After mounting pressure in recent months from local government officials, advocacy groups and a state agency, the county health department is now looking into reports of increased gastrointestinal illness at a South Bay urgent care clinic, Dr. Wilma Wooten, the region’s public health director, confirmed last week.
Dr. Kimberly Dickson, who runs South Bay Urgent Care in San Diego with her husband, Dr. Matt Dickson, said the clinic has noticed an uptick in gastrointestinal illness and diarrhea that appear to coincide when heavy rain pushes raw sewage across the border from Tijuana.
“We are concerned about the number of positive tests showing organisms such as E.coli, salmonella, shigella, campylobacter and norovirus,” Kimberly Dickson said.
Water and air pollution have worsened in recent years because of an inoperable wastewater plant in Baja California, a pipeline rupture, deferred maintenance and severe rainstorms. Tijuana and San Diego County’s southwest region are bearing the health and economic costs.
Testing performed from Oct. 16 through Jan. 27 by the Dicksons shows the presence of nine different pathogens among 28 of 54 patients whose results came back positive. Escherichia coli bacteria was the most commonly detected cause of gastrointestinal symptoms such as diarrhea, with 11 showing the presence of norovirus and two salmonella.
The Dicksons’ data, which is not part of a formal academic study, has been a key component driving the push for a formal investigation by the county. After they presented their findings before the California Coastal Commission in October, board members agreed the following month to ask the county to initiate an investigation. After some back and forth, the state agency learned last week of the county’s involvement.
The doctors’ data has also reached the White House. Late last month, state Coastal Commissioner and Imperial Beach Mayor Paloma Aguirre and a South County delegation she led shared the clinic’s observations with multiple White House staffers and Congress members to raise awareness about the effects of cross-border pollution and stress the need for $310 million in supplemental funding to fix and expand an international wastewater treatment plant in San Ysidro that continuously takes more sewage from Tijuana than it was designed to handle.
Wooten said in an interview last week that she dispatched members of her staff to the clinic to examine documentation of the cases that the clinic is referencing. Looking at medical billing codes, she said, did show that the clinic’s incidence of gastrointestinal illness was “higher than when we looked at two other clinics in the area.”
Overall, the director said that observations at South Bay Urgent Care do not seem to reflect the overall picture of illness in the larger community.
“We just have not seen any infectious diseases that are higher than what they normally would be expected to be, whether that’s through syndromic surveillance in the (emergency departments) or through the individual case reports that come directly to our epidemiology program,” Wooten said.
A request for more information from Imperial Beach Community Clinic, which operates the two locations the county checked, was not returned this week. Scripps Health and Sharp Health, which operate hospitals in South County, said they did not see a spike in gastrointestinal illnesses by test positivity or chief complaint over the last few weeks when compared to prior months.
Public health personnel made it clear that the department’s involvement at South Bay Urgent Care is not a formal epidemiological investigation. As per CDC recommendations, such investigations are triggered by observed cases or symptoms occurring at a rate that is above normal baselines.
While the local public health action at the clinic goes further than is usually the case without a firm signal in broader epidemiological data, Wooten said that the public’s interest in the issue has drawn her attention, especially as media coverage has broadened.
Saying she is “sensitive to the fact that … no one should be living in conditions like that,” the director said members of her staff would be present at the clinic for two weeks to help its staff dig deeper into the symptoms that are appearing.
“It’s looking at the diagnoses that have been made and asking additional questions to try to get to the crux of the problem,” Wooten said.
Asked to comment on the fact that the county’s examination of other nearby clinics does not seem to show increases in gastrointestinal symptoms or positive test results, Dickson said that while she could not speak to the experiences of other clinics, there are reasons why her location’s experiences may differ.
“Our clinic is structured to see the large volume of local patients on a walk-in basis for acute illness,” Dickson said. “This may be why we are capturing many of the patients with acute GI illness as compared to other clinics.”
Most of what the Dicksons have detected among their patients would not be reported to their local public health department. That’s because state and federal laws only mandate the reporting of infections and other conditions considered to be serious public health concerns.
From anthrax to Zika virus, California mandates reporting of nearly 90 infectious diseases and other conditions, but that list leaves out quite a bit. For example, infections caused by shiga toxin-producing Escherichia coli bacteria must be reported but other strains of that same pathogen, including six that are known to cause illness in humans, are not considered severe enough threats to require doctors and labs to send public health notices.
On Wednesday, San Diego County public health said that only four of the infections reported from South Bay Urgent care met reporting criteria. The remainder are considered “self limiting,” meaning they cause disease that goes away without medical treatment.
The Dicksons acknowledge that many of the infections they’ve been detecting through testing at their clinic are not technically on the list of pathogens that the government considers to be so serious that reporting is required. But that does not mean, they add, that they are of no consequence.
E.coli infections, Matt Dickson noted, can be extremely disruptive even if they aren’t of the most deadly strain.
“These other ones, they can cause two weeks of very uncomfortable abdominal pain and diarrhea,” he said. “I mean, these are people who are sick for weeks on end.”
Eileen Barnes is all too familiar with that pain. She and her daughter run the small, family-owned horseback riding business, Surfside Ranch, on Hollister Street in the Tijuana River Valley. As many others did on Jan. 22, they found themselves evacuating during the record-setting storm.
Barnes and her daughter were relocating a couple of horses on horseback to dry ground amid the heavy downpour when they fell into a sinkhole.
“It is really dirty water and it was up to my neck,” she said, adding that both began feeling sick and presenting symptoms like nausea and vomiting. One of their horse’s legs became swollen after being exposed to the flood waters. Barnes said an East County veterinarian diagnosed it with cellulitis, a bacterial infection that forms under the skin.
The Jan. 22 storm brought the highest flow of sewage-tainted water in the Tijuana River since 1993, with peaks over 14 billion gallons, according to the International Boundary and Water Commission. Millions of gallons more have since flowed over following last week’s storm.
Like many who live and work in the Tijuana River Valley, Barnes knows to avoid contact with stormwater discharged by the Tijuana River because it carries raw sewage from Mexico. But the more frequent flooding is increasing the risk for South County residents and workers who are being forced to wade into contaminated waters.
Matt Dickson said there is value in testing for and tracking the broader spectrum of infections that occur when rain pushes polluted waterways into residential neighborhoods because doing so, he argued, shows the full scope of human misery caused by failing to address pollution that is present every day of the year.
“We’re trying to show that there’s an outbreak here,” he said.
Wooten said she agrees that a deeper understanding of the infection situation reported by South Bay Urgent Care is worthwhile even if it is not necessarily setting off the typical public health alarms.
“I totally sympathize with the physicians and with the patients that they’re seeing, and the people in general that live in that community,” Wooten said.
