For the past five weeks, Toronto night nurse Keren Elumir has been handing out clean underwear and electrolyte packets at a safe consumption and overdose prevention site in Moss Park.
She’s been seeing more and more people with the telltale signs of a Shigella infection, also known as shigellosis: diarrhea, stomach cramps and fever.
Toronto has an outbreak of 11 confirmed cases, all among homeless people, who don’t always have reliable access to facilities like washrooms.
“You’ll hear people yelling, ‘I gotta go, I gotta go,'” she said. “So we’re trying to make space so people can access the washroom.”
The bacterial infection, one of the main causes of dysentery, spreads easily from person to person through an infected person’s stool. It takes as few as 10 bacteria units on contaminated surfaces, or in food or water, to get someone sick. The bacteria also remains contagious for weeks after episodes of intense diarrhea.
The spread is preventable through simple hygiene and sanitation measures. But it’s impacting some of the most vulnerable in Canadian cities — and becoming increasingly resistant to antibiotics.
‘Impossible’ to catch all cases
Elumir believes total cases are undercounted in Toronto.
“It’s almost impossible to catch all of it,” she said. “People are embarrassed. They don’t necessarily want to talk about it.”
It’s a suspicion Dr. Shovita Padhi at Toronto Public Health shares.
“Most people will resolve the infection on their own. So we’re really only capturing those who are seeking medical attention, going to the hospital to get tested.”
Preventive methods, like washing hands and taking showers regularly, are challenges for homeless people, the main group affected by the outbreak. Many have a hard time even accessing a washroom, says Elumir.
“You have to pay often to have access to a washroom, and not everybody has money.”
A shower, a toilet and a change of clothes
Toronto is not the only city that’s seeing a Shigella outbreak. In Edmonton, there have been on and off outbreaks since September 2022. Alberta Health Services says it has identified 447 people with Shigella since August 2022 — 309 of whom were hospitalized.
Edmonton public health officials were able to get case numbers down by helping people find a place to shower, use the washroom, do their laundry and get a change of clothes.
“When clients are coming in, especially if they have Shigella, it’s one thing to go to the bathroom. But if you’re still soiled, if you’ve still got that on you, you could get yourself sick or others sick,” says Elizabeth Klingenberg, health services manager at the Hope Mission shelter in Edmonton.
Some public health authorities even did outreach — carrying oral antibiotics to tents, in an effort to help curb the spread and treat the infected. Despite all the effort, Alberta Public Health says there’s still an ongoing outbreak among the inner-city population.
“As soon as you get somebody to the right place, four more would pop up,” Klingenberg said.
Changing populations
In Vancouver, homeless people weren’t always the most vulnerable to Shigella infection. Before 2020, the population most at risk used to be men who have sex with men, says Dr. Aleksandra Stefanovic, a clinical professor at the University of British Columbia and a lead author of a study looking into Shigella infections in the city between 2015 and 2022.
It’s difficult to say exactly how the infections moved from primarily within one population to another, but several factors — the geographical proximity between the two communities, and population overlap — suggest local spread, say the authors of the study.
What’s clearer is that once the infection spread among people who are homeless, it became more severe, too, manifesting in hospitalizations or even death.
“People who experience homelessness often have associated substance use disorders and could suffer from malnutrition,” she said. “And malnutrition itself can lead to dampening of immune response and potentially increase in severity of infection.”
Dr. Rohit Vijh, a medical health officer at Vancouver Coastal Health and one of the authors of the study, says the infection can spread like wildfire among people who don’t have access to toilets, sinks, or showers.
“Shigella, at least within our population that’s experiencing homelessness, is truly a communicable disease of poverty. It’s a disease of poor sanitation and limited to no access to hygiene,” Vijh said.
And over the past few years, Shigella infections have spiked whenever it gets colder outside or rains heavily, as people tend to then congregate indoors, he said.
“As soon as one person gets it, if we don’t have the appropriate sort of measures to disinfect, to have people properly wash their hands, it can spread quite rapidly.”
Treatment difficulties
What’s worse, the stomach bug is getting harder to treat.
For most of the cases in Toronto and Vancouver, no oral antibiotic therapies work. More severe cases require IV antibiotic treatment — meaning more people having to go to the already strained emergency department or hospital, said Vijh.
Strains of the bacteria that are even more resistant to antibiotics are being spotted elsewhere, too, like in Europe, Australia and the United States, says Stefanovic. Some have also even been detected in Canada.
“There’s been cases of it in Seattle, and we occasionally see cases in Vancouver, but luckily, it’s not well established,” said Stefanovic.
The best way to prepare against that type spreading widely in Canadian cities is through prevention, not just treating outbreaks, say public health experts like Vijh.
“Shigella is a very complex problem that requires a variety of different partners to come together.”
The main way to curb the spread? Giving homeless people access to hygiene and sanitation services, Vijh says — like public washrooms and washing sinks.