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- County of San Diego Health and Human Services Agency
- City of San Diego
- California Department of Public Health
County of San Diego Health and Human Services Agency
December 3, 2018
Ms. Elaine M. Howle
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814
Dear Ms. Howle:
The County of San Diego (County) has reviewed the sections of Audit Report 2018-116 pertaining to the County. Attached you will find our response. While our analysis differs in areas, your recommendations generally align with what the County already concluded in our May 2018 Hepatitis A Outbreak After Action Report. We continue to stand by the detailed findings and recommendations identified in the After Action Report.
Significant events such as the County’s unprecedented hepatitis A outbreak should always be reviewed with the benefit of hindsight—and we appreciate the contribution of the California State Auditor’s Office. As you have learned through this audit, this hepatitis A outbreak was unparalleled. With no previously established response playbook for this type of outbreak, a virus with an incubation period of 50 days, and an extremely difficult to reach affected population, the County’s response required innovation and agility. For example, County staff developed vaccination “foot teams” early in the outbreak to reach chronically homeless individuals who may be otherwise reluctant to seek medical care or vaccination at service delivery sites. This approach has been adopted as a nationally recognized model and was commended by the San Diego County Grand Jury. There is also a perception that deploying handwashing stations is a routine response to this type of outbreak, but this strategy was actually implemented for the first time by our own County public health officials. While there are areas in which we could have acted more quickly, success is not purely measured by the speed of the response, but also the effectiveness of the actions taken.
We are proud that the County’s actions have been recognized by public health subject matter experts who practice in this area such as the Centers for Disease Control and Prevention (CDC) and the California Department of Public Health. CDC experts stated they were “impressed with the rapid action of the San Diego County Health and Human Services Agency.” The County continues to share its best practices with states and other jurisdictions throughout the country that are still battling similar hepatitis A outbreaks, some of which have unfortunately far surpassed ours in severity.
While the Report implies that the County should have been more forceful with other local governments regarding their efforts to clean and sanitize their streets and sidewalks, the County believes strongly in collaboration as the best practice in working among local governments. We are proud of the relationships we have developed and will continue to work with local, State and federal agencies as well as our stakeholder partners. By focusing collective efforts on the three-pronged strategy of vaccination, sanitation, and education, our relationships helped mitigate this outbreak.
We appreciate the difficult task given to your Office in reviewing this complicated public health matter.
Sincerely,
NICK MACCHIONE, FACHE
Agency Director
c: Helen Robbins-Meyer, Chief Administrative Officer
County of San Diego Health and Human Services Agency (HHSA) Response to the California State Audit Report 2018-116 entitled San Diego’s Hepatitis A Outbreak: By Acting More Quickly, the County [redacted] of San Diego Might Have Reduced the Spread of the Disease
| Recommendation 1: | 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, schedules by which it expects to achieve these objectives, and the resources necessary to achieve its goals and objectives within the planned schedule. Furthermore, the county should update its emergency operations plan and other planning documents to reflect this change by April 30, 2019. |
| Responses: | The County of San Diego agrees with the overall recommendation. As noted in the County’s May 2018 Hepatitis A Outbreak After Action Report, in a public health outbreak, the County applies standard emergency management principles, including the Incident Command System (ICS) emergency management structure, to develop and deploy a tailored response strategy. During the hepatitis A outbreak, ICS management principles were applied, such as setting clear objectives for education, vaccination, and sanitation, designating outbreak roles and responsibilities, and establishing regular status reports and meetings to coordinate and forward the response. While we understand the audit was looking for more fixed objectives and measures, our approach recognized that unprecedented events, such as this outbreak, require plans, specifically the objectives, schedules and identified resources, to be nimble and constantly re-evaluated in order to adjust as the incident demands. The ICS was established in April 2017 and an Incident Action Plan, which outlined several hepatitis A planning objectives, was developed on May 5, 2017, and revised during the early to mid-outbreak time periods (May 24, 2017, June 7, 2017, June 9, 2017, July 24, 2017). Additionally, the County developed formal Response Plans and Implementation Plans, which went through several revisions and were finalized in November 2017 and October 2017 respectively. Several iterations of these plans were necessary in order to respond effectively. The Deputy Director for Infectious Diseases, California Department of Public Health stated the following about the County’s Hepatitis A Response Plan, “Overall, we found the plan to be well conceived, thoughtful, and comprehensive. This is a good model for other health departments to use when responding to the hepatitis A outbreak.” The County of San Diego’s Emergency Operations Plan (EOP) was recently updated and approved by the Board of Supervisors in September 2018 and was reviewed and approved by the Emergency Management Accreditation Program on November 7, 2018, an independent nonprofit organization that fosters excellence and accountability in emergency management and homeland security programs. The current EOP includes these critical planning elements, however we will again review to determine if any elements should be more explicit. |
| Recommendation 2: | 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 the representatives from relevant local jurisdictions. Furthermore, to facilitate improved communication with and participation from jurisdictions affected by disease outbreaks, the county should promptly share relevant data with each jurisdiction. |
| Response: | The County of San Diego agrees with this recommendation. Through the process of developing the Hepatitis A Outbreak After Action Report, the County acknowledged we should enhance our use of incident management structures to coordinate regional actions. One key structure was to regularly convene a policy group of County and regional executive leadership from affected jurisdictions during the outbreak. This policy to convene the policy group was finalized on November 30, 2018. The County agrees that in order to facilitate improved communication with impacted jurisdictions, relevant data should be shared accordingly, taking into consideration legal constraints regarding privacy. This practice was completed throughout the hepatitis A outbreak, as demonstrated by the multiple meetings held with impacted jurisdictions and stakeholders, as well as by over 400 presentations provided by County staff to jurisdictional staffs, organizations, and the public. Additionally, the County sends priority health communications to health care and public safety professionals in San Diego County through the California Health Alert Network (CAHAN) San Diego. Topics include communicable diseases outbreaks, emerging health issues, requests for heightened surveillance related to communicable diseases, recommendations on communicable disease identification, prevention, infection control, specimen submission and laboratory testing, and emergency preparedness information. The May 4, 2017 CAHAN specified that clusters of hepatitis A cases were noted at homeless services providers in downtown San Diego and El Cajon. Further, on August 17, 2017, during the Regional Taskforce on Homelessness meeting with various jurisdictional attendees, the County shared maps of hepatitis A cases. In September 2017, the County also shared maps with city-level data in a similar meeting. |
| Recommendation 3: | 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 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 |
| Response: | The County of San Diego agrees with this recommendation. The County has already begun to work towards this goal. The County of San Diego Public Health Services was selected to participate in the Kresge Foundation’s Emerging Leaders in Public Health Initiative. This national program equips local public health officers to enhance organizational and leadership skills for public health systems development. As part of this project, the County identified the need to have clear agreements on jurisdictional roles and responsibilities regarding public health topics and threats. The County’s intent is to have agreements with all 18 municipalities within the county. Given this goal, we will work to meet the March 31, 2019 target for the City of San Diego. |
Comments
CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM THE COUNTY OF SAN DIEGO HEALTH AND HUMAN SERVICES AGENCY
To provide clarity and perspective, we are commenting on the response to our audit report by the County of San Diego Health and Human Services Agency. The numbers below correspond to the numbers we placed in the margin of HHSA’s response.
The recommendations in our report address key issues not discussed in the county’s after action report. For instance, as we mention here, we believe the county could have responded to the hepatitis A outbreak more quickly than it did. Additionally, our recommendations listed here state that the county should include specific and achievable objectives, times frames by which to achieve those objectives, and the resources necessary to achieve those objectives in its future response plans, and that it should enter into an agreement with the city that clarifies each entity’s roles and responsibilities over public health matters that affect the city’s residents, none of which the county’s after action report addresses.
Our report does not indicate that the deployment of hand-washing stations is a routine response to this type of outbreak. Our concern regarding hand-washing stations was the length of time it took to deploy them. We state here that the county identified hand-washing stations as a preventive countermeasure to hepatitis A in early May 2017, but it did not fully implement hand‑washing stations until early September 2017, nearly four months later.
We say directly here that two months—from late-June when the county and city discussed hand-washing stations through the end of August 2017—was an excessive amount of time for the county to wait to issue a directive that the city immediately expand access to hand-washing stations and public restrooms within the city and implement a cleaning and sanitation protocol for public right-of-ways. During these two months, neither entity implemented the sanitation measures that the county deemed necessary; meanwhile, the outbreak continued even though the county health officer had the authority at any point to direct the city to implement such measures.
We disagree with HHSA’s statement that the county had set clear objectives for responding to the outbreak. As we state here, the county did not set clear objectives until October 2017. By then, the number of new reported cases of hepatitis A were already declining. Although it included the number of vaccinations it wanted to administer in some of its plans, the county did not include the number of vaccinations in its plans consistently; nor did it include a time frame for administering them or the resources required to complete those vaccinations. We also note that setting clear objectives in these areas would neither preclude the county from being nimble nor prevent it from adjusting its plans in response to the demands of an incident as HHSA implies.
HHSA’s reference to CDPH’s review of its plan needs additional context. We acknowledge here that officials with CDPH lauded the county’s response to the hepatitis A outbreak and here that CDPH adapted the county’s outbreak response plan to develop its own plan that could guide other jurisdictions facing similar outbreaks in the future. However, we also found that CDPH’s Hepatitis A Outbreak Response Plan is incomplete in that it omitted two critical elements regarding efficiency: establishing time framees to achieve vaccination targets and determining the number of resources needed to administer the vaccinations within the time frames.
The examples HHSA cites fail to demonstrate that the county properly communicated the severity of the hepatitis A outbreak to appropriate officials of the city of San Diego, the jurisdiction most affected by the outbreak. As we show in Table 2, more than half the outbreak’s hepatitis A cases occurred in the city. However, as we state here, the county did not provide location data by zip code to the city until November 2017, well past the peak of the outbreak. Further, the county health officer did not give explicit direction regarding sanitation measures to the city until August 31, 2017. Simply mentioning in a health advisory issued to the general medical community that clusters of cases occurred in the city or conducting group presentations did not convey to the city the appropriate sense of urgency to prompt immediate action. Moreover, the county missed an opportunity to properly communicate the severity of the outbreak when it failed to include representatives from affected jurisdictions, including the city, as members of the policy group it created to manage the response to the hepatitis A outbreak, as we indicate here.
City of San Diego
December 3, 2018
Ms. Elaine M. Howle
State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814
Dear Ms. Howle:
Thank you for providing the City of San Diego the opportunity to respond to the draft report.
From the beginning, the City of San Diego has welcomed your audit and appreciated the opportunity for the review of the City’s efforts during this unprecedented regional public health emergency.
We also acknowledge there were no recommendations as it related to the City’s efforts of education, and vaccinations prior to the public health emergency; nor with the City’s procurement processes during the emergency declaration.
The City of San Diego agrees with the two (2) recommendations addressed to the City and will implement them by the stated deadlines. By clarifying roles, responsibilities, and our partnership with the County of San Diego as it pertains to public health matters and re-examining our response prior to the County Public Health Officer’s sanitation directive, issued on August 31, 2017, we will be better able to ensure the safety of our community in a health emergency.
If you have any questions, please contact Stacey LoMedico, Assistant Chief Operating Officer, at slomedico@sandiego.gov or (619) 533-4548.
Sincerely,
Kris Michell
Chief Operating Officer
| cc: | Aimee Faucett, Chief of Staff, Office of the Mayor Stacey LoMedico, Assistant Chief Operating Officer Ron Villa, Acting Assistant Chief Operating Officer Mary Nuesca, Assistant City Attorney Katie Keach, Director, Communications Department |
California Department of Public Health
December 3, 2018
Ms. Elaine M. Howle
State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814
Dear Ms. Howle,
The California Department of Public Health (CDPH) reviewed the California State Auditor’s draft report titled, “San Diego’s Hepatitis A Outbreak.” CDPH appreciates the opportunity to respond to the report.
The report concludes that although CDPH has identified and made changes to improve response efforts for future outbreaks, additional improvement remains.
Below, we address the report findings in more detail followed by our response to the auditor’s specific recommendations.
Finding 1: CDPH’s Hepatitis A Outbreak Response Plan omits two critical steps: establishing schedules to achieve target vaccination rates and determining the resources needed to administer target vaccinations within schedule.
Recommendations to Public Health:
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 levels as soon as possible, establish time schedules by when they expect to achieve those targeted vaccination levels, and determine the quantities of resources necessary to administer target vaccination within those schedules.
Response: Agree.
CDPH agrees that amending the Hepatitis A Outbreak Response Plan to incorporate vaccination targets and resources would be helpful. CDPH will amend the plan by February 28, 2019, to reflect the auditor’s recommendations.
Finding 2: CDPH’s Public Health and Medical Emergency Powers guide fails to identify and provide examples of the measures a local health officer is authorized to take in an outbreak.
Recommendations to Public Health:
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 jurisdiction to prevent or contain the spread of infectious disease.
Response: Agree.
CDPH will incorporate the types of actions that local health officers can take related to the prevention or containment of infectious disease in the California Public Health and Medical Emergency Operations Manual, Emergency Powers chapter and release that chapter by April 30, 2019.
We appreciate the opportunity to respond to the audit. If you have any questions, please contact Monica Vazquez, Chief, Office of Compliance at (916) 306-2251.
Sincerely,
Karen L. Smith, MD, MPH
Director and State Public Health Officer