9
HOMELAND SECURITY AND EMERGENCY PREPAREDNESS

THE POTENTIAL ROLE OF MEDICAL EXAMINERS AND CORONERS IN RESPONDING TO AND PLANNING FOR BIOTERRORISM AND EMERGING INFECTIOUS DISEASES

Kurt Nolte

An emerging infectious disease is either a newly recognized, clinically distinct infectious disease or a known infectious disease whose reported incidence is increasing or threatens to increase in the near future in a given place or among specific populations (2003). In addition to emerging pathogens, we need to be concerned about the emergence of bioterrorism as a threat. Bioterrorism is the deliberate use of a biologic agent or toxin against a civilian population to induce fear or terror. Bioterrorism related infections can be viewed as a subset of emerging infections because they have increased in incidence and threaten to increase in the near future. Together emerging infections and bioterrorism constitute a strong rationale for improving our overall disease and death reporting system. If the nation builds the capacity to recognize fatalities from emerging infectious diseases and from other infections of public-health consequence, then it will have the capacity to recognize fatalities from bioterrorism.

Two case studies underscore this point. In 1993, an alert medical examiner in New Mexico was the first to report a cluster of fatal cases of respiratory disease. Three days later, an Indian Health Service physician reported similar cases to the New Mexico Health Department. A rapid multiagency investigation followed, and it led to the identification by CDC of an emerging infectious disease, hantavirus pulmonary syndrome, within weeks of recognition of the



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9 HOMELAND SECURITY AND EMERGENCY PREPAREDNESS THE POTENTIAL ROLE OF MEDICAL EXAMINERS AND CORONERS IN RESPONDING TO AND PLANNING FOR BIOTERRORISM AND EMERGING INFECTIOUS DISEASES Kurt Nolte An emerging infectious disease is either a newly recognized, clinically distinct infectious disease or a known infectious disease whose reported incidence is increasing or threatens to increase in the near future in a given place or among specific populations (2003). In addition to emerging pathogens, we need to be concerned about the emergence of bioterrorism as a threat. Bioterrorism is the deliberate use of a biologic agent or toxin against a civilian population to induce fear or terror. Bioterrorism related infections can be viewed as a subset of emerging infections because they have increased in incidence and threaten to increase in the near future. Together emerging infections and bioterrorism constitute a strong rationale for improving our overall disease and death reporting system. If the nation builds the capacity to recognize fatalities from emerging infectious diseases and from other infections of public-health consequence, then it will have the capacity to recognize fatalities from bioterrorism. Two case studies underscore this point. In 1993, an alert medical examiner in New Mexico was the first to report a cluster of fatal cases of respiratory disease. Three days later, an Indian Health Service physician reported similar cases to the New Mexico Health Department. A rapid multiagency investigation followed, and it led to the identification by CDC of an emerging infectious disease, hantavirus pulmonary syndrome, within weeks of recognition of the

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index case. Also in New Mexico, a young woman who died of anticoagulant poisoning from the suicidal ingestion of rat poison had a presentation that mimicked a fatal infection. The two cases illustrate the importance of a high-quality death investigation system in recognizing fatal emerging infections and infections of public health importance and in sorting out conditions such as toxins which may mimic infections. Autopsy-based surveillance of infectious agents is superior to use of death certificates because it is faster and it is not restricted to the coding categories listed on death certificates. Since 1919, US forensic pathologists have detected, several emerging diseases, including plague, malaria, and West Nile encephalitis. Overall, infectious disease mortality increased by 58% from 1980 and 1992 (Pinner et al., 1996). Autopsy pathologists were the first to identify an outbreak of anthrax in 1979 in the former Soviet Union, and they even identified the route of infection as inhalation (Walker et al., 1994). Today, autopsy-based surveillance not only has the capacity to determine pathogenesis, but it has broader reach and more rapid detection through diagnostic advances in immunohistochemistry and nucleic acid probes. Despite its potential, the ME/C system’s many limitations impede recognition of emerging infectious diseases. The bias of most ME/C systems is toward violent death. Forensic pathologists are well equipped to make general pathologic diagnoses (such as pneumonia) rather than organism-specific diagnoses (such as pneumococcal pneumonia). Many systems do not have access to sensitive diagnostic tests. If an autopsy is performed on an infectious disease death, there is no guarantee that the causative organism will be identified. The interpretation of postmortem microbiologic cultures is fraught with difficulties including issues of postmortem overgrowth and contamination. Serology has its limitations in that death may precede a detectable immune response. Investigators and pathologists may lack the training or the resources to recognize potential infections. Medical examiners and coroners form an important part of the complex response to a known bioterrorist event. Bioterrorism is the use or threatened use of biological agents or toxins against civilians with the objective of causing fear, illness, or death. Deaths as a consequence of a known bioterrorist or terrorist attack are homicides,

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so they fall under the jurisdiction of medical examiners and coroners. All five fatalities due to anthrax inhalation in 2001 were referred to medical examiners, and all five victims were autopsied. Bioterrorism has the potential for causing mass fatalities. Medical examiners are adept at responding to mass disasters; their skill sets having been honed through aviation accidents, heat wave deaths, and other large scale catastrophes. An unknown or covert terrorist attack is more difficult to detect. If sentinel cases die unexpectedly without a clear diagnosis, they would fall under ME/C jurisdiction. The quick response to the hantavirus pulmonary syndrome offers a good frame of reference because its symptoms mimic how a bioterrorism agent might present itself. Another event to use as a reference is the ME/C’s quick response to 1985 fatalities from cyanide-contaminated acetaminophen (Nolte et al., 2000). The New Mexico medical examiner's office and the Health Department have established a model, with funding from CDC, known as Med-X, for surveillance of bioterrorism mortality. The model is being replicated in Louisiana, New Hampshire, Oregon, and Wisconsin. The system features automatic referral for autopsy in the event of at least one of a predetermined set of symptoms (e.g., flu-like symptoms- fever, or chills or myalgias). The Health Department is immediately notified of the autopsy presence of at least one of a pre-defined set of pathologic syndromes (e.g., community acquired pneumonia/diffuse alveolar damage). The medical examiner endeavors to make an organism-specific diagnosis in each case with a defined pathologic syndrome. Thus far, New Mexico has determined that uniform autopsy and reporting criteria increase recognition of public health conditions and the likelihood of recognizing bioterrorism deaths. Timely reporting is possible but difficult. Because bioterrorism is rare, and fatal infectious diseases of public-health consequence are far more common, having a combined surveillance system serves the public good. The system, when used, can be tested and modified daily. Autopsy workers, because of direct inoculation and aerosolization, have the highest rates of laboratory-acquired infections (Grist, 1994). Several prominent cases in urban and rural settings have brought to light the problem of inadequate ventilation and insufficient respiratory precautions in ME/C and hospital pathology facilities

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(Nolte, 2000). Facilities are aging, many are not in compliance with existing standards. Ideally, autopsy rooms should function at Biosafety Level 3 (BSL 3) (Centers for Disease Control and Prevention, 1997) which provides protection from aerosolized pathogens, but very few function at that level. The Disaster Mortuary Operational Response Team (DMORT), which most people mistakenly think can respond to an emerging infectious disease or bioterrorism event, have no capacity for biosafety stringency and no capacity for microbiologic diagnosis. Overall, the current infrastructure is inadequate for responding to infectious-disease outbreaks or for responding to fatalities from bioterrorism. There should be uniform standards are needed for infectious-disease mortality surveillance; access to routine and advanced microbiologic testing, which is critical for generating organism-specific diagnoses; improved biosafety infrastructure; more funding; and a national strategy for federal agencies to assist with large numbers of infectious-disease fatalities. The Challenge of Terrorism and Mass Disaster Marcella Fierro Terrorism and mass disasters pose enormous challenges to ME/C systems. The systems have dealt with plane crashes, train crashes, fires, and floodsbut not with mass homicides. The magnitude of the deaths is a challenge, considering that terrorism brings the prospect of thousands of simultaneous deaths. The types of working relationships are different. Systems rarely have dealt with the federal government in the management of local disasters. In Virginia, which handled several anthrax cases in 2001, no one in the health department had ever worked with the Federal Bureau of Investigation (FBI). Money and manpower pose the greatest challenges. ME/C systems must be better prepared than ever before, particularly with gear for biohazards and radiation. There also are jurisdictional issues related to access to the scene and to working cooperatively with the FBI.

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The anthrax experience in Virginia uncovered other problems of preparedness. It pointed to the likelihood that sentinel bioterrorism deaths would probably be declined by the medical examiner system because the event would not necessarily have been identified as resulting from bioterrorism, leaving the private physician with the responsibility for signing the certificate. Virginia does not have a surveillance system that would allow the identification of bioterrorism deaths with any certainty. If cases are identified, one of the first decisions will be whether the bodies can be dealt with on site, at the ME/C facility, which might risk site contamination. Questions also arise about which types of cultures to take and who else is exposed, including health-care and EMS workers who transport the bodies from the hospital to the medical examiner facility. Most facilities do not operate at BSL 3. Surge capacity (especially if there are multiple simultaneous events), record-keeping, and traumatic stress on staff are other issues to consider. Research has documented that mass disasters impose enormous strain; measures must be taken to help workers cope with the overwhelming stress of death and destruction. A final issue—one that is highly sensitive—is disposition of bodies. Bodies containing some infectious agents cannot safely be returned to families. In other cases, the medical examiner or coroner may not be able to identify human remains at all. This is a very difficult issue for a nation that has never resorted to mass graves. The Office of the Air Force Medical Examiner Victor Weedn The Office of the Armed Forces Medical Examiner (OAFME) is the only federal medical examiner system in the United States. The office has experience with more mass disasters than has any other medical examiner office in the world. The OAFME was created largely as a response to the problems incurred in the handling of the autopsy of President John F. Kennedy. It is in the Armed Forces Institute of Pathology, and its primary jurisdiction covers military personnel who die on federal property, military personnel who die abroad (in accordance with the Status of Forces Agreement), and senior executive officials of the federal administration who die in office, including the president. In the

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case of military deaths, the office and its regional military network of medical examiners often waive jurisdiction to local medical examiner offices because of resource constraints. Recently, authority was extended to include limited jurisdiction in commercial-airline mishaps. The office also serves the pathology community through consultation, education, and research. For a fee, it assists local medical examiners. Support staff includes photographers, investigators, and an anthropologist. The office has a small forensic science laboratory, but a substantial toxicology laboratory and DNA Registry. The DNA Registry includes the Armed Forces DNA Identification Laboratory and a specimen repository of DNA specimens from all service members. The DNA Registry reflects the high priority accorded by the military to identifying service members who die in battle. The military’s commitment to individual identification dates back to the Civil War. The US Army was the first in the world to bury its war dead in individual graves, as opposed to mass graves. During the Civil War, and even before, soldiers devoted half-month's salary to inscribe their name on a piece of metal to ensure their identification if they fell in battle. The indestructible metal tags were so useful and so widespread that the military adopted the "dog tag" as early as 1906. Dog tags remained the standard method of identification for decades. During the Vietnam War, the military adopted fingerprints and, later, dental records as the primary means of identification. Dog tags had been found to be too unreliable because, like any other personal effects, they could be misplaced, dislodged, removed, worn by someone else, or simply not worn. Therefore the military moved to positive means of identification, specifically fingerprints and dentition. Fingerprints and dental records also had shortcomings, especially when those body parts were missing. In the Gander, Newfoundland air crash of 1985 (256 died in the worst military aviation crash in history), dentition identified two-thirds of victims, and fingerprints identified half, but 11% could not be identified except by exclusionary means and presumptive identification. The military now relies on DNA identification that can apply to most remains. DNA identification was first used by the military during the first Persian Gulf War. It can provide identification in the face of severe fragmentation, partial incineration, and decomposition. In some cases, it may also be quicker.

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Disaster Mortuary Operational Response Team Paul Sledzik Created in the 1980s, DMORT has gained prominence in responding to mass fatalities. Although an offshoot of the National Funeral Directors Association, DMORT was in the early 1990s formally incorporated into the federal government’s emergency-response capability. In 2003, DMORT was situated in the Department of Homeland Security (DHS) as part of the National Disaster Medical System (NDMS). On activation for a natural disaster, terrorism event, or aviation or technologic disaster, its 1,200 trained volunteersforensic, morgue, family-assistance, and management personnelbecome temporary government employees. They supply portable morgue units, computerized morgue management, and specialized protocols for victim identification and family assistance. If the site qualifies for federal disaster assistance, the federal government pays for DMORT’s costs; otherwise, the state pays. DMORT is comprised of private citizens, each with mortuary or forensic expertise and with licensure and certification recognized by all states. Teams can be activated in any region of the United States when the capabilities of local resources are exceeded. They work under the jurisdiction and guidance of all local authorities or federal agencies. The local authorities still sign the death certificates. During the terrorist attacks of 2001, DMORT teams were summoned to the site of the airplane crash by the coroner of Somerset, Pennsylvania. DMORT has a team to handle postmortem collection of DNA evidence, and the team works closely with the Armed Forces DNA Identification Laboratory. DMORT has a Weapons of Mass Destruction Team, but the team handles only chemical fatalities, not biologic or nuclear fatalities; this leaves a large hole in the federal response mechanism. Some issues facing DMORT are unresolved: what kinds of new roles will DMORT have in DHS? In addition to its strength in victim identification, should DMORT develop more forensic-pathology services? Finally, DMORT’s statute allows it to remain at the scene for only 2-3 weeks, but it is unclear what will be needed if a response takes longer.

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The Potential Federal Role in the Death Investigation System Victor Weedn State and local governments often look to the federal government as a role model, as well as for assistance, funding, and guidance. But at the federal level the forensic community is not truly owned by law enforcement, public health, or traditional medicine. Policy-makers and administrators often equate funding of forensic pathology as wasting money on the dead, and they fail to recognize that the community exists for the living. Forensic-Pathology Services The only federal medical examiner system in the United States is OAFME. OAFME is often consulted by other federal agencies, including the FBI, which has no internal medical examiner capability. OAFME also serves the pathology community through consultation, education, and research. OAFME reviews cases submitted to it for a fee. Its DNA Identification Laboratory is a useful asset to ME/C offices. The Department of Defense does not have a great interest in furthering forensic pathology, considering that OAFME was downsized to a low point of two forensic pathologists in 2002. OAFME has not been a strong research center. One important problem for the office is a lack of routine and typical forensic casework. Military-aircraft mishaps are the standard fare for the office. Thus, the forensic pathologists are often not highly experienced in routine forensic pathology. It is likely that the office will survive and even grow, but it has not been a substantial leader in the field of forensic pathology, as might be expected considering that it is the federal government's sole medical examiner office. DMORT is an element of the NDMS, which can be mobilized to assist local efforts in times of a declared disaster. It has provided valuable service to jurisdictions in need. Its services are most critical when a mass fatality occurs in a coroner jurisdiction that has forensic-pathology resources, training, or experience. Even well-funded state and local offices often have limited contingency or surge capacity, as noted by Marcella Fierro, the chief

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medical examiner for Virginia. Unfortunately, DMORT’s mission is generally limited to victim-identification services. Time will indicate how well the program will fare in its new home in DHS. Thus, the federal government has the ability to assist state and local agencies in times of emergency on a limited basis and often at local expense. The federal government does not have a federal office equivalent to that of state and local jurisdictions. Thus, federal forensic pathology services are minimal. Research NIJ has a forensic budget of about $75 million per year. Its mission is to support state and local law enforcement, including forensic-science services. NIJ has catered primarily to the crime-laboratory component but in recent years broadened its scope, even in forensic entomology. Accordingly, NIJ has shown interest in the medical examiner community and funded this IOM workshop. However, despite the prominence of forensic pathology among the forensic disciplines over the years, very few research projects even remotely related to forensic pathology have been funded. No funds have actually flowed to the medical examiner offices, other than their crime-laboratories. The most important NIJ support was for the establishment of the death-investigation guidelines. To be fair, NIJ has had substantial funding for the forensic sciences only recently. It also is probably true that the medical examiner community has not aggressively pursued NIJ projects. Regardless, NIJ could and should play a greater role in the support of the law-enforcement aspects of medicolegal death investigations. Substantial funding of the Paul Coverdell National Forensic Sciences Act and the National Forensic Science Improvement Act would help. However, NIJ most recently announced a DNA initiative to the exclusion of all other segments of forensic-science funding. CDC, which has a $7 billion budget, has also been a supporter of the medical examiner community and its public-health functions. The most direct support has been a small but important subsidy for the NAME annual meeting over many years. In the past, CDC has with some success facilitated the computerization of medical examiner

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offices. CDC has funded several projects, such as investigation of unrecognized sudden deaths due to infectious diseases. NIH despite having a budget of more than $20 billion, has not been an important source of research funding, even for the medical examiner community, because forensic-pathology research is not considered basic research. Seen as translational or applied, it is not a favored field of NIH research. Medical examiners have occasionally been asked to serve as consultant reviewers for investigations on drowning, SIDS, and the like. As forensic pathologists become the major experts in autopsy examinations, as medical examiners conduct more hospital autopsies, and as autopsies become more important sources of human tissue, NIH interest may increase. Total funding in forensic- pathology research from the federal government may range from zero to tens of thousands of dollars per year, not millions, and virtually no funding goes to support medical examiner offices or demonstration projects in medical examiner offices. Perhaps most important, the federal government seemingly has no interest in forensic pathology or medical examiners. Other than the small office in the military, there are no medical examiner offices in the federal government. It might seem logical that the CDC, FBI, National Transportation Safety Board, or the Office of Emergency Preparedness would have forensic-pathology staff but they do not. They might, however, maintain contracts with experts to provide forensic pathology consultation. Lack of Federal Commitment and Oversight The message seems to be that the federal government has no interest in forensic pathologists or medical examiners. One might conclude that crimes resulting in death are not given a high priority in federal investigations. Certainly, dead victims will not bring lawsuits, complain to newspapers, or testify before Congress. As states look to the federal government as a role model, they see a medical examiner office in the military. That is not very relevant to the states. An ME office could be situated in public health, but experience shows that it will always lose out in priority to live patients. An ME office could be situated in law enforcement, which

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has a substantially better political lobby, but then it would not be seen as objective, would be misunderstood, and would lose out to the cop on the street. A medical examiner office is probably too small an endeavor to stand on its own as an agency in the federal government. It would stand a far better chance if combined with the federal crime laboratory as a department of forensic-science services, as is done in England. Indeed, it has often been argued that the forensic sciences should conceptually be on neutral turf and not in a prosecutorial or investigative agency. Theoretically, DHS is a possible home for a medical examiner office. Medical examiners deal with homeland-security issues in a public-safety, public-health, and national-security context. Indeed, emergency-consequence management for disasters is being placed in DHS, in the Federal Emergency Management Agency and NDMS. For better or for worse, there is no effective regulation of medical examiner offices. Theoretically, state medical licensure boards could oversee the medical practices, but in reality they fail to do so. In fact, some forensic pathologists continue to practice without medical licenses. Judicial scrutiny seems ineffective to weed out poor practices. Voluntary NAME accreditation standards have yet to be adopted by a majority of medical examiner jurisdictions. Medical examiners often lose their jobs over scandals when longstanding poor practices or misunderstood practices are publicized. Investigations of deaths from child abuse, elderly abuse, and domestic violence are important to many federal agencies but do not support the offices that form the basis of the investigations. Investigations of deaths from infectious disease are important to CDC. Investigations of deaths from consumer products are important to the Consumer Product Safety Commission. Investigations of transportation deaths are important to the Department of Transportation. Investigations of workplace-related deaths are important to the Occupational Safety and Health Administration. Investigations of deaths in mines are important to the Bureau of Mine Safety. It is a recognition of the need for this information among the various federal agencies that has led Randy Hanzlick to suggest the

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formation of a National Office of Death Investigation Affairs (NODIA). One might consider medical examiner work to be essentially an unfunded federal mandate. Unless NIJ and CDC truly adopt the medical examiner community or a new lead federal agency is created, possibly in DHS, the ME/C community will continue as an orphan without to a parent to care for and feed it. Discussion A priority mandate for NIJ and the federal government is to abolish or replace antiquated coroner investigation systems with medical examiner systems staffed by competent forensic pathologists (Ellen Clark). One of the greatest barriers to collaboration between ME/C offices and public health is unfamiliarity with each other's mission. Public health has failed to develop formal collaborations with ME/C offices for bioterrorism (Marcella Fierro). To expand collaborations, there needs to be broader education of the public-health community about the value of death investigations to public healthnot just for vital statistics but also for collaborative investigations (Kathleen Toomey). ME/C collaborations with public health should also include the county health department. The county health department has been largely overlooked throughout the workshop (Randy Hanzlick). DMORT is expensive for states. The state of Georgia paid DMORT $250,000 per week for its assistance during the crematorium investigation (Kris Sperry). In an effort to reduce costs, DMORT is planning to offer partial services rather than the full complement of services (Paul Sledzik).