BOP Program Statement 6190.05 § 15

Testing for communicable diseases includes the following:

 V oluntary testing – occurs when an inmate sends a request for testing to Health Services.

 Mandatory testing – occurs when an inmate is deemed at risk for an infectious disease and

the test is clinically indicated and/or surveillance testing is required to monitor trends and

prevent an outbreak. Inmates must participate in mandatory testing. If they refuse, staff

should initiate incident report codes 227 (refusing to participate in a required physical test or

required examination unrelated to testing for drug abuse) and 307 (refusing to obey an order

of any staff).

 Involuntary testing – occurs either when an inmate is known to be at risk for an infectious

disease after an exposure or is the known source of an exposure incident, and the test is

clinically indicated. Inmate written consent is not required for involuntary testing. If the

inmate refuses testing, staff should initiate incident report codes 227 (refusing to participate

in a required physical test or required examination unrelated to testing for drug abuse) and

307 (refusing to obey an order of any staff). Involuntary testing will be conducted in

accordance with Program Statement Use of Force, Application of Restraints, and

Firearms.

§ 549.12 Testing.

(a) Human Immunodeficiency Virus (HIV) —

The Bureau utilizes different testing strategies and performs counseling for HIV infection as

indicated below.

(1) Clinically indicated. The Bureau tests inmates who have sentences of six months or more if

health services staff determine, taking into consideration the risk as defined by the Centers for

Disease Control guidelines, that the inmate is at risk for HIV infection. If the inmate refuses

testing, staff may initiate an incident report for refusing to obey an order.

In addition, inmates housed in Bureau institutions, who have risk factors for HIV infection or

clinical evidence of HIV infection regardless of commitment status, will be tested in accordance

with clinical guidance from the Medical Director.

The Bureau also uniformly uses opt-out testing. In opt-out testing, all inmates are informed upon

admission, either orally or in writing, that HIV testing will be performed unless they refuse

testing. If the inmate was previously tested within the Bureau and has been continuously

incarcerated since their HIV test was performed or if there is documentation of a prior positive

HIV test result, subsequent HIV testing is risk-based.

(2) Exposure incidents. The Bureau tests an inmate, regardless of the length of sentence or

pretrial status, when there is a well-founded reason to believe that the inmate may have

transmitted the HIV infection, whether intentionally or unintentionally, to Bureau employees or

other non-inmates who are lawfully present in a Bureau institution. Exposure incident testing

does not require the inmate's consent.

However, inmates who are identified as a source in an exposure incident will be informed of the

need for testing and provided education and counseling about it prior to testing being performed.

If the inmate refuses testing, staff will initiate and complete incident report codes 227 (refusing

to participate in a required physical test or required examination unrelated to testing for drug

abuse) and 307 (refusing to obey an order of any staff). If the inmate continues to refuse testing,

involuntary testing will be conducted to ensure the safety of staff and the inmate in accordance

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with the Program Statement Use of Force, Application of Restraints, and Firearms. The use of

force for involuntary testing must be authorized by the Warden or their designee.

(3) Surveillance Testing. The Bureau conducts HIV testing for surveillance purposes as needed.

If the inmate refuses testing, staff may initiate an incident report for refusing to obey an order.

(4) Inmate request. An inmate may request to be tested. The Bureau limits such testing to no

more than one per 12-month period unless the Bureau determines that additional testing is

warranted.

(5) Counseling. Inmates being tested for HIV will receive pre- and post-test counseling,

regardless of the test results.

Additional Bureau counseling requirements include:

 Written informed consent for testing is not required.

 Pre-test counseling will address, at a minimum, the limitations of the test (i.e., the inability to

detect early infections, false positive and false negative results), the possible need for

additional testing, and the complications and consequences of a positive or negative test

result. The institution’s A&O program will meet the HIV pre-test counseling if these

requirements are discussed.

 All post-test counseling will include information about the meaning of the test results, the

benefits of antiretroviral treatment (if appropriate), and avoiding risky behaviors.

 Pregnant inmates who test positive for HIV infection will also be counseled that the virus

may be transmitted to the fetus. They will be provided with information on current treatment

options to prevent perinatal transmission.

 All inmates testing positive will be counseled by a physician and referred immediately to

Psychology Services for evaluation and follow-up needs.

 Inmates testing negative will be provided with post-test counseling through an education

encounter documented in the medical record by a licensed health care provider.

(b) Tuberculosis (TB).

(1) The Bureau screens each inmate for TB within two calendar days of initial incarceration.

Due to the contagious nature of TB and risk of serious illness, active pulmonary TB must be

excluded as a potential diagnosis at intake. Screening for active TB in newly incarcerated

inmates includes the following:

 TB Symptom Screen.

 All inmates, including holdover and pretrial inmates, must be assessed by a health care

provider for symptoms of active pulmonary TB (e.g., cough, coughing up blood, fever,

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night sweats, and unexplained weight loss), using an interpreter or language translation

service if necessary.

 Inmates returning from writ must also undergo a TB symptom screen.

 The symptom screen must be documented in the inmate’s medical record.

 Inmates with symptoms suspicious for active pulmonary TB must wear a surgical mask,

be medically isolated, and further evaluated by Health Services.

Medical isolation consists of placing the inmate suspected of having active pulmonary TB in a

functional AIIR, or if one is not available at the institution, the inmate must be transported to an

institution or hospital with AIIR capacity. They must wear a surgical mask and be kept in a single

cell until transport can be accomplished. For transport infection control measures, see Section

17b. Transport.

 TB Testing.

 The preferred TB test in the Bureau is the Tuberculin Skin Test (TST). However, in

limited situations, a TB Interferon-Gamma Release Assay (IGRA) may be used.

 TB testing must be initiated within two calendar days of initial Bureau incarceration to

screen for active TB and latent TB infection.

 Inmates with a documented previously positive TB test while in Bureau custody should

not be retested.

 If an inmate had a previous negative TB test, repeat testing is required if the inmate has

been out of Bureau custody for more than 14 calendar days.

 A self-reported, undocumented, previous positive TB test is not a contraindication to

receiving a repeat TB test. However, if a severe reaction to a TST (e.g., whole arm

swelling or severe blistering) was documented in the medical record or is described by

the inmate, then an IGRA must be used.

 An inmate may not request to substitute a chest radiograph for a TB test. See subsection

(4) below for information on inmates who refuse testing.

 TB testing exception: Inmates who are in-transit or holdover status and stay at a Bureau

institution for less than four calendar days require only a TB symptom screen as long as

they meet the requirements in Section 16a. Tuberculosis (TB) Clearance Prior to

Transport of Inmates.

The types of tests used to diagnose latent TB infection and the indications for testing are based

upon guidance from the Medical Director. Health care providers who place and/or read TSTs

must have documented competency in TST placement and interpretation at least every two years.

 Chest radiographs (CXRs).

 Inmates with symptoms suspicious for active pulmonary TB are medically isolated and a

CXR is obtained as soon as possible.

 Asymptomatic inmates with a new, positive test for TB must have a CXR completed

within 14 calendar days of the positive test.

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 Inmates transferring within the Bureau, who have a history of a positive TB test and

negative CXR performed after the initial positive test, do not require an additional CXR.

 Inmates with a previous positive TB test in the Bureau who have been out of continuous

Bureau custody for 30 calendar days or more require a new CXR within 14 calendar days

of arrival.

Based upon data on the incidence of active pulmonary TB in an institution, the CD or designee

may request routine CXRs on all new intakes.

(2) The Bureau conducts screening for each inmate annually as medically indicated.

 The Bureau also conducts TB testing annually as medically indicated.

 Inmates with a prior negative test for TB must be screened for symptoms and tested annually

for potentially newly acquired TB.

 Inmates who test positive for TB must have a follow-up CXR within 14 calendar days. If the

inmate has signs or symptoms of active TB, the inmate must be medically isolated and a

CXR obtained as soon as possible.

 Follow-up CXRs are usually not indicated after a baseline negative CXR has been

documented following a positive test for TB – except if the inmate:

 refuses latent TB infection treatment,

 develops symptoms and/or signs of active TB, or

 has certain TB risk factors in accordance with guidance from the Medical Director.

 The conversion rate of annual inmate TB tests is calculated monthly by the IP&C nurse or

designee and compared to previous conversion rates. Conversion rates that exceed the usual

rate for the institution are investigated, in consultation with the HSD IP&C Section, to assess

the possibility of an undetected case of active TB in the population.

(3) The Bureau will screen an inmate for TB when health services staff determine that the inmate

may be at risk for infection.

The Bureau will also conduct TB testing when health services staff determine an inmate may be

at risk for infection. For example, when there has been a recent exposure to active TB or there is

clinical suspicion of active TB.

(4) An inmate who refuses TB screening may be subject to an incident report for refusing to obey

an order. If an inmate refuses skin testing, and there is no contraindication to tuberculin skin

testing, then, institution medical staff will test the inmate involuntarily.

 Involuntary testing will be conducted in accordance with the Program Statement Use of

Force, Application of Restraints, and Firearms.

 An inmate may not request to substitute an IGRA test or CXR in lieu of a TST. The only

exceptions are when there is a medical (including a psychiatric) or legally determined

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contraindication to testing or where involuntary testing may cause significant injury to staff

or the inmate.

 Legal contraindications (e.g., religious exemptions) are approved by the Warden in

consultation with the Office of General Counsel.

 The CD or designee is the approving authority for ordering an IGRA test or screening CXR

in lieu of a TST when there is a medical contraindication.

 Inmates who refuse TB testing are not placed in an AIIR unless there is a clinical indication

for medical isolation.

 A health care provider must document the inmate’s refusal of testing, and the education and

counseling provided to them.

 Incident report codes 227 (refusing to participate in a required physical test of required

examination unrelated to testing for testing for drug abuse) and 307 (refusing to obey an

order of any staff) should be used for those who refuse testing without a verified legal or

medical contraindication.

An inmate with a positive TB test who refuses a CXR may also be subject to incident reports 227

(refusing to participate in a required physical test or required examination unrelated to testing for

drug abuse) and 307 (refusing to obey an order). If the inmate has symptoms suspicious for

active pulmonary TB, they must be housed in an AIIR until active pulmonary TB has been ruled

out.

(5) The Bureau conducts TB contact investigations following any incident in which inmates or

staff may have been exposed to tuberculosis. Inmates will be tested according to paragraph (b)(4)

of this section.

The investigation will be conducted in consultation with the HSD Population and Correctional

Health Branch and local public health authorities. Once it has been determined a TB exposure

has occurred, the exposed inmate will be offered evaluation and treatment for active TB or latent

TB infection in accordance with guidance from the Medical Director.

(c) Diagnostics. The Bureau tests an inmate for an infectious or communicable disease when the

test is necessary to verify transmission following exposure to bloodborne pathogens or to

infectious body fluid. An inmate who refuses diagnostic testing is subject to an incident report

for refusing to obey an order.

An exposure incident is a specific eye, mouth, other mucous membrane, non-intact skin, or

parenteral contact with blood or other potentially infectious materials. Exposure incidents can

lead to infection with HBV, HCV, HIV, other bloodborne pathogens, or other infectious diseases.

Testing will be performed based upon clinical indications and guidance from the Medical

Director. If an inmate refuses testing, staff should initiate and complete incident report codes 227

(refusing to participate in a required physical test or required examination unrelated to testing for

drug abuse) and 307 (refusing to obey an order of any staff member).

The identity of the inmate who was the potential source of the exposure will not be revealed to

the exposed inmate(s) or staff and will not be recorded in the exposed inmate’s medical record.