A top county health official warned last April, in the early weeks of the hepatitis A outbreak, that last year’s devastating health crisis could be one of the worst outbreaks since vaccines were introduced, and urged an aggressive response.
Yet the county waited four months to declare a public health emergency . By then, the disease had killed 15 people and sickened hundreds.
The April 28 email, which Voice of San Diego for months sought through public records requests, is one of several blistering revelations about local governments’ response to last year’s hepatitis A outbreak in a state audit  released Thursday.
The title of the audit underscored the report’s overarching finding: “By acting more quickly, the county and the city of San Diego might have reduced the spread of the disease.”
The audit, which was requested by state Assemblyman Todd Gloria, concluded that local officials failed to adequately plan and quickly ramp up their response to an outbreak that eventually led to 20 deaths and sickened nearly 600.
The audit detailed the county’s stalled responses before finally declaring a public health emergency in September 2017, a move that triggered dramatic action  from regional officials and agencies.
“Had the county taken in June and July 2017 the actions that it took starting Aug. 31 and continuing through October 2017 – namely declaring a local health emergency, improving hygiene opportunities by directing the city to expand access to public restrooms and wash stations within the city limits and vaccinating more than 40,000 individuals against hepatitis A in both September and October – we believe it may have brought the outbreak under control sooner,” auditors wrote. “As we explain previously, the county had case information by the end of May that showed that its early efforts had not successfully contained the spread of the disease.”
Indeed, for months before the Sept. 1, 2017, emergency declaration, city and county officials had fumbled over bureaucratic processes  and responded slowly to an escalating crisis.
The audit revealed that the county’s medical director – who is not identified in the audit – wrote in the April email to Public Health Officer Wilma Wooten that “mass immunizations are just now getting underway” and described his fears that the outbreak could become one of the worst in the nation.
Both the county and the state auditor’s office confirmed Thursday that Dr. Eric McDonald, who directs the county’s epidemiology and immunization efforts, sent the email.
The audit said that the medical officer argued that the county should activate a broader incident command system to compel more dramatic responses, coordinate and increase resources from outside the county’s public health structure.
“Mass vaccinations are only just now getting underway,” McDonald wrote in a heavily redacted April 28 email obtained by VOSD after the audit was released. “In my opinion, if more aggressive measures are not coordinated immediately, this outbreak is on track to be one of the worst ones in the United States since the vaccine was introduced.”
The county did assemble an incident command system but did not pull in city officials, according to the audit.
The county previously did not release the email following VOSD’s August 2017 request for emails that mentioned hepatitis A, and after a later October 2017 request seeking emails documenting discussions about declaring a public health emergency.
County officials apparently determined the email exchange between the public health officials was exempt from the state Public Records Act.
The audit found that the county also failed to take critical steps in the early months of the outbreak.
Namely, the audit noted, county officials failed to set targets and timelines as they sought to vaccinate those at risk, and to compel the city to improve sanitation.
The audit concluded that the county was slow to vaccinate the homeless San Diegans and illicit drug users considered most vulnerable to contracting hepatitis A.
The audit reveals that in May 2017, UC San Diego infectious disease experts calculated that the county would need to ensure 71 to 80 percent of the at-risk populations were immune – meaning they were either vaccinated or had already had hepatitis A – to achieve so-called community immunity, which dramatically quells the spread of an outbreak.
From March through June 2017, auditors wrote that the county vaccinated just 5,500 people – or 7 percent of the at-risk population.
“The medical director stated at the time that he supported vaccinating at least 10,000 additional at-risk people in July 2017,” auditors wrote. “However, the county did not establish this as a target, nor did it develop new vaccination targets or time frames to reflect the information in the UC San Diego model.”
In the month after the county declared a public health emergency in September 2017, the county and other local agencies administered 41,400 vaccinations.
The rush to vaccinate seemed to work.
The number of new cases dramatically declined in the weeks after the emergency declaration. County data shows more than 70 percent of outbreak cases were confirmed before Sept. 1, 2017.
The lack of urgency also hampered efforts to implement sanitation measures that could have helped curtail hepatitis A, which spreads when a person ingests trace amounts of fecal matter from a person who’s infected with it.
The audit noted that the county worked with restaurants and distributed hygiene kits to homeless San Diegans but only slowly rolled out handwashing stations and street sanitation efforts that required coordination with the city.
The audit said that, as reported by VOSD last August, the city and the county repeatedly discussed handwashing stations and sanitation efforts before acting on them.
The city scrambled to accommodate handwashing stations and begin street-cleaning efforts after Wooten issued a directive on Aug. 31, the day after the VOSD story that documented bureaucratic idling . Within days, the county and the city teamed to install more than 40 handwashing stations, increase access to public restrooms and take steps to begin street-cleaning.
“The county health officer stated that she did not issue a directive earlier because the county wanted to work with the city first instead of forcing it to comply,” auditors wrote. “However, we believe that waiting two months – from late June through the end of August 2017 – was excessive.”
The latter statement was a reference to the two months that elapsed after the county suggested a handwashing station pilot and the installation of dozens of handwashing stations.
Before the county’s Aug. 31 directive , the county had installed just a few handwashing stations, including some that were in inaccessible locations far from where those most likely to contract the disease might use them.
A lack of information-sharing contributed to the delayed response, auditors wrote.
The audit noted that, as reported by VOSD  last year, the county did not share location data by ZIP code that would have made clear the city’s status as the central hub of the outbreak until last November.
An assistant chief operating officer told auditors the city didn’t act more quickly because county officials had not provided direction or raised alarms.
“The assistant chief stated that the county had never given the city a response to believe that the outbreak was a serious issue that warranted the immediate implementation of sanitation measures until the county health officer issued the sanitation directive in August 2017,” auditors wrote.
Auditors wrote that the city should have nonetheless taken steps to ensure it sufficiently protected the health of the homeless San Diegans most vulnerable to the outbreak since officials knew their city was home to a large percentage of the region’s homeless population.
The audit recommended that state legislators consider clarifying state laws to specify that public health officials can issue directives to other governments to ensure they take steps to control the spread of disease, and to require health officers to notify and update local entities on outbreaks that may affect them – and details that could guide efforts to respond.
Auditors also urged the county to update policies and plans to clarify responsibilities and encourage collaboration with other government entities during future outbreaks.
The audit also called on the city and the county to enter into an agreement to define their roles in responding to public health issues, and on the city to address issues that may have contributed to delays in implementing sanitation measures prior to the September 2017 public health declaration.
Despite the critical audit, the county’s top health official defended the county’s response to the hepatitis A outbreak in a Dec. 3 response to the state auditor and emphasized that the county had, in end, worked with regional, state and federal partners to eradicate the outbreak.
“While there are areas in which we could have acted more quickly, success is not purely measured by the speed of the response, but also the effectiveness of the actions taken,” Nick Macchione, who leads the county’s Health and Human Services Agency, wrote.
Despite Macchione’s pushback on details laid out in the audit, the county reported that it agreed with the audit’s recommendations.
The city said the same.
“We agree with the recommendations, particularly that the city and county should strengthen their relationship as it relates to responding to regional emergencies,” Kris Michell, the city’s chief operating officer wrote in a statement. “We look forward to working in partnership with the county on this recommendation.”
Gloria, who requested the audit, said in a Thursday statement he was still evaluating the report but said it was clear that lives could have been saved if local agencies acted with more urgency sooner.
“We now know that the county and the city could have planned better and acted sooner to contain the spread of this disease. Unfortunately, that was not done until it was too late,” Gloria wrote. “I will continue to pore over the audit’s findings in the coming weeks and I intend to propose solutions to ensure this never, ever happens again.”