Mass Fatality Response Plans

Mass
Fatality
Catastrophe
Response

Daniel Jordan, PhD, ABPP
drdanj@roadrunner.com

Objectives:
Develop and Organize
 Establish MFC Response Policy &
Procedures
 Understand Handling Deceased
 Assist Families and Loved Ones
 Familiarity with Death Certification Process
 Establish Role of Mass Fatality Response
Coordinator in an Operations Center


Mass Fatality Planning Objectives:
(FEMA)

 Don’t become
overwhelmed
 Overcome denial
and “disbelief”

Mass Fatality Planning Objectives:
(Jordan)

 vs.


FEMA Definition:
Catastrophes vs Disasters
 Mass vs Multi casualty and fatality
 Community activity breaks down
 Infrastructure (buildings, roads, water, power)
 Daily life: Work, leisure, education
 Social order
 Local governance into recovery and beyond
 Help from outside is not available
 FEMA and Enrico Quarantelli. “Emergencies, Disasters and Catastrophes
are Different Phenomena.”


Catastrophes:
High Probability, Low Frequency
 Health (Worst case, large scale, infrequent)
 Pandemic: 5,000 to 80,000+ Ventura County
deaths, nation/world-wide, no/little mutual aid
 Natural (Likely, not as large scale)
 7.9 or larger earthquakes, dam failure, tsunamis,
likely some mutual aid from outside CA
 Human-made (Less likely, smaller scale)
 Biological or dirty bomb attack, larger than 9/11


Mass Fatality Incident Guidance
 Planning tool,
not a plan
 Start with worst case
scenario


Reality Check

It "may not be ethical, it may
not be nice, it may not even
be legal, but it might be the
only thing you can do.”
 Michael Leavitt, Secretary of
Health and Human Services


Reality Check: It Could Get Bad --
Really, Really Bad
 “The corpses had backed up at the undertakers’,
filling every available area of these establishments
and pressing into living quarters; in hospital
morgues overflowing into corridors; in the
[Philadelphia] city morgue overflowing into the
street. And they backed up in homes. They lay on
porches, in closets, in corners of the floor, on
beds.”
 Barry, JM. (2004). The Great Influenza: The Epic Story of
the Deadliest Plague in History.


Reality Check: AHRQ* Plan
(See Any Problems with This?)
 Establish a Regional Home Death Management
Process
 Set up regional hubs for body retrieval and processing
with a review by the Medical Examiner, a registration
process, and a temporary holding place awaiting
definite management.
 Deploy refrigerated trucks from the hospital for body
management, exchanged daily to regional processing
sites.
 Arrange for Web-based death certificate processing
and secure tracking to the Department of Health.”
 *Agency for Healthcare Research and Quality
 http://www.ahrq.gov/research/mce/mce8b.htm

Reality Check: A State Pan Flu Plan
(See Any Problems with This?)
 Handling of Deceased Bodies by the General Public,
Such as At-Home-Death: If . . . the death of a family
member occurs in your home . . . isolate the body in an
area where it will not be touched or disturbed. If the body
must be moved or otherwise touched . . . wear gloves
and avoid contacting oral and respiratory secretions
(from mouth, eyes, nose). Wash hands thoroughly after
touching the body or surfaces contaminated by
secretions. Thoroughly disinfect surfaces and launder
clothing that may have been contaminated by secretions.
Call appropriate authorities to report the death.
 State of ------------, Dep’t. of Health. Public Health Pandemic
Influenza Response Plan, Ver. 5. (emphasis added)


Reality Check: Mass Fatality Plan
Weaknesses
 Consider:
 15-20% of the population has died

 35-40% of the population is very sick

 Nationwide pandemic, mutual aid is not
coming


Reality Check: Yes, It Could Get
Bad -- Really, Really Bad
 Epidemiological Modeling: Ventura County
could have between 5,000 and 125,000
deaths in a 6 to 8 week period (with a
second, smaller wave following the first)
 Our society is not prepared
 No society can be truly prepared
 But we must do our best


Nationwide Pandemic:
What’s Different from 1918?
 Travel:
Speed
 Numbers

 Frequency

of trips Plane landing at Maho Bay, St Maarten


Nationwide Pandemic:
1918 and Now
 More people have impaired immune systems
due to medical advances allowing them to
live longer . . . overall our population has
lower immunity levels*
 Elderly, transplant recipients, cancer survivors
getting chemotherapy or radiation, and viral
infections including HIV
 We’re actually in worse shape than in 1918
*http://www.evans.amedd.army.mil/PandemicFlu/1918.htm


Why Establish an MFC Plan?
 Notify and assist families
 Protect families, property, estates --
the future
 Identify the deceased, repatriate as possible
 Maintain evidence trail
 Determine and certify causes of death
 Track patterns for prevention and mitigation
 Properly dispose of remains

Need a Multi-Agency Plan
 Health Department
 Hospitals
 Community health entities
 Mortuaries
 County/City planning agencies, parks
departments
 and more


Community-Wide
Scene(s)
Plans

The Scene: Contained Event to
Nationwide Disease Outbreak
 Single Contained Incident
 County-wide event
 Regional to nation-wide
catastrophe


Transport of Deceased
 Assume: System is overwhelmed
 From scenes to funeral homes and/or
morgues
 Funeral homes and morgues to burial sites
 Access to appropriate vehicles, ambulances,
hearses, trucks,
 Body bags, boards, coffins, equipment


Morgue Standards
 Out of sight from bystanders and victims.
 Access control: Only authorized staff.
 Attempt to identify all human remains.
 Photographs and descriptive information for each
body.
 Collect and store, find refrigerated containers or
temporary burial to allow for subsequent
investigation and/or identification.


Family Assistance
Center
Plans
Psychological
First Aid
Community
Intervention

Family and Community Assistance
Centers
 Removed from the press, the morgue
 Mental Health staff trained in psychological
first aid
 Emotional support and practical information
 Gathering place for families to get
information and provide support to each
other
 Establish community response plans


Be able to address whether dead
bodies cause epidemics
 Dead bodies from natural disasters do not
have epidemic causing diseases (e.g.,
cholera, typhoid, malaria, or plague).
 Victims of disease need some precautions
 Follow precautions, use Personal Protective
Equipment (PPE) use
Partially Derived from: Morgan, O., Tidball-
Binz, M. & Van Alphen, D. Eds. (2006).
Management of dead bodies after
disasters: a field manual for first
responders. Washington, D.C: PAHO.

drdanj@roadrunner.com  Avian Flu Virus

How Urgent is Collection of Dead
Bodies?
 Body collection is not the most urgent task
after a natural disaster.
 The living are our priority.
 No significant public health risk is related to
simple presence of dead bodies.
 Collect bodies as soon as possible and
maintain identification.


Health Risks to the Public and
Workers Handling Dead Bodies
 Rescue workers, morgue workers, etc.
have small risk from tuberculosis, hepatitis
B and C, HIV, and diarrheal diseases.
 Infectious agents causing these diseases
last no more than two days in a dead body
(HIV may survive up to six days).
 Reduce risk with rubber boots and gloves.
 Little risk to general public


Handling the Deceased:
Examples of Advice
 Follow DOC/EOC  Cover the body or
instructions head before moving
 Universal precautions  Use backboards
 Volunteers only (even  Double glove and tape
staff should be wrists
volunteers)!
 Use shovels not hands
 Masks help emotionally


Human & Social
Welfare
Plans

Survivors: Special Considerations
 Orphans (especially if 1918 pattern held)
 Elderly
 People with special needs
 Language barriers


Mental Health Issues
 The primary desire of relatives (from all
religions and cultures) is to identify their
loved ones.
 Help with decision-making.
 Grieving and traditional burial are important
for the personal and community recovery
and healing. [See Cultural Competencies in
MFCs plan.]


Examples of Dealing with Victims,
Loved Ones, Bystanders
 Act with respect and dignity for all involved.
 Reduce pain witnesses may feel (they will
watch handling of the deceased).
 Handle deceased as if they were still alive.
 Avoid “M.A.S.H. humor.”
 Watch for signs of stress among responders
and help them get time.


Communications
and Media
Plans

PIOs, Journalists
 Challenge comments or statements
regarding the need for mass burial or
incineration of bodies to avoid epidemics.
 Consult PAHO/WHO, ICRC, the IFRC or
local Red Cross sources.
 Don’t join alarmists by spreading bad
information.


Disposition and
Collective Burial
Plans
It Can [Will] Happen Again

Coffins on loading dock 1918


Mass coffins 1918

drdanj@roadrunner.com 1918 pandemic viewing area

Mass grave digging 1918


Modern Collective Burial image


Cremation vs Burial
(PAHO* Guidelines)
 Cremation is not universally accepted destroys
evidence.
 Large amounts of fuel are needed.
 Achieving complete incineration is difficult, often
resulting in partially incinerated remains that have
to be buried.
 Logistically difficult to arrange cremation of a
large number of dead bodies.
 Pan-American Health Organization


Collective Burial Not Mass Graves
 2.5 acres can hold about 2,000 bodies.
 Gridding system, each body identified or
identifying characteristics recorded.
 Special training for heavy equipment
operators.
 Dilemma: Repatriation vs. permanence.
 Avoid trauma, even international
consequences of mass graves


Collective Burial Site Criteria
 Accessible yet able to be protected.
 Not linked to water tables.
 Relatively flat expanses of open ground.
 Dirt, low proportions of rock to be cleared.
 Convertible to permanent cemeteries.
 Neighborhood burials, local parks


Example Collective Burial Site Location:
This is not an actual planned site, but an
example of thinking through the process

Parcel ARN
234005014


One Hundred Year Flood Plain

Parcel ARN
234005014


Scary dairy close up with 100 year
Parcel ARN
floodplain
234005014


Memorializing
Plans
Collective burial sites planned as
temporary have become permanent

Winfield Township’s 1918 Influenza Mass
Grave Site
History Of the 1918 Mass Graves in Winfield
Township, Butler County PA


1918_Program_Service_b_Ukranian_C
atholic.jpg
www.saxonburglocalhistory.com/Winfield.html


Alaska Inuit mass grave marker
 site of a mass grave in
Brevig Mission, Alaska,
where 72 people were
buried following their
deaths during the
Spanish flu breakout of
1918. Ned Rozell
photo.

Photo by Ned Rozell

Castlebar, Ireland Memorial to
the Flu Victims of 1918

Castlebar, Ireland Memorial to the Flu Victims of 1918

Maori
memorial
 Carved wooden Maori
cenotaph erected at
Te Koura marae.
Cenotaph designed
and carved by Tene
Waitere of Ngati
Tarawhai.
 Photograph 1920 by
Albert Percy Godber.


September 16, 1928, a hurricane hit near the
Jupiter Lighthouse (FL) heading west across
Palm Beach County to Lake Okeechobee. It
destroyed hundreds of buildings and
damaged millions of dollars in property. Lake 1928 Hurricane, Florida
Okeechobee dike collapsed -- 1,800 to 3,000
fatalities. 1,600 buried in a mass grave in
Port Mayaca in Martin County. In West Palm
Beach, 69 white victims were placed in a
mass grave in Woodlawn cemetery and
approximately 674 black victims were buried
in this mass grave in the City's pauper's
burial field. Many others were never found.
On Sep. 30, 1928, the City proclaimed an
hour of mourning for the victims with rites
conducted at each burial site. 2,000 persons
attended at the pauper's cemetery, black
educator and activist Mary McLeod Bethune
(1876-1955) read the Mayor's proclamation.
This burial site was not again recognized
until 1991, when a Yoruba (Nigerian
religious) ceremony was held here.
National Register #02001012 (2002)


Hurricane memorial statue


International
Dimensions
Planning

Managing bodies of foreign
nationals
 Families or countries may demand
identification and repatriation of bodies.
 Problems could have serious economic
and diplomatic implications.
 Bodies must be kept for identification.
 Department of Foreign Affairs or Governor’s
Office, foreign consulates, embassies,
INTERPOL, etc.


Debriefing &
Demobilization Plans

Give Every Consideration to
Participants
 Operational Debrief
 Psychological First Aid, referral and
follow-up interventions
 Information capture, tactical changes,
organizational learning and practice
 Staff welfare, staff recovery
 Overall follow-up planning


Demobilization
 Body Recovery Demobilization
 Personal Effects Recovery Demobilization
 Family Assistance Center Demobilization
 Morgue Demobilization
 Collective Interment Operations
Demobilization


Breakout Session: Suggested (Initial)
Mass Fatality Annex Work Groups
 Scene(s) Management (may be entire For each domain we
County) including Transportation need at least:
 Hospital Mass Fatality Plans  Objectives
 Funeral Home/Mortuary Roles
 Disaster Morgue
 Policies
 Family Assistance, Identification &
 Management &
Viewing (cultural & religious issues) Organization Plan
 Health and Safety (universal precautions)  Procedures
 Social Welfare (e.g., orphans, displaced
people)
 Communications and Media
 Disposition, Collective Burial, Memorials
 Demobilization


Contact
 Daniel Jordan, PhD, ABPP
Research Psychologist
2240 E. Gonzales Road, Suite 220-M
Oxnard, CA 93036
Phone: 805-981-5258
Email: drdanj@roadrunner.com or
dan.jordan@ventura.org


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