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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