For nearly a month, San Diego officials have scrambled to stem a deadly hepatitis A outbreak that’s showing no signs of slowing.

They’re power-washing streets, organizing mass vaccination events and engaging in PR efforts to show San Diegans they’re doing all they can to combat the outbreak.

But for months, city and county officials defaulted to bureaucratic processes and often took weeks to move forward with seemingly simple tasks as the outbreak – and its death toll – exploded.

Emails released following public records requests, and even accounts from city and county officials, put city and county officials’ lack of urgency amid an outbreak that’s left 17 dead and sickened more than 460 people on stark display.

Here’s a breakdown of ideas and requests floated in response to the outbreak, and how long they were batted back and forth.


The Action: Provide emergency medical records on suspected and confirmed hepatitis A cases.

What Happened: At a May 4 meeting, a county public health official asked the city to provide information on ambulance transports of patients with hepatitis A. The city asked that the county make the request in writing.

Deputy Public Health Officer Dr. Sayone Thihalolipavan emailed a formal request to city Assistant Chief Operating Officer Stacey LoMedico and San Diego EMS Medical Director Jim Dunford on May 19, a Friday, at 6:30 p.m. Dunford forwarded the request to two Fire Department officials that night.

Almost two weeks later, Dunford followed up with the Fire Department officials. Deputy Fire Chief Gina La Mantia replied three hours later, saying another EMS official had reached out to the county the previous week and was waiting for the county to provide the names of patients. La Mantia said the EMS official would reach out to the county again.

In other words, there was continued confusion about exactly what the county needed long after the verbal request.

A mayor’s office spokesman said the county provided patient information to the Fire Department on June 5, and that the Fire Department provided records to the county the following day.

The Result: The city provided the information the county sought a full month after the initial request. Much of that time was spent waiting on the county to provide a formal request and then, to provide names of patients so that the information could be provided.


The Action: Provide guidance to downtown businesses about sanitation.

What Happened: At a May 4 meeting, city and county officials discussed providing guidance on sanitation steps to combat hepatitis A to the Downtown San Diego Partnership, a downtown business group.

LoMedico checked in with Thihalolipavan on May 11, noting she was still waiting for the sanitation tips. Thihalolipavan said the county was working on it and would be in touch “very soon.”

A week later, on May 19, Thihalolipavan said the county planned to send the guidance for businesses and a list of frequently asked questions early the following week.

On Wednesday, July 14, Thihalolipavan sent LoMedico a letter, FAQ list and updated flier to send to the Downtown Partnership. Within 10 minutes, LoMedico emailed her assistant to have her send the documents to the Downtown Partnership.

The Result: The city provided the sanitation information to downtown businesses more than two months after officials discussed doing so.


The Action: Distribute posters encouraging hepatitis A vaccinations to city recreation centers and libraries.

What Happened: At a June 28 meeting, Thihalolipavan and LoMedico discussed distributing public information posters on the hepatitis A outbreak.

LoMedico followed up on July 28: “I had this in my tickler file: Posters from the county to post in city public offices (e.g. libraries, recreation centers). Is there anything you need from us?”

Susan Bower, an assistant director in the county’s Health and Human Services Agency, emailed LoMedico and city homelessness point person Jonathan Herrera to share PDFs of posters on Aug. 7. LoMedico responded that day, asking if the county would provide printed posters or simply the links. Bower quickly replied that the county would soon print posters.

On Aug. 17, Thihalolipavan asked LoMedico, Herrera and the city’s communication director to let him know how many posters they’d like and where they should be delivered.

The Result: Posters went up in city libraries and recreation centers nearly two months after the city and county talked about distributing them.


The Action: Deploy handwashing stations.

What Happened: On May 4, the county had its first sit-down meeting with city officials. There, a county spokesman said, officials emphasized the need for improved sanitation and handwashing stations in areas where homeless people congregate.

“The city rejected that idea based on previous experience involving criminal activity around similar facilities,” spokesman Mike Workman wrote in a statement.

Two weeks later, Workman said, the county offered to pay for handwashing stations within the city and was told no.

“In late June, the city suggested an expanded permit process tied to large special events. They also suggested they would like us to launch a pilot program of handwashing stations on our own properties,” Workman said.

Greg Block, a mayor’s office spokesman, disputes this version of events. He said conversations about handwashing stations didn’t start until June, and that the city had concerns about public restrooms, not wash stations.

In a June 28 email to Thihalolipavan, LoMedico said she had mentioned to another county official that “we are waiting for the final description of what you envision the handwashing stations will look like (e.g. specifications) and locations that you may want to utilize.”

LoMedico said development services staff were “on stand-by” to provide information on permits that may be needed to install the stations in the public right-of-way.

Thihalolipavan replied that the wash stations were “only in planning phase right now.”

On July 13, two handwashing stations went up at a county facility in the Midway district, miles from the downtown streets considered ground zero of the outbreak. Nearly a month later, Thihalolivapan emailed LoMedico and Herrera to let them know the county hoped to install another handwashing station at a downtown welfare office. “Appreciate your help with permitting of course,” Thihalolipavan wrote.

A day later, LoMedico introduced another county official to a deputy director in the city’s engineering department and provided a link to a potential permit option.

“When the county staff is ready to move forward, they are aware to reach out directly to you,” LoMedico wrote in the email, referring to the engineering staffer. “It may not be this week but the key is that introductions have been made.”

County officials told VOSD on Aug. 25 that they planned to deploy more handwashing stations.

LoMedico, who also sat in on the Aug. 25 meeting, said the city was prepared to authorize a single permit to cover any sites the county wanted to proceed with within a few days.

Dale Fleming, a director in the county’s Health and Human Services Agency, said city and county lawyers had been hashing out the wording of the permit in the two weeks since LoMedico shared permit information.

A single additional handwashing station went up downtown on Aug. 30. County and city officials exchanged a series of emails that day discussing a handwashing station permit.

That same day, VOSD published a story documenting bureaucratic fumbling over the handwashing stations.

Only then did city and county officials spring into action.

The next day, Public Health Officer Dr. Wilma Wooten and county Chief Administrative Officer Helen Robbins-Meyer issued a directive demanding the city allow the county to install handwashing stations in at least 30 locations.

In an email that morning, LoMedico told a manager in the city’s development service department that she wanted to ensure the county understood it could quickly install the stations as the permit was being finalized.

“Make it clear they can install absent the executed permit,” LoMedico wrote.

The Result: The first stations went up four months after a county spokesman said county officials first mentioned the need for increased sanitation opportunities, including wash stations.

The bulk of those stations didn’t go up throughout the city until after VOSD published a story detailing delays.


The Action: Clarify whether hepatitis A could be spread via the San Diego River.

What Happened: In June, City Councilwoman Lorie Zapf said she started questioning whether hepatitis A could be spread through the San Diego River. Hundreds of homeless San Diegans live along the riverbed, and the outbreak has disproportionately pummeled the city’s homeless population.

Zapf said she began to ask county officials whether the outbreak, which is spread when someone ingests traces of fecal matter from an infected person, could be spread through the water. After all, the area’s littered with trash and feces.

Over the next few weeks, Zapf tried communicating with county officials about her concerns. She could not get answers. On July 14, she sent a letter to Supervisor Ron Roberts with seven questions about potential river contamination and the risk of spread of hepatitis A.

Wooten, the county public health officer, responded on July 26, nearly two weeks later.

Wooten wrote that four cases, including one death, had been linked to the river valley, though it was unclear they’d contracted the virus there. She also said that county nurses had visited the river valley to offer vaccinations for the first time on July 20, nearly a week after Zapf’s letter.

Wooten also noted that hepatitis A can persist in a river bed for “days to months” depending on the conditions. The risk of spread was unknown but expected to be “very low.”

Then came the kicker that rattled Zapf: “Our county team welcomes any of your suggestions and recommended partnerships to help protect the river valley and unsheltered individuals, seeking refuge in the area, the services they need.”

At the time, the memo was labeled confidential.

Donna Cleary, a Zapf staffer who’s led discussions with the county about hepatitis A, emailed Roberts’ chief of staff on Aug. 2 to ask if he would be interested in teaming on a clean-up effort.

“Let us give the suggestion some thought,” Giametta wrote that same day. “Will be back to you before long.”

Weeks passed. The City Council was on legislative recess through much of August, and Zapf didn’t speak publicly about her concerns.

Zapf ultimately confronted Wooten at a Sept. 13 City Council committee hearing. She asked if the city was solely responsible for clean-up efforts along the San Diego River.

Wooten explained that the county is responsible for unincorporated areas and the city within its boundaries.

The next day, Sept. 14, Zapf and City Councilman David Alvarez sent a letter to the mayor, county and four other agencies with jurisdiction over the river to ask that they help expedite a clean-up of the riverbed.

That day, the county’s chief administrative officer sent a letter to the city’s chief operating officer, saying the city – not county – needed to sanitize “all contaminated areas where homeless reside,” including riverbeds and ravines.

A mayor’s office spokesman said this week the city is planning clean-up activities in its portion of the riverbed within the next few weeks.

The Result: Concerns about potential contamination of the San Diego River and the spread of hepatitis A weren’t publicized for weeks despite Zapf’s questions. The stalled response and confusion over whether the city or the county would take responsibility for them likely also put off conversations about clean-up efforts.

Lisa is a senior investigative reporter who digs into some of San Diego's biggest challenges including homelessness, city real estate debacles, the region's...

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