The Public Health Role During Mass-Fatality Incidents

Many major disasters start without warning, continue for periods ranging from mere seconds to weeks or months, and leave behind a chaotic mass of useless rubble and ruined lives.  The work of public health agencies necessarily starts well before the first tremor, continues through the entire response/recovery/resilience process, and ends – well, never.

The term “mass fatality incident” is defined as an incident in which more deaths occur than can be handled by local resources. However, determining what constitutes a mass fatality incident varies from one jurisdiction to another not only because communities differ in both size and resources but also because such incidents can be caused by natural hazards, human-related hazards, or “pro-active” human hazards.

Although different from other types of public health services, and even counter to how most people view public health (i.e., as a sector dedicated to ensuring the health and safety of the public), mass fatality management is actually one of the key responsibilities listed – under the Federal Emergency Management Agency’s National Response Framework – as an Emergency Support Function (ESF). Mass fatality management comes under ESF #8, Public Health and Medical Services. In most if not quite all jurisdictions, the public health authority is specifically responsible for ESF #8.

The overall responsibilities for public health in a mass fatality incident vary considerably, though, by jurisdiction and state. However, public health still plays an important role during planning, response, and recovery efforts. Today, public health agencies have greater first-responder and overall preparedness roles than ever before. They also have more experience and are members of partnerships that are vital during major disasters – e.g., working with vulnerable populations, collaborating with community partners and volunteer organizations – and are expanding pre-existing relationships with laboratories and with medical examiners/coroners (ME/Cs).

Rules, Regulations & Responsibilities – With Numerous Exceptions

It is important to remember, though, that public health’s responsibilities during a mass fatality incident do not supersede those of the ME/Cs – or of such U.S. government agencies as the Federal Bureau of Investigation (FBI) and/or the National Transportation Safety Board (NTSB). However, jurisdictional and/or state authorities spell out the specific responsibilities of public health and other first responders vs. those of the ME/Cs. One example: In the State of Maryland, the Office of the Chief Medical Examiner (OCME) has jurisdiction over “any death which is the result of a casualty or accident, homicide, poisoning, suicide, rape, therapeutic misadventure, drowning, of suspicious or unusual nature, or of any apparently healthy individual while not under the care of a physician.” In all such cases, local public health departments provide support to OCME and law enforcement agencies – but have jurisdiction over and coordinating authority for all other types of mass fatality incidents that do not fall under OCME jurisdiction.

Under normal conditions, approximately 90 percent of the fatalities in Maryland, which result from natural diseases occurring under natural circumstances, are not OCME cases. However, approximately 90-95 percent of all of the mass fatality incidents in the state are under the jurisdiction of OCME – because they result from accidents, homicides, and/or other unusual or suspicious circumstances. For most jurisdictions, therefore, only a small percentage of mass fatality events fall outside the care of the ME/Cs (which have and must adhere to their own mass fatality plans). Nonetheless, public health and its partners must still develop detailed plans to ensure that: (a) there is a common understanding of their respective roles, responsibilities, and available resources; and (b) essential functions can and will continue during an incident.

After determining the general parameters of responsibilities – as specified by a state or other jurisdiction’s laws – during a mass fatality incident, the next step is to determine what agencies and individuals should be “at the table” at the beginning of the planning process. In that context, what might be and frequently is a very long list obviously should include at least the following: law enforcement agencies and fire departments; emergency medical services (EMS); homeland security/emergency management; hospitals and other healthcare facilities (including mental health providers; ME/Cs; volunteer organizations – the American Red Cross, for example); and representatives of the death care industry (funeral homes, cemeteries, and crematories). A number of state and regional agencies likely to be involved in various ways also should be included.

The Creative Process – Pitfalls and Problem Areas

The mass fatality management plan developed by the aforementioned stakeholders should not supersede but, rather, be complementary to the ME/C mass fatality plan, other responder plans, and/or state and regional plans. If and when possible, the planning process should review, and use as a template, existing plans and best practices/resources from other jurisdictions – e.g., “Managing Mass Fatalities: A Toolkit for Planning,” developed by the Santa Clara County [California] Public Health Department.

Following are brief descriptions of some but no means all of the principal topics, issues, and potential problem areas that should be included in a truly comprehensive and operationally effective plan:

Introduction: The first component of the plan is introductory in nature and states the rationale (purpose and objectives) behind writing the plan, as well as its scope and a list of emergencies covered – in this example, these are almost always health-specific and would probably include, but not be limited to, terrorist acts or threats, infectious-disease emergencies, the dangers caused by contaminated drugs and/or medical devices, food or waterborne disease outbreaks, and/or contamination of a public water supply. This section also should clearly state which incidents fall under the umbrella of law-enforcement agencies, and which do not.

Authorities and Definitions: The next section of the plan should list the legal authorities under which the plan is being written – e.g., State codes, local Emergency Operations Plans – as well as the relevant definitions. The latter should be as comprehensive as possible because, for legal purposes, the agencies participating may well have to rely on those definitions at a later date.

Situation and Assumptions: This section discusses the jurisdiction’s situation and assumptions, including numerous operational realities: the agencies (and/or officials) that have jurisdiction over decedents; various obstacles that have the potential to challenge a response to mass fatality incidents; the roles played by various federal agencies (e.g., NTSB, FBI); and the responsibilities of Disaster Mortuary Operational Response Teams (DMORTs).

Command and Control: This section provides detailed instructions on how an incident or event should be managed (as spelled out in Incident Command System/Unified Command guidelines) as well as how public health and other response agencies should support the ME/C, federal agencies, and the region, etc. This section might also include a detailed breakdown of the roles and responsibilities of health departments and other response agencies.

Concept of Operations: This section, often the longest and most detailed section of the mass fatality management plan, spells out the operational and procedural steps that must be taken to: (a) activate the plan; (b) communicate with partners, media, and the community at large; and (c) carry out the roles/responsibilities involved in each phase of mass fatality management. (Public health is usually not the lead agency designated to carry out the functions/activities under each phase, but it may be the lead coordinating agency and/or play a major supporting role. In addition, it should be remembered that, depending on the responsibilities assigned by local or state authorities, local agencies may be operating under the direction of ME/Cs.)

A Daunting and Detailed List of Duties

After the legal jurisdictional framework and chain of command have been spelled out, the planning process should shift to the specific tasks and responsibilities likely to be faced immediately following, during, and concluding a specific mass fatality incident. Following are a few specific examples of the mass fatality management phases and some probable public health responsibilities in each such phase.

  • Human Remains Recovery/Retrieval: Public health supports the lead agency (e.g., Fire/Rescue, EMS, and/or law enforcement) in acquiring supplies and resources, providing subject-matter expertise related to decontamination, and maintaining awareness of operations to anticipate challenges.
  • Transportation: Public health may coordinate transportation, but the lead agencies are usually the local transportation/public works administration and/or death care industry. Transportation needs should be requested through the Emergency Operations Center (EOC), but public health may offer guidelines for suitable transportation assets and the movement of remains, and maintain awareness of the community transportation needs of the death care industry.
  • Storage: Public health should work with applicable community partners such as hospitals and emergency management agencies toentify appropriate locations for both the short- and long-term storage of decedent remains.
  • Identification and Tracking: Although identification of decedents is usually led by law enforcement and the ME/C – with law enforcement serving as the lead in notifying the next of kin – all of the response agencies involved, including public health, are responsible for ensuring the careful and respectful tracking of decedents, body parts, and personal effects.
  • Interment: If remains cannot be stored in a refrigerated facility while awaiting final disposition, temporary interment (i.e., burial) may be considered. Public health assists in selecting appropriate temporary interment sites, ensuring that the appropriate resources are available, and – at the conclusion of the mass fatality incident – assisting with the process of re-interment.
  • Disposition: A key goal during a mass fatality incident is to ensure that each body reaches the “final disposition” stage in accordance with his or her religious and cultural practices as well as the wishes of the victim’s family. In support of this goal, public health assists the death care industry in developing a viable continuity of operations plan (COOP), providing situational awareness and appropriate public messaging capability, and ensuring that the resources needed are available.
  • Death Certificates: Although physicians and ME/Cs are responsible for filling out and signing death certificates, public health plays a key role in communities in which the health department processes death certificates. (The health department’s COOP may have to be activated, though, to ensure that the resources needed are readily available to help in the processing of death certificates.)
  • Law Enforcement/Security: Public health keeps law enforcement informed of security needs, a particularly important responsibility at all mass fatality incident operational areas – storage sites as well as incident sites.
  • Supply and Volunteer Management: Public health works with community partners, volunteer groups – the Medical Reserve Corps (MRC), for example, and Community Emergency Response Teams (CERTs) – and faith-based organizations to ensure that volunteers are appropriately trained, possess the equipment and other material resources needed, and fully understand their individual and collective roles and responsibilities (and limitations) during the event.
  • Family Assistance: The family assistance center (FAC) is a particularly important component of the jurisdictional infrastructure both during the planning process and during the event. Depending on the type of incident, the FAC, which can be either a physical or “virtual” location (a designated hotline, for example), usually serves as a primary resource for families that want to exchange information about missing and deceased relatives. The FAC also assists in the re-unification of families with decedents, and provides many of the resources and services needed not only by survivors but also their families (e.g., disaster behavioral health services, final disposition options, grief counseling).
  • Demobilization/Recovery: Depending on the type of incident, public health may have to provide immediate and/or ongoing support to mass fatality management to work toward a respectful resolution and final resting place for decedent remains. In addition, public health probably will have to manage certain environmental-surety issues such as decontamination, determining a safe return to facilities, and both water and soil sampling.

Laminated Checklists and Other Odds & Ends

Among several essential appendices to the completed plan would be such helpful data as the following: “Key Contacts” information (particularly valuable for agencies and organizations in the death care industry); a list of decedent storage and handling sites; local public and media communications outlets; religious and/or cultural organizations in the local community; a death management process checklist; communications links to ME/Cs; and the steps needed to access state, local, and/or regional mass fatality management plans available to the public.

It should be kept in mind at all times, moreover, that one of the most challenging aspects of the planning process is not writing the plan per se but, rather, ensuring that it is operationally possible, useful, and easy to follow during an actual emergency. Because a mass fatality plan is more technical in nature – and differs in several important ways from most other public health plans – it is particularly important that all of the agencies and individuals involved clearly understand not only their own roles but also the rationale used for the development and organization of the plan.

In addition to training and exercises, each response agency also should develop checklists or tip sheets of the plan – i.e., a relatively short (no more than 4-5 pages) document summarizing the key points and definitions used in the plan. Also included should be a checklist of the planning, response, and recovery responsibilities of each participating agency. These checklists can and should be laminated and should be carried by the units – police, fire, EMS, and health agencies, usually – most likely to be first on the scene for their respective agencies.

Incidents that produce large numbers of fatalities are more common today than ever before, and for that reason alone there is a compelling need to prepare and plan much more effectively than ever before – and earlier – for emergency responses of all types. Weather events such as the deadly tornadoes that devastated several U.S. communities earlier this year, Hurricane Katrina, the Japan tsunami/earthquake – compounded by the 9/11 attacks and other terrorist incidents, as well as aviation accidents and other “manmade” disasters – serve as stern but absolutely essential reminders of how traditional responses have been replaced in recent years by the compelling need for a much broader understanding of the comprehensive planning needed to deal effectively with complex mass fatality events.

For additional information: On the 15 Emergency Support Functions, click on the National Response Framework at www.fema.gov.

Raphael Barishansky

Raphael M. Barishansky, DrPH, is a public health and emergency medical services (EMS) leader with more than 30 years of experience in a variety of systems and agencies in positions of increasing responsibility. Currently, he is a consultant providing his unique perspective and multi-faceted public health and EMS expertise to various organizations. His most recent position prior to this was as the Deputy Secretary for Health Preparedness and Community Protection at the Pennsylvania Department of Health, a role he recently left after several years. Mr. Barishansky recently completed a Doctorate in Public Health (DrPH) at the Fairbanks School of Public Health at Indiana University. He holds a Bachelor of Arts degree from Touro College, a Master of Public Health degree from New York Medical College, and a Master of Science in Homeland Security Studies from Long Island University. His publications have appeared in various trade and academic journals, and he is a frequent presenter at various state, national, and international conferences.

Audrey Mazurek

Audrey Mazurek, MS, has worked at all levels of government for nearly 20 years in public health and healthcare preparedness, emergency management, and homeland security. She was a program manager with the National Association of County and City Health Officials (NACCHO) Project Public Health Ready program. She supported the U.S. Department of Homeland Security in the development of an accreditation and certification program for private sector preparedness. She also served as a public health emergency preparedness planner for two local public health departments in Maryland, where she developed over 30 preparedness and response plans, trainings, and exercises. She is currently a director of public health preparedness with ICF, primarily supporting the U.S. Department of Health and Human Services, Assistant Secretary for Preparedness and Response’s (ASPR) Technical Resources, Assistance Center, and Information Exchange (TRACIE) program as the ICF program director.

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