Shigella, a disease typically linked to poor sanitation in developing countries, is now thriving in the heart of Vancouver. A recent study on multidrug-resistant infections reveals not only a pressing health crisis but also the systemic inequities fueling its spread. For the city’s Downtown Eastside, this outbreak is a stark reminder of the intersection of poverty, marginalization, and public health.
A Global Disease Takes Root in Vancouver
Shigella is a bacterial infection that spreads through fecal-oral transmission, requiring only ten organisms to cause infection. Symptoms include diarrhea, fever, and abdominal pain, with severe cases progressing to bloodstream infections and sepsis. It is most commonly associated with developing nations, where inadequate sanitation and access to clean water facilitate its spread.
However, a recent study published in Clinical Infectious Diseases highlights a sharp increase in multidrug-resistant infections (MDR) Shigella infections in Vancouver between 2015 and 2022. Initially concentrated among men who have sex with men, these infections have shifted predominantly to people experiencing homelessness. Of the 163 cases reviewed, 77% in recent years occurred among unhoused individuals—a population for whom access to hygiene and medical care is already limited.
The rise of MDR Shigella in Vancouver is not merely a medical anomaly; it’s a reflection of the social determinants of health. Overcrowding, lack of sanitation, and unstable housing conditions have allowed this disease to flourish, turning a global health issue into a local crisis in development.
A Breeding Ground for Outbreaks
The Downtown Eastside (DTES) has long been a focal point for public health emergencies in Vancouver. Known for its high rates of homelessness, addiction, and poverty, the neighbourhood provides a snapshot of systemic inequities that exacerbate health risks. Shared bathrooms in single-room occupancy hotels (SROs), limited public restrooms, and scarce hygiene facilities create conditions where diseases like Shigella thrive.
The current outbreak is not the first time the DTES has faced Shigella. In 2021, the neighbourhood experienced an outbreak of MDR Shigella flexneri, resistant to all first-line treatments except azithromycin. By 2022, MDR Shigella sonnei replaced S. flexneri as the dominant strain, with infections showing higher hospitalization rates and severe outcomes.
Public health measures during the COVID-19 pandemic had briefly mitigated outbreaks, with no recorded cases of S. sonnei in 2020. Temporary initiatives like expanded hygiene stations and portable restrooms played a key role in limiting the spread. However, these measures were rolled back as pandemic restrictions eased, leaving the neighbourhood vulnerable once again.
Dr. Victor Leung, medical director for Infection Prevention and Control at St. Paul’s Hospital, sees the outbreak as a consequence of systemic neglect. “You expect to see dysentery in places in the world that are underdeveloped. It’s less common in developed countries except in crowded places with poor living conditions,” Leung said. His words highlight how the DTES, despite its urban setting, mirrors conditions found in areas of severe deprivation.
A Rising Threat of Antimicrobial Resistance
The spread of multidrug-resistant Shigella in Vancouver is part of a larger global issue: antimicrobial resistance (AMR). Among the 163 cases studied, over 60% were resistant to first-line antibiotics, including fluoroquinolones and azithromycin. This resistance not only complicates treatment but also increases the risk of severe outcomes.
For unhoused individuals in the DTES, the barriers to timely medical care exacerbate these risks. Many avoid healthcare services due to stigma, fear of judgment, or logistical challenges, allowing the infection to worsen and spread. This delay also contributes to the overuse and misuse of antibiotics, further fueling AMR.
The impact of AMR extends beyond the DTES. Treating resistant infections requires longer hospital stays, more expensive medications, and isolation measures, all of which strain healthcare resources. For public health officials, containing this outbreak is not just about addressing the immediate crisis but also mitigating the long-term consequences of AMR.
A Crisis Rooted in Systemic Inequities
The Shigella outbreak in the DTES is not simply a public health issue—it is a symptom of deeper systemic failures. The most effective prevention method for Shigella is regular handwashing with soap and water, yet this basic practice is unattainable for many in the neighbourhood. Public restrooms are few and far between, shelters are overcrowded, and hygiene supplies are not consistently available.
During the early days of COVID-19, temporary measures like portable restrooms and hygiene stations demonstrated that even small investments in public health infrastructure could make a difference. However, the rollback of these initiatives has again left the DTES exposed to preventable diseases.
Dr. Leung captured the gravity of the situation: “When you have people who are homeless and marginalized, how do you promote adherence? This is a disease of destitution.” His words underline the need for systemic solutions that address the disease and the conditions that allow it to thrive.
What Needs to Be Done?
Addressing the Shigella outbreak in Vancouver requires immediate and long-term action. Public health officials must reintroduce and expand hygiene initiatives in the short term, such as handwashing stations and access to clean restrooms. Distributing hygiene kits and increasing public awareness about prevention can also help curb the spread.
Long-term solutions, however, demand a broader commitment to addressing the root causes of homelessness and poverty. Investments in affordable housing, mental health services, and addiction support are essential to reducing the vulnerabilities that make outbreaks like Shigella inevitable.
The rise of Shigella in Vancouver is a wake-up call for policymakers, healthcare providers, and the public. It is a stark reminder that public health cannot be separated from social equity. Without sustained investment and systemic reform, the DTES—and other vulnerable communities—will continue to bear the brunt of preventable crises.
Shigella as a Warning
The Shigella outbreak in Vancouver is more than a medical emergency; it is a mirror reflecting the failures of a system that has left its most vulnerable behind. For the DTES, it is another chapter in a long history of neglect, where public health crises are treated as isolated events rather than symptoms of deeper inequities. The stakes are clear: without meaningful action, the lessons of this outbreak will go unheeded, and the cycle of vulnerability and crisis will continue. Shigella is not just a disease of bacteria—it is a disease of society’s blind spots. The question now is whether Vancouver and Canada are willing to confront those blind spots with the urgency they demand.
The study documenting the rise in multidrug-resistant Shigella infections paints a sobering picture: this is not merely a local outbreak but a warning sign of how quickly preventable diseases can spread without foundational support. The data highlights a shift from isolated cases to a sustained and escalating crisis within marginalized communities, pointing directly to the need for comprehensive and sustained solutions.
While public health measures such as expanded hygiene facilities and community outreach can provide immediate relief, they must be integrated into a larger framework that tackles housing insecurity, poverty, and the social determinants of health. The study is a clarion call for action for Vancouver and all urban centres grappling with similar inequities. Ignoring this warning risks further outbreaks and a more profound erosion of trust in a system that should safeguard everyone, especially society’s most vulnerable.
DOWNTOWNEASTSIDE.ORG is a collective author account used by several DTES contributors to discuss key issues and events in the neighbourhood. Articles under this authorship reflect diverse perspectives from those directly connected to the community. If you’d like to reach a specific contributor, please contact us via email.
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