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,

medical use of marijuana tobacco use,

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

Public Health Law Enforcement

A Sample of Agencies Involved

• CDC • FBI • Local and state health departments • Local, state, and federal laboratories • State Highway Patrol • State Bureau of Investigation • Hospitals and clinics • Emergency Medical Services • National Guard • Federal Emergency Management Agency • US Department of Agriculture • Homeland Security • Attorney General’s office • Pharmacists • Media

Public Health and Law Enforcement Goals

Public Health • Make people safer and healthier • Prevent disease outbreaks • Conduct disease surveillance and management Law Enforcement • Protection of public • Prevention of criminal acts • Identification, apprehension, and prosecution of 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 public health epidemiological, environmental investigation Notify state health department; conduct joint, preliminary epidemiologic investigation. If bioterrorist 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/state law enforcement notified.

Local or state public health notified. CDC 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.