Dead or Alive: Managing Both in Mass Fatality Incidents

1. Dead or Alive: Managing Both in Mass Fatality Incidents Martin A. Luna, D-ABMDI Laramie County Coroner Cheyenne, Wyoming

2. 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

3. Definition What is mass fatality? • Number of victims • Capacity of affected jurisdiction to respond • The type of disaster

4. A Descriptive Framework

5. Commonalities • All victims must be identified • The need to preserve evidence • Treat remains and relatives with dignity and respect • Political pressure • Public health concerns

6. 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

7. Assessing Disease Risk Presence of infectious agent Exposure to the agent Susceptible host 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 • Victims of natural disasters die from trauma/drowning/fire • Unlikely to have acute (epidemic) infections • Possible chronic infections O Morgan. Rev Panam Salud Publica. 2004: 15(5);307-12

8. Vaccination TB, HBV Gloves Basic hygiene Assessing Disease Risk Presence of infectious agent Exposure to the agent Susceptible host 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 • Victims of natural disasters die from trauma/drowning/fire • Unlikely to have acute (epidemic) infections • Possible chronic infections O Morgan. Rev Panam Salud Publica. 2004: 15(5);307-12

9. 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

10. Workers • Potentially a “high risk group” • No “occupational” infections • Physical injuries • Hazardous working environment • Injury • Tetanus • Hepatitis

11. Body Recovery • Feel the need to begin immediately • Confusion • Lack of prepared recovery personnel • Those that die in medical care facilities

12. Equipment: Basic Local equipment usually available

13. Equipment: Technical More sophisticated equipment • Not available • Necessary? • Time to respond

14. 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

15. 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!

16. Methods for Identification • Viewing and visual identification • Individual identifying features (scars, marks, tattoos) • Collection of photographs • Advance forensic techniques • Fingerprints • Dental • DNA • Other

17. Viewing • Decomposition may be too advanced after 24–48 hours • Logistically very difficult to arrange • Distressing for relatives • Error potentially quite high

18. 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

19. 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

20. Other Methods • Personal effects • Identity cards • Distinctive jewellery • Clothing • Location of body • Posters and flyers of missing • Internet sites

21. Suggestions for Identification • Photographs and documentation • Personal effects data + Viewing and visual identification if possible + Forensic investigation when needed Storage

22. 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.

23. 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

24. Storage • Not possible to keep bodies for long without storage • Limited options if numerous bodies • Refrigeration • Ice • Dry ice • Temporary burial

25. 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

26. 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.

27. Communities, volunteers, police, military, non-governmental organizations (NGOs) Doctors, medical staff, forensic specialists, FBI, DMORT, NGOs Coroners, physicians Coroner, ME, funeral directors Coordination and Support Body Recovery Identification Death certification Disposal

28. Technical Support • Planning assistance for technical support • Potential sources of support • American Red Cross • Mutual aid • DMORT

29. Disaster Preparedness • Develop fatalities management plans • Build local capabilities • Police/Fire • Military • Red Cross • Hospitals • Mental health organizations • Clergy • State partners • Public health

30. Review • Consider whether recommendations are suitable to all “mass fatality events.” • Time for action is short. • Decomposition 24–72 hours • Body recovery begins immediately • Specialized equipment or teams may arrive too late. • Simple methods of identification and data management need to be developed • Temporary burial may be best storage option where refrigeration is unavailable

31. Review (cont.) • Management of dead needs to be included in disaster preparedness. • Coordination by single person/agency with clear mandate and legal authority. • Technical support is needed for governments/local organizations. • Active engagement with the media. • Ongoing program of systematic learning from future natural disasters.

32. Above All… • Planning • Training • Exercising • Exercise beyond “The Hero” • Include multi-disciplinary approach to exercises • After Action Reports—Implement

33. And More… • Yearly training in fatalities management issues • Additional time spent exercising recovery and processing • Develop capabilities now

34. 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

35. Questions Martin A. Luna, D-ABMDI Laramie County Coroner 310 West 19th Street, #410 Cheyenne, WY 82001 307.633.4513 mluna@laramiecounty.com