The county of San Diego has now officially declared a public health emergency over its ongoing hepatitis A virus (HAV) outbreak, as the city’s death toll and hospitalization rate continues to climb, The Mercury News reports.

On September 1, San Diego’s director of public health services, Wilma Wooten, MD, initiated the state of emergency declaration, which would allow the county’s health and human services agency to request state assistance if necessary to help quell the outbreak. The San Diego Board of Supervisors has now ratified her decision.

According to the latest health department records, which were reported late last night by CNN, 16 people have now died as a result of the city’s hepatitis A outbreak. An additional 421 people have been sickened, and 292 of those individuals have been hospitalized. San Diego health officials say 65 percent of cases so far have been among people who are homeless or use drugs, and that the crisis appears to be intensifying among this population.

Meanwhile, San Diego’s homeless population is also growing: It increased by 5 percent countywide over the last year and by 27 percent in the city’s downtown district. Homeless advocates say more people are living on the street and fewer in shelters than last year — a worrisome trend in the midst of a viral outbreak that is largely spread through sharing unsanitary food, water, drugs and even everyday objects.

The city has taken several key steps in recent months toward ending the crisis, including doling out free hepatitis A vaccines at local homeless outreach centers, public libraries and other service programs since June. So far, the city reports, 21,000 people have been vaccinated during these outreach efforts. The city of San Diego also recently hired a sanitation company to periodically bleach the streets to help cut back on potential exposures.

After public outcry from locals this past summer, the city also says it is considering installing mobile showers and handwashing units in public areas for the at-risk homeless population and is working to find a way to help homeless people wash their clothes during the crisis. Flyers and pamphlets have also been distributed throughout San Diego to help raise awareness.