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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

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is for Epi

Epidemiology basics

for non-epidemiologists

Session v part ii

Session VPart II

Forensic Epidemiology

Learning objectives
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
Forensic Epidemiology

  • Merging public health methods in a setting of potential criminal investigation

Richard A. Goodman, CDC

What is epidemiology
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
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 epidemiology1
Forensic Epidemiology

  • Past uses

    • Courtroom

  • Current and future uses

    • Courtroom

    • Field-based investigations with law enforcement

Epidemiology in the courtroom
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
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
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
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
Field-based Forensic Epidemiology



Public Health

A sample of agencies involved



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



A Sample of Agencies Involved

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

Public Health and Law Enforcement Goals

Common goals
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
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
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
Criminal Intent Investigations

  • Naturally occurring vs. criminally motivated event

    • Covert action

    • Overt action

Covert attack
Covert Attack Investigations

  • 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
Covert Response Investigations

Unusual Symptoms/Disease clusters

Notify state health department; conduct joint, preliminary epidemiologic investigation. If bioterrorist incident, notify FBI and CDC.

Preliminary public health epidemiological, environmental investigation

Adapted from Butler J, 2002

Covert attack when to notify fbi
Covert Attack: When to Notify FBI Investigations

  • 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
Overt Attack Investigations

  • 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
Overt Response Investigations

Law enforcement identifies biological threat or potential biological materials.

Local or state public health notified. CDC notified.

FBI, Fire/Hazmat, local/state law enforcement notified.

Adapted from Butler J, 2002

Laws governing an investigation
Laws Governing an Investigation Investigations

  • 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 Investigations

  • 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
Legitimate Public Health Investigation Investigations

  • 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
Chain of Custody Investigations

  • 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
Handling Credible Threat Evidence Investigations

  • Handle as evidence and establish a chain of custody

  • Process evidence through an approved Laboratory Response Network (LRN)

Working with the media
Working with the Media Investigations

  • 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 Investigations

  • Public health

    • Confidentiality of patient and medical records

  • Law enforcement

    • Confidentiality of witness or informant

HIPAA Investigations

  • 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
Classified / Sensitive Information Investigations

  • 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 Interviewing Investigations

  • 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
What’s So Different about Bioterrorism? Investigations

  • 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
Review: Forensic Epidemiology Investigations

  • 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
References and Resources Investigations

  • 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).

  • 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 resources1
References and Resources Investigations

  • 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

References and resources2
References and Resources Investigations

  • 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.