DB for Public health in Disaster Management

DB for Public health in Disaster Management

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Joint Criminal and Epidemiological Investigations Handbook 2015 DOMESTIC EDITION TABLE OF CONTENTS INTRODUCTION SUMMARY Purpose………………………………………………………………………………………………………………………………………………………………………………………………………..6 The Biological Threat………………………………………………………………………………………………………………………………………………………………….9 Federal Bureau of Investigation (FBI)………………………………………………………………………………………………………………… 10 Centers for Disease Control and Prevention (CDC)…………………………………………………………………………. 14 Key Highlights of Introduction Section………………………………………………………………………………………………………….. 71 Key Highlights of Public Health Section………………………………………………………………………………………………………..72 Key Highlights of Law Enforcement Section…………………………………………………………………………………………… 74 Key Highlights of Joint Criminal and Epidemiological Investigations Model Section……………………………………………………………………………………………………………………………………… 76 PUBLIC HEALTH Epidemiological Investigation Goals………………………………………………………………………………………………………………….20 Epidemiological Investigative Methods………………………………………………………………………………………………………… 21 LAW ENFORCEMENT Criminal Investigation Goals…………………………………………………………………………………………………………………………………………38 Preventing Biological Attacks……………………………………………………………………………………………………………………………………..39 Criminal Investigative Methods………………………………………………………………………………………………………………………………..42 JOINT INVESTIGATIONS MODEL Introduction……………………………………………………………………………………………………………………………………………………………………………………….52 Benefits of the Joint Criminal-Epidmiological Investigations Model……………………….53 The Joint Criminal-Epidemiological Investigations Model: An Overview………….54 ●● Building Relationships……………………………………………………………………………………………………………………………………………. 55 ●● Information Sharing………………………………………………………………………………………………………………………………………………….. 55 ●● Joint Threat Assessment…………………………………………………………………………………………………………………………………….. 60 ●● Joint Investigations…………………………………………………………………………………………………………………………………………………….62 ●● Memorandum of Understanding/Joint Protocols…………………………………………………………….. 66 ●● Joint Training / Exercises……………………………………………………………………………………………………………………………………….. 67 2 APPENDICES Sample Joint Criminal-Epidemiological Investigations Material Appendix 1: Sample Procedure for a Joint Threat Assessment………………………………………. 81 Appendix 2: Sample Procedure for Joint Interviews……………………………………………………………………. 84 Appendix 3: Sample Joint Interview Questions…………………………………………………………………………………..92 Reference Material Appendix 4: List of Select Agents and Toxins (2014)……………………………………………………………………. 94 Appendix 5: Laboratory Response Network…………………………………………………………………………………………….97 Appendix 6: CSTE List of Nationally Notifiable Conditions (2013)…………………………….100 Appendix 7: HIPAA Privacy Rule & Permitted Disclosures………………………………………………….. 107 Appendix 8: Overview of the FBI’s WMD Coordinators………………………………………………………….. 111 Appendix 9: Bio-Related Laws to Prevent Bioterrorism…………………………………………………………..115 Appendix 10: Common Public Health and Law Enforcement Terminology…118 Joint Criminal and Epidemiological Investigations Handbook 3 INTRODUCTION INTRODUCTION Purpose This handbook was developed to facilitate the use of resources and maximize communication and interaction between law enforcement and public health. This combined effort can minimize potential barriers prior to and during the response to a biological threat. Specifically, this handbook aims to: ●● Provide an overview of both law enforcement and public health to enhance the appreciation and understanding of each discipline’s expertise ●● Discuss criminal and epidemiological investigational procedures and methodologies for a response to a biological threat ●● Identify challenges to sharing information and provide potential solutions that may be adapted to meet the needs of the various agencies and jurisdictions ●● Demonstrate effective law enforcement and public health collaboration Even with these common concerns, each discipline may be hesitant to share information because of actual or perceived limitations or barriers. Identifying and resolving these issues in advance of a biological threat will help facilitate more effective dialogue and information exchange, thereby increasing the likelihood of identifying an incident and protecting public health and safety in a more efficient manner. Simply put, working together helps both law enforcement and public health achieve their separate but often overlapping goals and ultimately allows for a more effective and efficient response to a biological threat. The 2015 edition of the Criminal and Epidemiological Investigation Handbook has been updated to reflect current Federal policies and includes modifications based upon experiences gained since the previous version was published. Law enforcement and public health are encouraged to read the entire handbook and not limit their review to just their respective sections. It is important to take the time to understand the different goals and needs of each other’s organization before a suspicious biological event occurs. Doing so, will enable law enforcement and public health personnel to more effectively respond in a coordinated manner during a biological threat. While both disciplines have varying objectives and protocols, both public health and law enforcement ultimately share three common concerns: 6 ●● Early identification of an outbreak ●● Determining whether the outbreak is intentional or naturally occurring ●● Protecting public health and public safety Joint Criminal and Epidemiological Investigations Handbook 7 INTRODUCTION The Biological Threat Key Highlights of Introduction Section ●● There has been a demonstrated interest and willingness by terrorist groups and individuals to acquire and employ biological agents at weapons against the American population. ●● The intentional release of a biological agent may initially be difficult to discern from a natural incident, which can result in separate law enforcement and public health investigations. ●● It is in public health and law enforcement’s best interest to work together when first investigating a suspicious biological outbreak, which includes fostering mutual awareness and establishing joint communication procedures. ●● By working together, public health and law enforcement can achieve their separate but often overlapping objectives of identifying the biological agent, preventing the spread of the disease, preventing public panic, and apprehending those responsible. There has been a demonstrated interest and willingness by terrorist groups and individuals to acquire and employ biological agents as weapons against the American population. Weapons of mass destruction (WMD) terrorism is an evolving threat to U.S. national security. In his 2010 testimony before the Senate and the House of Representatives, the Director of National Intelligence stated that terrorist groups have expressed an interest in obtaining WMD for use in future acts of terrorism. Indicators of this threat include the 2001 Amerithrax letters, the possession of WMD-related materials by Aafia Siddiqui in 2008, and multiple attempts by terrorists at home and abroad to use explosives improvised from basic chemical precursors. Over the past few years, there has been an increased interest in extracting ricin from castor beans, which are readily available to the public, to intentionally harm others. Ricin is one of the most discussed toxins online, which includes discussions of criminal plots. In 2011, federal authorities disrupted a plot by a militia group in Georgia to deploy 10 pounds of ricin against various federal employee and facility targets. Since 2013, there have been several incidents involving individuals creating ricin and utilizing the U.S. Postal System as a delivery system for ricin-laced letters. Most recently, the ‘Dark Web’ — the virtual black market for drugs, guns, explosives, and other illicit materials — has shown a growing number of sellers and buyers of biological material. The FBI has opened investigations on individuals who have attempted to sell or purchase illicit biological material, such as ricin and abrin, through the Internet. Concern that nefarious actors might use biological material as a weapon will likely remain a persistent threat for years to come, especially as scientific advancements in technical capability, knowledge, and accessibility continue to grow. Despite 8 Joint Criminal and Epidemiological Investigations Handbook 9 INTRODUCTION continued efforts in bioterrorism preparedness, the intentional use of biological agents as a weapon still poses challenges to both law enforcement and public health due to the unique circumstances of a biological incident. Since biological agents are often endemic or naturally occurring in the environment, an intentional release of a pathogen may be initially difficult to discern from a natural event, and efforts to respond to the attack and apprehend those responsible may be delayed. In the past, it was common for public health (which conducts epidemiological investigations to natural incidents) and law enforcement (which conducts criminal investigations to intentional incidents) to conduct independent investigations. Due to the challenges posed by a biological threat, an effective response calls for a high level of cooperation between both these two disciplines. The lack of mutual awareness and understanding, as well as the absence of established communication procedures, could limit the effectiveness of these disciplines’ separate, but often overlapping, investigations. During a suspicious biological incident, it is mutually beneficial for public health and law enforcement to work in partnership. By working together, public health and law enforcement can more effectively achieve their shared objectives of identifying the biological agent, preventing the spread of the disease, preventing public panic, and apprehending those responsible. Federal Bureau of Investigation (FBI) The FBI is an intelligence-driven and threat-focused national security organization with both intelligence and law enforcement responsibilities — the principal investigative arm of the U.S. Department of Justice and a full member of the U.S. Intelligence Community. The FBI is vested by law and Presidential directives as the primary agency of the U.S. Federal Government with the authority and responsibility to investigate threats to national security, including biological threats, within the United States and relating to U.S. citizens and 10 interests overseas. Activities of “threat to the national security” commonly involve violations (or potential violations) of federal criminal laws, such as Title 18, U.S. Code, Section 175 (biological weapons). Hence, investigations of such threats may exercise both of the FBI’s criminal investigation authority and of the FBI’s authority to investigate threats to the national security. Generally acting through the FBI, the Attorney General, in cooperation with other federal agencies engaged in activities to protect national security, coordinates the activities of other members of the law enforcement community to detect, prevent, preempt, and disrupt terrorist attacks against the United States. The FBI has multiple operational units to provide assistance in the event of a terrorist attack, including response teams trained to collect and handle hazardous materials and contaminated evidence. Along with the FBI Headquarters in Washington, D.C., there are numerous FBI field offices located in major cities throughout the United States. These field offices implement national level policy at the local level, where they are able to tailor their outreach to reflect the particular geographic threats and vulnerabilities unique to their specific jurisdiction. There is a common misconception that the FBI prosecutes cases; however, this is incorrect. The FBI gathers facts and evidence and then presents the results to the Department of Justice, which is responsible for deciding if an individual will be brought to trial and if so, conducts the prosecution of the case. Therefore, during a suspicious biological incident, the FBI would work closely with public health to investigate whether the outbreak is criminal in nature and if so, gather evidence to build a case for prosecution of those responsible. FBI WMD Coordinator The FBI is headquartered in Washington D.C. The offices and divisions at FBI Headquarters provide direction and support to 56 field offices in big cities, approximately 360 smaller offices known as resident agencies, several Joint Criminal and Epidemiological Investigations Handbook 11 INTRODUCTION specialized field installations, and more than 60 liaison offices in other countries known as legal attachés (Figure 1). These offices allow the FBI to interact with Figure 1. Map of FBI Field Offices and Resident Agencies local stakeholders and obtain unique geographic knowledge of their area of responsibility. Each field office has a designated Special Agent, called a WMD Coordinator, who serves as a WMD subject matter expert and point of contact for local and state emergency responders and public health. In the event of a bioterrorism event, the WMD Coordinator would act as a conduit for obtaining federal assistance (e.g., threat credibility evaluation and operational response) for local law enforcement. See Appendix 8 for additional information on WMD Coordinators. and knowledge of various federal, state, and local law enforcement agencies to maximize the United States’ collective ability to combat terrorism. Often memoranda of understanding (MOUs) are developed between participating law enforcement agencies to assist in determining in advance how law enforcement agencies can best prevent and respond to a terrorist event. The National Joint Terrorism Task Force is headquartered in Washington, D.C., and there are over one hundred area-specific Joint Terrorism Task Forces nationwide (many located at FBI field offices). FBI International Efforts The resources of the FBI are available to assist all law enforcement agencies throughout the world. FBI resources can be requested through the FBI Legal Attaché Office. The FBI has Legal Attaché personnel located in almost 70 countries throughout the world. The mission of these Legal Attaché offices is to foster strategic partnerships with foreign law enforcement, intelligence, and security services by sharing knowledge, experience, capabilities, and exploring joint operational opportunities. FBI Special Agents with specific expertise in WMD matters are located in Tbilisi, Georgia, and Singapore, Singapore. The FBI also coordinates extensively with INTERPOL and has a Special Agent with expertise in WMD stationed at the INTERPOL Headquarters in Lyon, France. FBI Legal Attaché contact information may be found at: http://www.fbi.gov/contact-us/legat Joint Terrorism Task Force In an effort to promote communication and collaboration across the various law enforcement entities, the United States implements a partnership called the Joint Terrorism Task Force. These task forces combine the resources 12 Joint Criminal and Epidemiological Investigations Handbook 13 INTRODUCTION Centers for Disease Control and Prevention (CDC) The Department of Health and Human Services (HHS) is the United States government’s principal agency for protecting the health of all Americans and a leader in promoting activities associated with the medical and public health response to a biological incident. As an entity of HHS, CDC plays a critical role in leading the nation’s public health efforts in strengthening capacity to detect and respond to a biological incident. To carry out these efforts, CDC conducts critical science and provides health information that protects the United States against For public health, health threats and responds when these arise. all response is CDC Global Health Efforts CDC’s global health programs, research, and training activities improve health and save lives around the world and protect Americans from diseases and other health threats that begin overseas. Collaborating with other federal agencies and with international partners CDC helps other countries build capacity to prevent, rapidly detect and effectively respond to emerging infectious diseases and biological threats, whether they occur naturally, are intentionally produced, or are the result of laboratory accidents. LOCAL! The response to a public health emergency, including an intentional release of a pathogen, is the responsibility of public health at the state and/or local level. Public health agencies at the state and local level will likely be the first agencies to recognize cases of illness associated with a biological threat. Upon recognition of an incident, public health will initiate an investigation and respond to determine the source and implement interventions to prevent additional illness. If the state and local public health agencies need additional resources then they will request federal assistance. Since a biological incident can occur in a variety of locations and populations, the FBI, CDC, and the Association of Public Health Laboratories (APHL) established the Laboratory Response Network (LRN). The mission of the LRN is to develop, maintain, and strengthen an integrated national and international network of laboratories that can respond quickly to needs for rapid testing, timely notification, and secure reporting of results that are associated with acts of biological terrorism or other high-consequence public health emergencies. All LRN member laboratories work under a single operational plan and adhere to strict policies of safety and security. 14 Joint Criminal and Epidemiological Investigations Handbook 15 PUBLIC HEALTH PUBLIC HEALTH Key Highlights of Public Health Section ●● The ultimate aim of an epidemiological investigation is to identify the source of the disease and implement efforts to control the outbreak and protect the public’s health. ●● An epidemiological investigation primarily involves the meticulous accumulation of information from patient interviews and surveys as well as data collected from surveillance systems. ●● 18 Goals of an epidemiological investigation include: »» Stopping the spread of disease (identify causative agent, determine source, mode of transmission and population at risk) »» Protecting the public’s health (surveillance, medical countermeasures, health education) »» Protecting public health and other response personnel (protective equipment and preventive vaccines/medications) ●● Important elements of an epidemiological investigation are: »» Detect unusual events »» Confirm diagnosis »» Identify and characterize additional cases »» Determine source of exposure »» Develop and implement interventions ●● Laboratory analysis of clinical specimens is used to assist the physician in making a definitive diagnosis. While most physicians will wait for definitive laboratory results to confirm a biological threat agent diagnosis, physicians are likely to begin treatment before laboratory test results are confirmed since early treatment of disease increases the probability the patient will recover from the illness. ●● A laboratory that tests for biological agents should meet applicable standards (e.g., quality control measures, biosafety, and biosecurity) and participate in relevant proficiency testing. Joint Criminal and Epidemiological Investigations Handbook 19 PUBLIC HEALTH Epidemiological Investigation Goals Epidemiology is the fundamental science of public health. It is used by According to the World epidemiologists to study diseases or Health Organization (WHO), events that impact human health in “Epidemiology is the study of the distribution and determinants of order to reduce disease or disability in health-related states or events a population. Whether it is in response (including disease), and the to a naturally occurring outbreak application of this study to the or a biological threat, public health control of diseases and other will conduct an epidemiological health problems.” investigation to gather information that will move investigators toward determining the source of the disease and the extent of the outbreak. When conducting an epidemiological investigation for a naturally occurring outbreak or biological threat, public health has the following basic goals: 20 ●● To stop the spread of disease: One of the most basic missions of public health is the prevention of illness in the population. While physicians focus on curing the sick and promoting health in the individual, public health strives for health promotion and disease prevention in the entire population. For the illness under investigation, epidemiologists use interviews, surveys and data analysis to identify the causative agent, mode of transmission, source of exposure, and population at risk to limit the spread of the outbreak. ●● To protect the public: Public health utilizes surveillance of health trends, medical information, and a variety of analytical tools to establish methods and implement interventions that protect the public from health threats. Vaccine campaigns, medical countermeasure distribution programs, disease surveillance, and health education all play a role in preventing and responding to serious health emergencies. ●● To protect public health and other response personnel: A major consideration during an investigation is the protection of responders. Since epidemiologists and other responders may come in contact with potentially infectious individuals, provision of proper protective equipment and preventive medications or vaccines for investigative personnel is essential. Epidemiological Investigative Methods Public health uses investigative techniques to identify the causative agent and determine the source and extent of disease outbreaks. An epidemiological investigation primarily involves the meticulous accumulation of information from patient interviews and surveys, as well as data collected from surveillance systems. Since interview or disease surveillance information may be relevant to a criminal investigation, law enforcement should become familiar with the elements of an epidemiological investigation. The following section provides a brief synopsis of the elements of an epidemiological investigation. Joint Criminal and Epidemiological Investigations Handbook 21 PUBLIC HEALTH In an epidemiological investigation, the nature of each outbreak and the availability of personnel and resources will determine the sequence and scope of the actions that will be performed during the investigation. Detect unusual events Develop and nd implement nt interventions ons Confirm diagnosis Epidemiological cal Investigationn Determine ne source of exposure re Identify additional cases Characterize additional cases Figure 2. Elements of an epidemiological investigation. Detect Unusual Events The first indication of an unusual event is often an unexpected increase in the number of people with similar symptoms, referred to as cases. This increase in cases is detected either by monitoring surveillance systems or receiving notifiable disease reports from healthcare providers. If an unexpected increase occurs, public health will begin to collect additional patient information, as well as further characterize the illness to determine the nature of the incident. 22 Based on the information collected, the incident may be classified as an infectious disease outbreak and public health would begin an epidemiological investigation to determine the extent and source of the outbreak. An outbreak is defined as an occurrence of cases associated with a specific place or group of people over a given period of time. For example, public health may determine that 15 cases of E. coli O157:H7 infection were due to victims having recently consumed unpasteurized apple cider from a local orchard in the last month. Since all of the cases have an association with the orchard over a similar period, public health may consider this an outbreak. For rare or uncommon diseases in the United States (e.g., botulism, SARS), public health may determine that a single case of the disease constitutes an outbreak since cases are not normally observed in their jurisdiction. Case Reporting All states and territories possess laws that require reporting of specific infectious diseases by healthcare providers. It is mandatory that reportable disease cases be reported to state and territorial jurisdictions when identified by a health provider, hospital, or laboratory. Each state has its own laws and regulations defining what diseases are reportable and the list varies among states and over time. In addition, notifiable disease cases are voluntarily reported to CDC by state and territorial jurisdictions (without direct personal identifiers) for nationwide aggregation and monitoring of disease data. The Council of State and Territorial Epidemiologists (CSTE) maintains a list of diseases that are reportable to the CDC (Appendix 6). States use the CSTE list of notifiable conditions to create their own reporting laws and may choose to add other diseases. For additional information on reporting requirements for a jurisdiction, contact the city, county or state health department. Joint Criminal and Epidemiological Investigations Handbook 23 PUBLIC HEALTH While disease case reporting is standard practice for identifying unusual events, it is a time and resource intensive process that can be adversely impacted by delays in symptom onset, clinical diagnosis, laboratory testing and results reporting. Depending on the illness, it may be days or weeks before public health is notified by a healthcare provider or laboratory of a case report. (See Figure 3) Lab Result Available Exposure 0–7 Courtesy of New Mexico Department of Health 1–3 Specimen Received at Public Health Laboratory 1–3 1–5 Symptom Onset Sample Collected Report Received Figure 3. A depiction of the typical reporting time from initial exposure to receipt by public health. Typically, a person is exposed to a pathogen and may experience symptoms within a few days. After a patient is seen by a physician, specimens are collected and sent to a clinical laboratory for initial diagnostic testing, results are provided within a few days. If specimens are positive for a reportable disease, public health is notified of the case and specimens may be sent to a public health laboratory for additional testing. 24 Frequent and timely disease reports are critical for detecting outbreaks; identifying populations or geographic areas at high risk; developing, implementing, and evaluating prevention strategies; and improving public health policies. Surveillance Systems Public health surveillance is defined as the ongoing collection, analysis, and interpretation of health data for use in the planning, implementation, and evaluation of public health practices. Generally, public health tends to rely on passive methods of disease detection. This may include receiving case reports from physicians, laboratories, or other individuals or institutions as mandated by law. However, in the event of an outbreak or other event of public health concern, more active surveillance techniques may be used, in which public health will regularly contact reporting sources to obtain information. Any surveillance system must include the capacity for collecting and analyzing data, as well as the means to disseminate the data to individuals or groups involved in disease prevention and control activities. Ideally, a surveillance system will detect the occurrence of disease within a sufficient time frame that allows public health to initiate an investigation and implement timely prevention and control programs, thereby limiting any impact on the public. For example, early detection of a contagious disease (e.g., influenza, measles, and smallpox) allows for implementation of a vaccination program that would greatly reduce the spread of disease and the number of people affected. For incidents involving biological threats, public health will want to decrease the length of time between exposure and traditional disease reporting. To assist with this process, some cities and states may utilize a syndromic surveillance system to track pre-clinical healthcare indicators. Syndromic surveillance is a Joint Criminal and Epidemiological Investigations Handbook 25 PUBLIC HEALTH system that relies on existing health data to identify clusters of disease, prior to clinical diagnosis or laboratory testing, or to look for disease symptoms that indicate patients are being misdiagnosed. The advantage of syndromic surveillance is that it may provide initial indication of an outbreak; track the size, spread, and tempo of an outbreak; monitor disease trends; or provide evidence that an outbreak has not occurred.2,3 Some healthcare indicators found in syndromic surveillance systems include: ●● Number of upper respiratory disease cases seen in emergency departments ●● Number of ambulance runs within an allotted period of time ●● Number of antibiotics or over-the-counter drugs sold at pharmacies It should be noted that syndromic surveillance is not guaranteed to detect the occurrence of an outbreak and does not replace other surveillance methods or direct case reporting to public health. However, it is a useful tool that enhances collaboration among public health, healthcare providers, information system professionals, academic investigators, and industry.3 Since many biological threat agents cause illness with symptoms similar to common ailments, supporters of syndromic surveillance believe that monitoring and analyzing healthcare indicator data will allow for rapid detection of covert biological threats. Confirm the Diagnosis Diagnosing the potential disease agent often begins with healthcare providers obtaining medical histories and conducting physical examinations of affected individuals. A medical history is the record of medical information gained by CDC. PHIN Messaging guide for syndromic surveillance: Emergency department, urgent care, and inpatient settings. HL7 Version 2.5.1. April. 2013 3 Henning, K. Overview of Syndromic Surveillance What is Syndromic Surveillance. MMWR. September 24, 2004 (Suppl); 5-11. 2 26 a physician during an exam and usually includes information on symptoms, recent events, travel, or any unusual circumstances that may contribute to an illness. Based on this information, physicians or public health may request laboratory tests to confirm the clinical diagnosis. However, physicians are likely to begin treatment before laboratory test results are available since early treatment of disease increases the probability the patient will recover from the illness, especially for biological threat agents. Laboratory Analysis of Specimens and Samples Diagnosing an illness by clinical signs Field Testing: and symptoms can be imprecise A field assay test combined with due to the nature and progression clinical symptoms might suggest of the disease, especially for many that a particular biological agent biological threat agents, since the is present, but the field assay test initial symptoms are similar to common alone cannot determine with infectious diseases (e.g., influenza). absolute certainty that a particular Therefore, laboratory analysis of biological agent is or is not clinical specimens is used to assist present. The lack of specificity and the physician in making a definitive comparably higher detection limits of these field assay tests make the diagnosis. Most physicians will wait use of an approved laboratory for definitive laboratory results prior to test critical. confirming the diagnosis if a biological threat agent is suspected. The materials that are typically collected to support a diagnosis or assist with a public health investigation may be clinical specimens (e.g., tissues, blood, and sputum) or environmental samples (e.g., food, water, air, dusts, powders, surface swabs). Some environmental samples may be considered hazardous materials and require specialized training and equipment for collection. Joint Criminal and Epidemiological Investigations Handbook 27 PUBLIC HEALTH Laboratories also vary in their ability to test for biological agents. For example, forensic laboratories that process criminal evidence may not be equipped to handle or test specimens containing a biological or chemical threat agent. Until the public health officials obtain the results from the confirmatory diagnostic test in an approved laboratory, such as the Laboratory Response Network, the diagnosis is considered unconfirmed or presumptive. Identify and Characterize Additional Cases The process of identifying and characterizing additional cases in an epidemiological investigation is very similar to that of a law enforcement investigation. In both disciplines, a generous amount of time and resources is required to obtain additional investigative information through interviews with cases and other contacts. Laboratory Response Network The FBI, CDC, and the Association of Public Health Laboratories (APHL) Due to their expertise and established the Laboratory Response proficiency, only LRN facilities should be used to test clinical Network (LRN) in 1999. The LRN is specimens or environmental a network of laboratories located samples for the presence of across the country that possess the biological or chemical threat expertise to conduct appropriate agents. Law enforcement agents analyses with approved equipment, should contact their local FBI qualified personnel, validated WMD Coordinator to determine assays, and accepted practices. LRN the location and procedures laboratories meet certain standards for submitting samples to the and continue to demonstrate their nearest LRN facility. readiness through proficiency tests that validate their ability to correctly identify biological and chemical threat agents. Sending a specimen to a non-LRN laboratory could dramatically delay the investigation and may destroy material required to confirm the agent’s identity and properly diagnose the causative agent of an illness. Additional information on the Laboratory Response Network is located in Appendix 5. The first confirmed case of an outbreak is referred to as the index case. To prevent further impact and to try and find the source of the disease, there is a need to identify new, unreported or unrecognized cases and their contacts. In the search for additional cases, public health will interview family members, associates, co-workers, and other possible contacts of the index case. These interviews require extensive time and personnel commitments. Interviewees may be contacted multiple times as the investigation proceeds if there is a need to obtain additional information. Information collected by public health can include the following: 28 ●● Demographic data (name, address, age, race, ethnicity, gender) ●● Clinical data (signs and symptoms, duration, onset) ●● Exposure history (travel, meals, and significant events; all based on the type of illness suspected) ●● Case contacts and knowledge of other cases Joint Criminal and Epidemiological Investigations Handbook 29 PUBLIC HEALTH EPI CURVE: Multistate Outbreak of E. coli O157:H7 Infection Multi-State Outreach of E. coli 0157:H7 Infection In addition to interviewing the index case and contacts, public health will attempt to identify additional cases by using a set of uniformed criteria, called a case definition. Public health provides the case definition to physicians, hospitals, and other health officials to identify any additional cases that may be related to the outbreak, both within and outside their jurisdiction. Number of Cases 8 Public health may also solicit assistance from the media in trying to identify additional cases. For example, public health may work with the media to inform the public that anyone with a certain type of symptom (e.g., skin rash, fever) may have been exposed to a biological agent and should report to a physician for an examination. Once additional cases have been identified, public health will collect information on each one to determine whether their illness could be associated with the outbreak. Determine the Source of Exposure Once the case/contact interview information has been collected, it is analyzed to identify common exposures and, ultimately, to suggest the source of illness. This process is known as descriptive epidemiology. An example of descriptive epidemiology is the creation of a histogram (a bar graph that estimates a probability distribution) in which the number of disease cases are plotted by date or time of onset in order to visualize the progression of the outbreak. This bar graph, called an epidemic curve or epi curve, provides a visual representation of an outbreak’s magnitude over a specific time period and can provide critical clues regarding the outbreak’s onset and duration. (See Figure 4) 5 4 4 4 3 2 3 2 1 1 12 14 16 18 20 22 24 26 28 30 2 4 JUNE JULY 1 6 8 10 12 14 16 18 20 Date of Onset Figure 4. The Epi Curve. 4 This is a diagram of the number of cases of E.coli 0157:H7 infection that were associated with this outbreak and date of occurrence. This graph, known as an epi curve, helps public health determine the source and spread of an outbreak. Once the descriptive epidemiology has been reviewed, public health will try to develop a “best guess” for the source(s) of illness. This best, or informed, guess is known as a hypothesis. For example, if multiple cases shared an exposure, such as attending the same organized event, then public health may develop a hypothesis that the common event is the source of disease. During an epidemiological investigation, public health may develop several hypotheses about the cause of the outbreak as they accumulate additional clinical, laboratory, and investigative information. To determine whether a Stehr-Green J. (2002) Multistate Outbreak of E.coli 0157:H7 Infection. Instructor’s Version. Retrieved from http://www.cdc.gov/epicasestudies/downloads/ecolii.pdf 4 30 Joint Criminal and Epidemiological Investigations Handbook 31 PUBLIC HEALTH hypothesis is correct, public health conducts a statistical analysis or study of data obtained using a standardized survey instrument or questionnaire. This process is known as analytical epidemiology. The statistical analysis provides public health with mathematical evidence to confirm or reject a hypothesis. If the analysis confirms a hypothesis then public health will develop and implement an intervention to prevent people from becoming ill. If a hypothesis is rejected by the analysis, then public health will develop a new hypothesis and continue to search for more cases in order to obtain additional information. Develop and Implement Interventions The ultimate aim of an epidemiological investigation is to identify the source of the disease and implement a plan to control the outbreak and protect the public’s health. Often there is a need to develop and implement an intervention before the disease agent has been confirmed in order to ensure a successful intervention. Many illnesses, including those caused by biological threat agents, can be treated successfully if antibiotics or antivirals are provided early in the course of the illness. Also, quarantine (restricting movement of healthy people who may have been exposed to a contagious disease) or isolation (separating ill persons who have a contagious disease from those who are healthy) measures may be used to control spread of a contagious disease; however, these measures must be implemented early in an outbreak to be effective. Some control measures may be directed at the environment to remove the source (e.g., insects, contaminated food) of transmission. Therefore, in the case of bioterrorism, interventions are often initiated based on the suspicion of disease rather than waiting for confirmation. Early suspicion, coordinated with law enforcement intelligence, can help public health intervene as quickly as possible and save lives. 32 Joint Criminal and Epidemiological Investigations Handbook 33 LAW ENFORCEMENT LAW ENFORCEMENT Key Highlights of Law Enforcement Section ●● ●● ●● 36 ●● Once there is suspicion that a crime has occurred, chain of custody procedures should be implemented by both law enforcement and public health to ensure accountability of evidence. Failure to properly maintain the chain of custody may render evidence unusable at trial. ●● In certain situations the environment might be contaminated; therefore, it is useful to have specially trained law enforcement teams to handle apprehension of the suspect and collection of evidence in contaminated environments. ●● The need for rapid collection and testing to save lives outweighs normal evidence collection procedures. Primary goals of a criminal investigation for a biological threat are: »» To protect the health and safety of the public »» To prevent subsequent attacks »» To identify, apprehend, and prosecute the perpetrators »» To protect law enforcement personnel If public health and law enforcement have established a working relationship prior to a biological threat incident, public health may feel more comfortable contacting law enforcement early in their investigation. Law enforcement should include various subject matter experts, such as public health, to assist in determining the credibility of a biological threat. Joint Criminal and Epidemiological Investigations Handbook 37 LAW ENFORCEMENT Criminal Investigation Goals Preventing Biological Attacks During a biological threat incident, law enforcement has the following basic goals: The first step in preventing a biological attack is to attempt to identify potential terrorists or terrorist organizations that are both capable of and have intent to execute a biological attack. This process allows FBI and other law enforcement officials to identify potential targets and possible modes of attack. Despite all efforts, a biological attack may not be prevented. Therefore, appropriate law enforcement agencies must be prepared to respond to an incident either while it is occurring or after it has perpetrated. Since soft targets are often more appealing than solid or more stable targets, a country’s strong response capability to a biological attack might be a deterrent for terrorists choosing a pathogen as their method of attack. ●● To prevent a criminal act and subsequent attacks: Through ongoing surveillance, investigation, and intelligence-gathering techniques, law enforcement personnel work to gather information to identify potential terrorists, their targets, and methods of attack before an attack takes place, or to prevent subsequent attacks from being carried out. ●● To identify, apprehend, and prosecute the perpetrators: Once a biological attack occurs, law enforcement gathers evidence and information to identify and apprehend the individual(s) responsible for the crime. Collection of evidence includes interviewing victims and witnesses as well as obtaining and preserving physical evidence. A criminal investigation is not complete until there is a successful prosecution and conviction of those responsible for the biological attack. ●● 38 To protect law enforcement personnel: Law enforcement personnel, including FBI agents, are likely to encounter situations where they may be at risk for exposure to a biological agent. Since some biological agents can be both infectious (can infect a person) and contagious (can spread from person to person), provision of proper personal protective equipment (PPE) and other preventive medications or vaccines for law enforcement personnel is essential. FBI WMD Threat Credibility Evaluation — Real or Hoax FBI/law enforcement personnel may be confronted with a number of situations involving the actual or threatened use of a biological agent as a weapon. These situations may include non-credible threats (hoaxes), announcements or indications that a release of a biological agent has occurred (overt), or unannounced releases of a biological agent (covert). During a covert event, the public health and medical community will likely be first to identify an occurrence of a bioterrorism incident as patients seeking treatment for an unexplained illness can often be a first indication of an attack. As soon as public health suspects an intentional event or is confronted with a case of illness caused by an agent or toxin of concern, they should notify law enforcement to determine the likelihood of a biological attack. If public health and law enforcement have established a working relationship prior to the occurrence of a bioterrorism incident, public health may feel more comfortable contacting their law enforcement counterparts early in the investigation, allowing for a more rapid initiation of the threat evaluation process. Joint Criminal and Epidemiological Investigations Handbook 39 All situations involving the intentional use of a biological agent require an FBIled threat credibility evaluation. In some jurisdictions, a local threat assessment may support the FBI threat credibility evaluation. Upon notification of a WMD threat or incident (e.g., an overt release such as a white powder letter accompanied by a threat), state and local law enforcement or emergency responders will contact their FBI WMD Coordinator to initiate the threat credibility evaluation process. The WMD Coordinator will then contact FBI Headquarters Weapons of Mass Destruction Directorate, which is responsible for convening a conference call to support the evaluation. A threat credibility evaluation should consist of three factors, plus an assessment of available intelligence and/or case information to determine the credibility of a threat: 40 ●● Technical Feasibility: Does the threat require technical expertise; if so, are those involved technically competent? (Will it work?) ●● Operational Practicality: Does the operation that is used to carry out the threat seem practical? (Can it be done?) ●● Adversarial Intent: Does the person display the behavioral resolve to carry out the operation? (Would the person do it?) redibility Evalua C t ti rea on During an overt biological threat, such as a “threat letter” or another announcement indicating the release of a biological agent, law enforcement will likely be the first to identify the incident since the threat would be reported to law enforcement before illness occurred. Even without the presences of a biological agent, hoaxes, can be a very effective way for perpetrators to cause fear since biological agents require an incubation time before symptoms develop, essentially causing the public to fear the unknown. Th LAW ENFORCEMENT Technical Feasibility Adversarial Intent Operational Practicality Intel Figure 5. Threat Credibility Evaluation. When a threat is made, FBI may conduct a threat credibility evaluation to determine how credible the threat is and what further action should be taken to mitigate the threat. During the course of the threat credibility evaluation, the FBI WMD Directorate may contact various partners and subject matter experts (e.g., CDC or United States Department of Agriculture) to assist in determining the threat credibility. If the threat is deemed credible, the FBI WMD Coordinator, along with state and local responders, will consult with FBI Headquarter assets to determine the next course of action, specifically regarding how to best collect and analyze the evidence, including environmental samples and other evidence. Additionally, the FBI Strategic Information and Operations Center (SIOC) will notify the DHS National Operations Center (NOC) immediately. If the threat is deemed non-credible, FBI may initiate an investigation to identify and prosecute those responsible for creating the perception that there was a threat (i.e., a hoax). Under federal law (18 U.S.C. 2332a and 18 U.S.C. 175), a threat involving a disease-causing organism is a criminal act, whether or not the perpetrator actually possesses the biological agent. Joint Criminal and Epidemiological Investigations Handbook 41 LAW ENFORCEMENT Criminal Investigative Methods FBI/law enforcement personnel conducting criminal investigations must operate within the applicable laws governing the investigations and the ensuing prosecution. As information is collected, it is necessary for law enforcement to develop a thorough understanding of the investigation and the unique circumstances of the case. This will help law enforcement to identify any missing or weak evidence, which may impact the ability to apprehend, prosecute, and convict the individual(s) responsible for committing the crime. A brief summary of criminal investigative methods is provided below. While some aspects of a criminal investigation may occur sequentially, they can also take place simultaneously. Gather Evidence The process of gathering evidence during the criminal investigation of a potential biological threat will involve collection of physical evidence (e.g., dissemination devices, clothing of victims and suspects), clinical specimens (e.g., blood or other bodily secretions), documents, photographs, and witness statements. Law enforcement must consider a variety of issues to ensure that any evidence they gather can ultimately be used in a criminal prosecution. The list below provides a summary of some of the key issues law enforcement must consider when gathering evidence. ●● Chain of Custody: Chain of custody is an issue of significant concern during a criminal investigation. Both law enforcement and public health personnel must provide accountability at each stage of collection, handling, testing, storing, transporting the evidentiary items, and reporting any test results. Failure to properly maintain the chain of custody may render the evidence unusable at trial if law enforcement is not able to unequivocally state where the evidence was located and who had access during the time the evidence was in custody. Responders should implement formalized chain of custody procedures once there is suspicion that a crime has occurred. ●● Delivery of Biological Samples to the LRN: Only laboratories within the Laboratory Response Network (LRN) should be used to test for biological agents. Submitting evidentiary biological samples to a non-approved laboratory will not only delay proper analyses, but may result in unintentional contamination of the samples and may be used to create doubt about the validity of test results in court. The FBI WMD Coordinators maintain a list of LRN laboratories within their field office’s area of responsibility. See Appendix 5 for further information about the LRN. Gather Evidence Provide Testimony Criminal Investigation Evaluate Evidence Apprehend Suspects Figure 6. Elements of a criminal investigation. 42 Joint Criminal and Epidemiological Investigations Handbook 43 LAW ENFORCEMENT ●● Documents: Original documents should be obtained by law enforcement when possible. Issues of authenticity and admissibility as evidence arise if copies are relied upon when original documents are available given that a copy could have been modified from the original.5 Example documents that law enforcement might gather as evidence include laboratory results or financial statements. ●● Witness Statements: Witness descriptions of dissemination devices, vehicles, suspects, odors, tastes, sounds, and other specific information must be obtained as soon as possible following a potential pathogen release. Witness information is time sensitive and the sooner the information can be obtained, evaluated, and disseminated to other investigators, the more value it adds to the investigation. As time passes, a witness’s memory can fade or become influenced by the opinion of other individuals. During an investigation of a biological threat, law enforcement may need to decide between collecting evidence for public safety or for criminal prosecution. There may be an overriding need by authorities to identify the agents or materials as soon as possible to ensure that the proper response is implemented and steps are taken to protect the responders and the public. In this instance, the need for rapid collection and testing to save lives outweighs normal evidence collection procedures. Evaluate Evidence Similar to other criminal investigations, in the event a pathogen is intentionally released, an investigator may be unaware of what is and is not a critical piece of evidence that will be needed to identify, arrest, and convict those responsible for the criminal act. As evidence is collected, an ongoing evaluation of the evidence must be part of the investigative process. An understanding of evidence types and the rules governing its admissibility will lead to better evaluation as the criminal investigation progresses. While not intended to be all-inclusive, Table 1 identifies and provides a brief explanation of some types of evidence collected during a criminal investigation. Table 1. Types of Evidence Collected During an Investigative Process Type 0f Evidence Explanation Example Direct Documents, records, physical evidence, notes, computer data, videotapes, or other types of information that directly relate to the case. Vehicle rental agreements, purchase receipts, phone records, eyewitness statements, dissemination devices. Circumstantial Facts, if proven, that allow the investigator to draw conclusions. Circumstantial evidence often has the same probative or substantiating value as direct evidence. Suspect was treated for cutaneous anthrax at or about the same time a release of anthrax was attempted. Very small particles of matter that can be examined microscopically, physically, and/or chemically. Biological agent residue, fingerprints, DNA, biological properties of the agent. Statements offered to prove the truth of the matter asserted; the person who made the statement is unavailable for cross-examination. A statement taken from a third party who heard another person describe seeing the suspect spray a substance during the time in question. Observation or sensation personally seen, smelled, heard, felt, or tasted. Witness reported smelling a particular odor, hearing a specific sound, or seeing someone. Trace Hearsay Eyewitness Testimony Potentially contaminated documents should be stored and examined utilizing procedures which protect both the individuals handling the evidence and the evidence itself. 5 44 Joint Criminal and Epidemiological Investigations Handbook 45 LAW ENFORCEMENT Generally, law enforcement should be accustomed to receiving results quickly when the event is significant, such as a death or high profile crime. Since evidence collected in a potentially contaminated environment must be assumed to be contaminated, this significantly complicates the evidence review and evaluation process. The FBI has specially trained teams to handle the collection of evidence in contaminated WMD environments. There are 24 fully operational Hazardous Evidence Response Teams that provide coverage of the FBI field offices, as well as specially trained FBI personnel, such as microbiologists and other scientists, trained to collect contaminated evidence. Following a biological attack, the FBI will have the collected evidence analyzed in a laboratory to support and guide their investigation. As mentioned before, only laboratories approved to handle biological evidence, such as those in the Laboratory Response Network, may accept samples. From the beginning of a criminal investigation for a biological threat and until the case is submitted to a jury for a verdict, all facts collected during the investigation must be verified and inconsistencies resolved. Documents must be carefully reviewed to ensure they have been thoroughly analyzed and interpreted correctly. Sometimes information contained in statements or reports is subject to differing interpretations. Law enforcement investigators must examine the evidence for conflicting interpretations and resolve these issues, or be prepared to explain the contradictions to the prosecutor. Apprehend Suspect(s) Once the threat to public health and safety has been eliminated, the top priority for law enforcement is the apprehension and prosecution of those responsible for the attack. During the apprehension of a suspect or group of suspects, law enforcement involved in the arrest must take precaution against possible injury from the perpetrator(s). It is also possible that the arresting officers will be confronted with either a contaminated environment or contaminated evidence. Therefore, appropriate PPE and a decontamination process must be utilized to prevent contamination by a biological agent. While apprehending the suspects is a goal of the criminal investigation, the safety of the arrest team and the general public is paramount. Provide Testimony Each law enforcement investigator involved in the case and potential witness should be available to meet with the prosecutor before he or she testifies at trial. It is important for the prosecutor to have the opportunity to evaluate each investigator and witness and his or her statements before appearing in front of a jury. During this time, any issues, problems, discrepancies, or gaps in evidence or testimony can be discussed and resolved. Once evidence has been collected and analyzed, it is important to submit all materials (e.g., statements, laboratory reports, documents, photographs) to the prosecutor in an organized manner to ensure all the facts are identified before the trial. Sufficient time should be allowed to permit the prosecutor to meet with the investigators and witnesses to review all reports, evidence, and anticipated testimony. 46 Joint Criminal and Epidemiological Investigations Handbook 47 JOINT INVESTIGATIONS JOINT INVESTIGATIONS Key Highlights of Joint Criminal and Epidemiological Investigations Model Section ●● ●● ●● 50 ●● A joint threat assessment, which utilizes the unique expertise of both disciplines, can help determine more quickly the nature of the incident (intentional or natural) and lead to a more appropriate response to the threat. ●● A joint investigation can maximize the efficiency for both law enforcement and public health in the event of a biological threat through the exchange of realtime investigative information. ●● MOU/joint protocols between law enforcement and public health are critical in determining roles and responsibilities prior to an event occurring and help ensure consistent practices between the disciplines during a response. Important information to include in MOU/joint protocols include: information sharing triggers, joint threat assessments, joint investigations, joint interviews, and methods for sharing investigative results. ●● Joint training and exercises are important elements of the Joint Criminal-Epidemiological Investigations Model since they allow public health and law enforcement to test, evaluate and refine their protocols. Amending protocols to reflect lessons learned from an exercise is particularly important to ensure best practices evolve and are strengthened over time. The Joint Criminal-Epidemiological Investigations Model is made up of six strategic elements. »» Building Relationships »» Information Sharing »» Joint Threat Assessment »» Joint Investigation »» Memorandum of Understanding/Joint Protocols »» Joint Training/Exercises Benefits to conducting joint investigations: »» Law enforcement has access to public health experts who understand disease epidemiology and can provide relevant medical information. »» Public health has access to law enforcement case information which could assist in identifying the source of exposure and containing an outbreak. The timely exchange of information in the early stages of a response is critical. Both disciplines have access to unique information that could help to prevent or detect a biological threat. Joint Criminal and Epidemiological Investigations Handbook 51 JOINT INVESTIGATIONS Introduction Collaboration between law The Joint Criminal-Epidemiological enforcement and public health Investigations Model highlights has not always been recognized as several practices and procedures beneficial. In the past, it was common that can be used by public health for law enforcement and public health and law enforcement to increase to conduct separate and independent collaboration and partnership. investigations during the response to a suspicious biological incident. However, following the 2001 anthrax mailings, a mechanism for increasing cooperation and coordination between law enforcement and public health was developed: Joint Criminal-Epidemiological Investigations Model. This model is not solely limited to the investigative process; rather, it incorporates a number of procedures and methodologies that require interaction between law enforcement and public health prior to the detection of a biological threat and through its resulting investigation. The Joint Criminal-Epidemiological Investigations Model is composed of six elements: Building Relationships Information Sharing Joint Threat Assessment Joint Investigation Memorandum of Understanding / Joint Protocols Joint Training / Exercises Benefits of the Joint Criminal-Epidmiological Investigations Model Public health and law enforcement share a set of common goals during the response to a biological threat, including: Protecting the Public Preventing / Stopping the Spread of Disease Identifying Those Responsible Preventing Future Attacks Figure 8. Common goals shared between public health and law enforcement during a response to a biological threat. The Joint Criminal-Epidemiological Investigations Model allows law enforcement and public health to achieve their common goals by enabling a more efficient response to a biological threat, resulting in earlier detection of an attack, identification of a source, and implementation of interventions, thereby mitigating the effects of the outbreak. Additionally, this model highlights the need to combine the investigative efforts of law enforcement and public health, which minimizes potential discrepancies between investigators and maximizes the opportunities to identify, apprehend, prosecute and convict the perpetrator of the attack. Figure 7. Elements of a Joint Criminal-Epidemiological Investigations Model. 52 Joint Criminal and Epidemiological Investigations Handbook 53 JOINT INVESTIGATIONS Law Enforcement Benefits When operating under the Joint Criminal-Epidemiological Investigations Model, law enforcement personnel have: ●● Access to experts who understand disease epidemiology (e.g., symptoms, diagnosis, possible causes) ●● Access to relevant public health/medical information (e.g., results of the epidemiological investigation that may inform the criminal investigation) Public Health Benefits When operating under the Joint Criminal-Epidemiological Investigations Model, public health officials have: ●● Access to law enforcement case information that may help to determine the source of the illness ●● Assistance in containing the outbreak from law enforcement (who can help identify information that may lead to apprehending the perpetrator, thus preventing future releases, exposure and illness) The Joint Criminal-Epidemiological Investigations Model: An Overview Generally, law enforcement and public health may exchange information once they confirm the existence of a criminal act or an outbreak. However, waiting until a crime or outbreak has been confirmed is too late. For an effective response to biological threats, public health and law enforcement need to share information prior to the confirmation that an intentional incident has occurred. The timely exchange of information in the early stages of a response is critical to containing the outbreak and apprehending the perpetrators. Therefore, the Joint Criminal-Epidemiological Investigations 54 Model begins with the identification of public health and law enforcement contacts prior to an incident. Building Relationships The purpose of identifying contacts prior to an incident is to initiate dialogue between the disciplines in order to build a working relationship. Strong personal ties between law enforcement and public health tend to foster increased information exchange. Many of the barriers believed to prevent collaboration between public health and law enforcement can be overcome by developing an understanding of each other’s roles/responsibilities and information needs and sensitivities. Over time, public health and law enforcement contacts become more familiar with each other and trust is gained, ensuring that information can be shared and properly protected. Information Sharing Both disciplines have access to unique information that may be important to share in order to prevent or detect a biological threat. Since neither agency will likely possess all the necessary data for a response, information sharing is an essential part of public health and law enforcement collaboration. Law Enforcement Public Health ●● Terror Groups / Organizations ●● Case Reports / Outbreaks ●● Threats ●● Laboratory Tests ●● Intelligence ●● Epidemiological Information ●● Victim Information ●● Patient Information Figure 9. Information that is unique to law enforcement and public health that, if shared, could be beneficial to both a criminal and epidemiological investigation. Joint Criminal and Epidemiological Investigations Handbook 55 JOINT INVESTIGATIONS Public health and law enforcement officials are encouraged to notify and involve each other early in a potential investigation of a biological threat, even if it turns out to be a non-criminal event. The establishment of pre-incident communication mechanisms is essential for the expeditious exchange of information during an actual incident. This exchange of information requires law enforcement and public health personnel to be familiar with one another, and to know who should receive the information. Information Sharing Challenges There are challenges to sharing information between public health and law enforcement. The challenges are both perceived and real, and should be addressed before both disciplines can legally and safely share information and conduct joint investigations. Public Health Challenges Due to the Health Insurance Portability and Accountability Act (HIPAA) and applicable state privacy laws, a common potential challenge for public health is concern regarding legal liability for the release of patient health information without the patient’s consent. Challenges arise when law enforcement requires access to “protected health information” as potential evidence of a crime from patient health records, which are maintained by public health, healthcare providers, health plans (health maintenance organizations, Medicare), or health care clearinghouses. However, as covered below, there are exceptions that allow law enforcement access to protected health information. Another potential challenge regarding the exchange of patient information is issues of ethics and trust. Patients often provide detailed personal information to physicians and public health with the tacit understanding that their information will not be disclosed. Public health may be concerned 56 that providing confidential patient information to the law enforcement community, regardless of reason or intent, jeopardizes their future ability to obtain data critical to identifying an outbreak source and implementing effective control measures. Law Enforcement Challenges Law enforcement may also have concerns regarding the exchange of investigative information. For any criminal investigation, the more people with access to sensitive information, the more opportunities exist for inadvertent disclosure. Furthermore, the inadvertent release of sensitive information could jeopardize the safety of confidential informants or classified sources by allowing the suspects to directly identify law enforcement’s source. As a result, suspected perpetrators may receive the advanced warning needed to facilitate the destruction of evidence, possibly avoid detection, and potentially affect a successful prosecution of the perpetrator(s). Legal Issues Related to Information Sharing Each agency’s legal counsel is encouraged to evaluate federal, state, and local laws and regulations to determine ways to share information. A review of the applicable federal and state statutes should be conducted to determine the actual limitations and the exceptions that may exist, which allow the exchange of information between public health and law enforcement. For example, HIPAA prevents an individual’s health information from being released without that individual’s consent; however, there are specific exemptions in HIPAA that allow for the release of patient medical information to public health officials and law enforcement. One exemption relevant to a law enforcement investigation is often identified as the “imminent threat exemption.” According to this exemption: Joint Criminal and Epidemiological Investigations Handbook 57 JOINT INVESTIGATIONS “A covered entity may, consistent with applicable law and standards of ethical conduct, use or disclose protected health information, if the covered entity, in good faith, believes the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is made to a person reasonably able to prevent or lessen the threat (See 45 CFR 164.512 (j)(1)(i)). Additionally, HIPAA requirements may be waived in certain circumstances. For example, in the event of 1) an emergency declared by the President and 2) a Public Health Emergency declaration by the Secretary of the HHS, the Secretary of HHS may waive certain HIPAA requirements under Section 1135 of the Social Security Act (42 U.S.C. § 1320b–5). Once both declarations are issued, covered entities may then request an 1135 waiver from the Secretary, which may allow for the disclosure of protected health information. The legal basis for allowing patient medical information to be shared with law enforcement should be researched and incorporated into a MOU/ joint protocol so all entities are properly informed and can comply with the legal requirements for sharing information. See Appendix 7 for additional information on the HIPAA law enforcement exemption. Information Sharing Triggers During a biological threat, certain information or a specific event should trigger the exchange of information between law enforcement and public health. For example, law enforcement conducts criminal investigations every day, and in recent years, there have been numerous hoaxes involving biological incidents. Therefore, what should prompt the law enforcement community to contact public health and involve them in the investigation of such an incident? Similarly, epidemiological investigations routinely take place; most outbreaks not caused by an intentional act. At what point during an epidemiological investigation should public health be prompted to contact law enforcement? Many factors could provide clues to potential biological threats. The difficulty of trying to use definitive criteria is that almost all infections produce initial symptoms that are non-descript and may be misdiagnosed as another disease. Furthermore, many biological threat agents cause rare or non-endemic diseases, often with unknown or poorly characterized etiology. As a result, physicians may not recognize the disease until it has progressed to its more serious and unique symptoms. In these cases, there may be a reluctance to report this “unknown” illness until a definitive diagnosis is determined. The following tables provide a preliminary list of factors that could trigger public health (Table 2) or law enforcement (Table 3) to share information. These tables are not intended to be all-inclusive. Law enforcement and public health may want to add or remove triggers to suit their individual needs. Table 2. Public Health Triggers ●● Any specimens (clinical) or samples (environmental) submitted to public health for analysis that test positive for a potential biological threat-related agent ●● Large numbers of patients with similar symptoms or disease ●● Large numbers of unexplained symptoms, diseases, or deaths ●● Disease with an unusual geographic or seasonal distribution (e.g., plague in a non-endemic area) ●● Unusual disease presentation (e.g.., inhalational vs. cutaneous anthrax) ●● Endemic disease with unexplained increase in incidence (e.g., tularemia, plague) ●● Higher than expected morbidity and mortality associated with a common disease and/or failure of patients to respond to traditional therapy ●● Unusual “typical patient” distribution (i.e., several adults with an unexplained rash) ●● Death or illness in humans preceded or accompanied by death or illness in animals that is unexplained or attributed to a zoonotic biological agent 58 Joint Criminal and Epidemiological Investigations Handbook 59 JOINT INVESTIGATIONS Table 3. Law Enforcement Triggers ●● Any intelligence or indication that any individual or group is unlawfully in possession of any biological agent ●● Seizure of bio-processing equipment from any individual, group, or organization ●● Seizure of potential dissemination devices from any individual, group, or organization ●● Identification or seizure of literature pertaining to the development or dissemination of biological agents ●● Any assessments that indicate a credible biological threat exists in an area ●● A HAZMAT response that involves the presence of biological agents The identification of law enforcement and public health triggers is intended to be a starting point to improve information sharing between agencies or jurisdictions. The most important aspect of this process is to overcome the hesitation or reluctance to share information before all of the facts are known. Early notification provides an early warning and should not be viewed negatively. Joint Threat Assessment To complement and support the threat credibility evaluation process coordinated by the FBI WMD Directorate, it is recommended that local FBI field offices, local law enforcement, and public health establish protocols for conducting a local joint threat assessment. Determining the nature of a reported incident (i.e., natural or intentional) and implementing appropriate response activities requires a joint assessment by law enforcement and public health. A joint threat assessment can be conducted in person (on the scene of an event) or over the phone (conference call). The outcome of the joint threat assessment is to determine the nature of the threat (i.e., credible or not credible). A threat is deemed a “credible threat” if it is determined that potential for a real threat does exist. In the U.S., a threat may also be deemed credible 60 if there is intent to cause terror even though no pathogen is used (e.g., an articulated threat in a mailed letter, which contains an unknown substance). To complement and support the information sharing process, law enforcement and public health should establish protocols for conducting a joint threat assessment prior to an event. Determining the nature of a reported incident (i.e., natural or intentional) and implementing appropriate response activities requires a joint assessment by law enforcement and public health. A joint threat assessment can be conducted when either discipline identifies a defined trigger. During the threat assessment, public health and law enforcement will possess critical information that should be shared so that the participants can make an informed decision regarding the nature of the incident and appropriate follow-up activities. Once all available information has been shared, law enforcement and public health should classify the incident into one of three risk categories: ●● No Threat: Highly likely the source of exposure occurred naturally (not intentional) ●● Possible Biological Threat: Information suggests possibility that exposure may be a result of an intentional exposure ●● Likely Biological Threat: There is a reasonable belief the exposure was caused intentionally Based on the risk category, public health and law enforcement perform the next steps: ●● No Threat: Public health will continue to manage the incident ●● Possible Biological Threat: Separate investigations or joint investigation ●● Likely Biological Threat: Joint Investigation Joint Criminal and Epidemiological Investigations Handbook 61 JOINT INVESTIGATIONS While the incident may be initially assessed at one of the above risk levels, it may be changed as the investigation begins and new information is collected. Procedures for conducting joint threat assessments should be decided on prior to a potential biological threat and included in an agreed upon protocol or MOU between the two disciplines. For reference, a sample procedure for conducting a joint threat assessment can be found in Appendix 1. Joint Investigations The objective of a joint investigation is to maximize the efficiency of both law enforcement and public health through the exchange of real-time investigative information. When a joint investigation is initiated, law enforcement and public health are empowered to share information throughout the course of the joint operations. The goals of joint investigations are to: 62 ●● Identify the disease causing agent ●● Identify the source and perpetrators of the attack ●● Determine the mode(s) of spread or transmission of the biological agent ●● Determine where and when exposure to the biological agent may have occurred ●● Identify who may have been exposed. Joint Investigation Criteria The following criteria may be used to establish a threshold for determining whether to conduct a joint investigation of a suspect bioterrorism incident: ●● Case-patient(s) positive for a select agent, ●● No known natural source to explain infection, ●● No known risk factors for disease occurrence, and/or ●● FBI intelligence suggests that the incident is criminal/intentional These criteria are not all-inclusive and may not cover every possible biological threat. Once a decision has been made to work jointly, law enforcement and public health should follow previously developed procedures for conducting a joint investigation. These procedures should be located in a MOU/joint protocol. Joint Investigations — Sharing of Investigative Information During a joint investigation it may be difficult for law enforcement and public health to know the type of information that can be freely exchanged. As a general rule, when conducting a joint investigation, law enforcement should share relevant criminal investigative information that will be helpful to public health in mitigating the effects of the outbreak. Likewise, public health should share any epidemiological investigative information that may assist law enforcement to identify, apprehend, prosecute, and convict the perpetrator(s). The following tables (Table 4 and Table 5) were developed to assist law enforcement and public health in determining the type of information needed by the other discipline. Joint Criminal and Epidemiological Investigations Handbook 63 JOINT INVESTIGATIONS Table 4. Public Health Information for Law Enforcement ●● Time and locations where exposures may have occurred (may be based on agent-specific characteristics or other investigational findings) ●● Names (including date of birth) for all confirmed, probable, and exposed case-patients ●● Positive laboratory results for a biological threat agent from an approved laboratory ●● Case definition (epidemiological picture of the outbreak) ●● Risk factors that may be associated with exposure (e.g., demographics, occupation, or other activities) ●● Hypotheses generated by the epidemiological investigation ●● Notification about when public health is planning to conduct interviews with case-patients or contacts ●● National or international health alerts that may be related to the current biological threat ●● Laboratory results used to characterize the specific biological agent (e.g., strain, genetic sequencing, antimicrobial resistance) ●● Identification of any unusual cases (e.g., past case-patients, coroners’ reports) ●● Any other investigative information that may be relevant to the biological threat (e.g., requests or theft of antibiotics, identification of a laboratory in someone’s home) Table 5. Law Enforcement Information for Public Health ●● Law enforcement investigative information (e.g., interviews scheduled and planned search warrants) that may assist public health with the identification of the agent and determination of the source of the outbreak ●● Information regarding any known group or sector that may be targeted (e.g., government or financial, entertainment, religious/ethnic groups) for an attack ●● Other law enforcement cases which may have ties to the existing biological threat investigation ●● Pre-incident indicators (e.g., videotaping, sketching maps, break-ins, perimeter breaches at facilities) that may be related to the biological threat incident ●● Information developed by law enforcement regarding the biological agent used, mechanism for delivery/ dissemination, date, time and locations of exposures ●● Information regarding any medical equipment, chemicals, toxins, biological agents or laboratory supplies stolen, developed, or uncovered that may be related to the biological threat Joint Interviews of Cases and Contacts Much of the joint investigation will initially focus on interviews with patients and potential contacts that will primarily address where and when exposures to biological threat agents may have occurred. While many public health and law enforcement investigators may be familiar with conducting interviews, many have not practiced or conducted a joint interview with the other discipline present. Although a joint interview with law enforcement can provoke anxiety in the patient, one interview with both agencies present may be less disruptive to the patient than two or more separate interviews repeating similar information. Additionally, separate questioning by law enforcement and public health may lead to conflicting statements, which can jeopardize the outcome of the criminal investigation. Therefore, a joint interview affords public health and law enforcement the opportunity to examine relevant facts based on the unique perspectives of both investigators. For reference, a sample procedure for conducting a joint law enforcement and public health interview can be found in Appendix 2. For public health there are concerns that the presence of law enforcement could compromise the collection of sensitive medical information (e.g., illegal drug use) by public health. However, a criminal investigation requires interviewing all potential witnesses and victims. In order to mitigate patient concerns, a provision should be established for confidential communications between public health and the interviewee in order to share specific healthrelated information during a joint interview. Special consideration should be made to protect the identifying information of the interviewees, due to privacy as well as the integrity of a criminal investigation. ●● Intelligence information regarding the characteristics of the biological agent (e.g., strain, antimicrobial resistance, or weaponized nature) 64 Joint Criminal and Epidemiological Investigations Handbook 65 JOINT INVESTIGATIONS In some instances, joint interviews may not be possible (e.g., the interviewee requests that law enforcement not be present) so each discipline should be aware of the types of information their counterpart is seeking. For reference, sample questions that may be asked by law enforcement and public health can be found in Appendix 3. Joint Investigations and the Media It is important for FBI, law enforcement and public health to coordinate their interaction with the media. The media will have a significant impact on the response and the public reaction to a biological threat. With public fear and the psychological impact of a bioterrorism incident, the media will aggressively seek information from the investigators. Therefore, FBI, law enforcement and public health must develop a working relationship with the media to help ensure that timely, useful information is shared with the media to keep the public accurately informed, but not overly alarmed. Memorandum of Understanding/Joint Protocols The creation of a Memorandum of Understanding (MOU) and/or joint protocols helps to establish joint investigative guidelines between law enforcement and public health, thus determining roles and responsibilities prior to an event actually occurring. These guidelines help to address many of the actual or perceived challenges and barriers to collaboration by outlining investigational procedures for the response to a biological threat or other naturally occurring incidents. In addition, MOU/joint protocols help establish consistent procedures among law enforcement and public health regardless of personnel rotation over time. In general, the MOU/joint protocols outline some of the components discussed above: information sharing triggers, joint threat assessments, and joint investigations. Additional information that could be helpful to incorporate into 66 a MOU/joint protocol includes sharing of investigative results and the analysis of information (e.g., agreement on appropriate methods for handling clinical specimens and environmental samples and how information obtained from these sources will be shared). The development of a MOU/joint protocol is a difficult task, requiring the input and agreement of many entities within law enforcement and public health. To assist agencies and jurisdictions with the creation of an MOU/joint protocol, the CDC and the Bureau of Justice Assistance (U.S. Department of Justice) convened a Public Health and Law Enforcement Emergency Preparedness Workgroup that developed a model MOU for joint public health and law enforcement investigations. To obtain a copy of the model MOU, send an email request to: [email protected]. Joint Training / Exercises Once relationships are established and MOU/joint protocols are developed, public health and law enforcement need to be trained in order to be proficient in joint investigations activities. It is important to already have MOU/joint protocols in place prior to conducting an exercise (and not use the exercise to create the joint protocol). Creating a joint training/exercise program will enable public health and law enforcement to test, evaluate and refine their protocols. Amending protocols to reflect lessons learned from an exercise is particularly important to ensure best practices evolve and are strengthened over time. Additionally, as new individuals are trained, it allows public health and law enforcement to continually build relationships with their counterparts and gain familiarity and expertise with joint investigations principles and methods prior to an actual incident. Joint Criminal and Epidemiological Investigations Handbook 67 SUMMARY SUMMARY This handbook provides an overview of law enforcement and public health roles and responsibilities and identifies the Joint Criminal-Epidemiological Investigations Model as a best practice to more effectively prepare for and respond to a biological threat. By implementing elements (e.g., increasing information sharing, conducting joint threat assessments and conducting joint investigations/joint interviews) of the Joint Criminal-Epidemiological Investigations Model, law enforcement and public health can maximize their resources and achieve their individual and common goals during the response to a biological threat. The procedures and methodologies described in the handbook are intended to serve as a guide. Law enforcement and public health should modify this guidance to accommodate the specific needs, statutes and authorities of their agency, jurisdiction, or country. 70 Key Highlights of Introduction Section ●● There has been a demonstrated interest and willingness by terrorist groups and individuals to acquire and employ biological agents at weapons against the American population. ●● The intentional release of a biological agent may initially be difficult to discern from a natural incident, which can result in separate law enforcement and public health investigations. ●● It is in public health and law enforcement’s best interest to work together when first investigating a suspicious biological outbreak, which includes fostering mutual awareness and establishing joint communication procedures. ●● By working together, public health and law enforcement can achieve their separate but often overlapping objectives of identifying the biological agent, preventing the spread of the disease, preventing public panic, and apprehending those responsible. ●● Law enforcement and public health are encouraged to read the entire handbook and not limit their review to just their respective sections, so each community can understand the different goals and needs of the other organization. Joint Criminal and Epidemiological Investigations Handbook 71 SUMMARY Key Highlights of Public Health Section ●● ●● ●● 72 ●● The ultimate aim of an epidemiological investigation is to identify the source of the disease and implement efforts to control the outbreak and protect the public’s health. An epidemiological investigation primarily involves the meticulous accumulation of information from patient interviews and surveys as well as data collected from surveillance systems. Goals of an epidemiological investigation include: »» Stopping the spread of disease (identify causative agent, determine source, mode of transmission and population at risk) »» Protecting the public’s health (surveillance, medical countermeasures, health education) »» Protecting public health and other response personnel (protective equipment and preventive vaccines/medications) Important elements of an epidemiological investigation are: »» Detect unusual events »» Confirm diagnosis »» Identify and characterize additional cases »» Determine source of exposure »» Develop and implement interventions ●● Laboratory analysis of clinical specimens is used to assist the physician in making a definitive diagnosis. While most physicians will wait for definitive laboratory results to confirm a biological threat agent diagnosis, physicians are likely to begin treatment before laboratory test results are confirmed since early treatment of disease increases the probability the patient will recover from the illness. ●● A laboratory that tests for biological agents should meet applicable standards (e.g., quality control measures, biosafety, and biosecurity) and participate in relevant proficiency testing. Joint Criminal and Epidemiological Investigations Handbook 73 SUMMARY Key Highlights of Law Enforcement Section ●● ●● ●● 74 ●● Once there is suspicion that a crime has occurred, chain of custody procedures should be implemented by both law enforcement and public health to ensure accountability of evidence. Failure to properly maintain the chain of custody may render evidence unusable at trial. ●● In certain situations the environment might be contaminated; therefore, it is useful to have specially trained law enforcement teams to handle apprehension of the suspect and collection of evidence in contaminated environments. ●● The need for rapid collection and testing to save lives outweighs normal evidence collection procedures. Primary goals of a criminal investigation for a biological threat are: »» To protect the health and safety of the public »» To prevent subsequent attacks »» To identify, apprehend, and prosecute the perpetrators »» To protect law enforcement personnel If public health and law enforcement have established a working relationship prior to a biological threat incident, public health may feel more comfortable contacting law enforcement early in their investigation. Law enforcement should include various subject matter experts, such as public health, to assist in determining the credibility of a biological threat. Joint Criminal and Epidemiological Investigations Handbook 75 SUMMARY Key Highlights of Joint Criminal and Epidemiological Investigations Model Section ●● ●● ●● 76 ●● A joint threat assessment, which utilizes the unique expertise of both disciplines, can help determine more quickly the nature of the incident (intentional or natural) and lead to a more appropriate response to the threat. ●● A joint investigation can maximize the efficiency for both law enforcement and public health in the event of a biological threat through the exchange of realtime investigative information. ●● MOU/joint protocols between law enforcement and public health are critical in determining roles and responsibilities prior to an event occurring and help ensure consistent practices between the disciplines during a response. Important information to include in MOU/joint protocols include: information sharing triggers, joint threat assessments, joint investigations, joint interviews, and methods for sharing investigative results. ●● Joint training and exercises are important elements of the Joint Criminal-Epidemiological Investigations Model since they allow public health and law enforcement to test, evaluate and refine their protocols. Amending protocols to reflect lessons learned from an exercise is particularly important to ensure best practices evolve and are strengthened over time. The Joint Criminal-Epidemiological Investigations Model is made up of six strategic elements. »» Building Relationships »» Information Sharing »» Joint Threat Assessment »» Joint Investigation »» Memorandum of Understanding/Joint Protocols »» Joint Training/Exercises Benefits to conducting joint investigations: »» Law enforcement has access to public health experts who understand disease epidemiology and can provide relevant medical information. »» Public health has access to law enforcement case information which could assist in identifying the source of exposure and containing an outbreak. The timely exchange of information in the early stages of a response is critical. Both disciplines have access to unique information that could help to prevent or detect a biological threat. Joint Criminal and Epidemiological Investigations Handbook 77 APPENDICES APPENDICES Appendices to Joint Criminal-Epidemiological Investigations Handbook Sample Joint Criminal-Epidemiological Investigations Material Appendix 1: Sample Procedure for a Joint Threat Assessment Appendix 2: Sample Procedure for Joint Interviews Appendix 3: Sample Joint Interview Questions Reference Material Appendix 4: List of Biological Select Agent and Toxins (2014) Appendix 5: Laboratory Response Network (LRN) Appendix 6: CSTE List of Nationally Notifiable Conditions (2013) Appendix 7: HIPAA Privacy Rule & Permitted Disclosures Appendix 1: Sample Procedure for a Joint Threat Assessment To assist in the response to a biological threat at the local level, it is recommended that law enforcement and public health develop protocols to conduct a joint threat assessment between agencies and jurisdictions. The following procedure is intended to serve as a guide for conducting a joint threat assessment; law enforcement and public health may wish to adapt the procedures below to better suit the needs of their agencies. Upon receiving a report indicating a potential biological threat, public health should immediately notify the local FBI WMD Coordinator to conduct a joint threat assessment. The purpose of the joint threat assessment is to determine the likelihood of an intentional incident and identify response actions that should be performed by law enforcement and public health. It is recommended that the joint threat assessment be conducted by a conference call and, at a minimum, include the following representatives: Appendix 8:…