Dead or Alive:Managing Both in Mass Fatality IncidentsMartin A. Luna, D-ABMDILaramie County CoronerCheyenne, Wyoming

Poll Question

In my career, the largest mass fatality incident that I have worked on involved

A. 6–20 fatalities

B. 20–100 fatalities

C. Over 100 fatalities

D. I have never worked on a mass fatality

Definition

What is mass fatality?

Number of victims

Capacity of affected jurisdiction to respond

The type of disaster

Natural disasters

Accidents/incidents

Pandemic events

Onset• Sudden

• Unexpected

• Sudden

• Unexpected

• Expected

• Preplanning

Deaths• Hundreds or

thousands• Tens or hundreds

• Hundreds or thousands

Infectious disease issues

• Same • Same• Potentially very

high

Legal context• “Nobody

responsible”• Medicolegal

framework• Public health legal

issues

Forensic investigation

• Identification

• Cause of death

• Identification

• Cause of death• Actual cause of

death

A Descriptive Framework

Commonalities

• All victims must be identified

• The need to preserve evidence

• Treat remains and relatives with dignity and respect

• Political pressure

• Public health concerns

Public Health

Why take a public health approach to management of the dead following mass fatalities incident?

Not just about identification

Physical health of survivors and relief workers

Impact on other healthcare providers

Mental health

Legal issues

Assessing the impact of the disaster

Assessing Disease RiskPresence of infectious

agent

Exposure to the agent

Susceptible host

• Victims of natural disasters die from trauma/drowning/fire

• Unlikely to have acute (epidemic) infections

• Possible chronic infections

Natural disasters• Public usually not

exposed

• Body handlers most likely to be exposed

• Susceptible to common chronic infections

• TB• HBV & HCV• HIV/AIDS• Enteric pathogens

O Morgan. Rev Panam Salud Publica. 2004: 15(5);307-12

Assessing Disease RiskPresence of infectious

agent

Exposure to the agent

Susceptible host

• Victims of natural disasters die from trauma/drowning/fire

• Unlikely to have acute (epidemic) infections

• Possible chronic infections

Natural disasters• Public usually not

exposed

• Body handlers most likely to be exposed

• Susceptible to common chronic infections

• TB• HBV & HCV• HIV/AIDS• Enteric pathogens

GlovesBasic hygiene

VaccinationTB, HBV

O Morgan. Rev Panam Salud Publica. 2004: 15(5);307-12

Risk to the Public

• Assessment suggests low risk

• Public may be isolated from incident

• Mortuary personnel may be the only “general public” at risk of exposure

Workers

• Potentially a “high risk group”

• No “occupational” infections

• Physical injuries

• Hazardous working environment Injury

Tetanus

Hepatitis

Body Recovery

• Feel the need to begin immediately

• Confusion

• Lack of prepared recovery personnel

• Those that die in medical care facilities

Equipment: Basic

Local equipment usually available

Equipment: Technical

More sophisticated equipment Not available Necessary? Time to respond

Managing Body Recovery

• Difficult to set up systems for body recovery “after” the disaster

• Should be considered as part of preparedness at local level

• Expectation that it will begin soon after the incident

Challenges

• Public/media want rapid disposal of bodies

• Demand proper identification of victims

• Short time before decomposition

• Identifying suitable storage

• Limited resources

• Preserve as much evidence as possible

• Families wanting closure now!

Methods for Identification

• Viewing and visual identification

• Individual identifying features (scars, marks, tattoos)

• Collection of photographs

• Advance forensic techniques Fingerprints Dental DNA

• Other

Viewing

• Decomposition may be too advanced after 24–48 hours

• Logistically very difficult to arrange

• Distressing for relatives

• Error potentially quite high

Photographs

• Photographs: face and body

• As soon after as possible

• Possibly the best postmortem information available in mass fatality incident

• Not as simple to do as it sounds Quality of photographs

Availability of photographic equipment

Cost

Advanced Forensic Methods

• Standard methods Lack of antemortum data

Availability of resources

• DNA techniques Collection of sample material

Facilities and expertise unavailable

Cost and practicability

Other Methods

• Personal effects Identity cards

Distinctive jewellery

Clothing

• Location of body

• Posters and flyers of missing

• Internet sites

Suggestions for Identification

• Photographs and documentation

• Personal effects data

Viewing and visual identification if possible+

Storage + Forensic investigation when needed

Data Management

What do we do with the data?

Lots of photos, information.

Difficult to use for identification.

Who owns the data?

Who verifies the identification process?

Provided for “lessons learned.”

Legal aspects.

Poll Question

In your jurisdiction, how many bodies can be stored at once?

A. 1-10

B. 10-20

C. More than 20

D. I don’t know

Storage

• Not possible to keep bodies for long without storage

• Limited options if numerous bodies Refrigeration

Ice

Dry ice

Temporary burial

Refrigeration

• Existing facilities too small

• Funeral homes do not have capacity to hold too long

• Refrigerated trucks can be used

• Up to 45-50 bodies in each container

Burial

• Preserve evidence

• Location of suitable grave sites difficult Local communities

Environmental health concerns

• Operational difficulties Lack of suitable documentation

Single graves or trench graves?

Clearly marked, not a “hole in the ground”

Minimum burial depth, distance from water sources, etc.

Coordination and Support

Body RecoveryCommunities, volunteers, police, military, non-governmental organizations (NGOs)

IdentificationDoctors, medical staff, forensic specialists,

FBI, DMORT, NGOs

Death certification Coroners, physicians

Disposal Coroner, ME, funeral directors

Technical Support

• Planning assistance for technical support

• Potential sources of support

American Red Cross

Mutual aid

DMORT

Disaster Preparedness

• Develop fatalities management plans

• Build local capabilities Police/Fire

Military

Red Cross

Hospitals

Mental health organizations

Clergy

State partners

Public health

Review

1. Consider whether recommendations are suitable to all “mass fatality events.”

2. Time for action is short. Decomposition 24–72 hours Body recovery begins immediately

3. Specialized equipment or teams may arrive too late.

4. Simple methods of identification and data management need to be developed

5. Temporary burial may be best storage option where refrigeration is unavailable

6. Management of dead needs to be included in disaster preparedness.

7. Coordination by single person/agency with clear mandate and legal authority.

8. Technical support is needed for governments/local organizations.

9. Active engagement with the media.

10. Ongoing program of systematic learning from future natural disasters.

Review (cont.)

Above All…

• Planning

• Training

• Exercising

Exercise beyond “The Hero”

Include multi-disciplinary approach to exercises

• After Action Reports—Implement

And More…

• Yearly training in fatalities management issues

• Additional time spent exercising recovery and processing

• Develop capabilities now

Sources

A Working Group Consensus Statement on Mass Fatality Planning for Pandemics and Disasters: July 2007

Joint Task Force Civil Support Mass Fatality Working Group

www.homelandsecurity.org/newjournal/Articles/displayArticle2.asp?article=160

Questions

Martin A. Luna, D-ABMDI

Laramie County Coroner

310 West 19th Street, #410

Cheyenne, WY 82001

307.633.4513

mluna@laramiecounty.com