Maine Pandemic Influenza Mass Fatality Management Planning

Maine Pandemic Influenza Mass Fatality Management Planning

Considerationsand Guidelines

Medical and health authorities have warned the world and placed a call for government andcitizens to take action in preparing for the onset of the next severe pandemic influenza virus. While human to human transmission of the bird flu has not progressed beyond somerare isolated cases, and the H1N1 2009 pandemic was similar in nature to a seasonal outbreak, the possibility of a severe pandemic developing with characteristics of high transmissibility and high mortality remains a very real threat.

The U.S. Department of Health and Human Services (HHS) has published the“HHS Pandemic Influenza Plan” outlining specific actions that local, tribal, state, and federal agenciesshould consider in planning for this potentially catastrophic event. In Maine, the State Department ofHealth and Human Services (DHHS) has published and updated aME CDC Pandemic Influenza Operational Plan (2011) providing a framework for DHHS pandemic influenza preparedness, response and recovery activities. Maine stakeholders are currently in the process of developing a comprehensive all hazards Mass Fatality Management Plan. A necessary component of both the ME CDC Pandemic Influenza Operational Plan and the Maine Mass Fatality Management Plan is a plan for managing mass fatalities as a result of a severe pandemic; a pandemicgenerating from a novel viruswith characteristics of high transmissibility and high mortality.

This document will discuss the unique considerations, challenges and actions required in preparation for, response to and recovery from a severe pandemic resulting in mass fatalities.

Mass Fatality Management Planning Assumptions for a Severe Influenza Pandemic

Susceptibility to pandemic influenza will be universal.
There may be a case fatality rate of up to 5% in addition to the average rate of deaths from other causes.
An estimated 5,000Maine residents will die from the deadly virus. Usual death rates experienced on a daily basis may be exacerbated due to lack of medical care.
Loss of 30% - 40% of the critical workforce due to illness, death or absenteeism during peak periods will significantly impede the capability and capacity of the Medical Examiner (ME) and supporting agencies to provide care and management of the deceased.
Critical infrastructure, necessary to carry out ME duties and responsibilities, may bedisrupted affecting job performance.
Essential supplies needed to perform ME functions may be in short supply or non-existent due to just-in-time inventories and nation/global competition for supplies.
ME mutual aid resources from state and federal agencies to support local response efforts may not be available during the course of the pandemic. Each region will face the overwhelming burden of taking care of its own fatality management needs.
It is estimated that 50% to 70% of deaths will occur outside of a hospital or medical treatment facility.
A severe pandemic in the US will trigger state and federal disaster declarations. Many local, state and federal laws and regulations will be suspended and / or imposed.
The death care industry could expect to handle about six months of work within a six to eight week period.
Common societal group activities and gatherings (including funeral services) will be curtailed or halted to inhibit the spread of the circulating virus.
Disposition of the deceased and funeral arrangements may not be consistent with accepted cultural/religions practices.
The time to complete fatality management of a PI event may exceed six months to a year.

Mass Fatality

Mass Fatality is defined as the number of fatalities that exceeds a local jurisdiction’s capacity to cope due to infrastructure / support limitations. Trigger points for initiating the Mass Fatality Plan may include:

The number of increased deaths,
Limited storage space at local mortuaries and funeral homes,
Worker absenteeism, or
A combination of these and other related factors.

These MFM Planning Considerations and Guidelines are intended to be used in conjunction with the Maine CDC Pandemic Influenza Operational Plan and the Maine Mass Fatality Management Plan.

Planning Considerations

Mass Fatality Management Planning Considerations for a Severe Pandemic
1. A severe pandemic will instantly become apublic health emergency requiring an all-outeffort of state, local, federal, and privateorganizations working together undersignificant political, social, and economicconditions. The pandemic could last from
18 months to several years, with two orthree waves of activity. / Deliberate pre-planning, training and tabletop
exercises based on likely scenarios andthe multi-agency coordination of plans andresponse strategies, at all levels of
government will assist in mitigating manyactual event issues. Developing pre-establishedexecutive orders, ordinances,administrative actions, etc., would beprudent.
2. A large number of people will die in ashort period of time and will continue to diefor an extended period of time during a
severe pandemic influenza event. The MEwill not have additional staff to manage this surge. The death care industry,comprised of public and private agencieswill not be able to process the dead in thetraditional manner due to the increasednumber of cases. Temporary Storage of thedead will be necessary. / The state may be requested to assist in identifying and obtaining adequate refrigerated storage facilities;obtaining additional supplies, including body bags; providing transportation resources; augmenting corpse recovery personnel; and suspending orimplementing laws and regulations to resolve ME and death careindustry response impediments.
PLANNING
3. Lack of vaccinations and anti-viraltreatment for ME and death careindustry personnel may become anethical/political issue resulting in severelydiminished protection for critical response
and recovery workers. / ME and death care personnelshould be given commensurate priority withother public safety/health first responders.The ability to adequately keep pace withmanaging the dead will help to alleviatesocietal repercussions.
4. The NIMS and ICS along with the Maine Pandemic Influenza Operational Plan and the Maine Mass Fatality Management Plan will guide the response. / All response personnel should have athorough understanding of ICS andinherent systems, standard operatingprocedures and Plans.
5. There will be delays in the issuance ofdeath certificates for both attended andattended deaths. This delay will placesubstantial pressure on the ME toissue death certificates so the next of kincan manage the decedent’s estate. / Those state and local governmentalagencies, legislative bodies, and legalsystems should be prepared to expeditenecessary suspensions, waivers, or specialorders to assist the ME and death
care industry in reducing death certificateissuance backlogs and problems.
6. Tracking and identifying the deceasedvictims in addition to the regular caseload may become unwieldy, disjointed, and
complicated during a pandemic. / Numbering systems for tracking the deadshould be standardized and currenttechnology should be utilized to ensuretimely and accurate processing andtracking of the dead. State agencies,
including the Department of Justice willassist the ME in identifying thedeceased through various data bases and
through DNA analysis.
7. Critical Infrastructure, supply chains willlikely be compromised due to numerousfactors. Manufacturing agencies within the
United States employ just-in-time inventorysystems and do not stock large inventories.Competition for supplies among states willbe intense. / The ME will be relying on local resources and agreements with vendors (ifviable). The state may be requested to helpidentify and/or obtain supplies essential for the ME to perform their duties.
8. Depletion in the workforce willincrease the requests for mutual aidpersonnel. Other priorities and dutiesas required during the event may divertthe ME staff from performingtheir fatality management tasks.Recovering and managing the deadrequires persons who are accustomedto the unique characteristics of the task. / Meeting the mutual aid personnelneeds of the ME during apandemic will be difficult. Actionsshould be taken to pre-identify
appropriate individuals and groups whocan fill positions within the ME organization. The statemay be requested to fill personnel
requests from national guard andfederal resources.
9. Public expectations regardingfatality management operations andfinal disposition may be modified tofacilitate the management of the dead.Traditional methods and culturallyaccepted means of handling decedentsmay not be followed causing family andsocial upheaval. Public distrust of thegovernment may be exacerbated. / Maine law (?)dictates that all human remains be returned to the decedent’snext of kin. If circumstances require aprolonged delay or other means of finaldisposition of remains, the state mayneed to provide legal remedies and,most certainly establish a unified voiceto publiclyaddress citizens’ unease regarding thedisposition of their deceased loved one.
10. Cemeteries may only have alimited surge capacity and it is likelythat they may not have the space toaccommodate thousands of deaths atone time. Funeral homes andcrematoriums may have similarproblems in providing services in atimely and sufficient manner. / Maine law/regulations(?)governingcemeteries and funeral directors mayrequire emergency actions to easerestrictions in order to facilitatedecedent final disposition.

IDERATONS COMMENTS

PLANNING CONSIDERATONS COMMENTS

General Guidelines for Mass Fatality Management Planning for a Severe Pandemic

During a pandemic, local authorities will have to be prepared to manageadditional deaths due to influenza, over and above the number of fatalitiesfrom all causes currently expected during the inter-pandemic period. These guidelines aim to assist local planners and funeral directors in preparing tocope with large-scale fatalities due to an influenza pandemic. A number ofissues have been identified, which should be reviewed with coroners/medicalexaminers, local authorities, funeral directors, and religious groups/authorities.

Personnel

All personnel will wear personal protective equipment as directed by the Health Officer.

Protecting employee health and reducing the spread of infection among workers is a priority.

All personnel handling dead bodies in mass fatality response will also receive proper immunizations as appropriate; training in blood borne pathogens, personal protective equipment (PPE), and proper lifting techniques; and PPE as defined by existing regulations, for example:
Disposable, long-sleeved, cuffed gown (waterproof if possibly exposed to body fluids).
Single-layer non-sterile ambidextrous gloves which cover the cuffs of the long-sleeve gown.
Surgical mask (a particulate respiratory if handling the body immediately after death).
Surgical cap and face shield if splashing of body fluids is anticipated.
Waterproof shoe covers if required.

Proper hand washing is always recommended when handling remains

Family Emergency Plans

The ME/C, vital records system, and death care industry should encourage employees to develop “family emergency plans” knowing that they may not be able to be with their families for extended periods during waves of severe disease during the pandemic period

Planning for Mass Fatalities

In order to identify planning needs for the management of mass fatalitiesduring a severe pandemic, it is important to examine each step in the management ofa decedent under normal circumstances and then to identify what the limitingfactors will be when the number of corpses increase over a short period oftime. The following table identifies the usual steps, planning requirements and possible solutions.

12-1

Issues Related To Managing Increased Numbers of Deaths in a Worst-Case Scenario Pandemic Influenza
Planning for Possible Solutions
Emergency Operations Center and Public Health Department Actions for Managing Deceased
Consider ME/C Office and death care industry personnel as first responders.

Classify ME/C Office and death care industry personnel as first responders for priority prophylaxis and antivirals.
Ensure the ME/C Office’s and death care industry’s priority access to labor, supplies, personal protective equipment, vaccines, fuel, raw materials, communication bandwidth, transportation, security, temporary housing as needed, and other resources.

Consider involving Public Health, the ME/C, and police in developing specific investigative checklists, which clarify the concepts of medico-legal determination of cause and manner of death, victim identification procedures, scene documentation, overall investigative requirements, and required PPE and personal decontamination, for all call centers and responders to unattended deaths during a PI event.
Train all first responders in the field about the symptoms of PI deaths and the actions to take when a suspected PI event related death is found vs. when non PI event related deaths are found.
Consider establishing a dispatch/tracking system with a centralized database that is separate from emergency medical services and 911 systems to track patients and deaths. Design it so that it can be managed through family assistance and patient tracking centers. Link all first responders/health care centers/collection points/morgues/family assistance/ME/C Office/law enforcement/etc. to this system. Consider facilitating its use by private citizens.
Consider establishing a county voluntary registry of next of kin so families can register information before a disaster.
Implement reciprocal licensing of mortuary services personnel to overcome variations in state licensing of funeral directors, embalmers, cemetery, and crematory operations, and unionized labor.
Educate behavioral health professionals, social service organizations and religious leaders regarding the process for managing human remains to ensure the process is understood and can be properly communicated to the general population in their response activities.
Advise the ME/C Office and death care industry of additional respiratory protection that is needed

During autopsy procedures performed on the lungs or during procedures that generate small-particle aerosols (e.g., use of power saws and washing intestines) in case the decedent was infectious when he/she died.
During embalming procedures prior to burial or cremation.

If families will be transporting loved ones who have died from pandemic influenza, provide education on general precautions for handling dead bodies. Special precautions are not required since the “body” is not contagious after death.
Track federal, state, and local laws applicable to the handling of human remains that impact the ME/C, vital records system, and death care industry. Existing laws, such as time requirements for completing death certificates and disposition permits, may need to be amended/waived. Alert all parties to waivers and modifications that impact services.
Death Reporting/ Missing Persons
Requirement:
If death occurs in the home/business/community then a call in system needs to be established.
Citizens call 911 to request a check on the welfare call for others.
911 or other system needs to be identified as the lead to perform this task.
Limiting Factors:
Availability of people able to do this task normally 911 operators
Availability of communications equipment to receive and manage large volumes of calls/inquiries
Availability of trained “investigators” to check into the circumstances of each report and to verify death is natural or other / Provide public education about the call centers, what information to have available when they call, and what to expect from the authorities when a death or missing persons report is made.
Consider planning a Call Center (toll free number) system 24/7 specifically for this task to free up operators for 911 calls on the living.
Search for Remains
Requirement:
If death occurs in the home/business then the law enforcement will need to be contacted.
Persons legally authorized to perform this task.
Limiting Factors:
Law enforcement availability. / Consider deputization and training (through the investigations unit of law enforcement) of people whose sole responsibility is to search for the dead and report their findings.
Consider having community attorneys involved in the legal issues training for the groups identified.
Recovering Remains
Requirement:
Personnel trained in recovery operations and the documentation required to be collected at the “scene”
Personnel protection equipment such as coveralls, gloves, and surgical masks.
Equipment such as stretchers and human remains pouches.
Limiting Factors:
Availability of trained people to perform this task
Availability of transportation assets
Availability of interim storage facility / Consider training volunteers ahead of time.
Consider refrigerated warehouses, tents or other cold storage as an interim facility until remains can be transferred to the family’s funeral service provider for final disposition.
Step: Death Pronounced
Requirement:
Person legally authorized to perform this task.
Limiting Factors:
If death occurs at home then one of these people will need to be contacted.
Availability of people able to do this task. / Provide public education on what to do if someone dies, how to access an authorized person to certify death, and where to take the deceased if family or friends must transport them.

Consider planning an on-call system 24/7 specifically for this task that is separate from the 911 System. Keep 911 focused on calls pertaining to life safety missions.

Allwho interface with decedents should record official personal identification information for patients who enter their systems and maintain this information in the patient’s police report and/or medical record.

If a deceased patient enters the system without an official photo identification, and identity is never established, healthcare facilities should report this person to the patient’s local police department. There is a possibility the deceased has been reported missing by a family member who can visually identify the decedent.

Consult with Native Americans, Jews, Hindus, Muslims and other religious groups that have special requirements for the treatment of bodies and for funerals and involve them in planning for funeral management, bereavement counseling, and communications with their respective communities in the event of a pandemic. During the pandemic, the wishes of the family will provide guidance, however, if no family is available local religious or ethnic communities can be contacted for information.
Step: Death Certified
(signing of a death certificate stating the cause of death)
Requirement:
Person legally authorized to perform this task.
Limiting Factors:
Legally, may not necessarily be the same person that pronounced the death. / ALL who interface with the deceased should record official personal identification information (first, middle, last name & suffix; race/ethnicity, color of eyes, hair, height, and weight; home address, city, state, zip & telephone number; location of death and place found; place of employment and employer’s address; date of birth, social security number & age; and next of kin—or witness—name, contact number & address).