.5 ?nuCOUNTY or MARIN '1 Benita McLarin, FACHE DIRECTOR Matthew Wiliis, MD, MPH PUBLIC HEALTH Lisa M. Sanford, MD, MPH DEPUTY PUBLIC HEALTH OFFICER 3240 Kerner Boulevard San Rafael, CA 9490i MS 473 4l5 473 2326 41.5 473 3232 TTY DEPARTMENT OF HEALTHANDHUMANSERVICES Promoting and protecting health, wellbeing, self-sufficiency, and safety of oil in Marin County. August 10, 2020 RE: SAN QUENTIN CONSOLIDATED WRIT PROCEEDING, In re tan Michael Hall (BLOTBI), Case No. 80212933, et seq. Dear Judge Howard: This letter is to describe ongoing health concerns for inmates related to the ongoing outbreak at San Quentin State Prison. These are based on my observations as Marin County Public Health Officer over the course of the outbreak response and my experience as an epidemiologist and Internal Medicine physician. As a member of the Incident Command response team established July 3, was based at the prison for five days and participated in at least ten tours within the housing units to assess conditions and medical care capacity across the facility. San Quentin State Prison lies within Marin County and is managed by the California Department of Corrections and Rehabilitation (CDCR). Marin County Public Health (MCPH) does not havejurisdiction over this facility, and MCPH has been asked to provide outbreak guidance for consideration by facility leadership. On June 1, 2020, MCPH was notified by CDCR that 122 inmates had been transferred from the Chino institution for Men (CIM) in Southern California to San Quentin. Transferred inmates had not been tested for within 14 days prior to arrival at San Quentin. Recognizing that some would be infected through exposure at CIM, MCPH recommended testing all transferred inmates, and sequestering them completely from the native San Quentin population. instead, transferred inmates were tested on June 1 and 2 and placed in a large shared unit with existing San Quentin inmates prior to the return of testing results. This placed all inmates and staff working in that unit at risk, and MCPH recommended mandatory mask wearing and preventing staff who had been exposed from working in other units. MCPH was informed by CDCR that local health officers lack the authority to mandate measures in state?run prisons. Lacking the authority to ensure standard outbreak management, and seeing the consequences of decisions made thus far, on June 3, MCPH recommended San Quentin ieadership establish an incident commander with expertise in outbreak management at the facility. After a June 24 appeal from the Marin County Board of Supervisors to Governor Newsom, an Incident Command was put in place on July 3 to integrate leadership between Corrections and Public Health. The following week an Alternate Care Site was established at the facility to manage inmates who did not require hospitalization. A method for isolating infectious inmates was also put in place, in tents placed in open areas, at the joint recommendation of Marin County Public Health and the California Department of Public Health. PG.20F3 Partly through these interventions the outbreak is now slowly resolving. Each week there are fewer new cases and hospitalizations. Currently approximately 2200 inmates have been infected, of the current total population of approximately 3400. The ongoing risk of inmates at the facility is based primarily on three things?-? the effectiveness of efforts to protect them from infection; their baseline health status; and access to healthcare. On~site mitigation efforts to prevent transmission remain a challenge. Those 1200 inmates who have not yet been infected are at significant risk of becoming infected. Despite significant progress compared to the poor initial standards?, the environment itself presents barriers that are nearly insurmountable within the existing architecture. The larger cell blocks, with pairs of men in hundreds of 4 8 foot cells with open bars, opening in to common space with limited ventilation, have proven to be an especially high risk environment to all living there. Attack ratesm defined as the proportion of Individuals infected in a given shared setting?u- have been extremely high and well above 50% in many of the buildings. In addition, the conditions and culture of infection prevention standards within CDCR, while there has been an admirable improvement, does not change overnight. Breaches in mask wearing, physical distancing and other fundamentals of infection control among staff still remains a concern. Approximately 300 correctional officers and other prison staff have been infected during thisoutbreak, indicating the institutional challenges of strict adherence to personal protective equipment and physical distancing standards in routine operations. It is also worth noting that the role of immunity-w- that is, protection for someone who has been infected from subsequent infection and illness? is still unknown. if immunity after infection is short-lived, or weak, another outbreak of this scale could reoccur. In that case all inmates, regardless of past infection, would be at risk if fundamental measures to prevent spread were not significantly improved. The second factor that defines risk is the baseline health status of inmates. Older individuals or those with underlying medical conditions are at higher risk for severe disease or death if they become infected. The San Quentin population has a high proportion of older inmates compared to other correctional facilities, especially men in the condemned unit. Further, due to the demographic makeup of the prison population, in income, race and education, there is high rate of underlying chronic diseases than place inmates at higher risk for mortality if infected. Lastly, the risk for poor health outcomes is affected by the quality and timeliness of healthoare services. While the permanent San Quentin medical staff is excellent, the team was not designed to match the demands of a large-scale outbreak. There is no on-site hospital for critically ill inmates. The recent additional medical support brought on site is for the management of inmates who experience mild Ail requiring higher levels of oxygen or intubation, or other critical care must be transferred out to a regional hospital by ambulance. This requires identifying a suitable receiving hospital and transportation in each case. This represents a functional barrier to timely access to care for the most critical cases. COUNTY OF MARIN HEALTH AND HUMAN 3240 Kernar Boulevard - San Rafael, CA 9490i PG. 3OF3 Taken together these factors sum to a picture of significant ongoing risk related to COVID-19 for inmates at San Quentin State Prison, despite progress over the past month to shift from a wholly under-prepared and underuresourced system. Most of the ongoing risk is attributable to factors that can, with concerted effort and resources, be addressed over time, but cannot be corrected in the short term. These include addressing crowding of inmates in single large settings, ensuring public health experts have institutional authority to manage outbreaks, and expanding clinical services in prisons to ensure timely access for all healthcare needs. Please do not hesitate to reach out to reach out if you have any questions or if I can offer further clarification. Matt Matthew Vl/illis, MD MPH Public Health Of?cer County of Marin COUNTY OF MARIN HEALTH AND HUMAN SERVICES 3240 Kerner Boulevard - Son Rufoei, CA 9490i