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San Diego's Hepatitis A Outbreak
By Acting More Quickly, the County and City of San Diego Might Have Reduced the Spread of the Disease

Report Number: 2018-116

Audit Results

Although the County Took Some Reasonable Steps Early in Its Response to the Hepatitis A Outbreak, It Did Not Establish Timely Objectives and Deadlines

In early March 2017, HHSA detected and began investigating an increase in the number of hepatitis A cases, and on March 10, it issued a health advisory to the San Diego medical community stating that an outbreak of hepatitis A had occurred. Because time is of the essence when dealing with such outbreaks, public health entities must respond promptly to prevent further cases, save lives, and limit health care costs. Both WHO and CDC identify vaccination, sanitation, and education as critical for preventing hepatitis A and responding to outbreaks of the disease. Given this general guidance, we expected the county and the city to have moved quickly to identify, plan, initiate, and monitor efforts to control the spread of the outbreak. Specifically, we expected the San Diego County local public health officer (county health officer)—who also serves as the health officer for the city—to have taken the following steps:

In light of state law that requires local health officers to take whatever steps are necessary to control outbreaks of reportable diseases, we also expected the city to have complied with any directives the county health officer issued.

The County’s Methods for Vaccinating At-Risk Populations

Points of dispensing—On-site mass vaccination clinics held at locations such as homeless service provider facilities.

Mobile vans—On-site vaccinations provided using mobile vans.

Foot teams—Teams of nurses, public safety officers, and social service providers who located homeless individuals and administered vaccinations in the field.

Source: The county’s after action report, May 2018.

Certain aspects of the county’s early efforts to respond to San Diego’s hepatitis A outbreak were consistent with our expectations and with general guidance from WHO and CDC. The county’s data show that by the end of March 2017, the county had identified 42 cases, 33 hospitalizations, and one death. In its March health advisory announcing the outbreak, the county identified the two primary at‑risk populations and noted the likely means of the disease’s transmission from person to person as through the fecal‑oral route. Its implementation plan for responding to the outbreak and other documents show that, by the end of April 2017, it had identified a three‑pronged approach to address the outbreak: vaccination, sanitation, and education. In addition, the county had identified the key personnel supporting its response and assigned areas of responsibility to these personnel. It had also begun coordinating with other public and community organizations to develop estimates of the sizes and locations of the at‑risk populations and to establish approaches to vaccinate these individuals. The transient nature of the homeless and illicit drug‑using populations, as well as challenges in building trust and engaging with these individuals, required the county to collaborate with community and other public organizations. By May 2017, the county had begun administering vaccinations at the events described in the text box.

In addition, shortly after it declared the outbreak, the county coordinated the distribution of educational materials throughout its jurisdictions to inform at‑risk individuals, key stakeholders and organizations, and the general population about the disease. For instance, beginning in April 2017, the county distributed fact sheets on hepatitis A to homeless services providers and health care providers, as well as to individuals attending community presentations and vaccination events. By the end of May 2017, the county had also issued at least two press releases that included the number of cases, hospitalizations, and deaths to date; described the disease’s symptoms; and advised at‑risk populations and people falling into certain other groups—for instance, travelers to countries that have higher rates of hepatitis A—to obtain vaccinations. It also had issued three more health advisories to the medical community with updates on the outbreak.

However, the county did not take other critical steps in the early months of the outbreak. Specifically, it failed to consistently establish agreed‑upon, concrete objectives with time frames that could have guided its response and better ensured the timeliness of its actions. As we discuss in later sections of the report here and here, it failed to set objectives that identified both the specific number of vaccinations it planned to administer and the rates at which it planned to administer those vaccinations; set appropriate milestones for when it planned to achieve vaccination‑related objectives; and calculate the amount of resources necessary—such as vaccines, nursing staff, and vaccination events—to meet those milestones. Further, although it eventually identified specific hygiene and sanitation measures to control the spread of the hepatitis A outbreak, it was slow to implement many of these measures and to communicate specific sanitation measures to the city to implement.

Likely as a result of this lack of planning and its delays in fully implementing its outbreak response, the county’s early efforts did not contain the spread of the disease. As Figure 1 depicts, the number of new cases of hepatitis A began significantly increasing in March 2017. By mid‑April 2017, the number of new cases per week exceeded 10. In total, from the end of March through the end of May 2017, the number of hepatitis A cases more than quadrupled to 180, the number of hospitalizations more than tripled to 120, and the number of deaths increased to four. Further, from May through mid‑September 2017, the outbreak became more severe. During this time, the average number of new cases per week was 20, three times higher than the average of six new cases per week during March.

Figure 1
The Number of New Hepatitis A Outbreak Cases Each Week Did Not Start Steadily Decreasing Until September 2017

A bar chart describing the number of new hepatitis A outbreak cases per week that occurred in San Diego County from November 2016 through January 2018.

Source: Analysis of Web Confidential Morbidity Reporting system data provided by the county.

The county health officer declared a local health emergency on September 1, 2017. From September through December 2017—the period when the county and city significantly increased their efforts related to vaccination and sanitation—the number of new cases each week dropped significantly. In fact, starting with the first week in October, the number of new cases per week dropped to 11 or fewer. We believe that the county’s and city’s more aggressive actions, which we describe below, were appropriate and appear to have been effective in reducing the spread of the disease. However, had the county and city taken these steps in early summer of 2017 rather than waiting until September, they could have better protected the health of county residents. By the end of January 2018, the county had experienced 584 hepatitis A cases from the outbreak, 398 hospitalizations, and 20 deaths. The county ended the local health emergency on January 23, 2018—10 months after announcing the outbreak—and declared the outbreak over on October 18, 2018, 19 months after its announcement.

Because of Weaknesses in Its Planning, the County Was Slow to Vaccinate Many of Its Most Vulnerable Residents

Entities That Reported Administering Hepatitis A Vaccinations From March 2017 Through July 2018

County—The county held a number of vaccination events at facilities including jails, public health centers, and locations such as homeless service provider facilities. In addition, it had foot teams that administered vaccines in the field.

Community clinics—These clinics are federally qualified health centers that provide necessary services to a medically underserved population and adjust their fees based on the patients’ ability to pay.

Hospitals, health plans, private providers, and pharmacies—Many private facilities provided vaccinations to patients during the outbreak.

Source: County of San Diego Immunization Registry data and California Association of Public Hospitals and Health Systems website.

The county recognized the need for vaccination early during the outbreak and mentioned in its March 10, 2017, health advisory the necessity of vaccinating at‑risk populations. Although the county developed a plan for implementing its response strategies as early as April, it did not consistently set objectives until October 2017 that clearly identified both the number of vaccinations it would administer and the rate at which it would administer them. As a result, it could not ensure that it had sufficient resources to promptly provide the necessary vaccinations. These crucial missing details suggest that the county failed to embrace fully that “time is of the essence” when responding to an outbreak, as the health officials association describes. Instead, through August 2017, the county relied mostly on its existing nursing resources to dictate the pace and scheduling of its vaccination efforts, and it also worked with certain private providers and community clinics to administer vaccinations. The text box describes the types of entities that reported administering vaccines during the outbreak. Although the county had entered into agreements with 24 health care providers by August 2017 to administer federally funded vaccines, it did not significantly increase its vaccination efforts until the county health officer declared a local health emergency in September 2017, more than five months after the county identified the outbreak. As Table 1 shows, the county’s increased efforts had positive results: total vaccinations in the county surpassed 41,000 in both September and October 2017, compared to about 7,700 in August, while the number of new cases in October dropped to 35, compared to 80 in September.

Table 1
Hepatitis A Vaccinations Accelerated in September 2017
March 2017 42 42 33 33 1 1   1,378 1,378 306 306
April 2017 51 93 35 68 2 3 2,399 3,777 1,265 1,571
May 2017 87 180 52 120 1 4 3,216 6,993 1,656 3,227
June 2017 73 253 50 170 1 5 3,869 10,862 2,305 5,532
July 2017 86 339 67 237 6 11 4,354 15,216 2,822 8,354
August 2017 94 433 62 299 5 16 7,630 22,846 5,173 13,527
September 2017 80 513 53 352 2 18 41,444 64,290 19,816 33,343
October 2017 35 548 20 372 2 20 44,689 108,979 17,217 50,560
November 2017 21 569 16 388 20 13,733 122,712 5,728 56,288
December 2017 8 577 7 395 20 6,886 129,598 3,464 59,752
January 2018 7 584 3 398 20 5,880 135,478 3,344 63,096

Source: Analysis of data from the county’s Web Confidential Morbidity Reporting system and San Diego Immunization Registry.

* Vaccinations that county programs, public health centers, and community clinics administered were likely administered to the at‑risk populations.

These cumulative totals include outbreak‑classified cases, hospitalizations, and deaths from November 2016 through March 2017.

Although the county’s April 2017 implementation plan described its proposed actions and response strategies, this plan and later versions of its various planning documents did not consistently include agreed‑upon vaccination targets combined with time frames for meeting these targets and analyses of the resources necessary for doing so. For example, the county’s incident action plan dated May 24, 2017, identified a target of vaccinating 8,000 homeless individuals, but did not include a date by which it planned to achieve this target. Similarly, although the incident action plan dated June 9, 2017, included a target of vaccinating 5,000 at‑risk individuals by June 30, 2017, the July update to this plan did not include new vaccination targets, a time frame for completing vaccination targets, or estimates of the resources necessary to administer the vaccinations within a specified time frame. In an email dated June 26, 2017, the medical director of HHSA’s Epidemiology and Immunization Services Branch (medical director) expressed concern that there was still no agreed‑upon vaccination targets to address the outbreak. In fact, the county did not set specific measurable targets with time frames for achieving its objectives until early October 2017, when the county established the targets of vaccinating 200 at‑risk individuals per week in each of the county’s six regions and 120 inmates per day. In October the county also formalized its Hepatitis A Outbreak Response Plan, in which it mentioned vaccinating as many individuals as needed to control the outbreak, which it identified as perhaps 125,000 or more. We believe that had the county set these types of targets in early summer 2017 and then identified the resources necessary to achieve them, it would have been better positioned to accelerate its vaccination efforts.

By late June 2017, the county had critical information to guide its vaccination efforts. Specifically, in May 2017 the county engaged the University of California, San Diego’s Division of Infectious Diseases and Global Public Health to create a model (UC San Diego model) to estimate the potential magnitude and duration of the outbreak and the potential impact of vaccination efforts. In late June 2017, the county received the UC San Diego model, which calculated that achieving community immunity would require 71 percent to 80 percent of the at‑risk populations to be immune to the disease, either because they had received vaccinations or because they had already had hepatitis A. Community immunity occurs when the percentage of a population that is immune to an infection is large enough to help protect those who are not immune because the disease has little opportunity to spread. According to an HHSA staff officer, HHSA’s Community Health Statistics Unit estimated that the county’s homeless and illicit drug‑using populations at the time of the outbreak consisted of between 25,000 and 240,700 individuals. Assuming that 60 percent of the potentially 240,700 at‑risk individuals had preexisting immunity, the parameters of the UC San Diego model suggested that as many as 77,000 at‑risk individuals would require vaccinations. The model also indicated that providing vaccinations as early as possible would avert additional infections.

As Table 1 shows, county programs, public health centers, and community clinics administered only about 5,500 hepatitis A vaccinations in the county in the four months from March through June 2017, or about 7 percent of the number estimated as necessary to reach community immunity. The medical director stated at that time that he supported vaccinating at least 10,000 additional at‑risk people in July 2017. However, the county did not establish this as a target, nor did it develop new vaccination targets or time frames to reflect the information in the UC San Diego model. Instead, county programs, public health centers, and community clinics performed only 2,800 of the 4,400 vaccinations administered in the county in July and about 5,200 of the 7,600 vaccinations administered in the county in August. Private parties such as hospitals and clinics accounted for the rest.

We believe the county did not accelerate its vaccination efforts to address the hepatitis A outbreak because it lacked a strong sense of urgency. Its failure to hire additional temporary nurses in a timely manner is symptomatic of this lack of urgency. Even though internal county meeting agendas from April 2017 through June 2017 indicate that the county discussed acquiring extra nurses to administer vaccinations, it did not initiate the procurement process to hire additional nurses until July 2017. Instead, the county responded to the early months of the outbreak by relying on its own nursing staff, soliciting vaccination assistance from certain community clinics and health care providers, and using its existing contract for temporary staff.

Within two weeks of receiving the UC San Diego model, the county initiated its procurement process to acquire additional public health nurses to assist in the vaccination effort. However, the county did not use an expedited procurement process as allowed during an emergency; instead, it initiated its normal procurement process for hiring additional nurses. Specifically, San Diego County’s Public Health Services division (Public Health Services) submitted a procurement‑planning request dated July 10, 2017, to the purchasing department, which then posted a request for quotation on August 4, 2017. Seven weeks after the initial request—effective September 1, 2017—the county had 18 contracts for temporary nurses in place, or three contracts for each of its six geographic regions.

If the county health officer had declared a local health emergency sooner, the county could have significantly accelerated this procurement process. According to the county’s purchasing and contracting director, the department of purchasing and contracting would expedite the posting of a request for quotation if an emergency declaration is in place, and it would further prioritize the contract. Further, once the county health officer declared the local health emergency on September 1, 2017, the county board of supervisors waived its competitive procurement policy and granted authority to the county’s purchasing and contracting director to award and amend contracts for goods and services as necessary to respond to the local health emergency. If it had more quickly declared a local health emergency and used an expedited procurement process to contract with the temporary nurses, the county might have accelerated its vaccination efforts before September and likely slowed the spread of the disease sooner.

Moreover, if the county health officer had declared a local health emergency sooner, it might have prompted the county and its partners, including private entities, to increase their vaccination efforts more quickly. The county health officer asserted that local health emergencies are typically called when the county exhausts the resources necessary to respond to an outbreak. Furthermore, she indicated that the county did not face a shortage of staffing resources in June and July 2017. However, we believe that the volume of new cases—around 18 per week from mid‑April through June—should have been a sufficient indicator that the county’s vaccination efforts were insufficient to stem the outbreak. The county did not begin significantly more aggressive vaccination efforts until September 2017: during this one month the county, public health centers, and community clinics administered more vaccinations—19,800—than in the previous six months combined. Further, during this same month, private entities, such as hospitals and pharmacies, administered another 21,600 vaccinations. The county continued this level of vaccination effort into the next month, and, combined with public health clinics and community clinics, administered an additional 17,200 vaccinations (out of nearly 44,700 in total) during October 2017.

The increase in vaccinations administered raised concerns about vaccine availability. According to CDPH, it recommended in October 2017 that the Governor declare a statewide emergency related to the hepatitis A outbreak based in part on California’s unusually high vaccine orders and in part on vaccine manufacturers, stating that the volume of vaccine orders would soon result in back orders and supply constraints. Citing outbreaks in San Diego and other California counties, the Governor proclaimed a state of emergency on October 13, 2017, to address concerns regarding the availability of the hepatitis A vaccine. As part of the proclamation, the Governor required CDPH to take all measures necessary to obtain hepatitis A vaccines, prioritize the vaccination of at‑risk individuals in affected locations, and control and coordinate all drugs and medical supply stocks intended for wholesale distribution. The Governor also authorized individuals with emergency medical technician or paramedic licenses in the affected locations to administer vaccines to at‑risk populations.

We believe that had the county significantly accelerated its response efforts earlier than September 2017, it could have more quickly reduced the opportunities for the disease to spread and thus minimized the risk of more hepatitis A cases occurring. Once the county and other public and private entities increased the number of vaccinations administered in September 2017, the number of new cases reported began a steady decline. In fact, the county’s data show that more than 70 percent of the confirmed outbreak cases occurred before September 1, 2017, the date the county health officer declared the local health emergency. As Figure 2 depicts, the sharp decline in new monthly cases coincided with a five‑fold increase in vaccinations across the county—from around 8,000 in August to more than 40,000 in September. By the third week of January 2018, the number of new cases reported during the month was five, a volume that the county considered to be within its staff’s normal capabilities for investigation and response. Thus, the county ended the local health emergency on January 23, 2018. If the county had accelerated its response efforts earlier, it might have more quickly reduced the risk of the disease spreading.

Figure 2
New Monthly Hepatitis A Cases Declined When the County and Other Providers Significantly Increased the Number of Vaccinations They Administered

A line and stacked bar chart depicting the number of new hepatitis A outbreak cases per month from January 2017 through January 2018 and the number of vaccinations administered monthly by the county and other providers. It shows that the number of new cases declined steadily starting in September 2017 after a significant increase in the number of vaccinations administered.

Source: Analysis of the county’s Web Confidential Morbidity Reporting system and San Diego Immunization Registry.

* Vaccinations that county programs, public health centers, and community clinics administered were likely related to at‑risk individuals.

The county uses the California Health Alert Network (CAHAN), a state‑sponsored web‑based system, to send warnings of impending or current situations that may affect the public’s health.

Weaknesses in the County’s Planning Also Contributed to the Slow Implementation of Sanitation Measures

Although public health organizations indicate that vaccination is the best method for preventing hepatitis A or controlling outbreaks, these organizations also note the importance of sanitation or hygiene efforts in stopping the spread of the disease. We expected the county and the city to have collaborated in response to the outbreak to implement such sanitation efforts. Specifically, we expected the county to have identified the necessary sanitation measures, including practices related to personal hygiene; to have communicated to the city and other local jurisdictions those measures they needed to implement, as well as the time frames for implementation; and to have monitored the city’s and other jurisdictions’ progress in implementing the measures. Furthermore, we expected the city to have implemented the measures that the county determined were necessary.

In certain instances, the county met our expectations. Specifically, in the spring of 2017, the county identified and implemented several sanitation measures in response to the outbreak. For example, in late March 2017, the county’s Department of Environmental Health began conducting investigations at food facilities, where individuals with hepatitis A had dined or worked. Additionally, according to the assistant director of Public Health Services, the county considered distributing hygiene kits to the at‑risk populations in April 2017; however, contemporaneous evidence shows that the county identified distributing hygiene kits as a solution in May 2017.

However, the county failed to promptly implement other critical sanitation measures. For example, the county identified hand‑washing stations as a preventive countermeasure in early May 2017, and it added sanitizing streets and sidewalks and opening public restrooms for longer hours by August 2017. Nonetheless, neither the county nor the city fully implemented these sanitation measures until nearly six months after the county identified the hepatitis A outbreak. Although the two entities discussed hand‑washing stations in June 2017 and again in August 2017, they agreed on a pilot project only. Moreover, although the county health officer had the authority at any point to direct the city to implement sanitation measures, such as hand‑washing stations and access to restrooms for longer hours in response to the outbreak, she did not do so until August 31, 2017. On that date, she directed the city to immediately expand access to wash stations and public restrooms within the city that were adjacent to at‑risk populations, as well as to immediately implement a cleaning and sanitization protocol for public right‑of‑ways, such as sidewalks and streets.

The county health officer stated that she did not issue a directive earlier because the county wanted to work with the city first instead of forcing it to comply. However, we believe that waiting two months—from late June through the end of August 2017—was excessive. Furthermore, although state laws do not specifically state that local health officers may direct cities’ actions to prevent the spread of disease, existing laws and regulations authorize the officers to take measures as may be necessary to prevent or control communicable diseases. The city’s assistant chief operating officer (assistant chief) explained that because the county did not tell or ask the city to install hand‑washing stations until the county health officer issued her directive on August 31, the county minimized the sense of urgency and seriousness of the outbreak. Had the county health officer exercised her legal authority sooner, the city might have implemented sanitation measures earlier.

After the county health officer issued her directive, both the city and county implemented more aggressive response actions related to sanitation and hygiene. After the county provided the right‑of‑way sanitation guidance to the city, the city contracted with a vendor that began sanitizing streets and sidewalks on September 11, 2017. In addition, the city expanded access to public restrooms beginning in September. For instance, city records show that the city increased access to 23 restrooms located in Balboa Park, including 14 that it kept open for 24 hours a day, and it also installed 16 portable restrooms in four locations. Further, the county ultimately installed 40 hand‑washing stations within the city within the first two days of September and installed 40 more by the end of November 2017. Finally, the county placed 10 portable restrooms in unincorporated areas during October 2017.

Although we recognize the effectiveness of the actions that the county and city eventually took, we believe that the county’s weak planning contributed to the significant delays in implementing these necessary sanitation measures. To ensure progress on containment of the disease, the county should have set a time frame for reaching agreement with the city on implementing sanitation measures, developed a plan that identified the measures for which each entity would be responsible, and established schedules for completing those measures. If the county and city were unable to reach consensus within the scheduled time frame, the county health officer should have directed the city to act on the sanitation measures. Developing a plan that defined the specific steps that need to be taken, the parties responsible for taking those steps, and the time frames for accomplishing them, would have fostered participation and increased accountability.

During the outbreak, the county also failed to fully use an available tool that could have helped it to foster the planning and coordination necessary for the prompt implementation of sanitation measures. The county’s emergency operations plan—which has aspects that users can implement in situations that fall short of emergencies—provides this tool. It states that it can be partially or fully implemented in response to a potential or actual threat, in anticipation of a significant event, or in response to an incident. According to the plan, responders to an incident are to use an incident command system (ICS). An ICS is a standardized management system that provides an integrated organizational structure that can reflect the complexity and demands of an incident, without being hindered by jurisdictional boundaries. One tool that an ICS provides is the ability to establish a policy group consisting of those responsible for managing the response effort. To ensure coordination among different jurisdictions, this policy group can include representatives of regions affected by the incident.

Given that the outbreak affected several cities within the county and that the response required the participation of community partners and local governments, we expected the county to have included leadership from these entities as part of the policy group to manage the response efforts. On at least two occasions in March and April 2017, the medical director mentioned to the county health officer the possibility of activating an ICS to respond to the outbreak, pointing to the increasing need for responses that crossed agency and county service lines. He also indicated that an ICS should be considered to address underlying hygiene issues for homeless people that were likely contributing to the outbreak.

The county decided to activate an ICS structure at the end of April 2017. However, in an email to the county health officer dated April 28, 2017, the medical director expressed concerns that the ICS activation was not HHSA‑wide and warned that the county’s outbreak could become one of the worst in the country since the introduction of the vaccine, which was an argument for a more aggressive approach. He advocated for an HHSA‑wide ICS activation, citing the need for coordination and resources outside of Public Health Services. Although the county eventually activated an agency‑wide ICS structure that included a policy group of county executives from different departments, this policy group did not include representatives from the affected cities. Moreover, the county provided no evidence that it used the ICS or policy group to regularly share information on the progression of the outbreak with the affected cities or to work regularly with them on coordinating the logistics of the specific sanitation measures necessary to prevent the spread of the disease.

In its May 2018 after action report, the county noted its lack of a policy group of county and regional executive leaders, and it acknowledged that regularly convening a policy group that included leadership from impacted jurisdictions would have been appropriate for the outbreak response. The emergency medical services coordinator for the HHSA’s Public Health Preparedness and Response Branch agreed that the county could have benefitted from improved—and earlier—coordination with stakeholder groups and jurisdictions. Had the county promptly implemented a policy group that included all jurisdictions affected by the outbreak, it might have improved participation and accountability among the participants, facilitated the coordination of necessary sanitation interventions, and mitigated misunderstandings. In response to its after action report, HHSA drafted policies and procedures related to activating and convening a policy group during a public health threat. Although these policies and procedures are not yet final, the assistant director of Public Health Services stated that HHSA already implemented them in response to a meningococcal outbreak at San Diego State University. According to a November 2018 organization chart for that outbreak, the county initiated a policy group that includes representatives of a number of county entities and three representatives from the university.

The county’s limited sharing of information specific to the city about the status of the outbreak also hindered the city’s full recognition of the seriousness of the outbreak and the need to implement sanitation measures quickly. As Table 2 indicates, the county had the data to determine early during the outbreak that the majority of the hepatitis A cases were occurring within the city. However, the county did not share location data by zip code with the city until November 2017. Had the county shared information with the city about the concentration of cases earlier, the city might have more quickly implemented the necessary sanitation measures.

Table 2
The Majority of the Outbreak‑Related Hepatitis A Cases During 2017 Occurred in the City
January 1   0 0%   1 100%
February 7 0 0 7 100
March 28 18 64 10 36
April 51 31 61 20 39
May 87 47 54 40 46
June 73 33 45 40 55
July 86 43 50 43 50
August 94 65 69 29 31
September 80 56 70 24 30
October 35 18 51 17 49
November 21 8 38 13 62
December 8 2 25 6 75
Totals 571 321 56% 250 44%

Source: Analysis of data from the county’s Web Confidential Morbidity Reporting system and San Diego Immunization Registry.

* Vaccinations that county programs, public health centers, and community clinics administered were likely administered to the at‑risk populations.

These cumulative totals include outbreak‑classified cases, hospitalizations, and deaths from November 2016 through March 2017.

State law requires the city’s governing body to take measures necessary to preserve and protect the public health. Although, the city fulfills this responsibility in part by contracting with the county to provide public health services within the city’s jurisdiction, we expected the city to have taken at least some additional steps to understand the actions needed related to sanitation to protect the public health of its residents. Such steps should have included requesting regular updates regarding the county’s outbreak response, and coordinating any of its own sanitation response efforts with the county. Because the city knew that it had a large homeless population residing within its jurisdiction, it should have taken steps to ensure that it sufficiently protected these residents’ health.2

Emails indicate that city leadership knew of the outbreak by April 2017, and the county and city met on May 4 to discuss the outbreak specifically. In fact, the city believed that it was adequately responding to the county’s requests because of its discussions about the outbreak with the county from May through August 2017, and its regular correspondence from the county for specific assistance as it pertained to educational materials and with reaching out to the at‑risk populations for vaccinations. According to the assistant chief, the city expected the county to manage the outbreak and provide the city direction on what was required or necessary because the city had a contract with the county and it is responsible for public health matters in the city. The assistant chief also stated that the county had never given the city a reason to believe that the outbreak was a serious issue that warranted the immediate implementation of sanitation measures until the county health officer issued the sanitation directive in August 2017.

By Applying Lessons Learned From the Outbreak, the State, County, and City Can Ensure They Are Better Positioned to Respond Effectively to Similar Situations in the Future

When we spoke to CDPH about the county’s response to the outbreak, it identified a number of strengths. The chief of CDPH’s Division of Communicable Disease Control (division chief) stated that the county responded to its hepatitis A outbreak with the appropriate vigor and was creative in developing solutions. Additionally, CDPH’s deputy director of its Center for Infectious Diseases highlighted the county’s use of foot teams to vaccinate a marginalized population. The division chief also stated that the county developed additional responses, especially regarding sanitation, that were not readily available. The division chief noted that CDPH had expected the outbreak to last as long as two years, based on the length of prevaccine‑era outbreaks, and stated that the cases in San Diego leveled off more quickly than cases have in other states. Similarly, the chief of CDPH’s Immunization Branch stated that the county had a robust response to the outbreak, and compared to other states, was the only jurisdiction that was able to bring an outbreak under control.

We acknowledge that the actions the county ultimately took were effective in controlling what could have been a much worse outbreak. That said, we believe that the county could have aggressively responded to its hepatitis A outbreak more quickly than it did. Had the county taken in June and July 2017 the actions that it took starting August 31 and continuing through October 2017—namely, declaring a local health emergency, improving hygiene opportunities by directing the city to expand access to public restrooms and wash stations within the city limits, and vaccinating more than 40,000 individuals against hepatitis A in both September and October—we believe it may have brought the outbreak under control sooner. As we explain previously, the county had case information by the end of May that showed that its early efforts had not successfully contained the spread of the disease. Furthermore, on April 28, 2017, the county’s medical director mentioned the immediate need for more coordination and vaccinations to the county health officer. He stated that “mass immunizations are just now getting underway” and that he believed that if more aggressive measures were not coordinated immediately, the outbreak was on track to be one of the worst in the United States since the introduction of the vaccine. Nonetheless, the county allowed four more months to pass before it significantly increased its efforts related to vaccination and sanitation. We believe that the State, county, and city can use the events of the outbreak to avoid delays in the future.

As a result of San Diego’s hepatitis A outbreak, CDPH, the county, and the city have identified changes to improve their response efforts to future incidents. However, we believe that room for additional improvement remains. For example, CDPH adapted the county’s Hepatitis A Outbreak Response Plan to create its own Hepatitis A Outbreak Response Plan to guide other jurisdictions facing similar outbreaks in the future. Although CDPH developed this document to establish a comprehensive response to hepatitis A outbreaks, particularly among the homeless and illicit drug‑using populations, the plan is incomplete. Specifically, it omits two critical steps: establishing time frames to achieve vaccination targets and determining the number of nurses and other resources needed to administer the vaccinations within those time frames. According to the division chief, CDPH did not include these two steps because local circumstances are very different and the time and resources needed to deliver vaccines vary based on these circumstances. However, as we described previously, time is of the essence when dealing with an outbreak. Because public health experts indicate that vaccination is the best method for controlling a hepatitis A outbreak, we believe that the performance of these steps is critical to ensuring the prompt response to outbreaks.

CDPH also created a draft Public Health and Medical Emergency Powers guide (medical powers guide) for the California Public Health and Medical Emergency Operations Manual to identify the powers and responsibilities of certain officials, including local health officers. However, the draft guide provides only partial clarity. Specifically, the guide clearly states the authority of local health officers to take measures as necessary to prevent the occurrence or spread of additional cases of communicable disease in their jurisdictions and to exercise this power regardless of whether an emergency declaration or proclamation is in place. However, other than orders for isolation, quarantine, or “social distancing,” the guide fails to identify or provide examples of the measures local health officers are authorized to take during outbreaks.3 When we asked the county health officer about imposing sanitation measures during the outbreak, she explained that she could not force the city to install hand‑washing stations and that she needed to comply with the city’s ordinances and policies. She also stated that she had never issued a directive before, and that based on discussions with county legal counsel, she believed that the directive on its own did not carry any legal authority. We believe that CDPH’s current draft guidance does not yet provide the necessary clarity on this matter.

San Diego County Grand Jury’s Recommendations to the County and the City Regarding the Outbreak

In its May 2018 report, the grand jury made the following recommendations.



Source: Report by the 2017/2018 San Diego County Grand Jury, The San Diego Hepatitis A Epidemic: (Mis)Handling a Public Health Crisis, May 2018.

After examining both the county’s and city’s response efforts to the outbreak, the San Diego County Grand Jury also had recommendations for improvement. Specifically, in the May 2018 report it issued, it made a number of recommendations to the county and city, including those listed in the text box. With the exception of the recommendation that the county declare a local health emergency sooner if confronted with a similar outbreak in the future, the county agreed to implement these recommendations. Similarly, the city’s mayor responded in October 2018 that the city has addressed two of the three recommendations and partially implemented the third.

Moreover, in its after action report for the outbreak, the county identified 21 recommendations, which included developing protocols to convene a policy group of county and regional executive leadership from affected jurisdictions for outbreaks with the potential for regional impacts, developing a notification process to communicate pertinent information to municipalities and other governmental agencies to assist in response to emerging public health issues, and using a multi‑disciplinary approach to monitor public right‑of‑ways and address sanitation needs. The county has taken action to implement some of the report’s recommendations. For example, in April 2018, the county surveyed cities and the unincorporated areas within its jurisdiction to determine the sanitation and hygiene activities each entity undertook during and after the local health emergency and each jurisdiction’s future plans for such activities. The county summarized the results from this survey in May 2018, and discussed the results with the cities in November 2018.

Although the city also issued a report following the outbreak, it did not assess the actions it took before the county declared a local health emergency. The report stated that its purpose was to analyze the city’s response to an incident, and that it identified 12 issues or areas for improvement. However, because the report covered only the time during which the local health emergency was in effect—September 2017 to January 2018—it did not identify any areas for improvement related to the implementation of sanitation measures before the declaration. As we previously explained, the city and county held discussions about hand‑washing stations in June and August 2017, but agreed only to a pilot project; the county did not begin installing hand‑washing stations in the city until September 2017. By not also assessing its actions before the local health emergency declaration, the city missed an opportunity to identify issues that may have contributed to delays in the implementation of sanitation measures and to develop steps to address these issues in the future.



To better ensure that local health officers can promptly respond to disease outbreaks, the Legislature should clarify existing state law to specify that the local health officer for each geographic jurisdiction may issue directives to other governmental entities within that jurisdiction to take action as the officer deems necessary to control the spread of communicable diseases.

To ensure that each local public entity has the information necessary to adequately respond and protect the public health of its residents during disease outbreaks, the Legislature should enact legislation requiring local health officers to promptly notify and update local public entities within the health officers’ jurisdictions about communicable disease outbreaks that may affect them. The legislation should also require health officers to make available relevant information to these local public entities, including the locations of concentrations of cases, the number of residents affected, and the measures that the local public entities should take to assist with outbreak response efforts.

San Diego County

To prevent delays when responding to future communicable disease outbreaks, the county should ensure that in the event of an outbreak, its response plans include the following critical elements: specific and achievable objectives, time frames by which it expects to achieve these objectives, and the resources necessary to achieve its objectives within the planned time frames. Furthermore, the county should update its emergency operations plan and other planning documents to reflect these changes by April 30, 2019.

To better ensure effective collaboration and cooperation with other local jurisdictions, the county should finalize its draft policy that requires it to respond to future outbreaks by promptly convening policy groups that include representatives from relevant local jurisdictions. Furthermore, to facilitate improved communication with and participation from jurisdictions potentially affected by disease outbreaks, the county should promptly share relevant data with each jurisdiction.

To ensure that it takes appropriate action to protect the public health of the residents of the city, the county should enter into an agreement—such as a memorandum of understanding—with the city or should negotiate revisions in its contract with the city by March 31, 2019, to clarify each entity’s roles and responsibilities over public health matters, and to include city leadership in coordinating response efforts when public health matters, such as disease outbreaks, affect the city’s residents.

City of San Diego

To ensure that the city is sufficiently aware of future disease outbreaks and other public health concerns that affect its residents and that it can take appropriate action to protect the public health of its residents, the city should enter into an agreement—such as a memorandum of understanding—with the county or should negotiate revisions in its contract with the county by March 31, 2019, to clarify each entity’s roles and responsibilities over public health matters, and to include city leadership in coordinating response efforts when public health matters, such as disease outbreaks, affect the city’s residents.

To identify and address any unresolved issues that may have contributed to delays in implementing sanitation measures before the county health officer’s September 2017 declaration of a local health emergency, the city should, by March 31, 2019, examine its actions related to the hepatitis A outbreak before the emergency declaration, identify any such issues, and use the results of that examination to develop a corrective action plan to address them.


To better enable other jurisdictions to more promptly respond to future hepatitis A outbreaks, CDPH should amend its Hepatitis A Outbreak Response Plan by February 28, 2019, to recommend that the jurisdictions set vaccination targets as soon as possible, establish dates by when they expect to achieve those targets, and determine the quantities of resources necessary to administer the vaccinations by those dates.

To further clarify the authority of local health officers, CDPH should finalize and issue its medical powers guide by April 30, 2019, and revise it to describe to the greatest extent possible the types of actions that local health officers can take within their jurisdictions to prevent or contain the spread of infectious disease.

We conducted this audit under the authority vested in the California State Auditor by Government Code 8543 et seq. and according to generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives specified in the Scope and Methodology section of the report. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Respectfully submitted,

California State Auditor

December 20, 2018


2 One report estimated the city’s homeless population to be about 5,000 as of January 2018. Go back to text

3 According to WHO, social distancing means reducing opportunities for exposure. Related measures include school and workplace closures, as well as the limitation or cancellation of mass gatherings such as large conferences, public events, and congregations. Go back to text

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