As cities and states across the country continue to grapple with hepatitis A virus (HAV) outbreaks, a San Diego grand jury report criticizes the city’s health department for not enacting a quick or robust enough response to its own local outbreak, The San Diego Union-Tribune reports. 

San Diego, which is considered ground zero for what has become a multistate hepatitis A crisis, faced an outbreak last year that killed 20 people and sickened more than 600 mostly homeless and drug-using residents across the city. Titled “The San Diego Hepatitis A Epidemic: (Mis)handling a Public Health Crisis,” the grand jury report sought to uncover the cause of the outbreak of the preventable, treatable disease.

After examining media reports and internal emails and conducting in-depth interviews with local health officials, the grand jury assembled its own timeline of the outbreak and concluded that the San Diego county health department could and should have declared a health emergency much sooner than it did. The report also criticizes major sanitation problems found in many of the city’s homeless camps, including lack of public bathrooms and handwashing stations and street washing services.

The report recommends that the city develop a better emergency action plan for elected leaders and top government staffers to respond to outbreaks more quickly and efficiently.

Jurors specifically called out the county’s Emergency Operations Plan, which gives five different officials, including the county Administration Officer and the county Public Health Officer, to activate the section of the larger plan that relates to public health.

By law, public agencies cited in the civil grand jury report must respond to within 90 days. Although the grand jury does not have the power to put anyone in jail, its report has led to the declaration of a formal audit of San Diego’s hepatitis response, which is expected to take five months to complete. 

But the grand jury’s assessment wasn’t all negative. The panel of health care experts commended the county for its use of vaccination foot teams embedded with law enforcement homeless outreach teams, which vaccinated more than 100,000 people against HAV.

“The biggest lesson is that our community can’t put off difficult decisions on homelessness because it makes the problem worse,” said San Diego Mayor Kevin Faulconer, in response to the grand jury report. “It’s clear there needed to be better coordination and communication when the outbreak was first identified and there were a lot of lessons that will help us going forward.” 

Although San Diego has declared an end to its local emergency, similar hepatitis A outbreaks have occurred or are occurring in Indiana, Kentucky, Michigan, Utah, West Virginia and Colorado.