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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 Highlights . . .

Our audit of the county and city of San Diego’s response to the 2017–2018 hepatitis A outbreak highlighted the following:

Results in Brief

In early March 2017, the County of San Diego Health and Human Services Agency (HHSA) announced an increase in the number of reported hepatitis A cases. Hepatitis A is a highly contagious liver disease, which can, in rare cases, cause liver failure and death. The outbreak that HHSA identified was disproportionately affecting two at‑risk populations—individuals experiencing homelessness and individuals who use illegal drugs—and the majority of the cases had occurred within the city of San Diego (city). State laws and regulations place the responsibility for containing outbreaks of communicable diseases on local health officers, but county and city governments are also required to take necessary measures to preserve and protect the public health in their jurisdictions. Shortly after the county of San Diego (county) detected the increase in reported cases, it took steps to understand the outbreak, determine the necessary interventions to contain it, and identify the characteristics and size of the at‑risk populations. However, its failure to adequately plan and quickly implement certain aspects of its response led to unnecessary delays in its execution of critical actions. As a result, the county was slow to mitigate the risk that more members of the two at‑risk populations might acquire the highly contagious disease and spread it to others.

In responding to the outbreak, the county identified vaccination as critical, an approach that aligns with general guidance from the World Health Organization and the U.S. Centers for Disease Control and Prevention. However, it did not consistently set measurable targets and time frames for administering vaccinations to the at‑risk populations early in its response, nor did it determine the quantities of key resources—primarily, nursing staff—needed to carry out the vaccination program. Instead, it considered only its own available resources to determine how many vaccinations it could administer, an approach that proved to be ineffective. Despite the county’s efforts, the number of new hepatitis A cases averaged around 20 per week from May through mid‑September 2017, three times higher than the average of six new cases per week during March. Vaccinations in the county significantly increased—about fivefold—beginning in September 2017, after new contracts increased the county’s access to additional public health nurses: the county and its partners administered more vaccinations in that month than in the previous six months combined. In fact, total vaccinations in the county surpassed 41,000 in both September and October 2017, compared to about 7,700 in August. This increase in vaccinations coincided with a dramatic decline in the number of new hepatitis A cases. Had the county accelerated its vaccination efforts sooner, it might have more quickly reduced the risk of the disease spreading.

Similarly, even though adequate sanitation is critical to controlling the spread of hepatitis A, neither the county nor the city promptly implemented measures to improve sanitation and hygiene conditions for the at‑risk populations in the city. To address sanitation issues, the county identified distributing hygiene kits, providing access to hand‑washing stations, sanitizing streets and sidewalks, and opening public restrooms for longer hours as measures. However, despite discussions in June and August 2017, the county and city did not fully implement the measures related to hand‑washing stations, restroom access, and street sanitizing until September 2017—after the county’s local health officer (county health officer) issued a directive telling the city it had to take action on the sanitation measures. The county health officer did not issue a directive sooner because she wanted to collaborate with the city instead of mandating its compliance. However, by exercising her legal authority before August 31, 2017, the county health officer likely would have prompted the city to implement the important sanitation measures sooner.

The county also failed to use a tool that could have helped it to foster the planning and coordination necessary for the prompt implementation of sanitation measures and to share information specific to the city about the status of the outbreak. The county’s emergency operations plan empowers the county to convene a policy group consisting of representatives of regions affected by an incident, such as the outbreak. Creating a policy group of this nature in response to the outbreak likely would have enabled the county to more promptly and efficiently facilitate coordination with the relevant jurisdictions, including the city. In the absence of such a group, the city’s assistant chief operating officer stated that the county did not give the city a reason to believe the outbreak was a serious issue until the county health officer issued her directive on August 31, 2017, nearly six months after the county had detected the outbreak. Additionally, the county did not share location data to inform the city about the concentration of the cases within its jurisdiction until November 2017. If the city had had more information, it might have more quickly understood the need for the sanitation measures. In its Hepatitis A Outbreak After Action Report (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.

Because the county did not do enough to inform and involve the city, the city lacked information that would have enabled it to understand the severity of the outbreak and the need to implement sanitation measures. State law requires the governing bodies of cities to protect the public health of their residents, which the city does in part by contracting with the county to address specified public health matters within the city. Nonetheless, we expected the city to have taken some additional steps to understand the actions needed related to sanitation to protect the public health of the at‑risk populations, such as requesting updates from the county regarding the response and coordinating any of its own sanitation efforts with the county. However, according to the assistant chief operating officer, the city expected the county to manage the outbreak and provide the city direction on what was required or necessary. Based on discussions it had with the county, the city believed that it was adequately responding to the county’s requests; thus, it did not see a need at the time to take additional action.

As a result of San Diego’s hepatitis A outbreak, the California Department of Public Health (CDPH), the county, and the city have identified changes they believe will improve their response efforts to future incidents. However, we believe room for additional improvement remains. For instance, although CDPH created a Hepatitis A Outbreak Response Plan to guide jurisdictions facing similar outbreaks in the future, the plan omits two critical steps: establishing time frames to achieve vaccination targets and determining the number of nurses or other resources needed to administer the vaccinations within those time frames. CDPH also created a draft Public Health and Medical Emergency Powers guide (medical powers guide) that more clearly identifies the powers and responsibilities of local health officers. However, this guide does not identify or provide examples of the measures local health officers are authorized to take during outbreaks. Regarding sanitation measures for the outbreak, the county health officer stated that she had never issued a directive before, and that based on discussions with county legal counsel, 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.

Additionally, both the county and the city completed after action reports related to the hepatitis A outbreak. The county identified and made recommendations for improvement in 21 areas, including using a multidisciplinary approach to monitor public right‑of‑ways, such as sidewalks and streets, and to address sanitation needs. It has taken action to implement some of these changes. Although the city also issued a report that identified 12 issues or areas for improvement, it did not assess the actions it took before the county declared a local health emergency on September 1, 2017. As a result, the city missed an opportunity to identify and address issues that may have contributed to delays in implementing sanitation measures.



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 those 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.

Agency Comments

The county, city, and CDPH agreed with our recommendations.

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