Closer coordination between county and city governments, better vaccine coverage for homeless and drug-using residents and more prompt use of volunteer nurses are among 21 recommendations included in a hepatitis A outbreak report released Thursday by the San Diego County Board of Supervisors.
Requested in January when the county board voted to end the region’s hepatitis A health emergency, the 200-page after-action report synthesizes the myriad aspects of the county health department’s response to tame a public health threat that infected 588 people and killed 20.
The new county report presents one among many potential views of the local hepatitis response. The City of San Diego, which had the vast majority of cases, announced Thursday that it will conduct its own after-action report using the county’s effort as a starting point, and the state Legislature may also decide to conduct an audit as requested last week by Assemblyman Todd Gloria.
There is much to study in a public health emergency that was first detected in March 2017, was traced back in time to late 2016 and which still has not technically ended, though the number of outbreak-linked cases has slowed to a trickle.
As the human toll continued to grow during the summer and fall of 2017, for a time becoming the largest such hepatitis A outbreak seen nationwide in more than 20 years, local public health officials found themselves under increasing scrutiny.
The situation began to gradually improve after Dr. Wilma Wooten, the county’s public health officer, declared a local health emergency on Sept. 1, 2017, and, one day earlier, ordered San Diego to begin pressure-washing streets frequented by homeless residents.
At the time, some questioned why these actions weren’t taken sooner given that there had already been 253 cases and five deaths by June 30. Though there was much talk that bureaucratic red tap got in the way of some sanitation work, such as installing temporary hand-washing stations, the after-action report does not delve into the matter directly.
The report’s first recommendation does call for the county to “enhance its use of incident management structures to coordinate regional actions,” and, for future outbreaks, to include a “policy group” that includes “executive leadership from affected jurisdictions.” But it does not break down who said what to whom behind the scenes in those early-summer months of 2017 when the outbreak was growing and many were grumbling.
Local politicians had varied views of the county’s after-action report.
In a statement, Dianne Jacob, the county supervisor who first called for the examination, said she’s satisfied.
“It spells out what I hoped it would — what went right and what the county could have done better during the outbreak,” Jacob said. “There are always lessons to be learned in a crisis and it’s critical that we learn from this one. While county health officials met the outbreak head-on, we need to address the report’s recommendations so we can better contain any similar emergency in the future.”
Craig Gustafson, a spokesman for San Diego Mayor Kevin Faulconer, was conciliatory while also letting the public know that the city’s Office of Homeland Security will now perform its own after-action review of the hepatitis outbreak.
“The county report has several solid recommendations including the need for better regional coordination and collaboration,” Gustafson said. “We agree and will continue to work with our county partners to improve the regional response to public health emergencies going forward.”
San Diego City Councilman David Alvarez, who has been the loudest critic of how local government handled the hepatitis outbreak response, said in his own statement Thursday afternoon: “The Hepatitis A epidemic occurred because homelessness is a problem. This report makes it clear that the County still doesn’t get it. At the same time homelessness exploded in San Diego, the County sat on millions of dollars in reserves that were supposed to be use for mental health. Until the county takes its health and human services responsibility seriously, it will be impossible to reduce homelessness in San Diego.”
Jacob quickly fired back: “Maybe Councilmember Alvarez should spend more time on ways to combat homelessness and affordable housing than sounding off on a report that he clearly doesn’t understand. The report isn’t intended to document the hundreds of millions of dollars the county spends on addressing housing, mental health and substance abuse.”
Assemblyman Gloria, who recently asked the state Legislature’s t audit committee to examine the local hepatitis response, did not offer his opinion on the county’s effort.
Those who read the report will come away with an understanding that the county’s outbreak-busting efforts were innovative and ultimately successful.
Much ink is given to the health department’s use of vaccination foot teams which, starting in May, began to send public health nurses paired with law enforcement officers on homeless outreach teams, into the canyons, brush-choked riverbeds and bridge underes to give vaccinations far afield from the public health clinics where such work is usually undertaken.
At the peak of its vaccination efforts, between 100 and 132 public health nurses were involved, with another 121 nurses brought in to help out under contract.
San Diego is home to a branch of the state’s Medical Reserve Corps, a volunteer force of trained and certificated health providers designed to help respond to large medical emergencies and public health threats.
Dr. Sayone Thihalolipavan, the county’s deputy public health officer, said that while some reserve corps nurses did participate in county vaccination efforts, their numbers did not come close to approaching the 799 currently listed in the reserve registry. And, the nurses were not able to the outbreak fight until relatively late in the game due to state law that, in most cases, requires an emergency to be declared before reserves can be activated.
Other states are not so strict and allow volunteer reserves to participate and drills and even care delivery outside of emergencies. Given that sheer numbers of health care workers are necessary to make a big vaccination push, having hundreds of nurses able to give vaccinations early on in the outbreak response would have been a big advantage, Thihalolipavan said,.
“We underutilize them, and fixing that is something that we’re talking about internally,” he said.
No. 16 among the report’s recommendations calls for the county to pursue a state-level policy that would explicitly allow the Medical Reserve Corps to act outside of declared emergencies. Several counties have also managed to get around the emergency limitation by taking out additional liability insurance to cover volunteer nurses acting on the health department’s behalf.
Vaccination has been seen as the main way that the public health effort stopped the outbreak’s spread through the community. More than 120,000 doses of vaccine were given during the wide-ranging effort.
But public health experts have noted all along that the real problem was that so many people who were at risk for hepatitis A infection were not vaccinated as they should have been before cases started appearing.
Federal vaccination recommendations already counsel doctors to offer hepatitis A vaccines to gay men, drug s and those with liver disease, yet many in these high-risk groups who became infected “reported never having been offered the (hepatitis A vaccine) by a medical provider.” The after action-report states that county public health will continue working with local primary care doctors to increase the number of people who get inoculated during the regular course of their care.
At the moment, the U.S. Centers for Disease Control and Prevention does not consider homelessness to be a specific indication for hepatitis A vaccination. The report, which notes that homelessness has been added to local vaccination recommendations, calls for the CDC to advocate for similar changes on a national level.
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