public health information network (phin) series i
DESCRIPTION
is for Epi. Epidemiology basics for non-epidemiologists. Public Health Information Network (PHIN) Series I. Series I Sessions. Session I – V Slides. VDH will post PHIN series slides on the following Web site: http://www.vdh.virginia.gov/EPR/Training.asp NCCPHP Training Web site: - PowerPoint PPT PresentationTRANSCRIPT
Public Health Information Network (PHIN)
Series I
is for Epi
Epidemiology basics for non-epidemiologists
Series I Sessions
Title Date
“Epidemiology in the Context of Public Health”
January 12
“An Epidemiologist’s Tool Kit” February 3
“Descriptive and Analytic Epidemiology”
March 3
“Surveillance” April 7
“Epidemiology Specialties Applied” May 5
Session I – V Slides
VDH will post PHIN series slides on the following Web site:
http://www.vdh.virginia.gov/EPR/Training.asp
NCCPHP Training Web site:http://www.sph.unc.edu/nccphp/training
Site Sign-in Sheet
Please submit your site sign-in sheet andsession evaluation forms to:
Suzi SilversteinDirector, Education and Training
Emergency Preparedness & Response Programs
FAX: (804) 225 - 3888
Series ISession V
“Epidemiology Specialties Applied”
What to Expect. . .
TodayLearn about the application and practice of three Epidemiology specialties:
1. Disaster Epidemiology2. Environmental Epidemiology3. Forensic Epidemiology
Session Overview
• Disaster Epidemiology– North Carolina case study: Hurricanes– Impact of natural disasters– Rapid Needs Assessment methods and
technology
• Environmental Epidemiology– Virginia regulations– Environmental investigations
• Restaurant inspections
Session Overview (cont’d.)
• Forensic Epidemiology– Public Health Perspective– Law Enforcement Perspective– Joint Operations
Today’s Learning Objectives
• Be able to distinguish Disaster, Environmental, and Forensic Epidemiology specialties
• Recognize the common Epidemiological methods used among the three featured specialties
• Recognize the special considerations or conditions faced by Epidemiologists in each specialty
• Appreciate how the context of law, media, business, and communities impacts Epidemiology practice
Today’s PresentersMark Smith, PhD, MS, MADirectorHealth Surveillance and Analysis UnitGuilford County Health Department, NC
Gary Hagy, MSEHDirectorDivision of Food and General Environmental ServicesVirginia Department of Health
Jennifer Horney, MPH, MAAssistant DirectorNC Center for Public Health Preparedness
Disaster Epidemiology
Mark Smith, PhD, MS, MADirector
Health Surveillance and Analysis UnitGuilford County Health Department
North Carolina
Public Health Grand Roundshttp://www.publichealthgrandrounds.unc.edu
• Click on “Archived Programs”• Broadcast title: “Disasters, People, and
Public Health: Are You Ready?”– September 1999, Hurricane Floyd – Immediate and long-term impact– Major components of a disaster response
plan– Mental health aspects for victims and
responders
North Carolina’s Evolving Public Health Response to
Natural Disasters
Rapid Needs Assessments after Hurricane Isabel and Charley
Overview
• NC’s Public Health Regional Surveillance Team (PHRST) Structure
• Rapid Needs Assessments (RNAs)• GIS and GPS Technology• Hurricane Isabel: 2003
– RNA methods and lessons learned• Hurricane Charley: 2004
– Evolution of RNA methods and lessons learned
NC Office of Public Health Preparedness and Response
Public Health Regional Surveillance Teams (PHRST)
Regional Team Members
• Physician-Epidemiologist• Nurse-Epidemiologist• Industrial Hygiene consultant• Administrative Assistant• Veterinarian liaison (NC Dept. Agriculture)• Three Pharmacist consultants shared
Rapid Needs Assessment After Natural Disasters
• Identify need for food, water, power, shelter, access to medical care
• Determine the magnitude of the need in order to plan and implement relief efforts.
Purpose
Rapid Needs Assessment
Background
• RNA methodology developed by WHO and CDC• Used after hurricanes and other disasters, e.g.,
Ankara earthquake (1999), ice storm in Maine (1998), and hurricane in the Dominican Republic (1998)
• Two-stage random sampling methodology allows generalization to sample area from only 210 surveys
Needs Assessment Sample Selection
• Select a sample area– storm path, damage reports, service areas
• Randomly select 30 population weighted geographic clusters in sample area
• Randomly select 7 households within each geographic cluster
• 210 total surveys, 10 survey teams
Hurricane Isabel: September 18, 2003
Rapid Needs Assessment:Hurricane Isabel
• Thirty census clusters selected for a survey sample across 14 counties
• Ten assessment teams comprised of Public Health Regional Surveillance Team (PHRST) staff, UNC Chapel Hill School of Public Health students, and state agency volunteers deployed to “forward base” in Greenville
• Organized deployment using Incident Command System (ICS) structure
Rapid Needs Assessment
Objective was to collect data about:
• External or flood damage to homes• Access to household utilities• Incidence of hurricane-related illness and injury• Access to food and water• Access to medical care or medication• Immediate needs
Survey Instrument
• One-page survey instrument
• 24 questionnaire items
• 33 data fields
• Accompanied by a one-page “explanatory notes” form for interviewers
Interview Process
Interview ProcessOverview
• Assessment teams deployed in official vehicles to assigned census block area
• From starting point, moved sequentially along roadways to collect data from seven households per cluster
• Data collection was paper-based
• Total of 210 interviews completed
Isabel RNA Results
• 2% flooded (95% CI 0.2 - 4.5)
• 32% damaged (95% CI 23 - 42)
• 65% no electricity
• 30% using a generator
Isabel RNA Results
• 43% bottled water supply
• 13% no access to 3-day food supply
• Household projections– 40,00 using bottled water– 12,000 no access to 3-day food supply
Lessons Learned
Lessons Learned
• Need for better randomization in second stage
• Use of paper questionnaires required double data entry
Can new technologies address these issues?
Options:
– Perhaps Geographic Information Systems (GIS) could be used in the 2nd stage randomization.
– Skip the paper and enter the data directly into the computer, a handheld computer.
What is GIS?• Set of tools that collect, store, retrieve, transform,
and display spatial data
• Used to construct maps that communicate spatial data– Raster-based: Data and image stored in a regularized
grid made of pixels [Satellite]
– Vector-based: Data and image stored separately in map layers (points, lines, polygons) – [Epi Map, ArcView]
• Map layers share a common coordinate system (e.g., x - y)
GIS Mapping Example: John Snow’s Broad Street Pump Investigation
GPS (Global Positioning System)
EPI InfoGIS
Field Team 1 Field Team 2 Field Team 3 Field Team 4 Field Team 5
Field data collection using IPAQ Pocket PCs equipped with GPS, GIS software and data collection forms.
Wireless: WIFI 802.11 or Bluetooth
Field Data Collection
Hurricane Charley: August 9-14, 2004
Changes in RNA Methodology
• Electronic field data collection • Use of GIS to randomly select households
for interviews
• Use of GIS and GPS to route interviewers to field data collection sites
Hurricane Charley RNA Assessment Area
Map made in Arcview 9.0
Selection of Census Block Groups
Map made in Arcview 9.0
BKG_KEY Population Cumulative Random#371419803002 1281 1281371419803003 736 2017 1811371419803001 1397 3414371419802001 1725 5139 4569371419805001 1470 6609371419804004 1555 8164371419802002 1362 9526371419805002 1179 10705371419804001 714 11419371419804003 1182 12601371419804002 1081 13682 13067371419804005 1347 15029371419805004 1616 16645 15446371419806003 857 17502 17023371419805003 578 18080370479905002 1181 19261 19601371419806001 680 19941371419806002 2684 22625 21047371419802003 1329 23954370479905001 914 24868370479904001 1468 26336371419802004 1136 27472370479905003 532 28004371419802006 1497 29501370479908001 774 30275370479905004 1261 31536371419802005 2462 33998 32902370479903001 909 34907
Using Random Number Generator to Select 30 Geographic Clusters
1st Stage Randomization in Excel
Census Block Group Identifier
Census Block Group map layer has population data
In Excel, create cumulative population field to randomize “proportional to population”
Use random number generator in Excel to generate 30 numbers, select Census Block Groups
Identifying Individual Census Block Groups
Map made in Arcview 9.0
HP IPAQ Pocket PC running ArcPad GIS software
ArcPad Routing Function
Assigns a unique case ID or incident #
ArcPad form programmed to automatically insert census block group population in survey
ArcPad programmed to automatically insert cluster # in database for complex samples analysis
EPI InfoGIS
Field Team 1 Field Team 2 Field Team 3 Field Team 4 Field Team 5
Field data collection using IPAQ Pocket PCs equipped with GPS, GIS software and data collection forms.
Wireless: WIFI 802.11 or Bluetooth
Field Data Collection
Hurricane Charley RNA Results
• 203 surveys completed• Training, data collection, analysis, report
writing completed in 24 hours• Findings showed little impact from the
hurricane– Estimated 1.4% of households without power– 6% of homes damaged but habitable– 2.5% of homes flooded with 1-12 in. water
Lessons Learned
• Prepare data collection forms in advance, if possible
• Provide mobile GIS training to potential field data collectors
• Consider alternatives for second-stage randomization procedure; i.e., tax parcels
Conclusions• RNA’s fulfill vital public health function
• Use of Incident Command System (ICS) vital to rapid deployment of resources
• Handheld computers, GIS and GPS adds value to field data collection in RNA– Eliminates double data entry– Provides routing and direction-finding for field teams– Improved randomization through GIS– Ability to quickly analyze and map data
Moderator Commentary
Disaster Epidemiology in The Context of The Series
5 minute break
Environmental Epidemiology
Gary Hagy, MSEH Director
Division of Food and General Environmental Services
Virginia Department of Health
Regulating Food Safetyin Virginia
VDH Office of Environmental Health Services
• Onsite Sewage and Water Services• Shellfish Sanitation• Wastewater Engineering
– Marina Program– Sludge
• Food and Environmental Services
• Any place where food is prepared for service…or any place where food is served
Restaurant - §35.1-1 Code of Virginia
Exemptions - §35.1-25• Churches, school,
fraternal organizations…
Administration
• State Board of Health
• State Health Commissioner
• District or Local Health Director
Three Primary Activities
Permitting
Inspecting
Enforcement
Permits
• Method of regulation operating through the “administrative lifting” of a legislative prohibition
• “Ministerial duty”
Denial of Permit
• Deny if not in compliance• Notify owner within 10 days• Reasons why• What needs to be done• Right to appeal
Inspections
Staple of public health enforcement
Similar to searches
As often as necessary to ensure compliance
Recorded on inspection form
Types of Inspections
• Pre-opening• Routine• Critical Procedures• Follow-up• Training• Complaint
Lawful Inspections
• Access
• Recording observations
• Identifying corrective actions
Inspections versus Investigations
Inspections / Sampling• Restaurants• Milk
Investigations• Recalls• Outbreaks
Recording Observations
1. Cite section – 12 VAC 5-421-08202. Describe observation – paint a picture
– “Cooked chicken breast on steam line at 125ºF”
3. Describe corrective action– “Discard and ensure potentially hazardous
foods are hot held at 140ºF or above.” or– “Rapidly reheat the food to 165°F and
maintain at 140°F.”
Types of Violations
• Non-Critical
• Critical
• “Swing”
Enforcement
Types of Enforcement Action
• Permit suspension
• Permit revocation
• Impoundment
Permit Suspension(12 VAC 5-421-3770)
• Substantial or imminent threat• No hearing required• Written notice required• Opportunity for hearing• Owner may request hearing within 10
days• Hearing granted within three days• May end when reasons no longer exist
Substantial or Imminent Public Health Threats
• Sewage back-up• Loss of water or contaminated supply• Loss of electrical power• Fire or flood• Communicable disease in foodservice
worker• Loss of refrigeration• Other situation deemed by the Director
Permit Revocation(12 VAC 5-421-3780)
• Flagrant and continuing • 15-day notice • Opportunity for hearing
Impoundment(12 VAC 5-421-3960)
• Food believed to be in violation• Notice• ID• Service• Storage vs. destruction• Hearing
VENIS
VirginiaENvironmentalInformationSystem
Why Post Inspections?
• Public interest
Why Post Inspections?
• Public interest• Public documents
Why Post Inspections?
• Public interest• Public documents• Preempt legislation
Why Post Inspections?
• Public interest• Public documents• Preempt legislation• Enforcement
Scope of the Project
• 34 health districts in Virginia• 30 districts use BOH’s Food Regs• 4 districts use locally adopted codes• 35 different websites
What to Post?
• Grades?• Scores?• Summary?• Actual written report?
Actual Report
• Identifying information• Code citation• Observation and correction statements• Repeat violations identified• Critical violations identified• EHS comments
Public Response
Media Coverage
• Midday news• 6 o’clock news• 11 o’clock news
Day 1Good News
• The website was popular
Day 1Not so Good News
• The website was VERY popular!
May 1, 2003 Stats
• 841,672 hits• 25,627 visits• 557,723 page views• Peak Hour: 6:43 p.m. - 77,667 HPH• Peak Minute: 11:50 p.m. – 8,175 HPM
May 2003 Stats
• 8,496,272 Hits (274,073 HPD)• 446,432 Visits (14,401 VPD)• 5,541,435 Page Views (178,752 PPD)
Website Stats
• Launched May 1, 2003• >42.7 million hits (~60,000 per day)• >1.7 million visits (~2400 per day)• >9.4 million page views (>30,000 per day)• >189 GB of information transferred• Average visit about 11 minutes
Internet Posting of Inspections:Consumer Response
Dear Mr. Hagy,
Providing easy access to food safety inspections is a great service to the public. I like being able to check out a restaurant's operational history before patronizing it. In addition, I'm very impressed with and grateful for the thoroughness of the inspections that are conducted. The potent combination of inspections and public scrutiny should make many foodservice establishments safer places to eat from now on.
Thanks!
G.Fredericksburg, Virginia
Hello – Just wanted to thank you for making this information available to the general public! My husband and I very appreciative of the efforts taken to put this information online. THANK YOU! THANK YOU! THANK YOU! M.M.Loudoun County
Moderator Commentary
Environmental Epidemiology in The Context of The Series
5 minute break
Forensic Epidemiology
Jennifer Horney, MPH, MAAssistant Director
NC Center for Public Health PreparednessUNC Chapel Hill
Learning Objectives
• Define Forensic Epidemiology; understand why discipline began, direction it is going, and challenges it faces
• Understand public health’s role in investigating natural outbreaks of disease and that certain unusual or unnatural findings in an investigation may suggest intentional criminal actions
• Understand the goals of public health and law enforcement officials and how these goals influence their investigations
• Understand differences between a law enforcement investigation and a public health investigation
Forensic Epidemiology
• Concept of merging public health methods in a setting of potential criminal investigation
Richard A. Goodman, CDC
What is Epidemiology?
• Study of distribution and determinants of health-related states or events in specified populations, and the application of this study to control of health problems*– Study risk associated with exposures– Identify and control epidemics– Monitor population rates of disease and
exposure
*Last JM, ed
A New Era in Public Health
• Investigation of health-related criminal cases
• Epidemiology can serve as a point of reference– Law, medicine, pharmacy, statistics, city
planning, emergency medical services
Forensic Epidemiology
• Past uses– Courtroom
• Current and future uses– Courtroom– Field-based investigations with law
enforcement
Epidemiology in the Courtroom
• Epidemiologists used to resolve disease-related litigation– Investigative experts– Consulting experts– Testimony experts
• Examples– Silicone breast implants, E. coli, tobacco use,
medical use of marijuana
Difficulties Using Epidemiology in the Courtroom
• Epidemiology studies disease in populations, not individuals
• Science is ever-changing
• Often difficult to prove exposure caused disease
Anthrax Investigations: 2001
• All isolates tested from 17 clinical specimens and 106 environmental samples in FL, D.C., NJ, NYC, and CT were indistinguishable
• Biological and physical evidence will be used to prosecute perpetrator(s)
Jernigan DB, 2002
Health-related Criminal Cases• Rabbit hemorrhagic disease virus; New Zealand,
1997
• Shigella; Dallas, TX, 1996
• Sarin; Japan 1990-95
• Anthrax– Failed release in Japan in early 1990s– Over 105 known hoaxes between 1998-2000
Field-based Forensic Epidemiology
Public HealthLaw
Enforcement
A Sample of Agencies Involved
• CDC• FBI• Local and state health
departments• Local, state, & federal
laboratories • State Highway Patrol • State Bureau of
Investigation• Hospitals and clinics
• Emergency Medical Services
• National Guard • Federal Emergency
Management Agency• United States
Department of Agriculture• Homeland Security• Attorney General’s office• Pharmacists• Media
Public Health and Law Enforcement Goals
Public Health• Make people safer
and healthier• Prevent disease
outbreaks• Conduct disease
surveillance and management
Law Enforcement• Protection of public• Prevention of criminal
acts• Identification,
apprehension, and prosecution of perpetrators
• Safeguarding all involved
Common Goals
• Protecting the public • Preventing or stopping the spread of
disease• Identifying those responsible for a threat or
attack• Protecting employees during response
and investigative phases
Martinez D, 2002, FBI
Mutual Benefits
• Law enforcement offers public health– Criminology expertise– Forensic laboratory collaboration– National and international law enforcement
connections
• Public health offers law enforcement– Medical and laboratory consultation– Collaboration with national and international public
health connectionsMartinez D, 2002, FBI
Differences in Public Health and Law Enforcement Investigations
• Criminal intent• Laws governing investigations• Sample/evidence collection• Confidentiality• Media interaction• Use of sensitive or secure information• Interviewing techniques
Criminal Intent
• Naturally occurring vs. criminally motivated event– Covert action– Overt action
Covert Attack
• Not initially recognized as an attack– Example: 1985 outbreak of gastroenteritis in
Oregon from salad bars initially thought to be from unintentional mishandling of food; found to be caused deliberately
• Public health officials usually recognize unusual signs, symptoms, or disease clusters through surveillance systems– First responders: emergency room, laboratory staff,
astute health care provider
Covert Response
Unusual Symptoms/Disease clusters
Notify state health department; conduct joint, preliminary epidemiologic investigation. If bioterrorist incident, notify FBI and CDC.
Adapted from Butler J, 2002
Preliminary public health
epidemiological, environmental investigation
Covert Attack: When to Notify FBI
• A case of smallpox or pulmonary anthrax• Uncommon agent or disease occurring in person
with no other explanation • Illness caused by a microorganism with
markedly atypical features • Illness due to food or water sabotage• One or more clusters of illnesses that remain
unexplained after a preliminary investigation• Deliberate chemical, industrial, radiation or
nuclear release
Overt Attack• Perpetrator announces responsibility for
something– 1995 sarin attack in Tokyo subway
• Law enforcement will usually detect event first– First responders: Emergency management
and law enforcement
• Often a hoax
Overt Response
Law enforcement identifies biological threat or potential biological materials.
FBI, Fire/Hazmat, local/state law enforcement notified.
Local or state public health notified. CDC notified.
Adapted from Butler J, 2002
Laws Governing an Investigation
• Public health officials have ability to– Examine medical records of person infected,
exposed, or suspected of being infected or exposed
– Implement control measures – Exercise quarantine and isolation authority – Enter premises where entry is necessary to
enforce public health laws• Law enforcement must obtain a search
warrant
Evidence• Law enforcement gathers evidence
• Public health gathers specimens
• Two criteria for specimens from public health investigations to be used in criminal investigations– Obtained as part of a legitimate public health
investigation– Collected and processed with a chain of custody
Legitimate Public Health Investigation
• Samples taken as part of a legitimate investigation of an outbreak or other public health situation may be used in a criminal investigation– Legitimate example: Collection of foods on a
salad bar due to a suspected outbreak– Incorrect example: Evidence found using
public health authority to inspect a hotel kitchen
Chain of Custody
• Required in law enforcement investigations
• Form providing– Name of person collecting evidence– Each person having custody of it– Date item collected or transferred– Agency and case numbers– Victim’s or suspect’s name – Brief description of item
Handling Credible Threat Evidence
• Handle as evidence and establish a chain of custody
• Process evidence through an approved Laboratory Response Network (LRN)
Public Health Laboratory
• Why is the Public Health Laboratory (PHL) Involved?– Mandate by Congress – Experience with biological agents of concern
and outbreak investigations– Link between local laboratory level, State,
CDC and other federal agencies
State Public Health Lab Role
• Disease identification and outbreak investigation• Reference services (additional, definitive testing
on isolates and specimens)• Specialized testing• Direct services• Environmental testing• Rapid testing• Applied research• Support of disease surveillance and
epidemiology investigations
Forensic Laboratory Role
• Conducts forensic examinations of evidence submitted by law enforcement agencies
• Firearms, Latent Evidence, Molecular Genetics, Documents, Drug Chemistry
• Works in partnership with the State Health Lab by educating LEO in proper protocols
• Forensic Lab does not conduct any biological hazard related testing but refers to State Health Laboratory / BSL III Labhttp://bmbl.od.nih.gov/sect3bsl2.htm
Forensic Laboratory Role
• Drug Chemistry and Toxicology• Latent Evidence Section• Trace Evidence Section• Molecular Genetics• Firearm and Toolmark• Documents and Digital Evidence
Working with the Media• Public health
– Open with media– Rely on media to get information to the public for
their protection
• Law enforcement– Not as open about ongoing investigations– Must preserve integrity of the case
• Joint Information Center (JIC)
Confidentiality
• Public health– Confidentiality of patient and medical records
• Law enforcement– Confidentiality of witness or informant
HIPAA
• Protected health information can be disclosed when:– Person exposed or at risk of contracting or
spreading a communicable disease created or caused by a terrorist act
– Weapons of Mass Destruction event causing public health issues
– Pursuant to court order, subpoena or administrative request from
– To identify or locate a suspect, fugitive or missing person
Classified / Sensitive Information
• Some public health officials should hold clearances to communicate with law enforcement when necessary
• Secure equipment should be available– Phone lines– Fax machines
Joint Interviewing
• Joint interviews with victims and witnesses
• Each discipline should be aware of the information counterparts seek– Law enforcement: personal, travel, incident,
safety, criminal investigation– Public health: personal, exposure, travel,
medical history
What’s So Different about Bioterrorism?
• High concentrations of agent dispersed• Large primary cohort exposed• Agent distributed in a well-traveled area• People present to different hospitals• May be second deliberate attack• Widespread panic• Hospitals may become flooded
Review• Forensic Epidemiology is the concept of joint public
health and law enforcement investigations in the setting of a potential criminal investigation
• Forensic Epidemiology was once primarily used in the courtroom, but is now increasingly used in the field to investigate health-related crimes, including bioterrorism
• While differences exist between public health and law enforcement investigations, by understanding the roles and responsibilities of each better, both can be more successful at protecting the public
Question & AnswerOpportunity
Moderator Commentary
Forensic Epidemiology in The Context of The Series
2005 Series II Preview!
“Outbreak Investigation Methods:From Mystery to Mastery”
“Outbreak Investigation Methods: From Mystery to Mastery”
Title Date“Recognizing an Outbreak” June 2
“Risk Communication” July 7
“Study Design” August 4
“Designing Questionnaires” September 1
“Interviewing Techniques” October 6
“Data Analysis” November 3
“Writing and Reviewing Epidemiological Literature”
December 1
Session V Slides
Following this program, please visit the Web site below to access and download a copy of today’s slides if you have not already done so:
http://www.vdh.virginia.gov/EPR/Training.asp
Don’t Forget!
Please submit your site sign-in sheet and session evaluation forms to:
Suzi SilversteinDirector, Education and Training
Emergency Preparedness & Response Programs
FAX: (804) 225 - 3888
References and Resources• Carus WS. Bioterrorism and biocrimes: The illicit use of
biological agents since 1900. Center for Counter proliferation Research, National Defense University, Washington, D.C.
• Centers for Disease Control and Prevention (CDC). http://www.phppo.cdc.gov/od/phlp/ForensicEpi/ForensicEpi.asp
• Jernigan DB, Raghunathan PL, Bell BP, Brechner R, et al. Investigation of bioterrorism-related Anthrax, United States, 2001: Epidemiologic findings. Emerging Infectious Diseases 2002;8:1019-28.
References and Resources• Last JM, ed. A Dictionary of Epidemiology, 3rd Ed,
New York, Oxford Univ Press, Inc., 1995.
• Law, D. (2005) Introduction to Geographic Information Systems. Methods in Field Epidemiology online course. UNC Chapel Hill School of Public Health.
• Martinez D. Presentation entitled Law Enforcement and Forensic Epidemiology at the Forensic Epidemiology Training Course. The Friday Center, Chapel Hill, North Carolina November 2-5, 2002.
References and Resources• Moore J. Responding to biological threats: The public
health system's communicable disease control authority. Health Law Bulletin 2001;78:1-10.
• National Institute of Justice. Accessed at http://www.ncjrs.org/txtfiles1/nij/178280.txt.
• NC Center for Public Health Preparedness (2004). Interviewing Techniques. Public Health Training and Information Network Broadcast.
• NC Center for Public Health Preparedness (2004). Designing Questionnaires. Public Health Training and Information Network Broadcast.
References and Resources• Inglesby, Thomas. Anthrax as a biological weapon.
JAMA 1999;281: 1735-1745.
• Torok, Thomas. A large community outbreak of Salmonellosis caused by intentional contamination of restaurant salad bars. JAMA 1997: 278: 389-395.
• Treadwell, Tracee. Epidemiologic clues to bioterrorism. Public Health Reports 2003; 118: 92-98.