Chapter 4: Forensic Epidemiology and the Forensic Nurse

Development/Definition of Forensic Epidemiology

• In the past, there was not much interaction between investigations carried out by law enforcement and those conducted by public health authorities.
• However, in today's society, the deliberate contamination of water, food, air, or land as an act of bio-terrorism has become very real.
• Law enforcement personnel may not initially recognize these incidences as a bio-terrorism threat, while public health personnel are able to detect abnormal or unseasonable increases in illness or types of death but are ill-equipped in the proper protocols in identifying, collecting, and preserving forensic evidence.
• During the late 1990s, the term forensic epidemiologists typically referred to traditionally trained epidemiologists who functioned as expert witnesses in civil trials.
• They testified to issues relating to methodology of the study, number of subjects, subject selection and exclusions, length of the study, methods of analysis, interpretation of the results, and any other limitations.
• Forensic epidemiology was first associated with bioterrorism in 1999 when the former chief deputy of the USSR bioweapon program, Ken Alibek, used the term.
• After the anthrax attacks in September and October of 2001, Dr. Julie Gerberding, a senior official with the Centers for Disease and Control (CDC) National Center for Infectious Disease, defined forensic epidemiology as that practiced by an epidemiologist who would be trained to respond to bioterrorism attacks as well as other public health emergencies.
• Many states have developed courses specifically designed to help law enforcement officers operate closely and more effectively with public health officers when investigating a public health problem that may have been caused intentionally or with crimes that have a public health consequence.
• In 2002, several definitions of forensic epidemiology emerged, including:
  • the use of epidemiological methods as part of an ongoing investigation of a health problem for which there are suspicions or evidence regarding possible intentional acts or criminal behavior as factors contributing to the health problem, and
  • the use of epidemiological and other public health methods in conjunction with or an adjunct to an ongoing criminal investigation.

Roles of Forensic Epidemiology

• Investigating outbreaks
  • Forensic epidemiologists investigate outbreaks of infectious diseases, foodborne illnesses, and other public health issues.
  • They identify the source of the outbreak, the mode of transmission, and the affected population.
  • They also provide recommendations to prevent future outbreaks.
• Determining causation
  • Forensic epidemiologists determine the cause of an illness or injury.
  • They use epidemiological methods to establish a link between an exposure and a health outcome.
  • This information is used in legal cases to establish liability and compensation.
• Providing expert testimony
  • Forensic epidemiologists provide expert testimony in legal cases.
  • They explain the epidemiological evidence and its relevance to the case.
  • They also provide opinions on the cause of an illness or injury and the likelihood of causation.
• Assessing damages
  • Forensic epidemiologists assess damages in legal cases.
  • They estimate the economic and non-economic losses associated with an illness or injury.
  • This information is used to determine compensation for the affected individuals.
• Developing public health policies
  • Forensic epidemiologists develop public health policies based on epidemiological evidence.
  • They identify risk factors for diseases and injuries and recommend interventions to prevent them.
  • They also evaluate the effectiveness of public health interventions.

Basics of Forensic Epidemiology

• The forensic epidemiologist's primary role in natural death investigations is to provide a constellation of characteristics that increases an individuals risk of developing a natural disease.
• Forensic epidemiologic investigations of drug deaths focuses on the type of drug, the concentration of each drug, the profile of the victim, and trends.
• Forensic epidemiologic investigations of MVAs attempts to ascertain if the cause of death was environmental, biological, or behavioral in nature.
• The homicide investigation by a forensic epidemiologist focuses on developing characteristic profiles of the victim and the perpetrator, the relationship between the two, and determining the circumstances that lead to the homicide.

Role of Nurses and Forensic Nurses in the Forensic Community

• Nurses at all levels of training play a key role in the identification, collection, documentation, and preservation of forensic evidence.
• Nursing notes provide an important record of the sequence of events that occurred with a patient from admission through death, providing critical information that can help the forensic pathologist ascertain the cause and manner of death.
• Nursing notes also provide a detailed record of the assessment of injuries, the lifesaving procedure implemented, the results of the admitting toxicology analysis, and the type and volume of blood, plasma, and drugs administered during treatment.
• Nurses play a major role in reducing the under- and overreporting of certain types of death, especially those caused by trauma.
• Forensic epidemiologists often hire nurses to review nursing notes with specific objectives in mind or to abstract key variables.
• Nurses play a major role in reducing the under- and overreporting of certain types of death, especially those caused by trauma.
• For example, an elderly female suffering a fall at her residence is transported to the local emergency department and admitted with a hip fracture.
  • The attending physician issuing the death certificate should understand the course of events that led to the development of the pneumonia and remind the physician that this death is an ME/C case.
  • This level of involvement will have several effects, such as ensuring that the death certificate accurately reflects the true cause of the death.
• Nurses and forensic nurses play an increasingly important role in the medical examiner's office, reducing the likelihood of underreporting and overreporting deaths.
• They also interact with family members, identify bite marks, and collect transient evidence. In some ME/C offices, death investigators are nurses who have become certified death investigators. SANE nurses are also used to conduct the examination.