Bexar County Jail: A Public Health Crisis

One of the biggest challenges facing local jails is managing the health and behavioral concerns of detainees. Jail detainees are more likely than the average citizen in San Antonio to have health problems ranging from serious and chronic illnesses to acute and temporary pain. Many of their health problems are public health problems because they are communicable diseases such as tuberculosis, HIV/AIDS, and Hepatitis C.

Standards for County Correctional Health Care

Texas Commission on Jails Standards (TCJS)
County jails are regulated by the Texas Commission on Jail Standards (TCJS). The Legislature created the commission in 1975 to implement a declared state policy that all county jail facilities conform to minimum standards of construction, maintenance and operation. The legislature expanded the jurisdiction of the commission to include private county and municipal jails.

The commission?s authority has expanded to deal with state wide crowding issues. The legislature added the requirement for count, payment, and transfer of detainees when precipitated by crowded conditions as well as expanding the commission's role of consultation and technical assistance.

It is the duty of the commission to circulate reasonable written rules and procedures establishing minimum standards, inspection procedures, enforcement policies and technical assistance for:

1. The construction, equipment, maintenance, and operation of jail facilities under its jurisdiction;
2. The custody, care and treatment of detainees; and
3. Programs of rehabilitation, education, and recreation for detainees confined in county and municipal jail facilities under its jurisdiction.

According to Terry Julian, TCJS Executive Director, commission staff offers technical assistance to county jails that are found to be in noncompliance with the state?s minimum standards. Julian stated that TCJS provides examples of jail success stories and coordinates communication between noncompliant jail administrators and the jails TCJS believes are model examples for bringing their facilities into compliance with the minimum standards.

TCJS Standards on County Correctional Health Care

According to the standard for the Health Services Plan stipulated by Rule §273.2 of the Texas Administrative Code, Bexar County produced a written plan, approved by the commission, for detainee medical, mental, and dental services.

Bexar County Correctional Health Care

Medical services are provided through the University Health Systems (UHS). According to UHS, the mission of Detention Health Care Services is to provide basic health care equivalent to community standards, to include health education, mental health care and preventative care to detained persons who are in the Bexar County Adult Detention Center, the Annex, the Bexar County Juvenile Detention Center and the Cyndi Taylor Krier Juvenile Correctional Treatment Center.

Mental Disabilities/Suicide Prevention Plan

According to the county?s Mental Disabilities/Suicide Prevention plan, mentally disabled and/or suicidal detainees are assigned to a special housing unit designed to provide observation.

An attempt was made to document the number of detainees housed in the Suicide Prevention Unit for 2003, 2004, and 2005. In response to an open records request (ORR), UHS stated that they do "not maintain a list of the number of detainees housed in the Suicide Prevention Unit (SPU) for any given year." Furthermore, UHS stated that whether a detainee is housed in a SPU would be recorded in the personal medical records of each detainee and to determine the number of detainees housed on the SPU would require UHS to review the individual records of each detainee incarcerated during 2003, 2004, and 2005.

The method used to prevent suicide in the jail relies on placing detainees diagnosed as suicidal on the SPU. According to the county?s Mental Disabilities/Suicide Prevention plan, suicidal detainees are under twenty-four hour close medical observation; medical security checks are conducted every 15 minutes. Unfortunately, individuals who are determined to commit suicide can do so in a matter of minutes.

Pattern of Correctional Health Care in Bexar County

UHS responded to an ORR regarding the rate of diagnosis for tuberculosis, Hepatitis C, HIV/AIDS, staphylococcus aureus bacteria, and methicillin resistant staphylococcus aureus.

Tuberculosis

According to the standard stipulated by TCJS, facilities having a capacity of 100 or more detainees, or housing detainees transferred from a facility with a capacity of at least 100 beds or housing detainees from another state, are required to develop and implement a plan for tuberculosis screening tests of employees, volunteers, and detainees.

Detainees confined in the jail for more than 7 days shall be tested on or before the 7th day after the day of confinement. Prisoners may be exempt from the screening test when the test conflicts with the tenets of an organized religion to which the individual belongs or when the test is contraindicated based on an examination by a physician. A detainee is not required to be retested at each rebooking if the prisoner is booked into the facility more than once during a 12-month period, unless the detainee shows symptoms of or is known to have been exposed to tuberculosis.

Hepatitis C

There is no standard mandated by TCJS that requires county jail facilities to report the number of positive Hepatitis C detainees that cycle through the jail each year. Consequently, statistics were only obtained for 2005. According to UHS, for the years 2003 and 2004, no such document exists and the information is not readily retrievable for the number of detainees that tested positive for Hepatitis C. However, UHS reported for the year 2005 that the number of patients/detainees whose laboratory samples were provided from the Bexar County Jail to UHS for analysis that tested positive for Hepatitis C was 14.

In a public hearing before the Subcommittee of Healthcare and Special Populations of the House Correction Committee, staff from the Correctional Managed Health Committee stated that 30% of prisoners received from the county jails test positive for Hepatitis C upon entry to the Texas Department of Criminal Justice (TDCJ).

HIV/AIDS

There is no standard that requires county jail facilities to test detainees for HIV/AIDS during their incarceration. Consequently, in response to an ORR that asked for the number of detainees that tested positive for HIV/AIDS during 2003, 2004, and 2005 UHS responded that no document exists nor is readily available for 2003 and 2004. However, for the year 2005, the number of detainees whose laboratory samples were provided by the Bexar County Jail to UHS that tested positive for HIV/AIDS were 33.

Staphylococcus Aureus (SA)

There is no standard that requires county jail facilities to test detainees for staphylococcus aureus bacteria or staph infection. According to UHS, no document exists or is readily available for the years 2003 and 2004 that identifies the number of detainees that tested positive for staph infection. During 2005, the number of detainee cultures that were sent from the Bexar County Jail to UHS that tested positive for staph infection were 59.

SA is commonly found on the skin and in the anterior nares (nostrils). Although SA usually colonizes humans without causing disease, it does cause infections that can be minor or serious and involve almost any organ in the body. SA is easily spread by direct or indirect contact with the products of infection and even by contact with the skin of a colonized person. In county jails, people live in close contact and often have less than exemplary personal hygiene habits; the close living conditions and the high detainee turnover, furnishings and linens may be shared without having been cleaned well enough to kill SA that may be present. It is not surprising that county jails are settings in which SA outbreaks are common.

Methicillin Resistant Staphylococcus Aureus (MRSA)

There is no standard that requires county jail facilities to test detainees for MRSA. According to UHS, for 2003 no document exists and the information is not readily available. During 2004, the number of detainees that tested positive for MRSA was 320, while during 2005 it was 301.

MRSA first became common in hospital settings in the 1960s when methicillin was the antibiotic of last resort for treating SA infections. Within a few decades of the appearance of MRSA, in some hospitals, it had become the most common SA isolate. MRSA should be considered endemic in jail settings, and sporadic cases should be expected. When MRSA infections occur more than occasionally, prevention and management of MRSA outbreaks require recognition and understanding of the MRSA problem, treatment of cases that are likely sources of transmission; and, perhaps most importantly, attention to the environment. The key to reducing transmission between prisoners is reducing the bacterial load in the environment and interrupting potential contacts between prisoners and bacteria.

Death Reports for Bexar County Jail Detainees

From 1984 to 1995, approximately 150 people died during their detention in the Bexar County Jail. The largest share of people (50%) that died in the jail were pretrial and had not been convicted of crime at the time of their death.

Additionally, the cause of death among Bexar County Jail detainees varied during this time period. The largest number of deaths from 1984 to 2005 resulted from natural causes. Suicides comprised 19% of the deaths reported during the time period.

Findings and Solutions

The continuity of medical care is important to the health of jail detainees and that of the public. The primary focus jails are custody and part of their responsibility as custodians is to identify and manage the health and behavioral health problem of detainees. University Health Systems delivers medical care in an environment where secure custody is the priority. Consequently, medical staff has limited access to prisoners housed in general population.

FINDING #1: Connecting with Community Resources

Jails are a revolving door. It is difficult to know how many jail detainees are accurately serviced by University Health Systems over an annual period. It appears from documents obtained through the open records process that UHS does not have a complete picture of the number of jail detainees it services on an annual basis. The Sheriff of Bexar County reports that 75,000 individuals were booked into the Bexar County Jail during 2004. Statistics obtained through the open records process indicate that during 2005, over 900 detainees tested positive for tuberculosis while over 300 tested positive for Methicillin Resistant Staphylococcus Aureus(MRSA). The significant numbers of individuals that cycle in and out of the jail means that thousands of people could have been exposed to these communicable diseases and in turn pose a public health threat to all citizens in Bexar County.

FINDING #2: Testing and Reporting

The lack of standards mandated by the Texas Commission on Jail Standards does not absolve Bexar County of its responsibility to test and contain the rate disease transmission in the jail facility. Through the open records process, it is clear that Bexar County does not assess health indicators on an annual basis, for diseases other tuberculosis, as a strategy to determine the rate of transmission for communicable diseases and contain them.

Consequently, it is recommended that standards be implemented at the state and local level that require county jails such as the facility in Bexar County to test detainees for HIV/AIDS, Hepatitis C, Methicillin Resistant Staphylococcus Aureus (MRSA), and Staphylococcus Aureus (SA) and report findings to the state Department of Health and Human Services on a monthly basis.

Requiring the testing and reporting of communicable diseases such as MRSA will improve accountability of jail and UHS administrators to identifying outbreaks and containing the spread of disease.

FINDING #3: Improving Sanitation as a Method to Contain the Spread of Disease

It is paramount that the outbreak of disease such as MRSA and tuberculosis is eradicated in the correctional setting because many jail detainees cycle out of the facility over a short period of time. Consequently it is important that jail and health administrators:

1. Inspect the facility to make sure that obvious opportunities for contact are interrupted. Eliminate shared towels in bathrooms, kitchens, laundry areas, workshops, or other locations;
2. Implement terminal disinfection procedures when one prisoner leaves a housing area and another enters it. Clean the fixtures, the mattresses, the furniture, and so on. Discard objects that cannot be disinfected properly;
3. Make sure that all cleaning solutions are properly bactericidal;
4. Review practices in booking areas. Simple plastic benches, for example, can become vectors for transmission. Frequent cleaning with solutions that leave a killing film can help stop this;
5. Bathrooms should be cleaned regularly, using appropriately bactericidal products;
6. Laundry facilities should be reviewed, inspected, and disinfected on a regular basis; and
7. Personal hygiene, most importantly frequent hand washing, is critical for interrupting transmission. This applies not only to the prisoners but also to health services employees.

FINDING #4: Using 24-Hour Monitoring to Reduce the Rate of Suicide

During the period form 1984 to 2005, 28 suicides were reported to be the cause of death among detainees in the Bexar County Adult Detention Facility. UHS reportedly does not know how many detainees were housed in the Suicide Prevention Unit for 2003, 2004, and 2005.

Consequently, it is recommended that standards be implemented at the state and local level that require county jails to track the number suicidal detainees incarcerated in the facility and report findings to the Department of Health and Human Services monthly.

Additionally, the county?s policy is to monitor suicidal detainees every fifteen minutes. However, it is widely recognized by mental health and correctional officials that individuals who are determined to commit suicide can do so in less than fifteen minutes.

As a result, it is recommended that the county adopt policies to monitor suicidal detainees 24-hours a day in an effort to eliminate any occurrence of suicide. This be can done in several ways by: 1) Assigning correctional officers to monitor suicidal detainees 24-hours a day; or 2) Installing video cameras in cells located in the Suicide Prevention Unit to monitor suicidal detainees 24-hours a day.

Conclusion

Improving the delivery of health services for Bexar County Jail detainees includes finding ways that use scarce public resources more efficiently and effectively to maintain the health of jail detainees. The most productive and economically sensible way to improve the health of detainees is to invest in opportunities that will maintain a sanitized jail facility and provide treatment.