Management of Mass Fatalities

Management of large numbers of fatalities is one of the most difficult aspects of disaster response. Natural disasters, in particular, can cause large numbers of deaths, as underscored by the massive loss of life (283,000) from the South Asian tsunami in 2004, the 2005 earthquake in the Kashmir region of northern Pakistan and India (86,000 dead) , and the Haitian earthquake in 2010 (310,000 dead).

As population vulnerabilities increase across the globe and the density of the populace and coastal habitation rates increase, modern disasters have a higher potential for creating large numbers of fatalities; this is so domestically as well. The evolution of current emergency management concepts is placing an increased emphasis on the effective management of mass fatalities, and it can no longer be an afterthought in the planning and operational response to such events. Within the United States, the estimated number of fatalities during another pandemic influenza outbreak is estimated to be between 3 million and 5 million people. As with any disaster-related surge, local authorities including the ME/C, law enforcement, public health, and funeral directors, as well as hospitals, nursing homes, and hospice care organizations, will be required to manage this surge in addition to the normal case load of day-to-day deaths.

The objective of this chapter is not to provide a conceptual academic discussion on concepts or controversial topics surrounding the management of a mass fatality event. Rather, the chapter is written to be a desk reference for planning strategies and tactics to address the historical challenges faced in past mass-fatality events.

Historical Perspective

In order to develop an accurate perspective of the term mass fatality , it is important to first define the paradigm in which we are working. The discipline of emergency management embodies a concept known as comprehensive emergency management (CEM), which dictates that disaster management initiatives incorporate all four phases of emergency management: mitigation or prevention, preparedness, response, and recovery. In addition, disaster management initiatives must maintain an “all-hazards” emphasis; engage, integrate, and coordinate with all stakeholders; identify and address all vulnerabilities; and be scalable to the size and scope of the event. With regard to mass fatality management (MFM), the all-hazards approach has important operational implications. No-notice or short-notice events such as earthquakes or tornados create a sudden surge of fatalities, whereas slower-evolving events, such as a biological attack or pandemic, develop over time and yet have the potential for greater numbers of fatalities. Explosions and aircraft disasters often produce highly fragmented human remains that may be difficult to recover, which greatly complicate the process of identification and reunification with next of kin, whereas remains that are contaminated with hazardous chemicals, radiation, or communicable diseases create other management challenges or decontamination and health risks to responders. Additionally, the meticulous criminal investigation and evidence collection requirements of law enforcement make the prospect of managing large numbers of deceased individuals a highly complex operation.

Although generally viewed as a second-tier response consideration after the immediate threats to life safety have been addressed, the appropriate handling, identification, and disposition of the deceased are still critical factors in the competent response to a mass fatality incident (MFI).

MFM plans must also provide adequate flexibility in order to address the unpredictable size and scope of different incidents. There are, quite literally, dozens of different definitions for the term disaster . However, the Federal Emergency Management Agency (FEMA), American College of Emergency Physicians (ACEP), National Disaster Life Support Foundation (NDLSF), and many other sources have developed some consensus in incorporating the concept of a destructive event that overwhelms the ability of a community to respond to and recover from the effects of that event. The key point of emphasis here is that a disaster is an event that overwhelms local resources and capabilities. This definition is intentionally flexible enough to be applied across all communities regardless of size and resource availability. As an example, a bus crash in a metropolitan area may produce a significant number of casualties but will not have the same overwhelming effects on the community that the same incident would have on a small rural community with far fewer emergency response resources.

Often, the terms disaster and catastrophe are used interchangeably, but there is an important distinction between the two. Quarantelli defines a catastrophic disaster by these four attributes:

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The majority of the entire community’s infrastructure is impacted.
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Local responders, health care providers, and officials are unable to perform their usual roles throughout most of the response and/or recovery phase because many of them are among the casualties.
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Most or all routine community functions (public services, health care, business and industry, and education) are immediately and simultaneously interrupted or destroyed.
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All surrounding communities are similarly affected; eliminating mutual aid assistance from the surrounding region.

Disasters overwhelm a community’s ability to respond and recover, whereas catastrophes create exponentially larger effects. The aforementioned disasters would more accurately be classified as catastrophic events. These distinctions are important to emergency planners because developing a MFM plan to manage 150 bodies from a tornado or an airline disaster is completely different from a plan to manage 10,000 bodies from a pandemic outbreak or that are contaminated with radiation from a radiologic dispersion device (e.g., “dirty bomb”).

Another important consideration in developing a MFM plan is whether the plan is facility specific or community based. Many documents on MFM planning fail to make this distinction. Even though a hospital MFM plan, for example, may not need to be concerned with search and recovery of human remains in the field, it is critical that all planners recognize the necessity to engage the wide array of stakeholders that will be involved in response to an MFI.

All strategic disaster planning must be based on evidence-based facts, if available, and assumptions as well as current best practice.

In the 3 decades 1980-2010 there were 640 natural disasters within the United States, which killed a total of 12,366 people. Commercial airlines disasters for the period 1959-2012 have accounted for 6574 fatalities in North America. All of these mass fatality events within the United States have been managed with the surge strategies outlined in this chapter with the exception of temporary interment or mass graves. Even though this proves our capability at some level to manage an MFI through the utilization of national resources, nowhere in the United States has anyone ever had to attempt to manage a truly catastrophic MFI with only local or regional resources. Even the terrorist attacks on September 11, 2001, which created nearly 3000 highly fragmented remains, were confined to three fairly localized areas, and the size and scope of each incident site did not overwhelm the capabilities of our nationwide resources.

What we have never experienced within the United States is the need to manage an MFI of even 10,000 bodies—let alone several hundred thousand, as has been the case in incidents around the globe. In recent history, we have never had to resort to mass burials in the United States, the very concept of which is highly controversial in our society. The challenge becomes getting emergency managers and disaster planners to even begin to comprehend and think beyond the 50 to 100 body event, up to and including plans on the catastrophic scale.

Current Practice

Current practice for MFM spans a wide spectrum that typically correlates to the capability of the respective facility, community, or state to manage any other aspect of disaster response or recovery. MFM plans can range from those that are very detailed down to one sentence plans that quite literally direct the reader to contact the coroner in the nearest major metropolitan area or the state emergency management agency. The major MFIs around the globe over the past 10 years in addition to the H1N1 influenza outbreak of 2009 have made most disaster planners realize the necessity of having a proactive and comprehensive plan in place.

Facts on the proper handling of dead bodies have been identified by Morgan et al., in their 2009 work for the Pan American Health Organization and World Health Organization (WHO), titled Management of Dead Bodies after Disasters: A Field Manual for First Responders .

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Dead bodies do not cause epidemics or pose public health risks after natural disasters.
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The risk to the public is negligible if they do not touch dead bodies.
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The surviving population is much more likely to spread disease.
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There is the potential (but as yet undocumented) risk of drinking water supplies contaminated by fecal material released from dead bodies.
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Most disaster-related fatalities are the result of some traumatic mechanism of injury, not by disease.
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Most disaster victims are not likely to be sick with epidemic-causing infections (i.e., Ebola, cholera, typhoid, and anthrax). However, those that are must be handled with appropriate infection control procedures.
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A few victims will have chronic blood infections (hepatitis or HIV), tuberculosis, or diarrheal disease.
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Most infectious organisms do not survive beyond 48 hours in a dead body. An exception is HIV, which has been found 6 days postmortem. The Ebola Marburg virus has been known to survive up to 5 days on contaminated surfaces, but to date no research has been done on human remains.
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Individuals handling human remains have a small risk through contact with blood and feces (bodies often leak feces after death) from Hepatitis B and C, HIV, tuberculosis, and diarrheal disease. Workers should also be cognizant of the hazards posed by highly fragmented remains as body fluids can be dripping from trees (e.g., airline disaster), soaked into surrounding soil, or become an inhalation hazard with airborne dust in collapsed buildings. Additionally, as seen in the 2014 Ebola outbreak, cultural burial practices combined with poor understanding of viral transmission greatly exacerbated the propagation of the disease through direct contact with infected corpses.
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Body recovery teams that work in hazardous environments (e.g., collapsed buildings and debris) may also be at risk of injury and tetanus (transmitted via soil).
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Considerations for MFM planning are based on the following assumptions identified in 2006 by the U.S. Northern Command and Department of Health and Human Services Fatality Management Pandemic Influenza Working Group :
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  Most catastrophic MFIs are single events that create the majority of the fatalities outside the hospital setting.
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  However, a virulent communicable disease outbreak such as pandemic influenza, hemorrhagic fever, or a biological attack will create a surge of mass fatalities within the hospital setting as well.
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  Further, a pandemic or biological attack is an ongoing event that will develop over a period of weeks and months; therefore body recovery will need to be a continual process both within the hospital and throughout the community.
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  In order to streamline this process, planners will have to establish multiple centralized locations throughout the local area for the collection, storage, and processing of bodies until the event abates to the point that normal operations can accommodate the surge in deaths.
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  A pandemic or biological event will affect the entire nation and strain the capabilities of every local community. Local and state authorities will have insufficient personnel, supplies, equipment, and storage capacity to handle the demand, and it is unlikely that mutual aid resources from surrounding jurisdictions will be available.
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  Therefore institutional-based providers, such as hospitals, nursing homes, home care and hospice care organizations, along with local public health departments, will be forced to rely on local resources from existing public and private agencies.
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  Every jurisdiction will require similar types of critical resources, including personnel, equipment, supplies, and storage capacity to manage the surge in the number of decedents. Further, current business and industry practices utilizing just-in-time (JIT) inventory and Lean supply chain strategies reduce overall community access to supplies and lower resilience to disaster impacts and will be unable to meet the spike in demand for these critical resources unless they have access to local or national supply stockpiles.
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  One of the primary strategies for containing the spread of disease is quarantining entire communities and closing state borders. Even though such actions provide limited proven disease containment value, they most certainly will impede the accessibility to critical resources.
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  Escalating death rates combined with social distancing and quarantine strategies will also affect the overall supply chain, causing shortages of water, food, medicine, and gasoline. These shortages will not only affect the entire population but will further hamper the delivery of public services as well. Public agencies may need to develop creative strategies to reduce their demand for gasoline and diesel fuel; both of which are projected to be the most difficult to obtain. Additionally, health care institutions should establish contingencies plans to ensure supply chain resiliency.
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  Additionally, public utility infrastructure including electricity, natural gas, water, and sewer may experience interruptions.
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  In jurisdictions that consider communicable disease fatalities to not be a ME/C case, the public health department may authorize the ME/C to take jurisdiction of the bodies.
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  The surge in fatalities will also overwhelm the death care industry as well. Funeral homes, coffin manufacturers, crematoria, and cemeteries will be unable to process remains in the traditional manner because of the increased number of cases. This will necessitate the establishment of temporary massive storage capacity until bodies can be properly processed for final disposition, in the absence of mass burial strategies.
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  Pandemic-related deaths will primarily fall into two major categories: attended and unattended. The process to identify remains from attended deaths will be relatively straightforward. However, unattended deaths will require verification of identity, issuing a death certificate, and notifying the next of kin, which will be both labor intensive and time consuming.
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  The resultant delays in issuing death certificates for both attended and unattended deaths will place substantial pressure on the ME/C so that the next of kin can manage the decedent’s estate.

Localized mass fatality disasters may overwhelm local and state resources, but mutual aid resources should still be available through the state-to-state Emergency Management Assistance Compact (EMAC), as well as the federal government. However, catastrophic nationwide events such as a pandemic or biological attack may overwhelm all resources, thus eliminating the potential for outside assistance.

One of the primary challenges in managing an MFI is the work necessary to positively identify each deceased victim. These procedures are collectively referred to as disaster victim identification (DVI). Positive identification of human remains is required for legal requirements necessary to settle the victim’s estate, as well as for the psychological well-being of the families of victims. The goal of DVI is to identify all victims by gathering and cataloguing all corresponding ante mortem and postmortem data.

In catastrophic events mortuary and morgue resources will be scarce and fatality processing throughput (e.g., identification, processing, and final disposition) will be limited; all existing resources should be focused on performing only the highest priority functions. These critical functions include body recovery, abbreviated processing, temporary storage, and tracking. With scarce resources the capability may not exist to perform even these critical functions simultaneously, necessitating the use of a sequential approach to managing remains.

Obviously, body recovery will be ongoing throughout the response phase of the event. Identifying those deaths that are likely the result of the pandemic makes the victim identification process more efficient and reduces the case load for ME/C. Those deaths that are attended by family members or health care providers will have a known identity and may have a signed death certificate. Unattended deaths will require the ME/C to further process remains in order to determine victim identification, issue the death certificate, track personal effects, and notify the next of kin.

These complications will be the rate-limiting factors that will overwhelm the ME/C and hinder the process of getting remains to the point of final disposition. Working on the assumption of no available outside resources, there will be no way of expanding the throughput to expedite the processing of remains. Because the processing capability (supply) is virtually fixed, then the only strategy for meeting the increased demand is to manage the demand. This can be accomplished by establishing multiple collection points and temporary morgues throughout the community to provide the capability of holding remains until they can be managed through a centralized process in the ME/C office.

Bodies can be stored for up to 6 months in refrigerated storage, which may provide the ME/C and funeral directors enough time to process all bodies in accordance with jurisdictional standards and traditional public expectations. Performing fatality management operations sequentially allows officials to leverage limited resources to employ best management practices during a worst-case scenario, to ensure that bodies will be properly identified and handled with dignity.

Although this sequential strategy of processing and releasing bodies back to the next of kin will be protracted, public expectations can be managed through proactive crisis communication planning that is well coordinated among state and local emergency management, public health, and public administration offices. The stress of delayed processing and reunification with next of kin will challenge the public trust in the government’s ability to manage the event; however, the crisis will be greatly magnified if bodies are handled haphazardly and the accuracy of identification is compromised.

In sudden onset, single point MFIs, local ME/C offices can call on state and federal mortuary surge assets. A component of the National Disaster Medical System (NDMS) under the Department of Health and Human Services (DHHS), Disaster Mortuary Operational Response Teams (DMORTs) are federal resources that are composed of volunteer medical and forensic specialists who have specific training and skills in victim identification, mortuary services, and forensic pathology and anthropology methods ( Fig. 50-1 ). Florida, Indiana, Michigan, and Ohio are among the handful of states that have robust state level disaster mortuary teams patterned after the federal DMORTs. These disaster mortuary teams provide the resources and forensic specialists, including fingerprinting, radiographic, and forensic dental identification, necessary to set up and operate a Disaster Portable Morgue Unit (DPMU) for the identification of disaster victims and reunification with next of kin ( Figs. 50-2 through 50-5 ).