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Grand jury scolds county for response to Hepatitis A outbreak

Grand jury scolds county for response to Hepatitis A outbreak

San Diego’s recent Hepatitis A epidemic was mishandled by public health officials, according to a newly minted country grand jury report. It charges San Diego County’s Public Health Officer was slow to declare a public health emergency and the command structure during the outbreak was lacking.

The 20-page report also speculates on the possibility that San Diego’s November 2016 ban on single-use plastic grocery bags might have sparked the outbreak because the action “deprived the homeless of an efficient and relatively sanitary method for containing and disposing of fecal matter.”

The report by the San Diego County Grand Jury does not mean anyone is going to jail. In addition to issuing criminal indictments and investigating public corruption, county grand juries in California perform a civil function as a “watchdog” for local government.

The San Diego Grand Jury decided to examine the response to the 2017/18 Hepatitis A outbreak involving 580 confirmed cases and 20 deaths, and issue recommendations.

Much of its focus is on the communication and cooperation between San Diego County and the City of San Diego, or where it was lacking. It says there was “little medical evidence” to support the theory about the plastic grocery bag ban.

Here are the grand jury recommendations:

  • Where there is a similar outbreak in the future, San Diego County should declare an emergency much sooner.
  • The Emergency Operations Plan needs revision to establish a command structure for use during public health emergencies. It should allow agencies involved to recognize and implement their duties within the structure.
  • San Diego County must establish clear lines of authority to prevent misunderstandings over department responsibilities.
  • The County should designate a project manager to communicate with the City of San Diego and medical personnel so health emergency actions are taken quickly.
  •  The City of San Diego should adopt procedures to reinforce the authority of the County health officer during public health emergencies.
  • The City of San Diego should designate a medical professional reporting to the Mayor to advise all city officials concerning public health announcements.
  • The City of San Diego should construct and maintain additional secure restrooms and handwashing facilities in areas “where homeless congregate.” Previous grand juries have made that same recommendation three times since 2004.

Numerous other states and localities have recently experienced sharp increases in Hep A cases. San Diego’s recent epidemic is the largest in 25 years. “The sudden increase in Hep A centered on the local homeless population and illicit IV drug users, and was unrelated to food contamination, ” according to the grand jury report.

The grand jury report says the county’s public health officer waited for six months before declaring an emergency. During that time 434 confirmed cases and 16 deaths occurred.

“Declaration of a public health emergency is a vital step in dealing effectively with a local epidemic,” the report says. “Such declaration gives Public Health Officer (PHO) the legal basis for directing the health-related activities of governmental entities with the county, rather than merely advising or negotiating with them regarding steps that could be taken to control an outbreak.”

The grand jury report says “no playbook” existed for dealing with the public health crisis and San Deigo County was “slow to respond.”

San Diego did have a  three-fold response to the crisis, including vaccination, sanitation, and education.

The grand jury recognized vaccinations are “most effective for protecting individuals who have not been exposed to the virus. “A single dose provides about 90 percent immunity, and the second dose given six months later provides close to complete immunity,” according to the report.

San Diego County began free vaccinations in March 2017, focusing on local shelters and other organizations that served the homeless community throughout the country.  “These programs were effective in reaching a substantial portion of the urban homeless population who were motivated to be vaccinated,” the report says.

“However, those who were not predisposed to accept vaccination and those who lived in isolated  settlements (e.g., along rivers or in canyons) were more difficult to reach, and innovative methods had to be developed to treat these groups.”

The grand jury does credit the county with such innovative methods for vaccinations as using firefighters and “foot teams” of nurse volunteers to reach homeless encampments.  By early 2018, the massive vaccination program had reached more than 100,000 people.

The sanitation efforts included distribution of over 11,000 hygiene kits and opening additional public toilets with handwashing facilities for the homeless. The City of San Diego did decline some locations and the issue remained in dispute between the jurisdictions. Street sanitation and riverbed cleaning were also part of the program.

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