PANDEMIC INFLUENZA
MASS FATALITY
RESPONSE PLAN
This plan is the property of The Arizona Department of Health and contains information that is considered.
This document is maintained by the Bureau of Emergency Preparedness and Response.
ADHS
150 North 18th Avenue
Phoenix Arizona 85007-3237
PANDEMIC INFLUENZA MASS FATALITY RESPONSE PLAN
Arizona Department of Health Services
(Developed and Maintained by the Bureau of Emergency Preparedness and
Response)
TABLE OFCONTENTS
SECTION
PAGE
1.0. General …………………………………………………………………………………… 1
1.1. Purpose ……………………………………………………………………............1
1.2. Planning Assumptions …………………………………………………………….2
1.3. Mission Statement ……………………………………………………………….. 3
1.4. Inventory of Federal Capabilities …………………………………………………4 Disaster Mortuary Operational Response Teams (DMORT) ………………….4 Disaster Portable Morgue Unit (DPMU) …………………..………………… 5 DOD Mortuary Affairs Assistance …………………………………………… 6 DOD Support to Civil Authorities (DSCA) in Arizona …………..….………. 7
1.5. Management of Mass Fatalities, Requirements, Limiting Factors and Possible Solutions ……………………………………………………………. 8
1.6. Scope ……………………………………………………………….……………..10
1.7. Direction and Control ……………………………………………………………. 11
2.0. Situation ………………………………………………….………………………………..11
3.0. Concept of Operations ……………………………..…………..………………………….14
3.1. Autopsies ………………………………………………………………………….15
3.2. Preparations for Funeral Homes and Crematoria …………………..……………. 16
3.3. Planning for Temporary Morgues ……………………………………………….. 16
3.4. Death Registration (Vital Records) ……………………………………………….17
3.5. Infection Control …………………………………………………………………. 18
3.6. Human Remains Recovery ………………………………………………………..18
3.7. Transportation of Human Remains ……………………………………………..... 19
3.8. Supply Management ………………………………………………………………20
3.9. Social/Religious Considerations……………………………….……………..…... 21
3.10. Role of the Arizona Funeral Directors Association (AFDA) …….……..……… 21
3.11. Storage and Disposition of Human Remains …..…….…………………………. 22
3.12. Mortuary Affairs Collection Point (MACP) ……………………………………. 22
3.13. Personal Effects (PE) Depot ……………………………………………………. 22
3.14. Temporary Interment …..……………….………………………………………. 23 4.0. Organizational Roles and Responsibilities …... 23
4.1. State Government …………………………………………………………………25
Office of the Governor ……………………………………….….…………… 25
Arizona Department of Health Services ………………………………………25
Infectious Disease Epidemiology Section ……………………………………. 25
Office of Vital Records ………………………………………………………. 26
Public Information Office ……………………………………………………..26
Bureau of Emergency Preparedness and Response ……..…………………….26
State Board of Funeral Directors ………………………………………………26
4.2. Local Government……………………………………………………..……….….26 County Health Departments …………………………………..……………… 26 County Office of the Chief Medical Examiner (OCME) …………………….. 27
4.3. Other Organizations Involved with the MAS ……………………………………. 28 State and Federal Corrections Institutions …………………………………….28 Hospitals and Clinics …………………………………………………………..28 Shelters …...
28
Arizona Funeral Directors Association (AFDA) …………………………….. 29
5.0 Post Pandemic Recovery ………………………………………………………………….. 29
6.0. References
TABLES,FIGURES ANDCHARTS
Table 1 Mortuary Affairs System Planning Guide ……………..………………….…………..8
Table 2 Roles and Responsibilities of Agencies Involved in Mass Fatality Planning……….... 23
Chart 1 Fatality Management Flow Chart …………………………………….….…………… 14
Figure 1 Personal Effects Flow……………………………………………………………..….5-4
APPENDICES
Appendix 1
MASSFATALITYPLANNINGGUIDE
Appendix 2 TEMPORARYMORGUE ANDMORTUARYAFFAIRSCOLLECTION
POST (MACP)PLANNINGGUIDE
Appendix 3
MORTUARY AFFAIRS PROCEDURES FORSEARCH AND
RECOVERY
1.0. Introduction….…………………………………………………………………….……..3-1
2.0. Search and Recovery Operations…………………………………………………….….. 3-1
2.1. Mission Accomplishment……………………………………………………….. 3-1
2.2. Search Operations……………………………………………………………….. 3-1
2.2.1. Planning……………………………………………………...................3-1
2.2.2. Preparation for Movement………………………………..…………… 3-1
2.2.3. Searching for Remains………………………………………………… 3-2
2.2.4. Search Operations…............................................................................... 3-3
3.0. Recovery Operations………………………………………….………………………….3-4
3.1 Recording Personal Effects……………………………………………………….3-4
3.1.1. Safeguarding Personal Effects…...
3-5
3.1.2. Obtaining Identification Media………………………………..……….3-5
3.1.3. Recording Identification Media…………………….………….……… 3-5
3.1.3. Obtaining Statements of Recognition………………………………… 3-5
3.2. Questioning Local Inhabitants…………………………….……………….……. 3-6
4.0. Evacuation Operations…………………………………………………………………... 3-6
5.0. Documentation of the Recovery Site…………………………………………………… 3-7
5.1. Mapping the Recovery Site………………………………………………………3-7
5.2. Field Notes……………………………………………………………………….3-7
5.3. Photographing the Recovery Site………………………………………………...3-8
Appendix 4.
TENTATIVEIDENTIFICATION
1.0. General……………………………………………………..…………………………….4-1
2.0. Evacuation to a Mortuary Affairs Collection Point…....................................................... 4-1
2.1. Mortuary Affairs Collection Point Operations……………………………..…… 4-1
2.2. Site Selection……………………………………………………………………. 4-2
2.3. Facility Layout…………………………………………………………………... 4-2
2.3.1. Receiving Operations…………………………………………………..4-2
2.3.2. Processing Operations………………………………………………….4-3
2.3.2.1 Identification of Remains……………………………………..4-4
2.3.2.2 Pandemic Influenza…………………………………………...4-4
2.3.3. Evacuation Operations………………………………………… 4-5
Appendix 5.
PERSONALEFFECTS
1.0. Purpose……………………………………………………………………………..…….5-1
2.0. Overview………………………………………………………………………………. 5-1
3.0. General Guidance……………………………………………………………………….. 5-1
3.1. Procedures………………………………………………………………………..5-1
3.2. County OCME Responsibilities………………………………………………….5-1
4.0. Personal Effects on Remains……………………………………………………………. 5.1
5.0. Personal Effects Depot…………………………………………………………………...5-2
5.1. Introduction………………………………………………………………………5-2
5.2. Package Verification……………………………………………….…………….5-2
5.3. Flow of Personal Effects…………………………………………………………5-2
5.4. Personal Effects Depot Flow Operations…..…………………………………….5-3
5.4.1. Receiving Section……………………………………………………... 5.3
5.4.2. Administrative Section…………………………………………………5-3
5.4.3. Processing Section…………………………………………………….. 5-3
5.4.4. Shipping Section………………………………………………………. 5-3
5.5. Receiving……………………………………………..………………………… 5-4
5.5.1. High Dollar Value Items……………………………………………… 5-5
5.5.2. Completing Inventory………………………………………………… 5-5
5.5.3. Logging…………………...……………………………………………5-5
5.5.4. Administrative Assistance…………………………………………….. 5-6
5.6. Processing……………………………………………………………………….. 5-6
5.6.1. Screening……………………………………………………………….5-6
5.6.2. Re-inventory and Documentation……………………………………... 5-6
5.6.3. Final Authority…………………………………………………………5-6
5.7. Storage and Shipping……………………………………………………………. 5-6
5.7.1. Labeling……………………………………………………………….. 5-7
5.7.2. Shipping Documents……………………...……………………………5-7
5.7.3. Verification……………………………………………………………. 5-7
Appendix 6.
TEMPORARYINTERMENTPROGRAM
1.0. General …... 6-1
2.0. Special Considerations ……………….…………….…………..…….………… 6-1
3.0. Site Selection ………………………………………….……………………….. 6-1
4.0. Temporary Interment Procedures ……………………….………………..……. 6-1
4.1. Personal Protection Equipment (PPE) ………………………………… 6-1 4.2.Row Construction ………………………………….……………..…… 6-2 4.3.Reception…………………………………………………………...…. 6-2
4.4. Opening the Burial Site ……………………………………..………… 6-2
4.5. Processing …………………………………………………………….. 6-2
4.6. Verification ……………………………………………………….…… 6-2 4.7.Contaminated Remains ………………………………………...……… 6-3
4.8. Preparation of Documentation ………………………………………… 6-3
4.9. Filing ……………………………………….………………………..… 6-3
4.10. Identification (ID) ……………………………………………………. 6-3 4.11.Form Completion …………………………………………………….. 6-4
5.0. Closing the Site …………………….…………………..…………………….… 6-4
6.0. Site Care Until Reopened …………………………………………………….… 6-4
6.1. Security …………………………………………………………….…... 6-4
6.2. Contract with a Cemetery…..................................................................... 6-4
6.3. Grounds Maintenance…………………………………………………... 6-4
6.4. Memorial (Temporary or Permanent)………………………………… 6-4
7.0. Disinterment…………………………………………………………………….. 6-4
7.1. Purpose…………………………………………………………………..6-4
7.2. Responsibilities of the OCME………………………………………….. 6-5
7.3. Trench Disinterment Procedures………………………………………...6-5 Tab 1 Temporary Interment Graves Registration Form………………………………6-6
Tab 2
Appendix 7. ESTABLISHINGAMORTUARYAFFAIRSBRANCHINTHE INCIDENT
RESPONSEPLAN
1.0. General……………………………………………………………………………........................ 7.1 2.0.Adding A Mortuary Affairs Branch To The Existing NIMS System……...……...…….. 7.2
2.1. Duties to be Preformed…………………………...……………………...……… 7.4
2.1.1. Mortuary Affairs Branch Director…...………………………...……… 7.4
2.1.2. Call Center/Public Inquiry Lines Group Supervisor…………...……....7.4
2.1.3. Investigation and Recovery Team Group Supervisor……………….....7.5
2.1.4. TRANSPORTATION GROUP………………………………………..…… 7.7
2.1.5. Storage Morgue Team……………………………………………...….7.10
3.0. Hospital and/or Medical Treatment Facility Deaths………………………...…….……..7.12
Appendix 8.
PERSONALHEALTH ANDSANITATION
1.0. Purpose………………………………………………………………………………..… 8-1
2.0. Overview……………………………………………………………………………..…. 8-1
3.0. Guidelines and Procedures……………………………………………………………… 8-1
3.1. Guidelines………………………………………..…………………………..….. 8-1
3.2. Medical Precautions…………………………………………………………….. 8-2
Appendix 9.
STANDARDOPERATINGPROCEDURES FORDECONTAMINATION
OF ALUMINUMFLOOR REFRIGERATEDTRAILERS
1.0. General History ………………………………………………………………….......…..9-1
2.0. Standard Operating Procedures for Decontamination of Aluminum Floor Refrigerated Trailers …………………………………………………...……………. 9-2
2.1. Personal Protection Equipment (PPE) requirements …..……….…………….… 9-2
2.2. Establishment of a “Hot Zone”……………………………………………….… 9-2
2.3. Cleaning Before Decontamination ………………………..….………………….9-3
2.4. Decontamination Using a Solution of 5.25% Sodium Hypochlorite …………... 9-3
2.5. Cleanup and Disposal ……………………………………………………….…. 9-4
Appendix 10.
MYTHSSURROUNDINGFATALITYMANAGEMENT
Appendix 11.
MORTUARY AFFAIRS UNITS,CAPABILITIES, ANDTEAMS
I. Mortuary Affairs Units and Capabilities …………………………………………………..11-1
1.0. Joint or Multi Service MA Assets ........................………………………….……..……. 11-1
1.1. Armed Forces Medical Examiner System (AFMES).….......................................11-1
1.2. Armed Forces Medical examiner …………………………………………….… 11-1
1.3. Armed Forces Institute of Pathology (AFIP) …………………………..………. 11-1
2.0. U.S. Air Force MA Assets …………………………………………………….…….….. 11-2
2.1. 512th Memorial Affairs Squadron …………………………………….……..…. 11-2
2.2. Air Force Bases ……………………………………………………………..….. 11-2
2.3. Air Force Services Agency, Mortuary Affairs Unit ………………………..……11-2
3.0. U.S. Navy MA Assets ……………………………………………………………….…..11-2
3.1. Mobile Medical Augmentation Readiness Team (MMART) …………............11-2
3.2. Special Psychiatric Rapid Intervention Team (MMART-SPRINT) ………..….. 11-2
3.3. Preventive Medicine/Vector Control Team (MMART-PREVMED ..…………..11-3
3.4. Chemical/Biological Assessment Team (MMART-CBAT) ………..………….. 11-3
3.5. Chemical/Biological Assessment Team (MMART-CBAT) ………..………….. 11-3
4.0. U.S. Marine Corps MA Assets …………………………………………………………. 11-3
4.1. 4TH FSSG Graves Registration Company …………………………………….. 11-3
4.2. Chemical Biological Incident Response Force Mission (CBIRF) ……………... 11-3
5.0. U.S. Army MA Assets …………………………………………………………..…….. 11-3
5.1. 54th QM Corps Collection Company (MA) …………………………..……….11-4
5.2. 111th QM Corps Collection Company (MA) ………………………….....……11-4
5.3. U.S. Army Technical Escort Unit (TEU) ………………...……………..……… 11-4
5.3. U.S Army Central Identification Laboratory (CILHI) …………………...…….. 11-6
6.0. National Guard/Reserve MA Assets……………………………………………………..11-6
6.1. 311th Quartermaster Army Reserve Company......................................................11-6
6.2. 246th Quartermaster Army Reserve Battalion……………………………………11-6
6.3. Weapons of Mass Destruction Civil Support Teams (WMD-CST)…………….. 11-6
6.4. National Guard CBRNE Enhanced Response Force Packages (NG CERFP)….. 11-7
7.0.Additional DOD MA Capabilities………………………………………………………. 11-8
7.1. Mobile Integrated Remains Collection System (MIRCS)………………………. 11-8
7.2. Mortuary Affairs Automated Tracking System (MAATS)………………...…… 11-8
7.3. The ARINC Aeromedical Pallet Systems (AAPS)……………………………... 11-8
II.U.S. Army Mortuary Affairs Teams and Composition………………………...………… 11-9
1.0.Unit Search and Recovery Teams………………………………...…………….. 11-9
2.0.The QM Collection Company (MA) Mortuary Affairs………………………….11-9
2.0. Collection Point (MACP)………………………………………………….…….……… 11-9
2.1. The MACP……………………………………………………………… 11-9
2.2. The QM Collection Company (MA)…………………………………….11-9
3.0. MA Main Collection Platoon……………………………………………………….……11-9
4.0. Mortuary Evacuation Point (MEP)……………………………………………………. 11-10
5.0. Personal Effects (PE) Depot………………………………………………………...… 11-11
6.0. MA Decontamination Collection Point (MADCP)…………………………………… 11-11
7.0. Army Casualty and Memorial Affairs Operations Center (CMAOC)……………...…… 11-12
8.0. Mortuary Liaison Team (MLT)……………………………………..………………………… 11-13
Appendix 12.
MORTUARY AFFAIRS ACRONYMS,TERMS, AND DEFINITIONS
PANDEMIC INFLUENZA MASS FATALITY RESPONSE PLAN
Arizona Department of Health Services
(Developed and maintained by the Bureau of Emergency Preparedness and Response)
1.0 GENERAL
During a pandemic, local authorities will have to be prepared to manage additional deaths due to influenza, far over and above the number of fatalities from all causes currently expected during the inter-pandemic period. Within any locality, the total number of fatalities (including influenza and all other causes) occurring during a 6-8 week pandemic wave is estimated to be similar to that which typically occurs over six months in the inter-pandemic period.
Medical examiners, funeral service personnel, cemetery and crematorium personnel, forensic dentists, forensic anthropologists, crime lab technicians, and any other person whose responsibility involves direct handling of human remains during a pandemic influenza eventshall be designated as first responders.
1.1. PURPOSE
Assuming two pandemic waves of six weeks each and a five percent crude annual all causes death rate (similar to 1918 pandemic), about 10,000 deaths per week per wave would occur in Arizona (This is more than 10 times the usual rate of about 900 deaths per week). Funeral businesses in the state could not meet this demand even if they were to remain fully operational, and they would most likely lose staff to illness, family illness, death, and refusal to work. (Crude Death Rate - the annual number of deaths in a given population divided by the mid-year population and expressed per 1,000 population..)
The capacity of all morgues in the State of Arizona would be exceeded in weeks one or two of the initial wave of pandemic influenza activity. The Office of Vital Records normally requires detailed documentation and is in close coordination with the Medical Examiner and other mortuary affairs systems to close out the case. Normal activities would slow the system down as Vital Records would not be able to process the high volume of cases produced during an influenza pandemic.
This guideline aims to assist local planners and funeral directors in preparing to cope with large-scale fatalities due to an influenza pandemic. A number of issues have been identified which should be reviewed with medical examiners, local authorities, funeral directors, law enforcement, emergency managers, cemetery owners, mental health professionals, hospitals, cultural leaders, and faith-based organizations religious.
• For purposes of plan development amass fatality is any number of fatalities, whatever the cause, that is greater than the local Mortuary Affairs System (MAS) effectively can handle without outside assistance from the County, State or Federal assets.
• This plan describes the Arizona State Pandemic Influenza Mass Fatality Response Plan.
• This plan also covers search, recovery, identification, preparation, and disposition of remains of persons for whom the Army is responsible by Statutes and Executive Orders.
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• In addition, this plan also sets procedures and guidelines for temporary interment.
1.2 PLANNING ASSUMPTIONS
A pandemic influenza incident that produces mass fatalities will place extraordinary demands (including tremendous religious, cultural, and emotional burdens) on local jurisdictions and the families of victims. The timely, safe, and respectful disposition of the deceased is an essential component of an effective response. Accurate, sensitive, and timely public relations are crucial to this effort. Mass fatalities will require Federal assistance to transport, recover, identify, process, and store deceased victims and support final disposition and Personal Effects (PE) processing at the end of the pandemic.
The actual work of search and recovery, identifying, and processing the victims can be lengthy and painstaking; often complicated by the desires of families and the needs of investigative agencies. Most local jurisdictions are not equipped to handle a mass fatality event and will experience profound difficulties managing the disaster. During a mass fatality incident, local jurisdictions will lack sufficient personnel, equipment, and storage capacity to handle significant numbers of deceased victims, especially if remains are biologically contaminated.
Assistance from Federal, public, and private agencies will be required to assist in the search and recovery, transportation, tracking, removal, processing, identification, PPE selection, and final disposition of victims and remains. Advanced methods of identification to include, but not limited to, DNA typing and information management will be essential to effectively support mass fatality disasters.
• In most cases, in the event of an influenza pandemic mutual aid resources and Federal assets will not be available.
• All potential or requested assets and resources may not be available to respond to a catastrophic incident due to competing requirements at their home institutions (e.g., DOD assets may not be available due to primary mission priorities), because of family concerns at home, and/or competition with assets required for those still living.
• There could be significant disruption of publicly and privately owned critical infrastructure.
• Implementation of social distancing measures, such as isolating the sick, screening travelers, and reducing the number of public gatherings (such as funerals), may help to slow the spread of influenza early in the pandemic period.
• Drafting, exercising, and executing this plan in collaboration with Tribal health organizations and Tribal governments will be crucial in the overall mass fatality management efforts.
• Federal and State declarations of emergency may change legal and regulatory aspects of mass fatality management during a pandemic.
• Logistics systems may be overwhelmed and unable to move, in a timely manner, the required volume of personnel, victims, and equipment.
• Protocols for processing (movement and identification) biologically contaminated remains.
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• There is a lack of standards for decontaminated (how clean is clean) biologically decontaminated remains.
• Currently with there are no methods of biologically decontaminating human remains, with the exception of cremation, there are no other methods of biologically decontaminating human remains,
• A storage area where remains can be processed for family members to help identify the remains could be a large, permanent, structure but would require refrigeration. Contracted refrigeration refrigerated vans would suffice.
• A storage area will be needed for personal effects; local procedures for inventorying personal effects may be incorporated into Federal inventory procedures.
• Supplies and equipment (e.g., pouches and litters) may be needed for large numbers of deceased. In addition, limitations may include materials to build shelving units for cold storage and the expertise to establish a large, temporary interment location for contaminated remains.
• There is a lack of dedicated remains retrieval (search and recovery) team. NOTE: DMORTs do not perform search and recovery. Separate arrangements will be required to support search and recovery, to include transportation from the incident site to the DMORT facility.
• First responders are typically not trained in remains retrieval, and may not be available in a timely manner to assist in such operations.
• Refrigerated trucks will most likely not be available because many agencies are planning to use them, and the trucks will be needed to keep the infrastructure running (i.e. refrigerated food stuffs to supermarkets).
1.3 MISSIONSTATEMENT
The mission of mass fatality management is to (as appropriate to the incident cause) recover, transport, appropriately process, and protect all human remains;
• Establish victim identities and causes of death; preserve all property found on or adjacent to the bodies; maintain legal evidence for criminal or civil court action; release remains promptly to the next of kin, if possible.
• Prevent further risk to the health of the living for the sake of the dead (this includes staff and those coming to assist).
• Provide respect for those who have died and show compassion for their survivors.
• Provide social and psychological assistance for family members and mortuary affairs personnel.
• Pandemic influenza mass fatalities will present unique logistical challenges with cold storage space, human remains pouches, PPE, and related mortuary affairs supplies.
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• Stacking or piling of remains can cause unnatural bruising, discoloration and disfiguring of the remains and also slows down the cooling process, thereby increasing decomposition. Accordingly, the ability to quickly secure long-term refrigerated storage will enable medical examiners time to identify, process, and “hold” remains until final disposition.
• Basic to a mass fatality response will be the identification and selection of a number of Casualty Collection Points (CCP), using a combination of refrigerated trucks, portable preparation and storage sites (generally tents), the use of existing facilities such as vacant or unused National Guard/Reserve facilities, Department of Veterans Affairs (VA) facilities, and/or abandoned or under utilized and convenient community structures. Collection sites will present significant challenges regarding access, traffic control, security, access to power, loading docks, air quality (related to diesel engines), and processes to handle the waste, effluent, and or contamination.
• Local medical examiners, State Funeral Director Associations, State and local Emergency Management agencies, local and interstate mutual aid, and local hospitals and clinics will immediately and actively respond to a pandemic influenza mass fatality event.
1.4 INVENTORY OFFEDERAL CAPABILITIES
Disaster Mortuary Operational Response Teams (DMORT).
There are currently 10 DMORTs each comprised of funeral directors, medical examiners, coroners, forensic pathologists, forensic anthropologists, medical records technicians and transcribers, fingerprint specialists, forensic odontologists, dental assistants, x-ray technicians, computer professionals, administrative support staff, and security and investigative personnel. During an emergency response, DMORTs - working within the incident command and management structure established by local authorities - provide technical assistance and personnel to recover, identify, and process deceased victims.
• DMORT capabilities include:
Victim identification
Forensic dental pathology
Forensic anthropology methods
Processing, preparation, and disposition of remains
• DMORT support to the local Medical Examiner includes:
Augmenting existing local resources.
Providing specialized personnel.
Providing mobile morgue facility(ies).
Providing computer-based tools.
Providing family support.
• DMORT members are required to maintain appropriate certifications and licensure within their discipline. When members are activated, licensure and certification is recognized by all States.
• DMORTs work under the guidance of local authorities by providing technical assistance and personnel to recover, identify, and process deceased victims.
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Disaster Portable Morgue Units (DPMU)
In support of the DMORT program, FEMA maintains two Disaster Portable Morgue Units (DPMUs) at FEMA Logistics Centers; one in Rockville, MD, and the other in San Jose, CA. The DPMU contains a complete morgue with designated workstations for each processing element and prepackaged equipment and supplies. The DPMU core team travels with this equipment to assist in the set up, operation, packing and restocking of all DPMU equipment.
• The DPMU requires a location that is completely secure and convenient to the incident scene with easy access for vehicles.
• The DPMU requires 8,000 square feet of operating area with ventilation, hot and cold water, adequate drainage, nonporous floors, some office space, rest and refreshment areas, and restrooms.
• Other support equipment required for mass fatality management operations includes refrigerated trucks, forklifts, fuel (diesel, propane etc.), and communications with the incident command post. The Family Assistance Act of 1996 created the Family Affairs Division within the National Transportation Safety Board (NTSB), whose responsibility is to assist the local authorities in the coordination of victim identification and family assistance for major transportation accidents. The NTSB has agreements with FEMA and other national entities to assist them in fulfilling their duties under this law. An agreement between the NTSB and USPHS gives the NTSB the ability to request DMORT support for all transportation accidents involving multiple deaths.
DOD Mortuary Affairs Assistance(See Appendix 6 for more detailed information)
DOD Mortuary Affairs Units can provide the following support to domestic catastrophic incident response and recovery operations, when authorized by the Secretary of Defense:
• Search for remains. Set up appropriate search methodology and prepare the necessary documentation for later research or use.
• Recover remains. Use any means available to recover all remains and portions of remains.
• Provide tentative remains identification assistance to the local Medical Examiner or Coroner. (Note: The local Medical Examiner is the office that provides positive identification of remains. DOD can only assist in this process.).
• Set up a Personal Effects (PE) depot. A PE depot is structured into four main sections: Receiving, Administration, Processing, and Shipping. The primary functions for these sections are as follows:
oReceiving Section: receive, account for, and store all PE. oAdministrative Section: prepare and maintain all required reports and case files and provide administrative assistance to the civilian mortuary affairs community. oProcessing Section: Screen, clean, inventory, and package PE. oShipping Section: Initiate required shipping documents, coordinate for transportation, and prepare packages for shipment.
• Evacuate remains to a mortuary affairs collection point (MACP). Evacuate remains, portions, and PE from the recovery site to a mortuary affairs facility. Transport remains in the most expedient manner to prevent the loss of identification media due to decomposition of remains. Operational requirements may dictate the use of all available covered transportation assets. However, use of medical and food-bearing vehicles is not encouraged.
• Perform DNA testing through the Armed Forces Medical Examiner’s Office to assist civilian authorities with positive identification. During mass-fatality incidents, the Dover Air Force Base (Delaware) Military Port Mortuary can be activated to process remains. This processing can include autopsy and/or medical examination when supported by the Armed Forces Medical Examiner’s Office. Both the Armed Forces Medical Examiner’s Office and FBI also provide support for identification of remains, as required.
The activation and use of Air Force Port Mortuary(ies) is an option available to civilian authorities. Following a CBRNE mass casualty/fatality incident, which may occur without warning and is expected to produce considerable confusion and demand for personnel, there is likely to be insufficient personnel to handle the sensitive tasks of caring for the dead. Federal, State, and local governments may request DOD assistance in a mass fatality incident that does not involve mass military fatalities.
• Mortuary affairs facilities include collection points, military mortuaries, and interment sites, and can provide the following support:
Collection, inventory, storage, and processing of personal effects of deceased and missing personnel.
Operation of permanent port-of-entry mortuary facilities in the continental U.S.
Preparation and coordination of shipment of remains for final disposition.
Response to mass-fatality incidents.
DOD maintains the capability to provide technical assistance to civilian agencies. This technical assistance will be provided when requested by the appropriate civil authority.
DOD has the capability to establish and operate a Mortuary Affairs Decontamination Collection Point (MADCP). The handling of contaminated remains at a MADCP is a three-phased process, as follows:
Recovery from the place of death to a MADCP, where decontamination and field verification occur.
Movement to a Quality Control Station, where a second verification check is made using specialized monitoring equipment.
Positive verification of decontamination is made prior to shipment of remains to a mortuary. Handling or working around decomposing remains requires strict enforcement of health and sanitation procedures. The potential for infection and the spread of contagious disease within such an environment is high; therefore, personnel should always be conscious of sanitation hazards, and keep themselves and their work areas clean. DOD Mortuary Affairs units can assist civil authorities with proper control point set-up.
DOD Support to Civil Authorities (DSCA) in Arizona
The State of Arizona recognizes that DOD support will be limited due to the pandemic influenza reducing their overall readiness. Six areas where DSCA support to Arizona would be helpful in the event of an influenza pandemic are: human remains Search and Recovery (S&R), providing assistance to the Funeral Directors/Homes, Temporary Interment, Personal Effects Depot setup, Mortuary Affairs Control Point, and Additional Supplies and Equipment. In most cases, personnel to supervise a task or lead a team will be needed..
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• S&R -The state has limited assets for S&R and very limited personnel trained in this field. DOD assets would be valuable in S&R of human remains, such as entering private dwellings, if no one is home, and there are suspected human remains. S&R teams would be accompanied by law enforcement if entering private residences or businesses to recover remains.
• Funeral Directors/Homes -Funeral Directors and their assistants are critical in managing human remains. If funeral directors cannot keep up with the increased human remains load, then storage problems will quickly arise. DOD Mortuary Affairs personnel, namely the MOS 92M, will be essential assets in lending assistance to funeral homes. The Mortuary Affairs personnel spend time at the Armed Forces Mortuary at Dover AFB and are familiar with human remains preparation. Their training in human remains handling will enable the 92M career personnel to assist with an orientation and possibly some of the training at the Funeral Home
• Temporary Interment -
oTemporary interment is a way of storing remains until final disposition can be arranged. Arizona Funeral Directors and Medical Examiners are not familiar with this form of graves registration. DSCA support will be invaluable to Arizona in assisting the Medical Examiners with this task. oDOD under Joint Publication 4-06, Joint Mortuary Affairs Operations have the forms and the plan for temporary interment. Someone familiar with procedures to assist the Medical Examiners on this process will be requested. oDOD Chaplains are familiar with different religious customs and would be a tremendous asset assisting with the temporary disposition of human remains.
• Personal Effects (PE) Depot Setup -DOD has set up a PE Depot many times and is currently using a Personal Effects Depot at Dover AFB for returning service member remains. DOD assistance may be requested in setting up a PE Depot. The PE depot should be located as close to the MACP as possible.
• Mortuary Affairs Control Point -Because of the DOD expertise in this area, they may be requested to assist by providing a person to help the State in setting up a MACP.
• Additional Supplies and Equipment - Items that are depleted quickly are human remains pouches, caskets, embalming chemicals, and other mortuary affairs items. The Defense Logistics Command may be requested to support the State of Arizona with supplies.
1.5 MANAGEMENT OF MASS FATALITIES, REQUIREMENTS, LIMITING FACTORS, AND POSSIBLE SOLUTIONS.
In order to identify planning needs for the management of mass fatalities during a pandemic, it is important to examine each step in the management of human remains under normal circumstances and then to identify what the limiting factors will be when the number of dead increases over a short period of time. The following table identifies the usual steps. Possible solutions or planning requirements are discussed in further detail in the sections that follow this table.
This document is intended to provide guidance for coordination in the State of Arizona of response to mass fatalities as the result of an influenza pandemic.
1.7 DIRECTION ANDCONTROL
Incident Command- ADHS will use the Incident Command System (ICS) as outlined in the National Incident Management System (NIMS) and directed by the National Response Plan (NRP) to work with other agencies and organizations in a coordinated manner based on the size and scope of the public health emergency. Emergency Management- ADHS will coordinate with the State Emergency Operations Center (SEOC) and local jurisdiction EOCs.
2.0 SITUATION
Most public health and healthcare agencies have limited experience dealing with mass fatalities and likewise most Medical Examiners normally do not have experience with mass fatality events. Communities in Arizona are unaware of what is necessary in planning for the large numbers of fatalities generated during a pandemic. Two pandemic waves of six weeks each, using a five percent crude annual, all cause death rates (similar to the influenza pandemic of 1918), and will produce about 10,000 deaths per week per wave in Arizona. This is more than 10 times the usual rate of about 900 non pandemic influenza deaths per week in the State of Arizona. This mortality rate will overwhelm the local mortuary affairs system in one or two weeks, especially if the counties have not prepared for the event.
Every community must develop a system of response to deal with mass fatality management at the local level. The State normally draws from resources within the state, however, during a pandemic all counties within the state will be affected and will be unable to assist other areas. Similar to the State, the Federal Government draws on resources from other states to assist a state during a time of crisis. The influenza pandemic will affect all states at the same time and any Federal help will be extremely limited. The Department of Defense will also be stricken and most likely will not be able to provide much relief.
It is a matter of national security that local jurisdictions develop realistic plans to handle the increased number of fatalities brought on by a pandemic. The local plans should have several objectives:
• First and foremost: protect the lives and health of the MAS personnel.
• Handle the dead with dignity and respect.
• Place a high priority on burying the dead.
• Place a priority on abiding by religious and cultural requirements to the maximum extent that the situation allows.
• Develop plans that include exact requirements for a paper trail of each body, to include:
Vital Records forms
Personnel effects logging forms
Temporary interment logging forms with Global Positioning System (GPS) coordinates.
DNA specimens and data if available
• Only as a last resort, plan for temporary interment of remains until they can be properly buried: oInvolve religious and cultural leaders in planning for temporary interment oAvoid the terminology of “mass grave” or “mass temporary grave”.
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Develop procedures and locations for temporary interment sites. Note: some family members may want to keep the body buried in the temporary interment site; choose a location that can be turned into a memorial if required.
In order to develop guidelines or adjust existing plans for a pandemic situation county pandemic planners should ensure that the following persons are involved in mass fatality planning as a minimum:
• The Office of the Chief Medical Examiner (OCME)
• The Chief Medical Officer
• Local and County Health Department
• The Department of Emergency Management
• Vital Records
• Public Information Officers (responsible to the Joint Information Center (JIC)).
• Local funeral directors
• Local cemetery directors
• Representatives from local health care facilities, to include clinics
• Representatives of local faith-based and ethnic groups.
• Representatives of local shelters for the homeless
• Representatives from corrections facilities
• Representatives of local law enforcement
• Other first responders or agencies as necessary
If the medical community is receiving prophylaxis and/or vaccinations, then MAS personnel should be included along with other first responders as a priority group since they will be having direct contact with bodies and bodily fluids. At this point the body fluids would be considered blood-borne pathogens and appropriate personal protection equipment must be utilized. If possible, provide prophylaxis to the MAS community workers or they may not respond when needed and for those that do, they may become ill and add to the number of incapacitated or deceased.
Existing disaster plans may include provisions for mass fatalities but should be reviewed and tested regularly to determine if these plans are appropriate for the relatively long period of increased demand which is characteristic of a pandemic, as compared to the shorter response period required for most disaster plans. There are currently no national plans to recommend mass graves or mass cremations. This would only be considered under the most extreme circumstances. The use of the term mass grave infers that the remains will never be re-interred or identified. Therefore, the term mass grave should never be used when describing temporary interment.
It is anticipated that most fatal influenza cases will seek medical services prior to death. However,whether or not people choose to seek medical services will partly depend on the lethality and the speed at which the pandemic flu strain kills. Under normal conditions,the majority of deaths (65.2 percent) occur in the place of residence, including nursing homes and other long-term care facilities (of the 42,736 deaths in 2004, only 34.8 percent occurred in hospitals). Hospitals, nursing homes and other institutions (including non-traditional sites) must plan for more rapid processing of human remains. These institutions should work with county pandemic planners and the OCME to ensure that they have access to the additional supplies (e.g., human remains pouches) and can expedite the steps, including the completion of required documents, necessary for efficient human remains management during a pandemic.
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In order to manage the increase in fatalities, some counties will find it necessary to establish temporary morgues. Plans should be based on the capacity of existing facilities compared to the projected demand for each municipality. Local planners should make note of all available facilities including those owned by religious organizations. Access to these resources should be discussed with these groups as part of the planning process during the inter-pandemic period. In the event that local funeral directors are unable to handle the increased numbers of corpses and funerals, it will be the responsibility of county OCME to make appropriate arrangements. Individual counties should work with local funeral directors to plan for alternative arrangements. Planning should also include a review of death documentation requirements and regulatory requirements that may affect the timely management of corpses.
Identification parameters will have to be established. In some cases, the existing parameters may be relaxed, a decision that will have to be made by the OCME with legal jurisdiction. Provisions should be made to allow the OCME to appoint additional medical examiner assistants to help with the added workload. Funeral homes will be overwhelmed, probably within the first two weeks, if not sooner. Very quickly there may be a shortage of human remains pouches, personnel and vehicles to handle the dead and Funeral homes will run out of supplies. For example, there will be a shortage of;
• Caskets, Urns and Vaults.
• Embalming supplies and equipment.
• Headstones, or other grave markers.
• Cremation is a slow process and a backlog of remains awaiting cremation will likely require temporary storage until they can be cremated.
3.1 CONCEPT OF OPERATIONS
The following flow chart, Chart 1. Fatality Management Flow Chart, shows the two paths of identification all the way to final disposition. Foreign, undocumented nationals, and homeless individuals will require a much greater effort and a longer time to identify and may be put into temporary interment awaiting identification at a later date. Medical Examiners may have to develop a method of separating those that will pose significant identification problems. These remains may have to be put into temporary storage awaiting identification. The fact that some remains will never be identified must be planned for.
Consideration for handling remains other than death due to pandemic influenza must be taken into account. There will still be other diseases, traffic accidents and natural cause deaths. During the 1918 influenza pandemic only 25% of the deaths were reported as influenza. This is suspected to be a low percentage as in many cases influenza may have brought on the death of a person who was ill due to another disease or injury. There may be an increase in suicides and euthanasia by family members as well.
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Chart 1. Fatality Management Flow Chart
3.2. AUTOPSIES
Many deaths in an influenza pandemic would not require autopsies since autopsies are not indicated for the confirmation of influenza as the cause of death. However, for the purpose of public health surveillance (e.g., confirmation of the first cases at the start of the pandemic), respiratory tract specimens or lung tissue for culture or direct antigen testing could be collected post-mortem. Serological testing is not optimal but could be performed if 8-10 ml of blood can be collected from a subclavian puncture post-mortem. Permission will be required from next-of-kin for this purpose.
Any changes to regular practices pertaining to the management of corpses and autopsy requirements during pandemic situations would require the authorization of the OCME. If a physician requires that an autopsy be performed, normal protocols will be followedincluding permission from the next-of-kin. In cases where the death is reportable to the OCME, the usual protocols will prevail as outlined in Arizona Law.
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Autopsy Risks -Biosafety is critical for autopsy personnel who might handle human remains contaminated with a pandemic influenza virus. Infections can be transmitted during autopsies by percutaneous inoculation (i.e., injury), splashes to unprotected mucosa, and inhalation of infectious aerosols. As with any contact involving broken skin or body fluids when caring for live patients, certain precautions must be applied to all contact with human remains, regardless of known or suspected infectivity. Even if a pathogen of concern has been ruled out, other unsuspected agents might be present. Thus, all human autopsies must be performed in an appropriate autopsy room with adequate air exchange by personnel wearing appropriate personal protective equipment (PPE). All autopsy facilities should have written biosafety policies and procedures; autopsy personnel should receive training in these policies and procedures, and the annual occurrence of training should be documented.
Standard Precautions are the combination of PPE and procedures used to reduce transmission of all pathogens from moist body substances to personnel or patients. These precautions are driven by the nature of an interaction (e.g., possibility of splashing or potential of soiling garments) rather than the nature of a pathogen. In addition, transmission-based precautions are applied for known or suspected pathogens. Precautions include the following:
• airborne precautions --- used for pathogens that remain suspended in the air in the form of droplet nuclei that can transmit infection if inhaled;
• droplet precautions --- used for pathogens that are transmitted by large droplets traveling 3-6 feet (e.g., from sneezes or coughs) and are no longer transmitted after they fall to the ground; and
• contact precautions --- used for pathogens that might be transmitted by contamination of environmental surfaces and equipment.
All autopsies involve exposure to blood, a risk of being splashed or splattered, and a risk of percutaneous injury. The propensity of postmortem procedures to cause gross soiling of the immediate environment also requires use of effective containment strategies. All autopsies generate aerosols. Furthermore, postmortem procedures that require using devices (e.g., oscillating saws) that generate fine aerosols can create airborne particles that contain infectious pathogens not normally transmitted by the airborne route.
Personal Protection Equipment -For autopsies, Standard Precautions can be summarized as using a surgical scrub suit, surgical cap, impervious gown or apron with full sleeve coverage, a form of eye protection (e.g., goggles or face shield), shoe covers, and double surgical gloves with an interposed layer of cut-proof synthetic mesh. Surgical masks protect the nose and mouth from splashes of body fluids (i.e., droplets >5 µm); they do not provide protection from airborne pathogens. Because of the fine aerosols generated at autopsy, autopsy workers should wear N95 respirators, at a minimum, for all autopsies regardless of suspected or known pathogens. However, because of the efficient generation of high concentration aerosols by mechanical devices in the autopsy setting, powered air-purifying respirators (PAPRs) equipped with N-95 or P100 high-efficiency particulate air (HEPA) filters should be considered. Autopsy personnel who cannot wear N-95 respirators because of facial hair or other fit limitations should wear PAPRs.
Waste Handling - Liquid waste (e.g., body fluids) can be flushed or washed down ordinary sanitary drains without special procedures. Pretreatment of liquid waste is not required and might damage sewage treatment systems. If substantial volumes are expected, the local wastewater treatment personnel should be consulted in advance. Solid waste should be appropriately contained in biohazard or sharps containers and incinerated in a medical waste incinerator.
3.2. PREPARATIONS FORFUNERALHOMES ANDCREMATORIA
In an influenza pandemic, each individual funeral home could expect to have to handle about six months work within a 6- 8-week period. This may not be a problem in some communities, but funeral homes in larger cities may not be able to manage the increased demand. Individual funeral homes should be encouraged to make specific plans during the inter-pandemic period regarding the need for additional human resources during a pandemic situation. For example, volunteers from local service clubs or churches or even contractors with heavy equipment may be able to take on tasks such as digging graves, under the direction of current staff. Crematoriums will also need to look at the surge capacity within their facilities. Most crematoriums can handle about one body every four hours and could probably run 24 hours to manage the increased demand. Cremations have fewer resource requirements than burials and, where acceptable, this may be an expedient and efficient way of managing large numbers of corpses during a pandemic. However, cultural and religious requirements may prohibit cremation.
3.3. PLANNING FORTEMPORARYMORGUES
Additional temporary cold storage facilities may be required during a pandemic for the storage of corpses prior to their transfer to funeral homes. Temporary morgues require temperature and biohazard control, adequate water, lighting, rest facilities for staff, viewing areas and should be in communication with patient tracking sites and the emergency operations center. A temporary morgue must be maintained at 38 – 44o F (3-7o C). However, corpses will begin to decompose in a few days when stored at this temperature. If the body is not going to be cremated, plans to expedite the embalming process should be developed since, in the case of a pandemic, bodies may have to be stored for an extended period of time. In counties where a timely burial is not possible due to frozen ground or lack of facilities, corpses may need to be stored for the duration of the pandemic wave (6 to 8 weeks).
Each county should make pre-arrangements for temporary morgues based on local availability and requirements. The resource needs (e.g. human remains pouches) and supply management for temporary morgues should also be addressed. The types of temporary cold storage to be considered may include refrigerated trucks, cold storage lockers, or refrigerated warehouses. Refrigerated trucks can generally hold 25-30 bodies without additional shelving. To increase storage capacity, temporary wooden shelves can be constructed of sufficient strength to hold the bodies. Shelves should be constructed in such a way that allows for safe movement and removal of bodies (i.e., storage of bodies above waist height is not recommended).
To reduce any liability for business losses, using trucks with markings of a supermarket chain or other companies should be avoided, as the use of such trucks for the storage of corpses may result in negative implications for business. If trucks with markings are used, the markings should be painted or covered over to avoid negative publicity for the business. (See Appendix 3,Arizona Department of Health Services Standard Operating Procedures for Decontamination of Aluminum Floor Refrigerated Trailers for truck cleaning and decontamination.)
Using local businesses for the storage of human remains is not recommended and should only be considered as a last resort. The post-pandemic implications of storing human remains at these sites can be very serious, and may result in negative impacts on businesses with ensuing liabilities.
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There should be no media permitted on the temporary morgue site. The OCME approves requests for entry to the site. If necessary, the OCME should coordinate with local flight control or the Federal Aviation Administration to establish a “NO FLY ZONE” for non-essential aircraft.
3.4.DEATHREGISTRATION(VITAL RECORDS)
Death registration is a state/county responsibility and each county may have its own laws, regulations, and administrative practices to register a death. Moreover, there is a legal distinction between the practices of pronouncing a death andcertifying a death.
In the pandemic situation, with the increased number of deaths, each county must have a body collection plan in place to ensure that there is no unnecessary delay in moving a body to the (temporary) morgue. If the person’s death does not meet any of the criteria for needing to be reported to the OCME, then the person could be moved to a holding area soon after being pronounced dead. Then, presumably on a daily basis, a physician or someone with legal jurisdiction from OCME could be designated to complete the death certificate.
Funeral directors generally have standing administrative policies that prohibit them from collecting a body from the community or an institution until there is a completed Certificate of Death. In the event of a pandemic with many bodies, it seems likely that funeral directors could develop a more flexible practice if directed to do so by a central authority such as the OCME, the Arizona Attorney General, or possibly the Registrar of Vital Statistics. These special arrangements must be planned in advance of the pandemic and should include consideration of the regional differences in resources, geography, and population.
3.5. INFECTION CONTROL
The Infection Control and Occupational Health Guidelines in the Arizona Influenza Pandemic Response Plan, Supplements 4 and 5, provide general recommendations on infection control for health care facilities and non-traditional sites during a pandemic. azdhs.gov Special infection control measures are not required for the handling of persons who died from influenza, other than the Centers for Disease Control and Prevention (CDC) Standard Precautions. Funeral homes should use the standard precautions when handling deaths from influenza.
Visitations could be a concern in terms of influenza transmission amongst funeral attendees. It is the responsibility of Public Health to place restrictions on the type and size of public gatherings if this seems necessary to reduce the spread of disease. This may apply to funerals and religious services. Local Public Health should plan in advance for how such restrictions would be enacted, and enforced, and for consistency and equitability of the application of any measures.
3.6. HUMAN REMAINS RECOVERY
The search for, and recovery of, human remains is the first step in the care and handling of deceased personnel. This is the systematic process of searching for human remains and PE, plotting and recording their location, and moving them to an MA facility.
Performing a search and recovery (S&R) mission requires the preservation of forensic evidence to support the requirements of the OCME and law enforcement. During recovery of human remains from a private residence, business, or vehicle, it is vital to coordinate with the on-scene commander and the OCME. Unless so dictated by the State Attorney General’s Office, local law enforcement shall be present with the S&R team. This will also help to ensure that information of any potentially hazardous conditions that still exist will be relayed to the S&R team.
Once an S&R team is tasked to conduct an S&R operation, it is essential that the planning phase begin immediately. The designated team leader should gather as much information, utilizing all available sources to determine:
• Suspected number of human remains to be recovered.
• Location of S&R area.
• Number of S&R team personnel.
• Personnel with specialized skills.
• Amount and type of supplies.
• Transportation assets.
• Route to the recovery site.
• Type of terrain, roads, and buildings to be encountered en route and at recovery site.
• Special equipment required.
• Hazards and risks that may be encountered.
• Communication requirements.
• Location of nearest MAS facility.
• Weather considerations.
• Security of the search area.
Once human remains, portions, and disassociated effects have been tagged and placed in HRPs, the human remains should be evacuated to the evacuation point. Human remains should always be:
• Carried feet first (patients are carried head first)
• Treated with dignity, reverence, and respect.
• Loaded head first onto fixed-wing aircraft.
• Loaded feet first onto vehicles or rotary-wing aircraft.
• Escorted to the most convenient MA facility.
During recovery operations, the team leader should keep a detailed record of every aspect of the recovery operation in a field notebook. The last page in the notebook should include the team leader’s information, dated, and signed. This notebook should be forwarded with the human remains to the MAS facility. If possible, photographs of the recovery site should be made using negative-based film. Close-ups and overall views of each item should be taken. A description and number of each photograph taken should be recorded in the field notebook. Each roll of film should be numbered and every roll forwarded with the human remains to the OCME (Note:It is important to safeguard this photographic evidence and ensure that no unauthorized photographs are taken.)
3.7. TRANSPORTATION
No special vehicle or driver’s license is needed for the transportation of a corpse. Therefore, there are no restrictions on families transporting bodies of family membersif they have a death certificate. Transportation of bodies from their place of death to their place of burial in Northern Arizona and isolated communities may become an issue. Local pandemic planners should consult existing plans for these communities and determine what changes can be made to meet the increased demand during a pandemic. If vehicles are to be used for collecting remains, certain guidelines should be observed:
• The vehicle shall have all markings removed if it is normally used for commercial business.
• The vehicle shall be covered so the public cannot see into the bed of the vehicle.
• Bodies shall not be stacked in the vehicle under any circumstances.
• The vehicle should be refrigerated. Air conditioning will not suffice unless there are no refrigerated trucks available. If there are no refrigerated trucks available, then in hot areas, human remains should only be moved in a covered truck at night. The truck should be opened up during the day to allow it to cool as fast as the air cools at night.
• Loading and unloading of the vehicle shall be accomplished discretely. Tarps or other ways of blocking the view may be used. The top must also be covered to prevent observance from the air.
The interior area used to store bodies should have a double plastic lining. After use, or if the plastic lining is grossly contaminated and must be changed out, disposal should be in accordance with the Occupational Safety and Health Administration’s Bloodborne Pathogens Standard (29 CFR 1910.1030). Shelving should not be wood, or materials in which bodily fluids may be absorbed. Metal or plastic shelving that may be cleaned off is acceptable. A method of securing the body within the shelf should be required.
Persons coordinating transportation should set up a schedule with hospitals for transfer of remains to a temporary morgue or temporary interment site. Schedules should be arranged and operate on a 24 hour basis. State and Federal Department of Transportation (DOT) Requirements must be satisfied for the transportation of human remains. Death certificates will most likely be required. Transportation across state lines will require approval of receiving state(s). Transportation across international lines (Canada and Mexico) may require State Department approval and the receiving nation’s approval.
Remember that other organizations will be requesting refrigerated trucks, so the vehicles may not be available when needed. Also, companies that have refrigerated trucks use them to haul critical infrastructure food and other supplies. These companies have very little or no reserve truck fleet. Using refrigerated trucks to keep the infrastructure running takes priority over the movement of human remains.
Ambulances shall not be used to carry human remains.
Quarantine measures may affect the movement of human remains. For example, can remains move into, through, or out of a quarantined area? If movement is prohibited, then temporary storage must be developed. While quarantine is designed to protect public health, plans must still be made for removing the dead.
3.8. SUPPLY MANAGEMENT
Counties should recommend to funeral directors that they not order excessive amounts of supplies such as embalming fluids, human remains pouches, etc., but that they have enough on hand in a rotating inventory to handle the first wave of the pandemic (that is enough for six months of normal operation). Fluids can be stored for years, but human remains pouches and other supplies may have a limited shelf life. Cremations generally require fewer supplies since embalming is not required.
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Families having multiple deaths are unlikely to be able to afford multiple higher-end products or arrangements. Funeral homes could quickly exhaust lower-cost items (e.g. inexpensive caskets) and should be prepared to provide alternatives. The OCME should be notified for approval if alternates are used (e.g. instead of approved caskets).
3.9. SOCIAL/RELIGIOUS CONSIDERATIONS
It is extremely important to follow religious and cultural practices as much as possible during a pandemic mass fatality event. Failure to do so could have far reaching social, legal, and political after effects.
Most faith-based and ethnic groups have very specific directives about how bodies are managed after death, and such needs must be considered as a part of pandemic planning. Christians, Indian Nations, Jews, Hindus, and Muslims, all have specific directives for the treatment of bodies and for funerals. The wishes of the family will provide guidance; however, if no family is available, local religious, or ethnic communities can be contacted for information. Counties should contact the religious and cultural leaders in the pandemic planning stages and develop plans.
Counties should document what is culturally and religiously acceptable, what can be compromised, and what practices are strictly forbidden.
As a result of these special requirements, some faith-based groups maintain facilities such as small morgues, crematoria, and other facilities which are generally operated by volunteers.
Faith-based groups should be contacted to ensure these facilities and volunteers are prepared to deal with pandemic issues. Religious leaders should also be involved in planning for funeral management, bereavement counseling, and communications, particularly in ethnic communities with large numbers of people who do not speak English or Spanish.
3.10. ROLE OF THE ARIZONA FUNERAL DIRECTORS ASSOCIATION (AFDA)
It is recommended that all funeral directors contact their OCME and County Health Departments to become involved in their disaster and pandemic planning activities with respect to the management of mass fatalities at the local level. Funeral directors should consider it a part of their professional standards to make contingency plans if they were incapacitated or overwhelmed.
The National Funeral Directors Association recommends that members begin thinking about state and local responses to the possible outbreak of an avian flu pandemic. Specifically, members are urged to:
• Protect yourself. Ensure that you and your staff are up to date with vaccinations against influenza, hepatitis, pneumonia and other infectious diseases.
• Consider how you can prepare for as many as two to three times the normal number of deaths over a six-month period. Do you have adequate supplies on hand or can you assure that they will be readily available if needed?
• Make contact with local medical examiners or coroners to discuss the possibility of a pandemic and how you will respond locally.
3.11. STORAGE AND DISPOSITION OF HUMANREMAINS
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Bodies can be transported and stored (refrigerated) in impermeable bags (double-bagging is preferable), after wiping visible soiling on outer bag surfaces with 0.5% hypochlorite solution. Storage areas should be negatively pressured with 9-12 air exchanges/hour.
OCME should work with local emergency management agencies, funeral directors, and the state and local health departments to determine in advance the local capacity (bodies per day) of existing crematoriums and soil and water table characteristics that might affect interment. For planning purposes, a thorough cremation produces approximately 3-6 pounds of ash and fragments. OCME should also work with local emergency management agencies to identify sources and costs of special equipment e.g. air curtain incinerators, which are capable of high-volume cremation, and the newer plasma incinerators, which are faster and more efficient than previous incineration methods. The costs of such equipment and the time required to obtain them on request should be included in county preparedness plans.
3.12. MORTUARY AFFAIRS COLLECTION POINT
The Mortuary Affairs Collection Point (MACP) is a centralized location with cold storage available where recovery people or families can bring the deceased. The workers should receive training on human remains handling prior to working at the MACP and should be supervised by either people from the OCME or by funeral home workers. Handling the remains with dignity and respect is paramount. The MACP should be the local focal point for human remains recovery and collection prior to being sent to a morgue. Equipment should be available for local agencies to communicate with one another, especially hospitals and other locations that will be handling human remains. Dispatch service for hospitals and other locations should be available on a 24/7basis to pick up remains when hospital morgues become overloaded. Security at the MACP should include physical security and methods to keep long-range photography from photographing remains handling procedures. Civil unrest may interfere with mortuary affairs operations. If security protection for MACP and recovery teams is not available, then teams should not go on recovery missions.
3.13. PERSONAL EFFECTS DEPOT
The high numbers of dead will require extensive control and cataloging of personal effects (PE). The PE depot should be co-located or close to the MACP. The primary mission of the PE depot is to receive, safeguard, inventory, store, process, and make final disposition of PE for the deceased. In addition, the PE depot must work closely with the OCME of jurisdiction to determine the eligible recipient. Disposition of PE includes the collection, receipt, recording, accountability, storage, and disposal of the PE of all deceased persons for whom the county is providing mortuary affairs services. The handling of PE begins at the time of initial collection by representatives of the recovery team and extends to the time of receipt by the persons entitled to receive the PE.
All PE should be inventoried and, upon completion of the inventory; the PE shall be placed in a secure room. High dollar value items and money should be placed in a safe with the appropriate labeling to link the PE to the body. Other PE items should also be packaged and labeled to associate the PE with the body.
3.14. TEMPORARY INTERMENT(see Annex 4 to this plan for procedures)
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Temporary interments are a last resort used for health, safety, sanitation, and morale reasons. The Director of the Arizona Department of Health Services and the Governor should be involved in the decision-making process to create temporary interment sites.
Clergy and/or cultural leaders’ support should be used to conduct committal services at temporary interment sites. There should be a permanent record made of administration of the final religious rites. Personnel performing mortuary affairs duties at temporary interment sites should be aware of customs followed by various ethnic and religious groups in their location. Many cultures have various customs for care of the dead that should be followed. If the customs cannot be followed then guidance from the clergy or cultural leaders should be obtained. Temporary Interment Site Selection should be done by the county Emergency Management/Planning/Zoning under the direction of the OCME. When temporary interment is necessary, the burial site should be on high ground with good drainage.
4.0 ORGANIZATIONAL ROLES AND RESPONSIBILITIES
The following table identifies roles and responsibilities of different agencies within the pre-pandemic, pandemic and post-pandemic period. The list is not all inclusive and is subject to change, based on the future planning considerations. The Planning Guide for Funeral Homes and Crematorium Services in Appendix 1 provides further planning considerations for the sector.
Table 2. Roles and responsibilities of some agencies involved with pandemic mass fatality planning and execution.
Governor’s Office:
• May declare an establishment of temporary internment sites.
• May order the closing of temporary interment sites and relocation of human remains to cemeteries.
• May authorize the appointment of Emergency Medical Examiner Assistants by the county OCME..
Arizona Department of Health Services PHIMS Command Staff and Section Chiefs:
• Meet daily or as needed to discuss situation.
• May request the establishment of temporary interment sites for public health and welfare.
• Determine mortuary affairs policy recommendations as they pertain to public health and coordinate with OCME.
Infectious Disease Epidemiology Section (IDES)/or Surveillance Group (depending on PHIMS activation):
• Provide information to key organizations regarding pandemic influenza. oWrite an article for the Arizona Funeral Director’s Association, etc. for distribution to their licensees and members via newsletters, websites, etc.
• Coordinate needs assessment of current morgue capacity across Arizona. oMorgue capacity at healthcare facilities.
Ask Arizona Hospital Association to conduct survey of morgue capacity at hospitals. Ask Division of Public Health Services to conduct a survey of other healthcare facilities. Assessing morgue capacity in non-healthcare facilities to be performed by OCME. OCME assessment of current capacity in county morgues. Surge capacity using refrigerated warehouses, trucks, and other storage methods.
Office of Vital Records:
In Arizona death registration is a process governed by it’s own set of laws, regulations, and administrative practices to register a death. Moreover, there is a legal distinction between the practices of pronouncing and certifying a death.
Funeral directors generally have standing administrative policies that prohibit them from collecting a body from the community or an institution until there is a completed certificate of death. In the event of a pandemic with many bodies, it seems likely that funeral directors could develop a more flexible practice if directed to do so by a central authority such as the Arizona Funeral Director’s Association, the Arizona Attorney General’s Office, or possibly the Registrar of Vital Statistics. These special arrangements must be planned in advance of the pandemic and should include consideration of the regional differences in resources, geography, and population. The Board of Medicine should support this effort by educating their members of the responsibility to complete the death certificate for their patients.
• Establish a voluntary “acute death reporting system” with sentinel county registrars. oReport number of influenza and pneumonia deaths as a proportion of the total number of deaths by week. oThis system would be activated during Pandemic Phase 6 with cases within the United States.
• Mandatory pediatric influenza death reporting.
• Set up a program for establishing the reporting and tracking of human remains deposited in a temporary interment site.
• Oversee the personal effects depot record and tracking operation.
Public Information Office (PIO) or the Communications Group (depending on PHIMS activation):
• Create press releases for the media concerning mortuary affairs system goals and the implementation of temporary interment sites.
• Conduct press conferences, as appropriate, to explain the need for mass fatality procedures, delay of death certificates, funerals, and MA processes/procedures.
• Assist County PIOs and ODME to prepare to work with the media
Bureau of Emergency Preparedness and Response (BEPR):
ADHS may be providing some assistance to the County Office of Chief Medical Examiner (OCME) under ESF#8 as outlined below.
• Utilize the Health Alert Network (HAN) to communicate with county health officials, OCME, hospitals, physicians, laboratory directors, community health centers, childcare centers, schools, and the media.
• Monitor the mass fatality situation to insure that a public health hazard does not exist with body storage awaiting final disposition. If it is determined that there is a public health hazard and there are too many human remains the Director of ADHS will advise the Governor. If the situation warrants, and the County OCME agrees, then jointly ADHS and the County will advise the Governor that Temporary Interment is necessary to protect public health.
• Develop public guidance and materials for public release on how the Mortuary Affairs system is handling mass fatality and where the Mortuary Affairs Collection Centers are located. Any guidance should be coordinated with the OCME with legal jurisdiction over the human remains prior to release. Keeping the public informed is extremely important if temporary interment has been taken as a necessary precaution to ensure public health.
• Develop public health guidelines to inform the public on how to handle dead family members and what precautions must be taken.
State Board of Funeral Directors and Embalmers:
• Oversee and assist in the management of increased deaths and burial activities.
4.2 LOCAL GOVERNMENT
County Health Departments:
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• Implement, isolate, and quarantine as needed and coordinate requirements for the movement of human remains inside and outside of the quarantine area.
Metropolitan Medical Response System (MMRS):
• Administer vaccine to funeral directors, funeral home workers, and MA system personnel, to include search and recovery personnel.
• Assist in providing PPE to funeral directors, funeral home workers, and MA system personnel, to include search and recovery personnel.
Office of the Chief Medical Examiner (OCME):
THE MEDICAL EXAMINER, WITH LEGAL JURISDICTION, COMMANDS AND IS
ACCOUNTABLE FOR ALL ASPECTS OF THE MORTUARY AFFAIRS SYSTEM AND ITS RESPONSE WITHIN THE COUNTY OF OCME JURISDICTION.
As the pandemic develops and becomes established within the State, the OCME takes jurisdiction over the following deaths:
• Cases in which there is no attending physician, (e.g. the decedent had no physician or medical treatment facility which treated them or the decedent’s physician is licensed out of state)
• The identity of the decedent is unknown and the normal investigative procedures completed by hospital, social services, police or law enforcement agencies, including fingerprinting, have not positively identified the deceased.
• Coordinating confirmation of identity with local police departments.
• The death is sudden and unexplained (e.g. does not meet the normal case definition).
• Death of an inmate or person in correctional custody.
• Assisting the interest of the State, when an individual who was sequestered into a private residence or public facility through the Isolation or Quarantine procedures and dies outside of a medical treatment facility. (This does not apply if an entire community is impacted by the public health order.)
• Normal Medical Examiner cases as defined by Arizona Code.
Additionally, the OCME may be tasked to:
• Collaborate with the County Department of Public Health Services to determine which, if any, cases will be considered medical examiner cases. OCME may be required to perform autopsies early in the pandemic to establish the presence of pandemic influenza in Arizona.
• Provide subject matter expertise on planning for and handling a mass fatality situation to key partners. OCME has a Mass Fatality Incident Plan in place which could be used to guide healthcare facilities in their planning and response.
• The appointment of Emergency Medical Examiner Assistants should be limited to the time of the Public Health Emergency and should be terminated when the Public Health Emergency Declaration is rescinded.
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• The Medical Examiner may waive licensing requirements, permits and/or fees required by the State Code, applicable rules, and regulations for the performance of the duties of the Emergency Medical Examiner Assistant.
• The Emergency Medical Examiner Assistant, appointed and acting in the scope of their prescribed duties should be immune from civil liability suits in the performance of such duties.
• OCME may experience a backlog of DNA identification early on in the pandemic.
• OCME will NOT be responsible for contracts that may be let for companies engaging in:
Casket manufacturing.
Grave digging.
Funeral Home expansion.
Recovery of Human Remains.
Mortuary Affairs Service Organizations.
Security.
Tracking remains out of their jurisdiction and legal authority.
• Oversee all aspects of temporary interment, reinterment, and final disposition of human remains following a pandemic.
State/ Federal Corrections Institutions:
While the State Corrections Institutions are a state asset managed and funded through the State of Arizona, they must comply with local jurisdictions when it comes to management of fatalities. As a minimum, State Corrections Institutions must:
• Develop a MAS plan, have it reviewed, and coordinated with the OCME and County of jurisdiction.
• Prepare for holding inmate remains for extended periods until they can be picked up by the MAS.
• Train employees how to handle remains and bloodborne pathogen and/or infection control precautions as required (will be released by ADHS if different from listed below).
Standard Precautions
Contact Precautions
• Find a cold storage location for remains (remember that many agencies are planning on using refrigerated trucks so they may not be available for your facility).
4.3 OTHER ORGANIZATIONS INVOLVED WITH THE MAS
Hospitals and Clinics:
• Prepare for holding patient remains for extended periods until they can be picked up by the MAS.
• Train employees how to handle remains and bloodborne pathogen and/or infection control precautions as required (will be released by ADHS if different from listed below).
Standard Precautions
Contact Precautions
• Find a cold storage location for remains (remember that many agencies are planning on using refrigerated trucks so they may not be available for your facility).
Shelters:
• Prepare for holding remains for extended periods until they can be picked up by the MAS.
• Partner with a Funeral Home or the OFME to assist in planning for remains removal.
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• Train employees how to handle remains and bloodborne pathogen and/or infection control precautions as required (will be released by ADHS if different from listed below).
Standard Precautions
Contact Precautions
• Find a cold storage location for remains (remember that many agencies are planning on using refrigerated trucks so they may not be available for your facility).
Arizona Funeral Directors Association (AFDA).
• Assist the OCME in the coordination of mortuary services.
Transportation, preparation and disposition of deceased persons.
Acquisition of funeral supplies.
Assist clergy support for funerals.
Provide family support.
• Assist in communication with key partners.
oProvide education and updates on pandemic influenza to members of AFDA. oServe as liaison to the National Funeral Directors Association. oServe as liaison to religious and cultural leaders and provide ethnic funeral consultation.
• Serve as a clearinghouse for mortuary concerns.
• Develop alternate forms of funerals if social distancing has been declared by the county health department(s) or statewide by ADHS through the Office of the Governor. The following methods are suggestions and other methods may be also acceptable to the community as alternate forms of funerals: Only immediate family members and communication to other family and friends such as:
Funerals released over the internet on dedicated websites.
Televised funerals.
Video taped funerals.
5. POST-PANDEMIC RECOVERY
After a pandemic wave is over, it can be expected that many people will remain affected in one way or another. Many persons may have lost friends or relatives, will suffer from fatigue and psychological problems, or may have incurred severe financial losses due to interruption of business. The Federal and Arizona State Governments have the natural role to ensure that mass fatality response concerns can be addressed and to support the “rebuilding the society”.
The post-pandemic period begins when the Arizona State Public Health Official declares that the influenza pandemic is over. The primary focus of work at this time is to restore normal services, deactivate pandemic mass fatality response activities, review their impact, and use the lessons learned to guide future planning activities.
• Deactivate MA emergency plans.
• Move remains from the temporary interment location to final resting place in cemeteries.
• Religious ceremonies conducted during reinterment and at the closing of the temporary interment locations.
• Closing, cleanup, and restoration of temporary interment locations.
• Determine when mortuaries and funeral homes can resume normal operations.
• Provide grief counseling to MAS staff and public as needed.
• Re-deploy human and other resources as needed.
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• Finalization of personal effects.
• Process record-keeping for financial purposes.
• Evaluate and revise the mass fatality plans as required.
In addition to the above responsibilities, an overall assessment of the mortuary affairs system, including the burden from human death, and financial costs of the pandemic, ought to be undertaken. This will be coordinated at the state and most likely at the national level.
WITH DIGNETY AND RESPECT, ALWAYS
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6.0 REFERENCES
1. Armed Forces Medical Examiner System, Department of Defense Directive, 6010.16, March 8-1988 and Army Regulation 40–57, AFR 160–99, 2 January 1991.
2. Care and Disposition of Remains and Disposition of Personal Effects, Army Regulation 638-2, 22 January 2002.
3. Deceased Personnel,Care and Disposition of Remains and Disposition of Personal Effects Army Regulation, 638-2 Unclassified) Headquarters Department of the Army Washington, DC, Effective date:
22 January 2001.
4. Deceased Personnel,Care and Disposition of Remains and Disposition of Personal Effects Army Regulation, Pamphlet 638-2 Unclassified) Headquarters Department of the Army Washington, DC, Effective date: 22 January 2001.
5. Doctrine for Logistics Support in Joint Operations, Joint Publication 4-0, 27 January 1995
6. Guidelines for Protecting Mortuary Affairs Personnel from Potentially Infectious Materials, U.S. Army CHPPM TG 195, October 2001.
7. Handling of Deceased Personnel in Theaters of Operation, FM 10-63/AFM 143-3/Navy Medical Manual p5016/navmc 2509-a, 26 February 1986
8.HHS Pandemic Influenza Plan, U.S. Department of Health and Human Services November 2005. The Next Influenza Pandemic: Lessons from Hong Kong, 1997
9. Identification of Deceased Personnel, HQ Department of the Army, Field Manual 10-286, 30 June 1976.
10. Joint Tactics, Techniques, and Procedures for Mortuary Affairs in Joint Operations, Joint Publication 4-06, 28 August 1996.
11. Kurt B. Nolte, M.D, et al, Medical Examiners, Coroners, and Biologic Terrorism, A Guidebook for Surveillance and Case Management, Weekly Morbidity and Mortality report, Centers for disease Control and Prevention, 53(RR08); 1-27June 11, 2004.
12. Mass Fatality Plan, National Association of Medical Examiners (NAME)
13. Military Assistance to Civil Authorities (MACA), DOD Directive 3025.15, February 18, 1997.
14. Military Personnel Casualty Matters, Policies, and Procedures, Department of Defense Instruction Number 1300.18, December 18, 2000.
15. NFDA Participates in Federal Mass Fatality Work Group, Recommendations Offered to NFDA
Members, National Funeral directors Association For Immediate Release NFDA # 44-05, December 14,
2005
29
16. René Snacken, et al. The Next Influenza Pandemic: Lessons from Hong Kong, 1997 , Scientific Institute of Public Health Louis Pasteur, Brussels, Belgium 2004
17. WHO Global Influenza Preparedness Plan The Role Of WHO And Recommendations For National Measures Before And During Pandemics, Department of Communicable Disease Surveillance and Response Global Influenza Programme, The World Health Organization 2005.
6.1 STATE PANDEMIC PLANS USED AS REFERENCES:
• Arizona
• California
• Colorado
• Kansas
• North Carolina
• Main
• Oregon
• Rhode Island
• Virginia
• Washington
• Wisconsin
6.2 INTERNATIONAL PANDEMIC PLANS USED AS REFERENCES:
• Australia
• Canada
• European Union
• Toronto City
• New Zealand
Version 1.3
APPENDIX 3 OF
ARIZONA PANDEMIC INFLUENZA MASS FATALITY RESPONSE PLAN
MORTUARY AFFAIRS PROCEDURES FOR SEARCH AND RECOVERY
1.0. Introduction
The search for, and recovery of, remains is the first step in the care and handling of deceased personnel. It is the systematic process of searching for remains and PE, plotting and recording their location, and moving them to a MAS facility. These actions may be conducted by First Responders as well as MAS personnel. S&R during a pandemic may also include entering private dwellings to remove human remains.
2. Search and Recovery Operations
2.1.To ensure successful mission accomplishment, the Team Leader tasked to conduct the S&R must gather all information available and preserve all forensic data for the mission. The safety of the S&R team members is of the utmost importance and shall not be compromised. 2.2.Search Operations.The success of an S&R mission depends on a well-organized search pattern that fits the particular situation. Additionally, strict discipline during the search must be maintained. This means that all team members must perform their duties and follow the established plan unless the on-the-scene situation dictates otherwise.
Establishment of a base camp may be necessary when there will be a lengthy S&R and the location is distance from the nearest Mortuary Affairs Collection Point .
2.2.1.Planning.Once a team is tasked to conduct a S&R operation, it is essential that the planning phase begin immediately. The designated team leader should gather as much information, utilizing all available sources to determine:
• Number of remains to be recovered.
• Location of recovery site.
• Number of recovery team personnel.
• Personnel with specialized skills.
• Amount of MA supplies.
• Transportation assets.
• Route to the recovery site.
• Type of terrain to be encountered en route and at recovery site.
• Special equipment required.
• Hazards and risks that may be encountered.
• Communication requirements.
• Location of nearest MA facility.
• Weather considerations.
3.1
2.2.2.
Preparation for Movement.Upon completion of the planning phase, the team leader should assemble the S&R team members, brief them on information gathered, and prepare personnel and equipment for movement.
• Perform map or aerial reconnaissance of the search area before the mission.
• Determine appropriate PPE
• Determine start point.
• Determine dismount point.
• Determine distance and direction from dismount point to recovery site.
• Assign individual duties at recovery site.
• Prepare load plans.
• Load equipment and supplies.
• Move to dismount point.
• Team members are responsible to:
Understand mission requirements.
Question local inhabitants.
Search only during daylight hours.
Always search with other team members (use the Buddy System)
Search places such as ditches, riverbanks, bushes, foxholes, trees, damaged structures, and disabled vehicles. Tag each remains and portion with an S&R number tag. Fill out the S&R Log (Tab 1) Make a sketch or photograph of the recovery site if necessary. Use a GPS device. Complete the required sections of the S&R log for each remains. Search area around remains for PE. Inventory PE. Keep PE secured to the remains. Keep remains shrouded (covered) except when they are being checked for identification. oEvacuate remains, feet first.
2.2.3.
When searching for remains, follow a systematic method. This allows for team members to thoroughly cover a large area.
• Ensure each team consists of a team leader, two flankers, and enough people to adequately cover the search area.
• Equip the team with a GPS, compasses, sketch maps
2.2.4.
Search Operations. Once the S&R team has arrived at the designated dismount point, the team leader should conduct a head count, conceal and secure the vehicle(s). Additional personnel may be required to stay at the dismount point for security and/or to relay communications. The team should move in a single-file, with the team leader and communications operator in the center of the formation.
Once the team leader has determined that the team is within approximately 100 meters of the given recovery site location, the team will assemble into either an open search 33 formation (double-arm interval), used for open or sparsely vegetated areas, or a closed formation (single-arm or close interval), used for densely vegetated areas or difficult terrain with limited visibility. The team should then use the “straight-line box” search method.
That is, the team leader will position him/her self in the rear center of the formation. The S&R team will move in the direction of the recovery site in a slow and steady pattern, searching side-to-side for items pertaining to the operation. The team leader should ensure that the team maintains proper intervals, moves in the direction of the recovery site, and always stays online.
2.4.1.
When a team member observes an item that may be relevant to the search, he/she will use a predetermined verbal or hand-and-arm signal to alert the team to halt. The team leader will examine the item(s) and determine its relevance. If the item is deemed to be human remains, portion of remains, or a disassociated PE, the team leader will mark the item with a predetermined color pin flag or other suitable marking method. The team leader will mark the pin flag using a grease pencil with the proper sequential “R” and the recovery number for remains, “E” and the recovery number for disassociated PE, or “P” and the recovery number for a portion of remains.
The team leader will then annotate the number assigned to the item and a description in a field notebook.Note:An “R” and the recovery number will be assigned to any item found that constitutes more than 50 percent of a human body. The team leader will make this determination. If there are no items representing more than 50 percent, each portion will receive a “P” and the recovery number.
2.4.2.
This search and marking method will continue until the team has reached a point of at least 100 meters past the last marked item. The team leader will then halt the team and direct the left or right flanker to perform an about-face, depending on which direction the search will proceed. The remaining team members will pivot around the flanker, remaining online until the team is facing in the opposite direction. The team leader will move to the rear-center of the formation and direct the movement of the team. This search pattern will continue until there is at least a meter buffer in each direction around the defined recovery area.
2.4.3.
Team members search until they find remains or until the team leader determines there are no remains in the area. Team members must be aware of areas where remains may be located. Team members should also search unusual ground disturbances that may be due to emergency interments, collapsed bunkers, or fighting positions. unusual odors, congregation of insects, scavenger birds, or animals should be investigated as they might lead to hidden remains.
3.0.
Recovery Operations
3.1. Once the entire area has been searched and all relevant items marked, the team will begin the documentation and recovery process. During combat, remains and disassociated personal effects should be considered booby-trapped. Thus, proper precautions should be taken prior to handling any remains, portions, or PE. Small portions and disassociated PE can be checked for possible booby-traps by close examination prior to handling. Remains represent a higher probability of being booby-trapped, so visual inspection may not always locate the presence of these devices.
3.3
3.2. To check remains for booby-traps, the recommended method is to use one team member, who will attach a rope or strong cord to the side of the remains opposite from the direction that he/she will pull the rope. With the remaining team members at a safe distance and behind cover, the designated personnel will pull the rope until the remains is rolled-over and moved slightly away from its original position. All team members will stay behind cover for at least one minute, after which the remains can be assumed safe to handle.
3.3.All personnel handling remains, portions, or disassociated PE should wear the proper PPE, i.e. protective gloves, coveralls and a face mask at a minimum. Pre-designated team members should complete the following tasks:
3.3.1
Recording Personal Effects
Personnel designated to document and safeguard PE should be the first personnel to come into contact with the remains after booby-trap checks are complete. These personnel must thoroughly check the entire remains including the hands, neck, pockets, boots, and load carrying equipment, etc. for PE . (Note:Never cut pockets or remove the identification from around the neck, if found.)
• Annotate these items on the S&R PE Log sheet (Tab 2) (No clothing is annotated on this form). Only PE found on the remains or in the remains’ clothing or equipment are annotated on this form.
• Use one sheet for each body. Use more than one sheet for an individual body’s PE if needed.
• Provide identification to team members completing other documentation.
• Place PE in a plastic slide-closure bag, then place in a PE bag.
• Attach the PE bag to the left wrist of the remains, if possible. If not, securely attach the PE bag to another location on the remains.
• Sign the S&R PE Log. This becomes the chain of custody document for the PE.
• Place the S&R PE Log in a slide-closure plastic bag with the PE.
3.3.2. Recording identification media
Personnel designated to locate and record items of official identification media should thoroughly check all areas of the remains’ clothing and equipment. (Note:Do not cut pockets or clothing.) Drivers License or Social Security Card, and any other identification should be annotated on S&R PE Log in the appropriate section.
3.3.3.
Obtaining statements of recognition
When there are S&R team members or other personnel in the recovery area that can visually identify the remains, a designated team member should complete a Statement of Recognition of Deceased (Tab 3).
• The S&R team member completing the form will annotate as much information as possible using information provided by the acquaintance out of sight of the remains.
3.4
• Once these blocks are completed, the team member will escort the acquaintance to the remains and determine if the remains can be visually recognized.
• Any discrepancies found during the viewing with the descriptions provided prior will be annotated in the “remarks” block of the form. (Note:Remains will not be washed or have clothing removed to aid the recognition process.)
• Complete all remaining blocks and have the acquaintance sign in the appropriate block.
• The team member completing the form will sign in the “witness” block.
3.4. Questioning local inhabitants
3.4.1. Completing tags for remains, portions, and disassociated PE:
• A designated team member should prepare two S&R tags for each remains, and one tag for each portion and disassociated PE.
• The S&R tags for remains should have the S&R number on one side.
• The reverse side of the S&R tag is left blank, except for remains recovered from aircraft crashes or vehicles. For remains from aircraft crashes, the reverse side of the tag would be marked “ACM” for advanced composite materials. This marking will alert receiving MA personnel that the remains may contain hazardous residue and special handling precautions may be warranted.
• S&R tags for portions and effects should have the number assigned to the item annotated on one side and the reverse side should be left blank.
• One S&R tag will be attached to each remains and the other to the zipper tab of the human remains pouch.
• The tag for each portion and disassociated PE will be placed inside a clear zip closure bag with the effect, or attached to the outside of the bag for portions. These items are then placed inside the human remains pouch containing the remains recovered nearest the item.
• The documents prepared for each remains should be put into a sealed, water tight container and placed inside the proper human remains pouch.
4.0. Evacuation Operations
Once remains, portions, and disassociated effects have been tagged and placed in human remains pouches, the remains should be evacuated to the MACP. Remains should always be:
• Carried feet-first.
• Treated with dignity, reverence, and respect.
• Loaded head-first onto fixed-wing aircraft.
• Loaded feet-first onto vehicles or rotary-wing aircraft.
• Escorted to the most convenient MACP facility.
5.0. Documentation of the Recovery Site
It is vital that all aspects of the recovery operation be documented. This documentation provides a spatial and contextual reference as to where remains, artifacts, and other material evidence is found within the recovery site. The recovery operation is documented in three manners: maps, field notebooks, and photos.
5.1. Mapping the Recovery Site.
Making accurate maps of every recovery site is essential. A map of the recovery site showing the locations of remains, portions, and effects in relation to the datum can be used for future excavations and recreation of the recovery site
5.1.1.
A detailed recovery site map should include:
• Codes for each remains, portion, and disassociated effect recovered.
• Quadrants for each item recovered.
• GPS coordinates and description of the location for each body.
• Team conducting recovery.
• Team leader name
• Date(s) of recovery operation.
5.1.2. Field Notebooks.
During recovery operations, the team leader should keep a detailed record of every aspect of the recovery operation in a field notebook. The last page in the notebook should include the team leader’s information, dated, and signed. This notebook should be forwarded with the remains to the MACP facility.
5.1.3. Photographing the Recovery Site.
If possible, photographs of the recovery site should be made using negative-based
film. Close-ups and overall views of each item should be taken. A description and
number of each photograph taken should be recorded in the field notebook. Each roll of film should be numbered and every roll forwarded with the remains to the MACP (Note:It is important to safeguard this photographic evidence and ensure that no unauthorized photographs are taken.)
5.1.4. The team leader includes as much detailed information as possible to aid any future S&R missions.
ARIZONA PANDEMIC INFLUENZA MASS FATALITY RESPONSE PLAN TENTATIVE IDENTIFICATION MOVEMENT AND TENTATIVE IDENTIFICATION OF REMAINS
1.0. General.There are a variety of ways that remains can flow from an incident site to a mortuary. MACP provides direct support in the receipt, processing, tentative identification, and evacuation of remains and their accompanying PE, usually to a mortuary.
2.0. Movement to a Mortuary Affairs Collection Point. After recovery, remains, portions, and PE are moved to a MA facility. Remains should be transported in the most expedient manner to prevent the loss of identification media due to decomposition of remains. Operational requirements may dictate the use of all available covered transportation assets. However, use of medical and food-bearing vehicles should be avoided. All vehicles will require decontamination after the pandemic is over.
2.0.1. While waiting for transportation, remains should be kept under refrigeration (36 to 38 degrees F) until ready for movement. PE should be inventoried on a “Record of Personal Effects of Deceased Personnel” (See Tab 1) or plain bond paper. If plain bond paper is used, all entries must be legible and signed by the person performing the inventory. Move remains from refrigeration only when the transportation source is ready to move. Screen/shroud the remains to the extent possible to prevent them from being in public view. Post guards to prevent the theft of PE and equipment. Keep unauthorized persons away from the remains.
2.0.2 When transportation arrives, begin loading. Carry remains feet first at all times.
While loading remains, maintain an attitude of reverence and respect. Load remains on vehicles and rotary-wing aircraft feet first. Load remains head first on fixed-wing aircraft with the head towards the front of the aircraft. Do not stack remains directly on top of each other. Secure remains in a manner that will prevent shifting during movement. Assign a team member to accompany the remains and PE during evacuation. If at all possible, the team member should be familiar with the deceased and be able to execute a statement of recognition. Evacuate remains to the nearest MACP.
2.1. Mortuary Affairs Collection Point Operations. The MACP is the basic building block for modern-day MA support. Mission planning provide for MACP to be geographically located throughout the local area. These MACPs provide receiving, refrigerating, processing, and evacuating of remains and their accompanying PE.
To accomplish their mission, MACPs are established in one of two ways: 1) MACPs are designed to provide direct support to the County OCME and 2) MACPs are also designed to provide general support to a given area as designated by the County OCME. In providing general support to the OCME, the MACP is more likely task-organized with increased receiving, processing, refrigeration, and evacuation capabilities. When serving as a transit or intermediate point for ME the MACP provides direct support to the local area and then forwarding human remains on to the central MACP or County Morgue.
2.2. Site Selection
MACPs providing general support to a given area, should choose a site based on the following:
• Close to a road network with a designated parking area and directional signs to reduce congestion and confusion associated with heavy traffic flow. Close to communications support.
• Ability to screen area using natural screening or screening material.
• Close to the S&R area.
• A central, secure location for local residents to drop off remains.
• Erect screening material at the earliest possible moment to prevent the operations of the MACPs from being in public view.
• Construct a perimeter to prevent unauthorized personnel and the news media from entering the area.
• Tailor the facility layout to the geographic and manmade features of the area to be used.
2.3.Facility Layout
A MACP is composed of three basic sections: receiving, processing, and evacuation. The facility layout is based upon the structure and the support mission of the MACP.
2.4.
Receiving Operations 2.4.1.
Prepare the Collection Point Register of Deceased Personnel (CP Register) (located in Tab 2 of this Appendix). The CP Register is a daily log of all remains received by a CP. Prepare a new register each day the CP is in operation. The reporting period starts at 0001 and ends at 2400 (local time). Retain a copy of all registers at the CP for internal records.
2.4.2.
Upon arrival of the remains, MACP personnel record all required information on the CP register, and confirm the actual number of remains being delivered. Remains are checked for recovery tags and any other accompanying paperwork. Recovery tags, if present, are removed and placed in the case folder file. Do not delay normal processing and evacuation for lack of information.
2.4.3.
Complete two evacuation tags for each remains. Evacuation tags will have what is believed to be the last name, first name, middle initial, SSN, of the remains or “unidentified” on one side of the tag. On the reverse side, the evacuation number issued to each remains which is then recorded on the CP Register. The evacuation number consists of a sequential number given to each remains during the current calendar year, the CP number, and the number on the seal which was used to seal the human remains pouch. One tag is attached to the remains and the other to the human remains pouch.
4-2
2.4.4. When MACP personnel process body portions, the evacuation tag is completed as follows: “portions” is written on one side of the tag; beneath “portions” the sequential “P” of portions is written. The reverse side is completed the same as for “remains”. When placing several portions into one pouch, each portion must be tagged and separately bagged. The pouch must also have an evacuation tag on the front on which the word “portions” is written, and beneath it the total number of portions contained in the pouch and is then recorded. The back of the tag is completed as all others. Do not physically associate any portions with other portions or remains.
2.4.5.
Based on the current workload, move the remains to the processing area or keep the remains at the receiving holding area under refrigeration to wait for further processing.
2.4.6.
Initiate an original and duplicate individual case file. The top portion of the file should have tentative name, rank, SSN, seal number, and evacuation number. Create an alpha index card containing the following information: deceased name or “unidentified”, SSN/Drivers License, evacuation number, and other appropriate remarks. This file is kept at the CP as a quick reference for questions about remains processed through the CP.
2.5.Processing Operations
2.5.1.
The method and extent of processing conducted at the CP depends on the prevailing operational constraints and local MA procedures. When the CP workload is overwhelming, the CP OIC may make the decision to follow the minimum hasty processing procedures. The minimum procedures that must be accomplished are: prepare evacuation tags, complete CP Register, remove any ammunition, explosives or weapons, place evacuation tag on remains, and place remains in pouch. Place the PE bag in the human remains pouch, then place an evacuation tag on the pouch and seal it. The remains are then placed in the refrigeration container. Finally, load the remains on the transport vehicle. The driver must sign for the remains on the CP Register. The original CP Register goes with the driver while a copy is maintained at the CP.
2.5.2.
Identify, inspect, and record all personal identification media, PE, and personal equipment using (Note:Do NOT cut pockets, clothing or equipment to inventory PE).Be particularly careful during processing to avoid contaminating or destroying forensic evidence. PE should be carefully removed, and handled minimally to preserve physical and biological forensic evidence. (i.e., If a ring won’t come off easily, leave it where it is and annotate it’s location on 1076.) Pay particularly close attention to locating the identification tags and the identification card. Leave identification tags around the neck if found there.
Use official identification media found as a basis for establishing tentative identification. Leave all clothing on the remains. Inventory PE and record these items on Record of Personal Effects of Deceased Personnel (RPEDP). Upon completion of the inventory, place the PE and one copy of RPEDP in a plastic slide closure bag to prevent the effects from being damaged by body fluids. Place slide closure bag in a PE bag. Secure the PE bag to the wrist or other suitable areas of the remains.
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2.5.3.
In cases when unassociated PE is received at a CP, do not attempt to associate them with particular remains. Create a file using the RPEDP. Generate an unassociated PE tag for the unassociated PE. The tags will have the words “unassociated effects” written on one side. On the reverse side assign a sequential “E” to each unassociated personal effect. Record service letter designator, the unit operating the CP, and CP number designator. Place the unassociated PE, with one copy of the RPEDP and the tag, in the slide closure plastic bag. Store in one or more PE bag(s) as needed. Place the other tag on the PE bag. Evacuate the loose PE when evacuating remains as a separate item.
2.5.4.
The use of computers at the CP will help facilitate expedient processing of remains information throughout the theater.
2.5.5.
Take two sets of pictures, using a digital camera, for each remains. Take a full facial picture, complete anterior photo of the body, then gently roll the body over and take a posterior view of the body. The pictures are used by the OCME to aid in the identification process and to document the state of the remains at the time the remains enter the MA system. Pictures should be stored on disk and only released by the OCME.
2.5.6.
The original, completed, case file is placed in a plastic slide closure bag and placed in the remains pouch. The duplicate case file is kept at the CP and a statement as to whether PE were present on the remains and if they were evacuated from the CP. Any additional documentation, required forms, and photos of the remains are placed in the case file. The remains pouch is then sealed and stored or evacuated. The seal number should already be recorded on the case file and both evacuation tags.
3.0 Identification of Remains
3.1. The process of identifying a deceased person begins when remains and all biological and physical evidence are recovered. Information from witnesses, the decedent’s unit, recovery personnel, medical, dental, and fingerprint records are vital in this process. The biological and physical evidence obtained in the theater and supporting post-and ante-mortem records are examined by the medical examiner to aid in determining the cause and manner of death and the identification process.
The remains, supporting biological and physical evidence, associated identifying media and PE are examined and the findings documented. The completed documentation makes up a Remains Case File. If a comparison of ante-mortem and post-mortem identification data, and the results of any scientific testing prove favorable, and the identification specialist feels he/she can take the case to court and be successful, a positive identification is made of the remains. If the completed documentation shows that the remains cannot be positively identified, the case is continued in an active status so that further attempts at successful resolution can be made.
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3.2. In many cases deaths due to pandemic influenza will be documented by a physician giving care to a patient who died at home, or in a hospital. In these cases the remains may end up in a MACP awaiting burial. No further identification will be needed.
4.0.
Evacuation Operations
4.1. Coordinate for transportation to evacuate the remains. When vehicles are used, they must be covered.
4.2. Remains awaiting evacuation must be kept under refrigeration. The temperature of the refrigerated container is maintained between 34 and 37 degrees Fahrenheit. Holding remains in a refrigerated container will minimize decomposition. Do not freeze remains under any circumstances. Ensure that the temperature is checked at periodic intervals. Additionally, ensure that maintenance checks are performed as prescribed in applicable technical manuals on the refrigerator unit and generator.
4.3. Upon arrival of transportation, load the remains on a first in/first out basis. Ensure the remains are handled in a respectful and reverent manner. Carry remains feet first and face up. Position remains in such a manner that prevents the stacking of remains. Secure remains in such a manner that prevents shifting during movement.
4.4. The evacuation location of the remains will be annotated on the appropriate CP register.
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