Ankita Kadakia, MD Chief/Medical Director Tuberculosis Control and Refugee Health County of San Diego Health & Human Services Agency

1. HIV & Global Health Rounds
The UC San Diego AntiViral Research Center sponsors weekly
presentations by infectious disease and global public health clinicians,
physicians, and researchers. The goal of these presentations is to
provide the most current research, clinical practices, and trends in HIV,
HBV, HCV, TB, and other infectious diseases of global significance.
The slides from the HIV & Global Health Rounds presentation that you
are about to view are intended for the educational purposes of our
audience. They may not be used for other purposes without the
presenter’s express permission.

2. A YEAR OF COVID-19 IN
REVIEW:LESSONS LEARNED AND
FUTURE DIRECTION
Ankita Kadakia, MD
Tuberculosis Control and Refugee Health Branch Chief/Medical
Director, HHSA, County of San Diego
Tri-Chair, County Covid-19 Vaccine Clinical Advisory Group

3. DISCLOSURES
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NO DISCLOSURES

4. LEARNING OBJECTIVES
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1. Apply County-specific data to guide decision making and equity
2. Understand innovations in science related to Covid-19 that affect policy decision making
3. Apply how lessons from COVID-19 can be utilized for other infectious diseases
4. Understand how the use of infection control practices in the pandemic can shape policy
decisions

5. ZOOM CHAT
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Please put into the chat pod one word that
describes the past year of the COVID-19 Pandemic!

6. 2020: A YEAR IN REVIEW
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• Dec 31, 2019- China alerts the WHO of a virus in
Wuhan
• Jan 21 –First US Coronavirus Case in
Washington State
• Jan 22 –Trump 1st impeachment trial begins
culminating in acquittal Feb 5
• Jan 27 –HHS Declares PH Emergency
• Jan 30 –WHO Declares Global Emergency, Mar
11 WHO declares a pandemic
• Feb 5 –Wuhan diplomatic evacuees at MCAS
Miramar
• Feb 11- WHO officially names the novel
coronavirus as COVID-19
• Feb 14 –The County declares local emergency &
assembles the COVID-19 Incident Command
Center

7. 2020: A YEAR IN REVIEW
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•March –The County’s Medical Operations Center
starts acquiring PPE and sanitation supplies to
distribute to healthcare provider
•Mar 8 – Cruise ships arriving in Port of San Diego
with COVID positives passengers, The County worked
with the CDC to assist with testing and disembarkation
plans
•Mar 16 –Activated the County of San Diego
Emergency Operations Center
•Mar 19 –Governor issues Stay-at-Home Order &
Implements Watch List
•Mar 20- The County went into its 1st lockdown
•March- Hoarding of toilet paper, sanitation supplies,
and empty grocery store shelves

8. 2020: A YEAR IN REVIEW
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• March – Much of the workforce converted to teleworking
• The County opened a 200 bed emergency military hospital at
Palomar
• The County assembled 2000 Public health hotel rooms for
isolation/quarantine
• City of San Diego and County of San Diego opened Convention
Center for homeless/unsheltered individuals
• Hospitals in San Diego County received patients from Mexico and
Imperial County as the pandemic filled their hospital beds

9. 2020: A YEAR IN REVIEW
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• April 12- Easter weekend, start to see “holiday surges”
2-3 weeks after a holiday
• May 1st – Mask mandate goes into effect in County of
San Diego
• May 26 –Killing of George Floyd by a white police officer
sparked protests and brought forward the Black Lives
Matters movement
• May 31- Beaches Reopen in San Diego County, beach in
Orange county experience crowding
• June 12 –Governor allows broader State reopening
• June 15-Supreme Court rules employers cannot
discriminate on the basis of sexual orientation or
gender identity
• July 13 –State orders second shutdown

10. 2020: A YEAR IN REVIEW
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• Jul 24 –Baseball Reopens with no fans followed
by other sports with empty stadiums
• Aug 4 – The County develops COVID-19
Compliance Teams to investigate claims of
noncompliance to the health officer’s order
• Aug 11- Biden announces Kamala Harris as his
running mate making her the first black woman
and first Asian woman on a major party’s
presidential ticket
• Aug 31 – State announces a color tier system
for county reopening
• Sep 7 –SDSU reopening for on campus
classes reports outbreak (1100 cases)

11. 2020: A YEAR IN REVIEW
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• Sept 18- Supreme Court Justice Ruth Bader
Ginsberg dies at age 87
• Oct 1 –President Trump diagnosed with COVID-
19
• Nov 4- The County Registrar of Voters has 4
days of in person voting to accommodate COVID-
19 safe voter protocols
• Nov 7- President Biden and VP Kamala Harris are
elected
• Dec 6 –Regional Stay-at-Home Order goes into
effect from the governor
• Dec 11- Pfizer receives FDA EUA for their MRNA
vaccine and becomes the first COVID-19 vaccine
to receive EUA in the US
• Dec 14 –First vaccine shipments arrive in San
Diego and roll-out begins

12. USING SCIENCE TO GUIDE PUBLIC
HEALTH POLICY

13. https://www.nature.com/immersive/d41586-020-03437-4/index.html

14. • Speed of science and
collaboration
• Coronavirus was identified
quickly and genome made
publicly available
• Collaboration of science between
labs/universities/countries
• Academic, private, and
government labs started
developing testing mechanisms
• Vaccine development
GENOME SEQUENCING

15. TRANSMISSION STUDIES
• Morawska published
transmission studies prior to
this commentary
• Challenged the idea of
respiratory viruses always
being droplet transmission
• Debate in scientific
community which delayed
aerosol and ventilation
guidance from WHO, CDC,
and public health
departments
• Adapted indoor business
guidelines, mask use during
exercise
• Mask guidance
Clinical Infectious Diseases, Volume 71, Issue 9, 1 November 2020, Pages 2311–
2313, https://doi.org/10.1093/cid/ciaa939

16. ASYMPTOMATIC AND PRESYMPTOMATIC
SPREAD
• Public health guidance changed on testing of SNF/LTCF residents and staff – state requirements for testing
• Brought to light even more the severity of disease and outbreaks in SNF/LTCF
• SNF/LTCF residents and staff first in vaccine prioritization
• Supported physical distancing and hand hygiene measures
• Changed quarantine and isolation guidance – updated health officer orders
• Supported widespread covid testing – county boosted our testing efforts

17. DEVELOPING A FRAMEWORK FOR
EMERGENCY OPERATION
PROTOCOLS DURING COVID-19
PANDEMIC USING EXPERIENCE FROM
OTHER INFECTIOUS DISEASES

18. H1N1 INFLUENZA OUTBREAK
• First case of swine flu in a 10 year boy in San Diego County
• A global pandemic ensued but death toll was much lower than COVID-19
• The County of San Diego used H1N1 experiences for development/improvement of the Incident
Command Structure, vaccination protocols during a pandemic, quarantine and isolation
procedures, case investigation and contact tracing, infectious disease surveillance

19. HEPATITIS A OUTBREAK-MARCH 2017
Top Antivir Med. 2019 Jan; 26(4): 117–121.
• CoSD declared a local health emergency 9/2017
• Developed and improved upon CosD Department of Environmental Services
sanitation protocols
• Developed mass vaccination clinics, mobile clinics, and vaccination using mobile
foot teams
• Developed partnerships with local healthcare systems for vaccinations

20. TUBERCULOSIS
• Translated TB infectious transport protocols for COVID use
• Translated TB-CDC-CBP protocols for border crossing and transport of COVID patients
• Using TB staff for case investigation and contact tracing for COVID
• Used TB infection control protocols for congregate housing and applied to Convention Center
• HMIS and other homeless shelter collaborative work with TB applied toward COVID- development of
screening tool

21. USING DATA TO GUIDE PUBLIC
HEALTH DECISION MAKING FOR
COVID
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22. STATE METRICS DETERMINE
TIERS
Adjusted case rate = # positive cases confirmed by PCR (rate) per 100,000 population
excluding prison cases averaged over 7 days with a 7day lag to account for testing delays
 Unadjusted test rate does not account for the test rate
 Excluding federal inmates, ICE facility residents, state hospital inmates, US marshal detainees
Testing positivity = # of positive cases/amount tested overall
 Also excludes testing in prisons
 CDPH states as counties focus on increased testing in the health equity metric and to support school
openings, they are likely to experience an increased number of cases. We want to avoid disincentivizing
increased testing, provided that test positivity is low and there is sufficient capacity for contact tracing and
isolation. We are therefore increasing the adjustment for higher volume testing.
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23. 23

24. CALIFORNIA HEALTHY PLACES INDEX (HPI)
-Health Equity Metric based on HPI
which uses local factors in a community
that affect life expectancy/health
outcomes and provides a percentile.
-The higher the percentile the healthier
the census tract-
( small, relatively permanent,
subdivisions in a county)
-25 individual indicators across housing,
transporation, education, healthcare access,
economics, clean environment,neighborhood
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https://healthyplacesindex.org/

25. HEALTH EQUITY METRIC (HEM)
• -Health equity metric = only applies to counties with population > 106K
• -Due to the limited number of census tracts, test positivity cannot be
reliably calculated by quartile for smaller counties
• -HEM for county census tracts divided into quartiles
• -Health Equity Quartile Test Positivity Rate Must Meet Specified
Threshold for Less Restrictive Tier.
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26. HEALTH EQUITY METRIC
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27. 27
• CoSD rotates testing sites per zip code data using the HPI
• Focused no appointment testing and increased testing sites in lower HPI areas
https://sdcounty.maps.arcgis.com/apps/opsdashboard/index.html#/e09887e8e65d4
fda847aa04c480dc73f

28. RACE/ETHNICITY DATA

30. PUBLIC HEALTH INNOVATION

31. INNOVATIVE PUBLIC HEALTH INITIATIVES
DURING COVID
• -Convention center for
homeless
• -Public health hotel/temporary
lodging
• -HOT teams and hygiene kits
• -Registrar of Voters - election
-Vaccination Super Stations
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32. OPERATION SHELTER TO HOME
-Collaborative effort between the City of San Diego and
County of San Diego to shelter 1500 individuals
- Infection Control protocols for mass amount of migratory
individuals in a massive space
-Collaboration with FQHCs for onsite medical/telehealth
care/mental health and SUD
-PH physicians and PH nurses onsite daily and weekends
-EMS onsite
-Screening tool adapted from asylum seeker shelter for
COVID
-Protocols for isolation/quarantine and public health hotel
-Lessons learned: elopement, criteria for hotel

33. INNOVATIVE PUBLIC HEALTH INITIATIVES
DURING COVID
• -Convention center for
homeless
• -Public health hotel/temporary
lodging
• -HOT teams and hygiene kits
• --Registrar of Voters - election
-Vaccination Super Stations
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34. PUBLIC HEALTH HOTELS
- 2000 rooms commandeered for
public health use
- Care and Shelter branch of EOC
- Infection control protocols
-PH physicians and PH Nurses
onsite daily to provide medical care
-Lessons learned: mental health,
EMS, elopement

35. INNOVATIVE PUBLIC HEALTH INITIATIVES
DURING COVID
• -Convention center for
homeless
• -Public health hotel/temporary
lodging
• -HOT teams and hygiene kits
• -Registrar of Voters - election
-Vaccination Super Stations
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36. HOMELESS OUTREACH TEAMS
-9 teams paired with PHN, police officer,
homeless outreach worker
-Screening tool for COVID-19
-Developed protocols for care, isolation,
shelter at hotel/CC
-9-10K hygiene kits distributed
-Lessions learned: HOT and PHN
partnerships, refusal of care/isolation
-Next step is vaccination

37. INNOVATIVE PUBLIC HEALTH INITIATIVES
DURING COVID
• -Convention center for
homeless
• -Public health hotel/temporary
lodging
• -HOT teams and hygiene kits
• -Registrar of Voters - election
-Vaccination Super Stations
37

38. ROV-PRESIDENTIAL ELECTION
-6 months of planning between PH and ROV
- Infection control protocols for in person voting, electoral
candidates, observation, ballet counting
- mass scale up of 1000 temporary staff including training,
235 polling sites
-the intersection of election laws with public health/infection
control
-political parties and their views on masking,social distancing
-PH physician/ROV/HR on call for 4 days of presidential
election
-Lessons learned: refusal to mask but allowed to vote-
acommodations

39. INNOVATIVE PUBLIC HEALTH INITIATIVES
DURING COVID
• -Convention center for
homeless
• -Public health hotel/temporary
lodging
• -HOT teams and hygiene kits
• -Registrar of Voters - election
-Vaccination Super Stations
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40. COVID-19 VACCINATION
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41. In a 1988 essay on pandemics Joshua
Lederberg, Nobel laureate and president of
The Rockefeller University, reminded the
medical community that when it comes to
infectious disease, the laws of Darwin are as
important as the vaccines of Pasteur.
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The New York Times, “The Virus Won’t Stop Evolving”, Nov 27,2020

42. COVID-19 Vaccine Goal:
The Numbers
*Estimated 250,000 vaccinations to be completed by end of January. 3,515,088 doses from
Feb 1 – July 1, 2021 (150 days) = 23,434 vaccine/Day
San Diego County Population: 3,370,418 residents
San Diego County Population age 16 and
older:
2,689,348 residents
Goal to vaccinate at least 70% San Diego
County Population age 16 and older by July
1, 2021:
1,882,544 residents
3,765,088 doses of vaccine
(first and second dose)
23,434 vaccines/Day*

43. COSD COVID-19 VACCINE OPERATIONS
COVID Vaccine Operations
 Standing up and staffing vaccination sites including superstations
 Operation Collaboration/CALFIRE/Paramedics/EMTs
COVID Vaccine Distribution/ MOC Logistics
 Protocols for handling vaccine
 Cold-chain distribution (ULT freezers)
 Ancillary supplies ( PPE, syringes/needles etc)
 Volunteer vaccinator coordinatiion
COVID Vaccine Clinical
 Vaccine Clinical Advisory Group – determining fair and equitable allocation recommendations
 Clinical operations of county vaccine administration- nursing workforce, training, clinical decision making
 Communications- educational materials, speakers bureau, vaccine hesitancy
 External stakeholder partnerships
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44. COVID-19 Vaccine Ecosystem:
Health Equity, Accessibility, & Convenience
County Hosted Vaccine Events
Vaccination Super Station Sites
Mobile Vaccination Teams
Hospital-based Vaccination Sites
Clinic-based Vaccination Sites
City Partnership Vaccination Sites
Military & Veteran Administration
Pharmacies

45. COVID-19 RATE BY HHSA REGION
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46. COUNTY OF SAN DIEGO
COVID-19 VACCINE CLINICAL ADVISORY GROUP
TRI-CHAIRS
COUNTY
CLINICAL REPRESENTATIVES
COMMUNITY
CLINICAL REPRESENTATIVES
Dr. Rodney Hood
Founder & CEO, Multicultural
Health Foundation
Physician, San Ysidro Health
Center
Member, CA Governor’s
COVID-19 Vaccine Task Force
Chair, San Diego County
COVID-19 Equity Task Force
Dr. Ankita Kadakia
Medical Director,
Public Health Services,
Health & Human Services Agency,
County of San Diego
Dr. Gail Knight
Chief Medical Officer,
Rady Children’s Hospital
Co-Chair, Hospital CMO
COVID-19 Advisory Group
Objective:
Determining fair and
equitable vaccine
allocation for San
Diego County
residents

47. ADDRESSING VACCINE BARRIERS
-

48. PROJECT SAVE
The pilot program is now operating in the
southern region of the county and is
managed by nine community groups who
have access to reserve appointments at
four vaccination sites.
The sites are:
•South Region Live Well Center – Chula
Vista
•Martin Luther King Community Center –
National City
•Mar Vista High School – Imperial Beach
•Southwestern College – San Ysidro
The reserved appointments will be filled
through outreach by community health
workers or promotoras who are contacting
people 65 and older at locations that
include grocery stores, faith centers, food
distribution sites and housing complexes in
the South Bay.

49. 211 ASSISTANCE FOR VACCINE APPOINTMENTS
211 FOR 65 AND OLDER WHO DO NOT HAVE ACCESS TO COMPUTER OR SOMEONE
TO ASSIST WITH VACCINE APPOINTMENTS
• 211 helping homebound
seniors access vaccination
• 211 is assisting with
transportation for seniors to
vaccine appointments

50. MTS PROVIDING FREE RIDES TO VACCINE
NEED TO BRING PROOF OF VACCINE APPOINTMENT

51. SPANISH LANGUAGE VACCINE APPOINTMENT
SCHEDULING
CAN SEARCH IN SPANISH BY MAP OR CALENDAR

52. REGIONAL VACCINATION SITES
• 5 Regional Vaccine Super Stations in partnership
with the County: Chula Vista, La Mesa, San
Marcos, Downtown/Petco Park, Del Mar
Fairgrounds
• San Marcos/211/West Pace/Gary and Mary
West Foundation POD for seniors – access
through 211
• Rotating pods in harder to reach communities
i.e. Malcolm X Library vaccine site with SDFD
• Project Safe
• Majority of vaccination sites are in hardest hit
Covid areas –East County and South Bay

53. LESSONS LEARNED AND FUTURE DIRECTION
PANDEMIC PLANNING IN PUBLIC HEALTH
Innovation
Partnership
Science

54. QUESTIONS?
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Ankita.Kadakia@sdcounty.ca.gov