Received AUG 09 2018

An earlier declaration of a local public health emergency would have provided the authority to direct the implementation of more effective measures to deal with the epidemic. Response: The County of San Diego Chief Administrative Officer disagrees with this finding. The Centers of Disease Control and Prevention has expressed, in a letter regarding the San Diego County hepatitis A outbreak1, that the most effective and demonstrated measure to stop the outbreak (one of the largest nationally to-date) was mass vaccinations. Despite public perception, the Public Health Officer's authority to direct the response, in particular the effort to vaccinate at-risk individuals, does not increase as a result of declaring a local health emergency. The County of San Diego (County) implemented mass vaccinations for the at-risk population upon identification of the outbreak. The declaration of a local health emergency had the positive effect of increasing the attention of the general public, partner entities, and the media; but it also had the negative effect of creating a climate where some not in the at-risk population (also known as the "worried well") utilized resources and vaccines needed for the targeted at-risk population. Declaring earlier could have diverted vaccine and nursing resources away from the critical at-risk population at the onset and hampered the urgent ability to reach the targeted population. The County procured additional supplies of vaccine out of an abundance of caution due to production shortages from the available phannaceutical sources at the time to enable us to expand our vaccination efforts to include lower risk needs including the '·worried well" without jeopardizing our ability to vaccinate the high priority at-risk population.

The Emergency Operations Plan failed to establish an incident conunand stmcture in a health emergency which led to confusion and jurisdictional conflict. Response: The County of San Diego Chief Administrative Officer disagrees partially with this finding. The County recognizes that communication is a vital component to the efficiency of a response to an emergency. When the outbreak was identified, communication lines were established with critical stakeholders. These included the health care community, the cities and service providers who serve the identified at-risk community. In addition, during this time, Public Health Services ATTACHMENT put a command structure in place to work with stakeholders and respond to the outbreak. A forn1al incident conunand structure is identified in the County·s Emergency Operations Plan and was implemented during the outbreak. HoweYer. consistent with the County"s Hepatitis A After Action Repo11 issued on May 10. 2018, the County is looking to enhance its use of incident 111anagement structures to coordinate regional actions. C0unty of San Diego. (2018). Hepw;rfs A .~fi:er Action Report. Retrie\·ed from ill\P'< \\ \\ \\ .sandic~\, ..~. 0u1H\ . ~(1\ ('\~nl~nt dam ::.d,: n1~J SanDi,:2.ol-kpatiti:-..•\Outhrcak-i() 1--l .S .:-\ ft<..·r .\l' ti\)nR.CD(lfL pjf

The lack of early cooperation between County and City resulted in rnmecessary delays in installation of handwasbing stations and other public health measures. Response: The County of San Diego Chief Administrative Officer disagrees partially with this finding. The County implemented a tlu·ee-pronged strategy to address the hepatitis A outbreak. The primary focus of responding to this outbreak was mass vaccinations, which is a demonstrated and effective way to stop the transmission of hepatitis A. The City and County were fully cooperative with vaccination and education 111easures to address the outbreak. Unfortunately, there is a perception that handwashing stations are a routine response to such an outbreak. However, deploying handwashing stations regionally to address an outbreak was an unprecedented and untested idea developed by San Diego County public health officials in Spring 2017 based on the method of transmission among the impacted population. The coordination of logistics between the County and the City was impacted by the experimental nature of this intervention.

The East Mesa Juvenile Detention Facility needs to develop programs aimed at reducing violence in the facility. Response: The San Diego County Probation Department disagrees partially with this finding. The Probation Depm1ment has already developed several programs designed to prevent and reduce violence among youth. including at East Mesa Jm·enile Detention Facility. which houses youth with the most extensive criminal justice histories. However, we will continue to develop and add to these programs. Probation is currently working with the Center for Juvenile Justice Reform at Georgetown University as part of their Youth in Custody Practice Model technical assistance program. This effort is aimed at adopting an approach that is focused on the development of youth in our detention facilities. One of the expected outcomes of this eff011 is a reduction in violence among youth. ATTACHMENT

City administrators and County health officers had different concerns in responding to the crisis and failed to appreciate each other's perspectives. Response: The County of San Diego Chief Administrative Officer disagrees partially with this finding. As with any government entity, the County and the City had the same concern which was the protection of the public health and safety. This shared concern was e,·ident in the cooperation between both jurisdictions with vaccination and education measures to address the outbreak. Roles and responsibilities between County Public Health and other local municipalities are sometimes different during public health emergencies. Enhancements in conmmnication and a clarification of roles and responsibilities is required.

Removing CLERE from the Public Safety Group will provide additional independence from those departments that CLERE reviews. Response: The County of San Diego Board of Supervisors and Chief Administrative Officer for the County of San Diego disagree with this finding. The County's Public Safety Group has no operational oversight over CLERE. The group's executive office provides only administrative support. The Public Safety Group is best suited to provide administrative support services to CLERE such as Human Resources and Finance because of the group's deep experience and knowledge in the subject areas addressed by CLERB. For example, Public Safety Group Human Resources staff members currently assist in the hiring of investigators to work in law enforcement-related areas for several County departments and are familiar with advising staff on recruiting and evaluating candidates.

The County has not designated a project manager with sufficient expe11ise to understand the administratiw concerns of City staff in responding to public health directives. Response: The County of San Diego Chief Administrative Officer disagrees with this finding, The County determined at the onset of this infectious disease outbreak that an appropriate representative to the City of San Diego was necessary. Thus, the County assigned the Deputy Public Health Officer as the primary liaison ATTACHMENT to the City. This liaison continues to work collaboratively and regularly with City staff to coordinate cross-jurisdictional public health activities. The Deputy Public Health Officer and the City of San Diego began communicating in April 201 7 and had the first fonnal meeting in early May 2017. These routine communications allowed for coordination of vaccination, sanitation, and education efforts. One of the City's main concerns was in regards to sanitation. The Deputy Public Health Officer assisted with coordinating discussions between the City of San Diego, the County of San Diego's Land Use and Environment Group, and the City of Los Angeles, which had established effective sanitation efforts that could be replicated. The County subsequently led efforts to set up a site visit with Los Angeles and coordinated a sanitation meeting with Los Angeles representatives that all San Diego County cities were invited to attend. In addition, the Deputy Public Health Officer presented to City's senior managers and to the Mayor's Homeless Solutions Conunittee. Ultimately weekly meetings were conducted between leadership from both jurisdictions, including the Public Health Officer and the Deputy Public Health Officer. These meetings further enhanced coordination and were conducted until the end of the emergency.

A single, centralized, user-friendly San Diego County graffiti reporting system would improve graffiti reporting and 111itigation. Response: The County of San Diego Board of Supervisors disagrees with this finding. A centralized, user-friendly system for graffiti reporting currently exists through 2-1-1 San Diego. In the County unincorporated jurisdiction, an effective system for collecting and handling graffiti complaints also exists. The County has found no evidence that citizens find it difficult to locate information on how to report graffiti. Throughout San Diego County, 2-1-1 San Diego provides a regional mechanism for citizens across the County to report graffiti, either by calling "2-1-1" or by filling out a fonn on the nonprofit's website. Staff members then pass along complaints to the jurisdiction legally responsible for responding. 2-1-1 's regional public-facing system is useful for public reporting. For graffiti mitigation, each jurisdiction takes action per their legal responsibility and local processes. In the County's unincorporated area, the County has found that the current methods are accessible and effective in supporting graffiti reporting. The County receives few complaints or questions regarding graffiti occurring outside of its jurisdiction, and when such complaints are received, County staff members route them to the appropriate jurisdiction. County staff members also provide the reporting party with the contact infonnation for that responding agency.