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					is for Epi
  Epidemiology basics
for non-epidemiologists
     Session V
      Part II
Forensic Epidemiology
          Learning Objectives
• Define Forensic Epidemiology; understand why
  discipline began, direction it is going, and challenges
  it faces
• Understand public health’s role in investigating
  natural outbreaks of disease and that unusual
  findings in an investigation may suggest intentional
  criminal actions
• Understand the goals of public health and law
  enforcement officials and how these goals influence
  investigations
• Understand differences between a law enforcement
  investigation and a public health investigation
      Forensic Epidemiology
• Merging public health methods in a setting
  of potential criminal investigation




                                   Richard A. Goodman, CDC
      What is Epidemiology?
• Study of distribution and determinants of
  health-related states or events in specified
  populations, and the application of this
  study to control of health problems
  – Study risk associated with exposures
  – Identify and control epidemics
  – Monitor population rates of disease and
    exposure


                                          *Last JM, ed
   A New Era in Public Health
• Investigation of health-related criminal
  cases

• Epidemiology can serve as a point of
  reference
  – Law, medicine, pharmacy, statistics, city
    planning, emergency medical services
      Forensic Epidemiology
• Past uses
  – Courtroom


• Current and future uses
  – Courtroom
  – Field-based investigations with law
    enforcement
 Epidemiology in the Courtroom
• Epidemiologists assist in resolving
  disease-related litigation
  – Investigative experts
  – Consulting experts
  – Testimony experts

• Examples
  – Silicone breast implants, E. coli, tobacco use,
    medical use of marijuana
    Difficulties Using Epidemiology
            in the Courtroom
• Epidemiology studies disease in
  populations, not individuals

• Science is ever-changing

• Often difficult to prove exposure caused
  disease
  Anthrax Investigations: 2001
• All isolates tested from 17 clinical
  specimens and 106 environmental
  samples in FL, DC, NJ, NYC, and CT were
  indistinguishable

• Biological and physical evidence will be
  used to prosecute perpetrator(s)


                                   Jernigan DB, 2002
 Health-related Criminal Cases
• Rabbit hemorrhagic disease virus; New Zealand,
  1997

• Shigella; Dallas, TX, 1996

• Sarin; Japan 1990-95

• Anthrax
  – Failed release in Japan in early 1990s
  – Over 105 known hoaxes between 1998-2000
Field-based Forensic Epidemiology



                        Law
 Public Health      Enforcement
A Sample of Agencies Involved

• CDC                         • Emergency Medical
• FBI                           Services
                              • National Guard
• Local and state health
  departments                 • Federal Emergency
                                Management Agency
• Local, state, and federal   • US Department of
  laboratories                  Agriculture
• State Highway Patrol        • Homeland Security
• State Bureau of             • Attorney General’s
  Investigation                 office
• Hospitals and clinics       • Pharmacists
                              • Media
        Public Health and Law
         Enforcement Goals
     Public Health          Law Enforcement
• Make people safer   •   Protection of public
  and healthier       •   Prevention of criminal
• Prevent disease         acts
  outbreaks           •   Identification,
• Conduct disease         apprehension, and
  surveillance and        prosecution of
  management              perpetrators
                      •   Safeguarding all
                          involved
            Common Goals
• Protecting the public
• Preventing or stopping the spread of
  disease
• Identifying those responsible for a threat or
  attack
• Protecting employees during response
  and investigative phases

                                     Martinez D, 2002,
                                     FBI
              Mutual Benefits
• Law enforcement offers public health
  – Criminology expertise
  – Forensic laboratory collaboration
  – National and international law enforcement
    connections


• Public health offers law enforcement
  – Medical and laboratory consultation
  – Collaboration with national and international public
    health connections
                                               Martinez D, 2002,
                                               FBI
Differences in Public Health and
Law Enforcement Investigations
•   Criminal intent
•   Laws governing investigations
•   Sample/evidence collection
•   Confidentiality
•   Media interaction
•   Use of sensitive or secure information
•   Interviewing techniques
             Criminal Intent
• Naturally occurring vs. criminally motivated
  event
  – Covert action
  – Overt action
               Covert Attack
• Not initially recognized as an attack
   – Example: 1985 outbreak of gastroenteritis in
     Oregon from salad bars initially thought to be from
     unintentional mishandling of food; found to be
     caused deliberately

• Public health officials usually recognize
  unusual signs, symptoms, or disease clusters
  through surveillance systems
   – First responders: emergency room, laboratory
     staff, astute health care provider
             Covert Response

Unusual Symptoms/Disease clusters




    Preliminary           Notify state health
   public health          department; conduct joint,
 epidemiological,         preliminary epidemiologic
  environmental           investigation. If bioterrorist
   investigation          incident, notify FBI and
                          CDC.
                                            Adapted from Butler J, 2002
Covert Attack: When to Notify FBI
• A case of smallpox or pulmonary anthrax
• Uncommon agent or disease occurring in person
  with no other explanation
• Illness caused by a microorganism with
  markedly atypical features
• Illness due to food or water sabotage
• One or more clusters of illnesses that remain
  unexplained after a preliminary investigation
• Deliberate chemical, industrial, radiation or
  nuclear release
              Overt Attack
• Perpetrator announces responsibility for
  something
  – 1995 sarin attack in Tokyo subway

• Law enforcement will usually detect event
  first
  – First responders: Emergency management
    and law enforcement

• Often a hoax
               Overt Response

Law enforcement identifies
biological threat or potential
biological materials.




  FBI, Fire/Hazmat,              Local or state public
  local/state law                health notified. CDC
  enforcement notified.          notified.
                                         Adapted from Butler J, 2002
          Laws Governing an
             Investigation
• Public health officials have ability to
  – Examine medical records of person infected,
    exposed, or suspected of being infected or
    exposed
  – Implement control measures
  – Exercise quarantine and isolation authority
  – Enter premises where entry is necessary to
    enforce public health laws
• Law enforcement must obtain a search
  warrant
                   Evidence
• Law enforcement gathers evidence

• Public health gathers specimens

• Two criteria for specimens from public health
  investigations to be used in criminal
  investigations
  – Obtained as part of a legitimate public health
    investigation
  – Collected and processed with a chain of custody
     Legitimate Public Health
           Investigation
• Samples taken as part of a legitimate
  investigation of an outbreak or other public
  health situation may be used in a criminal
  investigation
  – Legitimate example: Collection of foods on a
    salad bar due to a suspected outbreak
  – Incorrect example: Evidence found using
    public health authority to inspect a hotel
    kitchen
         Chain of Custody
• Required in law enforcement
  investigations
• Form providing
  – Name of person collecting evidence
  – Each person having custody of it
  – Date item collected or transferred
  – Agency and case numbers
  – Victim’s or suspect’s name
  – Brief description of item
    Handling Credible Threat
           Evidence

• Handle as evidence and establish a chain
  of custody

• Process evidence through an approved
  Laboratory Response Network (LRN)
      Working with the Media
• Public health
  – Open with media
  – Rely on media to get information to the public for
    their protection

• Law enforcement
  – Not as open about ongoing investigations
  – Must preserve integrity of the case

• Joint Information Center (JIC)
             Confidentiality
• Public health
  – Confidentiality of patient and medical records


• Law enforcement
  – Confidentiality of witness or informant
                   HIPAA
• Protected health information can be
  disclosed:
  – When a person is exposed or at risk of
    contracting or spreading a disease created or
    caused by a terrorist act
  – When a weapons of mass destruction event
    causes public health issues
  – Pursuant to court order, subpoena, or
    administrative request form
  – To identify or locate a suspect, fugitive or
    missing person
 Classified / Sensitive Information
• Some public health officials should hold
  clearances to communicate with law
  enforcement when necessary

• Secure equipment should be available
  – Phone lines
  – Fax machines
           Joint Interviewing
• Joint interviews with victims and witnesses

• Each discipline should be aware of the
  information counterparts seek
  – Law enforcement: personal, travel, incident,
    safety, criminal investigation
  – Public health: personal, exposure, travel,
    medical history
         What’s So Different about
              Bioterrorism?
•   High concentrations of agent dispersed
•   Large primary cohort exposed
•   Agent distributed in a well-traveled area
•   People present to different hospitals
•   May be second deliberate attack
•   Widespread panic
•   Hospitals may become flooded
 Review: Forensic Epidemiology
• Joint public health and law enforcement
  investigations in the setting of a potential criminal
  investigation
• Once primarily used in the courtroom, now
  increasingly used in the field to investigate health-
  related crimes, including bioterrorism
• While differences exist between public health and
  law enforcement investigations, by understanding
  the roles and responsibilities of each better, both
  can be more successful at protecting the public
      References and Resources
• Carus WS. Bioterrorism and biocrimes: The illicit
  use of biological agents since 1900. Center for
  Counter proliferation Research, National
  Defense University, Washington, D.C.

• Centers for Disease Control and Prevention
  (CDC).
  http://www.phppo.cdc.gov/od/phlp/ForensicEpi/F
  orensicEpi.asp

• Jernigan DB, Raghunathan PL, Bell BP,
  Brechner R, et al. Investigation of bioterrorism-
  related Anthrax, United States, 2001:
  Epidemiologic findings. Emerging Infectious
  Diseases 2002;8:1019-28.
      References and Resources
• Last JM, ed. A Dictionary of Epidemiology, 3rd Ed, New York,
  Oxford Univ Press, Inc., 1995.

• Law, D. (2005) Introduction to Geographic Information Systems.
  Methods in Field Epidemiology online course. UNC Chapel Hill
  School of Public Health.

• Martinez D. Presentation entitled Law Enforcement and Forensic
  Epidemiology at the Forensic Epidemiology Training Course. The
  Friday Center, Chapel Hill, North Carolina November 2-5, 2002.

• Moore J. Responding to biological threats: The public health
  system's communicable disease control authority. Health Law
  Bulletin 2001;78:1-10.

• National Institute of Justice. Accessed at
  http://www.ncjrs.org/txtfiles1/nij/178280.txt.
     References and Resources
• NC Center for Public Health Preparedness (2004). Interviewing
  Techniques. Public Health Training and Information Network
  Broadcast.

• NC Center for Public Health Preparedness (2004). Designing
  Questionnaires. Public Health Training and Information Network
  Broadcast.

• Inglesby, Thomas. Anthrax as a biological weapon. JAMA 1999;281:
  1735-1745.

• Torok, Thomas. A large community outbreak of Salmonellosis
  caused by intentional contamination of restaurant salad bars. JAMA
  1997: 278: 389-395.

• Treadwell, Tracee. Epidemiologic clues to bioterrorism. Public
  Health Reports 2003; 118: 92-98.