Report 2018-116 All Recommendation Responses

Report 2018-116: 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 (Release Date: December 2018)

Recommendation for Legislative Action

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.

Description of Legislative Action

AB 262 (Chapter 798, Statutes of 2019) authorizes the local health officer to issue orders to other governmental entities within the local health officer's jurisdiction to take any action the local health officer deems necessary to control the spread of the communicable disease.

California State Auditor's Assessment of 1-Year Status: Legislation Enacted


Description of Legislative Action

AB 262 (Gloria) would require a local health officer, during an outbreak of a communicable disease or upon the imminent and proximate threat of a communicable disease outbreak or epidemic that threatens the public's health, to notify and update governmental entities within the health officer's jurisdiction about certain communicable diseases that may affect them, if, in the opinion of the local health officer, action or inaction on the part of the governmental entity might affect outbreak response efforts.

California State Auditor's Assessment of 6-Month Status: Legislation Introduced


Description of Legislative Action

Assembly Bill (AB) 262 (Gloria) would authorize the local public health officer to issue directives to other governmental entities within the health officer's jurisdiction to take any action the health officer deems necessary to control the spread of the communicable disease.

California State Auditor's Assessment of 60-Day Status: Legislation Introduced


Recommendation for Legislative Action

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.

Description of Legislative Action

AB 262 requires a local health officer, during an outbreak of a communicable disease, or upon the imminent and proximate threat of a communicable disease outbreak or epidemic that threatens the public's health, to notify and update governmental entities within the health officer's jurisdiction if, in the opinion of the local health officer, action or inaction on the part of the governmental entity might affect outbreak response efforts. This statute also requires a local health officer to make any relevant information available to governmental entities within their jurisdiction.

California State Auditor's Assessment of 1-Year Status: Legislation Enacted


Description of Legislative Action

AB 262 would require the local health office to make any relevant information available to governmental entities and would require both the local health officer and the governmental entities to comply with applicable state and federal privacy laws with regard to information that the health officer provides to the governmental entities.

California State Auditor's Assessment of 6-Month Status: Legislation Introduced


Description of Legislative Action

AB 262 would specifically require a local health officer to notify and update the local public entities within the health officer's jurisdiction about communicable disease outbreaks that may affect them, and make relevant information available to those entities.

California State Auditor's Assessment of 60-Day Status: Legislation Introduced


Recommendation #3 To: San Diego, County of

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.

6-Month Agency Response

The Communicable Disease Outbreak Response Plan Framework was created to guide the development of County of San Diego response plans to address outbreaks of communicable disease requiring the activation of the Incident Command System. The purpose of this framework is to provide a flexible, comprehensive guide to response planning response for outbreaks of communicable disease that may vary considerably in the populations at risk, method of transmission, morbidity and mortality rates, and other important factors. It provides questions and examples to encourage the development of comprehensive S.M.A.R.T. (Specific, Measurable, Action-oriented, Realistic, and Time-sensitive) objectives and the identification of the resources necessary to achieve them.

The attached Hepatitis A Outbreak Response Plan has been revised to include information about the use of the Incident Command System to guide outbreak response activities, as well as how S.M.A.R.T. objectives are used to plan day-to-day operations during an outbreak response (p. 30). It also has been updated to clarify barriers and limitations to developing numerical targets for outbreak response objectives (p. 14).

California State Auditor's Assessment of 6-Month Status: Fully Implemented


Recommendation #4 To: San Diego, County of

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.

60-Day Agency Response

On November 30, 2018, the County finalized a policy titled Activation of the Policy Group for Management and Oversight of Public Health Threats. The policy provides guidance regarding the circumstances under which the Public Health Officer (PHO) should recommend the activation of the Policy Group in response to a public health threat. It also includes description of staff roles and responsibilities and decision-making process for activation/termination of the Policy Group. In addition, this policy details procedures for communication from the PHO to relevant jurisdictions.

California State Auditor's Assessment of 60-Day Status: Fully Implemented


Recommendation #5 To: San Diego, County of

To ensure that it takes appropriate action to protect the public health of the residents of the city, the county should enter into an agreementósuch as a memorandum of understandingówith 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.

6-Month Agency Response

The County and City of San Diego have developed and executed a memorandum of understanding to define the roles and responsibilities of each party and ensure appropriate representation in policy decisions during outbreaks of communicable disease and other public health concerns affecting both jurisdictions. This memorandum was fully executed on March 28, 2019.

California State Auditor's Assessment of 6-Month Status: Fully Implemented


60-Day Agency Response

The County and City met on February 5, 2019 to discuss the memorandum of agreement and a framework for the agreement was agreed upon. The County drafted and sent the draft agreement to the City on February 15, 2018 for the City to review. The County and City have scheduled a meeting on February 28, 2019 to review the agreement language. The intent of both the City and the County is to execute the agreement by March 31, 2019.

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #6 To: San Diego, City of

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 agreementósuch as a memorandum of understandingówith 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.

6-Month Agency Response

On March 27, 2019 the City and County entered into a Memorandum of Understanding (MOU) that clarifies roles and responsibilities of public health matters. This was submitted to the State Auditor on April 15, 2019. Thank you,

California State Auditor's Assessment of 6-Month Status: Fully Implemented


60-Day Agency Response

The City and County staff met on February 5, 2019. Based upon the meeting, a draft memorandum of agreement will be prepared by the County and provided to the City by February 15, 2019. There is a follow-up meeting scheduled for February 28, 2019 to review the draft. It is the intent of both agencies to execute the memorandum of agreement by March 31, 2019.

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #7 To: San Diego, City of

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.

1-Year Agency Response

In the initial update on February 15, 2019, the City anticipated to complete this recommendation by April 30, 2019. Staff completed the final draft of a Process Narrative (PN) which provides clear definitions of roles, responsibilities, and processes for City employees who may be contacted by local, state or federal official regarding public health issues.

Approval of the Process Narrative (PN) was subsequently placed on hold pending formal passage of a Memorandum of Agreement (MOA) between the City and County detailing communication and service protocols between the two agencies. The hold ensured that the PN and MOA would be consistent and avoid any future missteps in communication procedures. The MOA was approved by the City Council on December 9 and approved by the County Board of Supervisors on December 10. The City's Process Narrative was approved and published on December 9.

Establishment of the PN and MOA ensure that moving forward, the City has adequate procedures in place for internal and external communications to address local health emergencies in a timely and effective manner.

Supporting documents will be emailed directly to audit staff as a part of this response. First Full Month of Implementation will be January 2020.

California State Auditor's Assessment of 1-Year Status: Resolved

Based on the documents provided by the City of San Diego, we assess this recommendation as resolved.


6-Month Agency Response

In the initial update on February 15, 2019, the City anticipated to complete this recommendation by April 30, 2019. Staff has completed the final draft of a Process Narrative (PN) which provides clear definitions of roles, responsibilities, and processes for City employees who may be contacted by local, state or federal official regarding public health issues. In addition, the PN contains processes for notifying City elected officials of public health concerns.

It is anticipated the PN will be approved within 30 days. Once it is complete, it will immediately be transmitted to the State for review.

California State Auditor's Assessment of 6-Month Status: Pending


60-Day Agency Response

Staff met to discuss the recommendation and have identified a need for clear definitions of roles and responsibilities for city employees who may be contacted by a local, state, or federal official regarding a public health issues, such as an outbreak. To assist in this, a Process Narrative (PN) will be developed to clearly define the steps related to such a contact, in addition to having a robust city contractual arrangement with medical experts. It is the intent to have the initial review completed by March 31, 2019.

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #8 To: Public Health, Department of

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.

60-Day Agency Response

The California Department of Public Health (CDPH) has updated its Hepatitis A Outbreak Response Plan to ensure that at the time an outbreak occurs, the Department, in coordination with local health jurisdictions will:

- Establish target vaccination rates among defined populations

- Establish a schedule to achieve the target vaccination

- Determine staffing and other resources needed to administer the target vaccination within the established schedules

California State Auditor's Assessment of 60-Day Status: Fully Implemented


Recommendation #9 To: Public Health, Department of

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.

60-Day Agency Response

The California Department of Public Health (CDPH) has updated the California Public Health and Medical Emergency Operations Manual, Emergency Powers chapter to incorporate the types of actions that local health officers can take related to the prevention or containment of infectious diseases. The update has been released and is available on the CDPH website at: https://www.cdph.ca.gov/Programs/EPO/Pages/Resource_Publications.aspx

California State Auditor's Assessment of 60-Day Status: Fully Implemented


All Recommendations in 2018-116

Agency responses received are posted verbatim.