December 20, 2018
The Governor of California
President pro Tempore of the Senate
Speaker of the Assembly
Sacramento, California 95814
Dear Governor and Legislative Leaders:
As requested by the Joint Legislative Audit Committee, the California State Auditor presents this audit report regarding the response to the 2017–18 hepatitis A outbreak in San Diego County (county) and the city of San Diego (city). This report concludes that the county, which is responsible for the area’s public health matters, took steps to understand the increasing number of reported hepatitis A cases, determine the necessary interventions to contain the outbreak, and identify the characteristics and size of the at‑risk populations. However, the county failed to include critical details in planning its response such as identifying the number of vaccinations it would administer, the timelines for administering them, and the resources—primarily, nursing staff—needed to carry out the vaccination program. As a result, the county did not accelerate vaccination efforts until September and October 2017. Had the county hastened its vaccination efforts, it may have more quickly reduced the risk of the disease’s spread, which grew to include 584 reported hepatitis A cases, 398 hospitalizations and 20 deaths by the end of January 2018.
Although the county also identified multiple sanitation measures that could address the outbreak, neither it nor the city promptly implemented all of them. For instance, despite conversations between the county and city as early as June 2017, neither began fully implementing measures related to hand‑washing stations, public restroom access, and street sanitation until September 2017 and only after the county’s health officer issued a directive telling the city it had to take action on the sanitation measures. The county health officer did not issue the directive earlier because the county wanted to work with the city first before it resorted to mandating compliance.
Finally, the California Department of Public Health (CDPH), the county, and the city have identified changes to improve their response efforts to future incidents, but room for improvement remains. For example, CDPH created guidance for responding to future hepatitis A incidents, but this guidance omits two critical steps: establishing time frames to achieve target vaccination rates and determining the number of nurses or other resources needed to administer the vaccinations within those time frames. Furthermore, the county acknowledged that it would have been appropriate to include leadership from affected local jurisdictions in a policy group to manage their response, and it has drafted—but not yet finalized—policies related to activating such cooperation in future threats to public health. The city has issued its own report about its response to the incident; however, its analysis was limited to only the time during which the local health emergency was in effect—September 2017 through January 2018. By not also assessing its actions before the local health emergency declaration, the city missed an opportunity to address issues that contributed to delays in implementing sanitation measures.
ELAINE M. HOWLE, CPA
California State Auditor