Customers at Communal Coffee sit at tables placed six feet apart to prevent the spread of coronavirus. / Photo by Adriana Heldiz

Imagine a time when (and if) San Diego is hit by a second wave of COVID-19 cases.

If it happens soon, officials will need to tighten up the lockdown that they have not even finished easing. If it happens later – say, around the time everything has just reopened – society will be forced to take the long and grueling walk back into isolation.

This week, the San Diego County Board of Supervisors created a set of 13 complicated triggers that will dictate when to start dialing up that renewed lockdown.

The 13 triggers fall into three categories. Some triggers are also more powerful than others and they interact together in different ways depending on their category. Think of it as a convoluted board game. More than seven community outbreaks? Do not pass go.

Image courtesy of San Diego County

“I know that it is a little bit confusing,” said Supervisor Nathan Fletcher at a press conference Wednesday.

Three of the triggers are overarching. If any one of them is activated, public health officials will have the authority to take wide-ranging shutdown measures.

The three major triggers are Nos. 2, 7 and 9 in the chart above. They relate to increased community outbreaks, a shortage of intensive care unit beds in local hospitals and shortages of personal protective equipment for frontline health care workers.

One must also consider each of the categories: surveillance, hospital capacity and response. Their meanings aren’t exactly self-evident.

Surveillance refers to any trigger that relates to the surveillance of public health metrics, such as an increase in COVID-like symptoms or community outbreaks. The hospital capacity triggers are set to go off when hospitals don’t have enough beds or supplies. And the response category refers to actions controlled by the county public health department, such as testing and contact tracing.

If two triggers from separate categories go off, then public health officials would issue specific orders to address them. That means, for instance, if trigger No. 5 under hospital capacity and No. 11 under response were tripped, health officers would take action.

Image courtesy of San Diego County

If two triggers under the same category are tripped, health officers would not necessarily take action.

Each of the triggers will be monitored on a public website with an indicator colored green, red or yellow. Green is good. Yellow is caution. Red is bad.

Image courtesy of San Diego County

“All of the triggers now are green, so this is very good news,” said Dr. Wilma Wooten, the county’s chief public health officer.

Exactly what action health officers will take if some triggers turn red is not specified in the plan.

If community outbreaks happen across one industry – let’s say barbershops and hair salons – officials could shut down that industry. Or they might just close specific locations that experienced outbreaks.

If the triggers relate to hospital capacity, public health officials might ban elective procedures, as they did during the height of the pandemic.

Small gatherings could be banned. Beaches might be closed. Restaurants could be forced into doing take-out only again. The shelter in place order might come back. The options of how and when the lockdown might be tightened are endless.

Most of the county’s 13 triggers appear to be safely in the green. But as recently as Tuesday, one seemed very close to yellow – and it was one of the big triggers.

Only 57 percent of local hospitals had a 15-day supply of personal protective equipment, Wooten said at a Board of Supervisors meeting Tuesday. Should that percentage fall below 50 percent, the trigger would move into red. And since it is one of the three big triggers, health officials would take action.

Such action would likely be geared toward preserving personal protective equipment and might include increasing telehealth appointments or canceling some procedures.

On Wednesday, however, the supply of personal protective equipment increased substantially. Suddenly, 70 percent of hospitals reported having more than a 15-day supply of protective equipment.

The supply of available personal protective equipment is steadily increasing, said Fletcher. He doesn’t think the 50 percent threshold will be a major concern going forward, he said.

Image courtesy of San Diego County

The county’s dashboard, providing updated figures for each of the 13 metrics, went live on Wednesday:

  • Trigger 1: The five-day average number of new cases cannot increase by more than 10 percent (given testing remains stable). During the most recent five-day period, the number of cases increased by 4 percent, Wooten said.
  • Trigger 2: There can be no more than seven new community outbreaks in a week. Last week, there were three.
  • Trigger 3: An upward trajectory of cases with COVID-like symptoms. The number of these cases has been decreasing since mid-March.
  • Trigger 4: An upward trajectory of flu-like illnesses. The number of these cases has also been decreasing since mid-March.
  • Trigger 5: Hospitals should not begin to reach 80 percent capacity of available bed space. Most recently, 66 percent of hospital beds have been occupied.
  • Trigger 6: The average number of COVID-19 patients being hospitalized should not increase by more than 1 percent. Most recently, it decreased by 1 percent.
  • Trigger 7: ICU capacity should not be stretched beyond 80 percent. Currently, 64 percent of ICU beds are in use.
  • Trigger 8: Hospitals should always have at least 25 percent of their ventilators available for use. Currently, hospitals have 50 percent of their ventilators available for use.
  • Trigger 9: At least half of the county hospitals must have a 15-day supply of personal protective equipment. Currently, just 70 percent of hospitals meet that requirement.
  • Trigger 10: No more than 8 percent of COVID-19 tests should come back positive. During the last two weeks, an average of 4 percent of tests were positive.
  • Trigger 11: Case investigators (known as contact tracers) must begin investigations of at least 70 percent of new cases within 24 hours. Most recently, 93 percent of new investigations were initiated within 24 hours.
  • Trigger 12: When contact tracers begin an investigation, they must contact each person who the person with COVID-19 has been in close contact with. Contact tracers must attempt to contact at least 70 percent of close contacts within a 24-hour period. Most recently, contact tracers had managed to contact 77 percent of close contacts in a 24-hour period.
  • Trigger 13: The wording on this trigger is the most tangled. It means that the county must have available temporary shelter for at least 15 percent of the county’s homeless population. Of the county’s 6,000-plus homeless residents, there is currently available temporary shelter for 42 percent.

The county still has a ban in place for large gatherings. But during recent protests, hundreds and even thousands of people have stayed in close contact for several hours.

“It will be really significant in the next two weeks to look at the number of cases and potential outbreaks as a result of the civil unrest that we’ve seen over the past several days,” said Wooten. “We will be monitoring for that.”

Will Huntsberry

Will Huntsberry is a senior investigative reporter at Voice of San Diego. He can be reached by email or phone at

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