provide clean and sanitary facilities for people to wash their hands,'' Cox said.

``It just kind of re-emphasizes the fact that we need to do a better job as a region -- and I include the county and all 18 cities -- in dealing with the homelessness crisis that we have,'' Cox said.

Over the weekend, the county installed 40 hand-washing stations around San Diego, including in downtown, Balboa Park and near the San Diego River. City officials are putting together a sanitation plan for streets and sidewalks in areas where the homeless congregate.

San Diego City Councilman David Alvarez urged the supervisors to help open public facilities, and especially restrooms, to the homeless.

Alvarez, who plans to run for supervisor in 2020, criticized city officials for a lack of urgency on the hepatitis A matter.

Wooten said health officials were talking with counterparts in El Cajon and planned to meet with officials in other localities where a significant number of people have been sickened with the disease -- Escondido, National City and Vista.

Additionally, information about sanitation procedures have been sent to food facilities, and fitness and recreation centers that have public pools. She said the disease spreads through contact with microscopic amounts of fecal matter and by sexual contact.

The county has also distributed 2,400 hygiene kits, she said.County health officials said the number of those sickened by the outbreak is likely to grow because the disease has a long incubation period. Another 44 cases -- including an August death -- are suspected of being hepatitis A, but haven't been confirmed by laboratory testing.

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